JOHN A. KIRCHNER,
MD
Mr President, Ladies and Gentlemen: It is a tremendous privilege
and pleasure for Aline and me to be here as the guests of this great organization.
And it is especially rewarding to have been singled out by our President,
Dr John Tucker, whose research into the prenatal development of the human
larynx was always aimed at its clinical applications, especially in the
newborn - the shape of the cricoid cartilage, for example, and the prenatal
development of that confusing area of conflict and contention, the anterior
commissure. John Tucker's research easily identifies him as one of the
leaders of 20th-century laryngology.
Today I would like to mention several other laryngologists who have been
my teachers. This is a daunting task, because there have been so many of
them, including some here in the audience. I must limit the list to the
few with whom I actually worked or spent time. If you're not retired or
dead, please don't think you've been overlooked.
During my second year at the Yale Medical Center, I
met Dr Joseph Ogura at Maurice Cottle's rhinoplasty course in Chicago.
Three years later, in 1955, Joe published his Triological thesis, "Surgical
Pathology of Cancer of the Larynx."(1) He had dissected
59 laryngectomy specimens and described the patterns of spread, which he
traced by taking tissue samples from various parts of the larynx. Whole
organ sectioning was not available to him, but he recorded his observations
in line drawings of remarkable accuracy. Of 12 specimens with cancer at
the base of the epiglottis, he found that the preepiglottic space was invaded
in 11 of them. This added further support to the same observation reported
by LeRoux-Robert of Paris in his doctoral thesis published
in 1936.(2) Joe was aware of this work and cited LeRoux
in his bibliography. An important contribution by Ogura and his colleagues
in pathology was the term "transglottic." It is useful because
it reflects the tumor's likelihood of invading the laryngeal framework.
And it is useful because it is based on the cancer's location rather than
on a supposition as to where it began. Joe helped us with several postgraduate
courses in laryngeal and head and neck surgery in New Haven, and we kept
in touch by telephone from time to time. It was through Joe that I learned
of one of Europe's leading laryngeal surgeons, Dr J. L. LeRoux-Robert.
During two visits to Paris I had the privilege of watching LeRoux-Robert
operate and spending a few days with him. He preferred the anterior approach
for much of his laryngeal surgery. The drawings in his publications explain
each operation in precise detail. For his doctoral thesis at the University
of Paris in 1936, LeRoux-Robert had described his whole organ sections
of 60 surgical specimens removed by his chief, Dr A. Hautant.(2) The
first of their kind, his sections were probably prepared from paraffin
blocks. I have not been able to find the details of processing in his thesis,
and there are no photographs of the whole organ sections. Nevertheless,
the drawings he made from the sections illustrate the details of tumor
spread with remarkable accuracy. Among several original observations he
reported was that cancer invading the preepiglottic space remains confined
there for a considerable time and does not break its boundaries. He described
the barrier between the preepiglottic space and the base of the tongue
formed by the hyoepiglottic ligament. He reported central necrosis of large
tumors in the preepiglottic fat, and so far as I can determine from his
thesis, he was the first to describe the type of supraglottic carcinoma
that originates in the angle between the false vocal cord and the base
of the epiglottis.
Whole organ sectioning never gained much popularity
after the work of LeRoux-Robert, largely because of the difficulty with
large blocks of paraffin. In 1950, Dr John Keman of New York reported on
a horizontal serial section of a laryngectomy specimen he had prepared
in celloidin.(3) One section was selected from the center
for histologic study, the remaining sections being studied by a special
wax-embedding technique that provided l0x magnification. But it was not
until 1961 that whole organ sectioning was saved from
oblivion by Gabriel Tucker, Jr, who began mounting laryngectomy specimens
in celloidin, a technique used for temporal bone sections.(4) This
material provided wrinide-free sections of the larynx
suitable for permanent storage and for photography. Tucker's Atlas (5) shows
the excellent detail obtainable by this technique, and still serves as
a valuable reference.
Another great leader in conservation surgery was Ettore Bocca of Milan.
He had been trained by the originator of functional neck dissection, Professor
Suarez of Argentina. Bocca demonstrated the operation during his frequent
visits to America, but the concept was resisted in this country, because
it was difficult to believe that Bocca's functional neck dissection could completely
clear away metastatic lymph nodes. Eventually, Bocca's long-term results
proved that the operation, when performed correctly and with sharp dissection,
was just as effective as conventional neck dissection, and with less disability.(6)
Bocca taught us that releasing the hyoepiglottic ligament from the upper
edge of the hyoid bone delivers the preepiglottic tissue as an intact unit.
Preserving the hyoid allows a more secure closure of the pharyngotomy and
facilitates postoperative deglutition, in my experience.
These men were 20th-century landmarks in laryngology. But if I had to
name one among the giants as my mentor, it would have to be the late Dr
Max Som of New York City. Many of the younger members may not have known
Max. He was not a member of the Triological, and became a member of the
ALA late in his career. Max was controversial among his New York City colleagues,
probably because of his outspoken opinions on what he considered the incompetence
of certain other members of our profession. He described one particular
surgeon as "often in error, never in doubt." Despite his detractors,
his skill in conservation surgery was universally recognized and was reflected
in the names of celebrities who were patients, not only from many parts
of America, but from other parts of the world. The usual reason for consulting
Max was that they had been advised by another surgeon to undergo total
laryngectomy. His list would include highly placed government officials,
stars of Hollywood and Broadway, and names even better known to the FBI.
I learned a great deal from Max during the several weekends we spent in
my laboratory studying surgical specimens and whole organ sections. One
day, Max remarked, "I've never seen a supraglottic cancer that invaded
the thyroid cartilage." When Max used the term "supraglottic," he
meant a tumor that satisfied all the criteria that he, Joe Ogura, and Ettore
Bocca had developed - in other words, suitable for horizontal supraglottic
laryngectomy. As my collection of total and supraglottic resections grew,
there were eventually 112 specimens that qualified as supraglottic. In
none of these specimens was the thyroid cartilage invaded.
The practical importance of this principle is that in supraglottic laryngectomy
the external perichondrium can be relatively safely elevated, the saw cut
in the thyroid lamina encounters no tumor, and the external perichondrium
can be relatively safely used for repair of the pharyngotomy.(7)
Our weekends in New Haven were not all work. Max joined me one Saturday
afternoon at Yale Bowl to attend a function that the Yale Athletic Department
refers to as "football." Many summer weekends were spent together
at his home on B rant Lake, New York, a place I called The Adirondack Academy
of Laryngeal Surgery. Max kept a projector at the house, and I always brought
along several boxfuls of slides showing surgical specimens that we would
discuss at great length.
Max had one unique advantage over most of us who publish. His operations
were illustrated by his medical school classmate, Dr
Frank Netter, probably the world's most renowned and prolific medical illustrator.
The greatest compliment I ever received from a resident came as I was completing
a hemilaryngectomy. Dr Dewey Christmas exclaimed, "It looks just like
Netter's drawing!"(8)
These were only a few of my many teachers. As you and I practice our craft
in the clinic and operating room, I'm sure we occasionally stop and think, "I
learned this from my old chief!" Tennyson expressed it more elegantly
when he wrote, "I am a part of all that I have met."
1. Ogura J. Surgical pathology of cancer of the
larynx. Laryngoscope 1955;65:867-926. Return
2. LeRoux-RobertiL. Lesepitheliomes intralarynges
[Thesis]. Paris: Gaston Doin et Cie, 1936. Return
3. Keman JD. The pathology of carcinoma of the
larynx studied in serial sections. Trans Am Acad Ophthalmol Otolaryngol
1950;55:1O-21. Return
4. Tucker GF. A histological method for the study
of the spread of carcinoma within the larynx. Laryngoscope 1961 ;7 1: 1572-3. Return
5. Tucker GF Jr. Coronal section atlas. Human larynx.
Washington, DC: Armed Forces Institute of Pathology, 1971. Return
6. Bocca E, Pignataro 0. A conservation technique
in radical neck dissection. Ann Otol Rhinol Laryngol 1 967;76:975-87. Return
7. Som ML. Conservation surgery for carcinoma of
the supraglottis. J Laryngol Otol 1970;84:655-78. Return
8. Som ML. Cordal cancer with extension to vocal
process. Laryngoscope 1975;85:1298-307. Return |
