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A CASE OF PERITHELIOMA OF THE SUPERIOR MAXILLA AND ETHMOID.
1013 A CASE OF
PERITHELIOMA OF THE SUPERIOR MAXILLA AND ETHMOID. BY G. H. LAWSON
WHALE, M.D.CANTAB., F.R.C.S. ENG.,
SURGEON FOR DISEASES OF THE THROAT, NOSE, AND EAR TO THE HAMPSTEAD GENERAL HOSPITAL, AND TO THE LONDON TEMPERANCE HOSPITAL.
outwards; the nose further displaced to the left; and a large, irregular, hard prominence extended from the middle of the cheek, upwards and inwards, crossing the inner canthus to reach the nasion. (Fig.3.) A skiagram taken by Mr.C.Thatcher shows that the lower part of the antrum and the frontal sinuses were apparently free, but a shadow occupied the upper part of the jaw, side of the nose, and ethmoid region. FrG. 2.
female Belgian refugee, aged 52 to the came Hampstead General Hospital in years, with a lump in the right cheek 1914, September, of three and a half years’ duration. The whole right upper jaw bulged outwards, pushing the nose There was no depression of over towards the left. the palate; the temporal fossa and post-nasal space The right eye was proptosed, but vision were free. was perfect; the outer wall of the right nasal fossa was pushed inwards against the septum. Examination by transillumination and puncture revealed a solid tumour. There were no palpable glands. Under chloroform I incised the friable outer antral wall beneath the cheek, my intention being to remove a piece for histological diagnosis. But the bulk of the tumour came away so easily that I removed all I could, a mass larger than a golfball. (Fig. 1.) It was, however, impossible by this route to get any instrument or finger beyond the upper pole of the tumour, so it was obvious that,
patient,
THE
a
FIG. 1.
Microphotograph showing section of perithelioma of the right antrum and superior maxilla. Magnification 200 diameters.
Operation.-Ten days
after the extraction of all
teeth, except those in the affected upper jaw, intratracheal ether was given by Mr.
the
C. H. C. Visick.
Dr. J. Z. Truter assisted.
No
preliminary tracheotomy laryngotomy was performed, but the right external carotid was tied. An incision was then made, beginning in the middle of the eyebrow, in the line of which it was continued mesially to the root of the nose; then downwards in front of the lacrymal sac, or
The mass of growth which was removed by cheek at the first exploratory operation. thirds actual size.
elevating the
About two-
a cure, this proceeding had been unsurgical and insufficient. An extract from the pathologist’s and back to the sulcus between the nose cheek; from here down to the junction of report says :nostril and cheek, horizontally inwards to Richly cellular, irregularly circular areas present internally a roughly circular space filled with blood corpuscles. columella, and vertically downwards, dividing
for
Bounding the space externally, and the cellular area internally, is a layer of flattened cells, suggesting the internal lining epithelium of a vessel. External to this are many closely packed ovoid cells, with a well-defined nucleus, arrangedconcentrically around the lumen. These appearances
a perithelioma originating (Fig. 2.)
suggest
vessels.
in the small blood-
A week after exploring the antrum I went to and so lost sight of the patient; on my return in January, 1915, I again saw her. The mass had not recurred in the outer antral wall, from where I had formerly removed the large piece, but the palate was slightly depressed on that side; the eye more proptosed and pushed
France,
and the the the in the first
in the mid-line. From a point incision just below the lacrymal sac another curved horizontal incision was made in the line of the bony infra-orbital margin on to the malar prominence. These incisions are simply the classical one of Fergusson plus a prolongation half-way along the eyebrow. The usual large flap could now be turned down to expose the maxilla; and the skin over the root of the and inner half of nose thee eyebrow could be raised upwards and to the left, for the better inspection of the ethmoid and frontal sinuses. The whole right upper jaw, palate bone, nasal bone, and part of the malar were now
lip
1014 removed in one mass. (Fig. 4.) For cutting through the malar bone into the spheno-maxillary fissure a Gigli saw was used ; for dividing the hard palate Elsewhere all separations were a keyhole saw. effected with a knife or bone-cutting forceps. It was not possible to leave the orbital floor or FIG. 3.
Appearance .
of the
patient four months after first before second operation.
sinus and spheno-maxillary fossa were found to be free from disease. The attachment of the superior oblique pulley was not interfered with, The cavity was and the soft palate was left. swabbed everywhere with solution of zinc chloride, 40 grains to the ounce. The skin flaps were replaced
sphenoidal
FiG. 4.
and
shortly
The upper jaw and adjacent bones removed at the second radical operation. The growth has rendered the identity of this unrecognisable, were it not for the teeth. About two thirds actual size.
FIG. 6.
Patient after operation. the
Shows the ptosis and inability to raise on the affected side.
eyebrow
Shows how the globe has dropped, but there is
no
diplopia.
invaded. The C4 sus- and sewn up, and for 48 hours the cavity was kept of the globe was not plugged with wide ribbon gauze. encountered-the eye rested on nothing but the Subsequent history.-N ever at any time did the orbital fat. The growth had invaded the right temperature exceed 99’8° F. nor the respirations 24. ethmoid, which, with the lacrymal bone, was now On the third day a marked conjunctival chemosis entirely removed up to the cribriform plate. The appeared. This was attributed to the great
periosteum, as both ligament" pensory "
were
1015 mechanical circulatory and lymphatic interference;administered for prostatectomy, which during and a leech on the upper eyelid cured it. But onithe enucleation of the gland must be deep the fifth day it reappeared, and simultaneously a
__________________
SPINAL ANAESTHESIA IN 43 SUPRAPUBIC signs of nervousness. The method I use is as follows. A previous subPROSTATECTOMIES. cutaneous injection of morphia or omnopon and BY H. M. PAGE, F.R.C.S. ENG., atropine with or without scopolamine is given. I ANÆSTHETIST TO GUY’S AND THE WEST LONDON HOSPITALS. inject in the second lumbar space in the middle line with the patient lying on his side, using I HAVE found spinal anaesthesia of great assistin many genito-urinary operations, such as malignant disease of the bladder, lithotomy, some cases of lithotrity, extensive perineal fistulae, &c., but in this paper I have only included suprapubic prostatectomy. A report on this one particular ance
operation-performed,
as
it always is,
on men
who
all of advanced or great age, and in many instances suffering at the time of operation from the same kind of constitutional complications-is of a greater value for the comparison of spinal with general anaesthesia than if different operations, ages, conditions, and diseases had been are
included. The victim of enlargement of the prostate gland is not only frequently of great age, but often presents evidence of organic degeneration, such as
inadequately acting
renal
tissue, degeneration
of
the vascular system, emphysema, and bronchitis. The question of anaesthesia may therefore present a serious problem both as to the immediate result and ultimate recovery. The commonest causes of death following supra-
pubic prostatectomy are shock and haemorrhage, suppression of urine, pulmonary complications, and
paralytic distension of the bowel. From my experience in the administration of both general and spinal anaesthesia for this and many other kinds of operations I have come to the following conclusions. General anaesthesia
Barker’s needles and his internal cannula. The drug used in all these cases was novocaine. In the first 21 cases I used a solution weighted with mannitol. I have given up using weighted solutions altogether. In the last 22 cases the unweighted 5 per cent solution with suprarenin borate, as made by the Saccharin Corporation, was used. The dose of this last solution for these cases varies from 2 to 2-2L c.c. according to the age, size, and condition of the patient. Raising the buttocks slightly and flexing the thighs on the abdomen immediately after the patient is turned on to his back tend to raise the height of the anaesthesia even with unweighted solutions of novocaine or stovaine. The head is, of course, kept slightly raised at the same time. The advantages I would claim for the use of the unweighted solution, instead of the solution purposely made heavier than the spinal fluid, are as follows. Temporary collapse is met with in a certain proportion of cases after intrathecal injection of any of the drugs used to produce spinal anaesthesia. Should this occur it can be treated by raising the patient’s legs and lowering his head, and this is the most rapidly effectual treatment. With the use of this solution the foot of the bed can be raised on blocks immediately the patient has been put back there, and if he has to be carried up or down stairs after the operation this can be done with the head dependent.
PERITHELIOMA OF THE SUPERIOR MAXILLA AND ETHMOID. BY G. H. LAWSON
WHALE, M.D.CANTAB., F.R.C.S. ENG.,
SURGEON FOR DISEASES OF THE THROAT, NOSE, AND EAR TO THE HAMPSTEAD GENERAL HOSPITAL, AND TO THE LONDON TEMPERANCE HOSPITAL.
outwards; the nose further displaced to the left; and a large, irregular, hard prominence extended from the middle of the cheek, upwards and inwards, crossing the inner canthus to reach the nasion. (Fig.3.) A skiagram taken by Mr.C.Thatcher shows that the lower part of the antrum and the frontal sinuses were apparently free, but a shadow occupied the upper part of the jaw, side of the nose, and ethmoid region. FrG. 2.
female Belgian refugee, aged 52 to the came Hampstead General Hospital in years, with a lump in the right cheek 1914, September, of three and a half years’ duration. The whole right upper jaw bulged outwards, pushing the nose There was no depression of over towards the left. the palate; the temporal fossa and post-nasal space The right eye was proptosed, but vision were free. was perfect; the outer wall of the right nasal fossa was pushed inwards against the septum. Examination by transillumination and puncture revealed a solid tumour. There were no palpable glands. Under chloroform I incised the friable outer antral wall beneath the cheek, my intention being to remove a piece for histological diagnosis. But the bulk of the tumour came away so easily that I removed all I could, a mass larger than a golfball. (Fig. 1.) It was, however, impossible by this route to get any instrument or finger beyond the upper pole of the tumour, so it was obvious that,
patient,
THE
a
FIG. 1.
Microphotograph showing section of perithelioma of the right antrum and superior maxilla. Magnification 200 diameters.
Operation.-Ten days
after the extraction of all
teeth, except those in the affected upper jaw, intratracheal ether was given by Mr.
the
C. H. C. Visick.
Dr. J. Z. Truter assisted.
No
preliminary tracheotomy laryngotomy was performed, but the right external carotid was tied. An incision was then made, beginning in the middle of the eyebrow, in the line of which it was continued mesially to the root of the nose; then downwards in front of the lacrymal sac, or
The mass of growth which was removed by cheek at the first exploratory operation. thirds actual size.
elevating the
About two-
a cure, this proceeding had been unsurgical and insufficient. An extract from the pathologist’s and back to the sulcus between the nose cheek; from here down to the junction of report says :nostril and cheek, horizontally inwards to Richly cellular, irregularly circular areas present internally a roughly circular space filled with blood corpuscles. columella, and vertically downwards, dividing
for
Bounding the space externally, and the cellular area internally, is a layer of flattened cells, suggesting the internal lining epithelium of a vessel. External to this are many closely packed ovoid cells, with a well-defined nucleus, arrangedconcentrically around the lumen. These appearances
a perithelioma originating (Fig. 2.)
suggest
vessels.
in the small blood-
A week after exploring the antrum I went to and so lost sight of the patient; on my return in January, 1915, I again saw her. The mass had not recurred in the outer antral wall, from where I had formerly removed the large piece, but the palate was slightly depressed on that side; the eye more proptosed and pushed
France,
and the the the in the first
in the mid-line. From a point incision just below the lacrymal sac another curved horizontal incision was made in the line of the bony infra-orbital margin on to the malar prominence. These incisions are simply the classical one of Fergusson plus a prolongation half-way along the eyebrow. The usual large flap could now be turned down to expose the maxilla; and the skin over the root of the and inner half of nose thee eyebrow could be raised upwards and to the left, for the better inspection of the ethmoid and frontal sinuses. The whole right upper jaw, palate bone, nasal bone, and part of the malar were now
lip
1014 removed in one mass. (Fig. 4.) For cutting through the malar bone into the spheno-maxillary fissure a Gigli saw was used ; for dividing the hard palate Elsewhere all separations were a keyhole saw. effected with a knife or bone-cutting forceps. It was not possible to leave the orbital floor or FIG. 3.
Appearance .
of the
patient four months after first before second operation.
sinus and spheno-maxillary fossa were found to be free from disease. The attachment of the superior oblique pulley was not interfered with, The cavity was and the soft palate was left. swabbed everywhere with solution of zinc chloride, 40 grains to the ounce. The skin flaps were replaced
sphenoidal
FiG. 4.
and
shortly
The upper jaw and adjacent bones removed at the second radical operation. The growth has rendered the identity of this unrecognisable, were it not for the teeth. About two thirds actual size.
FIG. 6.
Patient after operation. the
Shows the ptosis and inability to raise on the affected side.
eyebrow
Shows how the globe has dropped, but there is
no
diplopia.
invaded. The C4 sus- and sewn up, and for 48 hours the cavity was kept of the globe was not plugged with wide ribbon gauze. encountered-the eye rested on nothing but the Subsequent history.-N ever at any time did the orbital fat. The growth had invaded the right temperature exceed 99’8° F. nor the respirations 24. ethmoid, which, with the lacrymal bone, was now On the third day a marked conjunctival chemosis entirely removed up to the cribriform plate. The appeared. This was attributed to the great
periosteum, as both ligament" pensory "
were
1015 mechanical circulatory and lymphatic interference;administered for prostatectomy, which during and a leech on the upper eyelid cured it. But onithe enucleation of the gland must be deep the fifth day it reappeared, and simultaneously a
__________________
SPINAL ANAESTHESIA IN 43 SUPRAPUBIC signs of nervousness. The method I use is as follows. A previous subPROSTATECTOMIES. cutaneous injection of morphia or omnopon and BY H. M. PAGE, F.R.C.S. ENG., atropine with or without scopolamine is given. I ANÆSTHETIST TO GUY’S AND THE WEST LONDON HOSPITALS. inject in the second lumbar space in the middle line with the patient lying on his side, using I HAVE found spinal anaesthesia of great assistin many genito-urinary operations, such as malignant disease of the bladder, lithotomy, some cases of lithotrity, extensive perineal fistulae, &c., but in this paper I have only included suprapubic prostatectomy. A report on this one particular ance
operation-performed,
as
it always is,
on men
who
all of advanced or great age, and in many instances suffering at the time of operation from the same kind of constitutional complications-is of a greater value for the comparison of spinal with general anaesthesia than if different operations, ages, conditions, and diseases had been are
included. The victim of enlargement of the prostate gland is not only frequently of great age, but often presents evidence of organic degeneration, such as
inadequately acting
renal
tissue, degeneration
of
the vascular system, emphysema, and bronchitis. The question of anaesthesia may therefore present a serious problem both as to the immediate result and ultimate recovery. The commonest causes of death following supra-
pubic prostatectomy are shock and haemorrhage, suppression of urine, pulmonary complications, and
paralytic distension of the bowel. From my experience in the administration of both general and spinal anaesthesia for this and many other kinds of operations I have come to the following conclusions. General anaesthesia
Barker’s needles and his internal cannula. The drug used in all these cases was novocaine. In the first 21 cases I used a solution weighted with mannitol. I have given up using weighted solutions altogether. In the last 22 cases the unweighted 5 per cent solution with suprarenin borate, as made by the Saccharin Corporation, was used. The dose of this last solution for these cases varies from 2 to 2-2L c.c. according to the age, size, and condition of the patient. Raising the buttocks slightly and flexing the thighs on the abdomen immediately after the patient is turned on to his back tend to raise the height of the anaesthesia even with unweighted solutions of novocaine or stovaine. The head is, of course, kept slightly raised at the same time. The advantages I would claim for the use of the unweighted solution, instead of the solution purposely made heavier than the spinal fluid, are as follows. Temporary collapse is met with in a certain proportion of cases after intrathecal injection of any of the drugs used to produce spinal anaesthesia. Should this occur it can be treated by raising the patient’s legs and lowering his head, and this is the most rapidly effectual treatment. With the use of this solution the foot of the bed can be raised on blocks immediately the patient has been put back there, and if he has to be carried up or down stairs after the operation this can be done with the head dependent.