long been known; if, from their too great simplicity, and their not being made up in the apothecary's shop,' they are less valued than they deserve. But while I consider the blast of steam as the most effective of all the modifications of this practice, I have often succeeded by means of it, in removing, almost instantaneously, a paroxysm of the severest Neuralgia of the face, and, occasionally, so as to put a stop, in the chronic disease, to an entire relapse, which, from all the patient's past experience, was expected to last some weeks." 391.

Cold applied to the part does sometimes give temporary, but never permanent relief. On the contrary, it generally exasperates the subsequent sufferings of the patient.

"Though I have already spoken of the use of narcotics, this is a more convenient place to point out one advantage to be derived from them; a fact which I purposely postponed, on account of its connexion with the useful effects of hot water and steam. As a means of diminishing pain during the painful state, they are nearly useless, unless pushed to such an excess as to stupify the patient; in which case, it is probable, as I already insinuated, that their effects are injurious, while it is easy to comprehend how they ought to be so, by inducing, indirectly, that debility which so prolongs and aggravates all the Neuralgiæ. But when the acute state is past, they become useful, as tending to remove that soreness which remains after the chief pain has ceased, and also by reducing the general irritation which has been excited by it. Thus also they sometimes act usefully, even as local applications, at least to sensible parts; and it is probably on this principle chiefly, that they are of advantage in the neuralgic inflammation of the eye." 394.

Dr. M. next adverts to the lædentia, and satirises with no small degree of force, the once celebrated practice of dividing the nerve in neuralgia; but as that practice is now laid in the "Tomb of the Capulets," we need not trouble our readers or ourselves on that point. The use or rather abuse of excessive purgation is next denounced by our author, and not without reason. Low diet, of course, comes in for its share of censure, and, as far as neuralgia is concerned, we have no fault to find with our author's strictures. But when he comes to ridicule the plan of abstemious living in dyspeptic complaints, he goes beyond his depth, and proves to those who have infinitely more experience than himself, that he knows nothing about the matter. This is the misery of having a hobby-horse. A man hits upon

one good idea or thing; but he is not content with making that idea or thing useful to the world-he must push it to extremes, and endeavour to make it the "universal good." Dr. Macculloch must be well aware that no medical journal has done him so much justice as ours; and that we have proclaimed his merits through every region of the earth, which the "rising or the setting sun surveys." He is too sensible not to know that our praise is the more valuable in proportion to the impartiality which we display towards his failings-at least what we consider his failings. The following case, which we shall give in Dr. M.'s own words, does not at all support his anathema against abstinence in dyspepsia, though it is brought forward by COUP DE GRACE" to that system.

him as a

"This unfortunate philosopher had been long subject to the usual dyspeptic and nervous symptoms of studious men, and was of a sallow and emaciated complexion; appearing, in familiar language, to be far more in want of additional blood than of its abstraction, while his disorder was continuously aggravated by a system of low diet, adopted on the same mistaken views. Passing every day with him, in company with an English physician, it was easy to watch that over which we had no control; as there would also have been no propriety in attempting to oppose the best advice in Paris.' Headach was, as usual, one of the occasional symptoms; and on one unfortunate day he was induced to send for his

surgical friend, by whom he was immediately bled. The headach, on the following day, continued, or rather returned, as it had formerly done, but with increased confusion of thought; the pulse, and all else indicating, to the English physicians in question, increase of general debility, and compelling us at length to offer advice, which was however opposed by the usual arguments. A second blood-letting of course took place; and the consequence was that he became, but only in the night, partially delirious; a result easily explained, in its very limitation. It was then determined in full consultation, that there was inflammation of the brain, to the exceeding surprise, not without remonstrances, of the two English physicians; and, consequently, with the addition of blisters, shaving the head, and ice, another blood-letting was ordered and practised. The delirium then increased, while the pulse became feeble enough, as might have been supposed, to have made any man reflect; but as this did not happen, or rather as the reflections took the opposite course, the practice was persevered in, and on the following day the patient died: leaving the physicians, doubtless, convinced, as usual, that he had not lost blood enough Such is a

French case; but it would be easy to give no small number of parallels from English practice and should it make no impression at present, the day will come round again when its value as well as its nature will be understood." 403.

:

Doubtless there might be many cases collected on both sides of the channel, where sanguineous depletion has been carried too far-and where irritation is mistaken for inflammation This is the great source of error. Where inflammation actually exists, there cannot be very much mischief done by taking away a little more blood than is necessary. But where the neuroses are treated as phlogoses, which was the case with the unfortunate gentleman in Paris, then indeed the havoc of constitution is tremendous, and life itself is often sacrificed. With the following specimen of our author's sarcastic strictures on physicians and physic, we shall close this article.

"It were well indeed if not only ruined constitutions, but even death itself, were not the frequent, the almost daily result of physic thus misapplied in all the analagous and parallel cases, as also in some others; the produce of a combination of system, fashion, and ignorance, which renders Physicians and physic the just terror at present of all those who can see and distinguish. It is difficult to speak without high indignation as well as horror, of what we thus daily witness: to suppress the former is impossible, when our own, perhaps dearest friends, have thus been destroyed: and well now, perhaps, will he decide, who, like Napoleon, resolves to exclude this art and its professors entirely; for, on the arithmetical average, he will assuredly be far on the side of security. It is but to open our eyes to see the truth of this every day; while if it is over the ruined health, or the life of females that we shall most often have occasion to grieve, from the obvious reason that in them the nervous affections thus mistaken and maltreated, chiefly abound, or are chiefly brought before physicians, so has there been a rapid increase of the evil, from the numbers who, returning from a continental residence with the consequences of marsh fever which I have so often described, have been subjected to this, truly mortal as well as mistaken treatment." 421.

The last chapter in the work is one of a different cast from the others. Having terminated his Essay when his evidence was exhausted, and his induction carried as far as it could safely go, Dr. M. ventures on a chapter of "conjectures respecting the condition of the nerves and nervous system in intermittent and neuralgic diseases." These conjectures are ingenious, and some of them plausible; but we have no space left for samples of them here. We part from our author with feelings of much respect and esteembelieving that he has contributed much more to the advancement of our science than many who have held their heads much higher in the republic of medicine.

VI.

OBSERVATIONS ON POLYPUS OF

THE UTERUS. lane, M.D.*

By John Macfar

A long, but an interesting, indeed valuable paper on uterine polypi has been published by Dr. Macfarlane, in the fourth Number of our respected cotemporary of Glasgow. The subject is so little understood by practitioners in general that we think we shall be doing some service to the state by noticing the present contribution very fully.

Dr. M. remarks, and we think with reason, that polypi are not so rare as they are thought to be, even by experienced and able practitioners. This, although owing at times, no doubt, to a want of either knowledge or care in discriminating between various morbid conditions of the uterine passages, accompanied as they are by general symptoms of a similar stamp, is partly to be attributed to the delicate nature of the case, the feelings of the patient, and the natural repugnance generally felt to any mechanical or manual examination. This latter, however, is absolutely necessary, and if it were oftener adopted "in women liable to habitual hæmorrhages, and to mucous, sanious, or watery discharges from the vagina, polypus would certainly be found to prove a more frequent disease." Dr Macfarlane's object being rather to discuss the more important topics suggested by the cases which have come within the sphere of his own observation, than to write an elaborate account of the disease, he has merely considered uterine polypi under two heads-the simple or benign, when the uterus itself is free from disease, and the cancerous or otherwise malignant, complicated or not with organic disease of the womb. These distinctions are made without reference to the part of the uterus from which the polypus takes its rise.

COMMON OR FIBROUS POLYPUS.

Polypus of the uterus is commonly firmer and more fibrous in its texture than polypus of any other organ, which perhaps may depend on the thickness and vascularity of the uterine substance, the condensed structure of the mucous membrane, or the intimate adhesion of the latter to the parts below opposing much resistance to the morbid growth. The frequent and often profuse hæmorrhages which take place in these cases from the vagina, have by many been attributed to the pressure of the os uteri on the neck of the tumour, impeding the free return of the blood, and causing engorgement and rupture of the superficial vessels. This, together with the pendulous position of the tumour and nature of the parts with which it is connected, will probably fully account for the circumstance. Authors, however, have attempted to explain in a similar manner the pyriform shape and narrow neck of the polype itself, but to this it may be answered that polypi, wherever they are found, assume more or less the above conformation, and cases not unfrequently occur where these tumours are confined to the cavity of the uterus, but possess notwithstanding the pyriform shape and narrow stalk. Dr. Macfarlane has witnessed three such cases, and several preparations illustrative of the fact. At the same time

it is clear, that when once the tumour has passed the os uteri into the vagina the inferior portion must enjoy in that part more room for expansion than when " cabin'd, cribb'd, confined" in the womb.

Unless the polype has emerged from the uterus, we have no correct means of ascertaining its presence, though of course from the bleeding and accurate examination of the state of the parts, a conjecture may sometimes be formed. In the following cases an accurate opinion was formed, and the ergot of rye was employed with success.

Case. The widow of a sea-captain who had had for some years an habitual leucorroa, was subject to profuse and almost daily discharges of blood from the vagina for the space of ten months, at the end of which time she consulted our author. Her health being impaired she was ordered to maintain the recumbent position, and the treatment consisted in the administration of mild laxatives, enemata, acids internally, cold to the abdomen, astringent injections into the vagina, and ultimately the introduction of a plug. At the end of three weeks, no benefit having ensued, a manual examination was requested and obtained. The os uteri admitted the point of the finger, but nothing could be felt to indicate a tumour or other disease. The uterus, however, appeared to be enlarged, and its walls bulged out, which induced Dr. M. to suppose that a polypus or some other tumour existed within, and led him to exhibit the ergot of rye. The character of the patient was so highly respectable, and the symptoms and history of the uterine affection such, that our author had no reason to believe she was pregnant, and therefore anticipated no bad effects from the use of the remedy. The first trial failed, as the ergot was apparently bad, but the second occasioned severe and continuous pains, followed by the projection of a smooth, firm tumour at the os uteri, about the size of a small melon. In the course of a few hours the bulk of the tumour had passed into the vagina, and its slender stalk could be felt with the finger. In consequence of the pain and irritation excited, some doses of laudanum were required, but four days after the exhibition of the ergot, the polypus fell off when rising to make water. She had two slight returns of flooding, and in a few weeks was restored to her former good health. The ergot was prepared by infusing a drachm in four ounces of boiling water, and administering one ounce every two hours. Four doses were given before the effect was produced.

"The known efficacy of the ergot in exciting uterine contraction, will readily suggest, in cases analogous to the above, the employment of this medicine, in preference to every other means, whether medical or mechanical. It is certainly superior in every respect to a practice alluded to by Gardien, in his "Traité d'Accouchemens," tome i. p. 430, in which a M. Bonnie dilated the os uteri by means of sponge tents, and afterwards applied a ligature to the polypus

"A spontaneous cure is sometimes effected when the pedicle is small, either by the neck of the uterus firmly compressing it; or more frequently the propulsive efforts of the uterus, by stretching the pedicle, causes it to ulcerate. This termination is by no means so common, however, as many authors would have us to believe. I have had frequent opportunities of examining tumours thus expelled, several of which were pronounced to be polypi; but after careful examination, the one above referred to was alone entitled to be considered as a specimen of this disease. The others were either the fungous excrescences, denominated "vivaces" by Levret, and supposed to arise from an ulcerated spot in the cavity of the uterus; or more generally fleshy moles, now believed to be the product of

conception. The true polypus which was separated by the action of the uterus, was of a firm texture, covered by a mucous membrane, and weighed about 6 ozs. Its substance was dense and homogeneous, showing only a slight fibrous appearance about the pedicle; a small portion of which was attached, and about the size of a quill. The one half of this specimen was carefully dissected, and the other macerated, but without throwing any light on its scructure or mode of growth. The mucous coat, after a few days, was easily separated, and the great bulk of the tumour that remained, broke down under the fingers, showing in some parts a lamellated arrangement of its texture. In this, as in every other specimen of uterine polypus which I have had an opportunity of examining, no very obvious disease of the mucous membrane was discoverable. It was sometimes found slightly thickened, irregular, and traversed by enlarged veins, but was always separable from the surface of the tumour; and it never appeared as if the whole bulk of the polypus had depended on a morbid change of that membrane, and a slow subsequent enlargement of the diseased portion;' a circumstance which Dr. Burns, in his excellent Principles of Midwifery,' considers as the most frequent variety of the disease. From whatever part or texture of the uterus the disease originates, it is probable that in a great majority of cases the mucous tissue of this viscus is not its primary seat; but that, in consequence of the tumour being developed behind it, it is gradually pushed forward, becomes elongated, and is afterwards liable to slight morbid changes, arising chiefly from mechanical distention or chronic inflammation. There is reason to believe, however, that in very large and old polypi, particularly in those which have a tendency to assume a malignant action, the mucous envelope will be found so much changed and assimilated to the morbid mass which it covers, as to have lost its natural appearance and distinctive characters." 416.

From several well-authenticated cases upon record it is proved, that pregnancy is not incompatible with the presence of a polypus of considerable size in the uterus. The following is, in Dr. Macfarlane's opinion, an almost unique instance, in many respects, of such a combination.

Case. Mrs. S. ætatis 30, was taken in labour of her first child, on the morning of the 13th October, 1825. About four o'clock on the succeeding morning the child was born; but its feeble condition and premature appearance tended to corroborate her own opinion that she was hardly eight months gone in pregnancy. In half an hour, the placenta was partly protruded by a slight bearing-down pain; but on Dr. Macfarlane's attempting to remove it, unexpected resistance was encountered, which was found, by examination, to depend on its adhesion to a large, firm, globular tumour that filled the vagina and rested on the perineum. The centre of the placenta, opposite the cord, adhered to the apex, and the rest embraced the sides of the tumour, all which attachments were separated during the examination, and the placenta itself brought away. At first it was thought that the tumour consisted in an inversion of the uterus, but on pushing it up before the hand, an immense firm polypus was found growing from the very centre of the fundus of the uterus, which had caused by its weight and descent with the placenta a partial inversion of that organ. The tumour was of almost cartilaginous hardness, its pedicle as thick as the wrist, and its depending part larger than a child's head at birth; its surface was smooth to the feeling except at the apex, where a roughness was occasioned by the adhesion of the placenta. From the thickness of its attachment it seemed evident to our author that any attempt to twist it off would more probably occasion laceration of the substance of the uterus than of the pedicle, and therefore any such idea was given up. During the minute and a half that this examination was proceeding, blood was profusely issuing from the apex of the tu