CYCLOP/EDIA 
OF 
OBSTETRICS AND GYNECOLOGY 
VOLUME NINE 
DISEASES • 
OF THE 
I FEMALE MAMMARY GLANDS 
BY 
TH. BILLROTH, M.D. 
PROFESSOR OF SURGERY AT THE ROYAL UNIVERSITY, VIENNA. 
AND 
NEW GROWTHS OF THE UTERUS 
BY 
A. GUSSEROW, M.D. 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT THE UNIVERSITY OF BERLIN 
ONE HUNDRED AND FIVE FINE WOOD ENGRAVINGS 
EDITED BY 
EGBERT H. GRANDIN, M.D. 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL', INSTRUCTOR IN GYNECOLOGY 
AT THE NEW YORK POLYCLINIC J FELLOW OF THE OBSTETRICAL SOCIETY, ETC, 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887. 
WILLIAM WOOD & COMPANY. 
Tiie Publishers' Printing Company 
157 and 159 William Street 
New York CONTENTS. 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
CHAPTER I. 
PAGE 
Anatomy of the Breasts 1 
CHAPTER II. 
Absence of the Mammary Glands; Supernumerary Mammary Glands 10 
CHAPTER HI. 
Diseases of the Nipple and Areola. 12 
CHAPTER IV. 
Wounds of the Mammae ; Spontaneous Hemorrhage and Congestion ; Ery- 
sipelas 14 
CHAPTER V. 
Puerperal Mastitis 16 
CHAPTER VI. 
Non-puerperal Acute anti Sub-acute Mastitis 30 
CHAPTER VII. I 
Chronic Mastitis; Tuberculosis; Syphilis; Induration 32 
CHAPTER VIII. 
Mastodynia 39 
CHAPTER IX. 
Anomalies of Secretion and Excretion 43 
CHAPTER X. 
Tumors of the Mammary Gland 47 
CHAPTER XI. 
Etiology and Statistics 127 
CHAPTER XII. 
Differential Diagnosis and Prognosis 144 
CHAPTER XIII. 
Treatment 147 IV 
CONTENTS. 
CHAPTER XIV. 
PAGE 
Animal Parasites of the Mammary Gland 151 
CHAPTER XV. 
Extirpation of the Mammae and of the Axillary Glands 153 
NEW GROWTHS OF THE UTERUS. 
Introduction ' 161 
CHAPTER I. 
The Anatomy of Myofibromata or Fibroid Tumors of the Uterus 165 
CHAPTER II. 
The Growth and Morbid Changes of Uterine Fibroids 188 
CHAPTER III. 
The Etiology of Fibroids of the Uterus 200 
CHAPTER IV. 
The Course, Symptoms and Complications of Uterine Fibroids 206 
CHAPTER V. 
The Diagnosis and Prognosis of Fibroids of the Uterus 233 
CHAPTER VI. 
The Treatment of Uterine Fibroids 242 
CHAPTER VII. 
Cysto-flbromata of the Uterus 281 
CHAPTER VIII. 
Uterine Fibroids in their Relations to Pregnancy, Parturition and Childbed. 294 
CHAPTER IX. 
Sarcoma of the Uterus 324 
CHAPTER X. 
Polypi and Adenomata of the Uterus 340 
CHAPTER XI. 
Papilloma of the Uterus 352 
CHAPTER XII. 
Epithelioma and Carcinoma of the Cervix Uteri 358 
CHAPTER XIII. 
Cancer of the Body of the Uterus 415 
Index 323 DISEASES 
OF THE 
Female Mammary Glands. 
BY 
TH. BILLROTH, M.D., 
PROFESSOR OF SURGERY AT THE ROYAL UNIVERSITY, VIENNA. DISEASES 
OF THE 
FEMALE MAMMARY GLANDS 
CHAPTER I. 
ANATOMY OF THE BREASTS. 
TTNDERNEATH the skin, on each side of the sternum, are situated 
two glands which in the female alone reach their fullest develop- 
ment, although they are similarly situated in both sexes. They 
form soft hemispherical projections above the surface of the body, and 
extend, when well-developed, vertically from the third to the seventh rib, 
and horizontally from the edge of the sternum to the anterior border of 
the axillary space; being situated for the most part on the pectoralis major 
muscle, and to a less degree on the serratus magnus (Luschka). It is 
worthy of note that these glands, at the same period of life and under 
similar functional conditions, differ in size, not only in different women, 
but also in the same individuals, and that there is no fixed relation between 
their size and that of the body. The circumference of the gland depends 
not only upon the amount of the gland-substance, but to a great degree 
upon the amount of the superimposed adipose tissue. Very near the 
middle of each gland is situated the nipple, in which the excretory ducts 
empty, and around which the skin is of a light rose-red or brown coloi' 
for a distance of 1| inches. According to Hennig the mammary gland 
has frequently a three-cornered shape, and one can distinguish an inner 
and two outer (an upper and a lower) extremities; the upper external 
extremity not infrequently sends out a process which extends under the 
pectoralis major muscle nearly to the axillary glands. The nipple does 
not generally denote the central point of the denuded gland, but is some- 
what internal to and above it. The right mammary gland is usually 
somewhat larger and heavier than the left. 
The mammary glands belong to the class of aggregate acinose glands, 
1 2 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
and are to be considered in their whole development and situation as seba- 
ceous glands of the skin, whose function is to secrete a fat emulsion (milk). 
As is well-known, this function is by no means a constant one, but depends 
upon certain occurrences in the sexual organs. In this respect there are 
analogous processes in the other sebaceous glands, in that the fluidity, the 
softness and amount of the secretion of these glands stand in a certain re- 
lation to the sexual organs, and that upon this relationship depends the 
great softness of the female skin. 
Between the mammary glands of a newly-born child and those of a 
pregnant woman, there exist such great qualitative and quantitative dif- 
ferences, that an especial consideration of these glands under these differ- 
ent circumstances is necessary, especially since a knowledge of these 
differences is of great weight in order to properly understand the patho- 
logical processes. 
The arteries of the mammary glands are chiefly given off from the in- 
ternal mammary and long thoracic arteries; the branches of these arteries 
anastomose to a considerable extent, and are much enlarged during the 
activity of the gland. They spread out into finer and finer twigs, until 
they form a capillary net-work surrounding the single lobules. From 
these capillary net-works arise numerous venules, which, following the 
course of the arteries, form dense net-works under the skin, and finally 
empty into the internal mammary and thoracic vein; many of the sub- 
cutaneous veins emptying into the external jugular (Luschka). 
The mammary glands are very rich in lymphatic plexuses, which are 
partly situated deep down in the gland, partly subcutaneous. They form 
tolerably narrow closed plexuses, not communicating with the connective 
tissue interspaces (Langhans), which surround the lobules of the glands 
near the capillary plexuses and accompany the excretory duct. They 
arise from club-like processes in the papillae of the mammary areola (as in 
the skin), form cutaneous and subcutaneous plexuses, and then unite to 
form lymphatic trunks. The superficial as well as the deep lymphatic 
trunks pass for the most part to the lymphatic glands of the axillary 
space, where they unite with the lymphatic vessels of the intercostal 
spaces and through these with those of the thoracic cavity. (Luschka). 
The nerves of the mammary glands are mostly of spinal origin, though 
to some extent there is a mixture of sympathetic elements. There are, 
according to Eckhart, especially, branches from the 4 to 6 intercostal 
nerves, which accompany the larger milk-ducts and are distributed in the 
parenchyma of the gland. Their mode of termination is not yet known, 
though it is very probable that they end in terminal bulbs, as they do 
in other acinose glands (as in the salivary glands, W. Krause). The skin 
over the mammary glands is very rich in nerves, which come from the 
internal and middle supraclavicular nerves, and from the external branches 
of the 2 to 6 intercostal nerves (Luschka). ANATOMY of the breasts. 
3 
The Mammary Glands of Infants and their Development. 
Similarly to other cutaneous glands, the mammary glands proceed 
from a growth of the rete Malpighii, and, so far as observations show, they 
first appear about the third month. The separate divisions of the gland 
are disconnected by a process of proliferation, and have a flask or pear- 
shape. They appear a little larger and a little more perfectly formed in 
newly born children, and are of the same size in both sexes. At the time 
of their first formation in the foetus, there is a slight excavation at the 
site of the nipple; but the nipples and the excretory ducts of the gland 
are developed during foetal life. Newly-born children have indeed toler- 
ably well-developed nipples. Th. Kolliker describes certain processes 
in the gland, which have been hitherto thought to be exceptional, as regu- 
lar and normal. He says, of the mammary glands of newly-born children: 
" The most striking appearance to be seen in all glands, though to a less 
extent in boys, is the ectasia or dilatation of a now large, now small num- 
ber of gland-ducts, so that they present a considerable lumen from their 
external opening to the terminal bulb. In these ducts, the lumen is filled 
with thrown-oif epithelium and a white granular mass, while the pre- 
Fig. 1.-Mammary Gland of Female Embryo. 7 inches long; enlarged 70 times. (Langer.) 
served epithelium is disposed in layers on the basement membrane." 
Further on he says: " The above described ectasia of the milk-ducts begins 
in the first week of life, and frequently goes on to pronounced paren- 
chymatous swelling, which may present the appearance of mastitis with 
great dilatation of the ducts, so that the whole gland has the appearance 
of a cavernous organ. In such cases, one never finds simple cylindrical 
epithelium, but the ducts either contain few epithelia, which seem to be 
pressed flat against the parietes of the cavernous space, or we find, what 
is more frequently the case, stratified epithelium with two or three layers 
of round cells. The greatly dilated ducts and lobules contain sometimes 
single epithelial cells, sometimes a granular, yellowish, crumbling mass, 
consisting of large plates, (changed epithelial cells?) and not taking 4 
DISEASES OF THE FEMALE .MAMMARY GLANDS. 
haematoxylin." " To sum up, we find in the beginning dilatation of the 
milk-ducts in different degrees as characteristic of the first year, which 
may reach such a degree that cavernous spaces are formed, against the 
parietes of which lie the flattened epithelial cells." " This occurrence 
is, in my opinion, physiological, when it occurs in a moderate degree, but 
when it occurs in a more marked degree and lasts for a longer time, it 
becomes pathological, and may be considered a mastitis, which, according 
to my observations, may lead under certain circumstances to similar wide- 
reaching changes in the whole gland, and must exert an influence upon 
the further development of the gland. Glands of this character, as shown 
in Fig. 2, (high-grade cystic dilated gland-ducts, Kolliker), are scarcely 
ever developed normally afterwards, and the faulty development of the 
breasts in otherwise well-developed women is very probably due to this 
mastitis of childhood." 
The further Development of the Female Mammary Gland and 
its Retrogression in Old Age. 
Up to the time of puberty the growth of the gland bears a close rela- 
tion to the bodily growth in both sexes; only a few gland-lobules are 
Fig. 2.-Gland Lobule from the Breast of a 
Girl 16 years old. X 70. (After Langer.) 
Fig. 3.-Gland Lobule from the Breast of a 
Girl 18 years old. X 70. (After Langer.) 
developed by proliferation. According to Hennig the right areola is 
always better formed than the left. ANATOMY OF THE BREASTS. 
5 
With the onset of puberty, there is a further development of the gland 
in females. Dp to this time the excretory ducts are but slightly formed, 
being for the most part blind sacs; now true terminal vesicles are formed, 
although of a more bulbous shape. 
Soon the connective tissue which immediately surrounds these gland- 
ducts has a peculiar compact hyaline quality; it is especially rich in nuclei, 
and different from the bundles of connective tissue which lie between the 
lobules; this peculiar covering of connective has doubtless an important 
relation not only to the later richer growth of vessels, but also to the 
development of the so frequently present pseudo-plasma in the mammary 
glands. 
Later the terminal vesicles develop into regular grape-like acini. 
These acini contain small round cells, such as epithelium; the excre- 
Fig. 4.-Mammary Gland of a W7oman during Lactation. About one-third natural size. {Luschka.) 
tory ducts have cylindrical epithelium. Coincidently the size of the gland 
increases, the epithelium grows by proliferation, while capillaries and firm 
connective tissue surround the newly developed acini. The acini and ex- 
cretory ducts contain no secretion; the firm elastic consistency of the 
virgin breast is due to the peculiarly firm quality of its connective tissue. 
During the first pregnancy, the number of acini greatly increases, 
especially by the development of the parietal acini; the lobules become 
larger, and the underlying cellular tissue becomes richer in vessels and 
more succulent. Whilst in a virgin breast the single lobules cannot be 
separated from the connective tissue, and the developed breast which does 6 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
not contain milk appears to the naked eye as thick, firm connective tissue, 
when the organ contains its secretion the single gland-masses are easily 
apparent in the surrounding connective tissue. 
The appearance of lobules filled with milk is shown in Fig. 5. 
More highly magnified, the acini present the appearances seen in Figs. 
6, A and G, B. 
In the functionating organ not only is every acinus distended with 
milk, but the surrounding connective tissue is very much richer in cell 
elements, which appear larger and more succulent, which is not the case 
in the non-secreting organ. By this enlargement and rich development 
of capillary vessels and lymphatics, the mamma assumes an appearance 
similar to that of other acinous glands, as the salivary and lachrymal 
Fig. 5.-Artificially Injected Mammary Lobules of a Puerpera. X 70. (After Langer.) 
glands. I have not been able to find a separate investing membrane of 
the acini, though it has been mentioned by many authors. According to 
Langer each acinus is sharply defined by a fine nucleated fibrous net-work. 
This highly developed condition is that in which the gland is most fre- 
quently described. The developed nipple is very contractile; it contains a 
large number of muscular fibres, which belong only to the cutis not to the 
excretory ducts, and the muscular fibres of the skin in this region are gen- 
erally strengthened. According to Hennig, these muscular fibres extend 
also deep into the gland, so that they surround, in interrupted layers, 
not only the excretory ducts but also the single gland-lobules. 
The nipple is pierced by from twelve to fifteen excretory ducts, which 
are here so small that the finest bristle can scarcely penetrate them. The ANATOMY OF THE BREASTS. 
7 
small, previously-mentioned nodules of the areola, which, with the areola, 
are of a brown or brownish-black color during pregnancy, are small acin- 
Fig. 6, A.-Section through the Terminal Lobule of the Mammary Gland of a Nurse, 
with Injected Blood-Vessels. Hartnack Sy st. 1-8. (Langer.) 
Fig. 6, B.-Reticular Connective Tissue from the Parietal Wall of two Gland Lobules, 
Hartnack Syst. 1-9. (Langer.) 
Fig. 6, A. 
Fig. 6, B. 
Fig. 7.-Greatly enlarged Cross-section of a Milk-duct, surrounded by Bundles of Or- 
ganized Muscular Fibres, piercing the Nipple. (Luschka.) 
ous glands and are considered by most authors as sebaceous glands of the 
skin. Luschka believes that these so-called Montgomery's glands, as 8 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
shown by Duval, are important parts of the milk-glands (glandules lac- 
t if eroe aberrantes), which do not perforate 
the nipple, but end in the areola. Either 
view is sound if we regard all the lacteal 
glands as sebaceous glands. Hennig thinks 
that sexual intercourse, without resulting 
pregnancy, has more to do with the develop- 
ment of Montgomery's glands than with the 
size of the areola and the weight of the 
glands. 
During the lying-in period and during 
lactation, the mammary glands often attain 
considerable proportions, feeling very firm 
and extending to the axillary space. Before 
emptying into the nipple, the excretory ducts 
widen very considerably into the sinus lactei 
(Fig. 4). This dilatation occurs really first 
during milk-secretion, but afterwards un- 
dergoes only a slight retrogression. The 
milk itself is an emulsion of serum and fat, 
the latter originating in the epithelial cells 
of the glands. The appearance of the fat- 
globules in these cells is best observed at the 
beginning of the secretion of milk, and in 
the colostrum, the thin fluid which is poured 
out from the nipple during the first stage 
of glandular activity. The quality and quan- 
tity of the milk secretion are of the greatest 
interest to the obstetrician and physician, 
less so to the surgeon. On the cessation of 
lactation, the acini collapse, though they do 
not disappear, but persist without secreting, 
only to be again, during the next pregnancy, 
first filled with cells and later again with 
milk. The connective tissue of the gland 
remains relaxed, and is soon transformed 
into fatty tissue, but it does not again take 
on the firm hyaline condition seen in the 
virgin state of the gland. 
With the complete cessation of menstru- 
ation about the fiftieth year, at the time of 
the so-called involution, atrophy of the 
gland-tissue begins-that is to say, a withering of the glandular epithe- 
lium and collapse of the acini. Only the excretory ducts remain, though 
Fig. 8.-Milk-Duct from the Breast 
of an Old Woman, in which the whole 
glandular parenchyma was shrunken, 
with collapse of the ducts, which were 
filled with a greenish cloudy fluid and 
were in places varicose; only in one 
smaii branch were rudiments of wasted 
finer ducts to be seen, x 27. (Langer.) ANATOMY OF THE BREASTS. 
9 
their epithelium withers. At the lobular ends of the excretory ducts of 
old wom^n, we may often find the traces of the collapsed canals. (Fig. 8). 
The breast of an old woman consists, then, of nothing more than con- 
nective tissue with fat and these gland-canals. Whatever portion of the 
gland-substance disappears is at times so completely compensated for by 
the addition of adipose tissue, that the breasts of well-nourished old 
women often have a round form and do not appear at all atrophied, 
although there may be no glandular tissue remaining. In thin old women 
many thick elastic fibres are found scattered through the connective tissue. 
The capillaries are partly obliterated, but, what is more noteworthy, a 
great number of the lymph capillaries have disappeared (Langhans). Cystic 
dilatation of the milk-ducts, with the formation of a brownish or greenish 
thin or viscid secretion is very frequent in old women. Although these 
changes are not infrequently absent, I still regard them as regular and 
physiological. CHAPTER II. 
ABSENCE OF THE MAMMARY GLANDS (AMAZIA) AND 
SUPERNUMERARY MAMMARY GLANDS (POLYMAZIA). 
/CONGENITAL absence of a breast (Amazia, Birkett) has seldom been 
observed; in one case seen by Louisier, it was hereditary. Froriep and 
Schlozer saw congenital absence of the breast with coincident absence of 
the greater portion of the pectoralis major muscle and a union of the 
third and fourth ribs with the sternum. An infantile appearance of both 
mammary glands has been observed by Pears and Cooper, Caillot and 
Laycock, usually with coincident absence or incomplete formation of the 
ovaries. 
More frequently there are more than two breasts (Polymazia, Meckel; 
Pleiomazia, Birkett). Sometimes this is only apparent, there being two 
or more nipples (Polythelia, nipple) in different places on one breast. 
According to Meckel von Hemsbach there are originally in man five 
mammary glands (as is the case in the bat), two at the centre of the 
thorax, which alone go on to development; two in the axillary spaces, and 
a median one above the umbilicus and immediately under the sternum.. 
Gorre saw all these five breasts developed in a woman and Sanderson saw 
five nipples in these different situations in a man. Four mammae have 
been observed by Cooper, Lee, Shannon, Champion and Gardner. Dreger, 
Bartolin, Hannasus, Borle and M. Jussieu saw three mammae on a woman. 
Robert reports the case of a woman whose mother had had a double 
nipple, and she herself had a supernumerary milk-giving mamma on the 
outer surface of the left thigh. This case is scarcely to be explained by 
developmental history or by comparative anatomy. Those cases where 
in cows an udder on the back is found in connection with supernumerary 
extremities, are without doubt to be placed in the category of double 
malformations. 
Leichtenstern, through his very careful investigations of such cases 
as have been reported, as well as by a series of cases seen by himself, has 
proved that the situation of these supernumerary breasts, (including the 
cases seen in the male sex,) is far more constant than has been thought. 
The reported cases of supernumerary breasts in the median line of the 
abdomen, on the acromion, and on the upper part of the thigh are very 
rare, and in part unique. Most supernumerary glands are situated AMAZIA AND POLYMAZIA. 
11 
below and somewhat internal to the normal situation, and very rarely in 
the axillary space. It is in the highest degree probable that these anoma- 
lies are to be regarded as a reversion to other and lower types of animals, 
which normally have several mammae, in fact, as a kind of atavism (Dar- 
win), even though Meckel's opinion, that man originally had five breasts, 
would not be further confirmed thereby. Supernumerary breasts should 
only be removed when, on account of their situation or size, they become 
troublesome, or when the nipple is impermeable, and a lactiferous cyst is 
thereby developed, as in a case of Hares. There seems to be no relation 
between these anomalies and later diseases of the breast. I have, in all 
my observations, seen only one case in which a tumor (acinous carcinoma) 
has developed in a breast with two nipples. Precocious development of 
the breasts accompanies too early development of the sexual organs. 
Kussmaul (Wiizburger, Med. Zeits., Bd. II., p. 321) has collected these 
cases and critically examined them. CHAPTER III. 
DISEASES OF THE NIPPLE AND AREOLA. 
TURING lactation the formation of fissures of the nipple is very fre- 
quent. When the cliild in nursing wounds the nipple, especially 
at its base, and the mother, despite the intense pain, continues to 
nurse the child without taking necessary precautions, deep, penetrating, 
chink-like ulcers are formed. In such cases nursing from the injured 
breast must cease entirely, or a nipple-shield must be used. As prophy- 
lactic against such wounds, the nipples should be washed with cold water, 
with astringent solutions or with alcoholic washes. For an already ex- 
isting fissure, touching it with lunar caustic, although very painful, is 
one of the best remedies; applications of lead-water, of weak solutions of 
nitrate of silver, etc., may be used. Repeated washing of the fissure with 
a 5# solution of carbolic acid is also to be recommended. Of course any 
application must be carefully washed off before the child is again put to 
the breast. 
Further practical rules regarding remedies to be used in the disturb- 
ances of lactation are to be found in works on midwifery. Especially 
comprehensive is the treatment of puerperal inflammations of the nipple 
given by Winckel. 
Inflammatory softening of the nipple, with ulceration and fungus 
granulations, which may also be due to nursing, are to be treated by appli- 
cations of lunar caustic and astringent fomentations. Aphthous disease of 
the oral mucous membrane of the child is not infrequently the cause of ul- 
cerative processes on the nipple of the mother or nurse. While there are 
many kinds of Schizomycetes (Vibrio, Bacterium, Leptothrix, Coccus and 
Straptcoccus) in the child's mouth and on unclean nipples, according to 
Haussmann, the Soor-pitz (oidium albicans, probably identical with oidium 
lactis) which can be planted alternately from the mouth of the child to 
the nipple, and vice versa, is capable in either place of provoking inflam- 
mation. Syphilitic ulcers also occur on the nipples, primary as well as 
secondary', the latter in the form of broad condylomata. General as well 
as local antisyphilitic treatment must be instituted, and lactation must 
be absolutely forbidden, when such ulcers are found on a nursing woman. 
The nipple and areola are sometimes attacked by chronic eczema, the 
cause of which may be uncleanliness, though in most cases this is un- DISEASES OF THE NIPPLE AND AREOLA. 
13 
known. This eczema of the nipple, which is not infrequently bi-lateral, 
is very obstinate to treatment; the remedies used may have to be changed 
frequently before a cure is effected. Local measures alone seem to be 
effectual. Careful and repeated ablutions of cold water are often suffi- 
cient, but when the young epithelium is regenerated, it must be protected 
for a long time with fat (glycerine, oil, cerate), or a relapse will occur. 
Astringent salves, especially of zinc, lead and white precipitate, best 
made with starch and glycerin, are of benefit, especially when the crusts 
have been carefully softened and removed. At times, every kind of 
moisture is harmful, and good results are obtained by the careful dusting 
of the parts with zinc-powder (white oxide of zinc with an equal amount 
of starch). More severe measures, such as the use of soaps, tar, etc., 
which are very useful in other torpid forms of chronic eczemas, are of no 
avail in the treatment of eczema of the nipples. 
Tumors of the nipple and areola are very rare; slowly developing epi- 
thelial carcinoma has been observed. Russel and Lebert have seen 
atheroma of the areola, which was probably developed from the areolar 
glands. CHAPTER IV. 
WOUNDS OF THE MAMMAE.-SPONTANEOUS HEMORRHAGE 
AND CONGESTION.-ERYSIPELAS. 
I NCISED, penetrating, crushing and shot wounds of the breast offer 
1 nothing especially interesting. On account of the toughness and 
elasticity of the tissue, a blunt instrument must strike with enor- 
mous force before it can produce a wound, and even then the injury to 
the ribs and lungs will be of much more importance than the wound of 
the mamma. 
Burns of the skin covering the breast and nipple are more frequent, 
partly from the pouring over the body of hot fluids, partly from burning 
of the clothing. The general treatment of burns is applicable to these 
cases. 
The nipple may be entirely destroyed or obliterated by cicatricial 
changes following burns, as well as by ulcerative processes. These cases 
have hitherto been so seldom observed, that we have no experience as to 
what would occur in such a breast, the glandular tissue of which may be 
entirely normal, in case pregnancy should supervene. It is probable that 
such a gland would at first secrete milk, but as there could be no excre- 
tion, the secretion would either cease and the gland subsequently atrophy, 
or suppuration would occur, with the formation of numerous abscesses; 
at least this is the case in other acinous glands, as the parotid after liga- 
tion of Steno's duct. Operative measures would avail nothing, since, even 
if, by removal of the remains of the nipple, the mouths of the ducts could 
be again opened, they are so small that they would not remain patent. 
Kicks on and bruises of the breasts occur frequently, but are usually 
of no immediate consequence. Sometimes they cause subcutaneous and 
intraglandular hemorrhages, which run the same course as in other 
regions of the body, being usually absorbed spontaneously. If the blow 
was a severe one, inflammation and subsequent abscess may result. If 
the extravasation has formed a cavity, it may be encapsulated and trans- 
formed into a cyst or fibrous tumor, which may be a long time in dis- 
appearing. 
Extravasations of blood into the mammae also occur without external 
wounds, especially in girls and young women subject to dysmenorrhoea 
and amenorrhoea; this has been observed by Cooper, Velpeau and Birkett, WOUNDS OF THE MAMMAE. 
15 
and is doubtless a so-called vicarious menstruation, though not so frequent 
as in other parts of the body. Such extravasations are usually absorbed, 
without further consequences; they are generally entirely painless, but 
are, in a few cases, accompanied by a feeling of tension in the breasts. 
Applications of lead-water, infusion of camomile, etc., may be ordered 
if medicinal treatment be desired. If the hemorrhage is more severe and 
causes great pain, a light compress is the most rational means of afford- 
ing relief. 
Dentu and Verneuil describe cases of sudden swelling of the mam- 
mary glands, with induration (engorgement, sclereme pklegmasique tem- 
poraire), which occur in old women, and disappear after a few weeks or 
months; some of these women had arthritis. 
When erysipelas ambulans attacks the breast, the diagnosis is easily 
made. An erysipelatous rash, primarily originating on the mamma, 
may spread from fissures in the nipple, as to the nature of which there 
may be at first some doubt. Great sensitiveness to superficial touch, sharp 
limits of the rash, slight tension of the glandular mass with a high eruptive- 
fever will make the diagnosis in one or two days. Infection of wounds of 
the nipple, especially in lying-in houses, through unclean matters from 
the mouth of the child, by aphtha?, are tbe most frequent causes; so also 
fright, digestive troubles and cold. The treatment of true erysipelas of 
the mammae is that of the disease generally. Nursing should be pro- 
hibited, as in so severe a disease the secretion of milk will be interrupted 
at all events the milk of an erysipelatous woman may be injurious to the 
child. CHAPTER V. 
PUERPERAL MASTITIS. 
/AN practical grounds we may consider the acute mastitis occurring 
v-'/ during the puerperium as a separate affection, though there is no 
doubt that the anatomical processes in mastitis are always the same, 
at whatever time the disease occurs. Acute mastitis occurs so very fre- 
quently during the puerperium that the affection under other conditions 
is relatively rare. Of seventy-two cases observed by Nunn, fi^ty-eight 
occurred during lactation, seven during pregnancy, and seven separate 
from these conditions. Bryant saw seventy-nine cases during the puer- 
perium, two during pregnancy and twenty-one outside of these condi- 
tions. I have seen in all fifty-six cases (almost all in my clinic on account 
of abscesses); in forty-four cases the affection had developed during lac- 
tation (usually unilateral, bilateral in a few cases), in four cases during 
pregnancy, and in six cases in unmarried or married, but non-pregnant 
or non-suckling, women. 
There are not statistics to show whether mastitis is more prevalent in 
lying-in houses than in private houses. Winckel writes, as follows, as 
regards the frequency of puerperal mastitis, in the Dresden Lying-in 
Institute: 
" Of 2300 nursing women, of whom 918 were suffering from disease 
of the breasts, I found 136 cases of parenchymatous mastitis; i.e., 6 per 
cent, of all the nursing women and nearly 15 per cent, of all suffering 
from affections of the breast; of those affected with mastitis, there were as 
many blondes as brunettes." Primiparae are more disposed to mastitis 
than multiparae. Winckel found the following proportions: Primiparae 
67.6 per cent.; Multiparae 39.9 per cent.; Multiparse, with rapidly re- 
curring pregnancies, 1.5 per cent. Mastitis is more frequent among 
suckling than among non-suckling women; thus: Ed. Martin in 150 cases, 
only 8 oi' 10, Winckel in 60 cases, only 1, in which the patient suffering 
from mastitis was not nursing. 
Puerperal mastitis is more frequent on the right than on the left side, 
and is very seldom bi-lateral. By summing up the cases in the table 
given by Hennig of mastitis and abscess, we find 156 cases of the right 
gland, 131 of the left and 37 bi-lateral. Winckel noticed in 141 cases, 
50 of the right, 68 of the left, and 23 of both glands. Bryant saw 55 cases PUERPERAL .MASTITIS. 
17 
of the right, 30 of the left, and 5 of both glands. The statistics of these 
three give: 261 of the right, 192 of the left, and 65 of both glands. As 
a rule, only part of the gland is affected, and most frequently the lower 
and the lower external part. Of 154 cases seen by Winckel, 
The inner part of the gland was affected. 
. 4 times. 
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upper outer 
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upper 
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upper inner 
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lower outer 
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lower inner 
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154 
The same result is shown by the smaller statistics of Nunn. Mastitis 
usually begins during the first four weeks after labor, and as a rule in 
the second half of this period (Bryant, Nunn, Winckel). Mastitis very 
frequently arises from lesions of the nipples caused by nursing. Accord- 
ing to Winckel, mastitis sometimes appears within the first twelve hours 
after the injury to the nipple, but more frequently within the first week, 
and most frequently on the third or fourth day after it. 
Etiology.-It was formerly thought that emotional disturbances, colds, 
blows and pressure most frequently caused puerperal mastitis, and these 
causes are at all events worthy of consideration in typical cases; of more 
consideration is the view that the irritable breast of puerperal women may 
be the result of milk stasis in certain parts of the gland. I will not deny 
that this may occur; from some unknown cause, the milk may coagulate 
in certain excretory ducts, causing an obstruction by which stasis of milk 
and inflammation around the tensely distended lobules may result; or, 
in consequence of greater laxity of the muscular tissue, or of incomplete 
emptying of the organ by the child, a great deal of milk may remain in 
certain cases and the circulation in the gland be interfered with. Still, 
when we so often see the women, in whom, for some reason, nursing has 
been interrupted, have no abscesses or inflammation - cases in which 
there is only firm tension, and then absorption of the retained milk-it 
seems doubtful whether retention of milk is so often the cause of acute 
inflammation as has been supposed. I believe therefore that Roser is 
entirely right when he maintains that the retention of milk is not the 
cause but the result of the inflammation, since the excretory ducts of 
some lobules are displaced by the inflammatory swelling. Most obstetri- 
cians are now inclined to this view, and regard puerperal mastitis as being 
in direct relationship to disease of the nipples. 
From the above statistics it is easily seen that nursing, especially by 18 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
primiparae, is an important factor in the causation of mastitis; further- 
more, that affections of the nipples, which are also especially frequent in 
primiparae, very frequently precede inflammation of the gland. Modern 
pathology admits that simple congestion, particularly pure passive hyper- 
aemia, is only exceptionally the direct cause of inflammation; it demands 
that there should be a particular irritant for the real inflammatory hyper- 
aemia, which plays such an important part in the tissue changes during 
inflammation. In all probability the same irritant is transmitted through 
the nipple to the interior of the gland, and consists of bodies which enter 
the lymphatics through the excoriated spot on the nipple and thence into 
the tissue, or which gain access to the latter through certain changes 
within the milk ducts, and from these to the deeper portions of the gland. 
The second view is less probable, because it can hardly be shown how 
bodies without active movements (such movements are not to be attributed 
to bacterium spores) can overcome the force of the current of the secre- 
tion. The view that bacteria, which so change the milk that it acts as 
an irritant to the surrounding tissue, need only to enter the ducts of the 
nipple to act from thence as a ferment on the milk, is certainly not proven, 
although it cannot be dismissed. As regards the parotitis of typhus fever 
(and the same is true of mumps) Virchow has asserted that the inflamma- 
tory irritant enters the gland from the mouth; this is always the most 
plausible hypothesis in regard to the causation of these diseases. The 
anatomical studies of puerperal mastitis, which I here offer, seem to sub- 
stantiate this view, although the appearances can be differently interpreted. 
Anatomy.-Hitherto no one has had the opportunity of observing 
histologically the first onset of a puerperal mastitis; but from clinical ob- 
servations of this process it is known that the gland is never affected at 
once in toto (as usually appears to be the case in parotitis), but that in- 
flammatory foci are formed in the gland, which may remain separate, but 
which as a rule gradually coalesce, and suppurate together. These foci 
may be considered partly as non-escaping milk, surrounded by inflamed 
tissue, partly as suppurating inflammatory foci, situated in the connec- 
tive tissue between the acini. Clear histological descriptions of this 
process have not, so far as I know, been given either before or since my 
work on this subject. Most frequently the observations of Kolb are 
cited. He says: "The affected parts seem hard, and usually form nodular 
tumors, section of which shows them to be distended with milk; the 
glandular tissue is hyperaemic and very succulent. In the acini, small 
extravasations of blood, the size of a pin's head, may be seen. As a rule, 
suppuration occurs early, and appears to me, indeed, to be a connective 
tissue suppuration; at least I could not discover anything in such cases 
which would indicate an epithelial suppuration. Pus appears at first in 
the acini, partly fluid, partly not, and as it seems to me most frequently 
with fibrous intercellular substance, so that we find in the grouped acini PUERPERAL MASTITIS. 
19 
heaps of yellowish, fibrinous plugs, analogous to those found in croupous 
pneumonia. Destruction soon overtakes the finer inter-acinous tissue, 
the small purulent foci coalesce, forming larger ones, the pus becomes 
fluid and the true mammary abscess is formed. The cavity of this abscess 
Fig. 9.-Suppurating Puerperal Mastitis. Hartnack Syst. 4. 
never has a smooth wall, but the membrane is rough, and not infre- 
quently nodular, and ragged particles of broken-down gland tissue are 
found projecting from it." 
This description agrees exactly with what I have seen in such abscesses 
during life, and in the examination of persons who died of puerperal fever 20 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
while having mastitis. I can, however, add something more accurate 
as to the histological processes in such cases. It may be seen in Fig. 9 
that the acini are all more or less surrounded and in part completely 
covered by a small-cell (inflammatory) infiltration; but the epithelium 
seems to take absolutely no part in the cell-formation. It is difficult to 
see, with greater enlargement even, what becomes of it, though finally it 
seems to break down with the walls of the gland lobules, and the infil- 
trated interstitial substance. At a, in the lower part of the figure, the 
pus, with the tissue detritus at the centre of the abscess, has disappeared 
from the preparation. It at first seems strange that here, in com- 
parison with Fig. 6, the acini are very small and milkless, and that 
in the fresh state the soft succulent interstitial tissue is so enormously 
developed. I cannot say how long after confinement the woman, from 
whom this preparation was taken, died, or how long she had nursed her 
child; still it is certain that it was more than a week, or the preparation 
would have appeared very different. Obviously the secretion of milk had 
ceased for some time, as the gland is already in a state of puerperal in- 
volution. It is very noticeable that only the immediate surroundings of 
the gland-lobules are infiltrated and that the very abundant interstitial 
tissue is not infiltrated. Finally, perhaps, another section of the gland 
would have shown gland-lobules completely normal. 
From this and many other similar representations, it is seen that the 
inflammatory irritant must proceed from the acini themselves, or from 
their immediate surroundings. The first view seems at first sight to be 
the most plausible, and agrees also with what has already been said. But, 
anatomically, it is not the only possible one, as may be seen from the 
following experiment. I produced suppuration by drawing through the 
moderately developed mamma of a non-nursing bitch, a white cotton 
string about .39 inches wide, and killed the animal a few days later. The 
inflammatory infiltration had not extended far around the string; it was 
not diffusely distributed in the inter-lobular connective tissue, as in a 
phlegmon, but surrounded the gland-lobules as in puerperal mastitis. 
This shows that there are channels of dissemination for inflammatory 
processes, which follow the ramifications of the gland; these can only be 
the blood and lymph-vessels, which surround the ducts and lobules. I 
might maintain that it is most probable that the irritative material is dis- 
tributed with the lymph through the gland, and thence acts upon the 
capillary net-work around the lobules, that the leucocytes emigrate an 1 
produce the purulent infiltration of the tissue immediately surrounding 
the lobules and their acini. As to whether the pus cells are formed more 
from themselves or from the connective tissue cells of the interstitial 
tissue, I cannot say. At all events, capillary stasis, thrombosis and 
necrosis of the tissue result, so far as this is not already the subject of cell 
infiltration. As regards the "fibrinous purulent" plugs, which Klob PUERPERAL MASTITIS. 
21 
found in the small abscesses of purulent lobules, I would prefer to look 
upon these as necrotic glandular and connective tissue. One may easily 
observe this change in suppuration of the subcutaneous tissue. I have 
not been able to convince myself of the formation of fibrin in mastitis, at 
least in the cases I have carefully examined, and would prefer therefore 
Fig. 10.-Groups of Micrococci in the Vessels around the Acini of a Hypertrophic Mam- 
ma attacked by Erysipelas. Hartnack Syst. 8. 
not to accept too readily the comparison with the finer processes of 
croupous pneumonia, which I have carefully studied. Further researches 
are necessary to prove that the process described by me in the tissue in 
puerperal mastitis is constant. These researches are now of new in- 
terest, as there is such a growing inclination to attribute all such infec- 
tious suppurations to the growth of micrococci. 
Ehrlick and I (Arch. f. KI. Chir., Bd. XX., p. 418) have shown the pres- 22 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
ence of enormous masses of coccus-vegetations in a hypertrophic mamma, 
which was attacked by erysipelas. I cite the short communication: " A 
third case occurred in a young girl with enormously hypertrophied breasts. 
A reduction of their mass was attempted by compression with elastic 
bandages; this had some effect, but soon the breasts became painful, and 
from some excoriated points there was developed a phlegmonous erysipe- 
las, which carried off the patient in a few days. In order to investigate 
the hypertrophic mammae, at first without reference to the erysipelas,pieces 
of the breast were removed and preserved in Muller's fluid. The large 
number of cocci contained in the diseased organs was an entirely accidental 
discovery. Many of the blood-vessels surrounding the enlarged acini 
were so densely filled with these balls of cocci, that it seemed as if a very 
large artificial gelatine-injection had been made. Here and there in the 
tissue cocci were found, but sparsely. The tissue surrounding the ves- 
sels containing the cocci was entirely unchanged. Unfortunately none 
of the skin covering the mammae was preserved, so that nothing can be 
said as to whether it contained cocci or not in this case." 
At the time these investigations were made, Langhans's work on the 
lymphatic vessels of the mammae was not known, or else it would have 
appeared probable to us then that these canals around the acini, in 
which the coccus-balls lay, were dilated lymphatics. It is plausible, 
however, from other researches, that there are occasions when a consid- 
erable time elapses before a coccus-invasion causes inflammation and sup- 
puration. It is even maintained by many that this follows only in an 
indirect way, that the contact of the coccus with the tissue acts much 
more directly and deleteriously upon it, that it immediately causes death, 
necrosis, and the suppuration is the result of the necrosis. I remember 
very clearly that the mammary tissue of a patient, which was studded with 
adeno-fibromata, was remarkably red, with here and there, perhaps, a 
yellow spot, as if of purulent infiltration, but at no place was there an 
abscess. Although there was no puerperal mastitis in this case, and al- 
though, at all events, the lactiferous ducts had not determined the 
direction of the inflammation, yet in this case also, the immediate sur- 
roundings of the lobules were the centre of the coccus vegetations, which, 
as in puerperal mastitis, would have caused abscesses with necrosis of the 
lobules. 
Besides the typical form of " parenchymatous puerperal mastitis," which 
has been described, there remains the " puerperal paramastitis," a phleg- 
mon which may develop partly upon the gland, partly behind it. The 
phlegmonous processes on the anterior surface of the gland arise usually 
around Montgomery's glands in the areola, and spread over the whole 
areola. Such subcutaneous cellular-tissue abscesses seldom arise in the 
peripheral portions of the mammae; these processes seldom spread, but 
rapidly form small abscesses at their point of origin. This form of para- PUERPERAL MASTITIS. 
23 
mastitis occasionally developes outside of the puerperal state, sometimes as 
a result of a deep-seated erysipelas ambulans. 
As regards the inflammation of the cellular tissue posterior to the 
mamma, it probably occurs only during the puerperium. In my experi- 
ence these cases always result in abscess of the deep-seated portions of 
the gland. The pus breaks through the fascia-like connective tissue of 
the gland into the loose cellular tissue, which separates the gland from 
the pectoralis major muscle, and spreads out here in all directions to such 
an extent as to lift it from the thorax; it seeks an exit at the periphery 
of the gland or is let out here, by an incision. Whether a " primary re- 
tro-mastitis " ever occurs without a coincident parenchymatous mastitis, 
I cannot say. I have seen in men very large acute abscesses upon and 
under the pectoralis major muscle, for which there was no known cause, 
and it is possible that the same thing may occur in women. 
Whether a mastitis arising during a puerperal fever is of a metastatic 
nature (whether it is to be placed on a parallel with abscesses, as they 
sometimes occur in other organs and in the cellular tissue in pyaemia,) is 
hard to say. There seems to be no doubt, though, that a very extensive 
suppurating mastitis may lead to pyaemia; it would not appear strange, 
reasoning from other observations, if slight cases of puerperal diseases of 
the genitals, which usually heal without difficulty, should, under the in- 
fluence of a pyaemia caused by mastitis, go on to marked suppuration; 
under these circumstances it would be difficult to decide which of the 
purulent foci found on section was the primarily infecting and which the 
infected. Hennig mentions a case of metastatic mastitis occurring in 
the course of typhus fever after a preceding parotitis. 
Symptoms, Course and Prognosis.-The commencement of a mastitis 
first manifests itself by pain in the breast; this pain is at first limited to 
a certain part of the breast, is increased by movement of the affected 
part of the gland, by dependence of the gland and by the act of nursing. 
Palpation of the painful part, if the inflammation be not too deep-seated, 
reveals a hardness and a more or less sharply defined nodule, which en- 
larges in the course of a few days. The affection frequently begins with 
a very high fever; often with a chill. With the formation of an abscess 
and the evacuation of the pus, the fever subsides completely if the pro- 
cess terminates here. As in many cases, however, the inflammation passes 
from one lobule to another, the fever exacerbates and indicates here, as in 
other cases, whether the inflammatory process in the diseased organ has 
ceased or not. 
The different forms of puerperal mastitis may be entirely dissipated by 
early and judicious treatment. More frequently, however, abscesses 
form, either upon or in the gland, according to the seat of the inflamma- 
tion. Redness and circumscribed fluctuation soon appear in simple 
phlegmon of the mamma; in abscess posterior to the gland, a fluctuating 24 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
tumor appears at some point in the circumferenoe of the gland, usually 
below and to the outer side. In inflammation in the gland several ab- 
scesses are usually formed, one near the other, in succession, which either 
empty into one another in the interior of the gland, thus forming sinu- 
ous suppurating cavities, or they open through the skin at different points. 
As in other inflammations, large or small fragments of gland tissue may 
be thrown off. The spontaneous openings through the skin are usually 
very small, and are a long time in occurring; their course is therefore a 
very painful one. The prognosis as regards life is seldom of great mo- 
ment; only in very weak, tuberculous women can an acute inflammatory 
process of a week's duration be considered dangerous, partly from the 
drain occasioned by the formation of pus, and partly through its exciting 
a fresh tuberculous outbreak in the lungs. Rupture of a retro-mammary 
abscess into the pleural cavity is exceedingly rare. These cases often hang 
on for a long time, not only because of the formation of new abscesses, 
but because the old ones will not close; fistulas remain, the treatment of 
which will be spoken of later. Since two of the fifty-six cases of puerperal 
mastitis treated at my clinic died, it is proper to state that one had 
thrombosis of both femoral veins when she was admitted, and the other 
died of an erysipelas ambulans contracted at the clinic. In neither case, 
therefore, was the mastitis the direct cause of death. 
The treatment of acute inflammation of the breasts in child-bed con- 
sists in ordering rest in bed, and antiphlogistic diet so long as the patient 
has any fever. The breast should be bandaged secundum artem, and lightly 
pressed against the thorax. Whether nursing should continue in such 
cases depends upon the situation and extent of the inflammation. In 
abscesses antero-posterior to the gland, the milk may be normal in 
quality, although smaller in quantity. If it be not too painful, nursing 
may be countenanced or even recommended, if the gland becomes so dis- 
tended as to increase the pain. If, however, the inflammation be seated 
in the gland itself, nursing had best be abandoned, at least from the 
affected breast; should the gland become very much distended, it may 
be emptied with the breast-pump. If nursing be carried on with the 
affected breast, we can only apply almond oil, and warm cataplasms to 
allay the intense pain and to hasten the formation of the abscess, or else 
use wadding. If lactation be interrupted, we may apply gray mercurial 
ointment or iodine ointment. In England there is a preference for bella- 
donna. Leeching is not to be recommended; it only mitigates the pain 
temporarily and often irritates the skin very much. The application of 
an ice-bag to the affected breasts may, under certain conditions, be tried, 
but it is seldom tolerated by the patient, and may give her a serious cold. 
In order to rapidly arrest the secretion of milk, we usually employ cathar- 
tics (ol. ricini, magnes. sulph., sod. sulph., or small doses of calomel) and 
seldom fail in our efforts; the internal administration of potassic iodide PUEKPEKAL MASTITIS. 
25 
is also highly recommended to quickly arrest the secretion of milk. 
Massage of the breast, practised by many midwives for this purpose, is 
very painful, may increase the inflammatory process and is feared by 
many women, because they believe it makes the breasts ever afterward 
flabby and dependent. Winckel states that in the Dresden Lying-in 
Institute, out of one hundred and thiry-six cases of puerperal mastitis, 
ninety-one (67 per cent.) recovered by absorption. 
Velpeau says that the antero- and retro-mammary abscesses should be 
opened early, that of the gland itself never. The first recommendation 
is certainly right, and usually relieves the patient greatly; we may often 
evacuate enormous quantities of pus from the abscesses posterior to the 
gland; the spontaneous openings are usually too small to allow of a proper 
escape of pus and rapid healing of the abscess. We may also open the 
abscesses in the gland, when the pus is close under the surface of the 
skin, but not earlier. The opening should always be made with the knife, 
as I can see no advantage in using any of the pastes in these cases, and 
the small hole made by a trocar is not sufficient. In rare cases, abscesses 
of the mammae contain a foul-smelling pus mixed with gas, without any 
communication with the pleural cavity; the causes of this are unknown. 
Velpeau reports a few such cases. I have found on opening these ab- 
scesses that the pus is always odorless; later, when suppuration has lasted 
for some time, the secretion has a sour smell. This decomposition of 
pus we can now avoid by careful antiseptic treatment. This method 
seems also to have a marked influence on the course, and at times on the 
spread of the affection, and the suffering patient is certainly spared a 
great deal of pain by it. Recent experiences have proven the good results 
of these methods, and I cannot too strongly advise that every physician 
make himself acquainted with them. The breast is at first carefully 
cleansed with soap, and then with a weak carbolic acid or thymol solution. 
The incision should be made in the direction of the radius of the gland, 
about .39 inches long, and down to the pus focus, and must be immedi- 
ately followed by the insertion of a drainage tube, which is kept from 
slipping in by a safety-pin. Gentle pressure is then made upon the gland, 
so as to force the pus out through the drainage tube; the breast is again 
washed with some disinfecting solution, the patient being in the recum- 
bent position; the whole breast is covered in with Lister-gauze, waterproof 
dressings over this, and then over all, especially below and towards the 
axilla, is placed a large quantity of salicyl-jute, and the whole dressing 
is then fastened with a bandage extending over the entire thorax from the 
neck to the umbilicus. The surgeon should not neglect to place wadding 
over the nipple of the sound breast, and to place sufficient wadding under 
the breast, so that it will not come in contact with the thorax. A quan- 
tity of wadding must also be placed in the axilla on the unaffected side. 
When the dressing has been completed by a gauze bandage, a jacket of 26 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
oil-silk is placed over it. If the abscess is very large and sinuous, it is 
well to renew the bandage after the lapse of twenty-four hours, and then 
to allow the second bandage to remain on from three to five days; but if 
the abscess is not very large, the first bandage may remain on for several 
days. The minute details of this dressing will not be regretted, when the 
interests of the patient are considered. The rest given to the inflamed 
organ, th., even compression, the prevention of pus-decomposition, the 
complete emptying of the pus through the drainage tube, the excellent 
absorption of the pus by the Lister-gauze, all these contribute to a pain- 
less and easy course, and lead to a relatively early healing even in severe 
cases. If, after the first or second dressing, no more pus is drained away, 
the dressing should be again renewed as before, allowed to remain three 
or four days, and after its removal the abscess will be found to be almost 
entirely healed. A deviation from this method is only allowable when 
there is a renewal of the fever and pain under the dressing; the dressing 
must then be taken off, and, in all probability, another superficial abscess 
will be found, which must be opened and drained. This may occur 
again and again, though there can never be such destruction of the gland 
as under the old expectant and timid measures, by which the patients 
suffered unspeakably, and the process continued for months, until it was 
finally necessary to make large incisions and break down all partitions 
between the abscesses, in order to bring the matter to a favorable con- 
clusion, by which means the gland was usually destroyed for the greater 
part and disfigured by cicatrices. 
In cases which come under treatment early and in which the abscess has 
been opened, the abscess cavity should never be injected with strong 
irritating solutions, for, in puerperal mastitis, the pus is rarely ever de- 
composed ; consequently there is nothing to disinfect or deodorize. It is 
different, however, in those cases in which there is already a spontaneous 
opening, or in which insufficient incisions have been made without anti- 
septic precautions; in these cases, the pus has already become acid, and 
has acquired irritating qualities through the lactic or butyric acid which 
it contains. These cases can be treated more conservatively than was 
formerly possible, when nothing more could be done than to make large 
radial incisions. We operate, as described before, but dilate the opening 
to about 1 inch, so that the finger, and with it the nozzle of an irrigating 
tube can be introduced: the cavities are now washed out with a three per 
cent, solution of carbolic acid until the solution returns tolerably clear; 
then the thin walls between the abscesses are broken down so that they all 
communicate one with another, the pus and the carbolic acid solution are 
expressed, and large drainage tubes are placed in the different openings. 
The whole is then dressed as advised above, and in these cases we may also 
attain most striking and rapid results. It is scarcely necessary to say 
that an anaesthetic is required in such cases. PUERPERAL .MASTITIS. 
27 
It is by no means always the fault of the physician when such cases 
of apparently neglected mastitis fall into the hands of the clinical surgeon. 
Women resent, for various reasons, the interference of the physician in 
cases of mastitis. In the first place most women of the poorer and mid- 
dle classes wish to nurse their children a*s long as possible, on the one 
hand, so as not to have to buy food, for milk is dear at times in large 
cities, and difficult to obtain in good quality; on the other hand, and this 
is the chief reason, they do not wish to become pregnant again so soon. 
Many women are not willing to use any means which will interfere with 
the secretion of milk, and, in spite of the physician's orders, they will 
continue to nurse the child from the affected breast, suffering the most 
intense pain, with the idea that the inflammation has been caused by 
milk-stasis and that it will disappear if the milk is withdrawn. Among 
the better classes there are still other reasons for the avoidance of the 
knife; the women believe that the cicatrix from a spontaneously opened 
abscess will be less noticeable than that from a knife. Young women, es- 
pecially, fear cicatrices on the upper half of the breast, since they will 
be visible with low-cut dresses. Finally, as in all cases of suppuration, 
the patients dread the pain of the incision, more so because they have 
become unusually sensitive on account t f the pain of the inflammation. 
Since also there are many patients (and many physicians) who dread 
anaesthesia, and since in the country it is difficult for the physician to 
make a daily visit to assure and advise the patient, the reasons for non- 
surgical treatment are so numerous that we cannot wonder at its non- 
employment. But it is culpable in the physician to repeatedly irritate 
and torment these patients with small incisions, which, without drainage 
and antiseptic compression bandaging, are of no more use than sponta- 
neous openings; and we cannot wonder that after six or eight such 
" operations," these women lose all faith in their physician. 
Sequels of Mastitis. 
After every acute or chronic abscess of the breast, fistulas may remain. 
The immediate causes of these fistulas are faulty escape of pus on account 
of a too narrow opening or valvular closure of the same, fungous or un- 
healthy granulations in the abscess cavity; anaemia, great general weak- 
ness and general diathetic conditions are the remote causes. Fistulas of 
the mammae usually discharge thin pus, seldom milk, and, as a rule, lead 
to sinus-cavities in or behind the gland. When of long duration, ab- 
scesses behind the breast may lead to suppuration of the pectoralis major 
muscle and of the periosteum of the ribs, and even to suppuration of the 
intercostal muscles and the pleura; the last, however, is very rare, and in 
such cases there would be pleural adhesions from the purulent process 
and pneumothorax would result. Long duration of these fistula? weaken 28 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
the patients very much; they become emaciated, often have a remittent 
fever, night-sweats, loss of appetite, become exceedingly irritable and are 
mentally depressed. If nothing unusual happens, the process may go on 
for months. If such patients are disposed to pulmonary tuberculosis, 
it may seize this opportunity to develop rapidly. 
As regards the treatment of such fistulas, it is usual to first cauterize 
with nitrate of silver and then to make injections of diluted or concen- 
trated tincture of iodine, carbolic acid solutions, etc. Many of these fis- 
tula? may be cured by inserting drainage tubes and using coincident 
compression. It seldom happens that in otherwise healthy women, all 
these measures fail to effect a cure; in many of the cases which have 
come to my clinic, the fistulas had existed unchanged more than a year, 
without there being any caries of the ribs, as is so much feared in these 
cases. The reason that such fistula? do not heal is, in my opinion, a 
purely mechanical one; the thickened abscess-wall, which is bound to 
the wall of the thorax, can only slowly contract and. shrink. In all the 
cases of long-existing fistula? of this kind observed by me, the reason for 
their existence was always found in abscess-cavities, which lay, for the 
most part, behind the mamma. The sluggish fungous granulations of all 
such cavities show no inclination to grow together; their secreting sur- 
faces are covered usually with a thin layer of epithelium, which never cor- 
nifies, though its epithelial character is evident, since the cells never 
coalesce and there is no vascular connection between them. When such 
abscesses heal, it is only through shrinking of the walls; but such shrink- 
age is difficult on the unyielding chest-wall, on the anterior surface of 
the pectoralis major muscle, and the abscess remains for a long time in the 
condition of one or several indurated fistulae. 
Formerly in such cases I made very large incisions in the periphery of 
the gland, following its circumference, so that the under surface of it 
had sufficient play to contract. But a long time was required for healing 
unless the whole cavity was so intensely irritated by such remedies as liq. 
ferri, turpentine, etc., that the old granulations were thrown off and 
new ones were formed. In two cases which I treated about a year ago, 
I split the fistulas so extensively that the abscess cavities could be seen to 
advantage; then I scraped out the granulations with a sharp spoon as 
completely as possible, excised the fistulous opening in the skin, washed 
the cavity for a long time with a three per cent, solution of carbolic acid, 
sutured the incision in which I had placed a drainage tube, then placed 
over the whole a compressing antiseptic dressing, which remained for 
five days. At the end of this time, the drainage tube was removed, a 
second dressing applied and allowed to remain five days. Healing ap- 
peared to have taken place by first intention. Unfortunately, as with 
other cold abscesses, this cure did not remain complete; in the course of PUERPERAL MASTITIS. 
29 
a few weeks other small fistulae appeared, which did not secrete as much 
as the first, and disappeared only after many months. 
Galactocele and cyst fistulae will be treated of in a later section. Indu- 
ration sometimes remains for a long time after mastitis, especially in 
those cases in which there has been no abscess formation. These indu- 
rations differ from " adeno-fibromata, " which are said sometimes to 
develop in the breast after the puerperium, in that they are less hard and 
less clearly defined than the neoplasms, and in that after iodine embroca- 
tions and compression they disappear, while the new growths remain 
stationary. 
Atrophy and disfigurement after very extensive suppurating mastitis 
are, unfortunately, not infrequent; In well-nourished women so much 
adipose tissue will usually be formed in the course of a year that the 
disfigurement will only be slight, and sometimes scarcely noticeable. 
The cicatrices caused by the incisions usually disappear entirely. 
[Puerperal mastitis need, nowadays, rarely extend to suppuration. 
It is always possible to forestall any extensive phlegmonous process, and 
even in its beginning we are usually able to check it. A valuable paper 
published by Harris of New Jersey, in the American Journal of Obstet- 
rics, for January, 1885, called the attention of the profession to the 
manner after which mastitis may be prevented or checked in its course. 
The same method was, at the time, being used in the New York Mater- 
nity hospital with the very best results, and under its uniform use we 
never, at this institution, have occasion to interfere surgically with the 
puerperal breast. The method depends simply on applying systematic 
and equable pressure to the mamma, and on absolutely prohibiting any 
manipulation whatsoever. The compression bandage used, and remarks 
in connection with it, will be found in Vols. I. and IV., of this cyclopae- 
dia.-Ed.] CHAPTER VI. 
NON-PUERPERAL, ACUTE AND SUBACUTE MASTITIS. 
TNFLAMMATIONS of the mammary glands at other times than during 
1 the puerperium are on the whole seldom met with; even though on 
account of its situation the organ is very much exposed to all sorts of 
accidents. Outside of its periodic function it has no marked tendency 
toward inflammatory processes. When such processes occur, their only 
known causes are rubbing of the nipple against the clothes, pressure, 
blows and falls upon the gland; in some cases there is no particular cause 
to be assigned. These inflammations never equal in intensity or duration 
the puerperal mastitis; they sometimes result in abscesses, but these ab- 
scesses seldom develop with marked phenomena and always remain iso- 
ated; their course is usually subacute. Mastitis may develop in newly- 
born children, even to the age of puberty, and at times during pregnancy. 
The mastitis of the newly-born is manifested by a painful swelling of 
one or both breasts, with reddening of the skin and secretion of thin 
milk; the functional and then the inflammatory irritation of the glandu- 
lar tissue become more prominent. The cause of this affection, which 
attacks equally children of both sexes, both in private practice and m 
lying-in hospitals, is not known. Fomentations of lead-water will 
usually cause this subacute and generally non-febrile affection to disap- 
pear quickly; still there are some cases in which suppuration occurs. The 
abscess must be opened as soon as it is developed, and the skin over it 
becomes thin. Children rarely die of this form of mastitis, when taken 
in hand early, but when a progressive phlegmon developes, as is but 
rarely the case, the condition of the little patient becomes dangerous. 
At the beginning of puberty a subacute mastitis sometimes occurs, 
consisting of considerable swelling of the glandular tissue with slight pain 
and at times a slight secretion of milk. The gland feels tolerably hard, 
like a disc under the skin. There is often a history of a blow or rubbing. 
The induration usually disappears rapidly under inunctions of iodine oint- 
ment; suppuration occurs but seldom. 
Subacute inflammations with formation of abscess aftei' puberty and 
unconnected with pregnancy are very rare. The course is more tedious 
and less painful than in puerperal mastitis; such inflammations are mostly 
circumscribed indurations of the gland, and may be dissipated by the use NON-PUERPERAL, ACUTE AND SUBACUTE MASTITIS. 
31 
of compresses, cataplasms, iodine ointment and rest in bed; sometimes 
however abscesses occur which slowly soften to a common focus. Such 
abscesses should not be opened until the surrounding induration is re- 
duced to a minimum, or we may wait until spontaneous evacuation occurs. 
Of the seven cases of this kind which I have seen, two underwent resolu- 
tion and five suppurated. Inflammation of the mammary glands occurs 
also at times during pregnancy. Nunn mentions seven cases. I have 
seen four cases of unilateral mastitis in women six to nine months preg- 
nant. The course was subacute, and in all four cases an abscess was 
developed slowly. One of these cases was unfortunately infected with 
diphtheria at my clinic; abortion and diphtheritic endometritis followed 
and carried off the patient. CHAPTER VII. 
CHRONIC MASTITIS.-COLD ABSCESS.-TUBERCULOSIS.-SY- 
PHILIS-INDURATION THE RESULT OF CICATRICIAL 
RETRACTION. 
/CHRONIC inflammations and cold abscesses of the mammae are exceed- 
ingly rare. When there appears near or under the gland a painless, 
slightly movable induration which finally, with or without early redden- 
ing of the skin, softens, it is far more probable that it is connected with 
some chronic inflammatory process of the ribs than with the gland. Cold 
abscesses in the mammary glands before puberty are never seen. After 
puberty they affect married as well as unmarried women, and particularly 
those of a scrofulous or tuberculous diathesis. An encapsulated extravasa- 
tion of blood, following a blow, may also form a cold abscess. In most of 
the cases hitherto observed, the induration began in single lobules of the 
glands without any known cause, and the most varied interpretation may 
be given to such indurations. In many cases, the diagnosis can only be 
made after long observation. I have very recently seen cases of cold ab- 
scesses, which have been described by II. Klotz (Arch. f. KI. Chir. Bd. 
XXV). In other countries these cases seem to be more frequent. Erich- 
sen, indeed, describes two forms: chronic diffuse abscess and chronic 
encysted abscess. The first form is seen in persons of all ages, married 
and unmarried, of scrofulous diathesis, and develops in the cellular tissue 
behind the mammae. (These are probably cold abscesses, which arise 
from some disease of the ribs). The second form is of especial impor- 
tance because it is with difficulty differentiated from tumors of the breast, 
and since on this account many unnecessary amputations have been done. 
These abscesses develop almost exclusively after confinement or abortion; 
they are indolent, indurate slowly, and after the lapse of months gradually 
soften in the centre. Retraction of the nipple is a result of this, and 
usually there is some oedema over the swelling. The diagnosis can only 
be made after lengthy observation, and, at times, only by puncture. 
The treatment consists of puncture, drainage and compression. Samuel 
Gross also mentions the difficulty of diagnosis, and he has seen the affec- 
tion in unmarried, scrofulous girls, but more often as a result of a sub- 
acute or chronic mastitis in women who had been confined, and especially 
in that breast to which the child had not been placed. CHRONIC MASTITIS. 
33 
Tuberculosis of the Breast.-All authors agree that true miliary 
tuberculosis of the breast does not occur, or that up to the present time 
at least it has not been observed. Kolessuikow {Arch. f. Path. Anat., 
Bd. 70) describes a form of necrosing interstitial mastitis occurring in 
cows, in which there is a growth of giant cells as in true tubercle. What 
Cooper and others, especially English authors, describe as " scrofulous 
tumors of the breast," is not sufficiently clear in order to draw conclusions 
as to the anatomical structure of these indurations. Velpeau speaks of 
tubercles in the skin of the mammae (probably disseminated carcinomatous 
nodules) and of fibro-tuberculous nodules (not clear) in the substance of 
the gland. While I was assistant in B. von Langen beck's clinic there 
was there for a long time a young, blonde, well-nourished girl of decidedly 
scrofulous habit, who had in one breast several nodules as large as a hazel- 
nut or walnut, which contained a yellow, cheesy pus; the affection was 
diagnosticated as tuberculosis of the mamma, and was cured by incision 
of the single foci and cauterization with nitrate of silver. I would 
designate this, according to the present nomenclature, as caseous, 
chronic lobular mastitis, without being able to say anything as to its cause 
(whether due to scrofula or syphilis); I have never seen a case similai* to 
it since, and, so far as I know, no anatomical investigations of such cases 
have been made. Through one of my assistants, I was enabled to observe 
the following case: Mrs. A. IL, 26 years old, came under treatment for 
pulmonary tuberculosis on August 23, and died three days later. The 
patient had never complained of the mamma; there was scarcely any 
noticeable swelling thereof, and therefore no mention of it was made in 
the patient's history. The diagnosis made after the autopsy was: chronic 
tuberculosis of both lungs, with phthisis of both upper lobes; tuberculous 
ulcer of the large intestine; tuberculosis of the right mammary gland. In 
the history of the patient it is stated- "Both mammae were very much 
withered, small, their skin wrinkled, nowhere excoriated or ulcerated. 
Nipples and areolae were darkly-pigmented. The right mamma was some- 
what larger than the left, and contained a disc-like body about 4 inches 
wide and f inches thick, having a nodular feel externally. The left 
mamma was uniformly soft and spongy. Section showed the right mamma 
studded with foci filled with caseous, crumbling masses, containing here 
and there a tuberculo-purulent fluid in the centre, besides small caseous 
foci as large as a hemp- seed. " 
The microscopic sections, made from the walls of the larger foci, were 
not sufficiently clear to draw conclusions from; the very atrophic glandu- 
lar elements were hardly perceptible, and the tissue was so clouded with 
a finely granular detritus strewn between the fibres, that J cannot say 
anything certain concerning the probable presence of giant cells in the 
boundary layers of the caseated foci. At any rate, the ahatomical de- 
scription leaves no doubt but that here was a rare case of true tuberculosis 34 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
of the breast. It is unfortunate that the other (left) apparently healthy 
gland was not examined, as it is possible that the first stage of this pro- 
cess might have been found there. 
Syphilitic Infiltration of the Mamma. -Gummous Mastitis. 
That different forms of syphilides may extend over the skin of the 
mamma is self-evident, and in themselves they have nothing to do with 
disease of the mammary gland. The presence of syphilitic ulcers of the 
nipple has already been mentioned. That gummata occur in the mam- 
mary gland has only recently been proved. Hennig describes a case, in 
which an autopsy was made: 
"A woman, 55 years old, was bedridden for four years on account of 
syphilitic ulceration of the bones of the knee. The mammary glands 
were of medium size and unchanged in their acinous parts. Between the 
lactiferous ducts, which were somewhat pushed aside, in the middle of 
each gland, though a little towards the anterior surface, there was a 
gumma, | inches long, wide, and on the right side, on the left, .07 
inches thick. The right was somewhat internal to and below the nipple, 
and was caseous in the middle, on both sides projected centrifugally flat 
nodules, bounded peripherally by a pale reddish-brown, somewhat jelly- 
like on the left, oedematous tissue-structure, by which the whole new 
growth appeared somewhat hilly. Superficially it occupied perhaps a 
third part of the extent of the gland." From this description, without 
microscopical examination, it cannot be said that it was necessarily a 
syphiloma which was seen; it might have been scirrhus, which is, at 
times, bilateral in old women. Among the cases reported by Ambrosoli 
(Gaz. Med. Italiana Lombardia, S.V., T. III. No. 36, 1864), one was in 
a young man the two others in young women, 19 and 24 years of age. 
Both of the latter had constitutional syphilis, had swellings in the anterior 
parts of the right mamma, which disappeared under the use of mercury. 
The cases cited by Hennig and Virchow from Sauvages, Marin, Biercher 
and Folhn, show nothing special as to the nature of the disease. Samuel 
Gross mentions Maisonneuve and Verneuil as observers of syphiloma of 
the breast, but without quoting any of their observations. Erichsen and 
many other experienced surgeons and gynecologists do not mention syphilis 
of the mamma at all. We must at least wait for further observations 
before we can form a clear picture of this affection. 
Nodular Induration and Shrivelling of the Mamma from 
Mastitis. 
The descriptions of this affection are so various, and in part so general, 
that we can scarcely form an exact picture of it. At one time it is the CHRONIC MASTITIS. 
35 
pain, then the atrophy, then the nodular formations, then the diffuse 
indurations (with or without retention cysts), then the results of long- 
continued. irritations, then the inactivity of the gland, which is made 
more or less of in the descriptions of this affection. The names, too, which 
are given to this rare affection of the breast, are various, so that it is a 
matter of doubt as to whether the different authors have been describing 
the same affection: fibroma mamma? diffusum, elephantiasis mamma? dura, 
induratio benigna, cirrhosis mammae, corps fibreux, mastitis interstitialis 
diffusa et circumscripta. 
As to the anatomical genesis of the process there is no difference of 
opinion. It does not consist in simple atrophy of the glandular tissue 
with more or less fatty degeneration of the connective tissue, since this 
would only show normal involution, and would only attract attention if 
this atrophy and its partial reparation proceeded at intervals in single 
portions of the gland. The process under consideration leads much more 
to partial or total indurations, which may eventually terminate in retrac- 
tion of the tissue, and even of the nipple and skin. But the tissue of 
the remaining indurations is not loose, senile connective tissue, but con- 
forms to the character of hard cicatricial tissue, and appears to retain this 
character, never becoming soft and tendinous, as cicatricial tissue some- 
times does. Any competent judge must conclude, even though he has 
not observed the different stages of this process, that it begins with 
small-celled infiltration of the connective tissue, and must therefore be 
regarded, morphologically at least, as a chronic inflammatory condition. 
We must, then, consider how the epithelial elements of the gland behave. 
How difficult it is to differentiate this from carcinoma mammae cicatricans, 
is well known by all who have given any attention to this subject. It is 
therefore no reflection, when we say that the descriptions of disputed 
subjects examined by the older methods-for example, the descriptions of 
Wernher-are, in spite of their fullness, not satisfactory. In the case pic- 
tured and described by Konig, there was, at all events, great dilatation 
of the acini and excretory ducts, with hard, fibrous, interstitial tissue; 
nevertheless, such involution-cysts are not so seldom found in carcinoma 
of the breast and also in senile breasts, without induration of the tissue. 
In the present state of opinion regarding carcinoma, it would be admissi- 
ble to consider such cases as healed or healing carcinomata. So long as 
the opinion, "Because the disease has neither re-appeared locally nor 
elsewhere in the body, it cannot be of a cancerous nature/' was held, the 
matter was a very simple one; but as we now no longer believe in this 
dogma, only an exact, anatomical, differential diagnosis can decide. 
Unfortunately I cannot offer anything to aid in the diagnosis. In 
the anatomical examinations which I have made on this subject, sufficient 
analyses with modern methods have always shown it to be carcinoma. I 
was very much disposed to doubt the existence of a chronic mastitis ending 36 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
with cicatricial shrinking (though I did not entirely disbelieve in it), when 
a short time ago I had a patient in whom there was a condition of the 
left breast which was without doubt what I had until then sought for in 
vain. A. M. W., a farmer's wife; 45 years old, always healthy; always 
menstruated regularly; had borne nine children, the first fifteen years, 
the last two and one-half years ago. She had nursed all the children at 
both breasts, usually for sixteen months, and had never had a bad breast. 
Fig. 11.-Shrivelling of the Left Breast from Chronic Mastitis, without Suppuration. 
(Unfortunately no mention was made in the history as to whether men- 
struation had ceased at the time or not.) While nursing her youngest child, 
which was born November 3, 1878, she noticed that a spot as large as a 
nut and above the nipple of the left breast was becoming hard; this in- 
duration constantly increased, particularly after the cessation of lactation. 
Depressions formed and gradually the gland atrophied, as shown in the 
illustration. The right breast, which was well-developed, remained abso- 
lutely unchanged. There had been no pain during the whole process, CHRONIC MASTITIS. 
37 
and even at this time palpation was not painful. The axillary glands 
could not be felt. The atrophied gland was freely movable over the pec- 
toral is major muscle: its consistence was that of a moderately firm cicatrix 
though not so firm as a scirrhus. There were no indurated nodules to be 
found in the degenerated organ. 
From my observation of this case, which was not examined anatomi- 
cally and which does not coincide with the descriptions of other authors, 
I do not think that I am entitled to give a general judgment on chronic 
atrophic mastitis, and so much the less as in this case two of the symp- 
toms mentioned by all authors, pain and induration, were entirely absent. 
As concerns the treatise of Wernher, after re-reading it, I have the same 
opinion that I had when I first studied it twenty-five years ago. Should 
we admit that Wernher had something special in view, most modern his- 
tologists would recognize in the accurate descriptions typical forms of 
atrophying cancer of the mamma. What Wernher understands by atro- 
phying sarcoma does not correspond to the modern view of sarcoma estab- 
lished by Virchow and myself. Whether Virchow has ever seen a case of 
chronic interstitial mastitis with atrophy during life, and then made an 
anatomical examination of it, does not appear from his statement. From 
all this we must understand that the process is by no means frequent, nor 
does it appear in various forms, with different symptoms. We know 
nothing as to the causes, except that it appears certain that the affection 
is much more frequent in women between forty and fifty years old, who 
have borne children and have nursed them. 
With the as yet uncertain* diagnosis, it is advisable not to delay opera- 
tive measures too long. All observations show that the intense shoot- 
ing pains, by which the patients are usually made miserable, can be 
removed in no other way, and that there are certainly no means of bring- 
ing the process to a stand-still. If the case be so simple and so clear as 
the one seen by me, and there are no pains, we should not think of 
operating. 
The presence of chalky concretions in the mamma is extremely rare, 
especially so if we except bone-formation in chondromata, as is tolerably 
frequent in bitches but is seldom seen in man. Gross saw, in two cases, 
irregular, roundish bodies of hard consistence, like dried mortar, and of 
a whitish color; both of the cases occurred in old women. Nothing is 
said as to the size of these bodies, and nothing as to whether the glands 
were otherwise normal, or whether the concretions lay in tumors. Pre- 
viously Gross says that such concretions are formed either in the substance 
of the gland or in the lactiferous ducts, seldom reaching the size of a pea, 
and are found in connection with fibrous and other tumors. Gross men- 
tions a case, reported by Berar, in which the walls of a mammary cyst 
were completely covered in by a bony scale. 
Velpeau doubts, from his literary researches, the credibility of this 38 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
very imperfectly recorded case, which perhaps he himself h;ul not seen; yet 
he (Velpeau) saw and described such a case. Velpeau saw several cases in 
old women, in which the breast was furrowed by chalky, hard plate parti- 
tion walls, needles, which lay in the otherwise healthy glands. Anatomi- 
cal examinations were not made in any of these cases, though Velpeau 
derived the impression that the calcareous masses lay partly in the con- 
nective tissue and partly in the lactiferous ducts. Earlier observations of 
this kind will not bear serious criticism It may be interesting to know 
that Morgagni claims to have known a widow, who had in her breast sev- 
eral stones, which when she walked or gently shook herself, struck 
against one another, sounding like a small bell. 
In themselves small concretions in the breast do not demand removal. 
Whether they arise from small caseous foci (yellow tubercles), or from so- 
called " butter-cysts," by gradual absorption of the fluid elements, or from 
cretefaction of the connective tissue, is unknown. I have seen, in a man, 
an encapsulated, crumbling, chalky concretion in the mamma, such as is 
described by Gross; it gave the impression that the contents of the capsule 
were atheromatous and had become calcified; unfortunately the capsule 
was not thoroughly examined. CHAPTER VIII. 
NEURALGIA OF THE MAMMA.-MASTODYNIA. 
"VYT'HAT we understand by neuralgia of the breasts cannot be placed 
' ' on a parallel with tic doloureux, sciatica, and other suddenly aris- 
ing pains, which always proceed from the same nerve trunks. By it we 
understand general, more or less violent pains in a breast, seldom in both, 
without the presence of inflammation or a tumor. Yet most authors 
speak of certain abnormalities of the breasts, which they have found in 
these cases, and which they bring into connection with these li neuralgias?' 
Since I have had very little experience with this affection, I must make 
use of the contributions of other authors. At the present, it is no longer 
allowable to speak of " neuralgias," if we have in mind only small growths, 
which upon touch and movement may be not only very painful them- 
selves, but are also radiating centres of the most intense eccentric pains. 
Every new growth may accidentally enter into such a connection with a 
sensitive nerve as to cause such results. Some of the cases described by 
Astley Cooper as " Irritable tumor of the breast," as well as many other 
observations of small painful tumors of the breast, which are here and 
there said to be the causes of " neuralgias," must be shut out of the terri- 
tory of pure neuroses; we could just as well include painful carcinoma of 
the breast under neuralgia. Gross says that the affection occurs at any 
time after puberty, and that it is especially frequent in girls and women 
between the ages of fifteen and twenty. It is a very intense pain, as if 
caused by electricity, and shoots through the whole breast, into the 
shoulder, the axilla, and sometimes down into the elbow and finger. 
Sometimes there is a certain periodicity in the pain, it always increasing 
just before the menstrual period. The sensitiveness of the skin over the 
mamma is at times so great that even the movements of the clothing 
cause attacks of pain. As a rule, they are persons of nervous temperament 
who are, without a certain determining cause, attacked by this affection. 
The breasts of such persons are usually normal, but they often have an 
uneven, granular feel, as though there were a great many small tumors 
scattered around in them; these are probably slight indurations of the 
connective tissue around the single lobules, which come and go in different 
parts of the gland without any known cause. 
Both Gross and Erichsen, whose descriptions are identical, consider 40 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
the affecti£Hi to be always connected with some alteration of the genital 
organs, and that the affected women belong to the hysterical class. 
Velpeau, who paid a great deal of attention to this affection, and who 
is entitled to the greatest consideration on account of the large number 
of cases which he fully describes, distinguishes tumeurs neuromatiques 
et nodosites, douleurs neurdlgiques et douleurs, tumeurs imaginaires. 
This appears to me the most correct division. The hard nut-sized tumors 
accompanied by radiating pains, already stated, must at all events be 
separated from the category of neuralgias, though the similarity of the 
radiating pain of these small tumors to that of a neuralgic attack is so 
marked, and, indeed, is sometimes complete. Treatment in these cases 
is very simple; the tormenting pains are quickly allayed by the removal 
of these small tumors. 
In a second category must be placed those cases in which the separate 
lobules of the gland are felt with unusual distinctness, sometimes as if 
indurated, accompanied by tormenting pains in the breast, which are 
seldom widely radiated. I have seen four such cases. 
The first case was that of a woman, of the lower middle-class, forty 
years of age. She had had several children and was very hysterical. So 
long as she was busily occupied she did not complain; but towards even- 
ing and at night there was no end to her complaints. She pointed out 
with great precision separate spots in the breast as the points of origin 
of the pains, which she described, not as neuralgic attacks, but as a con- 
tinual pressure, burning and stabbing, which were unbearable on account 
of their persistence. Both Schuh and von Pitha had several times ex- 
cised painful parts of her breast, and the patient asserted that, after each 
operation, she was better for a long time. When she consulted me, the 
pains were only violent above apd towards the axilla. Although I thought 
that she was either simulating, or was to a certain extent psychopathic, 
on account of her persistence and that of her family. I twice excised at 
the places which she indicated as the points of origin of the pain. Of the 
nodules previously felt or of the apparently indurated lobules, nothing 
could be found; moreover, there was no gland-tissue to be found, only 
ordinary adipose tissue, containing no more than the usual amount of 
connective tissue. I finally refused further operation, and do not know 
what became of the woman. 
The other three cases were in women of the better classes, about forty 
years old, tolerably strong, one unmarried, the others widows. In two 
the pains were principally in the upper and outer part of the breast, in 
the other deep down; the pain was partly spontaneous, partly caused by 
pressure. The very largely developed breasts had a nodular feel. When 
one of the breasts was taken by the sides or above and below, it gave the 
impression of containing a large nodular tumor; but when felt from other 
directions there was no such tumor to be felt. All three patients believed NEURALGIA OF THE MAMMAE. 
41 
that they had or were going to have cancer. It was only by careful ex- 
amination and earnest persuasion that they could be quieted for a short 
time. The pains, especially before the menstrual epoch, were often so 
great and tormenting as to prevent sexual intercourse, and at night they 
could not lie on the affected side. The three women were healthy, not 
only as regards their genital organs, but also in other respects; they were 
intelligent women and in no way hysterical. Immediately before each 
menstrual epoch, as already stated, the pains were most intense, and also 
after emotional disturbances. No locally applied anodyne, had any effect 
upon the pains, which sometimes disappeared completely during the day, 
though there seemed to be no especial cause for this. Cold compresses, 
elevation of the breast at night and the recumbent position were the only 
things that eased the pains and gradually brought about a more comfort- 
able condition. 
Finally, there is a third class of cases in which there are neuralgic 
pains sudden and typical, without any changes noticeable in the breasts 
on palpation. I have already expressed the belief that these are 
perhaps cases of intercostal neuralgia with radiation to the anterior part 
of the thorax. Eulenberg appears to share this opinion, to which Rom- 
berg and Hasse are also inclined. 
From his rich experience Velpeau (the disease seems to be strikingly 
frequent among French women) gives the following statistical data. Within 
four years he saw forty cases of neuroses of the breast, twenty-one of the 
right, seventeen of the left and two of both breasts. Of these women 15 
were 30 years of age; 7 were from 31 to 40 years; 8 were from 41 to 50 
years; 7 were from 51 to 70 years; 3 were over 70 years. 
In ten cases there was slight thickening of the glandular tissue (^eger 
empdtemenl, nodosites), and in thirty, there were no recognizable changes. 
As regards the treatment of neuralgia of the breast, it has been of 
little benefit in those cases in which there was no recognizable tumor. 
With increasing age, and especially with cessation of the menses, these 
neuralgias seem to disappear, or, at least, to be less troublesome. Exact 
observations as to the complete cure by time are wanting; it would be of 
importance to collect them. Though all authors assume a relationship 
between these neuralgias and the genital system, there are no definite 
statements as to which forms of disease of the genital organs produce the 
neuralgias; and in by far the greater number of cases no such relation- 
ship has been shown either therapeutically, clinically or anatomically. As 
to the relation of mammary neuralgia to hysteria there are few therapeuti- 
cal means called for, for hysteria is not too frequently amenable to thera- 
peutic treatment. From the impression which I have of hysterical persons, 
they are all to be considered more or less psychopathic. Congenital dis- 
position, developed by education and other external circumstances, gener- 
ally lies at the bottom of those conditions which we collectively denote as 42 
DISEASES OF THE FEMALE MANMAEY GLANDS. 
hysteria. As with many other unimportant functional disturbances, the 
appearances on the part of the genital system may be as frequently a 
symptom as a cause of the general diseased condition. That, in the treat- 
ment of neuralgia of the mamma, an assurance of freedom from danger 
plays no inconsiderable part is especially noted by the experienced Velpeau. 
The more the patients are occupied with their household affairs, busy 
from early till late, the less will they think of their pains. Physical 
fatigue in otherwise healthy persons will always cause sleep. Pure func- 
tional nervous troubles are very rare among the working classes, and are 
never completely developed. As slight as is the power of the physician 
of really effecting a complete psychical cure in hysteria, except perhaps in 
special institutions, just so slight is his power in a series of these cases. 
While in two of the cases observed by me, assurance that there was no 
risk acted favorably, in the third case it was completely in vain. 
As regards medicinal treatment, most authors do not fail to enumerate 
a number of external and internal remedies, though as a rule with the 
caution that the result is uncertain. Cataplasms and ice, leeches and 
iron with quinine, compression of the breasts, and complete freedom of 
the breasts by loosening the corsets, purgatives and opium, all have been 
used. Plasters and inunctions of belladonna, hyoscyamus, cicuta, stra- 
monium, aconite, veratrin, chloroform. The same drugs have been given 
internally, and to them must be added arsenic, quinine, colchicum, cannabis 
indica, bismuth, zinc, calomel, preparations of antimony, etc., etc. There 
is nothing else to do in such a stubborn affection than to use some of these 
means in one form or another for a time. The appearance of continuous 
exertion on the part of the physician is a source of alleviation and comfort 
to the patient. As regards the subcutaneous injection of morphia, I 
would advise that it be omitted in these cases, as the morphine habit would 
probably be induced. CHAPTER IX. 
ANOMALIES OF SECRETION AND EXCRETION.-GALACTO- 
CELE. 
TN such a gland as the mammary, which only functionates at certain 
times, we can only speak of "disturbances of function" when such 
disturbances occur during the period of functional activity, or when a 
secfetion is established at a time when, normally, such secretion should 
not occur. 
It is very seldom that there is entire absence of milk secretion 
(agalactia) after delivery; it only happens when there is complete absence 
of the glands. It is well-known, however, that, in poorly developed 
glands, milk-secretion is very slight, and that for this reason, especially, 
many women cannot nurse their children. Excessive secretion of milk 
after delivery is not always the result of abnormally developed glands, or of 
an especially strong constitution. It is frequently the case that weak, 
nervous women secrete a great deal of milk and thereby emaciate mark- 
edly, although they eat well. For weeks and months there is sometimes 
a continual flow of milk from the breasts (galactorrhoea) of women who 
have either not nursed at all or who have ceased to do so early; this is 
especially frequent in slender, flabbily built women. According to Birkett, 
Montgomery saw a case in which the flow of milk continued for three 
years after labor, and after five years milk could be expressed from the 
gland, though there had been no new pregnancy. 
Abnormal milk secretion has been repeatedly observed, though the num- 
ber of authenticated cases has not grown very much of late, as most 
authors cite the same old cases over and over again. I have no observa- 
tions of my own to offer, and can therefore only repeat what is already 
known. Beigel has collected all the known cases in literature. That 
milk can be expressed from the breasts of newly-born children, when the 
glands are swollen and tender, has already been stated. Th. Kblliker 
has shown that the lactiferous ducts are dilated in these cases, and are 
almost cavernous. The secretion ceases without the use of especial 
measures. A case is mentioned by Will, in which milk flowed from the 
breast of a girl thirty weeks old, for some time. Baudelocque mentions 
the case of an eight year old girl, in the village of Alenton, who often 
applied a child, which her mother had just borne, to her breasts, by 44 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
which means a milk secretion was established so that the girl was able to 
nurse the child for a long time. On October 16, 1783, the girl, from 
whose breasts a quantity of milk was at this time expressed, was exhibited 
to the Surgical Society of Paris. There were no other signs of puberty, 
except that, after the age of five years, she had a vicarious menstruation 
in the form of hemorrhage from the eyes (?) (This menstruation from 
the eyes is not very credible; furthermore, the nipples of an eight year 
old girl must have been extraordinarily developed, or the child could not 
have nursed; there must have been precocious development of the girl.) 
I will also cite from Beigel the observation of Dr. Carganico (1838). 
The fifty-nine year old wife of a working man nursed, without a coinci- 
dent delivery, her nine months old grandchild. At the beginning the 
child was nursed by its mother, who was, however, compelled to wean it. 
The child became so restless, that the old woman, who had not men- 
struated for ten years, placed it to her own breasts, after she had nearly 
satisfied its hunger by other means, to quiet it. Suddenly she felt pierc- 
ing pains in both breasts, and on examination she found some drops of a 
milk-like fluid. The child was then zealously put to the breasts, with 
the result of producing such a free flow of milk that it was exclusively 
fed by her. Observations of moderate milk secretion in non-pregnant 
unmarried, and in childless married women are frequently mentioned, 
as also the occurrence of "milk-like" fluid in the breasts of very old 
women (one of eighty-two years, for example). Here and there mention 
is made of the secretion of milk in connection with uterine and ovarian 
tumors. In the tolerably large number of such tumors which I have seen, 
I have never witnessed such coincidence with abnormal milk-secretion. 
Cases sometimes do occur in which the excretory duct of a portion of 
the gland becomes stopped up or is closed by adhesions. When the 
woman becomes pregnant and the gland becomes active, the milk cannot 
escape from the closed portion of the gland, but collects gradually in the 
lacteal sinus behind the nipple, and distends it more and more; this dis- 
tension may be very considerable without causing any pain, but simply a 
feeling of moderate tension. This condition is known as " Galactocele or 
milk-cyist." The nature and time of its origin, which, as a rule, will be 
definitely given by the woman, the situation of the tumor and the well- 
defined fluctuation, will, in most cases, leave no doubt as to the diagnosis. 
This manner of development of such retention milk-cysts is not frequent; 
I have never seen such a case, and other writers do not appear to have 
observed it often, since they all cite the same cases. Among these cases 
we find some, the descriptions of which answer more closely those of 
subacutely developed abscess. Que of the largest cysts of the kind, 
without doubt a galactocele, was observed by Scarpa. A woman twenty 
years old, of strong constitution, with normally developed breasts, noticed 
a swelling of her left breast ten days after her second confinement; the ANOMALIES OF SECRETION AND EXCRETION. 
45 
more the child was applied to the breast, the larger the swelling became. 
In two months the breast was thirty-four inches in circumference and 
reached down to the left thigh. The skin covering it was unchanged, 
but the glands of the left axilla were somewhat swollen. Ten quarts of 
pure milk were evacuated with a trocar, chemical analysis showing that 
it did not differ from normal human milk. Suppuration, which con- 
tinued a long time, followed, but the patient finally recovered com- 
pletely. Two years later she had another child, but nothing unusual 
happened to the breast. Erichsen states that Walpy evacuated ten 
pounds of milk from a cyst in a similar case (Erichsen does not say where 
the observation of Walpy is published; perhaps it was a private commu- 
nication; or can it be the above mentioned case of Scarpa? Beigel erro- 
neously ascribes Scarpa's case to Birkett, who only cites the case from 
Scarpa.) 
As to the fate of the milk in these cysts, it is thought that an oily, 
buttery, or even cheesy material is formed. It is possible that the milk 
in the gland may be changed into butter and cheese by simple thicken- 
ing of the milk, in consequence of the absorption of the serum, and we 
may speak of " butter-cysts " and " cheese-cysts; " but these observations 
will scarcely bear analysis. I do not doubt that some oil, butter and 
cheese-like substances are found in mammary cysts; I will later speak of 
such observations, but I doubt that such are developed from true galac- 
toceles, as above described. In the cases cited by Berard, Birkett, and 
Beigel, from Martini, Brodie, Dupuytren, Layd, and Forget, I do not 
find it mentioned that the tumor, most often noticed in the later stages 
of lactation, grew larger from putting the child to the breast, and then 
gradually grew smaller; this could scarcely escape notice if such an ab- 
sorption of water should occur as to cause the milk to become of a buttery 
oi' cheesy consistence. There is more probability in the case described 
by Astley Cooper, in which he opened a cyst in the breast of a thirty- 
eight year old woman, one month after the birth of her last child, and 
evacuated " six ounces of white, coagulated milk, mixed with some yellow 
serum; " the woman had had the tumor one year before Cooper saw her. 
Certainly nothing can be said here of a change of milk into butter or 
cheese. The woman had had an abscess of the same breast after a previ- 
ous confinement . 
The cases reported by Velpeau cannot convince me that the butter, 
cheese, and adipocere-like contents was thickened milk, in spite of the 
clear descriptions of the microscopical examinations made by Donne and 
Lebert. That cysts of the breast contain fat in drops and crystals and 
shrivelled cells in various forms, is not to be wondered at. Quevenne 
made a chemical examination of a cyst seen by Velpeau, and his language 
is very diplomatic: " des principes laiteux et butyreux, mais il ne pousse 
pas asses loin ses recherches pour les enumerer tous." 46 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
The treatment of galactocele consists in opening and draining the cyst. 
I must refer to Velpeau's case of a " galactocele by infiltration," cited by 
many authors, and represented as though a galactocele had burst subcu- 
taneously and the milk was extravasated into the meshes of the connect- 
ive tissue. The matter is not so clear as that. Velpeau writes: 11 In a 
woman, thirty-four years old, who was confined fifteen months previously, 
and had weaned her child six weeks before, the right mamma swelled to 
about double its size, was of a hemispherical form, of spongy consistency, 
and painful for a few days; the skin was a little more glistening than on 
the other side, not reddened, but the whole breast was doughy. By 
puncture with a bistoury a considerable quantity of milk was evacuated, 
which clearly came from the meshes of the cellular tissue." Whence he 
draws the conclusion is not stated. It is very possible that a large milk 
duct was opened by the puncture, and the milk evacuated from the prob- 
ably dilated ducts deep in the gland. That Velpeau took this view him- 
self is very probable from the fact that he placed the case in the category 
of "lacteal engorgements." The tumor disappeared in fourteen days, 
after the administration of purgatives, and after blood-letting and baths. CHAPTER X. 
TUMORS OF THE MAMMARY GLAND. 
rpHE anatomy and developmental history of tumors of the breast have 
for a long time been of especial interest to the anatomist and sur- 
geon. As it was formerly the remarkable variety of these tumors that 
interested the investigator, it is now the developmental history of these 
forms which always attracts him. But the physician who stands at the 
same time on a scientific and humanitarian basis, seeks a morphological 
solution of the question, as to whether the tumor belongs to the carci- 
nomata, which cut off so many women while still in their full strength, 
lie must at once cease trying to find means and ways for preventing the 
formation of this terrible neoplasm, as all dietetic and medicinal treatment 
has hitherto been vain, and he can only render assistance by the earliest 
possible recognition and removal of the first focus of disease, from which 
it may spread throughout the whole body. In the interest of the patient, 
therefore, it is especially important to recognize this dangerous disease 
early. 
Since the time that Astley Cooper first sifted and arranged the material 
m his unfortunately incompleted work, important progress has been made, 
not only in this special field, but in the great field of the knowledge of 
tumors, so that by exact anatomical examination of extirpated neoplasms 
there is very seldom a difference of opinion, and the diagnosis can usually 
be made with sufficient exactness. With the diagnosis in these cases, the 
prognosis is also given. 
It might be thought entirely superfluous to go thoroughly into the 
anatomy and developmental history of tumors of the mammary glands, 
since they do not differ in their nature from tumors in other places. 
This is true, since it is now the generally accepted opinion that neoplasms 
consisting of connective tissue (fibroma, lipoma, sarcoma, chondroma, 
osteoma) proceed from the cellular elements of the connective tissue, and 
adenoma and carcinoma especially from the epithelial elements of the 
glands. However, the structure and peculiar physiological conditions of 
the mammary glands admit of so many combinations in these respects 
that the acquiring of knowledge without guidance is not always easy. It 
is certainly very seldom that a tumor forms within the breast which 
simply pushes the gland-tissue aside. Neoplasms are almost always from 48 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
the beginning confined to the lobules of the gland; these rarely ever 
disappear entirely, but are changed in various ways. Most neoplasms not 
only spread in themselves, but attack the neighboring gland-lobules, so 
that sooner or later a more or less considerable part of the gland is in- 
volved. This peripheral extension (which, moreover, is not especially 
noticeable in the so-called benign tumors, and often enough is entirely 
absent) ceases, as a rule, at a certain point in fibromata ami sarcomata; 
the diseased portion of the gland then remains separated from the un- 
affected part, a condensed layer of connective tissue being formed around 
the tumor, and it is then said to be " encapsulated. " In carcinomata and 
in many adenomata and cyst-growths, this capsulation of the neoplasm 
does not take place as a rule, but the whole gland is gradually affected, or 
at least the greater part of it. In carcinoma the affection extends beyond 
the limits of the gland, forward into the skin and backward into the 
muscles, ribs and pleura. Then comes the infection of the lymphatic 
glands, followed by internal metastases. Usually there is no impor- 
tant difference in the anatomical or clinical relations between infiltrated 
carcinoma of the mammary gland and carcinoma of other organs; and as 
fibroma and sarcoma also always contain glandular elements, often com- 
bined with peculiar and manifold cyst-growths, so in this organ there are 
sometimes very carcinoma-like forms. Adenomata of the breast, also, 
as in other glands, have their specific peculiarities. Tumors of the breast 
are therefore not only interesting on account of their variety and pecu- 
liarities, but we can find the key to their peculiarities only by the study 
of their developmental history. 
On purely practical grounds I will first speak of the most infrequent 
occurring lipomata and chondromata of the mammary gland, in order 
not to interrupt the continuity of the presentation of fibromata, sarco- 
mata, cysto -sarcomata, etc. So far as I know angioma and true neuroma 
are never developed in the breast. (The cases reported by Klebs, 
Pathol. Anat., Bd. L, Abth. I., p. 1194, permit the belief that the 
angiomata were originally developed in the skin or subcutaneous adipose 
tissue over the mamma.) What is known as to the relation of the blood 
and lymphatic vessels to tumors of the mammary gland will be mentioned 
under the consideration of carcinoma. 
Lipoma. 
In the few cases which have been described as lipoma of the female 
breast there is a doubt whether they really originated in the connective 
tissue binding the lobules together, or whether they were developed be- 
hind or near the gland in the loose cellular tissue, and thence pushed the 
gland before them; in a few cases this seems certainly to have occurred. 
This was so in a case which I saw and which has been reported by Carl TUMORS OF THE MAMMARY GLAND. 
49 
Hegetschweiler: Agatha St., thirty-four years old, admitted February 
14, 1865; was entirely well until six years ago. At that time, while sawing 
wood, she felt a pain in the right breast just above the nipple, and at the 
same time noticed a tumor at that spot; the pain soon passed away, but 
the tumor grew constantly. In March, 1863, she was confined, and the 
swollen breast had possibly more milk than the healthy one, though she 
did not nurse her child from it at first, chiefly because the nipple was 
flattened by the tumor, and the child could scarcely get hold of it. The 
growth continued to increase, becoming especially large at each men- 
Fig. 13.-Woman, Thirty-four Years Old, with Enormous Lipoma behind the Right Mamma. 
strual period. The condition of the breast at the time of admission is 
shown in Fig. 12. 
The tolerably dark-colored nipple with the areola lay as nearly as pos- 
sible at the most dependent portion of the enormously enlarged mamma, 
which felt nodular, large-lobed, partly soft and partly firm and elastic. 
The length from the upper portion to the nipple was 17.2 inches. The 
skin over the tumor contained dilated veins, was thinned but did not 
adhere to the neoplasm. The lymphatic glands were not enlarged, and the 
general condition of the not very strong, though well-nourished woman, 
was not at all disturbed. 
Since scarcely anything else than diffuse hypertrophy and cysto-sarcoma 
of the breast attain such enormous size, I thought it must be one of 
these conditions or perhaps a combination of both. After the extirpation 50 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
on February 16, which consisted in amputation of the mamma, with 
removal of all superfluous skin, I found that it was a giant lipoma. Ex- 
amination showed that the mammary gland itself was pressed flat by the 
tumor and was pushed evenly forward. Unfortunately the tumor was 
not weighed, or, if it was, its weight was not noted. It had clearly devel- 
oped behind the breast, and in front of the fascia of the pectoralis muscle. 
The wound healed well. 
Astley Cooper saw a case very similar to this. The lipoma weighed 
fourteen pounds five ounces, and the mammary gland lay in front of it. 
The incision for the operation was thirty-two inches in circumference. 
The preparation is in St. Thomas's Hospital Museum in London. Vel- 
peau mentions three cases, the third of which was similar to that above 
described. The tumor developed behind the right breast of a young 
woman (age not given) of somewhat delicate constitution, and in three 
and a half years grew to enormous size; it was spherical, 19.65 inches in 
circumference, reaching, when the patient stood erect, downward to the 
crest of the ilium and on accouiil of its weight (44 pounds) it was some- 
what pediculated. The nipple lay below and to the outer side, and had 
no firm connection with the tumor. Though in the beginning it is said 
that the tumor was made up of a mixture of fatty and hypertrophic 
glandular tissue, no glandular tissue could be found by the microscope 
in that part which was supposed to be mamma and which contained in- 
spissated milk (?). In Velpeau's first case, the tumor was as large as two 
fists; in the second, as large as a hen's egg. Birkett, Erichsen, and 
Gross do not mention lipoma of the mamma at all. Of the cases of Por- 
talupi and Lebert (Becourt), mentioned by llegetschwciler, it is very 
doubtful if they had any connection with the mamma. 
Since, in the later years of life, after atrophy of the glandular tissue, 
the whole texture of the mamma is changed into fatty tissue, and there 
is no denying the possibility of the interacinous connective tissue forming 
fatty tissue, it is very remarkable that lipoma is so seldom formed within 
the mamma. There is no case known in which the glandular was in- 
cluded in the lipomatous tissue. 
The cases which have hitherto been observed up to the end of the twen- 
tieth year, did not occur in especially fat and strong women, but rather 
in slender women. The growth was of moderate rapidity, still not so very 
slow when its size at the time of operation is considered. The diagnosis 
can seldom be made positively. 
Chondroma.-Osteoma. 
What have been described by Velpeau and others as cartilaginous and 
bony tumors of the mamma are nothing else than true chondroma and 
osteoma, but there are chalky formations in the walls of all cysts, and TUMORS OF THE MAMMARY GLAND. 
51 
perhaps also chalky epithelial pearls, sand-like in small cysts. The only 
case, which seems with little doubt to be a partly bony chondroma, is the 
following described by Cooper: Maria F., thirty-two years old, had a 
tumor of the breast (right or left) for fourteen years; the tumor was very 
painful, and the skin covering it felt very warm compared with that of 
the surrounding parts, and required the constant use of evaporating lotions 
to moderate the warmth. The tumor was extraordinarily hard, painful 
to a high degree before menstruation, after which the pain moderated 
considerably. Various local remedies were used, such as cataplasms and 
irritating plasters, but they caused neither absorption nor suppuration, 
and as all discutient remedies had been used without result, the patient 
strenuously desired extirpation of the tumor. 
As the axillary glands were free from diseased changes, and as the 
general condition of the patient, even after so long a duration of the 
disease, seemed good, Cooper recommended the operation. 
On examining the tumor after removal, the greater part of it had the 
appearance of the cartilage which supplies the place of bone in young 
persons; the remainder was bony. 
The illustration (at least in my copy of Cooper's work) is unfortunately 
quite imperfect. Neither the typical light blue color nor the distinct 
division of the cartilage by connective-tissue septa seen in sections of 
chondromata, is recognizable; that which should be bone, seems to be fat. 
Nevertheless it seems to be certain from the short anatomical description, 
as well as from the previous description of cartilage and bone develop- 
ment in the embryo, that this was really a true chondroma. The ex- 
tremely slow growth of the tumor, which was about as large as a duck's 
egg, is strongly in favor of chondroma, as also, in a slighter degree, the 
painfulness and at times almost inflammatory appearances of the tumor 
during its course. Perhaps the case will never be cleared up. Birkett 
searched in vain in the London museums for the preparation. Virchow 
cites cases from Nelaton, Cruveilhier, Warren and E. Wagner, in which 
it is probable that the tumors contained some cartilaginous tissue. 
Thus far I have never seen in tumors of the breast in men anything 
that had any resemblance to cartilage. However, I once found in a large 
myxo-sarcoma of the mamma a considerable mass of small, hard nodules 
as large as flax-seed, which consisted of true bone substance, which had 
developed from the connective tissue. 
Cartilaginous tissue in various forms is not infrequently found in mam- 
mary tumors of bitches. These, on the one hand, may pass over to 
myxomatous tissue, or may go on to true bone formation, with develop- 
ment of medullary spaces. 52 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
Fibroma.-Fibro-Sarcoma. 
I have already spoken of a layer of hyaline firm connective tissue, rich 
in nuclei, which surrounds the acini and smaller excretory ducts, and in 
virgin breasts, especially, is usually largely developed. This connective 
substance, which at the same time forms the floor upon which the epi- 
thelia of the acini are fixed, and which first disappears where the firm 
walls of the excretory ducts begin, is the point of origin of all fibromata 
and sarcomata in the mammary gland. It-follows from this that the 
gland-spaces may be easily influenced in their form and situation by the 
development of such tumors, and indeed under certain conditions must 
be so influenced. We will next consider the fibromatous tissue, which 
is here quite frequently formed, and is, as a rule, of a very pale yellowish- 
Fig. 13.-Fibro-Sarcoma of the Mammary Gland, with Fissure-like Expanded Gland Ducts. 
Natural size. (After Astley Cooper.) 
red and of a firm homogeneous texture. It is not formed in regular 
bundles, loosely attached to one another, as is the subcutaneous cellular 
tissue, but is rigid and very hard to tear apart. In hardened sections, 
under the microscope, we see certain turnings of the fibre, shown only 
by the oval nuclei of the connective tissue cells, which are not very rich 
in protoplasm. These cells are abundantly strewn through the tissue, 
generally evenly distributed, and seldom heaped in groups; in some 
places, these heaps of partly round and partly spindle simple-shaped cells 
may be so large that we may well speak of a " fibro-sarcoma. " It is a 
peculiarity of these tumors that their tissue is always the same, whether 
the nodules have existed one or ten years. They are not richly supplied 
with blood-vessels. 
When we observe the cut surface of these tumors we seldom find them 
entirely homogeneous; as a rule they contain more or less ramifying 
fissures, filled with a little sero-mucous fluid which coagulates on the 
addition of acetic acid. TUMORS OF THE MAMMARY GLAND. 
53 
More rarely we see a few roundish cysts, as large as a pea, near the 
fissured spaces. 
When we make larger sections for examination with low powers, it is 
easily seen that these fissures are nothing more than the somewhat wid- 
ened and very much lengthened branched excretory ducts of the gland, 
the walls of which are closely adherent to the fibromatous masses, just as 
the veins and lymphatic vessels in other fibromata are inseparably con- 
nected with the fibromatous tissue. With a higher power it is seen that 
the cylindrical epithelium often lies against the wall in many layers. 
In the contents of these fissures are found a few mucous degenerated 
cells, and fine granules disposed in a clear homogeneous substance. The 
Fig. 14.-Fibroma from the Breast of an 18 Year Old Girl. About two-thirds natural size. 
tumors of this kind which I have examined were all in unmarried women 
or in women who had not borne children; the least clustered developed 
acini were unchanged, filled with roundish epithelial cells, and here and 
there were places in which the terminal vesicles were dilated. 
At the same time the epithelia assumed gradually the form and situa- 
tion of cylindrical epithelium; in the centre of the small cyst spaces lies 
a fine granular substance, in which we can differentiate a central globule 
and a peripheral layer; in the latter, we recognize with a higher power 
degenerated mucous cells, which before were completely lost in the mucus. 
What conditions are necessary for such a secretion will be mentioned 
later in the section on cyst formations. It may be said here that in the 
development of the already mentioned fissure spaces, and the small 
cysts from the terminal vesicles, there is doubtless an anatomical relation, 
and eventually a transition to the cysto-sarcoma, which will be spoken 
of later. 54 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
Symptoms and Course.-These fibromata usually come on unnoticed 
and without pain. As a rule they are first pointed out to the physician 
when they have attained the size of a large hazel-nut or a walnut; they 
are then nodular, hard, very movable inside the gland, and are painless 
or only very slightly painful on pressure. Occasional adherence to nerves 
may, in a few cases, be the cause of excessive painfulness of such small 
tumors. I have never known these tumors to exist before the age of 
puberty nor after the fortieth year; they most frequently develop between 
the sixteenth and twenty-fifth years. But it is not therefore to be con- 
cluded that small tumors of this kind seen in patients after the twentieth 
Fig. 15.-From a Mammary Fibroma. Dilated terminal vesicles. Commencing cyst formation. 
Hartnack Syst., 5. 
year, exist during or after the development of puberty, since the recog- 
nition of the very beginning of such unusually slow-growing neoplasms is 
very difficult even for the physician, especially when the smaller nodules 
form deep in the gland. 
It is very probable that by far the largest part of the tumors which 
Velpeau describes as " tumours adenoides," tumors which are also de- 
scribed in literature as tumours fibrineuses, tumours squirrhoides, tumours 
fibreuses (Cruveilhier), tumours par hypertrophic partielle (Vidal), chronic 
mammary tumor (Cooper), pancreatic tumor (Abprnethy), belong here, 
as also a few sarcomata and adenomata. According to Velpeau's sta- 
tistics, these tumors are most usually found in unmarried or sterile women. 
From Velpeau's statistics we obtain: TUMORS OF THE MAMMARY GLAND. 
55 
15 to 30 years of age, ..... 45 times. 
31 " 40 " " 38 11 
41 " 50 " " 34 " 
51 " 60 " " 12 " 
61 " 70 " " 2 " 
131 
60 on the left side, 59 on the right, 3 times in both breasts. 
Tne growth of these fibromata is an unusually long one, and indeed 
there are cases in which the duration can scarcely be determined. For 
five years a childless woman, now in the middle of her thirtieth year, 
and who has had such a nodule in her right breast for ten years, has 
visited me annually, and I cannot say that it has undergone any change in 
the time mentioned. According to other authors, pregnancies cause an 
enlargement of such growths for some time, followed by a period of in- 
activity. Most of the tumors which I have seen (and the number which 
I see in consultation is considerable) seldom attained the size of a hen's 
egg, and most of them were smaller; not infrequently, however, there 
are several in one breast or in both breasts. Only once have I had the 
opportunity to see such a tumor, in an eighteen year old girl, which 
reached the size of a goose's egg, when it was extirpated by B. von Lan- 
genbeck, and found to be not nodular, but uniformly round. Velpeau 
states that of 131 cases seen by him, in only 65 was the tumor as large 
as a nut or hen's egg. Whether the statement that 34 were " de la gros- 
seur de la tete," and later 2 " comme la tete d'un foetus" is to be taken 
as exact, or whether they were not cases of sarcoma and cysto-sarcoma, 
is very difficult to determine. It has already been remarked that small, 
fissure-like, smooth-walled cysts, seldom spherical, -with thin mucous con- 
tents and arising from the single gland-lobules, are found in these fibro- 
mata; they are never entirely filled with fluid and form no essential but 
only an occasional accompaniment of these tumors. 
A priori, it certainly would not be so improbable that such a fibroma 
should remain stationary for years, and that the fibromatous tissue should 
then change in some way to the form of soft sarcoma-tissue, with coinci- 
dent dilatation of the gland-ducts, acini or gland clusters, and with the 
formation of a large quantity of secretion in the hollow spaces. So far 
as I know such a change of an adeno-cysto sarcoma has not hitherto been 
observed; furthermore, it seems that the more malignant infectious forms 
always have such a beginning. It may happen, however, that fibrom- 
atous nodules, which remain painless for years, without noticeably in- 
creasing in size, may become changed into carcinoma. The statements of 
many women are so explicit in this respect that we can scarcely doubt it. 
If this is not so, wre would be forced to believe that the primary tumor 56 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
was a carcinoma, which had remained unchanged for years, though this 
would contradict everything that we know of carcinoma. I have else- 
where {Arch. f. Path. Anat., Bd. XVIII., p. 78) described a case anato- 
mically in which I believed that I could recognize such an occurrence from 
examination of the preparation; still, I confess that at the time I made 
the examination the important part taken by the epithelial elements of 
the gland in carcinoma had not been rightly determined, but it would be 
very difficult to explain the case in any other way. 
Soft Sarcoma.-Medullary Sarcoma. 
Soft sarcoma seldom occurs in the breast, though 1 have seen the fol- 
lowing cases of this group of tumors. 
A medullary granulation (round-celled) sarcoma, perhaps only acciden- 
tally combined with the development of striated muscular fibres, I have 
seen only once (Arch. f. Path. Anat., Bd. XVIII., p. 69) and that in a 
very young girl. 
D. B., 16 years old, somewhat chlorotic though otherwise strong, below 
medium size; has menstruated regularly for two years; came to B. von 
Langenbeck's clinic on March 14, 1859. Both breasts were well devel- 
oped for her age. Nine months before a swelling had appeared deep 
down in the left breast; it was but slightly sensitive to touch, not painful 
otherwise, began slowly, but in the last few months had grown rapidly. 
Local blood-letting, iodine, iron, did not check the growth of the tumor. 
It soon attained the size of a child's head, was freely movable under the 
skin and in the gland, though the skin over it was tense, and was red- 
dened at the summit of the tumor. The consistency of the tumor was 
very different at different places, partly soft and elastic, partly hard and 
nodular, and in other parts distinctly fluctuating. The axillary glands 
were not swollen. From all the symptoms a cysto-sarcoma was diagnosti- 
cated. Aftei' the tumor was extirpated, however, it was seen that it con- 
tained no large hollow spaces, but consisted partly of adenoid (externally), 
and partly of medullary substance, in which here and there small fissure- 
cysts could be recognized. The tumor, completely encapsulated, was 
thoroughly removed, and at the same time some of the surrounding 
healthy tissue and the greater part of the skin. The wound was closed 
with sutures, healed completely by first intention, and the patient left the 
hospital 14 days after the operation, cured. 
On July 22 the patient returned, because three weeks before a new and 
very rapidly growing tumor had developed in the cicatrix. The patient 
had been rid of her chlorosis by the use of chalybeate waters, and looked 
blooming. Under the cicatrix in the left mamma, lay a more or less 
clearly fluctuating tumor as large as the fist, which was entirely painless; 
the axillary glands were not swollen. The extirpated tumor had the ex- TUMORS OF THE MAMMARY GLAND. 
57 
act appearance of brain substance, and was sharply circumscribed. Heal- 
ing followed the extirpation of the tumox- and remainder of the gland 
very quickly, and on August 7 the patient left with a small healthy gran- 
ulating wound. But there is scarcely any doubt there was soon another 
recurrence, and that the girl finally died from the disease. 
It is seen from the illustration (Fig. 1G) that the original gland-ele- 
Fig. 16.-Medullary Sarcoma with Striated Muscular Fibres from the Breast of a 
Young Girl. Enlarged 200 times. 
ments are_ surrounded by the tumor, which contains besides small round 
cells, some fatty tissue also, which is not newly formed, but has not yet 
changed to sarcomatous tissue. 
More often I have seen broad band-like fibre-filaments in sarcoma and 
cysto-sarcoma of the mamma, though on isolation I could not draw the 
conclusion that they were organized muscular fibres. That such may 58 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
occasionally develop from the layer of muscular fibres of the larger ex- 
cretory ducts there is no doubt. There was no connection of the tumor 
to the pectoralis major muscle. Since no one will believe that striated 
muscular fibres are formed from the sarcoma cells originating from the 
connective tissue, there remains scarcely anything else, from our pres- 
ent histogenetic ideas, than the hypothesis that muscle-germs from the 
Fig. 17.-From a Lympho-Sarcomatous Degenerated Breast. The degeneration occurred 
bilaterally in a pregnant woman. Hartnack, Syst. 5. 
pectoralis major had wandered into the mammary substance in the first 
formation or during the development to puberty of this girl, and had 
taken on a supplementary growth by the development of the sarcoma. 
Lympho-Sarcoma of the Mamma. 
In the section on the etiology of mammary rumors, etc., I will give 
complete details of a case in which double and very acute sarcomatous TUMORS OF THE MAMMARY GLAND. 
59 
degeneration developed during pregnancy, and which had the character 
of lympho-sarcoma. 
Distinct acini were not found in the peripheral parts of the tumor exam- 
ined by me. Whether some of the larger alveoli corresponded to large 
gland-clusters, I cannot decide. In the centre of some of these alveoli 
were heaps of darker, punctiform, though not fatty, masses, as are some- 
times found in the centre of the alveoli of lymphatic glands. Further- 
more, there were seen in the larger connective-tissue trabeculae many large 
fissures, partly empty, partly filled with lymph-cells, as are also found 
in normal glands, especially during the puerperium; I looked upon these 
as largely dilated lymph-spaces. 
Alveolar Melano-sarcoma. 
Mrs. M. M., 68 years old, first seen July 12. 1869; noticed the begin- 
ing of a tumor in the right breast three years previously; a nodule had' 
formed externally to and below the nipple; she had borne ten children, 
but had nursed none of them. Menstruation was regular from her four- 
teenth to her fifty-third year. She had under the right eye a dark blue 
nodule about the size of a flax-seed, which she said she had had from her 
birth; her brother had a similar one in the same place. She had a similar 
one on the back in the region of the fossa supra-spinata, which had also 
existed from birth. 
The woman was pale and emaciated. The right mamma was larger 
than a child's head, hard, nodular, with the skin adherent to the tumor; 
a group of axillary glands could be felt. The whole tumor, which was 
freely movable on the thorax, together with the mamma and the axillary 
glands, was removed July 15, 1869. The operation was an extended one. 
When the patient left the hospital October 12, with the wound healed, 
a bluish nodule, which infiltrated the skin, was observed on the right side 
of the back. This subsequently developed into a black tumor, with sim- 
ilar nodules near it. The region near the scar and the axilla remained 
free. She died June 30, 1870. No autopsy was made. Duration of the 
disease, 4 years 
When I first reported this case in my Klinische Berichte (Vienna, 
1869-1870, p. 177) I had some hesitation about the classification of this 
tumor, and I wrote as follows. " On examination of this mammary tumor, 
which throughout its course has acted like a carcinoma, I was for a long 
time in doubt in what category to place it. The brownish-black pig- 
mentation and the arrangement of the large cell elements in somewhat 
small meshes, which here and there gave great security to the cell in the 
alveoli, made it appear for a long time probable that I had to deal with a 
sarcoma. Other situations of the tumor, as well as the method of spread- 
ing, the early involvement of the lymphatic glands, exquisite gland-like 60 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
forms of the large-celled cellular cylinders and bulbs, left also little doubt 
that it was a true, rapidly growing carcinoma of the mammary gland. I 
must finally conclude that it was a very intimate combination of carcinoma 
with sarcoma: a rapidly spreading epithelial growth and metamorphoses 
of the stroma into the tissue of an alveolar sarcoma very rich in pigment." 
It will be seen from the above citation that I very unwillingly reached 
the compromise of sarcoma and carcinoma. On more recent grounds, from 
Fig. 18.-From an Alveolar Melano-Sarcoma of the Mamma. The dark bodies in the trabec- 
ulaa correspond to the yellow, brown and brownish red pigment. 
repeated examination of the subject and wider experiences with alveolar 
sarcoma and melanoma, I do not hesitate to call the tumor under con- 
sideration simply a " sarcoma." I am especially prompted to do this be- 
cause I found the roundish alveoli in part filled with pigmented cells, 
and which I took for dilated gland-acini, also in the axillary glands, 
where they certainly could not have originated from the gland-clusters. 
Further, the continuous and detailed examination of rapidly growing 
melanoma has shown me that they are always sarcoma. Thus far there TUMORS OF THE MAMMARY GLAND. 
61 
has been no observation which furnishes proof that epithelial cells, for 
example, arising from the cutis, become pigmented in carcinoma; nor is 
there anything known as pigmented epithelial carcinoma. Now, since 
the epithelium of the mammary gland is derived from the epithelium of 
the cutis, it is in the highest degree improbable that it gives rise to true 
melanotic mammary carcinoma. It has been further especially proved 
as to large-celled alveolar sarcoma that it infects the lymphatic glands; 
that is, cell elements are prolonged into the lymphatic glands and there 
find a favorable soil for development, which is otherwise not frequent in 
sarcoma. So it was in the following case (see Fig. 19), which for a long 
time I took to be carcinoma, until repeated examinations of different 
portions of the tumor showed it to be a sarcoma. 
Alveolar Giant-celled Sarcoma. 
Mrs. Josefa F., 42 years old; had had several children and nursed them. 
She consulted me first in November, 1876, on account of a tumor as large 
as the fist which had existed a few months in the right breast. This 
tumor had large nodules, was lobulated, felt tolerably firm, completely 
encapsulated, and was easily movable in the gland; the axillary glands 
were not swollen. I did not get from it the impression of a carcinoma, 
but rather that of a lobular hypertrophy, and for that reason I used com- 
pression with a bandage for a week. The tumor did not become smaller, 
but was much more turgescent and painful. I extirpated it December 9, 
1876, and on account of the complete encapsulation I did not doubt that 
I had removed the whole diseased mass. It also appeared lobulated on 
section, was grayish red, and a fine granular jelly-like substance could be 
pressed from it; I therefore took it for carcinoma. My assistants, who 
made the microscopical examination, reported that the tumor contained 
strikingly large cells, and that it had the character of an alveolar carci- 
noma with some cystoid, muco-fatty foci of softening. The wound healed 
quickly by first intention. The operation was attended by an unusual 
amount of hemorrhage. In February, 1877, the patient returned with a 
tumor of the axillary glands, which was easily removed. In April a 
small recurrence near the cicatrix on the breast was removed. Soon 
there was a new recurrence in the axilla, which was extirpated on June 
28; the patient was attacked by erysipelas after this operation and died 
July 9. The autopsy showed double pleurisy, fibrino-purulent periton- 
itis, purulent cystitis, endometritis, salpingitis and bilateral oophoritis; 
no emboli anywhere and no metastatic tumors. 
I have again and again examined different portions of the tumor re- 
moved. Especially striking was the formation of the partially smooth- 
walled cystoid spots of softening in the axillary glands. If anyone could 
still think that these cysts, in tumors of the breast, arose perhaps by dil- 62 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
atation of the acini or excretory ducts, to which microscopic examination 
certainly gives no support, such ideas must surely be discarded in regard 
to the axillary glands. This cyst-growth, as is not unusual in giant-celled 
sarcoma of the bone, and also leads to the formation of hollow spaces with 
a perfectly smooth wall, similar to a serous membrane, certainly indicates 
sarcoma. Nevertheless some parts of the extirpated tumor appeared so 
Fig. 19.-From an Alveolar Giant-celled Sarcoma of the Mammary Gland. Hartnack, 
Syst. 5. 
markedly carcinomatous that I was constantly impressed with the idea 
that it was a carcinoma or a combination of sarcoma and carcinoma. 
Unfortunately I cannot so certainly decide the question in this case as in 
the former, because I myself did not make the microscopic examination 
in the first case, and because normal gland parenchyma, in which transi- 
tion forms could have been sought, was wanting in the preparation. 
The preparation, from which Fig. 19 is taken, is from the recurrent TUMORS OF THE .MAMMARY GLAND. 
63 
nodule of the mammary cicatrix. The lymphatic glands have a similar 
appearance. In order to form an idea of the size of those cells and their 
nuclei, one may compare this illustration (Fig. 19) with Figs. 16 and 17, 
as well as with the later illustrations of carcinoma, which are of the same 
enlargement. 
Pure spindle-celled sarcoma, myxo-sarcoma (myxoma) and plexiform 
sarcoma I have thus far never seen in the mammary gland. But in pro- 
liferating cysto sarcoma, which will be described later, there are not in- 
frequently parts which consist entirely of spindle cells, and not infre- 
quently also large portions which consist entirely of myxomatous tissue. 
Volkmann briefly mentions having observed an " intercanalicular spindle- 
celled sarcoma as large as a walnutin a woman 22 years old. 
Symptoms and Course of Soft Sarcoma of the Breast. 
The four cases reported show already how little infectious soft sarcoma 
of the mamma depends upon age: the cases were in the 14th, 31st, 42d 
and 65th years. As regards the course of these tumors, the reported 
cases in literature are not to be trusted. The differentiation of soft sar- 
coma from soft carcinoma and of the different forms of soft sarcoma from 
one another, is principally, and in part exclusively based on exact micro- 
scopic examination, and is the result of the progress made in the last ten 
years. By Velpeau, Erichsen, Paget, Gross, Birkett and other authors, 
these tumors are doubtless placed in the category of " encephaloid" ; 
though to completely identify them with these is impossible, or else 
Velpeau could not possibly say that the encephaloids are more frequent 
in the mamma than in any other portion of the body. He would also 
probably indicate the soft medullary appearing carcinoma as encephaloid; 
he considers it as identical with what Burns (1800) calls spongoid inflam- 
mation, Hey (1803) and Wardrop (1809), fungus haematodes, Abernethy 
(1804) pulpy medullary sarcoma. In a more singular way, he identifies 
it with carcinoma fasciculatum and carcinoma villosum (Rokitansky). 
Later there has arisen a class of " cancers fibro-plastiques " (Lebert), 
under which again napiform cancers, chondroids and colloid cancer have 
been placed as subdivisions. It is not to our purpose to discuss what we 
shall understand by these notations; the first incomplete beginnings of 
pathological histology brought a great deal of confusion into the former 
classification of tumors based on outward similarity. 
Since melanotic sarcoma is so clearly characterized by its color, the 
older surgeons of course described it when they found it in the mamma. 
But most of those who speak of it among the mammary tumors, say that 
they have not seen it. Velpeau only reports two cases, but he particu- 
larly says that the black nodules occurred in the skin near others of the 
same sort, and not in the substance of the gland. It therefore appears 64 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
that the above-described case is the only one that has been observed in 
recent times. Birkett mentions older preparations. In the museum of 
Guy's Hospital is a preparation of melanoma in the mamma, connected 
with melanoma in other parts. But it is not said of either case whether 
the melanoma in the mamma was the primary tumor. 
To present a clinical picture of soft sarcoma of the breast and its 
course is impossible on account of the small number of descriptions 
hitherto given. We can only say that the tumor is usually movable in 
the glandular tissue, is encapsulated, has solitary nodules on one side, 
and is seldom diffused in both breasts; that no age from the beginning 
of puberty up to the middle of the sixth decennium, is exempt, that it 
feels firm at first and grows slowly, then after perhaps one year it grows 
rapidly, is> usually painless, and then becomes larger and softer in differ- 
ent places. The differential diagnosis of cysto-sarcoma is not always to be 
made with certainty; the axillary glands are sometimes swollen, some- 
times not, recurrence appears quickly after operation, and death most 
frequently follows from internal metastases, especially of the lungs and 
liver. The duration of the disease is often very short, though sometimes 
as long as four years. 
Proliferating Cysto-Sarcoma. 
Very striking in their external configuration are the proliferating 
cysto-sarcomata of the mamma. They have long been known and de- 
scribed, though designated by many different names. The name " cysto- 
sarcoma" with the addition proliferum phyllodes, was introduced by 
Johannes Muller, and has been used by German anatomists and surgeons 
since that time. Virchow has proposed the term " intra-canalicular 
myxoma." In England the designations, sero-cystic sarcoma (Brodie), 
cellulose hydatids, (Cooper), glandular proliferous cysts (Paget), cysts 
containing solid growths, some with fluid, some without (Birkett), are 
used. Velpeau gives these cases many different titles, usually "tumours 
adenoides," then " cysts with thick walls," " encephaloids with cysts," etc. 
The not infrequently extensive tumors have large nodules, are encap- 
sulated and of very different consistency. When they are cut through, a 
great deal of serum and mucus usually escape. The cut surface is partly 
of a clear, pale reddish color, partly white, the tissue seeming yellow in 
places, oedematous (somewhat like nasal polypi), here and there studded 
with small extravasations, in other places tough and fibrous. The most 
striking thing on the cut surface is a more or less large number of irregu- 
lar hollow spaces, filled with a thin mucus, and into which project leaf- 
like (cysto-sarcoma phyllodes. Muller), or polypus-like growths, which 
more or less fill the hollow spaces. These growths are seen to rise from 
the hollow spaces, emptied of mucus, above the cut surface, so that they TUMORS OF THE MAMMARY GLAND. 
65 
have so much more the appearance of growing from the fissure-cyst- 
spaces. Besides, we also find a mass of large-branched fissure-cysts such 
as are described in the fibromata (Figs. 13 and 14); seldom are there 
simple round cysts, and more seldom the presence of white globules 
(epithelial pearls) in the cysts. The older anatomists have unhesitatingly 
assumed that cysts everywhere arise from exudation, and that new growths 
take place from their walls and in the cyst-spaces; they could with diffi- 
culty rid themselves of the parasitic nature of new growths. If it be con- 
ceded that the growths arise from a fibrinous, usually organized and 
vascular exudation from the blood, we still find no relation to the surface 
from which the new growths have arisen; an exudation which leads to 
the formation of such a cysto-sarcoma may, according to former views, 
just as well arise in muscle, bone, brain or anywhere else. According to 
Fig. 20.-Section of a Proliferous Cysto-Sarcoma of the Breast. One third natural size. 
the view of our predecessors as to the soil in which they developed, they 
have no further relation than that they draw blood and nourishment from 
there. The idea that the tumors are only a form of degeneration of tissue 
was at first very slowly developed, and has only been fully accepted among 
all anatomists and surgeons during the last ten years. Since on this ac- 
count we need not by any means give up a general knowledge of tumors, 
still, the development of tumors in each separate organ demands especial 
study. One of the greatest services rendered by Virchow is that he rec- 
ognized and filled this need. 
In the form which we have described, proliferating cysto-sarcoma can 
only occur in the mamma; it always includes glandular elements of the 
mamma. The fissure-cysts are the compressed excretory ducts of the 
lobules, lengthened, displaced, then again distended with fluid. The 
terminal vesicles are pressed together, lose their round form and also 
become fissure-cysts. 66 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
How the above-mentioned peculiar forms arise is very easily under- 
stood if we make a fine section of an apparent solid part of such a tumor, 
but which contains a number of fissure-cysts, and examine it with the 
magnifying glass or with very low power. At a, in Fig. 21, the termina- 
tion of an acinus is clearly seen; nothing of the gland-bulbs is seen; they 
Fig, 21.-From a Proliferous Cvsto-Sarcoma of the Mamma Hartnack, Syst. 5. 
are pressed into narrow canals. In this preparation there is nothing of 
the virginal mammary gland, but of the mamma of a woman who has 
borne and nursed several children; the spaces which now appear as narrow 
canals, not fused together on account of their epithelial covering, were 
formerly round gland-bulbs (acini) filled with milk. The narrow and 
during lactation almost shrunken connective-tissue sheath walls between TUMORS OF THE MAMMARY GLAND. 
67 
the bulbs have now grown to a colossal size, and as they form the floor 
for the glandular epithelium the epithelial surface must also grow. It is 
perhaps very much as in enormous enlargement of the cutaneous papillaj; 
with their growth also grows the epithelial surface. Therein appears to 
me to be the proof that the acini can have no true membrana propria, 
which, unconnected with the connective-tissue floor, is only loosely at- 
tached to it; if this be the case, it and the epithelial surface do not need 
to enlarge, since the connective tissue itself enlarges. But with this con- 
ception, there is a condition that the epithelium not only be preserved, 
but also increase with the growth of its floor. For, should the epithelium 
disappear, then by the growth of the tissue the gland-canals and acini 
would simply be obliterated. Finally, from the occurrence described, the 
further development of which may be seen at b and c (Fig. 21), there is 
no doubt that the growth proceeds from the layer of hyaline connective 
substance which immediately surrounds the gland-bulbs (Fig. 3), and that 
gradually more groups of gland-bulbs are involved in the manner de- 
scribed. A fibromatous or sarcomatous nodule is then developed in the 
general tissue, in which the lobules are enveloped with the immediately 
surrounding hyaline layer, and when once formed such nodules grow 
entirely central in and out of themselves (in the ideas of the older anato- 
mists); so they can only push the lobules to one side and compress them 
in toto. The above conception is also supported by the tuberous form 
of these tumors; the grouping in lobes is very clearly stamped on the 
younger parts of these tumors, as in Fig. 21; later they disappear as the 
connecting fibrous bundles degenerate into sarcomatous or fibromatous tis- 
sue. Reinhardt (Deutsche Klinik, 150, p. 121), Meckel von Hemsbach and 
W. Busch (Chirurg. Beobact., Berlin, 1854, p. 86), were certainly the first 
who clearly recognized all this, and who, though incompletely, stated it. 
Rokitanksy, though very much attached to his theory of the outgrowth 
of the connective tissue, by which he not only explained the growth of 
cancer structure but at the same time also the extensive growths from 
cyst-walls, still showed that he completely appreciated these growths, as 
may be seen from the illustrations in the third edition of his pathological 
anatomy. II. von Meckel saw a carcinoma of the breast in which he was 
able to cut from the nipple a dilated excretory duct and so free the growth 
(Fig. 22). As concerns the tissue itself from which this sarcoma arises, 
it is partly cedematous, fasciculated connective tissue, rich in cells, and 
partly myxomatous, lymphoid, but seldom spindle-celled tissue. The 
previously described preponderating medullary-appearing form of the sar- 
comatous tissue I have not found in these tumors so far, or at least only 
strewn around in a few places. It may happen, however, that these 
softer forms of sarcomatous tissue may lead to the formation of prolif- 
erating cysto-sarcoma. 
As already remarked, the consistence and increase of the glandular 68 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
epithelium play a very important part in the formation of these tumors. 
It is a tolerably regular occurrence for the epithelium in all the gland 
spaces and in the acini to become many-layered, and to take the character 
of cylindrical epithelium on the surface. Here and there it takes on active 
growth so that the spaces are entirely filled with epithelial cells, which 
finally roll together into spherical forms. I have seen no case in which 
Fig. 22.-Part of an Extirpated Cysto-Sarcoma of the Mamma. (After Meckel von Haus- 
bach.) About one-half natural size. The beginning of the peculiar disease is seen at a. 
this balling together of the epithelial cells lead to the formation of pearls; 
but Virchow mentions these growths in cysto-sarcomata of the mamma. 
Most frequently the epithelium is dissolved into homogeneous mucus, which 
then fills and expands the gland-sarcoma; some exudation may be added 
from the vessels to thin this mucus. 
Symptoms and Course.-These proliferating cysto-sarcomata of the 
mamma, the prognostic signification of which depends not on the contents 
and mass of the cysts, but on the histological character of the interstitial TUMORS OF THE MAMMARY GLAND. 
69 
tissue, always possess sufficient peculiarities to separate them from fibro- 
sarcomata, soft sarcoma and adenoma, though it must be remembered 
that these forms of tumors are not to be sharply differentiated anatomically, 
and there may be many combinations of them. 
They originate most frequently in the second or third decennium, 
more often in the married than in the unmarried, and most frequently 
in women who have borne children, less frequently in sterile women. 
Their upper surface is marked by large nodules; then- consistence is dif- 
ferent in different places; where the cysts lie near the surface, distinct 
fluctuation is often obtained, and in other places, the surface is firm or 
soft. They are always encapsulated and movable in the gland, never 
Fig. 23.-From a Cysto-Sarcoma, with Myxomatous and Sarcomatous Tissue. Hartnack, Syst. 7. 
adherent to the thorax, even when they grow to giant size. Their growth 
is very variable; there are cases in which they only attained the size of a 
hen's egg in two or three years, and others in which, in the same time, 
they have attained the size of a child's head. The growth is usually pain- 
less; they are not painful to touch or light pressure. In two cases noted 
by me, there was an appearance as though the cysto-sarcoma arose from 
fibro-sarcoma, which had remained dormant for many years (in one case 
19 years). 
Sometimes these tumors grow to enormous size as in the following 
case from Velpeau: 
Mrs. A., 54 years old; tumor began 4 years ago; menopause 2 years 
ago; one year ago the tumor was the size of the fist, but has grown 70 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
rapidly since then. Patient refused operation. The tumor varied in 
consistency; the base was solid, with large fluctuating spots in other parts. 
The skin was thinned, and was traversed by large veins; below and ex- 
ternally there was slight ulceration. The greatest vertical measurement 
was 14.14 inches, transverse 11.8 inches, and greatest circumference 44.3 
inches. The woman was very much emaciated and very weak. Over 3 
quarts of fluid, with tumor detritus, were evacuated through two punc- 
tures. Weight of tumor 44 pounds. Unfortunately nothing is said of 
the axillary glands, or whether metastatic tumors were found in internal 
organs. Death from marasmus. On account of the number of small 
cysts, the tumor is sufficiently characterized as cysto-sarcoma, though 
Fig. 24.-Enormous Cysto-Sarcoma of the Mamma. (Velpeau.) 
Velpeau calls it adenoid. The cases taken by Beigel from Pemberton 
and described as encephaloid tumors probably belong in this category. 
At all events, the cases illustrated by Cooper belong to such giant cysto- 
sarcomata. All these tumors were observed in old married women who 
had borne several children; the origin generally dated from the beginning 
of the sixth decennium, and coincided with involution; the growth was 
very rapid, these enormous tumors being formed in from two to four 
years, usually without involvement of the lymphatic glands, and without 
internal metastases. Ulceration has been observed several times, partly 
through spontaneous rupture of the cysts, partly from incisions into 
them, and by necrosis of tlie very thin skin, here and there adherent to 
the tumor. 
Erichsen describes a case in which the sarcomatous masses grew, in a TUMORS OF THE MAMMARY GLAND. 
71 
cauliflower-like mass, from the opened cyst. Of the nineteen cases seen 
by me, fourteen were married and five were unmarried. I can prove that 
twelve cases remained free from recurrence for from two to ten years after 
operation. Here was recurrence occurring locally, for, as a rule, only the 
tumors were removed, not the whole of the mammary gland. I operated 
on one woman five times in four years; there was quick recurrence. The 
whole gland has now been removed and there has been no recurrence for 
three years. In one case metastases occurred in the pleura, ribs and 
pericardium without infection of the lymphatic glands. In another case 
there was exquisite left-sided cysto-sarcoma with local recurrence and with- 
out infection of the lymphatics, and somewhat later exquisite right-sided 
carcinoma with involvement of the axillary glands, and death from inter- 
nal carcinomatous metastases. 
In general, it can be truly said that even if cysto-sarcoma of the breast 
grows to such enormous size, it is still seldom infectious. Unfortunately 
the anatomical descriptions in the journals are not sufficiently exact to 
draw any conclusions as to whether the cases with infection of the lym- 
phatic glands and with internal metastases had especial histological pecu- 
liarities by which the prognosis could be determined. Further observa- 
tions are needed m order to make a more extensive study. 
Adenoma (true Hypertrophy) and Cysto-adenoma. 
The differentiation of adenoma from many other tumors of the breast 
is unusually difficult. If the development of the gland-vesicles with for- 
mation of hollow spaces be regarded as the most important thing for the 
establishment of adenoma or true hypertrophy of the gland, still this 
cannot take place without a simultaneous growth of new connective tissue 
with vessels, else there would only be an interlacing cell-proliferation in 
the form of branched cylinders and terminal bulbs, which could not exist 
without formation of vessels Vessels grow, but never alone, in the epithe- 
lium, for they need surrounding supporting tissue, however slight it 
may be. Now since the pathology of a new growth is important, because 
the relation of the different tissue elements to one another is more or less 
of a deviation from the normal type, it happens that in adenoma at ne 
tinur the epithelial elements, at another the connective tissue with the 
vessels is more prominent, not only in all tumors, but also in different 
parts of one and the same tumor When the newly-formed onnective 
tissue near the epithelial glandular elements .omes o complete physio- 
logical and at the same time excessive development the expression 
" false," " incomplete hypertrophy/' or " elephantiasis" is used. If the 
newly-formed connective tissue remains for the most part in the earlier 
stage of development, we use the expression ' adeno-sarcoma. " If the 
growth of the epithelial elements is especially great, and if they are larger. 72 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
more varied in form than they normally are, then the purely anatomical 
differentiation from carcinoma in certain cases becomes very difficult, be- 
cause we scarcely dare set up a strict claim to an adenoma of the breast 
developing after an embryonal type, since immediately both hollow spaces 
and secretion make their appearance in the young acini, and this is not 
the case every where even in the development of the gland at puberty, 
but occurs first in the development accompanying the first pregnancy. 
As in many similar cases in the domain of pathology, we find in such a 
dilemma more support in the course and clinical appearances than in the 
(as Heinrich Meckel used to say " limited") anatomical analysis. 
This form of disease being so rare I think I am especially fortunate in 
having seen two such cases, and in having had the opportunity to examine 
one anatomically. 
Maria S., maid servant, virgo intacta, 16 years old,came under my ob- 
servation in the Autumn of 1868. In November, 1867 (then 15 years old), 
she menstruated for the first time; until April, 1868, she had very small 
breasts. In June they had reached their present size (in two and a half 
months), then became somewhat smaller until October, when they again 
grew to their present size. The left breast measured 23 inches in circum- 
ference at the base From the lower border of the third rib, where the 
breast began, up to the papilla was 10$ inches, and from right to left 9 
inches. Right breast: periphery of base 19| inches, from the third-rib to 
the papilla 9$ inches, and from right to left 84 inches. All measurements 
were made while the breast was dependent. The patient would not submit 
to an operation. I heard about one year afterwards that the girl was in ser- 
vice and able to do light work. The breasts had become a trifle smaller. 
Anna A., servant girl, came to my clinic on June 24, 1873; she was 22 
years old, of strong build, always healthy in childhood, first menstruated 
in her fifteenth year, and was always regular. About 3 years before (in 
her 19th year), she noticed a striking enlargement of both breasts; this 
came on slowly, without pain, and without any annoyance to her. 
The menses have been absent for five months, and now the breasts have 
grown so enormously that the patient is bent forward and is unable to 
work. When she came to the clinic, the breasts were so large that they 
reached down over the umbilicus, and were more prominent and far 
harder than in the first case. 
Within the soft granular parenchyma of the gland on both sides could 
be felt hard, movable nodules the size of a fist. The nipples and areolae 
were deeply pigmented, the first spread out. (Unfortunately also in this 
case it was not noted if colostrum could be pressed from the nipples). 
The circumference of the left breast at its base was 25.54 inches, and of 
Diffuse Hypertrophy of the Breasts. TUMORS OF THE MAMMARY GLAND. 
73 
the right 26.72 inches. From the upper boundary over the nipple down 
to the lower boundary was 28.68 inches on the left side, 29.86 inches on 
J ig. 25.-Hypertropay of both Breasts. Girl 16 years old. 
the right. The greatest circumference on the left side was 32.22 in- 
ches, and 33 inches on the right. The skin over the breasts was some- 
what thickened but not especially adherent to the glandular tissue. Ex- 74 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
tensive venous plexuses were seen through the skin. The patient had no 
pains in the breasts, but the weight was so great that she was obliged to 
Fig. 26.-Hypertrophy of both Breasts. Woman 22 years old. 
remain in bed. Examination of the abdomen and genitalia showed the 
existence of pregnancy, at about the fifth month. TUMORS OF THE MAMMARY GLAND. 
75 
Operation on such extensive tumors was not to be thought of during 
pregnancy. It seemed, however, that an attempt might be made to re- 
duce their size by compression; compression was tried at intervals for a 
short time with elastic bandage, but generally with ordinary cotton band- 
ages. After a few days the right breast appeared to be softer and smaller. 
But the pressure of the bandage caused some excoriations in the region 
of the nipple, and intense erysipelas was developed on July 5th; on July 
6th the patient aborted and quickly collapsed, though there was no con- 
siderable hemorrhage, and death took place on July 7th. 
Examination of the hypertrophic glands showed that true hyperplasia 
was present in part only, but that there were a number of large and small, 
soft and hard encapsulated fibromata, in which portions of the gland were 
inclosed, the excretory ducts of which were here and there dilated into 
branched fissures, as is usual in these tumors. Cross section of the 
mamma reminded me of a uterus studded with many fibromata, except 
that the tumors were softer and more succulent than is usually the case 
in uterine fibroma. 
Microscopic examination of these fibro-sarcomatous nodules showed 
nothing especial. I will only add now that the enclosed gland-ducts 
contained a considerable amount of very milk-like colostrum; from which 
it is seen that the enclosed portion of the gland, though not markedly 
changed, had not lost their physiological function in pregnancy and labor. 
I had previously had an opportunity to make a similar observation. B. 
von Langenbeck amputated the breast of a woman which contained a 
tolerably large fibro-sarcoma which had become inflamed after labor. 
Numerous abscesses had formed, the woman sank very low, and the 
whole gland was removed with the fibroma in order to cut short the pro- 
cess. The acini and excretory ducts in the fibro-sarcomatous tumor were 
all filled with milk. 
It has already been said that in this case the lymphatic vessels deep in 
the glandular substance were filled with cocci (in consequence of the ery- 
sipelatous infection). The glandular substance which was met with in 
excessive quantity near the tumor nodules, did not differ at the borders 
of the lobes from amply developed glandular tissue of a mamma prepar- 
ing for lactation. 
The contents of the gland vesicles was partly mixed with colostrum 
bodies. The acini appeared to be extraordinarily large. In other places 
there was no connective tissue for wide tracts, and in those places where the 
epithelial cells were especially large and the gland vesicles entirely filled, 
the latter were bent and irregularly formed, and one would easily get the 
impression that he had a piece from a carcinoma of the gland before him. 
Whether in this case, at the beginning, only the multiple fibroma-nodules 
existed, and hypertrophy of the portions of the gland not included in 
them first developed with pregnancy, is hard to say. The case shows that 76 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
growth of the connective tissue in the gland in the form of nodules, and 
growth of the epithelial elements, " true and false hypertrophy," (in this 
case in combination with the preparation for lactation), may develop at 
the same time. 
All authors who have written of diseases of the mammary glands have 
Fig. 27.-From the purely Hypertrophic part of the Mammary Gland of the Patient 
shown in Fig. 26. Hartnack, S.vst. 5. 
mentioned double diffuse hypertrophy, though not many appeal* to have 
made special observations, and hitherto the anatomical examinations have 
been very meagre. So far as I can find from obtainable literature, Paget, 
Birkett, Schuh, Rokitansky, Klob, Beigel, Bardeleben, and Konig have 
not even seen such cases. The case which Virchow mentions from his 
private practice does not appear to me to belong here, since the descrip- 
tion does not at all correspond to the other cases. As more or less cer- TUMORS OF THE MAMMARY GLAND. 
77 
tainly belonging in this category are the cases described by Cooper, Gross 
and Hanley, Erichsen, Renaud, Huston, Benoit and Monteils, Le Double, 
Fingerhut (?), Adams, Hey, Thomson, Manec (Gaz. des Hop., 1859, p. 
45), Hess (Correspondenzblatt des Vereins nassauiseller Aertze, 1859, p. 
17, 49), U. G. Grabs (Hygeia, Bd. 23, p. 318. Schmidt's Jahrb., Bd. 
118, 1863, p. 44), Gluck (Amtlicher Bericht uber die 39 Versammlung 
Deutscher N aturforscher und Aertze in Giessen im Sept., 1864. Giessen, 
1865, p. 219), to which may be added both of the cases observed by me. 
The following is to be said of the development and course of this con- 
dition: Diffuse hypertrophy of both breasts is always developed at the 
time of the first menstruation, or soon thereafter. The age most fre- 
quently noted is from 14 to 16 years; but in a few cases 2 or 3 years 
elapse after the first menstruation before hypertrophy exists (as in my two 
cases). The development of hypertrophy is always rapid in two or three 
months, and then as a rule remains in the condition reached, or it may 
attain a greater degree with the first pregnancy and then remain un- 
changed; there is no such thing as a continuous and indefinite growth 
of it. The skin grows proportionately to the development of the gland, 
and is often somewhat thickened and oedematous. The nipple is not de- 
veloped in proportion to the enlargement of the gland, but retains its 
usual size and becomes flat. The subcutaneous veins sometimes appear as 
dilated nets, though without becoming varicose. There is no pain with 
this condition. 
Galactorrhoea is not usually combined with this hypertrophy at the 
time of the development of puberty; milk is formed in the hypertrophic 
glands if the affected person becomes pregnant. It is not certainly shown 
that there is any influence on menstruation and the development of the 
genitalia. As a rule the menses are regular, or the general constitution is 
proportionately spare and not well developed. In one case an ovarian 
cyst developed, from the rupture of which the patient died. 
As to the course, it is only shown that from the weight of the breasts, 
the capacity for work is seriously interfered with, and that the nutrition 
of the patient affected with such hypertrophy is usually bad; there does 
not appeal' to be any further constitutional influence. So far as I know, 
death is never directly caused by thi condition. Whether the duration 
of life is influenced thereby is difficult to say; but it is certain that a per- 
son has lived eighteen years after the beginning of the development of 
hypertrophic breasts, and perhaps there are many who have lived longer. 
In Huston's case death followed from inflammation and ichorous ulcer- 
ation after contusion (it is said in the report, from acute hectic fever, 
though it would now be described as septic fever), in one of my cases from 
erysipelas. In Grah's case the patient died 18 years after the beginning 
of the disease, which developed in her fifteenth year, from rupture of an 
ovarian cyst. The formation of abscesses and fistules is noted in Grah's 78 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
and Hess's cases, and 'there was also some swelling of the axillary 
glands. 
Only in these last cases were there accurate anatomical examinations 
made. In the necropsical account of Huston's case it is said, (Am. Jour, 
of the Med. Sciences, No. XXVIIL, August, 1834, p. 3), that no particular 
diseased condition was found in the breasts, no collection of fluid, no 
tumor, only an enlargement of all parts of the gland: " The adipose and 
cellular tissues as well as the whole glandular apparatus, were enormously 
enlarged, but no appearance of disease or exudation of fluid was percep- 
tible. In short, a healthy structure was found, whose only anomaly was its 
mammoth proportions." We cannot expect any exact microscopical ex- 
amination as far back as 1834. C. G. Griihs writes of the case on which 
he made an autopsy that the tumors were as hard as scirrhus, and con- 
sisted microscopically of compactly pressed bundles of connective tissue 
fibres. Hess said that in the breasts extirpated by him no trace of gland- 
ular tissue could be found. What I found, in the second case related, 
has been mentioned above. It is very probable that in most cases there 
is a similar condition; it might be concluded from the very frequent men- 
tion that hard nodules are found in these breasts that the combination 
with fibro-sarcoma is very frequent. How long the hypertrophic tissue ex- 
ists as such, and whether it is finally supplanted by connective tissue and 
fat, we do not know; but I believe this to be probable. 
Many therapeutic measures have been tried in these cases, chiefly com- 
pression and iodide of potassium, but without result. The introduction 
of a seton (Thomson) is certainly not to be advised; it might result very 
dangerously, and even in the most favorable cases, the consequence would 
be a purulent breaking down of the tissue immediately surrounding the 
seton, and there would be no noteworthy diminution. Mance, Hess, and 
Gluck have performed amputation of both breasts in such cases with suc- 
cess; the two breasts were always removed at different times. One of 
these patients afterwards became pregnant, and had a normal labor; 
neither during pregnancy nor after labor was there any swelling or red- 
ness in the region of the cicatrix. Whether such hypertrophic breasts 
would retrograde if the women became pregnant and nursed their chil- 
dren for a long time, there are, so far as I know, no observations; in my 
second case the observation was unfortunately interrupted by the death 
of the patient from erysipelas. 
As concerns the cases which, especially in older literature, are described 
as colossal hypertrophy of one breast in women of midde age, there is no 
doubt from the description that they were large cysto-sarcomata, of which 
we have already spoken, as this sometimes attains an enormous size. The 
cases in which marked galactorrhoea is connected with unilateral so-called 
hypertrophy, as the case of Lotzbeck, {Wiener Med. Wochensch., 1854), 
the case from V. von Brun's clinic, and that of Ehrenhaus., {Berlin. TUMORS of the mammary gland. 
79 
Klin. Wochenschr., 1870), probably belong to the category of so-called 
galactoceles, of which mention has been made. 
Partial Hypertrophy of the Breast.-Adenoma and Cysto- 
ADENOMA. 
So far I never seen a tumor of the mammary gland which, on histolog- 
ical analysis, admitted absolutely no other designation than that of a partial 
and glandular hypertrophy, a purely circumscribed adenoma. It was a 
long time before I met with a case that corresponded nearly to what other 
authors had described as true partial hypertrophy of the mamma. It is 
therefore more as a concession which I make to the systematic complete- 
ness of this work, that I describe here the following cases; they should, 
perhaps, be brought in at other places (under fibroma, adeno-sarcoma, 
etc.) There are two entirely different groups of these so-called adenomata. 
Fibrous Lobulated Adenoma. 
The following figure gives a good idea of the appearance of the section 
of such a tumor, only the lower part is compact and fibrous; the largest, 
Fig. 28.-Fibrous Lobulated Adenoma of the Mamma. So-called partial hypertrophy of the 
mamma. Two-thirds natural size. 
upper part, consists of lobes and lobules which are held together by loose 
connective tissue containing fatty tissue. The lobules feel in the breast of 80 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
the patient firm and finally granular. Microscopic analysis shows that the 
centre of each lobule contains some partly dilated acini, though its prin- 
cipal mass consists of a firm fibro-sarcomatous tissue, as is always found 
in the fibro-sarcomata occurring in young persons. If one imagines the 
fatty tissue, which is replaced in the more central parts of the tumor by 
loose bundles of connective tissue, absent, and the fibromatous tissue, 
which surrounds the single gland lobules, to be continuous, the tumor 
would in no wise differ from the ordinary fibro-sarcoma of the mamma. 
Fig. 29.-From a Fibrous Lobular Adenoma of the Breast. Fig. 28. Hartnack, Syst. 5. 
I have no doubt that this tumor corresponds to what Forster saw, and of 
which he has made a teased preparation (Fig 30). 
So lobular and gland-like seemed the tumor which I saw, that I could 
not prove that the acini found therein were pathologically newly-formed. 
A short time ago I saw a very similar tumor, in an unmarried woman, 
about 30 years old, with poorly developed breasts; there had formed a 
large number of hard, granular nodules, which varied in size from that 
of a pea to a bean, and part of which had in the course of the last 
few weeks become confluent. After the extirpation, the single hard nod- 
ules looked exactly as shown in Fig. 29; between them there was com- TUMORS OF TTIE MAMMARY GLAND. 
81 
pletely normal tissue. It would seem right to me to describe these cases 
as multiple lobular fibroma, which they are, anatomically speaking; 
though, if we must absolutely have a partial hypertrophy of the mamma 
as a form of tumor, these tumors must be classed as such. 
Fig. 30.-Development of Gland Tissue in a Tumor of the Mamma. Partial hypertrophy 
of the mamma. Enlargement 200. (Forster, Atlas of Pathological Histology.) 
I cannot give a clinical picture of these two cases. I am convinced that 
almost all that has been said of the course and origin of fibro-sarcomata 
will also apply to these cases. 
The Soft Cysto-adenoma. 
I have seen two cases, which, if we cannot relegate them simply to the 
cysto-sarcomata, must be so described. At all events I have done this 
with one case, when recording it, for I found in my collection a tumor 
designated as " cysto-sarcoma," which answered to the histological pecu- 
liarities which will shortly be mentioned, though I could not find the pro- 
per clinical history, which had unfortunately become detached from the 
label of the bottle containing it. 
In examining the tumor, without knowing where it came from, one 
might imagine that it was from a mucous polypus of the rectum or uterus. 
It is very remarkable that the acini of the mammary gland distend to 
such long drawn-out hollow spaces with mucous contents; that they are 
all clothed with a many-layered, manifest, cylindrical epithelium is less 
striking, because I have seen the same thing in proliferating cysto-sar- 
coma. The distension is generally similar; it leads to irregular hollow 
spaces, into which, as may seem at first glance, papillary growths are 
forming. On closer analysis, it is soon found that these papillary growths 
are nothing else than the somewhat enlarged partitions between the acini. 
It is in miniature a similar developmental process to that occurring in 82 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
cysto-sarcoma, except that the interstitial tissue here is not markedly ex- 
uberant; not, or at least in only a few places, sarcomatously degenerated 
(the vascularisation therein had become somewhat richer, though the 
bundles of connective tissue remained most important), and that the dil- 
atation was equally diffused in all the acini, while in proliferating cysto- 
sarcoma, the excretory ducts become disproportionately dilated. Beigel, 
under the description " Sarcoma Adenoides mammae," and Konig, under 
Fig. 31.-From a Soft Cysto-Adenoma of the Mammary Gland. Hartnack, Syst. 5. 
" Cysto-sarcoma proliferum," give anillustration which corresponds tol- 
erably well to the above. A second case belonging here I have already 
described under "tubular cysto-adenoma of the mamma" (Archiv. f. 
KI. Chirurgie, Bd. I, p. 649). In this case there was as much difficulty 
in the clinical as in the anatomical diagnosis. I here quote from my 
former description: 
A short time ago (July, 1865) I extirpated a tumor from the right 
breast of a young married woman of about 24 years of age, who had never 
been pregnant; the tumor was about the size of a ben's egg, was immov- TUMORS OF THE MAMMARY GLAND. 
83 
able in the gland, felt lobular and uneven, and caused moderate pains 
which radiated to the arm of the affected side; it had developed in the 
course of one year. My diagnosis was uncertain; although the local ap- 
pearances were strongly in favor of carcinoma, the age of the patient was 
against it. It certainly was not a sarcoma. When I extirpated the tumor, 
I found it in intimate connection with the glandular tissue, and on the 
cut surface a solid mass filled with cavities from the size of a millet seed 
to that of a pea, from which a pulpy, granular, yellowish substance could 
be easily removed, and I could not yet reach a definite opinion; it might 
be a collection of small, caseated foci of inflammation (so-called tubercu- 
losis of the mammary gland), or an atheromatous formation of peculiar 
form, or again carcinoma with spots of softening. Microscopic examin- 
ation alone could differentiate." The patient now, 14 years after the 
operation, is perfectly well, and there has been no recurrence. 
On microscopic examination I found that the cyst spaces proceeded from 
enlarged gland-clusters; that very soft papillary excrescences were formed 
in them, which underwent muco-fatty softening after some time. Be- 
tween these small cysts was a very distinct net-work of branched gland 
canals, which had an easily recognized, open connection with the cysts: 
this net-work was imbedded in a firm cicatrix-like connective tissue; in 
many places the interstitial tissue had exactly the appearance of an atro- 
phying cicatrizing carcinoma. My explanation was as follows: new plexi- 
form gland tubules had formed and the gland-lobules had dilated into 
small cysts; I therefore chose the name "lobular cysto-adenoma." I 
then compared these growths with the same form of tumors in the sali- 
vary glands. But, since the latter, after Sattler's researches, are regarded 
as belonging to the class of " plexiform sarcoma," I was again doubtful 
whether the above mammary tumor did not also belong to the " plexi- 
form-sarcoma, " and I once more examined the well-preserved preparation. 
I arrived at exactly the same results as before, except that my expla- 
nation of the abnormal contents of the branched gland-ducts is now a 
different one. I am now convinced that these tubules are not newly 
formed, are not outgrowths of the already existing gland ducts during the 
development of the tumor, but that they are only pushed so unusually 
close together, partly narrowed, partly dilated, by the cicatricial contrac- 
tion of the interstitial tissue. I formerly underestimated the signification 
of this cicatricial connective tissue. The radiating pains from the tumor 
also show the existence of a process by which the nerves are compressed or 
torn. Unfortunately there is nothing in the clinical history as to whether 
the tumor began after a certain, recognizable, immediately preceding 
wound; from the anatomical examination I would deem this very prob- 
able. 
This explanation may now, perhaps, throw some light on the develop- 
ment of the cysts. I will return to this point in the next section, and 84 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
will now notice some other anatomical occurrences in the lobules of the 
gland. 
In Fig. 32 I have gathered together, without giving to it any sche- 
matic character, several changed gland lobules, which were widely separated 
from each other, in order to place developmental occurrences where thev 
mry be seen together. At b the section of an unequally widened acinus of 
Fig. 32.-Development of Cysts with Papillary Excrescences; from a cysto adenoma of the 
mamma. Hartnack, Syst. 5. 
a lobule is seen; the partitions have become very thin, and are already 
partly shrunken; the epithelium, already cylindrically formed, is in part 
still adherent; the desquamated and mucoid softened epithelial cells 
have fallen out. 
Before there is complete atrophy of all the fine partitions in a gland 
lobule, and before a faulty cyst, with few excrescences (the remains of 
these partitions), arises, as shown at d, there is not infrequently a con- TUMORS OF THE MAMMARY GLAND. 
85 
siderable growth of these papillary formations, as shown at c. The orig- 
inal round form of the acini has become very much drawn out. The 
connection of this illustration with Fig. 31 is easily apparent. The filling 
up of the small acini is at times so considerable, that we can really see no 
hollow spaces. 
Since from these descriptions it is very evident what I understand by 
cysto-adenoma of the mamma, and how it is anatomically developed, the 
classification of these few cases under " cysto-sarcoma " and 11 adeno- 
cystoma " should at all events be justified. It will scarcely be advanta- 
geous to be continually finding a name for every little departure from a 
once erected anatomical type, since we would also have to combine with 
it an exact clinical picture of the disease. Concerning this I can say 
nothing from the few cases in question. The degeneration of the gland 
vesicles into cysts is generally to be regarded as perhaps favorable prog- 
nostically; it usually appears where the epithelial exuberance cannot in 
any way break through the boundaries of the gland vesicles; it does not 
come from the floating of the epithelium through the lymphatic channels, 
nor through infection of the lymphatic glands. Should a more solid 
epithelial-celled growth appear, the surrounding tissue becomes softened 
from cell infiltration, and if the vascular network around the gland 
lobules is sufficiently developed to give the epithelial growths sufficient 
nourishment, they easily break through their physiological boundaries 
and go on to the development of carcinoma with infection. It is known 
that this occurrence first takes place, as a rule, in the fourth decennium 
of life. Adenomata, which are developed at this time, may therefore be 
much more dangerous than those originating earlier in life. 
Cysts. 
Mention has already been made of the origin of cysts in sarcomata and 
adenomata; the cysts were the occasional additions to other neoplasms. 
Bnt there are also cases in which solitary and multiple cysts originate in 
the mamma, without there being any other newly-formed tissue; cases 
in which the tumor is formed only by one or more cysts. I have clini- 
cally observed and operated on only five such cases; from this it might be 
concluded that the disease is infrequent, but such is not the case; it is 
only seldom that they attain considerable dimensions. Small ones are 
very frequent in elderly women, and especially at the time of involution; 
they are also found in entirely healthy breasts which have taken on the 
normal senile atrophy; and very frequently also in healthy portions of a 
partially carcinomatously degenerated mamma. Cooper illustrates such 
a mamma studded with larger and smaller cysts, which gives a very typi- 
cal picture of the affection,, and which, somewhat reduced, I have repro- 
duced in Fig. 33. 86 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
These cysts seldom originate before the fortieth year; they are pain- 
less, grow very slow'ly, and the largest of them only reach the size of a 
medium-sized orange. Their walls are usually very much distended, and 
for that reason, fluctuation is not always distinct. As a rule they lie more 
peripherally, though they also approach the nipple, as may be seen in 
the illustration. If there is a thick layer of adipose tissue over them, it 
is very difficult to make a positive diagnosis; according to the movability of 
the tumors, which at one time feel hard, at another soft and from the age 
Fig. 33.-Mamma with many small Cysts; prepared with a portion of the skin, the nipple and 
areola. (Astley Cooper.) 
of the women, one will at one time diagnosticate a sarcoma, again an ade- 
noma or carcinoma. The escape of brownish serum from the nipple 
occurs with so many tumors of the mamma that no diagnosis can be based 
upon that; in cysts of this kind, this is relatively frequent. These cysts 
are neither dangerous on account of their vigorous growth nor on ac- 
count of pain; in the interest of the patients, it was always an acceptable 
surprise to me to find such a solitary cyst, where I had expected to find a 
different tumor. Carcinoma or sarcoma may occur in their immediate 
vicinity, with their walls adherent. TUMORS OF THE MAMMARY GLAND. 
87 
The anatomical development of these cysts is easily seen in proper pre- 
parations. Mammae, in which perfect cysts of this kind occur, always 
Fig. 34.-Cystic Dilatation of the smaller Excretory Ducts. Hartnack, Syst. 5. 
show in the apparently normal parts the development stages of such 
cysts. These cysts always proceed from dilatation of the small excretory 
ducts. (Fig. 34). 
Fig. 35.-Section of a Cyst of the Mamma. Natural size. (Virchow.) 
Though it may possibly happen that a single gland lobule may dilate 
into a cyst, as seems to be the case, for example, in fibro-sarcoma (see Fig. 88 
DISEASES OF TILE FEMALE MAMMARY GLANDS. 
15), it is much more frequent that cystic dilatation attains the condition 
shown in Fig. 34, and so much the more as in the already partly involuted 
mamma, in which these cysts are developed, there is scarcely found a 
large number of terminal vesicles, and a much smaller number of larger 
gland clusters. 
What appears in the foregoing cut to be dilated, are probably only the 
finer gland ducts, whose acinous appendages are already atrophied. 
Against the idea of the expansion of single terminal vesicles is the fact 
Fig. 36.-Section of a Cyst wall with Undulating Elevations. Much brownish-red pig- 
ment; rich vascularisation. Hartnack, Syst. 4. 
that the larger and more developed cysts usually show the remains of dis- 
tinct, earlier, firm, intermediate septa. 
Papillary excrescences, also, equally as well to he regarded as the re- 
mains of former septa, are sometimes present on the inner surface of these 
cysts. Sections of the cyst-walls arranged for microscopic examination 
usually show nodulating elevations (Fig. 36), which must be regarded as 
the last traces of former septa. There is either no epithelium in the 
larger cysts, or there are only traces. 
A very peculiar case of multiple cysts of the mamma, both in regard to 
form and course, was observed by Richard and Jarjavay, and reported by TUMORS OF THE MAMMARY GLAND. 
89 
Velpeau. Gurot {Arch.f. Klin. Chirurg., Bd. III., Jahiesbericht, p, 315) 
has written up the clinical history of the case as reported in various 
French journals, in the following words: 
"Richard (Graz. des JJopit., 1861, p. 91) showed to the Societe de Chi- 
rurgie a woman 77 years old, with a very wonderful tumor of the breast. 
In 1851, Jarjavay, in Velpeau's division, removed a voluminous cysto- 
sarcoma of the right breast, consisting of a large number of small cysts 
and of hypertrophic mammary tissue. This woman was twice afterwards 
operated on by Richard, as the reproduction of the cysts followed rapidly. 
At each operation, several small tumors, formed of cysts or hypertrophic 
gland tissue, were removed, sometimes three or four, and at one time as 
Fig. 37.-Compound Cystoma. Natural size. (Velpeau.) 
many as ten. Two years ago all operations were discontinued, and in the 
region of the nodules and throughout the whole extent of the mamma 
was found a large number of small tumors, partly in groups, partly isolated, 
of different sizes, and having no connection with the deeper structures. 
They were covered with partly bluish and partly normally colored skin; 
some of them distinctly fluctuating, others somewhat harder and more 
elastic. The glands were healthy and the general condition very good. 
This unusually rare and peculiar case could only be judged correctly by 
an exhaustive histological examination; this was wanting, therefore we 
only express conjectures. In view of the age of the patient (the cysts 
developed in the middle of the seventh decennium) the most probable view 
is that of a multiple development of involution cysts. Notwithstanding 90 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
it is said the cysts were surrounded by " hypertrophic " glandular tissue, 
single small tumors only had originated from them. Hypertrophic mam- 
mary tissue in a woman 77 years old ' The histological examination cer- 
tainly could not have been a careful one. Consider, too, the course; with 
so many operations, every particle of the senile mamma should have been 
removed. Perhaps it was a myxoma, as such do occur in the cellular tis- 
sue of the thorax, and almost always recur locally in those of good general 
health; but it certainly would not have any relation to the glandular sub- 
stance of the mamma. 
In regard to the contents of these cysts, it is usually a thin, or some- 
what slimy fluid, and, as a rule, of a greenish or brownish color. Micro- 
scopic examination shows granular detritus, granular cells, translucent 
globules with long granules, haematoidin, cholestearin and other fatty 
crystals. So far as I know there have been no exact chemical examina- 
tions of the contents of these cysts. Birkett states that urea has been 
found, but this must be accepted with caution, as it is not stated by what 
method this noteworthy discovery was made. The greenish or brownish 
color probably originated from the changed coloring matter of the blood; 
I certainly know of no other portion of the body in which there is such 
an intensely gall-green color as in these small cysts. I can only cite the 
sometimes opalescent, light green color of the fluid contents of hydroceles 
as similar. The usually dark-brown colored cyst walls contain partly 
haematoidin, and partly a very dark-brown pigment, which is never black. 
It seems most probable to me that the vessels in the original septa gradu- 
ally become thrombotic from rarification of the tissue, so that the haema- 
tin of the blood passes from the thrombi into the cyst-fluid; though it is 
also possible that it may be due to haemorrhages from the highly vascular 
principal wall of the cyst into the contents of the cysts. 
As already remarked the cysts never attain a very large size; this is 
sometimes hindered by calcification of the walls (Berard). When this is 
the case, the contents are colorless, of a lighter yellow or white, like a 
fat-emulsion. 
In a few cases these cysts have oily (Wormaid, Gross), creamy, buttery 
(Velpeau) or mortar-like contents. It has already been said that it is 
very improbable that cysts with such contents arise from galactoceles. 
II. Klotz {Arch. f. KI. Chirurg. Bd. XXV) has accurately described two 
such cysts which were observed at my clinic during the last year, critically 
examined the literature of the subject, and made chemical analyses of the 
contents by exact methods in the laboratory of Prof. Ludwig, in Vienna. 
These showed that the contents consisted of saponified fat (lime-soap). 
Klotz has proved that these cysts originate by dilatation partly of the lac- 
tiferous ducts and partly of the acini. It is interesting that in his reflec- 
tions on these cases he comes to the conclusion that this abnormal as well 
as normal secretion depends on the action of the secretory nerves. The TUMORS OF THE MAMMARY GLAND. 
91 
origin of these cysts had no connection with pregnancy, though the patients 
were young women. 
However clear the anatomical development of these cysts may seem, the 
cause of their origin is very obscure. Though it is customary, and for 
certain reasons is correct, to place these cysts in the category of retention 
cysts (duct cysts), yet there are many other reasons why this should not be 
done. At all events the matter is not so simple and clear as is the devel- 
opment of atheroma, dropsy of the gall-bladder, etc. 
Normally the mammary glands secrete colostrum and milk only at the 
close of pregnancy and after labor; properly, therefore, galactoceles can 
only be regarded as retention-cysts of the mammary gland. But in the 
cysts just described, the quality of the cyst contents is just as abnormal as 
is the cyst formation itself. How occlusion of the excretory ducts, even 
if such a thing was shown for all these cases, can be followed by the devel- 
opment of retention cysts in a non-secreting gland is hard to understand. 
We can only set up a few hypotheses of more or less probability in regard 
to the matter. It certainly does happen sometimes that without preg- 
nancy the mammary glands secrete a thin mucous secretion, even in the 
newly-born, in young girls and in old women in the climacteric years. 
Though not infrequent, it is an abnormality, the cause of which we do 
not know. When in such cases then, for some unknown reason, the dis- 
charge is stopped, retention-cysts may be formed. We then have two 
unknown factors; one unknown explained by another unknown. A sec- 
ond explanation is the following: these cysts are produced principally at 
the time of mammary involution; at this time the connective tissue of the 
mamma contracts, the epithelium of the gldnd vesicles disappears, the 
vesicles are obliterated, and only the epithelium of the excretory ducts 
remains in existence for a time. Now, could not the excretory ducts 
be here and there unequally compressed by the unequal retraction of the 
connective tissue and be drawn apart in other places? Then there would 
be an exudation into the separated, dilated excretory ducts, and this exu- 
dation would be mixed with broken-down epithelium and some blood. I 
myself must object to this explanation, for we would have to suppose the 
connective tissue in the vicinity of the cystic dilatations in a cicatricial 
condition, which is not the case. Again, we might regard an exuberant 
growth of epithelium, with subsequent mucous softening, as the starting- 
point; but my preparations do not support any such explanation, though 
epithelial exuberance participates largely in the dilatation of the acini in 
adenoma and cysto-sarcoma (see Fig. 32). That the desquamation of the 
epithelium in involution of the gland does not always lead, without any 
thing further, to its destruction is shown by an observation of Ackermann, 
who found distinct calcified epithelial pearls and sand-like bodies in the 
for the most part obliterated glandular ducts, which were enclosed in a 
withering carcinoma of the breast. 92 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
I confess that the above explanations as to the immediate cause of the 
origin of the cysts do not satisfy me. Perhaps newer observations will 
bring us to a better understanding of these formations. I had already 
concluded this section when I met with a case which, although the an- 
amnestic data are very defective, I must report and designate as choles- 
teatoma of the mamma. A very fat woman, 46 years old, who had had 
several children, came to my clinic on account of fibroma of the uterus; 
laparotomy was performed and the patient died on the seventeenth day 
after the operation. Before the operation we had found in the right 
mamma an encapsulated, painless, movable tumor, about the size of a 
duck's egg, of the beginning of which the woman could give no infor- 
mation, other than that the nodule had existed fora long time, had never 
given any trouble, and had not grown noticeably for a long time; there 
Fig. 38.-Sabulous Bodies (calcified epithelial pearls) in a Retracting Carcinoma of 
the Mamma; enlargement corresponding to about Hartnack, Syst. 7. (Ackermann.) 
was, therefore, no reason for extirpating it, as it certainly was not car- 
cinoma. When the tumor was cut into at the autopsy, it was recognized 
as an exquisite specimen of a laminated cholesteatoma, a giant cholestea- 
toma. In the apparently well-developed, firm breast, there was not a 
trace of glandular tissue to be found; the whole organ consisted of fatty 
tissue (the heart and liver were also very fatty). The tumor lay close 
under the skin, but without being closely adherent to it. Whether this 
cholesteatoma proceeded from a lobule of the mamma or from a somewhat 
deeply situated sebaceous gland of the skin, I could not determine after 
examination of it (which on account of its rarity I did not care to dissect). 
It happened that about this time I saw a woman with an atheroma of the 
left breast as large as a pigeon's egg, which certainly would have been 
considered as belonging to the mammary substance had not the secretion 
been forced out of a small opening of the skin. TUMORS OF THE MAMMARY GLAND. 
93 
That the diagnosis of solitary cysts of the mamma is seldom to be made 
with certainty has already been said; but even in those cases in which it 
is possible, I would advise extirpation, in case the tumor, which in itself 
is not dangerous, is an annoyance. Velpeau recommended highly the 
injection of iodine (at that time frequently used by him in hydroceles and 
cysts with serous contents), but without showing any successful cases of 
cure by this method. I do not consider it impossible for a mammary cyst 
to be healqd by this method; in the single case in which I tried first the 
simple puncture, then puncture with injection of iodine, the patient was 
not cured. After the puncture, the fluid soon collected again; after the 
puncture with injection of tincture of iodine (with an equal quantity of 
water), the now somewhat sensitive breast burst, in three weeks, through 
the cicatrix of the puncture, and for four years a small fistula has been 
running; there are no other troubles connected with it, so the patient 
will allow nothing more to be done. 
Carcinoma. 
On account of its clanger, its frightful torments, by which death is 
hastened, and on account of its frequency, cancer of the breast is so well 
known, not only to physicians, but also to the laity, that every woman 
who feels a hardening of the breast is at once filled with anxiety lest a 
cancer may develop from it. It is therefore readily understood why the 
study of tumors finally leads up to the question, How can we recognize 
cancer of the breast at its very beginning ? How can we stop its develop- 
ment? Added to this, when we have removed a rapidly growing tumor 
of the breast, is the question: Can. we, from its external appearance, or 
by microscopic or chemical analyses, recognize whether this tumor is a 
cancer, or how soon and where it will recur? In this the question is 
transferred from clinical into anatomical territory. The answer which 
anatomy gives cannot, from the nature of the case, correspond always to 
the claims of the clinician; the latter has a prepared, symptomatic, path- 
ognomic model; the former must first develop such, but he can only build 
gradually, for the methods of examination formerly employed were too in- 
complete to obtain clear, morphological views. But these have increased, 
during the last twenty years, to such a degree of clearness that they offer 
at least as strong points of support as the developed clinical experiences 
of many hundred years. We may perhaps say that the clinical and ana- 
tomical picture covers the field of tumors quite .definitely. It was in 
former time snecessary not only to separate those tumors which were 
not carcinoma, as has been done in previous sections, and then to make 
it clear that, included in those separated, there are also recurring tumors, 
but it was also necessary to form new, positive anatomical pictures of car- 
cinoma. It was also particularly important to give an exact analysis of 94 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
tiie clinical course and further development of the different tumors at the 
same time with that of their anatomical structure, so as to make more 
and more precise the different situations of the recurrences and the man- 
ner of their appearance. 
In the section on etiology more exact.data were given as to the time at 
which carcinoma of the breast appears; it will only be said here that 
these tumors develop between the ages of 35 and 40 years; they seldom 
arise before the age of 30 or after the age of 55. As regards the rare 
cases in which mammary carcinoma has developed before the age of pu- 
berty, and from this time to the twenty-fifth year, they all appeared in 
the period when the diagnosis of tumors was very incomplete. Birkett 
mentions a case of "cancer developed in the mammary region" in an 
eight year old girl; I am inclined to believe that it was a sarcoma (he 
himself says that cancer of the breast is rare before the thirty-eighth year). 
The same applies to the cases of Carmichael and Everard Home, who are 
said to have observed cancer of the breast (bi-lateral) in the twelfth and 
fifteenth years, (cited by Gross without giving the source.) 
Cancer of the breast always begins as a partial induration or hard nod- 
ule in the gland, and is never distinctly movable within the glandular 
tissue, as are fibromata. It is usually not distinctly limited from the 
neighboring tissue to the touch; examination is ordinarily painless; 
firmer pressure sometimes causes stabbing sensations. In many cases the 
induration is developed painlessly and is discovered by accident, when it 
is already as large as a walnut; but in most cases the women become aware 
of the commencing disease by the lancinating pains, which occur spon- 
taneously; it sometimes happens that such sensations precede the palpable 
induration for months. Still I would not place too much dependence 
upon this (especially here in Vienna, where the women, and particularly 
the Jewesses, have strikingly largely developed mamma?), because such 
sensations in the breasts of women between thirty and forty years of age 
are very frequent at the time of menstruation, without there being, on 
that account, any prospect of carcinoma. 
After these first symptoms, which are common to all cases, the course 
varies; many run a rapidly fatal course, partly by local spreading, partly 
by the infection of the lymphatic glands and internal metastases, while 
other cases continue for a long time. The duration varies from six 
months to twenty years. It has therefore been necessary to differentiate 
different forms and different stages of cancer of the breast. 'Though the 
signs and limits of these different forms at different times of medical ob- 
servation were deduced from very different symptoms, yet the principal 
types are so characteristic that the descriptions in different centuries agree 
very nearly. For this it is only necessary to bear always in mind that it is 
not a question of systematizing from purely logical principles, but only a 
grouping of products of nature, the varieties of which are unusually nu- 95 
TUMORS OF THE MAMMARY GLAND. 
merous. While such a division of carcinoma of the breast into its different 
forms serves an important practical purpose, the inclusion of minute de- 
tails themselves, taken from the symptomatology or histology, is only of 
practical value when it gives some information as regards the prognosis 
and course; at the same time, a purely scientific interest in such details 
is not injurious, and may be in itself entirely right. But I cannot think 
Fig. 39.-Large Isolated, Soft Carcinoma Nodule (fungus medullaris') on an Atrophied 
Mamma with small Involution Cysts; very complete substitution of the mammary by fatty tissue. 
One-third natural size. 
it of value to divide carcinoma into so many kinds, as, for example, Vel- 
peau lias done, though I admire the fine gift of observation which there 
expresses itself. 
The surgeons of the middle ages differentiated three stages of malig- 
nant neoplasms. 
1. Scirrhus.-This denoted originally only " hardening," and was ap- 
Fig. 40.-Two Isolated Cancerous Nodules in a still well-developed Mamma. One-half 
natural size. 
plied to every kind of induration, whether due to a neoplasm or a chronic 
inflammatory process (these two were not as distinctly separated as now). 
The designation " scirrhus degeneration/' formerly did not include malig- 
nancy. It was in the beginning of the present century that it first be- 
came more and more the custom to use the expression schirrhus for the 
harder, and " fungus medullaris " for softer neoplasms, while for the 
chronic inflammatory indurations the designation "callous" came into 96 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
use. Later, when the expression " carcinoma " was used for malignant 
growths generally, and by German writers especially (in France and Eng- 
land, cancer and squirrhe are most used for the designation of malignant 
Fig. 41.-Infiltrated Mammary Carcinoma, which has grown through the Fat to the Skin. 
One-half natural size. 
tumors), the term scirrhus became more limited, and a number of authors 
have followed my example, and call only the retracting cicatricial forms 
scirrhus or " fibrous cancer." Others have used the term " fibrous can- 
Fig. 42.-Infiltrated Mammary Carcinoma, already advanced into the Skin, which is 
Thickened as in Elephantiasis. One-half natural size. 
cer " for those forms also which figure in English literature as " infiltrated 
cancer. ' ' 
2. Cancer OccuUus formerly denoted that form which had been 
perceptible as nodules, or as a tumor, and which had gradually become 
softer. TUMORS OF THE MAMMARY GLAND. 
97 
3. Cancer Apertus was applied to the broken-down cancerous ulcer- 
ation. 
In order to enable the reader to understand the different customary 
designations still used in different places, I will now give the most usual 
names together with those usually employed by me, choosing as types of 
the different schools in different countries, Schuh (Vienna school), 
Birkett (England), Gross (America), and Velpeau (France). 
Fig. 43.-Cicatrizing Mammary Cancer from an emaciated Woman. Almost natural size. 
1. The partly softer, partly harder carcinoma nodules; histologically 
appearing mostly as acinous carcinoma (Billroth). Identical with it: 
Fungus medullaris, fibrous cancer with large nodules (Schuh). Carci- 
noma medullare, encysted carcinoma, lobular carcinoma, attached to or 
involving only one lobe, tuberous form of cancer (Birkett). Encephaloid, 
tuberous form of cancer (Gross). Encephaloide, Squirrhe proprement dit 
Fig. 44.-Cicatrizing Mammary Carcinoma with marked Retraction of the Nipple; con- 
siderable development of fat in place of the mamma. Almost natural size. 
ou globuleux (Velpeau). As already remarked, many forms designated as 
soft cancer belong also to the category of soft sarcoma and cysto-sarcoma. 
2. Carcinomatous infiltration; histologically mostly appearing as tub- 
ular carcinoma. Carcinoma simplex (Billroth). Generally soon invading 
the skin, partly as infiltration, partly in the form of multiple nodules. 
Fibrous cancer with small nodules, lenticular cancer (Schuh). Intra- 
odandular carcinoma, infiltrating form of cancer (Birkett). Infiltrating 
form of cancer (Gross). Sguirrhe ligneux (densite et Vinextensibilite du 98 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
hois), squirrhe en masse, en nappe, squirrhe dissemine ou pustuleux, 
squirrhe lardace, keloides (Velpeau) 
3. The atrophying, contracting cancer of the breast. Scirrhus, (Bill- 
roth). Atrophic scirrhus (Gross). Squirrhe retractile ou atrophique 
(Velpeau.) 
4. Colloid cancer. Squirrhe gelatinaux, alveolaire, cancer colloide 
(Velpeau). Gelatiniform carcinoma (Gross). 
Anatomy of Cancer of the Breast.-1The manifested form of all pro- 
ducts of nature is dependent upon their finer structures, and this depends 
again upon the material and quality of its formation; so that different 
structures and different processes of development must lie at the founda- 
tion of the above-mentioned different forms of carcinoma. These will 
soon be mentioned. Of course the chief interest in all forms lies in the 
etiological factors, which unfortunately have thus far been hid from us 
almost entirely, but it also lies in the nature of its further development, of 
its course, concerning which a large number of observations has been col- 
lected, which it is difficult to collate. The anatomical structure of all car- 
cinomas of the breast offers common points of support, though it must not 
be forgotten that there are so many different varieties, that many cases 
cannot be understood as belonging together except by the most careful 
study, and especially by the study of their developmental history. 
The idea which is most frequently obtained in regard to the matured 
foci of carcinoma, which have not been changed by retrograde metamor- 
phoses (fatty degeneration, retraction) and which have received a typical 
signification, is partly due to the examination of the cut surface with the 
naked eye, and partly to the microscopic appearance of such cut surface. 
The naked eye appearance of a carcinoma of the breast is that of a grayish 
surface interwoven with paler, net-like meshes. No distinct capsule is 
perceptible at the periphery; we cannot separate the new growth from 
the adjoining normal tissue, as in the case of fibroid and sarcoma, but 
the tissue extends into the new growth (with more or less sharp bound- 
aries), so that it is dovetailed into the tissue more in the form of rounded 
nodules and ganglions, or which, as diffuse infiltration, has scarcely caused 
a projection, but may indeed have caused a contraction. In the softer 
forms the neoplasm is white, reticulated, yellowish towards the centre of 
the nodule (by fatty degeneration, carcinoma reticulare, J. Muller) or en- 
tirely yellow, and somewhat firmer and more grayish at the periphery. 
In the harder forms a firm, whitish, fibrous tissue is found in the centre, 
the periphery of the slightly uneven surface is yellowish-red (becoming 
darker on exposure to the air), homogeneous, fatty. If we draw the edge 
of a knife obliquely across the cut surface, a whitish, cloudy, and perhaps 
finely granular pap-like substance collects on the knife, the so-called 
"cancer juice." Microscopic examination of this cancer juice shows that 
it consists of large roundish and angular cells (cancer-cells), which are TUMORS OF TILE MAMMARY GLAND. 
99 
distinguished by large nuclei, and especially glistening nucleated bodies; 
occasionally also we find many fatty degenerated cells and granular fat- 
detritus. 
When we examine this carefully expressed cancer juice with a low 
power and without crushing it too much, we are soon convinced that the 
cells are placed together in large balls and branched cylinders, the con- 
tours of which are tolerably distinct, without our being able to recognize a 
membrane. Sometimes structures are found, which present, with a very 
Fig. 45.-Typical Picture of a Mammary Carcinoma. (Hartnack, Syst. 5.) 
low power, very distinctly the forms of acinous and tubular glands, with- 
out our being able to find cavities in them. If we now make fine sections 
of the parts from which the cancer juice was expressed and treat them 
according to modern methods, for observation with low and high powers, 
we will get something similar to what is seen in Fig. 45. In a more or 
less firm frame-work of connective tissue are found tolerably large cells 
(from four to six times as large as white blood-corpuscles); these have 
partly fallen out; by shaking and teasing the preparation, they can be 100 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
entirely removed, so that only the connective tissue frame-work or stroma 
(of the older authors) remains. This tissue was called "alveolar," and 
is considered as well as the cells contained therein as characteristic of 
carcinoma. The decisive signification of this alveolar structure for car- 
cinoma has been only very recently shaken. We have learned that many 
sarcomas, myxomas, and lymphomas also have a similar and sometimes 
precisely the same " alveolar structure." But as the alveolar and plexi- 
form sarcomas and myxomas, as well as lympho sarcomas are of the 
greatest rarity in the mamma, the structure described retains without 
doubt its characteristic signification for mammary carcinoma. For the 
older anatomists and histologists there was so little doubt that the neo- 
plasms arose from a kind, even though peculiar, of coagulating exudation, 
that all parts of the neoplasm appeared as pathologically newly-formed. 
The chief endeavor next was not only to explain the origin of the 
strangely formed cells, but also of the connective tissue frame-work. 
Rokitansky took the view that the connective tissue grew out in a knobby 
and dendritic manner and the cancer cells were included in it; and this 
process, derived chiefly from papilloma and villiform cancer, should lead 
to the formation of the carcinoma structure. It was soon shown, how- 
ever, that such interstitial papillary growths were also present on cyst 
walls and in the hollow spaces of previously formed glandular spaces, but 
that the development of the cancer frame-work depended not on the neo- 
plasm, but principally on the fact that the cell exuberances infiltrated the 
existing connective tissue of the gland, grew through it, and consequently 
the stroma of the carcinoma is nothing else than the old connective tissue 
of the organ, pressed asunder, in which and from which the carcinoma 
originates. This view is much advanced by the progress of developmental 
history, which teaches that the new cells are not separated from the 
amorphous blastema as crystals from a solution (Schwann), but that they 
only arise by budding and division of other cells. Now arises the ques- 
tion: from what cells are the cancer-cells developed? The more exact 
examinations of carcinoma, especially the examination of its boundaries, 
by which we hope to gain information regarding the development of the 
first pathological forms, show that there are almost always two kinds of 
cells to be found in carcinoma: 1, the larger, more epithelial-like form 
in the alveoli; and 2, smaller ones of the size of white blood corpuscles, 
more or less compressed and infiltrated between the fibres of the stroma 
(Fig. 45). That the first arise from one another by budding and division 
is easily seen by the recognized scries of forms, which arise in this way. 
In the smaller infiltrated cells, no division forms are seen; whether they 
are developed by budding of the connective tissue cells, or whether they 
are white blood corpuscles, which have migrated from the vessels, remains 
uncertain; in favor of the last hypothesis is the circumstance that they are 
frequently seen heaped in masses around the small veins. As regards TUMORS OF THE MAMMARY GLAND. 
101 
the origin of the epithelioid cancel- cells it has long been dombtful whether 
they also sprang from connective-tissue cells (stabile, movable connective- 
tissue bodies, endothelia) as do the small cells infiltrated in the stroma 
(Virchow), or whether they are offsprings of the glandular epithelial cells 
(Thiersch). Proof by direct observation will probably scarcely be fur- 
nished; we must always recur to the combination of certain stages of the 
development, as well as to analogous embryonal growths, and here it is 
conceivable that absolute certainty will not be reached. I have already 
accepted Virchow's opinion, and only granted the participation of the 
epithelial cells for those exceptional cases which I specially designated 
as epithelial carcinoma of the mamma. It is hard to understand why 
there is such an enormous difference in the size and form of the cells, 
which arise in the same place and from the same material; further, why 
at one time the cells, which have become large, collect in cylinders and 
bulbs, at another the cells which remain small are infiltrated in the con- 
nective tissue. Newer observations have, it is true, taught that similar 
processes occur in alveolar and plexiform sarcomas; still, such a great 
difference in the proportion of their form and size scarcely ever takes 
place, with the single exception of giant-cell development, which is an 
especial attribute of many sarcomas and also of miliary tubercle. 
We would probably have advanced but little, had we confined our 
studies of the development of sarcoma to cancer of the breast; neverthe- 
less, the studies of Thiersch, on cancer of the skin, illumined in a spirited 
manner by reference to normal histogenetic processes, soon advanced the 
matter further and brought it, with the exception of many doubtful points, 
to a certain conclusion. In this connection I may refer to the later works 
on pathological histology and general surgery, and would only call atten- 
tion to the fact that it has been made obvious, especially by Waldeyer's 
work, that in cancer of the breast the cancer cells lying in the alveoli, 
which he calls "cancer bodies," spring from the epithelial glandular 
cells. As these epithelial forms in carcinoma never spread over the em- 
bryonal parts of the gland, and also deviate in their formations from the 
normal types of the mamma, he rightly calls carcinoma an "atypical ep- 
ithelial tumor." 
As already said, we must give up trying to directly observe the deriv- 
ation of cancer cells from the true epithelia; so also the first stages of 
division are concealed by the complicated tissue in the examination. It 
appears that, through a few generations, the small epithelial cells of the 
acini or gland ducts scarcely ever (in many carcinomas perhaps never) 
grow out over the normal mass, but later, when they are freed from pres- 
sure by a kind of softening process of the surrounding connective tissue, 
they reach the size in which we find them in the formed parts of the car- 
cinoma. Nevertheless, we sometimes meet with carcinomas which allow 
us to see with especial clearness the process on their boundaries; there are 102 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
pictures especially, which we obtain by very low powers, which give us 
accurately, as it seems to me, undoubted conclusions in this direction. 
In Figure 4G we see, in a mamma, already in a state of involution, 
the gradual changes of the lobules in succession at a, b, c, d. The ends 
of the gland elements, which have again already become bulbar by the 
partial atrophy of the acini, are filled with cells and thus become larger 
and larger, though still clearly preserving the glandular forms for a time; 
and finally they grow over the boundaries of the connective tissue between 
Fig. 46.-From the Limiting Layer of an Acinous Carcinoma of the Mamma. (Hartnack, 
Syst. 2.) 
the gland lobules; in this way there occurs a confluence of foci, as at d. 
With a higher power this acinous structure becomes very distinct in cer- 
tain selected places, until it finally assumes the type of the alveolar tissue, 
(Fig. 45). 
Most of the soft, larger noduled carcinomas have this kind of develop- 
ment and this structure. 
Another form I have also designated as "tubular" carcinoma of the 
breast. It is characterized by the outgrowths of the epithelial mass in 
the form of elongated, ramifying cylinders or filled tubes (tubuli), which, TUMORS OF THE MAMMARY GLAND 
103 
Fig. 47.-From the Peripheral Layer of an Acinous Carcinoma of the Mamma. Formerly 
designated by me as "true epithelial carcinoma of the gland." Enlarged 250 times, (corresponding 
to about Hartnack, Syst. 7.) 
Fig. 48.-From the Boundary Layer of a Tubular Carcinoma of the Mamma (Hartnack, 
Syst. 2.) 104 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
soon growing ovei' the boundaries of the original acini, cause a confluence 
of these as in the previous form. 
The order of development in the last illustration (Fig. 48) is a, b, c, 
d, e. By rapid progressive growth, what is seen in Figure 45 is finally 
attained. It is clear that only by the careful adjustment of sections can 
the elongated forms, the tubuli, be brought into view, and that these, if 
cut across, may give the impression of acini. But besides this, combma- 
Fig. 49.-From the Boundary Layer of a Tubular Infiltrated Carcinoma, pushing for- 
ward into the surrounding Fatty Tissue (upwards). (Hartnack, Syst. 5.) 
tions of the acinous and tubular forms are quite frequent, and the separ- 
ation not always sharply defined. But there are still other marks, which 
serve to indicate this more tubular form. Here the cancer cells are usu- 
ally not so large as in the soft acinous forms. The character of the infil- 
tration is here more important than the formation of nodes and nodules. 
But especially important in these carcinomas, which principally correspond 
to the carcinoma simplex, the infiltrated carcinoma of the English, is an 
appearance which is infrequent in the first forms, namely, a peculiar kind 
of atrophy and a partial cicatricial contraction. TUMORS OF THE MAMMARY GLAND. 
105 
The small-celled infiltration of the connective tissue, which is found 
here and there in carcinoma, has exactly the character of a chronic in- 
flammatory infiltration. The more carefully I have studied the degener- 
ated tissue, the more have I been convinced that a collection of the small 
round cells in groups is of the greatest infrequency. The illustrations 
which formerly I thus explained allow also another interpretation, that 
these groups of cells are cross and oblique sections of thinner tubules, 
proliferating, but still slightly enlarged outgrowths (daughter-cells) of the 
epithelial cells, which push themselves forward, growing into the narrow 
connective-tissue spacbs. 
As regards the fate of the infiltrated fibrous tissue, it gradually becomes, 
Fig. 50.-Degenerated Vascular Net-work of a Centrally Broken-Down Carcinomatous 
Nodule of the Mamma. (Hartnack, Syst. 2.) 
by cellular infiltration, softer and more pliable, so that the epithelial cells 
can now expand more readily. With this small-celled infiltration is con- 
stantly connected an increase of the capillary and venous vessels, which 
likewise contributes to make the tissue softer, and, at the same time 
brings to it more fluid nutriment; there is thus a kind of chronic hypere- 
mia and a chronic, partial indurated oedema. In this way the similarity 
to a Chronic inflammatory process amounts to identity. We will best 
notice this, when the degenerative process attacks the skin; here the skin 
behaves exactly as it does before the outbreak of a chronic eczema on the 
leg, or before the beginning of ulceration in varicosities. The nature of 
the ulceration over these infiltrated cancers of the breast is exactly the 
same as on the leg under the circumstances mentioned. On the red, stiff 106 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
skin, vesicles, bullae, scabs, clefts and fissures are formed, under which 
at first superficial, and then constantly deepening, ulcers develop by slow 
breaking down of the tissue. 
In the interior there is also such a partial breaking down of the infil- 
trated tissue (both of the epithelial and connective tissue elements). The 
results of this are manifold. If the cell proliferation is very rapid and 
Fig. 51.-Crater-formed Fungous Cancerous Ulcer of the Mamma. 
luxuriant, there is consequently great compression of the nerves and ves- 
sels contained therein; the latter are gradually distended by the partial 
compression, and if the pressure increases, stasis and thrombosis •occur. 
In this way the flow of the fluid nutriment to the vascular territory ceases, 
and the cancer cells first take on fatty degeneration and then break down. 
This breaking down finally extends to the thrombotic vessels. 
The product of this breaking down is a clear yellowish substance like 
masses of tubercle in the large-nodular, soft (acinous) carcinomas. There TUMORS OF THE MAMMARY GLAND. 
107 
are cases in which this breaking down occurs very rapidly, and with ex- 
udation, so that the cavities eventually break externally, like a cold 
abscess; the contents are then evacuated, the edges of the healed nodule 
are turned outwards so that a crater-like ulcer is formed; then an agaric- 
like growth, as is so characteristic of these forms of carcinoma (Fig. 51). 
Though the secretion of such ulcers partly consists of true pus, yet there 
is seldom a formation of a really acute or chronic abscess in mammary 
carcinoma; it is much more frequent in infiltrated epithelial carcinomas 
of the lymphatic glands of the neck. 
In the infiltrated (tubular) mammary cancer the process, as a rule, is 
different. As, in this case, much more connective tissue is reserved with 
the contained vessels, because the cell-collection is less largely concen- 
trated in separate foci and nodules, the cell-degeneration is much slower. 
The still existing veins take off a part of the detritus with the blood, and 
only a small part remains behind, around which the infiltrated connective 
tissue contracts, and thus an interstitial cicatrix is formed. This process 
again corresponds to the similar processes in chronic inflammations, with 
the restriction that the tissue which has become infiltrated does not return 
exactly to its former state, but retains the character of a firm (callous, 
scirrhous) cicatricial tissue. The externally noticeable results of this 
process are very striking. The retraction acts on the skin, nipple and 
pectoralis major muscle; all these parts may be drawn in, i.e., drawn into 
the retracting centre, and even the remaining parts of the mamma may 
thus suffer considerable dislocation. Now since such a carcinoma, under- 
going partial retraction, consists in fact in part only of cicatricial fibrous 
tissue, this has probably led to the designation of these cases as " fibrous 
cancer," even though such carcinomas may still be very numerous in 
other parts and so remain. 
There are cases, especially in elderly women, in which the carcinoma- 
tous infiltration breaks down, for reasons unknown to us (perhaps on ac- 
count of deficient vascularity) so soon after their beginning, that the 
cicatricial retraction appears to follow immediately upon it. We find in 
such carcinomas, which I designate as scirrhus zar' in most places 
only a hard tissue, grating under the knife, which plainly consists only of 
connective tissue and an unusual amount of elastic fibres (Fig. 52). 
These are the cases which it is often difficult to differentiate from 
chronic interstitial mastitis (cirrhosis mammae, Wernher). Only by close 
examination of the fatty yellowish red boundary portions do we find the 
usually small tubular cancer bodies. 
From these considerations it does not appear to be impossible for a can- 
cer to completely cicatrize and heal spontaneously. I have never seen 
this, nor, so far as I know, have there been any observations of the kind 
by others. The most striking example of shriveling of a carcinoma which 
I have seen is the following: A woman, about 40 years old, came to my 108 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
clinic with an infiltrated carcinoma as large as an apple in the left breast; 
she refused an operation. A year afterward she came back on account 
of paralysis of the lower extremities, caused (as was shown later at the 
autopsy) by carcinoma of the vertebral column and spinal cord. Of the 
former tumor of the breast, indeed of the whole of the left breast, noth- 
ing remained, excepting a flat, indurated cicatrix, partially excoriated 
superficially, and in which no new infiltration occurred up to the time of 
Fig. 52.-From a Retracted Cancer of the Breast. (Hartnack, Syst. 5.) 
death, which occurred shortly. Unfortunately, in my brief notes, it is 
not noted whether the lymphatic glands were infected. However simple 
these processes, after the above exposition, may seem in the typical cases, 
it was very difficult to find and understand them. In fact, we must have 
a tolerably large amount of mammary cancer material at our disposal, 
and must use it industriously, if we would convince ourselves of all these 
things, and obtain typical pictures of the separate forms, which differ 
so widely from one another. By far the greatest difficulty is in correctly 
comprehending the relation of the epithelial growths to the small-celled TUMORS OF THE MAMMARY GLAND. 
109 
connective tissue infiltration in all cases. Here there are still many points 
to be cleared up by further researches. The relation to each other of two 
such powerful factors in carcinoma is not at all wholly clear for all cases. 
Fig. 53.-From the Boundary Layer of a Mammary Carcinoma. The gland-lobules are com- 
pletely surrounded by small-celled infiltration. Progress of the disease from below upwards. 
(Hartnack, Syst. 5.) 
For example, at one time we see, especially in the acinous forms, that 
the connective-tissue infiltration at first appears to be absent, and then 
again, though not often, at another time the small-cell infiltration is prom- 110 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
inent at the beginning, and the epithelial growth is so far surpassed that 
one is scarcely inclined to consider it an important factor. 
In Fig. 53 I give an illustration from the boundary layer of a mam- 
mary carcinoma, in which the single, already markedly atrophic gland- 
lobules are all enveloped by the small-celled infiltration, as if by a fog. 
With higher powers even, we cannot recognize what happens to the gland- 
ular epithelium under this cloud of cells; only later is the usual carcin- 
oma structure shown. In regard to this Klebs has rightly remarked that 
the boundary places do not always give the clearest pictures of the gland- 
ular structure of mammary carcinoma, but often those places, in which a 
part of the small-celled infiltration has already disappeared, and in which 
the tissue has begun to retract. The question, whether the epithelial 
growth or the connective tissue infiltration is the primary in the develop- 
ment of carcinoma, can hardly be answered directly; perhaps it is one in 
the one case, and the other in another case. 
An important objection to the essentially epithelial origin of cancer of 
the breast is, that it develops as a rule at a period of life in which the or- 
gan is either about to atrophy or has already completely atrophied, so 
that it is scarcely very probable that at this time the glandular elements 
are still in a vigorous state of growth. In the section on cysts, it is seen 
that the epithelia of the smaller and larger excretory ducts of the gland 
do not fall into decay imperceptibly, as do the epithelia of the acini, but 
they sometimes increase actively to the period of involution, are thrown 
oil and by their secretory function determine the quality of the contents 
of the cysts. Consequently the assumption that these epithelia, under 
certain conditions, take on an excessive growth, would not seem to be of 
great importance. 
We must then certainly expect that the neoplasms originating from the 
remaining excretory ducts lie usually near the nipple, since it is only here 
that finally the larger lacteal canals remain abundant But this view is 
shown to be erroneous, by the observation of the distribution of the small 
involution cysts in the atrophic glands, as these cysts frequently, indeed 
preponderating^, lie in the periphery of the organ, occasionally entirely 
imbedded in fat, and excepting them, no remains of glandular substance 
are to be found in their vicinity. We may perhaps assume that individ- 
ual groups of glandular vesicles often persist longer here than others, and 
are shut out from their connection with the 'nipple by early obliteration 
of their smaller excretory ducts. There is also the supposition, which is 
perhaps allowable, that there are aberrant lobules in the mamma, which, 
by inflammatory processes or from unknown causes, are at early periods 
deprived of communication with the large excretory ducts, and are then 
especially disposed, as are all abnormally situated parts of organs, to path- 
ological degeneration. (Volkmann, Cohnheim). Klebs has advanced 
the view that the epithelial cells are also able to wander, like the so-called TUMORS OF THE MAMMARY GLANDS. 
111 
connective-tissue cells, and sometimes find, in distant parts, the condi- 
tions for their abnormal further development. 
It now remains to speak of colloid carcinoma, which is very seldom 
found in the breast. Cases have been observed by J. Muller, Robert, 
Albers, Bennet, Lebert, and Doutrelepont. The case of Doutrelepont is 
most completely and exactly described {Arch. f. Klin. Chirurg., Bd. XII, 
p. 551). I too have observed such a case and possess the preparation, 
but unfortunately without reference to the corresponding clinical report. 
Fig. 54.-From a Colloid Carcinoma of the Mamma. (Hartnack, Syst. 5.) 
How exactly my case agrees with that of Doutrelepont, Fig. 54, as to 
structure may be seen by comparing my illustration with his. 
The epithelia play a very important part in these carcinomas; the col- 
lection groups of epithelial cells are especially distinct because they are 
surrounded by a homogeneous, colloid layer, as transparent as glass, the 
limits of which are distinctly fixed by the connective-tissue stroma. In 
other respects the conditions are the same as in other cancers of the breast; 
the very irregularly distributed small-celled infiltration, constant only at 
the boundaries, and the partial fatty change of the epithelial cells, are also 
to be found here; retraction alone appears never to take place in these 112 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
carcinomas, probably because the colloid substance is absorbed with great 
difficulty. The question, whence comes the colloid substance, we can 
only touch upon here very slightly. The regular disposition of the colloid 
material between the epithelial cells and the inner walls of the alveoli of 
the stroma permits the view, on the one hand, that the epithelial oells ex- 
crete the colloid material; on the other hand that the connective tissue is 
partly metamorphosed into colloid material (myxomatous tissue). That 
the individual epithelial cells undergo mucous metamorphosis appears to 
me to be without doubt from my preparations, though it is certainly not 
probable that, in this way, there would be such a regular disposition of 
the colloid substance. 
In Doutrelepont's opinion, the colloid substance is a peculiar protoplasm 
excreted from the vessels, which at other times goes on to cell growth, 
but here exceptionally chatnges to the colloid substance. Rindfleisch has 
accepted this View. Klebs is more inclined to the view that the colloid 
substance is excreted by the epithelial cells. 
Course of Mammary Carcinoma. 
1. Anatomical Observations on the Extension of Carcinoma and on the 
Metastatic Turners.-As a rule, one glandular lobule or several adjacent 
lobules in a mamma are first affected. The process often remains confined 
to such a region for a long time, especially in the soft, tuberous form. 
In other cases, especially in the infiltration forms, several parts of the 
gland are simultaneously affected, and then gradually the whole gland. 
Still, the extension is in no way determined by the glandular division (of 
which indeed, there is often very little left), but takes place peripherally 
in all, or at least in several directions at. the same time. As already re- 
marked, the small-celled infiltration often precedes this, and in a certain 
sense prepares the way for the epithelial growth by the softening and pro- 
per vascularisation of the tissue. In this way occurs, sooner or later, in- 
filtration of the cutis, of the retro-mammary fascia and of the pectoralis 
major muscle. But this extension does not take place, by any means, to 
an equal degree in all directions, but frequently in the form of cords 
which radiate from the carcinomatous focus into the adjacent tissue, and 
far more frequently, interruptedly, in the form of nodules, which appear 
around the carcinoma as a papular exanthem, constantly spreading in 
wider circles around the primary focus; between these parts the tissues may 
remain entirely healthy for a long time, until finally, if life lasts long 
enough, the nodules grow into a large confluent nodular tumor. When 
we see this on the skin, we can, as a rule, conclude that it is the same in- 
ternally in cellular tissue and in the muscle. By what means the growth 
of these nodules is limited, is, as yet, not definitely known. The suppo- 
sitions which have been made hitherto in regard to it do not bear the TUMORS OF THE MAMMARY GLANDS. 
113 
test of examination. If we assume that the epithelial growth (exuber- 
ance) is the primary step in the development of carcinoma, then we must 
expect that some epithelial cells are always present in the centre of the 
small nodules, whose exuberant growth would then be followed by a 
small-celled infiltration of the connective tissue. The reasons for the 
presence of these epithelial cells here and there, are to be sought partly 
in the fact that, getting into the lymph-stream, they adhere to the valves 
of the lymphatic vessels, or that they undertake an independent migra- 
tion from the carcinomatous centre, and then come to a stand-still when 
they cannot advance further in the lymphatic vessels on account of great 
numbers or too rapid growth. The most careful and lengthy examinations 
which I have made (a long time ago, I admit) have led to no satisfactory 
conclusions. If these theories be correct, however, the failures of the re- 
searches can only be explained by the supposition that the young epithe- 
lial cells which have swam away or migrated, are and remain so small on 
account of the compression exercised by the stiff cutaneous tissue, that 
they cannot be differentiated from the infiltrated cells. But this does 
not explain the presence of the nodules, which, for example, originate in 
the loose connective tissue between the muscular fibres. Though I have 
often examined such small nodules, I have never found undoubted epithe- 
lial elements in them. It was formerly believed that the nuclei of the 
muscular fibres and of the nerve sheaths likewise took part in the infiltra- 
ting growth (0. Weber); the exact observations of Volkmann and Steu- 
dener have shown that this view is a delusion. The muscular and nerve 
fibres become atrophied by the exuberant growth of cells and the conse- 
cutive retraction of the tissue; they pass, as I have elsewhere shown 
(Arch. f. Path. Anat., Bd. VIII, Heft. 9), over into fibres which are not 
to be differentiated from connective-tissue fibres. After this abortive at- 
tempt to clear up the origin of the coronary nodules around mammary 
carcinomas, one feels almost inclined to go back to the older view, that a 
peculiar irritating juice originates in the carcinoma, which penetrates the 
surrounding tissue, and puts it in formative excitation; but this would 
not contribute to the special explanation of the formation of nodules. 
I have never been able to show that the sweat glands, hair follicles and 
hair glands take part in the carcinomatous growth from the mamma to 
the cutis, though I have given special attention to this point. Doutre- 
lepont's observation, according to which the epithelium of the sweat gland, 
in his case of colloid carcinoma of the breast, had an important part in the 
formation of cutaneous nodules, thus far, so far as I know, stands alone. 
By the extension of the carcinoma into the deeper parts, the periosteum 
of the ribs, the ribs themselves, and the pleura costalis and pulmonalis 
are involved, usually by the formation of nodules, which gradually lead 
to firm fatty infiltration and shapeless cicatricial formations, if the un- 
happy women live long enough. Even these parts of the carcinoma (it 114 
DISEASES OF TllE FEMALE MAMMARY GLANDS. 
occurs only in infiltrated, primarily tubular carcinoma) seldom show a 
distinct epithelial structure; I have been able to recognize the structure 
of the primary mammary carcinoma at times in the tissue of the ribs, as 
well as in metastatically affected vertebrae, the humerus and the femur. 
The same is true of metastatic carcinoma of the lungs and liver. The 
a priori, according to our present views, almost only possible theory, that 
these carcinomas proceed from the primary carcinomas by emboli com- 
posed of cells, I am not in a position to uphold from observations. 
As a rule we find tissue, similar to that in the primary carcinoma, only 
in the lymphatic glands of the axilla, which have become infected from 
the cancer of the breast. As there are often large portions of healthy ap- 
pearing tissue, so far as can be judged by palpation and by the unaided 
eye, lying between the primary carcinoma and the affected lymphatic 
glands, infection of the affected spots can only have taken place through 
the lymphatic vessels or the veins. There certainly is seldom any proof 
that the carcinoma cells have a predilection for the lymphatics (Langhans), 
though they could break into the thin-walled lymphatic tracts from the 
tissue in so many places that anatomical proof of this is scarcely neces- 
sary. I have repeatedly seen the lymphatic trunks of the pleura and dia- 
phragm completely filled with carcinoma cells. 
I will forbear giving further details of observations on these difficult 
questions, and will only repeat my opinion, that I consider it certainly in 
the highest degree probable, in the present state of our ideas, that the con- 
tinued as well as the interrupted extension of carcinoma is brought about 
by misplacement of corpuscular elements, but that we are not yet in the 
position to prove this anatomically for all cases. I may add that I might 
claim a like power of infection for the corpuscular elements of the small - 
celled infiltration in carcinoma, according to which, carried to other 
places, they have the power of setting up chronic inflammatory processes 
resulting in induration and ulceration, and this, too, without bearing 
epithelial elements with them. Finally, I would again repeat that the 
course mentioned is especially peculiar to mammary carcinoma; I have seen 
nodular coronary extensions in the form described in the same way in sar- 
coma of the skin, but never in carcinoma (epithelial) of the skin, in 
which the continuous extension, as well as the infection of the lymphatic 
glands, as also the few cases of metastases, appear to be absolutely de- 
pendent upon the epithelial growth, their direction of growth, and their 
misplacement. 
2. Clinical Course of Cancer of the Breast.-There are cases of carci- 
noma of the breast which, from the beginning of the first nodule up to the 
time of death from internal metastases, last only six months; and other 
cases in which women carry carcinomatous nodules in the breast for more 
than twenty years without being greatly troubled by them. To make 
from these extremes exact types for different categories is as difficult as TUMORS OF THE .MAMMARY GLANDS. 
115 
it is to separate different kinds of carcinoma of the breast with anatomical 
exactness from one another. If, however, we try to accommodate the clin- 
ical course to the anatomical classifications given above, we can only do 
so by every reservation of transition and combination. The large and soft 
nodular (usually acinous) carcinomas have the most rapid course; in the 
majority of cases they occur in young women (from 35 to 40 years of age), 
though exceptionally there is a rapid course in older women. I will de- 
cribe the following case, which I personally observed, as an example of such 
exception: 
In a previously healthy woman, 55 years old, several soft nodules 
formed in the right mamma, without known cause; she came to me at 
the Zurich clinic, eight months after the beginning of the trouble; one 
nodule had broken down and assumed a crater-like form (Fig. 51 is a 
picture of this woman); the whole right breast had degenerated into a 
large, nodular tumor; the axillary glands were swollen, though movable. 
Operation. After fourteen days, healing no longer progressed favorably; 
marasmus, pain in the region of the liver, dyspnoea without fever, and 
pleuritic exudation on both sides, recognized by percussion, set in. Death 
four weeks after operation. Both lungs and the liver studded with many 
tolerably large, soft, carcinoma nodules. Duration of the disease (which 
in this case was probably not changed in its course by the operation), 
nine months. 
The infiltrated forms, by far the most frequent (carcinoma simplex, 
tubular form,) run an exceedingly different course. In the worst cases 
the course is but little different from that in those described above, except 
that it is more slow. It affects well-nourished women between thirty and 
forty years of age. It is an infiltrated, at first slow for a few months, 
then an ever-rapidly spreading induration, and soon the larger part of the 
gland is affected; after 6 to 8 months, swelling of the axillary glands, and 
soon swelling of the supra-clavicular glands set in. There is compression 
of the axillary vein, and indurated oedema preceded by neuralgic pains 
in the arm. There is ulceration of the skin after perhaps the lapse of 1 
to 1| years. State of nutrition is good for a long time. There are metas- 
tases in the pleura of the affected side, and also of the liver, of the bones, 
not infrequently of the vertebrae, and fearful pains, from which death 
finally frees the patient two or at most three years after the beginning of 
the malady. In other cases there is early adherence with the skin, and de- 
velopment of nodules in the skin, especially after the first operation. Radi- 
ating extension of these nodules around the cicatrix squirrhe tegumentaire, 
tuberculeux, dissemine-(Velpeau); repeated operations, without good 
results-such is the history. Axillary glands are hard, but not very large. 
The local extension constantly increases. The nodules in the skin soon 
ulcerate and become confluent. The skin over the whole anterioi' portion 
of the thorax is studded with nodules, and becomes immovable. A sim- 116 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
ilar process often begins on the opposite side; not infrequently hyperaemia 
in streaks {squirrlie, rayonneux, ramonneux-Velpeau) precedes the for- 
mation of nodules The whole thorax becomes surrounded by indurated, 
partly ulcerated skin. {Cancer en cuirasse-Velpeau). Emaciation, 
marasmus, late and not extensive internal metastases follow and death 
occurs from marasmus, loss of fluids (systemic drain), repeated hemor- 
rhages. The duration is 3 to 6 to 8 years and longer. 
All cases of colloid cancer take a similar course. In the case men- 
tioned by Doutrelepont the duration was 13 years. 
The mildest forms of infiltrated carcinoma pass from the form of 
the atrophying, cicatrizing carcinoma, to the scirrhus. How long the 
last may exist without causing death cannot be said. I know of cases in 
which old women bore such indurations for more than twenty years, and 
finally died of another disease. The nodules ulcerated several times; the 
ulcerations were checked by fomentations of lead-water; at times some 
necrotic tissue was thrown off, and the hole was closed again. In the 
axillary space superficial lymphatic glands were slightly swollen at times 
but were very hard; then they shrank without breaking, leaving a re- 
tracted, slightly hard scar. As I neither received these cases at the clinic, 
nor operated on them in private practice, only a few cases appear in my 
yearly reports. 
Detailed statistical data as to the most important periods of the course 
of carcinoma maybe found in Volkmann {Beitrage zur Chirurg. Leipzig, 
1875, p. 319) and in the previously mentioned book of Al. v. Winiwarter. 
The outer side of the breast is affected in by far the greatest number 
of cases (in 54.4 per cent, of all cases-von Winiwarter). 
The axillary and infra-clavicular glands are always affected before the 
supra-clavicular. The infection travels by degrees from below upwards 
(Volkmann), though deeply-lying glands are not infrequently affected be- 
fore superficial ones (von Winiwarter). The infection of the axillary 
glands follows in the course of 14 to 18 months after the beginning of the 
mammary affection. For single cases this does not answer, as the ex- 
tremes of the intervals are very great. In one case the axillary glands 
were affected within one month, in one case not until seven years after 
the beginning of the tumor in the mammary gland (von Winiwarter). 
It is true the axillary glands are affected somewhat earlier when the car- 
cinoma is situated on the outer upper part than when on the inner part, 
though the difference is not so great as one would a priori suppose (von. 
Winiwarter). 
Volkmann has observed cases in which, on one mamma being affected, 
the axillary glands on both sides were invaded; and also cases in which 
when the internal part of the mamma, lying nearest to the sternum, was 
affected, only the axillary glands of the opposite side were invaded. There 
is no doubt, though it is very rare, that purely inflammatory non-carci- TUMORS OF THE MAMMARY GLANDS. 
117 
nomatous swelling of the axillary glands does take place in carcinoma of 
the mamma, which disappears after operation. Von Winiwarter cites 
an authentic case of this kind. 
After extirpation of the mamma and of the axillary glands it not infre- 
quently happens that the swelling of the supra-clavicular glands, which 
has escaped observation before the operation and become perceptible soon 
afterwards, ceases for a long time, and even almost entirely disappears by 
fatty degeneration and contraction. 
Besides the cases mentioned by Winiwarter, the following case observed 
by me a short time ago belongs here: 
Two years ago I operated on a rapidly growing carcinoma of the right 
mamma in an otherwise healthy woman of about thirty years of age; the 
moderately enlarged axijlary glands were extirpated with the mamma. 
There was rapid healing of the wound. Six weeks after the operation, 
the patient returned with a supra-clavicular tumor of the lymphatic 
gland, as large as the yolk of a hen's egg. I gave an unfavorable prog- 
nosis. A short time ago I saw the patient; she had grown markedly in 
weight and had a blooming appearance. The tumor over the right cla- 
vicle existed as before, and gave her no trouble. Perhaps the following 
case is more remarkable. 
Von Pitha operated in October, 1871, on a woman about sixty-four years 
old, for carcinoma of the right breast. The whole left mamma and large 
masses of axillary glands were also removed; healing occurred rapidly. 
The very well-nourished woman, who lived in the best circumstances, 
felt excellent. Soon, however, a new tumor appeared deep in the axillary 
space and under the clavicle; this, without becoming very large, became 
constantly harder, and caused fearful neuralgic pains in the left arm, 
which gradually swelled, and attained such enormous proportions as to 
resemble elephantiasis, and this was only slightly improved by bandaging. 
The patient consulted all the surgeons whom she could get at. Not one 
wished to incur the responsibility of a new operation, which could only 
consist in a disarticulation of the humerus; they were much less inclined 
to such an extreme operation, as the woman was fat and healthy other- 
wise, and would probably be entirely well if she were not tormented, 
especially at night, by these pains in her arm; but as she tolerated mor- 
phine and chloral well, she lived in fail' comfort, until, in the summer 
of 1877, rhagades and ulcerations appeared in the axilla; this caused an 
arterial hemorrhage on November 2, 1877, to which the patient suc- 
cumbed. The carcinoma of the lymphatics in this case, had remained 
quiescent for five years. Unfortunately no autopsy could be made. 
How much a rapidly arising infiltration of the lymphatic glands may 
hasten the course, and how much an operation before the invasion of the 
lymphatic glands, will delay the fatal issue, may be learned from the 
following resume, from A. von Winiwarter. After operations, with exist- 118 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
ing lymphatic invasions, and .after extirpation of these, the average time 
from the last operation to death, from recurrence, is thirteen months, the 
total duration of the disease twenty-nine months. In cases in which the 
operation was performed before appreeiable involvement of the lymphatic 
glands the patients lived, on an average, after the operation, twenty-two 
months, and the total duration of the disease was fifty months. 
By metastatic tumors we understand those in which continuity of the dis- 
ease cannot be thought of. AV hen skin, muscles, ribs, pleura, anterior 
surface of the pericardium and heart, and the diaphragm are affected on 
the same side as that upon which the mammary carcinoma has its seat, 
we consider this a continuous disease. Whether it can also be considered 
that the affection may directly spread through the lymphatic vessels of 
the diaphragm to the liver, and through the posterior mediastinum to 
the vertebral column, remains uncertain. Of the nodules which are found 
after death in the substance of the lungs, liver and kidneys, we believe, 
according to our present views as already set forth, that they are the 
result of emboli, i.e., carcinoma cells get into the veins, and are then 
carried (with or without being surrounded by blood-coagulum) into the 
right heart, and thence to the lungs. If the elements are small enough 
to pass through the capillaries of the lungs, they go to the left heart and 
thence into the aortic system, in which they here and there remain adher- 
ent. If, on account of their size, the carcinomatous particles cannot 
pass through the pulmonary capillaries, they attain further growth here, 
penetrate into the pulmonary veins, thence into the left heart, and so into 
the aortic system. If this theory be correct, the frequency and distribu- 
tion, with all their contingencies, must be analogous to pysemic metas- 
tases. This is supported by the fact that the embolic theory of carcinoma 
and (sarcoma) metastases is powerfully supported by it. 
It may now perhaps be very possible that in the primary carcinoma 
some particles may grow into the veins and thence be carried away. But 
this never seems to be the case, for in all the cases known to me, the 
lymphatic glands were always affected; whether always before the inter- 
nal metastases is certainly hard to prove, as the latter cannot always be 
diagnosticated with certainty. This objection I consider excluded in the 
two cases reported by Volkmann, in which, in carcinoma of the mamma, 
metastasis occurred once in the liver, once in the sacrum and once in the 
lower part of the vertebral column, without the axillary glands being 
affected. As regards the time elapsing from the beginning of carcinoma 
of the mamma to the invasion of the lymphatic glands, until metastases 
occur, our knowledge is very deficient. It seems that there are great 
variations in this respect. Those cases on which we operate under entirely 
favorable circumstances, but in which the patients already have internal 
metastases, as is shown by the autopsy when the patients die shortly after 
the operation, are unfortunately not very infrequent. Of thirty-four who TUMORS OF THE MAMMARY GLANDS. 
119 
died after operation, five already had extensive internal metastases. The 
primary tumors were first noticed, five, six, seven (twice), and nine 
months before the operation; in three cases the metastatic nodules were 
situated in the liver, in one case on the pleura, in one case in the lungs. 
I remember several cases in which tumors of the liver could be felt a few 
weeks after an operation which had a favorable course. In other cases it 
is a very long time before internal metastases appear; but possibly these 
may occasionally grow very slowly, and if they are small, may give no 
trouble for a long time. It is well known that the lungs and liver may 
be completely studded with small neoplasms before their function is so 
interfered with as to become fatal. 
As regards the frequency of the situation of these metastases, there is 
a deficiency on this point in the histories of the great number of reports 
of autopsies of persons who have died of carcinoma of the mamma. Such 
a collection can be productive of good results only when made from the 
reports of autopsies performed in very large hospitals, and especially of 
cancer-hospitals. What data we have are based upon too small a num- 
ber. Birkett has collected thirty-seven cases in Guy's hospital. This 
collection was made at a time when very different views prevailed as to 
metastases, and such data are therefore scarcely fitted for our purpose. 
Still, some principal points are very distinctly brought out. Several 
metastatic tumors were found as follows: in the liver, 14 times; the lungs, 
7; the bones, 6; the kidneys, 5; the ovaries, 4; the uterus, 4; the cere- 
bral meninges, 2; the pericardium, 2. 
This scale of frequency corresponds very well for most of the organs in 
my experience. But as regards the uterus and ovaries, I must be some- 
what sceptical; probably some small superficially situated "fibromas" 
were taken for " scirrhus. " According to the experience of all patho- 
logical anatomists and surgeons, whom I have consulted on this subject, 
metastatic carcinoma of the uterus and ovaries scarcely occurs. 
In Zurich I observed metastatic nodules: in the liver, 15 times; lungs 
and pleura, 6; brain, 2; bones, 2. 
Von Winiwarter mentions metastatic tumors in the liver, 12 times; 
pleura and lungs, 10; bones, 7; dura mater and brain, 2; muscles of the 
back, 2. 
At all events this much is apparent from these statistics, that metasta- 
ses are by far most frequent in the liver, and then in the lungs, bonesand 
brain. 
As regards the bones it is doubtful whether we may regard the (not any 
too frequent) cases of carcinoma of the humerus, occurring on the same 
side as carcinoma of the axillary glands, as true metastases; they belong 
perhaps to the carcinomas arising by contiguous development. I have 
frequently seen cases of carcinoma of the vertebral column, though much 
more frequently in private than in hospital practice (in Zurich one case, 120 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
and in Vienna four cases are noted in my clinic). I estimate the num- 
ber of cases which I have seen at from twelve to fifteen. As it is not 
infrequent that kyphosis is thus developed, it must be assumed that the 
^eat of the disease is principally in the bodies of the vertebrae; but the 
carcinomatous affection must more frequently and more rapidly invade the 
spinal nerves than do the suppuration and tubercle-formation in Pott's dis- 
ease, for the most fearful neuralgic pains and paralyses are the rule in 
carcinoma of the vertebral column while they are the exception in caries 
of the vertebrae. I certainly know of no condition in which the severity 
of the pains is by any means so great, and particularly because it lasts for 
months, and even indeed for a year. I do not know whether it is an ac- 
cident or whether it is due to some intimate connection, that the carci- 
nomas of the vertebral column, which I saw, occurred especially in 
patients in whom the carcinoma of the breast belonged to the exquisite 
retracting form, and sometimes appeared so insignificant that it was first 
noticed by the physician. Even to-day I saw a case of this kind. Mrs. 
X., about 48 years old, very well nourished; for two years there have 
been nodules in the inner, lower quadrant of the left mamma, which are 
now scarcely as large as a hen's egg, painless, with the overlying skin 
markedly retracted. In the axilla, the glands are swollen to the size of 
a walnut, movable, not wrinkled; the patient cannot give any informa- 
tion as to the duration of their existence, as she was not aware of them. 
Pains for two months in the thoracic portion of the vertebral column; 
band-like sensation about the thorax; present inability to sit or to stand; 
continual pains-such are the symptoms. The fearful drama is just begun. 
A few words regarding the infrequent metastases in the intestine (v. 
Winiwarter) and regarding the, by me not so infrequently observed, later 
invasion of the second mamma. Von Winiwarter very appropriately re- 
marks: " We assume at present, at least tacitly, that an existing car- 
cinoma secures the body against a second invasion of carcinoma." As we 
formerly acted upon the view that a cancer originates always in conse- 
quence of an already previously existing latent dyscrasia, we could not 
wonder if cancerous tumors appeared gradually in many of the organs of 
the body. Now we act upon the view that cancer is in the beginning a 
purely local disease, which appears solitarily, and thence infects the 
whole body. Von Winiwarter rightly reminds us that we must not en- 
tirely forget that the same individual may be afflicted with a second tumor, 
in another place, from the same (unknown) cause from which the first 
tumor originated. Metastatic tumors and metastatic abscesses in the 
mamma, for example, are such exceedingly great rarities, that we can 
scarcely compare invasion of the second mamma by carcinoma to them. 
A continuous extension from one mamma to the other is excluded in 
many cases of this kind. One is obliged indeed to think of a kind of 
sympathetic affection, such as has been proved to occur almost only in TUMORS OF THE MAMMARY GLANDS. 
121 
the eyes, sometimes in the ears, and then only by inflammatory processes. 
Tumors of both ovaries are certainly not very infrequent; tumors in both 
testicles, on the other hand, do not occur frequently. There are still 
many problems to be solved. 
Duration of the Disease until Death. 
As tumors never disappear in a definite manner spontaneously, we can- 
not speak here of a spontaneous course going on to cure. Further, as we 
possess no therapeutic means which cause a carcinoma to disappear, we 
cannot speak of a cure in the ordinary sense. Only by operative removal 
of the tumor can the patient be guarded against the troubles which the 
tumor itself causes locally, and against the dangers which come from it 
to the whole organism in one or another form. 
In this section I shall only attempt to show clearly how long a woman, 
who is so unfortunate as to have a cancer of the breast, can expect, under 
certain conditions, to live. The researches made at different times on this 
point have, it is true, been based on a definite number of cases, yet it is 
again very evident, from the difference of the results, how dependent are 
the results of statistical researches upon the dispositions of the cases, and 
how the nature of the dispositions are again influenced by the views of 
different authors. It is now seen that no attention can be paid to 
the anatomical differences of the forms, because in this respect (even in 
my clinical journals) there are no sufficiently exact records. Further, 
the series of observations upon which the comparative percentage calcula- 
tions rest are so unlike, that here also are sources of error. So, for ex- 
ample, the number of observations of "not operated" cases is much 
smaller, with us at least, than that of the "operated," because the sur- 
geons are less concerned as to the fate of the former than of the latter. 
If, however, there is some conformity in the results of the statistical re- 
searches of this kind, it is only a proof of such an overwhelming frequency 
of a certain course that the type is expressed even in a few cases. Thus 
far calculations have been made almost only with regard to the length of 
time from the beginning of the formation of the tumor until death, and 
two categories have been made: the "operated" and "not operated" 
cases. From such series of cases, we have calculated the averages. 
I. 
II. 
Mean duration of life in " non-operated " 
Mean duration of life in 
mammary carcinoma: 
" operated" mammary 
carcinoma: 
Paget, 1st work, (75 cases) 48 months. 
64 cases, 52 months. 
" 2nd 43 " 
55 " 
Sibley 32 " 
53 " 
A. v. Winiwarter (25 cases) 32.9 " 
39.3 " 122 
DISEASES OF THE FEMALE MAMMARY GLANDS 
From this it is seen that there is a great difference between the earlier 
English and our modern statistics; only Sibley's and v. Winiwarter's 
figures fix the duration of life of the " not operated " cases pretty exactly; 
in other respects the figures of the English statistics are considerably 
higher than ours. Von Winiwarter says: " I explain these differences 
thus: 1, that the diagnosis in many cases is not certain (in the English 
statistics); and 2, that I must leave out all the cured women (by opera- 
tion, and who still live), because I cannot now report on the duration of 
their life. But now the existence of 21 cases, freed (permanently) of car- 
cinoma, give such an important result to judge from, that the earlier 
statistics, which only tried to show whether the operation caused an 
especial lengthening of life, have no further importance for us. But aside 
from this, I doubt if Paget's and Sibley's calculations, which concern the 
duration of the life of the patients operated upon, correspond to the reality; 
I consider them too great in general, if we are to understand that all 
operated carcinomas of the mamma, without exception, are included in 
them. I believe that this is partly due to the fact that in England at that 
time very different principles prevailed in regard to the operation. If, for 
example, I so arrange the cases (of operated mammary carcinoma, death 
from recurrence), that the carcinomas with glandular infiltration before 
the first operation are separated from the others, 1 obtain for the operated 
cases of cancer of the breast, in which the glands were free, a mean dura- 
tion of life of 50.4 months, while for the remainder there is a mean 
duration of only 29.2 months. It is evident, since the figure 50.4 corre- 
sponds much closer with the statements of Paget and Sibley (52, 53, 55 
months), that at the time in England, a carcinoma with infiltrated glands 
was never operated upon, but these cases were simply considered as noli 
me tangere, and were relegated to the inoperable class. But in this way 
also the average of life's duration for these last becomes much more fav- 
orable, since many of the cases even, with infiltrated glands, live several 
years. " 
Practically it seems from this that in many cases in which the opera- 
tion is done at a time when the glands are not yet infiltrated, the operation 
may not only be permanently curable (as will be shown later), but may 
also prolong life on the appearance of recurrence. 
As the mean numbers thus far taken into consideration have no great 
significance for the individual cases, and none at all for individual groups, 
von Winiwarter has arranged his cases in still another manner: he has 
made percentage calculations according to the time of the duration of life 
from the beginning of the carcinoma until death, and has grouped these 
by semesters. The following is his resume: "As may be seen, an equally 
large percentage of operated and non-operated cases die in the fourth 
half-year, but hitherto about 27.5 per cent, of the former have died and 
nearly 35 per cent, of the latter. At the end of the fourth year, 11.8 per TUMORS OF THE MAMMARY GLANDS. 
123 
cent, of the non-operated cases are alive, while 16.6 per cent, of the oper- 
ated are living. The highest mortality of the operated cases falls within 
the second year; they are those cases in which there is early infection of 
the lymphatic glands, with recurrence very soon after operation, and 
which become inoperable early. This group includes according to the 
above arrangement about 47 per cent, of the whole number of all who 
die of mammary carcinoma: the remaining 53 per cent, is divided, because 
the mortality very suddenly diminishes after the second year (from 19 to 
5 per cent.) and in later years in gradually decreasing numbers, the re- 
mainder show fluctuations, clearly due to the proportionately less number, 
and on which therefore I place no great value. If we especially consider 
the cases which die within the first year after operation (from recurrence) 
we find that they in no way concern very young women (as one might be 
led to think from individual impressions).. The age of the patients was 
44 (in two cases), 50 and 77." 
Recurrent Affections and Final Cure in Cancer of the Breast, 
It is not yet half a century since we have been freed from the dogma: 
" all recurrent tumors are cancers. " First we began to differentiate be- 
tween the multiple appearance of tumors in the territory of one and the 
same system of tissue, and between the multiplication of a tumor by a 
seed spread by it throughout the body. Then followed the division of 
the latter group into several classes. A strict limitation of this first re- 
sulted from a careful classification of recurrent and infectious tumors, as 
was especially done by Thiersch. At present we are accustomed to differ- 
entiate : 
1. Continuous Reczirrences at the Site of Operation.-These always 
arise from portions of the tumor left behind at the time of operation, 
either because they could not be removed on anatomical grounds, or be- 
cause they were overlooked. They are thus always the result of an in- 
complete operation or of one that cannot be completed. There is then 
always a fault with the operator, if we may designate the incompleteness 
of our store of knowledge as such. Operators have long hesitated to ac- 
knowledge this. These continual recurrences occur shortly after opera- 
tion, sometimes even before the wound is healed, because we usually 
allow the wound to heal by granulation, which, in extensive operations, 
may require three months or longer. It is seldom that foci, left in the 
mamma, remain quiescent and first begin to grow after a long time has 
elapsed. Both the patient and surgeon are soon aware of these, by far the 
most frequent kind of recurrences after extirpation of the mamma and 
axillarv glands. 
2. Regional Recurrences.-After a longer time, sometimes even after 
twenty years, a recurrence will appear at the cicatrix of the operation. 124 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
This is the case almost only in sarcoma, and is certainly very rare in car- 
cinoma. We can hardly imagine, that, in such cases, the smallest mi- 
croscopic foci, which have been left at the time of operation, have remained 
quiet for so long a time without growing, and we therefore conclude 
that new tumors have arisen at the site of operation from the same (un- 
known) causes, which originated the first tumor. Regional recurrences 
are thus entirely new tumors springing up independently of the first 
tumor. 
3. Infection Recurrences.-We amputate a mamma containing a car- 
cinoma and leave the axillary glands because they absolutely cannot be 
felt; a few weeks or months after the healing of the wound, a carcinoma 
appears in the axillary glands, perhaps without the simultaneous forma- 
tion of a regional recurrence, and even without such a recurrence devel- 
oping at all. In regard to this, the older humoral pathologists reflected 
as follows: The carcinomatous juices in the body have discharged into 
the breast, and there concentrated; we have removed the product of its 
action, the cancerous tumor, which continually draws the carcinomatous 
material from the blood to itself and consumes it; now the peccant ma- 
terial settles in the lymphatic glands and here forms new products. 
Conclusion: cancer should be allowed to remain, as it attracts all the 
juices to itself, as long as possible, though it gradually undermines the 
strength of the organism by its ulceration. If it was removed, it was 
thought that at least the blood would be freed from the peccant material 
by the cure or else it would continually reappear here and there. This 
view, which is rapidly disappearing from the minds of physicians, has an 
uncommonly strong hold upon the public, so that the craze of carcinoma 
patients for " blood cures" is still very great. 
Modern pathology takes a very different view of the matter. If car- 
cinoma has been thoroughly removed, so that no continuous recurrences 
appear, and yet carcinoma appears in the glands, we now generally take 
the view that particles of the primary tumor had already entered the 
glands before operation, which we did not know, because we could not 
recognize them (again a very unwilling and very gradually conceded 
incompleteness of our diagnosis) and which only now have come to a fur- 
ther development. They would have developed (perhaps even sooner) 
if we had not operated. The glands were, in fact, infected before the 
operation. Hence the very suitable designation " infection recurrences." 
4. Metastatic Recurrences, Metastases.-So much has already been said 
on this subject that we need not recur to the modern theory of their 
origin. 
While according to the older opinions the operation looking to the 
cure of the evil was absolutely hopeless, since the measures which are 
taken to free the supposedly diseased blood from the peccant material, even 
though used diligently, only disappointed, while the operation seemed TUMORS OF THE MAMMARY GLANDS. 
125 
even harmful, the more recent views give us the certain hope that the 
primarily, purely local disease can be entirely cured by the radical re- 
moval of the tumor, except in those rare cases in which carcinomata occur 
at the same time, or in succession, but independently of one another, in 
one and the same organism. If the operator can remove the carcinoma- 
tously degenerated part completely without injury to the most important 
functions of the organism, the patient is really cured of the tl cancerous 
disease." From this it is self-evident that it is our duty to remove all 
carcinomas that can be operated on, as early as possible. But when is that 
moment when we dare hope that we have really cured the patient of the 
frightful disease ? In order to know this we must learn how soon recur- 
rence generally appears in this or that form. Regarding this there are a 
number of careful researches. 
Weeden Cooke, by comparison of 413 operated cases of carcinoma of the 
mamma, found that 409 remained free from recurrence for 6| months, 
and later recurrence occurred in 4 cases. 
Benjamin calculated, from 80 cases, an average of 4| months. Von 
Winiwarter has also given very detailed data on this point. I will only 
mention here that according to his calculation from 91 cases, recurrence 
took place in 27.4 per cent, before closure of the wound, in 38.4 per 
cent, within the first month, and in 34.1 per cent, later than the first 
month; in these last cases there were so many recurrences in the first 
three months after the operation that the total of the recurrences which 
appeared within the first quarter of a year after the operation amounted 
to 82.4 per cent, of all cases. All were doubtless continuity and infec- 
tion recurrences. There remain 11 cases in which recurrence first be- 
became noticeable between the eleventh and twelfth month, and five cases 
in which recurrence first appeared If (2), 2 (2) and 3f years after the 
operation. It is difficult to judge of the nature of these last cases; we 
may either regard them as arising from long inactive remainders or as 
new affections, as regional recurrences. 
The results of all these researches very strongly support the following 
position of Volkmann: " If a whole year passes after the operation, with- 
out a local recurrence, glandular swelling or symptom of internal affection 
being demonstrated on most careful examination, we may begin to hope 
that a permanent, good result has been obtained, of which we are usually 
certain after two years, and, almost without exception, positive of after 
three years." I believe that we may be somewhat bolder and assert that 
if, by the examination of an experienced surgeon, it is shown that there 
is no recognizable recurrence one year after healing of the wound, we 
may be certain that neither a continuous nor an infectious recurrence 
will appear, and the patient may be regarded as radically cured. For 
the rarely occurring new affections, the so-called regional recurrences 
in carcinoma, we can set no time limit. I must especially emphasize the 126 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
fact that the examination, chiefly of the axillary space and of the supra- 
clavicular region, should be made by one who, in consequence of his ex- 
perience, has such a fine sense of touch, and the ability to bring the body 
into such positions as arc most favorable for examination, and can find 
the smallest nodules. 
If now the number of cures proved in this way has hitherto always 
been unfortunately relatively small, it is because the physicians who do 
not operate themselves always wait too long before impressing upon their 
patients the necessity for the operation, or both they and the patients, as 
I have seen, far too often, trust to the diagnosis " chronic mastitis," or 
refer to cases in which the development of carcinoma went on for years, 
or hold to the opinion that the evil is certainly incurable, so why torment 
the patients with operations. With the above given results, we may to- 
day predict with certainty that this will be better in a short time. The 
operation has lost much of its terror to patients through narcosis; the 
loss of blood, by modern technicalities and practice, is reduced to a very 
small quantity; the danger to life is minimized; the pains, on account of 
the modern antiseptic dressings, are insignificant, and the time required 
for healing has been reduced to one-fourth or less. All this, conjointly 
with the conviction of physicians, must show that operation and only 
operation can give a permanent cure, that we always attain more and 
more favorable and complete results as to cure. Of course there always 
will be individual cases of carcinoma of the mamma, in which (as in the 
greater number of carcinomas of the tongue and floor of the mouth) the 
infection of the lymphatic glands follows so very quickly that it already 
exists before the diagnosis can be positively made, and these will always 
remain incurable; but these are rare and fatal exceptions. 
I have seen in my experience 15 authenticated cases of mammary car- 
cinoma, in which 12, 6, 5^?, 4^, 4^, 3^2, 3-^, 3^-, 3j32, 2y2, 2^, 
2^, 2, 1^, and 1^ years passed after the last operation, without there 
being any recurrence, and Volkmann has had a number of such cases; 
it will probably be allowed that we made correct diagnoses. I know 
from my own observations that we should not despair of a radical cure 
so long as there is a prospect of removing all the disease, as in only a few 
of the cured cases was the operation a simple one, confined to the mam- 
ma. In most cases the axillary glands had to be extirpated; in many 
cases radical cure resulted only after a second operation, and in one case 
only after a third. CHAPTER XI. 
ETIOLOGY AND STATISTICS OF TUMORS OF THE BREAST. 
QO little has hitherto been done in the way of discovering the specific 
causes of most tumor formations, that we can hardly say anything 
positive as to why, under certain circumstances, tumors so frequently 
develop in the breast, and still less, why at certain times of life, benign, 
and at other times malignant forms of tumors develop in this organ. 
What we have to say in the following pages on this subject is the result 
of the most exact observations, which are well calculated to direct the 
attention here and there, but without discovering the specific causes. 
That in organs which, like the mammary glands of women, stand in 
such close relationship with the genital apparatus, there must be very 
peculiar arrangements, in order, ou the one hand, to be able to attain 
a rapid functional development, and, on the other hand, to retrograde 
again, is, a priori, very clear. The mammary glands, like the uterus 
and ovaries, are first completely developed at the time of puberty, and 
this is done within a few months, according as these organs have thus far 
grown in proportion to the other parts of the body. Then there is again 
a period of inactivity, and it depends upon impregnation (always a con- 
tingency), when the uterus as well as the mammae reach the highest at- 
tainable development with the first pregnancy. The development of these 
organs thus goes on in a certain measure by starts; there is now increase, 
eventually new growth of glandular elements, of interstitial tissue and mus- 
cular fibres, of blood and lymphatic vessels, of nerves. The first secre- 
tion of milk is connected with the first pregnancy, and is kept up by 
different women for very different periods of time according as the child 
is nursed by the mother for a longer or shorter time, or not nursed at all. 
But this seldom goes on for much over a year, and then the function 
ceases, the gland remaining without function until the next pregnancy, 
and so on. 
It is very evident, at first sight, that an organ which undergoes so 
much change in its peculiar condition of nutrition and in its functional 
performance, may more easily be altered in these functions and in the 
anatomical changes peculiar to it, than an organ which continuously and 
gradually attains its natural and appointed size, and then continues to 
perform its functions in this way throughout the whole life. It is a 
priori conceivable that by this rising and falling, not only of the nutritive 128 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
process, but also of the formative activity of the tissue of the organ, 
quantitative and qualitative disturbances, aberrations of formation and 
function, occur. It is again conceivable how any kind of occasional non- 
specific excitation of the perhaps hereditarily vigorous and active forma- 
tive strength may cause abnormal products in the form of tumors in 
strong women who are hindered by social circumstances from calming 
their sexual inclinations naturally, or who, for some reason, remain child- 
less in wedlock. 
To the explanation of this matter, statistics give a few very certain 
data. Unfortunately my researches in this direction do not support the 
above observations very satisfactorily. I might rather show that it is 
just as astonishing how typically and regularly the physiological functions 
of the mammary glands occur. Of my exact observations of 282 cases 
of tumors of the breast (up to the year 1876) I can cite only two cases of 
adeno-fibroma whose formation was combined with the puberal develop- 
ment of the mamma. All the other cases were after that period, though 
in a few cases only two or three years later. Only once have I seen a 
subacutely arising abscess of the mamma at the time of the development 
of puberty. 
Just as seldom is mastitis in pregnant women (I have seen only seven 
cases), and still more rare is the formation of tumors during pregnancy. 
When there are 2 such cases in about 282 cases, there must have been 
some specially favorable circumstances, since several surgeons and gyne- 
cologists whom I have asked regarding the matter, and whose observations 
are much more numerous than mine, had seen nothing similar. 
These cases have been published in my clinical records, but on account 
of their rarity, I will briefly report them here: 
Mrs. L., 31 years old, came to me first in May, 1869. She had had two 
children, and in November, 1868, felt herself pregnant for the third time. 
All went normally until in January, 1869, she noticed a strikingly rapid 
and vigorously growing tumor of the left breast. It was firm and hard, 
and from time to time a little serum escaped from the nipple; she had no 
pains. At first she paid no attention to the matter, until finally the 
growth of the breast became so striking, and she felt more exhausted and 
became emaciated; her general condition was not disturbed; there was 
no sign of disease of internal organs, and still emaciation increased. 
Finally in May, 1869, she determined to consult several Vienna surgeons. 
Their opinions differed; some were in favor of amputating the breast, 
while others were against it. When she came to me, I found the left 
breast as large as a large man's head, firm, elastic, the skin over it oede- 
matous, the mamma freely movable on the thorax, the axillary glands not 
swollen. In the right breast also indurated nodules could be felt already. 
The patient was sparely built and emaciated. I advised against an oper- 
ation, because I did not think it probable that she would survive amputa- ETIOLOGY AND STATISTICS. 
129 
tion of both breasts, and to me the malignant nature of the tumor seemed 
so indubitable that internal metastases were soon to be expected, if they 
did not already exist. With me the patient consulted Dr. Carl v. Braun; 
it seemed to us that it was better that the patient should wait until she 
was confined; as the tumor had formed during pregnancy, possibly as an 
aberration of a physiological process, it might be hoped that with the es- 
tablishment of the complete physiological function of the gland it might 
retrograde. 
Professor C. v. Braun brought on premature labor. On June 12th, a 
seventh months old child was born, which died soon after birth, and 
showed nothing abnormal. The patient was continually febrile to a mod- 
erate degree, began to cough, threw off much mucous sputum, became 
entirely anorexial, and died of marasmus on July 12th, one month after 
labor Unfortunately I was not permitted to make the autopsy; I could 
only obtain permission to remove some pieces from the mammae. (The 
right mamma had meanwhile reached the same size and condition as the 
left.) The tissue was light whitish-yellow in color, was soft, and tena- 
cious; a milky juice could be expressed from it. Microscopic examination 
showed that on both sides there was a granulation sarcoma (Gliosarcoma, 
Virchow's small-celled, round-celled sarcoma.) (Fig. 17.) 
I have now to add the following points. A true secretion of milk did 
notappear after confinement. The "milky" fluid mentioned above, 
contained no milk elements, but only small lymphoid cells. But what was 
very striking to me, and which was always confirmed on repeated exami- 
nations, was the fact that there was no trace of glandular elements in the 
many wedge-shaped pieces cut out even from the depths of the tumors, 
which, taken together, were larger than at first. At all events, we did 
not have to deal with an aberrative formative activity of the epithelium of 
the glands. Very similar was the second case observed by me. 
Mrs. Fanny J., 36 years old, working woman, had had several chil- 
dren. She said that five weeks before she came to the clinic, on June 
21, 1875, up to which time she had been perfectly healthy, and in the 
eighth month of her pregnancy, there suddenly appeared a feeling of ten- 
sion at the circumference of both breasts (as she said the result of catch- 
ing cold I) From this time on there was rapid growth and hardening of 
both breasts. Seven days previously she gave birth, without any material 
loss of blood, to a healthy child, after the induction of premature labor 
by C. v. Braun. On admission the patient was very much emaciated 
and very pale. The breasts were larger than a child's head, hemisphe- 
rical, firm, covered by tense, glistening skin, colored bluish by numerous 
veins, and, on account of the cutaneous tension but little movable on the 
subjacent parts. The tumors were firm, and in only a few places elastic; 
no colostrum could be expressed from the nipples. Axillary glands not 
perceptible. Compression of both breasts by bandnges. Patient became 
9 130 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
weaker daily, vomited whatever food she took, and died on June 28. 
The total duration of the disease was, therefore, only six weeks. To the 
above report I will add that the autopsy showed metastatic white nodules 
in the thyroid gland, pericardium, liver, mesentery and kidneys. The 
breasts were surrounded by a lobulated, mostly reddish, soft mass, show- 
ing a milk-white fluid on its cut surface, and were bound fast to the fascia 
of the pectoralis major muscle, by means of condensed, infiltrated cellu- 
lar tissue. 1 unfortunately neglected to make notes of the microscopic 
condition, but I can state the following with certainty. From the analogy 
with the first case I considered that this tumor was also sarcoma, especially 
since there were no tumors of the axillary glands. But I have since cor- 
rected this diagnosis on the hospital book, and have designated the case 
as carcinoma, because I found, besides the very abundant lymphoid in- 
filtration of the connective tissue, by which the interstitial tissue assumed 
the character of lympho-sarcoma, here and there indisputable epithelial 
cell cylinders and gland-like formations, which had the character of ordi- 
nary carcinoma. It may, therefore, have been a combination of carcinoma 
and sarcoma. I must add that, at that time, the occurrence of large- 
celled, alveolar sarcoma in the mamma was not known to me, and that 
unfortunately I could not find the preparation recently in order to make 
another examination of it. 
The similarity of these two cases is striking. Both women in the be- 
ginning of the thirties, both had already borne several children, and with- 
out ever having had any trouble. In both the tumors developed rapidly 
in the fifth and seventh month of pregnancy. In neither was there a 
regular secretion of milk, after the induction of premature labor. Nor 
can we say of the tumors, which had more the character of sarcoma than 
of carcinoma, that a formative aberration of the epithelial glandular ele- 
ments was the most important factor. It has already been said that true 
hypertrophy of the mamma can in no way be considered as having a defi- 
nite relation to pregnancy or lactation, without straining the facts; more 
probably it is connected with the development of puberty. 
Luecke,1 Volkmann2 and Hermann Klotz,' from some of their observa- 
tions, are especially inclined to concede to pregnancy a prominent influence 
in the development of carcinomas of the mamma. Al. von Winiwarter also 
supports this view by two cases observed in my clinic, in which a nodule 
developed in the breast during pregnancy (once in the cicatrix of an ab- 
scess), which subsequently became carcinoma. These cases, as almost 
all of those reported by Volkmann and H. Klotz, are not identical with 
those which I report above. True enough in two of Volkmann's cases 
1 Monatschrift fur Geburtskunde, Bd., 19, p. 261. 
2Beitrage zur Chirurg., Leipzig, 1875, p. 320. 
3 Ueber mastitis carcinomatosa gravidarum et lactantium. Diss. Halle, 1869. ETIOLOGY AND STATISTICS. 
131 
both mammae were successively attacked, though, as in my cases, there 
was a considerable interval of time, and the infiltration had the character 
of carcinoma simplex with rapid extension to the skin; in the other cases 
only one breast was affected, and the course was probably more rapid, 
though not different from the course of the other cases which did not 
coincide with pregnancy or lactation. In most of the cases of this kind, 
the carcinoma appeared early (in the twenty-sixth to the thirtieth year), 
and later than this in only a few cases. 
A further point, which can be cleared up by the statistical method, is 
the question whether the fact that the glands never came to functional 
development, is to be considered as favorable for the development of 
tumors; this, it seems to me, is far too often asserted a priori, without 
statistical proof. Statistics disprove this assumption. Out of 236 female 
patients observed by me with mammary carcinoma, 23 were single and 213 
married. The number of single patients is thus very small (9.74 per 
cent.). Velpeau found in 213 cases, 25 unmarried (15.34 per cent.). 
With such statistics based on hospital patients, we cannot take " un- 
married " as identical with " childless; " but though we wish to know how 
much influence, not only the absence of sexual excitation, but also the 
want of full physiological development of the breasts, has upon the origin of 
cancer of the breast, the material for these statistics is far too uncertain; 
whether this has any influence on the unimportant dissimilarity of Vel- 
peau's and my statistics, I cannot say. At all events, such numbers do 
not prove much more than that the unmarried are not free from carci- 
noma. If we wish to be more exact, we must know how many un- 
married and how many married lived under observation during a certain 
period of time, and thus fix the relative numbers; then we could say of 
the unmarried X years, X per cent, were affected, and of the married, 
X per cent., etc. As the numbers are now nearly the same, we cannot 
dispute the assertion that they sufficiently represent the proportion of 
the unmarried to the married during the period of life in question, and 
may thus prove as well that carcinoma is just as frequent in unmarried 
as in married women. 
Similar objections present themselves to the explanation of the number 
if we compare the number of fruitful and unfruitful married women 
suffering from mammary cancer. Velpeau noted 138 cases, of which 28 
(13.04 per cent.) were unfruitful and 110 were fruitful; I have observed 
209 cases, of which 23 (11 per cent.) were unfruitful and 186 were fruit- 
ful. How much depends upon the size of the numbers here, is shown by 
the statistics of Al. von Winiwarter, who has used some of my cases (170) 
in his statistics; he calculated the number of unfruitful women with mam- 
mary carcinoma at 16.2 iper cent.; it should be mentioned here that of 
the thirty-nine women whom I observed further only one was unfruitful. 
The difference varies in the third statistical calculation, in regard to the 132 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
unfruitful women between 11 and 16.2 per cent.; at all events it is not 
considerable. These numbers show indisputably that a greater number 
of fruitful than unfruitful women suffer from mammary carcinoma; but 
they do not show that fruitfulness is an important factor of the disease, 
since the number of fruitful women is enormously greater than the num- 
ber of unfruitful ones. If these numbers accurately represent the relation 
of the two categories to each other, then each is equally disposed to car- 
cinoma. 
I will now give the figures with regard to lactation. Velpeau noted: 
Of 110 fruitful women with mammary carcinoma, 60, or 54.54 per cent, 
had nursed; 50, or 45.46 per cent, had not. Al. von Winiwarter noted: 
Of 102 women with mammary carcinoma 37, or 36.2 per cent, had never 
nursed; 65, or 63.8 per cent, had nursed their children. This, probably, 
can only serve to show what is already known, that the French women 
more seldom nurse their children, or are more seldom in a condition to 
nurse them, than the Austrian women. That, therefore, more suckling 
women in Austria must be affected, is clear; and further, since the num- 
ber of nursing women in female hospital patients is always larger than 
that of those not nursing, the excess of the former is not astonishing; the 
figures do not furnish indisputable proof that lactation predisposes to mam- 
mary carcinoma. Certainly these relations are hard to express in figures; 
for if lactation is to enter into the question of the formation of carcino- 
ma, it will be of interest to know whether it has been soon and suddenly 
interrupted, or unduly prolonged, whether many or few children were 
nursed, at what intervals, etc., also the number of abortions or premature 
labors, etc.; and thus the question, apparently so simple, is dependent 
upon so many individual observations, that it is not yet worth while at- 
tempting to group them for statistical purposes. 
That hardenings in one or both breasts during lactation, remaining 
after the weaning of the child, and after the retrogression of the glandular 
function, grow and develop into tumors, perhaps sarcoma or carcinoma, 
is considered beyond doubt by many authors; but this rests almost exclu- 
sively upon the statements of the women, not upon the physician's obser- 
vation, and is therefore to be accepted with caution. 
It is certainly no pleasant task to analyze so critically the results of 
careful and arduous labors, and much less so, when one has himself taken 
the warmest interest in such work. I am far from undervaluing the 
worth of such statistical researches for clinical exposition; great progress 
has been made therein, compared with the former foggy statements re- 
garding such relations. But we cannot be too cautious when we use such 
researches as supports for these or those hypotheses which clear up the 
origin of tumors of the breasts, and eventually of all tumors. If an 
hypothesis is to have value, its supports must be irreproachable. That 
this is not the case with regard to the reiterated assertion that the mam- ETIOLOGY AND STATISTICS. 
133 
ma is especially predisposed, by the peculiar nature of its development 
and by its periodic function, to the formation of tumors is probably ap- 
parent from the above argument. 
In our helplessness in regard to the causes of the origin of tumors, we 
have left no way untrodden by which we could possibly find a point of 
support. Thus we have sought to find whether tumors develop more fre- 
quently in one breast or the other, or whether there is no difference in 
the two organs. Velpeau noted that of 362 carcinomas, 156 were right, 
191 were left, and 15 were bilateral. I found in 245 cases, 123 right, 
119 left, and 3 bilateral. The sum of both series of observations (607 
cases) gives 279 right, 310 left, and 18 bilateral. According to this car- 
cinoma would be slightly more frequent on the left side; but the differ- 
ence does not seem to me great enough to base hypotheses on. It is strik- 
ing that of the cases of fibroma, adenoma and cysto-sarcoma (32 in all) in 
which I have noted the affected side, there were 9 right, 19 left and 4 
bilateral, showing a preference for the left side (in my special statistics 
of carcinoma, however, there is a slight preference for the right side). 
Completely contradictory to what has been said are the statistics of 
Hennig. He has brought forward a number of cases which certainly seem 
to prove the opposite to ours. When we consider his statistics of the forms 
of carcinoma alone, it is seen that of 853 cases, 560 were right, 270 left, 
and 23 bilateral; and by later statistics 867 right, 538 left. This enor- 
mous difference in favor of the right side leads him to build up hypothe- 
ses as to the cause of these phenomena, which, from anatomical points of 
view, may seem plausible. But it is not shown how his statistics were 
collected, whether they really contain continuous series of observations 
from hospitals, or whether they also contained occasionally published 
individual cases, so we cannot accept his statistics as scientifically applica- 
ble without further confirmation. 
Of greater value would be statistics as to the time of life at which 
tumors of the breast, especially carcinomata, appear. I group the figures 
of Velpeau, Birkett and myself as follows: 
t1* 
aq 
: s ~ 7 t 
o 
-1 Ci ca rfx co to 
rrrTT? 
o g g g g g 
(D 
- r : -p 
y> 
301 
£ CO 10 
ca co co Ca co fP- 
II II II II II II 
CO co 
>-1 O c© CO H-1 
''elpeat 
ci oo ca ca Ci co 
ci to co ci co to 
238 
co ca co rf- h-i 
to O 00 co co to 
II II II II II II 
Billi 
M (C W 
OW^OGOO! 
o 
GO CX CO O O 
4^ O Ci -1 <X <X 
458 
HCCOOOH 
QI *3 CO O C 
II II II II II II 
w 
id to 
W-i >r> 
kett 
io U U* bo 
*ftO->COCC4^- 
But to estimate the percentage without these series of observations for 
more exact comparison, it is seen that the number of patients affected is 
by far the greatest in the fifth and sixth decennium (41-60). Still, not 134 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
only within this time, but also before and after it there are not incon- 
siderable differences in the three series. But I can scarcely believe that it 
is the difference of the absolute size of the figures, in which the fault lies. 
For example, if I take my Zurich statistics alone, and then von Wini- 
warter's statistics alone, these casual divisions of my observations give 
the same result as the above series. The greatest number always falls in 
the time from forty-one to sixty years of age. According to von Wini- 
warter's estimated series of observations as to the period of life, it is es- 
pecially between the ages of forty-one to forty-five that mammary carci- 
noma is most frequently developed. Now this does not correspond to 
Velpeau's observations. (The small series of statistics of Volkmann cor- 
responds with that of Velpeau.) According to him the time of most 
frequent affection is from fifty-one to sixty years. Still more striking 
is the frequent occurrence of mammary carcinoma in the third and fourth 
decennium in my series, while in Velpeau's series this age is far less 
frequently affected; it is so much the more striking, as many soft sarco- 
mas may have slipped in under Velpeau's " encephaloides," which more 
frequently occur in younger women. 
Opposed to these peculiar, and - it seems to me indisputable facts, w'e 
may perhaps point to the relations of the mammary glands to the sexual 
organs. I would at the same time emphasize more forcibly than Al. von 
Winiwarter has, that the greater part of my material for observation has 
been from the Galician and Hungarian Jewesses, in whom sexual matur- 
ity doubtless comes on much earlier than in French women; whether it is 
also extinguished earlier as a rule, I unfortunately cannot state positively, 
and yet it would be of importance to know this if we wish to compare 
the development of carcinoma with the climacteric. It is not uncommon 
for Hungarian Jewesses to menstruate in the eleventh year. Probably 
the menses usually cease in the middle of the fortieth year; yet I have 
met with Jewish women who still menstruated regularly in the sixtieth 
year, and in whom the first menstruation occurred in the tenth year. 
One thing seems settled, that no true mammary carcinoma has been ob- 
served before the beginning of menstruation. Further, all the cases of 
mammary carcinoma before the thirtieth year, of which I have known, 
occurred in married women. And against the statement, that the largest 
number of mammary carcinoma appear toward the end of the period of 
menstruation, and at a time, therefore, when the mamma begins to re- 
trograde, no valid objection can be made. 
These observations are also somewhat affected by the fact that mam- 
mary carcinomas in men, rare as they are, appear as a rule in the fifth 
and sixth decennium, and there can scarcely be any question as to retro- 
gression in these periods. The same holds good for carcinoma of the 
skin. Therefore the development of carcinoma of the mammary gland 
(which may always be regarded as a cutaneous gland) coincides generally ETIOLOGY AND STATISTICS. 
135 
with the time of development of carcinomas, so that, without regard to 
the incontrovertible especial frequency of carcinomas in the mammary 
gland, we can also explain away the connection with the functions of the 
genital apparatus. 
As concerns the rise in the scale up to the fiftieth year, the especial 
frequency of carcinomas of the mamma is certainly not to be disproved, 
and it is claimed for the series set up for comparison that they are abso- 
lutely valid as regards the disposition of age to carcinomatous affection. 
From the fiftieth yeai- onward the mortality of mankind increases so rap- 
idly that from the smaller number of cases observed, we must not con- 
clude that the disposition to the disease in question absolutely decreases. 
We see fewer women with carcinomas of the breast, and in fact, fewer 
carcinomatous patients from fifty to seventy years old, because there are 
in fact fewer people of this age living than there are of thirty to fifty 
years old. The numbers of the second half of the above series have there- 
fore only a relative importance. 
Though my observations regarding fibroma, sarcoma and adenoma are 
few, still they show some striking proportions as regards the age at 
which they appear; these proportions may be briefly examined. 
Of the prominently fibromatous tumors there originated: 6 in the second 
decennium, 9 in the third, 4 in the fourth. 
12 of these 19 tumors originated between the seventeenth and twenty- 
fifth years. Of the cysto-sarcomas and adenomas there originated: 1 in 
the second decennium, 4 in the third, 8 in the fourth, 5 in the fifth, 1 
in the sixth. 
The two bilateral colossal hypertrophies, which I observed, originated 
in the sixteenth and nineteenth years of life, in the first case in a virgo 
intact a, and in the second, menstruation began at the fifteenth year; 
then the hypertrophy developed, during which the patient became preg- 
nant; she aborted in the fifth month in consequence of erysipelas, and 
died. In the first case no anatomical examination was made, so that we 
can only make a probable diagnosis of diffuse adenoma; in the second case 
there was a colossal fibromatous growth combined with diffuse adenoma. 
Of all these tumors, not even one originated before the development of 
puberty. According to these observations the third decennium especially 
predisposes to fibromas, the fourth to cysto-sarcomas, and the fifth to 
carcinomas. If one will connect this with the development and function 
of the gland it may be said: in the second and third decennium, there 
is an especial tendency to an excessive growth of the fibroid layer, which 
encloses the short-branched terminal vesicles of the virgin breast. In the 
fourth decennium this layer is also very much disposed to exuberant 
growth, though the degeneration more easily passes over into the soft 
forms of sarcoma, and is partly connected with simple hyperplasia, partly 
with cystoid degeneration of the lacteal vesicles and lacteal ducts; 136 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
through the always more or less striking growth of the epithelium thus 
taking place, these neoplasms are very nearly related to the carcinomas, 
which somewhat later come more and more into the foreground, and 
finally occupy the ground almost alone. 
As to the frequency of the occurrence of the different forms of tumors 
of the mammary glands as regards one another and the cases taken gene- 
rally at a clinic, I can state the following from my own observations. 
While I was assistant at the Berlin clinic, I noted within six years 150 
tumors of the breast, of which 130 (86 per cent.) were carcinomatous, 
and 20 (14 per cent.) non-carcinomatous. 
In seven and a half years, in Zurich, there occurred 51 tumors of the 
female mammary gland, of which 49 (96.08 per cent.) were carcinoma- 
tous, and 2 (3.92 per cent.) non-carcinomatous. In nine years in Vienna 
I saw 239 tumors of this kind, 196 of which (82 per cent.) were carcino- 
matous, 43 (18 per cent.) non-carcinomatous. From this it seems that 
in Zurich benign tumors of the breast were very rare, the differences for 
Berlin and Vienna being unimportant. A summing up of these observa- 
tions shows: Of 440 tumors of the breast 375 (82 per cent.) were carcino- 
matous, and 65 (18 per cent.) non-carcinomatous. 
As regards the frequency of the occurrence of tumors of the breast in 
the surgical clinics from which my observations are taken, it is seen that 
in Berlin 5 per cent., in Zurich 1.2 per cent., and in Vienna 4.4 per cent, 
of all the female patients had tumors of the breast. From these numbers 
I can neither conclude that these tumors are especially rare in Zurich, 
nor that they are especially frequent in Berlin. It should be remem- 
bered that in the Canton's hospital in Zurich, even though not exclu- 
sively, yet few other women than those from Canton Zurich are received, 
while in the Berlin and Vienna clinics are cases from the most remote 
regions of Germany and Austria. 
Old and New Theories as to Tumor Formation, in Their 
Application to the Mamma. 
That tumors are parasites on the body and not connected with it by 
means of the blood and lymph streams, no one has believed for a long 
time; but that they originated from black gall, blood and malignant 
humors, which occasionally found a resting-place in the mamma, and then 
became connected with the circulation of the body, is an opinion that was 
generally disseminated until the middle of this century. As it was agreed 
in regard to their developmental history that all organs originated from a 
primarily unformed blastema, from which the cells are first formed, so, 
at the time when John Muller had already discovered that they originated 
from the same or similar tissue as the tissue of embryos, it was agreed 
that tumors grew from an unformed protoplasm, which was either blood ETIOLOGY AND STATISTICS. 
137 
or lymph, or excreted by blood or lymph vessels; that is to say, this 
juice contained the vital agents, though not always their corpuscular ele- 
ments. The proposition " omnis cellula ex cellulo " was first promulgated 
by Remak for the developmental history; he first used it in regard to 
the origin of carcinoma, and this idea was afterwards employed by Vir- 
chow to include all pathological neoplasms and with great consistency in 
all new researches. To-day no one believes in the origin of tissue from 
amorphous protoplasm, at least as regards the human organism. Still, 
as certainly and as systematically as we can now follow up the origin and 
further development of the most complicated tumors, there is one thing 
which remained obscure and is so to-day, namely, the reason of the ori- 
gin and the typical further development not only for the individual forms 
of neoplasms in the narrow sense, but also for the so-called inflammatory 
neoplasms. Clinical observation leads always and again to the thousand- 
fold observed fact, that after the irritations known to us, which may act 
accidentally on the tissue or be used exclusively for the purpose of ex- 
periment, and which we designate as " inflammatory," again do the same 
series of phenomena arise and run their course typically. And just here 
there is great difficulty with regard to chronic inflammations, which we 
can only imitate experimentally when we apply the irritation for a long 
time, or when we use substances which are very finely divided and main- 
tain the irritation, because they are not absorbed and excreted (tuberculous 
experiments). It is not yet possible to produce true tumors experimen- 
tally, and we therefore conclude that we do not know the specific forms 
of irritation which lead to tumor formation, or that we do not know the 
condition in which the tissues must be when tumors can be developed 
from ordinary known causes. Virchow, in his endeavor to explain the 
existence and growth of tumors, without the aid of unknown and more 
or less mystical factors, but only with the aid of known observations, or 
at least to bring them nearer explanation, clung to the opinion that one 
of the known must cause the origin of tumors, and for this reason used 
everything which could, from that point of view, throw a ray of light on 
this dark territory. It has now become correct to say that a blow, pres- 
sure, a fall is with great certainty the cause of the origin of tumors in 
many cases; that carcinomatous ulcers are proved to originate from scars 
and chronic sluggish ulcers; that the influence of wind and weather, and 
perhaps the irritation of the skin of the face by shaving, etc., especially 
favor the development of carcinomas of the face. As regards these pre- 
disposing factors in their application to the breasts, they have been so 
carefully discussed and proved by statistics by Al. von Winiwarter, that I 
must refer all, who are interested in this matter of etiology, to his book. 
He can only adduce 12 cases out of 170 (7.06 per cent.) of mechanical 
injuries (blows) acting at once, in which the declarations of the patients 
were sufficiently definite to induce belief; he states, however, that even 138 
DISEASES OF THE FEMALE MAMMARY GLANDS 
these few cases give but little etiological support, since the carcinoma 
either made its appearance immediately after the blow, or after a long 
time, without the appearance of the phenomena of contusion and. chronic 
irritation. 
As permanent irritations for the breast may be considered, the manifold 
pressure caused by wearing narrow bodices (corsets). Direct researches 
on this point have not been made. It is to tlie point, however, that of 
112 cases of von Winiwarter's observations, 61 were affected more in the 
external, and 15 in the internal portion of the gland, while in 36 cases 
the affection began in other places; for we can say that the external por- 
tion of the gland lies more on the corset than does the internal portion. 
But the fact that, on dividing the gland by a horizontal line passing 
through the nipple, 52 cases were found to be affected above the line, only 
20 below, and 40 cases in other parts, does not accord with this view. 
Paget has observed 15 cases in which eczema and psoriasis of the nipple 
and areola preceded the development of carcinoma by one year. I re- 
member only one single case in which eczema occurred on a carcinomatous 
breast. 
It may also be thought that a permanent intertrigo, which is found 
under the breasts of fat women, where the skin of the mamma and thorax 
join, would exert a bad influence on the mamma; but Al. von Winiwarter 
found carcinoma in this situation only twice. 
It has also been made a prominent point that carcinoma is especially 
developed in and from cicatrices and other stabile remains of former in- 
flammations. This opinion is principally due to the observation that 
cancer of the skin (epithelial cancer, epithelioma) is sometimes formed 
from fixed, frequently ulcerating scars (especially on the skull and the 
anterior surface of the tibia). It has never been observed so far as the 
skin is concerned, that a mammary or epithelial cancer has arisen from a 
cicatrix of the mamma. As regards the observations according to which 
carcinomas of the mamma have developed from cicatrices in the interior of 
the mamma this would not be proved, simply because it is repeatedly stated 
in reports that an abscess had developed in former years after confinement 
in the same mamma in which a carcinoma was found at the time of exami- 
nation, because it is difficult to establish the proof that the carcinoma was 
developed from the scar in the interior of the mamma. Another con- 
nection between mastitis and carcinoma is imagined from the statements 
of the affected women, that after the cessation of a puerperal mastitis, a 
nodule remained in the affected breast from which a carcinoma developed 
after several years. Al. von Winiwarter has sufficiently proved and shown, 
regarding his 9 cases, that there were 4|, 5, 7, 10, 16, 20, 21, 25, and 28 
years between the mastitis and the development of carcinoma. Finally 
it should also be considered that probably quite often a few not dilated 
lacteal lobules are broken off from their connection with their excretory ETIOLOGY AND STATISTICS. 
139 
ducts by suppurative mastitis, and that such lobules may be brought 
into functional activity by a subsequent pregnancy; the secretion then 
formed must be either totally or partially absorbed, and in the latter case 
it would probably remain inspissated. From this it should be expected 
that milk and butter cysts must often be developed after mastitis, but 
such is not the case. There is still the hypothesis that in such occluded 
gland lobules the epithelium is especially disposed to atypical proliferation, 
and that carcinomas are thus originated. It would be very difficult to 
prove this hypothesis; and statistics indicate otherwise. Al. von Wini- 
warter found that of 114 women affected with mammary carcinoma, 24 
(21.05 per cent.) had had mastitis. If now mastitis is very frequent and 
carcinoma likewise very frequent, so that a coincidence of the two pro- 
cesses will not be surprising, the frequency of mastitis to all cases of con- 
finement, according to Wincklers statistics, is still only 6 per cent. If 
then there be no especial contingencies in Al. von Winiwarter's statistics, 
we may assume provisionally that women who have had mastitis are more 
disposed to carcinoma than those who have not had it. As regards the 
nodules which commonly remain in the breast after confinement, I must 
say that those which I have had occasion to examine (I do not mean that 
I have extirpated and anatomically examined such nodules) seemed very 
much like small nodular adeno-fibromas. It is very possible that they 
may have existed before confinement, though not detected in the firmer 
mamma; they had perhaps enlarged during pregnancy and lactation, and 
were therefore more noticeable when the gland became more relaxed. 
So far as we may go in our search for further, newer irritation, which 
may possibly cause the origin of tumors, the objection always remains 
that in this way, probably, various acute and chronic inflammatory pro- 
cesses, and perhaps also the formation of retention-cysts and the like, may 
be explained, but not the formation of peculiar pseudo-plasms. We are 
thus always drawn into the territory of hypotheses, whose foundations 
derived from observation belong to the class inexplicable, even if they 
are not wholly without reason. 
I have set forth an hypothesis which leans towards the older ideas, 
namely, that the disposition to the formation of tumors is a congenital 
one; in other words, that we may assume a congenital diathesis for tumor 
formation in the same way that we have already long assumed a con- 
genital diathesis for chronic inflammations resulting in purulent, caseat- 
ing products (scrofulosis, tuberculosis). Though both diatheses are not 
absolutely antagonistic, it is certain that their coincidence in the same 
individual is very rare; individuals with scrofula and tuberculosis repro- 
duce-even when occurring in those years disposed to the formation of 
carcinoma-carcinoma only in the most exceptional cases, and, as excep- 
tionally, other tumors, which belong to earlier periods of life; whilst, on 
the other hand, individuals who have tumors, at whatever age they may 140 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
be, very rarely become tuberculous. Individual exceptions do not invali- 
date the accuracy of these observations. 
On this hypothesis, all factors which were formerly regarded as irrita- 
tions of different kinds may retain their complete importance as so-called 
exciting causes. 
When I say that such a diathesis must be assumed as congenital, I do 
not at all mean that it is identical with hereditary, though since most of 
our congenital peculiarities are hereditary, and, for example, the 
serofulo-tuberculous diathesis is known to be in a high degree heredi- 
tary, we may also expect that the diathesis for the formation of tumors 
is also hereditary. The indications of this are not very great in litera- 
ture. Al. v. Winiwarter has selected from the reports of my clinic the 
few certain observations; five cases are there noted in which the mother 
died of carcinoma of the uterus, then there are other cases in which 
either the mother or father died of cancel' of the stomach. Yet, from 
his observations von Winiwarter draws the conclusion that, in only ten 
cases of 170, did carcinoma certainly exist in the parents; according to 
this, the number of cases of heredity proved amounted to only 5.8 per 
cent, of all cases observed. It is to be considered with regard to this 
that, as the question has not been put methodically, nothing is said in 
many reports as to heredity, either because nothing was asked about it, 
or because the patients were unable to give the cause of their parents' 
death. It is to be further considered that the hereditary peculiarities are 
seldom known beyond one generation, and questions as to the cause of 
death of the grand-parents are seldom put, and could just as seldom be 
answered. The consideration that frequently several sisters from non- 
carcinomatous mothers are affected with mammary carcinoma, as is 
repeatedly mentioned in the reports, also well indicates the constitutional 
disposition and heredity of former generations. 
Though it is dangerous to base far-reaching conclusions on the remem- 
brances of former cases, I must say that, according to my recollections of 
consultations, it does not seem to me so rare that several consanguineous 
women were affected with carcinoma; for it is quite frequent that women 
with slight induration of the mamma come to the surgeon especially early, 
because the frightful course of carcinomas of the mamma has been observ- 
ed in their family. It will scarcely be possible, even from the carefully 
prepared clinical reports, to form a correct idea of the frequency of the 
heredity of carcinoma, for were we confined to such reports alone, we 
would gain no correct conception of the much more frequent serofulo- 
tuberculous diathesis. Only the old family physician could give us any 
valuable information on that point. I think, however, that in further 
statistical investigations on this point, which is more of purely scientific 
than practical interest, we should not restrict ourselves especially to the 
heredity of carcinoma in a particular organ, but we should endeavor to ETIOLOGY AND STATISTICS. 
141 
find out whether the formation of tumors became more frequent in the 
different generations of a family. When we inquire into the heredity of 
the scrofulo-tuberculous diathesis we do not restrict ourselves to the 
question of pulmonary tuberculosis, of laryngeal, intestinal, or tubercu- 
losis of the cord, caries of the knee, etc., but we know very well that, 
with the same hereditary disposition, one organ in this, another in that 
generation may be affected. So also may different forms of tumors of 
hereditary disposition altogether change in different organs and in differ- 
ent generations. That the investigations are thus made more difficult 
stands to reason. 
Broca has given an especially interesting report on the descent of 
carcinoma through several generations, which I will quote: 
1. Generation: Mrs Z. died 1788, 60 years old, of cancer of the breast. 
2. Generation: 4 daughters all married. 
A, died of cancer of the liver, aged 62, 1820. 
B. of the same, aged 43, 1808. 
C. died of cancer of the breast, aged 51, 1814. 
D. of the same, aged 54, 1827. 
3. Generation. Mrs. B. had 5 daughters and 2 sons. 
1. Son died young. 
2. Son died of cancer of the stomach, aged 64. 
3. Daughter died of cancer of the breast, aged 35. 
4. Daughter, of the same. 
5. Daughter, of the same. 
6. Daughter, died of cancer of the liver. 
- aged between 35 and 40 years. 
7. Daughter, remained free of cancer. 
In another form, I might say more localized, Cohnheim 1 has conceived 
the beginning of the tumor as an exquisitely and even exclusively congenital 
one. He first of all excludes a large part of the disease-processes and 
products, which Virchow had introduced into oncology, and places again 
the origin, as the older pathological anatomists and gynecologists had 
limited it. Further, from different critical discussions, he comes to the 
conclusion, to which I entirely assent, that the most important difference 
between a tumor formation and the inflammatory neoplasms can lie only 
in the territory of etiology, as all clinicians will agree without hesitation. 
Finally he says: "The main point is and always will be, that it is a fault, 
an irregularity of the embryonal foundation, which must be sought as the 
true cause of the later tumor." Without regarding this view as more 
than a plausible hypothesis, Cohnheim subsequently deduces the theory 
that there are probably always parts of a tissue or organ which have not 
come to normal physiological function on account of some disturbance of 
development, and from which tumors are formed during life. In so 
1 Vorlesungen liber Allgemeine Pathologie, Bd. 1, p, 622, et seq., Berlin, 1877. 142 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
ingenious a manner is tliis trairf of thought of Cohnheim carried out and 
supported, partly by known, partly by new observations, that one is cer- 
tainly, at first thought, somewhat impressed by the boldness of seeing a 
hypothesis, hitherto employed in explaining a few rare forms of tumor, 
suddenly set up as the etiological factor of tumors in general. But on more 
mature consideration, one can scarcely deny the fact that this hypothesis 
has a great deal in it, notwithstanding that its fundamental principle can 
scarcely be established even by direct research. It would be too much 
of a digression were 1 to more closely examine everything favorable or un- 
favorable to Cohnheim's view. Yet I shall make a few observations on it 
as regards the mamma. According to Cohnheim, tumors would only 
originate in those mammae in which an "irregularity of the embryonal 
foundation'' exists somewhere. In my opinion we should not take this 
literally for the mamma; an organ which is developed in three stages, 
(foetal formation, further development at the time of puberty, and complete 
growth with the first pregnancy), is exposed to irregularities of develop- 
ment in each of these three stages. These irregularities may probably 
only be shown in that, in a gland which, except as to difference in size, 
continually spreads like a tree, a developed branch or a developed lacteal 
cluster(of vesicles) is cut off from its connection with its trunk, its excre- 
tory duct, by constriction. Probably this can never be proved anatomi- 
cally, and as we can only examine microscopically the smallest parts of 
these glands by sections, the proof of the non-connection with the gland- 
ular tree pan never be exact. 
We may expect now any kind of abnormality from such a disconnected 
portion of gland, which either never or at most incompletely attains a 
physiological function, whenever any irritation acts on the gland-cells 
condemned to isolation; but it is hard to understand why without such an 
irritation the affected portion of the gland, in these abnormal circum- 
stances, cannot remain quiet throughout the whole life. It seems to me 
that even on this hypothesis the assumption is not supported that cer- 
tain physiological internal or traumatic external irritations operate upon 
such abnormal foundations as the exciting cause for the development of 
the tumor, so that what has been said before will be in no way upset by 
Cohnheim's hypothesis. 
We are in a far more difficult situation when we wish to clear up with 
the aid of Cohnheim's hypothesis, the origin of those mammary fibromas, 
sarcomas and chondromas (in bitches), in which the epithelial elements 
of the gland take so small a part that there can be no doubt as to their 
sole origin in the connective-tissue-like interstitial and supporting tissue. 
We would then have to assume that in the different stages of development, 
through which the mamma passes, occasionally a small focus of embryo- 
nal connective-tissue elements remains here and there for years in the 
stage of indifferent cellular tissue, and then on the occasion of an irrita- ETIOLOGY AND STATISTICS. 
143 
tion, which even here we cannot do without, suddenly develops to this or 
that pathologically formed connective tissue. I freely admit that I can- 
not really agree to this, especially in cases in which such a connective- 
tissue tumor includes probably a fourth or a third of the glandular ele- 
ments of the whole mamma. Also for those giant tumors, the cysto- 
sarcomas, which affect the whole mamma of women who have formerly 
nursed their children in a natural way, as well as for those cases of 
bilateral diffuse sarcoma of the whole mamma which originate during 
pregnancy, though so rarely, Cohnheim's hypothesis offers great difficul- 
ties. I am always ready to acknowledge that Cohnheim's statement has 
impressed me so very much, that the impression contributes materially 
in checking my intention of criticizing it sharply. CHAPTER XII. 
DIFFERENTIAL DIAGNOSIS AND PROGNOSIS OF TUMORS 
OF THE MAMMARY GLANDS. 
rpiIE diagnosis and prognosis of tumors of the mammary gland are much 
1 more simple in practice than may appear from the many forms of 
tumors which have been described as occurring in this organ. As in dis- 
ease of other parts of the body, so here the knowledge of the prepondera- 
tingly frequent occurrence of this or that tumor in this or that period of 
life, and further the age, size, movability, rapidity of growth of the 
tumor, with especial reference to the affected organ, guides us. What 
we have to say here on this subject will be only to give the beginner a few 
of the main points; the details are found in the section on anatomy and 
clinical course, in which the symptomatology is also included. 
When a tumor of firm consistency develops in the breast of a woman 
35 years old, and continues to grow, it is probably carcinoma. This is 
not to be doubted when the tumor is immovable in the gland substance, 
when the axillary glands swell and become hard, when the tumor is 
adherent to the skin and ulcerates. When the diagnosis of cancer has 
once been made in such a case, the prognosis is also thereby given, as a 
rule. Still, there may be many modifications in regard to this, especially 
as concerns the more rapid or slower progress of the growth of the tumor. 
If the tumor has grown comparatively quickly up to the time of inspec- 
tion by the physician, it will usually keep on growing rapidly; if its course 
up to this time has been slow, it will probably continue so, though there 
are exceptional cases in which, after years of slow growth and occasional 
cessations, a rapid growth is suddenly inaugurated without known 
causes. If a cancerous tumor undergoes rapid softening, if it becomes 
partially fluctuating and then breaks, it usually goes forward rapidly with 
the other subsequent phenomena. If rapidly and successively the largest 
part of the gland, or the whole of it, becomes infiltrated, the course as 
regards general infection is usually more rapid, also when the supra- 
clavicular glands, besides the axillary glands, are also rapidly affected; 
also those cases in which the skin is quickly affected and studded with 
innumerable cancerous nodules, as well as those in which both breasts are 
rapidly affected in succession or at the same time, are to be prognosti- 
cated very unfavorably. In all cases of already advanced carcinoma of DIFFERENTIAL DIAGNOSIS AND PROGNOSIS. 
145 
the breast the liver is to be examined. The most favorable cases are 
always those of scirrhus which come on in old age; their course is very 
slow, and they infect very late or never. 
There are a number of accessory symptoms of mammary carcinoma. 
Among these is retraction of the nipple; it occurs when the carcinoma 
originates in the neighborhood of the nipple, and the nipple region is 
drawn in by interstitial cicatrization. In other cases this symptom is also 
apparent when the skin immediately surrounding the nipple is affected 
and bulges forward, so that it more or less overtops the nipple. When 
the infiltrated nodules lie more remotely from the nipple the part of the 
skin which is adherent to the carcinoma becomes cicatricially retracted in 
case a process of shrinking occurs in the neoplasm. Pains are to be 
considered as accessory, but often absent, symptoms of mammary affection. 
They are often present at the beginning of the disease, and appear again 
at the time of softening and ulceration; many run their course with very 
great pains, and others are entirely painless. Of very little value are 
visible, dilated subcutaneous venous tracts over the tumor; they may be 
present in every tumor of the breast which compresses the deeply situated 
veins. So, too, I cannot hold that the escape of serous, brownish reddish 
fluid from the nipple is characteristic of carcinoma, though it is often 
present in this disease; it occurs also in other tumors of the breast and 
without the presence of any tumor. Of comparatively little significance, 
too, is the appearance of the patients; at the beginning they generally 
seem entirely healthy, and have none of the specific functional troubles of 
carcinoma; then towards the end of the disease the cachectic appearance 
comes on. It may depend upon different circumstances: cancer of the 
liver, lungs and pleura with exudation, hemorrhage, ichorous discharge 
and the septic fever connected with it. 
A diagnostic error in regard to carcinoma of the female breast can only 
occur after long observation when we take a deeply situated cyst for 
carcinoma, or the appearance of a carcinomatous tumor is simulated by 
the confluence of several smaller foci in chronic mastitis (which are gene- 
rally accompanied by marked pains). It is better to operate in such 
doubtful cases than to allow the tumor, which may be carcinoma, to con- 
tinue growing. 
As to the course in individual cases, we have already stated it. Even 
with great experience, it is very difficult to give a certain prognosis, only 
in months, as to the time when these carcinomatous patients will be re- 
lieved from their sufferings. The power of resistance is often very un- 
pleasantly great, especially in those cases in which the digestive tract, the 
liver and respiratory organs remain unaffected. But then, rapidly arising 
pleuritic exudations or repeated arterial hemorrhages sometimes end life 
with unexpected rapidity. 
Swellings and indurations of the breasts before puberty are almost 146 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
always of an inflammatory nature. Only medullary cancer (medullary 
sarcoma) has been certainly observed at this early age, and so seldom that 
these cases can scarcely be considered as curiosities for diagnosis. 
From the time of puberty up to the 30th and 35th year and later, 
roundish, lobulated, movable, usually painless tumors, as a rule of slow 
growth, are developed in the mammary gland. These may be chronic 
inflammatory foci; suspicion is so much the greater as regards this if 
there has been a previous traumatism, or when such nodules remain after 
pregnancy and lactation. The course will soon decide. The product 
of a chronic inflammation is either gradually dissipated, or softens and 
suppurates, but never grows continuously. If such nodules remain 
stabile and hard for months and years, if they are roughly lobular, and 
later, perhaps only during the menstrual period, become slightly turges- 
cent and moderately painful, they are benign fibromas, which often remain 
stabile. 
If the tumors grow slowly, but continuously, they are adenomas, 
adenoid sarcomas, or cysto-sarcomas. These differences are not of very 
great significance as regards prognosis. It is between the ages of 25 and 
35 that we find most frequently perfect cysto-sarcomas, not seldom of 
enormous size, probably also ulcerating and connected with swelling of 
the lymphatic glands. Though it is not very frequent, we must be pre- 
pared to find recurrence in adenoid sarcoma and cysto-sarcoma. They 
should always be excised early. 
A very rapidly growing, soft tumor of the breast (at first to be con- 
founded with abscess) in young girls and women, is most usually a 
medullary sarcoma, and is of bad prognosis; in these cases the disease may 
prove fatal in six or eight months from internal metastases. 
Cysts are easily diagnosticated if they are large enough and are super- 
ficial; otherwise not. If they contain no tumor tissue the prognosis is 
favorable. Deeply situated small cysts are not always to be differentiated 
from other tumors. 
Bilateral diffuse hypertrophy occurs almost solely in young girls at the 
time of the development of puberty. Epithelial carcinoma of the skin 
is said to have been seen radiating from the nipple; from the cases which 
I have found in literature I do not think them beyond doubt. I have had 
no experience with such carcinomas. CHAPTER XIII. 
TREATMENT OF TUMORS OF THE MAMMARY GLAND. 
A DISSIPATION (dispersion, spontaneous) of tumors of the mam- 
A_ mary gland is scarcely to be admitted; when such a thing has oc- 
curred, according to the statements of physicians and laymen, it was prob- 
ably the products of chronic inflammation. But since the diagnosis may, 
for a long-time, be doubtful, whether we have to deal with a product of 
chronic inflammation or with a tumor, the indications are to use such re- 
solvents as iodine ointment, ung. cupri oxyd. nigr., or resolvent plasters 
and the like. Compression with bandages (suspensorium mammas) or 
compresses especially adapted to individual cases have been used, and 
have even been recommended in carcinoma. I cannot support this rec- 
ommendation; for by them we never gain a really complete resorption and 
cure. The ointments, mixed with pure iodine, too often used, usually 
act in an irritating manner on these tumors, as does pressure also, espec- 
ially when they already are adherent to the skin. I believe that by them 
we will sooner promote ulceration and softening than resorption. 
If one does not wish to immediately advise an operative procedure, but 
wishes to watch the course for a time, he may use indifferent ointments 
or compresses with Goulard's extract (lead-water), in order that the patient 
may be quieted by the belief that something is being done for her; or he 
may use some favorite plaster, which has perhaps helped an aunt or a 
cousin, in case it contain no substance irritating to the skin; simple cover- 
ing of the carcinomatous ulcer with wadding or with a cat's skin suffices 
to protect it from pressure or blows. When a definite diagnosis and prog- 
nosis has been made at the beginning, or as soon as a definite prognosis 
can be given, we should be so much the more positive in advice and action. 
As a general rule, I might lay it down as a maxim, that every continu- 
ously growing tumor should be extirpated, of whatever nature it may be. 
In stabile tumors (small fibromas) and shrinking scirrhus in old women, 
we need not insist on an operation, though there is seldom any ground 
for refusal, if it is wished. As regards specially the benign tumors (in- 
volution cysts, adenomas, adenoid sarcomas, fibroids and cysto-sarcomas) 
they should be removed, because by their growth they gradually become 
more embarrassing, and also because it is not impossible that from some 
irritation or other, these tumors may take on the character of malignant 148 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
medullary carcinoma, or, in later years, of carcinoma with rapid course. 
There are plenty of cases from older and recent times which show that 
tumors which for years had every appearance of being benign, later took 
on a malignant character. In regard to this, there is scarcely a difference 
of opinion, even though this idea rests more upon the statements of the 
patients than upon direct observation by physicians. Having a tumor has 
usually a depressing influence upon every woman, and on this account it 
is humane to free them from the tumor, for there is, on account of the 
great frequency of cancer of the breast, the fear that a cancer might de- 
velop from theinduration. There are many women who are more relieved 
when the physician decides for them, whether a stabile tumor shall be 
retained or removed, than when it is left to their own decision. 
In cancerous tumors I would advise immediate extirpation so long as 
we can remove the whole of the appreciable mass of tumor without pre- 
sumptive danger to life. It is certainly true that many slow-growing 
tumors of this kind may be considered as innocuous for a long time; but 
then, the right moment for extirpation may easily be passed over with 
time. There is no doubt that infection of the lymphatic glands is hin- 
dered or at least diminished by early and thorough removal of the mam- 
mary cancer. Still, even when the lymphatic glands are affected and 
may still be extirpated, the operation should be done as quickly as possi- 
ble; for, perhaps in this way, general infection, even if not prevented, 
will be deferred much longer, inasmuch as the new arrival of infectious 
material will be prevented. Recurrences of tumors of the breast are also 
to be operated upon, when this can be done with a prospect of removing 
all of the diseased portion. If the recurrent oi' primary carcinoma is ad- 
herent to the pectoralis major muscle, this must also be removed in so 
far as it is diseased. Co-affection of the ribs is in my experience, in those 
cases in which operation is still a question, rare. In such cases I would 
scarcely decide on resection of the ribs, as an opening into the pleura 
under the circumstances would possibly and probably be followed by death 
from pyothorax; superficial diseased portions of the ribs maybe removed 
without any risk. Operations are usually in vain in cases in which the 
skin is studded with many nodes and nodules. If the axillary glands are 
strongly adherent to the vessels and nerves, as shown by the immova- 
bility of the tumor, and by oedema of the arm and by neuralgic pains, the 
supraclavicular glands being at the same time affected, no further opera- 
tion is indicated. Even the most expert and experienced operator may 
be deceived as to whether, in a severe case, every portion of the disease is 
removable. There may thus be differences of opinion between consultants, 
and also in regard to the question whether an operation should be per- 
formed or not. So too one operator will venture further in such opera- 
tions than another. It cannot be said, absolutely, therefore, that cases 
are not to be operated upon. Older operators are so often discouraged TREATMENT OF TUMORS. 
149 
"by the frequent and rapid recurrences that they refrain from operating, 
because they no longer see any remedy in it, also no anceps remedium. 
The English surgeons are the most conservative in operating on far ad- 
vanced cases of carcinoma, and the German surgeons, it seems to me, go 
the farthest in these operations. As regards the cases of compression of 
the vessels and nerves in the axilla, with the fearful neuralgias in and the 
indurated elephantiac cedema of the arm, such women have besought 
me, after they had suffered unspeakably, but were otherwise well and in 
a good state of nutrition, to give them relief or death by an operation. 
What can we do in such cases? We may divide the whole brachial plexus 
in the axilla; but as in laying this bare, we might be compelled to per- 
form high ligation of the axillary artery and vein (which would very prob- 
ably be followed by gangrene of the arm-as the collateral circulation, 
according to recent investigations, is established through the vasa ner- 
vorum), it would perhaps be more rational to exarticulate the arm, which 
is only an immovable burden, or would be at least aftei* neurotomy. But 
would this relieve th^ pain ? May not the supra-clavicular glands also 
exert pressure on the nerves ? In this case the neuralgias would remain 
after the exarticulation. 
With the removal by knife, many surgeons also consider the question 
of removing tumors of the breast by caustic pastes. The chloride of zinc, 
arsenic and Landolf's paste are the most popular comparatively, and are 
still used in various places in different forms (in France as caustic arrows, 
Maissoneuve). When these pastes are applied to non-ulcerated healthy 
skin over the tumor they cause very great pain. The application of caus- 
tic pastes to ulcerated tumors of the breast is sometimes followed by good 
results, if they act deeply enough; if such be not the case, they should be 
re-applied. The uncertainty of the procedure has mostly deterred me 
from using it, and I have therefore had very little experience with it. 
As regards the treatment of carcinoma, which cannot be extirpated, the 
ichorous discharge from the ulcer and the pains, as well as the marasmus, 
are the best indicators. Antiseptic dressings, such as a solution of chlo- 
ride of lime, permanganate of potassium, creosote water, charcoal, coal 
tar, and carbolic acid may be tried, and caustics may be applied locally 
for the destruction of the cancerous mass. 
Among the popular remedies against cancer, which have descended 
from the Middle Ages, pastes of carrots, of figs with milk, yeast, gastric 
juice of owls (formerly not infrequently used in Italy), played a great 
part. None of them have caustic or destructive properties, nor do they 
promote absorption. On one occasion I allowed an incurable patient, 
with a discharging, fearfully smelling cancerous ulcer of the breast, on 
which I had vainly used all disinfectants, to use dried figs cooked in milk. 
Contrary to my expectation, the odor, which had filled the whole house, 
and was mixed with that of chlorine and carbolic acid in the most disgust- 150 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
ing way, ceased; and, in place of it, there was a faint odor of lactic acid, 
given off from a process of lactic fermentation, which had been estab- 
lished. With two such dressings daily, the bad smell was entirely mas- 
tered; the deodorizing and antiseptic action was excellent. Artificial 
gastric juice, repeatedly applied to the ulcer, did not act as well; it proba- 
bly digested the necrotic tissue, though the deodorizing effect was not as 
good. 
After Thiersch had practised the parenchymatous injection of solution 
of nitrate of silver, experiments were made at my clinic with parenchy- 
matous injection of tincture of iodine. Fowler's solution, solutions of 
chloride of gold, albuminate of mercury, chromic acid, carbolic acid, etc., 
in carcinoma of the breast. The results were so absolutely negative, that 
in not a single case, would a report of the methods have been worth the 
trouble. Nor can I report anything favorably of electro-puncture (re- 
peatedly tried in my clinic for hours at a time). The continuous use of 
an ice-bag will not only check the growth of the carcinoma, but will 
sometimes reduce its size. In doubtful cases I have confined myself to a 
partial operation, in case the discharging ulcer was sufficiently localized 
and could be excised. At all events, a simple granulating wound is com- 
bined with fewer discomforts than an ichorous ulcer. In the periods of 
incurability, I pay no attention to the wishes of the patients or their 
friends for all sorts of cures with wonderful means. I have never 
seen any effects from them. But I do not mean to say that it is impos- 
sible to find remedies which may cause the disappearance and cure of 
tumors generally, and of carcinomas especially; and it is entirely right to 
seek for and use such remedies methodically. Still, until such remedies 
are found, we must remain true to the repeatedly expressed axioms as to 
operative treatment; we now know, more certainly than formerly, that 
radical cure, even of cancer of the breast, can be attained by early opera- 
tion; it is our duty, above all things, to follow this way energetically; un- 
fortunately there is no lack of carcinomatous patients, who seek for in- 
ternal cures, of whom it may be confidently asserted that they are no 
longer curable by operation. For easing the fearful pains towards the 
end of life,' we use anodynes. There is scarcely any sense in giving rob- 
orants to such patients, or in tormenting them with food. We let them 
sleep, sleep, sleep ' For these unhappy people, subcutaneous injections 
of morphia are the only and best means of relief. CHAPTER XIV. 
THE ANIMAL PARASITES OF THE MAMMARY GLANDS. 
1. Echinococci. 
OINCE by the name "hydatid," we formerly understood every sac 
filled with watery fluid, it is not always possible to determine as to 
some of the cases described in older literature whether they really were 
instances of echinococcus. Accepting every possible case as belonging 
really to the echinococci, there are perhaps not more than 20 known in 
literature. I have mostly practised in regions in which echinococci were 
indeed of the greatest rarity, and I have never seen such a worm in the 
breast. But even in Iceland, where echinococci are so frequent, physi- 
cians assert that their occurrence in the breast is of the greatest rarity. I 
take the following from the excellent work of Haussman. The statistics 
hitherto compiled from the literature on the subject are not to be re- 
garded as of great value. It is understood that rare cases are much 
oftener published than commoner ones. So when Bergmann reckons, 
that out of 102 cases of echinococci on the whole surface of the body, 15 
were in the mammary glands, these numbers do not give us much infor- 
mation as to the true frequency of its occurrence. Boecker's1 statistics are 
based on more correct grounds. Of 4770 persons treated in the Berlin 
Charite in 10 years, 33 were affected with echinococci; 14 of these were 
women, and in not one of these was the echinococcus in the mamma. 
According to Leuckart the echinococcus of man comes from the taenia 
echinococcus of the dog. The development in the mamma proceeds very 
slowly; according to Leuckart's researches, an echinococcus requires about 
5 months to form a vesicle as large as a walnut. Of course the growth of 
the parasite will encounter more or less resistance according to the laxity 
or firmness of the mammary tissue. Blows and other irritations would 
tend to accelerate the growth. Where exact anamnestic data are obtained 
they show that the process is very different under these circumstances. 
In a case operated upon by Birkett, the breast containing the hydatid was 
doubly as large as the other, and the enlargement was discovered 8 months 
previously. In a case seen by Cooper the hydatid was as large as a filbert, 
and had existed 11 months. In Le Dentu's case, the tumor, the existence 
'Statistics of Echinococcus, Dissert., Inaug., Berlin, 1868. 152 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
of which had been known for 2 years, was as large as an egg, and in 
Henry's case it had attained in 3 years the size of a walnut. In one case 
the echinococcus had a diameter of 3 to 4" after G to 11 years growth. Ac- 
cording to Bergmann, the echinococci thus far observed in the breast have 
never exceeded the size of a hen's egg or the fist. 
Hitherto only one mother vesicle has been formed in the mamma, and 
this in daughter vesicles developed in only a few cases; most of them were 
sterile. We often search in vain in the fluid for booklets. Suppuration 
around the vesicle, especially after traumatism, has been several times ob- 
served, giving the appearance of a cold abscess; in a few cases also the 
lymphatic glands of the axilla are swollen. 
Echinococci give rise to the same symptoms as cysts; they cause no 
pain, and scarcely a temporary feeling of tension. Hydatid fremitus is 
never observed in them, probably because it was not particularly sought 
for. It is probably more of an accident, when the diagnosis of echino- 
coccus is made before puncture. It is known to be characteristic of the 
transparent watery fluid, that it is free from albumin; only when the 
echinococcus dies is albumin sometimes transuded into the sac, or when 
the pus formed around the sac becomes mixed with the fluid in the vesicle. 
When the diagnosis has been established by puncture, the worm may 
be killed by the injection of iodine, and the cyst then shrinks to a certain 
extent. But it is a far simpler and shorter operation to incise the con- 
nective tissue sac, allow the echinococcus vesicle to escape, drain the sac, 
compress it and thus cause adhesion. 
2. Other Worms. 
Haussmann has collected a number of cases from literature, in which 
thread worms of an indefinable nature have come out of the mamma, es- 
pecially out of the nipple. Although we cannot in all cases, say what 
these questionable " worms " were, it seems to me that none of these cases 
will stand sharp criticism. There is therefore no use in entering further 
into the matter here; we must wait until the facts are better substantiated. CHAPTER XV. 
EXTIRPATION OF THE MAMMA AND OF THE AXILLARY 
GLANDS. 
TZTISTORICAL REMARKS.-In the history of cancer of the breast, 
-1-L we can study the different views as to the nature and treatment of 
cancer in general. Whoever is especially interested in the subject can 
find the material in the history of surgery by K. Sprengel, collected with 
great care, but with little criticism. Only a small portion of it can be in- 
troduced here. 
Hippocrates mentions the great frequency of scirrhus in the female 
breast, but Galen was the first to give an exact description of the nature 
of extirpation of the breast, and recommended that this be done with the 
knife. Later, hot irons were used for this purpose, alone or with the 
knife. The views as to the advisability of the operation varied a 
great deal. The capability of scirrhus for recurrence was perfectly 
known in ancient times. But the differentiation of swellings of the 
breast did not go beyond the conception of cancer occultus and aper- 
tus. It was much later in the middle ages that abscesses were differen- 
tiated as apostemata; and then was defined the difference between scir- 
rhus, cancer and struma of the mamma, although these were very much 
mixed. Caustics came into more frequent use in the middle ages, partly 
as popular remedies; sublimate or arsenic was generally used. Nor has 
there been any lack of recommendations of specifics against cancer from 
the middle ages to the present time, and almost all active therapeutic 
remedies have played parts as specific cancer cures. Arsenic, mercury, 
iron, and then hemlock and belladonna, were especially used internally. 
Most observing surgeons soon saw, however, the inactivity of internal 
measures, as well as the danger of insufficient caustic measures and other 
severe dressings. The recommendation to extirpate the concealed cancer, 
and to treat the open incurable cancer mildly, is very old. The best sur- 
geons have always spoken in favor of the early operation for scirrhus; but 
if there have been accounts of frequent complete cures, it is very prob- 
able that they refer to the benign, hard-feeling tumors, as every tumor 
which felt hard was formerly called scirrhus. A more exact differenti- 
ation of tumors of the breast, based on more painstaking observation of 
patients, and on anatomical examination of the tumors was first begun by 154 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
Abernethy and Astley Cooper, those heroes of English surgery at the be- 
ginning of this century. 
In the middle ages the whole breast was almost always amputated; later 
came the recommendation to incise the skin and extirpate the tumors, if 
they were small. The removal of the whole breast, with the greatest 
possible preservation of the skin, first came into vogue in the last century. 
Formerly the whole breast was raised, and cut off as quickly as possible 
close to the thorax with a large amputating knife. In behalf of more 
rapid and easier removal by this elevation of the breast, almost all modi- 
fications of the method of operating are made. Joh. van Horne drew 
stout threads crosswise through the breast in order to make it more tense; 
Corn, van Solingen used a large fork for the purpose; Adrian Helvetius 
used a forceps with double hook attachment for this purpose (from which 
the now so-called Muzeux's forceps probably originated); and II. Vylhorn 
invented a large cutting forceps for removing the breast quickly. 
Fabricius von Aquapendente and Fabry von Hilden were the first to 
remove the affected axillary glands, and for this purpose the finger was 
recommended as the best means, after the incision of the skin; a proce- 
dure which was more systematically perfected by J. L. Petit. 
Extirpation of the breast is total or partial, and is scarcely ever done 
except for tumors. Partial extirpation is especially done for benign 
tumors of the breast, where the tumor is dissected out of the gland, and 
the rest of the latter allowed to remain. In carcinoma, it is better in 
most cases to remove the whole gland, though, from my experience, I 
cannot prove statistically that recurrence is more rapid after partial ex- 
tirpation of smaller cancerous tumors with removal of a proper amount 
of the surrounding healthy glandular tissue, than after total extirpation 
of the gland. 
In these operations, besides the same preparations as for all bloody oper- 
ations, the following instruments are used: a scalpel of medium size, 
scissors, toothed forceps, Muzeux's forceps, sharp double forceps, a large 
number of sliding catch forceps, threaded suture needles with needle 
holder, sewing material; compresses and bandages must be at hand. All 
these operations should now be done by the antiseptic method, and every- 
thing necessary for this should be prepared. 
The patient to be operated upon is best placed upon a table, with the 
upper part of the body somewhat elevated. If the skin over the tumor is 
movable and healthy, and if the size of the tumor is not larger than that 
of a moderate sized apple, the incision through the skin should corres- 
pond to the longest diameter of the tumor, and should be made only after 
the tumor has been grasped by the left hand and fixed. After the incis- 
ion, the tumor will push forward, and a few superficial lateral incisions 
will be sufficient to almost entirely remove it; the tumor is then seized 
with the left hand or by an assistant, or grasped with Muzeux's forceps, EXTIRPATION. 
155 
is drawn forwards, and cut away with the knife or scissors. This is easily 
done with encapsulated tumors, but is impracticable with carcinoma: here 
the skin must be dissected away, the tumor drawn forward, and sound 
tissue removed from the gland substance for about one inch outside of 
the tumor and carcinomatous induration. 
If the skin is adherent to the tumor, or is very thin over it, or if ulcer- 
ation has already taken place, a part of the adherent or ulcerated skin is 
removed by an oval incision. The long direction of this oval incision is 
best made from above and to the outer side, downwards to the lower and 
inner side, as in this way the incision may be easily carried into the axilla 
if extirpation of the axillary glands is shown to be necessary. 
Total extirpation of the breast is done in the same way, except that the 
oval incision runs around the breast, and to get a better view of the field 
of operation, the arm on the affected side is held up. More or less skin 
is removed according to the size of the tumor, the extent of the adherence 
with the skin, or the ulceration; the gland is then raised and separated 
from the pectoralis major muscle, cutting from above downwards, an 
easy operation. If the tumor is adherent to this muscle, much of it must 
also be removed, whereby the ribs will often be exposed. If portions of 
the gland remain (especially below and outwardly, and above), they must 
be removed with the scissors. When there is an abundance of adipose 
tissue, whatever feels hard or nodular is cut away from it, as such places 
are always to be looked upon as beginning carcinomatous infiltrations; 
feeling is much better here than seeing. 
These operations must be done quickly, because the blood sometimes 
streams from a great number of arteries. Immediately after the removal 
of the diseased parts, the arteries should be seized with slide forceps, and 
after removal of the gland, must be ligated or compressed by means of a 
suture. When the hemorrhage is controlled, the wound must be very 
carefully examined for any trace of diseased or suspicious tissue, and this 
immediately be removed by the scissors if found. 
If the axillary glands are swollen or indurated these glands must now 
be extirpated. For this purpose the incision is carried from the existing 
wound as high up into the axilla as is necessary, in order to get at the 
swollen glands; in doing this the border of the pectoralis major muscle is 
laid bare, thus bringing us to the fascia, which is to be cut through. The 
finger can now be forced in and all the glands and fat be shelled out from 
the axilla and under the pectoral muscle. In doing this the glandular 
vessels are isolated with closed forceps or closed scissors, two haemostatic 
forceps or slide forceps being placed on each vessel, and the vessel cut 
between them. Then the central (proximal) end is ligated, and the for- 
ceps removed. The long thoracic artery usually has to be tied. If the 
glands are all adherent -to one another and to all the vessels and nerves, 
the operation is very difficult; it is very easy to teai' the axillary vein and 156 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
artery, and care, circumspection and presence of mind are necessary to 
remove all the diseased portions without wounding these vessels. I may 
advise that the operation be not undertaken without sufficient assistance, 
and not unless such operations have been previously witnessed. If the 
operator should be so unfortunate as to tear the axillary vein, it is best to 
place a double ligature on it immediately, as the entrance of air, with 
fatal consequences, has been observed. 
If one is in the habit of doing such operations often, he soon learns 
always to follow a certain method. After cutting through the fascia cov- 
ering the axillary glands and fat, I usually immediately loosen all the fat 
and the glands up to the large vessels and nerves, and then proceed back- 
wards and downwards with the operation. In this way the axillary vein 
is laid bare, as a rule, and usually at the point of entrance of the thoracic 
vein; if the latter can be ligated at about f inches from its entrance into 
the axillary vein, this should be done; it is not advisable to tie it closer 
than this, because in case of suppuration the short portion easily becomes 
necrotic, and dangerous secondary hemorrhage may result. In the cases 
in which the ligation cannot be done at the length mentioned, I would 
advise the ligation of the trunk of the axillary vein above and below the 
entrance of the thoracic vein, and its division between the two ligatures. 
Ligation of the axillary vein causes far less disturbance of the circulatory 
system of the arm than would at first be thought. I have performed the 
operation very often, and only rarely have I seen oedema of the arm from 
it. In the cases in which there is considerable indurated oedema in car- 
cinoma of the axillary and supra-clavicular glands, many more veins than 
the axillary must be compressed, or the compression must be much higher 
than the axilla. In purulent decomposition in the axilla, extensive for- 
mation of thrombi, softening of the thrombi, emboli in the lungs, and the 
characteristic symptoms of pyaemia may result. I cannot sufficiently 
advise against the use of styptics in these operations; we must search for 
and tie bleeding vessels, until bleeding ceases. We seldom come in con- 
flict with the axillary artery in these operations; if it be closely adherent 
to the Infiltrated carcinomatous tissue, we must perform a double ligation 
and extirpate the diseased portion. As a rule, gangrene does not follow 
simple ligation of an axillary artery and vein, but it might probably 
when the nerves are laid bare at the same time to a considerable extent. 
Only once, in the case of a girl, nine years old, have I extirpated the axil- 
lary artery, vein and portions from all the nerve-trunks, on account of a 
medullary lympho-sarcoma in the axilla; the arm did not become gan- 
grenous, but ulcers appeared on it on the least compression, which were 
only cured after a long time by the most careful treatment. 
That an expert operator can attempt more, and do it quicker and with 
less loss of blood, than one who only exceptionally does such an operation, 
is of course understood. EXTIRPATION. 
157 
Dressing and After- Treatment. -Formerly we were chary in uniting 
these wounds. As a rule, so much skin was cut away from over the 
mamma, that union was not to be thought of without modern therapeutic 
means, and the wounds in the axilla were not united on principle, so as 
the more certainly to avoid retention of secretion (so-called burrowing of 
pus), since this was the principal cause of extensive septic phlegmons, 
secondary hemorrhage, erysipelas and pyaemia. There is probably no 
doubt at all that, of all the methods hitherto employed in the treatment 
of wounds, the antiseptic method has earned the preference; it seems to 
give comparatively the most certain prophylaxis against the accidental 
diseases of wounds, to which formerly, and especially in operations in- 
volving the axillary space, so many patients fell a sacrifice. Therefore it 
cannot be recommended too strongly, that these operations should always 
be performed with strict antiseptic precautions, and particularly with 
those modifications of it in which the operator is most expert. As it is 
beyond the limits of the present discussion to speak generally of the an- 
tiseptic method, I will only call attention to those points which seem to 
me most important in the amputation of the mamma and the cleansing 
out of the axilla. 
In order to obtain union of the wound, wholly or in the greatest part, 
after amputation of the mamma, when almost all the skin over the mam- 
ma is removed, I cannot sufficiently recommend the use of a few button- 
sutures (silver wires, with lead plates, fixed with shot). When the skin 
has been approximated closely in this way, the usual sutures are inserted. 
It is astonishing under how great tension (fixation of the thorax and 
arms after the operation being presupposed) primary union will take 
place. But we must not be betrayed into taking away too little skin in 
amputation of the mamma for carcinoma, in order to get more rapid heal- 
ing. If it is impossible to unite the whole wound, so much as is possible is 
united at the sides, the wound is drawn together as much as possible by 
button-sutures, and the fresh wound, where it is not united, is covered 
with protective and Lister's dressing. 
Recently, after cleaning out the axilla, I have always united the wound, 
after it had been carefully drained. I have found it a good plan to trans- 
fix the soft parts below and behind (the deepest part of the wound with 
the patient lying on the bed) and put in a thick drain; besides this, three 
drains are put in above, the situation and patency of which are exactly 
known after closure of the wound. By putting two or three button- 
sutures, the cavity of the wound in the axilla can be diminished to one- 
fourth its size; the qdges of the wound are then closed by sutures as usual. 
Compression of the axillary cavity with the dressing, by means of curled 
gauze is very useful. The antiseptic dressing should be as extensive as 
possible, surrounding the arm, fixed to the thorax, the whole thorax to 
the neck, and should extend below to the twelfth rib, and be fixed by 158 
DISEASES OF THE FEMALE MAMMARY GLANDS. 
oiled silk bandages. If, after its completion with the patient in the sit- 
ting position, the dressing gapes below when the patient lies down, the 
gaps are to be filled with salicylic jute. 
The danger of the operation is extraordinarily diminished by the anti- 
septic method. I have often allowed my assistants to do these operations, 
because they teach a great deal about the technique of operating and 
dressing. Until the year 1877, I operated and dressed, with a few ex- 
ceptions, mostly abortive cases of antiseptic dressing, according to the old 
methods (application of charpie, etc.). Of 305 such operations (in private 
and hospital practice), 15.7 per cent, terminated fatally, and in fact 6.7 
per cent, were cases in which the mamma alone was operated upon, 
against 21.3 per cent, of the cases in which the mamma and axillary 
gland were operated upon at the same time, or the latter alone removed 
(for infection recurrences). Since January 1, 1877, until the present time 
(August 1, 1879), I have operated exclusively according to the antiseptic 
method Of 68 operations (in hospital and private practice) only 4 or 
5.8 per cent, have resulted fatally, 0.0 per cent, of the operations on the 
mamma alone, and 10.5 per cent, of extirpations of both mamma and 
axillary glands, or of the latter alone. In one case death was due to pri- 
mary hemorrhage occurring on the evening of the operation, and in three 
cases it was due to sepsis. 
If the objection be made that the contrast of the results of 305 opera- 
tions with those of 68 can give no exact basis of comparison, I can only 
say that any series of 68 operations may be taken from my general statis- 
tics of earlier or later times up to 1876, and the ratio of percentage will 
not be different. 
If we except from the four fatal cases, that of fatal hemorrhage on the 
first day, the mortality falls to only 4.4 per cent. I would not think it 
striking, however, if some operator should have 100 such cases in succes- 
sion without a death, as the personal expertness of the surgeon and his 
assistants is a matter of great consideration. New Growths of the Uterus. 
BY 
A. GUSSEROW, M.D., 
Professor of Obstetrics and Gynecology at the University of Berlin. 
TRANSLATED AND EDITED BY 
EDMUND C. WENDT M.D , 
Of New York. INTRODUCTION. 
rpUMORS develop in connection with the uterus as often, perhaps, as 
in connection with any other organ of the body. As regards the 
variety of growths that may invade its structure, the womb also occupies 
a front rank. It would be difficult, however, to establish by figures the 
proof of these statements. Indeed, we lack statistical evidence of an un- 
impeachable kind to guide us in our attempts to accurately establish the 
relative frequency of all neoplasms. According to the tables published 
by Gurlt,1 embracing 15,880 cases of tumor observed in the Vienna hos- 
pitals, males furnished 29.84 per cent., and females 70.16 per cent, of all 
cases. This proportion of about seven females to three males is all the 
more noteworthy, when it is remembered that more men than women 
(about five to four) were admitted to the V ienna institutions. 
The great preponderance of tumors in women is largely due to the 
frequency of neoplasms of the uterus. In 14,630 of the above cases, in 
which the nature of the growth was ascertained. 3,521 concerned the 
womb. (The other female sexual organs, including the mamma, were 
affected 3,009 times.) 
C. O. Weber2 has prepared a table of 740 cases of tumor, and according 
to his figures the uterus occupies only the tenth place as regards frequency 
of invasion. But Weber based his calculations on cases that came to him 
for operative relief in a general surgical practice. Moreover, he admits 
that uterine cases were rarely admitted to his wards. It will be seen, 
therefore, that no inference can be drawn from his figures. And indeed 
similar objections hold good for most clinical reports which have been 
published with a view to shed light on the relative frequency of tumors. 
While accuracy is thus out of the question, there is certainly no reason 
to doubt that the uterus is very often invaded by neoplasms. 
'V. Langenbeck's Archiv., Vol. XXV. 
2 Chirurgische Erfahrungen, Berlin, 1859, p. 284. 162 
INTRODUCTION. 
We have as yet no knowledge regarding the causes of the frequency of 
uterine tumors. It is true that there is nothing surprising about this 
phenomenon. We have only to remember the number of different tissues 
that compose the organ in question, the numerous changes incident to 
its peculiar functions, (e.g. menstrual congestions, and puerperal evolu- 
tion and involution), and it will appear quite natural that the uterus is 
more prone to disease than other organs, and especially to the develop- 
ment of tumors. 
But beyond such general conceptions concerning the probable etiology 
of tumors of the uterus, we have not hitherto progressed. 
Congenital uterine neoplasms are' of extreme rarity. Before puberty, 
and for some years after its advent, new growths of the womb are likewise 
of very exceptional occurrence. 
This again shows that the prime causative factors must be the recurrence 
of menstrual congestion, and the more profound structural alterations in- 
cident to childbirths. 
The well-known hypothetical views of Cohnheim respecting the origin 
of tumors, in accordance with which they all start from inclosed germs of 
embryonal formation, will not be discussed here. It is still an open ques- 
tion whether his inferences receive corroboration or refutation from a 
consideration of uterine tumors. In the more detailed account of the 
different kinds of new growths this interesting topic will receive further 
attention. It may be mentioned in this connection, however, that 
Cohnheim, in his work on general pathology, frequently refers to the 
uterus and to the tumors which are apt to grow in it. 
A certain number of cases are on record in which uterine neoplasms 
appear to have developed at a very early age, but in no instance has it 
been shown that they were really congenital formations. 
Uterine tumors may be classified as follows: 
I. 
Neoplasms which start from the proper substance of the womb, and 
are made up of connective tissue or muscular fibres, or both This group 
includes: 
1. Fibromyoma and Myxoma, which are clinically benign tumors, and 
represent histologically mature connective tissue or unstriped muscle. 
2. Sarcoma, which represents immature or embryonic connective tis- INTRODUCTION. 
163 
sue. These growths, however, may also start from the conjunctive tissue 
of the uterine mucous membrane. 
IL 
Neoplasms which originate in the mucous membrane of the uterus, and 
are composed largely of epithelium. This division embraces: 
3. Adenoma and certain polypoid growths, the latter being clinically 
benign, while the former occupies an intermediate position between 
malignant and benign tumors. 
4. Papilloma, which clinically may be called semi-malignant. 
5. Carcinoma, which is always malignant. 
As the descriptions which are to follow will be mainly based on clinical 
facts, the different sarcomata may be considered together in a single 
chapter, be their origin what it may. 
The so-called fibrinous and placental polypi will not be discussed, since 
they cannot properly be regarded as new growths. Tuberculosis of the 
uterus will likewise receive no attention. As regards uterine cysts, if 
we understand thereby isolated cavities containing fluid, and furnished 
with walls of their own, such formations exist in the pages of certain 
text-books, rather than in the bodies of patients. The composite growths 
known as fibro-cystic tumors will be described in a separate chapter. 
This translation is not a strictly literal one. A number of tables and 
cases, not appearing in the author's second edition have, for completeness 
sake, been incorporated with the present issue. For assistance in the 
actual work of translation, the editor is indebted to Drs. Wm. H. Flint 
and I. Oberndorfer of this city. NEW GROWTHS OF THE UTERUS. 
CHAPTER I. 
THE ANATOMY OF MYO-FIBROMATA OR FIBROID TUMORS 
OF THE UTERUS. 
BIBLIOGRAPHY. 
TN the following table, reference is made, as a rule, only to the inono- 
graphs and to those parts of general works which were consulted in 
the preparation of this chapter. References to special journal articles are 
made in the text. A f indicates that I myself have not read the work, 
and consequently cannot vouch for the correctness of the citation. 
Rokitansky : Lehrbuch der pathologischen Anatomie, III., Auflage. Wien, 1855. 
-Klebs : Handbuch der patholog. Anatomie, I., Berlin, 1873.-Klob : Patholog. 
Anatomie der weiblichen Sexualorgane, Wien, 1864.-Virchow : Die krankhaften 
Geschwtilste, III., Band. Berlin.-Barnes : Clinical History of the Diseases of 
Women, London, 1873.-Aran : Maladies de 1'utyrus, Paris, 1858.-Nonat: Mala- 
dies de 1'uterus, Paris, 1860.-Courty : Maladies de 1'uterus, Paris, 1866.-Demar- 
quay et Saint Vel: Maladies de 1'uterus, Paris, 1876.-Baker-Brown : Surgical 
Diseases of Women, London, 1861.-McClintock : On Diseases of Women, Dub- 
lin, 1863. Also the text books of C. West, Churchill, Kiwisch, Veit, Scanzoni, 
Schroder and Beigel. Wenzel: Krankheiten des Uterus, Mainz, 1816.-Roux : 
Mem. sur le polype uterin. Mel. de physiolog. et chirurg., Paris, 1809.-Mal- 
gaigne: Sur les polypes de 1'uterus, These, Paris, 1823.-P. U. Walter: Denk- 
schrift uber fibrose Geschwulste der Gebarmutter, Dorpat, 1842.-Amussat: Traite- 
ment des turn. fibr. de 1'uterus, Gaz. Med., Paris, 1843.-Cambernon : Considera- 
tions sur les causes et la frequence des polypes utyrins, Gaz. Myd., Paris, 1844.- 
Amussat: Mym. sur l'anatomie pathologique des tumeurs fibreuses interstitielles 
de la matrice et sur la possibility de les exstirper lorsqu'elles sont encore contenues 
dans le parois de cet organe, Paris, 1842-R. Lee : On Tumors of the Uterus, 
London, 1847.-Marjolin : Article, Polypes de 1'utyrus, Dictionnaire de Medecine 
en 30 volumes, Paris, 1846.-Bernaudeaux : Des corps fibreux de 1'uterus, These 
inaug. Paris, 1857.-Jarjavay : Des operations applicables aux corps fibreux de 
1'uterus, Paris, 1850.-Guyon: Des tumeurs fibreuses de 1'uterus. These pour 
l'agregation, Paris, 1860.-Duchymin : Quelques considyrations sur les tumeurs 
fibroidesde 1'uterus, These, Strasbourg, 1863.-Routh : On some points connected 
with the pathology, diagnosis and treatment of the fibrous tumors of the womb, 
London, 1864,-Monfumat; Etude sur les polypes de 1'uterus, Paris, 1867.-Koe- 166 
NEW GROWTHS OF THE UTERUS. 
berle : Documents pour servir a 1'histoire de 1'exstirpation des tumeurs fibreuses, 
etc., Strasbourg, 1864.-Caternault: Essai sur la gastrotomie dans des cas de 
tumeurs fibreuses peri-uterines, Paris, 1866.-Hildebrandt: Ueber fibr. Polypen 
des Uterus. Volkmann's Sammlung Klin. Vortrage, 1872, No. 47.-P6an et Urdy: 
Hyst^rotomie, Paris, 1873.-Pozzi : De la valeur de l'Hyst6rotomie dans le traite- 
ment des tumeurs fibreuses de I'ut^rus, Paris, 1875.-Urdy : Examen an point de 
vue du manuel op^ratoire de quelques cas difficiles d'ovariotomie et d'hyst6roto- 
mie, Paris, 1875.-Milliot: Sur les complications des tumeurs fibreuses de 1'uterus, 
These, Paris, 1875.-Winckel: Ueber Myome des Uterus, etc., Volkmann's Samm- 
lung Klin. Vortrage, 1876, No. 98.-L. Michels : Die Fibromyome des Uterus, 
Stuttgart, 1877. 
The tumors of the uterus commonly known and described as fibroids, 
are chiefly composed of smooth muscular fibres, or, more correctly 
speaking, they consist of the same histological elements as the uterine 
walls themselves, viz., unstriped muscular fibres and connective tissue. 
All the neoplasms belonging to this class invariably contain both kinds of 
tissue. But the proportion of one to the other varies largely in different 
cases. If the tumor represents mainly a simple hyperplasia of uterine 
Fig. 1.-Fibrillation of a Fibro-Myoma. Natural size. (From the Collection of the Pathologi- 
cal Institute at Strasburg.) 
tissue, (such as is normally witnessed in pregnancy,) there is a prepon- 
derance of muscular over connective-tissue elements. In that case the 
growth approaches the type of pure myoma. On the other hand, if from 
the very incipience of the new formation, the connective tissue predomi- 
nates, or if it does so secondarily by a process of fibrous induration, then 
the muscular tissue being held in abeyance, as it were, we get an almost 
pure fibroma. 
Nevertheless it would not be in accordance with histological principles 
to divide these tumors into myomata and fibromas, since, as already stated, 
both varieties of tissue invariably coexist in them. A better plan, and 
one based on clinical symptoms, is to separate hard from soft fibromyo- ANATOMY OF MYO-FIBROMATA. 
167 
mata. A diagnosis in this sense is often possible, thus justifying the dis- 
tinction recognized by English authors between white fibroids, and fleshy 
or red fibroids. The latter variety is always characterized by the prepon- 
derance of muscular elements. Such tumors are also more abundantly 
supplied with blood-vessels, and contain only sparing amounts of loose 
connective tissue. These soft fibromyomas are intimately connected with 
the true substance of the uterus, and a separation can be accomplished 
only with considerable difficulty. - Indeed they represent but a local hy- 
perplasia of uterine tissue.1 With the preponderance of fibrous elements, 
on the other hand, we observe a lessened vascularity. The harder the 
fibromyoma, the less firmly is it united to the uterine walls. As the lat- 
ter, i.e., the hard variety, is the one most frequently met with by far, 
the claim of absolute non-vascularity, or at least an extreme paucity of 
Fig. 2.-Spaces between the Muscular Fibres of a Fibro-Myoma. Natural size. (From the 
Collection of the Pathological Institute at Strasburg.) 
blood-vessels, has obtained a wide currency. It is true that attempts to 
inject these hard tumors from the uterine vessels, have only very rarely 
proved successful. (Barnes, Klob, Schroeder, van der Kolk.) 
Turner,2 however, alludes tq the successful injection by Goodsir of a 
pediculated, subserous myoma. Large vessels were seen to enter the 
tumor through its pedicle, ramifying under the peritoneal investment. 
The loose interstitial tissue was likewise quite vascular, whereas the solid 
mass of the growth looked very pale. Taken as a whole the neoplasm 
was much less vascularized than the adjoining uterine tissue. 
Klebs describes a peculiar arrangement of the muscular fibres of these 
tumors. For according to this author, they are connected with the ves- 
sels in such a way that bundles of smooth fibres surround the larger 
capillaries, thus leaving spaces between the vascular sheaths and the 
1 Comp. Spiegelberg: Archiv. f. Gynkologie, VI., p. 515. 
2 Edinburgh Med. Journal, 1861, p. 706. 168 
NEW GROWTHS OF THE UTERUS. 
muscles. Such crevices he regards as lymph-spaces. The growth of the 
tumors he then explains by a process of proliferation which begins in 
the connective tissue and muscle fibres that belong to certain vessels. In 
this way, he thinks a number of small growths originate, which by agglo- 
meration at length produce a larger tumor. 
Kleinwachter 1 describes the evolution of fibroids from certain round 
cells, which occur alongside of slowly obliterating capillaries. These 
round cells are transformed into spindle-shaped corpuscles, which arrange 
themselves in such a way as to form myomatous nodules. The arrange- 
ment of the interlacing fibres of these growths does not appear to be gov- 
erned by any law. 
Nerves, the presence of which had been previously assumed (Astruc, 
Dupuytren), were first actually found in fibroids by Bidder. 
Hertz' describes nerve-terminations in the smooth muscle-fibres of a 
uterine myoma. Delicate fibres, such as Frankenhauser and Arnold have 
described, could be traced as far as the nuclei of the muscle-fibres. But 
since the examination of Hertz was made on a piece of tumor spontane- 
ously discharged, there is no proof that the fibrils in question were 
really nerves. 
Lorey 8 records a case of uterine polypus, consisting of smooth muscle, 
in which he plainly saw medullated nerve-fibres. In one microscopical 
specimen, a nerve-fibre was seen to end in a " terminal body." 
The soft fibromyomas are usually found near the fundus uteri. As a 
rule they occur singly, the multiple tumors belonging to the harder, more 
fibrous type. This latter variety is seen far more frequently than the 
former. It has been already stated that, the soft and succulent neo- 
plasms are intimately connected with the substance of the uterus. Indeed 
this union is often so complete that it becomes difficult to isolate the 
tumor. But the hard fibroids are commonly distinct and separate from 
the surrounding structures, being enclosed in a sort of capsule. From the 
latter they can be easily enucleated. The capsule itself appears as a 
smooth cavity in the interior of the uterine substance. It originates from 
a pushing apart of fibres by the growth o^ the tumor, and never shows a 
true investing membrane. Even when the tumor has attained a very 
large size, uterine fibres completely surround it. But cases often occur 
in which at some point the uterine tissue has become so attenuated as to 
be barely discernible, forming only a narrow rim over the projecting 
mass of the tumor. Loose connective tissue is found between the sub- 
stance of the growth and its capsule. And it is this circumstance 'which 
so greatly facilitates enucleation. In this layer of tissue and in the ad- 
joining uterine substance, blood-vessels, principally of the venous kind, 
1 Zeitschrift f. Geburtsh. u. GynakoL, IX. 
2 Virchow's Archiv., Vol. XLVI., p. 235. 
3 Deutsche Klinik, 1867, No. 21, p. 194. ANATOMY OF MYO-FIBROMATA. 
169 
and often attaining a large size, abound. The arteries are generally smaller 
and are more scantily supplied. In some instances the uterine tissue imme- 
diately surrounding such neoplasms shows a distinctly cavernous struc- 
ture. From branches of these vessels the nourishment of the tumor is 
effected. 
As a general thing fibromyomata are of slow growth. Moreover it 
continues only during the period of functional activity of the sexual organs. 
It takes place in most cases in the direction of the least resistance to de- 
velopment. This leads to important variations in the seat of the tumors, 
variations which materially affect the well-being of the patients. The 
practical issues involved in this peculiarity will presently receive attention. 
Fig. 3.-Histological Structure of a Fibroid Tumor. The dots represent cross-sections of 
Fibres. (Magnified 30 diameters.) 
Fibroids may exist singly, or, what is more common, they occur in groups. 
Their size varies from growths not larger than a pea to tumors weighing 
sixty pounds or more, which fill almost the entire abdominal cavity. They 
are rarely met with in the cervix, their point of predilection being the 
posterior wall of the uterus. Next in point of frequency is the anterior 
wall, and then the fundus.1 Thomas Lee observed only four cervical 
tumors among seventy-four myomas, and Courty mentions twenty-one out 
of a whole number amounting to 131. 
Of greatest significance, as regards the symptoms and course, is the 
point at which the fibromyoma is developed. When the morbid process 
begins in the superficial, sub-peritoneal layers of the uterine tissue, the 
1 Houel, Manuel d'Anatomie Pathol., p. 596. 170 
NEW GROWTHS OE THE UTERUS. 
tumor, following the direction of least resistance, grows out into the ab- 
dominal cavity beneath the peritoneum, constituting a so-called sub-serous 
fibromyoma. 
If, on the other hand, the tumor arises within the uterine substance, in- 
vading gradually the neighboring muscular layers, we have what is called 
an interstitial (intra-muscular or intra-parietal) myoma. Finally, tumors 
which begin in the muscular layers immediately beneath the mucous 
membrane, the direction of growth being chiefly into the uterine cavity, 
are designated sub-mucous. Strictly speaking, those tumors only should 
be called sub-serous which hang free in the abdominal cavity, attached 
by a loose pedicle, and covered only by the peritoneum; in those cases 
the only connection with the muscular tissue of the uterus is through the 
pedicle. In like manner, we should call those growths only sub-mucous 
which hang by a pedicle in the cavity of the womb, and which have no 
muscular coat. But neoplasms of this kind are also frequently designated 
fibrous polypi. These two forms differ from each other and from the 
interstitial variety, in symptoms, prognosis, and treatment. A strict ana- 
tomical division, however, cannot always be maintained, at least not during 
life. As soon as an interstitial fibroma has grown beyond the thickness 
of the uterine wall, unless its growth be exactly even on all sides, it will 
project more into the abdominal or uterine cavity, and thus become prac- 
tically, as regards the symptoms, a sub-serous or a sub-mucous polypus. 
Anatomically, however, such a growth would still be classed among the 
interstitial tumors. Much more complicated, of course, are the symp- 
toms in case of multiple tumors in different situations. 
To whatever variety it belongs, the tumor may be at times observed to 
vary in size, quite independently of its natural growth. This change of 
volume takes place most frequently before or during menstruation. It 
may be due to increased fullness of the vessels, but more frequently, 
since these growths are but slightly vascular, is owing to increased suc- 
culence dependent upon menstrual congestion. In certain soft intra- 
muscular tumors, a diminution of size may occur through a contraction 
of the remaining muscular elements, a return to the former dimensions 
depending upon subsequent relaxation of the muscular tissues. (Vir- 
chow, Klebs.) 
The sub-serous fibroids are attached to the external uterine wall by 
a pedicle of varying thickness and length. The longer and thinner 
the pedicle, the more movable is the tumor in the peritoneal cavity. 
In the case of a large tumor with short pedicle, the uterus is often 
pulled up for some distance and its cavity deepened very considerably, 
while the tumor itself may extend up as high as the epigastrium. In 
such cases it may be impossible to reach the os with the finger introduced 
into the vagina. Spencer Wells1 observed a very large fibromyoma of this 
1 Transactions of the London Obstet. Soc., vol. XI, p. 73. ANATOMY OF MYO-FIBROMATA. 
171 
sort, extending from the posterior uterine wall, which he mistook for an 
ovarian tumor, and removed. This drawing up of the uterus may reach 
such a degree as to tear the body completely away from the cervix.1 Times2 
relates a case in which the uterine cavity was six inches deep, and the 
cervix was so stretched that its canal was obliterated an inch from the os. 
A space of two inches between the cervical canal and the cavity of the 
body was occupied by a thin muscular cord, in which the obliterated canal 
could be traced. This case, however, cannot strictly be regarded as a 
separation of the neck from the body of the womb. (See also Krister's 
Fig. 4.-Small Cretified Subserous Fibroids. (From the Obstetrical Collection at Strasburg.) 
case, p. 174.) Rokitansky3 by no means relates a case of this kind, 
as has been repeatedly attributed to him, but merely says that "a 
separation of the body from the cervix ' ' might occur. 
The shorter the pedicle is, the less distinctly can we determine an inde- 
pendent movement of the tumors. When, as is most frequently the case, 
they spring from the posterior wall of the uterus, they may sink down into 
Douglas's cul-de-sac and become immovably wedged there. Adhesions often 
form in these cases between the tumor and the peritoneum, so that the 
former is actually immovable. In other cases, in which there are no ad- 
hesions, the immobility is only apparent; and firm pressure through the 
vagina may force the growth out of the pelvis into the abdominal cavity 
1 Virchow Geschwiilste, vol. III., p. 161. 
2 Transactions of the London Obstet. Soc., vol. II., p. 34. 
3 Pathol. Anatomie, 3d edition, vol. III., p. 482. 172 
NEW GROWTHS OF THE UTERUS. 
(provided the pedicle be long enough), thus often relieving grave symp- 
toms of strangulation. These lodgments take place most frequently 
in the case of a tumor with a long pedicle, which allows the growth to 
obey the laws of gravity and to sink into the pelvis. So that when we 
find a tumor with considerable mobility in the abdominal cavity, provided 
it be not of great size, we may conclude that it has a rather short attach- 
ment. The greater or less mobility of these new growths often occa- 
sions a number of the most varying symptoms, which will be considered 
later. But it seems also as though a slight degree of local peritonitis, lead- 
Fig. 5.-Large Subserous Myoma of the Uterus. (After Spencer Wells, l.c.) 
ing to adhesions between the tumor and neighboring organs, were easily 
caused thereby. Thus adhesions of sub-serous fibroids with the anterior 
abdominal wall and the mass of the intestines are sometimes seen, which 
give rise to the most painful symptoms. The adhesions to neighboring 
organs may lead to an increased growth of the tumor, owing to the com- 
munications established with the vessels of the omentum, etc. (Virchow. 
See also the cases observed by Hofmeier at Schroder's clinic.1) Ab- 
scesses of considerable size even may grow into the tumor from the point 
of adhesion. (Chambers,2 Vogel, Rokitansky, and Virchow, loc. cit.) The 
adhesions may even so surround the tumor as to cause an apparent or real 
separation from the uterus itself. (Rokitansky, Virchow.) The tumor 
may become adherent to a movable organ, as the intestine, or to one 
1 Zeitschr. f. Geburtsh. u. Gynakol., vol. V. 
2London Obstet. Trans., vol. XL, p. 31. ANATOMY OF MYO-FIBROMATA. 
173 
whose form is changeable, as the bladder. In such case, provided the 
pedicle be long and thin, the tumor will follow the movements of the 
organ to which it is attached, and appear to lie free in the abdominal 
cavity. When the tumor is attached to the wall of the pelvis, the enlarge- 
ment of the uterus during pregnancy may cause a tearing loose of the 
new growth. This was the mode of production of the pelvic tumors de- 
scribed by Huguier and Nelaton.1 Depaul2 found a fibroid tumor lying 
detached from the uterus in Douglas's cul-de-sac. Turner 3 found a cal- 
cified fibroma, the size of a hazel-nut in Douglas's pouch, which was at- 
tached to none of the neighboring parts. In the same case a second 
smaller tumor was found separated from the uterus, but attached to the 
pelvic wall behind this organ. A third tumor, the size of a walnut and 
calcified, was discovered firmly united to the bladder and wall of the pel- 
vis, while it was still connected with the uterus by a thin pedicle. 
Simpson * states that he has met with several such cases. He relates 5 
especially the case of a lady, the subject of extra-uterine pregnancy, after 
whose death, consequent upon puerperal peritonitis, a fibroma was found 
attached firmly to the anterior abdominal wall, the pedicle of which, lead- 
ing to the uterus, had been torn by the growth of the latter organ. West6 
and Porter7 have also seen cases of this kind. 
The pedicle of such a tumor is usually very thin and contains a scanty 
supply of blood-vessels, so that the fibroma often atrophies or becomes 
calcified, and is seen as a little shrivelled-up mass. In other cases, where 
the tumors are bulky, the pedicle may contain very large vessels. Cham- 
bers (1. c., p. 33) saw several vessels the size of a quill in such a pedicle, 
and Graily Hewitt8 mentions some one-third of an inch in diameter. 
Martin le Jeune9 found a tumor weighing six pounds attached to the uterus 
by a pedicle two inches in length and one inch m thickness. Cruveilhier 19 
describes the pedicle of a twelve-pound myoma with the thickness of a 
quill pen. James Cappie 11 found in a woman suffering from a fibroid 
tumor of the uterus, who died from peritonitis consequent upon a fall, 
that the tumor, measuring twenty-four inches in circumference, was par- 
tially gangrenous. This had been caused by a twisting of the pedicle 
one and a half times around its axis, thus stopping the blood supply to 
the tumor. 
The most common seat of these sub-serous fibromata is the posterior 
1 Gaz. des Hop,, I860, p 411, and 1862, p. 77. 
2 Bull, de la Soc. Anatom., XIX., 13. 
3 Ed. Med. Jour., 1861, p. 698. 
4 Selected Works, Edinb., 1871, vol. I., p. 716. 
5 Obstetr. Works, 1st ed. p. 834. 
6 Lehrb. der Frauenkrankheiten, 2d ed. p. 313. 
1 Dub. Med. Jour., 1875, p. 247. 8 London Obstet. Soc., vol. II., p. 241. 
9 Mem. de M6decine, Lyons, 1835. 10Anat. Pathologique, III. 
11 Obstet. Jour., vol. IL, p. 303. 174 
NEW GROWTHS OF THE UTERUS. 
wall of the uterus; they are found but seldom at the side in the broad 
ligaments. Usually the tumors are multiple, though some may be intra- 
muscular oi* sub-mucous. 
The influence of these tumors upon the shape of the uterus has been 
spoken of above. The change of form, when it occurs, consists in an 
atrophy and a lengthening of the organ. Atrophy, without at the same 
time a considerable lengthening of the organ, has nothing to do with the 
existence of a tumor, but is commonly due to senile changes. E. Kiis- 
ter1 has observed a very peculiar case of this nature. By reason of the 
Fig. 6.-Large Subserous Myoma of the Uterus, starting from its posterior surface and wed- 
ged in the Pelvis without adhesions. (From the Collection of the Pathological Institute at Strasburg.) 
growth of «*i myoma, the size of a man's head, at the fundus, the uterus 
was greatly lengthened, the cervix especially being four inches long and 
with very thin walls. This elongated neck had become a cord the size 
of a finger, through a twisting of the womb two and a half times around 
its axis; the round ligaments were wound spirally around this cord, look- 
ing like two strings of the thickness of a goose-quill. The twisting had 
probably been caused by intestinal movements, as the anterior wall of the 
uterus was attached by ligamentous masses to the descending colon. 
As sub-mucous fibroids only those tumors are to be designated which 
' Beitrage fur Geburtshillfe, etc., of the Berlin Obstetrical Society, I., 1872, 
p. 7. ANATOMY OF MYO-FIBROMATA. 
175 
hang by a pedicle within the uterine cavity. They are entirely covered 
with uterine mucous membrane, as is also the pedicle. The latter is 
sometimes formed of mucous membrane alone. These so-called fibrous 
polypi differ greatly from the tumors with broad base which pro- 
ject into the cavity of the uterus. The difference lies in the fact that 
they have a pedicle (varying in size, but usually rather short and thick), 
as well as in the symptoms and therapeutical indications. 
Every fibroma of the uterus which is not pediculated must be classed 
among the intra-parietal tumors. These sub-mucous tumors resemble the 
Fig. 7.-Large Submucous Fibroid of the Uterus. (From the Obstetrical Collection at Strasburg.) 
sub-serous, except that they are apt to approach more nearly the myomata, 
or soft fibroids (Virchow, Rokitansky). There is but a scanty growth of 
intra-muscular connective tissue, so that it is easy to separate the bundles 
of muscular fibres from each other. Sometimes there are considerable 
spaces between them filled with a loose connective tissue. These in- 
terstices often become actual cavities, which may perhaps be regarded as 
lymph spaces. The tumors are covered with uterine mucous membrane, 
beneath which there is usually a thin layer of muscular tissue. This 
smooth " capsule" is often | cm. or less in thickness.' Although this is 
the usual formation of sub-mucous fibroids, yet some are met with which 
are without a muscular coat or even without a covering of mucous mem- 
1 Hildebrandt, Fibrous Polypi of the Uterus. Volkmann's Klinische Vort- 
rage. 176 
NEW GROWTHS OF THE UTERUS. 
brane. In those cases the pedicle consists entirely of connective tissue. 
Such tumors are really nothing but spontaneously enucleated myomata, 
whose coats (mucous membrane and muscular tissue) have disappeared 
(Miinnel, Matthews Duncan).1 Usually the mucous covering is greatly 
swollen, more or less in a condition of chronic catarrh, leading to bloody 
and muco-purulent discharges. When the tumor, however, has attained 
considerable size, the mucous membrane covering it is often greatly 
stretched and atrophied. By reason of this stretching of the mucous coat 
and the circulatory disturbances thereby induced, there is often vicarious 
congestion and swelling of the remaining portion of the uterine mucous 
membrane. 
Klob has observed in the membrane thus stretched, spaces which he 
says are produced by the falling out of the utricular glands. According 
to him, therefore, there is a complete disappearance of the investing mucous 
coat, the remains constituting merely a large-meshed net-work. It must 
remain undetermined how deeply the utricular glands grow into the 
tumor, or whether the dropping out of such glands can give rise to the 
formation of cavities. Probably tumors of this kind do not belong at 
all to the class under consideration, but find their proper place under dis- 
eases of the mucous membrane. Rokitansky (Klob) regards such new 
growths as adenoid sarcomata of the uterus, but even simple muscular 
tumors of the uterus he includes in general under sarcomata. Klebs 
found the mucous covering of fibroids lying in the vagina or external to it 
(the latter is a very rare condition) to be thick and rugous, and covered 
with flat epithelium, thus presenting the appearance of the vaginal mucous 
membrane. He stated that the portio vaginalis had on this account been 
mistaken for a fibroid. 
Scanzoni,2 on the other hand, mistook such a tumor for the portio 
vaginalis, a fold in the soft mucous membrane seeming to the finger to 
be the os. A. Martin 3 saw a very similar case in which a polypus was 
supposed to be the prolapsed uterus, on account of a similar depression 
existing on its under surface. The pedicle uniting these tumors to the 
uterine wall is composed of the same elements as the fibroid itself; its 
thickness and length, however, are very variable. The larger the tumor 
and the greater its circumference, the shorter and thicker usually is the 
pedicle. If the latter belong, the tumor hangs down low in the cavity of 
the uterus, or may even come outside of it. The large sub-mucous my- 
omata of the uterus are, however, usually of such broad base that it is 
difficult to distinguish them from the intra-parietal variety. Clinically 
we may say that all tumors that can be cut off, i.e., whose base may be cut 
through, belong to the pediculated, the sub-mucous variety; while those 
1 Edin. Med. Jour., 139, Jan. 1867, p. 640. 
2 Beitrage, II., p. 99. 3 Bost. Med. & Surg. Journ., June 11, 1867. ANATOMY OF MYO-FIBROMATA. 
177 
whose enucleation can be accomplished only through division of the cap- 
sule belong to the intra-parietal class. Cullingworth1 describes a fibrous 
tumor five and a quarter inches long by three and three-quarter inches 
in diameter, which had descended through the external genitals, and 
was attached to the uterus by two pedicles. Between the two was a 
space an inch and a half wide. The anterior pedicle was one-half inch 
long and three-quarter inches wide, and was attached to the left side of the 
uterus; the other, situated posteriorly and to the right, measuring one- 
quarter inch in length by one and a half inches in thickness, contained two 
good-sized vessels. Unfortunately no exact anatomical examination was 
made of this very peculiar case, the explanation of which anatomically 
seems so difficult. It is probably to be explained either by the formation 
of adhesions, or by suppuration causing a loss of substance in the tumor, 
for the report mentions the occurrence of suppuration. 
While the tumors are often quite vascular, especially containing large 
venous branches, the pedicle seldom contains large vessels, and very rarely 
large arteries. In a tumor of this kind the size of a small apple, attached 
to the portio vaginalis, I once found an artery the size of a crow's quill in 
the pedicle, but that was an exceptional case. In the wall of the uterus, 
in the neighborhood of the pedicle, there are often very large veins. Indeed 
Klebs speaks of varices in this situation. 
The more these tumors grow out into the cavity of the uterus, the 
more readily do they excite contractions of the muscular tissue, and are 
thereby forced down through the internal os, and not seldom even through 
the external os into the vagina. This process, which gives rise to a num- 
ber of the most constant symptoms of sub-mucous fibroids, we shall con- 
sider more fully later on. We will only remark here that the descent of 
the tumor is most evident during the menstrual enlargement of the uterus, 
and it occurs most frequently in the case of the softer variety, the fleshy 
myoma. The rapidity with which this extrusion, which has been aptly 
called the birth of the polypus, takes place, depends in general upon the 
rapidity of growth of the tumor, then upon the thickness of the pedicle, 
the condition of the uterine walls, the rigidity of the os, and other condi- 
tions which will be spoken of later. This process usually ceases when 
the tumor has passed through the os, although here and there cases occur 
in which the uterine contractions continue, and, especially in relaxed con- 
ditions of the womb, cause inversion. Such an occurrence takes place 
the more readily, the nearer the point of origin of the new growth is to 
the fundus. 
The form of a pediculated uterine myoma is usually roundish, though 
a more oval shape is often caused by the shape of the cavity of the womb. 
In rare cases the tumor has an hour-glass shape, occasioned usually by 
1 Obstet. Journal, June, 1876, p. 155. 178 
NEW GROWTHS OF THE UTERUS. 
constriction by the internal or external os, the part below the constriction 
becoming swollen from impeded circulation. Very rarely is the growth 
flat or doubled upon itself, as in a case described by L. Mayer.1 
The changes in the uterus itself occasioned by the sub-mucous pedicu- 
lated fibroids are tolerably constant. There is hypertrophy of the same 
form as in pregnancy. In the case of a large growth, the Avails of the 
uterus are thick, and the mucous membrane is hypertrophied and contains 
large dilated vessels; so that one really might speak of a il grossesse 
fibreuse. ' '8 
The mucous coat of the tumor itself can take part in these changes only 
when the growth is small; but it may become ulcerated through move- 
ments of the tumor. These ulcers, which however are caused most fre- 
quently by injuries from without (from the examining finger, etc.), exert 
a very great influence upon the nutrition of the tumor, an influence which 
we shall study more carefully further on. They may also lead to the 
formation of adhesions with the neighboring mucous membrane of the 
uterus or even of the vagina. Such adhesions to the opposing surfaces 
of the uterine mucous membrane, with partial occlusion of the uterine 
cavity, have been mentioned by Klob. Barnes also describes a similar 
specimen in the St. George's Hospital Museum. Demarquay3 observed a 
case in which close connective-tissue adhesions of a polypus to the va- 
matter of rendered the diagnosis, as well as the removal of the tumor, a 
ginal wall some difficulty. 
The intra-parietal (intra-mural, interstitial) fibroids of the uterus are 
those which have arisen deep within the muscular wall of the womb, and 
then by their growth stretched out the surrounding muscular layers equally 
on all sides. Very small growths of this kind may not be discovered ex- 
cept by a section through the Avail of the uterus. But the larger ones push 
the peritoneum outwards and the mucous membrane imvards, so that in a 
certain sense they may be regarded as at the same time sub-serous and 
sub-mucous tumors. In this way it may often be difficult, anatomically as 
Avell as clinically, to recognize this variety. It has been already pointed 
out above that in such cases the distinction must rest upon the presence 
of the so-called "capsule." Every intra-parietal myoma is surrounded on 
all sides by a muscular layer of nearly equal thickness, from which it is 
separated by loose connective tissue. Upon section of this muscular 
layer, the tumor can ordinarily be shelled out with the greatest ease. 
The structure of these growths is the same as that of the other fibromyo- 
mata, except that most of them seem to be more purely myomata, present- 
ing a localized hypertrophy of the uterine substance. The cells of which 
1 Berliner Beitrage, III., p. 80. 
2 Guyon : Des Tumeurs Fibreuses de 1'Uterus, Paris, 1860. 
3 Bailly ; Mouvement M6d., 1867, No. 4. ANATOMY OF MYO-FIBROMATA. 
179 
they are composed are frequently larger, and provided with larger nuclei, 
than those of the normal muscular tissue of the uterus. They resemble 
more the muscular tissue of the gravid uterus (Klebs). These tumors 
may attain a very considerable size, and are not infrequently multiple or 
mixed with other varieties of fibromata. (Schulze 1 counted over fifty 
tumors of this kind in one uterus.) Commonly if there is a single tumor, 
(though often also when there are several together), its point of origin 
lies in the posterior wall near the fundus; more rarely is it in the anterior 
wall, and exceptionally only is it found on the side. 
The influence which they exert upon the uterus is manifested first by a 
considerable hypertrophy of the entire organ which undergoes changes 
Fig. 8.-Intraparietal Myoma.-(From the Obstetrical Collection at Strasburg.) 
very like those occurring in pregnancy. Tillaux2 found in one case post- 
mortem that a few small fibroids, situated in the lower segment of the 
uterus, had caused an hypertrophy of the entire organ, so that it was of 
the size of a large child's head. The tissues surrounding these tumors are 
very vascular, while the tumors themselves often have but a scanty blood 
supply; not infrequently one sees large vessels, usually veins, passing into 
the growth. 
While hypertrophy of the uterine wall is the rule in this variety, we 
nevertheless not infrequently find atrophy to such a degree that the mus- 
cular tissue seems to have almost entirely disappeared and the tumor 
appears to be covered only by the peritoneum. This condition of the 
1 Jenaische Zeitschrift, 1870, Vol. V., p. 350. 
3 Gaz. des Hopitaux, 1867, No. 144. 180 
NEW GROWTHS OF THE UTERUS. 
uterus is not by any means always dependent upon the size of the tu- 
mor, but rather upon the age and general condition of the patient. 
The cavity of the uterus is almost without exception markedly increased 
in depth, but has usually lost its normal straightness, and seems to be 
flexed or even bent at a sharp angle. 
The shape of the uterus, except where there are multiple tumors, is 
usually rounded. But it may be so changed and the adnexa may be in 
so many ways displaced, as to give great trouble, on an anatomical ex- 
amination, in making out clearly the exact condition. 
The position of the uterus varies according to the situation of the 
tumor. There is seldom much elevation of the organ, nor is pro- 
Fig. 9.-Intraparietal Myoma. The Capsule has been destroyed, thus exposing the tumor 
(From the Obstetrical Collection at Strasburg.; 
lapse or even a very low position of the uterus frequently met 
with. A much more common condition is the complete dislocation of 
the womb toward the anterior or posterior wall of the pelvis; or there 
may be flexions of the organ. When the tumors have developed on the 
side, and especially when they extend between the layers of the broad lig- 
ament, the lateral deviation of the womb is marked. The most constant 
displacements are those which occur when the tumors are wedged into 
the pelvis, growing backwards and downwards from the uterus, and 
when they can in no way be dislodged. This is what often happens in the 
case of subserous tumors which have sunk down into Douglas's cul-de- 
sac. In such a case an intra-parietal myoma may seem to be situated not 
only behind the uterus but even posterior to the vagina. The tumors ANATOMY OF MYO-FIBROMATA. 
181 
may also develop downwards into the uterine cavity, and passing through 
the internal os, may reach into the vagina, the cervical canal having dis- 
appeared. In these cases one finds upon examination the same condition 
of things as in the birth or expulsion of a pediculated submucous fibroma, 
although the tumor is situated entirely within the wall of the uterus. 
There is a specimen of a very peculiar development of an intra-parietal 
myoma in the pathological collection of Strasburg (for permission to de- 
scribe which I am indebted to the kindness of Dr. von Recklinghausen). 
It consists of a myoma of nearly the size of a child's head, origina- 
ting within the anterior wall of the uterus, which has grown downwards 
Fig. 11. 
Fig. 10.-Large Myoma growing into the Anterior Lip of the Os Uteri. The capsule of 
the tumor has been destroyed at the anterior lip. 
Fig. 11.-The same Specimen from behind, a. Fundus Uteri, b, Anterior lip of Os Uteri, 
c, Remnant of obliterated posterior lip. d, Cavity of the Uterus, e, Upper end of the tumor, which 
arose in anterior wall and has grown downwards to b. 
Fig. 10. 
into the anterior lip. The posterior lip has entirely disappeared, while the 
anterior one, the size of a man's fist, reaches down into the vagina. At 
the lowest point there is a perforation of the capsule, as also of the mus- 
cular layer of the portio vaginalis, and the tumor projects through a lacer- 
ation of the anterior lip into the vagina. The case is described in the 
thesis of v. Duchemin.1 The patient was an unmarried woman, thirty 
years of age. The upper border of the tumor could be felt at the 
navel, while the lower part entirely filled the vagina. The tumor was 
dragged outwards and a ligature passed around it in order to strangulate 
1 Quelques Consid6rationes sur les Tumeurs fibroides de I'Utdrus, Stras- 
bourg, 1863. 182 
NEW GROWTHS OF THE UTERUS. 
it. Gangrene of the tumor set in and the patient died of tetanus. This 
case shows how a fibroma of the body may become one of the cervix. 
Although fibroids of the cervix in all three forms are developed ex- 
actly like those of the body, yet, not only on account of their rarity, but 
also because they occupy a peculiar position as regards diagnosis, symp- 
toms and treatment, it seems proper to devote a separate paragraph to 
them. Those which have the greatest practical interest, and whose re- 
moval seems impossible, are the subserous fibroids of the neck of the 
womb. These usually grow outwards and posteriorly from the cervix, 
seldom laterally; they are developed either toward the abdominal cavity 
between the layers of the broad ligament, or pressing up the pelvic peri- 
toneum, or else they grow downwards, behind the uterus or at its side, 
into the connective tissue of the pelvis alongside of the vagina. In the 
latter case they may be taken for tumors of the vagina. In every case, 
when they have attained a certain size, they must fill the pelvis more or 
less, and occasion thereby grave symptoms, especially, as we shall see later 
on, during child-birth. Since the attachment to the uterus is close, the 
mobility of these tumors is greatly restricted, especially as they cannot be 
pushed into the abdominal cavity on account of their extra-peritoneal 
situation. 
A tolerably large myoma of this kind is in the collection of the Stras- 
burg Obstetrical Clinic, but no history of the case accompanies the speci- 
men. 
Spiegelberg1 relates a typical case of a subserous fibroma of this sort 
growing from the posterior- wall of the cervix. He rightly emphasizes the 
fact that tumors of this sort may almost completely fill the pelvis, and be 
irreducibly wedged in there without having contracted any adhesions 
whatever with the neighboring parts. When we come to speak of partu- 
rition in connection with uterine fibroids, we shall have occasion to relate 
more cases of this kind, which are, however, very rare. Small tumors may 
of course exist without any great inconvenience. Samson Gommel, of 
Glasgow, found accidentally at an autopsy a myoma the size of a child's 
head, which stretched out to the right of the uterus, growing between the 
folds of the broad ligament, and attached to the neck of the womb by a 
slender pedicle containing very large vessels. The whole lay freely movable 
without adhesions in the true pelvis.2 Mattei3 has described a similar case. 
The submucous myomata of the cervix seem to be somewhat more com- 
mon than the subserous, though but few cases of the kind are found in the 
literature of the subject. They arise with a tolerably broad pedicle from 
the inner side of the cervical canal, and may, through their growth and 
'Archiv. fur Gynaekologie, vol. V., p. 100. 
'Archives de Tocologie, vol. I., p. 700. 
3Annales de Gyn6c., vol. VI. ANATOMY OF MYO-FIBROMATA. 
183 
their weight, drag the uterus or the cervix far down, even outside of the 
external genitals. In this way a very peculiar condition of the parts may 
be produced, the recognition of which during life is often difficult; and the 
larger the tumor, the greater the difficulty of diagnosis. The lips have 
so entirely disappeared and the os is so far displaced upwards, that in 
Fig 12.-Subserous Myoma of the Cervix Uteri, a, Fundus Uteri with a large Myoma, b. 
Internal os. c, External os. d, Subserous Myoma, e, Polypus, f, Vagina. (From the Obstetrical 
Collection at Strasburg.) 
most cases the observers for a long time thought they had to do with an 
inversion of the womb. Since the pediculated submucous fibromata of 
this variety very readily sink downwards they are often mistaken for pro- 
lapsus uteri; they may indeed produce this condition, which often dis- 
appears again upon the removal of the tumor. Characteristic cases of 
this kind are described by Peter Muller.1 He found a smooth doughy 
1 Scanzoni's Beitrage, vol. VI., p. 65. 184 
NEW GROWTHS OF THE UTERUS. 
feeling tumor, the size of a child's head, lying outside of the vagina; 
from this a slender pedicle passed into the vagina where it widened 
out into a thicker, conical, fleshy mass which seemed to go directly into 
the vaginal wall at the fundus. More careful examination revealed to 
the left of this conical body a fold 4 mm. wide, through which the sound 
passed for two inches into the cavity of the uterus. There was in this 
case a polypus of the anterior lip of the os, which had stretched it out very 
considerably. An artery was found in the pedicle. A similar case is re- 
corded by Hall Davis,1 in which the tumor arose from the posterior lip 
with a pedicle one inch thick, and had caused a prolapse of the womb. 15. 
Schultze2 removed two pediculated myomata, one of which measured 24 
Fig. 13.-Pediculated Myoma, starting from the posterior Lip with; Prolapsus Uteri. (After 
Barnes.) 
cm. in circumference and sprang from the posterior wall of the cervical 
canal with a pedicle 4 to 4| cm. thick; the other arose from the anterior 
cervical wall. 
Finally, a case related by Barnes3 is instructive: A patient, thirty-seven 
years of age, had a tumor composed of prolapsed vagina and uterus out- 
side of the external genitals. There was, however, no os discoverable, 
and while the tumor above was evidently composed of uterine tissue, 
the lower part, which was pediculated, was harder. As in the other 
cases, the whole mass was taken for a prolapse of the inverted uterus, until 
an opening was found anteriorly, which was seen to be the os. After the 
1 Obstet. Transact., vol. IX., p. 152. 
2 Schultze : Zur Casuistik der Uterusfibroide, Diss. Jena, 1875. 
3 Obstetr. Transact., vol. III., p. 211. ANATOMY OF MYO-FIBROMATA. 
185 
polypoid tumor attached to the posterior lip had been removed by the 
snare, although the fundus could be felt in the inverted vagina, the pro- 
lapse was reduced spontaneously. 
Submucous myomata of the cervix are in general easily removed when 
they are pediculated. This also applies to the interstitial variety, when they 
are developed in one lip and grow downwards. The latter grow less readily 
outside of the vagina, and also draw the uterus less frequently downwards 
and outwards, but are more often than the submucous myomata of the 
cervix mistaken for inversion of the uterus. When a large tumor of this 
kind grows downwards from one lip, the examining finger naturally finds 
the orifice of the cervix above; and through the even growth of the two 
lips in width the os becomes strongly stretched laterally, the free lips be- 
ing stretched closely against the tumor; in this way a narrow slit is formed, 
which may be easily overlooked or may be mistaken for the edge of the os 
of an inverted uterus. P. Muller describes such a tumor, larger than a 
goose egg, growing from the posterior lip, which seemed to have grown 
completely into the posterior wall of the vagina so that it could be pal- 
pated easily only through the rectum. The anterior lip could not be felt 
at all, and only after considerable trouble was the os discovered, in the 
anterior surface of the tumor, feeling like a little dimple; into it a curved 
sound could be passed backwards for two inches. The tumor was readily 
removed. It measured 10 cm. in length, 7 cm. in width, and 6 cm. in 
depth, and was enveloped in a layer of muscular tissue (the capsule) from 
2 to 3 mm. in thickness.1 
Murray5 saw a similar large interstitial myoma in the posterior wall of 
the cervix. (See Fig. 14.) 
Chiari3 describes a fibroma growing in the anterior lip, which had 
caused a prolapse of the entire uterus, and had drawn out the anterior 
lip into a pedicle the thickness of a finger. After removal of the tumor 
the prolapse was spontaneously reduced. 
Spiegelberg (loc. cit., see Fig. 15) saw a fibroma arising in the posterior 
wall of the cervix, which had become wedged into the vagina and had 
formed adhesions with its anterior wall. In attempting to excise the 
tumor an opening was made into Douglas's cul-de-sac, and the patient 
died from pyaemia. 
A very interesting case, belonging to this category, is described by 
Freund.4 There was a tumor the size of two fists outside of the vulva, 
the lower third of which was divided from the rest by a shallow depres- 
sion. This under part was whitish in color and not sensitive to a pin 
prick; the upper two-thirds was bluish red, gangrenous and very sensi- 
1 Scanzoni's Beitrage, vol. VI., p. 65. 
2 Obstet. Transact., vol. VI., p. 184. 
3 Klinik tier Geburtshillfe, etc., 1855, p. 411. 
4 Betschler : Klin. Beitrage, part III., p. 165. 186 
NEW GROWTHS OF THE UTERUS. 
tive. The tumor seemed to pass directly into the fundus of the vagina. 
A small opening was at length discovered on the posterior surface, through 
Fig. 14.-Large Interstitial Myoma of the posterior Wall of the Neck of the Uterus 
(After Murray.) 
which a sound passed to the left for 5 cm. into the atrophied uterus. 
There was in this case an interstitial fibroma, whose lower third had been 
Fig. 15.-Interstitial wedged-in Myoma of the posterior Wall of the Cervix. (After 
Spiegelberg.) 
uncovered by the bursting of the capsule, the upper two-thirds still being 
covered by it as by a cup. ANATOMY OF MYO-FIBROMATA. 
187 
We find in the literature of the subject other cases of cervical myomata 
related by Virchow, Schroeder, Bayle, Dupuytren and others. I myself 
once removed with ease a myoma the size of a man's fist, which occupied 
the anterior lip, and which gave at first the impression of an inversion of 
the uterus. Cystic myomata have also been observed in this situation by 
Lee and Consat. They will be described when we come to treat of 
cystic fibromata. 
Virchow is of the opinion that fibromata of the cervix have more the 
nature of connective tissue, and therefore grow more slowly. A consid- 
eration of the cases related above, that certainly constitute the most im- 
portant ones mentioned in the literature of the subject, does not throw 
much light upon the point in question. CHAPTER II. 
THE GROWTH AND MORBID CHANGES OF UTERINE 
FIBROIDS. 
A S a rule, fibromyomata of the uterus grow very slowly, their devel- 
v opment being inversely proportional to the contained amount of 
connective tissue, or, in other words, the more they approximate to the 
character of pure fibromata. Tumors rich in muscular elements, pure myo- 
mata, grow more rapidly. They may, indeed, at times, undergo an exceed- 
ingly rapid increase in size, especially when, as has been often noted, they 
are complicated with pregnancy. This condition' being excluded, a sud- 
den augmentation of volume of the tumors under consideration is due 
not, as many assert, to sudden growth, that is to proliferation and hyper- 
trophy of their histological elements, but rather to circulatory changes 
taking place in them, such as oedema, inflammation or other pathological 
processes. Thus, very vascular fibromata undergo changes in volume 
before and after menstruation; in fact, the subsidence in size after the 
cessation of the menstrual flow has been so marked as to have been mistaken 
for actual atrophy of the tumor. This phenomenon will be further des- 
cribed later on, when we reach the consideration of the different forms of 
so-called cystofibromata. Similar changes may often be observed in cases 
of pediculated fibromata, when these are extruded beyond the external 
os, and the latter encircles the pedicle so tightly as to partially strangulate 
it, giving rise thereby to passive congestion and consequent oedema of the 
parts beyond the seat of constriction. When this occurs it should also 
not be mistaken for a sudden growth. On the other hand, a transient 
diminution of volume has been observed during the course of various de- 
bilitating diseases, followed, after convalescence, by comparatively rapid in- 
crease in size. Braun, Chiari and Spath 1 state that this is particularly 
liable to happen in cases of Asiatic cholera. These changes also occur 
chiefly in the various kinds of cystofibromata, and can scarcely be regarded 
as examples of growth. The numerous instances of uterine myomata 
met with in the practice of every physician, and which, during periods of 
close observation lasting many years, are found to manifest no perceptible 
increase in size, all prove how gradual the growth of most of these tumors 
1 Klinik, p. 404. GROWTH AND MORBID CHANGES. 
189 
really is. Their development is, however, entirely arrested only after 
they have undergone calcification. 
In order to obtain a better idea of the growth of these tumors, I 
have endeavored, in the last fourteen of these cases which have been 
under my care, to determine how long they had already existed. This 
method is, it is true, quite unreliable, for in most instances we can 
designate the commencement of the new formation only by the date 
when it first gave rise to any symptoms. How uncertain such designa- 
tion is does not require demonstration. In each concrete case it is 
uncertain what disturbances are to be regarded as the initial symptoms; 
moreover the statements of patients are usually unreliable; and finally, 
the first subjective phenomena of disease depend very closely upon the 
size of the tumor. A submucous myoma will at an early stage of its ex- 
istence engender symptoms, while a subserous myoma may attain a large 
size before it manifests its presence by any morbid phenomena whatsoever. 
The following data will yield, therefore, only approximative figures in es- 
timating the rapidity of growth of myomata. Counting from the date of 
the manifestation of the first symptoms, in one case the tumor attained 
the size of a fist in six months, in another it grew to the size of an apple 
in a year; in still another it became as large as a fist in the same space of 
time. After a duration of one and a half years, post-mortem examination 
revealed in one case tile presence of two fibromata, one of them 55 milli- 
metres, the other 40 millimetres in diameter. In three cases the tumors had 
existed about two years: in the first the growth was as large as a fist, in the 
second the abdomen was distended by the tumor to a circumference of 76 
centimetres, in the third the swelling was as large as a child's head, but 
had apparently not grown for the last two years. After having been no- 
ticed for three years, in one case, the circumference of the abdomen had 
reached 88 centimetres, the distance from the ensiform process to the 
pubic symphysis being 38 centimetres; in a second case the tumor was 
about the size of the palm of the hand, in a third case the patient had 
noticed the swelling three years before, when it was as large as a hen's 
egg, while, when examined by me, it extended from the true pelvis up to 
the umbilicus. In two cases the tumor had existed five years, in one it 
was as large as a fist, in the other it projected three fingers' breadth above 
the symphysis. One tumor had existed for eight years, and was only as 
large as a fist, although it had not undergone calcification; and, finally, 
one had been noticed for at least nine and a half years, and had attained 
the size of a man's head. Judging from the above list, small though it 
be, it must be acknowledged that uterine myomata do not exhibit a par- 
ticularly rapid rate of growth. 
G. Richter 1 observed the evolution of a tumor of this kind in a girl 23 
1 Progres Med., No. 31, 1871. 190 
NEW GROWTHS OF THE UTERUS. 
years old. The growth was so rapid that in two and a half years the cir- 
cumference of the abdomen reached 1.62 metre. Schorler1 records the 
following observations, based on eighteen cases occurring at the clinic of 
Schroder. The first signs permitting a positive diagnosis were observed 
in three months. After a year there was still no very marked enlarge- 
ment. In five years the tumors were about as large as a fist, and in thir- 
teen had reached the size of a man's head. Eight months to one year ap- 
peared to elapse before the abdominal circumference had increased 10 
ctm., 2| years for 18 ctm. Twice the circumference increased 20 ctm. 
in about three years, and once in a year and a half. 
That fibroids cease to grow after the menopause, or even diminish in 
volume has been repeatedly observed. But according to Schorler (1. c.) 
women having fibroids reach the climacteric period later than others. 
The average age at the menopause may be placed at 47.13 years and at 
50 the menopause is sure to have occurred. But Schorler found the 
change of life to occur on the average at 49.14 years in 29 cases observed 
in private practice, and in 23 dispensary patients at the age of 48. At 50 
years of age (and over) 5.4 per cent, of all his private cases and 7.7 per 
cent, of all his dispensary cases of uterine fibroids still had regularly recur- 
ring menstrual periods. 
It appears probable that in all those cases where fibroids grow consider- 
ably after the menopause, the tumors have vascular connections outside 
of the genital apparatus.2 
The pathological alterations to which fibromyomata are liable are of 
great interest in this respect, that they may each and every one lead to 
spontaneous cure, that is, either to an arrest of development, or to the 
extrusion, or finally, to the complete disappearance of the tumors by ab- 
sorption. 
Quite often one reads of inflammations affecting a fibroid tumor, with- 
out being able to gain a clear idea of the change from a perusal of the re- 
ports. Inflammatory processes are no doubt met with in fibromata when 
necrotic disintegration of the growth happens to take place, as we shall take 
occasion to describe later on. In such cases we often find on the bound- 
ary line of the necrosed tissue a zone of reactive inflammation, which fre- 
quently exhibits marked purulent infiltration, giving the adjoining tissue 
a streaked appearance. I have never been able to discover any other form 
of inflammation, provided the uterine tumors were intact. That which 
has been described as such in literature, usually from a clinical point 
of view, is either an active hypersemia or an (edematous swelling, occur- 
ring as a rule at the time of menstruation, and giving rise to pain without 
fever. There can be no question but that inflammatory pains, now and 
1 Zeitschrift f. Geburtsh. u. Gynak., vol. XL. p. 153. 
2 See Hofmeier, Zeitschr. f. Geburtsh. u. Gynak., vol. V. GROWTH AND MORBID CHANGES. 
191 
then associated with fever, do sometimes occur in cases of subserous fibro- 
mata, but in these instances we undoubtedly have to do with a local- 
ized affection of the peritoneum, and not with inflammation of the growth 
itself. 
G. Braun 1 describes an instance of " suppuration " of a fibroma, where- 
by the uterus was distended to a length of seventeen centimetres. The 
pus escaped partly through the os uteri, partly through an opening in the 
right inguinal region. 
Hecker2 passed a trocar into a supposed ovarian cyst and let out many 
pints of pure pus, Post-mortem examination, a short time afterwards, 
showed not a cyst, but a large subperitoneal uterine fibroid. 
Ch. Carter3 demonstrated in the Obstetrical Society of London a speci- 
men of fibroma of the uterus, eight inches long and six inches wide, at- 
tached to the anterior wall of the uterus of a woman of sixty-nine years. 
The patient had first become aware of the existence of the tumor forty 
years before. The anterior wall of the tumor presented an opening as 
large as a sixpence, through which three pints of pus were evacuated. 
The internal surface of the cavity was rough and ragged, the enveloping 
shell being calcified, and varying in thickness from three quarters of an 
inch to two inches. Routh very properly inquired whether, taking into 
consideration the extreme rarity of suppuration in these cases, the sup- 
posed pus had been examined microscopically, and further, whether any 
history of traumatism could be elicited. No answer, it seems, was given. 
A similar, but very imperfectly reported case is that of Chambers.4 
He states that he found, on making an autopsy, a large, pediculated sub- 
serous fibroid, which yielded on incision from ten to twelve pints of pus. 
There can be no doubt that inflammatory processes, eventuating in sup- 
puration, and which have occurred around fibroids, in the connective tis- 
sue of their capsule, have been confounded with inflammation of the 
tumors themselves. Leaving out of consideration the cases that occur 
during the puerperal state, the former, although not by any means fre- 
quent are nevertheless more often met with than suppuration of the 
tumors themselves. Suppuration of this character in the capsule of a 
tumor either leads to gangrene of the latter with ichorous disintegration, 
or the tumor is thereby so thoroughly loosened from its connection with 
the uterus, that it is often expelled whole and uninjured. It is an open 
question whether such inflammations develop spontaneously or depend 
upon traumatic influences. 
It is claimed by some writers that suppuration is sometimes preceded 
1 Zur Behandlung der Uterus-fibroide, Wiener Med. Zeitschrift, 1867, Nos. 100 
and 101. 
2 Klinik der Geburtskunde, II., p. 133. 
s Obstetrical Transactions, London, 1872, vol. XIII., p. 167. 
4 London Obstetrical Transactions, XI., p. 31. 192 
NEW GROWTHS OF THE UTERUS. 
by oedema of the loose cellular tissue of the capsule. Fenerly and Empis* 
have each reported a case of these " bourses sereuses." Fenerly's2 case, 
however, is the only one having any value in this connection. That of 
Empis3 relates to a woman who died of puerperal peritonitis, in which 
disease oedema of the pelvic connective tissue and uterus is quite preva- 
lent. However that maybe, the above described "dissecting" suppu- 
ration and relaxation of the connective tissue of the capsule are most com- 
monly observed in cases of calcified fibromata, which are thus placed in 
a condition favorable for expulsion. In this category belong cases such 
as that of Tysow,4 who describes a fibroid, which, originating from the 
posterior wall of the uterus, and situated entirely within the true pelvis, 
underwent suppuration on its posterior aspect, thence pus made its way 
into the abdominal cavity, and gave rise to fatal peritonitis. 
Maisonneuve 6 reports an instance of purulent infiltration of the capsule 
of a myoma growing from the posterior wall of the uterus; here the pus 
penetrated through an opening in the wall of the uterus into the subper- 
itoneal pelvic cellular tissue. Similar cases have been observed by 
Huguier and others. 
Now, while inflammation of fibroid tumors of the uterus is seldom en- 
countered alone, it is frequently the cause of, and participate in, the 
breaking down and sloughing of these tumors. Many assume a condition 
of softening as a sort of transition stage from inflammation to mortifica- 
tion, but there are no grounds for regarding this condition as one peculiar 
to uterine fibromata. The softening is either simple oedema, such as occurs 
quite often in disturbances of circulation within these tumors, in which 
event it is frequently enough a forerunner of gangrene, or it is a true 
breaking down of the tumor, in which, for some reason or other, the or- 
dinary signs of decomposition, such as foetor, discharge and so forth, are 
not well marked. The particular varieties of softening, such as the 
mxyomatous form and that which occurs in the puerperal state will be 
discussed later on. (Compare Hecker, Klinik IL 130 ) 
Necrosis of fibromata may be occasioned by insufficient supply of nu- 
trient material. It is observed most frequently in cases of interstitial and 
submucous growths, when the overlying mucous membrane or the capsule 
is in any way affected. I am inclined to doubt whether simple catar- 
rhal inflammation of the mucous membrane is capable of producing such 
an effect. When, however, a tumor of this variety is pressed into the 
os, the blood-supply of that portion of the enveloping mucous membrane 
1 Compare Demarquay and Saint Vel: Maladies de 1'uterus, Paris, 1876, p. 158. 
2 Bulletin de la Soci6t6 Anatomique, XXIX., p. 336. 
3 Ibid., 1868, p. 228. 
4 A case of fibroid tumor of the uterus. Philadelphia Med. Times, March, 
1874. ' Canstatt's Jahresber., 1874, IL, p. 761. 
5 Comp. Demarquay, etc., p. 158. GROWTH AND MORBID CHANGES. 
193 
which lies in the latter situation is often interfered with and leads to 
ulceration at that point. For a time this may be of no particular conse- 
quence, but, finally, perhaps by infection from without, the ulceration 
presents a putrid aspect and then decomposition, starting from this point 
as a focus, attacks the entire substance of the tumor. 
More frequently gangrene starts from an injury to the enveloping mu- 
cous membrane, inflicted, either intentionally or accidentally, by the intro- 
duction of sponge tents or a uterine sound, from the employment of intra- 
uterine injections, or from attempts at instrumental removal of the tumor. 
Every gynecologist knows of one or more cases of this description. Putre- 
faction will also occur whenever the capsule, which is the carrier of the. 
nutrient vessels, is loosened from its attachments to the surrounding tissues 
by dissecting suppuration, and the tumor is thereby more or less cut off, 
from its sources of nutrition. For the same reason decomposition so often 
affects calcified uterine fibromata, inasmuch as either large portions of the 
tumor are directly starved, or because the greater extent of the capsule 
participates in the calcareous change. 
Pediculated submucous tumors also most frequently undergo decompo- 
sition as a result of injuries inflicted on their enclosing mucous membrane 
-not infrequently, however, also, as a result of obstructed circulation. 
When a tumor of this class protrudes from the mouth of the womb, that 
aperture commonly contracts so firmly around the pedicle as to prevent 
the return flow of blood from the tumor, giving rise first to oedema, then 
to extravasations of blood, and finally to necrosis of the prolapsed portion. 
Subserous tumors undergo putrefaction much more rarely, and in these 
cases, the process when not dependent upon an immediately preceding 
childbirth, is usually associated with partial calcareous degeneration. 
Of course, in this class of tumors hemorrhages may be occasioned by falls, 
blows and axial torsion 1 of the pedicle, and then decomposition of the 
extravasted fluid leads to putrefaction in the entire mass. 
I could quote numerous examples of all of the above-mentioned contin- 
gencies from my own experience and from the literature of the subject. 
I have personally investigated the cases reported by Pinault,2 Barth,3 
Willaume4 and Seyfert-Saxinger.5 Neugebauer6 reports the following 
remarkable case. The putrefying contents of a calcified, subserous fibro- 
ma broke externally through the anterior abdominal wall, the calcified 
shell remaining behind for a long period of time, presenting as a large 
1 J. Cappie : Obstetrical Journal, II., p. 303. 
2 Bullet, de la Soci^te Anatomique, 1828, p. 5. 
3 Ibid., 1850, p. 365. 
4 Archives Generates, XXIV., p. 449. 
6 Prager Vierteljahrsschrift, 1868, I., p. 89. 
6 Monatsschrift fur Geburtskunde, 28, p. 401. 194 
NEW GROWTHS OF THE UTERUS. 
cavity with rough, rigid and encrusted walls. Dumesnil ' describes an 
analogous instance of the spontaneous putrefaction of a subserous 
myoma. The case of Ziemssen9 and Braxton Hicks3 are remarkable as 
regards the size of the putrescent tumors. In the first case the summit 
of the swelling rose one inch above the umbilicus, while in that reported 
by Hicks the tumor dilated the uterus to the size attained in the seventh 
month of pregnancy. 
Instances of gangrene attacking pediculated tumors after partial or 
complete extrusion through the os uteri have been reported by Braun, 
Chiari and Spaeth (p. 402), McClintock,4 Freund,5 Mannel,6 and many 
others. Baker-Brown,7 Retzius,8 and Jager9 have intentionally lacerated 
the surface of such a tumor and induced decomposition as a curative 
measure. In another chapter we shall return to the consideration of 
these cases, as well as of those accidents of the same nature which occur 
during the puerperal state. 
The microscopical examination of such necrosed tumors does not dis- 
close any peculiar features. We find all of the cellular elements in a 
state of fatty or finely-granular cloudy degeneration. The connective 
tissue fibrils have become liquified into cloudy granular masses, contain- 
ing fatty corpuscles. The coloring matter of the contained blood is con- 
verted into crystalline and granular particles. Fat crystals are also pres- 
ent (Virchow), as well as sphcnxles of leucin (Waldeyer). 
While uterine myomata, when affected by sloughing, almost always at 
the same time undergo fatty degeneration, that process occurring alone 
and independent of other changes is certainly an exceedingly rare event. 
One is accustomed to speak of the fatty metamorphosis of these tumors as 
a very likely occurrence, particularly after childbirth, being led to this as- 
sumption by the recollection of the process of involution which the muscu- 
lar tissues of the uterus usually undergo after confinement. As a matter 
of fact, this occurrence has never, been demonstrated. Virchow, Spiegel- 
berg and others very properly call attention to the fact that the process 
of fatty metamorphosis attacks essentially only the muscular elements of 
the tumor, so that, at all events, the connective tissue stroma remains be- 
hind. Now since some tumors, the pure myomata, consist solely of mus- 
cular tissue, it is conceivable that these may undergo fatty metamorphosis 
1 Gazette des Hop., 1868, p. 6. 
9 Virchow's Archiv., XVII., p. 340. 
3 Obstetrical Transact., VII., p. 110. 
4 Dublin Quarterly Journal, Feb. 1868, p. 24. 
6 Beitrage, III. 
6 Prager Vierteljahrs„ 1874, H., p. 29. 
1 Obstet. Transactions, I., p. 330. 
8 Neue Zeitschrift f. Geburtskunde, 31, p. 425. 
9 Gazette M6d. de Strasbourg, VII., p. 185. GROWTH AND MORBID CHANGES. 
195 
throughout their whole extent, and there are cases in which the complete 
disappearance of such tumors can be explained on this assumption alone. 
But it would clearly be reasoning in a circle to attempt to demonstrate 
the frequency of such fatty degenerative changes, or even indeed their 
mere occurrence, simply from the fact of the disappearance, often more 
apparent than real, of uterine myomata. The literature of the subject 
abounds in instances of the so-called fatty metamorphosis of fibromyo- 
mata, but the only cases that are based on microscopical examination are 
those of Freund,1 who clearly demonstrated the presence of fatty degener- 
ation, although the tumors themselves had not undergone any diminution 
in volume, and A. Martin,-2 who records the case of a lying-in woman who 
had a broken-down fibroid filled with fatty detritus. Whether the obser- 
vations of Hecker (Klinik. II. p. 130) concerning the occurrence of pulpy 
softening in the interior of fibromata during the puerperal state have any 
bearing on this point, will be investigated later. 
There is another kind of regressive metamorphosis to which fibromata 
seem to be quite often subject. At any rate it cannot infrequently be de- 
monstrated anatomically, namely induration or atrophy. The most preg- 
nant examples of this change are met with in uterine tumors of a firm 
consistence, and rich in connective tissue, especially after the menopause. 
The muscular elements seem to be destroyed by fatty disintegration, while 
the connective tissue masses shrink and become atrophic and thus lead 
to a sort of cirrhosis of the growth. While such a condition is often ob- 
served in the bodies of people of advanced age, it may also be met with 
in rather young individuals. We may also include in this category all 
those cases in which a conspicuous and permanent decrease in the size of 
the uterine tumor has been observed during the life of the patient. 
Prieger,3 Simpson,4 and Kidd 5 have each reported a case of this kind. In 
Kidd's case, a tumor, which at one time reached midway between the 
symphysis and the umbilicus shrank, until only a small remnant could 
be detected. Meadows6 and many others have recorded similar cases. 
It must be acknowledged, however, that many of these observations are of 
questionable value. Pelvic exudations have been confounded with tumors, 
and the transient enlargement of a tumor during the catemenial epoch, 
with a subsequent decrease in size, has been mistaken for induration. 
The latter error has certainly been committed by Bartels,7 whose observa- 
tion was disputed by C. Mayer as soon as it was promulgated. 
1 KI. Beitrage fur Gynakologie, III., p. 152. 
2 Beitrage zur Geburtshulfe, etc., Berlin, 1874, III., p. 34. 
s Monatsschrift fur Geburtskunde, I., 1853. 
4 Obstetr. Memoirs, I., 115. 
5 Dublin Quarterly Journal, August, 1872. 
6 Obstetr. Journal, Dec. 1875. 
1 Verhandlungen der Berliner Geburtshiilflichen Gesellschaft, 1852, p. 1. 196 
NEW GROWTHS OF THE UTERUS. 
The last step in regressive metamorphosis, and one which follows closely 
on the heels of induration, is calcification. This process opposes a per- 
manent barrier to the further development of these tumors, which thereby 
become stationary, and are, as it were, destroyed. It consists in the im- 
pregnation of the connective tissue with lime salts, and is, in truth, an 
amorphous petrifaction. The salts most frequently observed are phos- 
phates, carbonates and sulphates. 
As it not infrequently happens that these calcified fibroids are expelled 
from the uterus, they were formerly regarded as genuine uterine calculi, 
and were supposed to have originated in the same way as vesical calculi. 
It is true that wo now and then meet with concretions in the vagina hav- 
ing some kind of foreign body as a nucleus (a fragment of bone, more 
often a pessary, etc.), and thus producing some analogy with the mode of 
development of vescal calculi, but stones coming from the uterus are pro- 
bably in all instances only calcified fibromata. 
It is certainly astonishing that as recently as August 9, 1874, Avieta 
Candura (El Siglo) could have discussed the various conditions favorable 
to the formation of true calculi within the uterus, asserting that the em- 
ployment of hard water for drinking purposes was particularly noxious 
in this respect. But it is still more astonishing to find such an article 
deemed worthy of serious consideration in the columns of the Annales 
Gynecologiques, III., page 160. 
Calcification usually affects the connective tissue of the tumor, and we, 
therefore, often find concentric strata of lime stilts, generally of the phos- 
phatic variety, usually traversing the tumor irregularly, but still following 
in the main the course of the bundles of fibres. It is much more rarely 
the case that only the outermost layers of the tumor, or the connective- 
tissue capsule alone is affected. We can readily conceive, then, how when 
the connective-tissue components of a tumor become calcified, the inter- 
spersed muscular elements are so prone to undergo degeneration, as is 
often observed. As both calcification and induration most frequently 
occur during the climacteric years, these processes are probably influenced 
to a great extent by the condition of the vessels of the uterine walls. 
The more the nutrient vessels of the tumor atrophy, the greater the ex- 
tent to which they are affected by atheromatous degeneration, the more 
readily will calcification develope. The size of the tumor seems to exercise 
no essential influence in this respect, for both small pediculated, as 
well as large interstitial growths, have been found in a state of calcific- 
ation. Turner (1. c.) maintains that the constitution of the pedicle and 
the condition of its vessels are factors of prime importance in this respect, 
but adduces no evidence in' support of his view. That even very large 
fibromata may become calcified is shown by Prumet1 who speaks of a 
tumor of this kind weighing ten kilogrammes. 
1 These sur les tumeurs de i'ut^rus, Paris, 1851. GROWTH AND MORBID CHANGES. 
197 
In the older literature of the subject calcification has sometimes been 
held to be ossification, but there can be no question that the formation 
of bone is not met with in this connection. Nevertheless Freund 1 gives 
the following description of a tumor: " After having been sawn through, 
the larger tumor was seen to be of a deep yellow color, the cut surface 
being smooth, and developing a high degree of polish after being rubbed 
upon a whetstone. After being moistened with hydrochloric acid, osseous 
tissue with well-marked bone corpuscles was distinctly seen under the 
microscope in the peripheral portions of the tumor. Towards the centre 
there was an ordinary incrustation with lime salts, after the removal of 
which, by prolonged immersion in hydrochloric acid, the texture of the 
fatty degenerated fibroid tissue came prominently into view." 
With reference to the much discussed question, may fibromyomata of 
the uterus undergo cancerous metamorphosis, it cannot be positively de- 
nied that such an occurrence is possible, in so far as cancerous infiltration 
may spread from the overlying mucous membrane to the subjacent mus- 
cular elements. But decisive observations, at least as far as regards the 
development of primary carcinoma, have not as yet been reported. A 
combination of fibroma with carcinoma of the uterus is by no means rare, 
but up to the present time no instances have been reported of the isolated 
cancerous degeneration of a fibroid. The older reports of this nature are 
unreliable, in the first place because fibromata themselves were formerly 
classed among the malignant tumors, and secondly because sarcomata 
have been confounded with carcinomata. 
Klob2 reports a case of this description, but so imperfectly that, to say 
the least, it can scarcely be regarded as conclusive. Forster's diagnosis 
in the case of Glaser3 is just as uncertain. At any rate, so great an author- 
ity as Virchow4 believes that in this instance a mistake may have been 
committed as between sarcoma and something else. Virchow himself (1. 
c. 172) reports some examples of myomata affected by cancerous disease. 
But Simpson,5 the very man who is always quoted as the authority for 
this occurrence, emphatically states that he has never observed the car- 
cinomatous degeneration of a fibroma. On the other hand, he has on sev- 
eral occasions met the two affections side by side in the uterus, and in 
these cases he is inclined to attribute the development of the carcinoma 
to the continual local irritation excited by the presence of the other 
tumor. Kiwisch's cases are equally indefinite in this respect. Benporath 
and Liebmann6 describe a fibroma affected with cancerous infiltration, oc- 
1 Beitrage zur Gynakologie, III., p. 152. 
2 Patholog. Anatomie der Weibl. Geschlechtsorgane, p. 163. 
3 Virchow's Archiv. XXV., p. 422. 
4 Geschwiilste, III., p. 172, and II., p. 350. 
6 Obstetr. Memoirs, 1st ed. I., 114. 
6 Monatsschrift fur Geburtskunde, 25, p. 50. 198 
NEW GROWTHS OF THE UTERUS. 
curring in a case of primary cancer of the vagina, the cancerous infiltration 
also involving that portion of the uterine wall immediately surrounding 
the fibroid. Hegar1 states briefly that he has enucleated a submucous 
myoma, 11 on that side of which, lying next the mucous membrane, a car- 
cinoma had developed, after perforation of the capsule." In view of the 
uncertainty surrounding this subject, and the admitted rarity of cancerous 
Fig. 16.-Fibroid of the Uterus, with Epithelioma of the Cervix and Vagina. From the 
Obstetrical Collection at Strasburg. 
degeneration of fibroids, the statements of Rodering (1 c.) appear very 
remarkable. This author mentions 24 instances of such degeneration 
occurring in 570 cases of fibroid. But it does not appear from his de- 
scriptions whether these cases were supposed to be examples of transform- 
ation of fibroid tumors into cancer, or whether there was a mere associ- 
tion of distinct morbid processes. There is probably no unimpeachable 
case on record of cancerous degeneration affecting a fibroid. But it 
should be mentioned here that adenoma may lead to such a transformation, 
and further that the mucous membrane in cases of fibromyoma may as- 
sume the character of a diffuse adenoma. 
As previously stated, the association of epithelioma of the cervix with 
1 Operative Gynakologie, p. 246. GROWTH AND MORBID CHANGES. 
199 
fibromyoma of the uterus is not uncommon. In these cases the combined 
affection runs a course parallel to that of cancer pure and simple, the ad- 
ditional presence of a myoma being of very little account. In another 
Fig. 17.-Fibroid of the Uterus, with Cancer of the Vaginal portion of the Cervix. Steno- 
sis of the internal os and dilatation of the Cavity of the Uterus, a, Cavity of the Uterus, b, Sub- 
serous Myoma. (Specimen of Dr. Wyder.) 
chapter, when we reach the subject of sarcoma, we will investigate the 
question, whether fibromata may become transformed into sarcomata, or, 
rather, to speak more exactly, whether the former may undergo sarco- 
matous degeneration. CHAPTER III. 
THE ETIOLOGY OF FIBROIDS OF THE UTERUS. 
"W1™ regard to the causation of uterine fibroids we know as little 
' ' as we do about that of most pathological neoplasms, namely 
nothing. This dictum must be adhered to in spite of the ingenious rea- 
sonings of Virchow (Geschwiilste III. p. 150), and in spite of the careful 
and interesting studies on this topic by Winckel,1 which support the views 
of the former author. Virchow called attention to the " irritative char- 
acter " manifested in the growth of myomata, and suggested that in these 
cases either an unusually aggravated degree of local irritation, or a condi- 
tion of local anaemia was the efficient agent. As acceptable as these 
phrases may be in a general way, as little are they supported by direct 
observation. And when in this very instance Virchow and Winckel refer 
to the periodical congestions of the uterus, to the processes occurring in 
tne puerperal state, to a previously existing chlorosis and so forth, they 
do not in the least help to explain how these every-day occurrences can 
give rise to the development of myomata in individual cases. More- 
over, if importance be attached to the condition of the functions of the 
uterus, on the one hand to their exercise (miscarriages, births), on Jthe 
other to their abeyance (sterility,) we find that the examination of statis- 
tics throws no light upon this topic. But, although such statistics are, 
as we shall see, quite unreliable, considering the imperfections inherent 
to this method, yet we should not, in our devotion to a pet theory, exclude 
them as altogether worthless. As far as concerns diseased conditions in 
the vicinity of the uterus or within that viscus, these are just as likely to 
be effects as active causes in the formation of tumors. The portio vaginalis 
affords a good illustration of the etiological insignificance of local irrita- 
tion. Although this region is most exposed to injurious influences, it is 
very rarely the seat of myomata. These tumors, moreover, are scarcely 
ever observed in prolapsed uteri. 
Patients' statements are not of the slightest value in determining 
questions of etiology. Of what avail is it to us to be told that three out 
of one hundred and fifteen patients affected with uterine fibroids noticed 
the first symptomsof the disease immediately after marriage. (Winckel.) 
1 Ueber Myome des Uterus, etc. Volkmann's Klin. Vortrage, No.'98. THE ETIOLOGY OF FIBROIDS. 
201 
Moreover, although Winckel quotes statements according to which vio- 
lent vomiting, a fall downstairs, intense mental excitement, etc., are 
positively put forth as the starting-points of the disease, he himself points 
out the fallacies contained in such statements. Granted even the correct- 
ness of these observations, as far as concerns the patients themselves, this 
does not bring us any nearer the solution of the question. At any rate, 
as far as I am concerned, I must confess that to me the formation and 
development of fibroids is just as incomprehensible now as formerly. I 
can understand how colds, improper behavior at the menstrual epoch, etc., 
may give rise to metritis, catarrh, and other affections, but I cannot con- 
ceive in what manner even "long continued and very fatiguing singing 
at the time of the monthly flow " may " under favorable conditions" lead 
to the formation of a myoma. Engelmann,1 indeed, found that catching 
cold during menstruation was the etiological factor in one (sic) out of 
three hundred and sixty-two cases of uterine fibroma I ! 
It has already been stated that Cohnheim2 attributes all neoplasms to 
the development of embryonal deposits, to germinal matter which has 
not been used in physiological, normal growth. Thus Cohnheim states 
that the phenomena of pregnancy afford proof of the truth of his hy- 
pothesis as far as regards the uterus, that is, as showing that this organ 
contains germinal matter which, under physiological stimulation, is capable 
of manifesting periodical growth. It is surely conceivable that this ger- 
minal matter may occasionally undergo irregular, atypical development 
without physiological stimulation, and this is particularly liable to occur 
when physiological stimulation is exercised seldom or not at all. This 
coincides closely with the fact that uterine myomata always develop after 
puberty, and are especially liable to be met with in old maids. We will 
shortly have to investigate how far the latter assertion is actually correct 
or the opposite. However this may be, it suffices to have directed atten- 
tion to the importance of the above hypothesis of Cohnheim, which is sat- 
isfactory in so far at least as it serves to again direct the researches con- 
cerning the causes of tumor formation into anatomical channels. Whether 
these researches result in the demolition or in the further support of the 
hypothesis, they will at any rate furnish us with wider views as to the 
etiology of tumors than the hitherto current, wholly unsatisfactory ones. 
In view of the imperfections attaching to medical statistics in general, 
all statements concerning the frequency of myomata possess very little 
value, if any. The inconsistencies in the individual reports are of so 
gross a nature that they only serve to lessen in a greater degree their 
mutual value. The experience of any single observer, no matter how ex- 
tensive it may be, is probably of scarcely any consequence. According to 
1 Zeitschrift fur Geburtshulfe, I., p. 130. 
2 Vorlesungen uber allgemeine Pathologie, Berlin, 1877 202 
NEW GROWTHS OF THE UTERUS. 
the statements of Bayle, which are perhaps the best known, and are of 
late so frequently quoted, among one hundred women above thirty-five 
years of age at least twenty possess such tumors. Again Monat found 
among the patients of the Salpetriere, one-fifth affected with uterine 
fibroids. In contradistinction to these, Richard found only seven exam- 
ples of fibroma in eight hundred autopsies, and Pollock found only 
thirty-nine tumors of this character among eight hundred cases of uterine 
disease (compare West, l.c.) 
Klob, on the other hand, claims that forty per cent, of all females above 
fifty years of age are affected with these growths. 
Little reliance can be placed upon statements as to the frequency of 
the individual varieties or the site of these tumors. Among a total of 
ninety-eight cases, Hewitt encountered only fourteen of sub-mucous (pedi- 
culated) fibroids. Of ninety-two cases reported by various observers in 
Mecklenburg (Winckel, 1. c.), thirty-nine were pediculated. Of two 
hundred and thirty cases collected by Marion Sims1 and Winckel, (1. c.), 
twenty-six were of the sub-mucous, seventy-four of the sub-serous, and 
one hundred and thirty of the intra-parietal variety. Of these one hun- 
dred and four were located on the anterior, and seventy-seven on the 
posterior wall of the uterus. 
Schorler (1. c.) observed 27 cervical tumors and 307 affecting the body 
of the uterus out of a total of 334 cases of fibromyoma. Of the 307 
tumors of the uterine body, 106 were interstitial, 128 sub-serous, 24 
sub-mucous, and 49 were classed as polypoid. The interstitial growths 
were found three and a half times more frequently in the anterior than 
in the posterior wall, whereas the sub-serous neoplasms occurred three 
times more frequently in the opposite situation. 
Jacubasch (Charite-Annalen, 1881) saw sixty cases, and of this number 
the body and fundus were the seat of the tumor fifty-eight times, the 
cervix was only twice occupied by the growth. Twenty-two cases be- 
longed to the sub-mucous variety of fibroid. 
As regards the age of the patients, it maybe stated that no indubitable 
case exists m which the disease has either been detected or has grown 
considerably before puberty, or after the occurrence of the climacteric 
period. It is rather difficult to determine whether, within these limits, 
certain ages are especially disposed to diseased action in this direction. 
It is useless to collect medical observations for the settlement of this 
question unless pathological research shall at the same time furnish us 
with approximate figures as to the frequency with which such neoplasms 
are met with in all autopsies held on females. More than this, the 
ratio of the ages of all the females in each of the districts from which the 
statistics emanate, would previously have to be determined. 
1 Uterine Surgery, 1866, p. 95. THE ETIOLOGY OF FIBROIDS. 
203 
I have collated from the compilations of West, Beigel, Hewitt, Dupuy- 
tren, Moore Madden,1 Engelmann,3 Rbhrig' and from my own notes, the 
following nine hundred and fifty-three cases, which are calculated to be of 
some service in this connection, and may be classified according to age as 
follows: 
10 years old, ........ 1 
14 " " 1 
16 " " 1 
17 1 
18 " " 3 
19 " " * 8 
20 to 30 years old, ....... 156 
30 " 40 " " 357 
40 " 50 " " 338 
50 " 60 " " 36 
60 " 70 " " 12 
over 70 " " . . . . . . . 5 
Of five hundred and twenty-eight cases collected by Winckel (which 
are not comprised in the foregoing table, because West's, Hewitt's and 
Beigel's cases have been included in both tables) there were: 
Under 20 years old, ...... 9 
20 to 30 " " 98 
30 " 40 " " 180 
40 " 50 " " 180 
50 " 60 " " 52 
60 " 70 " " . 6 
70 " " 2 
These statistics demonstrate that most of the patients affected with 
fibroids were between twenty and fifty years of age at the time when they 
first sought medical relief. Nothing is to be gained by classifying the 
above cases according to the age at which the first symptoms were noted. 
The latest table prepared by Schroder4 presents results which differ 
somewhat from previous averages. 798 cases are tabulated as follows: 
19 years, . . 2 cases equivalent to 0.25 per cent. 
20 to 30 years, . 58 " " " 7.26 il " 
30 " 40 " . 229 " " " 28.69 " " 
40 " 50 " . 407 " " " 51.00 " " 
50 " 60 " . 94 " " " 11.77 " " 
60 " 66 " 8 " " " 1.00 " " 
1 Obstetr. Journ., I., p. 468. 2 Zeitschrift fur Geburtshiilfe, I, p. 130. 
3 Berliner KI. Wochenschrift., 1877, No. 30. 
4 Krankheiten der Weibl. Geschlechtsorgane, Leipzig, 1884, p. 216. 204 
NEW GROWTHS OF THE UTERUS. 
A more interesting question is what influence do the sexual functions 
exert upon the development of fibromata. The opinion has been and still 
is widely entertained in Germany, that unmarried individuals of ad- 
vanced years are particularly disposed in this respect, but the experience 
of physicians shows that the contrary is undoubtedly true, and leads rather 
to the assumption that the exercise of the sexual functions favors the de- 
velopment of such tumors. 
The perusal of the reports of Schroder (1. c.), Ilewitt, Marion Sims, 
Moore Madden, Engelmann, and of my own notes, discloses the fact that 
of nine hundred and fifty-nine patients affected with fibroids, six hun- 
dred and seventy-two were married, and two hundred and eighty-seven 
unmarried. It is not to be supposed, of course, that all the individuals 
included in the latter category were virgins. Of those that were married, 
four hundred and sixty-four had borne children, the remainder were 
sterile. It will be shown later, that, according to the experience of phy- 
sicians at least, this sterility is a result rather than the cause of the tumor 
formations. 
Routh's statistics' form quite a valuable contribution for determining this 
question. His cases, however, as well as those of Winckel, which will be 
given shortly, may not be simply added to the foregoing 959 cases, or we 
should commit numerous errors in counting the same case two or three 
times over. 
Routh found that, of three hundred and one patients affected with 
myomata, two hundred and forty-one, or eighty per cent., were married. 
This fact, according to the author, must carry the more weight, when it 
is remembered that in England the number of unmarried females is twice 
as large as the number of married. (This observation possesses, however, 
but little value, since children are included in the above cases.) 
Some additional statistics of Routh's are more interesting in this con- 
nection. He states that the average age of married women in England is 
40. G years. Now between the ages of thirty-five and forty years, he found 
that fibromata were present in twenty-two married, but only in five un- 
married females-or, in other words, that at this time of life such tumors 
occurred 4.4 times as often in the married as in the unmarried. The 
importance of this ratio is, however, lessened by the fact that at this age 
the percentage of the married to the unmarried is as 3.7 to 1. 
Winckel's deductions are based upon a total of five hundred and fifty-five 
patients. Of these, one hundred and forty, or 24.2 per cent were single and 
childless, four hundred and fifteen, or 75.8 per cent, were married, and of 
the latter number one hundred and thirty-four, or 24.3 per cent.,were ster- 
ile. According to Winckel, there are in Saxony two thousand seven hun- 
dred and ninety-seven married females of middle age, to two thousand two 
' Vide Schmidt's Jahrbiicher, 1866, Vol. 129, p. 236. THE ETIOLOGY OF FIBROIDS 
205 
hundred and three single women, that is as 9 to 7.3, while the prevalence 
of myomata among the unmarried is to that among the married as 3 to 
9-in other words, tumors of this nature occur almost twice as often among 
the married as they do among the unmarried. 
It cannot be shown that childbirth exerts any influence upon the de- 
velopment of myomata. We shall, however, discuss this topic more fully 
in another chapter. 
All the other agents that have been here and there advanced as etiologi- 
cal factors in the development of fibromata, are the outcome of purely 
subjective reasoning on the part of their propounders, and may with 
propriety be passed over in silence. One point is, however, deserving of 
mention, namely that, according to the statements of Gaillard Thomas 
and St. Vel and Demarquay, these tumors are probably more prevalent 
among certain other races (particularly the negro) than among the Euro- 
pean. 
Hereditary disposition has, up to the present time, not been shown to 
play any role; still I have recently twice found fibroids in two sisters. 
This may be only a coincidence, yet it is an occurrence to which it may 
be worth while to direct attention. CHAPTER IV. 
THE COURSE, SYMPTOMS AND COMPLICATIONS OF 
UTERINE FIBROIDS. 
rpHERE are but few pathological processes, which in themselves ana- 
tomically so simple as uterine fibromata, are yet calculated to give rise 
to such manifold symptoms. The morbid manifestations naturally vary 
according to the size and location of the fibroids. In the first place it is a 
noteworthy fact that a not inconsiderable number of these tumors develop 
no symptoms at all during the life of their bearers. This is shown by their 
being frequently detected by pure accident in the living, but still more 
often in the dead subject. As a rule, the tumors give less trouble the 
smaller they are and the less active the sexual functions are. Thus, we 
find that, in individuals who have reached the climacteric period, they 
often, indeed usually, exist for years without creating any disturbance. 
This is also often the case in individuals who rarely or never have sexual 
intercourse, while, per contra, symptoms often manifest themselves with 
great intensity and astonishing rapidity, as soon as a patient affected 
with one of these tumors enters into wedded life or passes through a con- 
finement. 
The symptoms of uterine fibromata develop chiefly after puberty and 
probably depend, in the main, upon the location of the growth. Neverthe- 
less the individual phenomena are neither so characteristic nor so constant 
as to enable us to determine from them alone the location of the tumors, 
namely whether they are sub-serous, sub-mucous, or chiefly interstitial. 
This is the more readily understood when we remember that even the 
anatomical limits between these three varieties cannot always be accurately 
defined. In the following paragraphs each symptom will be discussed 
. singly, but their bearing upon the question of the location of the tumors 
will be considered under the heading of diagnosis. 
Among the various symptoms of fibroids of the uterus, there are two 
which for constancy of occurrence and importance are pre-eminent; these 
are hemorrhage and pain. 
Hemorrhage is usually the first, at any rate certainly the most frequent 
symptom, and in the majority of cases it occurs chiefly under the guise COURSE, SYMPTOMS AND COMPLICATIONS. 
207 
of a profuse menstrual flow, i.e., menorrhagia. The amount of the flow is 
often very considerable within a few moments, so much so that patients 
justly speak of a gush of blood when they have their courses. In other in- 
stances the great amount of blood lost during a period is due to the latter 
being prolonged over many days, so many, in fact, that there is often an 
interval of only a few days between successive menstrual epochs. While 
the menstrual type of hemorrhage is in this manner finally obliterated, 
irregular hemorrhages (metrorrhagias) also not infrequently occur, espe- 
cially after insignificant exciting causes, such as lifting a weight, and so 
forth. 
Hemorrhages are usually entirely absent in cases of well-marked sub- 
serous uterine myomata, especially when these are provided with a pedi- 
cle. Still, sub-serous tumors, even when pediculated, may be associated 
with such pathological conditions of the uterine mucous membrane as 
will give rise to hemorrhages; this will happen when the tumors are so 
situated as to interfere with the circulation within the uterus. Hemor- 
rhages are, however, observed more constantly and are of greater severity in 
all examples of sub-mucous, and in most instances of interstitial myomata. 
Sub-mucous pediculated tumors usually occasion the most profuse hemor- 
rhages while they remain enclosed in the cavity of the uterus. The bleed- 
ing very often ceases as soon as they protrude beyond the os uteri, but it is 
not seldom aggravated by this occurrence, as in case the contraction of the 
os is sufficiently powerful to induce venous stasis in the tumor and its 
enveloping mucous membrane. 
It is only in very exceptional instances that the hemorrhage proceeds 
from the tumor itself, as most of the ordinary forms of uterine myomata 
are but poorly supplied with blood-vessels, and are, moreover, always cov- 
ered by the uterine mucous membrane. Blood can escape from the 
tumor itself only when the latter is provided with vessels of large calibre, 
or with distended sinuses which have been laid open by ulceration or some 
other injury. Klob observed hemorrhage from the tortuous vessels en- 
veloping a uterine myoma, after fracture of the pelvis. Matthews Dun- 
can 1 observed fatal hemorrhage from the rupture of a venous sinus in a 
case of interstitial myoma. 
Cruveilhier describes a similar case, the bleeding proceeding from an 
opening in a uterine sinus in the lower part of the tumor. (Matthews 
Duncan, 1. c.) It is often stated that the investing uterine mucous mem- 
brane is the source of the hemorrhages ordinarily encountered in patients 
affected with these tumors, but this can only be true of a small number 
of cases. The investing mucous membrane of sub-mucous, pediculated 
tumors will bleed, only in case it is in a state of venous stasis, as the result 
1 Edinb. Med. Journ., Jan. and Feb. 1867. 208 
NEW GROWTHS OF THE UTERUS. 
of compression, or when it is ulcerated. In either of these events uterine 
contractions give rise to profuse or even fatal hemorrhage from the torn 
and dilated veins. 
But this accident scarcely ever happens when the tumors are sub- 
mucous and attached by a broad base, or when they are interstitial. 
In these cases the mucous membrane enclosing the tumor is more or less 
thinned, atrophied and stretched, according to the size of the growth, and 
Fig. 18.-Myoma of the Uterus. Death following rupture of a venous sinus (a). (After Mat- 
theivs Duncan.) Edinb. Med. Journ. 1867. 
is only here and there permeated by thin-walled, eetatic veins of larger 
calibre. There is neither sufficient evidence, nor are there known anal- 
ogous conditions to warrant the acceptance of the assertions of Atlee 1 and 
others, who claim that such veins may tear at any menstrual epoch, and 
1 Compare M'Clintock, Diseases of Women, p. 152. COURSE, SYMPTOMS AND COMPLICATIONS. 
209 
may thus occasion hemorrhage. At the same time I will not assert that 
such an occurrence is impossible. In fact I shall take occasion to describe 
later on a case, which belongs, perhaps, in this category. 
The stretching and atrophy of the investing mucous membrane always 
induce marked collateral venous stasis in the remainder of the mucous 
membrane, which condition in itself leads to swelling and increased suc- 
culence, and thereby to profuse hemorrhage at the menstrual period, just as 
always occurs under similar conditions, such as chronic metritis. To what 
an extent collateral congestion may develop, in cases of large-sized uterine 
fibromata, is well described by Cruveilhier: : " Les veines utero-ovariennes 
Fig. 19.-Rupture of a Uterine Sinus in the Lower Segment of a Fibroid, vith Fatal 
Hemorrhage. (After Matthews Duncan.) 
et les veines utcrines qui viennent de 1'hypogastrique ont un volume 
enorme, dans un eas de ce genre, ou les veines superficielles avaient 
sillonne la surface de 1'uterus, plusieurs avaient le volume d'une tres- 
grosse plume a ecrire et meme d'avantage. Les arteres n'avaient aug- 
mente de volume que dans une bien moindre proportion." 
The changes in the uterine mucous membrane are not always produced 
in a purely mechanical way by congestive hyperaamia. Tumefaction of 
the mucous membrane of a more inflammatory nature may also occur, 
arising from irritant action of the tumor. Thus hemorrhages sometimes, 
although rarely, occur in cases of pure sub-serous fibromata associated 
1 Traite d'Anatomie pathologique, III., p. 677, quoted from M. Duncan, 1. c. 210 
NEW GROWTHS OF THE UTERUS. 
with a diseased condition of various parts of the uterine tissue, which 
may best be designated as chronic metritis, and is more often associated 
with the presence of interstitial growths. How greatly developed and 
extensive the collateral congestion may be, is well shown by an observa- 
tion of llokitansky, who reports a case of fatal hemorrhage from rupture 
Fig. 20.-Atrophy of Mucous Membrane (a) in a Fibroid. Magnified 30. (Specimen of ]>r 
Wyder.) 
of a greatly dilated varicose vein of the mucous membrane of the bladder, 
in a patient affected with a uterine fibroid. The menstrual flow has 
always been unusually profuse in the few cases of uterine tumors, which 
have been both observed by me during the lifetime of the individuals, and 
recognized as pure myomata on post-mortem examination. In these cases 
Fig. 21.-Hypertrophy of Mucous Membrane in Fibroma Uteri, with dilatation of the glands 
(endometritis glandularis). Slightly magnified. (Specimen of Dr. Wyder.) 
the myomata had usually grown rapidly, especially in consequence of preg- 
nancy, conformably to which the uterine mucous membrane was exceed- 
ingly hypertrophic and was permeated by large venous sinuses. 
In 1878 Wyder 1 showed that the presence of fibroids of the interstitial 
and sub-serous varieties, leads to certain definite changes in the mucous 
1 Beitrage zur normalen and pathol., Histol. d. menschl. Uterusschleimhaut. 
Archiv. f. Gynakol., vol. XIII., p. 35, 1878. COURSE, SYMPTOMS AND COMPLICATIONS. 
211 
membrane of the uterus. He describes this condition in the following 
way: 
" The mucous membrane appeared much thickened. The microscope 
always showed considerable proliferation of the uterine glands. In some 
Fig. 22.-Hypertrophy of Mucous Membrane (endometritis glandularis) in Uterine Fibroma. 
(Specimen of Dr. Wyder.) 
specimens they were closely crowded and appeared like cork-screws placed 
perpendicularly to the surface. In other cases the mucous membrane 
presented a more areolar appearance. Dilated, but not cystic gland 
tubules were found in these. The tubules were separated from each 212 
NEW GROWTHS OF THE UTERUS. 
other by broad trabecles of interglandular connective tissue." Wyder 
further emphasizes the fact that these changes resemble the condition 
known as adenoma diffusum. The observations of Wyder have since 
been confirmed by von Campe.1 
In spite of the fact that in most cases of fibromyomata there is a con- 
stantly present swelling of the mucous membrane, the secretion from the 
latter, outside of the menstrual epoch, is by no means always uniformly 
profuse. Just before and after the periods there is usually a rather free 
mucous discharge which in many instances soon ceases entirely, or at any 
rate diminishes to such an extent that patients do not pay any attention 
to it. In case a purulent discharge, the so-called fluor albus, makes its 
appearance later, we will almost always be able to detectan ulcerated con- 
dition of the os uteri, with changes in the mucous membrane of the 
cervix. On the whole, it may be safely stated that a muco-purulent secre- 
tion is by no means a prominent feature in the life-history of uterine 
fibroids. 
Pain, or at least abnormal sensations of some kind, are almost invaria- 
bly present. The important bearing which this symptom, under certain 
circumstances, exercises in the diagnosis of the variety and location of a 
uterine tumor, compels us to enter into a rather detailed analysis of its 
various features. In the first place pain in most cases manifests itself at 
first during menstruation, and is of a stretching or dragging character, 
depending upon the distension of the uterine walls, or upon a swollen 
condition of the tumor itself in consequence of menstrual congestion. 
This kind of pain is quite characteristic of the more interstitial tumors, 
and m cases of this description it frequently developes to an intense degree 
before the appearance of the menstrual flow; in fact it is often markedly 
relieved by the latter occurrence. 
Even in cases of pediculated sub-serous myomata we not infrequently 
find patients complaining, at the time of menstruation, of similar pains, 
resulting from tumefaction of the tumor, and this seems mainly dependent 
upon the manner in which the tumor is connected through its pedicle 
with the uterus. The more abundant the vascular supply of the tumor 
by way of the uterus, the more extensively will the former participate in 
the menstrual swelling. In such cases well-marked peritoneal irritation 
not infrequently affects the serous envelope of the tumor, and in this 
event there is acute pain on external pressure. 
Peritoneal pain is not often observed, outside of the monthly periods, 
in patients with sub-serous fibroids, but when it does occur it is in many 
instances dependent upon true perimetritic processes, characterized by 
fever and other signs of peritonitis. These inflammations are probably 
1 Verhandl. d. Gesel. f. Geburtsh. u. Gynakol. in Zeitschr. f. Geb. u. Gynak., 
vol. X., p. 356 1884. COURSE, SYMPTOMS AND COMPLICATIONS. 
213 
often excited by the mechanical irritation incident to movements of the 
tumor, but they may of course develop during menstrual congestion. They 
often lead in an astonishingly short space of time to adhesions of the 
tumor with the surrounding organs, so that a distinctly movable, pedicu- 
lated fibroma may quickly become fixed. As we shall soon see, these tumors 
may cause peritonitis in other ways. The painful sensations which are 
felt during menstruation in cases of sub-mucous fibroids are of an entirely 
different nature They bear a closer resemblance to labor pains the more 
the tumors project into the cavity of the uterus, and are frequently so in- 
tense that the neck of the uterus commences to dilate, thus permitting 
the tumor to become visible. As the uterine contractions induced by the 
menstrual hyperaemia abate, the tumor retracts and the os again closes. 
This so-called ' birth ' of a sub-mucous fibroma often requires many 
menstrual periods for its completion. It depends to a certain extent upon 
the size of the downward growing tumor, but the chief factors are proba- 
bly the thickness and breadth of the pedicle through which the growth 
is attached to the muscular tissue of the uterus. The greater the resistance 
of the former the more powerful are the uterine contractions, which come 
to a standstill only when the tumor actually protrudes beyond the os. 
It is self-evident that similar labor-simulating pains may also occur in cases 
of interstitial tumors, but this is observed much less frequently. I have 
often been struck with the great intensity of these pains (uterine colic), 
when the fibromata were soft, that is, when they consisted almost en- 
tirely of muscular tissue. It would seem in these cases as if the tumors 
themselves participated in the contractions and thus aggravated the pains 
to an unbearable degree. 
As soon as uterine fibroids have grown at all considerably, the above 
described paroxysmal pains connected with menstruation are associated 
with the most varied abnormal sensations in the lower part of the ab- 
domen. A sense of fullness, of weight in the true pelvis, and of down- 
ward pressure, persists after the uterine colic connected with menstrua- 
tion has subsided. Painful sensations of a more chronic inflammatory 
character may also be present in these cases in consequence of perimetritis. 
There is rarely enough pressure on the nerves traversing the pelvic cavity 
to give rise to distinct neuralgia, still Kidd1 describes a case of sciatica 
caused by a uterine fibroid and relieved by lifting the fibroid out of the 
pelvis by means of an air pessary. 
Jude Hue2 relates a similar case of long-standing sciatica, which was 
cured by the same method of treatment. 
This kind of pain is produced by the pressure of the tumor, and is but 
one of the manifold and inconstant pressure-symptoms developed by 
fibromata. While no symptoms of this nature are caused by pediculated 
1 Dublin Quarterly Journal, 1872. 2 Annales de Gynecologic, IV., p. 239. 214 
NEW GROWTHS OF THE UTERUS. 
sub-serous myomata, a retro-vaginal, tightly wedged-in tumor may imperil 
the life of the bearer by pressure on the neighboring organs. The more 
closely the tumor is connected with the uterus, and the more sub-perito- 
neal it at the same time is, the more readily will it occasion marked dis- 
placements of the uterus, retroversion, retroflexion, or even complete dis- 
location forwards, and these changes of position will modify the whole 
train of symptoms accordingly as the uterus itself is more or less enlarged 
by venous engorgement, etc. 
Very large sub-serous fibromata, which greatly distend the abdominal 
cavity, may also exert sufficient downward pressure to give rise to irredu- 
cible prolapsus of the uterus and vagina. A comparatively more frequent 
Fig. 23.-Complete Inversion of Uterus with Prolapse, caused by Small Pediculated Fibroid 
of the Fundus. (After McClintock.) 
occurrence is inversion of the uterus dependent on sub-mucous fibroma. 
If such a tumor be situated at the fundus, its very weight may drag the 
latter downwards, but inversion of the uterus cannot take place until 
the tumor has passed the neck of the uterus. After this has been 
accomplished, either, as is usually the case, in consequence of powerful 
uterine contractions, or very slowly by gradual dilatation of the os uteri, 
the facility with which the fundus is extruded through the os, or even 
beyond the external genitals (as I have once observed it), will vary accord- 
ing to the closeness and breadth of its connections with the tumor. It is 
evident that pediculated myomata, so-called fibrous polypi, will much 
more rarely, or scarcely ever, give rise to inversion, as their distinct pedicle 
permits them to prolapse beyond the os uteri without at the same time COURSE, SYMPTOMS AND COMPLICATIONS. 
215 
dragging the fundus after them.1 Cases of this kind have been described 
with sufficient exactness by Higgins, Oldham, Valenta, Velpeau, San- 
tesson,2 Langenbeck,3 Copeman,4 and Betschler.5 
Martin6 observed inversion of the uterus in a nullipara from a pedicu- 
lated, dense fibroma. McClintock7 met with one instance of inversion of 
the uterus with prolapse of the organ, after violent emesis, in a patient 
affected with a tumor scarcely as large as an egg (compare illustration of 
case, Fig. 23). The same author describes a similar case (Fig. 24) in which 
a very small tumor of this kind also occasioned inversion. (This is prob- 
ably the same case which is quoted in West's text-book, p. 282, from 
Crosse.) 
Pozzi8 collected twenty-one cases from the literature, where fibromata 
attached to the fundus of the womb led to inversion and later to ampu- 
tation of that organ. It is questionable whether sub-serous fibromata may 
under certain conditions, such as perimetritic fixation of the inferior seg- 
ment of the uterus, cause inversion. 
Still Louis Mayer9 describes a case which may perhaps be an instance 
in kind. Enough has been said to show that inversion of the uterus is 
very rarely occasioned by broadly attached fibromata. 
Among four hundred cases of inversion collected by Crosse (cited by 
West, 1. c. p. 282), there were only forty which had developed in this 
manner, and even this small number includes numerous doubtful cases 
from older literature. Now although we must assume that there exists 
in these cases a certain amount of relaxation of the uterine substance ad- 
joining the growth, or an atrophy of that part of the fundus correspond- 
ing to the seat of the growth, yet in the only case which I have encoun- 
tered 10 nothing of the kind could be found. Neither was there any fixa- 
tion of the lower segment of the uterus, which, if present, would have 
favored the extrusion of the base of the uterus by labor-like pains. I 
have, moreover, not been able to find, in the literature of the subject any 
statements bearing upon these points. 
Other and sometimes very peculiar displacements and distorsions of the 
uterus are particularly liable to be induced by all myomata, that in any 
way fill out the pelvis. They are usually large sub-serous tumors growing 
1 Compare Scanzoni, Beitrage, 5, p. 83. 
2 Compare Scanzoni, 1. c. and Virchow, Geschwiilste, III., p. 170. 
3 Monatsschrift fur Geburtskunde, XV., p. 174. 
4 London Obstetric. Transactions, 1872, p. 232. 
6 Beitrage zur Gynakologie, I., p. 3. 
6 Monatsschrift fur Geburtskunde, 34, p. 410. 
'Clinical Memoirs on Diseases of Women, Dublin, 1883, p. 97. 
8 De la valeur de 1'hysterotomie, etc., Paris, 1875, p. 150. 
9 Beitrage zur Geburtshalfe, II., p. 26. 
10 Vide my paper on Carcinoma Uteri, Volkmann's Clinical Lectures. 216 
NEW GROWTHS OF THE UTERUS. 
from a broad base and which, starting generally from the posterior wall, 
develop in a downward direction so as to become retro-uterine, or even actu- 
ally retro-vaginal, pushing the cul-de-sac of Douglas before them. In 
consequence of their location and size, these tumors are immovably fixed 
in the pelvis, although they need not always have become adherent to the 
walls of this cavity. They constitute the wedged-in, the incarcerated, fibro- 
mata previously alluded to. 
Fig 24.-Cross-Section through an Inverted Uterus with Fibroid of the Fundus. (After 
McClintock.) 
Similar conditions may obtain in cases of large sub-serous tumors, ori- 
ginating on the lateral borders of the uterus, and growing between the 
folds of the broad ligament, so-called intra-ligamentous fibromata. Sub- 
serous tumors growing from the superior parts of the uterus, and large 
sub-mucous growths completely filling up the uterus, can only become in- 
carcerated in the pelvis in case either the uterus or the tumors have pre- 
viously contracted adhesions as the result of perimetritic processes. In COURSE, SYMPTOMS AND COMPLICATIONS. 
217 
either of these events the most varied symptoms of pressure with refer- 
ence to the pelvic viscera may be developed. 
In the first place and most frequently this pressure manifests itself by 
pain or other abnormal sensations (tingling, etc.) in the lower extremi- 
ties, as has already been alluded to. I have neither myself observed any 
instance of true paralysis from this cause, nor have I been able to find 
any references thereto in literature. Indeed, very little mention is made 
of the remaining pressure symptoms, although the lighter degrees occur 
very frequently, and the severer forms, such as often enough lead to the 
death of the sufferer, are by no means rare. 
Let us first consider the symptoms of pressure upon the urinary 
apparatus, particularly the bladder and ureters. Both movable and 
stationary tumors do not, as a rule, exercise any severe pressure upon 
the bladder; they simply prevent full distension of this viscus, and thus 
occasion frequent micturition or only a desire to pass water frequently. On 
the other hand they sometimes cause retention of urine, and in this way 
favor the development of vesical catarrh. With reference to this point, 
Hardie 1 calls particular attention to those fibromata which are situated 
in the anterior wall of the uterus, and which, although so small as not 
to excite any symptoms of incarceration, yet exert pressure upon the neck 
of the bladder and urethra, especially if they become more or less swollen 
during menstruation. 
Kidd 3 describes the occurrence of similar conditions in cases of small 
tumors when these have given rise to retroversion of the uterus. Close 
adhesions between tumor and bladder may also so obstruct the evacua- 
tion of urine as to render even catheterization difficult. Fourestie des- 
cribes a case of this kind, where the bladder, although empty, was spread 
out like a fan in front of the uterus, and extended as high as the um- 
bilicus. 
These conditions derive, of course, much greater importance in case 
the pressure upon the bladder and ureters is continuous or, worse still, 
is increasing, as happens in cases of incarcerated fibromata, which have 
either become firmly attached to the walls of the pelvis and to the 
neighboring viscera by perimetritic adhesions, or which, as is certainly 
much oftener the case, are firmly retained within the pelvis, being "in- 
carcerated " in the true sense of the word. 
Instances in which uraemic symptoms terminating fatally have been 
due to pressure exercised by the tumor upon the bladder and ureters, 
have been enumerated by Jude Hile3 and Murphy.4 Hanot5 records a case 
1 Edin. Med. Jour., Jan. 1873. 
2 Dublin Med. Journal, 1875, Nov. p. 456. 
3 Annales de Gyn6cologie, Oct. 1875, IV., p. 239. 
4 London Journal of Medecine, Oct. 1849. 
5 Soc. Anat, de Paris, Feb. 28, 1873. 218 
NEW GROWTHS OF THE UTERUS. 
of double hydronephrosis and consequent fatal uraemia, induced by a tumor 
having a diameter of twelve centimetres, and adherent to the walls of the 
pelvis. Hubert1 observed albuminuria, and diagnosticated " Morbus 
Brightii " in consequence of compression of the ureters. 
Budin's2 case is of importance from a diagnostic point of view. The 
patient was affected with a small, interstitial myoma in the inferior portion 
of the anterior wall of the uterus, completely occluding the outlet of the 
bladder, with great distension of the viscus. The swelling was diagnosed as 
an ovarian cyst, and was punctured with a fatal result, the cause of death 
being " Phlebitis uteri." Caternault3 and others mention similar errors 
in diagnosis. Dolbeau's' patient died of uraemia from a purely incarcer- 
ated tumor without adhesions. Fourestie 5 and others report the formation 
of abscesses of the kidneys from pressure on the ureters (?). 
Slight uraemic symptoms, such as persistent vomiting associated with 
scanty urination, are not infrequently observed.' 
Incarcerated tumors very often, of course, exercise pressure on the rec- 
tum. Nelaton7 reports such cases, among others, one in which total occlu- 
sion of the rectum having been produced by a small uterine fibroid, he 
performed enterotomy, with a fatal result. A similar case, in which Broca8 
performed enterotomy, also terminated disastrously. In this case the oc- 
clusion of the intestine was produced by adhesions, not by the direct pres- 
sure of the tumor. Ducheussoy9 observed a case which terminated in 
death, with tlie symptoms of intestinal obstruction from pressure upon the 
rectum. Similar cases have been observed by Holdhouse,10 Dolbeau 11 and 
P. Eade,12 intestinal occlusion having been produced by cord-like adhesions 
between small tumors and intestine 
Ringland's'3 and Jude Hile's" cases pursued a more favorable course, 
albuminuria and the symptoms of intestinal occlusion passing off after 
elevation of the tumor out of the pelvis. Let me also call attention to 
the fact that such tumors, although firmly adherent within the pelvis, 
1 Bull, de la Soc. Anat., 1873, p. 870. 
2 Archives de Tocologie, II., p. 60. 
3 Essai sui' la gastrotomie, etc., Paris, 1866. 
4 Milfiot: Sui' les complication des tumeurs fibreuses del'ut^rus, These, Paris, 
1875. 
5 Gaz. M6d. de Paris, Nos. 6 and 7, 1875. 
6 Compare Winckel, Ueber Myome des Uterus. Volkmann's Clinical Lectures, 
No. 98. 
1 Guyon: Des Tumeurs fibreuses, etc., Paris, 1860, p. 49. 
8 Faucon: Gazette des Hopitaux, 1873, Nov. 29. 
9 Jude Hiie, 1. c., p. 241. 
10 Transact, of the Patholog. Society of London, III., 371. 
11 Gazette des Hop., 1873, Nov. 29. 
12 Lancet, Dec. 21, 1872. 
13 Dublin Quart. Journal, August, 1867, p. 248. 
14 L. c., p. 247. COURSE, SYMPTOMS AND COMPLICATIONS. 
219 
and giving rise to symptoms of pressure, may yet manifest a certain de- 
gree of mobility on vaginal exploration, in so far as the vagina moves along 
with them.1 Further information concerning incarcerated uterine fibro- 
mata may be gained by consulting the papers of Spiegelberg3 and P. Mul- 
ler.3 Mild symptoms of pressure upon the rectum, such as obstinate 
constipation and hemorrhoidal conditions, are very frequently caused by 
even small fibroids. 
Among the very rare sequels of pressure by these tumors, is their 
growth into contiguous organs, the so-called hernia of the tumor. The 
hitherto reported descriptions of this occurrence are the more unreliable, 
the less attention has been paid to the condition of the neoplasm. 
Nothing is more common than the rupture of a tumor into the neigh- 
boring viscera, after it has undergone suppuration or putrid liquefac- 
tion. These cases will be discussed later. But in the cases to which we 
have reference at present, the unaltered tumor has made its way into the 
bladder, rectum, etc., by causing pressure-atrophy of their walls. When 
we closely examine large tumors which are situated in the cervical canal, 
or which have passed the external os, we not infrequently observe, as an 
initial stage of perforation, an atrophic excavation in the opposed wall 
with erosion of the mucous membrane. Bennett, Montgomery, Churchill 
and others have described this condition. 
Thomson 4 relates the case of a fibroma growing into the bladder, 
the intervening tissues having undergone absorption from pressure. In 
Fleming's6 case a diagnosis was made during life of vesical calculus, which 
proved post-mortem to be a calcified fibroma growing from the anterior 
wall of the uterus. Lisfranc reports the growth of a fibroma through the 
vagina into the bladder, from which the tumor could not be dislodged. 
In the last mentioned and in other cases the tumors filled out the false 
passage so as to completely prevent the escape of urine through the latter. 
Monod6 describes a case in which a tumor tunneled its way through the 
anterior wall of the uterus and through both walls of the bladder, leaving 
a hole as large as a five-franc piece, through which some urine escaped by 
way of the uterus, only a small amount passing off by the natural outlet. 
The tumor lay directly against the symphysis pubis, which could be felt 
on passing the finger into the uterus, and thence through the three per- 
forations. This patient died of peritonitis. Rokitansky (quoted by Klob) 
mentions perforation of the rectal wall. Lisfranc7 also describes ah in- 
stance of perforation of the rectum by a uterine fibroid, the tumor pro- 
1 Herrgott : Memoires de la Societe de Chirurgie, July, 1873. 
2 Archiv. fiir Gynakologie, V., p. 100. 3 Ibid., VI., p. 125. 
4 Cited by Klob and elsewhere.f 5 M'Clintock: Dublin Quart. Journ. 
6 Bullet, de la Soc de Chirurg., IX., p. 526. f Cited by Demarquay and St. Vel 
Traite, etc., p. 157. 
1 Demarquay, l.c. 220 
NEW GROWTHS OF THE UTERUS. 
trading from the anus during every act of defecation, after which it could 
be pushed back. It finally dropped off spontaneously. Larcher1 observed 
attenuation of the uterine walls, with and without absorption of the 
peritoneal envelope. A not very large tumor which had developed in 
the region of the os internum, bored a passage through one side of the 
uterus into the vagina, projecting into the latter canal. The tumor had 
also pushed forward in another direction until it penetrated into the 
abdominal cavity, giving rise to fatal peritonitis. In a case of retro-va- 
ginal fibroma of the uterus, Roux4 observed perforation of the posterior 
roof of the vagina. It must remain undecided whether in the above- 
mentioned and in other similar cases perforation has been accelerated 
by uterine contractions. The cases in which this factor has undoubt- 
edly played some part have been observed during and after childbirth,3 
and will be considered later on. 
Matthews Duncan 4 observed a case of fatal peritonitis excited by a 
fibroma which had worn away the wall of the uterus as far as the perito- 
neal envelope. Most of the other reported instances of perforation do 
not concern us at present, as they have either been associated with a 
sloughy condition of the tumor, or are, to say the least, doubtful, like the 
case of Demarquay," who found a large, oval hole in the posterior wall of 
the bladder and anterior wall of the uterus, with ragged edges, the growth 
being situated in the anterior wall of the uterus. In this case Huguier's 
dilator had previously been employed. Loir's6 case is equally doubtful. In 
this instance a fibroma, after causing perforation of the walls of the uterus 
and abdomen, was thrown off as a " black mass." Dumesnil's' case was 
undoubtedly one of expulsion of a gangrenous tumor. There were several 
brownish spots on the most attenuated portions of the skin of the abdomen, 
covering a tumor of the uterus which reached high as the umbilicus. Pres- 
sure on this point gave rise to distinct emphysematous crackling, while the 
percussion tone in the same situation was tympanitic. A few months later 
ulcers formed at these points, through which fungoid masses of the tumor 
sprouted. The various openings finally coalesced into a single large 
aperture, through which the gangrenescent tumor protruded and was at 
length expelled spontaneously, the patient recovering. 
Other instances of the same kind will be found under the heading of 
gangrene of fibromata. While the bursting through of the tumors is due 
in these cases to their decomposition, the contrary occurred in the cases 
1 Archives Gen6r. de M&L, 1867, p. 545. 
2 Demarquay, l.c. 
3 Hecker: Klinik d. Geburtskunde, II., p. 133. 
4Edinburgh Med. Journal, Aug., 1867, p. 179. 
5 Soc. de Chirurg. de Paris. June 22, 1859. Union Med., Paris, 1859, II., p. 609. 
6 Polypes UtSrins, M6m. de la Soc. de Chirurg. de Paris, 1851, II. 
1 Gazette des Hopit., 1869, No. 6. COURSE, SYMPTOMS AND COMPLICATIONS. 
221 
described by Schroder.1 In the latter the abdominal walls were greatly 
thinned, and were pushed out, so as to resemble hernial protrusions, by the 
pressure of large interstitial and submucous fibromata. In one case the 
abdominal wall was distended until it was as thin as a sheet of paper and 
finally underwent mortification, fully exposing the otherwise intact 
tumor. Neuschler's' case is almost identical. 
While peritonitis very seldom results in consequence of perforation from 
the pressure of fibroids, it develops more frequently as the result of mere 
tension of the peritoneal investment of these tumors, in case they begin to 
grow very rapidly or have become tightly wedged in the pelvis. Still, 
most of the cases of peritonitis which are observed in patients affected' 
with myomata, are due to changes which have taken place in the tumors 
themselves, such as calcification and purulent liquefaction. Indeed, in cases 
of incarcerated fibromata the incipient stage of sloughing, the oedematous 
softening which is so frequently observed as the result of pressure, often 
leads to fatal general peritonitis, or to circumscribed perimetritis. 
As frequently as perimetritic and parametritic processes occur in 
these and other cases of fibromata, as seldom do they, as a rule, end in the 
formation of abscesses. McClintock3 describes five cases of this descrip- 
tion, death resulting in four from general peritonitis. One of these cases 
should perhaps be excluded, as the disease occurred in connection with 
the operative removal of the tumor-a not infrequent sequel. Koberle4 
reports a case of fibroma in which a peritoneal abscess broke externally, 
leaving a faecal fistula. 
Ascites is a not very frequent accompaniment of uterine fibromata, 
although, on the other hand, it does occur if the tumors have un- 
dergone softening, or if great anaemia has been caused by hemorrhage. 
Even when present it need not excite any symptoms. Cases of very 
abundant ascites persistently recurring after tapping have been described 
by Koberle and Pean.5 
We need make but passing mention of some other symptoms of uterine 
fibroma, oedema, petechial extravasations on the lower extremities during 
the menstrual period (Winckel, 1. c. p. 25), thromboses in the encircling 
veins, more rarely persistent vomiting and enlargement of the breasts. 
They are so seldom observed in these cases, besides being occasionally met 
with in all sorts of uterine diseases, that a characteristic relation to fibro- 
mata cannot be assigned to them. 
We see then, that fibromata, even when they are stationary, give rise 
to very varied symptoms; moreover, that their course is usually one of un- 
1 Handbuch, etc., p. 223. 
2 Wurtemb. Corresp. Blatt. ,36, 2, 1366. f Cited from Schroder. 
3 Clinical Memoirs, Dublin, 1873, p. 444. 
4 Gaz. M6d. de Strasbourg, 1866, No. 5. 
6 Caternault: Essai sur la Gastrotomie, etc., Paris, 1866, pp. 11, 62. 222 
NEW GROWTHS OF THE UTERUS. 
interrupted growth up to the time of the menopause. This reached, 
a number of the more important symptoms, prominent among which is 
profuse menstruation, usually pass away, although this is not invariably 
the case. The tumor stops growing and the patent is relatively cured. 
While this is a not infrequent occurrence, it certainly happens much more 
rarely that patients perish in consequence of the tumor, provided the 
latter have undergone no morbid alteration. In these cases death may be 
due to severe hemorrhages, to acute peritonitis, or to uraemia from press- 
ure on the pelvic viscera, as has previously been described. Mention 
should also be made, in this connection, of fatty degeneration of the 
heart. It has been observed by others as well as myself in cases of uterine 
fibroids, and is presumably due to chronic anaemia of the patients. This 
condition is doubtless frequently responsible for the fatal issue of the 
cases under consideration. Indeed, Rbhrig (l.c.) observed " heart dis- 
ease " in 8.4 per cent, of his cases. (Cf. also the article of Rose.)1 
The course of the tumors under consideration is influenced chiefly by 
the anatomical changes to which they are liable. Among these the most 
favorable, and consequently the most important one is their complete 
disappearance, either by absorption (an undoubted but uncommon event), 
or more often by spontaneous exfoliation. Both processes are, indeed, ex- 
ceedingly rare. While it is doubtful, to say the least, whether the former 
is often caused by parturition and childbed, the latter appears to be 
chiefly dependent on these states, as will be shown in another chapter. 
Many refuse to accept the possibility of the perfect regressive metamor- 
phosis of these tumors, and many of the reported instances of this occur- 
rence arc undoubtedly illusory. Diagnostic errors of this kind have been 
made in numerous cases of parametritic exudation, of the presence and 
course of which we formerly possessed but imperfect knowledge. Hard, 
indolent, often spherical pelvic exudations attached to the uterus are, even 
at the present time, often diagnosed as fibromata, and nothing is more 
common than the disappearance of such infiltrations after a longer or 
shorter interval. Prieger's2 cases may probably be included in this cate- 
gory. On the other hand, fibromata often undergo atrophic shrinkage after 
the menopause, and it is at least questionable whether these cases belong 
here. Moreover, fibroids not infrequently enlarge during pregnancy, 
in consequence of swelling, and return to their original size during 
childbed. One cannot in these cases speak of an absorption of the tumor, 
in the proper sense of the word.3 
Notwithstanding all these objections, there remain a number of au- 
thentic instances, in which absorption has certainly been observed. But 
these cases are by no means as numerous as many have asserted. Thus, 
1 Deutsche Zeitschrift f. Chirurgie, vol. XIX. 2 Monatsschrift, I., 1853. 
3 Bartels: Verhandl. der Geburtsh. Gesellschaft zu Berlin, 1852, p. 1, with sub- 
sequent discussion. COURSE, SYMPTOMS AND COMPLICATIONS. 
223 
while Schroder1 collected thirty-six cases of this character from the litera- 
ture of the subject, careful sifting of the original reports demonstrates 
that a large number of these will have to be excluded. Among these 
there is one reported by Clarke (quoted by Ashwell), who states that the 
tumor was " as big as a child's head," and was provided with two excres- 
cences which became smaller after two years of observation,the uterus being 
as large as this organ is in the fifth month of pregnancy. Of Ashwell's2 
cases at least one must be regarded as an exudation. 
Matthews Duncan3 observed a fibroma as large as a child's head, 
which disappeared so suddenly that he himself imagined that it had been 
enucleated spontaneously and had been expelled unnoticed. Playfair's4 
first case was probably one of pelvic exudation (compare my review in 
Canstatt's Jahresbericht, 1869); in the second case the tumor underwent 
suppuration. Burnton 5 speaks of the disappearance of a " fibrous en- 
largement of the whole uterus " (probably chronic metritis) and men- 
tions particularly that it was " not a distinct or separate fibrous tumor," 
and again that " it was not a distinct tumor growing into or from the 
uterus." In short this case is not one of absorption of a fibroma. G. 
Braun6 describes in detail the suppuration of the tumor. Madge ' ob- 
served a diminution in size, that is to say, a partial disappearance of a 
fibromyoma after childbed. The description of Rigby's case, cited by 
Ashwell, is also so imperfect as to be unserviceable. In addition to the 
above nine cases I shall have to exclude one of Goodell, and one of Vel- 
peau, as I have not been able to obtain the original communications. That 
of Velpeau, moreover, seems to be the same one described by Cazeaux. 
The following are positive examples of complete absorption of uterine 
fibromata: 
M'Clintock,8 one case; Ashwell (1. c.) three cases-one disappeared in 
consequence of childbed; Kidd,9 two cases-one after menopause, one 
during childbed; Simpson,10 one case. 
Gueniot11 reports the absorption of a large fibroid with febrile symptoms. 
He also mentions an instance of complete absorption observed by Depaul, 
also one of marked diminution in size after premature delivery, and a case 
of Behier's. He also states that Herpin noticed the complete disappear- 
1 Lehrbuch, p. 228. 
2 Lancet, 1854, p. 180. 
3Edinb. Med. Journ., 1867. 
4 London Obstetr. Transact., X., p. 102. 
5 Obstetr. Transactions, XIV., p. 227. 
6 Wiener Wochenschrift, 1868, No. 100. 
10bstetr. Transactions, XIII., p. 227. 
8 Clin. Mem. on Dis. of Women, Dublin, 1863, p. 141. 
9 Dubl. Journ. of Med. Science, 1872. 
10 Diseases of Women, Edinb., 1872, p. 693. 
11 Bulletin Gen. de Therap., March 20, 1872. 224 
NEW GROWTHS OF THE UTERUS. 
ance of a fibroma after Csesarian section (?) In Cazeaux's1 two cases 
pregnancy and childbed respectively were the exciting causes of absorp- 
tion. Courty2 and Pean 3 each record a case of this description, but so 
imperfectly that the observations are not convincing. Hildebrandt1 ob- 
served absorption not connected with childbed, Routh 5 two cases during 
the menopause, while Boinet6 reports three cases of this description. 
Sedgwick 7 claims to have observed this occurrence thrice during child- 
bed. The influence of childbed in this direction was clearly demonstra- 
ble in Scanzoni's,8 Gussmann's 9 and Schroder's10 cases, and I am posi- 
tive that I have seen one similar case myself, while in several other 
instances the rapid disappearance of previously felt tumors threw a doubt 
on the correctness of my diagnosis, and served but to prove to me how 
very easy it is to commit errors of diagnosis in similar cases in spite of 
conjoined manipulation and rectal palpation. 
The cases of Holst and Spiegelberg11 have been very carefully observed, 
while Meadow's12 should probably not be considered here, as the disap- 
pearance of the tumor (by absorption?) occurred only after artificial dila- 
tation of the os uteri and partial enucleation from the capsule. During 
the progress of a confinement Lorain13 noticed a uterine fibroma as large 
as a child's head. On the death of the patient twenty-two days later the 
tumor was no larger than a nut. If we include this case among those of 
complete absorption, my list will embrace thirty authentic cases, of 
which thirteen have occurred in conjunction with childbed, while most 
of the others developed during the menopause. I may as well state, in 
this connection, that in none of the cases is there reasonable ground for 
assuming that treatment exercised the least curative influence. 
We shall be more likely to gain an insight into the nature of the cir- 
cumstances which lead to absorption, if we assume that this phenomenon 
took place chiefly in those cases of pure myomata which were imbedded 
in the tissues of the uterus, without the intervention of a capsule, as was 
emphasized by Spiegelberg (1. c.) The cases of Freund and A. Martin 
show that fatty metamorphosis alone is not sufficient to cause absorp- 
tion, nor is pulpy softening more efficacious in this respect (compare 
Hecker, 1. c.). If, however, these changes occur in soft myomata, which 
1 Bulletin de la Societe de Chirurgie, 1857, p. 94. 
2 Traite de Malad. de I'UtGrus, Paris, 1868, p. 828. 
3Gaz des Hop., 1871. 
4 Berl. Klin., Wochenschrift, 1872, No. 25. 6 Cited by M'Clintock. 
6Gazette H6bdom., 1873, No. 18. 'St. Thomas' Hosp. Rep., 1870. 
8Lehrbuch, 4 ed. I., p. 212. 9 Wurt'bgCorrespondenzb., 1868. 
I0L.c. 229. 
11 Archiv. fiir Gynakologie, VI., p. 512 and 515 
12 Obstetric Journal, Dec. 1874. 
13 Atrophie des corps fibreux de 1'uterus apres I'accouchement, Gaz. des Hop., 
1869, p. 361. COURSE, SYMPTOMS AND COMPLICATIONS. 
225 
are directly imbedded in uterine tissue, their absorption is the more 
comprehensible, as is also the influence in this direction of parturition and 
childbed, during which processes the contractions of the uterus and the 
involution of this organ induce similar changes in the entire mass of 
the muscular substance of the uterus. 
We can also understand that the soft tumors will participate more readily 
in the general atrophy of the uterus which takes place at the menopause, 
than will dense, encapsulated fibromata. Of course I do not intend 
thereby to deny the possibility of the disappearance of encapsulated fibro- 
mata, but I believe that the latter diminish in size rather as the result of 
induration and atrophy, and that distinct residua often remain, which 
anatomical investigation at least will succeed in detecting. It is just this 
condition of induration of the tumor, this diminution in size at the meno- 
pause, which is so very frequently combined with calcification, as has 
previously been stated. The cases of Hildebrandt,1 Fehling,2 Lente 3 and 
a large number of others are of this description. 
Another very favorable, but equally rare event, is the spontaneous 
expulsion of fibroids. This may happen, on the one hand, in cases of 
pediculated tumors as the result of simple tearing of the pedicle, or the 
tumor may actually be born, so to speak, through the medium of violent 
uterine contractions, and may then break off. But even in the case of 
the more interstitial tumors, those deeply seated beneath the mucous 
membrane, the capsule may be ruptured by the pains, and the entire 
mass may then be cast off. Both occurrences, although rare, terminate 
favorably with scarcely any exceptions. At most the act of expulsion is 
momentarily accompanied, or preceded, by a short period of profuse 
haemorrhage. Cases in which fibromata have torn away purely in conse- 
quence of their own weight have been described by Routh4 and R. Lee 
(1. c.). Mansfield Clarke mentions yomiting as contributing to the same 
result, Marchaud5 the association of straining during defecation, with 
violent hemorrhage. 
Barnes6 observed the expulsion of a fibroma as large as a walnut after- 
rupture of the thin capsule, or avulsion of the pedicle from uterine con- 
tractions resembling labor pains, Whiteford7 after intense pains lasting 
several days, Dorsch8 a similar event. Berdinel9 describes a case in which 
expulsion was preceded by pains resembling those of labor and by hemor- 
rhage during a period of two months. During a violent paroxysm of 
coughing, associated with very profuse hemorrhage, the tumor suddenly 
'Berl. Klin. Wochenschrift, 1872, No. 25. 
■ Archiv. fur Gyniikologie, VII., p. 384. 
3 Med. and Surg. Reporter, 1874. 4 British Med. Journal, 1864. 
5 Virchow, Archiv., LXVIL, p. 206. 6 Obstetr. Transact., VI., p. 101. 
1 Glasgow Med. Journal, Aug. 1872. 8 Deutsche Klinik, 1874, No. 5. 
9 Archiv. de Tocologie, III., p. 249. 226 
NEW GROWTHS OF THE UTERUS. 
sank until it lay just within the external genitals. No pedicle was de- 
tected. The patient died. Ilybre 1 reports a similar case of a myoma 
weighing 2420 grammes, which was driven down as far as the vulva. It 
will be shown later that such accidents are very prone to occur during 
or after parturition. 
The expulsion of uterine tumors after the occurrence of dissecting 
suppuration or disintegration takes place much more frequently than the 
above-described varieties of spontaneous extrusion. The processes of dis- 
integration do not affect the body of the tumor, or if so, only to a slight 
extent, but are confined to the capsule or to the lax connective tissue 
surrounding the growth. The inflammation either starts, as is usually the 
case, from the enveloping mucous membrane, or the latter only becomes 
secondarily affected. The tumor is in every instance expelled en masse, 
except that scattered patches of the growth are here and there encountered 
in a sloughing condition. This mode of expulsion is sometimes associated 
with febrile manifestations, but generally terminates without danger to 
the patient. Calcified fibromata-so called uterine calculi-are most 
frequently cast off in this manner. These cases also are often intimately 
•connected with the processes incident to parturition and childbed. In- 
stances of this description are numerous. Field 3 and Barnes3 each ob- 
served a case several weeks after childbed, Kuchenmeister4 saw one forty- 
five days after confinement, and Schneider5 one five weeks after confine- 
ment. It would take up too much space to mention all the cases reported 
in the literature of the subject : let it suffice to call attention to those of 
Kauffman, Ruge,6 and Wardie.7 
Although the process of expulsion after dissecting suppuration is in 
many respects analogous to that of purulent liquefaction of the entire 
mass of the tumor, yet there is a broad line of demarcation between the 
two, both the course and the final termination being essentially different. 
Thus, while dissecting suppuration usually leads in a short time to the 
expulsion of the tumor, purulent liquefaction generally requires a much 
longer time for its completion, according as the tumor is large or small. 
Moreover, the process of purulent liquefaction necessarily carries with it 
the greater dangers of pyeemic infection, and consequently often leads to 
a fatal termination. 
Uterine fibromata very frequently slough in consequence of the em- 
ployment of various operative procedures, either for purposes of diagnosis 
1 Annales de Gynecologie, I., p. 153. 
2 Boston Gynaecol. Journal. III., 342. 
3Obstetr. Transact., VII., p. 13. 
4Oesterr. Zeitschrift fur Heilkunde, 1869, No. 33. 
6 Schweizer Correspondenzblatt, 1872, No. 16. 
*Beitrage zur Geburtskunde, Berlin, III., p. 72. 
' Med. Tinies, July 6, 1872. COURSE, SYMPTOMS AND COMPLICATIONS. 
227 
(sponge tents, incision of the mouth of the womb), or in order to check 
hemorrhage (intrauterine injections), or finally after attempted extirpa- 
tion of the neoplasms. The injury inflicted in these cases upon the en- 
closing mucous membrane, often interferes with the nutrition of the tumor 
to such an extent as to induce mortification of the latter. The more 
extensive and severe the traumatism, and the more intimate the con- 
nections of the tumor with the uterus, the greater is the liability to septi- 
caemia and pyaemia. At any rate there is no doubt that a much larger num- 
ber of those patients die in whom operative interference has been followed by 
sloughing of the tumor, than of those in whom the tumor has undergone 
gangrene spontaneously. It is self-evident that the duration of the 
gangrenous process as well as the size of the tumor involved are of prime 
importance in this respect. 
Spontaneous gangrene develops most frequently from ulceration of 
the mucous membrane covering the tumor. Ulceration occurs quite 
rarely as long as the tumor is still entirely within the cavity of the uterus, 
and so long as no operative measures of any kind have been attempted. 
Under these circumstances it is most prone to develop during childbed, as 
will be shown hereafter. But these injuries occur very readily when the tu- 
mor has forsaken the uterus, and rests either wholly or partly in the vagina. 
On the other hand it has previously been explained how hemorrhages into 
and oedematous softening of a tumor may lead to spontaneous gangrene 
of the latter. 
It may also be stated here that according to Cruveilhier this process 
may be excited by thrombosis of the surrounding veins. Whenever I 
have found venous thrombi in the vicinity of sloughing tumors it has 
always seemed to me as if the former were rather the result than the 
cause of the latter. 
When gangrene starts from the mucous membrane and commences 
as an ulceration, hemorrhages are usually observed from the outset, and 
are followed almost immediately by a fetid and putrid discharge. When 
sloughing occurs from other causes, in an uninjured tumor, it is very 
often preceded by the symptoms of softening or of the so-called inflamma- 
tion of the tumor. The growth becomes larger, more tense, and fre- 
quently yields a feeling of 'fluctuation. It is painful to the touch, and 
spontaneously excites either painful contractions of the uterus, or painful 
sensations in the peritoneum. As far as my experience goes, these occur- 
rences take place spontaneously more often when the fibromata are soft 
-that is, when we have to do with myomata or myoma-than when the 
tumors are dense, although mortification is relatively frequent in cases of 
calcified fibromata. But in these instances it usually results from dissect- 
ing suppuration. The patients suffer from fever, rapidly emaciate and 
lose their appetite. Violent uterine contractions cause the mouth of 
the womb to dilate, and then the gangrenous tissue is expelled, usually in 228 
NEW GROWTHS OF THE UTERUS. 
rather large pieces mixed with an exceedingly fetid discharge of blood 
and pus. 
In other cases there is merely a discharge of a very penetrating odor. 
At the same time very high fever is almost always present, together with 
all the signs of putrid infection. The further progress of the case de- 
pends upon whether the sloughy masses have a free exit or not, and 
also upon the size of the tumor. In any event recovery is very rare- 
ly observed. In cases that have terminated favorably errors of diag- 
nosis have often been committed, in so far as the condition has probably 
been one of loosening and expulsion of the tumor en masse, after se- 
questration by sloughing. Still, there have been occasional recoveries after 
sloughing of the tumor in its entirety. Thus recovery occurred in a case 
of uterine myoma extending an inch above the umbilicus, reported by 
Ziemssen.1 This writer emphasizes the fact that the expelled masses 
consisted chiefly of muscular tissue, a fact to which attention has often 
been directed, and which suggests the question-are pure myomata par- 
ticularly susceptible to mortification, or does the intervening connective 
tissue slough away more rapidly and thus set free the muscular bundles? 
Baker Brown 2 observed sloughing in a tumor of this nature, the process 
lasting two years before the patient recovered. Braun, Chiari and Spath3 
report two favorable cases, in which the mortified tissue was expelled 
through the patent os uteri by violent contractions. 
In M'Clintock's4 paper, on the spontaneous elimination of uterine 
tumors, several instances are described of tumors which were first driven 
by uterine contractions outside of the vulva, and then became gangrenous. 
Similar cases have been reported by Field,5 Saxinger,6 Kristeller,7 Heiberg, 
Playfair/ Chassagnac, and Demarquay. 
Calcification, as has been already stated, appears to facilitate the de- 
velopment of spontaneous gangrene, and under these circumstances re- 
covery not infrequently takes place (Lumpe9). Under the heading of 
treatment, attention will be again directed to the fact that operative inter- 
ference in cases of uterine tumors is liable to lead to gangrene, either as 
an accidental sequel, or as an intentional therapeutic measure. 
The course of spontaneous gangrene differs widely from that induced 
by artificial means. In the former event recovery may take place, as has 
'Virchow's Archiv., XVII., p. 340. 
2 Obstetr. Transact., I., p. 330. 
8Klinik, etc., pp. 402, 403. 
4 Dublin Quart. Journal, Feb. 1868, p. 24. , 
6 Boston Gynatc. Journal, III., p. 342. 
6 Prager Vierteljahrsschrift, II., 1868, p. 72. 
'Berl. Klin. Wochenschrift, 1872, No. 35. 
8 Obstetrical Journal, June, 1874. 
9Zeitschrift <1. Gesellsch. d. Aerzte., Vienna, 1860, No. 29. COURSE, SYMPTOMS AND COMPLICATIONS. 
229 
been shown above. In the latter, as we shall see, almost all the patients 
perish. Even when symptoms of septicaemia manifest themselves during 
the course of spontaneous gangrene, the final result of the affection may 
be favorable, as is seen in a case reported by Hardie.1 In the whole 
literature of the subject I have succeeded in discovering but one case of 
fatal pysemia following the spontaneous mortification of a myoma. This 
was reported by Spiegelberg,2 and even in this one instance there is con- 
siderable doubt as to the spontaniety of the process. Compare also 
Braun, Chiari and Spilth, 1. c. Spontaneous gangrene, followed by ex- 
pulsion and ending in the death of the patients, are also described by 
La bat3 and Jackson.4 
Although it may be true that numerous cases of spontaneous gan- 
grene have not been made public, as not having been sufficiently striking, 
there is yet a well-marked difference in the course and final result of these 
cases, as contrasted with those of artificially induced gangrene. The why 
and wherefore of this difference will be best explained by the recollection 
of the fact that, spontaneous gangrene occurs, as a rule, only after the 
tumors have been cut off from their nutrient source, that is, from their 
connections with the rest of the body, while in every instance of op- 
erative interference, not only are fresh wounds inflicted, which facilitate 
the entrance of septic agents into the system, but the entire tumor still 
remains intimately connected with the uterus. 
These remarks do not, it is true, apply to the application of a ligature to 
the neck of a pediculated myoma, as the result of which sloughing almost 
inevitably occurs. The dangers of this procedure will be made apparent 
later. But in these cases the connection of the tumor with the rest 
of the body becomes very insignificant. When death results in cases of 
spontaneous gangrene it is more often caused by peritonitis, which is not 
necessarily due to the escape of mortifying tissue into the abdominal 
cavity. Cases have been reported by Braxton Hicks,0 Maisonneuve and 
Maslieurat-Laguemar.6 Cockle 7 reports a case of fatal peritonitis due to 
the passage of sloughy masses of the decomposed tumor through the 
dilated right Fallopian tube into the abdominal cavity. 
Finally rupture may occur in any direction in cases of central mor- 
tification, or when the os uteri does not dilate sufficiently to permit of the 
exit of the discharge, or when the tumor does not project into the cavity 
of the uterus. The perforation may occupy the abdominal wall in case 
this has previously become adherent to the surface of the tumor. 
Med. Times, July 6, 1872. 2 Archiv. fur Gynakol., V., p. 108. 
Progres Med., 1880, p. 26. 4 Obstet. Jour, of Gr. Brit., No. 139, 1880. 
Obstet. Tr., VIL, p. 110. 
6 Comp. Demarquay et Saint Vel. Maladies de 1'Uterus, p. 158. 
1 Med. Times, 1863, p. 697. 230 
NEW GROWTHS OF THE UTERUS. 
In addition to those instances of this accident which have been spoken of 
on page 220, let me mention one reported by Neugebauer.1 The patient 
was affected with a subserous pediculated fibroma, partly calcified, which 
became adherent to the abdominal parietes after parturition, and some- 
time afterwards underwent spontaneous mortification, with the forma- 
tion of an opening on the external surface of the abdomen. From this 
fragments of necrosed tumor tissue were removed, and there remained for 
a long time a cavity bounded by a calcareous shell. The patient finally 
recovered. 
Loir's2 case of gangrenous interstitial myoma, which worked its way 
through the walls of the uterus and abdomen, terminated unfavorably. 
Similar cases have been narrated by Dumesnil (compare page 220), Pinault * 
and Huguier.4 Viardin 5 observed perforation of gangrenous masses into 
the abdominal cavity, followed by fatal peritonitis. 
I should like to mention in this connection a very peculiar and inter- 
esting communication by W. A. Freund.6 This gentleman observed in 
two cases of uterine fibroma, which were attacked by spontaneous soften- 
ing or inflammation, the complete elimination of the tumors in the shape 
of a very profuse fluid discharge, mixed with solid fragments. No other 
signs of decomposition were present. The discharge was never fetid, 
there was no fever, there were no pains like those of labor, in short there 
were none of the symptoms which usually accompany the occurrence of 
true gangrene. The expelled masses consisted simply of softened fibroid 
tissue, with "eingesprenketten gelben, sehr lockeren Parthien, ohne jeden 
auffdlligen Geruch und vonb]assgel.ber Farbe" They also contained con- 
cretions of lime. Microscopical examination showed mainly fatty de- 
generation of the elements of the tumor.. Both patients recovered com- 
pletely. It must of course remain undecided whether, as asserted by 
Freund, the softening and expulsion of these tumors was due to the use 
of the mineral waters of Jastrzemb. 
A second case, of the same nature probably, is reported by Botureau,7 
who found a fibroma converted into a faintly yellow, purulent, and but 
slightly foetid fluid. 
Nothing need be added to what has been said above as to the final 
results of the calcification of uterine fibromata. These tumors either 
remain stationary and then give rise to no disturbance, or they are ex- 
Monatsschrift filr Geburskunde, No. 28. p. 401. 
2 M^moires de la Soci£t6 de Chirurgie de Paris, 1851. 
3 Bulletin de la Society Anatoinique, III., 1828. 
4 Hyst6rotomie, p. 180. 
6 Bullet, de la Soci6t6 Anatom, de Paris, IX., p. 43. Paris, 1834. 
6 Klin. Beitrage, etc., III., 1865, p. 142. 
1 Bull, de la Soc. Anatomique, XVII., p. 139. COURSE, SYMPTOMS AND COMPLICATIONS. 
231 
pelled in the form of so-called uterine calculi,1 after isolation by dissect- 
ing suppuration. 
Partial calcification, however, leads much more frequently to gangrene 
with all its attendant dangers. Perforation into the peritoneum, followed 
by fatal peritonitis, and perforation of the bladder by a calcified tumor, 
have also been observed (M'Clintock, l.c.). Compare also Simpson'2 and 
Aran.3 
The freely discussed question-Do uterine fibroids recur after removal ? 
-may be answered in the negative. Tumors, which possess a structure 
in all respects similar to that of the tissues upon which and from which 
they have originated, manifest the peculiarity of developing at several 
points at the same time. But after removal they do not recur in the 
same situation. This definition of benignity also holds good clinically in 
the case of uterine fibroids. All observations which appear to show the 
contrary are susceptible of different explanations. Not a single one is 
calculated to prove beyond doubt the recurrence of these tumors. When 
we come to the consideration of sarcomata of the uterus it will be shown 
that the so-called "recurrent fibroids" of the English are probably 
nothing else than sarcomata. This is clearly demonstrated by a recent 
observation of M. Muller,4 who found a sarcoma occupying the situation 
from which fibro-myomata had previously been removed. 
In other cases there seems to have been only the later growth of an 
incompletely extirpated fibroma. Thus Valenta 5 records an instance 
of fibroma which was cut away as far as possible after the vagina had 
become invaded, but which grew so rapidly that within a few months it 
again reached as far as the vulva, requiring the removal of additional 
masses weighing If pounds. L. Mayer6 offers the same explanation for 
the reappearance of a peculiarly lobulated fibroid in a situation from 
which a similar tumor, as large as a child's head, had been removed two 
years previously. 
Another explanation of seeming recurrence is that after the extirpa- 
tion of a large tumor, other previously existing but small, and therefore 
undetected, tumors continued to grow until they attained a size sufficient 
to cause disturbance. Multiple occurrence is very characteristic of uterine 
fibroids. This affords the simplest explanation of cases like that of Kidd,7 
who removed from the uterus of a young woman twenty-nine different 
fibrous polypi in the course of a few years. 
1 Trumet: These sur les tumeurs de 1'uterus, Paris, 1851, and Henocque : 
Archives de Physiologie par Brown-Sequard, etc., Paris, 1873, No. 4, p. 425. 
2 Obstetr. Works, I., p. 135. 3 Maladies de 1'uterus, p. 835. 
4 Archiv. fur Gynakologie, VI., p. 125. 5 Memorabilien, 1867, part I., p. 3. 
6 Beitrage d. Gesellschaft f. Geburtsh., Berlin, II., 1874, p. 80. 
7 Dubl. Journ., Nov. 1875, p. 456. 232 
NEW GROWTHS OF THE UTERUS. 
Finally it has happened to me (G. Braun 1 describes a similar case) to 
have removed only the lower half of an hour-glass-shaped fibroma, under 
the impression that it was the entire tumor, the remaining upper half not 
being detected until some time afterwards. When such an oversight is 
committed one is very liable to regard the subsequently appearing tumor 
as a recurrence. 
1 Wiener Wochenschrift, 1869, Nos. 35 and 37. CHAPTER V. 
THE DIAGNOSIS AND PROGNOSIS OF FIBROIDS OF THE 
UTERUS. 
T^TERINE fibroids can be diagnosticated only by careful palpation of 
the pelvic organs. Although the recognition of these tumors is 
ordinarily easy, it may be rendered difficult by various circumstances. 
Until submucous fibromata have attained a certain size, about that of 
an apple, they can be recognized by the touch only when they have caused 
dilatation of the os uteri, sufficient to render their smooth inferior border 
accessible to the palpating finger. The diagnosis is, of course, still easier 
when the tumor has become completely extruded from the uterus and can 
be felt, together with its pedicle, in the vagina. The dilated os may so 
tightly clasp the pedicle, if the latter be slightly developed or if the base of 
the tumor be very broad, as to closely simulate inversion of the uterus. 
The position of the fundus may be determined by the sound, by con- 
joined manipulation, and, if necessary, by rectal palpation, and errors in 
diagnosis may thus be prevented. 
It is well known that the opposite and more serious mistake of 
considering an inverted uterus an extruded fibrous polypus has been 
much more frequently made. Fibromata which had completely escaped 
from the uterine cavity have, also, been mistaken for prolapsus uteri.1 
Foster2 met with a case in which the prolapsed uterus w'as regarded as 
a fibroma and accordingly removed. The patient survived. Such errors 
could certainly be prevented by careful examinations. 
So long as small submucous fibromata are not accessible to direct pal- 
pation, performed according to the method already described, they dilate 
the uterus to an extent commensurate with their size. The uterus is, 
almost always, symmetrically enlarged, since the tumors are situated in 
its cavity. It has also preserved its natural form, or is, at the most, more 
globular than normal. 
Although the profuse hemorrhages and the uterine discharge may, in 
such cases, suggest the existence of chronic metritis, the uterine pains 
which are seldom absent, and which resemble those of labor, will direct 
1 Hall-Davis: Obstetr. Trans., IX., p. 152. Comp, also Scanzoni: Beitrage, II., 
p. 99. 
2 Allgem. Wien Med, Zeits., 1863, No. 26. 234 
GROWTHS OF THE UTERUS. 
attention to the possible presence of a foreign growth in the uterine cav- 
ity. The tumor can, however, only be diagnosticated after the dilatation 
of the cervix by means of a sponge tent, or of several laminaria tents 
simultaneously introduced. Shortening of the vaginal portion of the 
cervix uteri specially points to the presence of such a neoplasm in the 
uterine cavity. Owing to their great mobility, submucous fibromata are 
early forced against the os internum. Interstitial fibroids of small di- 
mensions are, likewise, difficult to diagnosticate. The enlargement and 
increased consistency of the uterus are, in this instance, likely to lead to 
the diagnosis of chronic metritis, since that disease accompanies the de- 
velopment of the neoplasm. In many cases the little fibroid may be dis- 
covered on the anterior or posterior uterine wall by conjoined manipula- 
tion. The sound furnishes more definite information, since the shape of 
the uterine cavity is of equal diagnostic importance with its enlargement. 
Anteflexion and retroflexion may, moreover, be excluded by the use of 
the sound. In many cases, however, it will be necessary to dilate the os 
uteri, and even this procedure will fail of establishing the diagnosis pro- 
vided the tumefaction of the endometrium be slight. 
If the interstitial fibromata be of large size they are easily accessible 
to palpation. The enlarged uterus is mobile as a rule, and has either 
descended lower into the pelvis than is normal or has risen above the 
superior strait. The nearer the tumor is located to the internal os the 
more is the vaginal portion of the cervix shortened. The only other 
cases in which a similar shortening is observed are those in which the 
tumor encroaches considerably upon the uterine cavity. The sound 
often reveals sinuosities and changes of direction in the uterine canal, 
and, usually, an enlargement of the uterus corresponding to the size of 
the tumor. These signs sometimes fail, however, and it is not always 
possible to reach the fundus with the sound. The diagnosis is specially 
difficult if several fibroids are present. Whatever cannot be de- 
tected in these cases by palpation, cannot, usually, be established by the 
sound. The depth of an interstitial fibroid beneath the uterine mucous 
membrane and the breadth of its base can, ordinarily, only be discovered 
after a thorough dilatation of the cervix. 
Efforts at determining the firmness of its attachment by traction upon 
the tumor are fraught with danger, if the removal of the fibroid be im- 
possible, because suppuration of the neoplasm may orginate in the lacer- 
ated wounds thus induced. The active and frequently repeated employ- 
ment of sponge-tents must also be avoided, lest we produce gangrene of 
soft myomata situated immediately beneath the mucous membrane. 
The direction of the cervix uteri often serves to indicate the seat of the 
tumor. If it be notably inclined toward one side, the assumption that the 
tumor is located on the other side is justifiable. If the position of the cervix 
te unchanged, the fibroma is usually pediculated, submucous and small. DIAGNOSIS AND PROGNOSIS. 
235 
The question whether an interstitial fibroma be located in the anterior or 
in the posterior uterine wall may be settled by feeling the extremity of 
the sound, on bi-manual exploration, either before or behind the tumor. 
The diagnosis of subserous fibromata will be easy, in proportion to the 
facility with which theii' connection with the uterus can be determined. 
This connection may often be discovered, in obscure cases, by imparting 
simultaneous movements to the tumor and the uterus by means of the 
sound. The looser' the connection between the uterus and the tumor, 
the less marked is the enlargement of the former. The broader the base 
of the sub-serous fibroid, the more difficult is it to decide whether the 
tumor belongs to the uterus or only adjoins it. This is particularly true 
if the fibroma be of large size. The difficulties of diagnosis increase 
if the neoplasm has become retro-vaginal and incarcerated, or if adhesions 
attach it in the pelvis or to other abdominal organs. This point will re- 
ceive special consideration in our remarks on differential diagnosis. On the 
other hand easily movable subserous fibromata with thin pedicles may 
likewise present difficulties in the way of diagnosis. 
The statement that cervical myomata are easily diagnosticated is, 
indeed, true of those tumors which may be easily felt because located in 
the lips of the os, or attached to them by a pedicle. When, however, small 
subserous or interstitial tumors are developed in the supra-vaginal portion 
of the cervix, their diagnosis is often very difficult, especially if they be 
encapsulated. When a fibroma, developed in one of the lips of the os, 
has attained a certain size, experience and authority confirm the fact that 
the difficulties of diagnosis are very great. Owing to the downward 
growth of such a tumor, which often completely fills the vagina, the os 
escapes upward. The free lip of the os is subjected to severe traction by 
the lateral growth of the tumor, and is transformed into a thin fold, lying 
in close apposition to the fibroid. An inversion of the uterus is thus 
simulated. A correct diagnosis is, however, easily made if the fundus 
be readily recognized by palpation. Breisky (1. c.) very pointedly calls 
attention to the fact that this is not always an easy matter. He says that 
the fundus is recognizable, however, by palpation of the round ligaments, 
the ovaries and the points of tubal attachment, either on one side or the 
other. If this cannot be easily effected rectal palpation may afford the 
desired information, although this is impracticable when the vagina is 
distended with large fibromata. Persistence in the investigation usually 
succeeds in the utilization of the sound, but the discovery of the os often 
demands much time and skill. 
If the neoplasm is located in the anterior lip of the os, an examina- 
tion in the lateral position with Sims's speculum is recommended. This 
method of examination is also adapted to cases in which the tumor 
develops in the posterior lip. If the os be discovered, the thorough 
introduction of the sound proves the absence of inversion. Such 236 
NEW GROWTHS OF THE UTERUS. 
cases have been described by Freund,1 O'Connel,* Barnes,3 Leon Le- 
fort4 and others. I myself encountered in two similar cases consider- 
able difficulties in making a diagnosis, and overcame them in one in- 
stance only by rectal palpation, and in the other by means of the sound. 
Simpson 6 likewise emphasizes the diagnostic difficulties presented by 
such cases. 
It has been asserted that the sensitiveness of the uterine mucous 
membrane, as contrasted with the insensibility of the fibroid tumor, 
may assist the physician. I once had occasion to enucleate a fibroma from 
the fundus of an inverted uterus, but could not discover any difference be- 
tween the sensibility of the mucous membrane and that of the tumor. 
Inflammation had, however, resulted from the inversion. 
The relative amount of muscular tissue and of connective tissue com- 
posing the myofibroma has some bearing upon treatment. Pure myomata 
have, in my experience, been characterized by severe paroxysmal pains, 
resembling those of labor, which could be induced by touching the tumor 
with the sound. Similar pains, of great severity, accompanied each 
menstruation, and at that time the tumors, which had been of a soft con- 
sistency, seemed to become harder and smaller, owing, probably, to their 
own contraction. In other cases pure fibromata seemed, rather, to be- 
come soft and large from congestion. The remark may be made, in 
passing, that these soft myomata are well adapted to treatment with ergot, 
but that they readily become gangrenous if any intra-uterine treatment is 
adopted. 
Only a few other morbid conditions simulate uterine fibromata. In 
the first place the symptoms, and even the pathological processes, may 
point to chronic metritis. This is the more likely to occur since, in 
many cases of uterine fibroid, the uterus is, actually, in a condition of 
chronic venous hyperaemia. The differentiation of fibromata from chronic 
metritis is only difficult when the former are small sub-mucous or inter- 
stitial ones. Larger tumors always occasion changes in the form of the 
uterus, and are, therefore, directly accessible to palpation. 
Even small fibroids usually produce decided uterine pains, which 
are rarely so well marked in chronic metritis. A uterus containing sub- 
mucous neoplasms is, moreover, of a globular form, and the vaginal 
portion of its cervix is often notably short, while the reverse conditions 
obtain in chronic inflammatory diseases of the uterus. Symptoms of 
uterine catarrh, particularly ulcerations of the cervix, accompany the 
1 Betschler : Beitrage, III., p. 105. 
2 Journal of the Gynsec. Soc. of Boston, I., p. 270. 
3 Transactions of the Obstetr. Soc. of London. III., p. 211. 
4 Tumeur fibreuse de l'ut4rus simulant un renversement, Bull, de la Soc. de 
Chirurg., 1872. p. 441. 
5 Obstetrical Works, 1st ed., vol. I., p. 120. DIAGNOSIS AND PROGNOSIS. 
237 
latter, while such morbid phenomena less constantly accompany uterine 
fibroids. 
Fibromata are readily distinguished from uterine displacements, partic- 
ularly ante-flexion and retro-flexion, by the condition of the uterine cavity. 
The direction of the uterine canal is, however, only to be determined by 
the sound. The reposition of the uterus by conjoined manipulation is 
by no means sufficient for the differential diagnosis of these conditions, 
for, on the one hand, the uterus may become fixed in an abnormal posi- 
tion, and, on the other hand, tumors, (those which have sunken low into 
the cul-de-sac of Douglas for instance,) may be displaced upward, together 
with the uterus. Evacuation of the bladder, by means of the catheter, 
must always precede the above-mentioned diagnostic manipulations. 
Even a moderately full bladder often interferes with examination. 
In the case of Budin1 a small fibroma having sunken into Douglas's 
cul-de-sac, and occasioned partial retention, the condition of affairs was 
not appreciated, and the bladder, consequently, punctured. Such cases 
are, fortunately, rare. 
Barnes2 discovered, by means of the catheter, that a fibroma, which 
seemed to be located in the anterior uterine wall, really belonged to the 
posterior wall of the bladder. 
Interstitial fibromata often produce an abnormal prominence of the 
opposite uterine wall, a condition usually only discovered during sounding. 
Fibroids must, farther, be differentiated from epithelioma. An 
epithelioma of the vaginal portion of the cervix, or carcinoma of the body, 
is not likely to be mistaken for a fibroma, but the reverse has occurred 
on several occasions. When a fibro-myoma has escaped from the external 
os and become gangrenous, the general condition of the patient is not 
only so bad that she presents a marked '1 cachectic " appearance, but the 
local condition may closely resemble epithelioma of the portio vaginalis, 
as I have myself once observed. The palpating finger penetrates a soft, 
pulpy mass which seems to distend the fornix vaginae, while gangrenous 
shreds adhere to the finger. The discharge is exceedingly copious, offen- 
sive and often bloody. If the other hand discovers, on abdominal palpa- 
tion, that the enlarged uterus is globular in form, an error is, however, 
readily prevented. If this be impracticable on account of the small size of 
the tumor, the relation of the gangrenous mass to the vaginal parietes 
must be discovered. Gangrenous epitheliomata always involve the vaginal 
walls, to a greater or less extent, while a gangrenous myoma leaves them 
intact. The healthy smooth lips of the dilated os uteri can always be 
discovered if the case be one of fibroma. It is also not so easy to 
remove parts of a gangrenous fibroma with the finger, as it is in cancer, 
and the shreds of the latter are soft and friable, while those of a fibroid 
1 Arch, de Tocologie, II., p. 60. 
2 Diseases of Women, p. 766. 238 
NEW GROWTHS OF THE UTERUS. 
are firm and fibrillated. A microscopical examination will clear up all 
doubts. (Conf. Braun, Chiari, and Spath, Klinik, p. 403.) 
Only carelessness in examination can cause advanced cases of preg- 
nancy to be mistaken for uterine fibroids. Real difficulties in the differ- 
ential diagnosis will be encountered only in the earlier months of 
pregnancy, when neither heart-sounds nor foetal members can be distin 
guished. Absence of menstruation and enlargement of the breasts are 
points in favor of pregnancy, although the mamma? sometimes enlarge 
and discharge colostrum in cases of fibroid. The uterus is, ordinarily, 
soft and elastic in the earlier months of utero-gestation, while the sensa- 
tion of a solid body floating in fluid is obtained on palpation of the ab- 
domen. The other signs of pregnancy will also be present. The diag- 
nosis can, however, in some instances, only be made with certainty 
after the observation of farther uterine development, or the discovery of 
the heart sounds. 
Spencer Wells, and particularly Winckel, have recently again called 
attention to the auscultatory signs of uterine fibroids. These were earlier 
studied by M'Clintock.1 Besides pure arterial sounds heard here and there, 
there is most constantly present a murmur resembling, in every particular, 
the familiar uterine souffle. Winckel heard it in 54 per cent, of his cases of 
uterine fibroma. It is by no means so infrequent as is commonly assumed, 
but is, usually, only observed in connection with large sized-tumors. 
McClintock states that he has heard it only in cases of interstitial, or, at 
least, never in cases of pediculated fibroids. This sign has no bearing upon 
the differentiation of pregnancy from fibromata. In one of Bricheteau's 
cases,2 his diagnosis of extra-uterine pregnancy was based upon the presence 
of the uterine murmur. Laparotomy was performed, the case was found 
to be one of sub-serous fibroma, and the patient died on the 6th day. 
Many cases are recorded in literature in which the diagnosis fluctuated, 
for a long time, between fibroma and extra-uterine pregnancy.3. The symp- 
toms of pregnancy or the termination of the cases finally solved the problem. 
Uterine fibroids are usually readily distinguished from ovarian tumors 
by the facts that the latter fluctuate and are not directly connected with the 
uterus, but are capable of independent motion. If these signs be absent 
the diagnosis may be difficult or impossible. Since the so-called fibro- 
cysts of the uterus are to be separately considered, I refer the reader to the 
chapter treating of the differences between ovarian cysts and fluctuating 
myomata. Allusion may, however, be made to the fact that sub-serous 
fibromata, with pedicles, have often been regarded as solid ovarian tumors 
1 Clinical Memoirs, p. 130. 
2 S6bileau : Des tumeurs fibreuses dans leurs rapports avec la grossesse, These, 
Paris. 1873. 
3 Comp. Routh: Brit. Med. Journ., 1864.) Jobert de Lamballe: Annales de 
Chirurg., 14, p. 219.f Courty : Maladies de 1'Uterus. 1st ed. p. 820. DIAGNOSIS AND PROGNOSIS. 
239 
{conf. Spencer Wells, Fig. 4., p. 9), because they seemed to have no con- 
nection with the uterus. Auscultation gives no aid in such cases. 
Since solid ovarian tumors (ovarian fibromata) are rare, any solid, 
movable abdominal tumor originating in the pelvis is, probably, a pedicu- 
lated uterine fibroid. Solid ovarian tumors have, in my experience, 
caused few symptoms, while solid uterine fibromata have occasioned much 
inconvenience. If ovarian tumors, especially small ones or those with 
solid walls, are adherent to the uterus, their differentiation from sub-serous 
uterine tumors is almost impossible, so long as they do not fluctuate. In 
such cases an exploratory puncture may furnish the desired information. 
Those cases are especially complicated in which, besides a uterine 
fibroma, an ovarian tumor is suspected. In such a case there should be 
two tumors, plainly distinguishable from each other. One of these is 
intimately connected with the uterus, while the other is distinct from 
it and independently mobile. If the latter also fluctuates, an ovarian 
tumor and a uterine fibroma are, in all probability, both present. The 
diagnosis is very difficult if one tumor is fixed in the pelvis and the 
other freely movable above it, because either ovarian or uterine tumors 
may be fixed in the true pelvis. Ovarian tumors usually grow much 
more rapidly than uterine fibroids. Puncture of that tumor which 
fluctuates the more plainly will establish the diagnosis. The cases of 
Grenser,1 Jules Simon,2 and Bouchet3 belong in this category. 
In a case of this kind I decided that the tumor which was the more 
closly connected with the uterus was a fibroid, because I had perforated the 
uterus with the sound, although the sounding was conducted with caution 
I assumed that such a change in the uterine parenchyma as would render 
it so friable, would rather attend the development of a uterine fibroma 
than of an ovarian tumor. The perforation of the uterus has not resulted 
prejudicially to the patients in those cases which have come under my 
observation. Although the diagnosis of fibroid was established in the 
case just referred to, I subsequently encountered a patient with an ovarian 
tumor, the parenchyma of whose uterus was so friable that every intro- 
duction of the sound, unless very carefully conducted, sufficed to produce 
perforation of the uterus. 
In a large number of cases the diagnosis rests between inflammatory 
pelvic exudation, heematocele, and fibroma, and is often difficult, since 
doubtless all, or almost all, the cases of fibroid said to have been cured 
by baths have really been inflammatory exudations. The distinction 
between these morbid conditions should, ordinarily, be easy if the history 
and the symptoms be duly considered. In pelvic inflammation there is 
fever, and hsematocele is developed with great rapidity. In fibroid there 
1 Arch. f. Gynakologie, VIII., p. 347. 2 Bull, de la Soc. Anat., Ill,, p. 69. f 
Ibid., 29, p. 136.f 240 
NEW GROWTHS OF THE UTERUS. 
is almost always a tumor with well-defined outlines, which is not the case 
in pelvic inflammatory exudations or in haematocele. If these effusions 
are present they may, moreover, be shown to be firmly connected with 
the pelvic parietes and to be directly continuous with the soft parts of 
the pelvis. This is true no matter how closely the uterus may be con- 
nected with, or how completely it may be displaced by, the extravasated 
blood oi' inflammatory exudation. Softness or fluctuation of the tumor 
usually speaks against the presence of uterine fibromas. 
After what has been said, it might seem almost impossible to con- 
found the conditions in question. But the so-called incarcerated fibroids 
easily lead to errors. Kiewisch1 and Spiegelberg designate as incarcer- 
ated fibroids only those which are originally interstitial, and which, grow- 
ing downward, more or less completely fill the true pelvis, and can neither 
be moved in or displaced from it. This designation is certainly applicable 
to a large series of tumors, susceptible of exact anatomical differentiation. 
These tumors may grow so far downward as to become retro-vaginal, and 
maybe occasionally mistaken for vaginal neoplasms. Since incarceration 
and its phenomena can only become the basis of a clinical classification, it 
is proper to include among the incarcerated fibromata all those tumors 
which, having either developed in or sunken into the pelvis, have not 
escaped from it in the process of growth. This definition has special 
reference to those fibroids which have become fixed in the pelvis by in- 
flammatory processes. 
The interesting case reported by Leopold2 provesthat tumors devel- 
oped from the fundus may become fixed in this manner. Since such 
displaced and firmly fixed tumors readily become (edematous, soft, or even 
fluctuating, from venous congestion, it may often be quite impossible to 
distinguish between them and pelvic exudations, particularly since the 
latter frequently complicate fibroids. So long as there are no inflamma- 
tory deposits the diagnostician can, usually, succeed in passing his finger 
between the globular tumor and the pelvic parietes, or in producing an 
indentation between the symphysis and the tumor by abdominal palpa- 
tion, thus rendering the presence of a uterine neoplasm probable. 
Rectal palpation is unavailing in these cases. Whenever it can be 
utilized the case is not one of incarcerated fibroma. 
Exploratory puncture is of value in differentiating haematocele and 
pelvic exudations from fibroids, but is not an entirely safe procedure. In 
incarcerated fibroids it is specially liable to result in circumscribed pelvic 
peritonitis. Even gangrene of the fibroma has been known to follow 
the operation and lead to a fatal issue. Spiegelberg3 saw this accident 
result from frequent examinations of the fibroma. 
1 Klin. Beitrage, L, p. 452. 5 Arch, fur Heilkunde, 1876, p. 408. 
3 Arch, fur Gynakologie, V., p. 100. DIAGNOSIS AND PROGNOSIS. 
241 
My experience impels me to disparage the use of Dieulafoy's aspirator 
in these cases. The forced action of the instrument often produces ex- 
travasation into the tissues of the tumor, accompanied by gangrene of 
the latter, or hemorrhage into Douglas's pouch attended by inflammatory 
symptoms. 
In a majority of these cases one must rest content with a diagnosis of 
probability, and must not aggravate the condition of the patients by a 
resort to dangerous aids to diagnosis. 
The prognosis in cases of uterine fibromata, if received from a purely 
anatomical standpoint, might be unhesitatingly pronounced good. 
These local and homologous tumors are, par excellence, of a benign char- 
acter, so that the patient may be regarded as absolutely cured after their 
successful removal. On the other hand it is obvious, from the preceding 
clinical history of these neoplasms, that they constitute grave morbid 
conditions and may jeopardise life in many ways. No farther explana- 
tion of this point seems necessary, since no individual case resembles any 
other with reference to the prognosis. Particular attention must be 
given to the location and the size of the tumor, to the chief symptoms, 
and to the age and general condition of the patient. An accurate ap- 
preciation of these varying conditions constitutes the chief skill of the 
gynecologist. CHAPTER VI. 
THE TREATMENT OF UTERINE FIBROIDS. 
^PIIE first indication in cases of uterine fibroids relates to their removal, 
by which the complete recovery of the patients is ordinarily as- 
sured. Symptomatic treatment is only necessary before the removal of 
the tumors, and in cases unsuitable for operative interference. 
Since time immemorial, two leading methods have been resorted to, 
for the cure of fibromata. One of these consists in the administra- 
tion of medicines operating both generally and locally-the other in com- 
plete or partial removal of the tumors by instrumental interference. It 
is unanimously conceded that we possess no certain means, no trustworthy 
methods, of producing reabsorption of a fibroma by constitutional treat- 
ment. 
Cases are, however, reported in which the use of Kreuznach, or 
some similar mineral water, is said to have cured such tumors. A 
similar result is reported to have followed the administration of 
calcium chloride (M'Clintock), bromide of potassium, iodide of potas- 
sium, phosphorus, arsenic (Gueniot), and mercury. The general opin- 
ion is that, if resorption of a fibroid have ever occurred during the 
use of these remedies, it must be regarded as an accident. The majority 
of such cases may probably be referred to errors in diagnosis, involving 
the confusion of these tumors with haematoceles or inflammatory deposits. 
We shall, later on, recur to the value of some of the above-mentioned 
remedies, in the palliative treatment of fibroids. 
We cannot, as yet, pass so definitive a judgment upon the results of 
hypodermic injections of ergotin, as first'employed by Hildebrandt.1 
It is not to be denied that, in pure myomata, especially if, as rarely 
happens, the tumor is' not separated from the uterine parenchyma by a 
capsule, ergot may so influenc the muscular fibres in and around the 
fibroma as to cause its atrophy and disappearance from defective nutrition. 
Spiegelberg2 has particularly emphasized this fact, which is not, how- 
ever, supported by any considerable statistical data Five cures have been 
observed by Hildebrandt in 25 cases of this nature, but so far as I know 
1 Berlin Klin., Wochenschr. 1872, No. 25, and Beitrage z. Geburtshiilfe, etc., 
von der Berlin, Gesellschaft fur Geburtshiilfe, III., p. 261. 
2 Arch. f. Gynakol., IV., p. 515. TREATMENT OF UTERINE FIBROIDS. 
243 
no others appear either in German or French literature. On the other 
hand Byford 1 cites, from American literature, 18 cures effected by White, 
Goodrich, Howard, Jackson and others. The accuracy of this statement 
is, however, rendered somewhat doubtful by the fact that Byford quotes 
a case of Chrobak,2 as cured, while Chrobak himself only claims that the 
symptoms were cured, while the tumor, a large part of which had been 
removed, could still be felt. It must, however, be admitted that a num- 
ber of complete cures have been effected by the hypodermic use of ergo- 
tin. The possibility of errors in diagnosis, in some of the reported cases, 
must always be borne in mind. Even Hildebrandt3 admits in his fifth 
case, the possibility that an inflammatory deposit may have been mistaken, 
for a fibroid. 
This method of treatment is an exceedingly uncertain one, since, ac- 
cording to universal experience, a cure can be counted on with but very 
little confidence. If it were possible to make the diagnosis of fibromata, 
with reference to their histology and their connection with the uterus, 
more exact, it might be easier to designate those cases in which hypodermic 
injections of ergot would be efficacious. It may be appropriate at this 
point to consider the value of this method of treatment in general. 
E. J ager4 found that, out of 27 fibro-myomata of the uterus, treated by 
Hildebrandt, with hypodermic injections of ergotin, the tumor disap- 
peared in 5, or 20 per cent. In 16 cases, or 64 per cent., amelioration of 
the symptoms occurred, i.e., hemorrhages were less frequent and the size of 
the tumors diminished. In 4 cases, i.e., in 16 per cent., no result was 
attained. In 20 other cases, reported by Bengelsdorf, Chrobak, Henning 
Scanzoni, Keating and Burrows, Jager found improvement nine times, i.e., 
in 42 per cent., no benefit eleven times, i.e., in 55 per cent., and no cures at 
all. He farther reports eleven cases, from E. Martin's clinic. In two of 
these improvement occurred, and in ten no result followed treatment. In 
five cases A. Martin (Jager, I. c.) saw no result from hypodermic injections 
of ergotin. Fehling,5 however, saw notable diminution in a tumor thus 
treated, and good results were attributed to the method by the members of 
the Leipzig Obstetrical Society, on the occasion of Fehling's report. 
Eggel, Schrenk, Lbhlein, and E. Martin reported four unsatisfactory 
cases to the Berlin Obstetrical Society.6 
On the other hand Winckel,7 although he failed of observing any com- 
plete cure after this treatment, still confirmed Hildebrandt's statements 
relative to the arrest of hemorrhage and the reduction in the size of the 
1 The Address in Obstetrics, Trans, of the Am. Med. Association, Philadelphia' 
1875. 
2 Arch, fiir Gynakol, VII., p. 293. 3 Beitrage, III., p 270. 
4 Behandlung der Fibromyome des Uterus, etc., Inaug. Diss, Berlin. 
5 Arch, fiir Gynakol., VIL, p.384. * Beitrage, etc., III., pp. 9 and 21. 
7 Klin. Vortrage, No. 98, 1. c., p. 29. 244 
NEW GROWTHS OF THE UTERUS. 
tumors. A considerable number of uterine myomata have been treated 
at my clinic, in careful pursuance of the method in question, and chiefly 
by my former assistant, Prof. Zweifel. We were unable to observe any 
considerable decrease in the size of the tumors, although the hemorrhages 
were, in many instances, checked, for a varying period, after the treat- 
ment. 
The diminution in the size of the tumors was transient and often 
characteristic, as long as the contractions referable to the ergotin con- 
tinued. True diminution cannot, however, be said to have occurred. 
A similarly deceptive appearance of diminution may be produced by con- 
gestion occurring at the menstrual epoch. 
In a case, observed by myself, the dimensions, taken with all possible 
precautions, were as follows: Circumference, at the umbilicus, 87 ctm.; 
at a point midway between the navel and the symphysis, 8G ctm ; 
distance between the ensiform cartilage and the umbilicus, 17 ctm.; 
distance from the symphysis to the xiphoid cartilage, 38 ctm. These 
dimensions increased, during the eight days preceding the menses, to 
90, 89, 18 and 40 ctm., in spite of injections of ergotin and without 
complicating tympanites. After violent hemorrhage, which continued 
5 days, they were again reduced to 85, 85, 15 and 33 ctm., respectively. 
Later they returned to their former size, and remained, thereafter, un- 
affected by the hypodermic administration of ergot. 
Emmet and Barker1 also reported, to the N. Y. Obstetrical Society, 
that they had had no success with this method of treatment. On the 
other hand Byford Joe. cit.) finds the results, in G1 cases, to have been as 
follows: Completely cured, 18; reduction of the size of the tumor and 
arrest of hemorrhage, 2G; arrest of bleeding, only, 5; no results, 12. 
Quite recently Leopold2 has published the following observations on the 
use of long-continued hypodermatic injections of ergotin. His cases were 
twelve in number. In three of them no change occurred in the fibroids. 
In five the hemorrhages were considerably lessened, and in four cases the 
tumors also became somewhat reduced in size. Similar experiences were 
recorded by Schorler (I. c.) at Schroder's clinic. In not a single instance 
was a cure obtained. Out of 61 cases occurring in private practice, 37 
were improved, and 24 not improved. Of twenty dispensary patients, 
seven were improved and 13 not improved. » 
On the other hand Jakubasch s states that in 22 cases he "almost in- 
variably observed an amelioration of symptoms." Fritsch,4 Brubecker,5 
and Dean6 have described cases of expulsion of sub-mucous fibroids 
1 Obstetrical Journal, II., pp. 432 and 433. 2 Archiv. fur Gynakoi. XIII. 
8 Charit6-Annalen, 1881. 
4 Centralblatt fur Gynak., 1879, p. 18. 
5 Philadelphia Med. Tinies, 1878, Jan. 19. 
6 Boston Med. Journ., 1878, Jan. 24. TREATMENT OF UTERINE FIBROIDS. 
245 
through the vagina, terminating favorably, after treatment of this kind. 
P. Muller 1 has published four cases in which he observed considerable 
reduction in the size of the tumors, following the injection of ergotin. 
All observers agree that, even when the treatment is most carefully 
conducted, i.e., by means of deep injections into the upper abdominal 
regions, very violent local pains, indurations, inflammation and abscesses 
of the skin may be the results. Transitory symptoms of ergot poisoning 
have, moreover, been occasionally observed. Considerable unanimity of 
opinion prevails regarding the necessity of making more than 50 hypo- 
dermic injections before any definitive conclusion can be drawn concern- 
ing their efficacy in any individual case. This fact makes it the more 
necessary to take the irritating local effects of the treatment into account. 
Lent2 observed notable improvement in one case, after the hypo- 
dermic use of ergotin. A peritonitis, of problematical source, caused the 
patient's death, and no statement is made concerning the possible connec- 
tion between the peritoneal inflammation and the treatment. 
Allen3 observed reduction in the size of the tumor and diminution of 
hemorrhage after the hypodermic use of ergotin. The injections were 
made, in his case, on the left side of the abdomen. After the 30th injec- 
tion an extensive thrombosis occurred in the veins of the left leg and per- 
sisted for three months. When metrorrhagia recurred, after several months, 
injections of ergot were resumed, this time on the right side of the abdo- 
men, and were soon followed by serious venous thrombosis in the right leg. 
Lusk4 treated a case of large myoma for one month by almost daily 
injections of one grain of ergotin. The tumor diminished in size, but 
became gangrenous. The patient died of peritonitis. 
A brief review of the preceding cases will beget the conviction that Hil- 
debrandt's method of sub-cutaneous ergotin injections constitutes a very 
valuable accession to our therapeutic armamentarium against uterine 
fibroids. This method seems well adapted fox- permanent or, at least, 
for long-continued arrest of hemorrhage, however uncertain its results 
may be with reference to the complete re-absorption or to a reduction in 
the size of the fibroids. In spite of the disagreeable results which may 
possibly result from this method, it is nevertheless the least dangerous and 
the most certain, particularly in cases of pure myomata of the sub-mucous 
variety. 
Hildebrandt very properly emphasizes the fact that this method should 
not be employed if the tonicity of the uterine walls be impaired by either 
atrophy oi' areolar hyperplasia. If inflammatory products, resulting 
from parametritis or from perimetritis, be present, the method in ques- 
1 Deutsche Zeitschrift f. Chirurgie, 20. 
2 Abstract in Annales de Gynecologic, II., p. 240. 
3 Abstract Ibid., IV., p. 385. 
4 New York Med. Jour., July, 1882. 246 
NEW GROWTHS OF THE UTERUS. 
tion is not to be recommended. Hildebrandt advised the use of a solution 
of the aqueous extract of ergot, 3 grammes, in glycerin and water, each 
7.5 grammes. An amount of the solution equal to the quantity contained 
in a Pravaz's syringe is used for each injection. Later, the same author 
used solutions of the aqueous extract of ergot, 3 grammes in distilled 
water, 15 grammes, and the preparation of Wernich. Martin employed a 
solution of extract of ergot, 2 grammes, and of carbolic acid, one drop, in 
10 grammes of distilled water. The aqueous extract of ergot deserves our 
preference, according to my experience. Wernich's preparation, for sale 
at the Augusta pharmacy, in Berlin, seemed to me to have no advantages, 
either with regard to certainty of its results or to freedom from pain, 
after its injection. It also spoiled very rapidly. w 
Dragendorff's sclerotinic acid was very badly tolerated by one of my 
cases, perhaps because it was not neutralized. The preparation of Zweifel 
deserves careful trial. 
For the sake of completeness I shall now mention other methods em- 
ployed for the radical cure of uterine myomata. None of them can 
claim recognition as genuine methods of treatment. Freund 1 saw spon- 
taneous degeneration and extrusion of the tumors in two cases, after the 
internal use of the Jastrzember saline waters. Simpson 2 calls attention 
to the possibility of producing calcification of the fibroid by irritating it. 
Breslau 8 attempted this method and jeopardized the patient's life by in- 
ducing pelvic peritonitis. A. Meadows4 violently opposes this treatment. 
Kimball5 tried electrolysis, introducing needles through the abdominal 
wall into the tumor, and employing a Bunsen battery. He claims to 
have completely cured a very large fibroma by this means. Routh 6 
reports a similar result. 
Freeman 7 uses electrolysis by introducing one needle into the tumor 
through the cervix, and the other through the abdominal walls. • He re- 
ports a case of large myoma, which almost disappeared after eight appli- 
cations of this kind. 
A. Martin,8 of Paris, employed this method as follows: The positive 
electrode is applied to the cervix and the negative is placed over the ab- 
domen. Eighty to one hundred seances are necessary, and fifteen to 
twenty-five cells *are used in the battery. Out of twelve cases thus 
treated, four were cured, four improved, and four not benefited. 
Zweifel9 used electricity in two cases, in one of which a beneficial result 
1 Klin. Beitrage, part 3, Breslau, 1865, p. 142. 
2 Obstetrical Works, 1st ed. vol. I., p. 115. 
3 Monatsschrift fur Geburtskunde, suppl. XXV., p. 134. 
4 Obstetrical Journal, vol. II., pp. 481 and 563. 
5 Boston Med. Journal, 1874.f Canstatt's Jahresbericht, 1874, p. 758. 
* Brit. Med. Journal, 1864 f (abstracted in Schmidt's Jahrbucher, vol. CXXIXA 
' Centralbl. fiir Gynak., 1878. 8 Annales de Gynecol., 1879. 
9 Centralbl. fiir Gynakol., p. 50, 1884. TREATMENT OF UTERINE FIBROIDS. 
247 
was obtained. Cutter1 used " electro puncture " in fifty cases of large 
fibroids. The electrodes were plunged through the abdominal parietes 
into the tumor. Each seance occupied from three to fifteen minutes, and 
the whole number from one to nineteen. Intervals of one or two weeks 
were allowed to elapse between the sittings. In seven cases no result 
was obtained, four times death ensued, thirty-two tumors ceased to grow, 
three were improved, and four " cured." 
Repeated efforts have been made to artificially produce gangrene of the 
tumors, which, when it occurs spontaneously, usually leads to favorable 
results. This method has been generally abandoned, on account of the 
great dangers incident to it, chief among which is absorption of septic 
material from the gangrenous tumor, which is still intimately connected 
with the uterus. Spontaneous gangrene is not attended by this danger, 
since it usually results from a separation of the tumor from the uterus. 
This point will be considered, at length, in our remarks concerning the 
enucleation of fibromata. Retzius2 first purposely induced spontaneous 
gangrene by repeated applications of the actual cautery. A cure ensued 
after protracted suppuration. West3 produced gangrene of a myoma by 
partial enucleation and multiple incisions. The course of the case was 
at first favorable, but the patient finally succumbed to peritonitis. 
It was Baker-Brown who emphatically recommended partial excision of 
fibromata in ordei- to render them gangrenous. lie incised the capsule, 
and chiseled or scraped out as much as possible of the tumor with a knife. 
He describes a successful case thus treated in the " Obstetrical Trans- 
actions," London, L, p. 329. Only sub-mucous fibromata, with broad 
bases, are, according to him, adapted for this treatment. 
In the "Obstetrical Transactions," III., p. G7, Baker-Brown reports six 
other cases treated in this way. In one of these the tumor disappeared by 
gangrene. In four cases marked diminution occurred, and death, resulting 
from pyaemia, terminated one. Baker-Brown subsequently partly aban- 
doned the operation.4 Nevertheless he reported two more successful cases. 
It produces a painful impression to find the statement frequently repeated 
by Baker-Brown, in the debates of the London Obstetrical Society, that 
any one can assure himself of the truth of his statistics by making in- 
quiries at the London Surgical Home. 
This method of treatment has not found many adherents. Playfair 5 re- 
ported a case of complete cure after long suppuration, by this means. Green- 
halgh's new method, consisting in incision of the capsule and destruction of 
the tumor by the actual cautery, belongs in this category. In one of his cases 
1 Amer. Journ. Med. Scien., July, 1878. 
2 Neue Zeitschrift f. Geburtsk., vol. XXXI., p. 423. 
3 Frauenkrankheiten, Gottingen, 1860, p. 364. 
4 Obstetrical Transactions, V., p. 21; also Surgical Diseases of Women, p. 196. 
5 Obstetrical Journal, II., p. 152. 248 
NEW GROWTHS OF THE UTERUS. 
the tumor was an incarcerated fibroid of the posterior lip. Its capsule was 
opened, at its most dependent part, and the tumor itself cauterized with the 
hot iron. After the occurrence of gangrene, a tumor larger than a child's 
head was gradually peeled out, the operation occupying a number of days. 
The cure was complete. In another case the hot iron was applied directly 
to a tumor occupying the os externum. The gangrene, inaugurated by 
this process, lasted some months, but the patient made a good recovery. 
Far more bold and original methods were resorted to in three other cases 
of incarcerated fibromata, which were not accessible from the os uteri. In 
these cases Greenhalgh reached the tumors by perforating the vagina 
with the hot iron, at the points where the pressure of the fibromata pro- 
duced bulging of the vaginal walls. Gangrene occurred in two cases. In 
one of these the tumor was entirely extruded, after repeated cauteriza- 
tions, and the patient recovered. The other case terminated in fatal 
pyaemia, after sloughing had lasted a month. The third case was one of 
incarcerated, spontaneously sloughing fibroid, which terminated by peri- 
tonitis. 
The operation of spaying must be classed with the symptomatic reme- 
dies, since it aims chiefly to bring about a cessation of bleeding. But it 
has also been claimed for this operation, that it diminishes or even obvi- 
ates the necessity for the more radical surgical measure of enucleation of 
the fibroid tumor. 
The operation of castration (spaying) was introduced into modern gyne- 
cology by Hegar, and immediately following him by Battey. This was in 
1872.2 
The removal of healthy ovaries in cases of fibroids of the uterus was 
first practiced by Trenholme8 (January, 187G), and a little later by Hegar 
(August, 1876). The latter has very clearly explained the principles un- 
derlying the subject under consideration. 
Experience has shown that with the advent of the menopause, the 
bleeding caused by fibroids not infrequently ceases, and that, moreover, 
retrogressive changes are inaugurated. It is certain that these tumors 
often cease growing after the climacteric period is reached. Now, an ar- 
tificial " change of life " can be secured by removal of the ovaries, and, 
as Hegar has pointed out, ligation of the nutrient vessels probably plays 
some part in bringing about this result. At times, however, no effect of 
this kind is obtained, and cystic degeneration of the uterine tumor occurs. 
For this reason Hegar advises that castration should not be done when the 
patient is already near the menopause, nor in those cases in which the 
1 Greenhalgh : On the Use of the Actual Cautery in the Enucleation of Fibroid 
Tumors of the Uterus, Medico-Chirurg. Transact., vol. LIX., p. 876. 
2 Hegar and Kaltenbach : Die operative Gynakol., 1881; also Centralbl. f. 
Gynakol., 1877, No. 5; and Stahl: Deut. Med. Woch., 1876, No. 51. 
3 Amer. Journ. of Obstet., 1876. TREATMENT OF UTERINE FIBROIDS. 
249 
growth of the uterus is undergoing degeneration or shows cystic forma- 
tions, nor, finally, when the tumors are very large. 
Hegar also holds that sub-peritoneal fibroids with accessible pedicles, 
and sub-mucous fibroids projecting far into the cavity of the uterus, 
should be removed and should not be treated by castration. On the 
other hand, spaying is indicated in small intra-parietal tumors, and in all 
those cases where enucleation or extirpation is beset by difficulties 
Since 1881 I have collected a number of cases, fifty-seven in all, includ- 
ing twenty-one reported by Hegar. Of this number ten died, forty were 
very much benefited, and in seven cases no improvement resulted. In no 
instance did the tumor disappear. It appears from this computation that 
the mortality was 17.5 per cent. 
Wiedow 1 has collected a larger number of cases. He found records of 
one hundred and forty-nine operations for fibroids, and fifteen of the 
number had a fatal result. This is equivalent to a mortality of about 10 
per cent. 
In seventy-six cases particulars of the final result of these castrations are 
given. There were observed: 
Atrophy of the tumors and menopause, . . 54 times 
Occurrence of menopause alone, ... 7 " 
Atrophy of tumors alone, . . . . 2 " 
Diminution of bleeding and atrophy, . . 6 " 
Menopause of three months duration followed 
by expulsion of tumor, .... once 
Irregular slight hemorrhages, ... 2 times 
Irregular severe hemorrhage, .... once 
Immediate good results followed by severe bleed- 
ing and growth of the tumors, ... 3 times 
At the present time, therefore, the following may be said concerning 
the value of spaying for uterine fibroids 
The operation leads with great certainty to an arrest of hemorrhages, 
provided the uterine tumors are not too large, and not in a condition of 
cystic degeneration. 
It is a much safer operation than extirpation by laparotomy. (The 
mortality of castration has been reduced to about ten per cent., that of 
radical extirpation is above thirty per cent.) 
On the other hand those who recover from the operation of castration 
still carry with them their uterine tumors, the presence of which entails 
manifold dangers. Again, a not insignificant proportion of those operated 
upon continue to have the same pains, and other symptoms due to the 
presence of the fibroids, as before spaying. 
1 Archiv. fur Gynakol., vol. XXV. 250 
NEW GROWTHS OF THE UTERUS. 
Those who survive extirpation of the fibroids are permanently and 
completely cured. 
Spaying must be classed with those measures which are directed against 
the chief symptom of fibroids, namely, the bleeding. Certainly among 
these measures, the operation is one of the most valuable, particularly as it 
can be used even in those cases where extirpation of the myoma seems 
contra-indicated or actually impossible. 
Spaying is indicated, more particularly, in cases of smaller fibroids that 
give rise to severe hemorrhages, and in all those cases where removal of 
the tumors appears too dangerous. 
It must, nevertheless, always be conceded that total extirpation of the 
fibroids is the " ideal " method of dealing with these growths. So, too, 
in comparing mortality statistics of the two operations under discussion, 
it must not be forgotten that myomotomy has certain " cures " in its 
favor, which experience has shown to be unattainable by castration. 
It seems sufficiently demonstrated, by the results of the above-mentioned 
modes of treatment, that radical relief from uterine myomata can be 
attained only by extirpation. In view of the numerous difficulties and 
dangers attending these tumors, their extirpation is indicated whenever 
practicable. The operation is easy in cases of sub-mucous fibroids which 
are provided with pedicles. The pedicle may be divided, even if it be 
rather broad, provided the tumor projects sufficiently beneath the mucous 
membrane to permit of its being encircled by the fingers or instruments, 
and to allow its pedicle to be elongated by traction. 
Attempts at extirpation are facilitated by projection of the myoma 
beyond the os uteri, particularly if it be possible to easily trace the pedicle 
upward. This is usually practicable, because the most violent symptoms 
only occur after the tumor has been forced through the os uteri 
When dilatation of the os has not taken place, the tumor must be ren- 
dered accessible by sponge-tents and incisions into the cervix. It is or- 
dinarily impossible to decide whether the tumor be provided with a pedi- 
cle or not until it is drawn downward. If the tumor be small, a sharp 
hook or a pince a creinaillere will suffice to draw it down. If it be 
larger it cannot be moved without Museux's or Greenhalgh's hooked 
forceps. 
The larger the tumor, the more necessary it is to draw it downward in 
order to reach the pedicle, and the more dangerous is it to do so, because 
of the liability to traction upon, and injuries to, the peri-uterine tissues 
resulting in para-metritis and peri-metritis. Inversion of the uterus may 
also happen, in which case severe injuries maybe inflicted upon the uterine 
parenchyma by the measures adapted for the removal of the fibroid. If 
the tumor be of large size it is often impossible to reach the pedicle with 
such ease, and reduction of the dimensions of the tumor by partial excision 
is inexpedient on account of the profuse hemorrhages certain to attend this TREATMENT OF UTERINE FIBROIDS. 
251 
operation. Under these circumstances, the pedicle may be best reached 
by a resort to the method described by Simon.1 
Transverse incisions are made into the tumor, or only through its cap- 
sule, with Cooper's scissors. The growth can then be elongated by trac- 
tion applied to its most dependent part, and the pedicle is thus rendered 
accessible. Hegar attains the same end by spiral incisions around the 
tumor. 
The pedicle having been reached by one of the above methods, and 
rendered tense by traction upon the tumor, it is severed by Casper's 
long scissors, or by Siebold's instrument, or by one similar to it, and 
the growth is removed by means of rotary movements. If the removal 
of the tumor be difficult, owing to its large size, it may be commi- 
nuted or compressed. No other instruments designed for severing the 
pedicle deserve mention, as they are either unnecessary or inappropriate. 
The conviction that the removal of a fibroid provided with a pedicle, by 
section of the latter, is the simplest and best method, is at present 
pretty generally accepted. The danger of hemorrhage during, or, rather, 
after such an operation tvas, at first, much dreaded and considerably over- 
estimated. Experience shows that the pedicles very rarely contain vessels 
of large size, and that hemorrhage from the severed end is, consequently, 
insignificant. Should it be at all profuse, it may be readily checked by a 
good tampon, or by cauterization of the bleeding point. 
The possibility of violent secondary hemorrhage from pedicles which 
do contain larger vessels must, however, not be disregarded. The primary 
hemorrhage, even in such cases, is trivial, because the muscular contraction 
resulting from the mechanical irritation of the uterus controls the bleed- 
ing. After a certain time the muscular contraction ceases and hemorrhage 
occurs. It is consequently advisable, when the patient cannot remain 
under the immediate supervision of the gynecologist, to insert a tampon. 
If hemorrhage be particularly apprehended, by reason of anaemia on the 
part of the patient, the pedicle may be severed by the galvano-cautery,2 
which is, however, very unsatisfactory, because one is by no means certain 
of obtaining an apparatus in good working order, and because it does not 
perfectly protect against secondary hemorrhage. 
Separation of the pedicle by means of the wire ecraseur of Braxton- 
Hicks, by that of Meier and Meltzer3 or by the constrictor of Maisonneuve4 
is simpler, but does not secure complete protection against hemorrhage. 
The ordinary ecraseur is very difficult of application, in spite of Marion 
Sims's chain adjuster, and does not afford immunity from hemorrhage. 
1 Monatsschrift fur Geburtsk., XX., p. 467. 
2 Ktichenmeister : Ktichenmeister's Zeitschrift, II., p. 378. f 
3 Especially recommended by Hildebrandt-Volkmann: Vortrage, No. 47. 
4 Gueniot: Arch, de Tocologie, II., p. 149. 252 
NEW GROWTHS OF THE UTERUS. 
Bayard1 witnessed such dangerous bleeding, after removal of a pedicu- 
lated tumor by the ecraseur, that a resort to acupressure was necessary. 
The chief danger attending the use of the ecraseur consists in the inclusion 
by the loop of the tissue adjoining the tumor. 
Tillaux2 opened the peritoneal cavity, while removing a fibroid with the 
ecraseur, and death resulted from peritonitis.3 The removal, by Boeckel/ 
of a myoma attached to the posterior lip of the os uteri, with a wire con- 
strictor, was followed by fatal tetanus. 
The separation of pediculated fibromata by ligation of the pedicle, a 
method often resorted to since the time of Levret, must be absolutely re- 
jected. The danger from septicaemia, phlebitis, peritonitis, etc., attend- 
ing this method, are so great that its employment might almost be desig- 
nated as malpractice. Idras3 recently reported another fatal case of this 
kind. Westa says that R. Lee lost nine out of twenty cases of this 
variety, thus showing the mortality attending the method to be almost 
twice as great as in lithotomy, and higher than in Asiatic cholera. If the 
pedicle can be easily ligated and if hemorrhage seems likely to occur 
from anaemia, let ligation be resorted to, but let the pedicle be imme- 
diately cut off, below the ligature, in order that gangrene of the tumor 
be avoided. 
In some cases, the pedicle is so thin and slender that a few powerful, 
rotatory movements suffice to separate the tumor. This process is, how- 
ever, seldom adapted to the removal of pediculated fibroids, and must be 
employed only where it succeeds without resort to unusual force. 
The pedicle must be divided as near to its uterine attachment as pos- 
sible. In certain cases this rule may be disregarded, since its observance 
is often difficult and liable to produce lesions of the uterine tissue. The 
remnant of the pedicle usually produces no inconvenience. It contracts 
and remains as an insignificant stump, or gradually sloughs away. If 
such a remnant be easily accessible, it may be destroyed by cauterization. 
It is not proven that new fibroids may be developed from the stump of the 
pedicle, a fact explained by the anatomical character of these tumors. 
The case is, of course, different if only partial enucleation of a large 
fibroma has been performed. 
Although the removal of pediculated fibromyomata is not always easy or 
safe, the operation is still so comparatively trivial and so free from danger, 
that it is the plain duty of the physician to remove them, as soon as the 
pedicles are accessible without much difficulty. The reverse is true of 
. 1 Boston Gyn. Soc., IV., p. 144. 
5 Annales de Gynecol., II., p. 461. 
3 Comp, also Annales de Gynecol., III., p. 70. 
4 Gazette M6d. de Strasbourg, June, 1875. 
6 Canstatt: Jahresbericht for 1874, II.. p. 758. 
6 Frauenkrankheiten, German Translation, Gottingen, 1860, p. 379. TREATMENT OF UTERINE FIBROIDS. 
253 
interstitial fibromyomata. These interstitial tumors which have grown 
symmetrically in both directions, and hence project equally into the uter- 
ine cavity and into the peritoneal cavity, must not be enucleated, since 
the operation would involve too serious a laceration of the peritoneum. 
Sub-serous fibromata are not adapted for enucleation. Only those in- 
terstitial fibroids which project far into the uterine cavity are to be 
treated by this method. The separation of broad-based fibromata, with 
very large pedicles, is, under these circumstances, not always easy, and 
many contradictory statements, in the literature of the subject, may be 
explained by this fact. Many an operator has been astonished at the fa- 
cility with which the " enucleation " of a large interstitial myoma was per- 
formed because he had really only been dealing with a broad-based fibrous 
polypus. The only practical point of distinction between these varieties 
is the capsule of the tumors. If the removal of the fibroid can only be 
effected after the perforation of a genuine capsule the tumor is, indeed, 
an interstitial fibroma, and enucleation has in that case really been accom- 
plished. 
If the capsule be absent, the case is one of fibrous polypus, or of a half- 
extruded interstitial myoma, which had already perforated its capsule 
and could be easily removed, either artificially or spontaneously. 
Velpeau seems to have first conceived the idea of enucleation of fibro- 
myomata projecting into the uterine cavity. Amussat first performed 
the operation and invited criticism upon it.1 
He was followed by Velpeau, Boyer, Berard and Maisonneuve.2 Some- 
what later Atlee gave a new impulse to the performance of enucleation in 
his work entitled " The surgical treatment of certain fibroid tumors of 
the uterus, heretofore considered beyond the resources of art," Philadel- 
phia, 1853. 
Various authors (as, for instance, Gilette, Annal. des. Gynccolog. 1875, 
III. p. 68) have called attention to the worthlessness of all so-called statis- 
tical compilations regarding the result of any operation for determining 
the value of the latter. In the first place it is well known that more suc- 
cessful than unsuccessful cases are published. There are, moreover, 
great differences in the temperaments of various patients and in their 
physical conditions at the time of the operation. The manner in which 
the operation is performed, or accidental circumstances relating to the 
after-treatment, also, often influence the result. 
So far as the operation in question is concerned, there are special diffi- 
culties in the way of utilization of statistics, because, in the first place, the 
exact significance of the term enucleation has not been definitely estab- 
lished. It is, moreover, frequently not stated whether, in a given case, the 
1 Revue Medicale, August, 1840, and Memoire sur 1'Anatomie pathologique des 
Tumeurs fibreuses de 1'uterus, Paris, 1842. 
2 Comp. Jarjavay : Des operations aux corps fibreux de l'ut6rus, Paris, 1850. 254 
NEW GROWTHS OF THE UTERUS. 
myoma was an encapsulated or only a broad-based one. In some instances 
the operation has been performed upon gangrenous tumors, and, in others, 
the expectant treatment has been adopted, after the first operative inter- 
ference, until gangrene has occurred. In still other cases the tumor has 
been removed at one sitting. 
It is even more important, in estimating the results of a given 
plan of treatment, to ascertain whether enucleation was performed 
upon a tumor already protruding into the os uteri, and was consequently 
of easy access, or whether the reverse conditions obtained. The above 
remarks will suffice to show the hopelessness of attempts at proving the 
value or otherwise of this operation by statistics, and yet one cannot dis- 
pense with the latter as a starting-point for inductive reasoning. 
The same statement holds for all important operations. Statistics con 
cerning ovariotomy, for instance, only proved, in the beginning, that the 
operation was justifiable in certain cases. At present the statistics are 
disregarded, and scientific significance is alone attributed to the results of 
individual operators. 
Just so long as the enucleation of interstitial fibromata is not per- 
formed, in any considerable number of cases, by individual operators, so 
long must we be content with statistical evidence obtained from medical 
literature. We, therefore, insert separately at this place the statistics 
at present published. These must not be tabulated together, since some 
series of observations might then be counted several times. An analysis 
of these statistics, which are of varying value, would necessitate too detailed 
a consideration of each case, and thus transcend the limits of the present 
work. 
West1 carefully collected the cases published between 1840 and 1858, 
and reports 27 of enucleation with 14 deaths and 13 recoveries. He, 
therefore, justly characterized the operation as one of the most dangerous 
kind. Mannel's2 well-known work, containing reports of 47 cases with 
30 cures and 17 deaths, next appeared. Mannel, himself, collected 22 new 
cases (since 1858), in 17 of which complete, and in 5 of which partial, 
enucleation was performed. Three cases resulted fatally. Twelve of the 17 
were neither pregnant nor puerperal women, and all made good recoveries 
C. Braun 3 collected 60 enucleations, with cures in 41 cases, i.e. in 68 
per cent. 
A. Martin4 collated 50 new cases, only 7 of which, or 14 per cent, 
terminated fatally. Manuel's and Martin's operations amount altogether 
to 66, with a mortality of 12 per cent. It is interesting to note that, ac- 
1 Loe. cit. p. 358. 
2 Prager Vierteljahreschrift, 1871. 2, p. 29. 
3 Wiener Wochenschrift, 1874, Nos. 39-41. 
4 Zeitschriftfiir Geburtshfilfe, etc., 1876, p. 143. TREATMENT OF UTERINE FIBROIDS. 
255 
cording to Martin's investigations, out of 12 cases in which enucleation 
was performed after the tumor had partially escaped into the vagina, three 
were fatal. The mortality thus amounted to 25 per cent, in these cases. 
On the other hand, those cases operated on before the tumor had escap- 
ed from the os uteri showed a mortality of 12£ per cent. 
Pozzi 1 gives very carefully prepared statistics of 64 enucleations with 
16 deaths, or 25 per cent. 
To these contradictory statistics I now subjoin the cases collected by 
myself, including those of West, because his cases show go high a rate of 
mortality, and because I shall, by including them, avoid the error to which 
the exclusive publication of favorable cases leads. I have not been able 
to consult the original report of West's cases, in all instances. I have 
either excluded the cases of all other observers which I could not find in 
the original, or have referred to the author's papers. I have not intro- 
duced cases of partial enucleation which lead to a cure by gangrene of the 
tumor, because they will be separately considered. 
On the other hand, enucleations which were begun but not completed 
have been included in the following list. The distinction between enucle- 
ations which were intentionally partial, and those in which accidental cir- 
cumstances led to an interruption of the operation, is not observed in 
the majority of the reports. 
The following are the favorable cases among those collected by West: 
Amussat, 2; Maisonneuve, 2; Grimsdale, Teale, each 1; Atlee, 7. 
I have also found the following cases which resulted favorably: Routh,2 
7; Hegar,3 7; Demarquay,4 3; Matthews Duncan,5 3; Hutchinson,6 12; 
Hutchinson,7 9, in which the capsule was perforated by means of the 
actual cautery; the same,8 four incomplete records; Guyon,9 5; By- 
ford,10 Whiteford,11 Boye,12 each 1 case; Marion Sims,13 8; Meadows,14 1; 
Hall Davis,15 2; A. Martin,16 4; Kuge,17 John Scott,18 Scott,19 Bourgeois,20 
1 De la Valeur de I'Hyst^rotomie, etc., Paris, 1875. 
* Brit. Med. Journal, 1864; Schmidt's Jahrb., vol. 129. 
3 Operat. Gynakolog., etc., p. 247. 
4 Maladies de 1'uterus, p. 266. 
8 Edin. Med. Journal, 1867, p. 707, and 1869, p. 848. 
6 Med. Times, 1857; Schmidt's Jahrb., vol. 129. 
' Cited by Courty, p. 830. 8 Cited by Courty, Mal de 1'Uterus, p. 830. 
9 Cited by Courty, p. 830. 10 St. Louis Med. Journal, 1869, p. 241. 
11 Edin. Med. Journal, Feb. 1870, p. 691. 
12 Canstatt. Bericht., 1871, p. 565. 
13 Uterine Surg'ery, p. 110; and On Uterine Fibroids, N. Y. Med. Journal, 
April, 1874. 
14 Obstet. Journal, I., p. 34. 15 Obstet. Transact., II., p. 17; and X., p. 227. 
16 Zeitschrift fur Geburtshiilfe, etc., I., p. 143. 
11 Ibid., p. 168. 18 Edin. Med. Journal, 1868, p. 362. 
19 Lancet, Dec. 20, 1872 20 Canstatt's Bericht., 1874. 256 
NEW GROWTHS OF THE UTERUS. 
Fleischer,1 Giommi,2 R. Barnes,3 Chroback,4 Mannel,6 Retzius,6 (each 
one case); Jordan,7 Frankenhauser,8 Gusserow,9 (each 2 cases); 0. 
Braun,10 (G cases.) 
The enucleations with a favorable result, collected by myself from the 
literature of the subject, thus amount to 103. We should remark that 
one of Frankenhauser's favorable cases died, a year after the operation, 
from obliteration of the vena cava, said by Frankenhauser to have de- 
pended upon morbid processes in the uterus. 
The following, cases resulted fatally: Atlee, 5; Berard, Baker-Brown, 
(each 2 cases); Maisonneuve, Boyer, Simpson, West (each lease); (quoted 
by West); Velpeau,11 2, (one of which was an unfinished operation); Routh, 
(loc. cit) 2; Hegar, Demarquay (loc. cit) each one; Hutchinson, (loc. cit) 
6, in which the capsule was split with the knife; G in which it was opened 
with the hot iron, and 2 unfinished operations. Guyon, (loc. cit.) 9; Sy- 
mington Brown,12 1 (incomplete); Marion Sims (loc. cit.) 5 (3 of them un- 
finished). Gusserow, 2 (not published and both unfinished). Total 
number of fatal cases 51. The total number of operations amounts to 
154, with a fatal issue in 51 cases, i.e., in 33.1 per cent. 
The cause of death was usually pyaemia or septicaemia, produced by gan- 
grene of retained portions of the tumors. In other cases death resulted, 
sometimes after weeks or months, from thrombosis, embolism, peritonitis 
or hemorrhage. 15 unfinished enucleations, with 9 deaths, are included in 
the above tables. In 29 cases the operation was done at different sittings, 
the intervals between which varied. Eight of these cases were fatal. 
It could be easily shown that improvements in technique, and a more 
careful selection of cases suitable for operation, have led to better results 
even up to the year 1877. But the introduction of antiseptic precautions 
has worked almost a revolution in this, as in so many other operations. 
Thus, for example, Lomer13has collected 130 cases embracing the period 
from 1873 to 1883. Of this number 18 died and 112 recovered, i.e., a 
mortality of 1G per cent. A few of the cases collected by him are con- 
tained in the above references, which extend up to 1877. The progress 
from a mortality of 33 per cent, to one of 16 per cent, is a decidedly re- 
markable one. 
Chrobak 14 has added 11 cases of his own (all successful), and 12 operated 
1 CanstatVs Bericht,, 1875. . 2 Ibid., 1875. 3 Obstet. Transact., 7, p. 55. 
4 Med. Chirurg'. Rundschau, 1871, cited by Mannel. 
5 Prager Vierteljahr., 1871, p. 29. 
6 Neue Zeitschr. f. Geburtsk., 31, p. 430. 7 Lancet, March 20, 1872. 
8 Correspondenzblatt fur Schweizer Aerzte, 1874. 
9 Monatsschr. f. Geburtsk., 32, p. 83. 
10 Wiener Med. Wochenschr., 1874, Nos. 39-41. 
11 Cited by Hegar, loc. cit., p. 247. 12 Pnilad. Surg. Reporter, 1871, No. 25. 
13 Zeitschrift f. Geburtsk. u. Gynakol., vol. IX., p. 277. 
14 Wiener Med. Blatter, 1884, Nos. 24-26. TREATMENT OF UTERINE FIBROIDS. 
257 
upon by C. v. Braun,1 with 5 deaths, to this number, which brings the 
total up to 153 with 23 deaths, a percentage of 15. If we add 2 cases by 
Bidder,2 and Engstrom,3 and two unpublished cases of my own, which 
were all successful, we get a grand total of 157 cases and 23 deaths, 
which is equivalent to a mortality of 14.6 per cent. 
From the statistics given above, it is at least possible to deduce the 
conclusion that the enucleation of interstitial fibromata is an exceedingly 
dangerous operation, and yet not so dangerous as to be unjustifiable, 
under certain conditions. The statement made above, that every sub- 
mucous, pediculated fibroma, which is accessible, should be removed, 
does not by any means apply with equal force to all interstitial myomata. 
In the first place it must be established what tumors of this variety ap- 
pear accessible for the purpose of the operation, and then the indications 
for the operation in these cases must be defined. 
We have already stated that only those interstitial myomata are 
adapted to the operation which have been chiefly developed in the direc- 
tion of the uterine cavity, and are, therefore, covered by as thick a mus.- 
cular layer as possible. It is by no means easy to establish the existence 
of these relations. It has been held that tumors of this description can 
not be sufficiently displaced from their original seat, by uterine contrac- 
tions, as to become accessible. But this has not been established. The 
relations of the tumor to the peritoneum may be better determined by 
palpation, and if possible by rectal touch. During enucleation it is also 
wise to locate the tumor, from time to time, by external palpation or by 
rectal touch, especially when considerable downward traction is being em- 
ployed. 
Although large tumors are often successfully removed, very bulky 
ones projecting far into the abdominal cavity are not adapted to the 
operation for several reasons. It is, in the first place, rarely possible to 
completely encircle them. Moreover, marked attenuation of the uterine 
walls attends the development of such fibromata, and they often can not 
pass through the pelvis, even when comminuted. Finally gradual and 
partial enucleation is attended by especial dangers. 
Enucleation is, also, always contra-indicated when the tumor has no 
capsule, or when the tumor's attachments to the uterus are so intimate and 
so extensive that a separation seems impossible. The so-called adhesions 
between the tumor and adjoining tissues, which are usually only strong 
muscular fasciculi extending into the tumor from the uterine walls, very 
frequently render enucleation impracticable, or so hinder it that it must be 
interrupted in order to be resumed after the occurrence of necrosis. There 
are, unfortunately, no means of discovering this connection between the 
uterine parenchyma and the tumor before the operation. The relation 
1 Lehrbuch d. ges. Gynakol., 1881, p. 457. 
2 St. Petersb. Med. Wochenschr., 1884. 3 Gynakol. Meddel., IV. 258 
NEW GROWTHS OF THE UTERUS. 
of the fibroma to the lowest segment of the uterus has the most impor- 
tant bearing upon the success of the operation. A long and conical por- 
tio vaginalis, with occluded os uteri, renders every effort at enucleation 
futile. In these cases, the tumor is either located so high in the 
uterus, or in such close proximity to the peritoneal cavity tlrat the opera- 
tion is either impracticable or too dangerous. The prospects of a success- 
ful operation are in direct ratio to the shortening of the lower uterine 
segment, to the permeability of the os uteri and to the facility with which 
the tumor may be felt within the latter. 
Courty evidently does not make a sufficiently sharp distinction between 
interstitial and broad-based sub-mucous fibromata when he requires, as 
one of the favorable prognostic signs, that the tumor shall, on traction, 
show evidences of possessing a pedicle. This is, however, often difficult 
whether from a clinical or from an anatomical standpoint. 
At all events, all severe traction on such a tun'ior, before the perfora- 
tion of the capsule, should be discountenanced, since it may lead to in- 
version, rupture of the peritoneum, hemorrhages, and, through injury of 
the capsule, to gangrene. 
If all the above-mentioned conditions are favorable, the indication for 
an operation is seldom doubtful. A fibroid of the kind in question 
almost always produces violent hemorrhages, which, of themselves, threaten 
the life of the patient. The pains are also, rarely absent, and the beginning 
symptoms of incarceration are often present. Rapid growth or sterility 
(Marion Sims) may likewise justify the operation of enucleation, more 
particularly in cases of cervical tumors. Another indication for enuclea- 
tion is beginning gangrene of the tumor, for the danger of systemic 
infection is only obviated, in such cases, by the removal of the offending 
mass. In this spontaneous gangrene the removal of the tumors is, ordi- 
narily, easy, since the capsule has already burst, and the connections 
between the fibroma and the uterus have been weakened by a dissecting 
necrosis. One must, nevertheless, not operate too early, even in these 
cases, for the more difficult the operation the more numerous and unavoid- 
able are the wounds necessitated by its performance and the more easy the 
absorption of septic matters. 
Even if strictest antiseptic precautions will doubtless diminish the dan- 
gers of an operation under such circumstances, surgical interference must 
never be attempted too soon. The general condition of the patient will 
have to govern our decision in this direction. 
There is an evident diversity of opinion regarding the method of the 
operation, some recommending that the enucleation be performed at one 
and others at two sittings. 
Matthews Duncan, Marion Sims, many others and myself have recom- 
mended the latter method, but never to the exclusion of the former. 
If it be easy to remove an intra-parietal myoma at one sitting, it would TREATMENT OF UTERINE FIBROIDS. 
259 
of course be unwise not to do so. It only seems advisable to await the 
effect of the pains and of beginning necrosis in order, perhaps, to bring 
the operation to a speedy end, at one or more subsequent sittings. This 
method is, at all events, better than a systematic attempt at the invariable 
completion of the operation, during one sitting. If the operation be 
undertaken with this end in view, it is often necessary to inflict most 
serious injuries, and even then to abandon the undertaking, after great 
exhaustion and injury to the patient. 
After the patient has been thoroughly brought under the influence of 
an anaesthetic she should be placed in the lithotomy position. Some 
operators, as Marion Sims, always prefer the lateral decubitus. The 
location of the tumor sometimes renders the latter position more appro- 
priate. Even after careful disinfection of the vagina, and, if possible, the 
cavity of the uterus, it is well to employ a two to three per cent, solution 
of carbolic acid throughout the entire course of the operation. 
if the os uteri is not sufficiently patulous to render the tumor accessible, 
it should be enlarged with scissors. Dilatation of the os with sponge 
tents, etc., is slower, less certain and more dangerous, because gangrene 
and infection are thereby invited. Even after enlargement of the os, by 
means of incisions, the tumor is often not sufficiently accessible. In this 
case the operation must be interrupted and ergot given with a view to 
producing descent of the tumor by means of uterine contractions. When 
the tumor has been brought within reach, which is effected through fixation 
of the uterus by external pressure on the fundus and by means of traction 
with a sharp hook, the capsule should be split, at its mostdependent part, 
with a bistouri or the scissors. (If the fibroid projects far into the uterine 
cavity it may be better treatment to make the incision into the capsule 
as near the base of the tumor as possible. Ilegar). It seems superfluous 
to use Sims's speculum for this procedure, or to excise a part of the cap- 
sule (Meadows). 
Perforation of the capsule with escharotics (Simpson), with the hot 
iron (Hutchinson), or by the galvano-cautery (C. Braun), has not been 
generally adopted. These methods are recommended for the prevention 
of hemorrhage, when the capsule is perforated, but they fail of accom- 
plishing this object in serious cases. The bleeding may, then, be best 
controlled by immediate section of the vessels in the capsule, and by a 
rapid completion of the operation, but it may become so severe as to ne- 
cessitate the use of the tampon. 
The use of styptics during the operation is inappropriate. If a por- 
tion of the tumor is exposed by the incision in the capsule, enucleation is 
at once begun. For this purpose the tumor must be seized and drawn 
as far downward as possible. Museux's, Greenhalgh's, or similar toothed 
forceps may be used. Marion Sims, A. Martin and others have invented 
special sharp hooks or hooked forceps, by which it is claimed that the 260 
NEW GROWTHS OF THE UTERUS. 
tumor may be more firmly held, and the soft parts of the patient pro- 
tected. None of the instruments perfectly accomplishes these ends. 
For reasons already given, too powerful traction must not be made with 
such instruments upon the tumor. Traction should never be so firm as 
to invert the uterus, as Hutchinson recommends. 
Enucleation may be best accomplished with the fingers, which usually 
separate the loose tissues of the capsule with facility. Tumor adhesions 
should be divided with the knife or scissors. If the hand can not reach 
high enough, it may be replaced by the enucleators recommended by 
Sims. C. Braun sometimes successfully used the cranioclast for crushing 
the tumors. As the enucleation proceeds the tumor must be drawn or 
twisted in a downward direction. If it is not easily accomplished the 
capsule may be separated, so far as possible, and the operation suspended 
for a few days, until beginning gangrene shall have produced a diminu- 
tion in size, and a loosening of the connections of the fibroma. 
The expulsion of large fibroids from the vagina after their enuclea- 
tion is sometimes quite difficult, resulting even in rupture of the 
perineum. Incisions into the latter are occasionally necessary (Dupuy- 
tren, Marion Sims), or the tumor must be comminuted before its expul- 
sion can be effected. After the removal of the tumor it is usually 
unnecessary, and may even prove dangerous, to remove shreds of tissue or 
retained portions of the capsule with sharp instruments. Let the uterus 
and vagina be washed with a five per cent, solution of carbolic acid (or 
1:2000 bichloride of mercury), and tampons dipped in glycerine and 
iodoform be inserted. The after-treatment, such as drainage, etc., is 
conducted in accordance, with general surgical principles. 
Beside the manifold dangers attending the operation, which have been 
cited above, collapse may follow. It is proportional in severity to the 
length of the operation and to the loss of blood. The general condition 
of the patient, also, at the time of operation will, of course, have impor- 
tant bearings on the development of this as well as other complications. 
A special modification of the operation of enucleation has been re- 
cently devised for those cases in which the fibroids start from the cervix, 
and are situated without the peritoneal cavity, growing in a downward di- 
rection. Such growths have been observed to narrow the lumen of the 
vagina. Caselli1 has reported a case of this kind, in which he success- 
fully removed a myoma by splitting the vaginal wall which formed a cov- 
ering for the tumor. Van Derveer9 proceeded in a similar manner in the 
case of a sub-peritoneal fibroid growing from the posterior wall of the 
uterus. By opening Douglas's pouch he succeeded in removing the 
growth per vaginam. 
Czerny8 has also recorded two successful cases of this kind, in one of 
1 Annali di Ostetr., 1881. 2 Boston Med. and Surg. Journ., 1879. 
3 Wiener Med. Wochenschr., 1881, Nos. 18 to 19. TREATMENT OF UTERINE FIBROIDS. 
261 
which Douglas's pouch had to be opened. He likewise mentions two other 
cases, one of which had a fatal termination. Lomer (1. c., p. 283) men- 
tions a successful case operated upon by Frankenhauser. and a second case 
by Schroder. In the latter case the tumor occupied the anterior wall of 
the uterus, and was successfully " peeled out" of the loose tissue beween 
the bladder and uterus. A case operated upon by Olshausen,1 also belongs 
in this category. It concerned a tumor that had grown downwards push- 
ing the posterior vaginal wall down before it. Enucleation was made 
possible without opening the peritoneal cavity and the patient made a 
good recovery. 
In a general way it may be stated that this method is applicable only 
to the smaller tumors which are situated outside the cavity of the peri- 
toneum. Growths so situated are, however, very apt to cause consider- 
able disturbance. 
We have already emphasized the difficulties attending a strict discrim- 
ination between partial enucleation or amputation of a fibroma, and 
incomplete enucleation. There are numerous cases, however, in which 
the impossibility of a complete removal of the tumor is recognized from 
the beginning, and in which, nevertheless, circumstances make it neces- 
sary to at least amputate a portion of the fibroid. Cases of incarcerated 
fibromata, reaching low into the pelvis, and producing serious symptoms 
by pressure upon the intra-pelvic organs, are those to which the above 
remark applies. In these cases it is at least necessary to remove those 
parts of the tumor situated within the pelvic cavity. The results of the 
operation, when performed under these circumstances, are very variable. 
This may be partly due to the difficulty with whjch broad-based sub'mu- 
cous fibromata are differentiated from interstitial ones. It is easier to 
understand how the remnant of the tumor should, in the former case, 
remain unchanged than in the latter class of cases, in which an intersti- 
tial fibroid is partially destroyed and robbed of its nutrient vessels by in- 
complete enucleation. 
P. Muller,2 Manuel (loc cif.), Chiari,3 Chrobak,4 Hutchinson, McClin- 
tock, Schroder and others have reported favorable cases in which partial 
amputation of the tumor resulted in the removal of the symptoms due 
to pressure. In some instances cicatrization, even attended in certain 
cases by diminution in the size of the tumor, occurred along the line of 
incision. In very rare instances the tumor is subsequently entirely ex- 
pelled, without undergoing mortification.' After partial enucleation gan- 
grene, however, usually occurs, and may, in isolated cases, lead to a cure, 
the tumor being expelled or gradually undergoing complete mortification. 
1 Klin. Beitr. z. Gynakol. u. Geburtsk., Stuttgart, 1884, p. 96. 
2 Archiv fur Gynakol., VI., p. 127. 3 Klinik der Geburtshiilfe, p. 408. 
4 Med. Chirurg. Rundschau, p. 871. 
6 Frankenhauser, Correspondenzblatt f. Schweiz, Aerzte, 1875, p. 225. 262 
NEW GROWTHS OF THE UTERUS. 
In the majority of the cases death results from pyaemia or septicaemia, 
the danger of which should be always borne in mind when partial enu- 
cleation is undertaken. Very instructive cases, of this kind, are reported 
by Marion Sims, by Spiegelberg,1 Riedinger2 and Breisky.8 
In all those cases of uterine fibroids which threaten the patient's life, 
and in which relief can not be obtained from the operations already de- 
scribed, laparotomy with removal of the tumor, or of the uterus with the 
tumor, is the last resort. The following remarks will show that this op- 
eration is undoubtedly justifiable in certain cases, although the belief that 
laparotomy for the removal of large uterine fibroids is neither more diffi- 
cult nor more dangerous than ovariotomy, is decidedly erroneous. These 
operations are not to be compared, even with reference to their relative 
utility. 
Laparotomy has passed through different periods of development, 
just as so many major operations, particularly ovariotomy, have done. 
Lizars (1825), Dieffenbach (1826), Atlee and others, opened the abdominal 
cavity for the purpose of performing ovariotomy when, really, only uter- 
ine fibroids were present. Considering it impossible to remove such 
tumors in this way, those observers simply closed the abdominal cavity. 
Out of fourteen cases of this kind, in which the operation was not per- 
formed, five died from the effects of the surgical interference.4 
Chas. Clay, in August, 1843, and Heath, in November, 1843, went a step 
farther: Having opened the abdomen, for the removal of what they sup- 
posed to be an ovarian tumor, they found uterine fibroids alone present and 
removed them through the abdominal wound. Both patients died.5 Chas. 
Clay (1844) and Parkmann (1848) had similar cases. Burnham (1853) 
having committed a like diagnostic error, removed the uterus, with its 
contained fibroids, and saved his patient's life. 
Peaslee (1855), Boyd (1856), Spencer Wells (1869), and Sawyer (1860), 
having made similar mistakes in diagnosis, performed the same operation 
without success. 
Kimball6 was the first to extirpate a previously diagnosticated uterine 
fibroma, with the uterus, in 1853. This case ended in recovery. Koeberle 
(1863), was the next to perform this operation, which was now removed 
from the domain of accident, and received among approved surgical 
' Archiv fur Gynakol., V., p. 100. 
2 Wiener Med. Wochenschr., No. 20, 1883. 
3 Zeitschr. f. Heilkunde, vol. V., 1884. 
4 Pozzi : De la Valeur de l'Hyst6rotomie, etc., Paris, 1875. 
5 Hegar, Operative Gynakologie, p. 214, says that Granville removed a pedicu- 
lated subserous myoma by laparotomy in 1837. The patient died. Atlee and 
Lane performed the same operation with success in 1844. Hegar does not mention 
his authority for these statements. 
6 Boston Med. & Surg. Journ., 1855. Compare P6an, Hysterotomie, Paris, 
1873, p. 6. TREATMENT OF UTERINE FIBROIDS. 
263 
measures, although it was reserved for later times to show in how far it is 
justifiable. 
All the statements made in our remarks on enucleation, regarding the 
uncertainty of deductions concerning the value of operations, as based on 
statistical evidence, apply equally to laparotomy in cases of uterine 
fibromata. In order, however, to give a point of departure for an estimate 
of the danger attending the operation I here append the statistics, pub- 
lished until 1878, without criticism, although many require it very much. 
It is not, as a rule, clearly stated in these reports, whether only the 
tumor was removed through the abdominal wound, the uterus and 
ovaries being left behind, or whether the latter were also extirpated. 
Moreover, all operations, of this kind, done on cysto-fibromata, are in- 
cluded in the tables. Pean (loc. cit.) collected 44 operations with 
30 cures. The mortality here amounted to 68.2 per cent. Marion Sims 
(on intra-uterine fibroids) found, among 11 extirpations done in Eng- 
land, 2 cures, i.e., a mortality of 82 per cent.; among 11 operations per- 
formed in America, 4 cures, i.e., a mortality of 64 per cent.; among 18 
operations, in France, 11 cures, i.e., a mortality of 39 per cent. 
Koerberle 1 found, up to 1864, 50 laparotomies, performed for the 
purpose in question, 35 of which were completed. 12 cures were attained, 
and 23 deaths occurred. 
Cateroault8 found among 20 gastrotomies, in which only the tumors 
were removed, 12 deaths, or 60 per cent. Among 12 extirpations of the 
uterus with the fibroids, he found 32 deaths, or 76 per cent. Routh 3 
collected 48 laparatomies, performed on account of uterine tumors; 15 of 
these were not completed (with 7 deaths), and 33 were completed (with 
23 deaths.) 
Gaillard Thomas's4 statistics are the most unfavorable of all. According 
to Storer, he cites 24 operations, with 18 deaths, or 75 per cent., and in 
addition quotes 10 other operations, done in America, 'all of which had a 
fatal termination. Schroder5 found, among 108 laparotomies, per- 
formed foi' uterine fibroids, 16 cures and 78 deaths, i.e., cures in 14.7 
per cent, and death in 85.3 per cent, of the cases. Of these 108 lapa- 
rotomies, 73 were combined with extirpation of the uterus. Among these 
cases there were 55 deaths and 18 recoveries The tumor alone was re- 
moved 35 times, death occurring in 23, and recovery in 12 cases. Pozzi 
1 Documents pour servir a 1'Histoire de 1'Exstirpation des tumeurs fibreuses 
de 1'Uterus, Strasbourg-, 1865. 
2 Essai sur la Gastrotomie dans les cas de tumeurs fibreuses p6ri-uterines, 
Paris, 1866. 
3 On some points connected with the pathology, etc., of fibrous tumors of the 
womb, London, 1864. 
4 Frauenkrankheiten. Translated by Jacquet, Berlin, 1873, p. 42g, 
5 Lehrbuch, p. 241. 264 
NEW GROWTHS OF THE UTERUS. 
{toe cit.) collected, up to 1875, 119 cases'of this kind, among which there 
were 77 deaths, i.e., a mortality of 64.7 per cent. 
All these statistics furnish, on the whole, a comparatively uniform and 
very unfavorable result. I have endeavored to prepare a more useful 
statistical table, which I now append. In the first place, I have omitted 
all cases in which laparotomy was done for the removal of a cysto-fibroma, 
because these tumors will be separately considered in the next chapter. 
Then, the laparotomies in which the uterus was not exsected have been 
carefully separated from those in which both uterus and tumor were re- 
moved.1 
I. Laparotomies for the Removal of Pediculated Sub-serous fibromyo- 
mata, without extirpation of the uterus. 
Koeberle 3 cases (2 reported by Caternault, toe. cit., 1 in Gazette Med. 
de Strasbourg, 1866, No. 5). Two fatal results. 
Sands I2 case. Death 5 minutes after the operation, from laceration 
of the common iliac vein. 
Gillespie.3 Large fibroma with many adhesions. Pedicle attached by 
clamp at lower angle of the wound. Death on the 2d day, from perito- 
nitis. 
Hackenberg.4 Pedicle separated by ecraseur. The tumor was con- 
sidered ovarian. Death on 3d day, from peritonitis. 
Burnham,5 recovery. 
Landi." Large soft myoma, considered an ovarian tumor. Death 
after 45 hours from peritonitis. 
Boye.7 In one case the pedicle of a sub-serous myoma was ligated and 
fixed in the lower angle of the wound. Death in 30 hours. In the other 
case the pedicle was secured with a clamp. Death on the 16th day. 
Vogt." Pediculated myoma, considered an ovarian tumor. Adhesions 
with arteries. Death on the 7th day. 
Kou th.9 Very Urge tumor (17| pounds) with ascites. Pedicle attached 
by clamp. Recovery. 
Spencer Wells.10 Fibroid mistaken for ovarian tumor. Pedicle held 
in clamp and ligated. Death on 3d day. 
Spencer Wells.11 Tumor with broad base, attached to fundus. The 
pedicle, when divided by the ecraseur, gave rise to hemorrhage, which 
could not be controlled until 2 needles were passed through the uterine 
wound, and having been surrounded by ligatures applied in a figure of 8 
form, were held in the lower angle of the wound. Recovery. 
1 Although these tables are omitted in the last edition of this work, it has been 
deemed advisable to retain them here, as they are useful for reference.-Ed. 
9 American Journal. Canstatt. 1866. 3 Edin. Med. Journal, July, 1866. 
4 N. Y. Med. Record, Jan. 15, 1868. 8 Boston Med. Journal, Jan. 9, 1868. 
6 Lo Sperimentale, 1871, p. 21. 1 Canstatt's Bericht., 1871. 
8 Canstatt's Bericht., 1873. 9 Obstet. Transact., XVIII., p. 5. 
10 Obstet. Transact., XL, p. 73. 11 Med. Times, July 29, 1871. TREATMENT OF UTERINE FIBROIDS. 
265 
E. Martin.1 Pedicle secured with clamp. Death from internal hem- 
orrhage. 
Hegar extirpated the tumor only. Death. 
Pean.3 One case. Recovery. 
The total number amounts to 17 laparotomies, with removal of the 
fibroma only. Among these 12 deaths or 70.5 per cent.4 (Koeberle 
collected 20 such cases, including cysto-fibromata, with 8 recoveries, i.e., 
a mortality of 60 per cent.) 
II. Cases of extirpation of the uterus for fibromata. 
Koeberle 5 3 successful cases. In one there was ascites and strong ad- 
hesions to the pelvic wall. 
Cutter.6 A sub-peritoneal fibroid. Adhesions to omentum. Death 
in 10 hours. 
Cutter.' Death in 75 hours. 
Peck? The tumor was considered ovarian. Death on the 2d day. 
Holston? A ery large tumor, also thought to be ovarian. Death on 
2d day. 
Atlee 10 saw death occur on the 5th day, as result of hemorrhage from 
the adhesions of the tumor. 
Hofmokl11 had a fatal case. 
Kimball.12 9 extirpations of the uterus; 3 cures. 
Lawson Tait13 successfully removed the uterus with a tumor weighing 
11 pounds. 
Chadwick.14 The cervix was secured in a clamp, after removal of the 
uterus. Death on 8th day from tetanus. 
Baker-Brown?5 Death in 12 hours from hemorrhage. 
Billroth16 lost one patient by septicaemia and another by shock, after 
extirpation of the uterus. A 3d recovered. He cites a 4th fatal case in 
1 Monatsschrift f tir Geburtskunde, 33, p. 242. 
2 Operationslehre, p. 214. 
3 Clinique Chirurgicale, Paris, 1876, p. 690. 
4 Kaltenbach describes two more cases of extirpation of the tumor by lapar- 
otomy (Zeitschr. f. Geburtshulfe undGynakol., Stuttgart, 1877, II., p. 186), which 
resulted favorably. These were not included in the above enumeration. 
5 Gaz. M6d. de Strasbourg, 1866, No. 72. Compt. Rend., 56, 1863. Professor 
Koeberle very kindly informed me recently, that, up to the end of 1877, he had 
performed laparotomy 19 times for the removal of fibrous tumors of the uterus, 
and of those cases 9 ended in recovery. 
6 Medical Record, New York, June 1, 1868. 
1 Ibid., October 15, 1869. 8 Phila. Med. Reporter, 1809. 
9 Ibid., 1869. 10 Am. Med. Journal, 1869. 
11 Wiener Med. Presse, 1873, Nos. 32 and 33. 
12 Boston Med. Journal, 1874. 13 British Med. Journal, November, 1874. 
4 Boston Med. Journal, 1875. 15 Obst. Trans., VI., p. 249. 
16 Wiener Med. Wochenschr., 1876, Nos. 1 and 2. 266 
NEW GROWTHS OF THE UTERUS. 
the practice of a physician of Zurich. The case described by Billroth,1 
in which an ovarian tumor was inseparably connected with a uterine 
fibroid, and in which death resulted from peritonitis, ought not, strictly 
speaking, to belong in this class/ 
Hegar3 reports 2 recoveries. In one, abortion was artificially induced 
before the operation. 
K. Thornton4 saw recovery after extirpation of the uterus, silk sutures 
having been passed through the cervix. 
Pean 3 performed 16 extirpations for fibromata, (not counting cysto- 
fibromata). 10 cures and 6 deaths. 
E. Boeckel.6 One fatal extirpation. The tumor was considered ova- 
rian. I finally cite, according tn Pozzi (toe. at.) 9 other hysterotomies 
(done by Bichet, Labbe, Ollier, Howtig, Stadfelt, Gayet and Pope). All 
of these ended fatally. One of Labbe's patients died of tetanus. One of 
Howtig's operations resulted favorably. 
The total number of extirpations of the uterus for simple (i.e., not 
fibro-cystic) myomata, thus amounts to 55. Among these there were 23 
cures and 32 deaths, i. e., a mortality of 58 per cent. 
We must compare with these results the statistics m which the fibro- 
cystic tumors are included. They are as follows: 
Koeberle found among 42 cases of extirpation of the uterus, collected 
by himself, in 1866, 8 cures. The mortality was thus 81 per cent. Boinet 
(1873) collected 42 cases, with 10 recoveries, i.e., a mortality of 73 per 
cent. 
Pean collected (toe. cit., 1876, p. 690) 25 hysterotomies with 17 cures, 
i.e., a mortality of 32 per cent. 
Among all these statistics the fact of the greatest value is that Pean 
(Pozzi, toe. cit.) saw, among 24 extirpations of the uterus, 8 deaths and 
16 recoveries. Koeberle notes, among 8 operations of this kind, (Pozzi, 
loc. cit.) 3 cures and 5 deaths. 
1 Wiener Wochenschr., 1873, No. 1. 
2 Billroth (Wiener Wochenschr., 1877, No. 40) recently reported another suc- 
cessful case of extirpation of the uterus, which is not included in the present 
list. There is still another case reported by Wolffel, in Langenbeck's Archiv for 
November, 1877. 
* Berliner Klin. Wochenschrift, March, 1876. 
4 Med. Tinies and Gazette, April 7, 1877. 
6 Clinique Chirurgicale, 1876, p. 690. The statistics of all Pean's operations 
(which cannot be included here) will be found in the Gaz. Obstet., No. 7, 1877. 
(Comp. Wiener Med. Wochenschr., No. 45, November 10, 1877.) We find from 
this report that Pean performed 33 extirpations of the uterus; of these there were 
21 for fibromata with 14 recoveries; 6 for " fibrocystic tumors " with 4 recoveries; 
4 for " cystic tumors of the uterus " with 3 recoveries, and finally 1 fatal case of 
"cystic carcinoma." 
6 Gaz. Med. de Strasbourg, June 1, 1875. TREATMENT OF UTERINE FIBROIDS. 
267 
The figures certainly plainly showed the unusual danger of laparotomy 
and hysterotomy, for the removal of uterine tumors. 
Since 1878, owing to the introduction of antiseptic methods of opera- 
tion, a great change has been wrought as regards the value of laparo- 
tomy in myoma of the uterus. Although the successful results of the 
operation cannot be compared to those obtained in ovariotomy, they 
nevertheless constitute one of the most marked advances of operative 
gynecology. A reasonable hope may be entertained that further pro- 
gress may lead to still better results, especially as regards the more 
dangerous kinds of tumors under consideration. 
Although it has been repeatedly shown that statistics are not of very 
great value, they are nevertheless essential to give us some general and 
approximate idea of the progress made in the results of operative interfer- 
ence. For this reason it seems proper to here borrow some figures from 
Bigelow's elaborate compilations. This author collected up to 1883, 573 
cases of laparotomy for the removal of uterine fibroids. Of this number 
311 recovered and 241 died, a mortality of 41.05 per cent. 
In 10G cases the tumors alone were removed (myomotomy in the strict 
sense), with a mortality of 49.03 per cent. In 229 cases the uterus was 
also removed (amputatio uteri supra-vaginalis), with a mortality of 41. 
04 per cent. As these computations include some of the older cases, the 
figures given have only a slight value. Nevertheless even they indicate 
progress. 
I have myself endeavored to collect as many cases as possible. Thus 
I found 359 cases, with 237 recoveries and 122 deaths, a mortality of 33.9 
per cent. To this number 245 other cases (by Schroeder, Olshausen, 
Braun, Tauffer and myself) should be added. Of the above-mentioned 
359 cases, 295 were amputations at the internal os, with a mortality 36.2 
per cent., and 64 were simple myomotomies, with a mortality of 20.5 per 
cent. 
The results published by individual operators are far more valuable 
than these general figures. The table on page 268 is the original of Bige- 
low,1 supplemented by Ilofmeier,2 and still later by myself. 
Bigelow (1. c.) has collected 279 cases occurring between the years 1878 
to 1883, with 244 recoveries, and a mortality of 35 per cent. 
All these figures merely show, in a general way, how much progress has 
been made in this operation. But as regards the advantages of any 
particular method of operation they show pothing at all, since it was not 
possible to separate one method from another. To compare myomotomy 
with ovariotomy is certainly inadmissible. 
Ovariotomy is always pretty nearly the same kind of operation, no 
' Amer. Journ. Obst., 1883 and 1884. 
2 Die Myomotomie, etc., Stuttgart, 1884, p. 7. 268 
NEW GROWTHS OF THE UTERUS. 
matter whether there are greater or lesser technical difficulties in the way 
of its performance. But this is by no means true of the operations for 
the removal of uterine fibroids. 
Cases. 
Recov'ries. 
Deaths. 
Mortality. 
Bantock 
Until Marell, 1883 
22 
20 
2 
9.092 
Tait 
" Sept. 1882 
30 
20 
10 
33.32 
Wells 
1882 
40 
19 
29 
52.52 
Thornton 
1882 
25 
16 
9 
36.02 
Koeberl6 
. 1882 
19 
9 
10 
52.02 
Billroth 
1882 
25 
10 
15 
HO. 02 
Schroder 
1884 
100 
68 
32 
32.02 
Hegar and Kaltenbach,. 
Sept. 1881 
12 
11 
1 
8.32 
Savage 
1882 
9 
6 
3 
33.32 
Thomas 
Sept. 1882 
13 
7 
6 
46.12 
Kimball 
Oct. 1883 
11 . 
6 
5 
45.42 
Pean 
July 1881 
51 
33 
18 
35.22 
Keith 
Dec. 1883 
25 
23 
2 
3.02 
Kaltenbach 
1883 
10 
9 
1 
10.02 
Olshausen 
1884 
29 
20 
9 
31.032 
A. Martin 1 
1884 
60 
27 
23 
38 32 
K. Braun 2 
1884 
16 
10 
6 
37.52 
Tauffer3 
1884 
16 
12 
4 
25.02 
Gusserow 4 
Early in 1885 
20 
12 
8 
40.02 
Total 
533 
338 
185 
Average mortality, 34.8%. 
The following classification may properly be made: 
1. The removal of pediculated or broadly attached sub-serous fibroids, 
simple myomotomy. 
2. The removal of tumors that have penetrated more or less deeply 
into the substance of the uterus, with partial excision of the womb, and 
with or without opening of the cavity of the uterus, amputatio uteri 
partialis. 
3. The removal of fibroids with excision of the uterus above the vaginal 
junction, i.e., invariably with opening of the cavity of the uterus, amputa- 
tio uteris supra-vaginalis. 
4. The enucleation of fibroids after opening the abdominal cavity, with 
or without opening of the cavity of the uterus. (Spiegelberg)/ Also the 
enucleation of these growths from within the cavity of the uterus, after 
incision of the latter as in Cassarean section. (A. Martin.6) 
5. Enucleation out of the cellular tissue of the pelvis, in those cases 
where the tumor has developed between the broad ligament, or altogether 
1 Magdeburger Naturforscherversammlung, Arch. f. Gynak., 25, p. 147. 
2 Wiener Med. Wochenschrift, 1884, Nr. 22 u. 30. 
3 Ibid., 1885. 
4 Not published. 
8 Archiv f. Gynak., vol. VI., p. 341. 
* Deut. Med. Wochenschr.. 1880, No. 27. TREATMENT OF UTERINE FIBROIDS. 
269 
outside of the peritoneal cavity, as in myoma of the cervix. These opera- 
tions are to be considered quite apart from ordinary enucleations involv- 
ing peritoneal adhesions. 
They are very difficult of performance, and offer a correspondingly 
poor prognosis. 
6. Total extirpation of the uterus, as suggested and carried out in some 
cases of this kind. 
In briefly considering these different methods, it may be premised that 
all those precautions characterizing "strictest antisepsis," are invariably 
to be taken. 
In dealing with the pediculated variety of sub-serous fibroid, the opera- 
tion will resemble simple ovariotomy. The pedicle is transfixed, secured 
by ligature near the uterus, and cut. If the pedicle is very broad, or 
very vascular, it is advisable to ligate each bleeding vessel, or to secure it 
by suture. 
If it becomes necessary to cut a part of the tumor out of the substance 
of the uterus, owing to a very broad attachment, the uterine wound is 
to be sewed up. 
These operations being comparatively simple, justify a favorable prog- 
nosis. Thus out of 21 cases Schroeder only lost 2, a mortality of 9.5 per 
cent. 
The cases mentioned under the second and third categories entail much 
more difficult and complicated methods of operation. In performing 
either partial or supra-vaginal amputation of the uterus, it is necessary to 
secure both the round and broad ligaments by double ligatures. When 
the uterus and the tumors that grow from it are thus made freely mov- 
able, it is best to place a rubber tube around the cervix, or at a point 
corresponding to the site selected for amputation. (Kleeberg.1) The 
uterus and tumor are then removed by ablation. If by this procedure 
the cavity of the uterus has not been opened, the wound is closed by 
suture, just as in simple myomotomy. In supra-vaginal amputation, the 
uterine cavity is of course always laid open, which constitutes a serious 
complication. The question in such cases is what to do with the pedicle, 
consisting of the cervix or the stump of the amputated uterus. At first, 
just as in ovariotomy, it was deemed advisable to use the extra-peritoneal 
method. But later the intra-peritoneal method was more generally 
adopted. Nevertheless, even at the present day, this point is still in 
dispute. 
In my opinion the intra-peritoneal method is to be preferred, as doing 
all that the others can do, but being in addition more simple and always 
possible of execution. Still, it is not to be denied that, in certain cases, 
the extra-peritoneal treatment of the pedicle may be almost a necessity. 
1 St. Petersburg Med. Woch., 1879, No. 1. 270 
NEW GROWTHS OF THE UTERUS. 
Two objects must be kept in view in treating the pedicle. The first is 
to obviate bleeding, and the second is to prevent infection. The oldex* 
method, as practised by Pean, Koeberle and Rose,1 consists in carrying 
through the region of the internal os a large needle armed with a double 
ligature of silk or wire, and then to tie the ends laterally. This prevents 
bleeding from the uterine arteries, and also shuts off the cervical canal. 
The stump can be secured by clamp in the lower margin of the abdominal 
incision, and kept, so far as possible, in an aseptic condition. 
But to carry out systematically the extra-peritoneal method of treating 
the pedicle, Hegar's plan is to be preferred to the others. This author 
stitches the pedicle to the abdominal walls in such a way that the parietal 
peritoneum is carefully sewed to the pedicular peritoneum. In this way 
the cervical wound is kept altogether without the cavity of the peri- 
toneum. 
For intra-peritoneal treatment Schroeder's plan is the simplest. After 
ablation of the tumor and while the rubber tube is still in position, the 
stump is trimmed in such a way that two opposing flaps are formed. 
These are secured by sutures placed in rows at different levels (Etagen- 
nahte). The edges of the peritoneal investment are finally closed by a 
series of very fine sutures. 
Olshausen excises a part of the mucous membrane of the cervix, closes 
the opening by stitches of catgut, but does not use the Schroeder sutures 
at different levels. He also catches the peritoneum as he goes along, in 
place of employing a series of separate stitches for that membrane. I 
have also always employed the latter method. I have simply closed the 
wound in the stump by very deep sutures, and have then introduced a 
tampon of iodoform from the vagina. 
Olshausen has, under certain conditions, allowed the constricting 
rubber band to remain in situ, without untoward effects, barring the 
formation of a fistula in one case. I have not deemed this necessary, 
always, like Schroeder, removing the rubber after application of the 
sutures. 
It cannot be denied that the ligatures which are dropped down with the 
pedicle have at times set up later disturbances. In those instances in 
which it is difficult to apply the rubber band, I have followed the method 
of Pean described above. 
It seems ad visable in these operations to remove the ovaries, along with 
the uterine tumor. These organs are at best useless after so large a por- 
tion of the uterus has been removed. Indeed they may do harm by being 
allowed to remain. Thus Pean lost a case in consequence of haamatocele, 
which took its origin from menstrual congestion of the ovary Koeberle 
observed extra-uterine pregnancy, after extirpation of the uterus with- 
Zeitschr. f. Chirurgie, 1883. TREATMENT OF UTERINE FIBROIDS. 
271 
out the ovaries, the cervical canal having been alloved to remain open. 
In another case of a similar kind, hemorrhage into Douglas's pouch and 
rectal bleeding occurred at the next menstrual epoch following the opera- 
tion. 
It follows, therefore, that as a rule, the ovaries should be removed in 
the operation. If it is found, however, that owing to adhesions, or other 
pathological conditions, this procedure would be difficult, it is best not to 
prolong the operation by attempts at removal of these organs. 
The methods just described presuppose a pediculated tumor, or at least, 
that the uterus can be made use of for the formation of a pedicle. It 
was for a long time thought that growths of a certain size invading the 
cervix, and those projecting into the cellular tissue of the pelvis, were not 
amenable to surgical treatment. Spiegelberg was the first to devise a 
method of dealing with tumors of the former variety. In a broadly at- 
tached cysto-fibroma, he performed abdominal section, split the capsule 
of the growth, enucleated it and then closed by suture the large uterine 
wound. The patient died. Other cases 1 in which the uterine wound was 
not sewed up, also ended fatally. More recently, aided by antiseptic 
measures, some successful cases have been recorded. It is always well to 
use the rubber tube for purposes of constriction, and with the idea of 
limiting the loss of blood. 
Sometimes, in doing this operation, it will be found that the uterine 
wound is so completely closed by contraction of the organs, that sutures 
are not necessary. But as a general thing it is advisable to sew up the 
uterine wound, especially when the uterine canal has been laid open. 
Operations of this kind have been performed by Schroeder (Hofmeier 
1. c.), Martin (1. c.) eight cases with three deaths), Moricke,2 N. Eck,3 
Olshausen (1. c.), Gusserow (one successful case), and others. 
More recently successful enucleations of tumors growing into the pelvic 
tissues have been recorded by Schroeder, Rose, Olshausen, Kaltenbach, 
Kiister, Gussenbauer, Breisky and others. In such cases also, whenever 
possible, " rubber constriction " should be used, in order to control bleed- 
ing. The peritoneal investment of these growths is to be split, and the 
tumor peeled out by the aid of blunt instruments, or preferably the 
fingers. Firm bands are to be ligatured and cut. The uterine wound is 
to be closed by deep sutures. Drainage will be necessary in some cases. 
Whether the additional performance of amputatio uteri is called for 
depends of course upon the uterine relations of the growth and its size. 
Prognosis is naturally made worse by the extent of the surgical interfer- 
ence. Schroeder lost twelve cases out of twenty-one of these complicated 
enucleations, a mortality of 57 per cent. 
1 Billroth, Wien. Med. Woch., 1876. Pean, Lyon M6d., 1869. 
2 Zeitschr f. Geburtsk. VII. 'Centralbl. f. Gynak., 1878. 272 
NEW GROWTHS OF THE UTERUS. 
Finally, total extirpation of the uterus has been advised and done for 
difficult cases of this kind. Bardenheuer (1. c.) performed the operation 
successfully four times. Kottmann* and v. Maudach2 have also reported 
similar cases. 
On the whole, it does not seem clear what advantages this extrertfbly 
difficult operation possesses over other methods of treatment, and, indeed, 
it has not beeen generally followed. 
For completeness sake, we here present Pozzi's (loc. cit., p. 150) statis- 
tics concerning amputations or extirpations of the uterus, most of which 
were undertaken on account of an error in diagnosis, occasioned by the 
development of fibroids at the fundus, and consequent inversion of the 
uterus. Two of these operations, performed with the knife, resulted 
favorably. Five amputations of the uterus, with the tumor, finished by 
means of the ligature, resulted in two recoveries and three deaths. In 
eight cases both methods were combined. The ligature having been first 
allowed to remain in situ for some time, so that adhesion between the 
opposite uterine walls should occur at the point of constriction, the am- 
putation of the fundus uteri and of the tumor was then undertaken. 
In these cases cures were effected five times and death resulted three 
times. The operation was also performed three times with the ecraseur. 
In two of the cases death followed. The operation was performed once, 
but unsuccessfully, with Maisonneuve's constrictor. One successful 
operation was done with the galvano-cautery. (The bibliography of the 
subject can be found in Pozzi's work.) 
The most frequent cause of death is septic infection, running its course 
under the form of septic peritonitis. Then follow loss of blood, shock, 
intestinal obstruction, unemia in consequence of ligation of the ureters, 
thrombosis of the crural or pelvic veins, and cardiac failure. The last- 
named cause of death is brought about by changes in the muscular sub- 
stance of the heart, such as traumatic atrophy and fatty degeneration 
following loss of blood. (Hofmeier, Rose, 1. c.) 
It has been shown that the particular method of operation to be chosen 
for the removal of myomas will depend chiefly upon the seat of the 
growth and its relation to the uterus. But a more difficult problem 
presents itself when we attempt to clearly formulate the indications for 
operative interference. 
Now for uterine growths of the kind in question removal is by no means 
a simple necessity, such as is generally the case in ovarian tumors. 
Even if we should succeed in reducing the mortality of extirpations of 
fibroids to the level of ovariotomy, we would nevertheless still have to 
take into account that fibroids per se are not dangerous to life. Hence 
1 Correspondenzblattf. Schweizer, Aerzte, 1882. Total extirpation per vaginam. 
2 Ibid. Total extirpation by the method of Freund. TREATMENT OF UTERINE FIBROIDS. 
273 
the mere diagnosis of fibroid of the uterus is not equivalent to an indica- 
tion for operation. Such indication is found, however, in the following: 
Hapid growth of the tumor, a size leading to disturbances of circulation 
and respiration; ascites, origin of the growths in the true pelvis, leading 
to symptoms of incarceration; violent pains (especially when they suffice 
to incapacitate the the patient for work), and finally hemorrhages that are 
not to be controlled by other measures. 
Among the rarer indications for surgical interference we will find 
pregnancy and changes occurring in the tumor, such as gangrene, etc. 
In all cases the condition of the patient, her age and her station in life, 
are also to be considered. In persons who depend for existence upon their 
ability to work, an operation is sooner called for than in those who can 
command every care and comfort. 
In these considerations there will also be found a reason why these 
operations will not easily give as good results as ovariotomy. The latter is 
called for in every case where the tumor is large, whereas extirpation of 
Fig. 25.-Greenhalgh's Forceps. 
fibroids is indicated generally in those cases that, owing to their course 
and symptoms, justify a poor prognosis. 
The above considerations sufficiently establish the fact that, in many of 
these cases, symptomatic and palliative treatment can alone be aimed at. 
In the first place we must consider those measures which try to arrest the- 
growth of the tumor, or to even reduce its size. We must next discuss 
all those methods of treatment the object of which is to produce by con- 
stitutional treatment a favorable effect upon the development of the 
tumors and upon the symptoms. Finally we shall consider the treatment 
appropriate for individual symptoms. 
We have already stated that there is no therapeutical agent by which 
a fibromyoma may be made to entirely disappear. No measures adopted 
for this end can boast of brilliant results. Even when the tumors have 
disappeared, under a given treatment, it has not been proven that their 
removal was the result of the therapeutic measures resorted to. The 
use of ergotin (according to Hildebrandt's method) and the internal 
administration of ergot1 are perhaps exceptions to this rule, although too 
little clinical evidence regarding this point has been accumulated. It is, 
1 Brunton : Obstet. Transact., 1872, p. 282. 274 
NEW GROWTHS OF THE UTERUS. 
however, not to be denied that some of the methods of treatment originally 
suggested for the complete removal of the fibroids have proven empiri- 
cally useful in many instances. After their employment many of the 
symptoms have disappeared, or the growth of the tumor has seemed to 
be more gradual. 
The supposed advantages of all the modes of treatment are seldom ap- 
preciable, while unfavorable results often follow them. Neither have we 
any criterion by which to judge whether any given treatment will furnish 
better results in one individual case than in any other. One often sees 
no result, or an unfavorable one after an apparently appropriate course 
of treatment, while benefit may accrue to the patient from measures ap- 
parently not at all indicated. 
We must assign the first rank to those methods of treatment designed to 
operate more or less directly upon the tumor. Among these methods, 
the subcutaneous or internal administration of ergot and its preparations 
is most trustworthy. Although abscesses, at the point of puncture, and 
even symptoms of ergotism may attend the use of this drug, it, nevertheless, 
very often retards the growth of the tumors. Particularly the soft tumors 
which are rich m muscular tissue, become harder, smaller and appear to 
undergo an arrest of development. After the use of ergot diminution in 
the hemorrhage, either brief or lasting, very often occurs. Almost as 
frequently, however, all these favorable results are lacking, and the un- 
pleasant ones necessitate an interruption of the treatment. The. sub- 
cutaneous injection of ergotin is tolerated, with special difficulty, by very 
fleshy persons, such as arc so liable to suffer from fibroids at the meno- 
pause. We should entirely discountenance the internal administration 
of iodine and bromine preparations, no matter of what form, as well as 
of chlorate of potassium, arsenic,1 mercury, turpentine and other similar 
drugs. There are no convincing proofs of their utility; on the contrary, 
most of them are calculated to act harmfully by disordering digestion. 
Certain celebrated medicinal waters and sea baths are now much em- 
ployed. Their efficacy, in certain cases, cannot be well denied, although 
their value is, on the whole, slight, and their effects uncertain. 1 have 
observed that, in general, anaemic persons do not derive benefit from 
mineral-water baths. Such patients rather experience relief from sea 
baths, or from the influence of life near the sea, upon their general 
health. It is difficult to distinguish between the local and general effects 
of these baths. They sometimes seriously aggravate the hemorrhages. 
Although a diminution of the menstrual flow often results from their 
use, I have quite as frequently seen an increase of it following their em- 
ployment. This is probably referable to increased afflux of blood to the 
1 P6an saw a tumor, which filled the pelvis, disappear almost entirely after 
the use of arsenic. L'hyst^rotomie, p. 36. TREATMENT OF UTERINE FIBROIDS. 
275 
abdominal cavity. This is also the reason of the prejudicial effect of hip 
baths, in these cases. 
The springs at Kreuznach, Reichenhall, Hall, Krankenheil, and 
Kissingen, in Germany, and at Salins and Salies de Bearn, in France, 
enjoy an especial although undeserved reputation in the treatment of 
uterine fibroids. 
The springs of Kissingen, Marienbad, Carlsbad and Vichy, and of 
Bourbonne, in France, are efficacious for fleshy persons inclined to con- 
stipation. These waters probably reduce the size of the uterus, and 
possibly of the tumor, by diminishing the tension in the abdominal arteries. 
I have often observed a temporary amelioration of some of the symp- 
toms, particularly of the hemorrhages, after the use of these waters. 
Few general directions can be given regarding the constitutional treat- 
ment of fibroids, although it is doubtless of great importance. It relates 
chiefly to regulating the mode of life, and must be carefully adapted to 
the requirements of each individual case. Some form of iron is indicated 
by the anaemia of most patients suffering from fibromata. Even in those 
cases, however, in which it is tolerated by the stomach, producing no 
digestive disturbances, I have never been able to observe any appreciable 
benefit resulting from its use. 
In those cases not adapted to operative interference, we are reduced to 
the necessity of symptomatic treatment. The symptom which is seldom 
or never absent; in cases of sub-mucous and interstitial tumors, and which, 
at all events, most imperils the patient's life, is hemorrhage. The means 
for checking dangerous hemorrhages are numerous and well-known. 
Among drugs for internal use, we shall consider at this time only ergot 
or ergotin; the utility of extr. hydrastis canadensis, so warmly recom- 
mended by Schatz1 and others, is not yet sufficiently well established. 
Aside from these remedies cold applications to the abdomen, and cold va- 
ginal douches prove valuable. I have never obtained permanent results 
from hot injections. The hemorrhage was indeed at once arrested by 
them, as a rule, but soon recurred.2 
Astringent vaginal injections of diluted liq. ferri chloridi, tannin, etc., 
likewise produce only temporary results. The only speedy and certain 
method of arresting the bleeding, consists in the careful introduction of 
a perfect tampon, preferably composed of cotton wool dipped in styptic 
solutions. 
I find by reference to modern literature, that transfusion has been 
twice performed, after threatening uterine hemorrhage. One patient died 
during the operation,3 the other recovered.4 Only human blood should 
1 Centralblatt fur GynakoL, 1883, No. 46. 
2 Runge : Berlin Klin. Wochenschr., No. 13, 1877. 
3 Filliette : Archiv. de Tocol., II., 444. 
4 Gentilhomme: Gaz. Hebdomad., No. 39, 1868. 276 
NEW GROWTHS OF THE UTERUS. 
be used for the transfusion. I should not have attended to this point 
were it not for the fact that the transfusion of blood from an Inferior ani- 
mal is favorably mentioned in a new gynecological text-book which is in 
many respects meritorious. It is a striking proof of the unscientific 
principles often governing modern medical practice that so venturesome 
and purely empirical a procedure as the transfusion of animal's blood 
should attract such general attention, at a time when the experiments of 
Panum and others have proven the deleterious results of the exchange of 
blood between different animal species. 
The prevention of the recurrence of hemorrhage and the moderation 
of menstruation is more important than the temporary arrest of bleeding, 
which is usually easily accomplished. The means adapted for this end 
are local and general ones. 
The latter variety embraces really only the subcutaneous administra- 
tion of ergotin, according to Hildebrandt's method. The haemostatic 
effect of this drug, in a considerable number of cases, is beyond question, 
and although this effect be by no means certain or permanent, it still has 
the advantage of harmlessness over other methods of treatment. 
The most radical measure for the prevention of hemorrhage is the ex- 
tirpation of both ovaries, even when sound. By this means the menstrual 
congestion of the pelvic organs, which is the chief cause of the profuse 
bleeding, is obviated. But this subject has already been fully considered. 
The operation is certainly not indicated if the hemorrhages have lost 
their menstrual type, or if the menopause has arrived. 
Baker-Brown1 first performed a much less formidable operation for the 
relief of hemorrhage. It consisted in incising the cervical canal, the os 
internum, and, if practicable, the capsule of the fibroid. Experience shows 
this operation to be adapted to the long-continued control of the bleeding. 
Nelaton, McClintock,2 Spiegelberg,3 Barnes,4 Savage,6 and others, includ- 
ing myself, have obtained good results from this method. The ration- 
ale of the effect produced by this, by no means trifling operation, is ex- 
plained m some cases by the section of many dilated vessels in the uterine 
mucous membrane, and their subsequent obliteration by the process of 
cicatrization. 
In the majority of cases, however, the result is, according to my experi- 
ence, attained by the release from pressure of the uterine mucous mem- 
brane, which has been distended and partly destroyed by the tumor. In 
consequence of this relief, the collateral congestion of the remaining 
mucous membrane is relieved, and hemorrhage from it diminished. 
1 London Obstet. Transact., III., p. 67, and VI., p. 21. 
2 Clinical Memoirs, etc., p. 149. 
3 Monatsschrift fur Geburtsk.. 29, p. 87. 
4 Diseases of Women, London, 1873, p. 773. 
5 Lancet, 1879, Sept. 29. TREATMENT OF UTERINE FIBROIDS. 
277 
Spiegelberg first advanced this theory, and supported it by demonstrating 
tiie fact that this method is only successful when the tumor is adjacent 
to the os internum, and the mucous membrane covering the growth is, 
therefore, directly relieved from pressure by the incision. Since the 
presence or absence of the anatomical conditions necessary to the success 
of the operation are not easily determined in advance, it has not found 
general acceptance. 
I have always performed the operation with Sims's curved scissors, 
after dilating the cervical canal by means of sponge tents, and have in 
addition incised the mucous membrane in and above the os internum. I 
have never seen unpleasant consequences follow the operation, nor are 
any recorded m literature. Ye^ it might give rise to parametritis, peri- 
tonitis and septicaemia, just as readily as incision of the cervix for other 
objects. Like most gynecologists, probably, I have not recently per- 
formed this operation. 
Several authorities, as for instance Scanzoni, recommend local abstrac- 
tion of blood in order to prevent excessive menstruation by depletion of 
the uterine vessels. The distinction between the loss of blood produced 
by artificial means, and that due to natural agencies is so slight that 
benefit is probably only exceptionally afforded by this treatment. It has 
not been generally adopted, so far as I am informed. 
Cauterization of the uterine mucous membrane has been quite pro- 
perly received with greater favor. This iutra-uterine method of treat- 
ment is, in many cases, the only one capable of setting a limit to the 
bleeding. Since solid escharotics are unsatisfactory, on account of the 
frequently varying form of the uterus, and because they usually only 
affect the secretion which covers the mucous membrane, without reach- 
ing the latter, fluid escharotics have long been exclusively used. 
The modus operandi of the different escharotics is identical. The 
cauterizing fluid, when brought in contact with the uterine mucous 
membrane, saturates it as far as possible, diminishes its tumefaction, tans 
it, as it were, and antagonizes menstrual congestion. The large, dilated 
vessels contract and are partially obliterated. Sometimes the escharotics 
produce superficial follicular ulcers, which interfere with the growth of 
the tumor or leave, as a result of their cicatrization, a tough cicatricial 
tissue in the place of the swollen hypertrophic mucous membrane. 
The many dangers attending intra-nterine injections are now known 
and sufficiently appreciated. The injections may produce uterine colic, 
which may, if too often repeated, lead to metritis, perimetritis and peri- 
tonitis. The irritation may directly involve the parametrium or the peri- 
metrium, and so give rise to dangerous inflammation. 
The injected fluid may, under exceptional circumstances, in the pres- 
ence of special pathological conditions, pass through one of the Fallopian 
tubes into the peritoneal cavity. The following cut represents the 278 
NEW GROWTHS OF THE UTERUS. 
uterus of a patient, in whose case intra-uterine injections of liquor ferri 
chloride had been repeatedly made and with excellent results. After one 
injection made, perhaps, when the os uteri was not sufficiently dilated, 
all the symptoms of peritonitis from perforation appeared, and the patient 
quickly succumbed The peritoneal cavity contained a large quantity of 
the fluid, which had escaped through an aperture in the uterine wall. 
The perforation had resulted from rupture of the wall, which was atro- 
phied, as is so often the case with uterine fibromata. The atrophied 
portion had yielded to the pressure of the injected fluid, since post-mortem 
experiments proved that the syringe used could not have reached the point 
Fig. 26.-Uterus showing a Fibroid, with Attenuation of Uterine Wall, and Perfora- 
tion AFTER AN INTRA-UTERINE INJECTION. 
of perforation, and was hence guiltless of the injury. These dangers 
may be completely avoided by never resorting to intra-uterine injection, 
unless the cervical canal and the os internum have been sufficiently 
dilated to afford the injected fluid free exit in a stream of the same size 
as the in-flowing current. 
The uterus must be merely washed out. The fluid must never be al- 
lowed to remain in the uterus, in order that the latter not be over-dilated 
oi' unduly irritated. 
It is more difficult to guard against one other source of danger, viz., 
the results of follicular ulceration. Such ulcers may exert a very favor- 
able influence upon the course of the disease by healing and cicatrizing. 
They may lead to adhesion of the opposing uterine walls, to obliteration TREATMENT OF UTERINE FIBROIDS. 
279 
of the cavity of the uterus, and to cessation of hemorrhage, as G. Braun' 
has observed. 
A frequent result of these ulcers is, however, gangrene of the tumors, 
which may terminate in expulsion of the fibroid and a complete cure.2 
Fatal septicaemia may, however, follow the gangrene, as I have observed 
in one case. 
When, therefore, one feels confident that ulceration has occurred, 
after repeated injections, he will under all circumstances be acting 
wisely to suspend treatment for a time, resuming it cautiously when 
recurrent hemorrhages show it to be indicated. 
I desire to particularly disparage long-continued intra-uterine injec- 
tions, in cases of probably soft myoma. Such tumors are specially inclined 
to become gangrenous, and their intimate connection with the uterine 
parenchyma facilitates the absorption of septic matters. 
Even this slight interference is not to be attempted without the rigid en- 
forcement of antiseptic details. 
The form of syringe to be employed is of no more special importance 
than the kind of fluid used. Personal preference and experience must 
settle this question, and the fluids recommended are so numerous that we 
must forego an enumeration of them. There are really only two favorite 
fluid escharotics, viz., liquor ferri chloridi and the tincture of iodine. 
Both should be used undiluted. The former is, on account of its free 
hydrochloric acid, more caustic, but is still weaker since it coagulates the 
blood covering the mucous membrane, and hence operates less effectively 
on the membrane itself. 
Tincture of iodine is said not to be open to this objection. 
Formerly I occasionally saw symptoms of iodine poisoning, in sensitive 
persons, after repeated applications of the tincture. 
But since employing irrigation of the uterine canal after every such 
application, I have never met with this accident, and I now prefer iodine 
to other remedies. 
Other escharotics, as nitrate of silver, nitric acid, acetate of lead, 
iodide of lead (Freund), etc., have been employed and commended. The 
application of these remedies in the form of ointments (Routh, Scanzoni 
and others) has not met with general favor. 
Curetting of the uterine cavity is now also generally employed, since 
the opinion has gained ground that pathological conditions of the mucous 
membrane of the uterus are so largely responsible for the hemorrhages 
observed in cases of myoma. This operation is done as follows: The 
patient being anaesthetized, the uterus is pulled downwards and its cavity 
washed with an antiseptic solution. The curette or blunt scoop is then in- 
1 Wiener Med. Wochenschrift, 1868, No. 100. 
2 Whiteford : Glasgow Med. Journal, 1872. 280 
NEW GROWTHS OF THE UTERUS. 
troduced, and the cavity thoroughly scraped. I commonly inject iodine 
after the curetting, and then again wash out the uterine cavity with an 
antiseptic. In a rather large number of cases treated in this way I have 
never had occasion to observe serious consequences. Slight cellulitis 
has, however, sometimes occurred. 
The second almost constant symptom, treatment of which is essential, 
is pain. The prevailing pain with sub-serous tumors, is due to inflamma- 
tion produced by traction upon and irritation of the peritoneum. Acute 
circumscribed peritonitis may be often developed, chiefly at the time of 
the menstrual congestion. 
If the pain be referable to inflammation, antiphlogistic measures afford 
the most ready relief. Local abstraction of blood maybe indicated in the 
case of strong persons, with sub-serous fibroids, particularly if the menses 
be scanty, as often happens. In still other cases good results will follow 
the local use of cold, by means of ice bags, cold applications, wet packs, 
etc. An abdominal supporter often renders good services if the pains be 
produced or augmented by unusual mobility of the tumor.1 
Greene's case,2 in which he performed laparotomy, on account of the 
intolerable pain, is unique. After the abdomen had been opened, it was 
found impossible to remove the fibroma and the wound was closed. The 
patient recovered and remained permanently free from pain, no change 
having occurred in the uterus. 
Pains resembling those of labor, and due to uterine contraction, are 
produced by fibroids, particularly by those which are sub-mucous or inter- 
stitial. Although these contractions are often of benefit in producing the 
expulsion of the tumors, they are sometimes so severe as to require allevia- 
tion. Morphia or other anodynes are, aside from operative measures, 
the only resource in these cases. 
The anodyne may be administered in a vaginal or rectal suppository, 
hypodermically or in a small enema. 
Pain is also produced by pressure of the tumors upon neighboring 
tissues. Pain due to this cause may often be relieved by pushing the tumor 
upward, out of the pelvis, and retaining it in its new position by a 
pessary. (Kidd.) Kingland ' once displaced a tumor upward by means of 
a Barnes dilator introduced into the rectum. In the majority of these 
cases, however, provided they are not adapted to other modes of treat- 
ment, narcotics are our only resource. 
1 GuSneau de Mussy : Bulletin de Therapie, 1867, p. 356. 
2 Boston Med. Journal, 1867, No. 23. 
3 Dublin Quarterly Journal, 1867, p. 248. CHAPTER VII. 
CYSTO-FIBROMATA OF THE UTERUS. 
BIBLIOGRAPHY. 
In addition to the works before mentioned, the following monographs have 
been consulted: Schuh: Ueber die Erkenntniss der Pseudoplasmen, Wien, 1851. 
Spencer Wells: Diseases of the Ovaries, London, 1872.-Atlee : Ovarian Tu- 
mors, Philadelphia, 1873. - Peaslee : Ovarian Tumors, London, 1873.- Gallez : 
Kystes de 1'Ovaire, Bruxelles, 1873. - O. Schroder: Ueber Cystofibroide des 
Uterus, Inaug. Dissert., Strassburg, 1873.-O. Heer : Ueber Fibrocysten des 
Uterus, Inaug. Dissert., Zurich, 1874.-Grosskopf : Zur Kenntniss der Cysto- 
myome des Uterus, Inaug. Dissert., Munchen, 1884.( 
AVE are, as yet, obliged to designate by the above name, a class of 
' 1 uterine tumors by no means identical in their morbid anatomy. 
They are either changed fibromyomata, or belong to the group of fibroids. 
Their common feature is the accumulation of fluid within the substance of 
the uterus. 
The special practical significance of these tumors is found in the fact 
that they have Usually been mistaken for ovarian tumors, by reason of 
their location and of their fluid contents. 
Aided by Virchow (Geschwulstlehre, III., p. 124) we have recently 
but just begun to establish pathological distinctions between the various 
tumors included in this class. Only uterine myxomyomata may, with 
propriety, be considered as constituting a special species of myomata. 
These are characterized, according to Virchow, as myomata with 
abundant interstitial tissue which is rich in fluid and closely resembles 
simple cedema. The microscope, however, shows that proliferation is oc- 
curring in the tissue of the neoplasm, since nucleated, round cells are 
found in the interstitial fibres. The fluid contains mucin. I have been 
unable to find, in literature, any statements regarding this subject, other 
than those of Virchow, and considei* it difficult to separate myxomyomata 
from the sarcomata. 
The other forms of the fibro-cystic tumors are fibromyomata in which 
certain pathological changes have occurred. The most frequent change 
consists in oedematous infiltration of the tumor. At the same time the 
intra-muscular connective tissue undergoes changes, apparently consist- 
ing at first in cedematous swelling. Finally, however, the tissue is com- 282 
NEW GROWTHS OF THE UTERUS. 
pletely disintegrated, and there appear spaces filled with clear fluid, 
similar to and in many cases identical with lymph, in its chemical com- 
position. The muscular fibres of the neoplasm are pressed together, and 
become atrophic. The tumor fluctuates plainly, but usually contains no 
large cavities, so that puncture only furnishes a little fluid. In some 
cases the fluid is more abundant. 
In many cases the fluid possesses the peculiar property of spontaneous 
coagulability, and this might lead to the assumption that the tumors in 
question belong to the class of lymphectatic myomata, soon to be de- 
scribed. That they are not akin to these, is proven by the fact that all 
observers have failed to find any endothelial lining of the spaces contain- 
ing the fluid. These alveolae must, therefore, be simple interspaces in the 
tissues, and not genuine cysts. It is true that Pean (Joe. cit. p. 84) at- 
tributes to Ranvier and Melassez the discovery of a lining composed of 
"pavement epithelium" in the spaces. The tumors they examined 
were, however, probably lymphectatic myomata, to the connection 
between which and this form of tumors we shall immediately recur. 
Although only a few well-investigated cases are to be discovered in litera- 
ture, the majority of the fibro-cysts probably belong to this class of in- 
filtrated fibromata. 
Spiegelberg1 describes a case belonging in this category as follows: 
• ' Thick and transparent, easily isolated membranous folds, permeated 
with numerous vessels, visible to the naked eye, and with connective- 
tissue bands, separate, complete and other incomplete cavities, varying 
in size from the head of a pin to a walnut, or from the boundaries of ir- 
regularly shaped cracks and orifices. In the solid portions between the 
connective-tissue fibres, are found numerous round, stellar or fusiform 
cells, of various sizes, and with one nucleus or several nuclei, together 
with muscle fibres, either entire or disintegrated. Nuclei, blood cor- 
puscles and detritus are also seen. The membranous parts of the epongy 
tissue are composed of young connective tissue, permeated by a close- 
meshed capillary plexus, and by vessels of larger calibre. Pavement 
epithelium was absolutely lacking. The fluid is dark yellow. Its s. g. 
is 1020 and its reaction neutral. About one-fourth of its total quantity 
is composed of large gelatinous, yellowish coagula, consisting of fibrin. 
The fluid portion contains large quantities of serum albumin. Paral- 
bumin and mucin are wanting." 
The second case of Frankenhauser* in which the fluid coagulated on 
evacuation, appears to belong here, although it was not anatomically in- 
vestigated. Similar cases were those of Baker-Brown,3 Spencer Wells,4 
1 Archiv fur Gynakologie, VI., p. 348. 
2 O. Heer : Ueber Fibrocysten des Uterus, Dissert. Zurich, 1874. 
3 Path. Transact.. XIV., p. 198. 
4 Diseases of the Ovaries, London, 1872, p. 194. CYSTO-FIBROM AT A. 
283 
Storer,1 Schuh, Thomas Bryant,2 and probably most of Atlee's3 cases. 
One case of this kind reported by myself4 was carefully investigated. 
The intra-uterine tumoi' discharged, on simple manipulation, large 
quantities of fluid spontaneously coagulable when exposed to air, which 
contained no mucin, but large quantities of serum, albumin and fibrino- 
genous material. At the autopsy (von Recklinghausen) the tumor was 
found imbedded in the posterior uterine wall, and covered to the depth 
of 2 to 10 mm., by uterine parenchyma, the mucous membrane covering 
which was still intact. The tissue of the neoplasm is reddish. Below it 
is paler; at the fundus quite gelatinous and only slightly trabeculated. 
Between the individual bands of fibres there are no large cavities, but only 
small spaces or chinks, of the size of a pea. The walls of these spaces are 
formed by the tissue itself. The microscope showed the tissue to be very 
rich in cells. Most of the cells are purely fusiform, or being rounded at 
one end are pointed at the other. On both sides of the spindle cells one 
sees fine, pale prolongations which terminate in part by free extremities, 
and in part are connected with other spindle cells. The cells themselves 
have rod-like nuclei, and are slightly granular. Large collections of 
connective tissue are rarely found, except in the superficial parts which 
are in close apposition to the uterine parenchyma. In those places where 
the fibres above-described are present in large numbers, and where only 
a few spindle cells are imbedded between them, one also finds large round 
cells of the size of mucous corpuscles, and larger, granular and not dis- 
tinctly nucleated. Similar cells are found disseminated through the whole 
mass, either isolated and at long intervals, or closely packed together 
between the fibrous processes of the spindle cells. In some places are 
seen small masses of granular detritus, and also masses penetrated by 
bright fibres similar to the processes of the cells, and filled with little 
granules. 
If this process of softening becomes widely disseminated, large cavities, 
often containing several quarts of fluid, may form in the uterine sub- 
stance. These cavities have no special walls, but are surrounded by 
torn muscular fibres, undergoing degeneration, and so separated as to 
form trabeculae. Dupuytren compared the inner wall of those spaces 
with that of the cardiac cavities. 
The tumor consists of a metamorphosed solid fibromyoma, as Virchow 
(loc. 200) definitely stated. This must be emphasized, because faulty 
interpretations of the pathological conditions are often found in foreign 
literature. The larger the cavities the more are their contents composed 
1 Am. Journal of the Med. Sciences, 1866. 
2 Obstet. Transact., XIV. 
3 Ovarian Tumors, 1873, p. 263 et seq. 
4 Comp. O. Schroder: Ueber Cystofibroide des Uterus, Inaug. Dissert., Strass- 
burg, 1873. 284 
NEW GROWTHS UE THE UTERUS. 
of detritus of the tissues, mixed with more or less blood, since numerous 
blood-vessels, large and small, are involved in the destruction of the 
muscular tissue. In accordance with the period at which the blood 
became mingled with the contents of the " cysts," their color is changed 
from bright red to dark brown or yellowish brown. The fluid mass 
usually does not coagulate It may partially coagulate, if it contains 
large quantities of comparatively fresh blood. 
The cavities vary from the size of a small nut to that of the adult male 
head. Although the terms myoma cysticum and cystofibroma are applied 
to this tumor, it is not a genuine cyst, since an independent wall, which 
is the chief characteristic of a cyst, is wanting. 
A case observed by Spiegelberg and kindly placed at my disposal for 
publication, best illustrates the close connection of this kind of fibrocysts 
with that just described, and shows them to be nothing more than a more 
fully developed form of the same. 1 again openly return thanks to 
Spiegelberg for his permission to utilize this case. 
The tumor was a large abdominal one, which presented all the physical 
properties of a multi locular ovarian tumor. Since, however, at the ex- 
ploratory puncture, 800 gm. of a thin sero-sanguinolent, spontaneously 
coagulable fluid was obtained, ovarian tumor was excluded. No direct 
connection between the tumor and the uterus could be discovered. The 
sound entered the uterine cavity to the depth of 9 ctm. The patient 
died suddenly of peritonitis, complicated with septicaemia, in consequence, 
as was subsequently ascertained, of gangrene in the tumor. The gan- 
grene was the result of the use of the uterine sound, which had been twice 
introduced to the depth of 17 ctm. by an assistant. The autopsy revealed 
the fact that the sound had perforated the uterine wall, and penetrated 
the tumor. 
The autopsy (Dr. Weigert) also revealed a large tumor, attached to the 
uterine wall, and permeated by innumerable small and large cavities 
varying from a hardly perceptible size to that of a child's head. The 
largest one, near the fundus uteri, was connected with the uterine cavity, 
by means of the artificial opening. The contents of these apparent cysts 
consists partially of sanguinolent and partly of yellowish fluid material. 
The walls of the cysts have, in some parts, a smooth glittering appearance, 
but no genuine membranous lining. The microscopical examination of 
the fluid showed red and white blood corpuscles. No epithelium can be 
found in the cyst wall, whether the specimen be fresh or hardened. 
The entire tumor consisted, for the rest, of smooth muscular fibres. 
This case is well adapted to show the genetic relation between the two 
forms of cysto-fibromata already described. The majority of the cases 
encountered in literature belong to the latter variety. 
It seems as though the processes of pregnancy and of the puerperal 
state had some influence upon the production of this metamorphosis in C YSTO-FIBROM AT A. 
285 
fibromyomata. This view is rendered more probable by the case of 
Hecker 1 than by any other of the recorded cases. These peculiar pro- 
Fig. 27.-Large Cysto-Fibroma of the Uterus, a. Vagina; b, Cervix; c, Cavity of the 
Uterus ; d, Walls of the Uterus with Cysts ; e, Points of Perforation. (Case of Spiegelberg.) 
cesses of infiltration have probably not been always distinguished from 
gangrene. 
The following cases undoubtedly belong to the class now under dis- 
cussion, and have been studied by myself in the original reports. Ki- 
1 Klinik tier Geburtskunde. Leipzig, 1864, II., p. 126. 286 
NEW GROWTHS OF THE UTERUS. 
wisch,1 Braun, Chiari and Spath,2 Spencer Wells,3 0. Mayer,4 Groethuy- 
sen.6 Tanner's case6 seems to have been possibly a cyst of the ligamen- 
tum latum. Haker,' Schuh, Atlee, Peaslee.8 Compare farther, the 
histories of 0. Schroder,9 of 0. Heer,10 and of Pean, Urdy and Pozzi. 
Also compare Robert,11 Bryant, Bixby,12 Demarquay,13 and Isaac Brown.14 
Koeberle 15 expressed the opinion, as early as 1869, that a number of 
these cysto-fibromata owed their origin to dilatation of the lymphatics. 
Klebs16 also called attention to the fact that in uterine fibromyomata, the 
lymph spaces are dilated into 11 smooth-walled cysts, devoid of a special 
membrane, and filled with a clear fluid. ' ' 
Leopold and Fehling,17 however, made the first determined effort to 
separate one particular form of cysto-fibromata from the others, and to 
designate it by the term fibromyoma lymphangiectodes. 
Their case was that of a tumor which had been diagnosticated as a 
uterine myoma with cystic degeneration, and which yielded, on punc- 
ture, 1500 gm. of bright yellow fluid, which immediately coagulated when 
exposed to the air. The reaction of the fluid was alkaline, and its s. g. 
1025. Its composition was as follows: Water 93.1, solids 6.9, salts 0.7, 
albumen 6.0, fat 0.04, fibrin 0.1. 
A characteristic ingredient of the fluid is, therefore, fibrin. The 
microscope showed that the tumor was a myo-sarcoma filled with cavities, 
which were lined with a fine endothelial covering, so that the case was 
plainly one of lymphangioma. Only one similar case has been reported 
since that one, by Rhein.'8 This case makes the identity of the three 
forms of cysto-fibromata which have been considered probable, and sug- 
gests the propriety of regarding them all as lymphangiomata. 
In Rhein's case there were large and small cavities filled with masses of 
tissue and a spontaneously coagulable fluid resembling blood. Microscopi- 
1 Klin. Vortrage, I., p. 455. 
2 Klinik der Geburtshiilfe und Gynakologie, 1855, p. 404. 
3 Diseases of the Ovaries, London, 1865, pp. 354 and 356. 
4 Verhandlung der Berliner Geburtshulfl. Gesellschaft, IV., p. 97. 
5 Monatsschrift fur Geburtskunde, 1863, XXI., p. 243. 
6 Virchow, loc. cit., III., p. 199; Obstet. Transact., III., p. 14. 
7 Brit. Med. Journal, 1863, p. 225. 
8 Ovarian Tumors, p. 147. 
9 Dissertation, Strassburg, 1873. 
10 Dissertation, Zurich. 1874. 
11 Obstet. Transact., 1872, p. 309. 
12 Boston Med. Journal. August 6, 1874. 
13 L'Union Medicale, 1868, p. 113. 
14 Transact, of the Path. Soc., XVIIL, p. 196. 
15 Gaz. Hebdomad., February. 
16 Handbuch der Patholog. Anatomie, Part 4, p. 887. 
17 Archiv fiir Gynakologie, VII., p. 531. 
18 Archiv fiir Gynakologie. IX., p. 414. CYSTO-FIBROMATA. 
287 
cal investigation showed that the smallest cavities possessed no wall of 
their own, but were here and there connected with spaces covered with 
endothelium, and which were, therefore, lymph channels. Rhein mentions 
still another case, that of lleintze, in which the wall of such cavities, in 
a fibromyoma, possessed a plain endothelial layer. 
However deficient our knowledge may be regarding the pathological 
genesis of cysto-fibromata, and however doubtful it is whether there be 
any anatomical distinctions between the different groups of these tumors, 
there is at least one class which can be anatomically, although not clini- 
cally separated from them. These are the myomata telangiectodes sen 
cavernosa of Virchow. 
The characteristic of this form is the abnormal development of blood- 
vessels in the myomata. Thoughout the whole, or in certain parts of the 
tumor, the blood-vessels dilate into cavities as large as a hemp-seed or a 
pea, so that the neoplasm presents a spongy tissue, filled*with blood, and 
closely resembling the corpora cavernosa penis. 
Virchow,1 who first called attention to this form of myoma, quotes 
cases of this variety reported by Cruveilhier, Krull, R. Lee and Klob. 
He also remarks upon the marked difference in the volume of the tumors 
before and after menstruation.2 
Since that time there has been, strictly speaking, only one carefully 
observed tumor of this kind reported, that of Leopold.3 The tumor was 
very large, sub-serous and attached to the fundus uteri. Even its capsule 
contained numerous vessels as large as a goose-quill. The neoplasm itself 
consisted of a dark, reddish brown, spongy mass containing innumerable 
cavities of variable size. All the cavities contained soft, brownish red 
thrombi. The parietes of all the spaces were of a dark, reddish-brown 
color, tender, thin, and nowhere possessed of a structure resembling that 
of a vein or of an artery. 
These large blood-spaces connected intimately with each other, had no 
peculiar channel of supply. The system of vascular cavities resembled 
that of the pregnant uterus, and was directly connected with the large 
blood-spaces in the capsule of the tumor. The cavities had thin walls 
invested with endothelium, so that they proved to be enormously dilated 
capillaries. Leopold believed that the thickness of the capsule, the 
bundles of muscular fibres which interlaced, in most instances, at right 
angles, and the weight of the tumor itself, could have produced such a 
venous congestion, that dilatation of the capillaries was the result. Simi- 
lar cases are reported by Weber4 and Grammatikati.5 
' Geschwulstlehre, III., p. 195; Archiv VL, p. 553. 
2 Virchow: Gesamm. Abhandl., p. 358. 3 Archiv fur Heilkunde, IV., p. 414. 
4 Zur Casuistik des Myoma telangiektodes s. cavernosum Uteri, Allgein. 
Wiener Med. Zeitung, 1860, Nos. 7 and 8. 
6 Archiv f. GynakoL, vol. XVII. 288 
NEW GROWTHS OF THE UTERUS. 
Although the so-called fibro-cystic tumors are, anatomically speaking, of 
dissimilar nature, it has thus far been impossible to establish clinical dis- 
tinctions between the different classes. The diagnosis and treatment of 
these neoplasms will, therefore, not be discussed separately, but the com- 
mon term cysto-fibroma will be applied to all the varieties. 
These tumors rarely occur in the uterus. 0. Schroder (Dissert. Strass- 
burg) collected thirty-one cases and 0. Heer (Dissert. Zurich) seventy, 
from the whole domain of literature. This gives an idea of the compara- 
tive rarity of these neoplasms. They are sub-serous, in the great majority 
of cases. 0. Heer found only five interstitial and two intra-uterine 
tumors among his seventy cases. Coussat1 mentions a cysto-fibroma, 
which sprang from the os uteri. These neoplasmata often attain enor- 
mous dimensions, especially when they contain several cysts, and have 
been known to weigh twenty-nine, forty, and even eighty pounds. 
When the sarcomatous and fibroid degenerations are associated, the re- 
sult may be tumors of incredible size. This actually occurs, although 
the individual cases have not been very carefully conducted. In rare 
instances uterine cysto-fibromata and ovarian cysts have existed simulta- 
neously, rendering the diagnosis exceedingly difficult. Supported by a 
few such cases, and by some actual diagnostic errors, Boinet2 made an 
absurd effort to disprove the existence of uterine cysto-fibromata. He 
regarded all these tumors as ovarian cysts closely connected with the 
uterus. This view does not claim any farther refutation than is afforded 
by pathological facts. 
Sub-serous collections of fluid found sometimes in the uterus and in 
the pelvic connective tissue, and which have probably been reckoned 
among uterine " cysts," have nothing in common with the variety now 
being discussed. 
After Koeberlc and others had called attention to the fact that the fluid 
from fibro-cysts coagulated spontaneously and immediately on contact 
with the air, Atlee, who found that this rule obtained in all of his cases, 
laid great stress upon its diagnostic value. Although the spontaneous 
coagulability of the cyst fluid is a very characteristic and constant condi- 
tion in a large number of the cases, it is by no means constant. 0 
Heer only found this phenomenon mentioned in fourteen of his seventy 
cases. 
The cystic fluid is more or less bloody, dark black, or consists of a vis- 
cid pulp containing shreds of tissues The variable nature of the fluid is 
easily explained by the differences in the genesis of the neoplasmata 
Only the lymphangiectatic tumors, or those connected with them, will 
contain a thin, spontaneously coagulable and usually clear fluid. Since 
1 Bulletin de 1'Academie Belgique, 1862. 
2 Gazette Hebdom., 1873, p. 117 ct seq. CYSTO-FIBROMATA. 
289 
studies into the etiology of fibromata have not resulted in enlightenment on 
this subject, we are obliged to admit that future investigations of the 
same question promise but little information. In regard to the age of 
patients, Heer found among fifty-one cases, 
8 cases between 20 and 30 years. 
17 " " 30 " 40 " 
23 " " 40 " 50 " 
3 " " 50 " 53 " 
It would be of interest, as Leopold suggested, to inquire if it be possible 
to obtain an anatomical investigation whether any obstacles have existed 
in the circulation which could have produce^ ectasia of the lymph or 
blood-vessels of the tumor, and what the nature of the obstacle was, if 
any such existed. We have already stated that injuries may produce 
hemorrhage within a myoma. In the majority of these cases the bleeding 
is followed by gangrene, which is not always carefully distinguished from 
tumors, which are, properly speaking, cysto-fibromata. 
We shall inquire farther on, to what extent the existence of the puer- 
peral state may favor the development of cysto-fibromata. 
The symptoms of these tumors are almost identical with those of 
myomata in general. Routh1 calls attention to the infrequency of 
hemorrhages due to them. This is accounted for by the fact that most 
of the fibromyomata are sub-serous, and hence have but little influence 
upon the mucous membrane of the uterus. In the case of sub-mucous 
fibro-cysts, observed by me, the hemorrhages were profuse, and a large 
quantity of watery fluid, similar in its character to the fluid in the tissue, 
was discharged in the intervals between the hemorrhages. 
The only symptom which can be regarded as somewhat characteristic 
of these tumors is their rapid growth, which results in an equally rapid 
aggravation of the disturbances referable to their pressure. We shall 
consider their physical signs in our discussion of the diagnosis. The fact 
that the varying arterial tension during and after menstruation produces 
great changes in the size and consistency of the myoma telangiectodes or 
cavernosum, may assist in the diagnosis of this class of fibromata, although 
the same phenomena are also encountered in other varieties. 
Weber (Zoc. cZZ.) also noticed the immense distension of the dilated 
vessels in the case of a sub-mucous myoma cavernosum, which was ex- 
pelled under his observation. 
The diagnosis of these tumors has only been made in the most excep- 
tional cases, and even then has been the result of accident rather than of 
correct appreciation of the symptoms. Fibro-cysts so closely resemble 
multilocular ovarian cysts, particularly in their location and in their 
1 Obstet. Transact., VII., p. 252. 290 
NEW GROWTHS OF THE UTERUS 
fluctuation, that the frequency with which they have been mistaken for 
ovarian tumors is not astonishing. 
The slow growth of the fibro-cysts, as contrasted with the rapid de- 
velopment of ovarian tumors, has been suggested as a diagnostic distinc- 
tion between these tumors, but the exceptions to the rule are so numerous 
as to render it uncertain. The same remark applies to the differences 
said to be discovered by palpation. Pean and Urdy emphasize the re- 
markable hardness, and others the usually smooth and uniform surface 
of fibro-cysts. Beatty1 states that they impart the sensation of soft flesh, 
being less tense than ovarian tumors. All the other diagnostic criteria, 
based upon palpation, have no practical value, although they may be 
useful in isolated cases. 
On auscultation one hears vascular murmurs, but not so frequently as 
Pean believes. If they be present it is probable that the tumor belongs 
to the uterus, although such murmurs are rarely heard over ovarian cysts. 
In the differentiation between ovarian tumors and cystomyomata, it is first 
necessary to establish the relations existing between the uterus and the 
tumor in question. 
If the tumor can only be moved together with the uterus, if it appears 
continuous with the uterine tissues, and if the sound when introduced 
into the uterine cavity, follows every impulse imparted to the tumor 
through the abdominal walls, the neoplasm is very probably a fibro-cyst. 
But all these phenomena are observed in cases of ovarian tumors which 
are closely connected with the uterus, as is not seldom the case. On the 
other hand, cases of uterine cysto-fibroma have been reported in which 
the tumor was attached to the uterus by means of a pedicle, was freely 
movable, and in short presented all the signs of an ovarian tumor. 
Spiegelberg has announced that rectal palpation affords no further in- 
formation in such cases. The only definitive information is obtained 
by puncture of the tumor. The trocar enters cysto-fibromata with 
difficulty, and very often only a few drops of sanguinolent fluid are 
evacuated through it. Although the same phenomena may occur with 
ovarian cysts, they are more characteristic of cystic myomata. If the 
fluid be clear, yellowish, slightly tinged with blood, and immediately 
coagulates when exposed to the air, we have to deal, not with an ovarian 
tumor, but as far as our present knowledge teaches,2 with a cystic 
fibroma. 
All these tumors have not, however, contents of this nature, and one 
accordingly often obtains, on puncturing the neoplasm, a bloody fluid filled 
1 British Med. Journal, Nov. 4, 1871. 
2 A spontaneously coagulating fluid may be present also in ovarian tumors by 
reason of similar changes in the lymphatic vessels. These cases, however, are 
very rare, and the instances recorded are not so absolutely certain but that the 
dictum above enunciated will hold good in the vast majority of cases. CYSTO-FIBROMATA. 
291 
with shreds of tissue, such as is occasionally found in ovarian tumors 
particularly malignant ones. The discovery of smooth muscular fibres, 
on microscopical examination, would establish the existence of a uterine 
fibro-cyst. 
The question now arises whether puncture for the purpose of establish- 
ing the diagnosis, be justifiable. Fehling and Leopold state that death 
occurred in ten out of eleven cases, as a result of the puncture. The 
dangei' of the operation is dependent upon the fact that the walls of these 
tumors are unyielding, and readily allow the access of air. The trocar, 
moreover, easily produces hemorrhage in the vascular and degenerated 
tisues; experience must decide whether a tentative puncture by means of 
Dieulafoy's aspirator, be attended by similar dangers. I am inclined to 
believe, with McGuire,' that an exploratory abdominal incision, which 
will afford a view of the tumor, is the safest procedure, especially since 
extirpation of the tumor may be at once performed if the case be suitable 
for the operation. 
Isolated cases, as that of Spencer Wells,2 in which the autopsy revealed 
the fact that a tumor, considered ovarian during and after the operation, 
was in reality a uterine tumor, show that even exploratory abdominal in- 
cision will not always establish the diagnosis. This fact is best illustrated 
by Virchow's case,3 in which it was even difficult, at the autopsy, to 
recognize a preuterine ovarian sarcoma to be such, and to distinguish it 
from a uterine tumor. 
The symptomatic treatment of the tumors in question differs in no 
respect from that of uterine fibromyomata. We desire to earnestly dis- 
parage the puncture of these fibro-cysts. Their extirpation by means of 
an abdominal incision, is rather indicated for their rapid growth; and their 
tendency toward gangrene decidedly distinguishes them from ordinary 
sub-serous or other uterine myomata. 
The fact that fibro-cysts are far more dangerous than simple myomata 
is shown by the statistics of 0. Schroder and Heer, according to which 
the duration of the disease is relatively short. The longest period which 
elapsed before death was ten years, while many cases terminated fatally 
in a few months. 
In speaking of the operations for the removal of uterine fibroids, it was 
stated that rapid growth constitutes an indication for early interference. 
Now cysto-fibromata are especially characterized by the rapidity of their 
development. 
The cystic tumors are also more dangerous on account of their tendency 
to become gangrenous, and to lead to thrombosis. 
Hence this class of tumors will frequently come under the surgeon's 
knife, even if their true nature has not been discovered. On the other 
1 Medical Times, 1872, No. 1. 8 Ovarian Diseases, p. 200. 
3 Geschwulste, III., p. 208. 292 
NEW GROWTHS OF THE UTERUS. 
hand, when a clear diagnosis is possible, their removal must generally be 
urged. 
Formerly the majority of operations of this kind were underUken in 
consequence of faulty diagnosis, the growths being mistaken for ovarian 
cysts. The following cases belong in this category :1 
1. Neugebauer,2 who removed a pediculated uterine cysto-sarcoma 
through the abdominal walls, with a fatal result. 
2. Routh3 could not complete the operation. The patient died of 
hemorrhage from the walls of the cyst. 
3. Demarquay." The patient died thirty-six hours after the operation, 
at which the tumor could be separated from the fundus. 
4. Browne.6 The operation was not completed. The patient died. 
5. Roberts.8 The clamp was used. Recovery. 
G. Bryant.7 The tumor had a pedicle which was clamped. Recovery. 
7, 8, 9. Treenholme,8 Frankenhauser (Dissert, of Heer). Keith (Lan- 
cet, 1875) operated successfully. 
10, 11. Cheever ' and Landi10 lost their patients. 
The following cases were diagnosticated as cysto-fibromata and then 
operated upon: 
12. Koeberle.11 Recovery. 
13, 14. Keith (loc. cit.) Two successful cases. 
15 to 22. Pean12 extirpated eight fibro-cystsof the uterus. The opera- 
tion was successful in six cases. There are besides the following cases 
(conf. Gazette des Hopit., 18G9, and Pozzi, loc. cit.): 
Unfinished operations: 
Atlee 1849, one successful case. 
Baker-Brown 1860 and 1862, two fatal cases. 
Spencer Wells 1864, one case with fatal issue. 
Completed and successful operations: 
Lane 1844, seven cures; Fletcher 1862, Storer 1865, Atlee 1868, E. 
Bbckel 1876, Krassowsky 1876, Hakes 1863, Wells 1863, Koeberle 1863, 
Atlee 1862, Stokes 1863, Ollier 1874, Hegar 1876, Janies Henry. 
I merely mention Spiegelberg's 13 case in this connection, but do not in- 
clude it in this class, since it relates to a special operation, viz., the 
1 This list is not reproduced in the 2d edition of Gusserow's treatise, but is re- 
tained here as valuable for reference, and for the sake of completeness.-Ed. 
2 Scanzoni: Beitrage, VI., p. 125. 
3 British Med. Journal, April, 1866; and Obstet. Transact., VII., p. 252. 
4 Union Medicale, No. 113, 186S. 8 Transact. Path. Soc., XVIII., p. 196. 
6 London Obstet. Transact., 1872, p. 309. 
11bid., 1873, p. 79. 8 Lancet, November, 1874. 
9 Boston Med. Journal, December, 1874. 
10 Lo Sperimentale, 1871. 11 Gaz. Med. de Strasbourg, No. 6, 1869. 
12 Hyst6rotomie, and Pozzi loc. cit. 13 Archiv fur Gynakologie, VI., p. 341. CYSTO-FIBROMATA. 
293 
enucleation of a cystic myoma from the uterine wall, through the ab- 
dominal cavity. 
The final result, attained by the difficult method of comparing statistics, 
vitiated by the reprehensible custom of repeatedly reporting the same 
case, is that laparotomy has been performed forty-one times, for fibro- 
cystic uterine tumors, with twenty-two recoveries, i.e., 53.6 per cent. It 
was impossible to carefully separate those cases in which the tumors were 
removed alone from those in which the uterus was likewise extirpated. 
Only seven of the thirty-eight operations could be completed. Only one 
patient recovered from the effects of the operation. It is certainly re- 
markable that out of the eleven extirpations performed after the diag- 
nosis had been correctly made, only two proved fatal. 
From these meagre details it appears nevertheless that the extirpation 
of cystic myomata by laparotomy, furnishes better results than the same 
operation when done for non-cystic tumors. 
In explanation of this circumstance, it is to be remembered that the 
former variety of growths are more easily removed, since they are specially 
connected with the exterior of the uterine wall and are less frequently 
interstitial. 
Under the influence of modern antiseptic methods, still more favorable 
results have been obtained. What has been already said in connection 
with fibroids in general, applies with equal force to the cysto-fibromata. 
It is not necessary to insert separate tables here, showing the detailed 
results of operations. Grosshoff has collected fourteen cases from the 
literature of the last few years, with a mortality of only four. CHAPTER VIII. 
UTERINE FIBROIDS IN THEIR RELATIONS TO PREG- 
NANCY, PARTURITION AND CHILDBED. 
BIBLIOGRAPHY. 
Here, as elsewhere, the titles of the monographs only are given, the reader 
being referred to the text-books on obstetrics for the complete literature of this 
subject. Puchelt, B. R.: De tumoribus in pelvi, partum impedientibus, etc., 
Heidelberg, 1840.-Michauk: Beitr. z. Pathologic d. Uterusfibroids, Inaug. 
Dissert., Leipzig, 1868.-Guyon : Des tumeurs fibr. de 1'uterus, These de Concours, 
Paris, 1860.- Dubar: Des tumeurs fibr. de I'ut^rus compliquant la grossesse, 
These de Paris, 1864, No. 29.- Etcheverry : Des corps fibr. de l'ut6r. au point 
de vue de la grossesse, etc., These de Paris, 1864, No. 5.-Ebner: Dissert, de 
tumor, quorund. fibrosor. uteri in part, et puerp. hab., Inaug. Diss., Konig-sberg, 
1865.-Lambert: Des grossesses compliqu6es de myomes ut6rins, These de 
Paris, 1870, No. 268.-Magdelaine : Etude sur tumeurs compliquants la grossesse, 
etc., These de Strasbourg, 1866.-Stisserott: Beitrage zur Caustik der mit Uterus- 
myomen complicirten Geburten., Inaug. Disser., Rostock, 1870.-Nauss: Ueber 
complikation von Schwangerschaft, etc., mit Myomen des Uterus, Inaug. Diss. 
Halle, 1872.-S6bileau : Des tumeurs fibreuses dans leurs rapports avec la gross- 
esse, etc., These de Paris, 1873. 
rpHE fact that sterility results from uterine myomata is easily explained. 
The manifold pathological changes in the uterine mucous mem- 
brane, dependent upon the development of these neoplasms, in addition 
to the catarrh and the profuse hemorrhages resulting from them, are 
obstacles in the way of conception. Numerous changes in the relations 
of the uterus to the adjoining organs, especially to the Fallopian tubes 
and the ovaries, and alterations in the form of its cavity, offer notable 
mechanical impediments to conception. This is specially true of sub- 
mucous tumors, although the statement is equally applicable to certain 
sub-serous fibroids. We accordingly regard sterility as a frequent sequel 
of fibromata, although there has always existed great diversity of opinion 
in regard to this point. Since the time of Bayle, pathologists-as, for 
instance, Meckel, Cruveilhier, Virchow and recently, Cohnheim-have 
steadfastly maintained that fibroids occur predominantly in nulliparae or 
in women who have not had sexual intercourse. From this premise they 
have deduced the conclusion that complete inactivity of the genital ap- UTERINE FIBROIDS. 
295 
paratus is either an exciting or at least a predisposing cause of the neo- 
plasma ta. 
Almost all gynecologists, with the exception perhaps of Scanzoni and 
Spiegelberg, have entertained the opposite view, and Winckel and Rbrig 
have quite recently demonstrated, by incontrovertible arguments, that 
sterility in these cases is the result of the tumor's presence. 
It is the more interesting and important to discuss this question, 
because Cohnheim1 adduces the presupposed fact that sterility leads to 
the development of myomata in support of his hypothesis concerning the 
formation of tumors in general. 
A definitive settlement of the question seems unfortunately impossible 
at present, because statistics, upon which the decision must depend, 
furnish as yet too few and too uncertain data. Another prime reason is 
that anatomists have tabulated no numerical statistics to be compared 
with those of gynecologists. Since, therefore, the latter have only the 
opportunity of observing those cases of fibroma which produce trouble- 
some symptoms during life, it is quite possible that the view of the 
pathologists would be generally adopted if the total number of uterine 
myomata, discovered after death, were known. 
The scanty material at our disposal must be considered from two points 
of view. In the first place, it must be determined whether myomata are 
more frequent in nulliparae, and in those who have not had sexual inter- 
course, than in women who have had intercourse, and have given birth to 
children. Then it must be ascertained whether women suffering from 
fibroids are or are not fruitful. 
The first question can only be answered with approximate accuracy by 
the pathologists. Gynecologists can only state to which of these classes 
the majority of cases of fibroids presenting themselves for treatment 
belong. 
Now the records all go to show, without exception, that these tumors 
occur with much greater frequency in married than in single women. 
Among 959 myomata, collected by ourselves, 672 occurred in married and 
only 287 in unmarried persons. The investigations of Routh have proven 
that these tumors also attack married women with decidedly greater rela- 
tive frequency in England. 
Winckel likewise reached the same result, having found the disposition 
to the development of fibroids twice as marked in the married as in the 
unmarried, that is in those persons who had seldom or never gratified 
their sexual desires. 
Beigel Joe. oil., p. 425) found 86 married women among 146 who had 
fibroids, Michels found only 33 unmarried women among 160 patients 
with fibromata. Schroder (Schorler, 1. c.) found 614 married women 
1 Vorlesungen iiber Allgemeine Pathologie, Berlin, 1877, p. 641. 296 
NEW GROWTHS OF THE UTERUS. 
among 792 cases, i.e., 77.5 per cent. A long series of observations lead- 
ing to the same results might easily be adduced. 
A similar unanimity of opinion prevails concerning the relation between 
fibromata and sterility. West found that only 7 among 43 married 
women with fibroids were childless. The remaining 36 had, however, only 
given birth to 61 children altogether, and 20 of the women had borne 
only 1 child each. 
Among 106 married patients Rorig found only 31 childless, although 
40 of the women had each given birth to but one child. The total 
number of children borne by 75 of the women was 190. Among Beigel's 
86 married patients 21 were sterile, and among 21 patients treated by 
McClintock, 10 were childless. 
Scanzoni found 35 childless women among 69 married women affected 
with fibroids. Michel had only 26 cases of sterility among 127 patients. 
Winckel's statistics on this point are the most elaborate. 
Among the 415 cases of married women with fibroids collected by him, 
only 134, or 24.3 per cent., were sterile and 281 or 51.5 per cent, had 
borne one or more children. His statistics regarding the number of 
children borne by 108 women, affected with uterine fibroids, are most im- 
portant. Winckel himself observed 46 of these cases and borrowed 62 
from the statistics of Susserott (Inaug. Dissert., Rostock, 1870.) 
37 of Winckel's 46 patients had borne 114 children. 
Siisserott's 62 patients bore 162 children. The average number of 
children for each woman was thus 2.7, while the average in Saxony was 
4.5 children to each mother. 
A second table prepared by Winckel, embracing these 108 cases, is still 
more instructive: 
I-P- 
II-p. 
III-p. IV-p. v-p. VI-p. 
VII p. IX-p. 
XI-p. 
XIII-p, 
Winckel 
10 
6 
8 6 2 3 
1 1 
- 
- 
Siisserott 
27 
10 
10 7 4 1 
1 - 
1 
1 
- 
- 
- 
-- 
- 
- 
Total 
37 
16 
18 13 6 4 
2 1 
1 
1 
37=41.6# I-p. 
43 
1-48.3 plurip. 
r 
H 
multip 
In Saxony the tables were as follows: 
22.7# I-p.; 55.2# plurip.; 22.1# multip. 
Schroder (Schorler, l.c .) found among 604 cases of fibroids, 400 (66.3 
per cent.) fruitful, and 204 sterile women (33.7 per cent.) Schroder has 
published this table: 
Private cases: 
146 i.e. 39.6# were sterile. 
12 i.e. 3.2# had aborted 
211 i.e. 57.1# had children. UTERINE FIBROIDS. 
297 
Dispensary patients: 
58 i.e. 24.7^ were sterile. 
12 i.e. 5.0^ had aborted. 
105 i.e. 70.3^ had children. 
Again 376 women had 1295 children, an average of 3.45. If the en- 
tire number of children is proportioned to the number of married women 
having fibroids, each woman would have 2.1 children. But the average 
number, according to the above, would be 4.5. 
Although the number of cases in these tables is not large, the conclu- 
sions deducible from them are surprising. Although the number of 
patients with myomata, who have had one child, is quite large, the num- 
ber of pluriparae and of multiparse is far below the usual average. This 
fact can only be explained by the supposition that the myoma prevented 
later conceptions. 
From the above tables, together with my own recorded cases, I was able 
to collect 564 cases of fibroids in married women. 153 of these were 
sterile. Mention should be made at this time, of Marion Sims's 1 statis- 
tics, which are based on original observations. Among 255 women who 
had borne one child and then become sterile, he found fibromata present 
in 38 cases, i.e., 1 to 6.7. Among 250 married women who were child- 
less, he found 57 cases of fibroid, or 1 to 4.3, and finally among 100 vir- 
gins who complained of pain in the hypogastrium, 24 fibromata, or 1 to 
about 4.15. 
We accordingly reach the conclusion that uterine myomata are much 
more frequent in those persons who regularly gratify their sexual desires, 
than in those in whom a similar gratification can not be assumed. 
The fruitfulness of women suffering from myomata is much dimin- 
ished, but one is justified, in the above statistics, in regarding this as the 
result of the tumor's development. This view of the gynecologists con- 
cerning the relation of myomata to conception, based, it is true, upon in- 
complete statistical data, does not accord with the experience and theories 
of pathologists. The point in dispute can only be decided by farther 
observations, particularly by those relating to pathological anatomy. 
The fact that pregnancy occurs with the greatest relative frequency 
in cases of sub-serous myomata, which produce the fewest pathological 
changes in the uterine cavity and the uterine mucous membrane, and 
that it occurs least frequently with sub-mucous fibroids, confirms the view 
that fibroids are rather the cause than the result of sterility. 
The above statement that pregnancy occurs most frequently in cases of 
sub-serous fibromyomata can hardly be established by figures, unless all 
the histories be passed in review. It may be said that the tumor present 
in every carefully described case of uterine fibroma, in which pregnancy 
1 Uterine Surgery, 1866, p. 94. 298 
NEW GROWTHS OF THE UTERUS. 
occurred, was of the sub-serous variety. The cases of interstitial and 
particularly of sub-mucous tumors is insignificant, as will be seen from 
what follows. 
The fact that one often has opportunities of observing fibromata, in 
pregnancy and parturition, which do not affect these conditions, because 
they are sub-serous, accords with the above statement. Such cases are, 
of course, not published, and therefore the claim can not be substantiated 
by any considerable number of recorded cases. 
It may be remarked, however, that Schroder's figures do not confirm 
this view. His table is as follows: 
Of 85 cases of interstitial fibroids 21 were sterile, i.e. 24.7# 
" 92 " sub-serous " 44 " " 47.8# 
" 18 " sub-mucous " 7 " ". 38.8# 
" 44 " polypoid " 4 " " 9.0# 
" 14 e( cervical ie 3 " " 18.7^ 
From this table it would appear that sub-serous tumors, more than 
any other variety, predispose to sterility, which is not in conformity with 
what has already been said. 
Great diversity of opinion has prevailed, particularly among French 
authors,1 concerning the changes effected in the development of fibroids by 
the physiological processes of pregnancy. 
Many tumors are not at all affected by pregnancy. Others are materi- 
ally changed thereby. Both conditions depend upon the seat and the 
structure of the tumor. The more closely connected the fibroma is with 
the uterus, the more will it participate in physiological processes occur- 
ring in that organ. The closer its resemblance to the uterine tissue, the 
more radical will these changes be. 
Sub-serous tumors are least changed by pregnancy, while sub-mucous 
and interstitial fibromata undergo the most marked alterations in struc- 
ture. Again, those sub-serous fibromata which have a long, thin non- 
vascular pedicle, are least affected by pregnancy, while the reverse obtains 
in the case of tumors with a broad base. The interstitial and sub-mucous 
fibromata which are separated from the uterine parenchyma by a stiff, 
firm capsule, containing few blood-vessels, undergo the least marked 
changes during pregnancy. 
While, therefore, the degree of the changes in the tumor is chiefly de- 
termined by the nature of its attachment to the uterus, the character of 
these changes will depend upon the structure of the fibroid. Pure fibro- 
mata, composed mostly of connective tissue, are but slightly changed, if 
at all. They become swollen and cedematous, owing to their great vas- 
cularity and that of the neighboring tissues. This morbid condition is 
frequently described as softening, and is so in reality, but must not be 
1 Corps fibreux de 1'uterus pendant la grossesse, Gaz. des Hop., 1869. UTERINE FIBROIDS. 
299 
confounded with those metamorphoses which pathologists designate by the 
name softening, and which consist of actual disintegration of tissue. 
Vascular fibromata and those composed largely of muscular tissue, most 
frequently become cedematous during pregnancy. Those tumors which 
are almost entirely composed of muscular tissue, and which are not en- 
capsulated, grow very rapidly during pregnancy by hypertrophy, and per- 
haps by hyperplasia of their elements. The more closely identified these 
tumors are in structure with the uterine walls, the more do they parti- 
cipate in the changes which pregnancy produces in the latter. 
It is still doubtful whether sufficiently extensive extravasations take 
place in these fibromata before birth, to augment the size of the tumors, 
and to occasion farther changes in their tissues. In most cases these 
hemorrhages are probably produced by the efforts attending parturition 
or by the pressure of the child's head. 
Cappie 1 had a unique case, illustrative of the condition under discus- 
sion. A woman was seized in the fourth month of utero-gestation, with 
violent peritonitis and symptoms of internal hemorrhage. 
The diagnosis of sub-serous uterine tumoi' which had grown rapidly 
during the later months of pregnancy was made. Abortion was induced 
but did not save the patient. The autopsy revealed, as the cause of the 
fatal attack, a softened, pediculated sub-serous myoma, which had be- 
come gangrenous owing to torsion of its pedicle. 
Quite recently Dolcris2 has asserted that the enlargement of myomata 
during pregnancy was due chiefly to proliferation of connective tissue, 
showing a tendency to undergo colloid or myxomatous degeneration. 
The cases of growth and enlargement of uterine myomata during preg- 
nancy, by one of the methods described, are numerous and authentic. 
The fibroids may have been so small as not to have attracted attention 
before the occurrence of pregnancy, and may have developed into enor- 
mous tumors, during its progress. On the other hand, the tumors have 
long existed, in some cases, as small though distinct prominences, and 
have produced various disturbances by their rapid growth. We shall 
find, as a general rule, that those tumors which increase rapidly in vol- 
ume during pregnancy, diminish with equal rapidity during the puerpe- 
ral state. 
The cases of this kind are so numerous that only the most important 
ones can be cited. Ingleby3 mentioned these occurrences, and Mont- 
gomery4 also referred to them, but called attention to the fact that 
growth of the tumor does not necessarily occur. ' 
1 Obstet. Journal, vol. IL, p. 303. 
2 Archiv. de Tocol., Jan. and Feb., 1883. 
3 Edin. Med. & Surg. Journal, 1836, p. 107. 
4 Signs and Symptoms of Pregnancy, 1856, p. 344. 
6 Dublin Med. Journal, vol. VI., 1835, p. 418. 300 
NEW GROWTHS OF THE UTERUS. 
Then followed the reports of Ashwell,1 Priestley,2 Hall Davis,9 Madge,4 
Depaul, Danyau, Cazeau/etc. Playfair,6 Lorain 7 and Pagan/all had 
the opportunity of twice observing, in the same person, the growth and 
disappearance of one .and the same myoma during pregnancy and the 
puerperal state. The cases of Spiegel berg/ of Breslau,10 and of many 
others should be compared with these. (Compare also Demarquay and 
St. Vel, Maladies de FUterus, p. 1G9.) 
Hardly a case of fibroids complicated with pregnancy is published 
without the statement being made that the tumor grew notably during 
utero-gestation. It is important, therefore, to emphasize the fact that 
there are numerous exceptions to this apparent rule. Gueniot," Scan- 
zoni/2 Guyon, d'Outrepont, Thibaut and others, beside Montgomery, 
have called attention to this point. 
We have already stated that any genuine softening, aside from the 
oedematous infiltration above described, does not occur in these tumors 
during pregnancy. This is confirmed by the statement of Nauss13 that 
he discovered, on post-mortem examination of nineteen such cases, that 
only oedematous infiltration was present in thirteen of them. In the re- 
maining literature of this subject I am unable to find any well-authenti- 
cated cases of softening due to other causes. 
Cases said to present softening of another kind have usually owed their 
necrotic disintegration to uterine contractions or to puerperal processes. 
It cannot, however, be denied that this change may occur in such 
tumors during pregnancy. 
Besides these changes in the growth of myomata during pregnancy, 
alterations in their forms are sometimes observed, and produce an ap- 
parent disappearance of the tumors. Myomata located in the lower seg- 
ment of the uterus may be so distorted and flattened by uterine contrac- 
tions, particularly if they be interstitial, that they can be no longer discov- 
ered by palpation. After the evacuation of the uterus the tumors re- 
appear, owing to the diminution in the size of the uterine parietes. 
1 Guy's Hospital Reports, 1st Series, vol. I., 1836, p. 300. 
2 Transact, of London Obstetr. Soc., vol. I., p. 217. 
2 Ibid., vol. VIII., p. 11. 
4 Ibid., vol. XIV., p. 227. 
5 Comp. Magdelaine: Etudes, etc., These Strasbourg, 1869, No. 171. 
6 Obstet. Journal, May, 1877, p. 116. 
1 Gazette des Hopitaux, 1869. 
8 Lambert : Des grossesses compliqu6es de myomes, These Paris, 1870. 
9 Archiv fill' Gynakologie, vol. V., p. 100. 
10 Monatsschrift fur Geburtskunde, vol. XXV. 
11 Gaz. des Hop., 1869. 
12 Lehrb. d. Krankh. d. Weibl. Sexualorgane, 1857, p. 208. 
13 Heber Complikation von Schwangerschaft, etc., mit Myomen des Uterus, 
Inaug. Dissert., Halle, 1872. UTERINE FIBROIDS. 
301 
The flattening of the fibroids may be produced by the pressure of the 
growing ovum, but is usually referable to the above mentioned changes in 
form of the pregnant uterus. The flattening has always been most 
marked in the case of pure myomata lying free in the muscular walls. 
Such cases have been observed by Depaul, Gueniot,' Spiegelberg,2 and 
Olshausen.3 Gueniot4 describes a similar case of a large, pediculated sub- 
mucous fibroma, which had been so imbedded in the uterine tissues 
during pregnancy, that it was. considered an interstitial tumor. It ob- 
structed labor to such an extent that it was necessary to perforate the 
child. The mother died, five days later, from peritonitis, and it was then 
discovered, for the first time, that the tumor was pediculated and might 
possibly have been removed before the death of the child. 
Mention should be made of the displacement of fibroids from their 
original sites during pregnancy. Charrier 5 saw a firm fibroma extruded 
from the uterus into the vagina of a woman in the seventh month of 
pregnancy without the occurrence of uterine contractions. It then began 
to mortify, and spontaneous abortion, which occurred twenty-four days 
later, was followed by recovery. When the tumor finally appeared at 
the vulva it was gradually excised. It is doubtful whether it be wise to 
leave a gangrenous tumor so long connected with the uterus during preg- 
nancy, parturition and the puerperal state as Charrier recommends. 
While this is the only case of the kind, so far as I know, which has been 
observed during pregnancy, similar ones are far more frequently encoun- 
tered during labor. It is easy to understand how the uterine pains may 
force downward movable tumors occupying the lower segments of the 
uterus. 
These changes in the seat of fibro-myomata are rare, but subserous 
tumors, situated in the body of the uterus, frequently wander from the 
pelvis into the abdominal cavity as the pregnant uterus enlarges. Nu- 
merous cases have been reported in which such a tumor, which originally 
completely filled the pelvis, gradually escaped from it into the abdominal 
cavity. 
However various the results of pregnancy may be upon the course of 
fibro-myomata, the influences of these tumors upon utero-gestation are 
still more manifold and of far greater importance to the patient. Cases 
are by no means rare in which pregnancy, labor and the puerperal state 
are not disturbed by the presence of such tumors. 
It is oftentimes surprising that these functions should be faultlessly 
1 Comp. Magdelaine : These Strasbourg, 1869. 
2 Lehrb. der Geburtsh., 1877, p. 292, and Monatsschr. f. Geburtsk., XXVIII. 
p. 426. 
3 Nauss : Dissert., Halle, 1872. 
4 Gaz. des Hop., 1864, Nos. 43 et seq. 
5 Gaz. des Hopitaux, No. 4, 1875. 302 
NEW GROWTHS OF THE UTERUS. 
performed in spite of great distortion of the uterus by numerous fibroids. 
Gueniot1 mentions the case of a woman whose pregnancy and confine- 
ment were normal, but whose uterus was filled with twenty fibromata of 
various sizes. Hecker2 and others report similar cases. 
On the other hand, abortion and premature delivery are often induced 
by comparatively diminutive tumors. Toloczinow3 found 21 cases of 
abortion among 119 pregnancies complicated with fibroids. West found 
28 abortions among 3G similar cases, and Winckel 1G abortions out of 46 
cases. Nauss found 47 cases of abortion among 241 pregnancies, and 
Sebileau4 15 abortions among 47 cases. Lefour 5 observed 39 abortions 
in 307 cases. The mothers died 14 times. He also saw 23 premature 
confinements, with 3 deaths of the mothers. 
It is impossible to decide, by reference to the data at our disposal, 
whether the tendency of fibromata to induce abortion be directly propor- 
tionate to the extent of their projection into the uterine cavity. It would 
rather seem that interruption of pregnancy is the more frequently pro- 
duced by these neoplasmata the lower their seat in the uterus, and the 
closer their approximation to the cervix. 
According to Forget, Sebileau, and Toloczinow, those tumors which 
are attached to the fundus rather produce abortion, while those located at 
a lower point induce premature deliveries. This theory has not been 
universally accepted. 
Abortion, when produced by these tumors, is caused by changes in the 
position of the uterus, by incarceration of that organ in the pelvis, and by 
hemorrhages referable to the presence of the tumors. But these exciting 
causes may be wanting, and the expulsion of the ovum be directly due to 
the tumor, or, rather, to its influence upon the uterine walls. Such cases 
of course occur more frequently than one would suppose from an examina- 
tion of the literature of the subject, since only few of them are interesting 
for publication. Hall Davis 6 describes such a case which produced the 
mother's death by pyoemia. Beatty7 reported a case of abortion at the 
third month, after which the tumor led to the development of uterine in- 
version. 
Fibromata very often produce backward displacements of the uterus in 
the first months of pregnancy. These retroflexions of the pregnant 
uterus are produced by the pressure of a very large fibro-myoma situated 
1 Quoted by Demarquay et Saint Vel. loc. cit., p. 176. 
2 Monatsschrift f. Geburtsk., XXVI., p. 458. 
3 Wiener Med. Presse, No. 30, 1869. 
4 Des tumeurs fibreuses dans leurs rapports avec la grossesse, etc., These 
Paris, 1873. 
6 Des fibromes ut^rines au point de vue de la grossesse, Paris, 1880. 
6 Med. Times, Feb. 17, 1866. 
7 Transact, of the Coll. Phys, of Ireland, vol. VI., 1824, p. 1. UTERINE FIBROIDS. 
303 
either at the fundus or on the anterior uterine wall. Still more fre- 
quently the displacement is due to pediculated or non-pediculated sub- 
serous tumors on the posterior wall. 
In some cases the uterus, together with the tumor, spontaneously re- 
turns to its normal position. In other instances symptoms of incarcera- 
tion manifest themselves, and manual reposition or artificial abortion be- 
come necessary. Sometimes spontaneous abortion results from the in- 
carceration or from attempts at reposition. Such cases of retroflexion of 
the gravid uterus, induced by tumors at the fundus, in which, after suc- 
cessful reposition spontaneous abortion occurred, are described by Simp- 
son;1 Lorimer,2 who reported a case in which a fibroma as large as an 
orange and in the posterioi- wall, produced retroflexion and incarceration of 
the uterus, which rendered artificial abortion necessary. The patient 
nevertheless died of gangrene of the bladder. Other cases are cited by 
Depaul and Ziegler {Conf. Nauss, toe. cit.) 
More frequently, for the rest, it happens that a myoma of the posterior 
uterine wall, which of itself produces incarceration of the uterus in the 
true pelvis and consequently induces threatening symptoms, is mistaken 
for retroflexion of the gravid uterus. Hall Davis3 describes such a case 
as retroflexio uteri. 
Exceedingly severe symptoms of incarceration, produced by a tumor 
on the posterior wall, or, more probably, in the cervix, occurred in a woman 
during the third or fourth month of pregnancy. Reposition seemed impos- 
sible. When the sound was introduced it showed that there was no re- 
troflexion. As a result of the exploration a putrescent foetus of about 
four months was expelled, after which the tumor was easily displaced 
from the pelvic into the abdominal cavity. The patient died of pyelone- 
phritis. 
Depaul4 reported a similar case, in which so marked an incarceration 
of the tumor and the uterus occurred, in the fourth month of pregnancy, 
that the patient could neither defecate nor urinate, and the diagnosis of 
incarcerated hernia had been made. Artificial abortion resulted in the 
expulsion of an entirely flattened foetus. The patient recovered, and, after 
five months, the tumor was no larger than a small apple. 
Sedgwick's 5 case proves that incarceration may be remedied by the 
upward displacement of the tumor beyond the superior strait. This 
case, however, terminated in spontaneous abortion. At a later stage of 
pregnancy the symptoms of incarceration may become so violent that all 
possibility of inducing artificial abortion disappears. 
1 Edin. Monthly Journal, 1848. 
2 Ibid., July, 1866. 
3 London Obstet. Transact., vol. VIII., p. 11. 
4L'Union M^dicale, 1857, p. 548. 
5 St. Thomas Ho»p. Reports, 1870, p. 349. 304 
NEW GROWTHS OF THE UTERUS. 
In such a case Gazin1 successfully performed Caesarean section in 
the seventh month of pregnancy. We shall revert to this subject later. 
Hemorrhage must be cited as another threatening symptom liable to 
result during pregnancy from fibro-myomata. It is not often men- 
tioned, because pregnancy rarely exists together with sub-mucous fibroids. 
Among nineteen cases of hemorrhage during pregnancy, collected by 
Nauss, there were sub-mucous myomata in eleven, interstitial in six and 
sub-peritoneal in two cases. These hemorrhages usually induce abortion. 
Nauss found only eight cases in which pregnancy reached a normal ter- 
mination in spite of repeated hemorrhages. 
Ramsbotham, Pajot, Ashwell, and Grimsdale2 cite cases of abortion, 
accompanied by profuse bleeding, produced by fibroids. Lloyd Roberts4 
saw a sub-mucous, pediculated fibroma extruded w'ith violent hemorrhage 
from the os uteri during the sixth month of pregnancy. Premature 
delivery did not occur in this case until a month later. Grimsdale 
was obliged to enucleate a fibro-myoma from the posterior uterine wall 
during pregnancy, on account of dangerous hemorrhage. On the second 
day after the operation a foetus, four months old, was expelled. The 
mother recovered. 
Tarnier5 and Daly8 mention violent pains, unaccompanied by inflam- 
matory phenomena, among the symptoms of fibromata complicating preg- 
nancy. Worship 7 saw death result in the sixth month of pregnancy from 
peritonitis. The foetus was not expelled. In this case a cystic myoma of 
the fundus was discovered to be the cause of the peritonitis. An attack 
of peritonitis, produced in the fifth month of pregnancy by inflammation 
in a pediculated sub-serous myoma, terminated in a similar manner. At 
the height of the disease artificial abortion had been induced. (II. Lee/) 
I have been unable to find any case of rupture of the pregnant uterus 
resulting from the growth of tumors. 
It would not be surprising if these tumors often gave rise to extra- 
uterine pregnancy. I have, however, been unable to find more than two 
such cases. Stolz 9 observed tubal pregnancy in a case where a sub- 
mucous fibroma filled the entire uterine cavity, and George Harley de- 
scribes a tubal pregnancy which ended in fatal rupture of the uterus the 
fifth month. The uterus contained several sub-serous fibromata. One 
of these, situated at the junction of the left Fallopian tube with the 
1 Archiv. de Tocologie, vol. I., p. 704. 
2 Comp. R. Lambert: Des grossesses compliqu6es de myomes uterines, Th6se 
Paris, 1870, No. 268. 
3 Lancet, 1867, p. 333. 4 Marion Sims : Uterine Surgery, p. 117. 
8 Gazette des Hopitaux, 1869. 6 Obstet. Transact., XVIII., p. 65. 
7 Obstet. Transact., London, XIV., p. 305. 
8 Clinical Midwifery, London, 1842. 
• Cited by Demarquay et Saint Vel., p. 171. UTERINE FIBROIDS. 
305 
uterus, was of specially large size. The ovum had been developed in the 
left Fallopian tube.1 
Nauss found the placenta abnormally located in only IGout of 241 cases 
of myomata. Placenta praevia occurred twice.2 The placenta was 
situated very deeply in three cases. In eight cases the placenta was situated 
entirely or in great part upon the tumor, and, in three instances, a small 
portion of it was located upon the neoplasm. In eight of the last-men- 
tioned cases sub-mucous tumors were present. It is at least probable that 
threatening hemorrhages, and perhaps gangrene of the tumor, in the 
Fig. 28.-Large Uterine Fibroids and Tubal Pregnancy. (After G. Harley.) 
puerperal state, may occur, with special frequency, after the expulsion of 
a placenta thus abnormally situated. 
Michauk3 describes a deficiency in the membranes as large as a saucer, 
produced by their adhesion to a sub-mucous fibroid and the consequent 
retention, in utero, of a part of their tissues. 
Morbid changes in the foetus, referable to these tumors, are rarely dis- 
coverable during pregnancy. Gussmann4 saw death of the foetus result 
from premature separation of the placenta produced by a fibroid. 
So long as the amniotic cavity is intact and the foetus is alive, or even 
with a dead foetus, so long as the liquor amnii has not materially dimin- 
ished in quantity, a fibroid can have but little influence on the shape 
1 London Obstet. Transact., vol. I., p. 101. 
2 Chadwick (Transactions of the Am. Gynecol. Soo., vol. I., p. 255) found eight 
cases of placenta prtevia complicated with fibromata. The death of the mother 
occurred in five of these cases. 
3 Dissert. Leipzig, 1866. 
4 Wiirttem. Correspondenzblatt, No. 19, 1868. 306 
NEW GROWTHS OF THE UTERUS. 
of the child, which is protected by the fluid from the pressure of the 
tumor. Flattening of the foetus, fissures of the skull, etc., occur only 
when labor is rendered very difficult by one of these tumors, and we shall 
revert to the consideration of these tumors in another place. The foetus 
is only compressed when it has died during utero-gestation, and been 
reabsorbed. Depaul1 and Lachapelle describe cases of this kind. Lever2 
saw a premature child born alive, but with its lower extremities bent, as 
if from close contact with a round body, in a case of fibroma which was 
large and hard. 
Pregnancy complicated by uterine tumors often renders a diagnosis 
exceedingly difficult. It is very common for either the pregnancy or the 
tumor to be overlooked. All the diagnostic symptoms of tumors cited 
above, as well as all the signs of pregnancy, must be carefully sought 
for. The most numerous and fatal diagnostic errors have been made 
because the possibility of co-existing pregnancy has not been considered. 
The fact that many of the tumors produce no symptoms during preg- 
nancy, accounts for the fact that they often escape observation. In other 
eases the symptoms due to the tumors become so prominent as to over- 
shadow those of pregnancy. Whenever a tumor, occurring in a patient at 
puberty, grows rapidly or induces violent symptoms with relative rapidity, 
one must always consider the possibility of co-existent pregnancy. The 
cedematous infiltration of- myomata, during pregnancy, has often caused 
these tumors to be regarded as of ovarian origin and to be punctured. 
The latter operation usually leads to abortion, and even to gangrene of 
the tumor. James Henry3 undertook the operation of ovariotomy in a 
case which proved to be a softened sub-serous myoma. The patient 
died two and one-half hours after the operation, and the autopsy dis- 
closed a foetus four months old in the uterus. 
The symptoms of pregnancy, combined with those of the tumor, have 
led, in a few cases, to the diagnosis of extra-uterine pregnancy, the inac- 
curacy of which has been demonstrated by the occurrence of spontaneous 
and normal labor. Madge4 and Simpson5 described such cases. The patient 
of the latter observer died two weeks after her normal confinement, and 
a sub-serous uterine fibroma, the pedicle of which had been torn from its 
uterine attachments by the process of involution, was found fixed by 
adhesions to the anterior abdominal wall. 
The treatment, during pregnancy, must be expectant and symptomatic. 
If symptoms of incarceration of the tumor in the pelvis appear, efforts 
at reposition must be made as soon as possible. Should these attempts 
1 L'Union Medicale, 1857. 
2 Guy's Hosp. Reports, vol. VII., 1842. 
3 Boston Gynecol. Journal, vol. IV., p. 330. 
4 Ob.stet. Transact., London, vol. XIV., p. 227. 
6 Obstetrical Works, Black, p. 155. UTERINE FIBROIDS. 
307 
fail, abortion or premature labor must be artificially induced, if possible, 
before the symptoms have reached a dangerous degree of intensity. 
These views have recently been opposed. It has been pointed out 
that abortion is dangerous to the mother, owing to the tendency to 
hemorrhage caused by the presence of the tumor, and again because the 
growth might undergo disintegration in childbed. Influenced by these 
considerations, Schroder 1 has done laparotomy for the removal of a 
myoma in the sixteenth week of pregnancy. The patient recovered and 
gave birth to a child at full term. The same surgeon did two similar 
operations in the third month of pregnancy, and both patients recovered.3 
These operations were performed on account of the dangerous condition 
of the patients, brought about by the rapid growth of the tumors. 
Hegar3 removed a sub serous myoma of the uterus in the third month 
of pregnancy; the patient died of septicaemia. Kaltenbach4 performed a 
successful operation of this kind in the fifth month of pregnancy. 
Wasseige 5 had a similar but unsuccessful case. Studsgaards6 removed a 
pediculated sub-serous fibroid in the third month; the woman recovered 
and did not have an abortion. 
Thornton7 had a similar but fatal case. Pean8 performed an operation 
of this kind, but overlooked the existing pregnancy (fifth month) on 
account of the enormous size of the tumor. The patient aborted but 
recovered. 
Landau9 removed two sub-serous pediculated tumors in the third 
month, the patient recovering and giving birth to a child at full term. 
Owing to these favorable results, it is certainly justifiable to remove 
fibroids during pregnancy, if these tumors produce serious symptoms. 
The induction of abortion, apart from its inherent dangers, does not rid 
the patients of their tumors. 
The influence of these tumors is still more marked upon parturition 
than upon pregnancy. The number and size of the fibroids is of less 
importance, with reference to their effect upon parturition, than their 
seat. Although tumors located in the cervix often obstruct labor owing 
to their size, the obstruction may usually be readily removed by the 
enucleation of the fibromata. Such cases are reported by Danyau/0 
1 Zeitschr. f. Geb. u. Gynakol., vol. V. 
2 Hofmeier (1. c.). 
3 Hegar u. Kaltenbach : Operat. Gynakol., 2d edition, p. 426. 
4 Ibid. 
6 Extr. bullet, de 1'Acad. Roy. de M6d., Beige., vol. XIV. 
6 Hospital Tidende, No. XIV. 
1 Quoted by Studsgaards, 1. c. 
8 Clin. Chirurg., 1876, p. 679. 
9 Berlin. Klin. Woch., No. 13, 1885. 
10 Gaz. des Hop., No. 42, 1851. 308 
NEW GROWTHS OF THE UTERUS. 
Langenbeck1 and by Braxton Hicks2 who enucleated from the anterior 
lip of the cervix a myoma which weighed one pound and had prevented 
the entrance of the head into the pelvis. The labor was easy and the 
case resulted favorably for mother and child. 
Sub-mucous fibro-myomata, particularly if pediculated, give rise to 
comparatively few disturbances of parturition. When located in the 
lower segments of the uterus they may be expelled in advance of the 
presenting part of the child, and are often spontaneously separated from 
their uterine attachment, provided the pedicle be long and slender. Forget, 
Ramsbotham, Marchal de Calvi (Demarquay and Saint vel., malad. de 
1'uter.). Dubois and Depaul have observed cases of this kind. In other 
instances it was necessary to separate a pediculated tumor from its attach- 
ments before the expulsion of the child, because the former offered an 
obstacle to delivery or occasioned profuse hemorrhage. J. Bell3 and 
Fergusson4 describe such cases. A calcified fibroma was in one instance 
mistaken by the physician for the child's head, and delivered with the 
forceps. The pedicle was next severed, and the child, which presented 
transversely, extracted by means of version. The tumor weighed about 
eleven ounces, was nearly four inches in length and three inches wide. 
(Saxinger5). A similar diagnostic error, committed by Fergusson," had a 
less fortunate sequel. He mistook a soft, pediculated myoma for the 
child's head, applied the forceps and extracted the tumor after tearing 
through the pedicle. The patient died after forty-eight hours, and a 
laceration of the uterus was found at the point of insertion of the pedicle. 
If such a pediculated tumor be located higher in the uterus, labor may 
be obstructed owing to limitation of intra-uterine space, so that perfora- 
tion of the child's head may be called for. (Gueniot,7 Priestley/) These 
tumors are, however, usually not observed until after the birth of the 
child, at which time they occasion bleeding, and are extruded from the 
uterus by the after-pains. They are then ordinarily removed by one of 
the methods above described, or are spontaneously separated from their 
uterine attachments. (Conf, cases of this kind observed by Depaul, Gar- 
diner, Montgomery, Holyoke, Radford, Collins and Churchill.9) 
If the tumor be interstitial and located in the lower uterine segment, 
thus partially belonging to the class of cervical myomata, it may lead to 
such a limitation of the intra-pelvic space as to seriously obstruct labor. 
These incarcerated myomata will be considered hereafter in connection 
with the sub-serous cervical tumors. Interstitial myomata frequently 
have no direct influence upon parturition. They sometimes precede the 
1 Deutsche Klinik, No. 1, 1859. 2 London Obstet. Trans., vol. XII., p. 273. 
3 Edin. Med. Journal, 1820, p. 365. 4 Quoted by Lambert, p. 116. 
6 Prager Vierteljahrschrift, vol. II., 1868. 
6 Lambert, loc. cit., p. 119. 1 Gaz. des Hop., 1864, p. 197. 
8 London Obstet. Trans., vol. I. 9 Quoted by Lambert. UTERINE FIBROIDS. 
309 
child's head in its descent into the pelvis, but often recede again into 
the abdominal cavity, particularly after the rupture of the membranes, 
or are gradually retracted over the head and trunk of the child by the 
uterine contractions. In other cases they are so soft as to be flattened 
out by the advancing foetus. (Tarnier.) 
It is more frequently asserted than directly proven that these tumors 
enfeeble the pains. This may be explained by the circumstance, pointed 
out by Nauss, that a large part of the fibroids consist chiefly.of smooth 
muscular tissue, which perhaps participates in the uterine contractions. 
Serious and even fatal secondary hemorrhages have, however, often been 
observed in these cases, and are referable to uterine atony. 
Fibroids may so protract labor as to imperil both mother and child. 
Treuer reports such a case, in which the labor was terminated by the for- 
ceps, after it had lasted three days, and the mother died. 
Bbhmer and Barnetsche report a case in which the woman's death oc- 
curred forty-eight hours after the termination of a labor which had con- 
tinued six days.1 M'Clintock2 saw death occur from exhaustion fifty 
hours after the beginning of labor, in a case of triple pregnancy. In 
none of these cases was there any obstruction due to the tumor, and en- 
feeblement of the uterine contractions could, therefore, be properly as- 
sumed as the cause of the protracted labor. 
Sub-serous myomata, when located in the cervix, complicate labor in 
the most dangerous manner. The nearer their location is to the fundus 
the less manifest is their influence upon the parturient act, although 
they may occasion weakening of the pains when occupying that position. 
Chaussier and d'Outrepont describe cases of sub-peritoneal fibroids, in 
which uterine atony led to fatal hemorrhages. Puchelt and Simpson men- 
tion cases in which "exhaustion" from the same source is cited as the 
cause of death (quoted by Magdeleine). When, however, these sub-serous 
tumors are pediculated, they may occasion, even when located near the 
fundus, very dangerous symptoms of incarceration. This is particularly 
the case if they possess a long pedicle, and are thus enabled to sink down- 
ward into Douglas's cul-de-sac, where they either become adherent or are 
incarcerated by the enlarging uterus. Blot3 was obliged to undertake a 
difficult version which resulted in the death of both mother and child, 
because of a large, pediculated, sub-serous myoma of the posterior uter- 
ine wall, which had become adherent to the pelvic parietes. 
Madge4 punctured an incarcerated myoma during labor, and was after- 
ward able to force the tumor upward out of the pelvis. The woman 
1 Cited by Lambert, p. 108. 
2 Clinical Memoirs, Dublin, 1863, p. 116. 
3 Gaz. des Hop., 1869, p. 147. 
4 London Obstet. Trans., vol. IV., p. 129. 310 
NEW GROWTHS OF THE UTERUS. 
died of peritonitis and a sub-serous, movable tumor was found attached, 
by a long pedicle, from the fundus uteri. 
. Before considering the serious disturbances of labor referable to incar- 
ceration of fibromata in the pelvis, it seems appropriate to emphasize the 
other methods by which these tumors unfavorably influence the course of 
parturition. 
First, in this connection, is the relation between these tumors and the 
position of the child. Nauss (Inaug. Dissert. Halle, 1872) found among 
86 labors complicated by fibroids, 46 cranial presentations, i.e., 53.4 per 
cent.; 22 breech, or 25.5 per cent.; and 18 transverse presentations, i.e., 
20.9 per cent. Siisserott (Inaug. Dissert., Rostock, 1870) found, among 
68 such cases, 40 cranial presentations, i.e., 59 per cent., 16 breech or 
23.5 per cent., and 12 transverse presentations, i.e., 17.5 per cent. 
Toloczinow,1 obtained similar results, finding among 48 labors compli- 
cated with fibromata, 25 cranial presentations, i.e., 52 per cent., 13 
breech or 27 per cent., and 10 transverse presentations, or 20.8 per cent. 
Tarnier2 encountered 9 breech presentations among 22 cases of this va- 
riety. The striking predominance of transverse and pelvic presentations 
will not excite surprise if one considers, beside the configuration of the 
uterine cavity, the fact that the entrance of the head into the pelvis must 
be impeded by the presence of fibromata deep in the pelvic cavity. 
I have already stated that these tumors do not affect the uterine con- 
tractions to such an extent as might be expected or as has been assumed 
a priori. The frequency of hemorrhage, however, particularly of pla- 
cental hemorrhage in the presence of sub-serous fibroids, may be, to a 
certain extent, dependent upon uterine atony. Nauss, nevertheless, 
found hemorrhage expressly attributed to atony of the uterus in only five 
cases. On the other hand Siisserott found that death was produced ex- 
clusively by hemorrhage in 9 out of 147 cases collected by himself. He 
also cites 33 cases of serious bleeding. 
Winckel,3 Segdwick,4 Henry Yeld,5 Senderling,6 Hecker2 and Daly6 re- 
ported similar cases. Chaussier, Burlatour, Chailly and others (Demar- 
quay and St. Vel, loc. cit.) saw fatal hemorrhages as the result of placenta 
prrevia complicated with fibromyomata. This category farther includes 
hemorrhages in inversion of the uterus referable to the presence of my- 
omata, which usually occur before the expulsion of the placenta. Lam- 
1 Wiener Med. Presse, No. 30, 1869. 
2 Gaz. des Hop., 1869. 
3 Klin. Beobacht. zur Pathologic der Geburt., p. 157. 
4 St. Thomas Hosp. Reports, 1870, p. 349. 
5 Brit. Med. Journal, June, 1871. 
6 Schmidt's Jahrbucher, vol. CXLV., 1870. 
1 Klin. d. Geburtsk., vol. II., p. 129. 
8 London Obstet. Transact., XVIII., p. 65. UTERINE FIBROIDS. 
311 
bert quotes six cases of inversion complicated by fibroids. In two of 
these cases death occurred. In two simple cases reposition was resorted to, 
and in two instances reposition was performed after the removal of the 
tumor. In one case reposition failed. 
Oldham, Desaulx and Herbiniaux report cases of inversion due to 
tumors and occurring after labor. (Demarquay, loc. cit.) If the pla- 
centa is attached over the seat of the tumor, profuse hemorrhages take 
place after confinement. Lambert cites seven such cases. In four of 
these most violent hemorrhage occurred, and two of the cases terminated 
fatally. (R. Lee and Ashwell.) Macfarlane,1 Aubinais2 and Ramsbotham 
witnessed the simultaneous escape into the vagina of the tumor and the 
placenta which had been located upon it. These observers believed, at 
first, that they were dealing with post-partum inversion of the uterus. In 
view of the fact that uterine atrophy often results from the growth of 
fibromata, and that the latter constitute absolute obstructions to delivery, 
one might expect that they would frequently produce rupture of the 
uterus. This is, however, not the case. Very few exact statements 
bearing on this point, aside from Fergusson's case, in which the rupture 
was produced by the operator, are found in literature. Nauss alludes to 
ten cases (beside that of Furgusson), but does not give their details. 
Among Siisserott's cases I only find five cases of rupture, and in only one 
of these, that of Vollmer,3 can the rupture be attributed solely to the 
tumor. 
In Bezold's4 case a transverse presentation and a fibroma co-existed, and 
version was not performed until labor had continued for 13 hours. 
Abegg's5 case does not belong to the class now occupying our attention. 
In his case there was a cancer of the portio vaginalis, with extensive car- 
cinomatous infiltration of the uterine parenchyma, and a fibroma at the 
fundus. Rupture occurred in labor. It is doubtful to what extent the 
fibroma was responsible, in Shekleton's6 case for the rupture, inasmuch as 
perforation and evisceration of the child, and amputation of its arm, were 
performed with a sharp hook after labor had continued seventeen hours! 
Lambert, moreover, mentions two cases in which women died of uterine 
rupture before delivery, the autopsy revealing fibromata of the uterus. 
Since, however, the presentations were transverse in each instance, the 
rupture was more probably due to that fact. 
The case of R. Barnes7 is unique. It was one of hard fibroid in the 
1 Ingleby : Obstet. Medicine, p. 142. 
2 Gaz. M6d. de Paris, 1844, p. 578. 
3 Schmidt's Jahrb., 1834, p. 28. 
4 Siebold's Journ. f. Geburtsk., vol. II., p. 125. 
5 Monatsschrift f. Geburtsk., vol. VII., p. 500. 
6 Dublin Quarterly Journal, 1869. 
1 London Obstet. Transact., vol. V., p. 171. 312 
NEW GROWTHS OF THE UTERUS. 
anterior inferior uterine wall, with rupture of the urinary bladder during 
labor. Including this case, thirteen women died undelivered, according 
to Susserott's statistics, which embrace the early observations of Voigtel, 
Hildanus, Kiwisch, Lee, Bartholin and Vollmer. In the other cases, 
cited by him, i.e., those of Hall Davis, Duntzer, Ostertag, and De Haon, 
the women died after the birth of the child, but before the expulsion of 
the placenta. Chaussier's case was one of transverse presentation, in 
which version was not undertaken. Lambert (loc. cit., p. 201) quotes 
a similar case from Boivin and Duges. 
Intra-parietal fibromata of the uterine body, particularly if located in 
the posterior wall, as well as sub-serous ones situated at the fundus, may 
lead to incarceration during labor, by either accompanying or preceding 
the child's head in its descent into the pelvis. 
These tumors, however, often spontaneously escape form the pelvis 
into the abdominal cavity; when the pains grow active, the head descends 
and the membranes rupture. The labor may then be easily accomplished. 
It is also often stated that these tumors may be displaced upward with 
surprising facility, by force applied to the vagina or the uterus. The 
case is quite different with another class of these tumors. They are lo- 
cated in the pelvis from the very commencement of pregnancy, become 
incarcerated very early, and increase so rapidly in size, owing to congestion 
of their vessels, that they often produce, even during pregnancy, partial 
or complete occlusion of the pelvic canal. 
When labor begins they are pressed, if possible, still deeper into the 
pelvic cavity, and do not permit the descent of the child's head into the 
latter. In other cases the head, or some other member of the child, en- 
ters the pelvis simultaneously with a segment of the tumor, but the in- 
carceration is thereby only rendered more complete, and delivery often 
becomes impossible. Cervical myomas, particularly if sub-serous, occa- 
sion these unfortunate results. Such occurrences are very frequently 
mentioned in literature. The seat of the tumors is, however, not clearly 
described, the degree and significance of the incarceration are not rightly 
appreciated, and doubt is thereby engendered regarding the operative pro- 
cedures adopted. 
There are, undoubtedly, cases in which delivery is normally accom- 
plished without the displacement of a tumor, partially filling the pelvis. 
Such cases are reported by Ingleby, Hecker, and by Spiegelberg,1 in which 
latter case maceration of the foetus facilitated its expulsion. Similar 
cases are cited by Lachapelle,2 Simpson/ Habit,4 and by E. Martin.5 Tn 
1 Monatsschr. f. Geburtsk., XXVIII., p. 426. 
2 Pratique des Accouchements, III., 381. 
3 Obstet. Memoirs, vol. I., p. 833. 
4 Zeitschr. d. Ges. d. Aerzte zu Wien, 1860, No. 41. 
6 Zeitschr. f. Geburtsk., 1876, vol. I., p. 232. UTERINE FIBROIDS. 
313 
one of Martin's cases the expulsion of the child was rendered possible by 
rupture of the anterior fontanelle, and in the other by maceration of the 
dead child. These phenomena are rare, but those cases are still less fre- 
quent in which a tumor located in the cul-de-sac of Douglas, or in the 
superior strait, has spontaneously ascended under the influence of the 
pains, and has thus rendered delivery of the child possible. The tumors 
have, in these cases, probably been either usually or invariably interstitial, 
or sub-serous fibroids of the posterior wall, and not cervical tumors of 
large size. 
Gueniot,1 Blot,2 Lehnerdt,3 Spiegelberg4 and Hecker5 report such 
cases. Only such cases of fibroid are, of course, included in this category 
as seemed partially or completely incarcerated in the pelvis, so that in 
some instances the propriety of a resort to Caesarean section had been 
considered. 
Far more numerous and important, in their practical bearings, are those 
cases in which the tumor is deeply incarcerated in the pelvis at the be- 
ginning of labor, but is at a later period displaced upward by force ap- 
plied in the vagina, thus enabling labor to be spontaneously or artificially 
accomplished. The reposition of the tumor seems to be most easily ef- 
fected after the rupture of the membranes, because the uterus is then 
smaller and more movable. Reposition naturally fails if the presenting 
part of the child be at the same time firmly impacted in the pelvis. In 
one series of cases the tumor had been punctured before reposition was 
attempted, most frequently because it had been considered ovarian, ow- 
ing to its soft consistency. 
In other cases the puncture was made for the purpose of reducing the 
size of the tumor as much as possible, and rendering it more movable. 
The object of the puncture was attained in only a few cases, since only a 
little bloody fluid was evacuated in most instances. The very dangerous 
nature of this operation must not be forgotten. It often produces gan- 
grene of the tumor or peritonitis. Spilth,6 Madge 7 and Spiegelberg (loc. 
cit., p. 110) describe such cases, in which reposition of the tumor was ef- 
fected, after its puncture, and delivery thus accomplished. In the two 
former cases the mother died. In Spiegelberg's she lived. Cases are 
more numerous in which simple reposition succeeded, and in these the 
women recovered with one exception, that of Pillore's B patient, who died 
1 Gaz. des Hop., 1864, No. 53. 
2 Gaz. des Hep., 1869. 
3 Beitrage z. Geburtsk., Berlin, IV., p. 16. 
4 Archiv f. Gynak., V.. p. 100. 
6 Klinik d. Geburtsk., II., p. 124. 
6 Zeitschr. d. Ges. d. Wiener Aerzte, 1860. 
1 London Obstet. Transact., IV., p. 129. 
8 Gaz. des Hop., 1854, p. 547. 314 
NEW GROWTHS OF THE UTERUS. 
after delivery. The other cases, fourteen in number, were observed by 
Ashwell, C. Mayer,1 Wegscheider,2 Siebold, Hecker,3 Hoogeweg,4 Beatty, 
Depaul,5 Barry,6 Hankin,7 Thirion,8 Playfair,9 and Winckel. Reposi- 
tion thus succeeded in eighteen such cases, in three of which the patients 
died. 
There are, finally, some cases reported in which the tumor could be 
removed before the child, and delivery thus effected. These were, of 
course, cases of sub-mucous or interstitial tumors of the cervix or of the 
lower uterine segments. Danyau 10 succeeded in enucleating a large fi- 
broma of the posterior cervical wall, which almost filled the pelvis. The 
child was macerated. The mother recovered. Heck's case (quoted by 
Siisserott, p. 34) terminated in a similar way, but both mother and child 
recovered. 
Wynn Williams11 met with a large calcified myoma, which was firmly 
pressed against the pelvic wall by the child's head. He could only ex- 
tract the child after perforating its head, and crushing the myoma with 
the cephalotribe. Portions of the tumor were then removed and the 
child delivered. Heiss (Siisserott, loc. cit., p. 21), Diintzer, Keating and 
Langenbeck 12 have described cases in which the tumor was removed before 
the child's extraction, but the mothers died. 
When the tumors do not completely fill the pelvis, the method of de- 
livery will depend upon the circumstances of the case, i.e., upon the limi- 
tation of intra-pelvic space, the position of the child, the character of 
the pains and the condition of the child. In short, the most varied con- 
siderations which determine the nature of operative measures must be 
taken into account. Since this is not the place to explain those consid- 
rations we merely quote some statistics from Siisserott's carefully compiled 
tables. 
Among 147 cases of labor complicated by fibroids, collected by him, 
the forceps were applied 20 times; 12 mothers and 7 children lived. Ver- 
sion was performed 20 times: 8 mothersand 3 children were saved. The 
placenta was removed by artificial means 21 times, and only 8 mothers 
recovered I 
1 Verhandl. d. Berl. geb. Gesellsch., 1852, p. 206. 
2 Ibid., 1855. 
3 Monatsschr. f. Geburtsk., XXVI., p. 446. 
4 Verhandl. d. Berl. geb. Gesellsch., 1852. 
5 Gaz. des Hop., 1868. 
6 Edin. Month. Journal, 1848, p. 137. 
1 Ibid., 1850, p. 12. 
8 Cited by Lambert, These, p. 148. 
9 Obstet. Journal, 1877, p. 116. 
10 Gaz. Med. de Paris, 1851, p. 239. 
" Obstet. Transact., XVII., p. 172. 
12 Deutsche Klinik., No. 1, 1859. UTERINE FIBROIDS. 
315 
After the induction of artificial abortion 3 mothers died and 5 lived. 
Death of the women resulted in 2 out of 6 cases in which the child was 
perforated. Delivery was effected with the blunt hook in 3 cases. In 
one of these the mother died. 
Whenever the pelvis is so completely filled by the tumor that none of 
the methods of delivery mentioned are practicable, and when neither re- 
position nor removal of the fibroid is possible, Caesarean section is our 
last resort. The results of the operation are worse if it be long post- 
poned than when it is undertaken early, as is the case with Caesarean sec- 
tion in general. 
The prognosis is, however, also materially clouded by the uterine dis- 
ease. Almost all operators specially allude to the profuse hemorrhages re- 
ferable to increased vascularity of the uterus and to deficient contractility 
of the organ, both of which conditions are due to the presence and growth 
of the fibroids. I find, as does Cazin,1 twenty-eight Caesarean sections 
performed on account of uterine fibromata. Fourteen of these are care- 
fully analyzed by Lambert. Beside these, mention should be made of 
the following: Braxton-Hicks,2 Duclos,3 Bristowe,4 Netzel,5 Spiegelberg0 
and Cazin (loc. cit. where references to the following cases may be 
found): Thomas, Shipman, Conway, Putegnat, (9cases),Retzius, Laroche, 
Bird. Only 4 out of the 28 patients recovered. 15 of the children were 
born alive, 8 were dead, and nothing is stated concerning the remaining 
5. Sanger 7 has recently collected 43 cases, in which Caesarean section 
was performed on account of fibroids. Only seven women recovered, 
i.e., a mortality of 83.7 per cent. 
Eight of these cases occurred after 1876; of this number 3 were in- 
stances of Porro's operation, all three dying, and 5 Caesarean sections, with 
only one death. 55.2 per cent of the children were extracted alive. 
In Storer's case R a uterine tumor undergoing softening rendered extir- 
pation of the entire uterus with its neighboring organs necessary, after 
the dead child had been extracted by Caesarean section. The patient 
died. 
A few cases of uterine fibroids have been cited above, in which pecu- 
liar injuries inflicted upon the child's head, during labor, must be attrib- 
uted to the effect of the tumors. 
Archiv. de Tocologie, vol. III., p. 321. 
2 Obstet. Transact., XI., p. 99. 
3 Comp. Cazin : Archiv. de Tocol., II., p. 647. 
4 Path. Trans., London, vol. IV., 1853, p. 218. 
5 Archiv. de Tocol., III., p. 321. 
6 Archiv f. Gynakol., V., p. 112. 
7 Festschrift zum Jubilaum, Credo's, Leipzig, 1881. 
8 Journal of the Gynec. Soc. of Boston, vol. I., p. 223. 316 
NEW GROWTHS OF THE UTERUS. 
Simpson,1 Kuchenmeister,2 Lachapelle and Blot3 saw compression and 
flattening of the child's skull. Chaussier (cited by Siisserott) and Boivin 
and Duges4 observed fractures of the cranium. E. Martin,5 saw sponta- 
neous rupture of the anterior fontanelle, and in another case laceration 
of the superior longitudinal sinus. 
We present, in conclusion, some statistics which may have a valuable 
bearing on the prognosis in the complication of labor now under consider- 
ation. 
Tarnier6 found among seven cases of uterine fibroids, in which labor 
was normally accomplished, one which was fatal for the mother, and three 
which envied disastrously for the child, The fate of one child was un- 
known. Forceps was applied in six cases, in four of which the mother 
died. The child also perished in four cases. Among six versions three 
resulted fatally for the mother, and three for the child. Five women 
died before their confinement. Artificial abortion was once produced 
and the mother recovered. One embryotomy was performed and the 
woman died. In one case of enucleation both mother and child died. 
Among 228 labors complicated by fibroids, 123 women or 53.92 per cent, 
died. Out of 117 children whose fate is mentioned G7 or 57.2 per cent, 
died (Nauss, loc. cit.) In 147 cases collected by Siisserrot, 78 mothers or 
53 per cent. died. The result upon the children is only stated in 138 in- 
stances, 91 of whom, or 66 per cent., died. 
Being unable to again enter into an extended consideration of the 
diagnosis of fibromyomata complicating labor, we shall now only briefly 
allude to the conditions for which they are most frequently mistaken. 
The fibroids have often been mistaken for a second child, or for some part 
of one. They have also given rise to the diagnosis of extra-uterine preg- 
nancy. They have been taken for uterine malformations and for pelvic 
exostoses. 
The fibromata are often confounded with ovarian tumors. This error 
is unfortunate, since it leads to puncture of the soft tumor from the 
vagina, which impairs the prognosis. 
Our present allusions to the treatment of these tumors must also be 
brief. If it be possible to remove the tumor during labor without too 
great danger, this must not be omitted. If its removal be impracticable, 
labor must be terminated in various ways according to the position of 
the child, and to the pelvic obstruction present. Energetic attempts at 
1 Obstetrical Memoirs, vol. I., p. 833; Obstet. Works, Ed. Black, p. 155. 
4 Michauk : Dissert. Leipzig, 1868. 
3 Gaz. des Hop., 1869. 
4 Caternault: These Strasbourg, 1866, p. 67. 
5 Zeitschr. f. Geburtsk., vol. I., 1876, p. 232. 
6 Gaz. des Hop., 1869, p. 175. UTERINE FIBROIDS. 
317 
reposition of the tumor through the vagina and rectum should always 
be made before more active measures of treatment are adopted. 
The effects of fibromata upon the lying-in period, and that of the latter 
condition upon the tumors, are various and important. 
In the first place we must remind the reader of the frequent and for- 
midable secondary hemorrhages, due to uterine atony induced by the 
development of fibromata in the parenchyma of the uterus, which occur 
within a few days after delivery. I will here append the history of a 
case observed by myself, and attended by hemorrhage from the neoplasm 
Fig. 29.-Large Fibroid of the Fundus Uteri. Death from internal hemorrhage quickly fol- 
lowed delivery. The bleeding proceeded from numerous small openings, mostly of the superficial 
veins. (From the Obstetrical Collection at Strasburg.) 
itself. The case seems to be unique, as I have failed to find one of the 
same variety in the literature of the subject. 
A woman twenty-seven years old presented herself at the Strasbourg 
gynecological clinic with a very large abdominal tumor, which presented 
fluctuation. The uterus was explored with a sound by the assistant phy- 
sician. Soon afterward a macerated foetus, aged four months, was ex- 
pelled. Pregnancy had been masked by the enormously developed tumor. 
On the following day, about forty hours after delivery, the patient died 
suddenly with symptoms of internal hemorrhage. At the autopsy the 
abdominal cavity was found filled with blood. A large, soft, sub-serous 318 
NEW GROWTHS OF THE UTERUS. 
myoma was attached to the posterior uterine wall. The surface of the 
tumor was covered with very numerous large and broad veins situated 
directly under or in the peritoneal coat. The vessels were almost all per- 
forated by very numerous little apertures, the size of the largest among 
which was that of a pin's head. (Compare the drawing, which does not 
well represent the -appearances). The hemorrhage had proceeded from 
these apertures. Isolated openings of the same kind were found in the 
uterine substance near the vessels where there were no veins. The mi- 
croscope showed (v. Recklinghausen) that there were no special morbid 
changes, but merely patulous interspaces between the tissue elements of 
the uterus. These spaces had passed quite through the walls of the veins, 
owing to the intimate connection between the muscles of the veins and 
those of the uterus, and had thus produced the hemorrhage. Since there 
was no evidence of any special morbid process, in this case the sieve-like 
perforation of the vessels must have been due to the effect of the muscu- 
lar contractions of the uterus in labor or during the puerperal state. 
The peritonitis, which often presents itself in cases of uterine myomata 
during labor, but principally in the post-partuni state, is perhaps, also 
partly due to the uterine contractions. This remark applies only to 
those cases of peritonitis which occur without any change in the struc- 
ture of the tumor, and are, therefore, not the result of softening or disin- 
tegration of the latter. Cases of this simple peritonitis are not very 
often encountered. Empis,1 Winckel,2 Desormeaux 3 and Hecker4 report 
such cases. 
Not only those cases are here cited in which the peritonitis seems to 
have been due to the tumor alone, without morbid changes in the same, 
but also those due to traumatism, but unattended by septicaemia. All 
cases are, therefore, excluded in which severe obstetrical operations, lia- 
ble to produce peritonitis, were undertaken. The infrequency of the 
cases is thus explained 
An interesting case observed by Spiegelberg,5 shows how difficult it is, 
in any given case, to decide whether the tumor be the cause of the peri- 
tonitis, or be only simultaneously diseased. The case was one of purulent 
peritonitis, with ulcerative endocarditis and uterine lymphangitis. The 
fibroid was surrounded by a purulent fluid which infiltrated the uterus, 
and had in its interior numerous cavities filled with pus. The cavities 
were not the result of abscesses, but were dilated lymph-spaces, which, in 
common with the remaining lymphatics of the uterus, were filled with 
1 Bull, de la Soc. Anatom., 1854, p. 336. 
2 Klin. Beobacht. z. Patholog. d. Geburt., 1869, p. 157. 
3 Caternault: These loc. cit. 
4 Klin. d. Geb., vol. II., p. 129. 
5 Monatsschr. f. Geburtsk., vol. XXVIII., p. 429. UTERINE FIBROIDS. 
319 
pus. Spiegelberg is inclined, in view of the history, to regard the tumor 
as the point of departure for the peritonitis. 
It can be readily proven by all the cases in which a primary change 
can be discovered in the tumor, that the latter is very often the cause of 
general peritonitis, or of puerperal septic processes. This is most plainly 
seen in gangrene of sub-mucous fibromata projecting into the cavity of 
the puerperal uterus. Sub-serous and interstitial tumors of that variety 
may, however, undergo peculiar softening processes which lead to the 
above-mentioned general diseases. In sub-serous fibroids the process is 
most easily explained when, as in the case of Robinson, (Susserott, loc. 
cit., p. 8) a laceration of the peritoneal covering of the tumor, with hem- 
orrhage into the peritoneum and consecutive peritonitis, is found. 
E. Martin 1 describes gangrenous disintegration of sub-mucous tumors 
leading to fatal pyemia. 
Horwitz2 mentions cases of sub-serous tumors leading to the same re- 
sult. In his cases it is, however, doubtful whether there were actual 
gangrene of the tumors or necrotic disintegration of the same, presently 
to be described. It is also possible that the sub-serous tumors had 
undergone th changes above-mentioned, as a result of septicaemia. Po- 
laillon 3 describes similar cases. Gangrene of sub-mucous fibromata, oc- 
curring in the post-partum state, by no means always leads to pyaemia or 
to other severe diseases. Extrusion of the tumor and a complete cure is 
perhaps more frequently the result of gangrene. Thus Kitchen meister 
(Michauk, loc. cit.) saw a myoma weighing 515 gm. expelled, on the 
forty-fourth day after confinement, after long-continued suppuration 
and high fever. Ramsey4 witnessed the expulsion of a tumor weighing 1^ 
kilogr., on the sixteenth day after labor. 
A sub- mucous myoma of the posterior uterine wall was gradually ex- 
pelled by a gangrenous process. In this case, gangrene was produced by 
injections of liq. ferri sesquichlorat. made immediately after labor, by 
Sedgwick,5 on account of secondary hemorrhage. Maunoury (quoted 
by Susserott, p. 14) and Ashwell {ibid. p. 20) witnessed the expulsion 
of such tumors by gangrene, during the post-partum state. 
Such tumors are sometimes expelled during the puerperal st; te, by 
simple uterine contractions without gangrene or degeneration cf the 
neoplasms, and a complete cure is thus effected in the safest possible 
way. Falin, Tarnier, Oldham (Demarquay et St. Vel, loc. cit.), Priestley 6 
1 Zeitschr. f. Geburtsk., vol. I., 1876, p. 232. 
2 St. Petersburger Med. Zeitschrift, XIV., p. 294. 
3 Archiv. de Tocologie, vol. I., p. 319. 
4 Edin. Med. Journal, July, 1858. 
5 St. Thomas Hosp. Reports, 1870. 
6 Trans.' Obstet. Soc.. London, vol. I., p. 217. 320 
NEW GROWTHS OF THE UTERUS. 
and Valtorta1 observed cases of this nature. Gangrenous disintegration 
of the tumors, attended by septic symptoms, must be carefully distin- 
guished from the peculiar necrosis occurring in large interstitial and sub- 
serous fibromata, which is almost exclusively observed in the puerperal 
state. 
The necrosis under discussion is characterized by softening of the 
tumor, beginning in the centre. This process is, however, not depend- 
ent upon the ingress of air or of any substance capable of producing 
putrefaction. The softening seems to begin with an abundant serous 
effusion into the tissues of the tumor, occurring in the early periods of 
the post-partum state, and perhaps produced by vascular disturbances. 
At all events the tumor becomes larger and softer soon after parturition, 
or furnishes distinct evidences of fluctuation. 
The change in size is often only apparent, because the diminution in 
the size of the uterus, in which the tumor does not participate, causes the 
latter to appear larger than before. In other cases this source of error 
may be easily eliminated, and the enlargement with concomitant soften- 
ing clearly demonstrated. 
The tumor is usually sensitive to pressure, under these circumstances, 
owing to its tense condition. This fact has often been referred to as- 
sumed inflammatory processes in the fibroid. Investigation of the tumors 
has, almost always, shown a disintegration of their tissues, attended by 
the formation of a soft, pulpy mass, which is of a light yellow color, if 
blood be absent. The pulpy mass is darker in color and not unlike coffee- 
grounds in appearance, if blood be present, and consists of disintegrated 
muscular and connective-tissue elements, the destruction of which seems 
to have been principally inaugurated by fatty degeneration. 
Since firm connective-tissue bands, particularly those accompanying 
the vessels, often remain intact, the entire cavity of the tumor presents a 
trabecular structure, the interstices of which are filled with the pulp of 
the degenerated neoplasm. The fibroid thus frequently assumes the ap- 
pearance of a compound cystic tumor. The most casual investigation 
shows, however, that the individual alveolae qr interspaces possess no wall 
peculiar to themselves, but consist merely of tissues undergoing degene- 
ration. No considerable collections of pus have been discovered in the 
degenerated fibromata, although the morbid process affecting them has 
.often been interpreted as a suppurative inflammation. 
Even fatty degeneration plays only a subordinate role in this morbid 
process. The above-mentioned case of A. Martin is the only accurately 
reported one of fatty degeneration extant. 
Beginning fatty degeneration of myomata has been more frequently 
observed to affect these tumors in the post-partum state, but it does not 
1 Monatsschr. f. Geburtsk., No. 31, p. 314. UTERINE FIBROIDS. 
321 
lead to the above-described degeneration. The causes of this peculiar 
morbid process are not definitely known. It is unsatisfactory to refer it 
to circulatory derangements occurring during pregnancy and parturition. 
Nor can it be explained by the retrogressive changes in the uterine mus- 
cles taking place in the post-partum state, because it should if referable 
to this cause, consist essentially in fatty degeneration. A review of the 
cases bearing on this question plainly shows that this form of degenera- 
tion has been observed with special frequency after difficult and pro- 
tracted labors. This fact suggests the thought that injuries of the tumors 
attendant upon parturition, and produced by compression of the fibroids 
between the child's head or the forceps, may act as a predisposing cause 
of fatty degeneration, by causing laceration of vessels with extravasation 
and consequent disturbances of nutrition. 
0. Lehnerdt's 1 case is very instructive with reference to the question 
under discussion. In that case the pelvis was considerably obstructed by 
a fibroma, which was extracted with the forceps. One half of the tumor 
had been transformed into a reddish, pulpy mass " not like pus," and 
" of the consistency of apple sauce." In the solid parts of the fibroid there 
were numerous extravasations of blood, which were probably the result 
of the injuries inflicted during labor. Hecker2 had a similar case. The 
question whether the tumor may be absorbed, and thus entirely disap- 
pear, must remain sub judice. 
In some cases of this nature the softening of the tumor is said to have 
resulted from peritonitis or pyaemia {conf, the cases of Howiz, loc. cit.). 
This is doubtless the case when the tumors contain genuine abscesses, 
which are usually situated, as Spiegelberg's careful investigations prove, 
in the lymph spaces of the tumor. Besides the cases of this kind 
already referred to, those of Banetche and Hecker {loc. cit.) deserve 
mention. Both cases were terminated by fatal peritonitis, which was, 
it is true, very probably caused by the morbid changes in the tumors. 
In C. Mayer's case 3 the tumor was punctured during labor, and changes 
in its tissues, which led to a fatal peritonitis, thus induced. This case, 
therefore, does not perhaps belong in this category. We must finally 
allude to Ashwell's case (Siisserott, loc. cit., p. 48) as belonging to this 
class. 
Our knowledge concerning these changes in fibromyomata, during the 
puerperal state is therefore not exact, and the same remark applies to 
the post-partum disappearance of these tumors. We have already alluded 
to the absorption of fibromata, and cited a number of cases in which it 
occurred. The number of well-attested cases in which these tumors grew 
1 Beitrage, etc., d. Berl. geb. Gesellschaft, IV., p. 16. 
2 Klinik d. Geburtsk., II., p. 125 et seq. 
3 Berliner geburtsk. Gesellsch., Feb. 1850. 
21 322 
NEW GROWTHS OF THE UTERUS. 
smaller, in the puerperal state, is quite small, but their complete disap- 
pearance has been proven to occur in still rarer instances. Besides the 
cases above quoted, in which evident diminution of the tumors was dem- 
onstrated, we farther cite those of Cazin, (toe. cit.,) Braer,1 Playfair,2 
Madge3 and finally the interesting cases of Lohlein.4 
It has already been stated that complete disappearance of uterine myo- 
mata is not easily imaginable, since the connective-tissue elements of these 
tumors can not be readily absorbed. It is, however, doubtless true that 
such a tumor, if rich in muscular tissue, may become so much reduced 
in size that it produces no symptoms, and can not be certainly demon- 
strated even by means of its anatomical characters. There is no doubt 
that such tumors do actually become decidedly smaller in the lying-in 
period. 
The majority of the reported cases of this kind possess, however, very 
little significance, because they were probably cases in which a fibroma 
had become hypertrophied or only oedematous, in the manner described 
during pregnancy, and having undergone atrophic changes in the puer- 
peral state, had been restored to its original size by uterine contrac- 
tions. If, therefore, in such a case the tumor had not been detected 
before, but was discovered during labor and was observed to diminish 
post-partum, it seemed, to the observer, to actually disappear. In real- 
ity, however, it only returned to its original volume. Those cases in 
which this process could be studied in several pregnancies of the same 
patient are very instructive. The tumors which were not perceptible, 
or were discovered with difficulty before, grew considerably during each 
pregnancy, and returned in each instance to their former size during the 
puerperal state. Lorain,5 Playfair (Joe. cit.) and others report such cases. 
There are, however, a few carefully observed cases in which the size of 
the tumor before conception was known, and in which the neoplasm be- 
came decidedly smaller or almost entirely disappeared post-partum. 
Lbhlein's case belongs here, in which a large fibromyoma, which had 
been observed a long time before the beginning of pregnancy, diminished 
materially in size during the puerperal state, and did not even attain to 
its original dimensions in a subsequent pregnancy. . ' 
Kauffman 6 saw a large fibroma disappear after abortion. Pregnancy 
ensued, but the tumor did not reappear. We wish to again call attention 
to the fact that fatty degeneration of the neoplasms, although often as- 
sumed, has not been so often proven to exist. 
1 Berliner Klin. Wochenschr., No. 26, 1875. 
2 Obstet. Journal, 1877, p. 116. 
3 Obstet. Trans., vol. XIV., p. 227. 
4 Zeitschr. f. Geburtsk. und Gynak., vol. I., 1877, p. 121. 
B Gaz. des Hopit., No. 92, 1869. 
6 Monatsschrift fur Geburtskunde, 1862. UTERINE FIBROIDS. 
323 
In some cases it has been found possible to remove sub-mucous fibro- 
mata, according to various methods, either immediately after confine- 
ment simultaneously with the placenta, or during the earlier stages of 
the puerperal state. 
This procedure is of course only really indicated when the tumor is 
easily accessible, and the injury inflicted trivial, since the prognosis of 
more serious operations might be sadly impaired by those conditions in- 
cident to the puerperal state. Henry Yeld, Senderling, Ramsay, Kiwisch, 
Wynn-Williams,1 Matthews Duncan,2 Weber,3 and Diintzer4 report cases of 
this kind. 
1 Cited by Mannel: Prager Vierteljahrsschrift, 1871. 
2 Obstet. Transact., XVII., p. 172. 
3 Monatsschr. f. Geb., XXV., p. 157. 
4 Neue Zeitschr. f. Geburtsk.. VIII., p. 219. CHAPTER IX. 
SARCOMA OF THE UTERUS. 
Lebert: Physiologic pathologique, II., 1845.-Hutchinson: Transact, of the 
Path. Soc. of London, vol. VIII., 1857, p. 287.-Callender: Ibid., vol. IX., p. 327. 
-West: Lectures on the Diseases of Women, London, 1864.-Mayer: Monats- 
schr. f. Geburtsk., XIII., p. 179.-Virchow : Die krankhaften Geschwulste, vol. 
IL, p. 350.-L. Mayer : Monatsschr. f. Geburtsk., XVII., p. 186.-Hardy : Dublin 
Med. Journal, May, 1864.-Ahlfeld : Wagner's Archiv f. Heilkunde, 1867, p. 560. 
-Langenbeck : Inversion des Uterus mit Sarcon. Monatsschr. f. Geburtsk., XV., 
p. 173.-Glaser : Virchow's Archiv., XXV., p. 422.-Veit: Krankheiten der weibl. 
Geschlechtsorgane, 1867, p. 413.-Gusserow : Arch. f. Gynak., vol. I., p. 240.- 
Hegar: Ibid., vol. II., p. 29.-Winckel: Ibid., vol. III., p. 297.-Spiegelberg : 
Ibid., vol. IV. pp. 344 and 351.-Chrobak : Ibid., vol. IV., p. 549.-Rabl-Riickard : 
Berl. Beitrage z. Geburtsk. u. Gynakol., vol. I., p. 76.-Kunert: Ueber Sarcoma 
Uteri, Dissert. Breslau, 1873; Archiv f. Gynak., vol. VI., p. 111.-Muller: Archiv 
f. Gynak., vol. VI., p. 126.-Klebs : Handbuch der patholog. Anatomie, 1873, 
p. 870.-Schroder: Lehrb. d. Frauenkrankh., 1st Ed., p. 284.-Scanzoni : Krank- 
heiten d. weibl. Sexualorgane, 5th Ed., p. 366.-Leopold : Archiv f. Gynak., vol. 
VI., p. 493.-P. Grenser : Ibid., vol. VI., p. 501.-Ahlfeld : Ibid., vol. VIL, p. 301. 
-Chambers: Cas d'6pith61iome du corps de l'ut6rus, etc.; Annales deGyn6cologie, 
vol. II., p. 139.-Barnes : Clinical History of the Diseases of Women, p. 825.- 
Thomas : Pract. Treat, on the Dis. of Women, 4th Ed., 1875, p. 539.-Hall Davis: 
Trans, of London Obstet. Soc., vol. II., p. 17 (a questionable case).-A. R. Simp- 
son : Sarcoma Uteri, Edin. Med. Journal, Jan'y, 1876.-Hackeling : Das Fibro- 
sarcoma canalis cervical is uteri, Inaug. Dissert. Gottingen, 1873.-Beermann : 
Ueber Sarcoma Uteri, Inaug. Dissert. Gottingen, 1876.-Fehling: Archiv f. Gyna- 
kol., VII., p. 531.-A. Rogivue: Du Sarcome de l'ut6rus, Inaug. Diss. Zurich, 1876. 
-J. Clay: On diffuse Sarcomaof the Uterus, Lancet, Jan'y, 1877.-W. A. Freund : 
Zeitschr. f.Geburtsh., etc., von Fasbender, Schroder, I., p. 232.-Gaillard Thomas : 
Sarcoma of the Uterus, N. Y. Obstet. Soc., March 17, 1874 ; London Obstet. Jour- 
nal, vol. II., 1875, p. 437.-Kurz : Zeitschr. f. Pract. Med., 1877, Nr. 24.-Breisky : 
Prag. Med. Wochenschr.,1878, Nr. 18.-Johannowsky : Ibid.,Nr. 42.-Jacubasch : 
Drei Faile von Uterussarcom : Zeitschr. f. Gynak. u. Geburtsh., VII., p. 53. 
-Spiegelberg: Archiv f. Gynakol., XIV., p. 178, und XV., p. 437.-Rein : Ibid., 
XV., p. 187.-Garrigues: New York Med. Journal, August, 1882.- Winckler: 
Archiv f. Gynak., XXI., p. 309.-Zweifel : Centralblatt f. Gynak., 1884, Nr. 26. 
BIBLIOGRAPHY. 
An atomy of Sarcoma of the Uterus. 
VARIOUS neoplasms were formerly designated by the name of sar. 
' coma. That term is now usually applied, at least in Germany, and 
according to the classification of Virchow, to all those tumors which be- SARCOMA. 
325 
long to the connective-tissue series, and are characterized by abundant 
proliferation of the cellular elements which more or less displace the inter- 
cellular tissues. Such connective-tissue tumors of the embryonic type 
(Cohnheim) are observed in the uterus, and when occurring here are 
always reckoned among the malignant growths. They certainly present 
the clinical features of malignant connective-tissue tumors. It has as 
yet been impossible to establish a strict distinction between round-celled 
and spindle-celled sarcomata of the uterus, although, as we shall see, 
pure forms of the latter have certainly been observed. 
Two forms of primary uterine sarcoma may, however, be easily distin- 
guished by their clinical and anatomical features. These are fibro-sarco- 
mata and diffuse sarcoma of the uterine mucous membrane. 
The fibro-sarcoma, sarcoma fibrosum, s. nodosum, appears in the form 
of a firm or sometimes of a soft, globular tumor, which is developed from 
the uterine parenchyma. It may, like the pure fibroma, be either sub- 
mucous, sub-serous or interstitial. These tumors consist in nodules of 
fibrous or muscular tissue, in which an abundant cell formation has oc- 
curred, and seems to have gradually displaced the original tissues. The 
growths are either sub-mucous, in which case they constitute broad-based 
polypous tumors, or they are interstitial. The predominant form is that 
of the round-celled sarcoma, but myxosarcomata are occasionally ob- 
served. Leopold, Grenser, Simpson and Schroder, (loo. cit.) each observed 
a simple isolated spindle-cell sarcoma. 
Certain sarcomatous infiltrations of the uterine tissues, which do not 
proceed from sarcomata of the mucous membrane (soon to be described) 
but are found isolated in the uterine parenchyma, must be included 
among this group of the fibro-sarcomata. (Hegar.) The entire organ 
may be uniformly permeated by infiltrations of this kind. (L. Mayer.) 
While some isolated cases of this kind are reported in earlier literature, 
and well characterized by the term " recurrent fibroid,''' attention was not 
specially directed to this form of tumors until Virchow's time. 
This form seems, on the whole, to be rare-at all events less frequent 
than diffuse uterine sarcoma, which we shall soon consider. Kunert 
could discover only nine such cases. (Tide ante.) Since that time only 
the following cases have been reported. Leopold and Grenser, each one 
case of spindle-cell sarcoma of the portio vaginalis. G. Muller, Schwartz 
(Dissert, of Beermann), Schroder, Scanzoni, Gusserow (unpublished), 
each one case. A. Simpson two cases, and six of Frankenhauser (Dis- 
sert. of Rogivue). 
In addition to these, Breisky, Johannowsky, Zweifel and Garrigues have 
each reported one case, and Jacubasch four cases. Including the nine 
cases collected by Kunert, the total number of cases, therefore, amounts 
to thirty-two. 
We must at once make the statement, however, that such statistics are 326 
NEW GROWTHS OF THE UTERUS. 
of a somewhat arbitrary nature, because it is by no means possible to de- 
cide with certainty, from the literature cited, whether any given case was 
one of genuine fibro-sarcoma, or of single irregular hyperplasia, in a soft 
sarcoma connected with the mucous membrane. It can not even be 
definitely settled whether combinations of both forms may not frequently 
occur. (Hegar.) 
The anatomical characteristics of fibro-sarcomata are easily stated. 
They occur as roundish, isolated tumors, usually of firm, but sometimes 
of very soft consistency. The microscope shows evidences of their fibrous 
and muscular structure, which is more or less replaced by the abundant 
proliferation of cells, which are usually round. The pure spindle-cell 
sarcomata are an exception to this rule. 
These sarcomata occur with the least frequency, as do fibromyomata, in 
the cervix. Only Spiegelberg, Leopold, Grenser, Scanzoni, Schwartz 
(Heermann, loc. cit.} and Zweifel have described undoubted cases of cer- 
vical fibro-sarcomata. 
The view that these tumors are usually developed from simple homolo- 
gous fibromata and myomata, and that they are rarely primary, was even 
advanced by Rokitansky, Virchow and others. Kunert, and recently 
Schroder, have advocated the theory that one always has to deal in these 
cases with a secondary metamorphosis of fibromyomata; that, therefore, 
fibro-sarcomata are always fibromata which have undergone sarcomatous 
degeneration. 
The transformation of fibromyomata into sarcomata is certainly demon- 
strated by a series of carefully investigated cases, while the evidence in 
favor of the development of primary fibroid sarcomata is less convincing. 
Chroback describes a case in which " an ordinary pediculated uterine 
fibroid" and a smaller cervical one were simultaneously developed. 
Sarcomatous tissue appeared in the older and larger tumor, and after 
the removal of the latter invaded the smaller, cervical tumor, probably 
by metastasis. When this latter tumor was removed after having grown 
rapidly for five months, a soft sarcoma, probably medullary, was found 
in the place of the original tumor. G. Muller's case was similar. He 
removed a portion of a large myoma which was producing symptoms of 
incarceration, and one year later excised from the same surface a cylin- 
drical bloody excrescence, which was attached to the stump of the ampu- 
tated fibroma, and proved to be sarcomatous. The large tumor, which 
had remained firm until that time, soon underwent sarcomatous degener- 
ation, and produced metastases, which led to a fatal issue. 
A. Simpson, Frankenhauser 1 and Kurz2 report similar cases. 
The fact that no carefully observed case is extant in which a uterine 
1 In Rogivue. 
2 Deutsche Zeitschrift fill* praktische Medizin, June 16, 1877. SARCOMA. 
327 
sarcoma was provided with a "capsule," as is the case with most fibro- 
mata, 1 has an important bearing on the question of the metamorphosis of 
fibromyomata into sarcomata. Winckel's case (loc. cit.)> which was far- 
ther observed by Schatz,2 is the most noteworthy on record with reference 
to this point. 
This case was at first one of a partially gangrenous myoma, in the pos- 
terior uterine wall, which was removed by Winckel. Within forty 
weeks after the operation, a soft sarcoma was developed near the 
stump of the pedicle and was excised. The tumor recurred half a 
year later, in the form of a round-cell sarcoma, and was spontaneously 
expelled after the injection of a solution of the chloride of iron. 
After more than two years a new tumor as large as a hen's egg pressed 
into the os uteri, was removed by Schatz, and proved to be a pure myoma 
without any trace of sarcomatous degeneration. It cannot be decided 
whether there was an actual recurrence of the original tumor in this case, 
or whether, as Schatz believes, the masses removed at the second and third 
operation were portions of inflamed myomata. This case possibly dem- 
onstrates the manner in which fibromata undergo the sarcomatous degene- 
ration. 
We merely allude, in this place, to other changes occurring in fibro- 
sarcoma, viz., transformation into myxosar^pmata, cysto-sarcomata and 
other heterogeneous tumors. 
A case of Rabl-Riickard deserves special mention, being adapted to show 
that uterine fi bro-sarcomata may have certain intimate relations to carci- 
nomata. A putrid tumor as large as a child's head was spontaneously 
expelled, during a coughing fit, from the uterus of a woman aged fifty- 
one years, who had suffered from uterine hemorrhages and violent pains. 
The tumor was a round-cell sarcoma with isolated carcinomatous nodules. 
The latter were elongated and formed of closely packed, large-sized epi- 
thelial cells, arranged at some points in concentric laminaa. (Wegner.) 
The neoplasmata found in the deeper layers of the uterine walls were 
decidedly cancerous in character, and the sarcomatous elements in them 
were represented only by the poorly developed interstitial tissue. 
In this case at least a fibro-sarcoma was combined with a carcinoma, 
unless we are to assume the transformation of the sarcoma into a cancer, 
lately insisted on by R. Maier.3 According to his researches it seems not 
improbable that a fibroma may be transformed into a carcinoma, by pass- 
ing through the process of sarcomatous degeneration. It remains un- 
settled whether the above was a case of this kind or not. 
Winckel removed a large tumor " which consisted of a fibrous capsule, 8-15 
cm. in thickness, and a mixed sarcoma larger than a child's head. The latter was 
easily isolated and enucleated entire." Berichte und Studien, II., p. 139. 
2 Arch. f. Gynak., IX., p. 145. 
3 Virchow's Archiv., vol. LXX., p. 378. 328 
NEW GROWTHS OF THE UTERUS. 
A certain connection between cancerous degeneration and round-celled 
fibro-sarcomata cannot, after what has been stated, be positively denied. 
This connection is, however, so much more marked and constant in cases 
of so-called diffuse sarcomata, that it is almost doubtful whether they 
should be considered as a special variety of neoplasmata. The term diffuse 
sarcoma, sarcoma of the uterine mucous membrane, has been used since 
Virchow's time to designate a new growth proceeding from the connec- 
tive tissue of the uterine mucous membrane, consisting mostly of small, 
closely-packed, round cells, though sometimes of spindle-cells, and con- 
Fig. 30.-Sarcoma of the Uterus. (Gusserow's Case.) 
stitutingan exceedingly soft, friable infiltration of the mucous membrane. 
This occurs in isolated clumps, or it may lead to a more decidedly sym- 
metrical proliferation of the entire mucous membrane. It usually in- 
volves the uterine muscles, infiltrates or penetrates the walls of the uterus, 
and even leads to the development of the peculiar new growths upon the 
external uterine surface. (Conf, the cases of West and two of the author's, 
one of which is published and is represented by Fig. No. 30.) 
The infiltration finally extends to the abdominal viscera and the ab- 
dominal walls, involving the adjacent organs in the sarcomatous degenera- 
tion. 
Virchow first called attention to the primary development of the very SARCOMA. 
329 
soft, round-cell, medullary sarcoma of the uterine mucous membrane, 
but characterized it as very rare. 
Cases of this kind have, however, been rapidly multiplied recently, and 
among them have been also included those in which the sarcomatous 
proliferation was not really diffuse, but rather polypoid, so that this 
form has not always been sharply differentiated from the variety previ- 
ously described. 
Fig. 31.-Sarcoma of the Uterus, and Tumors of the Vagina. (From the Collection of the 
Pathological Institute at Strasburg.) 
The proliferating tissues are always very soft, grayish-white, medullary, 
vascular and protrude, usually in forms resembling a cock's comb, above 
the healthy mucous membrane. Their surface is ordinarily undergoing 
disintegration. It is quite uneven and covered with blackish or brownish 
shreds. These new formations may be easily distinguished from benign 
hypertrophies of the uterine mucous membrane, i.e., granulation tissues, 
both by their anatomical and by their clinical features. The author and 330 
NEW GROWTHS OF THE UTERUS. 
Hegar called attention, in the first publications of this kind, to the ad- 
mixture of epithelial elements in these tumors, or, in other words, to the 
cancerous degeneration of the uterine mucous membrane. The number 
of cases of this kind has been so much augmented since that time, that 
Klebs (loc.cit.) properly points out the fact that most of these tumors are 
to be frankly styled carcino-sarcomata. Scanzoni calls attention to this 
fact as viewed from a clinical standpoint. 
In most of these cases the uterus is enlarged, the os is patulous, which 
fact is particularly noticeable in nulliparae, and the palpating finger easily 
enters the uterine cavity, the mucous membrane of which is found to 
present, either throughout or at one point, the proliferation just described. 
Mg. 32. 
Fig. 33. 
Sarcoma of the Mucous Membrane of the Uterus. (Specimen of Dr. Wyder.) 
Minute Structure of Sarcoma of the Utkrus. (Specimen of Dr. Wyder.) 
The fact that the cervical mucous membrane is very rarely the point of 
departure for the disease should be emphasized. (Veit, Spiegelberg, 
Schwartz, Zweifel.) In the great majority of the cases the sarcomatous 
degeneration originates in the sub-mucous connective tissue of the body 
of the uterus. 
Among the sarcomata we must distinguish, as a separate variety, papil- 
lary growths taking their origin from the cervix. But there is certainly 
no reason why we should distinguish a separate class of tumors as " papil- 
loma." We will return to this point later on. 
Spiegelberg (1. c.) was the first to describe (in 1878) a case which he 
designated sarcoma colli hydropicum papillare. 
It concerned a girl, aged seventeen, in whom papillary formations had 
rapidly grown from the anterior lip of the os uteri. They bled easily, SARCOMA. 
331 
and recurred ten months after removal. Microscopical examination 
showed the growths to be sarcomatous. In consequence of the repeated 
recurrence of the tumors, Freund finally performed total extirpation of the 
uterus. The patient died. Rein (1. c.) has placed on record a similar 
case, calling it myxoma enchondromatodes arbor esce us colli uteri. There 
is no doubt that this was an instance of sarcoma and not myxoma. The 
patient was a girl aged twenty-one. The growths recurred and caused 
the patient's death by becoming gangrenous, and leading to septicaemia. 
The next case of " papillary hydropic sarcoma of the cervix" is de- 
scribed by Spiegelberg (1. c.). The patient was thirty-one years old. 
The sarcoma took its origin from the cervix, and consisted of papillary 
excrescences, covered by epithelial layers. The interior of the tumor had 
a myxomatous appearance, owing to the great distension of the inter- 
papillary lymphatics. The growth having frequently recurred, Spiegel- 
berg at length performed total extirpation of the uterus after the method 
of Freund. The patient recovered. 
Winckler (1. c.) has also described a case of this kind observed by San- 
ger. The patient died after repeated operations for recurrence of the 
growths. 
These four cases are unquestionably instances of sarcoma of the cervix, 
that differ only in their papillary appearance and dropsical transforma- 
tion from other cases of sarcoma. The anatomical structure of the cer- 
vix (richness of papillae and lymphatics) sufficiently explains their pecu- 
liar features. 
Etiology of Sarcoma. 
The causation of uterine sarcomata is involved in still greater ob- 
scurity than that of fibromata of the uterus. Our knowledge concerning 
the causes of sarcomata is, if possible, less definite than it is in regard to 
the origin of fibroids and of carcinomata, because the number of cases 
thus far observed is too small to permit of satisfactory generalizations. 
By adding four cases reported by Simpson, two recently observed by my- 
self, and eleven others to the fifty-six cases which Rogivue collected, I 
obtained seventy-three cases distributed as follows, with reference to the 
ages of the patients. 
Before the 20th year, ..... 4 cases 
From 20 th to 29th year, 5 " 
" 30 " 39 " 15 " 
" 40 " 49 " 28 " 
" 50 " 60 " 18 " 
Above 60 years, . . . • . . 3 " (one of 
which occurred in the 72d year.) 
If these statistics justify any conclusion, it would be that the period 332 
NEW GROWTHS OF THE UTERUS. 
of the menopause predisposes somewhat to uterine sarcomata, as it does 
to other malignant growths. I refer for the rest to what was said of 
the value of such statistics under the etiology of fibroids, and to what 
will be said on the same subject, under carcinoma, the cases of which 
are at least more numerous. 
Since some etiological importance has been attributed to the number 
of births and to sterility by some authors, I here append a table bearing 
on that question. 
Among seventy-four cases of sarcoma (fifty collected by Rogivue, four 
by A. Simpson, two by Gusserow and seven by J. Clay) twenty-five were 
sterile, 
6 had had 1 labor. 
10 " " 2 labors. 
6 " " 3 " 1 
5 " " 5 " 
4 " " 6 " 
1 " " 7 " 
1 " " 8 " 
1 " " 9 ,l 
1 " " 10 " 
If it be desirable to deduce inferences from so few cases, the number of 
sterile patients is certainly striking, particularly since, at the age in which 
these new growths appeared in the above cases, sterility could hardly 
be regarded as the result of the sarcomatous growths. The reverse is 
true of fibroids. The contrast, in this particular, between sarcomata and 
carcinomata, may be noted, for in cancerous uterine disease fecundity 
seems augmented before the development of the tumors. 
Clinical History, Course, and Symptoms. 
Our knowledge of the symptomatology of uterine sarcoma would not 
be essentially improved by a separate consideration of the two distinct 
forms of these tumors above described. The two forms have so much 
in common, have been so little studied and so poorly differentiated in the 
reported cases, that their clinical pictures cannot be sharply distinguished 
from each other. It may be stated as a general rule, tliat fibre-sarcomata 
present, at first, the symptoms of fibromata, and only demonstrate their 
sarcomatous nature by their later course. These tumors were, therefore, 
known in earlier literature, especially in England, as recurrent fibroids. 
1 A case of Simpson's is placed here rather arbitrarily, for he only makes the 
statement that " the patient had borne several children." Of J. Clay's seven 
cases, it is stated that six had had repeated label's, and one was barren. For this 
reason the six have not been reckoned in the special table. SARCOMA. 
333 
There can be no doubt, alter what nas preceded, that the tumors in such 
cases were originally fibromyomata. 
The symptoms are due to pressure, and vary according to the location 
and size of the tumors. The chief one is pain due to growth of the neo- 
plasm, or to its propulsion downwards by uterine contractions. Hemor- 
rhages at first occur particularly in the form of menorrhagia, exactly as 
they do with ordinary fibroids, and often change their character at a later 
period, or are followed by a discharge resembling bloody water. 
A number of these tumors have been removed, as examples of fibromy- 
omata, by operative means, and their malignant character only detected 
by subsequent microscopical examination. In other cases their recur- 
rence and their farther course showed that they were not fibromyomata. 
There is often, however, even from the beginning, a peculiar differ- 
ence observed between these tumors and fibromyomata. It consists in 
softness of the tumor, from which, although it be not gangrenous, pieces 
may be broken off. These pieces may be penetrated by the finger. The 
absence of a capsule, in cases of fibro-sarcomata, is frequently striking, 
particularly during extirpation. Their growth is, moreover, rapid, the 
pains attendant upon their development unusually violent, and they 
occasion a discharge resembling the bloody water without becoming 
gangrenous. They also produce a cachexia, rapid emaciation and a loss 
of strength incompatible with their apparently benign character. 
However variable these symptoms may be, and however little charac- 
teristic of sarcomatous growths, the farther course, in all cases of sarcoma, 
is the same. If they are removed, they soon recur (after an interval 
varying from four to six weeks, to one or two years.) 
The tumor usually grows more rapidly after its recurrence, and occa- 
sions more violent hemorrhages, a more abundant discharge, more in- 
tense pain and more rapid and marked asthenia. 
Repeated extirpations may arrest the course of the disease, even for six 
and a quarter years (West). Death, however, always occurs, being pre- 
ceded by intense anaemia, and often with symptoms of fatty degeneration 
of the heart. In other instances the fatal issue maybe referable to intes- 
tinal obstruction, peritonitis, or to pyaemia following gangrene of the 
tumor. (L. Mayer.) 
Metastases are rare, but are found more frequently than in cases of 
diffuse sarcoma. They have been observed in the vertebrae (West, Hutch- 
inson), the lymphatic glands, the lungs, the pleura, the liver, and in the 
pelvic connective tissue. In the last position the secondary tumors had 
not been developed on account of mere contiguity of tissue. (P. Muller.) 
The symptoms of diffuse sarcoma are very similar to those described. 
In cases of this variety there is no distinct tumor perceptible by surface 
examination, the uterus is enlarged and moved with difficulty. (Conf, a 
few cases of West, Gusserow and others, in which these conditions did 334 
NEW GROWTHS OF THE UTERUS. 
not obtain.) The proliferating tissues often protrude, however, from 
the os uteri, and thus simulate a circumscribed tumor. 
The fact that the sarcomatous growths have spontaneously protruded 
from the os, in these cases, is proven by the absence of genuine uterine 
pains. Small portions of the tumors are, moreover, easily separated 
from the latter, and are expelled with the discharge. This does not occur 
with any other uterine neoplasm. Very violent hemorrhages are hardly 
ever wanting. They usually soon lose the menstrual type, and are more 
copious when they begin at or subsequently to the menopause. 
There are a few cases in which the hemorrhages, especially at the be- 
ginning of the disease, were trivial, or in which there was a persistent 
although trifling escape of blood. 
Together with the hemorrhages and in the intervals between them there 
is an exceedingly copious, sero-sanguinolent discharge, which usually has 
a repulsive, foetid odor, but is not the result of disintegration of the 
tumor. Disintegration of the sarcomata usually occurs, however, at an 
early period, and the discharge then assumes the character of the fluid 
emanating from gangrenous tissues. Most of the cases are characterized 
by the great severity of the pain, although pain may, in exceedingly rare 
instances, be absent. 
The pains do not, as a rule, possess the characters of rhythmical uter- 
ine pains. They are agonizing, tearing pains, which often cause the 
patients to cry out, and which are frequently difficult to control. 
It seems as if the special intensity of these pains was dependent upon 
the depth to which the sarcomatous infiltration had penetrated, and that 
the pains were due to morbid changes in the terminal nerve filaments. 
In regard to other points in the history of this form of uterine sarcomata, 
the statements made concerning fibro-sarcomas may be reiterated. Re- 
currences take place, at first, after long intervals. Later they follow each 
other with increasing rapidity. Death occurs sooner or later, as the result 
of anaemia and cachexia. 
Metastases are far rarer with diffuse sarcoma than with fibro-sarcomata, 
but the former often penetrates the uterus, invading the abdominal cav- 
ity and attacking the pelvic connective tissue, the bladder, the vagina, 
the rectum and even the external genitals. Its similarity to carcinoma 
is thus shown. 
We herewith present Rogivue's figures, which furnish certain data 
concerning the course of this disease. Among fifty patients who sub- 
mitted to an operation, six died soon after the operation, nine escaped 
farther observation, and three seemed permanently cured. 
Recurrences were observed in thirty-two cases. In eight of these the 
recurrence took place very soon after the operation. In twelve within 
six months. In ten within one year. In two after one year. Forty pa- 
tients out of sixty-five died. Twenty-five of these died within a year after SARCOMA. 
335 
the first investigation, and some of them after three, four and six years. 
The entire duration of the disease varied between four months (Franken- 
hauser, quoted by Rogivue) and ten years (Hegar). The average dura- 
tion was, according to Rogivue, three years. 
Reference should be made, at this point, to the frequency of inversion 
of the uterus in cases of sarcoma. Taking into consideration the small 
number of uterine sarcomata actually observed, the number of inversions, 
four in all, is, at all events, relatively large. These cases were studied by 
Wilks),1 Langenbeck (loc. cit.), Spiegelberg and A. Simpson. W. A. 
Freund's case is very peculiar. He diagnosticated sarcoma with hydro- 
metra in the occluded left half of a zcterus septzis and confirmed his diag- 
nosis by the autopsy.2 
Diagnosis and Prognosis. 
The diagnosis of uterine sarcoma or carcino-sarcoma can, doubtless, 
only be made by histological investigations. These researches are, how- 
ever, often impracticable during the patient's life and never furnish pa- 
thognomonic data for a diagnosis, unless an examination be made of the 
whole tumor or of the tumor and uterus while still connected. An ap- 
proximately correct diagnosis, in cases of fibro-sarcomata, can only be 
made aftei' extirpation of the tumor, while the small pieces, so readily 
obtained from a diffuse sarcoma, are by no means sufficient to positively 
establish a diagnosis. 
Since, now, the question of extirpation is really decided by, and the prog- 
nosis is chiefly dependent upon, the nature of the tumor, we must attempt 
to establish the diagnosis by means of clinical data, utilizing microscopical 
examinations, so far as is possible. It follows from the fact that fibro- 
sarcomata are often gradually developed from fibromyomata, that a 
differential diagnosis between them is frequently impossible. All fibro- 
sarcomata which appear in the form of distinct and isolated tumors give 
rise to the symptoms of fibroids. We may, therefore, refer the reader to 
the earlier chapters foi* these phenomena. 
The appearance of a so-called " fibroid," at the time of the menopause, 
or the sudden growth and increase at this time of a tumor which had 
previously been of small size, and had produced few symptoms or none 
at all, should arouse the suspicion that the tumor was originally a fibro- 
sarcoma, or has been transformed from a fibroid into a sarcoma. 
The occurrence of hemorrhages in cases of so-called "fibroid," long 
after the cessation of the menses, has an important bearing on the diag- 
nosis. While hemorrhages from fibromyomata frequently diminish or 
1 Lectures on Pathological Anatomy, 1859, p. 404. Quoted by A. Simpson. 
2 The histories of two cases, observed by Gusserow, are here omitted.-Ed. 336 
NEW GROWTHS OF THE UTERUS. 
cease at the menopause, those due to fibro-sarcomata are most profuse at 
that epoch, since these tumors frequently make their first appearance 
then. An abundant sero-sanguinolent discharge is even more charac- 
teristic of fibro-sarcomata than these hemorrhages, for it is really never 
produced by simple fibroids unless they are undergoing gangrene. It is, 
however, not a constant phenomenon in cases of fibro-sarcomata. The 
chief reason for the difference between the two varieties of new growths, 
in this particular, is probably that fibroids possess a so-called capsule, 
which fibro-sarcomata almost always lack. Another prominent reason is 
that sarcomata are very vascular, and fibromata almost always but slightly 
so, or that only vascular fibroids are predisposed to sarcomatous degen- 
eration. 
The rapid growth of a doubtful tumor, particularly if it take place 
during the climacteric years, in which fibroids hardly ever grow to any 
considerable extent, is another evidence in favor of fibro-sarcoma. Un- 
usually violent pains and soft consistency are also characteristics of the 
latter tumors. 
If the tumor be accessible to direct palpation, the softness referred to 
above, which often permits the finger to penetrate the new growth, or to 
break off small portions of it, is almost pathognomonic of fibro-sarcoma. 
Gangrene of a fibromyoma must be excluded by a careful investigation of 
the case. The diagnosis is usually easy if, in addition to the points 
mentioned, marked emaciation, asthenia, cachexia, and anaemia make their 
appearance. 
In the event of a successful extirpation, the microscopical examination, 
and, above all, distinct recurrences, afford definitive evidence concerning 
the nature of the neoplasm. 
The diagnosis of diffuse sarcoma is not so comparatively easy in every 
case. A differential diagnosis between this variety of sarcoma and car- 
cinoma of the fundus, may be at first impossible. This distinction is, 
however, practically useless, since a strict differentiation between diffuse 
sarcoma and carcino-sarcoma can not always be made, even by anatomi- 
cal appearances. 
Sarcoma of the cervix is easily distinguished from cervical cancer, by 
the healthy condition of the port io vaginalis. 
The sarcomatous tissues occasionally protrude so far beyond the os ex- 
ternum that they quite cover the border of the os, and seem to completely 
fill the latter. Careful examination with the finger, and the speculum, 
must decide the question in such cases. 
The differentiation of a diffuse sarcoma from certain benign hyper- 
trophies of the uterine mucous membrane, especially that form recently 
described 1 by the name endometritis fungosa, is more important, and in 
1 Olshausen, Archiv f. Gynak., VIII,, p. 113. SARCOMA. 
337 
fact more difficult. This disease occurs less frequently after the meno- 
pause than sarcoma, but the age of the patient is not a decisive diagnostic 
feature, inasmuch as the development of diffuse sarcoma is not exclu- 
sively confined to the period in question. 
The general condition of the patient, when subjected to long-continued 
observation, is more significant. In benign fungous endometritis the 
patient may, it is true, become anaemic, but she never develops a pro- 
nounced cachexia. 
Endometritis fungosa is rarely attended by any considerable discharge, 
especially since spontaneous gangrene, so common with sarcoma, never 
accompanies it. In sarcoma the os uteri is almost always permeable, in 
endometritis it is usually closed. In sarcoma the uterus is large, in filtrated, 
and ordinarily painful when it is moved. These points are absent in endo- 
metritis. In sarcoma the new growth often projects beyond the os, after 
the fashion of a polypus. This appearance is never observed in benign hy- 
perplasia of the uterine mucous membrane. Endometritis always remains 
as a superficial proliferation of the mucous membrane, and never involves 
the parenchyma; while sarcoma, being originally developed, as a rule, in 
the deeper structures, always invades them, and extends into and through 
the uterine parenchyma. Genuine recurrences of endometritis, such as 
occur with sarcoma, are not observed. The differential diagnosis between 
these two morbid conditions ought not, therefore, to be very difficult. 
The microscopical examination of isolated masses removed from the 
new growths (even when they belong to a sarcoma and are spontaneously 
expelled), does not furnish reliable evidence, since one often obtains pieces 
of healthy mucous membrane, in cases of sarcoma, and in endometritis 
polyposa, pieces looking like granulation tissue, or small-cell sarcoma. 
We omit a consideration of the differential diagnosis between sarcoma, 
parametritis, cysto-fibromata, luematocele, etc., because a careful ex- 
amination will protect from such errors, and because in cysto-fibromata, 
a strict distinction between sarcomatous and other cysto-fibromata is im- 
possible, intra vitam. Our last reason for the omission is that, in specially 
complicated and difficult cases, no more can be stated than has been 
already done. 
The prognosis in either form of uterine sarcoma must be characterized, 
after what has been stated, as unfavorable. These tumors are undoubtedly 
malignant. There is not a single well-authenticated case of sarcoma on 
record in which extirpation resulted in a permanent cure. Every tumor of 
this variety has led sooner or later to death. Nevertheless the prognosis, 
as contrasted with that of most uterine carcinomata, is a comparatively 
favorable one. The course of sarcomatous disease is much slower, at 
least in the beginning. Moreover the growths are more frequently diag- 
nosticated at so early a period, that trivial operative measures, often re- 
peated, may delay their progress and materially retard their development. 338 
NEW GROWTHS OF THE UTERUS. 
We have thus cited some cases above, in which the disease extended over 
a period of ten years, and the patients were not once so tormented by it 
as in cancer, but often enjoyed a very tolerable condition of health. 
Timely operative treatment has, at all events, a favorable influence 
upon the course of the disease, since it remains a local one much longer 
than carcinoma does. 
Treatm ent. 
There is little to be said regarding the treatment of uterine sarcomata, 
especially since it must be considered in extenso, under the head of car- 
cinoma. 
Every sarcoma must be removed as speedily and thoroughly as possi- 
ble. If removal of the tumors is impossible, the treatment must be 
symptomatic and analogous to that of fibromyomata and of cancer. 
In all cases of sarcoma the question will have to be considered of total 
extirpation of the uterus, or if the neoplasm is confined to the body of 
the uterus, of supra-vaginal amputation. Operative interference is always 
called for, provided a positive diagnosis can be made. A more extended 
consideration of this subject will be found under the head of cancer. It 
may be said in this connection that total extirpation of the uterus is all 
the more indicated, since the recurrence of the sarcoma is usually confined 
to that organ. 
Supra-vaginal amputation of the uterus has been successfully performed 
for sarcoma by Schroder, by Gusserow and others. Total extirpation was 
done by Freund once (fatal result) and by Spiegelberg once (recovery). 
Total extirpation per vaginam was successfully performed by Zweifel. 
Fibro-sarcomata should, if possible, be thoroughly excised with cutting 
instruments. Care should be taken not to wound healthy tissues, since 
the.possibility of their inoculation with sarcomatous material (Spiegelberg) 
cannot be entirely denied. The removal of the tumor must be as complete 
as possible, because a radical cure is not to be despaired of, and because 
the recurrence is delayed the longer the fewer the remnants of the tumor 
left behind. It is, therefore, urgently recommended to excise the tumor 
as broadly and deeply as possible, and then to thoroughly cauterize the 
surface of the wound, if this be possible. If the tumor cannot be thus 
thoroughly extirpated, on account of its soft consistency or of its loca- 
tion, the last resort is the method invariably employed in cases of diffuse 
sarcoma. It consists in shaving off the diseased tissues with Recamier's 
curette, or with Simon's sharp spoon, and in energetic cauterization of 
the surface of the wound. The cauterization may be most effectively 
accomplished with a fluid escharotic, viz., liq. ferbi chloridi, acid, chromic, 
acid nitric, fort., etc. Under certain circumstances the actual cautery 
may, with advantage, be applied to the cavity of the uterus, either by SARCOMA. 
339 
means of the porcelain electrode of a galvano-cautery instrument, or with 
Pacquelin's apparatus. 
The cautery must, naturally, be so applied as to avoid, so far as possible, 
the dangers of infection, hemorrhage, burning and gangrene. The 
necessary precautions will be considered in the article on carcinoma. 
Appendix. 
Although certain fibrous papillomata undoubtedly belong among the 
connective-tissue series of uterine new growths, it is as yet impossible to 
consider them separately from other papillomata. Allusion should, how- 
ever, be made to Thiede's case,1 in which abundant cartilaginous growths 
had so invaded a large fibrous papilloma of the portio vaginalis, that he 
designated the tumor a cartilaginous papillary fibroid. Since it recurred, 
however, after removal, and led to the patient's death by occasioning 
hemorrhage, we shall revert to the case under malignant papillomata. 
1 Zeitschrift f. Geburtshiilfe, etc., von Schroder, I., p. 460. CHAPTER X. 
POLYPI AND ADENOMATA OF THE UTERUS. 
BIBLIOGRAPHY. 
The reader is referred to the text-books of former days for the old literature 
of uterine polypi. Indeed, in the following chapter but little reliance is placed on 
the older writings, as it was not so very long ago that all pediculated submucous 
fibromata were regarded as polypi. Billroth : Ueber den Bau der Schleimpolypen, 
Berlin, 1855.-Beigel: Krankheiten des weiblichen Geschlechts, II., p. 468.- 
Hegar and Kaltenbach : Operative Gynakologie, 1874, p. 258.-Wagner : Arch. f. 
physiolog., Heilkund, 1855.-C. Mayer : Ueber Erosionen, etc., Berlin, 1861.- 
Matthews Duncan : Edin. Med. Journal, July, 1871. Aran: Legons cliniques sur 
les maladies de l'ut6rus, 1858, p. 429.-Luna : Des Kystes folliculaires de la ma- 
trice, These Inaug., No. 8, Paris, 1852.-M. Martin : Essai sur la tumeur folliculaire 
hypertrophique, These, No. 65, Pans, 1859.-Barnes : Diseases of Women, London, 
1873, p. 789, and On the hypertrophic Polypus, St. Thomas Hosp. Reports, 1871. 
-Monfumat: Etudes sur les polypes de 1'utdrus, Paris, 1867.-McClintock : Dis- 
eases of Women, Dublin, 1863, p. 155.-More-Madden: On Diagnosis and Treat- 
ment of Uterine Polypi; Obstet. Soc., Dublin, Obstet. Journal, I., p. 468. 
Anatomy. 
^pHE chapter on "Uterine Polypi" in German literature, was until 
1 recently a voluminous one. To day, however, it would perhaps be 
better, in the light of more thorough anatomical knowledge, to abolish 
this term, which is only based on external physical appearances. If, 
however, it be advisable to retain the expression uterine polypus for pedi- 
culated tumors, which seems desirable from practical considerations, only 
those proliferations of the uterine mucous membrane, which have long 
been known as mucous polypi, should be designated by the above title. 
Pediculated sub-mucous myomata, haematoma of the uterus (fibrinous 
polypi) and proliferations of the mucous membrane are still indiscrimin- 
ately designated, in accordance with their symptoms and treatment, as 
" Polypi." 
We have already considered pediculated myomata as a special form of 
these neoplasmata, and we do not, from an anatomical standpoint, in- 
clude uterine haematomata (placental polypi, etc.) among the new 
growths of the uterus. The term " polypus " must, therefore, be reserved 
to designate a pediculated proliferation of the uterine mucous membrane. POLYPI AND ADENOMATA. 
341 
True, it is somewhat arbitrary, and only appropriate on account of 
practical reasons, to lay the greatest stress upon the pedicle, but only by 
it do these proliferations become tumors or neoplasmata in a clinical 
sense. The difference between a diffuse proliferation of the uterine 
mucous membrane and a mucous polypus, is only a rough anatomical one, 
based upon external appearances and not a genuine one, founded upon 
the structure of these formations. One may, perhaps, even say that we 
have to deal, in the case of mucous polypi, with isolated circumscribed 
hypertrophies of the mucous membrane, such as follow general tumefac- 
tion of the membrane dependent upon chronic catarrh. 
To define adenoma according to modern views is still more difficult. 
Fig. 34.-Glandular Polypi of the Vaginal Portion of the Cervix. (After Luna.) 
In the first place we must mention, in this connection, most erosions of 
the cervix accompanied by ectropium of the mucous membrane. Huge 
and Veit1 have shown that the majority of these conditions belong ana- 
tomically to the new formations. Nevertheless we are not in the habit 
of regarding them in this light, from a clinical point of view. But it is 
quite true, on the other hand, that as regards the treatment at present 
adopted by most gynecologists, these erosions are looked upon as growths 
to be dealt with by ablation, or even amputation of the cervix. 
Another form of adenoma must be mentioned here. This variety has 
been known for a long time. Virchow described it as hypertrophy of 
1 Huge u. Veit: Zur Pathologic der Vaginalportion, Stuttgart, 1878.-Fischel: 
Ueber den Bau, etc., der Erosionen der Portio vaginalis. Zeitschrift fur Heil- 
kunde, Prague, 1881,-Heitzmann : Spiegebilder der Vaginalportion, Wien, 1883. 342 
NEW GROWTHS OF THE UTERUS. 
the lips of the os, or as follicular hyperplasia. He has shown that these 
growths are follicular polypi, which produce considerable hypertrophy of 
the lip, from which they take their origin. 
From simple hypertrophy of the cervix, these excrescences differ in 
being commonly pediculated and arising from a single point of the cervix 
or its mucous membrane. 
The latter participates largely in the pathological alteration, there being 
crypts, dilated glands, but also new-formed or simply hypertrophied 
glandular structures. There can be no doubt that the primary affection 
has its seat in the mucous membrane, and that the hypertrophy of the 
lips of the os is secondary to that change. This hypertrophy is brought 
about by a kind of infiltration of new-formed follicles into the cervix. If 
this process is limited to a single point of the cervix, the diseased part 
becomes stretched and a pedicle results. But if the cervix is more uni- 
formly affected, the disease has often been mistaken for epithelioma. 
Since Oldham's observations, such growths are mentioned in English 
literature as canaliculated polypi. Not infrequently the large participa- 
tion of the cervical papillae, covered by pavement epithelium, marks a 
transitional form between these and papillomatous tumors. 
In addition to the cases of this kind described by Virchow (1. c.), the 
following authors refer to them. E. Wagner,1 Martin,8 Beigel,3 Barnes,4 
McClintock,5 Luna,6 Demarquay and St. Vel (1. c.)., and A. Schulz.7 
The cases of Simon and Ackermann, placed by most writers in this cate- 
gory, appear to belong rather to the papillomata, and will be referred to 
in that connection. 
The third variety of neoplasms belonging to the adenomata differs 
entirely from those already described. It consists essentially of a pro- 
liferation of the mucous membrane of the cavity of the uterus, and quite 
rarely of that of the cervix. 
Besides simple catarrhal swelling of the uterine mucous membrane 
(endometritis chronica), conditions have long been recognized in which 
more or less diffuse proliferations of the membrane have been particularly 
noticeable. Olshausen 8 has only recently described these conditions, and 
with perfect propriety has separated them, under the name endometritis 
fungosa, from the genuine new formations of the uterine mucous 
membrane. 
' Arch. f. phys. Heilk., 1856, p. 511. 
2 Berl. Beitr. zur Geb. u. Gynak., II., p. 51. 
3 Frauenkrankheiten, II., p. 469, u. ff. 
4 Diseases of Women, p. 791, and Thomas's Hospital Reports, 1871. 
8 Clinical Memoirs, p. 155. 
6 Des Kystes folliculaires, etc., These, Paris, 1852. 
1 Casuistik der Uterusfibroide, Diss. Jena, 1875, Fall 1. 
8 Archiv fur Gynakologie, VIII., p. 97. POLYPI AND ADENOMATA. 
343 
Those symmetrical proliferations of the whole mucous membrane, 
which are usually connected with moderate dilatation of the glands, may 
occur isolate in various parts of the body of the uterus. They then 
appear as small, flat tumefactions of the mucous membrane, as large as a 
pea or a bean, with broad bases, and not only closely resemble an ordinary 
mucous polypus, but even produce the same symptoms as the latter. These 
simple mucous prominences consist of normal, symmetrically hypertrophied 
Fig. 35.-Follicular Hypertrophy of the Portio Vaginalis with small Mucous Polypi. 
(From the Collection of the Pathological Institute at Strasburg.) 
mucous membrane, and have been described and depicted by Virchow.1 
Gusserow,2 Olshausen (1. c.) and Schroder3 have called attention to morbid 
states of the uterine mucous membrane, which, on the whole, completely 
correspond to endometritis fungosa, yet differ essentially from it in the 
active participation of the uterine glands. The name diffuse adenoma of 
the uterus has been applied to these conditions, and their malignancy has 
been maintained by many observers. 
1 Geschwiilste, I., p. 241. 
2 Archiv f. Gynakol., vol. I., p. 246. 
3 Zeitschrift fur Geburtskunde, etc., I., p. 89. 344 
NEW GROWTHS OF THE UTERUS. 
Schroder lias observed a similar condition, but more in the nature 
of isolated, pediculated growths, and he has designated it adenoma poly- 
posum. Similar morbid changes have been described by Duncan 1 and 
Slaviansky, (the cases of Klob2 and Adolph Schulz might also be placed 
in this category), by Maslowsky,3 Winckel,4 Kuhn,6 Schatz,6 and others. 
Aside from the above-described molluscum uteri (Virchow), those cir- 
cumscribed tumefactions of the uterine mucous membrane, which usually 
Fig. 36.-Glandular Polypus of the anterior lip of the Os Uteri. (After Beigel.) 
proceed from a chronic catarrh of the cervical mucous membrane, and 
more rarely from the body, and lead to closure and dilatation of the mu- 
cous follicles, have been known as simple mucous polypi. The formation 
1 Obstetr. Journal, 1873, p. 497. 
2 Pathol. Anatomie d. weibl. Sexualorgane. p. 153. 
3 Edin. Med. Journal, Jan. 1882. Comp, also Centralblatt filr Gvnakologie, 
1882, No. 4. 
4 Pathol, d. weibl. Sexualorgane, p. 40. 
6 Correspondenzblatt schweiz., Aerzte, 1882, No. 17. 
6 Arch. f. GynakoL. Bd. XXII. POLYPI AND ADENOMATA. 
345 
of the pedicle, which is the essential part of the " polypus," is due to the 
closure and protrusion of the raucous follicles produced by swelling of 
their tissues. The ovula nabothi are the simplest and clearest example of 
this process. 
We have here to deal with a retention cyst, which has, at first, a broad 
base, and is elevated above the mucous surface. In its farther growth it 
elongates its base, by traction on it, and finally protrudes from the os as 
a mucous polypus with a slim pedicle. The more such cysts combine with 
Fig. 37.-Cross-section through an Adenomatous Polypus of the Portio Vaginalis. Slightly 
magnified. 
each other, and the more the proliferating mucous membrane is attenuated 
by traction, the largei' and more complicated does the mucous polypus 
appear, and the thicker is its pedicle. 
These tumors, the smallest of which are as large as a pea, and the 
largest the size of a hen's egg, are composed of the elements of the uterine 
mucous membrane, and are covered with layers of both cylindrical and 
pavement epithelium. They contain between their connective-tissue 
trabeculae numerous cavities, visible to the naked eye, which are dilated 
glands. The cavities are filled with mucus, which is thick or thin accord- 346 
NEW GROWTHS OF THE UTERUS. 
ing to the period of its retention. There are usually no large vessels in 
the pedicle. The superficial vessels have ordinarily numerous ramifica- 
tions and thin walls. This is the reason why the little neoplasms so 
readily occasion profuse hemorrhages. The favorite seat of mucous polypi 
is the cervix, which they often widely dilate and transform into a 
membranous, flaccid sac. They also protrude some distance beyond the 
os externum. Large-sized formations of this kind are much more rarely 
found in the mucous membrane of the uterine body. When they do 
exist they frequently protrude through the os internum or even present 
the appearance just described. In other cases the os internum does not 
dilate and the growths remain in the uterus, often without occasioning 
inconvenience. 
The development of numerous small cystic proliferations in the mucous 
membrane is oftener observed than the formation of one or more large- 
sized uterine mucous polypi. In aged persons it is not very rare to find 
the entire uterine mucous membrane covered by numerous isolated, small 
cystic polypi, resembling the ovula nabothi. These polypous growths 
produce the same symptoms, intra vitam, as diffuse hypertrophy of the 
mucous membrane, with which they were earlier often confounded. 
Endometritis fungosa may, however, as already explained, be anatomi- 
cally distinguished from endometritis cystica polyposa. (Virchow.) 
Meixner and Kuchenmeister1 have given a good clinical history of such 
a case of multiple, small mucous polypi of the uterine body. 
By way of appendix we here mention the new growths described by 
R. Maier,2 under the title deciduoma. They were small, polypous tumors 
which projected from the cervix uteri and had been removed. They 
consisted of decidual tissue. 
In one of the cases the patient was pregnant, so that it was probably 
not a case of tumor in our sense of the word. The other patient was not 
pregnant, and the supposed tumor, which consisted of decidual tissue, 
was a hollow cylinder. Farther observations are necessary before a new 
class of uterine tumors called deciduomata can be established. 
Kustner3 has described a case, called by him deciduoma, in which a 
tumor actually took its origin from a remnant of the decidua. He holds 
that this name should only be applied to such cases as he has described. 
A unique case of uterine polypus has been recorded by Zahn.4 The 
tumor was unquestionably composed of placental tissue, and had taken its 
origin from a piece of retained placenta. The neoplasm grew through 
the walls of the uterus, producing by their perforation a fatal peri-uterine 
haematocele. 
1 Ktichenmeister's Zeitschrift fur Medicin, etc., 1863. 
2 Virchow's Archiv, vol. LXVII., p. 55. 
3 Archiv fur Gynak., vol. XVIII. 
4 Virchow's Archiv, vol. XCVI., p. 15. POLYPI AND ADENOMATA. 
347 
Clinical History and Symptoms. 
The symptoms produced by those erosions which have been described 
as adenoma, do not differ from those of catarrh of the cervix and body of 
the uterus. Follicular hypertrophy of the lips of the os gives rise to the 
same phenomena observed in polypus. But adenoma diffusum as well as 
adenoma polyposum lead to hemorrhage. At first the bleeding usually re- 
tains the menstrual type, but in the farther progress of the disease, metror- 
rhagia appears. 
In this way extreme ansem.a may rapidly supervene. In addition to the 
bleeding, these new formations are characterized by their tendency to 
Fig. 38.-Mucous Polypus projecting from the Os Uteri. (After Luna.) 
recur after removal, and by the undeniable fact that, in a certain pro- 
portion of cases, they eventuate in cancer. Observations confirming this 
have been recorded by Breisky, Schroder, Maslowsky, Winckel, Schatz 
and others. 
The symptoms produced by the various kinds of polypoid growths are 
almost without exception simple and identical. Only when the polypus 
is in the uterine cavity does it occasion pain, and then only when it is un- 
usually large, and has not passed through the cervical canal. When it 
has passed through this canal, or when its original seat is the cervix, as 
is usually the case, it produces no painful sensations. If the polypi are 
large enough to fill the vagina, or if in virtue of their long pedicles they 348 
NEW GROWTHS OF THE UTERUS. 
have protruded between the external organs of generation, they occasion 
in the latter symptoms of pressure and of irritation. 
Two symptoms which are, however, very constant and of great impor- 
tance, are seldom or never lacking. These are hemorrhage and a muco- 
purulent discharge. The hemorrhages due to the vascularity of these 
little tumors, and to the tenuity of the epithelium covering them, occur 
particularly in the beginning at the menstrual epoch. They are, how- 
ever, often irregular and may be violent or trivial. Slight hemorrhages 
are especially liable to occur after every injury inflicted upon the polypus 
as it hangs in the vagina, as, for instance, aftei' violent exertions, straining 
at stool, after every coitus, etc. 
Any given hemorrhage is seldom dangerous, but frequently repeated 
losses of blood produce severe chronic anaemia 
Besides the hemorrhages the patients are, almost without exception, 
afflicted with a copious muco-purulent discharge, which is partly secreted 
by the tumor, but is chiefly due to the chronic catarrh of the uterine and 
cervical mucous membrane. When the tumors are located in the cervical 
canal, or have escaped from it, and are situated at the os externum, the 
so-called erosions of the os, desquamation of the cervical epithelium, ul- 
ceration and extrusion of the swollen cervical mucous membrane are rarely 
absent. 
Even very small polypi frequently cause sterility partly as a result of the 
conditions just described, and partly by occlusion of the os. When 
situated near the uterine opening of the Fallopian tube, they may oc- 
casion tubal pregnancy by mechanically opposing the exit of the ovum 
from the tube, or by producing catarrh of the tubal mucous membrane 
through their irritant action on all adjacent tissues. Such a case is de- 
tailed by Breslau,1 in which the polypus, which was situated near the 
opening of the left Fallopian tube, had caused intense tumefaction of its 
mucous membrane, thus preventing the advance of the ovum. 
Little need be said about the clinical history of polypoid growths. If 
not opportunely removed, they may induce extreme asthenia from 
hemorrhage, yet they may be tolerated during a life-time without great 
inconvenience. If the pedicle grows thin, owing to long-continued 
existence of the polypi, or to their rapid development, the latter are often 
spontaneously separated, and thus disappear. This frequently results 
from examination and use of the sound. In rare instances the tumors 
become gangrenous, and may, for a time, simulate carcinoma of the por- 
tio vaginalis, owing to their foetid discharge and their eroded appearance. 
The diagnosis of polypoid growths is easy, so soon as they have effected 
their escape from the external os. Their softness and the presence of a 
Diagnosis. 
1 Monatsschr. f. Geburtsh., XXI., Supplement, p. 119. POLYPI AND ADENOMATA. 
349 
pedicle render them recognizable by touch and by the speculum. By 
the same methods we may discover whether the growths are connected 
with the external os, the portio vaginalis or the cervical canal. This dis- 
tinction is difficult only when the tumors have a short pedicle, protrude 
but slightly from the uterus, show a lobulated structure, or are gangren- 
ous, as is not often the case. In such cases the tumors have been mistaken 
for epithelioma. 
Small polypoid growths which only reach and protrude into the os 
externum, have been overlooked or considered as erosions of the cervical 
mucous membrane. In these instances they were at fault for the persist- 
ence of the erosions. 
Remnants of the membranes, shreds of decidual tissue and even a small 
ovum, in cases of abortion, have been mistaken for polypi. Careful ex- 
amination by palpation and inspection protects against these and similar 
errors. It may often happen, however, that a small polypoid growth is 
plainly recognized at one examination, but can not subsequently be dis- 
covered, since polypi are often easily separated by manipulation. 
While polypoid growths originating in the cervix may thus be diag- 
nosticated without much difficulty, those situated in the uterus are often 
overlooked, because they cannot be recognized until the os uteri has been 
dilated. Patients with polypi are often subjected to a long course of treat- 
ment for menorrhagia, leucorrhoea and slight enlargement of the uterus, 
as cases of chronic metritis, until, finally, the dilatation of the os discloses 
the presence of a small polypoid growth. When the above-mentioned 
symptoms are present, and particularly when the hemorrhages are ir- 
regular, or the uterine discharge is sanguinolent, the attendant should 
dilate the cervix with sponge tents, or by other means, and convince him- 
self either of the presence or of the absence of a polypus. 
If the dilatation be carefully executed, it can result in no harm, and 
even a negative result of the examination will be useful with reference to 
the subsequent treatment. The use of the sound does not lead to so 
certain or easy a recognition of intra-uterine polypi, many authors to the 
contrary notwithstanding. Dilatation of the os internum must never be 
omitted if, in addition to the above signs of polypus, spontaneous dilatation 
of the os occurs, or the portio vaginalis assumes a semicircular form. 
The diagnosis of the various forms of adenoma uteri (diffusum et poly- 
posum) is only possible after the cavity of the uterus has been made ac- 
cessible. In all cases of profuse and long-continued hemorrhage, it will be 
necessary to scrape the internal surface of the womb with a Simon's scoop, 
or simply with a curette. A microscopical examination of the removed 
masses will then have*to be made, in order to determine the true nature 
of the affection. It is, however, by no means easy to always reach a diag- 
nosis, especially as there occur transitional forms from simple endometri- 
tis fungosa to adenoma, and because the number and size of the uterine 350 
NEW GROWTHS OF THE UTERUS. 
glands varies within physiological limits. Nevertheless the larger the 
glandular formations and the greater their numerical preponderance over 
the interstitial tissue, the more certain it is that we have to do with ade- 
noma. But microscopical examination will scarcely justify us in deciding 
as to the possible malignancy of an adenoma. For if we find cellular hy- 
perplasias in the gland structures, and nests of atypical formations, we 
are no longer in presence of an adenoma, but are already dealing with 
cancer. Thus the clinical history of a given case, such as rapid recur- 
rence of the growth, will afford more valuable evidences on the point in 
question than the microscope alone can furnish. 
Treatment. 
The only treatment for polypoid growths consists in their removal. 
The removal of most of these tumors is very simple, owing to the tenuity 
of their pedicles. It is only necessary to seize them with appropriate for- 
ceps, and to separate them by torsion or evulsion. This method is not 
appropriate to the removal of large polypi with thick pedicles, which 
should be cut off. Should there be grounds to apprehend hemorrhage, 
which in some cases of cervical glandular polypi may, indeed, be consider- 
able, the pedicle should be ligated before it is cut, or the wire ecraseur 
or galvano-cautery be employed. 
In general, however, one may dispense with these troublesome proced- 
ures and make use of the vaginal tampon, or of cauterization of the cut 
surface to arrest the bleeding. Serious injury hardly ever results from 
the removal of polypoid growths, unless metritis or parametritis are ex- 
cited by dilatation of the cervix, undertaken for the purpose of removing 
the polypi. 
Brown 1 saw tetanus follow the removal of an intra-uterine polypus by 
means of torsion. 
His description plainly shows, however, that the case was one of 
mucous, and not of so called fibrous polypus. All the instruments in- 
vented for the removal of "polypi," and which are called " polypotomes," 
are superfluous, as has been previously explained. 
The treatment of erosions is the same as that of catarrhal conditions, 
although at times it will be necessary to resort to surgical measures. But 
for follicular hypertrophy of the lips, ablation of the affected portions is 
called for. 
The therapy of true adenoma is less simple. Curetting the cavity of 
the uterus under antiseptic precautions is necessity in the first place. 
Personally I am in favor of following this up by an injection of tincture 
of iodine, with the idea of preventing or retarding a return of the growth. 
1 Boston Gynecological Journal, vol. II., No. 2. POLYPI AND ADENOMATA. 
351 
But the more clearly the case is one of adenoma, the smaller will be the 
benefit derived from this method of treatment. Preliminary dilatation 
of the cervix is not, as a rule, necessary for the performance of this opera- 
tion. 
If repeated recurrences of the new formations show that they are ma- 
lignant, it only remains to practice supra-vaginal amputation, or to do 
total extirpation of the uterus, either by laparotomy or per vaginam. 
The principles underlying our actions, as well as details of the technique, 
will be found under the head of cancer of the uterus. It may be said 
here, however, that the prognosis in adenoma is better than in carcinoma. 
Schroder, Muller and myself have performed supra-vaginal amputation 
for adenoma diffusum without recurrence of the growth. Schroder, 
Schatz, A. Martin and others have done total extirpation of the uterus for 
this variety of adenoma. Martin reports that he has twice observed a 
recurrence of the adenoma, or the formation of cancer in the cicatrix. 
In these cases the uterus was removed per vaginam. CHAPTER XI. 
PAPILLOMA OF THE UTERUS. 
BIBLIOGRAPHY. 
The following is not a complete list of all the works treating of papillomata 
of the uterus. The text-books, already several times referred to, have also been 
omitted. John Clarke : On the cauliflower excrescence from the os uteri, Trans, 
of a Society for the Improvement of Med. and Surg. Knowledge, vol. III., 1809, p. 
321, also Edin. Med. and Surg. Journal, vol. XVIII., 1822, p. 480.-Charles Clarke : 
Observations on some diseases of females which are attended by discharges, Lon- 
don, 1821, vol. II.-Gooch : An account of some of the most important diseases 
of women, London, 1829, p. 300.-J. G. Simpson : Edin. Med. and Surg. Journal, 
1841, p. 104, and Dublin Quarterly Journal of Med. Science, vol. II., 1846, p. 352. 
-Stafford-Lee : Von den Geschwulsten der Gebarmutter, Berlin, 1848, p. 96.- 
Virchow : Gesammelte Abhandlungen, 1856, p. 1015, und Cellularpathologie, Ber- 
lin, 1871, p. 551.-L. Mayer : Verhandlungen der Gesellschaft fiir Geburtshiilfe, 
zu Berlin, vol. IV., p. 1851, 111.-E. Wagner: Gebarmutterkrebs, Leipzig, 
1858, p. 12.- Mikschik : Zeitschr. d. Ges. d. Aerzte, Wien, 1856, XII., p. 40.- 
Braxton-Hicks : Guy's Hosp. Reports, 1861, VIL, p. 241.-H. Beigel: Zur Pathol- 
ogic d. Blumenkohlgewachse, Virchow's Archiv., vol. LXVI. 
TT seems at least doubtful whether it is justifiable to retain the class of 
1 papillomata in the category of uterine tumors. Virchow's 1 statement 
that both connective-tissue tumors (fibromata) may occur in the form of 
condylomata and papillary tumors, and that cancerous and epitheliomatous 
formations may assume the cauliflower appearance is, doubtless, true. 
Since, however, the mere outward form of a tumor does not justify the estab- 
lishment of a special class of neoplasms, i.e. the cauliflower growths of the 
os, this term, which since J. Clarke's time, has produced much confusion, 
should be simply dropped. From what follows it will, however, be seen 
that it is proper, viewed from either a clinical or an anatomical stand- 
point to apply the name cauliflower tumor or papilloma of the uterus to a 
certain class of neoplasmata. 
Fibrous papillary tumors of the portio vaginalis are not frequent, and 
may be characterized as benign growths. They consist of enlarged and 
proliferating preexisting papillae, and their surface is usually covered with 
squamous epithelium. Their fibrous character is shown by the fact that 
their pedicles are composed of connective tissue and muscular fibres. 
1 Cellularpathologie, Berlin, 1871, p. 551. PAPILLOMA. 
353 
These papillary fibromata thus completely resemble a " polypus," par- 
ticularly in that they seldom attain any considerable size. Their symp- 
toms are those of "polypi," viz., hemorrhages and muco-purulent se- 
cretions. They rarely become gangrenous. They do not recur after 
removal. The purest example of this variety is described by G. Simon1 un- 
der the title " wing-shaped elongation of the anterior lip with simultaneous 
abnormal elongation of the entire portio vaginalis of the cervix." The 
tumor, which was attached to the hypertrophied anterior lip, was pedicu- 
Fig. 39.-Papillary Fibroma with Hypertrophy of the anterior lip of the Os Uteri. (After 
G. Simon.) 
lated and composed of a layer of dense connective tissue from which closely 
approximated, slender papillaa projected. 
The papillse are covered with a thick layer of epithelium cells, super- 
imposed upon each other in several strata. There is no trace of follicles 
or of mucous glands to be seen. The relations are more complicated and 
the diagnosis of the tumor more difficult if the glands are involved in the 
morbid process. This was the case with the tumor described by Acker- 
mann,2 as a "glandular polypus of the anterior lip." 
The tumor was as large as an apple, was attached by a pedicle to the 
1 Monatsschrift fiir Geburtskunde, XXIII., p. 241. 
2 Virchow's Archiv., vol. XLIII., p. 88. 354 
NEW GROWTHS OF THE UTERUS. 
anterior lip, and consisted chiefly of connective tissue, which formed the 
pedicle and the ramifying papillary processes of the new growth. The 
papillse were clothed with a thick coating of pavement epithelium ar- 
ranged in numerous layers. In other places the surface was dotted with 
slender villi, covered with a single layer of cylindrical epithelium. 
Sections from the interior of the tumor showed long cavities, opening, 
in part, toward the periphery and clothed with cylindrical epithelium. 
There was, therefore, a proliferation or new formation of the cervical 
follicles, together with the papillary growths. Two years after the tumor 
had been excised, on account of profuse hemorrhages, the cicatrix showed 
no noteworthy appearances. Two small, pediculated tumors, of the same 
Fig. 40.-Papillary Fibroma with newly-formed Glandular Tissue, starting from the ante- 
rior lip of the Os Uteri. (After Ackermann.) 
kind had, however, been developed on the portio vaginalis and had been 
removed. 
A case described by Rindfleisch,1 by the name "papilloma cysticum," 
certainly also belongs in this category. In his case, however, the cavities 
lined with epithelium were said not to have originated from the follicles, 
but by coalescence of papillae, at their apices. 
Thiede's2 tumor, called by him "fibroma papillare cartilaginescens,'' 
also belongs in this class, as do also the previously described papillary 
sarcomata. 
It is certainly unjustifiable to erect these tumors into a special class, 
and even to call them cauliflower tumors, although they have many char- 
acteristic features, and can hardly, on account of their form and clinical 
history, be included with the fibromata. 
Still less is this justifiable in the case of papillary cancer of the cervix, 
1 Pathologische Gewebelehre, 1869, p. 63. 
2 Zeitschrift f. Gynakol., etc., v. Schroder, etc., I., 460. PAPILLOMA. 
355 
or epithelioma, although the error is daily committed and has found its 
way into many text-books. 
We shall see that this conftnon disease has such well-defined anatomical 
and clinical features that it quite suffices to designate it by the term 
epithelioma, and that the addition of the title cauliflower growth has only 
produced confusion. If one says, as is now customary, epithelioma or 
cauliflower growth (papilloma) of the uterus, the latter name is superflu- 
ous and may be dropped. 
Nevertheless, it seems proper, in accordance with the good, original 
observations of Clarke, Gooch and others, to apply the title cauliflower- 
growth (papilloma) to a peculiar form of cervical neoplasm in order to 
Fig. 41.-Microscopical Section of the Tumor depicted in Fig. 40. (After Ackermann.') 
emphasize the characteristic peculiarities of the same. It is certain that 
papillary tumors of the portio vaginalis are encountered, although very 
infrequently, which doubtless belong to the class of carcinomatous growths, 
but which are, foi' a long time, not cancers and do not possess the 
anatomical or the clinical features of the latter. These papillomata pro- 
bably invariably become cancers, if left to themselves, but they are certainly 
not cancers for a long time and do not recur if removed during the period 
in question. 
Clarke, and afterward Gooch, accurately described the tumors called, 
from their external appearance, cauliflower-growths of the uterus, as 
neoplasmata proceeding from the lips of the os, especially from their outer 
surface. They consist of isolated villi, which impart a wart-like appear- 356 
-NEW GROWTHS OF THE UTERUS 
ance to their surface, so that, in reality, no term so well describes their 
aspect as that inquestion. The color of the tumors is either light or dark 
red unless the surface be gangrenous, which is not often the case. 
Even Clarke pointed out the vascularity of these tumors and compared 
them, in this particular, with the placenta. He also showed that, after 
removal of the tumor, it completely collapsed, owing to emptying of the 
vessels, and was found to consist of a small quantity of solid tissue. The 
later histological researches of Simpson, Virchow and others proved that 
these tumors consist of proliferation of the papillae into the mucous mem- 
brane of the portio vaginalis. The papillae are, according to Klob's 
perfect description,1 either simple or compound. They usually ter- 
minate in fine points and are covered with a thin epithelial layer. In these 
slender papillae, often consisting, as it seems, of embryonic connective 
tissue, are situated large capillary plexuses or single vascular loops with 
remarkably thin walls. None of these cases are characterized by ingrow- 
ing of the epithelium into the papillae, by isolated epithelial proliferations, 
or, in fact, by any microscopical features of epithelioma. The clinical his- 
tory of the new growths at first corresponds to their structure. The tumors 
occasion no pain, and their growth appears to essentially depend on the 
expansibility of the vaginal walls. 
Even J. Clarke called attention to the fact that in nulliparae whose 
vaginae are narrow and rigid, the growth of papillomata is much slower 
than in multipart, the walls of whose vaginae are always relaxed. Spon- 
taneous superficial necrosis and gangrene of the tumors are, moreover, 
rare. The ever-present symptoms which early direct the attention of 
patient and physician to the new growths, are the profuse watery secretion 
and the unusually profuse hemorrhages. After the preceding description 
of the structure of these tumors, the above-mentioned symptoms are easily 
comprehensible. 
The attenuated walls of the widely dilated vessels, and the thin layer of 
connective tissue and epithelium which separate the vessels from the 
surfaces, render an abundant serous secretion and the profuse hemor- 
rhages almost unavoidable. The serous, watery, usually odorless dis- 
charge takes place continually, in almost incredible quantities. Rams- 
botham (Joe. cit.) mentions a case in which the patient used twenty 
dozen towels weekly to catch the discharge; all the towels were 
completely saturated. 
The violent hemorrhages are due, at first, to accidental causes resulting 
in laceration of the tumors. At a later period they occur spontaneously. 
All observers have been struck with the comparative immunity of patients 
affected with these tumors from constitutional symptoms. The fact that 
new growths, such as those described, do not recur if carefully removed 
1 Path. Anatomie d. weibl. Sexualorgane, Wien, 1874, p. 141. PAPILLOMA. 
357 
from a healthy portio vaginalis, harmonizes with the characteristic just 
alluded to. Such operations are followed by a complete cure. Simpson 
(Joe. cit.) found that one of his patients was quite well six years after the 
removal of such a tumor, and that she had borne three children since 
the operation. Colombat found no traces of a recurrence two years after 
the operation, and Boivin and Duparque (quoted by Simpson) none in 
two cases, after four years. 
Although these tumors, therefore, at first laid claim to a separate classi- 
fication, farther anatomical and clinical observations soon proved their 
relation to carcinomata. It is due to this fact that papillomata, as has 
been above explained, are either erased from the list of uterine tumors 
or simply designated as epithelioma of the cervix. Neither course is 
correct • 
Virchow deserves the chief credit of having first microscopically 
demonstrated that extensive epithelial proliferations, usually of an atypical 
nature, are already present in many of these "papillomata." He also 
showed that nests of epithelial elements are found in the tissue of their 
deeper layers, and that, in fact, the tumors are carcinomata, which have 
assumed the form of a papilloma. He accordingly made a positive dis- 
tinction between benign papilloma and malignant papilloma, i.e., epithe- 
lioma. 
C. Mayer then demonstrated, by clinical investigations, that these 
cauliflower growths "constitute the first stage of cancer." Such papil- 
lomata doubtless become transformed into cancers by the proliferation of 
their epithelial elements, after having existed for a long time. One often 
encounters carcinomatous infiltration on extirpating a supposed papil- 
loma, or the tumor recurs soon after its removal, either at the site of the 
operation or in its vicinity. Cases such as that so well described by 
E. Wagner (Gebiirmutterkrebs, p. 13) unquestionably occur, in which, 
after the removal of a pure papilloma, such as those described above, and 
in which most careful examinations failed to detect any epitheliomatous 
tissue, death nevertheless resulted from pronounced uterine cancer five 
months after the operation 
It is, therefore, certainly justifiable to recognize the connection between 
cauliflower growths and cancer, and, perhaps, to simply characterize them 
as initial stages of the latter. (Conf. also Gusserow, Carcinoma Uteri, 
Volkmann's Klin. Vortrag, p. 10.) It seems, however, practically im- 
portant to dignify this initial stage of uterine cancer, which is so well 
defined in regard to both its anatomical and its clinical features, with a 
special name. The treatment of these new growths is identical with that 
of epithelioma, and the reader is accordingly referred to the chapter 
treating of that subject. CHAPTER XII. 
EPITHELIOMA AND CARCINOMA OF THE CERVIX UTERI. 
BIBLIOGRAPHY. 
Only the more modern works, which have been consulted in the preparation 
of the following chapter, are here presented. References to the periodical liter- 
ature are given in foot-notes. Beyerl6: Ueber den Krebs der Gebarmutter, 
1818.f-E. G. Patrix : Traits sur le cancer de la matrice, Paris, 1820.f-E. von 
Siebold : Ueber den Gebarmutterkrebs, Berlin, 1824.-J. Siebold : De scirrho 
et carcinomate uteri adjectis tribus totius uteri exstirpationis observationibus, 
Berolini, 1826.-Hatin : M^moire sur un nouveau proc6d6 pour 1'amputation du 
col de la matrice dans les affections carcineuses, Paris, 1827.-Colombat : L'hys- 
t^rotomie ou 1'amputation du col de la matrice dans les affections canc^reuses 
suivant un nouveau procedA Paris, 1828.-Avenel: Sur le traitement des affec- 
tions canc6reuses du col de l'ut6rus. These, Paris, 1828.-Zeppenfeld: Diss, sistens 
casum carci nomatis uteri cum graviditate conjuncti, Berolini, 1828.-R6camier : 
Recherches sur le traitement du Cancer, Paris, 1829.-T6allier : Du cancer de la 
matrice, Paris, 1836.-Duparcque : Traits des maladies organique simple et can- 
cer. de 1'uterus, Paris, 1836.-M. Langenbeck : De totius uteri extirpatione, Diss. 
Gottingen, 1842.-Robert: Des affections granuleuses, ulc^reuses, carcinoma- 
teuses du col de l'ut6rus, Paris, 1848.-Breslau De totius uteri extirpatione, 
Dissert. Munchen, 1852.-Wagner : Der Gebarmutterkrebs, Leipzig, 1858.-Tan- 
ner : On cancer of the female sexual organs, London, 1863.-Blau : Einiges 
Pathol ogisch-Anatom isches tiber den Gebarmutterkrebs, Diss. Berlin, 1870.- 
Gusserow ; Ueber Carcinoma uteri, Volkmann's Sammi. Klin. Vortrage, 1871, 
No. 18.-Carrere : Quelques considerations sur le cancer uterin et son traitment, 
These, Paris, 1874.-Ruge and Veit: Zur Pathologic der Vaginalportion, Stutt- 
gart, 1878.-The Same: Der Krebs der Gebarmutter., Stuttgart, 1881.-Heitz- 
mann: Spiegelbilder der Vaginalportion, HL, Vienna, 1884.-Puchelt: De tu- 
moribus in pelvi partum impedient. Heidelberg, 1840.-Dietrich : Der Krebs des 
Geb&rmutterhalses als Complikation der Geburt., Diss. Breslau, 1868.-Chan- 
treuil : Du cancer de I'ut^rus au point de vue de la conception, etc., Paris, 1872.- 
Schafer : Zu Casuistik der Sectio Caesarea bei Carcinom der weiblichen Geburts- 
wege, Dissert. Breslau, 1876.-Ruttledge: Ueber die Complikation der Schwan- 
gerschaft und Geburt mit Gebarmutterkrebs, Dissert. Berlin, 1876. 
Anatomy. 
rpHERE is no task more difficult, at the present time, than that 
of defining the anatomical conception of " cancer/' from a purely 
medical point of view. While it seemed likely for a long time that 
histological investigations would furnish us with exact ideas as to the EPITHELIOMA AND CARCINOMA. 
359 
causes of the malignancy of certain tumors that have for centuries 
been called cancer, almost the contrary has resulted; for our anatomical 
comprehension of this most important group of affections has been greatly 
obscured, on the one hand, by the multiplicity of observations, and on 
the other by the dispute as to the starting-point of cancerous develop- 
ment. Although it is true that the epithelial character of cancerous 
neoplasms is almost universally acknowledged, by which remark I do not 
mean to assert that it has been decided whether it is the connective tissue 
or already existing epithelium of whatsoever variety that furnishes the 
matrix, yet the mystic formula of " atypic epithelial proliferation " no 
longer suffices to characterize carcinoma. As before, these neoplasms 
are still " malignant epitheliomata." It is not their morphological con- 
stitution, but their biological history, their clinical course, the study of 
their conduct while still a part of the living organism, and their relations 
to the latter, which are decisive. For ages back it has been known that 
tumors often develop in the uterus, especially in its vaginal portion; that 
these tumors make their appearance as a rule in later life; that they often 
break down resistlessly, invading the surrounding tissues, causing hemor- 
rhage and signs of gangrene, not infrequently giving rise to new deposits 
in distant organs unconnected with the original site of disease, and that 
finally they lead to the death of the individual, partly from the direct 
local effects of the disease and partly by its debilitating influence upon 
the whole organism (cachexia). These neoplasms constitute one of the 
most frequent sources of disease of the female genital tract and have 
always been termed cancer of the uterus. 
Now, while the above purely clinical definition may sound very old- 
fashioned, it still possesses the undeniable advantage of not overstepping 
the bounds of what we positively know. Although anatomico-histologi- 
cal research has been unable as yet to give us a satisfactory explanation 
of the malignancy of cancer, and has yielded scarcely any definite infor- 
mation regarding its etiology, yet we can by no means afford to neglect 
results gained in numerous painstaking investigations, if we desire to 
obtain any enlightenment as to the nature and course of this malady. 
We may divide cancer of the cervix uteri into two great classes, which 
we will designate by their old appellations of epithelioma and carcinoma. 
If we employ Kleb's1 classification, which, as far as my experience goes, 
conforms most closely with clinical observations, we may distinctly differ- 
entiate the flat epithelioma of the cervix, the cancerous ulcer, from the 
papillary variety. We have, besides these, the parenchymatous or infil- 
trated form of cancer of the uterus, which we might as well call carcinoma. 
Let us see how far this division corresponds with Billroth and Waldeyer's 
classification of epithelial and glandular carcinoma. In the first place 
1 Handbuch der patholog. Anatomie, vol. I., p. 867. 360 
NEW GROWTHS OF THE UTERUS. 
let me give Kleb's description of the above-mentioned varieties in the 
words of their author: The " flat epithelioma " of the cervix originates 
from the internal surface of the os uteri, strictly speaking from that part 
which is provided with transitional epithelium. The deeper epithelial 
strata of this region penetrate, according to Klebs, into the stroma of the 
mucous membrane and into the muscular tissue. The more the circu- 
lation is affected by the inward proliferation, the more rapidly do the 
epithelial masses on the surface break down, so that we not infrequently 
find a deeply excavated, crater-shaped ulcer extending up to, or even 
beyond,' the internal os at a time when there is as yet no trace of disease 
on the external surface of the vaginal portion. Every experienced 
gynecologist will remember having met with one or more instances of 
limited epitheliomatous ulceration of the external os, the portio vaginalis 
seeming to be in other respects healthy: these cases will have appeared to 
have offered a good opportunity for amputation through sound tissues, 
but close examination will have disclosed but too often that the cancerous 
destruction had already extended high up into the cervix and beyond the 
fornix of the vagina. The deeper the ulceration and the more extensive 
the invasion of the submucous tissues the greater is the attendant 
necrosis. In this way very large cavities are often formed-the destruc- 
tive process invading the bladder, the vagina, and the rectum. 
The papillary epithelioma begins, according to Klebs, on the vaginal 
aspect of the cervix, as a papillary hypertrophy. The proliferating 
epithelial investment of these new structures invades the subjacent 
tissues and then breaks down. New papillary excrescences develop on the 
base of the resulting ulcer, these in their turn necrose, and thus the pro- 
cess repeats itself until, finally, the most extensive destruction ensues, 
although perhaps its progress is somewhat less rapid than in the preceding 
variety. 
Carcinoma proper begins in the deeper tissues of the uterus, and 
consists of more or less firm, nodulated deposits, covered by healthy 
mucous membrane, which, spreading towards the surface only after a time 
and by no means invariably, become gangrenous and break down, form- 
ing cancerous ulcers which produce rapid necrotic disintegration of the 
tissues. It was formerly believed that this form of cancer originated in 
the connective-tissue framework of the uterine substance, but such opin- 
ion is not accepted by modern investigators, who hold that this variety 
also commences in the mucous membrane. Klebs, for instance, is inclined 
to locate the starting-point of the disease in constricted cervical glands. 
He assumes that the ovula nabothi in the region of the internal os are to a 
certain degree disposed to undergo cancerous metamorphosis, and explains 
in this way how this form of carcinoma of the uterus tends to extend 
upwards into the body and fundus of the organ, as well as downward into 
the cervix. In either case spheroidal tumors develop, which project 361 
EPITHELIOMA AND CARCINOMA. 
beyond the surface, or are distributed as isolated nodules in the muscular 
strata of the uterus and also as large nodes in the pelvic connective 
tissue. The individual masses are usually soft and succulent, and consist 
of irregularly shaped epithelial cells, often imbedded in a scanty interstitial 
tissue. Almost all authors recognize two forms of carcinoma of the 
uterus. Forster describes a papillary and a parenchymatous epithelial 
cancer. Waldeyer1 recognizes only epithelioma of the uterus. He has 
observed but one case of cancer develop from the glands of the cervical 
canal, and he believes that these cases are very rare. According to 
Waldeyer epitheliomata of the cervix originate from intra-papillary inward 
prolongations of the rete Malpighi of the lips of the os. If the papillse 
of the mucous membrane participate to any great extent in the process, 
a papillo-villous growth results; otherwise the affection consists either of 
a circumscribed or a diffuse infiltration, occasioned by an ingrowth of 
the deeper layers of the epithelium into the connective-tissue substratum. 
These views are on the whole nothing more nor less than the applica- 
tion of the current hypotheses of carcinoma in general to carcinoma of 
the uterus. The researches of Ruge and Veit have led these investi- 
gators to entirely different results, and have been widely accepted, especi- 
ally since they allow a readier comprehension of the clinical history of 
the various forms of cancer. Even the treatment of cancer has been 
influenced by the results of their anatomical researches. Nevertheless 
we need further studies before we can decide upon the true value of their 
investigations. These authors, then, as well as Schroder, distinguish 
positively between cancer of the portio vaginalis and cancer of the cervix 
proper. They claim that cancer of the " vaginal portion " never orig- 
inates in the pavement epithelium of the surface, but starts from the 
deeper connective tissue, or from the newly-formed glands found in 
erosions. Its boundary line would appear to be the external os, and it 
does not invade the cervix or body of the uterus. When it extends, the 
vagina and peri-uterine tissues become affected. 
Cancer of the cervix, on the other hand, starts from the connective 
tissue of the walls of the cervix, from submucous nodules, or from the 
glands of the mucous membrane. The disease does not extend outward 
beyond the external os, but very readily passes beyond the internal os, 
and thus reaches the pelvic cellular tissue. 
The simplicity of this description certainly has much in its favor, but 
we must not forget that daily practical experience shows that the above 
distinctions are not very easily ascertained. So that while these views 
may be welcomed as an attempt to elucidate a confused subject, they are 
not to be received as having finally settled it. 
It has recently been demonstrated that carcinoma may develop from 
1 Spiegelberg, Archiv f. Gynakol., IL, 233. 362 
NEW GROWTHS OF THE UTERUS. 
adenomata, that is from neoplastic utricular glands. Testimony to this 
fact is offered by cases reported by Breisky-Eppinger, J. Veit, and others. 
Heitzmann (1. c.) in many respects follows the teachings of Ruge and 
Veit. He describes, in addition, a variety of cancer resembling epithe- 
lioma of the skin, and corresponding to the " rodent ulcer" of older 
observers. 
Apart from these observations, next to nothing has been written con- 
cerning the initial stages of carcinoma of the uterus Liebman1 is of the 
opinion that epithelioma of the vaginal portion develops oftener than has 
heretofore been imagined from papillary excrescences of the mucous mem- 
brane of the cervix above the external os, and that it is therefore hidden 
from direct observation for a long time. He reports three cases of this 
description. Kiwisch, Wagner and others describe a similar condition. 
Virchow 3 in particular reports a case in which the cervical canal was in a 
Fig. 42.-Cauliflower Excrescence of the Portio Vaginalis. (After C. Mayer.) 
state of cancerous degeneration as far up as the internal os, while the 
external os was perfectly healthy. Starting from this point the cancer- 
ous infiltration had invaded not only the cellular tissue between the blad- 
der and the vagina, but had also involved the lymphatic glands and the 
vessels of the uterine adnexa, and had given rise to metastatic deposit in 
the kidneys, the su^ra-renal capsules, and the cutis. Schroder3 mentions 
a similar case. 
Hegar4 describes a case in which the vaginal portion had undergone 
cancerous degeneration, but which at the first glance seemed to differ in 
no respect from one affected by simple benignant hypertrophy. Micro- 
scopical examination disclosed marked hypertrophy of the connective 
tissue, with an abundant cellular proliferation, in the meshes of which 
1 Clinical notes on the early Course of Cancer of the Cervix Uteri. Transact, 
of the Obstet. Society, London, XVII., p. 66, and Cenni clinici intorno al primi 
stadii del cancro del collo uterino. 
2 Monatsschrift f. Gerburtskunde, X., p. 4. 
3 Handbuch der Krankheiten der weiblichen Sexualorgane, 1st ed., p. 270. 
4 Virchow's Archiv, vol. LV., p. 245. EPITHELIOMA AND CARCINOMA. 
363 
were scattered collections of epithelial cells having no alveolar boundaries. 
No papillary excrescences could be detected in the mucous membrane of 
the cervix, nor was there any evidence of the origin of the neoplasm 
from the glandular tissue. 
Although the title of this chapter would imply that in the con- 
sideration of cancer of the womb we have first to treat of the de- 
velopment of the disease in the cervix, we have nevertheless already 
identified carcinoma of the uterus with that of the vaginal portion. 
This is justified by the fact that the disease in the great majority of 
cases is confined to the cervix. Pichot1 believes that an isolated affec- 
tion of the fundus occurs only six times in one hundred cases of 
carcinoma of the uterus. Blau2 found about the same ratio-that is, six 
instances of isolated affection of the corpus uteri among ninety-three cases 
of cancer of the uterus. Courty,3 indeed^ found but one case of this kind 
among four hundred and twenty-nine cases of carcinoma of the uterus. 
The statistics of Forster4 yield almost the same result; of four hundred 
and twenty cases of cancer of the womb, observed in Vienna, but one of 
carcinoma of the fundus. 
Goldschmidt5 observed only one instance among 900 cases of malignant 
degeneration. 
These figures will suffice to show the rarity of isolated, primary cancer 
of the fundus uteri. Now although it is true, as will be shown later, 
that recent investigations have demonstrated a somewhat greater frequency 
of these cases, still it must not be forgotten that quite a number of these 
tumor formations belong to the group of sarcomata, while others have 
been merely instances of extension of the disease from other organs to 
the fundus uteri, and therefore have no bearing on this point. 
Of the various forms of cancerous disease of the cervix which we indi- 
cated above, both the flat ulceration and the papilllary cancerous ulcer 
should be grouped together under the common name of epithelioma, 
while the term carcinoma may be restricted to that variety which is 
located in the deeper tissues of the portio vaginalis, beneath the unaffected 
mucous membrane. This distinction is not without importance from a 
symptomatical and therapeutical aspect, but it cannot be strictly main- 
tained, since both forms become similar as soon as necrotic disintegration 
has set in. Moreover, they are undoubtedly met with in combination, or, 
to speak more correctly, one may become converted into the other. Thus 
after removal of an epithelioma in the portio vaginalis, one not infre- 
quently finds fresh cancerous nodules developing higher up in the uterus, 
1 Etude clinique sur le Cancer du corps, etc., de l'ut6rus, Paris, 1876. 
2 Einiges Pathologisch-Anatomiches tiber den Gebarmutterkrebs, Berlin, 1870. 
3 Maladies de l'ut6rus, p. 1012. 
4 Scanzoni, Beitrage, IV., p. 30. 
5 Beitrage, etc., der Berliner geburtshiilfl. Gesellschaft, III., p. 120. 364 
NEW GROWTHS OF THE UTERUS. 
although there is no recurrence of the epithelioma in loco. For these 
reasons it is also exceedingly difficult to determine, with any degree of 
accuracy, the frequency with which epithelioma and carcinoma of the 
portio vaginalis occur. In this connection I will mention only the results 
which I have tabulated in a previously published article,1 according to 
Fig. 43.-Epithelioma involving the Mucovs Membrane of the Cervix Uteri. (From the 
Collection of the Pathological Institute at Strasburg.) 
which, among 203 cases in which an anatomical diagnosis was possible, 
there were but 17 in which carcinoma alone, without papillary excres- 
cences, was observed. 
Even when we adopt the newer classification, as given above, the same 
difficulties present themselves. Thus Ilofmeier2 has collected 812 cases 
1 Volkmann's Klinische Vortrage, No. 18. 
2 Zur Statistik des Gebarmutterkrebses und seine operative Behandlung, 
Zeitschr. f. Geb. u. Gynakol., vol. X., 1884. EPITHELIOMA AND CARCINOMA. 
365 
of cancer of the uterus observed at Schroder's clinic. Of this number 
236 cases involved the portio vaginalis, 181 the cervix, and 28 the body 
of the uterus. 367 cases could not be classified. 
Fig. 44.-Cancer of the Cervix Uteri and Vagina, with Extension to Douglas's Pouch. 
(Specimen of Dr. Wyder.) 
This corresponds with what nas been recognized from time immemorial 
by all close observers, namely, that cancer of the uterus in the great 
majority of cases, not only commences as a localized affection of the cervix, 
but also retains its local character up to the very end; the rarity with 366 
NEW GROWTHS OF THE UTERUS. 
which epithelioma, in any part of the body, becomes generalized, has long 
since been recognized. Instances of epithelioma of the portio vaginalis, 
with disseminated deposits in distant organs, so-called metastases, un- 
doubtedly occur, but they are exceedingly rare. Those cases of cancer of 
the uterus which have been found associated with metastases elsewhere, 
were in all probability cases of carcinoma of the body of the uterus, in 
the above-defined sense of the term. Both forms of cancer extend by 
simple continuity to the neighboring tissues and organs. Beginning at 
the portio vaginalis, the affection very soon passes the internal os and 
attacks the body of the uterus. (In 93 cases Blau, 1. c., found that in 
87 the disease unquestionably began in the cervix uteri, being confined to 
Fig. 45.-Cancer of the Portio Vaginalis of the Cervix. Stenosis of Cervical Canal. Hydro- 
metra. (Specimen of Dr. Wyder.) 
this situation in 48, and extending beyond the internal os in 31 cases.) 
While then in epithelioma the invasion of the neighboring organs occurs 
in the guise of an ulcerative process, in carcinoma the affection advances 
as a more or less continuous series of deposits in the pelvic connective 
tissue, transforming this rapidly into a firm, rigid and nodulated mass. 
Epitheliomatous ulceration and cancerous infiltration almost always ex- 
tend to the vagina, whenever the destruction of the vaginal portion has 
progressed to any considerable extent. Wagner (1. c.), whose observations 
were based almost exclusively on post-mortem examinations, found that 
this was almost invariably the case. Blau (1. c.) states that this occur- 
rence was noted in 75 out of 93 cases recorded in the journal of the Pa- 
thological Institute of Berlin. 
Infiltration of the peri-uterine cellular tissue within the pelvis leads to EPITHELIOMA AND CARCIXOMA. 
367 
cancerous involvement of the pelvic lymphatic glands (in 30 out of 93, 
according to Blau) and of the ureters. Epitheliomatous destruction in 
particular very often attacks the bladder. Thus, in a total of 218 cases, 
^Vagner observed cancel- of the bladder in 83 instances, that is in 38 per 
cent.; in 28 of these fistulae were present. Blau met with cancer of the 
bladder in 45 out of his 93 patients. Similar figures hold good as regards 
the extension of the disease to the rectum. This complication was ob- 
served by Blau and Wagner in fifty-three out of two hundred and eighty- 
two cases, fistula) having been produced in twenty-four cases. 
Fig. 46.-Epithelioma of the Portio Vaginalis of the Cervix, with destruction of the pos 
terior Fornix Vagina. (From the Collection of the Pathological Institute at Strasburg.) 
The affection also generally spreads directly to the ovaries; this was 
noted forty-nine times in the above total of two hundred and eighty-three 
cases. In Blau's ninety-three cases the lumbar glands were involved in 
twenty-four, the soft tissues of the pelvis in twenty-three, and the retro- 
peritoneal lymphatic glands in fifteen cases. • 
Direct extension of cancer to the peritoneum is decidedly more rare, 
probably because the growth becomes encapsulated and separated from 
the peritoneal cavity by newly formed connective-tissue, usually at a very 
early date. This complication was observed in only eighteen out of 264 368 
NEW GROWTHS OF THE UTERUS. 
cases. It is still more rare to find cancer of the uterus extending directly 
to the pelvic muscles and bones, or to the urethra and external genitals. 
The following figures will serve to convey an idea of the frequency with 
■which metastases occur. In 283 cases of cancer of the uterus, metastatic 
deposits were found 22 times in the liver and as often in the lungs. In 
166 cases collected by Kiwisch (73) and Blau (93) secondary deposits were 
found six times each in the bones and pleura; five times each in the in- 
guinal glands, stomach, bronchial glands and kidneys; three times each in 
the thyroid gland, mediastinal lymphatic glands and heart; twice each in 
the brain, supra-renal capsules, mesenteric glands, jejunum, lumbar verte- 
brae and cutis; once each in the gall-bladder, dura mater, external genital 
organs, muscular system and mamma. 
When we consider the extraordinary frequency of primary carcinoma 
of the uterus, it is very striking how seldom metastases occur in the uterus, 
in general carcinosis, originating in other organs. Wagner found only 
five cases of the kind. Klebs substantiates the same fact, adding that 
when the uterus is secondarily affected the disease is usually situated in 
the peritoneal investment of the organ, very rarely in the mucous mem- 
brane. 
In cancer of the different organs of the pelvis the disease more often 
spreads by continuity to the uterus, a point to which we will again refer 
in discussing carcinoma of the fundus uteri. 
Etiology. 
Before discussing the causes of the local disposition of the uterus to 
cancerous disease, it is necessary to determine the frequency of cancer in 
general. Statistics show that carcinoma of the uterus is an exceedingly 
common affection, particularly in Europe.1 
According to the thirty-second annual report of the registrar-general 
of England (Tanner, 1. c.), the population of that country in 1860 was 
estimated at 19,902,918; the.mortality in the same year was 422,721, 
i.e., 215,238 men and 207,433 women. Of these deaths 6827 were put down 
as due to " cancer," 2100 occurring in males and 4727 in females, the 
latter sex, therefore, showing a preponderance of 2627. Another table 
issued by Hirsch2 yields similar results. Thus in the year 1855 the 
population of England was 18,787,000, 9,427,000 being males, and 
9,360,000 females. Of this number 6016 died of cancer, 1825 being men 
1 Histor. geograph. Pathol., II., p. 378. 
2 According to numerous statements, cancer of the uterus as well as of other 
organs is a much less common disease in Asia, Africa and North America than it 
is in Europe. Comp. Picot: Les grands processus morbides, Paris, 1878, II., p. 
1187. EPITHELIOMA AND CARCINOMA. 
369 
and 4191 women, an excess of 2366 in favor of the latter. The mortality 
resulting from cancerous disease was 0.32 in 1000 people, 0.19 in 1000 
males and 0.44 in 1000 females. On comparing still larger statistics it 
will be found that twice as many women as men die of cancer. Accord- 
ing to the registrar-general1 87,348 people died of cancer in England, 
between the years 1847 and 1861; of these 61,715 were women, 25,633 
men. The intimate connection between the above great preponderance 
of mortality in the female sex, and cancer of the genital apparatus 
(including malignant affections of the mamma), is shown by the fact that 
cancer befalls boys and girls in about the same ratio up to the age of fif- 
teen, while from this time on, that is coincidently with the commence- 
ment of puberty, the percentage augments very rapidly to the detriment 
of the female sex. This is more clearly demonstrated by the following 
table of 91,058 deaths from cancer (England and Scotland) which I have 
copied from Simpson (1. c.) 
Males. 
Females. 
Under 10 
years, .... 
617 
626 
10 to 15 
a 
134 
147 
15 25 
it 
562 
659 
25 " 35 
a 
1244 
3176 
35 " 45 
It 
2717 
9975 
45 " 55 
Ct 
4973 
16,668 
55 " 65 
6 c 
7220 
15,813 
65 11 75 
cc 
6286 
11,840 
75 " 85 
c c 
2637 
4616 
85 " 95 
tt 
364 
689 
Over 95 
cc 
20 
39 
This disproportion is rendered still more conspicuous by the frequency 
of carcinomatous disease of the uterus and mamma, if we examine more 
closely the statistics relating to the development of malignant tumors of 
the various organs in both sexes. 
Schroder gives a compilation according to which, of 19,666 women who 
died of cancer, 6548 succumbed to carcinoma of the uterus. The statis- 
tics tabulated by M. d'Espine and Virchow,2 show the relative fre- 
quency of cancer in various organs still more precisely. In these cancer 
of the uterus ranks second, constituting 15 per cent., while cancer of the 
stomach constitute 45 per cent, of all cases of the disease. Virchow sets 
the percentage of cancer of the stomach at 34.9, and that of cancer of the 
uterus at 18.5. The tables arranged by Picot (1. c., p. 1183) yield sub- 
stantially the same figures, as follows: 
1 Simpson, Clinical Lectures on the Diseases of Women, Edinb. 1872, p. 140. 
2 Lehrbuch der Frauenkrankheiten, p. 257. 370 
NEW GROWTHS OF THE UTERUS. 
Parisian Hospitals. 
Middlesex Hospital. 
Women. 
Men. 
Women. 
Men. 
Genital organs 
765 
20 
171 
12 
Mammary glands 
242 
1 
191 
1 
Stomach 
262 
379 
3 
6 
Liver 
91 
100 
2 
- 
Intestine 
26 
29 
2 
3 
Rectum 
19 
18 
7 
4 
Lungs 
5 
Pancreas 
3 
3 
- 
- 
Urinary bladder 
2 
2 
-- 
- 
(Esophagus 
- 
2 
- 
2 
1412 
559 
376 
30 
That is, of every 100 cases of cancer observed in the hospitals of Paris, 
51 were located in the uterus and mamma. The statistical examinations 
of Sibley and others show the same relation. The absolute frequency of 
cancer of the uterus is most strikingly demonstrated by the tables com- 
piled by E. Wagner from the records of 5122 post-mortem examinations 
in Vienna, Prague and Leipsic. Cancer was the cause of death in 441 
cases, the uterus being thereat of the disease in 113 instances. That is, 
of the total mortality 8.6 per cent, was due to cancer in general, and 2.2 
per cent* to cancer of the uterus. 
The explanation of this great prevalence of cancer is, however, very 
unsatisfactory. Before entering into the etiology of carcinoma of the 
uterus, it will be advisable to first refer to two factors which are always 
alluded to in the etiology of cancerous diseases in general. These are 
age and heredity. As regards the former, it may be stated that all in- 
vestigators agree in the assertion that cancer is essentially a disease of 
mature years. Thus, out of a total of 3385 cases of carcinoma uteri col- 
lected by Lever, Kiwisch, Chiari, Scanzoni, Saxinger (Seyfert's clinic). 
Tanner, Hough, Blau, Dittrich, Lothar Meyer, Lebert, Glatter, Beigel, 
Schroder, Schatz, Winckel, Champneys and myself, we find 
At 17 years, ..... 1 case (Glatter.) 
" 19 " . . . . . 1 " (Beigel.) 
Between 20 to 30 years, . . .114 cases. 
" 30 " 40 " . . . 770 " 
" 40 " 50 " . . . 1169 " 
" 50 " 60 " . . . 856 " 
" 60 " 70 " . . . 340 " 
Over 70 years .... 193 " 
That is, with but two exceptions, cancer of the uterus scarcely ever 
occurs before the twentieth year of age, at any rate not before puberty, 
and not even in the first few years after this period. Between the ages EPITHELIOMA AND CARCINOMA. 
371 
of thirty and fifty the frequency of the affection increases with great 
rapidity, subsides slowly between fifty and sixty, and decreases quickly 
after this age. One might from this conclude that the period of mature 
sexual development is most disposed to the occurrence of cancerous dis- 
ease of the uterus, but a closer inspection of the above table shows, on the 
contrary, that the greatest susceptibility exists between the ages of forty 
and fifty, and almost as great a one between fifty and sixty, that is, just 
in the climacteric years. This last conclusion is substantiated by the 
statistical investigations of Glatter,1 who found that the proportion of 
living women rapidly diminished with each successive year after forty- 
five years of age. For example, of every 1000 females living in Vienna 
in the year 1864, 193 were between forty-one and fifty years of age, 122 
between fifty and sixty, while there were 336 between twenty-one and 
thirty, and 249 between thirty and forty years of age. The mortality 
from cancer of the uterus was, according to the same authority, of all 
deaths occurring in females: 
Between 21 to 30 years, ..... 1.15^ 
" 31 " 40 " 5.09^ 
" 41 " 50 " 11.35^ 
" 51 " 60 " 9.05^ 
" 61 " 70 " 4.04^ 
It will now be our province to investigate whether it is to age solely that 
the predisposition to cancer is to be attributed, and this may seem at the 
first glance to be a valid conclusion when it is remembered that the same 
prevalence is observed in the male sex between the ages of forty and sixty 
(compare Picot, 1. c., p. 1184), or whether it is the menopause which 
exercises this influence. Not wishing to enter more fully just now into 
the etiology of carcinomatous disease in general, I will only point out 
that the influence of advanced age in general has been explained on the 
hypothesis of a diminished power of resistance of the various tissues. 
Now, while it will have been recognized from the above remarks that 
age undoubtedly plays an important role in the etiology of carcinoma 
uteri, it will be shown that the second factor, namely heredity, does not 
possess an importance to the extent that has been assigned to it. Al- 
though authentic observations are not wanting to show the influence ex- 
erted by a hereditary taint upon the development of cancer of various 
organs, yet the number of such observations, as far as concerns carcinoma 
of the uterus, is by no means so large as has been generally supposed. 
Whether this depends upon the nature of epithelioma of the uterus, that 
is, its more localized development and corresponding course, or whether 
it is due to imperfect observation, must remain undecided. At all events 
1 Einige Bemerkungen uber Medicinalstatistik u. s. w. Deutsche Vierteljahrs- 
schrift filr offentliche Gesundheitspflege von Reclam, 1870, p. 161. 372 
NEW GROWTHS OF THE UTERUS. 
it is certain that most investigations have been very deficient in this 
direction, on the one hand because the necessary researches have not been 
sufficiently painstaking, and on the other hand because these investiga- 
tions, even when conducted on a large scale, as is possible in hospitals, so 
often yield only meagre results from the ignorance of the ordinary hos- 
pital patients regarding the medical histories of their parents and relatives. 
We can only expect to derive information on this point from the records 
of private practice, among the more cultivated and intelligent classes. 
Out of 1203 cases of- this description (published by Tanner, Lever, 
Lebert, Scanzoni, L. Meyer, Sibley, Barker, Winckel and myself) there 
were but 90 or 7.8 per cent, in which it was stated that cancer had oc- 
curred among the more immediate relatives of the patients. Picot found 
an inherited predisposition in 13 per cent, of 978 cases of carcinoma of 
various organs collected by himself. According to these figures, heredi- 
tary taint would seem to possess less significance in the etiology of uterine 
cancer than in the same disease affecting other organs of the body. 
Other factors, to which etiological importance has sometimes been 
attached, such as the constitution, the temperament, the occupation, 
etc., of the individual, deserve only passing mention here, as neither my 
own experience nor the literature of the subject furnishes anything more 
than mere conjecture in this regard. The same is true of the etiological 
significance of previously existing disease. E. Martin's1 assertion that 
infectious diseases of the genital organs transmitted by intercourse from 
husband to wife excite a predisposition to the development of epithelioma 
of the uterus, must be regarded, for the present, as entirely without foun- 
dation, not even an attempt having been made to substantiate it by facts. 
Diverse local affections of the cervix uteri seem to be of greater signifi- 
cance as predisposing agents to cancerous degeneration. Persistent 
catarrh of the cervical mucous membrane, with the formation of erosions, 
has long been regarded as a precursor of malignant disease. Many have 
called attention to the fact that there is but a short step, anatomically 
speaking, between a papillary erosion and a true papilloma on the one 
hand, and between a papilloma aud an epithelioma on the other. In 
fact the latter transformation has been shown to have taken place. 
More recently Huge and Veit have shown that a causal relation exists 
between certain types of so-called erosions and ectropionic changes of the 
os uteri, and a neoplastic development of gland tissue, and they have also 
pointed out that these conditions were to be regarded as the forerunners 
of epithelioma. 
Breisky2 has also published some observations tending to show 
1 Zur ^Etiologie und Therapie des Gebarmutterkrebses, Berl, Klin. Wochen- 
schrift, 1873, No. 28. 
2 Ueber Beziehung des Narbenectropium am Muttermund zum Carcinoma 
uteri, Prager Med. Wochenschrift, 1877, No. 28. EPITHELIOMA AND CARCINOMA. 
373 
that eversion of the mucous membrane of the cervix uteri, after lacer- 
ation of the os (cicatricial ectropium of Emmet), may, in consequence 
of the long-continued irritation to which it is necessarily subjected, be- 
come the starting-point of a cancerous growth. Now while this and 
similar observations are most valuable, from a therapeutic aspect, they 
throw but an obscure light upon the etiology of these processes. 
It remains to investigate what connection there is, if any, between tne 
ordinary functions of the uterus and cancerous metamorphosis. In indi- 
viduals affected with cancer of the womb, the derangements of menstrua- 
tion that may have been present in previous years have usually been of 
so trifling a nature that they cannot be said to stand in any causal relation 
to the existing affection. The statements that have been advanced upon 
this subject, are so contradictory, and are based upon so small a number 
of cases, that they do not deserve especial mention.1 
It has previously been pointed out that there seems to be a peculiar 
predisposition to the development of cancer in the climacteric period. 
Additional weight is lent to this observation by the statements of Rocque,3 
who among fifty cases found but eight in which the affection manifested 
itself before the advent of the menopause. 
The current opinion that local mechanical or chemical irritation (trau- 
matism) is the chief exciting cause of the development of local tumors, 
has also been strenuously advocated in explanation of the occurrence of 
cancerous degeneration of the cervix uteri. Particular stress has been 
laid upon tw'o points, on the one hand the frequency, or according to 
others (Teallier and Scanzoni) the intensity with which sexual intercourse 
has been practised, together with the emotional excitement accompanying 
this act, and on the other hand the number of confinements. Without 
wishing to closely scrutinize here the value of the so-called "irritation 
theory," it may suffice to state with reference to the above-mentioned 
causes, that as far as the first is concerned, the local irritation of the os 
uteri during intercourse is not a very intense one, and with reference to 
the second, that the severer forms of injury caused by the parturient act, 
occur relatively but very seldom, and even then are separated by long in- 
tervals. 
Furthermore, when it is asserted that excessive emotional excitement is 
causally connected with the presence of malignant disease of the uterus, 
it is rather more probable that the former is but a symptom of the early 
stage of the latter. It is well known that pruritus of the external geni- 
tals is not infrequently dependent upon carcinoma of the uterus. If the 
opinions entertained by Wernich and others wrere correct, namely, that 
the portio vaginalis undergoes peculiar changes of configuration, a kind 
1 L. Meyer : Beitrage zur Geburtshiilfe u. s. w. Berlin, 1874, III., p. 7. 
2 Picot : Les grands processus morbides, II., p. 1186. 374 
NEW GROWTHS OF THE UTERUS. 
of erection witn increased downward protrusion into the vagina, in indi- 
viduals who possess hyper-sensitive sexual organizations, we could not 
deny that excessive sexual excitement is capable of inducing anatomical 
changes, and yet this would not in any manner serve to explain the im- 
portance of this influence upon the malady now under consideration. 
In estimating the significance of sexual intercourse, nothing of moment, 
for evident reasons, is to be gained by determining whether cancer of the 
cervix occurs more frequently among the married than among the un- 
married. It has, therefore, been proposed to ascertain whether the affec- 
tion is especially frequent in prostitutes. As far as my knowledge goes, 
the attempt has not been made, and I doubt whether it can ever be car- 
ried out with the required precision. For the malady, as we have already 
seen, usually manifests itself at an age when prostitutes have already long 
withdrawn themselves from official supervision. Parent Duchatelet1 states 
that he has observed carcinoma of the uterus in prostitutes much more 
rarely than he had expected; this statement is corroborated by Teallier, 
Collineau, Cullivier and Behrendt. Of 365 females who died in Vienna 
of cancer of the womb, Glatter (1. c.) found that 91, or almost 25 per 
cent, were classed as seamstresses (Handarbeiterinnen), and as it is cus- 
tomary for the majority of the Viennese prostitutes to designate themselves 
by this term, he concludes that this class of women furnish a relatively 
large contingent of cases of uterine cancer. 
The relations existing between cancerous disease and frequent confine- 
ments are more easily determined. In the first place it is remarkable that 
the disease rarely attacks sterile women. Thus but 121 out of 1540 cases 
collected by Tanner, West, Scanzoni, Seyfert, Beigel, Schroder, Winckel 
and myself had not had any offspring. 
It is more difficult to decide what influence the number of births exerts 
upon the development of carcinoma, since precise and accurate statements 
as to the number of premature births can but rarely be obtained, and yet 
these are of just as much consequence as full term deliveries, if one in- 
clines to the opinion that the processes of pregnancy and the expulsion of 
the ovum are factors of moment in the production of cancer of the 
uterus. 
West computes that every patient affected with this malady has had on 
an average 5.6 deliveries at full term, and 1.2 premature births, or a total 
of 6.8 births in all. Scanzoni's estimate is 7.01, Tanner's 6.5, Sibley's 
5.2, Lebeck's 3.9, Beigel's 5.9, Lever's 5.75, Lothar Meyer's 5.5, Winc- 
kel's 5.6, Schroder's 5.02, and my own 4.5. It has been found that in 
Prussia every married woman has on an average 4.6 children, in England 
4.2, and in France 3.4. Assuming the correctness of these figures it is 
undeniable that those women who become at some future date the sub- 
1 De la prostitution dans la ville de Paris, Paris, 1836, pp. 253-257. Cited by 
Lothar Meyer. EPITHELIOMA AND CARCINOMA. 
375 
jects of carcinoma, are more fruitful than other women. We arrive at 
the same conclusion when we compare statistics on a larger scale than 
those given singly by the above-mentioned authors. Thus, the grand 
total of children brought into the world by 580 patients (of West, Tan- 
ner, Scanzoni, Lever, Beigel, Lothar Meyer, and myself) was 3025, an 
average of 5.1 children to each woman, which certainly exceeds that of 
the average married women as estimated above. 
Winckel1 has more particularly laid stress on the difference existing in 
this respect between primiparous and multiparous women. 
In 130 cases of cancer he found 
13 I-paraa or 10 
53 II to V-parse or ..... . 40.8^ 
64 VI to XXVI-parae or 49.2^ 
Nevertheless it is an open question whether these facts stand in any 
causal relation with the development of cancer in the cervix uteri. As- 
suming the existence of such relation, we may safely leave it to the scien- 
tific convictions of each individual to decide whether he will accept it as 
evidence of the truth of the theory, concerning the origin of cancer from 
local irritation, or of the more recent doctrine of the development of ma- 
lignant disease from pre-existing, embryonal disease germs. For my own 
part I do not see that the assertion of the greater fertility of cancerous 
individuals lends weight to either theory. 
Many investigators believe that the disease not infrequently developes 
immediately after delivery. West observed this in 11.3 per cent, of his 
cases. Of 48 cases of cancer recently seen by me there were 9 in which the 
first symptoms of the malady were observed within one year after the last 
childbirth, the interval varying from a few weeks to eleven months, and two 
in which exactly one year had elapsed. H. Chiari2 describes these cases 
of cancer of the fundus uteri, in which the disease developed immediately 
following the lying-in period, and ended fatally in from three to six 
months. The patients were between twenty-three and twenty-four years 
of age. The cancers had originated at the placental site. 
W. A. Freund3 has described several cases of the propagation of can- 
cerous growths, from the rectum or bladder to the uterus, through the 
pelvic cellular tissues. 
Now since it is well established that secondary cancer of the womb is 
very rare, and since, in the cases of such an occurrence cited by Freund, 
the idea of local irritation from sexual intercourse or parturition, was with 
tolerable certainly excluded (the majority of them being virgins), the 
author sees therein an indirect proof that primary cancer of the portio 
vaginalis uteri usually does arise from local irritation. 
1 Pathol, der Weibl. Sexualorgane, p. 165. 
2 Wien. Med. Jahrbuch., 1877. 3 Virchow's Archiv., vol. LXIV., p. 1. 376 
NEW GROWTHS OF THE UTERUS. 
As long as cancer of the uterus is restricted to the portio vaginalis, and 
as long as disintegration has not occurred to the extent of causing ulcera- 
tion, so long may all symptoms of the disease remain totally in abeyance. 
This dictum is a necessary preliminary to a thorough comprehension of 
t'.ie course of cancer of the uterus in each and every instance. Perhaps one 
or more of those symptoms, the description of which will shortly follow, 
may have been present for but a few weeks or months, while the general 
condition of the affected individual may be excellent, and yet when we 
proceed to make an examination, we are often astonished to find wide- 
spread cancerous destruction of the cervix and fornix vagina?. This ex- 
plains how it is that the malady runs so rapid a course, once subjective 
symptoms have declared themselves, and also shows why an affection, so 
pre-eminently local as cancer of the cervix is, should so seldom beamena- 
ble to local treatment. 
Cancerous degeneration gives rise to no symptoms until ulceration has 
set in-none of the previously described forms and varieties of cancer of 
the cervix are exceptions to this rule. At most it may now and then 
happen that the deeply seated form, that which we have agreed to call 
carcinoma, may spread to the pelvic connective tissue and form nodular 
masses in Douglas's cul-de-sac, which may excite pain from pressure 
some time before the primary infiltration disintegrates. But this is not 
the rule. 
On the w..ole it may be asserted that all or at least the chief symptoms 
of cancer of the uterus are coincidental in their appearance with ulcera- 
tion in the vaginal portion. Before the development of these ulcers even 
obscure symptoms will but rarely have been present. The clinical 
features usually vary distinctly with the anatomical characters of the 
ulcers, as previously described. Thus, the symptoms accompanying the 
" flat epithelioma" (Klebs) are rather those of a simple ulceration of the 
vaginal portion, penetrating more deeply than is ordinarily the case; they 
consist in a moderately profuse, sero-purulent, inodorous discharge, pro- 
fuse menstruation, and, exceptionally, irregular hemorrhages. 
When we have to do with a papillary epithelioma, however, or with the 
more deeply seated carcinoma, ulceration occurs only in consequence of 
superficial gangrene and decomposition, and the symptoms are therefore 
of a corresponding nature, irregular hemorrhages, and the discharge of 
fetid, purulent and sphacelous masses. 
It will be seen from the foregoing that the most constant indication of 
a disintegrating cancerous mass is hemorrhage. This is usually also the 
first symptom, being preceded by a somewhat profuse discharge, or by pain 
in exceptional instances only. It was the first symptom in about fifty out of 
every sixty cases of far-advanced cancerous ulceration observed by myself. 
Symptomatology and Course. EPITHELIOMA AND CARCINOMA. 
377 
This preponderance, of course, may be explained on the assumption, that 
a bloody discharge is far more likely to attract the attention of the patient 
and to be fixed in her memory than would other more obscure and 
indefinite symptoms. 
The nature of the hemorrhage varies. In women who still menstruate 
the first thing that is generally noticed is a more or less profuse flooding 
at each menstrual epoch, which the patients as a rule attribute to impend- 
ing change of life. It soon becomes evident, however, that the menstrual 
flow has lost its normally intermittent character and a more or less con- 
tinuous discharge is established of a sanguineous fluid, which the patients 
liken to the juice of raw meat. In other cases severe hemorrhages often 
recur at irregular intervals, and this is usually the first symptom which 
attracts attention in women who have passed the menopause; it is then apt 
to be regarded merely as the reappearance of the menses. 
While the destructive metamorphosis of cancerous masses, then, is gen- 
erally ushered in and accompanied by free hemorrhage, there are not a 
few cases, especially flat epitheliomata, where there is only a constant 
discharge of fluid of a reddish tinge, now and then containing a few 
streaks of blood. In these cases genuine hemorrhage scarcely ever or 
very rarely occurs. In other cases, particularly in the incipient stages of 
papillary epithelioma, an insignificant hemorrhage takes place only after 
traumatism, most often at first after sexual intercourse, or as the result 
of physical over-exertion, violent straining at stool, and the like. The 
more rapidly the cancerous masses break down, with the correspondingly 
luxuriant reformation of the papillary excrescences, (these two processes 
go hand in hand, as is well known), the more frequently and profusely 
does hemorrhage recur, so that extreme anaemia is rapidly induced. 
Later on, the more extensive the area of sloughing and gangrene, the 
more rapid is the destruction of the cancerous infiltration, and therefore 
the sooner do the profuse hemorrhages cease, to give way to a sero- 
sanguinolent discharge. In this stage we see only now and then a rather 
free loss of blood, as when a large vessel is perforated. 
This is the reason why in so many instances hemorrhages cease entirely 
towards the close of the malady. It is nevertheless remarkable that one 
scarcely ever hears of a death from hemorrhage in these cases. 
Although, as we have just seen, hemorrhage is an occurrence seldom 
absent in cancerous ulceration, there is one symptom which is, if possible, 
still more constant, namely a discharge from the vagina. Like hemor- 
rhage this sometimes manifests itself before the neoplasm begins to break 
down, and it then either closely resembles an ordinary lencorrhoea or is 
more watery (in epithelioma). As soon, however, as a proliferating 
epithelioma gives rise to hemorrhage, the discharge generally approaches 
more to the nature of blood-serum, and becomes quite free, without hav- 
ing any particularly penetrating odor. 378 
NEW GROWTHS OF THE UTERUS. 
Flat ulcerating epitheliomata excite a somewhat similar, but more 
purulent and certainly less abundant sero-sanguinolent discharge. 
As soon, however, as gangrene attacks either of the various forms of 
cancer of the cervix, the discharge acquires a more or less pronounced 
and disgustingly fetid odor, and, while still possessing a very thin consist- 
ence, becomes of a dirty brown color in consequence of the admixture of 
fragments of sphacelated tissue. 
The two symptoms that have just been described comprise all that is 
characteristic of the cancerous ulcer. Although very few cases of cancer 
of the uterus run their course without occasioning pain, yet the latter is 
by no means an essential symptom, inseparable from the existence of the 
disease as such. On the contrary as long as a cancerous ulcer is restricted 
to the portio vaginalis it in most cases neither excites pain nor is it sensi- 
tive on manipulation. In those cases in which at an early period pain is 
complained of in the pelvis, abdomen, or back, there certainly exists some 
inflammatory irritation in the vicinity of the original focus of disease. 
The typical, violent pains that have been designated as cancer-pains 
chiefly depend on the other' hand on an extensive implication of the sur- 
rounding tissues in the morbid process. Thus when cancerous infiltra- 
tion spreads to the body of the uterus, pain results probably from lesions 
of the terminal nerve filaments in the substance of the uterus. In the 
same way, when the infiltration becomes diffused throughout the connec- 
tive tissue of the pelvis, the coincident mechanical irritation and stretch- 
ing of the numerous nerve ramifications of this region may excite constant 
pain of a tearing and lancinating character, the large nerve trunks, 
however, being generally exempt. For the same reasons both the 
normal distension and the evacuation of the bladder and rectum become 
painful. The less widely' cancerous infiltration extends into the sur- 
rounding pelvic cellular tissue, the less complaint is there of pain This 
most readily explains a frequently observed fact, namely, that wide- 
spread epitheliomatous destruction sometimes occasions no suffering worth 
mention, or at most, perhaps, only trivial pressure symptoms, rapid 
sloughing keeping pace with infiltration. Moreover, we often find that 
intense pain due to cancer of the connective tissue between the uterus, 
bladder and vagina ceases abruptly as soon as gangrene leads to the forma- 
tion of a vesico-vaginal fistula. 
Now while the so-called cancer pains are often mitigated when the can- 
cerous masses are attacked by sloughing, the latter process not infrequently 
gives rise to pain of another kind, namely from irritation of the peri- 
toneum in the vicinity of the cancerous ulceration. In addition to distinct 
attacks of peritonitis which not very rarely complicate the affection under 
consideration, a certain degree of pain or rather of sensitiveness on 
pressure of the pelvic peritoneum is always present. We sometimes find. EPITHELIOMA AND CARCINOMA. 
379 
also, an increased tension of the muscles of the abdominal parietes 
(Schroder). 
While, then, hemorrhage, discharge, and the above-described varieties 
of pain are almost inseparable attendants of cancer of the uterus, at least 
from the time that the neoplasm begins to break down, there are in addi- 
tion to these some other, more rare conditions, the dependence of which 
upon the disease in question is not quite so clear. This is particularly 
true of pruritus of the external genitals, which is by no means so frequent 
as some would lead us to believe, excluding of course that form dependent 
upon cutaneous affections of the external genitals due to the constant 
trickling away of urine through a fistulous opening. 
Certain other so-called " consensual " phenomena, such as mastodynia, 
as portrayed by Simpson, West and others, are still more rarely observed. 
On th6 other hand we quite often meet with gastric symptoms such as 
anorexia, nausea, and vomiting, which sometimes make their appearance 
in so early a stage that they must in truth be classified as "consensual " 
phenomena, while the gastric symptoms that occur during the later stages 
are caused by anaemia, peri-uterine irritation, uraemia, etc. 
All the remaining disorders of carcinoma uteri are dependent upon the 
further progress and course of the disease. Before I proceed to give a 
short description of the different forms of this course it is scarcely neces- 
sary to mention that the various occurrences that I am about to portray, 
may manifest themselves simultaneously or in varying succession in the 
same patient, and that the picture of the disease is usually, therefore, 
much more diversified than would seem from the following. It has pre- 
viously been stated that carcinomatous ulceration very quickly spreads to 
the corpus uteri, and that the lumen of the uterus, and sometimes even 
the whole organ, becomes converted into a cavity filled with a decompos- 
ing, fetid, pulpy mass, into which the individual cancer nodules project. 
In this manner destruction may proceed until only a small remnant of 
the fundus is left; sometimes even this melts away, leaving no trace of 
the viscus. These are the cases that have sometimes been strangely 
described' as expulsion of the diseased uterus 
These processes are almost invariably associated with adhesive inflam- 
mation of the fold of the peritoneum lining the cul-de-sac of Douglas, and 
give rise to the ordinary signs of this condition, and to interference with 
the functions of the pelvic viscera. This perimetritis in rare instances 
leads to acute peritonitis, which is rapidly fatal; more often it is the 
starting-point of a chronic peritonitis. On the other hand I have 
encountered acute peritonitis following the rupture into the peritoneal 
cavity of a collection of decomposing detritus in the walls of the uterus, 
or of an abscess in the newly-formed adhesions, and sometimes also in 
1 Case of Gallard in 1844, L'Union Medicale, 1873.+ 380 
NEW GROWTHS OF THE UTERUS. 
consequence of the escape of broken-down masses through a Fallopian 
tube into the abdominal cavity. 
Diffuse cancer of the peritoneum in the form of very numerous dis- 
seminated, miliary deposits is a comparatively very rare occurrence. 
Cancerous ulceration of the cervix very often also spreads to the vagina, 
and then gives rise to similar conditions as when the extension occurs 
upwards into the uterine cavity. We find wide-spread destruction of the 
vaginal walls, associated with active inflammation of the remaining rela- 
tively healthy parts of the canal. 
At first the surrounding pelvic connective tissue takes on a condition of 
simple inflammatory swelling and infiltration, but it soon becomes invaded 
by the disease proper, and before long the functions of the bladder and 
rectum are interfered with, and this too before these organs become dis- 
eased. Defaecation becomes difficult and painful, and quite often large 
hemorrhoids develop. Micturition also becomes painful, and patients are 
tormented by an incessant desire to pass water. Vesical catarrh is very 
prone to occur. As a rule the destructive process sooner or later invades 
the bladder and rectum, especially the former. In 311 cases of cancer of 
the uterus, the bladder underwent cancerous infiltration in 128 instances, 
in 56 of which vesico-vaginal fistulas resulted. The disease generally 
travels in a direct line from the vagina through the pelvic cellular tissue 
to the bladder, and therefore the posterior wall of this viscus and more 
especially the trigonum are the parts that are almost invariably attacked 
in the first instance. Isolated metastatic deposits in other portions of the 
bladder are extraordinarily rare. The above accidents are always com- 
plicated with vesical catarrh, and not infrequently also with diphtheritic 
inflammation and ulceration of the mucous membrane. It is, therefore, not 
surprising that septic poisoning should now and then develop, as is illus- 
trated by a case of Eppinger's.1 
Pyelonephritis is a relatively more frequent, but still rather exceptional 
complication of the affection under consideration. 
It was observed by Blau in ten out of the ninety-three cases recorded in 
the transactions of the Pathological Institute of Berlin. A participation 
of the ureters in the diseased process is a matter of great consequence. 
In his ninety-three cases of cancer of the uterus Blau noted fifty-seven 
instances of dilatation of one or both ureters with consecutive hydrone- 
phrosis. While this complication is of but little moment when one ureter 
only is involved, the contrary is true when both tubes are occluded, as 
then hydronephrosis, with all the symptoms of acute or chronic uraemia, 
rapidly develops. The constriction or the total obliteration of the lumina 
of the ureters is only exceptionally dependent upon cancerous infiltration 
in the walls of the ducts; the latter are usually compressed at their points 
1 Prager Med. Wochenschrift, 1876, p. 210. EPITHELIOMA AND CARCINOMA. 
381 
of entrance into the bladder. This pressure may be due either to dense 
cicatricial thickening or, what is more often the case, to cancerous infiltra- 
tion of the pelvic cellular tissue. Again we not very infrequently find the 
cause of the obstruction to consist in cancerous infiltration of the vesical 
mucous membrane in the region of the trigonum. This explains how it 
is that patients who have suffered for a short time from almost absolute 
anuria, and who have already begun to manifest symptoms of uraemia, are 
quite suddenly relieved by the formation of a vesico-vaginal fistula. 
Among the other changes that may affect the parenchyma of the 
kidneys we may mention parenchymatous nephritis (observed by Blau 
four times), atrophy of the kidney (seven times), and amyloid degenera- 
tion (four times). In two of Blau's ninety-three cases there was " cloudy 
swelling of the epithelium of the urinary tubules;" metastatic deposits 
were found in three instances. 
The rectum much more rarely participates directly in the cancerous 
degeneration than does the urinopoietic apparatus. In two hundred 
and eighty-two cases, the rectum was invaded fifty-three times, and in 
thirty-seven of these a recto-vesical fistula resulted. Moreover, as- 
sociated inflammatory states of the mucous membrane of the rectum 
occur much less frequently than is the case with the vesical mucous 
membrane. 
Another, and also not infrequent result of infiltration of the cellular 
tissue of the pelvis is a thrombosis from pressure of the large veins of the 
pelvis such as the internal iliac, the common iliac, etc., with consecutive 
tense oedema of one or both lower extremities. It need scarcely be stated 
that pyaemia also may arise from this cause. 
The various modifications and disturbances of function of the digestive 
tract have previously been cursorily alluded to. It is necessary, however, 
to again direct attention to them, because of the marked influence 
which they exert upon the whole course of the disease. Together with 
obstinate constipation there is almost invariably present, even from the 
beginning, loss of appetite, sometimes with disgust for all food, especially 
meat. In addition to this, more or less obstinate vomiting often sets in 
at quite an early period. This is very seldom due to cancer of the stomach, 
which affection rarely occurs simultaneously with cancer of the uterus. 
Somewhat oftener but still quite rarely it is attributable to cancer of the 
liver or peritoneum. Incessant vomiting may also be dependent on 
chronic peritonitis, that frequent complication of cancer of the uterus, 
or more often on ureemia. In most cases, however, the symptom is 
simply the result of an ordinary chronic gastric catarrh, such as usually 
develops quickly from habitual constipation or anemia. Another factor 
is undoubtedly the atmosphere in which these patients live, in spite of 
the most rigid cleanliness. 
Discharge, hemorrhages, vomiting and anorexia very soon induce 382 
NEW GROWTHS OF THE UTERUS. 
marked emaciation, with anaemia and hydraemia. Various regions of 
the body become oedematous, the skin assumes an anaemic discolored 
hue; in short we very soon observe all those signs and symptoms which 
go to make up the alas ! too well known, and yet not easily described 
cancerous cachexia. The lattei' condition and the aspect of profound 
suffering are particularly aggravated when incessant pain allows not 
even momentary repose by day or night to the harassed and tormented 
individual. 
As regards the final result of the disease it may be stated that death is 
in most instances due to marasmus, to a gradual wasting away and exhaus- 
tion. In these cases it cannot be at all accurately prognosticated when 
the end may occur; it may seem imminent and yet be postponed for days 
and weeks. In Blau's ninety-three cases this mode of death was observed 
forty-eight times. Venous thrombosis, dysentery, diphtheritic inflamma- 
tion of the bladder or of the rectum, and bed-sores, frequently enough 
hasten the final issue. In a large proportion of other cases the immediate 
cause of death is, as has already been stated, peritonitis in its various 
forms (38 times in 155 cases); sometimes it is a general purulent peri- 
tonitis (30 times), or it may result from perforation (8 times), or from 
direct extension (17 out of 155 cases). 
Blau also gives as the causa mortis pneumonia eleven times, pleuritis 
three times, and as often embolism of the pulmonary artery; once each 
pyelonephritis, fatty degeneration of jhe heart, pulmonary gangrene, and 
pyelophlebitis from a putrid clot in the portal vein. In the sixty-two 
cases mentioned in Seyfert's 1 Klinik the following causes of death are 
recorded: pyaemia, nine times, amyloid degeneration of the abdominal 
glands, five times, oedema of the lungs, three times, dysentery, three times, 
and uraemia, twenty-eight times. The last-mentioned affection is in my 
experience also one of the most common causes of death; its mode of de- 
velopment has previously been described. 
The chronic is, perhaps, the somewhat more frequent form; still, very 
acute cases with profound sopor and general convulsions are not at all rare. 
The rarity with which septicaemia and pyaemia occur in cases of car- 
cinoma of the cervix uteri must always have attracted the attention of 
investigators. A priori one would imagine that in an affection in which 
local gangrene develops at so early a period, especially in a situation in 
which under other circumstances absorption goes on so rapidly, and that 
when, as is here the case, numerous vessels are directly and constantly 
bathed in putrid fluids, one would imagine, 1 repeat, that under these 
conditions septic infection would very often be encountered. 
As far as I remember, Barnes2 is the only one who considers that the 
1 Saxinger, Prager Med. Vierteljahrsschrift, 1867, I., p. 103. 
9 Diseases of Women, London, 1873. p. 830. epitiielio.ua and carcinoma. 
383 
phenomena that constitute the cachexia which accompanies cancer of the 
uterus are but consequences of septic intoxication. Yet even this author 
concedes that genuine septicaemia or pyaemia, as defined by their anatomi- 
cal and clinical features, is very rarely observed. Eppinger (1. c.), whose 
investigations are based upon the abundant material collected in the 
Anatomical Institute of Prague, has recently substantiated this fact. He 
describes two cases of septicaemia dependent on cancel' of the uterus, in 
one of which the infection was propagated from the broad ligament, just 
as happens in puerperal pyaemia. The reason why septic infection is so 
seldom observed under conditions which would appear to be especially dis- 
posed to its development is, in my opinion, one in which Eppinger concurs 
in the main, that the tissues in the vicinity of the cancerous ulceration 
are in such a condition of cancerous infiltration and reactive inflammation 
that absorption is all but suspended. My own experience coincides with 
this view, for the only two cases of fatal pyaemia which I have met with in 
a very large number of cases of cancer of the uterus, were observed after 
operative measures had been undertaken. I had scraped away some 
epitheliomatous masses, leaving relatively clean wounds behind, which 
were scarcely or not at all separated by a wall of infiltration from the 
adjoining healthy tissues; in this way the absorption of decomposing 
mattei' was facilitated. 
It is very difficult, indeed well-nigh impossible, to determine the dura- 
tion of cancer of the uterus, because, as I have already repeatedly stated, 
the malady has almost without exception existed quite a long time before 
symptoms of such gravity have manifested themselves as seem to require 
professional advice. We can, therefore, only state approximately the 
length of time that usually elapses between the onset of the first symptoms 
and the fatal issue. Now, while this may vary in individual cases, 
especially since appropriate therapeutic measures quite often retard 
the further progress of the disease, yet it may be stated in general that 
carcinoma of the uterus usually ends fatally after a duration of from 
one to one and a half years, reckoning from the appearance of the initial 
symptoms. 
The average duration of the disease in West's cases was seventeen 
months, in Lever's twenty, and in Lebert's sixteen. Seyfert found the 
average duration to be from three to four years in " epithelial carcinoma," 
while it was only one and a half years in the "medullary" form. In 
twenty-four cases, in which positive statements could be made, Tanner 
found the shortest time to be six months, the longest four and a half 
years, while in twenty-four other cases, in which the information was 
less reliable, the duration varied between five weeks and twenty-one 
months. 
In twenty-two of my own cases I found the duration of the disease 384 
NEW GROWTHS OF THE UTERUS. 
to be once 36 months, twice 24 months, three times from 12 to 20 
months, 12 times from 9 to 11 months, once 8| months, once 6 months, 
and twice 4 months, or an average of exactly twelve months. 
Now while the gangrenous process in carcinoma of the uterus may be 
considered as a step in the direction of cure, in so far as cancerous 
masses are thereby being continually destroyed, yet we can by no means 
accept as reliable those few statements in the literature of the subject 
which claim that uterine cancer may undergo spontaneous cure. The 
evidence adduced up to the present time, in support of these assertions 
is not sufficiently convincing; the cases of Gallard and Barnes (1 c.) at 
any rate can lay no claim to be accepted as decisive. 
Diagnosis. 
A study of the symptoms of carcinoma of the portio vaginalis shows 
sufficiently clearly that the diagnosis of cancerous ulceration is compara- 
tively easy. One readily recognizes, on digital exploration, the luxuriating 
and ulcerating masses, the destruction of the vaginal tissues, the infiltra- 
tion of the pelvic connective tissue. The examination is generally fol- 
lowed by more or less hemorrhage. The foetid discharge, the general 
condition of the patient, all render the recognition of the disease an easy 
one. On examining with the speculum one sees proliferating masses 
sprouting from a deeply ulcerated base, and covered with black, necrotic 
shreds. In short I certainly do not assert too much when I say that it 
requires only an approximatively careful examination to diagnose a de- 
generating cancer of the vaginal portion. It is true, as I have pointed 
out on a previous occasion, that ulcerating fibromata in this situation have 
been mistaken for the affection which we are discussing; our doubts 
will speedily and easily be dispelled by paying attention to the condi- 
tion of the os externum, and by examining a piece of the decomposing 
mass. 
Carcinomatous masses crumble away at the lightest touch, and present 
minute tissue fragments, while in degenerating myoma the connective 
tissue and the muscular elements are removable with much greater diffi- 
culty, and show a fibrous structure both to the touch and to the naked 
eye. The nature of the disease is of course definitely settled by micro- 
scopical examination. The same is true in distinguishing ulcerating 
polypi; indeed these could in any event only be confounded with those 
exceptional forms of epithelioma which are actually or only apparently 
attached by a pedicle to the portio vaginalis, and which in England and 
in France are designated respectively as " mushroom " and "champignon " 
epithelioma. It is more difficult to understand how Bichet1 could have 
1 L'Ecole de Medecin, No. 1, 1874. EPITHELIOMA AND CARCINOMA. 
385 
mistaken an epithelioma of the cervix for a piece of retained placenta. 
An error of this nature should, it seems to me, exclude itself, when we 
remember the seat of the disease, and would seem possible only in con- 
nection with an isolated carcinoma of the corpus uteri, a subject which 
we have yet to discuss. 
The diagnosis of cervical carcinoma may sometimes be rendered difficult 
by reason of reactive inflammation, at any point of the vagina below the 
focus of disease, with the subsequent formation of a stenosis, sufficiently 
close to permit only of the escape of small quantities of blood and putrid 
fluid. On the other hand, it must not be forgotten that similar stenoses 
are sometimes encountered in the vagina, especially in its upper third, of 
old individuals, who are free from any cancerous affection. 
If catarrhal conditions are present in these cases, the secretions which 
escape through the aperture of the stricture may assume a foetid character 
in consequence of stagnation above the seat of constriction. If in such 
cases a positive diagnosis cannot be made by rectal examination, we must 
by some means open up the strictured portion of the vagina. 
It has been stated on a previous occasion that Liebmann 1 observed some 
cases of " flat epithelioma" commencing in the upper part of the mucous 
membrane of the cervix, the vaginal portion seeming externally to be 
perfectly healthy. In these cases the diagnosis wavered between simple 
cervical endometritis and epithelioma. What argued in favor of the lat- 
ter was not only the foetid odor and sanious tinge of the discharge, circum- 
stances which are certainly rare in endometritis, but above all, the fact 
that the discharge was entirely devoid of any slimy consistency. More- 
over, we can easily recognize an enlargement of the cervical canal through 
deep ulceration. We have here touched on a point which is at once the 
most difficult and the most important in the diagnosis of cancer of the 
uterus, namely, the recognition of the initial stage of the disease. 
In the same measure as the diagnosis of an ulcerated carcinoma of the 
portio vaginalis is easy, so is it difficult to detect incipient epithelioma and 
cancerous infiltration of the cervix underneath the, as yet, healthy mucous 
membrane. And yet it would be, as we shall see, of really invaluable 
consequence to us from a therapeutic aspect, could we recognize the first 
stages of the disease at a period early enough to allow us to readily and 
radically extirpate the degenerated tissues. 
Epithelioma of the os uteri always manifests itself at first in the form 
of the so-called erosion. It may sometimes be differentiated from the 
ordinary benign follicular erosion of the mucous membrane lining the 
cervix and that covering its vaginal surface, by the fact that the former 
is more deeply and evenly excavated and possesses more infiltrated bor- 
ders. The papillae springing from the base of the ulcer are often markedly 
1 London Obstetr. Transact., XVIII., p. 66. 386 
NEW GROWTHS OF THE UTERUS. 
hypertrophic, bleed very readily, and often exude at any early period 
the previously described fluid resembling meat juice, which is rarely the 
case when we have to do with the so-called papillary erosions. Still, 
some writers regard these very papillary erosions as the initial stage of 
epithelioma, while others such as Ruge and J. Veit1 consider them to ba 
the commencement of true carcinoma, so that even an anatomical differ- 
entiation is not always easy, to say nothing of the differential diagnosis 
during life. The latter may sometimes be established by the observation 
that in simple erosions (ectropium of the os) the cervical mucous mem- 
brane is swollen, relaxed and soft, while in incipient epithelioma it pres- 
ents a distinct ulcer and seems more than ordinarily adherent to the sub- 
jacent parenchyma. If in addition we notice on the floor of the ulcer 
large, scattered, hypertrophic excrescences, which bleed freely on the 
slightest manipulation, our suspicions of incipient epithelioma are 
strengthened, and if some of these excrescences admit of easy removal by 
simple scraping with a dull instrument or the finger-nail, the ill-omened 
diagnosis is established almost to a certainty. 
The diagnosis can not always be absolutely verified by removing with 
the scissors or knife small fragments of a suspicious erosion, as has 
been proposed by Ruge and Veit, since it is a well-known fact that it is 
often difficult to determine beyond a doubt the nature of a tumor as a 
whole, by microscopical examination of small particles of the growth.2 
I have always considered it justifiable, as I shall endeavor to prove 
when discussing the subject of treatment, to amputate the entire vaginal 
portion in these doubtful cases, even at the risk of having now and then 
performed the operation unnecessarily. We should never neglect to at- 
tempt the cure of a suspicious ulceration, by the ordinary remedies and 
procedures, and if it showa tendency to heal, to cicatrize from the edges, 
we may be sure that it is not a commencing cancer of the uterus. 
Now, while it is not easy to detect the initial stage of epithelioma, it is 
even more difficult to recognize carcinoma at its very beginning, when 
the deep-seated cancerous infiltration is hidden from view by overlying 
healthy mucous membrane. It is comparatively easy when the disease 
commences in the form of a few hard, isolated prominences situated be- 
neath the mucous membrane. These can often be seen, even through 
a speculum, as little protuberances of a peculiar, deep bluish-red color. 
When the vaginal portion, however, is uniformly enlarged, and is smooth, 
hard and greatly swollen, it is impossible to decide whether we have to 
do with a simple hypertrophy and chronic induration or with incipient 
carcinomatous disease. The diagnosis can only be cleared up by amputa- 
tion and microscopical examination. If one is satisfied to make an abso- 
lute diagnosis from the study of the symptoms alone, as was done towards 
1 Zeitschrift fur Gynaekologie, II., p. 416. 
2 See Friedlander's Mikroskop. Technik, 1882, p. 120. EPITHELIOMA AND CARCINOMA. 
387 
the middle of this century by Duparque, Lisfranc, Ashwell, Montgomery 
and others, why then of course we shall find that cancer of the uterus 
has in numerous instances been cured by amputation of the cervix. 
Now, as we should so far as possible avoid undertaking this operation, 
by no means an insignificant one, without well-founded diagnostic reasons, 
we ought to welcome any criteria which would enable us to differentiate 
the commencement of carcinomatous disease from simple induration. 
Spiegelberg 1 claims that the former is characterized, in the first place, by 
the density and immobility of the mucous membrane overlying the deep- 
seated carcinomatous tissues, and further that the affected parts are not 
susceptible of dilatation by sponge-tents or other similar agents, their 
natural elasticity having been destroyed by infiltration with cancer ele- 
ments. Unfortunately the hopes born of Spiegelberg's statements are 
justified neither by my own experience, nor, as it seems, by that of other 
physicians. 
A correct diagnosis may undoubtedly be established by the use of these 
methods, when the mucous membrane slides freely on the underlying 
tissues, and a sponge-tent readily succeeds in dilating the cervical canal, 
but when these conditions do not obtain, we are not yet justified in making 
a diagnosis of cancer of the cervix uteri. The normal degree of mobility 
of the mucous membrane of the vaginal portion is so variable, and is so 
difficult of determination, that it would be improper to base a diagnosis 
of such far-reaching importance on so insecure, I am almost tempted to 
say so purely subjective, a foundation. And as regards the dilatability of 
the cervical canal by sponge tents or laminaria bougies, it seems to me 
that this also varies so exceedingly, leaving entirely out of consideration 
the fact that the different tents exhibit such varying powers of distension, 
that it has never aided me in reaching a decision in doubtful cases. Dense 
fibrous indurations often require a considerable time, and repeated intro- 
duction of sponge tents, before they exhibit any noteworthy degree of 
dilatation, and, on the other hand, I have not seldom succeeded in dilat- 
ing the os with surprising facility by the above means, in cases of well- 
marked carcinomatous disease. Now while anatomical reasons would lead 
us to expect that tissues that have undergone cancerous degeneration, 
would, as a rule, soon lose their elasticity to a great extent, yet clinical 
observation teaches us that normal labor through an evenly dilated os, 
not very infrequently takes place in cases of advanced cancerous disease 
of the lower segment of the uterus; in other words, that cancer does not 
always entail a diminished dilatability of the cervix, or, at any rate, not 
to a degree that is always readily appreciable. 
In those doubtful cases of the above description it is important to make 
a careful examination of the pelvic connective tissues surrounding the 
1 Archiv fur Gynakologie, III., p. 233. 388 
NEW GROWTHS OF THE UTERUS. 
uterus. By so doing we are not infrequently able to detect at an early 
stage infiltration of these tissues, with more or less immobility of the 
uterus, and dense indurations, sufficient grounds for establishing a pre- 
sumptive diagnosis of malignant disease of the vaginal portion. 
Bi-manual exploration, preferably during narcosis, should not be 
omitted in all those cases in which operative interference is contemplated. 
Special attention must be paid to infiltration of the broad as well as the 
sacro-uterine ligaments. The mobility of the uterus, more particularly 
in a downward direction, must be ascertained, where total extirpation is 
thought of. In this connection it is well to remember that, so far as the 
technical difficulty of such an operation is concerned, it makes little 
difference whether fixation of the uterus is due to cancerous infiltration 
or merely to perimetritic adhesions. It is at times quite possible to differ- 
entiate between cancerous and inflammatory infiltrations by the above 
method of examination. 
Treatment. 
The now-a-days almost universally accepted view that cancer of the 
lower segment of the uterus is pre-eminently a local affection, which in 
but very few instances, and then only after a long period of existence, 
gives rise to metastatic deposits in distant organs, is in full accord w'th 
the experience of all times, according to which there exists no internal 
remedy and no medicinal procedure which is, or ever was, capable of curing 
cancer of the uterus. It is not necessary to adduce special evidence in 
support of the truth of this assertion. 
Since epithelioma of the vaginal portion continues during so long a 
period of its existence as a mere local affection, we have reason to hope for 
a radical cure after removal of the morbid tissues. Therapeutists have, 
therefore, been constantly engaged in the study of the best ways and 
means for extirpating the diseased portio vaginalis as completely as possi- 
ble. If we are able to entirely remove the degenerated masses, or, in a 
word, to operate within healthy tissues, it would afford the possibility of 
a complete and permanent cure. And, indeed, experience teaches that 
this has been done. 
Until very recently recourse was had again and again to caustics and to 
similar procedures, in the attempt to accomplish the complete destruction 
of the neoplastic deposits. Cures have been recorded of all of these 
methods, including electrolysis,1 cauterizations with sulphate of zinc 
(Simpson), with chloride of zinc, and similar agents. 
Routh2 claims to have cured epithelioma of the uterus by cauterizations 
with solutions of bromine, others by injecting gastric juice into the sub- 
1 Noeggerath, Obstet. Journal, April, 1878, p. 61. Neftel, etc. 
2 Obstetr. Journal, 1., p. 347; Obstetr. Transactions, London, VIII., p. 290. EPITHELIOMA AND CARCINOMA. 
389 
stance of the growths. Not one, however, of these and numerous other 
procedures, exhibits results which can withstand the test of strict and 
rigorous criticism, and I will, therefore, only mention them further on, in 
so far as they have any value as palliative measures. 
Actual, unquestionable cures can be and have been observed only when 
the attempt is successful to completely remove through healthy tissues 
the degenerated masses in the beginning of the disease. The following 
comprises all the cases that I have been able to collect of radical cure after 
amputation of a cancerous vaginal portion. One of J. Simpson's1 patients 
was well fifteen years after the operation, and had given birth to five 
children during the interval. The cancerous nature of the extirpated 
masses was verified by Goodsir.2 A second patient died four years after 
the operation of cancer of the peritoneum; this case may perhaps be 
classed as cured, in so far, at least, as there was no recurrence of the dis- 
ease in loco. A third patient succumbed also four years after operation, 
to dysentery. 
Mikschik,3 removed the diseased lower segment of the uterus, the 
patient dying ten years later of cancer of the stomach. Ziemssen's * 
patient died of pulmonary tuberculosis seventeen years after the removal 
of an epithelioma of the anterior lip of the os. Other cases are recorded 
by C. Mayer, Martin,5 and Griinewaldt.8 The last-mentioned states 
that he saw his patients alive and free from any recurrence of the disease 
five, ten, and twelve years respectively after the operation. C. Braun al- 
ludes to a case operated upon by Schuh, where twenty years later no re- 
turn of the disease was seen. Hegar's7 patient was in good health three 
and a half years after amputation. Scharlau8 amputated the cervix with 
the ecraseur for epithelioma, and some time afterwards destroyed two 
local recurrences with chromic acid. Four years later the patient was 
seen in perfect health, having given birth to a living child in the in- 
terim. 
Other similar reports may be found recorded in literature, but they 
do not deserve as much credence as the foregoing, partly because the 
period of observation after operation was too' short, and partly because 
the diagnosis does not appear to have been above doubt. The latter is 
particularly true of the cases of Osiander, Lisfranc, Dupuytren and 
1 Diseases of Women, Edinburgh, 1872, p. 169. 
2 Compare also a case published in the Dublin Quart. Journal, 1846, p. 355, and 
Edinburgh Med. & Surg. Journal, 1841. 
3 Zeitschrift der Gesellschaft der Wiener Aerzte, 1856, p. 52. 
4 Virchow's Archiv, vol. XVII., p. 333. 
5 Monatsschrift fur Geburtskunde, XVIII., p. 12. 
6 Archiv fur Gynakologie, XI., p. 501. 
' Operative Gynakologie, p. 229. 
8 Beitrage zur Geburtshtilfe, etc., Berlin, II., p. 23. 390 
NEW GROWTHS OF THE UTERUS. 
others, who, as is well known, not infrequently mistook simple hyper- 
trophy of the portio vaginalis for carcinoma.1 
C. Braun2 has very frequently performed this operation. Pawlick 3 
states that Braun operated upon 136 cases, of which number 10 died and 
16 received no benefit. Of the 110 immediate recoveries, 32 died after- 
wards (but only 16 of actual recurrence of the disease), and concerning 
22 there is no subsequent history. In 22 others the disease returned 
(once after nineteen months, and once after six years). Thirty-three 
patients remained well for from one to nineteen and a half years. In 
thirty-nine of these cases Douglas's pouch was opened during the opera- 
tion. None of the women gave birth to a viable child after the operation. 
When pregnancy occurred, it was invariably followed by abortion. 
Winckel4 removed the anterior lip in a case of epitheliomatous papil- 
loma. Three years later a similar growth appeared on the posterior lip. 
Schroder 6 amputated the cervix in thirteen cases, using the knife fol- 
lowed by the application of the actual cautery. 
One of these cases succumbed to trismus. Of the twelve patients who 
recovered, five remained well for two years, i.e., 42 per cent., and four 
had a return of the growth within that period of time, i.e., 32 per cent. 
Many similar operations have been done by others, but the reported 
cases are few in number. 
In view of what has been previously said on this topic it is not surpris- 
ing that such a relatively small number of recoveries is noted after ampu- 
tation of the cervix for cancer. We have seen that, by the time the first 
symptoms have been noticed the affection is almost invariably so far 
advanced as to make it seem impossible to operate through sound tissues; 
either the vault of the vagina is diseased, or the infiltration has already 
invaded the cellular tissue of the pelvis, or, finally, cancerous ulceration in 
the cervical canal has already progressed beyond the internal os, the 
surface of cervix as seen in the vagina still remaining intact. Finally 
there is not a small number of cases in which nothing of the preceding 
description is present, and in which the diseased parts seem to be sur- 
rounded on all sides by healthy tissue, and yet either microscopical exam- 
ination or the further course of the disease after operation very soon 
reveals that the apparently healthy tissue was already permeated with 
cancer elements. Let me repeat once more that our chances of securing 
more favorable and more reliable results in the treatment of cancer of 
1 Compare Pauly, Maladies de 1'utGrus d'apres les lemons de M. Lisfranc, Paris, 
1836. 
2 Lehrbuch, etc., p. 494. 
3 Behandlung der Uteruscarcinome, Wien, 1882. 
4 Centralb. f. Gynakol., 1882, No. 7. 
6 Krankheiten d. weibl. Sexualorgane, 1884, p. 296; and Hofmeier, Zeitschr. f. 
Geb. u. Gynakol., vol. X. EPITHELIOMA AND CARCINOMA. 
391 
the uterus than have hitherto been obtained, depend entirely upon 
whether we shall succeed in detecting with certainty the disease in its 
incipiency, or, at any rate, at a much earlier stage than has been the case 
up to the present time. 
It is nevertheless the duty of the physician in every case of cancer of 
the lower segment of the uterus, in which there seems to be a possibility 
of amputating beyond the limits of the disease, to do so without delay. 
The operation is usually not a dangerous one and the hemorrhage can be 
readily controlled ; in short the disadvantages involved are insignificant in 
comparison with the uncertain chances of a cure, by any other methods, 
of an affection of such gravity as cancer of the uterus. Besides, in those 
cases in which perfect recovery has not followed the extirpation, the 
growth having recurred, the course of the disease is certainly changed for 
the better by the operation, as I shall show later on. 
The operation is done as follows: Under antiseptic precautions the 
uterus is to be grasped, and dragged downwards, when the diseased por- 
tions are removed with the knife or scissors. 
When the disease extends up to the internal os, it is advisable to per- 
form a funnel-shaped excision, as particularly recommended by Hegar.1 
The hemorrhage is often very profuse, and is the more grave according to 
the degree of anaemia previously existing. It is, therefore, advisable to 
complete the operation as quickly as possible, and then to employ at once 
the actual cautery, or other styptics, such as chromic acid, chloride of 
zinc, bromine, etc. The hemorrhage can be securely arrested by drawing 
together and uniting the cut edges of the mucous membrane over the 
stump, but the procedure not only takes up a good deal of time, during 
which of course more blood is lost, but above all exposes the patient to 
greater chances of recurrence. If any cancerous foci have been left 
behind in the apparently healthy tissues they will not only continue to 
extend, but may also inoculate the healthy mucous membrane with which 
they are brought in contact. But if the hemorrhage have been arrested 
by the energetic application of caustics, long-continued suppuration sets 
in, in the course of which any remnant of the neoplasm may possibly be 
destroyed. Moreover, small recurrent growths can be much more easily 
detected on the ulcerating surface, and then admit of easy removal. 
If the wound does not gradually cicatrize it may be taken for granted 
that the amputation has not been performed through sound tissues; on the 
other hand the stump quite often cicatrizes and heals over in a compara- 
tively short space of time, and yet a recurrence follows shortly, in which 
event it is probable that deeply seated islets of cancer tissue, that have 
escaped the surgeon's knife, have sprouted outwards to the surface. 
For a time the employment of the ecraseur in its various modifications 
1 Hegar and Kaltenbach, Operative Gynakologie, p. 229. 392 
NEW GROWTHS OF THE UTERUS. 
(chain and wire ecraseur) was highly recommended in order to prevent 
free hemorrhage during the operation. But apart from its uncertain 
action in this respect, the instrument should be discarded because of the 
other well-recognized dangers that attend its application. Even in 
operations in which the utmost care has been exercised, and in which the 
uterus has not been dislocated from its normal position, the walls of the 
vagina and bladder and the peritoneum have in many instances been 
dragged into the loop and have been injured. Quite recently Atthill1 
reported a case of amputation with the ecraseur of a cancerous cervix, 
the instrument also laying open Douglas's cul-de-sac. One of the chief 
disadvantages of the method in the operation which we are now discuss- 
ing consists in the fact that it by no means permits of the removal of a dis- 
eased part within well-defined limits; the wide chain or the smooth wire 
can never be carried so accurately along the narrow line that separates 
diseased from healthy tissue as can the knife, the direction of which may 
be varied at any moment, at the will of the operator. 
The same disadvantage, although to a lesser degree, attends the em- 
ployment of the gal vano-caustic snare, which von Grnnewaldt,2 Spiegel - 
berg,3 Leon Labbe,4 C. Braun, and others have so often used with success 
in amputating diseased cervix. This method entails little if any hemor- 
rhage, and is therefore sometimes indispensable. Thus in some cases of 
cauliflower excrescence of the cervix, that form of cancer that offers rela- 
tively the best chances for radical cure after amputation, the patients 
have been reduced to so great a degree of anaemia by repeated hemorrhages 
that any bloody operation is entirely out of the question. 
Another advantage offered by this method is the cauterization of the 
field of operation The disadvantages are, in the first place, want of pre- 
cision in severing the tissues on the boundary line between health and 
disease, and, in the second place, the laboriousness attending its use, at 
least in private practice and in the smaller hospitals. 
Since it seldom happens, in epithelioma of the intra-vaginal portion of 
the cervix, that amputation of the latter can be performed through sound 
tissues, attempts have repeatedly been made to thoroughly extirpate the 
diseased parts even when the affection extends still higher. Funnel- 
shaped excision, after Hegar's method, sometimes suffices, as previously 
mentioned, for those cases in which the mucous membrane lining the 
cervix is diseased up to the internal os. 
Schroder5 has recently devised and successfully performed a new opera- 
1 Dublin Journal of Medical Science, Feb. 1877. 
2 St. Petersburg Med. Zeitschrift, 1864, II., 1-31; Archiv. fiir Gynak., XI., p. 
501. 
3 Arch, fiir Gynakologie, V., p. 411. 
4 Annales de Gyn6cologie, 1., p. 165. 
6 Verein derAerzte d. Charite zu Berlin. Sitzung vom 25 April, 1878; Berlin EPITHELIOMA AND CARCINOMA. 
393 
tion for those cases in which the disease has already invaded the fundus 
of the vagina to a slight extent, while the pelvic cellular tissue is still 
intact. Two strong sutures (these are not always required, according to 
Schroder's latest statements) are passed through the lateral walls of the 
fornix vaginae near the diseased parts so as to fix the latter firmly. The 
knife is now carried around the vagina as far as is required to sever the 
cancerous frpm the healthy tissues, cutting just deeply enough to expose 
the loose cellular tissue of Douglas's cul-de-sac, and of the space between 
the bladder and uterus. This tissue is now torn through with blunt 
instruments until as much as seems necessary of the lower segment of the 
uterus is laid bare, which is then cut away. It is then advisable, in order 
to prevent hemorrhage into the surrounding connective tissue, to pass all 
the sutures through the stump of the uterus. 
This so-called 11 high amputation " unquestionably constitutes a decided 
advance in the treatment of cancer involving the lower uterine segment. 
The method has been widely accepted, although but little has been pub- 
lished concerning it. 
Schroder* has recorded 105 cases of this kind. Thirteen of this number 
died. Of the ninety-two who recovered, twenty-seven within six months 
showed a recurrence of the disease that proved fatal after a shorter or 
longer period. Concerning twenty-seven patients nothing could be learned. 
Thirty-eight remained well six months after the operation. Twenty-seven 
of this number were still well after one year, twenty-two after eighteen 
months. Of this number eighteen were well after two years, fifteen were 
still in good health after 2| years, and twelve after three years. Five 
certainly remained well four years after the operation. All the others 
were either lost sight of, or suffered a return of the disease. 
Wallace2 has reported ten cases of high amputation of the cervix for 
cancer, with two deaths. In two cases the disease returned within one 
year. 
Of thirty-three cases of my own, of which I have accurate notes, three 
died of " sepsis " in consequence of the operation. One patient was well 
one year, another two years after the operation. 
Total extirpation of the uterus was formerly sometimes performed after 
a similar plan, or at any rate operations similar to Schroder's have been 
thus styled. It would be superfluous for me, on this occasion, to sift all 
the published cases of total extirpation of the uterus for cancer. The 
reader will find in West's treatise3 a record of twenty-five operations, of 
which twenty-two were fatal. 
Klin. Wochenschrift, 1878, No. 27: Ueber die theilweise und vollstandige Aus- 
schneidung der carcinomatosen Gebarmutter, Zeitschrift fur Geburtshtilfe und 
Gynakologie, vol. VI., p. 217; Krankh. d. weibl. Sexualorgane, etc. 
1 Krankh. d. weibl. Sexualorgane, 1884, p. 2, and Hofmeier, l.c. 
2 British Med. Journal, Sept. 15, 1883. 
3 Frauenkrankheiten, Gottingen 1860, p. 476. 394 
NEW GROWTHS OF THE UTERUS. 
At that time no definite plan was pm-sued. The uterus was sometimes 
" peeled out " from the pelvic connective tissue, by way of the vagina; 
at other times the organ was first dislocated by force, or the operation was 
performed on uteri that were in a condition of spontaneous prolapse. 
Laparotomy was sometimes practised, but the method of extirpation that 
has so often been pursued with success for fibroid tumors, could not of 
course be employed in carcinoma of the uterus, for in the for/ner case the 
line of division passes at the level of the internal os between the body 
and the cervix, the latter part being left behind. Besides the want of 
any satisfactory method, there remains the fact that in not a small num- 
ber of the older reports there exist well-founded doubts as to the correct- 
ness of the diagnosis; in short it seemed as if total extirpation of the 
uterus, for carcinoma affecting the lower segment, would have to be for- 
ever excluded from the list of debatable operations. 
In 1878, however, W. A. Freund1 devised a method ingenious in con- 
ception and daring in execution. As originally described it is as follows: 
After cutting through the anterior wall of the abdomen, and fixing the body 
of the uterus firmly with a loop, each broad ligament is separated into three 
portions by three ligatures, the last of which transfixes the vault of the 
vagina and the lower part of the broad ligament. Aftei- the uterus has 
in this manner beep severed from its lateral connections in the pelvis the 
anterior and posterior parts of the fornix are dissected off from the 
uterus and are then cut through from within outwards. Through the 
large gap between vagina and pelvis, which results after the uterus is 
removed, the ligatures are then passed so as to let their ends hang into 
the vagina. In this way a funnel-shaped opening is left, in which the 
peritoneal investments of the pelvis are in contact with one another, after 
which the margins of the opening are closely approximated by sutures so 
as to form a barrier between the vagina and the abdominal cavity. For 
the details and the various modifications of the operation I must refer 
to the previously mentioned paper of Freund and to the publications of 
numerous other operators. 
The results of an extended trial of the operation show that it is scarcely 
a justifiable procedure, and can be of value only in a small minority of 
cases of cancer of the uterus. It soon became evident from the publica- 
tions of Schink2, Linkenheld s, Baum,4 Schroder,6 Mikulicz,6 Ahlfeld,7 
1 Eine neue Methode der Exstirpation des ganzen Uterus. Volkmann's Clini- 
cal Lectures, 1878, No. 133. Also " Zu meiner Methode der totalen Uterusexstir- 
pation," Centralblatt fiir Gynakologie, 1878, No. 12. 
2 Inaug. Dissertation, Berlin, 1879. 
3 Centralblatt fiir Gynakologie, 1881, No. 8. 
4 Berliner Klin. Wochenschrift, 1880, No. 46. 
5 Zeitschrift fiir Geburtshiilfe and Gynakologie, vol. VI. 
6 Wiener Med. Wochenschrift, 1880, No. 47. 
7 Deutsche Med. Wochenschrift, 1880, No. 1. EPITHELIOMA AND CARCINOMA. 
395 
Czerny, 1 Klein wachter,2 Ohlshausen 3, Bardenheuer 4 and others that the 
operation was an extraordinarily dangerous one. According to Ahlfeld 
it resulted fatally forty-nine out of sixty-six, respectively sixty-nine times, 
according to Kleinwachter seventy out of ninety-four times, and accord- 
ing to Kaltenbach5 fifty-eight out of eighty-eight times. 
Hegar and Kaltenbach 8 have published a table of ninety-three cases 
with sixty-three deaths, a mortality of seventy-one per cent. Duncan 7 
collected 137 cases showing a mortality of seventy-two per cent. 
I have myself collected (including three unpublished cases of my own) 
148 cases, with 106 deaths, a mortality of 71.6 per cent. 
Now this high mortality rate would scarcely weigh in the balance, and 
the operation would remain one of the most brilliant achievements of 
operative medicine, if the few who survived its immediate effects were 
radically cured of their disease. Unfortunately, however, the malady 
recurred in all the cases that have been reported, and terminated fatally 
in a more or less short space of time (Linkenfeld). 
If the only benefits that accrue from the operation are simply a short 
prolongation of life, and a brief interval of freedom from suffering, then 
the operation is too'perilous, and we cannot justify ourselves in the fatal 
cases by stating that we have put an end to the suffering of the patient or 
have contributed to procure euthanasia. Pain may be alleviated and the 
end may be delayed by more innocent means. In spite of incessant 
torture many of these patients are content to linger along until they have 
arranged those duties which seem incumbent on them towards their 
families and others. 
It requires but little reflexion to recognize the incorrectness of a state- 
ment formulated by modern surgery (Bardenheuer 8), that the old style of 
treatment (amputation of the cervix, curetting, cauterization) " is more 
pleasing in its execution " to the physician. Every one who still feels it his 
duty to practise these old procedures knows how depressing and how 
laborious it is, how it most severely taxes the patience of the physician to 
adhere to it when contrasted with an interesting, technically difficult 
operation, in which at least a passing glow of satisfaction is experienced 
at the recollection of the numerous difficulties successfully overcome. I 
shall leave it to the impartial reader to decide which of the two is the 
more "discreditable" to medical skill, the old style of treatment, as 
1 Wiener Med. Wochenschrift, 1879,«Nos. 45-49. 
2 Wiener Med. Presse, 1881, Nos. 3 and 4. 
3 Berlin Klin. Wochenschrift, 1881, No. 35. 
4 Die Drainirung der Peritonealhohle, Stuttgart, 1881. 
5 Deutsche Med. Wochenschrift, 1881. 
6 Operative Gynakol., 1881, p. 408. 
7 Obstetrical Society, London, 1885. 
8 Die Drainirung der Peritonealhohle, Stuttgart, 1881, p. 38. 396 
NEW GROWTHS OF THE UTERUS. 
Bardenheuer thinks, or the delirious joy of a patient who has been told, 
after extirpation of her cancerous uterus, that she is cured (1. c., p. 39), 
and who finds after the lapse of a few months that the fell disease has 
reappeared. 
The situation would of course be entirely different if total extirpation 
of the uterus offered the possibility of a radical cure of the disease, or if the 
operation were less dangerous. In the latter respect much better results 
are warranted by the vaginal method of extirpation of the uterus, as first 
proposed, or, rather, as re-introduced by Billroth and Czerny. (The 
operation was first done by Sauter 1822, Blundel 1828, Recamier 1829, 
and others). 
According to a table prepared by Hahn 1 in 1882, out of forty-eigbt 
cases of total extirpation per vaginam, 14 (i.e, 29.1 per cent.) died. Hegar 
and Kaltenbach2 mention eight deaths in twenty-nine cases, a mortality 
of twenty-five per cent. Czerny 3 found twenty-six deaths in eighty-one 
operations, a mortality of thirty-two percent. Duncan (1. c.) has col- 
lected 276 cases, showing a mortality of 28.6 per cent. Sanger 4 found a 
similar mortality rate in 133 cases. I have myself found records of 253 
cases of this kind (including six cases of my own not yet published, 
with one death) with fifty-nine deaths, i.e. a mortality rate of only 23.3 
per cent. 
These figures show that the vaginal method of extirpation of the uterus 
is not only far less dangerous than the operation of Freund, but also that 
the mortality has decreased with the increasing number of operations. 
This fact is made particularly noticeable from the figures published by 
Pfannenstiel,& who found that in 154 operations done up to 1882 the 
mortality rate was twenty-three percent., whereas in thirty-six operations 
performed since then it had fallen to 8.3 per cent. 
As a palliative procedure the operation has, therefore, a high value. 
Whether it is destined to afford radical relief cannot at present be decided. 
It would certainly seem that the majority of patients succumb sooner or 
later to a recurrence of the neoplasm. 
Even if this operation gives results only as good as are observed in the 
removal of cancers elsewhere in the body, we must nevertheless welcome 
it as a justifiable, and possibly beneficent surgical interference. 
The chief condition favorable to the performance of this operation, 
consists in the absence of cancerous infiltration of the vaginal walls, and 
the pelvic connective tissue, »is well as downward mobility of the 
uterus. 
1 Berlin Klin. Woch., 1882, No. 24. 
2 Loe. cit., p. 409. 
3 Berlin Klin. Woch., 1882, Nos. 46 and 47. 
4 Arch. f. GynakoL, vol. XXL, 98. 
6 Inaug. Dissert., Berlin, 1885. EPITHELIOMA AND CARCINOMA. 
397 
Views still differ quite widely as to the best method of performing the 
operation under discussion. 
Under antiseptic precautions the uterus is to be dragged down, after 
as much of the cancerous masses as possible has been removed, destroyed 
or disinfected. It is advisable to pass a stout double ligature through 
the cervix. This affords a good purchase on the womb, and prevents 
contact of the diseased tissues with the fresh wounds. The vault of the 
vagina is then incised, behind and in front of the cervix, and without 
the use of cutting instruments the uterus is severed from its anterior 
and posterior connections. It is then pulled downwards and the broad 
ligaments are step by step ligated and cut (Schroder). The ligatures of 
the broad ligaments are passed outwards through the incision into the 
fornix of the vagine. This is closed by sutures, a drainage tube is 
inserted, and iodoform tampons placed in the vagina. It is not necessary 
to discuss here the various modifications of this procedure that have been 
suggested by different authors. 
Views also differ as to the advisability of complete closure of the vaginal 
wound, or of allowing the incisions to remain open. A middle course is 
probably the best, i.e., incomplete closure, with thorough drainage. 
It is very difficult to decide which one of the various operations described 
is indicated in a given case. If the cancerous disease has extended as far 
as, or beyond, the internal os, without, however, involving the pelvic 
areolar tissue, then the vaginal extirpation of the uterus is called for. 
Should the body of the uterus be so large that it is not feasible to pass it 
through the pelvis, Freund's operation may have to be done. But it 
seems advisable in all such cases to first sever the anterior and posterior 
connections of the uterus per vaginam, and then to remove the organ by 
laparotomy. 
In view of the great gravity of Freund's operation, it will always have 
to be seriously considered, whether the uterus, even if enlarged, cannot 
be removed per vaginam. by cutting the broad ligaments from below 
with the womb in situ. 
What method to choose when the cancer is still confined to the portio 
vaginalis cannot in the present state of our knowledge be strictly formu- 
lated. Intra-vaginal amputation, or total extirpation are, of course, to 
be weighed in the balance as to their relative dangers and possible advan- 
tages. In a general way I favor extirpation, because it is so often hard to 
say how far cancerous infiltration may have crept upwards in the mucous 
membrane of the uterus, and because the probability of recurrence 
should be less in the more radical operation. 
Thus, while there are but few cases of cancer of the uterus in which 
there is a good prospect of cure by surgical interference, and still fewer 
where this prospect is realized, there are many in which we are able to 
retard the progress of the disease and to abate some of the most painful 398 
NEW GROWTHS OF THE UTERUS. 
symptoms for a long time. In all cases of epithelioma, in which the 
ulceration is not very extensive, and has not penetrated the vault of the 
vagina as far as the peritoneum, nor caused perforation, the actual cau- 
tery should be employed to destroy the luxuriating masses as far as possi- 
ble. In order to make the application thorough, it is always necessary 
to previously remove as much as possible of these masses either by the 
knife and scissors, or, when the proliferating tissue is soft, by Simon's 
sharp scoop. The cutting and scraping must be done under the guidance 
of the hand, after which a series of large cautery-irons is to be rapidly 
applied to the wound, and pressed in forcibly, so as to insure deep and 
thorough cauterization. This procedure is of course entirely unsuited 
in the more deep-seated, true carcinomata, especially as long as these 
have not broken down and become ulcerated; they would, in fact, bring 
about the very conditions that are most to be feared in carcinoma of the 
uterus, namely, ulceration and decomposition, and are, indeed, not at all 
indicated in cases of spontaneous putrid liquefaction in dense and deeply- 
seated carcinomata, nor in flat cancerous ulcers. 
When limited, however, to their proper sphere, namely, epithelioma 
with crumbling papillary excrescences, the results obtained are often 
wonderful. Hemorrhage, discharge and not seldom pain, at all events 
all the symptoms consequent upon breaking down and ulceration of the 
epithelioma, often cease for a long time. In fact many patients think 
themselves cured, and it happens not infrequently that the entire opera- 
tion-wound cicatrizes. From ten to twelve months may elapse before 
any symptoms due to a recurrence of the disease appear, the length of 
the interval usually depending upon how much it has been possible to 
scrape away and to destroy with the cautery. When the application has 
been thorough, its effects last on an average from one to six months, and 
the operation may be repeated several times with suitable intervals. 
The procedure simply anticipates as it were the natural course of the dis- 
ease, inasmuch as the tissues, which would slowly slough away with re- 
peated attacks of hemorrhage if the affection were let alone, are rapidly 
destroyed and removed, leaving a comparatively clean ulcer behind. In- 
stead of allowing the proliferating cancer masses to undergo slow destruc- 
tion, with symptoms which rapidly consume the strength of the patient, 
we secure to the latter a period of relief from the most agonizing symp- 
toms. 
The dangers of the operation are exceedingly slight. I have had but 
two deaths from pyaemia in the very numerous instances that have come 
under my personal observation. Nor have I ever had the misfortune to 
wound the peritoneum, for whenever I have been able to feel the perito- 
neal investment of Douglas's cul-de-sac, while engaged in scraping out 
the vault of the vagina, I have desisted from applying the actual cautery, 
and no noteworthy reaction ever set in. EPITHELIOMA AND CARCINOMA. 
399 
The vagina and the surrounding parts are best protected, as far as my 
experience goes, by the double-walled speculum of Matthieu, which I 
have used to the exclusion of all others since 1867, since which date I 
have not observed any burns. The speculum is made of metal and con- 
Fig. 47.-Matthieu s Speculum. 
sists of two concentrically arranged cylinders, closed at both ends, and 
provided on each side with a short projecting tube, to each of which a 
piece of rubber tubing is attached. Through one of the latter ice-water 
is conducted into the space between the cylinders, and passes off by the 
tube on the opposed side. 400 
NEW GROWTHS OF THE UTERUS. 
The operation itself is so insignificant and gives rise to so little pain that 
anaesthesia is unnecessary, although it is often used to prevent the shock 
experienced by timid patients at the sight of the incandescent cautery-irons. 
The galvano-caustic apparatus is not capable of developing the necessary 
degree of heat. At first it seemed as if Pacquelin's thermo-cautery would 
prove an excellent substitute for the ferrum candens, but after an extended 
trial of the former, I have found it best to return to the actual cautery. 
Charred blood and tissue-fragments quickly adhere to the plate of the 
thermo-cautery, forming a thick, porous layer, which is constantly be- 
coming covered by fresh deposits of coagulated blood, and thus prevents 
the heat rays from coming into direct contact with the diseased masses. 
The same deposit occurs of course on a cautery iron, but when one is ren- 
dered unfit for use, it may be removed at once, the vagina washed out, and 
a second, already heated, applied. When the thermo-cautery is removed 
it requires quite a time before the deposit can be burned off by bringing 
the blade to a white heat, and even this does not always succeed fully; 
while even when a second instrument is at hand, the heat cannot be so 
uninterruptedly applied as with a series of cautery-irons. 
In those cases in which the actual cautery seems no longer available or 
suitable, we can improve the condition of the cancerous ulcer, and tem- 
porarily arrest its growth by other caustics, such as I have already referred 
to. The chief of these are chloride of zinc, Vienna paste, solid caustic 
potash, and fuming nitric acid. Recently Routh,1 Schroder2 and others 
have spoken highly of applications of one part of bromine in five of 
alcohol; the parts that it is not intended to cauterize must be protected 
by linen rags dipped in a solution of bicarbonate of soda. 
Marion Sims (Annales de Gynecol. 1880) claims to have seen good results 
from the following procedure. The diseased masses are removed, and a 
tampon soaked in liq. ferri sesquichlorati is introduced into the vagina. 
Four days later tampons saturated with chloride of zinc (1:2 water) are 
used, the vagina being protected by tampons dipped in bicarb sod. Cica- 
trization is said to be developed in from ten to fourteen days. 
I have never been able to procure by means of the above or similar 
agents anything like the results obtainable by the red-hot iron, applied 
in the manner previously described, and I therefore look upon them, one 
and all, merely as adjuvants in those cases in which the actual cautery can 
no longer be resorted to. 
The treatment of the individual symptoms in epithelioma of the cervix 
uteri is as difficult as it is uncertain. Simple astringent vaginal injections 
often suffice to moderate a discharge which is mostly muco-purulent, or 
is slightly tinged with blood. We may employ for this purpose cold 
1 Transactions of the Obstetrical Society, London, VIII., p. 290. 
2 Henneberg: Ueber Behandlung der Carcinome des Cervix uteri mit alkohol- 
ischer Brom solution, Inaugural Dissertation, Erlangen, 1874. EPITHELIOMA AND CARCINOMA. 
401 
solution of sulphate of zinc, sulphate of copper, alum, tannin, pyrolignous 
acid, etc., of different strengths. When the discharge assumes a more 
foetid and putrid character, the injections should consist of solutions of 
substances which possess more pronounced antiseptic properties, such as 
chloride of lime, chlorine, permanganate of potash, tar, carbolic acid, 
creosote and salicylic acid. 
Powdered charcoal suspended in water makes quite an efficient injec- 
tion, but is rather uncleanly when used for any length of time. It is 
always advisable to use different solutions from time to time. Substances 
applied pure, or nearly pure, to a sloughing cancerous ulcer, arrest or 
diminish a putrid discharge with more certainty. In this respect I have 
had very excellent results from tampons saturated with absolute alcohol, 
applied in the manner first introduced in my clinic by Professor Zweifel. 
They seldom cause any considerable pain, and their disinfectant action 
upon the ulcer is usually energetic. Stuffing the vagina with small bags 
filled with powdered charcoal and carbonate of lime is a tedious and un- 
cleanly procedure, although it deprives the discharge to a great extent of 
its odor. 
But of all substances iodoform is the most useful as well as safest. 
Iodoform tampons lessen the discharge, and have the additional advantage 
of being safely left in the vagina for several days. 
In all cases the external genitals must be kept thoroughly clean, and 
should from the beginning be kept smeared with a bland ointment, in 
order to prevent the putrid discharge from giving rise to excoriations, 
which readily assume a bad condition, and also cause the patients much 
torment in other respects. 
If there be much hemorrhage, use injections of tannin or liq. ferri 
sesquichlorati dissolved in ice-water, and if these do not suffice, tampons 
moistened with liq. ferri sesquichl. of full strength. 
Pain is on the whole the one symptom of cancer of the uterus which 
we are least able to control. If it is more of a perimetritic character, due 
to reactive inflammation in the vicinity of a cancerous ulcer, it can some- 
times be assuaged by covering the abdomen with moist compresses, or 
poultices. In all other cases, in which we have to do with the true 
"cancer pains" of various kinds and degrees of intensity, our last re- 
source will always be opium and its preparations, especially morphine. 
Commence as a rule with the smallest efficient dose, and employ the drug 
at first as seldom as possible. Having once begun the use of these reme- 
dies, it is almost invariably necessary to continue them in constantly in- 
creasing doses until the death of the patient. It is well also to vary, from 
time to time, the method of administration of the narcotic, giving it at 
one time in its different preparations by the mouth, at other times by 
subcutaneous injection, or in the form of vaginal or rectal suppositories 
made up with cacao-butter. Small enemata, containing a little aqueous 402 
NEW GROWTHS OF THE UTERUS. 
extract of opium or something similar, are sometimes excellent. All the 
othex- procedures that have been recommended, such as the inflation of 
the vagina with carbonic acid gas, the introduction of bits of ice into the 
vagina, cutaneous inunctions of chloroform, the administration of chloral 
in various forms, and so forth, may be suitable and useful at times, but 
are much inferior to opium and morphine. 
Demarquay 1 recommends suppositories of a half to one gramme of iodo- 
form as having both an anaesthetic and a cauterizing effect. Lawrence8 
gives ergot in doses of two grammes every six hours, with good results in 
violent, throbbing pain due to carcinoma of the uterus. The same writer 
also recommends croton chloral hydrate internally, and carbolic acid 
locally applied. Wagner also advises the last mentioned. It is not pos- 
sible to mention here the innumerable remedies that have been recom- 
mended from all parts of the globe, suffice it to say that their very multi- 
plicity but demonstrates how few drugs we possess that can be relied on 
for overcoming the pain arising from cancer of the uterus, and also shows 
how great a role the merely subjective opinions of the individual physician 
play in this regard. 
It is as easy to point out the further indications of symptomatic treat- 
ment as it is difficult to accomplish anything with the agents prescribed 
therefor. In this connection I can only repeat that which I have already 
written in No. 18 of Volkmann's Clinical Lectures. 
Almost all sufferers from cancer of the uterus become dyspeptic at an 
■early date, and take scarcely any nourishment. Whenever this is the case 
the diet should be appetizing, and at the same time nutritious and easily 
digestible. In place of regular meals it is often advisable that patients 
take a small quantity of food every hour, and take most of it cold. It 
becomes still more difficult for patients to take sufficient nourishment 
after they have once been attacked by uncontrollable vomiting and chok- 
ing sensations, that so often occur in this disease; whether these symp- 
toms be caused by the foetid odor of a putrid vaginal discharge, or be 
simply an aggravated condition of previously existing dyspepsia, the 
vagina should as often as possible be washed out with strong disinfectants, 
the apartments of the patient should be well aired, or should often be 
changed, and particular care should be taken to ensure good ventilation 
at night. I have often seen much benefit accrue in these cases from hav- 
ing the patients covered with a rubber sheet from the false ribs downwards; 
to a great extent this keeps away the odoi' from the patient and those around 
her, if the most scrupulous cleanliness be exercised at the same time. 
As useful in controlling the vomiting maybe mentioned ice, water-ices, 
cold champagne, iced punch, cold milk and strong cold tea, but always 
1 Bulletin therapeutique, LXXI1., 1867, pp. 369-406. 
9 Med. Tinies, 1877, p. 310. EPITHELIOMA and carcinoma. 
403 
in very small quantities at a time. The bowels should also be carefully 
regulated in these cases, even though the patients prefer to have a move- 
ment but once in many days, because of the severe pain attending the act. 
If the vomiting be uraemic, it may often be checked in an astonishingly 
short time, even if only temporarily, by stimulating the secretion of the 
kidneys. For this purpose copious draughts of Vichy or similar mineral 
waters, and the administration of digitalis, acetate of potash, iodide of 
potassium, etc., are useful. 
Pregnancy, Parturition and Childbed in Cancer of the 
Uterus. 
In cases of carcinoma uteri pregnancy occurs most readily during the 
initial stage of the disease, where the carcinomatous infiltration is con- 
fined to the deeper layers of the mucous membrane, or where the affection 
presents as slight papillary excrescences. When the diseased parts have once 
begun to break down, not only is cohabitation more seldom practised, but 
the contact of semen with the ovum is impeded by various obstacles. 
Per contra, the literature of the subject abounds in examples of preg- 
nancy in cases of far-advanced sloughing cancer of the cervix uteri (com- 
pare Bagli and Cazel, Chantreuil, 1. c., p. 6). 
In 127 cases Cohnstein1 found twenty-one which the disease 
had been detected quite a time, as much as a year, before the incep- 
tion of pregnancy. When, however, Cohnstein attempts from this 
collection of cases to draw the conclusion that cancer of the cervix 
uteri actually favors conception, he is contradicted not only by most 
authors, but also by the fact that the complication of cancer of the 
cervix with pregnancy is, in general, exceedingly rarely observed. At 
the same time, it is quite remarkable that in fifty-eight cases of this de- 
scription Cohnstein found sixteen between twenty-seven and thirty-three, 
nineteen between thirty-four and thirty-seven, and twenty-three between 
thirty-eight and forty-nine years of age. Carcinoma of the cervix uteri 
occurs infrequently before the age of thirty, while parturition also occurs 
infrequently after the thirty-eighth year. At all events the above small 
figures are not sufficient to prove that carcinoma of the cervix favors con- 
ception. 
The course of pregnancy seems to depend essentially upon the loca- 
tion, or, to speak more precisely, upon the extent of the disease. The 
more the degeneration is restricted to the external os, especially if but one 
lip be involved, the less likelihood is there of pregnancy being interfered 
with; while in proportion as the affection extends higher up into the cervix, 
1 Ueber die Complikation der Schwan gerschaft und Geburt mit Gebarmutter- 
krebs, Archiv ftlr Gynakologie, V., p. 366. 404 
NEW GROWTHS OF THE UTERUS. 
and particularly when it has penetrated up to or beyond the internal os, 
the greater is the probability of an abortion or a premature birth, proba- 
bly as a consequence of diminished capability of development of the lower 
segment of the uterus. In other cases the interruption of pregnancy is 
due to a succession of severe hemorrhages, for which reason it may be 
said that epithelioma is more likely to cause a miscarriage than is true 
carcinoma. 
Lewes states that forty per cent, of 120 women affected with cancer of 
the cervix aborted (cited by Chantreuil, 1. c., p. 14). Cohnstein found 
that the proportion of premature births was lower. Thus, in 107 cases 
delivery took place eighty-eight times at full term, while abortion occurred 
fifteen times, and in two instances the duration of pregnancy was longer 
than normal. 
The last-mentioned occurrence, so-called " missed labor," has been ob- 
served in several cases of cancer of the cervix uteri, and is certainly a re- 
markable phenomenon. The best-known example of the kind is that of 
Menzies.1 In this instance, after pregnancy had already lasted seventeen 
months, the woman died undelivered; the foetus was flattened out, and 
showed no trace of decomposition, while the amniotic fluid had been 
entirely absorbed. Judging solely from the report of the case, as given 
by Chantreuil, it seems to me not improbable that it was a case of extra- 
uterine foetation, complicated with epithelioma of the uterus. Depaul- 
Schmidt's2 case cannot be reckoned with certainty as one of missed labor, 
for while it is stated that the patient was affected with carcinoma of 
the lower segment of the uterus, and was somewhere in the tenth or 
eleventh month of pregnancy, it was not possible to determine the exact 
duration, and the pains were lasting and energetic, although not powerful 
enough to accomplish the delivery of the child. 
The only undoubted cases of missed labor, caused by carcinoma of the 
cervix, are the following. Miller's 3 patient died some time after the nor- 
mal end of pregnancy, without having been delivered; mild pains had 
occurred on several occasions, but had not led to the initiation of labor. 
Playfair4 reported an instance of cancer of the uterus, in which violent 
hemorrhage led to the death of the foetus in the sixth month of pregnancy; 
this was followed by labor pains, not strong enough, however, to accom- 
plish the delivery of the foetus. The product of conception underwent 
decomposition, and was expelled in fragments at long intervals. 
Beigel6 mentions a similar case. In all of these instances it is presuma- 
' Glasgow Journal, July, 1843, p. 229,f reported in full by Chantreuil, 1. c., p. 16. 
2 Archives de Tocologie, III., p. 111. 
3 Simpson, Obstet. Works, 1867, p. 498, and London & Edinburgh Monthly 
Journal for Medical Science, 1844, p. 279. 
Transact, of the London Obstet. Soc., X., p. 58. 
6 Lehrbuch der Frauenkrankheiten, p. 522. EPITHELIOMA AND CARCINOMA. 
405 
ble that labor, pains had occurred either at or before the usual time, but 
being unable to overcome the resistance offered by the hard and infil- 
trated cervix, had subsided. 
Cohnstein relates that seven patients died from spontaneous or artifi- 
cially induced abortion, five after, and two before delivery was accom- 
plished, and in premature labor one died before and ten after delivery. 
As regards the influence of pregnancy upon the course of the cancer- 
ous affection, several instances have been reported where the disease made 
no progress at all during pregnancy, remaining in statu quo. (Spiegel- 
berg.1) 
Fig. 48.-Carcinoma of the Body of the Uterus. Case of total extirpation of the Uterus. 
a, External Os. 
Cohnstein, indeed, found in cases in which carcinoma of the uterus 
had existed for rather a long time before conception occurred, that the 
latter seemed to react comparatively favorably upon the local affec- 
tion; thus, in thirteen cases of this kind, the disease was plainly acceler- 
ated in three, made no noteworthy progress in six, and came to a com 
plete halt in four instances. I will, however, venture to remind those 
who are inclined to draw the same deduction from these small figures, 
that it is controverted by a large number of observations showing that 
the symptoms of the disease first manifested themselves after conception, 
and that from that time on they speedily grew worse, under a rapid ex- 
tension of the degeneration. 
' Lehrbuch der Geburtshiilfe, 1878, p. 295. 406 
NEW GROWTHS OF THE UTERUS. 
Typical instances of this have been recorded by Depaul,1 Pfann- 
kuch,3 Galabin,3 Benicke4 and numerous other writers, and from my own 
limited experience also I am forced to maintain that, not only do the 
symptoms of cancerous disease quite often first develop during preg- 
nancy, but they quickly become intensified, corresponding to an astonish- 
ingly rapid growth of the neoplasm. 
It was formerly thought that the artificial induction of abortion or 
premature labor was the proper treatment in these cases, and Lee was 
perhaps the strongest advocate of this plan, but of late the practice has 
been almost universally abandoned. The reasons therefore will be most 
appropriately discussed when we reach the consideration of the phenomena 
of labor in carcinoma of the uterus. 
Starting out with the assumption that in cases of pregnancy complicated 
with cancer of the cervix, the chief task of the physician consists be- 
yond a doubt in preserving the existence of the foetus, one is tempted to 
denounce local treatment in these cases. Now while it is certainly true 
that energetic local treatment, such as amputation of the vaginal portions 
the removal of the diseased masses, or the application of strong caustic, 
may bring on abortion or premature h<bor, yet experience has gradually 
taught us that these accidents do not necessarily follow those procedures, 
but that, on the contrary, the latter may favorably modify the course of 
the disease and lighten tlie burthen of the patient's existence, and may 
even influence the conduct of delivery, contributing thereby directly to 
the preservation of the life of the child. 
There can be no question that abortion has occurred after amputa- 
tion of a diseased portio vaginalis. Instances of this have been reported 
by Cohnstein, Benicke B and many others. I have myself seen several. 
On the other hand a large number of cases of this kind, some of older 
date, but most of them of recent occurrence, have been reported, in which 
the operation or a similar procedure did not interrupt pregnancy, delivery 
occurring at the normal time, and terminating more or less favorably. 
Instances of this have been communicated by Schatz,8 Schroder and 
Benicke.7 Rutledge states that in eight operations of this description, 
gravidity was interrupted but three times. Galabin 8 amputated a diseased 
cervix in the first month of pregnancy with the galvano-caustic wire, 
1 Archives de Tocologie, I., p. 442. 
2 Arch, fur Gynakologie, VII., p. 169. 
3 Obstet. Transactions, London, XVIII., p. 286. 
4 Zeitschrift fur Geburtskunde und Gynakol., I., p. 337. 
5 Zeitschrift fur Geburtshiilfe und Gynakologie, I., p. 337. 
6 Arch, fur Gynakologie, V., p. 161. 
7 Loc. citat., p. 337; Archiv f. Gynak., X., p. 405. Schroder, Lehrbuch, etc., 
p. 392. 
8 Obstet. Journal, IV., p. 539. EPITHELIOMA AND CARCINOMA. 
407 
abortion not occurring, and delivery being accomplished at full term. 
Godson Savory1 removed an epithelioma of the external os with the 
ecraseur in thq seventh month of pregnancy, and a living child was born 
at the end of the tenth month. Although a recurrence took place, the 
patient shortly afterwards conceived again, and miscarried in the seventh 
month, the child being born alive, but dying immediately afterwards, and 
the mother dying thirteen days later. 
Wiener 2 amputated the cervix for cancer, and three days after the 
operation childbirth followed. 
C. Braun 3 advises the removal of all vaginal masses during pregnancy. 
If the cancer is confined to the uterus, he favors premature delivery, fol- 
lowed by total extirpation of the uterus. Where this is not practicable 
it may be well to wait until full term and then perform Caesarean section, 
in order to save the child. 
Spencer Wells 4 successfully performed Freund's operation in a woman 
six months pregnant. Bischoff 5 did a similar operation in the eighth 
month of pregnancy. The mother died but the child was saved. 
In another case of small cervical cancer Bischoff induced premature 
delivery. Eight days after the birth of a living child, he removed the 
diseased cervix by amputation. The woman recovered and years later 
gave birth to a living child. 
In view of the above facts it seems to me that it is the duty of the 
physician to remove as thoroughly as possible the diseased parts, even 
when gravidity is present, whenever there is a reasonable hope of being 
able to operate through sound tissues, and of either curing the disease 
radically, or of arresting its further progress for a lengthy period. If the 
area of the disease is so large as to render an operation of this kind no 
longer feasible, we are not justified in scraping or cauterizing the affected 
parts during the existence of pregnancy, unless the disease is making 
rapid progress and hemorrrhage and sloughing threaten the life of the 
patient. If this is not the case, and if the degeneration is not extending 
at all or but very slowly, all operative measures are contra-indicated as 
liable to endanger the existence of the fcetus. 
Whether delivery takes place before the normal end of pregnancy, or 
at full term, in cases of cancer of the lower segment of the uterus, its 
course depends altogether on the extent of the disease at the time. If 
only one lip of the os be affected, even a mature and fully developed 
infant may be easily and quickly born, either the diseased part participat- 
ing in the dilatation of the os, or the sound lip alone stretching sufficiently 
1 Obstet. Journal, III., p. 47; Obstet. Transactions, London, XVII., p. 82. 
2 Breslauer arztl. Zeitschrift, 1880, Nos. 4 and 5. 
3 Felsenreich : Wiener Med. Presse, 1883. 
4 Med. Chirurg. Trans., 1882. 
6 Correspb. Schweizer Aerzt., No. 4, 1881. 408 
NEW GROWTHS OF THE UTERUS. 
to permit of the passage of the head. Cases of this kind have been 
recorded by Cazeau, Chantreuil, Spiegelberg and others. Judging from 
Cohnstein's series of cases it appears to make a difference whether it is the 
posterior or the anterior lip that is affected. When the posterior lip alone 
was diseased spontaneous delivery always terminated favorably for mother 
and child alike, but when the degeneration was confined to the anterior lip 
the result was favorable for the mother in 87.5 per cent, and for the child 
in 83.3 per cent, of the cases. If this difference is not a mere coinci- 
dence, it may be attributed to the greater importance in general of the 
anterior lip of the os during childbirth. 
When both lips of the os, or the greater part of the vaginal portion is 
diseased, the resistance offered to delivery is so great that the latter very 
rarely terminates spontaneously. The pains are very seldom capable of 
dilating the infiltrated and unyielding lower segment of the uterus; and 
when delivery occurs spontaneously it is usually only after severe and deep 
lacerations of the diseased parts, which may extend into the cavity of the 
peritoneum, or after the degenerated tissue has been squeezed and 
crushed to a pulp. Under these circumstances profuse hemorrhage with 
subsequent rapid decomposition of the crushed parts, peritonitis, and 
septicaemia quickly lead to the death of the mother. Almost all the 
infants perish in these cases from the tedious course of birth, which, 
moreover, usually requires artificial aid for its completion. 
Depaul1 describes a case of cancerous tumor involving the whole of the 
cervix, in which a six months' foetus was born spontaneously, although 
delivery proceeded very slowly. Other cases have been reported, chiefly 
by Chantreuil, and also by Levret, Loenhardtt, d'Outrepont, Kilian. 
Nagele, and Pcdelaborde (loc. citat. pp. 25 to 28). Martel2 also wit- 
nessed the birth of a dead foetus after a labor lasting forty-five hours, the 
mother recovering. Cohnstein found that spontaneous delivery termi- 
nated favorably for the mother in 37.5 per cent., and for the child in 33.3 
per cent, of these cases. When the disease involved the entire cervix the 
percentage of recoveries was only 34.7 for the mothers, and 25.0 for the 
children. In one hundred and twenty-eight cases of unassisted labor at 
the normal end of pregnancy there were twelve fatal cases of rupture of 
the uterus, and five instances of laceration of the cervix, in three of which 
the death of the patient resulted. Of Herman's (1. c.) 180 cases, fifty- 
one were delivered normally at full term, and sixteen of the women diefl. 
In the more aggravated cases of cancerous disease which involve the 
whole of the cervix up to or beyond the internal os, and which are asso- 
ciated, as so often happens, with infiltration and degeneration of the sur- 
rounding cellular tissue, it may be asserted that spontaneous delivery is 
impossible. The dense, infiltrated parts offer an insuperable resistance, 
1 Arch, de Tocologie, I., p. 442. 
2 Ibid., IV., p. 745. EPITHELIOMA AND CARCINOMA 
409 
and the pains are not powerful enough to crush the intervening tissues. 
If timely operative assistance be not afforded the patients die undelivered 
from rupture of the uterus, hemorrhage, or septicaemia originating gener- 
ally in decomposition of the foetus, or exhaustion. Such cases have been 
described by Depaul,1 Churchill,2 Oldham,3 Simpson,4 and Pfannkuch.5 
The character of the subsequent period of childbed in these cases 
depends chiefly upon the gravity of the labor. If the latter have occurred 
spontaneously and without much difficulty, the women often make won- 
derfully quick recoveries, and sometimes even become pregnant once 
more (Savory-Godson, 1. c.), only to succumb to their disease after a 
longer or shorter time. In most instances, however, and even after 
a comparatively easy confinement, the disintegration of the cancerous 
tissue acquires a fresh impetus, and the patients rapidly sink under the 
exhausting influence of childbed. The more difficult the labor, the more 
frequently and the more rapidly does childbed run this course; the larger 
the mass of cancerous tissue destroyed, and the deeper the coincident 
lacerations, the more quickly does necrosis extend in all directions, to be 
followed by fatal peritonitis, pyaemia, thrombosis, etc. Heywood Smith 6 
lost a patient affected with epithelioma, from post-partum hemorrhage, 
four days after spontaneous expulsion of a five months' foetus. In Edis'7 
and Depaul's cases death was due to pyaemia and septicaemia. 
The diagnosis of cancerous disease of the lower segment of the uterus 
during pregnancy or parturition can only be difficult when the affection 
is in its incipiency. I have already discussed the possible sources of error, 
and will now only repeat that mistakes may occasionally be committed in 
spite of the utmost care. Imperfect or delayed dilatation of the os in 
parturient females may be a guide to a certain extent, but even here it is 
necessary to guard against error. Newman's8 case is very instructive in 
this connection. The os not dilating and the cervix being extremely hard 
and infiltrated, carcinoma was diagnosed, and Caesarean section performed, 
from which, fortunately, the patient recovered. Becoming pregnant 
again six years later, the woman was easily delivered with the forceps of 
a mature child. Two years afterwards she died of a strangulated ventral 
hernia (the result of the Caesarean section), and no trace of cancerous dis- 
ease was discoverable on post-mortem examination. This case would 
scarcely be classed as one of spontaneous cure of cancer of the uterus. 
1 Chantreuil, 1. c., p. 43. 
2 Ibid., p. 48; and Maladies des Femmes, Paris, 1866, p. 397. 
3 Ibid., p. 51. 
4 Obstetrical Works, I., p. 648. 
5 Arch, filr Gynakologie, VIL, p. 169. 
6 Transactions of the Obstet. Soc., London, XIV., p. 67. 
7 Obstetrical Transactions, London, XVII., p. 344. 
8 Ibid., VIII. and XVII., p. 213. 410 
NEW GROWTHS OF THE UTERUS. 
Among other errors, the degenerated parts have been mistaken at the 
commencement of labor for the placenta (Lachapelle, Lecorche-Colombat, 
Chantreuil, 1. c. p. 56), for foetal hands and feet (Depaul, Cazeaux'), for 
the child's head (Boivin and Duges), and for the breech (Chantreuil, 1. c. 
page 56). But in all of these cases careful and repeated examinations soon 
cleared up the diagnosis. 
It is evident from the foregoing that the prognosis of carcinoma of the 
uterus during pregnancy and at the time of parturition depends mainly 
upon the extent of the disease. The greater it is, the more difficult will 
confinement be. A second weighty factor is the general cpnditiou of 
the patient. If but slight indications of cachexia are present the patient's 
chances of surviving labor and childbed are better than if a high degree 
of anaemia and cachexia already exist. In Chantreuil's collection of sixty 
cases, twenty died during or immediately after confinement, the remainder 
passing through this ordeal safely, but eventually succumbing to the dis- 
ease. Of these twenty-five patients, six perished in consequence of rupture 
of the uterus, nine from peritonitis, and seven after grave operative 
measures, including multiple incisions, version, craniotomy, embryotomy, 
and excision of the tumor: the cause of death is not mentioned in three 
instances. Of the children twenty-nine were born dead, and twenty-eight 
alive, while nothing is stated of the fate of three others. 
Cohnstein found that of one hundred and twenty-six mothers fifty-four, 
or 42.9 per cent., survived childbed, the remainder dying during or after 
labor. Of one hundred and sixteen children, concerning whom informa- 
tion was obtainable, forty-two, or 36.2 per cent., were born alive, and 
seventy-four, or 63.8 per cent., were still-born. Of the latter class seven 
were killed by perforation or embryotomy, one, a six months' foetus, was 
delivered by Caesarean section, fourteen died in consequence of the death 
of the mothers before delivery was accomplished, and six perished during 
tedious labors, or after version, etc. 
By eliminating these deaths, as being consequences of treatment and 
not of the disease itself, Cohnstein finds that the mortality of the children 
in cases of cancer of the uterus is only 38.8 per cent. This elimination, 
however, is not entirely justifiable, inasmuch as the method of treatment, 
whether appropriate or not in the individual cases, was prompted mainly 
by the complicating disease. 
From Herman's figures we learn that out of 180 cases, the mothers 
succumbed in seventy-two. Eleven times death was due to rupture of 
the uterus. In thirteen women death took place before delivery. Of 
114 children, fifty-eight were born alive. 
1 Traite d'accouchement, Paris, 1867, p. 718. EPITHELIOMA AND CARCINOMA. 
411 
Treatment. 
When an epithelioma is restricted to one lip of the cervix there is 
reason to hope, for reasons above-stated, that labor will be accomplished 
spontaneously, and treatment should, therefore, for the time being be 
merely expectant. In all other cases, however, active interference is 
imperatively required, as soon as it is noticed that the diseased os is dilat- 
ing imperfectly and slowly, in spite of regular pains. Delay in these cases 
is always fatal to the foetus, and since the mother's disease is incurable, 
our efforts should be directed to saving the life of the child. 
Treatment must also be prompt in those cases in which a partial degen- 
eration of one lip prevents dilatation from taking place regularly. Only 
two methods of dilatation are available in these cases, either the application 
of Barnes's dilators, (laminaria and sponge-tents not being sufficiently 
active,) or incisions into the affected tissues. At the same time both 
procedures are efficient only when the pains are powerful and the area of 
the disease is so small that we may at least hope that nature will be able 
to complete delivery. In other cases the above-mentioned procedure 
may render possible the employment of other operative measures. Thus 
Savory 1 dilated the os with Barnes's dilators only sufficiently to allow him 
to turn a seven months' foetus. The latter, however, died during the 
operation, and the mother succumbed on the thirteenth day of childbed. 
A. Edis2 dilated the os with the same instruments until he was able to 
apply the forceps, and succeeded in extracting a fully developed, living 
child. The mother died of pyaemia two weeks later. 
Spiegel berg3 was more fortunate: after incising the os he delivered a 
living child with the forceps, while the mother passed safely through 
childbed. Other favorable cases have been reported by Gucniot and 
de Kataie,4 the latter after dilatation of the os with sponge tents, and 
subsequent application of the forceps. On the other hand it not seldom 
happens that incisions do not suffice to allow delivery to be accomplished 
quickly, and both mother and child perish. (Malgaigne, Chantreuil, 1. 
c., p. 75.) 
Cohnstein collected nine cases in which incisions had been made, one 
of them without any additional operative interference. Fifty per cent, 
of the mothers survived labor, and 62.5 per cent, of the children were 
born alive. Naturally the incisions easily lead to further crushing and 
laceration of the diseased lower segment of the uterus, and cannot, there- 
fore, act as sure preventives of rupture of the uterus or of peritonitis. 
'Obstetrical Transactions, XVIL, p. 82. 
2 Ibid., XVIL, p. 344. 
3 Monatsschrift f. Geburtsk., XI., p. 18. 
4 Chantreuil, loc. citat., pp. 80 and 87. 412 
NEW GROWTHS OF THE UTERUS. 
When incisions into the os do not suffice to bring about the desired re- 
sult, it is advisable to remove with the scoop or scissors as much as possi- 
ble of the cancerous masses, and to follow this up by delivery with forceps 
or by turning. Bischoff 1 practised this method in four cases, saving all 
the mothers as well as their offspring. C. Braun2 also favors this proced- 
ure, particularly as it permits a more radical operation after delivery. 
The forceps will be very serviceable in all cases in which the os is suffi- 
ciently dilated to render its application feasible, and the foetal head has 
descended low enough into the pelvis to allow of extraction. Although 
the use of the instrument may be attended with extensive lacerations of 
the maternal tissue, the thereby induced abridgement of labor certainly 
inures to the benefit of the child. 
Herman (1. c.) states that out of nine cases of this kind the mothers 
died four times. 
Version and extraction ought, I think, to be restricted to those cases 
in which they are indicated by a malposition of the child, such as trans- 
verse or breech presentations. (Danyau, Depaul.) The prognosis is 
always very bad for the child in these cases on account of the difficulty of 
freeing the head and arms, and it does not, therefore, seem appropriate 
to perform version when the head presents, as has been recommended by 
Simpson, although the latter in one instance executed it with a favorable 
result for both mother and child. It was also successful in the hands of 
Galabin J A similar case of Godson's4 terminated very unfavorably. 
Cohnstein found that, in eleven cases of the operation but 18.1 per cent, 
of the mothers and 12.5 per cent, of the children survived. 
Craniotomy and embryotomy offer scarcely any advantage in cancerous 
disease of the lower segment of the uterus, for the foetus must, of course, 
be sacrificed, while the result for the mother is unfavorable. According 
to Cohnstein four mothers died in six operations of this kind, two of rup- 
ture of the uterus, one undelivered, and one during childbed. Chantreuil 
records three instances of craniotomy, in two of which the mothers died, 
and two instances of embryotomy, in one of which the mother expired 
during the operation. Galabin 6 reports a case in which he performed 
cephalotripsy through an os which admitted only three fingers, and 
then, not succeeding in extracting the child during the next three hours, 
he was compelled to resort to version before delivery could be effected. 
Valenta" lost a patient from the same operation from a laceration extend- 
ing to the peritoneum. Freund 7 had a somewhat similar experience. 
1 Gonner : Zeitschrift f. Gynakologie, vol. X., 1884. 
2 Felsenreich, 1. c. 
3 Obstet. Journal, IV., p. 139. 
4 British Medical Journal, 1877, p. 231. 
5 Obstetrical Journal, IV., p. 539. 
6 Archiv fur Gynakologie, X., p. 405. 
1 Ernst: Inaug. Dissert. Strasburg, 1882. EPITHELIOMA AND CARCINOMA. 
413 
Now, although induced abortion offers a better prognosis for the mother 
than does labor at full term, yet the opinion is universally accepted that 
in view of the undeniably incurable disease of the mother, the former 
operation should be rejected, in order to save, if possible, the life of the 
infant. It has already been demonstrated that abortion is not to be feared 
in those cases in which there is a prospect of cure, or of long-continued 
improvement for the mother. When, however, the disease is so far ad- 
vanced as to forbid this hope, the induction of premature labor is entirely 
out of the question, since it does not guarantee any noteworthy benefit to 
the mother, while it materially impairs the prognosis as far as the child 
is concerned. 
Caesarean section offers better prospects, and it is our only resource 
whenever the pelvic cellular tissue is affected, and the degeneration has 
extended beyond the internal os. If performed at the proper time, it 
ensures the preservation of the child, and does not even, as experience 
proves, always entail the death of the mother, although the latter, of course, 
succumbs eventually to the disease. For these reasons Caesarean section 
should be resorted to in those cases also in which delivery is possible in 
other ways, but which at the same time, however, offer only slight pros- 
pects of saving the life of the child. 
The following comprises all the cases of Caesarean section for carcinoma 
of the uterus, that I have been able to collect. Bartholinus1 performed 
the operation for rupture of the uterus, the foetus being dead at the time, 
and the mother expiring on the following day. 
Oldham2 saved both mother and child. In Greenhalgh's3 case the 
patient died eighteen months later: nothing is stated as to the fate of the 
child. Galabin4 performed the operation upon a woman who was in 
labor in the eighth month of pregnancy, and who was already in a des- 
perate condition. The foetal heart sounds were no longer audible,-in 
fact the child was dead, and the mother died shortly after the operation. 
Zweifel5 was more fortunate: the mother died five days after the opera- 
tion, but the child was saved. Schroder6 saved a child by doing Caesarean 
section, the mother dying on the third day. The cases of Bischoff and 
Spencer Wells have already been mentioned. Herman records twelve 
cases of this operation, with death of tbe mother in eight. Two of the 
children were extracted dead. Newman's 7 case does not belong in this 
category, as the patient was not affected with cancer of the uterus, as 
already pointed out. 
1 Cited by Cohnstein, 1. c., p. 381. 
2 Guy's Hospital Reports, 1851, XI., p. 436. 
3 Obstetrical Transactions, IX , p. 341. 
4 Ibid., XVIII., p. 386. 
5 Bechmann, Berliner Klin. Wochenschrift, 1877, No. 21. 
6 Frommel, 1. c. 
7 Obstetrical Transactions, VIII. and XVII., p. 313. 414 
NEW GROWTHS OF THE UTERUS. 
If the tumor appears susceptible of removal before or during labor, as 
much of it should be extirpated as is feasible, in order to allow of the 
child being delivered alive if possible. Cohnstein reports six cases of 
this kind, four of the children being exti'acted in a living condition, but 
two of them dying shortly afterwards; in the two remaining cases, one 
child was decomposed, while nothing is mentioned regarding the other. 
Of the mothers, four lived through childbed, and two died during that 
period. 
The question will always arise, after successful delivery, whether a 
radical operation should be done in the interest of the mother, either at 
once, or after the lying-in period has terminated. CHAPTER XIII. 
CANCER OF THE BODY OF THE UTERUS. 
L. Pichot: Etude clinique sur le cancer du corps et de la cavity de l'ut6rus, 
Paris, 1876.-Crede : Casper's Vierteljahrsschrift, 1852 f (quoted in Beitrage zur 
Geburtshiilfe und Gynakologie, III., p. 121).-Szukits : Zeitschrift der Gesellschaft 
d. Wiener Aerzte, 1857. f-Strobel: Ein Fall von Carcinom des Uterusgrundes, 
D. Erlangen, 1857. f-Forster: Scanzoni's Beitrage, 1860, IV., p. 30.-Saxinger : 
Prager Vierteljahrschrift, 1867, p. 118.-Oswald : Transact, of the London Obstet. 
Soc., XVIII., p. 122.-J. Veit: Zeitschrift fiir Geburtshiilfe und Gynakologie, 
I., p. 467.-Chiari: Wiener Med. Jahrbucher, 1877.-Spiegelberg : Archiv f. 
GynakoL, VI., p. 123.-Kormann : Ibid., VII., p. 386.-Leopold : Ibid., VIII., p. 
205.-Playfair (Priestly): Transact, of the London Obstet. Soc., XII., p. 116.-Pro- 
theroe Smith: Ibid., p. 299.-Chambers : Obstetr. Journal, I., p. 552.-Ponfick : 
Beitrage zur Geburtshiilfe, etc.; Berliner Geburtshiilfl. Gesellsch., II., p. 129.- 
Goldschmidt: Ibid., III., 120.-Breisky-Eppinger : Prager Med. Wochenschrift, 
1877, p. 78.-C. Ruge and J. Veit: Zeitschrift fiir Geb. u. GynakoL, vol. VI.- 
Veit: Deutsche Med. Woch., No. 1, 1883. 
BIBLIOGRAPHY. 
Anatomy. 
TSOLATED carcinoma of the corpus and fundus uteri was, until re- 
cently, a rare and imperfectly understood affection. Pichot col- 
lected, mainly from French and English sources, forty-four cases, the 
analysis of which furnishes the basis of his above-mentioned monograph. 
Until 1878 there were reported, in addition to that number, thirty-six 
others, in all eighty cases. Since then a much larger number of cases 
•has been placed on record, so that I have found 122 cases, including three 
unpublished ones of my own. 
A certain number of these must be deducted as being true sarcomata 
of the uterus. In the literature of older date disintegrating and slough- 
ing fibromata have not infrequently been mistaken for carcinomata of the 
fundus, but these cases have also been excluded by Pichot. Of course we 
exclude all those cases of cancer of the body of the uterus in which the 
affection is merely secondary to primary carcinoma of some other organ. 
Thus Oswald observed the propagation of the disease from an ovary, and 
Crede from the rectum to the uterus. 
As an illustration of the rarity of isolated cancer of the body and fun- 
dus of the uterus, Szukits met with but one instance of it in 420 cases of 416 
NEW GROWTHS OF THE UTERUS. 
cancer of the uterus. Schroder 1 estimates that there were 28 cases of 
cancer of the fundus in 812 cases of carcinoma of tlie uterus, that is 3.4 
per cent. According to Pichot's statements there would appear to be G 
cases of carcinoma of the corpus uteri in 100 of cancer of the uterus. 
Schatz * found the body of the uterus affected twice in 80 cases of cancer 
of the womb. 
Just as in cancer of the cervix, we may divide carcinoma of the cor- 
pus uteri into two great classes. The parenchymatous or infiltrated 
variety (following Kleb's3 nomenclature) seems to occur most frequently. 
This form is made up of more or less numerous, isolated, roundish de- 
posits, which consist of soft, succulent masses (encephaloid cancer) contain- 
ing polymorphous and sometimes cylindrical epithelial cells imbedded in 
a sparse interstitial tissue. In this manner large, spheroidal tumors form 
in the substance of the uterus, distending it just as fibromata do, but 
always presenting a smooth surface, as they are not made up of single 
protuberances, like some myomata. These cancer-nodes, moreover, sel- 
dom break through the enclosing muscular tissue of the uterus, to pro- 
ject into the uterine or peritoneal cavity. As seldom do they undergo 
purulent disintegration and ulceration. Klebs also points out correctly, 
that a large number of these cases have probably been mixed tumors, car- 
cino-Sarcomata. . It certainly militates for, rather than against this opinion, 
that this variey of neoplasm not very infrequently gives rise to multiple 
metastases. 
The second variety of cancer of the corpus uteri begins in the mucous 
membrane, probably in the glandular tissue, and either presents as a 
widespread infiltration of the mucous membrane, extending into the deeper 
layers, or beyond them into the muscular substance, or it manifests itself 
in the shape of isolated, polypoid excrescences which project into the 
cavity of the uterus. In either case necrosis and ulceration set in, ap- 
parently very early. 
In regard to both forms of this rightly-named mucous cancer (Schleim- 
hautkrebs) of the body of the uterus, recent investigations seem to show 
the possibility, to say the least, of their origin from newly-formed glands. 
Breisky4 detected in a patient suffering from uterine hemorrhages, nu- 
merous diffuse, polypoid excrescences attached by broad bases to the 
uterine mucous membrane, the cervix being healthy. On scraping away 
some of these growths as a therapeutic measure, and submitting them 
afterwards to microscopic examinations, Eppinger found that they pos- 
sessed a typical adenomatous structure, consisting of hypertrophic utri- 
cular glands, lined with cylindrical epithelium. A succession of hemor- 
1 Hofmeier: Zeitschrift f. Geb. u. Gynakol., vol. X. 
2 Archiv f. Gynakol., vol. XXI 
3 Handbuch der Pathologischen Anatomie, 1876, p. 867. 
4 Prager Med. Wochenschrift, IL, 1877, p. 78. CANCER. 
417 
rhages recurring about four months later, more excrescences, similar to 
the previous ones, were scraped away, which were, however, softer and 
more friable, and possessed, even microscopically, a greater resemblance 
to cancer. On microscopical examination it was seen that the previously 
empty tubules were, now choked up with cells, and even that tubules 
which were invested with cylindrical epithelium at their periphery con- 
tained pavement epithelium and cancerous plugs in their centres. I am 
Fig. 49.-Adenoma of the Mucous Membrane of the Uterus. (After Breisky.) 
indebted to Professor Breiskyfor his kindness in allowing me to reproduce 
his illustrations of these specimens in this place. 
J. Veit1 describes a polypoid excrescence, growing from the mucous 
membrane of the body of the uterus, which was expelled spontaneously 
after dilatation of the os. The growth was found to contain gland 
tubules, plugged up with epithelial elements. 
According to Ruge-Veit (1. c.) cancer of the body of the uterus inva- 
riably arises in the mucous membrane. They distinguish a diffuse in- 
filtration from a polypoid form, the latter occurring in the shape of 
broadly-attached excrescences. Both varieties are characterized by their 
1 Zeitschrift f. Geburtshiilfe und GynakoL, I., p. 437 418 
NEW GROWTHS OF THE UTERUS. 
tendency to disintegration, so that we rarely encounter large growths. 
But the adjoining organs often suffer early from extension of the disease. 
Fig. 50.-Transition of Adenoma to Cancer. (From Breisky's case. fig. 49.) 
Fig. 51.-Transition of Adenoma to Carcinoma. (From the same specimen as figs. 49 and 50.) 
The papillary form of cancer, i.e., epithelioma, docs not occur on the 
mucous membrane of the uterus. CANCER 
419 
Etiology. 
It would be superfluous to repeat in this situation all the factors which 
enter into the causation of cancer in general, and which have been fully 
discussed in the chapter on Carcinoma of the Cervix. The disposition to 
carcinoma of the corpus uteri seems to develop at a more advanced age 
than is the case with carcinoma of the inferior segment of the uterus. 
In seventy-four cases, thirty-four of which are borrowed from Pichot, and 
the remainder from the sources mentioned at the head of this chapter, 
the distribution as to age was as follows: 
From 20 to 30 years, ..... 7 cases 
" 30 " 40 " 3 " 
" 40 " 50 " 12 " 
" 50 " 60 " 38 " 
" 60 " 70 " 13 " 
Over 70 years, ...... 1 case. 
This table shows a marked predisposition to the disease between the 
ages of fifty and sixty years, while in cancer of the cervix the greatest 
number of cases occur between the fortieth and the fiftieth year. 
Schroder1 calls attention to the fact that cancer of the body of the 
uterus occurs with remarkable frequency in nulliparous women. Hof- 
meier2 found six nulliparae in twenty-eight cases of this kind, i.e., 21 per 
cent., whereas of all other cases of cancer observed at the clinic of 
Schroder, only 2.5 per cent, had not given birth to children. Chiari's 
three patients, on the contrary, were confined within six months of the 
fatal termination, the disease making its appearance immediately after 
childbed and seeming to originate at the placental site. 
Symptomatology and Course. 
The symptoms occasioned by malignant tnmors of the body of the 
uterus resemble those of fibromata, especially in the incipient stages of 
the affection, and before purulent liquefaction has set in. Even after the 
development of the latter condition, they are often very similar to those 
of a sloughing myoma. This is particularly true of that form of carci- 
noma which occurs in the shape of knots and knobs. In all cases very 
intense, agonizing pain at an early stage is the most prominent symptom. 
Being caused by the rapid growth of the tumor it is much more violent 
and more constant than in cases of fibromata, where a sense of pressure 
predominates. When the tumors are spheroidal the pains often resemble 
labor pains, just as in cases of sub-mucous fibromata. In that variety of 
Handbuch der Krankheiten d. weibl. Geschechtsorgane, Leipzig, 1874, p. 280 
Zeitschrift f. Geb. u. Gynakol., vol. X. 420 
NEW GROWTHS OF THE UTERUS. 
carcinoma which begins in the superficial layers of the mucous membrane, 
suffering is complained of only after the disease has penetrated to the 
deeper layers, and attacks the nerve ends in the uterine substance, just 
as when cancerous destruction of the cervix spreads upwards and into 
the substance of the organ. 
At all events much more intense pain is felt, for above-mentioned 
reasons, in the early stages of carcinoma of the body of the uterus, 
than in the corresponding stage of ordinary epithelioma or carcinoma 
of the vaginal portion. But while the latter affections soon give 
rise to severe perimetritic and parametric symptoms by extension to 
the cellular tissue of the pelvis, this happens much more infrequently in 
cancer of the corpus uteri. Symptoms of pressure on the bladder and 
rectum are also very rarely observed, for the same reasons, and only de- 
velop in exceptional instances when these viscera are in contact with large 
cancerous growths, or when they participate in the disease. 
The second prominent symptom, hemorrhage, is even more constant, 
and thus again helps to simulate certain forms of myoma. While in 
cancer of the cervix, hemorrhages usually occur only after the tumor has 
begun to break down, in cancer of the corpus uteri they appear at first 
in the guise of profuse menstruation, and at a very early period, because 
the uterine mucous membrane is either actually diseased, or has, at least, 
undergone changes similar to those which take place in cases of intersti- 
tial fibromata. Very soon, however, an abundant, watery, serous dis- 
charge sets in, followed by profuse hemorrhages, as soon as the diseased 
tissues have commenced to ulcerate. 
Simultaneously with the latter, the discharge becomes either ichorous 
or purulent, and gives off a fetid odor, whiph is, however, seldom as in- 
tense as in cancer of the cervix, probably because the atmospheric air has 
not such free access to the ulcerating parts. 
These two symptoms, pain and hemorrhage, are the only distinctive 
symptoms of the disease. All further symptoms and signs depend upon 
how extensively or how soon the peritoneum participates in the morbid 
process, whether the cancerous infiltration spreads to the neighboring 
organs, and whether or where metastatic deposits occur. As neither of 
these events is quite common, death rarely takes place very quickly. 
Playfair mentions an instance, however, in which the tumor perforated 
into the 'abdominal cavity, with a rapidly fatal result. As ichorous dis- 
integration usually sets in late in the course of the disease, and with 
but moderate intensity, cachexia develops very slowly. All these facts 
help to explain why it is that cancerous affections of the body of the 
uterus run a much slower course than cancer of the cervix. Pichot found 
that only in four out of twenty-five cases was the duration of the disease 
less than a year, while in four it was more than four years. The average 
duration according to the same author, is thirty one months. CANCER. 
421 
Diagnosis. 
The differential diagnosis from cancer of the vaginal portion is very 
readily made, for the simple reason that in isolated cancer of the corpus 
uteri the cervix is perfectly healthy, both to the touch and on examina- 
tion with the speculum. It usually possesses the same shape and consis- 
tency that is found in healthy uteri; more rarely it is shortened, the os 
being fully dilated. The latter is usually the case when cancerous poly- 
poid tumors project into the cavity of the uterus, and dilate its lower 
segment either mechanically or by exciting pains like those of labor. A 
similar condition, or at least a partial patency of the os may result when 
the diffuse affection of the mucous membrane extends far downwards 
and transforms the uterine walls into unyielding, dense, infiltrated masses. 
As for the rest, the uterus is generally symmetrically enlarged and hard; 
but isolated, sensitive and exceedingly soft tumors can sometimes be 
detected as projections on its external surface. The enlarged and heavy 
uterus is as a rule freely movable, because there is usually no infiltration 
of the surrounding cellular tissue. Immobility of the organ when pres- 
ent, is generally caused by perimetritic adhesions. 
Another important diagnostic point is the discharge from the cervical 
canal, although sloughing fibromata occasion a similar discharge; but 
neither the microscopical examination of this fluid, nor the introduction 
of a sound into the uterus will suffice to establish the diagnosis with cer- 
tainty. Yet the diminution in depth of the cavity of the uterus, and the 
infiltrated condition of its walls, are very striking when contrasted with the 
symmetrical enlargement of the organ as ascertained by external palpa- 
tion. 
In order to arrive at a certain diagnosis it is first necessary to dilate the 
canal of the cervix and the internal os sufficiently to permit of the intro- 
duction of the finger into the uterus, when the infiltration of its walls, 
the hypertrophy of the mucous membrane, and the protuberant tumor 
masses can be distinctly felt. If a portion of the tumor be then removed 
and submitted to microscopical examination, we shall be able to determine 
whether it is a carcinoma, a sarcoma, or a softened myoma with which 
we have to deal. The smaller the particle of the tumor the more diffi- 
culty and uncertainty will there be in establishing an exact anatomical 
diagnosis. 
Treatment. 
In the treatment of these conditions, it is clear, after what has been 
already said in connection with malignant disease of the cervix, that re- 
moval of the affected organ is alone to be thought of. Of course this 422 
NEW GROWTHS OF THE UTERES. 
applies only to those cases where surgical interference is still feasible, 
owing to the fact that the neoplasm is confined to the uterus. 
Now, although quite a large number of operations have been reported, 
it is difficult, at present, to decide which method should be employed. 
Amputation of the body of the uterus after laparotomy has been repeatedly 
practiced. But it is not always easy to decide how far the disease may 
have encroached upon the cervix. In several cases recurrence from the 
cervix, which was allowed to remain, has been observed. Hence total ex- 
tirpation of the uterus is after all the safest procedure. From what has 
been already said concerning this operation, it appears that the vaginal 
method of total extirpation is to be preferred. When this is impracticable 
the operation of Freund is called for. I have collected the following in- 
stances of operations of this kind: Fifteen cases of amputation of the 
uterus following laparotomy (thirteen of these cases belong to Schroder), 
with four deaths, i.e., 26 per cent. Three total extirpations after the 
method of Freund, with two deaths. Ten total extirpations per vagi- 
nam, with one death. 
As regards recurrence of the cancer after these operations, we learn 
from Schroder (Hofmeier, 1. c.) that three of his patients died therefrom 
within one year. Four of his patients remained well more than two 
years, and one over five years. 
If a radical operation can not be done, the diseased masses are to be 
removed by the curette or scoop as thoroughly as possible. Care must 
be taken not to perforate with the instrument the infiltrated walls of the 
uterus (case of Spiegelberg, 1. c.). 
In addition to these measures we must employ the various caustics, in 
order to limit growth as far as possible, and to moderate hemorrhage and 
discharge. A detailed account of these measures has already been given 
in discussing sarcoma of the uterus. INDEX.' 
Abortion due to fibroids, 302 
Abscess of mammary gland, 32 
Absence of mammary gland, 10 
Absorption of fibroids, 223 
Acute mastitis, 30 
Adenoma of mammary glana, 71 
of the uterus, 340 
anatomy of, 341 
diagnosis of, 348 
symptoms of, 347 
treatment of, 350 
Anatomy of carcinoma of the mam- 
mae, 98 
Age in relation to fibroids, 203 
Anatomy of fibroids of the uterus, 166 
of the mammae, 1 
Areola, diseases of, 12 
atheroma of, 13 
Arteries of mammary gland, 2 
Ascites caused by fibroids, 221 
Atheroma of the areola, 13 
Atrophy of fibroids, 195 
of the mammary gland, 8 
Birth of fibroids, 213 
Breasts (vide Mammae) 
anatomy of, 1 
Calcification of fibroids, 196 
Canaliculated polypi of the uterus, 342 
Cancer of the body of the uterus, 415 
anatomy of, 415 
diagnosis of, 421 
etiology of, 419 
recurrence after operations, 422 
symptoms of, 419 
treatment of, 421 
of cervix uteri (see Epithelioma) 
Cancerous degeneration of fibroids, 197 
Cancer-pains in carcinoma uteri, 378 
Carcinoma of cervix uteri (see Epitheli- 
oma) 
of the body of the uterus (see Can- 
cer) 
of the mammae, 93 
course of, 112 
duration of, 121 
histology of, 98 
recurrence of, 123 
metastases, 118 
Castration for fibroids, 248 
Cauliflower excrescence of uterus, 355 
Changes of uterine fibroids, 190 
Childbed in cancer of the uterus, 403 
and fibroids, 316 
Chondroma of the mammae, 50 
Chronic eczema of the nipple, 12 
mastitis, 32 
Classification of tumors of the uterus, 
162 
Cohnheim's theory, 201 
Cold abscess of the mammae. 32 
Colostrum, 8 
Constipation in cancer of the uterus, 
381 
Course of fibroids, 222 
Cysto-adenoma of the mammae, 71 
Cysto-sarcoma of the mammae, 64 
symptoms and coui'se of, 68 
Cysts of the mammae, 85 
Cysto-fibromata of the uterus, 281 
diagnosis of, 290 
puncture of, 291 
symptoms of, 289 
treatment of, 292 
Deciduoma of the uterus, 346 
Decomposition of fibroids, 193 
Development of mammary glands, 4 
Diseases of the nipple and areola, 12 424 
INDEX. 
Diagnosis of fibroids. 233 
Differential diagnosis of fibroids, 238 
Discharge due to fibroids, 212 
in cancer of the uterus, 379 
Displacements of uterus in fibroids, 302 
Duration of cancer of the uterus, 383 
Dyspepsia in cancer of the uterus, 381 
Ectasia of the milk ducts, 3 
Emaciation in cancer of the uterus, 381 
Encephaloid cancer of the uterus, 416 
Endometritis cystica polyposa, 346 
fungosa, 342 
glandularis, 211 
Engorgement of the mammae, 15 
Enucleation of fibroids, 254, 260 
Epithelioma of the cervix uteri, 358 
anatomy of, 359 
diagnosis of, 384 
etiology of, 368 
symptoms of, 376 
treatment of, 388, 411. 
Erosions of the cervix uteri, 341 
Erysipelas of the mammae, 15 
Etiology of fibroids, 200 
of tumors of the mammae in gen- 
eral, 127 
Expulsion of fibroids, 225 
Extension of cancer of the cervix uteri, 
367 
Extirpation of fibroids, 250 
of the mammae, 153 
Fatty degeneration of fibroids, 194 
Fibroids of the cervix uteri, 182 
of the uterus, 161 
Fibroma of the mammae, 52 
Fibro-sarcoma of the mammae, 52 
Fibrous tabular adenoma of the mam- 
mae, 80 
Follicular hyperplasia of os uteri, 342 
Frequency of cancer of the uterus, 369 
Freund's operation, 394 
Frequency of tumors of the uterus, 162 
Galactocele, 43 
treatment of, 46 
Gangrene of fibroids, 193, 227 
Giant-celled sarcoma of the mammae, 
61 
Gland, mammary, 1 
Glands of Montgomery, 7 
Glandular lactiferce aberrantes, 8 
Glandular polypus of anterior lip of os 
uteri, 353 
Growth of fibroids of the uterus, 169,188 
Hemorrhage due to fibroids, 207 
in cancer of the uterus, 376 
in sarcoma of the uterus, 334 
Heredity, influence of on tumor for- 
mation in the mammae, 140 
Hernia of fibroids, 219 
Histology of fibroids of the uterus, 168 
Hypertrophy of the mammae, 72 
Incarcerated fibroids, 216 
Induration of fibroids, 195 
Infiltrated cancer of the uterus, 416 
Inflammation of fibroids, 191 
Inflammatory softening of the nipple, 
12 
Interstitial fibroids, 178 
Intramural fibroids, 178 
Intraparietal fibroids, 178 
Inversion of uterus caused by fibroids, 
215 
of the uterus due to sarcoma, 335 
Laparotomy for fibroids, 262 
Lipoma of the mammae, 48 
Lympho-sarcoma of the mammae, 58 
Lymphatic plexuses of the mammae, 2 
Mammae, animal parasites of, 151 
carcinoma of, 93 
continuous recurrence, 123 
infection recurrence, 124 
metastatic recurrence, 124 
regional recurrence, 124 
chalky concretions in, 37 
cysts of, 85 
development of, 87 
echinococci of, 157 
engorgement of, 15 
erysipelas of, 15 
extirpation of the, 153 
fibroma of, 52 
fibro-sarcoma of, 52 
fibrous tabulated adenoma of, 79 
giant-celled sarcoma of, 61 
hypertrophy of, 72 INDEX, 
425 
Mammae, hypertrophy of, symptoms 
and course of, 77 
treatment of, 78 
lipoma of, 48 
lympho-sarcoma of, 58 
medullary sarcoma of, 56 
melano-sarcoma of, 59 
neuralgia of, 41 
treatment of, 41 
osteoma of, 50 
proliferating cysto-sarcoma of, 64 
sarcoma of, 56 
soft cysto-adenoma of, 81 
angioma of, 48 
cholestraoma of, 92 
neuroma of, 48 
differential diagnosis of tumors of, 
144 
prognosis of tumors of, 144 
treatment of tumors of, 147 
Mammary glands, 1 
absence of, 10 
arteries of, 2 
atrophy of, 8 
nerves of, 2 
neuralgia of, 39 
treatment, 41 
of infants, 3 
supernumerary, 10 
tumors of, 47 
Marriage and fibroids, 204 
Mastitis, acute, 30 
chronic, 32 
nodular induration and shrivelling 
of mammae from, 34 
non-puerperal, 30 
puerperal, 16 
sequellae of, 27 
sub-acute, 30 
of the new-born, 30 
Mastodynia (vide Mammae, neuralgia 
of), 39 
Matthiew's speculum, 399 
Medullary sarcoma of the mammae, 56 
Melano-sarcoma of the mammae, 59 
Menopause in relation to cancer of the 
uterus, 373 
Metastases in cancer of the cervix 
uteri, 368 
Metastases in sarcoma of the uterus, 
333 
Mineral springs in fibroma uteri, 275 
" Missed labor" in cancer of the uterus, 
404 
Molluscum uteri, 344 
Montgomery's glands, 7 
Morbid changes of uterine fibroids, 
190 
Mucous cancer of the uterus, 416 
Necrosis of fibroids, 192 
Nerves of mammary gland, 2 
Nipple, diseases of, 12 
chronic eczema of, 12 
inflammatory softening of, 12 
tumors of, 13 
syphilitic ulcers of, 12 
Non-puerperal mastitis, 30 
Ossification of fibroids, 197 
Osteoma, 50 
Ovula nabothi, 345 
Pain due to fibroids, 212 
Papilloma cysticum, 354 
Papilloma of the uterus, 352 
anatomy of, 358 
diagnosis of, 354 
symptoms of, 355 
treatment, 357 
Parasites of the mammary gland, 157 
Parenchymatous cancer of the uterus 
416 
Parturition and fibroids, 307 
in cancer of the uterus, 403 
Pedicle of fibroids, 173 
Peritonitis due to fibroids, 220 
Polypi of the uterus (see Adenoma) 
Pregnancy and fibroids, 294 
in cancer of the uterus, 403 
Pressure symptoms due to fibroids, 217 
Prognosis of fibroids, 241 
Prolapsus uteri caused by fibroids, 214 
Puerperal mastitis, 16 
anatomy of, 18 
etiology of, 17 
symptoms, course and prognosis 
of, 23 
Recurrence of fibroids. 231 
" Rodent ulcer" of uterus, 362 426 
INDEX. 
Sarcoma coUi hydropicum papillare, 
330 
of the cervix uteri, 336 
of the mammae, symptoms and 
course of, 63 
(medullary) of the mammae, 56 
of the uterus, 324 
anatomy of, 325 
course of, 332 
diagnosis of, 335 
etiology of, 331 
prognosis of, 337 
recurrence of, 334 
symptoms of, 333 
transformation of other tumors 
into, 326 
treatment of, 337 
Scirrhus of the mammae, 95 
Sloughing of fibroids, 226 
Soft cysto-adenoma of the mammae, 81 
Spaying in fibroids, 248 
Spontaneous congestion and hemor- 
rhage of the mammae, 14 
Statistics of tumors of the mammae in 
general, 127 
Sterility due to fibroids, 294 
ue to polypi, 348 
Sub-acute mastitis, 30 
Sub-mucous fibroids, 175 
Sub-serous fibroids, 172 
Suppuration of fibroids, 191 
Supernumerary mammary glands, 10 
Symptoms of fibroids, 206 
Syphilitic infiltration of the mammae, 
34 
ulcers of the nipple, 12 
Theories as to tumor formation in the 
mammae, 136 
Total extirpation of uterus for fibroma, 
266 
Treatment of fibroids, 242 
Tuberculosis of the mammae, 33 
Tumors of the mammary glands, 47 
of the mammae, differential diag- 
nosis, 144 
prognosis, 144 
treatment, 147 
of the nipple, 13 
Urjemic symptoms caused by fibroids, 
218 
Vascularity of fibroids of the uterus, 
167 
Vomiting in cancer of the uterus, 381 
Wounds of the mammae, 14