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The recommendation of delaying the physical removal of the tumor in advanced cases is a strategic reform which conforms to other well-known surgical practices. One does not remove a ruptured appendix in a spreading peritonitis until one is sure that the spread is controlled and the power of resistance is sufficient. The goal in advanced cancer is complete eradication of the entire tumor mass. It does not differ from the aim in early operable cancer. However, the methods are not the same.

Post-operative X-ray radiation fails to accomplish complete eradication in advanced cases, as the frequent local recurrences testify. One of the reasons for failure is that cancer cells are only temporarily inactivated by the X-ray treatment by being locked up in fibrotic clusters. Direct irradiation at the time of surgery has been tried. Combined with artificial prolapse formation it may promise better results.

Another method is to combine the ripening treatment with the injection of radioactive isotopes. The problem is to concentrate these isotopes in the tumor mass. This can be easily accomplished in the artificial prolapse formation, either by the intraarterial or the introductal method (parotid tumors) or by any combination of these. Iophontoresis with radioactive isotopes is another suggestion which appears very promising when done in combination with prolapse formation.

While these recommended strategic reforms are applicable mainly to salvage surgery, the tactical reforms which now follow pertain to both salvage surgery and radical extirpative surgery. They are, moreover, essentially of a technical nature and directed against the danger of dissemination of cancer cells into inaccessible hideout places. One of the reasons for such unfortunate complications is that the laws governing the reciprocity between the lymph and venous outflow have been ignored in cancer surgery. It is known that clamping of the veins always increases the lymph flow temporarily and may even do so to a marked degree (Drinker). Therefore, the time-consuming ligation of numerous veins and other maneuvers which produce a venous congestion, as temporary exteriorization of the tumor for determining the operability in the beginning of the operation, predisposes to an increased lymph flow with the danger of cell dissemination.

In malignancies of the limbs the countermeasures tre simple. The application of suction boots to the parts that have to be ex-articulated, will effectively prevent an increased centripetal lymph flow (no Esmarch). This device cannot, of course, be applied to cancers situated in the trunk of the body. Nearly two decades ago, I tried unsuccessfully to employ a large suction glass in connection with an inoperable cancer of the breast. I did not realize at that time that the suction glass in its upper outer quadrant interrupted the continuity of the lymphatic flow from the nipple to the axilla, and the preservation of the continuity of the entire drainage area is necessary for a vacuum-cleaner effect, a principle often interferred with by X-ray treatment.

The artificial prolapse formation should imitate natural prolapse conditions. In stomach cancer Koenig's case shows how this should be done. A modified transverse incision starts high up on the right pararectically and runs olbiquely downward to the left flank allows a continuous steady downward traction of the stomach toward the left hypochondrium. This staves off cell dissemination into the systemic circulation by way of the left coronary vein.

The stomach should never be brought outside of the abdomen and the transverse colon and mesocolon should never be lifted up for the reason that such procedures, even when speeded up, produce a venous congestion which accelerates the lymph flow into the cysternal chyli. Virchow glands appearing a few weeks later testify to this unfortunate complication. There is no need to decide beforehand whether radical extirpative surgery or only salvage surgery should be done. If the surgeon discovers later during the operation that radical extirpation is impossible, he continues with a Devine exclusion operation combined with procedures which produce a permanent venous and lymph congestion. Absorbable sponges "Oxycel"-Parke, Davis & Co.-facilitate the execution of such procedures. The dissection en bloc is started from above in the lesser omentum. Abdominal pads, moistened with glycerine or Aleuronate, aid in reversing the lymph drainage and are to be immediately applied behind the stomach through a rent in the lesser omentum as a protection against spilling over of cancer cells into the cysterna chyli.

In radical breast operations the problem of the paradoxical metastases is complex. The time-consuming ligations of numerous peripheral veins in the

beginning of the operation, together with the interruption of the main lymphatic outflow from the nipple toward the axilla, lead to a reversed lymph flow into the deep lymphatics (for instance, mediastinal glands).

Another complicating factor in radical breast operations is the encroachment upon the lumen of the axillary vein during the glandular dissection. Goldmann pointed to this danger of a retrograde lymph dissemination when large venous trunks are ligated or congested. The explanation is that the lymphatic-venous connections which are present mainly in major venous trunks, carry cancer cells in the reverse direction. When the axillary vein is accidentally injured and needs to be ligated, the prognosis immediately deteriorates when adequate counter-measures are not taken against the resulting accelerated retrograde lymph drainage.

Batson, who proved by injection experiments a third circulation through the vertebral veins, believes that paradoxical aberrant cranial and spinal metastases, which occur in about 50 percent of all operated breast cancer cases, are due to such venous dissemination. It is my opinion that the lodging of tumor emboli in the vertebral venous lakes takes place through a special route via the lymphatics into the venous blood stream in the majority of cases.

Congestion of the entire drainage area of the superior cava vein has to be considered as a predisposing factor for accelerated lymph flow during the radical breast amputation. This anatomical fact explains why right-sided breast cancers have a more unfavorable prognosis than left-sided ones. Coughing and undue straining which lead to such congestion can be minimized by basal anaesthesia. Frequent carbon-dioxide inhalations are recommendable, to encourage deep inspirations and thereby counteract the congestion of the superior cava vein. The removal of both pectoral muscles which normally serve enforced inspirations predispose to deep lymph dissemination by limiting inspiration. The ensuing expiration is dangerous because it leads to congestion of the superior cava vein through the communicating major azygos vein by interference with the drainage of the hepatic veins (Hasse). Moreover, all conditions which favor expiration, as reclining, kyphotic posture in sitting, have to be avoided, I refer to the use of back rests and early walking as countermeasures.

In a paper submitted to the Public Health Office in Washington, D. C., in 1937, I recommended the revival of the old Sauerbruch low pressure chamber for radical breast amputations. (Also recommendable in cancer of the esophagus and cardiac end of the stomach and prostate.) The reason for this recommendation was that under a differential pressure of a few inches a good frictionless intrathoracic circulation could be maintained and at the same time a suction

effected which would bring spilled cell material to the surface. In the case of an accidental pleural injury the low pressure chamber will prove to be of particular advantage in contrast to the now employed positive pressure which impairs intrathoracic circulation and in this way predisposes to deep disseminations. Postoperative treatment in the Blanchard mechanical physiotherapist which subjects only the torso of the body to negative pressure may prove of great value.

Careful handling of the tumor mass, use of the electric knife, sealing the clamped vessel with a cautery (Percy), dissection en bloc, frequent changing of gloves, scalpels, and arterial clamps are recognized measures against cell dissemination. Repeated washing of gloves in the same basin should be avoided, running water instead substituted. A recommendable maneuver in absence of the iow compression chamber is a continuous and steady pulling down of the breast with the aid of two towel clips which leads to venous and lymph congestion. This maneuver imitates the pendulum breast which rarely is the seat of a malignancy. The dissection is then started from the axilla with the removal of all the skin covering the superficially running lymphatics from the nipple towards the axilla. Any too economical skin removal will endanger en bloc dissection. Male hormone injections or pellets in large quantities as well as sterilization are additional recommendable procedures.

In uterine cancer as well as in recto-sigmoid cancer the combined abdominalvaginal, respectively the abdominal-perineal, operation is the logical procedure, permitting a clear decision as to whether a one-stage or multi-stage operation should be performed. To start with abdominal exploration is essential, because the appearance of the primary tumor does not permit any deductions about the spread.

In cervical cancer the abdominal exploration permits the formation of the prolapse by severing the tubes, round and sacro-uterine ligaments and the safe separation of bladder and ureters from the cervix. This makes later X-ray or radium

treatment a safer procedure. Taussig's iliac adenectomy is added when indicated. The operation is finished as vaginal hysterectomy whenever possible, because the steady continuous traction, with slight twisting of the uterus, is a protection against cell dissemination. The uterus has to be developed without pushing the cervix back into the abdominal cavity. The naturally dependent drainage is an added safeguard against the accumulation of fertilizing material (Kennedy). Ample drainage is always essential in salvage surgery, sumpdrains serving well this purpose.

In recto-sigmoid cancer, ligation of the superior hemorrhoidal artery is necessary to produce a polapse. The sacal exteriorization is the last logical step ensuing upon abdominal exploration.

In prostate cancer there exists a similar problem of aberrant metastases as in breast cancer. Here, valves in the veins which drain toward the rectum, lead to the venous prostatic congestion which forces the lymph drainage anteriorally into the bony channels. Extra-peritonealization of the bladder is the first logical step, because it furnishes information about the spread along the seminal vesicles and large vessels. Moreover, it has the advantage of permitting a satisfactory bladder fistula in the vertex of the bladder. Radium insertions, when indicated, can be added. The operation should be finished by the perineal approach for the same reason as in cervical cancer. Castration and estrogenic treatment naturally should be employed.

There are many locations in which the technical difficulties for producing artificial prolapse are great, as, for instance, in parotid tumors. In such a case I left absorbable gauze in the retromandibular space to prevent the spread into later inaccessible areas.

One case of mine illuminates clearly the logic of the here recommended procedures. A woman with a right-sided cancer in the outer lower quadrant was operated on by me 9 months after the diagnosis was made because consent could not be obtained. The radical mastectomy was followed postoperatively with intensive deep X-ray therapy. Metastases appeared very soon in the right supraclavicular region. Their radiation was followed by metastases in the right tonsilar region. From there, after further X-ray treatment, they appeared in the left tosular region, in the left supra-clavicular region,and finally in the left breast.

There seems to be only one main objection to the here-proposed salvage surgery, namely, that multistage operations may increase the danger of cell transplantations. It is my firm belief that this fear will prove groundless because the permanent venous and lymph congestion makes cancer cells harmless.

The optimism expressed in this paper is based on the conviction that an immediate practical solution of the cancer problem is possible with the knowledge already at hand. Paul Ehrlich's pessimism that one has to solve the riddle of life in order to find the solution of the cancer problem is unjustified because cancer is a devolutionary process (Abbau) of life's processes such as regeneration, organization, differentiation, and involution. Therefore it is sufficient to explore the factors which lead to the disintegration of the altruistic forces that maintain the organism as a whole. For instance, regeneration, so prevalent in lower organisms, is partly substituted in higher organisms by functional rejuvenation processes (Popoff). Exhaustion of these functional rejuvenation processes by minor chronic irritations (Virchow) revives suppressed regenerative mechanisms which on account of the previously described mesenchymal damage, are of an inferior character. Such faulty regenerations (observed by FischerWasals, in carcinogenesis), faulty organizations, subinvolutions, and dedifferentiations, all belong to the complex precancerous picture.

As far as I know, this study is the first attempt to indicate the course of practical measures in inoperable cancer cases. It seems to provide the basis for a logical precedure in effectively limiting cancer spread, and if the suggestions made are further explored it would appear that salvage surgery will be of benefit. The contention that there are as yet insufficient case histories to support my original theses, should not deter those in charge of salvage cases from testing the efficacy of the methods I have proffered.

The vast material (in the United States alone some 400,000 cases) should be made available, under adequate control, for the many problems in cancer of humans which does not admit of a solution with laboratory animals alone.

Another urgent task is the elimination of all factors which bring on cancer in the reproductive ages (occupational cancers). The danger of such early cancers is that cancer parents may transmit defective genes, the biological atoms, to their offspring. Such defects endanger the unbroken chain of the supra-indi

vidual cell groups which are essential for the progress of the human race which is based on higher specialization of structures and functions. Reversions as present in the carcinogenesis are always a prelude to extinction as the course of evolution proves.

EXHIBIT 50

Hon. GLEN H. TAYLOR,

STATE OF IDAHO,
OFFICE OF THE GOVERNOR,
Boise, June 29, 1946.

United States Senator, Senate Building, Washington, D. C. DEAR SENATOR TAYLOR: Our department of public health has called to our attention Senate bill No. 1875 on which hearings will be held Tuesday, July 2. This is a bill concerning the control of cancer and research work. There is a companion bill, H. R. 4502, which would make an appropriation of $100,000,000 to be expended within a 5-year period.

The department of public health offers these suggestions in this consideration of the bill.

1. If the large sum of $100,000,000 be incorporated in the bill, the time limit for its expenditures should be extended.

2. That there be a provision made in the bill to allow for construction of facilities and the purchase of equipment where needed.

3. That the bill be amended to channel money through existing State agencies as grants-in-aid to the States, in Idaho it would be the Department of Public Health, rather than setting up a special Federal and State agency. This is being submitted to you for your consideration.

Very truly yours,

R. W. BECKWITH, Executive Secretary.

JULY 18, 1946.

Mr. R. W. BECKWITH

Executive Secretary, Office of the Governor, Boise, Idaho. DEAR FRIEND BECKWITH: I am grateful to you for your thoughtful and constructive letter of June 29 regarding the cancer control bill. The problem of cancer is a source of deep concern to me. It is the second most deadly killer of our people. In 1942, 163,000 people died of cancer. It is estimated by experts that 20,000,000 people now living will eventually die of this dread scourge. I feel that if we organize the country's medical and scientific talent as we organized our atomic physicists during the war and place adequate facilities and funds at their disposal, a solution can be found. The problem is no more insuperable than the problem of releasing atomic energy. I have maintained a close interest in the work of the subcommittee on public health, and was deeply gratified when I received letters which indicated that you and Mr. L. J. Peterson had a similar interest. I felt that the subcommittee should have the benefit of your thoughts, and I accordingly brought your letters to the hearing on July 2. They will be published in the hearing record along with the testimony of other authorities.

The amended bill, I am convinced, covers the points which you raise in your letter. With respect to your suggestion that the time limit be extended, you will note that the bill now contains no time limit at all. With respect to your suggestion that there be a provision made in the bill to allow for the construction of facilities and the purchase of equipment where needed, you will note that the terms of the bill allow the President broad and flexible powers, and that the framers explicitly intended this type of expenditure be permitted. Finally, you will note that the language of the bill is sufficiently broad and flexible to permit grants-in-aid to existing State agencies. It is contemplated that the President, in attacking this problem, will employ all available facilities, including State agencies, colleges, hospitals, and the like. In short, it empowers the President to make the same type of all-out attack on the cancer problem as was done on the problem of atomic energy. In so doing, he will set up a general staff for the purposes of coordination, but there will be the broadest cooperation with existing agencies.

I am writing a similar letter to Mr. Beckwith, executive secretary, Office of the Governor, Boise, Idaho.

With kindest regards, I am
Sincerely yours,

GLEN H. TAYLOR.

EXHIBIT 51

STATE OF IDAHO,

DEPARTMENT OF PUBLIC HEALTH,

Boise, June 29, 1946.

Hon. GLEN H. TAYLOR,

United States Senate, Washington, D. C. DEAR SENATOR TAYLOR: We have recently studied Senate bill 1875 which covers an appropriation and plans for a cancer-control program. We are greatly interested in this activity as this department has already done preliminary work in this field and has cooperated with the Idaho division of the American Cancer Society in our Idaho program. We know the United States Public Health Service is also deeply interested in this activity and has already set up extensive cancer research and control programs.

In studying this proposed bill we note it sets up a special board to administer the program and neither the United States Public Health Service nor State health departments would necessarily be considered in planning or administering this program even though all such activities have previously been centered in these two agencies.

This bill calls for an appropriation of $100,000,000 and limits its expenditure to a period of 5 years. We believe it would be impossible for even an existing agency, let alone a new agency, to establish and administer this amount of money economically in such a short period. We do believe work should proceed as rapidly as possible in this important field but believe such a program limited to 5 years would result in a great deal of waste.

We find no provision in this bill to allow for construction of facilities or purchase of equipment which would be needed for any program apparently anticipated by the $100,000,000 appropriation.

We strongly urge that you give consideration to amending the bill so that the United States Public Health Service will be the administrative agency on the Federal level with the State health departments responsible for the program on the State levels. We also believe the 5-year limit should be taken off the appropriation and that amount of money should merely be appropriated for cancer research and control in order that the program may be properly planned and administered.

We will appreciate your favorable consideration of this request and ask that you keep us informed of the progress of this legislation.

Sincerely yours,
X

L. J. PETERSON, Administrative Director.

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