C A N C B R ITS CAUSE AND TREATMENT "^O^Q.\ ^^^-^ ^- y^e/f^^ CANCER ITS CAUSE AND TREATMENT BY THE SAME AUTHOR. DIET AND HYGIENE IN DISEASES OF THE SKIN. $2.00 net. COMPENDIUM OF DISEASES OF THE SKIN, based 011 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 TREATMENT. $2.00. SYPHILIS IN THE INNOCENT (Syphilis inson- tium) clinically and historically considered, with a plan for the legal control of the disease. $3.00. ACNE AND ^ ALOPECIA. The Physician's leisure library. Fifty cents. THE SKIN IN HEALTH AND DISEASE. Fifty cents. THE USE AND VALUE OF ARSENIC IN THE TREATMENT OF DISEASES OF THE SKIN. Fifty cents. ARCHIVES OF DERMATOLOGY. A quarterly Journal of Skin and Venereal Diseases. Vols, I- VIII. $3.00 each. PAUL B. HOEBER, 67-69 East 59th St., N. Y. CANCER ITS CAUSE AND TREATMENT BY L. DUNCAN BULKLEY, A.M., M.D. Senior Physician The New York Skin and Cancer Hospital, etc. NEW YORK PAUL B. HOEBER 1915 Copyright, 1915 By PAUL B. HOEBER Published^ February , 1915 Printed in U. S. A. To THE GOVERNORS of the NEW YOBK SKIN AXD CAXCER HOSPITAL whose kind appreciation of and assistance to the author in his clinical work in their institution have done much to encourage him and to promote the interest of the pro- fession in the branch of DERMATOLOGY this little book is inscribed Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/canceritscausetr01bulk PREFACE Cancer has hitherto been regarded almost wholly from its histological and surgical aspects. The investigators and practi- tioners along these lines have been innu- merable, the work done prodigious, and the literature relating thereto enormous. But relatively little attention has been paid to the medical aspects of this most threaten- ing malady, although voices have been raised from time to time, with more or less force, all joining in the same plea that the basic cause of the disease lies in some de^ rangement in the vital forces of the organ^ ism, as influenced largely by diet and mode of life. It has, therefore, seemed to the writer that it was time to stop and look at cancer from a broader aspect, and by synthesis 7 8 PEEFACE and deduction to seek to understand some of the underlying causes of malignant dis- ease ; also to see if some general principles could not be ascertained upon wliicli could be based an explanation of the views he had long held, and of the practice which he had long followed in regard to the preven- tion and cure of this dire malady. And as his studies progressed he was more and more satisfied that the true solution of the cancer problem lay along the lines indi- cated, although there was still very much to be learned regarding the details and ap- plication of the principles involved. The lectures were prepared for and de- livered to practicing physicians at the New York Skin and Cancer Hospital, in con- nection with the regular Wednesday lec- tures on Diseases of the Skin, as I felt that I should give them the benefit of what I felt to be of value in my own practice, pri- vate and public. Although holding the views here ex- PREFACE 9 pressed for many years I have hesitated writing strongly on the subject before, lest I should be misunderstood or misjudged: for favorable results based solely on a clinical diagnosis of cancer are always doubted. I have also feared lest by advo- cating a dietetic and medical consideration and treatment of cancer, which possibly might not be carried out exactly, I might really do harm ; since some might be led to neglect operative measures in proper cases, at the proper time; and so in certain in- stances great injury and injustice might be done to the patient, and the time pass in which a surgical operation might possibly be of service. But with my views and experience, strengthened greatly by what studies I have been able to make in the midst of a busy professional life, I now feel that I should do wrong in not presenting the re- sults and conclusions of my study and ob- servation. And I wish also to enter my 10 PREFACE strong protest against the course which is usually followed in regard to cancer, both before and after operation. With a rather extended experience during the last forty years, I have rarely if ever found a patient with cancer who has received adequate and continuous medical care before operation, with a view of discovering and rectifying the cause of the morbid growth. Too often when a cancer is suspected or discovered it is taken as a foregone conclusion that the malady is hopeless, except as the re- sults of the disease^ that is the new growth, may be removed by the knife, X-ray, ra- dium, caustics, etc. And after a surgical operation, as far as my observation goes, the patients are invariably left entirely to their own resources, with the hope, alas, too often futile, that the tumor will not regrow, but with no attempt to so guide the life that there shall not be the same tendency to a recurrent malignant new- PREFACE 11 formation. Against this latter course I also raise my earnest protest. In presenting matter from literature bearing on the subject under discussion I am well aware that I have hardly more than touched the surface of the deep ocean of recorded observations on cancer, but it was the best that I could do in my busy life. I only hope that others will take up in earnest the subjects here presented, and that this pioneer work may lead to the building of a strong and permanent struc- ture regarding the true basic cause of can- cer. Truth never fears proof. In studying the subject I have been greatly assisted by the masterful work of Roger Williams, so often referred to and quoted from; and I feel that a candid and careful perusal of that book will be a reve- lation to many. I know that some have endeavored to throw discredit upon some of the deductions which he makes from 12 PREFACE various statistics, but in the main tliey all teach a valuable lesson and are worth seri- ous consideration, as they are taken from reliable sources. Eealizing fully that the problem of the cause and proper treatment of cancer is a most profound one, which master minds have long wrestled with and which cannot be fully settled without much further study, these lectures are presented to the profession at large in the hope that they may be the means of helping some one threatened with or suffering from malig- nant disease; and also that they may pos- sibly stimulate others to investigate even more diligently along the lines of the medical aspects of cancer. January, 1915. 531 Madison Avenue. CONTENTS PAGE LECTURE I Nature of Cancer 15 LECTURE II Frequency and C4eographical Distribution of Cancer 43 LECTURE III Metabolism of Cancer . . 70 LECTURE IV Relation of Diet to Cancer 106 LECTURE V Medical Treatment of Cancer . . . . . .135 LECTURE VI Clinical Considerations and Conclusions . .170 Bibliography 211 Index 221 CANCER ITS CAUSE AND TREATMENT LECTUEE I NATUEE OF CANCER It may be safely said tliat no disease which has afflicted mankind has received as much attention as Cancer, or concerning which there has been as much diligent search to find out its nature and cause. Tubercu- losis, which seemed at one time to threaten even the existence of the race, has sunk into relative significance, as we have learned its true nature and conquered some of the causes of its ravages, and reduced its mortality very largely. Syphilis, un- der various names, forms, and aspects, was formerly much more of a menace than now, 15 16 MEDICAL ASPECTS OF CANCER and in earlier years caused veritable epi- demics, but is now well understood and con- trolled. Leprosy is less of a terror than in earlier times, since it has been definitely shown not to be contagious. Smallpox no longer rages, and yellow fever, and the plague, and hook worm disease have been hunted down by scientific study and the application of proper sanitary and medical measures. And so on in regard to many of the ills which afflict mankind. But cancer has held its own and has even increased in frequency, with rapid strides and bounds in some localities, until now it looms large as a national ^ or even universal scourge ; it has been estimated to cause the death of half a million persons yearly among the civilized people of the 1 According to the United States Mortality tables for 1912 there were 44,531 deaths from cancer that year, or 77 per 100,000 living, while the rate in 1911 was 74.3, an increase of 2.7. Tuberculosis has shown a steady decline, the death for 1912 being the lowest on record, 149.5 per 100,000, it having fallen from 200 per 100,000 in 1900, or over 25%. NATURE OF CANCER 17 earth, and untold misery and suffering to many times this number. And all this is still going on in spite of the earnest, faith- ful, and intelligent labors of innumerable research workers, the sacrifice of countless animal lives, and the expenditure of vast sums of money; and the end, as far as re- lates to its prevention and cure, seems al- most as far away as ever, for many sur- geons, in past and present times, have acknowledged their inability to cope with the disease. Much, however, has already been estab- lished by scientific research, and still more earnest thought, observation, and endeavor should be given to seeking most diligently for the cause of the disease, in the labora- tory as well as in practice ; for there must be some cause of cancer, and also some reason for its steady increase. But it is never to be forgotten that, as Pope says, ^'the proper study of mankind is man,'' and clinical observation, with 18 MEDICAL ASPECTS OF CANCER laboratory research, on cancer as it ap- pears in the human being, must be the ulti- mate base upon which all true advance in the knowledge of the nature, treatment, and prevention of the malady can ever rest. To effect this we must study the human being in all relations of life, must know the constitution and class of subjects in which the disease is most apt to manifest itself, understand the chemico-physiologic actions going on in the system, before and during the existence of the disease, and by a proc- ess of synthesis and deduction understand what is wrong and endeavor to correct it. All this is indeed a great undertaking, and can only be accomplished by great ef- fort on the part of many careful and skilled observers. But I want, in these lectures, to give you an outline of my own thought and study for many years, and, if possible, to let you see as I do the lines along which investigation should be directed. It is hoped, therefore, that this and the follow- NATURE OF CANCER 19 ing lectures will throw some light on the connection of cancer with diet and mode of life, and some suggestions as to its pre- vention and cure. Parasitism has been excluded: for while at different times many observers have re- ported various organisms which were thought to be the cause of malignant growths, none of these have been definitely confirmed by others, in spite of earnest endeavor ; and all experimental and clinical evidence is against a parasitic etiology of cancer. It is therefore seen how improper it is to speak any longer of ^Hhe germ of caiicer/' for, as is now widely acknowl- edged, there is no such germ, it is an ig^iis fatuus which has been chased in vain. The contagiousness of cancer has also been excluded, certainly in the sense in which this term is applied to other affec- tions. For while in some animals inocu- lation experiments have resulted in the transmission of certain tumors, little has 20 MEDICAL ASPECTS OF CANCER been determined except that such tumor material when transplanted can, in some unknown manner, multiply its cells in- definitely and form a focus of malig- nant disease, with disastrous effects on adjoining tissue. The same occurs in metastasis in cancer patients. But this does not at all explain the true basic nature of cancer, nor its development in those who have had no connection with other patients so afflicted. On the other hand the instances of suggested or sup- posed human transmission of cancer from one individual to another are so remark- ably few, and so exceedingly doubtful, that a recent author, Janeway, states that *^no well-authenticated cases of the transfer of a malignant tumor from one human being to another exist.'' It has been found im- possible to inoculate human cancer into rats, mice, and apes, nor can animal tumors be inoculated into animals of a different species. Heredity has been advanced as a cause, NATURE OF CANCER 21 but statistics fail to verify this in any de- gree whatever. While certain instances have been brought forward in whieh hered- ity seemed evident, the study of large num- bers of those afflicted with cancer, in con- nection with others free from the disease, has shown almost the same proportion of antecedents with cancer in both classes of persons; although some recent evidence seems to show that there is some tendency in different families for different organs. Experimental studies have, it is true, seemed to demonstrate that tumors occur apparently along hereditary lines in some animals in regard to certain organs; but in these instances it is to be remembered that the animals were kept in captivity, and all fed alike, conditions which have been found to cause the development of malig- nant disease in wild animals when confined in Zoological Gardens. In former years malaria was believed to have an influence in the production of can- 22 MEDICAL ASPECTS OF CANCER cer, and some investigators have thought to trace the prevalence of the disease to tel- luric influences, showing a preponderance of cases along certain water courses, or in certain streets or houses; but no definite proof of such connection has ever been es- tablished, and this theory is dismissed by the best authorities. Syphilis, in its latent effects, has also been claimed as an element in the causation of cancer, and undoubtedly the disease may develop, in suitable per- sons, upon old syphilitic lesions, especially about the mouth, anus, and genital region : but no one well informed in regard to can- cer would regard syphilis as the real cause of the disease. All these and other etio- logical propositions are no longer consid- ered to be tenable, and the very multiplicity of suggested causes shows that we are yet very far from the true etiology of cancer. Age undoubtedly has a powerful influ- ence in the development of cancer, the vast majority of cases occurring after the age NATURE OF CANCER 23 of forty or fifty. But, again, this does not at all exjDlain the true nature of the disease, for only a certain proportion of elderly people are so afflicted, and malignant tumors have been observed in those of all ages, and even in young children. The de- generation of tissue belonging to advancing years undoubtedly renders it more suscep- tible to malignant disease, but this does not explain why one person is affected and not another, nor why the tissues in one locality or another take on this morbid action. More recent scientific study has at- tempted to show that cancer originates from what are called "embryonic rests/' or pre-natal, wrongly placed, tissue ele- ments, which at some time or other take on morbid action and develop into what we know as the various forms of cancer. "Williams says, ^'From a biological stand- point tumor formation must be regarded as a phenomenon of the same order as repro- duction in general : that is to say, as a spe- 24 MEDICAL ASPECTS OF CANCER cial form of overgrowth of the individual. ' * But here again it is necessary to determine what causes them at certain times and in certain places to thus proliferate and form new tissue, which then becomes malignant and may proceed to destroy all contiguous tissues, and even to cause death. Traumatism has been claimed by many as the cause which determines the activitv of the misplaced cells, and starts them on their disastrous or rampant course: the various percentages of the cases in which it was believed that traumatism started up the malignant process has varied greatly with different observers, even up to 50 per cent, or more. But it is far from proven that this is always the case, nor does local injury in any way explain the persistency with which malignant disease, when once started, pursues its destructive and even fatal career; nor can traumatism account for the great tendency to recurrence con- stantly observed, either in the former site NATURE OF CANCER 25 or at some distant focus, through the agency of the lymphatic or vascular system. For of multitudinous traumatisms, even in cancer subjects, how few ever develop into malignant disease ! It would seem, therefore, that for the de- velopment 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 *^ embryonic rest.'' On the basis of the embryonic theory surgeons have of late most earnestly advo- cated the very early and complete removal of malignant lesions, including those of suspected malignancy, and even also the removal of many innocent lesions which are observed occasionally to lead to can- cerous formation ; and unless a better plan can be determined this cannot be urged too strongly in proper cases. 26 MEDICAL ASPECTS OF CANCER But while early operation lias improved surgical statistics, it has not contributed to our real knowledge of the basic cause of cancer, nor has it taught us why those lesions or '^embryonic rests" will remain quiescent for years, or prove harmless in some individuals, while in others they be- come most formidable agents of destruc- tion. For it is now recognized that these wrongly placed tissue elements are very common anatomical or histological acci- dents, indeed it is claimed that they occur and exist in every individual: and the removal of isolated '^embryonic rests" which have developed into cancer, does not by any means prevent the transformation of other similarly misplaced cells into ma- lignant disease, as the frequent recurrence of cancer after operation demonstrates. The same is true of the many and vari- ous forms of treatment other than surgical excision, such as deep acting caustics, and even the X-ray and radium, which like NATURE OF CANCER 27 surgery, only remove the focus of possible systemic infection, and do not affect the basic cause of the complaint : this latter is being shown more and more, by scientific investigation and observation, to be asso- ciated with metabolic or chemico-physio- logical changes in the system, and evidence is accumulating that it is dependent upon them. iVU this leads thoughtful persons to inquire if there is not some deeper, fun- damental cause lying back of the trou- ble, which should be reached and rectified by medical skill and acumen, something to do with the life or diet of a person which renders the tissues liable to take on malig- nant disease. So that a recent surgical writer on cancer states that ''all study, whether clinical, pathological, or experi- mental, points to the fact that there is some underlying, hidden cause which leads to that aberration in the action of tissue cells which we call cancer," ... a cause 28 MEDICAL ASPECTS OF CANCER *^ residing in only the cells themselves or in some abnormal chemical constitution of the plasma bathing the cells, or in both of these possibilities acting together. '^ Occupation has been questioned, but with most unsatisfactory results, for in some statistics which have been gathered cancer has been observed in those follow- ing all possible pursuits : and while labor- ers stood first on the list, clergymen stood fourth, while carters, threshers, and guides, who would be exposed to local in- jury, were at the bottom of a long list. It has been found, however, to be more fre- quent in trades or occupations in which the individual is most subject to the ha- bitual abuse of alcoholics, as in bartenders, printers, etc. We see, then, that thus far no satisfac- tory cause has been established for the occurrence of cancer, much less for the steady and great increase of the disease of late years. And as far as can be learned. NATURE OF CANCER 29 no measures are recognized, or at least generally adopted, to prevent its occur- rence or recurrence; although, as already- stated, modem surgery has seemed to im- prove the statistics in regard to its mor- tality in certain forms or locations, and the X-ray and radium have certainly also been able to remove, perhaps temporarily, some of the products of the disease. We come then to the question, what is the real nature of cancer? Alas, all scien- tific, experimental, and clinical investiga- tions have failed to solve the problem, except that all ' * evidence points to the conclusion that cancer is to be considered as a pathological disturbance of the nor- mal cell life, ' ^ from some unknown cause. A curious suggestion has been made by Schmidt, who found that of 241 cases of cancer of the chylopoietic system, 180 had never had any infectious disease of child- hood, and 99 went through life without any infection of any kind; the figures point to 30 MEDICAL ASPECTS OF CANCER the existence of a cancer diathesis — one which is resistent to germs. It would carry us too far from the prac- tical side of our subject, even if we were at all able, to present or analyze the vast number of contributions which have been made to the pathological histology of can- cer, and the changes which take place in the transformation of normal cells into those of malignant character: the amount of microscopic work which has been done along this line can hardly be imagined, and the literature relating to it is enormous. Ewing, accepting the definition that the cancer process is *^ atypical and destructive proliferation of epithelium, ' ' quotes Ribert as saying that ^'no one has ever seen the beginnings of mammary cancer'': but he does not bring us much nearer to the solu- tion of the cancer problem than we were before. Bainbridge rejects all possibility of a blood condition, and finds the only solution of it in the early removal of every- NATURE OF CANCER 31 thing which is thought to lead to cancer, even the simplest benign new formations, but Ewing states that '4n some cases car- cinoma has developed after excision of wholly benigTi fibro-adenoma^': and the immense number of cases of recurrent can- cer after operations shows that we must look further than surgery if we wish to stay the progress of this formidable dis- ease. It would be useless to attempt to present the many theories which have been ad- vanced relating to cellular metaplasia, or even to detail all the more or less accepted views in regard to the manner in which normal cells change and degenerate into those of malignant character : but some of the principal facts may be of service in understanding somewhat of the mode of development of malignant tissue from that which has been normal. The statement of Virchow, ^^Omnis cellula e cellula,'' that is, ''where a cell 32 MEDICAL ASPECTS OF CANCER arises there a cell must have previously existed, just as an animal can spring only from an animal and a plant from a plant," forms the basis of all study on the genesis of cancer and all tumor formation; karyo- kinesis, or indirect nuclear or cell division, is at the bottom of all growth, both normal and malignant, and the two classes of growth differ only in their methods and activity. In healthy tissues cell prolifera- tion and destruction proceed in an orderly manner, forming homologous structures, as when the hair and nails are constantly produced from newly formed cells at the root, and the result of this new growth is removed mechanically when the hair and nails are cut from time to time, or the hairs fall out. In the case of the skin the epider- mal layers are pushed forward and finally exfoliated as useless epithelial debris. With the cells composing other, or inter- nal structures, however, the process is dif- ferent. For here each normal cell repro- NATURE OF CANCER 33 duces others of homologous structure, and the different parts of the system are thus kept in active service through anabolism, by means of which new cells are formed with renewed vitality, and the older, or elf ete cells are removed by catabolism ; the elements of which they are composed are thus split up into their component parts, and carried off by the blood or lymph stream, and are then either discharged as effete substances or reutilized in the sys- tem, along physiological lines. Wakefield has pretty clearly shown that the develop- ing cancer cell is the product of sub-cat- abolism, or a sub-oxygenation, induced by hyperacidity or oxidase deficiency in the surrounding medium of the blood plasma. A great deal of thought, study, and spec- ulation have been given in regard to the behavior of the cells themselves, and strong arguments are adduced for a local cell pathology, that is, regarding the cells as *' autonomous beings, possessed of mor- 34 MEDICAL ASPECTS OF CANCER pliological and physiological independ- ence. '^ But on the other hand we must recognize some restraining influence which continually causes the great mass of cells to reproduce those of homologous struc- ture, in an orderly manner, and only very rarely some of them to break loose and form tumors, which may then become ma- lignant and even destroy life. How this restraining influence is modified or with- drawn is, of course, a part of the problem of cancer. Those who maintain their au- togenous character lay great stress upon the polarity of cells, and the relation of the centrosome to the nucleus, indicating a change in the polar axis in cells about to be cancer-genetic, as does Ewing in his re- cent classical study of pre-cancerous le- sions. But whatever changes are observed microscopically we must recognize that the cells themselves must be influenced ulti- mately by that mysterious force which we call life, which ends with its extinction NATURE OP CANCER 35 from the body as a whole, and which is ultimately related to nerve action. We must also recognize that the cells every- where depend for their life and activity upon the plasma in which they are bathed and from whence they draw their suste- nance ; and this plasma is renewed day by day from the food and drink taken. Students of cancer are more and more recognizing and acknowledging that '^all these phenomena, apparently so different, are merely protean manifestations of one common process which underlies and is the cause of them all, to wit, cell growth and proliferation. The particular outcome of the process in any given case is due to the influence of the conditions of nutrition — understanding by this term the whole of the material changes wrought in the organ- ism through its relation with the surround- ing world. This being so it is easy to understand how, under favorable condi- tions, certain cells may take on independ- 36 MEDICAL ASPECTS OF CANCER ent action, growing and multiplying with- out regard to the requirements of adjacent tissues and of the organism as a whole. '^ There seems to be some reason to sup- port the view advocated by Williams, that tumor formation and growth are but forms of agamogenesis, or non-sexual reproduc- tion of cells, distinctly related to the de- cline in growth of the body in general. Hence while the forces of growth, develop- ment, and reproduction are in greatest ac- tivity the tendency to this disease is rela- tively small : but when growth declines and nutrition is relatively low the cells undergo gemmation, owing to perverted nutriment, and thus hyperplasia and not inflammation is the starting point of every neoplasm. Experimental work has time and again demonstrated that cell growth, either good or bad, is modified in no uncertain way by the character of the nutrition furnished. Cancer has repeatedly been observed to disappear spontaneously, as such cases are NATURE OF CANCER 37 on record by careful and competent medi- cal men: in certain of these instances it has occurred in connection with a radical change in the mode of life and diet, but in the majority of instances there is no record of the special cause of its disappearance. The lesson to be learned from this is that there are conditions of the system which are antagonistic to the abnormal prolifer- ation of cell tissue, even when it has begun to take place, as we must believe that there are other conditions of the system which favor such diseased action of aberrant cells. An interesting confirmation of this is at- tributed to Ehrlich, but I cannot find the original reference. He ^4ias shown that mice living upon a rice diet cannot be inoc- ulated with cancer, while mice living on a meat diet can be readily inoculated, can- cerous tumors developing quickly and con- tinuing to grow until the animal dies. Ehrlich also found that when mice with 38 MEDICAL ASPECTS OF CANCER cancerous tumors, the result of inoculation, were placed upon a rice diet, the tumors ceased to grow, and in many cases degener- ated and disappeared.'' Valuable cor- roboration of this has been given by Sweet, Corson, White, and Saxon. They made a series of experiments in regard to the ^in- fluence of certain diets upon the growth of experimental tumors," all with the same results. Of fifty white mice, 25 fed on glutenin and gliadin, and 25 on normal diet, 23 of the 25 on normal diet acquired tumors, against only 4 in the 25 on the glu- tenin and gliadin. This was repeated on 50 males, with the result of 18 in 25 against 3 in 25 : and in a third series, of 50 females, the figures were 15 in 25 against 7 in 25. Thus, they found that 75 per cent, of 75 mice developed experimentally inoculated tumors when under normal diet, while only 19 per cent, of other 75 mice developed such tumors when under a diet of glutenin and gliadin, that is, vegetable proteins; NATUEE OF CANCER 39 moreover, the tumors in tlie latter were in 30 days hardly larger than those in the former in 10 days. Eous has recently shown that large growths of certain trans- IDlanted rat and mouse tumors are checked in their development by underfeeding the host on a special diet. The chemistry of cancer has been studied in most varied directions, and the litera- ture relating thereto is very voluminous and can be hardly more than alluded to here. It is unfortunate, however, that most of the researches have been made in con- nection with patients who have advanced cancer, and very commonly with the dis- ease affecting internal organs, which of it- self interferes very greatly with their function, and so causes many of the per- turbations of metabolism observed. What is needed are researches in regard to the metabolism of patients before the develop- ment of the disease, or in its earlier stages, before it has exerted its injurious effects 40 MEDICAL ASPECTS OF CANCER on the system, in order to learn of the causes which lead up to and induce the wrong action of the cellular elements, whose invasion and malignant action sub- sequently become so serious. It is quite impossible in these lectures to enter at all fully upon the various bio- chemical studies which have been carried on in regard to cancer, but brief mention will be shortly made of some of the salient points. Not only has the structure of car- cinomatous tissue been examined chem- ically, but the blood and urine have been submitted to most painstaking investiga- tion, and metabolism in general has been studied in almost all possible directions, in the search for the cause of cancer ; and yet, as Beebe says, ''no phase of metabolism has been described in cancer which does not have a counterpart in non-cancerous con- ditions." But, as previously mentioned, all these observations and studies have been largely made upon advanced cancer NATURE OF CANCER 41 cases, when the system has already felt the unsettling and depressing effect of what is probably an injurious secretion from the deranged and actively proliferating cells of the cancerous mass. In a later lecture we will consider some of these matters in so far as they have relation to the dietetic and medical treatment of cancer. The essence of our study thus far has been, that in every instance what is called malignant disease is but an aberrant action of originally normal body cells. That, as normal cells find their nutriment in the cir- culating plasma, so some pathological change in this latter causes them to take on abnormal action, and they no longer de- velop homologous cells, capable of forming normal tissue, but heterologous elements which have a natural tendency to disinte- grate or break down, and exert a destruc- tive influence on adjoining cells of any kind; and in this process they secrete a hormone which is prejudicial to the system 42 MEDICAL ASPECTS OF CANCER and tends to destroy life. In later lectures we shall endeavor to understand this more perfectly, and consider some of the ele- ments in life which tend towards the pro- duction and arrest of cancer. LECTURE II FKEQUENCY AND GEOGRAPHICAL DISTRIBUTION OF CANCER Cancer in man exists all over tlie globe, but in ditferent degrees of frequency, ac- cording to varying conditions of life, as we shall presently see. Malignant growths occur also in animals and fishes, though also with greatly varying frequency under different conditions ; but there are few real tumors in reptiles or amphibians. Tumors are also occasionally found in vegetable or- ganisms, presenting increased growth and proliferation of cells, arising from adven- titious, or abnormally evolving buds, as also from parasitic and other external irri- tants. While these vegetable tumors are very interesting and in a measure instruc- 43 44 MEDICAL ASPECTS OF CANCER tive, in regard to tlie peculiarities of cell growth wliicli they exhibit, they bear, of course, no relation to cancer in the animal kingdom, although some have endeavored to argue otherwise. There is, however, a certain suggestion of analogy to be found in the observation made by one writer, that *4he origin of buds, as well as their subsequent development, is chiefly deter- mined by the conditions of nutrition. Wherever there is an excess of nutritive material, capable of being utilized for growth by the cells of the part, there buds may arise'*; we shall see later that the same thought applies to cancer in man and animals, when we come to the consideration of the relation of overindulgence along cer- tain lines of eating and drinking to cancer. Cancer has well been styled a disease of modern civilization, like tuberculosis, al- though of quite a different nature. Inter- esting studies have been made in regard to the increased death rate from the former FREQUENCY OF CANCER 45 in England, coincident with a diminislied mortality of the latter, in accordance with nutritional changes which have taken place in certain populations : and in the first lec- ture I mentioned that in the United States the mortality from tuberculosis had fallen 25 per cent, between 1900 and 1912 while, as we shall see later, the mortality from cancer has certainly risen. Williams, who quotes very largely from the accurate statistics which have long been carefully recorded in England, says that ^^ while tubercle has declined with great rapidity, cancer has increased at a still faster rate, and these inversely related changes are still in active progress. In illustration of these remarks it may be mentioned that during the last half of the nineteenth century, the cancer mortality for England tripled: while, during the same period the tubercle death rate de- clined to the extent of nearly one-half. Unless some great change in the national 46 MEDICAL ASPECTS OF CANCER habits takes place, of wliicli there is at the present no well marked indication, cancer will ere long claim more victims than phthisis, as is already the case in many localities — e. g., Hampstead, Clifton, Bath, etc." He further says, ^'I regard this de- cline in the presence of tuberculous dis- eases as the direct outcome of the better food and improved hygienic conditions, for which we are indebted to our increased na- tional prosperity: and I shall endeavor to show that conditions of this kind, by their action in another direction, are also mainly responsible for the augmented cancer mor- tality.'' We shall see later that cancer has asserted itself where modern civilization has augmented the opportunities of over- indulgence along many lines of eating and drinking: for while advancing scientific knowledge has undoubtedly diminished mortality in general, and has added to the average length of life, the various factors included in our modern mode of living have FREQUENCY OF CANCER 47 also with certainty increased morbidity along such lines as neurotic and vascular disorders, tumors, etc. All statistics from various localities show that cancer has certainly increased in frequency very greatly of late years, and though some have attempted to claim that this increase is only apparent, and is due to greater accuracy of diagnosis, and the prolonging of more lives to an age when cancer is more common, there is no doubt in the minds of those who have studied the figures that the increase is certainly very real; and unless there be found some way to check its production, the death rate at the end of the century will be appalling. It is quite impossible here even to give a comprehensive idea of the immense amount of work which has been given to the study of the statistics of cancer in vari- ous parts of the world, as collected in the remarkable works of Roger Williams and Jacob Wolff, but brief mention must be 48 MEDICAL ASPECTS OF CANCER made of some of the items observed and recorded in order to properly understand our subject. Williams in particular has analyzed the recorded facts in an interest- ing and convincing manner, and shown again and again in connection with the fig- ures from different countries, sections, and cities, that the occurrence of cancer bears a striking relation to the condition of the people in reference to their material pros- perity; namely, that the well-to-do, who can overindulge in many ways are vastly more subject to cancer than those in the poorer walks of life; also that aborigines in the wilder parts of the world are either almost exempt from cancer, or suffer from it to a very much less degree than civilized foreigners who come to their lands. This is also shown in a very striking manner by Wolff, and I present here a table which he gives in regard to the progress of can- cer in a single country, Australia, among the native born and foreigners. FREQUENCY OF CANCER 49 OF 100,000 LIVING THERE DIE OF CANCER IN AUSTRALIA X limber of yativG Eng- Other Year Inhahitants Born lish yationalities 1851 ... . . . 403,889 28 14 1861 ... . . . 1,153,973 5.6 30.5 19 1871 ... ... 1,168,377 9.7 56.7 25 1881 ... ... 2,252,167 16.8 72.9 32.6 1891 ... ... 3,183,237 19.8 119.8 45.9 1901 ... , .. 3,771,715 22.6 203.1 57.3 He remarks, ''We see from this compari- son in what a great degree the death rate from cancer has increased in foreigners as compared to the native born, in whom the disease has remained about stationary, when the increase in population is consid- ered. ' ' Another writer remarks that when native Australians mingle with foreigners as servants or employes, and adopt their diet and customs, cancer occurs more fre- quently in them. Much the same has been reported in regard to other peoples and nationalities, and later we will consider the influences of urban life on the production of cancer. 50 MEDICAL ASPECTS OF CANCER In New Zealand, according to Hislop and Fenwick, where the general death rate is the lowest in the world, cancer is on the increase, as civilization advances. In the great majority of cases the alimentary canal is the seat of invasion, even in women: all the patients studied were hearty eaters, taking also very much strong tea many times daily. The Polynesians and Melanesians seem to be peculiarly exempt from cancer. Sir William McGregor, although he had oper- ated several times on whites in the Fiji Islands, never remembers operating on a Polynesian or Melanesian, who are prac- tically vegetarians. He never saw a case in British Guinea in 9% years, and then saw an encephaloid cancer of the tibia in a Papuan, who for 7 or 8 years had lived practically a European life, eating canned Australian meat daily. In regard to Africa, Williams quotes Dr. Madden of Cairo, who says, ^ ^ The con- FREQUENCY OF CANCER 51 sensus of opinion among medical men in Egypt is, that cancer is never found, either in male or female, among the black races of that comitry. These include the Ber- berines and the Sudanese, who are all Mus- sulmans, and live almost entirely upon vegetable diet." Of 19,529 deaths among natives of Cairo during 1891, only 19 were due to cancer (females 10, males 9) or 1 in 1028. In England during the same year the proportion of cancer deaths to total deaths was 1 in 29. In the Islands of LagOo, on the West Coast of Africa, Dr. Johnson, in 14 years' practice there saw 5 ^ases of cancer in natives all of whom lived as Europeans. In southern Africa, *' among the Boers and Europeans, who are large flesh eaters, malignant tumors are common: but among the natives, who are mainly vegetarians, these tumors are so rare as to be almost unknown." Renner reports interestingly in regard to cancer among the descendants of liber- 52 MEDICAL ASPECTS OF CANCER ated Africans or Creoles, in Sierra Leone, Africa. During 30 years, from 1870 to 1900, there were but 20 cases recorded as malignant disease among 22,453 admitted to the Colonial Hospital: in the next ten years there were 26 among a total of 10,163, a slow but steady gain in cancer incidence, with the advancing influence of the white man. He says that while the aborigines eat no meat, the ^^ Creoles" eat much meat; the teeth of the latter are beginning to decay, like those of the whites, which is at- tributed to the sweets introduced by the latter. Every case of cancer recorded has been in a Creole, living like a European, and not a single case among the aborigines. Much the same freedom from cancer has been noted in regard to negroes when first brought to the United States in slavery, when their food and mode of life was sim- ple : but since emancipation and in propor- tion as they have mingled with whites and eaten their food, with their own natural FREQUENCY OF CANCER 53 tendency to gluttony and laziness, cancer has increased among them, although their death rate from malignant disease is still much less than that of Tvhites. 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 but- ter, and vegetables: they eat meat rarely, the immense majority of the people live a rural life, depending upon agriculture for their sustenance. Investigations of late years, however, might seem to indicate that cancer is more prevalent in India than previously sup- jDOsed, but its incidence still bears no real relation to that in many other countries, and an analysis of some recent reports ex- plains in an interesting and curious man- ner the reasons for the diversity of opinion as to the actual frequency of the disease. Thus, Benratt collected a total of 1700 cases onlv from 5 vears' statistics of 15 54 MEDICAL ASPECTS OF CANCER Mission Hospitals and 34 Government Hos- pitals, representing, of course, many mil- lion inhabitants, whereas in New York City, according to the weekly Bulletin of the Board of Health, there were 2193 deaths from cancer in the last six months, a striking illustration of the rarity of can- cer in India. Moreover of these 1700 cases, over 1200 were about the mouth, a very large share of these arising from the very common habit of chewing betel, which contains also much calcium, which latter is one of the salts incriminated in the causa- tion of cancer. Sandwith attempts to show that cancer is prevalent in India, but refers to only 2000 cases reported in the hospitals there, in three years, also among many millions of people, and he refers like- wise to the betel chewing cancer, and the ^^kangri burn" on the abdomen of men, from the charcoal furnace worn for warmth : these peculiar local disorders viti- FREQUENCY OF CANCER 55 ate any deductions wliicli could be drawn from such statistics. In China, according to a recent writer, ^'cancer is comparatively uncommon in those parts where the bulk of the people live on an almost exclusively vegetarian diet, being too poor to purchase any of the various flesh foods, which are there used for culinary purposes. But in places where cancer is said to be more prevalent, the reporter adds, ^^AU Chinamen there eat fish and pork at morning and evening meals : fowls and ducks are always on the table of all but the most humble of the coolie class.'' In regard to the occurrence of cancer in the Far East, however, some of the modern investigators, such as Bashford, have en- deavored to overturn the generally ac- cepted view as to its infrequency, but I do not feel that the evidence presented can at all weigh against the unprejudiced opinion 56 MEDICAL ASPECTS OF CANCEK of most capable medical men who have long lived and practiced in those regions, some of whom as medical missionaries have had most intimate contact and acquaintance with the natives. Only very recently a medical missionary, who has long been con- nected with the medical college and hos- pital in Beirut, Syria, told me that cancer was practically unknown among the thou- sands of patients who flock there from all over the Near East, he adding that they were all largely vegetarians. During a rather extensive trip through the Far East I was unable to see or even hear of any cancer, although I met a large number of medical men, and made diligent inquiry regarding the same. As I wished to verify my views in regard to the rarity of the occurrence of cancer among those who lived on rice or other vegetarian diet, I visited very many civil, military, and mission hospitals, with a total of many thousands of patients, and ministering to FREQUENCY OF CANCER 57 many millions of population; in Japan, Korea, China, the Philippines, India, Siam, and Egj^pt, I met the same response, that cancer was rarely seen among those vege- tarian natives. Brazil is credited with having the lowest cancer record of any portion of the west- ern hemisphere, especially among the na- tives in the Equatorial regions, while in the Argentine Republic, where meat is known to be largely consumed, cancer is fairly common. From many parts of the world there come reports of the relative infrequency or even absence of cancer among simple living natives, one writer in regard to the West Indies stating ''Even those cases which I have witnessed in this class of people have been among the better orders of them, whose habits of living as- similated to those of Europeans.^' England and Wales present the most satisfactory field for the study of the prog- ress of cancer, as the national vital statis- 58 MEDICAL ASPECTS OF CANCER tics have been well kept since 1840 ; even at that time under the able direction of Wil- liam Farr they had already acquired a well- deserved reputation for reliability, as Wil- liams remarks, from whom I shall freely quote. In that year, 1840, there died of malig- nant disease in England and Wales 1 in 5,646 of the total population, 1 in 129 of the total mortality, or 117 per million liv- ing. In 1905, the deaths, due to this cause were 1 in 1,131 of the total population, 1 in 17 of the total mortality, or 885 per mil- lion living : thus, while the population had only a little more than doubled, the cancer death rate per million living had increased ^Ye fold. Dr. Williams answers by figures and tables the several objections which have been raised in regard to the actual in- creased mortality from cancer, as it has been repeatedly claimed that the increase is only apparent and not real; thus it has been asserted that it is due — 1. To mere FREQUENCY OF CANCER 59 increase of population: 2. To the average age of the jDopulation having advanced: and 3. To improved diagnosis and more carefnl death certification. Time does not admit a full presentation of his statistical refutation of these claims, to which he de- votes some pages very convincingly, but it can be safely accepted that for some as yet unknown reason, cancer has made strides in England which are truly alarming. Williams has also made some most inter- esting studies in regard to the increase of cancer in connection with changed condi- tions of life, and from his analysis of sta- tistics, he very clearly shows that the spread of the disease has closely followed urbanization, and the rapid increase in ma- terial prosperit}^ of recent years: in Eng- land where 80 per cent, of the population are now town dwellers, this tendency to collect in cities and towns has gone farther than in any other community. He recog- nizes that any far-reaching, environmental 60 MEDICAL ASPECTS OF CANCER change of some duration is probably potent in disturbing the stability of the constitu- ents of living bodies, and the sudden change from poverty to riches and plenty is con- ducive to the development of cancer : allu- sion has already been made to the inverse relation of deaths from cancer and tubercu- losis, the latter diminishing with improved material conditions, while the former in- creases as wealth and indolence increase. He shows this by statistics from various localities, and by data from towns in ditf er- ent countries he makes it pretty clear that '^Cancer mortality is lowest where the con- ditions of life are hardest, the surroundings the most squalid, the density of population greatest, where the tubercle mortality is highest, the general and infantile mortality greatest, and where sanitation is least per- fect — in short, among the poor of the indus- trial class in our great towns: whereas among the wealthy and well-to-do, where the standard of health is at its best and life FREQUENCY OF CANCER 61 is easiest, and where all the conditions of life are just the reverse of the foregoing, there the cancer mortality is highest." "While this is a pretty strong statement and many exceptions could undoubtedly be found, careful investigation will show it to be true in the main; for it must be remem- bered that even among the poorer classes gluttony, especially in regard to proteids, is not at all uncommon, and indolence, with impeded metabolism, is not at all unusual. Dr. Latham found that the mortality from cancer in England, from 1881-1890, was more than twice as great among well-to-do men having no specific occupation, as among occupied males in general, the re- spective mortality ratios being 96 for the former and only 44 for the latter. Sir Wil- liam Banks confirms the steady increase in cancer very strongly, which he attributes to richer and more abundant food, of which males eat more than females, and conse- quently cancer is increasing proportion- 62 MEDICAL ASPECTS OF CANCER ately more among men, as all statistics show. Switzerland is reported to have the high- est death rate from cancer of any country, it having augmented from 114 per 100,000 living in 1889, to 132 in 1898. There again the cancer mortality varies greatly in the different sections or cantons : thus, in wealthy Lucerne it is 204 per 100,000 liv- ing, and only 36 in poverty stricken Valais. In the city of Geneva it is 177 per 100,000 living. Denmark, next to Switzerland, is reputed to have the highest cancer death rate of any country in Europe, viz.; 130 per 100,000 living in 1900. But here the statistics are only from the towns, which comprise but a quarter of the whole population: the per capita wealth is said to be higher there than any other country in Europe except France. France shows a high cancer mortality, with a constantly increasing death rate; FREQUENCY OF CANCER 63 and, next to England, France is the richest country in Europe, and T^ealth is much more widely diffused : the French workers own nearly 8 times, per capita, more than those in England. In Paris the cancer death rate has increased as follows, for each 100,000 living, in 1865, 84; in 1870, 91; in 1880, 94; in 1890, 108; in 1900, 120. Italy, a comparatively poor country, shows a low cancer mortality, hut even here it is increasing from 20 per 100,000 Hving in 1880, to 52 in 1899, and 58 in 1905. The consumption of meat is there the small- est in any European nation, namely 23 pounds per capita in 1895. In the chief towns the rate of death from cancer is high : thus for each 100,000 living, in Flor- ence 137, Ravenna 120, Venice 103, Milan 101, and Rome 77. Time does not permit a wider survey of the field of distribution of cancer, as pre- sented so remarkably from official sta- tistics by Williams, and Wolff ; but in con- 64 MEDICAL ASPECTS OF CANCER nection with the high percentages of deaths above quoted among the richer classes it may be interesting to mention some of the lowest records. Thus, in the poor country of Kerry, Ireland, it was 27 per 100,000 living, in the province of Dal- maltia 19, in the Shetland Islands 16, in Servia 8 (from 1895 to 1904), and in Cey- lon in 1903 the mortality from cancer was about 6 for each 100,000 living. The United States, unfortunately, has not kept the vital statistics of the country in years past with anything like the full- ness and accuracy which has obtained in England, nor even at the present time is it possible to learn definitely the frequency and increase of cancer in every locality. But all the statistics which have been gath- ered show unequivocally that the disease has steadily increased in a manner which is alarming. Analyzing the recorded deaths from cancer in thirty-one cities, and the percentage of increase in four years. FREQUENCY OF CANCER 65 one ^^n'iter estimates that, if the same in- crease is continued, bv the end of the century there will be a death rate, approxi- mately, of 1000 in every 100,000 inhabi- tants, or one in every hundred. In a recent Bulletin of the Board of Health of New York City the following statements are made in regard to the mor- tality from cancer in 1913: ^^The statis- tics of our seven largest cities recently tab- ulated, show that the cancer death rate was the highest on record. For New York City the rate was 82 per 100,000 of the population, against an average of 79, for the last five years : for Boston 118 against an average of 110 : for Pittsburg 79, against an average of 70: for Baltimore 105, against an average of 94: for Chicago 86, against an average of 81 : for Philadelphia 95, against an average of 88 : for St. Louis 95, against an average of 85. ' ' This aver- age increase of almost 8 per cent, of deaths from cancer in the combined population of 66 MEDICAL ASPECTS OF CANCER tliese seven cities, during the last five years is certainly an alarming fact, and cannot be explained on the ground of greater ac- curacy of diagnosis : for it is not to be pre- sumed that there has been such great im- provement along diagnostic lines during the single year 1913. It is difficult to state the exact preva- lence of cancer in the entire United States, as the ^'registration areas" include only about two-thirds of the total population: much can be learned, however, from the annual volumes published since 1900. Ac- cording to these Mortality Statistics of the United States, the deaths from cancer and other malignant tumors per 100,000 popu- lation were as follows : in 1900, 63, in 1904, 70.2, in 1909, 73.8 ; and in 1912 there were 46,531 deaths from cancer, or 77 per 100,000 population, an increase in the death rate from this disease of almost 25 per cent, since 1900 ; while, as before stated the FREQUENCY OF CANCER 67 tuberculosis mortality had fallen a little over 25 per cent, in the same period. As in other countries, which might also be expected from the statements already made, the disease varies in frequency in different localities and communities. Thus, cancer is stated to be much more prevalent in the northern than in the south- ern states, and as already stated, the ne- groes are much less subject to the disease than whites, especially when they are living their own natural home life ; but when they come to the cities, as waiters, etc., in hotels, their cancer death rate increases. But even in New York City in 1912 the deaths from cancer in negroes was 1 in 32.2 total deaths, against 1 in 17.7 in whites; the mass of negroes here, of course, live plainly and work hard. The North American In- dians also are believed to be almost exempt from cancer in their primitive savage con- dition, but as they have come under the 6S MEDICAL ASPECTS OF CANCER influence of civilization tliey are more af- fected. It has also been noted by several observers that immigrants and their de- scendants present a very much higher mor- tality from malignant diseases than pre- vails in their native countries ; from these and other considerations Williams sug- gests that abrupt change of environment may also be a factor in the causation of this disease. We have thus seen while cancer is very widely distributed over the globe it is pres- ent in varying degrees of severity in dif- ferent localities, and careful analysis shows that the disease atfects different classes of persons with unlike severity. All these statistical studies and observations serve to confirm the statement made earlier that cancer is a disease of so-called civilization, and that it has increased in proportion as human beings have come under the influ- ence of wealth, and consequent luxury and overindulgence, with bodily inactivity; all FREQUENCY OF CANCER 69 these elements lead to a disturbed metabo- lism, which as we shall see later, is, at least, a contributing cause to the deviation from normal of some of the cellular elements of the body. It also appears that some of these metabolic shortcomings have to do with a disturbed nitrogenous balance, which is due to the constantly increased consumption of meat. In 1909 the meat consumption in the United States had reached the high figure of 172 pounds per capita, as I learned recently from Wash- ington, a far greater amount than in Eng- land, 130 pounds, as already stated; and with this steady increase in the use of nitrogenous food cancer has also increased by leaps and bounds in both countries. LECTUEE III METABOLISM OF CANCER In the first lecture we saw that cancer was an alteration of the normal cells of the body, whereby they take on a malignant action and continue to do so, destroying contiguous tissues and leading to a lowered vitality, with an apparent poisoning of the system, which finally causes death. As the cells of various organs furnish different secretions, which in health contribute to proper metabolism, resulting in growth or maintenance of the tissues, so these disor- dered cells are believed to secrete a toxic substance, or malignant hormone, which has a prejudicial action on the body, and haBmolytic action on the blood, as has been brought out pretty clearly by Troisier and others. 70 METABOLISM OF CANCER 71 We saw that as yet the definite cause had not been determined, why at some period certain cells take on the action which we call cancer, nor why they persist in their destructive course. Long continued and abundant laboratory and clinical research have about decided certain questions nega- tively in regard to its etiology, so that in a n>easure the field is cleared for the study of some of the possible basic causes of the disease in question. Thus, all are pretty well agTeed that cancer is not contagious or infectious, that it is not caused by a micro-organism or parasite, that it is not wholly due to local injury, that it does not appertain to any particular occupation, that it is not hereditary to any great de- gree, that it does not especially belong to or affect any particular sex, race o»r class of persons, nor is it confined to any loca- tion or section of the earth, and that it is not wholly a disease of older age. We saw further that there appeared to 72 MEDICAL ASPECTS OF CANCER be good evidence that certain misplaced *^ embryonal rests'' were the original starting points of diseased cell action, but as these are now known to exist in every one from birth, this otfers no real explana- tion of the occurrence of the disease at different times in life. It is, of course, quite possible that local injury of one kind or another may be the exciting cause which determines that a cell or group of cells shall revert to its original reproductive activity, as Williams contends that the process is one of agamogenesis, dependent upon ex- cessive and faulty nutrition. The question as to the relation of uricacidsemia, or lithaemia, to cancer has never been fully studied, and it is worth considering whether, as in gout and rheumatism, to which cancer is often associated and per- haps closely allied, the exciting cause may not be the lodgment somewhere of uratic deposit, which is further excited and fed METABOLISM OF CANCEE 73 by effete or imperfectly oxidized nitro- genous elements ; for later we shall see that perverted metabolism, largely of proteid elements, is closely associated with cancer. AVe noted also that some attributed can- cer to independent cell action, relating to the polarity of cells, etc.; but it is incon- ceivable that a cell or cells can idiopathic- ally start out on a rampant course and pursue it with increasing severity, even until death results, without, at least, some definite pre-disposing cause, even though diligent and earnest work has not as yet de- termined just what that cause may be. The error has been, we believe, in search- ing too exclusively by the microscope and by certain laboratory methods, and not sufficiently along clinical and bio-chemical lines. For it must be recognized that all the cells of the body are continually bathed in the vitalizing fluid of the blood, whence they derive their nutriment, and into 74 MEDICAL ASPECTS OF CANCER which, with the lymphatics, they return the products of their vital action, by anabolism and catabolism. By exclusion, therefore, we are reduced to seek the etiology of cancer along other lines, and about all that is left is metabo- lism, as influenced by advancing, so-called civilization, which relates very largely to diet and mode of life. This we will take up later, but will first examine some of the scientific findings in regard to the blood in cancer, and data relating to the various secretions and excretions of the body bear- ing upon metabolism in this disease. That the blood shows great changes in advanced cancer is recognized by all, as is clinically manifested by the intense cach- exia and anaemia commonly present and always strongly marked toward the end, of which the cytology has been very fully studied and presented by Turk. When then examined there is found to be a marked reduction of red cells, low hsemo- METABOLISM OF CANCER 75 globin index, and distinct leucocytosis, with greatly diminished alkalescence. The reported changes in the blood have also varied with the location of the malig- nant disease, according as it may interfere mechanically or otherwise with the func- tion of certain organs, which fact naturally obscures the question of the true relation- ship of the blood to cancer. Thus, it is stated that in cancer of the liver and pan- creas there is always leucocytosis and gly- cogen, and that ^* cancer appears to inter- fere greatly with the function of the liver as a destroyer of intestinal toxins, they pass into the general circulation, probably cause the glycogen reaction, and at least part of the leucocytosis, and very often give rise to fever.'' There are also other microscopical alterations in the blood in late cancer. Thus, degenerative change in the leucocytes are common, with derange- ment in the normal proportion of their dif- ferent forms, as also changes in the ery- 76 MEDICAL ASPECTS OF CANCER throcytes, with nucleated red cells and megalocytes in severest cases. Price Jones in a study of the blood in 30 cases of cancer (9 of the breast) found the red blood cells diminished on an average of 6 per cent., the white blood cells increased 38 per cent., lymphcocytes increased by 10 per cent., large mononuclear cells increased 164 per cent, and polynuclears 42 per cent. Bumham states that in the severe grades of anaemia with malignant disease, poikilo- cytosis is marked, and nucleated cells of both normoblastic and megaloblastic type may be present. The red corpuscles may be reduced to 2,500,000, and exceptionally to 1,000,000. Cohnreich in a very tech- nical study of blood from cancer subjects, observed very great increase in the resist- ing power of the red blood cells to osmotic tension, that is, in regard to their haemo- globin, which he believed to be of diagnos- tic value in doubtful cases. Unfortunately, there have been relatively METABOLISM OF CANCER 77 few studies of the plasma of the blood in this or other diseases; and yet the condi- tion of this fluid must be of the utmost importance, as from it are derived the nu- trient principles not only of the solid con- stituents of the blood, but also those of the entire system, about 8 per cent, of it being serum albumen and serum globulin. It also holds in solution the phosphates, car- bonates, sulphates, and chlorides, the latter often varying greatly, and being chiefly re- sponsible for the isotonic relation of cells and serum. In cancerous cachexia a dimi- nution of carbonic acid, a constantly dimin- ished alkalinity, and an increase of acid principles of the blood have been fully demonstrated, pointing in all probability to the existence of an acid intoxication. The formation of the corpuscular elements of the blood must be greatly interfered with when metastases occur in the blood making organs, the l:^nnphatic tissue, bone, marrow, and spleen, which probably occur 78 MEDICAL ASPECTS OF CANCER more frequently than is generally recog- nized. It seems that the toxic secretion from a cancerous mass has a distinct action upon the blood, for after complete removal there is often observed an increase of haemoglobin, 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 tumor. Abderhalden states that in from two to three weeks after the operative re- moval of cancer, certain defensive fer- ments can no longer be found in the serum. Many laboratory studies have been made upon the chemistry of cancer tissue, seek- ing to determine the nature of the toxin produced, and its experimental effect on animals, but thus far no great results have been obtained. It has been observed, how- ever, by Grruner that when cancer juice is injected intra-venously a marked lympho- cytosis arises, which is followed by the ap- pearance of large mast cell myelocytes in METABOLISM OF CANCER 79 the blood. This cancer juice is supposed to be autotoxic in cancer patients, and to comprise toxic albuminoids, which being in quantities too great to be quickly neutral- ized ]3oison the system, especially the blood and the hgematopoietic organs. In regard to the real bio-chemistry of cancer, we are still greatly in the dark. Vast numbers of studies and researches have been made to determine the real char- acter and nature of the bio-chemical changes which occur in cancerous tissue, and the mere recounting of the reported findings and theories elaborated from them would occupy far more time than can be profitably given in these lectures. Some have claimed very positive findings which account in a measure, at least, for the pathological conditions, while others, as Beebe, state that ^ ^ the chemical study of tu- mors is in its infancy. We have scarcely proceeded far enough to know where the medical problems are, nor have methods 80 MEDICAL ASPECTS OF CANCER now available been perfected to sucb an ex- tent as to enable a decisive experiment to be made.'' ^^No phase of metabolism," says lie, **has been described in cancer which does not have a counterpart in non- cancerous conditions. This applies to such questions as the nutritive relations between the cancer cells and the normal body tissue, to the nitrogenous balance, re- tention, elimination of sodium chloride, ex- cretion of acetone, the relation of ammonia excretion, and a possible acidosis." He adds, however, ^^Diet doubtless forms an important part in the growth of cancer, possibly even in the origin of the disease." It is encouraging, therefore, to find that this able and careful laboratory investi- gator recognizes, in a measure, the basic cause of diet, toward which all evidence points so strongly, although the definite connection may not yet have been estab- lished by laboratory methods. METABOLISM OF CANCER 81 In all our study in regard to tlie relation of diet to cancer it must be remembered that tbere are divers elements and agencies -which combine to produce the many and various disordered conditions of the body, to vrhich we give the names of different diseases, and that cancer is no exception to this general rule. For instance, in old- fashioned gout the patient may have con- sumed an excess of Port and Madeira wine for years before the system finally rebelled and acute gout resulted; and among the causes for the systemic reaction we know that frequently it is great mental strain or shock which has so disturbed metabolism that the wine was no longer tolerated. Much the same is true in regard to cancer and nitrogenous diet. And we will see later that mental disturbance and nerve strain or shock often seem to be causative elements; also that constipation, or intes- tinal stasis, is so common in cancer sub- 82 MEDICAL ASPECTS OF CANCEE jects tliat it must be looked upon as one of the contributing causes among others, to be mentioned later. Although it is quite possible that many of the reported bio-chemical changes found in primary cancerous tissue and metas- tases may not be of etiological importance, it may be interesting to briefly refer to some of them as indicating the vital altera- tion in tissues connected with what we recognize as malignancy; even as in acute and chronic gout the affected tissues ex- hibit abnormal conditions in regard to uratic deposit. Many writers, some of them dating back many years, agree that albuminous con- stituents predominate in cancer tissue, and, as in actively growing structures in gen- eral, sugar forming substances abound. Wolter states that cancer of the breast contains 20 per cent, more nucleo-proteids than the normal breast. Casein is also present in breast cancers, and the abun- METABOLISM OF CANCER 83 dance of fatty matters, contained in tlie cells of such neoplasms, is well known. In regard to the proteids, Wolff, after many studies, concludes that their character is identical with that of normal tissues, and it is only the quantitative distribution of these that differentiates the tumor from the physiological tissue. Wells agrees with others that there is no very distinc- tive character in the bio-chemistry of ma- lignant tumors, but by reason of their ex- cessive chemical component, as compared with benign tumors, they naturally show a high content of nuclear proteins; they, therefore, contain a high proportion of phosphorus and iron. Interesting observations have also been made on other characteristics of cancerous tissues, such as the great abundance of en- zymes of great variety which are actively autolytic, also in regard to certain rela- tions of cholesterin, in regard to which Ewing has recently said, *^ There appears 84 MEDICAL ASPECTS OF CANCER to be sometliing in the chemical or mechan- ical nature of the irritation of cholesterin which is peculiarly effective in producing atypical proliferation of epithelium"; this has been found to be no less than 65 per cent, greater in quantity in fatty deposits, as in the mesentery, in subjects of cancer than in healthy persons, etc., etc. It would weary you to no purpose to attempt to re- fer further to the bewildering mass of re- search studies in connection with the bio- chemistry of cancer which are found in special literature: much of it is fragmen- tary and some of it contradictory, but all has its value as contributory to our knowl- edge of the actual conditions developed in connection with cancer growth; but up to the present time it cannot be claimed that any very practical results have been thus attained which will aid us in treating the disease. As all cell life and proliferation of tis- sue depends on the activity of the cell nu- METABOLISM OF CANCER 85 clei, miicli attention has been paid to the changes found in them and the behavior of the centrosomes and chromosomes, all of which is too technical for us to consider here: suffice to say, however, that several observers have demonstrated heterotyioic mitosis in malignant tumors, and that his- tologic examination confirms what other judgment has indicated, namely, that the cancer cell differs from a normal tissue cell mainly in its aberrant action under some stimulus, probably derived from the ani- mal fluids by which it is surrounded. Thus we come back to our original propo- sition, for these fluids are, of course, but a reflection of the nutrition of the body or diet, as modified by the action of the va- rious organs, including the internal secre- tions; all this is influenced again by the action of the nervous system. It is difficult to produce definite proof in regard to the influence of nervous and mental strain and shock in the production 86 MEDICAL ASPECTS OF CANCER of cancer, but careful observers have long claimed that there is such an influence, and from what I have seen I am firmly convinced that in some way these condi- tions often do so disturb the metabolism, or otherwise operate, in such a manner that cancer results. The influence of the mind upon the body is unquestionable, as has been so fully illustrated by Tuke, and from what I have observed I cannot doubt but that the mental depression common in those with the beginning of a process which they fear might result in active can- cer, has much to do with accelerating its growth; whereas, on the other hand, the hopefulness which can arise with the at- tempt to change the diseased process by diet and proper medication, has much to do with the favorable results which may follow in suitable cases. In the same way the constant fear of recurrence after op- erative removal can have its share in in- ducing and perpetuating the metabolic METABOLISM OF CANCEE 87 error wliicli excites the tissues to renewed cancerous action. I know tliat some of you will think that this is fanciful theoriz- ing, but many a scientific fact, in many branches of science, has been worked out from a theory which at first has seemed fanciful. We will now consider some of the data which have been recorded in regard to the relation of the secretions and excretions of the body to cancer, including the inter- nal secretions. Much labor has been expended, by very many observers, upon the analysis of the urine in connection with cancer, as that might be expected to reveal the metabolic changes connected with this disease. While many departures from the normal have been reported, and while under com- plete volumetric analysis the urine of a subject of cancer is rarely if ever that of health, it cannot be said that any definite and specific changes have been established 88 MEDICAL ASPECTS OF CANCER whicli may not be found in tliose without cancer; although there have been several who have so claimed even diagnostic signs from the urine. But minute, volumetric analysis is often of great service in guid- ing the nutrition and medication of these patients, and gross errors are continually met with, which have the greatest bearing on the case in hand, as indicating very great metabolic disturbance: and con- stantly the urinary excretion will be found to be extremely deficient, both as to its quantity and its total solid elimination. In one very interesting case of cancer of the breast, in a stout, flabby lady, near 55, in private practice, the total daily quan- tity of the urine, measured for weeks, is always very far below the normal amount ; and in spite of active medication it seems almost impossible to raise the total daily solids excreted in the urine, to more than one-half of that called for by the weight of the patient. We may now briefly consider METABOLISM OF CANCER 89 some salient points reported in connection with the urine in cancer. As remarked in regard to other elements in the study of the disease, it would be very desirable to have a knowledge of the urine in pre-cancerous stages of health, or ill-health, and also in very early cancer, likewise after surgical operations, that we might better understand the metabolic changes which lead up to malignant dis- ease; but unfortunately these are exceed- ingly few and unsatisfactory, and almost all the studies have been made in advanced cancer, and often when the disease has af- fected vital organs, or when by its own poison it has disturbed the workings of the economy. Many observers agree that there is a disturbance of proteid metabolism in can- cer, and dependent upon this many devia- tions from normal are found in the urine, some of which in turn are related to the in- anition which occurs. The urea is almost 90 MEDICAL ASPECTS OF CANCER invariably diminished, often very greatly, as I have verified time and again in many cases. A number of studies have been made upon the nitrogen partition in cancer by Einhorn, Kahn, and Rosenblum, also by De Bloeme, Swart, and Terwen, and oth- ers, showing an increase in colloid nitro- gen, to more than double the normal amount, increased elimination of xanthin, oxyproteic acid, and urinary ammonia, to- gether with many other changes which show that disintegration of the protein ele- ments is very imperfect and often excess- ive. An interesting statement is made by Blumenthal that the oxyproteic acids are increased even in very early cancer, and independently of the size of the tumor and degree of cachexia, seemingly showing them to have some specificity for cancer, because they have not been found in other forms of malignancy. He also states that urobilin is increased in a large proportion METABOLISM OF CANCER 91 of cases of cancer, especially when ca- chexia is setting in, and is a grave symp- tom. Reid, wlio lias confirmed many of these matters reported by others, says: "I have found an increase of amino-acid ni- trogen in practically every case of cancer I have examined"; . . . ''Hence we can only infer that in cancer, the liver, while not involved in the disease, is still unable, for some reason, to perform its functions in synthetizing urea. The organ is func- tionally injured, no lesions having been found to explain its insufficiency"; or pos- sibly . . . ''cancerous subjects form pro- teids which the liver is unable to deal with, so that they are excreted unchanged, or nearly so." Degrez has made confirma- tory studies along these lines, and found the nitrogen disintegration very imperfect, with increase of the ammonia fraction of nitrogen, and increased elimination of xan- thin bases. He states that "the toxicity 92 MEDICAL ASPECTS OF CANCER of the urine is increased apparently as the result of the presence of substances which have not been fully oxidized. ' ' Notable changes have also been recorded concerning the sulphur elements in the 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 fermenta- tion of protein elements, which also I have constantly observed. The chlorides, on the other hand, are, as a rule, diminished in cancer, especially in its late stages, when there is inanition or kidney insufficiency; and probably any change in them has only a relation to the nutrition of the patients, for the chlorides come from the food and are commonly an index of the amount of nutriment absorbed. Robin finds some relation between the ex- cretion of chlorine and nitrogen, according METABOLISM OF CANCER 93 to the stage or degree in which the system is affected by cancer. The phosphates are known to be in- creased in the nrine of cancer subjects, al- though irregularly and in an inverse ratio to the chlorides; as inanition increases there is greater autolysis of cellular struc- ture, and the nuclei ^deld an excess of phos- phates, which are excreted in the urine. A more or less general demineralization of the system through the urine has been observed by several, and has been recog- nized as a significant matter, and is of spe- cial importance when we consider what an important part minerals take in the nour- ishment of cell life. AVhile the changes which have been ob- served in the urine in connection with can- cer are not wholly pathognomonic, but oc- cur in connection with other diseased states of the system, so that none of them can be accepted as diagnostic of malignant 94 MEDICAL ASPECTS OF CANCER disease, tliey all have a certain significance as indicating the metabolic changes which accompany and, as we believe, have much to do with the etiology of cancer; and, as stated before, a careful, systematic, and frequently repeated volumetrical analysis of the urine certainly assists greatly in the proper management of these cases, that is when the departures from normal are care- fully studied and correctly interpreted. The saliva, and its action, constitutes a very important part in the process of di- gestion, and consequently of metabolism and the genesis of cancer ; far too little at- tention, however, has been paid to it prac- tically, in ordinary life or disease, al- though there have been many laboratory studies and writings on the physiological action of this secretion; but I have not been able to find in literature any investi- gations relating to its condition in cancer. And yet the experience and writings of Mr. Fletcher and others have demon- METABOLISM OF CANCER 95 strated wonderful results from perfect mastication and thorough insalivation, and a careful consideration of digestion must convince every one of the importance of this secretion in connection with nutrition, both in health and disease. Our time does not permit of more than a brief allusion to the subject, but in cancer patients I have so constantly found the salivary secretion acid, and often strongly so, instead of the normal alkaline or neu- tral, that I cannot but believe that this con- dition has some bearing upon the subject which we are studying; the saliva also is apt to be acid in diabetes, which is closely allied to cancer. It is to be remembered that the saliva, which amounts in health to between one and two quarts daily, varying somewhat with the food, is not wholly for the purpose of lubricating the mouth and facilitating deglutition, but its enzymes, ptyalin and maltase, effect radical and im- portant changes in the starchy matters 96 MEDICAL ASPECTS OF CANCER consumed. It is also to be remembered that the latter cannot be acted upon by the stomach secretions, but must be passed on to the influence of the pancreatic fluid in the small intestine, in case the action of the saliva has not been effective; hence there follows delayed and imperfect digestion, faulty metabolism, deranged nutrition, and possibly tumor growth. The importance, therefore, of very slow eating, thorough mastication, and perfect insalivation can- not be too strongly insisted on, both as an element of importance in the prevention of cancer, and also as a curative measure in patients in whom the diseased process has already manifested itself. The so-called internal secretions have also been the subject of much research and speculation of late years, in regard to their influence on metabolism and the life proc- esses of the economy, and many studies have been made concerning their connec- tion with cancer, which cannot be long METABOLISM OF CANCER 97 dwelt upon now ; but there seems to be lit- tle doubt but that the secretions of the ductless glands in common have much to do with regulating the metabolism of the cells. We know, for instance, that disease of the pituitary body produces bone dis- order, resulting in gigantism, that thyroid derangement results in myxoedema, and that disease of the supra-renal capsules gives rise to Addison's disease, or bronzed skin; and it is not at all impossible that the derangement of secretion of one or more of these and other organs may be an element in the disordered action of certain epithelial cells, resulting in cancer, nar- rower calls attention to the fact that can- cer is essentially a disease of that period of life when certain of the ductless glands lose their normal function, this loss entail- ing related changes in the whole chain of interrelated functions of the ductless glands. The supra-renal glands by their secre- 98 MEDICAL ASPECTS OF CANCEE tion have, as we know, great vaso-con- strictor influence, and their complete re- moval is followed by death ; it is more than possible that some failure in this secretion allows the exuberant blood to supply can- cerous growths. Sajous says: ^^ Certain growths, particularly the more malignant forms of sarcoma and carcinoma, seem closely connected with adrenal insufficiency and its normal consequences,'' and there have been some clinical and research data confirming such a conclusion. Sajous fur- ther says, ^^The adrenals, as supporters of the thyroid apparatus in the defensive process, and in sustaining oxidation, metab- olism, and nutrition, seem to otfer a new clew to the pathogenesis and treatment of cancer that is worthy of further inquiry.'* The pancreas has been thought to have some influence in a perverted metabolism leading to cancer, Kahle stating that there is a retention of silica in that organ in can- cer patients, to even double the normal METABOLISM OF CANCER 99 amount. A treatment of cancer intro- duced by Beard, also strongly presented by Saleeby, by trypsin and amylopsin, the en- zymes of the pancreatic fluid, excited some attention a while ago; but unfortunately no satisfactory results have thus far been obtained from this line of medication, as was fully demonstrated by Bainbridge at the New York Skin and Cancer Hospital, in one hundred cases. The pituitary gland by its secretion has undoubtedly some coordinating power, with the adrenals and thyroid, over the processes of metabolism, and a number of observers have regarded it as of impor- tance in connection with the genesis of can- cer. Little has recently reported some cases of cancer in which pituitary extract with that of the pancreas has produced re- markable results. The thyroid is now recognized as play- ing an important part in assisting metab- olism, and, like the adrenals and pituitary, 100 MEDICAL ASPECTS OF CANCER its complete removal, with the para- thyroids, in animals is followed by death. While the study of the hormones is still in its infancy, there seems to be no question but that the endocrinous glands act con- jointly, the one influencing the other, and that together they exert a very great influ- ence in the life processes of the body and on the behavior of its component cells. The thyroid has been shown to be one of the main factors in the management of cal- cium within the body, which is believed to be an element in cancer, and enhances the catabolism of toxic wastes, which are etio- logic elements in this disease. Many have reported favorably on the effect of thyroid feeding in cancer, and after an experience with it in many cases I am convinced that it has been one of the means which con- tributed to the good results obtained. On the other hand it has been claimed by Stu- art-Low that the surgical removal of the thyroid, or part of it, or ligation of the METABOLISM OF CANCER 101 thyroid blood vessels lias arrested cancer, in several cases. Thymus gland feeding has also been re- ported on favorably by a number of ob- servers (Eohdenburg, Bullock, and John- son, also Gwyer), they reporting relief of pain and improved general conditions, no- tably gain in weight and increased haemo- globin in all but one of sixteen cases, though some of them died. On the other hand Ross reports most unfavorably on the administration of thymus, which he gave to some inoperable and hopeless cancer cases, in which he said that in two or three weeks the tumors had quadrupled in size and the condition of the patients was very much worse; the same occurred also when some cancer patients were given calcium salts freely. Ross makes some in- teresting suggestions in regard to the thy- mus, and its relation to calcium and mag- nesium; these latter are freely utilized in the growth of bone up to the age of twenty- 102 MEDICAL ASPECTS OF CANCER ISiVe years, by which time the thymus gland has quite disappeared; but after this time these salts tend to have pathological rela- tions in various tissues, and also cancer becomes frequent. The internal secretions of the testicles and ovaries are also thought to have some share in metabolic processes, and observa- tions have been made in regard to their in- fluence in cancer. Thus Cahen reported that Beatson's operation of castration for cancer, done first in 1896, had been re- peated by many, so that Lott had reported 99 cases including his own. Of these in 23.2 per cent, the operation caused a dis- tinct improvement in the cancer. In 15 cases the improvement persisted for a year, in 4 cases for 4% years and in one case for over 5 years. Cahen operated on seven women with remarkable results; in two cases life was prolonged 4 and 6 years respectively. Others, however, have shown by statistics, that damage to the ovaries by METABOLISM OF CANCEE 103 disease, or their removal by operation, greatly increases the proclivity to cancer. Several writers have connected cancer with the waning of the sexual powers, and the suggestion is made by Sherrington and Copeman that in the period which ante- dates the cancer age, the reproductive glands, by means of internal secretions, are able to inhibit the growth of cancer. In looking back over what has been ob- served in regard to the secretions, includ- ing those of ductless glands, we see that very strong evidence has accumulated to show that they have a very intimate con- nection with the development of cancer, as was to be expected, since they are very im- portant factors in connection with metab- olism. We have also seen that while there has not been demonstrated any very definite and specific change in the bio-chemistry of tumors, and no specific enzymes or poison secreted by cancer cells which can com- 104 MEDICAL ASPECTS OF CANCER municate the disease, there is evidence that the disordered cells secrete a something which deranges the blood and ultimately tends to end life ; for the blood in advanc- ing cancer undergoes very radical, degen- erative changes, some of which improve decidedly when a cancerous mass is re- moved surgically, but return with the re- growth of the tumor. We have also seen that the urine mani- fests alterations which show a disturbed metabolism, and that the saliva has an ab- normal acidity leading to disturbed amy- laceous digestion. We have further seen that there is evi- dence that the internal secretions of many organs, probably, through their influence on metabolism, are factors of importance in connection with the genesis and cure of cancer. Little well says, ^ ' Cancer is a dis- ease of disordered nutrition, as a result of which cells revert to a primitive stage, which permits reproduction. The disor- METABOLISM OF CANCER 105 dered nutrition is due to relative li^qDo- f unction of the ductless glands." In later lectures we shall consider the basic causes of this deranged nutrition, which, as has been already intimated, has much to do with diet and the various elements of life which tend to induce functional and other derangements of the system, many of which are included in and influenced by what we term the advance of civilization. LECTUEE IV RELATION OF DIET TO CANCER In our earlier lectures we saw that cancer was undoubtedly a diseased action of orig- inally normal tissue cells, due largely to perverted metabolism, the special features of which were brought out last week. In the second lecture we studied the fre- quency and geographical distribution of cancer, which was found to be very differ- ent for various peoples in diverse sections of the earth, and which we saw was pro- portioned in a great measure according to their diet and mode of life. In this lecture we will examine into the details of these matters more particularly, and endeavor to discover their practical bearing upon the prevention and cure of cancer. 106 EELATION OF DIET 107 For the proper understanding of the re- lation of food and drink to cancer, and the satisfactory application of the principles involved, it is necessary to bear well in mind the chemistry of the body and the re- lation to nutrition of the various elements which contribute to form healthy and dis- eased tissues. The human body is composed of some fif- teen different elements, the relative pro- portions of which may be understood by the following table from Sherman, which represents probably as approximately cor- rect an average as any that can be given. COMPOSITIOX OF THE HUMAN BODY Per cent. Oxygen, about 65 Carbon, about 18 Hydrogen, about 10 Nitrogen, about 3 Calcium, about 2 Phosphorus, al30ut 1 Potassium, about 0.35 Sulphur, about 0.25 Sodium, about 0.15 Chlorine, about 0.15 108 MEDICAL ASPECTS OE CANCER Per cent. Magnesium, about 0.05 Iron, about , . . . . 0.004 Iodine Fluorine Silicon very minute traces As the actual composition of the body is changing day by day, through the activities of the system, so that it is commonly be- lieved that after some years all the tissues are entirely renewed, the daily wear and tear, as also the material expended in heat and activity, must be supplied by the diet. For the ordinary requirements of the sys- tem, in health, the appetite serves as a guide, which should suffice in man as in wild animals, to preserve the balance of nutri- tion. But man has also the power to grat- ify the taste, which must be recognized in our study as distinct from the satisfying of the appetite; and the refinements of civilization have added so greatly to the temptation of wrong and over-eating and drinking, as they have to many other temp- KELATION OF DIET 109 tations, that it is questionable if reason, and what is often spoken of as the natural instinct for food, can be trusted in man- kind. It is to be remembered that the advance of civilization, and the facilities of trans- portation and cold storage, have brought from f aT and near an innumerable number and variety of articles for food and drink, including condiments, which bear no rela- tion to the few simple articles formerly consumed ; even the fruits which we eat are rarely ripened fully by nature, but are picked more or less green, and undergo an artificial ripening without the action of the sun, which is really akin to decay. In the combination and preparation of articles of food also, so-called civilization and refine- ment have made the greatest departure from the simple life of the aborigines, who are free from cancer, and with increasing ease and wealth throughout the civilized world more and more individuals are shar- 110 MEDICAL ASPECTS OF CANCER ing in unnecessary and often harmful in- dulgences, more and more freely: and this is especially true of animal food, the con- sumption of which has increased so greatly. Many other elements likewise enter into the matter of the digestibility and conse- quent nutritive power of food and drink; such are nervous conditions, rapid eating, imperfect mastication and insalivation, heat and cold, character of the air breathed, micro-organisms, etc., and all the various causes which may derange the action of the digestive organs and so prevent the per- fect metabolism between nutrient material and the cells of the body, as I tried to show you in some former lectures. As is well known, the nutrition of man is supplied by the organic substances, protein, carbohydrates, and fat ; these are found in various combinations in animal and vege- tarian foods, and as a rule contain also much of the inorganic or mineral sub- stances necessary for the system; all of RELATION OF DIET 111 these with water, and its salts, and oxy- gen, supplied by the lungs, unite, through anabolism and catabolism, to build and maintain tlie human body in health. It is also well known that in order to pre- serve health and proper weight there must exist in the economy a certain balance or equilibrium between the amount of the in- gesta and excreta, representing the various elements which enter into nutrition; thus we speak of a nitrogen equilibrium, a carbo-hydrate equilibrium, a phosphorus equilibrium, and iron equilibrium, etc., some of which are disturbed continually in ill health and in various diseases, including cancer, as has been shown in our last lec- ture. Until quite recently the principles of diet (even if not often carried out in practice) have been established on lines laid down by Carl Voit, of Munich ; this eminent physiol- ogist, after studying the dietary habits of various classes of workers, claimed that 112 MEDICAL ASPECTS OE CANCER the adult man of 150 pounds, doing mod- erate muscular work, requires daily 118 grams of protein or albuminous food, 56 grams of fat, and 500 grams of carbo- hydrate, with a total fuel value of 3000 large calories, in order to maintain the body in equilibrium. But the remarkable and scientific experiments of Chittenden have demonstrated beyond question that perfect bodily and nitrogenous equilibrium can be maintained with one-third of the amount of protein called for by the Voit standard, and with a total value in the diet of only about 1600 calories, or about one- half of that indicated as necessary by Voit. These experiments were based on a group of ^Ye men of varying ages, professors and instructors at Yale, thirteen volunteers from the Hospital Corps of the United States Army, and eight students in Yale, all thoroughly trained athletes, twenty-six in all. It would be quite beyond the scope of RELATION OF DIET 113 tliis lecture to enter at all into tlie intricate questions connected with the metabolism of nitrogenous and other foods, but Chit- tenden has well put the reasons ^'why prominence is given to the establishment of nitrogenous equilibrium and why the proteid intake assumes a greater impor- tance than the daily amount of fat and car- bohydrate consumed. Fats and carbo- hydrates when oxidized in the body are ultimately burned to simple gaseous x^rod- ucts, viz., carbonic acid and water. Hence these waste products are easily and quickly eliminated and cannot exercise much dele- terious influence, even when formed in ex- cess. . . . With protein foods, on the other hand, the story is quite different. These substances when oxidized yield a row of crystalline, nitrogenous products which ul- timately pass out of the body through the kidneys. Prior to their excretion, how- ever, these products — frequently spoken of as toxins — float through the body and may 114 MEDICAL ASPECTS OF CANCER exercise more or less of a deleterious influ- ence upon tlie system, or, being tempora- rily deposited, may exert some specific or local influence that calls for speedy re- moval. Hence the importance of restrict- ing the production of these bodies to the minimal amount, owing to their possible physiological effect and the part they are liable to play in the causation of many dis- eased conditions.'' When we consider the small share which nitrogen plays in the composition of the human frame, as shown in the table pre- sented, only three per cent., it is easy to see how an excess of nitrogenous food must necessarily either pass off unassim- ilated or undergo imperfect metabolism, and so derange the general metabolism; and this is found to be the case in many conditions of disease, and, as has been shown, in cancer. Chalmers Watson and others have shown in a most remarkable manner, by animal experiments, that an EELATION OF DIET 115 excessive meat diet alters very materially the microscopic structure of very many organs and portions of tlie body. Beneke, who is often quoted, was one of the first to seriously consider the actual diet beneficial in cancer, his observations dating back to 1875 upon material in the service of Esmarck and Oldehop, who treated patients according to his plan. While the diet he gives is not wholly vege- tarian, he limits the nitrogenous intake very greatly, and reported some very favorable results, with the complete dis- appearance of some malignant new forma- tions. Eeferring now to the data presented in the second lecture, in regard to the fre- quency and geographical distribution of cancer, we can understand better, on scien- tific grounds some of the reasons why can- cer is so steadily increasing in civilized communities, and why in some sections of the earth it is less common, while certain lie MEDICAL ASPECTS OF CANCER aborigines have seemed to be almost im- mune. We found that in England the per capita consumption of meat was 130 pounds per year, and that it had doubled during the past fifty years, while during the same pe- riod cancer had increased four fold; but in Ireland, where the meat consumption was estimated in 1895 at only 40 pounds per capita, or less than one-third that in Eng- land, the cancer death rate is very much lower, not much over one-half. We found that in Italy, where the per capita con- sumption of meat was the smallest of any European country the cancer death rate was almost the lowest. Also that in cer- tain other countries, where vegetarianism was the rule, cancer was very infrequent, while among certain aborigines the disease was practically unknown; but we found also that in both the latter classes of indi- viduals cancer has slowly increased, in proportion as the inhabitants of different KELATION OF DIET 117 sections had come under the influence of modern civilization, and adopted the di- etary and other habits of foreigners. In the United States cancer has certainly increased very greatly during the last fifty years, and statistics were presented show- ing that in seven of the largest cities, dur- ing the past five years, the number of can- cer deaths had augmented between seven and eight per cent. It is known that the consumption of meat here has increased steadily, until in a communication from the Bureau of Agriculture in Washington we learn that it had recently reached the enor- mous amount of 172 pounds per capita yearly, much more than in England. Cancer has been repeatedly spoken of as a disease of civilization, and there are many other elements besides meat to be considered in connection with its etiology. Coffee and tea are so widely and almost universally used in civilized countries, and their apparently pleasant effect is so great 118 MEDICAL ASPECTS OF CANCER that few realize the harm that may result therefrom; although from time to time their injurious effects, especially along the line of digestive and nervous troubles, are dwelt on by medical writers. Of late years, however, more attention has been paid to their influence on metabolism and also to the relation of their consumption to the increase of cancer. From a report to the House of Commons in England, Holland is shown to be the largest per capita consumer of coffee of any country in Europe, and the cancer death rate there in 1905 was among the highest, while Hun- gary was the smallest consumer of coffee, and the cancer mortality in 1903 was only 39 per 100,000, or a little over one-third that in Holland. It may be interesting to know that Thompson states that *'the peo- ple of the United States consume one-third of the total coffee produced, or more than Germany, Austria, Hungary, France and the United Kingdom combined. On the RELATION OF DIET 119 other hand England and her colonies con- sume one-half of the world's output of tea, and the United States but one-fifth of it/' The scientific basis of a possible rela- tionship of the consumption of coffee and tea to the prevalence of cancer may be bet- ter understood when we remember that caffeine and theine belong to the xanthin group, and contain exactly the same equiv- alent of nitrogen as uric acid. A single cup of coffee of fair strength, it is stated by Hutchinson, contains from one to three grains of caffeine, and a cup of fairly strong tea 1.21 grains, or more than the average medicinal dose of this drug; and all know how great may be the consump- tion of coffee and tea by some individuals, and that many of the working class, espe- cially, consume enormous amounts of tea, which is kept brewing all day. Roberts has very clearly demonstrated, by clever experiments, that tea interferes very 120 MEDICAL ASPECTS OF CANCER greatly with both the salivary and gastric digestion. Alcohol, or some of its combinations, has also been shown by several observers to be undoubtedly an element contributory to the causation of cancer ; this relates not only to countries or cities where the con- sumption is the greatest or least, but also to various occupations, in which statistics show the more or less abundant use of dis- tilled or fermented drinks, and deaths from the same, and in regard to total abstainers ; and a careful study of the subject makes it pretty clear that the incidence of cancer corresponds in a measure with drinking habits; that is, that cancer mortality is highest among those classes of persons among whom primary or secondary mor- tality from alcoholism is greatest. There are so many elements to be taken into con- sideration in connection with the derange- ment of metabolism which leads to can- cer, that it is difficult to fix the precise RELATION OF DIET 121 influence which each may exert; but in watching cancer cases for any length of time it is easy to see the harmful effect when alcoholic beverages are indulged in, and the improvement when all such are absolutely excluded. An interesting confirmation of the bene- ficial results of a low diet and simple life, as regards cancer, is found in certain re- ports of Commissioners of Prisons and Asylums in England, where the matter has been studied, as given by Russell. ^^ Asy- lums contain an excessive number of per- sons who have inherited or acquired con- stitutional weaknesses, and in many cases tendencies toward consumption or cancer; also many alcoholics who are prone to these maladies. Yet the habits and rules of these institutions reduce the cancer rate much below the rate of the classes from which they are drawn, and below the rate of both occupied and unoccupied persons. ' ' The same is observed in regard to many 122 MEDICAL ASPECTS OF CANCER religious orders, where the members lead a very simple and frugal life, and where cancer is reported to be almost unknown. Kessler has called attention to the dis- turbance of sulphur partition in cancer in connection with diet, and the desirabil- ity of excluding those foods exhibiting an excess of sulphur, giving lists of the same and indicating a satisfactory diet. Packard has m-ade a strong argument in regard to the value and importance of tlie mineral elements contained in plant life, in connection with the disturbances in these same elements which has been oh- served in connection with cancer, as we have already seen. He recalls that mod- ern chemistry teaches that the inorganic principles of the vegetable kingdom are absolutely necessary to the highest degree and type of animal tissue and health, and resistance to disease. Plant life is the connection between the minerals and salts of the earth and animal life, but in the RELATION OF DIET 123 manufacture or refinement, and cooking, of products of the vegetable kingdom, many of tliem are largely demineralized ; this especially illustrated in the case of fine white wheat flour, rice, potatoes (in peeling and cooking), etc. So that while animals get plenty of mineral matter from plants and the earth, man gets but little, and while the herbivorous animals are rarely affected with cancer, civilized man is succumbing to it more and more. It is stated that among savage tribes, who are practically free from cancer, the water in which vegetables are cooked is also con- sumed as food, thus securing all the salts. The same idea has been popularly pre- sented to the public in a startling manner by McCann in a book which, with a great deal of verbiage contains a large amount of valuable information concerning nutri- tion, and its disturbance by erroneous, or worse, preparation and administration of food. 124 MEDICAL ASPECTS OE CANCER Possibly tliere are other dietary ele- ments which may play some part in the causation of cancer, but the demonstrated facts in regard to them are so few and un- certain that they need not detain us here, although it is certainly desirable to inves- tigate any that seem to have reasonable support. Some of these which have been sug- gested probably have to do with local irri- tant action on the digestive organs, as we have previously seen that local irritation undoubtedly plays an important part in the determination of the actual time of oc- currence and site of the cancerous disease. Thus, some have ascribed cancer to hot food or drink, or to stimulating drink, con- diments, etc. It is quite possible that these contribute to the development of can- cer in the pylorus, irritating the secreting cells in their passage. Mayo says: *^In civilized man one-third of all cancers are seated in the stomach. This is not known EELATION OF DIET 125 to be the case in uncivilized man or in ani- mals. There should, therefore, be some- thing — some one cause — ^which- causes this preponderance. The acid secretion may favor its development, for when we come to the colon, also with an acid secretion, we again meet with cancer, and we seldom see it in the alkaline, small intestine. Gas- tric ulcer, which may be precancerous, is coim.ected with hyperacidity. ' ' In Scandi- navia cancer of the stomach is remarkably frequent, according to Soegaard, thus, of 1235 cases in Norway, 73.9 per cent were in that location. In our last lecture we found that cancer in general was connected with a lowered alkalescence of the blood, and all our studies show hyperacidity to be related to cancer genesis ; and nitrogen- ous acidity, or uric acid (purin, xanthin, etc.), undoubtedly plays a great part in inducing malignant action in tissues, as Haig has so long contended, even in regard to cancer. 126 MEDICAL ASPECTS OE CANCER The increasing" frequency of cancer of the mouth, oesophagus, and stomach in men certainly looks toward an irritating char- acter of substances which traverse these« regions, including alcoholic drinks, and the irritant effect of tobacco should not be overlooked in regard to mouth lesions. But of the millions who use tobacco only very few are affected with cancer, and only those who are predisposed thereto by some metabolic disturbance, whose true character and other manifestations are not yet fully determined. We have already referred to the practice of so-called betel chewing in the Far East as a frequent cause of cancer within the mouth, also to the wearing of the Kangri charcoal baskets in India, for warmth, causing a burn on the front of the body which may develop into epithelioma; it is claimed, however, by by some that of the many cases of ^^ Kan- gri burn,'' but few result in epithelioma. There are yet other considerations con- KELATION OF DIET 127 cerning the relation of diet to cancer which are worthy of attention. We have men- tioned some principal agents, which seem unquestionably to have an influence in the production and continuance of cancer, namely, proteids, cotfee and tea, and alco- holics. But millions of human beings par- take of these with apparent impunity, while in the relatively few they appear to have cancer-genetic powers. This need not surprise or puzzle us any more than do the many other problems in medicine which we are seeking to solve : for we know how often it happens that the system reaches a point where certain things, once well borne, are no longer tolerated. We know, for instance, that Port and Madeira wine certainly can cause gout, but with many individuals they may be indulged in freely for some time before this result fol- lows: likewise that tobacco may even be abused for a long time, without apparent ill effects, when suddenly there is a revul- 128 MEDICAL ASPECTS OF CANCER sion of the system and tlie slightest use of tobacco will be intolerable : also that many edible substances which have long been well borne, will at a certain time act un- favorably and excite eruptions, urticaria, acne, eczema, etc. Psoriasis also furnishes an illustration which may be of service in understanding the relation of diet to cancer ; for psoriasis is characterized by a disordered epithelial growth, which both shows on the surface and manifests itself by epithelial prolonga- tions into the corium, which are quite com- parable to the ingrowing cellular masses of early cancer: moreover cancer is not very rare in psoriasis patients. In this eruption it has been very clearly demon- strated, clinically and experimentally, that error in nitrogenous metabolism is com- monly at the bottom of the eruption, which has been seen to promptly disappear en- tirely simply under an absolute vegetarian diet, correctly regulated, excluding also RELATION OF DIET 129 coffee and alcohol, without the use of any medical treatment whatever, internal or external; but, of course, this result cannot always be obtained, and sometimes the eruption will relapse during what is thought to be a strict vegetarian diet. There must, therefore, be some systemic disturbance which causes nutritive mate- rial, at some ]3articular time, thus to de- range cell action in the eruptions men- tioned, and the same is true in regard to the production of cancer. Some years ago Braithwaite called atten- tion to the occurrence of cancer among cer- tain peoples who were vegetarians, and attributed it to the great amount of salt which they consumed. While the sugges- tion of salt being a cause of cancer has been ridiculed, it is quite possible that a great excess of sodium chloride may dis- turb the salt equilibrium in the blood, by replacing the potassium which is so neces- saiy for proper cellular nutrition, and also 130 MEDICAL ASPECTS OE CANCER by hindering the excretion of uric acid, as Haig has pointed out. When we inquire into the cause of the systemic disturbance wliich tends to such faulty metabolism that the nutrition of cellular structures is deranged, even to the degree of taking on malignant action, we find many possible elements, more or less connected with what is known as modern civilization, to which we have time to but briefly allude. Williams has shown pretty clearly that wealth, with its tendency to luxury and idleness, greatly increased the proclivity to cancer: not only is this ob- served in different countries, but in cer- tain cities the difference is very striking between the cancer mortality in sections which are occupied by the rich and well- to-do, and those in which the poorer classes are herded. Also in England it was found in one decennium that cancer mortality was more than twice as great among the well-to-do men, having no specific occupa- KELATION OF DIET 131 tion, as among occupied males in general, the ratio being 96 to 44. Change in the mode of life, and sudden changes of environment have also been found to have a great effect in the produc- tion of cancer, as has already been men- tioned in another lecture. Finally, for our time does not permit a fuller discussion, nervous conditions un- questionably can and very often do exert a profound influence on the secretion of the various organs of the body, and can so disturb digestion, metabolism, and nu- trition that the most varied results may follow, to which the names of different dis- eases are given; so that nerve strain, more or less incident to modem life, must be accredited with a certain share of influ- ence in the production of cancer. The part which imperfect and deficient intestinal and urinary excretion play in inducing or perpetuating the disease will be treated of in later lectures. 132 MEDICAL ASPECTS OF CANCER In our next lecture we will consider cer- tain matters relating to the medical treat- ment of cancer, but from long experience and study I am firmly convinced that such measures are of relatively little service un- less coupled with a rigid care of the diet and hygiene. As Bell remarks, ^'Cancer is essentially a disease supervening upon a persistent neglect of hygienic laws. ' ^ It is a disease of sub-oxidation, and all the hygienic elements of importance in tubercu- losis are equally necessary in cancer ; fresh air and sunlight with, as far as possible, an ideal regulation of life in all its aspects, are indispensable. Inasmuch as there is no specific medical antidote for cancer, and we cannot be cer- tain of securing at once the metabolism of health, it is wise to remove and to keep away from the system those articles which have been shown to have more or less influ- ence in its production, namely, animal pro- teids, coffee, tea, and alcoholics. Time EELATION OF DIET 133 does not admit a discussion of vegetarian- ism, nor is it necessary, for there is abun- dant evidence in literature and on every side that perfect health can be maintained thereby, and I went over the subject pretty thoroughly two years ago. The vegetable kingdom contains protein enough to build up and maintain the tissues of the body, as is shown in animals, and an extra number of calories can be easily obtained from but- ter, of which a quarter of a pound contains some 800 calories, or fully one-third of the total daily quantity required by most indi- viduals. The details of a purely vege- tarian diet, which experience has shown to be of the greatest value in cancer, can be worked out for individual cases as re- quired. I am also firmly convinced that in this absolutely vegetarian diet, with other proper hygienic and medicinal meas- ures, to be detailed next week, we shall find a great power for the prevention of can- cer ; although many persons are already so 134 MEDICAL ASPECTS OE CANCER saturated with poisoned blood and tissues from prolonged errors of life, tliat per- haps no very striking general effect on the community can be obtained therefrom in this generation. In closing this lecture I must again urge upon you the necessity of great patience and perseverance, with very much careful study of the patient in all particulars, over a great length of time, if really favorable results are to be obtained in cancer; and this is true whether the disease be incipi- ent, or fully developed, or even post-oper- ative. The causes of cancer are deep seated, and, as with many chronic affec- tions, there is no tendency to continue an improvement once begun, but under a re- turn to the same conditions as before the disease will certainly assert itself. We have learned the lesson of assiduous perse- verance in tuberculosis; let us learn it in regard to cancer. LECTURE V MEDICAL TREATMENT OF CANCEE It is remarkable that so little serious at- tention has been paid to the medical treat- ment of cancer, in standard works, in view of the occasional strong statements and reports which have appeared from time to time in current literature and in occasional books, dating back for many years. Much of this, of course, relates to imperfect ob- servation and erroneous diagnosis, and also to crude medical knowledge, but there have been also plenty of good men, who knew the disease and have reported favor- able results, and even the complete dis- appearance of cancer, under dietetic regi- men and proper medication alone, without operative interference of any kind. Not to go back too far, reference can be 135 136 MEDICAL ASPECTS OF CANCER made to Lambe, who one hundred years ago wrote clearly in regard to the causa- tion of cancer 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, the diag- nosis of which was confirmed by prominent surgeons of the day, several of whom en- dorsed the vegetarian diet. Abernethy wrote pointedly, soon after, regarding the constitutional origin of tumors and says, ^' There can be no subject which I think more likely to interest the mind of the sur- geon, than that of an endeavor to amend and alter the state of a cancerous constitu- tion. The best timed and best conducted operation brings with it nothing but dis- grace, if the diseased 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 revived or renewed by its disturbance." TREATMENT OF CANCER 137 He then gives an endorsement of Lambe's dietetic treatment of cancer, and presents several reasons wliy it should be fairly tried. In the classical work of Walshe we find numerous references to the constitutional nature of cancer, original or quoted from recognized authorities, as well as expres- sions in regard to the futility of expecting that surgical interference would cure the real disease in any great proportion of cases. He says, "It would in theory ap- pear that the removal of a tumor cannot in itself cure the disease, as the local for- mation is but a symptom of a general vice of the economy." . . . ''This tissue being, as the normal textures, the seat of nutri- tion, is like them susceptible of its disor- dered actions," and he alludes more or less to the effect of diet on the disease. The late Willard Parker, one of New York's gTeat surgeons, in a study of 397 cases of cancer of the female breast, ob- 138 MEDICAL ASPECTS OF CANCER served from 1830 to 1880, wrote very strongly in regard to tlie constitutional re- lations of cancer. In considering the eti- ology lie places constitutional causes first, and says, * luxurious living, and particu- larly excess in animal food, increases the waste products of the body, and if coupled with insufficient exercise, the waste prod- ucts are retained in the system and have a tendency to produce abnormal growths.'' . . . ^'Cancer is to a great degree one of the final results of a long-continued course of error in diet, and a strict dietetic regi- men is, therefore, a chief factor in the treatment, preventative and curative.'' Concluding his study he says, ^' There is such a consensus of opinion as to the ad- visability of early removal of the growth, that a discussion of the subject would be useless. So then, in the first place, let us remove the tumor, and thoroughly. But after we have done so, after we have taken it out by the very roots, is this sufficient! TREATMENT OF CANCER 139 No. We must then adopt the means stated above to prevent a second development. We must change the diathesis; we must seek to modify the patient's constitution so that it will be no longer prone to repro- duce the disease: and then only may the surgeon be satisfied that he has done his duty." He further says, ^'In regard to the effect of abstemiousness on cancer I can speak with great positiveness, that vegetable, or at least a very bland diet, does check the progress of the disease, and, in some cases now under treatment, has been attended by an alleviation of symp- toms ; and in a few instances even by a re- cession of the growth." He also quotes from Sir Astley Cooper some strong lan- guage which, as he says, ^' shows a broader and more enlightened view of the subject than is contained in the writings of some more recent observers, who have supposed that they were working far in advance of the great English surgeon"; the rather 140 MEDICAL ASPECTS OF CANCER long quotation then given proves that that great surgeon also believed absolutely in the constitutional nature of cancer. Sir James Paget is often mentioned by writers, sometimes even with derision, as a believer in the Constitutional Nature of Cancer, and his words are very strong; says he, ^^I believe it to be constitutional, in the sense of having its origin and chief support in the blood, by which the consti- tution of the whole body is maintained," and speaks at some length in his lecture, in support of this view; I will give you one other small quotation. ^ ' The existence of the morbid material in the blood, whether in the rudimental or in the effec- tive state, constitutes the general predispo- sition to cancer,'' etc. It is remarkable that the views of this prince of surgeons and pathologists should not have carried more weight in regard to cancer, when his other views are so well accepted. Time does not permit us even to refer TREATMENT OF CANCEE 141 to the great mass of more or less similar views and corroborative evidence scattered in books and current literature during the last fifty years, but a few more references may be given. In 1884, and again lately, Merriam has called attention to cancer oc- curring as a reversion of tissue cells to earlier or embryonic forms under the influ- ence of a disordered, or as he calls it, a poisoned blood stream, from over nutri- tion from a meat diet; and Haig has long maintained that uric acid is a prominent factor in the etiology of cancer. While few will agree with Haig in all his conclusions, there is no doubt but that a faulty nitrogenous m-etabolism plays a not inconsiderable part in the causation of many diseased conditions, as has been also sho'^n in a previous lecture to be true in re- gard to cancer : and while it may not be ac- tually uric acid or urea which does the harm, as these are relatively harmless end products of metabolism, it is true that the 142 MEDICAL ASPECTS OF CANCER purin and xanthin bases, of many forms, and imperfectly oxidized nitrogenous ele- ments, are active agents in the production of disease. Venus and Isenberg have both written very strongly in regard to the un- questioned value of a vegetarian diet in cancer, the former citing many supporters of the view, from ancient times to the pres- ent. If time permitted any amount more of corroborative evidence could be given in regard to the connection of cancer with metabolic disorders. There have been many scattered articles concerning the chemico-pathology of can- cer, all looking in much the same direction as that which we are pursuing, which can- not even be alluded to, but brief mention must be made of a most illuminating and suggestive study by Bristol. Eeviewing the many theories of the etiology of neo- plasms he shows pretty clearly that cell reproduction comes from outside the cell, or from the surrounding cell medium by a TKEATMENT OF CANCER 143 process of diffusion, or by a definite chem- ical attraction, and is closely associated with the nutrition and growth of the cell, especially the nucleus; also that a fixed ratio between the salts in the blood, lymph, and tissues is necessary for normal activ- ity and reproduction of cells ; further that a disturbance in this ratio and an upset in the chemical equilibrium will lead to abnor- mal metabolism, growth, and reproduction, and result in an atypical growth in the local area involved. As before remarked, it seems strange that the medical profession and the public have been so slow in accepting the views here presented. But both have become so obsessed with the idea that nothing can be done for cancer except operative pro- cedure of some kind, and so dazzled with the glamour of modern surgery, so fasci- nated with the apparent definiteness of laboratory proceedings, and so attracted by the glory of purely scientific research, 144 MEDICAL ASPECTS OF CANCER that it is very difficult for any other doc- trines to make headway: moreover, any dietary or medical treatment, prophylactic or curative, is very tedious and also diffi- cult, in the way of attention to minute de- tails-, etc., and patients weary of restric- tions and are restless at seeing little or slow progress made. Haig found the same difficulty with Hospital patients, but does not hesitate to state, that in private prac- tice *^some undoubted cases of cancer have gotten well'' under his dietary restrictions. But when it is remembered that it is cal- culated that, under present existing condi- tions and treatment, fully 90 per cent, of those attacked with cancer ultimately die from it, and that there were last year nearly 50,000 recorded deaths from this cause in the ^'Registration area'' of the United States, covering but two-thirds of its population, and that the disease is rap- idly and surely increasing, it behooves the Medical Profession to put forth the best TREATMENT OF CANCER 145 efforts possible to stay the progress of the disease. In New York City, according to the Weekly Bulletins of the Board of Health, there were from May to Novem- ber, 1914, in 26 weeks, 2173 deaths from Cancer, Malignant Tumor, or an average of 83.5 per week, almost twelve deaths daily from malignant disease. Operative surgery has unquestionably been of great service in certain cases and along certain Hues of cancer, and the claim for the earliest possible removal of morbid growths is certainly a just and proper one ; moreover, with our present knowledge it is perhaps wise to attempt to remove the offending mass while there is some hope or prospect of benefit, and personally I am occasionally advising this in proper cases. X-ray and radium have also their sphere of usefulness in a certain class or group of cases, but the excessive exploitation of the latter, not long ago, did harm in raising false hopes in multitudes of sufferers, and 146 MEDICAL ASPECTS OF CANCER as these were shattered so also was confi- dence shaken in regard to all help for can- cer from other than surgical removal. But every one who has been brought much into contact with cancer knows full well what a mass of recurrent cases exist, possibly many of them due to bad oper- ation, in regard to which surgery has to acknowledge that it can offer nothing more, that they are inoperable and therefore they are regarded as incurable. Every one also knows how many cases there are which have advanced so far before coming to a competent surgeon, that they are also inoperable. Every one likewise knows that there are numerous cases of cancer in in- ternal regions, and in certain localities, and presenting peculiar features, which are also recognized as inoperable, at least with any proper justification. Thus it may safely be said that of the total number of cases of cancer existing at any one time, which would be included under the above classes. TREATMENT OF CANCER 147 fully 50 per cent, are sucli that operative surgery can offer no hope of material bene- fit : also, it must be acknowledged that but a relatively small proportion of all cancer cases are likely to secure the very best surgical service, such as claims the highest percentage of success. For this large number of hopeless vic- tims of this dire disease, at least, proper dietary and medical treatment should be most carefully studied and patiently ap- plied, with the hope and expectation that the same, if correctly employed, would more or less hinder or check its progress or prevent a recurrence after operation. But experience shows that such measures, if taken promptly and thoroughly, can also prevent the development of early threaten- ing lesions into those of malignant charac- ter, suggesting surgical removal, and these should never be neglected when there is the slightest suspicion of cancer. For it must be acknowledged that the surgery of 148 MEDICAL ASPECTS OF CANCER cancer is only an attempt at the physical removal of a something, which medical science and art should not have allowed to develop out of normal tissue. And in the matter of the general prophylaxis of can- cer it is certainly worth while to consider and act strongly upon the facts which have been presented, especially in those indi- viduals who have any hereditary suspi- cions, or who exhibit the habit of body or life which could lead to the development of cancer. The medical care of cancer, as of all dis- eases, naturally includes both prophylaxis and the treatment of a morbid condition which has already developed ; the former of these is always considered to be of the highest importance. Prophylaxis of Cancer. From what has preceded in this and other lectures it can readily be understood that the prevention of cancer lies largely along dietary and hy- gienic lines, including such medical atten- TREATMENT OF CANCER 149 tion as shall secure healthy action of the secreting and excreting organs. If the fig- ures and facts heretofore given are correct, if cancer has surely been observed to in- crease under certain conditions of life, if it is found to be absent or relatively rare under certain other conditions of living, if cancer has been known to disappear spon- taneously in certain individuals, especially when they have changed their mode of liv- ing, it must then follow that when the ex- actly correct habit and state of hf e are con- tinually assumed the disease will not oc- cur. In other words, when the blood stream nourishing the tissues is ideally correct, the individual cells of the body perform their functions normally, and as each cell is worn out it is removed by a healthy cat- abolism and renewed by a normal anabo- lism, and homologous cells then replace those which have ceased to be able to per- form their function. On the other hand. 150 MEDICAL ASPECTS OF CANCEE wlien there is perverted metabolism we have various forms of deranged action, to which we give the names of various dis- eases, one of which is cancer : here in place of homologous cells maintaining the tissues in a normal condition, we have a malignant metamorphosis into heterologous cells, which take on a disorderly or rampant ac- tion, and refuse to assimilate themselves to others, so as to form healthy tissue; we have then a mass of low vitality, tending to easily break down or ulcerate, and to extend their malignant action to adjoining tissues, under the continued influence of a contaminated blood current. When once ulceration has occurred, the ordinary para- sitic micro-organisms, which are prac- tically omnipresent, find an acceptable nidus, and aid in the destructive work, and also in the systemic poisoning of the tis- sues. The aim, then to be sought in the pro- phylaxis of cancer is to secure the most TREATMENT OF CANCER 151 perfect blood stream possible, wbicb is ac- complished by simple living, perfect masti- cation, and the avoidance of excesses, espe- cially along the lines of protein, tea and coffee, alcohol, etc., with the maintenance of healthy habits of life, especially in re- gard to bowel action. As already inti- mated, we do not know just why in some persons and at a certain time a disturbance of metabolism results in perverted cell growth, but there is, of course, a reason, and the physician's duty is so to regulate the patient's whole life that the metabolism is kept in the state of perfect health. All this seems very simple and trite, but really it is a task which is most important and often most difficult to accomplish, and re- quires very careful study and infinite pa- tience. Dr. Kellogg, of Battle Creek, says that of the many thousands who have passed under his care he has not known cancer to develop in any one who had been faithful to the principles which he incul- 152 MEDICAL ASPECTS OF CANCER cates, and I may say the same of the many who have been under my care in private practice, often with notes extending over many years. Time does not permit of going into de- tail here in regard to the special features of diet and hygiene, which I discussed with you fully two years ago, in my lectures, which were subsequently published : suffice it to say, as previously remarked, that the refinements of civilization add greatly to the temptation of over-eating, and wrong eating and drinking, as they do to numer- ous other temptations, and in many in- stances it requires the utmost amount of grit as well as patience, both in the pa- tient and doctor, to secure the perfect re- sult necessary. It is understood, I trust, that I believe that for the proper treatment of cancer, and to prevent its occurrence and recur- rence, it is absolutely necessary to main- tain a perfect vegetarian diet, which in- TREATMENT OF CANCER 153 eludes even the exclusion of eggs and milk, with food ; but the yolk of eggs may some- times be taken with advantage, and also milk alone and separate, at a body tempera- ture, one hour before eating, according to the plan which I have often demonstrated to you. As remarked in my last lecture, the vegetable kingdom contains proteid suf- ficient for the system, and the diet should be so arranged as to give the requisite quantity of calories, in proper proportion, of vegetable protein, carbohydrates, and fats: the latter is accomplished largely with butter, of which a quarter of a pound may be taken daily. Many writers on diet hold that the protein in casein acts differ- ently from that contained in meat, and this is allowed in many vegetarian dietaries : it also contains phosphorus, which is an inte- gral part of living cells, especially their nuclei. When nutrition seems to demand it, this can, perhaps, be added to the diet, mixed with cereals or in soups, and a small 154 MEDICAL ASPECTS OF CANCER amount of certain kinds of cheese is also sometimes allowable. It is impossible to elaborate the details of diet fully in a lec- ture such as this, and I must refer you to the many excellent works on food and nu- trition (Hutchinson, Sherman, Thompson, Buttner, Braithwaite), for further infor- mation. The medical treatment of cancer pa- tients is a matter which should receive most careful and constant attention; in- deed, the patient in whom cancer is threat- ening or has developed should be under the watchful and unremitting guidance of a physician who grasps the importance of the matter and is prepared to guard the health, and to meet and correct functional disorders as they arise ; for a careful study of patients with cancer for many years has constantly shown me gross errors in their life and in the action of various organs, and consequently disorders of metabolism TREATMENT OF CANCER 155 wMcli are of weight in connection with the disease. The first point of importance to which I wish to call your attention is in regard to the action of the bowels. Some of you may remember that even that great surgeon, Sir Arbtithnot Lane, has recently empha- sized the fact that one of the terminal results of intestinal stasis may be cancer. This may seem strange, but it would sur- prise you if you knew how very commonly there was imperfect intestinal excretion, or intestinal stasis, as it is now called, in these subjects ; indeed, I might almost say that it is the rule, and that this assuredly plays a most important part in the auto-intoxica- tion which leads up to cancer ; in fact, I al- most feel like saying that the toxins pro- duced by the millions of micro-organisms generated through intestinal stasis and fe- cal putrefaction are the real, incidental cause of cancer. Under a perfect vegeta- 156 MEDICAL ASPECTS OF CANCER rian diet there is less likelihood of trouble in this direction, bnt even then there is ne- cessity of watching continually, that there may be at least, one, full, free movement of normal character, daily, after break- fast. In many cancer patients I have se- cured this by having the entire potato eaten, skin and all, whether boiled or baked ; by this means also one gets the full value of the inner layer of skin, which con- tains the mineral salts so necessary to the economy, which are entirely lost when the potatoes are peeled before boiling ; so that potatoes should always be cooked in their skins, even if the outer layer is stripped off afterwards. But the regulation of the bowel action should not be left to the judgment and ac- tion of patients, with a spasmodic use of remedies, and with alternate constipation and purgation; the physician himself should carefully guide and direct the proper treatment frequently enough to se- TREATMENT OF CANCER 157 cure perfect results. Of course eacli one may have tlieir own ideas and methods, but I have long used with the best results the remedies which you have often heard me order in this clinic. Thus, at the begin- ning of treatment, and often on the same days of many succeeding weeks, I give ^ Ext. Colocynth. Co., Mass Hydrarg aa gr. X Pulv. Ipecac gr. ij M. Div. in Capsules No. IV. Sig. Take two at night and two on the second night after. For continuous use, or in the nights between these, I have long used a compound Cascarin tablet ( ^ Podophylin, Aloin, Cascarin aa gr. %) one or more each night, or have depended on the Cascara in a mixture of which I shall shortly speak. I do not like the action of salts or laxative mineral waters in these cases, and, of course, enemata are entirely useless to secure real, effective liver and intestinal action, and should be used only in an emergency. The action of the kidneys is also always 158 MEDICAL ASPECTS OF CANCER a very important element to watch and control in cancer j)atients; this does not have reference to albumen and casts, or glycosuria, but to a functional derange- ment of the secretion: for the former are relatively infrequent compared to the lat- ter. This is so large a subject that time does not permit of its elaboration; I made the matter pretty clear to you in my lec- tures not long ago on the relations of dis- eases of the skin to internal disorders. I must tell you, however, that, as a result of numberless studies of the urine of many cancer patients, I have almost constantly found a deficient or defective urinary se- cretion : in many cases I have had the total daily amount accurately measured, and re- ported in writing each week over long periods, and while the total quantity may at times be near normal, the total solids sometimes fall to, and remain at, even less than one-half the amount which should be passed for the patient's body weight. TREATMENT OF CANCER 159 I want here to urge upon you the impor- tance and value of rei^eated volumetric examination of all possible ingredients of the urine, as indicating in the best manner obtainable the state of the arterial blood, from which the urine is derived : especially is this true of the exact volumetric acid- ity, representing the diminished alkales- cence of the blood common in cancer. The actual medicinal and dietary treat- ment of the various possible departures from normal can hardly be elaborated here, but they are along very much the same lines which you have often watched in con- nection with certain diseases of the skin; for you must remember that carcinoma is an epithelial disease, and that the laws of nutrition are much the same for this as for various other morbid conditions of the economy. I may say, however, that very many of my cancer patients have received the greatest benefit from acetate of potassa, often in the formula familiar to you (^ 160 MEDICAL ASPECTS OF CANCER Potass. Acetatis gi Tinct. Nucis Vomic oiv Extr. Cascar. fld. oij-oiv Extr. Rumicis radicis fld. ad qIY M. Sig. One teaspoon- ful half an hour before eating, well di- luted). For many years I have adminis- tered potassa largely to these patients, and it is gratifying to find not only support but an incentive to its greater use, in the studies and experience of Ross, who pushes it to a very great extent, giving as high as 240 grains of potassium phosphate in a day. Ross also advises the free use of crude or brown sugar, as it contains a large proportion of potassium salts, which are for the most part removed from the white or refined article. I must also remind you of the great value of Bethesda water, in washing out the kidneys, given a tumbler- ful with each meal, and one tumblerful, hot, one hour before breakfast and also an hour before the evening meal. The blood should also be watched, and in my hospital cases I have a count made TREATMENT OF CANCER 161 every week; for the liaemogiobin content, and the number of the erythrocytes, and the percentage of the varieties of leucocytes afford very valuable information as to the physical state of the patient, and the prog- ress or recession of the cancer, and in a measure these data are of value in direct- ing therapy. I have also the iveigM of the patient taken and recorded each week, as a guide to nutrition and dietary matters. Also the saliva is tested and recorded be- fore and after each meal, and furnishes an indication in regard to the administration of alkalies. Iron is found to be greatly wanting in the blood and tissues late in cancer, and should always be an element in the treat- ment of this disease. Skene Keith, notic- ing that after a cancerous mass was re- moved the blood recovered in regard to hsemogiobin and erythrocytes, administered iron with arsenic, with the greatest benefit, the growth shriveling up and the patient 162 MEDICAL ASPECTS OF CANCER gaming in weight; lie recommends tlie citrate of iron and ammonia, the prepara- tion which I have given to patients for many years past. He also advises hypo- dermic injections of iron, arsenic, and soda, and reports cases thus treated, some of them with good results. There is a loss of phosphates in these patients, and phos- phate of iron or other phosphates are valu- able. When considering the metabolism of can- cer mention was made of derangement in the action of the ductless glands in this disease, and of the use and value of certain preparations of the internal secretions in its treatment. While a hormone therapy of cancer is still in its infancy, in spite of many books and innumerable journal arti- cles on the internal secretions, it is quite possible that the future may demonstrate its efficacy in helping to control the dis- ease : for, that the latter are efficient agents in carrying on the vital processes in the TREATMENT OF CAXCER 163 body, there can be no question, although as Biedl remarks, ''Our knowledge of the chemistrv of hormone formation is verv slight." But considerable clinical evidence has been accumulated that one at least of the internal secretions, namely, that of the till/ raid, has a definite beneficial effect upon cancer; this I have administered to many cancer patients, and have reason to believe that it contributed to the favorable results obtained. Sajous, believing that insufficiency of the adrenal secretion is an element in altered nutrition, advocates thvroid extract on the sTOund that it stimu- lates the activity of the adrenals : Vincent quotes Erlich as belie^-ing that "there may be substances circulating in the organism which may stimulate the body cells to re- sist the athreptic influence of cancer cells." Shirlaw advises a tablet made of thyroid 6 grains, supra-renal % gTain, and pitui- tary Ke grain. ^Vhile the treatment by 164 MEDICAL ASPECTS OF CANCER these hormones from internal secretions is really in rather an experimental stage, it would seem more than probable that the correct use of these pluriglandular ex- tracts, in combination with other proper dietary and medicinal treatment, would be of service in the prophylaxis and treatment of cancer. I have been a little cautious in the use of thyroid, beginning with two or three grains with meals, three times daily; for, as a promoter of catabolism it can dis- integrate tissue faster than the emunctories can remove the effete products, and may thus poison the system. Serum- and Vaccine-therapy are yet in a stage of development, and as I have had little or no personal experience with them I will not attempt to discuss their value, which time alone will demonstrate. While there have been many claims of success from treatment along these lines, unfor- tunately they have not been confirmed by later observations by others: I may say TREATMENT OF CANCER 165 frankly that they have never appealed to me as rational, in consideration of the views and experience I have long had along other lines of thought and practice. If, however, future investigations shall con- firm some of the remarkable reports which have been made, the latest of which is by Nowell, there may be opened a non-surgical line of treatment of cancer which would mean much to many otherwise hopeless cases. The local medical treatment of cancer is also an important matter which should re- ceive careful attention. For many years in early cancer of the breast, under proper, general, dietetic, hygienic, and medicinal treatment, I have seen the lump vanish under the continued application of the iodide of lead, in Hebra's diachylon oint- ment of the German Pharmacopoeia (3ss-5i ad gi), and in very many instances I have had the assurance of patients that its application relieved the pain and was 166 MEDICAL ASPECTS OF CANCER of the greatest benefit also in axillary and other metastases. In other cases the con- tinuous painting with ichthyol (50 p.c. in water) has seemed to be of great service, in combination with other proper treat- ment: all of this in earlier cases, before ulceration has occurred. After ulceration has set in, either in pri- mary or recurrent cases, proper local medi- cation is very important. The ordinary micro-organisms, finding a suitable nidus, very readily germinate and add greatly to the suppuration, and consequent exhaus- tion and pain, and by their toxins, aid also in the general contamination of the blood and tissues. Hydrogen peroxide, laid on with pledgets of absorbent cotton is often of great service in changing the conditions of the part, and when followed by Russian oil, also applied with cotton, makes a most satisfactory dressing. Adrenalin 1-1000 is also often of service, both in checking active hemorrhage, and in relieving pain. TREATMENT OF CANCER 167 and shrinking np tlie granulations. Ich- tliyol, 10 to 25 per cent, in Tvater, and per- manganate of potash in water, 1 to 2 per cent, are also often of service, likewise acetate of aluminium, 3 to 5 per cent. : methylin blue and fuchsin in watery solu- tion, 1 to 2 j)er cent, were formerly much used, and often served a good purpose. It is understood, however, that none of these measures have any great curative effect on cancer, but as contributory ele- ments they should never be neglected. Ichthyol ointment (I> Ichthyol oss-5i Zinc Oxid OSS Unguent. Aquae Eosse 51) often proves most satisfactory, spread on thin layers of absorbent cotton, and changed several times daily, after soaking the part with one of the liquids above mentioned. Time does not permit us to go into the matter of the X-ray, which undoubtedly has often been of great service in certain cases of cancer: it should be carefully but systematically employed, once or twice a 168 MEDICAL ASPECTS OF CANCER week in connection with other medical treatment ; radium can also be of real serv- ice in these cases. In some inoperable cases a mild surgery, especially with the actual cautery, in the way of removing exuberant masses, which would have to slough off, can add much to the good prog- ress of the case, and the occasional excision of cutaneous nodules removes just so much cancerous tissue, which by its secretion would poison the system. In our study thus far we have seen that there is much to be done for cancer besides the surgical removal of the offending mass, the existence of which is an opprobrium to medical science, which has not thus far guarded mankind against it : and until time has passed, and by right living and proper medical attention cancer has ceased to be produced, or become greatly diminished, surgery will probably be a great factor in its treatment, as its mortality statistics are constantly improving. But there can be no TKEATMENT OF CANCER 169 question but that with the adoption of proper dietary and medical treatment, even from the first suspicion of a malig- nant growth, and before, as also after oper- ation, the final results of operative pro- cedure will be even far better than have been yet attained. LEG TUBE YI CLINICAL CONSIDEEATIONS AND CONCLUSIONS The test of everything lies in the results obtained. Theories, discussions, and argu- ments are all unavailing unless results show their truth. In medicine, however, it is sometimes difficult to demonstrate re- sults until after the lapse of time, as was well illustrated by the preposterous claims first put forth for ^'606,'^ which is grad- ually attaining about its correct status. The same is true in regard to the surgery of carcinoma, where operations which for- merly were attended with veiy^ bad results have gradually been improved, so that, while the late Dr. Agnew of Philadelphia once said, toward the close of his life, that he did not know if he had ever been justi- fied in any operation he had performed on 170 CLINICAL CONSIDERATIONS 171 this disease, the best surgeons are now claiming notable successes, with relatively good percentages of recovery: but here again, time comes in, and while the three- year limit of freedom from recurrence is valuable, it is still said that fully 90 per cent, of those who have once been affected with true cancer, die of the disease, and its general mortality is still increasing in spite of all surgery. Dr. John B. MurjDhy of Chicago, has also repeatedly expressed himself most pessimistically in regard to the ultimate results of the surgical treat- ment of carcinoma, especially in those pa- tients who are fat, and with lax tissue, that is, exhibiting evidences of imperfect met- abolism. Dietetic and medical treatment of can- cer, in the fullest sense, have never yet been given a fair and fully intelligent trial on a scale large enough to produce general conviction in regard to their value. Many cases have occurred here and there which 172 MEDICAL ASPECTS OF CANCEE have recovered spontaneously, that is, without surgical interference, and often really to the surprise of the medical at- tendant: this of itself shows that under certain circumstances something may occur in the system which causes the malignant process to cease, and the cells to return to a normal function. This certainly should be a stimulus to discover what the reason is for this beneficial change, and we be- lieve that it is to be found in what has pre- ceded in these lectures. When the New York Skin and Cancer Hospital was founded, over thirty years ago. Cancer was included with Diseases of the Skin, in the hope and expectation that in studying the internal causes of the lat- ter light would be thrown on the etiology of carcinoma, which, as we know, is a dis- ease of epithelial elements ; and the earlier Eeport of the Hospital shows but one de- partment, including Cancer with Skin Dis- eases, with operating surgeons and a gynae- CLINICAL CONSIDERATIONS 173 cologist to assist, whenever tlieir services were requested by the physicians in charge. Before long, however, for reasons which cannot now be given, and against the judg- ment of the present speaker, the plan was changed, and a separate cancer depart- ment was erected under the exclusive charge of surgeons. A Prize Fund was also early established, which has been slowly increasing, for the discovery of a cure for cancer by other than surgical re- moval. For thirty or forty years I have held very much the same views regarding can- cer which have been presented in these lec- tures, and have acted on them more or less strongly, and in later years very strin- gently, and have rarely seen cause for re- gret. For one reason or another I have also had many hundreds of patients, with various affections, on a vegetarian diet over varying periods : in a number of cases I have records extending over many years, 174 MEDICAL ASPECTS OF CANCER in whicli I have observed the patients from time to time (one psoriasis patient having continued it for over twenty years) and with only the best results, so I trust that you will accept and test the validity of my statements. In looking over my case histories in pri- vate practice I find that I have more or less complete records of 96 cases of carci- noma, mostly of the breast (two of them having Paget 's disease), 29 of sarcoma in various situations, and 619 of epithelioma of different degrees of severity, of which four others had Paget 's disease; a total of 744 patients with these forms of neoplasm. Some of these patients were seen in consul- tation, others only once or for a brief period, but many of them were under care and observation for a greater or less length of time. During the past year I have also treated on the plan here indicated a num- ber of cases of recurrent carcinoma in the New York Skin and Cancer Hospital, CLINICAL CONSIDERATIONS 175 which have been submitted to very careful laboratory study, some of whom have ex- hibited decidedly favorable results: some of these will be referred to later, but they are too recent to afford positive data, and I prefer to confine my consideration mainly to private patients, in regard to whom more reliable evidence can be obtained. I will not weary you with any full analy- sis of these cases, nor will I consider any of them except those of carcinoma: for while I believe that sarcoma is of the same nature and origin, save that it relates to connective tissue cells, but few of the cases were submitted long enough to a vigorous treatment calculated to yield efficient re- sults. I may say in regard to the cases of epithelioma, mainly of the skin, that some of the more severe ones showed very markedly the benefit of dietetic and medici- nal measures of the character now being considered, and that it is my custom to treat such in the same manner : for reason 176 MEDICAL ASPECTS OF CANCEE would seem to show that the same causes would produce abnormal proliferation of epithelial elements on the cutaneous sur- face as well as in other parts of the body. In regard to the cases of carcinoma there were 6 in males and 90 in females ; of these the right breast was affected 42 times, the left breast 45 times, and both breasts 3 times. In 28 cases the patients were oper- ated on surgically before adequate treat- ment had been employed; many of these were earlier cases, or those seen in consul- tation. In seven instances it seemed wise to have an operation, after a more or less faithful trial of medical treatment. There were no cases of cancer of internal organs, except metastases, as these would not natu- rally come to me. The average age of the breast cases was 51.8 years. In the large majority of cases, except those who had been surgically operated on, the diagnosis was clinical only, as it is an accepted fact that it is very unwise to make CLINICAL CONSIDERATIONS 177 a biopsy, even before surgical removal, and manifestly imi^roper where this is not un- dertaken; but in most of the cases there was the indei3endent diagnosis of one or more other medical men, and many of the patients came to me on account of threat- ened operations by prominent surgeons, and even after these had been arranged for; in 27 cases there had been previous surgical removal with recurrence, and in several cases more than one operation, with again recurrence. The exact duration of cancer before coming under observation is always an un- certain item, for undoubtedly a tumor starts in an individual cell or group of cells, and has probably been forming some time before being noticed by the patient or attracting attention in any way. The aver- age stated duration of the disease was 1.6 years before coming under observation. Surgeons are fully agreed that the earlier a tumor is recognized and removed 178 MEDICAL ASPECTS OF CANCER the better tlie prospect of ultimate success, and this is eminently true in regard to remedial measures other than surgical: for as we have seen, after a cancerous proc- ess is well under way its cells secrete a something which hastens the general de- pravement of the system, and quickens the growth of the neoplasm, and naturally greatly increases the difficulty of overcom- ing the dyscrasia. Thus in the effort to get at and remove all possible or prospective cancerous le- sions, many innocent or non-mahgnant adenomata, etc., are operated on, which are afterwards found to be such microscopic- ally. In the same way it is quite possible that some of the small breast tumors which have disappeared under the dietetic and medical measures here described were still non-malignant, and should not be grouped with carcinoma. It is fair to say, therefore, that among my notes are also 22 cases of breast tumors CLINICAL CONSIDERATIONS 179 wliich have been excluded from the carci- noma list, and entered with other titles, such as abscess, cyst, chronic mastitis, adenoma, etc. But I claim that even if some of these also disappear under the measures we are considering, as they fre- quently have done, it is a better and more desirable result than if they had been re- moved by the knife : for in the former case the cause which induced the unnatural growth has been overcome, whereas by surgery only the obnoxious mass has been dislodged, and perhaps with it adjoining tissue and glands, but nothing has been ac- complished toward checking the cause pro- ducing the offending lesion. But the very fact of the frequent recurrences after oper- ation, in the neighboring skin or elsewhere, demonstrates the fact that surgery is but an attempt to rectify past errors, which might or might not have been prevented by careful medical foresight and action; we must, however, be thankful for the meas- 180 MEDICAL ASPECTS OF CANCER ure of success which has followed the noble efforts of our distinguished surgeons, only it is to be hoped that hereafter other meas- ures will also be more commonly adopted, looking towards a prevention of the recur- rence of carcinoma after operation. Not to detain you too long with these clinical considerations, I would like to give the details of a few of the cases which have been most striking. Mrs. B. E. C, aged 44, was first seen on account of trouble in the right breast, on September 19, 1892. She then had a flat tumor in the outer lower segment, an inch and a half in diameter, rather sharply de- fined, and tender on pressure at the sides, which she had noticed about two months. Not satisfied with the diagnosis of cancer, and hesitating at the thought of medical treatment, she consulted a well-known, prominent surgeon, i^^ho pronounced the tumor as undoubtedly cancer, and urged its instant removal ; this I did not know until CLINICAL CONSIDEKATIONS 181 slie informed me of it some time later, after the tumor had entirely disappeared under treatment. I saw her at frequent intervals for six months, and the breast became entirely normal. Four years later she was again seen in regard to the meno- pause, which she was undergoing, and the breast was found still to be normal: she was maintaining her diet. Nearly three years later I learned from her husband that she was in perfect health, with abso- lutely no breast trouble, and for eight years later, while he himself was under occa- sional treatment, I learned repeatedly that she remained still perfectly well, over six- teen years after beginning treatment, with no recurrence of the breast tumor. Miss B. M. L., aged 45, was first seen on January 4, 1894, with a tumor in the left breast, which had been diagnosed as can- cer by three medical men, and one of them, a surgeon of prominence, had arranged for immediate surgical removal the next day. 182 MEDICAL ASPECTS OF CANCER The mass was situated in the upper and outer quadrant, well defined, not painful on moderate handling, but subsequently she experienced pain in it. Two months later the lump was recorded as less distinct and flatter, and within eleven months it had en- tirely disappeared. A month or two later she had some pain in the breast, in connec- tion with the menstrual disturbance ac- companying the menopause, but no trace of the tumor. On Nov. 8th, 1905, she called, bringing a relative for treatment, and the breast was found perfectly normal, and again ^ve years later she called, with another trouble, the breast still remaining perfectly well, also sixteen years after first coming under treatment. Miss J. M. A., aged 45, was first seen Oc- tober 12th, 1905, with a tumor of the left breast, above, toward the median line, near the nipple, not painful on handling, though there was some pain afterwards, and it had been awaking her with pain at night CLINICAL CONSIDERATIONS 183 for some months, with also a mmib, shoot- ing pain in the daytime. She had seen a number of medical men always with the diagnosis of cancer, but she had declined operation. Two months later, Dec. 15th, 1905, it was recorded that there was very little to be felt in the breast, and there was no pain at any time, and on January 5th, 1906, both breasts were the same on palpa- tion, with no sign of the former tumor. For one reason or another she has been seen from time to time, almost up to the present date, and remains perfectly free from her former trouble, a period of over nine years. She has been a most faithful patient, adhering strictly to diet and more or less medication, except when on certain occasions I have let up on the same; and all the time from the first she has been un- der great strain of work, mental and phys- ical, as a city missionary. Another very similar case was in the person of Miss G. M., aged 44, who has 184 MEDICAL ASPECTS OP CANCER been under constant observation and treat- ment off and on for various troubles from November 13, 1905, until yesterday. Fif- teen years previous to her first visit she had fallen and struck the left breast which was bruised, but the effects wore off in some months, and there was no sensation in the breast for some years. Then 7 or 8 years later she began to have pain in the breast, aggravated before and during men- struation, which had continued until her visit, and for the last months she had been kept from her work in school, the pain be- ing severe in the breast, and more recently in the axilla : in July there had been bleed- ing from the nipple. She had seen a num- ber of medical men, with the diagnosis of cancer, and one surgeon of prominence in one of the large hospitals had strongly pressed for an immediate operation. When first seen there was a tumor be- tween two and three inches in diameter, in the upper, inner segment of the left breast. CLINICAL CONSIDERATIONS 185 hard, sharply defined, and more or less nodular on the surface: there were some enlarged glands in the left axilla. She had long been constipated and was passing about 60 per cent, of the amount of urinary solids proper for her weight. Under very active treatment it was recorded four weeks later that there had been hardly any sensations in the breast during the previ- ous week, that the tumor had diminished materially in size, with only moderate hardness, and that she was now out doors every day, and feeling much better. One month later it was recorded that the breast was very well and on examination was- al- most the same as the other, there being some general caking in both : she had had no pain for some time. One month or so later she was again at her duties as a pub- lic school teacher, which she has continued at since, with rare exceptions, when some temporary ailment prevented : the lump in the breast did not wholly disappear for a 186 MEDICAL ASPECTS OF CANCER month or two later, but on April 7th it was recorded that the left breast was the same as the other, and no glands could be felt in the axilla. From that time to the present she has had a variety of troubles, rheumatic and other, and it has been difficult to keep up a proper action of the bowels and kidneys; but in spite of strenuous and often exhaust- ing work as a New York City public school teacher, she has had no return of the breast trouble, now for over nine years. A sister, aged 60, has just died with cancer of the stomach in a distant country town. I could multiply these histories but do not want to tire you, though I do want to mention one more patient, to show what can be done in the case of recurrent carci- noma, after operation, of which I have had a number of cases with varying results, ac- cording to the duration and severity of the disease. Miss H. M., aged 61, came to me June CLINICAL CONSIDERATIONS 187 21st, 1913, with the following history: About two years previously a lump ap- peared in the outer, lower segment of the left breast, which was removed in August, 1911 ; this healed soon, leaving a good axil- lary scar, and there was no thought of trou- ble until two months before her visit, when a small red spot appeared near the edge of the sternum. Tliis enlarged and hardened and others appeared around the scar, until, when seen there were a dozen red nodules up to half an inch in diameter, near the cen- ter of the former site of the breast, with others, not red, above; with the tense skin and rapidly developing, multiple nodules here and there, further surgical operative procedure was out of the question. Since that date she has been under strict vegetarian diet and medication, including thyroid from time to time, with repeated application of X-rays, and under all these measures together many of the nodules have disappeared; although some 188 MEDICAL ASPECTS OF CANCER new ones have formed, several of which have been removed under local anaes- thesia, the wounds healing kindly. As she resides some distance from the city she has not been seen since October 7th, 1914, she wishing to take the X-rays nearer home, but she was earnestly charged to continue also the dietetic and other treatment* In this instance the pa- tient has lived comfortably and without pain for almost sixteen months after com- ing under treatment, and, although she has lost some flesh, the active cancerous proc- ess, which would otherwise have carried her off long ago, has been in a measure checked. What will be the further history of the case one cannot tell, for it is quite possible that being away from my care she may neglect dietetic and medicinal treat- ment, trusting only to the X-rays, which, of course, cannot influence the real nature and course of the disease. Reference was made to certain cases of CLINICAL CONSIDEEATIONS 189 recurrent cancer in the Hospital which had been under active medical treatment dur- ing the past year, with careful laboratory studies, but it is naturally too early to re- port anything very definite in regard to them, especially as most of tkem were des- perate cases, which had advanced far be- yond any possible operative relief. More- over several of them remained but a short time under treatment, as it is very difficult to convince this class of patients that any possible benefit can accrue from anything but an operation, and this being impossible they often give up and leave, preferring to die at home; moreover the dietary re- straint seems also very irksome and use- less to them and their friends. In one particular patient, however, there was such a remarkable improvement that it is worth reporting to you. Mrs. C. M. was first seen February 12th, 1914. Nineteen years previously she had an abscess of the right breast, which 190 MEDICAL ASPECTS OF CANCER healed and left a tumor the size of a pig- eon's egg in the inner, npper quadrant of the breast ; this remained quiescent until it began to enlarge, eleven months before it was removed at the New York Skin and Cancer Hospital, November 14th, 1912. The tumor was then about the size of a hen's eggy with an area of skin the size of a quarter, attached to it: a second tumor was felt just below the nipple, which was not retracted, and the axillary glands were involved : there were no signs of metastases in the abdomen. A complete operation was then performed, with dissection of the glands in the axillary and supra-clavicular regions, and she was discharged January 16th, 1913. On February 9th, 1914, she returned to the Hospital and was placed under medical treatment, with vegetarian diet. There was then an ulceration along the line of in- cision, from the second to the fourth rib, with many nodules around it, averaging a CLINICAL CONSIDERATIONS 191 third of an incli in diameter, raised and reddened. The liver extended two inches below the edge of the ribs, with a hard and nodular margin; the right arm was enor- mously swollen and helpless. When she left the Hospital, June 20th, 1914, the ul- cer had entirely closed, many of the cuta- neous nodules had entirely disappeared, the arm had returned to normal size, like the other, by measurement, and the liver had retracted to a trifle below the margin of the ribs, with hardly any nodules to be felt. The treatment had included twenty- five X-ray exposures, from 8 to 10 minutes each, about twice a week, over three areas each time. AVhile in the Hospital careful laboratory investigations were made, according to a definite schedule. The blood, studied weekly, maintained a haemoglobin of 80+ for over two months, then fell a little, and again rose. The erythrocytes were 3,262,- 000 on entering, and rose within two 192 MEDICAL ASPECTS OF CANCER months to 4,282,000, then fell a little and rose again to almost 4,000,000: tlie leuco- cytes were 9,000 on entering, and fell to 5,200 just before leaving, the poly-nuclear 69 per cent, on admission, fell to 60 per cent., and again rose a little, and the pro- portion of the other forms remained about normal. The urine, volumetrically an- alyzed every three days, was kept a little below the normal acidity, and the specific gravity a little low, with a free daily amount of excretion, largely by Bethesda water: in spite of the vegetarian diet the urea excretion was not much below nor- mal, and sometimes above, the chlorides were diminished, owing to the rather small amount of food taken, the phosphates va- ried a little above and below normal, there was never any indican, and the sulphates averaged a trifle below normal. The sa- liva, tested before and after each meal, was acid at first, but became neutral and alka- line off and on. The weight, taken weekly. CLINICAL CONSIDERATIONS 193 fell a little from the first, but maintained a good level, and rose a little before slie left the Hospital. Tills vas a very difficult patient to man- age, as she was a very ignorant Polish -svoman, tvIio often rebelled at the diet, and wearied of the routine and restrictions im- posed; she left the Hospital June 20th, 1914, against my wish, but with as great a change in her physical condition and dis- ease as could be imagined, after about four months and a half treatment, carried out under disadvantageous circumstances. One other case, seen recently, where the disease was recurrent after three opera- tions, desei-ves mention, although it will be some time before any decisive result can be reported. Mrs. W. C, aged 45, was first seen Sep- tember 17th, 1914. Nearly four years pre- viously she had noticed a lump in the left breast which was removed on January 6th, 1911, but it soon regrew, and a complete 194 MEDICAL ASPECTS OF CANCEE operation was performed at the New York Skin and Cancer Hospital, May 30th, 1911. Two years later there was some return, and she was again operated on at the Hos- pital, May 30th, 1914. About two months before her first visit, September 17th, 1914, a swelling of the sternum was no- ticed, and soon another above it, both of which increased pretty rapidly to the time of her visit. Wlien seen there was a hard mass in the scar over the sternum, about an inch and a half long, raised a quarter of an inch or so, reddened and immovable : an inch or so above it was another, smaller one, not reddened: they were not particu- larly painful on moderate handling, but painful when at hard housework. When last seen, December 7th, both lumps had subsided fully one-half, there was no pain at any time, and her general condition had improved immensely, she feeling better than she did four or five years ago, that is, before the beginning of the cancerous de- CLINICAL CONSIDERATIONS 195 velopment: she has been working all the time, unusually hard, as janitor of four buildings and also going out scrubbing and washing. She weighed 1571/4 pounds when first seen, then ran down to 154, but is again gaining, being 1551/2 at her last visit. The outcome of this case it is, of course, impossible to conjecture, for one can seldom be sure that patients will be ab- solutely faithful to treatment, for a long enough time, but certainly the change in the woman and in the lesions in this two months and a half has been remarkable, compared with the increasing development of the disease in the two months previous. I must mention one more case, which, al- though fatal, exhibited some of the good results of careful medical treatment even when a primary case had advanced far be- yond the possible aid of surgery. Mrs. M. B. J., aged 68, a private patient, was first seen on February 17th, 1914. Two years previously she noticed a lump 196 MEDICAL ASPECTS OF CANCER in the upper part of the right breast, after great and repeated mental distress from the death of a number of very near rela- tives, and a sister's mental derangement; the great nervous strain had been attended with various bilious attacks and nervous indigestion. The mass increased steadily in size and was kept concealed even from her family, until the day before she called, when her family physician who was con- sulted saw that it was far beyond the pos- sible hope from any operation, in which view a surgeon concurred. When seen the whole breast was in- volved, was double the size of the other, hard, immovable, and with an adherent crust over an ulcerating surface on its lower half, several inches in diameter, from beneath which was a moderate dis- charge: the axillary glands were enor- mously enlarged, as also the supra-clav- icular, and she was strongly cachectic. She was placed on an absolute vegetarian CLINICAL CONSIDERATIONS 197 diet, with no coffee or tea, and appropriate medical treatment, and the breast kept painted with fifty per cent, ichthyol and water, care being taken not to disturb the adherent crnst. In a very short time the discharge ceased, and the protective crust adhered until her death from exhaustion, with pulmonary oedema, on September 9th, 1914. On August 15th it was recorded that the breast had done very well, that it was soft and movable, and not larger than the other breast, with no discharge, and no pain since a short time after beginning treatment: the axillary glands had dimin- ished three-quarters in size, and the supra- clavicular glands were also very much smaller. And now, gentlemen, my task is done. I have tried to let you see cancer through my spectacles, as I have seen it for very many years past, and to share with me my optimism in regard to the prophylaxis and cure of cancer, if only there can be suffi- cient enlightenment in the profession and 198 MEDICAL ASPECTS OF CANCER public: and I must tell you that in collat- ing and preparing the material to support my long held views I have expended very much more time and labor in study, for some months past, than I could have be- lieved possible. But as the subject devel- oped, and as I discovered more and more support for my thesis, there was a fas- cination about the work which I could not resist; and if I have tried you with the many details of proof presented I beg that you will pardon me: for I wanted to pre- sent the subject so strongly that my hear- ers, at least, would accept the propositions I have developed, and believe what I have said in regard to my own experience with the terrible disease under consideration, and act upon both, and thus aid some suf- ferers with cancer. From my recent article on **The Eela- tion of Diet to Cancer'' many medical jour- nals have quoted me as ascribing the dis- ease wholly to the use of meat, but you CLINICAL CONSIDERATIONS 199 who have heard these lectures now know that animal proteids are only one of the contributing causes. I have tried to make it plain that met- abolic errors, inducing a vitiated blood stream, are the basic cause of the aberrant action in the cellular elements of the body which may ultimately lead to malignant disease ; and I have tried to show that there are many elements connected with modern so-called civilization which conspire to ef- fect this end. I have quoted many who were well acquainted with cancer, who be- lieved that luxurious living, which includes much animal food, coffee and tea, and alco- hol, with indolence or want of sufficient muscular activity to burn up the waste products, and the persistent neglect of hy- gienic laws, should be placed first among the causes of cancer : but I have also men- tioned that the refining and preparation and cooking of food prevented a proper supply of the mineral and other elements 200 MEDICAL ASPECTS OF CANCER of nutrition, and also tliat nervous influ- ences could so disturb the action of the organs of the body that they could not per- form their functions perfectly in the elab- oration of nutritive material, etc. But I cannot go over again all the mat- ter already given in these lectures, and only mention these to remind you that there is no one single cause of cancer, and consequently that its prophylaxis and cure can never be found in any one single rem- edy; hence I can never believe in the sole use of thyroid, much less in the idea that sero-therapy can overcome a disease de- pendent upon the continued operation of so many causes ; and still less can I believe that the mere cutting out of an already diseased portion of the body is the proper and only means of overcoming such a mal- ady as cancer. I have acknowledged that local irritation of many kinds may be the proximate cause for the development of a malignant tumor CLINICAL CONSIDEEATIONS 201 in any particular locality, as Ewing lias so clearly shown in Ms excellent resume on pre-cancerous lesions ; but I have also con- tended that we should withal look into and overcome the cause; why, when once started by local injury the cells should pursue such a progressive, aggressive, and invasive course; and this is found, I be- lieve, in the disturbed character of the flu- ids which provide them with nourishment for their abnornial growth. From this study of cancer in regard to its nature, frequency, geographical dis- tribution, metabolism, dietetic relations, medical treatment, and clinical consid- erations, what conclusions can be drawn? Have we solved the problem of cancer? Far be it from us to make any such claim. Scientific research and study must still go on in the laboratory, but clinical research and study, with laboratory work, on the human subject, which have not been hith- erto sufficiently cultivated, should be 202 MEDICAL ASPECTS OF CANCEE pushed, so that by a mass of carefully re- corded observations the truth or falsity of what has been here quoted and said may be refuted or confirmed. From the enormous work which has been done on cancer with the microscope and the test tube, it would seem sometimes that research workers have become some- what myopic, and not f arsighted enough to recognize the true value of statistical stud- ies and clinical observations. In these lectures we have attempted to make a brief synthetic study of some of the work which has been done in connection with cancer, and from this we believe that certain con- clusions can be drawn ; if these are correct and followed, it is hoped that much more can be accomplished in regard to the pro- phylaxis and cure of this more than threat- ening, fatal malady. In order that you may hold clearly the points which have been made I want to give you a synopsis or conclusions of them, as they have been CONCLUSIONS 203 brought out in this and preceding lectures. 1. Cancer is but a deviation from the normal life and action of certain of the or- dinary cells of the body, which, for some as yet unexplained reason, take on an ab- normal or morbid action; with this there is a continued tendency to a malignancy which invades contiguous tissue, and in the end tends to destroy life. 2. There is some reason to believe that this action first takes place in what are known as ^* embryonic rests,'' or pre-natal, wrongly placed tissue elements, which, however, are now shown to exist in every one, in many localities : but the reason why they take on this malignant action, and form cancer, has not been satisfactorily ex- plained. 3. Cancer is not wholly due to traumatic causes, although those play a not incon- siderable part in its occurrence in certain localities and cases. 4. It is pretty conclusively decided that 204 MEDICAL ASPECTS OF CANCEE cancer is not caused by a micro-organism, or parasite. 5. It is also known clinically and experi- mentally that it is not contagious. 6. Nor is it hereditary in any apprecia- ble degree. 7. Occupation has not any very great in- fluence on the occurrence of cancer, al- though it is more frequent in some pur- suits than in others. 8. Cancer is not altogether a disease of older age, although its incidence is greatly increased with advancing years. 9. It does not especially belong to or af- fect any particular sex, race, or class of persons. 10. It is not confined to any location or section of the earth, but has been observed in all countries and climates. 11. No single cause of cancer has yet been demonstrated, nor is it Hkely that this will ever be the case, as the experi- mental and other investigations have cov- CONCLUSIONS 205 ered almost every possible line of research, with only negative results. 12. The exclusion of almost every other possible cause of cancer, as well as its pathological history, leads to deranged metabolism as the only remaining possible etiological element; this acts by inducing changes in nutrition, which latter depends on diet and the proper action of the secretory and excretory organs, which, still further, may be affected by nervous influences. 13. While the bio-chemistry of cancer throws little light on its true nature, enough is known to show that the morbid changes in the cells are largely associated with deranged metabolism. 14. The blood, in advancing cancer, manifests changes which indicate vital al- teration in the action of the organs which form blood and control the nutrition of the body and its cells. 15. Clinical and experimental evidence 206 MEDICAL ASPECTS OF CANCER demonstrate that the secretions and excre- tions of the body exhibit departures from normal, which, while not pathognomonic of cancer, indicate metabolic disturbances in- volving the nutrition of the cellular ele- ments, which disturbances are of impor- tance. 16. The evidence seems certain that the cancer mass itself, when fully developed, secretes a poison which tends to augment its own growth and hastens the lethal prog- ress of the disease. 17. Cancer mortality is undoubtedly on the increase in every portion on the globe. 18. This increase seems to vary in- versely with the decline of tuberculosis, in many localities. 19. The incidence of cancer seems to fol- low "closely along the lines of modern civilization. •20. This extension of cancer seems to depend largely upon the altered conditions of life, particularly along the lines of self- CONCLUSIONS 207 indulgence in eating and drinking, and indolence. 21. The augmentation in the consump- tion of meat, coffee and alcoholic bever- ages appears to be coincident with a very great, and proportionately greater, aug- mentation of the mortality from cancer. 22. The nerve strain of modem life seems to be an element of importance, both through disturbance of metabolism, and by direct action on morbidly deranged cells. 23. No single remedy for cancer will probably ever be discovered, since it is conceded that there is no single cause for the disease. 24. Surgery has improved materially the statistics relating to the mortality of oper- ative cases; but the total achievements along this line are insignificant compared with the general ultimate mortality of over 90 per cent, of those once afflicted with cancer. 208 MEDICAL ASPECTS OF CANCER 25. Surgery has had, and may long have its function to perform in removing the products of the disease, more or less effi- ciently, curing some and prolonging the life of others, but it can never hope to les- sen greatly the morbidity of cancer. 26. The X-ray and radium, as also caus- tics, are in the same position as surgery, and can do relatively little more than cause to disappear lesions which have developed from causes which they cannot reach. 27. With all these means the measure of success, aside from the technical skill of the operator, largely depends on the time or period of development of the malignant tumor before treatment; the earlier the removal is undertaken, other things being equal, the greater the possibilities of suc- cess. 28. The same is true in regard to the treatment of the disease by means other than those mentioned : the earlier the mor- bid process leading to tumor formation is CONCLUSIONS 209 attacked by dietetic, hygienic, and medici- nal measures, the greater the promise and expectation of success, present and perma- nent. 29. The prevention of cancer, therefore, or the checking of its increasing occur- rence, depends largely upon the early enough adoption of such measures as will limit the agencies which induce a derange- ment of the body juices which tend to bad nutrition and derangement of the body cells. 30. The simple life, with the avoidance of the dietetic and other causes which have been found to induce cancer in nations and individuals, promises the best hope for the arrest of the rapidly increasing develop- ment of cancer throughout the world. 31. It is more than possible, however, that the long continued operation of many baneful causes has produced such a degen- eration of tissue in the human race, that it will take a generation or more of proper 210 MEDICAL ASPECTS OF CANCER living to make tlie beneficial impression on the general incidence of cancer which is so longed for. BIBLIOGRAPHY ^ 1. Abderhalden — Defensive Ferments. New York, 1914. 2. Abernethy — Surgical Observations on Tu- mors. Lond., 1816, 221. 3. Bainbridge — Medical Record^ 1909, LXXVI, 85. 4. Bainbridge — The Cancer Problem. New York, 1914. 5. Banks— La^ice^, 1900, I, 684. 6. Beard — The Enzyme Treatment of Cancer. Lond., 1911. 7. Beebe — Neio York Medical Journal, 1910, LXXXII, 1058. 8. Bell — Cancer: Its Causation and Its Cura- bility Without Operation. London, 1903. 9. Beneke — Berl. Klin. WocJiemchr., March 15, 1880. 1 No attempt has been made to collect an extensive bibliography, which might cover many pages, and a list is only given of those books and journal articles which I have been able to personally consult and to refer to in the text. 211 212 BIBLIOGRAPHY 10. Bevratt— Indian Med, Gaz., 1908, XLIII, 452. 11. BiEDL — The Internal Secretory Organs. New York, 1913. 12. Blumenthal — Handb. d. Spezial Pathol, d. Harns., 1913, 263. 13. Braithwaite — Lancet, 1902, I, 400. 14. Braithwaite — Plainer Food and Less of It. London, 1908. 15. Bristol— i^fecZ^■ca^ Record, 1913, LXXXIII, 787. 16. BuLKLEY — Relations of Diseases of the Skin to Internal Disorders. New York, 1906. 17. BuLKLEY — Some Problems in Metabolism, Jour. C'utan. Dis., 1911, XXIX, 217. 18. BuLKLEY — Diet and Hygiene in Diseases of the Skin. New York, 1913. 19. Bureau of Agriculture, 28th Annual Rep. Washington, 1911. 20. BuRNHAM — Haemocytes and Haemic Infec- tions, 1913 ; 92 ; 138. 21. Buttner — A Fleshless Diet. New York, 1910. 22. CAUEN—Deict. Zeitschr. /. CMr., 1909, CXIX, 415. BIBLIOGRAPHY 213 23. Chittenden — Phj^siological Economy in Nutrition, 1904. 24. CoHNREiCH — Folia Hcematologica, 1913, XVI, 307. 25. Cooper, Sir Astley — Lectures on Surgery, Boston, 1825. 26. DE Bloeme, Swart, and Terwen — Muncli. Med. Wochenschr,, 1914, LXI, 1718. 27. Degrez — Gaz. Med. de Paris, 1913, LXXXIV, 400. 28. EiNHORN, Kahn and Rosenblum — Arch. f. Verdauiuigskr., 1911, XVII, 557. 29. EwiNG — Cancer Problems, Report of the C. P. Huntington Fund for Cancer Re- search, Vol. II, 1908. 30. EwiNG— 3/ecZ^caZ Record, 1914, LXXXVI, 951. 31. Gruner— Biology of the Blood Cells, 1913, 153 ; 260. 32. GwiTER—Ann. of Surgery, 1907, XXXXVI, 86; 643, 1908, XXXXVII, 506; 631. 33. Haig — Uric Acid as a Factor in the Causa- tion of Diseases. Phila., 1908, 420. 34. Haig— 5n#. Med. Jour., 1912, II, 81. 35. Harrower — Practical Hormone Therapy, 1914, 29. 214 BIBLIOGEAPHY 36. HiSLOP AND Fenwick — Brit, Med. Jour., 1909, II, 1222. 37. Hutchinson — Food and Dietetics. New York, 1911, 324. 38. IsENBERG — Monotschr. f. prakt. Wasser- heilk, 1910, XVII. 39. Janeway — Sajous' Anal. Cyclopedia of Pract. Med., 1912, II, 753. 40. JouNSON— Brit. Med. Jour., 1900, II, 982. 41. Jones — Arch. Middlesex Hosp., London, 1911, XXIII, 72. 42. Kahle — Munch. Med. Wochenschr., 1914, LXI, 752. 43. Keith — Cancer : Relief of Pain and Possible Cure. New York, 1908. 44. K-EiTYL— British Med. Jour., 1909, II, 140. 45. Kessler — Neiv York Medical Journal, 1912, XVIC, 1122. 46. Lambe — Additional Reports on the Effects of a Peculiar Regimen of Cancer. Lon- don, 1815. 47. Little — Boston Med. and Surg. Jour., 1914, CLXXI, 587. 48. Mayo, W. J. — Annals of Surgery, 1914, LIX, 805. BIBLIOGRAPHY 215 49. ]\IcCann — Starving America. New York, 1912. 50. McGregor— J5nY. Med. Jour., 1900, II, 982. 51. Merriam — St, Louis Courier of Med., 1884, XII, 385; New York Medical Journal, 1912, XVIC, 378. 52. Mortality Statistics, Bureau of the U. S. Census, 1911, 1912. 53. Murphy's Clinics, Aug. 1912, Dec. 1912, Aug. 1913, Oct. 1913, Dec. 1913, Feb. 1914, June 1914. 54. NowELL — Xew England Med, Gaz., 1914, XLIX, 461. 55. Packard — Boston Med. and Surg, Jour., 1912, CLXVI, 452. 56. Paget — Lectures on Surgical Pathology. Philadelphia, 1854, 632. 57. Parker — Cancer. New York, 1885. 58. Reid — Cancer Research Laboratory, Man- chester Medical Chronicle, Nov. 1912, and April 1914. 59. Render— Bnt. Med, Jour., 1910, II, 587, also 1911, I, 110. 60. Roberts — Lectures on Dietetics and Dys- pepsia. London, 1886, II Edition. 216 BIBLIOGRAPHY 61. Robin — Bull. Gen. de Therapeutique, 1913, CLXVI, 433. 62. RoHDENBURG, BuLLOCK, and Johnson — Arch, of Int. Med., 1911, VII, 491. 63. Ross — Cancer, Its Genesis and Treatment. London, 1912, 88. 64. Rous — Jour, of Exper. Med., Lancaster, Pa., 1914, XX, 433. 65. Russell — Preventable Cancer. London, 1912, 96. 66. Sajous — Monthly Cyclop, and Med. Bidl., 1912, V, 219. 67. Sajous — Internal Secretions, Vol. I, 785. 68. Saleeby — The Conquest of Cancer. New York, 1911. 69. Sandwith — Clinical Journal, 1910, XXXV, 409. 70. ^cuMim—Medizin Elinilc, 1910, VI, 1690. 71. Sherman — Chemistry of Food and Nu- trition. New York, 1911, 260. 72. Sherrington and Copeman — Brit. Med. Jour., 1910, II, 787. 73. Shirlaw — Liverpool Medico Chir. Jour. 1913, XXXIII, 398. 74. Soegard — Zeitschr. filr Krehsforsch, 1913, XIII, 89. BIBLIOGRAPHY 217 75. Stuart-Low— Xawce^ 1909, II, 1138. 76. Sweet, Corson, White, and Saxon — Pro- ceed. Soc. for Exper. Biol, and Med. New York, Vol. X, 175. 77. Thompson — Practical Dietetics, 1909, 256. 78. Troisier — Oaz. des Hospiteaux, 1913, LXXXVI, 2221. 79. TuKE — Illustrations of the influence of the mind upon the body in health and disease. London, 1872. 80. Turck — Vorlesungen Vher Klin, Hcema- tologie, 1912. 81. Venus — Centralhl. f. d. Grenzenh. d. Med, u. Chir., 1910, XIII, 209. 82. Vincent — Internal Secretions and the Ductless Glands. London, 1912. 83. Wakefield^ — American Medicine, 1904, VII, 659. 84. Walshe — The Anatomy, Physiology, Path- ology, and Treatment of Cancer. Bos- ton, 1844. 85. Watson, Chalmers — Food and Feeding in Health and Disease. New York, 1912. Appendix. 86. Wells — Chemistry of Tumors, Chemical Pathology, 2nd Ed., 1914. 218 BIBLIOGEAPHY 87. Williams — The Natural History of Cancer. New York, 1908. 88. Wolf — Zeitsch. fur Krehsforsch, 1905, III, 95. 89. Wolff — Die LeJire von der Krehskra7ik- heit, Jena, 1913. 90. WoLTER — Chemistry of Cancer, BrocJcesn. Zeitschr., 1913, LV, 260. INDEX INDEX Abderhalden, defensive fer- ments in cancer, 78 Abernethy on vegetarian diet, 136 Aborigines, freedom from cancer of, 48, llB Abstemiousness, effect on cancer, 139. Acid, amino nitrogen, in- creased in cancer, 91 Acid intoxication in can- cer, 77 Acidosis in cancer, 80 Acids, oxyproteic, in the urine, increased in cancer, 90 Addison's disease, 97 Adrenals, relation to can- cer, 98 Africa, absence of cancer in, 50, 52 Agamogenesis, relation to cancer, 72 Age affecting cancer, 22 Ages of patients with can- cer, 176 Agnew on surgery in can- cer, 170 Alcohol, relation to can- cer, 120 Alkalinity of blood, dimin- islied in cancer, 77 Amino-acid nitrogen, in- creased in cancer, 91 221 Ammonia fraction of ni- trogen, increased in cancer, 91 Amylopsin in cancer, 99 Anabolism and cancer, 33 Anaemia in cancer, 74 Animal food a cause of cancer, 50, 51, 52, 55, 63, 69, 110, 113, 116, 117, 132, 138, 141 Animals, cancer in, 43 Argentine Republic, cancer in, 57 Australia, cancer in, 48 Autointoxication and can- cer, 155 Autonomous action of cells, 33 Bainbridge, local nature of cancer, 30 Baltimore, cancer in, 65 Banks, Sfr AYilliam, on diet in cancer, 61 Bashford, 55 Beard, trypsin in cancer, 99 Beatson's operation, 102 Beebe, diet and cancer, 80 Beirut, rarity of cancer in, 56 Bell, cancer from neglect of hygienic laws, 132 Beneke, diet in cancer, 115 222 INDEX Benratt, rarity of cancer in India, 53 Betel chewing cancer, 54 Beidl, hormone formation, 163 Bio-chemistry of cancer, 39, 79, 83 Blood changes in cancer, 74, 191 frequent study of, in cancer, 160 Blumenthal, oxyproteic ac- ids increased in can- cer, 90 Boston, cancer in, 65 Bowel action and cancer, 155, 157 Braithwaite, plainer fare and less of it, 154 salt and cancer, 129 Brazil, rarity of cancer in, 57 Breast, carcinoma of, 176 non-cancerous tumors of, 178 Bristol, disturbance of chemical equilibrium causing cancer, 143 British Guiana, rarity of cancer in, 50 Burnham, blood changes in cancer, 76 Butter, valuable in can- cer, 153 Buttner, a fleshless diet, 154 Cachexia in cancer, 74, 77 Caffeine, nitrogen in, 119 percentage of, in coffee, 119 Cahen on Beatson's oper- ation, 102 Calcium salts, effect on cancer, 101 Cancer in the occupied and unoccupied, 130 personal statistics of, 176 problem, 201 Carcinoma, personal sta- tistics of, 174 Casein sometimes allow- able in cancer, 153 Cases, personal, of cancer, 180-197 Catabolism and cancer, 33 Causes of cancer, 27 Centrosomes in cancer, 34, 85 Cheese sometimes allow- able in cancer, 154 Chemistry of cancer, 39, 79, 83 of cancer tissue, 78, 82 of the body, 107 Chicago, cancer in, 65 China, rarity of cancer in, 55 Chittenden's experiments on nutrition, 112 Chlorides in the urine, di- minished in cancer, 92 Cholesterin, relation to cancer, 83 Chromosomes in cancer, 85 Civilization, cancer a dis- ease of, 44, 46, 50, 68, 109, 117 Clinical considerations, 170 study of cancer, 17, 18 Coffee, consumption in United States, 118 nitrogen in, 119 relation to cancer, 117 INDEX 223 Cohnreicli, blood in cancer, 76 Cold storage, relation of, to cancer, 10!) Composition of human body, 107 Conclusions, 170, 203 Constipation and cancer, 157 Contagiousness excluded, 19 Cooper, Sir Astley on con- stitutional nature of cancer, 139 Creoles in Africa, freedom from cancer of, 52 Cytology of cancer, 74 Danger from thyroid in cancer, 164 Deaths from cancer in Xew York City, 145 in United States, 144 De Bloeme, Swart, and Terwen, imperfect ni- trogen partition in cancer, 90 Defective urinary excre- tion and cancer, 158 Deficiency of urinary sol- ids in cancer, 88 Definition of cancer, 30 Degrez, imperfect nitro- gen disintegration in cancer, 91 Denmark, cancer in, 82 Demineralization and can- cer, 113 Diabetes, relation of to cancer, 95 Diet, effect of simple, in cancer, 121 relation of, to cancer, 46, 51, 53, 55, 57, 61, 63, 67, 80, 106, 115, 116, 133, 198 Dietetic treatment of can- cer, 171 Disordered metabolism the cause of cancer, 74 Ductless glands in cancer, 97 Duration of cancer before treatment, 177 Early treatment of cancer, medically, 147, 178, 208 surgically, 177 Eating, wrong- and over-, and cancer, 152 Egypt, rarity of cancer in, 51, 57 Ehrlich, effect of diet on cancer, 37 Einhorn, Kahn, and Rosen- blum, imperfect nitro- gen partition in can- cer, 90 Embryonic rests in cancer, 23, 25, 72 Endocrinous glands, rela- tion of, to cancer, 100 England, cancer in, 51, 57, 61 increase of cancer, with meat consumption, 116 Environmental change and cancer, 59 Enzymes, autolytic, in can- cer tissue, 83 Equilibrium of tissue ele- ments, 111 Esmarck and Oldehop, vegetarian diet in cancer, 115 224 INDEX Etiology of cancer, 74 Ewing, change in polar axis of cells m can- cer, 34 relation of chlosterin to cancer, 83 Far East, rarity of cancer in, 55, 56 Fiji Islands, rarity of can- cer in, 50 Fletcher, imperfect insali- vation and cancer, 94 France, cancer in, 62 Frequency of cancer, 43 Functional kidney de- rangement and can- cer, 158 Geographical distribution of cancer, 43 "Germ of cancer," 19 Gigantism, 97 Gout, relation to cancer, 72, 81 Gratifying the taste, a cause of cancer, 108 Gruner, toxicity of cancer juice, 78 Gwyer, thymus feeding in cancer, 101 Haig, cures of cancer by dietary restrictions, 141 uric acid and cancer, 125, 141 narrower, relation of ductless glands to cancer, 97 Heredity, influence of, 20 Heterologous elements in cancer, 41 Highest cancer mortality, 62 Hislop and Fenwick, diet and cancer, 50 Holland, high cancer mor- tality in, 118 Hormones, relation of, to cancer, 100 Hormone therapy in can- cer, 162 Hungary, low cancer mor- tality in, 118 Hutchinson, amount of caffeine in tea and coffee, 119 Hygienic laws, neglect of, a cause of cancer, 132 Hyperacidity and cancer, 33 Ichthyol locally in cancer, 166, 167 Ideally correct blood stream and cancer, 149 Increase of cancer, 47 in the United States, 66 Incurable cancer, 140 Independent cell action, 73 Indians, North American, rarity of cancer in, 67 India, rarity of cancer in, 53 Infectious diseases and cancer, 29 Inoperable cancer, 146 Insalivation, thorough, im- portance of in cancer, 95 Internal secretions in can- cer, 96-103 Intestinal fermentation in cancer, 92, 155 INDEX 225 stasis and cancer, 155 toxins and cancer, 155 Intolerance of certain ar- ticles a cause of dis- ease, 127 Intoxication, intestinal, and cancer, 155 Iron, value of, in cancer, 161 Irritation, local, and can- cer, 124 Isenberg on vegetarian diet in cancer, 142 Italy, low cancer with low meat consumption, 63 Jones, blood in cancer, 76 Kalile, silica retention in cancer, 98 "Kangri burn" cancer, 54, 126 Keith, Skene, iron in can- cer, 161 Kellogg, absence of cancer with normal metabo- lism, 151 Kerry, Ireland, low cancer mortality, 64 Kessler, sulphur partition in cancer, 122 Kidneys, faulty excretion and cancer, 157 Korea, rarity of cancer in, 57 Laboratory study of can- cer, 175, 191 Lambe on vegetarian diet, 136 Lane, Sir Arbuthnot, in- testinal stasis and cancer, 155 Latham on cancer of the unoccupied, 61 Leucocytosis in cancer, 75 Lithaemia, relation to can- cer, 72 Liver, condition of in can- cer, 91 Local irritation and can- cer, 21, 124 medical treatment, 165 Lott, Beatson's operation for cancer, 102 Lowest cancer mortality, 60, 64 Lucerne, cancer in, 62 Luxurious living a cause of cancer, 68, 138, 199 McCann, erroneous prepa- ration of foods, 123 McGregor, absence of can- cer in Fiji Islands, 50 Madden, absence of cancer in Africa, 50 Malaria and cancer, 21 Mastication, thorough, im- portance of in cancer, 95 Mayo, acidity and cancer, 124 Meat consumption, in England, 116 in the United States, 69 Meat, relation to cancer, 51, 53, 55, 57, 63, 116 Medical treatment of can- cer, 135, 154 Melanesians, exempt from cancer, 50 Mental depression, influ- encing cancer, 86 strain, relation to can- cer, 81, 85 226 INDEX Merriam, meat diet a cause of cancer, 141 Metabolism, disordered, the cause of cancer, 74 of cancer, 70 perverted, and cancer, 150 Mineral disturbances in the system in cancer, 122 Mitosis, cell, relation to cancer, 85 Mortality from cancer 90 per cent., 144 Murphy on surgery in cancer, 171 Myxoedema, 97 Nature of cancer, 15, 29 Negroes, rarity of cancer in, 52, 67 Nervous strain, relation to cancer, 85 New York City, deaths from cancer in, 65, 145 negro death rate from cancer, 67 New York Skin and Can- cer Hospital, 8, 172 New Zealand, cancer in, 50 Nitrogen disintegration, imperfect in cancer, 91 increase in colloid, in cancer, 90 partition in cancer, 90 small amount needed in the economy, 114 Nitrogenous diet and can- cer, 51, 53, 55, 57, 63, 81, 116 Non-cancerous tumors of breast, 178 Normal body cells and cancer, 31, 41, 70 Nowell, serum therapy, 165 Nuclei of cells, in cancer, 84 Nucleo-proteids in cancer, 82 Nutrition and cancer, 35, 36 Occupation and cancer, 28 Ovaries, internal secretion of, relation to cancer, 102 Over-eating and cancer, 152 Over-indulgence, effect of, 68 Oxyproteic a,cid, relation to cancer, 90 Packard, disturbance of mineral elements in blood, in cancer, 122 Paget, Sir James, on con- stitutional nature of cancer, 140 Paget's disease, 174 Pancreas, relation of, to cancer, 98 Parasitism excluded, 19 Paris, cancer in, 63 Parker, Willard, on con- stitutional cause of cancer, 137 Patience required for med- ical treatment of can- cer, 134, 152 Perseverance required for medical treatment of cancer, 134 INDEX 227 Personal cases of cancer, 180-197 Perverted metabolism and cancer, 74, 150 Philadelphia, cancer in, 65 Philippines, rarity of can- cer in, 57 Phosphates in the urine, diminished in cancer, 94 Pittsburgh, cancer in, 65 Pituitary secretion in can- cer,''97, 99 Plants, cancer in, 43 Plasma of blood in cancer, 77 Pluriglandular extracts in cancer, 164 Polarity of cells in can- cer, 34, 73 Polynesians, exempt from cancer, 50 Potassium acetate in can- cer, 159 phosphate in cancer, 160 Precancerous conditions, 89 Prevention of cancer, 148 Prize fund for cure of can- cer, 173 Problem of cancer, 201 Prophylaxis of cancer, 148 Prosperity and cancer, 48, 68, 109 Protein foods, harm from, 113 metabolism, disturbed in cancer, 89 requirement of the body, 112 sufficient in vegetarian diet, 133 Psoriasis, lessons from, in cancer, 128 Putrefaction, intestinal, and cancer, 155 Radium, value in cancer, 29, 145, 168 Recurrent cancer, 146, 187- 195 Red corpuscles in cancer, 76, 77 Refinement of food, rela- tion of, to cancer, 109 Reid, increase of amino- acid nitrogen in can- cer, 91 Relation of diet to cancer, 198 Renner, rarity of cancer among Creoles, 51 Requisites for development of cancer, 25 Rheumatism, relation to cancer, 72 Ribert, beginnings of can- cer, 30 Roberts, disturbance of salivary digestion from tea, 119 Robin, relation between chlorine and nitrogen in cancer, 92 Rohdenburg, Bullock, and Johnson, thymus gland in cancer, 101 Rome, cancer in, 63 Ross, thymus and calcium, harm from in cancer, 101 relation of potash salts to cancer, 160 Rous, cancer in rats checked by diet, 39 228 INDEX Russian oil as a dressing in cancer, 166 Saaleby, trypsin and amy- lopsin in cancer, 99 St. Louis, cancer in, 65 Sajous, adrenals in rela- tion to cancer, 98 Salivary secretion, acid in cancer, 94, 95, 161 Salt, effect of, on cancer, 129 Sarcoma of same origin as carcinoma, 175 Scandinavia, cancer in, 125 Schmidt, infectious dis- eases and cancer, 29 Serum therapy, 1G4 Sherman, composition of the human body, 107, 154 Sherrington and Copeman, reproductive glands in- hibiting growth of cancer, 103 Shir law, pluriglandular extracts in cancer, 163 Silica, retention of, in pancreas, in cancer, 98 Simple diet, effect of, in cancer, 121 Soegaard, stomach cancer frequent in Norway, 125 Solids in the urine, defi- cient in cancer, 87, 88 Spontaneous disap p e a r - ance of cancer, 36 Stasis, intestinal, and can- cer, 155 Stuart-Low, relation of thyroid to cancer, 100 Sub-oxidation and cancer, 132 Sulphates, increased in cancer, 92 Sulpho-cyanic acid, in- creased in cancer, 92 Sulphur elements, altered in cancer, 92 Supra-renal glands, rela- tion of, to cancer, 97 Surgery, operative, in can- cer, 145, 147, 168, 179 Surgical aspects of cancer, 7, 9, 10, 25 Sweet, Corson, White, and Saxon, effect of diet on experimental tu- mors, 38 Sw^itzerland, cancer in, 62 Syphilis and cancer, 22 Taste gratified, a cause of cancer, 108 Tea, relation to cancer, 117 Telluric influences in can- cer, 22 Testicles, internal secre- tion of, relation to cancer, 102 Thompson on consumption of coffee and tea, 118, 154 Thymus gland in cancer, 101 Thyroid, danger from in cancer, 164 relation to cancer, 97 value of in cancer, 99, 163 INDEX 229 Tobacco, influence of, in cancer, 126 Toxicity of urine, in- creased in cancer, 91 Toxic secretion from can- cerous mass, 70, 78, 104, 206 Toxins, intestinal, and can- cer, 92, 155 Transmission of cancer, 20 Traumatism and cancer, 24 Trypsin in cancer, 99 Tuberculosis and cancer, IG, 44, 45 Tuke, influence of the mind on morbid proc- esses, 80 Turk, CTtologT of cancer, 74 ' United States, cancer in, 16, 64, 68 consumption of cofi'ee in, lis consumption of meat in, 117 Urea excretion, deficient in cancer subjects, 89 Uricacidaemia, relation to cancer, 72 Urinary disturbance, func- tional, and cancer, 158 Urinary solids, deficient in cancer, 87, 88 Urobilin, increased in can- cer, 90 Vaccine therapv in can- cer, 164 Valais, cancer in, 62 Vegetable protein, 133 Vegetable tumors, 43 Vegetarian diet afi'ords sufficient protein, 133, 153 Vegetarian diet and can- cer, 50-53, 55-57, 63, 115, 123, 128, 136, 142, 180-197 Venus on vegetarian diet in cancer, 142 Vincent, quoting Ehrlicli on resistance to ath- reptic infiuence, 163 Vircliow, on tumor forma- tion, 31 Voit's dietary standard, 111 Volumetric analysis of urine in cancer, 87, 94, 159 Wakefield on hyperacidity of the blood plasma in cancer, 33 Wales, cancer in, 57 Walshe on the cause of cancer, 137 Watson, effect of meat diet on tissue cells, 114 Wealth, relation to cancer, 48, 68, 109 Weight in cancer, 161, 192, 195 Wells, nuclear proteins in cancer cells, 83 Well-to-do men and can- cer, 130 West Indies, cancer in, 57 Williams, cancer prob- 230 INDEX lems, 36, 45, 47, 50, Wrong eating and cancer, 58, 72 Wolf, cancer in Australia, 47, 48 Welter, nucleo-proteids in cancer tissue, 82 152 Xanthin bases, increased in cancer, 90, 91 X-ray, value in cancer, 29, 145, 167 MEDICAL MONOGRAPHS PUBLISHED BY PAUL B. HOEBER 67-69 EAST 59th St., NEW YORK This catalogue comprises only our ow-n publications. It zi'ill be noticed that particular care has been exercised in the selection of Monographs of timely interest. IVe are akuays glad to consider the publication of new and original medical works. Correspondence with Authors is in- vited. ADAM — Asthma and Its Radical Treatment. By James Adam, M.A., M.D., F.R.C.P.S. Hamilton. Dispensary Aural Surgeon, Glasgow Royal Infirmary. 8vo, Cloth, viii-l-184 pages, Illustrated $1.50 net. ARMSTRONG— I. K. Therapy, With Special Reference to Tuberculosis. By W. E. M. Armstrong, M.A., M.D. Dublin, Bacteriologist to the Central London Ophthalmic Hospital, Late Assistant in the Inoculation Department, St. Mary's Hospital, Padding, W. 8vo, Cloth, x-f93 pages. Illustrated $1.50 net. BEDDOES — Syphilis, Its Diagnosis, Prognosis, Preven- tion and Treatment. By Thomas Hugh Beddoes, M.B., B.C. Camb., F.R.C.S. Eng. 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A Study in the Causes, Symptoms and Effects of Sexual Dis- ease, and the Education of the Individual therein. By A, Corbett- Smith, Editor of "The Journal of State Medicine" ; Lecturer in Public Health Law at the Royal Institute of Public Health. Large 8vo, Cloth, xii4-i07 pages. .$1.00 net. CORNET— Acute General Miliary Tuberculosis. By Professor Dr. G. Cornet, Berlin and Reichenhall. Trans- lated by F, S. Tinker, B.A., M.B., etc. 8vo, Cloth, viii+107 pages /r.$i.5o net. 2 HOEBER'S MEDICAL MONOGRAPHS CROOKSHANK— Flatulence and Shock. Bv F. G. Crook- shank, M.D., Lend., i\I. R. C. P. Physician (Out Patients) Hampstead General and N. W. Lend. Hospital; Assistant Physician The Belgrave Hospital for Children S.W. 8vo, Cloth, i\'-\-47 pages $i.oo net EDRIDGE-GREEN — The Hunterian Lectures on Colour- Vision and Colour Blindness. Delivered before the Royal College of Surgeons of England on February ist, and 3rd, 191 1. By Professor F. W. Edridge-Greex, M.D. Durh., F.R.C.S. England. Beit Medical Research Fellow. 8vo, Cloth, x+76 pages $1.50 net. EHRLICH— Experimental Researches on Specific Thera- peutics. By Prof. Paul Ehrlich, }^I.D., D.Sc. Oxon. Director of the Konigliches Institut fiir Experimentelle Therapie, Frankfort. The Harben Lectures for 1907 of The Royal Institute of Public Health. i6mo. Cloth, x-[-95 pages $1.00 net. EINHORN — Lectures on Dietetics. By ]\L'\x Eixhorx, Professor of Medicine at the New York Post-Graduate Medical School and Hospital and Visiting Physician to the German Hospital, New York. i2mo, Cloth, xvi-j-156 pages « $1.00 net. ELLIOT — Sclero-Corneal Trephining in the Operative Treatment of Glaucoma. By Robert Hexry Elliot, M.D., B.S. Lond., Sc.D. Edin., F.R.C.S. Eng., Etc. Lieut. Colonel LM.S. Second Edition. 8vo, Cloth, 135 pages, 33 illustra- tions $3-oo «^^- EMERY — Immunity and Specific Therapy. By Wm. D'EsTE Emery, ^I.D., B.Sc. Lond. 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Translated from the third German Edition by HuG» Walker, M.D., M.B., CM. Ophthalmic Surgeon to the Victoria Infirmary, Glasgow. Large 8vo, Cloth, 86 pages, Illustrated $2.00 net. HARRIS — Lectures on Medical Electricity to Nurses. An Illustrated Manual by J. Delpratt H.\rris, M.D. Durh., ]\I.R.C.S. Senior Surgeon and Honorary Medical Officer in charge of the Electrical Department, Royal Devon Hosp. i2mo. Cloth, 88 pages. Illustrated $1.00 net. HOFMANN-GARSON— Remedial Gymnastics for Heart Affections. Used at Bad-Nauheim. Being a translation of "Die Gymnastik der Herzleidenden" von Dr. Med. Julius Hofmann und Dr. Med. Ludwig Pohlman. Berlin and Bad-Nauheim. By John George Garson, M.D. Edin., etc. Physician to the Sanatoria and Bad-Nauheim, Evers- ley, Hants. With 51 full-page illustrations and diagrams. Large 8vo, Cloth, xvi+i^S pages $2.00 net. HOWARD— The Therapeutic Value of the Potato. By Heaton C. Howard, L.R.C.P. Lond., M. R. C. S. 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PEGLER — Map Scheme of the Sensory Distribution of the Fifth Nerve (Trigeminus) with Its Ganglia and Connec- tions. By L. Hemington Pegler, ]\I.D., M.R.C.S. Senior Surgeon, Metropolitan Ear, Nose and Throat Hospital, Etc. Mounted on Rollers, 4 ft. i in. x 4 ft. 8 in $7.00 net. Folded in Cloth Binder $8.00 net. RAWLING — Landmarks and Surface Markings of the Hu- man Body. By L. Bathe Ramming, M.B., B.C. (Cant.) F.R.C.S. (Lond.) Surgeon with charge of Out-Patients, Late Senior Demonstrator of Anatomy at St. Bartholomew's Hospital; Late Assistant-Surgeon to the German Hospital, Dalston; Late Hunterian Professor Royal College of Sur- geons, England, Etc. FIFTH EDITION. Svo, Cloth, 31 plates, xii+96 pages of text $2.00 net. RITCHIE— Auricular Flutter. By William Thomas Ritchie, M.D., F.R.C.P.E., F.R.S.E. Physician to the Royal Infirmary ; Lecturer on the Practice of Medicine, School of Medicine of the Royal Colleges ; Lecturer on Clinical Medicine in the University of Edinburgh. 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