there was an increased size or misshapen state of the cervix or body of the uterus, such as might result from the inclosure and distension of a polypus.

To convert, however, the probability derivable from such symptoms into a certainty, we must endeavour to read the true value of these rational symptoms by obtaining access to the cavity of the uterus itself, and ascertaining, by examination by the finger, if a polypus be present in that cavity or not, or if there be any other co-existent uterine lesion, capable of accounting for the symptoms. It is becoming every day more and more acknowledged, that we can alone discover uterine diseases, and discriminate them from each other, by appealing in this way to the evidence of physical diagnosis. And no remark could be, pathologically and practically speaking, more sound and true than that which Sir Charles Clarke many years ago made :- "The true character of any disease of the internal female organs can only be ascertained by examination." With this view, in order to enable the finger to reach and examine the cavity of the uterus, the os and cervix must be opened up by a succession of sponge tents in the way already described. When an adequate degree of dilatation is obtained, the finger will be enabled to touch the tip of the polypus; and then the pediculated or polypous character of the tumour may be farther made out by passing either the finger or a uterine sound between its body and the containing cavity of the uterus. In making this examination, as in making most other examinations of the uterus, a rule requires to be followed which is too often forgot, namely to use both hands for the purpose. For if we are examining the uterus internally with the forefinger, or fingers of the right hand, the facility and precision of this examination will be found to be immensely promoted by placing the left hand externally over the hypogastric region, so as to enable us by it to steady, or depress, or otherwise operate upon the fundus uteri. The external hand greatly assists the operations of that which is introduced internally; and farther, we can generally measure, between them, the size, relations, &c., of the included uterus.

If without, or before, using sponge-tents, we are desirous to examine at the time when the os uteri is naturally most relaxed, we will find that time to be either immediately after a menstrual discharge, or immediately subsequent to any severe attack of intercurrent hemorrhage. Under such circumstances, we can sometimes introduce the finger partially into the os uteri, and ascertain the presence of any morbid body in the lower segment of the cervix; when in the same patient, at other times, this orifice is so completely shut as to prevent entirely such a proceeding. Sometimes, indeed, a small or elongated intra-uterine polypus will pass through the os uteri, at these times, so as to be felt by the usual vaginal examination; but will become retracted into the cavity of the cervix,

1 Diseases of Females, vol. i. P. 250.

during the interval between the hemorrhagic discharges. In the following case this occurrence was observed :

CASE V.-About eight years ago, I occasionally saw a patient, who suffered much from leucorrhoea and menorrhagia. At last her health became so much broken in consequence of these discharges, and the pallor of the face and lips, and other symptoms of anemia, so alarmed the patient, that she agreed reluctantly to submit to a vaginal examination. She had an objection, however, to me, on the score of youth; and the late Dr Beilby was so good as make the examination, and found a polypus, of the size of an almond, projecting from the lips of the os uteri. On Dr Beilby returning, two or three days subsequently, to put a ligature around the neck of the polypus, none could be found, and the os uteri was shut. The other symptoms, however, did not change; and, on the recurrence of a new hemorrhage, Dr Beilby made another examination, again found the polypus protruding, ligatured, and removed it.

In this instance, as in many others, the passage of the polypus through the os uteri did not produce any appreciable degree of pain. In enumerating the symptoms of intra-uterine polypus, I have omitted to state that, like polypi which have passed through the os uteri, they very rarely are attended with feelings of pain; and too often, both by the patient and the practitioner, the absence of pain is erroneously supposed to be a proof of the absence of organic disease. Sometimes, however, as they are pressing upon the lower part of the cervix and os uteri, or distending and passing through these parts, uterine contractions and pains temporarily supervene, similar to those of miscarriage; and, if there is any difficulty in the passage of the tumour, these pains may become exceedingly severe. In a case, in which a fibrous tumour of the uterus that had undergone the calcareous degeneration, and part of which had assumed a semi-pediculated or polypous form, the recurrent pains, when the mass came down upon the os uteri, appeared at times as extreme as those of the last stage of labour.

CASE VI. The patient, now sixty-nine years of age, the mother of several children, had for several years suffered from recurring slight attacks of uterine hemorrhage. In February 1848, I saw her with Dr Hunter. The os uteri was drawn up so high, that it was with great difficulty that I could reach and touch it; the top of the vagina stretched up in the form of an inverted funnel, the apex being placed at its upper or narrow extremity, and hence it was impossible to introduce or use a speculum. At the same time, the abdominal parietes were so thick and full, that it was impracticable to ascertain in any way the state of the uterus by an external examination. Not feeling a polypus, however, I left with the idea that the cause of the menorrhagia was some form of carcinomatous disease of the uterus. Subsequently, in the month of July, all her symptoms became aggravated, and very severe bearing-down pains were superadded. These pains recurred regularly once a day, lasted in paroxysms for several long hours, and always left the patient weakened and prostrated. In consequence of them, Dr Hunter made another examination of the vagina, and found the os uteri, which was now pressed lower down, filled with an apparently irregular bony mass. I saw her again, and removed the calcareous mass, filling up the os uteri, with a portion also of fibro-calcareous tumour, which we found above it, and distending the lower part of the cervix.

See notice of an analogous case, by Dr Ramsbotham, in the Medical Gazette for 1835, p. 406.

The irregular calcareous portion protruded through the os uteri, was about the size of a hazel-nut, and the portion of fibro-calcareous tumour above it nearly four times that volume. The daily fearful pain which the patient had been lately enduring immediately ceased, and everything looked so favourable that we had every hope that the whole of the fibro-calcareous tumour, or polypus, had been removed. Last February, however, after some unusual exertion, the pains again recurred more severely, if possible, than before; and with this difference, that the attacks of them were now twice a day, instead of being only once, as on the first occasion. Opiates and sedatives had little or no effect towards their alleviation. On examining the os uteri, no new foreign body could be found anywhere within reach. As the patient's strength and spirits, however, were rapidly giving way, I dilated the os fully, by a succession of sponge-tents, and found the cavity of the cervix occupied by another fibro-calcareous mass, larger than the first. After an ineffectual attempt to break it down and remove it, by strong lithotomy and other forceps, I dilated the os still farther with tents, with the view of, if possible, getting two or three fingers up to seize the tumour, and assist in its detritus and extraction. To allow the hand to pass into the vagina with this view, I was obliged to incise its orifice; and, after no small difficulty, I was enabled to break off, by the fingers and forceps, four or five fibro-calcareous pieces from the mass in the cervix; and these pieces, when afterwards conjoined together, were found to form a roundish semi-pediculated tumour, of the size of an orange. In order to enable her to sustain the pain of these proceedings, the patient was kept, during this tedious operation, under the influence of chloroform. The pains again ceased from the date of the removal of this second intra-uterine tumour; and, under the kind care of her son, himself a physician, our patient made a good and steady recovery, and her health was restored by spending some of the autumn in the country. There still, however, remains in the uterine parietes some fibro-calcareous structure, as I lately ascertained by passing a uterine bougie into the elongated cavity of the uterus, and striking it against its hard stony surface.

The Treatment of Intra-uterine polypi requires to be varied according to different circumstances, but particularly by the tendency or probability of the tumour passing downwards or not through the os; by the effects of the symptoms or the urgency of the case; and by the size and site of the polypus.

Two plans of procedure may be followed according to the nature and necessities of the case, viz., first, to wait till the polypus descend farther; or, secondly, to remove it immediately. It is a generally acknowledged principle in obstetric surgery, that a polypus of the uterus should be extirpated as early after its discovery as possible.1 But when such a tumour is discovered still included within the uterine cavity, and the polypus seems gradually but certainly making its way down

1 "In the treatment of this disease (uterine polypus) the first principle, undisputed, I suppose, by those who are possessed of experience in the management of these morbid growths, is, that it ought by all means to be extirpated; for unless it be removed, it will continue to grow larger and larger, till it utterly wears out life, and this especially if it be shooting from the upper part of the uterus, or even from the neck. It is, moreover, of vast importance in polypus, not only that it should be extirpated, but that this extirpation should be accomplished as early as possible. Lay this down, then, as a most important part of your practice, that polypi are not only to be taken away, but that they are to be extirpated early, as soon as they are discovered, and as soon as it is practicable.”—Blundell's Observations on Diseases of Women, p. 126.

wards through the cervical cavity, and the hemorrhage and other symptoms are not urgent, it will assuredly be better to wait for its descent through the os; for after that its removal becomes much more easy and simple. The dilatation of the os and cervix by the sponge-tents will promote and facilitate its descent; and perhaps the internal use of the ergot of rye may aid it. But the degree of attendant hemorrhage and debility may be too great to entitle us to postpone the removal of the polypus; or the tumour may be attended by such a short pedicle as not to be capable of leaving the uterine cavity without dragging down with it, or inverting the fundus or some parts of the parietes of the uterus; or it may be retained in its descent by adhesions formed between the surface of the uterus and the surface of the polypus. I once witnessed the dissection of a case of a large fibrous polypus included in the cavity of the uterus, and where inflammation had been present before death; the surface of the polypus was adherent to the surface of the uterus through the medium of a recently effused false membrane. Even when an intra-uterine polypus has descended so far as even partially to open up the os uteri, it may remain in that situation for such a length of time, and with such results, as to place the patient in no small degree of danger. I shall quote, in illustration of this remark, an interesting case reported by Dr Meigs of Philadelphia, in his work on Female Diseases. Dr Meigs (p. 255), who quotes Dr Lee, to the effect, that "it would be folly to attempt the removal" of a polypus still retained in utero, details the case referred to in the following words :—

CASE VII.-Some months ago a lady came to me from New Jersey. She had been for some years labouring under a uterine disease, accompanied with violent and exhausting floodings. Upon arriving here, she was wholly unable to walk or sit up in her chair. I discovered a hard polypus, whose apex was lying just within the os uteri, which was a circular opening as large as a half dollar. The os uteri was pretty low down in the pelvis, it was very hard, and completely undilatable. The fundus uteri was half way up to the umbilicus, and the uterus hard and solid, so as to allow me to trace its outlines very clearly in my hypogastric palpation. I assure you I have rarely met with a more extreme case of anemia than in this person. This anemia was evinced not only in the pallor of her surface, and its flabbiness, and in her irregular breathing, the frequent palpitation of the heart, and the anemiacal throb of her pulses, but in the state of all her innervations, which were most miserable indeed, except when lying profoundly still in a low recumbency.

After a few days' refreshment from the journey, I attempted to do what I thought I should fail to do, namely, to get a ligature on the tumour. But I soon found how vain was such an attempt, for I never found the uterus a

1 Cases of intra-uterine and vaginal polypi tending thus to invert the uterus at the site of their pedicles, are detailed by Denman (Introduction to Midwifery, p. 106); Davis (Obstetric Medicine, p. 618); Dr Oldham (Guy's Hospital Reports, New Series, vol. ii., p. 105); Scoutetten (Gazette Medicale for August 1839); Crosse (Transactions of Provincial Medical Association for 1845, p. 321), &c.

2 Library of Medicine, vol. iv., p. 335.

moment relax, nor open beyond the size of a half dollar. My attempt caused an attack of hemorrhage to come on, that I was glad to suppress by cold, by rest, and by opium.

I kept her here many months, in hopes of seeing the uterus enter into powerful contractions to throw off the morbid mass. I gave her large doses of I thought the ergotism that was produced might expel the polypus, but I was disappointed, and subsequently had reason to believe the tumour had formed strong attachments to the inside of the uterine walls, so low down, that I could reach them with my finger, but could not break them up.'

During her residence here, I thought to see her bleed to death before my eyes; her life was hardly saved by the tampon, so perverse was the hemorrhage. At length I sent her home, with directions as to her health, and a request to be informed if the tumour descended into the vagina. It will never descend into the vagina, if the adhesions I supposed to exist are truly there.— Dr Meigs on Females and their Diseases, p. 257. Philadelphia, 1848.

But, secondly, the severity of the attendant hemorrhages, or the improbabilities of the speedy and entire descent of the intra-uterine polypus, may induce us to remove the tumour at once; and certainly this may be effected in most cases, though with greater difficulties than in cases in which the polypus has passed down into the vagina. To admit at all of the removal of an intra-uterine polypus, of any considerable size, the os uteri must be previously very fully dilated by sponge-tents; and perhaps it will sometimes be found necessary, at the time of operating, to gain additional freedom, by dividing any obstructing band of the os or cervix that may not have been fully dilated by the tents. Afterwards, we will require to proceed differently in different cases, in order to destroy or remove the polypus. We may only be able to accomplish this object by contusing and crushing the tumour, as I have described in a case already detailed. (See Case II.) In the instance in question, I grasped the polypus, for this purpose, with strong lithotomy forceps. In another similar case, after fully dilating the os and cervix, I seized a large intrauterine polypus between the jaws of a screw-propelled lithotomy instrument-invented for the purpose of crushing vesical calculi-and was enabled, by it, to crush and destroy readily the structure and vitality of the included tumour. Occasionally, we may be enabled to divide the stalk of the polypus with a silver wire or ligature, acting on the principle of the chain-saw; or we may reach it with very curved blunt-pointed scissors. The two following cases may serve to illustrate these two last mentioned methods of operating:

CASE VIII-A patient, æt. 36, about three years ago began to suffer under menorrhagia and dysmenorrhea. The catamenia became both too frequent in their return, as well as much too great in quantity; but there was little or no leucorrheal discharge. Latterly coagula of blood accompanied the menstrual periods, and the patient felt much weakened by each attack. The dysmenorrhea generally came on on the second day of menstruation, and confined the patient for a couple of days, the third day being usually one of much sickness

The use of the uterine bougie would probably have determined this point; or the mechanical dilatation of the os by tents would have enabled the finger fully to reach and break the adhesions.