the vessels predisposing them to rupture, and, secondly, upon deficient coagulability of the blood. (6) Case reports of hemophiliacs suffering from hemorrhages of the gums, brain, joints, intestines, during labor or during menstruation are found. Most authorities state that they may occur from any organ or tissue. I have been unable to find, after brief search, a case similar to this one. Neither have I been able to find the report of a case in which a severe intraabdominal hemorrhage had occurred wherein the patient did not manifest the usual symptoms accompanying such a condition. 80 Monroe Street. TWO CASES OF PREMATURE SEPARATION OF THE PLACENTA.* LESLIE H. S. DEWITT, M. D. INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY AND ASSISTANT DEMONSTRATOR IN OBSTETRICS IN THE UNIVERSITY OF MICHIGAN. ANTEPARTUM and intrapartum hemorrhage, with the exception of that coming from lacerations of the gentital tract, is due to either partial or complete separation of the placenta from its attachment to the uterine wall. Such a complication is liable to be serious, due to the fact that the uterus containing the fetus cannot contract sufficiently to close the uterine sinuses and stop the bleeding. The complication is inevitable during labor when the placenta is abnormally implanted in the lower uterine segment, as in placenta previa, but it occasionally occurs when the placenta is normally situated in the fundus. Much diversity of opinion exists as to the etiology of the separation of a normally implanted placenta. In about one-half of the cases there is a history of traumatism. Many believe that an endometritis, either inflammatory or noninflammatory is a causative factor. During labor, separation of the placenta may be due to traction on an abnormally short cord or to the sudden diminution of pressure from the rapid expulsion of a large amount of amniotic fluid in hydramnios or to the birth of the first child in multiple pregnancy. Premature separation usually occurs during the latter months of pregnancy or during the first stage of labor. The bleeding may be one of two types, either external or concealed. Fortunately the concealed type is more rare, as in fully two-thirds of the cases the bleeding finds its way to the outside. Concealed hemorrhage. occurs when the placenta becomes loosened in the center, its margins remaining attached, giving rise to a retroplacental hematoma; also with partial or even complete detachment, if the membranes remain adherent to the uterine wall, and finally when the presenting part acts. as a tampoon to the lower uterine segment. *Read before the Clinical Society of the University of Michigan, February 7, 1912. The following cases are examples of the external type of hemorrhage: Case I-Mrs. A., married, multipara, aged thirty-eight, was admitted to the Maternity Clinic, November 9, 1911. The patient enters the hospital because of bleeding. Her family history is negative. She has always enjoyed the best of health until seven years ago when a tremor of her hands appeared, gradually increasing until it became impossible for her to feed herself. Very soon the tremor affected her arms, head, and whole body. She became incapacitated for all her usual work, could not walk unaided and had to be fed by her family. About two years ago she experienced difficulty in talking which increased to such an extent that at times she could not be understood. Puberty was established at the age of fourteen. Her periods are regular, of the twenty-eight day type, lasting three days and necessitating about two napkins. There is no pain. The leucorrheal history is negative. This pregnancy is the patient's fifth. She has two children, aged sixteen and thirteen. About ten years ago she had two miscarriages each at about the fifth month. Her recoveries were uneventful. The date of her last menstruation was March 25, 1911, and the estimated date of her probable confinement, January 1, 1912. Fetal movements were first felt August 1. There are no symptoms indicative of a toxemia. The first hemorrhage was on August 24 and lasted for three days and four to six pads were soaked daily. There was no pain. During September and October she had two similar hemorrhages. On November 5 she flowed profusely and had some pain similar to labor pains. There was some bleeding when she was admitted to the hospital on the 9th but it was not severe. Her pulse was good in spite of a moderate anemia. Vaginal examination by Doctor Peterson showed that one finger could easily be inserted into the os but no placenta could be palpated. The probable diagnosis of premature separation of a normally implanted placenta was made, and it was deemed best to follow out an expectant line of treatment. The patient was kept very quiet in bed and the bleeding ceased. A diagnosis of multiple sclerosis was returned by the Neurologic department. During the third night of her stay in the hospital the bleeding recurred and soon became profuse enough to soak a large pad in one hour. This persisted throughout the next day. It was then thought unsafe to allow the patient to go longer without emptying the uterus. Examination under ether showed the cervix sufficiently dilated to admit two fingers. A dark bloody discharge came from the vagina. The membranes were intact and the fetus was presenting by the breech. Normal dilatation according to the Harris method was then done by Doctor Peterson. After dilatation the hand was introduced through the cervix but the placenta could not be felt. After rupturing the membranes a version was performed and the child easily delivered. The placenta immediately appeared at the vulva together with many old clots. About two-thirds of the placenta was infarcted and had no attachment. The child weighed four pounds and was a premature infant of about seven months. When the patient was returned to her room the pulse was 150 and she was badly shocked. She was given hypodermoclysis and strychnin and reacted so well that within an hour her pulse was down to 86. Four hours after the operation the patient cried out that she could not get her breath and wanted to be fanned. Her pulse was very weak and rapid and was soon lost at the radial. The respiration became shallow and developed into typical air-hunger. Her lips, nose, and hands became cyanotic. All treatment, including inhalations of oxygen was ineffective and she expired thirty minutes from the onset of the attack. The clinical picture was one of pulmonary embolism, which was undoubtedly the cause of her sudden death. The husband refused a necropsy. The pathologic diagnosis of the placenta was extreme infraction thrombosis, excessive sclerosis, and areas of inflammation. The condition may be explained by a primary syphilis with secondary pyogenic infection. Case II.-Mrs. B., aged thirty-eight, married, multipara, was admitted to the Gynecologic service January 6, 1912. Her family and personal history are negative. Menstruation began at the age of fourteen. Menses are regular, of the twnty-eight day type, and of three days duration, using about six napkins. She has no pain. The leucorrheal history is negative. She was married at the age of twenty and has had five children, four of whom are living, one dying in infancy. The last labor, two years ago, was instrumental. Her puerperia were uncomplicated. The patient enters the hospital because of bleeding. The date of her last menstruation was September 9, 1911; it was normal in every way, lasting five days. Beginning October 9, 1911, she flowed scantily over two days. The estimated date of her probable confinement is June 16, 1912. Throughout October she had severe morning sickness. During the night of December 26, 1911, she was awakened because of severe bleeding. The blood was bright red but she had no pain. The bleeding continued to be profuse, necessitating six or eight napkins daily and she was confined to her bed because of weakness. From the outset of the bleeding she noticed her abdomen grew larger. The patient when admitted was bleeding profusely. Hemoglobin was eighty per cent with Miescher's apparatus. Examination of the breasts showed colostrum to be present with moderate darking of the areola. Montgomery's follicles were prominent. Abdominal examination showed a swelling from the pubes to the umbilicus. Upon palpation the mass is smooth, hard, and very tender. It rises upward to within one finger's breadth of the umbilicus. Vaginal examination shows no blueness of the anterior vaginal wall. The cervix is softened and extensively lacerated. A diagnosis of pregnancy with a probable premature separation of the placenta was made. It was thought unsafe to allow the pregnancy to continue. The cervical canal and vagina were packed with gauze as a means of inducing labor. The method was unsuccessful and vaginal Cesarean section was decided upon which was performed January 9, 1912. A fetus, eighteen centimetres in length was removed. The uterine cavity was filled with many large old blood clots and the placenta was partially separated from its attachment to the anterior wall of the fundus. The patient made an uninterrupted recovery. TRANSACTIONS. CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.. THE PRESIDENT, ALBION WALTER HEWLETT, M. D., IN THE CHAIR. READING OF PAPERS PANTOPON IN THE PAINS OF LABOR. DOCTOR WILLIAM H. MORLEY, of Detroit, read a paper on this subject. (See page 104.) DISCUSSION. DOCTOR HOWARD H. CUMMINGS: I am sure we all appreciate Doctor Morley's interesting paper. We have had no experience here in using pantopon in obstetrics, but the results related tonight would surely justify its use in a series of cases. For years workers in obstetrics have been trying various means to lessen or remove the pain of child-bearing. Hypnotism, autosuggestion and general anesthetics as ether and chloroform, have been tried. Morphin alone and in combination with hyocin and scopolamin has been tried, but serious drawbacks have been discovered. Infiltration about the pudic nerve with cocain solution just before the head emerged from the vulva controlled pain but idiosyncracies made this procedure dangerous. The injection of novocain for spinal anesthesia has been tried but it was found to be dangerous. Pantopon, an opium derivative, having the therapeutic properties of morphin but lacking all the disagreeable properties, should be an ideal drug for obstetric work. Probably one of the most important uses of morphin in obstetrics. has been its use in cases of uterine inertia. A rest of a few hours seems to modify the labor pains so that they become stronger and accomplish their aim. Whenever morphin is used in this way it has been noticed that there is difficulty in resuscitating the child. This objection might hold for pantopon, in fact Doctor Morley, in his review of the literature, mentioned the inability of an obstetrician to resuscitate a child and in another case the fetal pulse fell to a rate of less than 100 beats and the labor was terminated with forceps. He also mentioned a case of fatal cerebral hemorrhage in a child. Of course, there are several things that may produce a cerebral hemorrhage in the newly-born and as far as I know, morphin has never been found to cause hemorrhage but observers are coming to believe that the careless use of chloroform in obstetrics does produce a chloroform poisoning in the child and fatal cerebral hemorrhage. In regard to Doctor Morley's work with pantopon, it would seem that a series of cases upon multiparous women would give a better idea as to the effect of the drug. There is a large individual equation in the pain of labor; one will see small women bear large children without showing a sign of pain, while others can be heard for blocks. DOCTOR CONRAD GEORG, JR.: It is interesting to note how Sahli was led to investigate the action of pantopon. He was looking for a preparation that could be injected hypodermically and still have all the good, effects of morphin and the other alkaloids present in opium. He first considered the watery extract of opium and found this to contain a lot of inert substances insoluble or slightly soluble and therefore it could not be used. Then he considered the tincture of opium and found that it contained so much alcohol that it was too irritating to use hypodermically. Then he hit upon this preparation of pantopon because he compared it with the digitalis group. For instance, in digitalis there is a preparation that contains an extract or is supposed to contain an extract of most of the alkaloids of the digitalis series but it was found that it was not as strong as digitopurin. He prepared pantopon by working along these lines. In the use of morphin we have a drug which is always certain in its effect. That it acts somewhat different in different individuals is supposed to be due to a fluctuation in the amount of drug present. In pantopon we have a preparation that contains all the alkaloids of the opium series, together with morphin. We know that these alkaloids are numerous, morphin making up about ten-twelfths per cent of opium and the other alkaloids about eighteen per cent. This series of alkaloids was formerly divided between the morphin and the codein groups, the morphin group being supposed to have the norcotizing effect and the other supposed to stimulate somewhat. This was tried out upon animals and although it was proved to be true experimentally, on human beings it has not always proved so in actual practice. Codein has been used wherever one wishes to get the effect of morphin without the nausea. After preparing pantopon it was found that it could be used where morphin was indicated and still not have the bad effects of morphin, for instance, in the postoperative treatment of laparotomy cases and in obstetrics. It occurred to me that we might use it in primiparæ where the cervix fails to dilate, the patient being in labor for hours and still presenting a rigid condition of the muscles. The injection of morphin at such a time by giving the patient a rest, will frequently bring about dilatation; there will be a short sleep and after that the pains will have more of a dilating character. It seems to me that when the propulsive pains come before dilatation pantopon would be good, for it has a sedative action without any of the bad after effects. In internal medicine there are numerous conditions that have not been mentioned: diarrhea can be cured by its use without |