CONGENITAL EROSION AND SPLIT OF THE CERVIX.
In describing the lesions of laceration of the cervix and cervical catarrh, frequent mention has been made of the cervical erosion or the catarrhal patch. The erosion, or red granular area, surrounding the external os seems to be caused by various factors. In laceration it is due to the eversion and exposure of the normal cervical mucous membrane, and perhaps to slight proliferation of the cylindrical cells of this mucous membrane on to the mucous membrane of the vaginal aspect of the cervix. In cervical catarrh it is caused by swelling and prolapse of the mucous membrane of the cervical canal, and extension of the inflammatory process beyond the limits of the external os, with partial desquamation of the squamous cells.
There are other cases, however, in which the erosion appears to be congenital. Such erosions have been observed by Fischel and other investigators surrounding the external os in new-born infants. Erosion of this character has been found, in a more or less marked degree, in 36 per cent. of new-born infants. Microscopically, these erosions appear to be a direct continuation of the mucous membrane of the cervical canal. They are covered with a single layer of cylindrical epithelium, and they possess mucous glands, resembling in these features the cervical mucous membrane, and not the mucous membrane of the vaginal aspect of the cervix, which, it will be remembered, is covered with squamous epithelium and contains no glands. This congenital erosion usually is of very limited extent, but in some cases it covers the greater part of the vaginal aspect of the cervix, and may then give rise to decided symptoms. The condition is due to imperfect development of the external os. In the well-formed woman there is, at the external os, a sharp line of demarcation between the squamous epithelium of the vaginal aspect and the cylindrical epithelium of the cervical canal. In the congenital erosion the epithelium of the canal extends beyond the limits of the external os, and meets the squamous epithelium at a lower level than normal.
Such congenital erosions usually give rise to no trouble, though perhaps they predispose the woman to cervical catarrh as a result of exposure of the mucous membrane. In extreme cases, however, in which the cylindrical epithelium of the cervical canal persists over the greater part of the vaginal cervix, and in which the glandular elements of the canal are found on the vaginal aspect, a distinct pathological condition arises. The symptoms of this condition resemble closely those of laceration of the cervix with ectropion. There is backache, a feeling of weight in the pelvis, and perhaps some ovarian pain. In addition, the woman complains of a leucorrhea presenting the characteristics of the cervical mucus. Decided nervous and digestive disturbances may be present.
If this condition of congenital ectropion exists along with a laceration of the cervix, the diagnosis becomes very difficult. If, however, we can exclude the possibility of a former conception, we may by careful study determine the real nature of the case.
Fig. 111.—Congenital erosion of the cervix.
[Fig. 111] represents the appearance of the cervix in a case of marked congenital erosion in a virtuous single woman twenty years of age. It will be observed that the appearance resembles somewhat that seen in a bilateral laceration of the cervix with eversion. The following are the points of difference:
In laceration—
There is a history of previous pregnancy.
The presenting face of the cervix is oval, with the long axis antero-posterior.
The angles of laceration may be determined, by sight or touch, either as more or less well-marked depressions or as hard plugs in case they are filled up by scar-tissue. The mucous membrane of the cervical canal may be made out as a strip on the anterior and posterior lips, from which there extends laterally a more or less well-marked erosion.
The vaginal cervix is not of the general mushroom shape seen in the figure.
If microscopic examination of the cervix be made, racemose glands will be found discharging only on the mucous membrane of the cervical canal—not all over the vaginal aspect.
In the congenital ectropion—
There may be no history of pregnancy.
The presenting face of the cervix is approximately circular.
There is no angle of laceration determined by sight or touch.
The erosion may extend evenly around the external os, and there is no one strip that corresponds to the exposed mucous membrane of the cervical canal.
The vaginal cervix is mushroom-shaped, with a decided stalk.
Microscopic examination reveals racemose glands discharging over the greater part of the vaginal cervix, to the sides of the external os, as well as in front of and behind it.
The ultimate test of this condition is the discovery of the glands discharging on the vaginal aspect of a cervix in which the mucous membrane of the cervical canal had not been exposed by laceration.
The treatment of congenital erosion of the cervix, when it is so marked as to produce distinct symptoms, is amputation of the cervix.
Congenital Split of the Cervix.—There is sometimes found a congenital split of the cervix, closely resembling a unilateral or bilateral laceration following labor or miscarriage. The recognition of this fact is of great medico-legal importance. One of the most positive signs of a former conception is a laceration of the cervix. In some cases, however, a condition resembling such a laceration may exist from birth. Marked lateral split of the cervix has been discovered in the new-born infant, and several cases have been observed in which this condition has been found in adults of undoubted virginity.
It is possible that this condition may become pathological. Cervical catarrh might be produced from exposure of the mucous membrane of the cervical canal. The lesion, however, is not of nearly such serious moment as a laceration after miscarriage or labor, for the last injury occurs in a uterus which must undergo involution, and the chief symptoms of laceration of the cervix are usually those incident to arrested involution.