Paraffinoma

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EDITORIALS’ I

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COLONIC DIVERTICULITIS It is within comparativeIy recent years that we have acquired a recognition of the significance of intestina1 diverticuIa and of the varied symptomatoIogy of diverticuIitis. There is, of course, much difference between the mere presence of a diverticuIum or diverticuIa and the affection that arises with inflammation therein; .and it wouId be interesting to know what percentage of individuaIs with diverticuIosis .escape attack? of diverticuIitis. In spite of the Iiterature that has.accumuIated on the subject, diverticuIitis is so much IPSS common than ChoIeIithiasis, appendicitis, uIcer, urinary caIcuIus, peIvic disease and neopIasms, that it is often forgotten or overIooked when one is confronted with a painfu1 abdomina1 affection. Yet it shouId be the first thought in subacute Ieft-sided abdomina1 compIaintespeciaIIy of pain in the Ieft Iower quadrant, since coIonic diverticuIitis is most common in the sigmoid. Two very interesting .articIes on this subject are presented in this issue of the JOURNAL. MaiIer reports two unusua1 cases, in which tubercuIosis and .diverticuIitis coexisted in the sigmoid coIon. BaIIin’s articIe, based on a con.siderabIe persona1 experience, presents very cIearIy the pathoIogy, the varying symptomatoIogy, the diagnosis and the treatment of coIonic diverticuIitis. It Ieaves but IittIe to add from the cIinica1 side. As he points out, adhesion to and perforation into the bIadder is more apt to take pIace in diverticuIitis than in carcinoma of the sigmoid, and intestina1 obstruction is much Iess apt to occur. We are famiIiar with reduction in the size of a carcinomatous mass after coIostomy, but the practicaJ ,disappearance of such a mass means, of course, as BaIIin emphasizes, that the supposed carcinoma was entireIy inff ammatory. Actinomycosis is another of the

unusua1 affections of the sigmoid that, Iike diverticuIitis, is sometimes mistaken for a neopIasm. CoIonic diverticuIitis may go on to the formation of a Iarger or smaIIer pericoIic abscess, or it may subside and Ieave the individua1 subject to further attacks. FormidabIe as is resection of the sigmoid, it deserves serious consideration in the presence of a diverticuIitis, because of its dangerous possibi1itie.s. Among these, though probabIy an uncommon compIication, is abscess of the Iiver. Indeed, an hepatic abscess not otherwise expIained may we11 suggest an inquiry into the possibIe presence of a sigmoid diverticuIitis, active or quiescent. Certain individuaIs have a syncopa1 attack when an enema is administered. Some of them, we hdve reason to beIieve, have sigmoid diverticuIosis.-W. M. B.

PARAFFINOMA McWiIIiams’ brief articIe in this issue of the JOURNAL very terseIy teIIs of the eviIs and the dangers of subcutaneous and the manner in paraf3n injections, which the masses they produce are to be dealt with surgicaIIy, to the extent that they can be deaIt with. Upon reflection, it seems hard to beIieve that there couId have been seriousIy accepted for the reIief of depressions in the face the injection of a hardening foreign body into tissues that shouId be soft, suppIe, eIastic, mobiIe. Indeed, so far asawe know, the procedure (which Gersuny introduced in Igoo and which had more or Iess vogue for a few years thereafter) has been pretty much abandoned by surgeons and, in this country, at Ieast, is practiced aImost excIusiveIy by quack “beauty speciaIists ” more boId than conscientious. In the course of time (often not a Iong time) the paraffin becomes surrounded by a mass of scar 180

‘New Series VOL. 11. No. 2

EditoriaIs

American Journal of Surgery

181

is none now that we have acquired experitissue far more disfiguring, and certainIy ence in transpIanting Iiving tissues. SaddIemore uncomfortabIe, than the depression for the cure of which the injection was nose is correctibIe by the insertion of a undertaken. Very often, however, the bad bone graft, and a depression in the soft resuhs of such injections are not onIy parts, if Iarge enough to warrant it, by an remote but immediate. What happens, not inIay of fat. The pathogenesis of paraf5noma is not infrequentIy, is this: a vain or morbid without interest. The hydrocarbon mass individua1, maIe or femaIe, distressed by becomes surrounded by connective tissue some smaI1 scar depression, abnorma1 and is aIso divided into compartments by dimpIe or wrinkIe in the face, permits a connective strands which, it has been “beauty specialist” to inject paraffin generaIIy assumed, grow into and through beneath it; a drop or two too much is used the paraffin from the enveIoping scar .and the depression becomes a sIight protissue. In a series of articIes published in trusion on one side of the face; to baIance the JOURNAL over twenty years ago, and this the victim is persuaded to have the reprinted in book form, l Luckett and Horn, opposite side of the face fiIIed out correof New York, showed that this assumption spondingIy by a second paraffin injection; was not valid, that these presumed-to-be on this occasion a little escapes into another spot and thus the side Iast treated has two ingrown strands of connective tissue are projections and the first side onIy one; present from the moment of injection, at which time the Iiquid paraffin “runs aIong so the beautifier again attempts to baIance the features by a third injection, this time in the direction of Ieast resistance, forcing, again on the first side; and so the process tearing and stretching its way between goes on unti1 the poor victim who goes to the Iayers, bundIes or even singIe fibers. . . with an insignificant running from one aIveoIar space to another, the “ specialist” depressed scar on one cheek finaIIy Ieaves encircIing, surrounding and encompassing him with both sides of his face as Iumpy as these Iayers, bundIes, fibers or ceIIs and a basket of appIes, and as hard. When the even bIood vesseIs.” This they demonparafhnomas are discrete something can be strated by sections made immediateIy done, sometimes, by their excision en after injections into animaIs and into masse; and if this can be accompIished cadavers. They found aIso that soIid parthrough the mouth so much the better. affIn masses inserted stibcutaneously in However, the reIief by extirpation is very animaIs showed Iater no permeation by incompIete for the connective tissue for- connective tissue or bIood vesseIs, whether mation is usuaIIy quite extensive. Indeed, Ieft as a singIe mass or broken into fragone sometimes sees the fair features of ments after impIantation.-W. M. B. some fooIish woman converted into a contracted, tense, dense mask, a Ioathsome, bluish, lumpy mass of scar tissue in which CLARENCE A. McWILLIAMS the jaws are fixed and onIy the Iips and eyeIids retain some measure of mobiIity! Dr. CIarence McWiIIiams of New York, For reIief from such a condition the onIy one of the EditoriaI Board of the JOURNAL, recourse is suicide; and in suicide has more died Iast month of pneumonia at the age of than one victim of the “beauty speciaIist” fifty-six. He was a member of the New sought escape. Of the appIications of par- York SurgicaI Society and of the American a&n injection that for saddle-nose is at and International SurgicaI Associations. once the most nearIy acceptabIe and the He was surgeon to the ,New York Skin and most dangerous. Whatever excuse there Cancer HospitaI and had been on the may have been for the employment of lluckett, W., and Horn, F. I. Paraffh in Surgery. these injections twenty years ago, there N. Y., rgo7.