CONTRIBUTIONS TO GYNAECOLOGY 
No. X. 
I. 
FIBRO-SARCOMATOUS TUMOR OF THE 
UTERUS 
OPERATION—RECOVERY 
11. 
CANCER OF THE RECTUM 
EXCISION—RECOVERY 
BY 
JOHN RYRMF, M.D.. M.R.C.S.E. 
Surgeon-in-Chief to St. Marj’’s Hospital for Diseases of Women, Brooklyn ; Late Clinical 
Professor of Uterine Surgery, Long Island College Hospital ; Fellow of the New 
York Academy of Medicine; Member and Ex-President of the New York Ob- 
stetrical Society; Fellow of the American Gynaecological Society; Cofre- 
sponding Member of the Gvnaecological Society of Boston; Permanent 
Member of the American Medical Association ; Member of the Kings 
County Medical Society; Member of the Brooklyn Anatomical 
and Surgical Society; and of the Pathological Society. 
Reprinted from the Annals of the Anatomical and Surgical Society, 
Brooklyn, Vol. ii, 1880, 
NEW YORK 
G. P. PUTNAM’S SONS 
182 Fifth Avenue 
1880 CONTRIBUTIONS TO GYNECOLOGY 
No. X. 
I. 
FIBRO-SARCOMATOUS TUMOR OF THE 
UTERUS 
OPERATION—RECOVERY 
CANCER OF THE RECTUM 
II. 
EXCISION—RECOVERY 
BY 
JOHN BYRNE, M.D., M.R.C.S.E. 
Surgeon-in-Chief to St. Mary’s Hospital for Diseases of Women, Brooklyn ; Late Clinical 
Professor of Uterine Surgery, Long Island College Hospital; Fellow of the New 
York Academy of Medicine; Member and Ex-President of the New York Ob- 
stetrical Society; Fellow of the American Gynaecological Society; Corre- 
sponding Member of the Gynaecological Society of Boston; Permanent 
Member of the American Medical Association • Member of the Kings 
County Medical Society; Member of the Brooklyn Anatomical 
and Surgical Society; and of the Pathological Society. 
Reprinted from the Annals of the Anatomical and Surgical Society, 
Brooklyn, Vol. ii, 1880, 
NEW YORK 
G. P. PUTNAM’S SONS 
182 Fifth Avenue 
1880 Press of 
G. P. Putnam's Sons 
182 Fifth Avenue 
New York. CONTRIBUTIONS TO GYNAECOLOGY. 
No. X. 
I. 
INTRA-UTERINE FIBRO-SARCOMA.* 
JOHN BYRNE, M.D. 
Dr. Byrne presented microscopic slides illustrating the 
histology of a case of intra-uterine tumor, which he had 
recently removed by operation. As shown by the sections 
presented, it belonged to the class of fibroids, but in his 
manipulation upon the growth he had not been able to 
detect any trace of a capsule enclosing it, and this fact he 
considered to be remarkable, as it was the first case of the 
kind in this class of tumors he had personally met with. 
The following is the history of the case: 
On December 13, 1879, I was requested to see Mrs. , aged 
42, the mother of six children, the youngest 13. Her family 
physician, Dr. Otto Rotton, informed me that until the winter of 
1876-77 she had always enjoyed the best of health ; she had had 
no miscarriages, and no disturbances of menstruation, except dur- 
ing pregnancy or lactation. 
Her first illness was a severe attack of bilious colic, accom- 
panied by vomiting, constipation and other symptoms, believed to 
* Presented at the meeting of the Anatomical and Surgical Society of Brook- 
lyn, January 19, 1880. 4 
JOHN B YRNE. 
be due to hepatic obstruction. During the succeeding twelve 
months she had repeated attacks of a similar nature, but always 
ushered in by spasms of an epileptiform character, and each time, 
as the paroxysm spent itself, she became deeply jaundiced. Fi- 
nally, anasarca, ascites and hydropericardium set in, and for a 
time her recovery seemed impossible, but ultimately these alarm- 
ing complications disappeared, and her general health improved 
slightly. 
In January, 1879, s^e was taken with what might be considered 
the first very severe attack of menorrhagia, though the catamenia 
had been gradually becoming more profuse for some months pre- 
viously. From this time the intermenstrual periods began to 
grow shorter and more irregular, so that for the last six months 
the flow has been almost continuous, and the slightest muscular 
exertion is followed by copious hemorrhage and excruciating 
pelvic pains. It is proper to state that a diagnosis favoring the 
existence of polypus had been arrived at previous to my seeing 
her. 
I found her condition, as might be expected from such a his- 
tory, truly deplorable. To the yellow tinge of the skin, which 
had never wholly disappeared, was now added a suggestive pallor, 
and an expression of helpless and hopeless anxiety characteristic 
of long physical suffering and exhausted powers of endurance. 
Owing to great dyspnoea on lying down, and a tendency to in- 
creased pain and hemorrhage when supported in the erect sitting 
posture, she was compelled, almost constantly, to assume a semi- 
recumbent position in bed. 
Her pulse was feeble and rapid, and on examining the heart, a 
systolic bruit was detected, while the liver was found to be some- 
what enlarged, and quite tender on pressure, particularly over its 
anterior lobe. On placing the hand over the hypogastrium, a firm 
and irregularly spheroidal tumor, the size of a uterus at four and 
a half months gestation, was found occupying a position not quite 
central, but slightly inclined toward the left. 
A vaginal examination was now made, carrying the finger cau- 
tiously up to the cervix, the uterus being steadied by the left hand 
externally, when a hard, smooth tumor was felt immediately within 
the os, and seemingly occupying the entire cavity. So far as the 
finger could reach and sweep around the presenting mass, it ap- 
peared to be free and detached, and any further investigation as 
to its character or the extent and nature of its attachment being INTR A-UTERINE FIBRO-SARCOMA. 
5 
deemed unwise, the diagnosis arrived at was uterine fibroid, prob- 
ably peduficulated. 
An operation with a view to its removal was advised, and though 
the employment of any ansesthetic was considered unsafe, she 
readily consented. 
December 18th, the patient having been placed on the left side 
and the uterus brought into view by a Sims’ speculum, a sound 
was passed into the cavity, in a direction toward the right and 
somewhat posteriorly, to the extent of six and a half inches. On 
withdrawing the sound and attempting to carry it into the cavity 
in any other direction, it was found impossible to do so, as it was 
arrested to the left and anteriorly at a point about three-fourths 
of an inch from the entrance. When again introduced as in the 
first instance, and an effort made to sweep around the tumor, the 
latter was now found to be sessile, its attachment occupying the 
entire left half and a portion of the anterior wall of the uterus as 
far as and including part of the fundus. 
The tumor was now seized by a strong vulsellum, and, in order 
to afford space for manipulation, the cervix was incised bi-laterally 
by galvano-cautery to the fullest extent practicable. Surmising 
that at least some considerable portion of 
the tumor might have its attachment to 
the uterine wall by loose cellular tissue, an 
attempt was next made to break up its con- 
nections, first by the index finger, and sub- 
sequently by means of a detached half of 
a flat-bladed polypus forceps. This instru- 
ment, being very deeply serrated, so that 
its edge was rough and saw-like, acted pre- 
cisely in the same manner as the invaluable 
device of Dr. Thomas for similar purposes, 
but beyond the separation of a very small 
portion at the lower part, its most energetic 
application produced no effect whatever on 
the dense fibrous substance with which it 
came in contact, and further efforts in this 
direction were abandoned. 
It now became a serious question as to 
the advisability of proceeding further, since a considerable amount 
of blood had already been lost, and the patient’s courage, as well 
as her strength, seemed fast ebbing ; nevertheless, as between 
abandoning the case at this stage, with no hope whatever of re 6 
JOHN B YRNE. 
covery, and risking her ability to live through a careful dissection 
of the mass from the uterus, there appeared but little choice, I 
decided to proceed as follows : 
Knowing that it would be impossible to dissect off the tumor 
entire, with so little space for manipulation, a loop of the galvano- 
cautery ecraseur was, with much difficulty, adjusted, so as to em- 
brace a large portion, say one-third, as shown by the dotted line 
in the cut. The excision of this part, which occupied but a few 
minutes, was thus accomplished without additional loss of blood, 
and its removal afforded ample space for the next and most criti- 
cal step in the operation. 
The remainder of the tumor was now firmly seized by a strong 
vulsellum, and by means of curved scissors the process of cutting 
through its base was cautiously proceeded with from below up- 
ward, and the entire mass thus removed piecemeal. 
Though this part of the operation occupied more than half an 
hour, there was but little blood lost, and as stimulants and resto- 
ratives had been freely administered from the beginning, her con- 
dition was on the whole fair, considering that she had now been 
nearly two hours on the table, and without any ancesthetic.* 
From the extreme hardness and density of the tissues through 
which the scissors passed, and the estimated thickness and cartila- 
ginous feel of the remaining uterine wall, coupled with the fact 
that there was a total absence of anything resembling a capsule, it 
seems quite probable that this large portion of the uterine body 
had undergone more or less diffuse fibrous degeneration. 
The uterine cavity having been carefully sponged out, the en- 
tire surface from which the tumor had been excised was now 
thoroughly cauterized by means of the dome-shaped instrument 
devised for such purposes, and an anodyne rectal suppository 
having been administered, the patient was put to bed. 
The subsequent history of this case, which was singularly and 
happily monotonous as regards serious complications and draw- 
backs, as well as the after management and treatment, may be very 
briefly stated. 
December 19th, twenty-four hours after the operation I found 
the patient quite cheerful, she had rested tolerably well during the 
night, and had taken and retained a fair amount of nourishment. 
* In addition to the effective cooperation of Dr. Rotton, I feel much in- 
debted for able assistance in this operation to my friends, Dr. Richard Hesse 
and Dr. Ernest Palmer. INTRA-UTERINE FIBROSARCOMA. 
7 
She only complained of an uncomfortable “ aching all over,” and 
a feeling “ as if she had been pounded.” 
On the third day she had a slight chill followed by a rise of 
temperature (102°), but without any local manifestation of pelvic 
or peritoneal inflammation, and no gastric disturbance. She was 
ordered full doses of quinine and opium, intra-uterine douches of 
warm carbolized water were employed twice daily, and in twenty- 
four hours all threatened complications had passed over. 
On the fifth day a copious purulent discharge mixed with 
particles of eschar and debris of fibrous material commenced and 
was kept up, but in gradually decreasing quantity for three weeks, 
when it finally ceased. It is also worthy of mention that no 
special precautions or topical measures of a haemostatic nature, 
beyond the thorough cauterization of the wound as already stated 
were resorted to, and there was no secondary hemorrhage whatever. 
Her progressive improvement now became more marked, and 
nothing worthy of note occurred until the end of January, nearly 
seven weeks after the operation, when she was alarmed by the ap- 
pearance of a sanguineous discharge accompanied by some pain, 
and which having continued for three or four days, I was again 
requested to see her. I found her much depressed in spirits 
and nervously apprehensive, lest the disease for the cure of 
which she had made such heroic sacrifices, had returned. In 
this anxiety, I fully but tacitly concurred and proceeded to make 
as careful an examination as circumstances would permit. 
I found the uterus quite moveable in all directions, and though 
still somewhat enlarged, not remarkably sensitive to such manipu- 
lation. On introducing a speculum, the most noticeable fact 
observed was the singularly normal appearance of the cervix, 
though trachelotomy had been performed but six weeks previously, 
and that too by galvano-cautery. Indeed, so little deformity was 
there that the most inveterate stickler for oral or cervical sym- 
metery might have been satisfied, nor could the laceration hunter 
however exacting, find any excuse for the display of his gynae- 
chirurgical dexterity. The flow which was observed slowly ooz- 
ing from the uterus did not present the appearance of active 
hemorrhage, but was in fact menstrual, and the cavity measured 
but little over three inches in depth, while on carrying the sound 
cautiously over its walls, especially the left, I could notice no ir- 
regularity of surface and no hyperaesthesia, nor was there any in- 
crease of the discharge following this examination. As a precau- 
tionary measure, however, she was advised to maintain the hori- 8 
JOHN B YRNE. 
zontal position for a few days, and to continue the use of quinine 
and iron which she had been taking for some weeks previously. 
Addendum. March 5th.—In conformity with the wishes of her 
attending physician, and in order to satisfy myself as to her 
present actual condition, I made my last visit to her. Had I 
entertained misgivings as to how I should find her, the alacrity 
with which she hastened down stairs, and her happy and cheerful 
manner would have quickly set at rest all such doubts. She in- 
formed me that her appetite was excellent, that she slept well 
and was amply able to superintend the duties of her household 
as formerly, but that she could not take much out-door exercise 
on foot without considerable fatigue. There has been no return 
of the catamenia up to the present time, and her physician in- 
formed her after an examination one week ago, that “ the womb 
had been restored to its natural size.” CARCINOMA OF THE RECTUM. 
9 
A CASE OF CARCINOMA OF THE RECTUM—OPERATION BY 
EXCISION—RECOVERY. 
JOHN BYRNE, M.D. 
Exsection of more or less of the rectal intestine for the 
removal of cancerous formation is, admittedly, a most 
hazardous surgical procedure, and at best one resorted to 
under certain pressing conditions only, and with the hope 
of obtaining for the unhappy victims of these maladies 
some temporary respite from suffering. The statistics 
of these, as of many other perilous operations, are as val- 
ueless as they are incomplete and meagre, and can afford no 
very reliable basis of estimate as to the dangers to be 
apprehended from hemorrhage, peritonitis, or septicemia, 
or how far we may be justified in expecting from such 
radical measures a degree of relief at all commensurate 
with the risk. 
By many of the highest surgical authorities, operative 
interference in cancer of the rectum is barely countenanced, 
while not a few look upon all such operations as useless, if 
not unjustifiable ; hence, in the majority of cases met with, 
whether in hospital or private practice, palliative measures 
alone, as by opiates and the like, usually constitute the 
entire treatment. In advanced stages of the disease only, 
and when fatal obstruction threatens, is the comparatively 
simple operation of colotomy, with its disgusting conse- 
quences suggested or undertaken as a dernier ressort. 
For my own part, and from a careful consideration of the 
subject, I am of the opinion that such operations should 
not, as a general rule, be resorted to unless when the disease 
is circumscribed, of limited extent, and situated low down 
in the intestine, yet above and clear of the sphincter. 
Moreover in the female subject, should the anterior rectal 
wall be involved, no possible benefit could be hoped for JOHN BYRNE. 
from excision, nor would any such interference be jus- 
tifiable. 
It is true if such experience as that of Prof. Niissbaum, 
of Munich, were made the sole basis of judging, rectotomy 
might seem entitled to a wider field than is here conceded, 
but if the positive risks and difficulties, and an equivalent 
necessarily problematical be duly considered, and a very 
moderate allowance made for unheralded disasters, the 
limit suggested would, in all probability, satisfy every de- 
mand of conservative surgery. 
Apropos of these reflections, the following may prove of 
more than ordinary interest: 
Mrs. T., aged 35, born in Canada, has been married 14 years 
and has had four children, the youngest two years. She says she 
has always enjoyed good health up to the fourth month of her 
last pregnancy, about which period, her bowels being then and 
for some time previously in a constipated state, she was taken 
with hemorrhage from the rectum, accompanied with “ bearing 
down ” pains like those of labor. Several attacks of a similar 
nature occurred during the following months of gestation, yet her 
confinement, at full term, passed over without any remarkable 
difficulty. Within a few days, however, she began to suffer much 
from constant lumbo-sacral pains, rectal tenesmus and obstinate 
constipation, while hemorrhage and excruciating agony attended 
every effort to evacuate the bowels. 
For a year past, but particularly during the last four months, 
her condition has been getting steadily worse ; no faecal dis- 
charges take place except from strong cathartics, and enemata 
have no other effect than to increase her suffering and provoke 
hemorrhage. In addition to all this she has had menorrhagia for 
the past six months. Up to quite recently she says she has been 
under homoeopathic treatment “ for the cure of her symptoms,” but 
without relief, and in entire ignorance of the true nature of her 
ailment. 
A few weeks ago she consulted Dr. Randolph, of this city, 
who at once diagnosed her case as one of cancer of the rectum, 
and advised her to apply for admission to St. Mary’s hospital. 
On examination a large cancerous mass of epitheliomatous CARCINOMA OF THE RECTUM. 
11 
character was found attached to the posterior wall of the rectum, 
which it entirely filled up and completely obstructed, commencing 
at a point about one inch from the verge of the anus and extend- 
ing up the intestine as far as the finger could reach. Much pain 
attended this examination, and considerable hemorrhage followed. 
The uterus was found to be healthy. An operation was proposed, 
and, being acquiesced in by the members of the Hospital staff, 
she readily consented. 
January 31, 1880.—The patient having been anaesthetized by 
ether, the perineum and recto-vaginal septum, as far as Douglass’ 
cul-de-sac, were slit up by means of a blunt-pointed scissors, 
guided by two fingers of the left hand. Hemorrhage to an alarm- 
CARCINOMA OF THE RECTUM. 
ing and almost fatal extent followed this first step in the opera- 
tion, but hypodermic injections of brandy served to restore the 
feeble heart’s action. The diseased part being now fully exposed 
was grasped by a vulsellum, and dissection by scissors commenced 
from below upward, but avoiding the sphincter, which was not 
involved. The lower third of the mass was movable, so that no 
great difficulty was found in drawing it forward and separating 
the intestine from its loose connections, but the upper and larger 
portion of the tumor involved the subjacent tissues, and, being 
firmly adherent to the sacrum, much difficulty was experienced in 
dissecting it out piecemeal. On examining the cavity a small 12 
JOHN B YRNE. 
glandular but not indurated body, the size of a hazel nut, was 
noticed in the upper left side of the pelvis, but as it was very 
deeply imbedded, and in dangerous proximity to large branches 
of the internal iliac artery, it was not deemed wise to attempt its 
exsection. Besides, the operation thus far was one of the blood- 
iest I had ever witnessed, and the patient seemed to be already 
in articulo mortis. The cavity was sponged out with a mixture of 
equal parts of acetic acid and glycerine, to which ten per cent, of 
carbolic acid had been added. The recto-vaginal wall and per- 
ineum were now stitched by interrupted sutures of carbolized 
silk, a vulcanite drainage-tube, of hour-glass shape at its rectal 
end so as to insure its retention, was inserted before tightening 
the last two perineal stitches, and the patient put to bed, but in 
an apparently moribund condition. Finally, to the free extremity 
of the tube a few feet of % inch rubber hose was attached, and 
its distal end immersed in a vessel of water for the reception of 
foecal and other discharges. 
By the application of warmth to the extremities and stimulants, 
reaction was gradually brought about, and at the expiration of 
an hour, one and a half grs. of opium was administered by the 
mouth. 
The following is an abstract of the record by Dr. Lubey, 
the resident physician :— 
February 1st, 9 a.m.—The patient has spent a comfortable 
night, having slept several hours, and is free from pain. Pulse, 
1x6 ; temperature, 100. 
7 p.m. —Has had a slight chill. Complains of pain in rectum. 
Pulse, 120 ; temperature 100. Ordered gr. iss of opium, and the 
rectum to be washed out with tepid carbolized water (two per 
cent). 
10 p.m.—Much more comfortable, and free from pain. Pulse, 
no ; temperature, 101. 
February 2d, 10 a.m.—Pulse, 112 ; temperature, 101. No 
pain. 
February 2d, 8 p.m.—Pulse, 120 ; temperature, Repeat 
injection by first washing out the cavity with carbolized water, 
and subsequently allowing one pint of the fluid to remain in con- 
tact with the parts for several minutes before draining off. Five 
grs. of quinine, and repeat the same night and morning. 
February 3d, 10 a.m.—Pulse, no; temperature, No 
pain. CARCINOMA OF THE RECTUM. 
13 
February 3d, 8 p.m.—Pulse, 116; temperature, iot. Repeat 
carbolized douche. 
February 4, 10 a.m.—Pulse, 112, and fuller, temperature, 100. 
Quite comfortable. 
February 6th.—The vagina and perineum examined by Dr. 
Byrne, and union found to be apparently perfect all along the 
line of incision. Sutures to remain in for twenty-four hours 
longer, and in the meantime to have a dose of castor oil, no 
faecal discharge having passed since day before operation. 
February 7th.—Castor oil, followed by copious discharges of 
faecal matter mixed with pus, but the vulcanite plug was forced 
out by the first movement, and the ano-perineal stitch torn away. 
Removed the sutures, and found union complete except at the 
outer sphincter. She says she had control over the last two evacu- 
ations, and but little pain. 
February nth.—No faecal discharges from bowels for two days 
past. No pain, but thinks she would feel more comfortable if the 
bowels were moved. Ordered ol. ricini § ss. 
10 p.m.—Bowels freely moved without much pain. 
13th and 14th.—Bowels moved without medicine, and little or 
no pain ; faeces of large calibre, and fair control over the sphinc- 
ter. She expresses herself as feeling quite well; takes plenty of 
nourishment, and sleeps each entire night through. A digital ex- 
ploration of the rectum was made by Dr. Byrne and other mem- 
bers of the Hospital staff, and nothing very abnormal observed. 
February 21st.—Has been up and exercising every day for the 
past week, and has fair control over the sphincter except when 
the contents of the bowels are in a liquid state ; laceration at 
anus granulating. She gains strength rapidly ; her expression and 
general appearance remarkably changed for the better. Having 
a great desire to return to her family, she was discharged. 
March 14th.—She returned, in accordance with instructions, for 
examination. Looks to be in excellent condition, and says she 
feels perfectly well, but would like to have a little more control 
over the contents of the rectum. Exploration by finger reveals 
nothing abnormal, and causes little or no pain or hemorrhage. Annals of the Anatomical and Surgical Society. 
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