CHAPTER XX.

HYPERTROPHY OF THE CERVIX UTERI.

THIS is a peculiar and rather rare affection. It differs from the enlargement of the entire uterus, which occurs in pregnancy and in some of the inflammatory affections. The hypertrophy is confined to the vaginal portion of the cervix, and is distinct from the enlargement of the supra-vaginal portion, which occurs in connection with metritis, subinvolution, and pregnancy.

Pathology.-The only change in structure of the cervix is in quantity. The length of the cervix is increased, which is the main point in the pathology. Sometimes it is thickened, but not in proportion to the elongation. It is characterized by great increase in length without increase in the diameter of the cervix, and no changes occur in the composition of the tissues. This is a true hypertrophy, which occurs from causes wholly different from the ordinary conditions which produce hypertrophy. The extent of hypertrophy differs in different cases; this is due, to some extent, to the stage of progress when the first examination is made. In some cases the cervix projects from the vulva one or more inches, while in others the cervix rests just behind the hymen or in the vulva (Fig. 165).

The cervix is generally conical and the os externum is generally small, as it should be in the virgin cervix.

It occurs in the unmarried most frequently, but occasionally in those who are married but sterile.

Symptomatology.-The symptoms are exactly the same as those due to prolapsus. In the first stage there is pelvic tenesmus, and a sense of overdistention of the vagina. The presence of this large cervix causes irritation of the vagina and consequent leucorrhoea. Owing to the great increase in the length of the uterus, it becomes doubled up in the pelvis, and this often affects the menstrual function, giving rise to dysmenorrhoea. In the last stage of the affec

tion, in which the cervix protrudes from the vulva, there is much discomfort; and the feeling of distention causes great irritability of

the general nervous system. Excoriations and ulcerations of the mucous membrane are produced.

Physical Signs.-The bimanual touch reveals the fact that while the fundus uteri is at its normal elevation, the cervix is either down at the vulva or protruding beyond it. At the same time the firmness of the vaginal walls, occupying their normal position, shows the great length of the extra-vaginal part of the cervix. This sign is diagnostic when the cervix is still within the vulva, but when the cervix has escaped through the vulva there is prolapsus of the vagina which obscures the signs to some extent. Emmet claims that elongation from prolapsus of the uterus has been mistaken for hypertrophic elongation. This does not seem possible for one who knows anything about the rudiments of gynecology. By restoring the prolapsed uterus, any little elongation which may have come from stretching will disappear, while no change of position will make any difference of length in hypertrophy. The use of the sound also

helps greatly in determining the extent of the hypertrophic elongation.

Causation.--The fact that this affection is limited to the virgin cervix makes it appear as if the hypertrophy might be due to neglected functions, but the fact is that its cause is not known.

Prognosis.-The hypertrophy yields to surgical treatment very promptly. All the

cases that I have treated, five altogether, have been completely relieved by amputation of the cervix.

Treatment.-The removal of the superabundant intra-vaginal portion of the cervix by amputation, is the only method of treatment which

gives satisfaction.

Several methods

of operating have

been employed, such as the circular method, made with the knife or scissors, the écraseur, and the galvano-cautery wire. Originally, in all of these methods the stump was left to heal by granulation. J. Marion Sims greatly improved the operation by covering the stump with mucous membrane. Simon and Marckwald made a doubleflap operation, and I have adopted a modification of this method. The details of the

operation, as I perform it, are FIG. 168.--Diaas follows:

gram of the picces removed.

A rubber cord is passed around the cervix and drawn tight enough to control the hæmorrhage; the ends of this cord are then seized with a fixation-forceps, which keeps them from slipping, and also holds the cervix in the desired position. The cervix is divided from the canal outward on either side as

high up as the amputation is to be made (Fig. 166). The double flaps are then made with the scalpel in such a way that the two

short flaps are on the inside (Figs. 167 and 168). The portions removed are wedge-shaped.

Two middle sutures are then introduced from the cervical mucous membrane, or short flaps, to the outer mucous membrane, and the lateral sutures are used in the same way as in restoring a bilateral laceration. Fig. 169 shows the sutures as introduced, and Fig. 170 shows them when tied.

Before tying the sutures the rubber cord should be loosened, and if there are any vessels that bleed freely they should be controlled. Slight oozing is controlled completely by tying the sutures.

The first is, that the cer

There are two things which have been brought out by experience, and these should be kept in mind. vix after amputation retracts or shrinks, so that it should not be amputated too high up, but left a quarter or three eighths of an inch longer than it should apparently be. It will be found short enough two or three months after the operation. The next point is, that the middle and outer layers 'retract after the operation far more than the mucous membrane of the cervix; especially is this the case when there is a cervical endometritis present. In several of my cases, I found several months after the operation that the mucous membrane protruded from the os externum, and had to be clipped

off. This is a simple thing to do, but by observing the directions this item of after-treatment will not be required.

The after-treatment is the same as that employed in the operation for restoring a lacerated cervix uteri, and need not be described here.

In a certain number of cases I have noticed that the outer walls of the cervix retract more than the mucous membrane after this operation. Immediately after the parts have healed, the cervix is quite perfect, but in a few months the mucous membrane protrudes beyond the muscular wall. This is more likely to occur, I think, in case there is a cervical endometritis accompanying the hypertrophic elongation. When this condition of protrusion or prolapsus of the cervical mucous membrane is found subsequent to amputation, the easiest and quickest way is to draw the superabundant tissue and clip it off.

Just here I may mention that hypertrophic elongation of the anterior half of the cervix occasionally occurs in bilateral laceration. When this elongation is very great, I have found it best to amputate the redundant part as a preliminary to the operation for the lacera- . tion. This is done in the same way as taking off a finger by the flap operation.