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579(5) aI95 T "Q'39-3^I0?i= And s*.ill ronain in thet Rpeai.Rlty? 10 d "A'IS:JERa I believe that my work has bQen mors and more confined chiefly to the care of cancers of the mouth and throat, and less nnd less of the plastic recon- structivo vork. "INTRS TIC': s And for how nahy y ears have you been dealing with cancers of the mouth and t`hroaE here at the Yayo Clinic4 " A*;SWERs nince 1943. "WIR5Tz0;;: Since 1;1+39 that is consi,derAbly over a decade; would you cn.-Flnin to the Court and lury the relatiQ::ship that necescarily existsg if anyl bet4cen plastic curgery, which was part of your specia7.ty and ce-ncerg of the raouth and throat? "A`1:T4M: Well s rtany people cone to the Clinio who havo lfsfons$ car.eerss tutors, about the lipst faees r;outh, throat, voice box -- who require surgical treat- ment, and naturally we are intorostAd in resf.orinR fune- tion. We don' twant thcm to bQ deforn ed if we can possibly help itq e.nd therefore we believe that people Vhd do this particular kind of k{ork should be trAined in plastic surgery too$ which deale with the restoration of ~ ~ ~ i'unctxon. ''rl~iliIbtdt I see. Doctort would you tell the ~ Court and Jury the z,,3-i:bnrship t`:at ;,ro~i 'httvo in nny ~ V v

5"9(7) ",t`~s''T0,*•'s v'hat other ^icdical sxie.*.ios and grovps do yoii belong to$ T1r. pevine? "A?tSWS??s Well, I nm a-mcn'zber of the knerican Association of Plastic IfZurr©onsj the !•.merierin ',*oeiety of Plastic and Feconstrvetive ;i.>>rgtiryq the knerican College of Ntrgeongq the !Lnericnn SoeIety of 'lead and Noek Surgeons, the Anerican Acadeiy of rphthahotogy and Otolaryngologys and t, eMir.nAsota Rcadomy of c>phthalrology and Otolar;,rngology. "^U~3T70't: And, of course, 1oGtor, you aro licensed to praotics your profession by the atnte of ?'ftlnesota? "A1'SI'Ut Yea, sirr. "Q~.T~:S'~10~i: Doctors when did the plaintiff in tr.ig case fall u^dQr your care and observation, nnd 2 tell you that you rjay na'Ke reference to P1Rintiff' s r.chibit 29 the }-:ospitAl recOrda." I thir.k these are the rPcordg, Xo,ir I?onar. "At.SW::Rs I first saw .Yohn PoEs on ?-13-52. "^t~;STI.O;~= And will you tell tl:e Jury in your own langaage what that was in conr.e,,tion with and vlhat for? "ANVUZ: I'e aa•19 to the C1 inic cotiplRininE of a hoarsoness, throo woe'lm. duration, jIa a1so "en;ioned n sore tbroat, and he told us that in his homo city that the f -- - -- --- ------ -- - -- - - ----- - -- ------ ---- -- ---- ------- •-•--------- --- ~

a79(18) T2-mf2 Nox, the throat is a bie place, and we doctors.use the wo d pharynx inatoad of throat. It :hou1d be used that way tth~n you are talking to another doctor.. And this cancer was, technically, in this part of his pharynx -- hypopr.arynx. Hypo aeanm below. I don't know whether you want me to bother these folks with hypopharynx, nasal pharynx, and so on. "QUESTIJPit I don't think it xe necessary unless they desire that you go Snto it specifically. HoN extensive was the cancer that you actually observed, Doctor? "ANSKL~t This was exwmined by our js ath.o2og.at when it was taken to the laboratory iaroediately, and round to be 3 by 1.8 by .4 centimeters. "QUNSTIONs And how big would that be in inches ' II roughl.yt °ANSWHR= Let i s see, there are two point five centimeters in an inch, I think that is right -- I will answar that question by aayini, that -- as I might answer it to a paticnt, is that it is a big cancer, And I miEht tell him that it isn't how big it is, it is sort of liko a cinder in your eye, it is where it is that eounts. And he happened to have it in a place wheret it often sprraadu quickly and where our chances of curing them arest 't too uood. ~ F O N 0 CO ~ ~ ~ 0 I

579(21) Y J but in actual practice he doesn't Qxamin8 each and every than the voice box, "gtnr,TIOrat All right, one of these -- it is just not possible.-- there is not enouSh tiroo.in the day to do all of that Work, tie examinea the nodes that are slizhtly enlarsed or that seem hard to him, and he checks them under the roieroscope „QUESTI02tt And did you perform the total larynSectormy yourselP, Doctor? "ANS'r1ERt Yea. "QUES'rIONi And would you -teil the court and jury how raueh of the larynx was taken out -• is that the voice box? ~iMSV;Ecc= 'Wsll, tha larynt is the voice box. Ta this type of operation, it is far better to remove more "ANUMs There are certain muscles outside of this box -- certain bones that we ahould remove, S.f we going to do a bood operation, because the cancer may bAVe spread or grown out into thes© things. In other words, our object is to try to take out as much as we can and still make the patient a useful person -- try to curo him if we can, "QU'r;STt4Ns Did you then take out the whole voice box? nAPa=xx.:.~t Yes. ard -o N O x -4 LA ~ w

57?f 13? v•L Ls13 any nod4s, --' and I rKight interrupt ther9 and say that tl:at i s an important statement beca"se these nodes refor to so-catled glnnda or lyr;ph or 1•ymph nodes. These are structuras tn our neck %,rhic}i swexl +sp uhen -.te get a cold or.sore throat or tonsillitis. ThAy a.o there to I help us overcome infections that !iight got in our blood stream from some infection or condition in o»r throatst and we feel for those to sen if thtry e.r e en2nrQRd. If they are Enlarged t in th© presence of a caneQr in the throat, then we have to cons{der that they are onlarged because cnr.cQr is in those nodes or glandst and so if I can continue, I saidt ' I can not tcel any nodes,+ and Imerzn} signiff.cant nodes, 'but he should hadct radical neck --', and I did not put in the word 'disseetion'# because to any exper ienced person who might read this history you would know that I nean 'radical neck dirsec- tion' 9 which means an operation to rez?ove these lyrzph glands or lynph nodos -- and to eontinuet 'total laryn- gectony.' T3•.is mQAnx the co:iplete rcmoval of ttiQ voice boxg and t..tiis adjacent tissue we have been roferring to. "Wg: iIO1Ft lCowt Doctort after yo» had made that; I prell*iinary oxsr.anationt did you then determine to eheck that by this exr,Minatton under anes•`.hosia? "AN3'-dFMt Mis is an irportant disartosis 111o ma•jA in nnyono' s 1i fe, bec-xtiic wa arre refrrrtnigtn the patJent' P1

;79ti6a nlnetf-five perccntf even though •aQ coutcin• t feel it baforehgnd._ 'r n.r: ;Tzoa= May I interropt there; t3octor, vaa that 'i:xportnnt because you positivoly identii'ied the cancer as being in his --? "a*;S'V,1Rt We kne•d he had a cancer in the throa4:s but we hnve no way of 1mowing if hQ has cancer out in the "QUESTI^?:'s You mran rz}. that time? "Ai?Sk'RR 1 Xos. Ve didn' t knows nor do we have , a:nepic test= and we have to depend imon past statistics and our feeling of the patient' s neck. "QUEsixOtft All rigbt. "E,NOM-SSR: t,'e kmoW that this busineas of V h@ther or not the patient has a cancer 3n the glands Is the *3ost important part of it all. It is not difficult to cvre the thing on the inside. The way we lose our patients I and the reason that they are not cured ':as to do raora with; the glands in the neck than vhat is going on on the ir sid So when you f irst fit:irted operating on him --? "Ai;IS"V;Rt ilo thought that is the 3.,iportant thing there. We wiIl find out whether or not the glands are involved, or whether they should R11 be -re~±oved. ";'1-,Sj"IO!Is 73y ro-!ovn;d! yau r1ean cut t'n"r oxit? 'r ,1ti"SU1;T1t Yes.

5'71)(t5) okay for anesthesiui that hit; general p!:ysieRl exsc~~i~q» tion •elas not renarkablet that his heart 'ar.d lungs and abdonen were negas:ive, va took him to the V9r.hodt.ut Hospi ta1 and on the morning of Ye3ruar-/ ].5l 145?1 ve exaTined his throat. "QCJssTIGms Did you determino at t?uAt tine i that the cancer that yov four:d in thes area could be ronovod surgically? "ANSi,fERt Xes, , "qrE3PI0,qs When did you peraorm the operation to reTM.ovQ the cancer gnd remove his larynx? "!NSWERc Thia operation was -perf orn, caa on February 16, 1952, ".^MBST10:;; Would yola doscribe for the Court and jury the procedure involved in the operation? "MRSWERs The raedieal te". for the operntion is radical neck dissection, total larynrr_-.ctomy And pPrtial ph$ryngectony. " ytlE ~~TIO~'s knd could yoij summari se for the ^ourt and jury what the surgAry consistod of? " A ! Rt Well, th4 first part of the operationl consisted of retioving those odes and glr~r:ds on the 1Rft~ r patients 1.i`ke ,'.r. Ross, that the ahanaas of having a cancer in one or t'l:eae g14nds vas nbol't eighty to ~ side of the neck. We 'mov fron rtudying :I large group of

579(i4) vris1'4 ability to ape2'c again, ctr.d t.his is a serious diQenset and whether or not ho will even got a cure is always In doubt In this type of troubinl s.nd so wo wah}ed to axanina hin a little nore thoroughly than ve co>>Xd in the offiee. PherAfore, we put down this 'Firs} get 0. K. anesthosia' -- In othpr vords, if this patient a cRndidatt suitable for operation and is he a cAndidatQ for general -- ' anesthesia, and from there we go to wha*t you read here '5-uspension'. Now this is an appara :ijs or a ngthod of exanining the larynx a.nd the tt:roat. In essences f." rean tho suspending of the patient i'rom some ovorhead fixed. pt,ii,t -- y:,u can cali it a dPrricx zf fou Vant. rnie instrumant is placed In the throat in a proper nosit-ions y I and then he i s held that w„ -..y b f placing t_+is inst .runent o the der riak, and th~:ref ora t?~Q s?irgncrn can t?^en work with ~ both hands and ho doesn' t'-mvE to hold the head and throat up with one hand and try to work wih th the other. Sol therefore, that word In there called suspension might oon4~usa poopl.et but to is it means direct laryngoscopy, ~TG*:i All ripht. Then, Doctor, upon thAt procc,dure did you and the tean proceed to perforn this surgical oporation on hin2 "I`.:i'VERs Yes. .4t'ter iios3 was axn^tined In one of *,ho g^1Era1 redicRl sections by F)r. Xcating on Feb;u- ' ary 14, 1952, after Pr. Yen'•,itip said that tlits rsan stAs !

T2-mr4 579(20) "A,'~SnERt Actua3ly, it isni t.poesibie to do a good disaec.tion of the neck to rcrxove any possible cancer nodes, unless certain structures are removed. There is a large musole in the neck, there is the deep Jugular vein -- "QUESTIONs The deep Jugular vein i I "ANSwTR t Or thel internal jugular vein. "QUESTTONt Was that cut out and removed? "At+SwERs That is part of the standard complete neck dissection. "QUESTIONt And what about the left upper ji.ig7ular °r "AIvSMt Well, we divide these nodes or glands into deep Jugular veins, or deep Jugular E1andg, Vttint%r t_inan it~m~l aw. a1 anr4a . 7 n.re.,+ Aft.... i,...,.t e.. -t...,A..v "'~ that is a method of doterminins where they are aAd it means soaething to another doctor il hQ knew we removed the upper deep Jugulars or the lower deep Jugulars. "QUESTrOfdt And how many were removed in this case? pAN3',rfERt well, if a pathologist -- that is a man who looks at this thing in the laboratory -- wanted to ait down and count all of thQ glands reraoved, he might -count upward of one hundred fifty.to two hundred Elanda,

579(23) and all patients like him -- have a permanent opening just above their eollar.bone3n the center of their neck through which they breathe, "QUESTIONs Do I understand you, then, Doator, that this mants windpipe doesn't go up into his mouth and his nose any moro? "ANSWEt t ho.. "QUESfiZOae And it aomes out inside of his neck? '"ANSWERt YeO. "QUESTIONs So when he breathes, ho doesn't breathe through his nose or roouth, he breathes through the hole In his neck, is that correct? "ANSwERt Ye$. "QV 1014t Doc tor, how long did this operation take? "ANSTOMfFrom 9135 in the Yrorning until 1 s 14 the afternoon. The anesthesia was started at 9s10. "QUESTIONs And the operation started at 9:35? ~ "ANSwF:R t Yen. "QUESTIONs And the operation finished at 1t10? "Arasc-rERs Yes. "QUESTIONs Dootor, would you tell the jury . • . - -- . -. -o what squanous cell' epitho.lioma means? " N O m peclail3 u`+ Tho lf.n tngs of our bidys r.4 es - -- ~ ~