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'^^^ k^ ^^ ■ H:'s

Ca) Case of Subohordal Spindle
celled Sarcoma, and its Suo-
cessfnl Bemoval by
Thyreotomy.

H. S. BIEKETT, M. D.,

Bniw DwnoBitnter of Auktaanf ud LMtaNT en Lana.

oUvr, MoCHU Ufltrmit^: Ufyagologtat to tlw

Montital a«a«nl Hn^itaL

xnmnMD nox tbb

IfttD ITofit HUMcal Jotmial

/or ITomnbtr 17, 1894.

Reprinted from the New York MedicalJoitrnal
for November 17, 1804'

• '1

A CASE OF
SUBCHORDAL SPINDLE-CELLED SARCOMA,

AND ITS SUCCESSFUL REMOVAL BY THYREOTOMY.*
By H. S. BIRKETT, M. D., Montreal,

SENIOR DBMON8TBATOR OP ANATOMY AND LEOTUBEB ON LARTNGOLOGT,

MC GILL UNIVERSITY ;
LARYNGOLOGI9T TO TUB MONTREAL GENERAL HOSPITAL.

Upon May 30, 1891, I was called in consultation by the late
Dr. Georjje Ross to see Mrs. McQ., aged twenty-two years, in
reference to marked dyspnoea, evidently due to laryngeal ob-
struction, from which she was suffering.

The patient stated that she began to be hoarse four months
ago, and that this had gradually increased until there was
almost complete aphonia. Dyspnoea set in four weeks ago and
slowly increased, until within tiie past two weeks it had been
so marked as to prevent the patient lying down, and for the
past few days any attempt to lie down would bring on an at-
tack of suffocation. Within this last-mentioned period— two
days — inspiratory stridor has set in, accompanied by depression
of the supraclavicular, infraclavicular, and suprasternal regions.

The patient is thin and anaemic-looking, is between eight
and nine months advanced in pregnancy (primipara) ; her facial
expression is that of anxiety ; sits in the upright position all the

* Accepted as a candidate's thesis for membership in the American
Laryngological Association, May, 1893.

-1.. V «j*^a

SUBCHORDAL SPINDLE-CELLED SARCOMA.

time, mouth widely open, and respiration is carried on with a
good deal of distress ; her voice is aphonic and inspiration is
accompanied by marked stridor.

Family and personal histories are absolutely negative re-
garding any phthisical, syphilitic, or malignant taint.

Laryngoscopic examination revealed a large subglottic tu-
mor, occupying so much of the space below the cords as to leave
only a very small chink, equal to the size of an ordinary knit-
ting needle, between the posterior surface of the tumor and the
posterior wall of the larynx, through which respiration is with
great diflBculty carried on.

The surface of the tumor is of a dusky red color and upon
it several small distended vessels are discernible.

The movements of the vocal cords are perfectly free and they
meet well over the surface of the tumor in the median line.
The right vocal cord is congested at its anterior third.

I advised preliminary tracheotomy as being at the present
moment urgent and necessary in order to relieve the dangerous
supervening symptoms of possible suffocation. Consequently,
on the following day I performed tracheotomy, being kindly
assisted by Dr. Roddick.

Chloroform was administered only to incomplete insensibil-
ity. There was nothing unusual to note during the steps of the
operation, further than that the isthmus as well as the lateral
lobes of the thyreoid gland were much enlarged, and coming
down from the isthmus to join the transverse innominate vein
were three very much dilated veins, each about the size of a
goose quill. It was found necessary to ligate the middle one,
which lay upon the center of the trachea, the others being held
to one side. I decided to open the trachea as low down as
possible, because it was uncertain how far down the tumor
might extend into the trachea. Upon the introduction of the
tube (Durham) the breathing at once became tranquil and
easy.

Twelve days later, the patient having hitherto progressed
satisfactorily, the temperature having never risen above normal,
upon consultation with Dr. George Ross and Dr. J. C. Cameron,
it was decided that premature labor should be induced, and

SUBCHORDAL SPLVDLE-CELLED SARCOMA.

with that in view Dr. J. C. Cameron undertook the charge of
the cnse.

Two days subsequently the patient was delivered of a well-
developed female cliild.

The influence of this delivery upon the condition of the
tumor was striking. Laryngoscopic examination showed that
the laryngeal tumor had decreased in size, leaving, consequently,
a larger breathing space, and the hypereemia of the right vocal
cord which was seen earlier in the progress of the case had
completely disappeared, leaving it perfectly white, and when the
tracheal wound was closed the patient could breathe more freely,
though still the breathing was labored.

Three weeks after the confinement the operation for re-
moval of the intralaryngeal tumor by means of thyreotomy was
undertaken. r

In this procedure I was kindly assisted by Dr. Shepherd.
Chloroform was administered through the tracheal cannula by
Dr. Evans.

The site of the of)eration was thoroughly cleansed by means
of hot water and soap; the head thrown back over a round
pillow. The incision was made in the median line from the
upper border of the thyreoid cartilage to the lower border of
the cricoid cartilage, continuing the dissection until reaching
the thyreoid cartilage, an-' <!uring these steps there were several
veins cut which bled ve.y freely, and the amount o^ fat sur-
rounding the structures added to the difficulty of readily expos-
ing the thyreoid cartilage ; this when thorou<:hly exposed was
incised from above downward, exactly between the two alee,
throughout their entirety, and continued through the crico thy-
reoid membrane to the upper border of the cricoid cartilage.

The alsB were held apart, thus completely exposing the
tumor, which was drawn up and out of the larynx and twisted
oflF close to its site of attachment.

The larynx was now thoroughly explored by means of trans-
mitted light, and by the aid of a rhinoscopic mirror inside of
the larynx it was seen that the tumor had had its origin on the
right alsB of the thyreoid cartilage, just below the vocal cord on
that side.

SCBCIIOUDAL SPINDLE-CELLED SARCOMA.

The site of attachment of the tumor was then cauterized
with chromic acid. After tying all the bleeding points which
had been secured by P6an's forceps, I endeavored to suture the
alee of the thyreoid cartilage, but the needle broke on one occa-
sion, and on the second it cut through the cartilage ; in order
then to bring them together, I passed three deep sutures (silk-
worm gut), approximating thus the deeper structures ; superfi-
cial ones closed the wound. The dressing consisted of powdered
iodoform and bichloride gauze.

The tumor after removal weighed twelve grains, and meas-
ured eighteen millimetres long, twelve millimetres wide, and
seven millimetres in thickness.

The tumor was kindly examined by Dn Finley, who de-
scribed it as " a spindle- celled sarcoma with the formation of
strands of young fibrous tissue, rich in embryonic blood-ves-
sels." This has kindly been corroborated by Dr. Wyatt John-
son and Dr. Adami.

The patient made an uninterrupted recovery, the temperature
never rising above 98 5°; was up five days after the operation,
and left for home four days subsequently.

Twelve days from date of last operation the tracheotomy
tube was removed, and the wound soon closed.

However, just at the lower edge of the thyreoid cartilage a
small granulating opening remained, and in spite of all endeav-
ors to close, it refused to do so, until one day, after searching
for some foreign body which probably was preventing its clos-
ing, a buried silkworm-gut suture was removed, and upon its
removal the opening soon closed, and the granulating mass
which was seen in the larynx at a point corresponding to the
opening outside soon disappeared, leaving the anterior wall of
the trachea quite smooth.

I frequently examined this patient, and saw her only four
months ago, previous to her leaving the city permanently, and
found the subglottic region perfectly normal in appearance and
no evidence of any recurrence of the growth ; the vocal cords
retained the normal pearly white appearance and the voice was
absolutely without any alteration in its natural tone.

*■

--^.^

SUBCIIORDAL SPINDLE-CELLED SARCOMA.

This case, so far as I am able to ascertain from the
literature at my disposal, stands unique, for I find no rec-
ord of any case of subchordal spindle-celled sarcoma in
which the operation of thyreotomy had been performed,
and no evidence of its recurrence two years after its re-
moval.

The operation of thyreotomy has frequently been per-
formed for many morbid affections involving the vocal
cords or the structure above and below them, such as
papillomata, myxomata, fibromata, carcinomata, cicatricial
stenosis, removal of foreign bodies, and lately for tubercu-
losis.

In the study of the statistics of the operation of thy-
reotomy, especially those tabulated by Bruns and Karl
Becker, we find that of two hundred and fourteen cases in
which thyreotomy was done for various conditions only
eleven succumbed to effects which could be attributed
directly to the operation itself ; these were pyaemia (two),
diphtheria (three), collapse (one), haemorrhage producing
pulmonary (jedema (five), and bronchitis (one). So, as far
as the operation itself is concerned, it is one therefore
practically devoid of danger, and if there is any danger,
haemorrhage into the trachea at the time of the operation
is the one to be feared.

In the case just cited this was avoided and the use of a
tampon done away with by carefully securing all the bleed-
ing points before the larynx was opened. As regards the
final result, this entirely depends upon the cause which ren-
ders the operation necessary, " while its effect upon the
voice entirely depends upon the seat of the lesion and on
its special character " (Cohen). "

" Some very conflicting opinions have been expressed
with regard to thyreotomy, some asserting that it is an
operation free from danger and threatening life, while oth-

SUBCn()ll[)AL SI'INDLR-CKLLKD SAnCOMA.

ors maintain the opposite. Probably ProfenHor Virchow's
opinion is correct — namely, that tbyrootomy, performed in
an otherwise healthy larynx, is an operation free from risk
and danger" (lieverly, British Medical Jountaf, 1801, ii).

The late Sir Morell Mackenzie did not think ample room
was obtained bv division of the thyreoid, and preferred to
do tracheotomy and then remove per vias natura/es, holdinuf
that the space obtained by thyreotomy was smaller than tlie
glottis (Holmes).

Wagner believes that the danger to life from the opera-
tion itself is very slight. Wagner, in a pHj)er on thyreoto-
my, states that " this operation sliould only be resorted to
for the relief of urgent dyspmea arising from laryngeal
obstruction caused by the j)resence of benign neoplasms or
a foreign body, and in which the operation per vias natu-
rales is unadvisable or impracticable. In cases of malignant
disease it should only be performed where there is a reason-
able possibility of eradicating the disease thereby."

Regarding the operation of thvreotomy for tuberculo-
sis, opinions are divided ; according to Becker, relief is al-
ways given even when death is merely postponed ; whereas
A. Bergmann warns against operative interference in tuber-
culosis of the larynx by laryngo fissure, scraping, and
cauterization ; he had signally failed in so treating two
selected cases (Solis Cohen in Sajous's Annual^ 1890 and
1891).

According to Wagner, the operation in tuberculosis is
unjustifiable, and death, which is inevitable in these cases,
is likely to be hastened by it.

The reasons for adopting the measure I did in this
case rather than removing the growth per vias naturales
are these :

1. The appearance of the tumor, as seen by the laryn-
goscope, and the history of its rapid development led me

•. f

■■

SUUCIIOHDAL SriNDr.K-CELLED SARCOMA. f

to believe that I had to deal with a tumor most probably
malignant in its nature, and that its thorough extirpation
could not be carried out satisfactorily except by tliyreot-
omy.

2. It was impossible to tell by laryngoscopic examina-
tion whether tiie tumor was limited entirely to the larynx
itself or had an attachment by a broad base to the anterior
wall of the trachea.

3. From the hyperscmic appearance which the tumor
had, it was more than probable that removal of it piece-
meal per vias naUirales would have been attended with
trouble — some hjemorrhage into the trachea.

4. Presuming the growth to be malignant, its removal
per vias naturales might have led to self-inoculation of
other structures within the larynx through slight abra-
sion of the mucous membrane caused by operative inter-
erence.

5. To insure its thorough removal as far as possible per
vias naturales would have entailed a long time in the train-
ing of the patient, which, under the then existing circum-
stances (pregnancy), might have been more trying and
tedious than the operation then performed. '

Note. — In May last I again saw this patient. Tliere was abso-
lutely no evidence of any recurrence, and the voice was perfectly clear
and the patient's health very good.— II. S, B.

New York Medical JoiiraaL

A, WEEKLY BEVXEW OF XEDICINE.

XDITBD BY

FRANK p. FOSTER, M.D.

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