The intention of the uterine supporter might, perhaps, be best illustrated by its resemblance to the easy introduction of two closed fingers, within the vulva, which, after passing through it, are separated, and applied to either side of the cervix uteri, so as to hold it up in its proper position.

The instrument which I have thus described, for the support of the prolapsed womb, will, I think, be found to fulfil all the requisite conditions laid down in a former part of this paper. The utmost separation of one of the free extremities from the other, when placed at the upper portion of the vagina, is about two inches, giving a support quite sufficient for the purpose, and yet not presenting so great a diameter as that of many of the globe and ring pessaries: the objection to Professor Kilian's instrument is at the same time obviated, and I have not found any patient complain of pain arising from lateral pressure. This, however, is easily explained, by recollecting that the upper portion of the vaginal canal lies naturally in a flaccid state, easily admitting the presence of such an instrument, without any peculiar degree of tension being felt by its walls.

In some cases I have found much advantage, by tying loosely round the instrument a piece of lint, or linen rag, saturated with either anodyne or astringent lotion, this mode of applying such remedies being much more effectual than the temporary syringing.

I have, at the present time, several patients who are wearing the "supporter," with, they inform me, great comfort to themselves, and who find no difficulty in its introduction and removal. One of these cases was, at first, complicated with retroflexion of the womb, attended with great agony, and serious affection of the general health. By the use of the instrument proposed by Dr. Simpson, the uterus was restored to its natural shape, fortunately, in the course of a few days, as I was unable to continue the employment of the instrument any longer, owing to the severe pelvic pains which it caused. After it was removed, the " supporter was used, since which period the patient has felt no pain whatever, and has

been able to walk out daily for some miles, which for months previously she was incapable of attempting.

I have employed the "supporter," also, with equal benefit, in another interesting case, where there was protrusion of the womb, containing a fœtus of nearly four months' development, with total inversion of the vagina. The uterus, with its contents, was replaced, the instrument worn for some weeks, and the case went on favourably to the full term of gestation.

A pessary, the invention of Dr. Bronard, has been shown to me by Dr. Locock, as somewhat on the same principle as the instrument described in this paper. It differs, however, materially, as will be observed on comparing them. The free ends, in Dr. Bronard's instrument, are placed downwards, so as to rest on the internal surfaces of the vulva, while the ivory ring acts as a support to the womb.

I have not, in the preceding observations, alluded to the different surgical operations proposed for the obliteration or contraction of the vagina, in order to effectually prevent descent of the womb, as I presume that they would not be considered as adapted to such cases as those I principally refer to, viz. such as occur in women at the child-bearing time of life. Artificial contraction of the vagina, and of the vulva only, as proposed by Fricke, D'Outrepont, and Berard, and the various methods brought forward in our own country, by Dr. M. Hall, Mr. B. Phillips, and others, would, of course, have reference only to those cases in which mechanical support had failed.

CONTRIBUTIONS TO THE STATISTICS

OF

VALVULAR DISEASE OF THE HEART;

WITH ESPECIAL REFERENCE TO AFFECTIONS OF THE SEVERAL ORIFICES,

AND

THE PARTICULAR EFFECTS OF CERTAIN RECOGNISED

CAUSES.

By A. WHYTE BARCLAY, M.D.,

PHYSICIAN TO THE CHELSEA, BELGRAVE AND BROMPTON DISPENSARY, AND MEDICAL REGISTRAR TO ST. GEORGE'S HOSPITAL.

Received April 14th-Read May 9th, 1848.

IN presenting these remarks on the subject of valvular disease to the Medico-Chirurgical Society, I feel it due to myself to state that the inquiry was entered into with no view to publication, but merely to ascertain facts for my own instruction, which published works on this subject did not supply. But having found that other results began to develop themselves, and having formerly experienced the need of such statistical information as the present paper contains, I have been led to hope that it might be useful to others. To render the results of the investigation more readily available, I have placed in a tabular form a short resumé of the more important pathological facts observed in various organs in the several cases analysed. These facts will, I trust, carry with them the more weight as they are put forward on the authority of Messrs. Hewett and Pollock, the successive curators of the Museum at St. George's Hospital, by whom all post-mortem

examinations there have for some years been conducted and recorded.

The cases included in the Table occurred during the last two years, when a constant personal examination of cases in the medical wards necessarily threw much light upon the results afterwards ascertained in the dead-house. But as my object has been to obtain correct general statistics, I have not limited myself to those only which came under my own observation, but have endeavoured, by a careful perusal of all the cases, to ascertain in how many instances valvular lesion occurred; to compare, one with another, the various forms it assumes; and to detail in connection with it the morbid changes in other structures, which have reference more or less defined to disease within the heart. And here let me also acknowledge my obligation to the medical officers of St. George's for the permission kindly accorded me to publish such facts as are derived more directly from the Museum Records of that institution, in which a mass of materials of a highly interesting character have been accumulated for several years past.

The whole number of deaths in the hospital during the period above referred to was 535; the condition of the organs of circulation was ascertained in 419 instances, and among these there were seventy-nine cases of valvular lesion. These have been arranged in the Table, according to the ages of the patients. The first two columns exhibit the particular condition of either valve which had become the subject of disease; the others show the number of cases in which atheromatous disease was found at the root of the aorta,--the cases in which the previous history of the patient decided whether he had ever suffered from an attack of acute rheumatism, or the contrary,-the changes in the muscular structure of the heart,-the instances in which the recent effusion of lymph or the persistence of old adhesions indicated inflammation of the serous membranes within the chest,and those in which any change was found in the structure of the kidney. Other lesions are occasionally mentioned, and the chief cause of death is stated.

The term "fibrinous deposit" has been generally employed in the Table, as distinctive of that condition of the endocardial membrane which we are in the habit of considering as the result of acute inflammation: it is not intended to imply an adoption of the theory which attributes its presence to deposition from the blood, in preference to that which derives it by exudation from the lining membrane. It occurs sixteen times among the first eighteen cases, reaching to the age of 34, and is only five times mentioned among the remaining fifty-one cases. In fourteen instances previous valvular disease had existed, while in seven the fibrinous deposit on the valve is the only condition of disease. The details of these cases will be considered under other heads; but it cannot fail to be remarked, that whatever circumstances may co-operate in the development of this condition, the presence of fibrinous deposit is more influenced by the age of the patient than by any other cause whatever.

The valves affected in the seventy-nine cases detailed in the Table are,

In 36 cases, the aortic and mitral valves, simultaneously; or, 45

These numbers may be taken as pretty correct representatives of the relative proportions of valvular disease in general; for on a larger survey, extending to nearly 200 cases, I find the numbers are

46 per cent. for the aortic and mitral together.

Or, taking for our standard of comparison the whole number of post-mortem examinations, in which the condition of the heart is reported, viz. 419, as before stated, we obtain18.8 per cent. of valvular disease;

and