148

THE CANADIAN MEDICAL ASSOCIATION JOURNAL

[Feb. 1937

19. BODANSKY, A. AND JAFFE, H. L.: Parathormone dosage and serum calcium and phosphorus in experimental chronic hyperparathyroidism leading to osteitis fibrosa, J. Ea>p. Med., 1931, 53: 591. 20. BPREHME, T(. AND GYoRoY, P.: Stoffwechselwirkung und klinische Verwendbarkeit des Epithelk6rperschenhormons (Qollip), Jahwb. f. Ki&de'rheilk., 1927, 118: 143; through Endoorinology, 12: 230. 21. LOWEwirURO, H. AND GINSBURG, T. M.: Acute hypercalceemia: report of a case, J. Am. M. Ass., 1932, 99: 1166. 22. BOWMAN, K. M.: Parathyroid therapy in schizophrenia, J. Nerv.. & Mental Dis., 1929, 70: 353. 23. JOHNSON, J. L. AND WILDER, R. M.: Experimental chronic hyperparathyroidism. I. Metabolic studies in man, Am. J. M. Sc., 1932, 182: 800. 24. SWINGLE, W. W. AND WENNER, W. F.: The effect of bleeding upon the serum calcium of thyroparathyroidectomized dogs, Am. J. Physiol., 1926, 75: 372. 25. NITESCU, I. I., et al.: Action de la saign6e sur le calcium etc., Oompt. rend. soc. biol., 1927, 97: 1109. 26. PARHON, C. I., et al.: Action de la saign6e et d'une injection unique de parathormone de Collip sur la calcemie etc., Om~t. re. soc. biol., 1930, 104: 437. 27. OKISY, R., 9TEWART, J. M. AND GREENWOOD, M. L.: The calcium and inorganic phosphorus in the blood of normal women at the various stages of the monthly cycle, J. Biol. aha., 1930, 87: 91.

28. ZWARENSTHIN, H.: The endocrine glands and calcium metabolism, Biol. Rev., 1934, 9: 299. 29. LaNDER, G. 0.: The influence of infection on the action of parathyroid hormone in imiani, Qwr. J. Med., 1935, 4: 131. 30. PUGSiLEY, L. I.: The effect of parathyroid hormone and of irradiated ergosterol on calcium and phosphorus metabolism in the rat, J. Physiot., 1932, 76: 315. 31. THOMSON, D. L. AND COLLIP, J. B.: The hormone of the parathyroid glands, Internat. Clinics, 1933, 4: 103. 32. GOADBY, H. K. AND STACEY, R. S.: On the action of parathormone, Biochem. J., 1936, 30: 269. 33. MOR4AN, A. F. AND SAMISCH, Z.: The sequence and extent of tissue changes resulting from moderate doses of vio,sterol and parathyroid extract, J. Biol. Chem., 1935, 108: 741. 34. HJORT, A. M. AND EDER, L. T.: Treatment of a case of strumiprivous tetany with parathyroid extract, J. Ain. M. Ass., 1927, 88: 1475. 35. BISCOoFF, G.: Nebenschilddriiselnhormon und Ergosterinhypercalcamie, Zeitschr. f. phys8ot. Chen., 1930, 188: 247. 36. MORAN, A. F. AND GARRISON, E. A.: The effect of vitamin D and of reaction of diet upon response to parathyroid extract, J. Biol. Chemi., 1930, 85: 687.

THE SURGICAL ASPECTS OF ORAL CANCER BY HAROLD WOOKEY

Toronto
treatradium in 'WVITH the introduction of it was feltthethat a cancer

tongue, and 170 cancers originating in the mouth elsewhere. ment of oral A few rather striking generalizations may be combined study of a group of cases would determine the exact rAle which radium and surgery made. In the first place, oral cancer is very might each play in the management of the dis- largely a disease of males. This is particularly ease. It was well known that surgical measures true of cancer of the lip. In the second place, alone had proved disappointing, particularly in oral cancer tends to be a local problem, that is the intra-oral group of cases, and it was hoped to say, the spread of the disease is to the lymph a great improvement would follow the employ- glands of the neck or neighbouring jaw, remote ment of radium. Accordingly, representatives metastases being rare. The average age is over of the surgical staff of the Toronto General 60 years; in lip cancers 63, in cancers of the Hospital have cooperated with the staff of the tongue 60.7, and in the buccal mucosa, 62.5. As Radiological Department in the examination, in cancer elsewhere, the younger the subject. treatment, and subsequent progress of all cases the more serious the outlook, the more rapid the of lip and intra-oral cancers. A series of papers growth, and the earlier the involvement of the by Dr. Richards has recently appeared in this lymph nodes. It should be remembered that Journal. These have been based on a study of the general expectation of life in these patients cases of oral cancer treated in the Institute of under normal conditions would not be great, Radiotherapy, Toronto, in the years 1929 to 1935 and that many of them were also suffering from inclusive. The primary lesions have all been some other form of chronic disease, particularly treated radiologically, whereas both surgery and cardiovascular and renal. In almost all cases radiation have been employed in dealing with there was very marked oral sepsis. For purposes of description it has been necesglandular and bone complications. This paper is intended to be a critical review sary to adopt some arbitrary method of classifiof the results of treatment not only of the cation, and, accordingly, the primary lesions primary lesions but more particularly of the have been classed into four groups, A, B, C, and disease as it affected the regional lymph glands D, depending upon the extent of the primary and the neighbouring bones. The cases under disease. In addition, the glands of the neck review correspond almost exactly with those have been classified into three groups, A, B, and already presented by Dr. Richards, and consist C. The A type of primary lesions is superficial of a series of 609 cases of oral cancer, of which and usually of short duration, whereas the D 338 were cancers of the lip, 101 cancers of the group cases are practically hopeless. The A

Feb. 19371 Feb 197

WOOKEY: ORAL CANCER

o-ORLCNE

149
4

type of enlarged gland is a small, freely movable node, the C, either an extensive and fixed mass or a bilateral enlargement of glands. No attempt whatever has been made to classify these cases according to their histological structure, as it has been felt that such a classification would be of doubtful value. In the early stages of glandular enlargement, it is almost impossible to determine whether this is due to inflammation or neoplasm, especially as the majority of the primary lesions are associated with obvious

majority were early lesions and the gland involvement was small, less than 9 per cent developing enlarged glands, whereas in those who died over 50 per cent developed enlarged glands. It should also be noted in the summary of Causes of Death that in almost half of the fatal cases death occurred from some other disease.
TABLE II. CANCER OF LIP-LIVING-TREATMENT OF GLANDS

infection. The mass of material and the intricacy of the whole problem have made it very difficult to simplify the subject and to present it in a way it would be easily understood. However, a series of tables has been prepared and it is hoped that they may be easily followed in the subsequent
comments.

In a series of 338 lip cancers, 292 are alive and 46 dead. Of the living cases, the great
CASES
OF

Dissections. 5 6 Early glands J.1 Positive-Living 2-5 years \5 Negative- " Late glands ....... 10 10 Positive- " 2-5 " No glands enlarged. 4 f 3 Negative- " 1-5 1 Positive- " 6 " Radiation onlyf2 living 1-4 years Early glands..... E5 living 6 months Late glands ...... 1 Living 3 years No treatment ...... 2 Living 9 months and 3 yeara
CANCER OF LIP-DEAD-TREATMENT OF GLANDS

TABLE I. CANCER OF LIP-LIVING

Glands on admission
A.
4 5 1

Dissections-

Early glands.. 5
Invasion of jaw

healed (3 Positive f21 uncontrolled ostvX

2 Negative-healed

Type No glands on Glands of case admission later

A. 233 B. 48
C. D.
9
2

Late glands... 8 8 Positive

Radiation onlyLate cases.... 9 All died of

(2 healed

B.
2 1 2

C.

3 uncontrolled 3 died while under treatment

227
42

6
1

4 4 2

cancer

292

276
CASES

10
OF

11
OF

No treatmen.t. 4 (3 died of cancer

CANCER

LIP DEAD
on

Glands
Type No glands

admission
C.

of
case

Glands admission later

on

A.

B.

Invasion of jaw
1

A. 15 B. 16 C. 12
D
3

12 12 1
25

1 3 1 5

2 3 2
7
OF

1 1 6
1

3
2

46

CAUSE
Ex-

DEATH
Other
cancer

Type No.
A.
B.

traneous Died of Un-

disease

Died while under

treatment

cancer

known
1 2
1

C.
D.

15 16 12
3
46

11
9

3
2

79
3
20

2 stomach

1 2
3

17

Table II shows the methods by which glands of the neck were treated. In the early dissections only 36 per cent showed cancer cells in the lymph tissue, whereas in the later stages of glandular enlargement 100 per cent were positive. Twelve patients are living following dissections which were positive, and of those who died, 4, though positive, were controlled by surgical measures. This table also shows that a number of early enlarged glands were treated by radiation only, and these patients are alive from six months to four years. However, it is probably fair to assume that the majority of these glandular enlargements were inflammatory in nature. There is one patient with late glands who has lived for three years following radiation. In the period under review 106 cases of cancer of the tongue have been treated. Table III shows the various types and the degree of glandular involvement. Twenty-eight per cent

150
150

T.HE CANADIAN AIEDicAL AssociATioiz JouRNAL

THE
CANADIAN
MEDICAL
ASSoCIA.TI0N
Jou1.NAL

[Feb. 1937
1937

CASES

OF

TABLE III. CANCER OF TONGuE-LIVING Glands on admission

TABLE IV.
CANCER OF TONGuE-LIVING-TREATMENT OF GLANDS

DissectionsInvasion of jaw

Type

No glands

of
case

on

admission
11
9

Glands later
1
1

A.
1
1

B.
2

C.

Early glands .......... 1 1 Positive-living 5 years " . glnds Late 6 I 1 Positive- " 2-5 Late glands Negative- " 3 5 Excisions of jaw ....... 1 Dead bone...........

A. 12
B. 12

Radiation only-

C. 5
D..

2 _ 22

Early glands .......... 2 Living 1 and 3 years

__ 2
OF

._
2
OF

CANCER OF TONGUE-DEAD-TREATMENT OF GLANDS

5
.. 1

29

Dissections-

CASES
Type

CANCER

TONGUE-DEAD

Glands on admission
No glands

of
case

Glands on admission later

4 19 11
4

A.
1

B.
7
5
2

C.

Invasion of jaw

12 uncontrolled 4 Positive 2 extraneous disease 21 uncontrolled 6 died while under treatment Late glands........30 30 Positive 3 died extraneous * disease Positive-uncontrolled No glands enlarged 1

Early glands....... 4

A. 5 B. 30 C. 26
D. 11

11 3

4 2

8
9

Radiation onlyEarly glands... 15 All died of cancer-3 mos. to 2 yrs.

72

34

18

7
OF

14

17

No treatment.. 7 All died of cancer-2 to 8 months.

CAUSE

DEATH

invariably found that the degree of involvement of glands was greater than had been anticipated
Other

traneous Died of UnType No.

A.
5

Ex-

Died while under

treatment 2

diseae
2

cancer

known

cancer

B. 30 C. 26 D. 11

6 2 ..
10

23

.. ..

19 9
52

Ca. rectum . . Ca. rectum 4 (2 R.)

.
..

..
2

2 (1 R.)
8

72
per

of the patients are alive and well. Thirty-one cent of these presented an enlargement of lymph glands, and in one case there was an invasion of the jaw. Of those who are dead 77 per cent of the cases were complicated by glandular invasion. It should be noted that of those who showed no glandular enlargement on admission over 50 per cent developed glands later, and also that 14 per cent of the fatal cases death was due to other disease. It is obvious, then, that in cancer of the tongue the problem of lymph glands is a very urgent one, a much higher percentage developing secondaries in the neck and much earlier in the disease than in the cases of cancer of the lip. Table IV shows the methods of treatment of the lymphatics. There are 6 patients living from two to five years in whom the glands were invaded with cancer, and, further, there were 2 others who died of other causes with the disease in the neck controlled. Dissections were undertaken in 30 late cases, and it was almost

from physical examination. In some of these patients bilateral dissections were done, and in practically all of them it was felt that earlier operation might have offered more chance of success. It is only fair to say that the majority of the cases treated by radiation were those in which the disease was well established in the neck or in which for other reasons operation was considered unwise. Patients receiving no treatment for enlarged glands were really hopeless cases in whom palliative radiation of the primary only was undertaken. Table V shows that there were 170 cases of intra-oral cancer in this series. Of these, 48 per cent of the patients are living without sign of disease. Only 18 per cent of the living patients developed glandular enlargement, whereas in the fatal cases 58 per cent were complicated by glandular extension, the vast majority of these bordering on the hopeless at the time of admission. This type of cancer has been complicated by invasion of the jaw, either by direct spread of carcinoma or by osteomyelitis. In just over 10 per cent the jaw was involved. In Table VI there are 10 patients living, all of them relatively late cases in whom extensive block dissections of the neck were done, showing invasion of gland tissue with cancer. In the fatal cases there were 5 others in which dissec-

Feb. 1937]
Feb. 1937]

WOOKEY: ORAL CANCER

WOOKEY: ORAL CANCER

151

151

TABLE V. CASES OF INTRA-ORAL CANCER, EXCLUSIVE OF TONGUE

-LIVING

TABLE VI. INTRA-ORAL CANCER, EXCLUSIVE OF TONGUE-LIVINGTREATMENT OF GLANDS Dissections-

Type No glandis on Glands of case admission later

A. 25 B. 39 C. 18 D...
82

Glands

on

admission

A.
3

B.

C.
.. .. ..

Invasion of jaw 1 4 6
11

Negative-living 412 yrs. Early glands .. 2 Positive- " Late glands........ 11 10 Negative- " 3-5 4 Late glands1
No glands enlarged. 1

25 31 14
..

1 1 1
3

5 4 9

Negative- " 6 mos. 4 Positive- 1 living 2 yrs. 3 " 5 Excisions of jaw.... 11 7 Negative-1 " 6 4 " 2" 1 2" 3"

70

CASES OF INTRA-ORAL CANCER, EXCLUSIVE OF TONGUE -DEAD

Type No glands Glands on of case admission later

INTRA-ORAL CANCER, EXCLIJSIVE OF TONGUE-DEADTREATMENT OF GLANDS

Dissections-

Glands on admission
A.
1

Early glands .
Invasion of jaw
Late glands ......

5 Positive

(3 uncontrolled {2 died of extraneous

disease

B.

C.
2 1 7
10

A. 1 B. 36 C. 34 D.17
88

18 19 5
42

2 Negative both uncontrolled 9 uncontrolled 3 died of primary; neck healed 15 15 Positive

3 2 ..5
5

8 4
13

10
23

2 6
1

No glands enlarged 1

3 died while under treatment Negative-died of primary

8 Positive

Excisions of jaw. . 9

CAUSE OF DEATH
traneous Died of UnType No. disease cancer known
1 A. B. 36 C. 34 D. 17

disease 1 died while under treatment 1 Negative-died of primary

All died of cancer within 1 year

(2 died of extraneous

(5 uincontrolled

Ex.. 3 2

Other cancer
1 Ca.(Esoph.

Died while under treatment

Radiation only-

Early glands.

Late glands .

5 13J

1 30 31 17 79

No treatment.... 7 All died of cancer within 1 year

.. .. .. 2 .1
3

88

tions of the neck, though positive for carcinoma, were apparently successful, the patients dying of other causes. Twenty partial excisions of the mandible were done, 11 subjects of which are alive and well, 2 others having survived for several years and died of extraneous disease. The disability produced by an excision of half the mandible has not proved to be great, and this procedure seems to have contributed materially to the comfort of the patients as well as towards saving life. MORTALITY WHILE UNDER TREATMENT Any patient dying within a month of treatment, either radiological or surgical, has been considered a treatment mortality. Only three patients have died following radiological procedures-one as the result of hsemorrhage and two others from pneumonia. In this series 112 dissections of the neck were done, with a mortality rate of 9 per cent. Most of the fatalities

occurred in connection with dissections in whicil there was an extensive involvement of the tongue and floor of the mouth. Two died as a result of coronary disease and the remainder of respiratory complications. Twenty-two excisions of the jaw have been done. One patient died three days after operation, apparently of an attack of coronary thrombosis.

SUMMARY In cancer of the lip radium has proved extremely effective in controlling the primary disease. There were only 11 failures, and these were for the most part advanced cases. The disease tends to be confined to the lip, especially in elderly subjects and in the early or Type A cases. Surgical measures have been effective in controlling the gland metastases if undertaken early and the dissections are thorough. Radiation alone has not proved to be satisfactory in the treatment of glandular metastases. Carcinoma of the tongue is an extremely grave disease. In 54 per cent of these cases the primary disease was controlled by the radiolog-

152

THE CANADIAN MEDICAL ASSOCIATION JOURNAL

[Feb. 1937

ical methods employed. In most of the cases of early and radical dissection are encouraging. sooner or later there was an invasion of the Operations for removal of portions of the jaw regional lymph glands. Surgical dissections have proved of great value in the treatment of offer the best hope of controlling the disease in a good many of these cases and can be done the neck and should be done early. One is fairly safely. inclined to believe that in cancer of the tongue In the series of oral cancer cases reviewed 5 dissections of the regional lymph glands might patients died as the result of an entirely indewisely be done before any enlargement of glands pendent form of caneer, although the original can be demonstrated. disease had been apparently cured. The results of treatment of intra-oral cancer The opportunity of has been are much more satisfactory than in the tongue afforded by the Professorstudying these cases this work of Suigery, and in cases. Most of the primary lesions have dis- I have been associated with Dr. Keith Welsh, who has contributed materially towards the preparation of this appeared under radium therapy and the results paper.

FACTORS IN THE PRODUCTION OF NEUROSESBY G. K. WHARTON, M.B., M.S., F.A.C.P. Department of Medicine, University of Western Ontario, London, Ont. TfHE term "neurotic" is often looselv used distributed aches, pains, and discomforts, unreferring to individuaLs who have no organic due fatigability, and preoccupation with anxbasis for their complaints. The old family doc- ious thoughts about health. "Psychasthenia" tor helped these people because he knew them as is a subdivision of neurasthenia, characterized friends. We often fail with them when charlatans by morbid fears, obsessions and impulses. succeed. We can aid them, but only by coming to "Hysteria" is a form of psychoneurosis which know them as individual personalities. In order manifests itself by simulation of a more or less to do this we must study personality as we study spectacular disease or disability. The symptoms the other fields of medicine. Each individual are endless in their variety, although they have may be studied from three main approaches: a common feature in that they may be produced physical, mental, and social. We must, therefore, voluntarily. An essential feature of the psyknow the life of the patient to advise him in- chological mechanism underlying hysteria is the telligently. Medical men attain a grasp of the existence of a concealed, illicit, ethically unphysical aspects of disease, but how many on tenable motive. "Malingering" is the feigning graduation have the ability to sum up the indi- of disease or disability, to acquire some desirable vidual? The successful physician will later end, whether it be money, attention, sympathy or acquire this ability, but may not have a very love. In the later stages the original idea or clear understanding of how he arrived at his aim becomes more and more divorced from its conclusions. Scientific medicine today has failed primary connection, assuming the proportions to recognize the importance of emotional reac- of a fixed idea; the patient at this point may tions. Psychologists also treat neurotic people not realize that his actions are acquired. His inadequately, because they, in tturn, lack knowl- condition may be indistinguishable from hysedge of the physical aspects of disease. An teria, which differs from malingering only in adequate diagnosis can be reached only by a that it represents unconscious instead of concomprehensive study of each patient. scious and deliberate simulation. "Psychosis" Let us first consider some of the many terms refers to definite mental diseases, such as manic. used in referring to the neurotic patient. depressive psychosis and schizophrenia. "Neurasthenia" refers to an ill-defined and Personality studies aim to throw light on the heterogeneous group of constitutional mental development of the present status of the indisorders. It includes the psychoneuroses, and dividual. We must know the family backis characterized mainly by vague and widely ground to evaluate inborn neuropathic or