filtrate the subepithelial layers of the mucous membrane, then extend into the deeper tissues. The extension of the growth is progressive, and occurs in a downward direction, appearing upon the vaginal surface of the cervix and slowly extending to the vagina. The infiltration is followed by superficial necrosis and exfoliation, and soon considerable-sized ragged ulcerations form, the surface becoming covered with fetid decomposing material. The growth extends into the peri-uterine loose cellular tissue between the uterus and bladder, and then in all possible directions, with inflammatory and sub

FIG. 322.--Adenocarcinoma of the cervix with extension to the polyp (a) and to both uterine horns. The cervix is considerably enlarged, and presents a rough, uneven surface, due to dome-like elevations varying in size from a pin's head to 5 or more millimeters in diameter, between which are a few finger-like projections. The growth has apparently penetrated the cervix for a distance of from 2 to 10 millimeters, and on one side has advanced almost to the cut surface. The cervical mucosa, near the internal os, presents the usual arborescent appearance. The uterine walls are slightly thickened. The mucosa of the posterior wall is apparently normal. Projecting slightly from the anterior wall is a polyp (a) (natural size) (Cullen).

sequently neoplastic unions between the uterus and other organs, and frequent fistulous communications between the uterus, vagina, bladder, and rectum. The tumor cells also distribute through the lymphatics to the corpus of the uterus, to the iliac lymphatic glands, and later to the inguinal, crural, and lumbar glands. Hematogenous distribution is rare, and the disease remains local, producing the most wide-spread pelvic disturbance, and death through accidental hemorrhage, peritonitis, etc., rather than by generalization.

Squamous epithelioma of the body of the uterus is very rare and seen only in aged individuals in which metaplasia of the endometrium-ichthyosis senilis uterina-has already transformed the normal columnar epithelium into a squamous form. In cases with considerable associated keratosis distinct epithelial pearls may be found.

Adenoma of the uterus is a tumor of doubtful existence, unless it be correct to speak of the papillary hyperplasias of the endometrium seen in polypoid endometritis as adenomata, or look upon the glandular hyperplasias of the cervix as such. Such conditions are probably benign.

FIG. 323-Adenocarcinoma of the cervix uteri. Almost the entire field is made up of the main trunks a and b, which send off many branches, a' and b'. c indicates cross-sections of terminal outgrowths. The stroma g consists of elongate cells with spindle-shaped nuclei. Covering the outer surfaces of the main and terminal branches are layers of epithelium, a single layer at e, several at d (Cullen).

Adenocarcinoma, malignant or destructive adenoma, usually originates from the posterior wall at the fundus of the uterus. It is sessile, more or less invading the surrounding endometrium, and covered with rounded, papillary projections where not ulcerated or necrotic. The tumor consists essentially of glandular elements of quite typical appearance, which invade the subendometrial and muscular tissues. It is the muscular invasion that separates the adenocarcinoma from the non-malignant glandular outgrowths. The muscular invasion may attain such limits as to be followed by complete disintegration of the muscularis and eventual perforation of the organ. The number of glandular elements present varies, some of the papillary projections consisting solely of the tubercles and blood vessels. Many of the tubules

are of the embryonal type, showing crowded, rapidly growing cells, irregularly arranged upon the limiting membrane.

The tumor grows from the tubular glands of the endometrium. Its malignancy consists chiefly in local destruction, metastasis not being common. According to Birch-Hirschfeld, it is correct to speak of the tumor as adenocarcinoma only when, in the formation of new epithelial elements, the cells lose their relation to the membrana limitans and begin to infiltrate the tissues irregularly. Up to that time the tumor is malignant or destructive adenoma.

Carcinoma is a frequent malignant tumor which arises in the corpus of the uterus from atypical growth and development of the endometrial glands; in rare cases it develops from the cervical glands. It is a cylindric epithelioma-usually an adenocarcinoma. The tumor may be soft and disposed to

FIG. 324-Carcinoma of the cervix uteri with interstitial fibroid tumors: a, Ulcerated and eroded cervix; b, fibroid; c, subperitoneal fibroid; d, tube, ovary, and hydatid of Morgagni.

rapid and extensive ulceration, or may be characterized by papillary outgrowths. The course of the tumor has already been sufficiently described in speaking of adenocarcinoma. The first metastasis is usually to the lumbar lymphatic glands.

Syncytioma malignum, or deciduoma malignum, also sometimes called chorioepithelioma, is a rare and peculiar tumor that grows at the site of placental attachment either during pregnancy or during the puerperium. It forms one or more masses of dark-colored spongy tissue, not a little like the placental tissue in appearance, and shows its malignancy by metastatic growths in the external organs of generation, in the lungs, liver, spleen, and other organs. It is usually fatal.

The histology of the tumor is very peculiar and interesting, in consequence of the embryonal tissue from which it develops and the unusual opportunities

afforded by the physiologic and anatomic alterations at the time at which it occurs, for cellular growth into blood spaces. The villi of the chorion and placenta are covered with a layer known as the syncytium, supposed to be derived from the trophoblast of the primitive embryo.

Marchand, whose view is usually accepted, teaches that the chief cells of

FIG. 325.-Squamous-cell carcinoma of the cervix with loss of the cervical landmarks. Attached to the outer surface of the fundus on both sides are numerous adhesions: at a is one of these containing adipose tissue. The entire cervix has been replaced by the new growth. The lower and ragged portion consists of large and small lobulated masses. The growth stands out in sharp contrast to the vaginal and uterine tissue, being much lighter in color. Laterally, it extends to the vaginal attachments and '; upward, it reaches to the internal The uterus is considerably enlarged, and its walls are much thickened. The mucosa appears to be normal (natural size) (Cullen).

OS.

the tumor are derived from the syncytium. The cells grow in masses extending into the blood sinuses and vessels of the surrounding part of the uterus, accompanied by thrombosis in the sinuses and vessels, and a wide-spread destruction of the tissue. The growth usually shows considerable retrogressive change in the form of myxomatous degeneration and necrosis. It is almost always hemorrhagic.

As the cellular extension takes place into the blood sinuses, irregular masses of nucleated protoplasm are formed from the syncytial cells. In these masses large nuclei with intense staining properties are said to multiply by direct division. Other cellular masses are also present, consisting of well-differentiated cells with smaller nuclei, said to divide by karyokinesis. In these cells glycogen drops may be present. Many smaller cells resembling endothelial cells, and some still smaller, similar to lymphocytes, are also present, there being no regularity in the distribution of any of the component cellular elements. The cellular masses grow into the blood sinuses and also into the intermuscular tissue, interrupting the blood supply of the uterus and thus contributing to secondary degenerations, etc.

Cysts of the uterus sometimes occur from softening of the muscular

tissue-colliquation cysts. Retention cysts occur at the cervix from obstruction of the glands-cysts or follicles of Naboth. Lymphangiectases also sometimes form cysts in the uterine wall. Dermoid cysts have been described by several writers. Parasitic cysts, caused by the cysticercus and echinococcus, are recorded, but are very rare. Sangalli has seen a uterus with a thickened wall occupied by numerous small serous cysts. The condition appears not to have been explained.

Prolapsus of the vagina may occur primarily-that is, independently of changes in the other organs; or it may be secondary to displacements and descents of the uterus, bladder,

etc.

The primary descent of the vagina depends upon relaxation and elongation of its tissues and descent of the inferior part of the organ, either in its entire circumference or in its anterior or posterior wall, the prolapsed portion projecting between the lips of the vulva.

Cases of secondary prolapsus including the posterior wall of the bladder and carrying it into the vagina are called rectocele vaginalis.