Medical Society of the State of North Carolina. An.

Transactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) online

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phase of cancer which relates to the public. Under the first head let me
say that to the profession cancer is not in any sense a new problem. Tt
is as old as history. We were taught in our college days, as were our
fathers, that cancer always begins as a local disease and becomes general
only late in its history. We were also told that surgery applied early
was the only sure remedy. We were further taught that lumps, moles,
chronic fissures, etc., should be looked upon with suspicion; that they
were either cancerous from the beginning or had a natural tendency to
malignant degeneration. I mention, these things simply to call your
attention to the fact that the intelligent physician has all along been
familiar with the most important phases of the cancer problem. The
chief difficulty has been to get the public to understand the true signifi-
cance of these things.

Hence this great movement for the education of the public in order
that those afflicted with cancer may have the benefit of prompt and.
efiicient treatment.

I said that intelligent physicians have understood the question all
along. This is true ; but we fell into the grievous error of assuming that
what was so clearly understood by thinking members of the professioit
must be patent to every one. In this we find we are mistaken. There
are still those in every community who believe, if we may judge by their
actions, that cancer is cured by rubbing the local disease into the system.
In this community, which justly boasts of a high order of intelligence,
there are people who pay a quack to rub a handkerchief between his
hands and lay it on their cancerous sores, believing in its healing powers.
All over the country, from time immemorial, the people have been cursed
by the so-called "cancer doctor," who has a remedy, always a secret
formula, possessing such discriminating virtues that it will eat out the
cancer and not harm the healthy tissues. Eecently I visited a great city
noted for its wealth, its learning, its philanthropies. In the midst of this
famous center I attended a meeting in a temple costing millions of dol-
lars. I never saw a better dressed, more intelligent-looking audience.
They gave every evidence of culture and refinement. I never saw so



SURGERY. 175

many limousines standing in front of one building. ]^ow, one of the
cardinal doctrines of this marvelous people is that cancer may be cured
by the patient believing that he does not have cancer. [Laughter.] We
smile at their credulity; but do we always manifest more wisdom than
they do in the exercise of their absurd belief? Even those who are near-
est to us sometimes surprise us by the ignorance they display upon ques-
tions of vital importance to their health. For instance, the daughter of
a surgeon, who is reputed to be fairly well up in his profession, married.
In due course of time she became a mother. During this trying period
of her life her father exercised the most extreme care and solicitude,
carefully supervising her diet, habits, secretions, etc. She passed through
the trying ordeal quite as nicely as if she had taken the 'Twilight Sleep."
A few days later her father congratulated her on the ease with which she
accomplished the supreme function of womanhood. In a burst of grati-
tude she said: "Yes; mamma had me to use $3 worth of Mother's
Friend." [Laughter.]

Nor is this lack of knowledge confined to the laity. On one occasion
a physician, who is a college-bred man from a distant city, a man who is
deservedly of good repute, who has a large practice and is held in high
esteem by his patrons and the profession, referred a patient with carci-
noma of the breast to me. She spoke of her physician in the most enthu-
siastic and grateful terms. Among other things, she said : "My doctor
has watched this lump in my breast for two and one-half years." I
exclaimed : "Gracious ! woman, your doctor ought to be a good Demo-
crat." "Why?" she asked. "Because he believes in 'watchful waiting' !"
[Laughter.] These are the reasons, ladies and gentlemen, why the pro-
fession has inaugurated this campaign to teach the people the truth
touching cancer and to remind that portion of the profession, which
unfortunately is yet quite large, who believe in watching these lumps
grow until the cancer is unmistakable and the neighboring glands have
become involved, that the aseptic scalpel used early in the game is the
only sure cure for malignant growths.

The first one to undertake this educational Avork was a German sur-
geon, George Winter of Konigsberg. He inaugurated the plan by Avrit-
ing articles for newspapers. He also wrote pamphlets especially for
women, midwives, and physicians. Understand, please, that in countries
like Germany the death rate is studied as carefully as is the science of
war. The result of Winter's education was that the death rate from can-
cer fell from 139 per 100,000 population in 1907 to 118 in 1912. In the
United States 75,000 people die of cancer in the registration area every
year. The registration area of the United States, or that portion in



176 NORTH CAROLIKA MEDICAL SOCIETY.

whicli births, deaths, causes of death, etc., are carefully registered, com- '
prises only 70 per cent of the United States. Granting the same ratio in
the unregistered areas, there are probably 100,000 deaths from cancer
every year, or an average of one every six minutes. I have been speaking
about twelve minutes, during which time two people have died of cancer.
The American Society for the Control of Cancer has shown that at ages
over 40 one person in every eleven dies of cancer. One woman in every
eight and one man in every fourteen are attacked by cancer. Because
of ignorance and neglect, cancer proves fatal in over 90 per cent of the
cases. It is generally admitted that cancer is on the increase. Do you
not think it is high time that the profession and the people as well
arouse themselves touching this question? Cancer is no respecter of
persons, race, creed, or social position. It is the common enemy to all
mankind, attacking poor and rich alike. It is insidious in its onset and
usually destroys life at its most useful period. One of the saddest things
in my professional work is to have a woman, the mother of several chil-
dren, brought to me with an inoperable cancer. Think of it ! A large
family of children made orphans and robbed of a mother's care, because
of ignorance.

But are the people to be censured for this woeful lack of knowledge?
You remember that when Philip was traveling across the desert he met
a eunuch of high authority, who had charge of the treasures of Candace,
Queen of Ethiopia. He was sitting in his chariot, reading the book of
Esaias, the prophet. Philip, under the guidance of the Spirit, said to
him: "Understandest thou Avhat thou readest?" and the eunuch an-
swered : "How can I, except some man guide me ?" Then Philip got up
in the chariot and set down by the eunuch and taught him the meaning
of what he was reading.

I maintain that the responsibility of the cancer problem rests with the
profession, and that it is our duty, as guardians of the public health, to
educate the laity. When once the people see the truth as it is they will
arise in the power of their knowledge — for knowledge is power — weed out
cancer quacks of every description, and instinctively turn to the right
source for relief.

We organized this symposium and have invited men of authority
within the State and men of National reputation from other States to
present the cancer problem to you plainly, squarely, fearlessly — to in-
struct the people.

The American Society for the Control of Cancer was organized two
years ago "To disseminate knowledge concerning the symptoms, diag-
nosis, treatment, and prevention of cancer ; to investigate the conditions



SURGEKY. 177

under whicli cancer is found, and to compile statistics in regard thereto."
This society adopted as its motto, ''In the early recognition and treat-
ment of cancer lies the hope of cure." The American Society for the
Control of Cancer has received the official approval of the American
Medical Association, the American Surgical Association, the American
Gynecological Society, the Clinical Congress of Surgeons, the American
Congress of Physicians and Surgeons, the Southern Surgical and Gyne-
cological Association, the Southern Medical Association, and indeed
every large medical and health society of importance. It cooperates with
the health organizations of cities, counties, and States. It organizes
societies of physicians and business men, public-spirited citizens and
women who are active in organizations for the upbuilding of every com-
munity, etc. "Agitate and educate" is the slogan.

On this occasion the American Society for the Control of Cancer has
sent to us Dr. Frederic E. Sondern of New York City, one of the noted
pathologists of America and a man who can speak with a high degree of
authority. Also we are favored with the presence of Dr. J. M. Wain-
wright, chairman of the Committee on Health and Public Instruction,
Scranton, Pa. I am sure that I voice the sentiment of this audience
when I say that we feel honored to have these distinguished gentlemen
with us, and we also feel that we will be greatly benefited by their words
of wisdom. I will not speak longer, since one of the best evidences of a
good surgeon is to know where to stop ; besides, there are those to follow
me who are greater than I.



WHAT EVERY PHYSICIAl^' SHOULD PREACH ABOUT

CANCER.



Hubert A. Royster, A.B., M.D., F.A.C.S., Surgeon to Rex Hospital,

SURGEON-IN-CHIEF TO St. AgNES HOSPITAX, RALEIGH, N. C.



The problem of educating the public in regard to cancer depends not
only upon knowledge which may reach the average layman through the
channels of literary propaganda, but also upon information given out by
the average physician on his daily rounds. If we are ever to conquer
this dread malady we must instruct the people in the fundamental facts,
and we must ourselves back up this instruction Avith intelligent and cou-
rageous action. It would never do for a layman who has been told the
dangers of cancer to go to a physician and receive half-hearted advice
12



178 NORTH CAROLINA MEDICAL SOCIETY.

concerning a perfectly evident lesion. It is not simply knowledge wliich
is required here, but moral courage of the highest order. Too often, I
fear, we like to say the pleasing things, to point the easy way, when per-
haps the burden might be forever lifted by jumping right into the issue
upon our better judgment. We have not done our whole duty Avhen Ave
describe the ravages of cancer ; we should set the sufferer in the right
road and sound the warning note in season and out.

There are certain facts about cancer which are supposed to be under-
stood by all physicians. It is generally accepted that about 75,000 deaths
from the disease occur in this country every year ; that its prevalence is
apparently on the increase; that over 90 per cent of all cases are fatal;
that the great obstacle to cure is the failure to get the cases early enough.
Bearing upon these admitted statements are some important principles
which it is the serious duty of every medical man, be he physician or
surgeon, to preach wherever he goes. Let us name and discuss these
principles.

1. The most important feature of all is the realization of the pre-
cancerous period. There was a time in every cancer when it was not a
cancer. In the majority of instances cancer begins in the site of a pre-
viously benign lesion and always at a point of least resistance or lowered
vitality. It is comparatively easy to observe this in an external growth ;
but the principle is as clear in grow^ths of the internal organs, and results
are even more disastrous when the principle is ignored. If the term
"preventive surgery" can justly be applied to any ailment, surely it has
a place in these precancerous lesions. Yet, how often do we see inaction
on the part of the physician, who is waiting to make sure of maligTiancy
before advising interference ! Is it right for a doctor to watch a lump
in a woman's breast for six months or more until it is undoubtedly a
cancer? Such things are happening over and over again all around us.
Sometimes I think text-books are the worst agencies we have. Wot long
ago there appeared in a book on surgery a full-page colored drawing of
what was labeled ''Cancer of the Breast." It represented a woman lying
in bed; her face drawn and yellow, the breast completely filled with a
large tumor mass, ulcerated and discharging; the axillary glands enor-
mously enlarged and supraclavicular nodules apparent. That case was
misbranded ; it was no longer a cancer of the breast — it was a cancer of
the whole body. What are we to expect if such misleading illustrations
are passed around and such instruction widely countenanced?

Furthermore, there is unfortunately still harbored in the conscious-
ness of a few physicians that old fetich, "If you cut it out, it will turn to
a cancer." It is not surprising to hear it from the laity, but when it



SURGERY. 179

comes from the profession itself hope seems long deferred. In times
past, perhaps, there Avas some reason for the attitude, because many
operations for the removal of malignant or even certain border-line
growths were incomplete and resulted only in dissemination of the malig-
nant cells, if they existed. But no enlightened practitioner in the present
day can hold to the opinion that an operation will cause a growth to
"turn to a cancer." The truth is more likely to be the reverse — if you
don't cut it out, it will turn to a cancer.

Malignant growths are usually painless until the late stages. This is
a point of serious moment, for the one factor which drives the average
patient to seek relief is pain. If a growth is painful in its early exist-
ence, it is probably not a cancer; but the suiferer (and at times the doc-
tor) will be more concerned about it than about the well advanced can-
cer which causes him no annoyance. The fact is, cancer as such has no
distinct symptomatology. There are no specific signs of its presence or
its progress. "When you can feel it you can recognize it, but there is not
one symptom produced by cancer, either early or late, which may not be
produced by some other disease. Therein we find our excuse for failure
to recognize it early, and therein we find our diificulty in coping with it.
The more you think of this statement, the more it will impress itself
upon you, and the more anxious you will become to get nearer some early
symptomatology." — (Park.) Depending upon its location in different
organs or tissues, certain phenomena may be manifested, especially when
the growth has fully developed. But here, as in many another condition,
so-called cardinal symptoms are merely terminal events. It behooves us,
therefore, to correct the false impression in regard to pain in cancer ; to
emphatically proclaim that cancer is symptomless until it is too late for
any signs to avail; and that the only favorable period is either the pre-
cancerous period or the early stage of real malignancy, when it is to be
diagnosed chiefly on suspicion.

2. Our second point, which is plain, but needs constant repetition, is
that cancer always begins as a local disease. And it is the beginning we
should fear, not the ending. The respectful fear, which brings action, is
to be encouraged, not the final fear that leaves us helpless. Even after
the full development of cancer, a part or the whole of the involved organ
may be successfully removed. So much the better will these results be if
the cancer can be discovered while it is yet localized. In growths of the
skin and exposed mucous surfaces evidences of cancer are to be seen
early, and the percentage of cures is high. Unfortunately, in the case
of the uterus, stomach, and intestine the signs are not so promptly evi-
dent, and it is rare to find cases in which the cancer is still confined to



180 NORTH CAROLINA MEDICAL SOCIETY.

the part first affected. Since cancer spreads by the lymphatics, it is easy
to note the immediate limits of the extending growth, but not easy to tell
whether it has progressed beyond the first line of trenches. When this
happens the disease is no longer a local affair.

It might well be a question as to what constitutes an early case. The
reliable guide is the matter of localization. Invasion of a removable
organ, or even of its surrounding glands which can be totally extirpated ;
restriction of the growth to a particular tissue ; involvement of certain
areas which can be readily effaced by treatment — all these are indications
of an early case. Prompt recognition of such conditions is the task
before us.

Delay is the deadly sin ; and the chief offending may be laid at the door
of the doctor in many cases. It is impossible for us to overlook the fact
that sometimes we know and fail to act, while at other times we would
act if we only knew. The patient cannot escaj)e his own responsibility,
provided he is informed. What we should most earnestly imbue him
with is the desire to follow up early recognition with prompt treatment ;
to inspire hope when there is room for hope, and not to present false
aspirations in the helpless stage. When a woman with a far-gone uterine
cancer is told that she must submit to a hysterectomy, or another with
cancer of the breast is so weak and emaciated as to be brought in on an
ambulance, something is undoubtedly wrong with our mental or moral
perceptions.

3. It is our bounden duty to urge early and frequent examinations of
all patients who may be suspected of developing cancer or who are
approaching periods of life when they are most likely to be victims of
the disease. In no other way can we so surely forestall its onset. This
is especially true of cancer of the uterus. Thousands of women are
losing their lives every year simply because they will not submit to
examination or because their physicians have not insisted on examina-
tion as the only safeguard against malignant disease and the only
rational basis for successful treatment. The proper position to assume
is the refusal to prescribe, suggest, or advise in any case of pelvic dis-
order without a careful examination. Untold mistakes might have been
prevented by following this course; lives and reputations might have
been saved.

The "change of life" bogey is still with us. If a woman is told by a
physician that "it is the change working on her," she is perfectly satisfied,
when it may be that serious pathological processes are rapidly under-
mining her life. Most often it is cancer. Cessation of the menses for
several months, followed by an unexpected return, is the common danger
signal. How any physician can sit still and wait in the presence of such



SURGERY. 181

a warning is more than the imagination can conceive. It cannot be for
lack of knowledge ; it is hardly due to a failure to suspect the trouble.
Very likely carelessness and a shrinking from meeting the issvie have
much to do with the attitude. Let us all resolve here and now that never
will we let an opportunity go by to declare the danger of these situations
and to impress patients with the necessity of being examined before even
they think it is demanded. Many uterine cancers get a good start before
the time for the menopause, so that as a general rule every woman at or
near the age of thirty-five ought to be examined by her physician regu-
larly every three to six months up to the age of forty or thereafter. By
such a plan numbers of cancers would be discovered soon enough to
promise a cure.

The gospel of examination is the gospel for us to preach. There may
be amongst us men Avho are wise enough to tell what is the matter with
patients by simply looking at them ; but the majority of us, I am sure,
do not possess this power. And those of us who have had the greatest
experience must admit that sometimes even after the most searching
investigations we are not warranted in giving positive opinions. How
necessary it is, then, that we should bring to our aid any means of arriv-
ing at conclusions. Examination is the thing.

4. "In the early treatment of cancer lies the hope of cure." This is
the slogan of. the American Society for the Control of Cancer, and it
expresses, as a corollary, the end and aim of our discussion. Prompt
recognition, early treatment, hopeful cure — these stand in direct relation.
Methods of treatment will depend very much upon the stage, the loca-
tion, and the kind of cancer. In the early cases the agent which will
most safely and completely remove the growth should be employed. This
is usually best done by a surgical operation, which has the additional
advantage of also including attention to any involved glands. It is true
that the cautery, the X-ray, and radium seem to be successful in some
instances of external cancer, and may be used with judicious caution.
Their results, however, cannot be said to equal those from excision where
it is indicated. The actual cautery, point or blade, can be used for cut-
ting instead of an ordinary scalpel, the heat giving it added effect. About
the only diiference between X-ray and radium is a matter of time.
Radium is very rapid in its action and accomplishes in hours what it
takes the X-ray days or weeks to do. ' Undoubtedly they, both have their
uses in the therapy of cancer. The X-ray will get rid of external growths
Avithout deformity if applied over a long period, but has little, if any,
penetrating effect.

The status of radium may be summed up as follows : "According to
the most authoritative opinion, the curative effects of radium are practi-



182 NORTH CAROLINA MEDICAL SOCIETY.

cally limited today to superficial cancers of tlie skin, and to superficial
growths of mucous membranes and certain deeper-lying tumors of bone,
etc., whicli are not very malignant. Radium has probably been shown
to exert a definitely curative effect on certain of these cases while the
disease is still local and in the early stages. Radium definitely relieves
suffering when used in the advanced stages of deeper-seated cancers ; but
in those cases it improves only the visible or tangible manifestations and
exerts no effect upon the disseminated disease as a whole. It is believed
that there is as yet no proof that radium has finally cured any case of
advanced and disseminated cancer. The best results of radium therapy
can be secured only when comparatively large amounts are available for
use, and the present limited world's supply of this metal places it out of
reach of the great majority of jjatients."*

In the late stages any remedy which relieves pain and promotes com-
fort is the one to be chosen. Palliative measures, however, occasionally
check the course of cancer and arrest it for long periods, if not entirely.
High degrees of heat appear to act favorably in many cases of uterine
cancer, too far gone for radical operation. Of course, we should strive to
get them before they are too far gone, and not be compelled to speculate
upon uncertain, last-resort measures. Above all, promises of recovery
must never be held out to patients who are actually incurable. To in-
spire them with thoughts of cure or to suggest ideas of radical surgery
to them is the height of ignorance and charlatanism. As soon as they
are finally enlightened, every lingering vestige of their faith is dashed
to the ground.

But there is splendid opportunity for hope. If left to itself, the mor-
tality rate of cancer is 100 per cent ; under early operation most of them
will get well. Every hour of delay diminishes the rate of cures and
increases the number of hopeless cases. What is the lesson? Early
recognition, early treatment, early recovery. Let us cry hope while there
is hope.



COI^CERIiriNG THE EARLY DIAGNOSIS OF CAN^CER.



Fbedeeic E. Sondern, M.D.



The pathologist also has frequent evidence that a malignant tumor
reaches an inoperable stage before a diagnosis of its nature is made.
This unfortunate oversight is generally due to one or more causes, such



♦Leaflet of Amer. Society for the Control of Cancer.



SURGERY. 183

as the delay on tlie part of the patient suffering from malignant disease
in seeking medical advice; the tardy diagnosis of malignant disease by
the clinician, and possibly a reluctance to have surgical counsel in sus-
picious cases ; and the error of the surgeon in mistaking a malignant for
a benign condition. The educational campaign instituted by the Ameri-
can Society for the Control of Cancer is intended to improve these con-



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 21 of 58)