THE WITHHOLDING OF REPORTS OF OPERATIONS FOR THE RELIEF OF CANCER OF THE THROAT BY D. BRYSON DELAY AN, M. D. PRESIDENT OP THE AMERICAN LARYNGOLOGICAL ASSOCIATION \ CONSULTING LARYNGOLOGIST, NEW YORK CANCER HOSPITAL, ETC READ BEFORE THE AMERICAN LARYNGOLOGICAL ASSOCIATION AT ITS FIFTEENTH ANNUAL CONGRESS REPRINTED FROM THE NEW YORK MEDICAL JOURNAL FOR OCTOBER 1I>, 1893 NEW YORK I). APPLETON AND COMPANY 1893 THE WITHHOLDING OF REPORTS OF OPERATIONS FOR THE RELIEF OF CANCER OF THE THROAT BY D. BRYSON M. D. PRESIDENT OF THE AMERICAN LAKYNGOLOGICAL ASSOCIATION ; CONSULTING LARYNGOLOGIST, NEW YORK CANCER HOSPITAL, ETC READ BEFORE THE AMERICAN LARYNGOLOGICAL ASSOCIATION AT ITS FIFTEENTH ANNUAL CONGRESS REPRINTED FROM THE NEW YORK MEDICAL JOURNAL FOR OCTOBER U, 1893 NEW YORK D. APPLETON AND COMPANY ] 893 Copyright, 1HSI3, By D. APPLKTON AND COMPANY THE WITHHOLDING OF REPORTS OF OPERATIONS FOR THE RELIEF OF CANCER OF THE THROAT. Fr is but too well known by all that the results of the present -L methods for the treatment of malignant disease of the throat are in the main far from satisfactory. The sole aim of this paper, therefore, will be to urge upon those in whose power it lies the im- portance of increasing our practical knowledge of the subject by their contributions, and thus enabling us to judge fairly and ac- curately as to our actual ability to deal with this variety of disease. In presenting it, the writer at the outset earnestly disclaims either the intention or the desire to reopen the discussion as to the relative merits of any one method of operation compared with an- other. Still less does he wish to throw discredit upon any method of operation which may have been employed, or to criticise any operator who may at any time, or in any place, have labored in this field of surgery. It has been his misfortune to see a considerable number of cases of cancer of the throat, and to learn from them, and from the recorded experience of others, the painfully well known fact that malignant disease of this locality, no matter of what his- tological character it may be, is always a most serious affection at the best, and that, occurring in the form of epithelioma, is practi- cally an absolutely fatal one. More than once new methods have been suggested which have seemed to offer a fair prospect of in- creased success; some of these, in the case of the less malignant forms of growth, have proved to be of decided value. In epithelio- ma, however, they have generally proved unsuccessful, and the record of such as have been reported is little better than a long and dis- 4 WITHHOLDING REPORTS OF CANCER OPERATIONS. heartening series of failures. Such indeed it must appear to the patient himself when seeking information upon this subject. The difficulties in the way of an intelligent prognosis have, up to the present time, seemed almost insurmountable. Of course, it is im- possible to judge of the actual result of any series of operations until after the lapse of a considerable amount of time. With can- cerous disease this is particularly the case, inasmuch as the very criterion of success of an operation is the extent to which the patient’s life has been prolonged by it, and most of the operations which we have under consideration have been proposed too recently to enable us to obtain satisfactory statistics as to the actual prolonga- tion of life which they have accomplished. « To illustrate the difficulty of obtaining accurate statistics, let us take the history of thirty operations upon the larynx in cases of epithelioma, already publicly reported or gained by the writer from private sources. They represent the work of several of the most eminent of living surgeons. Such cases should be divided into three classes : First, those in which the history is complete up to the time of the patient’s death. Second, those in which, at the time of the writing of the history, the patient is still living, but suffering from recurrence of the disease. Third, those in which at the date of the history the patient is alive and well. It is plainly unfair to confine our deductions to the reports of the first class without taking any consideration of classes two and three, as witness the following results: In the thirty patients operated upon and dead, the aggregate of the length of life was two hundred months, or sixteen years and two thirds; but it is often stated that the average duration of life in cases not operated upon is about eighteen months from the time at which operation would be likely to give promise of some success. In my own experience, by the way, this estimate is too liberal. Assuming it, however, to be approximately correct, the aggregate length of life of thirty patients unoperated upon would be about five hundred and forty months, or forty-five years. Thus it would ap- pear that in these unsuccessful operations there had been lost to the thirty patients no less than twenty-eight years. In so far as the record concerns class 1, this is true. When we come to compare it with collections of cases representing classes 2 and 3, however, it at once shows a wide variance. And yet, until the histories in these classes shall have been completed by the death of each patient, it will be impossible to arrive at any accurate conclusion. WITHHOLDING REPORTS OF CANCER OPERATIONS. 5 Again, one of the best summaries extant is that of Kraus.* In this he studies together the cases of laryngectomy collected by vari- ous authorities after the death of Emperor Frederick. In all they number four hundred and sixty-six, fifty-nine, or nearly thirteen per cent., of which he claims as successful because in them the patients were still alive, and had not suffered recurrence for at least one year after the date of operation. But it is hardly fair to say that a case is cured simply because the patient has managed to survive one year. The lapse of a few years more would show a marked falling off, as is proved by Kraus’s own statistics, for, of twenty patients who lived for over one year, fifteen died before the end of the third year. Moreover, recurrence may take place after the lapse of a considerable amount of time. Even the fact that death may have occurred with- out recurrence is not necessarily a proof of the success of the opera- tion, since the very demise of the patient may have been more or less directly due to his having been subjected to so severe a surgical procedure. Discouraging as these inaccuracies may appear, it has seemed to the writer that the time was rapidly approaching when the num- ber of cases operated upon by means of the various recognized methods would have increased to such a degree that a clearer idea could be gained of their relative value as compared with each other, and that a sufficient length of time would have elapsed to prove their ultimate results, so that the question as to whether they actually suc- ceed in prolonging life might be definitely settled, and if they do, the approximate extent to which they may be depended upon to so pro- long it. While many cases and collections of cases have already been recorded, and statistics have thence been deduced and offered to us, there is nothing which can to-day be relied upon as satisfac- tory in any department of this subject, either in the case of opera- tions performed by the natural passages or of those of the more radical and heroic kind. This is not alone owing to the small num- ber of cases operated upon. It is certainly due in part to the failure of many operators to record faithfully and fully all of their cases. Of course, it is not to be supposed that such operations are common. Doubtless they are not, and, when performed, they have not seldom proved so unfortunate that to have reported them would have been an unwelcome task. Many operators, it is true, have been most careful to publish everything connected with their work—as, for example, the excellent reports of Billroth, Hahn, Butlin, Lanz, David * Allgem. Wiener med. Zeitschr1891, No. 15. 6 WITHHOLDING REPORTS OF CANCER OPERATIONS. Newman, Cheever, Solis-Cohen, Fowler, Gerster, and others. But in this, as in other departments of medicine, it too often happens that the unsuccessful cases are allowed to pass unnoticed. Where this is the case and the successful ones alone are put on record, it is plain that the latter will be misleading and, to the statistician, worse than useless. To secure satisfactory knowledge, all cases, good and bad alike, must be reported. It is certain that, both in this country and abroad, published records have not been made of a considerable number of important cases, but that many have been allowed to pass unnoticed, and thus the lessons that might have been learned from them lost. If the truth must be confessed, this is probably quite as true of the simpler operations from within as of the capital ones, so that in considering the question we do so entirely without prejudice. The substance of the whole matter is this : namely, that heretofore the discussion of the value of the various methods has been based partly upon theory and partly upon evidence too meager to afford substantial proof. What is needed to-day is the largest possible collection of reliable data, embracing all of the different operations which are performed for each of the separate manifestations of cancer of the throat. The gravity of the situation is such, and the need for help so urgent, that we hardly go too far when we insist that a full, painstaking, and accurate account be given of the history of every malignant growth removed from the upper air passages. With such material at our command, many at least of our present difficulties and doubts might be removed, and while it would not at once be possible to solve them all, it would, without question, enable us to advise with more intelligence and to act with materially increased prospects of success. Thus it might be definitely determined whether or not a certain operation was under any circumstances justifiable, and if justifiable at all, under what circumstances it would be likely to yield the best results. Again, much more might be learned as to the relative value of different methods—as, for example, the operation for complete laryngectomy as compared with partial, or of laryngectomy in gen- eral as compared with intralaryngeal operation, or as to whether the average duration of life was greater where a cancerous tonsil was removed by external incision, division of the jaw, and extensive dis- section, than in cases operated upon by external incisions of a sim- pler nature. Indeed, as we survey the field many questions arise which are WITHHOLDING REPORTS OF CANCER OPERATIONS. 7 in need of definite settlement and which can only be determined by the study of full and accurate statistics. Thus, a fair comparison should be made between the results of operations for the removal of tumors of the pharynx and nasal cavities by severe preliminary opera- tions, such as Annandale’s, and those in which the galvano caustic loop has been employed; between laryngectomy and intralaryngeal operation, etc. Again, one method may be found to prolong life to a greater degree than another, and yet not indefinitely extend it. Laryngectomy usually results in death within three years, even al- though recurrence may not have taken place. May this not be due in many cases to the general effect of the operation ? Certainly in extensive operations about the nasal cavities profound shock may result from the necessary interference with the various important nervous structures in the neighborhood. Yet again, in view of the fact that the earlier statistics of laryngectomy are better than those of recent years, may it not be possible that this operation, if prac- ticed at all, should be performed by a few highly skilled and success- ful surgeons, rather than committed to those whose experience in it has been limited ? These are but a small part of all the unanswered questions. Let every case then be reported with careful detail, not only as to the method of operation, but, almost more important still, with clear and full description of the after-care of the wound and of the special difficulties and accidents presented with each individual, for the after-care is often by far the most trying and hazardous part of the whole matter. And, finally, when we have done our best and have exhausted our resources, in case all of our present methods of curing carcinoma should be proved practical failures, even this unhappy result would be of benefit in destroying delusive hopes, and, what is of far greater practical importance, in stimulating us toward the accomplishment of that not impossible discovery from which it shall be learned that cancer may be cured by other means than the knife. Dr. J. Solis-Cohen, of Philadelphia: I think we are very much in- debted to Dr. Delavan for calling our attention to this subject. There are various reasons which prevent men from giving statistics of their operations. The operations usually take place in busy hospital wards, and after the surgeon has attained a certain eminence and does not longer wish to advertise himself he neglects to present these cases to the pro- fession. He may make a memorandum, but he is busy with his work, puts away his notes and forgets about them. Even many successful cases Di$cu8«ion. 8 WITHHOLDING HEPORTS OF CANCER OPERATIONS. of operation for carcinoma of the pharynx, tonsils, etc., have thus never been reported. A younger man, on the contrary, will report his cases because he wishes his friends to know that he is in the field, and is as successful in the long run as his colleagues. Another point is this: A surgeon often operates and the case turns out unsuccessfully on account of neglect of the after-treatment. Some surgeons, for instance, will operate in a severe case in the morning and leave the patient to the usual attendant or to an assistant, and go fishing in the afternoon, and of course such men do not like to acknowledge their neglect. The patient may recover; but again he may not, and I think a great many failures are due to this cause—lack of proper supervision by the operator of the subsequent management of the case. Another cause: After a man gets along in practice he loses much confidence in statistics. A practical man, while he knows the general trend of opinion, finds that he does best by studying his own cases. lie may have performed a certain operation fifty or seventy-five times, and he will know or feel that in certain cases the operation will or will not prove successful, no matter what the general statistics may indicate. Therefore, if we depend too much on statistics, we are in danger of not looking sufficiently closely into the merits of each particular case. The success of an operation depends on a variety of things: the condition of the patient, his sur- roundings, his opportunities for after-treatment, the stage of the disease, etc. The statistics of such men as Billroth, Krause, Lange, and others, who keep accurate records of their cases, are of course very valuable. In this country hospital practice is different, too, from that abroad. There, physicians are often paid for their services, and certain duties are expected in consequence. The personal responsibility is greater. Here we are not paid for our work in the hospitals, and unless a case presents some peculiar features to which we desire to call the attention of the profession, we neglect it, just as we neglect a good many other things as we get older. Dr. Delavan: I admit that it is very difficult to get accurate statis- tics, but do not see how we can advance unless through the medium of just such material. It is desirable that each of the members of this asso- ciation should try to do his part toward stimulating his surgical friends to greater accuracy of detail in this matter. In the statistics of the last ten years, those of the last five years are less favorable than those of the preceding five. This is said to be due to the fact that during the first five years the operations were performed by distinguished surgeons, whereas in the last five years they have been done more generally. This should induce us to ascertain who the best surgeons are for this class of opera- tions. It is not alone the operation itself which requires especial experi- ence and skill. The after-treatment is an all-important matter, as Dr. Solis Cohen has well said, and upon it will often depend the success of the case. There are so many difficulties in the way of successful after- WITHHOLDING REPORTS OF CANCER OPERATIONS. 9 treatment, and such variety is presented in the special necessities of dif- ferent individual cases, that the full reporting of every case would, for he present at least, be valuable and instructive. The outlook for many of these cases is so unfavorable that we can not emphasize too strongly the necessity for recognizing and for giving to the world any information which promises to be helpful, even in the slightest and most remote de- gree. It is in this spirit that I have brought the subject before you. THE New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. 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