SURGICAL CASES.

By DANIEL H. WILLIAMS, M. D., Chicago. AN UNUSUAL CASE OF MOLLUSCUM FIBROSUM.

The man from whom this specimen was removed was a German 23 years of age. At the age of seven he first noticed a flat mole over the lower lumbar region. It grew steadily until it had attained its present size. Its weight when removed was twelve and one-half pounds, its longitudinal diameter fifteen inches, and its transverse ten and one-half inches. The growth produced no subjective symptoms beyond the more or less uncomfortable tension caused by its weight and bulk.

Several slides from the specimen have been made by Dr. J.M. Beffel, and in a note he states that “there is nothing unusual in the structure of this tumor. It is a papillomatous growth, with a considerable connective tissue stalk, this connective tissue extending out into all of the branches. The connective tissue stalk is completely covered by a thin epidermal layer.”

Small fibromata are common. They may be seen in the skin clinics of the larger medical centers of this country. Very large growths are seldom if ever seen in this country, there being no record in the United States of one as large as this specimen. At the time this one was removed, Dr. J. Nevens Hyde presented a photograph of it to the American Dermatological Society. He afterwards informed me that a larger specimen had been reported in Italy by an Italian surgeon. This one now belongs to the United States Medical Museum, at Washington. Through the courtesy of Dr. Daniel S. Lamb, Pathologist, it was forwarded to me for presentation here.

HERNIA OF THE BLADDER.

About ten years ago, this patient after jumping over a high board fence, discovered a hernia on the right side. It gave him some trouble at intervals for a few years afterwards. About two years after the appearance of the hernia in the right inguinal region, he noted the development of one on the opposite 0003 side. He states that the second hernia never gave him any trouble, and has about ceased to exist. He has never had an affection of the bladder, or of the uretha. He passes a full, free and forcible stream of urine. His bladder and entire pelvic field was examined through the inguinal incision, with a negative result. The bladder wall was rather thinner than usual, and could easily be drawn three inches through the inguinal incision.

Hernia of the bladder through the inguinal canal, is rather rare. The literature on the subject is very scanty. Hernia of the bladder, in the median line above the pubis, is not so rare. It occurs usually on account of the stretching of the scar tissue incident to the infection of abdominal incisions. Dr. William T. Belfield, of this city, an article in “Progressive Medicine,” December, 1899, Vol. 4, page 137, mentions Brunner, who collected one hundred cases. He states that is found three times oftener in men than in women. It is most frequently inguinal in men, and crural in women. Dr. Farquhar Curtis, in the “Annals of Surgery,” 1895, reports many cases of wounds of the bladder, in operations for hernia. It is supposed that these were cases of inguinal hernia of the bladder.

The inguinal canal was closed by Halsted's method.

FIBROMATOUS PREGNANT UTERUS.

The part of the history of this patient which is of interest in the study of this specimen, is that she is twenty-seven years of age; was twenty-six when she married; first menstruated at the age of fourteen, and has menstruated continuously without interruption until she became pregnant about June of the present year. Her general health has been exceptionally good, she never having required the services of a physician until she consulted Dr. A.P. Perry, about October 15th, when she supposed that she was suffering from symptoms incident to her pregnant condition.

When I saw her October 24th, she had been confined to her bed for several days. She was very much emaciated, no appetite, bowels obstipated, passing in twenty-four hours not more than sixteen ounces of urine of high specific gravity, with a trace of albumen, urea one and one-half per cent, and a few epithelial casts. Temperature, 102 degrees, pulse, 120, respirations 26 to 30.

Her condition and appearance were extremely unpromising. Her lips were blue, her face ashen and anxious, her features 0004

AN UNUSUAL CASE OF MOLLUSCUM FIBROSUM.

0005 pinched, her skin cold and clammy. Indeed, it was several days before I could make up my mind that she did not have pus about her. And to add to the uncertainly of the fact, she complained of continuous pain in the right kidney-region, extending down the thigh.

To increase the uncertainty, an examination of the right lumbar region revealed a considerable sized tumor, which it was thought might be a hydronephrosis or an infection from some cause. This supposedly enlarged kidney, turned out to be the rather large pedunculated tumor you see attached to the upper right pole of the specimen. It was firmly impacted against the kidney and diaphragm. The inability to dislodge it, or to associate it with the other growths of its kind, led to uncertainty as to its real character. The diagnosis of pregnancy was founded on presumptive signs, and the result of several examinations.

Reverting to her history, the fact is recalled, that she had been consistently regular in menstruating, having never missed a period from the age of 14 until June 10th. During the month following the interruption of her menstrual history, she began to notice hypertrophy of the mammary glands. The nipples were enlarged, elongated and prominent, the areola dark, Montgomery's follicles were largely developed, colostrum was secreted and milk squeezed from the nipples. The vaginal mucous membrane, showed the blue or violet color described by Jacqueman. The crevix was about one and one-half inches in length, very much atrophied, high, and to the extreme right. The large mass you see in the lower right quadrant of the uterus, bulged downward into the pelvis, almost entirely obliterating the landmarks. Without an anesthetic no information could be had of the size, shape or changed position of the uterus.

Abdominal palpation was negative on account of the unusually number of large, pedunculated growths present, which their long pedicles allowed to float over the uterus, thus interfering with an examination. Under anesthesia, abimanual rectoabdominal examination was made with relaxed abdominal walls. The growths were held aside, and the left fingers were pressed well down against the opposing fingers in the rectum. Elevating the mass by the fingers in the rectum, a soft, fluctuating tumor was made out. This tumor was continuous with, and shaded off, as part of the cervix at once making plain the fact that it was the uterus, and that contained fluid. By traction on the tumors above the uterus, the fluctuating area, the cervix, and the growth 0006 in the lower right quadrant were movable. This with the presumptive evidence already obtained, led me to conclude that the uterus was pregnant.

The uterus measures 8x7x6 inches; its posterior surface is somewhat nodular, and there are three large, more or less, irregular, roundish tumor masses, each of them about the size of an adult's fist Two of these tumors of these tumors are located near the upper portion of the uterus; both are freely movable. The third one is attached, by a fibrous band, near the lower right of the posterior surface. There are also several smaller nodules varying in size from a bean to a hen's egg, and most of these are intramural, producing the above mentioned nodular appearance of the uterus itself.

Near the fundus one sees besides several smaller nodules, two large tumors, one on each side, measuring 7x5x4 1/2. Both are somewhat kidney-shaped, with an indentation at the lower central portion, and from here rather small fibrous bands attach them to the uterus. The Tumor on the right shows at its upper portion evidences of torn adhesions; it is attached just above the junction of the Fallopian tube and uterus. The tube and ovary on this side do not show any changes. The attachment of the tumor on the left side is near the opposing tube, the latter, as also the ovary, not having been removed. The anterior surface is comparatively smooth; on the lower left there is another pedunculated tumor measuring 5 1/2 x 3 1/2 x 4 inches. Upon opening the uterus a well developed fetus of about 4 to 5 months was discovered. The membranes were intact. The placenta is situated near the anterior middle portion. The uterine wall varies in thickness from 1/8 to 1 1/4 inches. The os uteri is small and was filled with a mucoid material. There is also an intramural fibroid in the anterior wall, measuring 2x3 inches.

The operation was a supravaginal amputation such as is practiced by Kelly. There was a fatless omentum, nothing being left of it but large blood sinuses, which were distributed to and nourished part of the growths. The tumors, uterus, and ovary were removed in one mass. Pelvic and uterine uterine incisions were covered with peritoneum.

3034 MICHIGAN AVENUE.