Chapter XI., page 165.
Subinvolution.— This may be de- fined as a failure of the physio- logical hypertrophy of pregnancy to subside after labor. It is due not only to laceration of the cervix but to malposition of the uterus from weakening of the uterine ligaments and too long a stay in bed, with general debility follow- ing confinement. After the early stages of subinvolution infec- tion plays a role in most cases and there is present an interstitial metritis, formerly called areolar hyperplasia. In this disease the connective-tissue elements in the uterine wall are increased and the muscular elements diminished. In the acute stages there is a round-celled infiltration; the uterus is large and feels softer. In the later stages the uterus is large but the tissues are indurated. This is the time when the connective-tissue elements predominate and a pathological involution takes place. The lymph and blood vessels are diminished in size, crowded out by the connective tissue; the muscle atrophies and the uterine tissues become pale and in- durated. Such a state of affairs is found in uteri which have been many years the seat of chronic met litis, not in recenl c i.e., generally not before four or five years after the receipt of injury or misplacement. Subinvolution or chronic metritis may be associated with arterio-sclerosis of the uterine vessels in the later years of life.
Fig. 81.
Crescentic Lacerations of the Cervix.
208
LACERATIONS OF THE CERVIX UTERI
Diagnosis of Laceration
The symptoms of laceration of the cervix are the symptoms of the pathological conditions resulting from this lesion. Immediate hemorrhage following labor calls for prompt diagnosis. The specific nervous symptoms, such as pain in the suboccipital region, headaches of the vertex and neuralgia, considered by Dr. Emmet to be due to a "cicatricial plug" in the angle between the lips of old tears of the cervix, are now generally thought by the profession
to be due to a deterioration of the nervous system caused by pelvic disease in general.
The diagnosis of lacerations is not an easy matter, as becomes evident when we reflect that the diagnosis was not made until Emmet showed the way in 1862. The results of lacera- tions so obscure the landmarks that at the time when most lacerations come under the physician's observa- tion— several years after their receipt — he is at a loss to determine the exact situation and extent of the injury. (a) Recent Lacerations. — In the case of recent tears of the cervix the only bars to an exact diagnosis are the tumefaction of the parts and the exhausted condition of the patient. If there is excessive hemorrhage following delivery the diagnosis must be made at once. In other cases it may be made in a few hours or days, depending on the patient's condition. The woman should be in the dorsal position on a table in a good light. The perineum being retracted by a large Sims speculum in the hands of an assistant, the cervix is seized with a double tenaculum and drawn down and search is made for solution in continuity in the circle of the enlarged os. Tears can be repaired at this time by suturing. Some operators prefer to do this in an intermediate time, i.e., four or five days after labor, perhaps scraping the edges of the tear with sterile gauze before uniting
Fig. 82. — Diagram Showing Bilateral Laceration of the Cer- vix with Eversion of the Lips.
DIAGNOSIS OF LACERATIOX
209
them. The injuries must be followed carefully to their limits, whether they be confined to the cervix, or if they extend to the vagina, or even to the rectum or the bladder.
(b) Old Lacerations. — If every woman were submitted to a careful uterine examination after child-bearing, and injuries of the cervix, as well as those of the pelvic floor, found and repaired, there would be comparatively little for the gynecologist to do. It hap- pens, however, that most of the lacerations of the cervix come under the physician's notice for the first time some years after their re- ceipt. At this time the diagnosis is difficult because of enlargement and distortion of the cervix, eversion of the lips, and cystic degeneration of the Nabothian follicles and erosion. The trained vaginal touch after a little practice detects all of these features even to the erosion. For inspection the Sims position is best. Search first for the arbor vitse and thus deter- mine the situation of the cervical canal. The passage of the sound helps to define the situation of this canal, but the physician must be on
his guard not to be misled by the tions of the Cervix, Producing
malpositions of the uterus found in Obliquity of the Long Axis of the
1 , Uterus. (After Emmet.) The
cases of unilateral tear as pointed Reduplication of the Vagina is out by Emmet. (See Fig. 83.) In shown at W. this event the sound passed to the
cornu opposite to the seat of the laceration may appear to be in the canal (see figure), but because of the tilting of the fundus toward the laceration the sound occupies the laceration and not the normal cervical canal. Here a search for the arbor vitae will help to set us right and the bimanual touch will also assist. Putting the patient in the knee-cheM position, thus permitting the uterus to fall toward the abdomen high in the pelvis. <t raightens its axis and also pulls out the reduplication of the vagina on the side where the laceration is situated. In all lacerations of severe grade it is well to study the condition- as seen through the specu-
14
Fig. 83. — Unilateral Lacera-
210 DISEASES OF THE UTERINE LIGAMENTS
lum when the patient is in this position, because in the dorsal position the weight of the uterus — usually increased in cases of laceration — drives this organ downward so that the intravaginal portion of the cervix seems to be longer, especially if the upper vagina has become stretched. Therefore, there is present in ex- tensive lacerations of the cervix apparent hypertrophy and elon- gation of the cervix beyond what really exists. This reduplication of the vagina is shown at X in the figure. Next, with the patient in the Sims position, hook a tenaculum into the crown of each lip of the cervix and bringing the two tenacula together, try to reconstruct the cervix. If there is much induration of the tissues this feat is difficult of accomplishment. By palpation with the tip of the finger or the sound, determine the situation and extent of cicatricial tissue in the angle of the tear, pressure on the tissue causing pain. With the tip of the sound a laceration within the canal of the cervix may be appreciated, for in that situation the sound falls into an opening in the otherwise smooth mucosa of the wall of the canal. The internal os will be found abnormally large should the laceration involve this region, permitting the sound to be moved freely about after it has been passed through. When the arbor vitse has been made out the situation of the laceration with reference to it is determined.
Differential Diagnosis of Lacerations
Cancer of the cervix is the disease most often mistaken for lacer- ated cervix. The differential diagnosis is considered under cancer of the cervix, Chapter XVI, page 272. Carcinoma is attended by much induration of the tissues and ulceration, also cancer bleeds easily and the superficial portions are friable. Endocervicitis and erosion is a coincident condition in laceration, but may exist in the absence of laceration. The diagnosis is based on the absence of the signs of laceration. Eversion of the mucous membrane of the cervical canal may be present without laceration and it is well to bear this fact in mind. The cervix in such cases is of normal contour and there are no evidences of laceration.
DIAGNOSIS OF DISEASES OF THE UTERINE LIGAMENTS
The uterine ligaments are the broad ligaments, the round liga- ments, the utero-sacral ligaments, and the utero-ovarian ligaments.
THE BROAD LIGAMENTS 211
The Bkoad Ligaments
These become stretched in prolapse of the uterus so that they no longer support that organ. Under normal conditions they have enough elasticity, together with the utero-sacral ligaments, to re- store the uterus to its normal situation after it has been drawn down forcibly. Certain tumors originate in the broad ligaments, notably parovarian cysts, fibromata and lipomata, also dilatation of the veins, varicocele. The solid tumors are extremely rare, lipomata are seldom seen, and fibromata only occasionally, the lat- ter being not large as a rule and arising in the unstriped muscle fiber between the folds of the ligament. Sarcoma and carcinoma of the broad ligament are secondary to malignant disease of the uterus.
Parovarian Cysts. — These originate in Gartner's duct, Kobelt's tubules, or in the parovarium proper. Small pedunculated cysts may develop from one of these structures, or the cysts may be sessile and large. These large cysts, so called, develop between the layers of the broad ligament and are of slow growth. They are seldom larger than a child's head. The cyst has no pedicle, the Fallopian tube is stretched over its surface, and the cyst pushes the uterus to the opposite side of the pelvis. Adhesions are rare be- cause the cyst is covered by peritoneum. The wall of the cyst is thin, transparent, and of a greenish-yellow hue, the contents are a thin, colorless fluid of a non-irritating character having a specific gravity of 1002 to 1008. Upon rupture the cyst is apt not to refill, in this respect differing from an ovarian cyst. A parovarian cyst may be rarely the seat of papilloma and in this case the contents are opaque, the walls are thick, and the cyst is like a papillomatous cystoma of the ovary. The diagnosis is made by vagino-abdominal and recto-abdominal palpation, if necessary having the uterus drawn down by a vulsellum while the palpation is being practiced. (See Fig. 125, page 294.) The cyst is on one side of the pelvis, in close relation with the uterus. Its mobility is distinctly limited; it is ovoid in shape and has smooth walls; fluctuation is distinct, being felt through the vault of the vagina; there is no pedicle, but a groove between the cysl and the uterus can be distinguished. The differential diagnosis is considered in Chapter XVII, on ovarian tumors, page 297.
212 DISEASES OF THE UTERINE LIGAMENTS
Varicocele of the Broad Ligament. — This is not a very rare disease. It consists of dilated veins running transversely in the upper part of the broad ligament and forming a tumor that may be as large as a small hen's egg, though generally much smaller. Varicocele is found more often on the left side. Perhaps this is because the left ovarian vein is valveless and opens into the renal vein at a right angle. It is possible to make a diagnosis by recto-abdominal palpa- tion by finding a doughy-feeling tumor in the broad ligament, but as such a tumor is not tense except when the patient is in the erect posture, the diagnostician would be likely to miss it during the usual examination made with the patient in the dorsal position. If there are varicosities elsewhere in the body varicocele of the broad ligament should come into the physician's mind and he should examine the patient in the standing position. The char- acteristic symptom of varicocele of the broad ligament is a dull aching pain in the pelvis or back.
The Round Ligaments
The round ligaments vary much in size and in length in different individuals, therefore their ability to steady the uterus as guys is a variable quantity. The muscular fibers are situated in the inner two-thirds of the ligament and sometimes the ligaments are nothing but the slenderest of cords. Fibroma, fibromyoma, adenomyoma, fibromyxoma, and sarcoma of the round ligament have been de- scribed. The tumor is generally unilateral but may be bilateral. These tumors are thought by some writers to be associated with fibroids of the uterus. They may be found in any portion of the course of the ligament, — in the abdominal cavity, the inguinal canal, or in the labium majus, — and they develop slowly, but may be stimulated to more rapid growth by the presence of pregnancy. The tumors are hard and generally pedunculated.
Diagnosis of Tumors of the Round Ligament. — If a tumor is situ- ated within the peritoneal cavity it is felt by bimanual palpation in the front of the pelvis on one side. If it is in the inguinal canal or labium majus the tumor is felt from the outside in the course of the canal or in the labium. It must be differentiated from omental or ovarian hernia, hydrocele of the round ligament, a cyst of Bar- tholin's gland, or enlarged inguinal lymphatic glands. There is no
THE UTERO-SACRAL LIGAMENTS 213
impulse on coughing or straining and the enlargement can not be reduced by taxis. An ovary in the inguinal canal is very sensitive to pressure, and swells and is painful at the time of menstruation. A cyst of Bartholin's gland will present fluctuation, and enlarged inguinal glands are generally separate glands, i.e., they are multiple tumors and are situated to the outside of the inguinal canal.
Hydrocele of the Round Ligament or of the Canal of Nuck.— In the fetus the peritoneal covering of the round ligament projects as a tubular process into the inguinal canal. This tube is called the Canal of Nuck and it sometimes persists through life. If fluid collects in this canal and the abdominal end of the canal is oblit- erated there is found a cystic, translucent, oval tumor which may extend downward even into the labium majus. In size the tumor may be as large as a hazelnut or even attain the proportions of a cocoanut. It can not be pushed up into the abdomen, it fluctuates, and has an impulse on coughing if situated in the inguinal canal. In rare cases the cystic tumor may communicate with the peri- toneal cavity and in this event the fluid may be forced out of it by gentle pressure. Hydrocele is not tender like an ovarian hernia; it is of gradual development and often there is difficulty in distin- guishing a hydrocele from hernia. In the case of encysted hydro- cele the elastic, translucent character of the tumor that can not be reduced with the patient recumbent, serves to distinguish it. The hydrocele that connects with the peritoneal cavity can not be differentiated from hernia without an operation. In the case of an inflamed hydrocele the differentiation from a strangulated hernia is made by the absence of severe constitutional symptoms, and of symptoms of intestinal obstruction. As a matter of fact such tumors have generally been operated on for strangulated hernia.
The Utero-sacral Ligaments
The utero-sacral ligaments contain, besides connective tissue and peritoneum, as do the round ligaments, a certain amount of muscle fibers. When the uterus is drawn down forcibly there is elasticity enough in the ligaments to pull the uterus back again. The ligaments are much overstretched in prolapse of the uterus and are abnormally short in ret imposition with anteflexion, in the latter case being almost of a cicatricial hardness. Naturally liga-
214 DISEASES OF THE UTERINE LIGAMENTS
merits of this character limit the downward or forward excursion of the uterus. The diagnosis of shortening is made by the bi- manual vagino-abdominal and recto-abdominal touch. The uterus is raised and at the same time the ligaments are palpated to detect shortening and thickening, or the uterus is brought down by trac- tion with a tenaculum while the rectal touch is practiced. Short- ened ligaments are easier to make out than lengthened ones. In the infant, the uterus being very high in the pelvis, the utero- sacral ligaments course from their origins at the second piece of the sacrum to their insertions on the uterus in the form of an arch and may be felt in this shape by rectal palpation. The operator should not lose the opportunity afforded, during abdominal opera- tions when the cul-de-sac of Douglas is in view, to inspect as well as to palpate these ligaments from above.
The Uteroovarian Ligaments
The following tumors have been found in these ligaments: fibroma, sarcoma, and carcinoma. The last two must be regarded as extensions of the disease from the uterus; the former, fibroma, is very rare. These tumors can not be distinguished from ovarian tumors without opening the abdomen. In some cases the ovarian ligaments are very long, thus favoring prolapse of the ovaries.