British Journal of Oral and Maxillofacial Surgery (2000) 38, 209220

2000 The British Association of Oral and Maxillofacial Surgeons

doi:10.1054/bjom.1999.0273

BRITISH JOURNAL OF ORAL

& M A X I L L O FA C I A L S U R G E RY

Head and neck cancer and its treatment: historical review

M. McGurk,* N. M. Goodger
*Professor; Lecturer, Department of Oral and Maxillofacial Surgery, Guys Hospital, London UK
SUMMARY. Head and neck cancer has been known to physicians since antiquity, but until relatively recently any
material advance was limited by the lack of anaesthesia. The factors and people that helped to develop the subject of
head and neck surgery have been traced through history, and this paper provides a broad historical perspective with
which to compare the current standard of management for head and neck cancer.

Head and neck cancer is not a modern disease; defects

in the skull base indicative of nasopharyngeal carcinoma have been described in Egyptian skulls dating
from 3000 BC,1 and Moodie reported a range of jaw
and skull tumours in prehistoric Peruvians.2 Oral
cancer was not definitively described until the 17th
century, but Hayes Martin thought that there were a
number of veiled references in ancient manuscripts.3,4
Cancer was perceived as an uncommon condition
possibly because of the short life-expectancy, and one
notable 17th-century surgical text devoted only onetwentieth of its contents to malignant tumours.5
The therapeutic approach to cancer in the first and
second millennium was dictated by Galen (150 AD)
who explained cancer as a disease of one of the four
humours of the body. His authority was such that for
the next 1500 years cancer was perceived as a systemic
disease, and the consequence was to discourage local
in favour of general treatment.
In the 17th century, medical knowledge was gradually illuminated by scientific discovery. After learning
about the newly discovered lymphatic system,
Descartes
(philosophermathematicianphysician)
replaced Galens black bile theory with a mechanistic
lymph theory, which ultimately led to the concept of
lymph-node dissection, which is the cornerstone of
current management.
Against this background of enlightenment, the
opinions of two prominent physicians of the age,
Sennert and Zacutus Lusitanus, had a detrimental
influence on the treatment of cancer. They proposed
that it was a contagious disease. This may seem
incomprehensible today but must be viewed in the
context of medical knowledge at that time. Physicians
were unable to distinguish between cancers and
chronic ulcerative conditions such as tuberculosis or
syphilis, and this persisted until the turn of the present
century. The effect of this incorrect supposition was
to exclude patients from many hospitals up to the
middle of the 18th century.

Fig. 1 John Hill MD (Courtesy of the Wellcome Institute

Library, London).

included because it was relatively common and, perhaps more importantly, a syphilitic taint was often
blamed when other causes could not be found. Butlin
reported that only a few of his patients with lingual
cancers tested positive for syphilis despite the fact that
the infection was reported to afflict one-third of
people admitted to London hospitals in the 19th
century. Channing Simmons10 likewise reported that
only 14% of his patients in Boston had a positive
Wassermann reaction. Controlled studies by Fry et al.
suggested a small added relative risk of approximately
2.5%3% in patients with syphilis.11,12
Tobacco was first brought to public attention by
the explorers of the New World and was widely used
in the court of France by 1562.3 This fashion was not
accepted by everyone, papal bulls were issued against

AETIOLOGICAL FACTORS
A number of factors have been incriminated in the
induction of oral cancer.69 Syphilis was probably
209

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British Journal of Oral and Maxillofacial Surgery

it, and James I urged his subjects to avoid a custome

lothsome to the eye, hatefull to the nose, harmefull to
the brain, dangerous to the lungs and in the blacke
stinking fume thereof, neerest resembling the horrible
stigian smoke of the pit that is bottomlesse.13 This
was accompanied by restrictions on the production
and sale of tobacco and a heavy tax on its use. In
Russia, its consumption was punished by amputation
of the nose and in the Swiss canton of Berne it ranked
in the table of offence next to adultery.14 The use of
tobacco grew despite these threats, however, and by
1614 there were 7000 shops selling it in London
alone.13
Tobacco first implicated as a cause of cancer in
1761 by John Hill (Fig. 1).13 He wrote, with respect to
cancers of the nose, they are as dreadful and as fatal
as any others It is evident therefore that no man
should venture upon snuff who is not sure that he is
not so far liable to a cancer: and no man can be sure of
that. Later in that century, in 1775, Sir Percivall Potts
observations on cancer in chimney-sweeps were
published and Smmerring in 1795 mentioned pipe
smokers and cancer.15,16 Smoking was the preserve of
men, and the pipe was the primary way of taking
tobacco. In the 18th century, snuff superseded
smoking among the elite, and it was not until the Boer
war that cigarette-smoking became a habit that
transcended class.
Tobacco was alleged to lead to drinking, but our
Saxon ancestors were notorious drunkards long
before tobacco was available. In London, the
estimated per capita consumption of beer and spirits
in 1700 was strong beer 512 bottles, small beer 307,
and spirits 4.7.17 Drinks other than alcohol were few
in the London of the 1660s, as water was regarded as
dangerous. In Pepys time, wine was drunk as freely as
beer at every meal, and France was still the main
supplier, principally of clarets.
Alcohol has been part of most cultures throughout
the ages but curiously it was the Arabs who perfected
the art of distilling in AD 800900. Spirits were said to
have been brought back by soldiers returning from
war in the low countries, and by late in the reign of
Elizabeth I (15581603) they were consumed in
sufficient quantities to be taxed.3 By 1621 there were
200 strong-water houses in London, mainly selling a
spirit made from fermented grain called aqua vitae.

PRE-MODERN ERA (15001900)

Intraoral tumours
For centuries, it has been widely appreciated that large
portions of the tongue could be removed without
undue threat to life or function, as shown by
Hunerich, King of the Vandals who cut out the
tongues of the Christians in North Africa in 484 AD.18
Marchetti, Professor of Surgery at Padua in the
early 1700s, is credited as one of the first to remove a
lingual cancer, which he did with cautery.19 However,
by 1800 the knife seems to have superseded cautery.20

Fig. 2 An ecraseur.

Intraoral surgery
Surgical progress was not matched by developments
in anaesthesia, and pain was a reality that lead a
French surgeon in 1774 to state il nest pas exerc par
des hommes timides. However, the patient writhing in
agony was not the whole problem, but rather the
threat of uncontrollable bleeding. Large vessels were
caught and tied but general oozing was arrested by
hot irons, packs, and the application of caustics or
tincture of iron. The practice of ligating the artery
that fed the tumour before undertaking the main
operation was introduced by Louis in 1759,21 but the
continuing threat of exsanguination encouraged the
search for new, less dangerous techniques. Slow
strangulation of the tumour by encircling it with a line
of sutures was reported by Home in 1805,22 and a
development on this theme was ecraseurs (Fig. 2),
which were introduced by Bell in the middle of the

Head and neck cancer and its treatment

211

Fig. 3 Two ecraseurs could be used together to treat large

tumours of the tongue.
Fig. 5 A submental approach to the floor of mouth (Regnoli
1838).

in the angle formed by the base of the tongue and the

floor of the mouth. In 1854, Middledorpf added a
galvanic current, which heated the coil and in theory
at least combined the advantages of cautery and
crushing.23
Transoral surgery

Fig. 4 Routes of access for resection of intraoral tumours: 1,

Jaeger 1831 (Maisonneuve described bilateral incisions); 2, Roux
1836; 3, Regnoli 1838; 4, Billroth 1862; 5, Langenbeck 1875.

19th century.18 Two ecraseurs could be used together

(Fig. 3) and Boyer stated that with this device it was
possible to remove the anterior portion of the
tongue, the whole, the lateral half, or any tumour
which developed on the superior or inferior surfaces

It was soon recognized that the intraoral route gave

inadequate access and, by the early 1800s, the
Rabelaisian characters of modern surgery were
exploring more complicated routes of access (Fig. 4).
In this heroic age, one can only admire the stoicism of
the patient and the emotional fortitude of the surgeon, but it should be appreciated that these were not
common procedures but noteworthy events practised
by only a few surgeons, and then only rarely. Sedillot
described splitting the lower lip and jaw in the midline,3 still without anaesthesia. Regnoli in 1838 used
a submental approach to the floor of the mouth
(Fig. 5). 24In 1831, Jaeger first described splitting the
cheek25 and Maisonneuve took matters even further
by splitting both cheeks.26 Billroth appreciated the
importance of good access and took the procedure a
stage further, removing a section of the mandibular
body to reach the tongue and oropharynx, wiring the
bone back into position at the end of the procedure
similar to today.27 Evidence that more difficult cases
were being tackled is provided by Bernard von
Langenbeck, who in 1875 resected the ramus of the

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British Journal of Oral and Maxillofacial Surgery

mandible in continuity with the primary tumour.28 In

general the results were disappointing; Pemberton
wrote, Under the best aspects the treatment of cancer
of the tongue by operation can be looked at only as a
palliative measure, the tendency after all operative,
interference, however may well considered being to a
speedy relapse.29 Tonsillar tumours were approached
with similar trepidation as illustrated by the case of
General Ulysses S. Grant.30
Anaesthesia in the form of ether was introduced in
1847, and chloroform in 1849. Before this, the patient
was held by the surgeons assistants, or tied down, and
alcohol may have been used, although this is not
recorded.31 Even when anaesthesia was available, it
was often not used because its use in operations of
the mouth is a vexed question, with both surgeon and
anaesthetist fighting for a share of the airway. In cases
of severe haemorrhage, the patient was likely to awake
from the anaesthesic. In the latter years of the 19th
century, the problem of the airway was improved
when the Trendelenberg cannula was used through a
tracheostomy. Anaesthesia was an obvious advantage
for the patient but its effect on surgical practice was
more subtle, and ultimately more important. The
surgeon was gradually released from the strictures
imposed by time, and the relationship between careful
technique and improved outcome was soon apparent.
Maxillary tumours
Like intraoral procedures, surgery of the maxilla was
rarely attempted before 1800. There is mention of
partial removal of tumour by Wiseman,5 and a few
further references to such operations can be found,
but not in surgical texts.31 From 1800 onwards, there
were attempts at local removal of such tumours,
usually by raising skin flaps and local curettage. It is
thought that maxillectomy itself developed about
1820 and is recorded as first being done by Lizars in
1826.32 By the second part of the 19th century, the
operation was established within Europe. Various
facial incisions were recorded, the classic lateral nasal
incision being first described by Gensoul32 and the
infraorbital limb is attributed to Blandin by
Farabeuf.33 During the latter part of the 19th century,
the procedures were refined, and by 1902 the lateral
rhinotomy was described by Moure for treatment of
the nasal cavity and ethmoids.34 The palate was
restored by obturation from the earliest days, and the
technique was well established by the beginning of the
20th century.
Laryngeal tumours
No clear concept about how to manage laryngeal
tumours existed before the 19th century. It is difficult
to imagine the problems encountered by the early
laryngologists, because before the introduction of
cocaine in 1884 the larynx was hidden from view and
protected by forceful reflexes, which made adequate
examination impossible. The customary method of
examination was with a finger used with great speed

and dexterity; the mucous membranes were painted

with bromide of potassium, or solutions of morphia,
chloroform, or ether (none of which proved to be a
successful surface anaesthetic) and often the patient
was simply instructed to suck small pieces of ice for 15
or 20 minutes before examination. There were some
surgeons who could apparently identify vocal cord
paralysis manually,35 as well as lesions of the pharynx
and epiglottis. Diagnosis was a subjective exercise, as
biopsy was unheard of until instruments were made
to facilitate the evolving technique of laryngoscopy.
The first authentic attempt to examine the larynx
was by Leveret in 1743 with a bent mirror complemented by a snare for removing polyps. Manuel
Garcia, a singing teacher in Paris, popularized the
technique of indirect laryngoscopy with a dental
mirror (this new product had been one of the failures
of the London exhibition of 1851). With a long-handled dental mirror and an accompanying hand mirror
he was able to examine his own larynx at will because
of the tremendous control he could exercise over his
pharyngeal muscles. He communicated his findings to
the Royal Society in 1855.36 Further refinements were
required before the technique was widely adopted; an
artificial light and a concave mirror, first held in the
teeth were described by Czernak, and placing the
mirror on a head band with a ball and socket joint to
free a hand for manipulation of instruments was proposed by Walker in 1864. The great exponent was
Morrel MacKenzie, who learned the technique of
indirect laryngology in Vienna and then returned to
introduce the new specialty of laryngology to
London. He founded the Throat Hospital in Golden
Square, Soho. At this Sir James Paget remarked
derisorily that someone should start a hospital for
Diseases of the Great Toe. One of the effects of this
new interest in laryngology was that more tumours
were recognized. In previous centuries, only a score
had been described whereas more than 1000 were
reported in the two decades after the introduction of
indirect laryngoscopy. The important laryngeal diseases of the 18th century were tuberculosis, diphtheria, and tertiary syphilis, as illustrated by Frederick
Rylands Diseases and Injuries of the Larynx and
Trachea, published in 1837. This had a lengthy discussion on inflammation and only eight of the 328 pages
were devoted to tumours.37
Laryngofissure
In 1810, during the Napoleonic wars, Desault suggested an operation to split the larynx (laryngofissure) to remove trapped foreign bodies.38 A succession of surgeons subsequently used and developed the
approach; Brauers of Louvain in 1833 divided the
thyroid cartilage to cauterize a growth, and Gordon
Buck of New York used it in 1851 for treating laryngeal tumours.39 Statistics collected in 1879 showed
that the results of 19 thyrotomies on 15 patients with
carcinoma of the larynx were poor, and only two
patients survived longer than a year. The importance
of laryngofissure was that it raised the possibility of
laryngectomy.

Head and neck cancer and its treatment

213

Fig. 7 Theodor Kocher 18411917 (Courtesy of the Wellcome

Institute Library, London).

Fig. 6 Theodore Billroth 18291894 (Courtesy of the Wellcome

Institute Library, London).

Laryngectomy
As early as 1829, Albers of Bonn experimented with
laryngectomy in dogs40 and a systematic study of the
subject was undertaken by Czerny41 in Billroths clinic.
At operation, on New Years Eve 1873 (a contrast in
itself with todays Health Service), Billroth (Fig. 6)
undertook the first successful laryngectomy (Patrick
Watson of Edinburgh was reported to be the first to
do a laryngectomy in a human but it was for syphilis
not cancer, and was not a true laryngectomy). The
operation started as a laryngofissure but after the
larynx had been opened and found to be extensively
involved with tumour, the patient was revived from
the anaesthetic to give consent for a total laryngectomy. The procedure took 1 hour 45 minutes. The
tentative steps towards the standardized surgery of
today had begun.42
In contrast, the results of early laryngectomies
were generally disastrous because of the complications of fistulas, haemorrhage, shock, mediastinitis,
and bronchopneumonia. The first disasters arose
because the pharynx was left open and the trachea
unattached. The answer, appreciated by Gluck, was a
two-stage procedure. The first involved separating the
trachea from the larynx and suturing it to the skin to
form a secure tracheostome. The larynx was removed
two weeks later, which avoided the trachea and pharynx remaining in continuity after surgery with the
inevitable complication of inhalation pneumonia. The
Trendelenburg inflatable cuffed tracheostomy tube
stopped secretions entering the lungs, but it was often
left in position and not cleaned for days, which led to

local infection. Unfortunately, contemporaneous with

these developments, a widely publicized article by one
of the foremost laryngologists of the day, SolisCohen, appeared and reported a startling mortality of
50% for laryngectomy.43 It was still an uncommon
procedure for, despite many more laryngeal cancers
being recognized, only 108 operations were reported
between 1876 and 1886 with 21 cures. In retrospect, it
was not surprising that Mackenzie was reluctant to
advise that such an experimental procedure should be
tried on the Crown Prince of Germany. Not even the
surgeon was immune the dangers of this new operation for, after his first laryngectomy, Professor Felix
Nager of Zurich feared for his life as a result of
threats from the patient.
Despite these setbacks and early scepticism about
the procedure, Gluck and Srensen persisted with
laryngectomy and slowly refined the surgical technique to a single-stage operation with a well-formed
tracheostome. Their work was recognized as the most
progressive of the era and the last 63 of a series of
over 160 total laryngectomies were done without
mortality.44

Thyroid
Theodor Kocher, professor of surgery in Bern (Fig. 7)
and noted as a general surgeon, also practised and
wrote on the topic of oral and pharyngeal cancer. He
was reported to have treated 120 patients with lingual
cancer, and was one of the first to take advantage of
the advances in anaesthesia that allowed the development of meticulous surgical technique. In 1872,
Billroth had abandoned thyroid surgery because of
the great mortality from haemorrhage and sepsis.
During his first two years in Bern, Kocher did 13
thyroidectomies and in 1883 reported his first 100
cases; 30 of these were total excisions and resulted in

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British Journal of Oral and Maxillofacial Surgery

myxoedema. Billroths patients ironically had not

developed this complication. Kocher recognized the
problem, studied the evidence and thereafter avoided
total excision. He subsequently developed a large
practice in thyroid surgery, and in 1895 reported a
series of 900 thyroidectomies with an operative mortality of 1%. By 1898, a further 600 operations had
been added with only a single operative death and in
1901 he recorded 2000 thyroid operations with an
overall mortality of 4.5%. This achievement should be
judged against the conditions of the day with no
antibiotics, no fluid replacement, and the risk of
thyroid storm. Before this, thyrotoxic patients were
treated in stages by ligation of vessels, partial
thyroidectomy, injection of boiling water, or stealing
of the thyroid.45 The beneficial effects of preoperative
iodine were not reported by Plummer until 1923.46
Kocher received the Nobel Prize for his work on
thyroid disease in 1909. This remarkable surgeon,
with his careful, meticulous techniques, served as a
model for Halsted, who was studying in Europe at this
time.
Subsequently the leadership in thyroid and
parathyroid surgery shifted to the USA as Halsted
and his students adopted Kochers methods. Crile,
Lahey, and the Mayo brothers founded their private
practices largely on safe thyroid surgery. Perhaps a fitting epitaph to this period was captured in a lecture
given by Cushing in 1913: The accurate and detailed
methods, in use of which Kocher and Halsted were for
so long the notable examples, have spread into all
clinics at least into those clinics where you or I
would wish to entrust ourselves for an operation.
Observers no longer expected to be thrilled in an
operating room; the spectacular public performances
of the past, no longer condoned, are replaced by the
quiet, rather tedious procedures which few beyond the
operator, his assistants, and the immediate bystanders
can profitably see. The patient on the table, like the
passenger in a car, runs greater risks if he has a loquacious driver, or one who takes close corners, exceeds
the speed limit, or rides to applause.47
The merit of careful meticulous surgery had at last
been recognized, yet nearly a century later the lure of
speed still lingers.

THE MODERN ERA (19001990)

Radiation therapy
At the turn of the century, two important discoveries
were made at about the same time. On 30 November
1895, Roentgen48 announced the discovery of X-rays,
and in the same year Becquerel reported the phenomenon of radioactivity. These were followed by the
discovery of radium by the Curies in 1898.
Radiation therapy evolved through four phases.49
At first (19001920), it was governed by the concept
that the effectiveness of radiation was reflected in its
caustic action on the skin (Fig. 8), so irradiation doses
were initially measured in HED (German initials
for erythema skin dose and equal to roughly 1100

Fig. 8 Burns showed the caustic effect of irradiation on the skin

(from Coutard 1924 50with permission).

roentgens). The early physicians could be forgiven for

making this assumption because in that era treatment
involved brutal cautery or surgery with a similar
visual effect. In the second phase, the emphasis was on
selective destruction of the tumour with an attempt to
preserve local tissue, mainly influenced by the French
school at the Institut Curie. The effect of variables
such as time, size of tumour, and wavelength were recognized. The third phase reflected an emphasis on
accurate planning of treatment with respect to
anatomical fields and dosimetry, which was led by the
English school.50 Finally, as the full properties of radiation became known, its use became the more exact
science that it is today.
Initially, cancers of the larynx were treated with
empirical doses, duration and fractionation as judged
by each practitioner. This persisted for three decades
until Coutard51 provided a more uniform plan of
treatment. The early machines operated at 50100 kV
and the long exposure times were impractical, but by
1922 a 200 kV apparatus was available and in USA
700800 kV machines were in use by 1931. X-ray therapy, during the period up to 1940, played a secondary
role to radium implants and teletherapy.
In Coutards technique, the duration of treatment
was governed by the size of the tumour; small
tumours were treated in 15 days, medium ones in
2025 days, and large lesions with lymphadenopathy
in 3540 days. Interestingly, if treatment was less than

Head and neck cancer and its treatment

215

Fig. 10 Head devices for application of radium (from Cade 1929

63
with permission).

Fig. 9 Radium salts suspended between the vocal cords by

strings.

20 days, a multifractionation (two fractions a day)

technique was used (70 years later the method was
re-examined by the Medical Research Council). The
choice of case was important, but cures of 32% were
reported for laryngeal cancers. The complications
included oedema, and delayed osteoradionecrosis and
chondroradionecrosis, which caused death by infection and haemorrhage. In 1949 Baclesse, who succeeded Coutard at the Curie Foundation in 1937,
described three techniques: the first to avoid severe
skin reactions; secondly, the shrinking field technique
based on the premise that the centre of a tumour is
more resistant than its periphery (this required careful
topographical definition of the tumour); and thirdly
that larger lesions require higher doses for control. In
1951, Baclesse reported the five-year survival rates of
333 patients with cancer of the larynx, 17% between
1919 and 1939, and 37% for those treated between
1940 and 1946.
Curietherapy (radium therapy)
Radium therapy began when Becquerel and Curie
entrusted some material to Dr Danlos at the St Louis
Hospital, Paris. Its progress was dependent on the
availability of an extremely limited amount of the
element. For therapeutic purposes, radium was used

in the form of a radium bromide and not as the pure

metal. Initially, dermatologists were the main
champions of the technique, producing plaques of
different sizes covered with a special radioactive
varnish. The failure of topical treatment to treat
tumours within the body encouraged the application
of radium directly on or in the tumour. The initial
attempts were clumsy, with sausage-shaped bags containing radium salts being suspended between the
vocal cords by strings threaded through the mouth
and a tracheotomy (Fig. 9). Other cumbersome head
devices were also used (Fig. 10), as were surface applicators to irradiate the neck. Radon gas was a much
cheaper source of radiation than the salts, and in 1914
Stevenson of Dublin described a method of loading a
glass capillary tube filled with radon gas into a needle
for introduction into a tumour (the antecedent of
modern interstitial iridium wire radiation). Interstitial
treatment until then had involved burying one or two
tubes of radium (25 mg) in the tumour but the trauma
involved and the heterogeneity of the radiation field
made it unacceptable. The use of multiple needles
suitably placed offered the prospect of a more appropriately delivered dose of radiation. Access to the
tumour required surgical skill, and the first radiotherapists were accomplished surgeons. Radium treatment therefore took two forms; firstly, the application
of needles that contained varying amounts of radium
salt in platinum-lined tubes52 (the platinum was
important as it absorbed all the unwanted and
radiation) and were removed after a period.
Secondly, radon seeds were used, and as the radon gas
lost its radioactivity at approximately 10 days, the
seeds were left in place. Duane developed the technique and published his work in 1917.53 Bare glass
seeds were developed and widely used at Memorial
Hospital New York but, after experience of severe
tissue reaction and at Regauds suggestion, gold foil
was added, originating the Gold Radon Seeds.54
Initially interstitial radiation was not used in the
larynx but the poor results of the intra-cavity treatment using suspended bags forced a reassessment. In
1923, a combined surgeryradiotherapy approach was
introduced by Ledoux in Brussels who fenestrated the

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British Journal of Oral and Maxillofacial Surgery

Fig. 12 Sir Henry Butlin 18451912 (Courtesy of the Wellcome

Institute Library, London).

Fig. 11 Radium needles were placed against the perichondrium

(from Cade 1929 63with permission).

thyroid cartilage to allow needles to be placed into the

tumour so reducing cartilage necrosis. The technique
was improved by Finzi and Harmer,55 who just laid
the needles against the perichondrium rather than
piercing it, but the method was not widely practised
because of lack of materials (Fig. 11). Tonsillar
tumours were treated by exposure of the ramus of the
mandible through a submandibular incision (under
local anaesthetic). Bone was removed with rongeurs
and needles were placed deep to the tumour on the
pharyngeal wall.56

radium was placed at the disposal of the Westminster

Hospital to be used as a single unit housed in a belllike container. In 1933, Sievert described a machine
that would allow treatment of head and neck cancer57
and this was improved on by Grimmett and installed
at the Royal Marsden, London, in 1936.
Technical advances made cobalt and 2 MeV
generators available in the 1950s and more recently
linear accelerators and neutron beam therapy have
eclipsed cobalt in modern practice. The final development that has only truly been realized during the last
two decades has been the marrying of surgery and
radiotherapy to gain the optimum benefit from both.

MODERN SURGERY
Telecurietherapy

The turn of the century

It was not until the advent of telecurietherapy in

192535 that radiation therapy of the larynx became
routine. Telecurietherapy may be regarded as treatment with X-rays in which the radiation is provided
by a radioactive isotope. The primitive form of
telecurietherapy consisted of a radium collar; nontreatment surfaces were lead lined and the radium
source maintained at a distance of 5 cm from the
patient by cork or wooden slats. This had the disadvantage that much of the radiation was absorbed
by the superficial tissues and, because it was poorly
directed, it posed a risk to patient and staff alike. The
earliest types of apparatus produced a cloud of radiation rather than a beam and consisted of a box
weighing 150 lb suspended from the ceiling controlled
by a series of pulleys. The box was lead-lined and had
a window to allow the radiation to escape. A columnated beam was required. In 1919, a 5 g radium bomb
(a large quantity of radium in a single container) was
placed at the disposal of the Middlesex Hospital,
London, and the radiation delivered from a box like
apparatus. The results were poor. Subsequently, 4 g of

Modern surgery started at the end of the 19th century.

The advent of sound pathological concepts, the introduction of anaesthesia, and Kochers championing of
careful technique showed that head and neck surgery
was possible without the previous appalling mortality.
Henry Butlin (Fig. 12) maintained the progress
into the 20th century. He had been appointed to St
Bartholomews Hospital in 1880 and, as the most
junior surgeon, was offered the least popular clinical
practice from which he fashioned a distinguished
career in the treatment of head and neck cancer that
culminated in a knighthood. Butlin remarked on his
choice of surgical career by relating that at St
Bartholemews the staff post to the throat clinic fell
vacant and was discussed by the medical committee.
Finally the senior surgeon who was the chairman said,
Well Butlin is the youngest of us, he will have to do
it. So, said Butlin, he was thrust into a subject of
which he knew nothing.
His careful note-keeping and follow-up of patients
(in 1898 he was able to trace all but seven of 102 he
had treated) showed that the treatment of oral cancer

Head and neck cancer and its treatment

Fig. 13 George W. Crile Sr, 18641943 (Courtesy of the

Wellcome Institute Library, London).

was not as hopeless as suggested by contemporary

results (5% cure in 1883).58 In his hands, cure was
obtained in about 28% of patients. It was also
apparent to him that at least 30%40% of patients
who were treated successfully for their primary lesion
succumbed to nodal metastases. He therefore proposed and practised a nodal dissection of the anterior
triangle of the neck.58,59 Today this has been reintroduced and has found favour as a modified or selective
neck dissection. In 1909, on his retirement, Butlin
analysed 200 lingual cancers treated during his 25
years in practice, and reported a cure in the latter part
of the series of 41.5%. In the USA, his contemporary
George Crile Sr (Fig. 13) also realized the importance
of nodal spread, suggesting that the problem was
widely appreciated by the surgeons who treated these
patients. Although the relevance of node dissection in
cancer had been raised by Halsted (regarding the
breast), it was Crile who took the concept to its ultimate conclusion in the head and neck, and in 1906
published his classic description of radical neck dissection based on 132 operations.60 Crile had a particularly innovative mind, and his operation was
introduced in an era where there were no intravenous
fluid replacement, or antibiotics, and poor control of
the airway. He dealt with the anaesthetic problems initially by operating under local anaesthesia, but he
later used nasopharyngeal intubation with the tube
held above the larynx, and the pharynx packed to
avoid inhalation of blood. Sepsis was reduced by dissecting the neck as a separate procedure a month after
the primary resection in the mouth or pharynx,
thereby avoiding contamination of the neck by oral
fluids. To limit the incidence of shock, he used a rubber pressure suit to maintain the central circulation
during the operation, an ingenious invention that has
recently been reintroduced in emergency medicine as
the shock suit.60
Despite these advances, surgery was a desperate
affair plagued by complications the most common of
which were delayed healing and failed treatment. As
late as 1923, Billroths maxim avoid suturing the floor

217

of mouth and seldom see severe sepsis or secondary

haemorrhage was still being practised. With the rising
popularity of radiotherapy during this period, and
against the unequal challenge of sepsis, fluid loss, and
anaesthetic difficulties, surgery lost its momentum.
Unlike the abdomen, the happy hunting ground of the
general surgeon, the face is not concealed behind a
corset or waistcoat, and surgical excisions in the head
and neck left major functional and cosmetic defects.
There was also the fearsome reputation of the
tracheostomy, which was related to bleeding. It was
this fear, compounded by a convalescence that was
technically described as stormy that dissuaded
surgeons from tackling head and neck cancers.
Despite the fact that, in the UK there were many
capable general surgeons during this period, only
Trotter took an interest in the field of head and neck
surgery.
Against its primitive backdrop must be laid the
non-invasive, almost mystical action of radiation,
which was perceived as the Holy Grail for cancer
treatment. Sir Stanford Cade pointed out that
surgical treatment in the hands of conscientious and
skilled surgeons has given results so indifferent that
those obtained by radium appear brilliant.61 In the
USA, Quick, representing the Memorial Hospital,
New York, extolled the virtues of radiotherapy and
particularly the radium implant developed by Henry
Harrington Janeway (an accomplished surgeon who
studied the physics of radiation). Surgeons still preferred to remove early cancers, for instance TI tongue
or early cord lesions, but any lesion that required a
substantial resection was gladly handed over to the
radiotherapists.
By 1920, many of the teething troubles with
radium had been overcome. Every large hospital
struggled to obtain a supply of material and because
of its rarity special departments started to develop.
Initially the general surgeons nominated one of their
number to handle the radium cases: Stanford Cade at
the Westminster, Douglas Harmer and Finzi at St
Bartholomews and Mount Vernon, Ralston Paterson
at the Christie Hospital, and Douglas Lederman at
the Marsden Hospital (Royal Cancer Hospital).
Radiotherapy units blossomed and developed into
distinct departments ultimately with their own
premises by the late 20s or middle 30s. Between 1920
and 1940, radiotherapy dominated the management
of malignant disease in the head and neck, as
illustrated by Cades book on radiotherapy, a third of
which was dedicated to the head and neck.62
Radiotherapy evolved so rapidly that no training
pathway was designed until the 1950s although, by
1943, a diploma (DMRT) could be obtained. During
this period, new surgical fashions blossomed then
wilted. Electrosurgery was thought to be a great
advance in the treatment of head and neck cancer and
was championed by Harmer and Paterson. It was
used to reduce tumour bulk, particularly in the
maxilla, by what amounted to opening of the cavity
and electrocurettage, and was followed by intracavity
radium applied by dental obturators.63

218

British Journal of Oral and Maxillofacial Surgery

Fig. 14 Hayes Martin 18921977 (Courtesy of the Memorial

Sloan-Kettering Cancer Center).

The Resurgence of Surgery

By 1923 the initial enthusiasm for the new panacea
was already waning for it was recognized that small
cancers were eminently curable by surgery.
Radiotherapy was used to treat neck metastases, but
this practice was soon recognized to be unproductive
and, as early as 1928, Cade was advocating surgery.
Against the general euphoria for radiation therapy
some protagonists of surgery existed; V. P. Blair of
St Louis continued to advocate surgery and remarked
that cancer is best handled as if it were a skunk let it
alone or kill it quick, only grief can come from irritating it.64 These sentiments might be presented more
articulately today, but with less impact, as the first
course of treatment gives the best prospect of cure.
Hayes Martin (Fig. 14), a radiotherapist and
general surgeon at Memorial Hospital, New York, in
the early 1930s, had focused on improving cure rates
by treating the primary tumour with X-rays by the
Coutard method supplemented with gold radium
seeds. The radiation was not restricted to the primary
tumour as the neck was also treated and persistent
disease managed with a block dissection under local
anaesthetic an experience exhausting for surgeon
and patient alike. In 1939, Martin undertook a survey
of the results of treatment of carcinoma of the
pharynx, a standardized recording system having
been introduced in about 1934. The Memorial results
were modest compared to the claims of other institutions. Their survival for patients with a pharyngeal
cancer was in the region of 5%, or 95% failure.65

Martin became slowly disenchanted with the results

and became a proponent of radical surgery. This
change in attitude coincided with a number of allied
developments which collectively were a major asset to
the surgeon and reduced the risks of a major operation. Improvements in anaesthesia with the introduction of pentothal and curare allowed routine
endotracheal anaesthesia with a reduced risk of
aspiration. Blood replacement became available and
hypovolaemic shock compounded by dehydration
became a thing of the past. The commercial production of sulphonamides in the 1930s and penicillin in
the 1940s made it possible to counter infection, and
Martin was able to reintroduce the concept of a
combined neck and oropharyngeal approach. This
became known at Memorial as commando procedure (from wartime commando manoeuvres
involving an attack from two directions).66
As a direct result of the World War II, interest was
rekindled in reconstructive procedures that had previously been forgotten, and this complemented the
revival of surgery in the management of head and
neck cancer. The use of a split skin grafts had been
first introduced in 1917 by Esser and, in the same year,
he described an axial pattern flap based on the temporal artery.67,68 Blair introduced regional flaps in 192569
and these were later popularized by Egerton,70
Mcgregor71 and Millard.72 These were the antecedents
of the deltopectoral flap popularized by Bakamjian
and Littlewood.73 Martin was therefore able to pursue
a policy of radical surgery not available to his predecessors. Reconstructive surgery had come of age.
Gradually, the limitations that had been imposed
on previous generations of surgeons were lifted. One
consequence was that the severe complications that
used to accompany this form of surgery and that
deterred all but the most determined surgeon were
reduced. The surgical discipline became more attractive and a less daunting experience. In the USA, the
tentative advances of ENT surgeons (such as
Balantine, and Ogura) driven by their specialist knowledge of the larynx into what was considered the
domain of the general surgeon, brought withering
attacks from Martin.74 This was not the case in the
UK, where the practice of head and neck surgery had
been so completely abandoned by 1950 that there was
no critical mass of expertise remaining in general
surgery and this discipline was no longer in their
repertoire. The same applied in ENT. Surgery had
been so completely abandoned that after Lionel
College, who was one of the few ENT surgeons to
continue practising laryngectomy during the radiotherapy era, retired in 1944 and his assistant Sam
Burdstal, who retired in the 1950s, the techniques had
to be retrieved from the USA. This fell to the ENT
surgeons. Henry Shaw was one of the first to visit
Martin at the Memorial in the 1950s followed by
Williams in the 1960s. Stell went to Ogura at St Louis,
and Shaheen and Harrison visited Iowa. The wheel
had turned full circle; the US surgeons were now
instructing the Europeans as a result of the brief but
profound interaction between Kocher, Halsted and
Crile 80 years previously.

Head and neck cancer and its treatment

In the latter half of this century other aspiring

treatments have been introduced, which then faded
from view. A major initiative of the 1970s and 1980s
was cytotoxic chemotherapy, but the way that it was
applied it offered little material benefit in terms of
cure when used as adjuvant or neoadjuvant therapy in
advanced disease. However, there is currently a resurgence in its use for organ preservation. The prospect
of improved radiotherapy results was also raised by
the introduction of hyperbaric oxygen and radiosensitizers, but to little effect. More recently, the introduction of neutron beam therapy (which is not dependent
on oxygenation of the tissues, a factor held responsible for failed radiation) offered the prospect of a
breakthrough in non-invasive therapy. Unfortunately,
the initial results could not be substantiated.
There has been little advance in surgical techniques
for resection of tumours, other than the establishment
of craniofacial resection of lesions of the paranasal
sinuses. However, reconstructive techniques have
gradually improved with the advent of free vascular
flaps and continued with osseointegrated implants,
which produce vastly improved cosmetic results.
The evidence that has accrued over the last 100
years suggests that current treatment regimens, in
appropriate hands, are approaching their curative
potential. Multidisciplinary therapy is now the norm.
Patients expectations have produced a sympathy for
conservative and more selective surgical treatment
and clinicians have risen to the challenge, at the same
time trying to maintain or improve survival. The hope
for the future lies with the development and understanding of the molecular basis of cancer. Until this is
achieved, V. P. Blairs statement remains pertinent:
it is difficult to pick the incurable case and any procedure that gives a fighting chance is justifiable. The
other side of the picture is 100 per cent deaths, in the
worst form known.64
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The Authors
M. McGurk MD, FRCS, FDS, DLO, RCS
Professor
N. M. Goodger BSc, MBBS, FDSRCS
Lecturer
Department of Oral and Maxillofacial Surgery
Guys Hospital
London, UK
Correspondence and requests for offprints to: Professor M.
McGurk, Department of Oral and Maxillofacial Surgery, Guys
Hospital, London SE1 9RT, UK. Tel: +44 (0) 171 955 4342; Fax:
+44(0) 171 955 4165
Paper received 22 August 1998
Accepted 8 November 1999