thological and other states of the uterine
cervix, which severally exhibit the characters
just mentioned. Many of these, however,
when minutely examined, and tested by the
aid of the microscope, so little fulfil the con-
ditions of true ulceration, as to make it appear
that such a term could only have been applied
to them under, in some instances perhaps a
misapprehended, and in others a strained, view
of their real nature.

In the first class ma} 7 be included those
cases in which the filiform papillae of the
cervix are in an uncovered state, and either
of their natural size or hypertrophied ; ever-
sions of the cervical mucous membrane j and
hyper-trophic growths of the same. All, or
nearly all the non-excavated ulcers, so termed,
are referable to one or other of these con-
ditions.

Beginning with the normal variety of struc-
ture already described, in which the central
columnar folds of the cervical mucous mem-
brane take a perpendicular direction (fig. 424.),
and after running down to the very margin of
the os tinea? terminate there in a narrow bor-
der, or tuft of filiform papillae, the simplest form
which has been viewed as abrasion, excoriation,
or ulcer, is thus produced. The velvety pile,
constituting one of the most common features
of pseudo-ulcer, being formed by these slightly
prominent papillae, fringing the margins of
the os.

In a more marked degree of the same con-
dition, instead of a narrow line or margin, a
broader crescentic patch of uncovered filiform
papillae extends outwardly over either or both
lips. The papillae are gathered into little
groups, whose appearance, when magnified
by a common hand lens, may be compared to

* J. H. Bennet, foe. cit. p. 79.



695

miniature wheat -sheaves heaped together.
Each papilla is perfectly free and possesses
its own proper epithelial coat.* This little
group, which may cover half the circum-
ference of the cervical lip, is encircled or
semi-encircled by a thin non-elevated margin,
where the ordinary pavement epithelium co-
vering the rest of the cervical lip terminates.
There is no appearance of any loss of tissue
here, beyond that occasioned by the absence
of a portion of that dense layer of epithelium,
which, like a sheet cast over the papillae,
usually invests them, as far as the inner bor-
ders of the cervical lips, with one common
covering, in addition to their own proper
coat.

These papillae may retain their normal size,
or they may be hypertrophied. On account of
the large number of capillaries which they
contain, and from the circumstance that they
are uninvested by vaginal epithelium, they
present a florid and often turgid aspect.

When such a part is brushed over with
nitrate of silver, a line of demarcation is in-
stantly produced, the mucus entangled
among the naked villi is coagulated, and a
cloud of white chloride of silver is precipi-
tated among them, while the parts adjacent
which are covered by pavement epithelium
are less affected, and exhibit only a pinkish
white opalescence, that contrasts with the
dead white within, and with the abruptly
marked border of the epithelial edge. In
this way is produced another effect commonly
quoted as a test of ulceration. f

Those bolder and more marked projections
of a florid red colour which begin also from
the inner margins of the os, and spread out-
wardly, looking like granulations, consist of
hypertrophies of pre-existing structures inter-
mixed occasionally, though more rarely, I be-
lieve, with pathological new formations.

Such hypertrophies are chiefly the follow-
ing, viz. eversion of the cervical lining as
described at p. 693. ; hypertrophies of the
crested folds of that membrane, which when
everted, enlarged, and inflamed, constitute the
condition termed " cockscomb granulation ; "
and lastly, distended and closed muciparous
follicles gathered in groups around the os and
intermixed with the hypertrophied structures
just noticed. These latter add to the irre-
gularities and nodosities of the surface, and
together with fissures formed by deepened
natural folds, and varicose distensions of ves-
sels, constitute the more irregular forms of
hypertrophies which have been termed ulcers.

The second class of pseudo-ulcers termed
commonly aphthae and granulations, viz. those
which are dotted at regular intervals over the
lips of the cervix, but are often more endur-
ing than herpes, and do not usually in their
progress coalesce as herpetic spots when con-
tiguous almost invariably do ; these consist of

* Regarding the nature of this coat see p. 639.

t Precisely such an effect may be produced upon
mucus scraped with a piece of glass from the
tongue, and touched with argenti nitras.

Y Y 4



696



UTERUS AND ITS APPENDAGES.



enlarged muciparous follicles*, which in three
different conditions or stages correspond with
three varieties of pseudo- ulcers of the aph-
thous kind. In the first variety the follicles
are closed and project like millet seeds above
the general level of the cervix. They contain
a little glairy fluid, and may be compared to
the distended closed follicles described at
p. 640., as occurring within the cervical and
uterine cavities. They are almost always
placed at such regular intervals apart, that
they must be regarded as natural structures
enlarged, rather than as pathological new for-
mations.

The second variety consists not of closed
but open follicles similarly arranged. Within
and at the bottom of many of these may be
seen the filiform papillae enclosed, cup-like,
and resembling the stamens in a half opened
flower. Similar follicles to these occur some-
times within the cervix under ordinary circum-
stances.

When these papillae become hypertrophied
and sprout out above the cup-like level of the
containing follicles they form florid-looking
and elevated spots resembling granulations in
appearance, and these constitute a third va-
riety the " granulations simples sans ulce-
rations" of Pichard.-f-

The foregoing examples have been here
passed in review for the purpose of illustrat-
ing the principal anatomical and pathological
conditions of the uterine cervix, which when
viewed by the speculum during life exhibit
appearances that are regarded by many ob-
servers in the present day as affording un-
mistakeable characteristics of ulceration. With
this object they have been here grouped to-
gether, but they do not form a class ; many
of them indeed have no pathological relation-
ship, and to few can the term ulceration be
regarded as appropriate. In order, therefore,
to eliminate from the category those condi-
tions which have no title to be considered as
ulcers, it is needful to apply to them the test
of a definition. With this view, and also for
the purpose of avoiding the confusion which
from the time of Hunter downwards has at-
tended the employment of various terms for
the designation of ulcerative processes, of
those at least by which the particles of open
or exposed surfaces are removed, it may be
well to adopt some such distinction as that
proposed by Mr. Paget, namely, to regard as
abrasions or excoriations those conditions in
which the epithelium or epidermis of an in-
flamed part is alone removed, and those only
as liberations in which the removal extends
further to the vascular or proper tissues be-
neath the epidermis.}:

Judged by this test, there may be excluded,
first, all those apparent sores which, begin-



* See p. G40.

t Excellent representations of the varieties de-
scribed above will be found in Boivin and Duges'
Atlas, pi. 25. 27. and 33., and in Pichard, Mai.
des Femmes, pi. 3.

J Surgical Pathology, vol. i. p. 419.



ning invariably from within the margins of the
os, and appearing to spread outwardly more
or less over the cervical lips, present a florid
and often granular aspect, and being on a
level with surrounding parts, and without de-
finite edges or raised border, fulfil all the con-
ditions commonly assigned to ulcers of the
uterine neck. These, almost without excep-
tion, consist of the inflammatory conditions
already described as hypertrophies and ever-
sions of the cervical mucous membrane. The
apparently raw surface exposed to the eye is
not usually any portion of the outer cervix,
but the swollen inner surface of the walls of
the cervical canal now everted and brought
into view, just as the interior of the lip is
brought into view in common strumous
thickening about the mouth. The margin of
this apparent ulcer is the normal boundary of
the os, or line of demarcation between the
vaginal and cervical mucous membrane, now
disturbed and thrown out of its natural place.
The granulations upon this surface are the
thickened and inflamed papillae, follicles, and
rugae of the cervical canal. The edges are not
raised because they simply form the boundary
between the vaginal and cervical epithelium,
and the centre is not depressed, because there
is no erosion nor any loss of tissue.

These conditions of the uterine cervix in
respect of their true pathological relations
are exactly allied, in their different degrees, to
the inflammatory conditions of the eyelid
termed respectively Lippitudo, Ectropion and
granular lid. Both are attended by like
hypertrophies of structure and corresponding
depravements of their healthy secretions.
Both are reduced to their normal condition
by similar or even identical methods of treat-
ment, and both are alike entirely removed from
the category of ulcers.

Next to these may be enumerated the con-
ditions of the uterine neck which are distin-
guished by loss instead of hypertrophy of
tissue. When this loss consists solely in de-
tachment of epithelium the term " epithelial
exfoliation" appears to be a more appropri-
ate designation and preferable in many re-
spects to " excoriation or abrasion," terms
which seem to imply something of violence
in the mode of production of these conditions.
Exfoliation of the tesselated epithelium
covering the vaginal portion of the cervix ap-
pears to take place under some circumstances
with great ease. In uterine catarrh for ex-
ample, this shedding of epithelium com-
mences at the borders of the os, and extends
outwardly. Or it may involve the entire
epithelium of the vaginal portion of the cervix
together even with that of the vagina itself,
these being sometimes thrown off like a cast.
In such cases, a fresh epithelium is formed
beneath the old one that has been detached.*
But if the epithelium is not renewed the
villi remain denuded. This condition may be
precisely imitated after death by macerating
the part for a few days, and then peeling off

* See also page 707. and note.



UTERUS (ABNORMAL ANATOMY).



the epithelial covering. And it is probable
that profuse discharges lying in constant con-
tact with these parts during life may similarly
assist in softening and detaching this struc-
ture. But it is deserving of consideration
that the papilla; of the outer surface of the os
by this uncovering are merely reduced to the
same anatomical condition as those of like
form within the cervical canal. Whether this
deprivation of a natural covering usually found
here renders the villi of the outer cervix, which
are probably .specially sentient structures, more
susceptible ot irritation, particularly when in
a hypertrophied state, is a matter for consider-
ation that would extend the present inquiry
beyond its proper limits here. But it is pro-
bable that in this way may be explained those
constitutional and local erethisms which often
accompany faulty states of the uterine cervix ;
and which have led to such conditions being
invested with a degree of importance often in
excess of their true pathological value.

But the villi may be found in some speci-
mens denuded of vaginal epithelium, yet with-
out any evidence of inflammatory or other
changes. Such a part may appear quite na-
tural. The villi upon the cervical lips, and
those within the canal being in every respect
identical and alike natural in appearance, so
that the strictest microscopical investigation
may fail to detect any difference between them.
The examination of such specimens has satis-
fied me that the vaginal epithelium does not
always normally terminate precisely at the
inner borders of the uterine lips, but may cease
at some point short of this.*

In the third place are to be noticed those
cases in which the process of removal extends
to tissues deeper than the epithelium, i. e. to
the villi, the vascular and fibrous, and other
tissues. The removal of such tissues here
necessarily produces excavation with definite
borders, and all the characters of a true ulce-
ration. Ulcers of the uterine cervix exhibiting
these features are almost exclusively either
syphilitic, phagedenic, cancerous, or cancroid,
and such as occur upon the surface of a pro-
lapsed uterus. They are seldom, I believe,
scrofulous, and more rarely if ever do ulcers
occur upon the uterine neck as the result of
simple inflammation, fulfilling the conditions
that would entitle them to be admitted into
the category of true ulcerations.

Distensions of the uterine cavity, by liquid
or gaseous contents, constitute the affections
termed respectively hydrometra, hamiatometra,
and physometra. These collections result
usually from narrowing or atresia of some
portion of the vagina or cervix, whereby the
natural or morbid secretions of the uterus
become pent up in its cavity. They are
generally accompanied by hypertrophy, but
sometimes by atrophy of the uterine walls.

* Some of these morphological varieties have
been described in a preceding page; and such, to-
gether with many of the hypertrophies already
noticed, have been repeatedly submitted to me
during life as examples of ulcers of the uterine neck.



697

Hydrometra results usually from a combina-
tion of chronic uterine catarrh with oblitera-
tion, absolute or relative, of the lower uterine
orifices. Such obliteration, for example, may
be caused by chronic disease of the cervix, by
the presence of a submucous fibroid or a cer-
vical polypus obstructing the cervical canal,
or by the pressure of an enlarged neighbour-
ing viscus, as the ovary *, or of a chronic ab-
scess. If, with these or similar conditions,
uterine catarrh co-exists, the secretion from
the mucous membrane collects in, and gradu-
ally distends, the cavity ; the walls of the
uterus becoming at the same time hypertro-
phied, or sometimes atrophied.f The fluid
which accumulates in such cases may be thin
and watery, but it is more often puriform, and
in some instances, as in Dr. Hooper's ex-
ample, which resulted from the opening of an
abscess into the uterine cavity, it consists of
pure pus. To these cases, the term pyo-mctra
would be perhaps more appropriate. Collec-
tions of these kinds amount usually to several
ounces, or may reach one or two pounds. The
uterus enlarges to the size of a fist, and, in
rare examples, to the bulk of the gravid uterus
at term.J Pure hydrometra, i. e. without
haematometra, can only occur after the cli-
macteric period, or in combination with ame-
norrhoea.

When the inner and outer os uteri are both
closed, and the cervical and uterine cavities
are at the same time distended, the organ re-
sembles an hourglass in form. This consti-
tutes the uterus bicameratus vetularum of
Mayer.

Hydrometra is to be distinguished from
hydrorrhoea uteri, in which there is no ob-
struction, but a continual escape of a thin,
watery fluid, often to a large amount. This
condition, which may occur both in the unim-
pregnated and gravid uterus, is apparently
dependent upon excessive activity of the fol-
licular structure of the cervix, and may be
viewed as a coryza of that part.

Hcematometra consists in a collection of
blood, usually menstrual, in the uterine ca-
vity. It is commonly associated with atresia
of the vagina at some point, generally at the
orifice, as when the hymen is imperforate, or
when the orifice has become closed by inflam-
mation of the vulva in early infancy. Under
these circumstances, when the menstrual age
arrives, the fluid, for which there is no outlet,
collects in, and distends, the cavity of the
uterus, whose walls at the same time become
hypertrophied, as in pregnancy ; or occasion-
ally attenuated, as in the case of hydrometra
just stated. The fluid, which is generally
dark-coloured, and of the consistence of trea.
cle, may, if not artificially evacuated, escape
spontaneously in various ways, viz. into the
abdominal cavity, by travelling along the ovi-
ducts, or through lacerated or ulcerated open-

* Scanzoni, loc. cit. p. 165.
f Hooper, Morbid Anat. of Uterus, pi. III.
j Case. Dr. A. T. Thomson, Med. Chir. Trans,
vol. xiii.



698



UTERUS AND ITS APPENDAGES.



ings in the uterine walls ; or, if previous ad-
hesions are formed, the fluid may escape by
the vagina or rectum. Haematometra may
occur also in certain malformations of the
uterus, as already described (p. 680.).

P/iysometra. Pneumatosis s. tympanites uteri.
This affection, known to Hippocrates* and
Aretaeusf, consists in a collection of air in
the cavity of the uterus, which makes its
escape from time to time by the vagina, with
or without explosion. The air may be dry, or
accompanied by more or less fluid (physometra
humida). In ordinary cases it is inodorous,
but occasionally it possesses a most offensive
odour. In these latter cases (physometra
putrida), the gas appears to be generated by
decomposition of some substance within the
uterus, as a putrid foetus, the remains of a pla-
centa left in utero, and the like, while the
generation of an inodorous gas, on the other
hand, without the presence of any such sub-
stances, within the uterus, can only be com-
pared with those sudden developments of air
in the stomach and intestines which often
take place in hysterical women.

Hydatids. A case of acephalocysts within
the ovary has been given at p. 584., but this
is so rare an affection of the uterus that no
anatomical collection, 1 believe, in this city
contains an example of it. Rokitansky's
often-quoted casef appears to be the only
certain instance of acephalocysts in the ute-
rine cavity which pathologists in the present
day are able to adduce.

In the " Lancet" of 1840, vol. i. p. 691., a
case is reported as one of uterine hydatids,
the nature of which is not very clear. That
they were not acephalocysts (echinococcus
vesicles) may be inferred from the description.
This case, which is quoted here as an example
of the more doubtful instances of hydatids,
was probably one of interstitial pregnancy (see
p. 621.) combined with the vesicular degene-
ration of the chorion described in the next
paragraph.

Those vesicular masses and groups or strings
of watery vesicles, falsely termed hydatids,
which are so frequently expelled from the
uterus accompanied or preceded by abundant
serous discharges, combined with rapid dis-
tension of the abdomen and some symptoms
of pregnancy, consist invariably of moniliform
enlargements of the villi of an imperfectly de-
veloped chorion or placenta.

It is almost needless to observe that the
presence of a true chorion structure, which
these substances invariably exhibit, even in
their most degenerated and abnormal forms $,
constitutes unquestionable evidence of a prior
act of impregnation. Connected with these,
when the degeneration is not much advanced,
may be sometimes found an embryo per-

* De Morbis Mulierum.
t De Causis et Signis Morb. Diuturn.
j Loc. cit. vol. ii. p. 291.

For descriptions and illustrations of these struc-
tures see Wedl, Pathological Histology (Syd. Soc.),

P. A/.



fectly or incompletely developed*, but in
higher grades of this abnormal state the em-
bryo invariably perishes or is unformed.

Narrowing and obliteration of the uterine ca-
vity. Atresia. The defects which come under
this head may be either congenital or ac-
quired. They may consist in a simple nar-
rowing, or stricture of the cavities of the
uterus, or of the apertures leading to them, or
in a complete obliteration of some or all of
these. Probably most of the cases of atresia
which do not originate in the malformations
already described, have resulted from the or-
ganisation of the products of inflammation
affecting these parts.

Obliteration of the external os uteri, either
partial or complete, is the most common of
these conditions. In minor degrees, where
the form of the parts is not lost in adhesions
with adjacent structures, the os is found closed
by narrow membranous threads or bands. If
the closure is not complete, pregnancy may
ensue, but labour is obstructed, and the original
seat of the os is then with difficulty traced, or
it cannot be found.

The cervical canal may be e.ntirely oblite-
rated by the formation of fibrous tissue, in
which smooth muscular fibres have been some-
times found.

Obliteration, or narrowing of the inner ute-
rine orifice, may occur in the progress of senile
atrophy, or as a result of the same processes
that cause obliterations lower down. All the
foregoing atresia? may result in the collections
of fluids within the uterine cavity recently de-
scribed.

Lastly, the cavity of the uterine body may be
so completely closed that no trace of it can
be found. Such an example is delineated in
PI. 13. of Boivin's and Duges' Atlas, which
contains also the figure of another uterus,
the original seat of whose cavity is indicated
only by a narrow triangular band of white
tissue nearly as hard as cartilage.

Pathologic conditions which may involve se-
veral of the uterine tissues.

Cancer. The two main disorganising pro-
cesses by which the structure of the uterus is
metamorphosed or disintegrated and ultimately
more or less destroyed, are those under which
cancer and fibroid are respectively developed
in its tissues. Of these, regarded as destruc-
tive agents, cancer ranks second in point of
frequency, but first in potency.

Cancer occurs in the uterus as in the ovaries,
under the three principal varieties of encepha-
loid, scirrhous, and colloid. But while in the
latter organ colloid as a primary disease is
certainly more common than either of the
other two ; in the uterus, on the other hand,
both scirrhous and colloid are rare, while ence-
phaloid constitutes the chief form under which
cancer is found.

The development of cancer may undoubt-
edly commence in any portion of the uterus,
but the number of instances in which it occurs,

* Granville, Graphic Illustrations of Abortion
pi. iv. and v.



UTERUS (ABNORMAL ANATOMY).



first, in the cervix, and especially in the va-
ginal portion, is so preponderating, that this
may be regarded as mainly the seat of origin
of uterine cancer.

The comparative rarity of opportunities for
examining uterine cancer in the incipient stage,
has limited to a certain extent our knowledge
of this part of the subject.

The cervix in the incipient stage, smooth,
tense and hard, or exhibiting upon its surface
here and there knotty projections, is found
upon section to have its tissues infiltrated in
parts by the cancerous structure, which differs
in the character and relative proportions of its
elements, according to the form which the
cancer assumes. In the medullary variety a
white cream-like or lardaceous semi-fluid mat-
ter, composed of the usual cancer constituents,
is found interspersed among the meshes of a
loose reticulum, in the softer portions of which
few if any of the normal uterine fibres can be
traced. The larger preponderance of the en-
cephaloid matter, compared with the fibrous
stroma, occasions that semi-elastic feel which
the part early acquires, and at the same time
constitutes the main difference between en-
cephaloid and scirrhous cancer.

In the scirrhous or fibrous variety the
greater hardness of the structures is depend-
ent upon the presence of a large proportion of
a coarser fibrous stroma, composed of dense
white fibres, the minute interspaces of which
are occupied by a greyish or reddish softer and
often pulpy substance, which may be obtained
by scraping, or may be squeezed from the part.
In the harder forms of scirrhous but little fluid
is so obtainable ; but in some specimens here
and there, softer portions are found from
which a fluid cream-like matter exudes, dif-
fering in no respect from the pulp of ence-
phaloid cancer. These and the softer portions
obtained by scraping are composed of cancer
cells with molecules, granules, and disinte-
grated fibrous tissue.

The irregular nodulated projections oc-