A Remarkable Case of Fibro- Chondroma of Branchial Origin (Pharyngeal Teratoma) Removed from the Throat of an Infant Six Weeks Old. BY A. W. de EOALDES, M. D., Surgeon-in-Chief of the Eye, Ear, Nose, and Throat Hospital (New Orleans); Professor of Laryngology, Rhinology, and Otology in the N. O. Polyclinic School of Medicine ; Second Vice- President of the American Laryngological Association, etc., etc. REPRINTED PROM THE Meta ¥axk JtteMcal Journal for February 6, 1897. Reprinted from the New Yorlc Medical Journal for February 6, 1897. A REMARKABLE CASE OF FIBRO-CHONDROMA OF BRANCHIAL ORIGIN (PHARYNGEAL TERATOMA) REMOVED FROM THE THROAT OF AN INFANT SIX WEEKS OLD * By A. W. de ROALDES, M. D., NEW ORLEANS. The specimen which I exhibit to you, in connection with the accompanying photographs and cuts, was re- moved a few days ago from the throat of an infant child six weeks old. The history of the case is as follows: H. J. H., male, aged six weeks, horn in New Orleans, was presented hy his mother at the outdoor clinic of the Eye, Ear, Nose, and Throat Hospital of this city, recom- mended by the family physician, Dr. Lovell. The ex- amining surgeon, Dr. A. McShane, recognizing at once an unusual pharyngeal growth, called my attention to the case. The mother relates that almost immediately after birth the child was heard to produce “ a queer noise ” while breathing. When put to the breast, it could not nurse and seemed to strangle, this condition continuing until now. The bad suffocating spells did * Read before the American Laryngological Association at its eight- eenth annual congress. Copyright, 1897, by D. Appleton and Company. 2 FIBRO-CIIONDROMA OF BRANCHIAL ORIGIN. not, however, recur more than once or twice a week. They were at first ascribed to great accumulation of phlegm in the throat and bronchial tubes, then to a had attack of spasmodic croup. A few days ago another very violent attack led Dr. Lovell to examine closely into the case, when he diagnosticated the presence of a growth, and advised the parents to bring the child to our clinic. The parents are almost pure German, of ordinary men- tality and good apparent habits. The father is aged twenty-eight years and the mother twenty-six. There is no history of any family or hereditary deformity as far hack as they can go, and no reason to allege any ma- ternal impression during pregnancy. The child is of ordinary weight; the closest investigation fails to re- veal any congenital defect beyond the growth just re- ferred to. Its ears are perfect in every respect. Upon opening the mouth widely and depressing the tongue nothing very striking is observed at first; but, when the infant begins to cry, a movable growth, hidden in the postnasal space, is seen to emerge imperfectly from behind the soft palate and place itself in what I would call first position. With a continuation of the excite- ment the growth is apt to fall lower down into the phar- ynx, as far down as the vestibule of the larynx, in its second position. Gradually, after spells of coughing and successive efforts of violent expiration, the tumor is apt to recede back into the nasopharynx or to place itself on the base of the tongue, which finally propels it forward on its dorsum in its third position (as rep- resented in Fig. 1), with its lobule pointing forward on the middle line, giving the appearance at first sight of a supernumerary tongue, with the exception of its integument, which is decidedly cutaneous instead of mucous. From its third position, the tumor soon rotates around a marked point of attachment and places itself in the fourth position (as represented in Fig. 2), with an apparent size comparable to the last joint of the thumb of an adult hand. In this final posi- tion the growth reached fully the alveolar border of the superior maxilla. Upon introducing my little finger be- FIBRO-CHONDROMA OF BRANCHIAL ORIGIN. 3 tween the tongue and the tumor, I could feel that its lower surface presented distinctly a hardened, cartilagi- nous nucleus, and that the mass seemed to be attached to the left side of the bucco-pharyngeal cavity, but, owing to the lack of room, I could not reach farther than the fauces. The postnasal space, as ascertained with a probe through the nostrils, was found to be comparatively free, FIG. 1 FIG. 2.' no. 3 FIG.4 as compared with its fullness when the growth was in its first position. After the examination the case was re- ferred back to the next day in order to present it to my polyclinic class. On that occasion, during an attempt to show exactly the point of implantation of the growth, the little patient was seized with such a violent attack FIBR0-CH0NDROMA OF BRANCHIAL ORIGIN. of suffocation, cyanosis of the face, suffusion of the eyes, etc., that it was deemed prudent to at once extirpate the mass. For that purpose a Wright’s snare was quickly wired, and the tumor, then down to the vestibule of the larynx, was teased to place itself in its fourth positiou (Fig. 2), when it was grasped firmly with a forceps, the catch of which shows its imprint in Figs. 3 and 4. Fig. 5.—Longitudinal section of tumor, enlarged to double natural size. The wire loop was thrown over the growth, but, un- fortunately, it gave way at the eyelet, and partly con- stricted the growth, which had to be jerked away from its attachment, with scarcely any loss of blood. The respiration at once became natural. The point of im- plantation was then distinctly found in the left side at the middle part of the posterior pillar of the soft pal- ate, covering a surface of the size of a split pea. The avulsion of the pedicle was almost flush with the sur- fibro-cuondroma of branchial origin. 5 rounding parts. In order to satisfy some of my assistants, whose contention was that this raw surface might have been the result of some trauma caused by the loosened wire of the loop and my forcible evulsion of the growth, I took special pains the next day to examine under the mirror with the help of a good sunlight and of Jarvis rubber hands, passed through the nostrils and mouth and tied over the upper lip and gum. I was finally enabled to clear satisfactorily this point. The child was subsequently seen two or three times, and finally discharged in a perfect state of health. I will now add that when passed around to the class, without a word of comment on my part, the universal consensus was that the growth resembled an auricle. The appearances presented by this tumor are in- deed very remarkable, and if my researches are com- plete, certainly quite unique in shape from any endo- Fig. 6.—Microscopical appearance of ti mor. Ocular, 1 ; objective, 7. buccal or pharyngeal teratoid growth so far reported in the annals of science. As you will see by the accom- panying photographs and cuts, the morphology of the tumor plainly recalls the normal auricle even to its size, which is very nearly the same as the normal ears of the FIBRO-CIIONDROMA OF BKANCHIAL ORIGIN. patient (an inch and a half by an inch). The integument is composed of ordinary cutaneous tissue, with its epi- dermis, corium, hairy growth, and typical follicles, se- baceous glands, cartilage, etc. All these structures pre- sent but slight changes from the normal development The meatus only is missing. I deplore very much my inability to show you, as I had expected to do, the specimen itself, which, having been sent to my former distinguished teacher, Professor Lannelongue, of Paris, is now, unfortunately, detained in the New York Custom House. I will, however, read the following note, which has just reached me, from the pen of Dr. Achard, who has collaborated with Professor Lannelongue in one of the most exhaustive works on congenital affections: “ I have examined in the laboratory of Professor Lannelongue the pharyngeal tumor which you kindly sent him. In order not to spoil the specimen, I have limited myself to a few ‘ offhanded ’ sections on the cut surface of the growth. The greater mass is made up of tolerably loose connective tissue and of some adipose tissue. The fibro-cartilaginous nucleus is constituted of reticulated cartilage or elastic fihro-cartilage. The tumor approaches in character the branchial fibro-chon- droma observed by Mr. Lannelongue in the buccal cav- ity, but with this distinction that its integument is cutaneous and not mucous. “ There exists in the annals of science a small number of analogous cases. In the treatise on congenital cysts which Mr. Lannelongue and myself published in 188G we devoted a chapter to these productions, basing our description on a few observations disseminated through the whole medical literature. Since then, Messrs. Lan- nelongue and Menard, in their work on Congenital Dis- eases, 1891, page 588, have found a few more cases. Finallv, since that date I have heard of two or three more FIBRO-CHONDROMA OF BRANCHIAL ORIGIN. 7 observations. All the tumors are covered by skin, and constituted specially by connective tissue and fat. The cartilaginous nucleus is found only in Barton H. White, Arnold, Otto, and Conitzer’s cases. “ These tumors represent the simplest expression of the congenital productions known as ‘ epignath mon- sters.’ ” P. S.—Since writing the foregoing I have had occa- sion to show this interesting specimen to Dr. J. Bland Sutton, of London, the well-known authority on this subject, who was kind enough to furnish me, in a letter, with the following note: “.. . It is an example of dermoid tumor of the pharynx, and, though its shape corresponds to a badly formed pinna, the tumor can not in a true sense be de- scribed as a supernumerary auricle. “ Strictly, an auricle has a framework of yellow elas- tic cartilage, to which striped muscle fibre is attached, and the whole covered with skin. So that from an anatomical point of view the identity of this mass with an auricle fails. Dermoids of the pharynx and soft palate, like those of the rectum, appear as pedunculated skin-covered tumors, and in adults the skin is furnished with long hair. The tumor, then, does not differ from the usual kind of pharyngeal dermoid (or teratoma of many writers) except in the accidental resemblance it bears to a pinna.” 624 Gravier Street. The New York Medical Journal. A WEEKLY REVIEW GF MEDICINE. EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. Such a journal fulfills its mission—that of educator—to the highest degree, for not only does it inform its readers of all that is new in theory and practice, but, by means of its correct editing, instructs them in the very important yet much-neglected art of expressing their thoughts and ideas in a clear and correct manner. Too much stress can not be laid upon this feature, so utterly ignored by the “ average ” medical periodical. Without making invidious comparisons, it can be truthfully stated that no medical journal in this country occupies the place, in these par- ticulars, that is held by The New York Medical Journal, No other journal is edited with the care that is bestowed on this; none contains articles of such high scientific value, coming as they do from the pens of the brightest and most learned medical men of America. A glance at the list of contributors to any volume, or an examination of any issue of the Journal, will attest the truth of these statements. 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