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Chronic Cervicitis
CHRONIC CERVICITIS
MONTE C. PIPER CHRONIC cervicitis may include erosion of various types and degrees, chronic cellulitis and fibrosis, cysts, polyps, lacerations with infection, eversion and malignant changes. Symptoms resulting from chronic cervical involvement may be purely local or more extensively systemic. There is individual variation in the degree of distress. Rather extensive involvement of the cervix may produce surprisingly little discomfort in some cases and the diagnosis may be determined only by examination. In others the involvement may be mild but may seem to produce symptoms of an unwarranted severity. Leukorrhea usually accompanies any degree of chronic cervicitis and is the most frequent finding. Pelvic weight or heaviness is often aggravated by fatigue and, if the paracervical ligaments are much involved, may result in actual pain. Dyspareunia may be complained of. Menstrual irregularities or abnormalities and increased dysmenorrhea sometimes accompany chronic involvement. Metrorrhagia should lead to careful search for any possible early malignant process. Sterility is sometimes corrected by eliminating cervical lesions. More remote symptoms are most frequently complained of as urinary distress. The close proximity of the ureters and base of the bladder to the network of lymphatics, vessels and nerves surrounding the cervix explains the frequency of urinary complication. Both infections and neoplastic processes may readily invade the region of the bladder and the ureters by direct extension. The history of a patient who has chronic cervicitis may be clarified by a frequent review of the salient points. Frankly discussing with the patient her ideas about her symptoms and explaining to her the findings and their probable significance will help to encourage her confidence and to manifest the physician's understanding of, and sympathy with her in, her problem. Some women hesitate to tell their story completely at first and it may happen that the patient will divulge her innermost fear only after treatments are completed and at the time of dismissal. Her chief anxieties may be summed up in the fear of having some loathsome disease, of development of a malignant lesion or of an inability to perform her normal sexual functions. The history should record duration, remissions and previous therapeutic attempts. Pelvic heaviness or pain usually is responsive to the application of heat, to rest and to some of the more common analgesics. Back pain in the sacrolumbar region often accompanies cervicitis and its relief may follow elimination of the cervical involvement. It is fairly frequent for a patient to state that a chronic backache has been relieved in a 998
CHRONIC CERVICITIS
999
very few days after a cauterization of chronic cervical fibrosis containing multiple cysts. Records of about I,OOOG. 6 cases in which cervical cauterization had been performed from six to nine years previously were reviewed and questionnaires sent to the patients. Four hundred and forty had listed backache in their histories as one of their complaints. Of the patients who answered the questionnaire, 62 per cent reported the backache relieved while an additional 11 per cent said that the backache had been improved. It was not assumed that the treatment of the cervix was the only factor contributing to their relief but such a record seems significant. The assumption that chronic cervicitis is a focus of infection in more remote regions is probably more speculative than proved but streptococci are often found on culture taken from cervical lesions. Some ocular conditions, such as episcleritis, have responded favorably after correction of cervicitis and in cases of infectious rheumatism the cervix should be examined as a possible source. 1 Certain types of renal infection seem likewise to lose their tendency to exacerbations after the chronic cervical involvement has been healed. Some authors have classed the cervix as being as important as the tonsils and teeth as a source of infective processes. Chronic cervicitis is most frequently inaugurated at childbirth and thus occurs in the third or fourth decade of life, which is perhaps the age of greatest stress and strain to the mother. The psychic effect on her personality when she is relieved of her nagging pelvic distress is gratifying. The etiologic production of cervicitis is commonly attributed to infection though there are cases of erosion of the cervix in which it is difficult to discover an infection as a preceding involvement. Infective processes are usually superimposed on some form of trauma such as that produced during childbirth with the bruising and lacerations, in some previous instrumentation or as the result of an acute infection overwhelming the defense mechanisms. There is a resulting residue in the endocervical glands and tissues of the portio vaginalis and adjacent structures. The chronic infective organism is usually a streptococcus but its invasion may have been made possible by an acute onslaught in which organisms such as Neisseria gonorrhoeae, Escherichia coli, some types of staphylococci, diphtheroids, Mycobacterium tuberculosis and other less common bacteria were producers of the initial acute process. The foregoing acute infection may have destroyed the defense barriers of the tissues and that may have allowed the invasion of the streptococci. Racial and environmental characteristics may vary the incidence of the less frequent organisms but the streptococcus seems to be the offender which persists after the primary acute inflammation has subsided. A rather violent epithelial irritation may be set in action by parasitic
1000
MONTE C. PIPER
organisms such as Trichomonas vaginalis, Monilia albicans and some others and thus prepare a means by which streptococci gain access to deeper tissue and institute a more extensive involvement than is usually observed in cases of parasitic vaginitis. It is not known that the foregoing parasites of the vagina have invasive properties in themselves but it is believed that they act in symbiosis with pathogenic bacteria and allow of deeper chronic involvement. Defensive processes against infection in the cervix are manifested by an intricate anatomic structure of the endocervix and by the outflow of alkaline mucus, which is then liquefied and acidified in the vaginal vault by the action of the vaginal fluids. A mild chemical reaction thus occurs about the portio vaginalis. This process varies in different individuals and is influenced by their degree of natural immunity and general condition of bodily health. It is further varied by the hormonal influence on the vaginal epithelium in the quantity of glycogen available for conversion into lactic acid in the vagina, by the outflow of menstrual fluids and no doubt by other influences such as psychic stimuli not well understood. Examination of the patient in anticipation of treatment for any condition is benefited by a general systemic review. A good physical examination is as essential in dealing with pelvic conditions as in dealing with conditions in any other portion of the body. Leukorrhea being the most frequent symptom of cervicitis, the nature of the discharge should be sought and its origin ascertained. Cultures and smears are advisable to determine the presence of Neisseria gonorrhoeae, Trichomonas vaginalis or Monilia albicans and the character of the pus and of the desquamated epithelial cells. There are likely to be a suggestive odor and consistency to secretions associated with the foregoing types of infection and gonorrheal infection is likely to reveal involvement of Bartholin's and Skene's glands. Malignant processes have an odor of necrotic tissue and secretions may be watery and blood stained. Palpation should acquaint the examiner with the tone of the tissues of the vagina and supportive ligaments and the position, size and consistency of the cervix, the fundus and the adnexae. Nabothian cysts may possibly be more readily palpated than visualized. Palpation through the rectum is advisable if possible, as the adjacent cervical tissues and uterosacral and broad ligaments are often more accurately palpable by rectal than by vaginal examination. Inspection of the cervix requires that the patient be in a comfortable position. If the vagina is unduly sensitive, a mild local anesthetic may be used. A good light is essential. Evidences of lacerations, edema, polyps, erosions, cysts, bleeding points and ulcerations are looked for. A small cold light introduced into the cervical canal may reveal by translucence deeply buried cysts which would otherwise be unsuspected. Gently pressing on the surface of the portio vaginalis with a blunt tipped probe may reveal irregularities of resistance and spongy
CHRONIC CERVICITIS
1001
regions from which one may desire to remove tissue for biopsy. Perhaps tissue should be removed for biopsy from all lesions of the cervix but certainly from papillary or polypoid regions, regions which tend to bleed after slight trauma, an obvious ulcer, areas of leukoplakia or areas which are velvety and allow the probe to sink readily into the substance of tissue, a specimen should be removed and examined by a pathologist. A diffuse milky gray color of the surface of an erosion and superficial telangiectatic patches indicate advisable fields for biopsy. It is far wiser to have a negative pathologic report than to have destroyed by cautery a region which may have been the site of an early malignant lesion without having taken a specimen for biopsy. An erosion of the uterine cervix is an interesting and fairly common lesion. The usually accepted theory of the formation of erosions is that the squamous cell epithelium of the portio vaginalis becomes macerated by infectious debris and fluids and that cells of columnar type progress out from the endocervix and replace with a columnar celled covering the epithleium so macerated. Such an erosion is usually rather sharply limited on its outer border and its columnar celled surface is confluent with the covering layer of the endocervix. Yet the typical racemose glands of the endocervix are not always produced in the erosion and there is some question whether the nabothian cysts seen in the region of erosion may not be inclusion cysts produced by infolding of this abnormal tissue growth. Certainly many erosions are seen in which evidence of previous infection does not appear and the previously mentioned stage of maceration of the squamous layer is seldom encountered. Some erosions seem to grow by piling up of layers of cells, so that they may appear crowded into folds or tufts or into minute papillae so clpsely packed as to resemble the surface of clipped velvet. Various manifestations of infection and cyst formation do appear in association with some erosions but there are other erosions which seem to be an uncomplicated metaplasia, in which cells of columnar type have replaced squamous layers over a limited area. The basement cells, which formerly produced squamous cells, for some reason produce columnar cells. Why should such metaplasia occur? Is the area of metaplasia an extension of columnar cells from the endocervix or are these columnar cells formed by the existing basement cells? The hypothesis of cellular adaptation to an unfavorable environment7 allows a speculative inference that a similar process may occur in the production of an erosion of the cervix. The environment of the cervix is subjected to various influences, such as the hormonal variation of the host. The chemical reaction mentioned previously varies in its intensity with fluids discharged from the upper part of the genital tract and these fluids are derived from the endometrium. The stages of the menstrual cycle produce repeated rhythmical variations. Processes of metaplasia have been re-
1002
MONTE C. PIPER
ported 2 • 3 from such situations as the bronchus, gallbladder, stomach, pharynx, prostate and anus and over the exposed surface of a longstanding chronic inversion of the uterus. When the process of metaplasia occurs on the portio vaginalis of the cervix, the basal cells of the mucosa, which form the reproductive or functioning layer, seem to alter their product from the supposedly natural protective squamous type of epithelium to a more secretory glandular-like columnar epithelium and a so-called erosion is produced. The basal cells of both the columnar and the squamous types of tissues of the portio vaginalis are said to appear to be similar histologically. If such a process does occur and produce an erosion as a result of cellular adaptation to unfavorable environment, could not a hypothesis go further and assume that cellular adaptation to unfavorable environment of frequent recurrence might proceed to the production of the disorderly groups of cell arrangement found in "carcinoma in situ" or "noninvasive epithelioma"? If those tumors are truly malignant tissue, and evidence4 • 8 seems to be accumulating that they may develop into the more common examples of malignant process, they offer an earlier step in diagnosis than the commonly accepted stage 1 carcinomas of the cervix. Carcinoma in situ is not diagnosed except by the pathologist and no doubt many such carcinomas have been destroyed by cervical cautery when a specimen for biopsy was not obtained. Some reports indicate reduction in frequency of primary carcinoma of the cervix since cauterization has become more prevalent. Treatment of chronic cervicitis is aimed at eradication of the lesion. Actual destruction by some form of heat such as electric hot wire cautery is more commonly employed than surgical removal at the present time. Cauterization by nasal tip cautery is a convenient process and is performed under direct visualization. It may be an office procedure and the patient may remain ambulatory. Other processes of actual destruction of diseased tissue may be equally efficacious and may be preferred by some but actual cautery has the advantage of simplicity of equipment, of visual control of extent and of minimal complications. Burning should be done slowly with a dull red, rather than a bright yellow, wire loop and should extend to a depth just through the mucosa. The lines should be spaced closely enough together so that radiant heat l:oagulates the intervening tissue and turns it ash-white. Cysts are evacuated by cautery puncture and their lining membrane is coagulated. If severed small vessels tend to spurt or ooze, they are nearly always controlled with the cautery by holding the glowing tip against the bleeding point. Sometimes the bleeding is effectually stopped by cauterizing deeper in an adjacent line, thus reaching the vessel in deeper tissue. When the cervix is considerably thickened and the lips are everted and contain deeply buried cysts, the cautery incisions may
CHRONIC CERVICITIS
1003
be deeper and extend farther into the substance peripherally, so that the shrinkage which results tends to restore the cervix to a more normal size. Whether or not the endocervix should be cauterized depends on its involvement. In cases of simple superficial erosion there seems no good reason for destroying the endocervix and healing is completed in a shorter period if only a surface cautery is required. When the endocervix is involved and requires cauterization it should be quite thoroughly treated and the cautery lines from the endocervix should cut deeply at the os and extend to the periphery of the area to be cauterized on the portio vaginalis. The resulting fibrosis tends to result in an open os and is less likely to result in stenosis. The endocervix is not usually visualizable. When it is extensively involved, the procedure of conization may be preferable. However, this should be an operating room process and after conization there seems a greater incidence of subsequent hemorrhage and the need of frequent observation because of the tendency to stenosis. After actual cauterization there occurs a heavy slough, which softens and produces a foul leukorrhea for four to six days but which has usually cleared off in about ten days. During the healing stage it is permissible to wipe the cervix with a mild antiseptic on a cotton applicator, a procedure which will help to prevent some of the bad odor and at the same time permit inspection of the cauterized area for small adherent clots of blood or bleeding points. These clots may be wiped away and an astringent solution applied. Healing and a new surface have organized in four to six weeks but subsequent involution may not be completed for perhaps six months. Examination by palpation and inspection seems worth while at a three months' and again at a six months' interval, particularly to ascertain \vhether all cysts have been destroyed and whether the lesion is completely healed and to determine the amount of involution ultimately obtained by the procedure. Complications are usually not severe. Postcautery bleeding during the sloughing off of the eschar may require attention for a few days and many minor processes are utilized to check bleeding of the areas. In some instances a packing of iodoform gauze may be required. When it is employed, it should be left in place for forty-eight hours, so that the removal of the gauze may not again open the bleeding vessel. Pelvic ache may be aggravated for a few days in some cases and occasionally an unsuspected subacute inflammation of the adjacent pelvic structures will flare up so as to produce febrile reaction. However, such reactions usually subside promptly. Urinary complications are at times temporarily aggravated. A tendency to cervical stenosis of the os occurs in some cases and may respond simply to dilatation. If it repeatedly recurs, an enlargement of the opening may be effected by a crossed incision through the os by means of the cautery wire.
1004
MONTE C. PIPER
SUMMARY
A chronically diseased cervix may be the source of either local or more systemic symptoms. The causation of cervical erosions is an interesting field of speculation. The suggestion is offered that these erosions may perhaps be a manifestation of metaplasia resulting from cellular adaptation to unfavorable environment and that so-called carcinoma in situ may be a further step in such a metaplasia. The foregoing is only suggested as a speculation, for proof of such process seems lacking at the present time. However, erosions and other cervical lesions justify the taking of a specimen for pathologic analysis and the correction of lesions of chronic cervicitis seems to have assisted in a reduction of the occurrence of cervical malignant disease. REFERENCES 1. Benedict, W. L.: Episcleritis and its relation to disease of the female pelvic organs. Minnesota Med. 20:287-291 (May) 1937. 2. Broders, A. C.: The grading of carcinoma. Minnesota Med. 8:726-730 (Dec.) 1925. 3. Broders, A.
c.:
Personal communication to the author.
4. Macfarlane, Catharine, Sturgis, Margaret C. and Fetterman, Faith S.: The value 5.
6.
7. 8.
of periodic pelvic examination; in the control of cancer of the uterus. J.A.M.A. 126:877-879 (Dec. 2) 1944. Piper, M. C.: Lesions of the uterine cervix. M. CLIN. NORTII AMERICA. 19:347357 (Sept.) 1935. Piper, M. C.: Four common conditions of the vagina and cervix. Proc. Staff Meet., Mayo Clin. 11:689-691 (Oct. 28) 1936. Spencer, R. R.: Carcinogenesis and cellular adaptation; the George Chase Christian Lecture for 1944. Bull. Minnesota M. Found. >:1-7 (Nov.) 1944. TeLinde, R. W. and Galvin, Gerald: The minimal histological changes in biopsies to justify a diagnosis of cervical cancer. Am. J. Obst. & Gynec. 48:774-794 (Dec.) 1944.
MONTE C. PIPER CHRONIC cervicitis may include erosion of various types and degrees, chronic cellulitis and fibrosis, cysts, polyps, lacerations with infection, eversion and malignant changes. Symptoms resulting from chronic cervical involvement may be purely local or more extensively systemic. There is individual variation in the degree of distress. Rather extensive involvement of the cervix may produce surprisingly little discomfort in some cases and the diagnosis may be determined only by examination. In others the involvement may be mild but may seem to produce symptoms of an unwarranted severity. Leukorrhea usually accompanies any degree of chronic cervicitis and is the most frequent finding. Pelvic weight or heaviness is often aggravated by fatigue and, if the paracervical ligaments are much involved, may result in actual pain. Dyspareunia may be complained of. Menstrual irregularities or abnormalities and increased dysmenorrhea sometimes accompany chronic involvement. Metrorrhagia should lead to careful search for any possible early malignant process. Sterility is sometimes corrected by eliminating cervical lesions. More remote symptoms are most frequently complained of as urinary distress. The close proximity of the ureters and base of the bladder to the network of lymphatics, vessels and nerves surrounding the cervix explains the frequency of urinary complication. Both infections and neoplastic processes may readily invade the region of the bladder and the ureters by direct extension. The history of a patient who has chronic cervicitis may be clarified by a frequent review of the salient points. Frankly discussing with the patient her ideas about her symptoms and explaining to her the findings and their probable significance will help to encourage her confidence and to manifest the physician's understanding of, and sympathy with her in, her problem. Some women hesitate to tell their story completely at first and it may happen that the patient will divulge her innermost fear only after treatments are completed and at the time of dismissal. Her chief anxieties may be summed up in the fear of having some loathsome disease, of development of a malignant lesion or of an inability to perform her normal sexual functions. The history should record duration, remissions and previous therapeutic attempts. Pelvic heaviness or pain usually is responsive to the application of heat, to rest and to some of the more common analgesics. Back pain in the sacrolumbar region often accompanies cervicitis and its relief may follow elimination of the cervical involvement. It is fairly frequent for a patient to state that a chronic backache has been relieved in a 998
CHRONIC CERVICITIS
999
very few days after a cauterization of chronic cervical fibrosis containing multiple cysts. Records of about I,OOOG. 6 cases in which cervical cauterization had been performed from six to nine years previously were reviewed and questionnaires sent to the patients. Four hundred and forty had listed backache in their histories as one of their complaints. Of the patients who answered the questionnaire, 62 per cent reported the backache relieved while an additional 11 per cent said that the backache had been improved. It was not assumed that the treatment of the cervix was the only factor contributing to their relief but such a record seems significant. The assumption that chronic cervicitis is a focus of infection in more remote regions is probably more speculative than proved but streptococci are often found on culture taken from cervical lesions. Some ocular conditions, such as episcleritis, have responded favorably after correction of cervicitis and in cases of infectious rheumatism the cervix should be examined as a possible source. 1 Certain types of renal infection seem likewise to lose their tendency to exacerbations after the chronic cervical involvement has been healed. Some authors have classed the cervix as being as important as the tonsils and teeth as a source of infective processes. Chronic cervicitis is most frequently inaugurated at childbirth and thus occurs in the third or fourth decade of life, which is perhaps the age of greatest stress and strain to the mother. The psychic effect on her personality when she is relieved of her nagging pelvic distress is gratifying. The etiologic production of cervicitis is commonly attributed to infection though there are cases of erosion of the cervix in which it is difficult to discover an infection as a preceding involvement. Infective processes are usually superimposed on some form of trauma such as that produced during childbirth with the bruising and lacerations, in some previous instrumentation or as the result of an acute infection overwhelming the defense mechanisms. There is a resulting residue in the endocervical glands and tissues of the portio vaginalis and adjacent structures. The chronic infective organism is usually a streptococcus but its invasion may have been made possible by an acute onslaught in which organisms such as Neisseria gonorrhoeae, Escherichia coli, some types of staphylococci, diphtheroids, Mycobacterium tuberculosis and other less common bacteria were producers of the initial acute process. The foregoing acute infection may have destroyed the defense barriers of the tissues and that may have allowed the invasion of the streptococci. Racial and environmental characteristics may vary the incidence of the less frequent organisms but the streptococcus seems to be the offender which persists after the primary acute inflammation has subsided. A rather violent epithelial irritation may be set in action by parasitic
1000
MONTE C. PIPER
organisms such as Trichomonas vaginalis, Monilia albicans and some others and thus prepare a means by which streptococci gain access to deeper tissue and institute a more extensive involvement than is usually observed in cases of parasitic vaginitis. It is not known that the foregoing parasites of the vagina have invasive properties in themselves but it is believed that they act in symbiosis with pathogenic bacteria and allow of deeper chronic involvement. Defensive processes against infection in the cervix are manifested by an intricate anatomic structure of the endocervix and by the outflow of alkaline mucus, which is then liquefied and acidified in the vaginal vault by the action of the vaginal fluids. A mild chemical reaction thus occurs about the portio vaginalis. This process varies in different individuals and is influenced by their degree of natural immunity and general condition of bodily health. It is further varied by the hormonal influence on the vaginal epithelium in the quantity of glycogen available for conversion into lactic acid in the vagina, by the outflow of menstrual fluids and no doubt by other influences such as psychic stimuli not well understood. Examination of the patient in anticipation of treatment for any condition is benefited by a general systemic review. A good physical examination is as essential in dealing with pelvic conditions as in dealing with conditions in any other portion of the body. Leukorrhea being the most frequent symptom of cervicitis, the nature of the discharge should be sought and its origin ascertained. Cultures and smears are advisable to determine the presence of Neisseria gonorrhoeae, Trichomonas vaginalis or Monilia albicans and the character of the pus and of the desquamated epithelial cells. There are likely to be a suggestive odor and consistency to secretions associated with the foregoing types of infection and gonorrheal infection is likely to reveal involvement of Bartholin's and Skene's glands. Malignant processes have an odor of necrotic tissue and secretions may be watery and blood stained. Palpation should acquaint the examiner with the tone of the tissues of the vagina and supportive ligaments and the position, size and consistency of the cervix, the fundus and the adnexae. Nabothian cysts may possibly be more readily palpated than visualized. Palpation through the rectum is advisable if possible, as the adjacent cervical tissues and uterosacral and broad ligaments are often more accurately palpable by rectal than by vaginal examination. Inspection of the cervix requires that the patient be in a comfortable position. If the vagina is unduly sensitive, a mild local anesthetic may be used. A good light is essential. Evidences of lacerations, edema, polyps, erosions, cysts, bleeding points and ulcerations are looked for. A small cold light introduced into the cervical canal may reveal by translucence deeply buried cysts which would otherwise be unsuspected. Gently pressing on the surface of the portio vaginalis with a blunt tipped probe may reveal irregularities of resistance and spongy
CHRONIC CERVICITIS
1001
regions from which one may desire to remove tissue for biopsy. Perhaps tissue should be removed for biopsy from all lesions of the cervix but certainly from papillary or polypoid regions, regions which tend to bleed after slight trauma, an obvious ulcer, areas of leukoplakia or areas which are velvety and allow the probe to sink readily into the substance of tissue, a specimen should be removed and examined by a pathologist. A diffuse milky gray color of the surface of an erosion and superficial telangiectatic patches indicate advisable fields for biopsy. It is far wiser to have a negative pathologic report than to have destroyed by cautery a region which may have been the site of an early malignant lesion without having taken a specimen for biopsy. An erosion of the uterine cervix is an interesting and fairly common lesion. The usually accepted theory of the formation of erosions is that the squamous cell epithelium of the portio vaginalis becomes macerated by infectious debris and fluids and that cells of columnar type progress out from the endocervix and replace with a columnar celled covering the epithleium so macerated. Such an erosion is usually rather sharply limited on its outer border and its columnar celled surface is confluent with the covering layer of the endocervix. Yet the typical racemose glands of the endocervix are not always produced in the erosion and there is some question whether the nabothian cysts seen in the region of erosion may not be inclusion cysts produced by infolding of this abnormal tissue growth. Certainly many erosions are seen in which evidence of previous infection does not appear and the previously mentioned stage of maceration of the squamous layer is seldom encountered. Some erosions seem to grow by piling up of layers of cells, so that they may appear crowded into folds or tufts or into minute papillae so clpsely packed as to resemble the surface of clipped velvet. Various manifestations of infection and cyst formation do appear in association with some erosions but there are other erosions which seem to be an uncomplicated metaplasia, in which cells of columnar type have replaced squamous layers over a limited area. The basement cells, which formerly produced squamous cells, for some reason produce columnar cells. Why should such metaplasia occur? Is the area of metaplasia an extension of columnar cells from the endocervix or are these columnar cells formed by the existing basement cells? The hypothesis of cellular adaptation to an unfavorable environment7 allows a speculative inference that a similar process may occur in the production of an erosion of the cervix. The environment of the cervix is subjected to various influences, such as the hormonal variation of the host. The chemical reaction mentioned previously varies in its intensity with fluids discharged from the upper part of the genital tract and these fluids are derived from the endometrium. The stages of the menstrual cycle produce repeated rhythmical variations. Processes of metaplasia have been re-
1002
MONTE C. PIPER
ported 2 • 3 from such situations as the bronchus, gallbladder, stomach, pharynx, prostate and anus and over the exposed surface of a longstanding chronic inversion of the uterus. When the process of metaplasia occurs on the portio vaginalis of the cervix, the basal cells of the mucosa, which form the reproductive or functioning layer, seem to alter their product from the supposedly natural protective squamous type of epithelium to a more secretory glandular-like columnar epithelium and a so-called erosion is produced. The basal cells of both the columnar and the squamous types of tissues of the portio vaginalis are said to appear to be similar histologically. If such a process does occur and produce an erosion as a result of cellular adaptation to unfavorable environment, could not a hypothesis go further and assume that cellular adaptation to unfavorable environment of frequent recurrence might proceed to the production of the disorderly groups of cell arrangement found in "carcinoma in situ" or "noninvasive epithelioma"? If those tumors are truly malignant tissue, and evidence4 • 8 seems to be accumulating that they may develop into the more common examples of malignant process, they offer an earlier step in diagnosis than the commonly accepted stage 1 carcinomas of the cervix. Carcinoma in situ is not diagnosed except by the pathologist and no doubt many such carcinomas have been destroyed by cervical cautery when a specimen for biopsy was not obtained. Some reports indicate reduction in frequency of primary carcinoma of the cervix since cauterization has become more prevalent. Treatment of chronic cervicitis is aimed at eradication of the lesion. Actual destruction by some form of heat such as electric hot wire cautery is more commonly employed than surgical removal at the present time. Cauterization by nasal tip cautery is a convenient process and is performed under direct visualization. It may be an office procedure and the patient may remain ambulatory. Other processes of actual destruction of diseased tissue may be equally efficacious and may be preferred by some but actual cautery has the advantage of simplicity of equipment, of visual control of extent and of minimal complications. Burning should be done slowly with a dull red, rather than a bright yellow, wire loop and should extend to a depth just through the mucosa. The lines should be spaced closely enough together so that radiant heat l:oagulates the intervening tissue and turns it ash-white. Cysts are evacuated by cautery puncture and their lining membrane is coagulated. If severed small vessels tend to spurt or ooze, they are nearly always controlled with the cautery by holding the glowing tip against the bleeding point. Sometimes the bleeding is effectually stopped by cauterizing deeper in an adjacent line, thus reaching the vessel in deeper tissue. When the cervix is considerably thickened and the lips are everted and contain deeply buried cysts, the cautery incisions may
CHRONIC CERVICITIS
1003
be deeper and extend farther into the substance peripherally, so that the shrinkage which results tends to restore the cervix to a more normal size. Whether or not the endocervix should be cauterized depends on its involvement. In cases of simple superficial erosion there seems no good reason for destroying the endocervix and healing is completed in a shorter period if only a surface cautery is required. When the endocervix is involved and requires cauterization it should be quite thoroughly treated and the cautery lines from the endocervix should cut deeply at the os and extend to the periphery of the area to be cauterized on the portio vaginalis. The resulting fibrosis tends to result in an open os and is less likely to result in stenosis. The endocervix is not usually visualizable. When it is extensively involved, the procedure of conization may be preferable. However, this should be an operating room process and after conization there seems a greater incidence of subsequent hemorrhage and the need of frequent observation because of the tendency to stenosis. After actual cauterization there occurs a heavy slough, which softens and produces a foul leukorrhea for four to six days but which has usually cleared off in about ten days. During the healing stage it is permissible to wipe the cervix with a mild antiseptic on a cotton applicator, a procedure which will help to prevent some of the bad odor and at the same time permit inspection of the cauterized area for small adherent clots of blood or bleeding points. These clots may be wiped away and an astringent solution applied. Healing and a new surface have organized in four to six weeks but subsequent involution may not be completed for perhaps six months. Examination by palpation and inspection seems worth while at a three months' and again at a six months' interval, particularly to ascertain \vhether all cysts have been destroyed and whether the lesion is completely healed and to determine the amount of involution ultimately obtained by the procedure. Complications are usually not severe. Postcautery bleeding during the sloughing off of the eschar may require attention for a few days and many minor processes are utilized to check bleeding of the areas. In some instances a packing of iodoform gauze may be required. When it is employed, it should be left in place for forty-eight hours, so that the removal of the gauze may not again open the bleeding vessel. Pelvic ache may be aggravated for a few days in some cases and occasionally an unsuspected subacute inflammation of the adjacent pelvic structures will flare up so as to produce febrile reaction. However, such reactions usually subside promptly. Urinary complications are at times temporarily aggravated. A tendency to cervical stenosis of the os occurs in some cases and may respond simply to dilatation. If it repeatedly recurs, an enlargement of the opening may be effected by a crossed incision through the os by means of the cautery wire.
1004
MONTE C. PIPER
SUMMARY
A chronically diseased cervix may be the source of either local or more systemic symptoms. The causation of cervical erosions is an interesting field of speculation. The suggestion is offered that these erosions may perhaps be a manifestation of metaplasia resulting from cellular adaptation to unfavorable environment and that so-called carcinoma in situ may be a further step in such a metaplasia. The foregoing is only suggested as a speculation, for proof of such process seems lacking at the present time. However, erosions and other cervical lesions justify the taking of a specimen for pathologic analysis and the correction of lesions of chronic cervicitis seems to have assisted in a reduction of the occurrence of cervical malignant disease. REFERENCES 1. Benedict, W. L.: Episcleritis and its relation to disease of the female pelvic organs. Minnesota Med. 20:287-291 (May) 1937. 2. Broders, A. C.: The grading of carcinoma. Minnesota Med. 8:726-730 (Dec.) 1925. 3. Broders, A.
c.:
Personal communication to the author.
4. Macfarlane, Catharine, Sturgis, Margaret C. and Fetterman, Faith S.: The value 5.
6.
7. 8.
of periodic pelvic examination; in the control of cancer of the uterus. J.A.M.A. 126:877-879 (Dec. 2) 1944. Piper, M. C.: Lesions of the uterine cervix. M. CLIN. NORTII AMERICA. 19:347357 (Sept.) 1935. Piper, M. C.: Four common conditions of the vagina and cervix. Proc. Staff Meet., Mayo Clin. 11:689-691 (Oct. 28) 1936. Spencer, R. R.: Carcinogenesis and cellular adaptation; the George Chase Christian Lecture for 1944. Bull. Minnesota M. Found. >:1-7 (Nov.) 1944. TeLinde, R. W. and Galvin, Gerald: The minimal histological changes in biopsies to justify a diagnosis of cervical cancer. Am. J. Obst. & Gynec. 48:774-794 (Dec.) 1944.