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above in the abdominal wall and descend into the groin. They are usually large and pendulous, and easily enucleated with little hemorrhage. The fibrous tumors are, as a rule, more deeply attached, and consequently difficult of removal. They may be attached to the vessels. There are no less than three different classes of cystic tumors liable to occur in the groin: (1) Retention cysts, as the sebaceous, which are rare. (2) Exudation cysts, as the enlargement of the bursa lying between the anterior surface of the capsule of the hip and the posterior surface of the psoas and iliacus muscles. This is by far more common, and at times undergoes great enlargement. (3) Cysts of new formation, either serous or sanguineous.

It is to be remembered, in connection with the diagnosis of tumors in the groin, that there are other "swellings" which are even more common than the tumors named. Acute and chronic abscesses which point either above or below Poupart's ligament, hydrocele of the cord, hernia, undescended testicle, aneurisms, tuberculosis of the lymphatic glands, etc.

A cystic or solid tumor situated over the course of the vessels will have an impulse imparted to it, and the tumor may be mistaken for an aneurism. Extreme caution is necessary for the correct diagnosis and removal of growths in this region.

SCROTUM.

Sebaceous tumors may occur, and are usually multiple. They vary in size from a pea to a hickory-nut. Sometimes there are great numbers of them.

Other cystic tumors are very uncommon. As a rule they are small and multiple.

Dermoid cysts containing bone, teeth, cartilage, etc., are congenital.

Lipomas are rare. When present they are usually of small size and feel like a third testicle. Kimball reports a growth of this kind weighing two pounds.

Fibrous tumors are uncommon. They occur after middle life and attain a large size. Gross, the elder, removed one weighing nearly five pounds.

Elephantiasis of the scrotum is uncommon in this country. Tumors of this kind have been

reported by Larrey weighing one hundred and twenty pounds, and by Delpech, one hundred and sixty pounds.

Carcinoma of the scrotum is usually of the epithelial variety. It is so common in chimney-sweeps that it is often called the "chimney sweeper's cancer." Sarcoma is rare.

TESTICLE.

This organ, like the female breast, is frequently the seat of morbid growths. The tumors commonly found are cystic degeneration, enchondroma, sarcoma, and carcinoma. Myomata, lipomata, and fibromata are reported, but are so rare as to make it unnecessary to consider them in a practical study of the neoplasms of the testis.

Given a tumor of the testicle, the chances are, as in the mamma, that it is malignant. Simple cystic degeneration sometimes, though rarely, occurs. The cysts are multiple and generally of great number, varying in size from a pin's head to a walnut. Contents watery or gelatinous. This is the "hydated testis" of Sir Astley Cooper.

Cystic disease sometimes co-exsists with sarcoma, chondroma, and carcinoma.

Enchondroma. The parotid and submaxillary glands are the only structures of the body more often the seat of this tumor-than the testicle. It is liable to undergo sarcomatous change. It also co-exists with cystic disease.

Tuberculosis. This affection generally occurs in young subjects with evidences of tuberculosis elsewhere. Rarely is it limited to the testicle. It almost invariably affects the epididymis, and not the testis proper.

Sarcoma. This is the most common of all tumors. It is usually of the small, round-celled variety, the encephaloid sarcoma. It is impossible to diagnosticate this growth from the encephaloid carcinoma without the aid of the microscope. After a study of forty cases, S. W. Gross says that it affects younger subjects, even occurring in very young children, grows more rapidly, attains a greater volume, is more apt to invade the epididymis, more apt to cause enlargement of the inguinal lymphatic glands, but less apt to invade the cord than carcinoma.

Carcinoma. Most authors agree that the only variety of cancer found in the testicle is the encephaloid-the old fungus hematodes. It is most common about forty years of age, and is said never to occur in impubic subjects. It is invariably unilateral. Bryant and Holmes admit the possibility of scirrhus.

Tumors of the perineum must be extremely rare, as I find no mention of them in the standard works.

The only tumor I have ever met with in this region was a fibroma of many years' duration, in a man, sixty-seven years of age, whom I saw in consultation with Dr. H. M. Pusey. It was the size of an orange, and had grown very slowly. Six months before its removal it had taken on a more rapid growth, and the skin over its surface became discolored. A microA microscopical examination showed a limited amount of sarcomatous degeneration, the cells being of the small spindle variety. It was removed by Dr. Pusey two years ago, and, so far as I know, has not returned.

PENIS.

This organ is not often the seat of neoplasms. Benign growths, both cystic and solid, may occur, but they are so very rare that they need not be considered.

By far the most common growth is the carcinoma, and some authors claim that the only form of cancer to which the penis is liable is the epithelioma. It begins as a small wart or crack either upon the prepuce or glans penis. It soon ulcerates, and can be diagnosticated by the of fensive sanious discharge, involvement of inguinal glands, pain, age of patient, etc. It is more common in elderly subjects. I have seen one case in a lad of fifteen, though it is uncommon under thirty-five. Erichsen and Corte have seen scirrhus of the penis. It was situated in the sulcus behind the glans.

Sarcoma is extremely infrequent. Dr. W. G. Porter, of Philadelphia, reported a case of sarcoma beginning at the base of the penis of a negro aged forty-four years. This is the only case I find.

NATES.

The tumors of this region are cystic and solid. Cysts are common, and are sometimes congenital. When congenital they may be so

large as to seriously retard labor. Puncture has been necessary so as to permit delivery of the child.

Fatty, myxomatous, fibrous, and sarcomatous growths are the solid tumors usually found.

Myxoma is perhaps the most frequent of all. It may assume the type of myxoma-lipomatodes. All of these tumors may begin on the outside of the pelvis and project into it through the great sciatic foramen, or begin on the inside and pass out. These tumors are deeply placed and their diagnoses before removal difficult.

POPLITEAL SPACE.

Tumors of this region are cystic and solidmore frequently the former.

Cystic tumors of this region are classified as follows:

1. Enlargement of some one of the natural

2. Synovial cysts, caused by hernial protrusion of the synovial membrane.

3. Accidental cysts, serous or sanguineous. The first class is the most common. Enlargement of the bursa situated between the inner head of the gastrocnemius muscle and femur. is the largest and most common of these tumors. Next in order of frequency is the one situated between the tendon of the semi-membranosis and its insertion into the tibia. The bursæ on the outside of this space are smaller and less often enlarged.

Of solid tumors in this space we have sarcomas, fibromas, and lipomas. The sarcoma is most frequent. It frequently pulsates, and for this reason the femoral artery has often been tied for the relief of a supposed aneurism. The benign tumors are rare. Fatty tumors here often assume the form of myxoma-lipomatodes. The frequent occurrence of popliteal aneurisms and deep-seated abscesses in this region should make the surgeon extremely cautious in dealing with any tumor.

Dupuytren, Desault, and others have opened aneurisms in this situation under the impression that they were abscesses. I know of one such mistake necessitating ligation of the femoral artery.

Leaving the soft parts, we turn to the bones of this region.

The lower end of the femur, the condyles, and the upper end of the tibia are frequently the seat of enchondromas and sarcomas. Both of these diseases are more likely to grow from the inner aspect of the joint, the classical site of sarcoma being the internal condyle of the fe

mur.

HANDS AND FINGERS.

Enchondromas, ganglions simple and compound, fibromas, lipomas, exostoses, sarcomas, and carcinomas are met with on the hands and fingers. Enchondroma is by far the most common. They are usually multiple, growing from the thumb and fingers, and producing great deformity.

Fibromas are less common. They, too, are as a rule multiple.

Ganglions are usually situated on the back of the wrist and hand over the extensor tendons. Fatty tumors are extremely rare, and when they do occur are situated deeply in the palm of the hand.

Exostoses are uncommon.

Both forms of malignant disease, sarcoma and carcinoma, are rare. Of the malignant growths epithelioma is the most common.

FOOT AND TOES.

The neoplasms of the foot are the lipoma, fibroma, ganglions, epithelioma, and sarcoma. Fatty tumors are rare, and when found are usually in the sole of the foot.

Fibromas are also rare and generally situated at the posterior part of the sole, where they interfere very much with walking.

Ganglions are more common, and, as in the hand, are situated over the extensor tendons on the dorsum.

Epithelioma is more common than sarcoma, though both are rare.

LOUISVILLE, KY.

AN ANTI-PREMATURE BURIAL SOCIETY.— The Medical Record states that a number of physicians and laymen are about to organize a society having for its object the prevention of premature burial, an occurrence which the promoters of the organization believe to be more common than is generally supposed.

THE MANAGEMENT OF ABORTION.*

BY ANDREW SEARGENT, M. D.

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There are but few practical every-day ques tions in medicine upon which so much honest difference of opinion is found as on the subject of this paper. The young doctor, who finds himself confronted with a case of abortion for the first time, can find a precedent for any course of treatment he may decide to pursue, and have respectable authority to confirm his decision. It is not the object of this paper to review the different opinions held upon this important question, but to offer the writer's reasons for the treatment he is about to recommend, believing this to be the best way to induce a free discussion of the subject by the members of this Society.

I shall include under abortion the early expulsion of the ovum-that is, during the first, second, third, and fourth months of pregnancy only-and refer exclusively to cases in which we have decided abortion to be inevitable.

Having determined that preventive or prophylactic measures have failed, or that they are useless, we find ourselves confronted with two dangers threatening our patients, hemorrhage and septic infection, the former to be controlled and the latter to be prevented.

The sudden termination of pregnancy presents different phenomena according to the period when the abortion takes place, and it is therefore highly important to distinguish the accident in the first two months from that occurring during the third and fourth months of gestation.

When abortion takes place during the first and second months, the ovum is expelled entire in a large proportion of cases without any rupture of the fetal membranes, and no interference is necessary. Rest should be enjoined, and ergot may be administered. In the more serious cases, as a rule, the sac is ruptured, and, the whole or a portion of the contents being retained, the hemorrhage is more or less severe according to the amount of separation that has taken place.

In abortions of this character I believe it to

*Read at the May (1890) meeting of the Kentucky State Medical Society."

be the duty of the physician to make a thorough and careful investigation, and take nothing that he may learn from the patient or friends as true until proven. I consider such a condition to be very serious and unsatisfactory, one that requires close attention and careful watching, while delay or expectant treatment is fraught with dangers, fears, and accidents that should not be permitted outside of a hospital.

If, upon making a digital examination, I find the cervix sufficiently dilated to introduce my finger, I make it a rule to completely empty the uterus before leaving my patient; that is, I adopt the so-called radical plan of treatment. If the cervix is too firm and the membranes can be felt protruding, or in utero, I administer chloroform, and forcibly dilate with my fingers until I can by bi-manual aid explore the entire endometrium and remove the ovum and membranes if necessary. I use my finger or fingers to remove the contents of the uterus in preference to any instrument that I know of. After this, and not before, I administer ergot, and feel assured that my patient is safe from hemorrhage, and infinitely safer from sepsis. The after-treatment is the same as that required for an ordinary puerpera. Protracted rest in the recumbent position is imperatively demanded.

But abortion during the third and fourth months of gestation is altogether more serious, because the placenta has contracted, at this period, many and very intimate adhesions with the womb, while the latter has not yet acquired all the contractility of tissue that it possesses at term. The placenta being relatively largest at this period and the womb relatively weakest, therefore abortion is attended with more profuse hemorrhage and greater danger of retention at this time. The fetus escapes more readily than the placenta, and if the abortion is left to nature, the uterus, being partially evacuated, retracts, the cervix closes up, and the symptoms frequently disappear for a time, while the placenta and membranes remain in utero for eight to ten or twelve days, even for three months, according to Cazeaux and Tarnier, who advise the expectant treatment until there are symptoms of septic poisoning.

I wish to enter my earnest protest against delay in the management of these cases, or the expectant plan so-called. It is an easy way, and in the great majority of cases it is successful, thanks to the vis medicatrix nature; but why wait for dangerous symptoms before active interference? It may then be too late.

When called the physician will usually find the os uteri partly open, and a portion of the placenta or membranes can be felt protruding from or imprisoned in the uterine cavity. It is then better to accomplish artificial delivery, and empty the uterus in order to avoid the dangers of a tardy abortion. In acting thus the future safety of the patient is assured. This can generally be done with the fingers. Sometimes the adhesions of the placenta are so numerous that it is impossible to destroy them without strong pressure upon the hypogastrium to depress the womb so that the forefinger of the other hand can be passed into its cavity, gliding between the placenta and uterine walls. If this does not succeed, chloroform should be administered, the hand passed into the vagina, the fingers into the womb, and every particle of placenta and membranes be removed. This, followed by the use of antiseptics and the administration of ergot, makes us masters of the situation at once, and enables us to say to patients immediately they are out of danger.

This active interference in cases of prolonged abortion by the aid of chloroform is not difficult, and if performed gently, as all intra-uterine manipulations should be, will do the patient no harm. On the contrary, she is spared the danger of profuse hemorrhage, which might occur in the absence of the physician. She is spared the risk of septic infection, general or local; she is spared the mental anxiety to which otherwise she is subjected by delay. She is also less likely to abort in future pregnancies, because the above treatment will be less liable to be followed by sub-involution, hypertrophy, or displacement of the womb.

Again I wish to go on record as advising the immediate removal of the secundines in abortion, as the proper course; generally easy and always protecting the woman from accident.

HOPKINSVILLE, KY.

REPORT OF TWO CASES OF CLEFT IN THE SOFT PALATE.*

BY M. F. COOMES, A. M., M. D. Professor of Physiology, Ophthalmology, Laryngology, etc., in the Kentucky School of Medicine.

The first of these two operations was done on the person of a boy five years old and well developed in every particular, save that the soft palate was ununited, the cleft being complete in the soft structures, while the hard palate was unaffected.

The first operation in this case was done without chloroform, cocaine being applied to the parts. The boy was secured fast to Dr. F. Samuel, by the means of a bandage encircling both the patient and doctor. After many difficulties the freshened edges were united by the introduction of several stitches of silk ligatures. This was a bloody, torturing operation, and one that I will not try again on so young a patient without general anesthesia. The levator muscles of the palate were not cut, and the child was permitted to take fluid diet ad libitum. On the fifth day all the stitches were cut out, and the mother and father of the patient and myself were alike disgusted. After the parts had resumed their normal condition a second operation was done. This time, as before, I was assisted by Drs. Holloway, Marvin, and Samuel, and the patient was under the influence of chloroform.

The edges were freshened, and when well apposed were held in position by strong silk stitches; the muscles tending to separate the wound were cut, and the wound treated on this occasion as in the first operation. These stitches all cut out in four or five days, save the one in the tip of the uvula. The mother begged me to remove this, thinking that it was no good; but I declined, thinking there might possibly be chance of the wound uniting by granulation, which it did, and the final result was all that could be expected in such cases.

The second case was that of a young man, fifteen years of age, whose cleft was complete in the soft parts. He had been operated on during infancy, and the result was negative. The parts were cocainized and the edges pared

Read at the May (1890) meeting of the Kentucky State Medical Society.

and the cut surfaces brought together and held in position by seven large silk stitches. (The silk used in this case was No. 12.) Four out of the seven stitches remained, while three cut out. In both of these cases up to this time I had used the ordinary needles used for such purposes; and, to say the least of it, the task of closing a cleft in the soft palate with the oldfashioned needles fashioned needles is any thing but an easy or pleasant one. During first operation on this last case I determined to make a needle which would enable anybody to do this operation and to do it without the great annoyance and difficulty met with when the old-fashioned needles are employed.

The results of my labors in making a new needle for this purpose are better shown in the instrument itself than by any words that I can command. The instrument is nothing more or less than a steel hook with an eye in the end of the hook; the shank of the needle is flexible, so that it can be bent in any position in order that the hand may be kept out of the way while operating, and to enable the operator to reach any desired point in a wound or in any opening.

I have used these needles in one case and with the most gratifying results. I think that they speak for themselves, hence I shall have no further comment on them. I am fully confident that the larger the silk the less liability there will be of the stitches cutting out prematurely, and this is the great danger and one of the great causes of failure in these cases.

LOUISVILLE.

BISMUTH AND GONORRHEA.

THEODORE L. BENNETT, M. D.

Bismuth has long been employed as an effective agent in the treatment of chronic gonorrhea, and so it is in a certain class of cases ; but we are too apt to overrate a good thing and fall into a mechanical way of using it; hence my remarks concerning the use of bismuth as an urethral injection.

A young man consulted me with a case of gonorrhea of about five weeks' standing. The disease responded readily to treatment, it being my custom to inject these cases at my office,

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