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NOTE ON THE OPERATIVE TREATMENT OF MALIGNANT DISEASE, WITH SPECIAL REFERENCE TO THE TONGUE.
951 fever ; (2) almost universal absence of rash from the face ; (3) peeling tongue ; (4) absence of catarrh, especially in the eyes (except one case).
exhausted with attacks of recurring enlarged glands, and left-sided peritonsillitis in the third and fourth weeks. Cause of Infection. The cause of the infection was reduced to one of two sources : (1) A concert attended by the whole school in a neighbouring town, where, I heard, there had been some cases of scarlet fever and German measles ; the concert was 18 days before the first three, and 21 days before the fourth case (a mistress). (2) A maid developed a fibrinous tonsillitis (which proved not to be diphtheritic) seven days before the first three cases. She came from another neighbouring town where scarlet fever had been prevalent. After a few days she developed a quinsy, not the first in her life, and went home to convalesce, returning to her duties at the school on July 1st. The parents of the children had been notified when the first four cases occurred, and a good many pupils had returned home. About 20 days after the first four cases, one child was taken ill at home, and her medical attendant diagnosed mild German measles, slight rash, slight faucial redness, a cold, and no peeling. (Only one other child was reported ill after
I am disposed to agree with Dr. C. Dukes,of Rugby, that German measles is a diagnosis loosely applied to two diseases-epidemic roseola and " fourth disease," which should not be confused. The danger of confusion is much greater between " fourth disease " and scarlet fever. But, after all, what is the value of a diagnosis I when one is not able to isolate an organism ? am led to think that the streptococcus and its numerous relatives are at the bottom of most of these cases, and that the toxin of the various members of the family, virile or less active, of the first or third or fourth generation, may produce an irregular, though similar, series of manifestations. I should be very glad to be told of references to bacteriological work on this subject, which might be helpful when faced with such an epidemic. Broadstairs. __________________
NOTE ON THE
OPERATIVE TREATMENT OF MALIGNANT returning home, developing measles on August 12th, DISEASE, and I cannot think that this has anything to do with WITH SPECIAL REFERENCE TO THE TONGUE. our cases.) On July 6th four more cases occurred, on the eighteenth day after the removal of the first four to BY HERBERT J. PATERSON, C.B.E., M.C. CAMB., the sanatorium, and five days after the maid returned F.R.C.S. to the
ENG.,
school; and this time the latter was sent home
good. The second four cases conformed to type,I perhaps a little less severe ; marked scarlatinal rashes,I very irritable on the legs, red throats (two with some follicular tonsillitis, and these two children had later glandular complications). I may note here that one of the first four cases was a child who had had chorea ; though her pyrexia was somewhat persistent, and her usual movements rather more marked, she did not develop endocarditis, or recur as an acute chorea.
SENIOR
for
SURGEON,
LONDON TEMPERANCE HOSPITAL.
I
Diagnosis of Scarlet Fever. At this stage, all the cases were seen by an experienced colleague, who diagnosed them as scarlet fever. Three other patients developed the disease 18, 19, and 20 days from the second batch of children. Two conformed to type and peeled markedly ; one of these had secondary enlarged glands and slight albuminuria. This was the school matron, who was said to have had German measles twice ; she had the rash on her face, and also some conjunctivitis. The second case was the sanatorium maid ; the third was a maid in the school whose rash was somewhat morbilliform and did not peel, but without catarrh and with the red throat. It should be mentioned that one of the children is said to have had scarlet fever, and one to have had German measles. Here we have an epidemic with an incubation period of 18-21 days with all the signs and symptoms of scarlet fever, and without widespread infection to others. The occurrence of the case of tonsillitis just before the epidemic, and her return six days before the second four cases may have been misleading ; yet had she been allowed to remain who can tell what further cases might have arisen ? Apparently she infected no one at home.
IT will hardly be disputed that within the last decade the operative treatment of carcinoma has not made such strides as might have been anticipated. It behoves us from time to time to search out the reason for lack of progress, and to consider our technique, to see if in any way this is at fault, or in what way it can be bettered. I sometimes wonder whether we appreciate fully the part played by the lymphatic glands in Nature’s defence against the spread of carcinoma. May it not be possible that in modern surgery the glands are attacked too ruthlessly ? Two truths are established. A malignant growth spreads peripherally by invasion of the surrounding tissues, and distally by permeation of the growth through the lymphatics to the lymphatic glands into which they drain, which thus become infiltrated with growth. Most surgeons have met with cases where operation for a malignant growth has been necessarily incomplete, in that glands obviously infiltrated have been left behind, in spite of which fact the patient has lived 10, 12, or even more years, and in some instances has apparently been cured. Is it not a fair inference from this that the lymphatic glands are Nature’s defence against distal spread of the disease-in other words, that such patients have lived, not in spite of, but because of the incomplete removal of glands ? It seems clear that the lymphatic glands arrest, for a time at any rate, the progress of cancer cells ; it is even possible that they may be able to a limited extent to effectively with such cells. Does this suggest a modification of our technique ?2
deal
Possible
Advantage of Glands as Wound Scavengers." The modern practice aims at the removal of the whole of the growth, together with all contiguous glands, "
The Case Against Scarlet Fever and Roseola. On reflection one feels that the cases conform most " closely to the description of fourth disease," but I think it would be a brave medical officer who would risk not treating them as scarlet fever, while my experience of roseola has never brought me in contact with cases of such rashes and throats without catarrh, enlarged posterior cervical glands, and a wide epidemic. For simplicity I tabulate as follows the important points against scarlet fever : (1) Incubation (assuming the maid did not start the epidemic) ; (2) no sequelae
complications, except secondary enlarged glands ; (3) no early vomiting, except in two cases slightly ; (4) the case of German measles developed at home and possibly the last case described. Against roseola was the following evidence : (1) Acute onset with high or
in
one
If
piece.
we
could be certain of removing the
whole of the growth and leaving no isolated cancer cells behind, this procedure would undoubtedly be correct. In practice, however, it must be rarely possible to remove a malignant growth without leaving a few cells, either in the surrounding tissues or in the wound, as a result of the necessary manipulation of the growth. When cancer cells are left in a wound some or all of them probably permeate along the lymphatics the nearest lymphatic glands, where, temporarily at any rate, then progress is arrested. If, then, all glands have already been removed, the
to
removable
1
THE
LANCET, 1900, ii., 89, 1384.
952 cells may find their way to more distant groups and then three or four weeks later removing the of glands which are beyond the reach of surgical inter- glands. It seems to me that in this way any cancer cells vention. It is possible, therefore, that if the glands left behind in the lymphatics would find their way to draining the region occupied by the growth are left, the nearest glands and be removed with the glands they may arrest the cancer cells which have remained at the second operation. I operated for cancer of the behind, and prevent their spreading to more distant tongue by this method five times previous to the war. parts. After these glands have thus " scavenged " the During the war I had no further opportunity of trying operation area they can be removed before the cancer this method. The results in these few cases are so cells arrested in them have time to spread to more encouraging as to suggest further trial of this plan of The first operation was performed in remote regions. These considerations are especially campaign. applicable to cancer of the tongue. In operation for January, 1914, and the growth was reported by Dr. lingual carcinoma it is obviously impossible to remove E. F. Bashford to be of a very malignant type. In the growth and glands in the neck in one piece. A track 1921, seven years later, this patient came to see me, of lymphatics is left between the site of the growth and to my surprise I could find no trace of recurrence and the glands in the neck. This is one reason why either in the mouth or neck. This prompted me to operation for cancer of the tongue is followed so inquire as to the results in the other four patients. frequently by rapid recurrence. The lymphatics in I traced three of them and found that they were all this irremovable area are permeated with cancer cells. well, nearly seven years after operation. Presumably These cells may multiply in situ or migrate to distant the remaining patient had died. glands leading to metastases. This suggests the I would suggest, therefore, that in cases of carcinoma speculation, what would happen if, when the growth of thetongue (1) the growth be removed by the actual is removed, the glands in the neck were left for the cautery ; (2) three weeks later the glands in the neck time being. Might not the cancer cells left behind be be removed in the usual way. temporarily arrested in the glands of the neck ? I have latterly been trying the same plan in operation for breast carcinoma, but whether it is advantageous Operation in Two stages. These hypotheses suggested a trial of the results of or not it is too early to say, but as far as cancer of the operation in two stages-i.e., removing the growth at mouth is concerned it seems to be a rational procedure the first operation, using cautery rather than knife, worthy of further trial.
cancer
I,
Clinical and
spinal fluid under reduced pressure. Prof. L. S. Dudgeon examined the fluid that night and reported a pure culture of streptococcus- the next morning. Opc?-
Laboratory Notes. A CASE OF
STREPTOCOCCAL
MENINGITIS.
There was a small area of diseased bone at the of the mastoid. The mastoid cells contained pus. The diseased mastoid was gouged away and the antrum was THE following case of streptococcal meningitis with found full of pus. The antrum was irrigated with hydrogen peroxide, and the wound partly sutured, a gauze drain being operation and recovery is of interest. inserted down to the antrum. The dura was not touched. History.-The patient was a boy, aged 12, whose family Recove,ry.-On the night of the operation the boy vomited history was good. For two and a half years he had hadi twice, and not again. Pulse-rate and temperature began to in had a few’ cervical the abdomen he fall at once (see chart) : after 2hours the gauze drain was slight lymphadenitis ; palpable glands and occasional attacks of pain. He was subject to naso-pharyngeal catarrh with temporary deafness, !I and was often unwell and away from school for a few daysI In 1919 Mr. A. C. Gavin removed his at a time. and adenoids. I Condition on Exa.rraaraatiorz.-On Jan. 22nd, 1923, I saw the boy on account of earache. He had considerable deafness,I especially on the right side ; right tympanic membrane, slightly thickened ; no mastoid tenderness, but a small’ gland below the right pinna was very tender. Several slightly tender glands along anterior aspect of upper third of right sterno-mastoid, and some enlarged glands on left side of neck also. These glands were larger a year ago. j Further Examination.-On Jan. 26th Mr. Gavin saw him and reported deafness in both ears with the right tympanic membrane indrawn and thickened. Rinn4 tuning-fork test negative in both ears. A soft whisper heard at 12 ft. from either ear. Right tympanum ventilated inadequately owing to a nasal spur meeting right inferior turbinal and blocking Chart of case of streptococcal meningitis showing fall of this side of nose.
BY STEPHEN G.
operated.
ASKEY, M.D. CAMB.
tip
:
tonsilsI
I
.
temperature after operation.
Course of Case.-On Jan. 29th he began to have great occipital neuralgia on the right side, with normal pulse and temperature and no mastoid tenderness. On Feb. 8rd I saw him at 11 A.M., when lie still had neuralgia ; pulse and temperature normal, no visible change in ear, no vomiting, fimdi normal, knee-jerks normal. Owing to persistent neuralgia I warned the parents of the possibility of meningitis. Half an hour after I left the house the boy vomited violently without warning. I saw him again about 2 P.M., when lie was vomiting. The occipital neuralgia had ceased and hei complained of left frontal headache. The temperature was, 103.50 F., and the pulse-rate 108. There was no mastoid I tenderness ; Kernig’s sign absent, neck muscles normal. Left knee-jerk present, but right knee-jerk only justI obtained on reinforcement. Plantar reilexes indefinite ; no I nystagmus.
I
Dr. A. E. Russell saw him. Kernig’s sign then present, neck muscles definitely ’rigid, knee-jerks absent except for a flicker on the right on reinforcement. No paralysis of eye muscles, no mastoid symptom. Lumbar puncture under light anaesthesia revealed a turbid cerebroAt 9
r.M.
changed and the wound irrigated ; these processes were continued daily until March llth, when only a fine probe could be inserted. Knee-jerks began to return on Feb. 8th. The boy made an uninterrupted recovery and is about again. There is no impairment of mind, and at the time of writing his general health is better than it has been for a The condition of the right tympanic membrane is year. unchanged. This was an undoubted case of generalised streptococcal meningitis, the organism being obtained in pure culture from the lumbar region of the cerebro-spinal canal. The meningitis was well established and the cerebro-spinal fluid only dripped slowly on lumbar puncture, both factors being said to increase the of the prognosis. At operation the dura was not opened. The absence of signs of mastoid inflammation was rightly disregarded. Balham, S.W.
i gravity ’
exhausted with attacks of recurring enlarged glands, and left-sided peritonsillitis in the third and fourth weeks. Cause of Infection. The cause of the infection was reduced to one of two sources : (1) A concert attended by the whole school in a neighbouring town, where, I heard, there had been some cases of scarlet fever and German measles ; the concert was 18 days before the first three, and 21 days before the fourth case (a mistress). (2) A maid developed a fibrinous tonsillitis (which proved not to be diphtheritic) seven days before the first three cases. She came from another neighbouring town where scarlet fever had been prevalent. After a few days she developed a quinsy, not the first in her life, and went home to convalesce, returning to her duties at the school on July 1st. The parents of the children had been notified when the first four cases occurred, and a good many pupils had returned home. About 20 days after the first four cases, one child was taken ill at home, and her medical attendant diagnosed mild German measles, slight rash, slight faucial redness, a cold, and no peeling. (Only one other child was reported ill after
I am disposed to agree with Dr. C. Dukes,of Rugby, that German measles is a diagnosis loosely applied to two diseases-epidemic roseola and " fourth disease," which should not be confused. The danger of confusion is much greater between " fourth disease " and scarlet fever. But, after all, what is the value of a diagnosis I when one is not able to isolate an organism ? am led to think that the streptococcus and its numerous relatives are at the bottom of most of these cases, and that the toxin of the various members of the family, virile or less active, of the first or third or fourth generation, may produce an irregular, though similar, series of manifestations. I should be very glad to be told of references to bacteriological work on this subject, which might be helpful when faced with such an epidemic. Broadstairs. __________________
NOTE ON THE
OPERATIVE TREATMENT OF MALIGNANT returning home, developing measles on August 12th, DISEASE, and I cannot think that this has anything to do with WITH SPECIAL REFERENCE TO THE TONGUE. our cases.) On July 6th four more cases occurred, on the eighteenth day after the removal of the first four to BY HERBERT J. PATERSON, C.B.E., M.C. CAMB., the sanatorium, and five days after the maid returned F.R.C.S. to the
ENG.,
school; and this time the latter was sent home
good. The second four cases conformed to type,I perhaps a little less severe ; marked scarlatinal rashes,I very irritable on the legs, red throats (two with some follicular tonsillitis, and these two children had later glandular complications). I may note here that one of the first four cases was a child who had had chorea ; though her pyrexia was somewhat persistent, and her usual movements rather more marked, she did not develop endocarditis, or recur as an acute chorea.
SENIOR
for
SURGEON,
LONDON TEMPERANCE HOSPITAL.
I
Diagnosis of Scarlet Fever. At this stage, all the cases were seen by an experienced colleague, who diagnosed them as scarlet fever. Three other patients developed the disease 18, 19, and 20 days from the second batch of children. Two conformed to type and peeled markedly ; one of these had secondary enlarged glands and slight albuminuria. This was the school matron, who was said to have had German measles twice ; she had the rash on her face, and also some conjunctivitis. The second case was the sanatorium maid ; the third was a maid in the school whose rash was somewhat morbilliform and did not peel, but without catarrh and with the red throat. It should be mentioned that one of the children is said to have had scarlet fever, and one to have had German measles. Here we have an epidemic with an incubation period of 18-21 days with all the signs and symptoms of scarlet fever, and without widespread infection to others. The occurrence of the case of tonsillitis just before the epidemic, and her return six days before the second four cases may have been misleading ; yet had she been allowed to remain who can tell what further cases might have arisen ? Apparently she infected no one at home.
IT will hardly be disputed that within the last decade the operative treatment of carcinoma has not made such strides as might have been anticipated. It behoves us from time to time to search out the reason for lack of progress, and to consider our technique, to see if in any way this is at fault, or in what way it can be bettered. I sometimes wonder whether we appreciate fully the part played by the lymphatic glands in Nature’s defence against the spread of carcinoma. May it not be possible that in modern surgery the glands are attacked too ruthlessly ? Two truths are established. A malignant growth spreads peripherally by invasion of the surrounding tissues, and distally by permeation of the growth through the lymphatics to the lymphatic glands into which they drain, which thus become infiltrated with growth. Most surgeons have met with cases where operation for a malignant growth has been necessarily incomplete, in that glands obviously infiltrated have been left behind, in spite of which fact the patient has lived 10, 12, or even more years, and in some instances has apparently been cured. Is it not a fair inference from this that the lymphatic glands are Nature’s defence against distal spread of the disease-in other words, that such patients have lived, not in spite of, but because of the incomplete removal of glands ? It seems clear that the lymphatic glands arrest, for a time at any rate, the progress of cancer cells ; it is even possible that they may be able to a limited extent to effectively with such cells. Does this suggest a modification of our technique ?2
deal
Possible
Advantage of Glands as Wound Scavengers." The modern practice aims at the removal of the whole of the growth, together with all contiguous glands, "
The Case Against Scarlet Fever and Roseola. On reflection one feels that the cases conform most " closely to the description of fourth disease," but I think it would be a brave medical officer who would risk not treating them as scarlet fever, while my experience of roseola has never brought me in contact with cases of such rashes and throats without catarrh, enlarged posterior cervical glands, and a wide epidemic. For simplicity I tabulate as follows the important points against scarlet fever : (1) Incubation (assuming the maid did not start the epidemic) ; (2) no sequelae
complications, except secondary enlarged glands ; (3) no early vomiting, except in two cases slightly ; (4) the case of German measles developed at home and possibly the last case described. Against roseola was the following evidence : (1) Acute onset with high or
in
one
If
piece.
we
could be certain of removing the
whole of the growth and leaving no isolated cancer cells behind, this procedure would undoubtedly be correct. In practice, however, it must be rarely possible to remove a malignant growth without leaving a few cells, either in the surrounding tissues or in the wound, as a result of the necessary manipulation of the growth. When cancer cells are left in a wound some or all of them probably permeate along the lymphatics the nearest lymphatic glands, where, temporarily at any rate, then progress is arrested. If, then, all glands have already been removed, the
to
removable
1
THE
LANCET, 1900, ii., 89, 1384.
952 cells may find their way to more distant groups and then three or four weeks later removing the of glands which are beyond the reach of surgical inter- glands. It seems to me that in this way any cancer cells vention. It is possible, therefore, that if the glands left behind in the lymphatics would find their way to draining the region occupied by the growth are left, the nearest glands and be removed with the glands they may arrest the cancer cells which have remained at the second operation. I operated for cancer of the behind, and prevent their spreading to more distant tongue by this method five times previous to the war. parts. After these glands have thus " scavenged " the During the war I had no further opportunity of trying operation area they can be removed before the cancer this method. The results in these few cases are so cells arrested in them have time to spread to more encouraging as to suggest further trial of this plan of The first operation was performed in remote regions. These considerations are especially campaign. applicable to cancer of the tongue. In operation for January, 1914, and the growth was reported by Dr. lingual carcinoma it is obviously impossible to remove E. F. Bashford to be of a very malignant type. In the growth and glands in the neck in one piece. A track 1921, seven years later, this patient came to see me, of lymphatics is left between the site of the growth and to my surprise I could find no trace of recurrence and the glands in the neck. This is one reason why either in the mouth or neck. This prompted me to operation for cancer of the tongue is followed so inquire as to the results in the other four patients. frequently by rapid recurrence. The lymphatics in I traced three of them and found that they were all this irremovable area are permeated with cancer cells. well, nearly seven years after operation. Presumably These cells may multiply in situ or migrate to distant the remaining patient had died. glands leading to metastases. This suggests the I would suggest, therefore, that in cases of carcinoma speculation, what would happen if, when the growth of thetongue (1) the growth be removed by the actual is removed, the glands in the neck were left for the cautery ; (2) three weeks later the glands in the neck time being. Might not the cancer cells left behind be be removed in the usual way. temporarily arrested in the glands of the neck ? I have latterly been trying the same plan in operation for breast carcinoma, but whether it is advantageous Operation in Two stages. These hypotheses suggested a trial of the results of or not it is too early to say, but as far as cancer of the operation in two stages-i.e., removing the growth at mouth is concerned it seems to be a rational procedure the first operation, using cautery rather than knife, worthy of further trial.
cancer
I,
Clinical and
spinal fluid under reduced pressure. Prof. L. S. Dudgeon examined the fluid that night and reported a pure culture of streptococcus- the next morning. Opc?-
Laboratory Notes. A CASE OF
STREPTOCOCCAL
MENINGITIS.
There was a small area of diseased bone at the of the mastoid. The mastoid cells contained pus. The diseased mastoid was gouged away and the antrum was THE following case of streptococcal meningitis with found full of pus. The antrum was irrigated with hydrogen peroxide, and the wound partly sutured, a gauze drain being operation and recovery is of interest. inserted down to the antrum. The dura was not touched. History.-The patient was a boy, aged 12, whose family Recove,ry.-On the night of the operation the boy vomited history was good. For two and a half years he had hadi twice, and not again. Pulse-rate and temperature began to in had a few’ cervical the abdomen he fall at once (see chart) : after 2hours the gauze drain was slight lymphadenitis ; palpable glands and occasional attacks of pain. He was subject to naso-pharyngeal catarrh with temporary deafness, !I and was often unwell and away from school for a few daysI In 1919 Mr. A. C. Gavin removed his at a time. and adenoids. I Condition on Exa.rraaraatiorz.-On Jan. 22nd, 1923, I saw the boy on account of earache. He had considerable deafness,I especially on the right side ; right tympanic membrane, slightly thickened ; no mastoid tenderness, but a small’ gland below the right pinna was very tender. Several slightly tender glands along anterior aspect of upper third of right sterno-mastoid, and some enlarged glands on left side of neck also. These glands were larger a year ago. j Further Examination.-On Jan. 26th Mr. Gavin saw him and reported deafness in both ears with the right tympanic membrane indrawn and thickened. Rinn4 tuning-fork test negative in both ears. A soft whisper heard at 12 ft. from either ear. Right tympanum ventilated inadequately owing to a nasal spur meeting right inferior turbinal and blocking Chart of case of streptococcal meningitis showing fall of this side of nose.
BY STEPHEN G.
operated.
ASKEY, M.D. CAMB.
tip
:
tonsilsI
I
.
temperature after operation.
Course of Case.-On Jan. 29th he began to have great occipital neuralgia on the right side, with normal pulse and temperature and no mastoid tenderness. On Feb. 8rd I saw him at 11 A.M., when lie still had neuralgia ; pulse and temperature normal, no visible change in ear, no vomiting, fimdi normal, knee-jerks normal. Owing to persistent neuralgia I warned the parents of the possibility of meningitis. Half an hour after I left the house the boy vomited violently without warning. I saw him again about 2 P.M., when lie was vomiting. The occipital neuralgia had ceased and hei complained of left frontal headache. The temperature was, 103.50 F., and the pulse-rate 108. There was no mastoid I tenderness ; Kernig’s sign absent, neck muscles normal. Left knee-jerk present, but right knee-jerk only justI obtained on reinforcement. Plantar reilexes indefinite ; no I nystagmus.
I
Dr. A. E. Russell saw him. Kernig’s sign then present, neck muscles definitely ’rigid, knee-jerks absent except for a flicker on the right on reinforcement. No paralysis of eye muscles, no mastoid symptom. Lumbar puncture under light anaesthesia revealed a turbid cerebroAt 9
r.M.
changed and the wound irrigated ; these processes were continued daily until March llth, when only a fine probe could be inserted. Knee-jerks began to return on Feb. 8th. The boy made an uninterrupted recovery and is about again. There is no impairment of mind, and at the time of writing his general health is better than it has been for a The condition of the right tympanic membrane is year. unchanged. This was an undoubted case of generalised streptococcal meningitis, the organism being obtained in pure culture from the lumbar region of the cerebro-spinal canal. The meningitis was well established and the cerebro-spinal fluid only dripped slowly on lumbar puncture, both factors being said to increase the of the prognosis. At operation the dura was not opened. The absence of signs of mastoid inflammation was rightly disregarded. Balham, S.W.
i gravity ’