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J — ^ 
 
 What We Know About Cancer 
 
 A Handbook for the Medical Profession 
 
 Prepared by a Committee of the 
 American Society for the Control of Cancer 
 
 and Published Jointly by the 
 
 American Society for the Control of Cancer 
 
 and the 
 
 Council on Health and Public Instruction of the 
 American Medical Association 
 
 FROM THE 
 
 STATE INSTITUTE FOR THE STUDY OF 
 
 MALIGNANT DISEASE 
 
 BUFFALO, N. Y. 
 
What We Know About Cancer 
 
 A Handbook for the Medical Profession 
 
 Prepared by a Committee of the 
 American Society for the Control of Cancer 
 
 and Published Jointly by the 
 
 American Society for the Control of Cancer 
 
 and the 
 
 Council on Health and Public Instruction of the 
 
 American Medical Association 
 
 American Medical Association 
 
 Five Hundred and Thirty-Five North Dearborn Street 
 
 CHICAGO 
 
Am 3 23 
 
CONTENTS 
 
 Foreword 5 
 
 I. General Considerations 7 
 
 Publicity and Education 7 
 
 Responsibility of Physicians 8 
 
 Statistics 8 
 
 Experimental Work 9 
 
 Improved Operative Technique 10 
 
 Radium. Roentgen Rays. Cautery 11 
 
 Serum Treatment 13 
 
 "Cancer Cures" 13 
 
 II. Early Diagnosis and Treatment 14 
 
 Exploratory Operation 15 
 
 Biopsy 15 
 
 Early Operation Offers the Best Prospect 
 
 of Cure 16 
 
 Conditions Essential to Early Operation . . 16 
 
 The Patient 16 
 
 The Physician 17 
 
 Examination 17 
 
 Diagnosis 18 
 
 ' Consent of Patient to Operation 18 
 
 III. "Precancerous Conditions" 20 
 
 ( 1) Moles 20 
 
 ( 2) Keratoses 21 
 
 (3) Fissures and Chronic Ulcers 21 
 
 ( 4) Gallstones : 21 
 
 (5) Gastric Ulcer 21 
 
 ( 6) Lacerations of the Cervix 21 
 
 ( 7) Cystitis 22 
 
 ( 8) Leukoplakia 22 
 
 ( 9) Kraurosis Vulvae 22 
 
 (10) Involution of Breast and Prostate. . 22 
 
 (11) Benign Tumors 22 
 
 IV. Carcinoma of Different Organs 24 
 
 ( 1) External Skin 24 
 
 ( 2) Lip 25 
 
4 
 
 PAGE 
 
 (3) Tongue, Mouth, Jaws 26 
 
 ( 4) Larynx 28 
 
 ( 5) Thyroid 29 
 
 ( 6) Esophagus 29 
 
 ( 7) Stomach 30 
 
 ( 8) Colon 31 
 
 ( 9) Pancreas, Gallbladder, Liver 32 
 
 ( 10) Rectum 33 
 
 (11) Bladder, Prostate 34 
 
 ( 12) Uterus : Cervix, Body 35 
 
 (13) Ovary 37 
 
 (14) Breast 38 
 
 (15) Penis 40 
 
 (16) Vulva 40 
 
 V. Sarcoma 42 
 
 ( 1) Bones 42 
 
 ( 2) Fasciae 43 
 
 ( 3) Skin— Soft Parts 43 
 
 ( 4) Lymphosarcoma 44 
 
 (5) Melanosarcoma . . » 45 
 
 VI. Other Malignant Tumors 47 
 
 ( 1) Myeloma 47 
 
 ( 2) Endothelioma 47 
 
 ( 3) Glioma 48 
 
 ( 4) Hypernephroma 49 
 
 ( 5 ) Neurocytoma 49 
 
 ( 6) Adamantinoma 50 
 
 ( 7) Chorio-epithelioma 50 
 
 ( 8) Teratomata and Mixed Tumors... 51 
 
 VII. Treatment of Inoperable or Recurrent 
 
 Cancer 53 
 
FOREWORD 
 
 In February, 1917, by vote of the National Council 
 of the American Society for the Control of Cancer, a 
 committee was appointed to prepare the manuscript of 
 a Handbook on Cancer for circulation among the 
 members of the medical profession of the United 
 States. This was done as a part of the campaign the 
 Society inaugurated for the collection and dissemina- 
 tion of facts in regard to cancer, to the end that its 
 mortality might be reduced by a wider knowledge of 
 the disease. The first manuscript was submitted to the 
 Council of the Society at a meeting in April, 1917. The 
 manuscript was then sent to a number of different 
 members of the Council for the critical review of 
 special sections of the pamphlet. The criticisms and 
 suggestions thus obtained were utilized in a subsequent 
 revision of the manuscript, which was submitted to the 
 Council at a meeting held on Oct. 26, 1918, and with 
 certain changes, accepted and ordered published with 
 the endorsement of the Council and in the name of the 
 Society. 
 
 The Handbook is designed to provide in a brief and 
 readily accessible form the important facts about can- 
 cer in general, and its manifestations in the different 
 situations where it most commonly occurs. The critical 
 and controversial review of published statistics as to 
 the end-results of operative treatment could not be 
 included without enlarging greatly the size and scope 
 of the publication. It was decided, therefore, to pre- 
 sent only in general terms the expectation of success 
 attending the radical operative treatment of cancer in 
 each of its different situations. It is believed that in 
 these statements, as in other respects, a conservative 
 view has been taken of the situation, and that the state- 
 ments made can be thoroughly substantiated by the 
 published experience of the foremost surgeons of the 
 country. 
 
 Robert B. Greenough, M.D., 
 
 Chairman, Boston, Mass. 
 
 James Ewing, M.D., 
 
 New York, N. Y. 
 
 Jonathan M. Wainwright, M.D., 
 Scranton, Pa. 
 Committee on Publication of Handbook on Cancer. 
 Oct. 24, 1918. 
 
I 
 
 GENERAL CONSIDERATIONS 
 
 PUBLICITY AND EDUCATION 
 
 As a result of the campaign which has been con- 
 ducted by the American Society for the Control of 
 Cancer for the education and enlightenment of the 
 lay public on the subject of cancer, a greater and more 
 accurate knowledge of this disease is already evident, 
 and many fallacious ideas have been corrected. This 
 has been the primary and most necessary step in the 
 campaign to reduce the very great, and often unneces- 
 sary, mortality of this disease, for until the patient of 
 his own accord seeks medical advice no steps can, of 
 course, be taken toward making a diagnosis or apply- 
 ing the proper treatment. Much yet remains, to be 
 done in the way of education of the public, not only 
 in the more remote rural districts but in the towns 
 and cities as well, and it must be done wisely and tem- 
 perately, and without producing so great a fear of the 
 disease as to alarm people unnecessarily. It is the 
 knowledge that the disease can be cured by radical 
 treatment in its earliest stages that must be dissem- 
 inated. Many laymen, and some physicians, find it 
 hard to believe this fact. Cancer is not a disease that 
 runs its course, like pneumonia or typhoid ; it is an 
 actual entity — as much a part of the individual as his 
 finger or his nose, and it is either still a part of him 
 and growing to a fatal termination or it must be 
 removed entirely in order that he may be cured. The 
 layman knows of the many cases that are not cured, 
 whether an attempt at cure by operation has been made 
 or not, but he rarely knows of the cured cases, for the 
 reason that the individual who has been relieved of the 
 disease by operation goes about his or her business as 
 well as ever, and disguises, so far as possible, the loss 
 of the organ or the scar of the operation by which life 
 has been saved. It is difficult to controvert this per- 
 sonal experience of the individual by assertions of the 
 possibilities or probabilities of cure by operation, but 
 it must be done if the public is to understand the actual 
 facts of the cancer problem. Every physician should 
 
8 
 
 feel it his duty to make these facts clear to the laymen 
 within his reach. The physician of the present day 
 must do far more than care for the cases of disease 
 that call for his help. He is the health officer of his 
 own clientele, and they look to him for knowledge to 
 protect them from disease. The instruction which has 
 been given to the public is already bearing fruit, and 
 from many communities comes the report that patients 
 now present themselves to their physicians much 
 earlier than in the past with symptoms that they con- 
 sider suggestive of cancer. Under these circumstances 
 it behooves us to consider, as members 'of the medical 
 profession, the obligations which rest upon us as the 
 nearest and the first sought source of scientific knowl- 
 edge, to give to our patients that wise counsel which 
 they have a right to expect. 
 
 RESPONSIBILITY OF PHYSICIANS 
 
 It is a well known fact that a considerable proportion 
 of malignant tumors are not recognized by the doctor 
 when the patient presents the indefinite early symptoms 
 of the disease. Optimism too often replaces a careful 
 physical examination. The great majority of cancers 
 of the rectum are today treated as hemorrhoids for 
 from one to six months. Uterine discharges are often 
 not properly investigated, and curettings are not exam- 
 ined. Cancer of the tongue and mouth is permitted to 
 advance because there is a positive Wassermann. 
 Metastases are produced by repeated rough examina- 
 tions. Malignant moles and epitheliomas of the skin 
 are imperfectly removed. Clearly inoperable cases are 
 operated on, thus bringing operation into disrepute. 
 
 These conditions call for a far keener appreciation 
 of responsibility for the mortality from cancer than 
 now generally exists in the medical profession. To 
 collect and to make accessible to the physicians of this 
 country the most fundamental and essential facts about 
 cancer of the different organs and regions of the body 
 is the object of this pamphlet. 
 
 STATISTICS 
 
 Complete returns of cancer mortality are available 
 only for the registration area of the United States, 
 which, however, includes approximately 70 per cent, 
 of the total population. On the basis of this informa- 
 
tion it is conservatively estimated that the mortality 
 from cancer in the entire continental United States at 
 the present time (1918) is approximately 90,000 per 
 annum. According to sex, the mortality, by principal 
 organs or parts affected, based on the figures for 1914, 
 is as follows : 
 
 ESTIMATED ANNUAL MORTALITY FROM CANCER 
 
 CONTINENTAL UNITED STATES, 
 
 1914-1915 
 
 Organs or Parts Males Females Total 
 
 Buccal cavity 2,725 • 570 3,295 
 
 Stomach and liver 15,787 15,056 30,843 
 
 Peritoneum, intestines, rectum 4,544 6,027 10,571 
 
 Female generative organs 11,965 11,965 
 
 Female breast 7,771 7,771 
 
 Skin 1,982 1,098 3,080 
 
 Others 7,838 4,637 12,475 
 
 All forms 32,876 47,124 80,000 
 
 The recorded mortality from cancer in this, as in 
 other countries of the world, is gradually on the 
 increase. The annual increase in the cancer death rate 
 is approximately 2% per cent. The recorded cancer 
 death rate has practically doubled during the last forty 
 years. 
 
 EXPERIMENTAL WORK 
 
 During the past ten years commissions and labora- 
 tories for cancer investigation have been established 
 in many places in the United States, as well as abroad. 
 In all of these centers research work has been carried 
 on on the tumors of animals as well as on human can- 
 cer. All of the resources of chemistry, physics, physi- 
 ology and biology, and the study of immunity reactions 
 have been brought to bear upon the problem, and the 
 work is still being carried on ; but, as yet, the ultimate 
 cause of cancer is not known. Many important facts, 
 however, have been discovered, and by every fact 
 contributed the growing structure of our knowledge 
 of the disease is built up until, for instance, we now 
 know many things that cancer is not, and useless 
 expenditure in investigation along those lines has 
 ceased. We know that cancer is not due, in the sense 
 that infectious diseases are due, to a parasite. We 
 know that cancer is not communicated from one person 
 to another, and that there is no danger of the nurse 
 contracting the disease in caring for the cancer patient. 
 We know that the influence of heredity in the incidence 
 
10 
 
 of the common forms of cancer in human beings is so 
 remote that the factor of inheritance may, as a rule, 
 be disregarded. We know that one form of cancel 
 after another has been brought in relation to some 
 form of chronic irritation, as a direct or indirect pre- 
 disposing influence, and that cancer of the cervix, the 
 lip, the tongue, the rectum, the stomach, and many of 
 the forms of malignant disease of the external skin — 
 Marjolin's ulcer, the Kangri cancer of Kashmir, the 
 paraffin worker's cancer, and the roentgen-ray worker's 
 cancer — are all closely associated in their inception 
 with one form or another of chronic and repeated irri- 
 tation. It has also been shown in the laboratory that 
 rough compression and manipulation of a tumor are 
 fully capable of setting its cells free to form metastases, 
 and from this we learn to use the utmost gentleness in 
 the palpation of a tumor for diagnosis, as well as to 
 avoid compression, dragging, and all unnecessary 
 trauma to cancer tissue during the operation for its 
 removal. All of these facts we owe to the laboratory 
 investigation of cancer, and we may reasonably hope 
 that the next decade will contribute as much, or more 
 information concerning this disease. 
 
 IMPROVED OPERATIVE TECHNIC 
 
 In the great surgical clinics the technical details of 
 the operative treatment of cancer of the different 
 organs are constantly under investigation with a view 
 to improvement and to greater effectiveness. For most 
 of the common sites of cancer the operative technic 
 of the so-called radical operation is practically stand- 
 ardized. The site of origin and the mode of dissem- 
 ination of cancer in the different organs is well known, 
 and each standard operation aims to remove the tissues 
 of origin and the tissues suspected of secondary 
 involvement, by a wide margin and without cutting 
 into cancer tissue or scattering it broadcast in the 
 wound. There are problems still to be solved along 
 these lines, especially in the simplification of the oper- 
 ation and in the reduction of the mortality and the 
 possible complications, as in cancer of the tongue or 
 cancer of the uterus. It is possible, however, to give 
 a fair and guarded estimate of the comparative mor- 
 tality, and of the prospect of success of the operative 
 
11 
 
 treatment of cancer in different organs. A successful 
 radical operation results in the cure of cancer. While 
 it is everywhere admitted that no fixed limit of time 
 exists at the expiration of which an individual patient 
 may be said with certainty to be "cured" of the dis- 
 ease, yet it is a fact that the ordinary three-year period 
 is sufficient for all practical purposes. While 
 undoubtedly late recurrence may take place after the 
 three-year period has elapsed in a small number of 
 cases, especially in certain forms of cancer such as 
 cancer of the breast and cancer of the stomach, in the 
 vast majority of cases recurrence comes within this 
 period, if at all ; and the radical operation may be con- 
 sidered practically, if not absolutely, certain of success 
 if no signs of disease have developed within three 
 years. 
 
 RADIUM, ROENTGEN RAY AND CAUTERY 
 
 Radium and Roentgen Ray. — The effects of roent- 
 gen rays and of the radiation of radium, and of other 
 radioactive substances on cancer tissue, have aroused 
 great interest and much experimental and clinical study 
 of their action has been made. In general, it may be 
 said that effects ranging all the way from retardation 
 of growth to actual destruction of tumor tissue can be 
 secured by radiation. Certain forms of cancer tissue 
 appear to show a greater susceptibility to the action 
 of these radiations than the normal tissues of the body ; 
 especially is this true in regard to lymphoma, lympho- 
 sarcoma, giant-cell sarcoma of bone, and mixed tumors 
 of the salivary glands. Cancer of the mucous mem- 
 branes which is accessible to the direct application of 
 radium radiation can often be destroyed by treatment. 
 When metastatic deposits of cancer are present in the 
 lymph nodes, however, by extension from the point of 
 origin in the mucous membranes, radium cannot be 
 counted on to destroy the disease, and a permanent 
 cure is not to be expected. For these reasons radium 
 is a safe method of treatment only for superficial can- 
 cer of the skin of the nonmetastasizing types, or for 
 other forms of surface cancer which have been in 
 existence so short a time that metastasis to the regional 
 lymph nodes cannot possibly have already taken place. 
 This period is at best an indefinite one; but we do 
 
12 
 
 know that in certain locations, such as the tongue or 
 lip, eariy metastasis is the rule, while in other situa- 
 tions this period may be more prolonged. It is for 
 these reasons that the proper treatment of established 
 cancer of the lip, tongue, breast and other organs 
 which are prone to cancer of the early metastasizing 
 type is considered by surgeons to be by radical opera- 
 tion, with removal of the regional lymph nodes. The 
 use of radium for treatment of local lesions of this 
 nature, unless accompanied by surgical removal of the 
 suspected lymph nodes, is inadequate, and is not justi- 
 fied by our present knowledge of the effects of radium 
 on cancer tissue. For superficial nonmetastasizing 
 cancer, however, and for many superficial skin lesions, 
 such as keratosis senilis, or papillomata, which have 
 a precancerous tendency, treatment by radium is to be 
 preferred to operation. In certain cases of extensive 
 nonmetastasizing cancer, also, the combination of oper- 
 ative treatment and subsequent radiation is a recog- 
 nized and valuable procedure, and in the treatment of 
 inoperable and incurable cancer roentgen rays and 
 radium offer a field of the greatest usefulness. Under 
 heavy radiation a bleeding, ulcerated, offensive surface 
 can often be cleaned up rapidly, even though the dis- 
 ease continues to infiltrate the tissues and the meta- 
 static deposits increase until the patient dies. There is 
 no question of the symptomatic relief and comfort 
 afforded to the patient by palliative treatment with 
 roentgen rays and radium. 
 
 Cautery. — A method of treatment of cancer which 
 has a certain number of advocates is that of cauteriza- 
 tion. For small, superficial lesions the actual cautery 
 has long been employed, with some success. When 
 the disease is entirely destroyed the method is satis- 
 factory, although the healing of the wound is pro- 
 longed and painful, and the scars produced are far 
 more unsightly than after operation. A special adapta- 
 tion of the cautery to uterine carcinoma has been advo- 
 cated in the use of low heat and prolonged treatment. 
 This method is still under trial, and it would be prema- 
 ture at this time to pass on its merits. Other fields, 
 however, are open to the use of the cautery in many 
 forms of cancer: First, its use is strongly urged by a 
 certain number of surgeons as the most effective 
 
13 
 
 method to seal the lymphatics immediately after exci- 
 sion of a portion of a tumor for frozen section diag- 
 nosis, and, second, the cautery may be employed for 
 the palliative treatment of inoperable, ulcerated and 
 bleeding tumors, often in association with radium or 
 the roentgen rays. For the primary radical treatment 
 of operable cases of carcinoma of the deeper tissues, 
 however, the use of the cautery must be condemned. 
 
 SERUM TREATMENT 
 
 There have been innumerable attempts to produce 
 a cure for cancer by drugs or tissue products, instead 
 of by the mechanical destruction or removal of the 
 tissue which is obtained by radioactive agents, cauter- 
 ization or surgical operation. Not one of these meth- 
 ods has withstood the critical test of time — the serum 
 of supposedly resistant or cured human cases ; the 
 serum of animals subjected to inoculations of human 
 cancer tissue; the injection of human cancer emulsions 
 as a vaccine, or of bacterial toxins. Each method has 
 been given fair scientific trial and has been found to 
 be of insufficient value to warrant its continued use. 
 
 "cancer cures" 
 
 Drugs of all kinds have been employed, both for 
 local administration by injection or as caustic pastes, 
 and for more general constitutional effect. In some 
 the active agent is known as creosote ; in others the 
 remedy is secret, and the compound is sold at a high 
 price to physicians or to laymen who are sufficiently 
 credulous to purchase. No series of authentic cures of 
 cancer has yet been demonstrated by any of these 
 methods. Finally, the fake "cancer cures," herb and 
 Indian doctors, and Christian scientists, increase enor- 
 mously the mortality from cancer. It is charitable to 
 suppose that they do this rather from ignorance than 
 by intention, but the result is the same in any case. 
 The patient is encouraged to expect relief, until his 
 money is exhausted and his disease is too far advanced 
 for cure by operation, when he finally drifts to the 
 charity hospitals, where his sufferings can be con- 
 trolled only by opiates, and he dies a lingering death, 
 offensive as well to himself as to all with whom he 
 comes in contact. 
 
II 
 
 EARLY DIAGNOSIS AND 
 TREATMENT 
 
 The early diagnosis of cancer is recognized to be the 
 one factor of the greatest importance in the successful 
 control of the disease, and it is well for us to consider 
 all of the conditions on which this early diagnosis 
 depends. Unfortunately, cancer in the different organs 
 and regions of the body presents itself by a variety 
 of different symptoms such that they must be consid- 
 ered not as manifestations of one disease, but rather 
 as of many different diseases. In most situations, 
 however, the dictum holds true that the more certain 
 the diagnosis- the less the probability of cure. In one 
 organ, as the breast for instance, the earliest symptom 
 of cancer may be either a tumor, discovered by acci- 
 dent, or an indrawing of the nipple or puckering of 
 the skin. In another, as the tongue, the first symptom 
 noted by the patient is an ulceration which shows no 
 tendency to heal. In other portions of the body, like 
 the uterus or the rectum, the first symptom to attract 
 the notice of the patient, or the physician, may be a 
 discharge of blood from an internal ulcerated surface, 
 which is only to be detected by a digital or visual exam- 
 ination. In all of these situations conditions other than 
 cancer may give rise to similar symptoms — in other 
 words, the symptoms of early cancer are not distinctive 
 and serve only to arouse suspicion of the presence of 
 that disease. When the abdominal viscera are affected 
 by cancer the symptoms are still less definite, and the 
 early diagnosis is made even more difficult. In these 
 regions, however, the development of examination by 
 the roentgen ray has given us a means of early diag- 
 nosis which is not to be neglected. When symptoms 
 are present, suggestive of cancer but insufficient to 
 make a positive diagnosis, two courses are open to the 
 physician : The first is to wait until more distinctive 
 symptoms develop ; the second is to proceed at once to 
 an exploratory operation. The first method, that of 
 waiting until a positive diagnosis can be made, is the 
 one that has been most commonly practiced. It is the 
 
15 
 
 easy way, and it is one of the factors most directly 
 responsible for the present enormous mortality of this 
 disease. It is in the hope that this waiting method 
 may be abandoned that this pamphlet is prepared for 
 publication. 
 
 EXPLORATORY OPERATIONS 
 
 Diagnosis by exploratory operation is the method 
 which promises the greatest and most immediate reduc- 
 tion of the mortality of cancer. The exploratory oper- 
 ation must be adapted to the region or organ affected 
 by the disease, and it must be emphasized that a pro- 
 cedure which is suitable in one situation may be 
 extremely dangerous in another. The desirability of 
 an early exploratory operation, therefore, varies with 
 the situation of the disease. 
 
 BIOPSY 
 
 The operative removal of tissue for pathologic exam- 
 ination (biopsy) is a measure open to discussion. 
 Where a positive diagnosis can be made without this 
 aid, the best and safest treatment is, undoubtedly, to 
 proceed at once to immediate radical operation. To cut 
 into cancer tissue "in situ," undoubtedly adds to the 
 danger of dissemination of the disease. In certain 
 regions, however, the radical operation for cancer 
 involves such great operative risk and such serious 
 mutilation, that it cannot with justice to either patient 
 or physician be advised on anything but a positive 
 diagnosis. In this class fall especially cancer of the 
 larynx, cancer of the tongue and jaw, and spindle cell 
 sarcoma of the long bones. Under these conditions, 
 especially if the tumor is an ulcerated one, the removal 
 of a superficial fragment for immediate frozen section 
 diagnosis is held to be permissible, although no delay 
 should be tolerated, and the radical operation should be 
 completed under the same anesthesia. Many surgeons 
 believe that in such an exploratory operation the wound 
 in the suspected cancer tissue should be immediately 
 and thoroughly cauterized to prevent the operative 
 implantation of living cancer cells during the subse- 
 quent stages of the operation. 
 
 The safest procedure to be followed in doubtful or 
 suspected cases of cancer in each organ or situation is 
 
16 
 
 discussed in the subsequent sections of this pamphlet. 
 It is sufficient here to urge on the practicing physician 
 the dangers of delay, and the advantages to the patient 
 of an early positive diagnosis. 
 
 EARLY OPERATION OFFERS THE BEST PROSPECT 
 OF CURE 
 
 It is the well established opinion of the best medical 
 authorities that at the present day early and thorough 
 operative removal of the primary tumor offers the 
 most certain cure for cancer. Other methods of treat- 
 ment are of value in incurable cases, but to obtain a 
 sure and complete cure of the disease the original focus 
 must be eradicated, together with all of the tissues 
 which are known in each region to be the ones earliest 
 invaded with the beginning of extension of the dis- 
 ease. When the disease can be recognized in its early 
 stages, and this thorough and complete operation 
 promptly performed, the patient should, theoretically, 
 be cured of cancer with almost as great certainty as a 
 cure can be obtained in cases of appendicitis. Twenty 
 years ago the early signs of appendicitis were little 
 known. Cases came late into the hands of the surgeon, 
 and the mortality was enormous in comparison to that 
 of the present day when the public and the physician 
 both recognize the importance of early operation. It 
 is surely not too much to hope that a similar reduction 
 in the mortality of many of the more favorable forms 
 of cancer will take place when the imperative need of 
 early operation for this disease is better understood. 
 
 CONDITIONS ESSENTIAL TO EARLY OPERATION 
 
 1. The Patient. — The first essential in procuring 
 prompt treatment of cancer cases is that the lay public 
 should be educated to understand, as they now under- 
 stand in the case of appendicitis, the need of early 
 operation, and the importance of the early recognition 
 of the disease. We live in a period of publicity, and 
 medical matters are coming to be recognized as one of 
 the subjects in which greater public knowledge works 
 for the common good. The American Society for the 
 Control of Cancer has done a great deal by circulars, 
 public lectures, and by legislative and state committees, 
 to promote this work. City and state boards of health 
 
17 
 
 and individual health officers in special districts have 
 contributed the help of their official position to this 
 work, and the daily press and the magazines have given 
 their assistance in this worthy cause. A better knowl- 
 edge of the disease is already evident in those districts 
 where this publicity work has been carried on, but 
 much remains to be done, and there are many people 
 who can be reached only with difficulty who must rely 
 for instruction on the only health officer with whom 
 they come in contact — the family physician. It is on 
 him that the duty finally rests to inform, to correct 
 misapprehensions and obsolete ideas, and to teach his 
 people the early and significant symptoms of the dis- 
 ease. Nothing can be accomplished in the individual 
 case until the patient is sufficiently alarmed, by symp- 
 toms he has been taught to regard as suspicious, to con- 
 sult his physician for examination and advice. 
 
 2. The Physician. — It might well be supposed that 
 as soon as the patient consulted his physician his dis- 
 ease would be recognized and early and adequate treat- 
 ment at once applied. Unfortunately this is not always 
 the case. Most of the physicians of this country have 
 been taught in their medical schools and their text- 
 books of surgery the distinctive and typical symptoms 
 of cancer, and by the extent to which they are typical 
 they are the symptoms of cancer which is no longer 
 early but has already progressed to the inoperable 
 stage. It is the early and uncertain cases that must be 
 recognized if any material improvement in the mor- 
 tality is to be brought about. 
 
 3. Examination. — It would seem unnecessary to lay 
 stress on so elementary a method as actual physical 
 examination as an aid to diagnosis, were it not for the 
 fact that the neglect of a physical examination by the 
 physician too often robs the patient of his or her 
 chance to obtain a cure. Sometimes the examination 
 is abandoned or delayed in the mistaken object of sav- 
 ing the patient's sensibilities. Sometimes it is neglected 
 because the physician is not alert to the possible grave 
 significance of the patient's symptoms. In any case, it 
 may fairly be said at the present day that the physician 
 who fails, by a physical examination, to make sure that 
 the symptoms complained of are not due to cancer fails 
 to give his patient the chance of cure to which he is 
 
18 
 
 entitled. Especially is this true in cases of cancer of 
 the breast, of the uterus, and of the rectum, where the 
 early diagnosis depends entirely on physical examina- 
 tion. 
 
 4. Diagnosis. — If cancer is to be detected in its early 
 stages its earliest symptoms must be well known to the 
 physician, and a large number of doubtful cases must 
 be taken care of where positive symptoms are lacking 
 but a strong suspicion of cancer exists. How are such 
 cases to be handled? On the one hand the physician 
 does not wish to let himself get the reputation of being 
 an alarmist, and drive his patients to unnecessary oper- 
 ations on a mistaken diagnosis. On the other hand, he 
 cannot, for the sake of the patient, wait for the more 
 certain symptoms to develop, and for the disease in the 
 meantime to become incurable. It is the physician's 
 reputation against his patient's life. There can be only 
 one answer — the life of the patient is the only consid- 
 eration. Under these circumstances the physician 
 deserves the aid and the sympathy of the community. 
 The public must be taught that the physician who is 
 alert to recognize and procure operative treatment in 
 the early stages of the disease will undoubtedly at times 
 cause patients the expense of an unnecessary surgical 
 consultation- — an expense that most persons will gladly 
 bear if they can be assured that they are not afflicted 
 with this terrible disease. It is the early cases that 
 offer the difficult problems, and deserve the service of 
 the very best experience. And, finally, there are very 
 few regions of the body in which, in a doubtful case, 
 with the laboratory facilities of a modern hospital, an 
 exploratory operation cannot be performed to procure 
 an immediate positive diagnosis by frozen section 
 examination of the suspected tissues. The physician 
 who is alive to his responsibilities in the early diagnosis 
 of cancer and who brings his patient to operation dur- 
 ing the early and uncertain stages of the disease, ren- 
 ders the greatest service to his community, and deserves 
 that this fact be recognized. 
 
 5. Consent of Patient to Operation. — Granting that 
 the patient seeks early advice and that the physician 
 recognizes the early symptoms and advises immediate 
 operative treatment, the consent of the patient to this 
 operation must be obtained. In the experience of the 
 
19 
 
 older members of the community, and they are the 
 ones concerned in the cancer problem, one after another 
 of their friends and acquaintances has died of cancer, 
 and many of them of recurrence after operation. Is 
 it to be wondered at that they have little faith in the 
 surgical treatment of the disease? They do not know 
 that during the last twenty-five years the operations 
 for cancer of different organs have been standardized, 
 the patients have been operated on earlier, and the 
 numbers of cures have been materially increased. They 
 do not even know of the cured patients with whom 
 they come in daily contact, for the cured patients do 
 not tell, and the scars of operation are rarely visible. 
 These are some of the facts about the disease which 
 must be established with the laity. Such facts are 
 given in this pamphlet, and may be used with confi- 
 dence by any physician who wishes a fair statement of 
 the situation. 
 
Ill 
 
 "PRECANCEROUS" CONDITIONS 
 
 One factor which during the last ten years has 
 proved to be of great importance in the origin of cancer 
 is the element of chronic irritation. As the various 
 theories of the parasitic origin of cancer have been 
 disproved, the element of chronic irritation has been 
 found to become an increasingly important factor in 
 the incidence of cancer in one region after another. 
 This fact has made it possible to give prophylactic 
 treatment for the purpose of preventing the occurrence 
 of cancer, a procedure which is exactly as rational as 
 the prophylactic use of antitoxins in many of the infec- 
 tious diseases, and in fact is perhaps a more effective 
 life-saving measure. This prophylactic treatment con- 
 sists of the removal by a minor operation, often under 
 local anesthesia, of lesions such as keratoses, moles, 
 fissures, chronic ulcerations and indurations, and the 
 benign tumors, which so often precede the development 
 of cancer itself. This prophylaxis further demands the 
 avoidance of sources of chronic irritation, such as, for 
 instance, the removal of an ill-fitting tooth plate which 
 causes irritation of the gum, or the repair, at as early 
 a date as possible, of the deeper lacerations of the 
 cervix which occur at childbirth. 
 
 The more important lesions which may be regarded 
 as of precancerous significance may be summarized as 
 follows : 
 
 1. Pigmented moles have long been recognized to be 
 the starting point of that most fatal form of malignant 
 disease, the so-called melanotic sarcoma. 1 Not all 
 moles, of course, undergo that transformation, but all 
 must be held to contain that inherent possibility of 
 development, and on the slightest sign of increase in 
 size, irritation or induration, they should be widely 
 removed by radical operation. Pigmented moles on 
 the hands and feet are especially liable to repeated 
 trauma, and thus to malignant change. 
 
 1. Melanotic sarcoma is believed by some good authorities to be in 
 reality a form of epithelial tumor — i. e., carcinoma. 
 
21 
 
 2. The senile keratoses, or scaling patches of heaped 
 up squamous epithelium, so common on the face and 
 exposed parts of the body of those of advancing years, 
 are among the most common starting points for cancer 
 of the skin. 
 
 3. Chronic ulcers and fissures of the skin due to old 
 burns and scars, the effects of roentgen rays and 
 radium, tuberculosis of the skin, and old syphilitic 
 lesions often cause cancer. To this category belongs 
 the "Kangri" cancer of Kashmir (squamous cell car- 
 cinoma of the abdominal wall), occurring at the site 
 of chronic ulceration due to burning from the Kangri 
 basket, or hot stove carried against the abdominal skin 
 within the clothing of the natives. 
 
 4. Gallstones are accompanied by chronic irritation 
 of the gallbladder, and in a certain percentage of cases 
 carcinoma of the gallbladder occurs. 
 
 5. A certain proportion of ulcers of the stomach are 
 known to become the site of cancer of that organ, and 
 a history which can be interpreted as evidence of pre- 
 vious ulcer is obtainable in certain cases of gastric 
 cancer. 
 
 6. Erosions and lacerations of the cervix of the 
 uterus, the almost inevitable result of childbirth, are 
 the most common factors predisposing to cancer of 
 the cervix. While it is customary for the physician to 
 repair immediately the more serious lacerations of the 
 cervix, less extensive lesions can be detected only at a 
 later period after involution has occurred. The rou- 
 tine examination of all women for cervical lesions 
 three months after labor has been advocated, that these 
 lesions may be immediately repaired, and the predis- 
 position to cancer avoided. It is advisable that all 
 women who have borne children, as they approach the 
 menopause, should have a vaginal examination and an 
 inspection of the cervix at reasonable intervals until 
 the menopause is well established, and the normal 
 atrophic changes have taken place. Deep lacerations 
 should be repaired, and superficial lesions, if resistant 
 to local treatment, are sufficient indication for amputa- 
 tion of the cervix. The hyperplastic endometritis 
 which accompanies fibromyoma of the uterus is also 
 believed to be one of the most important predisposing 
 causes of cancer of the fundus. 
 
22 
 
 7. Cystitis of one form or another often precedes 
 cancer of the bladder, and the irritation of Bilharzia 
 parasites or of specific chemical irritants, such as 
 anilin, are recognized as producing changes in the blad- 
 der mucosa which may go on to carcinoma. 
 
 8. Carcinoma of the buccal mucous membranes — the 
 lip, tongue, cheek and jaw — have long been associated 
 with one or another source of chronic irritation. In 
 this country the most common source of chronic irri- 
 tation of the buccal mucous membranes is the use of 
 tobacco. It is significant, also, that in other countries, 
 as the orient, cancer of the buccal mucous membranes 
 appears to arise most directly as the consequence of 
 the chewing of other irritants, such as the buyo leaf 
 or the betel nut. Syphilis is also a recognized predis- 
 posing factor to cancer of the mouth, and the chronic 
 hyperplastic condition of the buccal mucous membrane 
 — leukoplakia — has repeatedly been observed to prog- 
 ress into carcinoma while under treatment. The irri- 
 tation of ill-fitting tooth plates, or the chronic irrita- 
 tion of pyorrhea alveolaris occasionally can be recog- 
 nized as forerunners of cancer of the alveolar pro- 
 cesses. 
 
 9. Kraurosis and leukoplakia of the vulva are forms 
 of superficial lesions, benign in origin, which exhibit 
 a definite tendency to subsequent malignant change. 
 Suitable treatment and close and continued observa- 
 tion to detect the early signs of the development of 
 cancer must not be neglected, in order that radical 
 operative treatment may be instituted during the early 
 stages when the disease can thus be cured. 
 
 10. Involution changes of a physiologic nature 
 appear to predispose to cancer in certain organs, 
 notably the female breast, and the male prostate. In 
 the breast the involution phenomena which give rise 
 to the condition commonly known as chronic cystic 
 mastitis show an incidence of carcinoma estimated at 
 from 10 to 25 per cent., while in the prostate chronic 
 prostatitis and hypertrophy precede the symptoms of 
 carcinoma in a notable proportion of all cases. 
 
 11. Many tumors which are essentially benign in 
 character have been shown to be capable of malignant 
 transformation, especially in the later years of life. 
 These include papillomas, adenomas of the thyroid and 
 
23 
 
 of the intestines, villous tumors of the bladder, papil- 
 lary and cystic tumors of the ovary and of the breast, 
 polyps of the uterus or the rectum, and, in fact, all 
 tumors in which the epithelial elements are in pre- 
 ponderance. 
 
 In all of the foregoing conditions the possibility, if 
 not the probability, of cancerous transformation has 
 been shown to be a serious element in prognosis. There 
 can be no question that the cure or the removal of all 
 such lesions is a vital indication. Removal of the pre- 
 disposing causes of cancer, and the early recognition 
 of cancer, when it is present, are the two measures 
 which give promise at the present time of yielding the 
 greatest results in reducing the mortality of the disease. 
 
IV 
 
 CARCINOMA OF DIFFERENT 
 
 ORGANS 
 
 1. CARCINOMA OF THE EXTERNAL SKIN 
 
 This is a common form of cancer found chiefly 
 among persons of advanced age, and on the exposed 
 parts of the body, especially in those who have long 
 followed outdoor occupations. It is slow growing, 
 usually only locally invasive and malignant, and rarely 
 produces remote metastases. There are two main 
 types : ( 1 ) those arising from the differentiated squa- 
 mous cells, and (2) those originating from the less 
 differentiated basal cells of the epithelium and repro- 
 ducing themselves in the form of gland ducts or hair 
 matrix cells. The squamous cell type is more likely to 
 show extension to the lymphatic glands in the neigh- 
 borhood, but not, as a rule, until late in the course of 
 the disease. Carcinoma of the external skin is espe- 
 cially liable to occur as a secondary change in preexist- 
 ing fissures, keratoses, and chronic ulcerations and 
 indurations. 
 
 Symptoms. — The development of a tumor involving 
 the skin, or of a chronic ulceration covered with a 
 crust and presenting an indurated base and periphery, 
 is suggestive of carcinoma and demands investigation. 
 Especially is this true when the lesion has been trau- 
 matized or subjected to chronic irritation. 
 
 Differential Diagnosis. — Differential diagnosis 
 requires that syphilis, tuberculosis, and some of the 
 rarer forms of skin diseases be considered. In doubt- 
 ful cases the operative excision of the whole lesion, 
 with a wide margin, and the pathologic investigation 
 of the tissue, is the safest course. 
 
 Precancerous Lesions. — Warts, keratoses and 
 chronic ulcers, when possible, should be excised or 
 destroyed before they have an opportunity to undergo 
 secondary malignant changes and become cancer. This 
 can usually be done by a very minor operation, often 
 with local anesthesia. Many of the more superficial 
 lesions of this nature can safely be eradicated by 
 radium, roentgen ray or even caustic applications, but 
 
25 
 
 the clean surgical excision is undoubtedly the safest 
 method. 
 
 Standard Operative Treatment. — The standard 
 operative treatment is total excision, with a consider- 
 able margin of healthy tissue. Where extension to 
 neighboring lymphatic nodes is thought to have 
 occurred, dissection of the affected territory, with 
 removal of the diseased nodes and those immediately 
 beyond them, in one mass, should be performed. Super- 
 ficial carcinoma of the face, especially in the region 
 of the eyelids, may be subjected to treatment with 
 roentgen rays or radium, in order that deforming scars 
 may be avoided. While less certain than operation, 
 treatment by radiation in suitable cases offers the pros- 
 pect of a soft and less conspicuous scar, and the same 
 may be said in regard to the treatment of very super- 
 ficial lesions with the curet and caustic agents, but 
 any application of such methods, especially freezing 
 or electrolysis, which does not insure the destruction 
 of every malignant cell, is to be condemned. 
 
 Results. — Statistics are difficult to obtain on cases 
 of this character. On account of the relative infre- 
 quency or retardation of metastatic extension, cure by 
 early complete excision should be obtainable in every 
 case of non-metastasizing carcinoma of the skin. It 
 is a fact, however, that an incomplete excision is often 
 done in the effort to remove no more tissue than abso- 
 lutely needed, whereas a wide margin is essential to a 
 successful operation. In the few cases which do pro- 
 duce metastases the block dissection of the regional 
 lymph nodes, together with the operative excision of 
 the tumor should yield a very large percentage of cures 
 in early cases. 
 
 2. CARCINOMA OF THE LIP 
 
 This is one of the more common forms of squamous 
 cell cancer, especially in men and has been, attributed 
 to chronic irritation such as the use of tobacco in any 
 form, but especially in pipe smoking. It produces 
 metastases in submental or submaxillary lymph nodes, 
 after a brief period estimated at two or three months, 
 but less early than in carcinoma of the tongue and jaw. 
 
 Symptoms.— Carcinoma of the lip occurs as an 
 indurated chronic ulcer or non-ulcerated thickening on 
 the free border of the lip; it rarely appears as a warty 
 growth. 
 
26 
 
 Differential Diagnosis. — Primary syphilis (chancre) 
 is rare. Syphilitic fissures are more common, and 
 may accompany cancer. A positive Wassermann does 
 not prove that cancer is not present, and delay for a 
 therapeutic test is not advisable. 
 
 Precancerous Lesions. — Chronic ulcers and scabs 
 (keratoses) are to be regarded as precancerous condi- 
 tions, and should be removed by excision, or in suit- 
 able cases by the use of radium. In doubtful cases 
 operative removal is to be preferred in order that a 
 pathologic examination of the tissue may be made, and 
 the radical dissection of the regional nodes performed 
 if a frankly malignant tumor is disclosed. 
 
 Standard Operative Treatment. — (1) Doubtful 
 cases : Excise with a generous margin, and if the 
 microscope shows carcinoma follow immediately with 
 dissection and removal of the lymph nodes of the sub- 
 mental region and of the submaxillary region on the 
 affected side. If the tumor is near the middle line, 
 both submaxillary regions should be dissected. The 
 whole of the submaxillary salivary gland must be 
 removed. (2) If diagnosis is certain, excision by 
 broad margin and dissection of lymph nodes, as above 
 is indicated. 
 
 Results. — Cancer of the lip recognized and oper- 
 ated upon in its early stages at the time when the 
 lymph nodes are not yet involved yields a high per- 
 centage of radical cures of the disease. The more 
 extensive the glandular involvement, the less the pros- 
 pect of success with operative treatment. Many cases 
 are allowed to become inoperable by neglect of the 
 regional neck dissection at the primary operation. 
 
 3. CARCINOMA OF THE TONGUE, MOUTH AND JAW 
 
 These growths are not rare, and are one of the most 
 malignant of the accessible forms of carcinoma. They 
 are of the squamous cell type, producing early metas- 
 tases to the submental, submaxillary, parotid, and 
 carotid nodes, and spreading rapidly by local invasion 
 into the adjacent tissues of the floor of the mouth and 
 across to the other side of the tongue, mouth and neck. 
 The influence of tobacco as a form of chronic irrita- 
 cion is held to be of serious importance in the origin 
 of cancer in this locality. 
 
27 
 
 Symptoms. — This type of carcinoma begins as an 
 indurated ulcer or thickening of the mucous membrane 
 of the tongue or mouth, or on the alveolar border of 
 the gum. Any such ulcer of two weeks' duration 
 should be regarded with suspicion. 
 
 Differential Diagnosis. — Chronic inflammatory con- 
 ditions, such as ulcers due to jagged teeth, ill-fitting 
 tooth plates, pyorrhea, etc., may be predisposing 
 causes. Late syphilis is often followed by carcinoma 
 and a positive Wassermann test does not exclude car- 
 cinoma. Leukoplakia, or superficial milky glossitis, is 
 also a predisposing cause. Tuberculosis has typical 
 punched out and undermined ulcer, and is generally 
 secondary to other tuberculosis. Actinomycosis of the 
 jaw is rare; it is suppurative, and does not extend to 
 the lymph nodes. 
 
 Precancerous Lesions. — To avoid delay, doubtful 
 cases are best handled by excision of the whole lesion 
 for microscopic diagnosis with cauterization to seal the 
 lymphatics. In operable cases avoid removal of a 
 single lymph node from the neck for diagnosis, as such 
 an incomplete operation almost invariably leads to local 
 implantation if cancer is present in the node. 
 
 Standard Operative Treatment. — Standard oper- 
 ative treatment demands removal of practically the 
 whole tongue, together with the floor of the mouth, 
 and block dissection of all lymphatic tissues of one or 
 both sides of the neck, usually including the jugular 
 vein and the greater part of the sternomastoid — a very 
 serious operation. If the jaw is divided, or removed, 
 as is necessary in many cases, the mortality is esti- 
 mated to be 25 to 30 per cent, owing to pneumonia or 
 mediastinal sepsis. The operation can be done in two 
 stages (Whitehead, Crile) with less mortality and 
 slightly less prospect of cure on account of the danger 
 of local implantation. 
 
 Residts. — Only moderately good results are claimed 
 for operation in the larger clinics. In cases that are 
 recognized early, and where the patient's constitution 
 is such as to withstand the severe operation, a higher 
 probability of cure may be expected, but in advanced 
 cases the chances of cure by operation become 
 extremely slight. 
 
28 
 
 4. CARCINOMA OF THE LARYNX 
 
 This is not an unusual form of carcinoma, affecting 
 males more than females, generally in the later decades 
 of life. Carcinoma of the larynx occurs especially in 
 two regions: (a) in the region of the vocal cords, and 
 (b) in the upper part of the larynx. 
 
 Symptoms. — Hoarseness and loss of voice are the 
 characteristic symptoms ; later dysphagia and pain may 
 appear, and when persisting beyond a reasonable length 
 of time demand investigation with the laryngoscope. 
 The growth may assume one of several forms, some- 
 times as a localized hyperemia, sometimes as a distinct 
 growth, and sometimes as a deep-seated infiltration, 
 later becoming ulcerated, and surrounded by hyperemia 
 and edema. Extension to the regional lymph nodes 
 generally occurs late in tumors of the larynx, later 
 when the tumor is in the region of the vocal cords 
 than when in the upper parts. 
 
 Differential Diagnosis. — Carcinoma of the larynx 
 must be differentiated from benign tumors (papilloma, 
 fibroma, etc.) of the larynx, and from syphilitic, tuber- 
 culous and other ulcerations. Removal of tissue for 
 pathologic examination (biopsy) should seldom be 
 practised, unless immediately followed by the radical 
 operation. It should be avoided if the diagnosis can 
 be made with reasonable certainty. 
 
 Standard Operative Treatment. — Thyrotomy with 
 removal of the disease and of all adjacent tissues has 
 given successful results in early cases, especially in 
 cancer of the vocal cords. As a rule total laryngec- 
 tomy with wide dissection of the regional nodes is the 
 operation of choice. The operative mortality is con- 
 siderable, due to infection of the air passages, and the 
 mutilation is often serious, but is preferable to the 
 otherwise certain fatal issue. Palliative tracheotomy 
 and gastrotomy may be done, and radium and roentgen 
 ray may prolong life and relieve pain for a limited 
 period. The application of radium before and after 
 the removal of the larynx has given good results. 
 
 Results. — Early partial, and later total operations 
 have yielded many successful results, but the prognosis 
 in any but early cases is very grave. 
 
29 
 
 5. CARCINOMA OF THE THYROID 
 
 This is one of the less common forms of cancer, but 
 is liable to occur especially as a late change in thyroid 
 tumors of long duration which have previously been 
 considered to be benign in character. Several types 
 are recognized. The tendency to remote metastases 
 in the lung, and especially in the long bones and skull 
 is to be borne in mind, even in tumors in which the 
 histologic picture shows only adenomatous tissue 
 (malignant adenoma). 
 
 Symptoms. — An irregular nodular tumor of the 
 thyroid, showing early fixation by adherence to sur- 
 rounding structures, involvement of the recurrent 
 laryngeal nerve, and extension to regional (jugular) 
 lymph nodes. 
 
 Differential Diagnosis. — Typical cases are recog- 
 nized only by symptoms of irregular induration, fixa- 
 tion, nerve involvement, dysphagia and dyspnea, which 
 indicate an incurable condition. Early cases are recog- 
 nized only as tumors of the thyroid of unknown nature, 
 cut are sufficient indication, after the age of 35, to 
 demand radical operative treatment. 
 
 Precancerous Lesions. — Any rapidly growing thy- 
 roid tumor in an individual of 35 or over should be 
 looked on with suspicion. 
 
 Standard Operative Treatment. — The standard 
 treatment for carcinoma of the thyroid is radical 
 thyroidectomy to the extent of total removal of the 
 whole gland and of the adjacent lymph bearing tissues 
 on both sides of the neck. Thyroid extract may be 
 administered to prevent myxedema, and parathyroidin 
 has been recommended to prevent tetany from removal 
 of the parathyroids. 
 
 Residts. — Favorable results are obtained only in 
 early cases before the capsule is invaded, and while 
 the diagnosis is most uncertain. Prophylactic treat- 
 ment by removal of benign tumors is the most effective 
 measure. 
 
 6. CARCINOMA OF THE ESOPHAGUS 
 
 This is a squamous cell and metastasizing carcinoma. 
 It is rare and possibly related to chronic irritation. 
 There are an equal number of cases among males and 
 females. 
 
30 
 
 Symptoms. — The first symptoms are usually dys- 
 phagia followed by progressive extension to the local 
 lymphatics in the neck or mediastinum, local invasion 
 of the trachea, or perforation into the pleura. The 
 patient suffers gradual starvation. 
 
 Differential Diagnosis. — This type of carcinoma 
 must be differentiated from benign strictures and 
 pouches by esophagoscopy, bougies, and roentgen rays. 
 
 Doubtful Cases. — These must be diagnosed by 
 esophagoscopy. 
 
 Standard Operative Treatment. — Radical operation 
 is still in the experimental stage. Palliative operations 
 — gastrostomy, jejunostomy — may be performed, or 
 radium applications may be used. 
 
 Results. — These cases are practically always fatal. 
 
 7. CARCINOMA OF THE STOMACH 
 
 Carcinoma of the stomach is one of the most com- 
 mon manifestations of the disease. It is the most com- 
 mon form of cancer in males, and is only exceeded in 
 frequency in females by cancer of the uterus and of 
 
 the breast. 
 
 Symptoms. — The symptoms of cancer of the stom- 
 ach are insidious. The patient appreciates only a 
 progressive disturbance of gastric digestion, with loss 
 of weight, and increasing gastric distress. These symp- 
 toms sometimes follow the symptoms of long standing 
 gastric ulcer — pain, hyperacidity, and the appearance 
 of blood in the vomitus or in the stools. 
 
 Differential Diagnosis. — The differential diagnosis of 
 any but advanced cases can be made only with the aid 
 of the laboratory analysis of the gastric contents, and 
 the use of the roentgen ray. 
 
 Standard Operative Treatment. — The standard oper- 
 ative treatment of cancer of the stomach is by excision 
 of the affected portion of the stomach with the adja- 
 cent lymph nodes. Only a small proportion of the 
 cases submitted to operation are sufficiently early to 
 permit an attempt at radical cure. 
 
 Results. — By a judicious selection of cases suitable 
 for radical treatment the operative mortality has been 
 much reduced. In cases which are thus favorable for 
 operation, cure of the disease is claimed in a large 
 
31 
 
 percentage in certain clinics. In general practice, how- 
 ever, the figures are very much lower, and where the 
 disease has developed to the extent of producing char- 
 acteristic symptoms the outlook is distinctly unfavor- 
 able. 
 
 8. CARCINOMA OF THE COLON 
 
 This is one of the common forms of cancer in elderly 
 persons. 
 
 Symptoms. — The symptoms are insidious — vague 
 intestinal indigestion and discomfort and loss of weight 
 in the early stage's. The symptoms become more pro- 
 nounced as the tumor produces intestinal obstruction, 
 with distension, colicky pains, and blood in the stools. 
 As a last stage the intestinal obstruction, which was 
 chronic and partial in the beginning, may become com- 
 plete and thus acute, with fecal vomiting, distension 
 and severe toxemia. 
 
 Differential Diagnosis.- — This requires that the causes 
 of benign obstruction — scars, ulcers, the pressure of 
 benign tumors outside of the intestine, inflammatory 
 conditions, diverticulitis or appendicitis and the vari- 
 ous forms of acute intestinal obstruction should be 
 eliminated. This can be done only by exploratory oper- 
 ation. The use of roentgen rays is of assistance in 
 the more chronic cases, and the examination with the 
 proctoscope is of value in the upper rectum and sig- 
 moid cases. 
 
 Doubtful Cases. — An exploratory laparotomy with 
 an intestinal anastomosis or a colostomy, followed later 
 by removal of the affected bowel, is the procedure to 
 be advised. 
 
 Standard Operative Treatment. — The standard oper- 
 ative technic consists of removal, by a wide margin, 
 of the affected bowel and its adjacent lymph nodes. 
 If the disease is already in the liver, radical cure is 
 not to be attempted. In advanced cases palliative 
 treatment by anastomosis is of great relief to the 
 patient. 
 
 Residts. — On account of the difficulty of early diag- 
 nosis, few cases are suitable for an attempt at radical 
 cure. As patients present themselves at a general hos- 
 pital the prospect of cure is distinctly unfavorable, 
 although successful cases are obtained from time to 
 time. 
 
32 
 
 9. CARCINOMA OF THE PANCREAS, GALLBLADDER 
 AND LIVER 
 
 (a) Pancreas. — Carcinoma of the pancreas is rare. 
 
 Symptoms. — These are chronic, progressive, pain- 
 less jaundice, accompanied by loss of weight, distur- 
 bance of digestion, and fatty stools. The gallbladder 
 is usually distended. 
 
 Differential Diagnosis. — Eliminate other causes of 
 obstruction of the common gallduct, such as that due 
 to a gallstone, or lymph nodes (lymphoma), or cancer 
 in the region of the common duct and chronic pan- 
 creatitis. 
 
 Doubtful Cases. — Exploratory operation is indicated, 
 but radical cure of cancer of the pancreas has not been 
 accomplished. 
 
 Standard Operative Treatment. — Palliative opera- 
 tions by establishing an anastomosis between the gall- 
 bladder and the duodenum, or small or large intestine, 
 give temporary relief to one of the most distressing 
 symptoms — jaundice. 
 
 Results. — Patients may be relieved of distressing 
 symptoms by palliative operations, but radical cure of 
 the disease has not been claimed. 
 
 (b) Gallbladder. — Carcinoma of the gallbladder is 
 rare. 
 
 Symptoms.— The symptoms are indefinite. There is 
 usually a history of gallstone attacks of long duration. 
 
 Differential Diagnosis. — The differential diagnosis is 
 between cancer of the liver or stomach and gallstone 
 disease. This is rarely accomplished except by opera- 
 tion. 
 
 Doubt fid Cases. — It is a well established fact that 
 cancer of the gallbladder is to be feared in cases of 
 long standing gallstone disease. For that reason, in 
 cases of gallstones, removal of the gallbladder is 
 becoming the operation of choice. 
 
 Standard Operative Treatment. — When cancer of 
 the gallbladder is evident, and its extension to the liver 
 has not occurred, removal of the gallbladder is the 
 standard operation. 
 
 Results. — A certain number of cases of cure of 
 cancer of the gallbladder have been reported. The 
 
33 
 
 disease extends very rapidly, however, . to the liver, 
 and when this has occurred a cure is not to be 
 expected. 
 
 (c) Liver. — Cancer of the liver is very common as 
 a secondary manifestation of cancer anywhere in the 
 intestinal tract, and in some cases of cancer of other 
 organs, such as the breast or prostate, melanotic sar- 
 coma and other forms of sarcoma. Primary cancer of 
 the liver is extremely rare, and so are other primary 
 malignant tumors of the liver, such as hypernephroma. 
 
 Differential Diagnosis.- — -This depends, as a rule, on 
 recognition of a possible primary focus of cancer else- 
 where. 
 
 Standard Operative Treatment. — There is no opera- 
 tive treatment. 
 
 10. CARCINOMA OF THE RECTUM 
 
 This is a common form of cancer and especially one 
 which is prone to occur not only in those of cancer age 
 but in younger persons also. 
 
 Symptoms. — Tenesmus, bloody stools, loss of weight, 
 and finally intestinal obstruction are symptoms of car- 
 cinoma of the rectum. 
 
 Differential Diagnosis. — Syphilis, tuberculosis and 
 extensive chronic inflammatory processes with fistulae, 
 must be considered. Digital and proctoscopic exam- 
 ination is imperative. 
 
 Doubtful Cases. — Benign polyps of the rectum and 
 chronic inflammatory conditions must be regarded as 
 predisposing to cancer of the rectum and should 
 receive appropriate treatment. Many cases of cancer 
 of the rectum are not recognized in their early stages 
 because the physician neglects to insist on a digital or 
 proctoscopic examination. Excision of fragments of 
 tumor tissue for pathologic examination is in general 
 to be condemned, but may occasionally be necessary 
 for diagnosis and should be made at the time of oper- 
 ation. 
 
 Standard Operative Treatment. — This consists in the 
 removal of the whole rectum and the pelvic lymphatic 
 tissue on account of the disposition of the disease to 
 spread in the coats of the intestine as well as to the 
 lymph nodes. This is usually done by a two-stage 
 operation — a primary colostomy, with examination of 
 
34 
 
 the liver and of the pelvic lymph nodes ; and the sec- 
 ondary removal of the tumor and a wide margin of 
 the adjacent rectum by the Kraske incision or by the 
 combined abdominoperineal route. 
 
 Results. — In early cases successful results from rad- 
 ical operation may be expected. There is an inevitable 
 operative risk on account of the severity of the opera- 
 tion but when the constitutional condition is good and 
 the disease has not had time to become too far 
 advanced a reasonable percentage of cases should be 
 successful. 
 
 11. CARCINOMA OF THE BLADDER AND PROSTATE 
 
 (a) Bladder. — This is one of the rarer forms of 
 cancer. It occurs in males and females. It often 
 develops in the base of a supposedly benign papilloma. 
 
 Symptoms. — Frequency of micturition, bloody urine 
 and tenesmus are symptoms of this condition. 
 
 Differential Diagnosis. — This is made by cystoscope. 
 Tuberculosis, calculus, bilharzia, and blood from renal 
 tumors and calculi must be excluded. 
 
 Doubtful Cases. — The precancerous conditions are 
 chiefly benign tumors and calculi. 
 
 Standard Operative Treatment. — Transperitoneal 
 operation with removal of the affected portion of the 
 bladder is the standard operation for radical cure. 
 Where this is not possible, intravesical operations with 
 the use of the cautery, radium or fulguration may be 
 attempted. 
 
 Results. — A considerable number of successful cases 
 of transperitoneal operation have been recorded. The 
 use of radium or other cauterizing agents, however, 
 can at present be considered only as palliative mea- 
 sures, although there is reason to hope that better 
 results may ultimately be obtained with radium. 
 
 (b) Prostate. — Cancer of the prostate is one of the 
 rarer forms of cancer. 
 
 Symptoms. — These are not materially different from 
 those of prostatic hypertrophy — i. e., frequency of 
 micturition, loss of power of stream, increasing to 
 retention of urine, blood in the urine, tenesmus. 
 
 Differential Diagnosis. — This depends on the stony, 
 hard and irregularly nodular feel of the prostate on 
 
35 
 
 rectal examination. Positive diagnosis can only be 
 made by microscopic examination of excised prostate. 
 
 Doubtful cases. — These should be treated by pros- 
 tatectomy. Only early cases can be cured by opera- 
 tion. In advanced cases radium may give some relief 
 to symptoms. 
 
 Standard Operative Treatment. — The standard oper- 
 ation is prostatectomy — suprapubic or perineal. 
 
 Results. — The radical cure of cancer of the prostate 
 by operation is virtually confined to cases of prostatic 
 hypertrophy in which prostatectomy has been done, 
 and the early changes of carcinoma have been discov- 
 ered only by the pathologic examination of the tissue. 
 In certain clinics the treatment of cancer of the pros- 
 tate by radium is claimed to have yielded more satis- 
 factory results. 
 
 12. CARCINOMA OF THE UTERUS 
 
 This is the commonest form of cancer in the female. 
 There are two varieties: (a) carcinoma of the cervix 
 (b) carcinoma of the body. 
 
 (a) Carcinoma of the Cervix. — This is the squamous 
 cell type of carcinoma. It almost always occurs in 
 women who have borne children, and especially if the 
 cervix has been lacerated and the lacerations have 
 been neglected or have become eroded, or subject to 
 constant irritation. 
 
 Symptoms. — Earliest symptom is a bloody discharge 
 not related to catamenia, or appearing after the meno- 
 pause; any change in the character of the discharge, 
 especially if it becomes more profuse, more foul, or 
 more irritating; or if it appears irregularly after exer- 
 tion, straining at stool, the use of a douche or after 
 intercourse indicates carcinoma of the cervix. The 
 appearance of a discharge even though not bloody in 
 character, after a period of freedom from discharge, 
 should be regarded as a suspicious symptom. An 
 examination shows an indurated excoriation or ulcera- 
 tion of the cervix which may be within the os. Later 
 there may be deep infiltration or a productive cauli- 
 flower growth, with ulceration, bleeding and offensive 
 discharge. It extends early to tissues of broad liga- 
 ments and vaginal wall by direct extension, and to 
 pelvic lymph nodes. 
 
36 
 
 Differential Diagnosis. — The early diagnosis of can- 
 cer of the uterus demands an early digital and visual 
 examination. Too often the disinclination of the 
 patient and the indifference of the physician combine 
 to postpone this examination until too late for cure 
 of the disease. Early cases can be distinguished from 
 nonmalignant ulcerations and lacerations only by 
 microscopic examination. 
 
 Doubtful Cases. — Lacerations due to childbirth form 
 the precancerous condition. For this reason all lacera- 
 tions should be excised and repaired as prophylaxis, 
 at least as soon as the probability of further child- 
 bearing is over. Some surgeons advocate the high 
 amputation of the cervix in suspected cases, while 
 others go so far as to advise an immediate hysterec- 
 tomy, without the preliminary removal of tissue for 
 pathologic confirmation of the diagnosis. 
 
 Standard Operative Treatment. — For established 
 carcinoma of the cervix of the uterus the standard 
 operation is total hysterectomy with the removal of 
 the pelvic areolar tissues and lymph nodes. This is a 
 very serious operation, and the results, except in very 
 early cases, have been rather unsatisfactory. On this 
 account efforts have been made in many clinics to com- 
 bine the use of radium with a subsequent radical oper- 
 ation. Time has not elapsed at this present writing 
 to permit a final judgment of the value of this com- 
 bined method of treatment. For inoperable cases, how- 
 ever, treatment with radium gives most satisfactory 
 palliative results, and in a few instances apparent free- 
 dom from disease has been obtained. The actual 
 cautery is also employed in the treatment of inoper- 
 able cases, as well as caustic applications. Such mea- 
 sures, however, are only palliative. 
 
 Results. — In advanced cases the results of radical 
 operation for cancer of the cervix are very unsatisfac- 
 tory. In early cases a reasonable percentage of cures 
 have been reported. The disease when established is 
 one of the most unsatisfactory forms of cancer for 
 operative treatment, and the mortality of the radical 
 operation is a serious consideration. 
 
 (b) Carcinoma of the Body of the Uterus. — Adeno- 
 carcinoma is much rarer than that of the cervix, and 
 more insidious. 
 
3/ 
 
 Symptoms. — These are discharge of blood or blood)' 
 serum independent of catamenia, or after menopause 
 and enlargement of the uterus. 
 
 Differential Diagnosis. — Conditions to be considered 
 in the differential diagnosis are hyperplastic endome- 
 tritis, polyps, cervical carcinoma, chorio-epithelioma. It 
 may occur in cases of fibromyoma. Diagnosis is ordi- 
 narily determined by curettage and examination of 
 tissue, although many surgeons believe it safer to avoid 
 the chance of setting free cancer cells in the blood and 
 lymph vessels by curettage, and to proceed at once to 
 a total hysterectomy. 
 
 Doubtful Cases. — These are especially fibromyomas 
 and hypertrophic and other forms of endometritis. 
 
 Standard Operative Treatment. — Panhysterectomy 
 with removal of both ovaries and tubes, and the pelvic 
 areolar tissue and neighboring lymph nodes is the 
 standard operative treatment. 
 
 Results. — Prognosis for cure in cancer of the fundus 
 of the uterus is better than that in cancer of the 
 cervix. If the disease can be recognized before gen- 
 eral extension to the peritoneum has taken place the 
 radical operation is usually curative, and the symptom 
 of hemorrhage makes this early recognition a possi- 
 bility. A routine examination of all curettings occa- 
 sionally reveals an unexpected carcinoma. 
 
 13. CARCINOMA OF THE OVARY 
 
 This condition is not very rare. It occurs as a sec- 
 ondary manifestation of otherwise nonmalignant cysts, 
 and cystadenomas of ovarian and parovarian origin, 
 and as a remote metastatic implantation from carci- 
 noma of other organs. 
 
 Symptoms. — These are abdominal swelling and feel- 
 ing of weight. They are rarely rapid in onset. 
 
 Differential Diagnosis. — Early carcinoma of the 
 ovary can be diagnosed only by operation on the sup- 
 posed benign cyst; late carcinoma, after peritoneal 
 involvement, by bloody ascites and ovarian tumor, or 
 exploration. 
 
 Doubtful Cases. — Exploratory laparotomy should be 
 employed. Precancerous condition is the benign ova- 
 rian cyst. All benign ovarian tumors should, if pos- 
 
38 
 
 sible, be removed unbroken as papillary intracystic 
 growths already may be present. 
 
 Standard Operative Treatment. — Ovariotomy should 
 be done with great care to avoid rupture of cyst and 
 dissemination of contents. Both ovaries should be 
 removed. 
 
 Results. — Radical cure of carcinoma of the ovary 
 when the cyst is unruptured and when the total 
 removal of both ovaries can be performed, is very 
 probable. It is the diagnosis of the condition which 
 is difficult. 
 
 (Note: Some cases of ovarian carcinoma of papil- 
 lary type are of a low degree of malignancy, and even 
 after laparotomy has disclosed a widespread peritoneal 
 implantation they may advance very slowly. Under 
 radium and roentgen-ray treatment the progress of the 
 disease may be much retarded.) 
 
 14. CARCINOMA OF THE BREAST 
 
 This condition is common in the female ; rare in the 
 male. 
 
 Symptoms.- — The earliest symptoms are those of a 
 tumor which is usually painless. The nipple may be 
 drawn in, or the skin may early show loss of mobility 
 over the tumor, or a definite adherence to it. This is 
 usually the earliest distinctive symptom. Later the 
 tumor enlarges, the axillary nodes show involvement, 
 extending to the subclavicular, the supraclavicular and 
 the mediastinal glands. Rarely the enlargement of the 
 axillary nodes is the first noticeable symptom of the 
 disease. The tumor becomes adherent to the muscles 
 of the chest wall, and may pass by direct extension to 
 the ribs, sternum, mediastinum, or pleural cavity, or 
 to the other breast. Ulceration may finally occur, or 
 the disease may extend to the liver, spine, cranial 
 cavity, or the long bones, such as the femur and the 
 humerus. The "brawny arm" of breast cancer is a 
 familiar late symptom, due to the blocking of the veins 
 and lymph vessels by the axillary growth. 
 
 Differential Diagnosis. — Conditions to be considered 
 are benign tumors of the breast — adenofibroma, papil- 
 lary cystadenoma, and other rare tumors — cystic dis- 
 ease of the breast, and chronic inflammatory processes, 
 such as syphilis, tuberculosis, or chronic abscess fol- 
 
39 
 
 lowing lactation. The most significant facts in the 
 diagnosis of cancer are the absence of pain, and the 
 early adherence of the skin to the tumor. A lump in 
 the breast of any woman, particularly if over the age 
 of 35 years, must be suspected to be cancer until path- 
 ological proof of some other disease is obtained. 
 
 Precancerous Conditions. — As age advances prac- 
 tically every one of the supposedly benign tumors and 
 diseases of the breast shows an increasing predisposi- 
 tion to malignant disease. Especially is this true of 
 chronic cystic growths, such as papillary cystadenoma. 
 Even the adenofibromas of adolescence occasionally 
 show subsequent malignant characteristics, either as 
 carcinoma or sarcoma. In any case, benign breast 
 tumors and diseases are best removed by operation if 
 the patient is over 30 years of age. 
 
 Doubtful Cases. — Cutting into normal tissue to 
 remove a suspicious nodule in the breast, and closing 
 the wound to wait a week or ten days for a micro- 
 scopic report, has been found to spread the disease and 
 to make cure improbable by subsequent radical opera- 
 tion, if cancer is found to be present. For this reason 
 the handling of doubtful cases is very difficult in dis- 
 eases of the breast. Two plans of procedure can be 
 recommended in doubtful cases : (a) Incision may be 
 made directly into the tumor, with removal of tissue 
 for frozen section diagnosis, if necessary, to be fol- 
 lowed immediately by cauterization of the wound, and 
 by the performance of the complete operation if can- 
 cer is discovered. This method of procedure is appli- 
 cable only where a sufficient knowledge of gross path- 
 ology, or the facilities for an immediate frozen section 
 diagnosis are available, and is recommended then only 
 in cases where, from the clinical symptoms, the proba- 
 bilities are against rather than in favor of the diag- 
 nosis of cancer, as in the case of women under 30 
 years of age. (&) In women of more advanced years, 
 where the symptoms are suggestive of cancer, the 
 safest procedure is to perform the radical operation at 
 once without incision into cancer tissue. In some very 
 small, and presumably very early cases, an amputation 
 of the breast and dissection of the axilla, without 
 removal of the pectoral muscles, may be permissible, 
 but the complete operation will be found the safest 
 method. 
 
40 
 
 Standard Operative Treatment. — The standard 
 "complete" operation for cancer of the breast demands 
 the removal in one piece of the whole breast, with the 
 skin over it, the pectoralis major and minor, and the 
 axillary contents, with the exception of the axillary 
 artery and vein, and the brachial plexus. Some sur- 
 geons advise the supraclavicular dissection also. The 
 incisions for this operation vary, and the defect to be 
 closed is always large. If the skin cannot be brought 
 together by plastic flaps a Thiersch graft may be neces- 
 sary. 
 
 Residts. — In favorable cases, with early operation, a 
 considerable percentage of cures may be expected. The 
 average case that comes to a general hospital, how- 
 ever, has only a moderate chance of cure. 
 
 IS. CARCINOMA OF THE PENIS 
 
 This condition is rare. It is associated with chronic 
 irritation, such as venereal warts or phimosis. 
 
 Symptoms. — These are papillary or ulcerated indu- 
 rated tumor, and early extension to the lymph nodes of 
 either groin, or both. 
 
 Standard Operative Treatment. — The standard oper- 
 ative treatment is amputation of the penis, and dissec- 
 tion of both groins. Prophylaxis, circumcision, clean- 
 liness and treatment of venereal warts and sores should 
 be employed. 
 
 Residts. — Early radical and complete operation gives 
 good prospects for radical cure. 
 
 16. CARCINOMA OF THE VULVA 
 
 This is the squamous cell type of carcinoma. It is 
 rare and almost entirely limited to women beyond the 
 menopause. 
 
 Symptoms. — These are pronounced itching, often for 
 several years, before the ulcer appears, moderate 
 bloody discharge, in some instances pain on urination, 
 early glandular involvement of inguinal and femoral 
 lymphatics. 
 
 Precancerous Conditions. — These are "kraurosis" or 
 leukoplakia of the vulva. Treatment of these condi- 
 tions by radiation may be advisable. 
 
41 
 
 Differential Diagnosis. — Syphilitic ulceration, chan- 
 croid, erosions from prolapse, and polyp of urethra 
 are to be considered. 
 
 Standard Operative Treatment. — Radical operation 
 with removal of vulva, together with all of the deep 
 and superficial inguinal and femoral lymph glands on 
 both sides is the standard operative treatment. 
 
 Results. — Only with early and radical operation is 
 the prognosis even moderately good. 
 
V 
 SARCOMA 
 
 Sarcoma is a malignant tumor of connective tissue 
 origin. Various types of rapidly growing connective 
 tissue cells may occur, such as large and small round 
 cells, spindle cells, giant cells, pigment cells, cells of 
 the mucoid type found in the umbilical cord, lymphoid 
 cells, and mixtures of all of these different types. Sar- 
 coma may arise primarily in any tissue of mesenchymal 
 origin, but in general the subcutaneous and submucous 
 tissues, the fasciae, the bones and lymph nodes, are the 
 more common points of origin. Sarcoma attacks per- 
 sons at all times of life, from infancy to old age. It 
 grows, as a rule, with great rapidity, as it is abundantly 
 supplied with blood vessels. It infiltrates surrounding 
 tissues, and through the blood vessels more than 
 through the lymphatics, spreads to distant parts. So 
 far as known there are no presarcomatous conditions, 
 although trauma is believed by many writers to have 
 significance in the etiology of bone sarcoma. We do 
 not know what causes sarcoma, and we can do nothing 
 to prevent its origin. 
 
 1. SARCOMA OF THE BONE 
 
 There are two main varieties : (a) spindle cell, or 
 periosteal sarcoma; (b) giant cell, or other medullary 
 sarcoma. 
 
 (a) Spindle cell or periosteal sarcoma is a tumor 
 of extreme malignancy. Its onset is insidious; its 
 growth is rapid. Obscure pain or impaired function 
 of a limb is followed by the development of a swelling 
 of the bone. Rarely a spontaneous fracture is the first 
 definite symptom. Extension to the viscera, the lungs, 
 the liver and other organs may take place at any time. 
 The diagnosis depends on the roentgen ray picture, 
 which is practically unmistakable. Treatment is by 
 early and most radical operation — amputation. The 
 results are very discouraging, on account of internal 
 metastases. Treatment of inoperable or recurrent 
 cases by radium or roen f/ en ray yield very unsatisfac- 
 tory results. 
 
43 
 
 (b) Medullary sarcoma arises in the bonemarrow, 
 and produces a distension and thinning of the cortex 
 of the bone such that spontaneous fracture is very 
 common. The onset is insidious, and the symptoms 
 vague. A roentgen ray is suggestive, but not always 
 to be relied on with certainty to exclude bone cysts 
 and other benign lesions. The tumor often contains 
 giant cells as well as large and small round cells, and 
 its malignancy is much less than the periosteal type. 
 Extension is not so rapid and internal metastases are 
 not so often found. Local excision, and even incision 
 and curettage have been sufficient to cure in certain 
 cases. Amputation may be necessary, however, on 
 account of the extent of the tumor, and the impossi- 
 bility of saving the vessels and nerves to the distal 
 part. The prognosis is much better than with periosteal 
 sarcoma, although internal metastases occur in rare 
 cases. Treatment by radium and roentgen ray gives 
 promise of benefit in certain cases of medullary sar- 
 coma. 
 
 2. FASCIAL SARCOMA 
 
 Fascial sarcoma is, as a rule, of the spindle cell type, 
 yet its malignancy is much less than the spindle cell 
 sarcoma of periosteal origin. It appears as a hard, well 
 defined tumor of the subcutaneous tissues, fixed to the 
 deeper structures, and generally of slow growth. Its 
 invasive character is not so pronounced, and its ten- 
 dency to remote and visceral extension is less, although 
 pulmonary and hepatic metastases do occur. Wide 
 local removal without incision of the sarcomatous 
 tissue often cures. 
 
 3. SARCOMA OF THE SUBCUTANEOUS TISSUE 
 
 Sarcoma of the subcutaneous tissues, and of organs 
 such as the thyroid, the breast, the ovary, the 
 uterus, the intestine, etc., present a varied cellular com- 
 position, and a marked variation of malignancy. In 
 the breast, sarcoma is usually of the myxomatous type 
 and of low malignancy. In the uterus and ovary it is 
 usually spindle cell, and also of relatively low grade 
 malignancy, while in the subcutaneous tissues mixed 
 cell or round cell sarcoma, of rapid growth, great 
 infiltrative power, and rapid visceral and cutaneous 
 metastases may occur. The early symptoms are merely 
 those of a tumor of more or less rapid growth. Exten- 
 
44 
 
 sive removal of any such tumor of unknown origin 
 should be performed as early as possible, and a wide 
 margin of healthy tissue should be included. Only 
 the microscope can indicate the exact nature of the 
 tumor, and an exploratory incision into the tumor 
 should be avoided. The close relation of sarcoma to 
 the blood vessels is well established, and it is becom- 
 ing more and more a principle of good surgery that 
 the possibility of artificial metastases by incision or 
 trauma of a tumor, in situ, is a measure to be avoided, 
 if the best results are to be obtained. If an explora- 
 tory incision is absolutely necessary it may be per- 
 formed with the cautery knife, in order to seal the 
 blood vessels and lymphatics at the instant of their 
 division. 
 
 4. LYMPHOSARCOMA 
 
 A number of tumors, or of diseases lying close to 
 the border line between tumors and inflammatory dis- 
 eases, occur in the lymph nodes. Among these condi- 
 tions two are of special interest: (a) malignant lym- 
 phoma; (b) lymphosarcoma. 
 
 (a) Malignant lymphoma (Hodgkin's disease). 
 This is a disease, the nature of which is still under 
 investigation, which starts with the enlargement of 
 one or more lymph nodes, and progresses to a disease 
 of practically the whole lymphoid apparatus, with infil- 
 tration, invasion, and even visceral manifestations 
 similar to metastases. Some authorities believe it an 
 infectious process, a granuloma ; some believe it a new 
 growth. It is possible that both are correct and that 
 it starts as the result of an infectious or toxic agent 
 and progresses to the character of a malignant tumor. 
 The disease is not uncommon. 
 
 Symptoms. — The lymph nodes of one region, usually 
 the cervical nodes, enlarge. The disease rapidly 
 extends to other groups of lymph nodes and to the 
 visceral lymphoid tissue. Death is finally caused by 
 mechanical obstruction to one or another vital func- 
 tion, generally the respiration. The diagnosis is estab- 
 lished by the removal of one or more of the affected 
 lymph nodes, disclosing a tissue histologically typical 
 of the disease. 
 
 Differential Diagnosis. — Tuberculous lymphadenitis 
 must be excluded by the removal of a gland for micro- 
 
45 
 
 scopic examination, if necessary. Leukemic enlarge- 
 ment of lymph nodes is recognized by the differential 
 blood examination. The blood picture of Hodgkin's 
 disease is believed by certain writers to be character- 
 istic, but this is not always to be depended on. 
 
 Treatment. — Radical surgical treatment is advocated 
 by a few authorities, and vaccine treatment has been 
 tried, without much success. At the present day the 
 usual treatment is by roentgen ray or radium, and even 
 under this treatment the relief afforded is usually but 
 temporary, although life may be made far more com- 
 fortable and may be notably prolonged. 
 
 (b) Lymphosarcoma. — This is a malignant tumor, 
 made up of large round lymphoid cells. It occurs in 
 several situations, notably the tonsils. It is of uni- 
 centric origin, and from that point it invades the adja- 
 cent tissues, either directly into surrounding muscles 
 and fasciae or systemically into regional lymph nodes 
 and lymphadenoid tissue. Such tumors are rare. They 
 extend rapidly to the adjacent lymph nodes as well as 
 through the blood vessels by metastases to the viscera. 
 They are extremely malignant tumors, and are rarely 
 cured even by the most extensive surgical operations. 
 They are sometimes favorably affected by radiation 
 for a relatively brief period of time, but this can be 
 considered only a form of palliative treatment. 
 
 5. MELANOSARCOMA 
 
 One of the rarer but one of the most malignant 
 known forms of sarcoma is that composed of cells 
 similar to the pigmented cells of the rete. mucosum 
 —melanotic sarcoma. Such tumors occur also in 
 the retina, choroid, and other situations where pig- 
 ment-bearing cells are found. It is because of the 
 occurrence of melanosarcoma in pigmented moles that 
 the universal rule for the removal of such moles is 
 promulgated. Melanosarcoma, in its invasive charac- 
 teristics and in its extension to adjacent lymph nodes, 
 resembles carcinoma rather than sarcoma, and some, 
 indeed, believe that its cells are of epithelial origin. 
 In any case it is one of the most rapidly growing and 
 one of the most malignant tumors with which we have 
 to deal. When extension has occurred to adjacent 
 
46 
 
 lymph nodes a cure is rarely obtained, even by the 
 most radical operation. The liver is early involved. 
 The disease must be prevented by the removal of pig- 
 mented moles by excision, before they have undergone 
 this malignant change, or, at least, by their radical 
 removal together with the regional lymph nodes, on 
 the slightest sign of induration, ulceration, or on any 
 disposition to increase in size. 
 
VI 
 OTHER MALIGNANT TUMORS 
 
 1. MYELOMA 
 
 Myeloma is a term applied to a rare group of tumors 
 of the bone marrow. Some are local in origin, rapidly 
 growing and productive of wide metastases, and rapidly 
 fatal, while others are more systemic, or multicentric 
 in origin, and more slow growing, but also generally 
 fatal. Multiple involvement of the lymph nodes occurs 
 in certain forms of the disease. 
 
 Symptoms. — The onset is obscure — gradually pain 
 and tenderness occur over certain bones, and later 
 definite local enlargement of the bone can be recog- 
 nized, and bone absorption demonstrated by the roent- 
 gen ray. The destruction of the cortical bone and 
 the occurrence of Bence-Jones albumose in the urine 
 are characteristic symptoms. 
 
 Diagnosis. — Myeloma is to be distinguished from 
 the relatively benign giant cell medullary sarcoma and 
 the bone metastases of hypernephroma by microscopic 
 sections, as well as from bone cysts, syphilis, and othei 
 bone lesions by the roentgen ray. 
 
 Treatment. — Only the more local and less malignant 
 forms can be relieved by radical operative removal 
 The more systemic type is best treated by the roentgen 
 ray with the hope of retarding the progress rather than 
 of curing the disease. 
 
 2. ENDOTHELIOMA 
 
 A rare tumor, similar in structure to carcinoma, but 
 arising from certain tissues of endothelial origin like 
 the meninges, lymph nodes or serous membranes, 01 
 blood vascular system. Some endotheliomas (men- 
 ingeal tumors) are relatively benign, while others show 
 invasive and metastatic tendencies of a definitely malig- 
 nant character. 
 
 Symptoms. — There are no characteristic symptoms 
 of endotheliomas. A tumor arising primarily in a 
 structure of endothelial origin, usually of slow 
 growth, and of a low degree of malignancy is occasion- 
 ally demonstrated by microscopic examination to be an 
 
48 
 
 endothelioma. The endotheliomas of the meninges 
 form the most important group of these tumors 
 because they are one of the relatively small number of 
 types of brain tumor susceptible to radical removal. 
 The symptoms of a meningeal endothelioma are those 
 characteristic of a brain tumor, and the pathologic 
 diagnosis after removal is the only positive evidence 
 of the nature of the disease. 
 
 Treatment. — The treatment of all endotheliomas is 
 by radical operation, when the situation is one which 
 permits this measure to be undertaken. The prog- 
 nosis after complete removal is very favorable. 
 
 3. GLIOMA 
 
 Glioma is the specific cellular tumor of the central 
 nervous system, arising at all ages and at any point in 
 brain or cord, and forming more than one half of all 
 brain tumors. It is, however, a rare form of malignant 
 disease. 
 
 Symptoms. — A glioma usually replaces a considerable 
 portion of brain tissue, causing symptoms from (a) 
 general cerebral pressure, and (b) from focal destruc- 
 tion of nerve tracts and centers. General pressure 
 symptoms are severe headache, vomiting, slow pulse, 
 and choked disk, with amblyopia or amaurosis. Focal 
 symptoms depend on the location of the tumor, which 
 can often be determined accurately by expert analysis. 
 The course is usually progressive and fatal within an 
 average of ten months. Gliomas do not produce bulky 
 tumors, but replace a portion of the brain by soft 
 vascular tumor tissue or a more solid opaque tumor 
 mass which is poorly defined. A peculiar feature is 
 the tendency to sudden hemorrhage into the tumor 
 tissue, which may cause attacks suggestive of apoplexy. 
 The gliomas are prone to recur locally, but they do 
 not produce metastases. The structure presents vari- 
 able proportions of ganglion cells and nerve fibers, 
 most of the cells being small and round. 
 
 Treatment. — The surgical treatment of glioma, 
 involving craniotomy, is very unsatisfactory, but most 
 cases deserve an exploratory operation on the suppo- 
 sition that the growth may be localized or that some 
 less malignant tumor may be found. The prognosis 
 
49 
 
 is grave on account of the invasive character of the 
 tumor, and the difficulty of complete removal. In any 
 case a decompression can be performed as a palliative 
 measure. 
 
 4. HYPERNEPHROMA 
 
 Although hypernephroma is the commonest tumor 
 of the kidney, it is nevertheless a rare disease. Most 
 hypernephromas arise from the renal tissue, a few 
 from misplaced adrenal rests in the kidney or other 
 organs, and some from the adrenal itself. They 
 exhibit all grades of malignancy, some being benign 
 adenomas, some adenocarcinomas, and others highly 
 malignant carcinomas. The cells are large and clear, 
 and resemble endothelium. The malignant tumors are 
 extremely vascular, grow rapidly, and produce bulky 
 tumors in a few months. They often invade the renal 
 vein and vena cava, and produce local peritoneal exten- 
 sions and general metastases in liver, lungs, bones and 
 brain. Bulky destructive bone metastases are charac- 
 teristic, and often appear before the primary tumor 
 is suspected. 
 
 Symptoms. — Local pain, a tumor in the region of 
 the kidney, and hematuria are the chief diagnostic 
 signs. Roentgen-ray examinations of the long bone? 
 are necessary to exclude metastases. 
 
 Treatment. — The treatment is immediate extirpation 
 of tumor and kidney, but it is successful only in the 
 early stages of comparatively benign tumors. The 
 first step in the radical operation should be the ligature 
 of the renal veins to prevent dislodging tumor emboli 
 into the general circulation. 
 
 S. NEUROCYTOMA 
 
 Neurocytoma is a cellular tumor derived from nerve 
 cells. It may originate from embryonic or adult nerve 
 cells. Two groups of these rare tumors are recognized 
 — those arising in the central nervous system (neuro- 
 epithelioma) and those outside the central nervous sys- 
 tem in the distribution of the sympathetic nervous 
 system (sympathetic neurocytoma). Both tumors are 
 chiefly of pathologic interest on account of the identi- 
 fication of typical neuroblastic formations of cells in 
 rosettes or with the characteristic neurofibrils of the 
 
50 
 
 peripheral nerve system. They are both extremely 
 malignant. Their symptoms are not characteristic, and 
 operative treatment rarely succeeds in accomplishing 
 their complete removal. 
 
 6. ADAMANTINOMA 
 
 Adamantinoma is a rare tumor in human beings, but 
 one of sufficient importance to justify its mention. It 
 usually occurs in young adults. The tumor arises from 
 the enamel organ of a misplaced or unerupted tooth. 
 The structure of the enamel organ which is designed 
 to secrete enamel from epithelial cells surrounding the 
 crown of the unerupted tooth, gives rise to a charac- 
 teristic histologic picture. When an overgrowth of 
 these cells takes place it duplicates a typical carcinoma 
 — that is, solid columns of epithelial cells grow in a 
 fibrous tissue matrix. Although the histologic picture 
 is that of carcinoma, these growths are relatively less 
 malignant. They are locally invasive of the surround- 
 ing tissues, and on this account show a tendency to 
 recurrence after incomplete removal, but only in rare 
 instances do they produce remote metastases. 
 
 Symptoms. — The symptoms are those of any slow 
 growing tumor of the jaw. The diagnosis is estab- 
 lished only by a pathologic examination of the tissue. 
 
 Treatment. — The treatment consists in the thorough 
 operative removal of the disease. Unless this is accom- 
 plished the danger of recurrence is considerable. 
 
 7. CHORIOMA 
 
 Chorioma or chorionic epithelioma is a highly 
 malignant tumor of the uterus which occurs chiefly 
 after hydatid mole (44 per cent.) ; after abor- 
 tion (30 per cent.) and after normal labor (22 per 
 cent.). It occurs so frequently at a period of from 
 five to eight weeks after hydatid mole that all such 
 cases should be watched for the development of. 
 malignant disease. All moles should be carefully 
 examined in the gross and microscopically for malig- 
 nant changes. Adherent moles or placentas and mul- 
 tiple pregnancies, especially, predispose to chorioma. 
 
 Symptoms. — The chief symptom is repeated bleed- 
 ing from the uterus, which may or may not be 
 enlarged. The bleeding usually begins in the third 
 
51 
 
 month of a supposed pregnancy. Bluish vaginal metas- 
 tases have often been the first sign detected. The 
 diagnosis is to be made from the curettings, showing 
 the characteristic two types of cells of syncytial and 
 Langhans layers. The prognosis is always unfavor- 
 able, but when villi are preserved in the tumor 
 (destructive placental polyp) not a few cases have 
 recovered. The association of chorioma with large 
 corpus luteum cysts is thought to be of significance in 
 the origin of these tumors, and it is believed by certain 
 writers that it is in response to the excessive internal 
 secretion of these lutein cysts that the syncytial cells 
 take on the enhanced invasive growth which leads them 
 to perforate into the blood vessels and produce remote 
 metastases. 
 
 Treatment. — The treatment is hysterectomy. 
 
 8. TERATOMAS AND MIXED TUMORS 
 
 Among the rare types of malignant disease are the 
 two groups of tumors of embryonic origin, called 
 teratomas and mixed tumors. Not all tumors of these 
 two groups are malignant, although all may be said to 
 have potential malignancy. They are due to vestiges 
 of tissue misplaced in embryonic life. 
 
 Tumors of the teratoma class may be regarded as 
 misplaced and incompletely developed masses of tissue, 
 which if not misplaced and incompletely developed 
 would have formed a complete fetus — a twin to the 
 individual who presents the tumor. 
 
 Mixed tumors are due to misplaced vestiges of tissue 
 less complicated than the teratoma, yet including two 
 or more distinct tissues arising from different ger- 
 minal layers. The best examples of teratomas are pro- 
 vided by the mixed tumors of the testicle and ovary, 
 which present tissues of great variety from all three 
 germinal layers, skin, gland-tissue, bone, cartilage, 
 endothelium, and a variety of mesoblastic tissues. The 
 more common mixed tumors are those occurring in 
 the salivary glands, and show chiefly glandular epithe- 
 lium and cartilage, and various types of more or less 
 embryonic connective tissue. 
 
 Certain of these teratomas and mixed tumors remain 
 virtually benign tumors throughout life, while others 
 undergo malignant change and develop a tendency to 
 rapid infiltrative growth and metastases of the most 
 
52 
 
 malignant character. While the form of malignant 
 change which is most common in these tumors is that 
 productive of tissue of a carcinomatous type, some 
 tumors, especially those of the testicle, show areas 
 which are not distinguishable from sarcoma, and the 
 terms of carcinoma and sarcoma have been used some- 
 what loosely in describing tumors of this type in litera- 
 ture. 
 
 Symptoms. — No symptoms are especially character- 
 istic of the teratomas and mixed tumors. Their origin, 
 however, being largely restricted to certain special 
 regions, leads to the suspicion of the diagnosis when 
 tumors of previously slow growth in those regions 
 suddenly take on malignant characteristics. 
 
 The teratomas occur chiefly in the ovary, testicle, 
 base of the skull, and in the mediastinum, whereas the 
 mixed tumors are found chiefly in the region of the 
 salivary glands, the breast and the kidney. 
 
 The diagnosis .of tumors of this character depends 
 ultimately upon the pathologic examination of the 
 tissue, and the recognition of its complicated structure. 
 
 The treatment in the earliest stages — i. e., before 
 the tumor shows extensive metastases, consists, of 
 course, of radical surgical removal. After the stage 
 of possible cure by operation has passed, roentgen rays 
 and radium offer the only hope of delaying the progress 
 of the disease, and of relieving the patient's symptoms 
 as they arise. 
 
VII 
 
 TREATMENT OF INOPERABLE 
 
 OR RECURRENT CANCER 
 
 Much may be done to relieve the patient with recur- 
 rent cancer. Not only can life be prolonged, but it can 
 be made much more comfortable by palliative treat- 
 ment. The more important methods of treatment are 
 as follows : 
 
 1. Roentgen Ray. — Heavy treatments with roentgen 
 rays from a tube of standard strength up to, but not 
 beyond, the resisting power of the adjoining skin, can 
 be used to relieve pain, diminish sloughing and dis- 
 charge, and to retard growth or even cause shrinkage 
 of tumor tissue. Where the tumor tissue is superficial 
 and ulcerated the best effects are obtained, and when 
 the tumor tissue is spread over a wide area, as in 
 recurrent cancer of the breast, roentgen rays are to 
 be preferred to radium. For deeply situated tumors 
 (abdominal, mediastinal, etc.) the roentgen ray is of 
 value, although its results are not so certain. 
 
 2. Radium. — Radium can be used in much the same 
 manner as roentgen rays. It is not so well adapted to 
 the treatment of large superficial areas as the roentgen 
 ray, but for intensive treatment of smaller superficial 
 areas, and for deep tumors of the mediastinum and 
 prostate, its effects are promising. It is especially val- 
 uable in recurrent cancer of the cervix and of the 
 body of the uterus, in cancer of the rectum and pros- 
 tate, in superficial and inoperable cancer of the mouth 
 and pharynx, and in some of the more general dis- 
 eases, such as leukemia and lymphoma, or Hodgkin's 
 disease. 
 
 3. Palliative Operations. — Palliative operations are 
 often indicated in cases of recurrent cancer to relieve 
 the patent of an offensive sloughing tumor, or merely 
 for the relief of pain or of other mechanical symptoms. 
 In such cases the cautery can often be employed to 
 advantage for the control of hemorrhage, and to 
 increase the destruction of tumor tissue without dis- 
 semination. Operations of this nature are often advis- 
 able in recurrent cancer of the cervix and of the breast. 
 
54 
 
 In cancer of the pharynx or larynx tracheotomy is 
 often an operation of necessity, and in incurable cases 
 of cancer of the stomach or intestine, where obstruc- 
 tion exists, a palliative gastro-enterostomy or an intes- 
 tinal anastomosis may relieve the patient's most dis- 
 tressing symptoms. Colostomy gives relief to much 
 of the distress in cancer of the rectum, and a supra- 
 pubic drainage gives relative comfort in cases of 
 advanced cancer of the bladder and prostate. In many 
 cases of advanced cancer about the face, a combination 
 of operation, cautery, and radium or roentgen-ray 
 treatment may yield results quite unattainable by any 
 one method used alone. Finally, even so severe an 
 operation as an amputation at the shoulder joint may 
 be performed for the "brawny arm" of recurrent can- 
 cer of the breast to relieve the patient of an intolerable 
 burden. 
 
 4. Symptomatic Treatment. — Symptomatic treatment 
 of recurrent cases of cancer yields results in the way 
 of relief of suffering which have not always been 
 appreciated. Opiates are indicated as surely in hope- 
 less cases of cancer as in any other condition with 
 which the physician has to deal. Their use, however, 
 should be guarded, and should be supplemented with 
 other sedatives in order to delay the necessary increase 
 of dosage. 
 
 Where the pain of nerve pressure exists, as in spinal 
 metastases or tumor infiltration of the brachial or 
 lumbar plexus, special operations for the division of 
 sensory nerves or spinal nerve tracts may be advisable, 
 although such measures are not widely practised. 
 
 Finally, the nurse can contribute quite as much to 
 the comfort of the advanced case of recurrent cancer 
 as can the physician. Frequent and gentle dressing of 
 ulcerated surfaces to diminish discharges, relieve offen- 
 sive odors and prevent distressing infections, do much 
 to make the patient's condition bearable, while the 
 maintenance of a comfortable position, the avoidance 
 of pressure sores, the occupation of the mind of the 
 patient, and the maintenance of nutrition by carefully 
 selected nourishment, all help materially to alleviate 
 distress. 
 
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