Charles B. Penrose

“ Sometimes the tumor appears to be of limited growth, and early attains its maximum size, or it may not increase at all in size after its first discovery by the woman; in other cases the tumor slowly but steadily grows until, after a lapse of ten or twenty years, it fills the whole of the abdominal cavity and renders the woman helpless from weight and pressure; and, finally, in some instances the tumor grows unlimitedly with the rapidity characteristic of an ovarian cyst, and in one or two years may crowd the woman out of existence. ”

“ The gross appearance of the disease varies as does cancer of the cervix or of any other part of the body.
Cancer of the uterus may begin upon the surface of the endometrium as a superficial ulceration, as a uniform swelling of the mucous membrane, as a polypoid or papillary projection, or as a large cauliflower-like mass projecting into the uterine cavity.
When the disease begins in the utricular glands, it may form nodules throughout the body of the uterus. These nodules are of various sizes, from that of a pea to that of a hen’s egg. They grow rapidly. ”

“ The diagnosis of cystitis is easily made by proper examination. It should always be remembered that not every woman who complains of painful and frequent urination and vesical tenesmus is necessarily suffering with cystitis. These symptoms are often caused by disease of the urethra, by displacement of the uterus, which drags upon the neck of the bladder, by the pressure of a tumor, or by displacement of the bladder such as may follow laceration of the perineum. ”

“ The structures of importance that are injured are the fascia, the levator ani muscle, the sphincter muscle of the vagina, and perhaps the transverse perineal muscle. All the supporting structures of the perineum and of the posterior vaginal wall are injured. If the laceration be bilateral, complete loss of support of the perineum and the posterior vaginal wall results, and if the condition be untreated, all the disastrous consequences of loss of support of the perineum occur—prolapse of the vagina, of the uterus, and of the other pelvic organs. ”

“ The intra-ligamentous fibroid grows from the side of the uterus or from the supra-vaginal cervix. It pushes apart the peritoneal folds of the broad ligament, and grows between them or beneath them. The tumor is thus outside of the peritoneum. It may fill the whole pelvis with a dense unyielding mass, pushing the uterus to the pelvic wall, destroying anatomical relations, and exerting most disastrous pressure upon blood-vessels, nerves, ureters, and other pelvic structures. ”

“ A dermoid may exist from childhood and give no trouble—in fact, may not be recognized until some accident starts it into rapid development. Even then it is of comparatively slow and limited growth, and danger from it is due to the accidents, such as inflammation and suppuration, to which it is especially liable.
Though the papillomatous cyst is also of slow growth when compared with the glandular cyst, yet the danger here is due to peritoneal infection, which very often takes place before the tumor has, by its size, begun to annoy the woman. ”

“ None of the symptoms are absolutely pathognomonic of cancer. During the menstrual life of the woman hemorrhage from the womb occurs as a symptom of a great variety of diseases; and even in the post-climacteric period, though hemorrhage should always excite alarm, yet it may be caused by a benign form of endometritis or intra-uterine growth. The pain of cancer may also characterize a variety of benign conditions; and the vaginal discharge, even when most offensive, may be simulated by that from a sloughing intra-uterine fibroid. ”

“ Extreme prolapse of the uterus, in which we find protruding from the vulva a pear-shaped tumor at the apex of which is the opening of the cervical canal, should not be mistaken for any other condition. Inversion of the uterus and a uterine polyp resemble it only in shape, and in no other particular. If there is any doubt, it may be dispelled by placing the woman in the knee-chest position, when the prolapse may readily be reduced and the normal anatomical relations restored. ”

“ Even if the tumor be discovered accidentally by the physician, and has never given any trouble to the woman, operation for its removal should be advised. A dermoid that has existed for years may suddenly endanger the woman’s life. Delay in the case of papillomatous tumors—and no one can determine in the early stages whether or not a cyst be papillomatous—is especially dangerous. About one-half the women upon whom I have operated for papillomatous cysts have come to me after the peritoneum had become infected. Though the peritoneum be extensively involved, operation is by no means hopeless. ”

“ The difficulty of making a differential diagnosis is well illustrated by many cases that have been recorded, in which it was impossible to determine the true nature of the tumor even after the abdomen had been opened.
It is of the greatest importance to exclude pregnancy. Many women have been subjected to the operation of celiotomy because the pregnant uterus was mistaken for an ovarian tumor. Women themselves often intentionally mislead the physician, especially if the pregnancy is illegitimate. ”

“ The usual causes of death after celiotomy are peritonitis and hemorrhage. The frequency of hemorrhage as a cause of death is often overlooked. The writer feels confident that many deaths which, without post-mortem examination, are attributed to peritonitis, are really caused by hemorrhage. Without doubt, peritonitis and hemorrhage often occur together; the blood that escapes into the peritoneal cavity may be too great in amount for absorption, and may become septic. The source of the hemorrhage is usually a vessel of the pedicle that escapes from the embrace of an imperfectly applied ligature. ”

“ If the ovary has become adherent in Douglas’s pouch, the condition can be relieved only by operation—celiotomy, and usually oöphorectomy.
A variety of pessaries have been invented for the relief of ovarian prolapse. They are of but little, if any, use. In many cases the pressure of the pessary upon the ovary renders its employment impossible. No pessary will cure a simple prolapse of the ovary. The cases in which the pessary does good are those in which there is a primary uterine displacement. ”

“ The sources of inflammatory infection of an ovarian cyst are the intestinal tract, the urinary bladder, and the Fallopian tube. Perhaps salpingitis is the most frequent cause of such inflammation. Infection often comes from the vermiform appendix, which is frequently found adherent to the surface of the tumor.
Old adhesions usually contain blood-vessels, which may be of large size, especially if they arise from the intestine, the omentum, or the uterus. ”

“ In all cases of cervical catarrh, even though dependent upon a distinct local lesion like a laceration of the cervix or a flexion of the uterus, the severity of the catarrh, as measured by the quantity of the discharge, is very much dependent upon the general health. The woman is often troubled by leucorrhea only at those times at which her general health is impaired by overwork, anxiety, or from some other cause ”

“ Diagnosis.—The diagnosis of chronic disease of the Fallopian tubes must be made from a study of the history, the symptoms, and by physical examination.
The history is always of value. Careful questioning will usually show that the ovarian pain dates from a criminal abortion, from an attack of fever after a miscarriage or labor, or from a suspicious coitus. Women who have been infected with chronic gonorrhea by their husbands attribute the origin of the disease to their marriage. ”

“ If there is no tubal and ovarian displacement—that is, if the ovary is not prolapsed; if the uterus has not been retroverted; if there are no extensive tubal adhesions; and if there is no gross disease of the tube, such as pyosalpinx, hydrosalpinx, hematosalpinx, a thorough curetting of the uterus, or, if necessary, a trachelorrhaphy or an amputation of the cervix, will often relieve the woman of her suffering, and it may not be necessary to operate for the damaged tubes. ”

“ The dangerous forms of degeneration—the edematous, the cystic, the telangiectatic, and the sarcomatous—occur with sufficient frequency always to be dreaded; and, even though these dangers be avoided, the anemia from the continual hemorrhage exposes the woman to fatal results from the diseases and accidents of daily life. ”

“ If the vulva is pricked with a needle, the woman draws herself away; there is no reflex muscular action, closing the vagina and drawing up the anus. The muscles of the perineum have been destroyed.
If the finger is introduced in the vagina and pressed backward and outward in either vaginal sulcus, the tissues are yielding and soft; no supporting sling of muscle and fascia is felt. ”

“ The most favorable course that we have a right to expect, in any case of fibroid tumor of the uterus that is not discharged as a uterine polyp, is that it will grow slowly, that it will produce symptoms not unendurable, and that at the menopause it will cease to grow and will atrophy or disappear. ”

“ Every woman who uses a pessary should be under the supervision of a physician, and for this reason it is often most advisable to recommend immediate operation to poor women as the quickest and surest method of cure.
Immediate operation should always be advised in all cases of retroversion with adhesion or with disease of the tubes and ovaries.
It should not be forgotten that we occasionally see women with retroversion of the uterus who present no symptoms whatever referable to this lesion. In such cases no treatment is required. ”

“ If the woman sits up or lies on either side, the relation between the areas of flatness and resonance is unaltered in the case of an ovarian cyst, while, as is well known, if the fluid be free it will gravitate to the most dependent portion of the abdomen.
Auscultation reveals nothing of importance in regard to ovarian tumors. It is of value in enabling one to make a differential diagnosis between an ovarian tumor and pregnancy. ”

“ The other changes, however, are often attended with great danger to life. The dangers of suppuration and of sarcomatous degeneration are obvious. The edematous fibroid is often of rapid and unlimited growth, and is usually accompanied by profuse hemorrhages from the uterus. The cystic fibroid may grow as rapidly and as large as an ovarian cyst. The telangiectatic tumors grow to large size and are attended by the dangers of thrombosis and embolism.
Cancer of the fundus with fibroid tumor may only be a coincidence, and we will not assume that predisposition to cancer is caused by the fibroid. ”