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MALIGNANT DISEASE OF THE BRONCHUS
MALIGNANT DISEASE OF THE BRONCHUS
THE LANCET LONDON: SATURDAY, DECEMBER 30, 1933
MALIGNANT DISEASE OF THE BRONCHUS OuR knowledge of cancer originating in the bronchus has increased greatly in recent years as the result of improved methods of examination, notably by bronchoscopy and by skiagraphy, assisted by the introduction of lipiodol into the bronchial tree. As would be expected, more cases have been correctly diagnosed during life, but there is no certainty that there is any real increase in the incidence of the disease. No doubt many cases diagnosed as cancer of the lung or pleura actually originated in a bronchus, and even in post-mortem examinations of advanced cases the true site of origin of such a growth may easily have been over-1 looked. Mr. F. C. ORMEROD has recently published his experience of a series of 27 cases, of which 23 were proved by biopsy and 2 by autopsy; in the remaining 2 the clinical diagnosis was so certain as to justify their inclusion. Males are known to be attacked more frequently than females, but Mr. ORMEROD’S statistics, 23 males to 4 females, show a greater preponderance than usual; more than two-thirds of the cases occurred between the ages of 40 and 60, the youngest being a woman of 27, while the oldest, also a woman, was aged 74 ; the right side was affected in 15, the left in 12 patients. Of symptoms, cough is always present, and is nearly always accompanied by sputum, usually of a mucopurulent character ; there was some degree of haemoptysis in 21 patients. This may be profuse in the later stages, and in two cases in this series was the immediate cause of death. Dyspnoea on slight exertion was a striking symptom in 21 cases, and was often pronounced when only a comparatively small area of lung was out of action. Three patients complained of hoarseness, and in 2 of these the left cord was paralysed by implication of the recurrent laryngeal nerve. Pain was present in 15 patients, most often as an ache referred to the interior of the chest on the diseased side. The clinical signs of cancer in this region are those of obstruction of a bronchus, usually with atelectasis. In partial obstruction there may be an expiratory wheeze with moist sounds in the lung below ; in complete obstruction the signs are dullness on percussion, absence of breath sounds, and sometimes increased vocal conduction ; the heart and mediastinum may be displaced, and the movements of the corresponding half of the diaphragm reduced, when there is massive collapse of the lung. X ray examination shows reduced mobility and displacement of the diaphragm and a shadow in the tissue of the lung which is due partly to the growth and partly to collapsed lung, the two being difficult to distinguish. After the introduction of opaque oil, the skiagram shows 1
Journal of Laryngology, November, 1933, p. 733.
1487
the upper margin of the growth, its outline in the bronchus being nearly always convex ; a fusiform shadow is probably due to inflammatory stenosis. Bronchoscopy reveals certain characteristic features ; the bronchial mucosa is less irritable than in cases of inflammatory disease, and there is accordingly less tendency to cough on examination. The growth is usually nodular, of the same colour as the normal mucosa, and its site of origin from the bronchial wall can be plainly seen. It is often of a firm consistence, even hard enough to make removal of a portion for bioscopy difficult ; but in advanced stages may be so soft and friable that pieces are coughed up. Pathologically the carcinoma is frequently of the squamous-celled variety ; in other cases there are masses of columnar cells or, again, of small ovoid cells. These ovoid cells were once believed to represent the oat-celled sarcoma of the mediastinum, but are now held to be carcinoma of the lung. After chronic inflammation the bronchial mucous membrane shows a marked increase in the cells of the small ovoid layer with, in advanced stages, a tendency to formation of masses of squamous epithelium ; it is therefore suggested that all the different types of carcinoma arise from the layer of small ovoid cells. No specimen has been observed which would suggest that the ciliated columnar cells of the bronchus or the flattened epithelial cells of the alveoli give rise to these growths. The squamouscelled tumours show a tendency to degeneration with formation of cavities. Metastases occur the mediastinal commonly in glands, from which the tumour may invade the hilum of the opposite lung ; they are frequent also in the suprarenals, liver, pancreas, brain, and almost any organ. Aspiration of fragments into the bronchus of the opposite lung may give rise to secondary deposits. If the growth extends to the pleura, its whole surface may become studded with deposits, or a continuous sheet of carcinoma may envelope the lung ; such cases have been erroneously described as primary tumours of the pleura. In treatment, removal of a small semi-pedunculated tumour has occasionally been possible by endoscopic methods, but radiation must be employed afterwards. Lobectomy has been per formed in a few carefully selected cases at the Brompton Hospital by Mr. J. E. H. ROBERTS and Mr. A. TUDOR EDWARDS ; the disease must be limited to one lobe and must be so situated that sufficient lung tissue can be left to secure closure of the main bronchus; secondary deposits. in mediastinal glands are a contra-indication. Most of the cases in Mr. ORMEROD’S series were treated by radium emanation applied through the bronchoscope in a special container. Treatment by the radium bomb has been very disappointing, for the distance of a growth in the lung is too great for success with any of the masses of radium used in this country. Deep X ray therapy has given some improvement in a few cases, especially in the upper lobe. Mr. ORMEROD holds that the results of treatment are unsatisfactory owing to the advanced stage in which most cases are seen. Complete disappearance of signs and symptoms is reported
1488
THE CALDECOTT COMMUNITY
in one of his patients, treated six months previously; another is alive and well after two years, and several have improved. Even this measure of success is gratifying in connexion with intrathoracic growths, for these were until recently regarded as hopeless, whether the oesophagus or a bronchus was the site. A few days ago we were able to record the pioneer work of Prof. GREY TURNER on cancer of the oesophagus. Mr. ORMEROD is working on an It is clear that organ just as inaccessible. intrathoracic surgery affords ample scope for
bravery. THE CALDECOTT COMMUNITY
The
experiment was a success. The children holidays to homes widely differing from the one in which they spent the terms and adjusted themselves with little difficulty; for those who had no suitable homes hospitality was sought among the friends of the Community. Selection from among the applicants became year by year more difficult, and in 1929 a decision went in the
was the natural outcome of undefined ideal for which the groping, largely stands. In their attempt to give a Community sense of freedom and security to less fortunate children of the country, they had selected at first those less fortunate in material things, children from poor but normal homes. But gradually, from the nature of the applications received, the council realised that it is not the child from the normal home, however poor, that knocks irresistibly for admission, but the one with an abnormal home. The function of the Community became more definite : to provide a home school for normal children, irrespective of class or denomination, whose homes are in any way abnormal, unhappy, or unsuitable.’ These are rightly held to need more than any others that balanced serenity of outlook which comes of a wise discipline in an environment not too institutional. No adequate provision is at present made by the State or by voluntary social organisations for the child who, owing to its home conditions, is in danger of becoming socially maladjusted. It is difficult to estimate how many of those who later become misfits, neurotics, or criminals come from broken homes, that is, homes where for some reason normal relationships with and between the parents are not obtained ; but such information as is available suggests that this is one of the fertile sources of maladjustment. Illegitimate children, those whose parents are divorced or separated, or, perhaps still worse, live in continuous friction rather than face open rupture ; step-children, even when kindness and consideration are shown by the newcomer ; orphans and children of unstable parents-all these are liable to lose confidence in life. Even chronic illness may lead to partial or total disorganisation of the home and often to an unsuspected state of anxiety and fear among the children which reacts adversely on their development. Medical men who know of such children-and who does not ?-and are doubtful how best to help them should make an effort to visit the Community, now established at The Mote, Maidstone, Kent, and form their own impression of its atmosphere. There are now 70 children in residence of ages from under six to sixteen. Those over eleven live in the Community but attend the senior, secondary,or technical schools in the neighbourhood. A small group, not more than 10, known as the home children," consists of intelligent youngsters presenting special difficulties-some are sent by was
reached which
the
THE discussion of the functions and possibilities our last week’s issue (p. 1432) recalls the achievements of one of these schools which has undergone a remarkable adaptive evolution. As long ago as 1911, at the foundation of their nursery school at St. Pancras, Miss P. M. POTTER and her fellow-workers adopted a passive rather than an active attitude in their relation to the children, and sought to encourage individual rather than collective effort. Their impulse to awaken and maintain in the children of workingclass parents the independence of spirit and joyous sense of security which is associated with a happy nursery led them to keep the children on till the ages of 7, 8, and even 9. From the first year of its existence arrangements were made by the Caldecott Nursery School to send the children to the country for a month, and it was the mental and physical effect of these holidays which convinced the honorary directors, Miss POTTER and Miss L. M. RENDEL, and the parents, that even under the most favourable conditions a day school in London could not adequately fulfil their conception of healthy child life. The courage that led them in 1917, when the country was still at war, to rent a house with seven acres of ground at East Sutton, Kent, was justified by the response of parents and of the friends of the Caldecott Community, as the venture was now called. The school at East Sutton opened with 30 children, 25 of whom had been in the Community for several years, and, as the only boarding school in this country for working men’s children, it began to attract attention in educational circles. Whereas in the public elementary schools the classes are large, the teachers few, and the curriculum rigid, here the staff were numerous and their self-imposed duties included cooperation in the activities of a household which must have completed its own chores before the intellectual work of the day can begin, and which depend to some extent on the cultivation of produce from a home farm for its maintenance. Their reward, to quote from a report of the Community’s activities, is the joy of watching the freeing of personality in order that personality, nurtured in communal life, may desire and acquire the power to serve. The school, child guidance clinics. They go to school with which in 1925 sought and obtained recognition as those of their own age, but have their own houseefficient by the Board of Education, had by this mother, playroom, and bedrooms ; their day is time been forced to find larger premises ; in that 1 The parents’ or guardians’ contribution is a minimum of £1 child. This covers less than half the annual year 55 applications for admission were received, a week for each the rest being supplied by subscriptions and while only 15 new members could be accommodated.expenditure, donations in response to appeals.
- "-
of nursery schools in
"
THE LANCET LONDON: SATURDAY, DECEMBER 30, 1933
MALIGNANT DISEASE OF THE BRONCHUS OuR knowledge of cancer originating in the bronchus has increased greatly in recent years as the result of improved methods of examination, notably by bronchoscopy and by skiagraphy, assisted by the introduction of lipiodol into the bronchial tree. As would be expected, more cases have been correctly diagnosed during life, but there is no certainty that there is any real increase in the incidence of the disease. No doubt many cases diagnosed as cancer of the lung or pleura actually originated in a bronchus, and even in post-mortem examinations of advanced cases the true site of origin of such a growth may easily have been over-1 looked. Mr. F. C. ORMEROD has recently published his experience of a series of 27 cases, of which 23 were proved by biopsy and 2 by autopsy; in the remaining 2 the clinical diagnosis was so certain as to justify their inclusion. Males are known to be attacked more frequently than females, but Mr. ORMEROD’S statistics, 23 males to 4 females, show a greater preponderance than usual; more than two-thirds of the cases occurred between the ages of 40 and 60, the youngest being a woman of 27, while the oldest, also a woman, was aged 74 ; the right side was affected in 15, the left in 12 patients. Of symptoms, cough is always present, and is nearly always accompanied by sputum, usually of a mucopurulent character ; there was some degree of haemoptysis in 21 patients. This may be profuse in the later stages, and in two cases in this series was the immediate cause of death. Dyspnoea on slight exertion was a striking symptom in 21 cases, and was often pronounced when only a comparatively small area of lung was out of action. Three patients complained of hoarseness, and in 2 of these the left cord was paralysed by implication of the recurrent laryngeal nerve. Pain was present in 15 patients, most often as an ache referred to the interior of the chest on the diseased side. The clinical signs of cancer in this region are those of obstruction of a bronchus, usually with atelectasis. In partial obstruction there may be an expiratory wheeze with moist sounds in the lung below ; in complete obstruction the signs are dullness on percussion, absence of breath sounds, and sometimes increased vocal conduction ; the heart and mediastinum may be displaced, and the movements of the corresponding half of the diaphragm reduced, when there is massive collapse of the lung. X ray examination shows reduced mobility and displacement of the diaphragm and a shadow in the tissue of the lung which is due partly to the growth and partly to collapsed lung, the two being difficult to distinguish. After the introduction of opaque oil, the skiagram shows 1
Journal of Laryngology, November, 1933, p. 733.
1487
the upper margin of the growth, its outline in the bronchus being nearly always convex ; a fusiform shadow is probably due to inflammatory stenosis. Bronchoscopy reveals certain characteristic features ; the bronchial mucosa is less irritable than in cases of inflammatory disease, and there is accordingly less tendency to cough on examination. The growth is usually nodular, of the same colour as the normal mucosa, and its site of origin from the bronchial wall can be plainly seen. It is often of a firm consistence, even hard enough to make removal of a portion for bioscopy difficult ; but in advanced stages may be so soft and friable that pieces are coughed up. Pathologically the carcinoma is frequently of the squamous-celled variety ; in other cases there are masses of columnar cells or, again, of small ovoid cells. These ovoid cells were once believed to represent the oat-celled sarcoma of the mediastinum, but are now held to be carcinoma of the lung. After chronic inflammation the bronchial mucous membrane shows a marked increase in the cells of the small ovoid layer with, in advanced stages, a tendency to formation of masses of squamous epithelium ; it is therefore suggested that all the different types of carcinoma arise from the layer of small ovoid cells. No specimen has been observed which would suggest that the ciliated columnar cells of the bronchus or the flattened epithelial cells of the alveoli give rise to these growths. The squamouscelled tumours show a tendency to degeneration with formation of cavities. Metastases occur the mediastinal commonly in glands, from which the tumour may invade the hilum of the opposite lung ; they are frequent also in the suprarenals, liver, pancreas, brain, and almost any organ. Aspiration of fragments into the bronchus of the opposite lung may give rise to secondary deposits. If the growth extends to the pleura, its whole surface may become studded with deposits, or a continuous sheet of carcinoma may envelope the lung ; such cases have been erroneously described as primary tumours of the pleura. In treatment, removal of a small semi-pedunculated tumour has occasionally been possible by endoscopic methods, but radiation must be employed afterwards. Lobectomy has been per formed in a few carefully selected cases at the Brompton Hospital by Mr. J. E. H. ROBERTS and Mr. A. TUDOR EDWARDS ; the disease must be limited to one lobe and must be so situated that sufficient lung tissue can be left to secure closure of the main bronchus; secondary deposits. in mediastinal glands are a contra-indication. Most of the cases in Mr. ORMEROD’S series were treated by radium emanation applied through the bronchoscope in a special container. Treatment by the radium bomb has been very disappointing, for the distance of a growth in the lung is too great for success with any of the masses of radium used in this country. Deep X ray therapy has given some improvement in a few cases, especially in the upper lobe. Mr. ORMEROD holds that the results of treatment are unsatisfactory owing to the advanced stage in which most cases are seen. Complete disappearance of signs and symptoms is reported
1488
THE CALDECOTT COMMUNITY
in one of his patients, treated six months previously; another is alive and well after two years, and several have improved. Even this measure of success is gratifying in connexion with intrathoracic growths, for these were until recently regarded as hopeless, whether the oesophagus or a bronchus was the site. A few days ago we were able to record the pioneer work of Prof. GREY TURNER on cancer of the oesophagus. Mr. ORMEROD is working on an It is clear that organ just as inaccessible. intrathoracic surgery affords ample scope for
bravery. THE CALDECOTT COMMUNITY
The
experiment was a success. The children holidays to homes widely differing from the one in which they spent the terms and adjusted themselves with little difficulty; for those who had no suitable homes hospitality was sought among the friends of the Community. Selection from among the applicants became year by year more difficult, and in 1929 a decision went in the
was the natural outcome of undefined ideal for which the groping, largely stands. In their attempt to give a Community sense of freedom and security to less fortunate children of the country, they had selected at first those less fortunate in material things, children from poor but normal homes. But gradually, from the nature of the applications received, the council realised that it is not the child from the normal home, however poor, that knocks irresistibly for admission, but the one with an abnormal home. The function of the Community became more definite : to provide a home school for normal children, irrespective of class or denomination, whose homes are in any way abnormal, unhappy, or unsuitable.’ These are rightly held to need more than any others that balanced serenity of outlook which comes of a wise discipline in an environment not too institutional. No adequate provision is at present made by the State or by voluntary social organisations for the child who, owing to its home conditions, is in danger of becoming socially maladjusted. It is difficult to estimate how many of those who later become misfits, neurotics, or criminals come from broken homes, that is, homes where for some reason normal relationships with and between the parents are not obtained ; but such information as is available suggests that this is one of the fertile sources of maladjustment. Illegitimate children, those whose parents are divorced or separated, or, perhaps still worse, live in continuous friction rather than face open rupture ; step-children, even when kindness and consideration are shown by the newcomer ; orphans and children of unstable parents-all these are liable to lose confidence in life. Even chronic illness may lead to partial or total disorganisation of the home and often to an unsuspected state of anxiety and fear among the children which reacts adversely on their development. Medical men who know of such children-and who does not ?-and are doubtful how best to help them should make an effort to visit the Community, now established at The Mote, Maidstone, Kent, and form their own impression of its atmosphere. There are now 70 children in residence of ages from under six to sixteen. Those over eleven live in the Community but attend the senior, secondary,or technical schools in the neighbourhood. A small group, not more than 10, known as the home children," consists of intelligent youngsters presenting special difficulties-some are sent by was
reached which
the
THE discussion of the functions and possibilities our last week’s issue (p. 1432) recalls the achievements of one of these schools which has undergone a remarkable adaptive evolution. As long ago as 1911, at the foundation of their nursery school at St. Pancras, Miss P. M. POTTER and her fellow-workers adopted a passive rather than an active attitude in their relation to the children, and sought to encourage individual rather than collective effort. Their impulse to awaken and maintain in the children of workingclass parents the independence of spirit and joyous sense of security which is associated with a happy nursery led them to keep the children on till the ages of 7, 8, and even 9. From the first year of its existence arrangements were made by the Caldecott Nursery School to send the children to the country for a month, and it was the mental and physical effect of these holidays which convinced the honorary directors, Miss POTTER and Miss L. M. RENDEL, and the parents, that even under the most favourable conditions a day school in London could not adequately fulfil their conception of healthy child life. The courage that led them in 1917, when the country was still at war, to rent a house with seven acres of ground at East Sutton, Kent, was justified by the response of parents and of the friends of the Caldecott Community, as the venture was now called. The school at East Sutton opened with 30 children, 25 of whom had been in the Community for several years, and, as the only boarding school in this country for working men’s children, it began to attract attention in educational circles. Whereas in the public elementary schools the classes are large, the teachers few, and the curriculum rigid, here the staff were numerous and their self-imposed duties included cooperation in the activities of a household which must have completed its own chores before the intellectual work of the day can begin, and which depend to some extent on the cultivation of produce from a home farm for its maintenance. Their reward, to quote from a report of the Community’s activities, is the joy of watching the freeing of personality in order that personality, nurtured in communal life, may desire and acquire the power to serve. The school, child guidance clinics. They go to school with which in 1925 sought and obtained recognition as those of their own age, but have their own houseefficient by the Board of Education, had by this mother, playroom, and bedrooms ; their day is time been forced to find larger premises ; in that 1 The parents’ or guardians’ contribution is a minimum of £1 child. This covers less than half the annual year 55 applications for admission were received, a week for each the rest being supplied by subscriptions and while only 15 new members could be accommodated.expenditure, donations in response to appeals.
- "-
of nursery schools in
"