J.L.W. Thudichum
1891 The Lancet  
THESE tumours of the naso-pharynx were formerly described as polypi, of which they represent the most severe forms. But they differ from tumours now commonly termed polypi in this, that if they are not removed by art they mostly lead to a fatal termination. Of the perniciousness of these tumours the literature of the subject contains ample evidence; death occurred most commonly by haamorhage, spontaneous, often repeated and long continued; some cases perished from the progress of the tumour to
more » ... s of the tumour to the base of the brain, others from suffocation, whatever was the temporary symptomatic relief-e.g., by tracheotomy. Not a few cases perished in or after the attempt to effect relief by surgical means; many perished of secondary effects succeeding an operation effective or attempted—pyæmia, pneumonia, anaemia, and other accidents. The second prominent peculiarity of the fibroma is its frequent recurrence after it has apparently been extirpated; an accident which necessitates periodical examination of such patients. The third peculiarity of these fibromata is that they occur in an active'state, mainly in males below the years of manhood ; they most frequently come under observation in fast growing lads, but are also observed in a quiescent state in older men, when from the history of the cases it can be ascertained that they were carried by the bearers from adolescence into manhood. They mostly become quiescent, at least as regards increase, after the age of twenty-one years or, physiologically speaking, after the completion of the structural development of the head and face. The tendency to haemorrhage continues a few years longer, but ceases with the atrophy of the base of supply by pressure. The rate of growth of these tumours is quick, and is increased, as is also the tendency to haemorrhages, when they are interfered with unsuccessfully. The tumours quickly send arms into the anterior nasal fossae, the antrum and ethmoid, and sphenoid cavities; they appear under the zygomatic arches, or in the orbits, and produce blindness by pressure on the optic nerves. The anatomical place from which the first growths which enlarge to these tumours mostly originate is probably the posterior end of the middle turbinated body, more rarely the pharyngeal rudimentary tonsil. The extraordinary haemorrhage which takes place in most of these cases is not rarely the first symptom which tells the patient that there is something wrong in his pharynx. In some cases it was the only symptom observed by the medical attendants. Obstruction of the meati, or even of one of them, is not a necessary symptom of the early stage of the disease; on the contrary, tumours of considerable size may exist in the pharyngeal space without the breathing being notably interfered with, and without the voice being more than slightly altered. A frequent result of the existence of the tumour is ulceration, either on the tumour itself or on the mucous membrane. This simulates ozsena, and is sometimes mistaken for it. But in reality it is the almost constant cause of the haemorrhages. Bleed-' ' ing from mere congestion, so common in cases of polypi of the uterus or rectum, seems an exceptional sequence of nasal fibromata. The fibromata have a remarkable effect in this, that by mere pressure, with and without ulceration, they effect the absorption, without purulency or expulsion or sequestration of dead particles of bones adjacent to the na.sal cavity. I have known the osseous palate underneath the tumour to be as soft and movable as the soft palate itself ; I have spen it pressed down low into the mouth, and pulsate synchronously with the tumour in the nose. In such cases quick relief is required to prevent perforation with all its attendant evils. When the tumour is removed, the bone is again rather quickly restored; the thin bones, such as the papyraceous laminae of the orbits are not restored, but supplanted by imperfect membranes. Sometimes all molar teeth are lost on the most affected side. The pernicious fibroma effects a highly vascular adhesion 1Substance of a paper read before the West London Medico-Chirurgical Society. to all parts of the mucous membrane with which it comes in contact. This adhesion becomes universal over its surface in contact, and results in the formation of a vascular layer, which is the source of all the fearful haemorrhages as well during the progress of the disease as during any operation for its removal. The substance or bodv ot the fibroma is remarkably free from bloodvessels of any kind. The mere touching of the adhesions with a blunt probe for the purpose of ascertaining the extent or firmness of the adhesion not rarely causes a rush of blood, for which it is difficult to suppose the lesion adequate. These baemorrhages are the principal impediment which the surgeon meets with in his attempt to remove the tumours. Surgical literature contains many descriptions of a great variety of operations which were instituted for the removal of these tumours. There is no possible anatomical direction which has not been taken to get at the root of the evil, and all are avowedly mainly modulated under the fear of haemorrhage in front. One can easily see that the means chosen were desperate expedients applied to cases judged to be equally desperate. After the introduction of anaesthetics, during the last thirty years, a very common set of operations was the following. The first step was tracheotomy and the insertion of an inflated plug in the larynx. Next the nose was split up from tip to root, the nasal bones were broken aside, or temporarily or permanently severed. The tumour was then attacked with forceps, scissors, and knives, and the bleeding was from time to time diminished by actual cautery. In this way the nasal meati might be cleared roughly, but the pharyngeal part could not be reached. This was therefore attacked through the mouth ; the soft palate was divided, and the tumour-or rather as much of it asewould yield-was cut away with scissors and twisted with forceps until a tolerable passage was produced. Of the cases attempted to be thus treated a number werp, left uncompleted owing to haemorrhage; some operations were protracted, in the hope of excising the tumour, over fourteen days, one known to me over thirty days, during which time the slit nose was kept open. In fact, when John Bell described the operation as a "horrid scene from which most surgeons had to retire in confusion and dismay," he stated the bare truth. About a third of the patients succumb to anaemia ; another third die from the immediate consequences-pneumonia and pyaemia ; and about a third escape death after a long and complicated run of septicaemia. Of these many have relapses. Wutzer (of Bonn) had seventeen cases of relapse out of a total not stated. Nelaton added a special severity to the operation, with the intention of destroying the root, by removing permanently a portion of the osseous palate. Middeldorpf applied the electrocautery to some such tumours, but he was confined to such as were pendulous and could be surrounded by the wire loop. For a tumour which filled the nostril entirely and adhered to a large surface he had no remedy. Moreover, he had no remedy for the profuse bleeding, which even the electro-cautery as commonly used allowed of in these cases. adhesions of a concentrated solution of ferric chloride. The electro-cautery is employed in two forms-one the forkburner, which cuts into the parts like the sharpest chisel; the other the electro-caustic loop, used white hot, as an ecraseur. The styptic is injected with a small syringe, armed with a long hollow platinum needle, the point of which is guarded, so that it can penetrate only to a measured depth. My patients are ordinarily not placed under any general anaesthetic, but, solaced with cocaine, give an intelligent aid to the operator; but where desirable a general an aesthetic is easily applicable. There is no tracheotomy, no plugging of the larynx, no splitting of the soft or hard palate, no dividing of the nose, no breaking of the nasal bones, no resection of the nasal ramus of the upper maxillary. Almost the entire operation is performed through the nose, whatever may be diagnosed or introduced through the mouth. Consequently, this new operation makes the patients absolutely free from the fearful risks to which, as the statistics of results show, the
doi:10.1016/s0140-6736(02)18536-9 fatcat:7d7jmfnqrjhthoxe7773nfsa3i