VOLUME 18

Original Contributions

THE SURGICAL ASPECT OF MALIGNANT DISEASE.*

BY H. H. GRANT, M. D.,

LOUISVILLE, KY.

It is not my intention to discuss any other feature of malignant disease except the clinical symptoms and the prospects under treatment. Up to the present time nobody knows definitely the intimate pathology of either carcinoma or sarcoma, and all study directed on whatever line, either laboratory, experimental, vivisection, or implantation has had the same result on clinical teaching of the present as it had 30 years ago. I have had no hope of adding anything new even to the clinical methods, but have a few illustrations to present and hope to invite discussion. My own experience in the operative field against malignant disease has dismayed me as to the prospects of cure except under very favorable conditions, though I am confident of the propriety of seeking relief by efforts at extirpation. The individual general practitioner sees but little malignant disease compared to the individual surgeon of a large community, and he is less disposed to appreciate practically the significance of the danger or the extent of the ravages, unless his attention is called to it. Carcinoma interests us most because it is more Read before the Medico-Chirurgical Society.

NUMBER I

common and more amenable to treatment than sarcoma.

The claim that malignant disease has increased in recent years is doubtless due to better method of investigation, and more careful observation than to any actual disproportion, nevertheless we dread it with the same anxiety, and we look with as much horror and hopelessness as did the surgeon of fifty years ago, upon its insidious development, its steady march to irresistible destruction, its mysterious and widespread dissemination throughout the system, and we approach the attempt at eradication with little more real prospect of giving relief to the wretched and heartsick sufferer who knows his condition. When in the case of carcinoma one reflects, that though the disease is primarily local, no knowledge can foretell the time at which a dissemination which may hopelessly involve remote and inaccessible situations in the body may begin, he can easily see that it is impossible to say when a carcinoma is certainly only local, and though such dissemination is not so prompt or far reaching in sarcoma, here the tendency to local infiltration is so great as to make extermination almost hopeless in more virulent forms, however early discovered. The extent of dissemination may be limited to one organ, or may involve nearly every one; it may be very general, and at times even held in abey

ance, or it may rapidly run a course of destruction, but when once established, it has but the one termination, death. It is, I think, doubtful that either carcinoma or sarcoma is inherited, or that aside from direct incision of their structure, they can be transferred by contact or infection. Direct translation of cancerous tissue or of blood and cells of such tissue may be engrafted on abraded tissue that is previously healthy, but this practically never occurs except where the knife has divided the tissue, and directly transported these structures where they may grow. Instances of apparent contagion of cancer are probable. coincidences of unsuspected lymphatic metastases. When the medical adviser is confronted with a condition which practically involves every uncertainty except the one that leads inevitably to death unless arrested by surgery, the determination to leave no effort untried which offers any hopeful prospect puts aside all questions of accurate diagnosis and classification. In sarcoma at all events the best that can be hoped in almost all cases is a general diagnosis without reference to special forms and the prognosis is usually a wish rather than a hopeful expectation. More accuracy may often. be achieved in the study of carcinoma, but even here accuracy of diagnosis should always be secondary to promptness and thoroughness, for when one reflects on what the lymphatics and the blood are doing every hour to scatter an irresistible and unconquerable destroying poison, there is no time to be lost in dallying with unprofitable tests. In almost all cases the surgeon has to determine with himself, not, "does this case require operation," but rather, "is it too late," and this determination is the point and question I am laboring to get before you.

During the year 1909 I operated 20

times for malignant disease; two of these cases were for carcinoma of the gallbladder, far advanced and operated to relieve jaundice, and with a far-fetched hope that the obstruction might be removed; neither lived three months.

One case was gastro-enterostomy for starvation from a large growth causing vomiting of all food. He lived seven weeks, in comfort.

Eight cases were carcinoma of the breast. One of these died after eleven or twelve months; one had a second operation for recurrence. The others are still well.

Four were hysterectomy for carcinoma of the cervix. One of these was a virulent case with rapid recurrence, and death in four months; another was in a woman, 38 years, apparently a hopeful case, but showed early signs of the involvement of the bladder and death occurred from exhaustion without external ulceration after about a year. The other two are living and well, one nearly two years and the other fourteen months after operation.

One case was an apparent primary carcinoma of both ovaries. Carcinoma of the ovary when bilateral is almost always secondary, and it is possible in this case the primary focus was located in some of the viscera and escaped observation. This woman died with recurrent ascites in six months.

The other four cases were sarcoma, one of the inferior maxilla, rapidly growing giving great pain. The half of the lower jaw was extirpated; there has been

no return.

One was case 20:

Case 20. Mrs. C., age 65. Seen with Dr. Moorman. She presented a fixed tumor in the pelvis, of three or four months standing, which resembled a fibroid in feel, but the history of her pain.

Case 87. Mrs. J., age 60. Seen with Dr. Roberts. She had been an invalid for some three or four months and was rapidly losing her strength and had developed a tumor which reached almost to the umbilicus. This tumor was nodulated and tender to pressure, both through the abdomen and through the vagina. Her age and the general constitutional depression, together with the external appearances and manifestations, led me to believe that the trouble was malignant. Still, in the hope that it might be a fibroid, operation was advised. When the abdomen was opened the omentum was found to completely cover the tumor and held it down in the pelvis. After the omentum had been loosened up, cystic condition of the left ovary was brought into view, but the whole left side of the pelvis was blocked by a semi-solid tumor, which was not connected with the uterus except by adhesions. It was found, upon manipulation, that this tumor could be separated from the surrounding structures, and it was gradually enucleated and brought

out of the abdomen without any pedicle. appearing. It was the size of a small hat, and from the appearance and surrounding conditions, I judged it to be sarcomatous. After its removal the tube and ovary on that side were also tied off. She really suffered very little shock and made an astonishing recovery, and at the present time, five months after the operation, has had no recurrence, though there is a persistent sinus with slight discharge.

A third was case 27:

Case 27. Mr. W., age 71. Referred by Dr. Ogilvie. Some three months before I saw this patient, at his home out in the State, he had noticed a tumor in the right inguinal region just below the Poupart ligament, which had been gradually increasing in size. When I saw him it fluctuated distinctly, and I believed it to be either an abscess or a hæmatoma, as there was a vague history of traumatism. Upon making an incision the tumor was found to consist of a large collection of fluid blood and clots of a suspicious. appearance, and though the diagnosis. was tentatively hematocele, still the prognosis was guarded because of a suspicion of sarcoma. The cavity was packed and two days afterwards the gauze was removed. Gradually the cavity closed until it was almost well, when it was seen to discharge again a fluid of a grumous character and somewhat bloody. Under aseptic surroundings I reopened the wound and, although I found at the bottom of it an unreleased ligature, I also found a hard tumor, larger than a walnut, growing from the fascia of the internal vastus muscle. This tumor was peeled off and the wound packed so as to heal from the bottom. This wound completely closed without suppuration. At the end of five weeks granulation was followed by a firm cicatrix. The leg continued, however, to enlarge, and he