mètres long (if necessary also a simple elastic catheter), mounted on a stilet. From its upper lateral eyelet-hole a loop of cord passes out. The coil of the prolapsed funis is loosely placed in that loop, and both are carried past the presenting part into the uterus. The stilet is withdrawn, but the elastic catheter remains, and is expelled only after the child, together with the placenta. The advantage is that the funis, which remains within the loop, is permanently retained in the uterus by the elastic catheter, which remains at the fundus.

In all other methods the umbilical cord, following the laws of gravity, again prolapses after reposition. To avoid this the position of the woman requires full consideration. She must be so placed that the lower uterine segment is no longer the deepest part of the organ. This is best effected by the knee-elbow posture. The lateral posture is not so suitable. Therefore if practicable the woman is to be placed in the knee-elbow posture for the reposition of the funis, and when this has been performed in that posture, attempts may be made to facilitate the entrance of the head by Kristeller's method of pressure. If that posture cannot be assumed, the lateral posture must be retained. The woman is placed on that side towards which the head has deviated. Thus, if the head lies to the left, the left lateral posture is assumed, though the funis may have come down on the right side. This posture is only altered when it becomes unsuitable.

When the os is insufficiently dilated and reposition impossible the life of the child can only be saved if the dangerous pressure can be taken off the umbilical cord. The danger arises when the head is pressed against the inlet. The danger is prevented by making the head deviate to one side, when the head position is converted into a transverse, or, still better, into a breech position.

Version with an undilated os is best made according to the method advocated by Braxton Hicks. The artificially produced transverse or breech position is then treated in the way to be mentioned below.

When the os is so far dilated as to admit one hand it is, doubtless, the most rational treatment to replace the funis, and to re-establish the normal relations. Reposition is always to be performed by the hand corresponding to the side towards which the funis has prolapsed; that is, the left hand, when the funis lies towards the right side of the mother; in the knee-elbow posture, however, the right hand for the right side. The funis is then carried by the fingers, formed into a cone, past the head of the fœtus, and, if possible, appended to one of the lower extremities, or placed in its natural position in front of the thorax and abdomen. If the funis remains there the fingers are immediately withdrawn; if not, they must be kept there for some time. All this time attention must be paid to the pulsations of the cord. During a pain the hand may be slowly withdrawn, and the head so placed by means of external manipulations as to render prolapse impossible.

Schmeisser recommends fastening the coil of the funis to the base of a properly constructed caoutchouc bag, and then to replace it. The bag is then to be inflated, and in this way it is retained within the uterine cavity.

However rational it may appear to replace the prolapsed cord, yet this must depend upon certain considerations. If the cord has not been at all compressed, and the foetal circulation is quite undisturbed, there is nothing to say against reposition; for if the worst happens, that it cannot be replaced, nothing is lost by it. If, however, the cord has been already compressed, even if reposition is rapidly and successfully effected, as happens in the most favorable cases, yet the life of the child may not be preserved; for the cord, without again entirely prolapsing, may come to lie so as to be exposed to fresh pressure. Examination of the sounds of the fœtal heart by the stethoscope will show, in such a case, that their frequency at first increases, but that after some time it gradually diminishes, thus furnishing a sure sign that the child is in danger. In still other cases, even if the funis lies so that it can by no means be compressed, the heart's sounds remain irregular. At one time they are extremely frequent, at another very slow, until they suddenly cease. It seems in such cases as if the circulation, once disturbed, would not again return to its previous course, although the cause of the interruption has ceased to exist.

Reposition, however, by no means always succeeds so rapidly and successfully. In many cases it is, as Boër says, "really a work of the Danaides." As often as we attempt to replace it, it comes down; and if, after much trouble, one coil has been luckily replaced at one spot, another coil has already prolapsed at a second place. The more time we lose in fruitless attempt to replace the cord, the greater becomes the danger to the child. We have, therefore, considered whether it would not be preferable, in all such cases in which the child is already in danger, and the circumstances give no reasonable prospect of an easy operation, to neglect for the moment the funis entirely, and immediately to turn and extract. Under not too unfavorable circumstances, in almost less than a minute, the child can be brought into a position to inspire atmospheric air, and is thus freed from the dangers which threaten it from a prolonged stay in the uterus, and if asphyxia already exists the necessary treatment can immediately be instituted. If under such conditions version is immediately performed, without previous trials at reposition, the child will not have more unfavorable chances than when reposition succeeds, but far more favorable ones than when, after unsuccessful trials at reposition, version must be performed.

If in prolapse of the funis the head is already in the true pelvis, unless delivery is very rapidly terminated, the child dies from compression. In primiparæ, therefore, when the head is in the pelvis, a pulsating loop of the funis will very rarely be felt. In pluriparæ it more frequently happens that when the head is high up the funis prolapses on the rupture of the membranes, and the head, at the same time, drops down. Unless the head is immediately born the forceps must be applied in order to extract at once. Under such circumstances the head is sometimes born so rapidly that there is no need of applying the forceps.

The treatment of prolapse of the funis in face presentation is essentially the same. It is better, however, at once to turn rather than to attempt reposition.

The case is different, however, in breech presentations when the

funis presents or has already prolapsed. For here everything favors prolapse, because the breech never fills the inlet so completely as the head. For the same reason the danger also is much less. The soft breech rarely exerts so much pressure upon the funis as to stop its circulation, and, if it has prolapsed at the side of the promontory, it is scarcely exposed to any pressure at all. Usually reposition is unnecessary, although it can often be successfully done, there being always room enough for it to come down again. But, because during the course of labour there may be possibly a greater pressure upon the funis, care must be taken so as to be able to terminate labour should danger arise. If the breech has not yet completely entered the true pelvis, it is urgently necessary to bring down one or both feet. Not only is the circumference of the breech diminished by it, but it also affords a good hold for extraction. During the progress of the labour it is, of course, necessary to watch carefully the pulse of the child and to extract it as soon as the frequency diminishes. When the breech has completely entered the pelvis with the legs high up, extraction must be tried as soon as asphyxia of the child commences. All that can be done here is to extract with all possible rapidity in order to save the child.

In pure footling presentations no further treatment is required, since the cord is not compressed.

In transverse positions it occurs much more frequently that the funis prolapses on the rupture of the membranes, but only in greatly neglected cases is it exposed to any dangerous pressure. If the os is still closed its dilatation is patiently awaited, and then podalic version and extraction made. Cephalic version with simultaneous reposition may also succeed under favorable circumstances. But it is difficult, and a favorable issue so little probable, that, indeed, it will very seldom be performed.

Another question remains to be decided, viz. is an operation indicated, when there is very slight, if any, pulsation in the funis. In the first case decidedly so; in the second there is no need of an operation if we are sure the pulsation has ceased for any length of time. For by rapid extraction we may save a child in a profound state of asphyxia, but in whom life is not yet quite extinct. The more immature a child is, the longer it can live in the uterus after the interruption of the placental circulation, but there is less probability of its living after its birth.

2. LACERATIONS OF THE SOFT PARTURIENT PASSAGES

A.-Lacerations of the Uterus

Solutions of continuity of the uterus are either incomplete, that is not penetrating through the whole thickness of the uterine parenchyma, or complete, that is, perforating into the abdominal cavity. The latter differ clinically, according to whether they are due to a sudden rupture, or to a gradual tearing through of the parenchyma of the uterus and of the peritoneum.

The non-penetrating or incomplete lacerations of the uterus are almost always situated in the cervix, and those of slight extent arise in

the physiological process of labour. In each labour the os uteri is torn at the sides and this can be felt after delivery. These rents do not give rise to special symptoms, and can afterwards be detected with great difficulty if at all. Only in succeeding pregnancies when the portio vaginalis is greatly swollen and oedematous, the old cicatrices which are not extensible are distinctly perceptible, and they form one of the best diagnostic signs between primipare and pluriparæ. It is very rare, indeed, that these small longitudinal rents of the cervix acquire a pathological significance. This only occurs in great rigidity of the cervix, most frequently in carcinomatous degeneration, and in very violent pains. Transverse rents of the cervix are very rare when the tissue is normal. In very exceptional cases the anterior lip of the os uteri is so violently bruised between the head and the symphysis that it is more or less completely torn from the uterus.

The ordinary rents in the cervix are not attended by any symptoms after delivery, but the larger longitudinal or transverse lacerations cause severe disturbances. There is inflammatory fever; the parts near the wound inflame and become infiltrated with the products of inflammation or with blood, the neighbouring connective tissue also participates in the inflammation, and the healing only slowly proceeds. If the lacerations extend almost to the peritoneum, perimetritis or even general peritonitis may be the consequence. During labour they cause little disturbance. The hæmorrhage, also, is usually moderate, for the lacerated tissue is exposed to so great a pressure from the head pressing against it that the vessels are more or less completely closed. Sometimes, however, much blood is effused into the tissue itself, forming a tumour which is distinctly felt in the vaginal vault. On the whole, delivery is effected in the usual way, and only after birth the lacerations cause profuse hæmorrhage, which is very difficult to stop. The bleeding spot is, in such cases, not easily detected, since uterus and vagina form an irregular cavity, with flabby and sinuous walls, over which the blood continually pours. The treatment is, therefore, usually limited to injections of cold water and vinegar, and they mostly suffice, because the hæmorrhage is parenchymatous.

Sudden perforating ruptures of the uterus perhaps never occur when the uterine tissue is healthy. They require a predisposition of the tissue and an exciting cause. In an otherwise normal uterus there may be some places which are feebly developed. Most frequently anomalous development, interruption of the normal tissue by interstitial fibroids or cicatrices, separation of the muscular fibres by submucous fibroids or by projecting small parts of the fœtus, or inflammatory softening of some portions of the parenchyma during pregnancy, predisposes to ruptures. The exciting cause proceeds from considerable impediments to the progress of labour. They are chiefly narrowness of the pelvis, hydrocephalus of the foetus, transverse positions, and a sudden and great increase of the contents of the uterus, as by introducing the hand in turning; it thus becomes intelligible why, in breech positions, the uterus seldom ruptures. A perforating rupture is easily produced by such an exciting cause when the predisposition already exists in the tissues. It is not improbable that a rupture may also proceed from a small spot in the uterine

wall, which had been injured by the pressure between the head and the pelvis, and that from this circumscribed lesion the lacerations start under the influence of a strong pain.

Usually the rent is so large that the child passes through it into the abdominal cavity. In the dead body it appears very small on account of the contraction of the muscular tissue. The rent is, as a rule, in the neighbourhood of the cervix, and then frequently has either a transverse or, at least, an oblique direction.

The symptoms of perforating rupture of the uterus are generally very characteristic. At the height of the uterine contraction the woman experiences a severe piercing pain, and at the same time feels a sudden turning of the child. She feels an oppression at the chest, a darkness comes over her eyes, a cold perspiration breaks out, her limbs tremble, the pulse becomes very small and frequent, and all the symptoms of an internal hæmorrhage set in. Uterine action suddenly ceases, the presenting part completely recedes or is, at least, more movable, and blood flows from the genitals. Almost always the child is partially or entirely expelled from the uterus into the abdominal cavity, the uterus then firmly contracts. For that reason the hæmorrhage is sometimes not very considerable, and the patient may sometimes recover from the first shock (especially if she has been delivered in the mean time).

In other cases, most of these symptoms may be absent. The rupture has taken place with scarcely any symptoms, and the cessation of the uterine action is almost the sole apparent sign. It is remarkable indeed to see how little sudden disturbance such a grave lesion sometimes produces. The pulse, however, in these cases always becomes frequent and small, and the subjective symptoms are, at least, never entirely absent.

From the clinical aspect above given a diagnosis can easily be made, but if the symptoms are as just described it will be somewhat difficult to interpret them correctly. A sudden cessation of the uterine action, when the pains have been very strong should always greatly excite the suspicion of the accoucheur.

If the presenting part until then immovable at the brim has receded from it and blood escapes from the vagina, the diagnosis is certain. The two latter signs, however, may be absent when the head is impacted in the brim. In such a case the diagnosis is made certain by palpation. The foetal parts are now much more distinctly felt than before beneath the abdominal walls, and near them a large hard ball-the contracted uterus. The general condition also gives very important indications, for there is rarely an entire absence of anxiety, nausea and attacks of syncope. Whilst the temperature is of no diagnostic value in this case, the state of the pulse is of great importance. The pulse which shortly before had been full and not very frequent has now become small, threadlike, and very frequent, and indicates a grave lesion.

Almost all cases of perforating rupture of the uterus are fatal to the child, for, unless it be very rapidly extracted, the placenta is detached by the contractions of the uterus. The mother may rapidly bleed to death, but usually dies from consecutive peritonitis in childbed. When the child remains within the peritoneal sac, a favorable issue is extremely rare, yet it is possible that the case may terminate