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 10.5 mm 216 x 276 mm

Moore • Bewley • Givi

A case-focused Otolaryngology primer for trainees
and practicing clinicians alike
As disorders of the head and neck continue to become more prevalent, otolaryngologic head and neck sur-
geons are in greater demand than ever before. Many schools of medicine are integrating Problem-Based
Learning (PBL) to help students develop the skills necessary for surgical management of head and neck
conditions, yet the selection of guidebooks available to trainee otolaryngologic surgeons is limited.

Essential Cases in Head and Neck Oncology uses real-life clinical cases to present clear and up-to-date
explanations of treatment strategies for a wide range of cutaneous, salivary gland, and upper aerodiges-
tive tract conditions, including benign and malignant tumors. Written and edited by renowned leaders in

Essential Cases in Head and Neck Oncology

the field, and endorsed by the American Head & Neck Society, this essential resource contains full-color
photographs, illustrations, and diagrams to better support readers in acquiring, synthesizing, and applying

Essential Cases in
essential skills and knowledge in a clinical context. Its chapters provide detailed coverage of the oral cavity,
skull base, trachea, thyroid, larynx, paragangliomas, salivary glands, and more.

Head and Neck

This textbook also:

• Covers the full spectrum of head and neck surgeries, including reconstructive procedures
• Discusses ethics related to cancer treatments, medical research, and other care issues

Oncology
• Promotes multidisciplinary critical thinking, clinical problem-solving, communication,
and collaboration
• Helps medical students and trainees evaluate their learning and contextualize their knowledge
• Features high-quality images and succinct explanatory text throughout

Essential Cases in Head and Neck Oncology is an indispensable study aid for trainee clinicians, residents, and
fellows studying for board certification and other exams, and an excellent reference guide for oncologists,
otolaryngologists, surgeons, and other practitioners working in medical oncology, radiation oncology, and
oral and maxillofacial surgery.
Edited by Michael G. Moore
Arnaud F. Bewley
Michael G. Moore, MD, FACS, Arilla Spence DeVault Professor of Otolaryngology-Head and Neck Sur-
gery, Vice Chair of Academic Affairs, Indiana University School of Medicine, and Medical Director of the
Indiana University Health Joe and Shelly Schwarz Cancer Center, Indianapolis, IN, USA.

Arnaud F. Bewley, MD, Associate Professor of Otolaryngology-Head and Neck Surgery, Chief of Head and
Babak Givi
Neck Surgery, University of California, Davis, Sacramento, CA, USA.

Babak Givi, MD, FACS, Associate Professor of Otolaryngology-Head and Neck Surgery, Section Chief,
Otolaryngology, Manhattan VA Medical Center, Patient Safety-Quality Improvement Officer, Department of
Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, NY, USA.

Cover Design: Wiley

Cover Images: © (Top) courtesy of Babak Givi;
(Bottom) courtesy of Dr. Charles Yates

www.wiley.com
Essential Cases in Head and
Neck Oncology
Essential Cases in Head and
Neck Oncology
Edited by

MICHAEL G. MOORE, MD, FACS

Arilla Spence DeVault Professor
Vice Chair of Academic Affairs
Department of Otolaryngology-Head and Neck Surgery
Indiana University School of Medicine
Medical Director, IUH Joe & Shelly Schwarz Cancer Center
Indianapolis, IN, USA

ARNAUD F. BEWLEY, MD
Associate Professor
Department of Otolaryngology-Head and Neck Surgery
Chief of Head and Neck Surgery
University of California, Davis
Sacramento, CA, USA

BABAK GIVI, MD, FACS

Associate Professor, Section Chief
Patient Safety-Quality Improvement Officer
Department of Otolaryngology-Head and Neck Surgery
NYU Langone Health
New York, NY, USA
Endorsed by:
American Head and Neck Society
Los Angeles, CA, USA
This edition first published 2022
© 2022 American Head and Neck Society. All rights reserved.

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The right of Michael G. Moore, Arnaud F. Bewley, Babak Givi and the American Head and Neck Society to be identified as the authors of the
editorial material in this work has been asserted in accordance with law.

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Library of Congress Cataloging-­in-­Publication Data

Names: Moore, Michael G. (Michael Geoffrey), 1976-editor.
| Bewley, Arnaud F., editor. | Givi, Babak, editor. | American Head and Neck Society, issuing body.
Title: Essential Cases in Head and Neck Oncology / Edited by Michael
G. Moore, Arnaud F. Bewley, Babak Givi
Description: First edition. | Hoboken, NJ : Wiley, 2022. | Includes
bibliographical references and index.
Identifiers: LCCN 2021034618 (print) | LCCN 2021034619 (ebook) | ISBN 9781119775942 (paperback)
| ISBN 9781119775959 (adobe pdf) | ISBN 9781119775966 (epub)
Subjects: MESH: Head and Neck Neoplasms–surgery | Otorhinolaryngologic
Surgical Procedures–methods | Case Reports
Classification: LCC RF51 (print) | LCC RF51 (ebook) | NLM WE 707 | DDC
617.5/1059–dc23
LC record available at https://lccn.loc.gov/2021034618
LC ebook record available at https://lccn.loc.gov/2021034619

Cover Design: Wiley

Cover Images: © (Top) courtesy of Babak Givi; (Bottom) courtesy of Dr. Charles Yates

Set in 10/12pt STIX Two Text by Straive, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
Contents
L I ST OF AU TH O RS x

Section 1 Oral Cavity 1

Section Editor Chase Heaton
Case 1 1
Babak Givi
Case 2 3
Babak Givi
Case 3 6
Michael G. Moore
Case 4 8
Alok Pathak
Case 5 10
Arnaud Bewley
Case 6 14
Ian Ganly

Section 2 Oropharynx 21
Section Editor Liana Puscas
Case 7 21
Raymond Chai
Case 8 23
Jason I. Kass and Glenn J. Hanna
Case 9 26
Aru Panwar
Case 10 29
Daniel Sharbel and Kenneth Byrd
Case 11 31
Daniel Pinheiro

Section 3 Nasopharynx 37
Section Editor Chad Zender
Case 12 37
Levi Ledgerwood
Case 13 39
Jesse Ryan and Alice Tang
Case 14 42
Bharat Yarlagadda
Case 15 46
Brian Cervenka

v
vi Co n te n t s

Section 4 Laryngeal Cancer 51

Section Editor Bharat Yarlagadda
Case 16 51
Bharat Yarlagadda
Case 17 54
Bharat Yarlagadda
Case 18 58
Chase Heaton
Case 19 61
Laureano A. Giraldez-­Rodriguez
Case 20 63
Rizwan Aslam
Case 21 66
Bharat Yarlagadda

Section 5 Hypopharynx 73
Section Editor Tanya Fancy
Case 22 73
Rizwan Aslam
Case 23 75
Chad Zender
Case 24 78
Bharat Yarlagadda and Chase Heaton

Section 6 Thyroid 83
Section Editor Rusha Patel
Case 25 83
Chad Zender
Case 26 85
Bharat Yarlagadda
Case 27 88
Luiz P. Kowalski
Case 28 90
Arnaud Bewley and Michael G. Moore
Case 29 93
Antoine Eskander
Case 30 95
Dustin A. Silverman, Peter J. Kneuertz, Fadi A. Nabhan, and Stephen Kang
 Contents vii

Section 7 Parathyroid 103

Section Editor Liana Puscas
Case 31 103
Raymond Chai
Case 32 106
Tanya Fancy
Case 33 108
Liana Puscas

Section 8 Paraganglioma 111

Section Editor Kenneth Byrd
Case 34 111
Thomas J. Ow
Case 35 114
Camilo Reyes and J. Kenneth Byrd
Case 36 117
Michael G. Moore
Case 37 119
Charles Yates and Michael G. Moore

Section 9 Neck 125

Section Editor Jason Kass
Case 38 125
Chase Heaton
Case 39 127
Tanya Fancy
Case 40 129
Michael G. Moore
Case 41 132
Chase Heaton
Case 42 134
Avinash Mantravadi

Section 10 Trachea 141

Section Editor Stephen Kang
Case 43 141
David Neskey
Case 44 143
Basit Jawad and Rizwan Aslam
Case 45 146
Yash Patil
viii Co n te n t s

Section 11 Skull Base 151

Section Editor Paul O’Neill
Case 46 151
Kenneth Byrd
Case 47 155
Zoukaa Sargi
Case 48 158
Carl H. Snyderman

Section 12 Cutaneous Malignancies 165

Section Editor Charley Coffey
Case 49 165
Arnaud Bewley
Case 50 167
Vasu Divi
Case 51 169
David Neskey
Case 52 171
Bharat Yarlagadda
Case 53 173
Rizwan Aslam
Case 54 175
Lucy Shi and Stephen Kang

Section 13 Salivary 179

Section Editor Antoine Eskander
Case 55 179
Michael G. Moore
Case 56 181
Chris Rassekh
Case 57 183
Michael G. Moore
Case 58 185
Michael G. Moore
Case 59 186
Jessica Yesensky
Case 60 189
Michael G. Moore
 Contents ix

Section 14 Reconstruction 195

Section Editor Rizwan Aslam
Case 61 195
Avinash Mantravadi
Case 62 198
Rizwan Aslam and Yash Patil
Case 63 200
Chase Heaton
Case 64 202
Rusha Patel
Case 65 204
Jesse Ryan

Section 15 Ethics 211

Section Editor Andrew Shuman
Case 66 211
Catherine T. Haring and Andrew G. Shuman
Case 67 213
Catherine T. Haring and Andrew G. Shuman
Case 68 215
Lulia A. Kana, Kevin J. Kovatch, and Andrew G. Shuman
Case 69 217
Lulia A. Kana, Kevin J. Kovatch, and Andrew G. Shuman

INDEX 223
List of Authors
Rizwan Aslam, DO, MScEd, MBA, FACS Ian Ganly, MD
Associate Professor Attending Surgeon, Head and Neck Service
Department of Otolaryngology Memorial Sloan Kettering Cancer Center
Tulane University Professor of Otolaryngology – Head and Neck Surgery
New Orleans, LA, USA Weill Medical College
Cornell University
Arnaud F. Bewley, MD
New York, NY, USA
Associate Professor
Department of Otolaryngology-­Head and Neck Surgery Laureano A. Giraldez-­Rodriguez, MD
Chief of Head and Neck Surgery Director, Voice and Swallowing Center of Puerto Rico
University of California Adjunct Faculty Department of Otolaryngology –
Davis, Sacramento, CA, USA Head and
Neck Surgery, University of Puerto Rico School
Kenneth Byrd, MD
of Medicine
Assistant Professor
San Jaun, PR
Department of Otolaryngology-­Head and Neck Surgery
Augusta University Babak Givi, MD, FACS
Augusta, GA, USA Associate Professor of Otolaryngology-­Head &
Neck Surgery
Brian Cervenka, MD
Section Chief, Otolaryngology, Manhattan VA
Assistant Professor
Medical Center
Department of Otolaryngology-­Head and Neck Surgery
Department of Otolaryngology-­Head & Neck Surgery
University of Cincinnati
NYU Langone Health
Cincinnati, OH, USA
New York, NY, USA
Raymond Chai, MD
Glenn J. Hanna, MD
Associate Professor
Assistant Professor
Department of Otolaryngology
Harvard Medical School
Icahn School of Medicine
Dana-­Farber Cancer Institute
Mount Sinai, NY, USA
Boston, MA, USA
Charley Coffey, MD
Catherine T. Haring, MD
Associate Professor
Head & Neck Fellow
Department of Otolaryngology-­Head and Neck Surgery
Department of Otolaryngology-­Head and Neck Surgery
University of California San Diego
The Ohio State University Wexner Medical Center
San Diego, CA, USA
Columbus, OH, USA
Vasu Divi, MD
Chase Heaton, MD
Associate Professor
Associate Professor
Department of Otolaryngology-­Head and Neck Surgery
Department of Otolaryngology-­Head & Neck Surgery
Stanford University
University of California
Stanford, CA, USA
San Francisco, CA, USA
Antoine Eskander, MD
Basit Jawad, MD
Assistant Professor
Clinical Instructor
Department of Otolaryngology-­Head & Neck Surgery
Department of Otolaryngology-­Head & Neck Surgery
University of Toronto
Tulane University
Toronto, ON, Canada
New Orleans, LA, USA
Tanya Fancy, MD
Lulia A. Kana
Associate Professor
Medical Student
Department of Otolaryngology-­Head & Neck Surgery
University of Michigan
West Virginia University
Ann Arbor, MI, USA
Morgantown, WV, USA

x
 List of Authors xi

Stephen Kang, MD David Neskey, MD

Associate Professor, Fellowship Director, Head and Neck Director of Translational Research
Oncology and Microvascular Reconstruction Sarah Cannon Research Institute
Department of Otolaryngology – Head and Neck Surgery Charleston, SC, USA
the Ohio State University Wexner Medical Center
Paul O’Neill, MB, FRCSI, MMSc, MD, MBA, ORL-HNS
the James Cancer Hospital and Solove Research Institute
Professor
Columbus, OH, USA
Otolaryngology-­Head and Neck Surgery
Jason I. Kass, MD, PhD Royal College of Surgeons – Ireland
Reliant Medical Group Dublin, Ireland
Head and Neck Surgeon
Thomas J. Ow, MD, MS
Worcester, MA, USA
Associate Professor
Peter J. Kneuertz, MD Department of Otolaryngology-­Head and Neck
Assistant Professor Surgery/Pathology
Division of Thoracic Surgery Albert Einstein College of Medicine
the Ohio State University Wexner Medical Center Bronx, NY, USA
the James Cancer Hospital and Solove Research Institute
Aru Panwar, MD
Columbus, OH, USA
Assistant Professor
Kevin J. Kovatch, MD Department of Otolaryngology-­Head and Neck Surgery
Head & Neck Fellow University of Nebraska
Department of Otolaryngology/Head and Neck Surgery Lincoln, NE, USA
Vanderbilt University Medical Center
Rusha Patel, MD
Nashville, TN, USA
Associate Professor
Luiz Paulo Kowalski, MD Department of Otolaryngology-­Head and Neck Surgery
Full Professor and Chairman, Director The University of Oklahoma
Department of Head and Neck Surgery and Oklahoma City, OK, USA
Otorhinolaryngology
Yash Patil, MD
University of São Paulo Medical School
Associate Professor
São Paulo, Brazil
Program Director
Levi Ledgerwood, MD Department of Otolaryngology-­Head and Neck Surgery
Head & Neck Surgeon University of Cincinnati
South Sacramento Kaiser Permanente Medical Center Cincinnati, OH, USA
Sacramento, CA, USA
Alok Pathak, MS, PhD
Avinash Mantravadi, MD Professor, Director
Associate Professor Department of Surgery, Surgical Oncology Research
Director, Head and Neck Surgical Oncology University of Manitoba
Department of Otolaryngology -­Head and Neck Surgery Winnipeg, MB, Canada
Indiana University School of Medicine
Daniel Pinheiro, MD, Phd
Indianapolis, IN, USA
Department of Otolaryngology-­Head and Neck Surgery
Michael G. Moore, MD, FACS Cancer Center for the Ozarks, Mercy Hospital
Arilla Spence DeVault Professor Springfield, MO, USA
Vice Chair of Academic Affairs
Liana Puscas, MD, MHS
Department of Otolaryngology -­Head and Neck Surgery
Associate Professor
Indiana University School of Medicine
Department of Head and Neck Surgery & Communication
Medical Director, IUH Joe & Shelly Schwarz
Sciences
Cancer Center
Duke University
Indianapolis, IN, USA
Durham, NC, USA
Fadi A. Nabhan, MD
Chris Rassekh, MD, FACS
Associate Professor
Professor
Endocrinology and Metabolism
Department of Otolaryngology-­Head and Neck Surgery
Department of Medicine
University of Pennsylvania
Ohio State University College of Medicine
Philadelphia, PA, USA
Columbus, OH, USA
xii Lis t o f Au t h o rs

Camilo Reyes, MD Carl H. Snyderman, MD, MBA

Assistant Professor Professor, Departments of Otolaryngology and
Department of Otolaryngology-­Head and Neck Surgery Neurological Surgery
Medical college of Georgia University of Pittsburgh School of Medicine
Augusta University Co-­Director, Center for Cranial Base Surgery
Augusta, GA, USA University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Jesse Ryan, MD
Associate Professor Bharat Yarlagadda, MD
Department of Otolaryngology and Communication Division of Otolaryngology – Head and Neck Surgery
Sciences Lahey Hospital and Medical Center
SUNY Upstate Medical University Assistant Professor
Syracuse, NY, USA Department of Otolaryngology – Head and Neck Surgery
Boston University School of Medicine
Zoukaa Sargi, MD, MPH
Boston, MA, USA
Professor of Otolaryngology and Neurosurgery
Residency Program Director Charles Yates, MD
Department of Otolaryngology Associate Professor
University of Miami Miller School of Medicine Department of Otolaryngology – Head and Neck Surgery
Miami, FL, USA University of Indiana
Bloomington, IN, USA
Daniel Sharbel, MD
Department of Otolaryngology Jessica Yesensky, MD
Augusta University Assistant Professor
Augusta, GA, USA Department of Otolaryngology – Head and Neck Surgery
University of Indiana
Lucy Shi, MD
Bloomington, IN, USA
Department of Otolaryngology-­Head and Neck Surgery
Ohio State University Wexner Medical Center Chad Zender, MD, FACS
Columbus, OH, USA Associate Chief Medical Officer, UC Health
Center of Excellence Leader, Head and Neck, UC
Andrew G. Shuman, MD, FACS, HEC-­C
Cancer Institute
Associate Professor, CBSSM
Professor Department of Otolaryngology – Head &
Department of Otolaryngology -­Head and Neck Surgery
Neck Surgery
University of Michigan
University of Cincinnati College of Medicine
Ann Arbor, MI, USA
Cincinnati, OH, USA
Dustin A. Silverman, MD
Head & Neck Fellow
Department of Otolaryngology
University of California – Davis
Davis, CA, USA
SECTION 1
Oral Cavity
Chase Heaton
CAS E 1
Babak Givi
History of Present Illness
A 53-­year-­old man presents with a 1-­month history of tongue
soreness and pain. He has not noticed any change in voice, dif-
ficulty swallowing, or a neck mass. However, the tongue pain is
persistent and has not gone away with over-­the-­counter medi-
cations. His past medical history includes type II diabetes, con-
trolled with oral agents, and hypertension. He does not smoke
and has no history of tobacco or alcohol abuse. No other past
medical history was identified.
Physical Examination
No palpable neck mass was identified. Oral cavity exam shows a
slightly raised lesion on the right lateral tongue, which is soft and
tender to palpation, measuring 1 cm in diameter (see Figure 1.1).
There is no mass noted deep to the lesion. The rest of the exam,
including fiberoptic laryngoscopy, is within normal limits.
Management
Question: What would you recommend next?
Answer: Tissue sampling with a punch or incisional biopsy of
the lesion, preferably from the corner of the lesion.
Question: The biopsy shows squamous cell carcinoma
(SCC), moderately differentiated, with a depth of inva-
sion of at least 4 mm (punch biopsy specimen with tu-
mor transected at the base). What would you recom-
mend next in the workup?
Answer: Imaging of the neck is usually recommended to
­assess lymph node involvement. A computed tomography
Essential Cases in Head and Neck Oncology, First Edition. Edited by Michael G. Moore, Arnaud F. Bewley, and Babak Givi.
© 2022 American Head and Neck Society. Published 2022 by John Wiley & Sons Ltd.
(CT) scan with contrast or an ultrasound of the neck (which
can be performed in the clinic) are both reasonable first options.
The risk of distant metastases in early (T1 and T2) oral cavity
SCC is extremely low. Therefore, extensive metastatic workup
is not necessary. While positron emission tomography (PET)/
CT has become more common, the evidence for its added
benefit does not exist. Obtaining a chest CT to rule out lung
metastases is considered adequate.
Question: A CT scan of the head and neck does not show
any evidence of regional metastases. How would you
clinically stage this disease?
Answer: Based on the AJCC staging manual, 8th Edition, the
clinical stage is cT1N0Mx, stage I.
Question: What treatment would you recommend?
Answer: Early stage tongue cancer treatment is wide local ex-
cision of the primary tumor and addressing the regional lymph
nodes. If the risk of regional lymph node metastases is presumed
to be higher than 20%, an elective, selective neck dissection should
be performed. Depth of invasion is a prognostic marker for the
presence of occult nodal metastases in the cN0 neck. With a depth
of invasion >3 mm, it is believed that the risk of occult nodal me-
tastases is >20%, and therefore an elective neck dissection should
be performed. In this scenario, the recommended treatment
is wide local excision of the primary tumor with 1 cm margins
and elective neck dissection (ipsilateral levels I–III, i.e., supra-­
omohyoid neck dissection). Alternatively, sentinel node biopsy
could be offered if adequate expertise in the treating facility exists.
Question: Patient undergoes sentinel node mapping fol-
lowed by wide local excision and sentinel node biopsy.
The tongue defect is repaired with biologic dressing
(Continued)
1
2 SECT I O N 1 Oral Cavity

CAS E 1 (co nti nued)

and secondary intention closure. On lymphoscintigra-

phy, the sentinel node is located in an ipsilateral level
II lymph node (Figure 1.2). Excisional biopsy and frozen
section assessment shows metastatic SCC in the level II
node. How would you proceed?
Answer: If the sentinel node is positive, completion lym-
phadenectomy (selective neck dissection, level I–IV) is
recommended.
The patient recovers well from the operation. The final
pathology report shows a 1.5 cm moderately differentiated
SCC with a depth of invasion of 7 mm. All margins are free
of tumor, with the closest margin being 8 mm from tumor. No
lymphovascular or perineural invasion is identified. One out
of 30 lymph nodes is positive for metastatic SCC without extra-
nodal extension, measuring 1.9 cm (sentinel node).

Question: Based on these pathologic findings, what is

the appropriate stage for this patient?
Answer: According to AJCC 8th Edition, tumors of the
FIGURE 1.1 This photo demonstrates the patient’s right oral cavity with a depth of invasion of more than 5 mm are
lateral tongue ulceration.

FIGURE 1.2 This image shows the patient’s fused CT-­lymphoscintigraphy image. Note the uptake at the injection
site and a right level II lymph node.

CAS E 1 (co nti nued)
considered T2, even if the diameter is less than 2 cm. There-
fore, the pathologic stage is pT2N1M0, stage III.
Question: What adjuvant treatment regimen, if any,
would you recommend to this patient?
Answer: Since the disease is stage III, consideration of adju-
vant treatment is warranted. Radiotherapy should be consid-
ered after discussion of the case at a multidisciplinary tumor
board. The benefit of radiotherapy is not as clear in N1 disease;
however, limited data exist that shows tumors with a depth of
invasion of greater than 4 mm are at increased risk of regional
failure without adjuvant therapy. Since there is no evidence of
primary site positive margins or extranodal extension, there is
no indication for adjuvant chemotherapy.
Key Points
• Oral tongue SCC is the most common malignancy of the
oral cavity. The most important risk factors are tobacco,
alcohol, poor dentition, diets low in fruits and vegetables,
and Fanconi anemia.
• The risk of occult metastases in early stage oral cavity can-
cers is usually upward of 20%. Level I clinical trial evidence
exists in the survival benefit of elective neck dissection in
early stage tongue cancer and clinically negative cervical
nodes when the depth of invasion is >3 mm. Currently,
imaging techniques are not sensitive enough to identify
occult metastases, and a negative CT or PET scan does not
rule out microscopic metastases.
• Sentinel node biopsy in oral cavity cancers has been studied
and shown to be reliable enough to identify the majority
of occult metastases. Sentinel node sensitivity is reported
CAS E 2
Babak Givi
History of Present Illness
A 64-­year-­old woman presents with a nonhealing ulcer of the
right mandibular alveolus for the past month after extraction
of the second molar. The lesion is not painful and does not
bleed. She has a more than 40 pack-­year history of smoking
and drinking two alcoholic drinks a day for the past 30 years.
She does not report any history of other medical problems or
prior malignancy.
SECTION 1 Oral Cavity 3
Question: The patient completes a course of adjuvant
radiotherapy. What is your recommended regimen for
follow-­up and clinical surveillance?
Answer: Based on National Comprehensive Cancer Network
(NCCN) guidelines, baseline imaging at 12 weeks after com-
pletion of adjuvant treatment should be obtained, followed by
physical examination every 1–3 months in the first year post-­
treatment and then 4–6 months in the second year. In years
3–5, a physical exam every 4–8 months is recommended and
annually after 5 years. Annual thyroid-­stimulating hormone
(TSH) testing is recommended since the neck has received ra-
diotherapy. Dental, nutrition, and ongoing depression evalua-
tion are also recommended.
as 86% with a negative predictive value of 95% based on
the European Organization for Research and Treatment
of Cancer.
• Recommended primary treatment of oral cavity can-
cers is primarily surgical. Wide local excision with a
1 cm margin and lymph node dissection (selective node
dissection in clinically negative neck) is the current
recommendation.
• Depth of invasion is an important prognostic factor. A
depth of invasion of more than 3 mm is associated with an
increased risk of lymph node metastases.
• The current indications for adjuvant radiotherapy are (i)
close or positive margins, (ii) nodal involvement, (iii) peri-
neural invasion, and (iv) advanced stage tumor (T3–4).
• Concurrent chemotherapy with platinum-­based agents
is only recommended in positive margins or extranodal
extension.
Physical Examination
No palpable neck mass is identified. Oral cavity exam
shows an ulcerative lesion limited to the occlusal surface
of the right mandibular alveolus measuring 2 × 1 cm. The
lesion is not tender to touch, does not extend to the buc-
cal mucosa or floor of the mouth (see Figure 2.1). The rest
of the exam, including flexible laryngoscopy, is within
normal limits.
(Continued)
4 SECT I O N 1 Oral Cavity
CAS E 2 (co nti nued)
FIGURE 2.1 This photo demonstrates the ulcerative mu-
cosal lesion of the right mandible gingiva.
Management
Question: What would you recommend next?
Answer: Since the lesion has been present for more than
2 weeks and a significant history of tobacco and alcohol
abuse exists, tissue diagnosis via incisional or punch biopsy is
warranted.
Question: The biopsy is performed and shows invasive,
moderately differentiated keratinizing SCC. How would
you stage this disease?
Answer: The clinical stage of the disease at this point is
T2N0M0, stage II. However, the alveolar lesions can invade
the mandible early in the process. Therefore, imaging of the
mandible to better delineate osseous involvement is indicated.
Question: How would you determine the involvement of
the mandible?
Answer: No imaging modality can offer 100% sensitivity and
specificity. CT scanning, especially cone-­beam CT, has been
utilized as a modality with high sensitivity. Magnetic reso-
nance imaging (MRI) could be useful in determining the in-
volvement of the bone marrow. In the absence of any single
definitive modality, attention to the overall clinical exam and
imaging findings could guide the clinician to determine the
extent of the disease. For oral cavity lesions with suspected
mandibular involvement, most surgeons would start with a
CT scan with contrast of the head and neck to evaluate the
primary site lesion and regional lymphatics.
A PET/MRI and neck CT with IV contrast are obtained.
The CT of the neck shows significant thinning of the lingual
cortex of the mandible at the site of the lesion and the absence
of the buccal cortex superiorly. The inferior alveolar canal
appears intact (see Figure 2.2). The PET/MRI shows intense
activity at the primary lesion without clear evidence of lymph
node metastases. On MRI, there is an abnormal marrow signal
at the location of the lesion, suspicious for marrow invasion.
There is no evidence of involvement of the mandibular canal.
Question: Based on imaging findings, what is the clini-
cal stage of the disease?
Answer: Since there is radiographic evidence of osseous inva-
sion, the disease is upstaged to T4aN0M0, stage IVa.
Question: What is the recommended course of
treatment?
Answer: Oral cavity SCC is primarily treated with surgery,
followed by risk-­adjusted adjuvant treatment. In this case, the
recommended treatment is composite resection of the lesion
with segmental mandibulectomy, selective neck dissection
(levels I–III), and reconstruction with microvascular free tis-
sue transfer, such as fibula free flap, to provide the best func-
tional outcome.
The patient undergoes segmental mandibulectomy and
selective neck dissection with fibula free flap reconstruction.
The final pathology shows a 2 × 1 cm ulcerative SCC of the gin-
giva with invasion of the mandible. All margins are free of tumor
(>5 mm). There is no perineural invasion. There is a microscopic
focus of carcinoma present in 1 out of 32 lymph nodes (level Ib
node, 2.3 cm) with no evidence of extracapsular extension.
Question: What is the pathologic stage?
Answer: Based on mandibular invasion and nodal involve-
ment, the pathologic stage is pT4aN1M0, stage IVa.
Question: What adjuvant treatment regimen would you
recommend to this patient?
Answer: In spite of negative margins and no perineural in-
vasion, advanced T stage and involvement of regional nodes
warrant adjuvant radiotherapy. There is no indication for
chemotherapy (positive margins and extranodal extension).
Therefore, adjuvant radiotherapy is adequate.

(a) (b)
(c) (d)
FIGURE 2.2 These axial images are from the patient’s CT (a, b) as well as the T1-­weighted MRI (c) and fused PET/
MRI (d). Note the lesion of the right mandible with associated cortical erosion and hypermetabolism.
Key Points
• Alveolus SCC is less common than tongue or floor of
mouth cancers.
• Achieving negative margin resection (>5 mm) is an
extremely important objective in the treatment of alveo-
lar cancers.
• To achieve negative margin resection, most alveolar tumors
will require resection of the underlying bone. Determining
the extent of the mandibulectomy required to achieve neg-
ative margins can be challenging.
• It is accepted that if there is no bone erosion on CT or MRI,
and there is enough height of the bone, marginal man-
dibulectomy can achieve negative margin resection. The
remaining mandible should have at least a height of 1 cm.
SECTION 1 Oral Cavity 5
• If there is bone erosion on CT imaging or MRI shows
changes in the bone marrow signal, segmental mandibu-
lectomy is recommended.
• There is no level I data on the best method to determine
bone involvement. Cone beam CT is considered a very
sensitive method.
• In good risk candidates, osseous reconstruction with fib-
ula, scapula, or iliac crest free flap is recommended.
• Osteocutaneous radial forearm or vascularized rib graft has
been described and used in patients who are not good can-
didates for fibula or scapula. However, the harvested bone
is not thick enough to host implants.
6 SECT I O N 1 Oral Cavity
CAS E 3
Michael G. Moore
History of Present Illness
A 68-­year-­old white male presents with a chief complaint of a
painful sore around his right lateral maxillary teeth. He states
he initially thought it was related to a dental infection, but
after having a tooth pulled, the area has continued to enlarge.
Question: What are the other important points in his-
tory taking?
Answer:
• Presence of other adjacent loose teeth.
• Facial numbness.
• Difficulty in opening the mouth.
• Dysphagia, odynophagia.
• Voice changes.
• Presence of neck mass.
For maxillary lesions, it is always important to determine
the extent of the disease. Signs such as loose teeth, difficulty in
opening the mouth (trismus), and facial numbness (perineural
invasion) could provide critical clinical clues to the extent of
disease and aggressive behavior.
Question: What additional aspects of the history and
risk factors should be investigated?
Answer:
• Tobacco or alcohol use.
• Any history of head and neck cancers.
• Past medical history for significant diseases: peripheral
vascular disease, diabetes, autoimmune diseases, chronic
kidney disease, coagulation disorders, to name a few.
This patient has a history of 10 pack-­year smoking but
quit 25 years ago. He drinks alcohol socially with no history of
excessive drinking. There is no history of significant diseases
or malignancy.
Physical Examination
Oral cavity examination shows a 3 × 2 cm ulcerative lesion
on the buccal aspects of teeth #2 to #4 with slight extension
onto the palatal aspect of these teeth. No obvious loose teeth,
but there is fleshy tissue at the site of the previously extracted
tooth #3. His upper teeth are otherwise intact.
Neck exam revealed a 1.5 cm, firm, mobile, slightly tender
right level 1b neck mass. No other neck masses were noted. No
trismus or paresthesias noted. The rest of the examination is
within the normal limits. Cranial nerves II–XII are intact.
Management
Question: What would you recommend next?
Biopsy of the lesion is the first step and is recommended even
before imaging.
An office biopsy is performed and shows a moderately
differentiated invasive SCC.
Question: What is the clinical stage at this point?
Answer: T2N1M0, stage III, based on a larger than 2 cm le-
sion and one palpable node. However, in alveolar lesions, it is
important to evaluate the involvement of the bone, and these
lesions could be upstaged to T4. Therefore, it is better to obtain
imaging before assigning a clinical stage.
Question: What imaging modality would be an appro-
priate next step in the evaluation and management of
this patient?
Answer: A CT of the neck and chest with IV contrast is an ex-
cellent next step as this will allow for evaluation of the extent
of the primary lesion and to look for bone erosion as well as
for any pathologic lymphadenopathy. CT of the chest helps to
complete the staging. Alternatively, a PET/CT would be rea-
sonable, but it may not allow for as good of resolution of the
primary lesion to evaluate for bone involvement. Given that
there is no evidence of neural deficits or concern for orbital
or infratemporal fossa extension on physical exam, an MRI is
probably not necessary (see Figures 3.1 and 3.2).
Chest CT demonstrated no evidence of metastatic disease.
Oromaxillofacial prosthodontics is consulted to assist
with a dental impression and the production of an obturator if
maxillectomy is considered.
Question: Based on your current assessment, what
would be this patient’s clinical stage?
Answer: This patient has oral cavity cancer. The primary lesion
is staged based on size and depth of invasion. Here, depth is
not known. Size puts it in the T2 category. Of note, minor bone
erosion or maxillary involvement through a tooth socket alone
does not upstage it to T4a. The patient has multiple ipsilateral
pathologic nodes, none of which are larger than 6 cm in size,
making him cN2b. Therefore, the stage is T2N2bM0: stage IVa.
Question: Given the above information, what would
be the most appropriate management approach for
this patient?
Answer: This patient has stage IVa oral cavity cancer. The op-
timal treatment strategy in patients who are amenable to sur-
gery is for upfront surgical resection of the primary lesion with
a concomitant neck dissection. Given the N2b neck dissection,
he would benefit from adjuvant radiation therapy (RT) or
chemoradiation therapy, depending on the final margin status
and the presence or absence of extracapsular spread.
Question: Figure 3.3 shows an intraoperative photo of the
oral cavity defect after surgical resection of the primary
tumor. What would you recommend for the reconstruc-
tion of the defects? What are the factors that should be
considered in the reconstruction of the maxillary defect?
Another random document with
no related content on Scribd:
Christ, we shall learn the full interpretation of that profound word. He
will draw all men, because it is not possible for any human soul to
resist the divine loveliness once it is fairly and fully presented to his
vision.
The sermon on the “Worship of Faith,” sets forth that “to worship
Christ is to bow down with love and wonder and thankfulness, before
the most perfect goodness that the world has ever seen, and to
believe that that goodness was the express image of God the
Father.” All aims and all ideals, that are not the aims and ideals of
Christ, are distinctly opposed to such worship, and the man who
entertains these alien ideals may not call himself a Christian. After
examining that attitude of the spirit towards Christ which belongs to
the worship of faith, the rest of the sermon is very practical. “Work is
Worship,” is the keynote: one longs that a writer who knows so well
how to touch the secret springs had taken this opportunity to move
us to that “heart’s adoration,” which is dearer to God; but, indeed, the
whole volume has this tendency. It is well to be reminded that “the
thorough and willing performance of any duty, however humble or
however exalted, is like the offering of incense to Christ, well-
pleasing and acceptable.”
The sermon on the “Righteousness of Faith,” is extremely
important and instructive. The writer dwells on the “deplorable cant”
with which we pronounce ourselves “miserable sinners,” combining
the “sentiments of the Pharisees in the parable with the expressions
of the publican.”
“Christ’s language about man’s sinfulness is altogether free from
vagueness and hyperbole; when He blames He blames for definite
faults which we can appreciate, and He is so far from declaring that
men can do no good thing, that He assumes always that man in his
proper state of dependence upon God has the power to do
righteousness. ‘Whosoever shall do the will of My Father, which is in
heaven, the same is My brother, and sister, and mother.’... But the
question remains, How, considering our actual shortcomings, can
any of us be spoken of by Christ as righteous here and now? This is
the question in answer to which St. Paul wrote two of his greatest
Epistles. His answer was, that according to Christ, a man is
accounted righteous, not from a consideration of his works, but from
a consideration of his faith in God. Human righteousness is not a
verdict upon the summing up of a life, but it is reckoned to a man at
any moment from a certain disposition of his spirit to the Spirit of
God; a disposition of trust, love, reverence, the disposition of a
dutiful son to a good father.... Righteousness, in the only sense in
which it is possible for men, means believing and trusting God.”
We have not space to take up in detail all the teaching of this
inspiring little volume. We commend it to parents. Who, as they, have
need to nourish the spiritual life in themselves? Who, as they, have
need to examine themselves as to with how firm a grasp they hold
the mysteries of our faith? Who, as they, need to have their ideas as
to the supreme relationship so clear that they can be translated into
baby speech? Besides, we have seen that it is the duty of the
educator to put the first thing foremost, and all things in sequence;
only one thing is needful—that we “have faith in God”; let us deliver
our thoughts from vagueness and our ways from variableness, if we
would help the children towards this higher life. To this end, we
gladly welcome teaching which is rather nourishing than stimulating,
and which should afford real help towards “sober walking in pure
Gospel ways.”

FOOTNOTES:
[11] “The Imitation of Christ” (Rhythmic translation).
[12] Pendennis. Thackeray.
 CHAPTER XIV

THE HEROIC IMPULSE[13]

“To set forth, as only art can, the beauty and the joy of living, the
beauty and the blessedness of death, the glory of battle and
adventure, the nobility of devotion—to a cause, an ideal, a passion
even—the dignity of resistance, the sacred quality of patriotism, that
is my ambition here,” says the editor of “Lyra Heroica” in his preface.
We all feel that some such expression of the “simpler sentiments,
more elemental emotions” should be freely used in the education of
children, that, in fact, heroic poetry contains such inspiration to noble
living as is hardly to be found elsewhere; and also we are aware that
it is only in the youth of peoples that these elemental emotions find
free expression in song. We look at our own ballad literature and find
plenty of the right material, but it is too occasional and too little
connected, and so though we would prefer that the children should
imbibe patriotism and heroism at the one fountain head, we think it
cannot be done. We have no truly English material, we say, for
education in this kind, and we fall back on the Homeric myths in one
or other of the graceful and spirited renderings which have been
made specially for children.
But what if it should turn out that we have our own Homer, our
own Ulysses? Mr. Stopford Brooke has made a great discovery for
us who look at all things from the child standpoint. Possibly he would
not be gratified to know that his “History of Early English Literature,”
invaluable addition as it is to the library of the student and the man of
letters, should be appropriated as food for babes. All the same, here
is what we have long wanted. The elemental emotions and heroic
adventures of the early English put into verse and tale, strange and
eerie as the wildest fairy tale, yet breathing in every line the English
temper and the English virtue that go to the making of heroes. Not
that Beowulf, the hero of the great poem, was precisely English, but
where the English came from, there dwelt he, and Beowulf was early
adopted as the national hero, whose achievements were sung in
every hall.
The poem, says Mr. Stopford Brooke, consisting of three
thousand one hundred and eighty-three lines, is divided into two
parts by an interval of fifty years; the first, containing Beowulf’s great
deeds against the monster Grendel and his dam; the second,
Beowulf’s conquest of the Fire-drake and his death and burial. We
are told that we may fairly claim the poem as English, that it is in our
tongue and in our country alone that it is preserved. The hero
Beowulf comes of brave and noble parents, and mildness and more
than mortal daring meet in him. When he comes to Hrothgar to
conquer Grendel it is of his counsel as much as of his strength that
we hear. The queen begs him to be friendly in council to her sons.
Hrothgar says to him, “Thou holdest thy faith with patience and thy
might with prudence of mind. Thou shalt be a comfort to thy people
and a help to heroes.” None, it is said, could order matters more
wisely than he. When he is dying he looks back on his life, and that
which he thinks of the most is not his great war deeds, but his
patience, his prudence, his power of holding his own well and of
avoiding new enmities. “Each of us must await the close of life,” says
he; “let him who can, gain honour before he die. That is best for a
warrior when he is dead. But do thou throughout this day have
patience of thy woes; I look for that from thee.” Such the philosophy
of this hero, legendary or otherwise, of some early century after
Christ, before His religion had found its way among those northern
tribes. Gentle, like Nelson, he had Nelson’s iron resolution. What he
undertook to do he went through without a thought, save of getting to
the end of it. Fear is wholly unknown to him, and he seems, like
Nelson, to have inspired his captains with his own courage. “I swore
no false oaths,” he said when dying; so also he kept his honour in
faithfulness to his lord. On foot, alone, in front, while life lasted, he
was his king’s defence. He kept it in equal faithfulness when his lord
was dead, and that to his own loss, for when the kingdom was
offered to him he refused, and trained Heardreg, the king’s son, to
war and learning, guarded him kindly with honour, and avenged him
when he was slain. He kept it in generosity, for he gave away all the
gifts that he received; in courtesy, for he gave even to those who had
been rude to him; and he is always gentle and grave with women.
Above all, he kept it in war, for these things are said of him, “so shall
a man do when he thinks to gain praise that shall never end, and
cares not for his life in battle.” “Let us have fame or death,” he cries,
and when Wiglaf comes to help him against the dragon, and Beowulf
is wrapped in the flame, Wiglaf recalls to him the aim of his whole
life:—
“Beowulf, beloved, bear thyself well. Thou wert wont to say in
youth that thou wouldst never let honour go. Now, strong in deeds,
ward thy life, firm-souled prince, with all thy might, I will be thy
helper.” “These,” adds Mr. Stopford Brooke, “are the qualities of the
man and the hero, and I have thought it worth while to dwell on
them, because they represent the ancient English ideal, the
manhood which pleased the English folk even before they came to
Britain, and because in all our histories since Beowulf’s time, for
twelve hundred years or so, they have been repeated in the lives of
the English warriors by land and sea whom we chiefly honour. But it
is not only the idea of a hero which we have in Beowulf, it is also the
idea of a king, the just governor, the wise politician, the builder of
peace, the defender of his own folk at the price of his life, ‘the good
king, the folk king, the beloved king, the war ward of his land, the
winner of treasure for the need of his people, the hero who thinks in
death of those who sail the sea, the gentle and terrible warrior, who
is buried amid the tears of his people.’”
We owe Mr. Stopford Brooke earnest gratitude for bringing this
heroic ideal of the youth of our nation within reach of the unlearned.
But what have we been about to let a thousand years and more go
by without ever drawing on the inspiration of this noble ideal in giving
impulse to our children’s lives. We have many English heroes, it may
be objected: we have no need of this resuscitated great one from a
long buried past. We have indeed heroes galore to be proud of, but
somehow they have not often been put into song in such wise as to
reach the hearts of the children and the unlearned. We have to thank
Tennyson for our Arthur, and Shakespeare for our Henry the Fifth,
but we imagine that parents will find their children’s souls more in
touch with Beowulf than with either of these, because, no doubt, the
legends of a nation’s youth are the pages of history which most
easily reach a child, and Beowulf belongs to a younger stage of
civilisation than even Arthur. We hope the author of “Early English
Literature” will sometime give us the whole of the poem translated
with a special view to children, and interspersed with his own
luminous teaching as we have it here. The quaintness of the metre
employed gives a feeling of eld which carries the reader back, very
successfully, to the long ago of the poem.
We have already quoted largely from this “History of Early English
Literature,” but perhaps a fuller extract will give a better idea of the
work and of its real helpfulness to parents. The cost of the two rather
expensive volumes should be well repaid if a single child were to be
fired with emulation of the heroic qualities therein sung:—
“The action of the poem now begins with the voyage of Beowulf to
the Danish coast. The hero has heard that Hrothgar, the chief of the
Danes, is tormented by Grendel, a man-devouring monster. If
Hrothgar’s warriors sleep in Heorot—the great hall he has built—they
are seized, torn to pieces, and devoured. ‘I will deliver the king,’
thought Beowulf, when he heard the tale from the roving seamen.
‘Over the swan road I will seek Hrothgar; he has need of men.’ His
comrades urged him to the adventure, and fifteen of them were
willing to fight it out with him. Among the rest was a sea-crafty man
who knew the ocean-paths. Their ship lay drawn up on the beach,
under the high cliff. Then—
“There the well-geared heroes
Stepped upon the stem, while the stream of ocean
Whirled the sea against the sand. To the ship, to its breast.
Bright and carved things of cost carried then the heroes
And the armour well-arrayed. So the men outpushed,
On desired adventure, their tight ocean wood.
Swiftly went above the waves, with a wind well-fitted,
Likest to a fowl, the Floater, foam around its neck,
Till about the same time, on the second day,
The up-curvéd prow had come on so far,
That at last the seamen saw the land ahead;
 Shining sea-cliffs, soaring headlands,
Broad sea-nesses. So the Sailor of the Sea
Reached the sea-way’s end.”
Beowulf l. 211.

“This was the voyage, ending in a fiord with two high sea-capes at
its entrance. The same kind of scenery belongs to the land whence
they had set out. When Beowulf returns over the sea the boat groans
as it is pushed forth. It is heavily laden; the hollow, under the single
mast with the single sail, holds eight horses, swords and treasure
and rich armours. The sail is hoisted, the wind drives the foam-
throated bark over the waves, until they see the Geats’ Cliffs—the
well-known sea-nesses. The keel is pressed up by the wind on the
sand, and the ‘harbour-guard, who had looked forth afar o’er the sea
with longing for their return’—one of the many human touches of the
poem—‘fastens the wide-bosomed ship with anchoring chains to the
strand, lest the violence of the waves should sweep away the
winsome boat.’... At the end of the bay into which Beowulf sails is a
low shore, on which he drives his ship, stem on. Planks are pushed
out on either side of the prow; the Weder-folk slipped down on the
shore, tied up their sea-wood; their battle-sarks clanged on them as
they moved. Then they thanked the gods that the war-paths had
been easy to them.... On the ridge of the hill above the landing-place
the ward of the coast of the Scyldings sat on his horse, and saw the
strangers bear their bright shields over the bulwarks of the ship to
the shore. He rode down, wondering, to the sea, and shook mightily
in his hands his heavy spear, and called to the men—”
“Who are ye of men, having arms in hand,
Covered with your coats of mail. Who your keel afoaming
O’er the ocean street thus have urged along.
Hither on the high sea!”
* * * * *
“Never saw I greater
Earl upon this earth than is one of you;
Hero in his harness. He is no home-stayer,
‘Less his looks belie him, lovely with his weapons.
Noble is his air!”
 Beowulf, ll. 237-247.

“Beowulf replies that he is Hrothgar’s friend, and comes to free

him from ‘Grendel, the secret foe on the dark nights.’ He pities
Hrothgar, old and good. Yet, as he speaks, the Teutonic sense of the
inevitable Wyrd passes by in his mind, and he knows not if Hrothgar
can ever escape sorrow. ‘If ever,’ he says, ‘sorrow should cease from
him, release ever come, and the welter of care become cooler.’ The
coast-guard shows them the path, and promises to watch over their
ship. The ground rises from the shore, and they pass on to the hilly
ridge, behind which lies Heorot.”
“The History of the Early English Literature” takes us into other
pleasant places. Here are two or three specimens of the riddles of
the old bards, and in riddle and saga we get most vivid pictures of
the life and thoughts, the ways and words of the forefathers whom
we are too ready to think of as ‘rude,’ but who are here portrayed to
us as gentle, mild, and large of soul; men and women whom we,
their posterity, may well delight to honour.

I. Here is Cynewulf’s Riddle of the Sword.

“I’m a wondrous wight for warstrife shapen;
By my lord beloved, lovelily adorned:
Many coloured is my corslet, and a clasping wire
Glitters round the gem of death which my wielder gave to me:
He who whiles doth urge me, wide-wanderer that I am,
With him to conquest.
Then I carry treasure,
Cold above the garths, through the glittering day;
I of smiths the handiwork! Often do I quell
Breathing men with battle edges! Me bedecks a king
With his hoard and silver; honours me in hall,
Doth withhold no word of praise! Of my ways he boasts
‘Fore the many heroes, where the mead they drink.
In restraint he lulls me, then he lets me loose again,
Far and wide to rush along; me the weary with wayfarings,
Cursed of all weapons.”
Riddle xxi.
 II. The helmet speaks:—
“Wretchedness I bear;
Wheresoe’er he carries me, he who clasps the spear!
On me, still upstanding, smite the streams (of rain);
Hail, the hard grain (helms me), and the hoar-frost covers me;
And the (flying) snow (in flakes) falls all over me.”
Riddle, lxxix. 6-10.

III. The horn speaks:—

“I a weaponed warrior was! now in pride bedecks me
A young serving man all with silver and fine gold,
With the work of waving gyres! Warriors sometimes kiss me.
Sometimes I to strife of battle, summon with my calling
Willing war-companions; whiles, the horse doth carry
Me the march-paths over, or the ocean-stallion
Fares the flood with me, flashing in my jewels—
Often times a bower maiden, all bedecked with armlets,
Filleth up my bosom; whiles, bereft of covers,
I must, hard and headless, (in the houses) lie!
Then, again, hang I, with adornments fretted,
Winsome on the wall where the warriors drink.
Sometimes the folk fighters, as a fair thing on warfaring,
On the back of horses bear me; then bedecked with jewels
Shall I puff with wind from a warrior’s breast.
Then, again, to glee feasts I the guests invite
Haughty heroes to the wine— other whiles shall I
With my shouting, save from foes what is stolen away,
Make the plundering scather flee. Ask what is my name!”
Riddle xv.

We do not say a word about the literary value and importance of

Mr. Stopford Brooke’s great work; that is duly appraised elsewhere.
‘There is nothing like leather,’ and to us here all things present
themselves as they may tell on education. Here is a very treasure-
trove.

FOOTNOTES:
[13] “History of Early English Literature,” by Stopford A.
Brooke, 2 vols. Macmillan & Co.
 CHAPTER XV

IS IT POSSIBLE?

The economic aspects of the great philanthropic scheme[14] which

brought timely relief to the national conscience before the setting in
of the hard winter of 1891, are, perhaps, outside our province, but
there are educational aspects of it which, we are in some measure,
bound to discuss. In the first place, the children in many homes hear,
“I do not believe that”—it is possible for the leopard to change his
spots. ‘General’ Booth’s scheme brings this issue before us with
startling directness, and what the children hear said to-day at the
table and by the fireside will probably influence for all their lives their
attitude towards all philanthropic and all missionary endeavour. Not
only so, but we ourselves, who stand in some measure in loco
parentis to the distressed in mind, body, or estate, are compelled to
examine our own position. How far do we give, and work, for the
ease of our own conscience, and how far do we believe in the
possibility of the instant and utter restoration of the morally
degraded, are questions which, to-day, force themselves upon us.
We must be ready with a yea or a nay; we must take sides, for or
against such possibilities as should exalt philanthropic effort into a
burning passion. The fact is, this great scheme forced a sort of moral
crisis upon us.
Whether or no the scheme commends itself to us for its fitness,
seasonableness, and promise, one thing it has assuredly done: it
has revealed us to ourselves, and that in an agreeable light. It has
been discovered to us that we, too, love our brother; that we, too,
yearn over “the bruised” with something of the tenderness of Christ.
The brotherhood of man is no fancy bred in the brain, and we have
loved our brother all the time—the sick, the poor, the captive, and the
sinner, too; but the fearful, and unbelieving, and slothful amongst us
—that is, the most of us—have turned away our eyes from beholding
evils for which we saw no help. But now that a promise of
deliverance offers, more adequate, conceivably, than any heretofore
proposed, why, the solidarity of humanity asserts itself; our brother
who is bruised is not merely near and dear; he is our very self, and
whoso will ease and revive him is our deliverer too.
The first flush of enthusiasm subsides, and we ask, Are we not,
after all, led away by what Coleridge calls the “Idol of Size”? Wherein
does this scheme differ from ten thousand others, except in the
colossal scale on which the experiment is to be tried? And perhaps
we should concede at the outset that this hope of deliverance is “the
same, only more so,” as is being already worked out effectually in
many an otherwise sunless corner of the great vineyard. Indeed, the
great project has its great risks—risks which the quieter work
escapes. All the same, there are aspects in which the remedy,
because of its vastness and inclusiveness, is new.
Hitherto we have helped the wretched in impossible
circumstances, not out of them. Our help has been as a drop in the
bucket, reaching to hundreds or thousands only of the lost millions.
Even so, we cannot keep it up; we give to-day, and withhold to-
morrow; worse than all, our very giving is an injury, reducing the
power and the inclination for self-help. Or, do we start some small
amateur industry by way of making our people independent? This
pet industry may sometimes be a transparent mask for almsgiving,
and an encroachment upon regular industries and the rights of other
workers.
Now and then is a gleam of hope, now and then a soul and body
snatched into safety; but the hardest workers are glad of the noise of
the wheels to keep the eternal Cui bono? out of their ears. There is
so much to be done, and so little means of doing it. But this scheme
—what with the amplitude of its provisions, what with the
organisation and regimentation it promises, the strong and righteous
government, the moral compulsion to well-doing—considering these,
and the enormous staff of workers already prepared to carry it out,
the dreariest pessimist amongst us concedes that General Booth’s
scheme may be worth trying. “But,” he says, “but——

do we believe in conversion?”
Everything turns on the condition the originator wisely puts first.
There is the crux. Given money enough, land enough, men enough,
fully equip and officer this teeming horde of incapables, and some
sort of mechanical drill may be got through somehow. But, “when a
man’s own character and defects constitute the reasons for his fall,
that character must be changed and that conduct altered if any
permanent beneficial results are to be obtained.” The drunkard must
be made sober; the criminal, honest; the impure, clean. Can this be
done? is the crucial question. Is it possible that a man can emerge
altogether out of his old self and become a new creature, with new
aims, new thoughts, even new habits? That such renovation is
possible is the old contention of Christianity. Here, and not on the
ground of the inspiration of the sacred text, must the battle be fought
out. The answer to the one urgent question of the age, What think ye
of Christ? depends upon the power of the idea of Christ to attract
and compel attention, and of the indwelling of Christ to vivify and
elevate a single debased and torpid human soul.
Many of us believe exultingly that the “All power” which is given
into the hands of our Master includes the power of upright standing,
strength, and beauty for every bruised human reed. That this is so,
we have evidence in plenty, beginning with ourselves. But many
others of us, and those not the less noble, consider with Robert
Elsmere, that “miracles do not happen.” The recorded miracles serve
as pegs for the discussion; the essential miracle is the utter and
immediate renovation of a human being. Upon this possibility the
saving of the world must hang, and this many cannot receive, not
because they are stiff-necked and perverse, but because it is dead
against natural law as they know it. Proofs? Cases without end? The
whole history of the Christian Church in evidence? Yes; but the
history of the Church is a chequered one; and, for individual cases,
we do not doubt the veracity of the details; only, nobody knows the
whole truth; some preparation in the past, some motive in the
present inadvertently kept out of sight, may alter the bearings of any
such case.
This is, roughly, the position of the honest sceptic, who would, if
he could, believe heartily in General Booth’s scheme, and, by
consequence, in the convertibility of the entire human race. To
improve the circumstances, even of millions, is only a question of the
magnitude of the measures taken, the wisdom of the administration.
But human nature itself, depraved human nature, is, to him, the
impossible quantity. Can the leopard change his spots?

the law against us—heredity.

Who are they whom General Booth cheerfully undertakes to re-
fashion and make amenable to the conditions of godly and righteous
and sober living? Let us hear the life history of many of them in his
own words:—
“The rakings of the human cesspool.”
“Little ones, whose parents are habitually drunk.... Whose ideas of
merriment are gained from the familiar spectacle of the nightly
debauch.”
“The obscenity of the talk of many of the children of some of our
public schools could hardly be outdone, even in Sodom and
Gomorrah.”
And the childhood—save the word!—of the children of to-day
reproduces the childhood of their parents, their grand-parents, who
knows? their great-grand-parents. These are, no doubt, the worst;
but the worst must be reckoned with first, for if these slip through the
meshes of the remedial net, the masses more inert than vicious slide
out through the breaks. In the first place, then, the scheme embraces
the vicious by inheritance; proposes to mix up with the rest a class
whose sole heritage is an inconceivable and incalculable
accumulation of vicious inclinations and propensities. And this, in the
face of that conception of heredity which is quietly taking possession
of the public mind, and causing many thoughtful parents to abstain
from very active efforts to mould the characters of their children.
Those of us whose attention has been fixed upon the working of
the law of heredity until it appears to us to run its course, unmodified
and unlimited by other laws, may well be pardoned for regarding with
doubtful eye a scheme which has, for its very first condition, the
regeneration of the vicious; of the vicious by inherited propensity.

the law against us—habit.

Use is second nature, we say. Habit is ten natures; habit begins
as a cobweb, and ends as a cable. “Oh, you’ll get used to it,”
whatever it is. Dare we face the habits in which these people have
their being? It is not only the obscene speech, the unholy acts; that
which signifies is the manner of thoughts we think; speech, act, are
the mere outcome; it is the habitual thought of a man which shapes
that which we call his character. And these, can we reasonably doubt
that every imagination of their heart is only evil continually? We say,
use is second nature, but let us consider what we mean by the
phrase; what is the philosophy of habit so far as it has been
discovered to us. The seat of habit is the brain; the actual grey
nervous matter of the cerebrum. And the history of a habit is shortly
this: “The cerebrum of man grows to those modes of thought in
which it is habitually exercised.” That ‘immaterial’ thought should
mould the ‘material’ brain need not surprise nor scandalise us, for do
we not see with our eyes that immaterial thought moulds the face,
forms what we call countenance, lovely or loathsome according to
the manner of thought it registers. The how of this brain growth is not
yet in evidence, nor is this the time and place to discuss it; but,
bearing in mind this structural adaptation to confirmed habit, what
chance, again, we say, has a scheme which has for its first condition
the regeneration of the vicious, vicious not only by inherited
propensity, but by unbroken inveterate habit?

the law against us—unconscious cerebration.

 Those who are accustomed to write know what it is to sit down
and “reel off” sheet after sheet of matter without plan or
premeditation, clear, coherent, ready for press, hardly needing
revision. We are told of a lawyer who wrote in his sleep a lucid
opinion throwing light on a most difficult case; of a mathematician
who worked out in his sleep a computation which baffled him when
awake. We know that Coleridge dreamed “Kubla Khan” in an after-
dinner nap, line by line, and wrote it down when he awoke. What do
these cases and a thousand like them point to? To no less than this:
that, though the all important ego must, no doubt, “assist” at the
thinking of the initial thought on a given subject, yet, after that first
thought or two, ‘brain’ and ‘mind’ manage the matter between them,
and the thoughts, so to speak, think themselves; not after the fashion
of a pendulum which moves to and fro, to and fro, in the same
interval of space, but in that of a carriage rolling along the same
road, but into ever new developments of the landscape. An amazing
thought—but have we not abundant internal evidence of the fact?
We all know that there are times when we cannot get rid of the
thoughts that will think themselves within us, though they drive away
sleep and peace and joy. In the face of this law, benign as it eases
us of the labour of original thought and decision about the everyday
affairs of life, terrible when it gets beyond our power of control and
diversion, what hope for those in whose debauched brain vile
thoughts, involuntary, automatic, are for ever running with frightful
rapidity in the one well-worn track? Truly, the in-look is appalling.
What hope for these? And what of a scheme whose first condition is
the regeneration of the vicious—vicious, not only by inherited
propensity, and by unbroken inveterate habit, but reduced to that
state of, shall we say, inevitable viciousness—when “unconscious
cerebration,” with untiring activity, goes to the emanation of vicious
imaginations? All these things are against us.

the law for us—limitations to the doctrine of heredity.

But the last word of Science, and she has more and better words
in store, is full of hope. The fathers have eaten sour grapes, but it is
not inevitable that the children’s teeth be set on edge. The soul that
sinneth it shall die, said the prophet of old, and Science is hurrying
up with her, “Even so.” The necessary corollary to the latest
modification of the theory of evolution is—acquired modifications of
structure are not transmitted. All hail to the good news; to realise it,
is like waking up from a hideous nightmare. This is, definitely, our
gain; the man who by the continuous thinking of criminal thoughts
has modified the structure of his brain so as to adapt it to the current
of such thoughts, does not necessarily pass on this modification to
his child. There is no necessary adaptation in the cerebrum of the
new-born child to make place for evil thoughts. In a word, the child of
the vicious may be born as fit and able for good living as the child of
the righteous. Inherent modifications are, it is true, transmitted, and
the line between inherent and acquired modifications may not be
easy to define. But, anyway, there is hope to go on with. The child of
the wicked may have as good a start in life, so far as his birthright
goes, as the child of the just. The child’s future depends not upon his
lineage so much as upon his bringing up, for education is stronger
than nature, and no human being need be given over to despair. We
need not abate our hope of the regeneration of the vicious for the
bugbear of an inheritance of irresistible propensity to evil.

the law for us—“one custom overcometh another.”

But habit! It is bad enough to know that use is second nature, and
that man is a bundle of habits; but how much more hopeless to look
into the rationale of habit, and perceive that the enormous strength
of the habit that binds us connotes a structural modification, a
shaping of the brain tissues to the thought of which the habit is the
outward and visible sign and expression. Once such growth has
taken place, is not the thing done, so that it can’t be undone—has
not the man taken shape for life when his ways of thinking are
registered in the substance of his brain?
Not so; because one habit has been formed and registered in the
brain is no reason at all why another and contrary habit should not
be formed and registered in its turn. To-day is the day of salvation,
physically speaking, because a habit is a thing of now; it may be
begun in a moment, formed in a month, confirmed in three months,
become the character, the very man, in a year. There is growth to the
new thoughts in a new tract of the brain, and “One custom
overcometh another.” Here is the natural preparation for salvation.
The words are very old, the words of Thomas à Kempis, but the
perception that they have a literal physical meaning has been
reserved for us to-day. Only one train of ideas can be active at one
time; the old cell connections are broken, and benign nature is busy
building up the waste places, even be they the waste places of many
generations. NO ROAD is set up in the track where the unholy
thoughts carried on their busy traffic. New tissue is formed; the
wound is healed, and, save, perhaps, for a scar, some little
tenderness, that place is whole and sound as the rest.
This is how one custom overcometh another: there is no conflict,
no contention, no persuasion. Secure for the new idea a weighty
introduction, and it will accomplish all the rest for itself. It will feed
and grow; it will increase and multiply; it will run its course of its own
accord; will issue in that current of automatic unconscious
involuntary thought of the man which shapes his character. Behold, a
new man! Ye must be born again, we are told; and we say, with a
sense of superior knowledge of the laws of nature, How can a man
be born again? Can he enter the second time into his mother’s
womb and be born? This would be a miracle, and we have satisfied
ourselves that “miracles do not happen.” And now, at last, the
miracle of conversion is made plain to our dull understanding. We
perceive that conversion, however sudden, is no miracle at all—
using the word miracle to describe that which takes place in
opposition to natural law. On the contrary, we find that every man
carries in his physical substance the gospel of perpetual, or of
always possible, renovation; and we find how, from the beginning,
Nature was prepared with her response to the demand of Grace. Is
conversion possible? we ask; and the answer is, that it is, so to
speak, a function for which there is latent provision in our physical
constitution, to be called forth by the touch of a potent idea. Truly,
His commandment is exceeding broad, and grows broader day by
day with each new revelation of Science.
 A man may, most men do, undergo this process of renovation
many times in their lives; whenever an idea strong enough to divert
his thoughts (as we most correctly say) from all that went before is
introduced, the man becomes a new creature; when he is “in love,”
for example; when the fascinations of art or of nature take hold of
him; an access of responsibility may bring about a sudden and
complete conversion:—
The breath no sooner left his father’s body
But that his wildness, mortified in him,
Seem’d to die too; yea, at that very moment,
Consideration, like an angel, came
And whipp’d the offending Adam out of him;
Leaving his body as a paradise
To envelop and contain celestial spirits.

Here is a picture—psychologically true, anyway, Shakespeare

makes no mistakes in psychology—of an immediate absolute
conversion. The conversion may be to the worse, alas, and not to
the better, and the value of the conversion must depend upon the
intrinsic worthiness of the idea by whose instrumentality it is brought
about. The point worth securing is, that man carries in his physical
structure the conditions of renovation; conditions, so far as we can
conceive, always in working order, always ready to be put in force.
Wherefore “conversion” in the Biblical sense, in the sense in which
the promoters of this scheme depend upon its efficacy, though a
miracle of divine grace in so far as it is a sign and a marvel, is no
miracle in the popular sense of that which is outside of and opposed
to the workings of “natural law.” Conversion is entirely within the
divine scheme of things, even if we choose to limit our vision of that
scheme to the “few, faint, and feeble” flashes which Science is as yet
able to throw upon the mysteries of being. But is this all? Ah, no; this
is no more than the dim vestibule of nature to the temple of grace;
we are not concerned, however, to say one word here of how “great
is the mystery of godliness;” of the cherishing of the Father, the
saving and the indwelling of the Son, the sanctifying of the Spirit;
neither need we speak of “spiritual wickedness in high places.” The
aim of this slight essay is to examine the assertion that what we call
conversion is contrary to natural law; and we do this with a view, not
to General Booth’s scheme only, but to all efforts of help.
Hope shows an ever stronger case for the regeneration of the
vicious. Not only need we be no more oppressed by the fear of an
inheritance of invincible propensities to evil, but the strength of life-
long habit may be vanquished by the power of an idea, new habits of
thought may be set up on the instant, and these may be fostered and
encouraged until that habit which is ten natures is the habit of the
new life, and the thoughts which, so to speak, think themselves all
day long are thoughts of purity and goodness.

the law for us—potency of an idea.

“Hath not a Jew eyes? hath not a Jew hands, organs,
dimensions, senses, affections, passions?”
In effecting the renovation of a man the external agent is ever an
idea, of such potency as to be seized upon with avidity by the mind,
and, therefore, to make an impression upon the nervous substance
of the cerebrum. The potency of an idea depends upon the fact of its
being complementary to some desire or affection within the man.
Man wants knowledge, for example, and power, and esteem, and
love, and company; also, he has within him capacities for love,
esteem, gratitude, reverence, kindness. He has an unrecognised
craving for an object on which to spend the good that is in him.
The idea which makes a strong appeal to any one of his primal
desires and affections must needs meet with a response. Such idea
and such capacity are made for one another; apart, they are
meaningless as ball and socket; together, they are a joint, effective in
a thousand ways. But the man who is utterly depraved has no
capacity for gratitude, for example? Yes, he has; depravity is a
disease, a morbid condition; beneath is the man, capable of
recovery. This is hardly the place to consider them, but think for a
moment of the fitness of the ideas which are summed up in the
thought of Christ to be presented to the poor degraded soul: divine
aid and compassion for his neglected body; divine love for his
loneliness; divine forgiveness in lieu of the shame of his sin; divine