and uterine prolapsus, as already distinguished, a marked difference as regards the hepatic condition and state of the portal circulation. In the former, the cause is usually localized to the vaginal tissues and its surroundings; in the latter, the uterine engorgement, ascertained by the touch and use of the sound, usually coincides with an amount of portal derangement which helps to explain the physical condition of the uterus on the data already given. The successful treatment in cases of acute prolapsus necessarily requires a diminution of the weight of the uterus. Wherever this weight depends upon a partial stasis of blood within the tissue, and where this has for its cause a retardation or obstruction of the portal circulation, with the coincident conditions already described, the course to be pursued for remedying the evil is evident. I omit from present consideration those cases of added growths, or intra-abdominal pressure, which involve special structural change, and all obvious mechanical influences-tight stays, heavy petticoats, straining efforts, and whatever causes irregular vesical or rectal pressure.

I sought some means of assisting or stimulating the action of the portal system, where its obstruction forms the original source of the trouble. The medicinal agent I selected and have largely employed is the hydrochlorate of ammonia. It is administered with the intention of immediate absorption into the portal venules which ramify beneath the surface of the digestive tract. It was first suggested by the results of certain well-known experiments on blood-stasis of the effects produced by injections and administration of different salts, and by a

consideration of the recorded influence and mode of action of the 'drug, which has been for many years commonly employed in Germany as a deobstruent.

The use of hydrochlorate of ammonia for the purpose indicated implies a recognition of its value generally as an important agent for the relief of hepatic portal congestion. This I believe to be very great, but only one result of such congestion has to be here considered. Mercury, podophylline, taraxacum, aloes, &c., may be resorted to with the same intent in cases suitable for their employment. But in the following instances, selected because subsequent opportunities enabled me to verify the permanence of the result, the treatment was exclusively based on the administration of the hydrochlorate of ammonia, aided by those regulations as to hygienic treatment which have been described, and which are of such importance that the best devised medical treatment will fail unless they be observed.

1. S. W., æt. 6o, thin and worn. Prolapsus commenced 5 years ago; carried heavy weights, felt her strength diminish, so wore a steel busk and laced herself up "for the sake of the support." Uterus gradually protruded more and more, and now extrudes to the size of a turkey's egg-cervix large, granular erosion round the os as large as a florin.

Sore touched with solution of iodide of silver. Prolapse reduced and supported by a ball of oiled wool. A Zwancke's pessary introduced below this. Ammon. hydrochl. c. Tinct. ferri sesquichl. ordered three times a day. In a week the sore was healed. The pessary was worn for a fortnight, the medicine continued six weeks. No prolapse or suffering during this time. Four months afterwards had experienced no return of symptoms; and the uterus was diminished in size, natural in position, and the cervix healthy.

HISTORY.

5. A. M., æt. 52, suffered from bearing down since change of life four years ago, when she had several severe attacks of menorrhagia; cannot walk now from the constant pressure in body. Thin

and sallow, subject to hepatic congestion all her life, "especially before poorly times;" always menstruated very freely; bowels constipated. Uterus just seen at vulva covered by a vesical protrusion; none of posterior vaginal wall.

6. T.D., æt. 53, a stout, florid woman; ten children; change of life six years ago; has suffered from a sense of bearing down ever since. The uterus first appeared externally three years ago, and now protrudes as large as an orange. She was a cook until middle life, subsequently kept a laundry, with constant standing and much hard work.

TREATMENT.

Zwancke's pessary, manganese and magnesia in the morning; ammon. hydrochl. and tinct. ferri sesquichl., with quassia and chloric ether. Twelve days afterwards walked a mile without suffering; left off treatment, had a relapse with increase of all her original symptoms. After resuming treatment, she was enabled to get about in a fortnight, but was two months before the medicine could be discontinued.

Treatment as above, with hip baths in morning. In a month (the uterus not having prolapsed) she left off the pessary, continuing the medicine. After two years she reported she had been "quite tight ever since," and without any sense of bearing down, though frequently turning a mangle for several hours a day.

In prolapsus uteri, comprising under this term all the varieties of delapsion already described, the cavity of the organ does not necessarily deviate from its natural direction. Though the cervix may present at the vulva, yet intra-uterine exploration by a bougie so prepared, as to show, on withdrawal, the direction it has taken, will indicate that the gentle curve from os to fundus is still maintained; for the organ has just followed that course which in health is presented by the vaginal canal.

In the forms of uterine displacement next in frequency to prolapsus, the organ may retain its elevation within the pelvis, and the vaginal canal be natural in length and direction; for the deviation occurs above the superior pelvic fascia, and within

the true pelvis. It may consist of an entire displacement of the uterus; its parts still maintaining their natural relation to each other, and the whole organ being more or less turned, like a pear on its stalk. To this condition the term "version of the uterus" should be exclusively restricted. Or the womb may be bent on itself, with a necessary alteration of the angle which the cervix forms with the fundus uteri : this constitutes flexion. In versions, the bending is at the top of the vagina; in flexions proper, it is in or above the uterine cervix.

Of these two conditions of disorder of place, that most frequently met with is uterine flexion. But this includes a wide range of displacement, ranging from a slight increase of the natural curve to a state in which the uterus is doubled down upon itself, and its cavity becomes bent like a hook. Curvature of the uterus to such an extent as to constitute a disorder of place, occurs most frequently in the direction forwards. Where the uterus is folded on itself at an acute angle, the fundus usually has its directions downwards and backwards, constituting retroflexion. The curvature forwards of the fundus uteri may exist to such an extent that the whole organ is bent like a crescent. Monsieur Valleix has especially directed attention to this condition; and its frequency, judging from my own experience, justifies special consideration of the conditions under which it arises.

ANTEFLEXION.-The purpose subserved by the close attachment of the superior part of the vagina, and inferior