of the inverted vagina, the horizontal rugae of
which are very conspicuous anteriorly between
the cervix and pubic arch, where a fluctuating
swelling is observed, caused by the presence of
a portion of the displaced urinary bladder.
(Fig. 469.) In chronic cases the surface of the
inverted vagina gradually loses the character of
a mucous membrane, and puts on the or-
dinary appearance of common integument.
After replacement, however, an extensive
shedding of epidermal scales ensues, and the
surface resumes in time the condition of a
mucous membrane.

In cases of great elongation of the cervix,
the latter alone may protrude, while the body
of the uterus remains within the pelvis.
Such a combination of hypertrophy with dis-
placement has passed with the ignorant for an
example of hermaphrodite formation.

Prolapsus is the most common displace-
ment to which the uterus is subject. It is
frequent in multiparae, and in women who
follow fatiguing occupations, especially those
of a relaxed habit of body ; but it also hap-
pens in nulliparae. In the latter, when it
occurs at an early period of life, it is often
associated with enlargement of the uterus or
its appendages, whereby both the weight of
the organ is increased, and a broader surface
is offered for pressure from above.

Elevatio uteri. Dislocation up war da. This
is the converse displacement to the foregoing.
The uterus, in consequence of some enlarge-



685

ment of the parts appended to it, as the ovary,
or on account of the formation of morbid ad-
hesions, may be drawn upwards to such an
extent that no portion of it, or only a part of
the cervix, is retained within the pelvic cavity.
This displacement is also occasionally ob-
served during pregnancy, and in multiparae,
whose abdominal walls are relaxed, and permit
the uterus to incline forward, so that at the
beginning of labour the os cannot be reached
by the finger.

Inversion. Eversion. The uterus, either
in the unimpregnated or gravid state, may
become partially or completely inverted. The
conditions which appear ordinarily to com-
bine in producing this displacement, are, first,
a distension of the uterine cavity*, as by
pregnancy or the presence of a tumour ; and
secondly, a force applied in the way of pres-
sure from above, or traction from below,
whereby the distended uterine walls become
folded within each other, somewhat after the
manner of the intestinal walls in intussuscep-
tion. Inversion of the uterus appears always
to begin at the fundus which is first depressed
into the uterine cavity, and then, under the
continued operation of the disturbing forces,
the part is gradually protruded through the
cervix and os uteri, Jig. 470., until it emerges
in an inverted form into the vagina followed by
the reversed walls of the uterine body, and
ultimately by those of the cervix. The inver-
sion of tlie uterus is now complete. The greater
part of the organ lies beyond the vulva as a
pyriform tumour, the base of which, formed by
the fundus, is below, while above the narrower
neck of the tumour consisting of the inverted
cervix lies in part within the vagina, the up-
per portion of which canal is also drawn down
and partly inverted. The vagina is thus ma-
terially shortened, and terminates in a cir-
cular fold marking the point of reflexion or
inversion, while the usual seat of the os uteri,
which is necessarily obliterated, is occupied
by the now inverted cervix (fig. 471.).

Inversion constitutes the highest degree of
displacement of which the uterus is suscep-
tible, for it is both prolapsed and inverted, so
that the relative situation of the entire organ
to surrounding structures, as well as of all its
parts to each other, is completely changed.
Inversion does not, however, always proceed
to the highest degree, but may stop short at
any of the intermediate stages just described.

When inversion occurs to the gravid uterus,
the accident usually happens during the ef-
forts of the organ to expel the placenta. In
this way, inversion may occur spontaneously,
or it may be favoured or produced by injudi-
cious attempts to extract the placenta, or
by too much traction applied to the funis. In
the unimpregnated uterus, a polypus attached
by a stem to the fundus may by its weight
slowly produce the same results. That a
sudden and spontaneous inversion of the un-
impregnated uterus is possible, was proved to

* Boyer, and some others consider that disten-
sion of the uterine cavity is not an essential pre-
liminary to inversion.



ITEUUS AND ITS APPENDAGES.



me in a case which I witnessed of an aged
woman whose uterus became completely in-



verted during a convulsion. In this instance,
the only apparent predisposing cause was the



Fig. 470.




Incomplete inversion of the uterus. (After J. G. Forbes.)

The fundus is beginning to protrude through the os uteri, dragging after it the Fallopian tubes, which
are drawn into the hollow formed by the inverted organ.

dilatation of the uterine cavity by a tumour surface of an ordinary procident uterus, and

.!__ r n . . i . i i . __!! I:_KI_J_I : i-.i .



the size of a flattened apricot, which was ex-
pelled at the moment when the uterus came

Fig. 471.




of the uterus. (Diagram.)



down completely inverted, the violent ac-
tion of the abdominal muscles and diaphragm
probably here producing or aiding the ever-
sion.

After complete inversion, the uterus may
remain incapable of replacement. Under these
circumstances, the external surface of the
protruding portion loses much of its original
character of a mucous membrane, and be-
comes covered by a thicker epithelial layer.
It continues, however, more vascular than the



is especially liable to abrasion and ulceration,
from the friction to which it is exposed.
When this displacement occurs during men-
strual life, and is permanent, the menstrual
fluid ma}' be observed at the periods exuding
from the surface of the inverted organ.

The internal relations of an inverted uterus
depend upon the extent of the inversion. In
extreme cases the interior of the tumour con-
sists of a sac lined by the peritoneum, which
originally formed the outer covering of the
uterus. The centre indeed of the broad liga-
ment may be said to be inverted so as to form
a pouch in which are contained the Fallopian
tubes and ovaries, and occasionally a portion
of small intestine ( % /?g. 471.).

In minor degrees of inversion the uterus
remains within the vagina, and the peritoneal
pouch in its interior contains only the roots
of the uterine appendages (fig. 470.).

Anomalies of Size.

a. Atrophy. Under this head maybe in-
cluded those examples in which the uterus
appears to have been originally well deve-
loped, but has since suffered atrophy of its
tissues. Such cases are to be distinguished
on the one hand from the imperfectly deve-
loped and prepubertal forms already described ;
and on the other from examples of senile
atrophy as it occurs in its ordinary course.
Whenever atrophy attacks the uterus before
the climacteric change the condition is to be
deemed abnormal. Such a wasting may affect
the entire uterus or some of its parts. In
either case the tissues become pale, soft, and
nearly bloodless. In atrophy of the uterine



UTERUS (ABNORMAL ANATOMT).



5



body tbe walls may not exceed in thickness
or de:,/-: ;> those of tbt urinarj bladder. S..; 1 :
a Dowfidoa .,;. KSCQT . oder dilatation ; tbe
> ":;-.-:.,;:. however 15 more com-
h :.:. increase in At Aiek-
parietes. The atrophy of
tbe uterine walls which is accompanied by
of tbe cavity, is distinguished as
and that which occurs in




may be combined
, of its canal, and is often
sition or morbid
line body or its appendages.

i> of far more frequent oc-
B atrophy. According as
dae entire uterus or only
of its parts, the organ either presents
figure but upon a larger scale, or
dbe a greater preponderance is given to one
that the uterus becomes malformed.
Hv>.rf; ::,;> ; ' the entire uterus commonly
results trout frequent pregnancy, from the

_- ... f : ; t " Durs, ;-r from accun tioi oi

kid within the cavity. In the latter cases
tbe uterine walls may acquire the same thick-
ness as in pregnancy and the hypertrophy
also to the same cause, viz. to a deve-
of smooth muscular fibre, such as
takes place in the gravid uterus.
Hypertrophy of the cervix is most fre-
quently observed in extreme prolapsus, of
which" in the chronic stage it appears to
:>: :-. constant sequence, Hi-r the hyper-
laces usually a uniform enlarge-
both lips, which form together "an
annular tumour divided transversely by a wide
os taacae.. fa. 472.



Pig. 47




But tbe cervix may become hypertrophied
in tbe longitudinal direction also. From this
there results a remarkable elongation of tbe
uterine neck, which may protrude to a con-
siderable distance beyond the vulva without a
corresponding degree of displacement or de-
scent of the body of the uterus. In the ac-
companying illustration, j%. 473., the manner
of growth of the elongated cervix is shown.
The body of the organ being only partially
displaced, a gradual addition to the length oJ[

J%. 473.







Elongation rf the cervix vteri from longitudinal hy-
pertrophy. (Ad JTat)

f, ftradus; io, internal os uteri; cc, cervix; TO,
vaginal walls.

the neck occurs until the vaginal portion pro-
trudes at the vulva. The canal of the cervix
may now measure several inches in length. By
degrees the protruded part undergoes in addi-
tion the concentric and excentric hypertrophy
which is common to all cases of procidentia,
and the lips gradually acquire the same ap-
pearance as in^/zg. 472.

Among tbe anomalies of size may also be
included those examples of imperfect involu-
tion of the uterus after pregnancy, in which
tbe organ retains for several months the or-
dinary size characteristic of it shortly after
labour.

Pathological conditions of the separate tissues
ofthe uterus. Reserving for future notice the
affections of the gravid uterus, those morbid
states which are observed in the unimpreg-
nated organ will be at present considered.
These may be divided into such as belong to
(1) the peritoneum; (2) tbe subperitoueal
tissue; (3) the parenchyma; and (4) tbe
mucous lining of the uterus.

1. Pathological conditions of the peritoneal
coat.

a. The external position of the peritoneal
coat, and tbe small amount which it con-
tributes to the bulk of the uterus, combine to



688



UTERUS AND ITS APPENDAGES.



render the morbid conditions of this coat, re-
garded singly, of less pathological importance
than the abnormal states of the other tissues.
The pathological conditions of the serous coat
are chiefly those of acute or chonic metroperi-
tonitis, terminating often in exudative processes
and the subsequent formation of adhesions be-
tween those portions of the uterus which are
invested by peritoneum and adjacent struc-
tures, such as the Fallopian tubes, ovaries,
fig. 420., small intestines, and the like.

These adhesions are occasionally so exten-
sive as to affect the figure of the uterus, and in
most instances they deprive it of its natural mo-
bility, and impede or destroy the functions of
the parts or organs appended to it, so that an
abiding sterility frequently results. The ova-
ries becoming invested by a capsule of false
membrane, are tied down and atrophied, while
the tubes lose their power of motion or their
canals become obliterated.

The uterine peritoneum is sometimes alone
affected, while the appendages escape. If the
inflammation has not proceeded to the form-
ation of bands of adhesion, there may result
only some slight processes of false membrane
which remain and fringe the surface of the
organ. These little fringes or processes, con-
sisting of delicate folds of membrane, often
contain vessels which are easily injected.

The peritoneum suffers considerable dis-
tension with correlative hypertrophy in the
case of tumours which project from the outer
surface of the uterus. These become inva-
riably covered by an extension of the peri-
toneum, which is especially strong about the
base of the peduncle occasionally acquired by
such tumours.

2. Pathological conditions of the sub-peri-
toneal fibrous tissue.

a. Perimetritis. Partial chronic wetrltis.
Peri-uterine phlegmon. Retro-uterine tumours.
The subperitoneal fibrous tissue which con-
nects the peritoneum with the uterine sub-
stance, like the peritoneal coat itself, is subject
to inflammation. In those situations where
the union of the outer and middle coats of the
uterus is very intimate, the distinction be-
tween a peritoneal and a subperitoneal inflam-
mation may not be possible, but where this
connexion is very loose, and is effected by the
interposition of a lax fibrous tissue, inflamma-
tion may apparently have an independent seat
without affecting at all, or with only a par-
tial inclusion of the uterine parenchyma, and
sometimes of its peritoneal investment.

The term "peri-uterine" has been employed
by some authors*, with a view perhaps of
avoiding confusion, though at the cost of a
solecism, to distinguish these affections from
others commonly termed perimetrial. In this
article, however, inflammation of the subpe-
ritoneal fibrous tissue will be designated peri-
itisy while inflammation of the peritoneum



* Monat, Observation Medicale (Gazette des
Hopitaux, 1850.) Bernutz et Goupil. Recherches



Cliniques sur les Phlegmons peri-ute'rines.
chives Ge'nerales de Medecine. Mars 1857.)



(Ar-



itself, which some include in the latter term,
is distinguished as metro-peritonitis.

Perimetritis consists in an acute, or more
often a chronic inflammation of the tissue,
which loosely attaches the peritoneum form-
ing the base of the broad ligament to the
proper substance of the neck and lower por-
tion of the body of the uterus. The relation
of the peritoneum and of the loose fibrous
tissue surrounding the cervix uteri have been
described at page 631., where also attention was
called to the peculiar lax tissue of this kind
which unites the posterior cervical wall with the
portion of peritoneum forming the retro-ute-
rine pouch (fig. 433. G.). Here, particularly,
this inflammatory affection has its seat, although
it occasionally extends around the sides of
the cervix, so as partially to encircle that part,
or more rarely it may involve only the fibrous
tissue connecting the anterior cervical wall
with the posterior surface of the bladder (fig.
426. b b, and fig. 433. F.).

The anatomical conditions of these peri-
metrial inflammations are deep congestion
of the vessels, accompanied by serous, and
occasionally by sanguineous, and possibly
fibrinous infiltration of the loose tissue of this
part, which, on account of its extreme laxity,
readily admits of a great degree of distension.
In this way is rapidly formed a tumour which
almost invariably occupies the space between
the peritoneum and the posterior wall of the
uterus, at the point where the body joins the
cervix (retro-uterine tumour).

The recognition of such a tumour or swell-
ing during life, by physical signs, is not difficult.
The finger introduced into the vagina, so that
its extremity reaches the point of reflexion of
the posterior wall of that canal forwards on
to the uterine neck, discovers, just above this
spot, a hard or semi-elastic projection, which
seems to grow out of the cervix just at its
point of junction with the body of the uterus.
The surface of the tumour towards the rec-
tum, upon which it encroaches, is convex,
and is either smooth or irregularly nodulated,
while between the tumour and the neck of
the uterus is usually perceived a notch more
or less deep, and comparable in form to that
which separates the body from the neck of an
ordinary retort. Hence this condition may
easily be mistaken for the retorted uterus,
which it closely resembles in many particu-
lars. The surface of the tumour is exquisitely
tender, while the adjacent uterine structures
are free from tenderness.

The comparative frequency of this affec-
tion *, and the constant and severe suffering
which result from it, especially in married
women, in whom it is usually found, may
justify here a brief exposition of the peculiar
anatomical condition and relation of parts which
appear to me to conduce to its production.
From the view of the pelvic viscera given in

* I believe that it is often confounded not only
with retroflexion, but also with retroversion, fibrous
tumour, and hypertrophy of the posterior uterine
wall, and that hence the frequency of its occur-
rence has not been commonly recognised.



UTERUS (ABNORMAL ANAT-M\ ).



(Jig. 433.) it will be seen, that while the normal
cervix projects obliquely into the upper part
of the vagina, the fbrnix or blind extremity of
that canal forms the actual termination of the
tube, so that this arrangement, while it tends
materially to the preservation of the os and
cervix uteri from injury during congress, at
the same time exposes the cul de sac of the
vagina to a certain amount of pressure, which
various circumstances, such as relative short-
ness of the vagina and other obvious condi-
tions, may render injurious. But exactly over
this spot lies the mass of lax fibrous tissue in
question, the meshes of which become easily
infiltrated under inflammation by serous or
fibrinous fluids supplied by the vessels, which
sections of this region show to be so abundant
in the neighbourhood. ( Fig. 429.)

Perimetrial inflammation occasionally reaches
the suppurative stage, and in this way are
formed 5ome of those abscesses which burst
through the cervix, or form collections of
matter between the folds of the broad liga-
ment.

3. Pathological conditions of the muscular or
proper coat.

a. Diminished and increased consistence of
the uterine substance, although generally re-
sulting from obvious morbid processes, is yet
sometimes found without any apparent dis-
ease of the tissue.

Diminished consistence may be found in
various degrees, from a slight friability or
softness to a nearly complete pulpiness (inar-
ciditas). In these cases the texture of the
uterus may be pale and exsanguine, or in a
state of tiyperaemia, with occasionally apo-
plectic effusion. Rokitansky associates the
latter condition with thickening, and some-
times ossification of the uterine arteries.

b. Parenchymatous inflammation of the uterus.
Metritis. Mctritu parenchymatosa. Inflamma-
tion of the substance of the uterus, which in
the puerperal state is so commonly fatal,
seldom leads to death in the unimpregnated.
Hence opportunities for investigating the ana-
tomical condition of the organ in the non-
gravid state under conditions of inflammation
are of comparatively rare occurrence. From
such opportunities, however, aided by what
may be observed during life, the following
may be concluded as to the changes which
inflammation produces in the muscular and
fibrous coat.

Under acute parenchymatous inflammation
the whole organ becomes increased in bulk,
and at the same time redder and softer. On
section blood flows freely from the divided
vessels, and the tissues are found permeated
by serous infiltration. Sometimes the highly
congested ve-seLs have in parts given way, and
ecchymoses or larger apoplectic collections
have resulted.

If no commensurate resorption of these
effusions takes place the organ continues of
abnormal size. This is more particularly ob-
servable when a portion of the uterus, as the
body or cervix, has been repeatedly inflamed.
The latter, especially, remains enlarged. The
Supp.



os tincae is patulous, and one or both lips of
the cervix present an cedeinatous hardness,
and occupy a larger space than usual in the
fornix of the vagina.

Occasionally inflammation of the uterine
parenchyma reaches the suppurative stage,
resulting in collections of matter which may
escape into the peritoneum between the folds
of the broad ligament, or externally by the
vagina or rectum.

Chronic inflammation produces likewise a
general enlargement of the uterus, but more
commonly the cervix is principally or exclu-
sively involved, and the resulting enlargement
is especially observable in its vaginal portion,
the lips of which become increased in breadth,
or elongated and prominent.

When chronic inflammation affects, on the
other hand, the parenchyma of the body of
the uterus chiefly, the walls of this part
become thickened and indurated, while the
cavity undergoes enlargement such as is exhi-
bited by the ventricles in excentric hypertro-
phy of the heart. Under chronic inflammation
the uterine tissue becomes indurated, so that
upon section it grates beneath the knife. This
induration is occasioned chiefly by hypertro-
phy of the fibrous element of this coat of the
uterus.

c. Fibroid. Tumor fibrosus uteri. Fibro-
muscufar tumour. Hard fleshy tubercle of the
uterus (Baillie). These and numerous other
titles have been employed by different authors
to designate a form of degeneration of the
uterine tissue which is so common that, ac-
cording to the often quoted calculations of
Bayle, it may be found in every fifth case of
women who die after the age of thirty-five.*

Fibroid of the uterus has for its basis the
same structure as fibrous tumours in general -J-
The surface of a section presents to the naked
eye a peculiar mottled appearance, caused by
the presence of numerous white lustrous
bands intersecting in all directions a more
homogeneous basis substance, which in these
uterine formations has always a greyish or
light brown colour, the latter being especially
distinct in spirit preparations. The difference
between these two, however, is more appa-
rent than real, consisting, as Paget suggests,
rather in the mode of arrangement than in an
actual differentiation of the component struc-
tures. These consist chiefly of very slender
filaments of fibrous tissue " undulating or
crooked," and exhibiting various degrees of
development in different specimens, being in
some large and wavy, and in others very short,
and often intermixed with cUoblasts and nu-
clei. Along with this fibrous basis is found
a variable amount of smooth muscular fibre,
which in some cases, especially in the polypi
hereafter noticed, forms the chief bulk of the

* Dr. West has furnished some interesting sta-
tistics upon this subject. (Lectures on the Diseases
of Women, Ft. i. p. '277. 1856.)

| For an account of these see Paget's Surgical
Pathology, Vol. II. LectV. ; and also for those of
the uterus, Bidder, in Walter ueber firbrose Kb'rper
der Gebarmutter.

Y Y



690



UTERUS AND ITS APPENDAGES.



mass, so that a muscular rather than a fibrous
tissue results. A small quantity of elastic
fibre is also occasionally found in these ute-
rine formations.

Fig. 474.




Section of fibroid tumour of the uterus. (Ad Jat.)

The structural variations observable in
fibroid of the uterus, are dependent chiefly
upon the peculiarities in arrangement of these
component elements. In the more dense
formations, the white shining fibrous bands
enclosing little pellets of the browner sub-
stance, form numerous small compact masses,
which are again closely united together by a
somewhat looser fibrous tissue that serves to
combine the whole into lobes or lobules, va-
rying in size from a pea to that of a man's
head. The variation in density of these
masses depends, further, upon their vascula-
rity. In the softer kinds, bloodvessels that
may be injected permeate the mass, running
along the bands and layers of fibrous tissue
connecting the lobules. Such tumours are
sometimes of a deep red colour. The denser
masses, on the other hand, are apparently
nearly bloodless ; at least, injections cannot be
made to penetrate them.

The different configurations which these
masses of uterine fibroid assume, appear to
depend in a great measure upon accidental
conditions. In this particular three varieties
may be noticed.

1st var. Interstitial fibroid. The mass
here forms a growth, sometimes of immense
size, but still contained within the proper
boundaries of the organ, occupying one or
other uterine wall, but neither encroaching
upon the uterine cavity, nor protruding ex-
ternally. Such is the case represented in
fig. 475., in which the external appearances
were those of the ordinary gravid uterus in
the seventh month. Such masses appear oc-
casionally at their periphery to merge gra-
dually into the healthy tissues of the uterus,