morning. During the acute stages the routine treatment is direct applications of 2 per cent nitrate of silver solution to the lids, made with a swab and followed immediately with a normal saline douche.

Complicated cases presenting ulcers, hyperaemia and beginning pannus have in addition, atropin instillations, the patient using hot applications at home.

In the sub-acute stage, the granules are expressed, the silver applications stopped and the copper stick substituted, shortly to be followed by a course of the alum stick treatment. The patient receives a 10 per cent copper citrate ointment for home use, the instruction being that it should be rubbed well into the lids for two minutes. Those cases requiring expression are held over for a convenient time, being treated as follows:

After the usual boiling of the instruments, washing skin of lids and adjacent parts with soap and water, then irrigating the conjunctiva with 1:5000 bichloride solution, an injection of 1 per cent cocain muriate solution of sufficient quantity to bulge out the upper fold, is made beneath the conjunctiva. This brings to plain view all granules and the operator, generally protected by a pair of goggles, uses a Graefe or other fine knife to open the individual "points," this being done by a motion as if scarifying a surface. Kuhnts' Expressor may now be used without pain, as the expression may proceed at once after the injection. The roller forceps has been argued against as productive of too much trauma, so promoting scar tissue.

Examination of the Lacrymal Apparatus before Cataract Extractions: Pressure with the index finger is made upon the lacrymal sac; if no secretion is demonstrable, the case goes to operation. Assuming conjunctiva and externa has normal appearance. Should there be doubt of the patency of the canaliculus a syringing is resorted to. In general the probe is condemned, as all have seen the lengthy infections, from injury to the walls of the canal even by gentle manipulation of Bowman's probe. Those cases having infection are treated by sac extirpation and the conjunctival secretion examined bacteriologically 3 to 6 times during

the following two weeks. As to acute Dacryocystitis as incision into the sac is refrained from unless perforation is imminent. Hot fomentations being preferred, any sac showing chronic bleuorrhea is promptly excited.

The indications for excision are:

1. All clinic patients where a lengthy treatment seems necessary.

2. Cases having sac infection on same side as contemplated cataract extraction or any intra ocular operation.

3. Old corneal ulcers with corresponding sac infection.

4. Chronic sac blenorrhea.

Lengthy treatments are painful and tedious for patient and physician. I have there seen only one case of pan ophthalmitis following lens extraction, directly traceable to sac infection. This of possibly 150 cases.

The Lacrymal sac operation: As this is described at length in Meller's "Opthalmic Surgery," I only briefly mention it. He is very particular to have the incision begin 2 mm. above and 3 mm. to the inner side of the internal canthus; then the incision should correspond to the anterior crest of the Fossa Lacrymalis. The incision should be a delicate one, as he lays great stress upon seeing the layers, of superficial fascia and orbicularis muscle separating this, then exposing the deep fascia, the latter to be slit open with scissors 2 mm. behind the anterior crest. Stress is laid upon holding only the fascia with the forceps; at this stage the sac is freed from its. bed of fascia, by means of the closed scissors, this should be done laterally both sides, then the head of the sac is to be freed, canaliculus severed and finally the sac itself is handled for the first time, in cutting it off low down at the bony canal. I wish to remark that although a lengthy procedure, it is a highly satisfactory one, when once its technique is mastered. Performed under local anaesthesia, cocain 1 per cent. adrenalin a few drops; total quantity only 1 cc.

I have repeatedly seen a painless operation performed.

Glaucoma:

It appears that this affection is far more prevalent abroad than in our country. Again, for the number of cases one sees there, and the vast out patient department, it

is surprising there are not more brought to light. Iridectomy remains the favorite procedure after a course of Eserin treatment. Of late, especially in those cases showing a very shallow anterior chamber, the operation of cyclodialysis has given some surprisingly good results. This they perform as follows: After cocainizing, washing and irrigating with 1:5000 bichloride solution, the patient looks up and in, the conjunctiva is dissected away in the outer lower quadrant 5 mm. back of the limbus. Now with a lancet the sclera is nicked through at exactly this distance behind the limbus, so avoiding the cilliary body; the scleral wound is 2 mm. long and parallel to the limbus. A spatula is introduced into the supra-chloroidal space and made to come out exactly in the angle of the anterior chamber; by swinging the spatula right and left the chil liary body is detached, the spatula is gently withdrawn, and the conjunctiva sutured. The spatula may, however, glide behind Descemet's membrane into the corneal substance if pressed too close along the sclera. This condition obtains when the end of the spatula is not freely movable in the anterior chamber.

The opacities resulting from this usually clear up, even if Descemet's membrane is

rolled back.

The results occur gradually. A minus three tension may occur.. The only symptom of glaucoma remaining is the dilated pupil with slight reaction to light. 40 per cent of cases are followed by temporary reduction of T. 30 per cent no reduction. 30 per cent permanent reduction.

The first class of cases certainly furnish the opportunity of performing iridectomy if signs of increased tension appear. So at the Fuchs Clinic, it is contended that, not being a harmful procedure if correctly performed, it has much in its favor. A lengthy Eserin treatment as formerly used in Glaucoma is abandoned.

Another procedure which they do not hesitate to use for the relief of increased intraocular tension is transfixion. In cases of seclusio pupillae, where "Iris Bombe" is present, a slender Graefe knife is entered just in front of the limbus at the outer side in the horizontal meridian. This passes through cor

nea the two thicknesses of the Iris bulge, to appear in front of the secluded pupil, re-entered into the Iris bulge of the opposite side, comes out of the other side of the cornea at a corresponding point, and gently withdrawn. The operation is simple and effective. In a small per centage of cases iritis with plastic exudate defeats its purpose, but in general the iris apertures remain open. with immediate good results.

I wish to mention a treatment used in a case of Keratitis Parenchymatosa. A strong well nourished girl of 15 had, two years previous, an eye trouble with which, though under treatment of eminent oculists, eventually resulted in total opacity of both cornea. The color was about like cartilage, no specific or other history obtainable. Examination showed O. D. V. & O. S. V. has fallen to light perception and projection. Externa conjunctiva and selera normal. Entire cornea opaque, of slightly darker color than the sclera. No vessel formation, no iris structure visible. Diagnosis: Parenchymatous Keratitis. Treatment was begun with intra muscular injection of atoxyl 10 per cent sol. in doses of O. 5 gm. being administered on alternate days increasing the dose to 1 gm. this dose being continued. Hot air applications were used daily followed by Dionin, after two weeks, slight vessel formation was seen extending from the outer corneal limbus of the right eye, a few days later this condition was present on the other eye. At the end of a month iris structure could be seen under illumination. The patient then recognizing smaller articles held 12 inches before the eyes. She could see quite well to get about, in comparison with the condition at the inception of treatment. When last I heard of the case she had regained vision to 6/36 O. D. & O. S.

The appearance of the cornea after one month's treatment was very velvety, soggy and highly opalescent, a few small blebs were no ticed; just as in degenerative changes, these disappeared after a few days, and new ones would appear. Nothing had been claimed for the method, beyond one or two cases had shown results which could not be said for the previously instituted regulation treatment, in the earlier cases as well as in the one I observ

ed, of course the atoxyl is used not only against the specific, but the obstinate specific nature of the disease. I do not know of a report issued by this eye clinic on the subject.

TREATMENT OF PLACENTA PRAEVIA.*

By HENRY SCHWARZ, M. D.,
St. Louis.

Professor of Obstetrics and Gynecology, Washington
University.

In February of the present year I read before the Alumni Association of the Washing

tampon of sterile cotton, or preferably of ster ile gauze, will with certainty and with safety control hemorrhage and provoke uterine contractions until dilatation is complete, when the case may be delivered by version and extraction.

I pointed out, that the tampon-method is the only one which does not destroy the entire ty of the ovum and which does not interfere with the natural mechanism of the first stage of labor. I insisted that students must be taught the method of packing cervix and va

Mechanisms and Treatment of Placenta Praevia."

On that occasion I denounced as foolish, if not criminal, all suggestions of abdominal or vaginal Cesarean Section as a means of treating any form of Placenta Praevia. I likewise denounced version after Brax.on-Hicks, because it deliberately sacrifices the child, and because it increases the chances for infection and because it interferes with the natural detachment of the placenta. I spoke against all attempts of forcing dilatation with steel-dila tors or other means, and advised also against the intra-uterine balloon-treatment, because it also requires a perforation of the placenta, thereby interfering with the natural detachment of that organ and increasing the chances for infection.

I pointed out, that the majority of cases of Placenta Praevia fall into the hands of the

general practitioner, and that it is the plain duty of teachers of obstetrics to teach and to practice methods which can be employed by the general practitioner in the home of the patient.

I pointed out, that in many instances dilatation is complete, or nearly so, when the phy sician reaches the patient; that under such circumstances the classical version, followed by immediate extraction of the child is, as a rule, the quickest and safest mode of delivery, and that therefore students should receive careful training in the classical podalic version.

I pointed out, that in those cases, in which there is insufficient dilatation or perhaps no dilatation at all, the cervical and vaginal

Read before the Obstetric Section of the St. Louis Medical Society, May 25, 1909.

a number of cases extending over the last 30 years, and I stated, that out of over fifty cases of all varieties, only one mother had been lost and that her loss was due to rupture of the uterus, in a case in which a practitioner had administered a large dose of ergot after packing.

I was induced to thus emphasize my views regarding the treatment of Placenta Praevia by the apprehension, that the unfortunate teachings of some of the leading German obstetricians, particular those of Kroenig of Freiburg, Sellheim of Tuebingen and Henkel of Greifswald, might be well received in this country and call forth another deplorable epi

demic of contraindicated Cesarean Section.

Kroenig advocates and practices abdominal cesarean section in all cases of Central Placenta Praevia that reach the hospital before there is complete dilatation, and that have not been tamponed or otherwise temporized with by the practitioner.

Sellheim recommends for the same class of cases the so-called extraperitoneal cervical cesarean section, and Henkel advises vaginal cesarean section for the majority of cases.

Permit me now to report in detail two cases of Central Placenta Praevia, which have come under my observation during the last few weeks, and which both furnished the ideal indication for Cesarean Section according to Kroenig, Sellheim and Henkel, both cases, however, did reasonably well under less heroic treatment.

CASE 1.-At noon April 4, 1909, Mrs. D. entered the Washington University Hospital with the following history:

The patient is 22 years old; she is married

ten months; she is pregnant for the first time; her last menstruation started on August 6th, 1908. On March 23rd, 1909, when patient was in the 33rd week of pregnancy, a severe hemorrhage occurred; Dr. E. H. Eyermann was called in; the hemorrhage soon subsided into moderate oozing of blood; patient was kept quietly in bed and put on bland diet and acidulated drinks; there were no uterine contractions until March 28th, when slight labor pains set in and the bleeding increased somewhat, but was not alarming. April 4th, patient was transferred to the hospital; the fetal head was felt movable over the inlet; the fetal heartsound was audible in the right lower quadrant. April 5th, at 9 p. m., there was considerable hemorrhage; the cervical canal was not unfolded and barely permitted the passage of one finger; nothing but placental tissue could be felt through the internal os. Cervical and vaginal tampon of sterile gauze; the tampon is changed five times between April 5th and April 7th. In the night of April 6th to 7th, strong labor pains set in and at 6:30 p. m., April 7th, the os is found almost fully dilated and filled out entirely by placental tissue; the patient is anesthetized; the right hand is introduced into the vagina; the placenta is peeled off from the left side of the uterine wall, until the membranes are reached; these are ruptured; the left foot is seized; the child is turned and extracted; the placenta is easily removed by Crede's method. The child, a girl, weighs 51⁄2 pounds, is about six weeks premature and born alive. The mother is able to nurse the baby; the puerperium was uneventful; mother and child left the hospital on the 18th day and continue to do well. The placenta in this case was very large and thin; although the os was fully dilated and entirely filled out with placenta, which had to be peeled off from the uterine wall, measured at least 15 centimeters.

CASE 2.-Mrs. E. entered the hospital at 9 p. m., May 3rd, 1909. She is 27 years old and this is her third pregnancy; her last menstruation began September 26th, and she is therefore in the beginning of the 32nd week of gestation. Pregnancy was uneventful until March 3rd, when patient bled some during the night and the following day; she remained in bed four days and was after that again undis

turbed until May 3rd, when at 2 p. m., severe hemorrhage set in and Dr. E. H. Eyermann was called and ordered her transfer to the hospital, where she entered at 9 p. m. There was no bleeding at the time; the cervix was high up and in the left side; the degree of dilatation was not ascertained as the obstetrician on duty feared to provoke hemorrhage by forcing the finger into the cervix.

During the night there were slight uterine contractions and a scant discharge of blood; at 10 a. m., there was a free hemorrhage; a hot douche was given and cervical and vaginal gauze-tampon inserted. At 9 p. m., examination shows the fundus uteri midway between navel and xiphoid process; the fetal head rests on the left iliac fossa; the fetal heart-sounds are heard in the left lower quadrant; the packing is removed; the cervix is found high up in the left side; hard to reach; the internal os is open for one finger and filled out with placental tissue. The cervix is now packed with iodoform gauze and the vagina with plain sterile gauze. During the night there were severe uterine contractions; at 9 a. m., May 5th, the packing is driven out and there is some hemorrhage; the physician on duty repacks, but not very tight, and the pains subside; at 12 noon this pack is removed; the cervix is still high up and hard to reach; shows about 3 centimeters of dilatation and is entirely filled out with placental tissue.

Cervix and vagina are repacked tightly and severe labor pains soon set in; when the pack is removed at 2 p. m., the os is found completely dilated (about 15 centimeters in diameter); the fetal heart-sounds are no longer audible; the patient is chloroformed; the left hand is introduced into the vagina; the placenta is peeled off from the right side of the uterus; the membranes are ruptured; the right foot is seized; the child is turned and extracted; the placenta follows easy after Crede's method.

The child, a boy, was stillborn; death seemed due to the fact that the detachment of the placenta was almost complete; the placenta was of average dimensions, so that when the os was fully dilated, a margin of not more than an inch remained attached to the uterine wall. The fact that the child had barely 31 weeks of

Since my first protest against Cesarean Section as a means of treating Placenta Praevia, a good many voices have been raised in support of safer and more conservative methods.

Professor Martin of Berlin, attacked Kroenig and Sellheim in an open letter (Monatsschrift fuer Geburtshilfe und Gynaekologie, Bd. 28, Heft 6); Hannes, of Breslau, claims that the intra-uterine balloon-treatment, as practiced in Kuestner's clinics, makes all other modes of treatment unnecessary. He insists that the bal loon must be placed inside of the ovum and not below it, if the best results are to be obtained (Centralblatt fuer Gynaekologie, 1909, N:3).

Zimmerman, a pupil of Martin, shows, that it is perfectly safe to place the metreurynter below the ovum and he has obtained excellent results. (Centralblatt fuer Gyn., 1909, N:10).

In the United States, the most pleasing features in this question, are the conservative views expressed at New York during the meeting of the American Gynecological Society, April 20th to 22nd, this year. Some of these opinions state the case so plainly, that I may be excused for quoting rather extensively.

Dr. Jewett, of Brooklyn, said: Even in complete previal inplantation and with undilated cervix, bleeding is amenable to one or more of the usual obstetric procedures, gauze-tamponade or waterbag, within the cervix or the lat ter passed through the placenta, and podalic version.

Grave hemorrhage in Placenta Praevia is due more to failure in the timely and well directed use of the obstetric measure, than to any lack of them. No shock attaches to the introduction of a hydrostatic bag and little or none to a Braxton-Hicks version.

Dr. Fry, of Washington, thinks that purely obstetric management will best meet the indication of 95 per cent of all cases of Placenta Praevia, but that in 5 per cent of the cases primiparity, small vagina, rigid and undilatable cervix and placenta praevia centralis will form the indication for cesarean section.

Newell, of Boston, hit the nail on the head when he said: The advocates of Cesarean Section have not recognized that their personal limitations furnish the great indication for an

Herbert Spencer, of London, stated that he uses the Braxton-Hicks method, while his colleague uses the Champetier de Ribes bag, reducing fetal mortality considerably, with some increase in maternal mortality.

Hofmeier, of Wuerzburg, thought that abdominal section should be limited to a small percentage of cases. The old method of combined version after Braxton-Hicks, generally accepted in Germany, and the treatment by means of metreurynter in cases of large and strong children gives good results.

Pleas for Cesarean Section have been made recently by Allen, Baltimore, and McPherson, New York. The former in an article entitled "A Plea for the more frequent performance of Cesarean Section" (American Journal of Obstetrics, Vol. 59, N:2), quotes Condon and says: Condon reports two operations for placenta praevia with recovery of mother and infants. Condon says: There is no doubt in my mind, that in case of Placenta Praevia Centralis, when the operation of Cesarean Section is done early, and before temporizing measures of various kinds are resorted to, the percentage of mortality can be cut down to as low a figure as ordinarily attends a simple laparotomy.

Allen also quotes Briggs, who has performed Cesarean Section twice for Placenta Praevia Centralis, with the result that both mothers and one infant were saved.

McPherson, in the Bulletin of the Lying-inHospital, in the City of New York (Vol. 5, N:3). says: Regarding the utility of the operation. in placenta praevia, it is my belief, that in cases af placenta praevia with central implantation, in the presence of a firm, undilated os, where the soft parts are firm and unyielding. less damage will be done to the mother, and we shall be more certain of securing a living child by a timely Cesarean Section than by resorting to the other usual modes of delivery.

Of all leading text-books the version after Braxton-Hicks is most commonly recommended.

Edgar's advice is dangerous; for rapid dilatation he recommends the Bozzi dilator. He says, that Champetier de Ribes bag or its modifications cause separation of the placenta and concealed hemorrhage and have no place in the