Crm^li^du (u^Xj- txxtC^Jx^f ^3**4 CASES OF POLYPUS OF THE WOMB. By WALTER CHANNING, M.D. CASES POLYPUS OF THE WOMB, WITH REMARKS. BY WALTER CHANNING, M.D. .^> eon ^'fr -'LTBRAT^T '' ^/n-t.on./-,> Republished from the Boston Medical and Surgical Journal for March 8th and 15th, 1855. BOSTON: DAVID CLAPP, PRINTER......184 WASHINGTON STREET. 1855. POLYPUS OF THE WOMB. Deavees says, in one of his Avorks on the diseases of females, or on midAvifery, that he had never seen a case of uterine polypus. As he Avas in very large midAvifery practice, and was consulted daily for female complaints, this statement seems to be a somewhat re- markable one; and but for his skill in diagnosis, shoAved in all his writings, one might be led to think that he had not discovered it when it existed. TAventy-tAVO cases have come under my notice, and in sixteen of which I have operated. In this enumeration are included four cases of poly-poid tumors. In it are some Avhich Avere con- cealed, or out. of reach. The greater number Avere extra-uterine. In all was this symptom—periodical hemorrhage, and hemorrhage at other times from accident. This flowing observing in some cases an exact periodicity, may and has led the physician astray from its cause, and has been allowed to continue for months and years, Avithout suspicion of its true cause. It has been treated as menorrhagia, and, of course, without the least benefit. We may be deceived in another Avay. Much blood is lost, and frequently. Still the patient keeps along pretty Avell. There is paleness, exces- sive paleness. But there are not other symptoms of anaemia—the pink-colored veins—the absence of coagulated blood, or blood very feebly coagulated—the cerebral, the cardiac, the pulmonary lesions of function. At least much time may pass and anaemic symptoms be wanting. There may be great weakness, loss of appetite—loss of flesh, and yet the observer looks in vain for the signs of the graver disease. In polypus, the blood coagulates, and if retain- ed, in very firm masses, and of a ring-shape, it may be, from the 4 mould, the space betAveen the tumor and the womb, in which it is cast. It is of a dark color Avhen thrown off under these circum- stances. Sometimes the coagula are broken, shreddy, but showing firmness. There are pains characteristic of polypus. Especially is that forcing, bearing-down pain AA-hich accompanies menstrua- tion. This may be unlike dysmenorrhcca, and the quantity and characters of the discharge are altogether different from that Avhich characterizes painful menstruation. Tavo forms under which polypus may exist were spoken of. And, first, of the concealed. Under this head I include cases in Avhich the tumor is contained, and retained in the uterine cavity. In these the loss is often very great, and accompanied by uterine force not exceeded by the demands of labor at the full time, even when these are more than of average strength or necessity. Of this the following is an example. Case I.—Mrs.----, between 30 and 40. Has had but one child, a daughter, now between 11 and 12 years old. Is very fleshy, and of sufficient color of complexion. Was some months ago attack- ed with uterine hemorrhage during menstruation, for which there was no assignable cause. This recurred again and again, and at length uterine contractions came on, which were most distressing by their strength and continuance. Her physician examined her in the intervals of periods, but detected nothing unusual in the cervix or os uteri. No permanent relief Avas obtained by medi- cines. At length he examined during a period or just at its close, and found the os uteri open, and just Avithin it a firm and insen- sible mass. He believed this was a polypus, and Avrote for my advice. I recommended ergot of rye to be given during menstrua- tion ; and if the tumor protruded, and he should desire my ser- vices, I would Avith pleasure come and see the case Avith him. He gave ergot as suggested. Uterine force responded, and he found the tumor fairly protruding into the vagina. Upon reaching the address I discovered a cylindrical tumor lying nearly horizontally across the pelvis. It was large and firm. Its outward extremity 5 was against the holloAv of the sacrum. I had never met Avith such a position of a polypus, and it was a question how a ligature could be passed round it. The following method Avas used. The Canu- te were carried up in front of the tumor as far as they could go and as near as possible to the os uteri. One Avas kept in place there, Avhile the other Avas slid along the tumor to its other end. It was noAv carried round this end, and slid back along the tumor till it Avas opposite the other. The ligature was thus passed round the tumor. The farther ends of the canute easily came down until they met, Avhen the slide Avas passed up and the Canute made one. The ligature was tightened, and the operation done. The ligature Avas drawn daily, and in four days the instrument came away. The tumor Avas removed, and it Avas found two and a half inches in diameter Avhere it had been cut through. I am struck Avith the ease of describing an operation, Avhen compared with do- ing it. We talk of " carrying up," and of " sliding along," as it were " as easy as lying." I have applied the ligature to polypi often, but in no case has the difficulty of doing it approached to that of this operation. Mrs. ------- recovered, notAvithstanding a protracted dysentery Avhich endangered life. Case If.—This occurred in the subject of the first. There was the same hemorrhage, the same pains at the menstrual period, the same exhaustion, and the same general ill health which accompa- nied that. It was first noticed between one and Uvo years after the first. Upon examining this patient, a tumor presented Avhich filled the vagina, as does the child's head in labor. It was perpen- dicular in its direction, and so could be treated after the common manner. The only embarrassments were in the size of the tumor, and its unequal surface. The first made it difficult to pass the canulae to the upper part of the Angina, or end of the body of the tumor at the pedicle, and Avhen this \A-as done, great Avas the difficulty in passing the moveable canula round the tumor to meet the stationary one. This Avas accomplished, and the ligature drawn tight. It was tightened daily, and after many days came off. The tumor re- 6 quired instruments for its removal. During her convalescence Mrs. ------Avas seized Avith pleurisy of intense violence, and died. The left chest was found filled with pus and serum, and the ordinary lesions of the organ diseased. The Avomb Avas carefully exa- mined. It Avas large, evidently from hypertrophy. The places formerly occupied by the polypi were distinctly visible, but as per- fectly smooth, and of as natural appearance as the rest of the cavity. From the fundus—(the other polypi rose from the body)—from the fundus hung a very small polypus, its pedicle about three fourths of an inch long, and the mass appended to it the size of a small cherry. It Avas perfect in all its characters, and but for death would have grown, and from its situation Avould in its groAvth and Aveight have probably draAvn down the fundus, and have inverted the womb. For the privilege of seeing these interesting cases I am in- debted to my friend Dr. Stevens, of South Reading, to whom I OAve like acknowledgments for an opportunity to see the same disease under quite a different form. Case III.—This was another instance in which polypus appeared twice in the same individual. The patient was unmarried, and Avas suffering the usual symptoms of the disease. Examination disco- vered polypus. This was some time after removal by ligature of the first tumor. These operations were done by my friend Dr. J. M. Warren, Avho has reported them in the Transactions of the Bos- ton Society for Medical Improvement. Case IV.—This Avas a case of concealed polypus. Mrs. ■------ betAveen 20 and 30, had always excellent health, not the least dis- turbance of menstruation. She became pregnant, and went her full time and was delivered Avithout accident. Some weeks after con- finement she Avas, without known cause, seized Avith profuse uterine hemorrhage. This recurred, and her physician, Dr. York, of South Boston, made a very careful examination of the womb. The os uteri was patulous, and at length admitted the finger, and in the cavity of the womb he discovered a tumor. It was firm and insensible. I Dr. York desired me to see the patient with him, which I did with pleasure, and examination confirmed his diagnosis. The polypus Avas an inch in diameter, and Avas long and cylindrical. I had taken Avith me the polypus Canute, and at Dr. Y.'s request proceed- ed to apply with them a ligature. It was not easy to do this. The polypus almost or quite filled the cavity, leaving little room to use the finger as a guide. The ligature was passed round the tumor, and draAvn very tight. It cut fairly through the mass, and brought away with it a circular bit, not more than a quarter of an inch thick at its centre, and going off to a thin edge—in short, a thin portion of the end of the polypus. There was no hemorrhage at the time, and none afterAvards. The polypus entirely disappeared, and the health of Mrs.-------Avas soon and satisfactorily restored. The early examination by the attending physician, and his accurate diagnosis, were of exceeding importance in regard to the result of this case, for already this patient exhibited the alarming signs of dangerous uterine hemorrhage, and might have irrecoverably sunken had not the true nature of the disease been discovered. While Avriting, I have been consulted in a case of very alarming uterine hemorrhage in —----, Ohio. Examination has not detected any such uterine lesion as explains the hemorrhage. The patient was about five months pregnant, and aborted without known cause. Hemorrhage soon followed, and had continued to the present time. In my answer to the letter containing these facts, I suggested that concealed polypus might exist in the uterine cavity and cause the flowing. In consulting Gooch on another point, I find a case in which " for nearly two years the patient had been subject to long and profuse menstrual periods. Fifteen months ago the uterus had been exa- mined by an eminent practitioner, who discovered nothing but that it was larger than natural. About five months ago, during expul- sive pains, a tumor had descended into the vagina, and noAV was so large as to fill the pelvis, and occasion a retention of urine, Avhich required the frequent introduction of the catheter." Here was a case of concealed polypus, which very nearly resembles those 8 I have above given, and which last Avere alluded to in my answer referred to. CAyE V.—This has a story. Two patients were taken in labor the same day. I agreed to attend them both. They lived Avide apart, one south and the other north, but a carriage in constant at- tendance enabled me to see them as often as was needed. Late at night, the case at the south had at my last visit so rapidly ad- vanced that I could not leave. The child Avas born. The after- birth did not appear. After waiting the usual time, the hand Avas introduced along the cord, and the placenta raised. I Avas sur- prised to find that a mass of some size still remained attached to the Avomb. An effort was made to detach it, but I soon saAv nothing was to be done in that way, and contented myself Avith the removal of the afterbirth, Avhich Avas perfectly natural. What Avas this groAVth ? It had no malignant characters, certainly had betrayed none before pregnancy, nor after delivery. There Avas not a sign of polypus about it. There had never been hemorrhage, nor me- norrhagic pain in its usual seats. Mrs.------- had ahvays had rugged health. I concluded, and stated this opinion to my class, that an arrest had occurred of processes in uterine development, Avhich result in the formation of a single cavity, and that the mass I felt might have been a portion of the original partition by Avhich the womb Avas left somewhat in the state of being partially double. I could reach no other solution of the fact, and left it where it Avas. As soon as the case was over, I drove north, but found the crisis of the case had arrived about the same hour as did that of the south, Avhen a neighbor doctor had been called in, and the case successfully completed. The day's—the whole day's Avork, the night being the longest half of it, Avas now done, and I drove home, which Avas midway of the extremes of my elaborate practice. I heard nothing more of these patients, who were left perfectly well, till I was called again to the patient Avhom I did not attend, who Avas again safely confined. Not long after, for such is my memory, I heard that the case Avhich I did attend was dead. I was told 9 that she was taken in labor, and sent for the physician she had engaged to attend her, Avho found an arm was the presenting part ; failing to return it, he sent for a physician in consultation. It Avas agreed to turn the child. The turning Avas accomplished. Death folloAved, and upon opening the body the womb was found rup- tured, and a polypus attached to the organ. At least I was told it was considered a polypus. By a someAvhat singular coincidence, the patient I visited with the one avIio died after delivery, not long since Avas seized with excessive menstrual periods. Being greatly reduced, she sent for me. 1 delected a polypus reaching from the os uteri almost to the external orifice. It was sucessfully removed. and the case will folloAV. Case VI.—This Avas an instance of partially concealed polypus. My friend Dr. Morrill called me to see his case, and I may re- member it more distinctly from its association Avith many, many other exceedingly interesting cases Avhich have occurred in the practice of this gentleman, and Avhich I have attended Avith him. The usual symptoms of polypus Avere strongly marked in this case ; profuse menstrual periods and intercalary losses from over-exertion, &cc. Her appearance showed no functional disturbance ; the Avhole trouble being directly the product of simple excessive hemorrhage. Dr. M. examined the vagina. He felt something unusual at the os uteri, and desired me to see his patient with him. I did so, and by the speculum discovered a tumor projecting slightly from the os, which last having Avith the cervix become very thin by the pressure, embraced the rounded end -of the polypus, which it was, as does the prepuce the glans in an intense form of phymosis. A small probe was Avith great difficulty forced beUVeen the tumor and the neck. It Avas agreed that Mrs.-------should take ergot, and when the tumor came within reach, that I should apply round it a ligature. The ergot avus given, and the tumor was forced by it more than an inch out of the womb. It was about an inch in diameter. The ligature Avas applied? Hemorrhage ceased the moment this was done, as it ahvays does. The canute in a few days came aAvay, 10 the polypus following it, and convalescence and perfect recovery without accident ensued. Case VII.—This occurred in a young unmarried girl, aged 18. She Avas of exceeding fair complexion, with the lightest colored hair, and eyes in harmony. Nothing could exceed the Avhiteness of the skin, under the hemorrhages Avhich accompanied her disease. It Avas like the most brilliant marble. The disease Avas at once diagnosed, and a ligature applied. In a few days the tumor drop- ped off, and recovery soon folloAved. The polypus differed from any I have seen either before or since. It Avas very firm, somewhat rough on its surface, but as white as snow. Case VIII.—This had existed between three and four years before it Avas diagnosed by Dr.-------, of------, a few miles from tOAvn. It had been mistaken for disease of the liver—an organ Avhich has many pathological sins to ans\Arer for, which in truth do no more belong to it than to the thymus gland. The skin had) got that taAvney, yelloAv, dirty tone of color, Avhich chronic disease, with or Avithout hemorrhage, so often, so generally produces. Hoav strongly does it mark organic, malignant disease, especially in the female ! The indications in Mrs. ------'s case Avere alteratives, astringents and tonics. The most regard would seem to have been paid to the latter, and carriage exercise most insisted upon. This did not, hoAvever, at all diminish the Aoav. The patient rather thought it increased it, and I should not wonder if it did. In the absence or illness of this lady's regular attendant, Dr. -------Avas called in. He found her exceedingly ill. She Avas exanguious —emaciated—too feeble to leave her bed. I Avas desired to meet him in consultation, Avhich I did. The polypus was found reaching almost to the external organs. By the speculum it exhibited a dirty grey hue, and Avas of a flabby texture. An offensive, thick, dark-colored discharge accompanied the use of the speculum. It was agreed that the ligature should be applied. This was done in a day or two. In about five days the canute came away, having 11 attached to it the tumor. The ligature was in place, and as tightly drawn as it could be. The pedicle had separated at its base, about half an inch above the ligature. This is the only instance in Avhich this has occurred, and verifies a remark made by Gooch, that it mat- ters not Avhere is the ligature. All .above it dies and is cast off, as is the umbilical cord, no matter hoAv far from the abdomen it has been tied. Case IV. furnishes evidence to the same effect. A practical remark might be hazarded here. Case VII. shoAvs how exceedingly important is manual examination in profuse menstrual periods—and, let me add, during a period ; for at such the uterine contractions which accompany the periods often bring a polypus within reach, and the patulous or relaxed state of cervix and os Avill aid exploration. Two cases, and but tAvo, have occurred in my experience, in Avhich pain follo\Ared the ligature. Case IX.—Mrs. -------, married, without children, had suf- fered long profuse floAving at menstrual periods, and groAving very feeble sent for her physician, my friend Dr. Homans. Examina- tion discovered a tumor protruding from the os uteri. I Avas asked to see Mrs.-------, and confirmed the diagnosis previously made. The tumor Avas hard, insensible and smooth. It was more flattened than I had found such masses, had a broader base, and resembled someAvhat in shape the inverted womb. A ligature was applied, and tightly draAvn. This gave pain. It was not severe, and it Avas agreed not to loosen the ligature, but to wait in order to ascertain if the pain Avould continue, increase or subside. It gradually be- came less, and at length entirely went off. The tumor came off in about a Aveek, and the patient soon recovered. As the base Avas large, no distinct pedicle having been felt, the ligature was proba- bly applied A'ery near to its base, or the Avomb, and in this way the pressure upon the polypus reached a portion of the womb, or by dragging it produced the pain. 1-2 Case X.—This was referred to when reporting two cases of labor which happened at the same time. Mrs.-------observed the men- strual periods increasing in quantity Avithout any special cause, un- less it were her occupation of standing at the counter of her shop many hours each day, and for some time. This last fact led her to think that her trouble did not depend upon her daily business, which induced her to call on me for advice. I prescribed, directed her to favor herself in regard to fatigue, not to stand so much, and if she did not get better, to call on me again soon- Sime time passed before I saw or heard from her again ; and examination hoav discovered a polypus quite low in the vagina—a tumor cylin- drical in shape, and insensible. Its length Avas unusual at this my first examination, and it is noted because at no subsequent time Avas it felt so low. It evidently had receded. Dr. Putnam Avas present Avhen I applied the ligature. It was carried up to the os, and there fixed, and tightly drawn. Some uneasiness folloAved at once, and a pain of some severity Avas complained of in the right groin, above Poupart's ligament, extending into the iliac fossa. As she had felt similar pains in the same spots, and she thinking it Avould soon disappear, ihe ligature Avas left in place, and Ave de- parted. I had been at home but a short time Avhen I was suddenly called to my patient. I found her in great distress. She Avas cold —the pulse scarcely perceptible—retching—and in her agony im- ploring relief. The ligature Avas at once loosened and removed. This Avas folloAved by partial relief, Avhich in no long time became perfect. I had been present in three cases of chronic inversion of the Avomb, and for the cure of Avhich the ligature had been used. In all of these precisely the same symptoms in kind and in degree existed, as characterized Mrs.-------'s case. I had no doubt of the accuracy of the diagnosis. I felt certain it was polypus. As its shape Avas cylindrical, and its base probably broad, it Avas pos- sible that the ligature trenched upon, if it did not include, a portion of the Avomb. A few days after, the ligature Avas again used, and loAver down than in the first effort. Not the slightest trouble en- sued, and on the fourth day the canute and tumor were cast off". 13 Hoav different was this from the cases of inversion. Every time the ligature Avas tightened, so much pain occurred that opium, ether, or loosening it, became necessary, to prevent wider and graver trou- ble. The shock to the nervous system declared itself every time the ligature was drawn, and this until the tumor was ready to drop off. The mass was so thick and dense that attempts to strangu- late it Avere futile, and ihe only safety Avas in adopting pressure to tolerance. And this course Avas successful. Case XI.—This came under my care a feAV weeks ago. Mrs. -------, 41 years of age, of Providence, R. I. Her first and only child is 22 years old. Mrs.-------dates her trouble nine years ago. It began Avith excessive floAving at her menstrual periods. In its progress pain Avas felt in the pelvis—a bearing-doAvn pain. As the disease increased, motion became more and more embarrassed, and sitting was accompanied Avith a sense of pressure upAvard, as if the diseased part, whatever it might be, came doAvn Avhen erect, and Avas reached by pressure Avhen the sitting posture was assumed. At a later period, and Avhen the patient had ascertained that the pelvis Avas filled Avith a tumor, a new difficulty arose.- The blood accumulated above and around the mass in consequence of its co- agulation, and produced an intolerable sense of pressure. The only remedy for this Avas its forcible removal, which the patient ac- complished, at least to a degree to produce some relief. Physicians Avere consulted. One recently made an examination, and pro- nounced it inversio uteri, and declined doing anything. Another Avas consulted, Avho from the rational signs said it was not inver- sion, but polypus. He made no special examination. Another re- garded it as an obscure disease, and treated it for its symptoms. It has been attempted to get a more detailed account of a case Avhich for so many years has truly afflicted this patient. But the attempt has failed. Physicians have been called when some press- ing symptom occurred. Disease has been tolerated, because no improvement, or at all permanent good, has been derived from any plan adopted. The patient has slowly but surely groAvn worse, 14 with little hope of ever being better. Mr.-------called on me and gave the above facts, and asked if it seemed to me that anything might be done to afford relief. An opinion Avas given that the dis- ease was most probably polypus of the Avomb ; and if so, I saw no reason why it might not be remedied. He desired me to come to Providence at an early day, and to examine the case, and do Avhat I might think best. I requeued him to engage a physician to meet me—as his family physician was absent—under Avhose care the pa- tient might be placed after the operation. My friend Dr. Putnam, Avho has kindly assisted me in almost every operation I have per- formed, agreed to go with me. We reached the address, and were soon joined by Dr. L. L. Miller, of Providence, than whom a bet- ter selection could not have been made. Mrs.-------was in bed, very much agitated by our visit and its purpose. She Avas pale— exanguious—the face full, oedematous. Pulse rapid, small—chilly. Examination discovered a large firm tumor filling the vagina, and making the operation very painful. The upper boundary of the tumor was reached, and Avas found so near to the cul-de-sac as to make it very difficult to pass a finger between them. As this line or face of the tumor Avas nearly horizontal, and broad, a very imper- fect notion Avas oblained of the size of the pedicle, or of the condi- tion of the os uteri. It Avas clear that the pedicle Avas not large —not more, probably, than an inch in diameter. Drs. Miller and Putnam came to pretty much the same conclusion. Very little blood Avas lost, in the examination, consisting mainly of shreddy black coa- gula,Avhich had probably been retained about the tumor for some time. What other discharge occurred Avas of a pale pink-colored serum, or Avater. A ligature was passed round the pedicle Avith Gooch's canute, and Avas drawn as tight as circumstances alloAved. From the description of the tumor it will be perceived that more than usual force was required to bring the noose in close and strong contact Avith the pedicle. There Avas not the least difficulty in any step of the operation. Dr. Miller suggested a method of fastening the ligature after drawing it, which answered admirably. It was to pass one end through one of the rings at the shoulder of one 15 of the canute, and to fasten it there by tying it; and then to draw the loop round ihe pedicle by drawing tightly the other and loose end of the ligature first passed through the ring of the other shoul- der. In thi> Avay all chance of slipping is avoided, and the subse- quent daily drawing of the ligature is made just half easier, and twice as effectual, than by the common method. Some pain ac- companied the tightening the ligature. It Avas slight, and soon be- came less, when Ave left. A few days after, the following commu- nication was made to me in a letter from Dr. Miller :— " On visiting Mrs.-------the next day, she had passed a comfort- able night, Avith a little pain in the lower limbs, none in the abdomen. Tightened the ligature half an inch. Sunday, much as yesterday. Tightened half an inch. Monday, has chills and headache ; pulse accelerated ; no special pain or soreness in abdomen. Gave her morphine. Tightened quarter of an inch. Tuesday, nausea ; thirst; pulse as yesterday. Speaks of general debility. Ligature does not render. Wednesday, less headache; other symptoms less. Ligature came off, and the tumor Avas removed with as lit- tle mutilation as possible. Mrs.-------is comfortable."^ As I Avas to hear if any untOAvard symptom occurred in this case, and as I have heard of none, I feel at liberty to place it among the successful cases. It dates from 1846. At least at that time its symp- toms Avere so strongly declared as to attract the attention of the patient. They steadily increased till January, 1855, and had al- ready become grave enough to produce alarm. Does not such a case teach the paramount duty of the medical attendant to make such an examination as will settle a question in Avhich the patient has the deepest interest ? Case XII.—The patient Avas a single lady of about 50, and for some time had had symptoms of polypus. An examination was * I received with the above the tumor itself, and it was found to measure ten inches in circum- ference and five inches in length. It was not weighed. It had shrunken since the application of the ligature, and had softened, so as to differ much in respect to size from its dimensions when first examined, on the day of the operation. 16 made, and a polypous tumor discovered. I applied a ligature, and in about a week the tumor came off. The recovery Avas rapid, and without subsequent accident. Case XIII.—I was desired to see this case in consultation, in consequence of severe and frequently-recurring uterine hemorrhages. Por the most part they occurred at the menstrual periods, and as pain frequently accompanied them, and much coagulated blood was discharged, they were sometimes regarded as abortions. When I reached the address, the attending physician said to me that the hemorrhage had nearly ceased, and suggested that it might be bet- ter to Avail till it was quite over, Avhen an examination might be made. I at once assented to this proposition, and did not again see the patient till some time after, Avhen I applied a ligature to a polypus Avhich had been discovered. The operation Avas perfectly successful. There is a polypoid out-groAvth from the os uteri, of which a number have come under my notice, which is less likely to be dis- covered than the preceding. And for this reason they are not al- ways accompanied by hemorrhage. It Avould be more correct to say they are very rarely accompanied by it. I have met Avith but tAvo such, Avhile many have had none at all. This symptom has in common polypus occurred during menstruation. These tumors are for the most part small—little more than filling, or moderately distending the os uteri; sometimes growing from one of the lips. Their color is deep red ; their tissue soft, easily broken doAvn, look- ing as if they Avould bleed with slight handling. They are pain- less. Sometimes enlargement and hardness of the cervix are pre- sent, and ulceration. This last I have not seen strongly marked. Along with these characteristics of the out-groAvths themselves Ave have symptoms incident to other uterine conditions, Avhether of dis- placement, or functional or organic lesion. Thus Ave see retrover- sion and anteA'ersion, rarely simple prolapse. I have seen the os turned so strongly towards the sacrum as to prevent the tumor being seen, the anterior lip being also morbidly elongated and bent back. 17 In this Case there was large menorrhagia with hemorrhage, and such Avas the attending pain that abortion Avas so exactly imitated as to lead to the opinion that abortion actually took place. In an- other Case the polypoid Avas large, and hemorrhage severe. It had existed a good Avhile before it was discovered. In this a ligature Avas applied Avith entire success. In a third Case the tumor has returned after removal by caustic. It was broken down and twist- ed off the second time, the result of which I have not learned. In a fourth Case the tumor Avas very large, for one of this kind, arising from a broad base. This was accompanied by ulceration. It Avas removed by caustic, as Avas the ulcer, and the organ restored to perfect health. I haATe not met with a case in which I so much feared malignant disease, which has more completely recovered. There Avas complicated with it an out-groAvth from the meatus uri- narius of a more painful kind ; while the rectum and anus Avere studded Avith insensible, small tumors, Avhich were removed by liga- ture or scissors. In a fifth Case the tumor Avas smaller. There Avas ulceration, but very slight menstruation. The general health, as in most similar cases, Avas perfectly good. Pregnancy had not occurred, and this was the fact in other instances. One had only one child. The tumor in the fifth Case Avas removed by ligature, argent, nit. being applied immediately after. Ulceration followed, which did not yield till several months after. REMARKS. Polypus is not a malignant disease. I have a confused remem- brance of a case of supposed polypus Avhich ended fatally, and I think by peritonitis. This patient had a most unpromising appear- ance, Avas exceedingly ill, and the ligature Avas applied to an out- growth from the womb to which Avas ascribed her almost hopeless condition. In a case of out-growth /row the os uteri, not through it, which Avas very large, irregular, sensitive, and attended Avith a Avatery discharge, at the earnest entreaty of the patient I applied a 3 18 ligature. I have never met with an instance of such intense desire to live. Mrs,-------Avas Avilling to submit to anything which pro- mised her any chance of lengthened life. " I have," said she, " consulted many physicians. They have all refused to do any- thing for me. Can you—are you Avilling—have you the heart " —her very words—" to do an operation to lengthen life, Avhich operation may itself be fatal ?" I Avas leaning upon the footboard of her bedstead, when she made to me this appeal. I shall never forget the expression of her eye, of her Avhole face, Avhile she Avas speaking. I said I felt equal to my professional obligations—that I should not shrink from Avhat duty demanded. An examination followed, and the extent and character of the disease ascertained, as above described. A ligature Avas applied, Dr. Putnam aiding me. It Avas tightly draAvn. " Have you pain ?" " Do not ask, only go on, and do all Avhich is demanded," Avas the quick ansAver. Mrs. -------became easy, and the next day the ligature Avas again drawn, and again Avith intense pain, and again and again Avas it done. One morning as I entered the chamber I saw her suddenly put something under the bed-clothes, looking at the same time very animated and pleased. I asked the cause. She showed me the canute, which had come off, and which she Avas rubbing when I entered. She had made them perfectly bright. I asked how they came off, as I left them the day before firmly fixed. " In turning suddenly in bed, the instrument got entangled among the clothes, and in too much haste I disengaged and tore it at the same time from the tumor." " Where is the tumor ?" " Nothing," she said, " had come aAvay but a feAv shreds Avith the string." Upon exami- nation, no tumor could be discovered. The vagina was perfectly empty. A small conical or thumb-shaped body Avas felt at the far- thest part of the vagina, springing from the Avomb, and from Avhich the ligature had been torn. EveryAvhere else smooth soft tissue could alone be detected. It seemed hardly possible that in so feAv days a tumor so large, so solid, broken as it Avas by deep sulci into strange shapes, could have been gathered as into one mass, and all of it so completely removed except the small portion just mentioned. 19 It was not possible to get a ligature round this. Injections Avere directed, Avhich it Avas hoped might have repressed its growth. Cauterizatian, actual and potential, had not then taken its place, whether for Aveal or for Avoe, as an every-day routinery, in the hands of everybody, hoAvever skilful or however the opposite. Mrs.-------■ rose from her bed, left her chamber, her house, the town. She felt Avell, and* visited distant places and friends. For some time there Avas no evidence of a return of the tumor. I Avas again called to see her. The tumor had returned—filled the vagina again—the system had yielded to its poAA'er, and she Avho had with such moral force done so much to live, was now willing to die, and death soon came to end a Aveary and suffering life. " This was not polypus." Certainly not, Sir. In some of its features it re- sembled cauliflower excrescence; but that disease, as far as I have seen it, has been insensible, and this Avas very sensible. But it en- tirely disappeared under the use of the ligature, except the small point from which the string Avas torn. It returned. This is true of cauliflower excrescence; and it Avas fatal, as is that. I have placed it here for diagnosis. The result will not deter me from repeating the same operation, Avith such subsequent measures as may make permanent Avhat seems a cure. Does polypus recur ? Two instances have been given in Avhich it did recur. Gooch says it does not return—but that what remains is absorbed or thrown off in a solid or semi-liquid way. This is true ; and it is also true that the tumor does not return in the same spot from which one has been removed. But it may appear elseAvhere. The examination of Dr. Stevens's case after death is conclusive on this point. I know no instance of a more important examination, so far as the determination of a pathological fact is concerned. The places from AA'hich two tumors had sprung Avere clearly visible, and a third tumor had already begun its groAvth at quite a distant point from these. It was in miniature, but its likeness to others Avas perfect. Dr. J. Mason Warren has met Avith a recurrence of poly- pus in the same patient. I feel very much obliged to this eminent surgeon for the following facts concerning that case. " The patient 20 was 34 years old, unmarried. The disease commenced by hemor- rhage after a fall against a stone step, Avhich confined her to bed for some months. An examination Avas made, and a polypous tumor Avas discovered projecting from the os uteri. At the time of the operation she was so exhausted by the loss of blood as to make it unsafe to place her in an erect posture. After the application of the ligature her recovery Avas rapid, and«she remained Avell for four years, to the time you saAV her Avith me—-or rather until six months previously to the recurrence of the same symptoms as before— namely, hemorrhage at the menstrual periods, severe pains, and bearing-doAVn sensations in ihe back and loins, and Avhich seemed to indicate a return of the disease. The last operation I believe produced a radical cure. At least I suppose so, as I have not heard from the patient since." I have made a division of polypi into concealed, and exlra-'ule- rine. I think this is an important division. Gooch mentions a case in Avhich more than tAVO years passed of hemorrhage and pain before the disease declared itself at all—at least only by the Avomb being larger than natural. At length violent uterine contractions occur- red, and a tumor filling the vagina Avas forced out of the womb. A most accomplished practitioner had made examinations, but never discovered a tumor. I am at this moment in consultation with a physician in Ohio, before referred to, concerning a case nearly resembling some cases described in this paper, and parti- cularly Gooch's. I have advised ergot at the catamenial period, Avhich may aid in settling the diagnosis—especially as there is bearing-down pain during the periods. Ergot here can do no harm. On the contrary, it often tends directly to check uterine and other hemorrhages. Pain on drawing ihe ligature.—In tAvo cases pain was complain- ed of. In a third it was stated to be present after it was inquired about. In only one Avas it alarming—so severe as to lead to loos- ening and removing the ligature. I allude to this subject again, because of its practical bearings. In two cases, which pretty re- 21 cently occurred in neighboring cities, polypus was complicated with inverted womb—in fact, produced the inversion. The liga- ture was applied as for simple polypus. Most severe pain follow- ed. The ligature Avas loosened, but not removed. At length one of the tumors dropped off. In the other Case, the operation was completed by the knife. The patients did well. In the cases of pain following the ligature in this paper, no inversion existed. In the most serious one, a second application of the ligature was successful. 24 Buifinch St., Boston, February 20, 1855.