Abstract
Each patient has been maintained in reasonably good health by the continued administration of cortisone. I am grateful to Dr. Ernest Bulmer for permission to publish Cases 1 and 2, and to Dr. A. G 780 OcT. 2, 1954 COLLAGEN DISEASE TREATED WITH CORTICOIDS MEDIC&LNRNAL Each patient has been maintained in reasonably good health by the continued administration of cortisone. Victoria Infirmary, Newcastle-upon-Tyne In 1939 during the course of a discussion at the Royal Society of Medicine on the treatment of carcinoma of the vulva, F. J. Browne suggested that since this was a fairly uncommon disease the results might be improved by concentrating all the cases in the hands of a few surgeons, who might thereby gain greater experience in handling the disease than if the cases were scattered in various clinics all over the country, usually in ones and twos. My interest in the disease was aroused by my former chief, Clifford White, who suggested that a study of it might prove useful, especially as the incidence appeared comparatively high in Newcastle-upon-Tyne. The more academic aspects of that study I have reported elsewhere (Way, 1951) , but, briefly, the research showed that the previously poor results were due not only to lack of experience on the part of those respon- sible for its treatment but also to the fact that standard treatments at that time were based on unsound patho- logical and anatomical principles. The removal of the vulva was insufficiently wide in most cases to prevent recurrence, and the node dissections were not extensive enough to deal with the metastases. As a result of this study, I devised the extended radical vulvectomy and node dissection which I have described elsewhere in full (Way, 1951) , but which in brief consists of the complete removal of the vulva from the mons to the anus, extending deep enough to expose the pubic bones and their associated muscles; the excision of wedges of skin from the groins and saphenous regions with the underlying lymph nodes which remain undetached from the skin during the operation; the division of the inguinal ligament; and the removal of the external iliac lymph nodes as far as the bifurcation of the common iliac artery. The groin wounds are sutured, but the vulval wound is so wide that it has to be left to granulate. If the vulval wound can be sutured then the cardinal principle of cancer surgery is violated and recurrence can be expected in a fair proportion of cases. The first of these operations I performed rather in the nature of an experiment in 1941. The patient had involved nodes, and died nine years later of coronary thrombosis without recurrence of the tumour or metastases. From 1943 onwards, with the help of my colleagues in the gynaecological and radiotherapy departments, all the cases seen in the centre were handled by me and were assessed for this radical operation; in addition, most of the cases occurring in the gynaecological departments of neighbouring hospitals, in particular the Newcastle-upon-Tyne General Hospital, were also re- ferred. The early cases were all performed in the Royal Victoria Infirmary, but the serious bed situation created by the long stay of these patients necessitated the provision of beds specially for them, and these were provided by the Newcastle Regional Cancer Organization in their associated hospitals, where more than half of the patients described in this paper were treated. The unselfish attitude of my colleagues and the co-operation of the Regional Cancer Organization, both before and after the advent of the National Health Service, played a great part in the excellent results that have been achieved, but without the very great assistance and encouragement of Professor Harvey Evers, who was quick to see the advantages of and to encourage the establish- ment of a special unit for this type of case, and Mr. John Thurgar, who, in the most difficult time, handed over radiotherapy beds for the surgical treatment of these cases, this planned attack could never have been carried out. This paper describes the results of 79 cases seen prior to March 31, 1949. A five-year follow-up is avail- able on all these patients, and they represent an unselected group who presented themselves for treatment at Newcastle hospitals. The results are believed to be representative of what can be achieved in any large centre where these cases are concentrated in the hands of a medical and nursing staff who see enough cases to become conversant with the problems involved.
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