child upward and to the side, causing the posterior shoulder to sink deeper into the pelvis, and furnishing more room for the introduction of the hand; then two fingers should be passed along the side of the child to the elbow joint, which should be pushed across the face, and brought down over the thorax. Pressure should always be made at the elbow joint, and not upon the humerus, otherwise a fracture of the humerus is liable to occur in releasing the anterior arm, as there is rarely space enough between the symphysis and the shoulder to allow the fingers to reach the elbow. It is customary after releasing the posterior arm to rotate the trunk, so as to bring the anterior arm backward into the cavity of the sacrum. This is accomplished by drawing the liberated arm upward, under the symphysispubis. If the back is turned to the left, the arm should be drawn upward along the left labia; and if turned to the right, it should be turned along the right labia. In making artificial rotation, it is well to bear in mind the warning of Dr. Barnes, that the atlas forms with the axis, a rotary joint, so constructed that if the head be rotated beyond a quarter of a circle the articulating surfaces will part, and the spinal cord is compressed or torn; therefore, in making rotation, be sure that the head is rotating with the body. It is well to mention here that the body is always to be kept wrapped in warm napkins until complete expulsion of the child.

EXTRACTION OF THE HEAD.

In the extraction of the head we have to distinguish, first, cases where the head has entered the pelvis, and has only to overcome the resistance of the perineum; second, cases where the head is retained at the pelvic brim by contracted pelvis, stricture of the osuteri, extension of the chin, or insufficient expulsive action of the uterus and abdominal muscles.

EXTRACTION OF THE HEAD AFTER IT HAS ENTERED THE PELVIS.

In Smellie's method, the child is wrapped in warm napkins, and placed astride the operator's arm; the index and middle fingers are passed into the vagina, and placed in the canine fossæ, to the sides

of the child's nose. By this means flexion of the head is induced. At the same time upward pressure is made with the fingers of the other hand, upon the occiput; then by raising the trunk the face is rolled out over the perineum. In case this method fails, we should use the combined method by placing two fingers in the child's mouth, and by traction upon the lower jaw flexion should be accomplished, and with the other hand traction should be made upon the shoulders, and as the head descends the body should be raised, whereby the face sweeps over the perineum. By the combined method, there is obtained the greatest amount of traction force, in combination with the least degree of violence to the child, as the power is exerted chiefly upon the shoulders. The fingers in the mouth are not likely to fracture the jaw.

When the occiput is turned into the hollow of the sacrum, forehead against the symphysis, the process just described should be reversed, as the fingers are forked over the shoulders, the back of the child should rest upon the arm, and with one or two fingers of the other hand the chin should be flexed, and traction made downward, and the forehead rotated under the symphysis.

EXTRACTION WITH THE HEAD AT THE BRIM.

Schroeder, and a considerable portion of the modern German school, employs combined traction upon the shoulders and chin for all emergencies alike, whether the head be high, or after its entrance into the pelvis; however, as the life of the child depends upon the speedy extraction of the head, it is well to become familiar with the different procedures, so that if you fail in one you can resort to the other.

The Prague method consists in seizing the feet with one hand and drawing the body of the child directly downward, the fingers of the other hand are hooked over the shoulders of the child, traction is exerted with both hands simultaneously, and, in the absence of pain, pressure should be made upon the head by an assistant, and after passing the superior strait the procedure should be as described above.

Forceps to the after-coming head has been condemned by some, and warmly approved by others; personally, I have never had any experience with them in any of these troubles, but it is recommended by some authors, in overcoming the resistance of a rigid perineum, in strongly built primiperæ; but it is chiefly indicated when both chin and occiput are arrested at the superior strait. With the chin anterior, the forceps should be applied under the back of the child, and the handles raised so as to bring the occiput into the hollow of the sacrum; with the chin to the rear, the forceps should be applied under the abdomen of the child, and draw the face of the child into the hollow of the sacrum. When the arrest of the head is due to stricture of the osuteri, the forceps will sometimes bring the head rapidly through the cervix, when traction on the feet only serves to drag the uterus to the vulva. In stricture of the cervix great care must be exercised to avoid laceration, as under no circumstances are extensive ruptures of the lower uterine segment more apt to occur than in the forcible extraction of the aftercoming head. The axis-traction forceps are particularly serviceable in these cases.

CIRCULAR LACERATION OF THE CERVIX UTERI.

HUGH CROUSE, M. D.,

VICTORIA, TEXAS.

The parous cervix nearly always shows some signs of laceration. The degree and type vary from the mere indentation to a deep tear, extending to, or into, the vaginal insertion, the type from a unilateral, bilateral, stellate to a circular separation, of the cervical tissue. In meeting the first of the two subsequent circular lacerations I am about to describe, I was totally astonished when specular examination acquainted me with the condition present. The symptoms of cervical lacerations are mainly objective, but yet, subjective indications may be present, when a post-partum hemorrhage of an extent inducing collapse exists, despite a properly retracted uterus. The treatment varies, according to the degree, from a passive inattention to the modern method of immediate repair. The friable condition of the uterine tissues, immediately after delivery, I have found difficult to retain sutures, sufficiently contracting in their efforts, to obtain a fair apposition of the parts; but yet, such an effort should be made. Literature upon the usual types, their nervous sequela and treatment, is appalling in its quantity; upon the circular form the greatest paucity exists. In fact, to such an extent is literature barren upon circular laceration, that I have hesitated to report the two cases noted. The thinrimmed os, of a slow labor, offers to the rough or hasty accoucheur the best chances for laceration, but yet the scarmarked cervix, presenting its resisting cicatricial tissue to the presenting part, and natural expelling forces, gives its quota of lacerations in the multipara. Case No. 2 is one resulting from, in my opinion, excessive scar tissue left in the closure of the wound, made in a vaginal myomectomy, done at the fourth month. Case No. 1 resulted from the

external force, backed by the proverbial ignorance of a colored midwife, who mistook a pendant cervix, after a twin delivery, in a thirty-six year old, 6 para, colored woman, where but a single placenta existed, for a second after-birth. Her chain of reasoning led her to believe that where two children were, there needs must be a dual placenta. Strenuously she strove, digging and gouging, despite, though plainly found, so the history given the attending physician and I the counsel, no second placenta could be delivered. One of my colleagues had been called, but failed to deliver. On being invited into the case, a careful examination showed an empty uterus, except for clots, instead, a peculiar ribbon of tissue united, to the extent of half an inch at both ends to the cervix (an incomplete band, as it were) presented itself. With proper light and instruments, the parts were exposed and the condition readily shown to be a circular laceration of the cervix. Ten hours had intervened since the delivery of the second child, and, as a result of the dragging, which the band had been subjected to, the parts between attached ends were black and devitalized. The band was removed by means of scissors, the edges sterilized, and antiseptic douches ordered twice a day, with good results.

Case No. 2, Mrs. F., white, age 30, 3 para, had a quick normal delivery, the three stages occupying but four hours. Rather free hemorrhage after placental delivery despite a well-contracted uterus, led to an investigation of the cervix. The posterior lip of the cervix was found to have a circular tear, involving nearly half of the circumference, the breadth of separated tissue being about one-half an inch. The part seemed well supplied with blood, hemorrhage lessening of its own accord rapidly, so a rather snug iodoform gauze packing was applied, and the nurse warned to note. carefully the flow. Twelve hours later, the gauze was removed and 1-10,000 bi-chloride douche ordered twice a day; results good. In this case, a vaginal myomectomy had been successfully performed at the fourth month. No doubt the cicatricial tissue had been caught through its excessive resistance to natural forces, and sepa