Reports of Societies

1886 Boston Medical and Surgical Journal  
B. Harrington, stating that she had had a miscarriage four years ago, and no pregnancy since. During a year past she had had much pain in the back and pelvis, with frequent haemorrhage. In September last she noticed a lump in the vagina, which afterward increased in size and then " went back." Three weeks ago, while lifting a heavy kettle, she felt something give Way in the pelvis, was immediately seized with haemorrhage, which had continued more or less profusely afterward, and found that the
more » ... and found that the tumor had again descended into the vagina. As the diagnosis was uncertain, Dr. Harrington asked Dr. Minot to examine the patient with him. There was a firm fleshy mass in the vagina, of about the size and shape of the uterus. Its surface was uneven, of a dark color, and covered with blood, which flowed freely during the examination. The tumor seemed to be connected with the interior of the uterus, but the sound could not be made to pass between it and the uterine walis into the cavity. A sound in the bladder could be felt by the finger in the rectum. On account of the restlessness of the patient from pain, the examination was not satisfactory ; and it was decided that she should enter the hospital for a more careful one and for treatment. On the following day, the patient being etherized, it was found that the pedicle of the tumor was attached to the interior of the cervix, almost completely around, so that the finger could not pass beside it into the cavity of the uterus. After some search a passage was found into which the sound easily entered to a distance of two and a half inches in the downward and backward direction. The openings of the fallopian tubes were sought for, but could not be found. To make sure, a small portion of the mass was excised, which showed the appearance of the ordinary fibroid growth. The mass was then drawn down and cut off with scissors. There was no haemorrhage of consequence, either at the time of the operation or since, and the woman has done well. The retroflexion explained the facility with which the catheter in the bladder could be felt in the rectum, as it passed directly over the uterus, thus adding to the embarrassment in the diagnosis. It might be said that uterine inversion was impossible with the history of the case ; but it was not thought justifiable to base a diagnosis, which might cost the woman her life if incorrect, upon her statements, since she might have some motive for concealing the real facts of the case. Dr. Franklin H. Hooper read a paper on adenoid vegetations in the naso-pharyngeal CAVITY.1 Dr. Knight, who, unfortunately, was unable to be > See page 193 of this Journal. present, sent the following notes to be read by the secretary : " I regret exceedingly to miss the reading of Dr. Hooper's paper, and not being able to open the discussion as you very kindly asked me to do. "I well remember bringing up the subject of adenoid hypertrophy at the pharyngeal vault many years ago, when it first began to attract attention, in our old quarters in Temple Place. Some of the gentlemen present may remember the excited manner in which the late professor of pathological anatomy denied that there was any adenoid tissue at the vault of the pharynx, and how, having a good dissection on hand, I convinced him of its existence. "A little later 1 was asked by a distinguished surgeon to examine with the posterior rhinoscope a young lady on whom he, a few days before, had performed tracheotomy, preliminary to the bloody operation of resection of the superior maxilla for naso-pharyngeal polypus. The gentleman confided to me with some anxiety that the tumor was not nearly so prominent as it had been. I found a moderate adenoid hypertrophy, which had probably been acutely swollen, and led to the erroneous diagnosis of naso-pharyngeal fibroid. The patient was discharged ' much relieved ' ! "As we know it at the present day, this adenoid is capable of enormous hypertrophy, so that nasal respiration is completely occluded. "In regard to its treatment, there is, I imagine, little difference of opinion about the necessity of removal, when it is sufficiently large to seriously obstruct nasal respiration, to seriously impair the voice, or threaten the hearing. To accomplish this, I have used the cutting forceps more than any other instrument, though I have occasionally removed large pendulous masses by means of the wire snare passed through the nose. " I have shared the prejudice against the sharp spoons of various kinds which have been recommended for this operation, but the perusal of Trautmann's recent monograph, including detailed accounts of one hundred and fifty cases, makes me think that the operation may be done much more expeditiously with such a spoon as he recommends. He uses a large very sharp spoon, which is passed under the soft palate up towards the septum, and then made to cut across towards the posterior wall of the pharynx, getting out much larger masses than with the forceps. 1 attach some importance also to the fact that Trautmann was familiar with and used the cutting forceps before adopting the spoon. " Shall the operation with forceps be done under the guidance of the rhinoscopic mirror ? Certainly, if that is possible, but I can but think that the dictum in a recent treatise that forceps should never be introduced into the post-nasal region except under guidance of the rhinoscopic mirror is unnecessary. In many cases, on account of the age of the patient or irritability of the fauces, the mirror cannot be used at all. In using the forceps or any instrument in the posterior nares by the sense of touch alone, I think our efforts should be directeol to clearing away the central mass which blocks nasal respirations and avoiding the lateral regions of the Eustachian orifices. " In the cases of unmanageable children, it seems to me most satisfactory to resort to etherization at once.
doi:10.1056/nejm188603041140904 fatcat:y256qeus2jhzvakubcrxeqjb5i