head slightly drawn back, muscular twitchings, and abdomen rigid. Complained of pain in back of neck and abdomen. Swallowed liquid nourishment with some difficulty. Dorsal decubitus with considerable arching from occiput to the hips. At 1 p.m. all previous symptoms were intensified; swallowed with much greater difficulty and pain; the left foot was slightly swollen, and about two inches behind web of large toe was a small black mark, the spot where the injury was received; did not appear to penetrate beyond the epidermis. Nothing else noticeable about the foot.

Dr. Shepherd decided to cut down and excise parts about the point of injury. Patient was etherized and an elliptical incision made around the wound. A small abscess was found in deep skin layer, which had no apparent connection with the external wound. Going deeper, another small abscess about the size of a pea was found, just over the tendon of the flexor longus hallucis. Still deeper, found an abscess under the tendon of the flexor brevis, directly over the metatarso-phalangeal joint. No connection could be found between any of these abscesses. There was considerable inflammatory thickening in all the tissues, and the tendons had a greenish hue. The operation wound was stuffed with iodotorm gauze and bandaged. At 4 p.m., patient recovered from the effects of the anaesthetic; breathing labored and chiefly abdominal; risus sardonicus very marked; tetanic spasms more severe than before; temperature 99°; pulse 100. At 5 p.m., patient became much worse; spasms very severe, and came on with greater frequency than before; opisthotonos marked; could not swallow at all; ordered morphia sulph. gr. hypodermically. Temperature 100°; pulse 120. At 6 p.m., temperature 103°; pulse 150. At 7 p.m., temperature 105°; pulse 160; morph. sulph. gr. hypodermically. At 8 p.m., temperature 106°. Patient died shortly after eight o'clock; temperature half an hour after death, 107.5°.

Remarks.- -Tetanus is a disease which has not been at all influenced by the introduction of antiseptics. In the first case the wound was in a very foetid condition, and it has been noticed that tetanus not uncommonly exists in those cases of crushing

injuries where decomposition has taken place in the wound. The first case illustrates this cause of tetanus. According to M. Gauthier, certain chemical changes, the result of decomposition, take place and the products are certain animal alkaloids or leucomaines which produce such irritation upon the peripheral nerves that the condition we call tetanus is produced. The second case is an example of how slight an injury may be followed by tetanus. In this case no doubt the affection was produced by irritation of the terminal nerve filaments. Although the excision was performed at a comparatively early stage of the disease, no good result followed.

MONTREAL DISPENSARY-DEPARTMENT OF

GYNECOLOGY.

CASES UNDER THE CARE OF DR. ALLOWAY.

CASE I.-Stenosis of Cervix Uteri treated by divulsion and division of posterior segment.

M. S., aged 29, married two years, no pregnancy. Menstruation occurs every fourth week, but is accompanied with such severe pelvic pain that she is compelled to remain in bed during the whole period. During the intermenstrual period she is tolerably well and free from pain; there is, however, some leucorrhoeal discharge.

Examination.-External parts normal; vagina small; cervix elongated and hypertrophied; the anterior segment of cervix abnormally short; os uteri small and its lips eroded and cicatricial, discharging a glairy mucus; cervix looks down the vagina and somewhat backwards; fundus anteflexed, resting over on the bladder; there is extreme tenderness in the fornices; uterus moveable. By the use of the glycerine tamponade for two months the tenderness gradually disappeared. She was now put to bed for three weeks on hot-water injections, at end of which time the following operation was performed :

The patient, under ether, was placed in the dorsal position, the vagina irrigated with sublimate solution, uterus drawn forward with volsella, and Sims' glove-stick dilator introduced. With this instrument the cervix was gradually stretched to a

certain point, a stream of sublimate solution being kept playing into the uterus between the bars of the dilator. The heavy Goodell's instrument was then introduced and the cervix gradually dilated to the full extent of one inch. The knife (Fig. 1)

FIG. 1.

J.

was then introduced and the anterior tense wall incised until the tension was relieved on the dilator. The instruments were now withdrawn, the patient turned on her left side, and the posterior segment of cervix slit up in the median line with a straight scissors as far as the vaginal junction. A triangular piece is completely excised from each flap, the base being at the os, the apex ending at the apex of the median incision. The mucous membrane of the cervical canal is now stitched to that covering the portio-vaginalis, as shown in Figure 2. By this method it is impossible for the incision to granulate downwards, which was the great difficulty Sims had to deal with in his method of dividing the posterior cervix and allowing it to heal by granulation.

It would appear at first thought that this procedure was simply creating a laceration of the posterior cervical segment, and that it would remain so as a deformity. This, however, is not the case, and it is due to the different states of the tissues involved in the

puerpera and non-puerpera. The change which takes place within the first month following the operation consists in a shrinking of the anterior segment and a general atrophy of the whole intravaginal cervix until it appears as represented in Figure 3. The

sound now passes directly forwards into the cavity of the uterus, and the os opens directly into the posterior vaginal pouch and semenal pool.

The knife represented is one made for me by Mr. Ford of New York. It has the exact curve of the blades of the Goodell dilator, and being a small blade set in a steel probe, can cut only to the depth of the blade, which is, I think, an advantage over Sims' original metrotome knife.

CASE II-Stenosis of Cervix Uteri treated by divulsion and division of posterior segment.

M. C., aged 30, married seven years; never been pregnant. Menstruation every fourth week, but suffers very severe pain just before and during the flow in utero-ovarian region and back. Has leucorrhoeal discharge and irritability of bladder.

Examination.-Perineum extremely rigid, causing difficulty in making satisfactory examination. Vagina small. Much tenderness and rigidity of pelvic floor. Cicatricial contraction of base of right broad ligament, drawing cervix to that side and backwards and fundus forwards on bladder. Intra-vaginal cervix elongated and hypertrophied as in Case I, but the lips around os were not eroded. Uterus in depth inch.

This patient was also placed under the glycerine tamponade treatment for ten weeks, which completely relieved the tenderness and tension of pelvic floor. And after two weeks confinement to bed on hot-water douches, rapid dilatation with incision was practised.

The material for sutures best adapted for these cases is, I think, Chinese silk. An antiseptic vaginal irrigation night and morning is used and the sutures removed on the eighth or tenth day. The best time to do the operation is midway between the menstrual periods, and the patient should be confined to bed until the following period has passed over. For the two months following the operation there is in some cases rather profuse menstruation, but should be positively without pain in the pelvic region. After this the periods gradually become less profuse until a normal condition is established. In my experience 1 have not seen the slightest disturbance of pulse or temperature, nor complaint of pain follow this operation.