worse

of the work in vaginal incision and vaginal punc- can readily see, some of these bad results are due ture. In vaginal incision the pus sac is freely to the manner of operating, and others to the peopened and drained, while puncture, as the culiarity of the disease itself. The greater stress name suggests, is only accomplished by a care- was placed on one or the other according to the ful thrust of a needle, from which only a small judgment of the operator. Some

surgeons portion of the septic matter could escape. Not thought that their operations were not radical only this, but the probability of reinfecting the enough, that some portion of the disease repus cavity was very great. Practically, then, mained, or that the uterus itself was the ultimate these two operations are distinct, and should not source of mischief,and they therefore recommended be referred to in the same connection. There are the total extirpation of that organ in all cases of many apparent reasons why vaginal incision soon bilateral suppurative disease. This technique became a popular operation. We are all aware of was particularly advocated by American surgeons, the great tendency to remove tubes and ovaries while the French surgeons practised hysterectomy about ten years ago, for the most trivial causes, simply to get at the suppurative disease above real or imaginary. The results were not satisfac- and to provide a drainage. As to the advisability tory. True, the patients recovered from the op- of removing th

uterus when it becomes necessary eration, but not 50 per cent. were cured. They to remove the tubes and ovaries I will not discuss, would return complaining of the same or

but will endeavor to adhere strictly to my subject, pains and the same nervousness. They felt no however hard that is to do, as often allied subjects better, in fact worse, because they realized they so closely interlock that the temptation to digress had been subjected to an operation with no results and explain is almost irresistible. justifying it, and had in addition their mutilation. Now, what are the indications for vaginal secThe more thoughtful operators began to see the tion and drainage in cases of suppurative disease uselessness of trying to cure every woman with of the pelvic viscera ? Here I propose to adhere pain and hysteria by salpingo-oophorectomy. The to the principles of general surgery that have been paucity of the literature on this subject forbids so efficient and successful in other regions of the further allusion to it here.

body. It is a well known fact that pus when formLearning by experience that removal of the ing travels in the direction of least resistance, and tubes alone would not cure these cases, and that unless its progress is interfered with by adhesions, the removal of the ovaries and tubes precipitated normal anatomical arrangements or limiting memthe menopause in those women who had not passed branes, that direction will be downward into the that period, that sexual changes resulted, that most dependent part. Should we pour a liquid melancholia often developed, conscientious men into the normal pelvis it would go into the hollow turned their attention toward conserving these or- of the sacrum, into the post-uterine peritoneal gans. They began to operate unly when well de- pouch. This, then, would be the natural route to fined lesions were recognizable, and if, when the drain the pelvis of objectionable fluids: the supraabdomen was opened, they found one ovary, or pubic, the unnatural. In cases of empyema we do even part of an ovary, healthy, it was spared. not open the apex of the thorax, but the most deThis method of procedure soon gave evidence of pendent part is opened and there drainage estabbetter results, for those symptoms depending upon lished. Many surgeons, recognizing the value of gross pathological changes were relieved and the vaginal drainage after abdominal section, often symptoms resulting from total mutilation did not open Douglas' fossa for that purpose. present themselves, or if they did they assumed a Shock is much less after vaginal than afterivenmild form as compared with the original symp- tral cæliotomy. My cases have, with but an exceptoms. Under 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.

accumulations the pedicle ligature would develop trouble com- naturally become walled off from the general perimensurate with the original condition, or

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

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

Pelvic pus

conse

a

fluids, an ovarian abscess, a pyosalpinx, an encyst- about the third month. In both cases the adheed peritonitis in Douglas' pouch or a true phleg- sions were carefully broken up and the parts put mon in the pelvic cellular tissue. When, how- in as natural a condition as possible. Both women ever, the tumor appears high in the pelvis, and made excellent recoveries. out of reach of the finger through the vagina, and Another of my vaginal section cases is of more the chances are very great of its being an unrup- than usual interest. Mrs. A. J., aged 28, mother tured ovarian or tubal abscess, or perhaps an ap- of one child, no miscarriages, always well. Two pendicitis, or when the mass is freely movable, the years ago she took suddenly with abdominal pain, anterior abdominal route should be preferred. which was accompanied by symptoms of an inDr. Abbott, of Minneapolis, believes that all ab. flammatory condition in the lower abdomen. She scesses below a line drawn from one anterior su. was treated for typhoid fever and slowly partially perior spinous process of the ilium to the other recovered in about three months. Since then she can be successfully treated through the vaginal in- has had more or less pain and tenderness in the cision. It is certainly surprising to what extent right side low down. Last April I saw her for the the finger can reach. I have explored and broken first time. She was then complaining of great up abscesses well around to the sides and even in pain in the pelvic region, was tympanitic, and had front of the uterus. Although I have not done so, two or three degrees of fever. Physical examinaI would not hesitate to practise anterior colpo- tion revealed a tumor low in right pelvis and extomy when the location of the pus seemed ante- tending two inches above the horizontal ramus of rior.

the pubis. My diagnosis was an old ectopic preg. Many objections have been urged by different nancy which had ruptured two years ago when she surgeons to vaginal incision as a regular surgical had her acute attack of abdominal inflammation. procedure in the management of pelvic pus dis- I advised operative interference, which was soon ease. They claim that it is resorted to only by agreed to, but before she could get to the hospital timid operators. The truth of the matter is that a bloody discharge appeared from the rectum. A as much, if not more, skill and surgical judgment digital examination of the rectum revealed an is necessary to suscessfully operate by the vaginal opening in its anterior wall, through which the finthan by the suprapubic route. By the vaginal ger could pe passed into the cavity. The patient route almost all of the work is done by the sense ready, I made the posterior incision for vaginal of touch, and the area of operation is niuch re- hysterectomy, to which I added Henrotin's cut. stricted. It is claimed by those opposed to the As soon as the cellular tissue was reached, I burvaginal operation that much diseased tissue re- rowed up behind the uterus until I penetrated a mains, and that, even if the pus is removed, the cavity, a suppurating hæmatocele.

This sac concicatrices that resulted would complicate any fut- tained blood clots, decidual and fæta! tissue and ure operative interference that might be necessary. pus. The opening into the rectum was easily demThat occasionally, even when the cases for vaginal onstrated. The abscess was emptied, packed with incision are judiciously selected, we may be called sterilized gauze and a glass drain inserted.

This upon to open the abdomen to more radically re- packing was removed on the second day and the move pathological conditions, I do noi deny; but cavity irrigated.

cavity irrigated. Fæcal matter passed out through I do deny that the fact of opening and draining the vaginal incision, and continued to do so for through the vagina complicates matters one iola. about two weeks. The cavity was irrigated daily Any abdominal surgeon, it seems to me, would with sterilized water until, at the end of the third much prefer to deal with cicatricial tissue and ad- week, the sinus had entirely closed. This woman hesions in a sterile condition than with pus com- has remained entirely well and has gained thirty plications. In a series of twenty-three cases a

pounds. The uterus is freely movable and menwhere I resorted to vaginal drainage for pelvic ab- struation normal. Now here is a case in which scess two have later required ventral coliotomy to ventral coliotomy would have been hazardous, to complete the cure. These two cases were drained say the least. She had been suffering from the of extensive abscesses of the tubes and ovaries, consequences of a suppurating ectopic gestation but subsequently the uterine symptoms continued for two years. Had had repeated attacks of periin the form of pain, metro endometritis or pro- tonitis and accompanying fever and sepsis. Just found disturbances of the pelvic circulation. how this gestation sac became infected I do not Upon opening the abdomen extensive adhesions know, but I should suggest its close proximity to between the intestines, omentum and the uterus the rectum as the most likely source.

A supraand the tubes were found. In one case the ovaries pubic cceliotomy would have necessitated breaking were cystic. Neither case contained pus. Both up a great quantity of dense adhesions to get at ovaries were removed in one case; in the other and remove the product of conception, and furonly one ovary was removed, the remaining ovary ther complications would have arisen owing to the and tube, being apparently healthy, was allowed communication with the rectum, from which it to remain. This woman became pregnant about

would have been almost impossible to prevent in four months after the operation but miscarried at fection of the peritoneum.

a

a

For the operation the patient must be prepared rectly under the eye. In those cases where I have as carefully and as thoroughly as for a hysterec- been compelled to operate intraperitoneally I have tomy. The utmost attention must be paid to seen no bad results follow. Unless there are adasepsis. Unless there exists some clear indication hesions the general peritoneal cavity can be kept to the contrary, the interior of the uterus should out of the field of operation by carefully placed be curetted and packed with plain sterilized gauze gauze pads. The abscess opened, I irrigate with until the main operation is completed. The idea a normal salt solution and pack with plain sterilof this is to prevent infection from the endome- ized gauze. I use no iodoform gauze for drainage trium. The cervix should be firmly seized with a in non-tubercular cases nor clean wounds. Iodostout volsellum and pulled well forward. A few form interferes with drainage, and may lead to pulls and releases of the volsellum will locate the toxic symptoms and is a useless incumbrance, exfold that marks the junction of the vaginal wall to cept when indicated in specific conditions. the uterine cervix, and at this point the posterior incision for vaginal hysterectomy is to be made. The mucous membrane may be severed, either

MOLLUSCUM FIBROSUM.* with a knife or a sharp pointed scissors, laterally to the extent of the width of the cervix, taking

By E. D. KEYES, M. D. care to keep up well against the posterior surface of the uterus.

Winona, Minn. 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

Having had a very interesting and characterismy left hand into the vagina, with the index finger

tic case of molluscum fibrosum, I thought it might in the incision (the nail of which I leave long), and

interest you to see photographs and listen to the with the right hand on the abdomen to make coun

history of the case and a few points on the disease

in general. ter pressure, I am able to explore the entire pelvic cavity behind, above and to the sides of the uterus

First, molluscum fibrosum is described as and to open all pus sacs within that territory.

chronic hypertrophic affection of the skin, charac. Now, the technique which we should execute just

terized by cutaneous or subcutaneous neoplastic at this point varies a little according to circum

tumors, projecting in different degrees from the stances. If we are dealing with a pelvic phleg. surface, of varying degrees of density, single or

. mon, or an unruptured tubal or ovarian abscess

multiple, and covered either by a sound and atsituated well down in Douglas' fossa, we can most

tached, or rarely by an ulcerated integument. likely evacuate and drain without entering the pe.

The affection has been called M. simplex, M. penritoneal cavity. On the other hand, if the abscess

dulum, M. albuminosum and fibroma M. is located higher, or if the adhesions have not

There are two general forms of the disease: one walled off the peritoneal cavity, it will probably

in which the surface of the body is covered with be necessary to pass over healthy peritoneum to

numerous small tumors, the other in which there reach the trouble. When such is the case it is

is a single large tumor, or at the most two or three best to elevate the patient's hips about four inches

of them. These two forms run into each other, and enlarge the opening by adding an extra incis

and it is often found that one or more large tumors ion extending from the middle of the original cut

occur with the generalized form, and a few small directly backwards along the median line of the

tumors occur with the circumscribed one. posterior vaginal wall to the extent of an inch,

These cutaneous tumors occur in any number carefully avoiding the rectum. The whole T

from one up into the thousands. They are situatshaped incision is then carried into Douglas' ed, when small, within or beneath the skin, where fossa. The exploring finger is then passed into

they can be distinguished as distinctly circumthe peritoneal cavity and the abscess located. A

scribed, indolent nodules, usually small, soft and piece of sterilized gauze with a string attached is

rounded, often projecting. When more fully dethen passed through the incision, pushing the in

veloped they become sessile, pedunculated, or testines back from the field of operation and wall

largely pendulous tumors, hanging from the part to ing off the peritoneum. The abscess may now be

which they are attached in folds. This form of opened either with the finger or, if it can be

molluscum fibrosum, like the other, is very indobrought down into view, a sharp-pointed scissors

lent; and it is only the large size of the tumors may be thrust into the sac, extending the blades

that renders them so inconvenient and troubleand withdrawing, thus tearing a wide opening.

some that surgical relief is in most cases sooner or If the lesion is difficult to bring into view, this

later demanded. Occasionally, under the influence desirable advantage may be much facilitated by

of some mechanical irritation, as of constant rub. pulling the cervix well forward with a volsellum,

These lesions are found on all parts of the sur- and this is the experience of many observers, while face, including the palms, soles and scalp. In it is combated by others. The precise cause of some cases, where post mortem examinations have the disease is unknown. Von Recklinghausen conbeen made, some of the internal organs have dis- cludes, from careful researches, that the disease is played these tumors, and in several cases they have originally a neuro-fibroma, the nerve at first being been found upon the nerves.

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

a 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

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 consist. ence, but are always more or less soft and Aaccid, except that in many of the pea or cherry sized tumors, they appear disteaded and firm as if cede matous. 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 de. veloped 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.