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Hypertrophic Elongation
CERVIX UTERI.
By J.  Masori Warren, M.D.

 
+    A 
[Extracted from the American Journal of the Medical Sciences for January 1864.]
HYPERTROPHIC  ELONGATION OF THE CERVIX UTERI OF TWENTY-
                   •   SIX YEARS' STANDING,

                                WITH
PROJECTION OF THE ENLARGED OS BEYOND EXTERNAL ORGANS; ULCER-
   ATION ; HEMORRHAGE; OPERATION, FOLLOWED BY COMPLETE CURE.



                 By J. MASON  WARREN, M. D.,
              SURGEON AT MASSACHUSETTS GENERAL HOSPITAL.
   A very elaborate work, with plates, has lately been published in Paris, by
, M. Huguier, on a disease described under the above title, showing its distinc-
 tion from simple engorgement and prolapsus of the uterus, with which  it
 has heretofore been confounded.   A most remarkable case of this disease
 has been published in the Boston Med. and Surg. Journal of Dec. 4,1862,
 by Henry A. Martin, M.D., Surgeon U. S. Volunteers.   Other  operations
 for this disease have been performed, in this country, by Dr. Gardner and
 Dr. Sims, but in none of their cases did the extent of the disease at all
 compare with that recorded by Dr. Martin. The following case came under
 my notice about  a week after the record of the case  of Dr. Martin had
 been made  public.   It  fully sustains the anatomical description of the
 disease as given  by Huguier  in his very interesting and important work.
 It  also shows how unsafe any surgical  procedure would  be, based  on the
 idea of a simple  enlargement of the os and cervix  uteri, without taking
 into view the very remarkable displacements of other organs which  occur
 in the  course of the disease when it has proceeded so  far as to be pro-
jected  to any extent beyond the labia.  I now  proceed to the relation of
 the case.

   Mrs. S., 56 years old, and of rather a delicate constitution, was married
 about  27 years ago ; shortly after her  marriage she took a long voyage,
 and suffered severely from sea-sickness, followed by a  miscarriage which



                                       1  H% 
2
was attended by some hemorrhage and  followed by extreme  prostration.
About a year after these events she was confined with her first child after a
tedious labour; this was followed by some prolapsus of the womb. During
a subsequent pregnancy the prolapsus was relieved, but after  the birth of
the child it was reproduced in a greater degree than before, and  from that
time to the present,  she  may be said to have been  continually suffering
from her present affection. When I first saw her the os uteri was enlarged
and projected between the external  organs, irritating  all the neighbouring
parts, and giving rise to constant embarrassment in locomotion.  The brain
also, to a considerable extent, was sympathetically affected, and for a num-
ber of years she had  been scarcely  ever free  from  a sense of  weight and
pain in the head.    Under the  skilful care  of Dr.  Sims, of  New York,
after all other mechanical treatment had failed, she had a year of  compara-
tive comfort from the use of a gilt-winged pessary, which supported the
uterus and prevented the external projection  of the  tumour.  This, how-
ever, ultimately failed of its effect. For some  months before I first attended
her, she had been confined to her room, both  from  the irritation  of the
disease, causing great difficulty  of progression, and  from great debility,
caused by repeated and severe hemorrhages from an ulcer of about the size
of a quarter of a dollar, situated near  the end of the tumour, and  similar  to
the ulcerations noticed in such cases by M. Huguier.  The tumour  seemed  to
be of an erectile character, having periods of increase and diminution of size,
the former state being accompanied by an effusion of blood from its face.
  Being  unwilling to operate on a case of this description out of town,
and without having first fully investigated it,  I advised her to come to Bos-
ton for treatment in a private room at the Mass. Gen. Hospital.   The fol-
lowing was her condition  at this  time.  She was quite pale and thin, and so
feeble as scarcely to be able to move about the  room.   The tumour presented
the following appearance.  It was from three  to four inches long,  and about
four inches in  circumference at its extremity, and at its  base covered  by
mucous membrane, which from  long  exposure had, to  a certain extent,
assumed the character of  skin. On the under  and back part of the tumour,
near its end, was the opening of the os,  into which the finger could  be  in-
troduced to the extent of from two to three inches.  A probe passed about
two inches farther.   At the base of the external tumour was the meatus
urinarius.  A catheter introduced into the bladder took a downward direc-
tion, and its point could be felt half way down the tumour. *  Of course
there was no cul-de-sac of the vagina in front, but behind the tumour the
finger could be introduced to a depth  of from two to three inches.  On  ex-
ploring the rectum by the touch, the  finger  could be hooked downwards
into the peritoneal cul-de-sac, which was dragged down  by the tumour to
a distance of about two inches external to the cavity of the  pelvis.  The
uterus could be felt, as a body, of about the thickness  of the thumb, and
an inch and a half long, in the  natural  position  of that organ.  It will
be seen, from the  above  description, that by any operation for removing
all the tumour which projected  between the  labia, about a third or a half
of the bladder, and a considerable  portion of the peritoneal  cul-de-sac
would be included in the  incisions.   The operation was performed as fol-
lows on the 18th of  November, 1862, the patient being first  prepared  for
it  by two or three days' rest.   Her physicians, Drs.  Cox and Mack, of
Salem, and Dr. Cabot, of Boston, giving efficient aid.  The patient being
etherized, the legs  bent as in the operation for lithotomy, the extremity of
the tumour was firmly seized  by strong  hooked forceps,  and  drawn down- 
3
 wards and forwards.   An incision was made in the back part of the tumour
 about two inches from its extremity, and just in front of the peritoneal cul-
 de-sac, which was marked by the finger hooked down into it from the rec-
 tum.  This investment being dissected backwards, the enlarged cervix was
 cut into about  an inch higher up, until its cavity  was opened.   Large ves-
 sels, which now spouted in every direction, were tied.   The dissection was
 now continued in front.  The tumour being carried backwards and a catheter
 introduced into the bladder, an incision was made directly in front of it
 and the bladder  dissected off from the body of the tumour as far as the
 level of the  incision  on the posterior aspect of the cervix.   The section
 of the tumour  was now completed, the base of it being firmly held  by the
 hooked  forceps until  all the  bleeding  vessels  were  secured  by ligatures.
 The form of the incision  is  well  shown in Fig. 1 by the curved  dotted
 lines s.  s.  Great care was taken to make  the  dissection slowly and  to
 secure every vessel as soon as cut,  and by this means, although  many
 vessels were divided, the loss  of blood was  very moderate.   On relaxing
 the hold  with the forceps, the portion of the uterus which  remained,
 together with the adjacent  organs, resumed  their natural position  in the
 pelvis.  At the end of the operation the pulse, probably from  the stimulus
 of the ether, was much stronger than at  the commencement.   There was
 some nausea produced by the ether, but no vomiting.   She took brandy in
 the  course of the night, and  paregoric for a pain in  the abdomen.  All
 went on well for two or three days; on the 23d, having  some pain in the
 abdomen, she was relieved  by a hot fomentation.   On the 24th was com-
 fortable—had  an opiate at night.   On the 25th, having gone  on  perfectly
 well for a week,  she was seized with a very severe chill, which  lasted three-
 quarters of an  hour, and was followed by great reaction, hot  skin, intense
 headache, great thirst, &c.   I could not discover the  slightest tenderness
 of the abdomen or any other evidence of local trouble,  and I was told that
 she was subject to similar attacks.  I had thus far  been unwilling to dis-
 turb the bowels with medicine.   An enema was ordered which had no effect,
 and was followed by a dose  of tincture of rhubarb.  On the following day,
 the 26th, she was wholly free from fever, and the  medicine having not yet
 operated, a dose  of infusion of rhubarb was  given with the effect of pro-
 ducing two dejections.   After this she began to take solid  food.   On the
 1st of December she had another chill,  which was relieved as before.  An
 examination at this time, with the speculum, showed the surface, from which
 the tumour had been removed, contracted  to the size of a quarter of a dol-
 lar ; two or three ligatures  which still adhered were taken  away.  About
 four weeks after the  operation the  patient was  able to  walk about, and
 was completely relieved of  all irritation  about the  pelvic organs,  which
 were  now retained in their natural  positions.  The pain  and feeling  of
 weight in the head, which had oppressed her  so long, had passed off as  if
 a cloud had been  swept away.  She returned home about the middle  of
 December, and  I  had  the satisfaction of seeing her entirely cured about two
 months later.   During the latter part of her stay at the  hospital, she was
 kept on  as full diet as she coud  bear, and porter and spirits were given
 freely,  with the effect of relieving the very anaemic condition  under which
 she laboured when she entered the house.

   This case is interesting from the perfect cure of a complicated and  rare
disease of many years' duration, and from the  operation being the only one,
so far as I know, that has been done in Boston, and with the exception  of 
4
Dr. Martin's case, which has been already referred to, the only one done in
this vicinity.
  I have heard from this lady within a few days (Oct. 10, 1863),  nearly
eleven months after the operation, in a condition of almost perfect health.
A. Mons veneris.
B. Right portion  of symphysis pubis severed
     through obturator foramen.
C. Upper portion  of bladder lying behind the
     pubes.
D. Anterior cul-de-sac of the peritoneum.
E. Body of uterus.
F. Posterior cul-de-sac of the peritoneum.
G. Peritoneal coat of rectum forming posterior
     wall of the posterior cul-de-sac.
H. Rectum.
I and J. Labia majora and minora.
K. Right genito-crural fold.
L. Meatus urinarius.
M, M. Anterior and posterior walls of vagina.
N, N, N. Opening made through  outer wall of
     tumour to show the relations  of the parts
     within.
0. Os uteri.
P. Base of the bladder  forming part of the tu-
     mour.
Q, Q. Elongated and hypertrophied cervix uteri.
Q', Q'. Outline of lower part of bladder.
R. Body of uterus also elongated.
S, S. Dotted line showing the course of the inci-
     sions.
T. Perineum.
U. Anus.
   The accompanying wood-cuts (Figs.  1 and 2)  are copied  from the work
of  M.  Huguier, and  are as  good a representation  of the present case  as
if taken  from  the  actual subject—with this exception, that in  Fi"  2
which represents the front view of the  tumour,  the anterior lip of  the os
uteri projected considerably beyond  the lower so  as to hide the orifice
The  ulceration described was on  the lower and  back  part  of the tumour
near the end. 
5
Fig. 2.
A. Projection made by the bladder through the
    anterior wall of vagina.
B. Os uteri.
C. Mucous discharge from os.
D. Posterior and superior wall of vagina brought
    down by the tumour.
  In connection with this case, the following one of hypertrophic elongation
of the cervix, and enlargement  of the os  uteri, together with  fibrous tu-
mours of the body of the organ, is not without interest :—

  A widow lady, 48 years old,  and  the  mother of one child, came under
my care at the Massachusetts General Hospital on the 16th of May, 1863.
Fifteen years ago she discovered a small tumour in the left side of the ab-
domen, which  gradually increased in size,  and was attended with a sensation
of weight and bearing down, but without acute pain.   Fourteen years ago
she had a  paralytic  attack of the left side of the body, from which she
partially recovered.   Profuse  flooding had occurred  several  times during
the four or five months immediately preceding her admission to the hospital,
and had materially diminished her strength.   She experienced much  diffi-
culty  in passing  urine, a  fact  easily  explained by  the displacement of the
uterus and surrounding organs.
  She was a good deal emaciated, but had a fair pulse and was able to take
some  exercise  out of doors every day.  The abdomen  was enlarged, and of
a conical form, from the presence of  a tumour of  about twice the size of a
cocoanut.   An elongated tumour, nearly three inches long, and of about the
same  circumference,  projected between  the  labia.   This tumour, which
mio-ht at first sight have  been mistaken  for a  simple  prolapsus of the va-
gina,  consisted in reality of the elongated and hypertrophied cervix and os.
The meatus urinarius opened upon the upper and front part of the tumour.
The boundary between the tumour and the coats of the vagina was marked
by wrinkles of the mucous membrane.  A careful exploration of the abdo- 
6
men disclosed two tumours, one above the other, which together filled  the
cavity  of the pelvis,  and encroached  on the rectum.  Simpson's sound
could be  passed but a  short distance into  the os ; the finger was arrested at
the os internum, but the obstacle was easily overcome by the use of a sponge
tent, and the finger  then passed  readily into the small cavity of  the
organ.
  A consultation with several gentlemen  distinguished in the obstetric art
resulted in a decision unfavourable to any operative interference.
  The patient remained  under observation in the hospital about a fortnight,
when she was seized with pains in the abdomen, and died in the course of
the next  week, with symptoms of  peritonitis.
  On post-mortem examination, a large intra-mural tumour was discovered,
obliterating nearly the whole cavity of the organ.   This was the tumour
which had been felt immediately above the pubes.  The second tumour, which
had been felt  above the first one, was attached to the exterior wall, directly
over the  other, and was  connected with the organ only by a small pedicle.
A third tumour, of the size of a pigeon's egg, was found  near the upper
part of the cervix,  making its way into the cavity of the uterus, and might
probably, after a time, have made  its appearance through the os, and thus
have come within  reach of  a surgical operation.   The external tumour
proved, as had been supposed, to be the os and  the greatly elongated  and
hypertrophied cervix.

  The fact that one of the large tumours was attached to the uterus by a
pedicle scarcely larger than  a goose-quill, is interesting as showing how
easily certain uterine tumours may be removed  by the operation of hypo-
gastric section.  The external tumour, that is,  the hypertrophied os  and
cervix, had there been no other disease to forbid it, might have been removed
as in the case just related. 
 
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