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J. A. (Joel Asaph) Allen.

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New York, I am confident that, sooner or later, a hernia will
develop at the point of exit of the cord structures. Another
decided objection to this procedure is the liability to adhesions
with the overlying fascia, which will not occur when they pass
between the serous covered tendons.



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150 CLINICAL EEPOBT.

Of something over thirty cases, operated upon by me after the
method of Bassini, I have had three recurrences. In each, suppur-
ation occurred, and the hernia made ita appearance during the
first six months.

CONCLUSIONS.

1. Reconstruction is the best method.

2. No drainage should be employed.

3. The use of trusses should be prohibited afterwards.

4. While a certain percentage will recur, the operation is
justifiable between four and forty years of age, unless some
physical disability contraindicates the same.

5. Where omental or intestinal adhesions exist, and the use
of a truss is unsatisfactory, the operation should always be
attempted, as the danger from strangulation is greater than that
from the employment of an anesthetic.

6. It is advisable to attempt a radical cure in all cases
operated upon for strangulation, unless the gut be gangrenous, or
the patient's vitality too low.

7. Where undescended testes exist, it will usually be found
to be complicated by hernia, and at the time the organ is anchored
to the scrotum, the inguinal canal should be reconstructed.

86 West Fifty-Ninth Steeet, New Yoek.



(sPiaicaP S^eporf.



CYSTS OF THE NASAL PASSAGES.'

By VV. SCOTT RENNEB, M. D.,
Professor of Laryngology, Medical Department, Niagara University, etc.

Until recently, cysts of the nasal passages were scarcely ever
mentioned in medical literature, and even since the development of
rhinology, and the rapid strides which have been made within the
last few years, few cases have been reported.

Four different pathological conditions of the nasal passages
have been described under this title. These are glandular reten-
tion cysts, cystic degeneration of nasal polypi, or cystic polyp,

1. Eead before the Section on Anatomy, Physiology, and Pathology, of the Buffalo
Academy of Medicine, September 19, 1893.



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CLINICAL REPORT. 151

osseoas cysts, inclading cysts of the turbinated bones, especially of
the middle, and dermoid cysts of the nasal passages.

Before speaking of these different forms of cystic growths, I
wish to relate the principal points of a case which occurred in my
practice.

The specimen which I now show you is the sac of a multi-
locular cyst of the nasal passage. It measures about two inches in
length and about three-fourths of an inch in breadth. The amount
of fluid which it contained, unfortunately, could not be estimated.

I removed this specimen from the left nostril of Mrs. J. N.,
thirty-five years of age, a charity patient at the Buffalo Eye and Ear
Infirmary. She came from the country, and applied for treatment
at the Infirmary in October, 1891. She complained of nasal
obstruction, headache, and catarrhal symptoms. She stated that
only the left side of her nose was constantly obstructed, the other
only at times. The left side had troubled her for years. I exam-
ined her nose, and found what I supposed was a large nasal polypus
filling the left nasal passage, anteriorly. This growth could be
easily seen without a speculum by lifting up the tip of the nose.
The same or a similar growth could be seen on the same side when
making a posterior rhinoscopic examination. It did not, however,
extend into the cavity of the naso-pharynx. Although I supposed
the tumor was an ordinary soft nasal polypus, it was much more
translucent than they generally are. I informed the patient that
she had a growth in the left nasal passage, which should be removed
in order to relieve her unpleasant symptoms. She consented to
the operation, and I operated rapidly with the cold snare. Much
to my surprise, as soon as I commenced to encompass the tumor, it
burst, and fluid of a light yellow color flowed from the nose. I
was compelled to tear the growth from its attachment with some
force, when I found that it was a multilocular cyst, of which the
largest cavity had been opened when the fluid escaped from the
nose, that the growth seen posteriorly was the same one which had
presented itself anteriorly, and that the whole growth had been
removed. I then applied a cocaine solution thoroughly to the
bleeding surface, and was able, in a few minutes, to demonstrate
that the growth had had an extensive origin from the free border
and anterior end of the middle turbinated bone of the left side. I
also discovered that the patient had no other polypoid or other
growths in the nose. The patient returned the following day to
the country, and has remained well ever since.



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152 CLINICAL REPORT.

I was inclined to think that this cyst was formed from a degen-
erated nasal polypus. Dr. William C. Krauss examined it, and
found it to be a multilocular cyst with no epithelial lining. He
considered it a degenerated soft nasal polypus, and not a retention
cyst, a condition of the mucous membrane of the nasal passages
which has been described by some writers. It is not uncommon
to find small cavities, or degenerated spots, in the center of old
nasal polypi, as well as in tumors in other localities, and not sel-
dom one of several polypi may have a large cystic cavity in its
center, filled with fluid, as was the case with this specimen. I
removed this (Specimen No. 2) from the naso-pharynx of a boy,
twenty years of age, who came to consult me, from the country,
about two years ago. The whole of his nasal and naso-pharyngeal
cavities were filled with soft polypi. When I first saw him, the
expression of his face was so peculiar that I thought that I had a
case of fibroma of the naso-pharynx. The specimen was one of
several large polypi which I found extending from their attach-
ment to the middle turbinated bone into the naso-pharynx.

Moure, of Bordeaux, in 1886, reported a case of cystic polyp,
partly occluding the posterior nares of the left side, in a patient
suffering from mucous polypi of the right side. The growth was
removed and expelled through the mouth, the fluid having escaped.
This cyst, when distended, was about the size of a small egg.
** The author looks upon the growth as a mucous polyp, a portion
of which had undergone cystic degeneration, a condition which he
does not consider uncommon, especially where polypi pass through
the posterior nares into the pharynx."

The late Dr. F. H. Potter, of this city, reported a case of uni-
locular cyst of the nasal mucous membrane attached to the middle
turbinated bone. Besides this, and the case of Moure's, which I
have just mentioned, I can find reference to but eleven cases of
cysts of the nasal mucous membrane in the literature at my dis-
posal. Park, Johnson, Watson, Bonauno, Zahn, Lefferts, Ingals,
C. W. Richardson, and Babcock, have each reported one case,
Chatellier two. This list does not, of course, include the reports
of osseous and dermoid cysts which may be found in the literature.
The original articles I have not been able to consult, in most cases,
on account of the short space of time at my command to prepare
this paper.

In Watson's case, the tumor was multilocular and attached to
the middle turbinated bone. In the cases reported by Lefferts,



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CLINICAL REPORT. 153

Johnson, and Potter, the cystB, although unilocular, were attached
to the middle turbinated bones, those of Lefferts and Johnson
extending into the naso-pharynx. None of these cases differ
materially from Moure's case of degenerated polyp, except in that
they were not associated with nasal polypi. These growths, in the
four cases enumerated above, resemble Moure's as well as mine, in
that they all were attached to the middle turbinated bone, which
is the favorite attachment for soft nasal polypi, a fact which would
make one suspect that these retention cysts were retention cysts
formed in the glandular tissue found in the substance of the
so-called myxomatous or soft nasal polypi. Two of these tumors,
like Moure's, extended into the naso-pharynx. It is quite com-
mon, according to Moure, for polypi extending into the naso-
pharynx to undergo cystic degeneration. This statement is sup-
ported by the second specimen which I showed you. A third one,
Watson's, was, like mine, multilocular and confined to the nasal
cavity. It is natural to suppose that a multilocular cyst is much
more likely to have its origin in a degenerated polypus than in an
obstructed gland. Potter's case was not multilocular, and did not
extend into the naso-pharynx. The two reported by Chatellierdid
not originate from the middle turbinated bones. The point of
origin of the other five cases I have been unable to learn.

Whatever the origin of these cysts, whether by distension of
a simple gland, or within a degenerating polypus, they are practi-
cally the same. In one case they form from the adenoid tissue of
the nasal mucous membrane, in the others, probably, from the
adenoid tissue found usually in soft nasal polypi.

By the operator, they are usually mistaken for polypi. He,
generally, only becomes aware that these growths are cystic after
be has commenced operating, except in cases attached far forward
in the nose, as they were in both of Chatellier's cases.

Osseous cysts of the nasal passages have been found most fre-
quently in the anterior extremity of the middle turbinated bones.
They pass unnoticed until the mucous membrane covering them
becomes hypertrophied, when the symptoms of pressure against
the septum cause the patient to consult the specialist. All such
enlargements of this part of the turbinated bone do not contain a
cavity, and no examiner of the nose can be positive of the presence
of such a cavity until he has removed the enlarged end of the
bone, unless it be of very great size, like the case reported by
Knight, of New York.



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154 PROGRESS IX MEDICAL BOIBNCJC

Tucker Eandl describes these cavities of the middle turbinated
bone as an anomalous condition of their development. He does
not consider them the result of any pathological process. Some
consider them the result of hypertrophic changes. Osseous cysts
of the septum and lower turbinated bone have been so described.

Dermoid cysts of the nasal passages are rare and interesting^
but foreign to the subject of this paper.

The prognosis in all these cases is good, and the treatment is
always surgical.

361 Pearl Street.



progreAA in Me3.icaP ^cience.



NERVOUS DISEASES.

Conducted by JAMES WRIGHT PUTNAM, M. D.,
Clinioal Professor of Nervous Diseases, Medical Department, University of Buffalo.

SPASMODIC TORTICOLLIS — TREATMENT BY EXCISION OF NERVES.

Noble Smith (The Lancet, August 26, 1893). In this article five
cases are reported. In Case I., after four years, there is no pain
in the neck ; there have been no spasms since the operation. The
spine has become straight. Motion of head is good, sensation is
normal, and the appearance of the neck is natural. This is the
result in a case of sixteen years' duration, in whom the spinal
accessory of the left side was operated on by excision of a piece.
Later, the same was done on the right side to the posterior branches
of the second, third, and fourth cervical nerves.

Case II. — A man, fifty-seven years old, had, in addition to
spasm of muscles on both sides of the neck, spasm of muscles of
the face. Two years after operation he wrote: "I am cured of
the distressing malady on the side of the head you operated upon^
but the other side gives me great trouble."

Case III. — Patient aged forty-five ; duration of disease, four-
teen years ; was free of pain one and one-half years after operation.

Case IV. — A woman, past sixty years, had spasms over fourteen
years. Excision of the left spinal accessory, and of the posterior
cervical nerves on both sides, resulted in perfect freedom from
spasms, although the strength of the neck has been somewhat
impaired.



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NEBVOUS DISEASES. 155

Case V. — Showed improvement after operation.
These results certainly show that excision of the nerve, for this
obstinate malady, is justifiable in obstinate cases.



FOR MYXEDEMA.

The Alienist and Neurologi&t^ July? 1893. (Abstracts from The
Lancet^ February 4, 1893.) The following are the methods of em-
ploying the thyroid juice in this affection : One-eighth of a thyroid
gland, in powder, given two to seven times a week in lukewarm beef
tea. — (Arthur Davies). One-half to one thyroid gland daily, eaten
raw — (Pasteur). One-half a thyroid gland, three times a week, fried
sufficiently to make it palatable — (Calvert). Equal parts of thy-
roid juice and glycerine, and a five per cent. aq. sol. of carbolic
acid. (3iss. equal to one sheep's thyroid.) Give m. x.-xv. hypo-
dermically, or 3i. by mouth — (Murray).



the men^tal symptoms of mtxbdema and the effect on them

of the thyroid treatment.
CiA>U8TON (British Medical Journal^ August 26, 1893). The author
reported nine cases of myxedema sent to the Royal Edinburgh
Asylum on account of insanity. Two of these had been treated
by thyroid extract.

One of the cases had been insane for one year, the other for
three years. The myxedema had existed for over five years in
both. Both were enfeebled in mental power, this having succeeded
exaltation, morbid suspicion, and excitement at the beginning of
the attacks of insanity. One case was cured in four months, the
other in six. A slow intermittent treatment, by small doses (one-
sixteenth of a thyroid twice a week), was found to be the best. In
both cases the mental symptoms disappeared with the bodily
symptoms. The whole mental powers acquired strength, and the
normal enjoyment of life was restored.



THE SENILE FORM OF MULTIPLE NEURITIS.

Oppenueim (Berlin Med, Wochenschrift, No. 25). The author
gives the result of a study of six cases as follows : The charac-
teristics of the senile form of multiple neuritis are : (1) The
absence of the etiological influences, intoxication, and infection ;
(2) the pronounced chronicity of its course ; (3) the absence of



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156 PBOGBKSS IN MEDICAL SCIENCB.

the mildness of irritative sensory disturbance ; (4) the incom-
pleteness of motor and sensory impairment ; (5) the freedom
from involvement of the cerebral nerves.

As a result of treatment, two cases were almost completely
restored, a third was decidedly improved, the fourth was made
worse. No change was observed in the other two.



OBSTETRIC PARALYSIS.

Carter (Boston Medical and Surgical JoximaX^ May 4, 1893).
Thirty-two cases are tabulated by the author, including sixteen of
his own. He concludes that paralysis is due to a stretching of the
nerve trunk, formed by the fifth and sixth cervical nerves, by
traction on the head or pressure on the breach when the head is
retarded, or by traction on the shoulder when the head is retarded.
It is not caused by pressure from the forceps. The paralyzed
muscles are the deltoid, supraspinatus, infraspinatus, teres minor,
biceps, and brachialis anticus with the supinators. In some extreme
<5ase8 the paralysis includes the extensors of the wrist and fingers.

The arm is rotated internally, the elbow points outward. The
paralysis is not noticed before the second or third day. Reaction
of degeneration is present after a few days. Treatment consists
of passive movements, massage, galvanism every other day through
the affected muscles, and brachial plexus.

The prognosis is good, though recovery is sometimes delayed
for months and even years. Permanent disability is very rare.



Meniere's disease, cured by salicylate op sodium.

Oay {British Medical Journal^ September 9, 1893). The writer
reports the case of a lady, aged 65, who had suffered since 1890*
Was treated with gelsemium without much benefit. The patient
was put on three-gram doses of soda salicylate, the fits being at
once reduced in frequency, but continued for some months.
March, 1891, saw her much better, but she suffered from heart weak-
ness in May, 1891. In June she had one fit. In November, 1891,
she considered herself cured, and has since remained free except
slight deafness in one ear.

Treatment lasted rather more than a year, salicylate being
taken daily. During the last six months, however, she had con-
siderable intervals without it.



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LACBBATION OF THE FEMALE PSBINBUM. 157

EFFECT OF OPIUM HABIT IN THE MOTHEB ON THE NBW-BOBN.

Db. Wood {Journal of Inebriety^ Jaly, 1893,) says: "When a
mother uses opium, the child in the womb has the opium habit at
the time of birth." It has frequently been noted that when chil-
dren are bom in women who are opium eaters, the child seems at
first well ; then, in the course of a few hours, goes into a collapse
and dies. Now, I believe that the collapse in these cases develops
because the child has not the usual stimulus of opium, and should
the child be given opium immediately after birth, it would live.



^efecfionA.

SUPERFICIAL LACERATION OF THE FEMALE PER-
INEUM.

By FBEDEBICK P. HAMMOND, M. D., New York City.

In THE evolution of research concerning the female perineum and
its diseases, a few suggestions do not seem out of place concerning
the pathological changes which take place following a laceration
of the skin and superficial connective tissue. Our older teachers
and many of the present day deal with the area of tissue between
the vagina and rectum as the perineal body, and teach that its
main function is the support of the female pelvic viscera. The
newer school, unable to believe Nature had been so imperfect in
her work as to leave the important organs of generation dependent
upon a mass of connective tissue and skin for their support, sought
for and found the more logical pelvic floor, consisting chiefly of the
levator ani and triangular ligament. But these, having found the
true support of the pelvic viscera, have in their enthusiasm lost
sight of this still important organ, the perineal body. For, in a
degree, it still remains a body, and its function is hardly less
important than our older teachers held, for it closes and protects
the vaginal outlet from the atmosphere and friction of the cloth-
ing, and affords support for the superficial perineal muscles.

From a careful observation among dispensary patients and in
my private practice, I have taken special note of the existing con-
dition of affairs in all cases presenting themselves where a lacera-
tion of the superficial perineum, or relaxation of the pelvic floor,
due to a division of the fibers of the levator ani, has existed, and
in both the resulting pathological condition has been the same.



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158 SELECTIONS.

From my observation, therefore, it seems conclusive that the more
modern teaching of the slight laceration of the superficial perineum
being harmless, further than for its cosmetic effect, is entirely
erroneous. For, if any gynecologist wishes to convince himself
that hypertrophy and edema of the vaginal walls follow a
superficial laceration as well as a relaxed pelvic floor, he has
ample opportunity in observing a number of the cases presenting
themselves before him. While I admit that the serious train of
symptoms, such as cystocele and rectocele, with its attendant
prolapse and subjective symptoms, is delayed in a case of simple
laceration, it as certainly results from a case of relaxation. For,
given any case, where the normal protection from atmospheric
irritation and friction of the clothing is destroyed, hypertrophy
and edema are the logical result. And while those with opposite
views would combat this argument with the circumstance that
they have observed cystocele and rectocele in virgins who have
passed the menopause, they must remember that they cite one of
the rare occurrencep of pathology, and might be brought to see
the absurdity of their views by going still further and calling to
mind the fact that cases of complete prolapsus uteri have occurred
in strong, robust domestics, who have the hymen intact.

The sooner we, in a degree, come back to a realization of the
fact that a laceration of the perineum, however slight, is a patho-
logical condition which demands interference as much as any of
the other ailments of the female genital tract, the earlier shall we
relieve our patients of so much suffering. There are many today
who, for a case of endometritis or salpingitis, advocate dilatation
of the OS and curetting — an operation not less serious in its
results than a salporrhaphy in the hands of an ordinarily
careful operator. Why, then, do we remain as extremists in our
views regarding this condition, when proof is forthcoming that in
this, as with nearly all others where minds have been at variance,
a middle ground is our shield and haven ? — Medical Mecord,



THE CAUSATION OF ANEMIA AND THE BLOOD-
CHANGES PRODUCED BY URIC ACID.
De. Alexandee Haig read a paper on this subject at the recent
meeting of the British Medical Association. He pointed out that
his previous researches on " anemic attacks," paroxysmal hemo-
globinuria, splenic leucocythemia, chlorosis, and anemia, showed



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DISLOCATION OF THE CERVICAL VEETEBRA. 169

that these troubles are very commonly associated with excess of
uric acid in the blood and urine. The excess of uric acid is not
the result of the blood-changes, but their cause ; for the uric acid
fluctuation begins before there are any blood-changes. The
speaker said that he had the power, by influencing the solubility
of uric acid, to bring it in excess through the blood into the urine
at pleasure, and it is also possible to increase the uric acid in the
blood and urine by taking a known quantity by the mouth.
Applying this knowledge to the experimental production of blood-
changes, he said the value of the blood fraction ^p^TZ^^u^^]u varies
with the amount of the uric acid passing through the blood from
day to day ; and by intentionally increasing the amount of uric
acid, definite and distinct falls in the value of the blood fraction
can be produced. Uric acid is more powerful than iron, and when
in excess in the blood, will prevent iron from raising the value of
the blood fraction ; hence the observation of Murchison, that iron
will not act when the liver is out of order, for dyspepsia entails
an excess of uric acid in the blood. Others have produced similar
blood-changes by the administration of thyroid extracts, which
are rich in extractives closely related to uric acid ; and a patient
under this treatment gave undoubted clinical signs of uric acid-
emia. The author explained, by means of this uric acid causation,
the anemia and chlorosis in girls, and the relation of these troubles
to the function of menstruation ; also the similar effect of fevers,
tropical climates, and diet. As a result of these observations, he
drew the conclusion, that anemia can be prevented by taking care
not to introduce an excess of uric acid into the body, and can be
cured by clearing it out of the blood. — Medical Record,



DISLOCATION OF THE CERVICAL VERTEBRA.

<j. L. Waj.ton, of Boston, states (iV. Y. MedicalJoumal) that this
condition is not rare, though frequently overlooked. Reduction
by extension, usually attempted, was unsuccessful. Spontaneous
reduction had occurred, showing that direction was more import-
ant than force. This fact had led him to the discovery of the
method theoretically correct, as shown by manipulation of the
vertebrae, and by experiments upon the cadaver, made by Dr. Rich-
ardson, of Boston, and himself. The method had been recently
demonstrated in practice by Dr. Beach, at the Massachusetts Gen-
eral Hospital, with successful result :



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160 SELECTIONS.

Suppose the left articular process of one vertebra has slipped for-
ward over that of the vertebra below and fallen into the depression
anterior to the articular process : This bends the head to the left and
turns the face to the right. The reduction is accomplished by extend-
ing the head diagonally backward to the right, so as to elevate the
articular process, after which rotation to the left replaces the displaced
vertebra. The transverse processes on the right act as a fulcrum.
The ligaments, which hold the vertebra firmly in the false position,
make no opposition to this manoeuver. which requires no force. In



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 16 of 78)