The PATHOLOGICAL ANATOMY may involve all the displaced organs. The circulation throughout the pelvis is impeded by traction upon the vessels, and the entire pelvic contents therefore become the subject of venous congestion, with consequences disastrous to local innervation and nutrition.
The ovaries may suffer concurrent displacement, with resulting inflammatory and cystic enlargement. The peritoneum which enters into the formation of the uterine ligaments and of the pelvic floor is dragged along with the uterus.
The vagina is hypertrophied and swollen. Its mucous membrane becomes the seat of acute vaginitis and chronic catarrh. In the third degree of descent the exposed vagina, no longer lubricated by the normal secretions of the uterus, becomes dry, parchment-like, oedematous, eroded, and ulcerated. Sometimes the cul-de-sac of Douglas is distended by downward pressure of the intestines, by a small tumor, or by ascitic fluid, and a consequent hernial sac may protrude into the vagina through some portion of the posterior vaginal fornix. The anterior fornix is subject to a similar accident. These conditions are designated enterocele vaginalis, anterior and posterior.
The rectum and bladder are subject to inflammation and chronic catarrh, and the bladder especially to concurrent descent. The uterus may be enlarged from any one or all of a variety of causes—congestion, subinvolution, hypertrophy, and hyperplasia. Its cervix is often the seat of extreme erosion or so-called ulceration. The endometrium, in order to relieve the organ of its surplus blood, gives forth an excessive secretion of mucus, which upon being increased in quantity becomes vitiated in quality. This is termed uterine catarrh. The enlargement of the uterus often pertains more to the cervix than to the body, especially in prolapse of the second and third degrees. An explanation of this may be found in Figs. 5 and 6.
| FIG. 5. | FIG. 6. |
| Descent of the Virgin Uterus into the Vaginal Canal, showing the Reduplicated Vaginal Walls. The utero-vaginal attachment, points X and Z, appears to be at X' and Z'. The apparent increase of length in the vaginal portion of the cervix due to the reduplication is measured by the distance from X and Z to X' and Z'. | Descent of the Uterus, showing Excessive Circular Enlargement of the Lacerated Cervix, consequent upon Reduplication of the Vaginal Walls and Out-rolling of Intracervical Tissues. The divided fragments of the os externum are at a and b. The curved lines forming the angles 1, 2, 3, 4, and 5 indicate the gradual process of the eversion. The angle of the laceration at point 1 has been forced by the swelling and out-rolling of the mucous and submucous tissues of the cervix to point 5. The apparent os externum is at point 5. The utero-vaginal attachment X and Z seems to be at X' and Z'. The vaginal portion of the cervix therefore appears much larger and longer than it actually is. |
Apparent elongation and disproportionate circular enlargement of the cervix are conditions which almost every standard author wrongly calls hypertrophic elongation and circular hypertrophy. The question of elongation is easily settled by placing the patient in the knee-chest position. Then the uterus by its own weight falls toward the diaphragm, the vagina unfolds, and the apparent utero-vaginal attachment X' Z' (Figs. 5 and 6) disappears, disclosing the actual attachment, X Z. Further, the point of the sound, passed into the bladder while the cervix is exposed by Sims's speculum, may be placed against the anterior wall of the cervix at Z, which would be impossible if the attachment were at Z'.
The comparatively small amount of hypertrophy in disproportionate circular enlargement is proved by the operation of trachelorraphy or by bringing the points a and b (Fig. 6) together with uterine tenacula, the organ being exposed by Sims's speculum. Then the out-rolled intracervical mucous tissues are rolled back, the proper diameter of the cervix is restored, and a laceration on one or both sides, extending past the vaginal attachment, becomes apparent.
Hypertrophy or hyperplasia usually causes a nearly symmetrical enlargement of the entire organ. At any rate, those cases in which the reduplication of the vaginal walls does not almost entirely explain the great elongation so called, or in which great disproportionate circular enlargement has not been caused by laceration of the cervix, are the rare exceptions. The great merit of having secured general assent to the foregoing proposition, and of having given to the subject a new and right direction, must be accorded to Emmet. The cervix now is seldom amputated except for malignant disease.