Symptoms of cancer

Unfortunately, the very smallest cancers give no symptoms unless they are on the skin or lip or tongue or elsewhere on the surface of the body; and in these situations the earliest diagnoses can be made. Cancers the size of a pea or but little larger are often diagnosed and removed by a surgeon with an assured result, if the operation has been properly done. In the stomach and internal organs, however, the cancer does not give rise to symptoms until it is quite large, and it is important, therefore, for anyone who has any disturbance of the stomach or intestines, loss of weight, or anemia, to go at once to a surgeon, because by modern chemical methods and by the use of the X-ray a diagnosis can often be made on one of these cancers long before it can be felt or seen. One of the last symptoms of cancer is pain; this is due to the pressure on the nerves by the growth spreading out through the tissues. When a cancer gives a great deal of pain it is usually beyond operation. Bleeding is a common result of cancer of the intestines and of cancer of the womb, and is one of the most important symptoms. Every one should know, however, that when a lump appears anywhere on the body, a physician should be seen immediately; the lump may prove to be an abscess or something quite harmless, for there are a good many tumors which are quite harmless; but, on the other hand, it may prove to be a cancer, and then if it has been seen early enough, it can be cured by operation.

Occurrence of cancer

It has been shown by the study of a large number of cases of cancer in various countries, that the disease afflicts chiefly those of middle age; that is, from forty-five to sixty-five years. Younger people and those over eighty years are rarely afflicted with cancer, except that in very old people various mild cancers of the skin are not infrequent; these, however, are easily cured by the X-ray or radium, and do not need operation. in all cases. Women about the age of forty-five to fifty-five should be very careful, if any lump appears in the breast, to have a careful examination made, and if after the change of life any flowing occurs, should be examined by a good surgeon to determine whether there is any trouble in the womb. Men of about this age, also, should be watchful of ulcers on the lip, tongue, or inside of the cheek, especially if the teeth are not good, and should have any such ulcers immediately examined by a physician. The physician may have to cut out a small piece and send it to a laboratory in order to determine whether or not the growth is cancerous, if it is too small to diagnose otherwise. It is very much better to have a diagnosis made early than to wait until the doctor is sure that the thing is a cancer, for then it is often beyond operation.

Most frequent sites for cancer

In males, the most frequent site of cancer is the stomach, about 20 per cent. of all deaths from the disease being due to this form. Closely following is cancer of the intestines and rectum, forming a trifle less than 20 per cent.; then come cancers of the liver and gall-bladder, comprising about 8 per cent., and of the esophagus about the same; cancer of the tongue is next, 6 per cent., and then that of the skin, 3.5 per cent.

In women, cancer is most frequent in the womb, in this situation causing 20 per cent. of all deaths from cancer at all ages, and 30 per cent. of deaths from cancer between the ages of thirty-five and fortyfive. This is followed closely by cancer of the breast, forming 16 per cent.; then come cancer of the stomach, of the intestine and rectum, and finally, of the liver and gall-bladder. Cancer of the skin is only one-half as frequent in women as in men; while in cancer of the esophagus the proportions are as one to three.

Certain facts as to the proportion of cancers in married and unmarried women are of interest. Cancer of the ovary, for instance, is twice as frequent in unmarried women as in married; cancer of the uterus is much more frequent in the married women; while the reverse is true of cancer of the breast.

Treatment of cancer

The proper treatment of cancer is the removal of the growth as early as possible, it being remembered always that cancer is a local disease when it begins and as a rule spreads through the tissues only after a considerable time. The removal of small cancers or of beginning cancers is often an easy matter and can be done under cocaine. Internal cancers, of course, can be removed only by an extensive operation; but the methods now are so successful that a very large proportion of the cases can be saved if operation is done early. There is a popular impression that cancer is incurable. This is not so. Early operation cures some kinds of cancer, for instance, those of the lip, in about 95 per cent. of the cases operated upon. If cancer of breast also could be operated upon at an early stage, nearly four-fifths of the cases would remain well. When operated upon at a late stage, only one-fifth of the cases are cured, that is, show no further appearance of the tumor. Radium and X-rays are very good treatment for the small cancers which appear on the faces of old people, and in some cases may be very useful in helping to complete the surgical cure by healing any small lump which appears after operation. They are also the best treatment for a cancer which has gone so far that it can not be operated upon, and in such a condition may frequently be of such benefit that the patient will live a couple of years in comfort

but as a rule they do not cure the cancer, and they should, therefore, never be used on a cancer of any size; instead, such a tumor should always be operated upon. Great care should be taken in selecting a physician to give the treatment with X-rays or radium, because only a few persons have enough radium for proper treatment, and only a few doctors know how to administer without burning the patient seriously, the large quantities of X-rays which are necessary to produce good effects. It is better that a patient should go to a hospital and get suitable treatment there, rather than to let his local physician experiment. The use of salve and other forms of treatment which are widely advertised in the newspapers are worse than useless. They often stimulate the cancers and make them grow more rapidly; or if they do eat off the top of the growth, they leave the bottom spreading in deeply, and what is worse, result in a waste of time, for the tumor should be operated upon promptly. No form of internal medicine will cure a cancer; that we know absolutely. Nor will any fluid injected under the skin cure a cancer. Cases of cures by such means which are reported in the papers or are talked about are merely instances of mistaken diagnoses, for the quack relies upon the ignorance of people as to what a cancer is and what it is not. Any small lump is called a cancer by the quack; then if it disappears he will say that he has cured it. As a matter of fact, a great many tests have been made of the cancer cures which are sold in this country, and none of them has been found to be of the slightest value in the treatment of real cancer, and real cancer is the thing in which people are deeply interested, because through it their lives are in danger.

THE NEED OF BETTER EDUCATION IN THE EARLY RECOGNITION OF CANCER

JOHN A. HARTWELL, M.D.

Director of Surgery, Cornell Division, Bellevue Hospital

If it be possible to disabuse the minds of the medical profession and the laity of deep-rooted misconceptions concerning cancer, a distinct step toward the control of the disease will be made. These misconceptions. arise largely from the fact that in the past the treatment of cancer has been woefully inadequate, and has been undertaken at the wrong end of the disease. The laity is perhaps excusably ignorant of the natural history of cancer, and only knows it as a disease of fearful aspect. The medical profession has no excuse for such ignorance and can be justly charged with failure to properly educate themselves, and to a less degree with responsibility for the ignorance of the laity. If we are able to substitute for the traditional picture of cancer, based on its late manifesta

tions, a less terrible picture based on its inception, there will be less reason to stand in almost hopeless horror before its ravages. Cancer no more springs into complete existence than does any other living thing. It has a definite beginning, and then possesses no greater menace to life than does a beginning tuberculosis or a beginning hardening of the arteries. Since, however, it is a living thing, it is endowed with the power of growth, and from an insignificant beginning sooner or later asserts that power at the expense of the life of its victim. If the simple truth be thoroughly established in the minds of any community that cancer begins in a comparatively innocent form, and in most instances in a recognizable form, that community will be in a position to successfully combat it.

At some future time the accumulated experience of thousands of workers may definitely prove the underlying cause of cancer, but we need not await this discovery to avail ourselves of the defense which is already known to us.

In its incipiency, cancer is a local disease; in its fully developed stage it is often a general disease. While a local disease it is nearly always amenable to treatment; as a general disease it is never so. Its fearful death rate is largely due to the fact that treatment is only instituted where it is dangerously near the latter condition. The lesson, therefore, is obvious. It must be treated at an earlier stage, and in order to do this both the physician and the laity must be better educated and more alert. It is no unusual thing, both in private practice and in the public hospitals, for the surgeon to be first consulted when the hopeless or nearly hopeless stage has been reached.

The organs in the body which are most commonly attacked are the stomach, the breast, the uterus, the rectum, the tongue, and the skin about the face and lips, more rarely the skin of other parts of the body. In each of these situations, cancer manifests itself by certain symptoms which the laity ought easily to learn to view with concern, and the physician to recognize, to escape the accusation of criminal negligence. This does not mean that cancer is always or usually easy to diagnose. It does mean, however, that a most careful and exhaustive study should be made in every case where suspicious symptoms are at hand. The patient must be taught that such study is necessary, and the physician must be aroused from the watchful waiting policy which so readily invites disaster.

It is impossible to enumerate all the signs which should raise the question of the presence of a cancer, because in its early stages these signs do nct differ from those of benign conditions. There are, however, certain changes from the normal in various organs which should be a matter of knowledge to every individual. When a person over forty

it may be even younger

suffers from a persistent "in

years of age digestion" which previously had not existed, it is essential that a thorough examination be made to determine the cause. There may be nausea and vomiting, but these are by no means always present. Pain is not invariable, though it often may occur early. There is often a distaste for food. The general nutrition is, as a rule, undisturbed for a long period. When all these symptoms are present, the disease has already advanced beyond the most favorable stage for cure by operation, and no other form of treatment is ever of the slightest benefit. How then may a diagnosis be made in the early stages? Only by a most complete and careful study of the patient with the aid of chemical tests and radiographs. In many cases doubt still exists after all our resources have been exhausted. A fine judgment is then needed to decide whether the final test of an exploratory operation shall be used. The more general employment of such exploration would, beyond doubt, disclose many early cases which now are left to reach a hopeless condition before the surgeon is consulted. Every surgeon sees innumerable cases in this stage to one in the early stage. In a recent series of hospital cases only three in more than sixty could in any sense be counted as favorable for operation when this was finally done.

The physician should be more thorough in his study of such patients. Unless as a result of such study he is able to say positively, "You have no symptoms of cancer of the stomach, and no symptoms even suspicious of it," it is his duty to lay before the patient the question of submitting to the exploratory operation. He should explain fully the facts cited above concerning the insidious onset of cancer, the impossibility of determining its very early presence and the hopeless condition it may reach before it fully declares itself. The danger of a negative exploratory operation is almost nil. The danger of the operation for relief of stomach cancer is far less than the danger of the disease itself. The cures already obtained by early operation amply justify its performance. We are firmly convinced that in honest, competent hands the human suffering and economic loss resulting from a far more general use of an exploratory operation in cases of unexplained "indigestion" will prove to be far less than the suffering and loss resulting from delay.

The female breast is another common site for the appearance of cancer. Here the problem is far less complicated and difficult. The breast is an external organ, and abnormal conditions are easily perceived. Any lump in the breast may be cancer. Again in its early stages it closely resembles benign disease. There is practically no exception to the rule that any lump in the breast, if allowed to remain, may become malignant. Therefore, every lump is under suspicion, and the only safe course is its removal. The constant advice which physicians give to