LONG IMMUNITY FROM RECURRENCE AFTER MOVAL OF EPITHELIOMA OF THE LOWER LIP.
DR. CHARLES N. DOWD presented an old man upon whom he had operated for the removal of an epithelioma of the lower lip early in December, 1895, that is, almost five years ago. Up to the present date there have been absolutely no signs of a recurrence.
The patient was first presented at a meeting of the Surgical Section of the New York Academy of Medicine in December, 1896, and the operation was described in detail in the New York Medical Record, February 20, 1897.
A photograph of the taken previous to the operation, showed that the growth extended along the entire length of the lower lip. It also involved a large number of the submaxillary lymph nodes, some having attained the size of the end of a man's thumb. The operation done was a modification of Malgaigne's. It differed from Malgaigne's in that the lower incisions were carried beneath the body of the jaw, extending from the tip of the chin nearly back to the angle of the jaw. Through these incisions the submaxillary spaces can be thoroughly cleared out. The patient made an uneventful recovery, and the plastic effects of the operation were excellent. The diagnosis was confirmed by the pathologist.
DR. Howard Lilienthal said the result in DT. Dowd's case was certainly remarkable, and in view of this he inquired whether the intervening tissues between the lip and the submaxillary spaces were also removed, and whether those tissues were at all infiltrated by the disease? DR. Dowd that the tissues immediately adjacent to the growth were removed, perhaps to a distance of one-half or three-quarters of an inch. The tissues in the narrow strip be tween this point and the submaxillary spaces were not infiltrated and were not removed.
The growth in this case had existed for four years previous to the operation, and it was only during the last year that it had advanced rapidly. It belonged to the slowly progressing type of epithelioma, and in this variety the prognosis is more hopeful than in those cases where the growth is rapid.
DR. Lilienthal said that in Dr. Dowd's case the disease had evidently extended by glandular infiltration rather than by direct infiltration of the tissues between the growth and the sub maxillary glands. The speaker said that the happy outcome of this case ought to render the surgeon more hopeful than many now feel in dealing with this class of malignant growths.
DR. F. KAMMERER said he thought the rule was generally accepted that in growths of this kind the lymphatics may be in volved without any involvement of the tissues between the origi nal site of the disease and the glands. Operations are often done in accordance with that theory.
DR. Curtis referred to the case of an old man with an epithelioma of the hand, and secondary involvement of the epi trochlear and axillary glands. The growth was removed, together with all the enlarged glands, and no recurrence had taken place three years after the operation. In that case it would have been impossible to remove the intermediary tissues except by ampu tation at the shoulder, and, although the general plan is to remove such tissues if we can, the compromise gave good results.
DR. Lillienthal said that to illustrate the point he had brought up he would call attention to the general rule of resort ing to amputation for the radical extirpation of malignant disease in certain regions, the amputation to be done as far away from the disease as possible. All our work in amputation of the breast has been based on the assumption that the intervening tissue be tween the breast and axilla is diseased. Still, Dr. Lilienthal said, he admitted the criticism of Dr. Kammerer.
AN EXOSTOSIS OF THE SHOULDER SIMULATING DISLOCATION.
DR.Ellsworth Eliot presented a boy who was brought to the Presbyterian Hospital last June, with the history that on the previous day he had suffered from a trauma of the right shoulder which was so severe that it had rendered the boy inca pable of using his arm. Following this injury a deformity of the shoulder was noticed : it was regarded as a dislocation, and a physician had made an unsuccessful attempt to reduce it.
When the boy was brought to the hospital he was unable to abduct the arm or make any movements of the shoulder-joint, and when these were carried out passively, they provoked a great deal of pain. Examination showed a large, round, hard mass on the inner side of the arm, extending from the level of the deltoid insertion below to a point opposite the anatomical neck of the humerus above. This mass was firmly fixed to the shaft of the bone; it was slightly lobulated ; its surface was smooth, and the skin over it was freely movable. The deformity was ascribed to a fracture or dislocation (or both) of the shoulder-joint. A sub sequent examination under an anaesthetic failed to show either a fracture or dislocation, and demonstrated that the deformity was due to a new bony growth to which attention had been attracted for the first time by the accident. It had never been noticed by either the boy or his parents, and had given rise to no symptoms until the time of the accident.
An incision was made in a direction corresponding to the border of the pectoral major, and the growth was exposed and chiselled off. There was no definite line of demarcation between the growth and the humerus, of which it practically formed a part. On account of its size, it was supposed to be malignant, and in excising it a wide margin was given. At the conclusion of the operation, the compact bone forming the external surface of the shaft alone joined the head of the humerus to its lower extremity (below deltoid insertion). Drs. Thatcher and Tut tle, the pathologists of the hospital, reported that it seemed to be an osteoma : they were unable to detect any evidence of sarcoma.
Since the operation, there has been a new growth of bone to take the place of that portion of the humerus which was ex cised, and the motion of the limb is slightly limited at the shoulder only by the contraction of the cicatrix.