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of the work in vaginal incision and vaginal puncture. In vaginal incision the pus sac is freely opened and drained, while puncture, as the name suggests, is only accomplished by a careful thrust of a needle, from which only a small portion of the septic matter could escape. Not only this, but the probability of reinfecting the pus cavity was very great. Practically, then, these two operations are distinct, and should not be referred to in the same connection. There are many apparent reasons why vaginal incision soon became a popular operation. We are all aware of the great tendency to remove tubes and ovaries about ten years ago, for the most trivial causes, real or imaginary. The results were not satisfactory. True, the patients recovered from the operation, but not 50 per cent. were cured. They would return complaining of the same or worse pains and the same nervousness. They felt no better, in fact worse, because they realized they had been subjected to an operation with no results justifying it, and had in addition their mutilation. The more thoughtful operators began to see the uselessness of trying to cure every woman with pain and hysteria by salpingo-oophorectomy. The paucity of the literature on this subject forbids further allusion to it here.

Learning by experience that removal of the tubes alone would not cure these cases, and that the removal of the ovaries and tubes precipitated the menopause in those women who had not passed that period, that sexual changes resulted, that melancholia often developed, conscientious men turned their attention toward conserving these organs. They began to operate only when well defined lesions were recognizable, and if, when the abdomen was opened, they found one ovary, or even part of an ovary, healthy, it was spared. This method of procedure soon gave evidence of better results, for those symptoms depending upon gross pathological changes were relieved and the symptoms resulting from total mutilation did not present themselves, or if they did they assumed mild form as compared with the original symp

toms.

can readily see, some of these bad results are due to the manner of operating, and others to the peculiarity of the disease itself. The greater stress was placed on one or the other according to the judgment of the operator. Some surgeons thought that their operations were not radical enough, that some portion of the disease remained, or that the uterus itself was the ultimate source of mischief, and they therefore recommended the total extirpation of that organ in all cases of bilateral suppurative disease. This technique was particularly advocated by American surgeons, while the French surgeons practised hysterectomy simply to get at the suppurative disease above and to provide a drainage. As to the advisability of removing the uterus when it becomes necessary to remove the tubes and ovaries I will not discuss, but will endeavor to adhere strictly to my subject, however hard that is to do, as often allied subjects so closely interlock that the temptation to digress and explain is almost irresistible.

Now, what are the indications for vaginal section and drainage in cases of suppurative disease of the pelvic viscera? Here I propose to adhere to the principles of general surgery that have been so efficient and successful in other regions of the body. It is a well known fact that pus when forming travels in the direction of least resistance, and unless its progress is interfered with by adhesions, normal anatomical arrangements or limiting membranes, that direction will be downward into the most dependent part. Should we pour a liquid into the normal pelvis it would go into the hollow of the sacrum, into the post-uterine peritoneal pouch. This, then, would be the natural route to drain the pelvis of objectionable fluids: the suprapubic, the unnatural. In cases of empyema we do not open the apex of the thorax, but the most dependent part is opened and there drainage established. Many surgeons, recognizing the value of vaginal drainage after abdominal section, often open Douglas' fossa for that purpose.

Shock is much less after vaginal than after ventral cœliotomy. My cases have, with but an excepUnder these circumstances the patients tion or two, suffered from no more shock than were either cured or much benefited, so that the from a curettement, and the convalescence has operation was satisfactory. The reason for this been as prompt. The operation by the vagina is was not the same in all cases. Although the pus generally accomplished extraperitoneally. Occawas removed and the abscess cavity obliterated sionally the peritoneal cavity is opened, but in this and the whole operation radically and success- case only a small area is exposed as compared fully completed, some patients would not rally, with what happens in this respect when the abothers developed peritonitis and died, and occa- dominal cavity is approached above the pubes. sionally intestinal paralysis or intestinal obstruc- I prefer to select my cases for operation per vagition would terminate an otherwise promising case. nam, by the physical condition and topographical In some of those that recovered from the opera- location of the tumor, rather than by any stage or tion adhesions would form between the viscera, or type of the disease. Pelvic pus accumulations the pedicle ligature would develop trouble com- naturally become walled off from the general perimensurate with the original condition, or conse- toneal cavity by the inflammatory exudate, which quences the result of imperfect drainage would often binds all the organs into one hard, doughey confront the surgeon, and lastly there is the liabil- mass. The mass felt on bimanual examination ity to the formation of a ventral hernia. As you may consist of effused lymph, pus or other septic

fluids, an ovarian abscess, a pyosalpinx, an encysted peritonitis in Douglas' pouch or a true phlegmon in the pelvic cellular tissue. When, however, the tumor appears high in the pelvis, and out of reach of the finger through the vagina, and the chances are very great of its being an unruptured ovarian or tubal abscess, or perhaps an appendicitis, or when the mass is freely movable, the anterior abdominal route should be preferred. Dr. Abbott, of Minneapolis, believes that all abscesses below a line drawn from one anterior superior spinous process of the ilium to the other can be successfully treated through the vaginal incision. It is certainly surprising to what extent the finger can reach. I have explored and broken up abscesses well around to the sides and even in front of the uterus. Although I have not done so, I would not hesitate to practise anterior colpotomy when the location of the pus seemed anterior.

Many objections have been urged by different surgeons to vaginal incision as a regular surgical procedure in the management of pelvic pus disease. They claim that it is resorted to only by timid operators. The truth of the matter is that as much, if not more, skill and surgical judgment is necessary to suscessfully operate by the vaginal than by the suprapubic route. By the vaginal route almost all of the work is done by the sense of touch, and the area of operation is much restricted. It is claimed by those opposed to the vaginal operation that much diseased tissue remains, and that, even if the pus is removed, the cicatrices that resulted would complicate any future operative interference that might be necessary. That occasionally, even when the cases for vaginal incision are judiciously selected, we may be called upon to open the abdomen to more radically remove pathological conditions, I do not deny; but I do deny that the fact of opening and draining through the vagina complicates matters one iota. Any abdominal surgeon, it seems to me, would much prefer to deal with cicatricial tissue and adhesions in a sterile condition than with pus complications. In a series of twenty-three cases where I resorted to vaginal drainage for pelvic abscess two have later required ventral cœliotomy to complete the cure. These two cases were drained of extensive abscesses of the tubes and ovaries, but subsequently the uterine symptoms continued in the form of pain, metro endometritis or profound disturbances of the pelvic circulation. Upon opening the abdomen extensive adhesions between the intestines, omentum and the uterus and the tubes were found. In one case the ovaries were cystic. Neither case contained pus. Both ovaries were removed in one case; in the other only one ovary was removed, the remaining ovary and tube, being apparently healthy, was allowed to remain. This woman became pregnant about four months after the operation but miscarried at

about the third month. In both cases the adhesions were carefully broken up and the parts put in as natural a condition as possible. Both women made excellent recoveries.

Another of my vaginal section cases is of more than usual interest. Mrs. A. J., aged 28, mother of one child, no miscarriages, always well. Two years ago she took suddenly with abdominal pain, which was accompanied by symptoms of an inflammatory condition in the lower abdomen. She was treated for typhoid fever and slowly partially recovered in about three months. Since then she has had more or less pain and tenderness in the right side low down. Last April I saw her for the first time. She was then complaining of great pain in the pelvic region, was tympanitic, and had two or three degrees of fever. Physical examination revealed a tumor low in right pelvis and extending two inches above the horizontal ramus of the pubis. My diagnosis was an old ectopic pregnancy which had ruptured two years ago when she had her acute attack of abdominal inflammation. I advised operative interference, which was soon agreed to, but before she could get to the hospital a bloody discharge appeared from the rectum. A digital examination of the rectum revealed an opening in its anterior wall, through which the finger could pe passed into the cavity. The patient ready, I made the posterior incision for vaginal hysterectomy, to which I added Henrotin's cut. As soon as the cellular tissue was reached, I burrowed up behind the uterus until I penetrated a cavity, a suppurating hæmatocele. This sac contained blood clots, decidual and fœta! tissue and pus. The opening into the rectum was easily demonstrated. The abscess was emptied, packed with sterilized gauze and a glass drain inserted. This packing was removed on the second day and the cavity irrigated. Fæcal matter passed out through the vaginal incision, and continued to do so for about two weeks. The cavity was irrigated daily with sterilized water until, at the end of the third week, the sinus had entirely closed. This woman has remained entirely well and has gained thirty pounds. The uterus is freely movable and menstruation normal. Now here is a case in which ventral cœliotomy would have been hazardous, to say the least. She had been suffering from the consequences of a suppurating ectopic gestation for two years. Had had repeated attacks of peritonitis and accompanying fever and sepsis. Just how this gestation sac became infected I do not know, but I should suggest its close proximity to the rectum as the most likely source. A suprapubic cœliotomy would have necessitated breaking up a great quantity of dense adhesions to get at and remove the product of conception, and further complications would have arisen owing to the communication with the rectum, from which it would have been almost impossible to prevent in fection of the peritoneum.

For the operation the patient must be prepared as carefully and as thoroughly as for a hysterectomy. The utmost attention must be paid to asepsis. Unless there exists some clear indication to the contrary, the interior of the uterus should be curetted and packed with plain sterilized gauze until the main operation is completed. The idea of this is to prevent infection from the endometrium. The cervix should be firmly seized with a stout volsellum and pulled well forward. A few pulls and releases of the volsellum will locate the fold that marks the junction of the vaginal wall to the uterine cervix, and at this point the posterior incision for vaginal hysterectomy is to be made. The mucous membrane may be severed, either with a knife or a sharp pointed scissors, laterally to the extent of the width of the cervix, taking care to keep up well against the posterior surface. of the uterus. As soon as the cellular tissue is reached the finger must be used to burrow into the infiltrated mass. I discard all retractors and pass my left hand into the vagina, with the index finger in the incision (the nail of which I leave long), and with the right hand on the abdomen to make counter pressure, I am able to explore the entire pelvic cavity behind, above and to the sides of the uterus and to open all pus sacs within that territory. Now, the technique which we should execute just at this point varies a little according to circumstances. If we are dealing with a pelvic phlegmon, or an unruptured tubal or ovarian abscess situated well down in Douglas' fossa, we can most likely evacuate and drain without entering the peritoneal cavity. On the other hand, if the abscess is located higher, or if the adhesions have not walled off the peritoneal cavity, it will probably be necessary to pass over healthy peritoneum to reach the trouble. When such is the case it is best to elevate the patient's hips about four inches and enlarge the opening by adding an extra incision extending from the middle of the original cut directly backwards along the median line of the posterior vaginal wall to the extent of an inch, carefully avoiding the rectum. The whole Tshaped incision is then carried into Douglas' fossa. The exploring finger is then passed into the peritoneal cavity and the abscess located. piece of sterilized gauze with a string attached is then passed through the incision, pushing the intestines back from the field of operation and walling off the peritoneum. The abscess may now be opened either with the finger or, if it can be brought down into view, a sharp-pointed scissors may be thrust into the sac, extending the blades and withdrawing, thus tearing a wide opening.

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If the lesion is difficult to bring into view, this desirable advantage may be much facilitated by pulling the cervix well forward with a volsellum, at the same time a long perineal retractor presses back the posterior wall of the field of operation. In this way often the place of puncture can be di

rectly under the eye. In those cases where I have been compelled to operate intraperitoneally I have seen no bad results follow. Unless there are adhesions the general peritoneal cavity can be kept out of the field of operation by carefully placed gauze pads. The abscess opened, I irrigate with a normal salt solution and pack with plain sterilized gauze. I use no iodoform gauze for drainage in non-tubercular cases nor clean wounds. Iodoform interferes with drainage, and may lead to toxic symptoms and is a useless incumbrance, except when indicated in specific conditions.

MOLLUSCUM FIBROSUM.*

BY E. D. KEYES, M. D.

Winona, Minn.

Having had a very interesting and characteristic case of molluscum fibrosum, I thought it might interest you to see photographs and listen to the history of the case and a few points on the disease in general.

First, molluscum fibrosum is described as a chronic hypertrophic affection of the skin, characterized by cutaneous or subcutaneous neoplastic tumors, projecting in different degrees from the surface, of varying degrees of density, single or multiple, and covered either by a sound and attached, or rarely by an ulcerated integument. The affection has been called M. simplex, M. pendulum, M. albuminosum and fibroma M.

There are two general forms of the disease: one in which the surface of the body is covered with numerous small tumors, the other in which there is a single large tumor, or at the most two or three of them. These two forms run into each other, and it is often found that one or more large tumors occur with the generalized form, and a few small tumors occur with the circumscribed one.

These cutaneous tumors occur in any number from one up into the thousands. They are situated, when small, within or beneath the skin, where they can be distinguished as distinctly circumscribed, indolent nodules, usually small, soft and rounded, often projecting. When more fully developed they become sessile, pedunculated, or largely pendulous tumors, hanging from the part to which they are attached in folds. This form of molluscum fibrosum, like the other, is very indolent; and it is only the large size of the tumors that renders them so inconvenient and troublesome that surgical relief is in most cases sooner or later demanded. Occasionally, under the influence of some mechanical irritation, as of constant rubbing, the tumor may become ulcerated and a sore produced. Sometimes free hemorrhages occur.

*Read before the Southern Minnesota Medical Society, August 5, 1897.

These lesions are found on all parts of the surface, including the palms, soles and scalp. In some cases, where post mortem examinations have been made, some of the internal organs have displayed these tumors, and in several cases they have been found upon the nerves.

and this is the experience of many observers, while it is combated by others. The precise cause of the disease is unknown. Von Recklinghausen concludes, from careful researches, that the disease is originally a neuro-fibroma, the nerve at first being present, and afterwards disappearing as the tumor grows and the connective tissue becomes predominant. Hyde says: "It is, however, reasonable to believe that it is a vice of local development under the influence of constitutional predisposition."

There is some question as to whether these growths originate in the deep interspaces of the corium, or in the connective tissue about the hair follicles or fat globules. The fibrous bundles pass downwards and unite with those of the derma or subcutaneous tissues, forming thus a firm attachment for the pedicle of all pedunculated tumors.

The diagnosis rarely presents any difficulty. The number and wide distribution of the lesions, the unchanged character of the skin covering the tumors, the variety in size and shape of the latter, and the pendulous character of the larger tumors, are all characteristic.

The prognosis of molluscum fibrosum is generally favorable. Occasionally, however, degenera

[graphic]
[graphic]

The seat of these lesions is in the derma, and they move with it. Their color is that of the normal skin or slightly pinkish, or, in the older larger growths, brownish, from varying degrees of pig.

mentation. The tumors are of variable consistence, but are always more or less soft and flaccid, except that in many of the pea or cherry sized tumors, they appear distended and firm as if cedematous. They hang from their point of attachment in loose baggy masses, and feel like flaccid, fleshy bags full of fibrous cords. In the more extensive cases the affection appears stationary. When, however, the number of lesions is small, one or two of them may be observed to develop, slowly at first, but with increasing rapidity, until in time. they acquire an enormous size.

This disease is rare. Of 112,775 cases of skin diseases reported to the American Dermatological Association, only 85 were cases of molluscum fibrosum. It is more common in women than men. While observed in adults, it is commonly first developed in childhood.

Hebra has asserted that the disease occurs in persons of stunted mental and physical growth,

tive changes may take place in one or more of the tumors with a tendency to malignancy.

The only treatment available for the relief of molluscum fibrosum is the surgical removal of such of the tumors as are unsightly or which interfere with the movements of the body.

CASE I.

Miss aged 43, unmarried. When 7 years of age, while picking flowers in the garden with her mother, suddenly gave a shrill cry of pain, and clutching her right arm at about the insertion of the deltoid, ran to her mother, who removed her sleeve as quickly as possible, and found what seemed to have been a hornet sting, as a long, yellow fly flew out. It swelled rapidly to the size of a walnut, and was very painful, requiring the service of a doctor. It was treated under his direction with lotions, etc., and finally quieted down into a caked mass, which remained, becoming softer and more flaccid. The doctor injected this tumor with some substance which he stated would cause it to go away; but, on the contrary, the bunch seemed to grow slowly, until, in the course of five years, it attained the size of a hen's egg. Four months after the sting she was knocked down in the street by a horse and carriage, her nose was broken and she was bruised severely about the head and body, so that she was unconscious for several hours, and dazed and peculiar for some time longer. The lump left by the sting seemed to have been bruised, as it was red and angry.

Four years after the sting a second tumor appeared in the right gluteal region, and grew steadily for about ten years, when she hit it against a projecting corner, and it immediately swelled to the size of a fetal head, and the doctor turned out large clots of blood, after two weeks, through an incision. It grew more rapidly after this and hung down, a long pendulous tumor, as shown in the photograph. It ceased growing actively ten years ago, or about twenty years after the first appearance. The large tumor on the left hip is the latest of the large growths, and was probably still growing at the time of removal, but had attained nearly its present size ten years ago. You will see by the photograph that the whole body is completely covered with these tumors, of small size, from that of a pinhead to a large cherry size or larger. They appeared little by little all through the early half of the history of this case, but the last ten years there has been very little change or growth in any part, except that the large tumors on the hips have dragged down so as to be more pendulous. These tumors are on every part of the body, and there are a few, at least, embedded in the tissues. The palms of the hands have several small tumors, and many occur on the feet. The patient consulted me for relief from weight and sweaty odors in connection with two large tumors on the hips. In summer the surfaces perspire and produce a very offensive odor, and the weight was so great that she was obliged to slip a sack or pocket over the longest one and pin it to her belt, so as to sustain its weight. These tumors have caused no pain or trouble except as above described, together with their unsightly and cumberous presence.

The one on the right hip with a comparatively small pedicle, and the original tumor on the arm, were removed April 15, 1896, and the larger, broader one on the left hip was removed June 15, 1897. The wounds after operation healed without difficulty.

MEDICAL ADVANCEMENT IN THE PAST TWENTY YEARS.*

By R. J. Hill, M. D. Minneapolis.

The past twenty years has witnessed greater progress in all departments of science than any similar period in the world's history. The improvements in labor saving machinery of all kinds has reached such a state of perfection that it is seriously considered by some as the cause of the great lack of employment. The telephone, through which we can recognize the voice of a friend in Chicago or New York; the megaphone, which reproduces the air of the latest opera; the electric light, of our streets and houses; the swift moving electric car, that has superseded the slow moving horse car; the marvelous X-ray, that enables us to locate bullets in any part of the body and prevents our mistaking a dislocation for a fracture, not to mention the other manifold uses of electricity which now seem to us a matter of course—all are discoveries of this time. The improvements in implements of war; the long range rifle; the mammoth guns; the smokeless powder and the deadly dynamite have made war so dangerous that arbitration has become a recognized means of settling the disputes of nations.

During this time medicine has kept pace with the other sciences, and from being one of the most inexact, is fast becoming one of the most definite. The chief aim seems to have been to discover the cause of disease and to devise means to prevent it-hence the greatest progress has been made in pathology, bacteriology and prophylactic medicine. Previous to the discovery of the bacillus of tuberculosis, by Koch, in 1882, no definite cause for the disease was known, though pathology had offered many theories, but the physician had to content himself with diathesis, predisposition and heredity, as explanations. With this discovery many things were made clear that had been previously surmised. The infectious character of the disease and the source of the infection in the expectoration of the patient, showed the necessity for isolation

*Read before the Minnesota Academy of Medicine, December 1, 1897.

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