diseased mass, but was merely softened and had its internal surface tumefied into nipple-shaped excrescences. From the midst of this softened mass, two ulcerated openings led into the descending portion of the duodenum and the transverse arch of the colon-adhesions prevented any communication with the peritoneal cavity. In the vicinity of the ulcerated openings the mucous membrane of the intestines was diseased; with respect to the duodenum the disease occupied its first and second portions and a part of the third, which were of their usual calibre; but the remainder of the small intestines were free from disease and much contracted in their diameter. The disease of the colon extended both ways, backwards to the cæcum and onwards throughout its whole length and even into the rectum. This disease consisted chiefly of a dark ecchymosed appearance of the valvulæ conniventes of the duodenum and the longitudinal plicæ of the colon, with thickening of the submucous tissue. The mucous membrane of the stomach was not obviously diseased, but the change in its appearance from the pylorus to the duodenum, where the opening existed from the softened tumor, was very abrupt.

Chest. The only morbid appearance discovered in the chest was an atheromatous, and in one spot earthy deposit at the commencement of the aorta, and an interstitial pliant deposit in the mitral valves.

CASE 5. Long continued ague with chronic diarrhea-enlargement and softening of the liver with biliary calculi impacted in the gall-bladder—the products of peritoneal inflammation of the surface of the liver and intestines—internal surface of the stomach coated with tenacious layer of mucus-morbid appearances denoting chronic colitis, with ulcerations in the process of healing.

E. M. æt. 36, widow and plat-worker, was admitted Nov. 2, 1837. She had had various attacks of ague ever since the preceding March-the type was at first quartan, but had become quotidian. During four months preceding her admission she repeatedly had attacks of diarrhoea, and, for two months, had suffered from pain in left hypochondrium, increased after each paroxysm of ague. At the period of her admission she was still labouring under ague, profuse diarrhoea and pain, with tenderness of the left hypochondrium; and presented a wan, sallowish aspect-appetite and digestion were at that time not greatly impaired. A blister was applied to the left hypochondrium and a few grains of sulphate of quinine directed to be sprinkled over the blistered surface-at the same time, a combination of hyd. c cret. and pulv. ipec. comp. and liquor calcis, were used to combat the diarrhoea. Under this treatment, the ague ceased and the diarrhoea was checked; but, on the 9th, a large but superficial slough had formed on the blistered surface, and she complained of pain with tenderness at the epigastrium, and had a very anxious look. The slough separated in a few days, and left an extensive granulating and suppurating surface; by this time (9th) the tongue had become very dry in the centre, and viscid and red, and the epigastric pain continued. On the 14th the diarrhoea again returned; from this time to the 16th of the following month, she had frequent relapses of diarrhœa, for which various remedies were used for the most part ineffectually, with the exception of the sulphate of copper, which given in of a grain doses every four or six hours had a considerable effect in controlling this state of the bowels. During this time her general condition varied very considerably, the appetite sometimes being good and the stomach capable even of digesting animal food in small quantities without aggravating the symptoms; while at other times food of any kind could scarcely be tolerated, and the pain in the epigastrium and left hypochondrium, with a very red tongue, returned.

On the 16th of Dec. the tongue again became dry and glabrous, and the abdomen was tense and resonant, with pain and tenderness in the right hypochondrium and right lumbar region. From this period the most urgent symptoms continued to be referrible to this region of the abdomen, with a relapse of pain in the epiNo. LIX. Ꮓ

gastrium, and afterwards a return of profuse diarrhoea. This state became gradually worse, till these symptoms, with the exception of the diarrhoea, were exchanged about the 6th of January, for those of sinking and collapse, which terminated in death on the 18th; during this period (from the 16th Dec.) little relief was derived from any remedies, a suppository of opium alone mitigating the diarrhoea-at an earlier period a few leeches had relieved the abdominal pain.

Post-mortem examination, nine hours after death.-Great emaciation-dema confined to the right lower extremity. The liver enlarged and reaching as low as the umbilicus, was covered with patches of soft adventitious membrane; the structure of the liver was soft, friable, and pale. The gall-bladder was contracted and elongated, and entirely filled by seven or eight gall-stones of the size of small marbles, sacculating the bladder. The small intestines, extremely dark, were glued together by cellular adhesions: from one to two pints of fluid were contained in the peritoneum. The spleen was of natural size and consistence, presenting only on its surface, slight, thin and white patches. The mucous membrane of the stomach was besmeared with a large quantity of mucus, as were the valvula conniventes with mucus tinged with bile. The cæcum, ascending colon, and transverse arch presented a healthy mucous surface: there was however an asc. lumbric. in the cæcum; and the arch was much dilated. The descending colon and rectum were greatly diseased-the coats being much thickened; the change from healthy to unhealthy mucous surface was quite abrupt, presenting a clean line of separation. The internal surface presented a dark, thickened, uneven condition of the membrane, with insulated fungiform portions; the whole patch which occupied the entire calibre of the descending colon, sigmoid flexure, and the greater part of the rectum, had the appearance of ulceration in the process of healing, being below the level of the adjoining healthy mucous surface. The large intestines contained a quantity of solid fæces. The neck of the uterus was of cartilaginous hardness.

ON THE BEST MEANS OF APPLYING PRESSURE TO THE UTERUS AFTER DELIVERY.

To the Editors of the Medical and Chirurgical Review.

GENTLEMEN,-The important principle of making such pressure on the uterus as will ensure its contraction immediately after the birth of the child, in every case of labour, is at length so fully established as to be received throughout the profession as one of the axioms of scientific midwifery. Every practitioner carries out this principle by some one or other of various methods which suggests itself to his mind, from the simple pinning of the long napkin to the formidable tourniquet and rolled pillow. With the ulterior desire of eliciting further mechanical improvement, I proceed to give an explicit description of two bandages which I have long used in my practice; and some medical friends, whose judgments I highly value, have tried them with the greatest satisfaction.

In forming these bandages my first object was to make pressure on the region of the uterus by a firm unyielding substance; because, by this means, the contraction of that organ was found not only to be more readily produced than by a similar degree of force applied by means of a bandage composed of linen or of any soft substance, but, having been so produced, was more readily maintained. To this principle we must refer the signal benefit derived from pressure by the firmness of the hands in cases of sluggish uterus; but hands and arms soon tire at this employment, and consequently the degree of pressure

necessary to the complete contraction of this organ, instead of being steadily continued, becomes relaxed, and hæmorrhage occurs; or if it has been momentarily suspended, is renewed.

Figure 2, in the subjoined engraving, represents a piece of mill-board, obtained from the stationer, seven inches by eight, padded on the inside with two layers of wadding, and covered with flannel or keth flannel or kerseymere. This plate has been previously divided down the middle, as seen in fig. 3; then united by pasting a strip of leather on each side, so as to form a joint; thus enabling it to be folded into half its compass, like a closed book; and, with the band, fig. 1, wrapped round it, to be conveniently put into the pocket. The band, fig. 1, which is made of variable length to suit the different dimensions of different females, is composed of webbing, three inches wide; is furnished with two buckles, and three sets of straps to regulate its pressure; and has four inches of India-rubber web let into it, so as to combine a degree of elasticity with the force of its pressure. Fig. 3 shews the bandage duly applied; the band being under the crests of the ilia, and carried round the hollow of the back, just at the junction of the sacrum with the spinal column, by which it is prevented slipping upwards. This bandage, from its easy application, I use immediately after the birth of the child, directing the nurse, if there be hæmorrhage, to increase the pressure by buckling it tighter. This simple bandage answers well for every purpose proposed, is capable of exerting a great degree of pressure, and of thus facilitating or accelerating the complete contraction of the uterus.

When the patient is comfortably in bed, I usually apply what I call my sash bandage: were it applied previously it would probably become soiled. This is represented, fig. 7, applied under the crests of the ilia, and carried to the hollow of the back, just above the sacrum. Fig. 5 represents the exterior, and fig. 6 the interior of exactly the same plate, with the joint as described in fig. 2; but on each side, within two inches of the bottom, are two holes through which a piece of tape is seen passed from the inside, to attach a pearl button on the outside of the size of half-a-crown, as seen in fig. 4. Fig. 4 shews this bandage before it is applied, folded in half: it is about 30 inches long, and made of white jean doubled; it incloses the plate, fig. 2; it tapers from the width of the plate towards each end, where twelve inches of strong broad tape are attached for tying under the buttons, as seen in fig. 7.

The bandage is sloped downwards to fit the hollow above the sacrum, and in its posterior portion a slit is made, through which its opposite end is passed. By placing the plate over the region of the uterus, carrying the two ends of the bandage to the hollow above the sacrum, and then bringing them round under the crests of the ilia-drawing them tightly over the plate, and tying the tapes in a firm manner under the buttons-a very effectual resistance is offered to the tendency which otherwise every bandage would have to slip upwards, and recede from the part which should receive pressure.

The specific advantage of the above plan, besides affording an extraordinary degree of comfort to the patient by the support it affords to the relaxed abdominal parietes, thus preserving the natural figure, is found by experience to be the prevention of uterine hæmorrhage and its dreadful consequences. Under the pressure which this bandage is capable of producing, even the formation of a coagulum of any size is almost impossible, and thus the accoucheur is enabled to leave his patient in a state of perfect security, which never can be the case if the uterus, though contracted at the time, be left without the support of some such pressure, which is therefore essential in every case in a greater or less degree. The natural expulsion of the placenta will be much accelerated by systematic pressure. Dr. Ruysch first, and afterwards Drs. Denman and Wm. Hunter, vainly imagined that the musculus orbicularis Ruyschii was self-sufficient for the expulsion of the placenta, and also for the complete contraction of the uterus; but even this muscular power is very greatly increased by the aid

of pressure. I could give the detail of several cases of retention of the placenta, which I have recently seen in consultation, where the uterus sympathizing with the general system, after a protracted labour, was in an atonic state. In these cases, as there was no hæmorrhage, I advised the continued permanent pressure by means of my bandage. The inherent muscular power of the uterus, thus assisted, safely expelled the placenta, in every one of these cases, without the introduction of the hand, and without any hæmorrhage. In one or two of these cases the placenta was retained three days and nights without any untoward symptom, and then securely and satisfactorily expelled by the natural efforts. A manifest mitigation of after-pains is acknowledged to be produced by means of these bandages by many females who have previously borne children, and have had no such assistance.

By securing the permanent contraction of the uterus, many cases of puerperal fever may be prevented, for it may be confidently asserted that puerperal fever is frequently produced by a congested state of the uterus. Nine tenths of the diseases of the uterus, especially the chronic and acute engorgements, may be traced to the condition of that organ after parturition, and may be prevented by means of a proper pressure, such as the bandage described is calculated to make.

We have much reason to wish that those who have witnessed the accurate precision with which the various diseases of the uterus are discriminated and treated at the different institutions at Paris, where I am given to understand the most rapid progress has lately been made in this department of our art, would throw some light on this obscure subject. We might then be led to abandon the absurd system of fighting with the symptoms of the disease of the uterus, as though they were in themselves diseases, for the adoption of a rational system founded on accurate knowledge of the various alterations of structure which produce those symptoms.-Your obedient servant, J. L. FENNER.

15, King's Row, Pentonville,

Gentlemen,-Incessant professional occupation has hitherto prevented me from replying to your illiberal and malicious attack, in your so-called review on my work, The Philosophy of Marriage, which appeared in one of the late numbers of your periodical. For my own part, I should have deemed your criticism totally unworthy of notice, as it is well known by all in the least acquainted with the periodical literature of the medical press in this country, that there was something like an old score, or quid pro quo, on your part, to be settled between us, after my former just animadversions upon your pitiful productions. This is now evident from the fact that you, and you alone, of all the medical reviewers, my former rivals, thought it a convenient opportunity to attack my work as soon as I had ceased to be a rival editor, for you durst not have done so before with impunity, as you are very well aware.

It also appears that you have not the common candour of allowing those whom you attack an opportunity of defending their works in your pages, and much less the space, unless by paying heavily for the mere insertion of retributive and just defence; notwithstanding that journals which have, and will continue to have, a far greater circulation than yours, invariably admit the insertion of replies to their criticisms. Availing myself of this liberal privilege afforded by the Medico-Chirurgical Review, which, by the way, has a circulation your precious Review can never even approximate, in consequence of the injudicious manner in which it was begun, and has been hitherto conducted, I now reply to you.

Had you not started aside from the usual observance of etiquette amongst fair and honorable editors, you would not, as I above intimated, have unwarrantably and maliciously attacked a former editor, solely because he conscientiously censured your productions, on account of their want of any, but negative merit.

When you published the first part of the Cyclopædia of Practical Medicine, I felt it my duty to criticise it in the spirit of truth and science; and pronounced it a meagre and spiritless compilation, far below mediocrity, made up, for the most part, of extracts from the old writers, without any useful additions derived from the then actual advanced state of science.