Chapter II: Part 2

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:

San Francisco 102.5
Boston 99.4
Providence 96.9
Los Angeles 94.9
Cincinnati 93
Hartford 91.9
New Haven 89.8
Dayton 88.5
Rochester 88.2
Springfield 86.9
District of Columbia 86
Baltimore 85.8
Omaha 85.7
Buffalo 84
New Orleans 82.2
Philadelphia 81.9
Hoboken 80.7
Columbus 79.5
Manhattan and Bronx 78.4
St. Louis 78.4
Denver 77.9
Newark 76.9
Chicago 76.5
Greater New York 74.1
Richmond 73.9
Kansas City, Mo 71.1
St. Paul 71.1
Indianapolis 70.4
Borough of Brooklyn 68.9
Milwaukee 68.4
Nashville 68
Pittsburgh 66.4
Minneapolis 65.3
Detroit 64.5
Cleveland 62.9
Louisville 61.1
Jersey City 60.5
Charleston 53.6
Seattle 50.2
Augusta (Ga.) 49.1
Memphis 48.7
Savannah 47.1

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.”

Death Rate per 100000 Population
From United States Mortality Statistics 1915
]

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.