H. T. Butlin
1903 BMJ (Clinical Research Edition)  
Nearly four years ago1 I gave an address at the Hunterian Society on what operation can do for cancer of the tongue, and I showed then that the success of operations for cancer of the tongue is really very much greater than it had been previously thought to be. To-day I intend to make a continuation of that address, and have all my results collected up to the present time; and with the help of Mr. Young, my junior house-surgeon, who has carried out the work excellently, I have been able to
more » ... e been able to collect the results of all my operations for cancer of the tongue performed up to three years ago. Thecases are 129 in number. And out of those 129, 32 may be regarded as absolute successes. And if you take away from the total, as we do in making up these statistics, the cases of I2 patients who died of some other disease within three years after the operation, the totals then are 32 in II7 cases; that is a proportion of successes of over27 percent. --a very considerable proportion when the severity of many of the cases is taken into account. Then I was not satisfied about three or four of the cases, and I thought that, although I had not the least doubt myself that the disease was malignant, yet other people might have taken a more favourable view of them, and said that they were on the border-line of cancer. So I cut out 4 cases, and on that account the totals are 28 out of 113; thus the proportion is nearly 25 per cent. Three years ago it was only 20 per cent. I put these figures before you now-and I put them before myself with very considerable satisfaction-because, as far as I know, no more successful statistics have been published of any large number of cases of operation for cancer of the tongue. I was more particularly gratified, too, on account of the nature of the disease in some of these cases, and the length of time which had elapsed since the patient was operated upon. Take, for instance, an old man who is now between 8o and go, on whom I operated in this hospital nineteen years ago. The case was very bad, because I removed not only a large part of the tongue, 'but the glands (which were malignant) on the same side of the neck.. Mr. Young received a letter from his daughter to say that he was still in perfect health, that he had never hadany further trouble in his tongue or in his neck, and that he would have come up to seeme if he had not been stricken by apoplexy three or four years ago, so that he was not able to travel to London. There was another case of a very bad kind indeed. A gentleman came to me four years ago. Just at that time he had a very badly ulcerated cancer on the right side of the tongue, extending into the floor of the mouth, and he had more than one enlarged gland, and this state of things had been going on for a long time. In his case I was obliged to remove the entire tongue, and in the course of two or three weeks I removed all the contents of the anterior triangle; and, fearing that I had not taken out sufficient of the floor of the mouth, I cut away a portion at the second operation, so that I left a large cavity from the mouth almost to the clavicle. He made a very good recovery; he was a very determined person, and from both operations he made admirable recoveries. Then the firm of which he was a very active member sent 'to ask what my opinion was-first, as to whether he should go back to his work; and secondly, what I thought would be likely to be the duration of his life. 1 replied to the first question that if he was inclined to go back to his work-and I could not conceive that he could do anything better-he -could, do so, because lie was an extremely valuable man of business to his firm. To the second question I answered that -in my opinion he would not live a year, and I should not be surprised if he was incapacitated for work in six months. Last November (I90I) he came to see me on a certain day and he said, " Do you know, Mr. Butlin, why I come tc-day ?' 6 I said' "No." He said, "Because it is exactly three years to-day since the second operation was performed." I have seen him again within the last two or three months, when he came previous to taking a voyage I think to China or Japan, where his firm have large interests. And I was very gratified, because I looked upon his as a case that was well-nigh hopeless. I speak strongly about these successful cases, because an opinion prevails in the minds of even eminent surgeons that no operation for cancer of the tongue is ever permanently successful. That is au opinion which' is not merely incorrect, it is most mischievous. As to the nature of the disease, in almost all these successful cases it was proved by microscopic examination, and the microscopical examination in the case of the patients operated upon in the hospital was made in the pathological department; therefore I am not responsible for it. And in some of the successful cases, not only was the disease in the tongue epithelioma, but the glands which were removed were also epitheliomatous; in fact they were transformed into epitheliomatous tumours. UNSUCCESSFUL OPERATIONS. So far, so good. But one day, not very long ago, I was sitting and working out these results on pieces of paper, and was in a really happy frame of mind at the number of successful cases and the kind of case in which success had attended operation, when, as it were by chance, I cast my eye on the other side, and then saw to my horror-for it dawned upon me suddenly-that out of the 129 patients on whom I had operated for cancer of the tongue, nearly ioo are dead. And I assure you that from a state of satisfaction I became quite despondent, and I began to wonder, considering what all these people had been througli in the way of pain and suffering, not only frdm the disease but from the operation, whether the game after all was worth the candle. When I had recovered myself a little, I began to consider whether things ought to be as bad as they certainly are at the present time, because the results I put before you are not what would be called bad results for cancer of the tongue. They would be called good; indeed I do not know any large statistics which are better, so that the proportion of unsuccessful eaEes is really very large. When I came to look into them I fbund that out of the 97 patients 12 died of some other disease than cancer of the tongue within three years, and 14 died of 'the operation, not a large mortality when the severity of many'of the operations is remembered. Unfortunately it is quite certain that some of these people, if they had not died of the operation or shortly after it, would have died from recurrence of cancer in the mouth or in the glands. Of the remainder, 29 patients died with recurrence in the mouth. The disease recurred in most of them very quickly,' and all those patients went through the same suffering before dedh which they would have had if no operation had been performed. Therefore we must regard those particular operations as absolutely unsuccessful. One patient is said to have died of secondary disease, and 41 patients died from affection of the lymphatic glands without recurrence in the mouth. So here you have 84 people who died either of recurrence in 'the mouth or of affection of the lymphatic glands, or of the operation itself out of I29 persons operated upon for cancer of the tongue. Truly it is a deplorable state of surgery. I have no hesitation in saying it is pitiable; and if we cannot do better than that in the future it seems to me to speak very badly either for the art of surgery or for something connected with it. Naturally when first I began to consider these results' I tried to discover what I might call extenuating circumstances. I mean in this way: I said, Very well ; if I were to perform these operations over again, upon the same people or on similar cases, I do not think I should lose so many patients from the operation. I tbink now, with the experience I h'ave, and particularly with the routine practice of preliminary laryngotomy, that I could operate with a very much smaller mortality. Again, I should know better now than to operate'on some of the patients on whom I operated years ago; for many of the cased were extremely bad, almost hopeless; but in this hospital our rule' in cases' of malignant disease and it is the rule of all my, colleagues 'is to operate if there seems to be the smallest' chante of relieving the patient. It is a rule which is very destructive 'to' good "statistics, but it is a good rule, and I hope we shall adhere toit. On the other hand' I had to ackno*iledge thliat'geveral of 'the patients who .died of the operation, or who died shortly afterwards" from some' other disease 'thancancer of the tohgue, [2 I98]
doi:10.1136/bmj.1.2198.353 fatcat:blrwal44lfhalf5ueef5wh6rji