History of Bone Tumor Pathology
Moderators: K. Krishnan Unni and Franco Bertoni
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. 
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.  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
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
To date the histogenesis remains "one of the debated fields of tumor
pathology. Whenever discussed, it invites acrimonious debate".  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.  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.
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. 
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.  By gathering
information under the microscope one has the proper basis for establishing a diagnosis and therapeutic
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.  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
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".  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".  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
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.  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
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
- 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.