was observed to be congested, and the left tonsil somewhat enlarged and inflamed, the right one less so; the submaxillary lymphatic glands were increased in size, more especially below angle of jaw on left side.

Submitted to treatment at my hands the following March, and expressed herself then, as she does now upon inquiry, as feeling generally very well. The thermometer, however, displayed a slight rise of temperature, and she was pale and evidently anemic, but withal bright and cheerful in spirits. The glands were now very prominent on left side of neck, and in the right axilla they were also found considerably enlarged, but nowhere else were they apparently different from the normal. The spleen was somewhat enlarged. A scaly rash covered the back.

In consultation with Dr. George Byrd Harrison, the diagnosis. of Hodgkin's disease was at once agreed upon, and she was forthwith given Fowler's solution, combined with the bitter wine of iron, to be taken three times a day. The propriety of extirpating the worst affected glands in the neck was briefly discussed and decided in the negative, on account of the evidence presented of widely-spread disease. Later on the diagnosis was concurred in by Dr. Charles E. Hagner, who also approved of the treatment adopted.

Meanwhile, the administration of the remedies has been persevered in without interruption; her diet has been a palatable and nutritious one, and in all respects her hygienic management has been unexceptionable.

The result is, that her general condition has greatly improved, but the glands, while perceptibly reduced in size, still present to view threatening proportions. The rash disappeared, after taking the medicine, in a short time. The urine has been tested once only, and was then proven to be free from albumin. The initial examination made of the blood revealed a marked increase of the white corpuscles, but each subsequent one has shown a steady diminution in their number, until now they apparently do not. exceed the normal ratio. The red blood-corpuscles present a crenated appearance, but do not seem to have undergone any numerical change.

An interesting question is, what effect might the supervention of a first menstruation have upon the progress of the malady? It is known that a greater susceptibility to leucocythemia is created by the natural cessation of the function.

Admitting, if only for the sake of argument, that the two diseases are really identical, and that the vital forces, under the circumstances attending the initiation and termination of the menstrual function, exert quite opposite influences in the economy, it would appear that the susceptibility to the disease attaching to the one period of life would not be evinced so

strongly at the other, and that, indeed, a remedial effect would accompany the puberal flow of the menses.

In conclusion, I will venture to formulate the following propositions:

1. That leucocythemia and lymphadenosis are different names for the same disease.

2. That this (single) disease may, and does often, appear in modified forms.

3. That inasmuch as it remains undecided whether this disease is primarily local or general, it may on that account, if none other, be, for the present at least, relegated to the same category with carcinoma.

A NEW METHOD OF TREATING AGGRAVATED ANTEVERSION.

BY

W. W. TURVER, M.D.,
Parkdale, Can.

IN the month of April, 1884, a patient, Miss S., about 28 years of age, came under my care for uterine trouble. Her history for the past eight years had been one of almost continuous suffering, notwithstanding the efforts of her medical advisers. For the past two years she kept her bed most of the time, the recumbent position being the one that made life the most tolerable.

On examination, I found that she had anteversion of an exaggerated character, that is, the cervix pointed upwards and backwards instead of downwards and backwards. The irritability of the bladder was constant, and the pain over the pubis severe. Examination of the fundus, which first met the finger, showed it to be tender and hard, especially after menstruation. When this tenderness existed, it was always associated with two little tumors, one on each side of the fundus. It became an important question to myself what these tumors were. Were they constant, or were they the ovaries enlarged and inflamed? Sometimes they were quite large, and at other times between the menses they were almost imperceptible.

I concluded early that they were the ovaries in a congested condition and, being glandular, became enlarged by the contiguity of the metritis and the endometritis which was present the greater part of the time. She never had her menses without having an attack of inflammation and great pain in front over the pubis and

the left side, which she learned to subdue with quinine and opium internally, and hot fomentations. Every morning, about four o'clock, she woke up with a pain, and several times during the month she had pains that were concentrated agony. These last pains I concluded were attacks of uterine colic brought on, no doubt, by the uterus attempting to expel its inflammatory products. After these attacks, which she always treated with hot fomentations, I noticed a bluish, degenerated-looking uterine discharge. This, together with the uterine colic and the difficulty I had in passing the sound, led me to the conclusion that there was obstruction of the internal os in addition to the anteversion, the metritis, the endometritis, and acute inflammation and congestion of the ovaries, more especially the left. My conclusions were as follows: The uterus is naturally a contractile organ. Any inflammation of its body or lining membrane would irritate the uterine muscular fibre so that it would contract and continue in a state of contraction while the irritation lasted. The os internum remaining in a state of contraction and in a state of chronic inflammation, the result would soon be complete obstruction; the uterus and its contents becoming like an abscess for the time being, the purulent matter being discharged through the internal os, the point of least resistance. Now the absorption of the purulent contents of the uterus by the lymphatics would easily produce an altered condition of the ovaries, setting up oöphoritis, and in the uterus metritis, and in the adnexa cellulitis, peritonitis, etc. Having arrived at these conclusions, I determined to dilate the internal os, inflammation or not, as it appeared to me to be the proper step; consequently I provided my patient with opiates and quinine, and trie 1 one of the dilators made on the glove-stretcher principle; but alas! three weeks' inflammation resulted, but after the next menstrual period there was less disturbance, and the uterine colic was very much relieved. In the mean time I tried my own and many other pessaries, and a baker's dozen of original designs. The difficulty of wearing an instrument was due to the metritis and bladder in front, congested and inflamed ovaries at the sides, and who ever heard of supporting an anteverted uterus from behind in Douglas' cul-desac, the only spot that didn't hurt in her case? The form of this support was a ring attached to a stem like the handle of a door key, the posterior cul-de-sac resting on the top of the ring, or in other words, I supported an anteverted uterus by the utero-sacral ligaments. This gave two months' great relief, but the colic came back again, and another dilatation was attended by so much disturbance that further interference was postponed until the fine weather in May. Another attempt at dilatation succeeded well. I used this time instruments devised by myself, using three sizes consecutively, with the very best success. The patient did very well with the key-handle-stem pessary, but was far from comfortable, as the left ovary was always in the way, so I concluded to try my soft-rubber Gehrung pessary, bending the soft-rubber

Anterior

apron down so that it would slip up easily into Douglas' pouch behind the cervix. It served two purposes: first, it held the cervix in its natural position downwards and backwards, and second, it elevated the uterus by its utero-sacral ligaments, lifting the cervix entirely off the posterior wall of the vagina; the cervix being now held steady by the pessary.

I instructed my patient to introduce daily two or three pledgets of cotton batting (not absorbent cotton), smeared with glycerin, against the front of the fundus uteri, by means of a short mediumsized cylindrical speculum. This cotton pressing against the anterior surface of the fundus uteri pushed it up into its natural position, the cervix being compelled to retain its natural position by the pessary. This result was obtained in the month of September,

This diagram shows the modified soft-rubber Gehrung applied in this case,' with the superior branch A applied behind the cervix in Douglas' cul-de-sac, instead of anteri orly as originally intended in these cases. Depending from the superior branch 4 is the flexible apron B. This apron prevents irritation of the posterior portion of the

cervix.

1885, and I have waited now eight months before writing the case up for the profession, as I wished to present a permanent result. This young lady has since returned home, has attended to her duties daily, and has hardly known what it is to spend a day in bed. She attends church, and teaches in Sunday-school. In the month of February this year, and once or twice during the winter, the uterine colic returned, which shows that her old enemy, the uterine obstruction, is not completely conquered yet. I have operated on her since for the obstruction, and expect to have to do so occasionally for the next year, or perhaps longer. She still continues in the enjoyment of her greatly improved state of health.

Another feature of this case was irritation about the lower part of the dorsal region. There was no constant pain, only a tenderness over the spinous processes. After relieving her of the worst features of her uterine trouble, and expecting her to take out-door exercise, I was met with what she described as a weakness of the spine. "Well," I said, "that must be helped too." Since last fall she has been supported by plaster-of-Paris jackets. This enabled her to have complete command of herself. I am sure the spinal irritation has been an element in the uterine obstruction from which she has suffered.

Now I will finish this, to me, remarkable case by offering a new physiological explanation of the mechanical principle that enters into the sustentation of a movable body like the uterus in a round cavity like the pelvis.

The principal supports of the uterus are the broad ligaments on either side. They are attached almost from the top of the fundus to the cervix, and extend laterally to the sides of the pelvis, while the utero-sacral and the utero-vesical are attached in front and behind just above the utero-vaginal junction. The broad ligaments are vertical in the natural position, or if not vertical, incline slightly to the bladder, the filling of which tends to keep them vertical. When vertical, they are a tower of strength to the uterus, but let them become horizontal with the small intestine resting upon them, reinforced by a full bladder folding over them, and the ever-constant force of inspiration, their strength is practically gone, or, in mechanical words, they are to the uterus what the Howe truss when vertical is to a bridge. Flat or horizontal, they proportionately lose their usefulness for sustaining the weight, just as a truss would in a bridge if laid flat. The broad ligaments are the Howe trusses of the uterus. In my patient I rotated the uterus on its long axis (see diagram) by holding the cervix behind with my pessary modified, and pushing up the fundus in front with cotton, thus rendering the broad ligaments, the uterine trusses, vertical. When vertical, the bladder and small intestines gravitate so as to assist in keeping them up; when flat or horizontal, the whole superincumbent weight of bladder and small intestines comes on the broad ligaments to their great damage. Without holding the cervix in the pessary, and applying cotton only, the whole structure would be elevated in the abnormal or flat position, and the rotation of the long axis of the uterus would not be secured, nor the broad ligaments become vertical.