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MEDICAL SOCIETY OF LONDON.

A MEETING of this Society was held on Feb. 26th,Lord DAwsoN, the President, being in the chair.

Mr. JAMES BERRY introduced a discussion on

the

VARIOUS METHODS OF TREATMENT OF CANCER OFTHE TONGUE.

He said that statistics on this subject might bemisleading, even those in the excellent report of theBoston Symposium on Carcinoma of Jaws, Tongue,and Cheeks. A common error was to describe acertain percentage of apparent successes amongst somany cases, of which a certain number were advancedcases, and not to mention the proportion of advancedcases amongst the recoveries. Statistics accompaniedby sufficient detail about each case to enable the readerto judge of its severity would be most valuable, butwere rare. Besides his own operative experience hehad had unusually large opportunities of seeing thework of others, and so realised that the ordinarymode of extension of cancer of the tongue wasbackwards and downwards towards the hyoid bone.Operations for such a cancer should often extendwidely in the two directions, and this could notbe sufficiently effected by an intrabuccal operation.After emphasising the importance of early treatmentof tongue lesions and of the excision of all doubtfululcers, &c., for microscopic examination, Mr. Berrystated his belief that an external or submaxillaryoperation offered the best chance of relief for advancedcases, for which, even if not curative, the operationafforded relief of the distressing condition within themouth. He did not agree with procedures involvingsplitting the cheek or dividing the lower jaw. Thedisease was essentially a local one with very little ten-dency to distant metastasis, but owed its malignancyto its tendency to affect the cervical lymphatic glandsat an early stage. Early free removal of the primarygrowth with a removal en bloc of the nearestlymphatic glands offered hope of permanent cure.

But if the growth originated in the posterior part ofthe tongue the deeper cervical glands (especially thepost-pharyngeal glands), which were early affected,could not be removed en bloc and permanent cure couldhardly be expected. He doubted whether the so-called" block dissection," with removal of jugular veins andsterno-mastoid, was ever worth doing. It was seldomnecessary for cases where the growth was situated onthe anterior part of the tongue, and he believed

generally useless for advanced cases when the growthwas situated posteriorly. Further, he thought itprobable that unsuccessful attempts to dissect outaffected glands merely favoured the spread of thedisease. The class of case which Mr. Berry haddealt with had been mainly those of cancer of themiddle and posterior thirds of the tongue.

Operative Treatment.For small carcinomata of the anterior half of the

tongue, not involving the floor of the mouth, he believedthat the removal of one-half of the tongue, followedlater by the free removal en bloc of all structures in thesub-maxillary, and if necessary the submental, regionof one or both sides was generally the best operation.For larger growths, wherever situated, and for allgrowths of the middle and posterior thirds, he had formany years practised an external operation. He haddone about 27 of these operations. A curved incisionwas made from the symphysis menti to the angle ofthe jaw, similar to that used in the classical operationfor ligature of the lingual artery, and the flap contain-ing platysma turned back. The entire submaxillaryregion was then cleared, the lingual and facialarteries being early identified, ligated far back,and divided. The digastric was divided and themylohyoid detached from the jaw, and the muscles

running into the front of the tongue divided close tothe jaw, so that the dissection could be carried right

down to the mucosa of the floor of the mouth, whichwas preserved intact. The buccal part of the operationconsisted of the usual splitting of the tongue in themiddle line. The mucosa was incised in the floorof the mouth from outside, and the tongue drawnout through the submaxillary wound and divided asfar back as necessary, so that the affected portion ofthe tongue was removed in one piece with the wholeof the submaxillary tissues. A sponge held in thewound prevented blood from running into the larynxduring the final division. The operation was almostbloodless. The wound left was partly drawn togetherby two catgut sutures and a drainage-tube left in themiddle of the wound and brought out through a

separate incision one inch lower. Mr. Berry did notfind intratracheal anaesthesia or preliminary laryngo-tomy necessary, and he had never had trouble fromblood entering the larynx. Illustrations and drawingsof the operation were shown, as well as specimensremoved at operation.

Treatment by Diathermy.Mr. W. H. CLAYTON-GREENE said that from the

American statistics one fact emerged-if carcino-matous glands were present very few cases lived forthree years. Upon all other points he agreed withMr. Berry that statistics were useless unless thenature and position of the growth were stated. Hisown results had been so poor that he took to diathermyfor the removal of intrabuccal carcinomata. Fordiathermy he claimed these advantages: (1) It waspossible by this means alone to destroy the tongueright back to the epiglottis by an operation through themouth ; (2) there was no danger of the implantationof cancer cells in the operation wound. As a dis-advantage it was stated, and rightly, that diathermyproduced a septic slough, but the slough only becameseptic after an interval during which the lymphaticshad become sealed off. He had only had one seriouscase of sepsis among 60 operations by diathermywithin the mouth. As regards treatment, there werein America two schools-that of Crile, who advocateda bilateral " block dissection " of the neck withremoval of the tongue later, and that of Quick, whomaintained that no operation was of any avail. Whilenot subscribing altogether to the latter view, heagreed that the results of surgical treatment, even inthe Mayo Clinic, were most depressing. The operationhe now performed resembled in some ways thatdescribed by Mr. Berry. Through an externalexcision, he made a clean sweep of the submaxillaryregion, and tied the facial and lingual arteries or theexternal carotid. The tongue was then removed bydiathermy. He had now abandoned the " blockdissection " since he had noticed that in many cases itappeared to favour recurrence in the neck, and thatthe results of this large operation were worse thanthose of the more limited ones. The same had beennoted by others with regard to operation for cancer inother places, notably in the breast. He regardedthe glands as constituting nature’s barrier to thedisease, and thought that in future more attentionwould be devoted to the extensive removal ofthe primary growth.

Treatment by Radium.Mr. A. E. HAYWARD PINCH described his experiences

of the treatment of cancer of the tongue at theRadium Institute. Of about 600 such cases, quite580 were inoperable when first seen, and 300 couldonly be described as appalling. While radium coulddo something to help these people, it could not beclaimed to have effected a single cure at the RadiumInstitute, although he did know of one case apparentlycured by radium. This was the case of a physicianin the West of England, who refused operation for asmall growth of the tip of the tongue, confidentlydiagnosed by two surgeons as carcinomatous. Hehad treated himself by the application to the growthof a small tube containing 10 mg. of radium forone hour daily for three months. Many methods

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of using radium had been devised, but Mr. Pinch’susual practice now was to use several tubes buried inthe growth for six hours. On the rare occasions onwhich he saw operable cases he invariably passed themon to a surgeon, and, in his opinion, there was verylittle difference between the results of excision bythe knife and by diathermy.

The Need for Radical Measures.Mr. G. GoRDON-TAYLOR agreed that the results of

operation for cancer of the tongue were appalling. Ithad been said that the surgery of cancer was the surgeryof the lymphatics, but it was not sufficiently realisedthat the lymphatics of the living subject differed fromthose described by anatomists, who obtained theirinformation by the injection of the lymphatics in thedead subject. He had been driven by his previousresults to perform more and more radical operations forcancer of the tongue and now performed a bilateral" block dissection " followed at a later period by theremoval of the tongue by diathermy. He consideredthat this operation, which he had only been practisingfor a few years, already showed better results thanthose of the more limited operations he had formerlyperformed. For, of the cases he had operated onbefore 1914 all but one had recurrence within 12months, whereas the larger operation had alreadyenabled several patients to survive for three years.He did not hesitate to remove portions of the jaw if itwere involved, and the operation he performed notinfrequently resulted temporarily in considerableoedema of the face, which he regarded in the samelight as the oedema of the arm following operation forcancer of the breast as showing a satisfactory removalof the lymphatics.

Mr. A. EDMUNDS inquired whether it was notgenerally observed that cancer of the tongue wasmuch less prevalent amongst the well-to-do classeswhose mouths were carefully tended. He alsopointed out that second attacks of cancer in thetongue occasionally occurred, and gave one instance.As regards the preliminary treatment of the mouth,he suggested that it was preferable to have the teethcleaned up rather than extracted, for extractionoften left troublesome sepsis in the sockets. Nothinghad done more to improve the operative treatmentthan the introduction of intratracheal anaesthesia,which he now invariably employed. When it wasimpossible to pass a tube at the beginning of theoperation it could still be passed at a later period,when it was most useful. Although he feared thatwhen extensive glandular involvement was presentoperation was almost hopeless, he still performed anextensive operation in the neck, and removed thetongue about ten days later. He did not ligaturethe lingual artery at the first operation. Goodaccess to the tongue was imperative, and to obtainthis he did not hesitate to split the cheek or to dividethe jaw when necessary. It was his practice tosacrifice as little mucosa as possible, and to suturethe edges of the wound in the mouth, where heobtained primary union owing to the frequent useof chloramine-T mouth washes.Mr. H. S. CLOGG pointed out that recurrence after

operation for cancer of the tongue was only rarelyin the mouth. He had therefore given a trial to" block dissection," but without any improvementin his results, for recurrence took place in the neckunder the upper part of the sterno-mastoid musclein the region of the apex of the mastoid process andthe posterior belly of the digastric. He now made aspecial attack upon this area by dividing the sterno-mastoid close to its upper attachment, although hecould not yet claim any improvement in results fromthis procedure. He now regarded the outlook as

hopeless, and the cases inoperable if the glands wereadherent to muscle or fasciae, or if they were cystic.

Mr. CECIL ROWNTREE said that the incidence ofthis disease was undoubtedly much less in the wealthyclasses than in hospital patients. He agreed thatfresh tumours occasionally occurred, and he instanceda case in which he had upon three occasions per-

formed a local excision of an early cancer from thetongue of one patient. His experience of this diseaseled him to regard such cases as suitable only for’apalliative operation unless they were very early.When the disease was well established he was contentwith the removal of as much tissue as possible nearthe mouth in order to prevent recurrence withinthat cavity. Only when the case was very earlydid he perform an elaborate operation involving anextensive dissection of the neck. In the employmentof radium for the primary growth, he considered itimportant to bring the emanations into the closestpossible contact with the growth, and he had recentlyinduced a patient to keep four " needles " in thegrowth for 24 hours.

Mr. W. G. SPENCER pleaded for earlier recognitionof the disease by the public and the general practi-tioner, and pointed out that the patient’s resistanceto squamous-celled carcinoma was very variable, andhad a greater influence on the results of operationthan the type of operation performed. While heagreed that the results were on the whole depressing,he stated that several of Butlin’s cases were stillalive. He thought that the division of the mylohyoidadvocated by Mr. Berry was unnecessary and led toconsiderable discomfort from the dribbling of saliva.He performed a modified Kocher dissection withspecial attention to the three angles of the wound.

Dr. A. LAPTHORN SMITH believed that with properattention to the teeth of the hospital classes cancerof the tongue would become a rare disease.

Reply.Mr. BERRY, in reply, said he could not understand

why a dissection of the glands should be performedbefore a removal of the primary growth, and heinquired what happened under these circumstances todisseminated cancer cells during the interval betweenthe two operations. He did not know what his resultshad been, although the fact that he rarely sawpatients after operation led him to suppose that theresults were bad compared with those of cancer inother situations. His most successful result had beenin the case of a medical student in whom a smallgrowth had been present for six weeks, and who

exhibited no secondary glands.CARDIFF MEDICAL SOCIETY.

A MEETING of this Society was held on Feb. 13th,Prof. E. J. MACLEAN, the President, being in thechair.

Dr. IVOR J. DAVIES read a paper on

Subacute Infective Endocarditis,based upon a report of eight cases. The term wasapplied to cases of old endocarditis with an added sub-acute infective process of streptococcal origin. Therehad been an apparent increase in the disease recently.Clinical data were submitted in support of Poynton’sview that no hard-and-fast line could be drawnbetween simple endocarditis and infective endocarditis.In four cases an arthritis of the larger joints waspresent, indistinguishable from that of subacuterheumatism. In one of these cases the post-mortemappearances resembled those of simple endocarditis,except that there was an extension of the morbidprocess to the wall of the left auricle. The clinicalpicture was described as, briefly, that of a case ofV.D.H., usually aortic in the case of ex-Service men,with certain general signs and symptoms added to thoseof the mechanical cardiac disability. These weregrouped under two heads : (1) toxic, (2) embolic.Enlargement of the spleen was perhaps the mostvaluable early sign. Clubbing of the fingers, too,occurred early in the disease. The embolic signsshown by the eight cases included petechiae, a papularand nodular eruption, mycotic aneurysms of the femoraland brachial arteries, intermittent albuminuria, andhaematuria. The duration varied from three monthsto two years and was 12 months on an average.