tural exhibit; the Plaza Santa Cruz; a demonstration of educational progress, including a Philippine school in active operation; a replica of the capitol building of the. Philippines; an exhibit of the tropical hard woods; an ethnology exhibit; a fisheries exhibit; an exhibit of mineral wealth, and groups of men and women selected from various tribes, including Negritos, Igorrotes, Moros, and others, all with their native surroundings. Besides these, many other items of interest that are too numerous and varied to justify mention in this brief article, are offered for the instruction and entertainment of visitors. All Americans interested in the progress making by our country in developing and improving its insular possessions should visit this marvelous collection of people and material.

Two commodious restaurants offer food and drink to the visiting public at reasonable rates; seats are scattered throughout the grounds, the use of the toilet rooms is free, cool, filtered drinking water is offered gratuitously, the Constabulary Band of eighty pieces gives a free concert twice daily, and no pains or expense have been spared to make the stay of the visitor to the Philippine Exposition interesting, pleasant and profitable.

THE Doctors' Chronological Lactopeptine Calendar is the name given to a new almanac issued by the New York Pharmacal Association, Yonkers.

BATTLE & COMPANY, of Saint Louis, have issued pamphlets one and two, of the series of twelve illustrations of intestinal parasites, these relating to the tenia saginata.

THE WORLD'S FAIR CATALOGUE.-The official catalogue of the exhibits of the Saint Louis Exposition reveals the tremendous scope and wonderful industrial development of the world as illustrated therein. In the first edition, which is sent by mail postpaid to any address on receipt of $5.33 by the publishers, more than 60,000 exhibitors are listed. In the full catalogue, which will contain in addition the exhibits of the Philippines and live stock, the exhibitors will reach 150,000. The first edition can be had by addressing The Official Catalogue, World's Fair, Saint Louis.

FOR

'OR SALE—A six-plate static battery in perfect order, with electric motor. Price, $250.00. This is an unusual bargain. Apply to Mrs. J. A. Reed, No. 1 North Pearl street, Buffalo, N. Y.

T IS difficult to formulate an exact definition of postpartum hemorrhage. A definition may comprehend too much or exclude too much to be acceptable to the majority of physicians. A hemorrhage occurring immediately after the termination of labor and sufficiently large to endanger the life of the mother is regarded by all accoucheurs as pathologic and is appropriately termed a postpartum hemorrhage. A small amount of hemorrhage from the placental site, insufficient to sensibly disturb the normal circulation may be properly regarded as physiologic and cannot be appropriately placed among postpartum hemorrhages. Between these two extremes occur hemorrhages of varying quantities about which there may be an honest difference of opinion as to their proper classification. Each medical attendant claims the right to determine whether any particular case of hemorrhage may be termed postpartum.

Cases of hemorrhage which produce a marked disturbance of the circulation and a sense of weakness on the part of the patient are regarded by the writer as cases of postpartum hemorrhage. The term flooding applied to these cases is expressive and readily understood.

The scope of this paper is to deal only with those hemorrhages which proceed from the internal surface of the uterus and especially from the placental site.

1. Presidential address delivered at the annual meeting of the Buffalo Academy of Medicine, June 14, 1904.

GRAVITY.

The extreme gravity of postpartum hemorrhage is recognised by every obstetrician who has witnessed such a condition. Standing at the bedside where the long expected advent of the newcomer has brought joy to the parents and friends he hears a gurgle as of a rush of water; his hand upon the uterus detects no contraction of that organ; the mother's face is blanched and expressive of anxiety; her pulse is weak and rapidly becomes fluttering; respiration is labored and soon there is gasping for breath; the patient calls for air and says she is cold and dying; windows and doors are thrown open; fans are brought into requisition; ammonia is applied to the nostrils; there is a general excitement among the attendants; as the patient sinks lower and lower a distant sob is heard here and there in the room, the outburst of pent up feelings of relative or friend; the appeals to the medical attendant to save the patient are heart-rending; on investigation he finds the bed almost literally filled with large masses of coagulated blood.

This picture drawn from nature is truly appalling. The contrast between present grief and the joy of a few minutes ago is overwhelming to the stoutest hearts. No wonder that the physician's countenance is white with fear, his throat dry and his heart beats violently with the heavy load of responsibility which he bears. This subject is important, not only to the expert obstetrician, but also to the general practitioner. Any day or any hour any physician may be summoned to an obstetrical case in which postpartum hemorrhage will jeopardise the life of the mother. At such a time energetic promptness, a resourceful mind and a skilful hand are in instant demand.

CLASSIFICATION.

All kinds of puerperal hemorrhage after the delivery of the child may be divided into two classes-namely, primary and secondary. A hemorrhage which occurs immediately after delivery and is stopped for 24 hours by a contraction of the uterus may be termed appropriately a primary hemorrhage; puerperal hemorrhages which take place after that lapse of time may be regarded as secondary. This classification is arbitrary but perhaps is as useful as any that can be made. Postpartum hemorrhage also may be divided into internal and external, according as the blood remains within the uterine cavity or is expelled from it.

FREQUENCY.

The frequency of postpartum hemorrhage is not easily determined. This difficulty arises mainly because many births are not

reported and deaths from this kind of hemorrhage frequently are reported as due to some other cause. Hence, the unreported births and the wrongly reported deaths are not available as a basis for accuracy in determining the frequency of postpartum hemorrhage. It is generally conceded that this kind of hemorrhage is of rare occurrence in cases of confinement. According to Herman, Guy's Hospital reports present but 1 dangerous case in 2,040 labors and the report of Saint Thomas's Hospital, 1 in 2,172. Hegar reports for Prussia, 1 case in 3,131 labors. It is the opinion of Studer, of Basel, that severe hemorrhage after birth occurs in 5 per cent. of all puerperal cases. Dr. C. S. Bacon, of Chicago, taking the ratio of Studer as a basis and using 60,000 as the annual birth-rate, finds that 3,000 cases of postpartum hemorrhage occur in that city yearly. These figures seem to the writer to be greatly exaggerated.

DEATH RATE.

According to Bacon, of Chicago, heretofore quoted, the number of puerperal deaths in that city annually is 300. He estimates that of this number, 30 were the result of postpartum hemorrhage. This ratio would give 1 death in every 100 cases of postpartum hemorrhage. Some authors give 1 death in every Dr. Thomas More Madden declares that, after an obstetric practice of twenty years in various countries and in the largest lying-in hospital of Great Britain, he has seen only one death from hemorrhage after childbirth. Even these figures, though not large, emphasize the importance of a more rigid vigilance in prophylaxis and intelligent skill in treatment.

300 cases.

CAUSES.

These are many and various. A full recital of them will not be attempted in this paper. They may be classified under the following heads: uterine atony; mechanical obstruction; meddlesome midwifery; systemic derangement, and traumatism. Whatever interferes with or prevents a closure of the bleeding vessels may be a cause of postpartum hemorrhage. The interference may be so slight that the bleeding cannot be termed appropriately postpartum hemorrhage. The closure of the ruptured vessels is dependent upon contraction of the uterine musculature. Any systemic condition which wholly or in part prevents this contraction is a factor in the production of postpartum hemorrhage.

Uterine atony. By far the most common cause which prevents uterine contraction is uterine atony. Uterine atony is a result of any one of various causes. There may exist debility of

the general system which weakens the uterine muscle; the uterus may lack proper innervation as a result of frequently recurring pregnancies; a tedious labor from any cause may exhaust the uterus to such an extent that it loses the power to contract, as seen in cases which offer any mechanical obstruction to the delivery of the child, and in cases in which the presence of an excessive amount of amniotic fluid produces infrequent and inefficient pains. Local atony may be the effect of paralysis of the placental site.

Mechanical obstruction.-A retained placenta or clots obstructing the os uteri; morbid adhesion of placenta; tumors, whether within or without the uterus, as polypi or fibroids; distension of either bladder or rectum; plural births in which there is a long interval between the deliveries, all these conditions and others

are factors in the prevention of effective uterine contraction.

Meddlesome midwifery.-After watching many weary hours at the parturient bedside the obstetrician desires as quick a release as possible from his tiresome task. The uterus is in a state of atony from a long service of hard work. It demands a rest; it is in no haste to complete the third stage of labor; it fails to contract with force sufficient to separate the placenta from its site. The impatient accoucheur, anxious to assist nature, pulls and tugs upon the cord, kneads the uterus, mayhap introduces his hand into the uterine cavity and tears the placenta from the uterine wall; he feels a sudden gush of warm fluid; to his dismay he has on his hands a genuine case of postpartum hemorrhage. He realises that he has contravened the course of nature. This is apt to be the experience of the young obstetrician who has seldom sat by the obstetrical bed, rather than of the older obstetrician who has superintended hundreds and possibly thousands of cases.

Nature should be allowed to express the placenta in all cases in which she is equal to the task. Two or three hours may elapse before the contractible powers of the uterus have regained force sufficient to throw off the placenta. For the careful obstetrician this is a time of waiting and watching. Nature rarely needs. assistance in this work; if she is unequal to its accomplishment, then is the accoucheur's golden opportunity to lend her a helping hand.

Systemic derangement.-Pregnancy invites an extraordinary quantity of blood to the generative organs and this accumulation of blood predisposes to puerperal hemorrhage. While this process is necessary and physiologic it may become detrimental, an instance of a physiologic process leading towards a morbific end.