The practice of otolaryngology circa 1900

Sir Henry Trentham Butlin

By Eugene N. Myers, MD, FRCS Edin (Hon), Distinguished Professor Emeritus, Department of Otolaryngology, University of Pittsburgh School of Medicine

Looking back on the practice of otolaryngology in 1900, it seemed rather primitive. It’s amazing that anyone survived. The most important indicator of survival of cancer of the head and neck is the extent of the cancer in the neck. Therefore, management of the neck is one of the most significant aspects of cancer control.

Metastasis to the neck is treated by surgery and radiation therapy, depending on the site and stage of the primary as well as the clinical pathological staging of the neck. The neck dissection was first described in 1847 by Dr. Chilious and then by other famous surgeons such as Drs. Kocher, Butlin, Jawdynski, Solis-Cohen, and Crile. Metastasis to the lymph nodes was largely untreated until the medical profession was aroused by Dr. George Crile’s paper systematically describing the radical neck dissection published in the Journal of the American Medical Association (JAMA) in 1906.

Cancer of the head and neck was relatively rare until the advent of factories that could produce cigarettes cheaply—then people started to smoke in the mid- to late 19th century. This led to a dramatic rise in the incidence of squamous cell carcinoma of the head and neck.

Sir Henry Trentham Butlin was a clever surgeon on the faculty of St. Bartholomew’s Hospital in London. He  transformed the department at St. Bart’s  into a center of excellence. He was the first to connect smoking and syphilis as  etiologic factors in carcinoma of the tongue. He advocated surgical treatment of chronic suspicious ulcers of the tongue  by excision with wide margins.

He began to speculate that subclinical malignant disease of the neck might be cured by elective neck dissection, and in 1895, he stated that every malignancy should be operated on radically and immediately. We’ve now come to use the selective neck dissection much as Dr. Butlin did in the management of cancer of the neck both in the N0 and N+ neck.

Dr. Codreanu, a native of Romania, performed the first total parotidectomy with facial nerve dissection in 1892.  However, it wasn’t until 1921 when Walter Ellis Sistrunk, MD, published a paper on surgery for tumors of the parotid gland that he actually recognized that the key to successful parotid surgery was the preservation of the facial nerve. His technique was to identify the cervical branch of the facial nerve and to dissect proximal to the bifurcation of the facial nerve into the upper and lower divisions. This resulted in a great decrease in facial nerve paralysis and in the recurrence of the tumor.

The Mayo Clinic’s experience with 1,360 primary parotid tumors compared the results of surgical treatment of parotid tumors during two consecutive periods, 1940-1954 and 1955-1969. The publication of their results in the American Journal of Surgery put the Mayo Clinic surgeons in a position to change the destiny of parotid surgery in the future.

In the early series, local resection was used, while in the later period a superficial or total parotidectomy with identification and preservation of facial nerve was used, which became the treatment of choice due to the decreased recurrence and facial nerve injury.

James E. Newcomb, MD, in his textbook published in 1901 by J.B. Lippincott, Philadelphia, stated that “tumors of the oropharynx were rare and the malignant growths were classified as lymphoma, sarcoma, or carcinoma.” It was thought that primary malignant lymphoma was rare in the pharynx and that carcinoma of the soft palate was incurable. They describe carcinoma of the oropharynx, which metastasizes quickly to the cervical glands and death usually results in 16 to 18 months.

It is a marked difference in the management of this cancer of the oropharynx now with either chemoradiation or transoral robotic surgery (TORS), which has saved many lives and certainly has changed dramatically the outcome of treatment since this publication in 1901.