pecially when subjected to irritation through rubbing of the
clothing, scratching, or pressure, are well recognized
precancerous conditions; this fact was emphasized in a
(now classical) paper by Professor Keen delivered in 1904.
He showed that the cancerous change frequently occurred
some thirty, forty, or even fifty years after the existence of
the wart or mole, and that, as there was no special reason
why the growth should be removed today rather than
tomorrow, or this year rather than next, it was allowed
THE PREVENTION OF CANCER 169
to remain until some local irritation, such as combing a
wart on the head, or through the pressure of a hat or rub-
bing of a collar on a mole of the neck, the wart or mole
suddenly took on a growth which in most cases was malig-
nant. The moral is to remove such at the first opportunity,
but if there are many warts or dark moles on the body the
subject may wait until there is the slightest sign of irrita-
tion or growth in any wart or dark mole, when it should be
immediately removed by a surgeon. The habit of par-
tially removing such growths by scraping them off the
skin and leaving the base is illustrated by a case coming
to the attention of the author, where a mole became irri-
tated and was partially removed, and a general malignant
disease of all the internal organs followed within a month
Warts or moles should be removed properly with their
skin bases by a surgeon after the injection of cocain.
Cancer of the lip is rarely seen except in smokers, and is
thought to be due to the heat or pressure of the pipe stem.
In the mouth white patches form on the tongue and inside
of the lips and cheeks more usually on the tongue in
smokers and this condition quite often becomes cancerous
unless smoking is stopped and the white patches are
cauterized. The constant taking of hot food or drink may
produce dangerous irritation in the mouth.
Parts subjected to blows should be carefully watched
and operation should be done on the slightest sign of malig-
nant disease. Coley has found a history of previous injury
in about one-third of 328 cases of cancer.
Cancer of the breast, so common in women, has a very
bright outlook when the tumor is removed early before
spread of the disease into the surrounding tissue and the
glands in the armpits as we have seen. Any lump in the
breast demands the immediate attention of a surgeon.
170 THE PREVENTION OF DISEASE
There are no means by which the innocent lump may be
distinguished from the malignant tumor in many cases.
The inflammatory lump or the innocent tumor frequently
become malignant in time.
It is common practice for a physician to find a movable
lump in the breast of a young woman, and tell her to come
back in six months or some other time, adding there is
nothing he can see to worry about. There is nothing that
anybody can see to worry about, but there may be some-
thing very serious that no one can see or feel to cause worry.
If such a lump is removed and found innocent the opera-
tion is neither dangerous nor disfiguring, and the patient
has the satisfying knowledge that there is no danger from
that source in the future. If it is allowed to remain, danger
threatens, and the lump ought to be a continuous cause of
anxiety. A typic cancer occurs in a woman of middle age
or over, is situated in the upper and outer part of the
breast, and is not painful or tender at first, but later may
become painful. After a time the tumor becomes fixed
in the skin and may cause dimpling of the skin or a
drawing in of the nipple, and then the tumor is not freely
movable. The tumor is best felt not by pinching up a
fold of the breast, but by pressing the surface of the breast
with the open palm against the chest while the subject is
lying flat on her back.
But there are all kinds of exceptions to this description.
A sore on the skin or irritation of the skin about the
nipple, or a discharge from the nipple, should lead a woman
to consult a surgeon at once.
Patients in their twenties may have cancer of the breast,
it may occur in any part of the breast, pain may be the
first symptom, it may be freely movable and not possess
the slightest suggestion of cancer, or it may appear inflam-
matory. At the risk of repetition, for it cannot be too
THE PREVENTION OF CANCER 171
strongly emphasized, a woman with a lump in her breast
should go at once to a competent surgeon for advice. The
modesty which causes the patient to hide her trouble until
it begins suddenly to grow apace is terribly false and mis-
taken. A tumor of the breast which has caused no trouble
for months or years, and then begins to rather rapidly en-
large is almost invariably cancer, and the chances' are that
the surrounding tissue will be so invaded that the likelihood
of cure will be much reduced. Almost one-third of the
patients with cancer of the breast now come to surgeons
when the growth has already advanced to a stage when
operation really offers no hope of cure.
Cancer of the Stomach. As we have seen, the stomach
is the most common situation of cancer in the whole body;
one-third of all the cancers originate in this organ. Dr.
Mayo has pointed out that cancer of the stomach is un-
common in animals and savages, that there is something
in the habits or preparation of food which favors the
occurrence of cancer in civilized man.
Cancer of the stomach can be less readily diagnosed in its
earlier stages than any other common form, so that at
present but about one-third of the cases at the best
come to the surgeon in time for successful removal of the
growth. But, as we have noted, ulcer of the stomach is
the most frequent precancerous condition, and a previous
history of ulcer of the stomach is found in more than half
the cases by some authorities, while positive evidence of
ulcer as a cause of cancer has been proved by microscopic
examination in 62 per cent, of cancers of the stomach re-
moved during several years at the Mayo clinic.
So that ulcer of the stomach must be treated to avoid
cancer. While this book is not intended as a text-book
in medicine, a few words as to ulcer of the stomach may not
be amiss. Many cases of ulcer were formerly called ner-
172 THE PREVENTION OF DISEASE
vous dyspepsia. The chief distinguishing feature is the
occurrence of pain at a regular time after eating one-half
hour to five hours which is relieved by food, vomiting,
or saleratus, and is accompanied with much gas, heart-
burn, and acidity. Attacks occur during periods for years
and there are long intervals of good health intervening.
Medical and surgical cure of chronic ulcer is possible, and
such symptoms should not be regarded lightly, if only be-
cause cancer may be the ultimate end.
Therefore cancer appears in persons who are having
symptoms of ulcer of the stomach, in those who have been
well for many years after a former history of ulcer, and in
about half of the cases the symptoms of cancer come out of
a clear sky in persons of middle age who have previously
enjoyed good health. This fact is one of the most sus-
picious possible i. e., the occurrence , of symptoms of
continuous severe indigestion in one of middle age or past
who has previously been free from stomach trouble.
Thus, the aggravation of previous symptoms of stomach
trouble, or the sudden appearance of them in a person past
young adult life, are equally suggestive. The general con-
dition is as characteristic as are stomach symptoms.
The patient begins to lose weight, strength, appetite and
energy, suffers from mental depression and weariness, and
has a sense of "impending evil." There is pallor about the
nose, eyes and mouth, and the face has a pinched expres-
sion (Graham). Pain in the stomach may be absent, but
usually there is a continuous indescribable feeling of dis-
tress, worse after eating, with the presence of much gas
Vomiting of undigested food many hours or days after
it has been taken is particularly suggestive, especially if
some dark blood is present.
The patient may feel a movable lump in the region of the
THE PREVENTION OF CANCER 173
stomach, and this tumor may be evidence of a rather favor-
able case for operation.
The new use for the x-ray in the examination of the
stomach within the last few years has been of much aid in
the diagnosis of ulcer and cancer, but should never be
employed apart from physical examination by an expert
in stomach troubles, as the findings of the x-ray must be
construed in the light of bedside experience.
Since cancer of the womb is common, and the majority
of cases (90 per cent.) come to the surgeon too late for
satisfactory cure, the importance of the knowledge of
suggestive signs cannot be too strongly emphasized
nor too quickly acted upon. The occurrence of local irri-
tation here is an important precancerous condition; that is,
the existence of lacerations, which are the rule following
childbirth. The repair of these is then always essential,
if only for the prevention of cancer, although they are a
source of many other troubles. Cancer should always be
thought of in women of middle age (thirty-five to forty)
when there is irregular flowing following severe exertion or
at other times. The same condition is common during the
change of life, and this causes women to slight the symptom
and neglect the trouble when it is in the most curable stage.
Women should always consult a doctor and insist on a
local examination in any case of irregular flow, even if it be
If such occur after the change of life is apparently past
the demand for local examination is even more urgent. A
colorless or brownish watery discharge, with or without un-
pleasant odor, is another suggestive sign. Pain in the
lower part of the body or thighs may or may not be present,
as well as pain and irritability of the bladder.
The repair of lacerations following childbirth may, there-
fore, prevent future precancerous conditions, while seeking
174 THE PREVENTION OF DISEASE
advice on the first appearance of the slightest irregularities,
as suggested above, may be the means of saving the pa-
tient's life in early middle age or at any time thereafter.
In the abdomen a chronic inflammation of the appendix
and gall-bladder may lead to cancer in these organs;
particularly is this so in the case of the gall-bladder.
Operations to remove these organs will, therefore, not only
cure the appendicitis and gall-bladder trouble, with their
accompanying digestive disturbances, but will prevent the
possibility of future cancer in these parts. s^
Cancer on the skin, we have seen, has its precancerous
stage in irritation of some already existing skin troubles, as
warts, pimples, and moles, or scaling or scurfy patches in
old persons. This remark applies especially to the thick-
ened, scaly patches perhaps as large as a pea or bean
that are common on the face, ears, or hands in middle age
and beyond. The scales -are white or brownish and come
off only to return again. Then there are hard, brown
warty patches on the face that crumble when picked off-
only to reappear. These conditions may be readily re-
moved by freezing with carbonic acid snow before they
become cancerous. Irritation about the nose, lips, tongue,
and angles of eyes should receive particular attention be-
cause these are favorite sites of cancer. All sores and
ulcers must be treated to prevent them from becoming
chronic, and then a possible source of cancer. Cancer
of the skin occurs more often on the face and head,
in elderly men on the site of skin defects. Cancer of
the lip is most frequent, and begins in men over forty
on the under lip as a thickening or warty growth at
the margin of skin and mucous membrane. This usu-
ally is produced by a straight, short-stemmed pipe,
as more likely to be hot. The little pea-sized wart or
thickening of the lip becomes raw and then scabs over, but
THE PREVENTION OF CANCER 175
does not heal permanently. After three or more months
lumps or enlarged glands form under the jaw, but when this
happens the proper time for operation is past. The radical
operation, in which all the glands in the upper part of the
neck are removed before they are invaded, is rewarded by
permanent cure in almost all cases, as noted above.
A small thickening or abrasion on the lower lip, persist-
ing for some months in a man over forty, is almost sure to
Cancer of the nose, face, eyelids, forehead, ear, back of
the hand, etc., beginning in a wart, mole, scurvy, patch,
or red, yellow, or pearly pimple, enlarges, crusts, and then
gradually disappears, melting away into a raw ulcerated
spot, which may gradually involve the surrounding skin.
The ulcerated or excavated raw patch has raised, pearly
borders. Its growth is slow and several years may be
required for it to become of much depth or size and extend
all over the face. In some cases the original wart, mole,
pimple, or scurvy patch may grow into a tumor, which later
breaks down and ulcerates, and in other cases it presents
a number of raw projections like a cauliflower. Cancer
of the tongue is quite common, and starts from the irrita-
tion of hot and cold food, an irregular and sharp tooth, or
the white patch caused by excessive smoking. There is at
first a crack in the tongue and soon a raw spot or ulcer with
a thickened base. Almost all of the skin cancers are quite
susceptible of permanent cure in the beginning by removal
with the knife before the disease has permeated into the
neighboring glands. Various means are used to remove
cancers of the skin, as caustics, x-ray, radium, freezing,
etc., but growths can be removed at once by the knife, and
only by this measure can just the proper amount of tissue
be destroyed by the directing hand of the able and ex-
perienced surgeon. But superior to this and all other cura-
176 THE PREVENTION OF DISEASE
tive means is the removal of the precancerous stage of
cancer of the skin and the avoidance altogether of the
occurrence of the naturally dreaded malignant disease.
re-Ray and radium may cure skin cancers, but they should
not be used to treat deep-seated or early growths anywhere
which are curable by the knife (Mayo). Cancer cells are
more readily destroyed by heat than healthy tissue cells,
so that heat, by a sort of slow cooking, is now used in the
treatment of cancer not curable by the knife. By this
means the cancer growth may be arrested even if a per-
manent cure is not obtained. An electrically heated in-
strument is used, with the patient under ether.
Immunity to Cancer. Gaylord found that there is im-
munity to cancer. That mice sometimes spontaneously
recover from inoculated cancer; that these cannot again
be given cancer; and that their blood confers slight curative
and immune effects when it is injected into animals suf-
fering from cancer.
There have been some recoveries from malignant tumors
in man caused by the injection of cancer cells from other
human patients or animals in the same way that we cure
infections by the use of vaccines composed of the dead
germs causing infections. One object of operating in the
early stage of cancer is that then the patient's immunity is
strongest. In the late stages of cancer operation may lead
to rapid recurrence and death, as it seems to aggravate
the disease in the absence of immunity. In cases where
the cancer is of slow growth there is much natural im-
Some persons and families appear to naturally possess
some immunity to the growth of cancer, and the opposite
tendency may explain an hereditary susceptibility to
cancer (much questioned). Dr. Slye has recently been
able to breed families of mice in which cancer occurred in
THE PREVENTION OF CANCER 177
most of the adult individuals. This is either due to in-
herited lessened immunity to cancer or to increased sus-
ceptibility to the effects of irritation or injuries to the
tissues. There is no reason why these facts cannot be
applied to the human being, and why we are not justified in
saying that cancer may be inherited, meaning, as in the case
of consumption, that the tendency is inherited. Editor-
ially, the Journal of the American Medical Association
(April 17, 1915) regards Dr. Slye's work as "one of the
great contributions to our knowledge of cancer." Dr.
Slye draws two practical deductions: (1) The elimination
of sources of irritation of the tissues in persons of high
cancer ancestry; and (2) that the control of marriage, so
that cancer may not be potential on both sides, ought to
decrease the frequency of human cancer to a considerable
degree. It has been found that after .great improvement
from one or two treatments of cancer with x-ray or radium,
the growth may suddenly become much worse and may
spread to various parts of the body. It is known that the
power of immunity against the growth of germs and cancer
in the body resides in the lymphatic system (and in
the bone-marrow and spleen), and that this system is
weakened by overuse of either radium or x-ray, hence the
need of the greatest care and experience in their use.
Cancer Heredity. The hereditary tendency to cancer
is doubted by leading medical authorities. Dr. William
Mayo affirms that he knows "no evidence that would lead
to this belief" i. e., that cancer is hereditary. He says
the tenet that some families have tissues which on chronic
irritation are more apt to develop cancer is purely problem-
atic, and also notes the fact that the occurrence of cancer in
several members of a family is not strange considering its
frequency. He quotes the enormous statistics of Hoffman,
statistician of the Prudential Insurance Co. of America,
178 THE PREVENTION OF DISEASE
who finds not the slightest evidence "to warrant the belief
that cancer is in any sense hereditary."
Taylor summarizes the influence of heredity in cancer as
follows: (1) That in most instances heredity exerts no
influence in cancer. (2) That there may possibly be an
exception in some families. (3) That some precancerous
conditions, as warts and birthmarks, may be hereditary.
The most striking example of a "cancer family" is that of
Napoleon. He himself, his father, two sisters, and one
brother died of cancer.
Cancer heredity is, then, doubtful and is not by any
means an ascertained fact.
Cancer is not contagious. Among the thousands of
cancers operated upon daily throughout the world not an
instance has occurred of cancer following from the many
accidental cuts and pricks sustained by surgeons in their
work. Other infections are frequently transmitted in this
way. Contact of husband and wife, even when the sexual
organs are involved by cancer, does not produce cancer in
the healthy party.
When cancer does occur in husband and wife, as is not
uncommon, it is only coincidence, such as would be ex-
pected from the frequency of the disease.
To indicate the enormous extent of malignant disease
in this country the statistics show that there are 80,000
deaths from cancer in the United States annually, includ-
ing 25,000 deaths from cancer of the stomach and 18,000
deaths from cancer of the breast. Also that the rate of
mortality from cancer is increasing 2.5 per cent, per
But if one heeds the preliminary stage of cancer, which
we have endeavored to impress upon the reader in this
chapter, the predisposing causes of irritation may be
removed in most cases before cancer results.
THE PREVENTION OF CANCER 179
Even when the patient goes to the surgeon for the first
time in the early period of genuine cancer the curative re-
sults of operation are wonderfully better than those ordi-
narily obtained in cancer in the various stages in which it
is treated today. Thus, Dr. Bloodgood, the distinguished
surgeon of Johns Hopkins, and the leading authority on
cancer in this country, offers the following encouraging
statement: "From what we know of the early signs of
cancer and the local growth in the early stages of cancer, or
what precedes cancer, we should draw the greatest en-
couragement as to the probability of the percentage of
cures possible in these early stages by good surgery. In the
breast it should be at its worst 86 per cent., in local cancers
of the skin over 98 per cent., in the lip and tongue over 90
per cent., in the bone over 75 per cent. With the ac-
cumulating experience of each succeeding year with such
early cases, the percentage of cures increases."
THE PREVENTION OF SEXUAL DISEASES AND
IN the realm of preventive medicine no more vital subject can
be considered than that which stands at the head of this chapter.
It is vital partly because of its fundamental relation to human
society and race betterment, and partly because until recently the
whole discussion of reproduction and the sex life has been distorted
by misconceptions, befogged by ignorance, and veiled by mysticism.
The medical profession will welcome the author's scientific and
conservative presentation of this subject as representing a message
from their profession to the public.
The laity will welcome the chapter as presenting much desired
and highly prized information expressed in clear and concise lan-
guage, authoritative and reliable.
The author is especially to be commended for the stress which
he lays on the care and instruction of children by their parents,
with a view of controlling physical conditions and of implanting
'at an early age wholesome ideas and high ideals.
WINFIELD SCOTT HALL.
This is a tremendous subject, but the discussion herein
will be chiefly confined to protection of the individual rather
than the public. There are but two important sexual
diseases gonorrhea and syphilis. The prevalence of
these diseases is much greater than most persons realize.
Authorities have estimated that 8 out of every 10 men in
New York have had gonorrhea, and that 3 out of every
5 married women have acquired the disease in some de-
gree in consequence. It is also calculated that 75 per cent.
THE PREVENTION OF SEXUAL DISEASES 181
of all operations on the sexual organs of women, and 60
per cent, of the work done by specialists in women's dis-
eases, and 80 per cent, of the deaths of women from inflam-
mation of the sexual organs, result from gonorrhea. A
large part of sterility in both men and women (estimated at
50 per cent.) is caused by gonorrhea. Ten per cent, of all
blindness and 70 to 80 per cent, of blindness in the newborn
are attributable to gonorrhea.
Gonorrhea is almost always contracted by sexual inter-
course with a victim of the disease, and five to six days
must intervene (more rarely three to seven days) before the
first symptoms arise. These usually consist in frequent
and painful urination, accompanied by a whitish discharge
from the urinary passage which causes a cloudiness of the
urine first passed.
The disease may run a few weeks with complete recovery
or may become chronic and last for months, or, rarely, for
years, during which time the patient may be capable of
communicating it by sexual intercourse. The inflamma-
tion frequently invades various parts of the sexual and
urinary tracts of the male and female, but is not by any
means confined to these organs.
Gonorrhea may produce general blood-poisoning
through the presence of the special germs in the blood, and
these may also attack the heart or joints, with the most
serious results. So-called gonorrheal rheumatism is
a very frequent complication, and there are many other
sequels of the disease. Husbands who have had attacks
of gonorrhea may infect their wives, and if the latter be-
come mothers, they may transmit the disease to the eyes of
their newborn infants during the process of birth. This is
due to direct -contact of the baby's eyes with germs of
gonorrhea in the birth-passages of the mother, and if this
does not happen, there is no other acquired or inherited
182 THE PREVENTION OF DISEASE
taint in the offspring from the disease in the parents.
Gonorrhea in either sex may lead to death years after its
apparent cure. Thus, a male patient of the author's has
recently died from the effects of a total obstruction of the
urinary passage (a stricture) caused by gonorrhea acquired
some forty years previous. The consequent retention of
urine led to a general poisoning (uremia) of the whole sys-
Syphilis, while usually contracted by sexual intercourse,
is sometimes acquired in other ways, as by means of
drinking cups, towels, eating utensils, brushes, combs,
barbers' and surgeons' instruments, kissing, etc. Syphilis