on the left side, and for partial dilatation the invented. Simpson's and Greenhalgh's metrotomes latter position offers many advantages. and Küchenmeister's scissors, with others of the same kind, have been and are still used. The results, however, from the cutting operation are not nearly so successful as those from rapid cervical dilatation. (b) Sterility. Where sterility is due to stenosis or anteflexion, then this operation will frequently bring about a cure. Marriage, as a rule, increases the dysmenorrhoea arising from obstruction, and often this symptom is developed after marriage in women who did not suffer from it previously. On examination the fundus will often be found pressing on the bladder, and it will be almost impossible to introduce a probe on account of the flexion. In such a case, rapid dilatation will not only widen out the cervical canal and thereby facilitate fecundation, but it will straighten the flexion, and, in consequence, overcome the obstruction to pregnancy. Where obstruction has existed for years, it cannot be wondered at that the general disorganization in the lining membrane of the uterus, fallopian tubes, and in the ovaries, resulting from the prolonged hyperæmia, renders fecundation doubtful, even after the first cause has been removed. If the operation cures the dysmenorrhoea, however, and allows a free flow for the menstrual fluid, and if the operation is repeated if contraction occurs, there is every reason to hope that time will rectify the other conditions and fertility will ensue. Fortunately statistics show that pregnancy frequently occurs soon after the obstruction has been removed. 2. Conditions to which the operation is applicable.-(a) Dysmenorrhoea. This condition may be due to stenosis of the cervical canal, or flexion with stenosis, or flexion alone. It seems to me impossible to differentiate these conditions by subjective symptoms. It is generally stated that where stenosis exists alone, the pain is excessive before the flow and gradually ceases as it becomes thoroughly established; whereas in flexion the menses are discharged in gushes, caused by the pent-up fluid straightening out the canal. All subjective symptoms are unreliable, simply because the excessive pelvic and ovarian hyperæmia, consequent on the obstruction, tends to mask the naturally concomitant symptoms of either stenosis alone, or when combined with flexion. Where obstruction exists the vaginal portion of the uterus usually becomes elongated and pointed, with, sometimes, the os externum exceedingly small. Likewise, the fundus becomes enlarged, and the sound frequently gives a measurement of three or three and a half inches. In stenosis, Dr. Barnes says, the seat of obstruction is generally at the os externum, and where obstruction exists at the os internum, it is due to flattening of the walls by flexion. Whether this be true or not as a rule, rapid dilatation of the cervix will rectify the flexion and cure the stenosis at the same time, when these conditions are found to exist together. The consequences of obstruction are thus given by Barnes: "(1) Congestion and enlargement of the body of the uterus, disposing to menorrhagia, and causing uterine (c) Intra-uterine Medication, etc. Frequently spasm and colic. (2) A similar condition of the it is necessary to make a digital examination of fallopian tubes. (3) Congestion, enlargement and the interior of the uterus, and this operation inflammation of the ovaries. (4) As an renders easy what is a difficult proceeding where ulterior result continued obstruction may entail, dilatation is produced by tents. Again, in cases through the action of inflammation or long inter- of menorrhagia suggesting a growth springing ference with function, atrophy of the ovaries and from the interior of the uterus, the operation of extinction of the menstrual phenomena." When rapidly dilating the cervical canal not only gives we consider the consequences which must ensue a means of diagnosis, but if a polypus is discovered, from the long continued congestion of the uterus, materially facilitates its removal. Generally in fallopian tubes and ovaries, and when we consider cases of menorrhagia the laxity of the tissues of the fearful suffering entailed on those in whom the cervix, resulting from the depletion, renders obstruction exists, we cannot magnify too highly easy the operation of dilatation, and usually the any means calculated to afford relief. To over- physician can dilate the cervix and remove the come the condition of stenosis the operation of polypus, if present, at one operation, contrasting incision of the cervix was devised, and to accom- favorably with the long, tedious waiting of dilataplish this, various cutting instruments have been tion by tents. Lastly, for using the currette and . for intra-uterine applications and injections, this operation offers many advantages over any other means of dilatation. In regard to the after-treatment, a hot water injection should be used immediately after the operation, and this should be employed, also, two or three times a day for a few days. It is advisable, likewise, for the patient to remain in bed for three or four days. If a proper time has been selected to perform the operation, viz., within a few days after menstruation, the danger of hæmorrhage is exceedingly small, much less at any rate than after the cutting operation, and the danger of inflammation is not so great as after using relays of tents. 3. Clinical Cases.-I shall now give a brief account of five cases, in whom I have operated by this method: Case 1.—Mrs. M. came under my care July 6th, 1886, married for three years, never became pregnant; slight dysmenorrhoea previous to marriage, which had gradually increased until her suffering became intense, necessitating large doses of morphia at the periods to give relief. On examination, the cervix was found greatly hypertrophied and the fundus doubled forward, pressing on the bladder. The cervical canal was small, and it was with difficulty a probe was passed, and gave a measurement of three inches. The case was plainly one of anteflexion, coupled with a narrow cervical canal. The operation of rapid dilatation was performed under chloroform. No bad symptom arose after the operation, although she was kept in bed four days and hot water injections used. In this case the dilatation was thoroughly performed and the flexion completely straightened. The time selected for the operation was three days after menstruation. The dysmenorrhoea was completely cured, and as she moved to the States shortly afterwards, I do not know whether pregnancy occurred or not. Case 2.-Miss L., aged 27, came under my care Aug. 18th. For the past three years has suffered greatly from dysmenorrhoea, causing her to be fretful, nervous and irritable. She attributes the trouble to a severe drenching received in October, which caused an attack of inflammation of the lungs. At the time the wetting occurred she was menstruating, and the flow suddenly ceased. Before resorting to an examination, every known remedy in the shape of medicine was used with no effect whatever. In the presence of her mother she was placed under chloroform and an examination made. The cervix was long, narrow and pointed, and the os-externum so small that only a fine surgical probe could be passed, and showed the uterus to be over three inches in length. No flexion existed, but the fundus was enlarged and slightly retroverted. Atlee's dilator was first used and the full extent of dilatation by that instrument accomplished. Then the Goodell Ellinger dilator was used, and the handles slowly and gradually brought together and kept there ten minutes. After the operation the uterus was shortened and the conical condition obliterated. She was kept in bed for a week, and hot water injections used, and no symptom of inflammation arose. On the first occasion of menstruation after the operation she suffered considerably, but the pain became less and less at each period, and four months afterwards the dysmenorrhoea had ceased, the nervous system became stronger, irritability subsided, and she became strong, robust and healthy, and as such she has continued since. Case 3.-Mrs. G., aged 22, married ten months, has not been pregnant; dysmenorrhœa began soon after marriage and it is increasing, frequent and painful mieturition, bodily health fairly good. On examination, anteflexion and stenosis of cervical canal at internal os. Operation of rapid dilatation with Goodell's dilator, and the flexion straightened. In order to more thoroughly complete the latter, the instrument was withdrawn, carefully re-introduced and the blades opened opposite the flexion. The result was that the dysmenorrhoea ceased immediately, and pregnancy took place shortly after the operation. Case 4.—Mrs. S., aged 31, married twelve years, no children and was never pregnant. Has always had dysmenorrhoea, the pain beginning several hours previous to the period and lasting a day or two after menstruation set in. Lately, excessive vesical irritability has. arisen, the pain has increased and menorrhagia developed, the period lasting seven or eight days, and the quantity lost four times what was usual. From the condition reported, I suspected an intra-uterine polypus, and advised an examination. The uterus, on examination, was found very much hypertrophied, the fundus enlarged and retroverted, but there was no flexion. On attempting to pass the sound the cervical canal was found narrowed, and at the os-internum complete stoppage occurred. With difficulty a fine probe was inserted. I freely dilated the cervix with the patient under chloroform, but found no evidence of a polypus. Clearly, the menorrhagia was due to hypertrophy consequent on the stenosis. The result was that the menorrhagia gradually ceased, and the dysmenorrhoea was very much relieved although pregnancy has not occurred. He of trachelorraphy was to be secured the longsought for panacea. How soon this faith became established and gynecological literature teemed with its success. Recently, Prof. Næggerath, of Wiesbaden, has thoroughly enquired into the subject, and entirely disproves almost every contention of Dr. Emmett and his followers. shows that laceration of the uterus does not conduce to miscarriage and that it increases the chances of conception; that the position of the uterus is not affected by it; the axis is not elongated thereby, erosions, and ulcerations, and cervical disease are not a consequence, and eversion of the lips is never directly produced by it. Finally, he proves that laceration has no influence in producing uterine disease, either as regards The frequency or intensity, and the restoration of the shape of the cervix can have no influence on the uterus. Thus another theory is exploded, and another discovery proved fallacious if Naggerath's views be sustained. Undoubtedly grains of truth lie hidden in the chaff of all these statements and theories; time and patience, and earnest, honest investigation are needed to place the truth beyond the cavil of blind worshippers of any one doctrine. I take it that gynæcology, like ophthalmology and laryngology, requires particular knowledge and experience for an accurate diagnosis; but the nervous phenomena playing so prominent a part in the subjects of these diseases, must be well understood and carefully considered in order to avoid error. Case 5.- Mrs. F., aged 28, married seventeen months, never has been pregnant; dysmenorrhoea severe, pain was present, slightly, previous to marriage. On examination there was found no flexion, but the cervical portion was elongated and the os-externum exceedingly small. operation of rapid dilatation was performed with the patient under chloroform. The result was not satisfactory so far as the dysmenorrhea was concerned, as it was only slightly relieved, but three months after the operation conception occurred. As I have already hinted, this operation, while undoubtedly beneficial in suitable cases, should not receive excessive laudation, for fear of its being recklessly applied Perhaps in no branch of the science of medicine have so many unwarranted and unworthy medical and surgical procedures been adopted, in blind faith, as in the science of gynæcology. At one time everything was ulceration, and many a uterus was unnecessarily cauterized. Again, displacements became the pass word to gynæcological success, and inventors plied their ingenuity to discover the most perfect support. Thus, many able gynæcologists held that anteversion of the uterus was a pathological condition, and anteversion pessaries in abundance was the result. We all know, now, that the natural position of the uterus is the condition of anteversion, and any pessary applied to rectify the same, must of necessity increase the very condition which the version was claimed to cause-viz., vesical irritability. Likewise, the condition of anteflexion can only be said to be pathological when it produces dysmenorrhoea. Not long ago, Dr. Emmett, of New York, started the theory that in laceration of the cervix was to be found the true solution of so many of the obscure female diseases, and that in the operation NECROTIC TONSILLITIS.* BY A. MCPHEDRAN, M.B., TORONTO. The name diphtheria always conveys to the lay mind so much dread, and justly so, that all cases of pseudo-diphtheria should, when possible to do so with certainty, be carefully distinguished to avoid giving needless alarm. The two following cases bear a certain resemblance to diphtheria, but at the same time present unusual characters worthy of consideration. Case 1. M T., aged five; a healthy child, of good family history. Her mother had large tonsils, which had to be removed. The child's tonsils were very large, almost meeting across the * Read at the Toronto Medical Society, at the stated meeting, May 17th, 1888. isthmus of the fauces. She was subject to frequent attacks of catarrhal sore throat. On November 26th, 1887, she became seriously ill, with a temp. of 103.5° and noisy, difficult respiration. On examining the throat, there was observed on the left tonsil a grayish, gelatinoid-looking, raised patch, about the size of a ten cent piece, intimately adherent to the tonsil and surrounded by deeply inflamed membrane. Swallowing was painful, the left cervical glands slightly enlarged. The appearance of the patch differed materially from the fawn-colored, tough-looking, opaque patch of diphtheria. Moreover, it was slightly marked in a stellate manner; the markings became more distinct later on. The patch separated en masse in four days, leaving a raw, ulcerated surface that healed with fairly distinct cicatricial contraction, reducing somewhat the size of the tonsil. Until the patch separated the temperature continued elevated, with thirst, loss of appetite and considerable prostration. The breath only slightly offensive. Convalescence was slightly protracted, but there were no paralytic symptoms Isolation though advised was very imperfectly carried out. None of the other members of the family, which consisted of the grandmother, parents and a younger child, contracted the disease. Case 2 differs considerably from the foregoing. Mrs. M., aged 50; from the country, visiting a sister whom she was nursing in confinement. She was a delicate woman, whose throat often gave her trouble; both tonsils were chronically quite large. I saw her first on February 25th, 1888. She complained of pain in the left side of the throat, and the left tonsil was found, on examination, to be completely covered with a whitey-gray membrane, intimately adherent and surrounded by a dark-red ball on the pillars of the fauces. The membrane was quite thin in several places and it terminated in a thin margin. It could not be stripped off, and the removal of a small piece left a bleeding surface. The left cervical glands were The left cervical glands were slightly enlarged. Temp. slightly sub-normal (97.3°), pulse 120, weak, no appetite. She had been in the city only two days, and thought there was some white deposit on the tonsil before she left home. She was carefully isolated for a few days, as besides the infant there were two other children in the house. Iron with chlorate of potash was given freely, and as much nourish ment as possible taken. Temperature rose to normal next day and remained so throughout; pulse continued about 120, and weak with general prostration. No change occurring in the membrane after a few days, a solution of argent. nitr. (3ss. ad 3j.) was applied three times a day with a brush. With this application the membrane gradually became thinner. By March 10th the whole surface was still covered with membrane. I next saw her about the 20th of March on her leaving for home. Most of the slough had separated, and had extended down into the tonsil to its base, dividing it into two unequal, wedgeshaped parts, the anterior about half the size of the posterior part. Between these the slough had not yet completely separated; of what remained the superficial was semi-liquid, and the deep shreddy a d adherent. Nearly one-half of the tonsil had been destroyed. The general health had improved considerably; there was now no pain in the throat. The term, necrotic tonsillitis, for such cases, is used by Strümpell in his Text Book of Medicine, and is the most appropriate available; they are scarcely severe enough to be called gangrenous, and the term phlegmonous is associated with the idea of a more acute inflammation. There can be no doubt as to the propriety of calling Case 2 one of necrotic tonsillitis, its appearance and course were typical of such a condition. Nor do I think Case 1 can be described as anything else, though the inflammation was here much more acute, separating the slough in a very short time. It, however, bears a strong resemblance to diphtheria, but that it was not a case of that disease I believe for the following reasons: It must be rare for so large a deposit accompanied by such sharp localized inflammation, to remain. so circumscribed, the uvula and soft palate were not affected, though in contact with the deposit. I have never seen one run such a course; the cervical glands would almost certainly have been much more seriously involved in so severe a case of diphtheria; no paralytic symptoms followed; there was no evidence of contagion; the appearance of the slough and of the ulcer resulting differed from those of diphtheria. Nevertheless, while all this is true, the fact remains that many cases of diphtheria cannot be diagnosticated from such cases of necrotic tonsillitis, and it becomes our imperative duty to exercise as much caution. with them, in the way of isolation and treatment, as if we were sure they were cases of that dread disease. It is best to err on the safe side. ON THE NECESSITY FOR A MODIFICATION OF CERTAIN PHYSIOLOGICAL DOCTRINES REGARDING THE INTERRELATIONS OF NERVE AND MUSCLE. BY THOMAS W. POOLE, M.D., LINDSAY, ONT.* THE EPILEPTIC PAROXYSM. With the experiments on the cervical sympathetic and splanchnic nerves before us, how can we say that the anæmia, or rather ischemia, of the brain, which ushers in the epileptic seizure, is due to "excessive action of the spinal centres," compelling the spasm or contraction of the arterial muscles on which this ischemia depends? Have we not had proof that the arterioles contract best when their vaso-motor nerves are cut, or are paralyzed, or dead; and if so, are we not bound to hold that not excess but failure of nerve power is the proximate cause of the epileptic paroxysın? And is not the question of such excess or failure of nerve force a most practical one in determining the treatment? How far in our comparative failure to cure this terrible disease due to our approaching it under the aegis of an erroneous theory—that nerve force here needed to be depressed rather than exalted? It is well for mankind that in this, as in some other instances, our practice has sometimes been directly at variance with the theory of the day. Thus we find Dr. Anstie assuring us that "our anti-spasmodics are stimulants"; and that "alcohol is one of the best remedies possible in the convulsions of teething in children" (a). ΝΟ MORBID NERVE FORCE. Spasms and convulsions frequently take place in the very act of dying, and under circumstances in which nerve force ought to be regarded as at a low ebb; as, for example, in uræmic blood poisoning. It is customary in some quarters to * Read before the Physiological Section of the Ninth International Medical Congress, held in Washington, September, 1887. (a) Stim. and Narcot., pp. 123, 129. attribute these or other spasms to a morbid irritability." or a morbid nerve force"; as if the central nervous ganglia were capable of producing two kinds of nerve force, one normal and the other "morbid," and the spurious variety of attaining extraordinary power just in proportion to the complete failure of nerve force proper. A little reflection, I think, will show that this is untenable. Nerve force may be increased or diminished: its condition may be one of excess or of failure, but that it may present a duplicate of itself, and its alter ego produce effects, for which nerve force proper is inadequate, and yet is responsible, is surely yielding too much to the exigency of an erroneous theory. 66 as Medical literature presents numerous examples of this appeal to a "morbid nerve action,” and it is rather surprising to find such a writer as the late Dr. Anstie referring to "the explosive disturbances of nerve force which give rise to the convulsions of tetanus something quite different in kind" from healthy nerve action (b). Now, if a nerve centre be thrown into action otherwise than by the exercise of its normal activity, then it is no longer the nerve centre which is acting, but a power extraneous to itself; a modern Archæus for which scientific medicine ought to have no place. And if tetanus be really due to an explosive activity of the nervous centres which are discharging nerve force with unwonted activity, surely to administer stimulants in such a case ought to be injurious, if not fatal! yet we find that Dr. W. A. Hammond, of New York, has produced statistics in which "stimulants” stand at the very head of the list of curative And agents in tetanus (c). Here again the theory of the day is surely out of joint with the clinical facts. CHLOROFORM AND RELAXATION OF ANESTHESIA. The answer is easy. I have been asked how the rigidity, at first, and subsequently the relaxation, of the muscles during anesthesia are to be accounted for in this theory. The rigidity is due to the partial paralysis of motor nerve influence, setting the contractile power of the muscle free to act. This occurs at a comparatively early stage of the process. The relaxation which attends complete anæsthesia is due to the loss of contractile power (b) Neural., p. 8. (c) Dis. Nerv. Syst., 4th Ed. p. 541. |