•A CONTRIBUTION 
TO TIIE 
DIFFERENTIAL DIAGNOSIS BETWEEN 
HOLLOW UTERINE POLYPUS 
AND 
COMPLETE INVERSION OF THE UTERUS. 
BY 
G. E. SUSSDORFF, M.D., 
New York. 
Reprinted from Tiie American Journal of Obstetrics and Diseases of 
Women and Children, Vol. X., Xo. IV., October, 1877. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1877. A CONTRIBUTION 
TO THE 
DIFFERENTIAL DIAGNOSIS BETWEEN 
HOLLOW UTERINE EOLYEUS 
AND 
COMPLETE INVERSION OF THE UTERUS. 
sy >y 
G. E. SUSSDORFF, M.D., 
New York. 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. X, No. JF, October, 1877. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1877. A CONTRIBUTION TO THE DIFFERENTIAL DIAGNOSIS BE- 
TWEEN HOLLOW UTERINE POLYPUS AND COM- 
PLETE INVERSION OF THE UTERUS. 
BY 
G. E. SUSSDORFF, M.D., 
New York. 
(With two woodcuts.) 
It is comparatively rare, even in an extended experience, to 
meet with cases of hollow uterine polypi, and rarer still to find 
them simulating complete chronic inversion of the uterus. 
Very little has been written about this variety of polypoid 
growth, and what literature there is upon the subject is meagre 
and barren of instruction in respect to their pathology, or of 
information that will assist in establishing a correct diagnosis. 
There are not more than four cases of this kind on record. 
Colombat mentions having operated upon a large hollow 
tumor, which looked so much like an inverted uterus, after its 
removal, that he at first feared he had mistaken an inversion 
for a polypus. 
Richmond and Jules Cloquet had a similar experience, but 
were not able to prove that the uterus had not been removed 
until some years after, when the patient died, and a post-mortem 
examination revealed its presence. 
Boivin and Duges mention a polypus of this character in 
their work, and state that before its removal it was considered 
an inversion by several distinguished physicians. 
The late Dr. Ilenschel, of New York, reported a case of the 
kind some few years since, before the New York Obstetrical 
Society. Baker Brown and Thomas simply refer to these 
cases in their works. 
With the exception of the above cases the archives of medi- 
cal literature yield no further information. AVItli the hope, 4 
Sussdorff: Diagnosis between IIollow Uterine 
therefore, of contributing something more to our present know- 
ledge on this subject, I propose, as briefly as possible, to report 
a case which came under my care some three years since, and 
to add a few remarks upon diagnosis and pathology. This 
unusual and in many respects extraordinary case illustrates 
very clearly the perplexing nature of these tumors, and the diffi- 
culties to be solved before a positive diagnosis can be made. 
The history of the case is as follows : 
Mrs. S. P , a tall, thin brunette, forty-nine years of age, and 
a widow for some years, was the mother of several children, the last 
of which she had borne twenty years before. She had never had an 
abortion, and had usually enjoyed good health, with the exception of 
occasional attacks of dyspepsia and intermittent fever. 
Her menses first appeared at the age of fifteen, and until the begin- 
ning of her present sickness she had never had, as far as she could 
recollect, any uterine trouble. 
According to her statement, her present illness began some two 
years before, and was brought on suddenly from having attempted to 
lift some heavy article of furniture. She was immediately attacked 
with hemorrhage from the vagina, pain in the loins and back, weight 
and dragging in the pelvis, nausea and great prostration—in short, 
by such symptoms as usually accompany a sudden displacement of 
some portion of the pelvic viscera. 
She was compelled to take to her bed at once, and her family phy- 
sician, who attended her, pronounced her case to be a form of uterine 
displacement, the exact nature of which I could not ascertain from 
her. Neither could I learn what treatment had been employed 
other than that she had been kept in bed for three weeks, and that 
pessaries had been worn for some time after. At the end of a month 
the acute symptoms had subsided, and soon after she was sufficiently 
recovered to attend to the ordinary duties of her household. 
Her general health had received a severe shock, and nervous 
symptoms soon came on, such as severe and continued headache and 
great irritability of temper. The menses, which previous to the 
attack had been regular, sufficient in amount, and without pain, had 
now become irregular, in respect to both time and quantity, and were 
always painful. There had been a considerable sanguino-purulent 
discharge at the beginning of her attack, which continued as a thin, 
irritating leucorrhcea. 
There had been considerable difficulty in defecation and some 
dysuria, until the pessaries which she had worn successively were 
abandoned, and all effoi’ts at supporting treatment discontinued. 
At the end of six months her general condition had not improved. 
It seems at this time her physician told her that she was passing 
through the climacteric period or change of life, and counselled her 
to be patient and endure her ills with as much fortitude as she could 
command, in the hope of permanent relief when cessation should Polypus and Inversion of the Uterus. 
5 
come. As a consequence of this advice, and from a mistaken im- 
pression on her part, and that of her friends, that no good would 
result from active medical treatment under such conditions, she re- 
ceived but little attention for many months. Cessation did not come, 
and despairing of relief from natural causes, (?) she again sought 
medical advice. At this time, some two months before I saw her, 
the menstrual periods had ceased to be distinct, the flow had be- 
come continuous. She was examined, and her case this time pro- 
nounced prolapsus uteri. The prolapsus, she was told, had then been 
reduced. 
In spite of the reduction and constitutional treatment, such as" 
large doses of tinct. ferri chlor., tinct. cannabis indicse, gallic acid, 
etc., and tonic treatment in general, the flow continued and her de- 
bility increased. 
To such an extent had this state of affairs reduced her that she 
presented, at my first visit, an almost exsanguinated appearance, and 
was so weak as scarcely to be able to move from her chair to the bed. 
This is the history of the case up to the time she first came 
under my care. The facts as here stated were given me by the 
patient and her sister, with whom she lived. 1 was unable to 
obtain any information from the physicians who attended her, 
which I regret, since this history might thereby have been 
made more complete. The period embraced in this history 
was about two years. 
Having obtained the information just given, and finding my 
patient willing to submit to a thorough physical exploration, I 
proceeded at once to examine her. 
Upon introducing the finger into the vagina, a large body 
was at once discovered lying a short distance from the vulva, 
and completely filling the canal. Carefully passing the finger 
along the surface of this body, and at the same time making 
downward pressure through the abdominal walls with the other 
hand, its extent and character were sought for. 
The body of the tumor was about the size of an orange, and 
seemed quite movable. Its surface was smooth, except a few 
circumscribed spots, which were elevated and a little rough. 
It was not lobulated but evenly ovoid. In consistence it was 
firm, though compressible, elastic, and tough. It was slightly 
sensitive, though not painful. 
The pedicle was attached to the cervix, and was but little 
smaller than the body of the tumor. It was firmly adherent, 
and was closely surrounded by the lips of the cervix, which 
were thickened, congested, and painful. 6 
Sussdorff: Diagnosis between IIollow Uterine 
The attachment was considerably higher on the right side of 
the cervical canal, as near as could be judged, very close to the 
internal os; it then gradually approached the external os on 
the left. 
The vaginal walls gave no signs of being diseased. The 
posterior portion of the vagina contained fluid, which was 
principally blood and mucus; but these secretions were not 
specially offensive. 
The tissues of the anterior portion of the pelvis and the base 
of the bladder were somewhat dense and painful. The peri- 
neum was in a normal condition. 
These physical signs so far indicated the tumor to be a 
polypoid growth, and seemed to explain the cause of all her suf- 
fering. 
All these symptoms and signs, however, belong as much to 
inversion of the uterus as to polypus. It needed, therefore, the 
confirming evidences of the sound to complete the diagnosis. 
The case seemed simple enough. 
Introducing the left index-finger into the vagina as a guide, 
an attempt was made to pass an ordinary Simpson’s sound, but 
at no point could an opening be found. Other probes of 
different sizes were used, every point between the pedicle and 
lips carefully and patiently explored, but with no better result. 
The probe was completely obstructed at every point. Suspect- 
ing the case might possibly be a complete inversion, instead of 
a polypus, 1 again examined the tumor with the fingers. All 
the signs previously elicited were confirmed, with this addi- 
tion: strong pressure upon the body of the tumor gave evi- 
dences to the feel that it was hollow. It could be indented, and 
would resume its original form as soon as the pressure was 
removed. It yielded to the finger like a soft hollow india- 
rubber ball does when pressed upon. 
This discovery, added to the failure to pass the sound, was 
sufficient to produce a considerable degree of perplexity. Other 
measures of physical exploration, however, remained, such as 
conjoined manipulation, rectal touch, and recto-vesical explo- 
ration, but finding my patient tired and nervous I thought it 
better to delay fiu-ther examination for the time, and left her, 
after having prescribed an anodyne and large doses of fluid 
extract of ergot for internal administration, besides astringent 
vaginal injections, and an enema to clear out the rectum. Polypus and Inversion of the Uterus. 
7 
The question to be settled was evidently one of differentia- 
tion, and the history of the case, interesting though it was, could 
give but little positive diagnostic information. This could 
alone be obtained from physical signs. 
At my next visit the following morning, the patient was seen 
with me by my friend the late Dr. C. B. Nottingham, of Georgia, 
and several other gentlemen of skill and experience, and a 
thorough and final examination made. 
A summing up of the investigation showed the following 
results: 
1st. The probe was completely arrested at the neck. 
2d. Conjoined manipulation did not reveal the uterine 
body, nor did it reveal a ring where one horn of the uterus 
should be. 
3d. Rectal touch revealed a small ovoid body, lower than 
normal for the uterus, and a little above a line corresponding 
with the junction of the vagina to the neck. 
4th. Recto-vesical examination by means of a sound in the 
bladder and two fingers in the rectum did not reveal the uterus 
in the anterior, upper, or lateral parts of the pelvis. The fingers 
in the rectum discovered the body before mentioned, but the 
probe in the bladder could not be made to touch it. 
5th. The pedicle was very large. 
An analysis of the above proved : 
That the probe favored inversion. 
Conjoined manipulation gave nothing. 
Rectal touch revealed a body which was probably the uterus, 
but it might be a tumor formed by the liquid confined in the 
recto-uterine sac of the vagina, or a pelvic tumor. 
Recto vesical exploration gave no reliable information. 
The size of the pedicle favored inversion. 
The evidence, when analyzed, was anything but satisfactory 
or conclusive. Had the uterine body been recognized, and the 
tumor been an ordinary polypus, the probe would have been 
worked through the tissues surrounding the pedicle into the 
uterus, and thus have proved incontestably the nature of the case. 
This necessary information was wanting, and, as matters stood, 
such a proceeding was not justifiable. 
With the view, therefore, to determine, if possible, the struc- 
ture of the tumor, a strong pair of placental forceps were ap- 8 
Sussdorff: Diagnosis between Hollow Uterine 
plied, and it was pulled down, and brought well without the 
vulva. It here presented the same characters as before stated, 
was covered by mucous membrane, and flecked over with 
bright, flesliy-looking spots, which were very vascular. Percus- 
sion and pressure confirmed the presence of a cavity. Detach- 
ment of the pedicle was attempted by means of the finger-nail 
and the handle of a scalpel, but the tissues were tough, and 
besides considerable bleeding ensued from the congested lips 
of the cervix which surrounded the pedicle. The tumor was 
returned to the vagina, and the best means of treatment, sup- 
posing the case to be an old complete inversion, were consid- 
ered. Amputation was the only measure likely to insure good 
and speedy results. The condition of the patient would admit 
of no prolonged course of treatment. 
But amputation of the womb is a very serious operation, ex- 
cision of a polypus a very simple one. Feeling unwilling to 
operate for amputation as the case stood, I determined once 
again to essay the probe. 
Two reasons in addition to those already mentioned 
prompted me to do this. First. When the tumor was being 
dragged to the vulva for inspection, I noticed that the lips of 
the cervix surrounding the pedicle remained the same; there 
was no shorteniny. The other reason was, that wThen trac- 
tion was made, the small ovoid body which was felt through 
the rectum followed the tumor downwards also. Selecting 
a stout Simpson’s sound, it was introduced between the ped- 
icle and cervix, and that portion of the attachment highest 
up, to the right, selected as the best point to make the effort to 
pass it. 
Counter-pressure was made through the thin abdominal walls 
with the left hand, and a firm and steady boring force used 
by means of the probe in the right. After a few moments, 
the tissues yielded and the probe slowly passed inwards. Find- 
ing that it would not enter to a greater depth than inches, 
I attempted to approximate it to the abdominal walls, which, 
after some effort, was accomplished. The probe had undoubt- 
edly entered the womb, and not the abdominal cavity. 
This proved incontestably the nature of the case. It cer- 
tainly was not an inverted uterus, but a polypoid growth. 
The treatment pursued, in a few words, was as follows: A Polypus and Inversion of the Uterus. 
9 
stout double silk ligature was passed through the pedicle high 
up within the cervix, tightly tied, and the parts returned into 
the vagina. The ligature was applied instead of the knife, 
because the tumor was very vascular and further hemorrhage 
would not have been borne by the patient without imperilling 
her life. The galvano-cautery would no doubt have been bet- 
ter, but was not procurable. No hemorrhage or constitutional 
disturbance followed the operation, and on the sixth day after, 
the tumor came off. From this time the patient began steadily 
to improve, and at the end of the year had regained health and 
strength. The hemorrhage ceased at the time the tumor was 
ligated, and the menses have not returned up to the present 
date. 
One point I came near omitting to mention, which will in a 
measure account for the absence of the uterine body from the 
anterior, upper, and lateral portions of the pelvis, and also for 
its low position as discovered by rectal touch. 
Three weeks after the operation my patient complained of 
dull, aching pain in the pelvis and back, and desiring to inspect 
the condition of the os, 1 made a specular examination. The 
cervix was still somewhat dilated, congested, and hypertro- 
phied. The sound entered the uterus two and a half inches, 
and discovered it to be in a state of extreme retroversion. It 
is quite likely that this condition of retroversion had existed 
for a number of years, and that it was present even to a greater 
extent at the time of my first examination, when the polypus 
was in situ. 
The close resemblance of this tumor to complete chronic in- 
version, with the relation of parts to each other, will, perhaps, 
be better appreciated by examining the accompanying wood- 
cut No. 1. 
REMARKS ON DIAGNOSIS. 
The diagnosis of these cases depends mainly upon the probe, 
but not always, since it sometimes happens, as in this case, that 
it will give but limited information when commonly essayed. 
In endeavoring to ascertain the presence or absence of the 
uterus by other means, the result in all such cases will be un- 
satisfactory, even in the most skilful hands. Indeed there are 
many instances on record in which errors were committed, fol- 10 
Sussdorff: Diagnosis between Ilolloiv Uterine 
lowed by fatal results, from a neglect to use with care this 
means of diagnosis. It is not a very infrequent occurrence for 
an inverted uterus to be mistaken for a polypoid tumor ; neither 
is it very unusual to mistake for the pedicle of such tumors an 
inverted part of the uterus to which it is attached, and remove 
it by incision or ligature. Instances of this last kind have been 
reported by Denham, William Hunter, and others, which re- 
sulted fatally. An instance of the first kind is cited by Dr. 
Thomas in his work, in which a celebrated surgeon of this city, 
after a hasty examination, removed a tumor which he thought 
a polypus hanging in the vagina, and found to his surprise that 
he held in his hand an inverted uterus and its appendages ; the 
patient fortunately made a good recovery. IIow many cases 
are there like this one, of which we hear nothing! The expe- 
rience of Colombat and Madam Boivin has already been 
alluded to. 
This cut is simply diagrammatic, and shows the 
uterus with polypus attached. 
The space represented here between the lips of 
the cervix and pedicle did not really exist—the 
parts were in such close juxtaposition that the 
finger could only with difficulty he forced between. 
It is intended by the space to show the attach- 
ment of the pedicle, and to illustrate the principle 
upon which traction gives positive diagnostic re- 
sults. 
Fig. 1. 
The information gained in my case from measures of in- 
vestigation commonly used, and before the probe was made to 
pass the obstruction, was of such an ambiguous character that 
a diagnosis might have been made of either inversion or poly- 
pus with equal plausibility. 
The solution of these difficulties by the probe, however, was 
brought about in this instance by corroborating measures not Polypus and Inversion of the JJterus. 
11 
usually resorted to, or fully appreciated in this respect. I re- 
fer to traction upon the tumor aud to rectal exploration. 
I regard these measures as scarcely second to the probe as a 
means of diagnosis in such cases, and especially where the 
patients are fat, and the abdominal wall thick. Traction upon 
tumors in the vagina is an old proceeding, and is usually done 
for the purpose of operating, but it is of importance in other 
respects. 
The tumor in this instance "was brought to the vulva for pur- 
poses of inspection, in order thereby to gain some definite in- 
formation respecting its structure, to verify the previous exam- 
ination made by touch, and to search for an opening into 
the rterns. The results gained from this have been stated 
before. 
The value which I attribute to traction as a means of diag- 
nosis has already been intimated, but I desire to call special 
attention to it as a method which cannot be over-estimated in 
such cases as have been considered in this paper. 
Traction, when carefully practised, will give the following 
information: 
If the tumor in the vagina is a polypus, attached to one lip, 
or by several points to the cervix, or if it be such an one as has 
here been described, the relation of the parts to each other, as 
they existed while in situ, will remain unchanged when brought 
to the vulva. If the tumor be an inverted uterus the relation 
of the parts to each other as they existed in the vagina will be 
greatly changed when exposed to view. The lips of the cervix 
which surrounded the pedicle will have disappeared, having 
also become inverted, and along with it, probably, the vagina 
at its junction with the neck. 
If the case be one of polypus, and partial inversion of the 
fundus at the point where the pedicle is attached, it will at 
once be revealed, whereby the errors cited by Denham and 
William Hunter may be avoided. 
If the force used in making traction be steady, slow, and 
gentle, no lacerations of integral parts will ensue, or bad results 
supervene secondarily. 
The operation of drawing the parts down is not usually diffi- 
cult. When the tumor is very large it may be troublesome to 
manage, but otherwise it is not so. Vulselluin forceps are rec- 12 
Sussdorff: Diagnosis between Hollow Uterine 
ommended for this purpose, and are good, but I regard the 
placental forceps, with blades which rotate, as much better. 
The blades can be made to dilate the vagina around the tumor, 
and will readily slide over the surface of the tumor and grasp 
it. If a stout pair be used, and the tumor fixed by its trans- 
verse diameter, its hold will be secure and there will be no 
slipping. The tumor having been brought without the vulva, 
and securely held there, the other means mentioned should he 
instituted, viz.: rectal exploration. The value of this means 
is only secondary to traction, because, to get positive informa- 
tion by rectal touch, the tumor must first be drawn down, 
otherwise the normal location of the uterus is almost beyond 
reach of the fingers. The parts being at the vulva, rectal 
touch will confirm the signs obtained of the presence or ab- 
sence of the womb. To do this effectually the sphincter ani 
muscle should be temporarily paralyzed by forcible dilatation 
with the thumbs and two fingers introduced into the rectum, 
the ends separated, and the uterus searched for. If the uterus 
is not inverted it can easily he felt lying low down in the pelvis, 
and its entire surface examined, the traction holding it steady, 
so there can be no rolling. 
If the uterus be inverted the fingers at once discover its 
absence, and will easily detect a ring made, either by one 
horn of the uterus or by the opening in the os. This pro- 
eedure is much superior in obscure cases to other methods. 
It will confirm and corroborate the information gained by 
fraction. 
If, therefore, the relation of parts is not changed by traction, 
and rectal exploration reveals the uterine body in the pelvis, 
the probe should be made to pass whatever obstruction there 
may be at the neck. Force, however, I consider bad practice 
under any circumstances. It seems to me a far better way is 
to first make a narrow, longitudinal incision in the pedicle as 
high as possible, and through this opening introduce the probe. 
This should be done while the parts are at the vulva. If the 
probe enters to the proper depth the diagnosis is complete with- 
out the shadow of a doubt. The parts are then in position to 
receive appropriate treatment, and should not be returned un- 
til the operation is completed, whether it be for amputation or 
.excision. Polypus and Inversion of the Uterus. 
13 
With these three means of diagnosis, viz., the probe, traction, 
and rectal touch, the difficulties of differentiation need no 
longer be formidable. 
A few words, in conclusion, respecting the pathology of hol- 
low uterine polypi—taking the one here represented as a speci- 
men. I regret exceedingly that I was unable to submit it to 
a microscopist for examination. It was minutely examined, 
however, by the unassisted eye, and its grosser character stud- 
ied several days after its removal. It was then considerably 
smaller than when in situ. In structure it was fibro-cellular, 
and covered by a thick mucous membrane. Its internal sur- 
face was composed of connective uterine tissue, with a few 
fibres of muscular structure. The walls were quite thick, more 
so in some portions than in others. It was least so at its fun- 
dus, where it measured about two lines, and gradually increased 
towards its attachment in thickness and density until it meas- 
ured from four to five lines. The walls enclosed a single 
cavity, which had undoubtedly been continuous with the canal 
of the cervix above the point of attachment. This cavity had 
a capacity of 3 iss. liquid measure. The remainder of a few 
Nabothian glands were recognized in the walls just beneath the 
mucous membrane. Its surface was smooth and not lobu- 
lated or fissured. No blood-vessels of any size were observed, 
although some would no doubt have been seen under the micro- 
scope, as the mucous membrane enveloping the growth was in 
a state of hypertrophy. I am unable to say positively that the 
cavity in the polypus did not contain any fluid previous to its 
excision. There were no evidences of this when examined, if 
I except a small quantity of viscid mucus, 
which probably came from the uterus. There 
were no signs of coagulated blood within the 
cavity, neither was there any cheesy matter 
present. In several places of limited extent 
there was considerable hardness of calcareous 
nature. Upon its external surface there were 
small elevated spots, varying in size from a 
millet-seed to a large pea, which were fun- 
goid, and had been one source of the hemorrhage. The sur- 
face was impervious. There were no openings leading to the 
cavity within. The appearance of the tumor after removal 
is represented by woodcut No. 2. 
Fig. 2. 14 
Sussdorff: Diagnosis between Hollow Uterine 
With respect to the formation of these extraordinary growths 
very little is known. Madam Boivin accounts for the one she 
describes, upon the theory that the uterus had become coated 
by some plastic material, had been ripped off except at its cer- 
vical attachment, and had become inverted by menstrual fluid 
collecting above. 
The specimen exhibited by the late Dr. Ilenschel was ex- 
amined by Dr. Noeggerath, who accounted for it in the same 
way as Madam Boivin. 
The history of the case which I have reported appears to me 
to warrant a different conclusion from that just mentioned. It 
appears far more reasonable to suppose that it began as an ex- 
foliation of the true mucous membrane of the body of the uterus, 
in fact was a remarkable case of membranous dysmenorrhcea. 
Some of the older writers, such as Dewees, Naegele, and Desor- 
rneaux, believed that the common forms of membranous dysmen- 
orrhcea were cases in which the uterine cavity had become cover- 
ed with plastic lymph from a diseased condition of the uterus 
which is now denominated endometritis. This theory is the same, 
no doubt, as the one upon which Madam Boivin based her opin- 
ion ; but this theory is no longer accepted as true. The theory 
first instituted by Dr. Oldham, viz., that the membrane expelled 
in dysmenorrhoea is true mucous membrane exfoliated as a 
consequence of congestion and irritation of the uterus, is the 
one now generally accepted, and may be applied to this case. 
In this instance the invasion of the attack was sudden, the ex- 
citing cause having been a straining effort to lift a heavy 
weight. The age of the patient at the time of the attack and 
the date at which the menses first appeared are sufficient 
grounds for believing that she was entering the climacteric pe- 
riod, and that the uterus previous to the attack was in a con- 
gested state, and was the predisposing cause. The exciting 
cause in this instance was the effort made in lifting, and the 
womb as a result was displaced and its mucous membrane at 
the same time forcibly detached to a very great extent of its 
surface, carrying with it more or less submucous and connec- 
tive tissue. This view of the beginning of the exfoliation is 
made stronger from the fact that there was a sudden and con- 
siderable hemorrhage at the time in addition to the symptoms 
indicating displacement. The gradual progressive exfoliation Polyjpus and Inversion of the Uterus. 
15 
of these tissues no doubt continued after this until the internal os 
was sufficiently dilated to admit of their extrusion into the vagina 
by the irritated body of the womb, and they were held at their 
attachment to the cervix, because the tissues there were too 
dense to permit further exfoliation. When the membrane was 
first expelled, which probably happened at least a year before 
it was removed, it is quite probable that it was perforated in 
many places and that these openings closed as the tumor be- 
came hypertrophied, or, rather, were filled up by a new tissue, 
which corresponded with the vascular spots of fungoid charac- 
ter, already alluded to. 
The predisposition of the uterus to polypoid growths about 
the time of the climacteric period is conclusively shown by Dr. 
Tilt in his work on Change of Life, in which he embodies in a 
tabular form his own and Dupuytren’s experience, embracing 
the history of fifty-seven cases. Of this number, twenty-three 
occurred in women between the ages of forty and forty-nine. 
This is favorable to the views expressed respecting the begin- 
ning of the exfoliation of the mucous membrane. I have not 
been able to gather any information fixing the ages of those 
patients operated upon for hollow polypus, except Mine. J3oi- 
vin’s case, in which the patient was 44 years and married, and 
my own patient, who was 49. It is not unreasonable, however, 
to infer from correlative statements occurring in the histories 
of the other three cases, that they also were between the ages 
of 40 and 50. 
Hollow polypi are a variety entirely distinct from all others. 
There are some other kinds which somewhat resemble them. 
“ The channelled polypus ” of Dr. Oldham, which he de- 
scribes in Guy’s Hospital Reports, April, 1844, is something 
like them, but a close examination and comparison of that tu- 
mor, as it is there represented by a woodcut, with the one here 
described, will at once show their dissimilarity. 
There is no similarity between hollow polypi and the cystic 
polypi which Dr. Lee has described. There may, however, be 
some analogy between these polypi and the one reported by 
Mr. Langstaff in vol. 17, Med. Chirurgical Trails., in which 
there was a small cavity filled with cheesy matter and hair. 
Still its structure and mode of attachment were different. 
Hollow polypi I would account for as the result of complete 16 
Sussdorff : Diagnosis, Etc. 
exfoliation of the entire uterine raucous membrane, inverted 
and expelled into the vagina by the womb except at its attach- 
ment, where it is held and nourished by the cervical blood- 
vessels, which cause its further development. 
44 West Twenty-Third Street.