Popular Science Monthly/Volume 42/January 1893/The Early Extirpation of Tumors
By JOHN W. S. GOULEY, M. D.,
SURGEON TO BELLEVUE HOSPITAL.
IN a paper, bearing the title of A Plea for the Early Extirpation of Tumors, Dr. Gouley makes a succinct argument, based upon long experience, in favor of removing morbid growths from the human economy in a very early stage of their development. What follows is therefrom abstracted, with the object of presenting to the general reader the main points discussed, and of calling his attention to the importance of the subject, in consideration of the fact that more than two thousand persons die annually from the effects of cancerous tumors in the State of New York, and in about the same proportion in other States and countries. How this percentage of mortality may be lessened is suggested in the course of the discussion.
The paper begins with the question, At what period of the development of a tumor is its extirpation justifiable? The answers to this question, for a long time, have been divided between early and late surgical intervention and non-intervention. Some surgeons, at home and abroad, have favored and do now favor early extirpation even in the case of benign tumors, but many advise non-interference so long as tumors are small, painless, stationary, or of slow growth.
If it were generally known among intelligent people that great numbers of innocent tumors sooner or later become malignant, and that malignant tumors often simulate benign tumors and remain quiescent for a great while, the sufferers would unhesitatingly consent to the removal of these morbid growths in their inception, long before the possible advent of serious mischiefs, or when the cure might be effected by minor operations which would leave the smallest scars, especially in such parts as the face, neck, arms, or hands.
In the discussion of the initial question the following points are considered: 1, The relative frequency of malignant and benign tumors; 2, the liability of the transformation of benign into malignant tumors; 3, the impropriety of delaying operative interference; and 4, the advantages of early operations.
1. The testimony of careful observors tends to show that the malignant tumors exceed the benign in frequency, and also that many malignant tumors remain stationary and seemingly harmless for one, two, six, eight years, and even for longer periods, then increase rapidly, and soon contaminate the system. (Then follow technical and statistical considerations in substantiation of these propositions.) Twenty-four per cent of all cancerous tumors affect the breast. Benign tumors of the breast are most frequent before the age of forty, and cancerous tumors of the breast are most frequent after the age of forty. Cancerous tumors are very much more frequent in the female than in the male sex. The discrimination of malignant and benign tumors at the bedside is often so difficult that surgeons are justified in advising immediate extirpation and in relying upon the microscope to insure the diagnosis and establish the prognosis.
2. The liability to the transformation of benign into malignant tumors has long been recognized, but the histological demonstration of the phenomenon is modern. It has happened that some tumors have been excised during their transition from the benign to the malignant type, and that this metamorphic process has been verified by careful microscopical examination of different parts of the growths. But so far it has not been possible to determine the precise time of the beginning of the transformation. Warts, moles, and other benign growths upon the face or body have been observed to undergo cancerous metamorphosis many years after their appearance. Fibrous and fatty tumors are often transformed into malignant tumors. So long as a tumor retains a comparatively high degree of organization it remains benign; but when its constituent tissues are disturbed, there is apt to be an accession of tissues of a low grade of organization and the tumor becomes malignant; the lower the organization the greater the malignity.
3. In stating the reasons why he believes it improper and unwise to delay operative measures for the cure of tumors, the author discusses the methods of general and local treatment employed. He considers some of them delusive, and others directly harmful, particularly the escharotics, which he thinks should be condemned. The anciently promulgated precept, that so long as a tumor is causing no apparent mischief and shows no disposition to increase in size it should not be disturbed, is still regarded by many as conservative, and commonly followed to the letter in the management of tumors. In accordance with the light thrown of late upon the natural history of tumors, it is proper to inquire if this precept can be regarded as truly conservative. The well-known fact that any solid benign growth is liable to become malignant should be sufficient to induce surgeons to condemn the arbitrary expectancy which is so generally counseled and which so surely leads to disaster. Even if a particular tumor increases without showing signs of malignity, there can be no advantage in waiting until it shall have attained a great size, as the larger the tumor the more formidable the operation for its removal. The advice that a morbid growth should not be removed because it is stationary and causes no inconvenience does not seem to be founded on sound principles. Because it does not produce present inconvenience gives no surety that it will not sooner or later cause the greatest distress, if only from its increase in size or its interference with a vital function; but the liability to malignant transformation is what is most to be dreaded. Therefore, as a general rule, it may be considered unwise to allow any accessible tumor to so increase in size as to be damaging to the individual, or, if it be stationary, to wait until it is metamorphosed before proposing an operation for its cure. The true spirit of conservatism is manifested by advising the removal of a morbid growth when it is benign, when it is stationary, when it is small, when the operation for its eradication is trifling in comparison with what it must be when the tumor has attained a great size, or when the neighboring lymph-glands are implicated. The modern improvements in inducing anæsthesia, simplifying surgical processes, and insuring asepticism of wounds render operations safe as compared to those of former times, so that no serious harm need now be apprehended from the extirpation of most tumors. Morbid excrescences of all kinds, being worse than useless to the human economy, should be treated like foreign invaders, and removed before they become too mischievous.
4. There can be no reasonable doubt of the advantage of excising a small tumor believed to be malignant, even if this be owing only to the ease with which the operation can be executed, or to the slight degree of violence inflicted upon the parts as contrasted with the magnitude of the procedure needed for the ablation of a growth which has attained great dimensions or which has infected the adjacent lymph-glands.
For a long time there has been a prevailing belief that extirpation of a quiescent malignant tumor only serves to stimulate the extension of the disease. But this belief does not appear to have been founded upon trustworthy clinical observations or pathological data. It is undoubtedly true that any incomplete cutting operation upon a malignant tumor, or its partial cauterization with silver nitrate or arsenic, only serves to stimulate its extension; but complete extirpation with the knife, including the adjacent connective tissue and lymphatics, leaves behind no disease to be extended. Recurrence of the disease in this case would take place after cicatrization of the wound, and would be by new cell proliferation and not by extension. External cancerous tumors have been excised, and in the course of a few weeks the patients have died of internal cancer; but in such cases, if the internal had not antedated the external disease, the metastatic process had surely begun before the operation, and would scarcely have occurred had the tumor been excised five or six months before.
Since it appears from analysis of the observations of surgeons of long and vast experience that a large proportion of benign tumors in time become malignant, and that most malignant tumors have a stage of benignity, there should be no hesitation in advising the extirpation of these tumors as soon as discovered, and this advice may be regarded as the very essence of conservatism and of prophylaxis. From a purely æsthetic point of view it is of no little consequence to minimize scars resulting from the excision of tumors of the face, neck, arms, or hands, particularly those occurring in the gentler sex, and this can be best accomplished by the timely removal of such morbid growths as are likely to increase to the extent of greatly disfiguring the patients. It should, however, be noted that almost any scar is better than an ugly tumor.
The nævi that appear upon the faces of infants, though benign, often grow so rapidly as to constitute serious disfigurement, and to require operations which leave extensive scars. If before these little vascular tumors cover a space of more than two or three millimetres they are promptly destroyed with the thermo-cautery, the ensuing scar is likely to be almost imperceptible. The operation is completed in a few seconds, and the pain is very slight.
The greatest mischief arises from temporization in the case of small epithelial growths upon the lip. Any tumor of the lip of doubtful character should unhesitatingly be removed. As a general rule, the subsequent dissection and microscopical examination of the tumor shows the operation to have been justifiable. Early excision is the surest means of obtaining a long period of immunity from recurrence. The period of immunity from recurrence after operations is very variable even in the same species of tumors. Thus, in cancer the average is stated by some observers to be three years and a half, and by others seven years; the extremes are three months and forty years. The writer has reported cases in which the periods of immunity varied from seven to forty years. As soon as a tumor recurs, when it is still small, painless, and apparently harmless, it should be extirpated. The moral effect of this timely operation is generally good, bodily comfort is thereby promoted, and life is prolonged. It is therefore wise to operate as often as the tumor recurs.
According to the observations of many experienced surgeons, the average duration of life is a little less than three years from the first appearance of the tumor in cases of breast cancers that have not been subjected to any treatment. Does this not indicate the wisdom of prompt action in the great majority of cases, since the shortest average duration of life after operations which were not performed during the stage of benignity of the tumors is three years and a half, and since it has been shown that early operations afford the best chance for many years of immunity from recurrence?
Very large tumors are now rarely seen in comparison with the great numbers recorded before the introduction of ether, nitrous oxide, and chloroform as anæsthetic agents. The dread of surgical operations was formerly so great that patients were ready for the use of any means proposed rather than the knife, although many of the modes of treatment employed were cruel in the extreme, far exceeding any torture that could have been inflicted with cutting instruments. Thanks to the several modern modes of inducing anæsthesia, the patients of to-day need have little fear of the knife, for they are assured that they will be rendered insensible to pain during and for a time after operation. The surgeon, conscious that he is inflicting no pain, is then able to give his whole attention to the work in hand, and performs the operation in accordance with the recent improvements in surgical procedures and with the best modes of insuring asepticism of the wound.
The categorical answer to the initial question is, that at the earliest period of the development of any accessible tumor its complete extirpation is not only justifiable, but should be regarded as an eminently conservative and equally humane act.
As described by Mr. C. Willard Hayes, of the Schwatka Exploring Expedition, the southern Alaskan coast mountains form a broad elevated belt with many scattered peaks, of which none perhaps have an altitude of more than eight or nine thousand feet, while there is no dominant chain. The southwestern front of the range rises abruptly from the waters of the inland passage, forming a rugged barrier to the interior. A few rivers have cut their channels through the range, and it is penetrated at varying distances by numerous deep fiords. From the head of Lynn Canal northwestward the range decreases in altitude and probably spreads out and merges in the broken plateau which occupies the eastern part of White River basin. This region is practically unknown, however, and the precise relation of the Coast Range to the St. Elias Range has not yet been determined.