CHAPTER IV.

THE FEMALE GENERATIVE ORGANS.

Section I. THE PUDENDA AND VAGINA.

[=Notice=: 1. Of the _pudenda_—malformations; condition of the labia and clitoris; size; color; abrasions; ulcers; eruptions; tumors; marks of violence, etc. _Orifice of urethra_—growths around, their number and size. _Hymen_—present or absent; entire or lacerated; imperforate.]

1. The Pudenda.

=Congenital Anomalies.= In rare cases the external organs are entirely absent, more frequently but partially developed.

The nymphæ may be found abnormally enlarged.

The clitoris may be abnormally long, perforated, or cleft.

Many of the cases of so-called hermaphroditism are instances of an undue congenital development of the clitoris, with an irregular development of the other organs of generation, either external or internal, or both.

=Hypertrophy.= We may find an hypertrophy of the labia, due to a kind of solid œdema, perhaps originally dependent upon a fissure or ulcer of the part. The nymphæ are often abnormally enlarged, not necessarily as the result of an abuse of sexual indulgence. In new-born infants, they normally project beyond the labia majora. The clitoris occasionally is enlarged, elongated and pendulous, and, in some cases, attains an enormous size. A specimen preserved in the Museum of the University of Bonn, is fourteen inches in circumference and weighs eight pounds. There is no necessary connection between an habitual sexual indulgence and an enlarged clitoris.

Varicose swellings of the labia may reach a considerable size, and, although not generally interfering with parturition, have been known to be lacerated at that time with fatal issue.

As the result of external violence, or during parturition, suggillations often occur in the labia, and may give rise to considerable swelling. The tumor presents a tense, smooth surface, of a livid color, thus distinguished from a varicose swelling, with the peculiar vermicular character of its contents.

=Inflammation.= The cutaneous covering, the mucous lining, the cellular tissue, and the sebaceous and mucous follicles, may be the seat of inflammation, resulting from external or internal causes.

Eczematous and apthous inflammations may result from derangement of the digestive organs, from pregnancy, from a want of cleanliness, or from excessive sexual indulgence, and are of frequent occurrence.

The loose cellular tissue is especially favorable to œdematous swelling, and when the inflammation has a phlegmonous character, extensive sloughing may result. It occasionally occurs as an epidemic among those in early life.

The vulvo-vaginal glands are also liable to inflammation of a catarrhal, herpetic or syphilitic character, resulting in chronic ulceration, or tedious discharges. Young children are frequently liable to a benignant inflammatory affection of these parts, giving rise to much irritation and a muco-purulent secretion.

Morbid Growths.

_Warty excrescences_, arising from a syphilitic taint, may affect the labia, the entrance of the vagina, and the clitoris. They consist of groups of small pedunculated tumors, producing a sort of mushroom appearance.

_Syphilitic mucous tubercles_ are described as round, flattened tubercles, raised above the surrounding tissues, sometimes becoming elongated, of a reddish-blue color, and frequently ulcerated on the surface.

_Cystic tumors_ are also met with in the labia. They consist of a membranous envelope, containing a transparent, glairy fluid, and often attain a large size.

The mucous membrane surrounding the orifice of the urethra, is liable to an hypertrophy of development, giving rise to small vascular, generally pedunculated tumors, extremely sensitive during life, and liable to become abraded.

_Elephantiasis_ may attack the labia majora, the nymphæ, or the clitoris, and may attain to a great size. It consists of the loose connective tissue of the part, infiltrated with serum, and covered either with the smooth skin, or one which has become roughened by hypertrophy of the papillæ. It may appear as a diffused hypertrophy, or be furnished with a pedicle, and resemble a polypus.

_Fibrous_, _fatty_ and _scirrhus_ tumors are also met with in this part of the system.

2. The Vagina.

=Congenital Anomalies.= The valvular fold of membrane which protects the virgin vagina, the hymen, may be imperforate or much indurated, and of a cartilaginous consistency. It may thus entirely close the vagina. Besides this, we may find the vagina terminating in a cul-de-sac, either with the uterus present or absent, and the ovaries normal or abnormal. The vagina may also be duplicated, by a septum extending the entire length of the canal, or only partially dividing it. There may be at the same time a double uterus. Entire absence of the vagina is also met with, the internal organs of generation being also absent, or but imperfectly developed.

=Morbid States.= Occlusion or stricture of the vagina sometimes occurs as the result of external injury, or of cicatrization of ulcers.

Dilatation, or lengthening of the vagina, also occurs.

The rigidity or laxness of the walls of the vagina, varies much in different individuals, according to constitution, age, and the effects of cohabitation and child-birth. Prolonged uterine or vesical disease, often produces a very lax condition of the mucous membrane of the vagina. In old women we often meet with this relaxed state, which may amount to a complete prolapsus. The anterior wall is particularly liable to be thus affected.

=Laceration and Rupture.= External mechanical injuries may produce laceration of the vagina. During parturition, either from unusual rigidity, or from want of care on the part of the attendant, the lower portion of the canal is apt to give way when the labor pains are at their height. The lesion may vary from a mere laceration of the fourchette, to a rupture of the entire perineum, from the vagina to the anus. Lacerations of the upper portions of the vagina also occur with rupture of the uterus, or even independently of it.

Lacerations of the vagina are not necessarily fatal, but may result in vesico-vaginal fistula, where a communication is established between the bladder or urethra, and the vagina; or in recto-vaginal fistula, where the fistula opens into the rectum.

=Inflammation.= The mucous membrane of the vagina is frequently the seat of inflammation. The commonest form is the _catarrhal_, which may be acute or chronic. In the first stage, the passage is reddened, heated and dry. This is followed by an abundant secretion of white, creamy mucus; or of a more purulent discharge, if the inflammation has anything of a specific character.

_Croupous inflammations_, in connection with general disease, or a similar disease of the uterus, may occur. They produce a solution of the mucous membrane and the submucous tissue, varying in shape and depth, and not unfrequently resembling gangrenous destruction. (Rokitansky.)

A chronic thickening of the mucous membrane, as the result of inflammation, is occasionally met with.

The follicular, syphilitic and carcinomatous ulcer also affect this part.

_Suppurative inflammation_ may result from injuries, ending in the formation of an abscess in the fibrous structures, which may burrow within the pelvic areolar tissue, or extend into the labia.

_Gangrene_ sometimes results from injuries received during parturition, or from a degeneration of croupous inflammation in a vagina affected with blenorrhœa of a gonorrhœal or syphilitic origin.

Morbid Growths.

_Polypi_ and _cysts_ are the varieties most frequently met with in this situation. The polypi may be either fibro-vesicular, or cellulo-vascular, varying greatly in size. The encysted tumors, originate in an obstruction of the follicles of the part, and contain a glairy, transparent, greenish, or dirty-brown albuminous fluid.

_Myomatous_ tumors may be found developed within the muscular coat of the vagina, the posterior wall being their usual position.

_Carcinoma_ may occur primarily, or by an extension of the disease from the cervix uteri.

The form in which it appears is the encephaloid kind, the appearance of which is described in connection with the uterus.

Malignant _epithelial_ growths are not met with in the vagina.

Section II. OF THE UTERUS.

[=Notice=: 1. _In situ_—absence or malformations. Size, and relation to surrounding organs and walls of pelvis; high or low in pelvis; versions; flexions; adhesions, etc. 2. _After removal_—os; size and shape, round, oval, irregular, etc. _Lips_—size; form; color; condition of surface; soft or firm; rough or smooth; abrasions; granulations; ulcers; tumors, etc. _External characters of body_—size; measurements; weight; tumors; rupture; consistence, hard or soft. _After section_—thickness of walls; density; condition of blood-vessels; abscesses; tumors, etc. _Uterine cavity_—size and form. Contents; serum; size and condition; blood; mucus; pus; tumors. Condition of mucous lining, cancerous growths, etc.]

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.[35] 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.[36]

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.[37]

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.[38] 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.[39]

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.”[40]

Section III. THE OVARIES AND FALLOPIAN TUBES.

[=Notice=: 1. _External Characters_ of ovaries; size; color; consistence; soft and boggy, or firm and hard; surface smooth, or rough, irregular and fissured; cysts beneath the surface, or projecting from same. _Characters on section_—color, density; condition of stroma, consistence, etc. Corpora lutea: number, size, situation; cysts; tumors; abscesses; tubercles; cancer, etc. 2. _Fallopian tubes_—absent or malformed; length; size of canal; thickness of walls; condition of fimbriated extremity; tumors, tubercle, cancer, etc.]

1. The Ovaries.

=Malformations and Malpositions.= The absence or arrest of development of one or both ovaries is occasionally met with.

The ovaries may be found in the labia majora as a congenital defect, or in the inguinal or crural canal, or in the foramen ovale, as congenital or acquired herniæ.

=Inflammation= is but rarely met with in post-mortem examinations in an isolated form. It generally is associated with affections of the uterus or its appendages, in connection with the puerperal condition. It does, however, occur as an idiopathic disease, and then generally attacks but one ovary. In the congestive stage there is more or less engorgement with blood, even amounting to extravasation, enlargement and softening of the organ.

=Abscesses.= As a result of acute inflammation, abscesses may form in the substance of the ovary. These may reach considerable size, and may burst into the peritoneal cavity, resulting in death; or they may discharge into the rectum, vagina or bladder, and end in recovery.

Morbid Growths.

=Ovarian Tumors= or _Ovarian Dropsy_, are generic terms for a class of affections characterized by the formation of cysts, which have a tendency to excessive development. The disease affects married females more frequently than the single, and the age from thirty to forty years is that most subject to it. According to statistics, the right ovary is more frequently the seat of the malady. Various forms of the disease are met with. The cysts may be simple or unilocular, compound or multilocular, or cancerous.

_Simple cysts_ have but a single, undivided cavity, containing fluid, and enclosed within the ovary or external to it. We may find one or more, varying greatly in size, some being no larger than a pin’s head or pea, while others contain several gallons of fluid. The contained fluid also, presents great varieties; it may be clear, straw-colored, highly albuminous, or present a viscid, glairy, more or less opaque character; or we may find it of a coffee color, or greenish, with a large quantity of oily matter floating on the surface. In the latter cases the appearance is due, as shown by the microscope, to the presence of blood corpuscles and cholesterine plates.

These simple cysts may acquire an enormous size, filling the abdominal cavity, and crowding the viscera from their position. In a case examined for Dr. B. Berens, in 1855, a free incision was made through what appeared to be the abdominal walls alone, when the cavity was found filled with a straw-colored, slightly gelatinous fluid, of which several gallons were removed.

Upon extending the incisions and looking into the cavity, it presented the appearance of an entire absence of all the abdominal viscera; the spinal column projected at the posterior portion, while above was seen what appeared to be the concave, under surface of the diaphragm, with no trace of liver, stomach, or other viscus. A careful examination of the edges of the incision disclosed the divided walls of the cyst, closely adhered to the abdominal parietes at all points. With a little care, these were gradually torn away, when, behind the tumor, was found the atrophied viscera, crowded and displaced upwards and backward into the smallest possible space.

_Pilo-cystic_ or _Dermoid cysts_ may be found containing hair and fatty matters. These appear, in many cases, to be the remains of blighted ova enclosed in the body. They are congenital in their origin, and usually contain some fœtal _debris_, such as portions of bone, teeth, etc.

CASE.—_Ovarian Cystic Disease—fatal termination. Autopsy revealing presence of bone and teeth in small cyst._

The following interesting case occurred in the practice of Dr. William A. Read, of this city, from whom the appended statement has been received:

Miss ——, aged 42 years, after having been treated by several physicians, came under the care of Dr. Read for the treatment of what was diagnosed as an ovarian tumor. Paracentesis was resorted to, with the result of drawing off a considerable quantity of gelatinous fluid, but without any permanent benefit. The disease pursued the usual course, and the patient finally died of exhaustion.

The autopsy revealed a large multilocular tumor, filling a large portion of the abdominal cavity. Upon removing the same from its pelvic attachments, and opening one of the smaller cysts within the broad ligament, the latter was found filled with a quantity of highly offensive fluid, and containing one large, irregular mass of bone, in which were imbedded two well-formed teeth, a smaller piece with one tooth, and nine detached teeth found in the same sac, making twelve in all.[41]

The first impression upon the discovery of such remains would naturally be, that the case was one of _extra-uterine pregnancy_; but in this instance, the well known character of the lady was such as to preclude such a theory; while the presence of the unbroken hymen was further evidence of virginity. From the impossibility of conception having been the source of the bony and dental remains found in this and similar cases, the problem can only be solved, by supposing that, two ova had been impregnated when this woman was conceived, one of which, in some manner, became imbedded within the other, so that at her birth this lady had within her abdomen the remains of her _undeveloped twin_. These became encapsulated within the pelvis, and finally induced the local disease, which resulted in death.

That this is the correct explanation of such cases, is confirmed by the fact that similar remains have been found within the bodies of males.

_Multilocular cysts_ disclose, instead of a single cavity, numerous chambers, containing secondary, and even tertiary cystic growths, either sessile or pedunculated, and with varying contents.

By the complicated form, we understand that in which, to some other diseased state of the organ—as hypertrophy, fibrous tumors, or carcinomatous growths—the cyst formation is superadded.

_Fibrous growths._ These are developed in the tissue of the ovary, and present a globular form, with well defined outline. They may attain an enormous size; the largest one on record, occurred in the practice of Dr. Simpson, and weighed fifty-six pounds. We occasionally meet with proofs of a tendency to so-called ossification, in the presence of calcareous matter, into which a portion of the tissue has been converted.

_Malignant disease_ of the ovary, is by no means a rare affection. It is generally limited to one side, and appears as scirrhus, encephaloid, hæmatoid, melanotic, or alveolar cancer, either as an isolated growth, or in the infiltrated form, and generally as an addition to some other morbid formation. It runs a rapid course, although it has been met with even before puberty; forty-one years was the average age at death according to the statistics collected by Dr. Walshe.

_Cartilaginous tumors_ are extremely rare in the ovaries.

_Tubercles_ are occasionally found as small, cheesy deposits.

2. The Fallopian Tubes.

=Congenital Anomalies.= One or both of the tubes may be imperfectly developed, in connection with an unsymmetrical development or total absence of the uterus. The tubes may be occluded by the closure of one or both ends, and the point of insertion into the uterus may be abnormal.

=Inflammation.= Catarrhal inflammation is of not unfrequent occurrence, and may lead to partial or total, temporary or permanent closure of the channel of the tubes. Thus the fimbriated extremities may become agglutinated to the ovaries, the broad ligament, or the uterus itself; or obliteration may occur at one or more points within the passage.

The continued accumulation of the secretion of the mucous membrane will cause distension, either simulating a cyst formation, or presenting the appearance of several saccular dilatations. The dilatations, containing mucus matter of a more or less purulent character, or fluid of an heterogeneous constitution, are rarely of large size, although an instance is on record in which the distension amounted to five inches in diameter. The morbid contents may be poured into the uterus, or in less favorable cases the sac is ruptured, and the contents are effused into the abdominal cavity.

Morbid Growths.

_Cysts_ of small size frequently affect the fimbriated extremities of the tubes.

We may also find _fibroid growths_, _carcinoma_ and _tubercle_; the two latter commonly, although not invariably, secondary to similar diseases of the uterus.

Section III. OF THE MAMMÆ.

=[Notice=: 1. _External Characters_—abnormalities; silvery lines on integument, indicating previous enlargement; sinuses; firm, or soft and flabby. _Nipple_—its size, color, retracted, ulcers; excoriations, etc. _Areola_—size and color. 2. _Appearance on section_—color of substance; consistence of gland and fluids exuding; abscesses; tumors; cysts; cancer, etc.]

=Anomalies.= Supernumerary mammæ, with the power of secreting milk during lactation, have been observed in a number of instances.

The cases of absence of one or both mammæ are rather to be classed as the result of arrest of development or atrophy.

A too early development of the glands in young children is occasionally met with, where there is a precocious development of the organs of generation.

While the mammary glands in the male usually remain in a rudimentary state during life, cases have occurred where they have acquired an increased size, and have been stimulated to such a functional activity as to permit of the suckling of an infant.

=Hypertrophy and Atrophy.= When puberty occurs, the breasts naturally enlarge and often become tender; and such a temporary enlargement very commonly accompanies menstruation.

An increase of size, such as normally takes place during pregnancy, between the fourth and ninth months, will occasionally commence at puberty, and go on until the organ attains an enormous size. In some cases the breast has been found, after death, to weigh as much as twenty pounds, the tissue being perfectly normal.

Both breasts are usually affected, although one is commonly more so than the other.

After the cessation of the menses, the breasts normally begin to atrophy.

We may also have an atrophy of the breast following upon lobular hypertrophy, as described by Sir A. Cooper.

=Inflammation and Abscess.= _Inflammation of the Nipple and Areola_, preceding or following a fissured state of the nipple, usually occurs at an early period of lactation, and especially with the first child. Abscess of the areola is often a consequence.

_Inflammation of the Breast_, generally terminating in suppuration, may occur in three positions: either in the subcutaneous areolar tissue, _supramammary abscess_; or in the areolar tissue, in which the gland is imbedded, _submammary abscess_; or in the gland itself, _mammary abscess_.

_Chronic Abscess of the Breast_ may be of two kinds: the diffused and the circumscribed or encysted. The former may occur at all ages, and in the single as well as in the married. It usually appears in the submammary areolar tissue, and may acquire a very large size; and by pushing the mammary gland before it, gives the breast a pointed, conical shape.

Chronic encysted abscess, so closely simulates various tumors in this situation, as to render a diagnosis in some cases very difficult during life. It usually commences as a result of pregnancy; sometimes as a consequence of lacteal inflammation; but usually without any injury or other direct local cause. An indolent, indurated swelling forms, and this may gradually soften in the centre, although fluctuation may for a long time be very indistinct, and even absent, owing to the thick wall of plastic matter that is thrown around the collection of pus. It is not unfrequently attended with retraction of the nipple.

Syphilitic ulcers are also found affecting the nipple; while eczematous and erysipelatous inflammation in this situation are of frequent occurrence.

Morbid Growths.

The mammæ are frequently the seat of adventitious growths, presenting the characters of non-malignant and malignant formations. The most common of the benignant tumors is, perhaps, the

=Adenoid Tumor or Adenocele=. This is most frequently met with in young women under thirty years of age, seldom commencing at a later period than forty. It may remain stationary for years, or it may slowly increase or grow very rapidly to a great size. It has frequently been mistaken for cancer, but the otherwise good health of the patient, the mobility of the mass, the absence of all implication of the skin or glands, the want of hardness and its circumscribed character, are points of diagnostic value.

On removal, it appears irregularly lobulated, is encapsulated, and its cut surface has a bluish or grayish-white color, which, on exposure to the air, assumes a rosy tint. On pressure, drops of thick, creamy fluid will often exude. According to Birkett, the microscope shows it to consist of imperfectly developed hypertrophy of the glandular tissue, the terminal cells of which are filled with epithelial scales. This tumor sometimes simulates malignant disease by its extreme rapidity of growth, especially where it developes later in life. It then, after section, presents a lobulated, glistening appearance, somewhat resembling a mass of rice or sago jelly, often having cysts interspersed throughout its substance containing fluid or semi-solid glandular tissue.

In rare cases, the adenocele may return, even after extirpation of the entire mammary gland.

=Cystic Tumors.= These may occur as the unilocular cyst, or as the cysto-sarcomatous tumor.

_Unilocular cysts_ usually occur as a small, thin sac, of about the size of a filbert, containing a clear, serous fluid, imbedded in the glandular structure of the breast, and movable under the skin. As they increase in size or become multiple, their contents may assume a greenish-brown or blackish tinge from effused blood. According to Brodie, they are originally formed by a dilatation of the lactiferous tubes.

Unilocular cysts occasionally attain an immense size at the same time that their walls remain thin and supple. In some of these instances, the fluid continues to the last, of a truly serous character; while in others, it becomes more or less glairy or mucilaginous.

Sometimes the walls of the cysts have been found to have undergone calcareous degeneration.

_The cysto-sarcoma_, occurs as an isolated, globular or oval, and more or less movable cyst; or there are numerous growths of this kind, varying in size from a pin’s head to a hen’s egg. The inner surface is smooth, or it presents a broad-based, lobulated, cauliflower growth or warty excrescences, and the substance of the surrounding gland is indurated and atrophied. A retraction of the nipple may also be observed. A transverse section shows a double sheath: one proper to the cyst, and the other the result of condensation of the adjoining textures. The contents are either fluid, of a limpid, opalescent, non-albuminous, or a grumous, brownish, highly albuminous character; or solid, approaching the character of a fibroid deposit, composed of a pale, compact substance, traversed by undulating fibrous lines, which imperfectly divide it into lobes of various sizes and shapes.

_Hydatid cysts_, containing the echinococus, occur in the female breast. The tumor is firm to the touch, and contains a clear fluid, in which the microscope detects the tenacula of the echinococus, the animalculum itself being attached to the internal wall of the cavity.

_Fibrous_, _cartilaginous_ and _osseous tumors_, are of doubtful or very rare occurrence.

=Carcinoma.= Cancer affects the mammæ more frequently than any other organ of the body. The age from forty to fifty years seems most liable to its occurrence. According to Dr. Walshe, the left side is more frequently affected than the right, and both are but rarely involved.

All varieties of carcinoma have been met with in the breast; but scirrhus is by far the most frequent form in which it occurs primarily. The encephaloid variety is generally engrafted upon the scirrhus, although it may also be primary. The colloid form is the most rare.

_Scirrhus_ appears as a hard, lobulated tumor, imbedded in the adipose tissue of the gland, causing adhesion to the skin and retraction of the nipple. Although at first movable, it soon becomes firmly adherent to the subadjacent parts, and involves more or less the gland tissue, the muscles of the thorax, and the adjoining glands. Instead of an isolated tumor, there may be an infiltration of the various structures of the part from the commencement. It will then have an ill-defined outline, sending out branches into the adjacent tissues, and involving in its mass the lacteal tubes and lymphatics. These become contracted and flattened into many bands, giving a peculiar appearance to this form of mammary cancer not observed in any other.

Ulceration of the skin gradually follows near the nipple; the edges of the sore are raised, everted and puckered. The surface is of a bluish-red color. A purulent, ichorous fluid, of a faint, fetid odor, is secreted; hæmorrhage may ensue, and the patient sinks from exhaustion.

The average time occupied by a scirrhus in reaching its full development is from two to three years. When the ulcerative stage has once begun, the system is soon broken, and the disease proves fatal in from six months to two years. The older the individual is at the first appearance of scirrhus, the more slowly does it pass through the various stages of its growth.

The axillary lymphatic glands are also in most cases found swollen, hard, and infiltrated with cancerous matter.

The pectoral muscles, ribs and costal cartilages are also found more or less involved; and a secondary affection of the pleura and lung is not unfrequent. We may also look for œdema of the extremity on the affected side, caused towards the termination of the disease by direct interference with the venous circulation.

The encephaloid form occurs earlier in life, and commonly runs a more rapid course. Its margin is less defined, the base of the tumor being diffused among the healthy cellular membrane, or other parts where it may be situated. It differs from scirrhus also in this: that the disease may advance to ulceration without any affection of the glands of the axilla.

The Male Mammæ.

The structure of the male mammæ resembles that of the female gland, though in a rudimentary state; hence we may find anomalies and morbid conditions in them similar to those found in the latter.

An increased number of mammæ have been met with.

Hypertrophy sometimes occurs.

There have been well authenticated instances of the secretion of milk by men.

The male breast may be the seat of non-malignant and malignant growths. Cancers, simple cysts, compound cysts, and other tumors occur, but exceptionally.

PART IV. MISCELLANEOUS SUBJECTS.