have known of the number of cures even now accomplished in the treatment of cancer in its later stages. Fewer have known of the tremendous possibilities of increasing the number of cures when cancer is recognized and properly treated in its earliest stages. The evidence available seems to prove that the control of cancer is simply a problem of education of the people, of the family physician and of the surgeon. Millions have been freely given and expended for the investigation of the cause of cancer. Little if any money has been given to investigate the clinical facts in regard to this disease. The evidence of the number of cures of cancer which have been accomplished by surgery has been obtained by different surgeons and different clinics working independently throughout the world. It is the evidence of this clinical experience that allows the new American Association for the Control of Cancer to start its propaganda of education and give its message of assurance to the people. The American Society for the Control of Cancer will use every effort to give to the public only the ascertained truth. It will use every effort to accumulate more clinical evidence for the benefit of the family physician and the surgeon, so that when the educated people call upon the enlightened family physician for help, in a condition which might be cancer in its earliest stages, the surgeon will be prepared to make the diagnosis and institute the appropriate treatment. The American Association for the Control of Cancer will be unable to accomplish its propaganda of education without the aid of the public press throughout this country. This association needs the help of the great English writers to put in simple and clear English, the message to the people. Those who control the press must understand and feel the great responsibilities of this educational propaganda. They must assure themselves that these messages are authoritative and represent the consensus of opinion of the best of the medical profession of this country. They must discourage the publication of untruthful or misleading articles. They must try to avoid sensational articles or any publication which may tend to advertise individuals or institutions. The publications to be given the public through the press by the American Association for the Control of Cancer represent no single individual or institution; but a uniformity of opinion based upon available evidence from many individuals and institutions who in the past and at present have been and are treating cancer, and who have kept the evidence and have ascertained the ultimate results. It is for those who can afford to help, to judge whether such a movement along these lines justifies financial aid. The work cannot be done without money and labor which cannot be purchased with money. In June, 1913, before the surgical section of the American Medical Association I again presented the paper which I delivered before your society with the title: "The Added Responsibility of the Surgeon When Called Upon to Treat Surgical Lesions in Their Earlier Stages. This will be published in abstract in the Journal of the American Medical Association and in full in the Annals of Surgery. On June 17th, 1913, an invitation from the Lehigh Valley Medical Society furnished further opportunity to present to the profession the problems in the control of cancer. This paper will be published shortly in the Journal of the American Medical Association. At the next meeting of the Clinical Congress of the Surgeons of North America in Chicago an entire evening will be devoted to the problems of cancer from the standpoint of not only the education of the public, but also of the education of the profession. sion. The Southern Medical Association and the Southern Surgical and Gynecological Association are already preparing for a symposium on these problems at their coming meetings. This shows that the medical profession is in earnest about the propaganda of education on cancer. The two following editorials will give you good idea of how the lay press has gotten hold of the question: THE CONTROL OF CANCER. H. L. Mencken in the Baltimore Evening Sun of The American Society for the Control of Cancer, in which several Baltimore surgeons are conspicuous, has a long and perhaps exciting campaign ahead of it, for it will find the public full of disheartening ignorance and the quacks extremely game, but if its members hold together and proceed with a proper mingling of enterprise and caution they will probably live to see results. Such things always move slowly-it took nearly twenty years to get the tuberculosis campaign under way-but once any definite progress is made, its fruits are permanent. The fact that the American people are swindled by a vast horde of cancer quacks is due less to their inherent credulity than to the traditional secretiveness of medical men. In the absence of good teaching they listen to bad teaching. The quack is always positive and eloquent. He never conditions his promises with ifs and buts; he is never in any doubt as to what he can do. In the past the surgeons have offered nothing but possibilities against his certainties. They have groped, in fact, in the dark, and have honestly admitted that groping. But now, at last, a measure of assurance begins to appear in them. Improvements in their art have All that given them definite and striking successes. is needed to wean the public away from superstition and quackery, is to make those successes knownto present the figures and proof. Fortunately enough, this progress in surgery has been simultaneous with a breaking down of the old and evil reticence of the medical profession. Such reticence, of course, has its uses in the days of blind floundering; it was a necessary mask to ignorance and hocus-pocus. But today the scientific physician has very little to conceal. He has made so much progress in a score of fields that he can afford to make a frank admission of his failure in other fields. The result must inevitably be a growth of confidence between the physician and patient. The public begins to trust the educated doctor, and the doctor begins to trust the public. And on both sides that confidence is well grounded. The last stand of the quacks-whether they be patent medicine medicine sellers, mental healers, bone-setters or what not-is against surgery. They still play upon the average man's reluctance to yield up his blood. They scare the credulous with fabulous tales of butchery. But that old fear, it must be plain, is fast dying out, even in the United States. Twenty years ago, or even ten years ago, it took a lot of rhetoric to convince the average appendicitis patient that laparotomy was not necessarily fatal. He went to a hospital, if he went at all, with a sense of doom hanging over him. But today he goes without any question, and his new courage has its reward. The death rate in appendicitis, once very high, is now almost neglible. In exactly the same way the death rate in cancer might be reduced if only the public could be induced to submit to radical surgery at the start, and not wait for something to happen. That something that happens is always the same thing: it is certain and painful death. But taken in time, the great majority of cancers may be safely and surely eliminated. The operation is neither painful nor dangerous, and ordinarily it leaves no serious disfigurement or crippling. But its success depends wholly upon its promptness. Every minute's delay, for consideration and the bolstering up of courage, decreases the chances of recovery. In the first stages of some of the commonest cancers, the percentage of recoveries is nearly 100; in the later stages it drops to next to nothing. The Society for the Control of Cancer is now engaged in preparing hospital records of the last decade or so for publication. When they are given to the public they will show, in very graphic and striking form, the dangers of delay, and by the same token they will show the marvelous efficiency of prompt and intelligent surgery. Here at the Johns Hopkins and at other hospitals there have been thousands of operations for cancer during the last ten years. The lesson they teach is always the same. The persons who submitted to the knife at the first sign of malignant tumor are alive and in good health today; nine-tenths of those who tried salves aud other such quackeries first are dead. The chief danger lies, of course, in a belated diagnosis, and that danger is one which the layman can do more to avoid than the physician. Too many persons put off consulting a doctor until the cancerous ulcer, perhaps harmless at the start, has got beyond bounds. And too many of them, after they have gone to him at last, combat his recommendation of an immediate operation. The result is that the surgeons get their patients too late. The do their best with the means available, and they bear the odium of the death rate-but that doesn't help the victims. Given a fair chance, they would do in all cases what they now do so magnificently in a few cases. As for the allegation, sure to be made by the rogues and vagabonds of medicine, that the surgeons undertake this campaign for their own profit, it is scarcely worth serious answer. If you have cancer, dear heart, you may be sure they will get you soon or late. After you have been tortured by caustics for a dreadful space, you will land upon the operating table at last, and the fee you pay will not be the less because the labor you demand is the more. No; the surgeons will not be in pocket by this campaign. All they will get out of it will be the satisfaction of doing better work, and of saving more human lives. LIFE OR DEATH? Samuel Hopkins Adams in Collier's Weekly, Cancer is the most justly dreaded of diseases. Strangely enough, in spite of its alarming increase and the universal terror which it inspires, less purposeful consideration has hitherto been given to it than to any other important problem of public health. The general ignorance of the subject is appalling when one considers that out of every ten middle-aged Americans one dies by its slow and agonizing doom; doubly appalling in the light of the known fact that a large proportion of the victims could be saved, either by preventive or curative measures, if they but knew how. The American Society for the Control of Cancer has recently been organized by a number of public-spirited men and women, with the main purpose of popular education on this vital topic. The public is to be taught three fundamental truths: First, that cancer is in the majority of cases curable if taken in the early stages; second, that, quacks and mistaken enthusiasts to the contrary notwithstanding, the knife is the only known cure; and, as a corollary to these two propositions, third, that prompt diagnosis and immediate recourse to a skillful surgeon on the first suspicion of cancer means a highly probable saving of life, whereas neglect means inevitable death. For the laborious work of investigation and tabulation, of circulating educational matter and of general propaganda, the society needs funds. Checks may be sent to Howard Bayne, treasurer, 60 Broadway, New York City. No other movement for the public weal deserves more hearty support. In this cause your dollar may mean the difference between life and death to sufferers of whom you have never even heard. In continuing this propaganda, what we need most are facts based upon the investigation of the ultimate results of the various types of tumors subjected to treatment in which the diagnosis is confirmed by a pathological examination of the specimen removed. We should have this evidence from as many of the larger clinics in this country as possible. The larger the material the more quickly will we be able to come to correct conclusions as to the best methods of diagnosis in the early stages of the dis ease and the method of treatment which will offer the patient the best chance of an ultimate cure. In view of the large material which has accumulated in the Surgical Pathological Laboratory of the Johns Hopkins Hospital and University since 1892, I became impressed with the importance of ascertaining the ultimate result in all cases. With this in mind I organized a staff of volunteer medical students, recent graduates and stenographers who began to work on June 1st, 1913. The cost of this investigation will be about $1,200, and this money has been given by generous friends. I trust this investigation will be complete by October 1st. Every case of tumor of which we have a record in the pathological laboratory is being investigated as to the ultimate result, whether the tumor was benign or malignant, whether the patient was treated in the Johns Hopkins Hospital or elsewhere. We are also ascertaining the results in other groups of cases which may have some relation to malignant disease. For exam ple: Every case operated on for acute or chronic cholecystitis with or without stones in the gall-bladder will be traced to ascertain how many developed cancer of the gall-bladder. This investigation will furnish us with useful data for the early recognition of cancer of the gall-bladder and of conditions of the gall-bladder which may later lead to the development of cancer, as well as with more definite indications for cholecystectomy. All the cases of jaundice with stone in the common duct will be traced for the later development of cancer in the diverticulum of Vater or head of the pancreas. There is an opportunity for the accomplishment of cures of cancer in the diverticulum of Vater or the head of the pancreas through earlier intervention based upon positive diagnosis. Resection of the head of the pancreas with the duodenum and lower end of the common bile duct is a feasible and justifiable operation for the malignant disease, but in the stage when the opportunity for the cure of cancer is best, the differential diagnosis is most difficult, and this radical resection, of course, is unnecessary for the cure of non-malignant obstruction. The investigation of the ultimate results of gastroenterostomy and of Finney's pyloroplasty for lesions of the stomach diagnosed benign, will be of the greatest interest and importance to determine how frequently malignant operable lesions have been treated in this conservative way on the diagnosis of benign lesions. The investigation of the ultimate results of all cases of appendectomy combined with the pathological study of the removed appendix will place on a more certain basis the possibilities of cancer of the appendix, especially at its base near the cecum. There are many other groups of cases which will bear investigation of the late results in relation to the problem of malignant disease. This investigation will depend in the first place upon the accuracy and complete ness of the original clinical records, and on the confirmation of the diagnosis by pathological study in every case. It adds to the reliability of the diagnosis to have preserved the original tissues or sections for re-examination and re-diagnosis. A recorded pathological diagnosis, especially one made many years ago is by no means as convincing as a recent study of new sections of the preserved material, because, without doubt, our abilities of making a histologic diagnosis are improving, especially in borderline pathologic lesions and the earlier stages of cancer. One can see how easily the per cent of cures of cancer can be increased by mistaken microscopic diagnosis. This is especially true in tumors of the breast, where complete operations have been performed for benign lesions and which have been recorded as cured of cancer. Unfortunately, in this country the number of hospitals and clinics which have such complete records is small, and even among these the ultimate result rarely forms part of the record. Of course, we cannot remake these incomplete records in all instances, nor can we use them for the investigation of the problems of cancer. We must be content to work at the present time with the records of those hospitals and clinics which have kept them complete and reliable, but we can stimulate other hospitals, clinics, and surgeons in their private practice to make clinical records, to have their material stuided pathologically and to keep this material properly labeled for future refer ence. I am convinced that it is due to the incompleteness of our clinical records and to the inaccuracy or absence of pathological investigation, that there is such a difference of opinion in regard to the best method of diagnosis and treatment for cancer in its different stages and different localizations. It is to be remembered that in the past surgeons have been called upon to treat cancer in its fully developed stage-a stage in which the diagnosis can be made clinically without the aid of a frozen section, and in which, with the rarest exceptions, the microscopic study confirms the clinical diagnosis. We have sufficient evidence to show that cancer in this stage has been cured, but the relative number of such cures is small. Here also the results after the complete and after the incomplete operation manifest themselves distinctly. In 1890 Agnew, professor of Surgery at the University of Pennsylvania, made the statement before his clinic that he had never accomplished a cure in cancer of the breast. Agnew never operated for a lump in the breast until it was clinically malignant, that is, associated with adherent or ulcerated skin and retracted nipple, and his operation consisted only of the removal of the breast. He did not even remove the fascia of the major pectoral muscle. When I came to Baltimore in 1892 Dr. Halsted was performing his complete operation for cancer of the breast. This operation consisted of the removal of the breast with a wide zone of skin, more subcutaneous fat, both pectoral muscles and the axillary contents in one piece. The wound was left open to heal by granulation. Later the open wound was covered with skin-grafts. When Dr. Halsted first published his results (Annals of Surgery, November, 1904, vol. xx, p. 497) the per cent of cures three years and more after operation was over forty. These figures demonstrate the difference between the results after incomplete and after complete operations for cancer of the breast. The permanent results after Dr. Halsted's operation for cancer of the breast have been again ascertained every three to five years since 1904. At the last investigation in 1908 the per cent of cures three years after operation was 42, and five years after operation 35. When, however, we study these cases in relation to the duration of the disease at the time of the operation, we find the following very significant facts: When the operation was performed for a lump in the breast clinically benign or doubtful, that is, cases in which the only sign of a breast lesion was a lump, the per cent of cures for five years has been over 80. It is important to note that in this group the diagnosis was made at the exploratory incision and the complete operation followed immediately. Of course the cases were all primary. That is, we may state from this experience that the complete operation for a malignant tumor of the breast, if performed early and radically, before clinical signs of cancer have developed, offers a probability of cure in at least 80 per cent of the cases. In all of these cases still earlier intervention had been possible. What the probability of a cure will be when such operations are performed within a few days after the first appearance of the lump, we do not know, but may in all fairness surmise that they will be better. When, however, the clinical signs of cancer were present so that the radical operation could be performed without the exploratory incision, the per cent of cures after five years dropped to 24. Comparing, therefore, Halsted's results with Agnew's, that is operation for cancer of the breast when the diagnosis could be made clinically, the figures are 25 per cent of cures after the complete Halsted operation, and none after Agnew's incompleteexcision of the breast only. What can be more impressive than this difference between the probability of a cure after a complete and an incomplete operation for the fully developed cancer of the breast on the one hand, and the increased probability of a cure after the complete operation properly performed in the earlier stages of cancer of the breast, on the other? What are the dangers of an incomplete operation for a cure of cancer of the breast in the early stage of the disease? The evidence I have at my disposal is as follows: First, in 54 cancer cases of which I have record in the surgical pathological laboratory the lump in the breast was clinically benign, but in the majority of cases the complete operation was performed immediately after an exploratory incision at which the correct diagnosis was made. In a few the operator preferred to perform the complete operation even in the doubtful case without an exploratory incision. The results are 80 per cent of cure after five years. The number of cases in which the complete operation was performed without the exploratory incision in this group is too small to admit definite deductions as to the danger of such an exploratory incision. I will discuss later why such an exploratory incision must be made in clinically doubtful cases. To compare with these results in 54 cases with 80 per cent of cures over five years after operation, I have records of 45 in which the operation was done in two stages: In 20 cases the lump only was first removed and then, some days or weeks later, after a microscopic study, the complete operation for cancer was performed; in 15 cases the breast only was removed at the first operation and then, later. in some, but not in all, the complete operation followed. It is only just to Dr. Halsted's clinic to state that of these 45 incomplete operations, only three were performed in his clinic, the remaining 42 cases were received from outside sources and were not operated on by Dr. Halsted or his associ ates. Of the 20 cases in which the tumor only was removed I have not a single record of a permanent cure over five years. One patient lived four years and then developed local recurrence. Of the 15 cases in which the breast only was removed at the primary operation, only two patients are living and free from recurrence five years after operation. In both of these cases the type of cancer was the least malignant variety of adenocarcinoma. In one the breast only was removed, the patient refusing further operative treatment. In the other the complete operation followed, but the glands showed no metastasis. These figures, therefore, show that in 45 cases of early cancer of the breast in which the probability of a cure, if the complete excision had been done at the primary operation would have been 80 per cent, there were but two cures, less than 5 per cent. It seeems to me that this illustrates the great danger of incomplete operation in the early stage of cancer of the breast and the added responsibility of the surgeon when called upon to treat a lump in the breast in its early stage. It also proves that, from a clinical and pathological investigation, the number of cures of cancer of the breast will be greatly increased by the proper complete excision in the earliest stage of canThese figures also show the difficulty of diagnosis in the early stage of cancer of the breast. cer. When the statistical data of the results in lesions of the breast shall have been completed to 1913, I hope to be able to publish the results based on a larger number of cases over an additional period of five years. The same statements can be made in regard to cancer in every localization. When women are educated to seek advice the moment they observe a lump in the breast, surgeons will be confronted with this difficulty in diagnosis in an increasing number of cases. If surgeons make the mistake of operating a malignant lump in the breast in two stages, it is quite possible that the per cent of cures of cancer of the breast will be decreased rather than increased. This, therefore, is the chief theme of this paper-to warn you of the dangers, to impress you with the increased responsibility, to call your attention to the difficulties of diagnosis, and to urge you to prepare yourselves for this additional burden, because undoubtedly this propaganda will bring patients to you in a period of the disease most favorable for a permanent cure, but most difficult for diagnosis. In regard to the relation between benign and malignant tumors of the breast, the figures available from the Surgical Pathological Laboratory are as follows: Malignant tumors 769 cases; benign tumors 542 cases; total 1,311 cases. Of the 769 malignant tumors of the breast in 99 cases the lump was clinically benign or doubtfulabout 11 per cent. With the propaganda of education this must undoubtedly increase. In Dr. Halsted's clinic a mistaken diagnosis has been made in 3 out of 57 cases -about 5 per cent. That is, in 3 instances the lump of the breast was first removed, and the malignancy recognized only later, after a complete microscopic study. This mistake has not been repeated since 1900thirteen years ago. What is possible, therefore, in one clinic should be possible in every other clinic. How often this mis take is made in other clinics and by other surgeons, I do not know, but I have records of at least 43 such cases in a period of twenty years in which specimens-either the tumor or the breast-have been sent to the laboratory for diagnosis. Among 407 benign tumors of the breast in only 95 was the age of the patient at the first appearance of the lump twenty-five years or less. As we have never observed cancer of the breast in patients younger than 28, we may state with a large degree of certainty, that the age of the patient in 95 cases indicated that the lesion was benign. In the remaining cases-over 300the age of the onset of the disease would not allow a differential diagnosis. The duration of the lump is helpful in the differential diagnosis when it has been present two years or more, because in the great majority of instances of cancer the clinical signs of malignancy develop before two years, but as a matter of fact, patients with benign lumps are more apt to seek advice earlier than patients with malignant lumps, because with the benign tumor pain and discomfort are observed in the early stages much more frequently than in the malignant. From our records, among 407 benign lesions, in about 100 the lumps had been present two years or more. However, when we have educated women to seek advice early after the first observation of a lump, we will no longer be aided by the long duration of the disease in the differential diagnosis. There will remain only one clinical fact of any value, and that will be the age of the patient when she is 25 years or younger. The object, therefore, of exploring a lump in the breast in a woman over 25, is not so much to remove the possible benign lesion, as to get the possible malignant lesion in the stage most favorable for a permanent cure, and the diagnosis must be made at this exploratory incision with or without the help of the frozen section. Every woman with a lump in the breast should be prepared for the complete operation, and this should be performed by a surgeon capable of making the diagnosis at the exploration. If the surgeon has any doubt as to the nature of the lump after exploration, the complete operation for cancer should be done. The only objection to this is the added mutilation, but that is little compared with the risk incurred from an incomplete operation for a malignant tumor. Surgeons should feel no chagrin at making such a mistake. Among 542 examples of benign lesions of the breast my figures show that in 54 the complete opera |
