regular hemorrhage during the first three months with premature birth and excessive hemorrhage at the beginning of the ninth month. The first pregnancy terminated in accidental abortion at the third month.

At the present time I have a patient who is in the fourth month of her fifth pregnancy. Her previous pregnancies have terminated in two abortions, one premature birth with death of the fetus, and one full-term birth with antepartum and postpartum hemorrhage. In all of these pregnancies hemorrhage was a symptom during the early months. The present pregnancy has had hemorrhage as a symptom at the exact times of the menstrual period, this hemorrhage being accompanied with pains and a markedly increased flow. I have made a provisional diagnosis of placenta previa as the present condition but at the urgent solicitation of the patient am following conservative treatment.

The history of these patients points conclusively to placenta previa for, as syphilis was ruled out in both cases, there is no other way to account for the symptoms.

It is stated by Strassman that placenta previa results in abortion in 18 per cent of the cases. Such being the case, we ought to regard all cases of threatened abortion, at least after the first month of gestation, as strongly pointing to placenta previa. The definite diagnosis of placenta previa during the early months of pregnancy must always be a matter of great doubt. The earlier the appearance of the hemorrhage, the greater the doubt. The appearance of a normal flow at the first period following impregnation of the ovum is so common that it would seem to have no significance; but repeated appearance of a so-called menstrual flow or its appearance after a cessation of one or more months in a woman showing other signs of pregnancy should constitute a suspicious symptom.

Hemorrhage during the later months of pregnancy is always an accidental hemorrhage or is due to placenta previa. Many of the cases diagnosed as accidental hemorrhage are placenta previa of the lateral or perhaps marginal type. The differential diagnosis between these forms of hemorrhage is made by vaginal examination. If we can feel the placenta with the examining finger we are sure of a diagnosis of placenta previa. If it cannot be felt, we are forced to consider the case as one of accidental hemorrhage until later developments prove it to be otherwise. The essential factor in making this diagnosis is the ability to penetrate the os. If placenta previa, this can usually be done with ease if the case is in the later months of pregnancy. If during the earlier months with placenta previa,

or at any time with accidental hemorrhage the non-dilatability of the os may have to be overcome with the branched dilator. The differentiating point between the placenta and a blood-clot, when palpated, is that the latter breaks up under the pressure of the finger. The higher the implantation of the placenta, the greater the difficulty in making a diagnosis. Also, the more doubtful the diagnosis, the greater the indication for conservative treatment. This is an unusual anomaly in the treatment of such a symptom as hemorrhage, the less we know of its source the less it concerns us. The reason lies in the fact that the higher the implantation, the less the danger.

In considering the treatment of placenta previa emphasis must be given to the statement that expectant treatment should never be chosen when a positive diagnosis of the condition has been made. We all meet with cases where the great desideratum is a living child and expectant treatment is demanded. Even such a case does not warrant us in continuing to subject a patient to the great dangers of her condition. Such a policy of conservatism should not be adopted unless the patient accepts the risk and places herself in a hospital where immediate relief can be secured if a serious hemorrhage should occur. We should advise in all cases where a positive diagnosis can be made that the uterus be emptied at once.

The method employed to empty the uterus depends wholly upon the stage of gestation, the condition of the cervix as to dilatability, the variety of the placenta previa and to a certain extent upon the conditions surroundings the patient bearing upon the possibility of properly carrying out the various operative procedures.

If the plancenta previa is recognized during the first three months of gestation, the ordinary operative technic of dilatation and curettage is sufficient to meet the conditions present.

After the third month and up to the time of viability of the fetus the operative measures chosen must vary according to the symptoms present. If hemorrhage is not excessive, we have a choice between tamponnade of the cervix and the use of dilating bags. If hemor rhage is excessive, vaginal cesarean section may best meet the emergency. This operation, however, is not indicated if the development of the fetus is such as to make it possible to perform a version.

After the time of viability of the fetus, the treatment chosen depends upon the variety of the placenta previa. If lateral, the membranes are ruptured and dilatation of the cervix secured by means of dilating bags. This, alone, is all that is necessary to control the hemorrhage in many cases. If it does not do so, immediate delivery should be made, either by forceps or version, preferably the

latter. If of the marginal type, the same method of procedure is followed but there is greater need of rapid delivery and manual dilatation of the cervix should supplement the action of the dilating bags. The urgent necessity for rapid extraction often leads to the carrying out of this procedure before the cervix is sufficiently dilated and this is almost certain to be followed by serious injury to the lower uterine segment.

There can be but one method of procedure in central placenta previa, namely, manual dilatation of the cervix sufficient to introduce two fingers, followed by penetration of the placenta, rupture of the membranes and combined version. If time permits, some advantage is secured by performing external version preliminary to dilatation and extraction. The hemorrhage is checked as soon as one or both legs have been brought down. Extraction of the body should be done slowly in order to secure delivery without injury to the cervix, an accident very liable to occur in this form of previa.

It is good practice to include the intra-uterine tampon in the after-treatment of all forms of placenta previa. It is an aid in the prevention of post-partum hemorrhage. Some do not advise this precaution but it has been my experience that it is a wise prophylactic measure. Another important factor in the after-treatment is the early use of salt solution to overcome the effects of the anemia as soon as possible. The sooner the normal volume of blood is restored, the greater the immunity of the patient and the less the liability of sepsis.

It will be noticed that I have omitted probably the most commonly used measure in the treatment of placenta previa, namely, the use of the vaginal tamponnade. I have done so because I consider the dilating bag superior to it in every way. There is no question. but that the tamponnade partially controls the hemorrhage, stim. ulates uterine contractions and finally effects a softening of the cervix but it does not meet the indications for treatment as well as the bags. Furthermore, a tamponnade is much more difficult procedure than the insertion of the bag and is far more dangerous as a factor in the production of sepsis.

I have also omitted reference to abdominal cesarean section. This method of treatment has some advocates and its chief merit is its low fetal mortality. The maternal mortality is not so good as in other methods of treatment. It is especially indicated as favoring the child in placenta previa of the central variety and possibly in some bad cases of the marginal type. It is clearly indicated as

favoring both mother and child in old primipara where difficult extraction is self-evident.

A new method of treatment has recently been brought to the attention of the profession. It consists in ligation of the uterine arteries followed by immediate extraction. It has been used in a number of cases, in some of which a living child was secured when at the time of operation, the fetal heart-beat could not be heard. The method is correct in principle and I believe that it will become more widely used than any other in the treatment of the more dangerour forms of placenta previa.

760 Rose Bldg.

HOMEOPATHY IN EYE, EAR, NOSE AND THROAT
DISEASES.*

BY WILLIAM H. PHILLIPS, M. D., CLEVELAND, O.

The incentive for this paper is first, an article published in homeopathic journal sometime since, on "The Homeopathic Treatment of Adenoids," which consisted in packing a pledget of hydrastis against the growth instead of doing the usual operation; and second, a paper by Burton Haseltine of Chicago, denying the right of the author of the above mentioned paper to parade it as homeopathic treatment.

The whole controversy opens up the question of how much homeopathy is used in the modern specialist's office practice anyhow, and of what real value it is to those who do use it.

As regards the number who use homeopathy we must remember this, that the great majority of men in specialty work today, who have had any special training at all, have received it in school clinics where nothing is ever heard of internal medication save the syrup iodide of iron, the double chloride of mercury or the iodide of potas sium. Unless the student at these clinics is well grounded in practical homeopathic therapy, and I mean by this, unless he has had the opportunity in a general practice to have formed the habit of careful prescribing, he is peculiarly liable to become infected with the drug agnosticism of the place, and it is exceedingly difficult for such a man ever again to become a good homeopathic prescriber. True, he may

*Prepared for the February meeting of the Cleveland Homeopathic Medical Society.

in an empirical way use drugs known to the homeopathic pharmacist but he rarely, if ever, takes up homeopathy seriously.

Again, some men in specialty work are impressed with the idea that they have graduated in materia medica and henceforth the only objects of their exceptional skill and vast knowledge are surgery and so called, rational treatment. They seem to think they should stand in a class apart from the general man, that materia medica is his weapon, surgery and local treatment theirs, and neither should step into the domain of the other. This seems to me to be wrong. The general man should have an accurate general knowledge of the whole field of medicine and is priviledged to use any therapy which he may be competent to prescribe or in a position to carry out. The specialist should supplement the general man's accurate general knowledge by an accurate special knowledge of the regions in which he is specializing, and this accurate special knowledge should not be confined to anatomy, physiology, pathology and surgery, but should comprehend materia medica and every aid known to medicine as well. He should have an accurate knowledge of the local symptomatology of drugs, for often in special affections we must differentiate our remedies by characteristics in their local symptomatology. My ob servation however, is that few men prepare themselves along this line. but that the average specialist practices a very mongrel species of homeopathy if he practices it at all.

Now as to the advantage of cultivating the art of specialty prescribing, and I cannot better illustrate it than by citing to you a few cases wherein all the special and rational knowledge I may possess had been expended in vain, and where a careful study of the local drug affinity to the disease seemed to quickly bring about the desired relief.

CASE I. A young lady of 27, teacher in the public schools, complained that for two or three years her hearing had been rapidly decreasing and a marked buzzing, whizzing sound was almost con stantly present, greatly aggravated in damp weather. Slight vertigo was occasionally present. Inspection showed a thickened, slightly depressed drumhead, the malleus moving easily during suction and compression. Inflation showed marked tubal obstruction and only the smallest bougie was admitted. Hypertrophic pharyngitis was present. The nerves were free although the turbinal mucosa was somewhat thickened. Diagnosis: Interstitial inflammation of the tube and tympanum. The tube was dilated till the largest size bougie passed easily and until inflation was perfectly free. Massage and the