Within a fortnight after the second operation, the patient left the hospital entirely cured.-Lancet, Jan. 23, 1869, p. 121.

93.-ON THE DIAGNOSIS AND TREATMENT OF UTERINE

POLYPI.

By Dr. GEORGE H. KIDD, Obstetric Surgeon to the Coombe Lying-in Hospital, Dublin. A polypus in the cavity of the body of the uterus causes the whole organ to grow in the same way that the ovum does in early pregnancy. Hence the cavity becomes enlarged and elongated, and the walls thickened and hypertrophied. If the polypus be of any size the fundus of the uterus will be felt in the hypogastric region, of irregular form, it may be, depending on the form of the polypus. When the enlargement is not so great it may still be recognized by the finger in the vagina, and the fundus may be traced by the bi-manual method of Marion Sims, but even though we have hemorrhage and the other symptoms enumerated, along with an elongated uterine cavity as measured with the sound, and an enlarged and irregular fundus, we cannot absolutely declare the existence of a polypus, inasmuch as all these signs, like the symptoms, may depend upon other causes.

Moreover, not only may these signs and symptoms exist without there being any polypus present, but we may have a polypus without any enlargement of the uterus, as when it grows in the cervix, and is of the small size usual in this situation, or when, even though in the cavity of the body of the uterus, it is of such small size that the elongation of the cavity, as measured with the sound, is scarcely appreciable; and yet, small as the growth is, it may, if not removed, run the patient down by hemorrhage.

The only certain proof of the existence of a polypus is the detection of it by the eye or finger, and, therefore, when from persistent hemorrhage or other cause, we suspect the presence of such a growth, and cannot otherwise discover it, we must dilate the uterine canal so as to be able to pass a finger to the very fundus, and make a minute and careful digital examination of the cavity throughout its whole extent.

[The use of sponge tents for facilitating explorations of the uterine cavity dates from 1844, when they were introduced by Sir James Simpson. They have, however, several disadvantages, such as requiring repeated applications of them, to get at the cavity of the uterus, and becoming foetid when allowed to remain a few hours in the uterus.]

The sea-tangle is free from all these objections, and seems to me not only to supply the boon to surgery desired by Marion Sims, by being an efficient, pleasant, and cheap substitute for sponge tents, but to be more easy of application, more prompt in dilating the uterus, and above all, more safe in its action.

When the uterine tissues are relaxed by hemorrhage, a fine tent can be passed at once through the whole length of the cervix and on to the fundus, and by a little care a number of fine tents can be packed alongside of one another in the canal, when a single large one, though not nearly of the size of the bundle so formed, could not be passed at all. The first tent introduced serves as a guide to the others, and when they absorb fluid and swell out, they not only dilate the os internum as much as the os externum, but also the cavity of the uterus itself, and thereby provide room for the manipulations necessary for the removal of the polypi, if any are found to exist.

I first used sea-tangle tents in the manner now described in the case of a lady, residing some miles out of Dublin, whom I was asked to see by my hospital colleague, Dr. Sawyer, on the 4th of May, 1867, on account of persistent hemorrhage, when it answered the purpose so well that I have ever since adopted the same method, and with the most satisfactory results. In one case, where the patient, though married seven years, had never borne children, the os was so small that it was necessary to leave a single fine tent

in it for some time before a sufficient number could be got in to effect a dilatation large enough to admit the finger, but it is the only case I have met with out of a large number where such a proceeding was necessary.

When it is determined to explore the uterus after this manner the patient is placed in the usual obstetric position, and the length of the uterine cavity is carefully measured by means of the sound. A No. 5 or 6 sea-tangle bougie is now cut into pieces a little longer than the uterine cavity, and the ends rounded off and smoothed. The patient is now desired to put her left arm behind her back, and to lie almost completely on her face, with her right leg drawn up and thrown in advance of the other-that is, in the semi-prone position of Sims. The "duck-bill" speculum is now introduced and given to an assistant to hold, the anterior lip of the os uteri seized with a fine tenaculum, the os having been brought into view and steadied in this manner, as many of the pieces of sea-tangle as can be got in without using force are passed one after another, till they almost touch but do not press on the fundus. Five or six pieces of a No. 6 bougie will dilate the uterus sufficiently for all purposes; and when these have been got in, the tenaculum and speculum are withdrawn and the patient is settled in bed, when a morphia suppository may be administered. If the uterus make expulsive efforts, it may be well to leave a pledget of cotton in the vagina; but if the tents do not actually touch the fundus, the uterus does not generally try to expel them.

At the expiration of twenty-four hours the exploration may be proceeded with. The tents are easily removed by seizing them one after another, with a toothed forceps. The patient must now be brought fully under the influence of chloroform, and then placed in the semi-prone position as before, when the anterior lip of the uterus must be laid hold of by means of a large strong vulsellum, and slowly and gradually, but steadily, drawn down to the vulva. If the blades of the vulsellum be not strong and firm they will spring at this stage of the operation and tear the uterus, and the instrument must be made so that the points when closed, will fairly meet and glide past one another without making fresh openings in the tissues, and when completely closed the blades must have ample space between them for the lip of the uterus, that it may not be in any way compressed, no matter how firmly the handles are held.

The uterus being brought down and fixed in this way, the vulsellum is given over to an assistant, who is directed to hold it steadily, and the forefinger of the right hand is now passed up into the uterus and its interior carefully examined, which will be much facilitated by placing the left hand over the fundus and pressing this part down on the finger. If a polypus be discovered a tolerably fine vulsellum is now passed along the finger in the uterus, and guided by it to the tumour, which is then seized. The finger is now withdrawn, and an ecraseur, armed with a single soft iron wire, is passed in, guid ed by the vulsellum in which the polypus is held. The loop of the wire is first passed over the handle of the vulsellum, and then the point of the ecraseur is placed against the blades of the vulsellum and run up as far as it will go.

The finger may now again be passed into the uterus so as to press the wire well down on the polypus; but if the eye of the ecraseur be passed well up to the uterine wall it will of itself draw the wire into its place. When the ecraseur is fixed in its place it is held steadily, and the wire slowly screwed up till it cut through the peduncle, when ecraseur, polypus, and vulsellum all come away together. The finger should now be again passed in, and if no more tumours be discovered the interior of the uterus may be brushed over with a saturated solution of the perchloride of iron in glycerine, and the patient may be put to bed and allowed to sleep off the effects of the chloroform. For a few days the vagina should be syringed out with tepid water.

I have now operated in many cases by this method, and I have also tried the plan of passing the entire hand into the vagina instead of drawing down the uterus, and also the plan of pressing down the uterus by a hand placed over the hypogastrium without passing the hand into the vagina or using any vulsellum for drawing it down, and am convinced that these methods do more violence to the surrounding parts, are less efficient, and are more irk

some to the operator than the proceeding just described. If the polypi be large and come into view, or can be seized, the drawing down of the uterus is, of course, unnecessary; but when they are small and concealed from view, I am convinced the foregoing is the safest way of operating.

Intra-Uterine Fibrous Polypi.—Intra-uterine fibrous polypi arise most frequently from the fundus of the uterus, or that portion lying between and above the openings of the Fallopian tubes, but they may also arise from some portion of the walls of the body, and are very rarely met with springing from the walls of the cavity of the cervix. Arising in any of these situations the polypus commences as a round submucous elevation which in general becomes pedunculated, and suspended with its largest portion free in the distended cavity of the uterus, but it sometimes remains sessile. In either case it may in the progress of its growth come to rest on and close the os internum, forining there a sort of ball valve, and preventing the exit of any fluid that may be poured into the cavity of the uterus. More frequently the tumour passes through the os, and (the peduncle becoming elongated) is gradually extruded from the cavity of the uterus, when it may be found either completely or partly protruded through the os externum, and may be easily recognized and easily removed. Generally speaking, they are single, but not unfrequently we find rudiments of smaller ones, consisting of submucous round elevations adjoining large polypi. Klob, indeed, says that sometimes two are found flattened from contact, but rarely more than two, and in the majority of cases only a single one; and West, contrasting them with fibrous tumours on the outer surface of the uterus, which are seldom solitary, and often very numerous, says, it is rare to find more than one projecting at the same time into the cavity of the uterus. This he thinks due probably to there not being room for more than one tumour at a time within the cavity of the womb, for it is not a very uncommon thing, he says, some months after the removal of one growth, to find another occupying the same situation, producing the same symptoms, and calling once more for a recourse to the same operation. In one case, however, twenty-nine fibrous polypi were removed within twelve months, at four operations, three at the first, nine at the second, eleven at the third, and six at the fourth. In this respect the case is, so far as I can learn, unique, no similar one having been recorded by any author with whose writings I am acquainted.

Case. Menorrhagia lasting Fourteen Years-Twenty-nine Fibrous Polypi Removed from the Cavity of the Body of the Uterus at Four Operations.Miss A., an unmarried lady, aged 36, was placed under my care by Dr. Martin, one of the physicians to Jervis-street Hospital, on the 22nd August, 1867, and admitted by me as a patient into the ward for diseases of women, in the Coombe Lying-in Hospital. She had been a governess, but been reduced to poverty by ill health, consequent on menorrhagia, from which she had suffered for 14 years. During this time she had been treated by several physicians, and in many hospitals; but, till she came under my care in the Coombe hospital, and I insisted on being allowed to do so, no examination of the uterus had been made. When I examined it I found it enlarged so that the fundus could be felt above the pubes. It was somewhat irregular in its outline, and its cavity measured an inch longer than it ought to do, but the os and cervix were apparently quite healthy. She was blanched from the loss of blood, her extremities were oedematous, her breathing was short and panting, and her debility was extreme. On consultation with my hospital colleagues, Drs. Ringland and Sawyer, and with Dr. Beatty, who kindly saw the case with us, it was agreed to explore the cavity, and for this purpose six pieces of sea-tangle were introduced on the 5th of September, 1867, in the manner just described. On the following day the finger was passed into the cavity up to the fundus with great ease, and so well was the canal dilated that we could even see one of the tumours lying above the os internum. Three tumours, each as large as a pigeon's egg, were found and removed with the ecraseur. The patient was kept in bed for a week, but suffered no pain or inconvenience, and at the expiration of ten days left the hospital.

For a time the menorrhagia ceased and she improved in health, but the

hemorrhage gradually returned, and in the month of March, 1868, she applied to be re-admitted into the hospital. The uterus was enlarged even more than it had been before, and again we dilated it and found a group of tumours filling it up. Dr. Beatty was still good enough to lend his valuable assistance, and with his help and that of my colleagues, I removed nine polypi, some of them large and pedunculated, others as small as a pea and sessile.

She recovered from this operation quite as well as on the previous occasion; but, although every tumour that could be discovered was carefully removed, the uterus never resumed its normal size; it remained large, and could still be felt above the pubes. The next menstruation was, however, healthy, both as to the quantity and character of the discharge; but in April the hemorrhage returned, and in May it was as bad as it had ever been, if not worse. The uterus was now greatly enlarged; it could be felt above the pubes as large as a man's shut hand, and the sound passed into its cavity nearly four inches. On the 16th May we again dilated the os, which was as small and apparently healthy as ever. We now removed eleven tumours, four of which were pedunculated and grew from the fundus, and were nearly as large as any of those that had been previously removed; the others were smaller and sessile.

After they were all removed we painted over the whole surface of the uterus very freely, with a saturated solution of the perchloride of iron in glycerine. For some days after the operation there was fulness, with pain and tenderness, in the lower part of the abdomen; but these symptoms quickly yielded to the use of poultices and injections of tepid water into the vagina, and on the tenth day the patient was able to be up and going about. The uterus, however, scarcely diminished in size. The os closed completely, and got into its normal state, as it did after the previous operations, but the body remained large and prominent above the pubes. No menstrual or other discharge took place till the 29th June, when it again occurred, and became hemorrhagic in character and very profuse. Consequently, on the 11th July, I again dilated the uterus, assisted as before by my hospital colleagues and Dr. Beatty, and by Drs. Churchill, M'Clintock, Atthill, and Collis, and I removed six tumours, one as large as a hazel nut, the others smaller in size. After their removal I applied strong nitric acid freely over the whole of the inner surface of the uterus. On the next day the patient expressed herself as feeling less uncomfortable than after any of the previous operations; the pulse was 104; there was no tenderness of the abdomen; and the only complaint she made was of having a very offensive discharge from the vagina. I had ordered her a grain of opium every second hour after the operation. I now prolonged the interval to every fourth hour, and ordered the vagina to be syringed out, and a poultice to be applied over the hypogastrium. The following day the pulse was down to 96, and there was no fulness, pain, or tenderness, and the day after the pulse was down to 80. There was some purulent discharge from the vagina, but not offensive, and she wished to sit up, which, however, was not allowed, but the poulticing and opium were discontinued. I believe this is the first time strong nitric acid has been applied to the interior of the uterus. I used it at the suggestion of Dr. Ringland, to whom we are, I believe, also indebted for the first suggestion to use this acid in affections of the os and cervix.

The uterus diminished much in size after this operation; it sunk down into the true pelvis, and could no longer be felt above the pubes. On the 1st of August, exactly three weeks after the operation, I made a careful examination. The os was closed, the cervix was in its normal condition, there was no discharge. Examined by the bi-manual method of Marion Sims the fundus could be found regular in its outline, but rather larger than natural, and when measured with the sound its cavity was found to be nearly an inch longer than it ought to be. This patient was kept in the hospital, partly that she might have the benefit of good nourishment, and partly to watch the case; but as the next menstruation was perfectly healthy, she became anxious to leave, which she did on the 9th of October, 1868, and in a short time afterwards undertook engagements as a visiting governess, which she has since

continued to fulfil. On the 6th January, 1869, she called on me at my own house, and reported that her menstruation had continued quite healthy-that the periods since she had left the hospital had lasted only four days each, and that she only required to use two napkins each day, notwithstanding that she had to walk a great deal, even during the period, in attending to her pupils. She said she felt strong and well, and " had got a blush in her cheek," all of which her appearance confirmed.-Dublin Quarterly Journal, Feb. 1869, p. 10.

94.-RECENT EXPERIENCE IN OVARIOTOMY.

By T. SPENCER WELLS, Esq., Surgeon to the Queen's Household.

Since last October I have completed the operation of ovariotomy in this Hospital in thirty-six cases, besides one case in which I performed the operation successfully for the second time on the same patient. Of the thirty-six women, thirty-one recovered and five died. And it is a remarkable fact that in every case in which the pedicle was long enough to enable me to use the clamp the patient recovered. There were thirty of these cases-thirty clamp cases in one year without a single death. In two cases I used the cautery. One of the patients recovered, and one died. In four cases I tied the pedicle, and returned it into the cavity of the abdomen after cutting off the ends of the ligature. All these four patients died. Two of them must have died, I think, in whatever manner the pedicle had been treated. They were almost hopeless cases, and the operation was done as a forlorn hope. In one case the patient was sinking fast from septicemia, a cyst filled with foetid fluid and poisonous gas having been washed out repeatedly, but ineffectually, with carbolic acid, and it was at last removed with only the very faintest hope of saving life. In the other case, extensive pelvic adhesions and disease of both ovaries had been pretty accurately made out, and had led to repeated tappings rather than ovariotomy. But at length, when tappings became of no avail, the cysts were removed, with some slight hope but with far greater apprehension. A clamp could not be used in either case. The pedicles were too short. The cautery might have been used; but the pedicles were of the kind where the cautery is often ineffectual in stopping bleeding-broad, thin, membranous attachments, with large vessels. In such cases the ligature succeeds well in stopping bleeding; but whether the ends are left hanging out through the opening in the abdominal wall, or are cut off short and returned with the pedicle, the results in my hands have been almost equally unsatisfactory. Other operators have been much more satisfied with the ligature than I have been, and every one must be guided very much by his own experience. But when I look back over the work of the past year in this Hospital, where all the patients have been treated in all other circumstances under similar conditions, and find no single death in thirty clamp cases, but every one a recovery, while of six cases treated otherwise five die, you will hardly wonder that I use the clamp whenever I can, especially as very similar results have been obtained in private practice. It is true, as I have just said, that two of these five deaths would probably have happened even if I had been able to use a clamp. But three of the deaths I attribute principally, or entirely, to the fact that, as I was unable to secure the pedicle outside the peritoneal cavity, I was driven against my will to the cautery or the ligature. Twice I used the cautery. In one it stopped all bleeding, and the patient recovered. In another it only stopped the smaller vessels, the larger having to be tied, and this patient died; so that her death might be added to that of the four who died after the return of the tied pedicle. Or if, as I think it is fair to do, we put aside (so far as the treatment of the pedicle is concerned) the two cases which probably must have died however the pedicle had been treated, we have three cases where death followed the use of the ligature; and, so far as I can judge from observation of similar cases, these three