oisr 
NASO-PHARYNGEAL 
POLYPI. 
BY 
H. B. SANDS, M.D. 
REPRINTED FROM 
Dr. Rrown-Sequ tvd’s Archives of Scientific and Practical Medicine, 
No. 6. 
NEW YORK: 
G. P. PUTNAM’S SONS, 
Twenty-third St. and Fourth Ave. 
1874. ARCHIVES 
OF 
SCIENTIFIC AND PRACTICAL 
MEDICINE. 
Vol. I. 
JUNE, 1873. 
No. 6. 
Original Communications. 
I. 
ON NASO-PHARYNGEAL POLYPI.* 
BY 
H. B. SANDS, M.D., 
PROF. OF ANATOMY IN THE COLLEGE OF PHYSICIANS AND SURGEONS J SURGEON TO THE BELLEVUE 
AND ROOSEVELT HOSPITALS. 
The experience I have lately gained by the successful treatment 
of a case of naso-pharyngeal polypus, induces me to believe that a 
succinct account of this rare and formidable affection may not be 
without interest to the members of this Society. 
With the ordinary soft nasal polypi every surgeon is, of course, 
familiar. Consisting of gelatinous connective tissue, covered by a 
layer of mucous membrane, they are essentially outgrowths from the 
latter, and may be attached by their pedicles to any part of the 
boundaries of the nasal fossae, or of the cavities communicating with 
them. They usually spring from the mucous membrane covering the 
superior or middle turbinated bone, and are rarely, if ever, connected 
with the septum narium. Polypi of the same character also occasion- 
ally originate in the antrum or frontal sinus ; and when situated in 
* Read before the New York County Med. Soc., June 23d, 1873. 
VOL. I.—28 494 
H. B. SANDS. 
either of these cavities, can be removed only by penetration of their 
bony walls. In all other cases, the morbid growth may be readily 
got rid of by the aid of a forceps, introduced into the nasal cavity 
through the anterior nares. 
But, besides the ordinary mucous polypus, another variety is some- 
times met with, which differs from the former in its structure, and 
usually, also, in its situation and attachments. It is composed es- 
sentially of white fibrous tissue, mingled with a few elastic fibres ; oc- 
casionally, also, round and fusiform cells are present, although very 
rarely in sufficient number to warrant the appellation of fibro-plastic, 
which is sometimes applied to the tumors in question. Such polypi 
are called fibrous, and are, in fact, true fibrous tumors, attached to 
the part from which they grow by a more or less constricted pedicle. 
Although they are covered by mucous membrane, the latter merely 
invests them, and does not indicate their true character' as morbid 
growths. 
Fibrous polypi differ from mucous polypi, moreover, in their origin 
and attachments. While the latter are chiefly outgrowths from mu- 
cous membrane, the former originate in the periosteum, with which, 
as well as with the subjacent bone, they are closely connected. This 
fact may partly explain the difficulties which are encountered in their 
removal, and also the failure of certain modes of operation, present- 
ly to be mentioned, whereby the tumor is removed by a simple 
division of its pedicle ; thus leaving the periosteal attachments of the 
latter to favor a recurrence of the disease. 
But, in addition to these differences in structure and attachments, 
the fibrous differs from the mucous polypus in its situation. This 
rule is not without exceptions. True fibrous polypi are sometimes 
found in the nasal cavities, where they originate in the periosteum 
covering some portion of their osseous walls. In 1846, the late Dr. 
[. Kearny Rodgers removed such a polypus from a patient in the 
New York Hospital.* The tumor was reached by excising the right 
nasal bone, and was ascertained to spring from the vomer. Fibrous 
polypi have also been found to grow from the external lateral walls, 
or from the floor of the nasal fossre. In any case, they increase 
gradually in size, and after a time cause an expansion of the facial 
bones, with corresponding deformity. 
But true fibrous polypi, originating in the nasal cavities, a*e ex- 
tremely rare. Such polypi are much more frequently connected with 
the base of the skull; and here we find two favorite seats of attach- 
ment. Sometimes the growth begins in the pterygo-maxillary fossa. 
* New York Journal of Medicine, 1851, vol. i., p. 323. As it enlarges, it may extend outward into the zygomatic and tempo- 
ral fossae, and inward through the spheno-palatine foramen into the 
pharynx. Tumors thus arising form a special group, and should be 
distinguished, both anatomically and clinically, from the remaining 
one, which embraces the fibrous growths most often met with in this 
neighborhood, and to which the name of naso-pharyngeal polypi has 
been correctly applied. 
In recounting the features of naso-pharyngeal polypi, I shall do so 
in the following order, and consider, ist. Their seat of attachment; 
2d. Their symptoms and clinical history; 3d. Their diagnosis; and 
4th. Their treatment. 
ist. Seat of attachment.—It is exceedingly important to determine, 
if possible, the exact situation and extent of the surface occupied 
by the pedicle of a naso-pharyngeal polypus, inasmuch as this is 
the part which must be reached to effect the removal of the tumor. 
On this point there is some discrepancy among surgical writers; but 
all agree that the parts from which these tumors grow form a region 
of small extent, situated at the base of the skull, and at, or near to, 
the top of the pharynx. Unquestionably, the pedicle is most often 
found connected with the inferior surface of the basilar process of the 
occipital bone, and the adjacent part of the body of the sphenoid. 
According to some authors, this is invariably the seat of attachment; 
but there is evidence enough to prove that the tumor may spring from 
any of the following parts, namely : the upper part of the pterygoid 
fossa ; the internal pterygoid plate ; the greater wing of the sphenoid ; 
the apex of the petrous portion of the temporal bone ; and the edges 
of the posterior nares. It is doubtful whether the anterior surface of 
the atlas ever affords attachment to these tumors, although the fact 
is affirmed by Michaux, Robert, and others. This surface is directly 
covered by ligamentous fibres. Over these are placed the anterior 
recti muscles, which are separated from the mucous membrane of the 
pharynx by lax, filamentous connective tissue. In none of these tis- 
sues are fibrous tumors prone to originate. On the other hand, their 
formation is favored at the base of the skull, which is invested with a 
thick and highly vascular periosteum, united firmly to a mucous mem- 
brane possessing similar characters. Without doubt, a naso-pharyn- 
geal polypus may be found in contact with the upper cervical verte- 
brae ; but it is highly probable that, in such a case, the union is not 
intimate, and that the contact has resulted simply from the down- 
ward course taken by a tumor having its origin at a higher point. 
Without attempting to settle this question, however, the fact remains, 
that the region in which a naso-pharyngeal polypus can originate is 
one of narrow limits, corresponding with the margins of the posterior 
ON NASO-PHARYNGEAL POLYPI. 
495 496 
H. B. SANDS. 
nares, and the summit of the pharynx. It may here be observed, 
that this region can be satisfactorily explored by the finger; and also, 
if necessary, by the aid of the rhinoscope. In this manner, a poly- 
pus may sometimes be discovered early, and its removal accomplish- 
ed by safe and easy methods. It is seldom, however, that the tumor 
is detected until it has attained a considerable size, and has extended 
far beyond its original site. Now, although there are many direc- 
tions in which such a growth may extend, there are two in which ex- 
tension is most common, namely, downward into the pharynx, and 
forward into the nasal fossae. It is doubtless owing to the tendency 
which these tumors exhibit to occupy the spaces mentioned, that 
they have been denominated naso-pharyngeal. When they extend 
downward, and have gained a certain size, they press upon the soft 
palate, which in extreme cases becomes greatly expanded, and so 
far changed in position that its surfaces may be more nearly vertical 
than horizontal, while, at the same time, it is pushed correspondingly 
forward. In many instances the tumor extends downward below 
the free margin of the velum, so that it may be distinctly seen, and 
it may even descend low enough to approach the larynx, thus caus- 
ing difficulty in respiration and deglutition. 
It might be supposed, that the growth of these tumors in the direc- 
tion of the nasal fossae would be resisted by the narrow boundaries 
of the posterior nares ; yet experience shows that the resistance thus 
offered is feeble, and that, sooner or later, the bones yield to the pres- 
sure of the tumor, which may finally not only penetrate the nasal 
cavities, but insinuate itself among nearly all the bones of the face. 
At first, it lies merely in contact with the parts bounding one or both 
of the posterior nares. As it grows, it extends into one or both of 
the nasal cavities, and causes either absorption or perforation of the 
septum, often becoming adherent to the posterior border of the latter. 
At a later period, it may extend so far forward as to be visible 
through the nostril. Before this happens, however, the bones which 
form the boundaries of the nasal fossae commonly yield to the pres- 
sure of the tumor, and either disappear by absorption, or are crowded 
aside to make way for the advancing growth. The more delicate 
bones, such as the turbinated, the ethmoid, the palate, and the vomer, 
yield most readily ; and at length the nasal bones, and the nasal pro- 
cesses of the superior maxillary are projected, giving rise to a striking 
and characteristic deformity at the root of the nose. At other times 
the tumor passes into the antrum, the walls of which may be dis- 
tended, thus causing disfigurement similar to that occasioned by mor- 
bid growths developed primarily in the antrum itself. Prolongations 
sometimes extend through the spheno-palatine foramen into the zygo- ON NASO-PHARYNGEAL POLYPI. 
497 
matic and temporal fossae, and through the spheno-maxillary fissure 
into the orbit, producing in the latter case protrusion of the globe. 
Such an instance is related by Spence.* Exophthalmia may like- 
wise be occasioned by the upward growth of the tumor through the 
orbital plate of the superior maxilla. The extension of the tumor 
into the cranial cavity is comparatively rare; but, when it does occur, 
it may cause fatal cerebral complications, and, of course, greatly 
increases the dangers attending a surgical operation. The growth 
may penetrate the cranium either by absorption of the walls of the 
sphenoidal sinuses, or the cribriform plate of the ethmoid bone; or, 
having once entered the orbit, it may pass into the cranial cavity 
through the sphenoidal fissure. 
It has already been remarked, that, as the tumor increases in size, 
the surrounding osseous and soft parts are absorbed or pushed aside. 
Should the mucous membrane investing the polypus remain intact, 
no adhesions will be formed; and, however large the tumor may 
become, it will be found adherent only by its pedicle to the base of 
the skull. This is not unfrequently the case; yet, on the other hand, 
superficial ulceration of the tumor often occurs, followed by adhesions 
to the surrounding tissues. These secondary adhesions, as they have 
been named, differ both in kind and degree from the primary adhe- 
sion of the tumor at its seat of origin. They are comparatively 
slight and superficial, and can generally be easily broken down. 
The surfaces left after their rupture rapidly granulate and cicatrize, 
and show no tendency to reproduce the morbid growth. The tissues 
invaded by the tumor are never incorporated with it, as is the case 
with cancerous and other malignant formations, but are either pushed 
aside, or become adherent to it in the manner which I have 
described. This fact has an important bearing on the success of 
surgical operations. 
Naso-pharyngeal polypi do not appear to be confined to any single 
period of life. They have been seen in old subjects ; and Winter f 
discovered one in a foetus of seven months. In a large majority of 
instances, however, they are found in young adults, and the discovery 
of a polypoid growth at either extreme of age would be presumptive 
evidence of its malignancy. Naso-pharyngeal polypi are also much 
more frequent in males than in females. 
These tumors, as has been already stated, are composed of fibro.us 
tissue, and are exceedingly firm and resistant. They are generally, 
however, tolerably vascular; and, when they grow to a large size, 
* Edinburgh Medical Journal, vol. ix., page 996. 
+ Gunther, Operationen am Halse, p. 311. 498 
H. B. SANDS. 
their blood-vessels are correspondingly developed. Moreover, as 
their vascularity increases, their consistency diminishes, and they are 
thereby rendered more liable to ulceration and hemorrhage. They 
grow rapidly; or, at least, they increase in size faster than most 
varieties of fibrous tumors; so that, after the lapse of a year or two 
from the first appearance of symptoms, and often at an earlier period, 
they demand surgical treatment. 
2. Symptoms atid Clinical History.—The symptoms caused by a 
naso-pharyngeal polypus may be mainly deduced from the facts 
already mentioned. Sometimes the tumor is discovered while it is 
yet very small, but it is more apt to remain unnoticed until it has 
caused some stoppage of the nose. Occasionally, an unnatural sen- 
sation during deglutition attracts the patient’s attention; and, on ex- 
amination, he discovers that the soft palate is depressed and pushed 
forward. Epistaxis is an early and oft-recurring symptom ; and the 
attacks are frequently severe, so that anaemia, with oedema of the 
lower extremities, results. Whether the hemorrhage, in these cases, 
is due to ulceration of the tumor, is uncertain ; it sometimes occurs, 
however, at an early date, and when no evidence of ulceration can 
be found. At a later period, the physical signs of the disease 
become prominent, and their precise character will depend upon the 
direction taken by the tumor in its growth. If it extends principally 
downward into the pharynx, inspection of the mouth will at once reveal 
the expansion and deflection of the soft palate, below the free margin 
of which the inferior portion of the tumor may perhaps be visible. 
Exploration with the finger will also detect the presence of the tumor, 
and enable tire surgeon to obtain important information respecting 
its size, its seat of attachment, its relations to surrounding parts, and 
the presence or absence of adhesions. 
When the tumor is of large size, and descends low in the pharynx, 
it will interfere more or less with respiration, especially during sleep ; 
thus causing the patient to awake frequently during the night with a 
feeling of suffocation. When the tumor grows forward, and occupies 
one or both nasal cavities, the breathing through the nose is ob- 
structed, and the tumor can be detected by the probe. If it enters 
the antrum, and distends it, any or all of the walls of this cavity may 
yield, and corresponding deformity will ensue. The disfigurement 
produced by displacement of the nasal bones has already been refer- 
red to ; it seldom happens unless the disease is far advanced. The 
cases are also rare in which the polypus extends outward through the 
spheno-palatine foramen. Having passed, however, through this 
opening, it is apt to extend forward on the outer aspect of the upper 
jaw, thus giving rise to a characteristic swelling of the cheek. Fi- ON NASO-PHARYNGEAL POLYPI. 
499 
nally, when the tumor extends in the direction of the cranial cavity, 
it may set up inflammation of the brain or its membranes, although 
this is seldom observed during the natural progress of the disease. 
Post-mortem examinations have often revealed perforations of the 
cranial bones, and contact of the polypus with the dura mater, where 
no cerebral symptoms had occurred during life. Such symptoms are 
much more likely to happen after a surgical operation, in which the 
connections of the tumor with the membranes have been forcibly 
severed. This accident is the more likely to happen, in consequence 
of such adhesions being often unsuspected at the time of operation: 
The natural termination of the disease is almost inevitably fatal, 
although a few instances are recorded in which the tumor was attacked 
by gangrenous inflammation, resulting in its detachment and in spon- 
taneous cure. Death may occur from hemorrhage, from exhaustion, 
from suffocation either gradual or sudden, or from cerebral complica- 
tions—the latter being very rare. 
3. Diagnosis.—Much has been said with regard to the uncertainties 
of diagnosis ; but it is only in rare cases that any serious difficulty is 
encountered in detecting the presence of naso-pharyngeal polypi. 
The only affections with which they can well be confounded are, 1st, 
malignant tumors having a similar origin and situation ; and 2d, 
fibrous polypi of nasal origin. 
Both cancerous and sarcomatous tumors have been found arising 
from the top of the pharynx ; and, at a very early period of their de- 
velopment, they might be mistaken for naso-pharyngeal polypi. 
They may be recognized, however, by their lesser consistency, their 
more rapid growth, and their tendency to ulceration and implication 
of the surrounding parts, which are not merely pushed aside, but in- 
corporated, as it were, with the advancing tumor. Should any doubt 
remain, it might be settled by excising a small piece of the tumor, 
and submitting it to microscopic examination. In this connection, it 
may be interesting to remark, that the true naso-pharyngeal polypus 
sometimes undergoes a change of type, losing its purely fibrous char- 
acter, and acquiring the characteristics of sarcoma. This change is 
most liable to occur when the tumor penetrates the cranial cavity, 
and when it recurs after partial removal. Oito Weber * relates an 
instance in which several operations were performed upon the same 
patient. The original tumor was distinctly fibrous ; but the recur- 
rent growths were soft, and contained the elements of sarcoma. 
After several incomplete operations, the tumor grew very rapidly, 
and proved fatal. Also in the case I am shortly to relate, the origi- 
* Handbuch der Chirurgie—Pitha and Billroth, Band III., Ab. i., S. 207. 500 
H. B. SANDS, 
nal polypus was firm and fibrous, while the recurrent growth con- 
tained a considerable number of spindle-shaped cells, and lacked the 
firmness of the original tumor. 
'From fibrous polypi of nasal origin, the naso-pharyngeal polypus 
can generally be distinguished by attention to the following points. 
Nasal polypi are not unfrequently confined to the nasal cavity, and 
at a comparatively early period cause deformity by pressure on the 
nasal and other bones of the face. If, in a suspected case, on digi- 
tal examination, the pharynx is found free, the existence of naso- 
pharyngeal polypus is disproved. But the converse of this proposi- 
tion is not true. A tumor occupying the pharynx may be of pharyn- 
geal origin, and this is likely to be the case if it is of large size, and 
the nasal cavities are comparatively unobstructed. Yet a tumor of 
nasal origin may undoubtedly grow backwards into the pharynx. 
In such a case, digital exploration would be important; and the fin- 
ger, introduced into the pharynx above the soft palate, might trace 
the pedicle, if of nasal origin, into one of the nasal cavities ; or if the 
polypus be naso-pharyngeal, but attached to the edges of the poste- 
rior nares, the seat of attachment might then be determined. It has 
been stated, however, that in the great majority of cases of naso- 
pharyngeal polypi, the pedicle springs from the base of the cranium, 
either from the occipital or sphenoid bone. Now I have satisfied my- 
self that this attachment, when it exists, can be plainly felt with the 
tip of the finger, which, when passed upward along the smooth pos- 
terior surface of the tumor, meets with no resistance until it reaches 
the pedicle, when it is suddenly and completely arrested. In my 
own case, I experienced no difficulty in tracing, with my forefinger, 
the inferior and lateral surfaces of the pedicle; its superior surface 
although free, was beyond my reach. I lay stress upon this means of 
diagnosis, because the evidence which it affords is conclusive, and 
because it has received little attention from surgical writers. Indeed, 
many authors deny that there is any diagnostic sign which can indi- 
cate the attachment of a pharyngeal tumor to the base of the skull. 
An examination of the parts on the cadaver will convince any one 
that this opinion is incorrect. The finger can be carried quite to 
the summit of the pharynx, and the pedicle of a tumor occupying 
this situation cannot fail to be recognized. 
4. Treatment.—The treatment of the disease is simple in principle, 
and consists in the removal of the morbid growth. If this can be 
thoroughly accomplished, the cure is likely to be permanent. 
The different modes of treatment are numerous, and much discus- 
sion has taken place respecting their comparative value. They may 
be briefly stated as follows :— ON NASO-PHARYNGEAL POLYPI. 
501 
i st. Avulsion or laceration. 
2d. Ligature. 
3d. Galvano-caustic ligature. 
4th. Caustics. 
5 th. Electrolysis. 
6th. Removal by excision, or otherwise, after some preliminary 
operation. 
It is not my intention to describe minutely these various methods, 
but to indicate their relative safety and efficiency. 
Naso-pharyngeal polypi may sometimes be treated successfully 
by avulsion, and this method is advocated by Schuh.* If the ped- 
icle is quite narrow, and springs either from the posterior edge of the 
vomer, or any other part of the boundaries of the posterior nares, it 
may be seized with a pair of curved polypus forceps, and extracted 
through the mouth. But cases suitable for such an operation are 
rare ; and in most instances the attempt to extract the polypus by 
the forceps fails. Neither is the operation free from danger, f Du- 
puytren once tried to extract a polypus with the forceps. He suc- 
ceeded in removing only a few fragments, and the operation was 
attended with copious hemorrhage. On the following morning the 
patient was found dead in his bed. The cause of death was. not 
satisfactorily made out at the autopsy, but was suspected to be 
hemorrhage. 
Mr. J. Cooper Forster J recently attempted the same operation. 
Profuse bleeding occurred at the time; and subsequently headache, 
aphasia, and convulsions followed,—the patient dying on the twelfth 
day. On post-mortem examination it was discovered that the cribri- 
form plate of the ethmoid bone had been fractured, the fracture 
having been doubtless caused by the act of avulsion. It is clear, 
therefore, that this operation, which is so successful in the treatment 
of the. ordinary nasal polypus, has but a very limited application to 
the disease under consideration, and should be restricted' to the 
class of cases above mentioned. 
Closely resembling the treatment by avulsion, is a plan proposed 
by Guerin,§ which he followed with success in a single case, and 
which he unwisely recommends for general adoption. It consists in 
putting the forefinger of the left hand in contact with the pedicle 
behind the soft palate, while with the right hand the tumor is torn 
from its attachments to the bones of the skull by means of a raspa- 
* Wiener Med. Wochenschrift, 1865, p. 99. 
t Brosse, Rust’s Magazine, vol. vii., p. 236. 
t Transactions of Clinical Soc. of London, vo!. iv., 1871. 
§ Gazette des Hopitaux, 1865, p. 144. 502 
H. B. SANDS. 
torium introduced through the nose. It is hardly necessary to re- 
mark that this mode of operation is exceedingly rude and uncertain, 
and that it would be impossible to carry it into execution, unless the 
pedicle were exceptionally narrow. Even if the surgeon succeeded 
in detaching the tumor, a portion of the pedicle would still remain, 
and the morbid growth would, in all probability, soon be reproduced. 
Guerin’s case was reported very soon after the operation, and the 
ultimate result is not known. 
The ligature has been employed successfully in a few cases, and 
may be applied in the following manner. The pedicle of the tumor 
having been surrounded by a loop of strong silk or whipcord, both 
ends of the ligature are brought out through the nostril. A double 
silver canula is then made to glide over the threads, through the nose, 
and when it has come into contact with the pedicle, the ligature is 
drawn tightly at its opposite extremity. Ulceration of the pedicle 
gradually takes place, and the tumor finally sloughs off and is with- 
drawn through the mouth. This mode of operation can be adopted 
only when the pedicle is small, and the tumor has not become ad- 
herent to the posterior border of the septum. In the latter case it 
would be impracticable, as also in cases where the tumor had insinu- 
ated itself among the bones of the face. The operation has been 
performed a number of times with success ; and although a portion 
of the pedicle is left behind, reproduction does not inevitably follow. 
Michaux* reports a case in which six years elapsed after such an 
operation, without recurrence, and Robert f affirms that the portion 
of the pedicle which remains after the use of the ligature undergoes 
atrophy. On the other hand, the tumor is apt to return ; nor is this 
the only objection to the ligature. It has often caused death, and 
the fatal event may happen in various ways. Gunther J relates the 
case of a man who was found dead several days after the application 
of the ligature. On examination, it was ascertained that the polypus 
had been detached by ulceration, and had fallen against the superior 
aperture of the larynx, producing death by suffocation. (Edema of 
the larynx, and pyaemia, have led to the fatal result in other cases. 
Even when the patient escapes with his life, his sufferings are extreme. 
Winter § operated by the ligature on a woman twenty-one years of age. 
On the fifth day, the putrid odor of the tumor was insufferable. On 
the seventh day, respiration and deglutition became so greatly em- 
barrassed, that the surgeon was obliged to seize the growth and com- 
* Schmidt’s Jahrbiicher. Vol. cxxxiv., p. 311. 
t Conferences Chirurgicales. 
t Operationen am Halse, p. 313. 
§ Chiron von Siebold, Bafid iii., St. 2, p. 327. ON NASO-PHARYNGEAL POLYPI. 
503 
plete its detachment by avulsion. The patient recovered. In view 
of these facts, I think that the use of the ligature should be aban- 
doned. 
Certain modifications of the ligature are more deserving of appro- 
bation. The galvano-caustic ligature,* the ecraseur,f and the chain- 
saw J have-all effected the removal of the tumor, and have the 
great advantage over the ordinary ligature, of causing separation of 
the growth at the time of the operation. 
These methods, however, are liable to many of the objections that 
apply to the ligature, and can never be depended on to secure a radi- 
cal extirpation of the morbid growth. 
The use of caustics needs only to be mentioned to be condemned. 
The deep situation of a naso-pharyngeal polypus, and its proximity 
to the larynx, render the application of escharotics both difficult and 
dangerous. The actual cautery, chloride of zinc, caustic potash, and 
the perchloride of iron have all been tried, but with very indifferent 
success. The destruction of the. tumor hardly keeps pace with its 
growth, and the surgeon is at last compelled to practise excision, after 
much trouble and loss of time. 
What has been said respecting the various methods of treatment 
thus far described, is intended to apply to them only when they are 
employed alone. We shall see that, when the tumor has been excised 
according to some one of the plans presently to be mentioned; the use 
of caustics, or the actual cautery, may render valuable aid in destroy- 
ing the last remnants of the morbid growth. The same remark ap- 
plies to the treatment by electrolysis, which is valuable only as an 
auxiliary. Cases are reported, it is true, in which polypi have been 
got rid of by this means. But the process is tedious, laborious, and 
uncertain. The destruction of tissue is effected very slowly, and in 
one case, reported as successful, no less than 130 sittings were required 
to effect a cure.§ I believe that the treatment by this method would 
nearly always fail in removing a large polypus, while a small one could 
be removed more readily and safely by the galvano-caustic ligature or 
the ecraseur. After the tumor has been excised, however, the stump 
of the pedicle might doubtless be treated with success by electrolysis. 
I am satisfied that neither in the removal of large naso-pharyngeal 
polypi, nor of any other large tumor, excepting perhaps one composed 
of erectile' tissue, can electrolysis be accepted as a substitute foi 
the knife; and I believe that the claims which have been put for- 
* Middeldorpff, Galvanocaustik, p. 152. 
t Chassaignac, Traite de l’ecrasement lineaire. 
X Deroubaix. Presse med. 1864. No. xvi. 
§ Von Bruns, Galvano-chirurgie, p. 86. 504 
H. B. SANDS. 
ward in favor of this method of treating tumors are extravagant and 
unfounded. 
The last procedures to be described are those that contemplate the 
extirpation of the tumor, after a preliminary operation has been re- 
sorted to for the purpose of rendering it accessible. The tumor may 
be exposed, either by an operation practised through the mouth, or 
by resection of some one or more of the bones of the face. The re- 
section may also be either permanent or temporary ;—that is to say, 
Fig. 1. 
LINE OF 
SECTION. 
the excised portions of bone may be removed altogether, or they may 
be replaced after the extirpation of the tumor. In the latter case, the 
operation is denominated osteo-plastic. 
Operations through the mouth are of ancient origin, but have been 
revived in modern times by Manne (1717), and more recently by 
Nelaton, their strongest advocate. They consist in laying bare the 
polypus, either by making a longitudinal slit in the soft palate, or by 
completely dividing the latter, or by adding to this procedure division 
or excision of the hard palate. The tumor having been thus exposed, 
it is seized and removed, after its pedicle has been divided, either 
with the knife, the scissors, the ec.raseur, or the galvano-caustic liga- 
ture. Should the removal of the tumor be satisfactorily accomplished, 
the wound in the palate may be closed at once by sutures; if any portion ON NASO-PHARYNGEAL POLYPI. 
505 
of the tumor is left behind and requires subsequent treatment, the 
wound must be united at a later period by staphyloraphy. 
The facial methods of operation embrace, 1st, Excision, partial or 
total, of the upper jaw ; 2d, Various osteo-plastic operations. 
Total excision of the upper jaw was recommended, and practised 
with success in 1840, by Flaubert,* of Rouen. Syine is said to have 
done the operation in 1832, but I have failed to find anything except 
a bare allusion to the operation in the Edinburgh Medical Journal. 
It is unnecessary to describe the steps of the operation, which are 
the same as when the excision is performed for disease of the maxilla 
itself. The jaw having been removed, the tumor is then extirpated, 
and its pedicle destroyed, if possible, by cutting or scraping, or by the 
Fig. 2. 
■ LINE OF SECTION. 
use of caustics, or the actual cautery. This operation has been re- 
peatedly done on the European continent, and is highly praised by 
Michaux, Robert, and others. It will be convenient to defer the 
discussion of its merits until the remaining methods have been 
described. 
Partial excision of the upper jaw for the removal of a naso pharyn- 
geal polypus was first practised by Maisonneuve, in i860, and is thus 
described by him f (Figs. 1 and 2): “ If the patient’s mouth is large, no 
* Schmidt’s Jahrbiicher, vol. xxx., p 63. 
t Gazette des Hopitaux, 98, i860. 506 
H. B. SANDS. 
external incision is necessary. In other cases the upper lip on the 
affected side is divided from its free edge upwards into the nostril; the 
external and anterior surface of the upper jaw is laid bare by division 
of the soft parts of the cheek ; the mucous membrane of the hard 
palate is divided by an incision from behind forward, in the median 
line, and the soft palate cut transversely from its attachment to the 
palate bone.” 
“A stout pair of straight-edged bone-forceps is now employed. 
One blade having been introduced into the nose, and the other into 
the mouth, the alveolar process and hard palate are divided. One 
blade of the forceps still remaining in the nose, the other blade is ap- 
plied to the external surface of the jaw, and a horizontal section is 
Fig. 3. 
made of the -latter, beneath the malar tuberosity. Simple depression 
now suffices to remove the bony fragment, which contains the pala- 
tine processes, the alveolar process, and nearly the entire pterygoid 
process.” The subsequent steps of the operation consist in extir- 
pating the polypus by one of the methods already mentioned. 
Maisonneuve’s operation was successful, and has frequently been 
performed by himself and others. 
Five osteo-plastic methods deserve a brief description, namely, 
two devised by Langenbeck, one by Huguier, one by Roux, and one 
by Dr. Cheever, of Boston. ON NASO-PHARYNGEAL POLYPI. 
507 
One of Langenbeck’s methods (Fig. 3) aims at reaching the pedicle 
through an opening made in the nose. After suitable incisions 
through the soft parts, the nasal bone and' the nasal process of the 
affected side are turned upward and outward, but are not detached, 
being left connected with the frontal bone by bands of periosteum 
and mucous membrane. The polypus having been removed, the dis- 
placed bones are restored to their proper position, and the external 
wound is closed by sutures. This operation has been done with suc- 
cess both by Langenbeck and others. 
Fig. #. 
LINE OF 
SECTION. 
Langenbeck’s second mode of osteo-plastic resection (Figs. 4 and 5) 
was devised and first performed for the removal of a polypus originating 
in the pterygo-maxillary fossa; but was afterward done with success 
by the same operator for a naso-pharyngeal polypus. It was exe- 
cuted as follows :—“ A curved incision, with its convexity downward, 
was made from the ala nasi to the middle of the zygomatic arch ; 
another incision extended from the nasal process of the os frontis, 
along the inferior margin of the orbit, until it met the outer extrem- 
ity of the first one. Without raising the skin from the subjacent 
soft parts, the periosteum of the upper jaw was divided in the line of 
the lower incision, and the masseter muscle separated from the infe- 
rior edge of the zygoma. The mouth having been widely opened, a 
straight, narrow, probe-pointed' saw was passed into the pharynx 508 
H. B. SANDS. 
through the spheno-palatine foramen, and the jaw divided completely 
by a horizontal cut from behind forward, while the forefinger, intro- 
duced into the pharynx through the mouth, protected the septum 
nasi from injury with the tip of the saw. The upper incision was 
now carried down to the bone and into the orbit, and the soft parts 
divided in the angle between the frontal and temporal processes of the 
malar bone. A second cut was next made with the saw from below 
upwards, through the zygomatic process of the temporal and the 
frontal process of the malar bone, into the spheno-maxillary fissure ; 
and thence through the orbital plate of the superior maxilla as far 
as its line of junction with the lachrymal bone.’ The resected por- 
Fig. 5. 
UHL OF SECTIONS 
tion of the superior maxilla was then left connected only with the nasal 
bone, and the nasal process of the frontal bone, by means of its nasal 
process. Over this bridge of bone, intended for the nutrition of the 
resected portion, the soft parts, including the skin, were left intact, 
and likewise the hard palate and alveola process were left uninjured. 
The resected piece was now raised upward and inward by an ele- 
vator, and was made to move like a hinge upon its attachments to 
the nasal bone and nasal process of the frontal.” This manoeuvre 
at once rendered accessible the pterygo-maxillary fossa, and gave ON NASO-PHARYNGEAL POLYPI. 
509 
sufficient space for the extraction of the polypus. The resected 
bone was then replaced, and the soft parts were united by wire 
sutures. The patient recovered, and bony union was thought to have 
taken place on the eighteenth day after the operation. 
Huguier* (Figs. 6, 7, and 8) proposed the following osteo-plastic 
method, and operated once with success. A transverse incision having 
separated the soft from the hard palate on the affected side, a ligature 
was introduced by means of a Belloc’s canula through the nose, and 
next through the slit in the soft palate, and then out of the mouth. 
This ligature was afterward used to make traction upon the resected 
maxilla. An incision then divided the cheek from the angle of the 
mouth to the anterior border of the masseter muscle. Another in- 
cision commenced at the side of the nose, midway between the ala 
nasi and the inner canthus, and extended round the ala nasi to the 
median line, and thence in the labial furrow through the entire thick- 
ness of the upper lip. The triangular flap thus indicated was raised 
from the superior maxilla, and turned upward and outward. The 
bone was then divided horizontally by the saw, the cut commencing 
just above the maxillary tuberosity, and terminating above the floor 
of the nares. The central incisor tooth on the affected side having 
been drawn, the hard palate was grooved, but not divided, with the 
saw, in the longitudinal direction, close to the septum. Next, the 
base of the pterygoid process was severed by strong bone forceps, 
thereby leaving the under part of the superior maxilla separated 
from the rest of the facial bones, and held only by the mucous 
membrane of the soft palate and alveolar process. By employing a 
chisel as a lever, and by making traction with the ligature at first 
introduced, the jaw was luxated downward and toward the median 
line. Through the opening thus afforded, the pharynx was exposed, 
and a large polypus, attached to the basilar process, the posterior 
surface of the pharynx, and the base of the pterygoid process, was 
removed. Its removal was effected partly with a sharp-edged metal- 
lic spoon, and partly with a curved scissors. The hemorrhage was 
alarming, and occasioned syncope. It was arrested with the actual 
cautery. The jaw was then replaced, and the external wound closed. 
Considerable difficulty was experienced in keeping the resected bone 
in position, and eight months after the operation, when the patient was 
exhibited before the Paris Academy of Medicine, the fragment was 
still movable, bony union not having, taken place. Meanwhile, 
necrosis had occurred, and a sequestrum was removed 2\ ctms. long 
and \\ ctm. wide. 
VOL. I. 2Q 
* Bulletin de l’Acad. de Mdd., 1860, p. 783. 510 
H. B. SANDS. 
Fig. 6. 
LINE OF section; 
Fig. 7 
LINE OF | 
COMPLETE SECTION] 
OF PARTIAL SECTION. ON NASO-PHARYNGEAL POLYPI. 
511 
An operation essentially the same as Huguier’s, was performed in 
the Boston City Hospital, in 1867, by Prof. Cheever.* In this case, 
however, the pterygoid process was not divided, and but one external 
incision was made, extending downward along the side of the nose to 
the angle of the mouth. The patient made a prompt recovery, but 
the tumor recurred ; and, eleven months later, a second operation was 
performed, the steps of which were identical with those of the first. 
After both operations, bony union of the resected maxilla took 
place. 
Roux’s f operation (Figs. 9 and 10) involves the resection of the 
Fio. a. 
LINE OF SECTION. 
superior maxillary and malar bones in a single piece, which is displaced 
upwards and outwards. It is described by Roux as consisting of five 
steps, as follows : 
1. A transverse incision, i ctm. long, is carried through the soft 
parts covering the frontal process of the malar bone. With a chisel 
and hammer, or chain-saw, the bone is divided in the line of the tem- 
poro-malar suture. 
2. A vertical incision, i ctm. long, is made over the zygomatic 
arch, and the bone is divided either with the saw or the chisel. 
* Medical and Surgical Reports of Boston City Hospital, 1870, p. 156. 
+ Gazette des Hopitaux, 1861, p. 354. 512 
H. B. SANDS. 
Fig. 9. 
LINE OF SECTION. 
Fig. 10. 
LINE OF SECTION. ON NASO-PHARYNGEAL POLYPI. 
513 
3. An incision is commenced below the inner canthus, and carried 
down along the ala nasi into the nostril, and thence to the median 
line, and downward through the entire thickness of the upper lip. 
The nasal process of the superior maxilla, and’ the inner wall of the 
orbit, are divided with the chain-saw or chisel at the level of the 
inner canthus. 
4. The connection of the maxilla with the pterygoid process is 
destroyed by the chisel and hammer, the former being introduced 
just behind the last molar tooth, where the superior maxillary, sphe- 
noid, and palate bones meet. 
5. The soft palate having been separated from the hard palate 
on the alfected side, and the central incisor of the same side having 
been removed, the hard palate and alveolar process are divided 
with a chain-saw close to the median line. 
The maxillary and malar bones, covered by their soft parts, are 
now forced upward and outward, until the interval between the two 
superior maxillary bones is wide enough to permit access to the 
pharynx. Should the space be found insufficient, Roux recommends 
that the operation be done on both sides. The tumor having been 
removed, the parts are to be brought together and maintained in ap- 
position in the usual manner. I am not aware that Roux’s operation 
* has ever been performe'd upon the living subject. 
Lastly, Dr. Cheever, of Boston,* performed an osteo-plastic resec- 
• tion of both superior maxillae, for the removal of a naso-pharyngeal 
tumor of unusual size. The operation is thus described :—■“ The 
primary incision through the soft parts was on either side of the nose, 
along the natural wrinkle from near the inner canthus, around the 
alae, and through the commissure of the myrtiform fossa of the lips. 
The flaps were freely reflected, so as to expose the bone beneath as 
far upward as the malar prominences. With a narrow saw the 
body of the bone was divided from the tuberosity, forward, beneath 
the zygoma, on each side with the middle meatus. The septum nasi 
and the vomer were divided with strong scissors. Nothing but the 
posterior attachments of the upper maxillae now prevented their de- 
pression ; and, hinging on the pterygoid processes, the upper jaw was 
brought down so as to expose the tumor. Its attachments were 
found to be to the body of the sphenoid bone, and to the ethmoid. 
These attachments, except the first, were divided by the finger, and 
a section of the growth was made by means of scissors as near the 
sphenoid bone as possible, the mass being too large to deliver alto- 
gether. With a gouge chisel the remaining portion was scraped 
* Medical and Surgical Reports of Boston City Hospital, 1870, p. 164. 514 
H. B. SANDS. 
away and removed. The whole growth was in size and shape like 
a large lemon. The depressed jaw was returned to its position, and 
retained firmly by silver wire passed on each side through the malar 
bones. The soft parts were opposed by silk sutures : and the whole 
physiognomy perfectly reinstated.” 
Dr. Cheever’s patient never fairly rallied from the shock of the op- 
eration, and died on the fifth day. Several other osteo-plastic opera- 
tions have been devised and executed, but I have referred to all that 
possess any special interest or importance. 
In discussing the relative value of the various preliminary opera- 
tions which have been recommended for the extirpation of naso- 
pharyngeal polypi, it may be assumed that, in the great majority of 
cases, some such procedure is necessary. That one will also be the 
best which enables the operator to gain access to the tumor with the 
least amount of mutilation, and of danger to the patient. It is highly 
important, however, that the exposure of the pedicle should be satis- 
factory, otherwise the tumor cannot be entirely removed. 
Operations through the mouth have the advantage of avoiding mu- 
tilation of the face, the features being left untouched. Nor can it be 
denied that such operations have sometimes been done with gratify- 
ing success. If the pedicle is narrow, and its situation of attachment 
central, it may be dealt with thoroughly after simple section of the 
soft palate ; and its attachment having been destroyed the wound in 
the palate may be closed at once by sutures, with every probability 
of securing primary union. But it must be confessed that the opera- 
tion can rarely be conducted in the manner described; and the pub- 
lished cases prove that it has generally been found impracticable to 
destroy the pedicle so completely as to warrant the immediate clos- 
ure of the wound in the palate. Accordingly, it is the practice of 
many surgeons to leave the wound open until the pedicle has been 
removed by some subsequent procedure, and afterwards to restore the 
palate by staphyloraphy. These facts alone prove that the method 
now under consideration does n<3t afford the space requisite for the 
removal of a tumor having extensive attachments, and that in this re- 
spect it must be rejected as defective. Moreover, it is by no means 
easy to destroy the pedicle afterward, and for similar reasons. The 
actual cautery, and various caustic applications, have been employed 
for this purpose. In many instances the pedicle has continued to in- 
crease in size in spite of the treatment, and the surgeon has been fin- 
ally driven to the alternative of excision of the jaw to gain the desired 
end. Furthermore, the irritation and suppuration induced by the re- 
peated application of caustics are exceedingly annoying, and often 
dangerous, to the patient. Indeed, it has been ascertained that fatal ON NASO-PHARYNGEAL POLYPI. 
515 
results have more frequently followed operations through the mouth 
than those of apparently greater magnitude, so that the former oper- 
ations cannot, as a rule, be recommended either for their safety or 
certainty. They avoid disfigurement, but do not guarantee success. 
Osteo-plastic resections may next be briefly considered as causing 
less deformity than ordinary excisions. Langenbeck’s first method, 
namely, that which consists in resection of the nasal bones, has been 
done several times with success, and is’adapted especially to those 
cases in which the tumor occupies the nasal cavity rather than the 
pharynx, and in which the attachments are situated pretty well for- 
ward. It certainly would not afford the facilities for reaching tumors 
which occupy the usual situation, as an examination of the cadaver 
alone will show. 1 have found that after the nasal bone and nasal 
process of the superior maxillary have been resected in the manner 
recommended, the distance of the basilar process of the occipital 
bone from the anterior opening is nearly three inches ; and although 
the boundaries of the nasal fossae would, in any given case, probably 
be dilated by the pressure of the tumor, the space thus afforded 
would rarely be found sufficient for the satisfactory manipulation of 
its pedicle. Langenbeck’s second operation, in which portions of 
the malar and superior maxillary bones are temporarily displaced, is 
admirably adapted for the removal of those polypi which originate in 
the pterygo-maxillary fossa, and it is for this purpose that it was origi- 
nally designed. I once performed the operation in such a case, and 
had no trouble in detaching the tumor. But although it has been also 
successfully done for naso-pharyngeal polypi, I think it is inferior 
to several other procedures for this purpose. The operation itself 
is difficult of execution, unless the spheno-palatine foramen is abnor- 
mally dilated ; and the pharynx is very imperfectly exposed, owing to 
the presence of the pterygoid process. These objections will be 
found, I think, to prevent the operation from being extensively 
adopted. 
Huguiers operation has been performed by its inventor, and, with 
slight modifications, by Dr. Cheever, of Boston. Both patients re- 
covered ; but one circumstance in each case deserves to be men- 
tioned. In Huguier’s case necrosis occurred, and a portion of the 
resected bone exfoliated, the remainder failing to unite by osseous 
union. In the patient treated by Dr. Cheever, the tumor recurred 
within a year after its removal, and resection had to be performed a 
second time in order to expose it. These facts constitute objections 
to the operation ; and the liability to recurrence of the disease after 
removal offers a strong argument against osteo-plastic operations 
generally. 516 
H. B. SANDS. 
I have tried Roux’s operation on the cadaver, but do not feel dis- 
posed to perform it on the living subject. It involves great mutila- 
tion of the facial bones, and does not afford satisfactory access to the 
pharynx. To expose a tumor having a broad attachment, it would 
be necessary to displace the maxillary and malar bones on both sides 
of the face, thereby greatly increasing the risks of the operation. 
Cheever’s operation is ingenious, and is not, I should judge, very 
difficult of execution. Although it terminated fatally in the single 
instance in which it has been performed, I agree with Dr. Cheever 
in thinking that there is no danger inherent in the operation that 
ought to prevent its repetition. 
Finally, let us endeavor to determine the value of ordinary exci- 
sion of the upper jaw, either partial or total, as a preliminary opera- 
tion. It may be remarked, in passing, that excisions of the upper 
jaw are, as a class, remarkably successful operations. The objections 
that apply to them are mainly owing to the disfigurement which they 
produce. We shall have occasion presently to see that this objection 
is almost groundless, so far as the operation of partial excision is con- 
cerned. In the next place, it maybe stated that excision of the jaw 
affords easier access to the pharynx than any of the other methods, 
k and thus enables the operator to attack the pedicle with the maximum 
chances of success. Accordingly, the probability of a recurrence 
will be correspondingly diminished. Neither the operations through 
the mouth, nor any of the osteo-plastic procedures which have been 
described, permit that satisfactory exposure of the base of the skull 
which is afforded either by partial or total resection of the superior max- 
illa ; and it must be evident, from what I have already said, that am- 
ple space is necessary, both for the thorough extirpation of the tumor, 
and for the prompt arrest of the hemorrhage that so often accompa- 
nies its removal. 
Another advantage of ordinary excision is, that a wide gap is left 
after the operation, through which the disease, when it recurs, can be 
readily recognized and treated. After an osteo-plastic operation, on 
.the contrary, the recurrence is not so easily detected; and, when it 
does take place, the entire operation must be repeated. This latter 
fact establishes an objection to osteo-plastic operations, which is not 
outweighed, in my opinion, by any of their alleged advantages. 
It remains to be ascertained, whether partial excision of the jaw, 
according to the plan devised by Maisonneuve, will not fulfil all the 
indications presented; and I believe that, in most cases, this ques- 
tion may be answered affirmatively. In the patient now exhibited to 
the Society, I removed, after partial excision, a polypus of large size 
and extensive attachments. Partial excision affords an excellent view ON NASO-PHARYNGEAL POLYPI. 
517 
of the pharynx, and leaves the patient with very slight external dis- 
figurement. The orbital plate and malar tuberosity being left intact, 
the eyeball does not descend from its normal position, and there is 
not that absence of the natural prominence of the cheek, which is 
noticed after complete excision. The skill of the dentist can readily 
imitate the lost portion of bone, and the gap in the palate can be 
closed partly by staphyloraphy, and partly by an obturator made of 
hard rubber. Of all the operations mentioned then, which are applicable 
to grave cases, I give the preference to partial excision of the upper 
jaw, as the one which is calculated to favor the complete removal of 
the tumor with the least practicable disfigurement. 
The conclusions to which I have arrived are based chiefly on the 
experience I have obtained in the treatment of the following case; 
and I may remark, finally, that operations for the removal of naso- 
pharyngeal polypi, although formidable in character, are remarkably 
successful in their results. This fact is especially gratifying, as they are 
undertaken for the cure of a disease which, if left to itself, leads in- 
evitably to a fatal termination. 
Case.—Josiah Dutcher, a farmer, aged 20, entered the Roosevelt Hospital in Oc- 
tober, 1872. He began to suffer from obstruction of the nose about a year pre- 
viously to admission ; and, six months later, noticed a swelling in the roof of the 
mouth. Ten months before admission he commenced to have attacks of hemor- 
rhage. Lately he had grown weak, and had lost flesh. When admitted, he was 
pale and anaemic. On examination' a large tumor was discovered, distending the 
pharynx, and extending downward so as to be visible below the free edge of the 
soft palate. The latter was crowded downward and forward, so that the plane of 
its surfaces was nearly vertical. The tumor was firm and elastic, and its pedicle 
could be traced to the base of the skull, where it had a broad attachment, extend- 
ing somewhat further to the right than to the left of the median line. The left 
nasal cavity readily admitted a flexible catheter backward into the pharynx ; the 
right cavity was nearly impassable. 
An operation through the mouth was performed on Oct. 17th, 1872. A longi- 
tudinal incision was made through the soft palate, just to the right of the uvula, 
extending from its free edge to a point about half an inch anterior to its line of at- 
tachment to the palate bone. A second incision, beginning where the first ended, 
was carried outward to the right alveolar border, and the flap thus mapped out, 
which included the horizontal plate of the palate bone, was reflected downward.. 
The hard palate was found in part absorbed from the pressure of the tumor. The 
latter was free from secondary adhesions, and no difficulty was encountered in sur- 
rounding the pedicle with the chain of a large ecraseur. The chain broke, and I 
then divided the pedicle, which was thick and firm, with a pair of stout scissors, 
making the section as close to the skull as possible. Copious hemorrhage immedi- 
ately followed, and much time was consumed in unsuccessful attempts to secure a 
'arge artery which had retracted to the deepest part of the wound, and which was 
inaccessible to the ligature. The bleeding finally ceased, in consequence of the 
prostration of the patient, who had several alarming attacks of syncope. It became 518 
H. B. SANDS. 
evident that the pedicle could not be satisfactorily detached at the time of the opera- 
tion, consequently the wound in the palate was left open. 
The tumor removed was firm, and distinctly fibrous. It was oval in shape and 
measured as follows; length, 2f inches; breadth, 2\ inches; thickness, i| inches. 
The surface of section of the pedicle was nearly circular, and its diameter an inch 
and a quarter. 
The patient rallied after the operation, under the influence of stimulants, and 
recovered without any bad symptoms, although he regained strength slowly, and 
remained, for several months, very pale and anaemic. Meanwhile, it was observed 
that the tumor had begun to grow again. I now decided to operate a second time, 
by making a partial excision of the jaw, and to remove the principal mass of the 
tumor with the galvano-caustic ligature. The recurrent growth had descended so 
low as to interfere considerably with respiration, and the patient was very anxious 
to get rid of it. In the mouth it presented a fungus-looking mass, extending 
forward and laterally nearly as far as the dental arch. The right nasal cavity was 
completely obstructed, and the tumor had grown firmly adherent to the posterior 
border of the septum narium. 
On May ioth the patient was etherized, and I operated as follows : With a 
scalpel, the tissues of the face were divided down to the bone, along a line extend- 
ing from just below the right inner canthus downward beside the nose and around 
its right ala into the opening of the nostril; thence along the junction of skin and 
mucous membrane to the middle line, and along the latter to the free margin of 
the upper lip, the latter being completely divided. 
The flap thus marked out was reflected upward and outward sufficiently to admit 
of the next step of the operation, as follows :— 
With a straight, narrow, button-pointed saw, known as Langenbeck’s, the malar 
process of the upper jaw-bone was divided upward and inward (the right central 
incisor having first been drawn), and into the upper end of the saw-cut a trephine 
centre-pin was entered, and a circular hole made into the antrum, to admit one 
blade of a large cutting bone-forceps, the other blade being passed into the inferior 
meatus of the nose. 
With this instrument, thus entered, the section of the front and inner walls of 
the antrum was completed. With the same instrument the hard palate was divi- 
ded on the right side, close to the septum. The soft palate was then separated 
with scissors curved on the flat, from the hard palate, and the detachment of the 
lower part of the upper jaw completed by grasping it with Fergusson’s lion-toothed 
forceps, and wrenching it away, the lower part of the pterygoid process coming 
with it. The inferior turbinated bone, which projected into the cavity thus left, 
was pulled away, and ready access to the tumor was then obtained. 
The tumor was found, like its predecessor, to be attached to the basilar process 
of the occipital, and the body of the sphenoid bone, and was adherent to the pos- 
terior free margin of the septum and hard palate, and to the right pterygoid pro- 
cess. 
The palatal and pterygoid processes, and the vomer, were all thinned, and in 
parts absorbed. 
The connections of the tumor with the septum, hard palate, and pterygoid plate 
were first divided, partly with the scissors and partly with the finger, a very large 
part of the septum, and nearly all the remains of the hard palate, being removed 
by the process. 
The pedicle, which was very broad, was then surrounded, near the base of the ON NASO-PHARYNGEAL POLYPI. 
519 
skull, with a loop of platinum wire, and the latter connected with from two to 
three cells of a Grove’s battery, the larynx and pharynx being protected by wet 
sponges from the leakage of heated fluids. The tumor was divided by thegalvano- 
caustic wire in six minutes, without the least hemorrhage. 
Examination now showed a considerable portion of the pedicle still remain- 
ing, and to this the galvano-caustic loop was again applied. Other smaller 
portions were removed with the fingers, aided by a large rugine, and the last piece 
left, in part, with scissors. The use of the latter was followed by a certain 
amount of bleeding, soon checked by the application to the stump of thegalvano- 
cautery, and the persulphate of iron, aided by pressure, and by the ligation of an 
artery in the pterygoid fossa. 
After all had been removed of the tumor that could be, a small prolongation of 
it was discovered running into the sphenoidal cells; and this I deemed it imprudent 
to attack. 
The flap of soft tissues was now replaced in position, and secured by one 
twisted and a number of interrupted sutures of silver and fine silk. 
Very little blood was lost during the operation, which lasted at least two hours, 
nor did what was lost penetrate the glottis to any dangerous degree. 
The patient’s pulse continued good throughout the operation, and at its end was 
less than 100. He bore etherization perfectly, and had no asphyxial symptoms from 
any cause. The great comparative ease and safety of operation resulting from the 
use of the galvano-caustic wire is thus forcibly illustrated. 
The tumor removed by this second operation consisted of one larger and one 
smaller piece, and of a number of fragments. The larger piece was 2§ inches long 
by i$ broad; the smaller, i£ inches by i-J. The surface of section left on the 
larger piece after the use of the hot wire was i j inches across. 
Microscopic examination showed the tumor to be essentially fibrous, the bundles 
of fibrous tissue being mingled with a certain amount of young cells, which were 
especially numerous beneath that point on the free surface of tire growth from 
which the first tumor had been removed. 
The patient recovered rapidly after the operation, and was allowed to sit up on 
the ninth day, union by adhesion having taken place throughout the entire extent 
of the external wound. He is now exhibited before the Society, to show how 
little disfigurement has resulted from the operation. 
At the present date, Feb. 1st, 1873, t^ie patient remains quite well, no recur- 
rence having taken place. 
Note.—lam indebted to my friend Dr. J. G. Curtis for the woodcuts accompanying this pa- 
per. With the exception of Fig. 3, they are all original. 
The accompanying photograph in which the parts are seen reversed, was taken two months after 
the second operation. No artificial contrivance had yet been made to replace the lost bone and 
teeth. ARCHIVES 
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The annual subscription price will be Four Dollars, to be paid in full, in 
advance. It is designed soon to confine the circulation to yearly subscribers only ; 
the first numbers, however, will be sold separately at fifty cents a copy. 
Papers by the Editor, on the following subjects, will appear in rapid suc- 
cession : 
On Asphyxia, Syncope, and Collapse. 
Ear Affections, and their Relations with Brain Disease. 
Mechanism of Production of Symptoms in Diseases of the Brain. 
Morbid Influences of the Nervous System on Organic Functions. 
Physiological and Pathological Proofs of Attraction M Blood by Tissues. 
Amaurosis and Deafness in Diseases of the Brain. 
Rational Treatment of Poisoning by Organic Substances. 
On the Various Kinds of Hemiplegia. 
On Counter-Irritation: Its Importance and Rational Use. 
Physiology and Pathology of Epileptiform Affections. 
On.Pneumonia and other Lung Affections in Diseases of the Brain. 
On Reflex Paralysis and other Affections produced by a Reflex Influence. 
Analogies and Differences between several Remedies (Belladonna, Digitalis, the 
Ergot of Rye, and the various Bromides). 
Artificial Epilepsy in Animals, and what it Teaches for the Treatment of Epilepsy 
in Man. 
On Transfusion of Blood : New Methods and Proper Conditions for its Use. 
On Differences between Americans and Europeans, as regards Diseases and Povvet 
of Resisting Injuries.