a piece of the growth, an easy proceeding and apparently without much danger. The following works may be consulted: TRAUTMAN, Archiv für Laryngol., 1905, xvii. p. 386. FINDER. Archiv für Laryngol., 1896, v. p. 302. DONOGÁNY and LÉNÁRT. Archiv für Laryngol., 1904, xv. p. 586. Frontal Sinus. IWANOFF. Archiv für Laryngol., 1904, xvi. p. 520. ONODI and BARTHA. Archiv für Laryngol., 1903, xv. p. 167. Of Antrum. KIRSCHNER. Archiv für Laryngol., 1903, xv. p. 1. WENDELL PHILLIPS. Journ. of Laryngol., 1898, xiii. p. 325. Sphenoidal Sinus. CITELLI. Archiv für Laryngol., 1903, xv. p. 252. RECURRING FIBROMA OF THE NASO-PHARYNX. These tumours are nearly always found in males between the ages of 15 and 25. They are attached by a broad base, usually to the body of the sphenoid, and thence extend forward into the nose or backwards into the throat. The neighbouring bones may become absorbed and the tumours extend to the cerebral cavity, to the antrum or to other accessory sinuses. They are always single, bleed readily when touched, and tend to recur after removal. Some of the tumours are pure fibromata, others resemble sarcomata, and it is often impossible to say in which group a particular tumour should be classed. Moritz Schmidt found 25 cases of fibroma in 58,000 patients: during this time he saw malignant disease in the post-nasal space in only 6 instances. In two sets of statistics quoted by Morell Mackenzie, comprising over 100 cases in all, with one exception the patient was a male under the age of 25. Symptoms. The earliest symptom is gradually increasing nasal obstruction with its consequences. Deafness and middle ear catarrh may arise from pressure upon the Eustachian tubes; the voice is markedly affected; and there is generally much purulent or muco-purulent nasal secretion. Epistaxis is common and often severe it may reduce the patient to an extremely anaemic condition. Thus the symptoms are similar to those of adenoid growths, but much more pronounced. A curious and not infrequent. symptom is excessive drowsiness, the patient falling asleep and snoring loudly even whilst standing or whilst following his occupation. Mackenzie quotes a case of a barber who whilst following his occupation fell asleep and dropped a hot curling iron on to his client's chin. If the growth spread down into the pharynx it may become visible below the soft palate, which is pressed forward and downward, and may give rise to dyspnoea and dysphagia. If the growth spread forwards into the nose or accessory cavities it may cause expansion of the face, giving rise to the deformity known as "frog face"; if it spread into the antrum it may cause a tumour of one cheek. On examination with the post-nasal mirror the growth can be readily seen: it is usually pale, white, or yellowish in colour, but rarely may be red and vascular. If the growth be small its point of attachment may often be recognised. Digital examination must never be omitted. The hard firm nature of the growth, its broad base and any probable extensions can thus be made out. A soft growth bleeding readily with the touch of the finger, with ulcerated or sloughing surface, is probably a sarcoma. Diagnosis. If the tumour be examined with the mirror and by digital examination, it can hardly be mistaken for any other affection; although it FIG. 102.-FIBROMA FROM POST-NASAL SPACE. may be impossible to distinguish between pure fibrous tumours and fibro-sarcomata, even by microscopical examination. An endeavour must be made to ascertain the extent of the growth. Signs of involvement of the cerebral cavity and of the antrum must be carefully sought for. Severe headaches, excessive drowsiness, vomiting, optic neuritis or atrophy, are indications of cerebral pressure. Pathology. The ordinary fibroma is exceedingly dense and consists of concentric layers of fibrous tissue. The vessels are numerous and thickwalled. Many tumours contain collections of round or spindle-cells, and the growth in places may resemble sarcoma microscopically, but without any signs of clinical malignancy." Prognosis. When a small hard growth is present, the prognosis is good, provided free removal is carried out. There was a general impression amongst the older writers, with which Morell Mackenzie and Macdonald agree, that these growths showed a disposition to atrophy at, or after, the age of 25. They asserted that if the growth could be kept in check by repeated removal its spontaneous arrest at this age might be expected. Without subscribing to the truth of this assertion, it is at least certain that simple operations such as removal with a snare may succeed ultimately, although one or two recurrences may occur. In sarcoma the prognosis is extremely unfavourable. It is almost impossible even by extensive operation at the earliest possible stage to eradicate a growth from this region; moreover, the glands on both sides of the neck are usually involved at an early period. Treatment. If the growth be small and hard, with no sign of involvement of the bones or of extension to the neighbouring cavities, the simplest and best treatment is removal with the snare. A strong instrument threaded with a stout wire must be used. If owing to the size of the growth there is some difficulty in passing the wire loop through the nose, the following manœuvre may be practised :—A small gum-elastic catheter is pushed down the nose until it appears in the post-nasal space. It is grasped with forceps and pulled forwards into the mouth, a piece of silk is attached and drawn through into the nose. The ends of a stout wire loop are now attached to the silk and drawn into the nose, whilst the loop is pushed back into the naso-pharynx and carefully adjusted by the fingers as close as possible round the base of the tumour. The free ends of the wire are now threaded and attached to a snare in the usual way. The growth must be slowly cut through to avoid bleeding. If the loop be hitched well up round its base the entire growth will often be enucleated. In this way I have successfully removed two growths, one from a female of 22: in neither case has recurrence taken place within two years. The method is almost without danger, and is applicable to all except the largest growths. If a very large tumour be present, extending forward into the nose, the best plan will be to expose it by the method introduced by Nélaton. This consists in splitting the soft palate, prolonging the incision on to the hard palate, turning aside the soft parts, and chiselling away some of the bone beneath. The operation is similar to that for malignant disease in this region, and has already been described (see p. 237). When the growth involves the accessory sinuses, various operations must be devised to meet the particular circumstances; these often require total or partial resection of the upper jaw. When the cerebral cavity is involved no, radical operation is possible. Various other methods, now mostly obsolete, have from time to time been advocated. They were designed to avoid haemorrhage, the risk of which has been greatly exaggerated. Moritz Schmidt strongly recommends electrolysis, a slow and unsatisfactory method. Evulsion piecemeal with forceps has also its advocates. The methods of injecting strong caustic solutions and of strangulation by ligature probably belong entirely to the past. The following works may be consulted: QUINLAN. Laryngoscope, 1902, xii. p. 840 (gives full references). Discussions at Laryngol. Soc. of London., Journ. of Laryngol., 1900, xv. pp. 77 and 155, and Journ. of Laryngol., 1896, x. p. 326. HENGST. Journal of Laryngol., 1899, xiv. p. 100. 1 See interesting case reported by Tilley in which four successive operations were performed. Journ. of Laryng., 1903, xviii. p. 45. Q SCHÄFER. Journ. of Laryngol., 1902, xvii. p. 155. BOWLBY. Lancet, 1895, ii. p. 913. KIJEWSKI and WROBLEWSKI. Archiv für Laryngol., 1895, ii. p. 78. DEMPSEY. Journ. of Laryngol., 1902, xvii. p. 439. HOLMES. Journ. of Laryngol., 1902, xvii. p. 399. Also the articles in Morell Mackenzie's, Greville MacDonald's, and Moritz Schmidt's books. CHAPTER XIV. * THE NASAL NEUROSES. HAY FEVER. ASTHMA. INTRODUCTION. THE nasal reflex neuroses form a much discussed but little understood group of affections. Hay fever was first described by Bostock in 1819, and the relationship of asthma to nasal diseases was pointed out by Trousseau. Voltolini, in 1871, first showed that asthma could be cured by the application of the galvano-cautery to the nose, and a series of similar observations soon followed, but it remained for Hack in 1882 to direct general attention to this subject. He greatly extended the province of the nasal reflexes, making it include such various affections as neuralgia, headache, cough, vasomotor skin troubles, epilepsy, chorea, etc., and started a controversy which has continued ever since and still remains unsettled. The subject is extremely important, there are numerous theories, but great difficulties in obtaining trustworthy data; hence the present unsatisfactory state of the controversy. A pathological reflex may be regarded as a reflex due to a stimulus which will act only if the normal resisting power be lowered or removed. The increased excitability of the reflex mechanism may be due to some individual susceptibility to particular stimuli, to undue acuteness of the peripheral nerve endings, or to instability of the nerve centres. The last is probably a constant factor and is shown in many ways. The subjects of these affections for the most part belong to the leisured classes, and inherit a tendency to neurotic affections. Most of the severer cases suffer from neurasthenia, hysteria, or allied neurosis. Many patients are affected only when run down, after a prostrating illness, or when overworked or worried. It is probable that sometimes there is an undue excitability of the afferent nerve endings When once a reflex disturbance has been produced it can be more easily excited again. Thus in persons predisposed to hay fever, which is usually excited by the irritation of hay pollen on the nasal mucosa, a paroxysm of sneezing may be set up by the stimulus of a strong light falling on the retina; and asthma, even if usually of nasal origin, may be excited in a predisposed person by disturbances in other organs; for instance, in the stomach. It is obvious that the more sensitive the |