but more commonly there exists a distinct
boundary formed by loose cellular tissue with
which the tumour is so lightly connected that



it may be easily detached and turned out of
its investing capsule (fig. 475 ).



475.




Interstitial fibroid of the uterus. (Ad Nat. )
The tumour is formed in the substance of the
posterior wall, which is so attenuated at one spot as
to be nearly broken through. The cavity of the
uterus is shown in the lower part of the figure un-
altered in size.

2nd var. Snbperitoneal fibroid. In this
variety the fibroid mass or masses protrude
from the external surface of the uterus. Here
one or several round or oval tumours are
formed which seem to grow out of the uterine
substance by a narrower or broader base, or
they remain attached to it by a peduncle.
These masses consist entirely of fibroid,
having either simply an investment of perito-
neum, or beneath that also, in many instances,
a layer more or less thick of uterine sub-
stance which is usually laminated, so that a
capsule composed of the natural tissues of the
uterus is formed around the tumour (fig. 476.).

3rd var. Sub-mucous fibroid. In this va-
riety the fibroid mass quits its bed in the
uterine walls, and projects into the cavity of
the uterus ; it becomes covered by an exten-
sion of the lining membrane of the uterus,
and sometimes also beneath this by a layer of
healthy uterine tissue. These tumours, when
they possess a peduncle, constitute the fibroid
polypi of the uterus.

A distinction has been made in these po-
lypi between such as form continuous out-
growths from the substance of the uterus, and
those in which the polypous mass forms a
discontinuous tumour, connected only by a
narrow stem of mucous and muscular tissue.

The original position of the fibroid growth
in the uterine walls, whether in the middle or
nearer to their inner or outer surfaces, proba-
bly determines, in a great measure, the direc-
tion and form which these growths ultimately
take, and is consequently productive of the
three varieties above noted.

The different forms which fibroid assumes
are in accordance with these varieties of po-



UTERUS (ABNORMAL ANATOMY).



sition. Fibroid growths retained within the
uterine walls, are at first almost invariably
spherical, but in course of growth become
ovate or flattened. Those which project from
the outer surface are usually nearly round,
while the polypi of the cavity, and those
which extend into the vagina, are pyriform,
and possess longer or shorter peduncles. The
greater part proceed from the fund us, com-
paratively few from the walls of the body,
and scarcely any of this kind from the cervix.
The latter are usually of a more spongy or
cellular character than the former, which con-
sist of a denser fibrous tissue.

The power of gro\\th of fibroid tumours
appears to be nearly unlimited. The known
extremes in such cases are, in point of num-
ber, from one to forty ; and in respect of
weight, from a few grains to seventy pounds.

Fibroid exercises a considerable influence
upon the form and position of the uterus.
Tumours within, or external to it, change the
position of the organ in various ways, pro-
ducing elevation, prolapsus, lateral obliquity,
and especially retroversion, according to the
seat which they occupy. Polypi distend the
cavity of the body and cervix, and the os
uteri, and sometimes produce prolapsus and
inversion of the uterus.

The influence of fibroid upon the thickness
of the uterine walls is also considerable. Ge-
nerally a marked hypertrophy, equal some-
times to that of pregnancy, takes place, while
in parts a thinning of the walls occurs. The
latter is especially observable in cases where
the tumours are numerous, as in Jig. 476.
These sometimes appear to grow at the ex-
pense of the whole uterine substance, so that
the original organ is \vith difficulty discovered
among the hypertrophied mass.

Fig. 476.




The uterus surrounded by outgrowths of fibroid which
hate pushed the peritoneum before them, several
having become pedunculated. (Ad J\~at. )

The uterus, at the expense of whose tissues the
tumours are formed, can scarcely be discovered in the
midst of the mass.

Important consecutive changes take place
during the process of growth of fibroid. So
long as the structure retains its original hard-
ness, the increase is comparatively slow, con-



691

sisting in a simple and uniform multiplication
of the elements already described. Occasion-
ally an increase of density is produced by cal-
cification of certain portions of the mass, and
in this way the so-called bony tumours of the
uterus are formed. Or, on the other hand,
under rapid growth, the tumour may become
softer, in consequence of serous infiltration
into its tissues ; the fluid occasionally collect-
ing in the centre of the tumour and forming
there a species of dropsy. Or, a process of
inflammation being set up, suppuration, and
sometimes sloughing, result. In the more
vascular fibroids the vessels may dilate and
burst, and the tumour then becomes infiltrated
with extravasated blood. It has been doubted
whether fibroid ever undergoes absorption.
I have reason to think, from occasionally wit-
nessing a marked diminution in bulk, that
this may sometimes occur. The explanation
of this is indeed easy when the mass of the
tumour consists of hypertrophied muscular
tissue, which in such cases has been found to
undergo fatty degeneration, and so its disper-
sion may be effected.

Subperitoneal and interstitial fibroid, when
extensive, interferes with pregnancy, and also
renders labour difficult or perilous, by weaken-
ing the expulsive power of the uterus and pre-
disposing the organ to rupture. Submucous
fibroid, in the form of polypi, may prevent
impregnation or shorten gestation. In the
unimpregnated uterus, all forms, but especially
the submucous and interstitial, are apt to be
accompanied by severe recurrent haemorrhage,
producing excessive anaemia and occasionally
death.

Lastly, it may be observed, in reference to
tumours which are commonly termed polypi,
that the present state of pathology demands a
separation of these, according to their struc-
tural differences, such as has long been esta-
blished, upon a similar basis, among those
objects of the animal kingdom whose sup-
posed resemblance, distant indeed, and at the
best fanciful, has given a name to this form of
tumour. For, as in that prototypal group of
animal forms, once termed polypi, three widely
separated classes at least are now known to
have been combined, so those pathological for-
mations, which are still familiarly termed po-
lypi, exhibit a more than equal number of va-
rieties, each marked by distinct differences of
structure. These may be distinguished as the
fibrous, including the cellular, which are com-
posed of a looser fibrous tissue ; the muscular;
the mucous, also frequently containing much
fibrous tissue, and the cancerous or malignant
polypi. And to these have been added the
so-called Jibrinous or blood polypi.

The fibrous polypus has been already de-
scribed, and the second, or muscular, may here
also be classed with it, as having its origin in
the middle coat of the uterus, but consisting
of muscular rather than of fibrous tissue.

These muscular polypi are comparatively
rare. Their structure, as exhibited in the ac-
companying Jig. 477., is precisely that of the
proper muscular coat of the uterus.

Y Y 2



692



UTERUS AND ITS APPENDAGES.





m$w

W [ lf

*?



Section of a polypus formed of the muscular tissue of
the uterus. (After Wedl.}

The fibres, arranged in bundles, run in different
directions. At a a, they have been divided trans-
versely, and in other parts obliquely. Compare
with/0. 436.

The malignant polypi, and those which are
formed of hypertrophied mucous structure,
belong to another category, and will be de-
scribed hereafter.

4. Pathological conditions of the mucous coat.
a. First under this head may be noticed
simple hypertrophy of the uterine mucous
membrane, followed often by a partial shed-
ding of that structure in the form of the so-
called

Dysmenorrhceal membrane. The term men-
strual decidua would probably form a more
appropriate title for these structures, which
consist of a greater or less thickness of the
mucous membrane lining the uterus, differing
in no respect from that membrane in its ordi-
nary condition *, except in the one particular,
that it has undergone a certain degree of
hypertrophy. (Fig. 443.) The hypertrophies
which the mucous membrane of the uterus
undergoes in various circumstances form a
most interesting subject for study, but all
of them are not pathological. The most
familiar example of normal hypertrophy of
the uterine mucous membrane is that which
occurs in ordinary pregnancy. Here, no
sooner does the uterus begin to enlarge,
than the mucous lining also expands, arid
its tissues become opened up by an in-
creased flow of blood, and a consequent
rapid development of the simple elements
composing this structure. This hypertrophy
occurs in every pregnancy where the ovum
enters the uterus. But it also happens very
generally in those cases where the ovum
never enters the uterus at all, but is developed
externally to that cavity (extra-uterine gesta
tion). Here a most perfect decidua is usually
found lining the uterus. The exceptions are
few in which the uterine mucous membrane,
under these circumstances, does not exhibit
anj r increase of thickness, but retains or nearly
so, its ordinary characters

* See on the structure of the uterine mucous
membrane, p. 635. of this article.



But a state of pregnancy is -not necessary
to produce evolution of the uterine lining, for
this may occur when the body of the uterus
is enlarged from other causes. Thus, in an
example in my possession of uterine fibroid, in
which the body of the uterus has undergone
the hypertrophy already described (p. 491.),
as common in that state, the hypertrophy
has extended to the mucous membrane, so
that the uterine cavity, which had also been
occupied by one of these tumours, exhibits a
delicate decidual lining.

The decidual membranes occasionally cast
off from the uterus under circumstances of
dysmenorrhcea, consist of fragments, or, more
rarely, of entire membranes forming casts of
the uterine cavity. The structure of all these
is nearly similar, and they differ chiefly in the
greater or less thickness of membrane de-
tached. All present upon their inner surface
the peculiar cribriform markings already de-
scribed as constituting the orifices of the
uterine glands, while their outer surfaces are
rough and shaggy, like the outer surface of
aborted ova, for this surface has been de-
tached or torn off from the uterus. Fig. 443.
represents a portion of such a membrane, as
seen from its inner or cribriform surface. The
microscopic characters of these membranes
are precisely those of ordinary decidua.

b. Hypertrophy of the follicular structures
of the uterine mucous membrane. Follicular
polypi. Mucous polypi. Cysts. The patho-
logical formations which take their origin in
the mucous membrane lining the uterus, con-
sist chiefly in hypertrophic growths of that
membrane, and of its follicular structures.
They present usually two varieties, according
as the follicular or the ordinary mucous tissue
abounds in their composition. Many of these
growths acquire a peduncle, and then consti-
tute the mucous or follicular polypi.

The follicular structure is most apparent in
those growths which spring from the body,
and especially from the fundus uteri near the
orifices of the Fallopian tubes. These vary in
size from a pea to a small plum. They have
usually a rounded or oval form, and become
partially flattened by the external pressure of
the uterine walls. A short and narrow pe-
duncle connects them with the spot from
which they arise. Externally they are smooth
and covered by a layer of epithelium, beneath
which is a thin extension of the uterine mu-
cous membrane. This is often sufficiently
transparent to render visible numerous opa-
line spots, indicating the seat of groups of
uterine follicles distended and elongated, and
containing a semitransparent gelatinous fluid.
Between these elongated follicles there is a
loose fibrous tissue connecting them together,
and giving substance to the mass. These
tumours possess little resistance, and are usu-
ally soft and elastic.

The more solid mucous tumours very ge-
nerally acquire a stem, and early take the
form of polypi. These mostly arise from be-
tween the folds of the lining membrane of the
cervix, and are evidently mere hypertrophies



UTERUS (ABNORMAL ANATOMY).



of that structure, including a variable propor-
tion of the sublying cervical fibrous tissue.
In size they range from a pea to a walnut,
and occasionally their peduncle measures se-
veral inches in length, so that they may pro-

Fig. 478.




Ptdunculated polypus of the cervix uteri. (After
Boivin and Duges.)

trude to a considerable distance beyond the
vulva. Their form is generally that of an
elongated pear. The surface is smooth, though
not uniform, being usually nodulated or lobed,
and in parts roughened by minute papillary
growths. Sometimes one or two of the cer-
vical folds or rugae, scarcely altered in cha-
racter from their ordinary condition in the
healthy cervix, are distinctly visible upon
them. These more solid tumours are covered
by cylinder or pavement epithelium and hy-
pertrophied mucous membrane. Internally
they are composed of loose inelastic fibrous
tissue, containing a few enlarged and ob-
structed follicles, one or two of which may
grow more than the rest, and form a cavity
distended by a slimy fluid.

The growth of both these forms appears to
be limited, and they never attain to the size
which the fibrous polypi often reach. With
the hypertrophies of the follicular structures
are also to be classed those single cysts, of
the size of a pea, or larger, and sometimes
pedunculated, which are very commonly found
lying between the cervical folds, or protrud-
ing from the os uteri. These consist almost
exclusively of distended Nabothian follicles.

c. Hypertrophy of the filiform papilla of
the cervix. A variety in the condition of



693



the filiform papillrc upon the vaginal portion
of the cervix has been described at p. 639.
These papillae, : nstead of being short, and
covered by pavement epithelium up to the
very margin of the os uteri, as they are upon
the rest of the cervical lips, may present the
same condition which they have within the
cervix, where they are longer and larger, and
are not bound down by a continuous layer of
covering epithelium. These papilla? often
appear at the margin of the os, and form
there little tufts, or extend over the lips of
the cervix in the crescentic manner already
described at p. 639. They then constitute
one of those conditions to which, in the pre-
sent day, the term ulceration is very fre-
quently applied ; yet there*is no more reason
for asserting that these are pathological for-
mations or conditions, than there is for as-
serting the same of the villi within the canal,
for both are identical in form. They can only
be regarded as pathological structures when
they obviously exceed the natural conditions
already described. Then, indeed, they may
be classed among the hypertrophies of special
structures of the cervix, and they will bear
the same relation to the natural papillae, that
the hypertrophied follicular structures, form-
ing the cysts and polypi recently described,
bear to the cervical follicles in a healthy con-
dition. Both the hypertrophied and the na-
tural papillae give to the finger that peculiar
velvety or mossy sensation which is usually
classed among the diagnostic signs of ulcera-
tion of the os uteri.

d. Simple inflammatory hypertrophy, with
extroversion of the cervical mucous membrane.
The mucous membrane lining the canal of
the cervix uteri under chronic inflammation
becomes frequently partly everted, so that a
portion of the inner surface of one or both
walls of the neck is rendered visible at the
lower orifice, taking here the place ordinarily
occupied by the inner border of the lips of
the os tincae. This affection is usually com-
bined with a corresponding hypertrophy of
the proper tissue of the cervix, and may be
compared in its effects to that thickening of
the upper lip common in strumous children,
which causes the part to become everted.

Figures 7. and 8. Plate IX. in Boivin and
Duges' Atlas represent an extreme degree of
this affection, in which the cervical mucous
membrane protrudes to an unusual extent,
so that the palmae plicatae and middle raphe'
on both sides are seen. In the more common
minor degree of hypertrophy with eversion, a
crescentic protrusion only of the cervical mu-
cous lining occurs. The unevenness of the
surface, caused by the slightly swollen and
prominent rugae, and as often by the numerous
little depressions consisting of enlarged mu-
cous crypts, according as one or the other of
these is the predominant normal structure in
the cervix *, gives to the part during life the
appearance of a raw or granular surface, while



For a description of these varieties, see p 640.

Y Y 3



694



UTERUS AND ITS APPENDAGES.



the natural boundary between the lower edges
of the cervical canal and the lips of the os
tineas being now transferred on to the latter
in consequence of this eversion, an abrupt
semicircular line becomes visible, which, while
it only indicates the natural termination here
of the vaginal epithelium (see p. 640.), is fre-
quently mistaken for the margin of an ulcer.

This condition may be observed upon only
one lip, or upon both simultaneously. It re-
quires special notice here, not so much for its
pathological importance, which appears to me
to have been overrated, as on account of cer-
tain views of late connected with it, under
the belief that it constitutes another form of
ulcer of the os or cervix uteri.

e. Catarrhal inflammation of the mucous
coat. Endo-metritis. Metritis caiarrhalis. Me-
trorrhcea. Catarrhus uteri. Acute and chronic
catarrh. Leucorrhea. Fluor albus.

The ordinary inflammatory affections of the
uterine mucous membrane in the unimpreg-
nated state, which were formerly known only
by the discharges to which they give rise, and
which were consequently confounded with
similar affections of the vagina, have in recent
times been more accurately examined, and
traced to their real seat. That the lining
membrane of the uterus, and its cervix in a
state of acute or chronic inflammation, is the
principal source of many of these discharges,
is now well ascertained, and the similarity of
these affections to the catarrhs of other mu-
cous surfaces is now also generally admitted.
Hence the term uterine catarrh, under the
various forms above quoted, has been employed
in most recent works on uterine pathology
to designate these affections. Inflammation,
whether acute or chronic, may involve the
entire uterine mucous membrane, or it may
be limited to that of the body or cervix.*
The ordinary anatomical conditions of this
membrane under inflammation are, first, deep
hyperaemic congestion, so that the surface
presents a uniform florid red colour, or it is
mottled with patches of red, intermixed with
paler and less vascular parts. In congestion
of the mucous membrane lining the body of
the uterus, the superficial capillaries, whose
healthy forms are represented injigs. 439 a and
b, become intensely loaded, so that rupture
occasionally takes place, followed by effusions
into the substance of the membrane. A se-
rous or sero-sanguinolent, and in more ad-
vanced stages, a muco-purulent fluid, covers
the surface, while the entire mucous mem-
brane becomes swollen, softened, and infil-
trated with serum. An abrupt line of demar-
cation, when the congestion is limited to the
uterine body, marks the boundary between
that cavity and the cervix, the lining mem-
brane of which may retain its natural pale
colour, just such an abrupt line of demarca-
tion between the highly congested membrane

* This distinction, not usually observed by con-
tinental authors, has been emphatically made by
Dr. H. Bennet. A Practical Treatise on Inflamma-
tion of the Uterus. 3d edit. 1853.



of the uterine body and the paler lining of the
cervix, as occurs during menstruation or in
early pregnancy.*

When inflammation affects chiefly or ex-
clusively the cervical mucous membrane, this
becomes turgid and swollen, and its vessels
congested. The congestion affects more par-
ticularly the capillaries of the vaginal portion
of the cervix, and of the interior of the canal
near the orifice. The lips of the os tineas are
at the same time tumid, the os is enlarged,
and the cervical canal expanded ; changes
which indicate that the structures immediately
beneath the mucous membrane are then also
involved. A loss of epithelium in the neigh-
bourhood of the external orifice, more or less
extensive, may occasionally accompany the
severer forms of this affection. From this it
results that the turgid and vascular papillae
beneath becomes exposed, and when these
are also hypertrophied, the surface acquires
the condition commonly termed granular.

The natural or healthy secretions of the
cervix become materially altered under ca-
tarrh. In a normal state the cervical secretion
is sufficient in quantity to cover the mucous
folds, and to fill the crypts and furrows, and
occasionally to block up the entire canal. It
consists of a viscid, tenacious, and nearly
transparent fluid, enveloping numerous mu-
cous corpuscles, granules, and epithelial scales.

When the catarrhal state ensues, this fluid
is greatly increased in quantity, and, according
to the severity of the affection, it passes
through the various conditions of a viscid
transparent jelly, resembling clear starch or
white of egg, of a thicker cream-like fluid, or
of a puriform mucus, in colour nearly resem-
bling pus. Blood also is occasionally found
mixed with these secretions.f

The ordinary secretions of the cervix, as
shown by Dr. Whitehead, have an alkaline
reaction within that canal, but they speedily
become acid when mixed with the vaginal
secretions, which also cause the previously
transparent cervical products to become opaque
as they pass through the vagina.

Acute specific catarrh of the vagina (gon-
orrhoea), as well as simple catarrh of that
canal, may be associated with the foregoing
affections.

Ulceration of the mucous coat. Melro-hel-
cosis. Granular ulcer. Simple erosion, abra-
sion and excoriation. These terms have been
severally employed to designate certain con-
ditions of the os and cervix uteri, regarding
the nature, frequency and pathological import-
ance of which, as is very well known, great
diversities of opinion are in the present day
entertained.

The affections of the cervix uteri, which

* This point, under both these conditions, is
illustrated with great fidelity in the coloured de-
lineations of Boivin and Duges. See Atlas, PI. I.
fig. 4., and PI. II. fig. 6.

t A descriptive account of some of these fluids,
accompanied by illustrations, will be found in the
paper of Dr. Tyler Smith, in Vol. XXXV. of the
Med. Chir. Trans.



UTERUS (ABNORMAL ANATOMY).



are commonly deemed ulcerative, are admitted
by those who so describe them to possess
certain characteristic and exceptional features
by which they are distinguished from ulcers
of other parts. For it is truly asserted,
that " whatever the character of an inflam-
matory ulceration of the cervix the ulcerated
surface is never excavated ; it is always on a
level with, or above the non-ulcerated tissues
that limit it, and its margin never presents an
abrupt induration."*

Further, with regard to the position of
these "sores,"' two principal circumstances
have been almost invariably noticed. As
seen by the aid of the speculum, they either
present the appearance of a red and apparently
raw surface commencing, within the cervix,
or at the margin of the os tincae, and spread-
ing outwardly to a limited extent over one or
both lips ; or they form numerous isolated
red spots, or sometimes depressions dotted
at nearly regular intervals over the whole
surface of the vaginal portion of the cervix,
and varying in size from a pin's head to a
millet seed.

It will aid description to take advantage of
these peculiarities for the purpose of arrang-
ing in two groups or classes the various pa-