President Ulysses S. Grant’s Tumor
A glimpse into 19th-century histopathology and survivorship care.
Claire Malhotra, BS, Swapnil Shah, BS, Dev P. Kamdar, MD, and Aru Panwar, MD, on behalf of and with support from the Head and Neck Surgery and Oncology Committee and the History and Archives Committee
Figure 1. President Ulysses S. Grant (1822-1885). Photograph of engraving “Ulysses S. Grant, head-and-shoulders portrait, facing slightly right, in oval within frame,” by W.E. Marshall (ca. 1885), retrieved from the Library of Congress.1
It was not until October of that year that he was referred to John Hancock Douglas, MD, a well regarded “throat specialist” at the time, who identified a growth on the right posterior faucial pillar and a suspicious neck lymph node and delivered the grim diagnosis of cancer. In February 1885, he underwent a biopsy of the right oropharynx under topical anesthesia using cocaine application.
The Role of Early Histopathology in Grant’s Cancer Diagnosis
Although microscopy was in its infancy at the time, physician George R. Elliott, MD, of New York, examined the slides and offered the diagnosis of “epithelioma,” which would correspond to squamous cell carcinoma in today’s classification of diseases. He wrote2:
“…the more or less lobulated appearance of the epithelial mass, the actual existence of some “cell nests”, the great diversity in the shape of the cell elements and the peculiar arrangement of the stroma would warrant from a microscopical standpoint a diagnosis of epithelioma of the squamous variety. It is with deep regret that I feel compelled to submit so unfavorable a report of the nature of the malady afflicting our esteemed Ex-President.”
Dr. Elliott’s account has withstood the test of time, highlighting features including cell nests, cellular pleomorphism, and other characteristics that remain relevant even today when assigning a diagnosis of squamous cell carcinoma. The slides of the tissue obtained from former President Grant’s oropharyngeal lesion remain available at the National Museum of Health and Medicine and represent the histopathologic examination techniques of the late 19th century (Figure 2).
This pictomicrograph represents the tissue biopsies from his right base of tongue obtained in February 1885. The hand razor-cut tissue sections are thick and uneven; however, the cohesive nature of the cells and areas of keratinization can be appreciated, representing a moderately differentiated invasive squamous cell carcinoma.
Figure 2. Pictomicrograph of former President Grant's oropharyngeal squamous cell carcinoma. Reproduced with permission and courtesy of the Otis Historical Archives of the National Museum of Health and Medicine.3
A Treatment Dilemma: Considering Radical Surgery
Former President Grant’s illness captured the attention of the broader community and his experiences during survivorship were vividly captured in contemporary news articles. His physicians provided detailed accounts of his tumor’s characteristics, his symptoms, and the care that was being delivered to him. On August 1, 1885, one of Grant’s physicians, G. F. Shrady, MD, wrote in the Medical Record4 that a “radical surgical operation” was discussed early in the course of treatment:
“[The operation] would have involved the division of the lower jaw in front of the ramus, the extirpation of the entire tongue and the greater part of the soft palate, together with the removal of the ulcerated and infiltrated fauces and the indurated glandular structures under the right angle of the lower jaw. This was considered mechanically possible, despite the close proximity and probable involvement of the tissues adjoining the large arteries and veins… but in the best interests of the distinguished patient the surgeons did not feel inclined to recommend the procedure.”
Dr. Shrady’s account astutely recognizes the tensions between the ideas of “resectability” and whether a tumor should be resected. Ultimately, former President Grant’s physicians decided that it was not certain whether complete resection could be achieved and there remained a significant risk for shock in their already frail patient (Figure 3).
Figure 3. Last photograph of Grant, four days before death. Photograph by J.G. Gilman (1885), retrieved from the Library of Congress.5
Palliative Care and Survivorship
The former president received palliative care for his symptoms, including syringe aspiration for choking and mucus accumulation, and smoking cessation was advised. When he experienced profound asthenia, his physicians administered hypodermic injections of brandy. When depression-related symptoms were noted, his physicians considered the role of poor weather and offered a change of scenery to rural surroundings as an “inducement.”
The tumor slough was treated with topical applications of iodoform, saline gargles, diluted carbolic acid, and permanganate of potash and yeast, and his pain was treated with a 4% solution of cocaine and morphine. As the tumor gradually grew to include the base of the tongue and soft palate, the former president experienced great difficulty due to pain, choking, and nasal regurgitation. He could only tolerate a liquid diet consisting of beef extracts, milk, eggs, and farinaceous materials, and he experienced over 40 pounds of weight loss.
These manifestations suggest the gradual progression of the tumor resulting in laryngopharyngeal dysfunction, velopharyngeal insufficiency, and malnutrition. In April 1885, Grant experienced hemorrhage from the throat, which spontaneously ceased, and the former president did not experience subsequent major bleeding until his passing on July 23, 1885. These experiences mimic those of survivors with advanced oropharyngeal squamous cell carcinoma who receive supportive care only.
Understanding of Cancer Risks Then and Now
In an account published by Grant’s physicians in the New York Times, they felt that his lesion may have started as local irritation exacerbated by his habit of smoking, however, posited that the cause of his cancer was “largely conjectural.” They acknowledged that some individuals may be more predisposed to the development of cancer than others who may share similar exposures during their lifetime.
These concepts preceded the contemporary understanding of malignancies, the association of smoking as a risk factor, and heterogeneity between individuals’ genetic and immunologic predispositions that may contribute towards carcinogenesis. More recently, human papillomavirus-mediated oropharyngeal carcinoma has been increasing in incidence and has been recognized as a distinct entity because of its unique etiopathogenesis, clinical behavior, and favorable prognosis relative to conventional smoking or alcohol-related squamous cell carcinoma of the oropharynx.
Despite these distinctions, the challenges that plagued survivors of oropharyngeal carcinoma in the 19th century remain daunting, including issues related to timely access to care and the physical and psychological distress related to the cancer and its treatment-related morbidity.
References
- Marshall, W. E. “Ulysses S. Grant, head-and-shoulders portrait, facing slightly right, in oval within frame” (ca. 1885). Retrieved from the Library of Congress, https://www.loc.gov/item/2013645299/.
- Elliott, George R. “The Microscopical Examination of Specimens Removed from General Grant's Throat.” Medical Record (1885) 27:290.
- Pictomicrograph of former President Grant’s oropharyngeal squamous cell carcinoma. Reproduced with permission and courtesy of the Otis Historical Archives of the National Museum of Health and Medicine.
- Shrady, GF. “The surgical and pathological aspects of General Grant’s case.” Medical Record (1885) 28:121.
- Gilman, J. G., photographer. “Last photograph of Gen. Grant, four days before death.” New York (1885). Retrieved from the Library of Congress, https://www.loc.gov/item/2018650356/.
