Chapter I: Part 1

CANCER
ITS
CAUSE AND TREATMENT

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

Senior Physician
The New York Skin and Cancer Hospital, etc.

NEW YORK
PAUL B. HOEBER
1915

Copyright, 1915
BY PAUL B. HOEBER

_Published, February, 1915_

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 branch of

DERMATOLOGY

this little book is inscribed

PREFACE

Cancer has hitherto been regarded almost wholly from its histological and surgical aspects. The investigators and practitioners along these lines have been innumerable, the work done prodigious, and the literature relating thereto enormous. But relatively little attention has been paid to the medical aspects of this most threatening malady, although voices have been raised from time to time, with more or less force, all joining in the same plea that the basic cause of the disease lies in some derangement in the vital forces of the organism, as influenced largely by diet and mode of life.

It has, therefore, seemed to the writer that it was time to stop and look at cancer from a broader aspect, and by synthesis and deduction to seek to understand some of the underlying causes of malignant disease; also to see if some general principles could not be ascertained upon which could be based an explanation of the views he had long held, and of the practice which he had long followed in regard to the prevention and cure of this dire malady. And as his studies progressed he was more and more satisfied that the true solution of the cancer problem lay along the lines indicated, although there was still very much to be learned regarding the details and application of the principles involved.

The lectures were prepared for and delivered to practicing physicians at the New York Skin and Cancer Hospital, in connection with the regular Wednesday lectures on Diseases of the Skin, as I felt that I should give them the benefit of what I felt to be of value in my own practice, private and public.

Although holding the views here expressed for many years I have hesitated writing strongly on the subject before, lest I should be misunderstood or misjudged: for favorable results based solely on a clinical diagnosis of cancer are always doubted. I have also feared lest by advocating a dietetic and medical consideration and treatment of cancer, which possibly might not be carried out exactly, I might really do harm; since some might be led to neglect operative measures in proper cases, at the proper time; and so in certain instances great injury and injustice might be done to the patient, and the time pass in which a surgical operation might possibly be of service.

But with my views and experience, strengthened greatly by what studies I have been able to make in the midst of a busy professional life, I now feel that I should do wrong in not presenting the results and conclusions of my study and observation. And I wish also to enter my strong protest against the course which is usually followed in regard to cancer, both before and after operation. With a rather extended experience during the last forty years, I have rarely if ever found a patient with cancer who has received adequate and continuous medical care before operation, with a view of discovering and rectifying the cause of the morbid growth. Too often when a cancer is suspected or discovered it is taken as a foregone conclusion that the malady is hopeless, except as the _results of the disease_, that is the new growth, may be removed by the knife, X-ray, radium, caustics, etc. And after a surgical operation, as far as my observation goes, the patients are invariably left entirely to their own resources, with the hope, alas, too often futile, that the tumor will not regrow, but with no attempt to so guide the life that there shall not be the same tendency to a recurrent malignant new-formation. Against this latter course I also raise my earnest protest.

In presenting matter from literature bearing on the subject under discussion I am well aware that I have hardly more than touched the surface of the deep ocean of recorded observations on cancer, but it was the best that I could do in my busy life. I only hope that others will take up in earnest the subjects here presented, and that this pioneer work may lead to the building of a strong and permanent structure regarding the true basic cause of cancer. Truth never fears proof.

In studying the subject I have been greatly assisted by the masterful work of Roger Williams, so often referred to and quoted from; and I feel that a candid and careful perusal of that book will be a revelation to many. I know that some have endeavored to throw discredit upon some of the deductions which he makes from various statistics, but in the main they all teach a valuable lesson and are worth serious consideration, as they are taken from reliable sources.

Realizing fully that the problem of the cause and proper treatment of cancer is a most profound one, which master minds have long wrestled with and which cannot be fully settled without much further study, these lectures are presented to the profession at large in the hope that they may be the means of helping some one threatened with or suffering from malignant disease; and also that they may possibly stimulate others to investigate even more diligently along the lines of the medical aspects of cancer.

January, 1915.
531 Madison Avenue.

CONTENTS

PAGE

LECTURE I

NATURE OF CANCER 15

LECTURE II

FREQUENCY AND GEOGRAPHICAL DISTRIBUTION OF CANCER 43

LECTURE III

METABOLISM OF CANCER 70

LECTURE IV

RELATION OF DIET TO CANCER 106

LECTURE V

MEDICAL TREATMENT OF CANCER 135

LECTURE VI

CLINICAL CONSIDERATIONS AND CONCLUSIONS 170

BIBLIOGRAPHY 211

INDEX 221

CANCER
ITS
CAUSE AND TREATMENT

LECTURE I
NATURE OF CANCER

It may be safely said that no disease which has afflicted mankind has received as much attention as Cancer, or concerning which there has been as much diligent search to find out its nature and cause. Tuberculosis, which seemed at one time to threaten even the existence of the race, has sunk into relative significance, as we have learned its true nature and conquered some of the causes of its ravages, and reduced its mortality very largely. Syphilis, under various names, forms, and aspects, was formerly much more of a menace than now, and in earlier years caused veritable epidemics, but is now well understood and controlled. Leprosy is less of a terror than in earlier times, since it has been definitely shown not to be contagious. Smallpox no longer rages, and yellow fever, and the plague, and hook worm disease have been hunted down by scientific study and the application of proper sanitary and medical measures. And so on in regard to many of the ills which afflict mankind.

But cancer has held its own and has even increased in frequency, with rapid strides and bounds in some localities, until now it looms large as a national[1] or even universal scourge; it has been estimated to cause the death of half a million persons yearly among the civilized people of the earth, and untold misery and suffering to many times this number. And all this is still going on in spite of the earnest, faithful, and intelligent labors of innumerable research workers, the sacrifice of countless animal lives, and the expenditure of vast sums of money; and the end, as far as relates to its prevention and cure, seems almost as far away as ever, for many surgeons, in past and present times, have acknowledged their inability to cope with the disease.

Much, however, has already been established by scientific research, and still more earnest thought, observation, and endeavor should be given to seeking most diligently for the cause of the disease, in the laboratory as well as in practice; for there must be some cause of cancer, and also some reason for its steady increase.

But it is never to be forgotten that, as Pope says, “the proper study of mankind is man,” and clinical observation, with laboratory research, on cancer as it appears in the human being, must be the ultimate base upon which all true advance in the knowledge of the nature, treatment, and prevention of the malady can ever rest. To effect this we must study the human being in all relations of life, must know the constitution and class of subjects in which the disease is most apt to manifest itself, understand the chemico-physiologic actions going on in the system, before and during the existence of the disease, and by a process of synthesis and deduction understand what is wrong and endeavor to correct it.

All this is indeed a great undertaking, and can only be accomplished by great effort on the part of many careful and skilled observers. But I want, in these lectures, to give you an outline of my own thought and study for many years, and, if possible, to let you see as I do the lines along which investigation should be directed. It is hoped, therefore, that this and the following lectures will throw some light on the connection of cancer with diet and mode of life, and some suggestions as to its prevention and cure.

_Parasitism_ has been excluded: for while at different times many observers have reported various organisms which were thought to be the cause of malignant growths, none of these have been definitely confirmed by others, in spite of earnest endeavor; and all experimental and clinical evidence is against a parasitic etiology of cancer. It is therefore seen how improper it is to speak any longer of “_the germ of cancer_,” for, as is now widely acknowledged, there is no such germ, it is an _ignis fatuus_ which has been chased in vain.

The _contagiousness_ of cancer has also been excluded, certainly in the sense in which this term is applied to other affections. For while in some animals inoculation experiments have resulted in the transmission of certain tumors, little has been determined except that such tumor material when transplanted can, in some unknown manner, multiply its cells indefinitely and form a focus of malignant disease, with disastrous effects on adjoining tissue. The same occurs in metastasis in cancer patients. But this does not at all explain the true basic nature of cancer, nor its development in those who have had no connection with other patients so afflicted. On the other hand the instances of suggested or supposed human transmission of cancer from one individual to another are so remarkably few, and so exceedingly doubtful, that a recent author, Janeway, states that “no well-authenticated cases of the transfer of a malignant tumor from one human being to another exist.” It has been found impossible to inoculate human cancer into rats, mice, and apes, nor can animal tumors be inoculated into animals of a different species.

_Heredity_ has been advanced as a cause, but statistics fail to verify this in any degree whatever. While certain instances have been brought forward in which heredity seemed evident, the study of large numbers of those afflicted with cancer, in connection with others free from the disease, has shown almost the same proportion of antecedents with cancer in both classes of persons; although some recent evidence seems to show that there is some tendency in different families for different organs. Experimental studies have, it is true, seemed to demonstrate that tumors occur apparently along hereditary lines in some animals in regard to certain organs; but in these instances it is to be remembered that the animals were kept in captivity, and all fed alike, conditions which have been found to cause the development of malignant disease in wild animals when confined in Zoölogical Gardens.

In former years _malaria_ was believed to have an influence in the production of cancer, and some investigators have thought to trace the prevalence of the disease to _telluric influences_, showing a preponderance of cases along certain water courses, or in certain streets or houses; but no definite proof of such connection has ever been established, and this theory is dismissed by the best authorities. _Syphilis_, in its latent effects, has also been claimed as an element in the causation of cancer, and undoubtedly the disease may develop, in suitable persons, upon old syphilitic lesions, especially about the mouth, anus, and genital region: but no one well informed in regard to cancer would regard syphilis as the real cause of the disease. All these and other etiological propositions are no longer considered to be tenable, and the very multiplicity of suggested causes shows that we are yet very far from the true etiology of cancer.

_Age_ undoubtedly has a powerful influence in the development of cancer, the vast majority of cases occurring after the age of forty or fifty. But, again, this does not at all explain the true nature of the disease, for only a certain proportion of elderly people are so afflicted, and malignant tumors have been observed in those of all ages, and even in young children. The degeneration of tissue belonging to advancing years undoubtedly renders it more susceptible to malignant disease, but this does not explain why one person is affected and not another, nor why the tissues in one locality or another take on this morbid action.

More recent scientific study has attempted to show that cancer originates from what are called “_embryonic rests_,” or pre-natal, wrongly placed, tissue elements, which at some time or other take on morbid action and develop into what we know as the various forms of cancer. Williams says, “From a biological standpoint tumor formation must be regarded as a phenomenon of the same order as reproduction in general: that is to say, as a special form of overgrowth of the individual.” But here again it is necessary to determine what causes them at certain times and in certain places to thus proliferate and form new tissue, which then becomes malignant and may proceed to destroy all contiguous tissues, and even to cause death.

_Traumatism_ has been claimed by many as the cause which determines the activity of the misplaced cells, and starts them on their disastrous or rampant course: the various percentages of the cases in which it was believed that traumatism started up the malignant process has varied greatly with different observers, even up to 50 per cent, or more. But it is far from proven that this is always the case, nor does local injury in any way explain the persistency with which malignant disease, when once started, pursues its destructive and even fatal career; nor can traumatism account for the great tendency to recurrence constantly observed, either in the former site or at some distant focus, through the agency of the lymphatic or vascular system. For of multitudinous traumatisms, even in cancer subjects, how few ever develop into malignant disease!

It would seem, therefore, that for the development of the local manifestation of cancer (the tumor or new growth) three elements are requisite, namely: 1. A predisposition or suitable blood condition. 2. A local stimulation or irritation of the part affected, _upon_, 3. The site of an “embryonic rest.”

On the basis of the embryonic theory surgeons have of late most earnestly advocated the very early and complete removal of malignant lesions, including those of suspected malignancy, and even also the removal of many innocent lesions which are observed occasionally to lead to cancerous formation; and unless a better plan can be determined this cannot be urged too strongly in proper cases.

But while early operation has improved surgical statistics, it has not contributed to our real knowledge of the basic cause of cancer, nor has it taught us why those lesions or “embryonic rests” will remain quiescent for years, or prove harmless in some individuals, while in others they become most formidable agents of destruction. For it is now recognized that these wrongly placed tissue elements are very common anatomical or histological accidents, indeed it is claimed that they occur and exist in every individual: and the removal of isolated “embryonic rests” which have developed into cancer, does not by any means prevent the transformation of other similarly misplaced cells into malignant disease, as the frequent recurrence of cancer after operation demonstrates.

The same is true of the many and various forms of treatment other than surgical excision, such as deep acting caustics, and even the X-ray and radium, which like surgery, only remove the focus of possible systemic infection, and do not affect the basic cause of the complaint: this latter is being shown more and more, by scientific investigation and observation, to be associated with metabolic or chemico-physiological changes in the system, and evidence is accumulating that it is dependent upon them.

All this leads thoughtful persons to inquire if there is not some deeper, fundamental cause lying back of the trouble, which should be reached and rectified by medical skill and acumen, something to do with the life or diet of a person which renders the tissues liable to take on malignant disease. So that a recent surgical writer on cancer states that “all study, whether clinical, pathological, or experimental, points to the fact that there is some underlying, hidden cause which leads to that aberration in the action of tissue cells which we call cancer,” ... a cause “residing in only the cells themselves or in some abnormal chemical constitution of the plasma bathing the cells, or in both of these possibilities acting together.”

_Occupation_ has been questioned, but with most unsatisfactory results, for in some statistics which have been gathered cancer has been observed in those following all possible pursuits: and while laborers stood first on the list, clergymen stood fourth, while carters, threshers, and guides, who would be exposed to local injury, were at the bottom of a long list. It has been found, however, to be more frequent in trades or occupations in which the individual is most subject to the habitual abuse of alcoholics, as in bartenders, printers, etc.

We see, then, that thus far no satisfactory cause has been established for the occurrence of cancer, much less for the steady and great increase of the disease of late years. And as far as can be learned, no measures are recognized, or at least generally adopted, to prevent its occurrence or recurrence; although, as already stated, modern surgery has seemed to improve the statistics in regard to its mortality in certain forms or locations, and the X-ray and radium have certainly also been able to remove, perhaps temporarily, some of the products of the disease.

We come then to the question, what is the real nature of cancer? Alas, all scientific, experimental, and clinical investigations have failed to solve the problem, except that all “evidence points to the conclusion that cancer is to be considered as a pathological disturbance of the normal cell life,” from some unknown cause. A curious suggestion has been made by Schmidt, who found that of 241 cases of cancer of the chylopoietic system, 180 had never had any infectious disease of childhood, and 99 went through life without any infection of any kind; the figures point to the existence of a cancer diathesis—one which is resistent to germs.

It would carry us too far from the practical side of our subject, even if we were at all able, to present or analyze the vast number of contributions which have been made to the pathological histology of cancer, and the changes which take place in the transformation of normal cells into those of malignant character: the amount of microscopic work which has been done along this line can hardly be imagined, and the literature relating to it is enormous.

Ewing, accepting the definition that the cancer process is “atypical and destructive proliferation of epithelium,” quotes Ribert as saying that “no one has ever seen the beginnings of mammary cancer”: but he does not bring us much nearer to the solution of the cancer problem than we were before. Bainbridge rejects all possibility of a blood condition, and finds the only solution of it in the early removal of everything which is thought to lead to cancer, even the simplest benign new formations, but Ewing states that “in some cases carcinoma has developed after excision of wholly benign fibro-adenoma”: and the immense number of cases of recurrent cancer after operations shows that we must look further than surgery if we wish to stay the progress of this formidable disease.

It would be useless to attempt to present the many theories which have been advanced relating to cellular metaplasia, or even to detail all the more or less accepted views in regard to the manner in which normal cells change and degenerate into those of malignant character: but some of the principal facts may be of service in understanding somewhat of the mode of development of malignant tissue from that which has been normal.

The statement of Virchow, “Omnis cellula e cellula,” that is, “where a cell arises there a cell must have previously existed, just as an animal can spring only from an animal and a plant from a plant,” forms the basis of all study on the genesis of cancer and all tumor formation; karyokinesis, or indirect nuclear or cell division, is at the bottom of all growth, both normal and malignant, and the two classes of growth differ only in their methods and activity. In healthy tissues cell proliferation and destruction proceed in an orderly manner, forming homologous structures, as when the hair and nails are constantly produced from newly formed cells at the root, and the result of this new growth is removed mechanically when the hair and nails are cut from time to time, or the hairs fall out. In the case of the skin the epidermal layers are pushed forward and finally exfoliated as useless epithelial débris.

With the cells composing other, or internal structures, however, the process is different. For here each normal cell reproduces others of homologous structure, and the different parts of the system are thus kept in active service through anabolism, by means of which new cells are formed with renewed vitality, and the older, or effete cells are removed by catabolism; the elements of which they are composed are thus split up into their component parts, and carried off by the blood or lymph stream, and are then either discharged as effete substances or reutilized in the system, along physiological lines. Wakefield has pretty clearly shown that the developing cancer cell is the product of sub-catabolism, or a sub-oxygenation, induced by hyperacidity or oxidase deficiency in the surrounding medium of the blood plasma.

A great deal of thought, study, and speculation have been given in regard to the behavior of the cells themselves, and strong arguments are adduced for a local cell pathology, that is, regarding the cells as “autonomous beings, possessed of morphological and physiological independence.” But on the other hand we must recognize some restraining influence which continually causes the great mass of cells to reproduce those of homologous structure, in an orderly manner, and only very rarely some of them to break loose and form tumors, which may then become malignant and even destroy life. How this restraining influence is modified or withdrawn is, of course, a part of the problem of cancer. Those who maintain their autogenous character lay great stress upon the polarity of cells, and the relation of the centrosome to the nucleus, indicating a change in the polar axis in cells about to be cancer-genetic, as does Ewing in his recent classical study of pre-cancerous lesions. But whatever changes are observed microscopically we must recognize that the cells themselves must be influenced ultimately by that mysterious force which we call life, which ends with its extinction from the body as a whole, and which is ultimately related to nerve action. We must also recognize that the cells everywhere depend for their life and activity upon the plasma in which they are bathed and from whence they draw their sustenance; and this plasma is renewed day by day from the food and drink taken.

Students of cancer are more and more recognizing and acknowledging that “all these phenomena, apparently so different, are merely protean manifestations of one common process which underlies and is the cause of them all, to wit, cell growth and proliferation. The particular outcome of the process in any given case is due to the influence of the conditions of nutrition—understanding by this term the whole of the material changes wrought in the organism through its relation with the surrounding world. This being so it is easy to understand how, under favorable conditions, certain cells may take on independent action, growing and multiplying without regard to the requirements of adjacent tissues and of the organism as a whole.”

There seems to be some reason to support the view advocated by Williams, that tumor formation and growth are but forms of agamogenesis, or non-sexual reproduction of cells, distinctly related to the decline in growth of the body in general. Hence while the forces of growth, development, and reproduction are in greatest activity the tendency to this disease is relatively small: but when growth declines and nutrition is relatively low the cells undergo gemmation, owing to perverted nutriment, and thus hyperplasia and not inflammation is the starting point of every neoplasm.

Experimental work has time and again demonstrated that cell growth, either good or bad, is modified in no uncertain way by the character of the nutrition furnished. Cancer has repeatedly been observed to disappear spontaneously, as such cases are on record by careful and competent medical men: in certain of these instances it has occurred in connection with a radical change in the mode of life and diet, but in the majority of instances there is no record of the special cause of its disappearance. The lesson to be learned from this is that there are conditions of the system which are antagonistic to the abnormal proliferation of cell tissue, even when it has begun to take place, as we must believe that there are other conditions of the system which favor such diseased action of aberrant cells.

An interesting confirmation of this is attributed to Ehrlich, but I cannot find the original reference. He “has shown that mice living upon a rice diet cannot be inoculated with cancer, while mice living on a meat diet can be readily inoculated, cancerous tumors developing quickly and continuing to grow until the animal dies. Ehrlich also found that when mice with cancerous tumors, the result of inoculation, were placed upon a rice diet, the tumors ceased to grow, and in many cases degenerated and disappeared.” Valuable corroboration of this has been given by Sweet, Corson, White, and Saxon. They made a series of experiments in regard to the “influence of certain diets upon the growth of experimental tumors,” all with the same results. Of fifty white mice, 25 fed on glutenin and gliadin, and 25 on normal diet, 23 of the 25 on normal diet acquired tumors, against only 4 in the 25 on the glutenin and gliadin. This was repeated on 50 males, with the result of 18 in 25 against 3 in 25: and in a third series, of 50 females, the figures were 15 in 25 against 7 in 25. Thus, they found that 75 per cent. of 75 mice developed experimentally inoculated tumors when under normal diet, while only 19 per cent. of other 75 mice developed such tumors when under a diet of glutenin and gliadin, that is, vegetable proteins; moreover, the tumors in the latter were in 30 days hardly larger than those in the former in 10 days. Rous has recently shown that large growths of certain transplanted rat and mouse tumors are checked in their development by underfeeding the host on a special diet.

The chemistry of cancer has been studied in most varied directions, and the literature relating thereto is very voluminous and can be hardly more than alluded to here. It is unfortunate, however, that most of the researches have been made in connection with patients who have advanced cancer, and very commonly with the disease affecting internal organs, which of itself interferes very greatly with their function, and so causes many of the perturbations of metabolism observed. What is needed are researches in regard to the metabolism of patients before the development of the disease, or in its earlier stages, before it has exerted its injurious effects on the system, in order to learn of the causes which lead up to and induce the wrong action of the cellular elements, whose invasion and malignant action subsequently become so serious.

It is quite impossible in these lectures to enter at all fully upon the various bio-chemical studies which have been carried on in regard to cancer, but brief mention will be shortly made of some of the salient points. Not only has the structure of carcinomatous tissue been examined chemically, but the blood and urine have been submitted to most painstaking investigation, and metabolism in general has been studied in almost all possible directions, in the search for the cause of cancer; and yet, as Beebe says, “no phase of metabolism has been described in cancer which does not have a counterpart in non-cancerous conditions.” But, as previously mentioned, all these observations and studies have been largely made upon advanced cancer cases, when the system has already felt the unsettling and depressing effect of what is probably an injurious secretion from the deranged and actively proliferating cells of the cancerous mass. In a later lecture we will consider some of these matters in so far as they have relation to the dietetic and medical treatment of cancer.

The essence of our study thus far has been, that in every instance what is called malignant disease is but an aberrant action of originally normal body cells. That, as normal cells find their nutriment in the circulating plasma, so some pathological change in this latter causes them to take on abnormal action, and they no longer develop homologous cells, capable of forming normal tissue, but heterologous elements which have a natural tendency to disintegrate or break down, and exert a destructive influence on adjoining cells of any kind; and in this process they secrete a hormone which is prejudicial to the system and tends to destroy life. In later lectures we shall endeavor to understand this more perfectly, and consider some of the elements in life which tend towards the production and arrest of cancer.

LECTURE II
FREQUENCY AND GEOGRAPHICAL DISTRIBUTION OF CANCER

Cancer in man exists all over the globe, but in different degrees of frequency, according to varying conditions of life, as we shall presently see. Malignant growths occur also in animals and fishes, though also with greatly varying frequency under different conditions; but there are few real tumors in reptiles or amphibians. Tumors are also occasionally found in vegetable organisms, presenting increased growth and proliferation of cells, arising from adventitious, or abnormally evolving buds, as also from parasitic and other external irritants. While these vegetable tumors are very interesting and in a measure instructive, in regard to the peculiarities of cell growth which they exhibit, they bear, of course, no relation to cancer in the animal kingdom, although some have endeavored to argue otherwise. There is, however, a certain suggestion of analogy to be found in the observation made by one writer, that “the origin of buds, as well as their subsequent development, is chiefly determined by the conditions of nutrition. Wherever there is an excess of nutritive material, capable of being utilized for growth by the cells of the part, there buds may arise”; we shall see later that the same thought applies to cancer in man and animals, when we come to the consideration of the relation of overindulgence along certain lines of eating and drinking to cancer.

Cancer has well been styled a disease of modern civilization, like tuberculosis, although of quite a different nature. Interesting studies have been made in regard to the increased death rate from the former in England, coincident with a diminished mortality of the latter, in accordance with nutritional changes which have taken place in certain populations: and in the first lecture I mentioned that in the United States the mortality from tuberculosis had fallen 25 per cent. between 1900 and 1912 while, as we shall see later, the mortality from cancer has certainly risen.

Williams, who quotes very largely from the accurate statistics which have long been carefully recorded in England, says that “while tubercle has declined with great rapidity, cancer has increased at a still faster rate, and these inversely related changes are still in active progress. In illustration of these remarks it may be mentioned that during the last half of the nineteenth century, the cancer mortality for England tripled: while, during the same period the tubercle death rate declined to the extent of nearly one-half. Unless some great change in the national habits takes place, of which there is at the present no well marked indication, cancer will ere long claim more victims than phthisis, as is already the case in many localities—e. g., Hampstead, Clifton, Bath, etc.” He further says, “I regard this decline in the presence of tuberculous diseases as the direct outcome of the better food and improved hygienic conditions, for which we are indebted to our increased national prosperity: and I shall endeavor to show that conditions of this kind, by their action in another direction, are also mainly responsible for the augmented cancer mortality.” We shall see later that cancer has asserted itself where modern civilization has augmented the opportunities of overindulgence along many lines of eating and drinking: for while advancing scientific knowledge has undoubtedly diminished mortality in general, and has added to the average length of life, the various factors included in our modern mode of living have also with certainty increased morbidity along such lines as neurotic and vascular disorders, tumors, etc.

All statistics from various localities show that cancer has certainly increased in frequency very greatly of late years, and though some have attempted to claim that this increase is only apparent, and is due to greater accuracy of diagnosis, and the prolonging of more lives to an age when cancer is more common, there is no doubt in the minds of those who have studied the figures that the increase is certainly very real; and unless there be found some way to check its production, the death rate at the end of the century will be appalling.

It is quite impossible here even to give a comprehensive idea of the immense amount of work which has been given to the study of the statistics of cancer in various parts of the world, as collected in the remarkable works of Roger Williams and Jacob Wolff, but brief mention must be made of some of the items observed and recorded in order to properly understand our subject. Williams in particular has analyzed the recorded facts in an interesting and convincing manner, and shown again and again in connection with the figures from different countries, sections, and cities, that the occurrence of cancer bears a striking relation to the condition of the people in reference to their material prosperity; namely, that the well-to-do, who can overindulge in many ways are vastly more subject to cancer than those in the poorer walks of life; also that aborigines in the wilder parts of the world are either almost exempt from cancer, or suffer from it to a very much less degree than civilized foreigners who come to their lands. This is also shown in a very striking manner by Wolff, and I present here a table which he gives in regard to the progress of cancer in a single country, Australia, among the native born and foreigners.

OF 100,000 LIVING THERE DIE OF CANCER IN AUSTRALIA

_Year_ _Number of _Native Born_ _English_ _Other
Inhabitants_ Nationalities_
1851 403,889 28 14
1861 1,153,973 5.6 30.5 19
1871 1,168,377 9.7 56.7 25
1881 2,252,167 16.8 72.9 32.6
1891 3,183,237 19.8 119.8 45.9
1901 3,771,715 22.6 203.1 57.3

He remarks, “We see from this comparison in what a great degree the death rate from cancer has increased in foreigners as compared to the native born, in whom the disease has remained about stationary, when the increase in population is considered.” Another writer remarks that when native Australians mingle with foreigners as servants or employés, and adopt their diet and customs, cancer occurs more frequently in them. Much the same has been reported in regard to other peoples and nationalities, and later we will consider the influences of urban life on the production of cancer.

In New Zealand, according to Hislop and Fenwick, where the general death rate is the lowest in the world, cancer is on the increase, as civilization advances. In the great majority of cases the alimentary canal is the seat of invasion, even in women: all the patients studied were hearty eaters, taking also very much strong tea many times daily.

The Polynesians and Melanesians seem to be peculiarly exempt from cancer. Sir William McGregor, although he had operated several times on whites in the Fiji Islands, never remembers operating on a Polynesian or Melanesian, who are practically vegetarians. He never saw a case in British Guinea in 9½ years, and then saw an encephaloid cancer of the tibia in a Papuan, who for 7 or 8 years had lived practically a European life, eating canned Australian meat daily.

In regard to Africa, Williams quotes Dr. Madden of Cairo, who says, “The consensus of opinion among medical men in Egypt is, that cancer is never found, either in male or female, among the black races of that country. These include the Berberines and the Sudanese, who are all Mussulmans, and live almost entirely upon vegetable diet.” Of 19,529 deaths among natives of Cairo during 1891, only 19 were due to cancer (females 10, males 9) or 1 in 1028. In England during the same year the proportion of cancer deaths to total deaths was 1 in 29. In the Islands of Lagos, on the West Coast of Africa, Dr. Johnson, in 14 years’ practice there saw 5 cases of cancer in natives all of whom lived as Europeans. In southern Africa, “among the Boers and Europeans, who are large flesh eaters, malignant tumors are common: but among the natives, who are mainly vegetarians, these tumors are so rare as to be almost unknown.”

Renner reports interestingly in regard to cancer among the descendants of liberated Africans or Creoles, in Sierra Leone, Africa. During 30 years, from 1870 to 1900, there were but 20 cases recorded as malignant disease among 22,453 admitted to the Colonial Hospital: in the next ten years there were 26 among a total of 10,163, a slow but steady gain in cancer incidence, with the advancing influence of the white man. He says that while the aborigines eat no meat, the “Creoles” eat much meat; the teeth of the latter are beginning to decay, like those of the whites, which is attributed to the sweets introduced by the latter. Every case of cancer recorded has been in a Creole, living like a European, and not a single case among the aborigines.

Much the same freedom from cancer has been noted in regard to negroes when first brought to the United States in slavery, when their food and mode of life was simple: but since emancipation and in proportion as they have mingled with whites and eaten their food, with their own natural tendency to gluttony and laziness, cancer has increased among them, although their death rate from malignant disease is still much less than that of whites.

In India all writers agree that cancer is rare among the inhabitants of warmer country districts, where they live largely on rice or millet, with a little milk and butter, and vegetables: they eat meat rarely, the immense majority of the people live a rural life, depending upon agriculture for their sustenance.

Investigations of late years, however, might seem to indicate that cancer is more prevalent in India than previously supposed, but its incidence still bears no real relation to that in many other countries, and an analysis of some recent reports explains in an interesting and curious manner the reasons for the diversity of opinion as to the actual frequency of the disease.

Thus, Benratt collected a total of 1700 cases only from 5 years’ statistics of 15 Mission Hospitals and 34 Government Hospitals, representing, of course, many million inhabitants, whereas in New York City, according to the weekly Bulletin of the Board of Health, there were 2193 deaths from cancer in the last six months, a striking illustration of the rarity of cancer in India. Moreover of these 1700 cases, over 1200 were about the mouth, a very large share of these arising from the very common habit of chewing betel, which contains also much calcium, which latter is one of the salts incriminated in the causation of cancer. Sandwith attempts to show that cancer is prevalent in India, but refers to only 2000 cases reported in the hospitals there, in three years, also among many millions of people, and he refers likewise to the betel chewing cancer, and the “kangri burn” on the abdomen of men, from the charcoal furnace worn for warmth: these peculiar local disorders vitiate any deductions which could be drawn from such statistics.

In China, according to a recent writer, “cancer is comparatively uncommon in those parts where the bulk of the people live on an almost exclusively vegetarian diet, being too poor to purchase any of the various flesh foods, which are there used for culinary purposes.” But in places where cancer is said to be more prevalent, the reporter adds, “All Chinamen there eat fish and pork at morning and evening meals: fowls and ducks are always on the table of all but the most humble of the coolie class.”

In regard to the occurrence of cancer in the Far East, however, some of the modern investigators, such as Bashford, have endeavored to overturn the generally accepted view as to its infrequency, but I do not feel that the evidence presented can at all weigh against the unprejudiced opinion of most capable medical men who have long lived and practiced in those regions, some of whom as medical missionaries have had most intimate contact and acquaintance with the natives. Only very recently a medical missionary, who has long been connected with the medical college and hospital in Beirut, Syria, told me that cancer was practically unknown among the thousands of patients who flock there from all over the Near East, he adding that they were all largely vegetarians.

During a rather extensive trip through the Far East I was unable to see or even hear of any cancer, although I met a large number of medical men, and made diligent inquiry regarding the same. As I wished to verify my views in regard to the rarity of the occurrence of cancer among those who lived on rice or other vegetarian diet, I visited very many civil, military, and mission hospitals, with a total of many thousands of patients, and ministering to many millions of population; in Japan, Korea, China, the Philippines, India, Siam, and Egypt, I met the same response, that cancer was rarely seen among those vegetarian natives.

Brazil is credited with having the lowest cancer record of any portion of the western hemisphere, especially among the natives in the Equatorial regions, while in the Argentine Republic, where meat is known to be largely consumed, cancer is fairly common. From many parts of the world there come reports of the relative infrequency or even absence of cancer among simple living natives, one writer in regard to the West Indies stating “Even those cases which I have witnessed in this class of people have been among the better orders of them, whose habits of living assimilated to those of Europeans.”

England and Wales present the most satisfactory field for the study of the progress of cancer, as the national vital statistics have been well kept since 1840; even at that time under the able direction of William Farr they had already acquired a well-deserved reputation for reliability, as Williams remarks, from whom I shall freely quote.

In that year, 1840, there died of malignant disease in England and Wales 1 in 5,646 of the total population, 1 in 129 of the total mortality, or 117 per million living. In 1905, the deaths, due to this cause were 1 in 1,131 of the total population, 1 in 17 of the total mortality, or 885 per million living: thus, while the population had only a little more than doubled, the cancer death rate per million living had increased five fold. Dr. Williams answers by figures and tables the several objections which have been raised in regard to the actual increased mortality from cancer, as it has been repeatedly claimed that the increase is only apparent and not real; thus it has been asserted that it is due—1. To mere increase of population: 2. To the average age of the population having advanced: and 3. To improved diagnosis and more careful death certification. Time does not admit a full presentation of his statistical refutation of these claims, to which he devotes some pages very convincingly, but it can be safely accepted that for some as yet unknown reason, cancer has made strides in England which are truly alarming.

Williams has also made some most interesting studies in regard to the increase of cancer in connection with changed conditions of life, and from his analysis of statistics, he very clearly shows that the spread of the disease has closely followed urbanization, and the rapid increase in material prosperity of recent years: in England where 80 per cent. of the population are now town dwellers, this tendency to collect in cities and towns has gone farther than in any other community. He recognizes that any far-reaching, environmental change of some duration is probably potent in disturbing the stability of the constituents of living bodies, and the sudden change from poverty to riches and plenty is conducive to the development of cancer: allusion has already been made to the inverse relation of deaths from cancer and tuberculosis, the latter diminishing with improved material conditions, while the former increases as wealth and indolence increase.

He shows this by statistics from various localities, and by data from towns in different countries he makes it pretty clear that “Cancer mortality is lowest where the conditions of life are hardest, the surroundings the most squalid, the density of population greatest, where the tubercle mortality is highest, the general and infantile mortality greatest, and where sanitation is least perfect—in short, among the poor of the industrial class in our great towns: whereas among the wealthy and well-to-do, where the standard of health is at its best and life is easiest, and where all the conditions of life are just the reverse of the foregoing, there the cancer mortality is highest.”

While this is a pretty strong statement and many exceptions could undoubtedly be found, careful investigation will show it to be true in the main; for it must be remembered that even among the poorer classes gluttony, especially in regard to proteids, is not at all uncommon, and indolence, with impeded metabolism, is not at all unusual. Dr. Latham found that the mortality from cancer in England, from 1881‒1890, was more than twice as great among well-to-do men having no specific occupation, as among occupied males in general, the respective mortality ratios being 96 for the former and only 44 for the latter. Sir William Banks confirms the steady increase in cancer very strongly, which he attributes to richer and more abundant food, of which males eat more than females, and consequently cancer is increasing proportionately more among men, as all statistics show.

Switzerland is reported to have the highest death rate from cancer of any country, it having augmented from 114 per 100,000 living in 1889, to 132 in 1898. There again the cancer mortality varies greatly in the different sections or cantons: thus, in wealthy Lucerne it is 204 per 100,000 living, and only 36 in poverty stricken Valais. In the city of Geneva it is 177 per 100,000 living.

Denmark, next to Switzerland, is reputed to have the highest cancer death rate of any country in Europe, viz.: 130 per 100,000 living in 1900. But here the statistics are only from the towns, which comprise but a quarter of the whole population: the per capita wealth is said to be higher there than any other country in Europe except France.

France shows a high cancer mortality, with a constantly increasing death rate; and, next to England, France is the richest country in Europe, and wealth is much more widely diffused: the French workers own nearly 8 times, per capita, more than those in England. In Paris the cancer death rate has increased as follows, for each 100,000 living, in 1865, 84; in 1870, 91; in 1880, 94; in 1890, 108; in 1900, 120.

Italy, a comparatively poor country, shows a low cancer mortality, but even here it is increasing from 20 per 100,000 living in 1880, to 52 in 1899, and 58 in 1905. The consumption of meat is there the smallest in any European nation, namely 23 pounds per capita in 1895. In the chief towns the rate of death from cancer is high: thus for each 100,000 living, in Florence 137, Ravenna 120, Venice 103, Milan 101, and Rome 77.

Time does not permit a wider survey of the field of distribution of cancer, as presented so remarkably from official statistics by Williams, and Wolff; but in connection with the high percentages of deaths above quoted among the richer classes it may be interesting to mention some of the lowest records. Thus, in the poor country of Kerry, Ireland, it was 27 per 100,000 living, in the province of Dalmaltia 19, in the Shetland Islands 16, in Servia 8 (from 1895 to 1904), and in Ceylon in 1903 the mortality from cancer was about 6 for each 100,000 living.

The United States, unfortunately, has not kept the vital statistics of the country in years past with anything like the fullness and accuracy which has obtained in England, nor even at the present time is it possible to learn definitely the frequency and increase of cancer in every locality. But all the statistics which have been gathered show unequivocally that the disease has steadily increased in a manner which is alarming. Analyzing the recorded deaths from cancer in thirty-one cities, and the percentage of increase in four years, one writer estimates that, if the same increase is continued, by the end of the century there will be a death rate, approximately, of 1000 in every 100,000 inhabitants, or one in every hundred.

In a recent Bulletin of the Board of Health of New York City the following statements are made in regard to the mortality from cancer in 1913: “The statistics of our seven largest cities recently tabulated, show that the cancer death rate was the highest on record. For New York City the rate was 82 per 100,000 of the population, against an average of 79, for the last five years: for Boston 118 against an average of 110: for Pittsburgh 79, against an average of 70: for Baltimore 105, against an average of 94: for Chicago 86, against an average of 81: for Philadelphia 95, against an average of 88: for St. Louis 95, against an average of 85.” This average increase of almost 8 per cent. of deaths from cancer in the combined population of these seven cities, during the last five years is certainly an alarming fact, and cannot be explained on the ground of greater accuracy of diagnosis: for it is not to be presumed that there has been such great improvement along diagnostic lines during the single year 1913.

It is difficult to state the exact prevalence of cancer in the entire United States, as the “registration areas” include only about two-thirds of the total population: much can be learned, however, from the annual volumes published since 1900. According to these Mortality Statistics of the United States, the deaths from cancer and other malignant tumors per 100,000 population were as follows: in 1900, 63, in 1904, 70.2, in 1909, 73.8; and in 1912 there were 46,531 deaths from cancer, or 77 per 100,000 population, an increase in the death rate from this disease of almost 25 per cent. since 1900; while, as before stated the tuberculosis mortality had fallen a little over 25 per cent. in the same period.