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Epithelioma of right superior maxilla
378 American JournaI of surgery bIood
vessels.
Surg.,
Meyer-Superior
Gynec. @
MaxiIIa EpitheIioma
Obst., 29: 781,
1924.
g. BELL, F. G. StructuraI variations in thyroid metastases in bone, with reference to benign metastatic goitre. &it. J. .%rg., 12: 331-341, ig24. IO. MIDDELDORPF. K. Zur Kenntniss der Knochenmetastasen ‘die SchiIddriisentumoren. Arch. f. klin. Cbir., 48: 502-508, 1894. I I. ODERFELD, H. and STEINHAUS, J. Ueber Metastasen von normaIem SchiIddrtisengewebe. Centralbl. f. allg. Patb. u. patb. Anat., 14: 84, 1903. 12. COATS, J. A case of simple diffuse goitre with secondary tumors of the same structure in the bones of the skull. Tr. Patb. Sot., Land., 38: 399-405, 1887. 13. KANOKY, J. Thyroid tumors of the bones, with speciaI reference to non-maIignant pulsating tumors of the skuI1. Surg., Gynec., ti Obst., 22: 679-687, 1916. 14. FLATAU, E. and KOELICHEN,J. Cancer of the occipi-
15.
16.
17.
18. 19.
taI and tempora1 bone and the cerebeIIum in a girI 17 years old, as a metastasis of a colloid adenoma of the thyroid gland. Medycyna, Warszawa, 34: 104, 122, 139, 159, 179,203, 1906. HALBRON, P. Cancer thyro’idien di.veIopp& au niveau du sternum et simuIant un anevrisme de I’aorte. Bull. et mCm. Sot. anat. de Par., 79: 373375, 1904. SIMPSON, W. M. Three cases of thyroid metastasis to bones; with a discussion as to the existence of the so-caIIed “benign metastasizing goitre.” Surg., Gynec. 42: 489-507, 1926. PATEL, M. Tumeurs btnignes du corps thyroide donnant des metastases. Rev. de cbir., 29: 3g8428, 1904. WILSON, L. MaIignant tumors of the thyroid. Ann. Surg., 74: 129-184, 1921. MUELLER,G., and SPEESE, J. Malignant disease of the thyroid gland. Univ. Penn. Med. Bull., Ig: 74-88, 1906.
CASE REPORTS BY DR. HERBERT WILLY NEW
EPITHELIOMA OF RIGHT SUPERIOR MAXILLA*
A
MAN of fifty-two, born in Porto Rico, was admitted to Dr. George H. Semken’s service at The New York Skin and Cancer HospitaI on August 25, 1927. He had had a sore on the aIveoIar border of the right upper jaw which had caused some pain for the two months previous to admission. The teeth in this region had dropped out by themseIves. Examination of the mouth presented the whole story of the deveIopment of an epitheIioma. He had various areas of Ieucokeratosis, precursors of cancer, and at the site of the uIceration a papiIIomatous growth which had turned into an epithelioma. The Wassermann reaction was negative, and he gave no history of specific disease. The characteristic appearance of the Iesion and its rapid onset and growth confirmed the diagnosis of epitheIioma. Resection of the right superior maxiIIa was indicated. My purpose in presenting this patient is twofoId. First to show the cosmetic resuIt of the type of incision used, and secondIy to draw to your attention the method proposed by * Presented before Section of Surgery, Academy of Medicine, March 2, 1928.
New
York
MARCH,,929
MEYER
YORK
Dr. Semken, of temporariIy anguIating the externa1 carotid artery during the operation so as to save blood, and aIso conserve fuI1 bIood suppIy to the ffap for heaIing purposes. The operation was performed on August 30, under 5 oz. of ether-oIive oi1 coIonic anesthesia, the idea1 anesthesia in our experience for this type of case. The incision for pIacing the Iigature around the externa1 carotid artery was made about I in. Iong at the IeveI of the hyoid bone aIong the anterior border of the right sternomastoid muscIe. The sheath of the sternomastoid muscIe is nicked and the incision deepened unti1 the interna juguIar vein is seen. By tearing through the thin fascia just below the junction of the common facia1 vein with the interna juguIar vein one comes down onto the buIge of the common carotid artery just before it divides into internal and externa1 branches. The first branch of the externa1 carotid artery is seen, the superior thyroid artery and the externa1 carotid artery are compIeteIy freed just above this point. The best instrument for this is a grooved director, and then a heavy catgut Iigature, singIe or double, is pIaced around the artery with a VaIentine Mott Iigature carrier, an exceIIent instrument for this purpose. Heavy catgut is advisabIe so as not to injure the artery or its intima when puIIing on the Iigature. This
NEW SERIES
VOL.
VI, No. 3
Meyer-Superior
MaxilIa
catgut Iigature is not tied and a hemostat is placed at its end. The wound is sutured. The sheath of the sternomastoid is cIosed with interrupted fine chromic and the skin is sutured with fine interrupted bIack silk. As soon as the incision for the resection of the superior maxilla is begun the second assistant anguIates the externa1 carotid artery by gentIy puhing on the catgut ligature and during the operation the operative fieId bIeeds very much Iess, as no bIood can enter from the externa1 carotid. It is important to pIace the Iigature above the superior thyroid artery as there is a Iarge anastomosis between the two superior thyroids from either side of the neck. At the end of the operation the catgut Iigature is cut cIose to the skin with a cIean scissors and this at once restores the norma circuIation and the skin ffap has its fuI1 bIood supply for good healing. This IittIe procedure as proposed by Dr. Semken and used on his service is exceIIent and highIy recommendabIe for various procedures in which formerIy the externa1 carotid artery has been permanentIy Iigated. The incision as used on our service is made from a point just beIow the inner canthus of the eye downward aIong the side of the nose, around the aIa of the nose to the midIine and then downward directIy through the entire thickness of the Iip. This incision is deepened to the bony structures and the flap is dissected outward by pushing the structures with a raspatory. As much of the mucous membrane is saved as possibIe, depending on the proximity of the cancer and its encroachment onto the bucca1 mucous membrane. The pyriform opening is we11 exposed and with this type of incision the entire outer surface of the superior maxiIIa is accessibIe. If necessary an additiona incision can be made horizontaIIy outward from the upper point of the incision aIong the inferior orbita margin. The mucous membrane of the nose is then most carefuIIy separated from the floor and outer bony waI1 of the nose and then the usua1 bone sections are made. As much of the floor of the orbit is saved as possibIe in order to prevent the annoying dropping of the eye. In this case this was possibIe as the lesion did not extend upward. After the superior maxiha had been thus removed the raw surfaces were cauterized with the hot cautery as used on Dr. Semken’s service in order to destroy any possibIe cancer ceIIs and aIso make a thin eschar which wiI1
EpitheIioma
AmericanJournalof Surgery379
prevent absorption from the raw surface. An iodoform gauze packing was then pIaced in the defect, heId in place with bIack silk sutures and the ffap returned in place and most carefuIIy sutured. The most important suture, the first to be pIaced and the last to be tied, is the one directly at the vermiIion border of the lip. With this patient very IittIe deformity was visibIe after the resection of the jaw. The pathoIogica1 examination showed the tumor to be a prickIe-ceI1 epithelioma. After compIete healing has taken place a denture can be made to cIose the opening in the region of the hard paIate if the patient is annoyed in swaIIowing or if diffrcuIty in taIking is experienced. Dr. Edward Kennedy, the consuIting dentist of the Skin & Cancer HospitaI has made most ingenious dentures for these cases composed of upper and lower pIates joined at the posterior end with a spring which automaticaIIy hoIds the pIates apart. As the mouth is opened the pIates come apart and the upper one keeps the opening in the upper jaw cIosed. When the patient closes the mouth he does so against the spring action. In this way the upper pIate is continuousIy heId against the upper jaw and the patients are most comfortabIe and are we11 abIe to taIk and eat. DISCUSSION
DR. HOWARD LILIENTHAL. There is a question whether the fuI1 return of circuIation is advisabIe in these cases. A number of years ago a prize essay was written by the Iate Dr. R. H. M. Dawbarn in which he discussed the treatment of certain inoperabIe cases of maIignant growth of the face and jaw by extirpation of both externa1 carotids with Iigation of a11 the branhes up to the interna maxiIIary. His theory of starvation of the growth was based on good physioIogy. It has been shown that maIignant growths necrose before the heaIthy structures when the bIood suppIy is cut off. I beIieve that if I had to operate on a case Iike this one I wouId extirpate the externa1 carotid and then do the operation under a permanent instead of a temporary ischemia. DR. MEYER (in cIosing). I agree with Dr. LiIienthaI that Iigation of main arteries in inoperable cancers is a wise procedure. It starves the tumor and retards its growth. If a cancer is operabIe, however, radicaIIy removabIe with proper cancer technique, and the tumor is removed in toto, then Iigation of the
380
American Journal of Surgery
Hinton-ExophthaImic
artery is of no vaIue. If a reconstruction operation has to be added, it is of the greatest vaIue and benefit to have the fuII bIood suppIy entering the operative fieId at the compIetion of the operation. This important point was demonstrated in the case presented. Ischemia was brought about by the temporary angulation of the externa1 maxiIIary artery instead of permanent Iigation.
SPLENECTOMY OF GUNSHOT WOUND OF SPLEEN
A
YOUNG man of twenty-six was admitted to the service of Dr. Carl Eggers, at the Lenox Hi11 HospitaI, during the night of May 8, 1927. He had been shot five times and roentgen-ray examination showed that one of the buIIets had penetrated the compIementary space of the Ieft pIeura1 cavity and had then entered the abdomen through the diaphragm and passed through the 12th rib posteriorIy and was Iying just under the skin in the region of the spIeen. There was evidence of injury to some intraabdomina1 organ. The kidney couId be ruIed out and a diagnosis was made of injury to the spIeen with hemorrhage or possibIy injury to the coIon. Immediate expIoratory Iaparotomy was indicated. It was found at time of the operation that there was a tear of the posterior surface of the
hlAHCII, 1929
Goiter
spIeen which was smaI1 and very high up in the vauIt of the diaphragm and covered by a much distended stomach. Access to the pedicIe was diffrcuIt. Therefore in order to get better access the Ieft Costa1 arch was turned up according to the technique as advised by MarwedeI and used by Dr. WiIIy Meyer in New York and published by him in 1906. This immediately gave most exceIIent access and the spIenectomy was very simpIe. The patient made a somewhat stormy convaIescence on account of the infection of the abdominal wound with Staphylococcus aIbus, probabIy carried into the abdomen with the buIIet. During convalescence the remaining buIIets were removed under IocaI anesthesia. The patient is now in exceIIent condition except for a weakness in the abdominal waII for which he is wearing an abdominal supporter. DISCUSSION
DR. WILLY MEYER: I wouId Iike to say just a few words in regard to resection of the Costa1 arch. If one has to operate within the dome of the diaphragm it is best that one can see what is going on. It is an advantage to have the exposure made by dividing farther downward the tissues aIready in front of the operator, making a Iarge skin-muscIe-cartiIageflap and turning that then we11up and outward. Then the surgeon can cIearIy see what he is doing.
CASE REPORTS BY DR. J. WILLIAM HINTON* NEW
EXOPHTHALMIC GOITER (2 CASES)
C
YORK
but for the past eight or ten months he had Iost weight, about 40 to 50 Ibs. His eyes were enIarged and he was extremeIy nervous. Had paIpitation of the heart. Had been toId he had a goiter but was advised against operation. Chief compIaint at this time was pain in his back. Stated that he had had this for the past two years. Had been unabIe to work due to the pain in his back and the goiter, Roentgenograms had been taken. Had worn a brace and beIt without reIief. His chief desire was to obtain reIief from his back and not from his goiter. Examination. Patient was a we11 deveIoped and nourished man, thirty-one years oId.
ASE I. W. H., maIe, admitted to PostGraduate HospitaI June 27, 1923. Chief CompZuint. SweIling of neck. Family History. Mother has had a goiter for forty-five years. Past History. The usua1 chiIdhood diseases. ScarIet fever when seven years oId. No surgica1 operations. VenereaI disease denied. BoweIs reguIar. No urinary disturbances. Present Illness. Patient stated he had had an enIargement of his neck for several years * Read before Section of Surgery New York Academy of Medicine, March 2, 1928.
vessels.
Surg.,
Meyer-Superior
Gynec. @
MaxiIIa EpitheIioma
Obst., 29: 781,
1924.
g. BELL, F. G. StructuraI variations in thyroid metastases in bone, with reference to benign metastatic goitre. &it. J. .%rg., 12: 331-341, ig24. IO. MIDDELDORPF. K. Zur Kenntniss der Knochenmetastasen ‘die SchiIddriisentumoren. Arch. f. klin. Cbir., 48: 502-508, 1894. I I. ODERFELD, H. and STEINHAUS, J. Ueber Metastasen von normaIem SchiIddrtisengewebe. Centralbl. f. allg. Patb. u. patb. Anat., 14: 84, 1903. 12. COATS, J. A case of simple diffuse goitre with secondary tumors of the same structure in the bones of the skull. Tr. Patb. Sot., Land., 38: 399-405, 1887. 13. KANOKY, J. Thyroid tumors of the bones, with speciaI reference to non-maIignant pulsating tumors of the skuI1. Surg., Gynec., ti Obst., 22: 679-687, 1916. 14. FLATAU, E. and KOELICHEN,J. Cancer of the occipi-
15.
16.
17.
18. 19.
taI and tempora1 bone and the cerebeIIum in a girI 17 years old, as a metastasis of a colloid adenoma of the thyroid gland. Medycyna, Warszawa, 34: 104, 122, 139, 159, 179,203, 1906. HALBRON, P. Cancer thyro’idien di.veIopp& au niveau du sternum et simuIant un anevrisme de I’aorte. Bull. et mCm. Sot. anat. de Par., 79: 373375, 1904. SIMPSON, W. M. Three cases of thyroid metastasis to bones; with a discussion as to the existence of the so-caIIed “benign metastasizing goitre.” Surg., Gynec. 42: 489-507, 1926. PATEL, M. Tumeurs btnignes du corps thyroide donnant des metastases. Rev. de cbir., 29: 3g8428, 1904. WILSON, L. MaIignant tumors of the thyroid. Ann. Surg., 74: 129-184, 1921. MUELLER,G., and SPEESE, J. Malignant disease of the thyroid gland. Univ. Penn. Med. Bull., Ig: 74-88, 1906.
CASE REPORTS BY DR. HERBERT WILLY NEW
EPITHELIOMA OF RIGHT SUPERIOR MAXILLA*
A
MAN of fifty-two, born in Porto Rico, was admitted to Dr. George H. Semken’s service at The New York Skin and Cancer HospitaI on August 25, 1927. He had had a sore on the aIveoIar border of the right upper jaw which had caused some pain for the two months previous to admission. The teeth in this region had dropped out by themseIves. Examination of the mouth presented the whole story of the deveIopment of an epitheIioma. He had various areas of Ieucokeratosis, precursors of cancer, and at the site of the uIceration a papiIIomatous growth which had turned into an epithelioma. The Wassermann reaction was negative, and he gave no history of specific disease. The characteristic appearance of the Iesion and its rapid onset and growth confirmed the diagnosis of epitheIioma. Resection of the right superior maxiIIa was indicated. My purpose in presenting this patient is twofoId. First to show the cosmetic resuIt of the type of incision used, and secondIy to draw to your attention the method proposed by * Presented before Section of Surgery, Academy of Medicine, March 2, 1928.
New
York
MARCH,,929
MEYER
YORK
Dr. Semken, of temporariIy anguIating the externa1 carotid artery during the operation so as to save blood, and aIso conserve fuI1 bIood suppIy to the ffap for heaIing purposes. The operation was performed on August 30, under 5 oz. of ether-oIive oi1 coIonic anesthesia, the idea1 anesthesia in our experience for this type of case. The incision for pIacing the Iigature around the externa1 carotid artery was made about I in. Iong at the IeveI of the hyoid bone aIong the anterior border of the right sternomastoid muscIe. The sheath of the sternomastoid muscIe is nicked and the incision deepened unti1 the interna juguIar vein is seen. By tearing through the thin fascia just below the junction of the common facia1 vein with the interna juguIar vein one comes down onto the buIge of the common carotid artery just before it divides into internal and externa1 branches. The first branch of the externa1 carotid artery is seen, the superior thyroid artery and the externa1 carotid artery are compIeteIy freed just above this point. The best instrument for this is a grooved director, and then a heavy catgut Iigature, singIe or double, is pIaced around the artery with a VaIentine Mott Iigature carrier, an exceIIent instrument for this purpose. Heavy catgut is advisabIe so as not to injure the artery or its intima when puIIing on the Iigature. This
NEW SERIES
VOL.
VI, No. 3
Meyer-Superior
MaxilIa
catgut Iigature is not tied and a hemostat is placed at its end. The wound is sutured. The sheath of the sternomastoid is cIosed with interrupted fine chromic and the skin is sutured with fine interrupted bIack silk. As soon as the incision for the resection of the superior maxilla is begun the second assistant anguIates the externa1 carotid artery by gentIy puhing on the catgut ligature and during the operation the operative fieId bIeeds very much Iess, as no bIood can enter from the externa1 carotid. It is important to pIace the Iigature above the superior thyroid artery as there is a Iarge anastomosis between the two superior thyroids from either side of the neck. At the end of the operation the catgut Iigature is cut cIose to the skin with a cIean scissors and this at once restores the norma circuIation and the skin ffap has its fuI1 bIood supply for good healing. This IittIe procedure as proposed by Dr. Semken and used on his service is exceIIent and highIy recommendabIe for various procedures in which formerIy the externa1 carotid artery has been permanentIy Iigated. The incision as used on our service is made from a point just beIow the inner canthus of the eye downward aIong the side of the nose, around the aIa of the nose to the midIine and then downward directIy through the entire thickness of the Iip. This incision is deepened to the bony structures and the flap is dissected outward by pushing the structures with a raspatory. As much of the mucous membrane is saved as possibIe, depending on the proximity of the cancer and its encroachment onto the bucca1 mucous membrane. The pyriform opening is we11 exposed and with this type of incision the entire outer surface of the superior maxiIIa is accessibIe. If necessary an additiona incision can be made horizontaIIy outward from the upper point of the incision aIong the inferior orbita margin. The mucous membrane of the nose is then most carefuIIy separated from the floor and outer bony waI1 of the nose and then the usua1 bone sections are made. As much of the floor of the orbit is saved as possibIe in order to prevent the annoying dropping of the eye. In this case this was possibIe as the lesion did not extend upward. After the superior maxiha had been thus removed the raw surfaces were cauterized with the hot cautery as used on Dr. Semken’s service in order to destroy any possibIe cancer ceIIs and aIso make a thin eschar which wiI1
EpitheIioma
AmericanJournalof Surgery379
prevent absorption from the raw surface. An iodoform gauze packing was then pIaced in the defect, heId in place with bIack silk sutures and the ffap returned in place and most carefuIIy sutured. The most important suture, the first to be pIaced and the last to be tied, is the one directly at the vermiIion border of the lip. With this patient very IittIe deformity was visibIe after the resection of the jaw. The pathoIogica1 examination showed the tumor to be a prickIe-ceI1 epithelioma. After compIete healing has taken place a denture can be made to cIose the opening in the region of the hard paIate if the patient is annoyed in swaIIowing or if diffrcuIty in taIking is experienced. Dr. Edward Kennedy, the consuIting dentist of the Skin & Cancer HospitaI has made most ingenious dentures for these cases composed of upper and lower pIates joined at the posterior end with a spring which automaticaIIy hoIds the pIates apart. As the mouth is opened the pIates come apart and the upper one keeps the opening in the upper jaw cIosed. When the patient closes the mouth he does so against the spring action. In this way the upper pIate is continuousIy heId against the upper jaw and the patients are most comfortabIe and are we11 abIe to taIk and eat. DISCUSSION
DR. HOWARD LILIENTHAL. There is a question whether the fuI1 return of circuIation is advisabIe in these cases. A number of years ago a prize essay was written by the Iate Dr. R. H. M. Dawbarn in which he discussed the treatment of certain inoperabIe cases of maIignant growth of the face and jaw by extirpation of both externa1 carotids with Iigation of a11 the branhes up to the interna maxiIIary. His theory of starvation of the growth was based on good physioIogy. It has been shown that maIignant growths necrose before the heaIthy structures when the bIood suppIy is cut off. I beIieve that if I had to operate on a case Iike this one I wouId extirpate the externa1 carotid and then do the operation under a permanent instead of a temporary ischemia. DR. MEYER (in cIosing). I agree with Dr. LiIienthaI that Iigation of main arteries in inoperable cancers is a wise procedure. It starves the tumor and retards its growth. If a cancer is operabIe, however, radicaIIy removabIe with proper cancer technique, and the tumor is removed in toto, then Iigation of the
380
American Journal of Surgery
Hinton-ExophthaImic
artery is of no vaIue. If a reconstruction operation has to be added, it is of the greatest vaIue and benefit to have the fuII bIood suppIy entering the operative fieId at the compIetion of the operation. This important point was demonstrated in the case presented. Ischemia was brought about by the temporary angulation of the externa1 maxiIIary artery instead of permanent Iigation.
SPLENECTOMY OF GUNSHOT WOUND OF SPLEEN
A
YOUNG man of twenty-six was admitted to the service of Dr. Carl Eggers, at the Lenox Hi11 HospitaI, during the night of May 8, 1927. He had been shot five times and roentgen-ray examination showed that one of the buIIets had penetrated the compIementary space of the Ieft pIeura1 cavity and had then entered the abdomen through the diaphragm and passed through the 12th rib posteriorIy and was Iying just under the skin in the region of the spIeen. There was evidence of injury to some intraabdomina1 organ. The kidney couId be ruIed out and a diagnosis was made of injury to the spIeen with hemorrhage or possibIy injury to the coIon. Immediate expIoratory Iaparotomy was indicated. It was found at time of the operation that there was a tear of the posterior surface of the
hlAHCII, 1929
Goiter
spIeen which was smaI1 and very high up in the vauIt of the diaphragm and covered by a much distended stomach. Access to the pedicIe was diffrcuIt. Therefore in order to get better access the Ieft Costa1 arch was turned up according to the technique as advised by MarwedeI and used by Dr. WiIIy Meyer in New York and published by him in 1906. This immediately gave most exceIIent access and the spIenectomy was very simpIe. The patient made a somewhat stormy convaIescence on account of the infection of the abdominal wound with Staphylococcus aIbus, probabIy carried into the abdomen with the buIIet. During convalescence the remaining buIIets were removed under IocaI anesthesia. The patient is now in exceIIent condition except for a weakness in the abdominal waII for which he is wearing an abdominal supporter. DISCUSSION
DR. WILLY MEYER: I wouId Iike to say just a few words in regard to resection of the Costa1 arch. If one has to operate within the dome of the diaphragm it is best that one can see what is going on. It is an advantage to have the exposure made by dividing farther downward the tissues aIready in front of the operator, making a Iarge skin-muscIe-cartiIageflap and turning that then we11up and outward. Then the surgeon can cIearIy see what he is doing.
CASE REPORTS BY DR. J. WILLIAM HINTON* NEW
EXOPHTHALMIC GOITER (2 CASES)
C
YORK
but for the past eight or ten months he had Iost weight, about 40 to 50 Ibs. His eyes were enIarged and he was extremeIy nervous. Had paIpitation of the heart. Had been toId he had a goiter but was advised against operation. Chief compIaint at this time was pain in his back. Stated that he had had this for the past two years. Had been unabIe to work due to the pain in his back and the goiter, Roentgenograms had been taken. Had worn a brace and beIt without reIief. His chief desire was to obtain reIief from his back and not from his goiter. Examination. Patient was a we11 deveIoped and nourished man, thirty-one years oId.
ASE I. W. H., maIe, admitted to PostGraduate HospitaI June 27, 1923. Chief CompZuint. SweIling of neck. Family History. Mother has had a goiter for forty-five years. Past History. The usua1 chiIdhood diseases. ScarIet fever when seven years oId. No surgica1 operations. VenereaI disease denied. BoweIs reguIar. No urinary disturbances. Present Illness. Patient stated he had had an enIargement of his neck for several years * Read before Section of Surgery New York Academy of Medicine, March 2, 1928.