■I 
 
 J,. ., 
 
PATHOLOGICAL ANATOMY 
 
 OF THE 
 
 FEMALE SEXUAL ORGAIS. 
 
 BY 
 
 JULIUS M. KLOB, M. D., 
 
 Professor at the University of Vienna. 
 
 TRANSLATED FROM THE GERMAN 
 
 Bt JOSEPH KAM MERER, M.D., 
 
 Physician to the German Hospital and Dispensary, New York, and 
 
 BENJAlVim F. DAWSON, M. D., 
 
 Assistant to the Chair of Obstetrics in the College of Physicians and Surgeons, New Yor 
 
 NEW YORK: 
 
 MOOEHEAD, SIMPSON & BOND, PUBLISHERS. 
 
 1868. 
 

 Euterecl according to Act of Congres?, in the year 1868, by Moorhead, Simpson & Bond, 
 
 in the Clerk's Office of the District Court of the United States, for 
 
 the Southern District of New York. 
 
 Agatiiynian Pkkss. 
 
YOL I.-AFFECTIONS OF THE UTERUS. 
 
PREFACE. 
 
 In presenting to the medical profession a translation of 
 Klob's eminent work, the translators trust that they need offer 
 no apology for having increased the number of works on this 
 subject already in existence. The Gynecologist, previous to 
 this publication, was compelled to search for information re- 
 garding the pathological anatomy of this specialty among the 
 general treatises on this subject, and the clinical works on the 
 diseases of females, as well as articles published at various 
 times in periodicals. The scientific work on the pathology 
 of the diseases of the genital organs of women which is 
 now presented to the reader, exhausts, as far as possible, the 
 anatomical researches made up to the present time in this de- 
 partment of medicine. It embraces the latest views of the 
 German school, together with many original ones of the 
 author. 
 
 Only those who are acquainted with the original of this work, 
 can appreciate the difficulties with which the translators have 
 had to contend. The peculiarities of style of some German 
 authors, the novelty of their views, and the number of new 
 
VI PKEFACE. 
 
 technical terms for whicli equivalents must be found, rendere 
 the task of translation an exceedingly arduous one. Tl 
 translators have sought chiefly to give the exact meaning < 
 the author, therefore scientific terms, perhaps not so familij 
 to the general reader, have been retained whenever intelj 
 gible. 
 
 Lastly, the translators are fully av^are that the present vo 
 ume cannot be classed with light literature, it being a woi 
 more for study than for casual reading. 
 
 New Yoek, December, 1867. 
 
INTRODUCTION. 
 
 I The actions of morbid, as well as healthy life, are mani- 
 fested in three ways : 
 ' 1. As plastic creative action — Formation. 
 
 2. As an action which ensures the normal maintenance of 
 the parts — Nutrition. 
 
 3. As that action which must be supposed to exist, even in 
 the minutest parts of tissues, and also in elementary organiza- 
 tions, and by means of which they are enabled to fulfil their 
 physiological ends in the system, and are rendered service- 
 able — Function. 
 
 To pathological anatomy belongs the study of those 
 material alterations which, difiering from normal ones, occur 
 in the tissues and their elementary component parts. That 
 any alteration in the process of formation or nutrition, must 
 I necessarily produce alterations capable of being anatomically 
 I demonstrated, is self-evident. But, according to our present 
 I views, in regard to the functional actions of elementary organi- 
 zations, normal functions are so dependent upon the integrity 
 I of the parts, that they can only be performed when the 
 
viu introductio:n-. 
 
 elementary parts are normally formed and nom'ished. Any 
 alteration in the function of the elementary component parts 
 of a tissue, always presupposes some change in its nutrition 
 or formation, and therefore we consider the alteration of a 
 function in a manner which we term disease, as secondary ; 
 or, at least we presume, that where some exciting cause 
 produces an apparently immediate alteration of function, this 
 alteration cannot generally take place otherwise than by a 
 simultaneous one in nutrition or formation, or both. 
 
 Pathological anatomy therefore investigates those apparent 
 material changes which are produced by the formative and 
 nutritive actions of morbid life, and we shall exclude from 
 our task only those material alterations which consist rather 
 of chemical metamor^Dhoses and are not capable of anatomical 
 demonstration ; such belong to investigations of pathological 
 chemistry. Fauctional alterations cannot be considered ob- 
 jects of investigation for pathological anatomy. 
 
 Consequently, pathological anatomy forms two great divi- 
 sions, the one having for its object, in general and special, 
 the investigation of the anomalies of formation, the other I 
 
 the AX03IALIES OF NUTRITION. 
 
 The results of physiological formation are : 
 
 1. The normal foetal disposition of an organ and its devel- 
 opment in normal form and position in proportion to the 
 neighboring organs and the entire system. This also in- 
 cludes development in length, breadth and thickness, as well' 
 as the normal proportion of cavities. 
 
 2. The normal extra-uterine development of an organ and' 
 
 its tissues, and its growth, so far as t]iis consists in the 
 
 i 
 
INTRODUCTION. IX 
 
 development of new elements either in a gradual, progressive, 
 or periodical manner, as peculiar to some tissues. 
 
 3. The restitution of elementary component parts, destroy- 
 ed by the consumption of tissue, especially in the so-called 
 transitory tissues with integral restitution, the group of which 
 is being constantly enlarged. j 
 
 4. Here we may include those normal formative actions 
 which are observed in connection with the functions of certain 
 organs, and the so-called physiological processes of involu- 
 tion may likewise be considered as the results of physiolo- 
 gical formative''action. 
 
 The result of physiological nutrition is the maintenance 
 of the organs and tissues, especially in this sense, that the 
 constituent parts of the ultimate active elements, after being 
 metamorphosed in the course of the exchange of material, be 
 returned to the tissues, by which they must be received in a 
 normal manner and transformed into parts of, or assimilated 
 with the same. 
 
 Pathological anatomy, as far as possible, distinguishes be- 
 tween the results of alterations of these actions, and treats of 
 them separately as deeaxqements of foemation, and deeange- 
 
 IVIENTS OF NUTEITION. 
 
 The derangements of formation manifest themselves either 
 in quantity or quality. Formation altered in quantity may 
 be either an excess or deficiency of development. The 
 anomalies of this class are partly congenital and partly 
 acquired. Under influences mostly unknown foetal develop- 
 ment may become excessive or deficient, or the very germ of 
 an organ or tissue may be wanting. In the same manner, 
 
X IXTRODUCTIOX. 
 
 derangements of formative irritation or irritability, occurring 
 in extra-nterine life, may similarly result in excessive or 
 deficient development. 
 
 Any alteration in the quality of formation affects both the 
 external and internal conditions of organs and tissues. 
 Among external conditions we include the form or shape 
 and position of an or2:an. and in hollow organs the alterations 
 in their cavities, especially as productive of changes in form. 
 These anomahes, like those of quantity, are either congenital 
 cr acquh-ed. 
 
 As regards the internal or textui'al conditions of the organs, 
 a change in the quality of the fonnative action, transforms 
 the normal tissue into one favorable for the development of 
 the various so-called adventitious growths or neoplasms, 
 which change generally coincides with a quantitive alteration 
 in formation. 
 
 The result of such alterations in the quahty of formation, is 
 a proliferation of elements which frequently, in some way or 
 other, resemble the tissues from which they arise. The 
 more these new formations resemble in their development 
 the parts from'which they spring, so much the less has form- 
 ative action been altered in quality. But the more their devel- 
 opment differs from that of the parent tissue, so much the 
 more different, various, and exti'aordinary has been the course 
 of formative action. It then exceeds in quantity and quaUty, 
 as in the development of bone, teeth, and cerebral substance 
 in the ovaries. 
 
 Derangements of nutrition may be divided in the same 
 manner into those of quantity and quahty. But, by nutrition 
 
INTRODUCTION. XI 
 
 we must not simply understand the ultimate process in the 
 elements themselves, namely, the reception of material into 
 the tissue, and its consumption and transformation, for these 
 are the privileges of all organized bodies, but we must also 
 consider the adduction of nutrient material, and the effects 
 or consequences of increased or diminished introduction of 
 material so far as manifested by local phenomena ; and this 
 we can do without hesitation, for, as Virchow says, life does 
 not merely exist in the blood or nerves, but in all the elemen- 
 tary parts. 
 
 Hypertrophy of tissue is considered the result of in- 
 creased nutrition: Atrophy as a consequence of dimin- 
 ished nutrition. The menstrual changes in the uterus, for 
 instance, represent a genuine although physiological hyper- 
 trophy. With the study of hypertrophy and atrophy, 
 hypersemia, anaemia, and the anatomical phenomena of inflam- 
 mation are closely connected. Inflammation is universally 
 considered as a derangement of nutrition, and we do not 
 hesitate to treat it as such, although we cannot deny the 
 influence of inflammatory stimulus upon formative action, 
 and consequently its characteristic effects upon formation and 
 nutrition. In inflammation consumption and proliferation, 
 destruction and creation, are so closely united, that they 
 cannot be separated without destroying the meaning of this 
 term which is so diflicult to define. In fact there is no 
 formation without nutrition, and probably no nutrition with- 
 out formation, although the latter condition depends chiefly 
 on the peculiarity of the tissue. This we can positively 
 assert of all the tissues subject to integral restitution, and 
 
Xll INTRODUCTION. 
 
 here the question arises, whether or not in all tissues, does 
 the exchange of material consist more or less of integral reno- 
 vation ; which assumption is not wholly imaginary. For why 
 should the blood corpuscle or epithelial cell be so inferior to the 
 parenclivmatous cell, that the latter should maintain its integ- 
 rity bv a supply of materia, and'the former be condemned to 
 an ephemeral existence ? and in what respect is the hepatic 
 cell superior to the epithehal cell in its organization, that we 
 should be authorized to make such an assertion? In the 
 liver, for instance, it is true we cannot directly demonstrate 
 the elements of new-formation which are so easily found in 
 the rete Malpighi. But where are we not at a loss for direct 
 proofs ? When have we demonstrated the brood-cell of the 
 cyhndrical epithehum of the intestines with a structure so com- 
 phcated that lately it has been doubted whether it belonged 
 to the simple cell-formation ? Yet, no one doubts of its 
 integral restitution. And although our means of investiga- 
 tion are not sufficient to allow us to speak of the different 
 organization of cells and to dissect them, nevertheless, 
 researches latterly made, have evidently rendered doubtful the 
 theory that the cell is the ultimate element of organization ; 
 and from the moment we drop it, the distinction between tis-\ 
 sues with and without integral restitution, is at once set 
 asid'j. 
 
 We cannot here continue the discussion of these highly 
 important questions, although they are of the utmost import- 
 ance for the formation of a new classification in physiology 
 as well as in pathology. 
 
 It will probaljly depend upon the quahty of nutrition itself 
 
INTEODUCTION. Xlll 
 
 whether its chemical process leads to normal results. When 
 it is altered in quality, dependent either on changes in the 
 nutritive material or on the abnormal energy of the nutritive 
 irritability oi the elementary parts, the result will be differ- 
 ent, inasmuch as certain products of metamorphosis or 
 altered action become visible in the elements of tissue. These 
 processes are known as degenerative atrophy^ (Virchow), and 
 retrograde metamorphoses (amyloid and cheesy degenera- 
 tion, etc.) 
 
 The classification to which I have adhered would now 
 seem to be sufficiently well established. A further discussion 
 of the matter would be out of place, and I must refer to the 
 works on this subject written by Yirchow and others, which 
 have long since been laid before the medical profession. 
 
INDEX. 
 
 Paoe 
 Peeface V 
 
 Inteoduotion vii 
 
 ANOMALIES OF THE UTERUS. 
 
 ANOMALIES OF FOEMATION i 
 
 I. ANOMALIES OF FGETAL DEVELOPIVIENT 2 
 
 Histological Preliminaries 2 
 
 A. Anomalies of Peimaet Development by Foemation Alteeed 
 
 IN Quantity 7 
 
 I. Excess of Development 7 
 
 11. Aeeests of Development 8 
 
 1. Absence of the Uterus 
 
 2. Eudimentaiy Uterus 12 
 
 3. One-Horned Uterus 15 
 
 4. Double Uterus 20 
 
 5. Two-horned Uterus 22 
 
 6. Non-horned Separated Uterus 29 
 
 7. Congenital Atresia of the Uterine Cavity 32 
 
 B. Anomalies of Peimaey Development by Foemation Alteeed 
 
 IN Quality 35 
 
 I. Congenital Anomalies of Foem 36 
 
 1. Obliquity of the Uterus 36 
 
 2. Anvil-Shaped Uterus 38 
 
 n. Congenital Anomalies of Situation 38 
 
 Extra-median Site of the Uterus 38 
 
XVI INDEX. 
 
 Page 
 II. ANOMALIES OF UTEKINE DEVELOPMENT DURING 
 
 CHILDHOOD 40 
 
 III. ANOMALIES OF FORMATION IN THE LATTER PART 
 
 OF EXTRA-UTERINE LIFE 44 
 
 A. Anomalies of Formation Altered in Quantity 44 
 
 B. Anomalies of Formation Altered in Quality 45 
 
 I. Anomalies of Site of the Uterus 45 
 
 1. Flexions 54 
 
 a. Anteflexion 56 
 
 b. Retroflexion 63 
 
 c. Lateroflexion 70 
 
 2. Versions 71 
 
 a. Anteversion 72 
 
 b. Retroversion 75 
 
 c. Lateroversion 80 
 
 3. Elevation 81 
 
 4. Prolapse 83 
 
 5. Inversion , 99 
 
 6. Hysterocele 106 
 
 II. Alterations of the Form of the Uterus 109 
 
 1. Acquired Stricture and Atresia 110 
 
 2. Hydi-ometra 116 
 
 3. Physometra 121 
 
 4. Hsematometra 123 
 
 III. Adventitious Growths 127 
 
 New Formations of Connective Tissue 127 
 
 A. Difiuse Proliferation of Connective Tissue in the Uterus... 127 
 
 B. Difl'use Proliferation of Connective Tissue in the Vaginal 
 Portion 131 
 
 C. Diffuse Proliferation of Connective Tissue in ^the Cervi- 
 cal Portion 136 
 
 B. Circumscribed Proliferation of the Mucous Membrane.... 138 
 
 JS'. Papillary Tumours of the Uterus 145 
 
 F. Fibrous Polypus of the Uterus 148 
 
 O. Round Fibroid Tumours of the Uterus 156 
 
 Cartilaginous and Osseous Tumours 177 
 
 Cystoid Tumours 178 
 
 Vascular Tumours 183 
 
 Cancroid Tumours 186 
 
 Carcinoma 191 
 
 Tuberculosis 206 
 
 Appendix: Entozoa and Entophyta 210 
 
INDEX. XVll 
 
 Paqk 
 
 ANOMALIES OF NUTIilTION 212 
 
 A. Quantitative Alter ations of Nutrition 212 
 
 1. Hyperaemia 213 
 
 2. Haemorrhage 216 
 
 3. Hypertrophj'^ 220 
 
 4. Atrophy 222 
 
 5. Parenchymatous Metritis 226 
 
 6. Endometritis 229 
 
 7. Acute Catarrh 230 
 
 8. Chronic Catarrh 233 
 
 5). Croupy Inflammation 236 
 
 10. Ulcerations 238 
 
 11. Wounds and Kuptures 244 
 
 B. Qualitative Alterations of Nutrition 254 
 
 1. Fatty Degeneration 254 
 
 2. Amyloid Degeneration 255 
 
 PUERPEEAL AFFECTIONS OF THE 
 
 UTERUS 267 
 
 a. Endometritis 265 
 
 1). Metritis 270 
 
 c. Thrombosis of Lymphatics and Lymphangitis 273 
 
 d. Venous Thrombosis and Metrophlebitis 279 
 
 e. Peritonitis 284 
 
 /. Paralysis of the Uterus 290 
 
 g. Introduction of Air into the Uterine Veins 293 
 
 h. Haemorrhages of Lying-in Women 294 
 
E E R A T A . 
 
 Page 5, second paragraph, read : " By the end of the," instead of 
 " During the eighth and." 
 " 10, line 7, omit "that" after "happens." 
 
 " 35, 5th hne from bottom, read, " Quality," instead of " Quantity." 
 ' ' 36, 2nd " " omit ' ' that " before ' ' a uterus. " 
 
 " 40, IL instead of III. before " AiSfOMALIES OF " etc. 
 " 44, III. instead of lY. " 
 
 " 108, 6th line from bottom, read, "non-gravid," instead of "gravid." 
 " 112, second paragraph, 4th line, read, " obstiTiction," instead of "oc- 
 clusion." 
 " " second paragraph, 10th line, read, " obstructions," instead of " oc- 
 clusions. " 
 " 121, New heading, read, " ttmpaxetes," instead of "ttmpa2«tis," 
 " 125, thu'd paragraph, read, " Krimer," instead of "Kriiner." 
 " 161, 3d line from bottom, read, "lamina," instead of " laminae." 
 " 185, second paragraph, 5th line, read, " ecta5'?a," instead of "■ ectasioB." 
 " 217, 15th line from top, read, "on the venous," instead of "in the 
 
 venous." 
 *' 230, first paragraph, insert loe^ after " that." 
 
ANOMALIES OF THE UTERUS. 
 
 As HAS already been stated in the introduction, those anom- 
 ahes of the uterus which are subjects of pathological in- 
 vestigation are di\dded into anomahes of formation and anom- 
 ahes 01 nutrition. 
 
 ANOMALIES OF FOEMATIOK 
 
 FoRikiATiVE action in the generative apparatus may be con- 
 sidered under three periodic divisions. The first result of 
 this action is the primary development or disposition of 
 the genital organs ; it may, therefore, be termed intra-uter- 
 ine or foetal formation or development. In extra-uterine 
 life, formative action causes the further development of 
 these organs in conformity with the whole organism. It has 
 long since been proved that only few and inconsiderable 
 changes occur in the genital apparatus from the time of birth 
 until puberty, and that the results of the second period of de- 
 velopment are of much the lesser importance, whilst, at the 
 time of maturity, a powerful energy of the formative action is 
 again manifested. We, therefore, denominate the effects 
 of this second formative action as the process of the develop- 
 ment of puberty. 
 
 When the period of puberty has been reached, this action, 
 with the exception of continued ovulation and the changes ac- 
 
Z ANOMALIES OF FOETAL DISPOSITION^. 
 
 companying pregnancy, is merely destined to replace the 
 waste of organic material, and tlins to normally maintain the 
 existence of the generative organs. After the climacteric 
 period, however, the physiological involution of these parts 
 commences in a regular manner. 
 
 I. ANOMALIES OF FCETAL DISPOSITION AND 
 DEVELOPMENT. 
 
 HISTOLOGICAL PRELIMINARIES. 
 
 Literature on embryology of the genitals : C. F. W o 1 f f, De formatione 
 intestinorum. Novi Comment. Acad. Scient. J. Petrop. XII. 1768 and 
 XIII. 1 7G9. — J. F. Meckel, Beitrage zur vergleichenden Anatomic 
 1808. Bd. I. Hft. L By the same author, Handb, der menschl. Anat. 
 Halle und Berlin 1815—1820. IV. Bd. — S e n n, Mem. sur I'etat des org. 
 genitaux de la femme avant la puberte etc. Journ. univ. des scienc. 
 nied. Tom. 37. 1825. — J oh. Mull er. Bildungsgeschichte der Genita- 
 lien. Diisseldorf, 1830. — Rat like, Abhandl. zur Bilduugs. und Ent- 
 wicklungsgesch. des Menschen und der Thiere. Leipzig 1832. Bd. I. 
 
 — Krause, Handb. der menschl. Anatomic. Hannover 1841 — 1843. 
 
 — Bi s c h o f f, Entvvickelungsgeschichte der Saugeth. und des Menschen- 
 Leipz. 1842. Arnold, Handb. der Anatomic des Menschen II. Abth. 
 1 . 1 847. — Thiersch, Bildungsfehler der Hern und Geschleclitswerk- 
 zeuge eines Mannes. Mimchner ill. med. Zeitung 1852. Bd. I Heft 1- 
 L e u c k a r t, das Weber'sche Organ und seine Metamorphosen. Munch, 
 ner ill. med. Zeitung, 1 852. 1.2. — K u s s m a u 1, Von dem Mangel, der 
 Verkum merung und Verdopplung der Gebilrmutter etc. Wiirzburg 1 859. 
 
 — A 1 b e r s, die weiblichc Cloakbildung. Monatschrift f. Geburtsk. und 
 Frauenkrankh. Berlin 1 8G0. Bd. XVI. Heft 4. — K 6 1 1 i k e r , Entwicke- 
 lungsgeschichte des Menschen und der hoheren Thiere. Leipzig 1861. 
 Besides these, the works on embryology and the special chapters on the 
 same, in the hand books on anatomy and physiology. 
 
 The primary elements of the nterus consist of a pair of fila- 
 mentous organs situated on either side of the inferior portion 
 of the vertebral column, and inwardly and anteriorly to the 
 Wolffian ducts, with which they first descend, and passing 
 
ATs^O]\[ALIES OF FCETAL DISPOSITIOIN". 6 
 
 beliind which, at a later period, descend with them into the 
 sinics iirogenitaUs. Each of these primordial elements, known 
 as Miiller's filaments, therefore, makes half a spiral tm-n aroimd 
 their corresponding Wolffian ducts. 
 
 ^liiller's filaments, in their rudimentary form, are recogniz- 
 able as solid cords, which, at a later period, become perforated 
 (Rathke confirmed by Bischoif, Thiersch and Kolhker). Rathke 
 considered them as primary elements of the uterus and Fallo- 
 pian tubes, and supposed the vagina to be developed indepen- 
 dently of them from an inversion of the caiialis xivogenitalis^ 
 which opinion has lately been again advanced by Albers. 
 Since the investigations of Bischoff and Leuckart, however, 
 most authors assume that not only the oviducts and uterus but 
 also the vagina are developed from Miiller's filaments, and, 
 therefore, basing my views on pathological data, I do not hesi- 
 tate to share in this opinion. 
 
 The superior extremities of Miiller's filaments are slightly 
 enlarged and club-shaped. After a time the inferior ends begin 
 to approximate and coalesce at that point where Hunter's lig- 
 ament, or later, where the round ligaments come ofi*, and from 
 these united parts the uterus is developed, while the ununited 
 extremities shape themselves into the Fallopian tubes. The 
 point, therefore, at which coalescence occurs, and where 
 the round ligaments originate, affords a sure point of demarc- 
 ation between the uterus and Fallopian tubes, which, in certain 
 cases, is of great importance. 
 
 As to the period at which these different stages of develop- 
 ment occur, it must be mentioned that up to the sixth week of 
 foetal life, no trace of the generative apparatus can be found 
 (Meckel), and that there is absolutely no difference in the early 
 development of Miiller's filaments, in either male or female. 
 
 If Miiller's filaments are to be developed into female organs 
 of generation, they undergo further changes. Cavities are 
 formed in them, and they become little canals, while on the 
 other hand the Wolffian ducts become shrivelled, and are 
 
4 ANOMALIES OF FCETAL DISPOSITION. 
 
 transformed into the so called female epididymites or Eosen- 
 miOler's organs. In the development of male organs almost 
 the opposite changes take place. 
 
 In the female foetus at abont the eighth week the inferior ex- 
 tremities of Miilier's filaments have coalesced, and at the same 
 time the ovaries as well as the oviducts (the superior ends of 
 Midler's filaments) come lower down. About this period the 
 coalescent portions of JMiiller's ducts exhibit a right and left 
 cavity separated by a septimi ; this septum, however, soon be- 
 gins to disappear throughout the whole line of their union, 
 commencing from below^ upwards, so that finally the cavities 
 of the uterus and vagina become one. 
 
 At the fifth month the uterus and vagina are distinctly 
 separate ; the superior extremities of Midler's ducts, which 
 are transformed into the extremities of the Fallopian tubes, 
 expand and become slightly fimbriated, and the upper por- 
 tion of the uterus diverges into two horns or processes. That 
 portion which is to form the fondus, and unite these horns, not 
 being yet developed, the union of the horns is only ac- 
 com]3Hshed at the beginning of the sixth month, after which 
 time a fundus uteri, somewhat arch-shaped, rises above the level 
 of the orifices of the oviducts The abdominal openings of 
 the oviducts now become fimnel-shaped and the fimbrise of the 
 superior extremities become more numerous, longer and broad- 
 er, and also more distinct from the ovaries. 
 
 During the sixth and seventh months the uterus becomes 
 more cyhndriform and of greater bulk, its horns diverge at an 
 incomplete rectangle, and fi'om being drawn into its substance 
 they seem to be disappearing. This increased bulk is most 
 marked in the cervix however, its walls at this time greatly 
 exceeding those of the body of the uterus. On the in- 
 terior surface of the uterus the jpahna plicata extends al- 
 most to the fundus, and from it folds extend laterally to the 
 orifices of the oviducts. The mucous membrane also of the 
 vagina becomes covered Avith excrescences, extending in 
 
Al^OMALIES OF FCETAL DISPOSITIOI^. 5 
 
 rows, from wliicli at a later period transverse folds are de- 
 veloped. 
 
 During tlie eighth and ninth months of foetal life the fundus 
 uteri becomes more rounded, and the disproportion in the 
 thickness of the walls of the body and neck of the uterus is 
 more equalized, although at the time of birth, and even after, 
 the substance of the cervix considerably exceeds that of the 
 body of the uterus. The oviducts at this time are very tor- 
 tuous. 
 
 During the eighth and ninth months, and at the time of birth, 
 the uterus has undergone its primarj^ development, and its fur- 
 ther growth ceases whilst other changes in the system oc- 
 cur. It is only at the beginning of puberty, when the organ 
 is to perform its actual function, that it undergoes a second 
 stage of development, whilst from birth until the fourteenth year 
 but slight changes are noticeable. At the time of second den- 
 tition the palma plicata of the body of the uterus disappears, 
 with the exception of a longitudinal fold, and the bulk of body 
 and cervix becomes more equal, the organ then gradually de- 
 scends into the pelvic cavity, and the vaginal segment becomes 
 more distinctly formed. 
 
 During the development of puberty, the uterus increases 
 considerably in size. Arnold has shown that this increase con- 
 tinues even beyond the twentieth year, and of such importance 
 is this circumstance, that it should be taken into consideration 
 by those about to marry, more than it usually is. 
 
 The body of the uterus during puberty gradually becomes 
 longer, and its walls increase in thickness, especially in com- 
 parison with those of the cervix ; the last trace of the palma 
 plicata in the mucous membrane of the body now vanishes, and 
 the mucous membrane becomes thicker by the formation of 
 glandular tissue. The walls of the cervix also thicken, its deep 
 furrows and insections disappear, and it becomes smooth and 
 firm, and thus the virgin uterus becomes two or three inches 
 long, its thinnest jDortion being that around the internal orifice ; 
 
6 a:n'omalies of fcetal dispositiois-. 
 
 the walls of the body, in the middle, are four to six Hnes in 
 thickness. 
 
 The anatomical changes which take place in the uterus dur- 
 ing menstruation are well known. During the hypersemia 
 in the genital organs, which occurs at the time of menstruation, 
 the uterus enlarges considerably, its muscular substance be- 
 comes more succulent and softer, its mucous membrane thicker, 
 of a dark red color, exudes blood, and, owing to extravasations 
 within its tissue, is covered with dark spots ; the utricular 
 glands in the body and fundus elongate in proportion as the 
 mucous membrane thickens, and a section of the latter pre- 
 sents a fibrous appearance. Immediately at the commencement 
 of menstruation, the ciliated epithelium of the mucous mem- 
 brane is cast off, and a luxuriant production of epithelial cells- 
 commences, resembling the rete Malpighi, and which under- 
 goes desquamation untill the termination of menstruation, 
 when they again become ciliated epithelium ; the menstrual 
 congestion of the uterus then also suddenly diminishes. The 
 mucous membrane of the cervix undergoes few or very slight 
 changes, and both lips of the vaginal segment become equal in 
 length. We will treat of the development of the uterus during 
 pregnancy and its subsequent involution, under the subject of 
 PUERPERAL AFFECTIONS, and the chr ^es to which it is subject 
 in the climacteric years, under the head of senile changes 
 
 OF THE UTERUS. 
 
 From what we have stated, it follows that the uterus has 
 strictly only two stages of development ; the former of which 
 may be termed the intra-uterine oy foetal, the latter that of 
 puberty. Uterine development results in the formation of a. 
 comparatively complete sexual apparatus, which retains a 
 foetal cliaracter until puberty, when, as compared with the 
 extra-uterine development of other organs, it is more fully de- 
 veloped in correspondence with the importance which the 
 female sexual organs then assume. The uterus of a girl who 
 has not yet menstruated, differs but slightly from that of 
 
EXCESS OF DEVELOPMENT OF THE UTERUS. 7 
 
 a newly born infant. With the maturing of the first ovnm and 
 the commencement of those periodic phenomena which from 
 this time denote the capabihty of the female to fulfil her 
 destiny, a powerful energy of the formative action, equal in 
 importance to that of intra-uterine life, is aroused in the gen- 
 erative appai-atus. 
 
 These various physiological stages of development are 
 sometimes deranged, and they may be arrested or hindered iu 
 some way by various circumstances, or may even exceed the 
 normal measure. Their physiological variety is equalled by 
 the pathological changes which accompany each of these periods 
 of development, and in general it may be said that anomalies 
 arisinsr from arrest in development are by far the most frequent 
 and important. 
 
 A. ANOMALIES OF PRIMARY DEVELOPMENT BY 
 FORMATION ALTERED IN QUANTITY. 
 
 Anomalies due to derangement in development, consist 
 either in a transgression of the physiological limits of develop- 
 ment, or an arrest of growth within those limits. In the 
 uterus anomalies of the former kind are rare, whilst those due 
 to arrest of development are frequently met with. 
 
 1. EXCEb^ OF DEVELOPMENT. 
 
 Literature: Meckel, Handb. der Path. Anat. Leipzig 1812. Bd. 
 IL Abtli. L pag. 4. — K u s s maul in the work mentioned in the litera- 
 ture of previous chapter, pag. 42. — Forster, die Missbildungen des 
 Menschen. Jena 1861, pag. 166. 
 
 We may consider those cases, in which the uterus of the new- 
 born infant is equal in size to that of the female approaching 
 puberty, as transgressions of the usual intra-uterine develop- 
 ment, and consequently, also those cases in which the body 
 and fundus of the uterus are of excessive size and the dispro- 
 portion between them and the cervix has ceased to exist. 
 Meckel quotes the case observed by Kerkring(Observ. Anatom. 
 87. p. 169) in which menstruation made its appearance regularly 
 
8 AEKESTS OF DEVELOPMENT OF THE UTEEUS. 
 
 from the day of birth ; also that of Langlade (Mem, de Paris, 
 1708. hist.) and that of Cmnineu (E})h. u. c. dec. 1. a. III. o. 
 CXIV.) in \vliich it commenced between the eighth and twen- 
 tieth day of life. Cooke (Med. Chirur. Trasn. voL II. 1817) 
 relates a case in which the external genitals exhibited prema- 
 ture development. Kussmaul mentions one in which men- 
 struation made its appearance in a girl two years old, and 
 conception taking place in the e'ghth year, was followed by 
 the normal birth of a completely developed foetus. It is im- 
 possible to say more on such cases, and therefore I restrict 
 mysell to these few remarks. 
 
 II. ARRESTS OF DEVELOPMENT. 
 
 1. ABSENCE OR DEFECT OF THE UTERUS. 
 
 Literature: Real d us Columbus, De re anatomica Lib. XV. 
 pag. 495. Paris 1572 (described as Vulva rara) — M o r g ag n i , De sedi- 
 bus et causis morborum. Venetiis, 17GL Lib. IIL Ep. 46. art. 11 — 13. 
 (only cases of living individuals, therefore doubtful.) — G. Hill, Diss, 
 de utero deficiente Prag 1777.— Engel, Diss, de utero deficiente, Re- 
 giomontl 1 781. (both doubtful cases.) — V o i g t e 1 , path. Anatomic Bd. 
 III. pag. 452. Halle 1805. —J. F. Meckel Handb. d. path. Anatomic 
 Leipzig 1812. Bd. L pag. 658. — B a u d e 1 o c q u e , L'art des accouchem. 
 3m. edition. Tom. L pag. 168. (only in living individuals.) — D u p u y - 
 tr en , Rev. med. franc, etc. Bd. XII. — Lang e n b e c k, Neue Biblio- 
 thek fiir Chirurgie. Bd. IV. 3. — S t e i n in Bonn. Aufeland's Journ. f. 
 pract. Heikunde etc. XLVIIL Bd. Mai 1819.— Burggr ae ve, Annal. 
 d'oeulist. et de gynecologic Vol. I. Liv. 12. (description of two cases 
 universally quoted, but Avhich do not prove absence of the uterus.) — 
 Gr under, Virgo sine utero; Preuss. Vereins-Zeitung. 1848. II. 6. — 
 Ziehl, Med. Corr. Bl. bayr. Aerzte. 1849. IL pag. 780.— Kiwisch 
 klin. Vortriige etc. 2 Aufl. 1849. II. pag. 357. — Kussmaul, as pre- 
 viously quoted, pag. 44. — For s t e r , Die Missbildungen des Mcuschen, 
 Jena 1861. pag. 160.— Gintrac, Journ. de Bordeaux. Janv. 1861. 
 
 Complete absence of the uterus has been doubted by many, 
 partly because a more careful study of cases recorded as au- 
 thentic rendered the presence of rudiments of a uterus pre- 
 sumable or evident, and partly because cases of absence of the 
 uterus. whi(;h are founded siniDly on examination of livinc: 
 
ABSENCE OR DEFECT OF THE UTERUS. 9 
 
 women, do not seem sufficiently conclusive. To the latter 
 class by far the greatest number of recorded cases, belong. 
 
 ^Notwithstanding this it has been proved that the uterus 
 may be entirely absent, and in such cases both the oviducts 
 and ovaries, especially the former, may exist either in a rudi- 
 mentary condition, or may also be wanting. In the latter 
 case it is exceedingly difficult to divine the sex of new-born 
 children, the rudimentary development of the external genitals 
 affording no means of deciding. The internal appearance of 
 the pelvic cavity in such cases, is exactly similar to that of the 
 male. The peritoneum descends backwards from the neck of 
 the bladder in an ample curve enclosing the rectum in the usual 
 manner, towards the posterior walls of the pelvic cavity (Quain). 
 There is consequently a deficiency of that transverse fold which 
 covers the uterus. When the Fallopian tubes and ovaries 
 exist, they are situated in the superior margin of a deep-seated 
 broad ligament, which extending from both lateral parietes of 
 the pelvis, inwards and backwards, reaches the lowest position 
 in that region which ought to contain the peritoneum-covered 
 portion of the uterus. In other cases, the peritoneum repre- 
 senting the broad ligaments, is found in the form of two half- 
 moon shaped folds, on both sides of the bladder, in which 
 folds the upper and outer portions of the Fallopian tubes and 
 ovaries lie obliquely imbedded. 
 
 The round ligaments in such cases are never wanting, but 
 branch off' near the inner extremities of the ovaries, the 
 Fallopian tubes being also shortened. 
 
 In regard to the condition of the other organs of the genera- 
 tive apparatus the following may be said. Where the uterus 
 is absent the ovaries may be normally developed, and there are 
 cases recorded in which Graafian follicles were found in them 
 (Burggraeve), but according to this authority the menstrual 
 flow and sickness are said to be absent in such cases, whilst 
 Scanzoni speaks of extravasation of blood and formation of 
 cysts, which certainly cannot be imagined to take place with- 
 
10 ABSENCE OR 
 
 out ovulation. Although it is not probable that the ova in 
 such cases are fully matured, still it is not easy to understand, 
 why with a normal formation of the ovaries an imperfect ovula- 
 tion should not possibly occur. Either of these hypotheses, 
 however, should be considered of about equal value until the 
 presence of mature ova is demonstrated. 
 
 It frequently happens that when the uterus is absent and the 
 ovaries are present, that the latter are small and contain no 
 traces of Graafian follicles or vesicles. Frequently also, as- 
 above mentioned, the ovaries aie entirely absent. 
 
 The Fallopian tubes are generally shorter, their inner ex- 
 tremities being about two, cr two and a half inches apart ; they 
 are either perfectly solid or partly hollow cords, the latter be- 
 ing especiall}^ the case in their exterior extremities; the ab- 
 dominal orifices of these tubes are distinctly fimbriated. In all 
 cases of complete absence of the uterus, the inner extremities- 
 of the Fallopian tubes seem to be perfectly solid for a certain 
 distance. The case of Klinkosch, in which the perfectly per- 
 meable Fallopian tubes terminated in a small vesicle situated 
 in the median line and closed in its lower portion, camiot be 
 considered as belonging to this class of anomalies, this vesicle 
 representing a rudimentary uterus. In many cases of absence 
 of the uterus the Fallopian tubes are also wanting. The vagina 
 is likewise often absent, or we find only its lower half, like a 
 narrow cone-shaped passage. 
 
 Although the uterus, ovaries and tubes may be absent, yet 
 the external genitals may be either perfect or defective. The 
 nymphaj may be absent, the clitoris very small, and the external 
 pudenda but slightly or not at all covered with hair, yet in ab- 
 sence of the uterus, ovaries and tubes, the contrary has been 
 observed, (Burggraeve). Whenever the external genitals are 
 perfectly developed, rudiments of a vagina also exist. In adults 
 of this kind tlie urethra is often found very much dilated from 
 its having served as a vagina '. 
 
 The breasts are frequently well developed (Morgagni and 
 
DEFECT OF THE UTEKUS. 11 
 
 others) and the pelvis may be of the usual female dimensions. 
 The general characteristics of such individuals are decidedly 
 feminine ; and in all it has been observed that sexual desire was- 
 not absent. 
 
 Complete absence of tlie uterus, especially when accompanied 
 with defective Fallopian tubes and ovaries, is rarely found 
 except in infants with an undeveloped condition of the lower 
 half of the body and incapable of existence ; cases of absence 
 of the uterus with complete development of the rest of the 
 body have been but rarely met with. 
 
 In investigating the anatomical character of such cases, two 
 circumstances must be particularly considered. First we must 
 be convinced that no rudiments of the uterus exist, which may 
 be almost inappreciable and are often found attached to the. 
 posterior walls of the bladder. Thus it is necessary for a per- 
 fect appreciation of these cases, to consider a thick layer of 
 cellular tissue and muscular fibres in the place where the uterua 
 should be, as a rudiment of the uterus, and to distinguish such 
 cases from those of total absence. Secondly, it will be neces- 
 sary to examine whether the case is not one of pseudo-her~ 
 maphroditism, which error would most likely occur where the 
 testicles have not descended from the abdominal cavity. 
 
 It has also frequently happened tliat rudiments of uterine 
 horns were mistaken for portions of oviducts or ovaries, and 
 therefore leading to the supposition that the uterus was entirelj 
 absent. The point of insertion of the round ligaments will 
 always explain the case, and muscular bodies, whether hollow 
 or not, when situated interiorly to those hgaments must be con- 
 sidered as belonging tj the uterus, and a proper attention to 
 this fact will always preserve us from error. 
 
12 EUD MENTAEY UTERUS. 
 
 2. RUDIMENTARY UTERUS (KUSSMAUL). 
 
 Literature: Mayer, Ueber Verdopplungen des Uterus u. s. w. 
 Journal v. Graefe und Walther Bd. XIIL Hft. 4. 1829.— Dupuytren, 
 Repet. d' anatomie patholog. Tom V. pag. 99. und Archives gen. de med. 
 1829. pag. 54:8.— Macf aria ne, Lancet, Aug. 18 1832.— Alb ers, 
 Rust's Magaz. Bd. XLI. H. 1. pag. 27. 1833. (exquisite case of uterus 
 bipartitas). — L u c a s , Lancet, January 21. No. 699. 1837. — R o k i t a n - 
 sky, Ueber die sogenannten Verdopplungen des Uterus. Oesterr. med. 
 Jahrbiicher Bd. XXVI. St. 1. 1 838.— M o n d i n i , Uteri humani bicom. 
 anatom. descriptio. cui animadv. nonnuU. adjectae sunt, quae in uni- 
 vers. ad uteri evolut. spectant. Nov. commentar. acad, sclent, instituti 
 Bononiens. Tom II. 1833. — N e g a, De congenit. genitalium foemineorum 
 deformitatibus, Dissert. Vratislaviae. 1838. — K rocker, Berliner med. 
 Centralzeitung, 3. Juli 1840. 27 St. — Mondini, Neue Zeitscbr. f. 
 Geburtskundeund Frauenkrankbeiten. Berlin. 1846. Bd. XX. — Kuss- 
 maul, in the work previously mentioned, pag. 62 and in the following 
 pages. 
 
 From the description of cases of absence of the nterus we 
 next come to the description of those in which the uterus is 
 indicated by the presence of muscular or fibrous structure. 
 Such I will term cases of rudimentary uterus. 
 
 Most of the imperfect observations and reports of absence of 
 the utenis undoubtedly belong to this class. At the point of 
 junction between the round hgaments and the inner extremities 
 of the Fallopian tubes, a thin membranous or fibrous septum is 
 seen descending, and either merging into the posterior walls of 
 the rectum, or tapering up from a cloaca or sinus urogenitahs 
 in the direction of a rudimentary vagina, and ending in a bhnd 
 sac. This form I would term meinhranous uterine rudiment^ 
 and classify with it the case of Lucas in which the vagina ended 
 in a bhnd sac two and half inclies from its orifice, and in place 
 of the uterus, a membranous tissue, one inch in width, extended 
 from the blind sac of the vagina to the position the uterus 
 should have occupied ; the roimd ligaments occupied the usual 
 position, and were at the exterior limits of this membranous 
 mass, with tlie inner extremities of the Fallopian tubes. 
 
KUDIMENTAKY UTERUS. 13 
 
 '• As a second form of rudiiiientaiy uterus, I consider the bulky , 
 densely fibrous and hnjperforate rudiment of Kussmaul. The 
 ntenis in this form is represented by a round, fibrous, soHd body^ 
 both sides of which elongate into two cord-hke horns. The case 
 of Khnkosch (Hill) in which a fixed cylindrical body three inches 
 long was found in place of a uterus, Fallopian tubes and ovaries, 
 belongs to this class. Kussmaul further mentions the cases of 
 Dupuytren and Macfarlane as likewise belonging to the above. 
 As a third form of rudimentary uterus w^e describe the bow- 
 shaped rudiment of Kussmaul. The uterus is represented by 
 a flattened, solid, muscular ligament, extending across the 
 pelvic cavity like a bow arched upwards, and merging on 
 both sides into the round ligaments. The neck of the uterus 
 is entirely absent, the horns and fundus being only outlined, and 
 not forming a uterine cavity. Kussmaul mentions the cases of 
 Nega and Krocker as illustrating this form. 
 
 The form next to be considered is that of an imperforate 
 body with round stalk-shaped horns resembling a continuation 
 of the round ligaments. Forster at the request of Kussmaul 
 gave a description of the specimen in the Gottingen Museum, 
 formerly described by Langenbeck as one of absence of the 
 uterus, and he considers it as belonging to the form just men- 
 tioned. 
 
 The condition of the other organs of the generative appara- 
 tus and the body in general, in cases of rudimentary uterus, is 
 similar to those in which the organ is com]3letely absent. 
 
 The last mentioned form of rudimentary uterus is closely 
 allied to that arrest of development which Mayer (of Bonn) 
 calls uterus bi/partitus^ and others uterus bifidus. 
 
 In this form neither the body or cervix have been fully devel- 
 oped, the horns only being formed as round bodies either hollow 
 throughout, or having a small cavity in them, which bodies can- 
 not be easily confounded with other parts. They consist chiefly 
 of flattened muscular fibres similar to the tissue of the uterus, 
 and are found interior to the point where the round hgaments join 
 
14 EXTDIMEIS'TAKY UTEEUS. 
 
 the Fallopian tubes. These rudimentary uterine horns are but 
 slightly connected with each other, or they are united by means 
 of a flat muscular or fibrous cord, representing the fundus uteri, 
 and from which rudiments of the body and cervix branch off 
 downwards. 
 
 The Fallopian tubes are rarely entirely absent in such cases, 
 but are most generally normally formed, though sometimes 
 they are only rudimentary. In the latter case they exist as 
 either simple slender fibrous threads or as solid cords which 
 <3nd externally in an oblong cyst, (Mundini) ; or they are tubes 
 distinctly fimbriated at their outer, and closed at their uterine 
 extremities ; sometimes also communicating with the cavity 
 of the rudimentary uterine horns. 
 
 In uterus bipartitus the ovaries are also frequently rudiment- 
 •ary but rarely absent. The external genitals in many but not 
 all cases are poorly developed and the pudendum sometimes ex- 
 hibits but little or no growth of hair. The general character 
 ol such individuals is decidedly feminine and never reminds us 
 of viragos. 
 
 It is hardly necessary to state that in such, conception can 
 never take place. Considering, however, that the ovaries are 
 frequentl}^ normally developed, it is not astonishing that ovula- 
 tion and accompanying menstrual sickness should occm*, which 
 may in cases where the tubes communicating vrith the rudi- 
 mentary uterine horns are perforated, give rise to hsematometra 
 {Forster). 
 
 In young individuals of this kind the vagina is generally 
 rudimentary, still it is often considerably dilated by mechanical 
 influences. Frequently, from the same cause, a rudimentary 
 vagina is combined wdth a spacious urethra. 
 
 The pelvis is usually well formed, its outlet sometimes re- 
 sembling that of the male (Rokitansky). 
 
ONE-IIORNED UTERUS. 15 
 
 3. ONE-HORNED OR UNICORNUTED UTERUS. 
 
 Literature: Pole, Mem. of the Lond. med. soc. Vol. 2 pag. 507. 
 1794:.— M e c k e 1 , Handb. d. patliolog. Anat. Leipzig 1812. I. pag. 
 674. (considers the uterus unicornis at the highest degree of abnormal 
 formation of the uterus, and in whicii the oviducts are not distinguishable 
 from the horns of the uterus, and refers to Pole's case.) — C haussier, 
 Bullet, de la faculte de med. a Paris, 1817. pag. 437. — C z ihak , Dissert, 
 de gravidit. extraut. acceditdescriptio memorandae cujusdam graviditatis 
 tubae. Heidelberg 1824. — Ro kit an sky (in the work quoted). — 
 Y r o 1 i k , Tabulae ad illustrandam embrj'ogenesini hominum et mam- 
 mal. 1849. Tab. 89. Fig. 8.— C h i a r i , Prager Vieiteljahrsschrift 1854. 
 II. pag. 98. — P u e c h , Compt. rend, hebdomad, d. Seanc. de I'Acad. de 
 Science. Paris. 1855. p. 643. (especially as regards the formation of 
 blood-vessels.) — S t o 1 1 z , Gaz, medic. 1856. Oct. Nr. 40 und : Note 
 sur le developpement incomplet d' une des moities de 1' uterus et sur la 
 dependence du developpement de la matrice et de 1' appareil urinaire. 
 Strasbourg 18G0. — K u s s m a u 1 and F o r s t e r in the works quoted. 
 
 The one-liorned uterus, properly speaking, represents only 
 lialf a uterus, the normal organ being developed from only a 
 single germ. Tiie development of bat one of Miiller's ducts, 
 either the right or left, will result in the above anomaly, which 
 is the development of the right or left half of the uterus, and 
 consequently an incomplete one with but one horn. The foetal 
 outline of the other side is either undeveloped, deficient or 
 rudimentary, exhibiting one of those forms described in the 
 preceding chapter, as the rudimentary uterus, affecting both 
 sides alike. In the one case where one side of the uterus shows 
 no trace of development, the corresponding tubes and ovaries 
 are also absent, in the other case the defective side has both 
 tube and ovary. It is therefore proper to make a distinction be- 
 tween a uterus unicornis without, and one with an accompany- 
 ing second rudimentary horn. 
 
 The appearance of the one-horned uterus is that of a long 
 cyhndrical or fusiform slender body, curved towards the side on 
 which the horn is situated, and its superior conical end merging 
 into an oviduct corresponding to the side to which a normal ova- 
 ry is attached in the usual manner. Such a uterus completely 
 
16 ONE-HOKNED OR 
 
 developed from one of Miiller's ducts, is somewhat narrower than 
 a normal one, and its section is tolerably round with a central 
 cavity. As regards the sides of such a uterus, the developed 
 or exterior one is concave, the undeveloped or interior one 
 convex. The broad ligament of the normal side is consider- 
 ably shorter than that of the opposite, the hgament of which 
 is situated lower down in the pelvis. 
 
 The vaginal portion of the one-horned uterus is smaller, 
 proportionately to the narrowness and diminished size of the 
 or2:an. In the cervix the palmse plicatse approach much nearer 
 to the margin (Rokitansky). The longitudinal axis of the 
 uterus is not in the median line of the pelvic cavity, but 
 deviates to the developed side, and is more curved in this direc- 
 tion than that of a normal one. 
 
 It must be remarked that in cases of apparently complete 
 absence of the other horn, a rudimentary outline of it on the 
 concave side of the uterus when the curve of the developed 
 horn is most marked, is frequently overlooked. But when the 
 second horn and its corresponding appendages are entirely 
 absent, the broad ligament of this side extends from the lowest 
 portion of the uterus to the lateral walls of the pelvis (Chiari) 
 In many cases, however, especially in those where slight indi- 
 cations exist of the apparently delicient horn, there is found in 
 the superior margin of the broad ligament of the rudimentary 
 side, which is attached to the uterus somewhat higher than in 
 those cases which Chiari mentions of complete absence of one- 
 half of the generative apparatus, a thin solid cord or almost 
 imperceptible line of fibres, terminating in a distinct rudiment- 
 ary Fallopian tube, and either disappearing in the substance o f 
 the hgament or terminating externally in an imperfect but un- 
 mistakably fimbriated extremity, hollow to a certain distance, 
 but always closed interiorly. The inner extremity of such 
 a rudiment of an oviduct, is easily recognized in those cases 
 in which a rudimentary round ligament branches off from the 
 broad ligament towards the inner inguinal ring. 
 
ONE-HORNED UTERUS. l7 
 
 We have thus far treated of the entire absence of the second 
 horn of the uterus, the various forms which it assumes in a 
 rudimentar}' condition may, according to Kussmaul, be grouped 
 as follows : 
 
 1. The second horn is only developed in outline, in the form 
 of a thin muscular or fibrous filament, or 
 
 2. It appears as a fiattened or round muscular imperforate 
 cord, varying in length, and egg-shaped just before its point 
 of junction with the round ligament. 
 
 3. The rudimentary half is hollow in the above-mentioned 
 egg-shaped part, and this cavity communicates externally with 
 the canal of the corresponding oviduct, which latter is either 
 completely or nearly developed. 
 
 Kokitansky states that the body of the one-horned uterus con- 
 tains less substance than the normal organ, and that its cervix 
 always exceeds the body in length and thickness. But we 
 must add that the cervix of a virgin uterus always exceeds the 
 body in bulk, and just as it happens in the normal uterus, so- 
 in the one-horned, pregnancy sometimes permanently removes 
 this disproportion. In those cases, however, of one-horned 
 uterus, in wliich this normal virginal condition is more marked 
 than usual, it might be presumed that the inferior portion of 
 Miiller's ducts fi-om which the cervix uteri is formed, has per- 
 haps, been normally developed on the side on which the rudi- 
 mentary horn is situated, and been united in a normal manner 
 to the other side, whilst that portion of the ducts from which 
 the body and horns should have been formed, was entirely or 
 partially undeveloped on that side. Such a uterus might be 
 said to be developed in its three-fourths, and the absence of 
 the last fourth would render it a one-horned uterus. This 
 assumption is justified by observations of cases in which the 
 upper half of a uterus was found fully developed with ac- 
 companying occlusion of the vagina, and others in which the 
 upper half consisted of nothing but a hollow vesicular rudi- 
 ment, whilst the cervix was of normal formation. 
 
18 OlS^E-HOKNED UTERUS. 
 
 Ehrman (Descript. de deux foetus monstres, Strasbui-g, 
 1852,) saw a double-horned uterus, with incomplete division of 
 the cavity b}^ a septum, considerable folding of the mucous 
 membrane and absence of the cervix in a siren-like monster. 
 The uterus communicated by a small opening with the rectum 
 (which was imperforate at its lower end). The external puden- 
 dum, vagina and bladder w^ere wanting .(Kussmaul). 
 
 The so-called fundus uteri being, strictly speaking, only 
 formed by the middle portion uniting the diverging horns, it is 
 therefore evident that the uterus unicornis has no fundus, and 
 that the w^alls of its body, tapering gradually upwards without 
 increasing in thickness, merge into the horn and tube. 
 
 Conception may take place in a uterus unicornis, and ac- 
 cording to the observations of Chaussier (in Tvhose case twins 
 ivere born) Rokitansky and Chiari, pregnancy may reach its 
 normal termination (in Chiari's case it only extended to the 
 7th month). The rudimentary horn appended to the uterus 
 nnicornis may also become pregnant, even in cases where 
 the junction wdth the normal one is solid, and therefore in 
 those cases also where its canal neither communicates with the 
 cavity of the uterus nor vagina ; consequently in such cases to 
 produce conception the semen must have penetrateci through 
 the normal horn and oviduct, to the ovary of the opposite side 
 from which the ovum entered the rudimentary horn in the 
 usual manner. The case of Czihak, cited by Kussmaul and 
 also examined hj many others, is remarkable for many reasons. 
 There was found a left uterus unicornis and a right rudiment- 
 ary horn, the uniting portion of which being solid, its cavity 
 consequently had no communication with that of the uterus. 
 In consequence of the presence of a six month foetus this rudi- 
 mentary horn had ruptured. The corresponding corpus luteum 
 was distinctly formed in the left and consequently the opposite 
 ovary. Kussmaul w^as unable to use this case w^ith regard to 
 his theory of the transmigration of the ovum, according to 
 which theory the ovum penetrates through Uhe oviduct and 
 
ON^E-HORNED UTERUS. 19 
 
 uterus into the opposite oviduct, he therefore contends tliat 
 the corpus hiteum may be absorbed and disappear (Kiwisch) 
 and that consequently in Czihak's case, the corpus hiteum con- 
 nected with the pregnancy might have been in the right ovary 
 and have disappeared without leaving any trace^ and that that 
 of the left side had no connection with the existing pregnanc3^ 
 I am however, very much inclined to advance this case 
 against Kussmaul's theory, for it seems to me to be rather 
 arbitrary, to assume that only that corpus luteum connected 
 with the pregnancy should have been absorbed, whilst another 
 menstrual corpus luteum should have been so completely de- 
 veloped. 
 
 In monopodia and cases of unilateral pelvis, the uterus uni- 
 cornis was found by Breschet, Heusinger and Vrolik, and in 
 the siren monster by Cruveilhier and Otto. But the uterus 
 unicornis is also found in well developed individuals. Some- 
 times in company with absence of the kidney and ureter of the 
 corresponding side ; in such cases the bladder is often of uni- 
 lateral development. This, together with the fact that the kid- 
 ney on the same side as the rudimentary horn of the uterus 
 may be absent, renders the cases of Pole, Heusinger and Puech, 
 exceedingly interesting. In these, from their description, there 
 was found a congenital hydro-nephrosis on the same side as 
 the undeveloped horn, w^hich circumstance leads to the conclu- 
 sion that perhaps the cause of the arrest in development should 
 be looked for in a foetal disease, which in many cases might 
 arise in the Wolffian duct, and involve the but recently devel- 
 oped Miiller's duct. Schupmann found congenital hydro-ne- 
 phrosis in a case of double uterus (Organ f. d. gesamni. Heil- 
 I kunde. Bonn. 1842. Bd. II. Hft. 1.). Vrolik in one of uterus 
 j bicornis. (Virchow, Ueber congenital Nierenwassersucht. 
 j Wurzburger Verhandlungen. Bd. Y. 1855). Thiersch thinks 
 I that the uterus unicornis as well as bipartitus and bicornis are 
 I caused by the Wolffian bodies being too far apart and remain- 
 ing so for a longer time than usual, and Eokitanksy adds 
 
20 DOUBLE UTERUS. 
 
 (Ztsclir. d. Ges. d. Ae. 1859. Nr. 33.) that absence of the kid- 
 ney of the correspondmg side, is sometimes caused by an ex- 
 cessive size of one of these bodies from obhteration of its ex- 
 cretory duct. 
 
 In lateral hermaphroditism we generally find only the uterus 
 unicornis. 
 
 4. DOUBLE UTERUS.— UTERUS DUPLEX SEPARATUS, OR 
 UTERUS DIDELPHYS (KUSSMAUL). 
 
 Literature: Palfyn, Desciipt. anat. de la disposition sui-pre- 
 nante de qiielq. part. ext. et int. de deux enfants etc. annexed to his De- 
 scr. anat. des part, de la femme, qui servent ^ la generat. etc. Leide^ 
 1708.— V. M a 1 a c a r n e , Mem. di Matemat. e di Fisica dell. soc. 
 Ital. delle scienze. T. IX. Modena, 1802. (Diliisteria, Dimetria). — J. 
 E r h a r t , Medic, chir. Zeitung. Innsbruck, 1825. II. Bd. pag. 489. — 
 Mayer in Bonn, (previously quoted). — E. L. W e d e 1, Diss, monstro. 
 hum. rar. descr. continens. Jenae, 1830. — H esselbach, Med. chir. 
 Beobachtungen und Erfahrungen. I. 2. 1833.— E s c h r i c h t, Miiller's 
 Arcliiv 1836. pag. 139. — R okitansky (previously quoted). — 1 1 a 
 (previously quoted). — G ruber, Mem. des savants etrang. Tom. VI. — 
 Kussmaul (previously quoted). 
 
 Undee the head of double uterus we find that form of arrest 
 of uterine development described, in which a uterus unicornis- 
 exists on both sides, and which are distinctly separated from 
 each other ; such cases are caused by the separate development 
 and non-coalescence of Miiller's ducts. Between these two one- 
 horned uteri the peritoneum does not intervene, but passes 
 directly from the posterior wall of the bladder to the anterior 
 wall of the rectum. These uteri are situated on both sides of 
 the bladder, are considerably curved outwards, and generally 
 incompletely developed. Thus transitory forms are produced 
 between this anomaly and uterus bipartitus, as also where the 
 horns are unequally developed, between uterus duplex and uni- 
 cornis with a second rudimentary horn. Most frequently the 
 lower half is deficiently developed and to each uterus a more \ 
 or less developed ovaiy and oviduct is appended. 
 
 The vagina is frequently entirely absent, or imperfectly de- 
 veloped, and when present it is most always double. Some- 
 
DOUBLE UTERUS. 21 
 
 times both uterine halves terminate in a cloaca (Palfyn and 
 Wedel). 
 
 Double uterus rarely occurs without some other anomaly 
 of development or formation, but is frequently found co- 
 existing with absence of the anterior abdominal wall, ectopia 
 of the bladder, absence of the symphysis and cloaca forma- 
 tion. 
 
 Erhart mentions the unusual width of the face, in his case, 
 and invites investigations of other cases in regard to this fact, 
 (see page 27). 
 
 Kussmanl, whose statements I have made use of as being the 
 most reliable in regard to this matter, mentions that up to the 
 present time, the uterus didelphys is only found in still-born 
 children, or in foetuses that have died early. 
 
 The many instances reported ©f conception having occurred 
 in cases of so-called double uteri, must be understood to imply 
 those of arrested development which will be described under 
 the head of two-hoened uterus. That malformation which, 
 according to Kussmaul, I have termed uteras didelphys, is only 
 found in short-lived children. 
 
 I would recommend the term utei'us dideljyhys^ used by Kuss- 
 maul, as being the most proper, for the reason that there is in 
 fact no duplicity apparent in such cases, but it is merely a 
 separation of the double germ which constitutes this anomaly 
 of development. 
 
 Yoigtel mentions a case of triple uterus (Thilow, Beschrei- 
 bung anat. patholog. Gegenstande. Gotha, 1804. B. 1. Th. 1. 
 pag. 14.) which was probably a case of uterus didelphys and 
 cloaca formation, combined with atresia of a rudimentary rec- 
 tum, which latter, being closed after a short upward course, 
 was mistaken for a third uterus. 
 
22 TWO-HOE>'ED OE 
 
 5. TWO-HORXED OR BICORXTTED TTZRUS. TTZRUS 
 BIC0R>1S. 
 
 Literature: May, Comjnerc. iiier. ZSTorimberg, 1733. — GraT el, 
 De snperi foetatione conjectnrae. Aigentorati, 1738. — ^E isenmann, 
 Tabul. anat. quatuor nteri-dnplicis observ. rar. sistentes. Areentorati, 
 1752. — B a g a r d . 3Iem de 1" academie des sciences. 1752. pag. 111. — 
 Y o i g t e 1 , Handb. d. path. Anatomie. Halle, 1805. IIL Bd. pag. 453 
 (older literature). — ^M e c k e 1 , (preTiously quoted) L Bd. pag. 673. — 
 C a r u s , Zur Lehre von Scliwangerselift und Gebtirt. HL. Abthlg. 
 1821.— Am m o n, angeb. cMr. Kiankh. T. 19. F. 13.— G e i s s , 
 Rusts Magazin. X. Bd. pag. 569. 1825. — C a s s a n , Recherch. anat. 
 et physiol. sur les cas d' uterus double et de supertetation. Paris, 1826. 
 These.— S alert, E. t. Siebold's Jonm. etc. DL Bd. 3 pag. 736. — 
 M a y e r in Bonn, (previously quoted). — ^R okitansky (preTiously 
 quoted). — F r. Schroder, De uteri ac raginae sic dictis duplicita- 
 tibus. Diss. Berlin, 1 841 . — T h i 1 o , Uteri bipartiti descript. Diss, Halae 
 1844.— H o h 1 , Deutsche Klinik, 1853. Y. Bd. 1.— K i w i s c h , klin. 
 Yortr. Prag, 1854. L Bd. — K r i eg e r , Monatschr. f. Gebk. u. 
 Frauenkkh. Beriin, 1858. XTT . Bd. — ^K ussmaul, (in the work pre- 
 Tiously quoted, which contains the complete literature on the subject). — 
 Rokitansky, Ueber Atresie des Uterus und der Yagina bei Dupli- 
 citat ders., Zeitschr. d. Ges. d. Ae. Wien. 1859. 33. und 1860. 31.— 
 S t o 1 1 z , Gaz. med. 1856. Oct. 40, and Xote sur le dcTeloppement in 
 complet d" une des moities de I'uterus et sur la dependence du dereloppe- 
 ment de la matrice et de 1" appareil urinaire. Strasbourg, 18'i<i». — ^H yr 1 1 , 
 Handb. d. tojwgr. Anat. 4. Aufl. 18C0 11. Bi. pag. 206.— F o r s t e r , 
 (in work previously quoted). 
 
 Bt the name of litems bicomis is meant a nteiTis the horns 
 of which, when viewed extemallv. are seen to diverge. Such 
 cases occur in consequence of the incomplete coalescence of 
 Miiller's ducts, the incompleteness of the union commencing at 
 the elevation of the internal orifice, or even a httle higher. The 
 coalescence is rarely so imperfect as to cause the divergence 
 of the honis to commence at the cervix. In many cases there 
 is an internal septimi commencing at the point where the ex- 
 ternal union of both uterine halves is perceptible, which septum 
 divides the cavity of the uterus and causes the internal division 
 to extend lower dovm than is apparent from the exterior. Thus- 
 Kussmaul is right in making a distinction between two forms 
 of uterus bicomis, according as the separation into two halves 
 by a septum, descending from the point of union of the two 
 
BicoPvNUTED utp:iuts. 23 
 
 liorns, is perfect or not. If the division of the cavity is com- 
 plete Knssmaul terms it uterus bicornis duplex, but if incom- 
 plete uterus bicornis infra-simplex or semi-duplex. 
 
 1. — The lUei'us bicornis dxqulcx^ or as it mio^ht be better 
 termed, the uterus bicornis bicameratus or S''ptus^ has been 
 described by many as uterus duplex. It differs however, 
 fi'om that arrest of development which we recognize as 
 uterus duplex, and which according to Kussmaul, to avoid 
 misunderstanding, we will term uterus didelphys, in this parti- 
 cular, that both uterine halves always appear externally to be 
 more or less united in their lower segments, whilst in the 
 uterus didelphys they are completely separated, and often from 
 one to two inches apart; in the uterus bicornis septus both 
 halves more fully developed and rarely rudimentary, whilst as 
 above mentioned, in the uterus didelphys they are generally 
 rudimentary. 
 
 The uterus bicornis septus on the whole has a broader cer- 
 vix than a normal uterus, both uterine halves of the body 
 diverge exteriorly in the shape of clubbed or fusiform processes, 
 and the size of the diverging angle of both horns is in direct 
 proportion to the bicornuity. Consequently, in this malforma- 
 tion both primordial germs have been developed separately, and 
 consequently we have a right and left uterus unicornis, whose 
 lower segments have at some period approached each other and 
 coalesced, and in consequence of which the bicornuity is more 
 or less marked exteriorly. In such cases the two separated 
 uterine bodies are of a similar anatomical character as the uterus 
 unicornis. 
 
 Eokitansky mentions the singular disposition of the palmse 
 phcatge. The anterior one is always internal and near the sep- 
 tum, the posterior one lies more externally. This corresponds 
 with the circumstance that not only the normal fundus uteri 
 but also the uniting portion representing it in such cases, and 
 the septum which descends from it, is considerably thicker pos- 
 teriorly than anteriorly. It is evident that this uniting portion 
 
24 TWO-HORNED OR 
 
 exerts considerable influence on both uterine halves in their re- 
 lations to each other, and on the form of the cavity. The 
 higher it is situated, and consequently the less the horns 
 •diverge, the more it assumes the character of a fundus uteri. 
 In all cases it occupies a horizontal position at the angle 
 ^here the horns meet (Rokitanksy). In accordance with the 
 ;greater thickness of the posterior part of the septum, which 
 -divides the cavity of the uterus into a right and left one, and 
 on the other hand unites the two separated horns into a uterus 
 TDicornis, the fundus or uniting portion is more prominent pos- 
 teriorly. 
 
 Anteriorly the uterus bicornis is shghtly concave from above 
 downwards, both halves gradually diverging. Its posterior 
 surface is slightly convex (Rokitansky). 
 
 The vaginal portion of J the uterus bicornis septus is either 
 single (Gravel, May), and the septum which increases in thick- 
 ness as it extends upwards, commences as a very thin mem- 
 brane which divides the vaginal portion into two cavities ; or 
 each uterine half has a distinct vaginal portion, each of which 
 is smaller than that of a normal uterus, but which together re- 
 present more substance than a simple normal vaginal portion. 
 Generally the same may be said of both halves of the uterus 
 bicornis compared with the normal organ, and no doubt these 
 conditions have induced Rokitanksy to consider this deformity, 
 as due to an excess of development. With this opinion, how- 
 ever, I do not agree. I consider the uterus bicornis always the 
 result of an arrest of development, even when it reaches that 
 condition called uterus duplex ; the effort of the formative action 
 is undoubtedly to bring Mliller's ducts together and cause them 
 to coalesce ; if this does not occur, as in the uterus bicornis, the 
 formative action has been arrested. Meckel also considers 
 bicornuity as dependent on arrest of development. It would 
 be allowable, so far as regards the substance of the uterus bi- 
 cornis, to say that it is the result of an excess of formation ; but 
 its bicorunity is undoubtedly the result of an arrest of develop- 
 
BICORNUTED UTERUS. 25 
 
 ment, even if it should be demonstrated that before the coales- 
 ence of Miiller's ducts, (consequently before the eighth week) 
 muscular tissue had been formed in both halves and thereby 
 hindered their union. 
 
 With increase in the breadth of such a uterus a correspond- 
 ing diminution in length always occurs. 
 
 The vagina of the uterus bicornis septus is either single or 
 double, the former is generally the rule when there is but a 
 single vaginal portion, the latter is more frequently though 
 not always the case where a double vaginal portion exists. 
 
 Although in most instances both halves of the uterus are 
 equaUy developed, still, not unfrequently they are of unequal 
 size. This inequality may be so considerable as to constitute 
 a transition to the uterus unicornis with an appended rudimen- 
 tary horn. In this category we might also include those cases 
 described by Rokitansky as very important and rare, in which 
 a congenital atresia of one-half of the uterus bicornis coexists 
 with a single vagina. 
 
 Combined with uterus bicornis septus a very interesting ano- 
 maly has been described by Cams, Cassan, Kokitansky and 
 others, consisting of a fold of peritoneum which, arising from 
 the posterior wall of the rectum, extends between the uterine 
 as a large falciform fold with the concave superior margin 
 towards the fundus of the bladder, and always including the 
 m-achus. When this fold is very high (I have seen it two 
 inches high in the middle, exactly above the uniting portion 
 of both uterine horns), the pelvic cavity is apparently divided 
 into right and left compartments, into each of which the body 
 of a one-horned uterus, with tube and ovary, ascends. Krieger 
 considers this ligamentous fold as a remnant of the allantois 
 which, by its abnormal presence, hinders the developement 
 of the uterus and at the same time frequently occasions an 
 abnormal attachment of the rectum to the posterior wall of the 
 bladder, or the posterior fornix of the vagina, which attach- 
 ment at a later period may disappear. 
 
26 TWO-IIOKNED OR 
 
 This lias also been described as ligamentuin recto-vesicale. 
 Knssmaul considers it as a suspensory ligament of tlie uterus, 
 and Kokitansky, as a compensation for the absence of the broad 
 ligament at the inner side of each uterine body. 
 
 Conception may take place in each half of the uterus bicornis, 
 and, in successive pregnancies, the foetus may be developed 
 alternately in them. Hohl, Salert, and Geiss observed a foetus- 
 in each half of a uterus bicornis, and Baj^ard even found twins 
 in one half. 
 
 When pregnancy occurs in one uterine cavity, its walls di- 
 late and thicken in the same manner as those of a normal 
 uterus. The impregnated horn ascends into the abdominal 
 cavity, and when both horns are equally developed, the unim- 
 pregnated one occupies the same position as the pregnant, and 
 its walls increase proportionately in thickness. If however, 
 the pregnant horn is the more developed of the two, it ascends 
 more or less vertically into the abdominal cavity, and the unim- 
 pregnated one is annexed to it laterally. Finally, if the less 
 developed horn becomes pregnant, it often ascends obliquely 
 into the abdominal cavity and the unimpregnated one some- 
 times occu2:)ies a perfectly vertical position. In most, though 
 not all cases ot pregnancy in one iiorn, tne mucous membrane 
 of the other is transformed into a decidna. 
 
 Although many instances are known where pregnancy 
 reached its normal limits and resulted in normal birth, still, the 
 existence of such an anomaly as bicornuity of the uterus, must 
 be considered as unfavorable to pregnancy and delivery, and, 
 according to Kokitansky, for the following reasons. 
 
 1st. Owing to the almost entire absence of the fundus uteri, 
 contraction of which is of such importance in childbirth. 
 
 2d. The uterine tissue, constituting one horn, is of insufficient 
 thickness, notwithstanding its increase during pregnancy, and 
 when contraction comes on, rupture of the uterus easily oc- 
 curs. 
 
 3d. Although the unimpregnated half generally increases in 
 
BICOKNUTED UTERUS. 27 
 
 substance during tlie pregnancy of the other, yet this does 
 not take place to the same extent, and the septum being 
 common to both, we may presume that the enhirgement of the 
 pregnant will be impeded by the opposite half. That this is 
 the cause of habitual abortion in many cases, as Rokitansky 
 asserts, is denied by Kussmaul, nevertheless the fact adduced 
 by the former must, in my opinion, be considered as an un~ 
 favorable one, although Cruveilhier and Busch report cases in 
 which the unimpregnated horn participated only shghtly, or 
 not at all, in the increase in size of the pregnant one 
 and still the foetus matm*ed; on the other hand, cases with 
 unfavorable terminations are universally known. 
 
 Kussmaul also denies the importance of the other two ar~ 
 guments of Rokitansky. He considers that if the fundus- 
 uteri was of such importance during delivery, in a case of 
 uterus unicornis labor must necessarily be tardy ; which is- 
 known not to be the case. That a diminution of substance 
 exerts any influence on labor is refuted by Kussmaul, who 
 proves that successful delivery has occurred in many such cases ; 
 still, in these instances he lays stress on the tardiness of the labor,- 
 which, in my opinion, is sufficiently accounted for by this con- 
 dition. He however attributes this tardiness of labor to the 
 deviation of the gravid uterine half from the axis of the pelvis 
 and uterine body, a circumstance which is certainly deserving 
 of consideration, but which does not lessen the importance of 
 the reasons advanced by E-okitansky. 
 
 Instances of rupture of the uterine walls dm*ing labor are 
 also recorded, and Busch mentions a case of uterus bicornis 
 septus, in which an exhausting haemorrhage occurred after de~ 
 livery, in consequence of the attachment of the placenta ta 
 the septum, which not contracting, the vessels remained open. 
 
 We may here mention another remarkable circumstance 
 observed by Erhart in a case of uterus didelphys ; namely, a 
 considerable breadth of the body coexisting with uterus bicor- 
 nis septus (Cams, Rokitansky.) 
 
28 TWO-HOENED OR BICORT^UTED UTERUS. 
 
 We sometimes find combined with uterus bicornis septus, an 
 incomplete development ot the uropoetic system, and especially 
 absence of the kidney (Schroder, Haller, Kokitansky, Stoltz). 
 
 2. — ^With Kussmaul we describe as uterus bicornis infra- 
 mvplex, or semi-duplex, or unicollis, that form of the uterus in 
 which external duplicity is combined with duplicity of its cav- 
 ity, but in which the cavity of the cervix remains single. If 
 we refer to embryology, in such cases the lower extremities 
 of Miiller's ducts must have approached each other in the 
 normal manner, and absorption of the septum from below up- 
 wards proceeded in the usual w^ay up to a certain distance, 
 whilst the superior extremities of Muller's ducts diverg- 
 ing more or less, were developed into separate uterine horns. 
 Whilst the extreme degree of this bicornuity resembles in its 
 external form the uterus bicornis septus with a single cervical 
 cavity, the lowest degree is represented by a broader uterine 
 body and fundus with distinctly diverging horns, and a whitish 
 seam-like line extending from the anterior to ^the posterior 
 surface. This line coincides with the septum descending from 
 the fundus, and extending more or less deeply into the uterine 
 cavity ; at the same time the body is slightly dilated in its 
 transition into the horns, which latter diverge more considera- 
 bly than usual. The further distinguishing characteristics of 
 the uterus bicornis septus are also found in a lesser degree in 
 the uterus bicornis unicollis ; in well marked cases of this 
 anomaly, we sometimes find the recently mentioned fold of 
 peritoneum, the ligamentum recto-vesicale. If coalescence 
 of the horns takes place above the internal orifice so as to 
 form only a slight depression at the fundus uteri with a mere 
 trace of an internal septum, this form is termed by Kussmaul 
 uterus arcuatus. 
 
 The unfavorable results of pregnancy and childbirth in this 
 form of uterus, are increased in proportion to the degree of 
 the abnormity. In consequence of the diminished thickness 
 of the uniting middle portion, as well as of the septum, the 
 
THE ISrOlSr-lIOKNED SEPxVRATED UTERUS. 29 
 
 other uterine half participates at an earlier period in the ex- 
 pansion of the gravicl one, and consequently the resistance 
 opposed to the gravid half is lesser than in the uterus bicornis 
 septus. The danger to the woman is therefore much lessened, 
 and far more well authenticated cases are recorded of successive 
 pregnancies and puerperal processes terminating favorably in 
 such cases, than in those of uterus bicornis septus. 
 
 The lesser degrees of uterus bicornis infra-septus, or unicol- 
 lis, in which the divergency of the horns is only indicated, 
 and the uterine cavity distinctly divided by a septum, form the 
 transition to the arrests of development hereafter to be de- 
 scribed. 
 
 6. THE NON-HORNED SEPARATED UTERUS, UTERUS BILOCU- 
 LARIS, (ROKITANSKY) ; UTERUS SEPTUS, (KUSSMAUL). 
 
 Literature: Gravel, De siiperfoetat. Diss. Argentor. 1738. — 
 E i s e n m a n n , Tab. anat. quat. ut. dupl. T. I. Fg. 1 . Argentorati 
 1752. — Ha Her, Icon, uteri lium. in fasc. tab. an. H. F. 2. — 
 M e c It e 1, in work quoted — Meckel, Journ. f. anat. Variet., fein. 
 u. pathol. Anat. Halle, 1815. Nr. 1. — A mm on, in work 
 quoted, — 1. Y r o 1 i k , in work quoted. B a 1 d u i n K i 1 1 e 1 , Die 
 Febler des Muttermundes und Beschreibung einer Gebiirmutter mit 
 doppeltem aussern Muttermunde. Diss. Wurzburg, 1823. — Otto, 
 Seltene Beobaclitungen etc. 2. Sammlung. 1824:, pag. 141. — Ki- 
 wi sch, Klin. Votr. I. Bd. pag. 92. — Cr u v eilbi er , Anat. 
 path. Livr. 4. PI. 5. u. Livr. 13. pi. 6. — Le ipmann, De duplicate 
 uteri et vaginae, Diss. Berol. 1830. — Rokitansky, Kussmaul, 
 F o r s t e r , in the works quoted. 
 
 The non-horned separated uterus is one which externally 
 appears single, but whose cavity is divided by a a septum de- 
 scending vertically from a more or less normal fundus, and by 
 which division a right and left cavity is formed. 
 
 The origin of this anomaly must be sought for in a relative 
 arrest of development, the two conjoined walls of Mliller's ducts 
 not having undergone involution, as in the case in the normal 
 development of the uterus. 
 
 Externally such a uterus presents a slight increase in breadth ; 
 in many, a ligamentous strip or longitudinal ridge is seen ex- 
 
80 THE NON-HOKNED 
 
 tending along the median line from above downwards. This 
 is more frequently observable on the posterior surface, although 
 I have repeatedly seen such a whitish longitudinal prominence 
 in uteri otherwise normal. Sometimes on the posterior sm*- 
 face of the bilocular uterus we notice a conical prominence, 
 presenting the appearance of a facette. 
 
 We must avoid confounding this peculiar increase of the 
 nterine substance with those alterations in the external form of 
 a softened and flaccid uterus, caused by the pressm-e of the in- 
 testinal convolutions, and which closely resembles that form 
 described by Meckel and Haller. 
 
 Kussmaul makes a distinction between the uterus septus 
 duplex in which a uterus, externally single, is divided internally 
 throughout its whole length by a septum into two lateral 
 halves, and the uterus subseptus^ in wliich the longitudinal 
 septum is incomplete. This incompleteness of the septum is 
 in its lower part, it descending from the fundus in different 
 lengths, but never reaching the external orifice. On this 
 difference in length of the septum, Kussmaul bases three dis- 
 tinct forms. If the septum reaches nearly to the external orifice, 
 this variety he calls uterus subseptus uniforis with a single ex- 
 ternal orifice ; if it extends from the fundus to the external 
 orifice, it constitutes the uterus suhsejjttcs unicoUis, and if the 
 septum is only perceptibly developed at the fundus we have the 
 uterus subseptus unicorporeus. 
 
 There are very instructive cases of incomplete separation of 
 the uterine cavity belonging to this class, in which only the 
 external orifice is divided into a right and left one. Kiwisch 
 describes ligaments of uterine tissue varying in thickness which 
 extend obliquely from lip to lip of the os externum, thus 
 dividing it into equal or unequal halves. Forster considers this 
 as an arrest of development, and I perfectly agree with him. 
 Kussmaul has termed this very rare form, uterus subseptus 
 biforis, supra simplex ; such cases were also observed by 
 d'Outrepont (Bald, Kittel), Otto and Kiwisch. 
 
SEPARATED UTEKUS. 31 
 
 In the uterus subseptus unicollis the septum terminates in a 
 concave bqrder, the posterior portion extending lower down 
 and merging more gradually into the posterior wall of the cervix 
 than into the anterior. 
 
 To the class of uterus septus or subseptus w^e must also add 
 those not unfrequent cases in which the septum is indicated by a 
 prominent ridge, especially on the posterior wall, and generally 
 with coexisting increase in the breadth of the uterus. I have 
 also seen this rudimentary ridge on the posterior wall of the 
 cervical canal. 
 
 In bilocular uterus the vagina is also often divided by a sep- 
 tum which may be of various lengths and is always a continua- 
 tion of the uterine septum. Such cases are strong supports 
 to the theory that not only the uterus and oviducts, but also 
 the vagina, are developed from Miiller's ducts. 
 
 In most cases of bilocular uterus the vagina is single, but even 
 in these a rudimentary septum is sometimes indicated by a 
 prominent longitudinal ridge on the posterior vaginal wall. 
 
 In all of the above mentioned forms of division of the 
 uterine cavity, the external pudenda are generally well de- 
 veloped, though in rare instances, we find deficient development 
 of these parts combined with the above malformations. Hyrtl's 
 statement that no hymen is found in cases of divided uterus, has 
 been disproved by Kussmaul by the description of several 
 cases, some of which are known to myself. 
 
 In all these malformations of the uterus, menstruation occurs 
 in the same manner as in the normal organ, and the menstrual 
 flow proceeds from both or only one uterine half (Kussmaul). 
 Both halves are also capable of impregnation, and a large num- 
 ber of recorded cases confirm this statement. There are fewer 
 unfavorable conditions for pregnancy in these malformations 
 than in the cornuted varieties. 
 
 It is my opinion that the classification contained in Kuss- 
 maul's elaborate work on these various forms of uteri, should 
 be universally adopted. First, he commences with absence of 
 
32 ' CONGENITAL ATRESIA OF 
 
 the uterus, uext come the rudimentary forms, then the uterus 
 unicornis. His double uterus unicornis constitutes the uterus 
 didelphys, and the transition from this to the normal form, is 
 established by the interposition of two intermediate forms, the 
 horned and non-horned divided uterus. The uterus bicornis 
 he makes either septus or unicollis, and so also the bilocular 
 uterus. The further subdivisions however, made by Kuss- 
 maul are, I consider, too minute in their details. 
 
 7. CONGENITAL ATRESIA OF THE UTERINE CAVITY, 
 ATRESIA UTERI CONGENITA. 
 
 Literature: Morgagni, Adversar, anatom. I. Tab. 3. — B o hm e r, 
 Observ. a. p. fasc. 2. p. 62. T. 7. — Meckel, patbol. Anat. I. pag. 
 662. — K i 1 1 e 1 , Die Fehler des Muttermundes etc. Wiirzburg, 
 1823. — L e r o y , Journ. d. connaiss. med. Fevr. 1835. — N e g a ,. 
 Dissert, de congeuit. genit. femin. deformit Vratislaviae, 1838. — 
 T r 11 m e t , Gaz. med. de Paris. 1851. T. VL p. 34. — K i w i s c li - 
 kl. Vortr. 1854. pag. 113. — D ec e s , Bullet, de la Soci§t§ anat. Juillet. 
 1 854. — Santesson, Preuss. Vereins-Zeitg. 1857. 50. — R o k i - 
 t a n s k y , Ueber Atresie des Uterus u. der Vagina etc. Zeitsclir. d. Ges. 
 d. Ae. Wien. 1859 Nr. 33 und 1860 Nr. 31. — K u s s m a u 1 , as pre- 
 viously quoted, pag. 36 a. 194. — Forster , Missbildungen pag. 132. 
 
 By congenital atresia we understand that arrest of develop- 
 ment in which the external orifice, or at the same time a por- 
 tion of the cervical canal is either imperforate or entirely 
 absent. As the extremest degree of this anomaly we might 
 consider that rudimentary form in which no cavity has been 
 formed. However, the term atresia is only applied to the 
 slighter anomalies just mentioned. Various theories may be 
 adduced to explain the origin of this anomaly. 
 
 In those cases in which the vagina is absent, the lower por- 
 tions of Mtlller's ducts were probably deficient from the 
 beginning, or we may presume that the primordial germs of 
 these canals were present and coalesced inferiorly without 
 forming a cavity, consequently the result was a solid body 
 varying in thickness, or a cord-hke part uniting the rest of the 
 well developed uterus with a rudimentary vagina. .- 
 
THE UTERINE CAVITY. 33 
 
 In other cases an infiammatoiy action may take place at a 
 late period of intra-uterine life, after the cavity has been 
 normally formed, which will also result in a congenital atresia 
 of the uterine cavity. It is evident that the distinguishing of 
 such cases is exceedingly difficult, and it was only my intention 
 to mention the three possible modes of origin. Kussmaul 
 terms the two first primative atresice, and those in which a 
 foetal adhesion of the walls of the cavity took place, congenital 
 secondary atresicB. The last form would seem to constitute 
 the only foetal derangement of nutrition known to us by its 
 results. 
 
 The opinion that primitive atresige are the most frequent, is 
 confirmed by the circumstance that congenital atresiae are 
 frequently combined with such arrests of development of the 
 uterus and system, as, according to embryology, must have 
 commenced at a very early period of foetal life. 
 
 Atresia presents some varieties of form. 
 
 The cervix of the uterus is in rare instances perfectly imper- 
 forate, and forms a slender cylindrical body consisting of 
 fibrous connective tissue interspersed with muscular fibres. 
 In such cases the vaginal portion of the cervix is either en- 
 tu'ely absent, or very imperfectly developed and small, and the 
 vagina is always rudimentary. In other cases the atresia is 
 Hmited to the external orifice, the occlusion being also effected 
 by muscular and connective tissues. In such, the vaginal 
 portion is generally small, but in some instances it is found 
 normally developed. Finally, we meet with cases in which the 
 vaginal portion and cervix are perfectly permeable, but the 
 atresia is formed by the mucous membrane of the vagina pass- 
 ing over and occluding the orifice of the vaginal portion. 
 
 In instances where the occluding tissue does not differ 
 from that of the cervix and vaginal portion, the most probable 
 assumption is, that in the primitive germ of the uterus a cavity 
 was never formed in the portion affected with atresia. 
 
 Regarding the combination of this arrest of development 
 3 
 
34 congejs^ital atresia of" 
 
 with other malformations of the uterus, the cases of atresia of 
 one-half of a uterus bicornis described by Eokitansky, Leroy 
 and Santesson, are so much the more instructive, as it would 
 be impossible to explain the morbid derangements necessarily 
 occuring at the period of menstruation without having recog- 
 nized this complication. 
 
 The first case reported by Eokitansky was a uterus bicornis 
 with the commissure at the level of the internal orifice. The 
 left uterine horn was slender, thin-walled and conical, with 
 a small vaginal portion implanted so eccentrically within the 
 vagina, that a symmetrical right vaginal portion was found 
 wanting in examining the fornix. (This reminds us of the 
 condition of the fornix in uterus unicornis, and extra-median 
 site of the uterus). The right uterine horn was comparatively 
 very large, thick- walled, and its cavity enlarged, particularly 
 its cervical canal, which was distended in the shape of a thin- 
 walled capsule one inch in diameter, without any trace of com- 
 munication with the vagina. The fornix of the vagina passed 
 flutly over this capsule; the inner surface of the distended 
 cervix was covered with cicatrices, and the right kidney was 
 absent. 
 
 In Rokitansky's second case (1860) the uniting portion of a 
 uterus bicornis was one inch below the insertion of the oviducts. 
 The right half of the uterus communicated by a normal vaginal 
 orifice with a single vagina. The left half was larger, the walls 
 of its body of uniform thickness and moderately distended, 
 the cervix was considerably dilated, and its inner surface cov- 
 ered with cicatricial depressions filled with ichorous matter. 
 This capsular form of the cervix presented a fluctuating pro- 
 tuberance bulging from the left half of the uterus, into a single 
 vagina belonging only to the right half A narrow passage had 
 perforated through the septum into the right uterine cavity, 
 but there was no direct communication between this cavity and 
 the vagina. 
 
 Eokitansky further describes a case of atresia, and one of ! 
 
THE UTERINE CAVITY. 35 
 
 stenosis of the vagina, occuring in uterus bicornis ; a similar 
 observation is recorded by Deces. 
 
 Leroy's case of enormous distenion of one-half of a uterus 
 bicornis imperforate in its lower portion, and extending up to 
 the umbilicus like a uterus in the sixth month of pregnancy, is 
 a very remarkable one. Santesson's case is very unintelhgibly 
 reported in Schmidt's Annals, which is also remarked by Kuss- 
 maul, and the original report I was unable to obtain. 
 
 Congenital atresia of the uterus in all its forms is a very 
 rare anomaly. It may exist unperceived up to the years of 
 puberty, and acquires pathological importance only at the com- 
 mencement of menstruation. The menstrual fluid accumulates 
 in the uterine cavity, from which it cannot escape, and conse- 
 quently distending the uterus, it causes that condition with 
 which we will become acquainted under the name of H^iviA- 
 TOMETEA. Frequently enough congenital atresia by its conse- 
 quences causes death. 
 
 Although a uterus affected with atresia cannot be impreg- 
 nated, yet after a successful operation not only conception, but 
 matm'ity of the foetus and a normal delivery, have been known 
 to take place. 
 
 B. ANOMALIES OF PRIMARY DEVELOPMENT BY 
 FORMATION ALTERED IN QUANTITY. 
 
 The congenital anomalies of primary formation altered in 
 quantity are only remarkable as regards the external condi- 
 tions of the uterus ; the condition of the uterine tissue so far 
 as known to this day, shows no alteration during foetal life. 
 The anomalies to be described under the above head are either 
 anomalies of the form or situation of the uterus. 
 
36 COXGEXITAL AIS^OMALIES OF FORM. 
 
 I. CONGENITAL ANOMALIES OF FORM. 
 
 1.— OBLIQUITY OF THE UTERUS, OBLIQUITAS UTERI. 
 
 Literature: Morgagni,De sed. et caus. morb. Ep XXIX. art. 12. 20 
 Ep. XXXV. art. 16. Ep. XLVIL art. 18. — Ruyscli, Obs. anat. 
 cbir. LXXXVIIL — Sandifort, Observ. path. anat. Lib. I, II 
 undlV. — Voigt el, path. Anat. IIL Bd. p. 463. — Ti e de- 
 man n, Von den Duverney'schen Drlisen und der schiefen Gestaltung 
 und Lage der Gebarmutter. Heidelberg, 184:0. — Meissner. 
 Frauenzimmerkiaukheiten. Leipzig, 1842. Bd. I. — Huschke, in 
 Th. V. S o m m e r i n g's Lehre yon den Eingeweiden und Sinnesorg. 
 des menschl. Korpers. 1844. pag. 534, — Velpeau, Annal. de 
 therapie med. et chirurg, Paris, und Gaz. des hopit. Nr. 2. 1845. — 
 Kiwisch, kliu, Vortr. II. Abschn. pag. 94 und Beitr, zur Geburtsk. 
 etc. — Kussmaul (as previously quoted.) pag. 37. — Roki- 
 tansky, Path. Anat. IIL Aufl. IH. Bd. pag. 455. 1861. 
 
 Besides those alterations of form to which the uterus is sub- 
 ject by the arrests of development hitherto described, there is 
 another anomaly of form consisting of unequal development 
 of the lateral halves, and which, in a certain sense, might be 
 considered with arrests of development. 
 
 It may be assumed that one of Mtiller's ducts has been 
 incompletely developed in length, thereby occasioning ob- 
 Kquity of the uterus. 
 
 The extreme form of oblique uterus would seem to be a 
 transition to those arrests of development which we have de- 
 scribed as uterus unicornis with an appended rudimentary 
 horn, and especially to that species in which the cavity of the 
 horn communicates with that of the uterus. 
 
 In such cases the body of the uterus is either thinner and 
 inclined towards one side, and both horns with their corres- 
 ponding oviducts diverge at the same elevation from the 
 body, in which case one half of the uterus must be somewhat 
 longer than the other ; or, the oviducts diverge at a different 
 elevation, in which latter case a considerable disproportion has 
 occurred in the development in length of both halves. Roki- 
 tansky describes as the most characteristic form of this congen- 
 ital obliquity, that a uterus which has been formed by such 
 a sliding of both uterine halves as to cause one horn with its 
 
COXGENITAL ANOMALIES OF FOinr. 37 
 
 oviduct to be higher than the other, and also renders the vagi- 
 nal portion correspondingly obliqne. But this sliding is not 
 the only cause of this alteration in form, for the longitudinal 
 and substantial development of the half apparently situated 
 lower down is likewise retarded. 
 
 The broad ligament of the rudimentary side is somewhat 
 shorter, especially in its upper part; the vagina and os uteri 
 he in the median line, still the vaginal portion is sometimes 
 so obliquely situated, that the f half belonging to the more 
 developed side is a little higher than the other, and at the 
 same time broader and more substantial. 
 
 Sometimes this inequality in the development of both halves 
 of the uterus seems to originate in the body, as I notice in the 
 specimen before me : — From a normally formed cervix with a 
 large and thick vaginal po]-tion, an oblique and thick uterine 
 body ascends in such a manner that the entire uterus appears 
 bent at an angle corresponding with the internal orifice of the 
 less developed half, whilst the more substantial right half 
 shows a convex lateral margin. (Tiedemann, E-okitansky). 
 In this specimen the lateral curvature to the left is in the body 
 itself. 
 
 The oblique uterus is either situated in the median line, or, 
 as is more frequent, its somewhat curved longitudinal axis 
 is placed obliquely to that of the pelvis, in such a manner 
 as to form an acute angle, opening upward on the developed 
 side. On a moi-e careful examination of such uteri it is also 
 seen that their longitudinal axis does not form a right angle 
 with their transverse axis, but that the upper angle is acute on 
 the side towards which the fundus is inclined. This oblique 
 form of uterus with oviducts diverging at the same elevation 
 relatively to the pelvis, has been also termed oblique position 
 of the uterus, and it has been asserted that this latter dis- 
 placement is generally combined with obliquity of form ; but 
 this is incorrect in so far as that the uterus is always obliquely 
 formed in this congenital obhquity of position, and I consider 
 
38 CONGENITAL ANOMALIES OF SITUATION. 
 
 such obliquity in form as tlie most essential point, and that of 
 position as the secondary. For when a uterus is placed 
 obliquely to the axis of the pelvis, either one half must be 
 longer than the other, or they present that pecuhar sliding con- 
 dition described by Rokitansky. 
 
 2.— THE ANVIL-SHAPED UTERUS (KUSSMAUL). UTERUS INCU- 
 DIFORMIS VEL BIANGULARIS. 
 
 This form of uterus consists chiefly in a broader develop- 
 ment of the fundus with outstretched lateral angles, and a cor- 
 responding shortening of the longitudinal axis of the whole 
 organ. In the cavity of such a uterus two lines are seen con- 
 verging at an acute angle towards the point of insertion of the 
 oviducts, the superior horizontal one of the fundus being com- 
 mon to both the above-mentioned angles. This consequently 
 would resemble a uterus in the fourth or fifth month of foetal 
 life, and might be regarded as an arrest of development. This 
 form it is said, predisposes to a transverse position of the foetus. 
 
 This anomaly is also said to be one of the rarest (Kussmaul). 
 
 Morgagni (De sed. et cans. mort. Eph. XLYII, Art. 33), 
 mentions such a uterus with "fundi cavum m transversum 
 ampHficatum." 
 
 II. CONGENITAL ANOl^IALIES OF SITUATION. 
 
 EXTRA-MEDIAN SITE OF THE UTERUS, SITUS UTERI EX- 
 TRA^IEDIUS, OBLIQUUS, METROLOXIA, HYSTEROLOXIA. 
 
 Literature: Cruveilhier, tr. d'anat, patLoL gen. I. p. 731. — 
 Tiedemann, in the work previously quoted. — Mikschik, 
 referat liber K i w i s c h kl. Votr. in der Zeitschr. d. Ges. d. Ae. zu 
 Wieu 1846. Octoberheft. pag. 509. 
 
 By the term obliquitas uteri quoad situin^ that displacement 
 of the uterus has hitherto been understood, in which its longi- 
 tudinal axis lies parallel with, and to the right or left of the 
 median line of tlie pelvis, the os being situated vertically below 
 the fundus (Tiedemann). I prefer calling this anomaly extra- 
 median site of the uterus, as I have observed that it is con- 
 stantly being confounded with lateral inclination and obliquity 
 
CONGENITAL ANOMALIES OF SITUATION. 39 
 
 of the uterus. Lateral inclination represents what has been 
 termed oblique position of the uterus, whilst in extra-median 
 site the longitudinal axis of the uterus is not oblique either to 
 the transverse or longitudinal axis of the pelvis ; therefore 
 the term oblique site is inappropriate. 
 
 The uterus, situated externally to the median line, generally 
 retains its normal form, but the round ligaments are of unequal 
 length, and the broad ligament of the inclining side of the 
 uterus is shorter, and consequently the ovary of this side Kes 
 nearer the uterus. Frequently the inequality in length of the 
 oviducts is out of proportion to that of the broad ligaments. 
 In such cases the oviduct on the side of the shorter broad liga- 
 ment is more serpentine than that of the other side. Very 
 frequently the oviducts are equal in length, in which cases of 
 com'se the same conditions are found on the side of the shorter 
 broad ligament. 
 
 In this anomaly the vagina is usually found situated exactly 
 in the median line, and the uterus implanted in it in such a 
 manner that a right or left large sac and a right or left narrow 
 slit are seen to form the fornix vagina. Mikschik attributes 
 this congenital displacement to an arrest of development of one 
 half of the fornix, because it is generally found combined with 
 a contraction and flattening of that part of the fornix into 
 which the cervix is implanted. This would, in my opinion, 
 explain the deviation of the vaginal portion from the median 
 hne, but not that of the fundus, and an arrest of development 
 of one half of the fornix might result in an oblique, but never 
 in an extra-median site of the uterus. 
 
 According to Velpeau, extra-median site of the uterus occurs 
 more frequently to the right than to the left, which maybe owing 
 to the cn*cumstance of the rectum lying to the left. EaHan 
 also remarks that the gravid uterus is always situated more or 
 less to one side, generally to the right, both the os and fundus 
 uteri occupying the same lateral position, whilst normally the 
 OS is turned to the side opposite that containing the fundus. 
 
40 a:n'omalies of utekine development 
 
 The anomaly of which we have been treating is of frequent 
 occurrence, and must consequently be considered as a normal 
 or nearly normal deviation of the uterus from the axis of the 
 pelvis, caused by the extra-median site of the rectum in the 
 pelvic cavity. 
 
 In very rare cases we meet with a genuine oblique site of 
 the uterus, in which its longitudinal axis crosses that of the 
 pelvis, and its fundus is inclined towards one or the other 
 side. Properly this displacement is a secondary one ; of the 
 acquired form of this anomaly we shall speak under the head 
 
 of LATERAL IXCLIXATION OF THE UTERUS. 
 
 Sometimes the uterus is found inclosed in a hernial sac, 
 forming congenital hysterocele, this we will consider with 
 
 ACQUIRED HYSTEROCELE. 
 
 in.— AN01L4LIES OF UTERIjN^ DEVELOPMENT 
 DURING CHILDHOOD. 
 
 Literature: M o r g a g n i , De sedib. et caus. morbor. L. Ill, Ep. 46. art 
 20—22. — Yoigtel (previously quoted.) IIL Bd. pag. 462. — 
 Meckel (previoush' quoted.) I, Bd. 677. — Lobstein, Lelirb. 
 d. path. Anat. Deutscli v. jSTeurolir. Stuttgart. 1834. p. dQ. — 
 D u p 1 a J, Ber. lib. die med. Klinik d. Prof. R o s t a n. ISTov. u. 
 Dec. 1833 u. Jan. 1834. Arch, gener. Mars. 1834. — Kiwis ch, Klin. 
 Yortr. — Y i r c h o w, Weibl. Hermaphroditismus. Wlirzburger Yerliand. 
 III. Bd. 1852. — Scanzoni, Lelirb. d, Krankbeiten d, weibl. Sexual 
 organe. Wien, 1857. — W. Merkel, Beitr. zur patbol. Entwicklungs- 
 gesch. der Genital. Diss. Erlangen. 1856. — Recklinghausen, 
 Monatschr. f. Gebtsh. u. Frauenkkh. Berlin, 1861. Bd. XYII. — 
 Kussmaul (previously quoted.) — Forster, 3Iissbildungen. pag. 161. 
 
 The extra-uterine development of the uterus which coin- 
 cides with puberty may become abnormal in two ways. On 
 the one hand development may take place earlier than usual, 
 and to this class partly belong those cases which we have 
 already mentioned under the head of excess of development- 
 (page 7), in which not only the intra-uterine development of the 
 uterus exceeded the shape and bulk of one at birth, but also 
 those changes took place which usually we only observe at 
 
DURING CHILDHOOD. 41 
 
 second dentition or the commencement of maturity. On the 
 other hand the energy of the formative action during ma- 
 tm*ity may lead to a result which we are obliged to consider 
 as an excess of formation ; but, according to experience, 
 probably these conditions most always coincide with increased 
 nutritive action, which latter must be considered abnormally 
 increased. We shall treat of these conditions in connection 
 with the other derangements of nutrition. 
 
 There is another class of anomahes of more importance 
 which it is proper to mention under this heading, namely, 
 those which we have recognized as having been caused by an 
 arrest of formative action during puberty. 
 
 After Mtiller's ducts have been developed into a uterus, and 
 after the septum separating the cavities of the two canals has 
 disappeared, then, in the normal condition, development of 
 muscular tissue takes place in the formerly membranous walls 
 of the uterus ; the still-existing disproportion, especially be- 
 tween the body and cervix, gradually disappears during the 
 developme*nt of puberty, and the uterus increases in substance. 
 Having previously treated of the arrests of development during 
 foetal life, we will now consider the anomalies of this kind 
 which occur during puberty. 
 
 Scanzoni describes d,^ uterus fmtalis such cases, where, in adult 
 females, a cyHndrical uterus is found, caused by a continuance 
 of the disproportion between the body and cervix. The same 
 author makes a distinction between this anomaly of develop- 
 ment and smallness of the uterus, which may coincide with 
 imperfect development of the entire generative apparatus. 
 The cause of the latter arrest of development lies either in 
 exhausting constitutional derangements, or diseases of the 
 blood which may occur at the period of maturity. In the 
 second form it is necessary to distinguish whether the retarded 
 development of the uterus exists without complications, or 
 simply as a partial phenomenon of the general development 
 of the individual. In the first case the importance of this 
 
42 AT^OMALIES OF UTERnSfE DEVELOPME]S^T 
 
 anomaly to the female will be so much the greater, if the 
 ovaries and oviducts show a normal development, and conse- 
 quently, if menstruation and conception are rendered possible 
 
 In the latter sense a small uterus belon2;ing to a small person 
 is also described as uterus infantilis^ although in such persons; 
 it would be more surprising to find a comparatively large 
 uterus. The dwarfed appearance of the uterus in such casesi 
 is only a partial phenomenon of general dwarfish growth, and 
 needs no special mention. Kussmaul makes a nicer distinction 
 between the two arrests of extra-uterine development termed 
 uterus fcetalis and uterus infantilis. The uteris foetalis has 
 the form of that belonging to a foetus at full term. The body 
 is small, six or nine lines in height, and ten to twelve in 
 breadth; the neck, which forms the greater mass, is from 
 eighteen to twenty lines in length. The cavity of such a 
 uterus, especially that of the body (Duplay), is either wanting 
 or is very small. 
 
 In those cases, however, which we regard as uterus infantilis, 
 the organ, on the whole, has the form of a virgin one, but is 
 altogether smaller; the most important anomaly is an excess 
 of connective tissue in its walls, which renders them denser 
 and more resisting ; the mucous membrane is paler and thin- 
 ner, and in many instances the rugse of the cervical canal are 
 imperfect. In the records of our institution I find a descrip- 
 tion of a uterus infantilis of a female cretin^ evidently of ad- 
 vanced age (the exact age was probably unknown), in which 
 folds of mucous membrane were found in the uterine cavity, 
 similar to the palmse plicatse : unfortunately this specimen was 
 lost. Kussmaul mentions a similar case of Barkow. 
 
 The vaginal portion of such a uterus is either very small or 
 entirely absent ; sometimes its presence is indicated by a wart- 
 like prominence, with a slight depression, leading to the cervical 
 canal. 
 
 In cases of uterus infantihs the organ and oviducts are gen- 
 erally very small, in the latter no Graafian vesicles are de- 
 
DURING CHILDHOOD. 43 
 
 veloped, and consequently menstruation or conception cannot 
 take place. Sometimes, however, the oviducts and ovaries 
 are so fully developed that their disproportion to the uterus is 
 apparent at first sight ; still in these instances also, as observed 
 by all authors, the individuals had not menstruated at all, or 
 very imperfectly. A peculiarly interesting case is Duplay's, 
 which Kussmaul calls a case of uterus foetalis irrvperforatus^ in 
 vrhich, notwithstanding the absence of both uterus and ovi- 
 ducts, distinct evidences of ovulation having taken place 
 could be noticed in the normally developed ovaries, both 
 ovaries exhibited dark spots and cicatrices (corpuscula nigra) 
 on their surfaces, and in the left one there was a cavity six 
 lines in diameter, tilled with clots and hned with a serous-like 
 membrane. There is no case known to me similar to this one 
 of Duplay. In such the occurrence of uterine haematocele ap- 
 pears almost unavoidable, yet Duplay makes no mention of 
 such an occurrence. 
 
 In uterus foetalis the vagina is generally very narrow, and 
 without the usual rugae ; the inner labia are very small, fre- 
 quently rudimentary (Morgagni), and the external pudenda 
 seldom well developed. The breasts are either deficient or 
 imperfectly formed. Virchow mentions the case of a virago 
 with a penis-like clitoris, a long urethra, a canalis urogenitalis, 
 and a uterus foetalis 1 1 inches in length, the cervix measuring 
 over an inch. 
 
 Smallness of the uterus, resulting from imperfect develop- 
 ment, frequently coincides with smallness of the heart. 
 
 Recklinghausen describes a uterus foetalis which was attached 
 to the posterior walls of the bladder by pseudo-membranous 
 adhesions, and he regards this attachment as the cause of the 
 arrest of development. 
 
 Rokitansky mentions a case (Handbook of Pathological 
 Anatomy, Vol. 11. page 525) of abnormal smallness of the 
 uterus, in which the cervix and vaginal portion were small in 
 
44 
 
 consequence of retarded development ; this condition is the 
 more remarkable, as the nterus fcetalis exhibits exactly the 
 reverse proportion. In the latest edition of the above work 
 this anomal}^ is not mentioned, and I have no knovrledge of 
 such a case. Kiwisch mentions analogous cases with well de- 
 veloped uteri, and very small vaginal portions ; and Kussmaul 
 terms such 2,^ iiterus jparvicollis and uterus acollis. 
 
 As Scanzoni remarks, there are a number of transitions, or 
 varieties of development, between that arrest of development 
 in which the uterus has remained in the condition of a mem- 
 branous organ, and those cases in which a more or less virginal 
 form, still with imperfectly developed walls, is observable, 
 and which cannot well be described separately according to 
 then- diiferent degrees. 
 
 The presence of a uterus infantilis, combined with other 
 conditions favorable to conception, would seem to explain 
 many cases of habitual abortion, and it is probable that many 
 spontaneous ruptures of thin-walled gravid uteri must be 
 attributable to this arrest of uterine development. 
 
 Lumpe mentions that the transformation of the infantile 
 uterus into the form and size of a virgin one sometimes takes- 
 place very slowly and at a late period. 
 
 IV. ANOMALIES OF F0E:\IATI0N IN THE LATTER 
 PAET OF EXTRA-UTEHINE LIFE. 
 
 A. ANOMALIES OF FORMATION ALTERED IN QUANTITY. 
 
 Thp: result of excessive formative action, not altered in quan- 
 tity, consists in an enlargement of the uterus, from increased 
 development of elements similar in character and disposition 
 to the physiological tissue of the organ. With the exce^^tion 
 of an increase of its volume, the uterus retains all its other 
 physical properties, and we call this condition hyperplasia^ or 
 numerical hypertrophy. 
 
a:^omalies of site of the uterus. 45 
 
 Taking the anatomical structure of the uterus into considera- 
 tion in this properly called hyperplasia, the muscular tissue as 
 well as the interstitial connective tissue must be afiected simul- 
 taneously with excessive formation, and thus the relative pro- 
 portion of both tissues in the enlarged uterus must remain 
 normal. This explains the unaltered physical properties of the 
 uterus, excepting its size. 
 
 As the opposite condition to the above, we must consider a 
 kind of atrophy which causes a diminution and softening of 
 the organ, in consequence of a low degree of formative action ; 
 this, in opposition to true atrophy, might be termed ajplasia. 
 
 Both the above conditions agreeing in their external phe- 
 nomena and predisposing causes, their consequences, with the 
 results of excessive or diminished nutritive action, will be con- 
 sidered in the appropriate chapter. 
 
 B. ANOMALIES OF FORMATION ALTERED IN QUALITY. 
 
 In this chapter we will discuss those alterations of formation 
 which relate to the external conditions of the uterus, namely, 
 anomalies of position and form, and as regards the latter, 
 especially those abnormities which afiect the form of the ute- 
 rine cavity. Next in order will be those anomalies of forma- 
 tion which relate to the texture of the organ and are followed 
 by productions which we comprehend under the collective 
 name of adventitious growths. 
 
 I. ANOMALIES OF SITE OF THE UTERUS. 
 
 The anomahes of position to which the uterus is subject by 
 disease in extra-uterine life affect either the entire organ or 
 only a part of it. In order to understand the controversies, 
 which, from the oldest date, continue up to the present day 
 between pathologists, in regard to the real causes of displace- 
 ments of the uterus, it is necessary to clearly understand the 
 attachments of the uterus, its position, and its relation to the 
 other organs of the pelvic cavity. 
 
46 AXO^IALIES OF SITE OF THE TTEEUS. 
 
 If, on opening the abdominal cavity, we proceed fi'om the 
 anterior pelvic walls toward the nterus, we first meet ^vith the 
 romid ligaments, which are correctly considered by some 
 authors, to be direct continuations of the uterine tissue. Each 
 round ligament, according to Rokitansky, divides at its uterine 
 extremity into two branches, each of which diverges upward 
 and downward on the anterior surface of the uterus. These 
 divisions, conjointly, enclose a diamond-shaped space, at 
 the lower angle of which is attached an arch-Hke bundle of 
 fibres two lines in breadth, with the convexity of the arch 
 directed downward ; the ends of these arched fibres descend 
 along the lateral margin of the cervix uteri toward the fornix 
 vaginae, thus secm-ing the duphcation or invagination of the 
 genital canal at the top, which corresponds beneath with the 
 excavation of the fornix. The round ligaments with their mua~ 
 cular filaments allow the uterus to rise and fall freely, and, at 
 the same time permit the fundus to approach the symphysis 
 pubis, while, nevertheless, they can oppose vrith considerable 
 resistence any considerable backward displacement of the or- 
 gan. But, as the course of the ligaments is a convex bend 
 anteriorly and exteriorly, the uterus may be displaced without 
 causing traction upon them until the above mentioned bend is 
 stretched, a traction of the round ligaments being borne so 
 much the easier since they are attached below to soft parts (fatty 
 tissue of the labia). Notwithstanding, I perfectly concur in 
 the opinion that the round h'gaments contribute somewhat 
 to the fixation of the uterus, and are not to be considered as 
 mere remnants of the Guhernacula Huntem. It might be pre- 
 sumed that the round ligaments are only means of fixing the 
 uterus in its position so long as they have not been stretched 
 or become less resistant. But, although they are considerably 
 stretched by the ascension of the gravid uterus, still, after the 
 puerperal state, and the termination of the involution of the 
 uterus, they resume their former length and resistancy, and I 
 cannot believe that the possibihty of traction after pregnancy 
 
ANOMALIES OF SITE OF THE UTERUS. 47 
 
 will now be lessened, or that the resistance which these liga- 
 ments might previously have opposed to certain displacements- 
 should now be entirely abolished. 
 
 The peritoneum of the uterus is formed by a fold transverse 
 to the pelvic cavity from right to left, and vertical to the 
 outlet of the pelvis, and into this fold the uterus is implanted 
 from below. The above membrane passes from the posterior 
 surface of the bladder, in the region of the basis of the trigo- 
 num (Langer), toward the uterus, at about the elevation of 
 the point which forms the limit between the body and the 
 neck, and consequently corresponding exactly with the in- 
 ternal orifice of the uterus. From thence the peritoneum, 
 ascending on the anterior surface, passes over the fundus and 
 covers its posterior wall. It then extends still further down- 
 ward, so as not only to cover the posterior surface of the 
 cervix, but also, in many cases, that part of the vaginal walls 
 which form the posterior fornix. Then the peritoneum ascends- 
 upwards posteriorly over the posterior walls of the pelvis when 
 it becomes the parietal layer. Thus it has lined the so-called 
 Douglas' sac between the uterus and rectum. From behind 
 the rectum, mostly deviating to the left from the median line, 
 is seen to bulge to such an extent that about two-thirds of its 
 circumference is covered by the peritoneum ; but this fre- 
 quently varies, and the rectum is often seen situated in the 
 median line or even to the right of it. 
 
 At both sides of the bladder fibrous lines of the pelvic fascia 
 pass from the os pubis along its lateral walls, to the point of 
 transition of the body into the cervix uteri, and are called by 
 Hyrtl ligamenta piibo-vesico-uterina. These ligaments, how- 
 ever, are mostly indicated by delicate outlines, especially in 
 comparison to their antagonists which we will next mention. 
 On both sides of the rectum two thick fibrous bundles of the 
 hypogastric fascia extend towards the posterior surface of the 
 cervix, forming an arch with its concavity looking inwards, 
 and sometimes raising the peritoneum of the utero-rectal space 
 
48 ANOMALIES OF SITE OF THE UTERUS. 
 
 in the shape of two distinct semilunar folds, which are particu- 
 larly apparent when the rectum is full, and which have been 
 called by Madame Boivin and Duges ligamenta utero-sacralia. 
 These prominent falciform peritoneal folds sometimes divide 
 Douglas' space into a large upper portion opening into the 
 abdominal cavity, and a smaller lower one ; this is still more 
 distinct when a small transverse fold passes across the posterior 
 sm'face unites both the lateral folds, as I have often seen. 
 
 As I have mentioned, these utero-sacral ligaments, [in my 
 opinion, are the antagonists of the pubo-vesico. uterine and the 
 round hgaments. They prevent an excessive movement for- 
 ward of the cervix, and, at the same time, a deviation of the 
 fundus backward and the fact that they are subject to a greater 
 tension when the rectum is full, leads me to suppose that in the 
 latter condition a pressm-e of the cervix towards the neck of 
 the bladder, otherwise unavoidable, is rendered impossible, 
 and that undue expansion of the rectum, which, in tliis region 
 is situated in the median line, is prevented, and the organ is 
 necessitated to develope itself more laterally, because the at- 
 tracted cervix opposes a soHd obstacle to its extension forward. 
 
 Yirchow demonstrated that both these duplications of the 
 peritoneum are continued as two sti'ong fibrous bundles, which, 
 varying in size in difierent individuals, insert themselves into 
 the posterior surface of the cervix uteri, converging towards 
 each other, and generally meeting below the region of the in- 
 ternal orifice, or sometimes disappearing in the sides of the uterus. 
 
 The lateral portions of the large duplication of peritoneum 
 into which the uterus is implanted are known as the broad 
 ligaments. They certainly contribute somewhat to the main- 
 tenance of the uterus in its upright position in the pelvis, 
 although then* assistance must seem inconsiderable considering 
 the great elasticity of the peritoneum. 
 
 The broad ligaments by their breadth certainly prevent, to 
 a certain extent, any inclination of the uterus to the right or 
 left, whilst they can oppose but little resistance to an inclination 
 
ANOMALIES OF SITE OF THE UTEEUS. 49 
 
 forward or backward, because of their elasticity at their point 
 of transition into the parietal peritoneum. 
 
 Independently of these ligaments, we must acknowledge that 
 there is a fiu-ther cause for the position of the uterus in the 
 anatomical condition of its tissue, as well as the manner in 
 which the organ is inserted into the vagina. 
 
 If we suppose the uterus and vagina to be one canal, to which 
 assumption we are led by embryology, we must explain the 
 formation of the vaginal portion and fornix by a slight invagi- 
 nation of the genital canal at the limits of the uterus and vagina, 
 the receiving part being the upper portion of the vagina, the 
 part received being that duphcation of the canal which forms 
 the vaginal portion of the cervix. 
 
 f After many investigations made, and uninfluenced by either 
 of the opposite opinions, I must state my views as follows: 
 
 The several membranous layers of the vagina are merged, 
 with more or less modification, into those of the uterus. The 
 vaginal mucous membrane is covered with pavement epithelium 
 and contains numerous papillge. This papillary structure is 
 also recognizable on the vaginal portion and os uteri. From 
 tliis point the mucous membrane becomes thinner, so as to form 
 a very deHcate layer in the interior of the cervix ; in this part, 
 also, it loses its papillary structure, and rises in transverse folds 
 which unite on the anterior and posterior walls in a longitudinal 
 elevation, forming the palmse phcatse. The mucous membrane 
 of the cervix is covered with cylindrical epithelium, the cells 
 of which become shorter as they line the larger ducts of the 
 mucous glands, which latter are found in great numbers at 
 the internal orifice. 
 
 Commencing from the inner os, the mucous membrane again 
 becomes thicker, softer, and covered with ciliated epithelium, 
 and bearing a relation to the utricular glands similar to that 
 of the stomach to its glandular elements it gradually merges 
 into that lining the oviducts. 
 
 The submucous tissue of the vagina is a very loose connec- 
 4 
 
'50 A]S"OMALIES OF SITE OF THE UTEEUS. 
 
 tive tissue, with large meshes, which suddenly become denser 
 at the vaginal portion, especially at the lower end of the inva- 
 gination of the cervix. From this point it becomes a very 
 resistant, dense, fibrous, connective tissue, which, especially 
 in the cervix, toward the internal orifice, acquires its greatest 
 thickness and a nearly callous fii'mness. From the internal 
 orifice upward, this layer gradually grows thinner, but still 
 continues up to the fundus as a dense submucous stratum ; 
 but, suddenly becoming thinner, it merges into the dehcate 
 submucous stratum of the oviducts. 
 
 Virchow declares this to be entirely erroneous, but de- 
 scribes, in absolutely the same sense, those conditions which 
 we have just given, namely, a diminution of the nmnber of 
 muscular fibres of the fibro-muscular uterine tissue as it ap- 
 proaches the mucous membrane, ending in a distinct, tolerably 
 dense, but, in the normal condition, inconsiderable sub-mucous 
 stratum. It cannot be doubted that the thickness of this 
 stratum varies in different individuals ; but even within the 
 normal limits it may be tolerably thick. 
 
 This submucous layer, which consists almost entirely of 
 connective tissue, with comparatively very few elastic fibres, . 
 forms the turnmg point of the difference of opinion in regard 
 to the predisposing causes of uterine flexions, between E,oki- 
 tansky and Yirchow. Eokitansky considers this tissue to be 
 the very framework of the uterus, and which enables it to 
 constantly maintain its position in the pelvic cavity. In his 
 article on the uterus and its flexions (Allg. Wien. Med. Zeitg. 
 1859, No. 17), an erroneous expression has crept in, which has 
 given rise to misunderstandings.* 
 
 Under the loose submucous stratum of the vagina there is 
 
 * "The mucous membrane of the vagina is transformed into the tliick, 
 callous membrane of the cervix, of which it forms the principal mass. " In 
 the Clinique Europeenne, Paris, 1859, No. 17, the above reads as follows: 
 " La muqueuse du vagin se transforme en celle du col de I'uterus qui est 
 plus epaisse et presque calleuse." 
 
ANOMALIES OF SITE OF THE UTERUS. 51 
 
 an external thin muscular layer, a part of which only becomes 
 involved in the duplication of the vaginal portion. It divides 
 into an inner and outer layer, and tlie fibres of the latter im- 
 mediately merge into those muscular fibres which, according 
 to Rokitansky, we have mentioned as descending from the 
 romid ligaments. The inner layer, however, which enters the 
 vaginal portion, becomes considerably thicker, ascends as the 
 muscular layer of the cervix, and is traversed by thick ridges 
 of connective tissue, which arise in the submucous cervical 
 layer and extend outward. Higher up the muscular coat in- 
 creases in thickness, so as to form the principal mass of the 
 uterine body and lundus. In the latter it is traversed by 
 slender segments of connective tissue, which hkewise arise 
 from the submucous connective tissue, and, meeting at the 
 external part of the organ, form the subperitoneal layer of 
 connective tissue, which, in its normal condition, is generally 
 quite thin. Toward the oviducts the muscular coat of the 
 uterus suddenly diminishes in thickness, and loses itself in their 
 tissue. 
 
 The whole genital canal, in its normal condition, forms two 
 angles, both of which open anteriorly. The superior one is 
 situated at the internal orifice, and, consequently, at the junc- 
 tion of the body and cervix uteri, and measures about 165 
 degrees, whilst the inferior one is between the cervix and 
 vagina, and measures about 155 degrees. The vaginal portion 
 is in a line w^ith the rest of the cervix, therefore the os tincae 
 occupies an eccentric position in the vagina, being directed 
 posteriorly. 
 
 The uterus being fastened in the position mentioned, the 
 constancy of the superior angle depends on the firmness of its 
 tissue, especially of the submucous layer above mentioned ; 
 but the constancy of the inferior angle depends on the liga- 
 ments of the organ, and the condition of the pelvic fascia. 
 
 The displacements to which the uterus is liable in its normal 
 condition are rendered possible by its mobility, however 
 
52 ANOMALIES OF SITE OF THE UTERUS. 
 
 slight, at the points mentioned ; and they are occasioned by 
 degrees of distension of the bladder on one side and the 
 rectmn on the other. 
 
 The anterior sm'face of the cervix is attached to the inferior 
 surface of the neck of the bladder by a loose connective 
 and fatty tissue. As is well known it possesses no perito- 
 neal covering. When the bladder is distended the cervix is 
 depressed somewhat downward and more backward, owing 
 to its easier deviation posteriorly than inferiorly ; and when 
 the bladder is greatly distended, the peritoneum of the vesico- 
 uterine excavation, lifted by the posterior wall of the bladder 
 during distension, partly draws the uterus upward. Virchow 
 argues that in consequence of the displacement of the cervix 
 backward, and from shortening of the round Hgaments or 
 pseudo-membranous adhesions between the uterus and the 
 posterior walls of the bladder, which, in a like manner, prevent 
 deviations backward, anteflexions of the uterus may occur so 
 much the easier, as this point is fixed somewhat at the dupH- 
 tion of the peritoneum, w^hich is situated exactly'on a level with 
 the internal orifice. In my opinion flexions of the uterus at 
 the superior angle are dependent on very different conditions. 
 
 Virchow positively denies that a relaxation of tissue is 
 always found at the point of flexion, and that when found it 
 is a primary condition. The former statement may indeed be 
 doubtful and the latter cannot be proved. When treating of 
 the different forms of displacements I shall revert more par- 
 ticularly to the general and special arguments in favor of this 
 assertion. 
 
 In general we distinguish between the following acquired 
 displacements of the uterus. 
 
 1. The superior normal angle between body and cervix 
 becomes smaller ; or the angle which normally opens forward 
 is straightened ; or the fundus and body may be flexed in an 
 opposite direction to the cervix, so that flnally there is an angle 
 formed at the same point, opening posteriorly. In many 
 
ANOMALIES OF SITE OF THE UTERUS. 53 
 
 cases the relative position of the body to the cervix is altered 
 in such a manner that an angle is formed which opens on 
 either side, these cases, however, are less frequent. Tliese de- 
 viations in the region of the internal orifice are termed flex- 
 ions. The original horseshoe-shaped curve of the longitudinal 
 axis of the uterus, cervix and vagina, forming, in its normal 
 condition, an angle of 165 degrees, is transformed into a nearly 
 rectangular flexion, or finally into an infraction, as we term 
 the highest degree of this anomaly. 
 
 Virchow opposes this distinction between infraction and 
 flexion, and is quite right in asserting that it will depend on 
 the resistance of the uterine tissue, whether the uterus be bent 
 in the shape of a bow, or at an angle ; and it is perfectly evi- 
 dent that if the relaxation of tissue be hmited to the point of 
 flexion, an angular deviation or so-called infraction will result, 
 and that if the relaxation extends further, perhaps over the 
 entire organ, a bow-shaped curvature will take place. This is 
 the reason why the so-called infractions occur more frequently 
 in young persons, and bow-shaped curvature in older and 
 wasted women, and also after the puerperal state. 
 
 2. The uterus as a whole deviates from the median line 
 of the vagina, and consequently changes its former normal 
 position in the pelvis, becoming inclined. If we consider the 
 uterus and vagina together as the genital canal, the inferior 
 angle, normally situated between the cervix and vagina, is 
 either dimmished, or straightened, or opens toward the opposite 
 side. These displacements we term versions, and distinguish 
 according to the direction the fimdus uteri has taken, between 
 inchnation forward — anteversion ; inclination backward — re- 
 troversion ; and lastly, lateral inclination to right or left — 
 right or left lateral version. 
 
 3. The uterus is displaced in the axis of the pelvis, upward 
 or downward, it either ascends from, or descends towards 
 the outlet of the pelvis ; we therefore consider the elevation 
 an anomaly of not much importance ; the opposite much more 
 
54 FLEXIOXS OF THE UTERUS. 
 
 important condition is termed sinking or descent of the 
 uterus, which, in its highest degrees, forms one of the most 
 important and frequent affections of the iitevm—jr/'olajjisus 
 
 4. Xext in order we shall consider inversio/i of the uterus. 
 
 0. Lastly, another displacement is constituted by the dis- 
 placement of the uterus into hernial sacs : hysterocele in its 
 various forms. 
 
 I. FLEXIONS OF THE UTERUS. 
 
 Literature: S a x t o r p h. Collectanea, societ. Havn. 1775, Vol. 11. 
 Xr. 32. — Deninan, Introduction to midwifery. London, 1801 und 
 1827. — Schweighauser, Aufs. liber einige phys. u. pract. 
 Gegenstande der Gebmtsli. Strasbui'g, 1817. — Walsh e, The 
 Lancet. 5. Jan. 1839. — Tiedemann (in the work quoted). — 
 Simpson, Monthly Journ. etc. July 1813, Dublin Journ. May 1818, 
 Obstetric memoirs and contrib. Edin. 1855. pag. 199. — E. Rigby, 
 Med. Times. Novbr. 1816. —Bell, Monthly Jom-n. Septb. 1818.— 
 V i r c h o w, Uber die EJnickungen der Gebm. Yerh. d. Ges. f. 
 Gebm-tsh. Berlin. Vs. pag. 80, Gesammelt. Abhandl. etc. Frankfurt, 
 1856, TTiener allg. med. Zeitung. 1859. Xr. 4. 5. 6. und 21. — Yerh. 
 der Ges. f. Geburtsh. Berhn. 1859. 3. u. 4. Bd. XIH. — Yelpeau, 
 Gaz. des hopit. 1815. Nr. 82, Revue med. chir. 181:9. Decbr. — 
 D e V i 1 1 e, Sur la |frequence des ante- et retroflexions de 1' uterus. 
 Rev. med. chir. 1819. Decb. — Bullet, de 1' acad. nat. de med. XY. 
 2 — 10. — F. C. S o m m e r, Beitrag z. Lehre von den Infractionen 
 und Flexionen der GebaiTiiutter. Diss. Giessen. 1850. — Mayer, 
 Yerh. der Ges. f. Gburtsk. Berlin. lY. 1851. — R ock wit z, Yerh. 
 d. Ges. f Gebtsk. Berl. Y. pag. 82. 1842, and Dissert, de antefl. et 
 retrofl. ut. Marbm'g, 1851. — Dechambre, Gaz. med. de Paris. 
 11. 1852. — Boulard. Rev. med. chir. Juin. 1853. — L at our, 
 Des deviations de 1' uterus. L' Union. 1851. Xr. 18. — Depaul, 
 Gaz. hebd. 1851. May. Xr. 31. — Scanzoni, Beitr. z. Geburtsh. u. 
 GjTiacolog. 1851. L pag. 10 and 1855. H. pag. 151. — Rokitansky, 
 Wiener allg. med. Zeitg. 1859. Xr. 17. u. 18. — B. Dunal, Etudes 
 med. chir. sur les deviations uterines. Paris. 1859. 
 
 The longitudinal axis of the uterus, in the first degree of 
 
 flexion, is bent in snch a manner that the normal angle 
 
 becomes larger, or is straightened, or a slight curve takes 
 
 place in the opposite direction. In the higher degrees of 
 
 flexion the uterus is bent, in its longitudinal axis, anteriorly 
 
 or posteriorly in the shape of a horseshoe. In the highest 
 
FLEXIONS OF THE UTERtJS. o5 
 
 degrees, the body of the uterus is flexed upon the cervix so 
 as to form an angle ; these highest degrees, or complete 
 flexions, were formerlj distinguished from simple flexions. 
 
 In the great majority of cases the flexion takes place at the 
 level of the internal orifice (Walslie, Eokitansky, Virchow). 
 Ashwell and Bell make the point of curvature to be generally 
 above the limit between body and cervix, which fact I cannot 
 confii-m. It is exceedingly rare to find the upper part of the 
 cervix participating in the curve, thereby causing the angle of 
 flexion to be located between the internal and external os. I 
 lately met with a case of retroflexion in which the angle of 
 flexion was in the body itself, which is the only one known to 
 me, and to which I have been unable to find an analogous one 
 recorded. When the point of flexure is in the cervix, as a 
 matter of course the angle is always nearer the inner than the 
 external os. iVccording to the direction in which the upper 
 portion of the uterus is deflected from the lower, we distin- 
 guish between anteflexion^ retroflexioji and lateroflexion. 
 
 The angle of flexion, with but few exceptions, being located 
 at the same point, the predisposing cause of it may be theo- 
 retically explained in two ways. If the cause of the erect 
 position of the uterus be supposed to lie in the organ itself, 
 from the rigidity and firmness of its tissue, then alterations of 
 its texture at the point of angle, must constitute the cause of 
 the displacement of that portion of the uterus which is less 
 firmly supported ; its body and fundus. But, if the cause of 
 the normal position of the uterus be found to lie in conditions 
 external to the organ, consequently in the attachment of its 
 neck or ligaments ; or, if circumstances arise which may cause 
 a deviation of the upper portion of the organ — by abnormal 
 traction or pressure — then the cervix, up to the point of 
 flexion, must be supposed to occupy a relatively flrmer posi- 
 tion, or to be more strongly fixed. In the confirmation of 
 these theoretical suppositions by anatomical investigations, the 
 causes of flexion are rendered e^ddent. - - 
 
56 ANTEFLEXION OF THE UTERUS. 
 
 A. ANTEFLEXION OP THE UTERUS. 
 
 Literature (besides tlie works quoted in previous chapter) : D e n m an, 
 W a 1 s li e und Simpson, (in works quoted) : — Ashwell, A 
 practic. treatise on the diseas. pecul. to women. Lond. 1845. Oppen- 
 heim's Zeitschr. 1486. Miirz. —J.Bell, Monthly Journ. July 1848. 
 — Rockwitz, Boulard. — Duncan, On the displacements of 
 the UteiTis. Edinbm'g 1854. — Virchow, Rokitansky,(as pre- 
 viously quoted.) 
 
 Up to the commencement of puberty the uterus is neither 
 bent forward or backward, only at the development of that 
 period does it assume a slight curve forward, the angle of the 
 cm've coinciding with the level of the internal orifice, and in 
 consequence of which the organ corresponds to the convexity 
 of the posterior wall of the bladder. The cause of this normal 
 anteflexion seems to me to he in the unequal development in 
 substance of the uterus at the period of puberty. It is chiefly 
 at this time that the development of what we have described 
 as a dense submucous stratum commences, and Rokitansky 
 observed that this tissue is more considerable in the posterior 
 semicircle of the internal orifice, consequently the anterior 
 wall of the uterus must deflect to a certain extent. 
 
 In anteflexion, the fundus is situated more anteriorly, de- 
 flecting mth the body from the cervix at the level of the inter- 
 nal orifice. In the higher degrees it descends more and 
 more anteriorly, but, as the vesico-uterine excavation extends 
 only as far as the level of the internal orifice, which is the 
 point of flexion, a further sinking of the fundus would be im- 
 possible if this peritoneal sac was not at the same time increased 
 in depth. This latter circumstance is due to the pressure of 
 the fundus on the peritoneum, which, owing to its elasticity, and 
 the looseness and elasticity of the subperitoneal cellular tissue, 
 readily yields to its weight. It is also partly and chiefly owing 
 to the fact, that the cervix in anteflexion always ascends 
 somewhat in the pelvic cavity, thereby causing the superior 
 portion of its anterior wall to become invested with a peri- 
 toneal covering. In the highest degrees of anteflexions, in 
 
ANTEFLEXION OF THE UTEEUS. 57 
 
 which the deflection of the body from the cervix is very 
 considerable, forming a very acute angle, the fundus lies 
 below the level of the internal orifice, of course anteriorly. 
 
 Concerning the causes of ordinary anteflexion, the opinions of 
 Rokitansky and Virchowhave quite recently been indirect oppo- 
 sition to each other. The former attributes anteflexion to an 
 internal cause, namely a relaxation or flaccid condition of that 
 dense submucous connective tissue which he considers to be the 
 framework of the uterus, especially at the level of the internal 
 orifice. He considers this relaxation to be caused, (1) either 
 by a catarrhal affection of the uterine mucous membrane, nearly 
 in relation to a menstrual process, and accompanied with 
 elongation of the utricular glands, and an inward growth of the 
 same into the submucous stratum in the region of the internal 
 orifice and cervix, in consequence of which the above men- 
 tioned stratum becomes atrophied ; or, (2) as we have frequently 
 observed, an excessive growth of the so-called ovulse Nabothi 
 takes place, which, from their increased size and consequent 
 pressm-e, cause the submucous stratum to become atrophied, 
 and which ultimately bursting, thereby cause a collapse of tissue 
 in the formerly dense framework of the uterus, leaving in its 
 place a flaccid net-like areolar tissue incapable of sustaining 
 the organ in its normal position. 
 
 Both the above processes occur quite frequently, and must 
 be considered as at least predisposing causes of flexions. That 
 in consequence of these conditions anteflexions occur more fre- 
 quently than retroflections, is explained by the fact already 
 mentioned, that the uterus in its original normal condition 
 exhibits a slight anterior curvature, and furthermore, by the 
 fact that the submucous stratum spoken of, is much thinner at 
 the anterior semicircle of the internal orifice than at the pos- 
 terior, and consequently is more readily atrophied. 
 
 Vircliow denies the existence of a thick submucous stratum 
 in the normal state, and asserts that it is not the thick callous 
 submucous stratum of the cervix that supports the uterus, but 
 4* 
 
58 AKTEFLEXIOX OP THE UTEEUS. 
 
 its fibro-muscular parencliTma, wliicli lias nothing to do with 
 the mncous membrane. But the mnscular portion of this paren- 
 chyma certainly is not the canse of the rigidity of the nterus, 
 but, on the contrary, the fibrous portion ; and it is precisely 
 this stratnm which Rokitansky has described as the framework 
 of the uterus.* 
 
 Virchow, on the other hand, considers the relaxation and 
 atrophy of this stratum as a consequence of flexion, or the 
 result of the pressure at the point of flexion. According to 
 this author the cause of anteflexion is to be sought for either 
 in a relative shortness of the roimd ligaments, or in false mem- 
 braues attracting the fundus forward, and preventing its dis- 
 placement backward. The cervix is the most flrmly fixed por- 
 tion of the nterus, being attached to the posterior wall of the 
 bladder, and its positions are dependent upon this attachment. 
 According to Virchow, if the bladder is much distended the 
 cervix is pressed backward, and the fundus, being adherent, 
 must necessarily bend at the point corresponding to the level 
 of the internal orifice, which would constitute anteflexion. 
 
 I agree with Rokitansky's opinion so much the more, as the 
 possibihty of anteflexion, originating from pseudo-membra- 
 nous traction of the fimdus, or from shortening of the round 
 hgaments, has not been denied, but it is my opinion that imder 
 the circumstances mentioned, an anteflexion will occur so much 
 the easier if the supporting tissue of the uterus in the region 
 of the internal orifice has undergone the change mentioned by 
 
 * Rokitansky in his description of the callous mucous membi'ane includes 
 the submucous stratum, which he considers as belonging to it, as 1 am 
 enabled to state from his remarks. His description is however by no means 
 absolutely false as Vu-cho\y states, but has been misunderetood, owing to a cer- 
 tain indistinctness in his expressions. It is decidedl}^ correct that the stratum 
 mentioned varies in thickness, but any one may convince himself that its 
 average thickness is sufficient to afford a certain firmness to the uterus, and 
 the absence or rudimentary condition of this stratum must in my opinion be 
 considered abnormal. 
 
ANTEFLEXION OF THE UTERUS. 59 
 
 Rokitansky. Where this is not the case, the attachment of 
 the cervix at its upper portion seems to me to be insufficient 
 to cause flexion at this point and I beheve that with a normal 
 firmness of the tissue in question, the uterus generally pos- 
 sesses too much rigidity in its longitudinal axis to be easily 
 deflected at the point, where that stratum most capable of 
 resistance, is proportionately thickest. On the contrary, it 
 seems to be more likely that false membranes, or short liga- 
 ments, will attract the fundus forward or keep it fixed ante- 
 riorly, and thereby cause a certain amount of pressure on the 
 fundus of the bladder, when the latter is fulL The bladder 
 must therefore of necessity distend more in that portion of its 
 anterior wall which corresponds to the trigonum, thus causing 
 the lower portion of the cervix uteri to be pressed backward, 
 whilst the whole organ is elevated. Under these circum- 
 stances, if the region of the internal orifice be firmly fixed, the 
 uterus must necessarily be rotated around a supposed trans- 
 verse axis, and such conditions, whilst insufficient to cause 
 anteflexion, will be followed by anteversion. 
 
 The cervix in anteflexion always deviates posteriorly, conse- 
 quently the vagina is elongated by a slight stretching. The 
 OS uteri points a little backward, and, after anteflexion has 
 existed for a certain tmie, the vaginal portion flattens some- 
 what in its antero-posterior diameter, and especially on its pos- 
 terior hp an oblique surface is observable, formed by pressure 
 of impacted fsecal matter in the rectum (Virchow). 
 
 In consequence of the bending of the uterus its cavity is 
 narrowed at the point of flexion, or it may be entirely oc- 
 cluded. A collection of mucus in the body and fundus must 
 therefore take place so much the sooner, as the mucous mem- 
 brane is generally afl'ected with hypersecretion in consequence 
 of a previous or existing catarrh ; or, if this has noi occurred, 
 the passive hypersemia existing at the internal orifice, in conse- 
 quence of pressure and traction of the broad ligaments, must 
 produce a hypersecretion of the mucous membrane in the 
 
60 ANTEFLEXIOI^ OF THE UTERUS. 
 
 deflected part, whicli in both instances often causes a very con- 
 siderable distention of the uterine cavity. The menstrual fluid 
 may likewise collect in and distend it. 
 
 A further consequence of venous h}^er8emia, arising from 
 hindered reflux of blood at the point of flexion, is oedema, with 
 tumefaction and genuine hypertrophy of the body of the uterus. 
 The reflux of blood from the uterine to the hypogastric veins 
 is interrupted, and in consequence of the collateral hypersemia, 
 frequently a very considerable dilatation of the plexmjpampi- 
 niformis takes place, because the blood can now only flow 
 through the spermatic vein. 
 
 Undoubtedly, in many cases of anteflexion, hypersemia of 
 the oviducts and ovaries, catarrh of the oviducts and oedema 
 of the ovaries result in consequence of the derangements of 
 circulation just mentioned. Some authors also mention a 
 combination with chronic oophoritis (Mayer). 
 
 Owing to the pressure occasioned by the anterior deflection 
 of the fundus uteri, as well as the stretching of the peritoneum 
 combined with the hypersemia aflfecting it, peritonitis fre- 
 quently sets in, and is often followed by pericystitis. If the 
 uterus is not immediately replaced, the inflammatory action in 
 the peritoneum causes the formation of false membranes, which, 
 added to those perhaps already existing, by their subsequent 
 retraction fasten the uterus in its abnormal position. The 
 ftmdus uteri now presses still more upon the posterior wall of 
 the bladder and hinders its dilatation, especially in those cases 
 in which hypertrophy, or dilatation and consequently enlarge- 
 ment of the uterus has taken place. 
 
 We may make a distinction between a perfect and imper- 
 fect degree of anteflexion, the latter has also been termed 
 inclination of the uterus (^Meissner). However the distinction 
 between them is arbitrarily drawn. 
 
 As illustrating a peculiar cause of anteflexion, I must mention 
 a case observed by myself. The subject was an old woman 
 with a flaccid anteflexed uterus, in the posterior wall of which 
 
ANTEFLEXION OF THE UTERUS. 61 
 
 a tumor filled with blood was found immediately above the 
 internal orifice, occupying the entire thickness of the wall and 
 considerably increasing its thickness. As I shall demonstrate 
 at the proper place, this tumour had probably originated from 
 the point of placental insertion. In this case it was an undue 
 elongation and turgesence of the posterior wall which caused 
 anteflexion ; moreover there was no trace of peritoneal false 
 membranes. 
 
 Anteflexion is of more fi'equent occurrence than retroflexion ; 
 but it never occurs before the development of puberty, and 
 rarely at an advanced age. Where we flnd anteflexion in an 
 old female, the whole uterus is generally flaccid and thin-walled ; 
 in general the characteristics of the marastic uterus afterwards 
 to be described, are distinctly noticeable. Generally in such 
 cases, atresia of the uterine cavity is found at the point ot 
 flexion, sometimes combined with a cicatricial retraction of the 
 atrophied stratum of connective tissue. In such the uterine 
 cavity is more or less, but seldom considerably dilated and 
 filled with a mucilaginous viscid liquid of a pale yellowish or 
 brownish color. 
 
 In aged women with exceedingly relaxed uteri, the pressure 
 of the intestines upon the posterior surface of the organ is suf- 
 ficient to cause anteflexion. Rokitansky mentions a very 
 remarkable circumstance, namely, that in women who have 
 borne many children, quite a large transverse vein is found in 
 the anterior semicircle of the uterine substance around the 
 internal oriflce, and which renders the uterus still more 
 liable to flexion. I have repeatedly found this vein more than 
 one, and sometimes one and a half lines in diameter. Some- 
 times a second smaller vein is seen above and parallel to this 
 one. 
 
 The fiii'st mentioned vein forms a constant anastamosis be- 
 tween the venous plexuses of both sides, and it is certain that 
 after each pregnancy it is left more considerably distended than 
 previously. According to Rokitansky this vein is situated in 
 
62 ANTEFLEXION OF THE UTERrS. 
 
 the anterior semicircle of the internal orifice, and is frequently 
 formed by the confluence of smaller veins of the inferior and 
 external portion of the utero- vaginal plexus ; it also receives 
 another large vein, originating in the broad ligaments, from 
 the internal spermatic plexus and having an oblique com'se 
 downward and. inward. This anastomosis always occurs at 
 the point when the peritoneal covering of the broad ligament 
 diverges at the lateral margin of the uterus in order to cover 
 the organ, and the venous trunk thus formed enters the uterine 
 substance, receives smaller branches from above and below, 
 and unites in the median line of the uterus with that of the 
 other side. Frequently this anastomosis is not transverse but 
 oblique, generally from the right and below, to the left and 
 upward. I have always found this vein a little above the 
 level of the internal orifice. 
 
 When anteflexion is so considerable as to nearly obliterate 
 the uterine cavity at the point of flexion, conception is rendered 
 very improbable, but still it may take place if no structm'al 
 occlusion or atresia has occurred at the above mentioned point, 
 for there may be space enough left to allow passage to the 
 spermatic fluid, and unless the uterus be held by false mem- 
 branes the flexion may be lessened in a horizontal position of 
 the pelvis during coition by the weight of the fundus, and thus 
 the occlusion of the cavity be diminished and the impregnating 
 fluid be allowed to pass. Considering therefore, the frequency 
 of sterility in females afiected with anteflexion (flayer found 
 60 anteflexions in 272 sterile females) other circumstances 
 should be taken into consideration, especially derangements of 
 menstruation, in the form of dysmenorrhoea and amenorrhoea, 
 perhaps, also, the altered position of the vaginal portion (the 
 OS uteri looking backward) as well as a certain amount of 
 cervical catarrh. 
 
 After an anteflexed uterus has been impregnated, it gene- 
 rally becomes straightened during the progress of pregnancy, 
 unless it is fastened in its abnormal position by flrm false 
 
RETBOFLEXION OF THE UTERUS. 63 
 
 membranes. A gravid uterus may also become anteflexed 
 during the first months without evil consequences to the 
 further progress of pregnancy; at a later period it may become 
 straightened, still a more considerable anterior inchnation of 
 the fundus may be apparent exteriorly, in the distention of the 
 inferior abdominal region. Under unfavorable conditions the 
 hypersemia mentioned may cause haemorrhage within the 
 membranes and death of the foetus. However, anteflexion of 
 the gravid uterus rarely occurs. 
 
 B. RETROFLEXIOK OF THE UTERUS. 
 
 Literature: Besides those works already mentioned : A 6 1 i u s Tet- 
 rabibolos, sermo IV. Cap. 77 — Ambroise Pare, Sur la generation, 
 1640. — R e i n i c k, 1732. — Saxtorpb, Collectanea etc. de ischuria 
 ex utero reflexo. 1775. — Henricus Cuyperus 1777. — Jahn 
 Diss, de utero reflexo, in, Schlegel's Sylloge 1787. — Henschel, 
 Loder's Journ. f. Chir. Geburtsh. und gerichtl. Arzneik. III. Bd, 3. 
 Jena 1801. — Merriman, A dissert, on retroversion of the womb, 
 etc. London 1812. — Schmitt, Ueber die Zuriickbeugung der Ge- 
 barmutter bei Nichtschwangern. Wien. 1820. — Hensley, Retrofl. 
 of the ut. Journal pr. 1848. 1—2. — T. S. L e e , Retrofl. of the ut. 
 London Gaz. 1849. June — Leonidas van Praag M. Zeitschr, 
 f. Gebtsk. Berlin. XXIX. 2. 1850. — Lehmann, Zur Lehre von der 
 Retrofl. ut., Nederlandsch. "Weekblad von Geneeskundigen. Nr. VIII. 
 Febr. 1856. — C. Mayer, Einige Worte iiber Sterilitat, Virchow's 
 Archiv. Bd. X. pag. 115. 1856. — Scanzoniin work previously 
 quoted. — Rokitansky and V i r c h o w previously quoted. — 
 John Moir, On retroflex. of the unimpregnated Uterus etc. Edinb. 
 med. Journal. 1860. 
 
 Eeteoflexion is that anomaly of position and form of the 
 uterus in which its upper portion, chiefly the body and fundus, 
 is deflected posteriorly from the lower portion of the cervix, 
 giving the organ a curve exactly the reverse of the normal 
 one. The consequence is a horseshoe-shaped curvature of the 
 uterus backward, and in the highest degree of this anomaly, 
 a complete sinking of the fundus into the recto-vaginal 
 space. 
 
 Whilst in anteflexion the smaller peritoneal sac, between 
 the bladder and uterus, prevents any considerable sinking of 
 
64 RETROFLEXIOK OF THE UTERUS. 
 
 the deflected fundus uteri ; Douglas' sac being larger, allows 
 such a considerable sinking of the retroflexed fundus that the 
 latter frequently falls below the level of the external orifice, 
 and may be felt in the fornix, per vaginam. 
 
 Retroflexion of the uterus is also combined with a shght 
 elevation of the organ, at least as regards the cervix. The 
 latter, chiefly its lower portion, is pressed forward so as to lie 
 more horizontally than is usual, consequently the os . uteri is 
 higher up and nearer the symphysis pubis, and sometimes can 
 scarcely be reached with the finger per vaginam ; the vagina 
 is drawn upward and forward, its anterior wall especially, being 
 stretched and considerably strained. 
 
 The vaginal portion is directed:, anteriorly and somewhat 
 upward, and at the same time flattened in its antero-posterior 
 diameter ; the anterior lip especially appears shorter and 
 narrower, and the traction exerted upon the anterior wall of 
 the uterus and vagina, obliterates the invagination constituting 
 the vaginal portion (Eokitansky). 
 
 On opening the abdominal cavity, and removing the intes- 
 tines covering the pelvic organs, the vesico-uterine excavation 
 appears shallower. Posteriorly from it, the cervix uteri form- 
 ing its posterior wall, has ascended somewhat higher ; that is, 
 its anterior surface, being partly covered with peritoneum by 
 its elevation, is situated more upward and forward. The 
 highest point of the uterus, as viewed from above, appears as 
 a roimded thick mass, the posterior periphery of which, at 
 least to the left, lies in such close contact with the rectum, 
 that Douglas' space has disappeared, that is, the entrance to 
 it is closed by the fundus uteri ; consequently the highest 
 point of the uterus is its anterior deflected wall, the flexion 
 occurring, almost without exception, at the level of the in- 
 ternal orifice. 
 
 On dividing a retroflexed uterus in an antero-posterior 
 direction, the alterations of the uterine tissue are seen, chiefly 
 at the point of flexion ; the dense submucous layer of connec- 
 
RETROFLEXION^ OF THE UTERUS. 65 
 
 tive tissue in the posterior semicircle of the internal orifice is 
 relaxed and softened ; and, if such a uterus be straightened, 
 there is sometimes a depression at the above point. In some 
 cases, the tissue mentioned has assumed a callous firmness, and 
 the retroflexion, to a certain extent, is rendered permanent by 
 this condition. Such a uterus, even in the dead body, on 
 being straightened, will resume its abnormal flexion. 
 
 It is well to again mention a case of retroflexion previously 
 described. In the posterior portion of the fundus of the 
 uterus of a woman, sixty-one years of age, a fibroid tumour, 
 the size of a hen's egg, was found in the uterine substance 
 under the peritoneum, bulging out at the median line, and 
 causing the uterus to be retroflexed in its uppermost portion. 
 At the inferior and anterior circumference of this tumour, its 
 arterial and venous blood-vessels were situated, and, at this 
 point the veins especially, were large and numerous, the 
 greater portion of the uterine tissue being substituted by a 
 venus flexus. x4.t this point, half an inch above the internal 
 orifice, the flexion was situated ; the cervix and lower portion 
 of the uterine body were lengthened by traction, the body 
 and fundus markedly hypertrophied, and the cavity de- 
 flected at an angle. The peritoneum of the pelvic cavity and 
 iliac fossae was in a natural condition. 
 
 Although it cannot be denied that the considerable disten- 
 sion of the veins arising from the fibrous tumour was probably 
 occasioned by hypersemia, consequent upon the retroflexion, 
 still, at an earlier period, the most yielding portion of the 
 uterus must have been at the hilus of the tumour. In conse- 
 quence of the development of the veins during the growth 
 of the tumour, the uterine substance must have been absorbed, 
 and the deflection have taken place at this point. According 
 to the theory of Virchow, the weight of the tumour which 
 depressed the posterior wall of the fundus, would seem suffi- 
 cient to have caused a retroflexion at the level of the internal 
 orifice; nevertlieless, the continued firmness of the uterine 
 5 
 
66 EETROFLEXION OF THE UTERUS. 
 
 tissue at the usual point of flexion, prevented in this case, a 
 retroflexion at that point. 
 
 In most cases, especially in young persons, the fundus and 
 body of the retroflexed uterus is hypertrophied, and chiefly 
 their posterior walls. The whole organ is thick-walled, and 
 its tissue dense, but its cervix is often decidedly relaxed. 
 
 It is very important to again note, that the most frequent 
 predisposing cause of retroflexion is atrophy of the submucov^ 
 tissue, especially around the internal orifice, in its posterior 
 semicircle. Although we may conceive that the latter altera- 
 tion of tissue, strictly speaking, only predisposes to retro- 
 flexion, still, when other circumstances accede, as a displacing 
 of the centre of gravity of body and fandus backward, retro- 
 flexion will the more readily take place if the first condition 
 continues to exist. The above circumstances are occasioned by 
 a considerable increase in thickness of the posterior wall of 
 the uterus, which is often owing to successive parturitions. In 
 the latter case retroflexion may take place so much the easier, 
 as the round hgaments, the peritoneum, &c. , are always more 
 elastic after even a single pregnancy, and will but slightly 
 oppose a gradual deflection posteriorly of the body of the uterus. 
 A predisposing cause of retroflexion must therefore be looked 
 for in pregnancy, as well as in the alterations of the uterine form 
 and tissue occasioned by puerperal involution. For the round 
 ligaments must be considered as important antagonists to the 
 tendency of a virgin uterus to deflect posteriorly, and unless 
 they have been considerably stretched by at least one preg- 
 nancy, and have become less resistant, notwithstanding puer- 
 peral involution, it is scarcely admissible that they would allow 
 the fundus to sink suddenly backward and downward, except- 
 ing when a gradual and continued traction of these Hgaments 
 produces the same elongating efiect as pregnancy. 
 
 I consider this circumstance as one of the causes why retro- 
 flexion is so comparatively rare in females who have never 
 borne children, but I would still further remark that the con- 
 
KETROFLEXIOX OF THE UTERUS. 67 
 
 tractility of the round ligaments, is never entirely destroyed, 
 not even by considerable stretching, and that after a certain 
 degree of retroflexion has taken place, the round ligaments, 
 the extremities of which have approximated, not only relax, 
 but also by their contraction under certain circumstances, may 
 contribute to increase the flexion, and even render it perma- 
 nent ; for the curtain-like peritoneal fold of the broad ligament 
 is unable to oppose their contraction, and the highest degree 
 of tension of the round ligaments certainly occurs in the 
 slighter degrees of retroflexion, whilst it must necessarily be 
 lessened in the higher degree of this anomaly. 
 
 xls a further cause we must mention, that constant disten- 
 sion of the rectum forces the vaginal portion and the cervix 
 forward and upward as far as the utero-sacral ligaments will 
 allow, and facilitates a sinking of the fundus toward Doug- 
 las' sac. Fibroid tumours and tumours in general, which grow 
 from the posterior wall of the fundus and body, will also 
 cause the uterus to gravitate backward, and produce retro- 
 flexion. Finally, the pseudo-membranous products of peri- 
 metritis and pelvic peritonitis should be mentioned, which 
 may be so situated as to cause a drawing of the fundus back- 
 ward and downward. Of all these causes it must be remarked 
 that, according to mechanical laws, they exert their influences 
 the sooner, the nearer they are situated to the fundus, and 
 consequently the longer the lever is, from the upper end of 
 which they exert then- power. 
 
 In the general relaxation of a marastic uterus, a pressure of 
 the intestines is snfficient to cause retroflexion. 
 
 The fundus uteri in retroflexion has frequently deviated 
 from the median line, and conjointly with the flexion, has 
 undergone a distinct displacement to one or other side. 
 In thirteen cases observed by Rigby, the fundus was situated 
 to the left in nine of them, once to the right, and twice 
 exactly in the median Line. This proportion is the more sur- 
 prising, as the rectum generally occupies the left pelvic 
 
68 RETEOFLEXIOX OF THE UTERUS. 
 
 excavation, and the gravid uterus is more frequently situated 
 obliquely to the right. These circumstances may be occa- 
 sioned by inequality in the length of the round ligaments. 
 
 The consequences of retroflexion are various. In rare 
 isolated instances it is developed into a complete angular flex- 
 ion, as when in consequence of softening or atrophy of the 
 posterior wall, a slight retroflexion has taken place, and then 
 the fundus from its weight falls backward or downward. The 
 resulting retroflexion, especially if the rigidity of the uterine 
 tissue in the anterior circumference of the internal orifice 
 remains unimpaired, may change into retroversion, and in this 
 way those authors may be right who regard retroflexion as the 
 first stage of retroversion ; that is to say, retroversion may 
 commence as a slight degree of retroflexion. After a time, 
 the retroflexed fundus sinks between the rectum and vagina, 
 and exerts pressure on both these organs, according as it is 
 enlarged either by hypertrophy or dilatation. In consequence 
 of pressure upon and stretching of the peritoneum, peritonitis 
 readily ensues, and in many instances, as a result of this 
 inflammation, false membranes are formed which may bind the 
 uterus in its abnormal position. On the other hand, gangrene 
 and perforation of the vaginal and rectal wall, may ensue in 
 consequence of the pressure, and the retroflexed fundus may 
 prolapse through the opening thus made into either of the 
 above canals. A very interesting case of this kind has been 
 mentioned by Rokitansky, in which a retroflexed fundus sank 
 through a perforation in the posterior fornix into the vagina. 
 At the same time the whole uterus was so displaced, that its 
 vaginal portion looked upward and its fundus vertically down- 
 ward ; in this case the flexion existing at the commencement, 
 was compensated by a total displacement much more con- 
 Bid erablc. 
 
 Rokitansky describes another case in which the fundus of a 
 retroflexed uterus was found adherent in a perforation of the 
 anterior wall of the rectum occasioned by sloughing. 
 
RETROFLEXION OF THE UTERUS. 69 
 
 Schott mIso describes another remarkable instance of prolap- 
 sus ntevi, with retroflexion and perforation of the posterior wall 
 of the vagina near the fornix. 
 
 It follows as a matter of com*se, that occlusion or diminution 
 of the uterine canal at the point of flexion, may cause disten- 
 tion of the cavity of the body and fundus, — hyclrometra and 
 h(mnatom.etra. But this seems to occur less frequently in 
 retroflexion than in anteflexion, and in general retroflexion is 
 rarely developed into complete angular flexion. 
 
 By the pressure of the hypertrophied retroflexed uterus, the 
 passage of urine through the ureters may be hindered, and dila- 
 tation of these organs and the renal calices, as well as dysuria 
 may ensue. 
 
 When the gravid uterus is retroflexed, which of course can 
 only happen during the first months of pregnancy, the life of 
 the foetus is endangered by impairment of circulation, and the 
 increasing enlargement of the uterus occasions an undue 
 pressure upon the pelvis viscera and blood vessels of the lower 
 extremities. Spontaneous straightening of the gravid retro- 
 flexed uterus does not occur, the promontory of the sacrum 
 being a hindrance to such an occurrence. A retroflexed uterus 
 may frequently conceive, still, Mayer records 36 cases of retro- 
 flexions in 272 of sterility. 
 
 Ketroflexion of the uterus is congenital in very rare in- 
 stances (T. Safford Lee), and sometimes it occurs before 
 puberty. Most frequently, however, it takes place after 
 repeated parturitions ; when it occurs during pregnancy, it is 
 rarely in primiparse. 
 
 On the whole, retroflexion is of rarer occurrence than ante- 
 flexion. Scanzoni in tifty-four cases of flexions, notes forty-six 
 anteflexions and only eight retroflexions. The higher degrees 
 of retroflexion are however comparatively of much more fre- 
 quent occurrence than the same degrees of anteflexions, and 
 yet in the latter ccmplete flexion is very rare. 
 
 In some rare instances retroflexion is combined with a 
 
70 LATEROFLEXIOK- OF THE UTEEFS. 
 
 second anterior deflection of the cervix, which causes the 
 vaginal portion to lie more horizontally and the uterus to 
 assume an S shaped curvature. 
 
 C. LATEROFLEXION OF THE UTERUS. 
 
 Literature: Besides tlie works already mentioned -. Meckel Handb. v. 
 path. anat. Leipzig, 1816. Bd. II. 1. — Seidemann, Yon den Duvem, 
 Drusen, und der schiefen Gestaltung und Lege der Gebarm. Heildel- 
 berg, 1840. Rigby, Times, August — Xovember, 1845. 
 
 It is only very rarely that the body and fundus uteri are 
 deflected from the cervix toward one or other side. This dis- 
 placement is sometimes congenital, and very rarely acquired. 
 The degree of flexion is of course very slight. The cause 
 of congenital lateroflexion may be sought for, according to 
 Yirchow, in congenital shortening of one of the broad liga- 
 ments ; that of acquired lateroflexion is mostly attributable to 
 pseudo-membranous thickening of the broad hgament of 
 either side, in consequence of which the lower part of the 
 uterus is di'awn toward one side, whilst its fundus is more or 
 less stationary. In these cases also, the highest degree of flexion 
 will be found at the region of the internal oriflce, especially if 
 the atrophy frequently mentioned, has occm-red at tliis point. 
 
 According to all authors, lateroflexion seems to occur fre- 
 quently in combination with anteflexion, and still more so 
 with retroflexion, and it is easily understood that lateroflexion 
 is Uable to tm-n into ante or retroflexion. Rigby's cases of 
 lateral deviation of the retroflexed uterus, belong to this 
 category. 
 
 In congenital lateroflexion, the cervical canal is always 
 straight and in the median line ; in acquired lateroflexion the 
 superior portion of the cervix deviates to the opposite side, the 
 vaginal portion and os uteri being directed obliquely toward the 
 side on which the angle of flexion opens. 
 
 Lateroflexion generally occasions no inconvenience, and only 
 becomes dano^erous from its liahilitv to turn into ante or retro- 
 
VERSIONS OF THE UTERUS. 71 
 
 flexion. In its congenital form it is sometimes combined with 
 obliquity of the uterus, in which case the angle of flexion is 
 formed on the side of the higher half. (Rokitansky). 
 
 2. VEESIONS OF THE UTERUS. 
 
 Literature: V. Doeveren, Spec, obs. acad. cap XL pag. 163. — 
 W. J. S c li m i 1 1 , Bemerkiingen u. Erfalimngen liber die Ziirlickbeug. 
 der Gebilrmutter bei Nichtschwangeren. Wien, 1820. — Schreiner, 
 Inangur. Abh. liber die Yor- iind Riickwiirtsneigg. d. Gebiirm. b. 
 Nichtschwang. Wiirzburg, 1826. — Mme. Boivinet Duges 
 Traite prat, des malad. de 1' uterus etc Paris, 1833. Atlas PI. |11. 
 Fig 4 et 5. — M e i s s n e r , Die Frauenzimmerkrankheiten. Bd. 11. 
 Leipzig, 1842. — Lisfranc, Clinique chirurg. de 1' hopit. de la Pitie. 
 Tom. Paris, 1843. — E. L a cro i x, De T anteversion et de la retrovers. 
 de r uterus. Paris, 1844. — J. Bell, Monthly Journ. September, 
 1848. — Cruveilhier, Traite d' anat. pathol. gen. p. 731. Paris, 
 1849. — K e r 1 e , Ueber die verschied. Arten von Schieflagen der 
 Gebamntter etc. Hanover. Corresp. BJ. IL 6. 7. 1851. — Valleix, 
 Lep. clin, sur. les deviat. uter. Gaz. de hop. 1852 u. 1854. — Duncan, 
 On the displacements of the uterus. Ediuburg, 1854. — Scanzoni, 
 KJ-ankh. d, weibl. Sexual org, Wien, 1857. — C. Braun, Lehrb. d. 
 Geburtsh. Wien, 1857. — Detschy, Wittelshofer's med. Wochen- 
 schrift. Wien, 1857. 29 u. 30. — Becquerel, Les deviations de 1' 
 uterus. Gaz. des Hopit. 1857. Nr. 61. — Rokitansky, Path. Anat. 
 HI. 
 
 In versions of the uterus the organ is deflected from the 
 vagina in its entire length, and in such a manner that the anterior 
 angle formed by the cervix and vagina, is either considerably 
 diminished or effaced, or is changed into a posterior one. 
 
 As regards the general causes of versions, it may be remarked 
 that pressure and traction, especially when acting ;n opposite 
 directions, upon the fundus and cervix, occasion a rotation of 
 the uterus aromid an axis located at about the region of the 
 internal orifice : at the same time this latter point ascends 
 somewhat higher in the axis of the pelvis than in the normal 
 uterus. If version is to take place, it is essential that the 
 uterine tissue be so far intact that its rigidity has not in the 
 slightest degree been diminished. A relaxed and atrophied 
 uterus seldom undergoes version, for the reason that a certain 
 degree of rigidity and firmness of its tissue is necessary for ver- 
 
72 ANTEYERSIO]^ OF THE UTERUS. 
 
 sion. It may therefore be inferred, that in many cases a com- 
 mencing flexion is changed into a version, simply from this 
 cause that notwithstanding the pressure exerted upon the uter- 
 ine substance at the point of the incipient flexion, atrophy of 
 the tissue did not take place, and consequently a permanent 
 deflection of the uterus in its longitudinal axis could not ensue. 
 
 As in flexions, so in versions we discriminate between the 
 direction of the inclinations, and call them anteversio7i, retro- 
 version and lateroversion. 
 
 Here we may remark that beginners will frequently confound 
 the terms inclination and flexion, which is somewhat excusable^ 
 since by the term inclination flexion may be understood, and 
 vice versa. 
 
 The confounding of these terms even by competent authors 
 would render a change in terminology desirable. Thus 
 Voigtel, Van Doeveren, Richter, Denman, Hunter, Levret and 
 Meissner term that condition which w^e call retroversion, a 
 retroflexion^ Vogel calls it, reflexion^ &c. 
 
 A. AlifTEVERSION OF THE UTERUS. 
 
 Literature: Besides the works quoted : L v e r e t , Journ. de Med. Chir, 
 et Pharmac. p. Roux Tom XL. Paris, 1773. — El. v. Siebold, 
 dessen Journ. f. Gebrtsh. etc. Bd. IV. pag. 458. — J. B. K y 1 1 , Beo- 
 baclit. liber Antroflexio uteri im nichtscbwangern Zustande. Seibold's 
 Journ. Bd. XYII 1. — Ameline, Diss, sur 1' anteversion etc. Paris, 
 1827. — Kiwiscb, klin. Votr. Bd. 1. pag. 180. — Depaul, 
 Traitem. des deviations uter. Paris, 1854. 
 
 In anteversion the uterus is so displaced that its longitudinal 
 axis forms an angle witJi the axis of the pelvis, the upper 
 portion of tlie organ deviating anteriorly, the lower posteriorly, 
 and the centre of revolution being located at about the height of 
 the somewhat elevated internal orifice. The uterus is conse- 
 quently inclined forward at the region of the external orifice, 
 its fundus leans toward the posterior wall of the bladder, the 
 vaginal portion approaches the posterior wall of the pelvis, 
 
ANTEVERSION OF THE UTERUS. 73 
 
 and may in the highest degree of anteversion, reach the prom- 
 ontory of the sacrum. The anteverted organ at the same 
 time always ascends in the pelvic cavity, which circumstance, 
 combined with the upward displacement of the vaginal por- 
 tion, stretches the vagina, and draws its superior portion 
 backward and upward. In the higher degrees of anteversion 
 the posterior vaginal wall becomes straighter and smoother. 
 
 As a matter of course anteversion of the uterus cannot attain 
 a very high degree. 
 
 The predisposing causes of anteversion are supposed to be, 
 pressure upOn the cervix posteriorly and the fundus anteriorly]; 
 shortening of the round and utero-sacral ligaments ; false 
 membranes, especially in Douglas' sac, which render it shal- 
 lower by traction; or pseudo-membranous adhesions to the 
 fimdus which by their retraction, draw it forward ; thickening 
 of the subperitoneal cellular tissue especially in Douglas' sac 
 and toward the posterior pelvic wall, in consequence of peri- 
 proctitis and perimetritis ; increased weight of the fundus, 
 particularly in its anterior wall, and especially when combined 
 with inclination forward of the pelvis, which is itself con- 
 sidered a predisposing cause of anteversion, the posterior 
 surface of the uterus in such cases being exposed to the 
 pressure of the intestines in a nearly vertical direction and for 
 a much longer time. Scanzoni also alludes to vaginal cystocele 
 as a predisposing cause, the permanent distension of the 
 bladder pushing the cervix uteri backward and thus causing 
 anteversion. Peritoneal exudations impacted between convo- 
 lutions of intestines and adhering to the uterus may also cause 
 anteversion. 
 
 The eftects of anteversion on the uterus itself are chiefly 
 hypercemia and hypertrophy occasioned by the traction of its 
 investing membrane and its vessels ; to the neighboring organs, 
 pressure on the fundus of the bladder, impediment to the 
 expansion of the latter, and pressure of the deviated vaginal 
 portion upon the rectum. Siebold in a case of anteversion. 
 
74 anteyersio:n^ of the uterus. 
 
 found the vaginal portion adherent to the rectum, and the os 
 uteri could be felt through it. 
 
 Anteversion in most instances comes on slowly, but may 
 take place suddenly. It seldom affects a gravid uterus, and if 
 so, only during the first months ; a sort of anteversion of the 
 gravid uterus however is sometimes found with relaxed abdom- 
 inal walls in diastasis of the recti-abdominal muscles. On 
 pregnancy anteversions can have no influence, for, as the 
 uterus gradually enlarges, it ascends spontaneously along the 
 anterior pelvic and abdominal walls into its normal position, 
 and in the natural condition, the pelvic and abdominal walls 
 present no hindrance to its ascent. Impediment to its ascent 
 might only occur from a conical outgrowth of the cartilage of 
 the symphysis, prominating inwardly, especially from the 
 superior portion ; or from exostosis or other tumom*s arising 
 from the pubic bones at their point of jimction, which would 
 have the same effect on anteversion as the promontory of the 
 sacrum has on retroversions. 
 
 As I have previously mentioned, anteversion may be devel- 
 oped from incipient anteflexion, and the causes of it are to be 
 sought for in a traction or pressm-e acting on the frmdus 
 anteriorly and cervix posteriorly, the tissue of the uterus at 
 the same time being sufficiently rigid to resist a deflection in 
 its longitudinal axis. 
 
 Anteversion in general is a rare form of displacement and 
 occurs much less frequently than retroversion. 
 
RETROVERSION OF THE UTERUS. 75 
 
 B. EETROVERSION OF THE UTERUS. 
 
 Literature: besides the general works quoted : K u 1 m u s, De uteri 
 delapsu, suppressionis urinae et subsecutae mortis causa. Gedani, 1732. 
 — Saxtorpli, Coll. Havn, Vol. 11. pag. 127 u. 145. 1775. — Hunter, 
 Medic, observ. and iuquir. Vol. V. pag. 388. — Voigtel, pathol. 
 Anat. Halle, 1805. Bd. HI. p. 463. — Merriman, Dissert, on retro- 
 version of the womb. London, 1810. — Ambr. Buczynsky, Diss, 
 de retrovers. uteri. Acta institut. Clin. Caes. Univ. Vilnensis. Cap. 
 XVn. Leipzig, 1812. — Bell, Dewees, Philosoph. Journ. London, 
 1821. Febr. Nr. 2. — P. Frank, Opuscula posthum. etc. Viennae, 
 1824. pag. 78. — O slander, Ursachen und Hiilfsanz. etc. Wlirzburg, 
 1833. —Mayer, Presse med. Nr. 20. 1837. Froriep's N. Notizen L 
 pag. 311. — Froriep, ebendaselbst. Bd. VH. Nr. 19. 1838. —Simp- 
 son, On retrovers. etc. Dublin quarterl. Journ. 1848. May. — Kiwisch, 
 kl. Votr. I. pag. 163. — G a r i n, De la retrovers. de la matrice. Gaz. 
 med. de Lj^on. 1854. Aout, September. — Bamberger, Scanzoni's 
 Beitrage z. Geburtsh. etc. Bd. H. 1855. — Grenser, Verhandlung. 
 der Sect. f. Geburtsh. d. 32. Vers, deutsch. Naturf. u. Aerzte. Wien, 
 1857. Wittelshofer's med. VVochenschr. Wien, 1856. Nr. 38 u. 39. 
 
 In retroversion the fuiidns uteri gradually sinks into the 
 hollow of the sacrum, whilst the vaginal portion ascends 
 towards the symphysis ; at the same time the uterus rises 
 somewhat higher in the pelvis, although not to such an extent 
 as in anteversion, and therefore the vagina is not so much 
 stretched as in the preceding anomaly. 
 
 Formerly three distinct degrees of retroversion were com- 
 monly made. In the first, if the fundus was inclined toward 
 the promontory of the sacrum it was sometimes called posterior 
 inclination of the uterus ; the second degree was assumed to 
 exist when the fundus had descended below the promontory, 
 and the cervix ascended upward anteriorly so as to touch the 
 inferior margin of the symphysis pubis ; the third and highest 
 degree existed when the fundus was situated deej^ly in the 
 hollow of the sacrum and the vaginal portion had risen above 
 the symphysis pubis. 
 
 The causes of retroversion of the uterus are enlargements 
 of the organ, especially of its body and fundus, combined 
 with relaxation of the round ligaments ; pregnancy up to the 
 third and fourth months ; excessive weight of the posterior 
 
76 KETROVERSIOX OF THE UTEKUS. 
 
 wall of the uterus, especially from tumours attached to it ; 
 excessive mobility of the uterus with pressure on the fundus 
 backward and downward, and on the vaginal portion forward 
 and upward, as from tumours impacted in Douglas' space 
 inverting the posterior fornix, which is more likely to occur 
 when they are so developed from the fundus or body as- 
 to exert simultaneous pressure upon the cervix forward, and 
 traction on the fundus and body downward and backward ; 
 vaginal hysterocele (Froriep); and traction of false membranes 
 in the direction mentioned. Finally, causes lying within the 
 pelvis, as an excessive projection of the promontory, whereby 
 the uterus when physiologically or pathologically enlarged, is 
 hindered from ascending; exostosis acting in hke manner; 
 excessive inward curvature of the horizontal rami of the pubis ; 
 excessive curvature of the sacrmn ; an inclination of the pelvis 
 less than normal ; and especially too great width of the 
 superior straite of the pelvis. 
 
 Over-distension of the bladder (Drejer, Osiander) cannot 
 well be considered as a cause of retroversion ; Saxtorph men- 
 tions amongst the causes, attachment of the placenta to the 
 posterior wall of the uterus, but we can scarcely assume that 
 this should increase the weight of the posterior wall ; it would 
 rather seem in Saxtorph's cases, that paralysis or unequal 
 involution of the seat of the placenta, had produced that form 
 of retroversion which Kiwisch describes as partial retroversion. 
 
 All the hitherto mentioned causes of retroversion cannot be 
 regarded as other than predisposing ones ; and in the majority 
 of instances certain mechanical influences are added to one 
 or other of them and thus immediately produce retrover-^ 
 sion, as for instance the pressure of the intestines during 
 violent contractions of the abdominal muscles, (Forster). 
 Retroversion almost always occurs suddenly, and this proves 
 that its final occurrence depends on mechanical causes, 
 as all the above mentioned predisposing causes are patho- 
 logical conditions, representing chronic ailments. The pre- 
 
EETROVERSION OF THE UTERUS. 77 
 
 disposing and direct causes arc supplemental to each other in 
 this way, that according as the former have been more highly 
 marked the latter may be the slighter and vice vei'sd. Neither 
 one of the predisposing causes, or a mechanical influence acting 
 alone, is likely to produce retroversion. 
 
 In the same manner as anteversion sometimes results from 
 anteflexion, so in isolated cases retroflexion is said to resolve into 
 retroversion, which statement, as regards the slighter degrees 
 of retroflexion, is certainly correct. The highest degree of 
 retroflexion, that in v^hich the fundus uteri prolapses through 
 the perforated rectum or vagina (Eokitansky), may lead to a 
 peculiar form of complete version of the uterus. 
 
 The consequences of retroversion are more important than 
 those of anteversion, for the reason that the former more fre- 
 quently attains a higher degree. The fundus uteri in well 
 marked cases, presses the more upon the rectum, according 
 as it is increased in size and weight, and although the rectum 
 can be displaced laterally at the entrance of the pelvis, yet 
 this cannot take place at all or only with difficulty in 
 the lower pelvic region, when it approaches the median 
 hne and the pelvic cavity becomes narrower. Here another 
 circumstance must be considered, namely, that in most 
 instances the rectum descending in the left pelvic space, is 
 attracted toward the median line by the cervix uteri approach- 
 ing the symphisis pubis, which consequently draws forward 
 and stretches the insertion of the utero-sacral ligaments en- 
 compassing the rectum on both sides. By this mechanical 
 action the rectum is drawn toward the dislocated fundus and 
 cannot give way to it, because its peritoneal coat is similarly 
 affected. 
 
 The vaginal portion of the retroverted uterus presses on the 
 anterior portion of the bladder, compressing it between itself 
 and the symphysis. In consequence of the pressure being 
 exactly on the trigonum, the evacuation of the bladder is 
 much more impeded than its filling. Bamberger mentions a 
 
78 RETROVEKSIOX OF THE UTERUS. 
 
 case of uraemia (observed in Oppolzer's clinique) which wa& 
 caused by a retroverted uterus pressing upon the trigonum of 
 the bladder, and which was followed by fatty degeneration and 
 sloughing of the vesical walls. 
 
 Hunter describes a case of extraordinary distension of the 
 bladder, in which the cervix of a retroverted uterus had drawn 
 the trigonum up to the entrance of the pelvis. Lynne and 
 Saxtorph even mention cases of ruptm*e of the bladder in con- 
 sequence of retroversion of the uterus. 
 
 The pressure exerted posteriorly by the fundus and body of 
 a retroverted uterus, may be due to enlargement from a pre- 
 vious pregnancy, or to inflammatory or hypertrophic tumefac- 
 tion, which latter may either have existed previously, and been 
 the primary cause of the retroversion, or may have been pro- 
 duced in consequence of such a condition. The pressure upon 
 the rectum will thus be increased, and defecation consequently 
 impeded, followed by all the usual consequences, even that of 
 stercoraceous fsecal vomiting. The pressure will also be 
 extended to the various canals ascending and descending along 
 the posterior walls of the pelvis, especially to the ureters, and 
 the veins in that region. This latter pressure will cause stag- 
 nation of the blood and oedema in the lower extremities. The 
 distension of the ureters above the point of pressure may extend 
 upwards to the calices of the kidneys, causing distension of the 
 same, and even atrophy of the organs [hydronephrosis). 
 
 We have already mentioned as being most remarkable, those 
 cases, often quoted, of complete version of the uterus, in which, 
 the fundus has descended deeply into Douglas' space, whilst 
 the vaginal portion, covered by the anterior wall of the vagina, 
 looks upward toward the abdominal cavity, or rather, is 
 imbedded into the anterior fornix so long as the latter exists, 
 and the duplication, constituting the anterior lip of the vaginal 
 portion, has not been effaced by excessive traction. 
 
 Retroversion occurs both in pregnant and non-pregnant 
 females. In the former it is of more frequent occurrence 
 
RETKOVERSION OF THE UTERUS. 79 
 
 during the first months, for, as abeady stated, pregnancy is one 
 of the predisposing causes of the affection. Excepting during 
 pregnancy, retroversion rarely takes place in females who have 
 never borne children. Kiwisch makes a distinction between 
 complete retroversion, occurring only during the first months, 
 and partial retroversion. According to this author, partial 
 retroversion is induced by the depression of part of the poste- 
 trior uterine w^all into Douglas' space, in the shape of a sac^ 
 whilst the anterior and superior portion of the uterus occupy 
 their usual position in the pelvic cavity. In this anomaly, the 
 vaginal portion of the uterus is said to be directed anteriorly 
 and upward. This deviation cannot be considerable, if as 
 Kiwisch expressly states, the anterior and superior walls of 
 the uterus are in normal position. From anatomical reasons 
 I agree with C. Braun, that the term partial retroversion 
 should not be applied to this condition ; partial retroversion, 
 in the true meaning of the term, being nothing more than 
 retroflexion of the uterus. Prolapse of the posterior uterine 
 wall (Dubois, Chailly, Hohl) is a more appropriate term, 
 though even this, strictly speaking, is not quite correct. 
 
 A case is described by Grehser, in which a uterus, two 
 months pregnant, had, together with the ovaries, penetrated 
 the posterior wall of the vagina, and appeared at the vulva ; 
 the cervix still remained in the pelvic cavity. Mayer also 
 mentions a similar case. 
 
 When a gravid uterus is retroverted, the foetus is apt to 
 perish from placental apoplexy, or miscarriage will sooner or 
 later take place. 
 
 The most common, immediate and important consequence 
 of retroversion \& perhnetiitis, or pelvic peritonitis^ which may 
 become general and terminate fatally. It is natural to sup- 
 pose, that in retroversion of the non-gravid uterus, menstrua- 
 tion will often be considerbly deranged. When retroversion 
 occm's after prolonged dysmenorrhoea (Bell) the latter must be 
 considered as the first symptom of some other affection which 
 
80 LATEROTERSIOX OF THE UTEEUS. 
 
 has produced the retroversion. In 272 sterile females examined 
 bj Mayer, 35 had anteversion of the uterus and only 3 retro- 
 version. 
 
 c. latero^t:iisiox of the UTERrS. 
 
 Literature: besides tlie general literature and the works mentioned on 
 Obliquity of the Uterus : Baudelocque, L' art. des accouch. T. 1. 
 Paris, 1781. —Boer, Abb. u. Yers. II. Th. Wien, 1792. 
 
 Inclixatiox of the uterus to one or the other side never 
 attains a high degree : the tundus is inclined either to the 
 right or left, whilst the vaginal portion takes the opposite 
 direction. This inclination is fj-equently combined with a 
 shght twisting of the organ, its anterior surface looking toward 
 the side to which the fundus is inclined. Latero-version is often 
 combined with obliquity of the uterus. The acquii-ed form is 
 chiefly caused by traction or dislocation of the organ by tumours. 
 It is not long since I saw a case of considerable right latero-ver- 
 sion, occasioned by inflammatory callousness above and along 
 the anterior portion of the left utero-sacral ligament; Douglas' 
 space was of considerable depth, and the uterus had been 
 rotated in the manner above mentioned. 
 
 A combination of latero- and anteversion. which might be 
 termed later o-anteversion, is produced by the protrusion of 
 an oviduct or ovary into the inguinal or crm-al sacs : also by 
 pseudo-membranous shi-mking of the round hgaments ; or, 
 after the occm'rence of an abcess in the peritoneal folds of the 
 latter, as in a case known to me in which an abcess perforated, 
 and afterwards cicatrized, in the inferior inguinal region. 
 
 The highest degrees of this displacement are fomid in con- 
 nection with large ovarian tumours, which during theu' growth 
 encroach upon the peritoneum of the broad ligament in such a 
 manner, as to lie in direct contact with the uterus. 
 
 The same occurs when large fibrous tumours grow fi'om either 
 lateral walls of the uterus, and in these cases the uterine cavity is 
 usually deformed, and the organ is sometimes enormously 
 increased in length, and curved in various directions. 
 
ELEVATION OF THE UTERUS. 81 
 
 3. ELEVATION OF THE UTERUS. 
 
 Literature: Colonibat de 1' Isere, Traitc des maladies des 
 femmes, etc. Tom. L pag. 339. Paris, 1838. — Busch, Das Gesch- 
 lechtsleben des Weibes etc. Bd. III. pag. 472. Berlin, 1839—1845. — 
 Meissner, Frauenzimmerkrankbeiten. Bd. IIL pag. 648. — Kiwisch, 
 Klin. Voitrage. Bd. L pag. 210. Prag. 1845. — Scanzoni, Krankh. 
 d. weibl. Sexualorg. pag. 126. Wien, 1856. — Rokitansky, path. 
 Anat. IIL Bd. Wien. 1861. 
 
 By elevation of the uterus is meant a displacement of the 
 entire organ upward. The fundus ascends into the abdomi- 
 nal cavity, both peritoneal cavities thereby becoming shallower, 
 and the fornix of the vagina being so stretched as to cause it 
 to become cone-shaped. At the same time the vaginal portion 
 disappears more or less, leaving merely a button-shaped rudi- 
 ment, (Rokitansky). The vagina is also so stretched in its 
 length, that its rugse disappear, and its inner surface becomes 
 smooth. 
 
 The causes of elevation of the uterus, lie either within, or 
 are external to, the organ itself. The causes that originate in 
 the organ itself, are an increase in volume of body and fundus, 
 unless the latter has previously been bound down by adhesions 
 in the pelvic cavity, in consequence of which ascent of the 
 uterus would be hindered ; distention of the uterine cavity by 
 mucus or blood ; formation of fibrous tumours, as round fibroid 
 tumours, as well as fibroid polypi. To the class of external 
 causes belong tmnours of the broad ligaments or ovaries ; 
 adhesions formed during pregnancy, or the puerperal state, 
 previous to complete involution (Rokitansky), and consequently 
 any impediment to its physiological decent, which is also 
 applicable to the few cases of successful Caesarian operation. 
 Finally, we may mention the vascular tumours of the vagina ; 
 tumours of the pelvis ; and in general, such as force the uterus 
 from below upward toward the abdominal cavity. As we 
 have stated, shght degrees of elevation are found combined 
 with flexions, and always with anteflexions. 
 
 The ^effect of elevation of the uterus, especially when pro- 
 6 
 
82 PROLAPSE OF THE UTERUS. 
 
 duced by other causes than tumours pressing from below, is 
 elongation of the organ, chiefly of the cervix, to sometimes 
 twice or three times its normal length, this elongation being 
 generally accompanied with diminution of its cavity, and 
 thinning of its walls ; the latter condition however, is not 
 proportionate to the elongation, and when it does occur, an 
 increase of substance has taken place. 
 
 The diminution of the uterine cavity by longitudinal trac- 
 tion, is always more considerable near the internal orifice, 
 even complete occlusion of the canal may take place. In 
 isolated cases an obliteration of the canal at the above point 
 occurs in consequence of rupture of so-called Nabothian 
 glands, from the ruptured walls of which connective tissue is 
 produced, and which ultimately leads to complete atresia of the 
 canal by agglutination. The thinning of the walls of a 
 stretched uterus, is also most considerable at the region of the 
 internal orifice, and if the traction be considerable, rupture of 
 the uterine substance may occur, causing the body and fundus 
 to separate from the cervix, being simply held together by a 
 peritoneal fold. It is easily understood, that in such cases, 
 the cavity of the body must previously have been separated 
 from that of the cervix. 
 
 4. PKOLAPSE OF THE UTERUS ; PROLAPSUS, DES- 
 CENSUS, PROCIDENTIA, HYSTEROPTOSIS. 
 
 Literature: Mauriceau, Traite des malad. des femm. gross, etc. 
 Paris, 1668. — Fabric. Hildanus, Observ. Cent. IV. obs. 80. — 
 Bohmer, De prolapsu et inversione uteri. Halae. 1745. — Morgagni, 
 de sedib. et caus. morb. Ep. XXXIV. art. 11. et Ep. XLV. art. 
 1—16. — Cbopart, Diss, de uteri prolapsu. Paris, 1772. — S a v i a r d, 
 Observ. chirurg. Paris, 1784. pag. 44 u. 66. — St ark, dessen Arch, 
 f. Geburtsb. 1798. I, Bd. pag. 73, 80 u. 87. — J. F. Meckel, dessen 
 Journ. f. anatom. Varietaet. Halle, 1803. — Vo igt el. Path. Anat. 
 Bd. Ill, Halle. 1805. pag. 465. —Clarke, Observ. on diseas. of 
 fern. I. 1814. pag. 62. Taf. I— III. — J. F. Meckel, Path. Anat. 
 Leipzig, 1816. Bd. IL Abth. 1. pag. 484. — Cru veil hier, Anat. 
 pathol. gen. Livi*. 26. pi. 4. — D upar c que, Traite theorique et 
 
PROLAPSE OF THE UTERUS. 83 
 
 prat, des maladies org. simpl. et cancereuses de 1' uterus. Paris, 1832. 
 pag. 201. — D. Davis, The principles of obstet. med. in a series of 
 systemat. dissertat. on midwif. etc. London, 1837. — Lisfranc, 
 Bullet, de therap. April 1843. — Mouremans, Ueber Gebarmut- 
 tervorfalle. Arch, de la med. belg. 1843. Nr. 1. — M. Retzius, 
 Einige Worte fiber Gebitrmuttervorfalle. Hygiaea, 1845. October — 
 Rigby, Med. Times. 1845. Aug. Novbr. — Froriep, Chirarg. 
 Kupfertafeln T. 61. 65. 388. 389. 416. 417. — Kiwis ch, klin. Votr. 
 Prag. 1845. Bd. I. — C. M ay er, Beitr. z. Kenntniss und Behandlung 
 des Prolaps. uteri. Verb. d. Ges. f. Geburtskde. etc. Berlin. Bd. pag. 
 123. — Virchow, Ueber Vorfall der Gebarmutter ohne Senkung 
 ihres Grundes. Yerh. d. Ges. f. Geburtsk. Berlin. 11. p. 205. — Li one. 
 de C o r b e 1 1 , De I'origine des hem. et de quelq. affections de la ma- 
 trice. Paris, 1847. — Seyfert, Prolapsus uteri geheilt durch Retro- 
 flexion. Prag Vierteljahrschr. 1853. Bd. I. pag. 156. — Forster, 
 Spec. path. Anatom. Leipzig, 1854. pag. 298. — C h i a r i , Klinik. f. 
 Geburtsk. n. Gynacol. Erlangen, 1855. pag. 374 und Wiener Zeitschr. 
 d. Ges. d. Ae. 1854. 6. Heft. — Retzius, Hygiaea XVHI. pag. 56. 
 1855 u. 1856, — Scanzoni, Krankh. der weibl. Sexualorg. Wein, 
 1857. pag. 107. — Aug. Mayer, Ueber Gebarmutter und Scheid- 
 envorfalle etc. Yerh. der Ges. f. Gebmtsk. in Berlin. Monatschrift etc. 
 XH. 1. 1858. — Yirchow, Yerh. d. Ges. f. Geburtsk. Berlin. Bd. 
 YH. u. YHL — Franque, O. v. der Yorfall der Gebarmutter in 
 anatom. u. khn. Beziehung. Wurzburg. 1860. — Huguier, Mem. 
 sur les allongem. hypertroph. du col de 1' uterus dans les affect, de- 
 signees sous les noms de descente, precipitation etc. Paris, 1860. — 
 S c h u h , Yollstand, Gebarm. und Scheiden- Yorfall etc. Wiener Medic. 
 Halle, 1860. 13. — Rokitansky, Path. Anat. HI. Bd. Wein, 1861. 
 Besides the above, the handbooks on gynecology, obstetrics and patholo- 
 gical anatomy. 
 
 By falling of the womb we generally understand a downward 
 displacement of the organ, in the direction of its longitudinal 
 axis, consequently corresponding with the axis of the pelvis. 
 
 The anatomical relations between the uterus and vagina will 
 not allow the assumption of a sinking of the former, either 
 without a corresponding shortening of the vagina by a kind of 
 shrinking, which shortening, owing to the external attachment of 
 the vagina, cannot easily take place ; or without the latter being 
 inverted by the sinking uterus. Hence, in most cases, ^^(9- 
 lapsus uteri is combined with inversion of the vagina^ and 
 according as this condition varies, three distinct degrees of 
 prolapsus have been adopted for some time. 
 
84 PEOLAPSE OF THE TTTERUS. 
 
 1. The uterus has simply descended somewhat into thef 
 vagina, the upper portion of the latter is inverted, or in other f 
 words, we might say, that the normal invagination of the 
 genital canal, forming the vaginal portion, has been increased. 
 In these cases the uterus is not visible at the vulva. This 
 degree is termed sinking of the iiterus^or descensus uteri. 
 
 2. The uterus has descended lower down, causing inversion! 
 of more than one-half of the vagina, and appears at the vulva." 
 This degree is termed incomplete prolapsus uteri. ' 
 
 3. In this the highest degree, the uterus has descended as[ 
 low as the vagina will allow, the whole or almost the whole; 
 length of which has been inverted, and protrudes from the^ 
 pelvic cavity. The prolapsed uterus now hes outside the! 
 vulva, forming a large tumour between the upper portion off 
 the thighs. This constitutes complete prolapsus uteri (Proci- 
 dentia uteri, hysterocele). 
 
 According to the degree of prolapsus, various accessory [ 
 conditions and consequences are developed. Even in the! 
 lowest degree the organ is always hypertrophied, and its Ion-! 
 gitudinal diameter especially, is increased. i 
 
 In the first degree or so-called descensus uteris in which the! 
 uppermost portion of the vagina is inverted, the vaginal por-| 
 tion appears much increased in length. Many authors posi-j 
 tively deny the possibihty of a simple descensus uteri, without' 
 accompanying inversion of the vagina, and; indeed, such a, 
 condition is difiicult to imagine ; for then only could we speak i 
 of descensus uteri without inversion of the vagina, if the| 
 latter was found much relaxed and marked with transverse! 
 folds, the uterus at the same time being very low down, a; 
 condition which I have never heard of in any case. With I 
 tolerable certainty we may assert, that what was thought tO' 
 be simple descensus without inversion of the vagina, was gen- 
 erally nothing but hypertrophy of the vaginal portion. • 
 
 Owing to the widely different opinions in regard to thef 
 normal length of the vagina, (it is estimated by Velpeau to be; 
 
PEOLAPSE OF THE UTEEUS. 85 
 
 I from 3 to 4 inclies, by Cloquet from 6 to 8, and more cor- 
 j rectly by Hyrtl at 2f inches*), it is often very difficult to 
 • distinguish hypertrophy of the vaginal portion from the first 
 j degree of prolapsus, (descensus uteri). 
 
 In well pronounced cases of complete prolapsus uteri, there 
 ] is seen protruding from the vulva, a rounded more or less 
 I pear-shaped tumour, the size of the fist, of a whitish-red or 
 I bluish-red color, the thick coriaceous and epidermis-like cover- 
 I ing of which, extends upward and all around, into the walls of 
 the vestibulum. In the covering of this tumom- we recognize 
 the various coats of the completely everted vagina, which, 
 especially in the higher degrees of prolapsus, and where the 
 latter has existed a long time, scarcely exhibits a trace of the 
 transverse folds which the vaginal mucous membrane possesses, 
 according to age and previous pregnancies, in its normal con- 
 dition. The disappearance of the rugae is in consequence of 
 the extreme distension of the vaginal walls. These rugae 
 or folds first disappear at the anterior surface of the tumour 
 forming the prolapsus, which is undoubtedly owing to the 
 shortness of the anterior vaginal wall, and which is therefore 
 stretched before the posterior one is completely everted. The 
 anterior surface of the prolapsus has a smooth and glossy 
 appearance, whilst the posterior one is frequently still marked 
 with transverse wrinkles. At the lowest extremity of the 
 tumour, the external orifice of the uterus is situated. It is 
 almost always directed somewhat posteriorly, a fact which 
 from observations I am forced to admit with Scanzoni, not- 
 withstanding the contrary might be inferred theoretically, 
 from the greater shortness of the anterior waU of the vagina. 
 StiU it must be mentioned that even independently of the 
 
 * "In the erect position, when its own weight and that of the intestines, 
 presses the uterus deeper into the pelvic cavity, the vagina shortens, and if 
 the woman squats down and presses at the same time, it may become so 
 short that the external os will be only an inch above the entrance of the 
 vagina." Hyrtl, topogr. Anatomic. lY. Anfl. 1860. II. pag. 157. 
 
86 PROLAPSE OF THE UTEEUS. 
 
 inequality in the length of the vaginal walls, the eversion ot 
 the anterior one is always more considerable and complete. 
 
 The external orifice has usually a semilunar form, with its 
 concavity directed posteriorly, or it appears as a transverse 
 gaping sHt, and no trace is left of the former vaginal portion^ 
 because the external layer of the duplication of the genital 
 canal which formed the vaginal portion, passes directly 
 upward in the same direction as the vagina. Sometimes the 
 external orifice is so dilated that the cavity of the cervix, usually 
 filled with viscid mucus, is to a certain extent open to view. 
 
 The surface of the tumour is coriaceous, compact and 
 unyieldiog, and covered with a thick layer of epithehum, 
 hence its whitish color ; at its lower end, generally near the 
 external orifice, spots varying in size, shape, (either round or 
 confluent) and color, (from rose to a dark red) are seen, and 
 which have the appearance of either superficial or deep ero- 
 sions, or even ulcerations, which generally have sharply defined 
 
 Kiwisch distinguishes from the usual form of prolapsus 
 uteri, senile prolapsus, in which the external orifice i& 
 more frequently narrower than in the normal state, and we 
 even meet with cases in which it is agglutinated or occluded 
 by excessive epidermic growth. 
 
 Notwithstanding the considerable stretching of the vagina 
 in prolapsus uteri, especially in its transverse diameter, its 
 w?Jls are always much thickened. This is chiefly owing to 
 proliferation of its epithehum, which forming successive lay- 
 ers, may attain the thickness of a hne, and appear in the 
 dead body in the form of shreds. The mucous membrane 
 underlying it is also thicker than usual, the submucous areo- 
 lar tissue more resistant and more or less oederaatous, and 
 muscular coat of the vagina is always considerably increased in 
 substance. Thus in every case of prolapsus uteri we find 
 well marked signs of hypertrophy of all the membranes or 
 layers of the everted vagina. 
 
PROLAPSE OF THE UTERUS. 87 
 
 In consequence of the tumefaction of the uterus prolapsed 
 into the everted vagina, and the stretching of the latter, the 
 vagina is generally considerably distended, and we have 
 already mentioned that lateral distention is the most consid- 
 erable, therefore we may assume, that in some instances, this 
 lateral distention of the vagina has occurred at the expense of 
 its length. 
 
 If we open the abdominal cavity in cases of complete pro- 
 lapsus uteri, we will always find, between the bladder and 
 rectum, a funnel-shaped inversion of the peritoneum toward 
 the floor of the pelvis. At either side of the upper and larger 
 entrance of this excavation, the ovaries and oviducts are found 
 drawn towards its margin, and frequently lying somewhat 
 anteriorly, and in the depths of the inversion the fundus uteri 
 will be discovered. The broad ligaments, especially in the 
 beginning of prolapsus, are always in a state of considerable 
 tension, and are sometimes stretched in the shape of folds, 
 which ascend obliquely from the lower part of the inversion 
 toward each side. The impeded reflux of venous blood occa- 
 sioned thereby, is apparent in the uterus, ovaries and oviducts, 
 as also in the everted vagina, presenting the appearance of 
 passive hyperaemia, and even stagnation, owing to the bluish 
 or bluish-red color from the intense varicose distention of the 
 veins. 
 
 As mentioned, the uterus has become larger and longer, its 
 walls, especially if the prolapsus is recent, are moister, soften 
 and even somewhat relaxed. In the majority of cases, how- 
 ever, they are dense and resistant, in consequence of consid- 
 erable hyperplasia ; the mucous membrane is always in a state 
 of hypersecretion and catarrh, and sometimes the cavity of 
 body and fundus is distended by mucus, especially if the elongj^- 
 tion of the organ be combined with a stricture of the inter- 
 nal orifice, however slight it may be. The relaxation of the 
 uterine tissue is noticeable in the region of the external orifice, 
 and consequently in what was previously the vaginal portion 
 
88 PEOLAPSE OF THE UTEEUS. 
 
 and lower segment of the cervix, which part often assumes a 
 spongy softness. This relaxation must be attributed to the 
 varicose condition of the blood vessels, and absorption of the 
 cervical tissue. 
 
 The intimate connection of the bladder and rectum with 
 the vagina, will not allow us to suppose a complete inversion 
 of the latter without traction of the connecting interstitial 
 tissue, and consequently also, of the posterior wall of the 
 bladder and anterior one of the rectum. In consequence of 
 these conditions, parts of the neighboring organs are drawn 
 down into the everted vagina. We will discuss this subject 
 more minutely when we come to consider eveesion of the 
 
 VAGINA. 
 
 Not unfrequently a uterus, which was prolapsed during hfe, 
 is found partly or entirely replaced after death. But in such 
 cases the relaxation of the stretched uterine ligaments ; the 
 wrinkling and looseness of the peritoneum in the elongated 
 Douglas' space ; the enlargement and especially the elongation 
 of the uterus ; the peculiar form of its external orifice ; and 
 especially the width of the vagina and thickness of its 
 walls, as also its peculiar appearance and coriaceous dry feel- 
 ing, will give evidence that there was prolapsus during lite. 
 It is very easy to reproduce prolapsus after death by shght 
 pressure upon the uterus. 
 
 Scanzoni remarks that the mobility of a prolapsed uterus 
 after replacement, is so much increased by the relaxation 
 of the stretched ligaments, that the organ is not only easily 
 returned into the pelvis, but may even be pushed into the 
 abdominal cavity considerably (1 to 2 inches) above its normal 
 position ; excepting of course those cases in which the 
 displaced organ is bound down by pseudo-membranous 
 adhesions. 
 
 A peculiar condition of the cervix is found in the higher 
 degrees of prolapsus uteri. As mentioned above, the external 
 orifice in many cases is so dilated that the cervical canal may 
 
PEOLAPSE OF THE UTERUS. 89 
 
 be viewed half way up. The latter is sometimes so rolled out 
 as to increase the prolapsus on the one hand, and the eversion 
 of the vagina on the other. In other instances, the puffed edges 
 of the external orfice separate, the vaginal portion becomes 
 more distinct, and the cervical canal is widely dilated in its 
 lower portion hke an inftmdibulum. In many cases the ever- 
 sion of the cervix may reach such a degree that the internal 
 orifice becomes the external one, the entire cervical canal 
 being everted. The eversion, however, of the latter, is never 
 so complete as that of the vagina; tlie inner sm-f ace of the 
 <3er^dx may become the inferior one of the tumour forming the 
 prolapsus, but it is never rolled out so far as to form its external 
 surface. The excoriations and ulcerations which usually denote 
 the external orifice, and which never extend above it, affect also 
 the mucous membrane of the cervix when the latter participates 
 in the eversion. The mucous membrane of the canal when 
 overted, appears as a bluish-gray ring encircling the entrance 
 to the uterus. 
 
 The vulva, in the higher degrees of prolapsus, is consider- 
 ably dilated, and in complete eversion of the vagina the vesti- 
 bulum likewise, especially its anterior circumference being 
 averted downward ; this causes the orifice of the urethra 
 to appear at the anterior surface of the prolapsus, and a 
 ■catheter introduced into it, will enable us to recognize the 
 ■complete alteration of its course. In such cases the urethra 
 passes from forward and above, in a direction backward 
 and below, as we will describe at the proper place. The 
 distention of the vulva is always more considerable ante- 
 riorly than posteriorly, and is apparent even in those 
 ■cases when the prolapsus has not yet appeared through it. 
 
 According to Kiwisch, the most important influence on the 
 occurrence of prolapsus rests in the vagina, the latter in its 
 normal condition being considered b}^ him as the main support 
 of the uterus; with which opinion however, after what I have said 
 in regard to displacements of the uterus, I cannot entirely agree. 
 
90 PROLAPSE OF THE TTEEUS. 
 
 In a certain sense we cannot deny that the vagma, or rather 
 the stretched fascia of the pelvis attached to the vagina, con- 
 tributes to the support of the uterus ; still other parts whic 
 contribute to normallv uphold that organ, must be taken into 
 account. To these, in my opinion, chiefly belong the joint 
 action of the ligaments, especially the broad, ihe round, and 
 the utero-sacral. The latter especially, forming a continuation 
 of the pelvic fascia, are certainly capable of opposing with some 
 resistance, a sinking of the cervix. In the above circumstances- 
 we also find a reason why prolapsus uteri occiirs much more 
 frequently in those who have borne children, and in whom 
 consequently, aU the hgaments are more elastic and more 
 readily stretched. In such, the vagina is of course much more 
 elastic and the floor of the pelvis more yielding. 
 
 Kjwisch makes three distinct divisions of prolapsus, accord- 
 ing to its causes : — 
 
 1. Simple prolapsus, in which the uterus is displaced pri- 
 marily by external violence or excessive abdominal pressure. 
 If the violence is considerable even a virgin uterus may be 
 prolapsed ; if the cause be less violent this form only occurs in 
 non-vii'ginal females, the predisposing cause being the same ;. 
 this latter is the variety most frequently met with. 
 
 2. Prolapsus occasioned by a prolapsed vagina drawing the 
 uterus down with it : or by shortening of the vagina in con- 
 sequence of a primary anomaly in formation ; or in conse- 
 quence of an ulceration with formation of a cicatrice : or as 
 the result of senile atrophy. 
 
 Prolapsus of the vagina, when commencing in its upper 
 portion, especially tends to cause prolapsus uteri. This form 
 differs fr'om the fii'st in this, that the vagina descends before 
 the uterus and the latter foUows, at the same time the cervical 
 portion of the uterus being necessarily much elongated. Thi& 
 form can never become very considerable. 
 
 3. That form of prolapsus caused by tumours, especiaUr 
 ovarian, situated in the vicinity of the uterus, and which 
 press or draw it downward. 
 
PROLAPSE OF THE UTERUS. 91 
 
 In regard to these statements, however, I must remark, as 
 is mentioned bj Kiwisch, that prolapsus from concussion of the 
 nterus can only occur from certain predisposing causes, namely, 
 a sufficient yielding of the pelvic floor, relaxation of the liga- 
 ments, and flaccid condition of the vagina ; and I cannot recog- 
 nize congenital shortness of the vagina as a predisposing cause 
 of prolapsus. 
 
 It is true Kiwisch adds, that a shortening of the vagina is only 
 the essential cause of prolapsus, if at the same time it is dilated 
 and relaxation of the ligaments still exists. Including even these 
 conditions, I doubt whether a short vagina predisposes to 
 prolapsus, excepting in this way, that when it does exist 
 the occurrence of complete prolapsus is rendered easier and 
 more liable at an earlier period. 
 
 The formation of cicatrices after ulcerations in the vagina^ 
 can only occasion prolapsus of the uterus in the following way, 
 that by a shrinking of the fornix vagina in its longitudinal axis, 
 downward traction may be exerted on the uterus, which 
 indeed may occasion some sinking of its vaginal portion, as well 
 as elongation of its cervix, and in rare instances, a certain de- 
 gree of sinking of its fundus, but the vagina will generally be 
 decidedly in the way of the occurrence of a complete prolap- 
 sus, especially by its simultaneous contraction. 
 
 The causes of prolapsus uteri consequently lie either in the 
 organ itself or in the vagina. In the first, from an increase in 
 its weight, from tumefaction (Duparcque), fibrous tumours and 
 polypi, unless the descent of the organ into the pelvic cavity 
 is rendered difficult or impossible by the tumefaction ; in the 
 latter, as previously mentioned, from shortening of the vagina by 
 contracting cicatrices. The congenital shortness of the vagina 
 already advanced by Mad Boivin, I cannot accept as either a 
 predisposing or direct cause of prolapsus. Another cause is 
 senile atrophy, which is generally combined with shortening 
 of the vagina from diminution of fatty tissue at its point of 
 origin, and the conical shrinking of the fornix and relaxation of 
 
92 PROLAPSE OF THE UTERUS. 
 
 the peritoneal attachments (Kiwisch). In stenosis of the ex- 
 ternal orifice with accompanying considerable distention of the 
 cervical canal, which occm*s not unfrequently in aged females, 
 a corresponding distention of the upper portion of the vagina 
 takes place, and if the distended cervix happen to collapse and 
 discharge its contents, prolapsus may easily ensue. Prolapsus 
 is also occasioned by primary inversion of the vagina combined 
 at the outset with, or followed by, cystocele or rectocele ; or by 
 descent of tumours or intestines into Douglas' space, or the 
 vesico-uterine excavation, which circumstances cause these 
 peritoneal sacs to be deepened, and induce inversion of the 
 vagina, and consequent descent of the uterus. Habitual accu- 
 mulation of faecal matter above the sphincter ani, causes a kind 
 of vaginal rectocele which may likewise be considered among 
 the causes of prolapsus. Scanzoni mentions as another cause, 
 over-distension of the bladder, producing relaxation of the 
 anterior wall of the vagina. 
 
 We may further mention as predisposing causes, in a certain 
 sense, relaxation and tenuity of the hgaments, either acquired 
 or congenital ; roomy pelvis ; insufficient inclination of the latter; 
 and especially rupture of the perinseum, upon the influence of 
 which in producing prolapsus Scanzoni has particularly laid 
 great stress, and whose description I have chiefly followed. 
 By perineal rupture the posterior wall of the vagina is deprived 
 of its greatest support, its lower portion protrudes through the 
 vulva, and dragging upon the uterus causes it to descend, in 
 consequence of which the subperitoneal attachments of the blad- 
 der are loosened, and the peritoneum which has been stretched 
 during previous labors, the more readily allows a considerable 
 deepening of the vesico-uterine and Douglas' space, into which 
 the intestines prolapse, and finally cause the uterus to descend 
 into the readily inverted vagina. Hydrops^ ascites^ and 
 encysted exudation, unless combined with pseudo-membranous 
 adhesions confining the uterus in its position, also retro-uterine 
 
PROLAPSE OF THE UTERUS. 93 
 
 haematocele, will likewise cause deepening of Douglas' space, 
 stretching of tlie ligaments, and finally prolapsus uteri. 
 
 Ashwell considered an insufficient action of the levator ani 
 and perineal muscles, and chiefly of the pelvic fascia, as the 
 principle cause of prolapsus. 
 
 Those forms of prolapsus which take place suddenly are 
 chiefly caused by some abdominal pressure, concussion, strain- 
 ing, carrying heavy weights, lifting and stooping. 
 
 The hgaments being relaxed and the floor of the pelvis 
 yielding, if a hypertrophied uterus descend on account of its 
 weight, hyperaemia fi-om traction of its vessels will ensue, and 
 the hypertrophied condition of the organ vdll be increased, 
 causing the incomplete prolapsus, or simple decensus, to be 
 gradually transformed into complete prolapsus uteri. 
 
 The immediate consequences of prolapsus are, derange- 
 ments of circulation and hypertrophy of the uterus ; chiefly 
 the cervical portion is elongated, often reaching an extra- 
 ordinary length (3 or 4 inches). The so-called prolapsus 
 of the uterus without sinking of the fundus, to which Yirchow 
 has again called attention, is highly interesting. He describes 
 a case of complete inversion of the vagina with the external 
 orifice of the uterus situated at its extreme end. In this 
 instance the fundus uteri was not only at its normal elevation 
 but rather above it. The enormous elongation of the uterus 
 affected chiefly the cervix, the substance of which was dense and 
 vascular. The entire length of the uterus from fundus to 
 external orifice measured 61 inches, 3 inches of which belonged 
 to the cervix (whilst according to Krause the greatest length 
 of a normal uterus is 3 J- inches). Of the conclusions drawn 
 therefrom by Yirchow in regard to prolapsus I shall mention 
 the two first ; that there exists a prolapsus of the uterus with- 
 out a sinking of its fundus, or as Morgagni states, with only 
 a slight sinking, and that this condition is caused by hypertro- 
 phy and elongation of the cervix. 
 
 It is therefore advisable in such cases, especially when the 
 
94 PROLAPSE OF THE UTERUS. 
 
 prolapsus is incomplete, to know whether we really have this 
 condition before ns, namely, a prolapsus without sinking of 
 the fundus, in which case a replacement could not be enter- 
 tained ; or whether we have a simple elongation of the vaginal 
 portion of the uterus. In the latter the fornix is often found 
 at its usual height, or only slightly drawn downward, whilst in 
 prolapsus without sinking, as well as in incomplete prolapsus, 
 the inversion of the vagina is always well marked. The ex- 
 pression "prolapsus without sinking" does not convey a 
 correct idea of the condition described. 
 
 The elongation of the cervix in prolapsus, notwithstanding 
 its hypertrophy, always takes place at the expense of its thick- 
 ness. At the same time the uterine cavity is narrowed, and 
 even complete atresia of the internal orifice may be found 
 combined with distension of the cavity of the uterus from ac- 
 cumulated mucus. 
 
 In complete prolapsus the vaginal portion is generally soft- 
 ened and spongy, but in many cases it is thickened and denser. 
 After the prolapsus has existed for some time, the excoriations 
 previously mentioned make their appearance, at first being 
 cu-cular and well defined but after a time becoming deep 
 ulcers, which secrete a corrosive ill-smeUing fluid. This cir- 
 cumstance is owing to the contact of the atmosphere, the 
 moisture from the urine, and friction of the thighs and clothing. 
 
 The vaginal epithelium increases, the external layers exposed 
 to the air become dry and scaly, like epidermis, the epithehal 
 cells lose their nuclei, and the other coats of the vagina 
 become hypertrophied. 
 
 In aged females the external orifice of the prolapsed uterus 
 is frequently found occluded by excessive epithehal growth, 
 leaving only a shallow depi'ession at the external part of the 
 tumour, denoting where the external os is to be found. 
 
 I have lately been convinced of the frequency of this occlu- 
 sion by mere epithelial growth in aged females. 
 i^ Owing to the considerable contraction of those bloodvessels 
 
PROLAPSE OF THE UTERUS. 95 
 
 whose office is to return the blood from the neighboring 
 organs, the passive hypersemia in th« latter must be greatly 
 increased, and catarrh and oedema of the oviducts and ovaries, 
 and thickening of the former, will frequently ensue. 
 
 If prolapsus has occurred suddenly, the sudden traction of 
 the peritoneum and resulting derangement of circulation, may 
 cause the hypersemia of the appendages to become inflam- 
 mation. Coiisequentl J per i7net?itis sets in, and the false mem- 
 branes formed dm-ing its course, are frequently the cause ot 
 the adhesion of the organs to each other or to the peritoneum in 
 their abnormal position. Owing to this circumstance the pro- 
 lapsus may become irreducible, especially as the thickening of 
 the sub-peritoneal areolar tissue may contribute to the abnor- 
 mal fixation of the uterus. 
 
 The inflammation of the pelvic peritoneum may also spread, 
 and fatal general peritonitis supervene. 
 
 A frequent consequence of prolapsus uteri, is descent of 
 the posterior wall of the bladder and the anterior of the 
 rectum, caused by the inversion of the vagina. In conse- 
 quence of the vaginal cystocele, the uterus undergoes consider- 
 able displacement and sometimes a moderate traction. In 
 complete inversion of the vagina, which occurs in the 
 highest degrees of prolapsus, the posterior wall of the bladder, 
 around the trigonum, and even the whole organ, is consider- 
 abl}^ drawn upon, and its complete distension upward is partly 
 hindered, by the descent of the vesico-uterine excavation 
 causing considerable tension of the posterior peritoneal surface 
 of the bladder. In consequence of these tractions, stasis of 
 blood in the hypogastric and spermatic venous plexuses, Ayper- 
 cemia, and finally catarrh of the mucous mevihrane is brought 
 on. If by inversion of the vagina, as is generally the 
 case, that portion of the bladder which corresponds to the 
 orifices of the uterus, is subjected to traction, accumulation of 
 urine, dilation of the ureters and hydronephrosis may ensue. 
 (E-etzius, Virchow). 
 
96 PROLAPSE OF THE UTEEUS. 
 
 As regards disarrangements of the sexual functions, gyneco- 
 logists do not agree in their statements. Whilst Scanzoni 
 maintains that prolapsus uteri is generally ^followed by derange- 
 ment of menstruation, other experienced authors state that, 
 strange to say, menstruation occurs with astonishing regularity 
 in those affected. From these opposite opinions of distin- 
 guished pathologists, we may conclude that prolapsus uteri 
 sometimes exerts an injurious influence on the function of 
 menstruation, and at other times it does not, although we are 
 unable to demonstrate with certainty the various anatomical 
 conditions on which this difference is founded. 
 
 Eepeated observations have however demonstrated that in 
 prolapsus, conception can take place. When the body of the 
 uterus has remained in the pelvic cavity, and enlarges during 
 pregnancy, it spontaneously ascends in the abdomen, and the 
 prolapsus is thereby rectified, the vagina being again drawn 
 up and returned to its normal position. However, there is- 
 great danger in such cases of a sudden renewal of the pro- 
 lapsus, and the occurrence of complete inversion of the uterus, 
 after delivery. 
 
 Yirchow mentions a case of Bartholins (Sepulchretum, Lib. 
 III. Sect. 31. Appendix, ad. Observ. 5 — Yirchow), in which 
 
 woman each time she conceived, was subject during the first 
 months of pregnancy to a slight prolapsus uteri, though she 
 never suffered from it during the intervals. Yirchow here adds 
 that Kiwisch denies the vahdity of the general opinion that 
 the uterus sinks at the beginning of pregnancy. 
 
 If a uterus already pregnant is prolapsed, which as a rule 
 occurs suddenly, and is only possible (under conditions other- 
 wise normal) during the first three months, the sudden 
 disarrangement of its circulation generally causes extravasation 
 of blood within the membranes or placenta, and consequent 
 death of the foetus and miscarriage. 
 
 If a prolapsus has been replaced by manipulation, it may 
 be permanently cm-ed by nature by the occurrence of ^form- 
 
PROLAPSE OF THE UTERUS. 9T 
 
 ative irritation in the peritoneum, and sometimes by the form- 
 ation of false membranes consequent upon inflammatory pro- 
 cesses, which afterwards hold the uterus in its normal position. 
 Still this cure, from an anatomical point of view, must be 
 considered as of a temporary character ; for the false membranes 
 will scarcely possess the firmness of the hgaments which nor- 
 mally maintain the uterus in position, and besides they gradually 
 become stretched into cords which will readily yield. Seyfert 
 mentions a case of prolapsus which was relieved by retro- 
 flexion ; but it is difficult to sa}^ which of these was the lesser 
 evil. A larger proportion of cures has resulted from impreg- 
 nation of the uterus, the prolapsus, as previously mentioned, 
 disappearing during pregnancy. If in such instances, after 
 parturition, puerperal peritonitis with pseudo-membranous 
 adhesions, comes on, the uterus during its gradual involution 
 being held in its natural position, a recurrence of prolapsus 
 may at least temporarily be prevented. 
 
 In the same manner a recurrence of complete prolapsus may 
 be prevented, in consequence (A jpiierperal vaginitis^ by cica- 
 trices contracting the vagina, although by their contraction in 
 the longitudinal axis of the latter, a slight sinking of the 
 uterus is necessarily occasioned. Both these occurrences have 
 been observed by Scanzoni. 
 
 The statement of Scanzoni, that traction of the round liga- 
 ments facilitates the occurrence of inguinal hernia, cannot 
 relate to the time during which the prolapsus exists ; for then 
 the ligaments are stretched out of the inguinal canal, and the 
 latter can never be dilated by this traction. Besides, the 
 tension of the peritoneum around the inner inguinal ring is too 
 considerable during prolapsus to allow its being everted into 
 a hernial sac ; and in addition to this, the abdominal space 
 allowed the intestines is increased by the deepening of the 
 pelvic cavity But if the prolapsus be replaced, the peritoneum 
 covering; the round ligaments must be considerable relaxed, 
 and consequent!}^ the occurrence of inguinal hernia rendered 
 much more easy. 7 
 
98 PROLAPSE OF THE UTERUS. 
 
 Prolapsus uteri, as may be inferred from what lias been said^ 
 takes place either in an acute or chronic manner. It occm*s- 
 in an acute manner when, in addition to the predisposing causes 
 mentioned, a pressm-e is exerted upon the uterus, as for instance, 
 from excessive abdominal pressure. In this case the chief pre- 
 disposing causes are, a relaxation of the uterine ligaments from 
 frequent pregnancies, and a greater yielding of the pelvic floor, 
 resulting from the same cause. Of 114 cases of prolapsus uteri 
 observed by Scanzoni, 99 were in woman who had borne 
 children. Still, senile relaxation of the parts mentioned must 
 be taken into account as an important predisposing cause. 
 
 Prolapsus arising in a chronic manner, is chiefly induced by 
 partial inversion of the vagina, especially when this inversion 
 commences with cystocele and rectocele, and the former 
 gradually reaching its highest degree, drags the uterus with 
 it ; it is also frequently occasioned by a deepening of Douglas' 
 sac from intrusion of intestines {vaginal entrocele). 
 
 According to Scanzoni's statements prolapsus uteri rarely 
 occurs in those who have not borne children. It is less 
 frequent in those who have borne one, than in those who have 
 had several children, the predisposition thus increasing with 
 successive deliveries. As age advances, its occurrence is ren- 
 dered easier in consequence of senile relaxation. We there- 
 fore meet with prolapsus uteri most frequently, and in its most 
 perfect forms, in aged women who have frequently been deli- 
 vered. It has never been known to occur before perfect 
 maturity. 
 
 In its highest degrees, prolapsus may cause death by the 
 previously mentioned effects upon the functions of the urinary 
 passages and the rectum, as also in its .acute form, by the 
 occurrence of general peritonitis. 
 
INVERSION OF THE UTERUS. 99 
 
 5. INYEKSION OF THE UTERUS. 
 
 Literature: H e i n r i c h v. S a n d e u, Observ. de prolapsu uteri inversi 
 ab exciesc. carneo-fungosa etc Regiomonti, 1722. — B o b m e r , Diss, 
 de uteri prolapsu et inversioue. Halae, 174:5. — Saxtorpb, Act. soc. 
 Havn. Vol. III. Nr. 27. Vol. IV. Nr. ]0. 17. — B aud elo cque , 
 L'art des accoucb. T. 1. Paris, 1781. — D e n m a u n , Collect, of Engrav. 
 tend, to illustrate tbe generat. and partur. of anim. and of tbe bum. spe- 
 cies. London, 1787. Tac. XL — M. Saxtorpb, De diversis uteri inversi 
 speciebus I. der gesammelten Scbi'iften. Kopenbagen, 1803. p. 300. — 
 V o i g t e 1 , Patb. Anatom. III. Halle, 1805. — Denmann, An 
 introduct. to tbe practice of midwif. London, 1806. PI. XII. — M m e. 
 Boivinet Duges, Traite prat, des mal. de 1' uterus et des ses 
 adnexes etc. Paris, 1833. — Martin, Memoires de med. et de cbirurg. 
 pratique etc. Paris, 1835. — Lawrence, Lond. med. Gazette. Decbr. 
 1838. — Kiwiscb, Die Krankb. der Wocbnerinnen. Prag, 1841. — 
 B u s c b. Das Gescblecbtsl. des Weibes. III. Bd. 1845. — M e i s s n e r, 
 Frauenzimmerkranlib. Bd. III. Leipzig, 1845. — Meigs, Obstetrics : 
 tbe science and tbe art. Pbiladelpbia, 1849. — Cruyeilbier, Traite 
 d'anat. patb. gen. Tom. I. 1849. — S. Merriman, Times, July, 1851. 
 — Tyler Smitb, Med. cbii\ Transact. Vol. 35. pag. 399. PI. IX. 
 1852. — Zwank, Monatscbr. f. Gebk. Berlin, 1853. Marz. — Vir- 
 cbow, Arcbiv. Bd. VII. pag. 167. 1854. — Kiwiscb klin. 
 Vortr. Prag, 1854. Bd. I. — Meigs, Women, ber diseases and remed. 
 Pbiladelpbia, 1854. Ed. 3. — Hobl, Scanzoni (1855) und C. B r a u n 
 (1857), Lebrbllcber der Geburtsbilfe. — Scanzoni, Kkb. der weibl. 
 Sexual. AVien, 1857. — Langenbeck, Monatscbrift f. Geburtsk. 
 Berlin, 1860 Miirz. — G u r 1 1 , Monatscbrift f. Geburtsk. Berlin, I860. 
 Jub. — Woodson, Americ. J ourn. of Med. Octob. 1860. — B e t s c b- 
 1 e r, Kbnicbe Beitr. zur Gynacol. v. Betscbler, W. u M. Freund I. Heft. 
 Breslau, 1862. — Besides tbe above, cbiefly tbe works on patbological 
 anatomy by F o r s t e r and Rokitansky. 
 
 By inversion of the uterus we understand a foldins: inward 
 of the organ into its own cavity, or into that of the vagina. 
 
 We may therefore, anatomically speaking, distinguish two 
 degrees of inversion ; either the fundus is inverted more or less 
 into its cavity, the inverted portion being within the cavity of 
 the uterus ; or, the uterus has been so completely inverted that 
 its mucous surface has become the external one, and its peri- 
 tonial surface the internal ; the vaginal portion turning upward 
 forms the highest portion of the uterus. 
 
 Busch distinguishes as the primary degree of inversion, simple 
 depression of the fundus uteri. In this case the fimdus or a 
 
100 INVEKSIOX OF THE UTERUS. 
 
 portion of the body is inverted, but has not passed beyond the 
 internal orifice, whilst in the second degree, the so-called iiicoin- 
 jplete inversion, the mverted portion protrudes through the os 
 uteri. Both of these degrees may be termed mcomplete inversion 
 of the uterus, in order that they may be distinguished from com- 
 plete inversion^ waich is the highest degree of this affection. 
 
 In a case of incomplete inversion of the utenis, on opening the 
 abdomen, and removing the intestines from the pelvis, we find 
 in the space between the rectum and bladder, a cylindical or 
 conical body, broader in its upper portion, on the superior sm-- 
 face of which a small funnel-shaped recess is seen, andtowai'ds 
 wliich, according to the degree of inversion, the insertion of 
 the oviducts into the uterus, are more or less di'awn laterally. 
 
 In incomplete inversion, we find between the bladder and 
 rectum a large space, and m its depths toward the outlet of 
 the pelvis, again a funnel-shaped fossa, smToimded by the 
 walls of the inverted uterus and lined with the peritoneal 
 covering of the latter. The fundus uteri forming the lowest 
 portion of this cavity, the hgaments of the uterus and the 
 oviducts likewise, are at least partly drawn into this space. 
 As regards the size of this cavity, and the relations of the uter- 
 ine appendages to it, Betschler has lately corrected the opin- 
 ions formerly held on this subject. The size of the cavity 
 depends upon that of the uterus before inversion. It must be 
 large when the inversion has occurred hi an acute manner after 
 labor, and much smaller if it has occm-red iu a chi'omc manner ; 
 as for instance, in consequence of a pathological growth. Dm'- 
 ing the enlargement of the pregnant uterus, the oviducts and 
 ovaries are drawn into the lateral margin of the former in such 
 a manner, that the ovaries are almost in contact with the ute- 
 rus; which circmnstance is certainly caused by the uterus 
 taking up the peritoneum of the broad ligament dming its 
 distention. If the uterus be inverted, it is evident that the 
 oviducts and ovaries will be found in the newly-formed exca- 
 vation. But if the inversion has occurred in consequence of 
 
INVERSION OF THE UTEKUS. 101 
 
 a tumour, neither the ovaries or the fimbriated extremities of 
 the oviducts, liave been so approximated to the uterus as to 
 be drawn into the inverted cavity ; on tlie contrary, we find 
 that in such cases only the commencement of the oviducts are 
 within the excavation. 
 
 After an inversion of the uterus, succeeding labor, has 
 existed for a certain length of time, the process of involution 
 of the organ is not arrested, and as this progresses, the above- 
 mentioned excavation diminishes, and the oviducts and ovaries 
 which in the commencement were in it, resume their original 
 position laterally from its margin. 
 
 Betschler calls attention to a peculiar relation of the intes- 
 tines to an inversion of the uterus. It is generally stated that 
 intestines may prolapse into the cavity formed by the inver- 
 sion; yet in the reported cases of amputation of inverted 
 uteri, it is never mentioned that intestines were found. If the 
 inversion is incomplete, and the uterus has not been inverted 
 deep enough, a portion of intestine may indeed happen to 
 fall into the cavity, and may prolapse still lower down as the 
 inversion increases. If then the fundus ateri passes through the 
 internal orifice, the inverted part may be constricted, and the 
 intestine incarcerated. But afterwards when the fundus 
 descends still lower down, the cavity of the inversion is dimin- 
 ished by contractions, which taking place from below upward, 
 and aided by the peristaltic action of the prolapsed intestines, 
 expel the latter. It is true that this may be prevented by 
 adhesions between the intestines and uterus. 
 
 From the anterior margin of the above cavity two tightly 
 stretched cords, the round ligaments, are seen to ascend in a 
 cm-ve towards the inner inguinal ring. The peritoneum 
 around tlie entrance to the cavity is stretched into folds, 
 especially on both sides ; sometimes ^posteriorly two sharply 
 defined peritoneal folds project, which are formed by the 
 utero-sacral ligaments. 
 
 In complete inversion of the uterus the organ protrudes into 
 the distended vagina in the shape of a pyriform mass, or as a 
 
102 IlSrVEESION OF THE UTERUS. 
 
 large and relaxed, or small and dense rounded tumour, chiefly 
 of a dark or bluish-red color, and covered with mucous mem- 
 brane, the superior limits of which may be easily felt. The 
 lips of the inverted vaginal portion form a sort of circular 
 rim, the lower border looking toward the fornix. The mu- 
 cous membrane of the uterus is now in direct contact with 
 that of the vagina, and it happens very frequently that, after 
 or contemporaneously with inversion, the vagina is also 
 inverted, and sometimes so completely, that the inverted uterus 
 descends below the vulva. This combination has very properly 
 been termed prolapsus of the inverted uterus^ and constitutes 
 a complete inversion of the entire genital canal. 
 
 Incomplete, as well as complete inversion of the uterus, can 
 only occur when the organ is in a relaxed state ; and it is only 
 in very rare instances that a nearly normal uterus can grad- 
 ually be inverted. 
 
 Inversion consequently occurs almost exclusively after 
 dehvery, at which period the uterine walls are very much 
 relaxed, and the cavity of the uterus comparatively large ; and 
 it is especially likely to occur if the contractions take place 
 unequally, the fundus contracting whilst the cervix is entirely 
 relaxed. Inversion is also met with independent of the puer- 
 peral condition, as when large polypi with broad pedicles are 
 attached at or near the fundus uteri, and having distended the 
 organ are expelled, drawing the fundus with them. To con- 
 sider hydrometra and hsematometra as causes of inversion, as 
 Busch does, is only allowable in rare instances, and in slight 
 degrees of inversion, for the reason that in the higher degrees 
 of inversion, the body and fundus uteri lose their contractile 
 power, whilst the cervix is generally well contracted and fre- 
 quently hypertrophied. Besides, these distentions of the uterus 
 seldom attain a higher d^egree, r.nd we may therefore presume 
 that only after sudden evacuation of accumulated mucus or 
 blood, inversion of the fundus uteri might possibly occur. 
 
 If inversion of the uterus takes place immediately after 
 delivery, it is either in consequence of precipitate labor, or 
 
INVERSION OF THE UTERUS. 103 
 
 shortness and twisting of the umbilical cord, and probably 
 also of incautious traction on it when the placenta is firmly 
 adlierent. 
 
 In women who have died from puerperal endometritis, 
 the uterus often bears deep imjjressions of the neighboring 
 organs, and its external form is often flattened from the pres- 
 sure of the intestinal convolutions. ' In many instances these 
 impressions become deep fossse, and may lead to complete 
 inversions (Kiwisch). 
 
 Merriman observed in most of the inversions of the uterus 
 which occurred after parturition, a firmer attachment of the 
 placenta to its walls, combined with greater thinness and 
 laxity of the organ, and he looked upon these conditions as 
 the cause of inversion. 
 
 Rokitansky particularly mentions the fact of the unequal 
 -contraction of the uterus, and especially, that that part to which 
 the placenta is attached, is most frequently imperfectly con- 
 tracted ; which condition combined w^ith abdominal pressure, 
 causes inversion. 
 
 A very remarkable class of cases are those in which, with- 
 out apparent cause, an inversion of the cervix into the vagina 
 takes place, drawing the fornix of the latter with it, and thus 
 forming a poh'pus-like tumour in the cavity of the vagina, 
 w^hich may reach down to the vulva, and at the lower extrem- 
 ity of which the internal orifice is situated, (Lawrence). In 
 these cases it is probable that partial inversion of the lower 
 portion of the cervical canal took place, being afterwards 
 complicated with prolapsus uteri. Virchow mentions these 
 partial inversions of the cervix as having been first described 
 by Tyler Smith. They are said to be caused by the development 
 of larger follicles in the vaginal portion, in consequence 
 which the external orifice is dilated, and the relaxed lips of the 
 OS uteri are gradually everted. When this inversion has once 
 occurred, every succeeding pregnancy contributes to increase it. 
 
 When prolapsus exists, and the external orifice is large and 
 wide, it is known that the uterus with its large and wide vagi- 
 
104 INVEESION OF THE UTERUS. 
 
 nal portion may increase the inversion of the vagina and the 
 prolapsing tumour, for the reason that the cervix is more and 
 more everted and rolled up, (Aug Mayer). 
 
 Al] these classes belong to one category, and consequently 
 partial inversion of the cervix may be the result of leucorrhoea 
 and an increase of the uterine follicles, especially when com- 
 bined with descensus uteri. But such an inversion of the 
 vagina may also be caused by prolapsus, if the vagina 
 is firmly attached and unyielding in its superior portion, 
 and offers resistance to the descensus, especially when the 
 cervix and vaginal portion are relaxed by catarrh, by cystoid 
 degeneration of the mucous folHcles, and more or less previous- 
 dilatation of its cavity. 
 
 Dr. Ulrich of Vienna observed a case, known to me from 
 the post mortem examination communicated by him, of inver- 
 sion of the posterior wall of the uterus caused by a fibrous- 
 polypsus, which was attached in the vicinity of the internal 
 orifice, and first descended with the inverted uterus into the 
 vagina, and afterwards with the completely inverted vagina,^ 
 through the vulva, a case having no analogy that I know of, 
 and one peculiarly interesting from the singular flexion of the 
 fundus. 
 
 Both forms of inversion of the uterus occur either in an 
 acute or chronic manner ; and accordingly their consequences^ 
 especially those of complete inversion, are different. 
 
 Complete inversions occurring suddenly, are, according ta 
 the statements of all pathological anatomists and gynecologists, 
 frequently fatal, in consequence of the shock which the ner- 
 vous system receives, and I am unable to refute this statement. 
 Still, its correctness can only be assumed from want of other 
 arguments. In the majority of cases, when inversion takes 
 place suddenly after delivery, hgemorrhage supervenes from 
 the open veins of the part to which the placenta was attached, 
 and which is the more obstinate on account of the uterus 
 being at least momentarily paralyzed and its vessels over-dis- 
 tended, from traction. This haemorrhage will sometimes con- 
 
IN^YERSION OF THE UTERUS. 105 
 
 tinue after replacement, because the veins at the seat of the 
 placenta remain open, owing to deficient contractile power of 
 the uterus, excepting the cases in which thrombosis occurs, 
 which may extend upward so much the easier as the veins are 
 enlarged, and then the consequences of extended thrombosis 
 may in various ways prove fatal. 
 
 In consequence of the excessive traction which the uterus 
 and its appendages suffer, inflammation of the organ, perito- 
 nitis, and especially perimetritis, may supervene. Cases have 
 also been observed of absolute stasis and gangrene caused by 
 the contraction of the cervix of the inverted uterus, and in 
 consequence of which the entire organ may slough^ away 
 (Martin, Davvill), and yet the case result favorably. We must 
 mention in regard to this contraction of the neck of the uterus, 
 that if intestines He in the cavity formed by the inversion, 
 they may be incarcerated, and consequently in very rare 
 instances such a termination may be observed. 
 
 In complete chronic inversion of the uterus, hsemorrhages 
 also occur, mostly from the uterine mucous membrane which is 
 exposed to external influences, but in general, chronic inver- 
 sion gives but little trouble. Those cases are also interesting 
 in which the uterus, inverted in an acute or chronic manner, 
 is so diminished in size by contraction and involution, that it 
 forms an inconsiderable tumour causing no inconvenience ta 
 the patient. 
 
 Li inversions, epithelial vegetations, excoriations and even 
 ulcerations are frequent on the surface of the mucous mem- 
 brane. The ej)ithelium of the inverted and, prolapsed uterus 
 is transformed, especially in the cases of vegetations just men- 
 tioned, into a pavement epithelium similar to that of the vagina. 
 
 During the presence of the inverted uterus within the 
 vagina, ulcerations on their respective surfaces may granulate, 
 and adhesion of the mucus surface of the uterus to that of the 
 vagina may result. 
 
 Kiwisch observed a case of carcinoma of an inverted fundus 
 uteri. 
 
106 HYSTEEOCELE OR METEOCELE. 
 
 6. HYSTEEOCELE OR METEOCELE. 
 
 Literature: Doring, De herniae uterinae atque hanc justo tempore 
 subsequentis partis caesarei Mstoria, Yitemberg, 1612. — Oelhafen, 
 De partibus abdoinine contentis. Gedani, 1613. — Oneides, Diss. 
 de hernia uteri. Lugd. Batav. 1680. — Sennert 0pp. omn. Tom. I. 
 Lib. II. part. 1. Cap. X. pag. 329. — Ruysch, Adversar. anatom. 
 Amstelodami. 1717. Dec. II. obs. 9. — Morgagni, De sed. et. caus. 
 morb. etc. Venet. 1761. Ep. XLIII. art. 14. — M. Saxtorph, Coll. 
 soc. Havn. Vol. II 1775. — Desault, Chopart et Desault, malad. 
 chir. Tom. II. pag. 207. Paris 1779. — Lallemand, Memoir, de la 
 soc. med. d' Emulation an 3. pag. 321. — Bull, de la Facult. de Med. 
 et de la soc. de Paris 1816. Tom. I. — Meckel, Path. Anat. Bd. U. 
 Abthl. I. Leipzig, 1816. — F. L. M e i s s n e r , Die Umsttilpung der 
 Gebarmutter u. der Mutterbruch. Leipzig, 1822. — Landesma, 
 Journ. de med. et chir. Paris, ] 842. — Fischer, Lond. and Edinb. 
 Monthly Journ. 1842. — Meissner, Frauenzimmerkrankheiten. 
 Leipzig, 1843. — ^shwell, A pract. treatise on the diseas. pecul. 
 of Women. London, 1845. — Jos. Bell, Monthly Journ. London, 
 1848. July. — Cruveilhier, Anat. path. gen. Livr. 34. PI. 6. — 
 S k r i V a n , und L u m p e , Zeu'schr. d. Ges. d. Aertze. Wien. 1851. 
 '9. H. und 1853. 2. und 6. aeft. — K i w i s c h, Klinisch. Vortrage. 1854. 
 Bd. I. pag. 205. — L e o t a u d , Gaz. des Hopit. 1859. Nr. 1805. — 
 Murray, Lancet, April 1859 • — Rektorzik, Ein Fall von Gravid- 
 itas extraabdominalis. Zeitschr. f. prakt. Heilk. Wien, 1860. Nr. 18. 
 
 When the uterus is so displaced that it is situated in a 
 hernial sac lined by the peritoneum, it constitutes what is 
 called hysterocele. 
 
 According to the situation of the hernia, the following vari- 
 eties of hjsterocele occur. 
 
 1. Inguinal hysterocele. In this form the entire uterus or 
 its fundus has entered an internal or external inguinal sac. 
 Cases of this kind are very rare, especially of the gravid 
 uterus, and the possibility of the latter is the more doubtful, 
 since extra -uterine pregnancy has been found in an inguinal 
 hernial sac (Skrivan), and has been mistaken for it (Lumpe). 
 A gravid uterus can only be displaced into a large inguinal 
 hernia existing previously, which is of rare occurrence in 
 females. From the above we take peculiar interest in the 
 case of Rektorzik, in which it was supposed that the rudi- 
 
HYSTEROCELE OR METROCELE. 107 
 
 mentary accessory horn of a uterus nnicornis, was situated in a 
 right inguinal hernia, and being impregnated in this position, 
 pregnancy reached its normal limits and a matured child was 
 delivered by the aid of the knife. An examination of the 
 mother who died soon after, was, I regret to say, not allowed. 
 Inguinal hysterocele is sometimes congenital (Maret), and is 
 of more frequent occurrence in children than adults, undoubt- 
 edly owing to the situation of the oviducts and ovaries, above 
 the entrance of the pelvis, being more favorable to the occur- 
 rence of such a hernia. 
 
 2. Crural hysterocele. In this variety the uterus prolapses 
 with its fundus foremost, into a crural henial sac. This may 
 occur to the gravid (Sennert, Doring, Saxtorph) as well as to 
 the non-gravid uterus, (Lallemand). 
 
 3. Dorsal, or more properly, ischiatic hysterocele. In this 
 the uterus passes into the hernial sac which prominates through 
 the greater ischiatic notch. This hernia was observed in an 
 incomplete stage by Papin (Epistola ad Hallerum de stupenda 
 hernia dorsali). The hernial sac may enlarge considerably 
 and extend further under the integrements. 
 
 4. Hysterocele through the foramen ohturatoinum or ovale 
 (Kiwisch). The uterus in this form is found protruding through 
 the foramen ovale of the hip bone. 
 
 5. TJmhilical hysterocele. Observed only when the gravid 
 uterus has passed into an umbilical hernial sac (Leotraud, 
 Murray). 
 
 To these true herni?e we may add the so-called 
 
 6. Ventral hysterocele — the most frequent variety of dis- 
 placement of the uterus. It occurs in consequence of rupture 
 of the aponeurosis, or more commonly, after the separation of 
 the recti muscles of the abdomen, which up to the present 
 time has only been observed in pregnant women. Kiwisch 
 states that in rare instances this displacement of the uterus 
 may occur laterally from the recti muscles. Ruysch describes 
 a case in which the gravid uterus was forced through a ruptured 
 
108 HYSTEEOCELE OP. METROCELE. 
 
 cicatrice, resulting from an abscess in the inguinal ring. 
 Roussett and Ashwell saw a case of ventral hysterocele, which 
 resalted from rupture of the cicatrice after a successful Caesar- 
 ian operation. In many cases ventral hysterocele docs not 
 constitute a true hernia, the peritoneum and aponeurosis being 
 pressed forward into the space formed by the separation of the 
 recti muscles. 
 
 Kjwisch speaks of this displacement as eventration of the 
 uterus with inchnation forward, a term more correct than the 
 former. In cases of ventral hysterocele the abdominal walls 
 are very thin. 
 
 Hysterocele in the majority of cases, should generally be 
 considered as a secondary displacement of the uterus. Prima- 
 rily the ovaries and oviducts enter the hernial sacs, and appear 
 to be adherent to them ; or rather that portion of the perito- 
 neum forms the hernial sac, which is nearest to the superior 
 exti'emities of the broad ligaments, whereby the ovaries and 
 oviducts are carried into the sac. Thereupon the sac increases 
 in size at the expense of the peritonemn constituting the broad 
 ligament, by which latter the uterus is gradually drawn to the 
 hernial ring, and finally enters the sac. In many cases the 
 uterus follows a prolapse of omentum or intestine into a her- 
 nial sac, especially if there are adhesions between the omentum 
 or intestines, and the uterus. 
 
 We must mention in regard to congenital inguinal hystero- 
 cele, that it is caused by an incomplete descent of the ovaries, 
 analagous to a similar process in the male, the uterus being 
 drawn with them. 
 
 The gravid, as well as the non-gravid uterus, may pass into a 
 hernial sac, and the gravid one may even be impregnated in this 
 position. Some forms of hysterocele, however, are peculiar to 
 the gravid uterus only, as umbilical and ventral hysterocele, 
 In such cases labor pains commonly come on before the full 
 term of pregnacy, still cases are known even of inguinal 
 and crural hei'nia of the OTavid uterus, in which the foetus 
 
ALTERATION OF THE FORM OF THE UTERUS. 109 
 
 matured and was delivered by an operation similar to the 
 Caesarian. 
 
 In general, hysterocele is of very rare occurrence, and only 
 of importance from the co-existing dysmenorrhoea and its 
 effects. 
 
 II. ALTERATION OF THE FORM OF THE UTERUS. 
 
 The anomalies of form of the uterus depend chiefly on 
 the condition of its cavity. Its form is also subject to various 
 irregularities in consequence of the developement of various 
 new-formations in different portions of its tissues, and further, 
 by mechanical causes acting by traction or pressure, but which 
 are so manifold, and may appear so peculiar in each individual 
 case, that they cannot be brought under one classification. 
 Various alterations in the form of the uterus are also described 
 by gynecologists, under the name of hour-glass uterus, which 
 is said to be caused by an annular contraction of the organ, 
 when the rest of its tissue is relaxed, but which is very rarely 
 seen in the dead body, or only in such an imperfect degree 
 that it is almost impossible for anatomists to consider such as 
 particular cases. We therefore content ourselves with men- 
 tioning abnormal proportions of the uterine cavity, as being the 
 most important conditions, which alter the form of the uterus. 
 
110 STKICTLKE AZS'D ATKESIA 
 
 ACQUIRED STRICTURE AND OCCLUSIOX OF THE CAVITY OF 
 THE UTERUS, STENOSIS AND ATRESIA UTERI ACQUISITA. 
 
 Lituratur e: H i p p o c r a t e s , De. morb. mulier. Lib. II, cap. 50 — Fa- 
 briciusHildanus. Opera observ. etc. Francof. 164G — L i 1 1 r e , Me- 
 moires, de 1' acad. des sciences. Paris. 1704, pag. 33; 1707. pag. 27 
 und 1720 pag. 16 — Morgagni, De sedib. et. caus, morb. Venetiis, 
 1;gi. Ep. XL. art. 14—21., Ep. XLYIL art. 1)., 11. — Trezel in E. 
 Sandifort Thesaurus disserat ionum. Vol. II. Nr. 3. — Weisse, His- 
 toria partus impediti ex membr. tendin. os uteri intern, arctante. 1761. 
 in Sandifort's Thesaur. diss. Vol. 11. pag. 75. — Hebenstreit. I 
 De uteri coucretione morb. Lipsiae, 1801. Siebold, Handb. der, 
 Frauenzimmerkrankh. Frankfurt, 182 1. H. Aufl. Bd. I. pag. 218. — 
 Kittel, Die Fehler des Muttermundes etc. Wiirzburg, 1823. — W.. 
 S c li m i 1 1 , Heidelb. klin. Annal. 1825. Bd. 1 . 4— K i 1 i a n , De perC 
 uteri gravidi atresia ; Diss. Bonn. 1831. — Tweedie, Zeit&clir. f. d, 
 ges. Medicin. 1838. Bd. VIIL Heft 4. — H. F. J. N a e g e 1 e , Mogosto- 
 cia e conglutinatione in externo uteri etc. Heidelberg, 1835, dann Med. 
 Annal. Heidelberg, 1836. 2. Bd., und Naclitrag in ders. Zeitsclir. 1840, 
 6. Bd. — Meissner, Frauenzimmerkrankbeiten. Leipzig, 1842. — 
 F. S e r V a e s , De conglutinatione in extemo uteri orif. posit. Halae, 
 
 1853. — Kiwisch, Klin. Votr. Prag. 1854. Bd. 1 pag. 152. — 
 Scbv^^eitzer, Narbige Verwaclisung des Muttermundes. Monatschr. f; 
 Geburtsk. 1855. Berlin. Febr. — Heue N. Zeitscbr. I Geburtsk. Ber- 
 lin. Bd. II pag 425. S c a n z o i , Beii*. zm* Geburtsk. etc. Wiirzburg,- 
 
 1854. Bd. I. pag. 176, imd Krankh. d. w. Sexual. TVein, 1857. pag. 53., 
 — Birnbaum, Deutsche Klinik 1857. Nr. 1. — C. Braun. 
 Lehi-b. d. Geburtsh. Wien, 1857. pag. 295. — E. y. S i e b o 1 d , Zur 
 Verklebung des Muttermundes als Gebm-tshinderniss. Monatschrift filr 
 Geb m-tskunde. Berlin, 1859. XVII Bd. 2. 
 
 Partial contractions and occlusions of tlie uterine cavity 
 take place chiefly at its orifices, and as regards frequency, 
 those at the internal orifice are more frequently observed than 
 those of the external ; whilst throughout the remainder of the 
 uterine cavity, stricture or occlusion is rarely found. Some- 
 times the entire uterine canal is diminished by concentric 
 hypertrophy or atrophy, but by the term stenosis, a partial 
 contraction is always understood. 
 
 Strictures of the uterine cavity are often caused by annular 
 contraction at a certain point, especially at the internal orifice. 
 From an anatomical point of view, however, we must above 
 
OF THE UTERUS. Ill 
 
 all mention the purely mechanical causes of stenosis at the 
 internal orifice. First, to this class belong contractions from 
 external pressure, including the cases in which fibroid tumours 
 in the wall of the internal orifice cause contraction ; aiid further, 
 those contractions arising from partial and complete flexions, as 
 well as tractions of the uterus in its long axis. In these cases 
 the diminution of the cavity is apparently a narrowing of it, 
 being most marked at the internal orifice and accompanied 
 with thinning of the uterine walls. A purely mechanical stric- 
 ture rarely afiects the external orifice, and perhaps those cases- 
 might be here included, in which after displacement, (especially 
 anteflexion) a flattening of the vaginal portion of the uterus 
 with a slight contraction of its canal, occurs in consequence of 
 pressure. When tumours, developed in the vaginal portion 
 and affecting either lip, exist, stricture is never observed. 
 Contractions arising from a diseased condition of tissue are 
 more important and equally valid for both orifices. To 
 this class belong in both orifices, thickening of the mucous 
 membrane from catarrh, enlargement of the follicles, with 
 increased j)rominence and degeneration into cysts. Fur- 
 ther, tumours which lessen the canal, as for instance such 
 as originate from the body and fundus, and come in con- 
 tact wdth the internal orifice, or when developed from the 
 cervix, grow outward to the external orifice. It must here be 
 mentioned that if these tumours possess a certain density, they 
 \vill first cause a dilatation of the corresponding orifice, which 
 is, however, again occluded by the pseudo-plasma, and we must 
 also mention that after the largest periphery of these new-form- 
 ations, which without exception are pedunculated, has passed 
 the orifices, a contraction of the latter ensues, causing the 
 pedicle, however thin, to be again tightly constricted. 
 
 Finally, those strictures must be mentioned which are caused 
 by the growth of granulating tissue, resulting in a constricting 
 cicatrice. At the internal orifice they frequently arise from 
 rupture of the so-called Nabothian glands; at the external 
 
112 STRICTUPwE AND ATRESIA 
 
 orifice, in consequence of cicatrization after ruptures, con- 
 tusions, and the various ulcerations occuiTing in that region. 
 
 Strictures from the inward growth of tumours, as met with 
 in other cavities, cannot occur in the uterine ca\dtj, from 
 the fact that its walls, in the normal state, are nearly in con- 
 tact with each other. Any tumour growing into the uterine 
 cavity only tends to increase the sm'face of its walls, even 
 when they lie in close contact. 
 
 Occlusion of the uterine cavity, acquired atresia proper, is 
 generally the final result of a strictm^e and arises from similar 
 causes. We may distinguish somewhat between obstruction 
 and occlu^io7i. Thus, occlusion of the uterine cavity and 
 especially of the cervical canal, is frequently caused by viscid, 
 tenaceous mucus, which even in the dead body, can only be 
 removed from its walls with difiiculty. Obstructions, especially 
 of the orifices, by prolapsed tumours may also be included 
 here in so far as these tumom's only leave a small portion of 
 the cavity open. The importance of occlusions caused by these 
 various tumom-s is much increased when an accumulation of 
 fiuids above the point of obstruction causes them to press upon 
 the orifices ; which accumulated fluid on the other hand causes 
 a corresponding dilatation of the latter, sufficient to allow the 
 passage of the broadest portion of the obstructing mass if it 
 be pedunculated. 
 
 Genuine atresia, difierent from agglutiuation and obtura- 
 tion, results from uniting growth of tissue, either from the 
 borders of the orifices, or the walls of the body of the uterus. 
 When in consequence of considerable traction of its long 
 diameter, or of fiexion, the walls of the uterus are brought 
 in contact under a certain amount of pressure, the texture of 
 the thin mucous membrane becomes altered, or it is absorbed, 
 and atresia occurs at this point. It is also often caused by 
 the rupture of previously existing Nabothian glands, from the 
 borders of which granulations arise and give rise to atresia. 
 This occurs much more easily when superficial erosions, arising 
 
OF THE UTERUS. 113 
 
 from catarrh or desquamation of epithelimTi, exist. Granu- 
 lations from ulcerated sm-faces likewise frequently lead to 
 atresia. 
 
 E-okitansky also mentions atresia of the uterus as the final 
 result of concentric atrophy. 
 
 Degeneration of the uterine mucous membrane and polypoid 
 hypertrophy of the same, frequently occasion atresia of the 
 cavity of uterus. In the uteri of aged females especially, we 
 often find bridge — or ridge-like adhesions of the uterine walls 
 in contact, chiefly in the neighborhood of the oviducts ; further, 
 adliesions of the posterior and anterior walls of the uterus are 
 ■caused by vegetations of the mucous membrane, or other 
 tumours developed from the lateral point of apposition of the 
 walls mentioned. 
 
 Those atresias which extend over a large surface, generally 
 involve the cervical canal. The tissue which causes the occlu- 
 sion in such cases, is a loose, sometimes vascular connective 
 tissue, which extends from one wall to the other in the form 
 of filaments or hands, fr-equently enclosing between them 
 spaces filled with serum, of which it is difficult to say, whether 
 they are remains of former follicles, or, which is more probable, 
 whether they are evidences of incomplete occlusion of the 
 oervical canal. In the majority of cases the adhesions may 
 be ruptm-ed without force with the aid of a steel probe, in the 
 examination therefore of doubtful cases it is best to divide the 
 body of the uterus longitudinally, through the middle of its 
 anterior wall, and then cautiously to divide vrith scissors the 
 anterior wall, down to the internal orifice. Examination of 
 the internal orifice from above downward, or a superficial exam- 
 ination with a whalebone probe, will always enable one to form 
 -a correct idea of this condition. When fibrous tumom's grow 
 from various points into the distended uterine cavity, and 
 flatten after coming in contact, there is frequently found a 
 loose connection of the tumom's by a dehcate connective tis- 
 sue, and in consequence of the coalescence of these growths, 
 8 
 
114 STEICTUEE A^^D ATEESIA 
 
 an obliteration of the uterine cavity results, which is mucb. 
 altered from its original form, and is onl j represented by the- , 
 interstices between the tnmonrs. In this way a partial or| 
 complete atresia of the superior portion of the cavity of the-' 
 uterus may take place, these tumours being only exceptionally 
 developed from the walls of the cervix. In such cases also I 
 the uterine mucous membrane is considerably thinned, audi 
 sometimes fissm'ed or absorbed by pressm'e, in consequence! 
 of which a kind of denuded patch is formed, from which the-j 
 agglutination commenced. 
 
 A singular atresia at the external orifice, which occurs in 
 prolapsus uteri, especially when combined with complete inver- 
 sion of the vagina, must not be omitted. In many cases of 
 prolapsus we find in place of the external orifice, only a 
 shallow depression ; sometimes even this slight indication of 
 the cervical canal is absent, and it is difficult to determine 
 from external appearance where the point of entrance should 
 be. If such a prolapsed uterus is bisected, it is observable 
 that the atresia of the external orifice is formed by a milk-l 
 white cuticle varying in thickness, (sometimes 1 line) some^ 
 times distinctly opalescent at the cut edges, and a close exam-J 
 ination of which shows that it consists of vaginal epithelium, 
 disposed in manifold layers, vegetating into thick strata in aj 
 manner similar to that of the vagina. Such may have beenl 
 the condition in those cases in which a slight atresia of thd 
 external border of the os uteri was described as being a whitq 
 membrane. j 
 
 I deem it improper however, to apply the expression ag^ 
 glutination to an occlusion by tissue, or, as Schmitt did^ 
 obliteration to a larger extent. 
 
 In my opinion there is no reason for retaining this old 
 expression. 
 
 Undoubtedly in some cases of obhteration by epithehal tis- 
 sue, a more substantial occlusion by connective tissue take& 
 place, which is, however, often limited to the extreme end of 
 the canal. ; 
 
OF THE UTERUS. 115 
 
 In rare instances, atresia of tlie external orifice may result 
 from cicatrization of deep ruptures or contusions, after labor. 
 
 The consequences of atresia and stricture are similar ; atre- 
 sia, as mentioned, may be considered as a consequence of stric- 
 ture. The further consequences of both affections are very 
 different, according to the age of the patient, especially in rela- 
 tion to menstruation and the condition of the mucous mem- 
 brane. 
 
 If atresia occm-s in a menstruating female, distention from 
 accumulated menstrual blood above the point of atresia, or 
 hsematometra, will be the consequence. When atresia occurs 
 in a female who has ceased to menstruate, the consequen- 
 ces will depend on the condition of the uterine mucous mem- 
 brane. The latter frequently continues active, or may even 
 be affected with catarrh. Therefore an accumulation of 
 mucus and its consequent effects, or a so-called hydrometra, 
 will result, in which the quality of the mucus will depend 
 upon the situation of the atresia. In aged females, especially 
 those affected with rigidity of the arteries, atresia of one or 
 other uterine orifice may be found with inconsiderable or no 
 distention of the uterine cavity above the atresia, which con- 
 dition is owing to diminished secretion of the uterine mucous 
 membrane. Notwithstanding the long duration of an atresia, 
 we sometimes meet with only a small quantity of hone3^-hke 
 gummy mucus in the cavity (which is scarcely distended) above 
 the point of occlusion. 
 
 Stenosis and atresia of the gravid uterus are very interesting 
 and important in their immediate consequences, as they fre- 
 quently constitute an impediment to delivery. They affect 
 almost exclusively the external orifice, and atresia in such 
 cases is chiefiy produced by a shght union of the eroded edges 
 of the external orifice. 
 
 KjwiscJi thought that atresia of the gravid uterus might possi- 
 bly occur in consequnce of the formation of a kind of decidua in 
 the cervical portion, representing an agglutinating intermediate 
 
116 DROPSY OF THE UTERUS. 
 
 I 
 
 layer, which afterwards, when the canal is distended, is increas- | 
 ed into a membrane of varying density. | 
 
 That form of atresia which has been described by many as 
 acquired mucous atresia of the external orifice, with or without 
 absence of the vaginal portion, I have never had occasion to 
 observe, unless the above-mentioned adhesion by epithelial 
 tissue be meant by it ; neither is the condition itself sufficiently 
 clear to me from the description given, and I cannot well 
 understand how the mucous membrane can occlude the 
 external orifice, except in congenital atresia. 
 
 In isolated cases, especially after the developement of hse- 
 matometra, a rupture of the occluding membrane occm*s. It 
 is also ruptm-ed during labor when it is inconsiderable. 
 
 HTDRO^VIETRA, DROPSY OF THE UTERUS. 
 
 Literature: Vesaliiis,De eorpor, human, fabric. Lib. Y. cap. 
 9. pag. 627. — M o r g a n i , De sed et caus. morb. Ep. 'XIN - art. 
 16, 21, 23 ; Ep. LXIX. art. 46. — C h a m b o n d e M o n t a u x , 
 Merkwiirdige Krankengescb. und Leicbenoffnungen. pag. 546. — Ge- 
 ras Constantini de Gregorini, Diss, de bydi'ope uteri. 
 Halae 1795. — El. v. Siebold, Frauenzimmerkrankheiten, I ' 
 pag. 532. Frankfurt 1811. — AY i r e r, Jom*n. f. cbii'. Gebuitsh. u. 
 gericbtl. Arzneik. Jena 1802. Bd. lY. 2. — B 1 a n c b a r d, Anatom \ 
 pract. rat. Cent. 11. obs. XXIX. pag. 242. — Tbomson Med. cbir. \ 
 Transact, of London Yol. 13. — C a r u s , Handb. der Gynacologie. | 
 Leipzig 1820. pag. 285. — Boivin et Duges, Traite pr. etc. I, 
 Paris 1833. Bd. 1. pag. 255. — Hooper, Tbe morbid anat. of tbe 
 uterus PI, 3. — A n d r a 1 , Precis d'anat. patbolog. Bmxelles. 187. 11. 
 pag. 245, — J o b e r t . Joum. de Cbirurg. Aout. 1843. — F o r s te r , 
 Spec. path. Anat. Leipzig 1854. pag. 293. — C. B r a u n , Lebrb. j 
 d. Geburtsb. Wien 1857. pag. 534, und Zeitscbi*. der Ges. der Aerzte., 
 Wien 1858. Nr. 17. 
 
 By dropsy of the uterus we understand an accumulation of i 
 serous or mucous fluid within its cavity. It is generally thei 
 immediate consequence of stricture or atresia of the orifices, i 
 and occurs in its true form only after the cessation of menstrua 
 ation. i 
 
DROPSY OB^ THE UTERUS. 117 
 
 If the efflux of uterine mucus secreted in considerable quan- 
 tity, be impeded by the above-mentioned causes, it accumulates 
 in the cavity of the body of the uterus when the impediment is 
 situated at the internal orifice, and in the cavity of the cervix, 
 when it exists at the external orifice. In rare cases also of 
 stricture of both orifices, accumulation of fluid takes place in 
 the cavity of the body as well as in that of the cervix. 
 
 In stricture of the internal orifice the cavity of the body of 
 the uterus dilates in such a manner as to become globe shaped ; 
 its walls are uniformly distended, and in general are found in 
 a state of eccentric hypertrophy. If the distention attains a 
 higher degree the uterus is finally transformed into a thin- 
 walled sac with inelastic walls. Investigations, especially of 
 cases of considerable hydrometra in aged females, show that 
 the elements of connective tissue predominate considerably 
 over those of muscular tissue and we must assume that the 
 latter are chiefly destroyed by the distension, and that the 
 hyperplasia accompanying nearly every case of hydrometra, 
 chiefly affects the connective tissue. 
 
 When the cavity of the body of the uterus is considerably 
 distended, its mucous membrane becomes thin and degener- 
 ates, and its external soft velvet-like appearance is lost, its sur- 
 face assuming the smooth, glossy appearance of serous mem- 
 branes. If the uterus be further distended it becomes net- 
 like in appearance, and is finally changed into a soft layer of 
 connective tissue covered with a single layer of frequently 
 j degenerated cylindrical epithelial cells. The latter generally, 
 I and in the higher degrees of hydrometra, always loose their 
 I cili?e, and appear shorter and thicker, resembling the so- 
 I called transitory epithelium. I have been unable, even in the 
 I highest degree of hydrometra, to discover the pavement epithe- 
 j Hal cell, which is found in analogous conditions of the gall 
 I bladder. The glands of the uterine mucous membrane in the 
 j commencement of hydrometra, are generally affected with a 
 fatty degeneration of their epithelium, and are finally destroyed, 
 
118 DEOPST OF THE UTERUS. 
 
 leaving indurations in the mucous membrane. Sometimes also 
 the utricular glands degenerate into small cysts. 
 
 The fluids contained in the cavity of the uterus are at first a 
 viscid mucus, sometimes clear or serous, sometimes sHghtly 
 turbid and yellowish or brown in color. In many cases of 
 atresia after menstruation has made its appearance for a short 
 time only, or several times and then ceased, a hsematometra 
 formed at first, may turn into hydrometra, and the hsematine 
 being changed into brown pigment, may give a peculiar color 
 to the fiuid. Upon closer investigation we find varying quan- 
 tities of cast-off epithehum and colloid bodies suspended in a 
 mucus fluid. After a longer continuance of hydrometra how- 
 ever, we generally find the contents strongly alkahne, very 
 fluid and nearly or perfectly clear. The mucous substance 
 contained in the secreted fluid may have been dissolved by its 
 alkalescence.* 
 
 In stricture of the external orifice the cervical canal is dis- 
 tended hke a pouch, and we may mention that the cavity of 
 the uterus participates only slightly in the enlargement. Fre- 
 quently enough I have observed pouch-hke distention of the 
 cervical canal without dilatation of the uterine cavity. In every 
 such case there was stricture only at the external orifice. Ob- 
 struction of the cervical canal being the chief cause of disten- 
 tion of the cavity of the uterus, w^e are led to assume that in 
 such cases there is no hypersecretion of the uterine mucous 
 membrane, consequently that the cervical mucous membrane 
 alone is diseased, or, which seems possible, that although the 
 cervical catarrh may be most severe, a slight catarrh of the' 
 uterine mucous membrane may co-exist, but that a temporary! 
 emptying of the cervical canal occm's from time to time and' 
 the uterus distended by accumulated fiuid, contracts and tem-| 
 porarily assumes its former size, whilst the less muscular cervixj 
 is distended to its utmost at an earlier period and remains 
 
 ♦ According to Berzelius mucous substances are soluble in alkalies. 
 
DEOPSY OF THE UTERUS. 119 
 
 permanently distended. The temporary evacuation of accu- 
 mulated cervical mucus is occasioned, I think, by its liquifac- 
 tion, and by pressure of the secretion in the cavity of the 
 uterus. 
 
 The fluid accumulated in the distended cervix is the well- 
 known limpid and extremely viscid mucus, which is often found 
 in the normal cervical canal, between the menstrual periods ; 
 and here also there is a possibiKty that with increasing alkales- 
 -cence it may become more fluid. Kiwisch especially calls 
 attention to the periodical discharges of hj^drometra in cases of 
 ■obstruction of the canal by simple flexion. 
 
 Finally, in rare cases, with stircture or atresia of both ori- 
 fices we find distention and dilatation of the cavities of both 
 body and cervix, each possessing the characteristics common 
 to their separate distensions. The cavity of the body is dis- 
 tended in the shape of a globe, the cervical canal in the form 
 of a pouch ; the distention of the former always being the 
 greatest. In such cases the uterus acquires the hour-glass 
 shape ; and by this term pathological anatomists generally 
 understand an alteration in form produced by hydrometra. 
 
 In hydrometra we always find the uterus in a state of hyper- 
 trophy, for although in the highest degrees of this disease 
 the walls of both the body and the fundus are exceedingly 
 thin, still, on the whole, the uterus possesses more substance 
 than in its normal condition. The mucous membrane of the 
 affected portion is always in a state of catarrhal tumefaction. 
 In the higher degrees of hydrometra, the globe-like body of 
 the uterus gradually ascends into the abdominal cavity, and 
 appears above the pubes as a round fluctuating tumour, except- 
 ing when the organ has previously been dislocated, as in ante- 
 flexion, or, which is more frequently the case, in retroflexion. 
 If the latter be the case in the slighter degrees, the uterus is 
 straightened, unless the promontory of the sacrum is ver}^ large, 
 but otherwise it is impacted in Douglas' space and presses upon 
 the posterior fornix as a fluctuating tumour, and besides im- 
 
120 DROPSY OF THE UTEEUS. 
 
 peded defecation, all those consequences of retroflexion occurs 
 which we have mentioned under that head. 
 
 All the forms of stricture or occlusion of the orifices men- 
 tioned in the preceding chapter, become causes of hjdrometra 
 when catarrh of the uterine mucous membrane and hyperse- 
 cretion occur in a non-menstruating uterus. During the years 
 in which conception may occur, hydrometra is rarely observed,, 
 and can only occur with complete ainenorrhoea. It is there- 
 fore most frequently observed in aged females. 
 
 In regard to the quantity of accumulated secretion, the old 
 observations quoted by Voigtel must be received vrith 
 caution. Although Yesalius pretends to have evacuated 180' 
 pounds and Blanchard 185 pounds from a distended uterine- 
 cavity, notwithstanding all the respect we have for these- 
 authorities, we are led to suspect that in these instances anj 
 ovarian cyst, lying close to the thin-walled uterus affected! 
 with atresia of the internal orifice, may have been mistaken, 
 for the uterine cavity. Of the more recent cases the one- 
 described by Kiwisch must be considered as one of the most 
 considerable as to the amount of fluid — two pounds of fluid 
 being found in the uterine cavity, which was distended to the size- 
 of an adult's head. Thomson mentions a case of hydrometra 
 in which the uterus attained the size of one at the full term of 
 pregnancy. In the cervical canal the quantity of accumulated 
 mucus seldom exceeds an ounce, and generally it is only one- 
 or two drachms. 
 
 Hydrometra has no consequences worthy of note, except when 
 it is combined with displacements of the uterus and especially 
 retroflexion. Sometimes, although the cervical canal be com- 
 pletely occluded and the mucous membrane considerably 
 softened, as in catarrh, but a very small amount of mucus- 
 accumulates. As this only occurs in marastic females, we pre- 
 sume that hypersecretion could not take place in such. 
 
 Obstetricians also describe a dropsy or hydrorrhcea of the- 
 gravid uterus, in which after the flfth month a considerable^ 
 
INFLATION OF THE UTERFS. 121 
 
 quantity of fluid is said to flow periodically from the organ 
 without miscarriage ensuing. Duges considered this to be 
 the allantoic fluid, abnormally increased, and proposed ta 
 call it kydrallcmte. In recent times Ingleby, Dubois and 
 Dugan concurred in this opinion. Gregorini had already dis~ 
 tinguished accumulation of water within the ovum from that 
 between the chorion and amnion, and also from that between 
 the chorion and the walls of the uterus. JSTagele considered the- 
 fluid the product of a secretion of the uterus, which from dis- 
 turbed endosmosis does not penetrate the membranes of the 
 ovum. C. Braun considered hydrorrhoea as the product of a. 
 serous endometritis which detaches a portion of the chorion, 
 and in consequence of which the fluid accumulates in larger or 
 smaller spaces, which, according to their proximity to the os, are 
 sooner or later emptied. Of course there are no pathological 
 observations of this condition, and I only mentioned this 
 afiection for the purpose of completing this subject, remarking 
 at the same time that C. Braun's opinion must be considered 
 the most credible. The microscopical examination of a pla« 
 centa expelled after hydrorrhoea, exhibited a new-formation 
 on its convex surface resembling a fine membrane consisting; 
 of connective tissue (Wedl). 
 
 INFLATION OF THE UTERUS, TYMPANITIS UTERI, 
 PHYSOMETRA. 
 
 Literature: J. Astrue, Traite des malad. des femmes. Paris 1761. 
 — Voigtel, Path. Anatom. Halle 1805. Bd. IIL p. 514. —Ken- 
 ning, Huf eland's Joui'n. etc. 181 7. — Dlisterberg, Rust's Magaz. 
 f. d. ges. Heilkunde. 1825. — TeSsier, Sur la tympanite de la ma- 
 trice. Gaz. med. 1844. 1. — Szerlecky, Physometra. N. Zeitschr. 
 f. Gebtsk. Berlin. VII. 3. 1858. — A. Y a 1 e n t a , Ueber Tympa- 
 nites uteri. Zeitschr. d. Ges. d. Ac. Wien. 1857. Nr. 7 und 8. 
 
 By physometra, gynaecologists understand an accumulation 
 of gases in the uterine cavity. 
 
 Different opinions were formerly advanced in regard to the 
 nature of these accumulated gases. Thus the old gynaecolo- 
 gists beheveii it must have been introduced into the uterine 
 
122 IlS^FLATION OF THE UTERUS. 
 
 •cavity from without, others advanced doubtful hypotheses as 
 to the generation of the gas by the uterine blood-vessels, or 
 from a peculiar chemical composition of the uterine secretions, 
 in virtue of which, gas was said to be spontaneously developed. 
 
 From a physiological and pathological point of view, we 
 may say in regard to the origin of physometra, that under cer- 
 tain circumstances the possibihty of the mechanical introduc- 
 tion of gas does seem probable, as when the uterus is relaxed at 
 the moment of expulsion of the foetus, and does not contract 
 as its contents are expelled. In regard to a peculiar chemical 
 quality of the uterine secretions there is little to say. But it 
 is a fact, that gases resulting from decomposition may collect 
 in the uterus if their escape is prevented, and that in the 
 various pathological processes to which the uterus is subject 
 there is sufficient cause for the production of such gases. 
 Yalenta, independently of the undoubted possibility of the 
 introduction of air fi'om without, considers two conditions 
 necessary for the production of tympanites uteri ; firsts that 
 there must be some decomposing substance in the uterus, and 
 secondly^ that the escape of the products of the decomposition 
 be prevented. 
 
 The substances which are hkely to be decomposed in the 
 uterus are generally those connected with pregnancy and labor ; 
 either a dead foetus, remnants of membranes, portions of the 
 placenta, or coagulated blood. But besides these, the various 
 tumours, especially carcinomata, by decomposing, may lead to 
 physometra, or it may result, from hsematometra or hydro- 
 metra (Scanzoni). 
 
 The condition of the inner surface of a physometrous uterus 
 therefore, differs according to the pathological process which 
 <iauses the formation or accumulation of gas. Distension of 
 the uterine cavity by gases seldom attains a high degree. 
 From analogy, we easily arrive at the conclusion that gases 
 arising from decomposition may enter the oviducts when open, 
 and thus escape into the peritoneal cavity, where^ they must 
 
HyEmatometra. 123 
 
 give rise to general peritonitis. Still no reliable cases of such 
 a kind are recorded. 
 
 Phjsometra, according to what lias been said, is always a 
 secondary affection. 
 
 In regard to the impediment offered to the escape of the 
 accmnulated gases, it is not always caused by stricture or 
 atresia, or spasmodic contraction of the uterus below the accu- 
 mulation ; but the gas which has been developed, may also be 
 retained in consequence of a passive condition of the uterus, 
 or a loss of power of the distended carity to contract. 
 
 H^MATOMETRA. 
 
 Literature: Kreiner Hufeland's Jonrn. Sept. 1834:. — B r o d i e , Lancet. 
 Nov. 1839. — Kiwis oh, Klin. Yortr. Bd. L p. 210. IL p. 214. — 
 Seyfert, Hamatometra, Prag. Vierteljalirsschr. 1854. 1. p. 132. — 
 S eh u h , Yerwachsimg der Sclieide mit Zurlicklialtung des ]\Ienstrua- 
 tions-blutes, etc. Zeitsclir. d. Ges. de. Ae. Wien, 1857. Wochenbl. Nr, 
 31. — Balver Brown, Lancet L 19. 1860. — C. Braun, Ueber 
 Hamatometra in den Pubertittsjahren. AUg. Wien. med. Zeitg. 1861. 
 Nr. 13 und 53. — Patry, Gaz. des hopit. 18. 1861. — Prell, 
 JVIonatscbr. f. Gebm-tsk. etc. Berlin Decemb. 1861. 
 
 By hsematometra, strictly speaking, we understand an accu- 
 mulation of blood in the non-gravid uterus. 
 
 According to the amount of the accumulation the uterus is 
 distended in various degrees, and after this has continued for 
 a length of time, its walls are almost always hypertrophied. 
 On section, the substance of its walls appears pale, often 
 milky white, congested and peculiarly soft, but still resistant. 
 After the uterus has been considerably distended, a thinning 
 of its walls becomes apparent, yet the amount bf its substance 
 is much greater than in its normal state. 
 
 The accumulated blood is mostly dark, deficient in fibrin, 
 discolored in various degrees to a blackish brown, thickened 
 rather than coagulated, tar-Kke, and sometimes mixed with 
 crystals of cholestearine. The inner surface of the uterus is 
 smooth, reddened, or dark brown. 
 
 Haematometra is generally caused by the cohection of men- 
 
124 H^MATOMETEA. 
 
 strual blood, in consequence of atresia of the genital canals 
 These atresise occur most frequently in the vagina from conge- 
 nital or acquired causes, or from imperforation of tlie hymen. 
 Congenital or acquired closure of the external genitals is a less- 
 frequent occurrence, and atresia of the external orifice and 
 cervix uteri the most rare. Seyfert denies that the thickened 
 and imperforate hymen is a most frequent cause of hsemato- 
 metra. He found it to be more frequently owing to atresia 
 of the vagina at a higher point. According to the situation 
 of the atresia, various portions of the genital canal may be 
 distended ; and, as a rule, that portion of the canal suffers 
 most distention which is immediately above the atresia. 
 
 If atresia occurs at the labia majora, the vestibulum ana 
 vagina are considerably distended, the uterus being only 
 slightly affected, until the distention attains a certain 
 degree. The vagina in like manner only participates in the 
 distention, if an imperforate hymen causes the retention of 
 menstrual blood. This distention likewise is called hmma- 
 tometra, therefore wrongly, since the uterine cavity in most 
 of these cases is not distended. Seyfert also considers the use 
 of the term hsematometra, in all cases improper as a general 
 one, and requires an exact description of the point at which 
 the passage of the fluid is prevented. The distended vagina 
 forms a round sac, which, according to the thickness and. ele- 
 vation of the occluding membrane, appears as a more or less 
 elastic distended tumour, of a bluish-red color, and which 
 reaches down to the entrance of the vagina or the vestibulum^ 
 If an imperforate hymen forms the occluding membrane, it is 
 thin and smooth, but if atresia is caused by cicatritial con- 
 traction of the vaginal walls, the lower part of the sac ia 
 thick and dense. The vaginal portion of the uterus is- 
 raised out of the vagina, the duplication effaced, and the 
 anterior and posterior fornix come together like a vault, at the 
 highest point of which the uterus is implanted. Posteriorly 
 the uterus presses upon the rectum, anteriorly upon the 
 
H.EMATO^rETRA. 125 
 
 bladder, especially upon its neck and the urethra. The uterus 
 is elevated, and its fundus frequently inclined forward. 
 
 If the atresia is located at the uppermost portion of the va- 
 gina, or at the external orifice, the cervical cavity is distended 
 like a large sac, and the caHty of the uterus proper always, 
 though to a less extent, participates in the distention. Thus we 
 may find a small cavity, resulting from distention of the superior 
 part of the vagina, and above this a much larger one, caused 
 by distention of the cervical cavity, which, in its upper portion 
 communicates with a smaller cavity formed by distention of 
 the cavity of the uterus proper (compare Schuh's case). 
 
 Lastly, if atresia of the entire cervical canal or internal 
 orifice exists, which but rarely happens, the uterine cavity will 
 be distended in the form of a globe, or round tumour. 
 
 In relation to the cause of atresia, the two cases of Braun, 
 in which atresia of the cervix and hsematometra, followed 
 amputation of the vaginal portion, are very interesting. 
 Kriiner states that h}^Dertrophy of the vaginal portion may 
 also lead to a contraction of the cervical canal, and thus hinder 
 the escape of menstrual blood. 
 
 This imperfect dilatation of the genital canal, is only met 
 with in slight degrees of hsematometra. After the distention 
 has reached a certain degree, the remainder of the above canal 
 is so affected, that a uniform cavity is formed, in which no sub- 
 di\dsions are recognizable. In atresia of the hymen, or 
 external genitals alone, the distention, when extreme, is 
 chiefly confined to the vagina, and therefore the term h^ma- 
 TOMETEA is inappropriate to this condition. 
 
 The oviducts in many cases, are also said to participate in 
 the distention by menstrual blood. 
 
 It is certain that the menstrual blood which is poured out, 
 contains less fibrin than is found in other extravations, and, as 
 is well known, it was considered absolutely deficient in fibrin 
 (Simon, Vogel), until Weber and Henle demonstrated its pres- 
 ence. But in retained menstrual blood however, fibrinous coagula 
 
126 H^M ATOMETEA. 
 
 have never been found, and we must therefore presume that in 
 such cases the fibrin is soon decomposed. I have also seen in 
 a tar-Uke fluid of this kind, shreds similar to those found on the 
 walls of old aneurisms whose fibrin had commenced to de- 
 generate. But, according to what has been said, a permanent 
 coagulation of the fibrin adhering to the walls of the cavitj 
 does not seem to take place in hsematometra. 
 
 Hsematometra is most frequently met with during puberty^ 
 for the reason that the atresise causing it are"] most frequently 
 congenital. It may exist for a long time, and attain an exces- 
 sive degree, but the amount of blood never equals in quantity 
 that which we suppose would have been poured out in normal 
 menstruation. Undoubtedly, between the menstrual periods, 
 the retained blood is considerably thickened by absorption. 
 Over 10 pounds have been found. The filhng of the uterus or 
 vagina may lead to extreme distention of their respective 
 walls. 
 
 In consequence of this distention of the uterus, peritonitis 
 frequently ensues, and firm adhesions are formed between the 
 neighboring organs and uterus. 
 
 If the contents of the uterus decompose, the gas formed in 
 consequence may produce ^hysohcBinatometra. The walls of 
 both the uterus and vagina may become gangrenous, or metri- 
 tis and colpitis may lead to their ulceration and ru pture. 
 
 Kiwisch observed a rupture of an oviduct from the entrance 
 of blood from the uterine cavity into it, and probably Schuh's 
 case must be similarly explained ; although the orifice of the 
 oviduct was found closed after death, and the rupture in this 
 case was the result of an ichorous process. Brodie mentions 
 that in re any cases partial evacuations of the accumulated 
 blood may ake place, through the oviducts into the peritoneal 
 cavity. 
 
 The extension of inflammation from the pelvic to the rest 
 of the peritoneum, often causes hsematometra to terminate 
 fatally, even where rupture, or evacuation through the oviducts 
 does not occur. 
 
127 
 III. ADVENTITIOUS GEOWTHS OF THE UTEEUS. 
 
 1. NEW-FORMATIONS OF CONNECTIVE TISSUE. 
 The new-formations of connective tissue which take place in 
 the substance of the uterus, are developed from its interstitial 
 tissue, and in their growth affect either the whole extent of 
 the latter, or isolated portions of it in a diffuse manner ; or, 
 these new-formations, becoming independent, are situated 
 under various circumstances in circumscribed portions of the 
 uterine substance ; or, lastly, they are considerably separated 
 from the rest of the tissue of the organ. According to these 
 different relations to the parent tissue, these varieties of new- 
 formation of connective tissue must severally be considered. 
 
 A. DIFFUSE GROWTH OF CONNECTIVE TISSUE IN THE UTE- 
 RUS. CHRONIC INFARCTUS OF THE UTERUS (KIWISCH). 
 
 Literature: Lisf ran c, Gaz. med. de Paris. Nr. Gl, 64,73. 1833. — 
 Simpson, MontMy Journ. Juni, Aug., Nov., 1843, und March 1 844. 
 — K i w i s ell , Kl. Vortr. Frag 1845. 1, pag. 104. — J a s eh e , Erfahi- 
 ungen liber die chron. Gebarm. Entziindung. Med. Zeitg. Russlands 
 1846. Nr. 22 and 28. — O. P r i e g e r , Ueber Hypertrophic und die- 
 harten Geschwillste des Uterus. Monatschr. f. Gcburtsk. Berlin 1853. 
 Marz. — Scanzoni, Krankh. d. wetbl. Sexualorg. Wien, 1857. pag. 
 141. — Oppolzer, kl. Vortr. etc. in Wittelshofer's med. Wochen- 
 schr. Wien 1858. p. 328. 
 
 In consequence of formative irritation, especially when it 
 has existed for a long time, the whole uterine connective tissue 
 sometimes proliferates either with accompanying increase of 
 the muscular substance, or, if this does occur, the connective 
 tissue predominates to such an extent that the muscular sub- 
 stance is comparatively of not much account. By this pro- 
 cess, an increase of the substance of the uterus is produced by 
 a portion of its tissue, which, as regards function, cannot be 
 considered as the most essential to the organ. I therefore do 
 not hesitate to classify this affection with the qualitative alter- 
 ations of formative irritation, inasmuch as the natural propor- 
 tion of the normal tissues constituting the uterus are thereby 
 considerably altered. 
 
 In this disease the uterus is uniformly increased in its diam- 
 
128 DIFFUSE aROWTH OF 
 
 eters, thougli not always in all of them ; its body and fundus 
 generally assume a spherical shape, and frequently attain the size 
 of a man's fist, and even larger. Its walls are sometimes consid- 
 erably increased in thickness, up to 12 or 15 inches, especially 
 the posterior one and the fundus. The cavity of the uterus is 
 absolutely enlarged, chiefly elongated ; but the uterine walls 
 lie close together, and an increase of its cavity, in the general 
 meaning of the term, is only met with in rare instances. I 
 should rather say that the cavity of such a hyperplastic uterus 
 was relatively smaller than that of a normal one. Exteriorly 
 the fundus uteri appears rounder and broader, the anterior 
 and still more the posterior walls thickened, the latter even 
 vaulted or of the shape of a boat's keel, the cervix more 
 ample and increased in substance, and the vaginal portion 
 broader and thicker. 
 
 The condition of the parenchyma of the uterus varies 
 according to the duration of the disease. In the first stages 
 it is more congested and turgid, owing to the immatured con- 
 dition of the newly-formed connective tissue. The longer the 
 duration of the disease, the more is the mucous connective tis- 
 sue transformed into the fibrillary variety, accompanied with 
 contraction of tissue ; the parenchyma on section appears 
 white, or of a whitish-red color, deficient in blood-vessels from 
 compression of the capillaries by the contraction of the newly- 
 formed connective tissue, or from partial destruction or obht- 
 eration of vessels during the growth of tissue ; the firmness of 
 the uterine substance is also increased, simulating the hardness 
 of cartilage, and creaking under the knife. The newly-formed 
 tissue is chiefly composed of thin fibrils, deficient in nuclei, 
 which cross the uterus in lines of various breadths in all direc- 
 tions, forming a compKcated felt-like network, and constituting 
 the greater substance of the uterus. In the first stages of the 
 disease the muscular fibres are broader and hj^ertrophied, 
 but at a later period may be completely lost in the proHfera- 
 tion of connective tissue. 
 
coisrisrECTiVE tissue in the uterus. 129 
 
 The causes of this diffuse growth of the connective tissue 
 must be sought for in habitual hypersemia, and I cannot con- 
 cur in that explanation which interprets the process described, 
 as chronic inflammation. It is true that inflammatory 
 derangement of nutrition is often followed by proliferation 
 of connective tissue, but it is impossible to conclude, that 
 from the presence of this formative irritation derangements of 
 nutrition are produced which are essentially of a destructive 
 
 character. 
 
 Diffuse growth of connective tissue constitutes the so-called 
 induration hitherto considered as a result of 'parenchymatous 
 inflammation of the uterus^ 
 
 Frequently this proliferation of connective tissue is de- 
 veloped after repeated deHveries in rapid succession, without 
 any previous or existing inflammation. It also occurs in 
 many displacements of the uterus, especially those in which 
 venous reflux is hindered in consequence of traction of the 
 uterine appendages. When tumom's exist, especially fibrous, 
 proliferation of connective tissue almost always coexists in the 
 rest of the uterus. When the uterine cavity is distended bj 
 accumulated mucus or menstrual blood, this proliferation gen- 
 erally exists iu the form of eccentric hypertrophy. Finally it 
 is often combined with the various tractions to which the uterus 
 is subject, and sometimes is developed in consequence of the 
 puerperal condition. 
 
 From the description of this affection it is evident that the 
 term ' ' infarctus" used by some gynecoly gists is absolutely im- 
 proper. For reasons mentioned I would also advise the dis- 
 use of the term ' ' chronic inflammation." 
 
 In most cases the mucous membrane of the vagina partici- 
 pates in the chronic irritation, we frequently finding it in a state 
 of epithelial desquamation, and even of catarrh, and blennor- 
 rhoea. The peritoneal covering of the uterus is generally thick- 
 ened and covered with various-shaped false membranes. The 
 
130 DIFFUSE GEOWTH OF, &C. 
 
 pampiniform and utero-vaginal plexuses are often in a varicose 
 condition, and tliis is not only caused by the contraction of the 
 blood vessels, but is also frequently the consequence of the 
 same cause which produced the diffuse growth of the above 
 tissue. 
 
 Besides local hypersemia, we must take into consideration 
 the general causes of this affection ; thus it is often found 
 complicated with diseases of the heart. Scanzoni calls par- 
 ticular attention to the fact that proliferation of connective 
 tissue rej)eatedly occurs after successive miscarriages, and is 
 also said to be met with in prostitutes. 
 
 "WTien the diffuse growth of the above tissue does not take 
 place uniformly in all parts of the uterus, hypersemic distension 
 of its blood vessels is apparent in those portions not at all, or 
 only slightly affected, and in these parts extravasations may 
 occur, especially in the external or internal layers of the uterine 
 tissue (Scanzoni). 
 
 The consequences of these pathological conditions are, 
 derangements of menstruation and sterility. As regards 
 their termination, it must be noted that in the majority of 
 cases, the proKferation gradually ceases after attaining a 
 certain degree, and no fiii'ther alterations of tissue take 
 place. In other cases, at the climacteric period, involution 
 occurs, commencing generally by distension of the uterine 
 cavity with an accumulation of mucus. What has been said 
 by various authors on the relations of diffuse growth of con- 
 nective tissue to the development of carcinoma, must be con- 
 sidered as a mere hypothesis ; this same question has been 
 raised in regard to other organs in which carcinoma is de- 
 veloped from a hypertrophy of tissue, and in a great many 
 cases it must be left to the discretion of observers, whether 
 they will classify certain cases with carcinoma. 
 
 In the preceding description I have only spoken of that 
 proliferation which uniformly affects the entire interstitial con- 
 nective tissue of the uterus, we shaU next consider the equally 
 
ELONGATION OF THE, &0. 131 
 
 important analogous conditions which only affect portions or 
 I layers of the uterus. 
 
 And fii'st we consider as such : 
 
 L. DIFFUSE PROLIFERATION OF CONNECTIVE TISSUE IN 
 THE VAGINAL PORTION, HYPERTROPHY, PROBOSCIS— OR 
 POLYPUS-LIKE ELONGATION OP THE VAGINAL PORTION 
 OP THE UTERUS 
 
 Literature: Krimer, Hufeland's Journ. Septbr. 1834. — Ken- 
 nedy, Dublin Monthly Jom-n. Noybr. 1838, Froriep N. Not. 1839. 
 Bd. IX. pag. 736. — Malgaigne, Traite d'anat. chirurg. Bruxelles 
 1838. pag. 386. — Simpson, Monthly Journ. June, Aug., Novbr. 
 1843 und March 1844. — Osiander, Hannov. Annal. N. Folge. V. 
 L — Cruveilhier, Anat. patholog. Livr. 39 PL 3. Fig. 2. — 
 Kiwis ch, Klin. Vortr. I. pag. 111. — Virchow, Ueber rlissel- 
 formige und polypose Verlangerung der Muttermundslippen, Archiv. Bd. 
 VII. pag. 164. 1854, und Verhandl. d. Ges. f: Geburtsk. Berlin Bd. 11. 
 pag. 204, und Bd. IV. pag. 11. — Herpin, Gaz. med. de Paris. 
 1856. Nr. 1 u. 2. — E. Wagner, Beitr. zur norm, und path. Anat- 
 omie der Vaginalpoition, Arch. f. physiolog. Heilkunde, 1856. 4. pag. 
 493. — Breslau, Diagnostik der Tumoren des Uteras ausserh. der 
 Schwangersch. u. des Wochenb. etc. Miinchen 1856. — Scanzoni, 
 Krankh. der weibl. Sexualorg. — Huguier, Union medic. 1859. 
 Nr. 32 — 48. — C. Br aun, Wiener med. Wochenschi*. v. Wittelshofer, 
 1859. Nr. 30. 31. — Scanzoni, Beitr. zur Geburtsk. u. Gynacol. 
 IV. pag. 329. 1860. — Matecky, Tygodnik lekarsky. Nr. 30. 1860. 
 
 Hypertrophy of the vagmal portion, as this condition is 
 universally called, consists of nothing more than diffuse and 
 excessive growth of connective tissue, and may affect the 
 whole vaginal portion or either of its lips. This, accordingly, 
 at once gives rise to various forms. Further varieties result 
 according to then- form, and according as the mucous foUicles 
 of the vagiual portion participate or not in the affection. In 
 the majority of cases, the increase of the entire vaginal portion 
 by this disease, is exclusively in its length. Consequently, the 
 external orifice extends fm-ther down, and the vaginal portion 
 forms a cone extending low down in the vagina, which is 
 isither perfectly smooth, fissured, or scarred, and resembles a 
 tonsil in appearance, (Yirchow). In the former case we find, 
 in females who have not borne children, that both Hps, which 
 
132 ELONGATION OF THE 
 
 have been increased in breadth, and length, snrround the os 
 as transverse sHts. Frequently, however, the enlargement 
 and elongation of the anterior hp is so excessive, that the os is 
 situated at the posterior part of the conical tumour, and its 
 entrance is of a crescentic shape, with superior and lateral 
 margins, which are frequently seen at the posterior surface ol 
 the anterior hp, forming ridge-like prominences ; or the 
 vaginal portion appears cylindriform, its inferior extremity 
 being frequently either obhquely flattened posteriorly by 
 pressure of the posterior wall of the rectum, or perfectly round 
 with a circular opening in its centre leading into the cervical 
 canal. The second form above mentioned, is only found in 
 females who have borne children ; in these we meet with 
 shallow or deep insections, corresponding to previous lacera- 
 tions of the vaginal portion. It is evident that the different 
 forms of the normal vaginal portion will cause varieties of the 
 so-called hypertrophic forms. Thus I have before me a 
 specimen of a vu-gin utems affected in this manner, the 
 vaginal portion of which is 1? inches long, tapering down- 
 ward like a cone, and obliquely truncated at its lower por- 
 tion (Tapiroid neck, Eicord). 
 
 K the diffuse growth of connective tissue affects only one 
 lip, it assumes the form of a flattened, somewhat circular cone ; 
 if it be the anterior hp, the os is found at its posterior surface, 
 if the posterior lip, of course on the anterior sm^face. Gen- 
 erally the elongation affects the anterior hj) of the cervix. 
 
 A peculiar form described by Virchow under the name of 
 polypus-like elongation of the hps of the os uteri, is evidently 
 caused by a disease of the mucous follicles of the vaginal por- 
 tion, in consequence of which they degenerate into cysts, and 
 finally rupture. This cystic degeneration takes place under 
 the influence of an irritation, aftecting in Uke manner the con- 
 nective tissue of the vaginal portion and causing it to proHfer- 
 ate profusely. In consequence of this, and the considerable 
 enlargement of the follicles, the vaginal portion is considerably 
 
VAGINAL PORTION" OF THE UTERUS. 133 
 
 enlarged, either in its entirety, or cliiefly in its anterior lip, which 
 enlargement may result in the formation of tumonrs the size of a 
 fist, the sm-faces of which, however, are not smooth, but uneven 
 and knotty, and traversed by deep fissures and grooves, 
 which circumstance caused Virchow to compare these tumours, 
 as regards both their external and internal appearance, with 
 enlarged tonsils. K a sound be introduced into these fissures, 
 it sometimes passes into regular sacs, which extend as far as 
 the base of the tumoui^ and the cavity of which is always 
 larger than their orifices. 
 
 If the entire vaginal portion is thus aifected, it forms an ir- 
 regular tuberous mass, which from mere manual examination 
 might easily be confounded mth carcinoma. The latter forms 
 diflfer from those of enlargement, previously mentioned, in 
 which only elongation is found, in this respect, that in these 
 there is also considerable increase in breadth. This explains 
 why these growths, when arising from either lips, and attached 
 to the cervix by a pedicle, were described as pedunculated 
 polypi of the vaginal portion. 
 
 The transitions from these last-named forms to those previous- 
 ly described as having smooth surfaces, are formed by those 
 elongations which have been called proboscis-like tumom-s, 
 which affect either of the lips, and are smooth on the surface 
 which Hes in contact with the vagina, but velvet-hke, wrinkled, 
 and villous on their inner surface, which is also covered with 
 large funnel-shaped depressions (Virchow and Kennedy). 
 
 The substance of such an elongated vaginal portion is gen- 
 erally succulent, of a grayish-red color, exceedingly vascular, 
 and exhibiting on section lines of white fibres. Under the 
 microscope we find connective tissue composed of thin fibres 
 deficient in nuclei, in which tissue Virchow first found 
 numerous arterial vessels with quite thick walls, and measur- 
 ing upward of 0.11 of a millimetre in breadth. It is well 
 known to gynecologists, that frequently after the removal of 
 such polypous elongations of the vaginal portion, haemorrhages 
 
134 ELOl^aATIOI^ OF THE 
 
 have ensued which were difficult to control. In such cases the 
 epithehum is always exuberant, and covers the external sui'face 
 of the tumoui' in thick layers. 
 
 Having recognized the depressions mentioned as enlarged 
 cysts and ruptured foUicles, it is highly probable that the elon- 
 gation of the vaginal portion is owing to this affection. Ca- 
 tarrh of the mucous membrane of the vaginal portion may 
 therefore be considered as a cause of elongation of the 
 latter. Still, without doubt, other circumstances must be 
 considered, especially in those cases in which the inner sm'face 
 of the elongated vaginal portion is found to be smooth, as I 
 have fi-equently seen ; and here Kennedy's statement, that 
 frequent pregnancy and labor predisposes to this affection, 
 may be of some interest, for this condition is found much 
 more frequently in females who have borne childi'en. Scan- 
 zoni also attributes this affection to contusion of the vaginal 
 portion dming labor. 
 
 The degrees of this affection are various, monstrous elonga- 
 tion, especially of the anterior lip, having been observed 
 (IVIatecky's case measm-ed 5 inches in length). The lower 
 portion of the elongation may even appear outside the labia. 
 
 The consequences of this disease, according to experience, 
 are ffi'st, sterility, which may arise from considerable displace- 
 ment of the OS, for there are cases mentioned of conception 
 occurring after amputation of the elongated vaginal portion 
 (Petrequin, Dupuytren). Catarrh and leucorrhoea are generally 
 combined with elongation of the vagmal portion, and erosions 
 readily occur on the tumefied parts, especially when the latter 
 extend far down in the vagina or between the labia ; in the 
 former case adhesions are said to be sometimes formed between 
 the waUs of the vagina and the elongated vaginal portion ot 
 the uterus. If conception should take place notwithstanding 
 this condition, oedema of the elongated parts may offer an 
 impediment to labor. In a girl who died after parturition and 
 whose body was examined in Rokitansky's anatomical institu- 
 
VAGINAL PORTION OF THE UTERUS. 135 
 
 tion, I found the posterior lip of the os uteri lacerated trans- 
 versely in such a manner, that its inferior margin was hanging 
 down and the fornix vaginse was ruptured as far as Douglas' 
 space (1859). 
 
 Although enlargement of the vaginal portion of the uterus 
 by diffuse growth of its connective tissue, is frequently found 
 combined w^ith stricture of the canal, as was the case in a 
 patient seen by Krimer, in whom hsematometra had occurred, 
 still, there are cases known in which the external orifice was so 
 much enlarged, that the cervical canal assumed the form of an 
 infundibuhim with its larger opening below, and the lips of 
 the cervix were so tumefied that they appeared everted (Tyler 
 Smith, Yirchow). (See chapter on inversions of the uterus). 
 This afiTords a clue to the origin of elongation of the vaginal 
 portion of the uterus, and these very cases prove that enlarge- 
 ment and cystoid degeneration of the follicles are not the only 
 causes of the above condition, but on the contrary, that they 
 only produce elongation of the inner hning of the vaginal 
 portion, ending in eversion of its inner surface. If formative 
 u-ritation extend over the whole vaginal portion the latter is 
 more uniformly elongated. From an inspection of the thick 
 polypoid elongations of the vaginal portion with fissures and 
 depressions, we see that these irregularities of surface are 
 always on the inner surface, or the external and inferior mar- 
 gin, which fact proves that in such cases an outgrowing of the 
 hypertrophied inner lining has taken place. It is, therefore, 
 not to be doubted that the degeneration mentioned stands 
 in causal relation to the polypus-like elongation or intumes- 
 cence of the uterus, and that in consequence of it, elongation 
 of the entire vaginal portion may take place by the extension 
 of the growth of connective tissue to its external Kning ; but 
 it is also undoubtedly true that the elongation of its external 
 hning must not necessarily follow, and also that entire or 
 partial proboscis-like elongation of the vaginal portion may 
 take place without an affection of the follicles or independent 
 of them. 
 
136 ELONGATIO]^ OF THE 
 
 Proboscis-like and poljpus-like elongation of the vaginal por- 
 tion miojht be confounded with a descent of the uterus into 
 tlie vagina, but the length of the vagina in the above affection 
 affords a valuable criterion. It would be easier to mistake it 
 for elongation of the cervical canal and eversion of the vagina; 
 in such cases our safety hes in the normal length of the vagi- 
 nal portion being demonstrable ; the shortness of an inverted 
 vagina should also be remembered. We especially allude to 
 those cases of which Yirchow has given so excellent an illus- 
 tration in his case of prolapsus uteri without descent of its 
 fiindus. A condition nearly related to this is 
 
 a DIFFUSE GROWTH OF CONNECTIVE TISSUE IN THE CERVI- 
 CAL PORTION OF THE UTERUS. 
 
 The cervical portion of the uterus may become affected 
 with diffuse growth of connective tissue similarly to the vagi- 
 nal portion. When such is the case its walls thicken and 
 elongate, which latter condition is not imaginable without co- 
 existing inversion of the vagina. The cervix may increase 
 three inches in length, and consequently the external orifice 
 may appear between the vulva, and form a prolapsus without 
 sinking or descent of the fundus (Virchow). Huguier con- 
 sequently makes a distinction between hypertrophic elongation 
 of the vaginal portion and that portion of the cervix situated 
 above the fundus of the vagina, and, in the latter case, he con- 
 tends that the vaginal portion is always hypertrophied but 
 never elongated, and the body and fundus uteri at the normal 
 elevation. Still, according to Huguier, this affection maj^ be 
 combined with hypertrophy of the body and fundus and thus 
 cause true descent of the uterus. The walls of the cervix 
 when affected with diffuse growth of connective tissue are 
 remarkably dense and firm, and its cavity is sometimes either 
 contracted or dilated and filled with a glazy viscid mucous. 
 
 I must remark, in regard to this proliferation of connective 
 tissue in the cervix, that it is easily mistaken for fibrous carcin- 
 oma, especially on account of their presenting nearly the same 
 
VAGINAL PORTION OF THE UTERUS. 137 
 
 external appearance, and because fibrous carcinoma is likewise 
 generally limited to the cervical portion of the uterus. Never- 
 theless, when it is the latter afiection, the vaginal portion of 
 the uterus is also affected, being knobbed and uneven, while in 
 diffuse growth of connective tissue in the cervix the vaginal 
 portion is frequently, though not always, normal ; or, at least, 
 it is not so diseased as to present the appearance of fibrous 
 carcinoma. In such cases a careful microscopic examination 
 will alone dispel all doubt. 
 
 The relations between induration^ hypertrophic elongation 
 of the cervix^ and fibrous carcinoma, as well as whether the 
 latter may be developed from the former, cannot strictly be 
 determined. G-ynecologists assert that it can be developed, 
 and anatomy has no arguments to the contrary. But it is a 
 fact, that diffuse growth of connective tissue, limited to this 
 part, as is the case in carcinoma, may exist for years without 
 the latter being developed from it. 
 
 Another proliferation of connective tissue, involving an 
 entire layer of uterine tissue, and complicated with perime- 
 tritis, will be considered when we treat of the latter affection. 
 
 In opposition to the diffuse growths of connective tissue 
 just described, we place those partial, and more or less cir- 
 cumscribed new formations, generally known by the name of 
 polypi. They are divided according to the uterine stratum 
 in which they are developed : 1st, into polypoid growths of 
 the uterine mucous membrane, with or without degeneration 
 of its glands ; 2d, into papillomata, originating chiefly in 
 the vaginal portion, and presenting the character of tumours 
 of connective tissue ; and 3d, and lastly, into fibrous polypi, 
 which are developed in the uterine tissue proper. 
 
 All these new formations resemble each other in this one 
 particular, that by one portion they are intimately connected 
 with the tissue from which they spring, and consequently 
 cannot be defijied from the substance of the uterus. 
 
 Two other affections, also classed with polypi, the so-caUed 
 
138 MUCOUS POLYPI. 
 
 fibrinous polypi (Kiwisch) and the placental polypi (C. Braiin), 
 
 will be considered in other chapters. 
 
 2), CIRCUj^ISCEIBED PROLIFERATION OF THE UTERINE MU- 
 COUS IVIEMBRANE, MUCOUS OR VESICULAR POLYPI. 
 
 Literature: Meissner, Uber die Polypen u. s. w. Leipzig, 1820. — 
 Donne, Recherclies microsc. sur la nature, du mucus etc. Paris 1837. 
 
 Nivet et Blatin, Sitz und Ursachen der Blasenpolype n Archiv 
 
 gen. Octob. 1838, Froripe K Notiz. Bd. IX. J. 1839. — H. Oldham, 
 Guy's Hospit. Rep. April 1844. — B ullen, Dublin. Journ. July 1844. 
 — H u gi e r , Mem. sur les Cystes de la matrice et sur les cystes follicul. 
 duvag. Soc.de Chir. Paris, Mai 1847. —Th. Staff. Lee, On tumors 
 of the ut. audits appendages. London. 1847. — C. Hirsch, Histo- 
 logie und Form der Uteruspolypen. Diss, inaug. Giessen 1580. — J. H. 
 B e n n e t , Pract. treat, on inflammat. of the uterus. III. edit. London, 
 1853. — K i w i s c h , kl. Vortr. Bd. I. pag. 497. — H. M il 1 1 e r , Verh. 
 d. physik. mediz. Gez. z. Wilrzburg, Bd. IV. 1854. — Kolliker und 
 Scanzoni, Das Secret der Schleimh. der Vagina und des Cervix ut., 
 in Scanzoni's Beitr. etc. II. Bd. 1855. — Scanzoni, Beitrage z. Pa- 
 thol, d. Gebarm. Polypen in the same Journal. — Billroth, Ueber 
 den Ban der Schleimpolypen etc. Berlin 1855. By the same author. — 
 Zur Anatomic der Schleimpolypen. Virchow's Arch. Bd. IX. pag. 302. 
 1856. — E. Wagner, Cysten in der Schleimh. d. Uterushohle. Ar- 
 chiv f. phys. Heilk. 1855. — By the same author : Beitr. zur nonn. il 
 path. Anatomic der Vaginalportion, in the same Journal, 1856. — By 
 the same author : Beitr. zu den Geschwlilsten des Ut. in the same Jour- 
 nal, 1857. — Leudet und Laboulbene, Zur Anatom. der folli- 
 cularem Uteruspolypen. Gaz. med. de Paris. 9. 1856. — Scanzoni, 
 Krankh. d. w^eibl. Sexualorg. Wien, pag. 223. — Rokitansky, 
 Denkschi'. d. kais. Acad. d. Wissench. Bd. I. pag. 328. and Lehrb. d. 
 path. Anat. III. pag. 488. 
 
 The growths, consisting mainly of connective tissue, which 
 are developed chiefly in the mucous membrane of the uterus, 
 exhibit certain varieties, according as they are developed from 
 the mucous membrane of the body or fundus, or from that of 
 the cervix. They also vary according to their relations to 
 the uterine glands. 
 
 First, we meet with growths, arising in the mucous mem- 
 brane of the body or fundus uteri, in the form of circumscribed 
 elevations, two to three lines thick, and having the shape of 
 flat placques^ the smfaceof the mucous membrane being tume- 
 
MUCOUS POLYPI. 139 
 
 fied by catarrh. These puffed elevations are red, shiny, velvety, 
 and smooth ; on scraping them with a knife, a milky fluid 
 exudes from them, which, under the microscope, exhibits 
 nothing but the glandular epithelium of the uterus, sometimes 
 transparent vesicles and colloid bodies of varying size (Wedl). 
 Specimens hardened in chromic acid, and thin sHces of them 
 treated with glycerine, will exhibit an areolar stroma of con- 
 nective tissue, with utricular glands partly enlarged and elongat- 
 ed, and partly obliterated. Even with the magnifier, delicate 
 capillary ramifications may be seen, generally uniting in bundles 
 and producing a roughened appearance. The vascularity of 
 these growths is sometimes extraordinary. Sometimes with 
 the naked eye we can see yellow or yellowish-white dots, 
 which, under the microscope, are recognized as obliterated 
 glands, with fatty degeneration of epithelium. In other cases 
 small vesicles are visible in these tumom's, resulting from con- 
 striction, and cystic degeneration of the utricular glands ; this 
 latter forms the transition fi'om these tumours to vesicular 
 polypi of the uterus. These growths of the mucous membrane 
 vary in size, up to an inch or more in diameter. 
 
 Many cases present the appearance, especially in the vicinity 
 of the orifices of the oviducts, and along the lateral walls of 
 the uterus, as if the walls of the uterus had become adherent 
 from such outgrowths, and band-like prominent lines of mucous 
 membrane are seen passing from the anterior to the posterior 
 wall. This is evidently the result of an outgrowth of mucous 
 membrane from the angles at which the uterine walls join. 
 Frequently enough we have occasion to observe that adhe- 
 sions between the uterine walls do take place in consequence of 
 such outgrowths of mucous membrane, especially when they 
 arise from opposed mucous surfaces. 
 
 Besides the above-mentioned degeneration of the uterine 
 glands, we find included in these proliferations of mucous 
 membrane the remainder of the glands, elongated, distended, 
 filled with large opaque cells, partly undergoing fatty degene- 
 
140 MUCOUS POLYPI. 
 
 ration, and pale, clear, delicate vesicles partly isolated, and 
 partly included in cells. 
 
 These vegetations of mucous membrane are frequent, and 
 chiefly result from chronic uterine catarrh, especially in aged 
 females. Pregnancies seem to exert no influence upon them, 
 for I frequently found them in uteri which had never borne 
 children. Owing to their vascularity, these vegetations may 
 give rise to considerable haemorrhage, and I have preserved 
 the uterus of a woman 36 years of age, who died from anaemia 
 induced by metrorrhagia, in which, after the most careful 
 examination, I was unable to find anything except such a 
 vegetation of mucous membrane about 1 inch thick, and IJ 
 inch in diameter. 
 
 It seems to depend solely on a further condition of the 
 utricular glands, whether from these just mentioned growths 
 from the mucous membrane, more or less prominating tumours 
 described as mucous polypi, will be developed. At first a con- 
 striction takes place at the point of hmitation between the 
 outgrowth and the mucous membrane, thus rendering the 
 former more prominent ; as the proliferation progresses, round, 
 well-defined tumours are formed, varying in size between a bean 
 and hazel-nut, and sometimes having smooth surfaces, and the 
 appearance of villous tumefied mucous membrane. Upon 
 dissecting such tumours, we frequently find in them one or 
 several vesicles, about the size of a hemp-seed, or larger, and 
 filled with sermii, or a thick, honey-like substance, which may 
 be either clear or turbid. The surface of larger tumours of 
 this kind are no longer smooth, but covered with small points, 
 corresponding to the transparent vesicles already described. 
 The number of vesicles which these tumours may contain 
 varies ; but we may state that the size of the tumour depends 
 upon the number of vesicles within it. A tumour may attain 
 the size of an egg or more, and distend the uterine cavity as 
 it increases. Whilst the tumour at the commencement is 
 shaped according to the uterine cavity, yet, at a later period, 
 
xMUCOUS POLYPI. 141 
 
 the latter is distended like a globe, and the tumor assumes a 
 spherical shape, unless there are several such, or other tumours 
 present, which, from contact with one another, become flat- 
 tened, and give the uterus various other forms. The longer 
 these polypi grow, the more distinctly they become peduncu- 
 lated, and the thickness of the pedicle varies, independently 
 of the size of the tumours. 
 
 Sections of these mucous or vesicular polypi show that their 
 framework consists of a delicate connective tissue wliich 
 exhibits chiefly an alveolar structure. Imbedded in this con- 
 nective tissue, composed of thin fibres, with a large number of 
 nuclei, we find vesicles with extremely thin walls, and upon 
 the inner surfaces of which, up to the present time, I have been 
 unable to find epithelium. Still, in the contents of many of 
 these vesicles we meet with desquamated cells which may be 
 remains of former glandular cells. H. Mliller found in one 
 such tumour, the size of a bean, from the uterus of an old 
 woman, a number of spiral ducts, which, without doubt, must 
 be considered as enlarged utricular glands. In tumours of the 
 size just mentioned I have now and then met with the ducts, 
 but in larger ones they have been searched for in vain. 
 
 Rokitansky mentions that the cysts situated at the periphery 
 of the tumours, from time to time rupture, and are replaced by 
 others ; sometimes also, at the surface of the mucous polypi, 
 smooth depressions are found, the origin of which may be 
 similarly explained. 
 
 These vesicular polypi are generally covered with desquamat- 
 ing, cylindrical or transitory epithelium, or simply with the 
 elements of mucus. The rest of the uterine mucous membrane 
 is affected with chronic catarrh, which we will discuss with 
 derangements of nutrition. The mucous polypi are either 
 single or multiple tumours, and frequently fibroid tumours are 
 simultaneously developed on difierent portions of the uterine 
 walls. 
 
 Mucous polypi are very frequently found in the body of the 
 
142 MUCOUS POLYPI. 
 
 aterus, especially in old women, and I mnst decidedly contra- 
 dict the experienced Scanzoni in his assertion that they are 
 but rarely developed from the body and fundus uteri. 
 
 In regard to other pecuharities of the new-formation I 
 remark, that even when they attain a very considerable size, 
 and greatly distend the uterine cavity, they very rarely pass 
 through the internal orifice into the cervix, or are expelled, as 
 is frequently the case with more solid polypi. The firmness 
 of the cervical walls, the elasticity of those of the uterine 
 body, and the softness of the tumom-s, seem to explain the 
 cause of the above-mentioned circumstance. 
 
 Although in many cases the ramifications and bundles of 
 blood vessels, which are especially noticeable between the vesi- 
 cles, seem very numerous, yet I must agree with Scanzoni's 
 statement that we never meet with true telangiectasia. I have 
 in fact never met with anything approaching such vascular 
 productions. Frequently in the most depending portion of 
 the polypus, a dark-red discoloration exists from imbibition 
 resulting from rupture of the blood vessels in a state of 
 hyj)Ostatic hyj)eroBviia, and also from extravasation into the 
 parenchyma. 
 
 Proceeding to the analogous productions developed from 
 the denser mucous membrane of the cervical canal, at the 
 commencement of their formation, we first find the glands of 
 the above canal degenerating into vesicles situated either in 
 the borders of a si \gle transverse fold of mucous membrane, 
 or when developed parallel on several such folds, arranged 
 into rows, and giving the inner surface of the cervix a 
 peculiar appearance. Or, the degenerated glands are found 
 chiefly along the longitudinal folds, sometimes neatly arranged 
 like a string of beads. One of these small cysts then becomes 
 more prominent, forming a round protuberance, which grows 
 out further and further so as to produce an excrescence, which, 
 in its rounded tumelied portion, contains the gland degenerated 
 into a cyst ; or, several such glands prolapse into the cervical 
 
MUCOUS POLYPI. 143 
 
 cavity. Lisfranc describes these as cellulo-vascular polypi. 
 In the majority of cases a single degenerated gland, or several 
 of them, become so attenuated as to be suspended only by thin 
 pedicles. It is more rare to find larger and broader growths 
 of this kind arising from the degenerated glands of the cer- 
 vical mucous membrane. Simpson called them polypoid 
 tumom-s. The vesicular polypi originating in the first-named 
 manner are generally very slender, and the rupture of the 
 vesicles seems to occur at an early period, even before the 
 clubbed tumefied extremity of the polypus has issued from the 
 cervical canal or external orifice. In such a case we frequently 
 meet with long band-like excrescences in the cavity of the 
 cervix, with their lower extremities fimbriated and sometimes 
 distinctly presenting the appearance of the ruptured cavity of 
 the degenerated glands, or the lower extremity of the tumour 
 IS flattened and broad like a club, in which case it is quite 
 fii-m, and it is not improbable that in these instances the pro- 
 lapsed glands were either obliterated or cicatrized after rup- 
 ture. 
 
 If the external orifice is wide enough, such vesicular polypi, 
 of quite a large size, may pass through it into the vagina and 
 become visible. But, undoubtedly, in many cases the tumefied 
 inferior portion of the polypus has increased in size after it has 
 passed the os. Very frequently the external orifice is narrow, 
 scarcely admitting a large sound, and yet we find a vesicular 
 polypus, the size of a hazel-nut, hanging from quite a thin pedi- 
 cle into the vagina. Probably in such cases a gland undergoing 
 cystic degeneration has drawn with it a portion of mucous 
 membrane containing several other glands, which, after the 
 thin polypus had passed the external orifice, also degenerated 
 into cysts, and thus caused a disproportionate enlargement of 
 the inferior portion of the polypus. The dependent position of 
 the polypus, and perhaps still more its constriction by the 
 external orifice, and consequent impeded cumulation, may be the 
 cause of the subsequent cystic degeneration of the normal 
 cystSj and the rupture of the vesicles formed. 
 
144 MFCOUS POLYPI. 
 
 The larger pedunculated mucous polypi developed from tlie 
 cervical mucous membrane, besides their vesicular elevations, 
 frequently present larger prominences, with deep fissures 
 between, several prolapsed glands or aggregations of glands, 
 being attached to one common stem, which is owing either to a 
 greater stretching of the mucous membrane, or in consequence 
 of the production of more prominences from secondary cystic 
 degeneration of a polypus having but a single clubbed 
 extremity. 
 
 Besides the formation of multiple excrescences from glan- 
 dular polypi, at first single, the pedicle of such single or multi- 
 ple growths sometimes exhibits a number of small papillary 
 points. This condition is not owing to an exuberation of 
 glands, but to the proliferation of the connective tissue of the 
 polypus itself, from which small prominences arise, which at 
 first are composed of mucous tissue and afterward of dense 
 fibrous connective tissue. This proliferation may become so 
 considerable that the vesicular polypus, after the rupture of its 
 follicles, is changed into a papilloma, resembling an arborescent 
 growth with a number of clubbed extremities. This may 
 have induced Hirsch to make a distinction between areolar 
 and papillary vesicular polypus. 
 
 A microscopical examination of the vesicular polypus of the 
 cervix uteri, exliibits a structural condition similar to those 
 which occur in the body of the uterus, with this exception, that 
 the pedicle of the former consists of a denser fibrillary tissue, 
 with a small num,ber of nuclei, similar to that of the sinews. 
 
 The consequences of these polypi are the same as of those 
 developed from the mucous membrane of the body; their 
 frequent prolapsing, and constriction by the external orifice, 
 causes frequent hsemorrhages, and thus renders them far more 
 dangerous. This latter circumstance, and the readiness with 
 which they may be detected by vaginal examination, has prob- 
 ably caused the errors of many of the gynecologists, who con- 
 sider them to be of more frequent occurrence than the mucous 
 
PAPILLARY TUMOURS OF THE UTERUS. 145 
 
 polypi situated higher up, and which, as I have stated, rarely 
 pass the internal orifice. We may concede that cervical mucous 
 polypi are more frequently met with than others, but it would 
 be wrong to say that mucous or vesicular polypi of the uterine 
 body are of rare occurrence. These polypi may also be 
 developed from the vaginal portion, exclusively from its inner 
 lining, and may hang by a pedicle into the vagina. I have 
 ^een them in the above region as large as and even larger than 
 A pigeon's egg, and it is only the partial eversion of the cer- 
 vical canal which sometimes causes the polypi to appear as if 
 attached to the inferior part of the cervix. 
 
 Rokitansky describes another kindred new-formation, the 
 result of chronic catarrh and blennorrhoea of the uterus, which 
 presents the external appearance of a soft polypus, but which 
 •dissection shows, is connected with the substance of the 
 uterus, like a plug driven into it, and exhibits distinct longitu- 
 dinal fibres. Rokitansky mentions that this rare growth 
 arises from an elongation of the glandular ducts of the uterus. 
 Oldham must have observed similar cases, for he describes, 
 under the name of " channeled polypi," a movable, slippery, 
 and vascular growth, the interior of which consists of numerous 
 wide ducts, opening in large orifices on the surface of the 
 polypus. He expressly mentions that sometimes these ducts 
 may be followed through the pedicle of the polypus, and also 
 that the latter are direct outgrowths from the elementary tissue 
 of the uterus. 
 
 JS. PAPILLARY TUMOURS OF THE UTERUS. 
 
 Literature: Clarke, Transact, of a society f. the improvement 
 of med. and surg. knowledge. Vol. III. pag. 321. 1809. —Simpson, 
 Edinb. med. and sm'g. Jom-nal 1841. — Anderson, Dublin Journ. 
 1845. Vol. 20. Nr. 78. — A. K r a m e r , Ueber Condylome and Warzen, 
 Gottinger Studien 1847. — T h. St. Lee, On tumours of the uterus 
 etc. London 1847. — Robert, Des affections du col de I'uterus, 
 Paris 1848. — Renaud, London Gazette 1848. Aug. — Watson, 
 Monthly Journ. 1849. Nov. — V i r c h o w , Ueber Cancroide und 
 Papillargeschwulste, Wilrzburger Verhandi. Bd. I. pag. 106. 1850. — 
 10 
 
146 PAPILLAKY TUMOURS 
 
 H i r s c h , Dissert, inaug. Giessen 1855. — C. Mayer, Verb, der 
 Ges. f, Geburtsk. etc. Berlin 1855. — M i k s c h i k, Zur Pathologie 
 des Clarke'schen Blumenkolilgewachses. Zeitsclir. d, Ges. d. Aerzte^ 
 Wien 1856. Janner, — E. Wagner, Beitr. zur norm. u. path.. 
 Anatomie der Vaginalportion. Arch. f. physiol. Heilkunde 1856. Bd IV. 
 — H. Ziemssen, Zur Casuistik der Uterustumoren, Virchow's- 
 Archiv Bd. XVII. pag. 333. 1859. 
 
 Since Clarke described the cauliflower excrescence of the o& 
 uteri (Lisfranc's champignon, vegetation fongueuse), the papil- 
 lary tumours developed from the vaginal portion of the uterus, 
 have generally been comprised under the name of cauliflower 
 excrescences. But a more minute investigation shows that 
 practical gynecology derived no essential benefit from it, 
 the important distinction between benign and malignant 
 tumours being thereby set aside without sufficient cause^ 
 Under the form of papillary tumours, there are developed 
 from the vaginal portion of the uterus, not only new-forma~ 
 tions of connective tissue and epitheKum, but also cancroid 
 tumours, and a microscopic examination usually enables us 
 to distinguish between them. 
 
 We recognize four forms of papillary tumours of the vaginal 
 portion. 
 
 As the first, I designate the so-called acuminated condylo- 
 mata caused by gonorrhoea. As the second form, the benign, 
 papilloma 2yro])er, As the third, the cancroid papillary tumour^ 
 Schuh's granular epithelial cancer^ and Clarke's cauliflower 
 excrescence. As the fourth form, the villous form of medullary 
 carcinoma. The two latter forms will be described in a subse- 
 quent chapter. 
 
 Microscopically, the first two forms are near alike. The 
 papillge of the mucous membrane of the vaginal portion pro- 
 liferate, either singly or arborescently, and we find either deli- 
 cate papillae terminating in fine points, and covered with a 
 layer of epithelium, or their extremities are tumefied similar 
 to a club. In these papillary outgrowths we always find a 
 blood vessel, sometimes of considerable size, which is either 
 
OF THE UTERUS. 147 
 
 single, or forms a ramification of large capillaries distributed 
 in a manner similar to that of the intestinal villi. The con- 
 nective tissue is either of recent formation, or dense, and 
 composed of thin fibres ; the epithelium of the innermost 
 layer is similar to the rete Maipighi ; in the outer layer we 
 find basement epithelium, with flaky cells frequently without 
 nuclei. 
 
 In so-called acuminated condyloma a considerable portion of 
 the substance of the vaginal portion is aflfected, and frequently, 
 also, the vagina and external genitals. From the mucous 
 membrane sharp-pointed papillary excrescences are seen 
 arising, either isolated or in groups, in which latter case they 
 may give a deHcate villous appearance to the part. These 
 vegetations are soft and rose-colored. At a later period the 
 dividing branches and their extremities become clubbed, and 
 assume the form of a raspberry, coxcomb or cauliflower, with 
 a broad pedicle, and are covered with an abundance of epi- 
 thelium, which gives them externally the appearance of a 
 smooth mass, the epithelial layers passing over the fissures 
 and insections of the papillary tumors. Such excrescences of 
 long date often acquire considerable firmness, which condition 
 may lead an inexperienced observer to mistake them for other 
 tumours. After removing the external epithelial layers, the 
 wart-like surface of the tumour is easily recognized, and when 
 separating the former you will find deep fissures between the 
 densely crowded papillae. Acuminated condylomata, although 
 not frequently found in the vaginal portion, are nevertheless 
 those which seem to be the most frequent form of papillary 
 tumours. Leucorrhoea always coexists with the latter. 
 
 True papilloma is seldom found in the vaginal portion and 
 is in no respect difterent from acuminated condylomata 
 grouped together in the form of a polypus. But in general 
 we may state that acuminated condylomata are generally 
 numerous and scattered over the mucous membrane of the 
 vaginal portion, sometimes in hundreds, whilst benign papil- 
 
148 FIBKOUS POLYPI 
 
 loma generally occurs as a solitary tamour and is not always 
 combined with blennorrhoea, as is always the case with condy- 
 loma. In many cases these papillary tumours consist of a 
 framework of caudate elongated cells with large oblong nuclei, 
 covered with the usual basement epithelium. It has, how- 
 ever, been conclusively demonstrated, that these simple papil- 
 lary tumours, after existing for a certain time, may assume a 
 cancroid character, and many class them with cancroids ; stiU, 
 cases are known in which these growths existed for years 
 without changing their benign character, and this fact has 
 induced me to make a distinction between simple papilloma 
 and papillary cancroid. 
 
 Acuminated condylomata, as well as simple papillomata, 
 may spontaneously become gangrenous, which may be caused 
 by the stagnation of circulation resulting from their dependent 
 position ; or traction of the pedicle may cause mortification or 
 sloughing of the tumor. Acuminated condylomata may also 
 disappear spontaneously, in consequence of a retrogressive 
 metamorphosis induced probably by obliteration of their blood 
 vessels. 
 
 From the various ulcerations of the os uteri, granulations, 
 simulating the form of papillary growths, sometimes arise, a 
 description of which we will give when treating of the ulcer- 
 ative processes ; for they constitute no permanent new-forma- 
 tion or independent morbid form. 
 
 T. FIBROUS POLYPUS, OR SARCOMA OF THE UTERUS. 
 
 Literature: Slevogt, Diss, de utero per sarcoma ex corpore ex- 
 tracto etc. Jenae 1700. — H. v. Sanden, Observ. de prolaps. uteri 
 invers. ab excresc. carneo fung. Regiomonti 1722. — Tanner, Diss, 
 de polyp, felic. ex utero exstirp. Argentorati 1771. — Baudier, i 
 Journ. de Med. Tom LXIII. 1785. — F. A. Walter, Annotat. 
 academ. Berol. 1786. — W. A. Niessen, Diss, de polypis uteri et 
 vaginae etc. Gottingae 1789. — Rothbart, Diss, de polypis uteri , 
 1795. — D e n m a n , Engravings of two uterine polypi. London 1802. 
 
 — Meckel, Handb. der path. Auat. Leipzig 1818. IL 2. pag. 242. 
 
 — Horlacher, Diss, de sarc. uteri. Onoldi 1826 — Paletta, 
 Exercit. patliol. IL Me<liolan. 1820. — Meissner, Ueber die Poly- 
 
OF THE UTERUS. 149 
 
 pen etc. Leipzig 1820. — C. G. Mayer, Diss der pf)lypis. uteri, 
 Berol. 1751.— Hope, Morb. anatom. PI. 211. 2lo.— Malgaigne, 
 Sur les polypes de I'uterus, Tliese Paris 1823. — Gerdy, Des polypes 
 de I'uterns etc. Paris 1733. — K. Lee, Beob. liber fibros. kalkart 
 Geschw. u. Polypen des Uterus etc. Lond. med. Gazet. Decbr. 1835. 
 P. U. Walter, Denkschr. liber fibros. Gesehwlilste der Gebarm. 
 Dorpat 184:2. — Marchal de Calvi, Annal. de cliirurg. Aout. 
 1843. — H. Oldham, On uterine polypi and their co-existence 
 with pregnancy. Guy's Hospit. Rep. April 1844. — T. St. Lee, 
 On tumors of the uter. etc. London 1847. — Cruveilhier, Traite 
 d'anat. path. Livr. 11. pi. 5. 6.,Livr. 13. pi. 45., Livr. 24. pi. 1. — O. 
 P r i e g e r , Ueber Hypert. u. die hart. Geschw. des Uterus. Monatschr. 
 f. Geburtsk. etc. Berlin 1853. Marz. — Kiwisch, Klin. Vortr. Prag 
 1845. L pag. 392. — Wedl, Pathol. Histologic. Wien. 1854. pag. 
 493. — Simpson, Edinb. Monthly Joum. 1850. Jan. ~ Loyr, 
 Monthly Joum. of Med. Science. April 1 850. — R. Barnes, Lan- 
 cet. Juni, Aug. 1854. — C. Hirsch, Dissert, inaug. Giessen J 855. — 
 Mayer, jun., Ueber Uteruspolypen. Monatschr. f. Geburtsk. etc. 
 Berlin 1857. IX. Bd. 2. Hft. — A lb e r s, Ueber blutende Fibroide der 
 Gebarm. Deutsche Klin. 1858. 9. — Rokitansky, path. Anatom. 
 in. Aufl. Wien. 1861. pag. 484, u. Zeitsch. d. Ges. d. Ae. Wien. ]860. 
 Nr. 36. — Habit, Erfahrungen liber fibros. Gebarm. Pol., Zeitschr. 
 d. Ges. d. Ae. Wien. 1860. Nr. 12. u. ders. Einfluss der Gesehwlilste der 
 weibl. Genital, auf Schwangersch. u. Geburt, ebendaselbst Nr. 41 u. 
 42. — Gurlt, Monatschr. f. Geburtsk. Berlin 1860. Juli. — Val- 
 e n t a , Wiener Medic. Halle 1861. 19. 
 
 The fibrous polypus of the uterus consists of a well circum- 
 scribed hyperplasia of the uterine substance, especially of its 
 connective and submucous tissue, to which latter it is analogous 
 in structure. 
 
 It generally commences as a round submucous elevation, 
 growing toward the cavity of the uterus in the shape of a 
 round tumour, being covered by the uterine mucous membrane 
 which at first is unaltered. As these new-formations increase 
 in size, they project more and more from the uterine sub- 
 stance, become pedunculated, and are suspended with their 
 largest portion in the distended cavity of the uterus. Their 
 form is generally round or nearly round, sometimes pear-shaped, 
 clubby or cylindrical ; frequently their longitudinal diameter 
 exceeds the transverse. They are either single, or in rare 
 cases divided into lobes by deep fissures. 
 
150 FIBROUS POLYPI 
 
 The solidity of fibrous polypi varies, according to their 
 age, and the stage of development of the new-formation, 
 between a soft and doughy elasticity, and a firmness nearly 
 cartilaginous. Their color varies according to their supply of 
 blood and vascularity. Fibrous polypi, as a rule, are quite 
 vascular, especially when compared with the uterine fibroid 
 tumours which are similar to them in structure. On dissect- 
 ing fibrous polypi we perceive that they are developed from a 
 portion of uterine tissue which has increased in density, and 
 that they are intimately connected with it ; that they are not 
 well defined at their point of insertion into the uterine tissue, 
 and consequently cannot be enucleated. When they extend 
 into the cavity of the uterus they are always covered by its 
 mucous membrane, but the latter frequently undergoes im- 
 portant changes. At first it is generally afifected with catarrh,, 
 afterward it is thinned, and numerous small indentations, vary- 
 ing in size between a needle-point and pin-head, indicate the 
 destruction of the utricular glands. Finally, the mucous mem- 
 brane is evidently destroyed, and is represented by a large- 
 meshed net- work (Rokitansky), the interstices of which cor- 
 respond with the dilated and fiattened glandular spaces. In 
 other cases the proliferation of the mucous membrane assumes 
 the form of a villous vascular spongy membrane, even in the 
 covering of larger polypi, and in such cases we frequently find 
 small cysts, as large as a hemp-seed, which have resulted in 
 consequence of distention of constricted utricular glands. 
 
 The structure of the polypi mentioned, consists essentially 
 of connective tissue in various stages of development, in con- 
 sequence of which the appearance of a polypus varies. If 
 the substance of the tumour is chiefly composed of newly- 
 formed connective tissue, a section of it is soft and presents 
 a homogeneous appearance, is of a grayish-red color, traversed 
 in various directions by white lines, which generally diverge 
 from the pedicle of the tumour into its substance. If, how- 
 ever, the substance of the tumour consists of connective tissue 
 
OF THE UTERUS. 151 
 
 of older date, fibrous bundles will be observed crossing each 
 other in different directions ; in rare cases they assume a con- 
 centric disposition around a more solid nucleus. A closer 
 examination of these tumours will show that they are generally 
 •composed of a wavy connective tissue with an abundance of 
 nuclei ; sometimes they contain caudate cells, of considerable 
 length, united in thick bundles and crossing in various direc- 
 tions. Thin sections treated with acetic acid bring distinctly 
 into view their long massive nuclei. 
 
 In many instances the structure of these uterine polypi is 
 not so simple. The utricular glands having become elongated, 
 constricted, and afterward degenerating into cysts, enter into 
 the composition of these tumom-s and give them the character 
 of Rokitansky's adenoid utemne sarcoma^ and adenoid uterine 
 cystosarcorria» In the following lines I copy ti'om the mas- 
 terly description of the discoverer of these tumours. " In 
 the substance of the sarcoma, consisting of straight-fibred 
 connective tissue, small excavations, scarcely perceptible, and 
 larger ones, circular, ragged and fissured, are frequently found 
 grouped together. They are either filled with a clear yellow- 
 ish Hquid, or some may contain a small quantity of blood, as 
 I observe in the specimen before me. Upon a closer exami- 
 nation with the microscope we perceive that these cavities 
 possess no lining membrane, excepting a scarcely perceptible 
 hyaline border, but now and then we meet with some, filled 
 with epithelial cells, and having all the appearance of tran- 
 sected ducts." The sm-face of the tumour next to the mucous 
 membrane, is usually closely adherent to the latter ; and in 
 close apposition to the spongy stratum representing the mu- 
 cous membrane we meet with the outermost succulent layer 
 of the new-formation, which appears covered with numerous 
 «mall excavations. In the degenerated uterine mucous 
 membrane which covers this new-formation, the elongated, 
 constricted, and cystoid utricular glands are found, a con- 
 tinuation of which is apparent in the excavations of the 
 
152 FIBROUS POLYPI 
 
 spongy external layers of the new-formation. Consequently, 
 the utricular glands have not only degenerated into ducts in 
 proportion to the increase of thickness of the mucous mem- 
 brane, but they have also grown into the submucous stratum 
 in which the tumour was developed, and at the same time- 
 have undergone degeneration. Those excavations, however, 
 found in the deeper layers of the tumour distant from its 
 mucous membrane, mostly originate from adenoid degeneration 
 of the fibrous polypus, and must be considered as new-forma- 
 tions of glandular tissue. 
 
 Upon section of such tumours we frequently find tuberous 
 bodies imbedded in them, and a careful investigation proves 
 without doubt, that from the walls of the several cavities 
 analogous to the adenoid cystosarcoma of the breasts, prohfer- 
 ations of connective tissue grew out of the mass of the tumour, 
 filling the round cavity in the form of tuberous or round papil^ 
 lary excrescences, in the substance of which new cavities may 
 be formed with further proliferations from their walls. These^ 
 tuberous masses growing into these cystic cavities may appa- 
 rently be completely enucleable, still it is easy to convince- 
 oneself that at one point they are firmly adherent to the wall, 
 of the cavity and form a continuous body with the substance 
 of the wliole tumour. 
 
 The formation of cysts in fibrous polypi has already been? 
 described by Hope. E-okitansky states that it is not improl>- 
 able that similar cavities may be formed in some fibrous^ 
 tumours growing toward the peritoneal surface of the uterus, 
 causing them to degenerate into adenoid cystosarcoma. 
 
 The larger cystic cavities of the tumours described, are^ 
 either filled with serum or colloid fluid, mucus and blood, and 
 may in isolated cases, after inflammation, contain pus and pre- 
 sent the characteristics of an abscess. 
 
 The blood-vessels of the fibrous polypus are very numerous, 
 and the calibre of the veins especially, is remarkable. The 
 latter frequently represent sinuous canals (Rokitansky). 
 
OF THE UTERUS. 153 
 
 The fibrous^ as well as the adenoid polypus is rarely met 
 with before the 20th year ; still, isolated cases are mentioned 
 of their occurrence in children (Pfaff ). After the 30th year 
 they are of rare occurrence. 
 
 The size of these polypi varies from the almost impercepti- 
 ble to the size of a child's head, and even larger. Their most 
 frequent size is that between an ^g^ and a man's fist. 
 
 They most frequently arise from the fundus uteri and the 
 superior portions of the uterine wall (internally), and, as 
 before mentioned, from the submucous stratum ; in very rare 
 instances they are more deeply attached in the parenchyma of 
 the uterus, and in such cases they sometimes grow outwardly 
 and form tumours inserted at the fundus and hanging into the 
 peritoneal cavity. Rokitansky mentions, that sometimes por- 
 tions of polypi branch ofi' in such a manner as to form tumours,, 
 which will cause prominences on the exterior of the uterus. 
 The fibrous polypi which grow toward the peritoneal cavity, 
 may also be attached by a thin pedicle, may be single or lob- 
 ular, and may attain an exceedingly large size (Rokitansky). 
 In many cases fibrous polypi have been found depending froni 
 the cervix uteri, or, which is more rare, from the vaginal por- 
 tion of the uterus. In the majority of cases only a single 
 polypus is found, sometimes, however, two are seen, flattened 
 from contact, but rarely more than two. Sometimes we find 
 adjoining a large polypus evidences of smaller ones, consisting 
 of submucous round elevations. When fibroid polypi are 
 present, the uterus is generally hypertrophied, and its substance 
 in a condition similar to that of a pregnant one (Kiwisch), 
 being succulent and spongy, and its veins distended. Fre- 
 quently the uterus is found to be aftected with profuse prolif- 
 eration of connective tissue. The condition of its mucous 
 membrane has already been particularly described. 
 
 After a fibrous polypus has attained a certain size, the uterus 
 manifests a tendency to get rid of it by contracting. This is 
 imdoubtedly caused by the downward growth of the tumour, 
 
154 FIBROUS POLYPI 
 
 which, after the uterus has been considerably distended, pro- 
 -duces effects analogous to those of labor ; the cervical canal 
 shortens, the internal orifice becomes fully dilated, causing the 
 cavity of the cervix to communicate with that of the uterus ; 
 the vaginal portion becomes elongated, and after the passage 
 of the broadest portion of the polypus through the external 
 orifice, an energetic contraction of the uterus expels it into 
 the vagina, or in other words the polypus "is born." In many 
 oases the polypus, after a portion of it has passed the external 
 orifice, is constricted, and thereby divided into a superior and 
 inferior portion. K the pedicle is thin and elastic, the uterus 
 may still retain its normal position, but if such is not the case, 
 partial or even complete inversion of the uterus may occur. 
 The latter accident is most likely to happen when the polypus 
 is inserted at the fundus or superior portion of the body of 
 the uterus, but even when attached lower down it may cause 
 partial inversion, and in this respect Ulrich's case, previously 
 mentioned, is interesting. 
 
 The metamorphoses which the structure of the fibrous 
 uterine polypus undergoes are : cystic degenerations which 
 oonstitute cystosarcoma, and fatty degeneration. In the lat- 
 ter condition the polypus becomes of a doughy consistence, and 
 its tissue abounds in fine granular fatty elements, which on 
 section appear as a pale yellowish net-work. Less frequently 
 we meet with gangrene of these polypi, which sometimes arises 
 in larger tumours of this kind which have prolapsed, and is 
 probably owing to stagnation of their circulation, in consequence 
 of considerable traction or twisting of the pedicle. Gangrene 
 generally first affects the lowest portion of the lining mucous 
 membrane of the polypus, and thence extends to its substance, 
 giving this portion of the tumour a jagged appearance. Under 
 these circumstances, even sloughing of the whole polypus may 
 take place, (Marchal de Calvi), and the ichorous process may 
 oxtend to the mucous membrane, and even to the substance 
 of the uterus. In rare cases such ichorous processes may 
 
OF THE UTERUS. 155 
 
 lead to perforation into a neighboring cavity, i. e., the blad- 
 der or abdominal cavity, or externally through the abdominal 
 parietes (Rokitansky and Loir), and may also occasion throm- 
 boses, ichoraemia, lymphangitis, etc. Ossification and calca- 
 reous degeneration never occur in fibrous polypi. 
 
 Large polypi may act injuriously by pressure upon the 
 canals which pass through the pelvis, causing distention of the 
 ureters, hydronephrosis, oedema of the lower extremities, 
 vai'icose condition or even thrombosis of the crural veins and 
 compression of the rectum. The mucous membrane covering 
 the most dependent portion of the polypus is often the seat 
 of hypersemia and even hoeniorrhage, which latter may prove 
 fatal. 
 
 Sometimes destructive ulceration commences in the uterine 
 mucous membrane, ultimately involving and destroying the 
 pedicle of the polypus. Excessive traction may also cause 
 spontaneous rupture of the thin pedicle of a fibrous polypus. 
 
 On the other hand, adhesions may occur between the degen- 
 erated mucous membrane covering the polypus and the lining 
 of the uterus, causing obliteration of the cavity of the latter. 
 If the lower portion of the polypus becomes adherent to the 
 internal orifice or cervix, hydrometra may result. Cases have 
 also been observed in which a polypus prolapsed from the 
 uterus into the vagina and became adherent to the w^alls of the 
 latter by the formation of false membranes. 
 
 If some authors have stated that a fibrous polypus may be 
 attached to the walls of the uterus by tw^o pedicles, one of the 
 latter has originated either from an adhesion of the polypus to 
 a second point of the uterine wall, or is formed in consequence 
 of the coalescence of two previously single polypi. 
 
 The condition of fibrous uterine polypi during menstruation 
 and pregnancy, is also interesting. Their tissue tumefies in 
 the same manner as that of the uterus, it becomes softer, 
 more succulent, vascular, and sometimes considerably engorged. 
 At the termination of the above processes involution ensues. 
 
156 ROUND FIBEOID TUMOURS 
 
 The presence of fibrous polypi s^enerally causes derange- 
 ments of menstruation, and if conception takes place a poly- 
 pus may injure the foetus by limiting the uterine space. 
 Among the frequent complications we must also inchide blen- 
 norrhcea of the uterus, fibroid tumours, dropsy of the oviducts^ 
 and perimetritis. 
 
 G. ROUND FIBROID TUMOURS OF THE UTERUS. 
 
 Literature: Morgagni, De sedib. et. caus. morbor. Ep. VII. art. 17, 
 XII 2., XXIII. 11., XXXVII. 29., XLV. 16. 23. etc. — Chambon 
 de Montaux, Des maladies des femmes. Paris, 1784. — Lefau- 
 c h e u X , Dissert, sur les tumeurs circonscrites et indol. du. tissu ceUn- 
 laire de la matr. et du vagin. Paris, 1802. — J. C o e n , Giom. per 
 servir ai progr. della Patol. et della mat. med. Tom. II. Fasc. 6. Art. 1. — 
 B ay 1 e , Sur le corps fibreux, Corvisart Joum. de Med. Ann. XL Ven- 
 dem. (1803 Octob.) — Sandifort, De tumorib. utero adnexis. Observ. 
 anat. pathol. Lib. I. Cap. VUI. pag. 107. und Museum anatom. Vol. I. 
 Nr. LL— Voigtl, Path Anat. Halle, 1805. IIL Bd. pag. 482. — Du- 
 p uy tr e n , Le^. oraies de cliniq. cMrurg. Paris, 1833. Tom. IH. pag. 
 454. — Boivin et Duges, Traite etc. Paris, 1833. Tom. I. pag. 
 311. —R. Lee, Med. chirurg. Transact. XIX. 1835. On fibrous 
 turn, of the uterus. — H. P. Krull. De nat, et caus. tum. fibros. 
 uteri. Gron. 1836. — Lisfranc, Maladies de I'uteras. Paris, 1836. — 
 J. A. Romer, De effectu tumor, fibros. Gron, 1837. — Andral, 
 Precis d'anat. path. Bruxelles, 1837. 11. pag. 239. — Amussat, 
 Mem. sur les tum. fibreux de Tuterus. Paris, 1843. — P. U. Walter, 
 Denkschrift etc. Dorpat, 1842. — Kiwisch, Klin. Votr. Prag, 1845. 
 
 I. pag. 373. — Th. St. Lee, On tumours of the uterus, etc. Lon- 
 don, 1847. — B i n a r d , Sur les Corps fibreux de la matrice. Journ. de 
 Bnixell. 1847. — Janv., Avril. — Cruveilhier, Anath. path. Livr. 
 
 II. pi. 5. 0. Livr. 24. pi. 1. — Krauss, Merkw. Osteoid der Gebarm. 
 Wtirtemb. Corresp. Bl. 1850. 1. — Forster, Pathol. Anat. Leipzig, 
 1854. 11. Bd. pag. 304. — Hack el, aus Vi re how's patholog. 
 anatom. Curse. Wittelshofer's med. AVochenschrift. Wien. 1856, Xr. 7. — 
 Albers, Ueber blutende Fibroide der Gebm. Deutsch. Klin. 1858. 9. 
 
 — Scanzoni, Krankh. der weibl. Sexualorg. Wien, 1857. pag. 186. 
 
 — B i n z , Deutsche Klinik. Juli 1857. — H y r 1 1 , Topogr. Anatom. 
 IV. Aufl. 1860. 11. Bd. pag. 185. — Lumpe, Seltener Ausgang eines 
 Uterusfibroides. Zeitschr. der Ges. d. Ae. Wien, 1860. Nr. 29. — Ro- 
 kitansky, Pathol. Anat. IIL Aufl. 1. Bd. pag. 164., IIL Bd. pag. 
 479. 
 
 The round fibroid tumour of the uterus is a growth con- 
 eisting chiefly of connective tissue, is always round, more or 
 
OF THE UTERUS. 157 
 
 less dense, of well-defined outline, and easily enncleable from 
 the surrounding tissue ; it is also the most frequent of those 
 tumours which affect the uterus, and although naturally 
 benign, may easily terminate fatally, either from pressure 
 upon the neighboring parts, or other accidents. It certainly 
 constitutes the most frequent affection to which the female 
 fiexual apparatus is subject, after puberty. 
 
 Various names were given to these growths by the old writ- 
 ers : Tuberculum (Morgagni), Cellulo-fibrous bodies (Bayle), 
 Steatoma (Voigtel), Sarcoma, desmoid, and fibrous tumours, 
 <fec. 
 
 At present we recognize the existence of two forms of fibroid 
 tumom-s, which are best distinguished as the simple and 
 <jompoimd. 
 
 The simple round fibroid tumour is developed from a hmited 
 portion of the uterine connective tissue, and grows by an inde- 
 pendent proliferation of its elements, simply by displacing the 
 sm-rounding tissue and thus completely defining itself from the 
 rest of the uterine substance. It generally forms a spherical 
 whitish or reddish-white tumour, and usually of such firmness 
 that considerable force is necessary in dividing it with a knife. 
 It is generally readily enucleated from the tissue of the 
 uterus ; if a division is made through both tumour and uterus, 
 the former rises above the divided surface of the latter in con- 
 sequence of a retraction of the uterine substance. The attach- 
 ment of the tumour is merely by a slightly vascular and 
 filender bundle of connective tissue ; its surface, after it has 
 been enucleated, is perfectly smooth and covered with a serous- 
 like membrane ; the cavity in which it was imbedded is also 
 smooth and shows no trace of any rupture of tissue. The 
 section of a simple round fibroid tumour generally exhibits 
 dense interwoven lines of fibres crossing in various directions, 
 and irregularly disposed ; and those cases are exceedingly rare 
 in which, on the divided surface, a somewhat dense yellowish 
 nucleus is seen, and around it a concentric disposition of 
 
158 ROUND FIBROID TUMOURS 
 
 fibrous lines. Here and there, in the outermost of the above 
 fibres, short arch-like striated lines may be seen, marking the- 
 periphery of the tumour. 
 
 As a second form, we may consider the compound fibroid 
 tumour, which consists, chiefly, of a larger or smaller 
 number of fibroids of unequal size, which are fiattened 
 by contact and united into a single mass by loose con- 
 nective tissue. In structure the compound fibroid tumour 
 is not difterent from the simple ones, only its component 
 tumours are less dense in structure, more succulent and vas« 
 cular, and their limits not sufiiciently well defined to allow of 
 their easy enucleation. Kiwisch remarks that whilst in the 
 simple fibroid tumour the fibrous lines are more or less regu- 
 larly disposed around one centre, in the compound tumour 
 several such centres exist, from which fibres of connective 
 tissue ramify ; and this is undoubtedly correct. Still, I must 
 add, that in the majority of cases the bundles of coimective 
 tissue arising from the central point are intimately interwoven 
 with others coming from a different direction, and that 
 between the difierent prominences of the tumour a loose con- 
 nective tissue exists, composed of long fibres, which forms a 
 kind of external envelope by which the whole mass is im- 
 bedded in the uterine tissue. The surface of such tumours is- 
 knobbed, lobulated, and irregular ; frequently small newly- 
 formed fibroid bodies, the size of pellets, are seen in the loose 
 external covering, especially between two or more lobes of the 
 tumour. These compound fibroid tumours seem to possess a 
 kind of hilus, large veins apparently issuing from the tumour^ 
 opposite to whicli liilus the uterine substance is completely 
 transformed into a cavernous tissue. The arteries are scarcely 
 perceptible, whilst the veins form a considerable plexus. If 
 you follow the course of the latter over the tumour, it is easy 
 to perceive that they represent large sinuous canals, which ex- 
 tend longitudinally between the lobes of the tumour, receiving 
 small ramifications which converge from the periphery of the 
 
OF THE UTERUS. 159 
 
 single lobes. Abernetlij could never succeed in injecting the 
 separate lobes of a compound fibroid tumour. Dupuytren 
 makes express mention of large arteries in the pedicles of 
 fibroid tumours which protruded inwardly ; and Caillard 
 describes such an artery which was the size of the radial. In 
 my own investigations I w^as unable to find such an artery, 
 even in large tumours. Once only I met with one, the size of 
 a uterine artery, in the hilus of a compound tumour as large- 
 as a man's head. 
 
 The number of capillaries varies in different fibroid tumours ;^ 
 successful injections have shown a surprising number, in con- 
 trast with the habitual paleness of these tumours. 
 
 Here it is proper to mention what Virchow has described 
 as a telangiectatic muscular tumour (Myoma telangiectodes) : 
 
 * ' The inferior portion of a large fibroid tumour exhibited 
 in its engorged tissue, isolated cavernous growths commencing- 
 as dense sieve-like tissue and gradually developing into large 
 cavities, varying between the size of a pea and hemp-seed. 
 The walls between these cavities were of the thinness of those 
 found in cavernous tumours of the liver, and consisted chiefly 
 of smooth muscular fibres." (Virchow, Archiv. vol. A''!., p. 
 553, 1854). 
 
 Virchow frequently found indications of such productions, 
 in the larger fibroid tumours of the uterus, but rarely so appa- 
 rent as in the case quoted literally above. I have likewise 
 met with several cases in which this production was shghtly 
 apparent, and recently with a case in which it was consid- 
 erable. 
 
 Uterine fibroid tumours vary from an almost impercep- 
 tible size to that of a man's head, or even larger. Cases 
 are recorded of these tumors attaining the weight of 14 
 pounds (Brinz) ; Dupuytren saw one of 25 pounds ; Gaulthier 
 de Claubry, one of 3 pounds ; Voigtel mentions the cases of 
 Eeisel, Moren, Pelargi, and others, in which the tumours- 
 weighed from 40 to 60 pounds. 
 
160 KOUND FIBROID TUMOURS 
 
 The seat of fibroid tumours is almost exclusively in the 
 body and fundus uteri. They are very rarely found in the 
 cervix, and more rarely still in the vaginal portion. The prog- 
 ress of these tumours, according to their situation, is of 
 interest. We find them arising in the different strata of ute- 
 rine tissue, and the direction in which they finally project or 
 prolapse, depends upon the situation of their point of origin. 
 A tumour developed from the centre of the uterine wall, 
 grows uniformly, and projects toward the uterine cavity, as 
 well as outwardly, the latter prominence always being the 
 most considerable. If a fibroid tumour has been developed 
 exactly in the centre of the substance of the fundus, and 
 grows to a considerable size, the uterus in consequence of the 
 external protuberance of this tumour assumes a form similar 
 to that in pregnancy, from which circumstance these two con- 
 ditions may be confounded, as has occurred in many instances 
 known to me. In consequence of the tumour causing an 
 inward prominence of the fundus,, which is always combined 
 with elevation of the whole uterus, the cavity of the latter 
 is increased in breadth, and its superior wall is depressed and 
 becomes convex. The uterus undergoes a similar change in 
 form when the tumour grows from a point situated in the 
 median line of the body, in the superior portion near the 
 fundus. When the tumour is developed nearer to the perito- 
 neal surface of the uterus, it projects more toward the abdom- 
 inal cavity, and grows out of the uterus in such a manner that 
 its attachment at first becomes constricted and neck-like, and 
 afterward is converted into a pedicle, which may be very 
 thin. 
 
 Rokitansky states that such pedunculated tumours may even 
 be detached from the uterus, and float about in the peritoneal 
 cavity, especially in the recto-vaginal space ; or, peritonitis 
 may supervene, causing the formation of false membranes, 
 which will render them immovable. Detachment of the 
 tumour may be caused by its weight stretching and rupturing 
 
OF THE UTERUS. 161 
 
 the thin pedicle, or by contraction of the false membranes 
 attached to the tumom*. If a fibroid tumour has been 
 developed near the mucous membrane of the uterus, or its 
 sub-mucous tissue, as is frequently the case, it grows toward 
 and into the uterine cavity, and at the same time distends it. 
 Gradually the tumour issues from the uterine substance, being 
 attached by a pedicle covered with a thin mucous membrane. 
 When they prolapse into the cavity of the uterus, such tumours 
 produce phenomena similar to those resulting from fibrous 
 pol}^i. When developed near the point of insertion of the 
 broad ligament, the tumour will ultimately grow between 
 both the laminae of the hgament; if it arises at a higher 
 point in the lateral margin of the uterus, the oviduct, to which 
 it becomes closely attached, arches over it, and is consequently 
 displaced; if the tumour arises lower down, it causes no 
 alterations in the form of the uterus, excepting a prominence 
 on both sides of the broad Hgament. A close inspection of a 
 fibroid tumom- arising apparently in the broad ligament, will 
 always lead to the discovery of a pedicle attached to the 
 uterus, and consequently will enable a correct opinion to be 
 formed as to the point of its origin. A fibroid tumour, when 
 developed within the broad ligament, generally projects uni- 
 formly anteriorly and posteriorly ; sometimes, however, it 
 may protuberate to one side only, either to the posterior or 
 anterior, and cases may occur in which such a tumour may 
 become pedunculated and prolapse into the recto- or vesico- 
 uterine space. I came into possession of a specimen a year 
 since, in which a prolapsed fibrous tumour, the size of a wal- 
 nut, with a thin pedicle, projects at the point of insertion 
 of the left broad ligament, into the vesico-uterine space. 
 
 If a fibroid tumour is developed from the lateral margin of 
 the cervix and grows out of the uterus, it causes the posterior 
 laminae of the broad ligament to prominate posteriorly and 
 markedly pushes the uterus in an opposite direction. If the 
 tumom- is situated laterally and low down, it causes obliquity 
 11 
 
162 EOUND FIBEOID TUMOURS 
 
 of tlie uterus, the fundus of the latter being directed toward 
 the side on which the tumour is situated. 
 
 Fibroid tumours arising in the vaginal portion of the uterus 
 cause considerable tumefaction of the latter, and grow into and 
 distend the vagina. An entire lip of the os may also be 
 involved, presenting the appearance of a large pedunculated 
 fibroid tumour, instead of the os uteri. 
 
 The alteration of form and position of the uterus, occasioned 
 by a fibroid tumour, depends upon the point of origin of the 
 latter. As previously mentioned, such tumours developed in 
 the median fine of the uterus cause uniform enlargement of 
 the organ, similar to that occasioned by pregnancy. K the 
 fibroid tumour arises in the median line of the posterior wall, 
 the uterus gradually ascends from the pelvic cavity, its own 
 cavity becomes elongated, and its posterior wall convex, and a 
 section of it presents a crescentic appearance. The uterus 
 proper is situated at the anterior circumference of the whole 
 mass. An opposite condition is found if the tumour originates 
 in the median hue of the anterior wall. The traction to which 
 the uterus is subjected in both cases may become excessive and 
 produce those alterations of position which have been described 
 as elevation of the uterus ; the vagiual portion and vagina 
 become elongated, and the effects of the traction within the 
 uterus are most marked in the region of the internal orifice, at 
 which point a stricture of its cavity and thinning of its walls, 
 may cause obhteration of the former and expansion of the latter. 
 
 When a fibroid tumour grows from either side of the body, 
 or from the fundus of the uterus, after attaining a certain size 
 it pushes the latter to the opposite side. If the tumom' is at 
 the same time an interstitial one, it projects into the uterine 
 cavity, and a transverse section of the organ presents a trian- 
 gular appearance. If a tumour grows lower down, near or at 
 the internal orifice, the entire uterus is in consequence pushed 
 into an extra-median position, or is fiexed laterally, with its 
 fundus inclining toward the tumour. This latero-flexion is 
 
OF THE UTERUS. 163 
 
 frequently only revealed on opening the cavity of the uterus, 
 and is much more marked, the nearer the tumour lies to the 
 mucous membrane and the internal orifice. When a fibroid 
 tumour is developed in the side of the cervical portion, which is 
 of rare occmTence, after attaining a certain size it will cause 
 obliquity of the uterus, with inclination of its fundus toward 
 the tumour. 
 
 If several fibroid tumours have been developed in the uterus, 
 their individual effects upon its form and size are combined. 
 The uterus often appears imbedded in a mass of tumours, and 
 from its external appearance we can form no idea of the course 
 of its cavity. It may be found in the lateral, anterior, or 
 (rarely) posterior periphery of the mass; or, if the cavity 
 passes thi'ough the centre, its shape is much altered by the 
 tumours projecting into it. In some places it may be contract- 
 ed, or there may be a dilatation above a point of stricture ; 
 or it may be elongated, narrowed, and curved like a bow or 
 the letter S ; or it may pass around the periphery of one or 
 more of the tumours ; or, in some cases, it may even be flexed 
 at an angle. Manifold and varied are likewise the alterations 
 of form to which the cavity of the uterus is subject from 
 tumours projecting into it at different points. 
 
 In regard to the microscopical anatomy of uterine fibroid 
 tumours, we must first state that their structure is quite analo- 
 gous to that of the uterus, the proportion only of the several 
 tissues constituting the latter being altered in these tumours. 
 In the majority of cases the connective tissue predominates ; 
 but we frequently meet with fibroids, in which the 
 smooth muscular fibres exceed the rest of the tissue (hence 
 the name oi fihro-inuscular tumour and myoma) ; and it may 
 generally be considered a rule, that the quantity of muscular 
 fibres entering into the structure of a fibroid tumour is nearly 
 in proportion to that of its succulence. 
 
 Thin slices made with a double-bladed knife, or with a razor, 
 after being rendered transparent, show that the connective 
 
164 ROUND FIBROID TUMOURS 
 
 tissue of uterine fibroid tumours is frequently composed of 
 broad, wavy fibres, crossing each other in various directions, 
 and causing a small section to appear divided in various ways 
 by fibres of connective tissue. The cells of the above tissue, 
 few in number, are spindle-shaped, ana rather small, with 
 oblong nuclei, and distinct nucleoli. Stellate cells and spiral 
 fibres of connective tissue (Forster) I have not met with hith- 
 erto in fibroid tumours. The fibres of connective tissue are 
 united in bundles of varying thickness, from which smaller 
 ones branch off and unite with others. If these lines or fibres 
 are divided parallel to their course, they present the appear- 
 ance of whitish glossy lines, whilst those divided trans- 
 versely appear grayish, which fact formerly led to the assump- 
 tion that fibroid tumours consisted of white connective tissue, 
 disposed in fibrous Knes or bundles, the intervening spaces 
 being filled with a grayish substance. Forster remarks, that 
 soft fibroid tumours, of recent formation, contain more 
 cellular elements, which may be transformed into fibrous 
 lines and connective tissue. This is the explanation given of 
 the aggregation of nuclei, sometimes met with in these 
 tumours, and I remember several cases in which tumours 
 resembling fibroids, but somewhat softer, consisted chiefly of 
 large oval, densely-crowded nuclei, in a homogeneous, partly 
 striated, intercellular substance, which tumours I could not 
 consider otherwise than fibroids at an early stage of develop- 
 ment. 
 
 In the majority of instances in which fibroid tumours exist, 
 the uterus is uniformly enlarged by an increase of its sub- 
 stance, either in consequence of general hyperplasia, or diffuse 
 proliferation of connective tissue. Frequently, however, this 
 increase in substance is irregular; isolated portions of the 
 uterine walls being affected with proliferation of their elemen- 
 tary tissues, whilst other portions are unaffected or participate so 
 slightly in the morbid process that the latter is scarcely noticea- 
 ble. The increase of the uterus in substance during the presence 
 
OF THE UTERUS. 165 
 
 of fibroid tumours, is especially evident when the latter are 
 developed within the tissue of its walls. When the 
 tumours are situated more externally, or project from a pedicle 
 into the peritoneal cavity, the increase of the uterus is much 
 slighter. Lastly, when fibroid tumours grow into and dilate 
 the cavity of the uterus, its substance may even be diminished, 
 in consequence of the distention of its walls. In such cases 
 the latter sometimes become membranous and reduced to the 
 thickness of one or two lines ; but if, in such cases, a consid- 
 erable blennorrhoea of the uterine mucous membrane coexists, 
 the uterine tissue becomes the seat of difiuse proliferation of 
 connective tissue. 
 
 The enlargement of the uterus from fibroid tumours, is 
 most frequent in young females, whilst in old women it is 
 generally found in a state of senile atrophy. In these latter 
 cases the congestion occasioned by the presence of the tumour 
 is insufiicient to counterbalance the wasting from old age. 
 In many cases atrophy of the uterine substance attains such a 
 degree that the walls of the organ become membranous (Wal- 
 ter's Membranous Uterus). Especially when compound fibroid 
 tumours attain a considerable size, the walls of the uterus may 
 become so thin that the separate tumours may be seen and felt 
 through them. In contradiction to the observation that the 
 increase of the uterine substance is always most considerable 
 in the immediate vicinity of the fibroid tumour, we must 
 mention those cases of compound tumours in which, in the 
 region of the hilus, the uterine parenchyma appears as if 
 absorbed by the presence of large-sized veins. 
 
 The changes which we notice in fibroid tumours of the 
 uterus, are partly owing to altered conditions of the latter, 
 and partly to the difierent stages of development of the 
 tumour ; or they may result from morbid processes afiecting 
 the tumour primarily or secondarily. 
 
 It is necessary to state that the round fibroid tumour parti- 
 cipates in all the changes to which the uterus is subject during 
 
166 EOU]^D FIBROID TUMOUES 
 
 menstruation and pregnancy, and this is especiallj tlie case 
 when its tissue is analogous to that of the uterus. During 
 menstruation we find the tumour enlarged and more succulent, 
 and during pregnancy also, the above changes take place. 
 Fibroid tumours found in women who have died during the 
 puerperal state, are peculiar for their flaccidity and softness of 
 tissue. It is reasonable to suppose that these tumours undergo 
 an involution after the puerperal state, analogous to that 
 described by Heschl as occurring in the uterine tissue. The 
 observations which I have been able to make in regard to this 
 statement, although not entirely convincing, have in no way 
 led me to infer the contrary. 
 
 Fibroid tumours of the uterus are subject to certain diseases 
 arising in their own structm'e, or developed in their vicinity by 
 their 'presence, and ultimately involving the tumour itself. 
 
 In the first place, it must be mentioned that, in the neigh- 
 borhood of fibroid tumours which prolapse into the cavity of 
 the uterus, an inflammatory process in the bed of the tumour 
 is often developed, beginning generally at the most dependent 
 portion of its mucous membrane, by hypostatic hypermniia, 
 and leading to the formation of pus or ichor, in consequence 
 of which the tumour is detached and expelled, either entire or 
 piecemeal, by labor-like contractions of the uterus. Thus 
 metritis may ensue, which, resulting in the formation of pus or 
 ichor, may ultimately prove fatal from the supervention of 
 pyaemia. A patient may recover after the expulsion of a 
 fibroid tumom- in the above manner. 
 
 It rarely happens that the whole tumour is enucleated from 
 the wall of the uterus by a purulent process at its circumfer- 
 ence ; such a process is generally accompanied with intense 
 lymphangitis. But whether the tumour is detached from the 
 uterus by an ichorous or simply purulent process, it is always 
 in a fiabby condition, collapsed, and oedematous. In very rare 
 cases small purulent cavities are also found in the substance of 
 the tumour. Hokitansky mentions a case in which a purulent 
 
OF THE UTERTTS. 167 
 
 sac, the size of an egg, developed iii a pedunculated tumour, 
 became adherent to the rectum and perforated it at three 
 points. 
 
 When the mucous membrane of the most dependent portion 
 of a pedunculated fibroid tumour becomes gangrenous, the 
 gangrene may extend to the tumour itself without detaching 
 it ; but it will, however, gradually slough away. Another 
 manner in which a fibroid tumour projecting into the uterine 
 cavity may be detached, is by destruction of its pedicle, con- 
 sisting of mucous membrane and uterine tissue, by gangrene, 
 in consequence of which the tumour lies detached in the cavity 
 of the uterus, and from which it is ultimately expelled by 
 uterine contractions ; or, it may become detached by rujptiire 
 of its pedicle, which has become elongated by the growth 
 and descent of the tumour. 
 
 A fibroid tumom- may become oedefnatous (Cruveilhier), 
 and this often arises without known causes, and becomes con- 
 siderable, especially in the compound tumours. When the lat- 
 ter are thus affected they suddenly increase in size, and repre- 
 sent fiuctuating, tuberous and irregular tumours, resembling 
 cystoid tumours of the ovaries. Upon section, we frequently 
 find the succulent connective tissue between the separate 
 tumom's of the whole mass, extraordinarily oedematous, and 
 infiltrated with a pale yellow or greenish fluid. Each single 
 tumour is separated from the others by a firm white substance, 
 which gives a peculiar appearance to the whole mass. The 
 more compact, round, and simple fibroid tumours are rarely 
 affected with oedema, and when so affected, are not visibly 
 altered by it. 
 
 Eawisch repeatedly noticed, especially at the menstrual 
 period, or previous to a hsemorrhage, an exceedingly sudden 
 increase of these tumours in volume, in consequence of which 
 their circumference was increased in the space of a few hours 
 nearly half an inch, and again decreased with the same sud- 
 denness. 
 
168 IlOlT:ffD FIBEOID TIJMOUIlS 
 
 Within some fibroid tumours cavities may be found, which 
 may have occurred in several ways. They either result from a 
 dropsical condition ; or the connective tissue of the tumour 
 undergoes colloid metamorphosis (mucous degeneration), com- 
 mencing at the centre of the tumour, and in consequence of 
 which its substance liquifies into an albumino-serous fluid. 
 Finally, haemorrhages into the substance of a tumour may lead 
 to the formation of cavities similar to the so-called apoplectic 
 cysts. The cavities found in the centre of fibroid tumom's, 
 are generally round and smooth-walled, and are often so 
 large that their walls are comparatively thin, and assume the 
 characteristics of a fluctuating tmnour, on which account they 
 may be mistaken for hydrometra, hsematometra, pregnancy, or 
 ovarian cysts. The inner layers of the walls of such cavities 
 are generally in a state of fatty degeneration. If the cavities, 
 however, are situated eccentrically, their origin, from the 
 separation of the concentric layers of the tumours, is evident 
 from their concavo-convex shape. The latter cavities, I am 
 inclined to think, frequently arise primarily from hsemorrhage, 
 for we generally find evidences within them of extravasation, 
 in the form of rusty-brown deposits, or rusty-brown pig- 
 mentous discoloration of the innermost layers of their walls. 
 When the circumference of a fibroid tumour has been afi"ected 
 with ulcerative infiammation, collections of pus are frequently 
 found in the peripheric cavities formed by the ulcerative pro- 
 cess mentioned. Generally the contents of the various cavities 
 in fibroid tumours, are a clear watery, yellow or brown, some- 
 times turbid and chocolate-colored serum ; or a viscid fiuid ; 
 or finally a gelatinous mass. In many of the cavities, especially 
 smaU ones, the contents are found to be fresh blood. 
 
 Wedl sometimes found in them imperfectly-defined spots, 
 with indented elongations, occurring singly, and unconnected 
 with the blood vessels, which he supposed to be recently 
 efi*used blood. I have never met with such a condition, and, 
 therefore, simply quote Wedl's observations. Possibly in 
 
OF THE UTERUS. 169 
 
 these he may have met with productions resembhng" those 
 described by Virchow and myself as telangiectatic myoma^ 
 the connection of which with the blood vessels can easily be 
 demonstrated. 
 
 From what has been demonstrated, we conclude that 
 fibroid tumours may be affected with haemorrhage ; still, 
 considering the firmness of the tissue of such tumours in an 
 advanced stage of development, and their relatively small 
 number of blood vessels, we must assume that haemorrhages 
 in such tumours will only occur when they are of recent 
 growth, and consequently softer ; or, when the tissue 
 of older and more compact tumours has been altered by 
 oedema, haemorrhage might possibly take place into a cavity 
 within them. The probability of the former assumption is 
 rendered possible by the fact, that haemorrhages in fibroid 
 tumom's rarely occur excepting during menstruation and 
 pregnancy. We may also mention the possibility of haemor- 
 rhage from the presence of telangiectatic myoma, and it is not 
 improbable that, in consequence of the retrogressive meta- 
 morphosis of such an extravasation, the affection causing it 
 may no longer be recognizable. The extravasation is generally 
 sHght, and the extravasated blood generally undergoes the 
 changes usually found in apoplectic cysts. Sometimes several 
 such effusions are met with in one fibroid tumour, and I have 
 never found them in tumours smaller than walnuts. Owing 
 to the greater vascularity of compound fibroid tumours, extrav- 
 asations are of more frequent occurrence in them. 
 
 In a woman who had fallen from a considerable height, I dis- 
 covered a fracture of the pelvis, and an extravasation of blood 
 between a fibroid tumour the size of an Qgg and the wall of the 
 uterus ; half of the periphery of the tumour was surrounded by 
 a thin layer of extravasated blood, by which one-half of it had 
 been detached. In scorbutic and analogous conditions of the 
 system, however, I have never met with such haemorrhages. 
 
 The retrogressive metamorphosis, to which fibroid tumours 
 12 
 
170 ROUND FIBROID TITMOURS 
 
 are subject, are fatty and calcareous degeneration. In fatty 
 degeneration, chiefly the muscular portions of the tumour are 
 affected, and we often find them transformed into fatty 
 granular cells. Besides this, fat is always found in large or 
 small drops. The cells of the connective tissue undergo a 
 similar metamorphosis. The external appearance of a fibroid 
 tumour undergoing fatty degeneration is altered ; it becomes 
 flabby, doughy, and soft ; pits on pressure, and is very fria- 
 ble ; its color changes to pale yellow or faded brown ; on 
 section, its structure appears uniform, it having lost its fibrous 
 character. We frequently meet, in combination with this 
 fatty degeneration, a considerable deposit of a fine granular 
 brown or yellow molecular substance, and granular calcareous 
 salts. 
 
 Fatty degeneration of a uterine fibroid tumour frequently 
 originates in the above manner during the puerperal state. 
 Sometimes it occurs after the change of life, probably from 
 senile involution^ and a tumour undergoing such metamorpho- 
 sis may thereby be diminished in size. At any rate, at the 
 inception of fatty degeneration, any further increase of the 
 tumour is arrested. 
 
 The second metamorphosis, which not unfrequently affects 
 old fibroid tumours of the uterus, is calcareous degeneration or 
 ossification. Dupuytren mentioned that the transformation of 
 uterine fibroids, usually termed ossification, properly speaking 
 is only a process of petrification. While fatty degeneration 
 chiefly affects the muscular substance of the uterus, a deposit 
 of calcareous salts generally takes place in the connective tissue 
 of the flbroid tumour. The results of this metamorphosis 
 are various. The calcareous salts either cohere in an amor- 
 phous mass, devoid of organization, or in thin segments of it 
 we flnd transitions from calcareous degeneration to ossification. 
 The intercelhilar substance appears, either as an aggregate of 
 large or small round bodies ; or it is uniform, striated here 
 and there ; or it exhibits a laminated structure around large 
 
OF THE UTERUS. l7l 
 
 ducts. In the intercellular substance weTfind irregular angu- 
 lar black, solid, or hollow masses, consisting of pigment 
 and fine granular matter, which till the small spaces of the in- 
 tercellular substance (Wedl), and must be considered as de- 
 formed rudiments of medullary canals. Besides these 
 masses, we sometimes find degenerated or imperfectly formed 
 bone-corpuscles of extraordinary size, but with few and short 
 radiations. Sometimes, however, in isolated portions of such 
 degenerated fibroid tumours, distinguished by their compact- 
 ness and smoothness, we find bone substance, perfectly sinailar 
 to normal bone, and generally with very large medullary 
 spaces. The formation of such normal bone substance in cal- 
 cified uterine fibroid tumours was first observed by Wedl. 
 
 Calcareous degeneration of uterine fibroid tumours com- 
 mences either at their periphery ; or isolated centres are 
 developed dispersely in various portions of the tumour, without 
 originating from its centre, which is of course, its oldest por- 
 tion. In the former case, flat concavo-convex shells are formed, 
 which finally coalesce, and may form a kind of osseous cover- 
 ing to the tumom-, from which irregular processes sometimes 
 radiate inwardly toward the centre of the mass. Frequently, 
 especially in nodulated compound fibroid tumours, isolated 
 portions are calcified, whilst the remaining substance is un- 
 affected, or in a state of fatty degeneration. Although a 
 fibroid timiour may appear to be calcified throughout, yet, 
 literally, such is rarely the case. Sometimes we find imbedded 
 in the substance of the uterus, round, whitish, heavy crystalKne 
 bodies, and of the hardness of bone, which are the remains of a 
 calcareous degenerated fibroid tumour. Such apparently solid 
 bodies on being sawed through, are found to contain irregular 
 small spaces, filled with a soft connective or muscular tissue 
 frequently in a state of fatty degeneration ; or we find a black- 
 ish gray substance scattered through these concrete bodies, 
 consisting of fine granular pigment between striated layers of 
 connective tissue. If such concretions are macerated, they 
 
172 EOUIN^D FIBROID TUMOUES 
 
 will resemble pumice-stoiie, and are particularly distingmshed 
 for their weight, and the compactness of their structure. From 
 a dissection of them we learn that they consist of a conglomer- 
 ation of solid ivory-like portions, connected by a more earthy, 
 chalky-white calcareous substance. This latter substance 
 is never visible in fresh sections, it being only formed by the 
 precipitation of calcareous molecules, scattered in an interme- 
 diary substance, which has not yet undergone calcareous degen- 
 eration. 
 
 Concretions of such structure are either carried without 
 injury, or they may be eliminated by sequestration, and this 
 certainly explains the numerous cases recorded in older litera- 
 ture, of concretions being cast out of the uterus. Barthohn 
 found such a blackish, ii-regular concretion, which weighed 
 four pounds. 
 
 Calcified uterine fibroid tumom-s were formerly described as 
 stony concretions. Here we must also mention those cases 
 described 2& petrifaction of the enthe uterus (Fobert, Mohren- 
 heim, Mackin, and others, vide Yoigtel), in which the organ, 
 almost membranous from atrophy, was overlooked in conse- 
 quence of the presence of one or several calcified fibroid 
 tumours. 
 
 As in fatty degeneration, so in calcification of fibroid 
 tumours, any fm'ther increase of the tumom* ceases. Fre- 
 quently calcareous and fatty degeneration affect different por- 
 tions of the same tumom\ 
 
 I must also mention, in addition to the above, the transition 
 of fibroid tumours into other adventitious growths. Although 
 celebrated anatomists and gynecologists absolutely deny the 
 possibility of carcinoma being developed from a fibroid tumour, 
 Kiwisch already states that in very rare cases ' ' infiltration of 
 carcinomatous substance " may take place in the tissue of a 
 fibroid tumour, which, in his opinion, however, only occurs 
 accidentally, with simultaneous carcinomatous deposits in other 
 organs. In 1862 a singular specimen was added to the Salz- 
 
OF THE UTEEUS. 173 
 
 burg museum. From a fibroid tumour the size of a child's 
 head, situated in the posterior walls of the uterus, carcinoma 
 had undoubtedly been developed without any other portion of 
 the body being affected, and I am therefore constrained to 
 allow the possibility of such a transition, although I cannot 
 recall a second case of this kind, either in the literature of the 
 subject or in my rather extensive experience. 
 
 The number of uterine fibroids found in one individual varies 
 greatly ; we may find one, or several. Ewisch once found 
 forty such tumours of various sizes and consistency. 
 
 The consequences following the presence of fibroid tumours 
 have been partly mentioned, as far as they relate to alterations 
 of the position and form of the uterus. Besides the latter organ 
 being increased in volume by the presence of such a tumour, 
 it is also enlarged by hyperplasia, which, as previously men- 
 tioned, is most considerable at the point where the tumour is 
 deeply imbedded in the parenchyma of the uterus, or is situated 
 beneath its mucous membrane. 
 
 Besides the relative dilatation of the uterine cavity from a 
 fibroid tumour growing into it, dilatation may also be caused 
 by obstruction of the internal orifice or cervical canal by a 
 pedunculated depending tumour, which may occasion hydrome- 
 tra or hsematometra so much the more easily, on account of 
 the uterine mucous membrane being, almost without exception, 
 in a state of hypersecretion. 
 
 On the other hand the uterine cavity may be completely 
 obliterated by the inward growth of fibroid tumours, the 
 mucous membrane covering the latter, after a preceding 
 blennorrhcea, and being thinned by distention, undergoing 
 the metamorphosis of connective tissue, to be described here- 
 after, and by which its opposing surfaces become adherent to one 
 another. This, according to experience, is of more frequent 
 occurrence when several fibroid tumours grow from different 
 points of the uterine walls, and become flattened by contact ; 
 and, in the majority of cases of this kind, especially where 
 
174 ROUND FIBROID TUMOURS 
 
 two tumours grow side by side, filamentous adhesions may be 
 found between them. We have ah^eady, when treating of 
 elevation of the uterus, mentioned the atresia of the uterine 
 cavity at the internal orifice, resulting from traction induced 
 by a fibroid tumour rising from the pelvis in consequence of 
 its size. 
 
 From what we have previously mentioned it is evident that 
 the position of the uterus may be altered by fibroid tumours, 
 inasmuch as the latter displace it by pressure or traction. The 
 uterus may be forced into an oblique position, or it may be 
 pushed downward, and thus uterine fibroids may be the origi- 
 nal cause of prolapsus uteri, or may augment an already ex- 
 isting prolapsus. I have also mentioned the partial inversion 
 of the uterus occasioned by prolapsing fibroids, as well as 
 complete inversion, which may be caused by the sudden 
 expulsion of these tumours when attached by thick pedicles. 
 
 Another class of displacements to which the uterus is sub- 
 ject in consequence of the development of fibroid tumours, are 
 flexions, especially ante- and retroflexions. The latter are the 
 more dangerous for the reason that a tumour deflected into 
 Douglas' space may be impacted there, and become so enlarged 
 that straightening of the uterus is rendered impossible. Scan- 
 zoni mentions, that if a fibroid tumor is developed in the ante- 
 rior uterine wall, its gradual increase leads first to straighten- 
 ing and then to retroversion of the uterus, whereupon, after 
 the pelvic cavity has become too small, it rises into the abdom- 
 inal cavity proportionately with its increase in volume. Clini- 
 cal observations are said to corroborate these changes of anom- 
 alies of position. But this can only be valid for those cases 
 in which, from previous anteversion, an imperfect retroversion 
 is developed, for as soon as the fundus uteri is enlarged by a 
 fibroid tumour, it sinks below the promontory of the sacrum, 
 the latter, as is w^ell known, ofiering considerable impediment 
 to the ascent of the uterus. When a retrofiexion of the uterus 
 has been caused by a fibroid tumour, spontaneous straightening 
 
OF THE UTERUS. 175 
 
 is of course out of question, whilst anteflexion will finally ter- 
 minate in elevation of the uterus. 
 
 In some rare instances fibroid tumours likewise produce 
 latero-flexion of the uterus. 
 
 Whilst subperitoneal fibroids produce no alterations of the 
 uterine tissue, excepting hyperplasia in the vicinity of the 
 tumours, yet, almost without exception, we find catarrhal intu- 
 mescence and blennorrhoea of the mucous membrane when 
 such tumours are situated in the centre of the parenchyma 
 of the uterus, or beneath its mucous membrane. 
 
 Fibroid tumours may further exert an injurious influence 
 upon the surrounding organs by pressure, and by displacements 
 of the same. Pressure on the bladder, even without coexisting 
 anteflexion, may become so considerable as to compress it 
 between the symphysis and tumour, giving rise in consequence 
 to secondary phenomena in the uropoetic system. The hyper- 
 8emia of the pelvic blood vessels, occasioned by fibroid 
 tumours, is frequently manifested in the mucous membrane of 
 the bladder as a varicose distention of its veins, especially of 
 those situated at the neck of the bladder ; and Rokitansky 
 even observed a case of rupture of a submucous cystic vein, 
 with haemorrhage into the bladder. Thomson relates a case 
 in which a perforation occurred in the wall of the above organ 
 from pressure of a large fibroid tumour, with adhesion of half 
 of the periphery of the tumour to the borders of said perforation. 
 
 On the other side pressure afiects the rectum, and defecation 
 may be completely prevented by fibroids impacted in Doug- 
 las' space. They may also cause varicose distention of the 
 hsemorrholdal veins, and hyperaemia of the rectal mucous 
 membrane in the same way as in that of the bladder. Eoki- 
 tansky mentions a case in which a fibroid tumour, the size of a 
 hen's egg, developed in the posterior wall of the uterus, caused 
 a portion of the rectum to slough away, and became adherent 
 to the edges of the perforation in consequence of peritoneal 
 adhesions. 
 
176 eouj^d fibroid tumoues 
 
 Yerj large fibroid tumours, especially when protruding into 
 the pelvic cavity, will also, by pressing upon the veins coming 
 from the lower extremities, cause distention of the same and 
 oedema of the tissues. Pressm-e upon the hypogastric or sper- 
 matic veins is followed by hypersemia of the pelvic organs, and 
 a varicose condition of the venous plexuses. RoMtansky ob- 
 served the rupture of a subperitoneal vein of a fibroid tumour. 
 The hypersemic intumescence of the mucous membrane of 
 the vagina and uterus, and especially of the latter, may lead 
 to haemorrhages into its parenchyma in the form of ecchymo- 
 ses ; or it may cause metrorrhagia. The last-named afiection 
 generally only occurs during the presence of fibroid tumours, 
 when they project into the uterine cavity in the form of 
 polypi, and when hypostatic hypersemia has been developed 
 in their most dependent portion. 
 
 In consequence of the derangements of circulation occasioned 
 by fibroid tumours in the above-mentioned manner, perime- 
 tritis is frequently developed. The peritoneum, which covers 
 uterine fibroids projecting into the abdominal cavity, is 
 frequently in a state of pseudo-membranous congestion and 
 thickening ; pseudo-membranous cords or bands, extending in 
 various directions, are so frequently found that we cannot help 
 considering the above affections as cause and effect. 
 
 Finally, we must consider the effects which uterine fibroid 
 tumom's exert on the uterus. Experience teaches that men- 
 struation frequently becomes irregular when they exist ; 
 gynecologists testify to then- injurious influence on conception ; 
 and from an anatomical point of view, the presence of uterine 
 catarrh, the frequent and various displacements of the uterus, 
 and the contraction and impermeability of the oviducts occur- 
 ring under certain circumstances (E-okitansky), may be consid- 
 ered among the causes of sterility. 
 
 If conception takes place in a uterus, in the walls of which 
 a fibroid tumour exists, retroflexion of the gravid organ easily 
 occurs if the tumour is located in its posterior wall. As already 
 
OF THE UTEEIJS. 177 
 
 mentioned, tumours projecting into the uterus, may be fur- 
 ther injurious to foetal development by encroaching on the 
 cavity of the organ, for during pregnancy they are very apt 
 to enlarge. 
 
 Fibroid tumours depending from the posterior wallj into 
 Douglas' space will narrow the cavity and outlet of the pelvis ; 
 the same may be said of the rare cases of tumom-s developed 
 in the cervical or vaginal portions. 
 
 When fibroid tumours are present, imperfect contractions of 
 the uterus have been observed during labor, owing probably 
 to the difluse proliferation of connective tissue, and many cases 
 of spontaneous rupture of the uterus are recorded. Owing to 
 non-contraction of the uterus during labor, hsemorrhage oc- 
 casioned by fibroids may occur. 
 
 In many cases of puerperal metritis, the bed of the fibroid 
 tumom- may be the point of origin of inflammation, excited by 
 traction exerted upon the attachment between the tumour and 
 uterus in consequence of unequal uterine contraction. I can 
 remember several cases of jpurulent sequestration of uterine 
 fibroids occuring during the puerperal state. 
 
 Round uterine fibroid tumours never occur before puberty, 
 and very rarely before the thirtieth year. From that period their 
 frequency increases, and at the climacteric period it is such, 
 that undoubtedly 40 per cent, of the uteri of females who die 
 after the fiftieth year, contain fibroid tumours. At a more ad- 
 vanced age these tumours are generally found entirely or partly 
 calcified, and the uterus at the same time afiected with marastic 
 atrophy. 
 
 Eokitansky mentions the frequent combination of fibroid 
 tumours with fibroid polypi. The so-called mucous, or vesicu- 
 lar polypi, often met with as consequences of uterine ca- 
 tarrh, are frequently associated with these fibroid tumours. 
 
 Of cartilaginous tumom's of the uterus {enchondroma), we 
 possess no rehable observations. 
 
 Under the name of osseous tumours of the uterus, calcifica- 
 13 
 
178 EOUND TTBEOID TUMOUES 
 
 tions and ossifications of round fibroid tumours have generally 
 been described. The case described by &auss of an osteoid 
 tumoQr of the uterus, also seems to belong to this category, 
 but from its pecuharity is deserving of mention. 
 
 "In place of the uterus, a pyriform osteoid tumour was 
 situated between the rectum and bladder, close to the right 
 margin of the pelvic entrance, and extending downward as a 
 cartilaginous mass, in form like the vaginal portion, without 
 an aperture. The thin broad ligaments, together with the ovi- 
 ducts, were inserted bilaterally above the point of transition of 
 the tumour into the cartilaginous appendix. The ovaries con- 
 sisted of thin, narrow, partly ossified, cartilaginous scales. The 
 tumour being sawn through, exhibited a bony structure, denser 
 in some parts and more porous in others, and in its centre an 
 oblong cavity was found, the size of a walnut, with irregular 
 walls, and a few transverse osseous filaments." 
 
 Krauss thinks that the form of this osteoid tumour renders it 
 presumable that an osseous layer was gradually formed around 
 the whole uterine body, which layer, increasing in thickness, 
 caused the gradual disappearance of the uterine substance 
 under marastic influence. From this it is evident that the term 
 osteoid tumour is an in appropriate one. For want of more 
 detailed anatomical facts (I could not obtain the original de- 
 scription) I am unable to derive any advantage from the above 
 case, and it seems to me to be closely allied to the cases of os- 
 sified uteri mentioned by Baiilie and Sommering. 
 
 CYSTOID TUMOURS. 
 
 Literature: Naboth, De sterilitate mulierum. Lipsiae 1707. — 
 V o i g t e 1 Path. Anat. Halle 1805. III. Bd. pag. 612. — N i v e t 
 etBlatin, Arcli. gener. Oct. 1838. — Rokitansky, Denksclir. 
 d. Wien. Acad. d. Wissenscli. Bd. 1. pag. 328 1819. — C. Huguier, 
 Mem. Bur les Cystes de la matrice et sur les Cystes folliculaires du vagin. 
 Soc. de chirurg. Mai 1817. — C h. R o b i n , Mem. pour serv. ^ Thist 
 anat. de la membr. muqueuse uterine de la caducque et des oeufs de 
 Naboth Arch. gen. de Med. 1818. T. XVIII. pag. 257. — K i w i s c h , 
 Krankh. des Uterus III. Aufl., II. Bd. pag. 389. — Cruveilhier, 
 Anat. path. Livr. 13. PI. 4. — H i r s c h , Ueber Histologie und 
 Form der Uterus-Polypen. Giessen 1850. — Billroth, Ueber den 
 
OF THE UTERUS. 179 
 
 Bau der Schleimpolypen etc. Berlin 1855 — L e u d e t und L a b o u 1- 
 b e n e Zur Anatomie der foUicularen Uterus-Polypen. Gaz. med. d. 
 Paris. 9 und 27. 185t). — E. Wagner, Anatomie der Vaginalport. 
 Arch, fur pbys. Heilk. 1856. 4. H. pag. 493 — By the same authors 
 B 6 i t r . zu den Geschwiilsten des Uterus. Arch. f. phys. Heillc. 1857. 
 1. — Rokitansky, Ueber Uterus-Drllsen-Neubildung in Uterus 
 und Ovarial-Sarcomen. Zeitschr. der Ges. d. Aerzte, Wien. 1860. 
 
 The formation of cysts in the uterus is a comparatively fre- 
 quent occurrence and each portion of the organ is distinguished 
 for peculiar varieties of them. Thus, in the body of the organ, 
 as well as the fundus, we meet with small thin-walled c^^sts, in 
 the cervix with large distended ones, and in the vaginal por- 
 tion with others of different construction ; this difference 
 depends on the anatomical basis from which the cysts are 
 developed. 
 
 The cystoid tumours of the mucous membrane of the body 
 and fundus present the appearance of thin-w^alled, isolated or 
 aggregated vesicles, scarcely larger than a hemp-seed, and 
 filled with a light yellow, seldom brownish, serous fluid. In 
 many cases, especially when they are situated in the posterior 
 wall, they are so densely crowded together that the mucous 
 membrane looks like a mass of cysts. These vesicles possess 
 a very dehcate capsule of connective tissue, the inner sm-face 
 of which is partly lined with small round cells, and in rare 
 instances their contents consist of a light-colored colloid sub- 
 stance. 
 
 The origin of these cysts must be looked for in the utricular 
 glands, the excretory ducts of which have been obliterated, 
 and consequently the glands become distended into small ser- 
 ous cavities. They are frequently found in women of advanced 
 age affected with chronic catarrh of the uterine mucous mem- 
 brane, and they seem to burst after attaining the size of a 
 hemp-seed ; and possibly the obliteration of the cavity of the 
 body of the uterus, so frequently combined with senile atrophy 
 of the organ, may be caused in consequence of their rupturing. 
 Sometimes they undergo the process of proliferation with the 
 
180 CYSTOID TIBIOUES 
 
 mucous membrane, and form so-called vesicular jpolypi. When 
 situated within polypi they are more liable to attain a larger 
 size. 
 
 Different from the above are those cysts which we find in 
 the mucous membrane of the cer\dcal canal, and which were 
 mistaken for ovula by their discoverer, ISTaboth, whence they 
 derived the appellation oiNabothian ovula^ which term is even 
 now sometimes used. 
 
 These Nabothian vesicles are small cysts, generally well 
 filled with viscid mucous, and sometimes exceeding the size of a 
 pea, which are either disposed in rows within the folds of the 
 cervical mucous membrane, or are situated between them, on 
 separate them in various ways. Owing to theii' presence, the 
 sm'face of the cervical canal acquires a tuberous appearance ; 
 generally we find a much larger number of smaller ones 
 imbedded in the submucous tissue, beneath those which pro- 
 ject from the mucous membrane. In one case I met with 
 one in the anterior wall, near the internal orifice, which was 
 nearly as large as a cherry, and it is said they may even attain 
 the size of a hazel-nut. 
 
 The contents of these formations consist of a gelatinous 
 viscid fluid, readily soluble in water, in the centre of which 
 you sometimes see a cloudy or weh-defiiied gray or milky 
 white turbescence, which generally consists of an accumula- 
 tion of oil globules, and cells undergoing fatty degeneration. 
 Besides this, you find here and there cihary epithelium, large, 
 fatty, granular cells, globules resembling johysalides^ free 
 nuclei, fat drops, colloid bodies, and sometimes crystals of 
 cholestearine. 
 
 E. Wagner attributes their origin exclusively to a distention 
 of the normal mucous follicles of the cervical portion, whilst 
 Rokitansky considers them, in the majority of instances, to 
 be direct new-foimations. In regard to their development 
 Eokitansky states, that they first appear as round groups of 
 nuclei, each nucleus being one millimeter in diameter, imbed- 
 
OF THE UTERUS. 181 
 
 ded at various depths in the submucous tissue of the cervix, 
 that they increase in size whilst the nuclei are being trans- 
 formed into cells, and that in the commencement they are 
 lined with basement or ciliary epithelium, but at a later period 
 are devoid of either. The large number of mucous follicles 
 in the normal cervix uteri renders the older opinion, which 
 has been accepted by Wagner, the most probable one ; and 
 although I have convinced m3^self of the correctness of the 
 process of their development described by Kokitansky, yet I 
 consider the group of cells mentioned by him as mucous folli- 
 cles, divided laterally from their median Hue and exhibiting the 
 cells proper of the glands. 
 
 The exuberant growth of the Nabothian vesicles is followed 
 by atrophy of the submucous layer of the cervical portion. 
 When, as is frequently the case, the ring of the internal orij&ce 
 is the chief seat of the Nabothian vesicles, flexion of the uterus 
 may take place, as has been mentioned under that head. In 
 the case in which I found a distended Wabothian vesicle the size 
 of a cherry, the uterus was immediately anteflexed after I had 
 eva^ uated the cyst of its contents by puncture. Spontaneous 
 rupture of these productions may also occasion atresia of the 
 cervix. In many cases, Nabothian vesicles developed from 
 the mucous folds, assume the form of pedunculated polypi. 
 
 We must now refer to those cysts which are frequently 
 found in large numbers in the vaginal portion. They cons st 
 of vesicles varying in size between the point of a I'eedle and a 
 hemp-seed, are round, or flattened by contact, and filled 
 either with a thin yellowish serum, or a yellow or brown col- 
 loid substance. In the contents of these, also, we find parent 
 ceUs with nuclei, colloid bodies and granular fatty cells. Their 
 smooth-walled cavity is lined with cylindrical epithelium, and 
 often with ciliary. Their cyhndrical epithelium is generally 
 short ; sometimes I have found transitory or basement epithe- 
 lium with small cells. Sometimes these cysts appear upon the 
 vaginal portion as small round protuberances, and sometimes 
 they are absent (E. Wagner). 
 
182 CYSTOID TUMOTTES 
 
 According to Wagner the development of these cysts takes 
 place from the glands of the vaginal portion, as follows ; the 
 lower third of the gland becomes tumefied and round, where- 
 upon, as this portion increases in size, the superior portion 
 becomes atrophied. This formation of cysts s often found 
 combined with the so-called papillary hypertrophy of the vag- 
 inal portion. This is certainly what Virchow means when he 
 speaks of the de > elopment of larger follicles in the vaginal 
 portion causing partial inversion of the inferior portion of the 
 cervical canal. Virchow, also, in many case,- attributes the pro- 
 boscis-like and polypoid elongations of the vaginal portion to 
 the abnormal development of such glands. 
 
 Besides the cases mentioned, we will now describe some 
 other v^ery rare but extraordinary. 
 
 Kiwisch describes a tumour occurring in a woman forty- 
 six years old, which arising from the posterior wall of the uterus, 
 extended down to the pelvic floor, filled the whole of the pelvic 
 cavity, and reached as far upward as the ensiform cartilage, 
 which tumour, after its removal, weighed forty-six pounds. 
 That portion of it situated in the abdominal cavity consisted 
 almost wholly of cysts, resembling common ovarian cysts and 
 filled with a lumpy fibrinous exudation. The largest of these 
 cysts was of the size of two heads. The base of the tumour 
 was formed by a flaccid fibroid tumour the size of a head, en- 
 veloped in uterine substance and adherent to the posterior wall 
 of the vagina. 
 
 Cruveilhier describes a similar case ; and we must call atten- 
 tention to the fact that fibroid tumours were present in both 
 cases, and consequently it is uncertain whether these were not 
 cases of formation of cysts in round fibroid tumours. In the 
 older literature no case of this kind is mentioned. 
 
 Kokitansky found in the walls of the body of a uterus, a 
 small cyst with a villous cancer developed from its inner sur- 
 face, combined with cysto- carcinoma of the ovaries and delicate 
 villous vegetations of a carcinomatous character in the perito- 
 neum. 
 
OF THE UTERUS. 183 
 
 There are also observations recorded of dermoid cysts of 
 the uterus. The first one mentioned by Baillie is that of a 
 uterus preserved in the museum of Copenhagen, containing 
 several hairs. Voigtel quotes cases from Fabricius von Bilden 
 and Vicq d'Azyr, in which hair was found in the uterus. 
 The case of Blancard, referred to by the same author, must be 
 considered as a dermoid cyst of the ovary. From the same 
 author we have a remarkable statement, that hair w^as also 
 found in uterine polypi ; but I have been unable to obtain the 
 paper of P. Gr. Schacher, referred to by him. Meckel speaks 
 of the finding of hair and teeth in the uterus as of common 
 occurrence, without, however, any details on the subject. 
 
 E. Wagner found a pedunculated fluctuating tumour in a 
 uterus, the size of a man's fist, containing numerous cavities 
 of various dimensions and thickness of walls, and differing in 
 their contents, mostly communicating with each other, and 
 containing hair, fat, teeth, cartilage and bone. Some por- 
 tions of their walls were similar to the external integuments, 
 and contained large sebaceous glands and roots of hair. Sud- 
 oriferous glands, however, were not found. 
 
 Finally, we must mention those cysts forming a capsule 
 around rarely occurring cysticerci. 
 
 Rokitansky's description of cysts originating in preexisting 
 or newly-formed glandular elements, which constitute the 
 adenoid uterine cystosarcoma, has already been mentioned. 
 
 VASCULAR TUMOURS. 
 
 Literature: Rob. Lee, Researclies on tlie pathology and treatment 
 of the most important diseases of women. London 1833. — K i 1 i a n , 
 Holscher's Hanov. Annalen I. 1. 1830. — C a r s w e II, Patholog, 
 Anatomy. Fasc. VI. Fig. 2. Tab. IV. — J a g e r (Erlangen), Beobach- 
 tmigen liber Blutungen im Wochenb. in Folge von Gefassgeschwulsten 
 des Uterus. Holscher's Hanuov. Annalen Bd. II. 1. 1837. — Balling, 
 Geschlechtskrankheiten des Weibes. Gottingen 1836. pag. 632. — 
 Meissner, Frauenzimmerkrankheiten etc. II. 1. Leipzig 1843 — 
 1845. 
 
184 VASCULAR TUMOURS 
 
 Whilst no mention is made in modern literature of so-called 
 vascular uterine tumours, we frequently meet with this term 
 in older writings, or with that of haemorrhoidal tumours, or 
 telangiectasis. 
 
 On closer study of the cases recorded, it becomes evident 
 that two classes were understood by these arbitrary expressions. 
 The first of these classes embraces the observation of haemor- 
 rhages after delivery, resulting in consequence of the tumefac- 
 tion and non-contractility of the uterus at the point of placental 
 attachment, and includes that which was recently called by C. 
 Braun, placental polypus. To the second class belong cases 
 of excessive vascularity of the various adventitious growths, 
 especially the papillary tumours of the uterus, which gives them, 
 in consequence, a red, spongy, and readily bleeding surface. 
 This is undoubtedly the kind of tumour which Jager consid- 
 ered as the vascular tumour of the uterus. The distention of 
 small veins, so frequently met with in the marastic uterus, 
 and one affected with chronic catarrh, in which numerous 
 stellate injected vessels are seen side by side, may also have 
 been described as telangiectasis. 
 
 The most unintelligible description of the above condition is 
 that given by K. Lee, in which the largest portion of a 
 uterus was transformed into a telangiectatic condition. 
 
 I am enabled to communicate a case of cavernous ectasia of 
 the uterus, observed two years ago in an old woman. The 
 uterus was anteflexed, its substance reddish-yellow, flaccid and 
 traversed by rigid arteries. In the posterior wall there was a 
 circular elevated portion, of spongy softness and two centime- 
 tres in diameter ; the mucous membrane covering it was thin, 
 slightly "hob-nailed," and of bluish red transparency. The 
 corresponding peritoneal surface was also tumefied, convex, 
 of bluish transparency, and the blood vessels of the peritoneum 
 were very distinct and full. A section made through the tis- 
 sue was immediately covered with dark fluid blood, after re- 
 moving which, a delicate framework, with isolated dark spots, 
 
OF THE UTEEUS. 185 
 
 became visible. In the cavities inclosed within this frame- 
 work and communicating with each other, there was fluid 
 blood. The appearance of this tumour on the whole, there- 
 fore, resembled the cavernous ectasice so frequently met with 
 in the liver, excepting that the framework was much thicker 
 than is usual in similar vascular tumours. The framework itself 
 consisted of smooth muscular fibres, inclosed in connective 
 tissue, and was covered in some places with cells resembling 
 pavement epithelium. In some portions of it there was an 
 outgrowth of connective tissue in the form of densely crowded 
 papillae without arborescence. 
 
 A communication between the cavity of the tumour and the 
 neighboring veins could easily be demonstrated, and at its 
 borders a gradual transition into the flaccid uterine tissue was 
 unmistakably recognizable, partly from an increase of the sub- 
 stance of its frame-work and partly from the entrance of en- 
 larged veins. 
 
 The rest of the uterus exhibited marked evidences of previ- 
 ous labor, and both ovaries contained large white bodies 
 (corpora albida), indicating that pregnancy had previously 
 existed. I do not hesitate to believe that this cavernous ecta- 
 sice was developed from the point of placental attachment, and 
 I do not doubt but that this was a case of paralysis of the 
 above-mentioned point after labor, this portion of the uterus 
 not having undergone regular involution, whilst the rest of the 
 organ had returned to its normal condition, and that the external 
 muscular layer near the peritoneum disappeared, partly from 
 involution and partly from marastic atrophy of the uterus, in 
 such a manner that flnally the entire wall of the organ was trans- 
 formed into this cavernous ectasia. I have already mentioned 
 in a previous chapter that, in consequence of this pathological 
 condition anteflexion of the uterus took place. 
 
 The productions found in fibroid tumours and described by 
 Virchow as telangiectatic myoma^ may also be considered as 
 belonging to this class. 
 14 
 
186 CAjS-CEOID tumoues 
 
 CANCROID TIBIOURS OF THE UTERUS. 
 
 Literature: J. Clarke, Transact, of a society for the improvem. 
 of med. and surg. knowledge. Vol. III. pag. 324. 1809. — Simpson, 
 Edinb. med. and surg. Journ. 184:1. — Anderson, Edinb. med. 
 Jom-n. 1842, und Dublin. Journ. Vol. 26, 78. 1845. — T . S t . L e e , 
 On tumours of the uterus etc. London 1847. — M e n a u d , London 
 med. Gaz. Aug. 1848. — Robert, Des affections du col de I'uterus. 
 Paris 1848. — Robin, Arch, gener. Juli et Octob. 1848. — 
 Frerichs, Jena'sche Annalen f. Physiol, u. Medicin. 1849. — 
 Watson, Monthly Journ. ISTov. 1849. — Yirchow, Verb, der 
 phys. med. Ges. Wurzbm'g. Bd. I. pag. 106. 1850 (Gesammelte Abhandl. 
 etc. Frankfurt 1856. pag. 1015). — C . Mayer, Verhandl. d. Ges. f. 
 Geburtsk. Berlin. Bd. lY. 1845. — B r e s 1 a u , Diagnostik der Ute- 
 ms-Tumoren ausserhalb der Schwangerschaft etc. Milchen 1855. — E. 
 Mikschik, Zur Pathologic des Clarke'schen Blumenkohlgewachses. 
 Zeitschr. Ges. d. Ae. Wien. 1856. Jannerheft. — E. Wagner, der 
 Gebarmutterkrebs. Leipzig 1858. — H. Ziemssen, Zur Casuistik 
 der Uterus-Tumoren I. Yirchow's Archiv Bd. XYIL pag. 333. 1859. — 
 L . Mayer, Yerhandl. d. Ges. f. Gebmtsk. , Monatschr. f. Geburtsk. 
 etc. Berlin. XYII. 4. 1864. — Rokitansky, Path. Anat._IIL p. 
 496. 1844. 
 
 The uterine cancroid tumour or epithelial cancer, is a com- 
 paratively frequent growth and appears under two forms. 
 
 In the description of papillary tumours I have alluded to 
 four different species, the two first of which, the acuminated 
 condylomata and true jpapilloma, I opposed as benign growths, 
 to cancroid tumom's and medullary villous cancer. 
 
 The cancroid papillary tumours of the uterus are developed 
 from the vaginal portion as a hyperplasia of the papillary 
 stratum, in consequence of which they grow from circumscribed 
 points, finally attaining the form of pedunculated tumours ; 
 or the papillse of the vaginal portion become arborescent, and 
 form a round tumour, covered with thick epithelial layers, and 
 having a warty, tuberous, or granular surface. Sometimes 
 this vegetation is limited to one lip of the vaginal portion, the 
 other remaining normal. The disease may be arrested for some 
 time after reaching this stage of development, and conse- 
 quently Virchow's assumption that these tumours should be 
 
OF THE UTERUS. 187 
 
 considered simple papillary tumours, is entitled to some credit, 
 althono;li we are oblis^ed to admit, with tlie same deo;ree of 
 probability, that the true cancroid tumour is developed from 
 such growths, and that cancroid papillary tumours, in most 
 cases, pass through this stage of development before their 
 characteristic elements can be demonstrated. 
 
 From what has been said, the relation of the simple to the 
 cancroid papillary tumour is rendered evident. A simple 
 papillary tumour may be developed and exist for years without 
 ever becoming a cancroid ; still, it may be impossible to deter- 
 mine from a microscopical examination or other signs, whether 
 the transition into cancroid will or will not ensue. On the 
 other hand, it may be said that a cancroid papilla^ry tumom* in 
 its primary condition is seldom distinguishable from a benign 
 papillary tumour. 
 
 To the naked eye the appearance of both tumours is seldom 
 so different as to allow us to draw a definite conclusion in 
 relation to their character ; the microscopical changes, however, 
 and the appearance of a section of a cancroid, are of great 
 importance. Whilst in the benign form, simply an arborescent 
 framework is covered by a more or less thick layer of base- 
 ment epithelium, in the cancroid tumour, so-called cancroid 
 alveoles are developed in the substance proper of the 
 tumour, and also in the "parent tissue," which is affected 
 with hyperplasia of connective tissue. A section, therefore, of 
 such a papillary tumour, presents the same granular appear- 
 ance, but between the grayish striated framework of connec- 
 tive tissue there are small cavities, sometimes scarcely percep- 
 tible to the naked eye, sometimes larger than a pea, and con- 
 taining a grayish-white fluid, which may be thick and greasy, 
 similar to the secretion of a sebaceous gland (cholesteatoma), 
 and may be removed with the handle of the scalpel as 
 a thick, lumpy mass. Pressure upon the tumour toward the 
 divided surface will cause the evacuation of semi-solid plugs, or 
 a whitish vermiform substance, resembling that evacuated from 
 
188 CANCEOID TUlVrOUES 
 
 comedones (Cruveilhier's cancer areolaire pultace). The prolif- 
 eration of connective tissue generally taking place in the form of 
 arborescent columns, more or less closely adjacent, the interme- 
 diary space between them is frequently filled with cylindrical 
 accumulations of the epid.ermoid substance forming the covering 
 of the tumour. The proliferation of epithelial cells in the inte- 
 rior of these tumours, however, does not always occur in 
 round cavities ; frequently they lie in a combination of ramify- 
 ing ducts, and the origin of this form from endogenous produc- 
 tions of ramifying connective tissue corpuscles was successfully 
 demonstrated by Pohl. 
 
 The various cells found in cancroids] differ somewhat in 
 form and manner of arrangement. In the outer layers of the 
 investing substance we find large basement epithehum, and 
 sometimes scaly cells, devoid of nuclei ; such being also the 
 productions contained in the alveoles. In the vicinity of the 
 framework, which consists of connective tissue, the cells of the 
 investing substance more closely resemble the cyhndrical epi- 
 thelium. In some of the alveoles, especially the smaller ones, 
 the cells are often more cylindrical, and form a lining to 
 the walls of the cavity, whilst in the larger alveoles they 
 He irregularly, side by side, or aromid a granular centre, or are 
 concentrically disposed around a sort of "brood-cavity" 
 (Bokitansky). 
 
 You will also find, almost without exception, cells under- 
 going fatty degeneration ; free molecular fat ; crystals of fat ; 
 cholesterine ; and finally, in some portions, the usual cheesy 
 transformation of substance. 
 
 At the basis of pedunculated tumom'S the framework of 
 coimective tissue is very powerful, containing mmierous 
 nuclei, and consisting of delicate fibres. Toward the surface 
 of the tumour it is converted into long arborescent ramifi- 
 cations, in which are found inclosed in the terminal delicate 
 connective tissue comparatively large, but thin-walled blood 
 vessels, forming single or double loops in the extreme vilH. It 
 
OF THE UTERUS. 189 
 
 is evident from this, that cancroid papillary tumours are some- 
 times exceedingly vascular, and that the danger of haemor- 
 rhage is so much greater, as these growths frequently ulcerate, 
 and are destroyed by spontaneous decomposition. Cancroid 
 papillary tumours are frequently found in a state of serous 
 infiltration^ and usually the uterus is aifected with leucorrhoea 
 during their presence. 
 
 Cancroid papillary tumours may be developed from the vagi- 
 nal portion or from the inner surface of the cervix, and in 
 very rare cases, from the mucous membrane of the body of 
 the uterus. 
 
 The second form of uterine cancroid tumours, in comparison 
 to the just-described Q2inQ,voidi papillary tumour, presents itself 
 in the shape of a difiuse growth of epithelial cells from the con- 
 nective tissue of the vaginal portion or cervix, generally near 
 ihe mucous membrane. In the substance of the part men- 
 tioned, nodose or imperfectly defined tumours are developed, 
 containing in smaller or larger alveoles, epithelial cells sus- 
 pended in a mucous-like intercellular substance ; or without 
 the latter and resembling a fatty, smeary mass» A section of 
 sucli tissue presents the same granular, glandular appearance ; 
 but tinally the pathological growth, after destruct on of the 
 connective tissue, degenerates into a whitish, yellow, soft, or 
 dry friable pulp, the wall of the cervix or vaginal portion be- 
 ing involved in the destruction of connective tissue. Thus the 
 cancroid idcer is formed, which, according to Rokitansky's 
 unsurpassed description, is characterized by well defined and 
 ragged hmits ; by deep sinuous exesions at its base ; by indura- 
 ted borders consisting partly of transparent, gelatinous, partly 
 opaque, white and dry epidermoid substance, and by a similar 
 wart-like base, which is generally granular from the alveolar 
 structure of the growth. 
 
 The disintegration of the pseudo-plasma having thus com- 
 menced, extensive destruction of the uterine substance may 
 ensue, causing in this manner nearly complete disappearance 
 
190 CANCEOED TUMOUES 
 
 of the cervix by an ichorus process. During tins, the cancroid 
 extends to the body and fundus of the uterus as well as to the 
 vagina, and appears again in the latter either as a diifuse, or 
 nodose mass in the shape oi^placques. Frequently, in the dif- 
 fuse form just mentioned, the base of the cancroid ulcers or the 
 adjacent mucous membrane proliferates as a cancroid papillary 
 tumour. The blood vessels of ^he uterus, especially the arte- 
 ries, are only involved at a later period ; for a long time they 
 remain permeable, but finally are eroded, and then profuse 
 hgemorrhage may occur, 
 
 A rare instance of the spreading of cancroids is described by 
 E. Wagner, in which the growth was developed in Douglas' 
 space. 
 
 Unless E. Wagner's peculiar form of medullary fungus of 
 the uterus be reckoned amongst this class, Forster's cylindri- 
 cal epithelial cancroid has not as yet been observed in the 
 uterus. 
 
 The uterine cancroid, whether appearing in one or other of 
 the forms mentioned, grows slowly, and readily becomes fatal, 
 either from the occurrence of an ichorous process or profuse 
 haemorrhage. Sometimes the ichorous process causes it to 
 become detached, and cases are known in which nearly the 
 whole vaginal portion thus affected sloughed away, and recov- 
 ery took place in such a manner that a funnel-shaped space 
 was found, surrounded by cicatricial tissue, and at the extrem- 
 ity of which the entrance to the cervical canal was situated. 
 
 In consequence of the excessive vascularity which sometimes 
 characterizes cancroid papillary tumours, they were formerly 
 described as fungus hcematodes^ fungoid cancer, bleeds 
 ing polypus, as a cancer resembling a softened spleen, or as 
 telangiectasis of the uterus. 
 
 The lymphatic glands in tlie vicinity of cancroid tumours, 
 especially the second form, are generally hypertrophied, red- 
 dened, sometimes considerably swollen and succulent, and 
 finally cancroid alveoles are developed in them, as I have ob- 
 
OF THE UTERUS. 191 
 
 served in a case in which the inguinal glands were considera- 
 bly affected in this manner. 
 
 Cancroid tumours and true carcinoma never occur prior to 
 the years of puberty. 
 
 The development of cancroid substance within the uterine 
 walls was first demonstrated by Virchow. 
 
 CAUCmOMA OF THE UTERUS. 
 
 Literature: Morgani, De sedibus et caus. morbor. Ep. XXXIX. 
 ait. 33. 1761. — A s t r n c , Traite des maladies des femmes. Paris 
 1761.— 1765. Vol. III. pag. 317. — V o i g t e 1, Pathol. Anat. Halle 
 1805. III. pag. 486. — A. Manzoni, Ueber den Krebs des Uterus. 
 Verona 1811. Giornale di medic, prat, compilato da V a 1 . L. B r e r a. 
 Vol. I. Abth. II. Heft. 11. Padua 1812. — W e n z e 1, Krankh. der 
 Gebarmutter, Mainz 1816. T. 1—6. — S c h m i 1 1 , Ueber Krebs des 
 Uterus, Ges. obstetr. Schriften. Wien. 1820. III. — Mme. Boivin et 
 D u g e s , Traite prat, des malad. de I'uterus etc. Tome II. Paris 1833. 
 
 — Montault, Joum. hebdomad. 1834. Nr. 20. — C h o m e 1 , 
 Lancette franc. Nr. 37, 841. 1834. — B a y 1 e , Traite des malad. can- 
 cereuses. Paris 1834.^ — P a u 1 y , Maladies de I'uterus, d'apres leslegons 
 cliniques deM. Lisfranc sl I'hop. de la pitie, Paris 1837. — 
 
 — Tanchon Recherch. statist, sur les malad. des femmes. Journ. 
 des connaiss med. 1836. 2. — Teallier,Du cancer de la matrice. 
 Paris 1836. — Hour man, Revue med. Fevrier 1837. — Colombat 
 de risere, Traite des malad. d. femmes etc. Tome II. Paris 1838. — 
 Duparcque, Traite theor. et prat, des malad. organ, simples et 
 cancereuses de I'uterus. Paris. 2. Ed. 1839. — Montgomery, Dub- 
 lin Jom'nal 1842. Jan. — K i w i s c h , Klin. Vortr. Prag 1845. I, pag. 
 423. — Scanzoni, Oesterr. med. Jahrb. 1846. Sept. — Nov. und 
 Krankh. d. weibl. Sexual. Wien. 1857. pag. 241. — W a 1 s h e , Nature 
 and treatment cf cancer. London 1846. — Th. Stafford Lee, 
 On tumors of the uterus etc. London 1847. — Cruveilhier, 
 Anat. pathol. Livr. 23. PI. 6., L. 24. 2., L. 27. 2., L. 39. 3. — L e b e r t, 
 Malad. cancereuses. Paris 1851. pag. 212. — Forget, Gaz. med. de 
 Paris 1851. — Kohler, Die Krebs- und Scheinkrebskrankheiten 
 etc. Stuttgart 1853. C h i a r i , Klinik fur Geburtsk. unn Gynacolog. 
 Erlangen 1855. — E. Wagner, Der Gebarmutterki'ebs. Leipzig. 
 1858. — L. M a y e r , Verhandl. der Ges. f. Geburtskde. Monatschr. 
 f. Gebiulsk. Berhn 1861. Bd. XVIL 4. — Rokitansky, Path. 
 Anat. m. 1861. 
 
192 CAECmOMA 
 
 Carcinoma of the uterus, in the majority of cases, occurs in 
 what we might call a fibrous medullary form, that is, in the 
 rare cases in which we are enabled to recognize and study the 
 primary condition of the carcinomatous growth in the dead 
 body, we find that form which is described under the name of 
 fibrous carcinoma or scirrhus, whilst in those cases in which 
 the disease proves fatal, we generally meet with the distinct 
 medullary variety of carcinoma. We may, therefore, with 
 certainty assume, that between the two forms of uterine carcin- 
 oma, still held distinct histologically by some anatomists, 
 there is always a transition or transformation of the fibrous 
 into the medullary carcinoma. The difference between these 
 forms lying only in the quantitative proportion of their frame- 
 work to the carcinomatous substance, we need not hesitate to 
 discuss both of them under one head, especially when they 
 occur in such organs as the uterus. 
 
 The fibrous medullary carcinoma of the uterus in the major- 
 ity of cases, affects first the vaginal portion to a various 
 extent, or it appears simultaneously at the inferior portion of 
 the cervix. The form of its first appearance frequently cannot 
 be distinguished, at least with the naked eye, from that pro- 
 cess which I have described as diffuse proliferation of the 
 connective tissue of the vaginal portion and cervix. 
 
 At the commencement of the disease the tissue of the vagi- 
 nal portion becomes either uniformly indurated aud tumefied, 
 or numerous large tuberosities are formed, generally combined 
 with considerable intumescence, causing marked distention of 
 the superior portion of the vaginal canal, and an increase of 
 the vaginal portion to twice and even ten times its normal 
 size. This may occur without the mucous membrane partici- 
 pating markedly in the degeneration. A section of such a 
 tumefied vaginal portion presents a pale gray or grayish-red, 
 very firm and dense tissue ; with the knife you will sometimes 
 succeed in scraping off a small quantity of albuminous slightly 
 turbid fluid, and a microscopical examination of the same will 
 
OF THE UTERUS. 193 
 
 enable jou to recognize a small number of free nuclei and cells 
 with large or multiple nuclei. Upon a close examination of 
 sections, the elements are seen scattered in irregular groups, 
 sometimes rounded, sometimes arborescent, and the prolifer- 
 ation of nuclei and cells will chiefly be found along the course 
 of the blood vessels. 
 
 In proportion as the firmness of the tumefied portion dimin- 
 ishes, its fluid becomes more turbid from the admixture of 
 cellular elements ; finally, after the tissue has attained a certain 
 degree of softness and elasticity, the fiuid which is now easily 
 expressed in larger quantity, becomes milky and creamy. 
 In the next stage of the disease the entire mass degenerates 
 into a pulpy, soft, brain-like substance, which is characteristic 
 of the exquisite medullary form of carcinoma. 
 
 Whilst at the outset, the mucous membrane of the vaginal 
 portion or cervix has scarcely participated in the degeneration, 
 at a later period it becomes more contracted, and finally the 
 pathological substance, which by this time has become softer, 
 after destroying the mucous membrane, grows into it, and 
 forms round whitish elevations covered with a delicate tur- 
 gid net- work of blood vessels. Owing to the confiuence of the 
 growths, the inner surface of the vaginal portion or cervix be- 
 comes tuberous or uneven ; here and there, between the dif- 
 ferent tuberosities, dark-red remnants of the mucous membrane 
 are still visible ; the cavity of the cervix and the entrance to 
 the vaginal portion are also variously deformed and contracted. 
 Finally, the last integument of the carcinoma disappears; it is 
 denuded, and an ichorous process commences at its surface. 
 Thus the cavity of the cervical canal is again enlarged, gener- 
 ally in such a manner, that from the inner surface of the vagi- 
 nal portion the greater amount of carcinomatous substance is 
 destroyed by gangrene, and finally sloughs away. Frequently 
 the entire vaginal portion has been thus destroyed, the vagina 
 being continuous with a funnel-shaped cavity, the villous 
 shreds and bleeding walls of which exhibit various sinuses, and 
 15 
 
194 CAKCITs^OKA 
 
 taper off in a point toward the internal orifice. Sometimes 
 in cases in which the destruction of the submucous structure 
 extends higher up than that of the mucous membrane, a struct- 
 ure depends from above, affecting a tubular form, and consist- 
 ing of mucous membrane not yet involved in the carcinoma. 
 
 Whilst the destructive and ichorous process extends from 
 below upward, the carcinomatous degeneration spreads farther 
 upward, and the adjacent portions of uterine tissue become 
 thickened and indurated by diffuse proliferation of connective 
 tissue (extending framework of the carcinoma) ; and, whilst in 
 the tissue immediately adjoining the ulcerated portion a creamy 
 whitish fluid is infiltrated, in the tissues beyond we find a 
 scarcely expressible fluid substance ; still, the transition to 
 portions with a merely hyperplastic appearance is gradual. 
 In this manner carcinomatous degeneration commencing in 
 the vaginal portion, extends higher and higher to the body of 
 the uterus, and finally even to its fundus. 
 
 It is a well-known fact, that a sort of limitation of the carci- 
 noma frequently occm'S at the internal orifice. The cause of 
 this may possibly be looked for in the circumstance that the 
 connective tissue, which is the germinal seat of the carcinoma, 
 is predominant in the cervix, whilst the smooth muscular 
 fibres prevail in the body of the uterus. The fact that tuber- 
 culosis takes a directly opposite com'se does not seem to con- 
 tradict this, the tubercle being developed from the mucous 
 membrane. However, in regarding this condition, we must 
 take into account the fact that individuals are rarely seen who 
 are able to bear such a considerable extension of this disease, 
 life becoming extinct at an earlier period from cancerous ma- 
 rasmus, haemorrhages, or secondary cancerous deposits in other 
 organs. The ichorous process is generally limited at the internal 
 orifice, whilst cancerous deposits in the body of the uterus may, 
 to a certain extent at least, easily be demonstrated. 
 
 Hypertrophy of the uterus above a carcinomatous mass, 
 alluded to by other authors, I consider in the majority of cases 
 
OF THE UTEEUS. 195 
 
 to be an early stage of carcinoma ; the development of the 
 latter in the vaginal portion and cervix commencing likewise 
 in a manner that cannot be distinguished from proliferation of 
 connective tissue. For this same reason, the analogy between 
 this affection and the development of carcinoma in the stomach, 
 seems to me to be perfect, whilst many authors are inconsist- 
 ent in their appreciation of these similar processes. 
 
 According to the description hitherto given, carcinoma ex- 
 tends from any point of the vaginal portion and cervix in a 
 diffuse manner ; still, those cases are not very rare in which 
 it is found in the vaginal portion in the form of nod- 
 ules. By an increase in size of several such nodules and 
 their final confluence, the transition into the diffuse form is 
 generally established. 
 
 In relation to the minuter structure of the fibrous and me- 
 dullary carcinoma, important investigations have lately been 
 ii ade by E. Wagner, which, however, I have been able to 
 only partially follow up. In the majority of cases of uterine car- 
 cinoma Wagner found an intermediary condition between 
 fibrous and medullary cancer, and very frequently i i the lat- 
 ter, a sort of alveolar disposition of tissue. The alveoles were 
 mostly in the form of glands or ducts, rarely angular, ovoid 
 or round. Their contents generally consist of cells of peculiar 
 form and disposition, and they closely resemble cylindrical 
 epithelia, and line the inner surface of the alveoles in close 
 apposition. The nearer you approach the centre of the alve- 
 oles the more irregularly these cells lie. Amongst numerous 
 cases examined, I have only met with this disposition twice, 
 and for the present must therefore confirm the observations of 
 E. Wagner ; still I am. ignorant as to whether this alvi olar 
 structure of uterine carcinoma is really the most frequent. 
 From a general point of view we might be led to form the 
 opinion, that these were cases of cancroids of the cylindrical 
 epithelial formation described by Forster, still, in the cases ex- 
 amined by myself, although the cells lying closest to the alve- 
 
196 CAECINOMA 
 
 olar walls were disposed in rows and similar to cylindrical 
 epithelium, yet fm-ther inward, and even where they were 
 densely crowded, they were mnltiform ; such as can only be 
 found in a well-developed medullary carcinoma. It is clear 
 that such alveoles are developed from '"brood-cavities." Wag- 
 ner states that he found dii'ect transitions from connective tissue 
 corpuscles to the parent cell, with multiple nuclei and smaller 
 carcinomatous alveoli in the majority of cases. 
 
 Besides destruction by an ichorous process, carcinoma some- 
 times undergoes fatty degeneration, which affects its cellular 
 portions, and is visible to the naked eye upon section as a net- 
 like or dotted configuration. The observation of such rare 
 cases induced Kiwisch to follow the example of John Mliller 
 in admitting the existence of a reticiilav carcmorna of the vag- 
 inal portion, which is to be distinguished by its lobular form, 
 the net-like disposition of its cellular frame, and its lesser firm- 
 ness of tissue. 
 
 In regard to the mucous metamorphosis, according to the 
 later opinion of E. Wagner (which I am inclined to confirm 
 after careful investigations of such changes in other organs), 
 the gelatinous cancer constitutes no particular species, but is 
 an excessive mucous metamorphosis of medullary cancer. 
 Those cases seem to belong here which have been described 
 as alveolar gelatinous cancer of the uterus (Rokitansky, Le- 
 bert) ; they seem nearly allied to those described by E. Wag- 
 ner, in which an alveolar type of medullary carcinoma is per- 
 ceptible. 
 
 The extension of uterine carcinoma offers some peculiarities 
 as regards the organs in contact with it. From the upward 
 course of the previously-mentioned degeneration, the oviducts 
 in rare cases may be involved in the disease. 
 
 Frequently medullary carcinoma spreads downward from 
 the vaginal portion to the vagina, and appears there in the 
 form of flat, circular, whitish or whitish-red masses, covering 
 the mucous membrane like mushrooms, sloughing away at the 
 
OF THE UTEEUS. 197 
 
 surface, and thus enlarging the ichorous cavity formed by the 
 destruction of the carcinomatous mass. Rarely, however, 
 does carcinoma extend lower down than the upper third of 
 the vagina. 
 
 In many cases the cancerous process involves the lymphat- 
 ics of the uterus, w^hich consequently degenerate into whitish 
 or whitish-yellow rosary-like ducts, which sometimes extend 
 far up under the peritoneum. The most interesting case of 
 this kind is the one described by Hourmaun, in which, on both 
 sides of the carcinomatous uterus, long plexuses, as thick as a 
 finger, were developed, consisting of knotty lymphatic ducts, 
 which extended as far up as the lumbar vertebrae and dia- 
 phragm, and enveloped the internal spermatic artery and 
 vein. It is possible that similar cases have induced Cruveil- 
 hier to admit the development of carcinoma from venous ves- 
 sels, and to consider the cavities of the former filled with 
 liquid as venous canals. 
 
 The extension of carcinoma to the posterior wall of the blad- 
 der is important and of extremely frequent occurrence. In the 
 commencement, the cellular tissue lying between the cervix 
 uteri and bladder becomes thickened, causing the latter to be 
 attracted to the cervix and the trigonum to become stretched. 
 Upon opening such a bladder from above, it is easy to perceive 
 the excavation at the point corresponding to that of the trac- 
 tion. The cancer next extends into the cellular tissue men- 
 tioned, and between the muscular fasciculi of the attracted and 
 hyperplastic vesical wall, and thence spreads more and more 
 in the submucous connective tissue. The mucous membrane 
 at this period frequently appears oedematous, and raised in the 
 shape of flabby yellowish-red transparent elevations, or it may 
 become more tense, the carcinoma growing into it in the 
 form of roundish, knotty prominences, or, which is most 
 frequently tlie case, in the form of the so-called medullary vil- 
 lous cancer. Frequently the rest of the membrane lining 
 the bladder is in a state of catarrhal intumescence and consid- 
 erable congestion. 
 
198 CARCINOMA 
 
 If at this point of the disease the destruction of the carcin- 
 oma extends from the uterus to the bladder, the cavity of 
 the latter is ultimately made to communicate with that pro- 
 duced by the destruction of the carcinomatous cervix and 
 vaginal portion. The perforation into the bladder is seldom 
 larger than a silver dollar (U. S.), and frequently in its ragged 
 borders, arborescent carcinomatous vegetations are found. 
 
 More rarely, but still frequently enough, the carcinoma- 
 tous growth takes a direction from the uterus toward the rec- 
 tum, in a manner exactly similar to its course toward the 
 bladder. It first extends in its framework, attracts the ante- 
 rior wall of the rectum, and grows through the muscular coat 
 of the intestine, in the form of whitish septa. It also fre- 
 quently extends into the rectum in the for.u of medullary vil- 
 lous carcinoma, that is, the mucous membrane is finally 
 involved in the carcinomatous process, or, as is frequently the 
 case, the mucous membrane becomes gangrenous at the point 
 in contact with the pathological growth, and afterward, when 
 the carcinoma is destroyed, a communication between the 
 vagina and rectum is also established. 
 
 The peritoneum is generally in a state of chronic inflamma- 
 tion; 'pseudo-membranous cords and bands bind the pelvic 
 viscera to each other and to the walls of the pelvis ; the excava- 
 tions situated before and behind the uterus disappear in con- 
 sequence of traction, agglutination, and occlusion ; sometimes 
 cancerous substance grows from these points through the peri- 
 toneum and fills the excavations. Frequently, besides such 
 tuberous carcinomata growing into the peritoneal cavity, 
 collections of yellowish serum are found between pseudo- 
 membranous lamella', which predominate like cysts and some- 
 times grow to the size of an orange. 
 
 In this manner, from the destruction of the uterine carcino- 
 ma, a communication may be established on the one hand 
 with the bladder and on the other with the rectum, so that 
 from the vagina, the upper third of the walls of which are 
 
OF THE UTEEUS. 199 
 
 ulcerated, yon have access into a large ichorous cavity, the 
 walls ot" which are formed of medullary carcinoma in a putres- 
 cent condition, with villous, shreddy, dark-brown remnants of 
 tissue hanging into the cavity ; in some places the walls feel 
 rough from mcrusted urinary salts, in others, fungous growths 
 sprout out, the surfaces of which decompose. The cavity is 
 jfilled with a chocolate-colored, intensely nauseating fluid, 
 mingled with small coagula, gangrenous shreds of tissue, por- 
 tions of carcinoma, or fecal matter. The anterior wall of 
 such a cavity you recognize to consist of the anterior wall of 
 the bladder, superiorly is seen the body or fundus of the uterus, 
 united to the fundus of the bladder in consequence of the oblit- 
 eration of the vesico-uterine excavation, and adjoining this the 
 rectum, the posterior wall of which forms the posterior wall of 
 the cavity. 
 
 If imperfect adhesion has occurred at both the excavations 
 of the peritoneum, perforation of the latter may take place in 
 the depths of those spaces, causing the fundus uteri to be sus- 
 pended from the round and broad ligaments above the dis- 
 tended ichorous cavity. 
 
 The cancerous degeneration may also, after involving the 
 bladder, extend to the lower portions of the ureters, in conse- 
 quence of which they become strictured, deflected in various 
 ways, or finally involved in the destructive process, and there- 
 by causing a dripping of urine into the ichorous cavity. 
 
 Outwardly the carcinoma spreads into the subperitoneal 
 areolar tissue as well as that of the pelvic floor, and passes from 
 thence to the pelvic muscles, and the periosteum of the sacral 
 and iliac bones especially, finally involving the bone itself. 
 Not unfrequently in such cases, an abscess is formed inferiorly, 
 which opens in the perinseum and gives rise to ichorous per- 
 ineal ulcers or fistula of the rectum. 
 
 If the lymphatic glands of the pelvis become hkewise affect- 
 ed with carcinoma they unite with the mass, and this becomes 
 so enormous as to completely fiU the pelvis and involve its 
 
200 CAECINOMA 
 
 walls throughout. K the large excavations become obliterated 
 by carcmomatous substance and false membranes, frequently, 
 after opening the abdominal cavity and removing the intes- 
 tines, the pelvic cavity is found filled as high as the level of 
 the superior margin of the symphysis, its superior limit being 
 formed partly by carcinoma, partly by flat false membranes, 
 and above which the fundus uteri projects Like a round tumour. 
 
 Finally, the spreading of carcinoma to the sheath of the 
 sacral nerves is of some importance (Montault, Kiwisch) as 
 considerable trouble may be occasioned thereby. 
 
 Sometimes the disease extends to veins which have pre- 
 viously become varicose and involved in the carcinomatous 
 mass. A phenomenon frequently observed in the venous sys- 
 tem is thrombosis, which, especially in ichorous carcinoma, 
 commences in the ramifications which have become involved 
 in the carcinoma, and spreads upward to the internal hypo- 
 gastric and spermatic veins. An extension of the thrombosis 
 into the common ihac, and also the crural veins, not unfre- 
 quently occurs, especially if the cancerous mass has extended 
 far into the pelvic cellular tissue. Thrombosis of the crural 
 veins is more frequently observed on one than both sides, 
 and is soon followed by oedema of the corresponding lower 
 extremity. 
 
 It has already been mentioned that when carcinoma extends 
 beyond the uterus, perimetritic false membranes are generally 
 formed, which extend in various directions, and cause adhe- 
 sions between several pelvic viscera. Frequently the oviducts 
 and ovaries are thereby involved in the disease in such a 
 manner as to be completely lost in the pathological mass, 
 false membranes rendering isolation of them extremely difii- 
 cult. Frequently, however, this pseudo-membranous attach- 
 ment of the neighboring movable organs extends fru'ther up, 
 and, in consequence of ihac peritonitis, the caecum and the 
 appendix vermiformis may become adherent on the right, and 
 the sigmoid flexure, as well as some of the lower intestinal 
 
OF THE UTEEUS. 201 
 
 convolutions, may become adherent on the left. It then hap- 
 pens, especially where the carcinomatous degeneration extends 
 up to the fundus uteri, or iu the rare cases in which the dis- 
 ease was primarily developed at the fundus, that the degener- 
 ation also involves the adhering portions of intestines, and by 
 the process of destruction of the pathological mass, the cavities 
 of the intestines are made to communicate with that formed at 
 the lower portion of the uterus. Perforation of adherent por- 
 tions of intestines may also occur in another manner from the 
 ichorous process to which carcinoma is subject (Chomel, Ki- 
 wisch, Eokitansky). The lower portion of the omentum majus 
 also often becomes adherent to the carcinomatous mass. 
 
 Medullary carcinoma of the uterus is usually the primary 
 deposit of cancer in the system, and cancerous growths of the 
 medullary form occurring in other organs are secondary to it. 
 The most frequent of such secondary fornas are, cancer of the 
 inguinal, lumbar, and retro-peritoneal glands, ovaries and 
 breasts. 
 
 Cancer of the uterus has been known to occur secondarily 
 to a similar affection of the ovaries, and in very rare instances, 
 as a continuance of primary carcinoma of the vagina and peri- 
 toneum. Cancer of the fundus uteri, when developed in its 
 peritoneal covering, appears at the commencement as subperi- 
 toneal, isolated, or confluent medullary knots, which gradually 
 extending deeper into the parenchyma, the entire substance 
 of the fundus becomes carcinomatous. 
 
 As already stated, the usual seat of uterine carcinoma is in 
 the cervix and vagioal portion, but still, cases are known in 
 which it was primarily developed from the body and fundus 
 of the uterus. In the rare cases of primary cancer of the body 
 of the uterus, it almost always, without exception, arises 
 nearer the external orifice than the fundus. From the latter 
 it generally grows into the distended cavity of the organ, in 
 the shape of irregular lobular tumours, which soon become 
 involved in ichorous destruction. 
 16 
 
202 CAECINOMA 
 
 Kiwisch observed a remarkable case in which primary can- 
 cer was developed from the fundus of an inverted uterus. 
 
 I had occasion to see a case of uterine carcinoma, which 
 originated from the posterior, superior, and lateral walls of 
 the body of the uterus. I have deposited the specimen in 
 the museum of Salzburg, and the case is of peculiar interest, 
 as it evidently proves that medullary carcinoma may be 
 developed from the round fibroid tumour. The pathological 
 growth represents a tumour larger than a child's head, which 
 so enlarged the uterus as to cause it to resemble one at the 
 fifth month of pregnancy ; inwardly, the tumour covered by a 
 layer of uterine muscles, projected from the left side into the 
 dilated uterine cavity, and was everywhere well defined, and 
 enucleable from the uterine substance like a fibrous tumour. 
 Sloughing had occurred in its lower two thu^ds, and ichorous 
 destruction in its lowest portion ; in its upper third perfect 
 medullary cancer was recognized at the same time with fibro- 
 muscular tissue. Besides this the uterus had spontaneously 
 ruptured transversely in its left lower portion, and the woman 
 died from haemorrhage. The portions of the tumour men- 
 tioned by myself as being distinctly and unmistakably fibro- 
 muscular, cannot be considered as fibrous portions of a car- 
 cinoma, the distinct demonstration of the presence of muscular 
 fibres contradicting such a supposition. 
 
 Carcinoma of the uterus is followed by a pecuHar marasmus, 
 common to every medullary cancer. Still, in regard to this, 
 it caunot be denied but that it may exist comparatively a long 
 time before the general phenomena of the so-called cancerous 
 cachexia are developed. Rokitansky mentions as the most re- 
 markable phenomena occasioned by uterine cancer, osteomala- 
 cia of the bones, anoemia, smdi fatty and amyloid degeneration 
 of the liver, spleen and kidneys. A considerable hydrometra 
 is also sometimes produced, in consequence of occlusion of 
 the cervical canal by the cancerous growths. 
 
OF THE UTEEUS. 2t)3 
 
 Uterine carcinoma, in consequence of ulceration of large 
 vessels, may suddenly prove fatal from haemorrhage. Death 
 may also be caused suddenly by an embolus, where there is 
 thrombosis of the large veins of the cancerous mass. 
 
 The remote consequences of carcinoma of the uterus are, 
 impeded passage of urine through the ui'eters, amyloid de- 
 generation of the kidneys, or hydronephrosis^ and not unfre- 
 quently we meet with parenchymatous nephritis, and even 
 abscesses, in consequence of the stagnation of the urine in the 
 kidneys. General peritonitis may also cause death quite sud- 
 denly, in consequence of perforation ; but this is a rare occur- 
 rence in comparison to the frequency of the perforation of 
 Douglas' space, and I find that the imfrequency of general pe- 
 ritonitis is owing to the circumstance that the above-mentioned 
 space is generally closed by false membranes, and also, that 
 the ichorous fluid always finds a free escape below and conse- 
 quently cannot easily get into the abdominal cavity ; at 
 least I have seen several cases of ichorous destruction of the 
 floor of Douglas' space without any signs of general peritonitis. 
 
 Carcinoma of the uterus is also frequently combined with 
 dysentery, ascites, and dropsy in all its forms, especially oede- 
 ma of the lower extremities from thrombosis of a crural 
 vein ; the latter is always the cause of oedema limited to one 
 of the lower extremities. The other dropsical phenomena are 
 partly the consequences of anaemia and partly of consecutive 
 affections of the kidneys. Finally, in most cases there is oede- 
 ma of the lungs. Not unfrequently also, we meet with diph- 
 theritic patches in the bladder and rectum ; and especially 
 the oedematous portion of the vesical mucous membrane around 
 the trigonium, previously mentioned, seems to be the primary 
 point of origin of this pathological formation. 
 
 In opposition to the above phenomena, which inevitably 
 lead to death, the universally acknowledged possibility of spon- 
 taneous recovery from uterine cancer, is interesting. Not un- 
 frequently do we observe in cancer of the vaginal portion of the 
 
204 CARCINOMA 
 
 uterus, that it sloughs away, but generally a new growth of car- 
 cinoma is developed from the ulcerated sm^face. In extremely 
 rare cases, ulceration and sloughing of a carcinoma limited to 
 the vaginal portion, takes place, the loss of tissue being 
 relieved by cicatrization, in consequence of which the vagina 
 and body of the uterus are drawn together, and the cavity of 
 the former terminates in a cone at the internal orifice, which, 
 in consequence of the sloughing, has become the external one 
 (Eokitansky and Scanzoni). 
 
 Besides this mode of spontaneous recovery, Kiwisch observed 
 a kind of gangrenous sequestration in a uterus affected with 
 carcinoma. Scanzoni's patient, however, died of cancer of the 
 right breast, in a year and a half after the sloughing of the 
 carcinoma. 
 
 According to the teaching of experience, uterine carcinoma 
 does not absolutely prevent conception, so long as destruction 
 of its tissue has not commenced. Females thus affected may 
 conceive ; still, during labor, the danger of rupture of the cervix 
 and vaginal portion from softening is very great, which acci- 
 dent may also give rise to profuse haemorrhage ; and in conse- 
 quence of severe contusion, rapid gangrene and puerperal 
 endometritis may easily ensue. 
 
 Medullary cancer rarely occurs before puberty, and the 
 twelve cases in which Madame Boivin says she observed carci- 
 noma in females under twenty years (amongst 409 patients 
 affected with it), render her numerical statements unreliable. 
 The cases recorded by Lever, Kiwisch, Lebert, Scanzoni and 
 Chiari embrace 440 observations, which, arranged according 
 to the percentage of the age of the patients, gives the follow- 
 
 ing result: — 
 
 
 
 
 
 
 Between 20—25 
 
 years 
 
 there 
 
 were 4 cases, 
 
 or 0.9 per cent 
 
 u 
 
 25-30 
 
 
 
 21 <' 
 
 4.7 
 
 (« 
 
 30—40 
 
 
 
 121 
 
 27.1 " 
 
 a 
 
 40—50 
 
 
 
 175 " 
 
 39.2 " 
 
 11 
 
 50—60 
 
 
 
 87 
 
 19.5 " 
 
 " 
 
 60—70 
 
 
 
 31 " 
 
 5.9 " 
 
 Above 
 
 70— 
 
 
 
 5 " 
 
 1.1 
 
OF THE UTEEUS. 205 
 
 Taking into consideration that the absolute number of females 
 from fifty years upward decreases very rapidly, it becomes 
 evident from the above table that the frequency of the oc- 
 currence of uterine carcinoma rapidly increases with advanc- 
 ing age. From an approximate calculation, made from the 
 records of the Vienna hospitals for several years back, the 
 result is that about 0.9 per cent, of the deaths of females was 
 from carcinoma. Kiwisch remarks, that in no less than two- 
 thirds of the cases of cancer in females the disease is located 
 in the sexual organs, and in the majority, in the uterus. 
 
 Sometimes the so-called villous form of medullary carcinoma, 
 or villous uterine cancer, is developed either from the point 
 of origin of the common medullary carcinoma, especially after 
 it has penetrated the uterine mucous membrane (Rokitansky), 
 or it arises directly from the mucous membrane. In 
 the latter case it has either originated from distinct circum- 
 scribed portions of the mucoas membrane, and forms, as pre- 
 viously mentioned, the fourth class of papillary tumours of 
 the uterus ; or the whole mucous membrane proHferates into 
 villous cancer, and, according to my observations, chiefly or 
 exclusively that of the fundus and body. The excrescences, 
 which are generally very delicate and thickly crowded, are 
 distinguished for their extraordinary vascularity, they are 
 almost always dark red in color, very soft, and surrounded by 
 a thick, creamy fluid. Sometimes they distend the cavity of 
 the body and fundus of the uterus, similarly as ves- 
 icular polypi do, into round fluctuating; tumours the size of an 
 apple, and in such cases where the excrescence occurred near 
 the internal orifice, causing obliteration of the latter, coagu- 
 lated blood or hsematometra is likewise found in the cavity of 
 the uterus. Rokitansky mentions that the arborescent frame- 
 work of the villous cancer sometimes grows out into long 
 rosary-Hke filaments, either single, or branching, and depend- 
 ing far into the vagina. 
 
 Another form of cancer, hkewise occurring in the uterus in 
 some instances, is the melanotic or pigment cancer. 
 
206 TUBEECULOSIS 
 
 As far as I can remember, to this day there is no case known 
 of primary melanotic cancer of the uterus. It sometimes appears, 
 coexisting with similar productions in other parts of the body, 
 either in the shape of nodules growing from the peritoneum 
 into the substance of the uterus ; or, isolated knots are found 
 in the external layer of the uterus, simultaneously with growths 
 of the same kind in the peritoneum. I remember, however, a 
 case, I saw in E-okitansky's Anatomical Institute m Vienna, of 
 diffuse spreading of melanotic carcinoma in a hypertrophied 
 uterus, combined with cancerous productions in both ovaries. 
 
 TUBERCULOSIS OF THE UTERUS. 
 
 Literature: M o r g a g n i , De sedib. et caus. morb. Ep. XLVII. 
 art. 14. — Kiwisch, Klin. Vortrage. Prag 1845. Bd. L pag. 462. 
 
 — Cruveilbier, Anat. patbol. Livr. 39. PL 3. — Holmes 
 C o o t e , Tubeiculosis of tbe uteras, London med. Gaz. Jun. 1850. — 
 W. G e i 1 , Ueber die Tuberculose der weibl. Geschlecbtsorgane Erlan- 
 gen 1 851 . — C h i a r i , Uterustuberculose, Klinik d. Geburtsh. u. Gyna- 
 cologie von Chiari, Braun nnd Spiith. Erlangen 1852. pag. 691. — 
 Paulsen, Ueber Uterintuberculose, in Hospit. Middlesex. S. 4, 
 Schmidt's Jahrb. 1853, Bd. 80. 11. — Snow Beck, Bristowe 
 und Wood, Verbandi. der pathol. GeseUscb. London, Febr. 6. 1855. 
 
 — H. Cooper, Union medic. Nr. 54 1859. — Rokitansky, 
 Allgem. Wiener med. Zeitung 1860. Nr. 21. — G. N ami as, Sulla 
 tuberc. deU' utero ecc. Mem. dell' Instit. venet. Vol. IX. Venedig 1861. 
 
 Tuberculosis of the uterus commences in the mucous mem- 
 brane of the organ, and thence extends into the deeper tissues, 
 especially the submucous stratum. 
 
 At first the mucous membrane appears to be congested and 
 swollen, especially in isolated portions of the walls of body 
 and fundus ; afterwards, small yellowish-gi*ay tubercles, scat- 
 tered or grouped, are developed in it, varying in size from a 
 millet to a liemp-seed, and which, when examined microscopic- 
 ally, are recognized as conglomerations of small round granu- 
 lar nuclei. 
 
 This affection is at first limited to isolated portions of the 
 fundus, then it spreads downward toward the internal orifice. 
 
OF THE UTEEUS. 207 
 
 and even beyond to the mucous membrane of the cervix. The 
 tubercles first formed, increase in size, their color changes to a 
 dark or pale yellow, and finally they ulcerate, perforating the 
 mucous membrane simultaneously^ and producing a small 
 round ulcer with a yellowish- white indurated margin. The 
 base of this ulcer is uneven, fissured and corroded, and is com- 
 posed of a whitish-yellow tubercular substance. Around its 
 margin the mucous membrane is generally considerably in- 
 jected. In consequence of the confluence of several such tuber- 
 cles into one, and owing to their subsequent ulceration, larger 
 portions of the inner surface of the uterus are, as it were, eaten 
 away and covered with a cheesy, fatty, pulp-like substance. 
 Upon section, the mucous membrane is found degenerated 
 throughout its entire thickness into the above pulp-like sub- 
 stance. 
 
 The further extension of tuberculosis into the muscular tis- 
 sue of the uterus, seems, in many cases, to be preceded by a 
 hyperplastic condition of its connective tissue, in which proKf- 
 eration of nuclei peculiar to the tubercle, takes place. The 
 ulcerative process first commences in the tubercles of the mu- 
 cous membrane, then extends, sometimes irregularly, into the 
 parenchyma at various depths, producing at certain points, 
 cavities in the uterine tissue. In many cases, the caseous de- 
 generated tuberculous substance, broken up into isolated 
 particles and suspended in an exuded fluid, accumulates in the 
 cavity of the uterus in consequence of an accidental closure of 
 the internal oriflce, and causes a distention of the body of the 
 organ resembling hydrometra (Hokitansky). 
 
 Very frequently tuberculosis of the mucous membrane of the 
 uterus is combined with a similar affection of the oviducts. 
 When such is the case, either the former or latter is the pri- 
 mary affection, or, tuberculosis has been developed simultane- 
 ously in both organs. More frequently, however, according 
 to my experience, tuberculosis of the oviducts seems to be the 
 primary affection. 
 
208 TtJBEECULOSiS 
 
 Contrary to what we observe in carcinoma, tuberculosis of 
 the uterus is developed and extends from above downward, 
 and often the internal orifice limits its fm^ther progress. How- 
 ever, as in carcinoma, exceptions also occur here ; the disease 
 may even primarily be developed in the cervix, but such cases 
 are exceedingly rare. I have seen such cases of cervical tu- 
 berculosis which resulted in the formation of a cavity in the 
 wall of the cervix, and I presume that this cavity was fii'st a 
 Nabothian vesicle, from the walls of which tuberculous ulcera- 
 tion may have extended, which is often the case. Tubercu- 
 losis may likewise extend from the cervix to the vagina. 
 
 Kiwisch also mentions the occmTence of tubercular granu- 
 lations in the vaginal portion of the uterus, and the develop- 
 ment in it of small lenticular, corroded, tubercular ulcerations, 
 which are generally arranged in small groups. 
 
 The uterus is rarely the primary seat of tuberculosis; 
 most frequently it coexists with advanced pthisis of the lungs 
 and the retro-peritoneal lymphatic glands. Besides tuber- 
 culosis of the oviducts aheady mentioned, we frequently find a 
 similar affection of the peritoneum existing as a comphcation. 
 
 A remarkable fact is the frequent occurrence of this disease 
 after the puerperal condition, even after the uterus has under- 
 gone nearly complete involution. In such cases, tuberculosis 
 commences at the point of placental attachment, and the fatty 
 degeneration of the muscular fibres of the uterus, which as a 
 rule follows the puerperal state, is somewhat increased, and 
 causes a uterus thus affected to be soft and friable. That a 
 uterus affected with tuberculosis may still conceive, seems to 
 be proved by Cooper's case, in which a female in the third 
 month of pregnancy died from spontaneous rupture of the 
 uterus, which on examination was extensively affected with 
 tuberculosis. 
 
 As regards the frequency of this disease, Kiwisch remarks 
 that amongst forty women dying of tuberculosis, its presence 
 in the uterus was observed in about one. The youngest 
 
OF THE UTERUS. 209 
 
 female affected with tuberculosis of the uterus observed |by 
 Kiwisch, was fourteen years old, the oldest seventy-nine years, 
 consequently no period of life seems to be exempt from it. 
 
 Rokitansky likewise describes a case of acute tuberculosis of 
 a puerperal uterus, which is the only one known in literature 
 to this day. The inner surface of this uterus, the walls of 
 which were thickened (six lines at the fundus, ten lines at the 
 point of placental attachment), was covered with a bloody, 
 dirty, grayisli-red secretion, and presented an unusual appear- 
 ance, its mucous membrane being marked with fine erosions 
 from small grayish or grayish-yellow distinct tuberculous 
 granules, varying in size up to that of a millet-seed. The 
 membrane presented the appearance of a loose, succu- 
 lent, areolar stratum, infiltrated throughout with the above 
 granules. The entire thickness of the substance of the uterus 
 beneath it, as far as the peritoneum, was likewise infil- 
 trated with the same granular substance, as was also that 
 portion to which the placenta was attached. Beside this, here 
 and there the tissue of the organ appeared softened, and pale, 
 yellowish, opaque points were seen, which proved to be accu- 
 mulated molecules of fat, resulting from fatty degeneration of 
 the muscular fibres. The granules consisted of groups of 
 nuclei, and the fibres of uterine tissue exhibited an abundance 
 of nuclei, though varying in number. In some places the origi- 
 nal nucleus had been elongated, and replaced by a few newly- 
 formed nuclei ; at other points the fibres presented the appear- 
 ance of longitudinal rows of nuclei, or, from an excessive 
 growth of the latter, had wholly disappeared. The mucous 
 membrane of the oviducts was also infiltrated with gray tuber- 
 cular granules ; in addition, besides old tubercles, the lungs were 
 found affected throughout with acute tuberculosis, and the 
 liver exhibited fatty degeneration. The woman was thirty-four 
 years old, and had given birth to an eight-month male child 
 nineteen days before death. Rokitansky, whose description I 
 have followed on account of the importance of the case, states 
 17 
 
210 ENTOZOA AND EKTOPHYTA 
 
 that the development of the tubercles having only taken place 
 after delivery, the puerperal iiterus should therefore be classed 
 amongst the organs subject to simultaneous affection with 
 acute tuberculosis of the lungs, and in consequence of its 
 increase in substance, it is apt to be a favorite seat for the 
 development of tubercles. In other respects he considers the 
 case important, because it proves that an existing predisposi- 
 tion, in consequence of the puerperal condition, may terminate 
 in an acute production of these pathological formations. 
 
 {Appendix.) 
 
 ENTOZOA AND ENTOPHYTA OF THE UTERUS. 
 
 Literature: Fahner, Beitrage zur gerichtl. u. pract. Arzneikunde 
 Bd. 1. 1799. Nr. XI. pag. 98. — S c h 1 e g e 1 , Material, filr die Staats- 
 arzneiwissensch. St. III. pag. 158. —Wilton, Lancet 1840. Nr. 19. 
 H y s 1 o p , Monthly Journal April 1850. — R okitansky, Handb. 
 der spec. path. Anat. 1842. 11. Bd. pag. 539. — Stuart Wilkin- 
 son, Lancet. Octob. 1849. 
 
 We find numerous descriptions in the older literature, of 
 vesicular worms of the uterus, which were confounded with 
 the so-called hydatid moles. The only well authenticated case 
 seems to me to be the one mentioned by Rokitansky, which 
 was an acephalocystic sac in the uterus. 
 
 With some degree of probability, we may may also admit 
 the observations of Hyslop and Wilton to be cases of echino- 
 coccus altricipariens of the uterus. Hyslop observed three cases 
 of echinococcus in the uterus, and the only thing which might 
 render this doubtful, is, that he should have been able to 
 observe three cases of an affection which the most experienced 
 pathological anatomists never met with. The encysted echin- 
 ococcus, after rupture of the germinal cyst, had escaped into 
 
OF THE UTEEUS. 211 
 
 ! the vagina, and was small and semi-transparent in appearance. 
 
 i Another cause of doubt is the occurrence of all three cases in 
 
 I females capable of being impregnated. 
 
 I In Wilton's case, the cyst forming the capsule, ruptured 
 into the peritoneal cavity, and the only question is, was this 
 not an echinococcus of the peritoneum which had become ad- 
 herent to the uterus, and caused an indentation into its sub- 
 stance by pressure, which was afterward considered an envel- 
 oping cyst formed by the uterine tissue ? Although the 
 original paper has not come into my hands, the extreme rarity 
 of such an occurrence must give rise to well-founded doubts. 
 
 Schlegel's case of tcenia hydatigena^ as it is called, men- 
 tioned by Voigtel, is a very pecuHar one. According to the 
 description given, it must have been a cysticercus celluloscB ; 
 ' ' its length was two inches, and it was suspended by its head, 
 which was retracted toward its neck, to one end of the encir- 
 cling cyst, causing the latter to be somewhat inverted at this 
 point." 
 
 In the case of Meckel, quoted by Fahner, possibly an echin- 
 ococcus altmcijparms may have been present. 
 
 Kiichenmeister in his work, makes no mention of uterine 
 entozoa. 
 
 The observations of entojphyta are fewer still. Stuart Wil- 
 kinson describes a case in which thallus-filaments one 1-8000 
 to one 1-4000 of an inch in diameter, were found in the uterine 
 discharge of a woman seventy-seven years of age, affected 
 with blennorrhoea and puritus vulvce ; also oval and round 
 granules, with and without nuclei, and molecules. The thal- 
 lus-filaments on being treated with acetic acid were transformed 
 into long cells. Stuart Wilkinson called these entophyta 
 ^'lorum uteri.'''' I have some doubts but that these fungi may 
 have originated in the vagina. 
 
212 ANOMALIES OF ^^UTRITIOK 
 
 ANOMALIES OF NUTRITION. 
 
 The anomalies of nutrition of the uterus, like those of for- 
 mation, may be divided into two classes according as the sup- 
 ply of nutritive material is increased or diminished, without the 
 formative 2>T0cess in the organ having undergone any altera- 
 tion ; or, as has been mentioned in the inteoduction, in so 
 far as the chemical process of nutrition, or its effects upon the 
 elements of tissue appears abnormal. 
 
 To consider inflammation among the qicantitive alterations ot 
 nutrition, is open to some doubts which I do not underrate, 
 still, it will be admitted that true parenchymatous injlaimnation 
 consists essentially of an abnormally increased nutritive pro- 
 cess, and this may justify our classification. Under the head 
 
 of QUANTITATIVE ALTEEATIONS OF NUTRITION, hypcrmuia is also 
 
 considered, so far as an increased or diminished afilux of blood 
 must exert some influence upon nutrition As an immediate 
 consequence of hypersemia, hoemorrhage is the next to come 
 under consideration. 
 
 The results of qualitative alterations of nutrition in the ute- 
 rus, are only known ii^ fatty and amyloid degeneration. 
 
 A. QUANTITATIVE ALTERATIONS OF 
 NUTRITION. 
 
 K we divide nutrition into two factors, one of which, the 
 afflux of blood, being to the other, the reception of nutritive 
 
OF THE UTERUS. 213 
 
 material, as nutritive irritation is to nutritive irritability, all 
 the quantitative anomalies of nutritition may be classified ac- 
 cording to this principle. Increased, as well as diminished 
 afflux of blood is characterized by anatomical changes, and al- 
 though in inflammation we presuppose an increased afflux, still, 
 the principal morbid condition seems to arise from the elemen- 
 tary parts, and therefore we discuss the anomalies contained 
 in this chapter in the following order: — Hyperemia of the 
 uterus ; H^moerhage ; Hypertrophy and Atrophy ; Inflam- 
 mation in its various forms ; the Ulcerative Processes ; and 
 finally Euptures of the uterus. The consideration of all these 
 affections, excepting the last, relates to the non-gravid uterus. 
 
 1. CONGESTION OF THE UTERUS. HYPEREMIA. 
 
 Hyperaemia, as a physiological action, occurs in the uterus 
 periodically from the beginning of puberty to the termination 
 of sexual life as onensintal hypersemia, and the anatomical 
 changes occurring v^^ith it are essentially the same as those of 
 morbid hypersemia. 
 
 Hypersemia affects either the mucous membrane of the 
 uterus separately, or simultaneously with its muscular sub- 
 stance, and the anatomical phenomena of hypersemia of the 
 mucous membrane vary according to the age of the patient, 
 and the form of hypersemia. 
 
 The changes which take place during menstrual fluxion have 
 already been described, and it is certain also, that in morbid 
 hypersemia of a uterus capable of impregnation, the elongation 
 of the utricular glands, already mentioned, is sometimes very 
 considerable. 
 
 After the period during which conception may take place, 
 the turgescence of the hypersemic mucous membrane is gener- 
 ally of a darker red, and the membrane is more considerably 
 relaxed, but we rarely meet with the same increased thickness 
 of the membrane, which depends chiefly upon the condition 
 of its glands. 
 
214 HTPEEJE3IIA 
 
 Hypersemia of the uterus is either active {fluxion), or passive, 
 that is, caused by impeded venous reflux. The former occurs 
 most frequently during the period in which conception is hkely 
 to occur, and undoubtedly is in close relation to the sexual 
 function. ^lensti'ual hyperemia may be abnormally in- 
 creased, or the changes accompanying it may be of longer 
 duration. In regard to increased menstrual hypersemia I must 
 mention a certain condition to which Rokitansky called my 
 attention. We at times meet with considerable hypersemic 
 intumescence of the uterus, especially of its mucous membrane, 
 sometimes greatly exceeding the normal measure of the 
 menstrual process ; simultaneously with this, we also find in 
 one or other ovary, a corpus luteum of a much larger size than 
 one of ordinary menstruation. Eokitansky explains these 
 occurrences in the following way ; that conception probably 
 took place, but the impregnated ovum did not become at- 
 tached, and consecjuently abortion occurred in the fii'st days of 
 pregnancy. In many cases it is scarcely possible to give any 
 other explanation, but the age of the corpus luteum should al- 
 ways be taken into consideration, for its mere increase in size 
 may have been occasioned by an increase of menstrual fluxion 
 into hypergemia, imder the influence of which the corpus 
 lutemn may attain a size usually only met with after concep- 
 tion has taken place. 
 
 Independently of the sexual functions, however, active hyper- 
 gemia of the uterus may occm-, and may continue to exist as 
 habitual chronic hypersemia occasioned by various adventitious 
 gi'owths developed in consequence of it. 
 
 Peculiar forms of hvpersemia, which have been termed 
 venous, sometimes affect the uterus in the course of typhoid 
 diseases, eruptive fevers, especially small-pox, and the so-called 
 dissolutions of the blood. 
 
 Passive hypersemia of the uterus depends either upon gen- 
 eral derangements of venous reflux, consequently impediments 
 
OF THE UTERUS. 215 
 
 of circulation, affections of the heart, impediments in the vena 
 cava ascend ens ; or it originates from local causes, as for in- 
 stance, displacements of the organ, causing traction or compres- 
 sion of the veins coming from it, especially flexions ; also, from 
 thrombosis of the spermatic and hypogastric veins, the latter 
 frequently being a continuation of thrombosis ot the crural 
 vein ; and also from pressure upon the veins mentioned. 
 
 The primary consequences of hyperaemia are enlargement of 
 the uterus, formative irritation of its connective tissue, and 
 development of diffuse proliferation of the latter {chronic en- 
 gorgement). Hypersecretion of the mucous membrane of the 
 uterus is induced, the secretion of the glands of the cervix 
 becomes thicker and more \ iscid, so-called Nabothian vesicles 
 are developed, and undoubtedly from simple hypersemia, polypi 
 of various kinds may originate, and the development of other 
 adventitious growths may commence with it. A fm'ther con- 
 sequence of hypersemia is haemorrhage, and finally, it may 
 turn into inflammation. 
 
 Hypersemia either affects the whole uterus uniformly, or is 
 confined to one or other portion of it — frequently the vaginal 
 portion and cervix. The former, after passive hypersemia has 
 existed for a certain length of time, becomes of a spongy intu- 
 mescence, and, owing to the permanent dilatation of its blood- 
 vessels, easily bleeds. Active hypersemia also frequently causes 
 considerable tumefaction and induration of the cervix uteri. 
 
 From what has been stated it is evident that hypersemia 
 may either disappear, or result i in so-called chronic hyperoemia, 
 with permanent proliferation of connective tissue. In this 
 condition its external phenomena may disappear in con- 
 sequence of contraction of the newly-formed connective 
 tissue, or the enlargement of the blood-vessels may continue, 
 causing succulence of the tissue of the uterus and blennorrhoea 
 of its mucous membrane. 
 
 In females who have never menstruated, and in children, the 
 uterus, after death, frequently presents a dark-red appearance, 
 
216 H^^IORPwHAGE 
 
 which might lead us to suppose that it was due to hyperasmia, 
 but it is in fact merely owing to the greater succulence and a 
 certain transparency of the recently deyeloped connectiye 
 tissue. 
 
 2. HAEMORRHAGE FROM THE UTERUS. :METR0RRHAGIA. 
 
 :mexorrhagia. 
 
 Literature: Lerov, Lecons sur les pertes de sang, etc. Paris 
 ISOl. — G o f f i n. Essai sur lesliemorrliag. en general et particulierment 
 sur la menorrliagie. Paris 1S15. — D uncan Stewart, Treatise on 
 uterine liaeniorrhage. London 1816. — C ruyeilhier, Anat. patholog. 
 Livr. 24:. pi. 2. — B lierre de Boismont, De la menstruation 
 etc. Paris 1812.— K 1 w i s c h , Klin. Yortr. 184:5. L pag. 318.— 
 D u f o u r d , Traite pratique de la menstruation, etc. Paris 1847. — 
 Cliiari, Braun und S p a t h. , Klinik der Geburtsh. u. 
 Gynacologie, Erlangen 1852. 2. Lief. 11. Beitr. pag. 167. — Chiari, 
 Menon-liagie u. Metrorrhagie. Ebendas. pag. 703. — E. J. Tilt, 
 Diseases of women and ovarian infiammat. 2 Edit. London 1853. 
 Oppolzer, Ueber die Ursacben der Metrorrbagie bei Xicbtscb- 
 wangem Allg. Wiener med. Zeit. 1858, Nr. 22. 
 
 Hsemorrhasres of the non-grayid ntenis are divided into 
 exte'mal — when the blood escapes per vaginnm (so-called 
 flooding) — and internal, when the hsemorrhage occurs within 
 the tissues of the organ. (Cruveilhier's ''Uteeixe Apoplexy.") 
 
 Hemorrhage ojciUTiiig from profuse menstruation, is termed 
 rnenoTvhagia ; when it takes place between the menstrual 
 epochs, or independently of them, it is simply called metror- 
 rhagia. It is, therefore, natural that the morbid processes 
 which finally give rise to metrorrhagia must previously, in the 
 majority of cases, produce menorrhagia. 
 
 The causes of metrorrhagia are partly traumatic, partly de- 
 pendent on uterine affections, and partly due to alterations in 
 the blood. It is developed from excessive hyperemia of the 
 uterus, and is accompanied bv extravasations the size of hemp- 
 seeds or lentils, into the greatly relaxed and swollen mucous 
 membrane. Probably under this heading that affection must 
 be included which has been described as hoeinorrhagic inetntis. 
 
FROM THE UTERUS. 21 7 
 
 Acute catarrh of the uterus is sometimes accompanied with 
 hsemorrhage. In the course of chronic catarrh, however, 
 heemorrhages occur, especially when various growths, as 
 mucous polypi, have been developed from the uterine 
 mucous membrane. These growths are often exceedingly 
 vascular, and very small ones may give rise to fatal haemor- 
 rhage. This is caused either from rupture of their delicate 
 vessels under the influence of an exacerbating hypersemia, or 
 occurs in consequence of a so-called hypostatic hypersemia 
 fi'om the lowest portion of a pedunculated depending polypus, 
 or, by a destruction of this portion. The same may be said of 
 the fibrous polypi of the uterus. Fibroid tumours likewise 
 cause metrorrhagia in consequence of hypersemia of the uterine 
 mucous membrane, and from the hypersemia engendered by 
 the pressure they produce in the venous plexuses, especially 
 when they are developed beneath the mucous membrane. 
 The excessive vascularity of the so-called papillary tumours 
 has already been mentioned as a frequent cause of exhausting 
 haemorrhage. 
 
 Carcinoma of the uterus in the same manner, partly also by 
 erosion of large blood-vessels (as the uterine artery or its 
 larger branches), may give rise to the most violent me- 
 trorrhagia, which may hasten the fatal termination of the 
 disease, even before the marasmus, consequent upon the 
 presence of cancer, has exhausted the patient. Cancroid 
 tumours, especially Levret's and Herbiniaux's ' ' bleeding poly- 
 pus," also frequently give rise to considerable haemorrhages. 
 
 Lastly, we must mention the rare cases of rupture of the 
 non-gravid uterus and the various ulcerative processes, which 
 latter may cause haemorrhage by erosion of the blood-vessels, 
 or from profuse granulations. 
 
 In the course of many diseases, as for instance, in typhus, 
 
 the eruptive fevers, the typhoid stage of cholera, acute yellow 
 
 atrophy of the liver and septicaemia, haemorrhages from the 
 
 uterine mucous membrane occur, in consequence of passive 
 
 18 
 
218 IliEMOKRHAGE 
 
 hypersemia. The haemorrhages of scorbutic females, as well 
 as of those suffering from hcematophilia, generally occur under 
 the form of menorrhagia. Kiwisch observed that in scorbutic 
 women profuse metrorrhagia occurs during the process of in- 
 volution after the puerperal state.* 
 
 In organic diseases of the heart, with considerable pul- 
 monary afiection, menorrhagia especially, and frequently 
 intense metrorrhagia, is produced. The metrorrhagia which 
 sometimes accompanies early menstruation and precocious de- 
 velopment of the sexual organs, or occurs in consequence of 
 mental impressions, Chiari considers to be due to derangements 
 of innervation. 
 
 Kiwisch classifies the causes of metrorrhagia and menor- 
 rhagia as follows. Causes due to constitutional anomahes 
 or diseases of organs lying outside to the sexual sphere: 
 to these belong, first, menorrhagia from precocious develop- 
 ment of the system, and particularly of the sexual organs ; 
 second, menorrhagia and metrorrhagia from dyscrasia ; third, 
 menorrhagia and metrorrhagia from impeded circulation; 
 fourth, from congestive and inflammatory affections of the 
 organs surrounding the uterus. Causes due to irregularities 
 within the sexual apparatus: fifth, precocious development 
 of the sexual organs ; sixth, abnormal irritability of the latter ; 
 seventh, relaxation of tissue ; eighth, acute (hsemorrhagic) 
 metritis ; ninth, reception of morbid products, to which may 
 be added, tenth, the influence of external injuries, causing 
 so-called secondary menorrhagia and metrorrhagia. 
 
 The extravasated blood either escapes, or is retained within 
 the cavity of the uterus from stenosis of its oriflces, and thus 
 gives rise to hsematometra and the phenomena described 
 under that head. 
 
 ♦ Wacbsmuth relates the case of a young girl belonging to a family affected 
 with Ti-BmatopMUa, who bled to death on the first night of her marriage, in 
 consequence of rupture of the hymen. (Virchow's Pathologie, etc., 1854, p. 
 2G5, vol. i.) 
 
FEOM THE UTERUS. 219 
 
 The consequences of metrorrhagia are those of haemorrhage 
 in general: ancemia and drojpsical jphenovnena. 
 
 Hsemorrhage into the tissue of the uterus, as a rule, only 
 occurs in aged females, and was described by Cruveilhier as 
 apojplexy of the uterus. The entire uterus in such cases is in a 
 state of marastic atrophy, flaccid, soft and friable. Upon its 
 divided surface the rigid arteries project somewhat, appearing 
 as whitish non-retracted vessels. The mucous membrane of 
 the posterior wall especially (sometimes exclusively), and the 
 subjacent tissue to various but never considerable depths, 
 appears dark-red, friable, and transformed into a uniform mass 
 resembling coagulated blood. Cruveilhier, according to the 
 thickness of the affected layers, distinguishes three varieties or 
 degrees of this disease, and remarks, that when the haemorrhage 
 has occurred beneatii the mucous membrane into the sub- 
 stance of the uterus, hypertrophy of the latter always exists ; of 
 which fact I have never been satisfactorily convinced. Some- 
 times in this affection small coagula are found in the cavity of 
 the uterus ; and I can likewise recall cases in which I found slight 
 hydrometra, and an accumulation of viscid mucous without 
 any admixture of blood, which fact affords sufficient proof that 
 the haemorrhage occurred exclusively within the parenchyma of 
 the organ. The mucous membrane of the cervix and vaginal 
 portion never participate in this affection. 
 
 The inner surface of the uteri of aged females sometimes 
 appears discolored (yellowish and rusty brown) to the depth of 
 a line, and is friable and infiltrated with fatty molecules and 
 granular and yellow pigment, which Rokitansky considers to 
 be residua of uterine apoplexy. 
 
220 HYPEETEOPHY 
 
 3. HYPERTROPHY OF THE UTERUS. 
 
 Literature: Lisfranc, Gaz. med. de Paris. Xr. 61, 64, 73, 1833. — 
 Simpson, Monthly Joum. Juni, Aug. Nov., 1843, und Marcli 1844. 
 — K i w i s c h, Kl. Yortr. Prag. 1845. 1. pag. 104.— Jas c h e , Erfah- 
 rungen iiber die cliron. Gebarm. Entztindung. 3Ied. Zeitg. Russlands 
 1846. Kr. 22 and 28. — O. P r i e g e r, Ueber Hypertropliie und die 
 harten Geschwlllste des Uterus. Monatscher. f. Geburtsk, Berlin 1853. 
 Marz. — S c a n z o n i , Krankh. d. wetbL Sexualorg. Wein, 1857. pag. 
 141. — O p p o 1 z e r , Kl. Voitr. etc. in Wittelsliofer's med. Woclienschr. 
 Wein 1858. p. 328. 
 
 According to Trhat lias been previonsly said, genuine h-y-per- 
 trophy of the uterus is an enlargement and intumescence of 
 the organ, caused by a surplus of nutritive material received 
 into its elementary parts : and I have ah-eady described the 
 enlargement of the uterus during menstruation as a physiolo- 
 gical hypertrophy. We consequently speak of hypertrophy 
 of the uterus as a disease, in the strict acceptation of the term, 
 in such cases only where a surplus of nutritive material is 
 received into its tissue by abnormal irritation, and, therefore, 
 an increase of all its elementary parts has taken place. Wiiilst 
 in the process generally called hypertrophy or chronic en- 
 gorgement of the uterus, the connective tissue is chiefly affect- 
 ed ; in genuine hypertrophy we chiefly find an increase of the 
 muscular elements. The characteristics of such hypertrophied 
 uteri have already been described. 
 
 It is evident that the intumescence of the uterus by this 
 process is hmited, and we cannot conceive a uterus remaining 
 in this condition for any length of time without either destruc- 
 tion of tissue occurring, for every element is only enabled to 
 receive nutritive material to a limited degree without impair- 
 ment of its integrity ; or without the occurrence of formative 
 alterations leading to some of the aflections already mentioned 
 — diffuse or circumscribed proliferation of connective tissue, 
 formation of pol}^i, or development of fibro-muscular tumom'S. 
 
OP THE UTEEUS. 221 
 
 Genuine lij^^ertropliy of the uterus is rare, being generally 
 accompanied with and dependent on proportionate congestion. 
 It occurs most frequently as a consequence of menstruation, 
 the hypertrophic intumescence of the uterus continuing for 
 some time after. 
 
 It generally aftects the entire organ, but chiefly either the 
 fundus, body, or vaginal portion. 
 
 In very rare cases numerical hypertrophy or hyper2}lasia of 
 the uterus, may be demonstrated in the sense previously ex- 
 plained (see page 44). In such cases of genuine liyperplasia, 
 as also in the enlarged uterus, the elements constituting a com- 
 pound tissue must be present in normal proportion if we 
 maintain the distinction between proliferation of connec- 
 tive tissue and uterine hyperplasia. The exciting cause must 
 produco a uniform increase of formative action in all the 
 elementary tissues of the uterus, which is rarely the case, this 
 activity appearing to be much more excitable in the connective 
 tissue in which it is aroused bj^ the slightest irritation, whilst 
 the latter is insufficient to produce any marked changes in the 
 remaining tissues. 
 
 From this it is also evident that hyperplasia of the uterus, 
 in the majority of cases, affects only the connective tissue, 
 or, if the other tissues are affected, the former is pre- 
 dominately so ; and consequently, b}^ the affection usually 
 called hypertrophy of the uterus, diffuse proliferation of 
 connective tissue is meant. This incorrect denomination seems 
 to have no further practical bearing. 
 
 The occmTcnce of genuine hyperplasia is, however, proven 
 by those cases in which an unusually large uterus is found in 
 women who have died in the puerperal state. It is true, facts 
 should be adduced to prove, that the occasional development 
 of muscular fibres, extraordinary in number and size, did not 
 take place during pregnane}^, which many considerations lead 
 us to suppose. The contracted walls of such a uterus are 
 sometimes two inches and more in thickness, and I may at 
 
222 ATEOPHY 
 
 once mention, that sometimes spontaneous rupture of such 
 enlarged uteri has occurred during labor. 
 
 For further details I must refer back to what has been 
 mentioned on the subject of diffuse proliferation of connective 
 tissue in the whole uterus or different portions of it. 
 
 4. ATROPHY OF THE UTERUS. 
 
 Literature: Morgani. De sedib. et caus. morbor. E. XXXTV. 
 11. XLVI. 20. XLYH. 2. — E. Kennedy, Dublin. Journ. 1838. 
 Novbr. — John O'Bryen, Schmidts Jahrb, 1841. pag. 48. — 
 Meissner, Frauenzimmerkrankheiten. Leipzig. 1842. Bd. 1 pag. 
 172. — K 1 w i s c h, Khn. Yortr. 1845. pag. 99. — C h i a r 1, Klinik 
 der Geburtsh. u Gynacol. von Chiari, Braun u. Spath. Erlangen. 1852. 
 pag. 271. — Scanzoni, Ea'ankh. d. weibl. Sexualorg. 1856. pag. 
 63. — R o k i t a_n s k 7, Path. Anat. Bd. HI pag. 454. 
 
 Atrophy of the uterus is an affection of mature age, and 
 generally commences simultaneously with puerperal involu- 
 tion, or it must be considered as marastic degeneration of the 
 organ. In chlorotic women also, a sort of atrophy of the 
 uterus is sometimes met with, generally comphcated with 
 displacements, and derangements of menstruation. Besides 
 these causes, atrophy may result from pressm^e or be due to 
 mechanical causes. 
 
 As regards the degree or extent of this affection, we may 
 distinguish between general and partial atrophy. The latter 
 affects either the body, fundus, cervix or vaginal portion of 
 the uterus. 
 
 Whilst we have recognized hyperplasia in its usual form as 
 a proliferation of connective tissue, in atrophy chiefly the mus- 
 cular substance of the uterus is affected, and the framework 
 of connective tissue remaining intact, the character of atrophy 
 is at once evident. 
 
 The substance of the uterus is therefore flaccid and soft, yet 
 still of some resistancy. Only when the organ remains atrophied 
 after puerperal involution, is its tissue friable and considerably 
 
OF THE UTEEUS. 223 
 
 softened. Its walls are generally thin ; and this condition in- 
 creases the more its cavity is distended. Cases are even 
 recorded in which the uterine walls were only of the thickness 
 of paper (Hopfengartner in VoigteFs work mentions Walter's 
 membranous uterus). 
 
 As regards the cavity of the uterus a distinction has been 
 made between concentric atrophy with diminution, and eccen- 
 tric atrophy with dilatation of the cavity. 
 
 Marastic atrophy generally affects the whole uterus, the 
 organ being smaller, frequently ante- or retroflexed, and some- 
 times has a granular rough feeling. In the appendages of the 
 uterus, the course of the arteries is exceedingly tortuous, and 
 the subperitoneal vessels, owing to their rigidity, are ele- 
 vated above the serous membrane. Upon section we find 
 the uterine tissue pale gray, or grayish-red. Upon the 
 divided surfaces, the ends of the arteries, their walls 
 being thickened and partly ossified, prominate as small 
 whitish pomts with comparatively small orifices. The mu- 
 cous membrane is loose, soft, dark-red, and frequently in 
 an apoplectic condition, which latter sometimes extends deeply 
 into the parenchyma ; or it is sometimes dotted with a num- 
 ber of small vesicles ; or, lastly, it is thin and reduced to a 
 serous, glossy stratum of connective tissue. 
 
 Atrophy which sometimes follows the puerperal condition, 
 consists chiefly of a derangement of puerperal formative action, 
 the older muscular fibres, as usual in puerperal involution, 
 being destroyed by fatty degeneration (Heschl), and restitution 
 by new-formation not taking place ; or it is caused by the de- 
 struction of the newly-formed muscular elements, by fatty de- 
 generation from anomalies of nutrition of the system. In 
 these cases the uterine tissue is of a grayish-yellow or yellow- 
 ish-red color, and very friable, the torn surfaces being united 
 by dehcate mucous cobweb-like threads or filaments. This 
 form of atrophy chiefly affects the body and fundus of the ute- 
 rus. It is chiefly met with in cases in which a pathological 
 
224 ATEOPHY 
 
 condition, especially tuberculosis, puts an end to life by sudden 
 and extensive hsemorrliage after the puerperal condition. 
 Chiari observed two cases of atrophy vritb complete cessation 
 of menstruation, lactal secretion still continuing, and he con- 
 siders them cases of premature senile atrophy. 
 
 Traction of the uterus causes a pecuhar form of atrophy, the 
 cervical portion being the part chiefly affected. It is thinned, 
 its cavity diminished, especially at the internal orifice ; the 
 vaginal portion disappearing, and the vagma terminating in a 
 point. I have abeady discussed these conditions under the 
 head of so-called Elevatiox of the Uterus. 
 
 The vaguial portion is either seemingly atrophied, in con- 
 sequence of its elongation and elevation of the uterus, or 
 absorption and retraction from lacerations dming labor has 
 occurred, analogous to that which affects the hymen after its 
 rupture, and Rokitansky sometimes observed atrophy of this 
 portion, due to some unknown cause, in young women at the 
 time of puberty. 
 
 Apparent atrophy of the vaginal portion is also occasioned 
 by adhesions between its external surface and the vagina. This 
 adhesion sometimes affects only a part of its circumference, or 
 is more considerable on part of its surface than on the rest ; 
 then the remaining normal portions encircle an orifice leading 
 into a cavity formed by the anterior or posterior fornix, and 
 which may even be entirely closed. 
 
 In the uteri of aged females, not unfrequently the entire 
 vaginal portion has disappeared, leaving only small folds at 
 the top of the fornix, which converge toward the cavity of 
 the cervix. 
 
 Frequently atrophy of the uterus accompanies the develop- 
 ment of fibroid tumours, and it may happen that in place 
 of the uterus, an aggregate mass of round fibroids is 
 found, between which you can scarcely detect traces of the 
 uterine fibres. The cavity of the uterus has also either been 
 entirely obhterated, or is merely represented by a small space 
 
OF THE UTERUS. 225 
 
 filled with gelatinous mucous, situated somewhere within the 
 mass. The cervix uteri is either normal, or elongated and 
 consequently thin. Sometimes, when calcified fibroid tumours 
 exist, the uterus is atrophied to such a degree as to form a 
 membranous organ, and consequently escapes observation, 
 (cases which have been described as ossification of the whole 
 uterus). Sometimes, in consequence of excessive distention of 
 its cavity by accumulated mucus (hydrometra), a considerable 
 thinning of the walls of the uterus from atrophy, is observable. 
 The cavity of the seiiile atrophied uterus is often, independently 
 of any atresia, found distended to the size of a filbert, and 
 filled with a mucilaginous fluid, and this I consider to be true 
 eccentric atrophy, caused by an accumulation of such fluid in 
 consequence of deficient contractile power in the organ. 
 
 A peculiar atrophy, or rather consurrvption, affects the 
 submucous stratum of the uterus, in consequence of en- 
 largement of the follicles of the cervix and vaginal portion, 
 or from excessive development of Nabothian vesicles, and I 
 have abeady mentioned these conditions when speaking of the 
 causes of flexions, and stated that this form of atrophy 
 chiefly affected the tissue around the internal orifice. 
 
 Senile atrophy of the uterus occurs much earlier if the 
 organ is affected with chronic catarrh ; consequently we 
 often find atrophy combined with mucous or cystic polypi, 
 adhesion of the uterine walls, and the other consequences of 
 uterine catarrh. 
 
 Finally, atrophy of the uterus frequently occurr. after de- 
 liveries, in rapid succession, and in conjunction with atrophy of 
 the ovaries. 
 
 Scanzoni also mentions as a cause of atrophy, imperfect 
 innervation of the pelvic organs, consequent upon paralytic 
 conditions of the system (paralysis of the lower half of the 
 body, followed by amennorrhoea), and of which he observed 
 several cases. 
 19 
 
226 INFLAMMATION 
 
 INFLA:^DIATION OF THE UTERUS. 
 
 Lit erature: Cbr. G. K i e s s 1 i n g , De utero post mortem inflam- 
 mato. Lipsire 1754. — C i g n a, uteri inflammatio. Dissert. Turin 175G, 
 — B (i 1 1 g e r , De inflaramatione uteri. Rintel. 1 760. — M o r g a g n i. 
 De scdib. et caus. morb. Ep. XX. 9., XXI. 29., XLYIII. 28.— 
 Brother son, Diss, de utero, et inflammatione ejusdem. Edinb. 
 1776. — J. C. Gebhard, De iuflammatione uteri. Marburg 1786. — 
 P 1 o u g u e t , Diss, observ. hepatit. et metritid. etc. Ttibingen 1794. — 
 V o i g t e 1 , patliol. Auat. Halle 1805. — W e n z e 1 , Ueber die 
 Krankh. des Uterus, Mainz 1816. — S t r e h 1 e r. Ueber Entzundung 
 der Gebiirm. Wiirzburg 1826. — G u i 1 b e r t , Consid. prat, sur cert, 
 affections de I'uterus, en particulier sur la phlegmasie, etc. Paris 1826. — 
 D up arc que, Traite theoiique et prat, des malad. org. simpl. et cane, 
 de rut5ru3. Paris. 1832. — Lis franc, Maladies de I'uterus et des 
 ses adnex. Gaz. med. de Paris. Nr. 61. 64. 73. 1833. — Mme B o ivin 
 e t D u g e s, Traite pratique, etc. Paris 1833.— Tom. H. pg. 198.— E. 
 K e n n e d }% Hj^pertroph. and other Affect, of the neck of the uterus. 
 Dublin Journ. 1838,— Lever. Prat, treat, on organ, diseas. of the 
 uterus. London 1843. — pg. 13. — Rigby, Times. Septb. 1844. Juli 
 1845. — K i w i s c h , KUn. Yortr. Prag 1845. I. pg. 477. — R o b e r t . 
 ' Bullet, de therapie. Novr. 1846. — E. Kennedy DubUn Journ. Febr. 
 1847.— 1 d h a m, Guy's Hospit. Reports. 1848. YL 1.— H u g u i e r. 
 Mem. sur les engorgements de la matrice. Gaz. des Hopit. 1849. 127. — 
 Tilt, Lancet 1850. August. — Bennet, A pract. treatise on in- 
 flammation of the uterus and its appendages, and on ulceration and 
 induration of the neck of the uterus. London 1853 3d. Edition. — 
 Rigby, Med. Times and Gazette. Jan. 1856. — M i k s c hi k, Zur 
 akuten Gebllrmutterentz. bei Ungeschwangerten. Zeitschr. der Ges. d. 
 A. Wien 1855. Hft. 7. u. S. — S c a n z o n i, Krankh. d. weibl. Sexual. 
 Wien 1857. — A ran. Maladies de Tuterus Paris 1858. — B ecquerel. 
 :^[aladie3 de I'uterus. Paris 1860. R o k i t a n s k y. Path. Auat. UI. 
 Bd. 1861. 
 
 The inflammatory processes to which the uterus is subject, 
 aflfect either its ?nuscular substance^ its raucous lining^ or its 
 peritoneal covering. The latter will be discussed with anoma- 
 lies of the uterine ligaments and peritoneum. 
 
 f). INFLAMMATION OF THE MUSCULAR SUBSTANCE OF THE 
 UTERUS. METRITIS. 
 
 Ir.flammation of the substance of the non-gravid uterus 
 seems to be one of the rarest affections to which tliis organ is 
 
OF THE UTERUS. 227 
 
 liable ; and if some uterine pathologists doubt the existence of 
 such a disease, and explain the cases diagnosed as metritis 
 as cases of perimetritis, pathological anatomy, considering 
 the small number of semi-authenticated post-mortem cases, 
 must pronounce upon it with some reservation. I have 
 not met with a single case, which, with any degree of 
 certainty, I could pronounce to be one of genuine metritis, 
 and I therefore borrow the following description from other 
 authors. 
 
 In acute parenchyinatous vietritis the uterus, especially in 
 its upper third, is found to be enlarged (even to the size of a 
 goose's Qg^', thickened anteriorly and posteriorly, and reddish 
 or bluish red, in some places more than others. The sub- 
 stance of its walls is very succulent, and marked with 
 small extravasations, and a viscid fluid can be expressed from 
 it, containing free nuclei and a small quantity of pus-corpuscles. 
 In many cases its tissue may be so relaxed as to occa- 
 sion larger extravasations with destruction of tissue. The 
 mucous membrane of the fundus and body is vascular, red- 
 dened and softened ; that of the cervix is generally normal. 
 The vaginal portion is tumefied, oedematous and eroded, and 
 the papillae are sometimes distinctly prominent. 
 
 The most obvious alterations in the inner layers of the sub- 
 stance of the uterus, resulting from acute parenchymatous 
 metritis, occur in that portion of the organ which contains the 
 largest amount of connective tissue ; the inflammatory action 
 generally extends outward, giving rise to perimetritis and 
 pelvic peritonitis, and is frequently combined with encolpitis, 
 metrosalpingitis and oophoritis. 
 
 Acute parenchymatous metritis may terminate— ^r^^, in 
 resolution with absorption of the exudation and a return of 
 the uterus to its normal size ; second, iii consequence of the 
 inflammatory action, proliferation of connective tissue may 
 ensue, resulting in permanent enlargement or induration of 
 the substance of the uterus ; third, as it is incorrectly stated. 
 
228 INFLAMMATIOK 
 
 acute metritis may become chronic, and chronic engorgement 
 be developed. 
 
 Kiwisch makes three distinct forms of parenchymatous 
 metritis: firsU metritis with oedema of the uterus, which 
 according to his description may be considered as hypersemia 
 with intumescence from transudation; second^ metritis with 
 increased firmness of tissue, or acute infarctus of the uterus ; 
 and finally, thirds hsemorrhagic metritis.* 
 
 A further termination of parenchymatous metritis is the 
 extremely rare formation of an abscess in the substance of the 
 uterus. Bartholin's observation (the uterus of a girl 13 years 
 old, filled with ulcers) does not seem to belong to this class, 
 but Eeinmann (in Voigtel's work) describes an abscess of the 
 uterus which opened externally through the abdominal walls. 
 Scanzoni also observed one the size of a goose's egg, 
 in the right circumference of the fundus uteri, which ruptured 
 into the peritoneal cavity. Bird {Lancet^ Feb. 1844) describes 
 a case in which an abscees, situated in the posterior wall of the 
 uterus, opened into the rectum. 
 
 The directions in which a uterine abscess may perforate, 
 vary, of course, according to its situation ; it may open in- 
 wardly into the uterine or vaginal cavity, or outwardly. If 
 adhesions exist between the uterus and nelgboring organs, the 
 abscess may perforate externally through the anterior abdomi- 
 nal wall, or into the bladder, csecum, ileum, and sigmoid 
 flexure of the colon ; or the pus may burrow between the folds 
 of the broad ligaments into encysted portions of the abdominal 
 
 * Any one unprejudiced must be struck with the uncertainty of the great 
 gynecologist in his description of metritis and his rather unsuccessful 
 attempt at classifying it. His description of serous metritis is deficient of 
 all anatomical requisites of inflammation ; in "acute infarctus," an analogy 
 to chronic infarctus was intended, which latter he was unwilling to drop ; 
 for he (Kiwisch) says, that the more acute the affection (that is, metritis 
 with increased firmness of tissue) the more relaxed the uterine tissue is 
 found. Finally, haemorrhagic metritis is nothing else but acute uterine 
 catarrh with haemorrhage. 
 
OF THE UTERUS. 229 
 
 cavity (recto-uterine or vesico-uterine spaces) ; or lastly, it may 
 pas& directly into the peritoneal cavity, which latter occurrence 
 is always followed by general peritonitis. A uterine abscess 
 may also cause death from metastatic processes ; or the long 
 duration of the purulent secretion may exhaust the patient. 
 
 Acute parenchymatous metritis generally arises from acu.te 
 catarrh of the uterus. 
 
 6. INFLA3mATI0N OF THE MUCOUS MEMBRANE OF THE 
 UTERUS. ENDOMETRITIS. 
 
 Literature: Morgagni, De sedib. et caus. morbor. Ep. XX. 9., 
 XLV. 21. 23, XLVIII. 11. — Raulin, Traite des Aems blanches. 
 1766. — D e u m a n n, Medic, facts and observat. London 1791. Vol. 1. 
 Nr. XII. pag. 108. — J. B. B 1 a t i n, Du Catarrhe uterin on des fleurs 
 blanches. Paris 1801. — D up arc que, Traite theor. et prat, des 
 malad. simpl. et cane, de I'uter. Paris 1832. — Donne Recherch. 
 microscop. sui' la nature du mucus et la matiere des divers ecoulemens 
 des org. genit. urin. chez Thomme et la femme. Paris 1837. — M o n t- 
 g o m e r y. An exposition of the signs and symptoms of pregnancy. 
 London 1837. pg. 147. — Nivet et Blatin, Sitz und Urs. der 
 Blasenpolypen. Arch. gen. Octb. 1838. Schmidts Jahrb. 1839. — 
 Du rand-Fardel, Mem. sur les blennorrhagies des femmes, etc. 
 Journ. des connaissanc. med. chir. 1840. Juli — Septb. — C h u r c h i 1 1 , 
 Diseases of females. London 1844. pg. 102. — C o p 1 a n d, Diction, of 
 pract. Med. II. 1844. — K i w i s c h, Klin. Yortr. Prag. 1845. I. pg. 
 241.— R o b e r t , Bull, de Therap. Novbr. 1846.— R e c a m i e r , Des 
 granulations dans la cavite de I'uterus. Annal de therap. Aoilt 1846. — 
 J. G. Simpson, On the nature of the membrane occasionally ex- 
 pelled in dysmenorrh. Monthly Journ. Septm. 1846. — Oldham, 
 Membranous dysmenorrhcea. London med. Gaz. Decemb. 1846. — W. 
 Tyler Smith. The Pathology and treatm. of Leucorrhoea. Medic. 
 chir.Transact.il. Ser. Vol. 17. 1852.— J. H. Ben net, Practic. 
 Treat, on inflammat. of the uterus 3' Edit. London 1853. — N el at on, 
 Fongosites uterines, etc. Gaz. des hop. 1853. 17. — F o r s t e r, Spec, 
 path. Anat. 1854. pg. 313. — F a u r e, Mem. sur la dysmenorrhee, Gaz. 
 des Hop. 1854. 49. — C h i a r i . Klin, fiir Geburtsk. und Gynoec. 3. 
 Lief. Erlangen 1855. pg. 711. — B e ig e 1 . Ueber die Secaete des Fluor 
 ^ albus. Deutsche Klinik 1855. 19. — K 6 1 1 i k e r und S c a n z o n i , Das 
 Secret der Schleimh. der Vagina und des Cervix. Scanzon. Beitr. II. 
 
230 ACUTE CATARRH 
 
 Bd. 1855. — Vircliow, in Gesammelt. Abhandl. Frankfurt 1856. pg. 
 850 u. 774. — E. Wagner, Zur normal, imd patholog. Anatomie der 
 Yaginalpoition. Ai'cbiv f. physiolog. Heilkunde 1856. 4. — S c a n z o n i. 
 Krankh. der weiblichen Sexualorg. Wien 1857. pag. 151. — Veit. 
 Krankh. des weibl. Geschlechtsorg. Vircliow's spec. Pathol, u. Therap. 
 — 31 a y e r, Yersamml. der Naturf. und Aerzte zu Konigsberg 1860. 
 Monatschr. fdr Geburtsk. Berlin 1860. XVI. 5, und dessen klin. 
 Mittheil. aus dem Gebiet der Gynacol. Berlin 1861.— R o k i t a n s k y, 
 Patholog. Anatom. III. Wien 1861. — H e n n i g, der Katan'h der 
 inner, weibl. Geschlechtsorg. Leipzig 1862. 
 
 The inflammatory processes occurring in the non-gravid 
 uterus are various, and we may distinguish as the chief forms 
 of such processes, catarrhal and croupy inflammation- To 
 this will add the anatomical description of the so-called 
 membrajious dysmenorrhoia^ as I am persuaded that this mor- 
 bid process is more an inflammatory derangement than any 
 other. Catarrhal inflammation of the uterus, as elsewhere, is 
 divided into the acute and clii'onic form. 
 
 7. ACUTE CATARRHAL mPLAlVDIATIOX OF THE UTERUS. 
 
 Acute catarrh (catarrhal endometritis) affects the whole 
 mucous membrane of the uterus, but chiefly that of its body 
 and fundus, whilst that of the cervix is rarely affected. 
 
 In this affection the mucous membrane of the body and 
 fundus uteri may be so intensely injected as to appear dark- 
 red, tumefled and velvet-like ; the utricular glands, however, 
 are not so much elongated as during menstrual fluxion ; the 
 membrane is also so softened that it may readily be removed, 
 or scraped off with the handle of a scalpel. In the higher 
 degrees of this disease small round striated extravasations are 
 seen scattered over the mucous membrane as dark red spots. 
 
 The mucous membrane lining the cervix is more injected 
 than swollen where it covers the turgid follicles ; that of the 
 vaginal portion of the uterus is generally of a darker red. In 
 virgins the os uteri is transformed into a small round depres- 
 
OF THE UTERUS. 231 
 
 sion, owing to the tumefaction of the vaginal portion, the mu- 
 cous follicles of its lips are enlarged, and frequently have small 
 erosions between them, and the papillae of the vaginal portion 
 are visible to the naked eye, especially at the edges of the 
 above-mentioned erosions. 
 
 The whole substance of the uterus generally appears to be 
 increased, and its tissue more vascular and succulent, especially 
 in the layers nearest the mucous membrane. The cervix, 
 beyond increased succulence, hardly exhibits any change, 
 while the vaginal portion is hypersemic, tumefied and oedema- 
 tous, and sometimes of a spongy softness. 
 
 At the outset of the inflammation, the mucous membrane of 
 the body and fundus secretes a thin clear mucus, which, as 
 the inflammation progresses, becomes viscid, thick, and turbid, 
 from the admixture of desquamated epithelium. In regard to 
 the latter, it is necessary to state that, in many cases the glan- 
 dular utricular follicles cast off their entire cellular coverings, 
 which latter are found in the mucus as collapsed casts. Ny- 
 lander and Yirchow have observed a similar expulsion of the 
 whole contents of glands during menstruation, and I have 
 repeatedly seen the same in various tumefactions of the 
 uterine mucous membrane. Finally, the color of the secretion 
 changes to yellow or yellowish, and from the admixture of 
 purulent elements it becomes cream-like. 
 
 It is different with the secretion of the cervical portion ; its 
 glands at the outset of the inflammation imdoubtedly secrete a 
 larger quantity of, and a thicker mucus. Nabothian vesicles 
 are developed, and the fluid contained in them presents the 
 turbid cloudy appearance previously mentioned, finally be- 
 coming whitish or white. If the inflammatory process increases 
 in intensity, the mucus becomes dehquescent, and on open- 
 ing such a vescicle its entire contents flow out like water in 
 which the cloudy turbescence appears in streaks. These ves- 
 icles, however, burst spontaneously, and the hypersecretion of 
 the cervix becomes very fluid and finally purulent. In no 
 
232 ACUTE CATAERH 
 
 other secretion do we so frequently and distinctly observe a 
 so-called cellular halo (cells having no investing membrane). 
 Kolliker and Scanzoni also sometimes found a few fungi with 
 round branches, similar to those seen in fermenting liquids, 
 and isolated vibriones. I must not omit mentioning that the 
 cells of the secretion are often disposed in rows like strings of 
 beads. 
 
 Acute catarrhal endometritis rarely or never occurs before 
 puberty ; after that time, however, it is quite frequent. Du- 
 parcque states that, in females who have sexual intercourse, 
 the mucous membrane of the cervical canal is always the first 
 portion affected, and that from thence it spreads to that lining 
 the body of the uterus. 
 
 As causes of this affection we find mentioned, colds taken 
 during menstruation, excesses in drink and sexual intercourse, 
 infection with gonorrhoeal virus (virulent catarrh), and other 
 diseases, such as typhus, dysentery, cholera, general tubercu- 
 losis and diseases of the heart (metastatic constitutional 
 catarrh, Kiwisch). 
 
 Acute catarrh has a tendency to extend to the oviducts, and 
 undoubtedly from them to the peritoneum ; it also sometimes 
 causes inflammation of the peritoneum independently of any 
 such process in the oviducts. It may extend do^\Tiward to the 
 vagina, unless it has originated there and extended upward to 
 the uterus. Acute parenchymatous metritis, as previously 
 mentioned, may also arise from it. 
 
 Acute catarrh may terminate in resolution, but in the major- 
 ity of cases it passes into the chronic form. 
 
 The so-called hydrorrhoea of pregnant females is considered 
 by some to be catarrh of the gravid uterus, and it seems rea- 
 sonable to suppose that a portion of the uterine mucous mem- 
 brane, unlike the rest, may not be transformed into a decidua, 
 and consequently give rise to increased transudation, from the 
 hypersemia connected with pregnancy. 
 
OF THE UTEEUS. 233 
 
 8. CHRONIC CATARRH OF THE UTERUS. 
 
 Chronic catarrh of the uterus, a condition frequently met 
 with, is characterized by a permanent irritation, often com- 
 bined with considerable hypersecretion of the mucous mem- 
 brane of the organ. 
 
 The mucous membrane of the body and fundus uteri is 
 generally swollen, but not always highly congested, in the dead 
 body ; on the contrary, it is rather pale, and especially when 
 considerably intumesced, of a bluish-gray color. We find 
 scattered throughout it numerous dots or specks of pigment, 
 generally gray or blackish-gray, but rarely of a rusty dark brown 
 color. Its surface is either smooth, or papillary and uneven, 
 the latter being especially the case at the posterior wall, 
 which is sometimes covered with various secretions, and 
 growths resembling granulations. The membrane is also 
 generally softened and more succulent, but can seldom be 
 separated from the uterine walls in as large pieces as in acute 
 catarrh. 
 
 The mucous membrane of the cervix is likewise injected at 
 various points and covered with viscid secretion, Nabothian 
 vesicles are numerously developed and exceedingly distended, 
 and the transverse folds are swollen and sometimes even oede- 
 matous. The vaginal portion is frequently enlarged, its tissue 
 in a state of spongy relaxation, and its external surface affected 
 with papillary hypertrophy. On its inner surface the swollen 
 mucous follicles are prominent, and the external orifice is 
 frequently dilated. In the majority of cases the latter is sur- 
 rounded with excoriations a.nd even granulating ulcers. 
 
 The secretion in some cases of chronic uterine catarrh is 
 often very great (blennorrhoea), but in others it is slight ; there 
 is generally, however, a marked hypersecretion. The mucus 
 secreted is turbid or even purulent to various degrees, but 
 rarely mixed with blood (excepting shortly before or after 
 menstruation). Scanzoni. 
 20 
 
234 CHRONIC CATAERH 
 
 The uterine substance is either affected with a diffuse growth 
 of connective tissue, in consequence of which it becomes denser 
 and firmer, or it is flaccid and markedly atrophied. In the 
 latter case, the cavity of the organ is often much distended, 
 especially in those cases in which the cervical canal is occluded 
 by the well-known glassy mucus. 
 
 When chronic catarrh is of long duration the mucous mem- 
 brane, especially that of the body and fundus, undergoes im- 
 portant anatomical changes ; its glands, either from constric- 
 tion or atrophy of their superior portions, frequently change 
 into small cysts, or are cast off, which latter occurrence, espe- 
 cially when the cavity of the uterus is distended, gives the 
 mucous membrane a net-like appearance. 
 
 The ciliary epithelium which was cast off at the outset of 
 the disease, has been replaced by cylindrical epithelium ; this 
 also is finally cast Qi^^2.\iA polymoiyhous lining cells, which can 
 hardly be called true basement epithelium, occupy its place. 
 In some cases we also notice a desquamation of the epithelium, 
 erosions, and small smooth-lined depressions, evidently formed 
 by the rupture of small cysts. It is probably owing to this 
 development and rupture of cysts that the delicate ridge-like 
 elevations are formed, especially at the internal orifice, which 
 give rise to adhesions. 
 
 While, as above mentioned, the epithelium is transformed, 
 and the glands become atrophied, the mucous membrane also 
 becomes thin, and is finally replaced by a delicate layer of 
 connective tissue, which is covered by the polymorphous cells 
 mentioned. More rarely we find , the mucous membrane 
 transformed into a callous stratum varying in thickness and 
 attached to the submucous connective tissue, and in this stra- 
 tum we find small cysts which are the remains of degen- 
 erated glands (Rokitansky). 
 
 More frequently the dense submucous stratum, especially 
 at the borders uf the internal orifico, becomes atrophied, and 
 Nabothian vesicles are developed in it, thus causing a pre- 
 disposition to flexion of the uterus. 
 
OF THE UTERUS. 235 
 
 The consequences of chronic uterine catarrh have already 
 been described ; they are : circumscribed proliferations of the 
 mucous membrane, glandular and cystic polypi, .and fibrous 
 polypi when the submucous tissue has a tendency to prolif- 
 erate ; perhaps also fibroid tumours will be developed if 
 the formative-action is sufiiciently increased. After the de- 
 velopment of such growths, their presence seems to occasion a 
 constant irritation, thereby favoring the continuance of the 
 chronic catarrh. Hydrometra and hsematometra may also be 
 developed in consequence of adhesions. 
 
 Chronic uterine catarrh generally proceeds from acute 
 catarrh, and sometimes occurs in consequence of the puer- 
 peral state. It is also readily developed in cachectic women, 
 and lastly, may be caused by the virus of gonorrhoea. In 
 young women and prostitutes it is said to occur as a conse- 
 quence of masturbation. It is said to extend down to the 
 vagina and up to the oviducts, and in the latter case especially, 
 it leads to serious consequences; sometimes, however, it 
 originates in the vagina and spreads by continuity. 
 
 Uterine pathologists assert that chronic- uterine catarrh is 
 generally associated with derangements of menstruation, and 
 that conception is not impossible, but rarely occurs when it 
 exists. It is an interesting observation that females whp have 
 sufifered for a long time from blennorrhoea have a predisposi- 
 tion to the occurrence of placenta proevia. 
 
 The frequency with which chronic catarrhal endometritis 
 is complicated with chlorosis, scrofula, tuberculosis and diseases 
 of the heart, is a fact universally admitted, and the profuse 
 secretion and purulent discharge, contribute not a little to the 
 complete exhaustion of the patieat. In scrofulous and tuber- 
 culous girls, chronic uterine catarrh generally sets in at the 
 period of puberty, and is combined with amennorrhcea. In 
 such cases, the various proliferations of the mucous mem- 
 brane rarely occur as a sequel to the catarrh, but the latter 
 sometimes precedes tuberculosis of the uterus. 
 
236 CROUPY INFLAMMATIOIT 
 
 9. CROUPY IXFLA3DIATI0N OF THE UTEKUS. 
 
 Cronpy inflammation rarely affects the uterine mucous 
 membrane. Sometimes in the vicinity of ulcerating carcino- 
 mata, a thin, fibrinous, pale-yellowish film is seen upon the 
 softened mucous membrane, which is covered with small 
 hemorrhagic spots. Croupy endometritis occurs as a second- 
 ary affection in the com'se of typhus fever, cholera, eruptive 
 fevers (scarlatina and small-pox), and especially with diphther- 
 itic inflammation of the vagina (Eokitansky). 
 
 As an appendix to the inflammatory affections of the uterus, 
 I mention the so-called clysraenorrhoic meinbrane. 
 
 Morgagni, Madame Lachapelle, Boivin and Diiges had 
 already observed in dysmenorrhoea, the expulsion of peculiar 
 membranes from the uterus, the striking resemblance of 
 which to the inemhrana decidua had been remarked by P. 
 Frank. Desormeaux, Churchill, Montgomery, Chereau and 
 others, considered these membranes as croupy exudations, 
 until their true natm^e was demonstrated by Simpson, Oldliam, 
 and Yirchow. 
 
 The membrane, which is generally covered with coagula 
 when expelled in its integrity, is of a flattened and triangular 
 shape, with two long borders and a short one ; the posterior 
 and anterior layers being united at their margins, the mem- 
 brane consequently forms a sac. At its angles this triangular 
 sac is open, and the borders of these openings have a ragged 
 appearance. Its external surface is rough and felt-hke, and 
 perforated by numerous openings, some of which are larger 
 than the puncture of a needle, and are also visible on the inner 
 surface, giving the walls of the sac a sieve-like appearance. 
 Its inner surface is smooth and of uniformly soft feeling. 
 
 It is now clearly demonstrated that this membrane is nothing 
 more than the exfoliation of the whole mucous membrane of 
 
OF THE UTEEUS. 237 
 
 the uterus during menstrual intumescence, for it is easy to 
 detect in it, witli the aid of the microscope, the characteris- 
 tics of that membrane. Simpson recognized the above- 
 mentioned perforations in the membrane as correspond- 
 ing with the utricuhir gLands, and found them to consist 
 chiefly of nucleated cells ; he therefore concluded that this 
 membrane was nothing more than exfoliated hypertrophied 
 mucous membrane. Yirchow, even with the naked eye, 
 noticed large blood vessels in these membranes. 
 
 Consequently, in this affection, the uterine mucous membrane 
 is cast off as far as its matrix, and a sort of decidua is formed in 
 consequence of a condition which Yirchow calls "pregnancy on 
 a small scale," and for which membranes he therefore proposed 
 the name of menstrual decidua. According to Oldham, this 
 membrane is formed between the menstrual periods, the pro- 
 cess commencing with considerable congestion of the ovaries, 
 which extends to the posterior w^all of the uterus, and fre- 
 quently occasions retroversion of the latter. 
 
 I have already stated that menstrual intumescence of the 
 uterus differs very little from that accompanying acute 
 catarrh. If therefore we are constrained to consider the pro- 
 cess producing the menstrual decidua as an excess of menstAial 
 phenomena, especially in the mucous membrane of the uterus, 
 it follows, that those pathologists were not far from the truth, 
 who described such cases as endometritis. 
 
 Finally, I must also mention those cases which Rokitansky 
 suspects to be abortion during the first days of pregnancy 
 although this connection is not clearly proven. 
 
 Membranous coagula, consisting of fibrin formed in the 
 cavity of the uterus from extravasations, and moulded to the 
 shape of the uterine cavity, are sometimes mistaken for men- 
 strual decidua. Of course they are entirely destitute of organi- 
 zation, and not always of the peculiar sieve-like appearance. 
 
238 ULCERATIONS 
 
 10. ULCERATIOXS OF THE UTERUS. 
 
 Literature: C. M. Clarke, Obserrat. on the diseases of femal. Lon- 
 don 1821. 11. pg. 185. Taf. 3. — R i c o rd , Gaz. Med. de Paris 1833. 
 Nr. 38. — Heyfelder, Sanit. Ber, iib. d. Fiirstentli. Sigmaringen 
 1833-34., Schmidts Jahrb. 1835. YIII. — Lisfr anc, Gaz. med. de 
 Paris 1834. Xr. 10 Mars. — Gib er t, des ulcerations du col de Tutenis. 
 etc. Rev. med. 1838. Decbr. — Cruveilhier, Anat. patholog. Livr. 
 94. pi. 2., L. 37. pi. 2. — tt e r b urg. Lettres sur les ulc^rat. de la 
 matrice. Paris 1839. — Velpeau, Sur les granulations du col de 
 rutaras. Gaz. des Hopit. 1844. 1. 9. — Recamier, Jomn. de Chirurgie 
 1843. — Lever, Practic. treatise on organic diseases of the uterus. 
 London 1843. pg. 145. — Kiwisch, Klinisch. Vortr. Prag 1845. I pg. 
 466. — E. Kennedy, Dublin quarterly Joum. 1847. Febr. — 
 Robert, Des affect, granul. ulcer et carcinom. de I'uterus. These. 
 Paris 1848. — Ashwell, A practic. treatise on the diseas. peculiar 
 to women. London 1848. Deutsch v. Holder, pg. 408. — Simpson, 
 Lifiammat. eruptions upon the mucous membr. of the cervix uteri. 
 Monthly Joum. 1S50. April 1851. Juli. — West, Ueher die patholog. 
 Bedeut. der Ulcerat. des Muttermundes. London 1854. Mtgeth. von 
 H e c k e r, Monatschr. f. Gebmtsk. etc. Berlin 1854. lY. 2. — F 6 rs- 
 ter, Spec. Patholog. Anat. 1854. pg. 317. — Simpson, Ob- 
 stetric mem, and contrib, Edinburgh. 1855. Vol. I. — Scanzoni, 
 Ki'ankh. d. weibl. Sexual. Wein 1857. pg. 171. — Meyer, Vers. d. 
 Naturf. und Aerzte zu Konigsberg 1860. Monatschr. f. Gebmtsk. etc. 
 Berlin 1860, XYI. 5. — Rokitansky, Path. Anatom. HI. pg. 
 478. 1861. 
 
 Ulcerations of the uterus, with, the exception of those re- 
 sulting from abscesses, tuberculosis and carcinoma, are limited 
 to the vaginal portion, and, in very rare cases, only extend to 
 the lower portion of the cervical canal. 
 
 Uterine pathologists make a distinction between the simple 
 erosion, the simple granulating, the fungous granulating, the 
 varicose, the follicular, the phagedenic, and the srphilitic 
 ulcer, and the more frequent observation of such in the living 
 than in the dead body, does not authorize pathological anato- 
 mists to alter this classification. 
 
 An erosion consists simply of a loss of the epithehum 
 covering the vaginal portion. The denuded surface is very 
 
OF THE UTEEUS. 239 
 
 moist, its borders generally well defined, its form circular, and 
 its size varying ; its centre is smooth, intensely reddened, and 
 moist, and marked with small dark-red spots. Upon a closer 
 examination you perceive that the latter correspond with the 
 mucous papillae, the hypersemic extremities of the blood vessels 
 of which form these dark-red discolorations. Single erosions 
 frequently become confluent, in consequence of which their cir- 
 cular form is altered to a sinuous, irregular one, and frequently 
 they form a circle around the external orifice. The borders of 
 these erosions are either of a rose-color, nearly like normal 
 tissue, or are altered by the coexistence of acute catarrh. 
 When combined with luxuriant epithelial growth, their cir- 
 cumference is pale, and even milky white, as for instance, 
 with coexisting prolapsus of the uterus. 
 
 Erosions are generally accompanied with acute or chronic 
 catarrh of the uterus or vagina, and are caused either by this 
 or other forms of intumescence of the mucous membrane. 
 Syphilitic erosions have also been described ; but I agree 
 with Scanzoni, that they have no distinguishing character- 
 istics from the non-syphilitic, and that erosions occurring on 
 the uteri of syphilitic women, must simply be attributed to 
 catarrh, which is rarely absent. I would further state that the 
 rarity of true syphilitic ulceration of the vaginal portion of the 
 uterus seems to contradict the assumption of syphilitic erosions 
 in this locality. 
 
 Strictly speaking, an erosion is the first stage of ulceration, 
 and from an examination of it, we will be unable to say 
 whether it will continue as such, or whether it will pass into 
 one or other of the forms of ulceration. Erosions have also 
 been described under the name of jphlyctmnoe of the os (Lis- 
 franc). 
 
 Scanzoni likewise observed the so-called aphthous form of 
 erosions of the external orifice, and considers them identical 
 with the herpetic forms described by Lisfranc, Robert, and 
 others. In these latter forms the epithehum of the vaginal 
 
240 ULCEEATIONS 
 
 portion appears elevated in small vesicles, whicli finally burst- 
 ing, leave an eroded surface. From an anatomical point of 
 view, two forms of erosions may be distinguished ; either the 
 epithelium of the vaginal portion is softened at certain points 
 by the acrid catarrhal secretion, or an exudation within the 
 tissue of the vaginal portion raises the epithelial covering in 
 the form of small vesicles, or large ones from confluence. The 
 latter form would seem to represent the herpetic eruptions. 
 The form described by Scanzoni does not bear sufficient resem- 
 blance to diphtheria to authorize us to use the term aphthous 
 erosions. 
 
 The herpetic eruption frequently occurs in consequence of 
 dyscrasia. The bases of the erosions are covered with 
 a thin layer of the germinating stratum of the epithelium, and 
 secrete a thin transparent fluid. 
 
 Here it is well to mention the observations of Joulin (Gaz. 
 des Hop. 1861. No. 40.) and C. Braim, (Med. Jahrbiicher, 
 Wien. 1861), relating to pemjMgus of the cervix uteri. The 
 former met witli circular bullae with regular margins, which 
 appeared hke large drops of thick viscid mucus hanging from 
 the cervix, and generally surrounded at their bases by a red 
 circle. C. Braun observed in a pregnant female, aftected with 
 hypertrophy of the papillary body of the vagina, numerous 
 elastic bullae as large as peas, which covered the whole vag- 
 inal portion and the posterior fornix. 
 
 The ulcerations proper of the vaginal portion originate from 
 erosions. The loss of substance in an ulceration is character- 
 ized by its greater depression, as also by profuse purulent secre- 
 tion from its surface and an early tendency to granulate. 
 
 Granulations of the vaginal portion are distinguished by 
 their vascularity, and their sometimes excessive luxuriance, in 
 consequence of which they frequently form large tumours. 
 They are generally developed from the papillae of the vaginal 
 portion, and grow either from isolated portions of the border of 
 the ulcer, or from its base, in the form of soft, strawberry or 
 
OF THE UTERUS. 241 
 
 raspberry-like, dark-red tumours, which bleed excessively on 
 the slightest touch. Yelpeau made a striking comparison be- 
 tween these granulations and those of granular conjunctivitis. 
 A more excessive development of these granulations character- 
 izes the so-caWed fungo2/.s ulcer. Granulating ulcers rarely exist 
 independently, but are generally combined with chronic uter- 
 ine affections. When present, the external orifice is generally 
 patulous, and its lips have a soft, spongy sensation. Velpeau 
 states, that he found them in two-thirds of the females affected 
 with leucorrhoea. They are of rare occurrence before puberty, 
 and not less so in aged females, but are most frequent between 
 the ages of eighteen and thirty-six years. They are said to occur 
 frequently in scrofulous individuals. Sometimes they extend 
 into the cervical canal. 
 
 Lee states that he never saw an ulceration of the os, either 
 in a living or dead woman, that was not due to some constitu- 
 tional disease. 
 
 Robert asserts that granulations are not always developed 
 from ulcerated surfaces, but may arise from direct prolifera- 
 tion of the papillae of the mucous membrane of the vaginal 
 portion. 
 
 When exuberant granulations attain a considerable develop- 
 ment, the shape of the mass is changed by the pressure of the 
 walls of the vagina. Kennedy called ulcers covered with such 
 granulations coch^s-comh ulcers, and the more simple, small, 
 and readily-bleeding ones, bleeding ulcers. 
 
 Under the name of ulcerated fissures or linear ulcers, we 
 find described those frequent, extensive, and deeply-penetrat- 
 ing ulcerations which result from lacerations occurring during 
 labor. 
 
 Frequently the mucous folhcles of the vaginal portion be- 
 come swollen, giving a granular appearance to its mucous 
 membrane, which circumstance has probably induced Chomel 
 to regard granulations of the vaginal portion as diseased or 
 hypertrophied follicles. 
 21 
 
242 ULCEEATIOITS 
 
 Many gynecologists also make varicose ulcers another dis- 
 tinct class. Upon the livid, blue mucous membrane of the 
 swollen vaginal portion, numerous and distinct varicose venous 
 plexuses are said to be visible ; the mucous membrane covering 
 them becoming softened, gives rise to erosions, the bases 
 of which appear bluish-red, and beneath which the underlying 
 venous plexuses may be seen. Scanzoni observed in such an 
 erosion a vein as large as the quill of a raven's feather, and 
 from which he evacuted two ounces of blood. Recamier 
 observed similar destructions of tissue, with granulations grow- 
 ing from them which he compared to hsemorrhoidal tumours. 
 
 In scorbutic females, the borders of such ulcerations are of a 
 bluish-gray color, their bases dark bluish-red, and the tissue 
 around them ecchymosed. 
 
 Jfollicular ulceration of the vaginal portion I have never 
 observed in the dead body. It occurs in consequence of the 
 formation of pus in a follicle, which swells, finally points, and 
 bursts. Follicular ulcers are circular, varying in size from a 
 hemp-seed to a pea, and have smooth, clear bases. They are 
 said to heal readily. 
 
 T\\Q phagedenic ulcer of Clarke, or corroding ulcer of the os 
 uteri, seems to be an extremely rare form of ulceration, and 
 was first described by Clarke, Lever, and Baillie. All German 
 gynecologists incline toward the opinion, that under this name 
 ulcerative carcinomata were described by English authors. But 
 Rokitansky and Forster observed such ulcers which undoubt- 
 edly had no cancerous origin, which fact is sufiicient to prove 
 the existence of such an ulcer. It generally commences at the 
 vaginal portion, penetrating deeper and deeper into its sub- 
 stance, which is always afiected with profuse proliferation of 
 connective tissue. The form of the ulcer is sinuous, irregular 
 and angular, its base villous, and of a greenish-black color, 
 and its borders indurated. At the same time there is a gelat- 
 inous proliferation of connective tissue, the vaginal portion, 
 and finally the cervix, being completely destroyed by it. Ro- 
 
OF THE UTERUS. 243 
 
 kitansky calls attention to the resemblance between this 
 ulcer and ulcerating lupus, and Forster declares the process to 
 be ulceration, with gangreous destruction of tissue. In some 
 cases the bladder and rectum have become involved in the 
 ulcerative destruction. This ulcer bleeds very readily, 
 secretes a thin, nauseous, ichorous fluid, mixed with gangren- 
 ous tissue, and terminates fatally from exhaustion. No cases of 
 this kind have come under my notice, and those described by 
 English authors as corroding ulcers are not quite so well 
 authenticated as those mentioned by our German anatomists. 
 This ulcer is said to occur, without known cause, only in 
 advanced age. 
 
 The syphilitic ulcer, or chancre of the vaginal portion, is 
 rarely met with, and is distinguished by its circular or round- 
 ish form, its sharp, well-defined border, and its exquisite lar~ 
 dacious base. Ricord found it more frequently on the anterior 
 than posterior lip of the vaginal portion. In rare cases 
 the ulcer extends to the mucous membrane of the cervix, 
 but generally it is limited to the vaginal portion. Arising as 
 simple erosions, they may become deep ulcers, perforating even 
 the bladder and rectum (Forster). Usually such a chancre is 
 combined with intense blennorrhcea, or similar affections of 
 the vagina. The healing of the ulcer commences by the for- 
 mation of a cicatrix, with considerable contraction. 
 
 Kiwisch and Forster also mention syphilitic erosions as 
 the primary stage of syphilitic ulcers. If common erosions 
 in these parts heal without cicatrization, as in other parts of 
 the body (and syphilitic ulcers never heal without it), then 
 the small radiating cicatrices, which are not unfrequently seen 
 upon the. vaginal portion, may perhaps be referred to healed 
 syphilitic ulcers. 
 
 Cicatrices resulting from the healing of syphilitic ulcers 
 in the cervix, may lead to stenosis and even atresia, of its canal, 
 and Forster thinks, that at the internal orifice they may produce 
 slight flexion of the uterus. 
 
244 WOUI^DS AND EUPTUEE8 
 
 WOUNDS AND RUPTURES OF THE UTERUS. 
 
 Literature: Behling, Casus rupti in partu uteri. Altdorfii 1736. — 
 Q u e 1 1 m a 1 z , Dissert, de uteri ruptura. Lipsiae 1756. — L i n d , 
 Diss, de ruptura uteri. Erfurt 1772. — Steidele, Sammlung merliw. 
 Beobacht. von der in der Geburt. zerriss. Gebai-mutter. Wien 1774-, und 
 Nachtrag 1775. — Douglas, Observ. on a ruptured uterus. London 
 1785. By the same author: On the rupture of the gravid uterus. London 
 1789. — Canestrini, Histor. de uter. dupi. alterutro quarto 
 gravid, mens. rupt. August. Yindelicor. 1788. — M. Baillie, Anat. 
 d. krankh. Baues. etc. A. d. Engl. v. Sommering, Berlin 1794. — 
 Ch. Khite, Mem. of the soc. of Lond. Yol. IV. XX. 1795.— 
 V o i g t e 1 , path. Anatom. Halle 1805. HL pg. 489. — T h . Fl a 1 1 , 
 London med. Repository. Vol. VHl. 1817. Mai. — W. P. D e w e e s, 
 Philadelphia Joum. of the medic, and physic, science. 1820. Vol. I. Nr. 
 1. — Ramsbotha m, Pract. Observ. in Midwif. Part I. London 
 1821 .—E i s e 1 1 , Hist. rupt. uteri. Prag 1829.— R . C o 1 1 i n s , A pract. 
 treat, on Midwifery etc. London 1835. — Bluff, Die Zerreissung des 
 Uterus und der Scheide wahrend der SchTvangerschaft, etc. El. v. Sie- 
 bold's Journal Bd. XV. 2. 1835. —Murphy, Dublin Journ. 1835. 
 May. — Duparcque, Hist, complet. des ruptures et des dechirures 
 de I'utlrus du vagin et du perinee. Oeuvr. coronn. Paris 1836. — Cook, 
 Case of loss, etc. London 1836. — K e nn e d y , Ueber die Ablosung des 
 Muttermundes bei der Geburt. Froriep's Notiz. 1839. 18. XL Bd. — D . 
 L a n g h e , Annal. de med. Beige. 1836. Fevr. — R. F. P o w e r , 
 Ueber Ablosung der Vaginalport. Dublin Journ. 1839. Septbr. — F e 1 d - 
 m a n n , Preuss. Ver. Zeitg. 1844. Nr. 10. — J ames Y. Simpson, 
 Edinburgh Journ. 1844. Octob. — R e n d e 1 1, Medic. Times 1844. 
 Nr. 241. — K i w i s c h , klin. Yortr. etc. 1 pag. 201. R o b i qu e t, 
 Heilung eines Risses, etc. Annal. et. Bull, de la societ. de med. de 
 Gand. April 1846. — W. L a n g e, Anat. Befund nach einem. geheil- 
 ten Kaiserschnitte, etc. Prager Viertelj.-Schrift. 1846. 4. pg 126. 
 
 — Trask, American Journ. of med. science. Jan. April. 1848. — 
 R o o k e , London med. Joum. 1850. Febr. — O. Prieger, Rhein. 
 Monatschr. 1850. Mai. — A r n e t h, Die geburstshilfl. Praxis, etc. Wien 
 1851-L e w y , Circulare Abstossung des untersten Segmentes des Uterus. 
 Schmidt's Jahrb. 1852. 12. — Grenser, Lehrb. der Geburtsh. Mainz 
 1854. pag. 631. Forster, Spec, pathol. Anatom. 1854. pg. 302. 
 
 — C. Bjaun, Lehrb. der Geburtsh. Wien 1857. pag. 385. — L. 
 L e h m a n n , Beitr. zur Lehre Uber die Rupt. des Uterus und der Vag. 
 Monatschr. f. Geburtsh. Berlin 1858. XH. 6. Aldridge, Lancet L 
 
OF THE UTERUS. 245 
 
 28. Juni 1 859. — V i r c li o w , Monatschr. f. Geburtsk. etc. Berlin 
 1860. Bd. XV. pg. 176. — Rokitansky, Path. Anatom. III. pg. 
 476. 1861. — Klob, Anat. Studien liber Perimetritis, Wittelshofer 
 med. Wochenscbrift. Wien. 1862. Nr. 48. 49. 
 
 Ruptures of the uterus may occur eitlier independently of, 
 or during pregnancy, but most frequently liapj)en during labor. 
 The non-gravid uterus can only be ruptured when its cavity 
 has been considerably distended, either by the accumulation of 
 different fluids, or by adventitious growths without increased 
 hypertrophy of its walls. Rupture of such a uterus will 
 most likely occur when the accumulated liquids or distend- 
 ing growths rapidly increase. If the uterine cavity con- 
 tain ichorous fluid or pus, its inner surface is generally ulcer- 
 ated, and rupture can therefore more readily occur. The 
 same applies to ulcerative carcinomata, which may produce 
 loss of substance or degeneration of the uterine walls. 
 
 Fibroid tumours, by their considerable growth in a very 
 short period, frequently cause rupture. Kiwisch, even in the 
 presence of small fibroid tumours, observed partial fissures 
 and penetrating ulcerations of the uterus. 
 
 Perforation of the uterus by abscesses has already been men- 
 tioned. 
 
 Without distension of the cavity of the uterus, and a certain 
 tension of its walls, even violent mechanical concussions will 
 hardly produce rupture. In women who have fallen from a 
 considerable height, and whose pelves were completely frac- 
 tured, I have never seen rupture of the uterus, even when the 
 latter was considerably enlarged by menstrual congestion. 
 But if its cavity is distended, and its walls stretched, a 
 blow on the abdomen, a fall, or even violent bodily exertion, 
 will often cause rupture. 
 
 The natural consequence of rupture of the non-gravid uterus 
 is, more or less considerable, or even fatal haemorrhage into 
 the peritoneal cavit3^ If death does not take place directly 
 from this cause, any fluid which may have been in the uterus 
 
246 WOUNDS AKD EUPTITEES 
 
 passes into tlie peritoneal cavity, and if of an irritating charac- 
 ter (decomposing blood, pus, or ichor), general peritonitis may 
 ensue, unless the fluid is shut off from the peritoneal cavity by 
 adhesions between neighboring organs, or, as happens in rare 
 cases, if the rupture takes place into the adherent bladder. 
 
 In the most favorable cases, however, metritis and perime- 
 tritis will commence at the point of rupture, and ultimately 
 cause its cicatrization. 
 
 Ruptures of the pregnant uterus are of much more impor- 
 tance. They are liable to occur, as it appears, during any 
 month of pregnancy, although Duparcque never observed a 
 case before the second month. They certainly happen less 
 frequently during the first half of pregnancy. The most 
 common causes of rupture of the pregnant uterus are defi- 
 ciency of substance from arrested development, and displace- 
 ments (retroflexion). 
 
 The so-called interstitial pregnancies generally terminate 
 fatally before the fourth month, from rupture of the uterus. 
 Among the other causes of rupture during pregnancy, we must 
 mention affections of the tissue of the uterus, causing par- 
 tial thinning of its walls, also fibroid tumours and carcinoma. 
 
 During pregnancy, especially at its commencement, only 
 the body and fundus of the uterus are distended, the cervix 
 participating in the enlargement at a later period. If the 
 stretched uterine walls then contract violently, rupture will 
 more readily occur, as the cervix remains contracted and 
 inelastic (Kiwisch). Finally, the mechanical causes of rup- 
 ture must be mentioned, which will produce the same effect as 
 if the non-gravid uterus was distended, as previously men- 
 tioned. 
 
 Rupture of the uterus always occurs at its body or fundus, 
 sometimes near the internal orifice ; in interstitial pregnancy, 
 near the orifices of the oviducts. Sometimes the seat of the 
 placenta is the point of rupture. 
 
 Rupture of the uterus is either complete or incomplete. In 
 
OF THE UTERUS. 247 
 
 complete rupture the foetus may escape into the peritoneal 
 cavity without rupture of its investing membranes. If death 
 does not ensue from profuse haemorrhage, peritonitis, excited 
 by the death of the foetus, may supervene, or a fatal termina- 
 tion may take place from metritis or metro-lymphangitis, 
 commencing at the place of rupture. 
 
 In very rare cases the expelled foetus is transformed into a 
 lithoj)(jedion, the fissure in the uterus being closed by cicatri- 
 zation. 
 
 The most frequent ruptures of the uterus are those happen- 
 ing during labor. They occur either spontaneously or me- 
 chanically. The causes of spontaneous ruptures lie in the 
 uterus itself, or in its vicinity, especially in the pelvis, or they 
 are due to anomalies of the foetus. 
 
 To the former belong strictures and rigidity of the external 
 orifice, atresia, tumours of the vaginal portion, and inequal- 
 ity of contractions from a yielding of the thinned uterine 
 walls. The latter is chiefly occasioned by the pressure of 
 foetal parts during labors with unfavorable presentations 
 (Kiwisch). 
 
 Relaxation of the uterus, in consequence of previous deliv- 
 eries, would also seem to be a cause of rupture. However, 
 we must also mention circumscribed metritis and fatty degen- 
 eration of the muscular tissue of the uterus. In several cases 
 of spontaneous rupture I have observed fatty degeneration of 
 the muscular tissue at the point of rupture. This was also 
 observed by Lehmann in his case. Another remarkable 
 circumstance in some cases of rupture is an extraordinary 
 thickness of the uterine walk, or hyperplasia of the uterus 
 (C. Braim), causing extreme disproportion between the body, 
 fundus and cervix. Fibroid tumours involving part of 
 the uterine walls and thereby causing unequal contractions, 
 and carcinomata, which from pressure, render the uterine tis- 
 sue more friable, or cause a direct loss of substance, may also 
 cause rupture during the contractions of labor. In some very 
 
248 WOUNDS AXD RUPTUEES 
 
 rare cases rupture was observed to take place after a successful 
 Caesarian operation, in consequence of rupture of the cicatrix. 
 Cases are also known in which rupture has occurred laterally to 
 the cicatrix, owing, probably, to the age of the latter. Fi- 
 nally, I must mention proliferation of connective tissue in the 
 external layers of the uterus, which, according to my experi- 
 ence, occui's as a sequel to perimetritis, and is frequently 
 noticed in ruptm-ed uteri, although I am unable to explain the 
 effect of this condition in producing rupture. [This subject 
 will be entered into more minutely under the head of Perdie- 
 
 TEITIS.] 
 
 In the second class of causes (mechanical) of rupture, we place 
 tumours, which arising from the appendages of the uterus or 
 from the pelvis, narrow the pelvic outlet, and consequently 
 cause excessive but ineffectual uterine contractions. The 
 pelvis itself may occasion rupture, owing to some anomaly 
 of its shape. In general, the narrow pelvis comes under this 
 head ; but especially an unusual prominence of the promontory 
 of the sacrum, and of the linea ileo-pectinea (Mm'phy, Burns) 
 are considered causes of rupture. By excessive prominence 
 of the promontory, the uterus may be perforated by being 
 pressed upon it, especially if the margin of the fifth lumbar 
 vertebra and the base of the sacrum form an angular promi- 
 nence, as is frequently the case in greatly inclined pelves. 
 
 With regard to the foetus, its size, especially that of its head 
 (consequently hydrocephalus), has been considered a cause of 
 uterine rupture. In regard to this I must mention the fact 
 observed by obstetricians, that ruptures of the uterus occur 
 much more frequently during the birth of boys than of girls. 
 vSimpson, in thirty-four cases of spontaneous rupture of the 
 uterus, notes twenty-three births of boys, and only eleven of 
 girls ; Collins, in fifty-four cases, thu-ty-eight of boys ; and 
 Burns counts three-fourths of the cases of uterine rupture as 
 happening during the birth of boys. Further, it is known 
 that spontaneous rupture of the uterus is more frequent in 
 
OF THE UTEKUS. 
 
 249 
 
 multiparae than primiparse. In twenty-eiglit cases observed by 
 myself, only live were in primiparse ; in one, rupture occurred at 
 the nineteenth birth, in two at the tenth, and in two others at 
 the ninth. Trask (American Journal of Medical Science, 1848) 
 computed three hundred cases, which showed that age was of 
 considerable importance. 
 
 There were under 20 years 3 cases. 
 " from 20— 25 " 14 
 " " 25-30 " 34 
 " " 30—35 " 36 
 " 35—40 " 37 
 « " 40—45 " 15 
 
 As regards the number of pregnancies : 
 
 In 1st pregnancies there were 24 cases of rupture. 
 
 2d 
 
 3d 
 
 4th 
 
 5th 
 
 6th 
 
 7th 
 
 8th 
 
 9th 
 
 10th 
 
 11th 
 
 12th 
 
 13th 
 
 18 
 
 17 
 
 21 
 
 18 
 
 16 
 
 9 
 
 5 
 
 5 
 
 9 
 
 8 
 
 3 
 
 Ruptures of the uterus are divided into penetrating or com^ 
 jplete^ and non-penetrating or incomjplete. 
 
 In almost every labor, however normal, the vaginal portion 
 is fissured in one or more places ; but these fissures are not class- 
 ed with pathological ruptures. A fissure of the vaginal por- 
 tion sometimes extends to a varying height into the cervix, even 
 as far as the internal orifice, and involves the uterine tissue in 
 varying degrees. The upper end of a fissure rarely extends 
 deeper than the innermost layer of the cervix, while inferiorly 
 the entire thickness of the vaginal portion is ruptured, hence 
 the triangular form of the fissure, that is, the lower edges of 
 the fissure are much more widely separated than the upper, 
 22 
 
250 Vv^ouNDs a:n^d euptures 
 
 all the transverse fibres of the cervix at the former point 
 being completely divided. 
 
 Frequently a few fibres of uterine tissue remain intact at the 
 upper portion of the fissure, extending from one edge to the 
 other, and bridging across it. The rupture evidently begins 
 within and extends outward, and the inner layers of tissue are 
 general^ ruptured higher up than the outer ones. 
 
 It is more rare for such ruptures to extend above the internal 
 orifice into the body of the uterus, and I can remember only 
 one case in which a fissure extended along the posterior wall 
 of the uterus nearly as far as the orifice of the right oviduct. 
 On the other hand, those fissures previously mentioned, to 
 which the pregnant uterus is liable, occur exactly in its 
 body and fundus. In extremely rare cases, a transverse fissure 
 occurs, or the latter is combined with a longitudinal one, 
 thus forming a kind of fiap. I have met witli two such cases in 
 which the ruptures extended longitudinally through the whole 
 cervix, uniting with transverse fissures at the upper portion of 
 the latter, so as to form an angular rupture. Those cases are 
 remarkable in which the body of the uterus is completely sepa 
 rated from the cervix, or the entire organ from the vagina. 
 Cook describes such an occurrence in an inverted uterus. 
 
 Blufi" states that fissures occur more frequently on the left 
 side of the uterus (whilst Stein found the contrary), the head 
 of the foetus presenting more frequently toward the left than 
 the right. In cases known to myself, it was not apparent that 
 ruptures were more frequent on one side than on the other. 
 
 Under peculiarly unfavorable circumstances, the fissure 
 extends downward, and is combined with various, and even 
 considerable ruptures of the vagina. On the other hand, the 
 bladder, or even the rectum, may be involved in the rupture. 
 Still, I believe both the latter accidents only occur when the 
 uterus is forcibly ruptured, as in a case I remember testifying 
 to before the courts. 
 
 In regard to complete ruptures of uterine tissue, it must be 
 
OF THE UTERUS. 251 
 
 remarked, that sometimes they extend to the peritoneum 
 without tearing through it, which circumstance is accountable 
 to the great elasticity of that membrane. Not unfrequently, 
 however, I found the peritoneum in a peculiar condition from 
 traction, blood oozing from a number of small openings which 
 had been formed here and there, in consequence of a separa- 
 tion of its fibres. Considering the very great stretching which 
 the sub-peritoneal tissue undergoes during pregnancy, it is 
 easily conceived that it will possess so little resistancy that an 
 extravasation may undermine or separate the peritoneum to a 
 great distance from the point of rupture, even to the ihac 
 bone, and further up along the vertebral column. The same 
 may be said of the submucous connective tissue of the pelvic 
 cavity, which is frequently found to be dark-red from extra- 
 vasated blood, and considerably relaxed. The extravasation 
 may even extend downward to the labia, causing a bluish-red 
 tumefaction. 
 
 We must make a distinction between ruptures and contu- 
 sions of the uterus. Contusions are apt to occur when promi- 
 nent hard foetal parts press against projecting portions of the 
 pelvis, thereby compressing the intermediate tissue. In a nor- 
 mal pelvis these points are chiefly the symphysis pubis, and 
 the promontory of the sacrum, in the triangular pelvis, the 
 horizontal rami of the pubis, and exostoses which may happen 
 to exist. With regard to the symphysis, Professor Ki-assnig 
 called my attention to the frequent posterior prominence of 
 the cartilage of the symphysis, which fact deserves particular at- 
 tention. Corresponding to the above points, penetrating 
 contusions sometimes occur in the anterior or posterior uter- 
 ine wall. I have also observed and already mentioned a case 
 of transverse rupture of the posterior lip of the vaginal portion. 
 
 If ruptures of the uterus do not cause death by profuse 
 haemorrhage, metritis, endometritis, metro-lymphangitis, and 
 gangrene frequently arise from the point of rupture, or follow 
 extravasation ; or, an ichorous process, combined with throm- 
 
252 WOUNDS AND KUPTUEES 
 
 bosis and metastatic affections, finally terminates life. Gan- 
 grene and the ichorous process are rendered more acute and 
 exhausting if rupture of the bladder exists. Extensive perito- 
 nitis almost always follows rupture. 
 
 Kokitansky mentions, that sometimes the uterine artery is 
 denuded by gangrenous sloughing, and finally becomes the 
 source of fatal haemorrhage. In rare cases, even considerable 
 ruptures will heal, the hsemorrhage being arrested by contrac- 
 tion of the uterus immediately after the rupture has occurred, 
 and by a uniting of the edges of the wound by granulations. 
 If the rupture extends up to the body, a portion, or even the 
 whole extent of it may remain open, and only become closed 
 by an adhesion of the edges of the wound to the abdominal 
 wall (Rokitanskv). 
 
 A singular fait, deserving particular mention, is the rare 
 occurrence of spontaneous ruptures in primiparse, from which 
 fact several of the mentioned causes of rupture are diminished 
 in importance. Thus I find mentioned in DeLanghes' case, 
 that three times healthy children were born, and, at tlie birth 
 of the fourth, rupture occurred, which was attributed to an 
 antero-posterior diameter measuring only three and a half 
 inches. Murphy relates a similar case occurring at the fifth, 
 and Rooke one at the fourth delivery. The former, however, 
 expressly states, that ruptures never occur when the texture of 
 the uterus is in normal condition, not even when the pelvis is 
 contracted. Lehmann, in like manner, in his case, notwith- 
 standing a contracted pelvis, attributes the rupture to fatty 
 degeneration of the uterine tissue at the point of rupture. 
 
 Clarke and ColHns observed a case in which the peritoneum 
 only was ruptured near the fundus during labor, and death oc- 
 curred from internal iieemorrhage. 
 
 Rupture of the uterus always appears considerably less in the 
 dead body, owing to the uterus contracting considerably after 
 death. 
 
 In regard to the healing of wounds of the uterus, we possess 
 
OF THE UTERUS. 253 
 
 but little reliable data. The manner in which the wounds from 
 Caesarian operations heal, possesses considerable interest. 
 
 The following is what may be gathered from the few cases 
 recorded of this operation. The healing generally takes place 
 by removal of the uterus from contact with the abdominal 
 walls by its contraction, and healing of the wound by cicatriza- 
 tion. The cicatrix is always very considerable, and frequently 
 radiates into the uterine tissue. In the cicatricial tissue, 
 round calcareous masses are sometimes found, resembling 
 those met with in fibroid tumours. The detailed account of a 
 case published by Lange (report of post-mortem by Pro- 
 fessor Dlauhy), differs somewhat from the above, the fundus 
 uteri lying immediately below the pubis, having displaced 
 the bladder upward and to the right, and become adherent 
 to the anterior abdominal wall by a cone formed of a whitish 
 dense tissue. Externally, the point of attachment corresponded 
 to a grooved indentation. The cone mentioned inclosed a fun- 
 nel-shaped eversion of the uterine cavity communicating with 
 the latter, and was lined with mucous membrane as far as its 
 apex. Lange is of the opinion that the wound of the 
 uterus, resulting from Caesarian section, is never closed other- 
 wise than by a plastic exudation from the inflamed peritoneum, 
 but it is difficult to understand why this should be laid down 
 as a rule, as ruptures of the uterus, possessing less favorable 
 conditions for healing, may become perfectly closed without 
 peritonitis having existed. The mode of healing in Lange's 
 case is, however, very interesting and in accordance with the 
 theory of Rokitansky, according to which, ruptures of the 
 uterus are only perfectly closed through the intervention of the 
 abdominal walls. As previously mentioned, the cicatrix 
 resulting from Caesarian section, may be ruptured by succes- 
 sive pregnancies, still, cases are known in which this has not 
 occurred, as well as other cases in which rupture occurred 
 laterally to such a cicatrix. 
 
254 FATTY DEGENERATION 
 
 B. QUALITATIVE DEEANGEMENTS OF NU- 
 
 TKITIOK. 
 
 Fatty and amyloid degeneration of the^uterus must be con- 
 sidered as results of qualitative alterations of nutrition, and it 
 is necessary to state that both these metamorphoses affect 
 chiefly the muscular tissue of the uterus, whilst the connective 
 tissue only slightly participates in such changes. The cause 
 of this is probably owing to a higher degree of vulnerability of 
 the muscular elements of the uterus as compared with the 
 connective tissue. 
 
 1. FATTY DEGENERATION OF THE UTERUS. 
 
 Literature: Andral, Precis d'anatom. patliolog. Bruxelles 1837. II. pg. 
 237. — B u r e a u , Weisse Er^veicliung des Uterus in Folge der Entbin- 
 dung. Froriep's Notizen Nr, 631. 1844. — H e s c h 1 , Untersuchungeu 
 iiber das Verhalten des mensclil. Uterus nach der Geburt. Zeitscbr. der 
 Ges. d. Aerzte. Wien 1852. 9. pg. 228. — S i m p s o n , Monthly Journal. 
 J. August 1852. — Kolliker, Microscop. Anatomie etc. Leipzig 
 1852. II. 2. pg. 451. — R o k i t a n s k y , Patbol. Anat. Wien 1861. 
 in. pg. 498. u. 510. 
 
 Fatty degeneration, as mentioned above, affects chiefly the 
 muscular fibres of the body and fundus of the uterus, whilst 
 those of the cervix are generally not thus affected. 
 
 We can usually distinguish two varieties of fatty degenera- 
 tion ; the one is always to be traced to previous labor, and 
 according to our classification belongs to anomalies of post- 
 puerperal formation which was demonstrated by Heschl and 
 KolUker ; the other variety does not depend upon the puerpe- 
 ral condition, but is the consequence of morbid affections of 
 the uterine arteries, and therefore depends on ischcemia. 
 
 The most frequent affection of the uterine arteries is senile 
 rigidity in consequence of hyperplasia of their inner and 
 
OF THE UTEKUS. 255 
 
 outer coats, and by wliicli finally the channel of the vessels is 
 diminished and even closed. Under the effects of the conse- 
 quently deranged nutrition, the muscular fibres are transformed 
 into fat, and finally are absorbed. As a final result of this anom- 
 aly, -we find the uterus reduced to a fiaccid organ, composed 
 essentially of connective tissue, and usually in an abnormal 
 position, the firmness of its tissue having been considerably 
 diminished. This affection, therefore, coincides with senile 
 atrophy, the characteristics of which it represents ; at the same 
 time the mucous membrane varies in color between dark-red 
 and black, the uterus is small, flaccid and friable, its body 
 and fundus thin-walled, whilst its cervix maintains nearly its 
 normal resistance and thickness. 
 
 Fatty degeneration of the uterine muscular tissue also occurs 
 in ^tuberculosis of the uterus, and I am inclined to explain 
 this in the same manner as senile degeneration, the blood ves- 
 sels in this disease also being affected with proliferation of 
 nuclei and diminution of calibre (Wedl), resulting in ischsemia 
 and fatty degeneration of the muscular tissue. 
 
 For the same reason, fatty degeneration of the uterus w^ould 
 be hkely to occur as a consequence of embolus of the uterine 
 arteries ; but this, to my knowledge, has never been observed. 
 
 Fatty degeneration generally commences in the innermost 
 layers of the uterine substance, and gradually extends outward. 
 It is generally combined with shriveKng of the ovaries, and 
 atrophy of the oviducts. 
 
 Post-puerperal fatty degeneration will be considered in the 
 next chapter. 
 
 2. AMYLOID DEGENERATION OF THE UTERUS. 
 
 Literature: R. Virchow, Neue Beobachtungen Ueber amyloide 
 Degeneration, in bis Ai'cbiv. Bd. XL pg. 188. 1857. 
 
 The only case of this affection known at the present time is 
 recorded by Yirchow. It was taken from an elderly woman 
 
256 FATTY DEGENEEATIOIT. 
 
 in whom also amyloid degenerations were found in both 
 kidneys, the spleen, liver, intestines, heart, lungs, and even 
 the nerves. The uterus, the anterior and posterior walls of 
 which were enlarged, was of a peculiar yellowish-gray and 
 transparent appearance, and a micro-chemical examination 
 showed, that the thick bundles of smooth muscular fibres were 
 undergoing complete amyloid degeneration, while the thick- 
 walled blood vessels and the intervening connective tissue show- 
 ed no chemical reaction. 
 
 Yirchow therefore thought, that amyloid degeneration 
 should be distinguished as a separate affection from so-called 
 hypertrophy of the uterus ; but the former seems to be an 
 exceedingly rare afiection. In one case only, a woman fifty- 
 eight years old, I noticed that the enlarged uterus was of a 
 peculiar pale-grayish color, its muscular fibres being enlarged 
 and peculiarly glossy ; upon the application of iodine and 
 sulphuric acid the smallest uterine arteries assumed a distinct 
 blue color, whilst the muscular fibres showed no such reaction. 
 The blood vessels of the kidneys from the same subject, how- 
 ever, as well as those of the liver, exhibited a similar reaction 
 in a lesser degree, but still sufiicient to be recognizable. The 
 woman had died of apoplexy of the brain. Friedreich, in one 
 instance, also found the blood vessels of the uterus affected 
 with amyloid degeneration, combined with the same afi[ection 
 in other organs (Virchow's Archiv., XIII. , p. 498). 
 
PUERPERAL AFFECTIONS OF 
 THE UTERUS. 
 
 From the moment of conception and fixation of the ovum in 
 the uterus, a powerful energy of nutritive and formative 
 action is aroused, the result of which we term development 
 OF THE PREGNANT UTERUS. This development, in the majority 
 of cases, is probably induced by the changes belonging to the 
 last menstruation continuing in the form of permanent 
 hypereemia, and reaching their climax during the development 
 of the foetus. 
 
 Under the influence of pregnancy the uterus increases in 
 size, whilst at the same time the whole organ gradually sinks 
 somewhat into the pelvic cavity, until the spherical enlargement 
 of its body and fundus causes it to gradually ascend again into 
 the abdominal cavity. 
 
 The occurrence of anteflexion or anteversion during preg- 
 nancy, as mentioned by some authors, is a mere illusion. 
 The anterior wall of the uterus distends at an early period, 
 assuming a rounded form, which produces a sort of flexion 
 at the anterior circumference of the internal orifice, with- 
 out a corresponding curvature at the posterior circumference. 
 The descent of the uterus, observed by all authors during 
 the first months of pregnancy, in itself contradicts the possi- 
 bility of anteversion. 
 
 The uterus increases in substance beyond the first half of 
 pregnancy, which increase is owing to a simple and numerical 
 hypertrophy of its muscular fibres, the uterine tissue at the 
 23 
 
258 P[JEEPEEAL AFFECTIOITS 
 
 same time becoming softer and more succulent. These changes 
 chiefly affect the body and fundus of the uterus, its cervix par- 
 ticipating only sKghtly in them. During the latter period of 
 pregnancy the cervix participates in the enlargement of the 
 uterine cavity, the internal orifice is dilated, the cervical canal 
 becomes funnel-shaped, with its larger opening upward, and 
 finally shortens, and the vaginal portion, forming an inactive 
 valve, represents the narrowest portion of the genital canal. 
 It is of the greatest importance to the physiological process of 
 labor, that the least contractile portion of the uterus encloses 
 those parts of the foetus which occupy the lowest position. 
 
 The most important alterations are those which take place 
 in the mucous membrane of the body and fundus in the devel- 
 opment of the decidua. 
 
 The arteries of the uterus become considerably distended 
 and the veins still more so. The dilatation of the latter is 
 most considerable at the point of placental attachment, at 
 which place they appear like exceedingly thin-walled sinuous 
 canals, the size of a finger, the intervening walls of which have 
 probably ruptured at certain points, causing the innermost 
 layers of uterine tissue at the seat of placental attachment to 
 be replaced by a vascular tissue ^-ith large cavities, which, 
 when the latter are filled, projects somewhat inwardly, and 
 has been termed the ''^ maternal jplacenta,'''' 
 
 Dm-ing pregnancy, beneath the distended mucous mem- 
 brane, which has become transformed into a decidua, a sort of 
 rete Malpighi is developed, consisting of a loose, succulent, 
 very thin stratmn of chiefly young cells, which probably cause 
 the decidua to be so easily separated. 
 
 The question has again and again come up as to whether, 
 during labor, the mucous membrane which is transformed 
 into a decidua, is cast off, and consequently, whether the enth-e 
 inner surface of the uterus should be considered a raw sur- 
 face, or whether the decidua remains attached, and returns 
 to the condition of a mucous membrane ? If the former is 
 
OF THE UTEETJS. 259 
 
 the case, the mucous membrane must be formed anew. If 
 the latter, only the point of placental attachment must be con- 
 sidered a denuded surface. In regard to this, Eokitansky 
 states that " in the normal puerperal process, at least a layer 
 of the decidua remains, which, from the condition of a soft, 
 succulent, wide-meshed structure, returns to that of the 
 uterine mucous membrane." Heschl and others are of the 
 opinion, that the muscular substance of the uterus is denuded, 
 and that here and there delicate shreds, which are remnants of 
 the decidua, may be seen attached to it. They state that a few 
 days after delivery the whole inner surface ol' the uterus is 
 covered with a more or less red, soft, pulpy, villous substance. 
 From my own experience, and after a careful investigation 
 of the subject, I must assert, that in normal labor, that 
 portion of the decidua remains attached which I have men- 
 tioned as being a sort of rete Malpighi, and, that upon the 
 external surface of the expelled membranes a thin layer of 
 cells is found, similar to those which constitute the succulent, 
 wide-meshed stratum covering the inner surface of the 
 uterus. I would compare it to cases in which the epidermis 
 is raised in the form of bullae (bhsters or pemphigus), in 
 which similarly a thin layer of the germinating cells of the 
 epidermis remains upon the denuded surface. From a 
 theoretical point of view it is difficult to understand from 
 what elements the uterine mucous membrane with its glands, 
 which are essentially epidermoid structures, could be re- 
 constructed, if in every normal labor the muscular substance 
 was denuded. 
 
 About the fourth day after the expulsion of the foetus fatty 
 degeneration of the smooth muscular fibres of the uterus com- 
 mences, and progresses in such a manner as to cause degen- 
 eration of the fibres into fatty granular cells, which finally 
 are completely absorbed (Heschl). At the same time the 
 completely contracted uterus becomes small, the substance 
 of its body and [fundus of a pale yellow, yellowish-red color, 
 
260 PITEEPEEAL AFFECTIONS 
 
 and friable, especially its innermost layers, and its mucous 
 membrane is replaced by an extremely succulent, velvet-like, 
 dark-red stratum. 
 
 According to Heschl, the commencement of a new-for- 
 mation of muscular fibres is seen at the fom-tli week after 
 labor, in the form of nuclei and caudate cells, and thus the 
 involution of the uterus is generally completed at the end ot 
 the second month after delivery. 
 
 The muscular substance of the cervix degenerates in like 
 manner, but, owing to its lesser importance, its external 
 character is less altered; this involution of the cervix is 
 said to be accompanied at the same time with extravasations 
 within its tissue. 
 
 By the complete contraction of the uterus the veins at the 
 seat of the placenta are nearly completely closed, still, hsem- 
 orrhage would continue from the open vessels if clots were 
 not formed to insure their perfect closure. Consequently, at 
 the seat of the placenta, physiological thrombosis occurs 
 after' delivery (Yirchow), and the free ends of these thrombi, 
 projecting into the uterine cavity, produce that tuberous 
 uneven appearance noticed at the above-mentioned place 
 during the fii'st days after deHvery. The walls of the vessels 
 finally coalesce, and for the most part are absorbed by fatty 
 degeneration. The occluding thrombi decompose, or are cast 
 off and mix with the so-called lochial secretions, whereupon 
 normal mucous membrane grows over the former seat of the 
 placenta. 
 
 Literature: Denham, On puerperal fever, etc. London '1768. — 
 Leake, Pract. observ. on childbed-fever. London 1772. —Kirk- 
 land, Treatm. of childbed-fever. London 1774. —Walsh, Pract. 
 observ. on puerperal fever. London 1787. — J. C 1 a r k e , Essay on 
 the epidem. diseases of lying-in women of the years 1787 and 1788. — 
 Gordon, Treat, on the epid. puerper. fev. of Aberdeen. London 
 
OF THE UTERUS. 261 
 
 1795 — F. C. N a g e 1 e , Schildening des Kindbettfiebers, etc. Heid- 
 elberg 1812. — B r e n a n , Thoughts on puerp. fever, etc. London 
 181-4. — Armstrong. Facts and observ. relat. to puerper. fev. 
 London 1814. — Hey, Treatise on puerperal fev. etc., London 1815. — 
 Campbell, Treat, on the epidem. puerper. fever, as it prevailed in 
 Edinburgh 1821 — 1822, to which is added an appendix, containing the 
 essay of the late Dr. Gordon, etc. Edinburgh 1822. — E. v. S i e b o 1 d, 
 Versuch einer pathol. therap. Darstellung des. Kindbettfiebers etc. 
 Frankfurt, a. M. 1826. — F. C. Baudelocque, Traite de la peri- 
 tonite puerperale. Paris 1829. M. T o n e 11 e , Des fievr. puerper. ob- 
 servees a la Matemite pendant I'annee 1829. Paris 1830. — Dance, 
 De la phlebite uterine etc. Arch. gen. de Med. Decbr. 1828 et Fevr. 1829. 
 — G. Balling, Zur Venenentzilndung. Wurzburg 1829. pg. 286. — 
 D a n y a u, Essai sur la metrite gangreneuse Dissert. 1829. — Baude- 
 locque, Traite de la Peritonite puerperale. Paris 1830.— C r u v e 11- 
 h i e r , Anat. pathol. Malad. de I'uterus et des ovaires. Livi\ IV. 6 ; 
 XHI. 1 — 3. — Nonat, Sur. la metro-peritonite puerperale, compliquee 
 de I'inflammation des vaisseaux IjTnphatiques de I'uterus, Paris 1832. — 
 R. Lee. Research, on the path, and treatment of the most import, 
 diseas. of Women V. 1. London 1833. — B o i v i n e t D u g e s, Tr. 
 prat. des. malad. de I'ut: Paris 1833. H- pg. 206. — Dup 1 a y, Von 
 der Eiterung der lymphat. Gefasse der Gebarm. in Folge der Geburt- 
 Arch. gen. Mars 1835 et Mars 1836. — G. M o o r e , An inquiry into 
 the pathol. causes and treatm. of puerpr. fever. London 1836. — Th. 
 Helm, Beob. liber Puerperalkrankh. Oest. med. Jahrb. XXHI- Bd. 
 
 1. St. 1837 Eisenmann, Die Wund- und Kindbettfiebr. Erlan- 
 
 gen 1837 — I n g 1 e b y , On the Connection between Puerperal Fever 
 and Erysipelas. Edinb. med. and surg. Joum. April 1838. — R o k i- 
 t a n s k y , Der dysenterische Process auf d. Dickdarme u. der ihm 
 gleiche am Uterus. Oest. msd. Jahrb. XXIX. Bd. 1. St. 1839. — Th. 
 Helm, Puerperalkrankheiten, Zurich 1839. (2. Aufl. Wien 1815.) — 
 K i w i s c h , Krankh. d. Wochnerinnen. 1840. 1841. — Ferguson, 
 Essay on the most import, diseas. of women 1. 1839. — Locock, on 
 puerperal diseases in Tweedie's hbrar. of med. I. London 1840; ~R o - 
 k i t a n s k y , Handb. der pathol. Anat. Wien 1842. IIL pg. 557. — 
 E n g e 1, Die Eitergahrung des Blutes. Arch. f. physiol. Heilk. 1842. — 
 S a ch e r o, Annal. univers. di medic. Febr. 1842. — T o m a s i n i , 
 ibidem Juni 1842. —Churchill, Dublin Joum. 1843. Septbr. — 
 L i t z m a n n, Das Kindbettfieberin nosol. geschichtl. u. therap. Bez. 
 Halle 1844. — M ikschik, Zeitschr. d. Ges. d. Aerzte. Wien 1845. 7. — 
 L u m p e , Das Puerperalfieber, Zeitschr. d. G. d. Ae. Wien 1825. Febr. 
 — K i w i s c h, Klin. Vortr. 1845. I. pg. 500. — Scanzoni, Bem- 
 
 5 
 
262 PITERPERAL AFFECTIONS 
 
 erkg. liber die Genes, d. Kindbettfiebers. Prag. Viertelj.-Schr. 1846. 4. 
 
 — Skoda, Zeitsbr. d. G. d. Aerzte. Wien 1850. Februar. — Z e n- 
 g e r 1 e , Wlirtemb. Corr. Bl. 1859. 22—25. — S e y f e r t , Prag. 
 Vieitelj.-Schrift. 1850. 2. — Scanzoni, ibidem. — K i w i s c b , 
 Einige Worte liber die Entdeckung des Dr. Semmelweis. Zeitscbr. d. 
 Ges. d. Aerzte. Wien 1850. Juni. — H. Bamberger, Deutscbe 
 Klinik. 8 — 12. 1850. — Simpson, Analogy of puerpr. fever witb 
 surgical fever. Edinb. Montbly Journ. Novbr. 1850. — L u m p e , Zur. 
 Tbeorie der Puerperalfieber. Zeitscbi". d. Ges. d. Aerzte. Wien 1850. 8. 
 
 — C o r m a c k , London [med. Journ. 1850. Octb. — H e n 1 e , Eat. 
 Patbologie, Braunschweig 1851. — Bonders, Nederlandscb Lancet. 
 Nr. 1. Juli 185L — K i w i s c h, Febris gravidarum et patmientium. 
 Wiener med. Wochenscbr. 1851. 3. — C. B r a u n, in Cliiari, Braun 
 und Spilth's Klinik. der Geburtsbilfe. u. Gynilcol. Erlangen 1852. — 
 C h i a r i , Pj^amie obne Gebarmutterleiden. Zeitscbr. d. Ges. d. 
 Aerzte. Decbr. 1851 — Scanzoni, Lebrb. d. Geburtsbilfe. 2. Aufl. 
 Wien 1853. ~ C 1 i n t o c k , Union 1853. 74. -- H. M e c k e 1 , Annal. 
 der Obarite. V. 2. 1854. V i r c b o w , Patbologie und Tberapie. T. Er- 
 1 a n g e n 1854. pg. 156. — J. V o g e 1 , ibidem. — Forster, 
 Spec. path. Anatomic 1854. pg. 315. — J. Y. Simpson, Pathol, 
 observ. on puerperal arterial obstruct, and inflammat. Edinb. 1854. — 
 E n g e 1 , Leichenerscheinungen. Wien 1854, — V e 1 1 , Krankh. d. 
 weibl. Geschl. Org. in Virchow's Pathol, u. Therap. 1855. pg. 306 u. 
 282. — M ikschick, Bsmerkung. liber einige Nachkrankh. d. Wo- 
 chenb. Zeitscbi'. d. Ges. d. Aerzte. 1856. 3. 4. — Duncan, Edinb. 
 med. Journ. Decbr. 1857. — Chisholm, Edinb, med. Journ. 1857. 
 June. — C. B r a u n , Zeitscbi-. d. Ges. d. Ae. 1856. und Lehrb. d. 
 Geburtsbilfe. Wien 1857- pg. 913- — Virchow, Der puerperale 
 Zustand. Das Weib und die Zelle. Verhandl. d. Gesellscb. f. Geburtsk- 
 etc Berlin 1848. Bd. III. Gesammelte Abbandl- Frankfurt 1856. pg. 
 735, und Verhandl. d. Ges. f. Geburtsk. etc. Monatschiift etc. Berlin 
 1 858. XL 6. — S k o d a , Ueber Krankheiten bei Puerperen. Allg. 
 Wiener med. Zeitg. 1858. 20. 21. — H. S i 1 b e r s cb m i d t , Hist, 
 krit. Darst. der Pathol, des Kindbettfieb. Erlangen. 1859. — O p p o 1 - 
 z e r , Ueber Puerperal -Fieber. Allg. Wiener med. Zeitg. 1862. 13. 14. 
 — R okitansky, Lebrb. d. pathol. Anatom. III. Bd. pg. 500. — 
 Semmelweis, Aetiologie, Begriff und Prophylaxis des. Kindbett- 
 fiebers. Pest. Wien. u. Leipzig 1861. — H e c k e r und Buhl, Klinik. 
 der Geburtskuude. Leipzig 1861. 
 
 Under the name of puerperal diseases all those affections 
 are comprised which, commencing with pregnancy, dehvery, 
 
OF THE UTERITS. 263 
 
 or the puerperal state, assume an acute course during the 
 latter, and the origin of which can be traced to anatomical 
 alterations accompanying the former conditions. 
 
 We do not propose in these few lines to follow the investi- 
 gations, however interesting, upon the general etiology of 
 puerperal diseases, and I intentionally avoid entering into 
 the discussion of questions which have already been discussed 
 with peculiar acrimony, especially that of cadaverous infection. 
 
 But in general it must be stated, that undoubtedly puerperal 
 affections occur here and there in an epidemic form, and that 
 epidemics of puerperal fever frequently coincide with other 
 epidemics, chief among which we must reckon epidemic 
 erysipelas, an affection nearly related to, if not identical with 
 puerperal diseases. It should also be mentioned that puerperal 
 diseases occur at many locahties in an epidemic form (Kiwisch), 
 however singular such a statement may seem. 
 
 Before proceeding further, I must unconditionally agree 
 with Kiwisch and Buhl, that in all puerperal diseases the 
 inner surface of the uterus is the first affected, and that all 
 subsequent affections derive their origin from puerperal 
 metritis or endometritis, and are dependent directly or indi- 
 rectly on them. 
 
 The primary affection, therefore, is always local, and its 
 extension is either limited to the organ afterward affected, 
 which is the uterus, or it spreads by contiguity to adjacent 
 parts, as the oviducts, peritoneum, and ovaries ; or, finally, it 
 extends to the lymphatics and veins, in which case the disease 
 has progressed far beyond its original seat. 
 
 The inner surface of the uterus in the majority of cases, 
 being the primary seat of the puerperal affections, the next 
 question is, what is its normal condition? I have already 
 stated that the uterine mucous membrane, which was trans- 
 formed into a decidua, is not wholly cast off, but only its 
 innermost layers, leaving behind at least a part of the 
 germinating stratum of the membrane. A portion of the 
 
264 PUERPEEAL AFFECTIONS 
 
 inner surface of the uterus is occupied bj the seat of the 
 placenta. At this point we find open veins, the calibre of 
 which is diminished by normal contraction of the uterus, and 
 which are partly occluded by coagula. Finally, we must men- 
 tion those frequent fissures always occurring in primiparae, 
 which commence at the vaginal portion and extend more or 
 less highly and deeply into the substance of the cervix. French 
 pathologists have pointed to these fissures as the exclusive 
 causes of puerperal affections, which is absolutely false, for we 
 observe quite a number of the latter without there being 
 any traces of fissm-es. 
 
 In the three conditions just mentioned, I hope to be able to 
 establish the causes of puerperal diseases. 
 
 The first lies in the thin mucous lining of the uterus, an 
 exceedingly vulnerable tissue, consisting of young elements, 
 which readily slough and require only a slight exciting cause 
 to produce that affection which has been termed endome- 
 tritis. 
 
 The point of placental attachment being the seat of physio- 
 logical thrombosis, may become the starting point of exten- 
 sive thrombosis, and the cases formerly described as puerpe- 
 ral metrophlebitis mostly belong to this class. 
 
 The fissures occurring during labor represent wounds in an 
 organ whose absorbing power is increased to an extraordinary 
 degree. Deleterious influences, as malarious miasmata, will 
 therefore readily affect the blood through this som-ce. 
 
 The latest classification of puerperal fever, as given by 
 Buhl, is based upon anatomical data, and therefore deserves 
 a careful consideration. 
 
 Buhl distinguishes three forms ; the first, represented by 
 jpuerjyeral jperitonitis without pycBraia, is developed from endo- 
 metritis, by extension of the latter through the oviducts to 
 the peritoneum. 
 
 The second form, puerperal pyoemia without peritonitis, is 
 developed in the form of traumatic pyaemia; the primary 
 
OF THE UTEEUS. 265 
 
 afFection is again endometritis^ with absorption of ichorous or 
 foetid substances into the veins, and thrombosis of the uter- 
 ine veins, especially at the point of placental attachment ; this 
 form might therefore be termed puerperal pysemia with phle- 
 bitis. Evidently, this form is very dangerous from its metastic 
 tendency. 
 
 The third iorvci which Buhl mentions h puerperal pycBmia with 
 peritonitis, or pycemia with lymphangitis ; endometritis in this 
 the most malignant form of puerperal disease, extends to the 
 lymphatics. 
 
 Finally, as 2i fourth form, Buhl mentioTis puerperal pycemia 
 without phlebitis and lymphangitis, which being combined 
 with retroperitoneal oedema, he considers as coming under 
 the third form. iUl the epidemics of true puerperal fev*^r, 
 according to him, are distinguished by the prevalence of the 
 third form. 
 
 How far I agree with Buhl, will appear from the follow- 
 ing description of the individual processes and their con- 
 sequences. I will state at once, however, that I only differ 
 from him in some details, and unhesitatingly accept his 
 classification of three forms of this affection. 
 
 a. PUERPERAL ESTFLAMMATION OF THE UTERINE MUCOUS 
 MEMBRANE. PUERPERAL ENDOMETRITIS. 
 
 Puerperal endometritis chiefly affects the mucous mem- 
 brane of the cavity of the body of the uterus, while that 
 lining the cervix, remaining in its integrity, does not always 
 participate in the affection, or if at all, only in a very shght 
 deo:ree. 
 
 Eokitansky distinguishes three degrees of puerperal endo- 
 metritis, between which no exact limit can be drawn, but 
 which, nevertheless, may easily be distinguished anatomically 
 from each other. 
 
 In the first or slightest degree of endometritis, we find the 
 24 
 
266 PUERPEEAL ENDOMETRITIS 
 
 mucous membrane in a generally well contracted uterus, 
 softened, swollen, and visibly congested. The inner surface 
 of the uterus is covered by a viscid, sometimes muco-purulent 
 fluid": at the points where the submucous tissue is denuded, 
 an albuminous fluid is frequently found in the form of yellow- 
 ish, or greenish-yellow transparent, or slightly turbid striated 
 collections, extending along the intermuscular fibres of connec- 
 tive tissue. The inner stratum of uterine tissue is generally 
 found in a state of oedematous relaxation ; at the seat of the 
 placenta however there is scarcely any apparent change. In 
 the severer forms of this disease the mucous membrane of the 
 body and fundus, which is easily removed, is covered with a 
 furfuraceous pale-brown or brownish-yellow deposit, the in- 
 nermost layers sloughing away as in diphtheria. This is either 
 limited to small isolated points, or extends over the whole 
 mucous membrane, with the exception of that lining the 
 cervix, and forms the second degree of puerperal endome- 
 tritis. 
 
 In this degree the uterus is not so well contracted as in the 
 slighter, still, its contraction is tolerably normal. Its mucous 
 membrane is more swollen, relaxed and congested, and soon 
 changes into a whitish, yellowish, brownish, and discolored 
 slough, which is easily removable, and sometimes hangs in 
 shreds. At other points croupy membranes are found, vary- 
 ing, but generally slight in extent ; the uterine tissue appears 
 more succulent, and between the bundles of muscular fibre, 
 especially of the deeper layers, a considerable amount of album- 
 inous exudation is found. 
 
 Sometimes the mucous membrane, partly in a sloughed 
 and partly in an intensely congested condition, is raised in 
 round elevations by an exudation frequently mixed with 
 extravasated blood, and I remember several cases in which 
 the still adherent decidua was so relaxed, partly from 
 uterine contraction, partly from exudation mixed with blood, 
 as to form loose sacs, and causing the inner surface of the 
 
 I 
 
OF THE UTEKUS. 267 
 
 uterus to appear as if covered with varicose veins. Here I 
 should remark, that the non-detachment of portions of 
 the decidua has not hitherto been duly appreciated. I 
 have frequently convinced myself, that when portions of the 
 decidua remain attached to the uterus, they are the first to 
 become gangrenous, owing to deficient nutiition (especially 
 if contraction of the uterus is impeded by other circumstances, 
 or from miasmatic or contagious infiuences). Although reten- 
 tion of portions of the decidua is of lesser importance than the 
 retention of portions of placenta, I would neverthelecs advise 
 more attention to be paid to the former, as I am of the opinion 
 that a considerable number of cases of puerperal endometritis 
 are attributable to the retention and subsequent gangrenous 
 condition of portions of the decidua. These remnants of 
 decidua are most frequently found in the vicinity of the seat 
 of the placenta. 
 
 While in the slighter degrees of puerperal endometritis the 
 above-mentioned part is unaltered, in the higher degrees it is 
 generally more prominent, and the coagula occluding the open 
 vessels are generally discolored, of a greenish, whitish-gray 
 color, and sometimes putrefy at their inner extremities. The 
 thin septa between the deepest sinuous venous spaces occluded 
 by the coagula are sometimes found in a gangrenous con- 
 dition. Here and there collections of pus and sloughing por- 
 tions of parenchyma are met with (Rokitansky). 
 
 In this degree of endometritis the contents of the uterus 
 consist of a muco-purulent fluid mixed with blood, also 
 detached diphtheritic portions of mucous membrane, remnants 
 of decidua, loose and putrefying portions of coagula, or a dis- 
 colored reddish-brown, or blackish, offensive fluid. Eoki- 
 tansky has compared this development of puerperal endo- 
 metritis with a form of dysentery in which similar elevations 
 are found, a tumefaction of the submucous tissue, similar to 
 that occurring in some cases of endometritis. 
 
 The highest degree of this affection, presents a condition 
 
268 PUERPEEAL EIS-DOMETEITIS 
 
 which is unsurpassed in frightfulness by any other disease, 
 and for which j)utrefaction of the uterus would be a mild 
 name. To the honor of the obstetrical art be it said, that 
 such degrees of destruction are very rare. Plagge's endo- 
 metritis nosocomialis ; Cruveilhier's typhus 2^y'Q'>"peralis, metri- 
 tis sejptica^ sphacelus uteri puerperalis^ and 'Boev^s putrescentia 
 uteris are synonyms for this condition. In such cases the 
 uterus is imperfectly contracted, its walls are thin, its perito- 
 neal surface reddish and discolored, and presenting various 
 shallow depressions from pressure of adjacent coils of intestine 
 (Kiwisch). The uterus consequently projects considerably 
 into the abdominal cavity, and is generally directed obliquely 
 toward one or other side. Upon dissection, the submucous tis- 
 sue underlying the brownish-black mucous membrane, is found 
 transformed into a whitish or yellowish slough, well defined 
 from the muscular tissue, the latter, however, presenting a 
 dirty-reddish, succulent and softened appearance. The seat 
 of the placenta is generally deeply ulcerated, the thrombi cast 
 out from the extremities of the veins, slough mto shreds, and 
 between and within them is a discolored, chocolate-like 
 ichorous fluid, or a purulent substance, and sometimes creamy 
 thick pus. Sometimes the sloughing extends into the uterine 
 substance proper, causing deep excavations on the inner 
 surface of the uterus, and destroying a considerable amount 
 of its muscular tissue. The destructive process in one or 
 several well-defined points, may extend through the entire 
 thickness of the uterine walls to the peritoneum, which, at its 
 centre, is of a pale-brown color, finally resulting in perfora- 
 tion of the uterus. Owing to the sharply-defined limits of 
 such a penetrating slough, the perforation sometimes has the 
 appearance of being closed by an incarcerated gangrenous 
 plug (Rokitansky). 
 
 The rest of the uterus is generally of a dirty bluish-red color, 
 is doughy and soft, and its muscular tissue lacks that firm- 
 ness, which, if this term is apphcable to the fulness and 
 
OF THE UTEEUS. 269 
 
 elasticity of a recently-delivered uterus, is noticed even in 
 the dead body. The external surface of the organ presents 
 depressions from pressure of adjacent tympanitic coils of in- 
 testines. 
 
 As previously mentioned, this affection of the mucous 
 membrane lining the body of the uterus, rarely extends to that 
 of the cervix ; in the severest forms of this disease, however, 
 the latter appears tumefied and oedematous, frequently to such 
 an extent that the transverse folds of the palmse plicatse 
 project like loose flaps or clubbed appendices. In rare cases, 
 however, croupy membranes are formed on the mucous mem- 
 brane of the cervix, or the latter is in a state of diphtheritic 
 sloughing. 
 
 The oedema of the uterus in such cases frequently extends 
 to the parametritic cellular tissue, and sometimes high up 
 along the mesentery of the small intestine and toward the lum- 
 bar vertebrae. 
 
 Puerperal endometritis not unfrequently extends to the 
 mucous membrane of the oviducts, causing similar phenomena 
 in these organs. The inflammatory process may even extend 
 beyond and produce puerperal perimetritis, and afterwards 
 general peritonitis. In many cases endometritis is combined 
 with metritis, which latter may be followed by ichorsemia, lym- 
 phangitis, thrombosis of the veins and lymphatics, and phlebitis. 
 
 It is evident that the local anatomical character of puer- 
 peral endometritis, is essentially different from the forms of 
 inflammation usually affecting mucous membranes, and is 
 analogous only to a peculiar form of dysentery. I agree 
 perfectly with Virchow, that in such cases we have a specific 
 inflammation, resembling the phlegmonous erysipelas of the 
 skin and subcutaneous tissue. Virchow therefore defined 
 puerperal endometritis as '-'- internal malignant jpuerjperal 
 erysipelas.^^ Its effects upon the blood consist in the ab- 
 sorption of specific substances in a state of decomposition 
 formed by the fluids in consequence of the action of mias- 
 
270 PUEBPEEAL METRITIS 
 
 matic or epidemic influences, and possessing infectious 
 properties. 
 
 Puerperal endometritis is frequently fatal without the inter- 
 vention of any other disease. Among the latter, as arising from 
 puerperal endometritis, we must chiefly mention puerperal peri- 
 tonitis from contiguous infection. Besides this, it is frequently 
 followed by ichorsemia producing sudden inflammations of 
 serous membranes, as the pleurae, meninges, and pericardium, 
 with copious serous exudation, extensive oedema and gan- 
 grene of adjacent connective tissue, especially the subser- 
 cous, intermuscular, subcutaneous, and submucous connective 
 tissue; inflammation of the joints, especially of the synovial 
 membranes of the knee, shoulder, and sterno-clavicular 
 articulations (Rokitansky) ; abscesses of the liver, spleen, 
 parotid, etc. 
 
 Puerperal thrombosis of the lymphatics and uterine veins 
 will engage our attention hereafter. 
 
 a. PUERPERAL METRITIS. 
 
 Inflammation of the substance proper of the uterus, in the 
 majority of cases, is a consequence or extension of endometri- 
 tis. As we stated in describing the latter, the uterine connec- 
 tive tissue in this affection is found in a state of cloudy swell- 
 ing (triibe Schwellung) owing to the exudation of an albumin- 
 ous fluid. According to Virchow, this condition probably 
 commences as hypersemia, and even in its flrst stage, an ex- 
 perienced eye will detect certain cloudy opaque lines and 
 patches. The swelling is said to be less apparent in the begin- 
 ning than the cloudiness, but as the disease increases in inten- 
 sity the former becomes more marked, and you may perceive 
 a slightly gelatinous condition of the intermuscular connective 
 tissue — a kind of firm oedema. Upon microscopical examina- 
 tion the corpuscles of the connective tissue are seen to be en- 
 larged, their contents denser and more abundant, and some- 
 times distinctly granular. At an early period the nuclei also 
 
OP THE UTERUS. 271 
 
 become enlarged and divide, which fact indicates the commence- 
 ment of formative changes. After this, the cells also divide, and 
 sometimes you find adjoining rows of small, round granulation- 
 cells. From this almost literal description of Virchow, I 
 only difier in this one unimportant particular, that in precise- 
 ly such cases I have distinctly recognized endogenous prolifer- 
 ation of elements. < As the disease advances, pus is formed in 
 the connective tissue, and the formerly clear and light-yellow 
 infiltration becomes turbid and creamy from the admixture of 
 purulent elements, until finally the portion of tissue afiected is 
 " infiltrated Vj^ith pus." Tfie connective tissue is destroyed by 
 this formation of pus, the ac^^acent muscular elements from their 
 previous condition of cloufly swelling have passed into that of 
 fatty degeneration or sloug'king, and thus contribute to the en- 
 largement of the space occupied by the newly-formed pus, or 
 uterine abscess. In some rare cases, the individual fibre-cells 
 degenerate into thick, gloj/sy, dense structures of sclerous ap- 
 pearance. (Virchow). 
 
 Puerperal metritis, it is true, frequently affects the entire 
 substance of the body and fundus of the uterus, but the forma- 
 tion of pus generally takes place only in isolated and limited 
 portions of the uterine walls ; hence, we speak of metritis in 
 the form of purulent collections. Virchow states, that diffuse 
 metritis is more likely to occur in the external layers of uterine 
 tissue beneath the peritoneum, as for instance in the 
 anterior, posterior or lateral walls, and thence extends to the 
 loose connective tissue around the vagina and cervix, and from 
 the latter to the broad ligaments and the sheaths of the blood 
 vessels and lymphatics. 
 
 The abscesses formed in the above manner, are sometimes, 
 from degeneration of the pus, transformed into ichorous 
 cavities which may extend from sloughing of their walls, and 
 ultimately perforate through either of the uterine surfaces. 
 Eupture of the abscess into the cavity of the uterus is the 
 more simple termination, and perforation into the peritoneal 
 
272 PUEEPEEAL METEITIS 
 
 cavity the more important, as it either leads directly to peri- 
 tonitis, or, neighboring viscera, which have previously become 
 adherent, may likewise be perforated, thus establishing a com- 
 mimication between the separate cavities. This is chiefly the 
 case with the intestines, and the communication of their cavi- 
 ties with such abscesses is most important, as the ichorous 
 process maintained, and sometimes ag^i^vated, by contact 
 with faecal matter. 
 
 Uterine abscesses are distingy' . enlargement 
 
 of the lymphatics by puerperal ]j and sloughing 
 
 of lymphatic thrombosis, by tl:( the investing 
 
 membrane. They are less dis^y ^xe from purulent 
 
 phlebitic collections, with wliich . S . frequently combined 
 
 in such a manner that an abscess/ ing the course of the 
 
 affected veins is added to phlebitis. a single cavity is finally 
 
 formed by sloughing of the ven < rails. Metritis may be 
 protracted for an indefinite time, i the isolated abscesses 
 become larger at the expense of t uterine tissue, and finally 
 lead to so-called ^/l^A^s^5 of the pue aral uterus. 
 
 Uterine abscesses are generally cor.bined with endometritis 
 and other puerperal affections of such severity that a cm-e 
 rarely follows. Nevertheless, we sometimes find that the in- 
 carcerated pus undergoes either fatty or calcareous degenera- 
 tion, and a sequestrating growth of connective tissue takes 
 place in the walls of the uterus, resulting in the formation of 
 a cavity containing a condensed, fatty, lardacious substance. 
 Undoubtedly, diffuse metritis may terminate favorably at an 
 earher period, by fatty degeneration and absorption of the 
 purulent cells previously formed. Another termination of dif- 
 fuse metritis, is analogous to so-called induration of tis- 
 sue. In such cases, formative irritation may have existed, 
 from the commencement, and the destructive tendency of the 
 inflammatory process may have been arrested at an early 
 period. Permanent hyperplasia of the connective tissue is the 
 early result of this process. 
 
OF THE UTERUS. 273 
 
 The most frequent form of metritis, is that which arises 
 from laceration of the cervix and vaginal portion, and which 
 is always found to a considerable" extent in conjunction with 
 endometritis. The laceration gives rise to moio or less 
 haemorrhage, which is arrested by thron bosis, a membra- 
 nous coagulum, commencing at its upper angle or sub-mu- 
 cous borders, gener^^'V extending over the lacerated surfaces. 
 In the adjacei' tissue, aJriflammatory oedema takes place, and 
 frequently lymjomes turbii-bosis is superadded. In other cases 
 the surface of <nts, until fin uighs, and the diphtheritic mem- 
 brane is cast (J^ith pus." Tj tissue infiltrated with turbid fluid. 
 
 Owing to theiiiis, the ad origin, we must distinguish from 
 lacerations, contusioi'^ clou jj-ing in the lower portion of the 
 cervix, frequently in islougitior wall, but which, nevertheless, 
 exhibit the same phend© occ^,. 
 
 Puerperal metritis, t)^^ ^ re, is developed either as an in- 
 flammatory process, froC^^^ e extension of endometritis, or it 
 arises from lesions occur g during labor. The latter form 
 very rarely leads to the ^c mation of abscesses. 
 
 Puerperal metritis is frequently combined with lymphatic 
 thrombosis, (metro-lymphangitis), especially when lacerations 
 of the cervix exist, likewise with metro-phlebitis and the 
 sequelae of those afiections. The inflammatory oedema occa- 
 sioned by lacerations of the cervix may finally terminate in 
 extensive ichorous parametritis. 
 
 c. PUERPERAL THROMBOSIS OF THE LYMPHATICS 
 AND PUERPERAL LYMPHANGITIS. 
 
 Afiections of the uterine lymphatics during the puerperal 
 state are very frequent, and are always secondary, that is to say, 
 they generally arise from metritis or endometritis. Here again 
 credit is due to Virchow for having enlightened us on the sub- 
 ject of inflammation of the lymphatics of the uterus, and I 
 cannot otherwise than corroborate his recent investigations 
 on this subject, and entirely approve of his conclusions, 
 25 
 
274 PUEEPEEAL THEOMBOSIS 
 
 In Bome puerperal affections of the uterus which are com- 
 bined, without exception, with imperfect contraction of the 
 organ, we usually notice a dilatation of the lymphatic ves- 
 sels, which is rarely uniform but generally sac-like, and 
 is frequently so extensive that distinct elevations are 
 formed on the surface of the uterus. These distended 
 lymphatics contain a pale-yellow, loose, gelatinous, some- 
 times firm coagulum which adheres to the walls of the vessel, 
 and is evidently of a fibrinous nature. This coagulum frequent 
 ly softens from its centre into a purulent, pale, yellowish fluid, 
 sometimes containing several large fibrinous flakes, and if 
 such a lymphatic varix is incised, it will seem as though an 
 abscess had been opened. But after removing the coagulum 
 attached to the periphery of the wall, you will easily be con- 
 vinced that the lymphatic vessel is perfectly intact, notwith- 
 standing its considerable distention. 
 
 It is evident that lymphangitis is out of the question in such 
 cases, and that we have simply to deal with lymphatic throm- 
 bosis. If you inquire into the origin of this affection, the 
 first question to be asked is, — what caused the coagulum of 
 lymph, it being recognized that normal lymph contains 
 fibrinogenous but no fibrino-plastic material, and, therefore, 
 lymphatic fibrin does not coagulate spontaneously ? We must, 
 with Yirchow, answer the question as follows : that probably 
 under the influence of the local affection which causes 
 lymphatic thrombosis, the fluids of the tissue have undergone 
 such changes as will cause the production and spontaneous 
 coagulation of flbrin in the tissue itself. In such cases we always 
 find the tissue of the uterus, infiltrated with a kind of gela- 
 tinous or fibrinous substance, which originates probably from a 
 chemical transformation of the inter-cellular substance of the 
 connective tissue, combined with increased transudation. 
 Lymphatic thrombosis, therefore, is always combined with 
 fibrinous endometritis and parametritis, and is consequent 
 upon these affections. 
 
OF THE UTEKUS. 275 
 
 The second question relates to the cause of the dilatation, and 
 the explanation of the process is found in two circumstances : 
 first we must remember that coagulated lymph cannot circu- 
 late and must, therefore, be retained in the vessels ; and sec- 
 ondly, as I have already stated, that lymphatic thrombosis is 
 always found under circumstances in which the muscular ele- 
 ments of the uterus, and undoubtedly the walls of the lym- 
 phatics, have lost their contractility, causing passive dilatation 
 from the very beginning. The concurrence of these two cir- 
 cumstances is certainly suflficient to cause considerable dilatation. 
 
 Lymphatic thrombosis affects either the lymphatics of the 
 uterus only, or it extends to those of the broad ligaments and 
 along the spermatic veins or vertebral column up to the dia- 
 phragm. Frequently, thrombosis affects only the lymphatics of 
 one side, generally that on which the corpus luteum has been 
 formed, or to which the placenta has been attached (Buhl). 
 Frequently it is combined with adenitis, and in severe cases 
 even the thoracic duct becomes filled with purulent dissolving 
 coagula. 
 
 With the occurrence of complete thrombosis of the lymphat- 
 ics, the passage of altered fluids into the blood is prevented, 
 and on^this account the prognosis of this disease is not unfavora- 
 ble ; it is a barrier to infection (Yii'chow) so long as the thrombi, 
 which are naturally soft, do not dissolve and cause direct infec- 
 tion of the blood. But the cause of lymphatic thrombosis, 
 diffuse phlegmonous inflammation, possesses in itself such a 
 marked tendency to destructiveness, that the unfavorable ter- 
 mination of such forms can be explained independently of a 
 direct infection of the blood through the lymphatics. 
 
 It must also undoubtedly be admitted, that all the lymphat- 
 ics are not always affected with thrombosis, some of them allow- 
 ing absorption of putrid substances of local origin, while others 
 are incapacitated from so doing by thrombi, and also that 
 the latter may be formed after a sufficient amount of ichorous 
 fluid has been admitted into the blood through these vessels. 
 
276 PUEEPEEAL LYMPHANGITIS 
 
 As we frequently find thrombosis extending higli up, even 
 beyond the first intervening lympliatic glands, we therefore 
 have sufficient proof, that the lymph was rendered coagulable 
 by a local process, and that it coagulated spontaneously only 
 after a certain time. 
 
 In the same manner we will be obhged to explain those 
 cases in which we find adenitis without thrombosis of the 
 lymphatics. These are frequently the worst cases, and I am 
 compelled to conjecture, that the fluids absorbed in such were 
 absolutely uncoagulable, and that the fibrinogenous substance 
 was previously decomposed^and so chemically transformed as to 
 render coagulation impossible. At the same time a leucocy- 
 thcemic condition of the blood is developed, and general infec- 
 tion is evident from the well-known secondary affections which 
 we recognize in various organs, presenting the character of 
 phlegmonous inflammation, and even diphtheritic degeneration. 
 
 The connections between the lymphatic dilatations and the 
 lymphatic ducts is not always easily recognized, as the vessels 
 frequently appear deflected from the well-defined distended sac. 
 
 After lymphatic thrombosis has existed for a certain time, a 
 secondary derangement of nutrition, generally of an inflamma- 
 tory character, is developed in the walls of the lymphatic ves- 
 sels (lymphangitis). * 
 
 The anatomical characteristics of lymphangitis are well 
 known ; while at the commencement the inner coat of the 
 vessels was smooth and glossy, it now becomes dim, grayish, 
 opaque, and is easily removed, and the outer coat becomes thick- 
 ened from imbibition and proliferation of cells, small purulent 
 collections being formed beneath the inner coat of the vessel, 
 which are visible as pale yellow spots. The muscular elements 
 of the wall of the vessel generally become atrophied from fatty 
 degeneration, and at the same time you perceive that the 
 thrombi have deliquesced into a purulent mass. In the higher 
 degrees of this disease, the wall of the lymphatic vessel frequently 
 appears bluish-red from imbibition, and its purulent contents 
 
OF THE UTERUS. 277 
 
 show a bloody tinge, attributable not to a direct admixture of 
 blood, but also to imbibition. Finally, the contents of the 
 vessels degenerate into a discolored, dar.v-brown, nauseous 
 iclior, its wall is likewise discolored or even destroyed, and 
 the lymphatic sac is thus made to communicate with ichorous 
 cavities formed from degeneration of abscesses originating in 
 the uterine tissue, or, in the walls of the lymphatic vessel. This 
 condition is chiefly found in those cases denominated by Boer 
 as piitrescence of the uterus. 
 
 Puerperal lymphangitis^ strictly speaking, is therefore a ter- 
 tiary disease, that is, from diffuse metritis, especially when it 
 assumes a phlegmonous character (internal malignant erysip- 
 elas), thrombosis of the lymphatics is first developed, and in 
 consequence of this, inflammation of the lymphatic walls. This 
 does not mean to imply that lymphangitis cannot possibly 
 occur independently of thi'ombosis ; in such cases, inflamma- 
 tion of the glands along the vertebral column, and of the 
 iliac and inguinal regions, generally exists. At the same time 
 we must presume, that an infection of the blood has preexisted, 
 the consequences of which are frequently apparent in other 
 organs after death. 
 
 The most important and frequent consequences of lymphan- 
 gitis are the following : 
 
 The peritoneum is first affected, peritonitis setting in with 
 copious exudation and abundant production of fibrin and 
 pus. The spleen is always enlarged, softened, and dark-red ; 
 the Malpighian bodies are often greatly enlarged, and milk- 
 white ; the liver is sometimes enlarged and blood-red, but in 
 the majority of cases it is flaccid, ansemic, and appears fatty, 
 and microscopical examination distinctly shows an acute degen- 
 eration of its elements, similar to that found in Eokitansky's 
 acvie yellow atrophy of the liver. Buhl describes this condition 
 more minutely, and takes it for granted that Rokltansky's 
 yellow atrophy of the liver is only the highest degree of a 
 process frequently met with in a slighter degree. By de- 
 
278 PUEEPERAL LYMPHANGITIS 
 
 monstration of the primary seat of the infectious disease being in 
 the uterus, the concomitant affections of the Hver appear only 
 as a partial phenomenon of an analagous process occurring also 
 in other organs. Thus, we almost constantly find fatty meta- 
 morphosis of the muscular fibres of the heart, which is apparent 
 to the naked eye from the condition and pale-yellow color of 
 the organ. 
 
 Buhl also found acute softening of various muscles of 
 the body ; once those of the right arm ; another time, the 
 glutei muscles of the left side, with staff-like scattering, 
 and molecular degeneration of the bundles of muscular fibre 
 into a reddish-yellow or reddish-brown pulp, imbibition with 
 granular parenchymatous fluid, varicosity of the capillaries, 
 and infiltration of their walls with molecules. The kidneys 
 are frequently found in a flaccid condition, and their epithelium 
 partly in a state of cloudy sioelling, other parts of them contain- 
 ing fattymolecules and undergoing destruction. 
 
 Buhl describes a case in which the pancreas was enlarged at 
 least one-half, from parenchymatous inflammation ; and in some 
 cases in which adenitis extended up the vertebral column, I 
 have seen the pancreas considerably tumefied from interstitial 
 oedema. 
 
 Among the consequences of this infection of the blood, we 
 never meet with metastatic abscesses of the lungs, but not unfre- 
 quently with diphtheritic sloughing of the bronchial mucous 
 membrane and a similar lobular affection of the lungs. I have 
 also the notes of a case in which the lymphatic glands, situated 
 at the pulmonary hilus of the left side, were gangrenous, and 
 ichorous infiltration extended quite a distance along the bron- 
 chus, with diphtheritic deposits in the surrounding lung tissue. 
 Buhl mentions the increased destructibihty of the pulmonary epi- 
 thelial cells, the contents of which appear dusky and dim owing 
 to the presence of a fine granular substance ; once he observed 
 lobular diphtheritic inflammation of both lungs. Pleurisy, 
 which is also frequently observed, is engendered, according to 
 Buhl and E. Wagner, by local lymphangitis. 
 
OF THE UTEEUS. 279 
 
 From the manner in which these secondary affections 
 appear, it is evident that they have distinct characteristics, 
 and must be attributed to a derangement of nutrition, which 
 can be accounted for in no other way except that of blood- 
 infection from absorption of putrescent fluids (ichor?emia). All 
 these secondary affections, in my opinion, may be classified in 
 two groups ; they are either merely active inflammatory 
 processes, arising from a continuation and extension of inflam- 
 mations originating in the uterus, and nearly allied to 
 erysipelas, or, they are complicated in the above manner with 
 lymphatic thrombosis simultaneously with infection of the 
 blood. These alterations are characterized by an abundant 
 exudation of fibrin and formation of pus ; or they are due to 
 asthenic derangements of nutrition, as in fatty degeneration of 
 the liver and heart, and I would call attention to the frequency 
 of fatty degeneration of these organs manifesting itself, although 
 in a slight degree, even during pregnancy. However, I do 
 not mean to contradict the statement of Buhl, that in the liver 
 and kidney a specific parenchymatous infiammation is fre- 
 quently met with. ^^ ^^ 
 
 d. PUERPERAL VENOUS THROMBOSIS, AND PUERPERAL 
 METROPHLEBITIS. 
 
 Puerperal thromboses are formed in the venous system, 
 especially the utero-vaginal plexus, the origin oi the hypogas- 
 tric and internal spermatic vein (pampiniform plexus), either 
 as primary or secondary thrombosis. 
 
 Primary thromboses are either continuances of those at the 
 seat of the placenta, or they are developed from compression, 
 dilatation, or marasmus. 
 
 I have already stated the fact established by Virchow, that 
 contraction of the uterus, although essential, is not sufficient to 
 arrest the haemorrhage from the placental veins, and that 
 closure of the compressed venous extremities is finally accom- 
 
280 PUEEPEEAL VENOUS TSEOMBOSIS 
 
 plishcd by a physiological thrombosis. The size of these 
 thrombi must be in proportion to the contraction of the nterus, 
 and, consequently, according to the intensity of the endome- 
 tritis, we find at the seat of the placenta small or large thrombi 
 which give the characteristic uneven and nodulated appear- 
 ance to this part. Thrombi thas developed sometimes extend 
 in a central direction, and as a matter of course, the point 
 of placental attachment will determine this direction. At first 
 thrombosis generally affects the uterine veins, and from them 
 extends to those of the broad ligaments, thence to the internal 
 spermatic veins, or in rare instances, to the hypogastric and 
 iliac veins, from which it may extend in a peripheric direc- 
 tion to the crural veins. 
 
 Thrombi in the uterine veins are formed by continuous 
 apposition, and generally wholly occlude the cavity of the 
 vessels. At the commencement, they are pale yellow or reddish 
 in color, tolerably firm, and adhere to the walls of the veins, 
 which as yet show no apparent alterations. At a later period 
 the centres of these thrombi, either at isolated points or in larger 
 portions (generally within the seat of the placenta), begin to 
 soften, finally they are transformed into a yellowish or red- 
 dish-yellow purulent pulp and assume the appearance of hollow 
 tubes. By this time a change is also apparent in the walls of the 
 veins ; their inner coat becomes dull, felt-like, and friable, 
 their muscular coat is destroyed or softened, and dimmed with 
 fine granular elements, small purulent collections are some- 
 times formed in their external coats. After the dissolution of 
 an entire thrombus, the walls of the vein are likewise destroyed, 
 and an abscess is developed in the uterine tissue. 
 
 Dissolution of occluding thrombi, as already described, 
 consists chiefly in a breaking up of the coagulated fibrin 
 mixed with the colorless elements of the blood, generally in a 
 state of degeneration, and perhaps a small amount of free fat 
 and cholesterine chrystals. Sometimes, however, the coagula 
 are transformed into an offensive dirty, pale or reddish-brown 
 
OF THE UTERUS. 281 
 
 ichorous fluid, followed by destruction of the walls of the veins, 
 and consequently causing the formation of large icho- 
 rous cavities, the walls of which are composed of gangren- 
 ous tissue. 
 
 In proportion as the dissolution of a thrombus advances, it 
 increases in a centripetal direction, its cavity always remaining 
 closed at the end farthest from the open extremity of the vein. 
 It rarely happens that the central dissolution of the thrombus 
 extends so far as to cause that extremity of it which opposes 
 the current of blood to be only a line in thickness. 
 
 Puerperal thrombi may also be developed in consequence of 
 compression of the veins, especially of the common and 
 external iliac and hypogastric veins. They are also sometimes 
 formed during pregnancy, but generally during labor, especially 
 in unfavorable presentations, owing to the pressure of the 
 child's head upon the veins, and arrested venous circulation. 
 (Velpeau). 
 
 Thrombosis from dilation occurs in the pampiniform, as well 
 as the utero-vaginal plexuses. These veins are considerably 
 distended during pregnancy, and after labor an active contrac- 
 tion of the veins must take place to prevent the current of blood 
 from being so slackened as to cause the formation of thrombi. 
 K this contraction does not occur, coagula are formed in them, 
 which ultimately extend in the same manner as placental 
 thrombosis. 
 
 We may class with thrombosis developed in consequence 
 of dilatation at the seat of the placenta, those thrombi formed 
 by retention of a portion of the placenta. If a portion of 
 placenta adheres more firmly to the uterus, the corresponding 
 uterine tissue cannot contract so perfectly as the rest. The 
 tissue of the placenta, ramifying into the venous trunks, 
 maintain a certain expansion of the uterine tissue, giving rise 
 to the well known obstinate haemorrhages and thromboses, 
 the cause of which I attribute to this dilatation of the veins. 
 
 Finally, thrombi are sometimes formed during the puerperal 
 26 
 
282 PUEEPEBAL METEOPHLEBITIS 
 
 state, and for the present, unless a local cause be found for this 
 occuiTence, we must assuroe that a so-called marastic thrombosis 
 has been developed from a lessening of the heart's action. Its 
 production during the puerperal state may easily be accounted 
 for if endometritis or metrolymphangitis is present, as molec- 
 ular alterations of the muscles of the heart, previously alluded 
 to, sufficiently account for the diminished contractile power 
 of the organ. 
 
 The consequences of thrombosis, from whatever cause they 
 may be developed, are generally the same. In the first place, 
 from continued extension of coagulation, they may reach the 
 main venous trunks, and their conical extremities may pro- 
 ject into the latter. A large venous trunk may thus be occluded 
 by new coagula, whereupon the consequences of interrupted 
 venous circulation are developed in the corresponding parts. 
 Thus, the so-called phlegmasia alba dolens may be produced by 
 thrombi developed at the seat of the placenta extending into 
 the iliac vein. More frequently, however, this disease seems 
 to be occasioned by thrombosis arising from compression or 
 dilatation. 
 
 A further local consequence of thrombosis is inflammation of 
 the walls of the veins ; phlebitis is then superadded to throm- 
 bosis. The alterations then occuring in the walls of the veins 
 have already been described. 
 
 Puerperal uterine phlebitis generally leads to the formation of 
 abscesses originating chiefly in the outer coat of the uterus, and 
 the formation of ichorous cavities which are most extensive 
 in the highest degrees of endometritis (putrescence of the 
 uterus). 
 
 The most important consequence of thrombosis is the 
 danger of emboh, large or small portions of softened thrombi 
 being carried off by the circulation, and arrested chiefly in 
 the pulmonary vessels. Large emboli may occasion sudden 
 death by obstructing the pulmonary artery. Smaller parti- 
 cles become lodged in peripheric ramifications of the pulmonary 
 
OF THE UTERUS. 283 
 
 artery, causing either sudden occlusion of the vessels, 
 ischsemia in the surrounding tissue, and increased collateral 
 circulation with haemorrhages, or, they diminish the cahhre of 
 the vessels in which they have lodged, and secondary thrombo- 
 sis being developed, leads to complete occlusion of the vessels. 
 In both instances, especially when degeneration of the thrombus 
 has alread}^ commenced, or ichorous cavities have been 
 formed in the uterine tissue, so-called metastatic abscesses 
 and gangrenous affections of the lungs are developed, which 
 latter have a tendency to ultimately involve the pleura, and, in 
 consequence of the perforation of the latter, ichorous pleurisy 
 or pneumo-pyothorax is developed. 
 
 If in conjunction with metastatic abscesses in the lungs, sim- 
 ilar destruction of portions of the spleen, kidneys and brain are 
 found, they must generally be attributed to mechanical meta- 
 stasis originating in the lungs. Sometimes, however, meta- 
 static abscesses are found in the last named organs, the origin of 
 which cannot be traced to the lungs. In such cases I have been 
 unable to convince myself that small detached particles pass- 
 ing through the entire capillary circulation of the lungs without 
 being arrested, could so increase by apposition during their 
 transit through the blood, as to occlude the smaller arteries of 
 the spleen, kidneys and brain. In such cases I would rather 
 search for the source of the embolus in the left ventricle of 
 the heart, and I have been able to demonstrate so-called 
 globulous vegetations in the apex of the left ventricle, the 
 origin of which could easily be referred to an affection of the 
 muscular tissue of the heart. 
 
 Although hitherto we have spoken of puerperal uterine 
 phlebitis, only as a secondary affection, still, there is not doubt 
 but that sometimes it is primarily developed during the puer- 
 peral state, thrombosis ensuing as a secondary phenomenon. 
 Metro-phlebitis generally occurs in the highest degrees of puer- 
 peral endometritis, and usually originates at the seat of the 
 placenta. Consequently it most frequently affects the upper 
 
284 PUEEPERAL PERITONITIS. 
 
 portions of the uterus, but sometimes extends downward along 
 its lateral walls. 
 
 Notwithstanding the frequent occurrence of all the condi- 
 tions favorable to an extension of thrombosis, puerperal 
 thrombosis is quite a rare affection, a fact already noticed by 
 Cruveilhier. More rarely still do we observe puerperal 
 metrophlebitis, especially as a primary affection. 
 
 €, PUERPERAL PERITONITIS. 
 
 Puerperal peritonitis is either general or partial. In the 
 latter form it chiefly affects the peritoneum of the uterus, 
 btoad ligaments and pelvic viscera in general (pelvic perito- 
 nitis). 
 
 Partial peritonitis is generally a consequence of puerperal 
 metro-salpingitis, which is itself due to endometritis. 
 
 General peritonitis is either developed from partial perito- 
 nitis, or it occurs as a direct complication with the puerperal 
 state, and, Kke inflammations of other serous membranes, 
 must be referred to ichorsemia. It is, therefore, combined 
 with endometritis, thrombosis of the l}Tnphatics, and puerperal 
 lymphangitis. 
 
 I must contradict the assertion of some authors that a slight 
 perimetritis occurs after every normal delivery during the puer- 
 j)erium, and that in every woman who dies during the puer- 
 peral state, although from no puerperal disease, products 
 of inflammation are found on the peritoneum covering the 
 uterus, in the form of thin, pale-yellow, false membranes. But 
 it cannot be doubted that peritonitis may be developed during 
 the puerperal state, especially in the form of perimetritis or 
 pelvic peritonitis, independently of salpingitis, oophoritis, or 
 ichoraemia. A predisposition arising from previous similar 
 affections or excessive traction of the peritoneum during labor 
 must account for such cases, as derangements and altera- 
 tions of circulation sufficiently explain the return of an affec- 
 
PUERPERAL PERITONITIS. 285 
 
 tion which otherwise has no connection with the puerperal 
 state. 
 
 Pelvic peritonitis is characterized by proliferation of connec- 
 tive tissue which, in the form of pseudo-membranous bands 
 and membranes, binds the pelvic viscera together, and may 
 consequently give rise to serious consequences, which will 
 be discussed with affections of the ligaments of the 
 
 UTERUS. 
 
 General peritonitis is frequently accompanied with abundant 
 exudation, development of pus and proliferation of tissue. 
 The abdomen is generally distended to an enormous extent, 
 the intestines are filled with gas, adjoining portions of them 
 become agglutinated by yellow coagula which sometimes 
 present a distinct icteric tinge, and the points of agglutination 
 are surrounded by a circle of congestion. Here and there 
 a whey-like, purulent fluid is enclosed between the agglutina- 
 tions. The intestines occupy the anterior and superior por- 
 tions of the abdomen, the lateral portions and the pelvic 
 cavity containing a turbid, whey-Kke exudation, mixed with 
 fibrinous coagula. Frequently thick pus from its weight 
 accumulates at the bottom of the pelvic cavity. 
 
 In the highest degree of endometritis, which is frequently 
 combined with ichorous puerperal salpingitis, also when 
 metritis or puerperal oophoritis have terminated in abscesses 
 or perforation, the exudation degenerates into a pale, brown- 
 ish-red, nauseous, discolored fluid ichor, usually with accom- 
 panying intense inflammation of the peritoneum of the uterus 
 and appendages. 
 
 Puerperal peritonitis alone, will often cause sudden death, but 
 its fatality is still greater when compHcated with other 
 diseases. In other cases it continues for a long time as 
 chronic peritonitis ; the purulent collections mentioned become 
 encysted by proliferation of peritoneal connective tissue, and a 
 considerable amount of pus collects between adherent intes- 
 tines and in encysted portions of the peritoneum. Pus thus 
 
286 PUERPERAL PERITONITIS. 
 
 encysted may become harmless from fatty degeneration and 
 may undoubtedly be absorbed, or transformed into a whitish, 
 fatty pulp, mixed with calcareous salts. In other cases, 
 however, the production of pus from the connective tissue and 
 the destruction of purulent elements continues, and the patient 
 ultimately dies from exhaustion. 
 
 These purulent collections will not unfrequently cause 
 destruction of the tissue around them, the false, membrane 
 undergoing fatty degeneration or sloughing inwardly. This 
 destructive process extending to the peritoneum and walls 
 of the intestines, finally causes perforation of them, and thus 
 allows the escape of gas and fecal matter into these encysted 
 cavities, whereupon the pus contained in them decomposed 
 into ichor, and either acute extension of the peritonitis or 
 ichorsemia terminates the life of the patient. The involution 
 of the uterus in this case is always arrested, and its tissue 
 remains flaccid and friable for a long time. 
 
 The ichorous process in the peritoneum (peritoneal phthisis) 
 according to what has been said, may extend not only to the 
 mtestines, but also to all the pelvic viscera, and the abdominal 
 walls. Communications may be formed between several 
 cavities, or perforations of various canals and reservoirs (gall 
 and urinary bladders), of the diaphragm and anterior ab- 
 dominal wall may take place ; parametritis may extend from 
 Douglas' sac, and the ichorous cavities may penetrate to the pel- 
 vic bones, involving their periosteum, and causing superficial 
 necrosis of them, or they may perforate through the perineum, 
 and even into the vagina. Erosions of the adjoining abdominal 
 viscera (hver and spleen), with considerable haemorrhage, 
 have also been observed as consequences of such peritoneal 
 ichorous cavities. 
 
 In acute peritonitis, extreme distention of the intestines, 
 and consequently of the entire abdominal cavity, is caused by 
 paralysis of their muscular coat ; the diaphragm in such cases 
 is sometimes pressed upward as far as the level of the superior 
 
PtTERPEEAL FEVER. 287 
 
 margin of the third rib, at the same time the heart is pushed 
 considerably to the left, and sometimes there is compression 
 of the inferior lobes of both lungs. 
 
 With the exception of puerperal oophoritis and metrosalpin- 
 gitis, we have described those conditions which form the 
 anatomical bases of so-called puerperal fever. The depend- 
 ence of these several processes upon each other is easily under- 
 stood, and it now only remains for me to describe the manner 
 in which the several affections are combined, and the group 
 of consequences which correspond to the several groups of 
 complications. 
 
 Endometritis is generally the primary affection, and is fre- 
 quently combined at its very commencement with diffuse, or 
 at least partial metritis, where deep lacerations of the uterine 
 tissue have occurred. 
 
 Most frequently, endometritis and diffuse metritis, which 
 latter easily escapes attention, are combined with lymphatic 
 thrombosis, lymphangitis, or adenitis. The disease generally 
 assumes the character of erysipelatous inflammation of the 
 skin and connective tissue, and as the cause of this specific 
 affection (malignant puerperal erysipelas, Virchow,) miasmatic 
 and contagious influences are adduced. We, therefore, 
 mostly meet with these forms in post-mortem examinations 
 made during puerperal epidemics. The infection of the 
 blood, therefore, originates in the uterus, chiefly in an indirect 
 manner, from infection of the lymphatic fluids. Lymphatic 
 thrombosis stands in a different relation to lymphangitis 
 than venous thrombosis does to phlebitis. Where primary 
 phlebitis occurs, venous thrombosis is always the direct 
 consequence of it, and from this, the mechanical metastases, 
 which are almost regularly developed in consequence of these 
 thrombi. But, if lymphangitis occurs primarily, coagulation of 
 lymph is not a necessai'y consequence, the effect of deranged 
 
288 PUEEPEEAL FEYEE. 
 
 nutrition on the vascular wall being insufficient to cause 
 spontaneous coagulation of the fibrinous substance in the 
 lymphatic fluid. In puerperal lymphangitis, therefore, me- 
 chanical metastasis very rarely occurs, but general infection 
 is produced by the entrance of ichorous fluids into the blood, 
 from the lymphatics. The consequences of this ichorsemia 
 have already been mentioned. They appear in the form of 
 erysipelatous or diphtheritic inflammations of other organs. 
 We are unable to prove that these processes are the results of 
 mechanical metastasis, and are constrained to believe, that 
 in the affection of the blood alluded to, the connective tissue 
 is first in danger of being secondarily affected. 
 
 In regard to only a few of these affections, as for instance per- 
 itonitis, abscesses in the liver and spleen, and possibly pleurisy, a' 
 direct extension from the lymphatics communicating with the 
 uterus might be surmised. Whether lymphatic thrombosis may 
 originate and extend in a peripheric manner, as for instance, like 
 venous thrombosis, may be admitted from analogy, but direct 
 proofs are wanting. It is apparent that if lymphatic throm- 
 bosis extends along the lumbar plexus, or, if the lymphatic 
 glands of that region participate in the inflammation from com- 
 tinuity, the lymphatic current coming from the lower extremi- 
 ties will likewise stagnate, and finally give rise to phlegmasia alba 
 dolens, which may arise from such a condition (C. Braun). 
 This reminds me of those cases in which, notwithstanding 
 extensive inflammatory oedema of the lower extremities, no 
 coagulation is found in the veins. Notwithstanding the dis- 
 senting opinions of many pathologists, I cannot lay aside the 
 hypothesis that phlegmasia alba dolens may also originate in 
 this manner, especially as in these cases the inguinal glands 
 are generally found in a state of inflammatory swelling. Simple 
 thrombosis of the veins does not sufficiently explain spargano- 
 sis puerperarum, for the former is not always combined with 
 the latter. Probably infection of the blood must be super- 
 added, and this must be taken into consideration in lymphan- 
 
PUERPERAL FEVER. 289 
 
 gitis, as well as in Ivrnpliatic thrombosis, wlien considered as 
 a cause of sparganosis pnerperarnm. 
 
 Virchow distinguishes two forms of puerperal peritonitis, — a 
 malignant form of diphtheritic character, and a milder one 
 with superficial exudation and formation of pus. The former 
 belongs to well marked endometritis with lymphangitis, 
 whilst the latter exists in the milder degrees of endometritis, 
 and frequently arises from extension of salpingitis. 
 
 It is very rare that endometritis is combined with metro- 
 salpingitis and thrombosis. Cruveilhier, who made no distinc- 
 tion between thrombosis and phlebitis, remarks the rarity of 
 metro-phlebitis in comparison with puerperal lymphangitis, 
 and he sought to explain the infrequency of metastatic 
 abscesses in the latter disease by assuming that the pus con- 
 tained in the lymphatic veins was prevented from entering the 
 circulation by the intervening lymphatic glands. We have 
 remarked, on the strength of recent investigations, that 
 infection of the blood may take place through the lymphatics, 
 not by the formation of embolic metastasis, but b^^ the 
 transportation of ichorous fluid, which passing without 
 difficulty through the lymphatic glands may produce ichor- 
 semia and its consequences. In such cases adenitis always 
 exists, because the material elements of the ichorous fluid 
 arrested in the lymphatic glands must necessarily occa- 
 sion considerable irritation of the latter ; probably also lym- 
 phangitis, however slight, is always present. Cruveilhier also 
 noticed the frequency of the combination of puerperal lym- 
 phangitis with peritonitis, whilst phlebitis he states, is rarely 
 combined with it. 
 
 The dissertations pubhshed at Vienna and Prague during 
 the fifth and part of the sixth decennium of this century, upon 
 the origin of puerperal fever, are all written under the immedi- 
 ate influence of the Crasis theory, carried by Engel to its cli- 
 max, and consequently the cause of puerperal fever was sought 
 for in a pecuhar condition of the blood of pregnant women, and 
 27 
 
290 PUERPERAL PARALtSiS 
 
 it was asserted that hyphiosis afforded an immunity from 
 the croupy forms of puerperal fever, and that the hyperinotic 
 form was apt to change into the j9?/(^?/zzc, and in severe 
 epidemics, into the sej)tic forms. To Yirchow the credit 
 chiefly belongs of having overthrown these mystic views, and 
 Buhl's excellent work on the details of these affections, as well 
 as Yirchow's on lymphatic thrombosis and its relation to 
 lymphangitis and diffuse metritis, have probably mainly con- 
 tributed to elucidating the points in question. 
 
 The remaining puerperal affections of the uterus have no 
 direct connection with the combination of symptoms commonly 
 called puerperal fever, and I shall now proceed to the con- 
 sideration of them, although contrary to the order hitherto 
 observed. It was my intention to place at the head of this sec- 
 tion the most important affections which are generally found 
 combined in clinical cases ; and this may be my excuse for 
 subsequently considering other not less interesting puerperal 
 affections. 
 
 /. PUERPERAL PARALYSIS OF THE WHOLE UTERUS, AXD 
 ESPECLiLLY OF THE SEAT OF THE PLACENTA. 
 
 Literature: ColombeDela delivrance, these soutenue a la Faculte 
 de Med. de Paris. 1834.-8 t o 1 1 z , De la delivi-ance. Strasbourg. 1834 — 
 R o k i t a n s k y, Handb. d. spec. path. Anatomic. Wieu 1842. pg. 555. 
 
 — J. E n g e 1 , Todtliche Metrorrhagie iu Folge partieller Liihrnung des 
 Uterus. Med. Jahrb. d. osteiT. Staates. Wien 1842. XXXI. Bd. ; 2. St. 
 pg. 310. — K i TV i s c h , Klin. Yortr. L Prag 1854. pg. 354. — 
 Meigs, Obstetric, mem. the Science and the Art. Philadelphia 1849. 
 
 — M e r r i m a n , i\[ed. Times 1851 July. 
 
 Rokitansky was the first to call attention to a condition 
 which is noticed after diflicult and protracted deliveries, 
 and which consists of complete atony and non-contractility of 
 the muscles of the uterus. In such cases the uterus is 
 extremely large, thin-walled, rather more collapsed than con- 
 tracted, flaccid, and evidently in a paralyzed condition. 
 
OF THE UTEPwUS. 291 
 
 These phenomena are either apparent in the whole organ or 
 hmited to portions of it. The paralysis is either complete or 
 partial. 
 
 Partial paralysis more frequently affects the inferior than the 
 superior portion of the uterus, and, according as it is either 
 lateral or annular, the organ assumes various forms. The 
 greatest portion of tissue seems to be accumulated in the non- 
 paralyzed parts of the uterus, whilst the paralyzed portions 
 are thin and flaccid. 
 
 The occurrence of such a paralysis may be due to two causes. 
 In the first place fatty metamorphosis may occur during preg- 
 nancy at certain points, which, however minute, can be de- 
 monstrated with the microscope, and must be considered suffi- 
 cient cause of imperfect contractions at such points. Kiwisch 
 and Scanzoni have both remarked, that undoubtedly in many 
 cases, partial metritis is developed during pregnancy and 
 may lead to spontaneous rupture of the gravid uterus. Other 
 causes may likewise produce derangement in the nutrition of 
 corresponding tissue, and gradually cause fatty degeneration 
 of muscular fibre and paralysis of that portion of the uter- 
 us. Constant pressure from without (as from a projecting 
 promontory), or from within (as from pressure of foetal parts), 
 may give rise to derangements of nutrition in portions of the 
 uterus, and therefore gradually produce paralysis of the affect- 
 ed portion. 
 
 On the other hand, the causes of imperfect uterine contrac- 
 tions seems sometimes to be dependent on constitutional causes. 
 It has long since been known that sometimes after successive 
 efforts during labor, or exhausting pains, death suddenly takes 
 place. The anatomical examination of such cases frequently 
 reveals an imperfect contraction of the uterus, but beyond this 
 nothing but hypinosis ; consequently acute defibrination of 
 the blood has occurred, as happens in acute tuberculosis. In 
 such cases a slight haemorrhage has usually taken place during 
 labor, which, in itself however, is absolutely insufficient to 
 explain the fatal termination. 
 
292 PCTERPEEAL PAEALYSIS 
 
 As perfect contraction of the uterus is an indispensable requi- 
 site to the stoppage of haemorrhage, partial or complete paraly- 
 sis of the organ is consequently a fi'equent cause of puerperal 
 haemorrhage. 
 
 Imperfect contraction of that portion of the uterus to which 
 the placenta was attached is of the greatest importance, for 
 when such is the case, this portion descends into the distended 
 uterine cavity in the shape of a conical or ovoid mass with 
 a neck-like contraction, whilst the rest of the uterus is tol- 
 erably well contracted. On the corresponding external sur- 
 face of the uterus there is an infundibuliim-like depression, 
 or a more or less considerable inversion of the uterine walls. 
 The inverted part, filling the cavity of the uterus like a tumour, 
 is spongy, bleeds readily, and exhibits the characteristics of the 
 seat of the placenta ; in the majority of cases either a retained 
 portion of placenta or large coagula are attached to it. 
 
 Eokitansky remarks, that such inversion of the paralyzed 
 seat of the placenta is often owing to mechanical removal 
 of the latter, and I attach much importance to this fact, as I 
 am unable to understand why the paralyzed portion of tissue 
 should always sink into the uterine cavity, as the latter is 
 diminished by energetic contraction of the rest of the uterus. 
 It seems absurd to suppose that pressure of the intestines could 
 cause inversion of the paralyzed portion of the uterus. Abso- 
 lute or relative shortness of the umbilical cord, in some 
 cases, may also be considered as a cause of inversion of the 
 paralyzed portion. The consequences of the above condition 
 are haemorrhages which may terminate fatally. 
 
 The frequency of this occurrence after miscarriages is remark- 
 able, and the first case described by Engel was that of a woman 
 thirty-four years old, who had passed safely through seventeen 
 deliveries and yet miscarried at the fourth month of the 
 eighteenth pregnancy. In this case Engel considered the 
 number and rapid succession of the pregnancies as causes of 
 the paralysis at the seat of the placenta, and he states that the 
 
OF THE UTERUS. 293 
 
 tumour formed by the inverted paralyzed portion might easily 
 have been mistaken in the dead body — and much more so in 
 life — for an adventitious growth, or a polypus ulcerated at its 
 extremity. 
 
 Here it is proper to consider the possibility, admitted by 
 many, of the entrance of air into the open uterine veins. The 
 etatement of Cormack (London Med. Journal, October 1850,) 
 that the uterus, when relapsing into a relaxed condition after 
 contraction, absorbs a considerable amount of air, unless the 
 open extremities of the veins be closed by coagula ; and that 
 the au' thus absorbed is afterwards forced through the veins by 
 renewed contractions of the organ, is founded on the errone- 
 ous supposition that relaxation of the uterus may cause the 
 walls of the veins, which were formerly in apposition, to be 
 again separated. If the first contraction, which closes the 
 veins, could be overcome by other antagonistic contractions 
 the effect of which would open the veins ; if muscular fibres ex 
 isted analogous to the radial and circular fibres of the iris — 
 then entrance of air would be inevitable, but upon the cessation 
 of that uterine contraction which causes the walls of the veins 
 to come together, they possessing too little elasticity, can- 
 not, like a rubber tube, reassume the shape of open vessels. I 
 have not yet seen a case which convinced me that air had 
 passed into the open veins of a recently delivered uterus, and 
 I cannot conceive the mechanical possibility of such an occur- 
 rence. Lionet, Lever and Simpson assert, that they have 
 observed such cases, and further remark, that the occurrence 
 was immediately followed by a scarlatinous discoloration of 
 the skin, which may be explained as the effect of sudden 
 oxydation of the blood contained in the capillaries of the 
 the skin. Without wishing to lessen the authority of Simpson, 
 it is impossible not to advance the question, whether this was 
 not a case of Helm's jpuerperal scarlatina with rapid putres- 
 cence and development of putrescent gases in the blood ? 
 
294 H^MOEEHAGES 
 
 g. HEMORRHAGES OF LYING-IN WOMEN. FIBRINOUS POLY- 
 PUS (KIWISCH). INTRA-UTERINE PLACENTAL POLYPUS 
 (C. BRAUN). 
 
 Literature: Kiwiscliv. Rotterau, Klin. Yortrage etc. Prag 
 1845. I. pg. 420. — F. M. K i 1 i a n , Henle u. Pfeuffer's Zeitschr. fiir 
 ration. Medicin 1848. V. 2. pg. 149. — Chiari, Braiinu. 
 S p a t h , Zur Lelire und Beliandlung der Hiimorrliagien. Klinik der 
 Gebiirtsb. u. Gynacologie. Eriangen 1852. pg. 167. — Scanzoni, 
 Die Genese der fibrinosen oder Blutpolypen des Uterus. Verliandl. der 
 physic, med. Gesellscli. zu Wlirzburg Eriangen 1852. II. pg. 30. — Ki- 
 wi s c b , Notiz. ilber fibrinose Polypen des Uterus, same journal pg, 
 218. — Vircbow, same journal — Mikscliik, Bemerkungen liber 
 MetrorrLagien im Wochenbette, veranlasst dm-ch zuriickgebliebene Pla- 
 centareste. Zeitschr. d. Ges. d. Aerzte. Wien 1854. Juni. 6. pg. 469. — 
 Scanzoni, Lehrb. d. Krankh. der weibl. Sexualorg. Wien 1857. 
 pag. 228. — Rokitansky, Ein Beitrag zur Lehre vom Abortus 
 und vom fibrinosen Uterus-Polypen Zeitschr. der Gesellschaft d. Aerzte. 
 Wien 1860. Nr. 33. — C. B r a u n, Ueber die Nosogenic der intrauter- 
 inen Placentarpolypen. Allg. Wiener med- Zeitung I860. 43. — S t e i- 
 g e r , Fall von heftiger Metrorrhagie, veranlasst durch ein altes Blut- 
 coaguhim in der Gebarmutterhohle. Yerh, der phys. med. Gessellsch. 
 zu Wurzburg. Eriangen 1860. X. 2. u. 3. Hft. pg. 243- — R o k i t a n s - 
 k y , Path. Anat. Wien 1865. Ill 'pag. 502 u. 538. 
 
 From preceding discussions the sources of puerperal hasmor- 
 rhage are already understood. Although it cannot be denied 
 but that by the casting off of the uterine mucous membrane 
 transformed into a decidua blood vessels may be laid open, 
 which, unless closed by uterine contraction, may bleed, still, the 
 principal source of puerperal haemorrhage must be from the seat 
 of the placenta, at which point large venous vessels are left open 
 after the placenta is detached. In addition to this, various 
 lacerations and contusions of the uterus, and secondary erosions 
 of blood-vessels from destructive puerperal processes, may 
 also give rise to fatal haemorrhages. 
 
 Those cases are of the greatest importance in which, from 
 continuous ligemorrhage, coagula are formed in the uterine 
 cavity at the point of haemorrhage and adhere directly and 
 indirectly to the walls of the uterus. With these we classify 
 
FROM THE UTEEUS. 295 
 
 \\\e Jihrinous polypi of Kiwisch, and Braun's intra-uterine jpla- 
 cental poly;pus. 
 
 Kiwiscli describes extravasations which are retained with- 
 in the uterine cavity and undergo the usual metamorpho- 
 sis ; that is, a fibrinous membrane is formed at the periphery 
 of the clot, while in its centre soft, slightly coagulated, or 
 fluid blood is found. At the same time the cavities of the body 
 and cervix of the uterus are dilated. Most frequently the coag- 
 ulum assumes the form of a pedunculated polypus, the pedicle 
 of which is composed of dirty-white fibrin whilst its body 
 consists of soft coao-ulum with a thin fibrinous coverino-. This 
 polypoid form is owing to the easier distention of the inferior 
 portion of the uterus. 
 
 Kiwisch states that he has only found this kind of polypus 
 in young women who have never borne children but have 
 indulged in sexual intercourse, and that suppression of men- 
 struation for a period of from six to twelve weeks had 
 preceded every case. Contraction of the body and fundus of 
 the uterus and the absence of an ovum, were sufficient reasons 
 to this distinguished Gynecologist to exclude any connection 
 between such formations and miscarriages. The latter cir- 
 cumstance was also deemed a sufficient distinction between 
 fibrinous polypi and blood-moles. 
 
 Kiwisch imagines, as Scanzoni proves, that tlie source of 
 this haemorrhage is ordinary menstruation, and that the reten- 
 tion of menstrual blood is owing to undue excitement 
 during coition. '* The patients always considered themselves 
 pregnant." 
 
 Scanzoni refutes the possibility of the accumulation of 
 menstrual blood in a healthy uterus, and remarks that a 
 coagulum formed by gradual extravasation cannot possibly 
 assume the form of the polypus mentioned by Kiwisch (having 
 an external fibrinous covering, and a soft red centre). 
 
 Scanzoni also called attention to the pecuhar distention of 
 the uterine cavity, which, in the majority of cases, is du'ectly 
 
296 FIBRINOUS POLYPUS 
 
 contrary to that occurring during pregnancy. "If the 
 external orifice is closed, as is frequently noticed after miscarri- 
 ages during the first four months of pregnancy, the blood ex- 
 travasated during a subsequent haemorrhage may accumulate 
 in the uterine cavity and gravitate toward the lower portion of 
 the organ, which is deficient in contractile power, and thus pass 
 into the cavity of the cervix, which has remained dilated after 
 the recent miscarriage. Gradually the body and fundus of the 
 uterus contract, which occurs more readily as the soft coagulum 
 oifers but slight resistance to the contraction, and thus the 
 upper portion of the coagulum is compressed and narrowed, 
 whilst the lower portion, lying within the less contractile 
 cervix, becomes round and club-shaped. In the firm periphery 
 of the mass, fibrin, partly unorganized, partly transformed into 
 connective tissue, is always demonstrable. The upper con 
 stricted portion of the mass, consisting chiefiy of connective 
 tissue, always adheres firmly to the walls of the uterus." (Scan- 
 zoni.) 
 
 The frequent connection of fibrinous polypi with miscar- 
 carriages is next pointed out, and the latter is considered one 
 of its principal causes. Scanzoni asserts that previous dilata- 
 tion of the uterine cavity is an indispensable condition for the 
 formation of these fibrinous polypi. The case which Kiwisch, 
 in opposition to the views of Scanzoni, cites in a later paper, 
 was insufficient to invalidate the weighty objections of the 
 latter author. 
 
 Scanzoni's views were most decidedly confirmed by Roki- 
 tansky in the description of two remarkable cases, a brief 
 account of which will be given in the chapter on extea-uter- 
 
 INE PREGNANCY. 
 
 Rokitansky's cases were as follows : ''An ovum, after its at- 
 tachment to the mucous membrane of the uterus, and after it 
 had been completely enveloped by the decidua reflexa, passed 
 from the uterine cavity into that of the cervix, there it re- 
 mained and continued to grow and distend the cervix, being 
 
OF THE UTERUS. 297 
 
 at the same time attached to the uterus by a pedicle (resemb- 
 ling a bundle of extremely elongated utricular glands) com- 
 posed of the excessively proliferating mucous membrane. It 
 is highly probable that the ovum was crowded toward the cer- 
 vix by premature contractions of the body of the uterus, and 
 not being detached, the decidua was stimulated to unusual 
 proliferation. In such cases, after the membranes were rup- 
 tured, or perforated by ulceration, and the embryo expelled, a 
 considerable portion of the membranes or the stump of the 
 pedicle might remain attached, and haemorrhage occurring, 
 they might become the nucleus of a fibrinous polypus. The 
 extravasated blood would readily accumulate and coagulate 
 in the dilated cervix, as it would be subject to only slight 
 pressure, the superior portion of the uterus being already 
 contracted. The intimate connection of the coagulated blood 
 and the membranes or pedicle of the ovum would constitute 
 an exquisite specimen of fibrinous polypus, formed by a pre- 
 vious passive dilatation of the cervix from displacement of the 
 ovum." Meissner and others have described polypi, composed 
 of a tissue similar to that of the placenta, occurring in recently 
 delivered uteri, and they mention that in several cases it appear- 
 ed as if fungoid growths had been developed from remnants of 
 placenta or decidua which remained attached, which opinion 
 was confirmed by an observation of Cams. 
 
 C. Braun believes ' ' that fibrinous polypi in the form of 
 pedunculated growths, and consisting merely of coagulated 
 blood, rarely occm- in the uterus, and that such polypoid 
 bodies are usually the productions of pregnancy, and are 
 occasioned, 1st, by abortion of the ovum during the first 
 months of pregnancy; 2d, by fleshy moles; 3d, retention of 
 an immature placenta for several weeks after the birth of a 
 non-viable foetus ; 4th, retention of a portion of matured pla- 
 centa during several months after the birth of a full-time child ; 
 5th, retention of an abortive ovum after twin pregnancy and 
 birth of a viable loetus ; and lastly, 6th, expulsion of a spuri- 
 28 
 
298 FIBRINOUS POLYPUS 
 
 ous placenta after the birth of a viable foetus, and spontaneous 
 expulsion of an apparently normal placenta." 
 
 Microscopical examination of so-called fibrinous polypi, 
 having enabled C. Braun to recognize them as parts of an 
 ovum or placenta, he is inchned to call them ""placental 
 polypV 
 
 To C. Braun also belongs the credit of having classified the 
 causes of the formations under consideration. The fieshy 
 mole mentioned as cause No. 2, I cannot consider as such, for, 
 according to Yirchow, I understand it to' be a hyperplasia of 
 the villi of the chorion, leading to the formation of a tumour 
 unconnected with hsemorrhage. It is a matter of some diffi- 
 culty, however, to class all these cases under the name of pla- 
 cental polypi. 
 
 The facts elucidated by the preceding investigations may be 
 resumed as follows. 
 
 1. We observe in the uterus polypoid masses, which are the 
 results of conception, consist chiefly of coagula, are frequently 
 attached to the fundus of the uterus by a pedicle, and depend 
 into the dilated uterine or cervical cavities. 
 
 2. These formations are incapable of further organization, 
 are never developed into pei-manent tissue, and consequently 
 have none of the characteristics of organized growths. 
 
 3. They are formed either of retained membranes of an 
 abortive ovum ; that is, membranes adherent to the uterus 
 form the nucleus of a fibrinous coagulum. This occurs previ- 
 ously to the development of a placenta ( during the first and 
 second months of pregnancy). 
 
 4. Betained remnants of placenta, or analogous productions 
 form the centre of these growths ; or 
 
 5. The coagula which occlude the open veins at the seat of 
 the placenta increase inwardly into the dilated uterine cavity. 
 
 Although I entirely coincide with the views of C. Braun 
 that the term fibrinous polypus is improper, and should cease 
 to be used, still, the proposed name of placental polypus 
 
OF THE UTERUS. 299 
 
 does not seem justified, according to the pathological anat- 
 omy of these productions and their origin, as strictly speaking, 
 only those productions mentioned in cause No. 4 deserve 
 this name, laying aside the fact that hitherto by the name 
 " polypus " a proliferation of tissue has always been understood 
 which has no relation with the productions under considera- 
 tion. 
 
 It has not unfrequently been observed that the thrombi pro- 
 jecting from the veins at the seat of the placenta, are capable 
 of increasing by the addition of new coagula, and may project 
 into the uterine cavitv as rounded masses, especially during a 
 paralyzed condition of the uterus, in which case the placental 
 veins remain partly open, and the cavity of the uterus is not 
 diminished by proper contractions These coagula, however, 
 rarely remain adherent to the uterine walls for a long time. 
 At the seat of the placenta they are either loosened and the 
 haemorrhage is renewed, or endometritis and metritis super- 
 vene, causing sloughing of them; or energetic contrac- 
 tions of the uterus expel the coagulum, at the same time 
 diminishing the size of, or closing the open veins at the above- 
 mentioned point. 
 
 The effects of retained remnants of the placenta will be 
 considered with the pathological anatomy of the latter. 
 
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