affixed to its top, of a heart-shaped figure, and intended, first, to receive the two canule, with their contained ligatures, and afterwards to serve as a point of resistance during the cutting action of the ligature upon the pedicle of the tumour. The canule and ligatures (Fig. 3) are first applied in the same way, and according to the same rules, as those of Niessens and Gooch. After the pedicle is encircled by the ligature, the two lower extremities of the canule and included ligatures are passed through the ring (a, Fig. 1) of the second portion of the instrument. This second portion of the instrument is then run up, with its ring surrounding the included canulæ, till it reaches the pedicle of the tumour; the projecting side of the ring being turned towards the pedicle. The canula are then slipped off, and withdrawn, leaving the wires or ligatures alone in the terminal ring of the instrument. Subsequently, these wires are twisted around, and fixed upon, the knob (b, Figs. 1 and 2) attached to the screw (Fig. 2). Lastly, by moving the knob downwards, by the operation of the screw, the ligature is made to cut into and through the pedicle.

In the following case, I was enabled to divide the pedicle of a large intra-uterine polypus with a pair of well-curved blunt-pointed

scissors.

CASE IX. The patient was aged 48, and unmarried. About 14 years ago, she was first seized, when in service, with a severe flooding. It returned at short intervals, and reduced her strength so much that she was obliged to leave her situation, and has never been able to take another. The hemorrhage she describes as having been almost constant for many years; that is, there was always some red oozing, and fluid blood and clots often escaped when she made any exertion. She had been treated by various medical gentlemen during this period, chiefly with iron, styptics, and astringents. A vaginal examination had never been made, in order to ascertain the source of the hemorrhage. During last autumn she presented herself for advice, at my house. She was blanched, thin, and debilitated, and scarcely able to walk. On examination per vaginam, the uterus felt enlarged, more particularly in its cervical region. A sponge-tent was introduced, and on her returning, two days afterwards, I found a polypus descended upon the distended os. Dr Ziegler, Mr Carmichael, and Dr Duncan, were present at the removal of the polypus. In order to reach, if possible, with the scissors, the pedicle of the polypus, I required to make a slight incision into the thin lips of the os. I was enabled at last, after some difficulty, and by seizing the polypus with a vulsellum on one of its sides, to turn the polypus laterally, and obtain access, with the scissors, to its pedicle, which was small and easily divided. After the polypus was completely separated, it took no inconsiderable amount of traction to drag it through the os uteri. The polypus was round, of the size of a small orange, and of a fibrous structure. The patient was rendered anesthetic during the operation. The vagina was plugged with sponge, and the woman sent home. Next day the plug was removed. The patient has ever since kept free from any return of the flooding, and a degree of leucorrhoea, which followed, as often happens, the removal of polypi, is subsiding under the use of medicated pessaries. A month subsequent to the operation, she stated her strength to be greatly improved beyond what it had been for many years.

The preceding remarks, relative to the treatment of intra-uterine polypi, principally refer to these tumours when they happen to be of a NEW SERIES.-NO. I. JANUARY 1850.

C

large size. But uterine polypi are often too small to be removed by the knife, scissors, or ligatures; and yet these small polypi not unfrequently lead to severe and long-continued menorrhagia. From the analogy of hemorrhoidal tumours, we know that the mere size of a polypus is not to be taken as any measure of its capability of producing hemorrhage. Small vesicular, mucous, or cellular polypi sometimes grow from the fundus uteri, giving rise to considerable and long-continued hemorrhagic discharge. I have preserved specimens of them from the dead subject, and have met with them in the living. They can hardly be properly termed polypi, as they are scarcely pediculated at their attachment, and sometimes short, but in other cases long and slender, in their body.

The following case may be cited as an illustration of this form of the disease

CASE X.-A lady, the mother of ten children, became irregular in her menstrual discharge during her 44th year. At times it was wanting at the usual monthly periods, at others it amounted to menorrhagia. About a year after this irregularity commenced, such an amount of fluid blood and coagula escaped as at first to lead on her part to some suspicion of miscarriage; but it continued to go on profusely for two or three weeks. At the end of that time, I visited her, with Mr B. Bell, and Dr Malcolm. On examining the uterus, we found a small vesicular polypus attached to the inner surface of one of the lips of the os, and it was easily removed by avulsion. The discharge, however, was not abated in consequence, as we expected. A series of sponge-tents was then introduced, so as to open up, first, the cavity of the cervix (which was found free from additional polypi), and ultimately the cavity of the body of the uterus. When the distension of the whole uterine cavity was at last completely effected, both Dr Malcolm and I found that we could touch two or three small slender polypoid bodies, hanging from the very fundus of the uterus. I removed them cautiously from the surface to which they were attached, with the nail of the first finger. After this the hemorrhage ceased, but some local treatment was required to cure the ulcerated state of the cervix. The polypi were removed in April. The patient went soon afterwards to spend the summer in the country, where she soon gained strength, and enjoyed much-improved health. I saw her lately. The menorrhagia had not recurred, but she still looked anemic, having never recovered her colour since the hemorrhages in spring.

Dr Malcolm informs me that, since meeting with the above case, he has seen another similar one, and treated it successfully in the same way. I may add, that in several cases of chronic and severe menorrhagia, in which I have been induced to open up the cavity of the uterus with sponge-tents, in order to ascertain whether there was any small intra-uterine polypus present or not, I have merely found the interior of the uterine cavity rough and granulated at particular points, which I have generally tried to remove and scratch off with the nail. Whether owing to their removal or not, or owing to the irritation resulting from the pressure and distension of the sponge, I know not, but certainly in two or three cases, the menorrhagia has subsequently abated and ceased.

By far, however, the most common site for the origin of small vesicular polypi, is the interior of the cervix uteri. In fact, the

small cellular or vesicular form of cervical polypus, is infinitely the most common form of polypous disease of the uterus. Several specimens of them are represented in Plate IV. These cervical vesicular polypi are generally of a small size, like a pea, or orange pip, and vary from this to the size of a hazel nut. Sometimes they are sessile; and sometimes pediculated, as represented in the sketch from Cruveilhier. (Fig. 4). Occasionally they are single (Fig. 3), or they form a single complex cluster; but more frequently they are gregarious, as represented in Madame Boivin's drawing of them, copied in Fig. 1. Indeed it is, I believe, the rule rather than the exception to it, that when we find one (perhaps protruding at the os uteri, as in Fig. 12), we shall find, on further search, that there are others, sometimes to the number of four, five, or six, springing from other points of the interior of the cervix, and not discoverable till the cavity of the cervix is dilated by a sponge-tent. When hanging from the os uteri, their stalk is sometimes so loose and long, and the small depending polypus is itself so small and soft, that it moves away before the finger in making a tactile examination, and one unaccustomed to this peculiarity will not feel perfectly sure of the presence of such a polypus till the speculum is used, when the polypous body will be easily seen generally of a cherry-red, or purplish colour. Such polypi, though small, are often apparently the source of much menorrhagia and leucorrhoea, for they almost always co-exist with, and probably produce, some degree of ulcerative inflammation of the contiguous surface of the cervix.

In trying to remove these small vesicular polypi of the cervix, it is, therefore, to be held in recollection, that there are generally more than one present, and that to ascertain this point with any precision, it is necessary to dilate and expand the cavity of the cervix with a sponge-tent.

In more than one instance I have found these polypi (when their pedicles were perhaps long and easily broken) come off, imbedded in the surface and foramina of the sponge, which had torn them off during its expansion. But, in twenty-nine out of thirty cases, more methodic measures are required for their removal, as scratching them off with a sharp nail, seizing and tearing them off with polypus forceps, or dividing their stalks with a pair of scissors. If we can use the speculum, these modes of removal are greatly facilitated by the sense of sight. Indeed, if we require to use the polypus forceps

1 A small cervical polypus may even produce death by the extent of hemorrhage to which it gives rise. In an excellent practical paper on polypi, published by Dr Locock, in the London Medico-Chirurgical Transactions for 1848, he states (p. 171), "Upwards of twenty years ago, the late Dr Robert Hooper showed me a preparation of a uterus, laid open, having a polypus not larger than a pea, with a short and narrow peduncle attached within the cervix, high up, considerably within the os uteri, and not perceptible till the cervix was slit open. All the history which he could give me was, that the uterus was removed from the body of a young woman, who had died in the Marylebone Infirmary, from long-continued uterine hemorrhage."