.........
BEFORE ORAI
.
BEFORFE OPERATION.
...
AFTER OPERATION.
FRIDENBERG: Ezxostosis of the Frontal Sinus.
289
DR. W. H. CARMALT.- Dr. Bull made use of an expression' that does not hold good in regard to bone tumors of other parts of the body, viz.: that sarcoma following injury to the bones of the orbit is rare. In regard to other bones, we consider that sarcoma not infrequently follows trauma-; this is certainly true in regard to fractures. The history of general surgery is very positive in that direction, but I have not looked up the literature with special reference to the bones of the orbit. and while Dr. Btull is undoubtedly correct in his statement, the exception is worth noting. DR. W. B. JOHNSON.- I think these cases of sarcoma of the bone following traumatism are only frequent as related to tumors of the bone in other localities, and not as related to tumors in general, of malignant character. I had a case the counterpart of Dr. Bull's which I reported to this society, I think, a year or two ago, in which the nose, frontal sinus, antrum, and ethmoidal sinuses were all involved in the disease, which resulted from a blow received while entering a gate, and the removal of the superior maxillary bone and tumor was made. The child recovered from the operation, but died two months afterwards from extension of the disease through the ethmoidal sinuses to the cerebral cavity. It is a question what to do with these cases. I reported several cases at the Pan-American Medical Congress in which operation was performed, and I think they were more comfortable than were other cases which had gone on until death without operation. There is also the remote possibility of the tumor failing to return, which helps to make such operations justifiable.
EXOSTOSIS OF THE FRONTAL SINUS - ENOPH-
THALMOS. BY EDWARD FRIDENBERG, M.D., NEW YORK CITY.
Professor Dolbeau of Paris was the ilrst surgeon to successfully remove by operation an orbital osteoma having its origin in the frontal sinus. His patient, operated in I867, recovered after a slight attack of meningitis. Knapp in i88o removed a similar growth by the method of subperiosteal enucleation without any
290
FRIDENBERG: Exostosis of the Frontal Sinus.
untoward symptoms. Since that time quite a number of cases have been published in which these osseous tumors have been extirpated, and the danger of erysipelas, meningitis, or cerebral abscess, from which all cases treated by purely operative measures, previous to Dolbeau's, had perished, seems to be in great part obviated. The improved prognosis of the operation for exostosis of the frontal sinus is due principally to early operation, thorough antisepsis or asepsis, and finally to the fact that we have learned not to attack the tumor itself, but to chisel away the bone, usually the anterior wall of the frontal sinus, holding and confining it. The case which I present has two features of interest: (i) The position of the tumor, which was located much more toward the temporal aspect of the orbit than usual, the mass of the osteoma being about at the center of the upper orbital margin. (2) The position of the eye, which was crowded backward into the orbit and slightly downwards. In other words, there was enophthalmos instead of the customary exophthalmos. The patient, R. I., a Scotchman, aged 28, was first seen in August, I893. He stated that at the age of fourteen he was often "joked " by his friends because his left eye was a trifle smaller than the right. He had always had better vision in the right eye, the difference increasing markedly of late years. Nine years ago he noticed a swelling at the upper margin of the left orbit, which has grown slowly but steadily, pressing the eye back and closing it up. There was no pain and no history of traumatism or constitutional taint. An operation was proposed, but refused. The patient returned in January, I894. The tumor had grown slightly and presented as a nearly smooth, rounded mass, about thr size of a walnut in the center of the left supraciliary ridge. It was absolutely hard to the touch, immovable, not painful on pressure. The eyelid hung down, being otherwise of normal appearance. When the lid was lifted vision was 20/CC., with 4.50 D cyl., ax. 550 20/L. On January io, I894, the patient was operated at the German Hospital. An incision was made along the eyebrow, through the
t
*rc
C
A Anterior (temporal) surface.
lb.
B Inferior.
C Posterior.
D Anterior (en face).
WILSON: Fibro-Sarcoma of Right Orbit.
291
soft parts down to the bone. The thin periosteum was stripped off and the anterior wall of the sinus chiseled away until a fine probe could be introduced, which showed the tumor attached by a moderately broad pedicle to the posterior wall of the sinus. Grasping the tumor firmly with a bone forceps, it came away readily, leaving a rough surface at the point of attachment. Recovery was uneventful, and there has been no return of the growth. The eye is still slightly lower than the right, but in the same antero-posterior plane. Vision 20/CC. Javal shows 8.oo D. of astigmatism and with + 4.oo D. cyl. Ax. go° ^ 4.oo D. cyl. Axis I80°. V. = 20/L. The tumor is composed of a dense ivory-like shell, enclosing a mass of cancellous tissue, in the center of which there is a cavity of moderate size. A very deep, narrow furrow divides the anterior larger portion, which was external to the sinus, from the smaller posterior portion. The growth measures: Length, 3Imm.; height, 25mm.; depth (antero-post.), 20-28 mm.; greatest at nasal extremity.
FIBRO-SARCOMA OF RIGHT ORBIT. BY F. M. WILSON. BRIDGEPORT, CONN.
Bridget Clancy, age 58, stout, healthy Irish woman. The tumor has been large enough to attract attention for twenty-three years, but most of its growth has been during the last three years. She claims to have suffered no pain until within a month. She also claims that her sight was " good " in the right eye until about three years ago. The external portion of tumor is roughly spherical and about 24 inches in diameter. The most anterior portion is the cornea when the upper lid is let alone, but by frequent
manipulation with her finger she keeps this enormously stretched upper lid pulled over the cornea most of the time. The palpebral slit is two inches in length. The stretched lower lid fits the tumor
BEFORE ORAI
.
BEFORFE OPERATION.
...
AFTER OPERATION.
FRIDENBERG: Ezxostosis of the Frontal Sinus.
289
DR. W. H. CARMALT.- Dr. Bull made use of an expression' that does not hold good in regard to bone tumors of other parts of the body, viz.: that sarcoma following injury to the bones of the orbit is rare. In regard to other bones, we consider that sarcoma not infrequently follows trauma-; this is certainly true in regard to fractures. The history of general surgery is very positive in that direction, but I have not looked up the literature with special reference to the bones of the orbit. and while Dr. Btull is undoubtedly correct in his statement, the exception is worth noting. DR. W. B. JOHNSON.- I think these cases of sarcoma of the bone following traumatism are only frequent as related to tumors of the bone in other localities, and not as related to tumors in general, of malignant character. I had a case the counterpart of Dr. Bull's which I reported to this society, I think, a year or two ago, in which the nose, frontal sinus, antrum, and ethmoidal sinuses were all involved in the disease, which resulted from a blow received while entering a gate, and the removal of the superior maxillary bone and tumor was made. The child recovered from the operation, but died two months afterwards from extension of the disease through the ethmoidal sinuses to the cerebral cavity. It is a question what to do with these cases. I reported several cases at the Pan-American Medical Congress in which operation was performed, and I think they were more comfortable than were other cases which had gone on until death without operation. There is also the remote possibility of the tumor failing to return, which helps to make such operations justifiable.
EXOSTOSIS OF THE FRONTAL SINUS - ENOPH-
THALMOS. BY EDWARD FRIDENBERG, M.D., NEW YORK CITY.
Professor Dolbeau of Paris was the ilrst surgeon to successfully remove by operation an orbital osteoma having its origin in the frontal sinus. His patient, operated in I867, recovered after a slight attack of meningitis. Knapp in i88o removed a similar growth by the method of subperiosteal enucleation without any
290
FRIDENBERG: Exostosis of the Frontal Sinus.
untoward symptoms. Since that time quite a number of cases have been published in which these osseous tumors have been extirpated, and the danger of erysipelas, meningitis, or cerebral abscess, from which all cases treated by purely operative measures, previous to Dolbeau's, had perished, seems to be in great part obviated. The improved prognosis of the operation for exostosis of the frontal sinus is due principally to early operation, thorough antisepsis or asepsis, and finally to the fact that we have learned not to attack the tumor itself, but to chisel away the bone, usually the anterior wall of the frontal sinus, holding and confining it. The case which I present has two features of interest: (i) The position of the tumor, which was located much more toward the temporal aspect of the orbit than usual, the mass of the osteoma being about at the center of the upper orbital margin. (2) The position of the eye, which was crowded backward into the orbit and slightly downwards. In other words, there was enophthalmos instead of the customary exophthalmos. The patient, R. I., a Scotchman, aged 28, was first seen in August, I893. He stated that at the age of fourteen he was often "joked " by his friends because his left eye was a trifle smaller than the right. He had always had better vision in the right eye, the difference increasing markedly of late years. Nine years ago he noticed a swelling at the upper margin of the left orbit, which has grown slowly but steadily, pressing the eye back and closing it up. There was no pain and no history of traumatism or constitutional taint. An operation was proposed, but refused. The patient returned in January, I894. The tumor had grown slightly and presented as a nearly smooth, rounded mass, about thr size of a walnut in the center of the left supraciliary ridge. It was absolutely hard to the touch, immovable, not painful on pressure. The eyelid hung down, being otherwise of normal appearance. When the lid was lifted vision was 20/CC., with 4.50 D cyl., ax. 550 20/L. On January io, I894, the patient was operated at the German Hospital. An incision was made along the eyebrow, through the
t
*rc
C
A Anterior (temporal) surface.
lb.
B Inferior.
C Posterior.
D Anterior (en face).
WILSON: Fibro-Sarcoma of Right Orbit.
291
soft parts down to the bone. The thin periosteum was stripped off and the anterior wall of the sinus chiseled away until a fine probe could be introduced, which showed the tumor attached by a moderately broad pedicle to the posterior wall of the sinus. Grasping the tumor firmly with a bone forceps, it came away readily, leaving a rough surface at the point of attachment. Recovery was uneventful, and there has been no return of the growth. The eye is still slightly lower than the right, but in the same antero-posterior plane. Vision 20/CC. Javal shows 8.oo D. of astigmatism and with + 4.oo D. cyl. Ax. go° ^ 4.oo D. cyl. Axis I80°. V. = 20/L. The tumor is composed of a dense ivory-like shell, enclosing a mass of cancellous tissue, in the center of which there is a cavity of moderate size. A very deep, narrow furrow divides the anterior larger portion, which was external to the sinus, from the smaller posterior portion. The growth measures: Length, 3Imm.; height, 25mm.; depth (antero-post.), 20-28 mm.; greatest at nasal extremity.
FIBRO-SARCOMA OF RIGHT ORBIT. BY F. M. WILSON. BRIDGEPORT, CONN.
Bridget Clancy, age 58, stout, healthy Irish woman. The tumor has been large enough to attract attention for twenty-three years, but most of its growth has been during the last three years. She claims to have suffered no pain until within a month. She also claims that her sight was " good " in the right eye until about three years ago. The external portion of tumor is roughly spherical and about 24 inches in diameter. The most anterior portion is the cornea when the upper lid is let alone, but by frequent
manipulation with her finger she keeps this enormously stretched upper lid pulled over the cornea most of the time. The palpebral slit is two inches in length. The stretched lower lid fits the tumor
