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September 9, 1944
To the Editor:—I am interested to note your editorial of August 12 on the matter of claims for disability said to have resulted from cancer caused by a single injury. In my opinion this editorial is timely but scarcely goes far enough. Traumatic cancer attracted my interest for a rather brief period following the death of the late Dr. James Ewing. Dr. Ewing had been interested in this matter for years and at his death a number of unfinished cases were turned over to me for completion.
In the course of hearings in these cases I acquired an exceedingly bad taste both for certain members of the legal profession and for members of the medical profession who seemed to me to be quite willing to testify to almost anything for a fee. I likewise learned to distrust the type of referee who is so afraid of possible injustice to a claimant that he tends to make awards in the face of incompetent evidence, and I believe he actually practices sociology rather than medicine. He rewards the “deserving” laborer at the expense of the insurance carrier and in so doing uses supposedly scientific medicine to further his notion of proper social behavior.
As for medical testimony, it appears to me that (1) such testimony can be purchased at a price or (2) those individuals who testify are hopelessly ignorant of the commonly known facts of cancer pathogenesis, which in turn is the result either of bad teaching in the cancer field or of dependence on casual statements heard in medical schools or encountered in textbooks on the subject. Lastly, it would oftentimes seem that the supposed expert doesn’t take the trouble to reason at all. Let me illustrate: The same surgeon who will testify that mammary cancer has resulted from a single trauma will at the least provocation operate for a benign lesion of the breast and would never think of warning a patient that because of his operative trauma, which usually greatly exceeds the casual industrial trauma, she should give heed to the possibility that she will develop a cancer of the breast. The same surgeon who will do all sorts of orthopedic jobs involving chiseling into bone or insertion of such objects as ice tongs or pins or screws may testify that a blow which has left no real signs has caused an osteogenic sarcoma, although he never thinks his surgery will do so nor has he ever warned a patient with the severest form of bone trauma—a fracture—to be on the lookout for a possible sarcoma. A man testifies that a blow has caused a soft part sarcoma and yet that man and his colleagues throughout the world will do hundreds of thousands of appendectomies involving the cutting of abdominal wall musculature and observe no tumors. Another says that a malignant melanoma has followed a pin prick and yet no melanoma has ever followed the millions of venipunctures for complement fixation tests or intravenous medication. A third will say that testis cancer is the result of single trauma although the same tumor, histologically indistinguishable, appears in the ovary and no one assigns that to trauma. As far as I know I have never seen a cancer which I could logically and irrevocably assign to single trauma and, even more important than that, I do not know that any one has ever observed the development of a process which could be called “precancerous” after a trauma. The absurd efforts made in our compensation courts to emphasize the severity of traumas rests on the nonsensical point of view that there is some dividing line between the degree of trauma which will or will not cause cancer, under the popular supposition that the metabolic changes which make a cell a cancer cell require a few additional dynes for their complete florescence.
Some means should be found to exclude these figments of imagination from our compensation courts and place such claims in the hands of a truly expert commission—not composed of individuals who have nothing else to do or who have political friends either within medicine or without—and make the findings of this commission binding on the compensation referee, thus avoiding time wasted at hearings, questions and insults from cheap lawyers, and the mental anguish resulting from having to listen to the testimony of ignorant doctors, that in itself, judged by medicolegal standards, might be deemed a sufficient cause for development of a glioma in the expert. I tried this in a way. That is, I wrote a few letters to people who should have been interested and didn’t get anywhere and am unable to wage a one man war on the racket. It will certainly be hard to break, for, under the law, compensation is profitable to claimant, physician and lawyer, and of course in the end the public foots the bill.
Fred W. Stewart, M.D., New York.
Acting Director, Memorial Hospital for the Treatment of Cancer and Allied Diseases.
Correspondence: Cancer Said to Be Caused by a Single Injury. JAMA. 2019;322(10):985. doi:10.1001/jama.2018.15506
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