LACERATION OF THE CERVIX UTERI.
Laceration of the neck of the uterus is of very frequent occurrence. It is said that nearly every woman suffers with a laceration of greater or less extent at her first labor. The majority of such lacerations, however, undoubtedly heal during the puerperium and give no subsequent trouble. The lacerations that concern the gynecologist are those that persist, remaining ununited after the woman leaves her bed. The description of the injured parts and the treatment therefor will be applicable to such old cases of laceration. It is true that some gynecologists have advised immediate examination and the primary operation for repair in case of laceration of the cervix, as in case of injury to the perineum; but such a course has at present but little endorsement. It is difficult to obtain a satisfactory examination under such circumstances. A digital examination alone, unless the sense of touch be very acute, would often fail to detect the lesion in the soft cervical tissue. The woman is exposed to the danger of infection of the upper genital tract from the manipulations of the examination and the operation, and such exposure may be unnecessary, because there is no doubt that many lacerations of the cervix unite of themselves.
It has been found necessary to perform the operation immediately after labor on account of severe hemorrhage from the lacerated wound.
Laceration of the cervix may take place in any direction, and the injury is described according to the direction and number of the tears. A lateral laceration takes place on either side of the cervix. A bilateral laceration involves both sides ([Fig. 104], A). The left is the more usual lateral laceration ([Fig. 98]), and in case of a bilateral tear the injury on the left side is usually the more extensive. The stellate laceration ([Fig. 99]) occurs when three or more lacerations radiate from the cervical canal. The less common varieties of laceration seen by the gynecologist are through the anterior and through the posterior lip. It may be that such lacerations occur as often as the lateral lacerations, and that spontaneous repair more often occurs, so that they produce no subsequent trouble. The relations of the neck of the uterus are such that accurate apposition of the injured parts is more likely to occur in case of antero-posterior laceration than in the lateral form of the injury. In some cases there seems to be no doubt that the laceration has extended through the posterior lip of the cervix into the cellular tissue above the posterior vaginal fornix, and that spontaneous repair has taken place, leaving a dense band of scar-tissue to mark the site of the lesion.
Fig. 98.—Left lateral laceration of the cervix with erosion.
Fig. 99.—Stellate laceration of the cervix.
An incomplete laceration of the cervix is sometimes found. In this injury the tear has extended but part way through the wall of the cervix. The mucous membrane of the cervical canal and the muscular wall of the cervix are lacerated, but the injury does not involve the mucous membrane of the vaginal aspect, beyond, perhaps, a slight splitting of the external os ([Fig. 100]). The lesion is thus concealed, and separation of the portions of the cervix is prevented. The injury may be detected by introducing a sound in the cervical canal and placing a finger on the vaginal aspect of the cervix, when it will be found that at this spot the point of the sound and the finger are separated only by the thickness of the vaginal mucous membrane, and not by the normal thickness of the wall of the cervix.
Fig. 100.—Incomplete laceration of the cervix.
The appearance of a lacerated cervix varies with the time that has elapsed since the receipt of the injury. A few weeks or months after the occurrence the torn portions of the cervix will be found, by sight or touch, lying in more or less close apposition, the general conical shape of the cervix being unaltered. After the lapse of a longer period, however, the edges of the laceration become rounded, and a certain amount of eversion, or turning out, of the portions of the cervix takes place, so that the mucous membrane of the cervical canal becomes exposed. This eversion is always most pronounced in the bilateral laceration, and is especially striking when the tear has extended entirely through the cervix into the lateral vaginal fornices. In such cases the cervix assumes the shape of a split stalk of celery ([Fig. 101]). The cases of laceration with eversion of the lips are those in which the most marked symptoms are found. When eversion occurs, and the mucous membrane of the cervical canal is exposed, the shape and appearance of the cervix are very much altered from the normal. Before the true nature of this lesion had been pointed out by Emmet such a cervix was said to be ulcerated, the raw-looking surface, corresponding to the exposed, irritated, and inflamed mucous membrane of the cervical canal, having been mistaken for an ulcer. Even at the present day such a mistake is not infrequently made.
Fig. 101.-Bilateral laceration of the cervix with eversion. The dotted line shows the normal shape of the cervix.
Microscopical examination of such raw-looking surfaces shows that they are in no sense ulcers. “The surface is covered with a single layer of epithelium; the cells are smaller than those which line the normal cervical canal, and, being narrow and long, have a palisade-like arrangement; the thin layer of cells allows the subjacent vascular tissue to shine through, hence the redness of color. The surface is further thrown into numerous folds, producing glandular recesses and processes; these processes cause the granular appearance of the surface” (Hart and Barbour).
These red patches are larger than the surface of the everted mucous membrane of the cervical canal; they are continuous with, but extend beyond the limits of, this mucous membrane. It is said that this increase is occasioned by proliferation of the epithelium that lines the cervical glands.
As a substitute for the misleading term “ulceration,” applied to this condition, there have been proposed the terms “erosion,” “ectropion,” or “eversion” of the mucous membrane, and “catarrhal patch.”
A true ulcerated surface is sometimes found on a lacerated cervix as a result of excessive irritation, but such a condition is rare.
As the laceration occurs in the cervix before involution has begun, this process is impeded, so that a state of subinvolution of the cervix results, and the part remains hypertrophied or much larger than normal.
The cervical glands share in this condition of subinvolution, retaining much of the increased size and activity that are normal in the pregnant state.
Changes due to chronic congestion and inflammation also take place. The connective tissue increases in amount, and the cervix becomes hard, indurated, or sclerotic.
The racemose glands, which open upon the cervical mucous membrane, become inflamed, and, as a result of change in the consistency of the glandular secretion or of obstruction of the gland-orifices, retention takes place, with the production of small cysts called Nabothian cysts. Such cysts often extend peripherally, so that the distal end of the occluded gland approaches the vaginal aspect of the cervix, and appears beneath the mucous membrane as a translucent vesicle about the size of a small pea. Puncture of such a vesicle permits the escape of a drop of gelatinous fluid.
The whole of the body of the cervix may be filled with innumerable cysts of this kind, of varying size. When projecting beneath the mucous membrane they feel like small shot imbedded in the cervix. A cervix in this condition is said to have undergone cystic degeneration. The inflammation of the lower exposed portion of the mucous membrane of the cervical canal extends upward, so that a condition of general chronic cervical catarrh results. This exceedingly common disease is usually caused by laceration of the cervix.
The focus of continuous irritation in the cervix interferes with the normal involution of the body of the uterus, so that there occurs a condition of uterine subinvolution, which may be the cause of the chief symptoms with which the woman suffers. The endometrium shares in the subinvolution, and, as a consequence of this, and perhaps also from extension of inflammation from the cervical mucous membrane, various forms of endometritis may occur.
In some cases of laceration of the cervix no groove corresponding to the angle of the laceration can be felt or seen, because it has been filled with a plug or mass of cicatricial tissue. In such cases this plug of scar-tissue may be felt, distinguished by the palpating finger from the softer surrounding tissues of the cervix.
Symptoms.—The symptoms of laceration of the cervix uteri are usually referable to pathological conditions that are secondary to the laceration, and are in no way characteristic. Leucorrhea, or a discharge from the exposed and inflamed cervical mucous membrane, is usually present. Menstruation is often irregular, and is increased in duration and amount as a result of the subinvolution of the uterus and the chronic congestion, and perhaps inflammation, of the endometrium. Backache and vertical headache may also be present from the same cause.
If the tear is at all extensive—and especially if it extends through the cervix into the cellular tissue of the broad ligament—pelvic pain, referred to the general position of the scar, may be experienced.
Movement of the cervix or of the uterus that causes traction upon the scar in the broad ligament produces pain. Such pain may result from the bimanual examination, from jarring or movements of the body, from defecation, or from coitus.
Much of the pelvic pain with which women suffer in laceration of the cervix is probably due to the pelvic lymphangitis and lymphadenitis that are caused by the continuous irritation of the diseased cervix.
Sterility is a not unusual accompaniment of laceration of the cervix. It may be due to the malposition of the external os or to the profuse cervical discharges. In case conception occurs, abortion may follow on account of the pathological condition of the body of the uterus and of the endometrium.
Sometimes very marked reflex nervous disturbances are caused by a laceration of the cervix. Such disturbances are most pronounced in those cases in which there is much cicatricial tissue, and in those in which the cervix is hard and sclerotic or cystic as a result of long-standing inflammation—in other words, in those cases in which the substance of the cervix is most affected.
Neuralgia may occur in any part of the body. It is usually situated in the pelvis, or it may extend to the groin and down the thigh. Reflex nausea and vomiting may result from this as from other lesions of the uterus. Cataleptic convulsions and neurasthenia may also result from an old laceration of the cervix. The pelvic focus of irritation is constantly wearing and exhausting nervous energy.
Diagnosis.—The diagnosis of laceration of the cervix is readily made by digital examination. The palpating finger feels the one or more angles of laceration. The cervix loses its normal dome-like shape and becomes broader and flatter. In those cases of bilateral laceration where the eversion of the lips of the cervix is so marked that the angles of laceration are obliterated—becoming, in fact, 180 degrees—or where the angles have become filled up by a plug of cicatricial tissue, the angles of the laceration, of course, cannot be felt. We may often, however, detect the presence of the plug of cicatricial tissue, which feels harder than the surrounding tissues of the cervix; and we can always determine the presence of the eversion which seems to have obscured the lesion. As the finger is passed over the flattened presenting cervix it is found that the shape is not round, but oval, with the long axis antero-posterior. The finger passes around a corner or edge as it glides into the anterior or posterior vaginal fornix. This corner or edge is the extremity of the torn everted lip of the cervix. It corresponds approximately with the margin of the normal external os. The apparent external os, or the opening of the cervical canal, which occupies the center of the presenting cervix, is really a part of the cervical canal higher up than the normal os—a part of the canal that has been exposed by the laceration and separation of the lips. This fact should be remembered when the length of the uterus is measured by the sound. The measurement taken from the apparent external os is often half an inch, or even one inch, less than it would be if the cervix were restored. The degree of subinvolution of the uterus indicated by the measurement of the length is often, therefore, considerably greater than would be supposed after such imperfect measurement.
The presence of an erosion on the face of the cervix may also be determined by palpation. The eroded surface has a soft and somewhat velvety feeling, in contrast with the smooth surface of the normal vaginal cervix covered with squamous epithelium.
The cystic degeneration is readily detected by feeling the small shot-like cysts that cover the cervix; and the sclerotic condition is indicated by the increased hardness or induration, which is easily perceptible to the finger.
The most satisfactory visual examination of a lacerated cervix is made through the Sims speculum, with the woman in the Sims or the genu-pectoral position. The bivalve speculum, by separating the upper vaginal walls, often increases the eversion of the lips and masks the lesion.
The nature of the injury in cases of bilateral laceration with eversion may readily be proved in examining through the Sims speculum. If the anterior and posterior lips of the cervix be seized with tenacula and then drawn together, it will be observed that the area of erosion disappears and the normal shape of the cervix is approximately restored.
Treatment.—All forms of laceration of the cervix in which there exist eversion, erosion, cystic degeneration, and sclerosis should be operated upon. A slight laceration in a young woman in the active childbearing period does not demand operative treatment if there are no symptoms referable to the laceration. In women approaching middle life (forty years of age) all lacerations of the cervix should be closed, whether or not they produce symptoms.
It should always be remembered that cancer is most likely to originate in a cervix that has been lacerated, and the woman should be protected against this danger.
The treatment of laceration of the cervix is operative. A definite mechanical injury has been inflicted, and the parts must be repaired by operation.
The operation for the repair of a lacerated cervix is called trachelorrhaphy. The operation consists in denuding or excising the tissues on the torn surfaces and bringing the freshened surfaces together with sutures.
The form of the operation for a bilateral laceration is shown in [Fig. 104]. The operation should preferably be performed immediately after a menstrual period.
The instruments necessary for the operation of trachelorrhaphy are two double tenacula, two single tenacula, tissue-forceps, needle-holder, shot-compressor, Sims’ speculum, needles, ([Fig. 102]), knife, and scissors, sharp-pointed and curved on the flat ([Fig. 103]). The needles should be spear-pointed and should be strong and sharp, as the cervical tissues through which they are passed are often very dense. The straight or the curved needle may be used.
Fig. 102.—Cervix-needles.
Silkworm gut, shotted, is an exceedingly good suture-material.
The woman should be placed either in the Sims or the dorso-sacral position. The vulva, vagina, and cervix should be thoroughly cleansed and rendered as aseptic as possible. The cervix should be exposed through the Sims speculum. The anterior and, if desirable, the posterior lip of the cervix should be seized with a double tenaculum and held by an assistant; or the lip may be transfixed by a silk ligature, with which the cervix may be held.
Fig. 103.—Curved scissors for performing trachelorrhaphy.
The denudation, which may be made with a knife or with scissors curved on the flat, should be begun upon the lower lip. The tissue to be removed may first be marked out with the knife. The tissue to either side of the old external os is seized with a tenaculum or with toothed tissue-forceps, and a strip is elevated by an incision extending into the angle of the tear. A corresponding opposite portion of tissue on the anterior lip is then seized in a similar manner, and a similar strip of tissue is excised, meeting and joining the strip first raised in the angle of the tear. We thus remove a wedge-shaped portion of tissue. The operation is then repeated upon the other side. The strip of mucous membrane that is left on the center of the lips to form the new cervical canal should be about a quarter of an inch in width.
If the finger be passed over the freshened surfaces, small indurated masses of tissue are sometimes felt. Such tissue should be caught with the tenaculum or the forceps and excised. This condition is most usual when the tear has been of long standing and the cervix has undergone sclerotic changes. It is important that the excision of tissue should be carried well up in the angle of the laceration, in order that all hard cicatricial tissue may be excised.
The excision of tissue should be done as nearly as possible in the plane of the laceration. A frequent mistake is to remove too much tissue from the vaginal aspect of the cervix.
There is usually but little bleeding in the operation of trachelorrhaphy, and whatever bleeding there is may always be controlled by properly placed sutures.
The first suture should embrace the angle of the laceration. It should be introduced on the vaginal aspect of the cervix, near the edge of the mucous membrane, and should emerge on the edge of the mucous membrane of the cervical canal. It should then be reintroduced at a corresponding point on the opposite lip, and should emerge on the mucous membrane of the vaginal aspect. It is often difficult to bring the first suture out on the mucous membrane of the cervical canal. This, however, is not necessary if the suture embraces the whole of the denuded angle.
The other sutures, usually two or three in number, are introduced in a similar manner near the edge of the mucous membrane of the vaginal aspect, pass around the whole of the denuded surface, and emerge on the mucous membrane of the cervical canal, near the edge. They are then re-introduced on the opposite lip, and emerge at a corresponding point on the vaginal aspect of this lip.
A frequent mistake is to bring the sutures out on the raw surface so that the lateral union of the torn lips is shallow and superficial, often consisting only of the thickness of the mucous membrane of the vaginal aspect of the cervix. As the result of such an operation the new-formed cervical canal is spindle-shaped, much broader than normal, and the condition of an incomplete laceration of the cervix results.
Fig. 104.—Steps of the operation of trachelorrhaphy for bilateral laceration of the cervix uteri: A, bilateral laceration with erosion; B, the area to be denuded has been marked out with the knife; C, the denudation has been accomplished; D, sutures introduced; E, completed operation.
After the operation the vagina should be washed out with a 1:2000 solution of bichloride; it should then be dried with sponge or gauze, and a light vaginal pack of sterile gauze should be introduced.
The gauze pack should be removed at the end of forty-eight hours, and after this a daily douche, with subsequent drying of the vagina, should be administered. The woman should remain in bed for two weeks. There is always present some subinvolution of the uterus, which is much benefited by rest in the recumbent position.
The sutures may be removed at any time after two weeks. To do this the woman should be placed in the lithotomy position. The perineum should be retracted with a Sims speculum, and the anterior vaginal wall should be supported by an elevator in the hand of an assistant.
If a perineorrhaphy is necessary, it should be performed at the same time as the trachelorrhaphy. In this case the cervix sutures should not be removed for three or four weeks, in order to avoid pressure upon the perineum by the retracting speculum.
If there is present marked subinvolution of the uterus with accompanying endometritis, the cervical canal should be slightly dilated and the body of the uterus should be thoroughly curetted immediately before performing the trachelorrhaphy.
If the operation of trachelorrhaphy is performed within a few months after the receipt of the laceration—before sclerotic, cystic, and erosion changes have appeared—there is usually required but little preparatory treatment. When, however, there is a marked and widespread erosion, and the cervix is full of numerous Nabothian cysts, or is hard and sclerotic from inflammatory exudate, it is necessary to devote from two to six weeks to preparation of the cervix for operation. Many failures in the operation of trachelorrhaphy are due to neglect of such preparatory treatment. The hard, cystic cervix may unite but imperfectly after operation, or the symptoms referable to the diseased cervix may remain unrelieved by the operation. We often see women in whom laceration of the cervix has been closed with good union, and yet the sclerotic cystic condition of the cervix, and perhaps subinvolution of the uterus, persist, and symptoms continue as pronounced as before operation.
The preliminary or preparatory treatment consists of the administration of vaginal douches, regulation of the bowels by saline purgatives, and local applications to, and puncture of, the cervix uteri.
The woman should take, two or three times a day, a vaginal douche of one gallon of hot water (110° F.). The douche should be administered in the recumbent posture.
One or two watery fecal movements should be produced daily by Rochelle salts, sulphate of magnesium, or some similar preparation.
Fig. 105.—Cotton tampon.
Every five or six days the woman should be placed in the knee-chest position and the cervix should be exposed with the Sims speculum. The Nabothian cysts, which appear as translucent vesicles beneath the mucous membrane, should each be punctured with a sharp knife-point. If the cervix is much enlarged and congested, it should be freely punctured over the whole vaginal aspect to produce local depletion. Half an ounce or an ounce of blood may be removed in this way. The cervix should then be thoroughly dried, and an application of Churchill’s tincture of iodine should be made over the whole of the cervix and the vaginal vault. The excess of iodine should be removed with a little cotton, and a cotton tampon (to which is attached a string) saturated with glycerin should be placed against the cervix ([Fig. 105]). The hygroscopic action of the glycerin is most useful in depleting the cervix. The woman should be told to remove the tampon by traction on the string at the end of twelve hours, and to follow the removal with a vaginal douche of hot water.
Such local treatment should be instituted immediately after a menstrual period and should be repeated every five or six days, and continued until the erosion and the cysts have disappeared and the induration has diminished. Three weeks of such treatment usually produce a very marked change. The cervix not only becomes much more healthy in appearance, but most of the symptoms of which the woman complained vanish. The leucorrhea diminishes or ceases; the backache and headache disappear. The relief is often so marked that the patient suggests the advisability of deferring operation. This, however, should never be countenanced, as all the symptoms will return with cessation of treatment.
If, after the careful administration of the treatment here prescribed for five or six weeks, the induration and cystic degeneration do not disappear, then the case is not one that will be benefited by trachelorrhaphy. The mere closure or union of the indurated and cystic lips of the cervix will not cure the woman if these conditions persist.
If the inflammatory changes secondary to the laceration have become so deeply seated that they are not relieved by the preparatory treatment, amputation of the cervix is necessary. In any doubtful case, therefore, this preparatory treatment is to a certain extent indicative of the character of the ultimate operation to be performed.
The description of the operation already given is applicable to the most usual form of laceration—a bilateral laceration. If the injury be unilateral, it may be necessary to split the cervix on the sound side in order to denude, and to introduce sutures, on the injured side. The case may then be repaired as in the bilateral form of injury. In the case of the unusual stellate laceration the lacerations must be separately repaired, or two lacerations may be converted into one by excision of the intervening tissue.
The incomplete laceration may be recognized in the manner already described, by introducing a sound into the cervical canal and a finger in the vaginal fornix. Such an injury should be treated by splitting up the cervix and converting the incomplete into a complete tear, and then denuding where necessary and closing as in the case of an open laceration.
If, in an old laceration, the sclerotic and cystic condition of the cervix does not yield to the preparatory treatment advised, amputation of the cervix is necessary.
Fig. 106.—An old incomplete laceration of the cervix with hypertrophy and cystic degeneration. Amputation is necessary.
Amputation of the Cervix.—This operation is performed as follows: The cervix is split bilaterally to the vaginal junction with knife or scissors. Two flaps are formed in this way, and each flap is then amputated separately, the posterior one first (Figs. 107-109). An incision is made on the vaginal aspect of the posterior flap, extending from the angle of the split on one side to the angle of that on the other. The knife is thrust deeply into the cervical tissue and is directed toward the cervical canal. An incision is then made across the mucous membrane of the cervical canal, on the anterior aspect of this flap. The posterior lip is thus removed. The anterior lip is removed in a similar manner. The stump of the cervix is then closed by sutures. Two or three sutures are introduced on each side of the cervix to close the angles, just as in the operation of trachelorrhaphy for a bilateral tear, and two sutures are introduced on each flap to attach the mucous membrane of the cervical canal to the mucous membrane of the vaginal aspect, to form the new external os. The first sutures should be passed well up in the angles at the lateral vaginal fornices, to control bleeding. Bleeding is more likely to be free in this operation than in a simple trachelorrhaphy, but it may always be controlled by the proper application of the first sutures placed in the angles.
Fig. 107.—Operation of amputation of the cervix uteri: A, the cervix has been split laterally, forming an anterior and a posterior flap; B, the posterior flap has been partly amputated.
Fig. 108.—A, the posterior flap has been amputated; B, both flaps have been amputated.
Fig. 109.—A, the sutures have been introduced; B, completed operation.
The post-operative treatment is similar to that after the operation of trachelorrhaphy.
Amputation of the cervix does not interfere with conception, with the course of pregnancy, or with labor.