as though another breath were impossible. The pulse became almost impalpable.

My condition was critical for an hour, when it was relieved by a hypodermic of morphine, atropin and nitroglycerine, and within five or six hours it cleared up so that I was fairly comfortable. The most distressing symptom to contend with afterward was the agonizing itching due to a general uticaria, which would not yield to any form of local treatment. This lasted almost continuously for about two days and three nights and then only occasionally short attacks for a period of seven or eight days.

The writer wishes to state his peculiar idiosyncrasy to the odor of horses. It is impossible for him to work in or about a stable without suffering from slight asthma and sneezing. Even riding behind a horse, especially during the shedding season, the same condition is produced.

On looking over reports of similar cases, the writer found almost a parallel one in the Medical Record, October, 1909, of a young physician in Germany who possessed a similar idiosyncrasy to the smell of horses, and on account of which he nearly collapsed after an injection of an immunizing dose of 1000 units of anti-toxin. Furthermore, investigation of the reports of these cases shows that persons affected with hay fever, cardiac or renal asthma, or any form of respiratory embarrassment, are in danger after using any form of horse

serum.

Dr. Herbert F. Gillette, of New York, who reported several cases in the American Medical Association Journal, says that collapse or death is accompanied by a respiratory crisis, and when death occurs it usually takes place in less than ten minutes from the time of the injection. He also states that the administration of any variety of horse serum is liable to cause collapse or death if the subject suffers from respiratory distress, and it is not due to any toxin or anti-toxin, or any errors on the part of the makers of the serum, or to the age of the serum, but is due to some highly organized proteid which is present in the serum, and it is the reaction of the proteid which causes the crisis.

This reaction takes place only in certain cases, as mentioned in the foregoing report.

ANTE AND POST PARTUM HEMORRHAGE.

BY DR. W. J. DAVIS, WILKES-Barre, Pa.

READ OCTOBER 26, 1910.

The subject that I bring for your consideration this evening is of special interest to the majority of physicians, but especially to the general practitioner, for he is the one called upon to do this kind of work.

The subject is a large one and it may have seemed to some that I had taken several chapters out of some text book, when you received your notice. A comparison of the causes, symptoms and treatment led me to bring this, as a whole, for the two forms of hemorrhage may occur in the same patient. The cause and method of treatment are similar and adapted in both forms of hemorrhage, except in the anemic, tuberculous, or some blood dyscrasia. The woman of the child-bearing period who ceases to menstruate is supposed to be pregnant. It is the first thing she notices, but there are certain pathological conditions of the internal genital tract that may bring on menstruation, or what is supposed to be menstruation, after conception.

There are a few cases on record of where women have menstruated regularly during the whole course of pregnancy, but these are extremely rare. Cases of one or two menstrual periods after conception have come under the notice of most of us. The ovum does not fill the cavity of the uterus until after the third month, and the hemorrhage may come from the lower part of the uterus. It is possible that this occasional loss of blood comes from an erosion of the cervix or a small polapus and also from placenta previa. A hemorrhagic discharge coming on after the absence of one or more periods may be a valuable sign of extra uterine pregnancy or abortion.

If the discharge really does appear periodically after the third month, it can only come from the cervical canal. According to our present understanding of the pregnant uterus it consists of three parts which are distinct, both anatomically and physiologically. The upper section or body is divided into

two sections, the cervix forms the third part. Its properties in the upper part are contractility and retractility. That of the lower segment dilatability. These explain the entire mechan

ism.

The physiological function of the cervix is active only during labor. The normal arrest of the ovum is a little below the tubes and the attachment of the placenta to the side of the uterus in the majority of cases. The fundal implant is rare. The area of attachment in early pregnancy is small and the development of the placenta will conform to the growth of that part of the uterus to which it is attached. In the upper section the uterus becomes thicker and ready for its action of contractibility, below it becomes thinner and expands.

This explains why in placenta previa we have hemorrhage -the placenta is in an abnormal location.

There are certain pathologic conditions that predispose to ante and post partum hemorrhage. Some of these causes will operate in both conditions. A woman may have an ante partum hemorrhage in placenta previa or accidental hemorrhage, and the same cause may bring on a post partum hemorrhage.

The multipara are more likely than the primipara to have hemorrhage as a complication. She may have a diseased mucosa an endometritis, a version or flexion, or such condition as abortion or early rising, causing subinvolution; these may predispose to ante and post partum hemorrhage. Placenta previae is said to be more common in the poorer class, because they have to get around to work too soon.

The placenta is said to be previae when it is attached to the lower portion of the uterine segment. There are three varieties central when the placenta covers the os after dilation; placenta partiales when it partially covers the os after dilation and placenta previa lateralis or marginlis where the placenta does not reach beyond the margin of the os after dilation. This is the most common form.

This condition is found more frequently in multipara than primapara, the proportion being 6-1; it occurs about once five hundred cases, of which we have knowledge. I believe it true that many cases of early abortion may have

been placenta previa. The hemorrhage from these cases is sometimes profuse. The low implantation of the placenta renders it more liable to detachment from mechanical causes, as shocks, jars, etc., than when normally situated. The placenta is larger and thinner, more unevenly developed, being thick above and thin below. The upper part is more firmly attached, while the lower is very slender. The first symptom to attract our attention to this condition is hemorrhage which may occur without any warning and varies from a few drops to such an amount to put our patient in a serious condition of anemia ; these hemorrhages are usually slight at first, but keep increasing in amount, or if it should not show till at or near full term, it may be tremendous and place the patient's life in danger.

It may be safely accepted as an axiom that once hemorrhage has occurred the patient is never safe, for excessive loss of blood may occur at any time without warning and no assistance at hand.

If it occurs before term, it often happens premature labor comes on after one or more hemorrhages; the hemorrhage occurs at any time of pregnancy from the beginning of the third month to delivery, being most frequent in the last month of pregnancy. The more nearly central the attachment of the placenta, the earlier the occurrence of the hemorrhage; there is usually no show of blood in the marginal variety until the beginning of labor. It is now generally admitted that the source of hemorrhage is from the lacerated utero placental vessels; each contraction of the uterus causes fresh portions of the placenta to separate. In a certain way contractions do favor hemorrhage by detaching fresh placental tissue, but the actual loss of blood comes from the uterus during the interval of contractions.

In the treatment of placenta previa I find, in looking over the literature, that the profession is not of one mind on this subject; they are all of one opinion as to what should be done, but there is some difference of opinion in the application of

treatment.

The greatest difference of opinion seems to be in regard to

Cesarean section for this condition; some maintain it has no place in placenta previa; others that it may have in a small number of selected cases, as in a small pelvis or an extremely rigid os and the desire of the mother for a living child; on the other hand the opinion of the majority is that it should be treated in an obstetric way.

Treatment: Whenever in the latter months of pregnancy a sudden hemorrhage occurs the possibility of placenta previa will suggest itself. By a careful vaginal examination this condition may be readily ascertained, for the os is usually sufficiently dilated so as to satisfy us. The first question arises and is justified in temporary using means to check hemorrhage as we would in threatened abortion and allowing pregnancy to continue. This is a debated question and I will leave it for you in the discussion. I believe the opinion is that no attempt should be made to prevent the termination of pregnancy, but that our treatment should rather contemplate its conclusion as soon as possible.

If the hemorrhage is not profuse and the cervix dilated or dilatable, we may rupture the membrane and allow the presenting parts to descend, this causing enough compression to control the hemorrhage; should the hemorrhage continue the child should be extracted with the forceps or version.

If the os is rigid and the cervix not easy to penetrate, a cervical and vaginal gauze tamponade is the most efficient means at our command. This gauze will arrest bleeding and will assist in the induction of labor as soon as the cervix is dilated; if the hemorrhage is severe, then rupture the membranes and do version either Braxton Hick method or podalic.

In case the placenta is centrally implanted the physician should bore his hand right through it and then perform version; a leg brought down is a very efficient means at our command for controlling the hemorrhage, and gentle traction on a leg is one of the best dilators possible to have.

Another form of hemorrhage that may occur during pregnancy or labor is what is called accidental hemorrhage. Holmes thinks the name ablatio placenta is a better name for this condition. The separation may be partial or complete, the former