immediately followed by a very great diuresis, which removed within eighty hours the last vestiges of the vast and general infiltration. It is rare, I think, to find the most hydropic leg containing any serum three days after the child is born.

In the course of your practice you will be often called on to advise, on the subject of œdema gravidarum. As it is extremely common for primiparous women to have swollen legs in the last six weeks, and sometimes earlier, of their gestation, you ought never to forget that such a woman is more exposed than another to the alarming attack of eclampsia, or puerperal convulsion. In fact, I have known but few other women to have convulsions in labor than those with swelled legs. The pressure of the gravid womb on the ascending blood and the absorbents, causes the effusion of serum; the same pressure, be it observed, is exerted on the aorta, impeding the descending current of blood, and of course directing a more abundant circulation in the trunks and branches of the subclavians and carotids; the consequence of which is an augmented arterial determination to the head and upper extremities. If you permit this morbid determination to continue unmitigated, the slow but sure foundation is laid for puerperal apoplexy and eclampsia. The woman should be bled and dieted in a prudent and careful way, and all massive obstructions arising from a surcharged state of the colon ought to be obviated by gentle laxatives.

I repeat that I do not think you can reasonably expect to cure a considerable cedema by venesection; yet that it may be moderated by the use of the lancet and kept within safe bounds I do not doubt.

I shall close this letter here, with the design of speaking to you in the next, of certain other disorders to which the labia are subject; and I am very truly your friend and servant,

C. D. M.

LETTER VI.

WOUNDS, LACERATIONS OF LABIUM.

GENTLEMEN: I design in this letter to say something as to certain very distressing injuries of the labia, suffered by parturient women, and which are caused by the extreme tension of the labia themselves, or by the tension of other parts, whose accidents or diseases, implicate these external textures.

You are acquainted with the origin of the pudic artery from the ischiadic, in some individuals, and in others from the internal iliac; and you are aware that this vessel runs upward on the inner face of the ramus of the ischium, and sends branches forth to supply the external organs. Now, it occasionally befalls a woman in labor, or one affected by a wound, to fracture this pudica interna artery, or a considerable branch of it;-and as the labium externum is full of loose cellular tela, it is easy to see how a rupture of the vessel may cause such a quantity of blood to be dashed into the distensible texture within the labium, as to give the appearance of an enormous tumor, of a very livid or even black color; and producing all the pain to be expected from laceration of the inward textures, and the stretching of the others not immediately broken, by quantities of congealed or fluid blood, with which the organ becomes thoroughly soaked and filled.

The rupture of a vessel within the brain may suffice to tear the brain like a wooden wedge driven into it. So, in the spleen, a vessel giving way tears that organ to pieces-and, in like manner, a broken trunk or branch of the pudic artery, may demolish the internal texture of the labium majus.

I have seen examples of the accident of various degrees of severity. Some of them were discovered before the termination of the labor, and others not until many hours subsequent to the accouchement. In the cases where the mischief is not complained of until long after the child is born, we may infer that the vessel is an arteriole only, some branch of the pudic; which had given way during the expanded state of the inner genitalia, and which could

not bleed while they were so expanded; but commenced to scatter the extravasation within them, as soon as the distending and compressing cause was withdrawn. Such cases are less likely, I think, to prove mischievous, than the other sort, in which the labium begins to swell before the child's head has descended so far as to push the labium aside. When the labium fills in this way, antecedently to the emergence of the presentation from the arch of the pubis, we must suppose it to arise from the rupture of a trunk, not an arteriole. It is, therefore, more dangerous.

The quantity of fluid thus extravasated is surprisingly great; and doubtless the bloody infiltration will run backwards into the loose cellular lamina that are in relation with the sides of the vagina; producing disorder and difficulties to an unknown extent within; in addition to the more visible and tangible marks of them on the front of the pelvis.

A lady in this city was in labor of her first child in —, 1844, and after long-continued efforts to dilate a rigid os uteri, drove the head into the vagina, where it rested, on account of a complete cessation of the pains, from exhaustion of the supply of uterine innervation. Her medical attendant, intent on procuring the expulsion of the fœtus, administered to her a portion of secale cornutum, the influence of which was soon manifested by the renewal of the labor contractions in great force. The ergotic spasm thus excited, gave way, after no very long interval, from a second exhaustion of the nervous energy directed into the womb;-and it was found that the left side of the vagina, the parts about the left crus ischii, and the left labium, were swollen, tense, and painful. Being called to a consultation upon the case, I observed a large protrusion of the left half of the perineum, occasioned by bloody extravasation, which had gone so far backwards, as to fill the cellular material in front and to the left of the rectum; while the looser texture of the labium had been rendered by it as turgid and dark as possible.

It would have been impossible to extract the fœtus from such a canal as was thus prepared, and as the indication was to use the forceps, I prepared the way for their successful application by making an incision into the inner and lower surface of the labium, out of which I extracted by means of the finger, which passed far inwards, a great quantity of coagulated blood, besides much fluid blood and serum; which being done, I next adjusted the forceps

to the head, and painfully, slowly, and with much effort, extracted the child, which was dead.

The patient was sorely exhausted by such a dreadful labor. Her very bad pulse did not amend after the delivery; the injured parts were attacked with erysipelas, to which she fell a victim, in the course of a few days.

I have thus given an account of a case which I hope may set, in a clear point of view, the nature and dangers of these bloody infiltrations; and I wish the perusal of it may set you on guard against similar occurrences, of which you will perhaps become the interested spectators. I should think the foregoing remarks enough to show you that the mere filling up a labium is a matter of small consequence, in comparison with the inward mischief and demolition likely to accompany such accidents. I pray you, then, not to disregard the complaints of your patients in child-bed, as to the affections of the external genitals; but the rather, that you should pay very great regard to them, nor suffer the fastidiousness of a modest female, or your own sense of delicacy, to prevent a complete and early investigation.

Do you not think that if a patient under your care, in labor, should begin to have extravasation (thrombus) filling up the labium, it would be charitable, and dutiful, and prudential to lay open the mucous surface by an incision conducted in the longitude of the organ, and deep enough to give issue to the infiltrating blood? Would not such an aperture, by allowing the hemorrhage to exhaust itself upon cloths or napkins, prevent it from tearing to pieces, or obstructing the lax textures outside of the vagina and inside of the pelvis? Be you the judges to decide upon any case presented in the course of your practice. I think, that where a labium is already filled with blood, before the distending power of the head begins to be exerted upon it, if you allow the injecting force of the hemorrhage to go on unchecked or unrestrained, you will have reason to dread the extending of the thrombus to very deep-seated textures; and hence I should much prefer to allow the fluid to escape through an incision made on the mucous face of the labium.

I pray you to consult Dr. Dewees' article on this subject, in the Treatise on Females; it is a very good one, and you ought certainly to consult the writings of that celebrated man—the more especially as he was an American authority.

I have said nothing of the after treatment of the accident. Of course, you will not expect to discharge from the thrombus all the blood contained in it, by an incision. You will get out all the coagula, very great in quantity, and pass out much fluid blood and serum of the coagulations. The discharge of the rest will take place, partly by outflowing under the textural contractility of the parts, and partly by the absorbents, which will carry it away. I am sure I have seen at least a pint of blood effused beneath a man's skin, from a blow, taken up and carried away by the absorbents in about a fortnight.

The most convenient treatment will consist in very emollient dressings, either of tepid water, mixed with a little red wine or vinegar, or of flaxseed tea, mucilage of slippery elm, applied as stupes or fomentations, or linseed or bread and milk poultices, or poultices composed of crumbs of bread mixed with the petals of chamomile. These dressings, when the tumefaction becomes sufficiently reduced, ought to be followed by cerate dressings; whether of simple cerate, basilicon, or Goulard's cerate. The selection will depend on your judgment as to the wants of the case.

When a woman has suffered from such an accident, it must be expected, if the injury be of a grave character, that she will have great pain and constitutional disturbance from it. I need not say, that you ought not to leave the nerve system to the unmitigated perception of such painful impressions; but that you ought to quell both its impressible and perceptive faculties, by keeping them within moderate bounds, by the use of anodyne medicines in some convenient form; such as the Dover's powders, which may he repeated in doses of four grains every two, four, or six hours, until the therapeutical end of its exhibition is attained.

Should much febrile heat, and sanguine exaltation attend the early stages, you might perhaps prefer a medicine like the following recipe.

Take of fresh lemon juice, 1 tablespoonful; carb. of potash, 18 grains; mix them and add, solution of sulphate of morphia, of a grain to make a draught, to be taken every two, four, or six hours.

It will be obvious also, that where a full or tense pulse is found to accompany the accident, or to follow it as a consequence, it