OfortteU Imoeraita ffiibratg atliata. New ^nrk BOUGHT WITH THE INCOME OF THE SAGE ENDOWMENT FUND THE GIFT OF HENRY W. SAGE 1891 Cornell University Library arV19387 The medical treatment of cancer 3 1924 031 268 901 olin.anx Cornell University Library The original of tliis bool< is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031268901 THE MEDICAL TREATMENT OF CANCER BY THE SAME AUTHOR CANCER, ITS CAUSE AND TREATMENT. Vol. I. $1.50 net. CANCER, ITS CAUSE AND TREATMENT. Vol. II. $1.60 net. DIET AND HYGIENE IN DISEASES OF THE SKIN. $2.00 net. COMPENDIUM OF DISEASES OF THE SKIN, based on an analysis of thirty thousand consecutive cases, with a Therapeutic Formulary. $2.00. THE RELATIONS OF DISEASES OF THE SKIN TO INTERNAL DISORDERS. $1.50. PRINCIPLES AND APPLICATION OF LOCAL TREATMENT IN DISEASES OF THE SKIN. $1.00. THE INFLUENCE OF THE MENSTRUAL FUNC- TION ON CERTAIN DISEASES OF THE SKIN. $1.00. ECZEMA, with an analysis of eight thousand cases of the disease. $1.25. ACNE, ITS ETIOLOGY, PATHOLOGY, AND TREAT- MENT. $2.00. SYPHILIS IN THE INNOCENT (Syphilis insontium), clinically and historically considered, with a plan for the legal control of the disease. $3.00. ACNE AND ALOPECIA. The Physician's leisure U- brary. Fifty cents. THE SKIN IN HEALTH AND DISEASE. Fifty • cents. THE USE AND ABUSE OF ARSENIC IN THE TREATMENT OF DISEASES OF THE SKIN. Fifty cents. ARCHIVES OF DERMATOLOGY, A quarterly Jour- nal of Skin and Venereal Diseases. Vols. I-VIII. $3.00 each. THE MEDICAL TREATMENT OF CANCER BY L. DUNCAN BULKLEY, A.M., M.D. Senior Physician to the New York Skin and Cancer Hospital, etc. PHILADELPHIA F. A. DAVIS COMPANY, Publishers ENGLISH DEfOT Stak-ley Phillips, LoiTDOif 1919 Copyright, 1919 F. A. DAVIS COMPANY Copyright Great Britain All rights reserved To THE GOVERNORS of the SEW TOEK SKIN AND CAKCEB HOBPITAI 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 pro- fession in the branches of DEEMATOLOOT and CAXCEB this volume is inscribed "MEDICINE TO SUPPLANT KNIFE." New York Sun, November 17, 1913. Db. J. B. MuEPHT, OF Chicago, Sayb 26 Yeab3 Will Find DntroB in Lead. Chicago, Nov. 16. — Internal medicine will take pre- cedence over surgery for the next twenty-five years, is the belief of Dr. John B. Murphy, one of the foremost surgeons of America. He expressed this view before the Congress of Clinical Surgeons, following his election as President of the organization. "It is internal medicine," he said, "that goes into the details, and the advance in it in the next quarter cen- tury will be greater than the advance in surgery. If I were to start over again I would start in internal medi- cine, because its possibilities are unlimited." Seeing the above in the morning paper, I sent it to Dr. Murphy and asked him if it was true, remarking that if it was so I wanted to congratulate him and humanity. His reply follows: November 26, 1918. Dr. L. Duncan Bulkley, 631 Madison Avenue, New York City. Dear Doctor: In reply to your letter of the 17th, I would say that the press report was correct as to the essential details. Internal medicine offers unquestionably greater opportu- nities to-day than does surgery, and if the same amount of labor, energy and skiU were exercised in the inter- nal medicine line as is exercised in surgery, I feel that greater results could be accomplished. I feel that inter- nal medicine is a field for wholesale achievements, while surgery will of necessity always be retail work. Further- more, a survey of the possibilities of the future in the way of diagnosis, early recognition and treatment should offer enormously more in the way of rewards to the peo- ple and the profession than the surgery of the next two decades, as far as we are able to judge from present viewpoints. I wish to thank you for your letter and to say that it has been the work of many of your class that has stimu- lated me to greater endeavors and aided me in my work. With expression of esteem and highest regard, I am" dear doctor, Sincerely yours, (Signed) J. B. Mukpht. PEEFACE ♦ Cancer is still a pressing problem. Ac- cording to the latest report of the Mortal- ity Tables of the United States the death rate has continued to rise steadily and la- mentably, in spite of assiduous and faith- ful work in the laboratories, and arduous and intelligent efforts of skilled surgeons, who have also made a strenuous propa- gandism in regard to the necessity of early and complete extirpation. In my former volumes I have endeav- ored to present the reason why with this method of simply removing the products of the disease, the offending tmnors, with the knife, we cannot expect to eradicate cancer which, as we know, affects the whole system, and in the end causes the death of ninety per cent, of those once at- tacked. It is understood that this does 7 ' 8 PREFACE not refer to epithelioma of the cutaneous surface, but to true cancer, affecting inter- nal organs. In former volumes I have also endeav- ored, as far as possible, to present the, medical aspects of cancer, the systemic conditions which are at fault, and the measures, dietary and other, whereby they can be corrected and the disease con- trolled, giving illustrative cases, out of many others, in which this has been fol- lowed by the disappearance of the oflfend- ing tumor. It is very satisfactory that the audi- ences of physicians whom I have ad- dressed, and the medical journals, have received the new doctrine so favorably, and rarely have there been any adverse criticisms. Many letters have also come from physicians in this country and else- where, sustaining my claims and mention- ing cases verifying the same. But the sur- geons seem still to hold to their precon- ceived ideas. When the first volume ap- PREFACE 9 peared a surgeon remarked that so small a volume could not effect anything in changing the universal opinion in regard to cancer. I asked him if he had ever seen an acorn, and, remarked that if I planted an acorn, and left it unprotected in an open field where there were some bulls I might not expect to grow an oak, but by hedging it around until the oak was fully grown, I should then expect the tree to take care of itself and be a blessing. It is gratifying to observe that this has in a measure happened, and that there is a widespread interest in the subject which has been so often presented, and a grad- ual acceptance, by many, of the principles involved. It takes time for all new ideas to be adopted, whether in medicine, sci- ence, mechanics, arts, or politics. A lead- ing medical editor to whom I offered a rather radical article on cancer accepted it at once, adding in his letter, "It is hard to overthrow entrenched error with gentle words." 10 PREFACE As the journalistic reviews of my sec- ond little book have been so encouraging I venture to put forth another, a third acorn, in the hopes that it may excite further interest in this most important subject, and lead others to investigate the matter and to report their experience and cases along the lines indicated. I should also be glad of just criticisms on a sci- entific basis. It is not a little remarkable that during the past year or so there has been such a singular dearth of surgical articles on cancer, as a careful search of literature shows, and so many journal articles, editorial and other, looking toward the thoughts on cancer which I have endeavored to present. It is sin- cerely to be hoped that this ratio will in- crease more and more, and we shall soon see a radical diminution in the death rate of cancer, which is so longed for by all. There are encouraging signs of this al- ready, in the remarkable diminution of deaths from cancer in New York City, as PEEFACE 11 shown in Chapter IV, on the cancer death rate there during 1918; there has also been a slight decline of the same through- out the United States in 1917. Most of the material in this third vol- ume on "The Medical Treatment of Cancer" has been delivered before differ- ent medical societies, in a number of the States in the Union, and much of it has already appeared in various medical jour- nals. It has been thought best to collect it in one volume for reference, inasmuch as some subjects are considered which were not included in the former volumes, and certain subjects are developed more fully than was possible in the lectures composing the former volumes. These latter are necessary to a complete under- standing of the facts concerning the metab- olism and systemic changes in cancer, upon which the whole thesis is based. The bibliographical references to the names here mentioned appear at the end of the first volume. 12 PREFACE There will consequently be found in this volume considerable repetition of facts and figures previously given, which, however, may suffice to more fully impress those here and previously presented, and to lead to further thought and study of the important questions involved, as to "The real cancer problem" and the most satisfactory treatment of the disease, and its prevention. Some one has said that it was necessary to repeat a new idea five times. First, because one does not hear; second, because he gives no attention; third, because he does not understand; fourth, because he does not believe: So the fifth repetition is necessary in order to make a real and effectual impression. L. Duncan Bulkley. Januaby 1, 1919. 531 Macllson Ave. CONTENTS PAGE Pbeface 7 CHAPTER I A Plea fob the Rationai, Xbbatment of Ganceb 15 CHAPTER II Canceb as a Non-Suboicai. Disease 25 CHAPTER III Canceb Death Rate in New Yobk Cut Dttbing 1917 41 CHAPTER IV Cahceb Death Rate in Xew Xobk Cut Dubins 1818 49 CHAPTER V Canceb fbom a Medical Standpoint . 53 CHAPTER VI Medical Aspects of Canceb .... 71 CHAPTER VII The Relation of Diet to Canceb . 121 CHAPTER VIII Dietetic and Medical Tbeatment op Canceb 144 CHAPTER IX NON-SUBQICAL Tbeatment OF Caitceb . . . 169 CHAPTER X Pathology of Cancee 181 CHAPTER XI Medical Tdeatmei^t of Caxcbb .... 211 CHAPTER XII Precancebous Conditions .... 248 CHAPTER XIII BoDT Elimination iir Cancer .... 262 CHAPTER XIV Canceb and Civilization .... 278 CHAPTER XV Cabcinoma of the Buooal Cavitt . . . 289 CHAPTER XVI What Should the Genebal Pbactitioneb Do About Canceb? ..... 307 CHAPTER XVII Conclusions and Results .... 821 THE MEDICALTREATMENT OF CANCER CHAPTER I A PLEA FOB THE BATIONAL TBEATMBNT OF CANCEE Many cases of undoubted cancer, both primary and recurrent after operation, are on record whicli have disappeared entirely and remained absent under a complete change of diet and mode of life, with more or less of proper medical treatment. Mul- titudes of cases are known everywhere in whom the disease has recurred, with ter- rible severity and death, even after the most complete removal, by the most com- petent surgeons, of very early lesions di- agnosed as cancer, some of which proved to be only adenoma, microscopically. 15 16 MEDICAL ASPECTS OF CANCER The enormous mass of laboratory stud- ies which have been recorded has added thus far very little to our knowledge of the real nature and cause of cancer, and really nothing to treatment, except to ad- vocate the surgeon's claim of the right to remove instantly everything suspected to be cancer or "precancerous"! Surgery has striven, more and more actively of late years, to stem the rising tide of mortality from cancer, but, alas ! the Mor- tality Tables of the United States show the futility of this means, for the death rate from this disease has risen almost 30 per cent, from 1900 to 1917. Laboratory researches have rendered, however, a valuable service in connection with cancer, by the negative results ob- tained, so that the ground is pretty well cleared for a proper understanding of the real nature and cause of the disease. Thus, all are pretty well agreed that can- cer is not due to a parasite, nor conta- gious, that it is not strongly hereditary, EATIONAL TREATMENT 17 nor due wholly to local irritant action, that it is not altogether a disease of old age, nor belonging to any particular occu- pation, and that it does not affect any special sex, race, or class of persons : can- cer exists all over the earth, but with strik- ing differences in frequency, according to certain peculiarities in diet and mode of living, associated with advancing civiliza- tion. The exclusion of the various suspected causes of cancer by the prolonged study of many trained laboratory and other workers along the lines mentioned leads the thoughtful person to inquire if there is not still some line of possible etiology which has not yet been fully explored ; for assuredly there is some actual, physical cause for the aberrant action of originally nonnal tissue cells, which we call cancer. There is nothing mysterious about the dis- ease, except that thus far its real cause has eluded laboratory workers; but many clinical workers have long suspected and 18 MEDICAL ASPECTS OF CANCEE suggested one without much, if any, effect on the profession, so enamored has it be- come of surgery, and so insistent and loud have been the claims for a wholly local origin and nature of the disease. But the failure of surgery to make any appreciable beneficial impression on the morbidity and mortality of cancer, as al- ready mentioned, and the exclusion of all other possible causes, naturally leads us to look to a faulty metabolism, which has to do with such a multitude of other human ailments ; and the deeper we search the laboratory and other studies which have been made regarding this, the more clear does it appear that it is along these lines we shall find the true means for the prevention and cure of cancer. It is impossible in a brief article to pre- sent the evidence in which this statement is founded, which has been developed pretty fxdly elsewhere,* and it must suf&ce * Bulklev — Cancer: Its Cause and Treatment, Voli. I and II Hoeber, New York, 1015, 1B17. EATIONAL TREATMENT 19 to concisely state the principal points. Cancer has been found definitely to in- crease with the spread of modem so- called civilization along the lines of lux- ury and attending indolence. This has been observed especially in the over-con- sumption of meat, coffee, and alcohol, as proven by statistics. Many have recorded changes in the urine which indicate imperfect metabolism, especially of nitrogenous matter. Careful daily studies of the urine, both in the very earliest stages of cancer and late in the disease, show a very marked failure of elimination by this excretion, the solids being often not one-half of that called for by the body weight of the individual. Careful observation will also detect a great failure in intestinal elimination, in both the very early stages of the disease and all through its course. So true is this that Sir Arbuthnot Lane has declared that cancer may be one of the late results of intestinal stasis. This probably oper- 20 MEDICAL ASPECTS OF CANCER ates through the poisonous action devel- oped by the millions of micro-organisms formed in the large intestine, indican being not an infrequent urinary exhibit. It has been shown that cholesterin is also an important element in connection with the genesis of cancer, and there is strong evidence that derangement of the endocrin- ous glands is associated with the produc- tion of this disease. It is quite true that the exact metaboUe disturbances, or the actual blood state, inducing and perpetuating cancer, have not as yet been demonstrated, and perhaps they never will be. But it has also never been shown exactly how cancer begins, or when a benign tissue becomes malignant, as Eibert has said, "no one has ever seen the beginnings of mammary cancer" : both aspects of the question, the constitutional and the local, rest on clinical grounds, and not a shadow of proof has ever been pre- sented that the lump which we call cancer is purely local in character. RATIONAL TREATMENT 21 On the other hand, the constant ten- dency to a recurrence of the disease in the same or other locations, even after the most complete removal of the local lesion and surroundings, and the continued de- pression of vitality and degeneration of the blood, all point to something more than a local disease; they all show a con- stitutional cause which induced the orig- inal stasis and degenerative action of tis- sue in some particular locality which was unduly irritated, probably the site of an "embryonic rest," that is, a heterologous tissue ready to revert to reproductive life. This latter would seem to be the starting point, inasmuch as the tissues in general of cancerous subjects heal kindly, and, after injury on various portions of the body, there is little or no tendency to tumor formation. Even the occurrence of metastases ac- cords also with the view of a constitu- tional disorder. For after surgical oper- ation the patient is invariably left uncared 22 MEDICAL ASPECTS OF CANCER for, as far as any attempt to alter the dyscrasic condition which engendered the disease, and very naturally the transfer- ence of cancerous elements by the blood or lymph stream produces a local condi- tion which the vitiated blood current de- velops into a fresh local lesion. The apathy of surgeons to medical sug- gestions of their own distinguished mem- bers, past and present, is very surprising, but not less so than the practical disre- gard of cancer by physicians. One finds the strongest expressions in regard to the constitutional relations of cancer by Lambe, Abernethy, WiUard Parker, Sir Astley Cooper, Sir James Paget, Esmarck, Sir Arbuthnot Lane, and others ; and finally Dr. William J. Mayo, in his recent presi- dent's address before the American Surgi- cal Association, asks, "Is it not possible, therefore, that there is something in the habits of civilized man, in the cooking or other preparation of his food, which acts to produce the precancerous condition!" EATIONAL TEEATMENT 23 And yet there has been relatively little serious attempt to investigate this line of thought or to test the principles underly- ing the metabolic theory of cancer, in its relation to diet and mode of life, as in- fluenced by so-called civilization. While the microscope and laboratory work on animals have undoubtedly advanced the science of medicine prodigiously, they seem to have reached their limit in regard to cancer. Their negative conclusions, however, have paved the way for the med- ical man, through clinical study and physi- ological chemistry, to reach the real basic cause of the disease in the activities of the system as a whole, as influenced by diet and mode of life. This plea is made, therefore, with the hope that the matter may be thoroughly investigated and tested, and that it may result in a more rational treatment than the present one of attempting only to re- move the proditct of the disease, the local tumor, while the cause of the formation 24 MEDICAL ASPECTS OF CANCER of the malgrowth remains still active. Only by a rational treatment of the cause can we hope to restrain the steady in- crease of cancer, and to reduce its fright- ful mortality of 90 per cent, of those whom it has once attacked. CHAPTER II CANCEK AS A NON-STJBGICAL DISEASE* Cancer is not a surgical disease, al- though of late years cases of this nature have been almost always relegated to the surgeon. It is true that the local results of the cancerous process can be removed by surgical measures, and that the wound may heal primarily and that in some pro- portion of instances the tissues may re- main sound. But the experience of all has shown that the mere removal of the cancerous tumor and adjoining tissues sur- gically does not insure that the disease 1 will not return in or near the scar, or j elsewhere. It is now recognized and ac- knowledged that somewhere about 90 per cent, of those once affected with cancer • Read at the Annual Meeting of the Medical Soci- ety of the State of New York, at Saratoga Springs, May 17, 1916. 25 26 MEDICAL ASPECTS OF CANCEE die from that malady. Surgery as a cure for cancer has been tried in the balance and found wanting, since under its super- vision and treatment the death rate has increased to a lamentable degree of late years. According to the United States Mor- tality Reports, the deaths from cancer under surgical control, have increased steadily and alarmingly since 1900, when they were 63 per 100,000 of the popula- tion, to 79.4 per 100,000 in 1914, or over 25 per cent. During the same period the mortality from tuberculosis, under intelli- gent medical supervision, has diminished from 201.9 to 146.8 per 100,000, or over 27 per cent., making an actual difference of over 50 per cent, in their relative mor- tality since 1900. At this rate the deaths from cancer will outstrip those of tu- berculosis in fourteen years more. Is it not time for us to seriously consider whether the present attitude toward can- cer is correct or not? A NON-SURGICAL DISEASE 27 It is understood that the present in- quiry relates to cancer as a disease affect- ing many different organs ; epithelioma of the skin is left practically out of consid- eration, as it is a relatively mild affair, when properly treated; it caused a com- paratively insignificant proportion of the deaths from cancer, 2.7 per 100,000 pop- ulation, which rate has increased only in a trifling degree since 1900. And yet many of the arguments presented in the recent surgical propaganda as to the con- trol of cancer relate to the early surgical treatment of this epithelial disease of the skin! No one has ever seen absolutely the first beginning of an internal cancer, and we have no knowledge as to exactly how the process starts; although microscopic re- search on cutaneous cancer has revealed much concerning the early changes occur- ring in tissue cells in this disease. But the laboratory has not told us wherein lies the malignity of the true dis- 28 MEDICAL ASPECTS OF CANCER ease which ultimately destroys so many lives, why cells which were once normal take such a morbid, uncontrollable and even rampant action that they can invade and destroy adjoining and distant tissues. We shall see later that the hypothesis of a purely local origin and nature of cancer is quite untenable in the light of modem investigation and thought. The laboratory, however, both in a neg- ative and positive maimer, has done much to clear up our field of vision, and to open the way for a correct understanding of the cancerous process. Time does not admit of even a brief survey of the enor- mous work which has been done on can- cer by thousands of earnest and honest workers in laboratories, at a vast expen- diture of time, money, and animal lives; but a concise statement of the status of certain questions regarding the etiology of. the disease will assist us in properly ap- preciating the medical aspects of the sub- ject. As just suggested, the points thus A NON-SUBGICAL DISEASE 29 far acknowledged by those who have most deeply studied cancer are both negative and positive, and may be mentioned under these heads: 1. Clinically and experimentally cancer is shown to be not contagious or infec- tious; although imder just the right con- ditions certain malignant new growths can be inoculated in some animals, but hu- man cancer cannot be transplanted, 2. Although micro-organisms of many kinds have often been found and claimed as the cause of cancer, there has been no concurrence of opinion in regard to them, and it is now pretty conclusively agreed that cancer is not caused by a micro-or- ganism or parasite, 3. Cancer is not wholly a result of trau- matism, although local injury may have much to do with its development in some particular locality, even as in connection with late lesions of syphilis. 4. Cancer is not hereditary in any ap- preciable degree; although some tendency 30 MEDICAL ASPECTS OF CANCER in that direction has been demonstrated in certain strains of mice. 5. Occupation has not any very great influence on the occurrence of cancer; al- though it is more frequent in some pur- suits than in others. 6. Cancer is not altogether a disease of older years ; although its occurrence is de- cidedly influenced by advanciug age. 7. It does not especially belong to or affect any particular sex, race, or class of persons. 8. Cancer is not confined to any location or section of the earth, but has been ob- served Lq all countries and climates. But while laboratory and other investi- gations have not demonstrated any sin- gle cause of cancer and have yielded only negative results, they have, by elimina- tion, cleared the way for a study of its cause along other lines, which are bright with promise. They have also established certain facts which confirm the views which from time to time have been briefly A NON-SURGICAL DISEASE 31 expressed by many who were best ac- quainted with, cancer; namely, that, be- cause of its constant recurrence, and from the failure of surgery to check its rising mortality, it must be of a constitutional nature, intimately associated with dietary or nutritional elements, as I have else- where shown. The positive results of laboratory inves- tigation are more encouraging: 1. We know now that the local mass, which we call cancer, represents but a de- viation from the normal life and action of the ordinary cells of the body. These once normal cells for some as yet unexplained reason, take on an abnormal or morbid action, with a continued tendency to ma- lignancy, which invades and destroys con- tiguous tissue, and is associated with a progressive anemia which destroys life. 2. Microscopic study has shown that there is a certain change in the polarity of cells about to be cancer-genetic, with an altered relation of the centrosome to 32 MEDICAL ASPECTS OF CANCER the nucleus. These changes are again at- tributed to an alteration in the enzjrme contained in the cell, which further de- pends on the nutrition of the cell as in- fluenced by a faulty metabolism of food elements. 3. The exclusion of all other possible causes leads us naturally to look to a disordered metabolism as a cause of the disturbed action of the hitherto normal cells; and we find much to confirm this view both in laboratory studies on the bio- chemistry of cancer, and also in clinical and statistical observations. 4. The blood in advancing cancer has repeatedly been shown to exhibit many manifest changes, which indicate vital al- teration in the action of the organs which fonm blood and so control the nutrition of the body and its cells. 5. Laboratory and clinical evidence dem- onstrate that the secretions and excretions of the body, both in early and late stages of cancer, exhibit departures from normal A NON-SUEGICAL DISEASE 33 which deserve consideration. Although none of these have as yet been established as pathognomonic of cancer, they indicate metabolic disturbances which influence the nutrition of the cellular elements, and so these secretory and excretory disturbances are of importance in connection with its causation. 6. As all healthy cells of the body, by their catabolism and anabolism contribute a hormone or something to the general circulation, so experimental evidenced shows that the cells of a cancer mass it- self, when fully developed, secrete a hor- mone or something which is poisonous to animals, and which probably hastens the lethal progress of the disease. 7. Eepeated laboratory experiences have demonstrated, in a most remarkable man- ner, the absolute controlling effect of diet on the development of inoculated cancer in mice and rats, so that the process was inhibited almost entirely with certain veg- etable feedings. 34 MEDICAL ASPECTS OF CANCER 8. We thus see that as the laboratory has eliminated the local nature of cancer, it has also, in a measure, established the fact that there are medical aspects of the disease which further studies will show to be of the utmost importance. These all tend to demonstrate its constitutional ori- gin, that is, its relation to deranged met- abolism, which is now recognized as the basis of so many diseases. But clinical and statistical studies come in with overwhelming force to confirm the correctness of this position. 1. We have already seen that with utter medical neglect cancer mortality has stead- ily and greatly increased in the United States, of late years, in spite of the pro- digious advances in surgery during the same time. We have seen also that tu- berculosis, as a result of careful medical attention, has decreased in mortality, by an even greater percentage. The same is reported by reliable observers all over the civilized world. A NON-SURGICAL DISEASE 35 2. Any number of observers, in many lands, have recorded the almost entire ab- sence of cancer among aborigines, living simple lives, largely vegetarian; they have also shown the definite increase in the dis- ease, and in its mortality, in proportion to their adoption of the customs and diet of so-called modem civilization. 3. This increase of cancer seems to de- pend largely upon the altered conditions of life, particularly along the lines of self- indulgence in eating and drinking, and in indolence. 4. Statistics from many countries show that increase in the consumption of meat, coffee, and alcoholic beverages, appears to be co-incident with a very great and pro- portionately greater augmentation of the mortality from cancer. 5. Clinical observation has time and again shown the effect of specific nerve strain and shock in the development of cancer; and there seems to be little ques- tion but that the enormous nerve strain 36 MEDICAL ASPECTS OF CANCER of modem life is an element of impor- tance in this direction, both through met- abolic disturbance, and by direct action on living cells. 6. At present no clear demonstration is possible of the direct method by whieh errors of metabolism effect the changes in cells to -Hrhich we give the name malignant, ' any more than we know how other alter- ations in the body are produced, such as arterial degeneration, bone changes, obes- ity, etc., which are recognized as due to metabolic derangement. 7. The results which have been observed in connection with the starvation of can- cer, by ligature of vessels, illustrate the relation of the blood supply to growing cancer. 8. Finally, the repeated observation and report of the spontaneous disappearance of cancer, by careful and competent med- ical men, shows that conditions of the sys- tem may arise which are antagonistic to malignant growth, even when it has begun A NON-SUEGICAL DISEASE 37 to take place ; just as there are other con- ditions of the system which favor aber. rant action of previously normal cells, resulting in cancer. The medical aspects of cancer thus ap- pear ia quite a different light from that in which they have been commonly viewed. We now begin to see some of the reasons why cancer is not primarily a surgical disease, and some of the lines along which observation and investigation should pro- ceed, namely, biochemistry, secretory and excretory derangements, metabolic distur- bances, diet, etc., etc. The subject is too new a one to afford a great amount of corroborative proof at present, other than the long personal experience of the writer and others, who have seen tumors disap- pear under means other than surgical, ex- cluding also fl^ray and radiimi. More clinical and laboratory studies of human beings are needed, and not only studies and experiments on animals, valuable as these have been in the advancement of 38 MEDICAL ASPECTS OF CANCER medical science in connection with other diseases. Time does not here permit of develop- ing the lines of thought and practice along the dietary and medical treatment of cancer which can be successfully car- ried out in early cases, and which are of value in later stages, which have been pre- sented elsewhere. The purpose of the present paper is to direct attention to the hitherto neglected medical aspects of can- cer, and to present the evidences of the cor- rectness of the thesis presented. It is fully recognized that the almost uni- versal opinion of the profession and the public favors only a surgical aspect and treatment of cancer, and it is difficult to make headway against such odds. It is also fully recognized that there is a certain danger in advocating a dietary and medi- cal control of cancer, lest, if this is not properly and efficiently understood and carried out, failure to control the disease may result and thereby time may be lost A NON-SURGICAL DISEASE 39 in which a surgical operation might pos- sibly be of some service. But after many years of observation and practice along these lines, together with much study in later years, I feel constrained to urge up- on the profession views which are contrary to those which are accepted by so many, who perhaps have never had their atten- tion seriously turned in this direction be- fore. There is not time to enter into details concerning the dietary and medical treat- ment of cancer, which have been presented elsewhere. I must only remind you that to carry out this line of treatment success- fully requires infinite patience and the ap- plication of the greatest diligence in study- ing and understanding the exact condition of the patient, and meeting every possible departure from health, and rectifying every derangement of metabolism. I caimot do better in closing than to re- mind you that the medical aspect of can- cer is not an absolutely new proposition, 40 MEDICAL ASPECTS OF CANCER although it has never before been pre- sented in a definite and concrete manner. Literature is full of allusions to the sub- ject, without any attempt to fully discuss it, and many of the strongest surgeons have expressed themselves convinced of the constitutional, and largely dietary, origin of the local lesion which we call cancer. This view finds abundant support in the writings of Lambe, Abemethy, Willard Parker, Sir Astley Cooper, Sir James Paget, Sir Arbuthnot Lane, and quite re- cently has been advanced by Dr. William J. Mayo and many others. Is it not, there- fore, high time that serious attention be di- rected away from the purely surgical treat- ment of a symptom or result of a great disease, and that careful inquiry should be made into the underljniig causes which ul- timately result in such a great relative mortality, approaching 90 per cent, of all those affected, exceeding that of any other one disease? CHAPTER III CANCER DEATH BATE IN NEW YORK CITY DURING 1917 In 1914 the New York Board of Hesalth in its Monthly Bulletin for April presented a long article from the American Society for the Control of Cancer on "Cancer as a Public Health Problem." From this some data may be quoted. Based on the statistics from the United States Registration area up to 1912, it showed very clearly and indisputably the steady and great increase in the mortality from cancer from the year 1900, when it was 63 per 100,000 to 77 per 100,000 in 1912, or 22.22 per cent. In New York State the increase had been from 66 in 1900 to 86.5 per 100,000 in 1913, or over 30 per cent. In New York City it had risen from 41 42 MEDICAL ASPECTS OF CANCER 63.3 in 1898 to 81.7 per 100,000 in 1913, or over 29 per cent. Throughout the world the cancer death rate from 1900 to 1909 had advanced, on an average of all coun- tries reporting, 23.3 per cent. Cancer was rightly spoken of as "a menace to so- ciety." The question of the apparent or real in- crease in mortality was discussed, and it was remarked that "it seems unlikely that accuracy of diagnosis has advanced at such an even rate as to result in almost exactly the same addition to the recorded cancer death rate each year. ' ' Since 1914, when there was started the active propaganda for the more radical surgical treatment of cancer, the increase in the death rate has been much greater than before that time. Thus in the United States the mortality figure has steadily risen, so that in 1915 it was 81.1 per 100,- 000, or a total rise of 28.7 per cent., since 1900, In 1916 it was 81.8 per 100,000, or 29.84 per cent, increase since 1900. 1917 MOETALITY IN NEW YORK 43 It is a little interesting to note that dur- ing the five years immediately preceding 1915, at which date snrgery became more active, the mortality rose only from 76.2 to 79.4, a total of 3.2 deaths per 100,000 popu- lation, or much less than one per year; while in 1915, after the vigorous educa- tional and surgical propaganda, the death rate rose from 79.4 in 1914 to 81.1 per 100,000, or 1.7 more deaths per 100,000 population in a single year; this is an in- crease of 2.13 per cent., more than double that in the preceding years. Could this be ascribed to more accurate diagnosis? A confirmation of the reality of the in- crease in deaths from cancer happens to come in the Bulletin of the North Dakota State Board of Health for October, 1917. In it we find a quarterly mortality sum- mary of all the deaths during July, August and September, 1917, with a column com- paring these with the data of 1916. We find that while the general death rate, partly or wholly due to increase of popu- 44 MEDICAL ASPECTS OF CANCEE lation, had risen 22 per cent., the increase in the cancer death rate had increased 30 per cent. — ^from more accurate diagnosis? Turning now to the mortality from can- cer, in New York City, in 1917, as shown in the Weekly Bulletin of the New York Board of Health, we find that there were 4,859 deaths recorded from cancer, ma- lignant tumor, 2,143 males and 2,716 fe- males. This total number divided by 365 gives 13.33 persons dying daily from this cause. During 1916 there were 4,635 deaths from cancer, or 12.68 persons per day. During 1917 there was a total of 78,467 deaths from all causes in Greater New York against 77,948 in 1916, an increase of 519, or less than one per cent. ; whereas the increase in cancer deaths was 224 or al- most five per cent. Surely such figures, which cannot lie, and which show an in- crease of cancer mortality nearly five times that from general causes, cannot be ex- plained away by greater accuracy of diag- 1917 MOETALITY IN NEW YORK 45 nosis or more perfect recording of death, certificates. In all this study of mortality statistics it is well to remember that these figures do not necessarily represent truly the real increase of cancer as a disease, which is probably even much greater than the fig- ures show. For undoubtedly many cancer patients die of intercurrent diseases, under which the death is recorded, and in many instances the diagnosis of cancer is with- held from the death certificate for per- sonal or family reasons. The alarming increase in the deatb rate from cancer under surgical care may well be compared with the notable and steady decrease in the deaths from tuberculosis under rational and careful medical super- vision and treatment. In 1900 the death rate from tuberculosis, in the United States Registration area, was 201.9 persons in each 100,000 population, and by 1916 it had fallen to 141.6 or a decrease of 60.3 per- sons in 100,000, or almost 30 per cent.; 46 MEDICAL ASPECTS OF CANCER whereas during the same period the death rate of cancer had risen 29.84 per cent. ! In 1900 the two diseases were 138.9 points apart in mortality, and in 1916 only 59.8 apart ; at this rate of increase and decrease cancer will soon claim more victims in each 100,000 population than tuberculosis. In the light of what has preceded is it not possible that there is something wrong in our conception of cancer and its treat- ment, as I have repeatedly endeavored to show? If any other disease presented such a steady and alarming rise in its death rate would we not stop and consider if our treatment were the best possible! If, with the introduction of antitoxin, the mortality from diphtheria had steadily risen until it was 90 per cent, of all cases, which is the acknowledged ultimate death rate of can- cer, would we persist in employing it? And yet the profession and laity go blindly on with the idea that .surgery offers the best and only hope of reaching cancer, by removing a local lesion which is only the 1917 MORTALITY IN NEW YORK 47 'product of a previous constitutional de- parture from health. As well might one excise a syphilitic gumma, or a tubercu- losis lesion, or amputate a gouty toe, with- out other treatment, and hope that there would be no further trouble; for all ex- perience shows that cancer is exceedingly prone to manifest itself anew, either in the same location or elsewhere. It is a curious comment on human cre- dulity that with this steady rise in its mor- tality so many should have accepted the dictum that cancer was only a surgical dis- ease, and reached only by surgical meas- ures, when all along the past one hundred years single voices of surgeons and medi- cal men have now and again spoken so strongly in favor of its constitutional ori- gin, as I have shown in my first volume. The lure of surgery is strong, and sur- geons have "made great claims, while medi- cal men have not yet reported any single specific for the disease, for the single rea- son that no specific will ever be found. 48 MEDICAL ASPECTS OF CANCEE It is not the purpose of the present writ- ing to enter upon the proof of the constitu- tional nature of cancer and its successful treatment by other than surgical measures, which have been abundantly considered in the books referred to. It can, however, be truthfully claimed that under proper and prolonged medical treatment more can be effected than with the knife. Not only is the death rate smaller, but the ultimate suffering is less. Moreover, with the fear of an operation removed, together with the known uncertainty as to the ultimate re- sult, patients would be more inclined to seek aid in the earlier stages of the dis- ease, when the prospects of overcoming it are better. CHAPTER IV CANCER DEATH BATE IN NEW TOBK CITY DXJBING 1918 Mortality statistics are an interesting and instructive study in their relation to therapeusis, as all recognize. For if a new remedy or course of treatment for any disease were introduced and year by year the death rate from that disease was shown to rise, eager search would be made for other remedies or measures to cheek the same. Years ago tuberculosis was called the great white plague, increas- ing in mortality so greatly that fear was excited that it would sweep off nations; but we know now that with well directed medical care its death rate has diminished thirty per cent, since 1900 in the United States. Syphilis, the great black plague, swept through Europe and elsewhere in 49 50 MEDICAL ASPECTS OF CANCER the 16th and 17th centuries, whole towns and communities being infected, often quite innocently, until the proper use of mercury with the recent introduction of Salvarsan has largely rid the world of the fear of this foul disease. Leprosy was once alarming, but under wise manage- ment and the knowledge of its non-con- tagiousness it has lost much of its terrors. Yellow fever and cholera no longer threaten regions where scientific medical activity controls. But our recent experi- ence with poliomyelitis and the Spanish grip show that there is yet much for the medical profession to investigate and con- quer. Cancer, the great red plague, still holds its own as a menace to civilization, for the United States Mortality Tables show that since 1900 its death rate has risen nearly 30 per cent., almost as much as that of tuberculosis has fallen; and it is com- monly asserted that 90 per cent, of those once affected die from the disease, under 1918 MORTALITY IN NEW YORK 51 the prevailing treatment. It is certainly time to consider well what should be done to check this fearful mortality. But the death rate from Cancer in New York City, during the past year 1918, seems to show that wiser counsels are be- ginning to prevail, as appears from the weekly reports of the New York Depart- ment of Health, During 1916, as previously reported, there were 4635 deaths from cancer, malignant tumor (an average of 12.68 per- sons daily) while during 1917 there were 4859 deaths, 2143 males and 2716 females (an average of 13.31 persons daily) an excess of 224, that is almost five per cent, increase: whereas the increase in deaths from all causes was only 519, or less than one per cent. During 1918 there were 4895 deaths from cancer, 2150 males and 2745 females, (an average of 13.39 persons daily), or an increase of only 36 deaths over last year: that is, less than one per cent., as 52 MEDICAL ASPECTS OF CANCER against a five per cent, increase of 224 for last year, 1917, over the preceding year, 1916. If figures teach anything they seem to show that in New York City the profes- sion is beginning to learn that the hereto- fore rash attempt to cure cancer with the knife is giving way to wiser procedures. CHAPTER V OANCEE TEOM A MEDICAL STANDPOINT.* In Ms excellent address Dr. Bloodgood has presented most ably the surgical as- pects of the control of cancer, and I can concur with pleasure in every word he has said. I only regret that time did not al- low him to show all of his pictures, that you might better understand the different phases of cancer, and better appreciate the disease with which we have to deal, which kills 75,000 persons in the United States yearly, with an acknowledged ulti- mate mortality of about 90 per cent, from it, of all who are once attacked. He has warned you of the danger of delay in at- tending to the disease, and urged early • Address before the Medical Society of the State of Nfew York, Eighth District Branch, September 22, 1915. 53 54 MEDICAL ASPECTS OF CANCER and complete surgical removal, which is certainly most wise when such measures are decided on. But, gentlemen, did you notice the figures which Dr. Bloodgood gave in re- gard to the end results of the surgical control of cancer? He stated that one- half, or 50 per cent, of all cases of cancer are inoperable when they are seen by the surgeons! Did you notice that of the other, operable one-half, not over 25 per cent, ultimately recover and remained permanently well, under the best surgery? Adding these figures together we have 87% per cent, of all cases of cancer, in different locations which are not reached by surgery, but which succumb to the dis- ease! Did you notice also that he said that the percentage of cures mentioned related to the "best surgery," from which one must infer that the mass of cases under ordinary surgery would show a still smaller ratio of cures: for relatively few of the 200,000 continually existing MEDICAL CONSIDERATIONS 55 cancer patients can afford to go to such brilliant operators as the Mayos or Dr. Bloodgood. What then of the other 87% per cent, of cases for which surgery offers no hope? Are they to be left to struggle unaided against the dire disease, until relieved by death? I have frequently protested against the course which is usually fol- lowed in regard to cancer, both before and after operation. With a rather extended experience during the last forty years and more, I have rarely if ever found a pa- tient with cancer who has received ade- quate and continuous care before opera- tion, with a view of discovering and recti- fying the cause of the morbid growth. Too often when a cancer is suspected or discovered it is regarded as a foregone conclusion that the malady is hopeless, ex- cept as the results of the disease, that is, the new growth, may be removed by the knife, a;-ray, radium, caustics, etc., only too often to recur. And after a 56 MEDICAL ASPECTS OF CANCEE surgical operation, as far as my observa- tion 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 malig- nant new formation. I would like to ask if any one present has had a different ex- perience, if so to kindly raise the hand. I wait for an answer: but as none comes I take it for granted that you all, as medi- cal men, follow the general custom of turning over all cancer cases to the sur- geon or to the undertaker. And yet, gentlemen, after many years of study, observation, and experience, I believe that the present, common attitude toward cancer, is all wrong, and that while surgery may always have its function to perform, in removing certain obnoxious products of the disease, more or less ef- ficiently, curing some patients and pro- longing the life of others, it can never MEDICAL CONSIDERATIONS 57 hope to lessen greatly the morbidity of cancer. I believe, however, that its mor- bidity and mortality can be materially di- minished if intelligent, serious, and pro- longed attention is given to it from a medical standpoint, along metabolic lines, which line of thought finds abundant sup- port both from laboratory work and from statistical teachings and clinical experi- ence, all along the past years. Time will not allow me to elaborate at all, as I would like to, the proof of my as- sertion, and I do not know how many of you will believe what I say. Dr. Park Lewis yesterday quoted an unknown writer who said that it is necessary to re- peat a proposition five times to have it effective, for the reason that the first time one does not hear, the second he gives no attention, the third he does not under- stand, and the fourth he does not believe, so the fifth repetition is necessary. Un- fortunately I can not repeat everything five times, so please believe at once, for 58 MEDICAL ASPECTS OF CANCER what I am to say is vital and serious to the hosts of cancer sufferers, present or future; and I stake my reputation on the truth of it, which I believe will be widely accepted before long. As a basis for my thesis I beg you to look carefully at the wall chart before you, which is an exact copy of one in the volume of United States Mortality Statistics for 1913.* This represents the recorded deaths, from several diseases, in the registration areas from 1900 to 1913. The upper red line shows that the mortality of all forms of tuberculosis has steadily fallen over 25 per cent, during that period. We fur- ther see that organic heart disease gives a constant rise in death rate, of from 15 to 20 per cent., nephritis nearly 15 per cent., and apoplexy over 10 per cent., while the deaths from cancer have coin- cidently increased from 63 to 78.9 per 100,000, or over 25 per cent. ; in New York City there are twelve deaths from cancer * This chart is now brought np to 1917. From United Stdtes Mortality Sl MEDICAL CONSIDERATIONS 59 every day, according to the statistics of the Board of Health, It is worth while to consider these figures seriously for a moment, and the lessons they teach us. The mortality from tuberculosis has declined over 25 per cent, in these thirteen years ; how has this been accomplished? By the surgeons cut- ting out its lesions'? Not at all, but by a steady, persistent, medical attention to the disease in all its aspects, and by the application of correct principles of liv- ing, largely dietetic; for, when we give the patients fresh air and sunlight we promote a proper metabolism, or nutrition, which enables the system to resist the still pres- ent bacillus of tuberculosis. We have further seen from the chart that organic heart disease, nephritis, and apoplexy present a constantly rising mor- tality, and no one questions that they are due to errors in living, incident to mod- em civilization, especially along the lines of food and drink, with want of proper 60 MEDICAL ASPECTS OF CANCER exercise to promote perfect metabolism and elimination. Now cancer closely follows the same lines of increasing mortality, only it ex- ceeds them all, it having risen over 25 per cent, in the same thirteen years; the death rate for 1913 was 78.9 per 100,000, the highest ever attained, in spite of ever increasing activity in the study of can- cer, and transcendent zeal, intelligence, and skiU in the surgeons, who are trying to control it. I submit to you, gentlemen, if the argu- ment does not seem overwhelming that cancer is no longer to be regarded as a purely local disease, but that, as its death rate rises coincidently with that of the other diseases mentioned, it must have a more or less similar cause; and with the utter failure of surgery to control its in- crease, we must look in some other direc- tion for means to check its morbidity and mortality? Time fails me to expound to you at all MEDICAL CONSIDERATIONS 61 fully the line of argument supporting all this, which is based on published labora- tory studies in the physiological chemis- try and metabolism of cancer, as quoted in my little book on "Cancer, Its Cause and Treatment"; nor can I give more than a slight reference to the many expressions found in literature, by men well acquaiated with cancer, who have clinically been im- pressed with the constitutional nature of the trouble, of which the local lesion, or cancer, is but a result. But that you may know that I am not alone in urging a medical consideration of cancer, I must very briefly refer to a few prominent names of those whose opinion should bear weight. Indeed, the more I study litera- ture, new and old, the more I wonder that the valuable suggestions found there have not already directed serious atten- tion to and investigation of this aspect of the disease, in place of the immense amount of labor and expense which has been given to laboratory studies with the 62 MEDICAL ASPECTS OF CANCER microscope and test tube, and experiments on rats and mice! Neariy 100 years ago the great Aber- nethy, in his "Surgical Observ-ations on Tumors" wrote: "There can be no sub- ject which I think more likely to interest the mind of the surgeon, than that of an endeavor to amend and alter the state of a cancerous constitution. The best timed and best conducted operation brings with it nothing but disgrace, if the dis- eased propensities of the constitution are active and powerful. It is after an operation that, in my opinion, we are most particularly incited to regulate the constitution, lest the disease should be re- vived or renewed by its disturbance." Following down in time I have quoted from Walshe, Willard Parker, Sir Astley Coop- er, Sir James Paget, Sir Arbuthnot Lane, and others, all of whom, often in very strong language, declare emphatically their belief in the constitutional nature of MEDICAL CONSIDERATIONS 63 cancer, many of them attributing it to dietary errors. The most recent supporters of this view are Dr. Wm. J. Mayo, who in his presi- dential address before the American Sur- gical Association alluded to the matter a number of times, in no uncertain language, and Dr. James Ewing of Cornell Univer- sity, who in discussing the subject said to me, "Bulkley, I believe you are right, and our laboratory is now devoting itself to metabolic studies in cancer." I wish that I could give you briefly my experience in following this line of thought and treatment in cancer cases in private practice, during more than thirty years, and in the New York Skin and Cancer Hospital more recently, upon the special request of the Board of Governors, but must refer you to what I have written on the subject. I may say in advance that I am not here to offer any special new form of treatment or any novel or certain cure for cancer. Sadly thei rising 64 MEDICAL ASPECTS OF CANCER mortality path of cancer is strewn with the wrecked hopes of multitudes of sufferers who have tried in vain the innumerable "Cancer Cures" brought forth and often vaunted loudly, both by those who were within and those outside of the regular medical profession. Personally I do not believe that any one remedy, whether it be a serum or a pharmaceutical combination, will ever be found which can be spoken of as a "cure for cancer," although some of them have, for a whUe, seemed to be of service. The reason for this belief is f oimd in the true nature of the disease itself. The basic cause of the nutritive dis- turbance which eventuates in the new growth which we call cancer, being a dis- ordered metabolism, due to many causes, it seems entirely irrational to suppose that any brief course of medication by injec- tion or otherwise, can alter the deranged metabolism, or affect the organs concerned in nutrition, in such a manner that they will permanently operate correctly if the MEDICAL CONSIDERATIONS 65 dietetic or other errors which, uiduced the malignant new growth are allowed to per- sist and perpetuate the disorder. The real prohlem in regard to the proph- ylaxis and cure of cancer, therefore, re- lates to such a modification of the condi- tions of life as will induce a perfect hlood stream which carries on a perfect anab- olism and catabolism, resulting in the for- mation of normal body ceUs, in place of the heterologous cells of cancer. Time does not permit of the elabora- tion of the subject as one could wish, but to make my position clear I must very briefly touch upon some of the principal points involved, which I have presented in my little book. I must first state that I quite agree that chronic irritation has much to do with the localization of the morbid growth, even as local injury will commonly induce the local manifestations of gout, rheumatism, and late syphilis. I also accept the view that probably the malignant growths of cancer take their 66 MEDICAL ASPECTS OF CANCER origin in "embryonic rests," or wrongly placed epithelial elements. But repeated irritation occurs continually without caus- ing cancer, and we are told that "embry- onic rests" exist in every one, even in great numbers, while relatively few indi- viduals are affected with cancer. It would appear, therefore, that some- thing more is necessary, and that is f oimd in the soil in which the "embryonic rest" germinates, or rather in a vitiated blood stream, perverted by a deranged metabo- lism, which is again dependent upon the erroneous life induced by modem civili- zation. You aU know, imdoubtedly, that it has been pretty clearly shown that can- cer is a disease of civilization, and that the morbidity and mortality of cancer have increased with its advance, and with its attendant evils of over-indulgence in eating and drinking, with indolence, nerve strain, etc. ; these all help to pervert met- abolism, and are more or less accountable for disease of the heart, kidneys, and brain. MEDICAL CONSIDERATIONS 67 whose steadily rising mortality does not, however, keep pace with that of cancer. You know also that the errors of diet lie largely along excess of animal pro- tein, coffee, and alcohol, and that cancer mortality is the highest where the per capita consumption of these is greatest. You know likewise that cancer is exceed- ingly rare among herbivorous animals and aborigines who follow a diet largely com- posed of vegetables, fruits, and cereals; moreover laboratory studies have demon- strated that feeding has the greatest in- fluence on the effect produced by the ar- tificial inoculation of cancer in rats and mice, and that an absolute rice diet al- most inhibits its development. The teach- ing of all this is that in the human being an absolute vegetarian diet plays a very important part both in the prophylaxis against cancer and in its treatment, with or without surgical operation. But there are other elements connected with the production and control of cancer 68 MEDICAL ASPECTS OF CANCER which must be very briefly alluded to, that you may fully appreciate cancer from a medical standpoint. Proper and perfect elimination of the waste products of the body is the basis of all good health, and imperfect or deficient elimination is the source of innumerable ills to which different names are given; why the results are different in different individuals one does not know, and per- haps never will know, but careful clinical observation, both in recent and recurrent cancer, shows certain faulty conditions of elimination which are believed to be related to the etiological factors of the disease. These are exhibited in the excre- tion from the kidneys and the intestines. This is a very large subject, and time does not permit of more than the bare mention of the fact that cancer patients, even in the very early stages are almost uniform- ly constipated, and that a most careful and repeated volumetric analysis of the urine, in every possible particular, shows MEDICAL CONSIDERATIONS 69 that it is rarely if ever that of health. This latter statement does not refer to the presence of albumen or sugar, which are seldom found, but to the many in- gredients which represent the ultimate result of tissue metabolism. The medical treatment of cancer, there- fore, opens a very wide field of observa- tion and study, and the applied therapeu- tics in different cases may vary very wide- ly. But with the steady and persistent aim and effort to rectify metabolic errors, and properly correct disorders of elimina- tion by diet, hygiene, and proper medica- tion, I know that much impression can be made upon the morbidity and mortality of cancer, as I have witnessed in private practice for forty years, in large numbers of cases. My time is up and I must stop; but I can not close without urging you to accept my views, so far at least as to study care- fully your cancer patient from a medical standpoint, and not think that the only 70 MEDICAL ASPECTS OF CANCEK possible hope is in tlie surgical removal of tlie product or result of a systemic condi- tion, which in the end carries off a very large proportion of its victims, under the prevailing views in regard to the dis- ease. Eemember also that the earlier, the more earnestly, faithfully and intelli- gently proper medical measures are car- ried out, the more hope and expectation there is of checking the disordered blood and cell action which so commonly even- tuate in death. CHAPTEE VI MEDICAL ASPECTS OF CANCER* In his recent president's address before the American Surgical Association, Dr. William J, Mayo spoke in regard to the in- ternal causation of cancer in a manner which should attract serious attention. Few have had a wider acquaintance with the surgical aspects of the disease than he, and few others know better than he how relatively impotent surgical procedures are to stay the steadily increasing mortality from cancer, which now claims about 90 per cent, of those whom it once attacks. As a text for what I have to say, I want to quote a few of his words, as they confirm so strongly the views I have held and by which I have practised for thirty years * Address before the Rhode Island Medical Society, March 4, 1915. 71 72 MEDICAL ASPECTS OF CANCER and more, with results which I have sel- dom, if ever, had cause to regret. Speaking of the prophylaxis of cancer, mainly from its surgical aspects in regard to early operation, Dr. Mayo says: "Can- cer of the stomach forms nearly one-third of all cancers of the human body. So far as I know this is not true of the lower ani- mals, nor of uncivilized man. ... Is it not possible, therefore, that there is something in the habits of civilized man, in the cooking or other preparation of his food, which acts to produce the precancer- ous condition? . . . Within the last 100 years four times as much meat is taken as before that time. If flesh foods are not fully broken up, decomposition results and active poisons are thrown into an organ not intended for their reception and which has not had time to adapt itself to the new function. ' ' In conclusion he says : ' ' Where cancer in the human is frequent, a close study of the habits of civilized man as contrasted with primitive races and lower GENERAL RELATIONS 73 animals, where similar lesions are con- spicuously rare, may be of value, and finally the prophylaxis of cancer depends, first, on a change in those cancer-producing habits, and second, on the early removal of all precancerous lesions and sources of chronic irritation." I shall hope to show you that cancer is indeed a disease of modern civilization, like tuberculosis, although of quite a dif- ferent nature, and that the increase in its prevalence and mortality has closely fol- lowed the habits of man, in regard to diet and mode of life, as influenced by so-called civilization. We shall see that as the death rate of tuberculosis has diminished, that of cancer has steadily increased, the one un- der improved nutrition, the other under ex- cessive or erroneous nutrition. It is strange that the medical profession has been so slow in accepting, or unwilling to accept and act upon the suggestions along this line which have been thrown out from time to time, for very many 74 MEDICAL ASPECTS OF CANCER years, by surgeons of prominence, who were well acquainted with cancer, and who felt their inability to cope with this dis- tressing and fatal disease. And yet in- numerable, earnest, faithful, and intelli- gent research workers have expended any amount of time and labor, countless animal lives have been sacrificed, and vast sums of money have been spent in searching for the cause of malignant disease, with little if any but negative results ; from the stand- point of laboratory investigations thus far a satisfactory answer as to the problem of cancer seems as distant as ever, with no practical suggestions in regard to the pre- vention and cure of the malady, except by local means, including surgery, aj-ray, ra- dium, etc. From the surgical aspect the problem does not seem much brighter, as we shall see later. All honor to the surgeons who have so earnestly and valiantly striven to cure the disease by these means, but alas, their efforts have proved unavailing to GENERAL RELATIONS 75 check to any degree the constant rise in the general death rate from cancer, as shown by the mortality tables from many lands; and this is because the effort has not been along the right lines, as I shall hope to show. I am well aware of the improvement in surgical statistics which has been reported in regard to cancer in certain localities during the last few years, and of the im- portance of very early operations, if good results are to be obtained; but I hope also to show that the same pertains to the die- tetic and medical treatment of the disease. "While operative procedures may remove the tumor, and with it the source of toxic material generated in the same, they do not in any way affect the primeval or basic cause of the trouble; whereas, if exactly the right measures are employed to reach the fundamental source of the difficulty, not only will the original new formation disappear but there will be little or no tendency to its recurrence. What these 76 MEDICAL ASPECTS OF CANCEE lines of causation are will appear later. Dietetic and medical treatment of cancer, in the fullest sense, have never been given a fair and completely intelligent trial, on a scale large enough to produce general con- viction in regard to their value and to lead to their general adoption. 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 and treatment be- fore operation, with a view of discovering and rectifying the cause of the morbid growth. Too often when a cancer is sus- pected or discovered it is taken as a fore- gone conclusion that the malady is hope- less, except as the results of the disease, that is the new growth, may be removed by the knife, aj-ray, radium, caustics, etc. Also after a surgical operation, as far as my observation goes, the patients are in- variably left entirely to their own re- sources, with the hope, alas, too often fu- tile, that the tumor will not regrow, but GENERAL EELATIONS 77 with no attempt to so guide the life that there shall not be the same tendency to a recurrent malignant new formation as be- fore. Against this latter course I also raise my earnest protest. That you may know that Dr. Mayo is not alone in his impressions that there is "something in the habits of civilized man . . . which acts to produce the precan- cerous condition," I must very briefly re- fer to some of the leading surgeons of the past who, from time to time, with more or less force, have claimed that the disease is constitutional, and that it depends largely on diet and mode of life : later I shall hope to present sound grounds for such belief. One hundred years ago Lambe wrote clearly in regard to the causation of can- cer from luxurious living, and adduced strong proof to show the effect of diet in curing certain cases of undoubted cancer of the breast and uterus. Abemethy, shortly after, wrote point- edly rega"rding the constitutional origin of 78 MEDICAL ASPECTS OF CANCER tumors, endorsing Lambe's dietetic treat- ment of cancer and presenting several rea- sons why it should be fairly tried. Walshe in his classical work on cancer, says, "It would in theory appear that the removal of a tumor cannot in itself cure the disease, as the local formation is but a symptom of the general vice of the econ- omy," and he alludes more or less to the effect of diet on the disease. The late Willard Parker, one of New York's great surgeons, in a study of 397 cases of cancer of the breast, observed from 1830 to 1880, wrote very strongly in regard to the constitutional relations of cancer. In considering its etiology he places first "luxurious living and particularly excess in animal food. ' ' He says, ' ' Cancer is to a great degree one of the final results of a long-continued course of error in diet, and a strict dietetic regimen is, therefore, the chief factor in the treatment, preventative and curative." He further says, "In re- gard to the effect of abstemiousness on can- GENERAL RELATIONS 79 cer I can speak with great positiveness, that vegetable, or at least a very bland diet, does check the progress of the dis- ease, and in some cases now under treat- ment has been attended by an alleviation of symptoms ; and in a few instances even by a recession of the growth." Sir Astley Cooper is quoted by Dr. Par- ker in some strong language, as follows: "The cause of this disease is supposed to be some accidental blow or the pressure of a part of the dress ; but although the blow may produce a swelling on the bosom, yet that swelling will not be of a schirrous na- ture unless some defective state of the con- stitution disposes to malignant action. If the constitution be good the effects of the blow are speedily dissipated: but if the constitution be faulty, the swelling grows into a formidable disease." Later we shall see what some of these constitutional con- ditions are which induce certain cells of the body to take on malignant action. Sir James Paget, that prince of surgeons 80 MEDICAL ASPECTS OF CANCER and pathologists, comes out very strongly for the constitutional origin of cancer when he says twice in his Lectures on Surgical Pathology that cancers are "local manifes- tations of certain specific morbid states of the blood"; and again, he says, "I believe it to be constitutional, in the sense of hav- ing its origin and chief support in the blood . . . the existence of the morbid mate- rial in the blood, whether in the rudimental or effective state, constitutes the general predisposition to cancer." Benecke, in 1875, elaborated a diet highly beneficial in cancer, which was endorsed by Esmarck and Oldehop. If time permitted I could give any amount of further corroborative evidence, in the way of scattered remarks and allu- sions, like those of Dr. Mayo, expressing the conviction of many others, that cancer is not a purely local affection, but is only the result of some previous systemic dis- turbance, which we now recognize as met- abolic. GENERAL RELATIONS 81 But these many fugitive observations have never attracted the attention they de- serve, and it would sometimes seem as if they were deliberately ignored, and that scientists and practitioners had combined to recognize only the local nature and treatment of cancer. The truth is that very little serious effort has ever been made to assemble all the evidence of the constitu- tional nature of the disease, and by synthe- sis and deduction to establish a basis for the recognition and treatment of the consti- tutional elements of cancer. While it has been impossible to gather all the proof that could be desired, I shall hope to give enough to establish the correctness of the basis oi the thesis which I have long held. Cancer is more or less widely diffused over the whole globe, but in singularly dif- ferent degrees in various sections, and time will permit of only the briefest statement of the same, which can be verified and ex- panded from the remarkable recent works of Williams and Wolff. 82 MEDICAL ASPECTS OF CANCER Thus in England cancer mortality is very high, and during the past 40 or 50 years it has increased four or five fold, while the population has only a little more than doubled. Switzerland is credited with having the highest death rate from cancer of any country, it having augmented from 114 per 100,000 living in 1889 to 132 in 1898. Denmark stands next with 130 per 100,000 living in 1900, and France has a high cancer mortality, with a constantly increasing death rate. In Paris it has in- creased from 84 per 100,000 living in 1865 to 120 in 1900. In Holland, the death rate from 1867-1879 was 49 per 100,000, and 101 in 1905. The United States shows a lower death rate from cancer than the countries men- tioned, namely 78.9 per 100,000 living in the registration area in 1913; but it had in- creased from 63 in 1900, over 25 per cent., while deaths from tuberculosis had fallen a little over 25 per cent. : in 1913 there were over 50,000 deaths from cancer in the GENEEAL RELATIONS 83 United States. In a recent study regarding New York, Boston, Pittsburgh, Baltimore, Chicago, Philadelphia, and St. Louis, it was found that there had been an increase of almost 8 per cent, of deaths from cancer in their combined population in 1913, as compared with the average of the five years preceding. I am quite aware that some have claimed that the increase of death from cancer is only apparent, and not real, and is account- ed for by a greater longevity into the can- cer age, by more accurate diagnosis, and by greater exactness in recording deaths. But these points have been carefully and sat- isfactorily refuted by Williams, and surely the increase of 8 per cent, in these seven cities could not be thus accounted for. In New York City, according to the "Weekly Bulletins of the Board of Health, there were 2173 deaths from cancer in the six months from May to November, 1914, or almost twelve deaths daily from malignant disease. 84 MEDICAL ASPECTS OF CANCER While cancer is steadily increasing everywhere, under the influence of modem civilization, there are certain sections where the mortality is much lower than has been mentioned. Thus Italy has a low but increasing mor- tality, it having risen from 20 per 100,000 living in 1880 to 58 in 1905. Hungary had a cancer death rate of 26 in 1897 and 39 in 1903; in the county of Kerry, Ireland, the cancer death rate was 26 and in the province of Dalmatia 16 per 100,000 living population. In some regions, however, cancer is very rare and in others almost unknown. In Africa all observers agree that the disease is exceedingly rare, as also among those in the interior of China and India ; in Bra- zil it is seldom seen, while several testify that in many of the islands of the sea it is practically unknown. During a rather extensive trip through the Far East I was xmable to see or hear of any cancer, although I met a large num- GENERAL RELATIONS 85 ber of medical men, and made diligent in- quiry regarding the same. I visited very many civil, military, and mission hospitals, with a total of many thousands of patients, and ministering to many millions of popu- lation : in Japan, Korea, China, the Philip- pines, India, Siam, and Egypt, I met the same response, that cancer was very rarely seen among the natives. Now there must be some reason for this unequal distribution of cancer. Labora- tory researches have not helped us m dis- covering it, except that they have done much to clear the way for a proper under- standing of the real nature and cause of cancer, though the evidence furnished is largely of a negative character. In order to appreciate fully the basis on which our thesis rests, it will be well to state very briefly the accepted facts in regard to can- cer. 1. Cancer is but a deviation from the normal life and action of certain of the or- dinary cells of the body. 86 MEDICAL ASPECTS OF CANCER 2. It is possible that the diseased action may begin first in what is known as "em- bryonic rests," or prenatal, wrongly placed tissue elements. 3. Cancer is not wholly of traumatic ori- gin. 4. It is not caused by a micro-organism, or parasite. 5. Cancer is not contagious. 6. Cancer is not hereditary in any appre- ciable degree. 7. Occupation has not any great influ- ence on the occurrence of cancer. 8. Cancer is not altogether a disease of old age. 9. It does not especially belong to or af- fect any particular sex, race, or class of persons. 10. Cancer is not confined to any loca- tion or section of the earth. 11. No single cause of cancer has yet been demonstrated, nor is it likely that this will ever be the case, as the experimental GENERAL EELATIONS 87 and other investigations have covered al- most every possible line of research, with only negative results. Bnt there must be some cause, or reason, why cancer is thus unevenly distributed and why it is so steadily increasing al- most everywhere ; why it is so exceedingly prevalent in some localities and among certain peoples, and again so rare or even absent among others; for we have seen that aborigines are not affected, while oth- ers, in proportion as they have been af- fected by so-called civilization are corre- spondingly affected. Wolff has shown in a remarkable table, that while cancer in the native Australians has remained about stationary, it has increased among the Eng- lish residents in cities seven fold, and an- other writer remarks that while the native Australians are practically free from the disease, when they mingle with foreigners as servants and employees and adopt their diet and customs it occurs more frequently among them. The same has been observed 88 MEDICAL ASPECTS OF CANCER among native Africans and those in India and elsewhere. Analyzing the various data obtained, we find that cancer has increased in proportion to the consumption of the three articles, meat, coffee and tea, and alcohol. In England, where the consumption of meat has doubled during the past 50 years and recently was 130 pounds per capita yearly, cancer mortality has increased four fold. In Italy, where the consumption of meat is the least of any of the European countries, cancer is least frequent, and in the county of Kerry, Ireland, where meat is seldom eaten, the death rate from can- cer is not one-third that in England. The same comparison may be made between a number of other countries, did time permit. The United States in 1909 consumed much more meat than England, namely 172 pounds per capita, and, as already stated, cancer has increased over 25 per cent, since 1900. Alcohol must also be accredited with a GENEEAL RELATIONS 89 portion of the increase of cancer in both these countries, as it is well known that the disease presents a far greater augmenta- tion in those occupations where alcoholic drinks are indulged in, as in bartenders, printers, and others. Coffee has been shown to have its largest per capita consumption in Holland, where the cancer death rate is among the highest, while Hungary is the smallest consumer of coffee, and the cancer mortality there is among the lowest, namely 39 per 100,000 living. The people of the United States consume one-third of all the coffee pro- duced, more than Germany, Austria, Hun- gary, France, and the United Kingdom combined. England and her colonies, where cancer is steadily increasing, consume one- half of the world's output of tea. Williams has given some interesting and important data regarding the effect of prosperity and wealth, leading to self-in- dulgence and indolence, in the augmenta- tion of cancer mortality, which time does 90 MEDICAL ASPECTS OF CANCER not permit our long dwelling upon. He shows clearly that as these elements of modem civilization have developed, cancer has surely increased, and he gives striking illustrations of the same. In England it was found in one decennium that cancer mortality was more than twice as great among well-to-do men, having no specific occupation, as among occupied males in general, the ratio heing 96 to 44. Nerve conditions have also been found by many to be an important element in the production of cancer, and the very great nervous strain accompanying modem civ- ilization must be reckoned among its causa- tive factors, possibly through its effect on metabolism. To understand how these various ele- ments mentioned, and probably others, have an influence in the genesis of cancer we must briefly consider the physiology of nutrition and the metabolism of cancer as far as it has been ascertained. All recognize, of course, that the body GENERAL RELATIONS 91 nutrition, in health and disease, depends upon the nutritive elements taken into the system, as proteids, carbohydrates, and fats, with oxygen inhaled and water im- bibed. We know, of course, that there is a certain equilibrium to be maintained in regard to its various component parts, and that over-indulgence in certain articles can without doubt produce disease as, for in- stance, acute or chronic gout from free in- dulgence in Port and Madeira wine. Just where the fault lies, and why after a cer- tain time the system rebels and refuses to properly metabolize and remove waste products, or why the latter exert such a baneful influence on different portions of the economy, and give rise to various in- flammations and misgrowths, is hard to tell, and must be the subject of future study, but the fact no thinking man can doubt. Later we shall hope to throw some little light upon it. The metabolism of cancer has been the subject of considerable research, and there 92 MEDICAL ASPECTS OF CANCEE have been many reports in this direction which can be but briefly alluded to here; unfortunately, however, most of these in- vestigations have been made upon ad- vanced cases, where the system has been already depressed by the poisonous toxins produced in the already well-developed cancer mass, or where the disease process has already involved important viscera and interfered with their proper action. What we need is careful metabolic studies on pre- cancerous states of relative health, also in very early cancer, and likewise after sur- gical operations, when the local manifes- tations of the disease have been removed; only thus can we rightly learn the true errors of metabolism which lead up to can- cer. But enough has been developed to show that the cancerous person manifests grave aberrations from the normal state, other than the local tumor. The blood exhibits great changes in can- cer, especially toward the end of the dis- GENERAL RELATIONS 93 ease. The hemoglobin content tends to constantly fall, and the red cells to dimin- ish, and to exhibit various phases of de- generation. The white cells increase, and the proportion of their varieties changes greatly. Unfortunately the plasma has not been much studied, and yet the condition of this fluid must be of the utmost impor- tance, as from it are derived not only the solid constituents of the blood but also those of the entire system. It also holds in solution the phosphates, carbonates, sul- phates, and chlorides, the latter often vary- ing greatly and being chiefly responsible for the isotonic relation of cells and serum. In cancerous cachexia a diminution of car- bonic acid, a constantly diminished alka- linity, and an increase of acid principles of the blood have been fully demonstrated, pointing in all probability to an acid intox- ication. It seems that the toxic secretion from a cancerous mass itself has a dis- tinctly injurious action on the blood, for after the complete removal of a cancerous 94 MEDICAL ASPECTS OF CANCER mass there is often found an increase of hemoglobin, as I have witnessed, and a high leucocytosis has disappeared after the removal of schirrus of the breast, only to return again with the recurrence of the tu- mor. The urine in cancer has also been much studied, and is rarely if ever found to be that of health, although it cannot be said that any definite and specific changes have been established which are pathognomonic of the disease: the urinary excretion will constantly be found to be extremely defi- cient, both as to its quantity and its total solid elimination. In one very interesting case of primary cancer of the breast, in a stout, flabby lady, near 55, in private practice, the total quantity of urine, meas- ured daily for weeks, is always very far below the normal amount, and in spite of active medication it seems almost impos- sible to raise the total daily solids excreted in the urine, to much more than one-half of that called for by the weight of the GENERAL RELATIONS 95 patient. This I have observed in very many cases. In regard to the changes which have been reported in the urine of cancer patients, many observers agree that there is a dis- turbance of proteid metabolism, and de- pendent upon this many deviations from normal are found in the urine. The urea is invariably diminished, often very great- ly, as I have verified time and again in many cases. The nitrogen partition is greatly disturbed, with increase in colloid nitrogen to more than double the normal amount, and an increased elimination of xanthin, oxyproteic acid, and urinary am- monia; oxyproteic acids are reportied by Blumenthal as increased even in very early cancer, and independently of the size of the tumor and degree of cachexia, seeming- ly showing them to have some specificity for cancer, because they have not been found in other forms of malignancy. Notable changes have also been recorded concerning the sulphur elements in the 96 MEDICAL ASPECTS OF CANCER urine, with a great increase in neutral (un- oxidized) sulphur, and a considerable ex- cess of sulpho-cyanic acid, together with an increase in sulphates and indican, showing the results of intestinal fermentation of protein elements, which I have also con- stantly observed. There have been like- wise other changes reported, which time forbids our considering. The saliva is an important element in the digestion of carbohydrates, and conse- quently in metabolism and the genesis of cancer ; but, unfortunately, I have not been able to find any investigations relating to its condition in this disease. But in very many tests which I have made in cancer patients it is commonly found acid, often strongly so ; in my hospital cases I have it tested before and after each meal, and watch with considerable interest its change to alkaline imder efficient treatment, which includes prolonged mastication. The internal secretions have also been the subject of much research and specula- GENERAL RELATIONS 97 tion of late years, in regard to their influ- ence on metabolism and the life processes of the economy, and some studies have been made concerning their connection with can- cer, which cannot now be long dwelt upon. But there seems to be little doubt but that the secretions of the ductless glands in common have much to do with regulating the metabolism of the body cells. We know for instance, that disease of the pituitary body produces bone disorder, resulting in gigantism, that thyroid derangement re- sults in myxedema, and that disease of the suprarenal capsules gives rise to Addison's disease, or bronzed skin. May we not rightly argue that derangement in one or more of these has something to do with the cellular changes which we call cancer? The favorable results which have attended the administration of thyroid, which I have myself often witnessed, as also a combina- tion of the three extracts, as reported by some, would seem to confirm this. The pancreatic secretion performs un- 98 MEDICAL ASPECTS OF CANCER doubtedly an important part in metabolism, and although some researches have seemed to show that Beard's claim for it in cancer was not well founded, the matter should be again investigated, possibly along the diet- ary liae herein considered. Very much more could be given in regard to the metabolism of cancer, did time per- mit, but enough has been said to show that there are gross perturbations of the system connected with this disease, and that the local tumor is but an expression of one aspect of a constitutional disorder, which if unchecked tends to death, aided imdoubt- edly by a virulent poison secreted by the malignant cells of the tumor, when it has once developed. Everything has its beginning, but, as El- bert says, "no one has ever seen the begin- nings of mammary cancer," nor of any other malignant lesion, and we are in utter ignorance of the first change which takes place when a cell or cells take on a rampant or malignant action. But whenever or GENERAL RELATIONS 99 however it takes place the impetus must be from the plasma bathing the cell whioii was previously normal and innocent. We have not time to discuss the subject of "embry- onic rests," which quite possibly have to do with the genesis of the disease. But these are now known to be common ana- tomical or histological elements, many of which are present ia every one, and which are ordinarily quite harmless. It is, there- fore, quite unreasonable to ascribe the cause of cancer to them alone — there must be some deeper, underlying cause which ex- cites them to take on and continue malig- nant action, and that cause is found in the perverted blood and lymph stream result- ing, as several writers have affirmed, from a prolonged violation of the laws of perfect health, although other evidence of this may not have been previously recognized in the individual patient. It is more than probable that a local ir- ritant is the exciting cause of the starting up of the aberrant action of some particu- 100 MEDICAL ASPECTS OF CANCER lar cell or cells. These then go on multi- plying inordinately, destroying adjacent tissues, and finally break down, instead of forming normal tissue. But the local irri- tant cannot explain why, when once started by local injury, the cells should pursue such a progressive, aggressive, and invasive course. The reason is found, as Sir Astley Cooper and others have believed, in some faulty condition of the system, which is now shown to be from a perverted metab- olism, arising from many causes, and among others from over-indulgence in an- imal protein, coffee and tea, and alcohol. 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 pre- disposition or suitable blood condition. 2. A local stimulation or irritation of the part affected, upon, 3. The site of an "embry- onic rest." In but a relatively small proportion of cases can the direct local irritant be made GENEEAL RELATIONS 101 out with certainty, and even in cancer of external parts, as the breast, there is often no consciousness of external injury or even a blow, while in cancer of internal parts this is very seldom recognized. I am quite aware that cancer may follow gastric ulcer, that gall stones may act as an exciting cause, and fecal impactions in intestinal diverticula are the starting-point of can- cer, etc. But the relative rarity of such occurrences shows that there must be some hidden, underlying, constitutional cause which feeds the deranged cells. I appre- ciate, also, the part which metastasis plays in spreading the disease to distant parts, but this is because generally the faulty met- abolic cause is allowed to continue, for when this is checked by proper dietary and other treatment even metastatic foci disap- pear. We come now to the question as to what this metabolic disorder is which incites for- merly normal tissue cells to take on and continue this diseased action, which is real- 102 MEDICAL ASPECTS OF CANCER ly the true problem in cancer. Alas, the ac- tual and exact state of blood which leads up to the disease has not yet been fully de- termined, although all that has been learned and already briefly alluded to under the metabolism in cancer, points clearly to the lines of study which should be more closely followed. And even if we should be long in establishing a definite and true metabolic disorder, or should never determine it, this should not deter us from acting on clinical grounds, from experience, even as is constantly done in regard to many other ailments, illustrations of which will readily occur to every one. Indeed, how constantly diseases are treated em- pirically, with greater or less success, with- out any great knowledge of their real eti- ology. Coming now to the important question of the prophylaxis and treatment of can- cer to which this study of its medical as- pects leads, we find that we have advanced far toward a proper understanding of the GENERAL EELATIONS 103 same. We have seen that cancer is but a wrong development of certain previously normal body cells, possibly "embryonic rests," by a process of agamogenesis, de- pendent upon excessive and faulty nutri- tion. Laboratory and other studies have decided pretty certainly that it is not due to a parasite, nor contagious, that it is not hereditary, nor due wholly to local irritant action, that it is not altogether a disease of old age, nor belonging to any particular occupation, and that it does not affect any particular sex, race, or class of persons, and that it occurs all over the earth, but with striking difference in frequency ac- cording to certain peculiarities of life, as- sociated with advanciag civilization. We have been thus forced, by exclusion, to rec- ognize that it must be due to some sys- temic change, whereby the perverted nutri- tion offered to certain irritated cells causes them to take on a morbid action, whidi is prolonged by a continued malnutrition, and increased or aggravated by a vicious 104 MEDICAL ASPECTS OF CANCER secretion from these diseased cells them- selves; in other words, that it is a disease of faulty metabolism. It will be interesting and instructive to consider for a moment some of the other diseases which are also causing a constant- ly increasing mortality, as shown by the ac- companying table, taken from the volume of the United States Mortality Statistics. These are all recognized as due to faulty metabolism, induced by advancing so-called civilization. It is seen here that while the death rate from infectious diseases, tuberculosis and pnexmionia, has declined steadily and rap- idly, that of organic heart diseases has risen greatly, and nephritis has shown a steady rise, as also apoplexy. This latter has about kept pace with cancer, which has risen from 63 deaths per 100,000 living in 1900 to 78.9 in 1913, a gain of 15.9 per 100,000 in 13 years, or over 25 per cent. If we accept the fact that the mortality of these diseases is steadily rising from GENERAL RELATIONS 105 I90O igol eoz.1303 m raos raot 1907 1908 m bio ran rau. i9U aio 2.00 190 c IgO -»J 170 - parent to all. Such are the nervous strain and stress of modem life, often with its hurried eating and imperfect mastication and insalivation, the over-indulgence in wrongly selected, prepared, and combined food and drink, luxurious and indolent habits in many, etc, etc. The subject is a great one, worthy of profound study, and the only wonder is that there has been such a myopic tend- ency in scientists and surgeons, who have PEECANCEEOUS CONDITIONS 261 overlooked the broad medical principles which underlie all nutrition, both benign and malignant, and have spent so much time, money, and energy in searching for some specific cause of cancer, and in the surgical removal of the accessible prod- ucts of the disease, while leaving its main and fundamental causes uncared for. CHAPTER Xin CANCBB IN BBIiATION TO BODY BUMINATIOlir With the large number of laboratory studies which have been reported concern- ing blood and urinary changes in cancer, it is surprising that so little attention has been paid to the clinical importance of these findings, and to the relation which body elimination bears to the production and continuance of the disease. The laity as well as the profession have, of late years, become so obsessed with the idea of its purely local character, and so car- ried away with the craze for surgery, that practically every one thinks only of local operative treatment, by the knife, ic-ray, radium, etc. And thus it happens that when cancer is suspected or diagnosed, the physician feels helpless and the pa- tient only waits for an ox)eration or death, 262 BODY ELIMINATION 263 which latter is now acknowledged to fol- low from the disease in about ninety per cent, of those once affected. And yet for many years eminent sur- geons have time and again acknowledged their inability to cope with cancer, as such, and have contented themselves with at- tempting to remove the product of the dis- ease, namely, the malignant new growth, glands, etc. But little regard has been given thus far to the real cause of this new growth, although infinite labor has been expended in the laboratory to dis- cover its histological characters, mode of development, etc. And all this in spite of the fact which every one must recognize that all growth, whether normal, abnor- mal, or malignant, depends upon the char- acter of the blood supply, which again derives its quality from the food and drink taken, and the manner in which the metabolism of the system is carried out. Cancer has too long been regarded as a purely surgical affection, and the surgeon 264 MEDICAL ASPECTS OF CANCER as the sole arbiter of the fate of those suffering from this most fatal disease. With the steady rise in its mortality, of over twenty-five per cent, since 1900, as shown by the United States mortality ta- bles, under this line of action, it would seem well for the medical men to take up the study and to endeavor to learn if there is not some basic cause, thus far overlooked, which may be found in the metabolic action of the system, as influ- enced in many ways, such as by the diet, mode of life, etc. Should we not try to discover why cancer is increasing so great- ly with civilized life, while it is rare in some animals and seldom if ever seen in certain aborigines? Literature is full of isolated facts tending to show conclusively that the disease is but an aberrant action of originally normal tissue cells, resulting from a vitiated blood stream. Space does not permit the full presenta- tion of facts which have been collated else- where, nor to do more than mention the BODY ELIMINATION 265 names of some of the eminent surgeons, there quoted, who have expressed strongly their belief in the constitutional nature of cancer, from erroneous living. Among these are Lambe, Abernethy, Willard Parker, Sir Astley Cooper, Sir James Paget, Esmarck, and Sir Arbuthnot Lane, as also Walshe, in his classical study of cancer. Finally, Dr. William J. Mayo, in his recent president's address before the American Surgical Association, has ex- pressed himself in no uncertain way in regard to there being some constitutional cause leading up to the aberrant action of cells in cancer. While the exact condition of the blood which excites normal cells to become can- crogenetic and then feeds them in their luxuriant growth, is not capable of demon- stration yet, and perhaps never will be, clinical study reveals certain conditions of the system so constantly observed in pa- tients with this disease that there can be little if any doubt that they are contribu- 266 MEDICAL ASPECTS OF CANCEB tory elements, at least, to the production of malignant disease; these relate to the conditions of faulty metabolism and faulty imperfect body elimination. These errors may be observed, not only in advanced and recurrent cases of cancer, but also in those which are in very early stages; in- deed their occurrence in recently forming cancer, and in patients soon after opera- tion forms a strong argument for their causative relation to the disease. The evidences of imperfect metabolism and faulty body elimination in cancer are found in the condition of the blood, and in excretions from the kidneys, bowels, and skin, and minute and careful study will seldom fail to detect these departures from normal in patients with this disease. It is impossible in this brief article to pre- sent any full account of these errors which have been elaborated in the references al- ready given, but a brief mention may be made of some of the most important items. BODY ELIMINATION 267 The blood is known to present great de- generative changes in cancer, which in- crease as the disease advances ; the hemo- globin content tends constantly to fall and the red cells to exhibit various phases of degeneration. The white cells increase and the proportion of their varieties changes greatly. Unfortunately few if any studies have been made in precancerous conditions of relative health, but it has been recorded that after the surgical re- moval of a cancerous mass there has been a decided increase of hemoglobin, as I have witnessed, and a high leucocytosis has disappeared, only to return again with the recurrence of the tumor. It is recognized that the cancerous cells them- selves secrete a malignant hormone, which aids in increasing the depraved condition of the blood as the cancer advances; for just as the particular and peculiar cells of the various secretory and excretory or- gans produce a hormone which probably influences other secretions, so all the cells 268 MEDICAL ASPECTS OF CANCER of the body, healthy and diseased, produce something of a secretion which has some influence on the economy. When cancer juice is injected intrav- enously a marked lymphocytosis arises, which is followed by the appearance of large mast ceU myelocytes in the blood. This cancer juice is supposed to autotoxie in cancer patients, and to comprise al- buminoids, which being in quantities too great to be quickly neutralized, poison the system, especially the blood and the hema- topoietic oi^ans. In cancerous cachexia a diminution of carbonic acid, a constantly diminishing alkalinity, and an increase of acid principles in the blood have been definitely demonstrated, pointing, in all probability, to the existence of an acid in- toxication. The urine in cancer has been investi- gated by very many observers, and al- though no definite and specific changes have been as yet found which are surely indicative of the disease, very many de- BODY ELIMINATION 269 partures from the normal have been re- ported which are of significance, and im- der complete volumetric analysis the nrine of a subject of cancer is rarely if ever that of health. Many observers agree that there is a disturbance of protein metab- olism manifested in the nrine, and an in- crease in colloid nitrogen to more than double the normal amount: there has also been reported an increased elimination of xanthin, oxyproteic acid, and urinary am- monia. The urea in the urine is almost invari- ably diminished, often very greatly, as I have verified time and again in many cases. There is also an increase of amino- acid nitrogen, showing that the liver, even when not involved in the disease, is still unable to perform its functions in syn- thetizing urea. The urinary secretion will constantly be fotmd to be extremely deficient, both as to the actual quantity passed in twenty-four hours, and in its total solid elimination, 270 MEDICAL ASPECTS OF CANCER which, of course, is the true indication as to the efficiency of this excretion. In many cases, even of very early cancer, in which the urinary secretion has been measured and recorded every day for weeks, I have found the elimination of solids often less than one half of the amount called for by the body weight of the patient. As the 'tumor has melted away under proper diet- ary and other general treatment, the kid- neys have often brought up the removal of waste material to a normal standard. So constantly have I observed this faulty urinary elimination early and late in these subjects, that I cannot but believe that it indicates some defect in metabolism which has a bearing upon the genesis and rebel- liousness of cancer. The action of the bowels, in regard to their true eliminative function, is a more difficult problem to study, and yet from long observation I am convinced that it plays a most important part in connection with cancer. I am not aware of any lab- BODY ELIMINATION 271 oratory studies whiclj have been made concerning the intestinal discharge in this disease, and my deductions are entirely clinical. Sir Arbuthnot Lane, in one of his lectures on intestinal stasis, has re- cently emphasized the fact that one of the terminal results of this may be cancer, and the more I have considered the sub- ject, in connection with very many pa- tients, the more the truth of this state- ment is impressed upon me. It will sur- prise many to learn how very commonly there is imperfect intestinal elimination in the subjects of cancer, both in the very early, formative stages and throughout the whole course of the disease, which is fur- ther accentuated when the time comes for them to take morphine. So commonly have I recorded this, especially in private pa- tients, that I might almost say that is the rule, and time and again I have noticed that if real constipation occurs there is an increase of pain in a cancerous lesion, with more or less of relief from active 272 MEDICAL ASPECTS OF CANCER purgation. The constant occurrence of this imperfect intestiaal elimiaation points strongly to the possibility that the toxins produced by the millions of micro-organ- isms generated through intestinal sta- sis and fecal putrefaction are the real, in- cidental cause of cancer. While this is only a clinical conclusion, it is hoped that laboratory research turned in this direc- tion will confirm the finding. The liver has been shown by many re- searches to exhibit many departures from normal action in connection with cancer. Reid, from the Cancer Research Labora- tory, in Manchester, England, reports that "in cancer the liver, while not involved in the disease, is still unable, for some reason, to perform its functions in syn- thetizing urea. The organ is functionally injured, no lesions having been found to explain its insufficiency . . . cancerous subjects form proteids which the liver is unable to deal with, so that they are ex- creted unchanged, or nearly so." Blum- BODY ELIMINATION 273 enthal states that urobilin is increased in a large proportion of cases of cancer, and others have confirmed hepatic functional disorders in connection with the disease. The relation of the elimination from the skin to cancer has, of course, never been studied, and perhaps never will be. But there are certain considerations which may be of importance in connection with the general disturbance or failure of elimina- tion in this disease. We know that the skin performs most important functions in connection with regulating the heat of the body. While the relative amount of solids in the sweat is small, the daily total given off by the sudoriferous and sebaceous glands is not inconsiderable, and its character is known to vary considerably under cer- tain conditions, urea and uric acid occur- ring at times, while cholesterin, an element of importance ia cancer, appears in the se- baceous secretion, etc. In cancer the skin is apt to be dry and inactive, and possibly later researches may show that it also 274 MEDICAL ASPECTS OF CANCER shares in the deranged metabolic condi- tion connected therewith. It is realized that the study of cancer along the lines here indicated is yet in its infancy, as it has heretofore been regard- ed almost wholly from its histological and surgical aspects. The microscope and ex- perimental work on animals have seemed to engross most of the attention, to the relative exclusion of careful clinical ob- servations of the real "precancerous" con- ditions occurring in the system, which lead up to the disease. Endocarditis, nephritis, and apoplexy are shown, by the United States mortality tables, to have had a continuous and great rise in their death rate, per 100,000, of late years, and, as already mentioned, can- cer has had also a coincident rise in mor- tality of over twenty-five per cent, since 1900. As the three former diseases are recognized to be largely due to the inci- dents of modem civilization, mainly in the line of erroneous eating and drinking, BODY ELIMINATION 275 it would seem reasonable to ascribe can- cer to the same cause. Faulty metabolism and imperfect elimination are characteris- tics of endocarditis, nephritis, and apo- plexy, and close and continued observation will show them to be integral features of the bodily condition leading up to and as- sociated with cancer. CHAPTER XIV CANCBE AND CIVILIZATION/ Civilization has its advantages and also its disadvantages. All recognize that the mortality from tuberculosis had steadily been increasing under the evil effects of overcrowding and bad sanitation, incident to advancing civilization, until wiser methods have succeeded more recently in arresting its rising progress, and greatei^ care has lessened its death rate immensely, almost 30 per cent., from 1900 to 1916. Cancer deaths have also long been stead- ily increasing all over the world, under advancing civilization, as has been often shown. But instead of diminishing, as in the case of tuberculosis, they have in- creased so surely and steadily of late 'Read at the Forty-second Annual Meeting of the American Academy of Medicine, New Tork City, June 4, 1917. 276 CANCEB AND CIVILIZATION 277 that unless something is done to arrest its continued progress, cancer will soon rival the latter disease in its morbidity and mortality. According to the mortality statistics of the United States, the death rate from tuberculosis in 1910 was 201.9 per 100,000 population, which under most careful med- cal supervision has steadily dropped, until in 1916 there were only 141.6 deaths per 100,000 population, or a diminution of over 29.8 per cent. During the same period the deaths from cancer under solely surgical management have risen from 63 in 1900 to 81.8 in 100,000 Ijving in 1916, or over 28.84 per cent. ; that is, almost equal the rate tuber- culosis has fallen. Thus the mortality of the two have approached each other in these 15 years by over 58.64 per cent. ; and if the same progress in each direction should continue, the death rate from can- cer will far outstrip that of tuberculosis in 16 years more. 278 MEDICAL ASPECTS OF CANCER The rational deduction of this would seem to be that we should inquire as to whether there is not something wrong in our present conception of cancer and its treatment. This is not the time nor place to discuss this real cancer problem, which has been fully met elsewhere, as our in- terest is as to how far and in what man- ner modern civilization is responsible for the increase of cancer morbidity and mor- tality. One will see, however, as we pro- ceed, that all evidence points to the fact that cancer is not a purely local disease, of totally unknown causation, but that there are deep constitutional causes, based largely on some of the baneful influences of civilization, and that it is upon the recognition and rectification of these fac- tors that the true prophylaxis and cure of cancer rest. Abundant testimony has come from all over the world that cancer is very rare among aborigines, living simple, mainly vegetarian, lives, some of which evidence CANCEE Am) CIVILIZATION 279 is presented in the volumes referred to, and is amply shown in the admirable treatise by Williams on the "Natural His- tory of Cancer," as also in the remark- able compilation by Hoffman, on "The Mortality from Cancer throughout the World. ' ' A few illustrations may be given, largely as presented by Williams and Hoff- man, whose intensive studies and abundant references to literature merit close atten- tion. In Australia cancer is everywhere fairly com- mon among those of white descent . . . but among the aborigines it is so rare as to be almost unknown. In New Zealand the aborigines are seldom affected. It seems perfectly clear that malignant tumors are of much rarer occurrence in Africa than in any other of the great divisions of the world .... and even here it is those of white de- scent who are the chief sufferers, for the natives are seldom affected. In the American Continent .... this mal- ady is common in all parts of British North America, except among the aborigines. Among the North American Indians cancer appears to be extremely rare, and 280 MEDICAL ASPECTS OF CANCER one careful investigator declares that they are actually nearly immune from the dis- ease. In Mexico and the Central American commu- nities cancer is decidedly rarer than in the United States. The negroes in the United States were known to have almost no cancer while liv- ing in slavery, when the food and mode of life were simple. But the statistical re- ports since the Civil War show a steady increase of mortality from malignant dis- ease among them, since they have mingled with whites and eaten their food, with their own natural tendency to gluttony and idleness. In the cities this is most striking, and in New Orleans the rate per 100,"000 for negroes in 1914 was actually greater than that of whites. In Australia cancer is rare among the natives in the interior, but when they mingle with foreigners as servants or em- ployees, and adopt their diet and customs, the disease appears more frequently among them. CANCER AND CIVILIZATION 281 The Polynesians and Melanesians seem to be peculiarly exempt from cancer. 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. In Ceylon the death rate from cancer was reported as the lowest of any locality in Asia, namely 5.6 persons for 100,000 population. During a rather extensive trip through the Far East I was unable to see or hear of any cancer, although I met a large number of medical men and made diligent search and inquiry for the same. I visited very many civil military and mission hos- pitals, 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 with the same response, that cancer was rarely seen among these vegetarian natives. Let us now briefly sketch the steadily 282 MEDICAL ASPECTS OF CANCER increasing death rate of cancer as it has been recorded in connection with so-called advancing civilization, for it has been re- marked by one investigator of statistics that "the mortality from cancer is in a direct ratio to the intensity of human civilization." England has long furnished the most accurate statistics of cancer, as of other diseases. In 1840 the cancer death rate was 17.7 per 100,000 living, which rose steadily until in 1905 it was 88.5 per 100,000; the population had only a little more than doubled, while the death from cancer had increased by exactly five fold. In 1913 the mortality from cancer in England and Wales was 94.7 per 100,000 population, and in London it was 114.9 in 1913. Time does not admit of the full presen- tation of the increase of cancer deaths in other highly civilized countries, which is abundantly shown in the works of Wil- liams and Hoffman already referred to CANCEE AND CIVILIZATION 283 and also in the work of Wolff — Die Lehre von der Krebskrankheit, Jena, 1913, et seq.; but a few points may be mentioned. In France, cancer mortality in 1892 was 88 and in 1905 it was 100.2 per 100,000 in- habitants. In Paris it had risen from 97.2 per 100,000 in 1881 to 112.4 in 1912. In Germany, deaths from cancer in- creased from 53.5 in 1891 to 90 per 100,000 living in 1912. In Berlin, the increase in the cancer death rate was from 64.6 in 1881 to 132.8 per 100,000 in 1912, that is, had more than doubled in proportion to the living inhabitants. In Holland, the mortality from cancer rose from 57.6 per 100,000 in 1881 to 109^ in 1913. In Amsterdam, the rise was from 72,2 to 114.8 in the same period. In Belgium, the rise ia the mortality from cancer was from 59.4 per 100,000 population in 1903 to 71.3 in 1912. In Ant- werp, it was from 47.6 in 1896 to 90.9 in 1912; in Brussels, it was from 88.2 per 100,000 living in 1901 to 106.2 in 1912. 284 MEDICAL ASPECTS OF CANCER In Italy, the death rate from cancer was 21 per 100,000 population in 1880, and in 1912 it was 64.7. In Rome, it had risen from 79.1 in 1898 to 99.6 in 100,000 popu- lation in 1912. It would be interesting, did time permit, to trace the death rate of cancer in many other localities, to show the relationship of the disease to some of the elements which go to make up what is called mod- em civilization. Mention has been made of the steady de- cline in the mortality from tuberculosis in the United States, and it is most interest- ing to study its declining mortality in many other regions, in an inverse proportion to the rise of the death rate from cancer; for, as we shall see, the two diseases de- pend upon two opposite conditions of nu- trition developed eoincidently with mod- em civilization. Time does not permit of the presenta- tion of the evidence which has been so carefully collected by Williams and Hoff- CANCER AND CIVILIZATION 285 man to show the interrelation of tuber- culosis and cancer to the conditions of life in various localities, but a careful study of the statistics Williams gives war- rants the rather remarkable statement which he makes, as follows: Such an examination shows that the cancer mortality is the lowest where the struggle for existence is the hardest, the density of popula- tion greatest, the tubercle mortality highest, the birth-rate highest, the average duration of life shortest, the infantile and general mortality highest, and where sanitation is least perfect — in short, among the poor of the industrial classes in our large towns ; whereas among the wealthy and well to do — where the standard of health is at its best, and life is easiest, and aU conditions of existence are just the reverse of the foregoing, there the cancer mortality is highest. These are strong words and may be contested by some, but a very careful study of the facts and statistics collected by Williams will convince the impartial stu- dent that they are not far from the truth. All are familiar with the clinical history of tuberculosis. When from unsanitary surroimdings, poor nourishment and over- 286 MEDICAL ASPECTS OF CANCER work, with deficirait oxygen the patient's health fails, there comes a time when a focus of tuberculosis is discovered, and unless che(^ed by a reversal of the con- ditions inducing the depression of health, the disease proves fatal. With cancer, however, the clinical his- tory is quite the reverse. The subjects of beginning cancer are commonly seen to be in apparently excellent health; they are often ruddy and blooming in appear- ance and can hardly be made to believe that the dire disease has actually begun in them. This may be seen even in re- gard to cancer of internal organs, which is often first suspected and recognized from a steady departure from a previous condition of excellent and robust health. The two diseases represent exactly two opposite phases of nutrition, both induced by the artificial conditions of existence pertaining to advanced civilization. In the former there is commonly undernour- ishment with overwork, while in the latter CANCER AND CIVILIZATION 287 there is habitually an ovemourishment with underwork. In the period from 1881- 1890, Dr. Latham, Register General, found the death rate from cancer in England to be more than twice as great among well- to-do men having no specific occupation, as among occupied males in general, the mortality ratios being 96 for the former as against only about 44 for the latter. If time permitted, a mass of evidence could be adduced to show that cancer is a disease of "hypemutrition" as Williams remarks. This does not mean that normal nutrition can be overdone if all the con- tributing elements are correct. But the complex of modem civilization, with all its temptations and errors in regard to eating and drinking, and living, together with the nervous strain felt everywhere, and the absence of sufficient physical ex- ercise, has produced such a disturbance in the normal metabolism and nutrition, that under some slight provocation a het- erologous growth of certain tissue cells 288 MEDICAL ASPECTS OF CANCER results, with malignant tendencies, in- stead of the normal, homologous, and stabile structures which compose healtiiy tissues; and this departure form normal ceU action we call cancer. This is not the time or place to develop the biochemic changes associated with can- cer which have been abundantly demon- strated, and which confirm the views ex- pressed. These have been presented more or less fully elsewhere. The fact remains that whUe cancer is very infrequent among primitive people and among ani- mals living in a state of nature, it has been shown to increase very steadily in morbidity and mortality with the inten- sity of human civilization, and also among animals as they become domesticated. There can, therefore, be hardly any other conclusion than that this dire disease de- pends largely upon the conditions de- veloped by or associated with our artifi- cial existence, to which is given the name of "modem civilization." CHAPTER XV CABCIKOMA OP THE BTJCOAL CAVITY.* Carcinoma is a malignant disease af- fecting epithelial structures. Sarcoma is one affecting connective tissue cells. Both are commonly called cancer, and both oc- cur in the oral cavity, although the epi- thelial disease is many more times fre- quent than the latter. It will be best to consider them separately, speaking first of epithelial carcinoma. It is especially in regard to this that dentists or oral sur- geons have a great responsibility, for they of all others are most apt to see the dis- ease in its inception; and if entirely neg- lected or wrongly treated, as with ni- trate of sUver, the chances of an ultimate *Bead before tbe Harlem Dental Society, October 17, 1918. 289 290 MEDICAL ASPECTS OF CANCER recovery are immeasurably diminislied. For all agree that the end results of oral cancer are very discouraging, the disease usually recurring after surgical removal and endiag the life of the patient with much misery, except in cancer of the lip when removed very early and well. According to the Mortality Statistics of the United States there were somewhat fewer deaths from cancer of the oral "avity in 1916 than when I reported them for 1914. In 1914 there were 2270 deaths of this class, or 4.3 per cent of the total deaths from cancer. In 1916 there were 2091 deaths or 3.6 per cent of the total of 58,000 deaths from cancer in the regis- tration area. There was, therefore, a dim- inution of 178 deatiis, or nearly 8 per cent, from cancer of the oral davity, in spite of a rise of the deaths from cancer in general. It is to be hoped that this diminution in mortality was due to the prevalence of more rational views in re- gard to the disease : it certainly could not CANCEB OF BUCCAL CAVITY 291 be due to more active surgery, under which the mortality of cancer in general has risen nearly 30 per cent, since 1900, ac- cording to the United States Mortality Eeports. Of these 2091 deaths from cancer of the buccal cavity, or 2.9 persons per 100,000 of the population, 1730 or 82.75 per cent, were males and 361 or 17.25 females; the males were therefore almost five times the number of females. The locations of the disease are given as fol- lows: cancer of the lip 374, tongue 534, mouth 214, jaw 796, others of this class 173. It may be interesting to note that in the United States registration area the mortality from this class of cases has increased more than from cancer in any other locality. Thus in 1916 it was 2.9 per 100,000 against 1.6 in 1900, or 81.3 per cent, increase, while the general in- crease in cancer mortality has been 30 per cent. It is now pretty clearly recog- 292 MEDICAL ASPECTS OF CANCER nized that of all those affected with can- cer, in various regions, about 90 per cent, die from the disease. The early recognition of cancer of the buccal cavity is not always easy, even to the expert. But one should always re- member the possibilities and seriously consider even small lesions in this locality, for what appears to be an innocent mucous irritation may, under proper conditions of the system, end in a most malignant and serious disease. There is not time, nor is this the occasion to discuss what these con- ditions of deranged metabolism are which induce cancer; they have been fully pre- sented elsewhere. All are aware of the re- markable healing powers of the tissues of the mouth, as after extraction of teeth, ac- cidental injuries, and various operations, in spite of the great numbers of various micro-organisms found therein, and it seems strange that its tissues should ever take on such malignant action as may occur. This certainly points to some con- CANCER OF BUCCAL CAVITY 293 stitutional alteration of the blood which favors this morbid departure from normal cell action. Suffice to realize that cancer has its starting point in cells which have been previously healthy, and that long con- tinued irritation is the local cause of the development of the disease in some par- ticular locality. Especial care should there- fore be given to any lesion which has per- sisted for some time, and when in doubt as to the nature of the sore skilled ad- vice should be sought. Cancer is not an entity, a something which has been in- troduced from outside, an infection; it is not infectious or contagious at any stage, for no surgeon, nurse, or pathologist in contact with cancerous tissues has ever been infected, and laboratory experiments have always failed to inoculate human cancer. Cancer is simply a disordered ac- tion of originally normal or healthy cells, which continue to act in a disordered man- ner, increasing steadily, exercising their 294 MEDICAL ASPECTS OF CANCER malignant influence on surrounding tis- sues, and, unless checked, producing a hor- mone, or something, which ultimately de- vitalizes the blood and causes death. During its various stages epithelial can- cer in the oral cavity presents quite differ- ent appearances. In its earliest phases it is nothing but an eroded surface, non-in- flammatory, discharging but little, and with rather sharp margins. As it pro- gresses the edges harden, and there is some superficial ulceration. Later it at- tacks deeper tissues, spreading also periph- erally and ulcerates more, and the ad- joining glands beneath the jaw are en- larged. In early stages there may be little or no discomfort, but as the disease pro- gresses there is lancinating pain and ir- ritation from food. Later the pain may be more distressing, while in recurrent cases, after surgical operation the pain and agony become unbearable and the condi- tion of the patient most pitiable, until death ends the scene. CANCER OF BUCCAL CAVITY 295 There are a number of diseases whose lesions appear in the mouth, which are to be differentiated from epithelial cancer. 1. Aphthous stomatitis, or canker sores, are perhaps the most common lesions found in the mouth, and may be impor- tant as the possible starting point of can- cer, especially if they are "touched up" with nitrate of silver, as is so commonly done, but which should never be done. They are the result of disordered diges- tion, and some persons have repeated at- tacks with each recurrent stomach de- rangement. They are commonly multiple, round or oval, inflammatory in character with superficial ulceration, appearing sud- denly with some little soreness. They usually disappear soon after the patient is placed under proper digestive treat- ment, with a mild mouth wash of bicar- bonate of soda and frequent touching of the spots with burnt alum powder, ap- plied with moistened finger. If one or more of them persist it is always weU to 296 MEDICAL ASPECTS OF CANCEE consider the possibility of its being the beginning of a true cancer. 2. Simple vlceration of the tongue or buccal cavity should always receive care- ful attention, and if persistent should be regarded with suspicion as a possible antecedent of cancer. This may be caused by broken, rough or decayed teeth which of course should be most carefully at- tended to by the dentist. Sometimes they are caused by ill-fitting or rough plates, and in certain instances I have believed tha/t a red rubber plate has been the cause, when the trouble has ceased after a black rubber or gold plate has been sub- stituted. Tobacco often plays an impor- tant part, as it has been often shown that smoking, especially of a pipe, is largely responsible for the occurrence of cancer of the lip. Alcohol may also have a share. Some such causes for the local appear- ance of cancer in the mouth seem prob- able from the fact mentioned that nearly five times as many men as women die CANCER OF BUCCAL CAVITY 297 from oral cancer. In the East, where the practice of chewing a mass composed of be- tel leaves, tobacco, and lime is customary, by men and women, these malignant lesions are seen in the month of both sexes. 3. Syphilis. Syphilis is a great disease with many manifestations, and mouth lesions are not uncommon at some period of its course. These are sometimes diffi- cult of absolute diagnosis, though the "Wassermann blood test may often be of great help. It is hardly possible here to go over the whole ground of differential diagnosis, but some suggestions may be of value. Syphilis may appear in the mouth as the primary lesion, or chancre, mucous patches, and late gummy lesions. The primary sore, the seat of infection, according to large statistics, occurs extra- genitally, generally in an innocent man- ner, in something over 5 per cent, of all cases of syphilis. Of these a very con- siderable proportion occur about the mouth, quite sufficient to make it an ob- 298 MEDICAL ASPECTS OF CANCER ject of interest, in this connection, and should never be forgotten. In a study of extra-genital chancre,' I was able to col- lect from literature, 9058 cases of which 1810 were on the lip, and 1544 within the mouth, making a total of 3354 chancres in this region, or 36.6 per cent, of all cases. Of the oral cases 734 are record- ed as in the buccal cavity, 307 on the ton- sils, 264 in the throat, 157 on the tongue, and 42 on the gums, a considerable num- ber of which were attributed to infection through dental work or instruments. The dentist should never forget the danger of syphilitic infection of himself or patients when unusual lesions are found on the mucous membranes. The chancre begins as a small abrasion which soon hardens and remains many weeks, giving off a glairy mucous secre- tion, which, of course, is very contagious. As stated, over one-half of the cases oc- 'Bulkley: Syphilis in the Innocent. New Tork, 1894. CANCEE OF BUCCAL CAVITY 299 cur on the lips, generally the lower, as a button-like lesion which is sometimes mis- taken for cancer and excised. Mucous patches are the principle source of danger of infection. These are flat, superficial, rather pearly white, mucous lesions, of which there are generally sev- eral, commonly sharply defined and giv- ing off a sticky secretion. In the early stages of syphilis they are intensely con- tagious and are the cause of most of the cases of syphilitic infection, both genital and extra-genital, a chancre developing in the site of inoculation. Mucous patches may appear at any period of syphilis, but in the very late stages they are less contagious. The late gummy lesions of syphilis, es- pecially on the tongue often resemble ad- vanced cancer very closely, and indeed are occasionally the starting-point of true can- cer. They are very slightly, if at all, con- tagious. 4. Leucoplakia. This consists of a 300 MEDICAL ASPECTS OF CANCER rather pearly white, often streaked con- dition of the mucous membrane, commonly on the inside of the cheeks and tongue which is most rebellious to treatment, and commonly persists a long time; it is to be distinguished from mucous patches and is not at aU contagious. It is relatively rarely seen in females, and it is commonly regarded as caused by tobacco ; but it also occurs in those who have never used the weed. It should never be "touched up" with nitrate of silver, as this may goad a relative innocent affection into cancer. The main interest of the dentist in this disease is that it is claimed to be a pre- cursor of cancer, and any ulcerative change in it should always be regarded seriously, and the dentist may often be the first to give the warning. 5. Tuhercidar lesions or Luptis occa- sionally resemble cancer in the buccal cavity, but they are very rare. They oc- cur on the tongue and gums, and consist of rather soft, pulpy tissue, a little darker CANCEE OF BUCCAL CAVITY 301 than normal, which bleed rather easily, and do not harden up like cancer. On the lips the dentist may frequently see lesions which may be precursors of cancer, and they may be the first to give warning. Prolonged fissure of the lip is always significant, and cannot be too care- fully guarded. Any persistent ulceration, from biting the lips, smoking, or even after a "fever blister," should always be regarded seriously. Sarcoma. This differs in many re- spects from the epithelial disease just described, or epithelial cancer, although it also passes under the name of cancer. Although sarcoma is much less frequent than carcinoma, it is of interest to the dentist who may often be consulted about it before it is seen by the surgeon. It is a deep-seated disease, affecting mainly the upper and lower jaw, and the dentist may be first consulted on account of the deep-seated pain, supposedly from the teeth. These are extracted but the pain 302 MEDICAL ASPECTS OF CANCER continues and the gum becomes swollen and red. Presently a tolerably definite mass is formed, often at the site of ex- traction, which is hard on deep pressure, but with swollen, purplish gum tissue over it. Sometimes the tumor first ap- pears at the side of the lower jaw. In the upper jaw it often starts in the an- trum of Highmore, and is not seen in the mouth until there has been a considerable growth, even pressing in the vault. Sar- coma has none of the early characteristics of epithelioma, as previously described. It occurs far more frequently in the young than in the old, the reverse of carcinoma. Malignant disease, carcinoma and sar- coma, is in general much more prevalent in older than younger persons; according to the United States Mortality Statistics there were but 29 deaths, 16 males, and 13 females, below the age of 25, out of a total of 2091 deaths from cancer in this locality. After 25 years of age the number rises steadily and rapidly, and CANCER OF BUCCAL CAVITY 303 the deaths are singularly equal in each of the five years from 55 to 74, namely 263, 282, 278, 269, a total of 1091 deaths, or over half the total number in these twenty years of life against 29 in the first 25 years. Carcinoma of the buccal cavity is a most important subject, and it is well for dentists to bear it constantly in mind, for the sake of suffering humanity. Their work lies mainly along the line of prevention, for when far advanced it is practically hopeless, almost constantly re- curring in an even more terrible form. Earely do I consent to a surgical opera- tion within the mouth, though in early cancer of the lip a very radical and per- fect operation may be successful. Radi- um has proved of value in some cases, even within the mouth, but a proper and perfectly carried out medical treatment I am confident, from experience, yields infinitely better results than surgery. It is never safe to excise a portion for mi- 304 MEDICAL ASPECTS OF CANCER croscopic examination, as this most cer- tainly leads to wide infection and dimin- ishes greatly the possible chances of any advantage from a later radical operation, or of the success of medical treatment. This is not the place to dwell on the treatment of carciaoma of the oral cavity, for I do not suppose that you undertake such cases. But a few words may be said ia regard to the part the dentist may play in averting this dire disease. As has been intimated, some of the main exciting causes or oral cancer arise from irritating, broken, or decayed teeth, and also from ill-fitting plates. It be- hooves the dentist, therefore, to search for these and to remedy them effectively. .In the case of prolonged irritation or ul- ceration of the mucous membrane good warning should be given the patient not to neglect it, but to seek and follow at once the proper advice. In what has been said a warning has been given against the employment of ni- CANCER OF BUCCAL CAVITY 305 trate of silver within the mouth, or to epithelioma anywhere. I cannot urge this too seriously, for by its injudicious ap- plidation lesions which originally were quite innocent, or would remain harmless, may easily be goaded on to take on maUg- nant action, in systems predisposed there- to. Nitrate of silver cannot cure them, and I regard its use as an almost criminal procedure. All stimulation should be carefully avoided, and all sources of ir- ritation should be removed. Carcinoma- is known to develop under conditions of acidity, as in the stomach, large intestines and urinary bladder, and the saliva is generally found to be acid in these cases, and often excessively and persistently so. Only mild mouth washes should be em- ployed, and of these a fairly strong solu- tion of bicarbonate is about the best, soaking the mouth freely with it half an hour before and soon after eating. It is difficult to cover so large a sub- ject as cancer of the oral cavity in a 306 MEDICAL ASPECTS OF CANCER single address, but I trust that enough has been said to invite discussion and to lead to more observation, thought, and study on the subject. If one could know and see some of the frightful ravages in late and recurrent cases of this disease, which caused the death of over 2000 per- sons in the United States during the year, surely every endeavor would be made, by everyone who had the opportunity, to lessen this suffering and mortality. As the profession and the public become edu- cated as to its predisposing and exciting causes, it is certain that this morbidity and mortality will decrease, even as the deaths from tuberculosis have declined almost 30 per cent, from 1900 to 1916 under careful medical supervision; while those from cancer have risen almost 30 per cent., during the same time, under the care which has heretofore been given. And I am confident that the dentists can contribute no inconsiderable share in bringing about this most desirable result. CHAPTEE XVI WHAT SHOULD THE MEDICAL PEACTITIONEB DO ABOUT CANCEB? * The answer to the question, "What should the medical practitioner do about cancer?" in accordance with modern cus- tom, seems plain, namely, "Leave it to the surgeon." But why, and is this really the correct thing to do? Or, shall the disease be left to the advertising quacks? It is now pretty generally believed by the medical profession and the laity that surgery offers the only hope in cancer. However, I hope to show that real cancer, other than epithelioma of the skin — on which latter so many of the arguments for surgery are based — is a medical rath- *Read before the Litchfield County (Connecticut) Medical Society, July 3, 1917. 307 308 MEDICAL ASPECTS OF CANCER er than a surgical disease, and that with proper and prolonged dietary and medi- cal treatment the results are far better than from surgical intervention. Careful medical attention must b^ given to the disease if we ever hope to diminish the distressing increase in its morbidity and mortality, as I have many times tried to show. The reasons why the medical profession and the laity have so universally accepted the dictum that cancer belongs to the do- main of surgery are not difficult to dis- cern. The medical profession, being occupied largely with acute disease, with apparent- ly definite and speedy results, very natur- ally became discouraged by the unsatis- factory course commonly observed in can- cer; as was the case in regard to tubercu- losis, until the revival of interest in the latter in recent years, with the well-known beneficial consequences, to be considered later. CANCER IN GENERAL PRACTICE 309 Then the surgeons took up the treat- ment of cancer, and, as the wounds gener- ally healed well after excision and the immediate results of the operation seemed favorable, little thought seems to have been given to the constant recurrence in subsequent years, for unfavorable statis- tics are seldom published. By the brilliant advances in modem surgery along many lines, the laity have become so obsessed by the idea that in many directions its possibilities are limit- less that the cancer-patients have con- stantly yielded themselves to the knife, in the face of the steadily rising mortality of late years. The glamor of surgery aud its often spectacular results have quite blinded the eyes of many to the real facts. The enormous accomplishments with the microscope with reference to the minute structure of the diseased tissues, and the elaborate and extensive work done in ani- mal experimentation, together with the expressed opinion of many laboratory- 310 MEDICAL ASPECTS OF CANCER workers that cancer is a local disease, only requiring early extirpation, have turned the thoughts of many away from the homely and practical studies of the human frame in its various departures from health. In this way, relatively little at- tention has heen given to its biochemistry and the deranged activities of the various organs. We have also studied too little the perverted metabolism resulting from the stress and strain of modern life, to- gether with the temptations as to eating and drinMng that accompany the existing intensity of present-day civilization. Cancer being left to the surgeons, it is hardly to be expected that they, would in- cline to any other treatment than that with the knife. Nor would one expect that the surgeon would think along medi- cal lines and investigate metabolic condi- tions, when the immediate results of opera- tions seem, often, to be so satisfactory. Neither would one expect the surgeon to seek from statistics the unfavorable as- CANCER IN GENERAL PRACTICE 311 pects of this line of treatment, but rather, those from which he would draw encour- agement in trying to overcome so dire a disease. It is to be observed, however, that of late years even the surgeons have ex- tended the time after which cancer can be said to be cured, from a former two years limit, to three, five or more years, while some are candid enough to say that no definite period can be set, for often recurrences have been observed ten, fif- teen or twenty years after surgical re- moval. This agrees with the more ra- tional view of regarding cancer as a con- stitutional metabolic disease, which may manifest itself anywhere and at any time, whenever the systemic conditions of the individual are suitable for a new develop- ment of the malignant new growth to be generated. What, then, should the general practi- tioner do with reference to cancer? Let us look for a moment as to what 312 MEDICAL ASPECTS OF CANCER proper medical, dietary, and hygienic treatment has done for tuberculosis, de- spite the persistience of tubercle-bacilli in affected subjects. In 1900, in the regis- tration area of the United States, 201.9 persons out of each 100,000 population died of tuberculosis. In 1916, under care- ful medical guidance, the number of these deaths had fallen to 141.6, or a decrease of 60.3 persons per 100,000; in other words, 29.86, or almost 30 per cent. Now, during the same period, the re- corded deaths from cancer had risen, under active surgical care, from 63 per 100,000 population, to 81.8, or 29.84 per cent.-r-almost exactly the same percentage that deaths from tuberculosis had fallen. Thus the death rates of the two diseases have approached each other with an amaz- ing regularity almost 60 per cent., so that while in 1900 they were 139.9 points apart, in 1916, they were only 59.8 points apart ; at this rate of increase of cancer deaths and decrease in deaths from tuberculosis. CANCER IN GENERAL PEACTICE 313 the former will soon claim more victims per 100,000 population than the latter. It may be interesting here to mention the latest information in regard to the cancer death rate in New York City, as obtained by a study of the actual figures furnished by the local board of health in its weekly reports. During 1917, there were 4,859 deaths recorded from cancer in New York City (2,143 males and 2,716 females). This total number divided by 365 days gives an average of 13.31 per- sons dying daily from this cause in New York City! During 1916, there were 4,635 deaths from cancer, or, an average of 12.68 persons per day. Further: in the year 1917, there was a total of 78,467 deaths from all causes in Greater New York, against '77,948 in 1916— an increase of 516, or less than one per cent.— whereas the increase of cancer deaths was 224, or over four and one-half (4.5) per cent. What, then, I again ask, should the gen- eral practitioner do in regard to cancer? 314 MEDICAL ASPECTS OF CANCER Evidently, he should not pursue a plan of treatment that shows a steadily increas- ing mortality, so that now it is about agreed that 90 per cent, of those once af- fected with cancer die from it! This would not be tolerated in any other dis- ease. It is high time, indeed, for the medical man to take up earnestly the study of cancer in its medical relations and to seek to understand its cause and to seek to rectify the systemic errors that lead to the formation of heterologous, malignant tis- sue, or tumors, instead of to the homolo- gous tissues of health. The limits of this article do not allow of a discussion of the real nature and cause of cancer and its medical treatment, which have been pretty fully presented elsewhere, but a few practical sugges- tions may not be out of place. All nutrition, good and bad, comes from the food and drink taken. Under normal conditions, the cells of the various tissues CANCER IN GENERAL PRACTICE 315 of the body are contimially subjected to catabolism, "a breaking down of complex bodies of living matter into waste prod- ucts of simple cbemical composition," and anabolism, or "the process of assimi- lation of nutritive matter and its conver- sion into living substance," these together constituting metabolism. In effecting these metabolic changes in the system, the vari- ous secretory and excretory organs of the body, including the ductless glands, each perform a certain part, and in health the final results are carried off by the lungs, kidneys, bowels, and skin, in an orderly manner. In various chronic disorders of the sys- tem, from different causes, including er- rors in eating and drinking, there is some disturbance in the operation of some of the organs, with an altered blood current, and there result various derangements in the tissues, to which derangements we apply, respectively, the names of different diseases, one of these being cancer. 316 MEDICAL ASPECTS OF CANCER Cancer is simply the misgrowth of epithelial cells, such as had previously been normally produced — as all patholo- gists agree. Microscopic studies have demonstrated that within the cells the earliest cancer-genetic change is found in a certain disturbance in the polarity of the cells; also in the relation of the centrosome to the nucleus, whereby the cells multiply, by a deranged karyokinesis, in an irregular, luxurious, and riotous manner, this resulting in what is known as cancer. Why or just when certain cells begin to take on this heterologous action has not been determined : for no one has ever seen and recognized the very begiimings of the malignant process in true, internal cancer, any more than has been seen and recog- nized the first inflammatory change in the tissue of the gouty toe, and the like. Suffice to say that there must be a cause; and this has been well defined as a sub- catabolism, induced by hyperacidity or CANCER IN GENERAL PRACTICE 317 oxydase deficiency in the surrounding me- dium or blood plasma, especially tlirough the agency of the myeloid leukocytes, which contain a ferment of the oxydase variety. All this speculation, though, and much more that has been advanced, really helps us very little in explaining the true patho- genesis of cancer ; still, it has its practical bearing with regard to the prophylaxis and treatment of the disease. For oxy- dase has the property of deamidizing, that is, destroying amidoacids, or the nitrog- enous elements, which have been found by many observers to be at fault in can- cer patients. This leads us to the subject of the in- fluence of the nitrogenous diet in the pro- duction of cancer, which I have previ- ously shown, statistically, clinically, ex- perimentally, and analytically, to be a pre- dominating element in the causation of this malady. Several observers have con- firmed the existence of a faulty splitting 318 MEDICAL ASPECTS OF CANCER of nitrogenous elements and an increase of amino-add nitrogen in those afiBicted with cancer. In view of all this, once more, what should the medical practitioner do with regard to cancer? Of course, it is readily seen that the mere excision of the particu- lar local lesion which has developed some- where never can eradicate the systemic error that produced it and which probably will cause a recurrence : nor can the a;-rays or radium-treatments be expected to elBEect such a change. All surgeons agree about 50 per cent, of the cases are inoperable when first seen by them. Of the remaining 50 per cent, few claim more than 25 per cent, perma- nent cure of the general run of cases, ex- cluding those of skin-cancer. This makes only 12.5 per cent, of the total number of cases of true cancer, or about 90 per cent, of deaths, when we consider the number of cases lost sight of or with late recurrences. It would be quite impossible here to in- CANCEE IN GENEBAL PRACTICE 319 dicate the exact lines of treatment, die- tetic, medicinal, local, and so on, that the medical practitioner should pursue, and which have been more or less detailed elsewhere. As the surgeons have been so strenuous of late in insisting on the early recogni- tion and treatment of cancerous lesions, so as to medical treatment the best results can, undoubtedly, be secured by the earli- est possible detection of the disease. As patients recognize that they can escape the knife and that there is a far greater ex- pectation of cure by means of proper and prolonged medical treatment, they will be less inclined to hide the trouble until too late, and it can be more easily overcome by proper medical care. People, therefore, should be encouraged to report any questionable signs of the disease at the earliest possible moment, and the case should be minutely investi- gated and active treatment begun at once, and continued even long after all tangi- 320 MEDICAL ASPECTS OF CANCER ble signs have disappeared for some time. For, the dietary and other proper meas- ures looking toward the correction of the faulty metabolism leading to the dis- ease are harmless and often beneficial to those who may not have cancer. In ad- vanced and even inoperable cases, very active treatment may often be of the greatest service, as I have elsewhere shown. CHAPTER XVII OONCLXISIOlirS AND EBSULTS " If the statistics quoted in the preceding pages are correct, and they can be readily proved, if the statements ia regard to laboratory researches are authentic, and they can be verified by literature, and if the affirmations of the writer, in this and the preceding volumes, as to results ob- tained by medical treatment are credible and believed, serious attention should be paid to "the real cancer problem" as presented in the Second Volume. In re- gard to no other disease has the profes- sion and the laity been so blind as it has been in regard to cancer. But from jour- nalistic literature and personal communi- cations it would seem that the medical portion of the profession is beginning to '■ Read before the North Western Medical and Surgi- cal Society, New Tork aty, February 19th, 1919. 321 322 MEDICAL ASPECTS OF CANCER see matters in their right light, and the day dawns brighter for the elimination of the fearful morbidity and mortality of cancer. What are we to conclude from our studies on cancer, as represented in the preceding pages? Is the cancer problem solved completely? By no means; it has only begun to be solved; but there are here indicated the lines along which the best prospects are offered. For it is evident that surgery alone has had its day and has failed. Much more observation and study are needed, both in the laboratory and on patients, but along lines quite different from those heretofore followed. The mi- croscope has revealed about all that is possible in regard to the histological char- acters of the diseased tissue and the mor- phological elements of the blood. It is refreshing to observe in the report of the Research Laboratory of the Memorial Hospital, signed by Dr. Ewing, that "The extension of research to clinical questions CONCLUSIONS AND EESULTS 323 made possible by the increased endow- ment has not restricted the laboratory studies, but on the contrary has greatly added to their nxmiber and importance. The main topic being investigated in- clude the influence of diets upon cancer in lower animals, the chemical changes in the blood and in tumor tissue, etc." It would be well if it had been added "also in patients in the earlier and later stages of cancer," — ^but this will undoubtedly follow and unquestionably will be rich in results. What are we to think of the facts and figures presented in the preceding pages? Can they be ignored? For they have never been refuted in print or in open dis- cussion, although abundant opportunity has been offered in many medical societies and the challenge is still open. With the marvellous diminution in the death rate from tuberculosis under rational treat- ment, can we refuse to apply the same, properly devised, to cancer, whose mortal- 324 MEDICAL ASPECTS OF CANCER ity has risen so alarmingly under the treatment thus far given to it? Can it be anything but a willful ignorance to ignore this line of effort? In the preceding pages the medical as- pect of cancer has been presented in al- most every possible light, repeating neces- sarily much that has appeared in the two previous volumes. Its connection with diet has been developed statistically, ex- perimentally, and clinically. The meta- bolic changes constantly observed in pa- tients with early and late cancer have been recorded, as also the definite changes in the blood. "What is lacking to carry a conviction which shall result in a general change of view, as to its systemic or constitutional character, in place of a purely local nature of the disease? Con- stant new development of cancerous le- sions after surgical removal, metastases, or development of the disease in internal organs, and the later phenomena ending in death, all surely point to something CONCLUSIONS AND EESULTS 325 more than a local disease. Malignant primary disease in deep organs, the brain, pancreas, kidney, liver, certainly cannot be accounted for by local injury. The thesis or theory of a systemic or constitutional origin of malignant as well as non-malignant growths is fully sus- tained by all that is summed up in the one word "nutrition," We know that wrong nutrition accounts for tuberculosis, rickets, obesity, and many complaints, and we know that nutrition depends upon the food and drink taken; and we know that proper nutrition accounts for the marvellous re- sults obtained in tuberculosis, in spite of 'the continued presence of tubercular ba- cilli. We know, further, that good or bad nutrition depends also upon the proper or improper action of one or more of the various internal organs, and is also in- fluenced by nervous conditions. What reasonable objection can be raised to the assumption that cancer is also due to er- rors of nutrition? K the latter is true it 326 MEDICAL ASPECTS OF CANCER follows naturally that the exactly proper food and drink, together with correct ac- tion of all the internal organs, will pre- vent and cure cancer. In the first volume it was remarked that "the test of everything lies in the results obtained. Theories, discussions and argu- ments are all unavailing unless results show their truth." This phrase was re- peated with more force in the second vol- ume. It is now four years since those words were first written, and they can now be repeated again with still greater confidence. For these and former years of further observation and treatment of* patients with cancer have abundantly demonstrated the correctness of the thoughts presented, while the study of lit- erature has served only to confirm the views which have been held, and on which practice has been based for thirty and more years. In some few reviews of the previous CONCLUSIONS AND EESULTS 327 agnosis of the cases reported was founded on clinical grounds only and was not es- tablished by the microscope. In answer to this it may be said that in virtually all the cases recorded then or now the diagnosis had been made previously or confirmed by one or more surgeons, who had urged, and ia some instances ar- ranged for, immediate operation. Also it is well known that biopsy before operation is universally condemned, and it would be particularly dangerous in patients who underwent only medical treatment. Fur- ther, it is to be remembered that of the vast nimiber of cases operated on the di- agnosis before operation is almost invari- ably clinical. Reference and further report may be made concerning some of the cases re- ported in previous volumes, as illustrat- ing and impressing what can be done for cancer by non-surgical measures. In the first volume eight cases of can- cer of the breast were reported, from 328 MEDICAL ASPECTS OF CANCER among many others, two of whom were followed, remaining perfectly well, sixteen years after first beginning treatment. The second two cases had been watched and continued perfectly well for nine years under medical treatment alone: that was four years ago, and, traced recently, they remain still well, thirteen years after being first seen. The next three cases were of inoperative recurrent cancer, one of whom showed most remarkable gain during her stay of four months and a half in the New York Skin and Cancer Hos- pital, the details of which were fully re- ported. One of the cases, in private prac- tice, was watched almost sixteen months, and when lost sight of, that she might take a3-rays nearer her home in the coun- try, a very large share of the cutaneous nodules had disappeared, and she had lived comfortably and without pain, and the disease which would have carried her off long before had certainly in a measure been djeoked. The last case was de- CONCLUSIONS AND RESULTS 329 scribed as showing how much could be done even in a most hopeless condition. The lady for two years had neglected a diseased breast, until it was the size of half a melon, hard and immovable, with some superficial ulceration and with enor- mous axillary and supra-clavicular glands and profound cachexia: the trouble had been revealed to no one until the day be- fore her visit, when a physician and sm- geon pronounced it hopeless. For seven months under careful treatment she lived comfortably, the breast softening very greatly, and diminishing to about the size of the other, and the glandular swellings becoming about one-half the size. She passed peacefully away with exhaustion and pulmonary oedema, about seven months after being first seen without hav- ing taken a particle of morphia or other hypnotic. In all my cases, even in recur- rent cancer, it has so rarely been neces- sary to use these that I can recall hardly any instance where they were employed: 330 MEDICAL ASPECTS OF CANCER when under full dietetic and medicinal treatment tlie element of pain is almost negligible. Opiates check the secretions and excretions, and retard metabolism, and in my experience increase the ten- dency to an extension of the carcinosis. In the second volume nine more cases of malignant neoplasm were reported, in which the results of this line of treatment were shown. One was a very remarkable case of sarcoma of the upper jaw, recur- rent after operation. The final result of this was a plastic operation to cover the large ulcerative opening which had com- pletely healed in about four months, dur- ing which time she had gained from 89i/^ to 130 pounds, which latter was 10 pounds more than she had ever weighed before. The thick skin graft to cover the opening took at once perfectly, and she remains weU two years since I reported the case. Six cases of cancer of the breast were recorded, three primary and non-op- erative, and two of recurrent cancer, one CONCLUSIONS AND EESULTS 331 of whom had been submitted to four op- erations, and the last one with an im- mense ulcerative mass of the right side of the chest, which was transferred to my medical service in the hospital by the surgeons, as being absolutely inoperable. This last patient made a splendid fight, for about a year, gaining ia flesh, with a blood count raised to 4,110,000, and sleeping well without the opiate she had previously taken. The case was a very difficult one, as the kidneys refused to excrete anywhere near the proper amount of solids required, and she passed away easily a year after entering my service. Of the other two cases of post-operative cancer of the breast, I may report that the one who had had four operations (case IV) did remarkably well for a while, al- though when first seen there was a large ulcerating surface over the site of former operations, on the left side, with axillary glands enlarged, and a greatly swollen left arm. Five months later she wrote 332 MEDICAL ASPECTS OF CANCER that she felt very well and "friends think that there cannot be very much the mat- ter with me." She made occasional trips from a distant town until about eight months from the first visit when she fell and broke her hip; treatment was then interfered with for some time and she began to go down and passed away about a year after I first saw her. The other recurrent case where both breasts had been removed two years previously, had a great development of cutaneous nodules on both sides of the chest, forming a veri- table "cancer en cuirasse," She was treated in the out-patient medical clinic of the hospital, and when I presented her at my lecture clinic about four months later her condition was so changed that there was hardly a trace of the nodules on passing the hand over the surface. She had been working hard all the time and had had no pain since soon after be- ginning the treatment. She disappeared soon after that and I could not trace her. CONCLUSIONS AND RESULTS 333 Of the three primary cases, non-opera- tive, in private practice, two seem to have recovered, and the other (Case I) made a most wonderful fight under very adverse circumstances, working very hard and with much family sickness and death. She had a hard mass in the left breast, at- tached to the skin and with enlarged ax- illary glands, and had been given six months to live by a surgeon of prom- inence, if not operated on. The improve- ment in her general condition and the mass in the breast seemed so good, after the first few months that it appeared as if the disease would yield entirely: she had been to Chicago and back by auto, slept perfectly, had no pain and felt perfectly well. Ten months after her first visit she had a very severe attack of grip, being in bed three weeks in another city, and this, with many weeks neglect of treat- ment, set her back, and she was lost sight of about fourteen months after she had been given six months to live. 334 MEDICAL ASPECTS OF CANCER The other two cases were most satisfac- tory. One of them, whose breast tumor was diagnosed as cancer by at least four medical men, one of them a prominent surgeon, remained absolutely free from trouble when examined five and a half years after her first call. The other pa- tient (case 11) was then reported as per- fectly well and free from any breast trou- ble two years after being first seen; she had been confined of a healthy child two years ago, and was examined on Sept. 23rd, 1918, more than four years after her first visit; there was no trace of the breast tumor and she was in excellent health. Two cases of totally inoperable cancer of the uterus, as diagnosed by several sur- geons, were there reported; both had re- covered, as evidenced by the careful ex- aminations of several physicians and sur- geons. One of them (case VII) has been under my constant observation and treat- ment during these two years, travelling CONCLUSIONS AND RESULTS 335 many times from a far-distant city, and is in as perfect healtli as could be desired, still weighing more than she did at first, walking much, and a recent examination reports that both of these cases are "free from any evidence of disease." In the second volume was given a list of the cases of malignant disease, upon which the studies were based, and it is not necessary to refer to these again, nor to detail others of the cases similar to those already reported. Reference will therefore be made to those seen in the two years since its publication, and only those in private practice will be counted, as hospital cases are not nearly as satis- factory as those among the more educated classes in private practice. A considerable number of these patients were only seen in consultation, or a sin- gle time, and a number of them have been treated only for a short period, too short to report definitely concerning them. But there were 21 who were treated suf- 336 MEDICAL ASPECTS OF CANCER ficiently long to observe distinct im- provement, as recorded on their histories. When we realize the ordinary course of cancer, and that when not improving pa- tients constantly get worse, we cannot ig- nore a steady gain. And in the light of the cases previously mentioned, we must realize that when one improves and goes up hill in regard to the disease and in general health continuously, one is not likely to go down hill at the same time; and, moreover, if the same conditions and treatment are faithfully persisted in long enough, there is reason to expect that the final result will be favorable, as it has been in so many instances during the many years past. During the last two years, since the second volume was published I find case histories, more or less complete of 140 new cases of malignant disease affecting different locations. Of these 43 cases were of cutaneous epithelioma, which lat- ter are excluded from our present study. CONCLUSIONS AND RESULTS 337 as are also a number of cases of suspected cancer and non-malignant tumors. Of the remaining 65 cases there were 39 patients with cancer of the breast, 3 of the uterus, 5 of the stomach, 2 of the rectum, 1 of the bladder, 1 of the kidney, 2 of the prostate, 5 of the buccal cavity, 32 of the lip, 1 of the axilla, and 6 of sarcoma, three of which were in the buccal cavity. These cases were seen in all stages of the disease, 27 were recurrent after from one to three operations, and 38 were pri- ma,ry cases. With hardly an exception, I believe all the latter had been seen by other medical men, who had made the clinical diagnosis of cancer, and many had been strenuously urged by surgeons of re- pute to have an immediate operation, as the only hope of saving life. I have else- where mentioned the universal belief among the best men that to attempt to take a section for microscopic examination is extremely dangerous in surgical cases, and it would be almost fatal in those 338 MEDICAL ASPECTS OF CANCEE treated medically. Many of the recurrent cases have experienced the greatest ben- efit from the line of treatment advocated in these volumes, as indicated in some of those previously reported, and in those to be given. In some instances life has been prolonged far beyond that expected and prognosticated by the surgeon, and with a measure of comfort often most gratify- ing. As far as I have learned there have been six deaths, but there were probably many more, as a nimiber of those seen in consultation were far advanced. Brief mention may be made of some interesting points in connection with certain pri- mary and secondary cases. Cancer of the breast. The average age of these 39 patients was just 47, the youngest 27 and the oldest 85: twenty of them were between 40 and 50 years of age when seen. There were 22 married and 17 single. In 24 cases the left breast was affected, in 10 the right breast, both breasts in 3 cases, and unrecorded in one CONCLUSIONS AND EESULTS 339 case. The duration of the disease before observation varied from a week or two in one instance to six years in one lady aged 59, who had never been operated on; the average was about a year and a half, but there were a number of the primary cases who came quite early, and in them nat- urally there were the best results. Of these breast cases 19 were recurrent after from one to three operations, or a;-ray or radium, and 20 were primary, who had hever been operated on. I must first mention one additional, very interesting case treated in the medical clinic for can- cer at the hospital. Case I: Mrs. S. J., aged 33, first no- ticed a lump in the right breast two months previous to her visit, Feb. 28th, 1917. This steadily increased until seen, when it was fully an inch and a half in either direction, in about the median line above the nipple, with sharp rather hard edges, and a small, palpable gland in the axilla: she had been having sharp pains 340 MEDICAL ASPECTS OF CANCER radiating from the breast to the axilla. To confirm the diagnosis I called in the surgeon in attendance who at once recog- nized it as carcinoma and strongly urged an immediate removal, as the only hope, my assistants also agreeing as to the di- agnosis. She was extremely constipated, the mouth dry and the saliva acid. She was placed on the usual dietary and me- dicinal treatment and in two weeks it was recorded that she felt better than for a year. The lump was materially smaller, though the edges were sharp and nodular. There was no pain except in extreme ex- ertion, doing her housework and caring for two children. She was faithful to treatment, generally coming every week, and six months later it was recorded that the lump had markedly diminished, being about an inch in diameter, and very shal- low, and with absolutely no pain. Six months still later practically nothing could be felt. About a year or more after her first visit three physicians were told CONCLUSIONS AND EESULTS 341 that she had had a breast tumor, and all of them feeling the breasts decided that it must have been in the left breast, in- stead of the right, as there was a slight shronic mastitis there. Very recently a fourth physician made the same mistake. She had been pregnant and gave birth to a dead bom child. When seen recently, nearly two years after the first call, there was nothing to be felt in the right breast, but still a little chronic mastitis in the left. • One of my assistants recently reported to me a very similar case, where the lump had disappeared, and after a year the same mistake was made by a doctor ex- amining both breasts, who decided wrong- ly as to which had been affected. Case II: Miss C. M. S., aged 35, seen first January 15th, 1917. Six months be- fore she had a severe blow on the right breast which soon enlarged and was pain- ful, it had been poulticed and iodex ap- plied. When first seen there was a lump. 342 MEDICAL ASPECTS OF CANCER the size of an English walnut, quite well defined, and with darting pain; no axil- lary glands were felt, though small en- largements developed two months later, as she had neglected the treatment given. After a few weeks of rigid treatment the breast was softer, with some pain and drawn feeling. Two months later the right breast felt almost the same as the left, though there was still a sharp njar- gin in one place. When last seen, about 18 months after the first, the right breast was normal, but a little caking in the left breast, and she had had some little feeling in both breasts during menstrua- tion. This was a difficult case to handle, as she had much care, work, and trouble keeping a boarding house, with her mother sick at times. She had much gastric dis- turbance and was much constipated before treatment. Case III: Miss Gt. D., aged 45, was under treatment for eczema which had about disappeared, when on January CONCLUSIONS AND RESULTS 343 22nd, 1917, she called attention to a lump in the left breast which had existed for six months or more. It was just above the nipple, the size of an egg, with sharp edges and some adherence to the sMn, with some glandular enlargement and sharp pain occasionally. This patient has been under frequent observation and constant treatment now for almost two years, and while the lump has not wholly disap- peared it is not one-half the size, is softer and without the sharp edges, and the glands can hardly be felt: there is rarely any pain, except after much exertion. She keeps her color and weight well, and has been active as an attendant upon an elderly lady. There is every reason to believe that the absorbing process will go on, as she is very faithful to treatment, and that ultimately the trouble will dis- appear entirely. Case IV: Mrs. G. K. L., aged 59, re- ceived a slight blow on the inner upper quadrant of the left breast, and immedi- 344 MEDICAL ASPECTS OF CANCER ately felt a peculiar sensation which passed off, and the lump was not noticed until four years ago. Since then the breast has felt heavy and gradually the mass increased in size, until it was about 3^ inches in diameter, hard and charac- teristic, when first seen, with some en- larged glands in the axilla. She had been under a partial "Green card" diet for a year. Being placed on very strict diet with medication, at the end pf three months the tumor had diminished more than one-half in size, and was much soft- er, as verified by another physician. She had gained 4 pounds from the first, in good color, and felt better than she had for a long time. Case V: Miss L. M., aged 55, a recent case, presents points of interest. Four- teen months before her visit, November 4th, 1918, she noticed a small lump in the right breast, which had been kept secret imtil a week previously. It was painful from the first, the pain increasing as the CONCLUSIONS AND EESULTS 345 mass grew, uatil of late it had caused many sleepless nights. When first seen there was a large mass, two or three inches in diameter in the inner upper segment, near the nipple, with a purplish red, pro- truding area an inch in diameter. The whole breast was tense, and the axillary glands enlarged and painful on handling: there was no supraclavicular adenopathy. The almost immediate relief to many symptoms from a strict vegetarian diet, according to the "green card" previously referred to, and appropriate medical treat- ment, was surprising. In a week the tense- ness of the breast had materially lessened, and the pain was decidedly less. After ten days the lump was less hard and the axil- lary glands less prominent. A week later the purplish color had almost gone, ichtarol having been applied frequently from the first, and the axillary glands had dimin- ished one-third or more, as verified by a physician who watched the case with me. While the final result with such a large 346 MEDICAL ASPECTS OF CANCEE tumor cannot be surely foretold, if im- provement should be arrested I might have the offending mass removed by the Strobel chemical extirpation, as was done in the case next to be mentioned. This avoids severing blood vessels and lym- phatics, which are sealed by the caustics, and the process is not commonly followed by the recurrence so common after re- moval by the knife. Case VI: Mrs. L. H., aged 36, came under observation and treatment Septem- ber 20th, 1918. She had had two chil- dren, one 12 years of age, who had been nursed three months, and one six years old. She had much milk in the left breast but the nipple was sore for two weeks and the baby was weaned. Her mother had died of malignant disease of the bladder, at the age of 55. Fourteen months pre- vious to her visit she had first noticed a lump in the left breast, the size of a mar- ble, which had increased gradually, but was supposed to be doing well under CONCLUSIONS AND RESULTS 347 vegetable diet and various medications, until she had a severe blow on that breast two months before coming for treatment; since that time it had increased rather rapidly, with shooting pains extending down the left arm. When first seen there was a large, hard mass in the upper outer segment of the left breast, 2 or 3 inches in diameter, adherent to the skin, with a moderately reddened area, an inch or so in diameter. The saliva was acid and the urinary excretion insufficient in its solid ingredients. Under active dietary and other treatment it was recorded one month later that the breast was less swol- len and less red, but that she still had considerable pain the previous week, dur- ing the menstrual period, and that the axillary adenopathy seemed more pro- nounced, and one or two enlarged supra- clavicular glands were found a week later. She had however done well physically, had gained in flesh a little, had good color, slept well without pain, but had 348 MEDICAL ASPECTS OF CANCER some dartmg pains during the day time. In view of the size of the tumor and her general nervous condition, and the ex- treme tediousness of its medical removal I decided that it would be wiser to have the breast removed by local caustic treat- ment, as I have had a number of my cases so treated at the New York Skin and Cancer Hospital by Dr. Strobel, with good results. The process was begun on Oct. 31st, the last apjilication of the plaster being made on November 9th. On ac- count of the difficulty in reaching and re- moving the enlarged axillary glands, skin grafting was not done until November 26th, when there was still some slough- ing to take place in the axilla. The grafts took perfectly over the breast area, giving a smooth, healthy surface, leaving still some raw space in the axilla, to be treated later. The slough there finally separated on December 8th and skin graft- ing was done December 13th, and has taken well. CONCLUSIONS AND RESULTS 349 One or two cases may be mentioned to illustrate what can be done for pa- tients where the disease has recurred after one or more surgical removals. Case VH: Miss H. K., aged 45, first seen December 17th, 1917, had noticed a lump in the right breast in April, 1915; this had been removed surgically within three months, with a good axillary opera- tion the following July 14th. About the middle of June, 1917, she noticed a lump in the left breast, in the outer, lower seg^ ment. When seen there was a mass the size of an egg, hard and with some ir- regular nodosities; the glands along the pectoral muscle were enlarged, with some doubtful axillary adenopathy. She was always constipated and the saliva was acid ; the menopause had not yet occurred. Placed on a strict diet and medication she has been very faithful, though living in a distant city, and coming to New York many times up to the present. The tiunor is materially smaller and softer, and no 350 MEDICAL ASPECTS OF CANCER adenopathy can be detected. When we consider what would ordinarily happen in such a case in a year, and contrast her present condition, when she "says that she "feels very well indeed", there is certain- ly reason to believe in the internal rela- tions of cancer. Case VIII: Mrs. B. E., aged 49, had the right breast removed, by a very com- plete axillary operation for adeno-carcino- ma, by one of the leading surgeons in New York, on September 27th, 1916. She had never thought of the breast until five or six weeks before the operation, the lump beginning the size of a walnut and growing rapidly in extent, with glandular enlarge- ment. Four months after the operation, January 30th, 1917, she came under ob- servation and treatment with recurrence in the axilla, a swollen arm, paining and aching, and some areas of tenderness. She had long had persistent constipation, depending on cathartics all the time. She had borne three children, 21, 20, and CONCLUSIONS AND EESULTS 351 13 years of age; the menses had ceased five years. For almost two years she has been a most faithful patient, coming almost weekly from a neighboring town, except during the summers when she was far away, and wrote occasionally. The course of this case has been interesting fcut not wholly satisfactory, showing how deeply seated is the constitutional error which first manifests itself in a single /esion in the breast, and that the early and perfect removal of this could not ar- rest its progress. During these nearly two years with complete and careful carrying out of all dietary and medicinal measures, there have been repeated manifestations of the cancerous dyscrasia, in the way of cuta- neous nodules and erythematous patches, with also axillary and supraclavicular adenopathy, and latterly bone involvement in the sternum and cough, indicating in- ternal adenopathy. But, on the other hand, without this constant and faithful 352 MEDICAL ASPECTS OF CANCER treatment the disease would undoubtedly have had a lethal ending long ago. More- over until quite recently she had had no pain to speak of and has never taken a narcotic, and has been active and with a good color. For the last few months she has had much anxiety in regard to her two sons, who are at the front in France, which has had a manifest effect on the disease. During the treat- ment she has had many applications of the a;-ray to glandular enlargements, and also latterly radium emanation insertion in some of them, and radium to the sternal lesion by a most competent operator. Although the total results have not yet been satisfactory, there is hope that with the nervous strain removed by the shortly expected return of her sons from the war, she may respond better to further treat- ment. Latterly, however, the cough and shortness of breath have increased, and on November 29th, 72 ounces of fluid were drawn from the pleura. This exhausted CONCLUSIONS AND RESULTS 353 her, as learned by letter from her hus- band, in a distant town, and matters look serious. He adds however, "I am fully convinced that you have added consider- able to her life, in comfort and length of days." Cancer of the uterus. Three cases of cancer of the uterus were recorded, one of which was seen only once in consultation, very far advanced and under large doses of morphine for months. The other two, totally inoperable, and ultimately fatal cases, exhibited in a striking manner the great value of proper medical treatment. Case IX: Mrs. N. E. M., aged 55, was first seen December 27th, 1917. She had been examined by Dr. John G-. Clark, of Philadelphia, and others, with the diag- nosis, of inoperable cancer, with not over six months to live. There was a "great ragged crater, extending back to the rec- tum and forward almost into the bladder, and laterally to the pelvic walls." She was then examined by one of the surgeons 354 MEDICAL ASPECTS OF CANCEE of the New York Skin and Cancer Hospi- tal, where she was treated, with confirma- tion of the condition, and a very hopeless prognosis was given, of but few months to live. She had two children, 35 and 30 years of age, and the menses were normal ap to their cessation three years ago. But nine months ago she had a profuse watery vaginal discharge and occasional bleed- ings since, with pain over the pubis. On entering the hospital she had an offen- sive bloody discharge. She had been habitually constipated and the saliva was found to be very acid. She was treated, as were the other uter- ine cases already reported, dietetioally and medically, and with a vaginal douche of very hot water, one pint, containing half a teaspoonful of carbolic acid and two of borax, thrown in deeply and strongly with a Davidson's syringe, night and morning, and later also at noon. Within about a month there was a marked improvement in her looks and feelings. The douche came CONCLUSIONS AND EESULTS 355 away clear, with no blood and only a little cloudy with a few shreds, and with no odor. The nrine, which had been scanty, in- creased to quite a normal amount and character, and the saliva became neutral, she slept well most of the time, without much pain in the pubic region. She was given in addition capsules of the pyro- phosphate of iron and her color, weight and vigor improved, so that, in the light of the other cases, it seemed as though she would pull through. But the dullness above the pubis slowly iacreased, with bowel obstruction and tympanites, the urine became scanty and albuminous, with swollen legs and feet and other signs of serious kidney involvement. The blood, which had been fairly normal showed great degeneration, with only 50 per cent, haemoglobin, 1,350,000 erythrocytes, 13,000 leucocytes, of these 70 per cent, polynu- clear, 5 large mononuclear, 50 small mononuclear, 4 transitional and 1 eosini- phile. She finally passed peacefully away 356 MEDICAL ASPECTS OF CANCER in coma on August 16th without requiring or having taken a partide of morphia or other hypnotic, except a small dose 'of chloral and bromide occasionally at night when sleepless. She had some sciatic pain which was helped by the free use of aspirin. When we consider the course of the disease in this patient, with her constant hopefulness and comfort during these eight months, instead of six months or less, as compared with the agony often suffered, especially in cases recurrent after operation, and the amount of mor- phia often taken, there is reason for be- lieving in the value of the proper consti- tutional treatment of cancer. With the enor- mous infiltration of the abdominal viscera, and the great ulceration, the case was, of course, hopeless from the beginning. Case X: Mrs. T. F. V., aged 64, first noticed bleeding from the vagina three months before her first visit, November 23rd, 1917. She had had pain in the back CONCLUSIONS AND RESULTS 357 a little while before, and some bleeding every two weeks, and for a day or two at a time. She had not felt well since Jime, and had lost twenty pounds, weighing 107 when first seen. She had been examined by a surgeon two weeks before, coming from Maine and pronounced to have inop- erable uterine cancer. She was examined here, by a gynaecologist, who found ex- tensive cauliflour ulceration of the cervix, with the uterus of great size. She had had six children, 38 to 28 years of age, and the menses has ceased twenty years ago. She was always constipated, the urine had always been scanty, and the saliva was very acid. The uriae was of low specific gravity, contained a moderate amount of albumen, and the urea low. Under careful dietetic and medical treat- ment, with the same vaginal douche as in the preceding case, she improved greatly, gained two pounds and a half in weight, and "felt like a different person," within a month, coming frequently to the office. 358 MEDICAL ASPECTS OF CANCEE She had relatively little pain, never re- quiring an opiate, and two months from the first it was recorded that she "felt freer from pain during the preceding week than for weeks or months." The douche came clear, and without blood. The urine continued of low specific gravity, but oc- casionally without albumen, and the saliva contiaued very acid. Two weeks later she had a strange attack, with suppression of urine, and she became somewhat irrational, and was moved to the hospital, as she could not be well cared for ia a boarding house. This condition continued for a while, but two weeks later she was per- fectly rational and wanted to go to her home in Maine; she said that she had no pain. She was taken home and died peace- fully 25 hours after reaching there, on March 21st, 1918. She thus lived almost four months in comparative comfort; not taking a particle of morphine or other hypnotic, and died without pain, sleeping peacefully, as reported by letter. The CONCLUSIONS AND EESULTS 359 case was of course hopeless from the be- ginning. Cancer of the stomach. Five cases were recorded, all males, aged 65, 58, 56, 44, and 43, but only one of them is report- ed; one was seen only once in consulta- tion, far advanced, who died not long afterwards. , Case XI: W. B., aged 56, had been sickly and not working for a year before his first visit, August 30, 1916, and had seen many physicians and surgeons, aU of whom diagnosed the trouble as cancer of the stomach. He had had pain in the epigastrium for a long time, with swelling and hardness. On examination there was dullness on percussion over the pyloric region, and a mass could be felt. He had chronic constipation with coated tongue, and was very weak, having lost many pounds. Placed on a rigid diet and strict regulations as to mastication and living, with medication, he improved greatly, looking and feeling much better at the 360 MEDICAL ASPECTS OF CANCER the few visits he made from another city. Seven months later I learned from his brother-in-law, who had brought him, that the patient was very well, and was work- ing again. I realize that the diagnosis is very difficult in these cases, and that he may not have had real cancer, but his whole appearance and the clinical symp- toms, with his cancerous cachexia, loss of weight, etc., indicated the probable cor- rectness of the diagnosis made by several medical men, and the results certainly were most satisfactory. Cancer of the rectvm,. Two cases were recorded, one a woman aged 55 and a man aged 42, the latter only being treated. The former had had an artificial anus made, and subsequently intestinal anas- tomosis for inoperable cancer of the rec- tum, and was seen only once. Case XTE: Mr. R. G., aged 42, came for treatment June 13, 1917. Two and a half years before he had had an operation for ulcer of the stomach, and had had no CONCLUSIONS AND EESULTS 361 trouble until November, 1916, when lie was given Eussian oil for obstinate constipa- tion. About a montb before his visit he was seen by a surgeon of prominence, who diagnosed cancer of the rectum, veri- fied by microscopic findings, and advised an operation, which he refused. When seen he was rather thin and haggard, hav- ing lost a good many pounds, pulse 92 and poor, tongue badly coated. His sleep was disturbed by having to get up three or four times for small thready, bowel movements, of which he had from twelve to fifteen in the 24 hours. On examina- tion there were no external signs of dis- ease, and digital examination revealed little, the disease beiag higher up. Under dietary and other treatment the bowel movements were soon reduced to four in the twenty-four hours, one of them at night, but still watery and generally with some blood, but no pain. Six months later he was haviag often formed move- ments of good size and had been better 362 MEDICAL ASPECTS OF CANCER in every way the preceding month than for a year, with only slight pain in the rectum occasionally: there was stUl a little blood passed, although on April 12th, after an absence of a month, it was re- corded that there was no blood in the passage. When last seen, nearly a year from the first, he was in about the same condition, he had been steadily at work iu a dry goods house all the time while under treatment. In view of the unsat- isfactory results commonly obtaiaed by operation and the distressing condition of a patient after colostomy, the results in this case may be considered satisfactory. Cancer of the prostate. Two cases were seen, aged 74 and 54; one was seen only once. Case XII : B. S., aged 54, had long had enlarged prostate, with frequent urination day and night. He had lost flesh, es- pecially during the six months preceding his first visit, October 26th, 1917. He had then an earthy, cachectic look, was thin CONCLUSIONS AND RESULTS 363 and depressed. On examination by a sur- geon the prostate was found enlarged and the inguinal glands on both sides were greatly affected, forming great masses vis- ible to the eye, there being no lesions on the penis. Under the "green card" diet and medication there was a great change in a few weeks. The patient felt and looked much better. The glands ia the groins had subsided greatly, and shortly thereafter they had quite disappeared, the cachexia was gone, and he had not an ache or a pain. He was lost sight of; and al- though written to did not respond, but I learned by the daily paper that he died suddenly. As in cancer of the stomach a clinical diagnosis is often difficult, but such a result of the treatment was cer- tainly satisfactory and preferable to surg- ical interference, with all its uncertainties. Cancer of the kidney: One case has been under my constant care for two years and the results illustrate well the value of continued internal treatment. 864 MEDICAL ASPECTS OF CANCER Case XIV: Mr. H. H. B., aged 55, liad been indisposed for a year, his color was bad, and work difficult to accomplish. On August 25th, 1916, he passed blood in the urine, and the next day red blood, and also coagulated, with much pain in the back. The a;-ray was said to show noth- ing, nor cystocopy, except blood from the right kidney. This latter was removed on September 1st, in another city, and found to be enlarged four times in size, weighing over two pounds, and shown to be cancerous miscroscopically. He made a good recovery, and had no pain while in bed, three weeks, but on walking had pain 'in the left side, increasing toward afternoon and rendering life miserable up to his coming under treatment January 30th, 1917. The pain generally ceased on lying down at night. He weighed 173^^ pounds, and was a large eater of meat and very fond of milk and eggs; he had never had any restriction of. diet, nor di- rections or other treatment of any kind. CONCLUSIONS AND EESTJLTS 365 Under strict vegetarian diet and varied treatment at frequent consultations, with voluminous notes, he has for two years been able to do his work, has gained 14% pounds in weight, and for long periods has been free from pain, although there are times when he has pain over the left kidney. Eecent notes show that he was "doing normal work" and "stands well the hardest strain," "felt better than for years" and "never had so good a color or circulation." The urine has been watched, measured daily all the time, and frequently analyzed volumetrically and has commonly averaged over 50 ounces daily; the various ingredients are gen- erally about normal, except that the urea is low, owing to the vegetarian diet. He has been, and I believe will be very faith- ful to treatment, which has certainly pro- longed his life and usefulness, and given great comfort and ease. How long it will be necessary to continue active treat- ment it is difficult to say; a relapse to 366 MEDICAL ASPECTS OF CANCER his fonner method of living and entire neglect of protective treatment might naturally be expected to again induce a serious involvement of the remaining kid- ney. He has, of course, never take a par- ticle of morphine or other hypnotic, the pains occurring at times being largely re- lieved by the frequent use of aspirin. Cancer of the bladder. One case of this has been under prolonged treatment with eminently satisfactory results. Case XV: Mr. G. W. H., aged 68, had been under my care for a number of years, for various difi&culties, when on March 27th, 1914, he brought two specimens of urine with clots of blood and a consider- able amount of albumen in the evening sample, and was seen the next day. There had been no especial paia in the back, nor on passing urine, which had cleared since. Three days later he was again passing blood and was feeling weak, and thought he had lost two pounds in weight. He had to urinate every two CONCLUSIONS AND EESULTS 367 tours, twice at night; the blood appeared mainly at the end of the urination. Blood pressure 160, systolic. On April 2nd he was cystoscoped by Dr. A. E. Stevens. The bladder muscosa was found to be normal except near the left urethral ori- fice. Just above this there was a small nodular, well defined, sessile mass, with small blood vessels over its surface, pretty typical of carcinoma of the bladder wall. Eadical excision was advised, or else ful- guration. Declining these very positively he was treated medically for a month, when he yielded and on May 7th Dr. Stevens treated the lesion by fulguration, which was repeated on May 22nd. On August 5th, there was some recurrence seen, in a slight crescentic mass, which was destroyed by high frequency current, with again a slight operation on August 10th. On October 22nd he was cysto- scoped and no sign of recurrence was seen, only a sear. On February 23rd, 1916, there was a small regrowth, not one-half 368 MEDICAL ASPECTS OF CANCER the former size, which was treated with the high frequency current, and again slight- ly on March 2nd. He has been repeatedly cystoscoped since that date, up to the present time, by three urologists, and there are no signs of recurrence now nearly five years from the first symp- toms observed. The patient has been under constant medical treatment, with strict diet all this time, for various troubles attending high blood pressure which has reached 200 systolic, but is commonly kept under control to about 150 systolic and 80 dias- tolic. On December 22nd, 1916, Dr. Stevens found a "large, elastic prostate (not carcinoma)," which, however, seemed to cause no special symptoms until Decem- ber 7th, 1917, when blood clots were found in the urine, which have continued to ap- pear much of the time ever since; these clots show only blood and fibrin, and no evidence of new growth tissue as report- ed by Dr. Jessup. On repeated cystoscopic CONCLUSIONS AND RESULTS 369 examinations no trace of the original or any other trouble in the bladder has been found, but "an adenomatous hy- pertrophy of the prostate and a slight bleeding from the prostatic portion of the urethra." This was confirmed by two other urologists. During all this time under strict regimen and varied medica- tion he has maintained his usual health, color, and weight, and pursued his usual business. Cancer of the buccal cavity. Five cases were observed, four males, aged 47, 48, 59, and 72, and one female aged 44: of these two were of the right upper jaw (not sarcoma), two of the tongue and one of the tonsil; there were also three cases of sarcoma, two of the left upper jaw and one of the right lower jaw, be- sides two other cases of sarcoma located elsewhere. The cases of carcinoma of the jaw were seen only in consultation, one was a terrific post-operative case for which little or nothing could be done. 370 MEDICAL ASPECTS OF CANCER The sarcoma cases were also seen in con- sultation, and one was advised to see Dr. Janeway, for radium treatment. The fe- male with cancer of the tongue was seen once in consultation, the other case, though rather recent, and also the one with cancer of the tonsil are worthy of mention. Case XVI : Mr. K. M. A., aged 59, seen September 11th, 1918, first noticed an irr ritation of the right side of the tongue, from a broken tooth, in May, and on May 11th, it was operated on with a knife and healed so that he went to work on May 20th, with no pain for three weeks. It then began to ulcerate and a knife was again used and it was cauterized on August 5th, and he left the hospital August 11th, five weeks before his visit; since that time the trouble has been increasing rapidly, until when first seen the tongue was enormous, filling the buccal cavity, with a large ulcerative, hard patch, an inch and more on the side with sharp, hard CONCLUSIONS AND EESULTS 371 edges : the submaxillary glands were very large, hard, and matted together, and the case was considered wholly inoperable by the surgeons whom he had seen. He had always smoked much, but took little al- cohol, coffee or tea. The saliva was very acid, the urine contained much indican, also oxalates and phosphates. Being placed on the green card diet, with absolutely no smoking, alcohol, coffee or tea, and with the mixture of acetate of potassa, nux vomica, cascara, and extract of rumex, the improvement began almost at once. He also used a mouth wash of a saturated solution of bicarbonate of soda, diluted one-half, held in the mouth some minutes, a quarter of an hour be- fore and also after taking food. He could take only liquid food, having great diffi- culty in swallowing. By the end of three months the change was most remarkable. The ulceration had ceased at the side of the tongue which had greatly diminished in size, though 372 MEDICAL ASPECTS OF CANCER still hard. He swallowed much better, the jaws opened much wider and he could chew some, and the glands beneath the jaw were smaller and less adherent and movable, as was verified by two physi- cians. He remarked the "great improve- ment" in his condition and his wife said "the change from the first is marvellous." He still complained of some pain in the neck, running up to the head, but he has never taken any morphine or anodyne. "When seen later, very recently, the im- provement was still more marked. It is, of course, too early to claim a cure, but with continued proper treatment, of vari- ous kinds, there is every reason to be- lieve that the progress toward that end will continue. This case illustrates well the harm from curetting and cauteriza- tion, which stimulated an ordinarily slight ulcerative process from a rough tooth into a malignant disease. Case XVII: Mr. F. F., aged 72, came under observation and treatment on Octo- CONCLUSIONS AND RESULTS 373 ber 2nd, 1918. For three months he had felt a pressure of something wrong on the right side of the throat, and on Sep- tember 3rd, had had some sort of an op- eration from within, the nature of which could not be determined. He had seen many physicians and surgeons who ad- vised a complete operation from the out- side, which was refused. Wassermann had been taken and found negative. On ex- amination the right tonsil was found to be the seat of an ulcerative process, half an inch or more in diameter, very hard to the feel, with sharply defined hard edges, and considerable inflammatory ac- tion of the surrounding parts, reaching over almost to the left tonsil. The glands beneath the right jaw were greatly en- larged, the size of a large walnut, but rather movable. The saliva was very acid. He had been in the habit of taking beer twice daily, and smoking, which, of course, were stopped. Placed on a rigid vegetarian diet, with the same mixture as 374 MEDICAL ASPECTS OF CANCEE in many other cases, and the soda gargle, held in the throat a good while before and after each meal, he began to improve from the first. Within two months the ul- ceration had about ceased and much of the adjoining inflammatory action subsided. The hardness had largely disappeared, though the edge was still hard. He re- marked, "I feel all right and have noth- ing to complain of." The gland in the neck had diminished to the size of a small almond. A little later it was re- corded that there was still slight mar- ginal hardness, but superficial, in the dis- eased area, the gland was still smaller and freely movable, and he said that he felt "perfectly well," "find no complaint of any kind." Cancer of the lip. Many cases of can- cer of the lip have been under observation during past years, varying gently in their severity. Excision has been advised and practiced in a considerable number, and certain earlier cases have been treated CONCLUSIONS AND EESULTS 375 medically with perfect success. I have never felt that the x-raj was to be relied on, though good results have been re- ported from this and from radium, but the percentage of even apparent cures is not very large, nor ultimate results ob- served over a long period. In certain rel- atively small lesions of cancer of the lip careful medical treatment, accurately car- ried out long enough, is certainly capable of producing a clinical cure, as I have re- peatedly observed. For the trouble is really a local affair, due to prolonged irri- tation of the mucous membrane, in those subject to certain constitutional condi- tions, and the altered tissue resumes its normal condition when properly handled, and the cancerous proclivity overcome. Of 32 cases, some dating back 10 years or more, 9 at least were clinically cured, and many others so greatly improved when last seen that the ultimate result was probably good. One man, a butcher, eating very much meat, and weighing 215 376 MEDICAL ASPECTS OF CANCER pounds, had a very characteristic epitheli- oma, about % inch long on the right side of the lower lip, existing about a year. In six months it was absolutely well, and a year or so afterward when another patient looked bim up he had forgotten even the location of the trouble. A single case may be reported more in full. Case XVIII: Mr. W. H. N., an unu- sually intelligent gentleman, aged 45, from a distant city, had a slowly growing epi- thelioma of the lower lip for several months, for which an immediate radical opration was insisted on by several prom- inent surgeons and friends. When first seen, Feb. 6th, 1917, there was an oval epitheliomatous lesion, just to the left of the median line, about half an inch in diameter, and raised a line or so. He was placed on a rigid "green card" diet, with no smoking, liquor or beer. The surface was kept covered, night and day, with an ointment ( ^ Ichthyol Sss Zinci Oleat Sss Unquent. Aquse Bosse CONCLUSIONS AND EESULTS 377 31), spread on the thinnest possible por- tion of absorbent cotton, which adhered perfectly over the lesion. This was re- placed twice a day or oftener. In a week there was a decided change, the mass being much softer, though with still de- cided induration. The ointment was changed from time to time, with occa- sionally one per cent, of powdered sali- cylic or pyrogallic acid added, reverting at times to the first ointment, when these seemed a trifle irritating. Nine months later he kindly presented himself at my lecture at the New York SMn and Cancer Hospital, and himself gave the physicians present a remarkable lecture on the dis- ease and its treatment, stating that he was a Harvard graduate, and had studied medicine a while, and knew what he was talking about, urging them seriously to carry out this treatment. A year later he wrote enthusiastically about his case. The secret of success lies in the absolute protection of the diseased surface, night 378 MEDICAL ASPECTS OF CANCER and day, with the closely applied soothing and alterative ointment, spread thickly on the thinnest possible layer of absorbent cotton, pressed closely on; this, of course, is accompanied with other proper general treatment for the cancerous state. In this and the preceding volumes are recorded over thirty cases of cancer, from among many others, in which the benefit of a properly regulated medical treat- ment was clearly manifest. Some of the earlier breast cases had been followed from 13 to 16 years, remaining perfectly well without operation; others well from three to five years; and the two uterine cases, reported in the second volume re- main well for almost three years, with no recurrence, being still under treatment. The more recent cases have showed such steady improvement that it can hardly be doubted but that, if they remain still faithful to treatment, they will ultimately recover. The fatal cases were mostly CONCLUSIONS AND RESULTS 379 post-operative, but they also exhibited strikingly the benefits from this treat- ment, in prolongation of life and great comfort. As far as I can learn from my notes none of the patients required or re- ceived any anodyne, from soon after the time that they began treatment. When all this compared with the ordinary course of cancer cases it does seem that we are on the right track concerning the treatment of cancer. It is not claimed that the goal has been reached, or that the details of this line of treatment are complete. Laboratory and clinical study on the blood plasma, as well as on the secretions and excretions will undoubtedly elaborate more perfectly the best plan of dietary and other treat- ment, and as other observers follow this plan of treatment there will doubtless be found a gradual reduction in the mortali- ty of cancer, greater even than has oc- curred in New York City during 1918. It 380 MEDICAL ASPECTS OF CANCER is surely to be hoped that as "The real Cancer Problem" is fully solved there will be, under proper constitutional treat- ment, the same lowering of mortality that has occurred in tuberculosis under wise medical treatment. And as correct views of living prevail the morbidity of cancer will decrease with its mortality. INDEX Abemethy on a constitu- tional cause of can- cer, 62 Aborigines, cancer rare in, 35, 67, 233, 279 Acidity of saliva in can- cer, 96, 228, 305 Adenoma, removal of, fol- lowed by cancer, 114 AebU on untreated can- cer, 235 Alcohol, influence on can- cer, 88 Australia, cancer in, 279 Belgium, cancer In, 283 Bio-chemistry of cancer, 203 Bladder, cancer of the, 365 Blood, changes In cancer, 92, 170, 204, 225, 267 Bowels, elimination from, in cancer, 110, 164, 178, 270 Breast, cancer of, 115, 327, 338 Buccal cavity, cancer of, 289, 300, 368 Butter, value in cancer, 176 Cancer and body elimina- tion, 262 and civilization, 128, 200, 276 and coffee, 89, 233 Cancer and diet, 33, 35, 40, 76, 121, 144, 150, 201, 239 and heredity, 219 and lymphatics, 205 and meat, 88, 128, 146, 232, 258 and metabolism, 32, 91, 205 and metastasis, 205 and nutrition, 202, 314, 325 and occupation, 287 and the medical practi- tioner, 307 and tuberculosis, 26, 34, 59, 284, 285 as a non-surgical dis- ease, 25 bio-chemistry of, 203 caused by intestinal stasis. 111, 164, 178, 270 changes in the blood in, 92, 170, 204, 225, 267 clinical findings in, 190 constipation, cause of, 111, 164, 178, 270 constitutional nature of, 18 cure of, medically, 336 cures, 64 death rate compared to tuberculosis, 26, 34, 284 382 INDEX Cancer, death rate in 1917, ' in New York City, 41 deatb rate in 1918, in New Tort City, 49 deatb rate of, in the world, 81 derangement of liver in, 272 dietetic treatment of, 144, 151 diet most important in, 239 due to faulty metab- olism, 33 early, health of patients with, 224 early medical treat- ment of, 319 ethnological relation of, 200 families, 220 from a medical stand- point, 53 genetic changes in cells, 316 geographical relations of, 200 harm from nitrate of silver, 304 in Australia, 279 in Belgium, 283 in England, 282 in France, 283 in Germany, 283 in HoUand, 283 in Italy, 284 influence of alcohol on, 88 influence of coitee on, 89, 233 Cancer, influence of meat on, 88, 146, 232, 268 intestinal stasis cause of 111, 164, 178, 270 juice, 268 laboratory findings, negative, 29, 185 positive, 31, 187 malignant hormone se- creted by, 267 meat eating cause of, 88, 146, 232, 258 medical aspects of, 71 treatment of, 144, 211, 242 nitrogen partition in, 228 non-surgical treatment of, 169 nosological relations of, 198 not altogether a dis- ease of old age, 30 not a surgical disease, 25 not contagious, 29 not from occupation, 30 not hereditary, 29 not parasitic, 29 not wholly due to local injury, 29 of the bladder, 366 of the breast, 115, 327, 338 of the buccal cavity, 288, 369 of the kidney, 363 of the Up, 374 INDEX 883 Cancer of the prostate, 362 of the rectum, 360 of the stomach, 359 of the tonsil, 372 of the uterus, 334, 353 only the product of previous systemic disease, 126 pathology, teachings of, 181 patience 1 n medical treatment of, 238 perseverance in medical treatment of, 238 problem not fuUy solved yet, 322 prophylaxis of, 72, 102, 106, 161, 236, 252 product of metabolic error, 181 rarity of, in aborigines, 35, 67, 233, 279 rarity of in vegetarian countries, 130, 234, 281 results of medical treat- ment, 321 rice inhibiting, 231 saliva acid in 96, 228, 305 skin elimination in, 273 study of patients with, 208 surgical aspects of, 74, 309 time of cure of, 311 ultimate death rate from, 25, 54 untreated, 235 Cancer, urine in, 94, 111, 166, 177, 227, 269 vegetarian diet in, 121, 151, 161 report of, 115, 327, 339 Chart of cancer death rate, 58 Civilization and cancer, 201, 276 Clinical findings in can- cer, 190, 286 Coffee, influence In can- cer, 89, 233 Cohnheim, embryonic rests, 216 Conclusions and results, 321 Constipation a cause of cancer. 111, 164, 178, 270 Constitutional nature of cancer, 18, 210, 229 Contagious, cancer is not, 29 Cooper, Astley, on intesti- nal cause of cancer, 79 Cure of cancer, medically, 336 teachings of pathology, 181 time of, 311 Death rate of cancer in 1917, New York City, 41 of cancer in 1918, New ork City, 49 of cancer in the United States, chart, 68 384 INDEX Death rate of cancer in the world, 81 ultimate, from cancer 25, 54 Diet and cancer, 33, 35, 40, 76, 121, 144, 150, 201, 239 and growth, 230 effect in cancer, 33, 35, 40, 121, 144, 150, 201, 239 Dietetic treatment of can- cer, 144 Diet for cancer, 151 most important in can- cer, 239 relation to cancer, 121 Early medical treatment of cancer, 319 Elimination and cancer, 262 Embryonic rests, 126, 216 End results in cancer, 54 England, cancer in, 282 Ethnological relations of cancer, 200 Epithelioma, death rate of, 27, 196 Far East, rarity of cancer in, 234, 281 France, cancer In, 283 Geographical relations of cancer, 200 Germany, cancer in, 283 Health of patients with early cancer, 224 Heredity, insignificant in cancer, 29, 219 Holland, cancer in, 283 Hormone, malignant, se- creted by cancer, 33, 160, 267 Ignored, evidence cannot be, 323 Indians, rarity of cancer in, 279 Intestinal stasis, cause of cancer. 111, 164, 178, 270 Italy, cancer in, 284 Kidney, cancer of, 363 Laboratory findings nega- tive in cancer, 29, 185 Lambe on Internal cause of cancer, 77 Lane, Sir Arbuthnot, on intestinal stasis cause of cancer. 111 Lip, cancer of the, 374 Liver, derangement of. In cancer, 272 Lymphatics and cancer, 205 Mayo, W. J., prophylaxis of cancer, 252 on internal cause of cancer, 71, 229 Meat and cancer, 88, 128, 146, 232, 258 not the only cause of cancer, 258 INDEX 385 Medical aspects of cancer, 74 standpoint of cancer, 53 treatment, cases Illus- trative of, 115, 327, 339 treatment of cancer, re- sults of, 321 practitioner and cancer, 307 Medicinal treatment of cancer, 144, 211, 242 Metabolism and cancer, 32, 205 Metastasis and cancer, 205 Mexico, rarity of cancer in, 280 Morbid tissue growth, 222 Mouth, cancer of, 289 Murphy, John B., pessi- mism of, 252 Negative results of re- search, 29, 30, 185 Nervous strain and can- cer, 90 New York City, cancer death rate, in 1917, 1918, 4,1, 49 Nitrate of silver, harm- ful in cancer, 305 Nitrogenous metabolism, faulty in cancer, 227, 255 Normal tissue growth, 221 Non-surgical disease, can- cer a, 25 treatment of cancer, 169 Nosological relations of cancer, 198 Nutrition and cancer, 202, 314, 325 Occupation, Influence in cancer, 30, 287 Old age and cancer, 30 Oral cavity, cancer of, 289 Paget, Sir James, on con- stitutional nature of cancer, 79 Parasitic, cancer is not, 29 Parker, WUlard, on Inter- nal cause of cancer, 78 Pathology, teachings of, in cancer, 181 Patience in medical treat- ment of cancer, 238 Perseverance in medical treatment of can- cer, 238 Plasma of blood, relation of, to cancer, 171, 204 Plea for the rational treatment of can- cer, 15 Positive results of re- search, 31, 187 Precancerous conditions, 248 Problem, cancer, not ful- ly solved yet, 322 Product, cancer, of meta bolic error, 182 Prophylaxis of cancer, 72 102, 106, 161, 236 252 386 INDEX Prostate, cancer of the 362 Radium in cancer, 55, 76, 209, 303 Real cancer problem, 321 Rectum, cancer of, 360 Report of cases, 115, 327, 339 Results of medical treat- ment of cancer, 244, 321 Rice inhibiting cancer, 231 Saliva acid in cancer, 96, 228, 305 Sarcoma of buccal cavity, 301 Sarcoma of jaw, 330 Serum therapy of cancer, 109 Skin, elimination from, in cancer, 273 Spontaneous disappear- ance of cancer, 36 Stasis, intestinal, cause of cancer. 111, 164, 178, 270 Stomach, cancer of, 359 Study of cancer patients, 157, 208, 238, 241 Sulphur partition, de- ranged in cancer, 228 Surgical aspect of cancer, 54, 74, 309, 318 Sweat, elimination of, in cancer, 273 Syphilis of buccal cavity, 297 Time of cure of cancer, 311 Tonsil, cancer of the, 372 Traumatic, cancer is not wholly, 29 Treatment, medical, of cancer, 211 Tuberculosis, death rate compared to can- cer, 26, 34, 59, 284. 285 ntimate death rate of cancer, 25, 54 Frea in cancer, 269 United States, cancer death rate in, 68 TTrlne in cancer, 94, 111, 165. 177, 227, 269 Uterus, cancer of, 334, 353 Vegetarian diet in cancer, 110, 160 W a 1 s h e. constitutional nature of cancer, 78 Williams on tumor forma- tion, 223 World, cancer death rate in, 81