CLINICAL LECTUREON

AN OBSCURE TUMOR OF THE ABDOMEN—AMPUTATION OF THE BREASTFOR PAGET’S DISEASE FOLLOWED BY CANCER—TUBERCU-

LOSIS OF THE TONSIL AND SOFT PALATE, BY AMETHOD WHICH AVOIDED SPLITTING OF THE

CHEEK OR DIVIDING THE JAW.

DELIVERED AT THE

JEFFERSON MEDICAL COLLEGE HOSPITAL

BY

W. W. KEEN, M.D.,Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College.

[Reprinted from Dunglison’s College and Clinical Record, February, 1597.]

swrgial OTttic.OBSCURE TUMOR OF ABDOMEN-

AMPUTATION OF BREAST FORPAGET’S DISEASE FOLLOWED BYCANCER —TUBERCULOSIS OFTONSIL AND SOFT PALATE;OPERATION BY A METHOD WHICHAVOIDED SPLITTING OF THECHEEK OR DIVIDING THE JAW.

Delivered at the Jefferson Medical College Hospital, November25, 1896,

BY PROF. W. W. KEEN, M. D.

The first case I shall show you is a manwith an

Obscure Tumor in the Epigastrium,who has been examined at my request by mycolleague, Prof. James C. Wilson, from themedical standpoint as well as by myself fromthe surgical.

Please remember, gentlemen, no matterhow much knowledge you have you will notuncommonly run across obscure cases. Neverhesitate for a moment to say theyare obscure,and to ask for a consultation with one inwhose judgment and acute clinical powersyou have confidence, as I have in those ofProf.Wilson.

You will remember that this man was be-fore you three weeks ago. I show him nowin order that you may observe the effectof treatment, and to show you that the tenta-tive diagnosis we then made is, without muchdoubt, correct. His history, you may re-member, was as follows :

O. D., age thirty-seven, was admitted to theJefferson Hospital Nov. 2, 1896. His familyand personal history have been very good,with the exception of the fact that he has had4 attacks of gonorrhoea and 5 chancroidswith suppurating buboes in each groin aboutfive years ago. He denies any primary syph-ilitic attack or secondary symptoms. Hispresent trouble began about one year agowith pain in the epigastric region, which alsowas felt, but to a less extent, in both hypo-chondriac regions. The attacks have been

irregular, the intervals being from one day toabout two weeks. Occasionally during thelast summer he had attacks of vomiting onrising, the fluid ejected being practically clear.He has never vomited blood nor has he everpassed blood in his stools. His weight ispractically the same as it has been for a num-ber of years. His appetite is good ; bowelmovements regular. His food has never lainany length of time in his stomach.

On examination, a hard, nodular tumor,apparently about Iby 1 inches, is felt inthe epigastrium just beneath the abdominalwall, or possibly even in it. It is slightlytender, and dull on percussion. The dulnessis continuous with that of the liver, whichextends about 2 inches below the border ofthe ribs. He has never had jaundice. OnNovember 4th the stomach was emptied, a

test meal given him, and free hydrochloricacid found. The urine is clear amber, acid,sp. gr. 1.027, neither albumin, sugar, nor bilepigment is found. Microscopically, also,nothing is found except normal constituentsof the urine. His temperature is normal.

The diagnosis here lay, first, between atumor of the liver; second, of the pylorus;third, possibly of the omentum ; and, fourth,on account of its apparently superficialposition, that it might possibly be a tumorof the abdominal wall. Careful examina-tion showed that it was movable in relationto the abdominal wall, and, therefore, wascertainly not connected with it. The absenceofall gastric symptoms, vomiting, dyspepsia,retained food, dilatation of the stomach,etc., militated, in the opinion of Prof. Wilsonand myself, against its being pyloric, or, infact, any form of gastric tumor. Omentaltumors are not, as you know, very common.Hepatic tumors are much more common.The presumption, therefore, simply on thedoctrine of chances, was rather in favor of itsbeing hepatic. The man’s admission of thevery frequent possibility ofsyphilitic infectionshould weigh very seriously with us, althoughhe denies, at least, any knowledge of such aninfection. The absence of marked hepaticdisturbance itself would look toward a syphi-

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litic gumma. Were it a cancerous nodule, thepain would be much greater, and there wouldbe more disturbance of his general health,and probably, or at least possibly, some dis-turbance of the hepatic function. Percussiongave us but little information, but auscultationwas of greater value, especially in limiting itprobably to the liver. The phonendescopewould seem to indicate that it is hepatic, as,while the phonendescope was upon the tumor,tapping upon the liver at any point gave us amarked resonance, whereas when we left theliver the resonance diminished very much.We made, therefore, a tentative diagnosis ofa gumma of the liver, and placed the patientupon iodide of potassium, beginning with 10grains three times a day, and gradually in-creased it until there was evidence of improve-ment. To-day I am very glad to show youthe result: the tumor itself is still there, butit has diminished very much in size, so that itis just perceptible, and presumably will dis-appear, therefore, entirely; and the man’sgeneral health has so much improved that heis anxious to get back to his work. He hassteadily taken the iodide for four weeks, thedose having been gradually increased untilhe has of late taken a drachm three times aday. It is not uncommonly a pretty safepractice to remember, when you have obscuretumors, to place the patient on iodide ofpotassium. The denial of syphilis is verycommon, but if the diagnosis is obscure itwill do little, if any, harm to give the iodide;and sometimes it will prove that the patientlied, and, at the same time, will cure him.

The second case that I shall show you isone of

Paget’s Disease of the Nipple Fol-lowed by Cancer of the Breast.

Her history is as follows; Mrs. D., agesixty-two, Bath Run, Pennsylvania. Was ad-mitted to the Jefferson Hospital November22, 1896. Her mother died at seventy-eightfrom influenza; her father at sixty-nine fromapoplexy; 6 brothers and sisters are livingand in good health. She was married attwenty-seven and has had 7 children. She

never had any trouble with the breast innursing her children. In March, 1895, shenoticed a small crust at the apex of the leftnipple. By January, 1896, instead of healing,this had become redder, and exuded a stickydischarge, with some burning in the diseasedarea. In the summer of 1896, sharp shootingpain developed in the left breast itself, andabout that time the whole nipple sloughed off.She has observed for the last three monthsthat the breast has grown rapidly and thepain has become much more severe. On ex-amination I found that both breasts were verylarge; in the left one, there was a distincttumor to be felt in the upper outer quadrant,movable, slightly nodulated, and dense instructure. The nipple is gone and a fissurehas replaced it. From this fissure there is amoderate amount of clear, watery, but glutin-ous discharge. The glands in the axilla areindistinctly felt.

The diagnosis in this case is easy. Thereis no retraction of the nipple, so frequentlyinsisted on in cancer of the breast, for thereason that there is no nipple; it has droppedoff, having been ulcerated away. The diseasewith which this woman was first attacked fortwenty-one months is that known by varioussynonyms, as chronic eczema of the nipple,psoriasis of the nipple, or Paget’s disease ofthe nipple. Whenever you have a woman,especially if she is approaching or past forty,with a chronic ulceration of the nipple, bevery watchful of such a case. Should it notheal after a reasonable time, you may bealmost sure that you have to deal with a formof disease which most pathologists now be-lieve to be an epithelioma of the nipple, andwhich, certainly in very many cases, is thebeginning of cancerous disease of the entirebreast. In this very case, you see that it hasbeen followed by a large, hard nodule of un-doubted cancer in the breast. Not long sinceI operated upon a case in which thirteenyears had elapsed from the beginning of theulceration of the nipple. But not only in thenipple, but if on the lip, the anus, on thehands, the foot, in fact anywhere in the body,an ulcer is chronic and does not get well

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within a few weeks, your suspicions as to itscancerous nature should be aroused, and youshould investigate it with great care; if needbe by excision of a piece for microscopicalexamination. Only one exception occurs tome to this rule, and that is the very commonand very chronic ulceration which developsjust above the ankle, and especially above theinner malleolus. These are often long-con-tinued chronic ulcers without any tendency,excepting in very rare cases, to become ma-lignant.

The operation that I shall do is that ofHalsted’s; namely, removal of the breast,both pectoral muscles, and all the contents ofthe axilla, excepting- the blood-vessels andnerves, all in one piece. In so large a breastas this the operation is necessarily difficult,long, and we will have rather more bleedingthan usual. As you see, however,, as I goalong, no very special trouble has arisen. Iam always, however, afraid of another troublein such very fat breasts—that we may havenecrosis of the fatty tissue even without anyprimary infection. This I have seen repeat-edly, together with a very sour butiric smellfrom the fermentation accompanying thenecrosis.

Before the operation no glands could be felt,but the operation has revealed a number ofglands about the size of buck-shot, especiallyjust below the clavicle and in immediate juxta-position to the vessels. The supraclavicularglands are not involved and I therefore didnot remove them.

After-history. —The patient was entirelywell and the stitches out within a week, herhighest temperature having risen only onceto ioo°. The microscopical diagnosis re-ported by Dr. Rhoads, the pathological andbacteriological assistant in the surgical clinic,was that both the nipple and the breast werecarcinomatous of the scirrhous variety, andsome of the supposed small glands in theaxilla were in reality aggregations of carcino-matous cells.

The third case that I shall show you is oneof

Tuberculosis of the Tonsil and theSoft Palate.

You will notice the order in which I haveshown these patients : First, the patient uponwhom no operation was done; second, thebreast case, which was a clean, aseptic op-eration from the beginning ; and, third, theoperation on the mouth, where my lingerswould necessarily be carried into the mouthand become more or less soiled. Had I op-erated on the breast case last, the soilingmight have been carried over to the breastcase in spite of intervening disinfection ofthe hands. The rule in our clinic, as youknow, is always the clean cases first; infectedcases last.

The patient’s history is as follows: Hisfather and mother died from unknown causesat eighty-seven and seventy years respect-ively; two sisters died in childhood andthree brothers and sisters are living and ingood health. With the exception of malariaat twenty-six, he has always enjoyed goodhealth till six years ago, since which time hehas complained of sore throat, especially onthe left side, which pained him especially onswallowing any hard food. About six weeksago, he noticed a small tumor under the angleof the jaw on the left side. With this therehas been an increased dull pain in the lefttonsil, with a constant desire to swallow. Theurine is normal.

On examining the throat, the nature of thetrouble is very quickly seen. The entire lefttonsil presents an ulcer, the ulceration extend-ing from the soft palate nearly to the uvula byway of the anterior and posterior arches of thepalate, and also, below the tonsil, extendingdown almost to the tongue and somewhat onthe lateral wall of the fauces. By touch this isdistinctly hard, and the tissues are infiltratedto a moderate distance around the growth.The appearance of the growth, together withthe enlarged glands under the angle of thejaw, makes the diagnosis practically quitecertain—that of epithelioma. It is, however,quite remarkable that the soreness, presum-ably from the disease in the tonsil, shouldhave existed for so long a period as six years.

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The treatment is quite as clear as the diag-nosis ; namely, extirpation both of the dis-eased tissues in the throat and of the enlargedglands. In fact, if the glands were not en-larged, I should decide,—just as in cases ofcancer of the breast the axillary glands arealways removed, —to make an incision underthe jaw and remove all the submaxillary lym-phatic glands which could be detected. Weare sometimes apt to forget principles in rules.If it is right to remove the axillary glands inevery case of malignant disease of the breast,the same should hold good in every otherpart of the body ; glands under the jaw or inthe neck should be removed in every case ofmalignant disease of the face, and the saph-enous glands and the glands of the groinshould also be removed in malignant diseaseof the foot or of the genitals.

The first step here will be removal of theglands in the neck. This can be accomplishedas a primary operation, and without openingthe mouth. In addition to this we can thendetermine whether it will be possible to re-move the tonsil and the adjacent structuresfrom the wound in the neck, or whether itwill be best to attack them through themouth.

Operation.—An incision was first made fromjust below the chin to the ear, passing a littlebelow the angle of the jaw. One very largeand several smaller but enlarged glands wereremoved. The dissection was made difficultby the fact that the large gland was veryclosely adherent to the jugular, and had dis-placed it and the carotid forward. When Ihad completed the removal of these glands,therefore, the jugular and the common, theexternal and the internal carotids, and thehypoglossal, as well as the spinal accessorynerves, were all exposed to view. I thenpassed my left forefinger into the mouth incontact with the ulcer and with my right fore-finger in the wound under the jaw pro-ceeded to explore the extent of the disease:how much thickening there was of the tissues,etc. I was struck with the fact that the twofingers were not very far apart, and it occurredto me that I might be able so far to dissect

or separate the diseased tissues of the pharynxfrom the deeper tissues of the neck by myright forefinger, guided by the left, as to freethem to such a degree that I could both re-move them without endangering the vesselsor other structures, and, also, that the loosen-ing of these tissues would enable me thento pull them forward in the mouth sofar as to make them much more access-ible. This I found to be perfectly true.All the diseased tissues were thrust in-ward toward the mouth and separated fromthe other deeper parts with a good deal ofease, especially guided and assisted by theother forefinger in the mouth. The patientwas then placed in the Trendelenburg posi-tion, the mouth gagged widely open, the leftcheek retracted very far by means of a cheekretractor, and I was then able, seizing the softpalate with a pair of toothed forceps, to cutaway by my knife, first, a little over one-halfof the soft palate, including the uvula, andthen, as I proceeded downward and back-ward, to separate both arches of the palate,and, drawing well forward the excavated andulcerated tonsillar tissues, to cut all theseloose from the underlying tissues.

Not a single vessel required a ligature;pressure by gauze sponges dipped in hotwater enabled me to check entirely the hem-orrhage. I then was able to unite the mar-gins of the mucous membrane perfectly well,and in that manner shut off the neck from,the cavity of the mouth.

For the first three days the patient will befed by a new and disinfected Nelaton cathe-ter passed through the nostril and connectedwith a funnel by an additional piece of rubbertubing. Milk and broth will be fed to him,and when the meal is completed a little waterwill be passed into the stomach through thetube, so that when it is withdrawn no soiling ofthe wound will take place by the food.

Later History.—Primary union took placethroughout the entire external wound, so thatthe stitches were removed and the wound wasentirely healed at the end of a week. Thewound in the throat was quickly healed. Thepatient was out of bed on the third day, and

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felt so well that he wanted to go home imme-diately. His temperature never rose above99.20 , excepting on one occasion.

This method of operating is, to me at least,entirely new. It is very rare to find a case inwhich the infiltration will be so slight, espe-cially after so long a period as in this case, asto allow the diseased tissues to be easily sepa-rated from the parts underneath. I was, how-ever, very much struck with the advantagesof operating in this way in cases in which itis possible. It avoids splitting the cheekor dividing the jaw in order to remove thedisease. A valuable lesson to learn fromthis case is the importance of shutting off themouth cavity from that in the neck, wheneverit is possible, by completely suturing the mu-cous membrane in the mouth. If this can bedone, it prevents infection of the cervicalwound by dropping through of saliva andmucus from the mouth, and promotes to avery large degree primary union. In fact,where the wounds cannot be shut off fromeach other, primary union in the cervicalwound is rare in my experience.

Remarks. —I have thought it only just topublish this clinical lecture just as it was de-livered, for the reason that, at the time, I fullybelieved the case to be one of epithelioma.Its hardness, its appearance, the enlargedgland under the jaw, which was not caseating,all convinced me that it was an epithelioma ;

so much so that I did not follow my usualpractice of removing a small piece, undercocaine, for a microscopical diagnosis. I wasgreatly surprised, therefore, whenDr. Rhoads,the bacteriological and pathological assistantin the surgical clinic, and Prof. Coplin, in-formed me that the disease was tubercular,as illustrated in the accompanying drawingmade by Dr. Bevan.

The result shows very clearly that it is wisein all cases in which a small piece of a tumorcan be removed for microscopical examinationthat it should be done. So far as the treat-ment is concerned, it would not, I think, havebeen changed even had I known that it wastubercular. The disease was so extensive,and had been so long-continued, that I should

have extirpated it in either case. The resultcertainly leaves nothing to be desired; eventhe patient’s voice is quite clear, and far lessaltered than I had anticipated it would be.The facility with which the diseased structureswere separated from the underlying parts bythe finger is explained also by the nature ofthe disease as disclosed by the microscope,

Tonsil Showing Tubercle of a Lymphoid Follicle withBeginning Degenerative Changes. Beck, g obj.; oc., A.The tuberclebacilli are drawn in from another specimen stainedby carbo-fuchsin. Zeiss, obj.; oc., C.

Remarks by Prof. Coplin.—Tubercu-losis of the tonsil in an otherwise non-tuber-cular individual is certainly sufficiently rare todemand record. In patients having tuber-culosis of the larynx or lungs implication ofthe pharynx, tonsils, or uvula may be ex-pected (Isambert, B. Frankel, Scheck). Allauthorities agree, however, as to the in-frequency of primary tuberculosis of theseparts.

Further, it is of unusual interest that themorbid process may be quiescent for an al-most indefinite period, and that an outbreakmay be long delayed. Indeed, it has beenmaintained by Dmochowski that the tonsilmay be the seat of tubercular infection andpermit extension to the gland of the neckwithout itself evincing any gross change. Themicroscope, however, shows us in this case

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infiltration of the lymphoid follicles and thestroma by tubercle bacilli, and, where the in-filtration is marked, degenerative changes inthe lymphoid elements. An enormous ex-cess of leucocytes in the stroma is one of thecharacteristic histological phenomena of tuber-culosis of the tonsil; the accompanying draw-ing shows this point. Where ulceration occurs

it is by coagulation necrosis in the lymphoidstructure, secondary infection by other bacte-ria, and subsequent softening. In some casesinvolving the mucosa and the lymphoid struc-ture as it overlies the muscular tissues of theuvula or pillars, the tubercles may be seenand a diagnosis made without any difficulty.Such cases are infrequent.