PRIMARY MELANO-SARCOMA 
OF THE YULYA 
BY 
R. W. TAYLOR, M. D. 
SURGEON TO CHARITY HOSPITAL, NEW YORK 
REPRINTED I ROM THE NEW YORK MEDICAL JOURNAL FOR JULY 6, 1889 
NEW YORK 
D. APPLETON AND COMPANY 
1889 THE NEW YORK MEDICAL JOURNAL, JULY 6, 1889 
DR. R. W. TAYLOR’S CASE OF PRIMARY MELANO-SARCOMA OF THE VULVA. 
A SECTION OF THE LESS PIGMENTED PORTION PRIMARY MELANO-SARCOMA 
OF THE YULYA • 
BY 
R. W. TAYLOR, M. I). 
SITRGEON TO CIIARTTY HOSPITAL, NEW YORK 
REPRINTED FROM THE NEW YORK MEDICAL JOURNAL FOR JULY G, 188& 
NEW YORK 
D. APPLETON AND COMPANY 
1889 PRIMARY MELANO-SARCOMA OF THE VULVA* 
All forms of malignant new growths—epithelioma, car- 
cinoma, and sarcoma—upon the external genitals of the 
female are of exceedingly rare occurrence. When found 
on these regions, they are usually primary lesions, and ex- 
ceptionally they occur as secondary deposits, or, still more 
rarely, by extension downward from the internal genital 
tract. While epithelioma of the uterus is far from common, 
it has been noted that from thirty-five to forty cases of it 
occur to one of the same disease of the external parts, yet 
epithelioma takes first place in the order of frequency of 
malignant new growths of the vulva. In medical literature 
the histories of so many cases of epithelioma of the vulva 
are given that its history and course are tolerably well 
known, and it has ceased to be a clinical rarity. Carcinoma 
and sarcoma of the vulva are exceedingly rare, and an ex- 
tended study of the meager statistics relating to them seems 
to warrant the conclusion that the former is more frequent 
than the latter in the proportion of two to one. An atten- 
tive study of the literature of these cases is exceedingly dis- 
appointing, since their history is given in a very fragment- 
ary manner, and a sharp definition of the nature of the cases 
is not made. In truth, much has yet to be added to our 
stock of knowledge of primary carcinoma of the vulva, and 
the same may be said, in the main, of primary sarcoma of 
this region, of which there are less than six indifferently 
recorded cases. Coming now to melano-sarcoma, the occur- 
rence of which primarily in the eye, upon the skin, and in 
the viscera, can hardly be called common, we find but six 
satisfactory cases on record (and very vague mention of*the 
subject in a few text-books) in which this new growth be- 
gan upon the vulva. Primary melano-sarcoma of the vulva, 
therefore, may be considered as among the rarest of all 
forms of malignant new growths of these parts. 
In this connection it is necessary to emphasize the fact 
that a number of cases of melanosis of the vulva have been 
reported which are really instances of melanotic carcinoma. 
The result is that confusion exists in the minds of many 
who have not clear ideas of these two forms of malignant 
1 new growths. The word “melanosis” should,therefore,be 
discarded since it is so misleading. Melanotic carcinoma 
has its origin in the epithelial structures; melano-sarcoma, 
like simple sarcoma, is a disease of the connective tissue. 
In this essay I shall give the history of a personal 
case of primary melano-sarcoma of the vulva, and a syn- 
opsis of the cases of Goth,* Terrillon,f Muller, J Haeck- 
el,* Bailly, || and Fischer,A all thus far reported, with the 
hope of throwing light upon the subject. 
Melano-sarcoma of mucous membranes should be studied 
with the aid of our knowledge of similar conditions in the 
skin, since between the course of the two there are many 
analogies, though the disease of the mucous membranes is 
lacking in the rich objective symptomatology of its dermal 
congeners. It is important in this study to remember the fol- 
lowing primary modes of development of melano-sarcoma : 
1. The primary melano-sarcoma of the skin, which be- 
gins as one nodule, or as several small ones, on a pigment, 
mole or freckle, a vascular nsevus, or on any congenital ab- 
normity of the skin, or cutaneous outgrowth, upon or in 
consequence of any chronic hyperplastic process of the skin 
or as a result of mild or severe injury to a part. In all of 
these instances irritation or traumatism seems to be an im- 
portant and essential factor. 
2. The primary local melano-sarcoma, which may or 
may not become disseminated, which, from a want of knowl- 
edge of the causes which produce it, may be called idio- 
pathic, and is sometimes of congenital origin. This form 
is akin to the first type. 
3. The simultaneous multiple idiopathic melano-sarcoma, 
which, as a rule, begins upon the hands and feet, and from 
these regions invades the body, which has been called 
“Kaposi’s” type, and is regarded by that observer as a gen- 
eral morbid atfection from the very outset. In exceptional 
cases the disease begins, in unique form, elsewhere than 
upon the extremities, particularly on the various parts of 
the face and the trunk. 
* “ rigmentsarkom der ausseren Genitalien,” “ Centralblatt fur Gy- 
niikologie,” October 1, 1881. 
f “Melanose generalisee ayant debute par une petite levre de la 
vulve,” “ Annales de gynecologie,” July, 1886. 
| “ Zur Casuistik der Neubildungen an die ausseren weiblichen Geni- 
talien,” “Berliner klin. Wochenschrift,” No. 31, 1881. 
* “ Ueber melanotisclie Geschwiilste der weiblichen Genitalien,” 
“Arch. f. Gynak.,” xxxii, 1888, pp. 400 et seq. 
|| “ Tumeurs melanotiques de la vulve,” “ Gaz. hebd. de med. et de 
chir.,” 1868, No. 47, pp. 740 et seq. 
A “ Ueber die Ursachen der Krebskrankheit und ihre Heilbarkeit 
durch das Messer,” “ Dtsch, Ztschr. f, Chir.,” xiv, 1880—’81, pp. 548,560. 
* Read before the American Association of Genito-urinary Surgeons 
at its third annual meeting, May 21, 1889. 4 
PRIMARY MELANO-SARCOMA OF THE VULVA. 
4. Melano-sareoma originating in the uveal tract (the 
chorioid and its duplicatures). 
5. Melano-sareoma beginning in any of the viscera or in 
lymphatic ganglia (unusual). 
6. Melano-sareoma of the mucous membranes, conjunc- 
tiva, mouth, vulva, and penis.* This type is most frequent- 
ly seen in the form of secondary deposits (using the word 
“frequently ” with a due appreciation of the rarity of these 
growths). As a primary disease it is of great rarity, and 
as a type it should be classed with its kindred growths, 
outlined in subdivisions 1 and 2 (vide supra). 
In a general way it may be stated that the conditions 
inherent in the tissues to the development cf melano-sar- 
coma vary in progressive degrees, according to the amount 
of pigment which normally exists in them. For example, 
the uveal tract (the chorioid and its folds) is the seat of by 
far the largest number of these new growths; the skin is 
much less frequently affected, and the mucous membranes 
much more rarely than the skin, in all of which tissues there 
is a decreasing ratio of pigment. 
groin had become smaller. About November of this same year 
another small blue, wart-like tumor was observed a little to the 
right of the meatus and extending to and along the upper right- 
hand margin of the introitus vaginae. From that date until 
June 1, 1887, a period of about eight months, this new growth 
increased in size, and about April a smaller growth began to 
the right and just above it, on that portion of the labium 
minus which draped off from the clitoris. The appearance of 
the lesions as I first saw them are well shown in the colored 
plate. The large tumor was of a bluish-black color, perfectly 
smooth, homogeneous, and slightly shining on its surface. It 
looked like a ripe plum, except that it was conical on its upper 
end, near the clitoris. It was about an inch and a half long 
by an inch and a quarter wide. Its -structure was firm, but 
compressible with moderate force. It was firmly adherent to 
the mucous membrane on the right of the vaginal orifice, and 
its base, which was about an inch in diameter, encroached up 
to but did not involve the meatus urinarius. Traction upon the 
tumor caused elevation of the subjacent tissues with it. The 
tumor, thus growing on the right side of the vagina, inclined 
inward and stopped up the vaginal orifice like a plug. The 
smaller tumor was evidently seated well under the mucous 
membrane, which, being mildly stretched, allowed it by its 
translucency to shine through as an oval mass which was quite 
firmly fixed to the subjacent tissues. The two tumors were 
continuous with each other. There were no inflammatory com- 
plications, nor was there a particle of abnormal discharge. In 
the right groin were a number of hyperplastic ganglia matted 
together in a tumor of the size of a walnut. The left groin 
showed marked salience in its middle portion. Here was seated 
a hard, slightly lobulated, conical tumor, the base of which 
seemed fully three inches in diameter, and its obtuse apex pro- 
truded fully an inch above the normal plane, being covered with 
healthy skin. Examination showed that the hyperplastic ganglia 
were quite firmly adherent to the deep fibrous tissues, and that 
the mass could be moved slightly by sliding it, but could not be 
[(inched up. 
The vulvar lesions caused the patient much mental anxiety. 
The presence of the large tumor caused local uneasiness, espe- 
cially on lying down, and it was a slight impediment to urina- 
tion. The recurrence and persistent growth of the tumors, the 
thought that they were incurable, and the fears of possible un- 
toward complications, preyed on the patient’s mind and kept her 
in a state of constant terror. This was shown, in a measure at 
least, in her great emaciation, her want of strength and of ap- 
petite, and her troubled look. Both she and her husband in- 
sisted that the vulvar tumors should be excised. To the latter 
I explained that such an operation could only be palliative, and 
that the leaven of the disease would still remain in the infil- 
trated ganglia, which could not be operated upon with any cer- 
tainty of thorough extirpation, and which would necessitate 
an operation-wound of some size. The fact of the former re- 
lapses was also emphasized, and the possibility of a similar re- 
currence dwelt upon. On the other hand, the amenability and 
accessibility of the tumors to ablation and the possibility of 
perfect healing (as we so frequently observe after the removal 
of sarcoma and pigment sarcoma) were also brought forward, 
and it was decided that the operation should be performed. 
This was done June 16th in the presence of Dr. Morrow 
Dr. Trenholme. Having made traction upon the tumor, I snared 
it with a galvano-cautery wire, heated to a dull-red color, as 
near its base as I could get. When the wire was well imbedded 
in the tumor, the battery (which had just come from the mak- 
er’s hands in supposed perfect condition) gave out. I then cut 
off the tumor just above the normal level of the labium minus, 
and proceeded to get the base away piecemeal. This was a long 
Case I—Personal.—Mrs. X., aged sixty-two, the wife of a 
well-to-do merchant, mother of five healthy daughters, came 
under my care June 1, 1887. She had always enjoyed good 
health, had never suffered any injury to her genitals, nor, to 
her knowledge, had there been any abnormal condition of them, 
even slight. Her family history was excellent, and cancer wras 
unknown in her family. The history obtained was as follows: 
About two years previously (she being then sixty years old), 
she experienced a slight smarting sensatiou in the vulva, and 
several times saw a little bloody stain on her under linen. She 
then noticed a bluish streak in the sulcus between the large 
and small labium of the left side. This was followed in a few 
months by a small, round tumor, which was seated on the same 
side near the meatus urinarius, and, in a short time after, by a 
small pea-sized tumor to the right of the meatus. At this time 
there was a painful lump in the right groin. The vulvar lesions 
were pronounced to be cancer by Dr. Trenholme, of Montreal, 
who removed them with the knife in the latter part of June, 
1886. The wound healed promptly, showing no trace of the 
neopla«m. About two months later she noticed a little blue 
spot to the right of the urethra, which grew rapidly uxffil Oc- 
tober of the same year, when it was excised by Dr. Trenholme. 
About this time it was observed that a marked swelling existed 
in the left groin, and it was thought that the lump in the right 
* Primary sarcoma and melano-sareoma of the penis are also very 
rare. After considerable search I have found the following cases: W. 
H. Battle describes (“ Primary Sarcoma of Penis,” “ Trans, of the Path. 
Society of London,” xxxvi, 1886, p. 271) a case of a man aged sixty. 
T. Holmes, in the same society’s “ Transactions,” vol. xxiii, 1872, under 
the title “ Melanosis of Penis,” narrates the case of a man aged fifty- 
two. In Gross’s “ System of Surgery,” sixth edition, p. 834, the case 
of a negro, aged forty-four, is given. In Guy’s Hospital Museum a 
morbid specimen, removed by Golding Bird, is preserved. 
My colleague, Dr. A. W. Stein (“Medical Record,” May 21, 1887), 
has reported the case, with autopsy, of a man, aged thirty-three, with 
generalized melano-sareoma, and with marked infiltration into the blad- 
der, urethra, corpora spongiosa and cavernosa, testicles, and cord. No 
history of the primary development of the disease could be obtained. 
The case of Demange (“Etude sur la lymphad6nie,” “Th&se de 
Paris,” 1874) and Yidal has been quoted as an instance of primary 
melano-sareoma of the glans penis, but its history shows that the dis- 
ease began upon the extremities, and that in about three years the 
genital organ was attacked. PRIMARY META NO-SA RGOMA OF THE VULVA. 
5 
tedious task, and was best done with my thumb-nail by persist- 
ent but cautious gouging, scraping, and pinching manipulations. 
In this way I removed all of the morbid tissue and exposed the 
fascia, which looked as smooth as one’s palm. Care was taken 
that no minute specks or filaments of the neoplasm were left in 
the contiguous territory. The haemorrhage was very slight. 
The after-treatment consisted of scrupulous cleanliness aud light 
dustings with iodoform, covered with simple gauze. Complete 
healing, which was accelerated toward the end by slight stimu- 
lation with nitrate of silver, took place in twenty-four days. 
Thereafter the site of the neoplasms showed a small, pinkish 
atrophic cicatrix. 
The health of the patient improved in a marked manner. 
She regained her strength and spirits and became five pounds 
heavier than before the operation, one pound less than her 
maximum weight at any time. On her return from the com.try 
in October, I began the use of hypodermatic injections of 
Fowler’s solution, which it had been my wish to commence in 
July. For a period of two months she received these injec- 
tions in doses commencing at seven and ending at t»n drops. 
She had one abscess during this time. The injections, made 
with great antiseptic care, were administered on the thigh and 
on parts as near as admissible to the large mass of ganglia in 
the left groin. By the patient’s preference the arsenic was then 
given by the mouth for a month, and as it by this method also 
produced annoying symptoms, it was discontinued. The result of 
the three months’ course of arsenic was the perceptible sub- 
sidence of the tumor. wTiich became distinctly more movable and 
decidedly morfe lobulated on its superior surface. In December, 
1887, the patient complained of coldness in the left heel; in 
June, 1888, her appetite began to fail. Then she had nu nbness 
in the leg and the corresponding arm, which was followed by 
slight loss of muscular power. This sensory and motor disturb- 
ance kept on apace. In April the right pupd became persistently 
enlarged, and there was right hemiansesthesia of the face. The 
left sided paralysis and the right-sided disturbances continued, 
marasmus supervened, and the patient died July 26, 1888 about 
thirteen months after the last operation, and three years fr-un 
the date of invasion of the initial new growth. She was under 
the care of another physician in a distant city during the last 
six mouths of her life. 
Case II—Goth.—The woman, age not stated, first seen in 
February, 1882, had been healthy all her life, and never had 
borne children. For two years previous to date she had noticed 
the development of a tumor on the vulva which caused neither 
inconvenience nor pain. Goth found a rounded tumor of the 
size of the fist, of a bluish-black color, not sensitive to press- 
ure, but with a tendency to bleed, and upon it several small 
ulcers dependent on the loss of epithelium. Close examination 
showed that the tumor was composed of a large upper and a 
smaller under flap, which fell together and appeared like a sin- 
gle tumor when the patient was in the horizontal position. The 
upper portion developed from the superior portion of the left 
labium minus, extended over the praeputium clitoridis and down 
the right labium minus for a short space. Its length was 7 ctm., 
width 5 ctm , and thickness 2-5 ctm. The small lower flap 
seemed to spring from the lower portion of the left labium 
minus. The growth reached backward to the posterior border 
of the vulva and ended in a number of digitate processes. The 
tumors were traversed by numerous superficial fissures, giving 
the under surface an uneven and the outer a lobular appear- 
ance. The presence of the tumor compressed and pushed the 
urethra out of its axis, and obstructed the vaginal orifice. The 
lymphatic ganglia were not enlarged, and the patient seemed in 
fair condition. Under chloroform narcosis, the upper flap was 
drawn firmly upward and forward, transfixed with a sharp- 
pointed scalpel, and removed. The haemorrhage, though profuse, 
was, with some effort, controlled. The lower flap was removed 
by a deep incision, extending well into the posterior vaginal 
wall. Care was taken to clip away all suspicious filaments. 
Under careful antiseptic measures, perfect healing resulted in 
four weeks. Goth emphasizes the facts of (a) the relatively 
benign course of the new growth ; (l) the absence of infiltration 
of lymphatic ganglia; (c) the non-recurrence of the disease five 
months after ablation. 
I may add that it is a great pity that the report of the case 
was not delayed until five years alter the operation. 
Case III—Terrillon.—An hysterical woman, aged sixty-two 
years, was admitted to the hospital April 28, 1885. suffering 
from mental derangement and hemi-ansesthesia of the left side, 
and gave a confused History of moderate pain in the vulva, and 
of slight bloody discharge, both of recent date. Examination 
showed, on the right labium minus, a small tumor of the size 
of a large nut, firm, smooth on its surface, and absolutely black. 
It spread out by prolongations be'ond its inser ion. and was 
movable with the labium minus. Around the tumor the mucous 
membrane was of a uniform black color, studded with little 
patches of healthy tissue. This discoloration existed on the 
opposite labium, and was traced into the vagina as far as the os 
uteri. There was no tumor, however, except the one men- 
tioned. There was no swelling in either groin, nor could any 
tumor be found on deep palpation in the iliac fossa. 
The tumor gave rise to no pain, and it could be examined 
without discomfort to the patient. It was removed on June 28, 
1 85, by means of the galvano-cautery. The wound healed 
kindly by the 15th ot July. Early in the following November 
the patient, who had become much emaciated, presented in the 
right groin (corresponding to the side of the ablated tumor) a 
distinct, uneven swelling of the ganglia. From this time on 
multiple tumors developed rapidly in various portions of the 
body. The woman’s general condition became much worse. 
She walked with difficulty, lost her appetite, and presented 
every indication of a profoundly morbid state of the system. 
On the 17th of February, eight months after the operation, stdl 
more marked changes were observed. The discoloration bad 
increased ; the labia majora were swollen and oedematous; there 
were several small, prominent black nodules on the left labium 
minus, while the cicatrix of the operation was unaffected. The 
orifice of the urethra was invaded, and there was a blackish 
mass of the size of the little finger upon the posterior surface 
of the vagina. At this time the tumor in the right groin was 
of the size of the fist, uneven on its surface, and adherent to the 
deep tissues. The overlying skin was healthy, though somewhat 
thinned, and through it the ganglionic tumor presented a black- 
ish color. In the left groin there were several small, hard, and 
isolated infiltrated ganglia. There was also a large indurated 
ganglion in the right subclavicular fossa, and a nut-sized black 
tumor upon the integument of the back. The patient’s general 
condition continued to be very bad; emaciation was great; the 
face was swollen, and the abdomen and legs swollen and oedem- 
atous. She grew worse and died March 6th, suffering from 
violent dyspoena and severe abdominal pains. At the autopsy 
the inguinal, iliac, abdominal, and thoracic ganglia were found 
to be filled with a black substance, and some of them were of a 
pulpy consistence. The liver and spleen contained blackish 
nodules. Examination of the post-mortem specimens by Cornil 
showed generalized melanotic sarcoma. 
Case IV—Muller.—This case, which is entirely wanting in 
the details of age and clinical history, was taken from the pri- 
vate journal of Martin, of Berlin, after his death, by his assist- 
ant, Muller. 
A tumor of the size of a goose-egg involving the clitoris was 6 
PRIMARY MELANO-SARCOMA OF THE VULVA. 
removed by operation. The woman was too weak to undergo 
a second operation on tbe enlarged inguinal ganglia. She died 
twelve days after the operation. At the autopsy, melanotic 
sarcomata were found in the brain, lungs, pericardium, liver, 
spleen, kidneys, retro-uterine fossa, bladder, round ligaments, 
stomach, jejunum, and thyreoid, tracheal, bronchial, suprarenal, 
mesenteric, and inguinal ganglia. 
It is not certain that the disease began upon the clitoris. 
The principle of “ better late than never” seems to have guided 
the operator in this case. 
Case V—Haeckel.—A woman, aged sixty-nine, well nour- 
ished and strong for her age, was first seen April 9, 1887. She 
had had six children and two miscarriages. Eleven months pre- 
vious to examination she had noticed a small tumor on the ex- 
ternal genitals which gradually grew larger. Five months later 
the left inguinal ganglia became swollen, and five months after 
that those of the right side became affected. Her only com- 
plaint was of a sense of fullness in the vagina. Haeckel found 
a tumor of the size of a child’s fist, of a dark-blue color streaked 
with white, which was seated on the wdiole of the left labium 
minus, on the clitoris, and on the upper part of the right nympha, 
and resembled a horseshoe with unequal shanks. The bluish- 
black new formation, which contrasted strongly with the color 
of the surrounding tissue, jutted into the left labium majus and 
in a less degree into the right one. There was a small nodule 
at the orifice of the urethra and two others between the left la- 
bium majus and minus. In the depth of the mons Veneris two 
hard cords were felt which were supposed to be the infiltrated 
crura of the clitoris. In the left groin there was a plum-sized 
mass of infiltrated ganglia and a smaller one on the right side. 
The left epitrochlear ganglion was enlarged. There were no 
abnormal pigmentations upon the body, and no pigmented nasvi. 
An operation was performed by which all the vulvar mass and 
the fatty tissue of the mons Veneris and the infected ganglia 
were removed. The healing of the wound was rather slow. 
Ascites, icterus, oedema of the lower extremities, together with 
severe cachexia, developed, and the patient died five months after 
the operation. 
Case VI—Bailly.—A woman, aged seventy-two, of nervous 
temperament, had suffered from rheumatism prior to her sixti- 
eth year, after which she was well. Ten months before exami- 
nation she felt an indolent tumor of the size of a lentil in the 
thickness of the right labium minus near the clitoris. After 
remaining quiescent for rather less than a year, this tumor grew 
with great rapidity and became superficially ulcerated. Later 
on a tumor identical in structure and course appeared on the 
left labium minus externally and toward the fourchette, which 
obstructed the vaginal orifice. Patches of black pigmentation 
also were present on the vulva and in the vagina, which, owing 
to tenderness, was not accessible to examination. The tumor 
was ablated. 
The history of this case was written a month after the opera- 
tion, at which time the wound had not healed and there was 
no apparent ganglionic involvement; but the ominous state- 
ment is made that the patient presented a pinched and care- 
worn look, that she was growing thinner day by day, and that 
she kept her bed. 
Case VII—Fischer.—A woman, aged fifty-six, was first seen 
April 22, 1870. Five months before, a small swelling appeared 
upon the left labium majus, which grew to the size of a walnut, 
ulcerated, and bled. The corresponding inguinal ganglia became 
enlarged simultaneously with the appearance of the new growth. 
The tumor was ablated and the patient discharged, healed, in 
four weeks. A few weeks later a recurrent growth appeared 
upon the labium. Six months after the operation the inguinal 
ganglia became ulcerated, and the patient became weak and 
died. It was thought that the irritation of a chronic leucorrhoea 
was a possible factor in causation. 
Clinical History.—The mode of development of these 
melano-sarcomatous tumors of the vulva is essentially the 
same as that of their congeners of dermal origin. In their 
course, however, the former present certain peculiarities 
and modifications which are ingrafted upon them by the 
highly vascular nature of the mucous membrane, and by 
the anatomical conformation of the parts. A knowledge 
of the clinical history of cutaneous sarcomata is of much 
aid in this study.* 
Melano-sarcoma of the vulva begins as a minute red or 
purplish spot seated in the deeper portions of the mucous 
membrane. This spot soon becomes a papule and then a 
nodule, a good example of which is shown in the chromo- 
lithograph in the smaller oval lesion just within the margin 
of the right labium majus and above the tumor proper. 
This nodule on a flat surface is of round or oval shape, but 
in a cleft like that of the labial sulcus it may be of linear 
shape (as it was at the inception of the disease in my case). 
On an anfractuous surface (near urethra, vaginal orifice, and 
fourchette) the shape of the lesion would be indefinite. The 
nodule being, as we may say, the well-developed lesion 
of the morbid process, its subsequent progress is readily 
traced. If it enlarges in area it produces at first ses- 
sile tumors, but if, as in ray case, the morbid growth is 
very exuberant in an outward direction, a true pedun- 
culated tumor may be the result, as shown in the colored 
plate. 
When a larger extent of surface is involved we find ses- 
sile tumors of various sizes, which may be as large as the 
fist or a goose-egg, as in Goth’s and Muller’s cases; or, not 
* In this connection it may be interesting to present the brief notes 
of cases of juxtapudendal melano-sarcomatous tumors which are scat- 
tered throughout medical literature, and have passed current as vulvar 
tumors. 
A tumor, in all probability of melano-sarcomatous nature, was re- 
ported by J. Fergusson (“ Recurrence of a Melanotic Tumor; Removal,” 
“ Lancet,” 1851, vol. i, p. 622). A woman, aged forty-five, had a solid, 
movable tumor, of the size of an orange, in the right groin, extending 
from the iliac spine half way down Poupart’s ligament. Two years 
previously she had a small pedunculated, bluish-black tumor on the 
right side of the mons Veneris. The skin over it ulcerated, and a fungous 
growth remained, which bled profusely. This was ablated and healing 
followed. The inguinal tumor (undoubtedly lymphatic in origin) was 
secondary to that of the mons Veneris. No microscopic examination 
was made, but the tumor was pronounced melanotic. 
Fischer (op. cit.) reports the following case: A woman had had since 
her thirty-fourth year a blackish growth on the perinseum. Prior to her 
fifty-fourth year, a tumor of the size of two fists, involving the left 
inguinal ganglia, appeared, which was extirpated. Eleven years after 
there was no recurrence. 
Wagstaffe (“ Pigmented Myxoma, Alveolated, removed from near the 
Labium Majus,” “ Trans, of the Path. Society of London,” vol. xxiv, 
1873, p. 167) reports the case of a woman, aged forty-two, having a 
conical tumor, of the size of a pigeon’s egg, on the left labium majus, 
near the point of origin of the gracilis muscle, which began deeply in 
the connective tissue. It was pronounced to be of the type of myxomata 
and sarcomata. 
It may be mentioned that melanotic growths of the uterus are very 
rare, and are usually of the form of melano-sarcoma. Neither melano- 
carcinoma nor melano-sarcoma has been found to originate primarily in 
the ovaries or vagina. PRIMARY MELANO-SARCOMA OF THE VULVA. 
7 
reaching this magnitude, they may merely jut up more or 
less from their bed, as they did in Tcrrillon’s case. To the 
touch these tumors are firmer than sponge and less resistant 
than unvulcanized rubber; their density may be compared 
to that of a plum. Their surface may be smooth, or finely or 
coarsely lobulated. They appear to be composed of a homo- 
geneous substance, and, in different shades of light, present 
black or blue tints, or a combination thereof. Though 
firmly adherent, motion or traction is readily produced. 
When very large; these tumors may become warty, or even 
fungous, upon their surface, and then from them exudes a 
bloody ichor (perhaps of offensive odor), and they may 
become more or less incrusted. Superficial ulceration from 
erosion may occur, and in this, as well as in the warty or 
fungating stage, haemorrhage, mild or severe, may occur. 
Central softening of the tumors may also take place, and 
foul and destructive ulcers may result. We are unable to 
say whether in this form of melano-sarcoma spontaneous 
absorption takes place, as it sometimes does in kindred 
skin lesions. From the fact that the connective tissue is 
sparse on the vulvar sites of these tumors, it is not probable 
that we shall see anything analogous to the subcutaneous 
nodules of cutaneous melano-sarcoma. Ablation of these 
tumors may or may not be followed by perfect healing. 
From our present knowledge it may be stated that the 
progress of these malignant growths is sometimes slow and 
again quite rapid, while it is decidedly exuberant. This 
being the case in old subjects, it will be interesting to watch 
the course of the disease in younger ones should they pre- 
sent themselves. 
In Terrillon’s case a diffuse black pigmentation of the 
whole vaginal membrane, without any other form of hyper- 
plasia, is mentioned.’ This would seem to be analogous to 
the general bronzing of the skin which is sometimes seen 
in melano-sarcoma of the skin. It was also seen in Bailly’s 
case. 
The symptoms of melano-sarcoma of the vulva are de- 
cidedly mild. Early in their course they cause slight pru- 
ritus or smarting, and they may give rise to more or less 
bfemorrhage. Later on they cause inconvenience by reason 
of their size. If developed near the urethra, they may act as 
impediments to urination, and if near the vulva, they may 
be very objectionable mechanical obstacles. In the stage 
of degeneration of the tumors they may cause much suffer- 
ing and worry. 
Such are the uncertain mode and course of the generali- 
zation of melano-sarcoma, like those of all malignant 
growths, that it is impossible to give a description of it, 
since in no two cases is it similar. The dissemination of 
the disease in this form is through the lymphatics, which 
lead directly to the viscera; therefore it is in these organs 
that we should expect to see the gravamen of the secondary 
infections. In skin sarcomata the malignant dissemination 
is through the vessels and lymphatics, and by contiguous in- 
fection ; therefore we so constantly see new crops of the dis- 
ease upon the cutaneous envelope. It is probable that in 
melano-sarcoma of the female and male genitals the skin 
will not be involved so early and so frequently as the lym- 
phatic system and the viscera. It is to be noted, how- 
ever, that in Terrillon’s case, in addition to great visceral 
infiltration, a melano-sarcoma nodule was found upon the 
back. 
In my case it is probable that the metastatic malignant 
new growth was seated in the lower part of the pons. From 
the absence of symptoms it is probable that there was not 
metastasis to any other organ. 
The date of the generalization or metastasis of melano- 
sarcoma of the vulva, like that of the whole family of sarco- 
mata, is uncertain. In Terrillon’s case it began in the 
groin, in about eleven months, and in my case the appear- 
ance of the morbid nervous phenomena, about thirty 
months after the onset of the disease, gives weight to the 
view that secondary changes began in the brain about that 
time. But it must be remembered that the ganglionic en,- 
largement began between a year and eighteen months after 
the onset of the disease. Since death occurred in Haeckel’s 
case five months after the operation, in Fischer’s case in 
six months, and in Bailly’s case in all probability in a few 
months, it is fair to assume either that marasmus set in or 
that metastatic growths were developed. The cases of Goth 
and Muller give us no information on this subject. 
In my case and that of Terrillon the age at which the 
malignant growth began was sixty years, and, though Goth 
fails to state it, it is evident, from his description, that his 
patient was beyond the middle period of life. Haeckel’s 
patient was sixty years old, Bailly’s was seventy-two, and 
Fischer’s was the youngest on record, being fifty-six. The 
statistics of other forms of sarcomata prove that they are 
more prone to appear late than early in life, but the fore- 
going figures would seem to indicate a more uniform evolu- 
tion of melano-sarcoma of the vulva in late periods of life. 
Thus Kaposi, speaking of skin sarcomata, places the date of 
invasion between forty and sixty-eight; Tanturri, according 
to Perrin,* between forty-three and sixty ; and De Amicis, 
between the thirty-ninth and seventy-fourth years of life. 
Exceptions to these averages are not common. Kobner’s 
case was that of a girl nine years old ; Billroth’s patient 
was ten years, and Perrin’s twenty-two years of age—all 
the growths were skin sarcomata. It is probable that fur- 
ther statistics will place the period of invasion of sarcomata 
of mucous membranes,in middle and old age. 
Microscopical Examination.—The anatomical diagnosis 
in my case is small- spindle-celled melanotic sarcoma. The 
mottled black and gray pigments of the tumor consist of 
clusters of closely aggregated, small, spindle-shaped cells) 
lying in a scanty stroma. The epithelial investment of the 
vulvar region was not present in any of the sections. Both 
the stroma and the tumor cells contained granules and 
larger and smaller masses of brownish pigment (see Fig. 2). 
In some places the sections are comparatively free of pig- 
ment. In other places hardly anything else but masses of 
pigment can be seen. The examination and microscopic 
drawing were made by Dr. Ira Van Gieson. 
In Goth’s case the anatomical diagnosis was melanotic 
alveolar sarcoma. 
In the tumor in Terrillon’s case the round cells of 
* “ De la sarcomatose cutanee,” Paris, 1886. 8 
PRIMARY MELANO-SARCOMA OF THE VULVA. 
melano-sarcoma were found. Examination of the blood 
and urine showed the presence of minute blackish granules. 
Microscopical examination of the tumor in Muller’s, 
Haeckel’s, and Bailly’s cases showed melanotic sarcoma. 
PEtiology.—There is nothing in the history of these 
cases which gives even a clew to the origin of this malignant 
new growth. From analogy with kindred skin lesions it 
may be inferred that any congenital lesion, particularly if 
pigmented, any structural defect of the parts, hereditary or 
acquired, or that irritation or traumatic causes, or simple 
hyperplasia, might serve as the starting point of it, but we 
have no positive knowledge. 
Hildebrandt * speaks of the case of an old woman 
in which sarcoma of the vulva supervened upon the repeat- 
ed cauterizations of some caruncles of the urethra with the 
actual cautery and acids. The lesson conveyed by it is that 
in old subjects these lesions should be excised rather than 
cauterized. Indeed, any irritated hyperplastic growth of 
the genitals of old women, or of those of middle age even, 
may take on a malignant nature; therefore they should be 
handled cautiously.f Leucorrhoea was looked upon as a 
possible causative factor in Fischer’s case. 
Taking an average of all the cases of sarcomata re- 
ported, it is found that they occur more frequently in males 
than in females. 
Diagnosis.—So well marked are the features of melano- 
sarcoma of the vulva that their recognition is usually easy. 
A distinction may be necessary between it and melanotic 
carcinoma, which is prone to appear on cutaneous surfaces 
(the labia majora), or at their junction with mucous mem- 
branes; also on the skin of the extremities. 
Melanotic carcinoma has the general appearance of epi- 
thelioma ; is often accompanied hv small or large pigment 
deposits, and the initial nodule is soon followed by new 
ones in its vicinity. In its course it is more rapid than pig- 
mented sarcoma of these parts. In general, the carcino- 
matous growths tend to burrow’ rather deeply, while the 
sarcomatous luxuriate upward. Kaposi says that a moderate 
amount of swelling and diffuse.infiltration of the surround- 
ing tissues may occur early in the disease. It is important 
to remember that melano-sarcomatous tumors may later on 
become warty or fungous on their surface, and that this feat- 
ure appears early in the course of melano-carcinoma. It is 
of vital importance that the diagnosis should be made at an 
early date in this, as in all forms of cancer, since upon it 
depends the future of the patient. 
Prognosis.—It has been tritely remarked that the in- 
vasion of mucous membranes by sarcomatous growths is a 
sign of evil omen. This statement made regarding second- 
ary deposits in cases of cutaneous and visceral sarcomata is 
particularly true concerning those of the primary invasion 
of mucous membranes. In these very vascular structures 
the morbid growth is exuberant and the disease seems to 
take an especially firm hold upon them. Then, again, those 
portions * of mucous membranes upon which sarcomata, sim- 
ple and pigmented, show a tendency to develop (the face and 
genitals), are in closely contiguous relation with large groups 
of lymphatic ganglia, which seem to be more readily in- 
fected than when the new growths are seated in the skin. 
In my case, and in that of Terrillon, death was induced in 
about two and tluee years, and in both the new growth re- 
appeared within a few months after the removal of the 
initial tumor. Goth’s case of freedom from the disease five 
months after the removal of the pigment sarcoma stands for 
nothing. It should have been reported five years after op- 
eration, rather than five months. The significant fact ap- 
pears in Terrillon’s report at the date of his operation, that 
the inguinal ganglia corresponding to the seat of the vulvar 
tumor were not perceptibly enlarged, and that, although 
the new growth did not reappear on that side, eight months 
later a ganglionic tumor, of the size of the fist, was found 
there. 
And it may be added that in the literature of malignant 
new growths in general, the fact is not infrequently noted 
that a patient discharged cured after extirpation of the 
tumor returns later on, in months and even years, with in- 
filtrated ganglia which, upon dismissal, had been thought to 
* “ Die Krankheiten der ausseren weiblichen Genitalien,” Billroth’s 
“ Handbuch der Frauenkrankheiten,” Stuttgart, 187V. 
f Cases of melano-carcinoma of the vulva are also rare, and are 
sometimes classed as sarcomas. The following have been reported: 
Prescott Hewitt’s case (“ Melanosis of the Labium and Glands of 
the Groin,” “ Lancet,” vol. i, 1861, p. 264) was that of a woman, aged 
fifty-nine, who observed a tumor on the anterior surface of the labium 
eight months before the operation. It was thought that it began upon 
a brown spot which had been there for years. The tumor grew rapidly, 
ulcerated, and bled freely. Though only palliative, the operation was 
radical, and included the removal of two or three black spots seated 
deeply in the wound. Two months later the disease reappeared in situ, 
and cerebral symptoms supervened, which led to the woman’s death six 
months after the operation. 
Klob (“ Pathologische Anatomie der weiblichen Sexualorgane,” 1864, 
p. 467, quoted by Haeckel) briefly mentions the case of an old woman 
who had a melano-carcinomatous nodule on the labium, and who died 
of a disseminated metastasis of the disease. 
Muller (op. cit., p. 447) reports the case of a nulliparous woman, 
aged thirty-three, who had a dark-blue, elastic, painless tumor, of walnut 
size, on the inner surface of the right labium majus, near the clitoris, 
which had grown rapidly within a few months. This tumor was quite 
well circumscribed, and became lost in the depth of the tissues, as fat- 
down as the pubic bone. It had not been preceded by a mevus-like 
growth. It was removed by deep incisions, the wound healing satisfac- 
torily. Just after the operation the right inguinal ganglia became en- 
larged, but they afterward became normal. Three years after the 
operation the patient was well. Microscopic examination showed the 
tumor to be of a melano-carcinomatous nature. 
In Kaposi’s “ Atlas der Syphilis ” (Heft i, Taf. xii) will be found an 
excellent colored drawing of a melano-carcinoma of the external portion 
of the left labium majus. 
* Mr. Jonathan Hutchinson—“ Clinical Lectures and Reports of 
London Hospital” (“Cancer of Female Genitals”), London, 1865— 
speaking of epithelioma of the vulva, says: “ The average length of life 
is scarcely longer than it is in the cases of medullary cancer of bones and 
testis, and it is very much shorter than what occurs in cancer of the 
breast. The explanation of the rapidity of progress is to be sought in 
the vascular condition of these parts, their rich endowment with lym- 
phatics, and the early age of the patients attacked. We very often 
meet with cancer of the female genitals in patients under thirty, and I 
have observed it as early as twenty-four. In the young the processes 
of growth and absorption are much more rapid than in the old. Hence 
all varieties of cancerous action tend to be acute if occurring in com- 
paratively young persons.” Since melano-sarcoma of other parts has 
been observed in the young, it is possible that it may appear at earlier 
dates than it did in the six cases detailed in this essay. PRIMARY MEL A NO-SA R COMA OF TEE VULVA. 
9 
be unaffected. In no case, therefore, where the tumor is 
removed and no enlargement of the ganglia is found, are 
we warranted in assuming that the patient will not have a 
recurrence in them or elsewhere. 
In cases wrhere the tumor is young, small, readily re- 
movable, and without ganglionic implication, a guarded and 
moderately hopeful prognosis may be given. .When the 
new growth is old, large, and firmly fixed, and particularly 
when accompanied with lymphatic complication, the out- 
look is gloomy. Early enlargement of the ganglia is a seri- 
ous symptom, and the late development of this condition 
inevitably brings death in its train. The death of my pa- 
tient and of Terrillon’s, at the end of about two years, to- 
gether with that of Haeckel’s and Fischer’s within a few 
months, emphasizes its lesson. 
Upon the fact that the sarcomata are more prone to form 
metastases through the medium of the vascular system than 
the carcinomata, which, as a rule, form metastases through 
the lymph channels, the greater malignity of the former 
depends. 
Treatment.—It may, I think, be stated as an axiom that 
all sarcomatous growths of the vulva, simple or melanotic, 
being of such extreme malignancy, should be removed as 
quickly as possible. The sight and presence of these 
growths tend to demoralize the patient in mind and body; 
consequently, if there is a reasonable chance of subsequent 
healing, ablation should be performed. Though there is in 
all cases a probability of relapse in situ, and almost inevit- 
ably subsequent deposit in some part of the economy, the 
patient’s comfort is greatly conserved by operation. My 
experience with these and other malignant forms of new 
growths of the vulva has convinced me that the best pro- 
ceeding in general is to first remove the greater portion of 
the mass down near the skin level, and then to finish the 
operation by patient clipping and picking, by gentle gouging 
with the nails or with the handle of the scalpel, until all 
suspicious portions are removed. Such a course is far pref- 
erable to the destructive cauterization, chemical and ther- 
mic, which is recommended by some. When in these cases 
the lumen of the urethra or vagina is invaded, the task of 
the surgeon is much more difficult and tiresome than when 
the tumors are seated on the labia alone. For some cases 
the galvano-cautery is applicable, for others the knife is re- 
quired. The haemorrhage may be profuse, but it is readily 
controlled. Such is usually the woe-begone condition of 
these patients at the time of operation that the simultaneous 
removal of infiltrated ganglia is hardly warranted. The pro- 
priety of their subsequent removal must be left to the good 
sense and experience of the surgeon. If the ganglia are 
movable, and the mass is not too old, they may be removed. 
In my case, where the mass was as large as a goose-egg and 
firmly adherent to the fascia, an operation would have been 
simply foolhardy. 
In these cases, where the outlook is uniformly so gloomy, 
all measures which offer a chance of future immunity should 
be tried. With the experience of Shattuck,* in his proba- 
ble cure of a case of melano-sarcoma, and of Kobner,f in 
his case of seemingly positive cure of a child similarly af- 
fected, in my mind, I began, at the first available oppor- 
tunity, the use of hypodermatic injections of arsenic. This 
agent certainly did soften the mass and caused its partial 
absorption. Earlier in the history of the case it might pos- 
sibly have been curative. The logical conclusion, therefore, 
to be derived from our present knowledge of the effect of 
arsenic on the sarcomata is that it should be administered 
hypodermatically, in full and increasing doses, as early and 
for as long a period as possible. 
Though the outlook is inevitably fatal, there is a modi- 
cum of satisfaction in the assurance we can give the patient 
that, when perfect removal of the vulvar mass is practicable, 
she may thereafter be free from this hideous reminder of 
her doom. 
* “ Journal of the American Medical Association,” July 4, 1885. 
f “Berliner klin. Wochenschr.,” No. 2, 1882. REASONS WHY PHYSICIANS SHOULD 
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