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.
[Illustration: FIG. 98.--Left lateral laceration of the cervix with
erosion.]
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.
[Illustration: 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.]
[Illustration: FIG. 108.--_A_, the posterior flap has been amputated;
_B_, both flaps have been amputated.]
[Illustration: 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.