large accumulation. Yet it is certain that
sometimes a much more considerable collec-
tion has been observed.
Thus in " Bonnet's Sepulchretum Anato-
micum*," a case is given in which one of the
tubes held thirteen pounds of fluid ; and De
Haenf mentions an instance in which the
hypertrophied tube weighed seven pounds,
while the quantity of fluid contained in it
amounted to thirty-two pints.
Other cases, of more or less authority, have
been recorded, in which the collection of fluid
has been estimated at 112, 140 and 150 Ibs.
But it is exceedingly doubtful if the tube
walls are capable of dilating to the extent
that would be necessary to support so large
an amount of fluid without laceration. For
it is very well known that in tubal pregnancy
rupture of the tube almost always occurs
before the middle period of gestation is
reached ; and even in those cases where the
reports are founded upon post-mortem ex_
* Lib. III. Sect. XXI. Obs. 39.
f Rat. Med. Tom. III. p. 29.
620
UTERUS AND ITS APPENDAGES.
animation it is very possible that a part of
the fluid was contained in the ovary, for a
concomitant enlargement of both tube and
ovary is a very common occurrence, as in the
case represented in fig. 422.; and on this
account no record of any very considerable
dropsy of the Fallopian tube should be con-
sidered as complete, unless the condition of
the corresponding ovary is also mentioned.
Collections of puriform fluid in the tube.
Abscess of the tube. The presence of pus in
the Fallopian tube is most frequently asso-
ciated with suppurative puerperal inflammation
of the uterus and its appendages generally.
But it may also occur independently of the
puerperal state, and as a consequence of ca-
tarrhal inflammation of the mucous lining of
the tube which may have passed into the sup-
purative stage. These cases differ from the
foregoing, not only in the nature of the con-
tents of the tube, consisting here of pus or of
puriform fluids with admixture of other in-
flammatory products from the lining membrane
of the tube ; but also in respect of the great
tendency which is here observable to the for-
mation of adhesions and the establishment of
fistulous openings into adjacent parts, as into
the bladder, intestines, or peritoneum, into
which cavities these fluids are occasionally
discharged.
Cysts containing fluid attached to the tube.
Very commonly there may be observed one
or more cysts containing a small quantity of
transparent fluid, attached by a narrow pe-
duncle to the tube, and particularly to the distal
extremity (fig. 368. e). The nature of these
cysts has been already explained. (See p. 597.)
They can only be regarded as morbid when
they attain to an unusual size, as in fig. 421.
They are occasionally found as large as a nut,
but they very seldom exceed, and indeed do
not often attain even to this size.
Fibrous tumours. One of the most re-
markable points of difference between the
morbid conditions of the Fallopian tube and
of the uterus respectively is the very great
rarity of the occurrence in the former of those
fibroid growths, which in the latter constitute
its most common abnormal peculiarity. No-
thing can mark more distinctly the difference
of texture between these two parts than this
very characteristic circumstance : since it is
now known that the peculiar fibrous tumour
of the uterus is formed at the expense of the
natural tissues of that part. Occasionally,
indeed, small fibrous tumours are found in
the parenchyma of the tube, but these never
attain to any considerable size. These oc-
casionally undergo calcification, from a deposit
of earthy material in their texture, and thus
form little masses of stony hardness which
project from the walls of the tube, and are
covered by its peritoneal coat.
Tubercle is occasionally formed in the Fal-
lopian tube. It occurs there usually in the
form of tuberculous infiltration, which, in the
opinion of Rokitansky, affects chiefly the
mucous membrane of the tube. The occur-
rence of tubercle here presents nothing re-
markable enough to call for further special
description.
Cancer of the tube is not a common oc-
currence. I have never met with it inde-
pendently of cancer of the ovaries or uterus ;
but when either of the latter organs are exten-
sively affected, the tubes are also occasionally
involved. Upon the malignant diseases of the
Fallopian tube most pathological writers are
nearly silent ; nor has our literature been
enriched by any considerable number of special
records bearing upon this point in Pathology.
Rupture of the Fallopian tube. Spontaneous
laceration of the walls of the tube occurs
sometimes as a result of over-distension, OF
too great attenuation of its tissues, whereby
the parietes are rendered no longer capable of
resisting the increasing pressure of the fluids
accumulated within. In this way large col-
lections of serous, purulent, or sanguineous
fluids are sometimes poured out into the
cavity of the abdomen, unless, indeed, by the
previous adhesion of the walls of the tube
to surrounding parts, the point of rupture is
directed to some neighbouring hollow viscus
by which the fluids escape externally. But
rupture of the tubes will most frequently
happen in connexion with the tubal form of
extra-uterine gestation, which is next to be
described.
Detention and abnormal Development of the
Ovum in the Oviduct. Tubal Gestation. Gra-
viditas tubaria. This constitutes a second
species of those aberrant forms of gestation,
commonly termed extra-uterine, one of which
has been considered under the title of Ovarian
Gestation, (p. 586.)
It has been already shown, that one prin-
cipal office of the Fallopian tube is the con-
veyance of the ovum from the ovary, or place
of its first formation, to the uterus, or seat of
its final development ; and that the ovum,
whilst in transitu, not only becomes impreg-
nated, but also exhibits certain indisputable
evidences of commencing development, which,
however, has usually advanced only a few
stages by the time that the ovum enters the
uterine cavity. The tube, therefore, as well
as being an oviduct, is also the seat of normal
impregnation ; whilst, in addition, it serves to
protect and possibly, in some slight degree, to
add to the material of the ovum, although the
actual operation of the tube walls upon the
surface of the ovum in this respect must ne-
cessarily be very slight in the mammalia, since
it so rarely happens that any increase in its
size is perceptible from the time of its quitting
the ovary to that of its reaching the uterus.
But the impregnated ovum, instead of en-
tering the uterine cavity, may be accidentally
detained in the tube, and undergo further der
velopment there. The extent to which this
development may proceed will depend in a
great measure upon the capability of expansion
of the tube walls ; a circumstance which
seems to vary greatly in different individuals,
and also in some degree according to the
portion of tube which the ovum occupies.
The differences observable in this latter
FALLOPIAN TUBE OR OVIDUCT (ABNORMAL ANATOMY).
respect have led to a division of cases of tubal
gestation into three varieties, viz. tubo-ovarian,
tubal, and interstitial.
In the first variety, graviditas tubo-ovaria,
the ovum becomes developed in a sac, of
which a principal portion appears to be fur-
nished by the hypertrophied walls of the
infundibular end of the tube, and the proper
tissue of the ovary combined. In the second,
graviditas tubaria, the developed ovum occu-
pies some part of the canal of the free portion
of the oviduct ; while in the third, graviditas
inter stitialis, the seat of development of the
ovum is that part of the tube which traverses
the uterine walls.
In the first, or tubo-ovarian variety, the
parts supplying the principal foundation of the
cyst, which surrounds the foetus, are in the
first instance probably chiefly normal struc-
tures ; and it is easy to understand how,
during the progress of growth of the ovum,
when the limit of expansibility of these parts
has been reached, there may be superadded
to them materials for the extension and fur-
ther growth of the cyst walls ; and in this
way are apparently formed these large sacs, or
artificial uteri, which have been sometimes
observed to surround a fully developed foetus,
and which in the course of their growth have
come to include omentum, mesentery, or in-
testine, and other portions of the abdominal
viscera or parietes, by which the sides of the
sac become strengthened and enlarged.
As in the case of ovarian gestation for-
merly described, so in the varieties termed
ovario-tubal, it is only when death has taken
place during the early stages of formation of
these embryo-bearing cysts that the exact
nature and relation of the parts originally
composing them can be made out. Hence the
difficulty of determining, in more advanced
stages of gestation, when other parts have
been superadded, in what precise situation
the development of the ovum was commenced.
And hence the probability that some at least
of those cases which have been recorded from
time to time as examples of the fetus deve-
loped in the cavity of the abdomen, and among
the intestines (graviditas abdominalis), may
have been originally cases of the tubo-ovarian
variety, in which the cyst walls, commencing
their formation by the artificial union of the
expanded termination of the oviduct with a
portion of the ovarian parietes, have in the
course of their growth come to include many
other parts.
The second variety, which includes all cases
strictly termed tubal (graviditas tubaria), con-
stitutes by far the most common of all the
forms of extra-uterine gestation. Here the
ovum is developed within some part of the
free portion of the tube, whose walls appear,
from the examples which most of our mu-
seums furnish, to be capable of a very limited
degree of expansion in most individuals.
Hence, when the ovum has attained to a cer-
tain size, and usually by the time that the
second or third month of gestation has been
reached, rupture of the tubal wall occurs,
621
followed by rapid death from haemorrhage.
And thus the parts are usually obtained for
examination in such a state as to leave no
room for question regarding the precise seat
which the ovum occupies, and the nature of
the parts enclosing it. For in these cases of
early rupture the tube has contracted no
adhesions with surrounding parts, and the
walls of the embryo-bearing sac are formed
of the parietes of the oviduct alone.
The third variety of tubal gestation, distin-
guished by M. Breschet under the title of
Graviditas in uteri substantia; and by Profes-
sor Mayer, of Bonn, as Graviditas interstitialis,
has been made known, particularly by an essay
of the former devoted to this subject.*
This variety differs from the last mentioned
chiefly in the circumstance, that the seat of
development of the ovum is that portion of
the canal of the tube which passes through
the solid walls of the uterus. Here the sac
surrounding the foetus is formed in a great
measure at the expense of the proper uterine
tissues, and consequently the parietes of these
cysts exhibit under the microscope a very
different composition from that which the
tube walls show in the second variety.
In interstitial cases the walls of the sac
surrounding the ovum sometimes attain in
parts a thickness nearly equal to that of the
gravid uterus. On section of these portions
the appearance which they present is precisely
similar to that of the gravid uterus itself.
There is here seen precisely the same arrange-
ment of large vascular openings, being the
divided canals or sinuses which everywhere
permeate the solid walls, in whose composi-
tion may be traced the same abundance of
smooth muscular fibre, as in the ordinary
gravid uterus.
Within such a sac, formed out of the walls
of the tube in the first instance, and in the
case of this third variety further strengthened
by the addition of a large quantity of tissue
derived from the uterus, the ovum lies, pre-
senting its ordinary character of an external
chorion and inner amnion ; the fetus or
embryo itself, according to the period of ges-
tation, being perfectly formed. The walls of
the sac, being in this case usually much
stronger than when the ovum lies nearer to
the distal end of the tube, resist pressure for
a longer time, and consequently the fetus
may attain a greater growth.
One of the most interesting questions con-
nected with this subject is, whether a decidua
is here formed. Schroeder van der Kolk, in
his recent most valuable work on the struc-
ture of the Placenta f, answers the inquiry in
the affirmative, in contradiction to the state-
ment of Virchow J, by whom it is asserted
that in the case of tubal gestation no decidua
* Memoire sur une nouvelle espece de grossesse
extra-uterine. Par M. Breschet.
| Waarnemingen over het Maaksel van de Men*-
schelijke Placenta, Amsterdam, 1851, p. 88. et seq.
J Yirchow, ueber die Puerperal Krankheiten
Verhand. der Ges. fur Geburtshelfe. Berlin, 1848,
B. III. s. 180.
622
UTERUS AND ITS APPENDAGES.
is to be found in the tube. According to
Schrceder, a decidua is here formed in tubal
pregnancy, notwithstanding that in the walls
of the tube glandulae utriculares are entirely
wanting. The villi are here embedded in
little hollows of the decidua, upon whose
walls the blood vessels terminate in open
mouths, and thus the blood is poured out
into the placenta. The decidua is, indeed, in
this case firmer, and does not exhibit so many
valvular openings as are present in an ordi-
nary placenta ; probably from the absence of
the utricular glands. In this case, also, an
epithelial layer derived from the decidua
covers the villi, and serves at the same time
as a means of junction between the parts.*
Associated usually with the abnormal deve-
lopment of the ovum in the oviduct is the for-
mation of a decidua in the uterus, the nature of
which structure will be considered in a subse-
quent portion of this article (pp. 635. 652).
And here it naturally occurs to inquire into
the probable causes of the development of
the ovum in a situation so unfavourable to its
further and complete evolution. Since, not-
withstanding the wonderful power of adapta-
tion which is in these cases exhibited by the
parts immediately surrounding and containing
the ovum, it is plain that the oviduct how-
ever altered, yet, on account of its peculiar
form and texture, can but inadequately supply
the offices of a uterus. It can serve but im-
perfectly for the nutrition and protection of
the foetus, and not at all for its expulsion,
even should the latter reach the term of its
dependent or intra-uterine life.
One of the most remarkable circumstances
relating to this curious subject, is the fact
first noticed, I believe, by Dr. Oldham, that in
a large number of cases of tubal gestation, the
corpus luteum, correspondiug with the ovum
impregnated, is found in the ovary of the op-
posite side to that of the tube in which the
ovum is developed. Thus if the left Fallo-
pian tube contains the ovum, the right ovary
will often display the corpus luteum of a cor-
responding date, and vice versa. Not being at
first aware of Dr. Oldham's observation, I had
myself noticed the same circumstance in re-
peated instances, and had arrived at the same
conclusion as he has done in explanation of
it, namely, that at the time of the ovum
quitting the ovary, the tube of the one side
embraced the opposite ovary, and conducted
away the ovum, which being impregnated in
the ordinary way, and then being delayed at
the angle formed by the bending of the tube,
has its further progress obstructed at that
point until it attains too great a size to ad-
mit of its subsequently passing the lower
orifice and entering the cavity of the uterus.
If it be objected that this explanation is
not satisfactory, because it assumes the ap-
parent improbability of the fimbriated ex-
tremity of one Fallopian tube being able to
* Upon this point I do not here give any obser-
vations of my own, as I am preparing these for
publication in another form.
grasp the opposite ovary, then I can point to
a preparation in the Cambridge University
Anatomical Museum *, in which both the
Fallopian tubes grasp the same ovary to which
their extremities are affixed by morbid ad-
hesion.
Another and very different explanation of
this remarkable circumstance of the impreg-
nated ovum and corresponding corpus luteum
being found on opposite sides, has been given
by Dr. Tyler Smith f , who believes that the
ovum, after descending the Fallopian tube of
one side, traverses the upper part of the
uterine cavity, and ascends the opposite ovi-
duct, where it becomes developed. I might
also furnish the advocates of this doctrine
with an argument founded upon a most in-
teresting and curious observation of Bischoff,.
which appears to have been overlooked, but
which would at first sight seem to support
this view. Bischoff, in his essay on the de-
velopment of the ovum in the dog and rabbit,
frequently noticed a remarkable apportioning
of the ova between the two cornua of the
uterus, so as to equalise their number on
the two sides, when these had been ori-
ginally unequal, as shown by the number of
corpora lutea found in the ovaries. Thus,
in the case of a bitch whose right ovary ex-
hibited one, and the left ovary five corpora
lutea, each half of the uterus contained three
ova, so that two of the ova must have tra-
velled across from the right to the left side.
But it must be observed, that in the cases
recorded by Bischoff the ova never ascended
the Fallopian tube, but only travelled from
one cornu of the uterus to the other.
When, therefore, we take into considera-
tion the great difference between the solid
uterus of man and the intestine- like organ of
the mammalia, on which these observations
were made, there appears to be great diffi-
culty in supposing that the ovum could after
once arriving at the uterus again enter an
oviduct, especially when also it is remembered
that while the conical form of the Fallopian
tube, whose smallest aperture is towards the
uterus, constitutes a provision for ensuring
the arrival of the ovum there, this arrange-
ment would greatly diminish the possibility of
a retrograde movement taking place in the
human subject, if indeed it would not alto-
gether prevent it.
But to those cases of tubal gestation in
which the corpus luteum is found in the cor-
responding ovary, neither of these explanations
would apply. Here it is only necessary to
suppose, that either the developmental changes
already described as occurring normally to the
ovum in the tube, have proceeded more rapidly
than usual, or else, that the ovum, having been
accidentally delayed for a longer time than
ordinary in transitu, had acquired too great a
magnitude to admit of its passage by the ute-
rine orifice, even admitting, as some have
supposed, that this orifice may, to a certain
* No. 722.
t Lancet, No. xv. vol. i. 1856.
UTERUS (NORMAL ANATOMY).
extent, dilate, for the purpose of allowing the
ovum to pass, just as the os uteri dilates at
the time of labour.
UTERUS.
NORMAL ANATOMY.
(Syn. Womb, Mother, Eng. ;
Gr.: Uterus, Matrix, Lat. ; Utero y
Ital. ; Matrice, Fr, ; B'drmutter, Geb'drmutter,
Fruchth'diter, Germ. ; Baarmoeder, Lijfmoe-
der, Dutch.)
The uterus is that segment of the genera-
tive track which lies between the lower ex-
tremities of the Fallopian tabes and the fornix
or upper end of the vagina. In man it is
normally formed by the complete coalescence
of the two uterine cornua, which in most
of the mammalia remain more or less distinct
constituting the bicorned or divided uterus.
These, in man and the quadrumana, unite to
form a single symmetrical organ, serving for
the passage of the seminal fluid, and for the
reception, protection, nutrition, and final ex-
pulsion of the mature ovum.
The uterus is not altogether peculiar to the
female. Like the mammary gland, it has its
representative in the male, though only in a
rudimental state. The existence of such a
rudimentary organ is more easily shown in
the male of many mammalian animals than
in man, in whom, perhaps, it is the least
conspicuous, and where its presence, as a type
of structure, can only be proved by a close
study of homologies, and by the aid of those
occasional exemplifications of the true rela-
tions of this part which the comparatively
rare occurrence of hermaphrodite forms
affords.
Situation and position. The unimpregnated
uterus is situated entirely within the pelvis,
where it lies deep among the other pelvic con-
tents, with many of which it is in immediate
relation ; the bladder lying anteriorly, the
rectum posteriorly, the ovaries and Fallopian
tubes laterally, the small intestines supe-
riorly, and the vagina and perineum inferiorly
with regard to it. These several parts, aided
by the broad and round ligaments, serve to
support the uterus and maintain it in its natu-
ral position. But this position will of neces-
sity vary according to the condition of the
neighbouring organs, and in some degree also
with the varying postures of the body.
The nature and degree of the variations in
regard to situation and position of which the
uterus is susceptible will be more easily
understood after the ligaments and other con-
nections by which these movements are re-
strained have been described. At present it
will be only necessary to observe that the mo-
tions of the uterus are restricted chiefly to
three directions. First, the broad ligaments,
which maintain the organ nearly in the median
line, permit by their laxity a slight deviation
towards eithe'r side. Secondly, a certain
amount of ascent and descent is allowed by
the structures which attach the uterus to the
623
lower part of the pelvis. But the former of
these movements will be limited by the utero-
sacral ligaments, and the weight or pressure
of the superincumbent viscera ; and the latter
also especially by the same ligaments, and to
a certain extent by the support derived from
the posterior wall of the vagina and the parts
which close the pelvis below. Thirdly, the
uterus enjoys a certain range of motion in the
direction of a line drawn from pubes to sacrum
in order to accommodate it to the state of
fulness or emptiness of the adjacent viscera.
For when the bladder is full and the rectum
empty, the uterus will be carried nearer to the
sacrum ; and conversely, with an empty blad-
der and a distended rectum, the position of
the uterus will be proportionately nearer to
the pubes ; and these alterations of position
will be constantly and daily repeated.
But an equal degree of mobility does not
belong to every part of the uterus ; for while
the movement of the cervix is limited by the
attachment of the vagina and utero-sacral
ligaments, the fundus is left entirely free to
follow the alternate fillings and emptyings of
the bladder. Thus a movement of nutation
will result, the fundus uteri approaching the
pubes and sacrum alternately ; and this is
probably the greatest range of motion of which
any portion of the uterus is normally suscep-
tible.
But allowing for these variations, there will
still be an average position which the uterus
occupies in the pelvis, and this may be as*
sumed to occur at the time when the bladder
and rectum are both moderately distended.
Under these circumstances, the position of
the uterus relatively to surrounding parts will
be in accordance with the accompanying sec-
tional diagram (Jig. 423.), representing the
Fig. 423.
Sectional diagram to show the normal position of tfie
uterus in the pelvis.
pelvic contents. Here A represents the ute-
rus, B the bladder, and c the rectum, both of
the latter being moderately distended.
624
UTERUS AND ITS APPENDAGES.
At such a time the uterus, supported be-
tween the folds of the broad ligament, which
constitutes a moveable dissepiment, dividing
the pelvis transversely into two unequal parts,
and sustained by the parts attached to it
around and below, lies with its fundus directed
obliquely upwards and forwards, while the
cervix or neck looks downwards, and very
slightly backwards towards the orifice of the
rectum. The relative heights of these several
parts are determined by two lines : the one,
a fl} drawn from the lower border of the
symphysis pubis to the promontory of the