Section Ii. of the Uterus.

According to the measurements of Kilian, the uterus in the virgin adult, varies in length from twenty-four to twenty-six lines; the greatest breadth is eighteen lines; the thickness nine lines; the cervix is from ten to twelve lines long; its breadth from six to eight; its thickness from five to six lines. The length of the uterine cavity is twelve lines, and its breadth nine lines. After one or more births all these measurements increase from one-fifth to one-quarter. The weight of the uterus varies from eight to twelve drachms, and may, after several pregnancies, amount to two ounces.

=Congenital Anomalies.= The entire absence of the uterus is an exceedingly rare occurrence, and need not affect the health of the individual. A seeming multiplication of the organ is occasionally met in the bilocular and horned uterus. In the former, a more or less perfect septum extends through the organ in the median line, while in the latter, the uterus is divided into two lateral portions, by a prolongation of the angles or cornua, giving a resemblance thus to a permanent form seen in many of the lower animals. We may also find the so-called uterus unicornis, where only one of the two rudimentary bodies from which the normal uterus is developed arrives at maturity.

All these kinds of uteri are capable of becoming impregnated, but parturition, although not necessarily fatal, seriously endangers the life of the patient; owing, according to Rokitansky, partly to the want of the necessary dimensions of the part that undertakes the functions of the entire organ, and partly to the obstacle opposed to the uniform development of the impregnated half by the unimpregnated half. These circumstances favor rupture of the uterine walls.

=Hypertrophy and Atrophy.= These are in part normal at the periods of puberty and change of life; as a morbid state, the first is of more frequent occurrence than the last. Either may affect the entire organ, or only a part. After the climacteric period the cervix often disappears entirely.

=Hydrometra.= As the result of inflammatory processes, the os internum or the os externum may become occluded, causing a retention of the secretions from the diseased mucous membrane of the uterus. This secretion gradually changes into a sort of thin serum. The uterus becomes dilated, and we have hydrometra.

Hæmatometra is a condition where the uterus is dilated with serum mixed with blood, or exclusively with retained menstrual blood. This latter state is more frequently the result of congenital than of acquired atresia.

The amount of dilatation may vary greatly.

=Malpositions of the Uterus.= These may be of two kinds: (1) where the direction of the axis is changed; or (2) the organ becomes altogether displaced, so that its relation to all the pelvic viscera is altered. Of the former class, are ante- and retro-versions, with flexions, and lateral obliquities; of the latter, prolapsus procidentia and inversion.

Inversion may occur spontaneously or as the result of manual interference in the removal of the after birth. The fundus may pass but a short distance into the cavity of the organ, or the uterus may be turned completely inside out. Inversion may also result in an unimpregnated uterus from the presence of fibrous polypi, growing from the inner surface of the fundus. These growths, when complicating pregnancy, favor inversion by disturbing the regular expulsive contractions.

=Hæmorrhages.= An effusion of blood into the cavity of the uterus, occurs normally at every period of menstruation; from some morbid condition of the vessels of the uterus, it may at times amount to an hæmorrhage. Attending parturition, it may be due to placenta prævia; or following, to atony or defective contraction of the uterine walls, where we find the uterus maintaining its dilated condition with flabby and soft walls; or to spasm or irregular contraction, to which the term, “hour-glass contraction,” has been applied.

The presence of polypoid tumors is frequently attended by hæmorrhages.

=Peri- or Retro-uterine Hæmatocele=, is an accumulation of menstrual blood, generally in the utero-rectal cul-de-sac. It may arise from rupture of a blood-vessel, from defect in the excretion of the menses, or from a morbidly profuse exhalation of blood from the genital organs. The extravasation may be reabsorbed, or may by perforation be discharged by the rectum or vagina, or may lead to suppuration and the formation of an abscess.

=Inflammations.= The traces of acute catarrhal inflammation are but seldom to be discovered. They present the same features as catarrhal inflammations of other mucous membranes, congestion and swelling, with a more or less abundant secretion of muco-pus.

In chronic catarrhal inflammations, the membrane is found thickened, of a brownish or slate-gray color, with a more or less purulent secretion, often blood-streaked. The walls of the uterus may be atrophied or hypertrophied.

Catarrhal erosions, and follicular ulcers, the result of the bursting or suppuration of the stopped-up follicles, usually accompany catarrhal inflammations.

Acute Metritis. Here we find the organ swollen and congested, and its substance of a darker color. The mucous membrane shows symptoms of a catarrh, and the peritoneal covering is also congested. Occasionally extravasations of blood are found in the substance or cavity of the uterus. The inflammation may lead to the formation of abscesses within the uterine walls.

In Chronic Metritis the organ is generally much enlarged. The walls are remarkably pale and dry, thick and hard. The mucous membrane almost always presents the appearances described under chronic catarrhal inflammation, while the peritoneal covering frequently shows numerous adhesions to the neighboring organs.

=Ulcerations= may be catarrhal, with superficial erosions or follicular ulcers; or syphilitic, in the form of the hard and soft chancre; or we may, in rare cases, have the corroding ulcer, described by Dr. John Clarke, and differing from genuine carcinoma only in the absence of an indurated deposit.

Morbid Growths.

Fibroid tumors are of most frequent occurrence. They are found either imbedded in the texture of the uterus, or protruding from its inner surface into the cavity, or from some part of its external surface.

Those projecting into the cavity of the uterus, called also fibrous polypi or submucous tumors, are most frequently met with. Their pedicles are generally situated just below the openings of the Fallopian tubes, although they spring also from the posterior wall and from the fundus, less frequently from the anterior wall, and still more rarely from the cervix uteri.

Recent investigations go to show that these tumors are to be classed with the homologous, rather than heterologous productions, and that they are developments of true muscular tissue. To the naked eye this structure varies in some respects; at times they present a concentric disposition of fibres, but more commonly an irregular, wavy appearance, without any uniformity of arrangement, and in the latter case, frequently with cavities containing blood, a dark-colored gelatinous fluid, or a clear serum. Under the microscope, a fibrous structure is scarcely perceptible, but elongated nuclei are seen, imbedded in an amorphous stroma.

The vascularity of fibrous tumors varies. The majority are but scantily provided with vessels. The tumors imbedded in the uterine tissue form globular, white, glistening, dense tumors. There may be only one, or they may be numerous, and may vary in size from that of a pin’s head to that of a melon. These growths are subject also to secondary changes; thus we may find abscesses in the very centre of fibroid growths, or they may contain encysted melanotic tumors, or a species of calcification may be developed.

Fibrous tumors have not been observed before puberty, but occur, according to Lee and Bayle, most frequently in virgins.

=Polypi and Polypoid Growths.= These growths—not to be confounded with the fibrous tumors, as is frequently done—are soft and succulent, and project into the cavity of the uterus, or hang into the vagina. They are attached by a pedicle of greater or less width, to the surface from which they spring, and are covered with the mucous membrane of the part. They are essentially a morbid condition of the structures of the surface, the mucous membrane, the follicles, or sebaceous crypts of the different parts of the uterus.

Polypoid tumors may give rise to hæmorrhages. They may become inflamed, suppuration or even gangrene supervening. In this way the pedicle may be destroyed, and the tumor be expelled.

=Cysts and Tubercular Deposits= are extremely rare in the uterus. The latter affect primarily the lining membrane, where it occurs in the miliary form, or accumulated in masses, aggregated into nodules, or forming a cheesy layer over the entire surface. The uterine tissue may be secondarily affected, and is then liable to become infiltrated with the morbid product. Traces of the disease are found also in the vagina as spots of ulceration, and in the Fallopian tubes.

=Cancer.= Carcinoma of the uterus is of frequent occurrence. The period of life in which it is most frequently met with, is that between the fortieth and fiftieth years. Although met with in single women, it is found most frequently among the married.

In general, this disease attacks the cervix first, whereby it is distinguished from fibroid growths.

Many instances of supposed cancers, prove on microscopic examination, to be nothing more than an irregular thickening and induration of the cervix, consequent upon chronic inflammation.

According to Rokitansky, the prevailing form of uterine cancer is the medullary carcinoma, appearing as an infiltration of a white lardaceo-cartilaginous, or loose encephaloid matter, in which the uterine tissue is lost, and giving rise to the characteristic nodulated surface of the cervical portion of the organ.

Of rarer occurrence is the fibrous cancer, consisting of dense, whitish, reticulated fibres, containing in their meshes a pale-yellowish translucent substance. Its limits are not sharply defined, but are lost in the uterine tissue.

Nowhere does the destructive character of the cancerous disease manifest such virulence, as when attacking the uterus. The degeneration spreads more or less rapidly to the adjoining parts, and, in extreme cases, the whole contents of the abdomen are matted together, and present a frightful spectacle of disorganization and destruction.

=Cauliflower Excrescence= of the cervix, is regarded by both Rokitansky and Renaud, as a modification of encephaloid growth. It appears as an irregular projection, with a base as broad as any other part of it, attached to some part of the cervix. The surface has a granulated feel. On removal from the body it collapses, owing to its vascular character.

Morbid Conditions following Parturition.

=Rupture of the Uterus= is not unfrequent as a concomitant of pregnancy in the horned or bilocular malformation of the organ. It is also met with in the normal uterus. A laceration of the os tincæ occurs at every birth, and so long as it does not extend beyond the circular fibres of the cervix is not dangerous. The result is generally more disastrous when the rupture extends beyond this point. It may penetrate the entire thickness of the organ, so as to allow of the escape of the fœtus into the abdominal cavity, or only one layer of the walls may give way, or only the peritoneal investment may be lacerated, while the uterus itself remains uninjured. Rupture of the uterus may also result from external injury before parturition. It is not necessarily fatal. Primiparæ are more liable to this accident than multiparæ.

=Puerperal Inflammations.= Where the uterus has itself been the main seat of inflammation, we find that an exudative process has given rise to the formation of a yellowish or greenish, more or less, gelatinoid lining on its internal surface, causing a ragged, patchy appearance. This exudation may be easily detached from the subjacent mucous membrane, which, according to the intensity of the disease, is more or less reddened, tumefied and softened. This condition may penetrate to the deeper tissues, and involve the entire thickness of the uterus, which will then, also, be more or less softened and discolored, infiltrated with a thin sanious product, and even converted into a mere pulp.

The dirty-colored, brownish, flocculent matter that is found investing the inner surface of the uterus soon after delivery, and which is merely the residue of the decidua, must not be mistaken for the product of disease. The ragged appearance of the part to which the placenta was attached, due, according to Dr. John Clarke, to the remains of the maternal portion of the placenta and the coagula of blood left after its separation, is also liable to be the source of error. In both cases, however, if the apparent exudation be scraped off, which can easily be done, we find the healthy surface underneath.

In putrescence, the lowest form of uterine inflammation, we find the internal layer of the organ covered with a thin, opaque, or more dense product, varying in color from pale green to dark brown, beneath which the tissue to a greater or less depth is converted into a similar pulp. We sometimes find small abscesses within the muscular tissue without any perceptible change in the surrounding parts; in most cases, however, the structure of the muscular fibre is entirely destroyed.

Metrophlebitis. Inflammation of the venous channels and lymphatics of the uterus, is a very frequent cause of the fatal termination of cases of puerperal fever. Tonnellé found it present in one hundred and thirty-two cases out of two hundred and twenty-two. Besides the appearance of the vessels common to ordinary phlebitis, we find the uterus studded with small abscesses which may be traced to the vessels. The lymphatics may be primarily and coincidently affected, or they may be attacked separately and secondarily; the former is the more frequent. They present the same varicose appearance as the veins, and are thickened and distended with the purulent or sanious products of the inflammation.

Puerperal Peritonitis, is the lesion most commonly associated with puerperal fever. It may be confined to the surface of the organ, particularly to the part surrounding the neck, or may involve more or less entirely the whole sac. In the sthenic forms, the appearances presented, resemble those of ordinary peritonitis. In the low typhoid forms, there is a peculiar absence of congestion and redness. The ordinary character of the exudation, is a copious effusion of an aplastic character, of a dirty-yellow, greenish, or brownish hue, in which flocculent particles of lymph are found floating, while but small patches of a thin, non-coherent exudation, are observed in the peritoneal sac. The smell of the fluid is distinctive, differing from anything found in the human body in health or disease, and after having been once noticed, cannot fail to be recognized.

Extra-uterine Pregnancy.

This species of gestation may be considered under the following varieties, receiving their names according to the part of the passage where the ovule becomes fixed:

1. Abdominal Pregnancy.

2. Tubo-abdominal Pregnancy.

3. Tubal Pregnancy.

4. Interstitial Tubo-uterine Pregnancy.

5. Utero-tubal Pregnancy.

1. Abdominal Pregnancy. This includes all cases in which the fecundated ovule fails to engage in the tube. Three varieties may occur. The ovule may remain in the ruptured ovisac and there be developed, giving rise to an internal ovarian pregnancy. Should it after escaping from the Graafian vesicle adhere to the surface of the ovary, we have an external ovarian pregnancy. Finally, if the ovule, escaping from the ovary, fall into the peritoneal cavity, and there undergo development, a peritoneal pregnancy results. In the last class, the points to which the ovule may attach itself are exceedingly numerous. The placenta has been found attached to the peritoneum covering the right or left iliac fossa, sometimes to a part of the small or large intestine, and sometimes to the anterior wall of the abdomen.

2. Tubo-abdominal Pregnancy. This name is applied to those cases where the ovule having but just entered the tube, is arrested by an obliteration or constriction of the canal, and there undergoes development. The placenta is attached in the interior of the tube, and the fœtus developed in the abdominal cavity, and both are surrounded by a cyst, the walls of which are partly made up by the walls of the dilated tube. This includes also what has been described as tubo-ovarian pregnancy.

3. Tubal Pregnancy is the most frequent of all varieties of extra-uterine pregnancy. The ovule is here arrested and developed at some spot within the tube, between its abdominal extremity and the point where it enters the uterine walls. The fibres of the enormously distended tube constitute the envelope of the fœtal cyst.

4. Interstitial Tubo-uterine Pregnancy. Here the ovule is arrested in that part of the tube that traverses the thickness of the uterine walls. It may remain, during its development, enclosed by the tube, or it may make its way through these and be developed within the muscular fibres of the womb itself.

5. Utero-tubal Pregnancy is a very rare but possible form of extra-uterine pregnancy. The ovule may ingraft itself just at the internal orifice of the canal. “In this variety, the fœtus is found in the abdominal cavity; the cord leaving the umbilicus enters the Fallopian tube, traverses its whole length, and is inserted in the placenta, which is itself attached to the internal surface of the uterus.” The tube has evidently been ruptured, allowing the passage of the fœtus into the peritoneum, while the placenta remained in the uterus.

In all these pregnancies, the ovule has originally its proper membranes, the chorion and the amnion. The structure of the walls of the enclosing cyst varies according to the species of extra-uterine pregnancy. As a general rule, the fœtus exhibits nothing peculiar in its development. The most common of the numerous alterations which it may undergo, are putrescent dissolution of its soft parts, and the separation of the various pieces of its skeleton; a complete drying-up or mummification; and transformation of all its tissues into an osseous or cretaceous substance.

In the tissues of the mother, new or increased vascularity of those parts where the ovule is attached will be noticed, while the womb will be found to have sympathized with the development of the fœtus by an hypertrophy of its mucous membrane, which, however, does not last more than a few months. A gelatinous substance, a kind of thick, ropy mucus, is also frequently found in the neck of the uterus. These appearances are generally wanting in the womb, where the pregnancy has advanced beyond term.

Extra-uterine pregnancy generally terminates fatally. In the abdominal form, the pregnancy may progress to the later months of gestation, when, losing its vitality, the fœtus may decompose, producing peritonitis and death, or it may become encapsulated and gradually absorbed; or by the ulcerative process, the remains may be discharged into the intestinal canal, or through the abdominal walls. Where the case has been diagnosed before death, the dead fœtus has been successfully removed by abdominal section.

In the varieties of tubal pregnancy, rupture of the tube, and death from hæmorrhage usually takes place in the early months, as in the following case:

CASE.—Tubal Pregnancy, with Rupture of the Fallopian Tube—Hæmorrhage and Death.

Mrs. C——, aged thirty-three years, four years married, but childless, had been indisposed for two weeks. Early in the morning of July 9th, she was taken with severe pain in the lower abdomen, nausea and vomiting, rapid prostration, increasing tumidity of the abdomen, and death at 7 o’clock P. M.

Thirty-six hours after death, assisted by the attending physicians, Drs. H. J. Sartain and E. Calvin, I made a post-mortem examination. “A quart of bloody serum was sponged out of the abdominal cavity, then a pint and a-half of black coagula was removed, when the pelvic viscera were exposed. The right Fallopian tube was found enlarged and ruptured, within an inch of its connection with the uterus. The ovule had lodged in the tube, about half an inch from its outlet, and there formed its attachments. The oozing blood from the ruptured arterioles and venules of the tube, had destroyed the outline of the embryo, leaving a sort of granular debris lying in the fragments of the membranes, which were detached from the inner surface of the tube. The nidus measured externally about an inch in length, and three-quarters of an inch in transverse diameter. The walls of the uterus were slightly softened, and the decidua had formed.”