On Primary Malignant 
Tumors of the Clitoris. 
CHAt?BES OI?EETIE COIWSTOII, S.JH.S., JW.D., 
Boston, JtSiss. 
Reprinted from Annals of Gynaecology 
and Pmdiatry. 
boston, 1896. On Primary Malignant Tumors of the Clitoris. 
A CLINICAL LECTURE DELIVERED AT THE TREMONT DISPENSARY 
CHARLES GREENE CUMSTON, 8.M.5., M.D., 
Instructor in Clinical Gynaecology, Tufts’ College; Member of the Societe Franc/xise 
(VElectrotMrapie; Director of the Gynaecological Clinic, Tremont 
Dispensary, efc. 
Gentlemen ; 1 propose to-day 
to discuss particularly the question of 
primary cancer of the clitoris, and I 
trust that my efforts may be success- 
ful. This subject is one that should 
be known to you, as this affection is 
met with, though infrequently, as a 
primary lesion of the clitoris, and it is 
well to be on your guard. 
cause, a case of which is reported by 
Boivin and Duges. Hutchinson be- 
lieves that parts formerly affected by 
syphilitic lesions are particularly 
prone to become the seat of malignant 
neoplasms, and he says : “ Syphilitic 
ulcerations with inflammation and 
hypertrophy can degenerate into 
cancer so gradually and imperceptibly 
that it is quite impossible to say when 
one lesion ends and the other com- 
mences.” It is probable that syphili- 
tic lesions act by creating a “ locus 
minoris resistentice," thus forming a 
predisposed spot for cancer in predis- 
posed subjects. 
All the ordinary causes of cancer 
in general may be applied to epithe- 
lioma of the clitoris. Dauriac, in his 
studies, came to the conclusion that 
this neoplasm appears rather after the 
menopause, between the age of forty 
and sixty. He reports one case in 
which the affection appeared at 
seventy, and another at seventy-six, 
while Lafleur mentions a case of 
melanotic sarcoma of the clitoris in a 
woman of eighty. 
Pruritus vulvse has also been ac- 
cused as an etiological factor on ac- 
count of repeated irritation from the 
fingers to which it gives rise. 
However, childhood is not exempt, 
and as a proof of this I would mention 
a case reported by Dr. de Saint- 
Germain, of a sarcoma of the clitoris 
in a child of five years. 
In other cases, psoriasis and chronic 
eczema of the mucous membrane of 
the vulva is often the starting point 
of the affection. Vaginal discharges, 
producing a constant irritation, pro- 
longed sitting, have also been men- 
tioned as a cause by some writers as 
predisposing to cancer of the clitoris. 
Former labors and trauma appear 
to be predisposing causes of cancer of 
the clitoris. Repeated manipulations 
of this organ have been the supposed 
The affection belongs to all classes 
of society, while according to Bernntz 2 
CHARLES GREENE CUMSTON. 
esthiomene of the vulva is the result 
of poverty and vice. 
epithelial and the embryonic elements 
was so insensible that it seemed as if 
the transformation could be observed. 
Some vessels seemed to be cut through 
pure epithelial tissue, while others 
were filled with a colloid substance. 
The epithelium threw out branches 
which penetrated the deepest parts of 
the tissue. 
Of all the varieties of malignant 
neoplasms met with in the region of 
the clitoris, epithelioma is by far the 
most common. 
The encephaloid carcinoma, the 
melanic carcinoma, squirrhus and sar- 
coma have been met with, but these 
types are rare. 
Boivin and Duges mention a case 
of encephaloid carcinoma, and one of 
squirrh of the clitoris. In a case due 
to Demarquay, the histological exami- 
nation showed it to be a melanic 
cancer. Two cases of sarcoma of the 
clitoris are cited bp Dauriac. The 
first was reported by de Saint- 
Germain ; the histological examina- 
tion of the growth showed the follow- 
ing peculiarities. In some spots the 
normal covering of the mucous mem- 
brane was preserved. The under- 
lying layer of epithelium was made 
up of small round elements, having a 
very large nucleus. A considerable 
quantity of capillary vessels were 
detected between them. These ele- 
ments were closely embodied against 
each other. In some places they had 
a fusiform or star-shaped aspect, and 
were separated by an abundance of 
amorphous and granular substance. 
The following is a report of a 
complete histological examination of 
an epithelioma, made by Dr. Hutinel. 
The piece was first hardened in gum 
and alcohol. The sections, made per- 
pendicular to the surface of ulceration, 
showed them to be full of epithelial 
prolongations, like a glove finger, 
“en masse ”or like cylinders; some- 
times anastomosing one with another, 
and separated by a very vascular con- 
nective tissue, and presenting in places 
embryonic proliferations. Each of 
the epithelial cylinders was made up 
of large cells, identical with the cells 
of Malpighis’ body, but were not so 
regular in disposition. 
Elongated cells, closely cemented 
together, were to be seen beside the 
epidermic globes. In other places, 
the cellular character had nearly dis- 
appeared, giving place to a yellowish 
substance of colloid aspect, in some 
parts of which yellowish nuclei stood 
out, evidently being the traces of cell 
nuclei. 
In another case examined by Prof. 
Cornil, the piece was hardened in 
alcohol, and the sections colored with 
picro-carmine and log-wood. The 
epidermis was markedly altered in 
the centre of the neoplasm, and it 
was difficult to distinguish the epider- 
mis from the dermis. Between the 
epidermic cells were found a large 
number of cells filled with pigment 
In the neighborhood of the neo- 
plasm, the connective tissue was in- 
filtrated by embryonic cells, filling up 
the spaces between the connective 
tissue fibres and around the vessels. 
In several places the transition of the MALIGNANT TUMOR OF THE CLITORIS. 
3 
and throwing out multiple prolonga- 
tions. 
tus is very severe, so much so as to 
be the starting-point of genital excita- 
tion, obliging the patient to resort to 
masturbation. 
The deep cells of Malpighi’s stra- 
tum contained pigment, the papillae 
were filled with cells more or less 
voluminous, rounded or of irregular 
shape, and very pigmented. 
With this pruritus of the vulva, 
you may perhaps on examination, 
find that there is a sero-bloody liquid 
with a foetid odor discharged from 
the parts, and moistening the entire 
region. 
If from the epidermis, the central 
parts of the specimen were examined, 
the tumor was seen to sink deeply 
into the dermis. It was principally 
made up of cells of variable size and 
rounded in shape, the greater number 
of which measured from 10 to 15 
micromillimetres, with a few attain- 
ing the diameter of 40 millimetres. 
These cells were closely stuck to- 
gether and piled up, forming nodules 
or more or less regular agglomera- 
tions, separated from each other by 
connective tissue containing numerous 
and dilated vessels. The majority of 
the cells contained pigment granula- 
tions in their interior, consequently 
showing the tumor to be a melanic 
sarcoma. 
It will most likely be at the time 
this discharge begins that you will be 
consulted, that is to say about a few 
months after the commencement of 
the affection. 
Now, if you make an examination 
of the vulva, you will find either a 
tumor or an ulceration. In the first 
instance, which is by far the most 
frequent, you will be in presence of 
the nodular type of epithelioma. The 
tumor at this time varies from the 
size of a nut to that of a large egg. 
Its color is usually reddish, and is 
made up of a number of lobes ag- 
glomerated and clustered together, 
having the appearance of a cauli- 
flower. 
Cancer of the clitoris begins, in the 
great majority of cases, insidiously, 
and developes slowly. During a cer- 
tain time, which is of variable length, 
the neoplasm gives no signs of its 
presence, and remains unnoticed by 
the patient. 
These lobes are sometimes covered 
by a delicate membrane, which, if 
torn, gives rise to slight bleeding. 
In other cases, the tumor is reddish, 
irregular, there are depressions over 
its surface which presents yellowish 
points. At the same time, the sur- 
face is usually bathed in purulent, 
bloody liquid of very foetid odor. 
These tumors sometimes give place to 
slight haemorrhage, but which is not 
of any danger to the patient. 
Later, however, the patient will 
complain of a sensation of heat or 
burning at the vulva, especially after 
walking or after sitting for some 
time. In other cases, a disagreeable 
pruritus of the vulva is the first sign 
which calls the attention of the 
patient to her genitals. You will 
find some women in whom this pruri- 
The consistence of the neoplasm is 
different, but quite often it is firm. 4 
CHARLES GREENE CUMSTON. 
At first, limited to the clitoris, the 
growth tends little by little to invade 
the neighboring parts, first the labia 
minora, and majora, vagina, etc. 
rounding the ulceration may be 
covered with patches of psoriasis. 
You will sometimes find them fis- 
sured or thickened, hard and reddish, 
and looks as if it were raised up by 
a subcutaneous projection from the 
tumor. The labia, which is the seat 
of the ulceration, is undurated, tume- 
fied, and may be so large as to attain 
three times its normal size. 
The patient may only consult you 
when the growth has already invaded 
the clitoris and labia minora, so that 
it will be difficult to decide on the 
initial points of the neoplasm, which 
is all the more natural, because the 
patient is often deceived herself as to 
the primary seat of the growth. 
In this case, when the neoplasm 
has taken such a development, the 
hair follicles may have their vitality 
destroyed, rendering the vulva hair- 
less. 
In a case published by Richet, the 
patient stated that the tumor com- 
menced on the labia majora. In spite 
of this fact, Richet, after a most care- 
ful examination, concluded that the 
epithelioma began by the clitoris, 
this being all the more probable, 
because the clitoris corresponds to the 
corpus cavernosa in man, which is 
quite often the seat of this affection. 
Both nodular and ulcerous types 
of epithelioma develop sooner or later 
an inguinal adenitis. 
Edes has reported two cases of 
epithelioma of the clitoris. The first 
case was an unmarried female of 
forty-five, who for the past five years 
had complained of irritation of the 
parts but had oidy recently noticed 
the presence of a growth. There was 
also some irritation about the meatus 
urinarius, sometimes accompanied by 
pain on urinating. For three weeks 
the patient had noticed a discharge 
from the tumor. The inguinal glands 
were not involved. The clitoris with 
the neoplasm were removed with a 
Paquelin cautery ; the operation was 
not complicated by haemorrhage of 
any consequence. 
In the ulcer type of epithelioma, 
you will find an irregular ulceration, 
with an indurated base, and elevated 
above the surrounding parts. This 
ulceration varies in size from a ten 
cent piece to a dollar piece. The 
surface is either covered by fleshy 
granulations, which are exuberant 
and bleed easily when touched, or the 
ulcer is deeply seated, irregular in 
surface, and has a reddish color. The 
borders of the ulceration are hard, 
elevated, rough, unequal, and covered 
with exuberant granulations. They 
are sharply cut, moist, of a rosy color 
on the inner aspect, and covered with 
scabs on the periphery. 
The second case was that of a wo- 
man who had been treated for chancre 
for over a year, but without improve- 
ment. The inguinal glands were 
enlarged. The neoplasm was re- 
moved, but the patient died three 
months later. 
Epidermic scales, similar to those 
found in a commencing cancroid may 
also be met with. The parts sur- MALIGNANT TUMOR OF THE CLITORIS. 
Another case of carcinoma of the 
clitoris, due to Merkle, was that of a 
woman of sixty-one years, who had a 
tumor the size of an apple, which was 
just beginning to break down. There 
was found one enlarged gland in the 
left groin. The neoplasm was re- 
moved with the thermo-cautery ; the 
patient, however, died seventy-three 
days after. The autopsy showed the 
growth to be an epithelioma of the 
clitoris wtth metastasis in the lym- 
phatics. 
Simple or melanotic sarcoma of the 
clitoris have also been met with, as 
well as myxosarcoma. A case of a 
little girl of five has been reported by 
de Saint Germain. The growth con- 
sisted of a soft mass, hanging from 
the clitoris and pushing aside the 
labia ma’ora. 
At its upper part it continued di- 
rectly with the skin forming the hood, 
while at its lower aspect it presented 
lobules, separated by deep clefts. 
There was no pigmentation of the 
skin or hypertrophy of the inguinal 
glands. 
Besides epithelioma, which is the 
most common malignant primary 
neoplasm of the clitoris, I would men- 
tion others, of extreme rarity it is 
true, because the possibility of then- 
presence should be known to you. 
From these characters the neo- 
plasm was considered to be only a 
simple hypertrophy of the clitoris 
and its hood. 
A melanotic carcinoma was ob- 
tained by Demarquay in 1868, in a 
woman aged seventy-two. This tumor 
in the beginning was only the size of 
a pea, black in color, and perfectly 
indolent. It remained for a consid 
erable time without increasing in size, 
and then suddenly it took on such a 
rapid growth that it ended by nearly 
completely obliterating the orifice of 
the vulva. 
Extirpation was performed, and 
microscopical examination showed 
that it was a sarcoma. The neoplasm 
recurred several times in spite ef 
three successive operations, and the 
little patient died from general me- 
tastasis of the affection. 
Melanotic sarcoma may also be met 
with in the clitoris, as the two follow- 
ing cases will show you. The first, 
reported by Lafleur, was a woman of 
eighty. The patient suffered from 
severe periodic haemorrhages from the 
parts. The growth had been grow- 
ing for three years. 
At the same time it ulcerated in 
several places, giving rise to a dis- 
charge of a sticky liquid, which at 
first was white and finally became 
yellow, staining the underclothing. 
The clitoris became the seat of a 
slightly oozing sero-bloody liquid 
and very sharp lancing pains. The 
patient was operated on and micro- 
scopical examination of the growth 
showed it to be a melanotic carci- 
noma. 
It was amputated, the patient mak- 
ing a good recovery. Microscopical 
examination of the neoplasm proved 
that it was a melanotic sarcoma. 
Dr. Terrillon has recorded the case 
of a woman of sixty-two years, who 
presented a tumor the size of a wal- 
nut at the site of the clitoris. This ('H A H LES (iKEENE CUMSTON. 
tumor was hard, regular in shape, 
without nodules or clefts, and per- 
f ctly b’ack in color. All around the 
grow th the mucous membrane of the 
vulva was also black, uniformally 
pigmented, excepting in a few spots 
of healthy tissue. This coloration 
had invaded all of the vaginal mucous 
membrane up to that of the cervix. 
The inguinal gauds were not en- 
o o 
la rged 
I am acquainted with but one case, 
and that due to Robb. The patient 
was a married woman of twenty-six. 
She complained of pain about the ex- 
ternal genitals, which was increased 
by the act of coitus. A tumor was 
found which occupied the left crus 
clitoridis. It was pointed at either 
end, hard, movable and slightly lobu- 
lated The neoplasm was contained 
in a fibious capsule, which rendered 
enucleation easy to accomplish with 
cocaine. Some free oozing followed, 
but the wound healed well. Micro- 
scopical examination showed the neo- 
plasm to be a myxosarcoma. 
Fhe neoplasm was totally removed, 
the whole wound healing rapidly. 
However, four or five months later, 
several small blackish tumors ap- 
peared on the right labia minora. At 
the same tinea large bunch of glands 
was found in the corresponding groin. 
This bunch was the size of a fist, ir- 
regular in shape, and was adherent 
to the skin. 
In another form of epithelioma of 
rhe clitoris, which is most interesting 
and important to note, is where the 
neoplasm is preceded and accompa- 
nied by patches of psoriasis of the 
vulva, similar to psoriasis of the 
buccal cavity, so well described by 
Prof. Debove. 
In the left groin, a few indurated 
glands were felt, but they were sep- 
arated from each other. An enlarged 
gland was also discovered in the sub- 
clavicular space on the right side. 
()n the back was seen a blackish tu- 
mor the size of a walnut, situated in 
the skin. Fhe patient soon died from 
the extension of the affection. 
A case of this kind was recorded 
by Dr. Pean, and I desire to relate it 
as it will be of considerable instruc- 
tion to you. 
The patient had an ulceration of 
epithleomatous origin the size of a 
fifty cent piece, extending from the 
clitoris to the internal aspect of the 
right labia majora. The base of this 
ulcer was indurated, and the indura- 
tion extended in an irregular manner 
for some distance away from the 
growth. 
O 
Fhe autopsy revealed, besides the 
above-mentioned lesions, a liver and 
spleen filled with small foci of black- 
ish color. Fhe inguinal, iliac, ab- 
dominal and thoracic glands, were in- 
vaded by a melanotic deposit and 
were very soft. 
A histological examination demon- 
strated the presence of a melanotic 
sarcoma, a generalized sarcomatosis, 
having for starting point the clitoris. 
Around the ulceration were seen 
some whitish patches, which were 
cracked, and presented the character- 
istic aspect of psoriasis. They ex- 
tended three or four centimetres and 
As to myxosarcoma of the clitoris, MALIGNANT TUMOR OF THE CLITORIS. 
covered the mucous membrane in all 
points where the induration was felt. 
mucous membranes, and even vagi- 
nitis. 
'The patient declared that these 
whitish patches, which were indolent, 
had preceded the appearance of the 
ulceration at least two years. 
As the cancer progresses, and in so 
doing invades the neighboring tis- 
sues, the functional disturbances are 
still more pronounced. If it extends 
to the meatus urinarius, micturition 
will become painful and difficult, and 
the patient will experience such a 
burning that she will dread the time 
for urinating. If the growth invades 
the canal of the urethra, of course the 
dysuria will be greatly increased and 
may even result in retention of urine. 
Walking will be given up on account 
of the pain produced by friction of 
the parts. 
ddie inguinal glands were perfectly 
normal. 
Now, gentlemen, this leucoplasia of 
the vulva, which may precede and 
accompany epithelioma of the clitoris, 
appears to me to create an interesting 
analogy between epithelioma of the 
clitoris and cancroid of the lips. 
This is not the only point of likeness 
in these affections; they both have a 
marked tendency to recur after oper- 
ation . 
The growth will also be an obstacle 
to the act of coitus, which will be- 
come painful or even impossible on 
account of spasmodic contractions of 
the vaginal sphincter. 
Neoplasms of the clitoris give place 
to a number of functional disturb- 
ances which are common to all types. 
So long as the epithelioma remains 
limited to the clitoris, the patient will 
only complain to you of heat or burn- 
ing sensations, which are all the 
more sharp, according to the greater 
or less amount of surface of ulcera- 
tion. which is naturally irritated by 
the passage of urine and vaginal secre- 
tions. 
I'he lymphatics are usually long in 
being invaded in epithelioma of the 
clitoris. Generally several months 
elapse before they are attacked, and 
this fact is of course a most favorable 
point for the treatment and ultimate 
result. 
The progress of epithelioma of the 
clitoris is, generally speaking, slow, 
and it is safe to say that its duration 
may be considerable. 
The neoplasm may produce an 
extremely bad and constant pruritus 
of the vulva, or it may cause sharp 
lancing pains, which may shoot up as 
far as the breasts. 
As 1 have pointed out to you, the 
beginning is slow and insidious; the 
growth may have been present for 
several months before the patient 
notices it. 
When a secretion is established 
from the tumor, which has the usual 
fetor and irritating qualities found in 
all liquids coming from malignant 
growths, it will little by little pro- 
duce aii inflammation of the vaginal 
It is after the latent stage of the 
malady that a series of functional dis- 
turbances, of great discomfort to the 8 
CHARLES GREENE CUMSTON. 
patient, make their appearance, and I 
will not repeat them. Now, it is just 
at this time that the patient will con- 
sult you, and on examination you 
will find a condition of things that 
generally will not be difficult to 
recognize. 
voided per vaginam, while in the 
second its appearance is intermittent 
and only is present during mictura- 
tion. 
These eomplications are infrequent, 
and fortunately so for the patient. 
Epithelioma may attain the cervix 
and the body of the uterus as well, 
and at the same time the inguinal 
and lumbar glands undergo a second- 
ary degeneration. 
If you remove the neoplasm, as 
you should if the disease be not too 
far advanced, a permanent cure may 
be obtained, but recurrence is fre- 
quent and takes place with most 
astonishing rapidity, especially in 
cases of melanotic sarcoma. 
Among the very infrequent compli- 
cations, 1 would mention the propaga- 
tion of the affection to the rectum, 
which is indicated by a great activity 
of the intestinal secretions, a copious 
diarrhoea, and occasionally rectal ten- 
esmus. In still more infrequent cases, 
the disease, instead of following the 
mucous membrane, extends over the 
skin of the pubis or perineum. 
If an epithelioma is left to itself, 
spontaneous cure, although most ex- 
ceptional, is not impossible. 1 would 
quote to you what so great an author- 
ity, Prof. Cornil, says on this question: 
“ It is certain that the tubulated form 
of epithelioma may be so superficial 
that it may get well, leaving a com- 
plete cicatrization on a large portion 
of the skin. The ulcerated part 
itself gives proof of the possibility of 
cicatrization, for the centre of the 
ulceration does not differ from a 
healthy wound, and the inflammation, 
after destruction and elimination of 
the epithelial mass, extends no further 
than the dermis.” But, I repeat, this 
ultimate result is very exceptional. 
A case is recorded by McClintock, 
in which the neoplasm invaded the 
entire external genital region, the 
pubis, groin, perineum and around 
the anus. 
Other cases are reported where an 
epithelioma invaded the labia majora, 
the skin of the pubis and groins. 
If the neoplasm be a melanotic 
sarcoma, you are, gentlemen, in the 
face of the most terrible of all malig- 
nant growths. It extends with a 
most astonishing rapidity, invading 
the lymphatic system, the abdominal 
and thoracic viscera in a very short 
lapse of time. As an example of its 
ravages 1 would mention the case of 
a lady of about forty, from whose 
breast we removed a small melanotic 
sarcoma. At the time of the opera- 
tion. some lymphatic glands in the 
An epithelioma left to itself will 
progress in most instances, invading 
the neighboring tissues, and particu- 
larly the mucous membrane of the 
vagina. The meatus urinarius and 
the neck of the bladder can be suc- 
cessively invaded, resulting in perfor- 
ations, which are followed- by vesico- 
or urethrovaginal fistula. In the 
first case, the urine will be constantly MALIGNANT TUMOR OF THE CLITORIS. 
9 
corresponding axilla were found en- 
larged and were removed. This 
operation was done, if I remember 
correctly, in June, 1890, and the 
patient died the following August. 
At the autopsy the liver, kidneys, 
spleen, lungs and brain, were filled 
with foci of metastasis. 
clitoris from other affections which 
resemble it in appearance. 
As I have already pointed out, the 
tumor in the beginning only produces 
a few slight functional disturbances 
which do not annoy the patient suffi- 
ciently for medical advice, conse- 
quently an early diagnosis is hardly 
ever made. 
In addition to the local functional 
disturbances attending the presence 
of a neoplasm of the clitoris and its 
extension, you will have before you, 
as the case advances, the usual 
picture of the cachectic condition, 
oedema, diarrhoea, and intense suffer- 
ing close the unhappy scene. 
But if you have an aged patient 
who complains of itching and pruritus 
of the vulva, which is exasperated by 
walking, and if this patient has cancer 
in her family history, you should al- 
ways have in mind the possibility of 
cancer of the clitoris in its early 
stages, and do not hesitate to ask for 
an examination, which should be care- 
fully done. By this means you may 
be fortunate enough to find a tumor 
in its commencement, or discover the 
presence of patches of psoriasis of the 
vulva, which as I have shown you, is 
sometimes the prelude of epithe- 
lioma. 
As to the prognosis of malignant 
growths of the clitoris, it may be ad- 
mitted that it in no way differs from 
that of the same tumors in other parts 
of the human economy. Recurrence 
is frequent after operation, and the 
patients end their existence by a gen- 
eral invasion of the affection. 
As to the diagnosis, gentlemen, I 
have something to say, as it is most 
important. Now, if an aged person 
should consult you for a tumor of 
the clitoris, covered with vegetations 
which bleed when touched, and secret- 
ing a dirty liquid with a foetid odor, the 
diagnosis of epithelioma is easy. But 
it is not always so, and in some cases 
the diagnosis may give rise to con- 
siderable difficulty and error. 
Later on, when an epithelioma has 
developed into a tumor, be it ulcer- 
ated or not, the diagnosis may be 
quite difficult. ‘ 
I do not think that you would have 
any trouble in recognizing the various 
benign tumors which may develop in 
these parts, such as papilloma, erectile 
tumors, cysts of the urethral glands, 
vegetations, etc.; but hypertrophy of 
the clitoris, the soft or hard chancre, 
elephantiasis and esthiomene of the 
vulva might easily lead you into error, 
as they have other men, even of 
great experience. 
In several cases the neoplasm was 
regarded as an indurated chancre, and 
the patients were put on an anti- 
syphilitic treatment, thus losing much 
valuable time. 
I will trace out the various means 
of distinguishing epithelioma of the 
Simple hypertrophy of the clitoris 
is distinguished by its more regular 10 
CHARLES GREENE CUMSTON. 
shape and firmer consistency; also 
from the absence of bleeding granula- 
tions and foetid secretions. The lym- 
phatic glands are normal. 
If, after all, you should still be in 
doubt, put your patient on specific 
treatment, which will in all proba- 
bility produce a rapid amelioration in 
the case of syphilis. 
The differential diagnosis of hard 
chancre and epithelioma is more diffi- 
cult. Both affections may appear as 
a small circular ulceration, with a 
slightly elevated base, hard and pain- 
less. 
There are some patients of lympha- 
tic constitutions, in whom the ulcus 
molle may take on a phagedemic form, 
and their lesion mistaken for cancer. 
But the indurated base of malignant 
disease is absent in soft chancre, and 
remember that the progress of the 
latter affection is much more rapid 
than in the former; and furthermore, 
the inguinal adenitis is very much 
quicker in appearing, or a bubo may 
form, a complication which will never 
arise in the case of malignant neo- 
plasms. And still more, the soft 
chancre is highly auto-inoculable, and 
this inoculation is favored in the 
female on account of the friction of 
the external genitals which are so 
closely opposed. 
But an epithelioma makes slower 
progress, and usually has been pre- 
ceded by a more or less severe pruri- 
tus, which attracts the notice of the 
patient. A cancerous ulceration is 
ragged and irregular, and usually 
covered with a dirty liquid, and the 
inguinal glands are becoming en- 
larged. 
The surface of a indurated chancre 
is more regular, shiny and dry, and 
is accompanied by enlarged inguinal 
glands, and what is the most im- 
portant of all, are the secondary 
symptoms, which remove all doubt as 
to the real nature of the affection. 
From the above mentioned charac- 
terics, I do not believe that you will 
be long in coming to a correct con- 
clusion, if you carefully consider the 
question ; but if there still remains a 
doubt in your mind, why then I 
should advise you to inocidate your 
patient with the discharge from the 
surface of the ulceration, which in the 
case of ulcus molle, will be followed 
in a few days by a positive result. 
Tertiary lesions may also be mis- 
taken for malignant disease. In 
both, the lesions may have that 
withered and dirty appearance in an 
old cachectic patient. Now, if the 
lesion be one of syphilis, you will 
have the history of the secondary 
manifestations of the affection ; there 
will be no bleeding from the parts 
and only a slight induration of the 
bottom and borders of the ulcer; and 
still more there will probably be 
other manifestations of the diathesis 
at some other part of the body, if you 
take the necessary care in looking for 
them. 
Epithelioma or sarcoma may be 
confounded with an affection of the 
vulva, first described by Huguier 
under the name of esthiomene, and 
which in reality is only lupus of the 
vulva. Now, contrary to lupus, whose 
progress is slow, and in which disease MALIGNANT TUMOR OF THE CLITORIS. 
11 
the ulcers have a strong inclination to 
repair, malignant growths advance 
with greater rapidity, invade the 
tissues, at the same time destroying 
them, without ever showing any signs 
of cicatrisation. 
tubercular ulcerations, and this sign 
should be looked for. At the same 
time the lungs should be examined 
for signs of tuberculosis, and the 
spleen should be percussed in order to 
ascertain if it be enlarged. 
You must also bear in mind that 
lupus is a frequent manifestation of 
the scrofula diathesis, so that you 
must go over the patients antecedents 
carefully, and make an examination 
in order to ascertain if there are any 
signs of old symptoms, or if the 
lesions so characteristic of the affec- 
tion are present, such as enlarged 
glands, and chronic disease of the eye, 
nose or ear, troubles which are so 
common in strumous subjects. 
Carcinoma is to be distinguished 
from epithelioma by its more rapid 
progress and its more destructive 
action on the surrounding tissues, as 
well as more severe haemorrhages. 
As to the treatment of malignant 
neoplasms, I would advise you to only 
use the knife. Formerly surgeons 
employed the ecraseur or the thermo- 
cautery in order to avoid haemor- 
rhage. But since the clamps devised 
by P£an are now currently employed, 
bleeding is not to be feared. You 
will consequently dissect out the en- 
tire growth, removing with it part of 
the surrounding healthy tissue, not 
forgetting to extirpate all the en- 
larged inguinal glands, if any are to 
be found. The corpus cavenosus 
should be removed with the clitoris, 
and you will take great care not to 
injure the meatus urinarius if this 
canal is not invaded by the neoplasm. 
In a case where the urethra is in- 
vaded by the growth, you must in- 
troduce a sound into the bladder and 
dissect the parts away, using the 
sound as a guide. 
Guerin and Bernutz laid great 
stress on the co-existence of lupus of 
the face with that of the vulva. Do 
not forget the aid that bacteriology 
may be to you, and in doubtful cases 
make careful examinations for Koch’s 
bacillus, which although difficult to 
obtain, will be of utmost importance 
in the point of diagnosis, if its presence 
be detected. 
The age of the patient must also be 
considered, as epithelioma is more 
often met with in the aged, while 
lupus and sarcoma are diseases of 
adult life. 
The diagnosis between a tubercu- 
lar and carcinomatous ulceration may 
be difficult; however, you will remem- 
ber that in the former the ulcer has 
a granular bottom of a rosy-gray 
color, secreting a yellowish pus. The 
much regretted Prof. TrGat pointed 
out that a number of yellowish points 
were scattered around the limits of 
After thorough hsemostosis, the 
surfaces are united by silver wire, or, 
as I prefer, with sublimated silk. If 
you employ proper asepsis you will 
probably obtain reunion by first in- 
tention. 
The dressings should be composed 
of iodoform gauze covered with sub- 12 
CHARLES GREENE CUMSTON. 
limated gauze, the whole being held 
in place by a T bandage or a spica. 
as possible, three or four hyperder- 
mic syringes are taken from the ster- 
ilizer and filled with absolute alcohol. 
The patient being placed in the genu- 
pectoral position, the first injections 
are made in the centre of the neo- 
plasm. When the needle has pene- 
trated sufficiently, so that a normal 
resistance is felt, three or four drops 
of alcohol are injected. 
Inoperable cases will call for medi- 
cal treatment. You must keep the 
parts as clean as possible with a one 
per cent, solution of creolin, eucorline, 
or lysol, and dust the surface with 
iodoform, or what is better, I think, 
with europhene. 
To relieve the pain, morphine must 
be used freely. 
If bleeding occurs from the pene- 
tration of the needle, you should wait 
until this has stopped, otherwise the 
alcohol would run out with the blood. 
Cheron recommends the following 
as a vaginal injection when the dis- 
ease has invaded the vagina : 
Seven or eight drops of alcohol are 
injected, and the stop-cock of the 
needle is closed, the syringe with- 
drawn. Another needle is then in- 
serted and the same technique fol- 
lowed. Four or five injections are 
thus practised at one seance, always 
proceeding from the centre of the 
neoplasm towards the periphery of 
the neoplasm, the last one penetrat- 
ing the apparently healthy tissue. 
R 
Kalii carbonat, 18.0 
Tinct. oph, 5.0 
Aqufe, 200.0 
m. f. solut. 
Of this solution two or three spoon- 
fuls are added to a litre of water, 
which is used as a vaginal irrigation, 
night and morning. 
As it is my duty to instruct you in 
the latest ideas, I must before closing 
this lecture say a few words regard- 
ing a new treatment for inoperable 
carcinoma, which has lately been de- 
scribed and practised by my former 
and esteemed teacher, Prof. Vulliet, 
of Geneva. This treatment consists 
of intra-perenchymatous injections of 
alcohol. 
In closing, let me mention the in- 
terstitial injections of an alcoholic so- 
lution of salicylic acid, and last of all 
the toxins of erysipelas, as practiced 
by Dr. W. B. Coley of New York. 
These various injections should be 
tried in all cases of inoperable ma- 
lignant neoplasms. 
After rendering the parts as aseptic