Chapter XXII., page 433.)
Diagnosis of Uterine Anomalies Due to Arrest of Development. —
The diagnosis of uterine anomalies due to arrest of development rests on the symptoms in the rare eases where accumulation of secretions forms a sac that presses on the bladder or rectum, or causes cramps; or cases in which menstruation does not occur at the normal age. As regards the latter it should be remembered that menstrual blood may flow from one half of a uterus while it is collecting in the other half. Abortion and premature labor are more frequent in the case of double uterus, and the presence of a septum makes deliver}' difficult and involution slower. A decidua
fwroicj nodules
of cervi* w,/'.
Fig. 78. — Bicornute Uterus, One External ( K Two Uterine Cavities. Removed from Single Woman 31 Years old, Jan. 27, 1903, for Rebellious Dysmenorrhea.
forms in the empty half of a septate pregnant uterus or in a rudi- mentary horn just as it forms in the uterus in the case of tubal pregnancy.
By examination the presence of two vaginal canals is a definite indication of a double uterus. If the vagina is single the two ora of a didelphys uterus may be palpated by the examining finger and may be seen through the speculum. Two uterine horns, or a divided fundus, may be felt by bimanual examination if the conditions are exceptionally favorable, that is, a thin and lax abdominal wall and absence of much fat. If the uterus feels normal to the bimanual palpation except for the presence of two ora in the cervix, two sounds arc passed simultaneously, one into each os, and an attempt made to make them meet in the uterus.
202 CONGENITAL ANOMALIES OF THE UTERUS
If they do not meet, the case is one of uterus septus. If the sep- tum does not reach to the external os the diagnosis is more diffi- cult, and in this case the lower edge of the septum may possibly be felt with the tip of the sound. If the bimanual touch shows that there is a depression in the fundus we have to do with a case of uterus didelphys or uterus bicornis, the latter being much more frequent. The halves of a uterus bicornis are commonly closely adherent well above the level of the internal os and can not be moved independently, whereas in the case of uterus didelphys the two halves are well separated and can be so moved. They may lie even at some distance from each other, and the point of separation may be felt by rectal palpation, and if the conditions for palpation are favorable, an ovary attached to each horn may be palpated.
The diagnosis of the one-horned uterus is not easy. The fundus is found to one side of the pelvis, it is tapering, and only one ovary can be made out. Hematometra or pyometra may be present, and are to be diagnosed as swellings occupying a portion of the uterus. The diagnosis is difficult and is seldom made exactly without opening the abdomen.
Differential Diagnosis. — It is important to distinguish pregnancy in a detached cornu of an anomalous uterus from a fibroid tumor. The occurrence of irregular hemorrhage from the uterus and the absence of the signs and symptoms of pregnancy, together with hardness and irregularity of the surface of the tumor, serve to point toward a fibroid.
II. Anomalies Due to Arrest of Growth
These are infantile or "puerile uterus, in which the uterus of the adult remains of the type found at birth, — and congenital atrophy of the uterus, in which the organ, though of the type of the adult, is atrophied as a whole. These two sorts of malformations are not very uncommon. The condition known as retroposition with anteflexion (see page 231) would seem to be closely allied to the infantile uterus.
Infantile Uterus. — This is a relatively common condition. The infantile uterus is narrow in proportion to its length, has a long cervix and a short body, and the uterus is situated well back and
ANOMALIES DUE TO ARREST OF GROWTH 203
high in the pelvis at the end of a long vagina, there being at the same time more or less anteflexion. The os is a ''pinhole os" and the cervix is conical. Menstruation is usually absent in these cases, but the breasts, figure, hair, and voice may be perfectly normal; sexual desire is absent and the patient is necessarily sterile. The diagnosis is made by the bimanual recto-abdominal touch and by passing the sound. The situation of the internal os, where the tip of the sound or probe catches, is well up in the total length of the uterus and is characteristic, and the relatively large and long cervix, and short and slender body, can be made out easily. The ovaries are apt to be small in these cases. Help in the diagnosis is obtained often if the uterus is drawn down by a tenaculum held by an assistant while the bimanual touch is practiced.
Congenital Atrophy. — The congenital atrophic uterus is a rare condition. Here the diagnosis is made by finding a well-propor- tioned uterus which is small in all of its diameters. This anomaly is associated with lack of body growth, absence of pubic hair and sex characteristics. We must suppose that the individual attained a proper growth of the uterus to the virgin type followed b}T atrophy. The condition has been found in dwarfs and cretins and in cases of early tuberculosis and chlorosis.
Puerperal Atrophy. — The opposite of subinvolution is puerperal atrophy, superin volution. Vineberg of New York has added to our knowledge of lactation atrophy. (Amer. Medico-Surg. Bull., N. Y., 1895, VIII., 1518.) It is a shrinking of the uterus in size symmetrically below the virgin type, following prolonged lactation, and is due probably to overstimulation of the uterus due to nursing. It is not a permanent condition, the uterus returning to its normal size two or three months after nursing has been discontinued. It would appear that a certain amount of atrophy is normal during the puerperium irrespective of lactation, therefore superinvolution is a distinctly pathological stale
Non-puerperal Atrophy. — This occurs even more rarely than puerperal atrophy, in chronic wasting dig is in tuberculosis,
and in the acute4 infectious diseases, such as scarlatina. I have Been one case following steaming of the uterine cavity. Non- puerperal atrophy may or may not be permanent. The exact causes are not known.
204 LACERATION OF THE CERVIX UTERI
DIAGNOSIS OF LACERATION OF THE CERVIX UTERI
The credit for a proper understanding of laceration of the cervix uteri is due to Thomas Addis Emmet, of New York, who published his first paper on the subject, " Surgery of the Cervix Uteri," in the American Journal of Obstetrics in February, 1869. Previous to this the effects of lacerations were treated under the name of ulcerations of the womb, coxcomb granulations, or erosions of various sorts.
In a large proportion of cases the cervix is torn during labor, the few cases where it is injured by forcible dilatation or incision at the hands of the physician being disregarded here, although it happens not at all infrequently that the upper portion of the cervix is injured by the two-branched steel dilators employed in dilata- tion for curetting.
Anatomy
The normal cervix in the virgin is slightly conical and projects into the vagina from a half to five-eighths of an inch (1 to 1.5 centi- meters). The os is round or oval in shape and about a sixteenth of an inch in diameter. In women who have borne children the os is more of a transverse slit (see Figs. 65 and 66) and may be irregular from lacerations, and the cervix is rounder and less conical than in the virgin. To the feel the tissues are firm, but not hard, and seen through the speculum are of a yellowish pink color. The wall of the cervical canal presents anteriorly and posteriorly a longitudinal column from which proceed a number of oblique columns, giving the appearance of branches from the stem of a tree. This is called the uterine arbor vitce. These columns become more indistinct after the first labor, but they are not obliterated.
Etiology
The causes of laceration may be enumerated as: (1) A rapid second stage of labor, (2) A large child and a small cervix, (3) A rigid cervix, as in abortion, or from diminished elasticity of the tissues,, (4) Instrumentation, as from the forceps or instruments used in embryotomy, or in dilatation, (5) Friability of the tissues of
MECHANISM AXD PATHOLOGY
205
the cervix due to prolonged pressure by the presenting part, or to disease of the cervix.
Mechanism axd Pathology
In the virgin uterus the canal of the cervix at its widest part, i.e., midway between the external os and the internal os, is about one-fifth of an inch in diameter. During delivery this must be dilated to the diameter of the child's head, some four and a half inches. The muscular fibers of the cervix become stretched ex- cessively and it is not surprising that lacerations occur, especially if insufficient time is given for the dilatation. Lacera- tions may occur in any di- rection or in several direc- tions, that is, they may be unilateral, bilateral, or stel- late, and anterior or poster- ior. They are most often lateral. Extensive tears which involve the cervix above the attachment of the vagina are apt to result in infection of the perimetric tissue (cellulitis). During
pregnancy the cervix together with the rest of the uterus is enlarged to accommodate the growing fetus, The rhythmical contractions of the uterus during the entire pregnancy reach their climax in labor when the major part of the hypertrophied uterine muscle acts as an expellent force, while the small portion of the uterus, the lower part of the cervix, acts a passive r61e and is dilated. This lower part of the cervix may be likened to the sphincter ani muscle. After receiving an excessive stretching as a preliminary to an oper- ation for hemorrhoids, or other operation on the rectum, the sphincter ani does not recover its tone and is unable to contract for forty-eight hours, more or less in fad it has been stretched for this very purpose. So in the case of the lower cervix after labor. It is a flabby, soft ring that has no power of contracting. Under normal conditions, and when not lacerated, it contracts to the
Fig. 79.-
Bilateral Lacerations of the Cer- vix with Erosions.
206
LACERATION OF THE CERVIX UTERI
dimensions of a parous, normal cervix in the course of a few days. When torn the lips are turned out into the vagina by the weight of the large uterus above and the contracting power of the cervix is thus lost. (See Fig. 82.) The intracervical tissues are everted into the vagina, the uterine circulation is interfered with, the tissues become engorged and remain swollen — therefore there is no longer room for them within the uterine canal. Infection of the rolled-out mucosa adds to the trouble and erosions, endometritis and cystic degeneration result, with ultimate thickening of the torn lips from subinvolution. Because of the downward excursion of the heavy
uterus the cervix projects relatively farther into the vagina and the attachments of the latter organ to the cervix appear to be higher up on the uterus, although in reality they are not, and thus the torn cervix seems to be larger than it is. Sub- involution, or chronic me- tritis, keeps the uterus heavy and in this manner accent- uates the eversion. Lacer- ations of not great extent unite readily in the absence of infection. If pelvic inflammation is present lacerations are apt not to heal so soon, if at all, and extensive lacerations may involve the vagina and even the bladder or rectum, leaving fistulse behind them. It often happens that the laceration is in the canal of the cervix and that the external os is little, if at all, involved.
Fig. 80. — Stellate Lacerations of the Cervix.
Results of Laceration
The immediate results of laceration of the cervix are hemorrhage, or the production of a fistula. The later results are endome- tritis, subinvolution of the uterus, cystic degeneration and ero- sion of the cervix (see Chapter XL on endometritis, page 184), thus furnishing a favorable soil for the growth of cancer, cellulitis
RESULTS OF LACERATION
207
(see Chapter XII. on pelvic inflammation, page 192) , cicatricial stenosis of the uterine canal, and a tendency to sterility and abortion. As regards the last, Dr. Emmet's tables (''Principles and Practice of Gynecology," 3rd edition, pages 447, 448) show- that following lacerations of the cervix 71.34 per cent of his 164 cases were sterile, and of the 47 who became pregnant, 51 per cent aborted one or more times. These were in the preaseptic days and infection as a sequence to injury was undoubtedly more frequent than now.
Endometritis is considered in