August, 1937 UTERINE CERVIX-MILLER 81 terest, yet chronic cervicitis is very common and ORIGINAL ARTICLES unquestionably the source of much physical suffer- ing. The physician would do well to view cervicitis THE UTERINE CERVIX: ITS DISORDERS AND as exhibit "A" among common disorders of the THEIR TREATMENT* cervix. EROSION By NORMAN F. MILLER, M. D. Trauma, actual, bacterial or chemical is generally Ann Arbor, Michigan thought to cause cervical erosion. Many observers place preexisting cervical infection in the leading PROBABLY the full significance of the trite old role in this connection. I believe erosions likely to saying, "An ounce of prevention is worth a be of endocrinal origin, but these unsettled ques- pound of cure," has not yet been fully realized so tions need not confuse us in our more practical con- far as the uterine cervix is concerned. The physi- sideration of the subject. Erosions are common cian looking at the cervix should see more than just and easily recognized as the reddish area surround- a simple lesion. He should see future disease often ing the cervical os. The first stage of an erosion is foreshadowed by the minor disorder before him. said to be the result of cervical infection ( ?) which While there are a great many things about common leads to maceration and superficial slough of the lesions of the cervix that are poorly understood, squamous epithelium surrounding the external os. this need not influence our practical attitude toward Actually and for a short time there may exist a true them. Time and research will likely alter our ideas, erosion. This first stage of depithelization is pre- but until that time arrives existing evidence justi- sumably replaced by columnar epithelium similar fies reasonable concern over their presence and to that lining the cervical canal where it continues correction. until the environment or something else again pre- CLASSIFICATION disposes to the return of squamous epithelium. The While much has been written regarding cervical source of the columnar epithelium is open to con- disorders it is pertinent to our discussion that we troversy, but generally it is thought to be derived briefly review these lesions, particularly their ac- from the cervical glands. With subsidence of the cepted cause and histopathology. Generally listed cervicitis or disappearance of the causative factors, among common disorders of the cervix are: the second stage, clinically characterized by the 1. Cervicitis (acute and chronic). red-appearing columnar epithelium, gives way to squamous epithelium once more, the so-called heal- 2. Erosion. ing of an erosion. A great deal of significance is 3. Cystic change. attached to this interplay of epithelia in the devel- 4. Cervical polyp. opment of cervical cancer. 5. Laceration. CYSTIC CHANGE 6. Eversion. Healing of an erosion seldom obliterates all evi- 7. Leukoplakia. dence of its previous existence. Glands developed By separately naming the disorders we imply as part of the lesion on the vaginal surface of the distinct disease, each with its etiology and indi- cervix are either plugged by colepithelium or other- vidual histopathology. Existing knowledge, how- wise have their ducts occluded in the healing proc- ever, suggests that this is incorrect. Bacterial ess. In either case the glands, unable to discharge trauma is likely to be an important etiological fac- their content, become distended and clinically ap- tor, and there is evidence to show that glandular pear as small pearly bodies which, when ruptured, dysfunction may also play an etiological role. discharge a thick tenacious mucus. Actually this However, such cause-and-effect relationship re- cystic cervix is but a late phase of a preexisting mains to be proved. Generally speaking, infection erosion. For clinical purposes, however, it is easier of the cervix is probably at the root of more evil to designate the condition by the term cystic cervix than has generally been conceded in the past. which, after all, clearly describes the lesion at this stage. In evaluating these cysts it should not be CERVICITIS forgotten that the visible cysts are but a part of the In acute cervicitis the inflammatory process is at process, and that similar gland changes also occur first limited to the glands lining the cervical canal in the deeper tissues of the cervix. It requires no gradually spreading to the point where there is stretch of imagination to realize how extensively extensive and deep-seated involvement. Clinically, the neck of the uterus may come to be altered by acute cervicitis is easily recognized, for the puru- the changes described. lent or mucopurulent discharge coming from the cervical canal is a familiar picture. Less readily CERVICAL POLYPS appraised are the chronic cases where the external Adenomatous polyps of the cervix are common appearance is nearly normal and gives rise to little sequelae to chronic irritation and particularly in- cause for concern. The amount of discharge may fection. The polyp is readily recognized on spec- not be great nor sufficiently purulent to excite in- ulum examination, but may easily be missed on digital examination alone, a point to be remem- * From the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan. bered in making a study of any woman's pelvis. Guest-speaker address given at the first general meeting They vary in size from tiny pinhead tumors to of the California Medical Association during the sixty- sixth annual session, Del Monte, May 2-6, 1937. structures measuring three to four inches in length, 82 CALIFORNIA AND WESTERN MEDICINE Vol.47,No.2 and half an inch in diameter. Soft in texture, red 1. Cancer.-Carcinoma of the generative tract in color and painless, they seldom undergo malig- is the most frequent form of cancer seen in the nant change, but even so warrant microscopic study female, and cervical cancer heads this list. There is wherever possible. Their presence always suggests much about cancer that no one understands, and chronic irritation of inflammatory character. carcinoma of the cervix is no exception. In our attempt to evaluate common cervical disorders LACERATION from the precancerous standpoint, let us avoid While deep tears of the cervix and especially controversial matters as much as possible, and be those associated with extensive scarring are clini- guided by evidence generally accepted today. The cally significant, the same concern cannot be said increasing evidence pointing to a questionable re- to apply to minor healed lacerations without exten- lationship between common cervical disorders and sive scarring. Lacerations may predispose to cer- cancer need not at this time influence our accept- vical infection, but aside from this there is scanty ance of such relationship. The tie-up between com- evidence to indicate that the average healed cervical mon cervical disorders and cancer may be summed tear does any harm. Doubtless much of the grief up in a few sentences. Cancer probably does not attributed to cervical tears in the past originated begin in healthy tissue; it is local in its incipiency, from other sources. and there probably is a precancerous state even EVERSION though we cannot, as yet, positively identify it. If we are willing to accept these statements, then there As the name implies, eversion or ectropion, as it appears to be no good reason why these common is sometimes called, is merely a rolling out of the disorders should not be viewed with suspicion-not endocervium or mucous membrane lining the alarm-and treated until cured. The simple yet- cervical canal. This condition occurs secondary to generally-adequate measures for treating such dis- cervical lacerations, and except for the fact that by orders today, generally without inconvenience to being so exposed it more readily becomes infected, the patient, no longer justifies indifference or the condition has no particular significance. Clini- watchful neglect. While not convinced of direct cally it appears as a red area extending down from cause-and-effect relationship between some of the cervical canal and involving only the central these common cervical disorders and carcinoma, I surface of the anterior and posterior cervical lips. still can see no good reason for their neglect. It differs from an erosion in that there is actually Therapeutic vacillation is bound to occur, but no no misplacement of epithelium. The deep reddish physician should foster indecisipn regarding the color is due to the columnar epithelium and its em- of clearing up any cervical disorder. mediate underlying structures. Similar coloring, advisability and for the same reason, is noted in an erosion. 2. Foci of Infectioni.-In some respects the case against the infected cervix as a focus of infection LEU KOPLAKIA is even more impressive. True, abundant direct This term is rather broadly applied to any area or data are again lacking, but the evidence is so strong spot of thickened epithelium on the cervix. Interest that such relationship appears to be extremely in this particular change is relatively recent, and likely. The anatomical location and histological may be attributed to the use of the colposcope in structure of the cervix is ideal from the focal infec- studying the cervix. Extensive leukoplakias are tion standpoint. And we may, therefore, well ponder readily recognized clinically by the grayish-white why a focus in one part of the body (tooth, tonsil, appearance of the involved area. gall-bladder, appendix), should be considered a serious menace to health, and vet an active infec- COM MENT tion of the cervical glands be viewed with indiffer- These then are the common disorders of the ence and its treatment characterized by neglect. The cervix seen by physicians every day. Easily recog- mere fact that, in the past, treatment of cervical in- nized, they do not always impress the practitioner fections has failed to show the spectacular general with their probable significance. Too often he sees improvement sometimes noted following removal only the cervix and fails to recognize that a muco- of other foci, means little. In years past methods of purulent discharge from the cervical os is more treating cervicitis were characterized by topical than just a medical term-cervicitis. Indeed, unless applications, and did no more toward the eradica- the physician sees beyond the narrow limits of the tion of deep-seated cervical gland infection than disorder before him and envisions disease in its did similar treatment in clearing up tonsillar infec- broader aspects-forecast perhaps by the insignifi- there is no in cant-looking lesion before him, he is likely to tion. Certainly justification comparing- fumble a great opportunity for prevention of removal, on the one hand, and topical application, disease in the female pelvis. We must recognize on the other. Yet, such is the situation: the tooth, that the real importance of these common cervical tonsil, and gall-bladder are freely excised, while disorders lies not so much in their existence as a the infected cervix, in the vast majority of in- local abnormality, but in their future potentialities. stances, is subjected to treatment much less effec- tive. I am not advocating random removal of the SEQUELAE cervix-far from it; I do urge, however, wider To fully comprehend the significance of these recognition of the cervix as a probable focus of lesions they should be weighed in the light of re- infection and more diligence in its treatment. The mote sequelae as follows: acute infection of the cervix is not so much a prob- August, 1937 UTERINE CERVIX-MILLER 83 lem; it is the chronically-infected, presumably tions. The greatest significance of common cervical asymptomatic cervix that goes untreated. Few tis- disorders lies not so much in their immediate effect sues in the body endure chronic infection without, but more in their ability to cause remote disease. sooner or later, showing local or general manifes- tation, and the cervix is no exception to this rule. TREATMENT 3. Local Discomnfort.-As a source of local dis- Except for chronic cervicitis, the problem of comfort, the cervix plays no small r6le. True, pa- treating common cervical disorders is no longer their toward the difficult. Whereas our predecessors had to choose tients seldom direct complaints between surgery and application of some antisep- cervix, but this is readily understandable. Gener- tic, physicians today have quite a wide choice. One ally speaking, women have only a vague idea as to reason why we may well be emphatic regarding the location of the cervix and, except during dili- treatment of cervical disorders is this wide choice tation, the cervix is not particularly sensitive. Its and the fact that remedy no longer implies great response to trauma and irritation is, therefore, sel- expense, long hospitalization, and anesthesia. To- dom manifest in the form of pain, but rather as day most of these disorders can be quickly and more remote pelvic discomfort-interpretated dif- satisfactorily cared for by office treatment alone. ferently by patients and variously described as In general the only common disorders here dis- soreness, bearing-down sensation, tenderness, dys- cussed calling for surgical treatment are, (1) the pareunia and aching. Leukorrhea is another local occasional, extensively-torn, badly-scarred cervix, manifestation of cervical origin. Except in acute and (2), the extensively and chronically infected cervicitis, this is seldom profuse, but like a chronic cervix, particularly in women past thirty-five years discharge from the nasal passages it is enough to of age. Seldom does the simple laceration or the cause inconvenience and discomfort. How often ordinary hypertrophy call for surgical intervention. cervical infections cause dysmenorrhea, backache, The badly and chronically infected cervix which urinary symptoms, can only be guessed at, but it is fails to respond to office measures is best treated by safe to assume that these symptoms do arise on conization or electrosurgical coning out of gland the basis of cervicitis. The secondarily involved bearing tissues. In our practice this method has parametrial tissues in low grade chronic cervicitis completely supplanted the Sturmdorf operation. may also account for some of the low backache It requires but a few days' stay in the hospital, and commonly seen in women. its performance is many times simpler than the 4. Sterility.-With contraception occupying an Sturmdorf technique. It must be remembered, how- important place in contemporary social and medical ever, that such procedure is no substitute for the thought, consideration of sterility may seem out of simpler office measures in the vast majority of place. Yet to most gynecologists sterility has be- cases. Furthermore, stenosis occurs in about 6 per come an increasingly important problem. Judging cent to 10 per cent of cases. from the number of patients who seek advice re- For acute cervicitis rest, cleanliness, and avoid- garding nonfertility, it would appear that the num- ance of intracervical manipulation appears to be ber of nonproductive marriages is high indeed. the only safe treatment. Most cases subside quickly. This is further emphasized by the great demand While chronic cervicitis may respond to local for babies for adoption, the demand today being therapy in the form of heat (cautery, coagulation, many times greater than the supply. Sterility, then, diathermy, copper ionization, etc.), many cases are is a real problem, and one which not infrequently stubborn and unresponsive. In women past the has its origin in some earlier disorder of the uterine active child-bearing age, we have recourse to elec- cervix. The acutely-infected cervix prohibits up- trosurgical conization or to surgical procedures ward progress of the sperm, but this phase is but, obviously, such radical steps are seldom war- recognized and treatment generally instituted. It is ranted in younger women. The vast majority of the chronically-involved, seemingly innocent cervix erosions, eversions, cervical cysts and polyps are that is overlooked even by competent gynecologists. successfully treated by simple cautery. The wise 5. Dystocia of Cervical Origin.-The relation- choice for treatment for these conditions is indi- ship here is seen in the slow or even total lack of cation of their responsiveness as well as effective- dilation even after a long, hard labor. Severe cases ness of methods used. due to a badly-scarred cervix are not common, but Certainly, with the remote sequelae of common every obstetrician can recall one or more such disorders of the cervex so potentially hazardous, examples. Less apparent, but real, is the slow dila- and satisfactory remedial measures so generally tation even in the presence of adequate pains, available, there is today no good reason why every occasionally seen in young, healthy women due to diseased cervix should not be treated until cured. long-since forgotten cervical infection and its coin- A diseased cervix is likely to be just as much of a cident increase in connective tissue. For the same health hazard as a diseased tonsil. Neither should reason, perhaps, cervical tearing is more likely to be condoned. Because present-day views seem to indicate a definite relationship between these com- occur in women who have harbored cervical infec- mon cervical disorders and more serious disease tion and acquired a liberal increase in connective manifest later in tissue. usually life, the advisability of treating any diseased cervix until cured should be a In considering common disorders of the uterine foregone conclusion. cervix, then, it is wise to think of late complica- School of Medicine, University of Michigan.