Neoplasms Of The Upper Air-Passages
By JONATHAN WRIGHT, M. D.,OF BROOKLYN, N. Y.
As introductory to the subject, I translate from the interesting and valuable work of Prof. Moritz Schmidt, the initial page of his chapter on New Growths of' the Upper Air Passages :"
"In order to give some idea of the frequency Of neoplasms in the upper air passages, I will make a resume of those observed by me in the last tell years. These occurred among a total number of 32,997 patients, and were as follows.
In the nose:
a. Mucous polypi, 757 (462 men; 295 women).
b. Fibroma, 2 (men).
c. Papilloma, 6 (3 men; 3 women).
d. Lymphoma, 2 (women).
e. Lympho sarcoma, 2 (women).
f. Cyst, I (man). Sarcoma,
g.(1 man; 5 women).
h. Carcinoma, 5 (3 men; 2 women).
In the naso pharynx :
a. Fibroma, 13 (7 men; 6 women).
b. Cysts, 101 (60 men; 41 women).
c. Angio sarcoma, 1 (man).
d. Sarcoma, 1 (man).
In the oro pharynx:
a. Fibroma, 3 (1 man; 2 women).
b. Papilloma, 40 (29 men; 11 women). In reality the figures should be higher, since from the slight interest in these growths, careful account of them was not kept.
c. Cyst, I (man).
d. Tonsillar polypi, 5 (3 men; 2 women).
e. Sarcoma, 2 (1 man; I woman). ,
f. Carcinoma, 16 (15 men; 1 woman).
In the larynx:
a. Fibroma, 256 (178 men; 78 women).
b. Papilloma, 46 (31 men; 15 women).
c. Singers' nodes, 109 (56 men; 53 women).
d. Lipoma, I (man).
e. Myxoma, 3 (men). In recent years they are not especially mentioned. Weigert regards them as edematous fibrous polypi. They are included under (a).
f. Fibro myxoma, 1 (mail).
g.Tubercular tumors, 36 (14 men; 22 women).
h. Cyst, 8 (2 men; 6 women).
i. Sarcoma, 3 (men).
k. Carcinoma, 75 (61 men; 14 women).
In the trachea :
a. Carcinoma, 2 (1 man; 1 woman)."
NASAL NEOPLASMS.
Neoplasms of the nose and throat, of in flammatory origin, are met with very frequently. At a glance it may be seen in Schmidt's tables how mark¬edly the mucous polypi preponderate over all other nasal growths. The same mav be observed in the larynx, under the beads of fibroma and singers' nodes. True tumors, especially those of benign origin, are excessively rare. Much confusion has arisen from the mistaken conceptions of laryngologists in regard to the pathological character of these growths. Much of this has resulted from the exceedingly unsatisfactory theories of the pathogenesis of tumors in general. It is doubtless true that there are many neoplasms which to all histological appearances are true tumors, which yet depend on the over nutrition of inflammatory processes for their origin. It is not the province of the writer to attempt here the task of drawing a satisfactory line of division between true tumors and the neoplasms of inflammation.
Edematous polypi of the nasal mucous membrane belong to the latter category. They are usually called myxomata, which in some degree they resemble, both microscopically and macroscopically ; but they are in the vast majority of the cases, in the nose, the result of a chronic inflammation; and hence, serous infiltration being their. most marked characteristic, they are better called edematous polypi. It should be remembered that the word polypus refers simply to their pedunculated form. Exactly the same histological condition is found in the nasal mucous membrane in a sessile form.
Histology. The epithelium resembles that of the surrounding mucous membrane i. e., columnar ciliated cells in the upper part of the nasal chambers and non ciliated below; flat cells in the lower pharynx and larynx. This epithelium may undergo metamorphoses from the attrition of surfaces or other irritation, such as the flowing of pus from the ethmoidal sinuses, so that the cilia may be lost from the columnar cells and the latter become more or less flattened, resembling the squamous type. The layers may become thickened either uniformly or digitations may form, dipping into the stroma at irregular intervals. The epithelium may, on the other hand, be entirely unchanged.
The stroma is separated by the effused serum into bundles, leaving spaces between. The size of these spaces or meshes and the quantity of the Stromafibers differ greatly apparently according to the degree and the age of the process.
The fluid contains some mucin and fibrin. When coagulated in the hardening processes of histological technic, the fibrin, unless broken up into granules, may be easily mistaken for connective tissue fibers. Round cells of varying diameters are entangled in the meshes of the stroma and in the fibrin. These and connective tissue are found most abundantly in the region of the blood vessels (Fig. 623) and glands, if they exist.
Glands are usually scanty. If present at all, they are usually found in or near the pedicle. From being barely visible, they are frequently dilated so as to form cysts of a size occupying almost the whole of a large pedunculated polypus (Fig. 624). They are found also in the sessile forms.
Blood vessels are also scanty and capillary in size, being found most abundantly just under the epithelium, forming a delicate red tracery visible to the naked eye.
Nerves have been demonstrated in the stroma.
The pedicle, when it exists, is made up of the firmer unseparated stroma of the mucous membrane.
Etiology. The so called "polypoid degeneration," although histologically the same, is more conveniently considered under the head of chronic rhinitis, where, indeed, both forms pathologically belong.
Both forms are the result of chronic inflammation of the nasal mucosa. There may or may not have been previous symptoms of this rhinitis, but evidently the effusion of serum into the tissues is caused by some vascular change which is as yet imperfectly understood. We may conjecture from anatomical reasons,' which it is not necessary to detail here, that there is some interference with the efferent blood current as well as with the walls of the capillaries themselves. Chronic hypertrophic rhinitis rarely occurs in children ; therefore these growths are more common in adults than before twenty. They have, however, been reported at all ages, and even congenital cases have been observed. They are more common in men than in women. Ont of 200 cases, according to Morell Mackenzie,' 123 occurred in men.
Situation. A nasal edematous polypus has its origin in the vast majority of cases from the mucous membrane covering the middle turbinated bone or from that part of the ethmoid near the hiatus semilunaris. Edematous polypi may be found, however, at any point within the nasal chambers. At the posterior end of the turbinal bodies and on the septum we usually find the sessile form combined with dilatation of blood vessels; rarely, pedunculated growths are found in these localities. The size of the polypi varies greatly from that of a pin's head, sprinkled over the mucous membrane of the middle turbinated bone, to enormous dimensions. I extracted one from the nostril of a man with symptoms extending over twenty years, which presented externally and projected posteriorly into the pharynx. It had filled one nostril completely, and bad pushed the cartilaginous and bony septum so far to the other side as to cause complete occlusion. It was folded on itself, so that when it lay straightened out on the table it measured nearly 5 inches in its long diameter, and in some places was more than 1 1/2 inches thick. Its pedicle was comparatively small. The pressure which it had exerted had resulted in the atrophy of the internal structures of the nose to such an extent that the enormous cavity left after extraction bad smooth walls. I can find no record of any as large as this; but several have been reported that approximated it in proportions. They rarely exist separately, but when complete nasal obstruction exists there are usually multiple growths. Occasionally they fill the ethmoid cells, causing absorption of their bony walls, and once or twice I have seen distortion of the bridge of the nose. The edematous process, by pressure or the extension of the inflammation, frequently causes caries or disintegration of the ethmoidal bony tissues, and this has been called by Woakes 1 “necrosing ethmoiditis." On this account the masses removed frequently have spicule of bone embedded in them. The bone has been described by some writers as newly formed. This is probably a mistake.
Symptoms. These depend largely upon the size and number of the polypi and the extent of the edematous process. Nasal obstruction may be complete on both sides, giving rise to great discomfort, or one or more polypi may exist in the nose for years without signs. A flapping valve like action on respiratory efforts may be appreciated by the patient or even heard by the examiner.
Headaches are very common, and this is especially the case when the polypi have their bases of attachment high tip, or if they invade the accessory sinuses.
A watery discharge from the nose frequently exists, causing excoriation of the margins of the nostrils and redness of the skin of the nose. This may be accentuated to an erysipelatous flush over the nasal regions.
Various complications ethmoiditis, frontal, maxillary, or sphenoidal sinus troubles may be present; the patient frequently suffers from catarrhal deafness all symptoms are aggravated by cold, damp weather.
Examination shows masses of varying extent blocking the nasal chambers or hanging down from above. They have the appearance of the pulp of a grape, and are frequently traversed by a delicate tracery of red capillaries. The color may be pink or of a dusky red hue. Rarely, in large nasal chambers, the attachments may be seen along the borders of the middle turbinal, but usually the masses themselves preclude any attempts at inspection of the upper region of the Dose, and it is impossible in the majority of cases even to ascertain with a probe the exact point of insertion. There may be great tenderness, but usually the fossae are tolerant of examination. With a rhinoscopic mirror the masses may be seen projecting into the naso pharynx They may be confined to one side, but usually exist to an unequal degree on both.
Treatment. Modern rhinology has practically abandoned all methods of removal but that by the nasal snare.
It is frequently desirable, and occasionally possible, to remove the anterior end or lower border of the middle turbinated bone in order more surely to reach their place of origin. This has been especially urged by Dr. Casselberry,' who has devised an instrument for that purpose. Various other instruments have been used, such as rongeur forceps, snares, drills and trephines. It is an operation which the writer has frequently found impossible to do satisfactorily. When disease of the ethmoid cells and of the middle turbinated bone coexist with the polypi, as happens in a large proportion of cases, it is well to remove as much of the bony walls as can be included in the snare or Dipped off with rongeurs, care being taken not to encroach upon structures lying too close to the cribriform plate of the ethmoid. When, however, extensive bone involvement coexists, the treatment of that becomes the chief aim and the extraction of polypi merely incidental.
It is said that edematous polypi tend to recur. When a polypus is severed at its base, it is doubtful if another appears in the same locality. When the middle of the mass is cut through by the wire, that portion left behind will sometimes shrivel up, but usually it will grow again to nearly its former size. Apparent recurrence comes from the pathological fact that large areas of mucous membrane in the middle' meatus are edematous and send forth new buds and projections as fast as room is made below for them. An attempt should therefore always be made to curette this surface or cauterize it thoroughly. The cautery, however, should never be used unless a view can be bad of the field of' operation. Most frequently the bases of these growths are out of sight. The curette in skilful hands is then of service. As may be readily understood, no certain assurance can ever be given after any operation or series of operations, however thorough, that further polypi may not subsequently develop; and the patient should be cautioned to present himself after a lapse of several months for a careful inspection of the nasal chambers. Not infrequently it will then be seen that recurrence has not taken place, but that more or less atrophy of the mucosa has supervened. The question of the degeneration of nasal polypi into sarcoma has been much discussed. It is impossible to deny that this does sometimes, take place, but many of the cases so reported are open to well grounded suspicion of having been sarcomatous from the first, as many malignant growths present an edematous appearance.
Vascular Neoplasms of the Septum. These are very frequently called angiomata, but they usually have exactly the same structure as do the hypertrophies of the posterior border of the inferior turbinal bodies, and are evidently dilatations of new and old blood vessels in the mucous membrane of this locality. Many cases reported as angiomata are apparently sarcomatous or fibromatous growths, in which vascular dilatation is a marked feature. This is especially true of growths occurring elsewhere than on the septum or in the erectile tissue of the turbinal bodies. Such are' many of the growths reported in Roe's tables, in the Transactions of the American Laryngological Association, 1885.
In the Archiv fur Laryngologie, Bd. 1, there is a symposium of reports of vascular tumors of the septum: 13 were reported, and 5 cases may be selected from Roe's tables as undoubtedly benign vascular neoplasms; I have sections of 2 other growths, making altogether 20.
Some of these doubtless are true angiomata i. e., made up of newly formed and dilated vascular channels; but it is impossible to separate them from the vascular growths which are entirely made up of an hypertrophy of one or more of the elements of the normal mucous membrane combined with marked vascular changes. The fibrous elements may predominate or the lymphoid laver may be greatly proliferated; but more frequently there is an unequal and irregular increase of all the elements of the mucou's membrane the surface epithelium is usually proliferated, and frequently the cells are altered in shape. In other words, marked vascularity is a characteristic of all septal neoplasms.
Growths of similar structure in the erectile tissue of the turbinal bodies the " turbinal varix " of English writers will not be Considered here, as they are usually included under the head of hypertrophic rhinitis.
Symptoms. Nasal obstruction on the affected side may have existed for many years. Hemorrhage from the nostril frequently occurs, and may be dangerously abundant. The growth does not erode the neighboring tissues, although it may completely fill the lumen of the naris. Some of the cases reported have been of rapid growth, and yet apparently benign.
Examination shows a rounded growth with a somewhat irregular surface of a bright red or dark purple appearance. It may be abraded in places, and when probed bleed easily. It is more or less movable, according to its size and the thickness of its pedicle. It is usually attached to the anterior part of the septum.
Prognosis. If the growth is shown to have no malignant elements, the prognosis is good. Removal is comparatively easy, and recurrence is very exceptional.
Treatment. The galvano cautery snare, armed with an irido platinum wire loop, is the instrument of choice. Jarvis's original snare may be used and the steel wire loop slowly tightened, sometimes using several hours in the process. A rapid cutting operation is pretty sure to be followed by severe hemorrhage, and this may occur after an operation with the wire, however slow. For slight oozing the galvano cautery is sometimes efficacious. Firm packing with strips of iodoform or berated gauze should be employed in obstinate cases, and pressure exerted against the ala from the outside, since the site of the growth is usually far enough forward for this simple procedure to avail.
Fibroma. While it occasionally occurs in and about the naso pharynx, fibroma springing from the nasal structures is exceedingly rare.
One reported by Dr. Charles H. Knight' I had the privilege of examinin microscopically (Fig. 625). It was a smooth movable growth, attached to the posterior end of the middle turbinal body, and was darker in color than the average edematous polyp. Microscopically it was seen to be covered by columnar epithelium, and was made tip exclusively of homogeneous bundles of curling elastic fibers. Its removal by the cold snare was easily performed and produced no hemorrhage. There was no recurrence. A number of cases have been collected from literature by Bosworth,' Casselberry and others; but a perusal of the reports leaves one in considerable doubt as to the accuracy of the histological diagnosis or of their intranasal origin. Even the case referred to here as of undoubted histological character and springing front an intranasal structure, might be more conveniently considered under the heading of naso pharyngeal growths.
Fibroma Papillare or Papilloma. Ten or a dozen undoubted cases, and probably a few more, have been reported, but some confusion exists as to their identity ; the same name having been given by Hopman;` and many of the Germans to the papillary hypertrophies of the nasal mucous membrane, which occur so frequently in the regions of erectile cavernous tissue. True papilloma is made tip of epithelial cells supported by a delicate framework of new connective tissue, rising on the surface as papilla and dipping into the underlying stroma as digitations. They grow prillcipally by the proliferation of epithelial structure. They occur in the nose, either as soft pedunculated masses or as hard warts on the anterior portions of the septum. The soft growths also occur on the floor of the nose and on the anterior portions of the external wall. So constantly is this the rule in those cases which have been examined and properly classified, that any papillary growth seen to 'be sprigging from other localities or reported without microscopical proof as having been found elsewhere in the nose, may be regarded as probably not a papillary fibroma. Exactly such a growth as figured in Zuckerkandl's " Anatomy of the Nasal Fossae " springing from the middle of the under surface of the inferior turbinal I once examined and found to be a papillary hypertrophy.'
True papillomata of the septum have been observed at all ages. I have examined one for Dr. Arrowsmith of Brooklyn coming from the nasal fossa of a child of five, and Santi has reported one in a man of eighty four. Sex seems to have no influence.
They are usually of slow growth and painless, but sometimes bleed easily. They cause nasal obstruction and have a valve like action on the respired air, as in the case of the ordinary polyp. They have a vascular fungous look and are freely movable. Hemorrhage on removal may be abundant, but is easily controlled. They do not tend to recur.
“Bosworth, by saying that all naso pharyngeal fibromata spring from the basilar process of the occipital or the body of the sphenoid bone, excludes all of those whose origin is in the immediate vicinity, just within the choanoe. These be evidently includes among the nasal growths, since he refers to 41 cases in literature, most of which seem to have bad all the cliaracteristics of the naso pharyngeal growth and some probably sprang in reality from behind the choanoe, forming secondary attachments within the Dose. Mackenzie, on the other hand, gives a more liberal interpretation to the term naso pharyngeal fibroma, and includes those which spring from the immediate vicinity of the naso pharynx and present the same or nearly the same clinical features. Thus it comes that lie is able to report but one case of his own of nasal fibroma and to refer to very few in literature. The case of Dr. Knight sprang from the posterior end of the middle turbinal body and projected into the naso pharynx. So that nearly all true fibromata have their origin on or in the immediate vicinity of the roof of the naso pharynx; and absolutely none occur in the anterior part of the nasal fossil. This is exactly what we should expect, when we remember that the fibrous sheet at the roof of the pharynx spreads out laterally upon the pterygoid plates, and anteriorly for some little distance along the roof of the nose, and on the vomer and posterior surfaces of the upper turbinated bones.
The following references will be found to include nearly all the reports of true papillomata up to August, 1896, though some of these are of doubtful character:
Michel: Krankheiten der Nasenh6hle (Translated by Shurly, p. 72).
Zuckerkandl: Anatomic der Nasenhdhle, 1882, p. 70.
Aysaguer: Annales des Maladies de l'Oreille, Nov. 1885, p. 335.
Butlin: 81. Bartholomew's Hospital Reports, 1885, p. 150.
Verneuil: Bull. et Men. de la Soci6tg de Chirurgie de Paris, No. 12,1886, p. 658.
Solis Cohen: Revue de Laryngologie, 1889, p. 151.
Cozzolino: Revista Clinica et Teropeutica, No. 2, Feb., 1887, p. 75.
Mulhall: Trans. Amer. Laryng. Assn., 1890.
Santi: The Lancet, Dec. 8, 1894.
Wright: nans. Amer. Laryng. Assn., 1895.
Mackenzie (G. Hunter): Lancet, Aug. 15, 1896.
Treatment. Removal by the snare can usually be accomplished without much hemorrhage. As the growths are situated in the anterior part of the nose, bleeding, if it occurs, may be easily controlled.
Bony cysts of the nose are of moderately rare occurrence. They are found in the anterior end of the middle turbinated bone, and may contain only air or a yellow viscid fluid or pus. .
Pathology. The middle turbinated bone is considerably enlarged anteriorly, and is covered by hypertrophied and usually edematous mucous membrane. Edematous polypi are frequent complications.
Microscopical examination of the bony wall must be made after decalcification. Sections are then cut, and it will be seen that the cyst cavity, which may be as large as a cherry, is lined by a scanty stroma without glands or many blood vessels and by columnar ciliated epithelium. The bony tissue itself is seen to be in a condition of hyperplastic and rarefying inflammation, with the formation of new bone tissue and the absorption of old and new bone. This is carried on by means of osteoblasts and osteoclasts and the formation of Howship lacuna There are lakes, or rather gulfs and bays, of new connective tissue, which nourish the peculiar cuboidal cells which line their shore, and which have the power of secreting and absorbing bone salts. Figs. 626, 627, from a section of a specimen sent me by Dr. Butts of New York City, show this process , which is essentially the same as the physiological process of bone growth.
Occurrence. The condition is almost wholly confined to women after puberty and before old age. We see here, as well as in atrophic rhinitis and naso pharyngeal fibroma, the marked influence of sex on morbid processes in the nose. I am not aware that these cysts have been reported as existing in any other locality in the nose than at the anterior end of the middle turbinated bone.
Symptoms. Pain with frequent exacerbations is the prominent symptom in these cases. Nasal obstruction also exists, but may not be complete: at times it is the only symptom present. As the patient nearly always has edematous polypi in the same nostril, the symptoms depend somewhat on that condition. These symptoms have usually extended over many years.
Examination after removal of projecting polypi shows a rounded resisting mass at the anterior end of the middle turbinated bone, a part of which it forms, pressing firmly against the septum and sometimes causing a marked deviation of it. The feeling imparted to a probe conclusively shows that the mass is made up of bone.
Etiology. From what has preceded, the inference is pretty clear that we have here a pathological condition which is the result of chronic inflamma¬tion. This beginning in the mucosa, results in the formation of edematous polypi, as explained under that heading. The inflammatory process is in time transmitted to the underlying periosteum and bone, and we have then the condition of hypernutrition which causes the growth of the bony structure. This we should expect to result in the porous formation observed in other hyperplastic bone processes, and this we frequently see in dried specimens of the middle turbinated. Since there is mucous membrane lining the walls of these cysts provided with columnar ciliated epithelium, we must presume that communication has existed at some time with the external sur¬face. The demonstration of the proliferative bone formation in the walls of these cysts shows pretty clearly the method of development into large spaces of what were originally small cavities. Their communication with the ,ethmoidal labyrinth may have closed before the end of embryonic development, or it may have existed prior to inflammatory changes and have been .closed by them, or the communication may still exist. Dr. T. Passmore Berens of New York was kind enough to show me a dry specimen of cystic, enlargement of the anterior end of the middle turbinated bone, in which the communication was wide and direct.
Treatment. The steel wire snare may be used to remove these bony outgrowths. If they are too resistant or too firmly wedged against the septum to allow the use of this instrument, a perforation may be made into the cavity with a dental burr or trephine and the bony walls then removed piecemeal with rongeur forceps. Hemorrhage may be considerable, and there may be considerable inflammatory reaction. When, as frequently happens, there are carious bone and edematous polypi, curetting must also be employed.
LITERATURE OF BONY CYSTS OF THE NOSE.
Zuckerkandl: Norm. and Path. Anatomic der Nasenhahle, 1893, vol. i. p. 63.
Stieda: " Inaug. Dissertation," Rostock, 1995.
Glasmacher: Berlin. klin. Woch * , No. 36.
Beyer: Internat. Centralb. f. Laryngologie, etc., vol. ii., No. 5, p. 237.
Schaffer: E~fahrungen in der Rhin. and Laryng., Wiesbaden, 1885.
McBride: " Diseases of Throat, Nose, and Ear," original report, Edinburgh Med. Journ., Dec., 1888, p. 304.
Schmiegelow: Revue de Laryngo(ogie, etc., No. 10, 1890.
B. Frdnkel: Berl. klin. Woch., No. 22, p. 498, 1890.
P. Hegernan: Ibid.
Chas. H. Knight: Trans. Amer. Laryng. Assn., 1891; N. Y. Med. Journ., Mar. 19, 1892.
Stieda: Archiv f. Laryn. und Rhin., Bd. 3, No. 3, 1895.
Wnnier: Rev. de Laryngol., etc., No. 22, 1895.
Castafieda: Archivos Latinos de Rinologia, Sept. and Oct., 1895.
Macdonald: Lancet, June 20, 1891.
Zwillinger: Wiener klin. Woch., No. 19,1891.
Wright: X Y Medical Journal, June 27, 1896.
Cysts of the nasal mucous membrane, sometimes called Cystomata, are occasionally reported. They are always, I believe, of glandular origin, resulting from The excessive dilatation of glands in edematous polypi or tissue.
Osteoma and chondroma have both been reported as new growths in the nose. They are of exceeding rarity, and are not to be confounded with the very common exostoses and ecchondroses of the septum.
As has been intimated, true tumors i. e., circumscribed neoplasms not due to inflammation are rare in the nose, and in my experience such benign tumors are much more rare than malignant growth, It is exceedingly difficult, however, to gain any idea of this from rhinological literature, as all sorts of inflammatory phenomena are classified as tumors. The writer does not speak of true myxoma of the nose, because out of many hundred sections of 50 or 60 specimens of mucous polypi examined microscopically, and many more nasal neoplasm’s seen and operated on clinically, be has never observed a nasal growth that was plainly a true myxoma. There is hardly a case reported in literature, in which the diagnosis is not open to grave criticism from the data given or from insufficiency of data. Nevertheless, it is probable that such true tumors do occasionally grow in the nose.
Adenoma is said to be a benign growth; but it is so frequently combined with carcinomatous or sarcomatous elements, and it is said, even when pure, to degenerate so frequently into malignancy, that its occurrence in any structure is to be looked upon with suspicion as to its benign character. Pure adenoma (Fig. 628) in the nose is almost unknown, although hypertrophy of the glandular structure of the mucosa is occasionally seen carried to such at) extent that the question Of its inflammatory origin may well be raised. A typical adenoma is made tip of epithelial cells so arranged as to form convolutions and tubules more or less resembling gland structure. Indeed, it usually springs from the glandular cells of various organs. There is very scanty connective tissue, round cells, and blood vessels. I have in my possession sections of a nasal tumor, in portions of which, at least, pure adenomatous structure may be observed. The case was tinder the care of Dr. Thomas J. Harris. at the Manhattan Eye and Ear Hospital, and to him I am indebted for the following history:
“The patient, Mr. C., is seventy five years old, and has been under my care some eighteen months. When he first came to the hospital in November, 1893, he was a most pitiful object. There was total occlusion of' the nares, with muco pus constantly dripping from them. They were filled with masses of tumors presenting all the appearances of the common gelatinous polypi. By snare and curette in a number of operations I removed everything, making a diagnosis (from repeated recurrences) of myxosarcoma. For nearly a year, with occasional gentle curetting, the nares remained clear. His appetite returned and lie pronounced himself cured. In November, 1894, exophthalmos (left eye) appeared with constant pain. I then supposed that the ethmoid sinuses bad been invaded, but on account of his age determined to attempt no operation. The nose still remained comparatively free. Some two weeks ago the mass which I sent you suddenly appeared. This 1 removed with the cold snare, and considerable hemorrhage followed. The macroscopical appearances of the tissue had long since changed, and it now shows much necrosis. Its malignancy has certainly very much increased in the eighteen months in which I have observed the case."
This patient, Dr. Harris informed me, lived until the following summer (189 5). The greater part of the sections of the mass were taken up with convolutions and involutions of glandular epithelium. The layers of epithelium were never more than two or three deep, and were supported by a framework of new connective tissue.
In the portion of the growth sent me, from which the section shown in Fig. 628 was made, I am unable to find any plainly sarcomatous tissue; but there are. extensive areas of round and spindle cells which, although they more closely resemble the granulation tissue of inflammation, may be of a sarcomatous nature. Moreover, the clinical history plainly shows that the growth, at least in its later stages, was of a malignant character. By a coincidence, such as so strangely and so often occurs 'in clinical work, a similar instance of an adenoma this time, however, plainly showing sarcomatous tissue came under Dr. Harris's observation shortly after the first case.
Dr. Bosworth says that be has been able to find in literature the reports of only a very few cases, and even in these there is a reasonable doubt as to the unmixed character of the growth. Not only does it have on the one hand a puzzling resemblance and a close relation to glandular hypertrophy, but, on the other hand, it is frequently combined with epitheliomatous appearances the so called tubular or adeno carcinoma.
Papillary Epithelioma (Zottenkrebs). Closely allied to adenoma, if not identical with it, is a rare nasal growth which Biflroth,' who reported 2 cases, called "Zottenkrebs." Michel,' Hopman,' Zarniko,' and Kieselbach' have each reported a case.
The last named called it a papillary epithelioma. It is a benign growth, as a rule, and resembles a papilloma. In Fig. 629 will be seen the drawing of a slide sent me by Dr. Hinkel of Buffalo. It came from a tumor which occurred on the middle turbinal of a woman. It will be seen that it is made up of convolutions and involutions of columnar epithelium supported by a framework of fibrous tissue infiltrated with round cells. It forms a villous surface like a papilloma, but differs from it in that the layers of epithelial cells are not thickened and do not dip into the stroma. There is no infiltration of tissues nor concentric epithelial nest formation in the tissues, as in cancer. In one of Billroth's cases it had existed for eleven years, and in Kieselbacb's case he bad removed successive portions of the growth for a period of six years. In the cases of Zarniko, Kieselbach, and Hinkel' it has been reported as occurring on the middle turbinal. In Zarniko's case it was combined with edematous growths.
From the history of Verneuil's case, which I have placed among the papillomata because it was so reported, we may conjecture that it was possibly also of this nature. Otherwise it is a unique case of papilloma.
Sarcoma, in my experience, is the most common tumor of the nasal fossae, if we exclude those benign neoplasms which are the result of the various forms of chronic inflammation or directly connected with them. This, however, I am aware, does not coincide with the statements of those who have had larger experience and perhaps wider fields of observation. The discrepancy, as intimated above, is evidently, however, one of pathological nomenclature.
This is not the place for an extended description of the histology of sarcoma, which in the nose presents no characteristics to distinguish it from sarcoma elsewhere in the body. Dr. Bosworth I has given abstracts of the histories of 41 patients with sarcoma of the nose.
Newman, in his excellent monograph on, “malignant Disease of the Nose and Throat," gives the history of 3 cases of sarcoma and 2 of carcinoma of the nose, as well as a complete bibliography of the subject. His table of ages at which sarcoma occurs is given as follows:
Below 10 years ………………………………………………. 6 per cent.
10 to 20 ………………………………………………. 19 “
20 30 ………………………………………………. 8 “
30 40. ………………………………………………. 9 “
40 50 ………………………………………………. 39 “
50 60 ………………………………………………. 8 “
60 70 ………………………………………………. 9 “
Above 70 ………………………………………………. 2 “
I have in my collection microscopical sections of two specimens sent me by Dr. Thomas J. Harris of New York one of adeno sarcoma, the other of angio sarcoma (Fig. 631), also a specimen of endothelial sarcoma (Fig. 630 ), from Dr. F. W. Hopkins of Springfield, Mass., and one of alveolar sarcoma, from Dr. W. P. Brandegee of New York. Gouguenheim and Hilary, Dansac and Katzenstein have reported 5 others. This makes 53 cases in all, from which certain facts are apparent.
It is difficult to ascertain what form of sarcoma has been most frequently observed in the nose, as the nomenclature in the reports varies so. All forms seem to have been noted, the round celled variety perhaps more frequently.
As to age, 15 of them were between forty and fifty, 11 were over fifty, and 17 were under forty years of age. Of those in whom sex was mentioned, 29 were women, 24 were men. The right side of the nose was affected 15 times and the left side 9 times.
Etiology. This is entirely unknown. Too many people have chronic rhinitis to permit us to state that nasal catarrh is a predisposing factor. Injury is too infrequent an incident in the clinical history to allow us to look on it as an exciting cause. It occurs most frequently in middle life, when, as a rule, over nutrition of cell life has ceased and before degeneration changes have set in.
It may be well again to say that convincing evidence of sarcomatous degeneration in benign tumors or in inflammatory neoplasm’s of the nose is lacking. None of the cases of such asserted malignant transformation are free from the reproach of insufficient observation or incomplete examination. Surface appearances and the early clinical history are not criteria of histological structure. The possibility of such transformation, however, cannot be denied.
Symptoms. Un remittent and increasing unilateral nasal obstruction, accompanied often by repeated epistaxis, is the initial sign of malignant nasal disease. The patient soon complains of pain, referred to the brow or temple. At first a watery, then a sanious muco purulent, discharge comes from one or both nostrils. Photophobia and epiphora on the affected side are usually present, and there may be affection of the vision from pressure on the optic nerve. The general health is at first but slightly affected. As the tumor grows, pain and loss of appetite, sleepless nights, frequent epistaxis, the nauseous odor and the mental distress cause rapid loss of strength and flesh, making an unmistakable picture of human misery. Exophthalmos, the widening of the bridge of the nose (the so called " frog face "), edema and discoloration of the face are the external evidences of the disease.
Examination at an early stage may reveal implantation of the growth at any point in the nasal chambers. It may be a smooth, somewhat resilient growth; but it is usually, especially in the later stages, a friable fungous mass, bleeding easily when touched. Portions of it are apt to be edematous, and it may have every appearance of the ordinary nasal polyp, but the color is apt to be darker. It is evidently more vascular, and it may not be at the usual site of origin of the ordinary polypus. The growth soon reaches such a size that it is impossible to make out its origin. The nasal cavity is filled, and it encroaches upon and fills the naso pharynx. It may grow into the antrum. It soon projects from the nostril anteriorly. It may grow upward, absorbing the cribriform plate and causing death; or it may grow downward, pushing down the soft palate or eroding the bony nasal floor. Cervical glands at the angle of the jaw are usually not involved until a late stage of the disease, when the diagnosis is tolerably clear.
Diagnosis. The patient usually does not present himself until it is perfectly evident that we have a malignant growth to deal with, but some cases have been reported as seen in their earliest stages. Its vascularity or its lack of transparency, its unusual implantation, its proneness to considerable hemorrhage, or its appearing as a single growth, may arouse suspicion that it is not an ordinary edematous polypus. Its prompt extirpation and microscopical examination should follow. If the microscope should reveal the appearances of a round celled sarcoma, the clinical observer must not unreservedly accept the diagnosis, however skilled a microscopist may have made it. The vigorous administration of the iodid of potash combined with mercury may disprove the most positive assertion of the pathologist and the most careful diagnosis of the clinician. The other forms of sarcoma, however, do not so much resemble the granulation tissue of syphilis or tuberculosis. From the vascular growths of the septum, the so called bleeding polypi or angiomata, sarcoma is to be distinguished by its more rapid growth and by its greater friability and tendency to bleed on slight provocation. A sarcoma of the septum in its early stages may, however, closely resemble these vascular growths both in structure and general appearance.
Prognosis depends largely on the character of the elements, the situation, involvement of parts, rapidity of growth, and the promptness with which the character of the trouble is recognized and the proper treatment instituted. Mingled with fibrous, vascular, or glandular hyperplasia, prompt and thorough eradication may result in cure, or at least in indefinitely putting off recurrence. Frequent recurrences do not necessarily make the case hopeless. It should be carefully watched and new growths promptly and thoroughly removed. When situated in the upper part of the nose it may easily have involved intricate and vital structures, rendering complete removal impossible. Wherever it may be attached, no operation should be attempted that does not hold out a chance of complete removal. Any incomplete operative measures will only accelerate the growth and render the patient's doom more certain.
Treatment.' When the growth is circumscribed or has a pedicle, removal by the hot or cold snare and subsequent curetting of its base may be efficient. Application of caustics, cauterization, or electrolysis should be avoided. An external operation may bold out prospects of thorough removal which internal operations do not : if so, this heroic treatment should be promptly adopted.
Carcinoma of the nose is of rare occurrence. Many of the cases referred to by Bosworth are apparently Dot substantiated by a microscopical diagnosis. Seifert and Kahn picture one in their histological atlas, and Dr. Beaman Douglas has lately reported one in the X. Y. Medical Record, Aug. 8, 1896. The symptoms do not differ materially from those of sarcoma, from which it must be dia nosticated by means of the microscope.
The prognosis is entirely bad. Operation does not lengthen life nor, as a rule, alleviate suffering.
TUMORS OF THE SINUSES.
Benign neoplasms of the maxillary sinus are: Bony cysts, which occur in connection with the roots of the teeth. Edematous polypi,' which occur occasionally as the result of purulent inflammation, but are also frequently found at autopsy, having given no sign during life.
Cysts of the mucous membrane are also seen very frequently postmortem. Rarely they fill the whole antrum, as in a case reported by Dr. Cbas. H. Knight.
The suggestion was made many years ago and adopted by Virchow that the cases of the so called hydrops of the antrum of Highmore were probably of this nature. The cysts are, as in the nose, of glandular origin.
Osteoma, apart from the very common exostoses, is occasionally noted post mortem.
De Roaldes has reported a remarkable case of compound follicular odontoma of the antrum.'
Malignant Neoplasms of the Antrum. Sarcoma has frequently been reported as primary in the antrum, and Schmidt makes the statement that carcinoma is not an infrequent occurrence. While I have seen several cases of sarcoma which presumably began in the antrum, I have never seen; a carcinoma, and I am familiar with only one report in general literature .2 This case is so well authenticated and the history so well reported by Dr. Reinhard 3 that an abstract of some of the points may be useful to the rhinologist as illustrating the course of malignant disease in this locality. The patient was a man of sixty five. For five years he had suffered from left sided nasal obstruction and for one year from unilateral nasal suppuration and radiating pain in the left side of the face, with loss of flesh and strength. The anterior molar tooth of the upper jaw having become carious, the patient had it removed, and this was followed by the discharge of foul smelling pus through the alveolus into the mouth. The left side of the face became somewhat swollen, and the alveolar opening into the antrum became larger. On using a probe it was evident that it did not move freely in the antrum, but was engaged in some soft substance. Fluid syringed in the opening came out of the hiatus semilunaris much more quickly than in simple empyema of the antrum. There were no glandular enlargements and no eye symptoms; the patient receiving no benefit from constant irrigation of the antrum, a snare was introduced through the alveolar opening and some of the tissue removed. A polyp was also removed from that side. Microscopical examination showed the antral growth to be carcinomatous, and that the nasal polyp was a hypertrophy of the nasal mucosa. On account of the severe pain, excision of the jaw and extirpation of the growth, which was more extensive than expected, was performed, with at least temporary relief from all symptoms. The patient was discharged five months later with no recurrence. A similar case has been reported by Dr. Wendell Phillips.' I have had the privilege of seeing the patient and examining the specimen.
This illustrates how a malignant growth may set up an empyema of the antrum, which may be taken for the sole and primary trouble. It also shows that the excision of the jaw may be indicated and successfully performed for temporary relief of the symptoms, which in this case and in all such cases are unendurable if the operation, however severe and dangerous, holds out any hope of relief. Death on the operating table may perhaps be considered the most successful outcome for the patient.
The neoplasms of the ethmoidal sinuses may be considered as having been treated of under the head of nasal neoplasms. Nearly all the edematous polypi spring from the mucosa of this region, and they may infiltrate the ethmoidal cells to such an extent as to simulate malignant growths by causing external deformity. The malignant growths of the etbmoid are inoperable, and prove rapidly fatal by extension to the cerebral cavity.
Neoplasms of the Frontal Sinuses. Osteomata sometimes occur in the frontal sinuses, and usually give rise to no symptoms. Schmidt' says that occurring in the nose they usually start from the mucosa of the frontal sinus, and the same is true of many orbital exostoses. Cysts of the mucous membrane are rare, but even dermoid cysts have been noted in the frontal sinuses and in the anterior parts of the nose.
Edematous polypi and especially edematous swelling of the mucous membrane are found in connection with empyema of the sinus, and occasionally without pus formation, as a complication of a similar condition in the nasal mucosa.
Sphenoid Sinus. Similar pathological conditions as to neoplasms are reported by Zuckerkandl as having been found in the sphenoidal sinus, but the diseases of these cavities have not as yet been sufficiently studied to make a consideration of their neoplasms profitable here.
TUMORS OF THE NASO PHARYNX.
Naso pharyngeal Fibroma. Naso pbaryngeal fibroma is a tumor which, in many respects, presents peculiar characteristics. It is bistologically a benign growth, but owing to its situation gives rise to symptoms which, if unrelieved, are almost certain to result in death; and it demands operative treatment which the most skilled rhinologist and the most daring surgeon are sometimes unable to afford with success.
It occurs almost exclusively in males between ten and twenty five years of age. So marked is this influence of age, that not a few cases are recorded of spontaneous recession of the growth after this period, affording in this respect a marked resemblance to another naso pharyngeal growth viz., lymphoid hypertrophy or adenoid vegetations.
It is fortunately tolerably rare, and it falls to the lot of very few rhinologists to have seen more than two or three instances. Situated at the base of the brain and at the junction of the air and food paths, almost at the center of the skull, endowed with the faculty of unlimited growth, pressing upon and absorbing even bony structure, its early recognition and its prompt and vigorous treatment are of vital importance to the patient and of great difficulty to the surgeon.
It springs from the dense fibrous tissue and periosteum which cover the under surface of the basilar process of the occipital bone and the body of the sphenoid. This fibrous tissue extends to some extent laterally down to the pterygoid plate of the sphenoid and perpendicular plate of the palatebone, as well as on to the posterior ends of the upper turbinated bones and the vomer. From these situations, also, fibroma occasionally takes its origin. From whatever source it springs, it may contract adhesion; with contiguous structures by inflammatory processes.
Histology. Its structure is dense, being made up almost entirely of white fibrous tissue, between the fibers of which may be seen in places areas of round and Spindle cells, which remind one of sarcoma.
Etiology. Its more or less sharp limitation to the age of adolescence and the male sex would seem to point to some connection with the cranial development, which is so marked during this period ; but it is not an unknown affection in the female or before or after the period of ten to twenty-five, which includes the great majority of cases. Symptoms. The initial symptoms are apt to be those of post nasal catarrh, accompanied by repeated and at times grave epistaxis. The evidences of post nasal obstruction soon supervene the dead voice and thick speech and difficulty in respiration. Deafness, more or less marked, is present. A peculiar condition of somnolence has been noted in many cases, the patient being often overtaken by sudden and irresistible drowsiness. Possibly this may be akin in its etiology to the aprosexia from which some adenoid cases stiffer. Later, pain and a muco purulent discharge may be present. Pressure on the neighboring parts results in external deformity the separation of the maxillary bones and the exophthalmos producing the hideous aspect known as “frog face." Growth downward forms a hindrance to deglutition; while occasionally, though rarely, upward growth through the foramen lacerum medium or by absorption of the bone may cause cerebral symptoms and death. According to Greville Macdonald,' vomiting is sometimes a distressing symptom.
Examination with the post nasal mirror shows a smooth rounded mass of a color varying from pink to dark purple. Varicose blood vessels may be seen on the surface. It may project into the nasal fossae and be seen by anterior inspection. It may grow through the spheno maxillary fissure and be felt under the zygoma. When of moderate size its base of implantation may be seen; but usually it fills the post nasal space, and so frequently has contracted adhesions to neighboring parts that its origin cannot be distinctly made out. It usually has a broad base, but it sometimes has a small one, being pedunculated and freely movable. This may be appreciated by a probe through the nasal fossae or by the finger behind the palate. To the finger it has a firm elastic feeling. Considerable care and gentleness must be exercised in these maneuvers, as alarming hemorrhage is apt to occur.
Diagnosis. The chief difficulty in diagnosis is to distinguish it from sarcoma. The age and sex of the patient, the place of origin, and to some extent the firm consistence of the tumor, may serve to establish its nature but frequently the microscope must serve as the final arbiter.
Prognosis. Naso pharyngeal fibroma is a grave disease at best, but it is rendered still more so when it has progressed so far as to render an external or preliminary operation necessary. Left to itself, it usually results in a suffering death; although some cases are related where spontaneous cure has taken place. When occurring near the end of the period of liability, they have been observed to retrocede and even to slough away. This, however, should never be expected or waited for if operative procedures hold out any hope of successful removal. The favorable cases are those which present themselves with a pedunculated growth, and in whom the whole nasopharynx is not filled with it; and if I may be allowed to make the remark, their chances are considerably better if at this stage they fall into the hands of a skilled rhinologist rather than into those of a general practitioner who does not at once recognize the character and gravity of the case, or of a general surgeon who is disposed to recommend at once an external operation.
Treatment. Several methods of procedure may be adopted. When the, whole or a part of the growth can be included in the loop, the irido platinuin wire of a galvano cautery snare should be used. Sometimes the difficulties of the technic are so great that it may be necessary to abandon this and make the attempt with the steel wire of a cold snare, occupying several hours in completing the removal. Subsequent cauterization of the stump of the growth is usually recommended, but its utility is open to some doubt. Unfortunately there are a number of cases where this operation with the snare is impossible. The shape and broad attachment of the tumor is such at times that a wire cannot be made to encircle the growth. Electrolysis should then be tried, more with the hope of diminishing the size of the mass or altering its shape to such an extent that the snare operation is practicable. It is sometimes only possible to remove it piecemeal. Hemorrhage does not occur with the hot snare, and is not uncontrollable with the cold wire. Tamponing the post nasal space may be necessary, and firm pressure may be made with curved instruments against the stump.
Recurrence is frequent, and a number of operations may be necessary. If the growth can be kept in check until the period of immunity is reached, the recurrence may be finally prevented, and even retrocession in the growth may be expected. The other methods of treatment are injection of various substances into the growth. Lactic acid has been recently used by Ingals with great success. The galvano cautery electrode may also be used to advantage at times, but usually as an adjuvant to more thorough methods of removal. Finally, as a last resort, the patient may he submitted to the risk of an external operation. An operation for a Naso pharyngeal growth which cannot be removed by intranasal maneuvers is necessarily one of the gravest and most dangerous which the general surgeon can undertake ; and statistics of the results both in intranasal operations and in the preliminary external operations seem to warrant the preference of the best authorities for the former, while the latter procedure should be resorted to only when all other methods have been demonstrated to be absolutely of no avail.
Fibro mucous polypi are described by various writers as partaking partly of the character of the pure fibroma and partly of that of the edematous polypus within the nose. These growths are evidently fibromata of sluggish growth which have become edematous. Such growths usually have their origin partly, at least, within the nose. They do Dot bleed, nor do they tend by their pressure to invade other regions and absorb adjacent structures. They are usually pedunculated, and their removal is not attended with any great difficulties. They seem to be regarded as of rare occurrence; but it is probable that their comparatively trivial character has led to less frequent reports than of the more formidable fibromata. They are said by Bosworth to occur more frequently in females.
The symptoms are those of post nasal obstruction and irritation.
Examination shows that the growth is paler in color and has a softer consistency and a smaller pedicle than the true fibroma. It is more movable.
Treatment is correspondingly easier, it being usually possible to remove it with the cold snare introduce through the Dose or to twist it from its attachment with forceps or fingers from the mouth. It shows little or no tendency to recurrence.
Enchondroma. Bosworth reports from literature only 2 cases of enchondroma of the naso pharynx. Nasal obstruction, with headaches and some external deformity from pressure, were noted.
Hairy Pharyngeal Polypi. Reports of ten of these curious growths have been collected by Conitzer, who contributed to the number a case of his own. They contained not only hairs and their follicles, but also the other normal constituent parts of the skin. Most of them also contained cartilage. They were pedunculated tumors, attached usually to the posterior surface of the soft palate and more frequently to the left of the median line, but some in the vault and posterior wall of the pharynx. They were presumably all congenital. A similar growth was reported by Wagner,' in 1884, who called it a dermoid cyst. It is not included in Conitzer's table.
Under the head of Teratomata, a number of. similar cases are referred to by Lennox Browne, in Burnett's System of Diseases of the Ear, Nose, and Throat, vote ii. p. 726 ; and he speaks of them as occurring also in the middle and lower pharynx.
Sarcoma of the Naso pharynx. Sarcoma is an occasional occurrence in the naso pharynx. Bosworth,' in 1892, had collected from literature 18 cases, and added the complete history of a remarkable case of his own. Fourteen of these cases were in males and 5 in females. Their ages ran as follows :
1 to 10 . . . . . . . . 2 30 to 40 . . . . . . . . . . 2
10 to 20 . . . . . . . . . . 5 40 to 50 . . . . . . . . . . 7
20 to 30 . . . . . . . . . . . 3
We see here, as in sarcoma of the nose, that from forty to fifty is the decade of life furnishing the largest number of cases.
It is hardly necessary to repeat here the history of the symptoms of nAsopharyngeal fibroma, which those of sarcoma so closely resemble; but it is more profitable to point out some differential points. In the first place, we do not expect fibroma after twenty five years of age, but younger than this the growth in question may be either sarcoma or fibroma. The symptoms have usually run a more rapid course in sarcoma, and on examination it will be seen there has been a correspondingly rapid growth in the tumor. Epistaxis, while as frequent, is not apt to be as copious as in fibroma. Ulceration of the surface appears earlier. In Bosworth's case and in one other there was a general diffusion of the growth over the pharynx. Under the microscope the appearances are usually characteristic enough; but even here the diagnosis of sarcoma, especially when of the round celled variety, is in some cases extremely difficult. Many cases of undoubted fibroma present in places histological appearances almost identical with round celled sarcoma.
The prognosis is almost uniformly bad, although Bosworth's case recovered after piecemeal removal with the snare, and Warren's cases were all well or nearly so after external operation. This is so unusual as to raise some doubt as to the diagnosis, although well certified to in Bosworth's case.
Treatment. Fortunately the treatment does not hinge on a differential diagnosis between fibroma and sarcoma. Prompt and thorough removal by intranasal procedure, if possible, is indicated in both cases. In Bosworth's case this was done piecemeal with the cold snare, and although the mucous membrane was extensively infiltrated, complete success was attained and the growth had not recurred after seven years. While encapsulated or circumscribed sarcomata may be thoroughly removed by means of the snare, it is difficult to conceive how a new growth, with malignant potentialities widely infiltrating the tissues, can be so thoroughly removed by means of a snare, which necessarily only removes surface protuberances, as to destroy its power of growth; yet the microscopical diagnosis in the case is indisputable, so far as the skill of the examiners is concerned.
The treatment by external excision is so frequently fatal and ineffectual that the question of its advisability is in many cases doubtful. Carcinoma. Carcinoma of the naso pharynx is of much rarer occurrence. Bosworth having bad one case himself, has collected from literature the records' of 5 others. In only one of the latter, however, does there seem to have been a microscopical examination. I have a microscopical section of another case which was reported by the late Dr. Sidney Allan Fox' of Brookl yn an abstract of the history of this case may be of value here.
The patient was a man forty years old. Family history was good and the patient had always enjoyed good health. A year previous to his coming under observation be was much exposed to wet and cold weather. This was followed by sharp pain in the ear, partial deafness, and a feeling as if his own voice was very loud. His general strength began to fail somewhat, and his nervous system to deteriorate. Six months later lie began to be troubled very much with headache, especially in the daytime. He was also troubled with the earache above mentioned, with deafness and with obstruction of the posterior nares. When he came under observation his appetite was poor; he was unable to sleep at night because of an inability to breathe through the nose and the constant annoyance of mucus dropping in the throat. His bearing was defective and he was diploic. The odor from the naso pharynx was fetid in character. Anterior rhinoscopy showed nothing, but posteriorly the naso pharynx was seen to be filled by a cauliflower like growth. The lateral walls of the pharynx, as well as its posterior wall, were matted with the growth, as were also the choanae and the spaces about the Eustachian orifices. There was no evidence of external or internal glandular involvement. Microscopical examination showed it to be an epithelioma.
A preliminary operation (Annandale) was done by Dr. Fowler, and as much as possible of the growth removed. It rapidly grew again, and the patient died two months later. Autopsy showed that the growth bad perforated the base of the skull, involved the brain, and bad extended into the left orbit, possibly also the right.
As was said in speaking of the treatment of nasal sarcoma, the best hope that can be held out to the patient in advising such a surgical operation is that he may not survive it. Life can doubtless be prolonged more by cleansing and cautious removal of obstructing protrusions of the growth with the cold snare than by any radical operations.
BENIGN NEOPLASMS OF THE FAUCES, TONSILS, AND ORO PHARYNX.
By the oro pharynx we mean that portion of the anatomical pharynx which we may say roughly, can be seen by direct vision in its whole extent e., from the level of the hard palate to the level of the arytenoid summits. Below this point the region belongs to the digestive and Dot to the respiratory, system.
Papilloma of the soft palate, and especially of the uvula, is the most common of all true tumors of the nose and throat. They vary from the size head to that of a cherry, though the majority of them are not anterior than on free edge of the soft palate and faucial pillars. They are of the same structure as true papilloma, or fibroma papillare, elsewhere. The normal epithelium lining the oropharynx, made up of pavement cells, is exposed to attrition by the passage of food and the rubbing of opposing mucous surfaces. Probably it is to this, rather than to the change in the type of epithelium which takes place behind and above the soft palate, that we are to ascribe the frequency of these growths. Jurazs' speaks of having seen 14 cases in his clinics, of which 10 were between twenty and thirty, and all between nineteen and forty four years of age. Eleven of them were men.
Symptoms. They usually give rise to no symptoms, but are frequently seen in examining the pharynx, either as sessile warts on the mucous membrane or as pedunculated growths banging from the tip of the uvula or the edge of the palate. Sometimes they cause tickling and coughing; but this seems to depend quite as much on the idiosyncrasy of the patient and the hyperesthesia of the mucous membrane as upon the size and shape of the growth.
The diagnosis is easily made from the gross appearances, and because it is by far the most common of all growths in this locality; but occasionally the best of observers is deceived. A notable instance of this was in a case reported by Dr. Lefferts,' in 1889, as a typical papillorna in a girl of sixteen. He made no microscopical examination .3 The growth recurred after removal, and was again removed by Dr. Simpson' and reported by him, after microscopical examination, as an instance in which a benign neoplasm bad degenerated into a sarcoma. It seems very evident that the growth was malignant from the first. Lennox Browne relates" a similar mistake as occurring in the practice of Morell Mackenzie; so that, however great the probability, the microscope must complete the evidence.
Prognosis. They are benign growths and, as a rule, of no significance.
Treatment. When large enough to cause symptoms or give the patient any alarm, they may be cut off with a pair of uvula scissors.
Fibroina. Bosworth refers to 7 cases in the tonsils and 7 in the oropharynx. Lefferts' has reported a case. They are benign growths and easily removed.
Angioma. Pbillips has reported a case 7 Bosworth refers to 2 others, and Flatau to another."
Lipomata have been reported by Farlow" and Schmidt.
Adenoma. Natier reports a case." He refers to 2 cases by HutchinSOD."
Cysts of the Mucous Membrane. I have observed one case in a middle aged woman who complained that something had been growing in her throat for the last eighteen months. A small round tumor, a little larger than a pea, was seen growing at the base of the right posterior faucial pillar. It was smooth and sessile. It gave no evidence of its presence until the patient, who had a family history of cancer, noticed it. Fig. 632 shows a section of the walls, which are fibrous and lined on both sides with squamous epithelium similar to that of the surrounding mucous membrane. There were no glands and no lymphoid tissue. Its fluid contents escaped in the removal. It was probably an inclusion cyst, having its origin in some acute inflammatory condition of the mucosa.
It will be noted in Schmidt's table that lie mentions one cyst of the oropharynx, but gives no further details.
There is a growth connected with the tonsils which is occasionally seen in the throat usually but wrongly called a supernumerary tonsil. Its formation seems to be brought about by a fibrous growth shutting off a portion of the lymphoid tissue of a hypertrophied tonsil. The fibrous tissue is gradually lengthened into a pedicle. Such a growth I have examined microscopically for Dr. W. F. Dudley of Brooklyn. These growths, as well, indeed, as many others of the oro pharynx, may by the length of their pedicle cause alarming dyspnea or interfere markedly with deglutition.
MALIGNANT TUMORS OF THE FAUCES.
There seems to be a certain practical line of division between malignant disease of the contiguous structures of the soft palate, tonsils, and oro pharynx, due, doubtless, to difference in anatomical structure, physiological function and pathogenic influences. This makes it seem desirable to consider them separately.
On looking over Schmidt's tables we see that more carcinomata were observed in the oro pharynx and larynx than all other growths combined, if we rule out papillomata and the inflammatory growths, the so called laryngeal fibromata and tubercular tumors. It will also be seen that it is very much more frequent in men than in women at a ratio of 15 to 1 for the pharynx. This same influence of sex is discernible in the reports of 30, cases of carcinoma of the fauces collected by Bosworth. Only one was in a woman. Bosworth comments on this as a curious coincidence. The chances are very great, however, that there is hidden behind the fact an etiological significance of which we can at present form no surmise. The cases that I have observed and know of personally have all been in men. We can hardly suppose that the greater exposure of men in their occupation to irritative causes would entirely account for this.
Sarcoma of the Soft Palate. A few cases have been reported, Bosworth, in 1892, collecting 20. It is much more frequent in males (13 to 4), and occurs as often in patients over forty years of age as in younger ones.
All forms have been noted, with no especial preponderance of any one.
Symptoms. It is usually of slow growth and does not tend to ulcerate quickly. It frequently gives rise to no symptoms until it has existed some time. Interference with deglutition and the thick sound of the voice may be the first symptoms complained of. Pain, however, may be prominent from the first, and this is especially so if ulceration has occurred, in which case excessive salivation and foulness of the breath add to the discomfort of the patient. The general health deteriorates. As a rule, glandular involvement in the neck does not occur until the growth has invaded other structu res. Hemorrhage is not reported as an incident in the course of the disease.
The tumor is usually circumscribed a round, smooth growth covered by mucous membrane and enclosed in a capsule, or it may be more diffuse and nodulated. It may spring from any part of the soft palate and spread over its whole extent, but does not show a marked tendency at first to invade contiguous structures.
The duration of the disease varies from six months to several years. Sometimes it has apparently existed for years in a quiescent condition.
Diagnosis. The same caution should be observed in excluding a, syphilitic growth by the administration of large doses of the iodid of potash. This should be especially borne in mind when the microscope reveals round celled structure.
It is easily distinguished from tuberculosis, which almost never occurs without manifestations elsewhere. From fibroma it cannot be surely distinguished without a histological examination. The rarity of fibroma in this situation, and the slowness of its growth, its firmness of consistence, and the lack of pain in the history will tend to exclude it.
The prognosis is always grave; but not a few cases have been reported in which many years bad elapsed without any recurrence after thorough operation. Much will depend on the rapidity of growth and involvement of neighboring structures. Those cases are particularly favorable which are seen early.
Treatment. Incision of' the mucous membrane may enable the operator to shell out an encapsulated growth; but usually the field of operation should include healthy tissue, and suspicious areas should be thoroughly burned out with the Thermo cauterv. No radical operation should be undertaken unless with hope of the complete extirpation of the growth. Without such hope, removals of projecting and obstructing portions with the snare (from time to time) may be advisable. The use of' a cleansing mouthwash, such as the ordinary Dobell solution or the peroxid of hydrogen, will tend to relieve the fetor. Weak solutions of cocain or a 10 per cent. spray of antipyrin help to assuage the pain when violent. The liberal use of' opiates is indicated in these hopeless cases.
Carcinoma of the soft palate, although somewhat more frequent than sarcoma, is still a very rare growth. Bosworth has collected the reports of 30 cases up to 1889. In looking over Semon's Cetralblatt fib. Laryngoloyie for the years since then, I can find a reference to only one case.' We see at once what a marked contrast this forms to the frequency of epithelioma of the tongue; while the benign epithelial growth papilloma is so frequently seen on the soft palate and so rarely on the tongue.
Among Bosworth's cases is one of twenty five and another of twentyseven years of age; but forty to fifty shows a slightly larger number (5) than any other decade.
Of the 31 cases, including Katzenstein's, all but one were in men, affording a more striking example even than sarcoma of the greater frequency of malignant growths of the throat in men Owing to insufficient microscopical reports, it is impossible to ascertain what form of carcinoma is most frequent.
It occurs as a rapidly growing infiltrating neoplasm with a fungous or irregular surface. Ulceration occur, early in its course.
Symptoms. Pain radiating in various direction is usually the prominent symptom, but is not always present at first. Stiffness of the palate is complained of in some cases. Notwithstanding these symptoms, the growth has usually advanced so rapidly that, when it comes under observation, considerable infiltration of the soft palate and ulceration have already taken place. The ulceration is characteristic as of cancer elsewhere. The underlying infiltration raises the floor of the ulcer, while the surrounding fibroid border is not sharp cut, but rounded. The floor of the ulceration may be covered with whitish secretion or may be fairly clean and pink looking; but it is always irregular and nodular. Hemorrhage frequently occurs and the general health rapidly deteriorates. Foul smelling secretions from the ulcer and lancinating pains destroy the appetite and render the patient's life miserable. Glandular enlargement is sometimes absent even in late stages of the disease, and is usually not present until the disease has spread to contiguous structures. This, however, it rapidly does, involving the base of the tongue, the lateral pharyngeal wall, and the hard palate; but, as Bosworth remarks, they usually die even before this takes place.
The prognosis is entirely hopeless.
The diagnosis from sarcoma has been sufficiently indicated by the previous remarks. The microscope must, of course, be the final arbiter between the two. As between cancer and syphilis, the microscope is a perfectly satisfactory means of diagnosis and should always be promptly employed. Carcinoma rarely resembles papilloma in this situation. The infiltration is marked.
Treatment. Occasionally a radical operation may be advisable; but usually this holds out to the patient no hope even of diminishing suffering. Cleansing and disinfecting washes and opium include the palliative indications.
Sarcoma of the Tonsils. Gray, in reporting a case, gives a list of 18 other reports of sarcoma found in literature. I have been able to find trustworthy accounts of 13 other cases 2 since then. Others have been reported; but either the reports are not accessible to me or satisfactory data are not given. Indeed, Bosworth in his book has collected 45 cases, and others have been reported since then. Of the 32 cases which I have studied, the following facts are apparent. As lympho sarcoma and round celled sarcoma are synonyms in the reports, we find that all the cases but 5 come under that one bead, showing pretty conclusively that the growths, as a rule, spring from the lymphoid, and not from the fibrous, elements of the tonsil, even at an age when the lymphoid activity has sunk into insignificance.
From 50 to 60 there were 9 cases.
“ 60 to 70 “ “ 8 “
Over 70 “ “ 4 “
From 10 to 20 “ “ 3 “
“ 30 to 40 “ “ 2 “
“ 20 to 30 “ was 1 case “ “ 40 to 50 “ “ 1 “
Younger than 10 “ “ 1 “ From this analysis we see that more than half the cases occurred in persons over fifty years of age. With the exception of one case of six years, the 3 youngest cases were seventeen years old. Therefore we see that this lymphoid growth almost always occurs in the pharynx at an age when benign lymphoid hypertrophies (enlarged tonsils) are unknown to begin. Sex seems to have no influence (13 to 17); and there seems to be no marked preponderance on either side of the throat.
symptoms. The onset of the symptoms frequently resembles an attack of tonsillitis. Instead of entirely subsiding, some swelling and tenderness are left behind. This may remain stationary for a few weeks; but gradually the size of the tonsil increases, the surrounding tissue of the pillars of the fauces and the soft palate and uvula become reddened and edematous. The pain increases, as a rule, although in some cases it is never a prominent symptom. Ulceration occurs much earlier than is usual in sarcoma. Glandular involvement is also more frequent and comes on earlier. Hemorrhage is an occasional symptom. The general health becomes seriously affected after a few months; the sense of taste and smell are soon lost; foul discharge and odor are present. The growth may extend backward and downward, interfering with deglutition and respiration.
Prognosis. The disease usually goes to a fatal termination within a year, and sometimes in a few months. Round celled sarcoma in any situation has a most unfavorable prognosis, but in the tonsil it is especially rapid and fatal. One of Newman's cases lived five years after the operation and died of a recurrence in the other tonsil: this was a spindle celled sarcoma. Weinlechner's case (quoted by Bosworth), another spindle celled sarcoma, was injected with iodoform and ether and the common carotid artery was tied after the case had been pronounced hopeless by Billroth: the case entirely recovered. Another case, which was called a lympho adenoma, lived two and a half years after operation, and still another lived seven years. In reading the literature it seems that the chance of a favorable prognosis is proportionate to the chance of mistake in diagnosis; and the suspicion arises that the microscope or our understanding of the patlologIy of sarcoma is at fault.
Diagnosis. What has been said of tertiary syphilis, in connection with the diagnosis of sarcoma elsewhere, applies with equal force to tonsillar growths. The growths are so rare that differential diagnosis between sarcoma and carcinoma can only be settled by the microscope, because no one's experience is wide enough to trust to the ~6 clinical sense " which is of value in so many cases. Iodid of potash and the microscope should be our chief aids.
Treatment. Owing to the hope. though a forlorn one, which has been realized in a few cases, thorough extirpation should be Undertaken where it is a possibility. The necessity of an external incision for the removal of diseased glands, as well as for the complete removal of the growths is frequently evident. Otherwise, palliative measure ; are to be adopted as mentioned above.
Carcinoma of the tonsils is of more frequent occurrence than sarcoma. About 100 cases may be found in literature.
It has been reported in a case as young as seventeen (Bryant) and as old as eighty two. Sarcoma however. has not only been reported at a younger age (six), but also in a woman of eighty nine. The average age of carcinoma, according to Bosworth, is fifty t wo and one half years. It occurs much more frequently in males
Calculating from the figures given by Bosworth, it occurs in the tonsils about once in 2000 cases of carcinoma of all parts.
Symptoms. A careful study fails to Dote any essential difference between the subjective symptoms of sarcoma and those of carcinoma of the tonsils. The duration also seems to be about the same from a few months to a year and a half
Diagnosis. The appearance of the growth seems to vary a little from that of sarcoma. There is more apt to be ulceration with carcinoma. A fleshy pinkish mass, fungoid and rough, projects into the pharynx, sprouting from the swollen tonsils and the infiltrated mucous membrane around it. A sarcoma, on the other hand, usually shows a smooth projecting surface, and is less completely covered with ulceration or fungoid excrescences. However, as said before, the microscope must be the final arbiter, for nothing is so deceiving as the external configuration of tumors.
The prognosis is, of course, as bad as possible, although in one of Newman's cases operated upon by him, there was no recurrence at the end of two years, and in another case no recurrence at the end of five months.
Treatment. It is hardly necessary to speak of treatment. The only treatment for cancer is the knife and at once, if there is any possibility of complete eradication of all the tissue. Palliative treatment has been mentioned above for sarcoma.
Sarcoma of the Oro pharynx. Few authenticated cases have been reported. Dr. F. 1. Knight' reported a case in 1879, and reviewed the reports which had been made, of pharyngeal growths, up to that time ; but many of them were apparently not really sarcoma. Bosworth, in 1892, mentioned 14 or 15 cases. By referring to Semon's Gentralblatt fur Larynyologie, I find the following cases reported since 1886
Felix: Monatsch.f. Ohren., 1894, p. 255.
2 cases, spindle celled; pedunculated; removal successful.
Montaz: Medicine Mod., Sept., 1894.
" Lymphadenoma; " eleven years old; death from suffocation.
Delmas and Cannieu: Bourn. de Marked. de Bordeaux, No. 14, April 7, 1895.
Hoppe: Die Mariana GeschwUlste der Pharynx. Dissert., Berlin, 1892.
Katzenstein: Berl. Laryng. Sec., May 20, 1892; in Centralblatt fair Laryngologie, No. 9, 1892. Short notice, 2 cases in report.
Cheatham: Amer. Practitioner and News, Dec. 7, 1889.
Norton: Had. Press and Circular, May 22, 1889.
Felici: It Morgaqni, March, 1888 (mentioned by Bosworth).
Black: Glasgow tied. Journal Feb., 1886.
This makes a record of 25 or 30 cases altogether, and the list is tolerably complete.
We have seen how malignant a growth is sarcoma of the tonsils. When it occurs in the oro pharynx this is far from being the case. In this locality the growth is very frequently pedunculated or has a small base of attachment. It grows more or less slowly and does not have a tendency to glandular involvement. It is more frequently of the spindle celled variety, which is usually less virulent. They are reported as springing from the posterior pharyngeal wall or low down on the sides of the pharynx.
Their usual occurrence is after middle life, although we again see here an instance in a child of eleven years. It is here also more frequent in men.
Symptoms. It usually gives rise to no symptoms until deglutition or respiration is interfered with, which occurs at an early date, however, owing to its situation and the common presence of a pedicle. It may cause cough by encroaching in its growth upon the arytenoid summits or folds. Dyspnea from this cause has been reported as severe and dangerous ; and, in the case ,of the child reported by Montaz, death occurred from the impaction of a portion of the growth in the larynx. As to duration, it seems from the histories that the disease may extend over several years, although it is sometimes rapidly fatal.
Prognosis. Of course, the usual termination is in death; but if the tumor is such in shape and situation as to allow of complete removal, there is a fair chance of no recurrence; and if it recurs, a second operation may be more successful.
Treatment. When pedunculated and not too large, the growth may be removed with the galvano cautery snare. When, however, it has a broad base of attachment, or when it is so large as to make such a manipulation of doubtful success, a lateral, or better a subhyoid, pharyngotomy may be done. One or two cases were operated on through the mouth after preliminary tracheotomy.
Carcinoma of the Oro pharynx. Below the tips of the arytenoid cartilages i. e., in the laryngo pharynx carcinoma, often of scirrhous nature, is a very frequent occurrence. Above this point, however, it is one of the rarest of growths (Fig. 633).
Bosworth refers to about 30 cases, although some of these bad their origin evidently in the laryngeal part of the pharynx. I have been able to find very few reports since then.
The variety is usually epitheliomatous or scirrhous. One case was reported as young as twenty; but pharyngeal carcinoma is no exception to the rule which obtains elsewhere as to age. The larger number of cases seem to have been in females, a contrast to what we have hitherto noted in neoplasms of the upper airpassages.
Symptoms. Gradually increasing discomfort and pain in swallowing first attract the patient's attention. Extension of the growth to the larynx and esophagus causes dyspnea and increases the difficulty of deglutition. Involvement of the cervical glands occurs early, and deterioration of the general health rapidly ensues. There may or may not be any bleeding. The duration of the disease is from six to eighteen months.
Prognosis is of course bad, but some prolongation of life by early surgical interference may be expected in favorable cases. Treatment, if radical, of course belongs to the general surgeon. Tracheotomy, feeding per rectum, and opium are the palliative measures that are indicated in some of the cases.
BENIGN NEOPLASMS OF THE LARYNX.
It is said by Moore,' quoting from Schwartz's tables of Fauvel's cases, that these growths occur in about 1 per cent., of the cases of laryngeal disease. Of late years chronic laryngeal disease, except the specific lesions ,of tuberculosis, syphilis, and cancer, seems almost to have disappeared from our nose and throat clinics in America. There is hardly any way of explaining this except by suggesting that the prompt and thorough treatment of nasal diseases, which all patients receive in this country, has produced this marked diminution of laryngeal disease.
It is my impression, however, that the proportion of benign growths to other affections of the larynx is rather more than 1 per cent. in New York City. Nevertheless, such are exceedingly rare, and very few of us see more than a very few cases each year in the public clinics. One has only to look at the works of Turck, Stork, Fauvel, and Mackenzie to realize that the early laryngologists saw a much larger number than occurs in the practice of any laryngologist to day.
This may be graphically seen on referring to Semon's statistical tables 2 of his investigations, where Fauvel and Stork each say they had seen 600 cases of benign laryngeal growths, and others with " prerhinological experience note very large numbers.
Thev are more common in men than in women. According to Mackenzie, out of 287 cases of benign laryngeal growths in his own practice and in that of others, 197 were males and 90 were females. They are most common in middle life, although some forms as papilloma are more frequent in children. They are more common in those who make professional use of their voices. In children an attack of the measles has been frequently noted as the time at which the symptoms of papilloma began. Syphilis and tubercu , losis produce their own neoplastic phenomena in the larynx, but have no appreciable influence in producing independent tumors.
Looking at Schmidt's tables, we again note the great preponderance of certain laryngeal growths. Fibroma, papilloma, singers' nodes, and tubercular tumors so far outnumber the other benign growths lipoma, myxoma, and cysts that the contrast is striking; while adenoma, chondroma, angioma, neutered, with others which Gerhardt mentions,' have not been seen in his experience. This clinical fact alone, which is the common experience of all laryngologists, is strongly suggestive of the conclusion that, if they are not all of them results of chronic inflammation, the latter is a prominent factor in their etiology.
“Singers' nodes" are acknowledged by all to be the direct products of chronic inflammation. The name refers to their external appearance and the etiological factor in their occurrence. Their histological structure, while always giving evidence of inflammation, is not always the same. Occasion¬ally the principal hyperplasia is in the epithelium, whose flat layers are thickened and supported by subjacent structure. More frequently there is marked increase in the lymphoid elements, raising up the epithelium into surface protuberances; while in other cases the stroma is increased in volume, and frequently its fibers are separated by effused serum. Usually, however, there is a combination of these pathological changes with an increase of they ascularit of the parts. They are seen onl upon the true cords, nearly always in their anterior thirds, either upon their superior surfaces or at their edges. They are sometimes bilateral at the edges, but of unequal size, having the appearance that one had been formed first and then affected by attrition the edge of the opposite cord. Occasionally it will be observed that the protuberance on one cord has made a little concavity at the edge of the opposite cord (see page 1105).
Etiology. They occur chiefly among professional people who overuse their voices. This especially is the case in amateur singers. It is occasionally observed in news boys and in choir boys.'
Symptoms. A young woman who has been singing a few months, or a vocalist from the music halls who has been overstraining her voice, comes with the complaint of inability to produce certain notes or that a very little practice tires her larynx. Later in the course of the trouble there is complaint of occasional hoarseness and fatigue of the voice in ordinary conversation. The patient may be otherwise in perfect health.
Examination reveals one or both cords congested and rough at the edge or throughout the whole extent. It may be swollen and ecchymosed, and looks as if it had been bruised between two hard surfaces. A sessile growth from the size of a pin's head to that of a split pea may be seen on the anterior part of one or both cords, or there may be a number of these little protuberances scattered over their surfaces.
Prognosis, of course, relates entirely to the restoration of the voice, and this depends largely on whether the voice has broken down under use or abuse. It is doubtless true that in many of these cases the trouble at the bottom is really a natural structural weakness of the vocal organs. In others overuse of the voice has produced the trouble. The former cannot be corrected, and these patients cannot sing except in extreme moderation; but the ordinary voice may be entirely restored. Others, by proper care and treatment, may regain the singing voice.
Treatment. First, rest as absolute as possible must be insisted on for the larynx. The patient should not be allowed to talk more than necessity requires. The air passages in the pharynx and nose must of course be put in order. Applications of nitrate of Silver or sulphate Of zinc (10 gr. ,3j) should be made daily or three times a week. Usually after several weeks this will result in the subsidence of the neoplasm. If it is of large size and should persist, attempts at removal may be made. It is occasionally of such a size and shape that it may be seized with forceps or shaved off with the laryngeal guillotine or snare. The laryngeal bistoury, either protected or unprotected, cannot be too strongly condemned. The most disastrous wounds, have been inflicted by it even in ;killed bands.' The galvano cautery electrode is usually to be preferred for operative procedures oil these growths.
Laryngeal Polypi. By this term we understand benign growths of the larynx, whatever their histological structure, which have more or less circumscribed bases of attachment. Their symptomatology and treatment are so nearly identical that these will be spoken of a a whole, following a brief account of the pathogenesis, histology, gross appearances and occurrence of each.
Edematous Polypi of the Larynx the so called Fibromata. in the nose, where edematous hypertrophies of the mucous membrane are often called myxomata, so in the larynx we find practically the same structure in growths, which until very recently have been almost universally called fibromata or fibro myxomata.
In the nose these serum soaked neoplasm , are covered by a translucent columnar epithelium, and are scantily supplied with blood vessels. In the larynx, on the other hand, they are covered by an opaque stratified pavement epithelium. They are more exposed to bruising by the muscular movements of the vocal cords and the forcible air currents in coughing and loud speaking, which produce extravasations Of blood into the meshes of the separated stroma fibers. These two circumstances give them either a solid white look or a dark red appearance.
My own histological examinations as well as clinical experience lead me to believe that Chiari is correct in stating that they are local hypertrophies of the vocal cords. Their structure closely resembles that of edematous nasal polypi. As has been stated, the surface epithelium and the extravasated blood constitute the chief differences. There are also more blood vessels, which are usually much dilated, making vascular channels across the loose stroma. Hyaline bodies are also frequently met with, and supposed to be due to the degeneration of the stroma fibers (Fig. 635).
Etiology. In studying their structure we see at once that they are the result of chronic inflammation, and therefore have the same cause as do the singers' nodes already referred to. As a matter of fact, their structure is identical with many of the latter growths, which may therefore be looked upon as early stages of laryngeal polypus. They are more common in men, and are seldom seen in children.
Physical Appearances. They are smooth, rounded bodies, which may be sessile or may have a long pedicle. They may be red and congested or look pale and opaque. They usually have their attachment to the anterior part of the true cords, but may also spring from the ventricles or false cords, the subglottic space (see Fig. 563), or from the anterior commissure. They may be very small, in which case they are usually sessile (singers' nodes) ; or they may be so large as almost to fill the larynx, leaving surprisingly little room for respiration. When large they are commonly pedunculated, pearshaped growths. They are usually single, but may have several lobules.
Papilloma is of such frequent occurrence in the larynx and is so closely allied to various manifestations of inflammation, such as pachydermia and the surface phenomena of certain tubercular and syphilitic lesions, that we must presume that the local irritation of inflammation is an important element in its pathogenesis. Generically it has been classified by pathologists among the fibromata and called a papillary fibroma; but its chief characteristic is epithelial proliferation, and to be consistent with pathological laws it would seem that its name should rather be "benign epithelioma." According to Schmidt's tables, he met it in about 10 per cent. of his cases of larvngeal neoplasms. Schrotterl places its proportions at IS per cent., while Moure' agrees with Bruns, Fauvel, Massei, Krishaber, and Elsberg in saying that it occurs in about 50 per cent., and Mackenzie puts the figure as high as 67 per cent. Schnitzler' says it is the most frequent of all laryngeal growths, especially in children ; while in adults papilloma becomes less frequent and fibroma more common. This discrepancy probably depends on how many of the inflammatory nodules, already spoken of, are placed in the category of tumors. Its most frequent site of attachment is the vocal cords in their anterior third and at the anterior commissure, but it may occur everywhere in the larynx. A growth may have a long pedicle which allows its attachment beneath the cords, and yet the mass may present above them.
In children it presents certain features in diagnosis and treatment not observed at other periods of life nor in other growths. Congenital cases have been reported in which the child was aphonic from birth. In very young children laryngoscopical examination is usually unsatisfactory and always more or less incomplete. When the growths are situated in the upper part of the larynx they can sometimes be felt by the examining finger. Hoarseness in a child, slowly increasing to aphonia and dyspnea, render the diagnosis exceedingly probable; Tracheotomy may then be indicated, in the course of which the diagnosis will be established. The growths are usually sessile and frequently disseminated. While Hooper has succeeded in operating on children after tracheotomy, and even without it, by endo laryngeal methods under ether, this is usually not practicable nor satisfactory. Tracheotomy should be performed, when indicated, for the dyspnea, and the tube left in for several months before thyrotomy is done, which may, result in permanent loss of voice or serious impairment of it.
A large number of cases have been reported of spontaneous cure after tracheotomy, presumably due to the rest afforded the larynx. Thyrotomy may be done and the larynx thoroughly curetted and cauterized, but recurrence even then is common. Intubation has been tried in hope that the pressure of the tube would cause absorption of the growths, but not with satisfactory results.
Physical Appearances. They may be single or multiple, with a long pedicle or broad based. They may dot the surfaces of the cords as little buds or fill the whole cavity of the larynx with a fungus looking mass, which may be pale or of a dark red color. Their size, however, is not usually larger than a pea.
Differential Diagnosis. There are certain conditions in the larynx which may give rise to a mistaken diagnosis of papilloma. The one which possesses most interest is epithelioma. As has been said, papilloma is itself a distinctly epithelial growth. Every laryngologist knows that occasionally a beginning cancer will present exactly the same appearance in the larynx as a papilloma. Indeed, there may be no carcinomatous elements in the surfaceproliferations, and thus a microscopical examination of portions removed by endo laryngeal procedure may be misleading. A papillary tumor occurring in the larynx under twenty five is in all probability a benign growth. Occurring in a patient over fifty, who has badly no previous laryngeal trouble, however benign in its appearance, it is always to be looked upon with s uspicion. If it is pedunculated, and after existing several months the surrounding mucous membrane presents no appearance of infiltration or zone of inflammation, it is presumably benign. Any limitation of movement in the excursion of the vocal cords is a suspicious circumstance, which if marked is almost pathognomonic of malignant disease. Recurrence after thorough removal in case of malignancy is apt to be accompanied by infiltration, while when benign this is not noted; but recurrence itself in a patient past middle life is not a favorable omen, although in children it is the rule in benign growths. Unless the piece removed for examination includes some of the tissue from which the growth springs, a negative microscopical examination is not conclusive. On the other band, even a surface clipping may show the character of the growth; but frequently a concentric arrangement of epithelial cells leaves the examiner in doubt as to their significance. Under such circumstances time must be allowed to watch the progress of the case, but it should be examined at frequent intervals by a competent diagnostician.
Tuberculosis of the larynx presents occasionally an appearance which to the novice closely resembles a papillomatous growth (see Figs. 612, 616, 617, 622). Papillary masses at the posterior commissure or, less frequently, more anteriorly, may so project into the larynx as to hide underlying infiltration or ulceration. Examination of the chest or sputum may even be negative or the former doubtful. The position of the growth at the posterior commissure, its sessile character, the paleness of the larynx, the prominence of cough as a symptom, and the general history of the case, will usually allow the experienced laryngologist to make a diagnosis without the aid of pulmonary signs. Microscopical examination will frequently show tubercle bacilli ; but these may also be absent, and only the epithelial proliferation is to be noted.
Cysts' (Fig. 636), angioma (Fig. 634), myxoma, lipoma (Fig. 637), chondroma, 5 adenoma, 6 lymphoma 7 (Fig. 638), and colloid growths are all occasionally met with in the larynx, while amyloid degeneration' has been noted in various tumors.
Symptoms of Benign Laryngeal GrowthS. In a general way it may be said that supraglottic tumors first produce cough, neoplasms of the vocal cords first give rise to hoarseness, and infraglottic growths to dyspnea ; but it will be readily understood that no absolute rule can be laid down.
Glottic spasms, aphonia, and apnea are the graver forms of the same clinical character. Pedunculated growths, by changing their position in relation to the glottis, frequently cause intermittency or exacerbation of these symptoms.
Benign tumors being usually of slow growth, the advent of dyspnea is not noted by the patient, except in the case of pedunculated growths, when it is intermittent or spasmodic, until very surprising encroachment has been made on the air way. They so gradually become accustomed to interference with respiration that it is not noticed until some sharp attack of inflammation still further blocks the larynx and perhaps produces dangerous choking. The laryDgoseope, of course, establishes a diagnosis which, until it is used, is mere surmise.
Treatment. The treatment of benign laryngeal neoplasms consists in their removal from the larynx or their destruction in situ. The method and means employed will depend almost entirely upon the size, shape, and situation of the growth. Small sessile growths can best be destroyed by the galvano cautery. The various forms of laryngeal forceps, snares, and guillotines are the endo laryngeal instruments, among which selection must be made for the pedunculated or circumscribed growths. This selection will be largely a matter of the individual preference of the operator. Urgent dyspnea may necessitate immediate tracheotomy. In many eases the tumor may be so large that it is advisable to have tracheotomy instruments at hand for immediate use, should the emergency of the moment require it during an endo laryngeal attempt. Rarely, in subglottic or in broad based hard growths, such as chondromata, a thyrotomy is necessary.
MALIGNANT TUMORS OF THE LARYNX.
Carcinoma of the Iarynx. It is not intended here to treat of those cases of cancer which, originating elsewhere. have spread by continuity or metastasis to the larynx. Such are the malignant growths of tile laryngopharynx and esophagus, and of the cervical glands.
In 1889 Semon' collected the statistics of laryngeal cancer in such numbers that from the facts given we are able to gather a better and more definite knowledge of malignant growths in the larynx than in any other part of the air passages. This was due to the interest aroused in the tragic fate of the Emperor Frederick of Germany, and to the unfortunate quarrels of his medical attendants.
Semon's tables show the reports of 107 observers, whose collective experience comprised 10,747 cases of benign growths and 1550 malignant tumors, a proportion of about 7 to 1. Since, as we shall see later, considerably less than 100 reports of laryngeal sarcoma could be collected in 1894 from literature, we may disregard these growths in estimating the relative frequency of carcinoma of the larynx.
As will be seen from his list, Schmidt bad himself seen 75 cases. From Semon's tables we find that Stork bad seen 100 in Vienna, Ocrtel 46 in Munich, 'Massei 39 in Naples, Fauvel 150 in Paris, Semon 56 in London, Cohen 100 in Philadelphia. These are figures given in some cases as estimated, and the number is proportionately larger owing to the numerous cases seen in consultation.
Gerhardt says carcinoma of the larynx is three times more common in men than in women. According to Schmidt's experience it is nearly four times as frequent. Jurasz's own experience was 15 men, I woman. He quotes Baratoux's collected statistics as showing 88 per cent. in men.
Jurasz's cases showed it most frequent in the decade from 50 to 60. Gerhardt, quoting Kraus, gives the following table as to age.
20 to 30 . . . . . . . . . . . . . . . . . . . . . . . . 4
30 to 40 . . . . . . . . . . . . . . . . . . . . . . . . . 18
40 to 50 . . . . . . . . . . . . . . . . . . . . . . . . . 49
50 to 60 . . . . . . . . . . . . . . . . . . . . . . . . 76
60 to 70 . . . . . . . . . . . . . . . . . . . . . . . . . 30
70 to 80 . . . . . . . . . . . . . . . . . . . . . . . . ..10
187
Sebrotter says lie has seen it in a child of three and a half and in a girl of ten and a half years. It has been noted that it occurs more frequently in well to do people, and especially in those who use their voices constantly. Heredity seems to have a marked influence in some cases. The site of growth in Jurasz's cases was as follows :
Whole larynx . . . . . . . . . . . . . . . . . . . . . . I
Right side of larynx . . . . . . . . . . . . . . . . . 2
Epiglottis of larynx . . . . . . . . . . . . . . . . . . 3
True cords, I right, 1 left, 2 both . . . . . . . 4
True cords and ventricular bands . . . . . . . 3
Arvtenoids and interarytenoid –pace. . . . . 2
15
In Mackenzie's 53 cases, however, 28 sprang from the ventricular bands. Bosworth, quoting from Gurlt, says that out of 11,131 cases of carcinoma it occurred in the larynx in 63 cases, as against 47 in the air passages above it.
Epithelioma is the form usually observed, but encephaloid, adeno carcinoma, and scirrhus have all been reported in the larynx. The medullary cancer is more frequently extrinsic and the scirrhus is very rare. Out of 68 cases collected by v. Ziemssen, 57 were epithelionia, 9 encephaloid, and 2 villous tumors; out of Mackenzie's 53 cases, 2 were scirrhus. The usual duration is about three years, but some cases of adeno carcinoma' have lately been reported which lasted five or six years.
Symptoms. Hoarseness is the first symptom, which usually comes on gradually and lasts for several months before any other symptom supervenes. The majority of the patients are in good general health. The hoarseness, after a longer or shorter time, is accompanied by dyspnea and cough: the former rapidly increases until tracheotomy is urgently indicated. Later in the disease glandular enlargements may be felt in the neck; but they are usually not present at first, although Frankel reports cases in which the glandular involvement was the most marked feature of the case from the first. Dysphagia sooner or later occurs, and pain, worse at night, robs the patient of sleep. These symptoms are more marked and come on earlier when the ulcerated growth is on the posterior wall or the epiglottis and aryteno epiglottic folds ; but are late when the tumor is on the vocal cords or 'in the laryngeal ventricles.
The general health deteriorates, the appetite fails, and there is loss of flesh and strength.
Ulceration gives a peculiar and, Frankel says, characteristic odor to the breath, which is identical with that from a pharyngeal carcinoma. In a recent case of carcinoma of the pharynx, before I realized the source of the odor, the first impression 1 bad of it was that the patient bad been using a gargle of the solution of the chlorid of' iron oil a fetid surface.
Finally the growth becomes apparent to external palpation, perforating the laryngeal cartilages, which crackle under the finger on pressure. It may even perforate the skin and appear as a fungous mass externally. The last phases of the disease present a most pitiable aspect of' human suffering. Tracheotomy has long since become necessary. Granulations block the tube and, growing below it, slowly suffocate tile patient. Continual cough, inability to swallow, lancinating pains, and the foul odor make a picture which every laryngologist should have in mind in considerin g the treatment of the disease in its early stages. Pieces of necrosed cartilage are coughed out, or portions of the tumor may fall into the trachea and bronchi. Perforation of the esophagus frequently supervenes and food may penetrate the bronchial tubes. Hemorrhage is sometimes abundant, although blood is usually only mixed with the copious discharges from the throat. Perforation of tile carotid may, however, end the case. Death may come thus, or from exhaustion, or from supervening pneumonia due to penetration of piece of the growth or food and blood into the lungs the so called “Schluck Pneumonie." Suffocation is, therefore, not the only termination of the disease, although it is a frequent one.
Diagnosis. The laryngoscopical appearances of laryngeal cancer must be considered in connection with its differential diagnosis, so far as its initial stages are concerned. Its differentiation from papilloma has already been alluded to. In its incipient stages epithelioma frequently resembles tile benign growth. At other times flat, indolent ulcer oil the vocal cord may be seen at the first laryngoscopical examination. When the edge are infiltrated and round we may suspect carcinoma, but sometimes this is not tile appearance. The edges may be more or less flat and sharp cut. Anti¬syphilitic treatment in decisive doses of mercury and the iodid of potash most be given while a Microscopical examination is being, made. Tuberculosis must be thought of, and at) examination of the lungs for physical Signs, and of the sputum for bacilli, must be made.
When the growth occurs in the ventricle of the larynx, the problem is a much harder one to Solve. We find a smooth swelling presenting above the cords. Being covered by mucous membrane it is impossible to remove a piece for examination. There is a limitation or entire abolition of movement of that side of the larynx. There is: nothing to be done but to try to exclude a syphilitic gumma by the vigorous administration of the iodid of potash. Nice I saw such a growth which was evidently tubercular. We must remember that cancer may coexist either with a Syphilitic history or pulmonary phthisis. We must also remember that the administration of tile iodid of potash may cause a sensible, although temporary, diminution ill the size of a cancerous swelling. As Frankel Says, it seems as though tile disease was simply catching its breath for a fresh start. The surface finally is involved and the diagnosis becomes evident.
The appearance of the growth, which in the early stages varies so, in the later stages is more uniform and characteristic. The ulcer of cancer then differs in DO way from its appearance elsewhere. A fungous mass covered by grayish or whitish secretion fills the larynx more or less completely. The growth cats into the cartilages, causing the swelling characteristic of perichondritis. It has nearly always, even in the initial stages, burrowed more deeply into the underlying tissues than appears on the surface. It grows upward over the top of the larynx, infiltrating the surrounding tissues, and producing then marked glandular involvement.
Semon has pretty conclusively settled by his statistics the question of the degeneration of a benign into a malignant growth of the larynx. The exceeding rarity and doubtfulness of this occurrence was one of the assertions of pathologists which clinicians had been loath to accept. In only 45 out of the 10,747 cases reported did this seem possible ; while as following upon endo laryngeal operations it was only reported 33 times. Many of these reports render the opinions expressed extremely doubtful ; so that excluding all but the certain cases, Semon's proportion is I to 1645 of malignant degeneration after endo laryngeal operation. And after all, we may say that the proof is necessarily a post hoe, ergo propter hoe argument. We must allow the possibility of a benign tumor becoming malignant, although the strongest microscopical proof must be required to admit of its probability in ally case.
The prognosis of laryngeal carcinoma is, of course, very bad; but the statistics hereafter quoted, it should be remembered, include many cases in which the growth was not confined to the "box of the larynx."
The same rule here holds good, as to the difference in the prognosis of those cases operated on early and those operated on late, as elsewhere in the body ; although the cartilaginous walls shutting off the growth from surrounding tissues would seem theoretically to give the incipient cases an especially good prognosis. Without operation all cases die miserably.
Treatment. Of late years the conviction has grown among laryngologists that every primary intrinsic carcinoma of the larynx in its early stages is a case for extra laryngeal rather than endo laryngeal operation. The diagnosis once made, the laryngologist should see noti me tangere written in the larynx of every case. No operator, however skilled, can ever be sure that be has removed the infiltrating cancer cells. There is every reason to believe that cancer is a local disease, which, if disturbed by any operative procedures short of extirpation, is apt to spread rapidly beyond the reach of the knife. Frankel and Moure both state their belief that the removal of pieces for histological examination does no harm, but that the wound usually heals over. The majority of observers, however, do not agree to this. Doubtless, ineffectual tampering with an already malignant though quiescent growth has, by its results, given rise to the opinion formerly held by some, that such procedures were the exciting cause of a malignant degeneration.
No rules for operation can be laid down that will apply to every case. In a general way it may be said that all cases which are confined to the interior of the larynx and in which there is no glandular involvement are cases for operation by laryngectomy or some of its modifications. Excision, according to Powers and White,' has been performed upwards of 300 times. From them I quote the following table, which gives at a glance a general report of the results attained :
1. TOTAL ExcisioN OF TIRE LARYNX.
Cases reported prior to January, 1892 . . . . . . . . . . . . . . . . . . . . . . . . . 180
Died as result of operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Died in first year, 5 from recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Recurred in first year, either dead or living when reported. . . . . . . . . . . 51
Recurred after 1 year (13 months 2,2 years 2,2 years 1 month, 2 years 7 months, 3 years 4 months, 9 years) . . . . . . . . . . . . . 8
Reported in first year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Reported in second year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Reported in third year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Reported after 3 years, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. PARTIAL EXCISION OF THE LARYNX.
Cases reported prior to January, 1892 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Died as result of operation (8 weeks) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Died in first three years (3 from recurrence) . . . . . . . . . . . . . . . . . . . . . . . . . 5
Recurrence in first year, either dead or living when reported . . . . . . . . . . . . 17
Recurrence after I year (13 months, 16 months, 17 months) . . . . . . . . . . . . 3
Reported in first year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Reported in second year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Reported in third year, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Reported after 3 years, free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
After what has been said of the course of laryngeal cancer left to itself, it will be admitted that the many cases who died as a result of operation are not to be looked upon as necessarily an argument against the procedure; nor are. the cases of complete recovery to be looked upon as unqualified successes. The loss of a larynx is a terrible mutilation of the human organism, and the after life. of the patient, with or without an artificial vocal apparatus, is not an enjoyable existence. Gussenbauer and Wolf have invented mechanisms which permit these patients to produce articulate speech; but many cases have been reported in whom some fold of tissue has been formed by nature to serve as a vibrating membrane in the production of sound and its modification by the lips and tongue into speech.
Cohen's well known case of adeno carcinoma, in which the larynx and upper part of the trachea being removed, the remaining tracheal orifice was stitched to the skin above the episternal notch, is still alive (November., 1896) nearly five years after operation and he speaks hoarsely, but distinctly, by means of swallowed air which be holds in a kind of a pouch in his pharynx and expels past some vibrating fold of, mucous membrane in the neighborhood of the pillars of the fauces. He breathes without cannula through the cervical opening.
Excision of the larynx is an operation which, in fairness to the patient, should only be performed by a surgeon skilled in all the technic of modern surgical methods and equipped by previous surgical experience with tile ability and presence of mind to meet grave and often unexpected problems which may arise during its performance. Cohen and especially Semon I are the laryngologists who have had the most gratifying results in these operations; but, as a rule, it is not a task to be undertaken by even the experienced laryngologist.
In many cases the tumor has spread, either by direct growth or by metastasis, beyond the larynx. The inclusion of these in the tables given is what makes the percentages of recurrence and death so high. In each case, as it is met, a decision as to a radical operation or a palliative treatment is to be decided on its merits and according to the wishes of the patient, when the conditions are explained to him. Tracheotomy for the passage of air is always indicated, and even gastrotomy for the introduction of food may be a means of prolonging a miserable existence.
Sarcoma of the Larynx. Bergeat has presented the most complete and exhaustive review of the reports of sarcoma of the larynx yet published. His list is as follows
Laryngeal sarcoma. primary . . . . . . . . . . . . . . . . 8 5 Tracheal and bronchial sarcoma, primary . . . . . . . . . . . . . 7
Laryngeal sarcoma, secondary, by continuity . . . 10 Tracheal and bronchial sarcoma, secondary in main . . . . 9
Laryngeal sarcoma, secondary, by metastasis . . 2 Tracheal and bronchial sarcoma, secondary in animal (dog) 1
Doubtful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
114 17
Reports of the following cases (not included in Bergeat's tables) are at hand Chappell,' female, aged 32, symptoms 4 years. Sarcoma (perithelioma) of epiglottis, very large, pedunculated, removed with hot snare; weight 360 grains; size 41/2 X 3 5/8 inches in circumference. Thompson 2 male, aged 35, blacksmith, symptoms 6 months, right side of larynx, laryngotomy.
Mackenzie says that he had seen only 5 cases of sarcoma of the larynx. As lie had seen 53 cases of carcinoma, we have the ratio in his experience of about 1 to 10. Schmidt's proportion, it will be seen, is 3 to 75 or 1 to 25; while Bergeat quotes Gurlt as giving the general relative occurrence throughout the body as 1 to 13. Bosworth, quoting Gurlt, says that out of 848 sarcomata, the larynx was the seat of disease in only I case.
In Bergeat's tables, out of 66 cases of primary sarcoma, 48 were of tile male sex and 18 female in general, he says, sarcoma occurs in men 10 per cent. more frequently. It occurred in men almost twice as frequently (15) from 50 to 60 as in any other decade; the next in frequency (8) being from 40 to 50. The youngest was 7 years old; the oldest 81. In women it occurred from 21 to 53 inclusive, there being 5 each from 30 to 40 and from 40 to 50, and only 2 from 50 to 60. Curiously enough he notes its more frequent occurrence in people who came often in contact with horses.
In variety they were spindle celled, 22; round celled, 12; alveolar, 5 or 6; mixed, 4; giant celled, 2 or 3; fibro mvxomatous, 1.
It had its origin most frequently on the vocal cords, but also occurred in almost every other locality. Oil the vocal cords and epiglottis the spindle¬ celled sarcoma was almost the exclusive form found. No instance is recorded in which the growth originated in the larynx and spread to the pharynx; the secondary invasion was always the other way. Erosion and perforation of cartilage were rarely observed. In spite of the numerous observers who have drawn attention to the lateness of glandular involvement in laryngeal carcinoma, Bergeat noted it in 15 per cent., of tile cases of laryngeal sarcoma. This was especially marked with the round celled and alveolar sarcomata. The course of these forms is frequently very rapid; but the duration of sarcoma of the larynx seems to vary greatly, the symptoms sometimes dating back only a few weeks and sometimes running back for several years; some as long as 7, 8, and 10 years. Pain and dyspnea are not so prominent as in carcinoma, and ulceration is also not so usually observed. The general health is frequently not seriously affected; but there is the greatest variation in the severity of the symptoms.
Diagnosis from carcinoma is usually impossible without a microscopical examination. The same caution must be observed here as elsewhere in distinguishing small round celled sarcomata from syphilitic and other granulomata. In summing up all the cases, as Bergeat has done, it is seen that the average course and clinical picture differ materially from those of carcinoma, and yet in any given case the differential diagnosis upon these alone is not satisfactory. Bergeat lays some stress on a striking yellow color which is sometimes observed in sarcoma, but never in carcinoma, on the slower growth, the later and more infrequent ulceration. Sarcoma is sometimes pedunculated. There are rarely any sharp pointed projections, but they are usually round and broad.
Prognosis. Ili a general way the prognosis after all methods of operating is better than in carcinoma, one case of total extirpation being well and able to work after fifteen years ; and in one case the duration was twenty one years, during which many endo laryngeal operations were performed. In the larynx, as elsewhere, there are many cases in which the diagnosis is a matter of considerable doubt, even with microscopical examination.
Treatment. The same indications obtain as in carcinoma.
NEOPLASMS OF THE TRACHEA.
Avellis gives a resume of the literature of benign tracheal growths. He refers to 17 reports, making with his own about 20 undoubted cases. A few have been reported since 1892.
Many cases are reported of granulation papillomata and polypi around tracheotomy wounds, and a few cases are recorded of the projection of pieces of thyroid hypertrophies into the trachea. There are also some reports in which it seems evident that the growths really sprang wholly or principally from the subglottic portion of the larynx. The benign growths were usually papillomata or fibromata. An adenoma and a chondroma have also been noted; but we may be permitted to doubt the nature of these, since the former is so rare anywhere in the air track and of such a doubtful nature when reported, and chondroma is apt to be confounded with ecchondrosis. Ecchondroses pure or partially ossified have often been noted post mortem.
Carcinoma of the trachea is so rare that when Cornil and Ranvier published their work in 1884 they denied 3 absolutely that it ever occurred there primarily. Nevertheless, several bad been reported. Ten years later Pogrebinski 4 was able to give abstracts of 13 reports of carcinoma of the trachea, 3 of which he looked upon as doubtful, while 1 was known to have started in the esophagus. To this number lie adds a ease of his own an epithelioma primary in the trachea. Many of these cases were of the encephaloid variety. There are a number of other cases reported in which the trachea was secondarily involved from growths in the esophagus and in the thyroid gland. Not included in this list is a doubtful case of Schmidt and a genuine case described by Oestreich. Another case is referred to in the Centralbl. fur Laryngol., viii. p. 396. We have seen that in Bergeat's tables but 7 cases of primary tracheal sarcoma are on record, thus refuting the statement of Koch,' that sarcoma is the more frequent malignant neoplasm.
The chief symptom is dyspnea, and when dyspnea occurs from a tracheal growth, that growth always dangerously occludes the air way In the upper part of the trachea always, and in the lower part usually the laryngoscope will reveal the nature of the trouble. The physical characteristics of the growths differ in no way from similar neoplasms in the larynx. A low tracheotomy may gain time for a more extensive opening of the air tube and extirpation of a benign growth. Many eases of death from it are on record; but endo tracheal operations are usually impracticable. Malignant growths are almost uniformly unrelieved and fatal; although in Schmidt's case of epithelioma, diagnosticated microscopically by Weigert, the patient was alive two years after operation. Dyspnea without other symptoms usually appears so late that in malignant cases the patients present themselves only AN ben their condition is hopeless. Indeed, many of the reports are from the postmortem table.
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