Page images
PDF
EPUB

dark as to other essential etiological factors. Everyone in densely populated cities is probably daily exposed to the tubercle bacillus, and yet only a small minority are affected with tuberculosis.

That the old theory of continued irritation of epithelial tissues is almost, if not quite, necessary to explain the development of cancer I do not question. One has only to reflect that all forms of carcinoma are very generally found at points subject to persistent irritation, viz.: the lips, esophagus, stomach, cecum, rectum, tongue, uterus, and mammary glands. At least one excellent book has been written during the last year emphasizing the importance of heredity as a predisposing cause of cancer, and showing that at least one-third of all cases give a cancerous history. There is no question, I take it, that with the passing of the constitutional theory of cancer and the demonstration and acceptance of its local origin, about thirty-five years ago, there began a tendency to minimize the influence of heredity as a predisposing cause. It has been carried too far; just as has been the case with tuberculosis. The disease, of course, is not inherited, but the soil is prepared and made ready should the seed be sown at a time when epithelial tissues are prone to run wild.

That race, environment, temperament, habits, trauma, and possibly diet are at times influential may be allowed, but it would seem that more than one cause is usually operative.

Precancerous Conditions.-Much is written, more is thought, judging by statements one hears made in private conversation and from discussions in medica! societies, concerning the precancerous state, yet comparatively little seems based upon indisputable facts. We hear a great deal about malignant degeneration of benign tumors and while it does occur, though much less frequently than is generally supposed, a careful investigation reveals the fact that very generally it is sarcomatous and not carcinomatous degeneration. Beyond the fact that superficial moles and warts, congenital or acquired, not infrequently late in life undergo malignant transformation, there is little trustworthy evidence.

J. C. Warren reported a series of breast cancer, 100 in number, in the December number of the Annals of Surgery, and in only a single case

was there the slightest evidence that a benign growth had undergone cancerous change. A small fibroma, the size of a horse-chestnut and of twenty years' duration became the seat of carcinomatous change. I know of no other series of cases so accurately and conscientiously reported, and nearly all were examined by one microscopist of national repute, Dr. W. F. Whitney. If such malignant transformation can be shown but once in a hundred cases of breast cancer, the region of all others where it is supposed to occur most frequently, are we not, in recognizing its possibility, too strongly accentuating the probability of such change? According to Mr. Raymond Johnson, of London, the general opinion that breast tumors originally benign are prone to degenerate into malignancy, is incorrect, and cannot be proven. In a series of lectures delivered at the Royal College of Surgeons, of England, Mr. Johnson devoted considerable time to combating this well-nigh universally accepted view. He asserts that adenoma, which is by most authors supposed to be exceedingly liable to cancerous change, never does so, and says that no one has ever reported a case where encapsulated tumor, as the adenoma, has been seen bursting through its capsule and infiltrating the surrounding tissues. Until he has seen such specimens and examined them macroscopically and microscopically, he cannot believe they are of common occurrence, if indeed they exist at all.

Paget's Disease.-There is perhaps no opinion more general or more tenaciously adhered to by physicians, surgeons, and pathologists than the one that eczema or psoriasis of the nipple and areola, the so-called "Paget's disease," frequently leads to cancer. The commanding position of the surgeon first promulgating this view at once caused it to be generally accepted and taught. In a paper read before the Surgical Section of the American Medical Association at Baltimore, in 1895, I questioned the accuracy of the observation, and expressed the opinion that the Paget's disease was secondary to tubular cancer, and that the discharge from within caused the irritation without. Since then I have operated upon one case of Paget's disease, and it was undoubtedly secondary to duct carcinoma. This is the only case of Paget's disease that has ever

come to operation at my hands, and in a measure it confirms the theoretical opinion I had formed. This question has become an acute one since the excellent Bradshaw lecture of Mr. Mayo Robson, of London, in December last, in which he made a strong plea for operation in the precancerous stage. His position has been challenged by several, notably Roger Williams, who states that in only one-half of one per cent of areolar disease is there subsequent cancer; 2,000 cases analyzed. Of the one hundred cases of Warren there was but one in which Paget's disease was, or had been, present. So at most the association between the two conditions is infrequent, and when it does occur the probabilities are that the external, areolar disease, is secondary to, and not the cause of, duct cancer. This view is supported by the investigations of Thin, Roger Williams, Raymond Johnson, and others.

were

Phimosis. As fixed in the professional mind is the belief that phimosis is frequently antecedent to, and causative of, cancer of the penis. This would seem theoretically to be so; but is it?

Phimosis is too common a condition the world over, and cancer of the penis too rare a disease for there to be any close connection bewteen them.

Less than one per cent, according to the Registrar General's statistics, of the deaths from cancer in Great Britain, resulted from cancer of the penis.

In 1898 in my Chairman's address before the Surgical Section of the American Medical Association I called attention to the rarity of cancer of the penis in negroes. I had never seen a case; none had been treated in in the Louisville City Hospital; and the records of the Health office for the City of Louisville for a period of thirty years recorded no death from cancer of the penis in a negro.

I also pointed out that the negro, far more than the Caucasian, was affected with phimosis, in fact almost universally so and often to an extreme degree. The census statistics of the United States for 1900 are even more cogent and to the point, and show that although the death-rate for male negroes was 28.6 per 100,000 living, no death resulted from cancer of the penis. This cannot be explained by racial insusceptibility, for the African is more liable to both cancer of the

uterus and mammæ than the Caucasian. Further, the Gnos, according to Roger Williams, are as liable to cancer of the penis as non Gnos. There is at most only a potential relation between phimosis and cancer of the penis.

In his position that gall-stones may cause cancer of the gall-bladder I believe that Mr. Robson stands upon ground better chosen, and yet we should not forget how rare primary cancer of the gall-bladder is, and how frequent gall-stones are, occurring, it has been said, in ten per cent of all persons examined at autopsy. It is doubtless true that in only those cases of infection and chronic ulceration, with its subsequent cicatricial tissue, of the gall-bladder that the danger of cancerous implantation is great. Too many such instances are reported by accurate observers to be ignored. It is only of recent years that gallstone disease has been studied with care and accuracy, generally followed by operation, and supplemented by careful microscopic examination of the viscus when cholecystectomy has been performed. That increasing and incontrovertible evidence sustaining Mr. Robson's position will be forthcoming, now that cholecystectomy is so frequently resorted to, I have not the slightest doubt. The statistics controverting this view cited by Mr. Williams and others are convincing to those who rely entirely upon statistics. But as I have already said, it should be recalled that we are almost at the very threshold of any accurate knowledge on the subject of gall-stone surgery, and old statistics, while not valueless, are not necessarily conclusive.

Ulcer of Stomach.-While the possibility of gastric ulcer terminating in carcinoma has always been admitted since Cruvielheir's classical work in 1839, it is only recently that such a change is believed, and now only by a few, to be frequent. Opinions have yet to be crystalized upon this point. Zenker thinks that practically all cancers originate in ulcers, whereas his pupil Hauser estimates that only six per cent of all carcinomata have their origin in gastric ulcers. Mayo Robson performed gastro-enterostomy for cancer 64 times and in 38 (59.3 per cent) there was a "long history of painful dyspepsia suggesting the possibility of ulcer preceding the onset of the malignant disease." Of 157 cases of gastric carcinomata oper

ated upon by Wm. J. and Chas. H. Mayo, 60 per cent gave a good history of previous ulcer, and almost exactly the same number as shown by Robson's experience. The opinions of such experienced clinicians and practical surgeons are far more weighty, because they are reinforced and confirmed by direct exploration, than the more theoretical opinions or even observations made at autopsy. I called attention to this point in the address on Surgery given before the American Medical Association at Atlantic City in 1900. Subsequent experience has taught me that a greater number of ulcers than I then supposed undergo malignant transformation.

The topography of ulcer and cancer is the same, and there is no room to doubt that many of the latter have their inception in the former. This is one of the strongest possible reasons for the surgical treatment of all chronic or rebellious ulcers, preferably by excision of the ulcer, or, if multiple, of the ulcer-bearing area, pylorectomy. Gastro-enterostomy, satisfactory as it is for a time, does not remove the lesion, and therefore prevent malignant change. I have never doubted that it must, in such cases, either give way to or supplement radical procedures.

The frequency of cancer of the cecum, and the fact, now pretty well established, that many begin in the appendix, is an additional reason for removal of the organ where it has suffered repeated attacks of inflammation. I have operated twice in elderly men during the past six months. for advanced cancer of the cecum, and the evidence was positive in one case, and next to it in the other, that the malignant disease had its inception in the appendix. That cancer frequently originates in the inflammatory and cicatricial tissues about the caput coli, resulting from previous appendiceal attacks, I have not the slightest doubt.

So this already fertile surgical region has within the year become of even greater interest on account of the fact that tubercular peritonitis often has its beginning in a tubercular lession of the appendix, as demonstrated by Mayo, and the further probability that carcinoma not less frequently has its inception in a neglected chronic inflammation of this viscus.

It will be seen later on that no one believes more than I in early-as early as possible-and complete operation in malignant disease, but I

do not go so far as to advise operation in many of the so-called precancerous states. It is first necessary to show that a precancerous state exists, and then our duty becomes reasonably clear. I would not operate upon a leukoplacia of the tongue or lips because such condition has been supposed to invite epitheliomatous change. I have seen hundreds of epitheliomas about the mouth, and I have no trustworthy evidence that any, if preceded, resulted from leukoplacia. I certainly would not operate upon a case of Paget's disease in a young woman of child-bearing age on account of any tendency, per se, for it to be followed by cancer. I would operate upon a chronic ulcer of the stomach, preferably excising it, for here the evidence is more convincing. Further: Aside from the danger of cancer there are even greater hazards, such as perforation, stricture, resulting in dilatation, hour-glass stomach,

etc.

We have been told that it is also best to operate in the pre-perforative stage of typhoid fever. Most of us, I fancy, find it difficult enough to make a diagnosis when perforation has actually occurred. If in doubt, we should perform an exploratory operation, and the same rule should obtain in suspected cancer, for the danger of delay is immeasurably greater.

With these preliminary, and I trust germane, remarks, we approach our subject, "Mammary Carcinoma."

Diagnosis. He who advises a woman with a tumor of her breast, especially a woman past forty, to wait and see if it be malignant, is guilty of an unwarrantable and, therefore, censurable act. If he cannot make a diagnosis there are others who can in nearly every case, and in all cases by a perfectly casy, safe, and quick exploration. Let the public be educated, as they will be in time, to believe that an early diagnosis and prompt operation are both as necessary—I will go further-are more necessary in cancer than in appendicitis, for the latter may recover, and frequently does, without an operation, while the former without surgical intervention, inevitably leads to one of the most painful, lingering, and loathsome of deaths, anxiously awaited and prayed for many times, by sufferer and loved. ones, before it comes.

We are just beginning in America to see an awakening on the part of laymen to the hazards

of appendicitis, and nearly every enlightened person knows something of its symptoms, its dangers, and the conservatism of early operation. Though the surgeon be ever so assiduous and discreet in his efforts to shield the practitioner who has dilly-dallied with the case, as is so frequently done, the patient and his family hold the physician, not the surgeon, responsible for an adverse result. Physicians realize this, and, having become more astute diagnosticians in this affection, they advise early, and therefore safe, operation. There has been a most remarkable improvement in this respect in Philadelphia in the past few years. My own experience shows but three pus cases in forty-seven operations for appendicitis, most of them acute, since September 1, 1904. That all were successful is largely due to the fact that in most instances an early diagnosis was made. In this disease we are far ahead of the English and the Continentals. I was surprised to find, three years ago, that cases of appendicitis going to some of the very best English hospitals were sent to, and kept in, the medical wards until pus formed, when they were considered, for the first time, surgical cases, and transferred. Visiting the same hospitals last summer I had a similar experience. But while this is true the English are keen on the subject of cancer. They have studied it carefully, and, as a general thing, rank and file, they are more alive to the possibilities of surgery for its relief than others. I am satisfied that practitioners throughout Great Britain are more impressed with the importance of, and do make earlier diagnosis in, breast cancer than is the case with us. The late Sir Mitchell Banks, while I was his guest in Liverpool last July, assured me that there had been an enormous change in his practice in this respect in the preceding five years. I saw him do several operations, and all were early, and what we would call good operative, cases. In none was there an evident tumor to the eye, though distinctly so to the touch. Two had moderate axillary infection of the lower glands; one little, if any, glandular involvement at all. Remarking upon the favorableness of his cases he told me of the great change for the better which had come in recent years. We cannot say that this is true of only Liverpool and its environs where the great

influence and teaching of that forceful and charming man were most directly felt. Everywhere I went it was the same, and I now understand, better than I could before, the operative results of English surgeons.

Although the radical method of operating for breast cancer was introduced by Moore of the Middlesex Hospital, in London, in 1867, the English were slower than the Germans, Austrians, and Americans to give attention to the teachings of Moore, and to put them into practice. Banks, of Liverpool, was an early champion of Moore's operation, which consisted in a large incision, free removal of skin, sacrificing the entire gland in every case, and a free axillary dissection. The muscles were not disturbed, not even the fascia covering the pectoralis major. This step was introduced by Volkmann a few years later. The English were particularly sensitive about the most important step of the operation, a free axillary dissection and removal of all diseased glands and fat. They both overrated its danger and underrated its necessity. Notwithstanding the fact that they were slow to put into practice the teachings of Moore, Banks, Volkmann, Gross, Meyer, and Halsted, their ultimate results were as good as those of the surgeons of other countries. This can be explained only in one of two ways: First, incomplete operations are as satisfactory in their ultimate results, and yield as great a percentage of cures, as complete operations; secondly, their cases were operated earlier. Certainly no one believes the first proposition. At the present time, and it gives me pleasure to record it, as many, perhaps more, English surgeons are doing a more thorough operation, usually Halsted's method, than is the case with us.

In addition to the usual signs and symptoms of cancer of the breast there are two methods by which a positive diagnosis can be made:

1. Aseptic incision into the tumor has been advocated and practiced. It is neither accurate nor safe, and many cases have been reported where infection of the adjacent tissues occurred through cells and juices thus liberated. It is unquestionably a dangerous practice unless followed by immediate operation.

2. It is much better to get the consent of the patient to a complete operation in all cases where

malignancy is suspected, provided both macroscopic and microscopic examination prove it to be necessary.

In the latter case a competent microscopist is asked to be present, and in ten minutes he can give a reliable opinion as to the nature of the growth. During the short period of waiting the wound should be plugged with gauze, the knife and instruments that have been used laid aside, and the hands of the operator again sterilized. It is best to send the entire tumor to the pathologist. If the report comes back benign nothing further is necessary beyond suturing the wound; if malignant a complete operation, preferably by Halsted's method, should at once be done. I have used this method for many years, have never known ill result from it, and by it, moreover, have, more than once, been saved the possible humiliation of removing needlessly a breast in young, child-bearing women. Twice have I been made to recognize cancer in two of the youngest subjects I have ever operated upon, 23 and 27 years of age, respectively, when it had hardly been suspected. One of the best disquisitions on this subject to which I have listened, or know of, was by one of your members, Prof. J. Clark Stewart, in his paper before the Surgical Section of the American Medical Association last June. I cannot understand why this practice is not a more general one. It is practicable, of course, only in a hospital. It is a little troublesome and tedious on account of arranging for and awaiting the pathologist's report. There is, moreover, I admit, the bare possibility of autoinfection where the surgeon is careless, leaving an open wound and failing to re-sterilize instruments and hands. But these objections are as nothing, mere trifles as light as air, in comparison to the weighty reasons for an absolutely safe diagnosis that it may be followed immediately by a complete operation. If we limit the exploration to aseptic incision, closing the wound and waiting indefinitely to remove the breast, if malignant, then the objections that have been made are quite to the point. Such practice cannot be too pointedly condemned. Aside from its immediate dangers it encourages procrastination, and this, in mammary growths, is always hazardous. But removal of the entire growth with capsule, if there be one, and, in

[blocks in formation]

patent,

2. The age of its host materially influences the rapidity of a mammary cancer. In the young, lymphatic vessels are numerous and whereas in the old many have atrophied. Therefore metastases occur quickly in the young, often before they are suspected, which fact should prevent procrastination and encourage complete removal. For a better understanding of the lymphbearing vessels of the breast in the young and old, relatively, we are mainly indebted to Chas. H. Mayo, Poirier, and Cuneo.

3. When carcinoma involves either of the sternal quadrants or the inner hemisphere of the gland, other things being equal, the prognosis. is worse than it is in growths situated in the outer hemisphere or axillary quadrants. This is due, of course, to the danger of mediastinal infection. I must here insist, as I have done on former occasions, that malignant growths are more frequently thus situated than is generally believed.

Treatment.-It is easier to understand than to excuse the pessimism still too frequently expressed by surgeons, as well as by physicians, as to the curability of cancer by operation. Some, fully abreast with the times in other respects, are far behind in this one. Internists cannot be blamed for their lack of faith when surgeons frequently, and teachers occasionally, express doubts as to the beneficient results of a timely operation. There are some doing abdominal

« PreviousContinue »