The extension of the surgery of neoplastic diseases by endothermy

THE EXTENSION OF THE

SURGERY OF NEOPLASTIC DISEASES BY ENDOTHERMY* GEORGE A. WYETH,

M.D.

NEW YORK

S

OME seven years ago the writer, dissatisfied with the resuIts obtained in the surgery of mahgnancy, and moved by Doyen’s concIusion that, “of a11 means empIoyed in the destruction of pathoIogica1 Iesions the onIy certain method is that of heat,” went to eIectrotherapy to find the best method of inducing heat in the tissues. There was a rich Iiterature devoted to the methods and rest&s of the appIication of high frequency currents to disease and, ahhough considerable patience was needed to untangIe the confused nomencIature of its presentation, the investigator was repaid by findings covering a period of more than twenty years. Doyen and NageIschmidt had demonstrated so Iong ago the high value of eIectric coaguIation in the destruction of malignancy. CIarke of PhiIadeIphia had for more than fifteen years used with brihiant success the Iighter current to accomphsh that desiccation by which Lesions of the more dehcate tissues may be destroyed without injury to surrounding areas. It was impossible to doubt the authenticated resuIts which these men and many others presented-resuhs far outweighing the unwarranted cIaims by scientific students had which Iess brought criticism upon the whoIe heId of eIectrotherapeutics. Our own interest in what has been deveIoped as endothermy was greatIy stimuIated by our experience with a case of tumor of the bIadder. The usua1 suprapubic incision was made by the scaIpe1. The growth was exposed by eIectric Iight * Read before the Surgical Section,

in the bIadder and was desiccated in situ and removed. The bIadder was then sutured in the usua1 way, without drainage. After three months cystoscopic examination showed the site of the Iesion so free that it was diffrcuh to be sure just where the growth had been. AIong the Iine of the scaIpeI’s incision, however, were three carcinomatous noduIes. There couId not be a more graphic picture of the beneficent action of the high frequency current as contrasted with the scaIpeI’s Iack of protection against the impIantation of malignant cehs. The need of perfecting a cutting current which shouId extend surgery’s usefuhress as a weapon against neopIastic growths seemed urgent. From the reahzation of this need the perfected cutting current, the endotherm knife, was deveIoped and presented before the Surgical Section of the State Medical Society in Rochester, ApriI, 1924. In reporting our work we reahze that it is not conchrsive. Sufficient time has not yet eIapsed nor have we had a sufficient number of cases for us to offer fina results. The work is, however, indicative and on this ground it is presented. As we hereafter discuss the methods by which resu1t.s are achieved it wiII be observed that a sound surgica1 training is the basis of its successfu1 empIoyment. But equahy important is a thorough knowIedge of the precise use of the currents for they differ wideIy in character and effect. In the treatment of Iocahzed mahgnancy which can be immediateIy removed we no Ionger use roentgen ray or radium.

New York Academy 413

of Medicine,

Feb. 3, 1928.

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FIG.

FIG.

I.

2.

FIGS. I and 2. R. A. Five years oId. Fibro-angio-sarcoma of scaIp. At birth the chiId showed nothing abnc ,rmaI excf :pt a bIack mark on the posterior half of the scaIp, the size of a twenty-five cent piece. Note astatic gIands of the neck. On June 17, 1925, the growth was excised by the endotherm knife with Iittle hemorrhage and no surgica1 shock. Hearing has been steady and uninterrupted. By u’nderm lining and left in situ to be abso rb;ed . the skin the gIands of the neck were coagulated by bipoIar endothermy Mic :roscopic examination established the fibro-angio-sarcoma diagnosis. Note gIands of both sides of nec6 :.

El

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They are time-consuming, uncertain in action and in this type of case shouId not be empIoyed.

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reported that of 303 cases of carcinoma of the tongue which came under their observation between January I, 1910 and

FIG. ‘3. Lesion healed after excision with the endotherm

Recent knowIedge and Broders’ cIassification of neopIastic growths on the basis of ceI1 differentiation or degree of malignancy have shown the foIIy of generalization in treatment. AIthough surgery stiI1 remains the cancer sufferer’s chief hope, it is as wrong to cut a11 cancers as it is to treat a11 cancers by physical measures. Grades one and two, being Iess maIignant, are more responsive to treatment and can be reached by a wider range of curative measures than can grades three and four, which offer far Iess hope if attacked soIeIy by conventiona means. The vaIue of this to the patient is very great. So many cases of cancer, however, are aIready beyond the reach of the scaIpe1 when first seen by the surgeon that there is urgent need for a new method. To iIIustrate: In 1925, Simmons of Boston, reporting from the CoIIis P. Huntington MemoriaI HospitaI, found that of 103 cases of carcinoma of the tongue who applied for treatment, 76 were inoperabIe, SimilarIy, Clinic. Judd and New. of the Mavo

Journal

knife.

January I, 1922, 186 (61 per cent) were inoperabIe. To seek to Iimit the number of these so-called inoperabIe cases mereIy

FIG. 4.-Gross

specimen removed in toto.

by urging earIy examination and earlier operation is not enough. There is need of a&icabiIitv of surgerv’s an extension

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that wiII not onIy reach a much Iarger percentage of cases as they appIy but wiI1 reach them with more Iasting benefit. Judd has since said: “For growths too extensive for radica1 surgica1 removal diathermy offers the best prospect.” We go further and suggest that a remedy which offers the best prospect in cases too extensive for scaIpe1 remova offers aIs the best prospect in cases not too extensive for scaIpe1 remova1.

FIG. 5. Photomicrograph of fibro-angio-sarcoma. (Figs. 1-5 from Wyeth, G. A., Surgery of NeopIastic Diseases by EIectrothermaI Methods. New York. PauI B. Hoeber, Inc., 1926.)

In endothermy we have three procedures: to desiccate the maIignancy, to coaguIate the maIignancy, or to exercise the maIignancy with the endotherm knife which seaIs Iymphatics as it cuts. There is aIso a technic of combining the use of the coaguIating and the cutting currents to make possibIe the destruction of maIignancy in situ and its excision as a dead mass instead of as a group of viabIe ceIIs. This greatIy reduces the danger of metastasis and the IikeIihood of recurrence, and the operation can be done without hemorrhage. These severa procedures are not interchangeabIe; each has its own indication and shouId be Iearned and used accordingIy. It is in the fieId of mouth carcinoma that

APRIL, 1928

endothermy finds its greatest usefuIness. Danger of mechanica transpIantation is minimized, hemorrhage and surgica1 shock are eIiminated and there is an immediate steriIizing effect of intense heat upon the fou1, painfu1 area which permits the earIy return to norma diet. In a11 cases of cancer of the ora cavity we reaIize that the great probIem Iies in the neck. In the brief space aIIotted this paper there can be no discussion of detaiIed treatment. We wouId say onIy that our experience has Iead us to share the view of Mr. CIayton-Greene and his EngIish confreres. Mr. CIayton-Greene more and more says : “I am becoming doubtfu1 as to the vaIue of big gIand dissections practised in cases of carcinoma of the tongue. If the gIands are not invoIved the operation is unnecessary and if they are extensiveIy affected it does not seem to prevent recurrence.” To the surgeon whose teaching has incIuded the remova of a11 gIands of the neck in treating cancer of the mouth and who is unwiIIing to change the fixed routine of the operation, we suggest onIy that in the endotherm knife there is provided a means by which this dissection may be done without opening Iymphatics. In those exceptiona cases, meIanomas and the various maIignant Iesions which by their very extent or by the depth of their invoIvement must be cIassed as inoperabIe by any carefu1 user of the scaIpe1, endothermy greatIy extends surgery’s usefuIness. Its resuIts cannot be dismissed as the accompIishment of a cautery and endothermy shouId not be spoken of as cauterization. There is no burning. The appIicator is aIways coId when appIied, the heat coming from within the tissues in response to the many osciIIations of the high-frequency current. In tumors of the breast endothermy finds further opportunity for service. ArchibaId Leitch, Director of the Cancer Research Institute, London, said in 1925: “The surgica1 treatment of cancer of the breast has not undergone any marked improvement during the Iast quarter of a

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century; nothing that is both new and true has been added in that time to our knowIedge of the surgica1 pathoIogy. It wouId appear as if the Iimits of operation had . . It is a fact that been reached. onIy some IO per cent of cases that have been operated wiII be aIive after ten years.” We beIieve that it is now time to mention something that is both new and true by way of improvement in the technic of breast cancers and to indicate briefI\

the radicaI breast operation in the new endothermic methods. We have recentIy done a number of radical breast operations various suspicious as we11 as excised eIectrothermic using noduIes, Iooking methods aIone, securing primary union in al1 but one, a simpIe amputation in a fat patient. In the radical procedures the axiIIary and infracIavicuIar tissues were also compIeteIy dissected out with the endotherm knife. ”

FIG. 6. Appearance February 18, 1928. GIands have been completely absorbed and are no longer palpable. Scar is from oId biopsy.

FIG. 7. F. M. FemaIe, thirty-five years oId. Grade IV (Broders) squamous ceI1 epitheIioma of the tongue. Hemiglossectomy without hemorrhage and shock by bipolar endothermy and the endotherm knife (June 6, 1927). This figure shows appearance February 16, 1928.

different methods of. attack in several breast conditions. First, in the very earIy cases of breast tumors where there is but the presence of a suspicious noduIe, we use a very fine needIe for the cutting current and incise down to the * smaI1 tumor. GraduaIIy eIevating it by working around it, we remove the noduIe without opening the Iymphatics. We are thus enabIed to make a definite microscopic diagnosis without jeopardizing the patient through mechanica dissemination. In discussing radica1 amputation of the breast with the endotherm knife and without Iigatures, KeIIy of BaItimore, weIcomes changes which tend to shorten the length of operation and decrease the handIing of the wound whiIe protecting the patient from the Iikelihood of infection and the dissemination of tumor ceIIs. He says: “We beIieve we have such an improvement in

In advanced carcinoma of the breast, particularly of the fungating variety, if shows no bone or the roentgenogram Iung metastasis and the patient’s baIance has not been broken, by the combined technic of bipoIar endothermy and the endotherm knife we perform a two-stage operation which isoIates and immediateIy removes the offending part first and later cleans out the axiIla and cares for the supraclavicular space. There is time to speak but brieffy of the cases of maIignancy Iocated in cavities which may be made accessibIe, such as maIignancy of the antrum, Iarynx, bIadder. One would say in general that it is our custom to open the cavity with the endotherm knife, expose the neopIastic growth to full view and proceed to destroy and remove it after the indicated technic of endothermy. SureIy one is justified in

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first offering to his patient this akernative of eIectrothermic destruction before submitting him to the crippIing operation of compIete Iaryngectomy for a beginning carcinoma. The procedure is a new one and in recommending new methods and the modification of old methods to the attention of the profession we wouId quote what Dr. Lewis McArthur so effectiveIy said

at the meeting of the American Medical Association in St. Louis. Urging upon his colIeagues the importance of deviating from accepted surgica1 axioms and even, in rare instances, operative procedures at variance with estabhshed surgica1 teaching, Dr. McArthur said: “Otherwise surgica1 judgment is banished and surgery becomes a set of formuIas; the surgeon disappears and there remains onIy the operator.”