bloodless; but the polypus was red, from engorgement and effusion of blood in its tissues. Its structure was fibrous; and there was another small fibrous tumour imbedded in the walls of the uterus, near the uterine extremity of the right Fallopian tube. It had descended lower down than at the time we examined, so as to have already dilated the cavity of the cervix; and the os, at the time of death, had begun to open. It was evident that, if the cavity of the os and cervix could have been artificially dilated during life, the polypus would have come within reach, and the patient's life been saved.-(See Plate I.)1

I have seen several other cases of intra-uterine polypus, where the hemorrhage was both long in continuance and great in quantity. Some years ago, along with the late Dr Henderson, of Corstorphine, I excised a slender pendulous polypus, hanging from the os uteri, in a patient who, some time previously, had nearly died of excessive uterine hemorrhage of several days' duration, at Leamington; but at the period of that dangerous attack, the attendant physicians had been unable to discover any uterine organic disease, to account for the discharge. The polypus had not yet passed the os uteri."

When nature, in cases of intra-uterine polypi, begins to expel the tumour, and open up the os uteri, we may, at that stage, as stated in a preceding quotation from the work of Roche and Sanson, find it possible to make a diagnosis of the disease by being able to "feel the rounded tumour within." If art could furnish us with any means of producing, at will, the same extent of opening of the os uteri, it would enable us in the same way to "feel the rounded tumour within" with our finger; and it is evident that, by this means, we would possess a power of detecting, with all the certainty of physical diagnosis, the existence or not of the disease within the cavity of the uterus, in cases in which the attendant rational symptoms-as the menorrhagia, uterine leucorrhoea, and perhaps the swelled state of the neck or body of the uterus-might lead us to conjecture the probable presence of an intra-uterine polypus.

In 1844, in a communication3 laid before the Medico-Chirurgical Society of Edinburgh, I proposed a means of safely opening up the cavity of the cervix and body of the uterus, to such an extent as might enable us to introduce a finger into the uterine cavity, for the purposes of diagnosis and operation in this and other diseased

1 The uterus and its included polypus, from this patient, are in the University Museum; and Plate I. presents a faithful sketch of them, made from the preparation, and showing the size and site of the polypus, its place and mode of attachment, and the slight dilatation of the os that had taken place before death.

2 In this, and in one or two other instances in which I have seen extreme degrees of flooding attendant upon small polypi, the narrow elongated polypus was of a cellular structure internally, and externally spotted and roughened over by numerous small linear-placed elevations, like those on the shell of the echinus.

3 "Mechanical Dilatation of the Cavity of the Os and Cervix of the Uterus, as a Means of Diagnosis and Treatment in some Affections of that Organ."See abstract of it in the "Monthly Journal of Medical Science," 1844, p. 734.

polypus. A purulent discharge followed, and three largish pieces of organised structure were subsequently cast off. Her recovery of health, after these discharges ceased, was gradual but perfect. There has been no return of menorrhagia. About a year ago she called upon me, and the change from excessive pallor and emaciation of the face, to the hue and ruddiness of health, was so great, that I had difficulty in being convinced of the identity of my former patient.

The Symptoms which might, a priori, induce a practitioner to conjecture the probable existence of an intra-uterine polypus, are, as we have seen in the quotations I have already given (p. 3), of a very uncertain and equivocal character. The polypus, while still included within the uterus, is principally liable to give rise to the following groups of symptoms:

1st. Menorrhagia, in consequence of the discharge of blood from the surface of the tumour. The attendant hemorrhages take place particularly at the menstrual periods, but are apt to recur also at other times; and the blood is sometimes fluid; sometimes coagulated; occasionally there is an almost constant red stained discharge. The effects of these repeated floodings upon the constitution of the patient vary with their amount; but if they go on increasing (as they usually do) in quantity and frequency, the patient's constitution becomes gradually more and more shattered and broken down by the amount of hemorrhagic discharge; and all the symptoms of anemia in their most marked degree at last supervene, as pallor of the face and lips, great muscular debility, palpitation, vertigo, dyspepsia, oedema, &c.

2dly. The discharge of mucous, purulent, or serous matter from the cavity of the uterus, in consequence of the mucous membrane of the organ becoming often irritated, inflamed, and even ulcerated by the presence and pressure of the polypus. If a severe leucorrheal discharge is present, and we ascertain by the speculum that it does not originate in ulceration or other morbid state of the external surface of the cervix, or of the vagina; and if we further detect, with the speculum, the discharge issuing from the cavity itself of the uterus, the probabilities of it originating in some pathological irritation within the uterus, will be necessarily increased. Sometimes the discharge, in cases of polypi, is fœtid, especially if it be retained, or mixed with decomposing blood.

3dly. Increased size of the cervix and body of the uterus in consequence of its interior being distended by the presence of the polypus, is traceable in those cases in which the polypus is of any great size. Not unfrequently intra-uterine, like vaginal polypi, are found combined with the presence of fibrous tumours in the walls of the uterus; and by these tumours the magnitude of the organ is increased, and its shape rendered more or less irregular. Fibrous tumours of the uterus are seldom or never situated in the walls of the cervix; and if the swelling and distension affect the cervix, there is consequently much more chance of its being a polypus and not an interstitial fibrous

tumour, than when we have similar symptoms attendant upon a similar augmented state of the body of the organ. Further, the probability of the disease being intra-uterine polypus would be increased, if, on successive examinations, we had an opportunity of ascertaining that the enlarged and distended state of the cervix was descending gradually lower and lower down towards the os; for polypi in their progress and descent (as seen in Case I. Plate I.) gradually dilate the cervix from above downwards in the same way as happens in pregnancy or abortion. They are born by a kind of chronic labour. 4thly. There may be symptoms of irritation and pressure upon the bladder, rectum, &c., if the polypus happen to be so large as to exert mechanical compression upon these or other parts, or dysmenorrhoea if it fills up the cavity of the cervix. And sympathetic pains may be present in the loins, limbs, &c.; or there may be sympathetic disturbance of the stomach, heart, &c., if the uterus is much irritated and excited by the presence and distension of the polypus.

But one or more of the preceding groups of symptoms may be altogether absent, though the uterus contain an intra-uterine polypus. The mechanical and sympathetic symptoms last alluded to are the most uncertain of all. For while almost all uterine diseases, however intrinsically different, give rise to similar secondary and sympathetic symptoms, we have often in other instances of the very same diseases, these same symptoms entirely wanting; just as in one woman during pregnancy we sometimes see severe, even serious, local, and constitutional symptoms; and in another woman, or even in the same woman in another pregnancy, we see the same condition of the uterus unattended by any special, local, or constitutional disturbance. Again, there may be no ascertainable increased volume of the uterus, as the polyus, especially if it is vesicular, and originates in the interior of the cervix, may be far too small to lead to any appreciable augmentation in the size of the organ, although, notwithstanding, the menorrhagia may be great; for the extent of flooding does not depend on the size of the polypus, small polypi like small hemorrhoidal excrescences, often being the source of severe and repeated hemorrhages. Further, the leucorrheal discharge which is sometimes attendant, may be entirely absent, as the polypus may not be irritating the mucous surface of the cavity in which it is inclosed. And lastly, polypi occasionally, though not very frequently, are present for a long series of years without producing any degree of hemorrhage or menorrhagia. In the following case, for example, there was a state of longstanding amenorrhoea, instead of menorrhagia, co-existent with the presence of a polypus, though the two conditions (the amenorrhoea and polypus) had probably no causal relation to each other.

CASE III.-A poor woman, from East Lothian, aged about 35, and of a weak and debilitated frame, came, some three or four years ago, to ask for advice regardShe described her case as one of long-standing ing the state of her health. amenorrhoea. For five or six years the catamenia had been entirely absent; and NEW SERIES.-NO. I. JANUARY 1850.

B

she ascribed her broken health to this cause. On examining the uterus and ovaries, in order to ascertain if there was any organic change to account for the amenorrhoea, I found, with the uterine bougie, the cavity of the os and cervix uteri very small, and the latter apparently obstructed, about three quarters of an inch from the orifice. I introduced a long thin sponge tent, with the view of determining more correctly the state of the cervical cavity. On removing the sponge, two days subsequently, I found the lower part of the cervix natural, but a flattened polypus, of the size of a small cherry, attached by a short pedicle to the interior of the higher portion of the cervical cavity. The pedicle was easily seized with a pair of long slender polypus forceps, and separated by torsion or avulsion. For some time subsequently to this little operation, menstruation recurred,—the irritation of the sponge tent having probably so far roused the uterus to a restoration of its secreting functions; but a patient, from the same neighbourhood, about half a year ago, informed me that her health had relapsed again into its former unsatisfactory state.

The polypus, in the preceding case, was intra-uterine. During the past autumn I removed a uterine polypus, which had long passed down into the vagina, and yet had never given rise to menorrhagia.

CASE IV. The patient, 55 years of age, had, for at least twenty-five years, been aware of the occasional protrusion, between the labia, of a portion of what she supposed a fold of thickened and insensible skin. When she first noticed it, she had called the attention of her medical attendant to it, an eminent London obstetrician, under whose kind care she was for many years placed. He examined the tumour and its relations; but advised her to let it alone. Two or three years ago a little sanious discharge began to appear, and continued to recur almost daily. On examining the projecting body, I found it an elongated polypus, of the size and figure of the fruit of the date, and depending by a long slender stalk, which passed upwards through the os uteri. I divided the stalk with a pair of blunt-pointed scissors, immediately below the os uteri, and in four days afterwards the patient set off on a long journey. The polypus was of a dense cellular structure. At one point, near its fundus, its surface was ulcerated. The ulcer was of about the size of a sixpence, and, no doubt, the source of the discharge that had latterly appeared. Perhaps the removal of this polypus, when it was first discovered, would have enabled the patient to become a mother, and saved from extinction one of the highest and oldest titles in the kingdom.

Cases, however, like the above, of uterine polypi, of long duration, without attendant hemorrhage, are exceptions, and not very common exceptions, to the general rule. And certainly the existence and return of attacks of menorrhagia, draining and undermining the powers of the constitution (without the presence of any ascertainable organic disease in the vagina, or around the os uteri, to account for the floodings, and the persistence of this discharge, in despite of all constitutional care and treatment)-forms always the most frequent and principal symptom that would induce the practitioner to use means to ascertain if there existed an intra-uterine polypus, or any other intrauterine lesion, that was the probable source of the hemorrhage. He would, a priori, have more expectations of detecting, in his investigation, an intra-uterine polypus, provided, along with the menorrhagia, there was an occasional leucorrheal or sanious discharge, coming-as proved by the speculum-from the cavity itself of the uterus, and not from the surface of the cervix; and provided, also,