The life and times of Madame du Barry

Front matter

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Preface

The propriety of discussing the diseases of the uterine cervix separately from those of the corpus, rests fundamentally upon the anatomical division of the uterus into two parts, a superior segment, and an inferior segment, sharply marked at the internal os.

This division, which concerns all the structures of the organ, is apparent in the embryo. It continues with increasing distinctness through development and growth, both iutra-uterine, and extra-uterine, and is carried into the final up-folding of the uterus that characterizes the close of reproductive activity.

Corresponding to this structural division, there is a specializing of the functions performed by the two segments of the Qterus ; and in as much as all disease is based upon health, and finds its cellular prototype in normal histology, and accomplishes its metabolism according to physiological laws, the pathological processes that have their initial development in the uterine cervix, are quite distinct in their etiology, construction, and clinical course, from those that originate in the uterine corpus. Diseases of the inferior segment may invade the superior segment of the uterus, and those having their origin in the superior segment may spread downward, but their pathogenesis can always be made out, and their clinical

S histories diHerentiated.

The advantages that accrue from a separate consideration o[ the diseases of the uterine cervix, are those that belong to special investigations In general. Particular lines of study pursued independently of each other, lead to an accurate and exact knowledge of a subject when these lines are made to converge, and their relations and inter-dependence adjusted, and balanced.

H. I. O. .Vfw Vori. iff04.

aaagoM

Removal of the Uterus. — Abdominal Hysterectomy. — ^Vaginal Hysterectomy, 296

Thbrapbutics, 329

Rbpbrtory, 343

LiTBRATURB, 35'

INDBX, 359

THE

Diseases of the Uterine Cervix.

Chapter I. Development Of The Uterus And Vagina

The development of the uterus and vagina in the human fcetus forms a part of the history of the Wolffian Body» or Mesonephros, a mesoblastic embryonal orphan developed in the intermediate cell mass, that lies in the lumbar region on either side of the mesentary. This body attains its maturity early in the second month of fcetal life; by the third month its primary function, that of a kidney, becomes vestigial, its permanent parts being then connected with the genital system.

The WolfHan Body» after it has ceased to perform its function of primordial kidney, and given rise, from the Wolffian duct, to the permanent kidney, evolves three organs.

The Genital Ridge, lying on the mesial side of the Wolffian Body, a differentiated body covered with germinal epithelium derived from the mesoblastic lining of the coelum, or peritoneal cavity, from which the genital glands, ovaries, or testicles are developed.

The WolfHan dact» the first longitudinal duct to appear in the uro-genital system, is recognized at the end of the third month of embryonal life as a tube, formed by an invagination of the epiblastic layer into the intermediate cell mass, into which the WolfHan tnboles enter. The Wolffian duct is the essential embryonic male genital duct, as it gives rise to the organs and parts concerned in conveying the fertilizing elements from the male se.xual glands to the female genital organs. The Wolffian duct has no well-defined function to perform in the female; its relation to the adult female genital system is accessory.

18 DEVELOPMENT OF THE UTERUS AND VAGINA.

and when more than this, it becomes pathological. The only portion of the Wolffian duct that persists in the adult female, is a tube that occupies the meso-salpinx between the ovary and the Fallopian tube. This portion, together with its genital tubules, which in the male form the vaso-efferentia and coni-vasculosa, becomes the parovarinm and paroophoron, functionless structures, vestigial organs, and as such peculiarly susceptible to the development of pathological processes. The continuation of the meso-salpingial portion of the tube passes down through the uterine cervix and vagina, to terminate in a bulbous mass of epithelium, which quite occupies the lower end of the fused Mullerian ducts. These buds are subsequently hollowed out, save that portion which forms the hymen, and thus give the epithelial lining to the vagina. All traces of the inferior portion of the Wolffian duct is then lost, excepting its epiblastic structure, the lining of the vagina. When the parts that pass through the cervix persist, they are known as Gartner's ducts, and are to be regarded as embryonal organs in mature structures.

The Mullerian duct is the last of the three embryonal organs of the uro-genital system to appear. It is the essential embryonic female genital organ. From it are developed the uterus, the Fallopian tubes, and vagina. In the female it is a true oviduct, but in the male it persists as the :r/ ;///.? pocularis in the prostate gland, and pathologically, the end of the duct remains as a sessile hydatid on the testicle.

Towards the close of the fourth week of embryonic life there appears on each side of the outer surface of the Wolffian body, inferior to the Wolffian duct, a slight thickening of the intermediate cell mass, into which, by a process of invagination of the mesothelium, a tube is gradually formed — the Mullerian duct. These ducts, two in number, are continued downwards on the outer side of the Wolffian ducts into the pelvis, where during the third month of foetal life they are fused together to form the uterus and vagina. The head of the duct, or beginning of the lumbar portion, remains open into the ccelum, from which its mesothelial lining is derived, and becomes the fimbriated opening of the Fallopian tube. The pelvic portion of the

DEVELOPMENT OF THE UTERUS AND VAGINA. 19

MuUerian ducts, from which is developed by fusion the uterus and vag^ina, constitute, together with the Wolffian ducts, the genital cord. In this situation the relation of the four ducts be* comes altered. The Mullerian duct, as it bends quite abruptly towards the median line to join the duct of the opposite side, has attached to it a fold of the Wolffian body, the inguinal fold, which becomes, by the addition of muscular elements, the round ligament. At this point the uterine cornua is devel* oped, and below it, the Mullerian ducts increase in size, pass in front, and to the inner side of the Wolffian ducts, and fuse in the median line.

From the parallel tubes thus fused are developed the nteros and vagina, by a gradual disappearance of the septum of union, and differentiation of cell masses, which mark off the vagina from the cervix, and the cervix from the corpus uteri.

It is thus seen, and this point may be emphasized because of its bearing upon the pathology of the uterine cervix and portio-vaginalis, that the corpus nteri is developed almost wholly from the Mullerian ducts, mesohlastic structures^ and that the cervix uteri has, in embryonic life, a slight incorporation with the Wolffian duct, an epihlastic structure^ that should entirely disappear from the cervix before the fourth month, and that the vagina is a compound organ, depending for its structural parts upon the Mullerian duct — mesohlastic — and for its lining upon the Wolffian duct — epihlastic.

Changes in embryology are rapidly accomplished. When fusion between the Mullerian ducts takes place — the third month— there remains a septum in the mesial line which extends the whole length of the union, a condition that persists in some vertebrates as a double uterus and vagina.

The first portion of the septum to disappear, the process by which this is accomplished is one of resorption, is that which corresponds to the cervical canal. This begins almost immediately after fusion takes place, and is completed by the middle of the third month. The next portion to disappear is the vaginal septum, this is completed by the end of the third month. The third and last portion of the septum to disappear, is that of the fundus; this is completed before the fifth

20 DEVELOPMENT OF THE CTERLS AND VAGINA.

month. Until this time the nascent atems is doable homed, the exact line of demarcation between the Fallopian tabe and the atems* the comaa, not being well marked, but by the consolidation of the corpus with the comaa the orcran gradaally acquires the shape it bears at birth.

In the early part of the fifth month, the entire septum of fusion of the MuIIerian ducts having disappeared, the vagina is marked off from the uterus by a circular outsrowth of cells. which forms the exteml os» and by a change in the epithelium, which becomes stratified, while the epithelium of the upper half of the cervical canal, and the corpus, remains columnar. About the middle of the fifth month a nodule develops from the anterior segment of the differentiated os. the besdnning of the aaterior % of the os iteri. A little later a similar process repeated posteriorly, results in the development of the porterior Bp. By the sixth month, the anterior and posterior lips are fused laterally. But the line of union is neither always perfect, nor secure, for cases of bilateral laceration have been observed at birth.

During this period there is a rapid growth of muscular tissue in the lower segment of the uterus, which thus becomes markedlv thickened, and bv the seventh month, the tntemal os is formed, and the cervical canal differentiated from the superior segment, or body of the uterus.

Thus far the embr>*ological developments have been principally architectural, that is, building according to a plan of construction. The last two months of foetal life are occupied largely in perfecting the structure already built, in preparing it for functional activity.

The MuIIerian duct possesses no muscular tissue, and while muscle ctrlls begin to appear by a separation of the mesoblastic enibryonal celU as early as the fifth month, the developaieiit of nmsailar tissue in bjth the vagina and uterus proctreus more rapi'ily un the lines of gpjwth than of development, durinirthe eighth :iii«i ninth months of intra-uterine life. The innt-r Li> er of cells, which results from the separation of the inesobhistic Cells, becomes the deddoil tissue of the uterus, which .^nulually assumes its structure of functional perfection.

DEVELOPMENT OF THE UTERUS AND VAGINA. 21

The s^enital canalt uterus and vagina, is at first lined with simple stratified columnar epithelium. Changes in this are not especially marked until these organs have begun to assume their splanchnological type. The first change noticed is in the fourth month, when in the lower third of the cervical canal, the columnar epithelium begins gradually to pass into stratified pavement epithelium, and this into the cylindrical epithelium of the upper part of the canal.

At the ninth month, the epithelial cells of the cervix elongate and change into mucous secreting cells, which arrange themselves into macons racemose s^lands. By the end of the ninth month, the entire epithelial lining of the cervical canal has undergone this change, and the inferior segment of the uterus may be regarded as a glandular organ, as far as its function is concerned.

This part of the uterus does not seem to possess any function that would connect it with either menstruation or pregnancy, and inasmuch as it is the entrance to the foetus-containing organ, and the abdominal cavity, and its glands secrete a peculiar substance that acts as a barrier to the entrance from without of all but mechanical measures, may we not regard the uterine cervix as the guardian of the lower segment of the uterus, and as such the key to the pathology of the uterus.

Chapter II. Anomalies Of Development, And Congenital

DEFECTS.

Developmental irregularities of the lower segment of the uterus are associated with more or less pronounced expressions of the same erratic force in other parts of the uro-genital system, and therefore any discussion of malformations of the cervix uteri must include reference to the embryological periods through which the entire system passes to perfect development.

Malformations of the lower segment of the ateras» as well as of the whole organ, and of the Fallopian tubes, have their origin in developmental irregularities that date from the beginning of the second month of embryonic life. At this period ingrowths of the mesothelial lining of the coelum take place in to the Wolffian ridge. From these ingrowths the Mnllerian ducts are developed, and malformations of the oviduct may occur at any stage of development until coalescence of the Mullerian ducts on the median line, which forms a single tube — the uterus and vagina — is accomplished.

Each malformation is a permanent expression of a stage of development through which the perfect organs are evolved from the oviducts, and therefore anomalies of development are arrests of the developmental process, and have to do, first, with the formation of the Mullerian ducts; second^ with their fusion; and third, with the inconiplete removal of the septum of union.

The ingrowth of mesothelium from which is formed Muller's duct, is at first a solid cell mass. Towards the end of the second month, or the beginning of the third, this cord acquires a lumen, and from that time becomes tubular, assuming the anatomical formation of an oviduct.

Failing to become tubular, but in other respects pursuing a normal course of pelvic descent, the Mullerian duct, as a solid body, occupies a position in the median line, between the folds of the meso-salpinx, the broad ligament. Thus is formed, from developmental irregularities, the ateros mdifflentarins, the first arrest in the development of that part of the uro-genital system from which the uterus and vagina are formed.

The rudimentary uterus appears as a solid muscle, or fibroinuscular body, occupying the position of the normally developed uterus, between the folds of the broad ligament. Sometimes there is a slight dimple to indicate the position of the external os ; at other times there is no such depression. It is the development of a single MuUerian duct, the second duct commonly being absent, or lying as a detached body anterior to the rudimentary organ. One ovar>' is usually present, and though amenorrhcea must be a clinical feature of such malformations, the menstrual molimen may occur, or vicarious menstruation take the place of the normal flow.

The vagina is generally rudimentary, or may be absent, represented only by a cul-de-sac. It is rather difficult to explain how that portion of the Mullerian duct from which the vagina is formed could become tubular, while the upper segments remain solid throughout their greater, or their whole extent. The most acceptable accounting for the rudimentary uterus and vagina, is, that the vagina is only such in appearance, and is in reality an irregular and exaggerated persistence of the uro-genital sinus, which should terminate at the hymen, but is in this anomaly deepened, to meet the lower segment of the rudimentary uterus.

The rudimentary uterus is chiefly of clinical interest. The subject is sterile, ami upon this issue medico-legal questions of great mon^.cnt may arise. Sexual feeling may be normal, and coitus may take place, though the shallow introitus may render the act extremely painful. Instances are on record in which the urethra has fulfilled the oflice of a vagina.

The treatment of mdimentary utems, must in the majority of cases be limited to protecting the patient from physical injury, and if the malformation is known in adolescence, advising against any steps that look towards assuming the marriage relations. It is within possibility that active

ovaries may give rise to such local and general disturbance, there being no menstrual flow, as to support the advisability of oophorectomy to bring on an artificial menopause ; and if it could be established by examination that only the lower segment of the uterus is solid, that the corpus contains a cavity, it might be advisable to endeavor to establish a communication between the vagina and the uterine cavity, upon the same principle that we seek to reconstruct an imperforate rectum. Or, what I look upon as a more surgical procedure, any treatment being called for, amputation of the solid cervix, up to the internal os. Thus would be avoided the almost certainty of contraction and consequent failure. It is not, however, likely that the surgeon will be called upon to apply his skill to the remedy of this malformation, for in the absence of positive proof, exceedingly difficult to obtain, that the procedure would be followed by reproductive possibilities, no operative treatment should be undertaken.

Absence of the atems, atems deficiens, or any of its segments, is among the rarest recorded anomalies. A positive diagnosis must be reserved for the laparotomist, for it is impossible to feel certain that some portion of Muller'sduct does not remain in the pelvis that would represent a uterine body, without the aid of an abdominal examination. Hence, uterus deficiens, while previously suspected, has only been positively diagnosed after opening the abdomen with some other object in view.

Inasmuch as the uterus is not developed from the same embryonic process that gives rise to the ovaries — s^erminal cells — it does not of necessity follow that the ovaries are absent when there is no uterus. Indeed, as in the case of rudimentary uterus, painful amenorrhcea may lead to an examination which arouses the suspicion that no uterus exists. In such a case pain will be caused by ovulation, and oophorectomy offers the only means of relief.

In the third month of embryonic life, the process of fusion of the lower portions of the two Mullerian ducts begins. If the two ducts remain separate throughout their entire length, there remain two distinct uteri, uterus didelphys, each provided with its own cervical canal, imperfect corpus, single Fallopian tube and ovary. The vagina also is usually double. In this anomaly no fusion has taken place, the oviducts lying parallel with each other, slightly connected by cellular tissue. Occasionally one cervical canal is closed, the lower end of that duct remaining solid. This, if the ovary of the corresponding side is active, and theuteruscapable of forming a decidual membrane, will lead to tematometra at puberty, while the other uterus performs its menstrual function normally. Operative procedures undertaken for the relief of pain, discover the true nature and extent of the malformation.

The diagnosis of aterus didelphys is not difficult, whatever may be the uncertainty as to the extent to which fusion has failed between the other segments of Muller's duct. Each vagina is surmounted by a cervix, into which, if there is a cervical canal, the uterine sound can be passed. Save by a lateral deviation of the sound within the uterine corpus, the uterus Bicornis, in which coalescence of the Mullerian ducts has taken place in the region of the cervix, but not in the upper portion, or that which corresponds to the uterine corpus, cannot be recognized without the assistance of an intra-abdominal examination.

The clinical features are the same as those of the double uterus, nor are the clinical phenomena attending the two conditions to be distinguished from each other. The Uterus Didelphys, and Uterus Bicornis, are different degrees of expression of the same developmental irregularity, but in both the lower portion of the Mullerian ducts present identical anomalies.

Treatment.— Inasmuch as pregnancy may take place in either one of the uteri, our concern is limited to the possible risks attending the process of gestation, and the necessary development of the imperfect uterus, which the increasing size of the foetus requires. Under this, and similar conditions of danger from full term gestation, the practice of repeatedly producing abortions for the purpose of saving life cannot be too strongly condemned. Our duty is to save life, not to destroy it, and while occasions may arise, in which through ignor-

26 ANOMALIES OF DEVELOPMENT.

ance of the conditions a woman's life is placed in extreme jeopardy by the development of a foetus within the uterus, it may seem justifiable to arrest gestation, and empty the uterus, such practice should not be repeated. The persons who are knowingly responsible for the conception must bear its consequences, and should not look to the medical profession to assist them to avert the certain results of their conscious action.

Dysmenorrhoea from the inability of the uterus to perform its part of menstruation may necessitate oophorectomy. Under such circumstances the operation is justifiable. The patient is practically sterile, and consigned to years of suffering unless the menopause is artificially induced.

Before the middle of the third month, fusion of the two Mullerian ducts has taken place. The removal of the septum then begins, and the arrest of this process in any of its segments results in a permanent division of the corresponding portion of the uterine canal. The first part of the mesial wall to disappear is in the region of the cervix, where the uterus and the vagina are differentiated. This is usually accomplished about the ninth week, and if arrested, results in a membranous division of the cervical canal - uterus biforis supra simpiix— which extends from the internal to the external os. The vaginal portion, the next to disappear — about the twelfth week — may share in the same developmental irregularity, the septum continuing down to the region of the hymen, the opening in which may also be double, formed as it is from the hollowed out termination of Muller's duct.

Uterus subseptus presents no difnculties in diagnosis, and is usually discovered quite by accident, during an examination made for some other condition. The vagina being normal, the OS gives no indication of malformation, and the cervical canal is not known to be divided until the introduction of the sound makes this manifest.

Clinically the persistence of the cervical septum has no other importance than its interference with parturition. It does not prevent impregnation, but may, according to its substance, obstruct the passage of the child from the uterus. Removal of the septum is the only treatment called for. This should be done as soon as discovered. Dilation of both cervical canals is essential as a preliminary step in the technique. The septum can then be divided with blunt pointed scissors, and the canal packed with gauze. If the vaginal septum is intact, it will be divided before the cervical operation.

In this event I prefer to make two operations, several days apart, or not to operate upon the cervix until the vagina is healed. This is a matter of convenience in dressing, for I do not like to leave any uterine dressing in place for a longer period than forty-eight hours, while I frequently do not disturb a vaginal dressing for four or five days. If I anticipate contraction of the vagina, I find a rubber condom introduced into the vagina, and packed to the required degree with gauze, a most useful dressing. The vagina remains distended, and the rubber, over which before introduction a handkerchief of iodoform gauze is placed, is sufficiently elastic to prevent undue pressure. I have applied the same prinoiple in dressing the cervical canal, using a rubber finger tip for the purpose. But of this I will speak more fully when discussing dilation of the cervical canal.

Uterus foetalis, or preservation of the intra-uterine type of the uterus, is probably of frequent occurrence. By the seventh month of embryonic life the mesial septum has entirely disappeared, and further development proceeds on the lines of proportional growth. At this period the lower segment forms two-thirds of the length of the uterus, its walls are thick, and lined with columnar non-ciliated epithelium, and contain a large number of racemose glands, while the upper segment is lined with columnar ciliated epithelium and contains no glands, these being developed at birth. The entire supra-vaginal portion of the cervix is elongated, but the infra-vaginal remains undeveloped and suited to a dwarfed uterus. The ovaries are usually present and functionally capable, but the uterus is not sufficiently developed to respond, either to the ovarian stimulus, or to the menstrual nerve centre, and hence dysmenorrhoea is an almost constant concomitant of the ((ttal, or infantile uterus.

The foetal or infantile uterus, for purposes of study they may be classed together, is one of the most interesting and important expressions of developmental irreEularity that the gynjecologist encounters.

It is obvious that the lower segment of the uterus has but little to do with the conditions thai attend this imperfect development, unless cervical stenosis exists as a complication. Anatomically it is of interest as beint; greatly elongated and encroaching unduly upon the vaginal vault, thus giving rise to the impression that the dysmenorrhcea is mainly occasioned by obstruction to the menstrual flow; but an examination of the canal will show that the cause is located in the body of the uterus, in that portion which is especially concerned with the process of menstruation.

The causes that lead to the persistance of the uterus foetalis have to do more especially with the forci:s that regulate and favor growth, rather than with those that concern development, for we will remember that at the period represented by this anomaly the type of human uterus has been reached, and that this type, minus growth, remains permanent.

Foremost among the causes of arrested growth are those that regulate local nourishment and control metabolism. Inherited vicious cell life, the effect of which is felt in unusual multiplication, in that which the cell gives out, and that which it absorbs or abstracts from the system in its process of division, as syphilis and tuberculosis, are not without influence in arresting the growth of the uterus. But the acquired diseases of infancy are more potent as etiological factors. The eruptive diseases, measles and scarlet fever, are well recognized as capable of causing such changes in nutrition as result in an arrest of uterine growth; and parotitis, because of the intimate relation that exists between the parotid glands and the genital glands, may be looked upon as capable of inducing changes that deprive the uterusof necessary nourishment at a time and period when the entire genital system requires an extraordinarily large supply of food.

Diagnoiis — The existence of an infantile uterus is usually not suspected until puberty, when irregularities in the establishment of the menstrual function are observed. The flow is late to appear, and is usually scanty, but rarely painful. The general chlorotic condition of the patient and. the history of a severe illness, typhoid fever, scarlet fever, or measles, may give rise to a suspicion of the cause of menstrual irregularity. Until the period of adolescence has passed, and that of maturity entered, the infantile uterus is sufficiently developed to perform the menstrual function indifferently well, but after this, when the other parts of the genital system have assumed their fuller powers of reproduction, the dwarfed organ can no longer perform the task put upon it. In its repeated attempts at decidual formation, an endometritis is induced, and perpetuated because of the narrow and long cervical canal, and flexion usually present. The dysmenorrhoea of infantile uterus, therefore, becomes of an obstructive type.

b the treatment of infantile nterost but slight hope of improvement can be expected from the administration of medicine ; no system of treatment that has not for its basis a bettering of general metabolism, and does not seek to establish a demand on the part of the system for over-nutrition, as well as to supply such a demand, can hope to accomplish favorable results. Exercise, active or passive, that promotes pelvic circulation, should form a part of the treatment. The Brandt system of abdominal massage in competent hands, is well planned to promote pelvic circulation. The judicious use of the bicycle I have found a valuable adjunct in the treatment of pelvic derangements where I have desired to regulate the supply of blood to the pelvic organs.

If flexion of the uterus exists it should be corrected, and the organ maintained in position, preferably by a welt-adjusted tampon, but if necessary, a soft pessary may be used.

When the question becomes one of defective drainage, the cervical canal must be dilated, especial attention beingdirected to the inner os, which is likely to be more contracted than the external opening. It may seem wise to amputate a portion of the elongated conical cervix, having in view the existing stenosis, and also the possibility that an operation induceschanges in the circulation that make for the increased nourishment of the entire uterus.

30 ANOMALIES OK DEVELOPMENT.

In connection with general hygienic measures, some success has followed the use of a stem pessary in the treatment of uterus foetalis. The theory of its action is based upon the development of muscles by use. The pessary within the uterus acts as a foreign body and causes the organ to contract, hence determines blood to it, and increased nutriment. The objection to the prolonged use of an intra-cervical pessary — and it must be worn for a considerable length of time to accomplish satisfactory results — is that which belongs to any foreign body. It may do more than we desire. Both of these objections may be overcome by careful attention to aseptic manipulation, by maintaining an absolutely aseptic genital canal as long as the pessary is worn, and by keeping the patient under observation until the tolerance of the uterus is demonstrated.

Chapman's hard rubber pessary retains its position in the uterus better than any other that I have used. It should be introduced under an anaesthetic, as its introduction requires complete relaxation, and is rather painful. The patient should remain in bed for four days, and then if there is no pain may be allowed to resume her usual avocation. After each menstruation the patient must be examined, and when this function is normally performed, the pessary should be removed, but if symptoms of imperfect function return, the instrument may be again introduced.