the child is born it is already stationary and it does not often grow. You can by the use of the ophthalmoscope, by dilating the pupil slightly with a solution of atropine, see the clear cut of the cataract, and you can tell what operation has to be made.

Dr. Stirling (closing the discussion): I have practically nothing further to add, except that I still consider that the solution of nitrate of silver to be used in these cases ought to be a strong one. I do not think the pain of a twenty-grain solution is much greater than that caused by five grains, and its advantages are shown by experiment. I have had under my care a great number of these cases, and the effects of a single application of the twenty-grain solution have always been so plainly beneficial, while the pain has apparently been so slight and of so short a duration, that I shall certainly continue its use in preference to weaker strengths, which I have also used.

With reference to lamellar cataract, the question which I wanted to bring out was whether or not the cataract is born with the patient. Dr. Crawford says it is. The argument I advanced in my paper was that it was thought on certain grounds to be the result of rickets in early life. This is an open question.

he

Again, I do not quite agree with Dr. Crawford when

says that lamellar cataracts do not grow; as a matter of fact, I may safely say that a certain proportion of these cataracts do grow and ultimately involve the whole lens.

RAPID DILATATION OF THE UTERUS A

CONSERVATIVE OPERATION.

BY R. M. HARBIN, M.D, ROME, GA.

My attention was recently called to an article in the British Medical Journal by Dr. Fournel, condemning rapid dilatation of the uterus as not being a conservative operation.

So far as my observation goes, the dangers from the operation are very slight where proper precautions have been taken. Divulsion of the uterus offers more relief in selected cases than the more complicated and dangerous operations and should be done before advising the latter.

The main indications for the operation are narrowness of the os and cervix of the uterus, flexions with dysmenorrhea and sterility, and the reflex symptoms arising from same. Personal observation makes me believe that many cases of obstinate nausea and vomiting of pregnancy can be relieved by rapid dilatation shortly before an expected conception, as we often have to perform abortion in cases that conceive very soon afterwards, rendering the operation again necessary. The cause of dysmenorrhea and sterility in a majority of cases is mechanical, and dilatation is usually followed by a relief of the symptoms if not a cure of the sterility. The contraindications are pyosalpinx and acute peritonitis. In an aggravated case of chronic pelvic peritonitis rapid dilatation can be done with safety after a few weeks of general and local treatment.

The operation should be done about a week before menstruation and the technique is simple. The patient should

be prepared by having been given a saline purge the day previous and a 1-4000 bichloride vaginal douche the day of the operation. The dorsal position and the bivalve speculum are preferable.

An anesthetic is required only in exceptional cases, and most women prefer some pain to the unpleasantness of the anesthetic.

A set of graduated uterine sounds is necessary to determine the direction and point of stenosis of the uterine canal. The canal should be straightened and gradually dilated so as to admit the dilator, and this part of the operation requires more tact and patience than any part of the proced

ure.

The cervix being drawn down and steadied by the vulsellum forceps, the dilator is introduced and the dilation is made about half an inch in opposite directions.

The lighter forms of dilators are preferable for this oper ation. Rest in the recumbent position and carbolized douches for a few days complete the treatment. If there has been much pelvic inflammation, absolute rest in bed for four or five days is required. I will mention an illustrative

case.

Mrs. Blank, a small woman twenty-three years old and has been married one and a half years. She has had dysmenorrhea ever since she was seventeen years old, when menstruation first began. Two years before I saw her, she had appendicitis and since then has had chronic pelvic peritonitis, which was aggravated at each menstrual period. She had almost constant pelvic pain and difficulty in walking. During the last few menstruations she had hysterical convulsions and coma which would last four or five days. I was asked to see her with the attending physician, and found a narrow vagina with the uterus flexed retro-laterally and prolapsed with posterior adhesions, making it immovable. The ovaries were prolapsed and inflamed with adhesions.

Two

The smallest uterine sound could not be introduced. skillful physicians and one gynecologist advised ovariotomy and anterior fixation of the uterus in view of the great disturbance arising from dysmenorrhea and the remote effect of the convulsions on the mind.

A more conservative course was pursued and the patient. was given local treatments of iodine and ichthyol for three weeks, and then the uterus was subjected to rapid dilatation. Great difficulty was experienced in introducing the dilator, but I finally succeeded without the use of an anesthetic. After the operation she menstruated with comparative comfort and in three months conceived and is now eight months pregnant and her health has been excellent. After she is delivered I believe she has a better prospect for health than to have submitted to a radical operation. We take a great responsibility on ourselves to advise the removal of the ovaries in young married women and destroy all hopes of maternity.

DISCUSSION ON DR. HARBIN'S PAPER.

Dr. R. R. Kime, Atlanta: This is a very interesting subject. We have some leading men in the profession doing gynecological work who condemn dilatation of the uterus, and claim that a great many of the troubles with the tubes and ovaries and pelvic inflammatory trouble are produced by meddlesome interference with dilators and the curette. I am rather inclined to believe that many of the ill effects that come through the use of the dilator and curette in ordinary gynecological work are from the faulty manner in which they are used; in other words, that the work is not done in an aseptic manner. Frequently practitioners in doing work of this character fail to recognize the importance of infection of their patients with the dilator or with the sound, or with some other instrument that is being used in the uterine cavity, and by which means in

fection is carried to the uterine cavity that did not previously exist there. But if practitioners will recognize the fact that dilatation of the cervix is a surgical procedure and requires preliminary preparations in order to do it in a thoroughly aseptic or antiseptic manner, then the results will not be so injurious. I think it is a conservative measure in a number of instances, and when properly carried out, as the doctor has stated, is beneficial and conserves the complications that may arise from want of drainage from the uterine cavity. There is no question in my mind that in many cases where we have pelvic complications due to endometritis, sterility due to an anteflexed or retroflexed uterus, an elongated cervix can be materially benefited by free open dilatation of the cervical canal, thus securing good and free drainage from the uterine cavity. In those cases I rarely ever find an instance in which I would dilate the cervix without supplementing it with a curettement of the disease that requires dilatation of the cervix. It is also essential to remove the diseased condition at the time you produce dilatation of the cervix. If we fail to remove the diseased condition of the endometrium, the traumatism produced by dilating the cervical canal may cause infection from above and not from below through instrumentation; the material coming down from the uterine cavity may be infectious in character, and you open up a new avenue of infection by the traumatism incident to the dilatation of the cervical canal. Your instruments and hands should be aseptic in your operations, but the uterine cavity should also be rendered as near as possible aseptic at the operation. It is here I think gauze tampons have a legitimate use in gynecological work, as well as in cases after operation. Some of you are aware that I strongly condemn the use of tampons in cases of septic infection after labor. In these cases, after dilatation of the cervical canal the tampon acts as a surgical dressing and controls the application of the