696 



UTERUS AND ITS APPENDAGES. 



enlarged muciparous follicles*, which in three 

 different conditions or stages correspond with 

 three varieties of pseudo- ulcers of the aph- 

 thous kind. In the first variety the follicles 

 are closed and project like millet seeds above 

 the general level of the cervix. They contain 

 a little glairy fluid, and may be compared to 

 the distended closed follicles described at 

 p. 640., as occurring within the cervical and 

 uterine cavities. They are almost always 

 placed at such regular intervals apart, that 

 they must be regarded as natural structures 

 enlarged, rather than as pathological new for- 

 mations. 



The second variety consists not of closed 

 but open follicles similarly arranged. Within 

 and at the bottom of many of these may be 

 seen the filiform papillae enclosed, cup-like, 

 and resembling the stamens in a half opened 

 flower. Similar follicles to these occur some- 

 times within the cervix under ordinary circum- 

 stances. 



When these papillae become hypertrophied 

 and sprout out above the cup-like level of the 

 containing follicles they form florid-looking 

 and elevated spots resembling granulations in 

 appearance, and these constitute a third va- 

 riety the " granulations simples sans ulce- 

 rations" of Pichard.-f- 



The foregoing examples have been here 

 passed in review for the purpose of illustrat- 

 ing the principal anatomical and pathological 

 conditions of the uterine cervix, which when 

 viewed by the speculum during life exhibit 

 appearances that are regarded by many ob- 

 servers in the present day as affording un- 

 mistakeable characteristics of ulceration. With 

 this object they have been here grouped to- 

 gether, but they do not form a class ; many 

 of them indeed have no pathological relation- 

 ship, and to few can the term ulceration be 

 regarded as appropriate. In order, therefore, 

 to eliminate from the category those condi- 

 tions which have no title to be considered as 

 ulcers, it is needful to apply to them the test 

 of a definition. With this view, and also for 

 the purpose of avoiding the confusion which 

 from the time of Hunter downwards has at- 

 tended the employment of various terms for 

 the designation of ulcerative processes, of 

 those at least by which the particles of open 

 or exposed surfaces are removed, it may be 

 well to adopt some such distinction as that 

 proposed by Mr. Paget, namely, to regard as 

 abrasions or excoriations those conditions in 

 which the epithelium or epidermis of an in- 

 flamed part is alone removed, and those only 

 as liberations in which the removal extends 

 further to the vascular or proper tissues be- 

 neath the epidermis.}: 



Judged by this test, there may be excluded, 

 first, all those apparent sores which, begin- 



* See p. G40. 



t Excellent representations of the varieties de- 

 scribed above will be found in Boivin and Duges' 

 Atlas, pi. 25. 27. and 33., and in Pichard, Mai. 

 des Femmes, pi. 3. 



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



ning invariably from within the margins of the 

 os, and appearing to spread outwardly more 

 or less over the cervical lips, present a florid 

 and often granular aspect, and being on a 

 level with surrounding parts, and without de- 

 finite edges or raised border, fulfil all the con- 

 ditions commonly assigned to ulcers of the 

 uterine neck. These, almost without excep- 

 tion, consist of the inflammatory conditions 

 already described as hypertrophies and ever- 

 sions of the cervical mucous membrane. The 

 apparently raw surface exposed to the eye is 

 not usually any portion of the outer cervix, 

 but the swollen inner surface of the walls of 

 the cervical canal now everted and brought 

 into view, just as the interior of the lip is 

 brought into view in common strumous 

 thickening about the mouth. The margin of 

 this apparent ulcer is the normal boundary of 

 the os, or line of demarcation between the 

 vaginal and cervical mucous membrane, now 

 disturbed and thrown out of its natural place. 

 The granulations upon this surface are the 

 thickened and inflamed papillae, follicles, and 

 rugae of the cervical canal. The edges are not 

 raised because they simply form the boundary 

 between the vaginal and cervical epithelium, 

 and the centre is not depressed, because there 

 is no erosion nor any loss of tissue. 



These conditions of the uterine cervix in 

 respect of their true pathological relations 

 are exactly allied, in their different degrees, to 

 the inflammatory conditions of the eyelid 

 termed respectively Lippitudo, Ectropion and 

 granular lid. Both are attended by like 

 hypertrophies of structure and corresponding 

 depravements of their healthy secretions. 

 Both are reduced to their normal condition 

 by similar or even identical methods of treat- 

 ment, and both are alike entirely removed from 

 the category of ulcers. 



Next to these may be enumerated the con- 

 ditions of the uterine neck which are distin- 

 guished by loss instead of hypertrophy of 

 tissue. When this loss consists solely in de- 

 tachment of epithelium the term " epithelial 

 exfoliation" appears to be a more appropri- 

 ate designation and preferable in many re- 

 spects to " excoriation or abrasion," terms 

 which seem to imply something of violence 

 in the mode of production of these conditions. 

 Exfoliation of the tesselated epithelium 

 covering the vaginal portion of the cervix ap- 

 pears to take place under some circumstances 

 with great ease. In uterine catarrh for ex- 

 ample, this shedding of epithelium com- 

 mences at the borders of the os, and extends 

 outwardly. Or it may involve the entire 

 epithelium of the vaginal portion of the cervix 

 together even with that of the vagina itself, 

 these being sometimes thrown off like a cast. 

 In such cases, a fresh epithelium is formed 

 beneath the old one that has been detached.* 

 But if the epithelium is not renewed the 

 villi remain denuded. This condition may be 

 precisely imitated after death by macerating 

 the part for a few days, and then peeling off 



* See also page 707. and note. 



