ABSENCE AND ATROPHY OF THE CERVIX UTERI.
As a rule these conditions are considerPd in connection with acquired gynatresias, under the heading of hematometra, since the conse quences and the treatment of both are very much alike. This may be practical, but it is by no means a scientific or systematic mode of treat ment. The atresias belong among the uterine malformations.
As the highest grade of this kind of deformity I reckon those so-called instances of rudimentary uterus in which the membranous, hollow, and Wadder-shaped womb is united to the vagina by a raiment of a cervix. The uterus in these cases, it is true, is atrophic, but it differs from other cases of rudimentary uterus in that it possesses a cavity into which men struation may take place, and a blood tumor collect, which is not the case with the ordinary rudimentary and solid organ. The cervix, on the other hand, is either absent, or only traces of it are visible; or, it may be present, but is solid. A small part of the vagina also may be obliterated.
And I believe, on the other hand, that many cases of vaginal atresia belong here also. We know that there is no such thing as congenital total vaginal atresia without the uterus being more or less atrophied also; and that these cases might be reckoned either as vaginal atresia or rudimen tary uterus. Or, if the uterus itself is more or less normal, the cervix at all events takes part in the atresia. But there also occur cases where the vagina is only partly obliterated; where that organ forms a quite ex tensive blind sac, only a small part of it being closed. If hematometra occurs, there will be a more or leas thick membrane between the retention tumor and the blind vagina; this membrane consisting not only of the obliterated vagina, but of the closed cervix also. For if after puncturing the tumor we dilate the artificial canal and introduce our finger, we find only an open space, and no trace of a cervical canal; the atresia has in cluded all the tissues up to the os internum. The cavity is that of the uterus, and the closed part is composed mostly of cervix, including a part of the vaginal vault. Undoubtedly here also the chief seat of the
malformation is in the cervix.
Here also belong the pure atresias of the cervix, where a portion of the cervical canal, or perhaps the os externum alone, is implicated, the part of the genital tract above (uterus) and that below (vagina) being entirely normal—cases which become typical ones of hematometra when menstruation sets in.
Here also belong those rare e,ases where only the os internum is closed, or where, as in Trumet's case, both ostia are closed, while the cervical canal is free.
Hence the rudimentary but hollow uteri and high-seated vaginal atre sias form the most marked, while atresias of the external os form the slightest, cases of the deformity due to a rudimentary cervix.
The cervix may be entirely absent, or-it may be replaced by a fibrous band, or by a solid, oval, not sharply limited thickening; or the os exter n= alone may be absent. The consecutive hematometra usually leads to the discovery of the anomaly, and changes the form of the cervix still more.
As regards the time of origin and the cause of these malformations there are various ideas. We may admit some disturbance of the original genital structures in cages where we find traces of rudimentary structures, and of double formations, in the unaffected portions of the genitals. But where.these latter are intact and simple, it is very probable that after both Mfdlerian ducts have united, the lumen of the simple canal has been de stroyed by nutritive disturbances, pressure, etc. It must then have oc curred after the first two months of embryonal life.
The physiological importance of these anomalies depends chiefly upon whether menstruation occurs or not, and this again depends upon the condition of the ovaries. It is probably also necessary for its occurrence that the uterine c,avity is so lined that it can undertake the function. Thus Kivrisch haa described preparations in which there was undoubtedly a uterine cavity, but it was empty, and outside it was found the remains of a blood tumor, a hematocele.