559 open-the uterus appeared to the taxis enlarged, but not unnatural in consistence, and not painful to the touch. The weather being warm, the doors and windows were thrown open. She had, of her own accord, remained perfectly in the horizontal posture, lying upon a mattress from the moment of her arrival at home, and taken everything cold. I administered a tumblerful of cold spring water ; plugged the vagina firmly with pellets of sponge; adjusted a T bandage and compress, and exhibited

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... achm doses of the ergot of rye, with a view of exciting the uterus to throw off any body that might be contained within its cavity. Very slight pains followed the employment of the ergot. At the end of eight hours the plug was removed; a firm clot was found filling the mouth of the womb, which, when drawn out, exhibited a cast of the uterine cavity. I fathomed the uterine cavity, now that the orifice allowed me, with a bougie, but found no contents. I then could assure my patient that all was come away. The catheter was employed, that she might not be raised from her horizontal position, and she was left with the security of a firm broad band and compress applied round the abdomen. 27th.-Going on favourably. She has taken no opiate, there being neither restlessness nor sleeplessness. An aperient was ordered, and her convalescence was gradual, but progressive and complete. jRemars.— From the previous good health of the patient, I apprehend that the suspension of the catamenial function in this case was due to a natural cause, and that the product of conception had been overlooked in the clots which had escaped prior to her leaving for London. The cause of this lady's mishap may be attributed to much fatigue and excitement, which she had undergone in superintending-in the absence of all inclination for the duty on the part of the husband-the arrangements for their new habitation. In the treatment of this case, the acetate of lead was not exhibited; the application of ice was not made, for the reason that, although the loss had been absolutely large in amount, there was not the urgent necessity, on account of prostration from haemorrhage, which was manifested in the case of Mrs. A. The combined influence of the "plug" and the ergot of rye, with free ventilation of the room, appeared to me, therefore, quite adequate to the wants of the case. The exhibition of stimulants so strongly indicated in the instance of the above reported case of uterine congestion, was, for the reasons already stated, not here indicated, and would, probably, in the sequel, have led to some ' , , inflammatory attack in the puerperal state. The ordinary treatment and restricted regimen for the puerperal period were strictly ' enforced and adhered to. IT is easy to perceive, that independently of the relations which we have noticed between the various conditions of disease, we have frequently that of co-existence or complication. In the first place, it is not by any means to be inferred, that when one condition has induced another it must itself necessarily cease to exist, and that in setting up a further state of derangement, it must accomplish its own rectification. When the primary morbid condition is of a permanent or chronic kind, it remains in combination with the secondary disorder, so that the disease accumulates as it proceeds; and this, indeed, is the case in most instances of morbid association. Hence, a disease is, as it were, built up by the superaddition of one condition of disease on another, and a new source of interest arises from the consideration of the modifications produced by the complication. In the second place, it is quite clear that two or more derangements may be simultaneously produced by a common cause, so that they may each be regarded as equally traceable to the same extrinsic influence. The agency of malaria in fever is probably exercised contemporaneously on the blood and on the nervous system, so that if we could conceive either of its effects to be removed, it would not render impossible the occurrence of the other. Far from this being the exception to the general rule, there are, in fact, few instances in which the external causes of disease are altogether operative in originating a single morbid action, and for this reason we have had, from time to time, to exercise a kind of mental analysis in order to separate and point out the conditions which are blended together, and which acknowledge a common causation. I In the third place, a succession of influences may contribute to establish a complicated malady, the first condition receiving the second, though it do not produce it; and it can scarcely be considered curious, that when the body is already under the influence of disease, it should be obnoxious to further morbid accessions. In the case of some eruptive complaints, it would appear that the presence of one derangement precludes the arrival of another, and Mr. Hunter endeavoured to explain the curative operation of mercury by the supposition that it originated a specific disorder of the system, which was incompatible with that for which it was prescribed. This doctrine, however, plainly requires much limitation, for we know that it is rather the tendency of disease to render the body more highly susceptible of other disorders than to give it any immunity. It is only in those cases where the two actions are contradictory in their nature, that they are incompatible in their existence. In the fourth place, the co-existing derangements are sometimes quite accidental, but they are not on that account the less deserving of attention, nor, indeed, beyond the reach of anticipation and careful consideration. Accidental combinations are not, however, to be considered as rare. On the contrary, it would be rare to find a disease without them. Nor should we be disposed to view accidental combinations as undeserving a share of our regard. Perhaps they should in reality be allowed to claim an especial attention, because we are the least prepared for them, and because we are the less likely to have reduced our notions to a clear and practical form. Any one may be prepared to treat a case of phthisis or of pneumonia, but if we find pneumonia in a phthiical subject, we have a new source of anxiety on the adjustment of our remedial measures. It must be apparent, that the subject of complication is one of the deepest importance, inasmuch as it bears most intimately on the diagnosis and treatment of disease. The consideration of important complications leads us, in many instances, to moderate the activity of our treatment, and in others, to use more decided and vigorous means. In reality, every judicious practitioner must and does consider the effects of morbid combinations, though he may himself be scarcely aware of it; for every measure must be regulated by the nature of co-existing and therefore modifying circumstances. At the bedside of the patient we do not look for a case of pure inflammation, or the derangement of a single organ ; we look for a combination of morbid conditions, and have to bear in mind the whole fabric of derangement, commencing, perhaps, with the hereditary defect in the constitution, passing to the acquired morbid peculiarities, and embracing all the actions and reactions of the various morbid states which are present. We have nothing to do with disease in the abstract. Sometimes we are called upon to treat the young, sometimes the old ; now the plethoric, now the spare ; at one period, the man reduced by previous illness, and at another, the subject of an acute disorder; now the lesions of a single organ, and now those of a multiplicity of parts. There is no subject, perhaps, in the practice of medicine, which requires a more nice discrimination than the treatment of compli-' cated derangements. How often there is an apparent contrariety of disorder, or, at least, that combination which seems to call for a curious modification of treatment; a clashing of opposite indications, which we scarcely know how to combat. On the one hand, we have to subdue morbid action, whilst on the other we have to sustain the strength and economize the remaining powers of life. Whilst we seek to preserve vitality, we fear to add fuel to disease, or light up the smouldering flame of inflammation. We have often to sail between the Scylla and Charybdis of disease. It is obvious that the various pathological conditions which have been enumerated, must often be united in a very complex manner, and often, lesions, which might have been supposed incompatible, are found in combination. The contention of opposing actions often produces a mean state of disorder which requires a different form of treatment from that which would be called for by any of its component elements. Neuralgic affections are sometimes found blended with inflammatory action, and chronic changes are accelerated by the supervention of acute hypersemia. That combination of derangement which composes what is understood by the term debility, is not incompatible with acute inflammation. Again and again we hesitate between contrarieties of practice, or what one would recommend another would deprecate. In many cases, it is proper to pursue a medium course; to combine local depletion with the use of the lighter tonics and the diffusible stimulants. The use of mercurials and the application of blisters are often found safe and efficient measures. But, after all, the difficulties are frequently of the most perplexing nature. We may be fearful of impairing our efficiency by a too rigid neutrality, and still we know not by what indication our remedies are chiefly solicited. It may, perhaps, be possible to connect some observations on the treatment of co-existent conditions of disease with the considerations which will hereafter be offered, but much will always be left to the practitioner, and his skill must ever be deter-