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.
[Illustration: 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.