Naso-Pharyngeal Carcinoma. 
Report of a Case, with a 
Consideration of the 
Treatment of this 
Disease. 
BY 
SIDNEY ALLAN FOf, M. D., 
SURGEON-IN-CHIKF TO THE BROOKLYN DISPENSARY FOR 
THE TRE ATMENT OF THE NOSE, THROAT, AND LUNGS. 
REPRINTED FROM 
<£!)* Ncto ITotfc fHetncal journal 
for March 8, 1890. Reprinted from the New York Medical Journal 
for March 8, 1890. 
NASO-PHAKYNGEAL CAKCINOMA. 
REPORT OF A CASE, WITH A 
CONSIDERATION OF THE TREATMENT OF THIS DISEASE.* 
By SIDNEY ALLAN FOX, M. D., 
SURGEON-IN-CHIEF TO THE BROOKLYN DISPENSARY FOR THE TREATMENT OF 
THE NOSE, THROAT, AND LUNGS. 
That carcinoma of the naso-pharynx is a rare disease 
no one familiar with the literature of the subject will deny. 
In one of the most recent works, by an eminent specialist, 
on diseases of the nose and throat, we find only six authen- 
tic cases reported, and of these only one occurred in the 
exceedingly large experience of the author. By naso- 
pharyngeal carcinoma is meant any of the three forms of 
cancer—viz., epithelioma, scirrhus, or medullary cancer— 
having its origin in the naso-pharynx. In looking up the 
subject I have consulted the following authorities—viz.: 
Boswortb, Sajous, Seiler, Browne, and Mackenzie. I find 
nothing satisfactory except in Bosworth’s book, and he de- 
votes only a single chapter of four pages and a half to this 
subject. My excuse, then—if one be needed—for report- 
ing the following case of primary naso-pharyngeal epithe- 
lioma is its rarity: 
On October 2, 1889, Mr. J. M. called upon me with the fol- 
lowing note from my esteemed friend Dr. George R. Fowler: 
* Read before the Medical Society of the State of New York at its 
eighty-fourth annual meeting. 2 
NASO-PHARYNGEAL CARCINOMA. 
“ October 2, 1889. 
“Dear Dr. Fox—This will introduce to you Mr. M., who is 
suffering from a growth in the naso-pharynx. He has been un- 
der treatment elsewhere, but, becoming discouraged, came to me 
for the purpose of obtaining my judgment as to the speediest 
way out of his troubles. . . . The evident Eustachian trouble, 
I judge, is likely to result in the loss of his position, which adds 
to his anxiety. Pray take his case under your skillful care. 
“ Very truly yours, George R. Fowler.” 
Mr. M. was forty years old, was married, and a clerk by 
occupation. He was thin, nervous, and cachectic, the face pre- 
senting a peculiar doughy or putty-like color. He stated that 
he had pain in the top of the head and also frontal headache. 
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 into the throat. His hearing 
was very much impaired, and he complained of rumbling noises 
in the ears. He was at times diplopic. The odor from the 
naso-pharynx was foetid in character, and this made the suf- 
ferer offensive to every one with whom he came in contact. 
The patient stated that he preferred death to his existing con- 
dition. An anterior rhinoscopic examination proved negative, 
but posterior rhinoscopy showed the post-nasal space plugged 
with 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 ori- 
fices. There was no evidence of external or internal glandular 
involvement. As I had never seen a case like this before, I was 
considerably puzzled. I, however, removed with the post-nasal 
cutting forceps about an ounce of the mass, and sent a specimen 
of it to Dr. Eugene Hodenpyl for microscopic examination. He 
reported as follows: 
“ Laboratory op the Alumni Association op the College 
of Physicians and Surgeons, No. 437 West Fifty- 
ninth Street, New York, October 21, 1889. 
“ Dear Doctor : I have completed the examination of the 
specimen sent me on October 17th. A considerable number of NASO-PHARYNGEAL CARCINOMA. 
3 
the larger bits of tissue are blood-clots and shreds of mucous 
membrane. There are, however, a number of whitish masses 
which present on section the characteristic picture of epithe- 
lioma. These nodules, moreover, contain a large number of 
thin-walled blood-vessels, many of which contain blood in their 
lumina. The cells in the nodule are so arranged that I can not 
entertain the possible diagnosis of leukoplakia. 
“ I am yours sincerely, Eugene Hodenpyl.” 
Realizing that I had a very serious case on hand, I consulted 
Dr. Fowler. We agreed that we would best try Annandale’s 
operation for removal of the growth. With this object in view, 
the patient was admitted to the Methodist Episcopal Hospital 
on October 24, 1889. For the following history and report of 
the case from that date I am indebted to my friend Dr. James 
S. Reeve, the house surgeon : 
Patient has enjoyed good general health, although he has 
not been robust. Family history is excellent. Patient has 
never had any very serious illness. In the winter of 1887-’88 he 
was exposed to very bad climatic influences, being out of doors 
much in cold and rainy weather. His occupation at that time 
and for some time following was such as to require him to use 
his voice a great deal. 
In November, 1888, he was much exposed to wet and cold 
weather, and this was followed by sharp pain in the ear, par- 
tial 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. In April, 1889, he overworked greatly, 
and his physical condition grew still worse. At this time he 
began to be troubled very much with headache, especially in 
the day-time. He was also troubled with the earache above 
mentioned, witli deafness, and with obstruction of the poste- 
rior nares. This has continued ever since. He has received a 
variety of treatments, including catheterization of the Eusta- 
chian tube, cauterization, etc. Examination previous to ad- 
mission had shown a neoplasm occupying the lateral pharyn- 
geal wall and naso-pharynx, blocking up more or less com- 
pletely the posterior nares. A considerable mass was removed 4 
NASO-PHARYNGEAL CARCINOMA. 
at one time, microscopic examination of which showed it to be 
an epithelioma. 
In spite of all treatment, the patient has grown steadily 
worse, and he is admitted for removal of the growth at all 
hazards. Demonstration by Dr. Fox shows a large mass of 
new growth occupying the lateral walls of the pharynx and 
the whole naso-pharynx, extending well into the posterior nares. 
October 2J^th.—Admitted to ward on full diet. 
29th.—Operation by Dr. Fowler. Annandale’s operation 
was performed, the upper lip being reflected and a separation 
of the hard palate being made by sawing from the nasal cavity. 
It was found that sufficient separation of the palate could not 
be obtained because of its very narrow and peculiarly arched 
shape. 
The soft palate being divided, the growth was removed 
with curved cutting forceps, the different portions of the growth 
being detected by the index-finger. The soft parts were sutured 
with catgut, bone wired. 
30th.—Patient has reacted excellently from the operation. 
Had no pain last night. Nose irrigated with boro-salicylic so- 
lution. 
November farinaceous diet. Nose irrigated 
daily. The odor is quite offensive. 
3d.—Allowed to sit up. 
6th.—Allowed clothes. 
10th.—Allowed restricted diet. Breathing is fairly good 
through both nares. Patient does not gain strength very rap- 
idly, but otherwise is doing well. 
llf,th.—There is considerable swelling about the eye and 
some tendency to strabismus. Nose is becoming closed, so that 
irrigation from nose into the mouth is impossible. Ordered so- 
lution of sulphate of atropine (two grains to an ounce) instilled 
into eye twice daily. 
25th.—Patient is growing steadily weaker. There are evi- 
dences of a return of the growth. Ordered chloroform lini- 
ment for back, p. r. n., for muscular pain. 
27th.—Ophthalmoscopic examination shows optic disc very 
greatly clouded except at lower and inner angle. NASO-PHARYNGEAL CARCINOMA. 
5 
December 12th.—Condition has not materially changed since 
last note. Ordered liquor potassii arsenitis, five minims, every 
night; dilute hydrochloric acid, ten minims, thrice daily. Pa- 
tient complains of insomnia. 
18th.—Mouth-wash made of solution of permanganate 
of potassium. Nose irrigated daily. Patient grows stead- 
ily weaker. Is not able to sit up. Insomnia, anorexia, and 
general depressed condition are marked. Odor of breath is 
very offensive. Diet is made as nutritious and varied as pos- 
sible. Patient does not complain greatly of actual pain. 
22d.—Ordered spiritus frumenti, half an ounce, day and 
night. Tincture of digitalis, ten minims; sulphate of atropine, 
one one hundred and fiftieth of a grain every three hours day 
and night. 
23d.—Patient has loss of power in left hand. Right side of 
face is swollen and puffy. 
2jj,th.—Failing steadily. Breathing very difficult. Pulse 
rapid. Patient semi-delirious. 
25th.—Patient sank steadily all day, and died at 8.30 
p. m. Pulse grew very rapid and feeble, but patient pre- 
sented few symptoms beyond those of general failure of vital 
powers. 
Autopsy, December 27, 1889. — Body emaciated. In and 
around the pharynx are growths of epitheliomatous character. 
Larynx, trachea, and oesophagus normal; blood-vessels of brain 
normal; oedema over convexities; pia normal. At the base of 
the skull in middle fossa is a loss of substance involving the 
body and portion of greater wing of the sphenoid bone and 
eroding the inner end of the petrous portion of the temporal, 
making an irregular opening about three inches in diameter. 
This space is distended with the broken-down tumor mass and 
clots, and leads directly into the naso-pharynx. The growth 
involves the left orbit, possibly also the right. On posterior 
surface of right lung is a little fresh fibrin ; lungs cedematous; 
heart normal; spleen enlarged. 
The report of this case is, so far as I have been able to 
ascertain, the only complete one in existence. By com- 6 
NASO-PHARYNGEAL CARCINOMA. 
plete I mean that a microscopic examination of the growth 
established the diagnosis; that then an operation was done 
to remove the growth; and that subsequently an autopsy 
was performed. 
The table of naso-pharyngeal carcinoma to date, ac- 
cording to Bosworth, to which I add my own case, is as 
follows : 
No. 1. Reported by Durand-Fardel. The diagnosis 
was not established by microscopic examination. No op- 
eration was performed, but an autopsy was held. The 
tumor is reported as one of scirrhus and was probably of 
primary origin. 
No. 2. Reported by Maisonneuve. The diagnosis was 
established; an operation was performed, but an autopsy 
was not secured. The growth was diagnosticated as being 
a carcinoma, and was probably of secondary origin. 
No. 3. Reported by Lotzbeck. The diagnosis was es- 
tablished ; operation not performed, but an autopsy was 
made. The growth is reported as carcinoma, and was 
probably of secondary origin. 
No. 4. Reported by Flour. The diagnosis was guessed 
at, for no microscopic examination was made; no operation 
was performed and no autopsy made. The growth was 
regarded as a carcinoma, and was probably of secondary 
origin. 
No. 5. Reported by Schmid. The diagnosis was made 
by microscopic examination; an operation was performed ; 
no history of an autopsy. The growth was a primary 
small-celled medullary carcinoma. 
No. 6. Reported by Bosworth. The diagnosis was es- 
tablished by the microscope ; several operations were per- 
formed, but no autopsy was made. The growth was a 
“ medullary cancer involving lymph tissue,” and was of 
primary origin. NASO-PHARYNGEAL CARCINOMA. 
7 
No. 7. Reported by Sidney Allan Fox. A microscopic 
diagnosis was made. Annandale’s operation was performed, 
and an autopsy was secured. The growth was a primary 
epithelioma. 
Prognosis.—The prognosis in such cases is, I believe, 
invariably fatal. 
Treatment.—The only treatment that should ever be 
considered in this class of cases is as follows : Generous 
diet, tonics, disinfecting and deodorizing washes to cleanse 
and remove the foetor, and a thorough removal, from time 
to time, of the growth with the post-nasal cutting forceps 
and wire snare. The operative part of the treatment can 
be rendered almost painless by the use of cocaine, and can 
be done as thoroughly and as radically, if not better, than 
can be accomplished by the numerous capital operations 
recommended and sometimes performed. The latter en- 
danger the life of the patient and cause more or less mutila- 
tion ; moreover, the loss of blood and the shock thereby 
sustained can ill be borne by the patient. REASONS WHY 
Physicians sMA SuMe 
~ FOR- 
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