The pains were regular and persistent and bearing down in character, although the patient complained that the pains were "doing no good." At the expiration of the seventh hour I again examined and detected the membranes presenting at the mouth of the uterus, but the os was yet undilated. Pains hard, continuous and bearing down. From this time the membranes continued to descend, and a tumor, external to the os, was gradually formed. At short intervals I examined the os, and found it externally, dilated, soft and patulous, yet upon my finger reaching the internal portion, I found it undilated and the edges sharp and resisting. Immediately outside the internal edge of the cervical canal the membranes expanded and a pyriform tumor formed, the apex of which reached the internal os, the base gradually extending toward the vagina. As yet there was nothing calculated to create any uneasiness, as there was no hemorrhage, and the pains were frequent and disposed to bear down.

I continued making examinations at short intervals; found the intra-vaginal tumor increasing, but no more dilatation of the internal os. The tumor, soon filled the vagina and protruded between the labia. I had been careful to preserve it, supposing that it would assist in the dilatation, although as yet I had not been able to pass my finger within the os uteri, consequently could not tell anything in regard to the presentation. I had no reason to doubt but the tumor was the ordinary bag of water and contained nothing but amniotic fluid. I informed the patient that the water would soon be discharged, and that then her pains would become more efficient.

At 3 A. M., nine hours after the beginning of labor, and during a severe pain, the sac ruptured and a large amount of fluid was discharged. I waited a few moments, the fluid being rapidly poured out. The patient remarked that there must be a "great deal of water," and that it was "still passing very fast;" I was struck with the pallid face of my patient, and putting my hand under the covering I was astonished to find a large mass of clotted blood in front of the pudenda, and that at every contraction of the uterus it was still being poured out. I immediately forced my hand into the vagina and found it filled with soft clots of blood, which I removed, and running along the membranes up to the neck of the uterus I found the blood pouring through the internal os,

which was but very little dilated. I at once forcibly introduced the tip of the index finger and began dilating the opening. In a few moments I introduced the second finger and detected the edge of the placenta loosely lying over the internal os. I introduced my fingers between the placenta and uterus and separating them back as far as I could reach, the hemorrhage now ceased, uterine contractions became vigorous and I awaited development, not yet being able to diagnose the presentation. After a few sharp pains I examined and detected the side of the thorax presenting. I immediately comprehended the gravity of the situation and informed patient and friends, and decided that version was the only alternative. As it was 2 A. M., and the patient reduced very much, I determined to anesthetize her and deliver without waiting to send for additional aid. After giving her a full drink of brandy I administered chloroform to anesthesia, when the friends and nurses all deserted me and I was compelled to desist before introducing my hand into the uterus, as the moment the anesthetic was withheld, violent contractions of the uterus ensued. I made a second attempt, the husband of the patient promising to stand by with the anesthetic. After partly dilating the mouth of the uterus I was again deserted and the anesthetic withdrawn.

In vigorous language I denounced their cowardice, and ordered another physician called. After waiting an hour, Dr. J. H. Bigger made his appearance, and coincided with my views of the case and its demands. He took charge of the anesthetic, and in a few minutes, for the third time, I dilated the os, and introduced my hand into the uterus. Seizing the feet of the child, it was delivered in a short time, and was dead. The placenta was not delivered promptly, and I again was compelled to introduce my hand into the uterus. The placenta was detached and delivered, patient rallied promptly and had a good getting up, and has done well ever since. Upon examining the placenta we found that the edge which presented at the os had been previously detached and that the former uterine surface for an inch back toward the center had cicatrized, and a surface four and one-half inches wide had been recently attached to the uterus, and about the center of this surface a rent in the placenta large enough to admit two fingers was found,

and furnished conclusive evidence of having been the point from which the blood had emerged into the anmiotic sac.

Let us notice a few points of interest:

1. The condition of the detached edge of the placenta. This had evidently been detached some time previous to the time of labor, as the detached surface had firmly cicatrized, and was in a sclerotic condition. That this had taken place the month before, at the time of the severe hemorrhage, I have no doubt, and as repair of both the surface of the placenta and of the uterus had occurred, no hemorrhage at the beginning of labor was encountered.

2. The remaining utero-placental attachments were abnormally firm, whether from the effects of the efforts at repair of the former injury, or from some other cause, I am unable to answer.

3. The laceration and detachment of the placenta at its middle, while the edges were firmly attached, is an interesting point, and I account for it by the fact that the presentation was a transverse one, and that the vigorous uterine contractions, acting upon the irregular shaped transverse mass, with an abnormally adhesive placenta, had evidently ruptured the utero-placental attachments immediately over a large uterine sinus, and the placenta being thus loosened, an accumulation of blood would take place between the sinus and placenta, and a severe contraction of the uterus would produce increased pressure upon that portion of the detached placenta, and rupture occurred, and the blood poured from the open sinus directly into the sack containing the fetus. The only possible way to arrest it was to detach that part of the placenta between the lacerated portion of the os uteri. This being done, the uterus could uniformly contract and close the bleeding vessels.

4. The persistently contracted condition of the os uteri was owing to (a) the irregular shape of the uterine contents, the transverse position of the child not allowing contraction to occur uniformly, and instead of the ordinary relaxation of the muscular fibers of the internal os, a tonic contraction resulted from disturbed normal clonic contractility; (b) the unyielding adhesion of the utero-placental surfaces prevented the transmission of the effect of the contractions of the fundus of the uterus to the cervix, and the circular fibers around the cervix were unaffected by the contractions of the base of the uterus.

5. I desire to call attention to the fact that there was no external hemorrhage until after the rupture of the membranes. This is a very unusual occurrence, and I fail to remember of ever having seen it mentioned. It could only occur as suggested above. It certainly seems strange that so many factors entered into this particular case. As far as my reading has extended I believe the case is a unique one.