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CANCER

ITS

CAUSE AND TREATMENT

VOLUME

BY THE SAME AUTHOR

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CANCER
ITS
CAUSE AND TREATMENT

BY

L. DUNCAN BULKLEY, A.M., M.D.

Senior Physician to the New York Skin and Cancer Hospital, etc.

VOLUME

NEW YORK

PAUL B. HOEBER

1917

Copyright, 1917

By PAUL B. HOEBER

Published, April, 1917

Printed in U. S. A.

To

THE GOVERNORS

of the

NEW YORK SKIN AND CANCER HOSPITAL

whose kind appreciation of and assistance to the author

in his clinical work in their institution have

done much to encourage him and to

promote the interest of the profession

in the branches of

DERMATOLOGY

and

CANCER

this second volume

is inscribed

PREFACE

Two years ago the present writer ventured to put forth a small book in which cancer was considered from quite a different standpoint from that commonly held by the profession and laity. The kindly reviews of the medical press indicated that, while this was antagonistic to accepted views, there was warrant for such an investigation, in view of the steadily increasing mortality from cancer all over the world, under the present mode of purely surgical treatment.

In these two years there has been very active study of cancer together with a campaign of education in regard to the desirability and necessity of operating very early in the disease, and consequently an increased surgical activity. In spite of all this, or possibly on account of it, the mortality from cancer during 1915 has been appreciably higher than the average yearly death rate during the preceding five years. It would seem, therefore, that there was increasing necessity for the study of the conditions which cause the disease, as found in the human system, rather than an increased study of pathological specimens and experimentation on animals.

During these two years the writer has sought to understand the disease better by constant clinical observation in private and public practise and by wider acquaintance with literature, and has been only strengthened and confirmed in the views which were set forth in the former small book, and which he has held and practised for over thirty years.

With some care he has prepared a second series of lectures which were given to practising physicians attending the regular Wednesday afternoon clinics at the New York Skin and Cancer Hospital in November and December, 1916, and which are now submitted to the profession at large.

The reasons for presenting the medical aspects of cancer were given in the former volume, also the hesitancy I felt lest, from an imperfect carrying out of the necessary lines of internal treatment, harm might be done or time lost in which there might possibly be some gain from surgical treatment.

But the more I have studied cancer in the living and dying subject, and the more I have tried to compass literature and analyze statistics, the more have I felt compelled to push forward a campaign of education in regard to the basic causes of the disease, ever with the thought of prophylaxis, by inculcating right living.

It has been painful to me to present the mortality statistics in such an unfavorable light as is seen in the following pages: but truth is truth and truth must prevail.

No one can study carefully the remarkable book of Hoffman on “The Mortality Statistics from Cancer Throughout the World,” and Williams’ “Natural History of Cancer,” and Wolff’s “Die Lehre von der Krebskrankheit,” and the special volume concerning “Mortality from Cancer and Other Malignant Tumors in the Registration Area of the United States,” recently issued by the Bureau of the Census, without feeling that something more should be attempted to arrest the progress of this direful disease.

This seems all the more necessary and proper in view of the gratifying decrease of mortality which has been obtained in tuberculosis, of 27.8 per cent from 1900 to 1915, by diligent and intelligent medical supervision.

The problem of cancer is indeed a great one, but surely it is not to be solved by greater activity along the lines under which its mortality has steadily risen 28.7 per cent during the same period just mentioned, in which tuberculosis has fallen so greatly. If this death rate of both diseases should continue the same for fifteen years more, cancer would outstrip tuberculosis in its actual fatality. Reason would seem to indicate the necessity of a radical change in our point of view and a complete change in our line of treatment.

In the text of these and former lectures I have endeavored to show why and how cancer should be regarded from its medical aspects, and to illustrate by a few cases some of the results which could be obtained from this line of procedure. There is absolutely no claim or suggestion that the cancer problem has been solved, but only an aim to put the real cancer problem in such a light that others might follow and develop the subject in a manner fitting to the very great importance of the end so strongly desired by all, namely, the checking of the steadily rising morbidity and mortality of cancer.

Laboratory studies are of practical value as they supplement and enlighten clinical observation. The microscope and test tube have accomplished much for medicine and with animal experimentation have undoubtedly rendered inestimable service in its scientific advancement. But divorced from the practical study of patients they may fail in the ultimate end desired. In these and the former lectures I have endeavored to indicate certain lines of scientific investigation along which much more laboratory effort is desirable, in order to determine more definitely the metabolic and blood conditions which lead up to cancer. These I have attempted to follow to a limited degree in many cases, and found them of great service in their management.

In some of the reviews of the former volume some adverse criticism was given on account of the absence of microscopic findings confirming the diagnosis of the cases reported. I explained at the time that any attempt to excise portions of tissue for such study would at once endanger the patient and imperil the success of treatment, by giving occasion to metastases, from the opening of blood vessels and lymphatics. This matter is treated of more fully in the present lectures. It is to be remembered that the vast majority of operations for cancer are undertaken upon a purely clinical diagnosis, and it may be undeniably stated that not one half of them are confirmed subsequently by competent microscopic evidence, except, of course, in properly equipped hospitals. In some of the cases now presented pathological proof has been presented, while in every one the clinical signs were so unmistakable that no one could possibly doubt the correctness of the diagnosis.

A number of reviewers of the former volume regretted that fuller and more definite statements had not been made in regard to the exact diet and mode of treatment employed in the cases reported. I had explained that it was very difficult to develop all this in the brief compass of a few lectures; indeed I may now say that it would take many times the space and time which could be given to it to develop fully all the possibilities and requirements of a dietary and medicinal treatment in every case. The object rather was to inculcate the basic idea of the true causation of cancer, leaving it to the practitioners present to carry out the measures calculated to reach the desired end. In order to make matters very clear I may occasionally have repeated some things said in the former lectures, and some repetition may be found in these successive lectures; but this will be pardoned when it is considered how necessary repetition often is in order to establish correctly a new thought. The cases were given as illustrations of what could be accomplished along the lines indicated.

In the present lectures I have endeavored to carry the thought still further and to develop the fundamental principles on which treatment and prophylaxis are to be based. I have also been much more explicit in regard to diet, and have given the exact dietary which has been used with advantage in very many cases in private and hospital practise. In regard to medical treatment I have also been more definite, although it would be quite impossible to indicate all the different remedies which those and other patients have taken over varying periods of time, to meet different requirements of the system and individual peculiarities. I think and believe, however, that sufficient data are given to enable the competent and careful physician, who is able and willing to give sufficient time and adequate attention to these cases, to accomplish the same results, provided he has thoroughly mastered and applied the matter contained in these two small books.

I fully realize the responsibility I have undertaken in gathering and revealing the evidence of the unsatisfactory results of the manner of regarding and treating cancer in years past, and certainly would not have done this were I not so strongly assured that there was something better to offer. How far I am right in my thesis I now leave to the kindly judgment of my professional brethren. My only hope is that I may, in some measure, have assisted in stemming the tide of the fearful ravages made by cancer, and that others may investigate still more deeply along the lines of its medical aspects, with increasingly satisfactory results.

L. Duncan Bulkley.

January, 1917.

531 Madison Ave.

CONTENTS

CANCER

ITS

CAUSE AND TREATMENT

LECTURE I
CANCER AS A MEDICAL OR SURGICAL DISEASE

In my lectures given here two years ago I considered, as far as I could in the time allowed, the nature of cancer,[^[1]] and the evidence in favor of its being a medical rather than a purely surgical disease; and in order that the trend of what shall follow may be clearly understood, brief reference may be made to some of the principal points studied and developed in the preceding lectures. To this end I may restate the conclusions presented at their close, as developed in the lectures, perhaps with some alterations or additions which two years’ further study, observation, and treatment of cancer may suggest.

1. Cancer is but a deviation from the normal life and action of certain of the ordinary cells of the body, which, for some reason, difficult to understand, take on an abnormal or morbid action: with this there is a continued tendency in them to a malignancy which invades contiguous tissue, associated with a pernicious anemia which in the end tends to destroy life.

2. There is some reason to believe that this diseased action first takes place in what are known as “embryonic rests” or pre-natal, wrongly placed tissue elements. These latter, however, are now shown to exist in every individual in many localities, but the reason why at some particular time they take on this malignant action, and form cancer, has not yet been satisfactorily explained.

3. Cancer is not wholly due to traumatic causes; although these may play a not inconsiderable part in its occurrence in certain localities and cases.

4. It is pretty conclusively decided that cancer is not caused by a microörganism or parasite; although various forms of these have been found in connection with the disease, and each has been claimed as the cause of cancer.

5. It is known clinically and experimentally that cancer is not contagious.

6. Nor is it hereditary in any appreciable degree; although certain rare instances have been reported in which such seems to be the case, and though some tendency in that direction has been demonstrated in certain strains of mice.

7. Occupation has not any very great influence on the occurrence of cancer; although it is more frequent in some pursuits than in others.

8. Cancer is not altogether a disease of older years; although its incidence is greatly increased with advancing age.

9. Cancer does not especially belong to or affect any particular sex, race, or class of persons. It is, however, more frequent in females than in males, although of late years the proportion in the latter is steadily rising.

10. Cancer is not confined to any climate, location, or section of the earth, but has been observed in all countries and climates, though with different frequency.

11. No single cause of cancer has yet been demonstrated; nor is it likely that this will ever be the case, as experimental and other investigations have covered almost every possible line of research, with only negative results.

12. The exclusion of almost every other possible cause of cancer, as well as its pathological history and biochemical studies, all lead, therefore, to deranged metabolism as the only remaining possible etiological element. This latter acts by inducing changes in nutrition, and these in turn depend on diet and the proper or improper action of the secretory and excretory organs; these latter may, still further, be affected by nervous influences.

13. While the biochemistry of cancer does not as yet throw very great light on its true nature and cause, enough has been determined to show that the morbid changes in the cells are largely associated with deranged metabolism.

14. The blood in advancing cancer manifests changes which indicate vital alterations in the action of the organs which form blood and control the nutrition of the body and its cells.

15. Clinical and experimental evidence demonstrate that the secretions and excretions of the body exhibit departures from normal; these, while not wholly pathognomonic of cancer, still indicate metabolic disturbances which involve the nutrition of the cellular elements, and these disturbances are of importance.

16. The evidence seems certain that the cancer mass, when fully developed, secretes a hormone or poison which tends to augment its own growth, and hastens the lethal progress of the disease.

17. The mortality from cancer is undoubtedly on the increase in every portion of the globe, in spite of the assiduous activity of the laboratories and the immense advances in surgical procedure.

18. This increase in mortality is seen to vary inversely, and in about the same proportion, with the steadily diminishing mortality of tuberculosis, under recent careful medical guidance.

19. The increase of cancer mortality is found to follow closely along the lines of modern civilization.

20. The extension of cancer appears to depend largely upon the altered conditions of modern life, particularly along the lines of self-indulgence in eating and drinking, and indolence.

21. The augmentation in the consumption of meat, coffee, and alcoholic beverages in civilized communities is seen to be coincident with the great and proportionately greater augmentation of the mortality from cancer.

22. The nerve strain of modern life seems to be an element of importance, both through disturbance of metabolism and by direct action on morbidly deranged cells.

23. No single remedy for cancer has been, or will probably ever be, discovered, since it is conceded that there is no single cause for the disease. The history of cancer abounds in the heralding of various vaunted remedies, quack and other, including sera, whose employment has only ended in the disappointment of medical men and in the deluded hopes of innumerable sufferers.

24. Modern surgery has materially improved the statistics relating to the immediate results of operative procedures; but the total achievements along this line are insignificant when compared with the steadily rising death rate, and ultimate mortality of about 90 per cent of those once afflicted with cancer.

25. Surgery has had, and may yet have, its function to perform in removing some of the products of the constitutional state causing cancer, more or less efficiently, curing some patients and prolonging the life of others; but from past experience it can never hope to lessen the morbidity of cancer. The reason for this is that it attacks a symptom only, and not the underlying cause.

26. The X-ray and radium, as also caustics, are in the same position as surgery, and can do little more than cause to disappear, more or less temporarily, some of the lesions which have developed from causes which they cannot reach.

27. With all these means the measure of success, aside from the technical skill of the operator, depends largely on the duration and the extent of development of the malignant growth before treatment: the earlier such local treatment is undertaken, other things being equal, the greater the possibilities of success.

28. The same is true in regard to the treatment of cancer by dietary and medical means. The earlier the morbid constitutional process, or state, leading to tumor formation is attacked by proper dietetic, hygienic, and medicinal measures, the greater the promise and expectation of success, present and permanent.

29. The cure and prevention of cancer, therefore, and the checking of its increasing occurrence and mortality, depend largely upon the early adoption of such measures as will limit the agencies which induce the formation of the new growth: these are certain derangements of the body juices which tend to bad nutrition and disturbance of the action of the body cells.

30. The simple life, with the avoidance of the dietetic and other causes which have been found to induce cancer in nations and individuals, promises the best hope for the arrest of its rapidly increasing development and mortality throughout the world.

31. It is more than possible, however, that the long continued operation of many baneful causes has produced such a degeneration of tissue in the human race that it will take a generation or more of proper living to make the beneficial impression on the general occurrence and mortality of cancer which is so longed for.

It is quite impossible and unnecessary to elaborate again the facts upon which these conclusions are based, which were given very fully in my previous lectures and book; but we may briefly consider some of the features just presented, and some of the evidence why cancer should be considered from a medical rather than a surgical standpoint. For it must be conceded that both the general medical profession and the laity still regard the disease as belonging to surgery, and look only to the knife for any hope in its treatment. In spite of all that has been done the present outlook for the checking of its rising mortality by this means, and for the prevention of cancer, is bad indeed, as will be shown in a later lecture.

But, gentlemen, many great surgeons, in past and present time, as quoted in my former lectures, have acknowledged verbally and in writing their inability to cope with cancer as a disease, and have recognized time and again that they operated only because they knew of nothing better to do. Often it is acknowledged that the operation is only palliative, in the hope, alas, how often futile, that some good might result from it, in the chance that the dread disease would not return. We shall see later, when we come to study the mortality of cancer in various locations, and an analysis of surgical statistics, how slight the foundation is for such hopes.

Both in the past and present times many surgeons of eminence, well acquainted with the disease, whom I quoted in my former lectures, have also more or less casually expressed the conviction that there was some deep-seated constitutional cause of cancer which baffled recognition, but which must have to do with the diet or mode of living of those afflicted. The most recent of these is Dr. William J. Mayo, who has spoken in no uncertain terms along this line, in a recent address as President of the American Surgical Association. And yet how relatively little intelligent effort has been put forth to discover and amend these conditions, and to remove the bodily derangement which eventuates in the formation of the foci of disease which later become malignant and form what is called cancer, or to modify the blood changes which ultimately destroy life!

In a long experience I have seldom, if ever, come across a patient with cancer who had had any intelligent and prolonged attempt to check its development by dietary, hygienic, and medicinal means; invariably the knife, X-ray, and radium have been the only measures under consideration. Also, after an operation the patient is dismissed, or watched for a recurrence and again operated on, with no prolonged effort to so modify the constitution that the same causes shall not reproduce the malady in the same or other localities. And yet I have narrated to you cases of undoubted cancer, verified by competent surgeons, who urged instant removal, which had entirely disappeared without operation under the line of treatment detailed, and who remained in perfect health for many years, sixteen in two instances. I also reported cases illustrating the beneficial result of dietary and medicinal measures in cases recurrent after operation. This matter will be more fully considered in a later lecture, with further illustrations.

We may now consider some general matters bearing on the question of a medical rather than an exclusively surgical aspect of cancer.

The founders of the Index Medicus placed cancer among the diseases of metabolism, along with gout, obesity, chronic rheumatism, diabetes, and a few conditions of minor importance. This grouping of cancer in no wise interferes with the idea that a chronic local irritant may be the exciting cause of the local development of the tumor, which becomes malignant, in any particular situation; any more than what is observed in the case of late syphilis, where a gummy tumor or a bone lesion may appear at a point of injury, or where gout will develop in a joint which has been bruised.

But it does show that broad medical thought has long recognized that cancer is not a purely local disease, but that it arises from some disturbance of nutrition, tending to localize in some particular spot, even as a neuralgia will occur in some special nerve and be reached, not by local measures, but by those of a general nature. Repeated casual observations have often been made by clinicians, and even by surgeons of prominence, of the apparent relations between cancer and gout or rheumatism, and also diabetes, and all recognize the rebelliousness of cancer when it occurs in connection with obesity. The late Dr. John B. Murphy was very strong in regard to this latter point. The constant occurrence of cancer in rheumatic individuals is a very striking feature, which I observe almost daily.

It is worthy of remark that cancer begins to appear at a wholesale rate at the age when metabolism begins to slow up, and some time after the body growth has become fully established. At this period people are apt to lose the balance between physical effort and the intake of food, eating as much as ever, perhaps more, while becoming more sedentary. At the same time the emunctories become less active. The various affections of metabolism now tend to appear and are associated with imperfect oxidation, or diminished tolerance toward certain ingesta. It is interesting to note that in a study of many thousand cases of eczema I found the disease to be actually more frequent, in proportion to those living, between the ages of 50 and 55 than at any other period of life after the infantile period, or the first five years of life; just about the same time when cancer is most common. And the constitutional conditions at the bottom of eczema are very much the same as those in cancer.

Patients with a cancer just beginning will often, or even generally, seem to be in excellent health. It is indeed remarkable to observe how commonly patients with beginning breast cancer will seem to be in a splendid condition of health. They are ruddy and blooming in appearance, and when the lump is first discovered it is hard indeed to believe that if the erroneous life processes which caused the cancerous lesion to develop are not checked, the patient will before long succumb to the direful disease. Williams remarks that “such types are indications of hypernutrition.”

But a most careful study of these patients in every particular will so constantly reveal such errors of life and derangements of metabolism that these must be looked upon as contributing causes, at least, to the development of the local condition which later becomes malignant; in the same way as the patient will appear to be in blooming health just before an attack of acute gout. For when these conditions are rectified by proper dietary and medicinal measures the local cancerous condition not only ceases to develop but actually disappears without surgical removal, as I have repeatedly shown you. These errors and derangements are not commonly evident on a superficial examination, and often are recognized only after very painstaking search, and re-search.

We have not yet arrived at such a clear knowledge of metabolism as to understand just where the fault lies in these cases of seeming perfect health, with the beginning of a neoplasm which may eventuate so disastrously. But we do know that what passes for good health is often fictitious, and is quite compatible with even grave disorders of various kinds. It is more than possible that the apparent well-being of the patient with beginning cancer, which is often observed to be associated with uricacidemia, points also to the correctness of our thesis in regard to its internal causation. As remarked in one of my former lectures, quoting Ribert, “no one has ever seen the beginning of mammary cancer” and no one will ever see the beginnings of cancer of internal organs.

But, whatever may be thought of Haig’s theories or statements regarding uric acid, there is no question but that many maladies of many kinds have their origin in the concatenation of processes which has long been recognized clinically as lithemia. Personally I believe that sooner or later it will be generally recognized that the starting point of cancer occurs in some cell or cells, previously normal, probably as the result of local irritation, in which there is a deposit of some of the elements of faulty nitrogenous partition, induced by undue ingestion of animal protein: and that the malignant, reproductive process in the cells is kept up by a continuance of the same supply of imperfectly disintegrated nitrogenous matter.

The condition of the urine furnishes a most invaluable indicator and guide as to the systemic derangements and their correction. This has not reference to the presence of sugar, albumin, or casts, but rather to other features, reflecting the manner in which metabolism is performed. This subject was gone into pretty thoroughly in my former lectures, but must be briefly considered here, because of the great importance of the subject.

It is well known that, while the products of the digestion and disassimilation of carbohydrates and fats pass off by the lungs, generally without harm, those of protein and salts are eliminated by the kidneys, and may be the cause of various systemic derangements. The urine, therefore, when most carefully analyzed volumetrically, exhibits in the clearest possible manner how the metabolism is carried on and where the error lies.

From a study of hundreds of complete volumetric analyses of urine in dozens of cancer patients, both in the very early and late stages of the disease, I have found that this excretion almost invariably exhibits departures from normal which are significant.

First to be mentioned is the relation of the total solids excreted daily to the body weight of the individual; for it is evident that a person weighing 200 pounds should pass off more than a smaller person. The following table represents fairly well the total solids that should pass daily in order to maintain a healthy equilibrium:

These figures do not represent much active exercise, and with increased bodily exertion the solids passed should be more. Men excrete about one-tenth more than women; there are also less urinary solids passed with advancing age, and about five per cent may be deducted for each ten years after forty.

The estimation of the total solids is easy with Haines’ modification of Hasser’s method. Multiply the last two figures of the specific gravity of the urine by the number of ounces voided in 24 hours, and add ten per cent to the product. Thus, if the amount passed in 24 hours was 36 ounces with a specific gravity of 1.021, it would be 36 × 21 = 756 + 10 per cent = 832 grains of solids in the whole amount of urine excreted that day. By comparing this with the table it can be readily ascertained if the amount is above or below the normal standard for the body weight of the patient. For many years I have employed this method of determining the urinary output in hundreds of patients with various diseases of the skin and cancer, and have found it of inestimable value. It is understood, of course, that by dietary and medicinal measures the urinary solids are to be brought up to and maintained at normal.

The actual acidity of the urine, as measured by the oxalic acid and phenolphthalein test, is also of the greatest importance. This is not difficult of application and is daily used in my laboratory; the litmus paper test is of relatively little value in comparison with an actual chemical measurement. Thus, with an average standard of 300 we not infrequently find an acidity of 500 or 600, or even 1000 or more, or it may sink to 200 or 100, or even be strongly alkaline. In cancer I have striven, by diet and remedies, to keep it a little below normal, as it has been shown that the blood in this disease exhibits a constantly increasing tendency to diminished alkalescence, or, wrongly called, increased acidity.

But further and very careful volumetrical urinary analysis is very important to determine and maintain the metabolism in its proper condition. Time does not permit such an elaboration of this subject as might be desired, and I can only call your attention briefly to some of the points brought out in my former lectures.

Many observers have found the nitrogenous disintegration very imperfect in cancer cases, and oxyproteic acids are increased and even that in very early cancer. An increase of amino-acid nitrogen was found by Reid in practically every case studied. Others have found an increase in colloid nitrogen, to more than double the normal amount, and also increased elimination of xanthin and urinary ammonia; so that all observers testify to a disturbed nitrogen partition in cancer. The elimination of urea is certainly greatly diminished, even in early stages and when on a full diet, as I have almost invariably observed.

The sulphur partition is also found to be imperfect, in new and old cancer cases, and even a great increase in the urinary discharge of sulphates is constantly noticed in my analyses. Associated with these errors in the nitrogenous and sulphur element is the very common and persistent increase of indican, showing stasis in the small intestine, with bacterial putrefaction.

Imperfect intestinal elimination is constantly observed in cancer cases, both habitually and in the very early, formative period, and also later, even before any recourse to morphin, which, of course, heightens the trouble. In recording the statements of these patients I have been so struck with the almost invariable history of constipation before the first appearance or suspicion of the cancer that I cannot help feeling very strongly the possibility that the toxins produced by the millions of microörganisms, generated through intestinal stasis and fecal putrefaction, play a great part in the production of that blood dyscrasia which culminates in the formation of the malignant new growth.

I mentioned to you last year that in hundreds of tests of the saliva in cancer patients the reaction was found to be acid almost invariably, until corrected by dietary and other treatment. I have this test made and recorded daily, half an hour before meals and half an hour after meals, on my cancer patients in the New York Skin and Cancer Hospital. I have also the urine volumetrically analyzed each week, and the results all tabulated in columns on the history sheet, so that the changes may be compared weekly, in regard to each constituent, as treatment progresses. The same is done with the weekly studies on the blood, which I hope to present in full before long.

I think, gentlemen, that from what I have said you can see that the medical aspects of cancer loom up pretty large, and yet we are only beginning to study the disease along these lines. We see, thus, that cancer is not primarily a surgical affection, and that the mere ablation of an offending portion of the body which has become diseased can never preclude a new portion from becoming affected, or prevent a recurrence in the same location; indeed, this often seems to be stimulated and increased by the trauma and by the deranged lymphatic and vascular circulation caused by the operation and the dissemination of actively growing cancer cells through these channels. This will appear more fully later when we come to study the increasing mortality of cancer during these later years of active surgery, and when we come to analyze the actual reports of operative procedures.

I hope, gentlemen, that by these lectures I may succeed in satisfying your minds that if anything is to be done towards staying the steadily rising frequency and increasing mortality of cancer, it must be by carefully wrought out medical means, and not by the knife.

LECTURE II
INFLUENCE OF SEX, AGE, OCCUPATION, RACE, CLIMATE, AND FOOD ON CANCER

While cancer is no respecter of persons, and affects all, rich and poor, old and young, male and female, there are some interesting features regarding the disease as it occurs under various conditions which are worthy of consideration.

We have seen in the former lecture that cancer is not a definite something, from without, that attacks the human frame, but that it is only a faulty development and action of certain body cells, which were once normal, with a steady decline in bodily health which tends to a fatal issue in a very large proportion of those once affected with the disease.

We have seen that the cancer patient, both in the very earliest stages and during the whole period of the disease, gives evidence of departures from the ideal normal life, and presents functional disorders of various organs, with derangements of metabolism; these point to errors of nutrition, which latter are of significance in connection with the development and continuance of the malignant disease. The conclusion offered was that cancer is a medical affection, due to systemic causes, and that the simple surgical excision of a certain diseased portion cannot be expected to check or remove such a malady, or to prevent recurrence. And this has been abundantly demonstrated by the history of the disease, with its steadily increasing mortality under increasingly active surgical treatment during the last fifteen years, as was shown in my former lectures and will be further illustrated later.

Recognizing, then, that cancer is a great and widespread disorder of nutrition, let us consider some of the facts regarding its extension and some of the influences concerned in its production.

Sex.—Cancer is much more frequent in females than in males. In the United States Mortality Reports for 1914 there were 31,138 females to 21,282 males; thus, in a total of 52,420 deaths from cancer 59.4 per cent were in females, with a preponderance of 9,856. This excess is largely due to cancer of the breast, from which there were 5,423 deaths, and cancer of the female genital organs, causing 8,152 deaths, of which 7,470 were from cancer of the uterus.

The death rate in males, however, seems to be increasing of late years; in the United States in 1912 males formed 39.7 per cent; in 1913, 40.1 per cent; and in 1914, 40.6 per cent. In England, according to Williams, the proportion of males to females is increasing much more rapidly. This greater mortality of males is due to the greater number of deaths from cancer of the stomach and liver, buccal cavity, and skin. In 1914 there were 19,889 deaths from cancer of the stomach and liver, or 37.9 per cent of the whole number; of these 10,122 were in males to 9,767 in females, or an excess of 355 males, whereas in 1912 the females were 87 in excess. In the United States the cancer death rate for males has increased since 1901 31.8 per cent and for females 25.3 per cent.

Age.—Carcinoma is exceedingly rare under 20 years of age, most malignant tumors at that period being sarcomata. After 25 the number of deaths from cancer about doubles each five years up to 40, and then increases steadily, until the actually greatest number of deaths, 6,909 (3,071 males, 3,838 females), occurred between 60 and 64 years of age, after which they decreased steadily; there were 267 deaths at 90 and over, 8 of them being 100 years and over. At no period did the deaths of males exceed that of females, and from 35 to 39 years of age the latter were almost three times that of males.

Occupation.—Many attempts have been made to trace the influence of occupation upon the incidence of cancer, but thus far very little of practical interest has been demonstrated; the difficulties concerning this investigation are immense, owing to absence of essential and accurate data. There have been many lists presented, but few of which agree as to details, and all need to be corrected as to the proportion of those living at different ages. There is also the question as to the effect of local or general agencies; thus, as to the result of local injuries on the skin, and also in regard to other agencies, whatever they may be, which produce internal cancer; for tables of occupation do not generally refer to sex, age, or location of the disease.

First, to dismiss the question as to the direct result of local injuries in inducing cancer of the skin, which, at the most, caused only 3.7 per cent of all cancer deaths in 1914, we may cite a few instances in which this appears to be pretty well established.

The occurrence of epithelioma as a direct result of repeated and protracted exposure to X-ray is familiar to all, and is particularly interesting because it occurs commonly among younger persons, and at a time of life when epithelioma is rare; and especially also because the X-ray is constantly effective in curing epithelioma. The rarity of epithelioma resulting from X-ray, considering the enormous amount of exposure which must have occurred in making and using X-ray tubes, implies, however, that there must be some other cause also at work. It has been urged, therefore, that the skin tissue being altered and weakened from repeated and protracted exposure to X-rays, more readily falls prey to some of the chemical or other irritating agencies which have been observed to be followed by epithelioma.

Time does not permit even a mention of the various elements, which are many, that have been credited as excitants of cutaneous epithelioma; but brief allusion may be made to one which formerly attracted much attention, mainly in England; this refers to chimney-sweeps cancer, the mortality from which was at one time at least 5 times greater than that from cancer in males generally, at the same age. This is now, however, of relatively infrequent occurrence, owing to the adoption of other methods of cleaning chimneys. The epithelioma, which more commonly developed on the scrotum, was believed to be due to the long continued irritation caused by the constant presence of soot on the part; other products of combustion and tar derivations have also been accredited with the same result.

The question of the influence of occupation along other lines is really more interesting, because more obscure; but a careful study of available data tends to show the correctness of the thesis on which my former lectures and these are based. This, as you know, is that our so-called advancing civilization, with all its errors of life, in many directions, is at the bottom of the steady increase in the mortality from cancer.

One of the most interesting contributions to this was the investigation made by Dr. Latham, Registrar-General, in a study of cancer returns in England; this showed that the mortality from the disease was more than twice as great among well-to-do men having no specific occupation as among occupied males in general, the respective mortality ratio being 96 for the former and only 44 for the latter. The same observation has been made elsewhere.

Moreover, it is reported from several reliable sources that the death rate from cancer in many cities is proportionately greater among the rich and those in easy circumstances than among the poor, wage-earning element of society. This would seem to show that occupation in general acts favorably against the development of cancer. This fact is quite understandable when we consider that those engaged in active work are less liable to suffer from the effects of gluttony and indolence, with their concurrent metabolic disturbances, than the well-to-do with ease and luxurious habits. It is remarkable, however, that in asylums, homes for the aged, prisons, convents, monasteries, etc., where the inmates are relatively unoccupied, many writers confirm the fact that cancer is very seldom seen; but this again is explained by the simple and frugal diet enforced, with very little meat, which agrees with our thesis.

Statistics from life insurance companies show that cancer is decidedly more common among persons of over-weight than among under-weights.

In regard to the occupations of those dying from cancer it is interesting to note that standing among the highest per 100,000 population, in English statistics, come brewers, inn-keepers, and butchers, whose metabolism can be greatly disturbed by alcohol and meat; also indoor servants are more apt to be affected, while those of more or less sedentary occupation, such as school teachers, clergymen, physicians, and tailors, likewise stand very high on several lists. On the other hand, those engaged in active physical exercise, such as miners, farm laborers, carpenters, blacksmith, mail-carriers, and others, are among those least frequently attacked.

Race.—Cancer has been observed in every race, though the proportion of cases is observed to vary greatly among different peoples; but it is interesting to note that it is universally agreed by those that have studied the subject that the difference in frequency relates very largely to the degree of civilization involved. The blond Nordic race, however, seems to be more susceptible to the disease than the darker races, originally of Asiatic origin; and it is the former who have pushed forward modern civilization, with all its errors of life.

Thus cancer is everywhere reported to be rare, and sometimes almost absent, in primitive, uncivilized peoples, but it has been repeatedly observed, in many localities, that as these same people mix with Europeans and adopt their diet and mode of life, cancer is sure to increase, until its frequency often about equals that in their highly civilized neighbors. I went over this matter pretty fully in my former lectures and cannot dwell on it now, or give examples. I can only emphasize the fact that this furnishes a strong support to the contention that cancer depends upon disorders of metabolism, which are certainly increasing under the various elements which compose what is called advanced civilization.

Climate and Locality.—There is no evidence to prove that climate has any influence in the production of cancer, nor is it affected by locality; the disease occurs in hot, warm, temperate, and cold climates, and in every possible location on the earth. But it is undoubtedly most prevalent in temperate regions, for the reason that it is in these that modern civilization, with all its faults and foibles, is most highly developed.

The subject of the topical distribution of cancer, or its occurrence in certain regions, has been the subject of much controversy in England and France especially, and to read certain statements one would be inclined to believe that certain telluric conditions were of influence in its production, as along certain water courses, etc. But a more careful analysis of all these statements shows that such elements can act only as contributing causes, as, for instance, through a rheumatic influence, which is known to be found in so many cancer patients.

The same may be said in regard to so-called “cancer houses” concerning which there are still occasional references. A careful investigation of these houses has commonly found them to be old, moldy, damp, badly ventilated, and otherwise unsanitary; also that such old houses are commonly tenanted by old people in succession, so that there are more at a cancer age to be affected. With our present knowledge of the causes which lead up to cancer we cannot but conclude, therefore, that the occurrence of the disease in groups, with some apparent connection, has been only the result of all living under the same conditions of ill health, including wrong diet, etc.; for we know that cancer is not contagious or infectious, and there is no other reasonable explanation which can be sustained.

Food and Mode of Life.—In my former lectures I presented very fully the evidence that cancer was certainly a disease of civilization, its frequency and mortality advancing steadily in proportion as various tribes or peoples, previously exempt, have come more or less under its influence and adopted its manners and customs.

When we speak, therefore, of the influence of food in the production of cancer it must be understood that it is not claimed that the diseased process depends wholly and exclusively on the character of the food, including drink, taken. In my former lectures I tried to show that cancer was the result of a deranged nutrition, and we know that one of the greatest elements in inducing this latter is erroneous metabolism, depending again on the diet, to a very great extent. In a later lecture I shall hope to develop this subject further, and indicate more completely than on the previous occasion, the elements of causation and the measures which can be successful in overcoming the disease.

In order to understand rightly the rôle which diet may have in the production of cancer I may have to briefly repeat, more or less, some of the matters brought forward in my lectures two years ago, and shall treat of the correction of diet in a later lecture.

We understand, of course, that the body is a vast laboratory, wherein, by exceedingly complicated processes, material from the outside world is appropriated to the needs of the economy, and after its use is cast out in very different and elementary forms. To effect the various changes necessary in this material we have a very considerable number of what are called organs of secretion and excretion, whose functions are combined and correlated in a marvelous manner, which is even yet very imperfectly understood.

The actual biochemical processes by means of which the transformation of external food elements into living tissue and force, physical and mental, takes place are known as: 1. Anabolism, or the process of assimilation of nutritive matter and its conversion into living substance; and 2. Catabolism, or the breaking down of complex bodies of living matter into waste products of simpler chemical composition. These together constitute 3. Metabolism, or the sum of the chemical changes whereby the function of nutrition is effected. The actual procedure by which most of these activities is carried on is one of oxidation, by means of the oxygen supplied largely by the lungs, which constitutes about 65 per cent of the human body.

Now to make up for the daily waste of the other 15 elements, which form 35 per cent of the body tissues, and to support the necessary activities of the system, mental and physical, it is necessary every day to take a more or less even supply of substances, which we call food and drink, which should contain about the proper proportion of the requisite bodily components. Under normal conditions of healthy living the appetite ordinarily serves as a proper guide for health in man and beast, serving to regulate the selection of material to preserve the balance of nutrition. But man especially has temptations to gratify the taste, which is quite a different thing from satisfying the appetite, and all are familiar with the many forms of disaster and disease which arise from gratifying the taste in food and drink; moreover, the temptations to this seem to increase continually with the so-called refinements of civilization.

The actual nutritive elements which are required are relatively few, and fall mainly under three classes: 1, Protein; 2, Carbohydrates; and 3, Fats. Of these the latter two furnish most of the 18 per cent of carbon in the body, and the animal or vegetable protein furnishes the nitrogen, which forms only about 3 per cent of the body tissues: all these substances are, of course, used up constantly in providing heat and energy, physical and mental, day by day, the protein being concerned chiefly in replacing wasted tissue. The combustion of the carbohydrates and fat is relatively simple, and the waste products pass off harmlessly, mainly by the lungs, as carbonic acid and water.

But the course of the protein, or nitrogenous and sulphur and other mineral elements, is quite different. In the anabolism and catabolism of protein there are a vast number of intermediate changes, and various products are elaborated which we know to be of great significance in the system, and which when imperfectly completed are the source of much disorder and disease in the economy. Of this the gouty state is a notable example, with a long list of secondary disorders.

But few realize, however, that cancer is another disease which is quite as striking in its relation to faulty nitrogenous and sulphur metabolism. In my former lectures I developed this subject pretty fully and need not repeat it here, but could adduce more recent proof, did time permit. Suffice to remind you that many independent observers have recorded very important and significant errors in the nitrogen and sulphur partition in cancer, both in its early and late stages, some of which I have verified in hundreds of volumetric urinary analyses. As these errors are made to disappear by proper dietary and medicinal treatment the carcinomatous lesions have steadily improved, and in many cases have disappeared entirely, as I hope to demonstrate in a later lecture.

We must, therefore, accept the fact that cancer has very close relations to the elaboration of protein in the system, and the rational deduction of this is that an overconsumption of nitrogenous food has something, if not everything, to do with the production of cancer. As yet we know little or nothing in regard to actual cancer-genesis; no one has ever demonstrated, and probably no one ever will demonstrate, the absolute beginning of the change in some normal cell or cells, in the breast or elsewhere, which eventuates in their taking on the rampant or malignant feature which we call cancer. But this change does occur, and though the exact alterations in the polarity of the cells and the disturbance of their centrosomes and nuclei, which have been described, may not be perfectly understood, there is some definite cause for their occurrence. Some have suggested the hypothesis that the mononuclear leukocyte, by conjugation with disturbed cells, gives them an abnormal reproductive power by which they eventually develop the tumor and invade other tissues. But back of all this there is still some activating cause, which is found in the fluids which bathe every tissue, namely the blood and lymph, which we shall see later are deranged in cancer.

The fact that with innumerable injuries occurring everywhere and at all times cancer develops from them very rarely, should teach us something. We must conclude, therefore, that there is some constitutional condition, or rather some state of the blood, which nourishes the cells and which favors this continued malignancy—some fuel which feeds the malignant process and at the same time induces a progressive lowered vitality, ending fatally. For we have already seen in these and former lectures that the local lesion which we call cancer is but one manifestation or result of a pernicious anemia, which, if not checked, may end life in a relatively short time.

As cancer is not contagious or infectious, this anemia, with all its concomitants, including the local trouble which we call cancer, must be autotoxic, and evidence is strong that it is of a nitrogenous origin. We look naturally, therefore, to see if there can be found any relationship between an augmented consumption of protein-bearing food and the steady increase in cancer mortality which is reported on every side.

England has furnished more fully and for a longer period than any other country the mortality and dietary statistics of its population, and from these we can learn a great deal of value in our study.

According to a carefully prepared table by W. R. Williams showing the total population in England during the years from 1840 to 1905, cancer deaths had increased from 17.7 per 100,000 population in 1840 to 88.5 in 1905, or five times in numbers, and in 1913 there were 105.5 deaths from cancer in 100,000 population. During this time the meat consumption had more than doubled, to 130 pounds per capita in 1904; so that, according to Williams, it is estimated that among the adult well-to-do population the per capita meat consumption was from 180 to 330 pounds per year, in addition to large quantities of game, poultry, eggs, fish, etc.

The United States Report of the Meat Situation, 1916, also furnishes some valuable information to aid in this inquiry.

The Argentine Republic stands next in the consumption of meat, with 140 pounds per capita, and with a cancer mortality of 91 per 100,000 in 1900.

The United States comes next, with a per capita consumption of meat at 201.1 pounds in 1909 and a death rate from cancer of 73.8 per 100,000 in that year, which, as previously stated, was 79.4 in 1914 and 81.1 in 1915.

New Zealand exceeds the United States a little, with a meat consumption in 1902 of 212.5 pounds per capita, and an increase in cancer mortality from 32 in 1877–1888 to 60 per 100,000 in 1900 and 71 in 1903. This increase is mainly among British and other immigrants, whereas the aborigines, living simple lives, are seldom affected.

Australia stands first in the consumption of meat, with the enormous rate of 262.6 pounds per capita in 1902, and the increase of deaths from cancer there is most striking. In 1851 the death rate per 100,000 living was 14, in 1900, 62.6, and in 1913, 75 per 100,000 living. The most striking difference is exhibited between those who are native born, who in 1900 had a cancer death rate of only 22 per 100,000, while the British born had a mortality from cancer of 203, or nine times as great; a still higher ratio was found among immigrants of other nationalities. Those who have written there on the subject ascribe this proclivity to cancer to the gluttonous habits of immigrants, who have meat for breakfast, lunch, dinner, tea, and supper (MacDonald, Williams).

Italy, consuming the least quantity of meat, 46.5 pounds per capita, in 1901, has the lowest cancer death rate, but the present meat consumption cannot be learned. In Italy, however, the mortality from this disease is steadily rising, from 50.9 per 100,000 in 1860 to 1900 to 63.6 per 100,000 from 1906 to 1910.

But, as I have tried to show you all along, it is some derangement of metabolism which is at the bottom of neoplastic growths, and that derangement is not necessarily due to any one single cause, as diet. There are other elements of disturbance besides the nitrogenous malassimilation which is due to the intake of an excessive amount of the proteid of the animal kingdom; for cancer is said to have been seen in vegetarians, although I have never met with such a case. We know, however, that some or many articles from the vegetable kingdom, such as the pulses and some nuts, contain a very large proportion of proteid; thus dried peas contain 21 per cent, haricot beans 23, lentils 23.2, dried lima beans 26.4, soy bean flour, 39.5, butternuts 27.9, black walnuts 27.6, peanuts 25.8, and almonds 24 per cent of proteid, all more than is contained in beef and mutton. Thus a large supply of any of these might produce the same error in the blood stream as that induced by meat.

In my former lectures I pointed out also that coffee and alcohol were found by statistics and clinical experience to have a prejudicial effect on cancer, and therefore must be considered as elements in its production. In a later lecture I shall deal more specifically with these matters, in reference to the prophylaxis and treatment of the disease.

At the present time I will only remind you of what I have so often said before: that it is the complex of modern civilization, with all its temptations and errors in regard to eating and drinking, and living, including the nervous strain felt everywhere, that in some way produces alterations in nutrition which account for many of our diseases. This operates through the blood current, which ministers in such a way to the tissues that under some slight provocation a heterologous growth of certain tissue cells occurs, with malignant tendencies, instead of the normal homogeneous and stabile structures which compose healthy tissues; and this departure from normal cell action we call cancer.

LECTURE III
THE MORTALITY FROM CANCER; ANALYSIS OF SURGICAL STATISTICS

As has been already shown in these and previous lectures, the death rate from cancer has been steadily and alarmingly increasing in almost every locality, ever since statistics have been collected. The attempt has been made from time to time to show that this increase is not real, but is apparent, and that the error arises from three main causes. These are: 1. The increased longevity in general, leading to the existence of more people of the cancerous age; 2. Improved diagnosis; and 3. More careful death certification.

Time does not allow us to go into this matter very fully, but this erroneous impression is so widespread, and one so constantly meets it in conversation, that it is desirable to present briefly the grounds and proof for an absolute denial of the assertion that there has been very little or no real increase in the mortality from cancer.

First, it may be stated that most of the arguments quoted against the correctness of statements regarding the steadily rising death rate of cancer date back to King and Newsholme, who, in 1893, some twenty-three years ago, attempted a study of early statistics and drew certain conclusions from them. This was long before the era of careful research and reliable diagnosis and statistics, and can have little, if any, weight. Bashford and Murray in the Second Scientific Report of the Imperial Cancer Research Fund, in 1905, attempted to show the same thing. But even this was eleven or twelve years ago, and the utter fallacy of the sophistical arguments appears in the absolute, steady increase in the death rate of cancer as shown by official tables from many countries, and as especially collected and seen in the remarkable book by Hoffman on “The Mortality from Cancer Throughout the World.”

It is impossible in a brief lecture to give even a faint idea of the immense and valuable amount of research represented, and consequently the most useful information furnished in this monumental work; the material is taken from original documents with new information, freshly obtained from original sources. All is given with an impartiality and clearness which are refreshing when compared with some recent writings on the subject. With the immense accumulated data on record, some of which will be referred to, all showing a steady rise of mortality up to the present time, and that during a period of especial study of cancer such as the world has never known before, it is quite unreasonable and impossible to believe that this advance is only apparent, and that it is influenced by the three suppositions mentioned. While accuracy of diagnosis may be important in early cancer, it is certain that in late stages and at death, from which the various mortality tables are taken, there is rarely any question as to the diagnosis. There is evidence, however, to show that cancer is increasing even more rapidly than appears from mortality statistics.

In 1900 the recorded mortality from cancer in the registration area of the United States was 63 per 100,000 living, and in 1914 it had risen to 79.4, or an increase of 16.4 per 100,000 living, or over 26 per cent. While in 1915 there were 54,584 deaths from cancer against 52,420 in 1914 in the registration area of the United States, or 2,164 more deaths. The total number of deaths in the entire United States is estimated at about 80,000 last year. The death rate in 1915 was 81.1 per 100,000, or a rise of over 28.7 per cent since 1910. The increase during this past year has been 1.7 per 100,000 living, while the gross increase for the preceding five years was but 5.6 per 100,000, or less than an average of 1.2 per 100,000 each year. So that the great activity in cancer education and in operative surgery during that year has succeeded in raising the death rate from cancer by .5 per 100,000 over the average of the preceding five years!

It is to be noted that this increasing mortality from cancer has been steady and constant, though with slight diminution occasionally, some years ago, before the great activity in cancer research, cancer control, and cancer surgery. All this would certainly indicate some deep-seated cause of the malady which had not been recognized; indeed the mortality during the last five years was as follows: 1911, 74.3; 1912, 77; 1913, 78.9; 1914, 79.4; and in 1915, 81.1 per 100,000.

It may be of interest to know that the mortality from cancer varies very greatly in different portions of the United States, and it would be instructive to investigate the cause; but the data for this do not exist. The highest death rate for 1914 was in Vermont, 109.9; Maine had 107.6; Massachusetts, 101.8; New Hampshire, 100.8; California, 97.9; all against the general average of 79.4 per 100,000 inhabitants in the registered area of the United States. The lowest among the registration States was Utah, with 45.8 per 100,000 living. In New York State the deaths from cancer in 1914 were 88 per 100,000 population in the cities and 96.1 in rural districts.

Many cities, of course, show a higher death rate from cancer than the average, owing in part to the number of patients coming for treatment, and also to the more complex life of the cities, with the greater temptations leading to the disturbances of metabolism causing cancer. Thus, the average of twenty large cities gives a rise in death rate of cancer from 48.6 from 1881 to 1885, to 89.3 per 100,000 living in 1913.

The following table gives the average cancer mortality from 1906 to 1910 per 100,000 in certain American cities:

In the city of New York, as given by the Board of Health Bulletin, there were from July 1, 1915, to June 30, 1916, 4,672 deaths from cancer, or an average of just 12.8 persons per day; in the last six months, July 1 to December 31, there were 2,264 deaths from cancer, 990 males and 1,274 females, with a daily average of a little higher than last year.

It is readily understood that many factors enter into the study and proper understanding of the statistics of cancer, such as age, sex, location of the lesion, etc., and the limits of a lecture do not permit any adequate presentation of the subject, but a few points may be mentioned.

Thus, in regard to age, the States which represented the greatest number of deaths from cancer, Vermont with 109.9 and Maine with 107.6, show that the proportion of individuals over 45 years of age was over 27 per cent, compared with 17.7 per cent for Kentucky and 16.2 per cent for Montana, which latter gave almost the lowest mortality from cancer.

The same is true somewhat in regard to sex, although sufficient data are not at hand to show the relative number of living males and females in the different States. We know, of course, that the great preponderance of cancer in females is due to that affecting the breast and uterus, and where females preponderate in the population the total cancer mortality would be the highest.

The location of the lesion has also a bearing upon the understanding of statistics. Thus in Norway, for some unexplained reason, cancer of the stomach caused the great mortality of 60 per cent (66.9 males, 52.9 females) of all cancer mortality, while cancer of the breast caused but 7.6 and of the uterus 16.2 per cent of the whole, the general rate being 93.9 per 100,000 inhabitants. In the United States, in 1914, cancer of the stomach and liver caused the deaths of 37.9, cancer of the breast 10, and cancer of the female genital organs 14.2 per cent of all deaths from cancer.

There are other points also to be taken under consideration in connection with cancer statistics which we cannot even touch on and can only mention one, namely, the physical condition; for the disease is known to be more frequent proportionately among the better nourished and well-to-do classes, etc.

Turning to other countries, we find abundant confirmation of the persistent and considerable increase in the mortality from cancer, in many cases much greater than has occurred in the United States; and in nearly all of them the increase can be recognized as commensurate with the progress or advance of so-called civilization, especially as emphasized in city life.

England and Wales afford us about the most satisfactory statistics in this regard. W. R. Williams has given a valuable table, already referred to in connection with food, showing the prevalence of cancer and its relative increase in England and Wales from 1840 to 1905. In 1840 the cancer death rate was 17.7 per 100,000 living, with a proportion of 1 to 129 of total deaths. The deaths from cancer increased with almost a perfect regularity until in 1905 there was a mortality of 88.5 per 100,000 living, and 1 in 17 of the total deaths was due to cancer, as against 1 to 129 in 1840. The total proportion of deaths from all causes is given for each year, and while the population has only a little more than doubled in these 65 years, the deaths from cancer have increased from 2,786 to 30,221, or over ten times the number; the rate of cancer deaths per 100,000 living had increased five times, while the ratio of deaths from cancer to total deaths had multiplied more than seven times. Since 1905 the cancer death rate in England and Wales has advanced to 99.3 per 100,000 in 1911, and to 105.5 in 1913, and in London the cancer mortality is 114.9 per 100,000 population.

Statistics from other countries, collected by Hoffman, show the same steady increase. I will not weary you with much more of statistical detail, but it is interesting to record a few of the more striking facts, illustrating the universal increase in the cancer death rate during these later years of cancer research and active surgery. The data are from 1896 to 1910, and the countries will be arranged according to proportionate increase in the death rate per 100,000 population. Thus, Ireland comes first, with an increase of 20.7, which is explained in part by the emigration of younger persons, leaving more of the cancer age; next comes Denmark, increased from 118.9 to 137.3, or 18.4 per 100,000 population; then the German Empire with an increase of 13.4; Hungary, 12.9; Italy, 12.7; Holland, 11.6; Norway, 10.9; Austria, 9.4; and France from 97.3 to 102.7, or only 5.4 per 100,000 population. During this same period the deaths from cancer in the United States have increased about 18 per 100,000, or almost as much as the highest of the countries mentioned.

In regard to the bearing of all these figures upon the alleged apparent and not real increase of cancer, I may quote from Hoffman: “The evidence is so convincing” as to the reality of the increase of cancer “that it may be safely maintained that no other statistical conclusion in medicine is so concisely and incontrovertibly established as this: in any event, no satisfactory evidence is available to successfully contradict this conclusion at the present time. If all this evidence, however, is inconclusive and worthless, then no alternative remains but to discredit the statistical returns of every country in the world with regard to any single disease or group of diseases, although the returns are accepted as approximately accurate in regard to every other important cause of death.”

In order that the real increase in the mortality from cancer may be readily understood, the accompanying chart (now hanging before you) has been copied from that given in the volume of the United States Mortality Statistics for 1914, and it will help to visualize what has just been stated. The data for 1915 have been added through the courtesy of Mr. Rogers, Director of the Census, in a personal communication.

The striking fact brought out in this chart is the comparison between the steadily diminishing death rate of tuberculosis, through careful medical supervision, and the steadily increasing death rate of cancer, under surgical care. While the mortality of tuberculosis has fallen from 201.9 persons in 1900 to 145.8 in 1915, or 56.1 less deaths in each 100,000 population, or over 27.7 per cent, the cancer death rate has risen in the same time from 63 to 81.1 per 100,000, or over 28.7 per cent. They have therefore approached each other by 56.4 per cent, and unless this rate of progression is changed in some way, the lines will have crossed one another in less than fifteen years more, even as that for organic heart disease has already crossed that of tuberculosis, it having risen almost 27 per cent.

Another interesting lesson to be drawn from this chart is that the death rate from organic heart disease, nephritis, and apoplexy have all risen coincidently with that of cancer, only that the rate of the latter has outstripped them all. If we accept the fact that the increasing death rate of these three diseases is largely the result of modern civilization, especially from erroneous eating and drinking, it would appear that cancer is due to the same cause.

Realizing, then, that the mortality of cancer is materially and steadily rising, in spite of most diligent research by innumerable honest and capable scientists, with the expenditure of vast sums of money and countless animal lives, and in spite of the work of ardent, earnest, and capable surgeons, who have failed to stay the terrible progress of the disease, let us briefly study some of the reported statistics in regard to the results of operative interference in cancer.

It may be first stated that this is a most difficult task, so different are the reports from different surgeons. There are many elements which affect the statistics relating to the surgery of cancer. First of these is, perhaps, the stage of the disease at which the operation is performed. Second, the results vary, of course, immensely with the knowledge and skill of the operator and the excellence of the technique. Third, the class of cases operated on has much to do with favorable or unfavorable results reported. Fourth, the length of observation after operation is always to be considered in connection with surgical statistics. Finally, the optimism of the reporter must be regarded in weighing the true value of reports as to ultimate results. We will briefly consider these points.

First, as to the stage of the disease at which the operation was performed. We have seen in this and previous lectures that the lesion which we call cancer is but a result of a deranged blood state, and is not a purely local process, a something simply to be removed surgically in order to have the patient get well and remain well. For one sees plenty of cases where there were recurrences even after the very earliest operations possible. But the claims put forth that favorable results are conditioned on very early operations are so strenuous and persistent that we must believe that a measure of the favorable results can be thus accounted for. We know, of course, that very late in the disease operations are out of the question. It is a little curious, however, that most of the pictures shown, statistics presented, and arguments adduced by these ardent advocates of early operation relate to cancer of the skin, especially about the face, which cause hardly 2 per cent of all the deaths from cancer in various countries; whereas those who see much of cutaneous epithelioma know that if properly handled it is generally a comparatively mild affair and relatively easily cured without surgical operation, as you have so constantly seen in this clinic in past years. But mortality statistics are greatly influenced by the class of cases which the operator takes, and so if epithelioma of the skin is included, the ratio of cures will be high. Selected cases also always give more favorable statistics.

Second, the knowledge and skill of the operator and the perfection of technique undoubtedly influence surgical statistics. The ordinary practitioner or surgeon cannot hope for as favorable results in many operations on cancer as can those who are past masters in this line, and these latter are the ones who furnish the favorable statistics.

Third, the class of cases operated on affects surgical statistics very greatly. While epithelioma of the face, and even of the lip, when well removed, may yield most favorable statistics, cancer of the breast, uterus, stomach, intestines, gall bladder, etc., yield increasingly unfavorable statistics, as will be presently seen.

Fourth, the duration of observation after operation affects very seriously the validity of statistics. Not long ago three years’ freedom from disease was considered the time to regard a cancer as permanently cured; but this time has been lengthened more and more, by the observation of any number of cases where the disease has recurred even long afterwards, and reliable observers are now very chary in expressing an opinion as to the final cure of a cancer. This will be more fully considered in another lecture.

Finally, the optimism of the reporter seems often to have something to do with the reliability of surgical statistics. This need hardly be discussed. The older and more experienced the surgeon the less confident he is of having actually cured cancer with the knife. At a discussion in the New York Academy of Medicine, some years ago, Dr. Robert F. Weir said that the late Dr. Agnew, a celebrated surgeon of Philadelphia, had remarked, just before his death, that he doubted if he had ever been justified in an operation upon cancer, and he, Dr. Weir, stated that he could almost say the same.

Turning now to the actual statistics of operative surgery on cancer, we will find that the percentage of reported cures varies very greatly, in accordance with the points just stated. It is understood, of course, that no accurate statements can be made from statistics in reference to the actual mortality of cancer in any location, partly owing to the paucity of figures, and partly because the stages and extent of the disease differ so greatly, and the results vary with the previous duration of the lesion and the period of observation after the operation.

Cancer of the skin presents the best operative statistics of any region, and the claim is made that all cases are curable if operated on early enough and rightly. While this is not wholly true, it is certain that if all lesions which one chooses to call “pre-cancerous” are thoroughly extirpated very early, and included in the statistics, the percentage of cures can be reported as very high. So that it may be said that, taking all statistics together, including very small as well as large lesions, the favorable results, that is permanent cures of lesions which can be truly called cutaneous epithelioma, may run as high as 75 per cent. But against this is to be set the fact that a very large share of these cases, taken early and by competent persons, are equally amenable to cure by lighter measures, without the horrible disfigurement which one sometimes sees after purely surgical procedures.

Cancer of the lip, when taken early and treated radically, including gland extirpation, also yields a fairly satisfactory result, depending, of course, on the stage of the disease, or amount of involvement of tissue and glands, and the completeness of the operation. But while some operators have claimed 75 per cent of cures, Hertzler makes the percentage of permanent cures not much over 25 per cent. And here again, if taken very early and treated correctly, many of these cases yield without the knife, whereas very late cases may be practically inoperable.

When, however, we come to cancer within the mouth, the tongue, etc., it is quite a different story, and the end results of surgery are commonly unsatisfactory. Certain European surgeons have reported an operative mortality in cancer of the tongue as high as 36 per cent, while recurrences are the rule, and really permanent cures the very great exception.

As before stated, it is extremely difficult to give any true and accurate estimate of the real end results from operative surgery as ordinarily performed in cancer affecting various regions. The obvious reason of this is that most of our statistics are from those who are especially occupied with the disease under most favorable hospital facilities, and also certain statistics may be from selected cases; moreover, operators are naturally inclined to report mainly satisfactory results, while the other aspect of the case is seldom presented. Aside, then, from superficial epitheliomata, about the only locations in which there is even a fair chance for the patient under the knife are the breast, uterus, and rectum, and for these large statistics are available; but again these are unsatisfactory, as they vary so greatly.

The reported statistics of cancer of the breast are very provoking. Individual operators have claimed as high as 50 and even 70 per cent of cures (Rodman). Murphy, on the other hand, on a basis of end results states that the plump woman invariably succumbs, and that Paget’s disease ends fatally in 90 per cent of cases. Hildebrand mentions 606 operations in which the percentage of permanent cures varied from 15 to 23 per cent; late recurrence is not uncommon in cancer of the breast. He thinks that 35 per cent is the maximum possibility for permanent cures. He would be very suspicious of any higher figure. Judd reports that of 266 cases of carcinoma of the breast in the Mayo Clinic, which could be traced, 39.8 per cent were reported as alive at the end of five years, although there was recurrence in 6 cases.

Lubhardy, in an article on recurrence, in 1902, states that 1,321 recurrences were known to have occurred after 2,107 operations, or nearly 63 per cent, 4 per cent of which were late recurrences; he does not mention the number “cured” nor the number of patients untraced. Unfavorable results in breast cancer are seldom published. Dr. H. C. Coe in a discussion quotes the experience of a friend who had operated on between 200 and 300 cases of cancer of the breast with exactly 13 recoveries.

Levin (Med. Record, Jan. 27, 1917, p. 175) has recently made some startling statements in regard to the recurrence of carcinoma after breast operations. While granting that early cases without lymphatic involvement yielded good results, he states that these represented at the utmost only 25 per cent of the cases operated on: 75 per cent were advanced cases with involvement of the skin and lymph glands. Of these barely 25 per cent could be cured by radical operation, and in 52 per cent of the advanced cases operated on metastases appeared in distant organs without local recurrences. The longer the period after the operation the greater was the number of recurrences.

He quoted Heurtaux, a French surgeon, who had followed up 284 cases which he himself had operated on during the previous 20 years. H. stated that four years after operation 43 per cent remained free of the disease, eight years after only 16 per cent, and 20 years after only 2.5 remained free from the disease. There were a great many cases of carcinoma of the breast reported in which the patient died from metastasis in different organs without local recurrence 10, 15, and 20 years after the operation. The late metastases most frequently took place in the skeleton, which was due to the fact that skeletal lesions might continue a long time without causing clinical symptoms.

Dr. Levin confirmed the skeletal involvement by roentgenograms of ten cases of carcinoma of the breast observed during the last two years, in which it was found that the metastases must have been present at the time of operation.

Dr. Willy Meyer in the discussion said that physicians had long been too prone to consider carcinoma a local disease, and when he found signs of metastatic infection he never felt that he could expect anything from an operation.

We can only state with Hartwell and others that every especially favorable series of cancer cases, and this applies particularly to the breast, should be subject to close scrutiny. Why did this or that operator get marvelous results and an equally efficient man get very poor ones?

There are also many factors to be considered. How many cases were of the senile or scirrhous type? How many of the tumors removed were proved microscopically to be cancer? If one operates radically on every tumor or swelling in the breast, however small, the end results will, of course, be more favorable; for undoubtedly many innocent lesions, chronic mastitis, adenoma, cystic tumors, etc., are often removed unnecessarily. The question also arises as to what was the after care, and what steps were taken to prevent recurrence? In view of the statement of Hildebrand, just quoted, that 35 per cent is the maximum possibility for permanent cure, and considering the terrible pain and miserable death one so constantly sees in recurrences, it really becomes a question as to the advisability of surgical interference.

The opinion has been expressed more than once by those who have watched the disease, that if left alone, with ordinary medical care, the entire average of 100 cases would be better, as to length of life and suffering, than if submitted to operation. I shall hope to show you in a later lecture that a greater proportion of breast tumors, diagnosed as cancer by competent surgeons, have recovered completely for years, under proper dietary and medical care than the percentage yielded by operative procedure.

There is a wealth of statistics regarding operations for cancer of the cervix uteri. Despite the figures obtained by radical operators like Wertheim, the vast majority of those surgeons who practise either vaginal or abdominal hysterectomy have obtained far inferior results to those of Byrne, with his cautery, which is still in use. Wertheim once reported the astonishing figure of 61 per cent of 5–year recoveries. In a later report, however, Wertheim stated that only about one half of the cases that come to him are operable, and of these about one half are cured by operation, that is, about 25 per cent of all cases. But experience shows that if these cases could be followed up there would be very many late recurrences. The claims of Wertheim and others must be offset, however, by the high operative mortality reported by many; as the cases must have been incipient in order to be operable, it is possible that Byrne with his cautery could have done nearly as well, and Byrne never lost a patient. But Klein of Munich, by circular letters compiled many statistics, and concluded that the percentage of cure was but 4.5 per cent, and Klein himself obtained only 3.6 per cent. Reinecke asserted that only 10 per cent of cases of cancer of the cervix can be cured.

Fredrick (Trans. Gynæcol. Soc., 1905, p. 136) collected the records of 500 hysterectomies for cancer of the cervix performed by prominent colleagues and himself. Of this entire material there had been but 13 five-year cures. In discussion Henrotin stated that he had practically given up abdominal hysterectomy. Currier stated that surgery was a failure as a cure for cancer.

At an earlier session of the Society, 1900, in a discussion of Pryor’s paper, Van de Warker asserted that surgery had done nothing for cancer; Lapthorne Smith said that many women did better if left alone. J. Byrne stated that hysterectomy for cancer was a crime. Engleman thought that cancers left alone may insure a longer survival than those treated surgically.

In a discussion before the same Society in 1896 (on Byrne’s paper) vaginal hysterectomy was discussed. While Boldt, Dudley, and Baldy claimed excellent results, Segond is known to have had but 5 relative cures (2–5 years) in 80 cases. Mundé saw a rapid return in all his 25 cases. Polk had recurrence in every one of 50 cases. Byrne collected notes of 283 operations by ten men, and the results were as follows: died, 7 per cent; life prolonged, 11 per cent; and became worse, 82 per cent.

In the Transactions for 1912 (Discussion of Neal’s paper, Wertheim’s operation) Bovee stated that only 10 per cent of cancers of the cervix were operable. Polak had no survivors from operations, although four were living from Byrne’s cautery method. Chalfant had 3 cures (6 years) in 30 cases. In general the saving of life was offset by the high operative mortality. Later I shall report two remarkable cases of very extensive cancer of the cervix which have entirely recovered, with normal cervix, without operation.

In regard to operative results in cancer of the stomach there are relatively few satisfactory statistics. W. J. Mayo reported recently (Levin, Hoffman “Statistics of Mortality,” etc., 1915, p. 210) on 996 cases of carcinoma of the stomach. Of these 344 cases only were operable and of the latter 25 per cent remained cured five years and over, after operation. In other words, about 9 per cent of cases of carcinoma of the stomach can be cured by surgery at the hands of Mayo, how much less in the hands of most other surgeons? Against such success must be opposed the analysis of 1,000 cases of cancer of the stomach by Friedenwald (Amer. Jour. Med. Sci., November, 1914). He states “of the entire number, operations were performed in 266 instances; of these there is not one patient living.” But few lived more than a year after operation; the majority died within the first six months.

In cancer of the gall bladder several good operators have reported that there have been absolutely no good results.

In cancer of the rectum there is a high operative mortality and very questionable ultimate curative results; indeed, there are very few reliable statistics in regard to this. In 27 perineal and sacral operations Mayo reports 7 per cent primary mortality, and in 44 abdominal and combined abdominal and perineal operations 20 per cent operative mortality. Tuttle reports a higher operative mortality. While there are no available data in regard to the duration of life after operation, it is well known that the disease usually recurs, and in many a colostomy is performed, with all its distressing features and very intangible results.

Time does not admit, nor is it necessary for me to go further into the brave but futile attempts which have been made by surgeons to cure such cases of cancer as can be reached by the knife, which, as we have seen by the testimony of many foremost in their ranks, has been found ineffective to a very great degree. In addition to the locations just mentioned there are many others where the attempt has been made to eradicate the disease surgically, but either with results quite as unsatisfactory as those mentioned, or much worse. Thus cancer of the tongue, palate, esophagus, cardiac orifice of stomach, liver, gall bladder, pancreas, small intestine, bladder prostate, etc., also of the brain and spinal cord, are most unfavorable, and both the operative mortality and end results are disheartening. All surgeons agree that at least 50 per cent of all cancers are inoperable, so that in all the reports concerning the results of operations this must be taken into consideration, and the real percentage of cures of cancer by surgery must be divided into at least one half. Thus, if operative surgery yields an average of 25 per cent of apparent cures in all cases operated on, this would mean only 12.5 per cent of all cases of cancer. This, considering the late recurrences often not traced, bears out the commonly received opinion that about 90 per cent of all patients once attacked by cancer die of the disease.

Surely the outlook for surgery, borne out by the steadily rising general mortality from cancer, is most unpromising, and one naturally turns to medicine, to know if there is not some means of modifying the system so that there shall not be this tendency to malignant tissue change, so destructive to life. In my former lectures I attempted to show that all experience and biochemical laboratory studies looked this way, and in a later lecture I shall hope to show that by dietary, hygienic, and medicinal measures the disease can be and has been checked repeatedly, and cancer cured without surgical operation. The permanence of the cure depends, of course, upon the continued faithful adherence of the patient to the means and measures which caused the dissipation of the tumor. For no one can doubt but that, if the real cause is met and kept in check by prolonged proper measures, the disease will not and cannot redevelop.

Do not misunderstand me and think that I claim that each and every case of cancer, in any stage, can be cured. Alas, my sad experience with the many deaths from recurrent and inoperable cancer, especially in the New York Skin and Cancer Hospital, has taught me the contrary, and I have often been appalled at the impotence of human endeavor; although even these patients have often been grateful for the amount of benefit and relief afforded by proper measures, and in my former lectures I reported to you several such cases. But I do assert that the total percentage of cures in reasonable cases is far, far greater under the line of treatment I am presenting to you than under that most commonly employed.

LECTURE IV
INOPERABLE AND RECURRENT CANCER; METASTASIS; THE BLOOD IN CANCER

We saw in our last lecture that surgery had failed to check the rising mortality of cancer, and that during the year 1915, in the United States Registration Area, the death rate had augmented from 79.4 to 81.1, or an increase of 1.7 persons in every 100,000 living; this was a greater increase than the average rise in the death rate for the preceding five years which was only 1.2 points. This, moreover, occurred during a still active period of laboratory research, with wide publicity as to cancer control, by education as to the benefit of early operation, and with active and skilful surgery.

We saw that fully 50 per cent of all cases of cancer were quite inoperable when first seen by competent surgeons, while the average end result, or cure, in the cases operated on, for all kinds together, good and bad, slight and severe, did not total as much as 25 per cent; this makes but 12.5 of the entire number who applied for surgical relief. We quite naturally asked, therefore, if some form of medical treatment, including diet and hygiene, could not afford a better prospect of arresting this fearful mortality. It is especially in regard to the large number of inoperable and recurrent cases, comprising over 60 per cent of the whole, that this inquiry is particularly important. We will briefly consider these latter sad conditions.

Looked at from its broadest aspect, in connection with what I have tried to show here and on former occasions, all cancer will be inoperable, or rather, not needing operations, when the principles I have tried to develop are fully elaborated by the wide experience of others, and when they are firmly established, and correctly carried out. For when it is universally realized that it is the errors of life, determined and accentuated by advanced civilization, so-called, which lead up to and cause cancer, and when public education has been advanced along correct lines, the tendency to cancer will diminish and there will be fewer cases, either operable or inoperable. The former will melt away under correct internal and external measures, and the latter will be helped by, or slowly yield to the same, unless the malignant process has already progressed beyond the possibility of retrogressive metabolism. But, of course, it is too much to expect that such longed for results will be fully attained within a generation or two.

Inoperable cancer is truly a most distressing condition, especially after it has become so after one or more surgical operations. The hopelessness and despair of the patient when told that no operation is possible is bad enough. But when with recurrence, time and again after repeated operations, it is decided that no further relief by the knife is possible, the despondency is indeed pitiful—especially as ordinarily one can only look forward to a sure and most painful death, at a not very distant day. It is very difficult to convince many of these patients that medical treatment, including diet, can do any good, so firmly fixed is the idea that an operation is the only possible remedy; many, therefore, get weary of the restraint necessary when immediate results are not seen. And yet in my previous lectures I gave several such cases to show that much can be done medically along these lines, even in these distressing cases, and later shall hope to narrate other instances, similar to those reported in my lectures two years ago.

It is undoubtedly true that some of these cases which are inoperable when first seen could have been operated on at a much earlier period, with as much success as follows in those in which this is tried. But we have already seen in the last lecture how small a proportion of these selected cases survive a long time; for we have yet to find statistics regarding those who have been traced even as long as ten years. In my previous lectures I reported concerning two patients with undoubted cancer of the breast who had been watched for sixteen years, with no trace of the trouble remaining, and two others who had been seen each for nine years; these latter have been watched since, and have been seen recently, eleven years after beginning treatment, with the same results, all without operation. These cases had all been diagnosed as undoubted cancer by competent surgeons, some eminent, and had refused operation, which had been urged. Later I shall hope to relate other similar instances of early cancer.

Inoperable cancer, comprising at least 50 per cent of all cases applying to the surgeon, presents many features of interest and worthy of consideration. The reasons for inoperability may be grouped as follows:

1. Those occurring in regions quite inaccessible, as in the brain, esophagus, liver, pancreas, etc.

2. Those otherwise accessible, but which have advanced too far before seeking surgical relief, occurring in many locations.

3. Those in accessible regions where experience has shown that recurrence is pretty sure to take place, such as advanced cases in the oral cavity, bladder, prostate, etc.

4. Those which have recurred after repeated operations, with extensive spreading of the disease, as in many cases of the breast, uterus, etc.

5. Those with already very great metastatic involvement, in many regions, presenting a true carcinosis.

6. Those in close proximity to or involving vital organs, blood vessels, ureters, etc.

7. Those in which there are other reasons, such as advanced age, lowered vitality, great cachexia, etc.

8. Those who absolutely refuse to be treated with the knife.

There is no necessity of troubling you with details as to the character or appearance of inoperable cancer, which are dwelt on in standard works, as our study relates rather to the causes of the disease and the means of arresting its progress.

Nor need I dwell much further on this distressing aspect of cancer, for I believe that all see the necessity of seeking some other measures than operative surgery to aid in solving the question of relieving the present condition of affairs. It is for this mass of otherwise hopeless cases that any reasonable method of treatment is worthy of serious consideration, both for the measure of relief which may be secured along many lines by exactly the proper care, and especially for the possibilities of its value in regard to prophylaxis.

Unfortunately it must be acknowledged that many claims, quack and other, have been put forth in times past for remedies and measures which would control or remove, and even cure, the disease in all stages. But the failure of each in turn has very naturally discouraged many from accepting any new proposition, and the profession and laity have almost given up the hope for a real cure of cancer.

In the present instance, however, there is no attempt to present or urge any single means or measure as a cure-all for cancer. But there has been an endeavor to study the fundamental causes of the disease along biochemical lines, and to meet intelligently the errors found. We have seen cancer developing more and more as the ill effects of modern civilization have manifested themselves, and have found that its increase has kept pace coincidently with and even exceeded that shown by certain other diseases, cardiac, arterial, and renal, which are recognized as due to errors of living; and there is every reason to believe that cancer is of the same origin. In a later lecture I shall hope to show how some of these errors may be overcome, with the consequent cessation of the cancerous process and even the disappearance of the malignant lesion already formed.

Recurrent cancer represents only the continuance and further operation of the internal or systemic causes which induced the formation and development of the first lesion, and are a natural sequence therefrom. Otherwise why should there be such an almost universal tendency of the disease to redevelop either in the same or other localities? It is granted, of course, that the very complete ablation of an early tumor and its surroundings removes a focus in which disease has started, and from which is generated a hormone or poison which tends to further lower the vitality of the blood. But this does not by any means reach the basic cause, as we saw in the former lectures.

In estimating, however, the real value of an operative procedure, which has seemed to be successful for some period of time, we must also inquire if there has not been some other cause which may account for the absence of further cancerous deposits? It is more than likely, in successful cases, that the previous occurrence of the disease and the fear of recurrence have so modified the life of the patient in many respects, that the primal cause is more or less removed. It is incredible to believe that the mere removal of the portion of tissue in which the systemic disorder has localized can forever prevent a new focus from developing. As well might we expect that the removal of a gouty toe, a tubercular deposit, or a late syphilitic gumma would inhibit further manifestations of the disease.

Recurrent cancer, then, is but the result of a continuance of the operation of the same causes which produced the first local lesion, and need surprise no one, if those causes are left entirely unchecked and the system unchanged. Undoubtedly in many instances the recurrence, or increased production of the disease, is made more certain by the operation itself; it is also recognized that handling or manipulation then or at any time may also contribute to this, as may be understood from the following:

1. Cancer cells, which have a reproductive capacity, may be forced into the adjoining tissue, or find entrance into blood vessels or lymphatics severed during operation, and there continue their activity and produce new lesions.

2. By implantation, cancer cells, already started on their reproductive career, may be transferred to freshly cut surfaces, and there may develop new lesions, favored by the continued derangement of the blood current.

3. Cancer cells may have existed outside of the immediate area which was removed surgically, and so may continue to develop new lesions, being further stimulated thereto by the manipulations attending the operation.

4. We know, finally, that the occasional removal of lesions which are afterwards shown microscopically to be benign, such as adenoma, cysts, chronic mastitis, etc., will sometimes be followed by the development of true cancer, which will then pursue a malignant course.

On the occurrence, therefore, of any lump or lesion which might possibly be or become cancer, the greatest caution should be exercised to avoid all manipulation, lest a spread of the disease should render it more rebellious to treatment. For in the medical management of cancer it is naturally more difficult to cure a patient when there are large numbers of diseased cells, in one or various locations, which are already giving forth their poisonous hormone, vitiating the blood stream.

The New York Board of Health has recently inaugurated a service for the examination of specimens excised from suspected cancer, in order to establish the diagnosis microscopically before surgical operation. There could hardly be devised a more effective plan to increase the mortality from cancer and to render many more cases really inoperable than this one would surely be; for by thus cutting into cancerous tissue and opening lymphatic channels and blood vessels, with the opportunity for absorption of cancerous elements during the necessary delay, metastases would certainly be induced which would render a surgical removal or a dietary and medicinal treatment immeasurably less effective. It is to be hoped that this scheme will be immediately abandoned.

Recurrence of cancer is far more common during the first year after operation than in any other single year, but, as we shall see shortly, there is no time limit when the disease may not manifest itself anew. It is understood, of course, that recurrence depends also largely on the previous duration, extent, and malignancy of the tumor, and exact statistics are very few and imperfect in regard to these matters.

It is well known that not long ago three years was considered as the time at which, if there had been no recurrence, the cancer could be considered as cured, and very many statistics have been based on this period. But with further experience and closer observation, and with more diligent following up cases, it was found that recurrences did take place more or less frequently at subsequent periods, and now the time limit has been arbitrarily extended to five years. This is because the very large proportion of recurrences are in the first year, varying for different locations and conditions from as high as 50 to 80 per cent in different statistics.

But as the patients who have lived out the five-year limit are followed up more carefully, it is found that recurrences do happen all along the following years, so that they are recorded as occurring 6, 8, 9, 20, and 25 years after operation; I have met with many after 3 or 5 years, and even as late as 15 years after operation. The vast majority of cases, however, are not thus accurately followed out, much less reported, and thus far we have few data on which to make accurate statements as to the actual permanent cure of cancer by the knife.

Recurrent cancer, as one constantly observes it, is most deplorable, and many who have had much to do with these cases realize that the distress is often far greater than in other cases in which the disease has run a natural course, without operation and under good medical guidance. The pain attending growths in scar tissue is generally intense and commonly requires anodynes continually and increasingly; these in turn, by disturbing digestion and locking up the secretions, seem to augment the disease. Even with these patients, however, very much may be done to relieve their suffering by proper dietary and medicinal means, with suitable local medication, as I have constantly seen, so that opiates need be but little used.

Metastases form a very considerable and important element in inoperable and recurrent cancer, and we will briefly consider these. They occur mainly through three channels: 1. The lymphatic system; 2. The venous system; and 3. The arterial system. The permeation theory of Handley relates to direct extension laterally through lymphatic spaces, and belongs to the first mentioned means of extension. It is also believed that metastases may be formed in the peritoneal cavity, and likewise in the pleural cavity, by direct contact of cancer cells or pieces of malignant tissue which have gained access to those cavities and have been carried down by gravity and movement of viscera. They then become engrafted on healthy tissue and form metastases there.

While holding firmly to the belief that the original cancerous growth and other foci of disease are developed from a vicious state of the blood current, there seems to be no reason for doubting that the disease may also be extended in the manner above indicated. Although cancer material cannot be inoculated from one person to another, or from a human being to animals, nor from one species of animal to another, experience and observation show that the malignant process can be transferred from one organ or structure of the same individual to another part or structure, whether there has been a surgical operation or not.

The lymphatic system is apparently the first means for the spread of the malignant process, and all are familiar with the lymph nodes seen in the neighborhood of cancerous masses. It is supposed that these are caused by the lodgment of detached cells which have taken on the abnormal reproductive action which characterizes cancer. As with other foreign bodies, pus cocci, etc., the minute lymphatic glands seek to arrest their passage into the circulation, and it is probable that some of them are destroyed there, for the single enlarged gland will often remain for a long time as the only manifestation of metastasis. In many cases, where the original cancer has disappeared under dietary and medicinal treatment, the enlarged glands also disappear, as I have seen many times.

When the disease is unchecked, however, the glands fail in their endeavor to protect the system and continue to enlarge one after another along the line of the lymphatics, and the lymph stream then carries certain cancer elements through the thoracic duct into the venous circulation; thence they reach distant parts of the body, through the arterial system, and, being lodged in capillaries, a more or less general carcinosis results. Cancer elements can also proliferate along lymphatic tracts, and, furthermore, they may enter the venous and arterial systems directly by the invasion of a malignant growth.

All these and other points regarding the metastasis of cancer form a very interesting study, but time does not permit of further elaboration. All know that while primary carcinoma of the liver is very rare, its secondary or metastatic involvement is very common. The bones, lungs, spleen, kidney, and viscera generally are all often found to be the seat of metastases, and in general carcinosis, which has lasted some time, metastases will be found abundantly both in the lymphatics of many parts of the body and in many organs and tissues. Metastases in the lungs are not uncommon in breast cancer, as also metastasis in the bones of the thorax. In the last lecture reference was made to the frequency of metastases in the skeletal structures of the body, which probably have much to do with the pernicious anemia which carries off the patient.

An interesting study relates to the extension of the carcinomatous process in the skin; this occurs at first near, and then around, and even at a distance from the site of an operation, especially after removal of the breast. These nodules are at first small, and felt deep in or below the skin, and are not colored. They steadily increase in size, and when about that of a small pea, they become red and elevated a line or so. Later they may appear more numerous and even involve a large area, forming the so-called cancer en cuirasse, and may ulcerate. Sometimes single lesions of some size may appear here and there, even some distance from the site of the original tumor, and may not be colored. While these may represent lymphatic infarctions, it is often impossible to trace any direct connection with lymph ducts, and they more probably arise from capillary deposits of cancerous elements. I have frequently had these scattered cutaneous lesions excised, in cases under medical treatment, with a view of removing mechanically some of the foci from which the disease could be spread. The wounds have invariably healed promptly and perfectly, and no carcinomatous process has resulted.

The BLOOD IN CANCER has been studied mainly in reference to its solid constituents, and very little in regard to its plasma; whereas it is from the plasma that the blood corpuscles are formed, and this is the principal agent in the development and nutrition of tissues, normal and malignant. For it is to be remembered that the chyle is discharged directly into the venous blood current, and the venous radicles absorb much of the nutritive material directly from the abdominal organs. The plasma, therefore, carries with it constantly a varying quantity of partially assimilated material to be oxidized in the lungs, and slowly purified by the agency of the kidneys; the serum albumen and serum globulin are also active agents in the formation of tissue, malignant or other. There is great need of laboratory studies along these lines, and also on the alkalescence of the blood, which we found to have a marked diminution in cancer.

We know also comparatively little in regard to the origin and destruction of the cellular elements of the blood, and can only depend on the microscopic examination of their forms and appearances in health and in many conditions of disease. These have been abundantly studied morphologically, but mainly in the more severe forms and later stages of cancer, as detailed somewhat in my former lectures. Enough was there quoted to show the continued degeneracy of the blood after a cancerous growth had acquired some progress; there has also been observed some improvement for a while after the removal of a tumor, evidencing the deleterious effect of the hormone secreted by a cancerous mass.

The laboratory study of the blood from 22 of the cancer patients in the New York Skin and Cancer Hospital under my care, has been instructive as well as valuable along certain lines. In most of them it was made weekly, and often over long periods of time, and the results tabulated for easy comparison, in order to study closely the condition of the patient and the effect of remedies. No very startling revelations were made by these blood studies, they confirmed in the main the observations of others, though some interesting facts were learned from an analysis of the data. They referred to ten cases of cancer of the breast, four of the stomach, two of the uterus, one of the rectum, one of general abdominal carcinosis, and the rest in scattered locations.

The lowest hemoglobin index was 35, with 2,800,000 red blood cells, in a woman aged 59 with cancer of the stomach. The next lowest hemoglobin index was 45, with which the patient, aged 53, died, with inoperable cancer of the right breast; the blood count showed 3,700,000 erythrocytes, and 10,400 white blood cells, 76 per cent of which were polynuclear. During the course of observation, covering several months, the red blood cells were once 2,100,000, but under careful treatment rose to 4,110,000 not long before death. The next lowest red cell count observed was 2,200,000, with 12,000 white blood cells, and 65 hemoglobin index, in a man aged 52, with a terrible inoperative cancer of the cheek and neck, of which he died.

The highest red cell count made was 5,400,000, in a case of cancer of the uterus, in a patient aged 52, the count being 4,064,000 on entering the hospital. The highest hemoglobin index was 90 in a number of severe cases, and 100 in one case of sarcoma, to be detailed in the next lecture. In one recurrent case of cancer of the left breast, which was very distressing at first, the patient died peaceably and without pain, with a hemoglobin index of 90, and 4,900,000 red cells, and 7,400 white cells, of which 75 per cent were polynuclears, 17 per cent small lymphocytes, and 7 per cent mononuclears. Her hemoglobin had been 70 per cent on entering the hospital with 3,360,000 red cells. The highest leukocyte count observed was 18,600 in a case of inoperable cancer of the right breast, not long before death, in an unmarried female of 53; but in the course of treatment it had fallen to 6,200, about normal, from 10,520 before beginning treatment.

I will not weary you with more of these figures, which are interesting and instructive as one studies them week by week in connection with the physical condition of the patient. However much can be done for these distressing and inoperable cases of cancer, one has to acknowledge that when general carcinosis has set in we are still helpless in arresting the lethal progress of the disease, although very much can be done in prolonging life and alleviating suffering; and this does not mean with morphia or codeia which in the end does harm, and was very seldom administered to the patients referred to.

Forbes Ross, after ten years of constant microscopic clinical and surgical research, has made some interesting observations, covering many pages, on the blood of cancer patients, which have a close bearing on our subject, and to which I can only briefly allude, and I do not know if I can make it clear in the time I can give to the subject. By long study of sections of carcinomatous tissue he claims that the mononuclear leukocyte behaves in a very different manner from the polynuclear. Briefly he charges the mononuclear white corpuscles with actually producing the disease, by conjugating with certain epithelial cells, thereby giving them the reproductive capacity which enables them to push forward on their destructive career. The polynuclears seem to come up to the defense of the body, but are overcome by the poison secreted by the rapidly growing tumor cells.

The red blood cells he also finds, with other observers, nucleated more frequently in cancer than in any other form of secondary anemia, and subject to a change of composition, and deficient in lecithin and nuclein. He shows the importance of potash, which we shall later find clinically of such great value in cancer, and I cannot do better than quote some of his words: “How vitally important potassium salts are to the red corpuscles is shown by the following: One thousand parts of red corpuscles are found to contain six hundred and eighty-eight parts of water, three hundred and eight parts of organic solids, and eight parts of mineral. Of these eight parts three and one half are of potassium chlorid, two and one half are potassium phosphate, and decimal one potassium sulphate; the remaining 1.9 parts are divided between the iron, sodium, calcium, and magnesium, comprising the rest of the corpuscles. More than three quarters of the total mineral ash of the red corpuscles is, therefore, composed of potassium. This fact is an important one, and the reader is earnestly requested to bear it in mind.” Later we will again see some of the valuable clinical suggestions which arise from his researches.

From our study of inoperable and recurrent cancer, and of metastasis and the blood conditions in the disease, we see what a formidable task is before one who would attempt to lessen its morbidity and mortality. We see also how blind all have been who have so long looked to surgery to stay its progress. In my former lectures I collected and quoted statements from many surgeons of prominence in times past, and even some in quite recent times, all expressive of a belief in a constitutional origin of cancer, and many of them looking to a dietary cause. I also gave biochemical laboratory and experimental evidence showing the medical aspects of cancer. I then remarked that it seemed strange that the medical profession and the public had been so slow in accepting and acting on the accumulated evidence which I have tried to put before you in these and the former lectures.

The reason for this seems to be that the medical profession, being occupied largely with acute disease and apparently definite and speedy results, became readily discouraged with the unsatisfactory course commonly observed in cancer; as in the case of tuberculosis, until the revival of an interest in the latter in recent years, with the well known beneficial consequences. They, therefore, turned the cancer cases over to the surgeons, in the hope that they could do better.

By the brilliant advances in modern surgery along many lines, the laity also have become obsessed with the idea that it has limitless power in many directions, and have yielded to the knife in spite of the rising mortality of late years. The glamour of modern surgery and its often spectacular results have quite blinded the eyes of many to real facts.

It is not a little interesting to note that the period to which we have referred, 1910 to 1915, in which the mortality of tuberculosis has fallen so steadily while that of cancer has so steadily risen, even in greater proportion, is that in which active laboratory work has also dazzled the public and professional mind. The enormous activity with the microscope in regard to the minute structure of the diseased tissues, and the elaborate and extensive work done in animal experimentation, have turned the thoughts of many from the homely and practical studies of the human frame in its various departures from health; thus too little attention has been given to the deranged activities of its various organs, and the perverted metabolism which, has resulted from the stress and strain, with the temptations and errors accompanying the present intensity of human civilization.

Matters being as they are it is hardly to be expected that the surgeons would incline to any other treatment than by the knife, especially since good pathologists have asserted that cancer is only a local affair and have urged its early removal. Nor would one expect that the surgeon would think along medical lines and investigate metabolic conditions, when the immediate results of operation seemed often to be so satisfactory. Neither would one expect the surgeon to seek from statistics the unfavorable aspects of this line of treatment, but rather those from which he could draw encouragement in trying to overcome so dire a disease.

But slowly light is beginning to shine, and you have seen and heard enough to realize that the simple removal of the product of the cancerous process, and surrounding tissues, can never check greatly the morbidity and mortality of cancer. You know now what the real cancer problem is. It surely is not the sole continuance of a line of treatment under which the death rate has steadily risen from 63 to 81.1 persons in each 100,000 living, or 28.7 per cent since 1900, with a mortality of about 90 per cent of those once affected with the disease.

The cancer problem is by no means yet solved, but I think that you will all agree with me that we are on the right track, and I cannot do better than to close with a remark I made to you two years ago: “Scientific research must still go on in the laboratory; but clinical research and study, with laboratory work, on the human subject, which have not been hitherto sufficiently cultivated, should be pushed, so that by a mass of carefully recorded observations the truth or falsity of what has been here quoted and said may be refuted or confirmed.”

LECTURE V
DIETETIC AND MEDICAL TREATMENT OF CANCER PROPHYLAXIS

Although all statistics show a steady and alarming increase in the death rate from cancer when regarded and treated as a surgical disease, it is probable that this course will be persisted in until sufficient evidence is accumulated to satisfy the medical profession and the laity that relief can be obtained by other means. For, as the drowning person catches at a straw, so the cancer patient hopes against hope that an operation will be permanently successful in this particular case, though the odds are so immeasurably against it. You have already seen some patients who have illustrated the possibility of controlling cancer by dietary and medical measures, and in the next lecture I shall hope to show and report other cases and present statistics which will further illustrate this possibility. We will now consider briefly what this dietary and medical treatment of cancer consists in, and how it is to be carried out, and also the bearing of all this on the prophylaxis of cancer. In order to make this clear I must more or less repeat some things that I have said in former lectures.

We have seen that, as shown by the kidney excretion and the condition of the blood, the metabolism is deranged, both in the early and late stages of cancer. We have seen that the nitrogenous and sulphur partition is materially different from that of health, and reason indicates that in some way protein, or rather its metabolism, is at fault. We have seen that there is a deficiency in the urinary secretion, not only as to the actual quantity, but also that the total urinary solids are commonly far below the normal, often not half the amount required for the body weight of the individual. We have seen that the intestinal excretion is commonly imperfect and that constipation is the rule in these cases, even long before the administration of anodynes. The secretion from the skin is also generally defective, and the tissues dry and harsh, and the saliva is generally acid.

All these, and perhaps other, elements point to a faulty performance of the bodily functions, and to erroneous or deficient elaboration and elimination of the waste products of the body; these latter are known to be toxic to animals, and we know that in the human system they lead to an auto-intoxication and derangement of the blood stream, which in turn causes faulty cell and tissue action. Such a condition is recognized in gout, as causing the local inflammatory manifestations, and in rheumatism, which is so common in cancer subjects. All recognize that obesity is due to some nutritive change, naturally acting through the blood, and it is well known that cancer is peculiarly rebellious in those subject to obesity. Diabetes likewise relates to a peculiar blood condition, and there have been many observations concerning the relation of diabetes to cancer. All these diseases and many more have their foundation in faulty nutrition, depending largely on dietary errors.

We see, then, that to understand and rightly treat the systemic condition belonging to cancer, which is indeed its basic factor, one needs to take a very broad view of the complex processes in the human system which pertain to metabolism and nutrition. This is indeed quite a different proposition from the very simple surgical view which regards the tumor as a local matter, of absolutely unknown origin, which only needs the knife to end its career. Deranged, disturbed, perverted nutrition is then the bottom fact of all erroneous growth, whether it be obesity or a benign or malignant tumor.

Now it must be acknowledged that we are yet in the dark regarding the exact or precise blood changes which precede and accompany cancer; but in our last and also in previous lectures we saw that the blood did exhibit changes which were evidently connected with the production and continuance of the disease. Until all these matters which have been referred to have been accurately determined by laboratory work and investigation we are forced, as in time past, and as is still the case also in regard to many diseases at the present time, to rest our judgment and treatment on clinical experience, joined with deductive observation, based on such knowledge as we have. And this we have endeavored to do in these and former lectures.

Coming down, then, to the actual and practical facts relating to the dietary and medical treatment of cancer, we readily see that the real cancer problem relates to placing the patient in such a normal or ideal state of life that the function of nutrition is performed in an exactly proper manner, as nature intended, and from which man has erred through the manifold temptations incident to our artificial existence, in the presence of our so-called advanced civilization; for we have seen that all over the world cancer has steadily increased with the intensity of human progress.

Since first writing on the subject under discussion medical reviewers have spoken as though I regarded the eating of meat as the sole cause of cancer, and enforced absence therefrom as the single element in its cure and prevention. From what I have just said you can see that this is by no means true. But that I regard animal protein as a fertile cause of the derangement of metabolism which leads up to and fosters the growth of cancer, is most certainly true; this I have developed largely in my lectures two years ago. While there are many elements which contribute to the deranged blood stream of cancer, the question of diet is so preeminently important that we must treat of it very fully. For, as in gout the continuance of an indulgence in Port and Madeira wine in excess would invalidate any attempt to cure the trouble permanently, so in cancer an excess of animal, or even a large amount of vegetable protein, militates against any effort to remove the disease medically; this is probably true also of coffee and alcohol.

The first point, therefore, is to remove from the intake of food everything which furnishes an excess, or even such a modicum, of nitrogenous matter as is found by laboratory means to be badly metabolized. The second step is to eliminate effete nitrogenous elements from the system, including the cancerous mass, and the third step is to restore the system to a proper tone by remedies and measures which improve the blood and nutrition. It may happen, therefore, that in treating a cancer patient over the long time necessary to effect a cure, the greatest number and variety of remedies may be employed from time to time, as intelligent observation and experience may indicate, to restore and hold the metabolism and nutrition in a perfectly normal state: the erroneous action of certain individual body cells which in the aggregate we call cancer, will then cease to exist, as is seen in cured cases.