Malignant Neoplasmata: Read 
in tlie Discussion before the 
"New York State Medical 
Association, October 
10, 1888. 
Br 
JOSEPH D. BEY ANT, M. D. 
PREPRINTED PROM 
Neb) Yrorit fftcbfcal journal 
for December 22, 1888. Reprinted from the New York Medical Journal 
for December 22, 1888. 
MALIGNANT NEOPLASMATA: 
READ IN THE DISCUSSION 
BEFORE THE NEW YORK STATE MEDICAL ASSOCIATION, 
October 10, 1888. 
JOSEPH D. BRYANT, M. D. 
Question 7. What is the rationale of the recurrence of 
excised neoplasmata in distant parts ? 
Question 8. What is the explanation of the tendency 
of certain neoplasmata to involve secondarily neighboring 
glands ? 
Question IS. Are malignant neoplasmata ever cured ? 
These and kindred queries have been made audibly and 
inaudibly for many years. The acute clinicians of the past 
have propounded them to the correspondingly learned pa- 
thologists of their time. The skilled surgeons too, in addi- 
tion to this, have silently interrogated their own and the 
experience of others for the correct answers. The unfortu- 
nate victims of this disease have anxiously addressed the 
last question of this series to any and to all who might per 
chance offer them encouragement and consolation in their 
affliction. And now at the latest moment, after these yea’s 
of thoughtful consideration given to them by master minds, 
the questions are asked again ; therefore 
“ Together let us beat the ample field, 
Try what the open, what the covert yield.” 2 
MALIGNANT NEOPLASMATA. 
For the purposes of this discussion it is proper, I think, 
to limit consideration to malignant neoplasmata alone, since 
these are the growths that excite the greatest apprehension 
and call for the most judicious opinions and treatment. In 
this connection the expression malignant is understood to 
apply to the neoplasmata that are malignant by reason of 
their inherent nature, rather than by reason of certain de- 
structive changes that may occur in growths irrespective of 
their nature, whereby the strength of the patient is sapped 
and death finally ensues from exhaustion dependent on sep- 
tic and other secondary influences. 
That a malignant neoplasm of a similar character as the 
one excised may occur in a part distant from the seat of the 
excision is a fact too well and too long recognized to re- 
quire even a moment’s consideration at this time ; still, the 
exact reasons for this occurrence or recurrence are yet un- 
settled. It is aptly said : “ The whole creation is a mystery, 
and particularly that of man.” It might well be said, and 
as aptly, that normal vital force is a mystery, hence per- 
verted vital force is alike mysterious. 
It seems to me to be hardly necessary to give an entirely 
separate consideration to each of the first two questions al- 
lotted to me (seven and eight of the series). They are in- 
terdependent, for, when the “ rationale of the recurrence 
of excised neoplasmata in distant parts” is stated, it will be 
seen that the explanation of this fact will comprehend all 
that is reliable regarding “ the tendency of certain neo- 
plasmata to involve neighboring lymphatic glands.” The 
latter occurrence is but a well-defined step in the course 
of the more extended journey of the former. There are 
two genera of recurrent neoplasmata to which it is particu- 
larly desirable that attention be called—viz., carcinoma and 
sarcoma. These genera represent to the fullest extent the 
phenomena of the inception, cause, and termination of ma- MALIGXAXT NEOPLASMATA. 
3 
lignant growths. It is advisable at this time to recall some 
of the theories regarding the reasons for the occurrence and 
spread of carcinoma. It will be noticed that these proposi- 
tions are of both a diverse and an interdependent character. 
1. That carcinoma is the expression of a specific blood 
condition. 
2. That a morbid material is present in the bloodr 
which, coming in relation with appropriate tissue, enters 
into combination with it and causes the growth of the 
tumor. 
3. The dyscrasia theory ; the theory that the disease 
has its origin in the constitution at large, the tumor being 
only the local manifestation. 
4. That the disease is purely local in its nature, arising 
from a local embryonal or idiopathic point of departure. 
5. That it is due to a constitutional predisposition not 
dependent on dyscrasia in the ordinary acceptation of the 
term. 
6. That it is due to perverted nervous influence. This 
is a curious but not a rational theory. In addition to these 
can be added a more modern theory—one that is attracting 
much attention at this time, viz.: 
7. That malignant growths are of an entirely local ori- 
gin, dependent on a specific local virus, endowed with 
characteristic bacilli. 
There are many examples of this presumptive contagion 
cited, which, to say the least, aff< rd somewhat startling 
evidence in favor of this last theory, since they can hardly 
be referred alone to the strangeness of coincidence. 
If carcinoma and sarcoma were the expressions of a spe- 
cific blood condition, the peculiar morbid blood state should 
then antedate the appearance of the tumor, and its ex- 
istence should be quite as well marked before as after the 
appearance of the tumor. The fact is, the tumor, when ex- 4 
MALIGNANT NEOPLASMATA. 
ternal, always antedates the appearance of a depreciated 
blood state, often for some time. 
The removal of a growing carcinoma or sarcoma may be 
followed by complete recovery from the disease, the patient 
maintaining perfect health thereafter. This could hardly 
happen if the occurrence of the disease had depended on a 
specific or peculiar blood state, unless it is assumed that 
the only tissue of the body susceptible to its influence had 
been removed by the operation, or that the blood had be- 
come pure, or that the tissues had become tolerant of the 
poison. 
If carcinoma or sarcoma depended on a specific or pe- 
culiar blood condition, either of the growths should appear 
in different parts of the body, in like tissues at about the 
same time, and, too, each should recur after removal in a 
tissue similar to that which was first attacked, as in the op- 
posite mammary gland, etc. 
That these diseases have a hereditary bearing of im- 
portance, dependent either on tissue transmission or on 
some other process, it seems almost impossible to deny. 
The percentage of cases of cancer having hereditary associa- 
tion has been variously estimated. Sir James Paget ex- 
pressed the belief that at least in one in three of the 
afflicted heredity could be traced, and traced, too, in such 
as had undoubted cancer. It is important to remember in 
this connection that not a few die of cancer in whom its 
existence has not been suspected. But why spend further 
time “ carrying coals to Newcastle ” ? To-day the mass of 
evidence seems to point to the following facts: 
1. That carcinoma and sarcoma depend entirely on local 
causes for an existence in many cases. 
2. That they are more commonly a local manifestation 
of an inherent peculiarity of the tissues, called forth by 
some form of irritation at the seat of development. M A LIGN ANT NEOPLASM AT A. 
5 
Be this as it may, the local manifestations of these dis- 
eases are the first to be seen ; they appeal first to the fears 
of the patient, and for these reasons they first invoke the 
wisdom of the medical profession. It is these manifesta- 
tions that present to the mind of the medical profession the 
only point of departure from which to begin successful 
treatment. In this connection the question can now be 
asked, “ How do malignant growths infect neighboring and 
distant parts? ” There seems to be no doubt of the fact at 
this time that either the nuclei or the granular matter of 
the cells peculiar to malignant growths, or the cells them- 
selves, are the agents that directly or indirectly cause the 
spread of the disease from the primary point of occurrence. 
These agents of infection are carried from the primary site 
by the lymph-vessels associated with the growth, and they 
often find a resting place in the lumen of these vessels, and 
are checked in their journey through them by the lymph- 
glands nearest to the point of departure. These infective 
agents are also conveyed directly to distant parts or viscera 
by means of the capillary blood-vessels, whose open mouths 
are frequently to be seen within the intimate structure of a 
highly vascular malignant growth. The cells of sarcomata 
especially possess an inherent tendency to “ move on ” and 
to otherwise extend their area and influence by increase of 
their number through the recognized process of cell-growth. 
By reason of these latter facts the normal tissues that sur- 
round malignant neoplasms become so infiltrated with the 
elements of the growth that ere long they, too, form a part 
of it, and exercise in turn a like influence on the neighbor- 
ing structures. In sarcomata the blood-vessels are the chief 
means of the spread to distant parts, due, it is thought, to 
the better accommodation afforded by the blood-vessels to 
the size of the cells of the growth, and also to the intimate 
relations existing between tbe blood-vessels and these cells. 6 
MALIGNANT NEOFLASMATA. 
Sarcomatous tumors, therefore, spread more rapidly than 
the carcinomatous, and occur secondarily at greater dis- 
tances from the initial growth. The cells of these growths 
reach their final resting places more commonly by means of 
the blood-current, which is rapid transit indeed as com- 
pared with the movement in the lymph-vessels, irrespective 
of the frequent interruptions of the latter by the lymph- 
gland locks of these vessels. 
If such is the method of the spread of malignant 
tumors, it naturally ought to follow that the direction, ex- 
tent, and rapidity of the spread will be in direct relation 
with the degree of vascularity of the growth, the richness of 
the region in lymphatics, and the density of the surrounding 
tissues, other things being equal. Tliese conclusions seem 
to be well substantiated by clinical evidence, for the more 
vascular the tumor, the more rapid is its growth, and the 
sooner secondary processes of a similar nature are estab- 
lished in distant parts; the richer the contiguous structures 
are in lymph-vessels and glands, the sooner the disease 
establishes secondary footholds in the neighborhood and 
he more difficult the eradication becomes; the denser the 
surrounding tissues of the growth, the slower are the pro- 
cesses of infiltration. The influence of this density is often 
well shown by the irregularity in the outline of a rapidly 
developing tumor, which extends more rapidly in the di- 
rection of the least resistance. Malignant growths can be 
produced also by inoculation and self-inoculation. These 
methods of causation are believed to be strong arguments 
in favor of the specific-virus theory of the causation and 
dissemination of malignant formations. Malignant growths 
vary from each other in the rapidity of dissemination, a 
pact which appears to depend largely indeed on their ana- 
tomical peculiarities; as, for instance, abundant granular 
matter, small cells, great vascularity, and loose structural ar- ERRATUM. 
Page Y, line 5 from bottom, for “the late Professor S. D. 
Gross” read “Professor S. W. Gross.” MALIGNANT NEOPLASMATA. 
7 
rangemcnt of the tumor and of the surrounding tissue, are 
some of the conditions that are associated with rapid dis- 
semination. It now remains to he said that the carrying 
from the initial growth to a near or distant part of any of 
the infecting elements of a growth, by either of the means 
of transmission already mentioned, causes the development 
in the part at the place of lodgment of a growth similar in 
all respects to that from which the infecting agent took its 
departure. In this secondary depot, processes and changes 
take place similar to those that had occurred in the primary 
one, and it in turn disseminates its virulency to the parts 
allied to it by associated function or contact. 
Thus far in this paper the constitutional aspect of the 
question of the production and dissemination of malignant 
neoplasmata has not been given a hearing. The lack of 
time and space will not permit me to discuss this phase of 
the disease up to the point of the belief that I shall express 
in the matter. Malignant disease as such is not inheiited, 
but analogy alone in respect to transmitted similarities of a 
different kind teaches us that the tendency of malignant 
disease, as expressed by the vulnerability of the cell tissue to 
the peculiar or exciting influences of the growth, is trans- 
missible from parent to offspring. 
Question 13. Are malignant neoplasmata ever cured ? 
This question can be safely answered in the affirmative. 
The efforts of nature alone are reported to have effected a 
cure in rare instances. The endeavors of the surgeon, too, 
have been followed by a fair percentage of cures. Tbe site 
of the growth, however, has much to do with the result in 
this respect. The late Professor S. D. Gross expressed the 
belief that 9 per cent, of mammary cancers could be cured 
by thorough operation when employed at the proper time. 
Butlin reports 38 per cent, of the cases of cancer of the lower 
lip to have passed the three years’ limit of cure without re- 8 
MALIGN AX P NEOPLASM AT A. 
turn. Gross felt assured that a year might be added to the 
lives of patients by operation on those unfavorable for cure. 
It is not my intention to cite cases of real or presumptive 
cure that have come under my personal observation, since 
they will add nothing important to the results that have 
just been mentioned. It is my intention, however, to em- 
brace this opportunity, under this heading, to speak in em- 
phatic terms of the measures which I think necessary to be 
adopted to gain the full benefit to the patient of the sur- 
geon’s ability to cope successfully with a larger number of 
cases of this disease. 
This consideration will he divided into the following 
headings ; 
1. Early diagnosis of the nature of the morbid growth. 
2. Prompt and thorough treatment of it. 
The early diagnosis of malignant disease will require the 
timely action of three distinct agents: (1) of the patient; 
(2) of the medical attendant; (3) of a microscopical expert. 
The natural inclinations of a member of the human family 
who is in the possession of a rational mind lead him to resent 
the idea of the occurrence of malignant disease in himself 
or in one of his own, lie will not infrequently seek advice 
from the sources which will afford him the greatest personal 
comfort, irrespective of the wise promptings of his own 
judgment in the matter. This course, on his part, is due 
quite as much to pride and sentiment as to dread of being 
informed of the actual facts of his case. The medical at- 
tendant can do very much indeed to rectify this unfortu- 
nate state of affairs. He should consider it a case of emer- 
gency in the full sense of the terra, and advise the patient 
of a course of action that will meet the full requirements of 
it. But how does the medical attendant in a multitude of 
instances fulfill his duty in this respect? lie, too, is often 
controlled by sentiment, or by a habit of professional moral MALIGNANT NEOPLASMATA. 
9 
syncope that permits him to shirk unpleasant responsibility. 
Sentiment causes the physician to encourage the patient in 
the belief of non-malignancy; to smile at his fears, if he 
has any, and, whether he has them or not, to say to him; 
“Come in a week or two if it is no better,” or, “Come and 
see me again after a while,” or, “Don’t think it amounts to 
much ; any way, don’t worry,” and at the same time he rcc-' 
ommends something simple “for the blood ” or for external 
application. A physician might do worse than this, and 
there is great danger that he will ; he might disguise the 
characteristics of the morbid growth and accelerate its de- 
velopment by the application to it of some form of caustic, 
believing it to be good treatment in any case. Professional 
carelessness—better named professional shiftlessness—may 
permit the medical attendant to omit obtaining the history 
of the case or omit the examination of the diseased part ex- 
cept with a glance. Such methods of procedure as these are 
culpable, whether the patient is afflicted with a real or with 
a fancied disease. A hospital surgeon, or one with a private 
clientele, can recall many instances of consultations with vic- 
tims afflicted with malignant disease in whom the oppor- 
tunity of affording more than temporary relief has been 
sacrificed by the ignorant or sentimental dalliance of a medi- 
cal attendant. Patients should be educated in the belief 
that “an ounce of prevention is better than a pound of 
cure.” The adoption of this line of action will cause pa- 
tients to seek information whenever anything unusual hap- 
pens to them, and then the physician who performs his 
Christian and professional duties well will solve the nature 
of the affliction at once, or as soon as possible thereafter. 
The patient who is left largely to his own discretion by the 
emasculated admonitions, “Drop in when you are this way ” 
or “ when you come to town,” etc., is lured into a sense 
of safety that will lead him to stifle the wise promptings of 10 
MAT, IGNANT NEOPLASMATA. 
bis own good judgment. If the physician finds'him self un- 
able to determine the nature of the growth by the means at 
his command, the aid of the microscopist should be sought 
at once. It may be said that this aid can not be had in all 
instances, and that it too is not conclusive. The instances 
when this aid can not be had are very few indeed. The 
medical attendant has only to remove a small portion of the 
growth, if accessible, properly inclose it and send it by mail 
to the nearest recognized authority on the microscopical ap- 
pearances of morbid growths, with a statement of the part 
of the body from which it was taken, and of his suspicions 
regarding it. In a few days at most the answer will be at 
hand. It is proper to add, in this connection, that the in- 
closure of a fee for the examination will in no way delay 
matters, nor detract from the value of the opinion. As to 
the importance to be placed on the opinion, I think I may 
say that it should always be considered as one of the deter- 
mining factors of a diagnosis, rather than as conclusive evi- 
dence of it. In only rare instances in my experience has 
the microscope failed to decide the question for or against 
malignancy. 
None but simple and unirritating applications should 
have been made to a suspicious growth prior to the comple- 
tion of the diagnosis. If it be necessary to remove a sus- 
picious growth, for any reason, before a diagnosis can be 
confirmed by microscopical examination, this aid should be 
sought as soon thereafter as possible, since the knowledge 
thus gained will become of great importance in estimating 
the subsequent treatment and final prognosis. 
Treatment.—The treatment should always be twofold— 
constitutional and local. The former should be of a kind 
intended to strengthen the patient in every possible man- 
ner, in order that the healthy tissue cells of the patient’s 
organism may be the better able to resist the influence on MALIGNANT NEOFLASMATA. 
11 
them of the cells and other products of the malignant 
growth. Special general medication, with the view of cur- 
ing or delaying the progress of the growth, will proved elu- 
sive, and will be destructive, if it is employed to the exclu- 
sion of operative procedure. Let the maxim ev'er be, Operate 
first, medicate afterward. The use of the knife is the opera- 
tive measure to which the patient should be subjected. The 
growth should be removed thoroughly by excision at the 
earliest possible moment after the diagnosis is made, and, if 
a doubt exist as to the nature of the growth, give the benefit 
of that doubt to the patient and remove the growth at once. 
The earlier the removal, the better will be the chance of pre- 
venting and limiting dissemination. Any and every meas- 
ure of treatment that will stimulate unnecessarily the flow 
of blood to the growth, or stimulate the action of the 
lymphatics in the neighborhood, should be avoided, for 
these results of irritation of the growth are directly pro- 
ductive of the dissemination of the infecting agents of the 
disease to the lymph-glands and distant parts by means of 
the blood and lymph currents associated with it. The knife 
meets the indications better than all other means for the re- 
moval of malignant growths for the following reasons: 
1. It can be applied with precision at a greater distance 
from the growth than can any other measure. 
2. It acts promptly and with less injury to contiguous 
tissues than any other agent; and without pain if anesthe- 
sia be employed. 
3. Healing takes place immediately when removal is 
done early and with proper care. 
4. Neither irritation nor pain attends the healing process 
if the surgical indications of the wound have been carefully 
observed. 
5. Cicatrization and deformity are less than from the 
use of caustics and other local agents. 12 
MALIGNANT NEOPLASMATA. 
The preceding are some of the practical advantages 
that attend the proper use of the knife for the removal of 
malignant growths with antiseptic precautions. The con- 
verse of these usually attends the use of caustic, cautery, and 
other means that are more slowly effective, and with the 
use of which, suppuration, ulceration, and sloughing, and 
their histological processes, antedate and often complicate 
the final healing. I am of the opinion that with an early 
diagnosis, prompt, repeated, and wide removal of malignant 
growths with the knife, a much larger number of lives will 
be spared, with a minimum of suffering to the patients. 
The surgeon’s watchwords ought to be, Cut early, cut often, 
cut ivide, and remove contiguous lymphatic structures when 
practicable, whether diseased or not. REASONS WHY 
Physicians Should 
Subscribe 
FOR 
The New York Medical Journal, 
Edited by FRANK P. FOSTER, M. D.,‘l 
Published by D. APPLETON & CO., 1, 3, & 5 Bond Si 
I. BECAUSE ; It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medical 
men of this country. 
4. BECAUSE: Its “Original Articles” are the results of scientific 
observation and research, and are of infinite practical value to the 
general practitioner. 
5. BECAUSE : The “Reports on the Progress of Medicine,” which 
are published from time to time, contain the most recent discov- 
eries in the various departments of medicine, and are written by 
practitioners especially qualified for the purpose. 
6. BECAUSE : The column devoted in each number to “Therapeu- 
tical Notes ” contains a resume of the practical application of the 
most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number con- 
tains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8, BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement cf the sci- 
ence of medicine, as viewed from a standpoint looking to the best 
interests of the profession. 
9. BECAUSE : Nothing is admitted to its columns that has not some 
bearing on medicine, or is not possessed of some practical value. 
XO. BECAUSE : It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, $5.00 per Annum, Volumes begin in January 
and July.