688 



UTERUS AND ITS APPENDAGES. 



render the morbid conditions of this coat, re- 

 garded singly, of less pathological importance 

 than the abnormal states of the other tissues. 

 The pathological conditions of the serous coat 

 are chiefly those of acute or chonic metroperi- 

 tonitis, terminating often in exudative processes 

 and the subsequent formation of adhesions be- 

 tween those portions of the uterus which are 

 invested by peritoneum and adjacent struc- 

 tures, such as the Fallopian tubes, ovaries, 

 fig. 420., small intestines, and the like. 



These adhesions are occasionally so exten- 

 sive as to affect the figure of the uterus, and in 

 most instances they deprive it of its natural mo- 

 bility, and impede or destroy the functions of 

 the parts or organs appended to it, so that an 

 abiding sterility frequently results. The ova- 

 ries becoming invested by a capsule of false 

 membrane, are tied down and atrophied, while 

 the tubes lose their power of motion or their 

 canals become obliterated. 



The uterine peritoneum is sometimes alone 

 affected, while the appendages escape. If the 

 inflammation has not proceeded to the form- 

 ation of bands of adhesion, there may result 

 only some slight processes of false membrane 

 which remain and fringe the surface of the 

 organ. These little fringes or processes, con- 

 sisting of delicate folds of membrane, often 

 contain vessels which are easily injected. 



The peritoneum suffers considerable dis- 

 tension with correlative hypertrophy in the 

 case of tumours which project from the outer 

 surface of the uterus. These become inva- 

 riably covered by an extension of the peri- 

 toneum, which is especially strong about the 

 base of the peduncle occasionally acquired by 

 such tumours. 



2. Pathological conditions of the sub-peri- 

 toneal fibrous tissue. 



a. Perimetritis. Partial chronic wetrltis. 

 Peri-uterine phlegmon. Retro-uterine tumours. 

 The subperitoneal fibrous tissue which con- 

 nects the peritoneum with the uterine sub- 

 stance, like the peritoneal coat itself, is subject 

 to inflammation. In those situations where 

 the union of the outer and middle coats of the 

 uterus is very intimate, the distinction be- 

 tween a peritoneal and a subperitoneal inflam- 

 mation may not be possible, but where this 

 connexion is very loose, and is effected by the 

 interposition of a lax fibrous tissue, inflamma- 

 tion may apparently have an independent seat 

 without affecting at all, or with only a par- 

 tial inclusion of the uterine parenchyma, and 

 sometimes of its peritoneal investment. 



The term "peri-uterine" has been employed 

 by some authors*, with a view perhaps of 

 avoiding confusion, though at the cost of a 

 solecism, to distinguish these affections from 

 others commonly termed perimetrial. In this 

 article, however, inflammation of the subpe- 

 ritoneal fibrous tissue will be designated peri- 

 itisy while inflammation of the peritoneum 



* Monat, Observation Medicale (Gazette des 

 Hopitaux, 1850.) Bernutz et Goupil. Recherches 



Cliniques sur les Phlegmons peri-ute'rines. 

 chives Ge'nerales de Medecine. Mars 1857.) 



(Ar- 



itself, which some include in the latter term, 

 is distinguished as metro-peritonitis. 



Perimetritis consists in an acute, or more 

 often a chronic inflammation of the tissue, 

 which loosely attaches the peritoneum form- 

 ing the base of the broad ligament to the 

 proper substance of the neck and lower por- 

 tion of the body of the uterus. The relation 

 of the peritoneum and of the loose fibrous 

 tissue surrounding the cervix uteri have been 

 described at page 631., where also attention was 

 called to the peculiar lax tissue of this kind 

 which unites the posterior cervical wall with the 

 portion of peritoneum forming the retro-ute- 

 rine pouch (fig. 433. G.). Here, particularly, 

 this inflammatory affection has its seat, although 

 it occasionally extends around the sides of 

 the cervix, so as partially to encircle that part, 

 or more rarely it may involve only the fibrous 

 tissue connecting the anterior cervical wall 

 with the posterior surface of the bladder (fig. 

 426. b b, and fig. 433. F.). 



The anatomical conditions of these peri- 

 metrial inflammations are deep congestion 

 of the vessels, accompanied by serous, and 

 occasionally by sanguineous, and possibly 

 fibrinous infiltration of the loose tissue of this 

 part, which, on account of its extreme laxity, 

 readily admits of a great degree of distension. 

 In this way is rapidly formed a tumour which 

 almost invariably occupies the space between 

 the peritoneum and the posterior wall of the 

 uterus, at the point where the body joins the 

 cervix (retro-uterine tumour). 



The recognition of such a tumour or swell- 

 ing during life, by physical signs, is not difficult. 

 The finger introduced into the vagina, so that 

 its extremity reaches the point of reflexion of 

 the posterior wall of that canal forwards on 

 to the uterine neck, discovers, just above this 

 spot, a hard or semi-elastic projection, which 

 seems to grow out of the cervix just at its 

 point of junction with the body of the uterus. 

 The surface of the tumour towards the rec- 

 tum, upon which it encroaches, is convex, 

 and is either smooth or irregularly nodulated, 

 while between the tumour and the neck of 

 the uterus is usually perceived a notch more 

 or less deep, and comparable in form to that 

 which separates the body from the neck of an 

 ordinary retort. Hence this condition may 

 easily be mistaken for the retorted uterus, 

 which it closely resembles in many particu- 

 lars. The surface of the tumour is exquisitely 

 tender, while the adjacent uterine structures 

 are free from tenderness. 



The comparative frequency of this affec- 

 tion *, and the constant and severe suffering 

 which result from it, especially in married 

 women, in whom it is usually found, may 

 justify here a brief exposition of the peculiar 

 anatomical condition and relation of parts which 

 appear to me to conduce to its production. 

 From the view of the pelvic viscera given in 



* I believe that it is often confounded not only 

 with retroflexion, but also with retroversion, fibrous 

 tumour, and hypertrophy of the posterior uterine 

 wall, and that hence the frequency of its occur- 

 rence has not been commonly recognised. 



