Popular Science Monthly/Volume 25/May 1884/Our New Skin and Cancer Hospital
By WILLIAM J. YOUMANS, M. D.
THE project recently initiated for establishing in New York on an adequate scale a hospital for the treatment of skin-diseases is of great importance to this community. It has been long understood that medical progress can only be best facilitated by the concentration of thought upon special groups of diseases, and that for this purpose special institutions are demanded. We have in New York four eye and ear hospitals, two for the ruptured and crippled, one for the throat, several for children's diseases, and the great Woman's Hospital known the world over for the advances in science made within its walls. But in regard to hospitals for the treatment of cutaneous affections we are not only behind the age and greatly deficient in this country, but in a condition of almost complete destitution. Something has been done in Philadelphia in this direction in a small way, but nowhere else until the beginning now made in this city. Students have been compelled to go abroad to find adequate facilities for the study of skin-diseases in the large hospitals of Paris, Vienna, Berlin, London, and other places; although cases of diseases of the skin and cancer are very common in this country, very many occurring among us of the most severe, distressing, and often destructive character.
In regard to the relative frequency of these diseases in this city and country it may be stated that the number of persons thus afflicted is very large and appears to be increasing; at least 15,000 new cases of skin-disease occur in this city yearly among the poor, while there is no proper hospital accommodation for their care. In the matter of cancer the needs of the city are still more painfully evident. The malady is reported by the registrar-general to be on the increase in Great Britain, and the mortality from it has increased in New York of late years, according to the returns of the Board of Health, as may be seen from the following figures:
"In 1869 there were 304 deaths from cancer, being a little over one per hundred of deaths from all causes. In 1879 there were 572 deaths from cancer in this city, or a little over two per hundred of all deaths: that is, in ten years the proportion of deaths from cancer had nearly doubled, one death out of every fifty being from this dreadful disease. In 1880 there were 659 deaths from cancer, or 2·06 per cent of all deaths in this city; in this latter year cancer actually caused more deaths than scarlet fever, this being a very light year, with 618 deaths from this latter disease. In 1882 the mortality-tables showed 731 deaths from cancer in this city, or more than two daily. During these fourteen years 6,843 persons died of cancer in New York city. Patients suffering from cancer are welcomed in no hospital; in most institutions they are absolutely refused, and nowhere in this country are cancer cases grouped together with a view of studying the disease as to its nature and cure."
These painful facts show the urgency there was to take some serious steps toward the alleviation of this vast amount of suffering, and the New York Skin and Cancer Hospital has been established for this purpose. The institution was incorporated in 1882, and a dwelling-house was secured in 1883 at No. 243 East Thirty-fourth Street, where patients have been received and treated for the past year. The accommodations are, however, very limited, and so wholly insufficient that vigorous measures are now being taken for the extension of its operations until they shall become adequate to meet the public wants. Not only could but few patients be received, as the hospital now contains but twenty-nine beds, but serious difficulty has been encountered from the application of numerous cases of cancer for which the accommodations were wholly unsuitable. Some of these were in such advanced stages that their admission would have resulted in polluting the atmosphere to such a degree that the other beds could not be occupied. This experience has forced the managers to enter upon an enlarged plan of operations by which all patients, in whatever stage or condition of disease, may be taken for treatment without detriment to others.
A question may obviously arise as to the propriety of associating cancerous with skin diseases in the same institution; but the authorities of the hospital are well convinced that great advantages will ensue from this combination, and they have given the reasons for it in an instructive circular which we here reproduce with but slight abridgment:
Cancer, as popularly understood, does not represent a distinct disease, such as pneumonia, small-pox, or diphtheria, but the name suggests only some terrible malady of an eating or destructive nature, often, if not generally, terminating fatally after a period of great suffering. Among the medical profession the term cancer has been in time past, and to a certain extent is to-day, applied somewhat carelessly to a variety of diseases, or morbid conditions, presenting the feature of destruction of tissue to a greater or less extent; and even the highest science has not yet fully determined to what state or disease the name cancer should belong exclusively. Therefore, if a hospital were established exclusively for cancer it would be extremely difficult to determine just what cases should be received, and in the end but a small proportion of really proper cases would be cared for, if all but true cancer, as scientifically determined, were excluded.
This may be illustrated, by supposing that a section of the city were taken, say from Thirty-fourth Street to Forty-second Street, and from river to river, and from every house all persons were gathered, who either—1. Supposed or feared that they had cancer; 2. Had been told by friends or by some quack doctor that they had cancer; or, 3. Had been informed by a legally licensed physician that they were afflicted with this disease. It would be perfectly safe to say that not one half, if indeed one third of all these persons would be the subjects of carcinoma, or real cancer, such as could be rightly entered under that name on the books of a hospital. The remainder of the large number would be afflicted with a great variety of affections, excluding, of course, some who were perfectly healthy, but with imaginary ailments. Of these others, who had not cancer, some would have very simple skin-diseases, entirely curable by proper treatment; many would have some of the ulcerating forms of syphilis, which are constantly mistaken for cancer, and which often so closely resemble it as to render the diagnosis most difficult, indeed impossible to one not fully acquainted with the former disease; some would have lupus, a skin affection which may also simulate cancer; besides these there are ulcers of various kinds, also rare diseases, such as sarcoma, rhinoscleroma, lipoma, morphœa, keloid, lymphangioma, and other diseases belonging to the department of dermatology, to say nothing of true leprosy which occasionally is presented for treatment. All of these could readily at times suggest the disease cancer to the patient or physician. Besides these there would be tumors of various kinds, abscesses, swellings of bones and many different conditions which the body or its parts may take on in disease, which would constantly be presented at the clinic of an institution for the cure of cancer.
The argument and suggestion are submitted, if one whose attention and thought are constantly devoted to the various diseases which appear on and beneath the skin, and which may at times very closely simulate cancer, if such a one is not more likely to recognize and treat the disease successfully than one who takes the single disease cancer for treatment without being acquainted with other apparently similar affections? If the dermatologist is not competent to care for cancer, under whose province does it specially fall? It must be remembered that there is nothing peculiar in the treatment of cancer, and that there is perhaps no regular physician in this country who can be said to stand distinctly pre-eminent in the knowledge of its nature and treatment: it is the quacks who are mainly known in connection with cancer.
Cancer is described and treated of in the books on diseases of the skin, and is constantly exhibited and lectured upon in the public clinics on diseases of the skin. In many instances cancer attacks the skin alone, and in many more instances it appears first on or just beneath the skin, and afterward affects other organs. The cases of skin-cancer, which are often terribly destructive, constantly fall under the care of the dermatologist, and are most frequently sent to him in consultation and for treatment by other physicians.
By the union of cancer with skin-diseases in the same institution, many persons may be led to seek relief long before the case would be recognized as cancer either by the patient or by many physicians; and thus the disease may often be arrested very early in its course, when wrong and harmful treatment or neglect may allow the disease to spread until it is too late to hope for any permanently good results from treatment. Of this many cases in proof could be cited.
Many individuals would be inclined to go to an institution which treats skin-diseases in conjunction with cancer, when they would be unwilling to admit that they had cancer; as a rule, the disease is kept secret as long as possible. There would also be less fear of a surgical operation connected with such an institution than in one specially devoted to cancer alone. It often happens that patients who are afflicted with true cancer refuse to have a surgical operation performed, either at all, or until, after long suffering, they are led to it as a last resort, when it is too late. Such patients will often submit to treatment by caustics, which in certain cases yield most excellent results. In skin-cancer the method by caustics is often to be preferred to operations by the knife, the results being rather more sure, and the scar often much less disfiguring. Such cases certainly are best cared for by the dermatologist, who daily has to do with applications soothing or caustic to the skin.
If the future offers any hope for the real cure or prevention of cancer, is it not in the way of careful and patiently conducted experiments with diet, drugs, etc.? Who is better fitted for the study of cancer as a disease than the dermatologist, who has devoted his attention to the study and management of the system as influenced by such constitutional conditions as gout, rheumatism and scrofula, and such poisons as malaria, leprosy and syphilis? The dermatologists, also, have been foremost in the study of pathology and microscopic anatomy, upon which our present knowledge of cancer largely rests.
The study of such a chronic disease as cancer, then, belongs very naturally to the dermatologist, who has continually to do with maladies often very destructive in character, which may last over months, and sometimes years, although, as in many other affections, he may require to call in the aid of others to accomplish certain ends; as, when the eye or throat is affected, or serious surgical or gynæcological operations are to be performed, etc.; the same may happen in the practice of any medical man.
The surgeon, who naturally inclines toward operative interference, is less likely to take an active interest in chronic cases and those unfit for operation than one who sees the complaint more broadly, and probably earlier, from its medical stand-point, and who seeks the aid of the surgeon only in suitable cases, as occurs also in private practice. In his endeavor to avoid the use of the knife he is the more inclined to search for the cause of cancer and the means of reaching it medically, and is thus more nearly on the right track toward prevention and cure than he who sees a case of cancer mainly from its operative aspect.
For the reasons here set forth, the New York Skin and Cancer Hospital was planned several years since, and nearly two years ago the foundation of the institution was laid by a few gentlemen, who signed the certificate of incorporation, April 8, 1882. After very considerable thought, and after conference with gentlemen well acquainted with hospital work, and with a number of prominent medical men, it was decided to organize the medical service upon this plan, and to have the main conduct of the institution devolve largely upon those who were well acquainted both with cancer in its various phases and with also the other affections with which it might be confounded.
But as it was recognized that many very serious operations have constantly to be performed in connection with this disease, it was determined to secure for the institution, and for the patients requiring aid, the very best surgical skill obtainable. Believing that those connected with other large hospitals, and in the habit of operating daily, could operate more skillfully and successfully than those whose experience was more limited, it was decided to add to the medical staff two operating surgeons, who should "perform such operations as are requested by the attending physicians, subject, however, to their own judgment and the advice of the consulting physicians and surgeons, if desired." In this manner, while the disease is studied and cared for medically, none need suffer for the lack of the best surgical aid when required.
It was also recognized that many operations upon women were better performed by those who were familiar with this branch of practice, and who were operating daily in their own special department. For this purpose a gynæcologist was added to the service, who should have charge of cases of internal cancer in females. Inasmuch as this class forms quite a large proportion of all the cases occurring in females, and the disease may at times prove very troublesome, a separate ward was set apart for the purpose, under the exclusive care of the gynæcologist, where special treatment could be more satisfactorily carried on.
To meet the further requirements of the hospital, a consulting board of physicians and surgeons was formed, containing gentlemen of prominence in various departments of medicine, in order that the best advice might be obtained in cases affecting the eye, ear, throat, etc., and in matters of general medical importance. A pathologist was also added to aid in the study of disease.
In the consideration of the subject of the association of cancer and skin-diseases in the same institution, it must be remembered that it is against common medical precedent to have a hospital devoted to a single disease, such as cancer. The tendency of specialism is to become too narrowed, to fix too much attention upon one single subject or portion of the body, to the exclusion of others which may and generally do have the utmost relative importance. When, from studying or practicing a special branch of medicine, one comes to confine the attention to a single disease, the danger is increased manifold. Those who have heretofore claimed to devote their exclusive attention to cancer have been mainly found among the class of quacks who prey upon the credulity and ignorance of suffering humanity. Cancer, to be studied and treated scientifically, requires to be still kept where it belongs, one disease out of others of the same class. The London Cancer Hospital, the only one of its kind, as far as we know, would undoubtedly have been the means of much greater good if it had not been a special institution for a single disease, which from that cause has never had the hearty support of the British medical profession; its usefulness might have been greatly increased had it either been attached to some other hospital (as, for instance, there is a cancer department attached to the Middlesex Hospital), or had it received at the same time the many cases of skin-disease which are often confounded with cancer.
If it be asked why the necessity of including the name cancer in the title of the hospital, it may be answered that only thus is the full scope of the institution made known to the public, and by this means multitudes of persons will be reached, who otherwise would never know that this disease was treated in the institution. As it appears by its recent annual report, the work at the hospital has been steady and useful; it has been limited, however, by the capacity of the present building and by the limited means at hand for the work. With the establishment of the Country Branch Hospital, which has been contemplated from the first, and which will shortly be accomplished, which can be enlarged to any extent on the isolated pavilion plan, it is hoped and expected that the institution will soon devote much of its energies to cancer in all its forms and phases. The comparatively small number of persons with skin-diseases requiring treatment in bed may soon be greatly outnumbered by the cancer cases, but the institution will still remain a skin and cancer hospital, if the foregoing principles are correct, and if it is sought to do the greatest amount of good to the largest number of sufferers.
It being determined for these cogent reasons to adopt the plan of combining skin-diseases and cancerous affections in the same hospital, the problem arose as to the best method of carrying out the project, and for this purpose it was decided to establish a branch of the institution in the country adjacent to the city of New York. In his late address at the first annual meeting of the officers and friends of the hospital, Dr. L. Duncan Bulkley, the first of the medical officers, briefly reviews what has been done, and gives a very clear statement of the reasons that have induced the authorities to organize a country branch of the establishment. We give the main portions of his address:
"At this our first annual meeting, we find that the accommodations thus far secured are totally inadequate for the needs of the service; during the last few months our building has been quite as full as is desirable for health, while cases have been turned away which were unsuitable for our contracted quarters, and many male patients have been unable to gain admittance, all the beds devoted to this class being kept continually full....
"The object of our thought this evening is, therefore, the means of extending the capacity and efficiency of our hospital, that it may approach somewhat to the size and requirements demanded by the large numbers of sufferers who call for our sympathy and aid. How can these ends be best attained? In which direction shall we enlarge, and how can we secure the greatest benefits to those who put their lives and their health in our hands?
"The tendency has been in all cities to build large and expensive structures, into which the greatest number possible of patients should be crowded, with the impression that thereby the best medical and surgical aid was afforded to the largest number of individuals.
"But the matter of bringing many patients together for treatment in one room and under a single roof has been studied from statistics by a number of competent and conscientious persons, and the results obtained are not a little startling when the mortality of such institutions is compared with that found among patients in private houses, and in cottage hospitals made to conform as nearly as possible to the conditions found in private houses.
"While the present magnificent building of the New York Hospital was being erected in Fifteenth Street, a committee of the governors of that hospital were engaged in making a report in regard to 'a village of cottage hospitals,' which was printed in 1876, and is a most careful and thorough study of the subject, from a scientific stand-point, and is most conclusive in favor of the country plan of treating patients. From this report, and also, from the work on hospital construction and organization issued by the Johns Hopkins Hospital, I shall draw various of the facts and statements which I wish briefly to present.
"Careful study has demonstrated beyond peradventure that the nearer the condition of the patient approaches that of a member of a well-ordered household, the better are the chances of recovery; in small and separate hospitals the mortality diminishes with the size of the building, while in larger and more crowded hospitals the mortality is found to increase proportionately, and it reaches its height in those in which these conditions have existed for the longest time.
"In the report referred to is a quotation from Sir James Y. Simpson's essay on 'Hospitalism,' giving the following figures regarding mortality after amputations, which may be well considered in the present connection:
In other isolated cottage hospitals in England during the year 1869, the mortality after operations was reduced to 6·7 per cent.
"In Bellevue Hospital there was at one time a mortality of forty-eight per cent after amputations, and at two of the public reception hospitals in New York the deaths in 1870, after amputations, were respectively sixty-five and sixty-two per cent. Other more recently built and better constructed hospitals show, of course, a very much smaller mortality, but the fact can not be gainsaid that large, substantial structures of brick and mortar, in a crowded city, do everywhere show a mortality much higher than that obtaining in locations where pure air, quiet, and sunlight can assist in man's endeavors to combat disease and injury. Spencer Wells, a prominent English surgeon, expressed the view that no surgical operation attended with risk to life should ever be performed in a great general hospital in a large town, except under such circumstances as would render removal to the country, or to a suburban cottage hospital, more dangerous.
"Much more could be added to show the advantages to be derived from securing a country location where a certain proportion of our cases could be sent, but time allows only a brief mention of important points in regard to the scheme actually proposed.
"Several locations have been under consideration for some time; for, from the first inception of the hospital it was designed to have a country branch hospital where the more offensive and chronic cases could be provided for in a better manner and more cheaply than in a building in the city. From the statistics now at hand we learn that seven hundred and thirty-one persons died, from cancer in New York city during 1882, that is at the rate of two daily: from this number it is probable that there are between two and three thousand cancer patients now in the city, and, as this is the only institution in the United States especially devoted to cancer, the numbers who would ultimately seek aid from this city, and from other portions of the country, would be very large.
"The idea, therefore, of a country hospital would be one composed entirely of pavilions containing a few patients each, so that the capacity of the hospital could be enlarged to almost any extent, as necessity required, while each pavilion, being of comparatively little cost, could be removed and destroyed whenever those terrible scourges of hospitals occurred in them, such as pyæmia, erysipelas, hospital gangrene, and other unknown causes of excessive mortality.
"In regard to the comparative cost of locating and running such a hospital, the showing is very greatly in its favor. Recently it was proposed to erect a wing or separate building in connection with the Woman's Hospital of this city, for the treatment of cancer, and the cost was to be about $140,000. This would give accommodations for not over eighty patients at the utmost, and could not be increased in size, however great the necessity; moreover, the objection would always exist in regard to the possibility or rather probability of the building becoming infected sooner or later with the poisonous germs of cases so loathsome as certain of those afflicted with cancer must become sooner or later. In addition, the mortality there must necessarily have been high, from the crowded locality, and from the presence of the noisy railroad.
"Now there is at present under consideration a tract of ground in a most desirable locality, containing nearly one hundred and fifty acres, with a number of valuable buildings upon it, which can be obtained for $50,000. Upon this twenty pavilions, each containing four beds, could be erected for $1,000 each, including furnishing. This would give accommodation for eighty patients at a cost of but $70,000, one half the cost of the proposed city building, leaving $70,000 of the amount for investment. Moreover, the country hospital could be extended to almost any size as occasion demanded, whereas, at the beginning there need be only a few pavilions erected, the number being increased as required.
"The cost of maintaining patients in such a place would be less than in the city, whereas the advantages arising to the patients would be incomparable.
"With fifty and more gentlemen and ladies thoroughly interested in our work, and with the support and encouragement of the medical profession and the press, no hesitation should be felt in pressing forward to such an extending of our usefulness as the importance of the subject seems to demand.
"Our president, Mr. Scribner, has been over the plot of ground under consideration, and can testify as to its suitability for the purpose.
"I would move that a committee of three gentlemen and three ladies be appointed to take the matter into consideration, and to visit this proposed site, if thought best, and to report on the subject to their respective boards."