age around the neck. The renewal of this dressing from day to day was all the treatment the wound received. I discharged the patient about the middle of November, the wound being entirely closed.

The mode of healing in this case was entirely by granulation, and exhibited that wonderful power of nature in filling up, where the surgeon fails to bring together, and of absorbing and smoothing down to a small cicatrix the superabundant granulations.

It may be suggested by some that fatal hæmorrhage would necessarily follow such a wound. In answer, I quote from Gross on "Injuries and Diseases of the Neck." "It has been doubted whether the windpipe and æsophagus could be completely severed without injury of the carotid artery and jugular vein; but. the possibility of the occurrence has been tested by several well-authenticated cases." There was no vessel cut in this case that needed ligation. I add this case to our present records on this subject.

NOTE.---All of the departments in this number are curtailed to make room: for the Transactions of State Societies.---ED..

ECLECTIC DEPARTMENT.
"Carpere et colligere."

ART. I.-THROMBUS OF THE VULVA. A Clinical Lecture, Delivered at Bellevue Hospital by FORDYCE BARKER, M. D.,. Professor of Clinical Midwifery and Diseases of Women,, Bellevue Hospital Medical College, N. Y.

Gentlemen,-A long time ago, at the very commencement of my practice, I was called to attend a young woman in labor. Everything seemed to be progressing favorably, when suddenly

the patient screamed, threw herself to the other side of the bed, and appeared to lose all self-control. A few minutes before this I had made an examination, and found the cervix dilated, and the head descended into the pelvic cavity. I was promising myself a speedy termination of the labor, till startled by the interruption of it just described.

The patient was suffering such intense pain, and the parts were so tender, that it was some little time before I could get another examination. Then I, at first, discovered a tumor of a hardness resembling that of the foetal head; and I thought the foetus was just escaping from the vulva, and that it was the agony attending this which had brought the patient to her distressing condition. But I soon found that she was losing a good deal of blood, and that the uterine contractions had ceased. Her excitement and anxiety I was able to calm by perfect self-possession; but I was unable to make a satisfactory diagnosis. The indication was evidently to prevent loss of blood, though as to what the hemorrhage meant, I had not the least idea. To fulfil this indication, I applied a saturated solution of alum, and made a pretty strong pressure upon the tumor, which I kept up for an hour or two, the labor-pains all the while being stopped.

The case being so obscure, I decided to call a consultation. A physician much older than myself was sent for, who made a comparatively hasty examination, and at once pronounced the case one of placenta prævia; saying that he had often had such cases; that owing to the severe pain produced by my application of alum and compression, I had arrested the labor, and it might be some hours before the pains returned, when he would be sent for again. On the whole, he damned me with faint praise; thought I had done very well, considering that I was a young man, just beginning practice; and, as I afterwards learned, censured me to the family for the ridiculous folly I had been guilty of in making my applications. He left, with directions to be called when the labor commenced. I was hurt and humiliated, but not convinced. I found, too, that the consult

ing physician had not favorably impressed the family, while I had rather won their confidence and sympathy.

In the meantime, my measures had stopped the hæmorrhage. About an hour later it returned to a considerable amount; and as the patient's chief danger seemed to be from loss of blood, I saw nothing better than to renew them. They could certainly do no harm. In applying the compresses, I embraced the opportunity to make examinations, and presently came to the conclusion that there must have been some solution of continuity in one of the labia to account for the bleeding. The nurse was a sensible woman; and directing her to keep on the alum and compresses, I went home to consult my books. Though my library was tolerably rich in works on obstetrics, I could find nothing, as I hastily turned them over, except a short description of extravasation into the labium, with no directions for treatment. I reflected that it would not do for me, a young, unmarried man, with a reputation to make or to mar, to let the woman die with a child in her. So I turned over my books again for directions as to the use of the forceps, took my forceps, and went back to the house.

During my short absence the tumor had so increased in size that it was with difficulty that I could pass my fingers into the vulva, especially since it caused the patient so much suffering; for this was long before the days of anaesthetics. The head was pretty low down, but the woman had lost still more blood. I said to myself: With this bleeding and this tumor there is no chance of the labor terminating spontaneously; or, if there be such a possibility, and I wait for it, there must, at least, be a great loss of blood; the patient will probably die, and that will be ruin to me. I applied the forceps, and delivered a living child. This was my first forceps case. Immediately following delivery there was a tremendous gush of blood, and almost as soon as the blood escaped the tumor filled up again. With no authorities and no experience to guide me, I could only follow a sort of instinct, with the conviction that it was leading me right, or, perhaps, a non-formulated logic which it would have been

difficult for me to defend. I am sure, gentlemen, that no general in time of battle, considering that he held the fate of an army or a nation in his hands, ever felt a heavier weight of responsibility than I did here; and although this was twenty-eight years ago, every incident and detail of the case is stamped indelibly on my memory, as vividly as if it had occurred but yesterday. From further examination I satisfied myself that laceration of the labium had taken place, and that the extravasation of blood was into this. I recollected that Hunter, in his work "On the Blood" (which I had studied carefully in my early pupilage, and which still remains a great favorite with me), had described the case of a woman who had accidentlly fallen upon the handle of a water-pail, causing laceration of the labium with great hæmorrhage. Hunter had left the coagulum to compress the lacerated vessels and stop the bleeding; had then poulticed the part and bled the patient, to keep the tissues soft and relieve pain. Suppuration had taken place, with discharge of clots, and eventual recovery with a slough. This case had not occurred in pregnancy, but it was my only guide, and I followed the plan of treatment there indicated. It was sometime before my patient recovered. She had a gangrenous slough, by which the whole labium was completely destroyed. The woman got well, however, though with only one labium, and the child also lived.

Now, gentlemen, if you look through all the text-books on midwifery in the English language, including translations into English, you will not find in one of them plain directions for the management of such a complication of labor as this. To be sure, thrombus of the vulva is now described in several books, though not in the text-books on obstetrics, with the exception of Cazeaux, as a complication of labor. Very shortly after this first case of mine, I found in Dewees on Diseases of Females (not his work on midwifery) a very clear description of this class of accidents. Meigs also, in his Familiar Letters on Diseases of Women, gives a pretty clear description of it, and also McClintock on Diseases of Women. There is a short ac

count in Simpson on Diseases of Women, and another in Burns. Cazeaux has the clearest and best-written article on the subject, extending to several pages, and giving excellent instructions for treatment where the accident occurs previous to labor. Bedford, in his Obstetrics, gives a very fair description of this complication, but the directions for treatment are vague. The periodical literature of medicine does not lack reports of such cases, and in a French monograph by Deneux, published in 1830, there are sixty-two reported cases of thrombus of the labium, occurring before, during, and after labor; and out of this number twenty-two of the women died, and twenty-one of the children were lost.

I need make no apology, then, for endeavoring, in some measure, to supply the deficiences of your text-books upon this subject by bringing before you to-day a case which occurred in this hospital a week ago last Sunday. The patient is now being brought in, and the house-surgeon (Dr. Alexander C. Graham) will read you his report of the case.

Margaret, æt. 19, New York, primipara. Labor-pains began about 12 o'clock the night of January 15th, and continned with only slight intensity all the next day. At 5 P. M. (January 16th) the bag of waters broke, and the immediately sent to the lying-in ward.

patient was

On examination no deformity of the pelvis or of the soft parts was found; the cervix was soft, moist, and dilatable, the os being an inch and a half in diameter. The vertex was presenting in the left occipito-anterior position. Foetal heart heard on the left side below the umbilicus, 130 per minute. At 7:30 P. M. the cervix was fully dilated, and the uterine pains continued good and regular. In a short time the head descended to the inferior strait, and remained there till 11:10 P. M. The woman seemed to suffer a good deal of pain, and could not be made to bear down.

While making an examination at this time, I noticed that the right labium majus was more swollen than at the previous examination, and that it was rapidly enlarging. I supposed