Section 3 -

James Ewing - Cancer Man Andrew G. Huvos Memorial Sloan-Kettering Cancer Center New York, NY

James Ewing died in 1943, full of years and honors, having been the outstanding tumor pathologist of his generation. The first half of the 20th century produced many medical "stars" in North America, including Harvey W. Cushing, the legendary surgeon; William Osler, the brilliant internist and William Henry Welch, the dean of public health. Among these notables, Ewing, dubbed by Times Magazine as the Cancer Man, was a central figure in the rapidly expanding field of neoplastic diseases. [1] He was born on Christmas Day in 1866 in Pittsburgh, PA, the second son of a prominent attorney and judge, of Irish-Scottish descent, and his wife Julia Hufnagel, a German American from Stockbridge, MA. [2] who was a teacher educated at Mt. Holyoke College in South Hadley, MA. He had four siblings, but his youngest brother (by 2.5 years) was closest to him all through his life. His father, after whom James Ewing modeled himself, was a man of tireless energy, pure intellect, and self effacement. [3] As a 14 year old high school student following an ice skating injury James Ewing developed chronic osteomyelitis with a draining sinus, resulting in a hip joint ankylosis. For several months thereafter he was bedridden, but eventually was taken to Philadelphia to be seen by the most prominent surgeon of the time, Samuel W. Gross, who with others, concluded the leg needed to be amputated. The teenager overheard this damning discussion which made a horrible life-long impression on him. Since that episode, surgeons in general were not his favorites. The family doctor opposed this radical treatment and advised a conservative approach instead. After many years the draining sinuses healed, leaving Ewing with a permanent limp and chronic pain. He stoically suffered all through his life, rarely mentioning his infirmity and successfully overcoming it by sheer willpower. He became a fine tennis player, playing until he was 70, mostly on the courts of the Westside Tennis Club eventually becoming the Club's president. After earning a Master of Arts degree at Amherst College, in 1891 he graduated with an M.D. degree from Columbia University College of Physicians and Surgeons where he was a tutor in Histology and an instructor in Clinical Pathology. A most important aspect of his personal life was his brief happy marriage to the much younger and beautiful Catherine Crane Halsted which lasted only three years. They had one son, James J. His wife's untimely death due to toxemia of pregnancy with their second child completely changed Ewing for his entire long life. He became withdrawn, morose and buried himself in work. A fastidious dresser before her death, he became slovenly with rumpled untidy clothing carelessly worn. Cornell University Medical College was founded in 1898 and in 1899, at age 33, Ewing became its first professor of pathology, a prestigious position he held for 33 years. In 1913, Ewing also became the first Director of Pathology at Memorial Hospital (at the time called New York Cancer Hospital) a position he was in for 26 years. In 1939, he was succeeded by Fred W. Stewart, a close associate, who held the directorship for two decades. Following his retirement from Cornell as Chairman of Department of Pathology, Ewing became the Director, in 1931 of Memorial Hospital for Cancer and Allied Disease. In 1921 Ewing drew renewed attention to a peculiar primary malignant bone tumor which to this date bears his name. He popularized and designated it as a diffuse endothelioma and later an endothelial myeloma. [4, 5] To date the histogenesis remains "one of the debated fields of tumor pathology. Whenever discussed, it invites acrimonious debate". [6] In his book and later in his lectures to Cornell medical students he recounted the first patient he saw: a 14 year-old girl with a large tumor of the ulna. [7] Amputation was recommended, but the thought of amputation for this teenager and Ewing himself was quite distressing. The patient was eventually treated with x-ray irradiation only, resulting in the complete disappearance of gross tumor and a remarkable restoration of the ulnar shaft. The girl died of the disease a year or two later. By seeing other similar cases Ewing realized that this peculiar type of bone sarcoma previously known only as a round cell sarcoma of bone, is characterized not only by its typical microscopic features, but also by its extraordinary radiosensitivity. Defining a tumor by its microscopic appearance as well as by an exquisite response to radiation treatment was a novel concept. His association and later friendship with James Douglas, a mining engineer and wealthy philanthropist was an important aspect of Ewing's belief that radium and x-ray treatments were potentially beneficial and curative in various cancers. [8, 9] Ewing and Douglas traveled to Europe in order to learn more about the newest advances in the cure of cancer. Douglas had a personal incentive as well, since his sole daughter had breast carcinoma and he hoped to find a way to cure her disease. In Europe Ewing and Douglas bought a substantial amount of radium and established radiation research and treatment facilities at Memorial Hospital. As time passed, Ewing became more and more convinced that radiation therapy was the best method of treating various cancers. He based his somewhat categorical opinion on the preeminence of the pathological examination which gives important information to the treating physicians as to the choice of treatment by rendering a histological diagnosis. Throughout his professional life, he maintained that a pathologist is not only a microscopist, but a physician's physician with unparalleled insights into sound therapeutic recommendations. [10] He believed that the primary role of a cancer pathologist is to lay down rules in regard to therapy because all sound treatment is based upon pathological principles. [10] By gathering information under the microscope one has the proper basis for establishing a diagnosis and therapeutic principles. The traumatic origin of cancers was an important topic occupying Ewing's thoughts. He concluded that the "great majority of traumas bring to light a pre-existing tumor" and do not cause it. [8] His opinion was based on careful study of the facts and laying down exact criteria before one can accept the traumatic origin of bone sarcoma. Very few cases would meet these requirements, he found. Ewing had a high professional regard for the famous pathologist Pierre Masson (1880-1959) of the University of Montreal. "What he says in the field of schwannomas deserves a great deal of respect." [6] The wit and wisdom of Ewing shines through these lectures. He, for instance subtly admonished the students, "gentlemen−−it seems to me that you are now getting quite noisy in the acquisition of knowledge so that at times it becomes quite impossible to do very satisfactory work. No doubt you notice it when you are looking for information". [6] Or, he skewered the misconception on giant cell tumor by the famed Bostonian pathologist, Frank Burr Mallory (1862-1941) as a "marvel of mental isolation". [6] On discussing meningiomas he warned the medical students, no doubt smilingly, "if you come from Boston, or want to live there, you call the tumor meningioblastoma". [6] Reading the transcripts of the thirty pathology lectures he delivered to medical students at Cornel during the scholastic year, Ewing emerges as a delightfully vivid character, knowledgeable, opinionated, self-deprecating and whimsical. Ewing's pioneering book "Neoplastic Diseases" published in 1919 first codified what was known in the fast emerging field of cancer. [7] Its author demonstrated a fierce gift for observation, a meticulous eye for detail, a keen sense for scientific analysis and the virtue of graceful writing. The information in the book was updated through the fourth edition in 1940. The work became the standard on the pathology of cancer and was translated into several languages. If the noticeable limp and associated hip pain were not enough to overcome, Ewing was additionally plagued by a severe case of trigeminal neuralgia (tic douloureux). This was characterized by excruciating paroxysmal pain which extended along the course of the fifth cranial nerve leaving Ewing in agony. Even an operation by Harvey Cushing to alleviate it remained unsuccessful. In spite of all these personal setbacks Ewing still remained a likable figure who elicited deep personal devotion among his colleagues and members of his family. To people who knew him well and to close colleagues he was warm, cleverly amusing, loyal, and an animating influence. Colleagues revered Ewing and referred to him fondly as the "Chief". [2] In spite of being financially independent if not wealthy, he lived frugally in spartan and austere surroundings in a mid-Manhattan hotel which eventually acquired a bad reputation. He was known for his personal financial generosity by giving those who were in tight financial straits, a blank signed check where the recipients would fill in the amount of money they needed. Ewing himself lived an unpretentious unassumingly simple existence with a dislike of artificiality and hypocrisy. He was economical in the extreme and was known to reuse envelopes by writing on their insides. All through his distinguished and productive long life Ewing struggled to better understand the disease of cancer, but tragically he himself succumbed to bladder carcinoma in 1943. "Without turning Ewing into a monument he certainly remains an interesting human being, warts and all". [11] References Time Magazine, Cover page, Jan 12, 1931. Del Regato, JA: James Ewing. Int J Radiat Oncol Biol Physiol 1977; 2: 185-198. Robbins, G: James Ewing - The man. Clin Bull (MSKCC) 1978; 8:(1) 10-14. Ewing, J: Diffuse endothelioma of bone. Proc N.Y. Path Soc 1921; 21:17-24. Ewing, J: Further report on endothelial myeloma of bone. Proc N.Y. Path Soc 1924; 24:93-100. Ewing, J: Lectures on Tumor Pathology. Cornell University Medical School class of 1934, New York 1933. Second edition. Ewing, J: Neoplastic Diseases: A Treatise on Tumors. W.B. Saunders Philadelphia, New York, 1919; 2nd edition. 1922; 3rd edition 1928; 4th edition. 1940. Ewing, J: Causation, Diagnosis and Treatment of Cancer. Williams and Wilkins Co. Baltimore 1931. Ewing, J: Early experiences in radiation therapy. Janeway Memorial Lecture. Am J Roentgenol Rad Ther 1934; 31:153-163. Ewing, J: A review of the classification of bone tumors. Surg Gynecol Obstet 1939; 68:971-976. Stewart, FW: Obituary: James Ewing Arch Pathol 1943; 36:325-330.