cancer it must be understood that it is not claimed that the diseased
process depends wholly and exclusively on the character of the food,
including drink, taken. In my former lectures I tried to show that
cancer was the result of a deranged nutrition, and we know that one of
the greatest elements in inducing this latter is erroneous metabolism,
depending again on the diet, to a very great extent. In a later lecture
I shall hope to develop this subject further, and indicate more
completely than on the previous occasion, the elements of causation and
the measures which can be successful in overcoming the disease.
In order to understand rightly the rôle which diet may have in the
production of cancer I may have to briefly repeat, more or less, some of
the matters brought forward in my lectures two years ago, and shall
treat of the correction of diet in a later lecture.
We understand, of course, that the body is a vast laboratory, wherein,
by exceedingly complicated processes, material from the outside world is
appropriated to the needs of the economy, and after its use is cast out
in very different and elementary forms. To effect the various changes
necessary in this material we have a very considerable number of what
are called organs of secretion and excretion, whose functions are
combined and correlated in a marvelous manner, which is even yet very
imperfectly understood.
The actual biochemical processes by means of which the transformation of
external food elements into living tissue and force, physical and
mental, takes place are known as: 1. Anabolism, or the process of
assimilation of nutritive matter and its conversion into living
substance; and 2. Catabolism, or the breaking down of complex bodies of
living matter into waste products of simpler chemical composition. These
together constitute 3. Metabolism, or the sum of the chemical changes
whereby the function of nutrition is effected. The actual procedure by
which most of these activities is carried on is one of oxidation, by
means of the oxygen supplied largely by the lungs, which constitutes
about 65 per cent of the human body.
Now to make up for the daily waste of the other 15 elements, which form
35 per cent of the body tissues, and to support the necessary activities
of the system, mental and physical, it is necessary every day to take a
more or less even supply of substances, which we call food and drink,
which should contain about the proper proportion of the requisite bodily
components. Under normal conditions of healthy living the appetite
ordinarily serves as a proper guide for health in man and beast, serving
to regulate the selection of material to preserve the balance of
nutrition. But man especially has temptations to gratify the _taste_,
which is quite a different thing from satisfying the _appetite_, and all
are familiar with the many forms of disaster and disease which arise
from gratifying the taste in food and drink; moreover, the temptations
to this seem to increase continually with the so-called refinements of
civilization.
The actual nutritive elements which are required are relatively few, and
fall mainly under three classes: 1, Protein; 2, Carbohydrates; and 3,
Fats. Of these the latter two furnish most of the 18 per cent of carbon
in the body, and the animal or vegetable protein furnishes the nitrogen,
which forms only about 3 per cent of the body tissues: all these
substances are, of course, used up constantly in providing heat and
energy, physical and mental, day by day, the protein being concerned
chiefly in replacing wasted tissue. The combustion of the carbohydrates
and fat is relatively simple, and the waste products pass off
harmlessly, mainly by the lungs, as carbonic acid and water.
But the course of the protein, or nitrogenous and sulphur and other
mineral elements, is quite different. In the anabolism and catabolism of
protein there are a vast number of intermediate changes, and various
products are elaborated which we know to be of great significance in the
system, and which when imperfectly completed are the source of much
disorder and disease in the economy. Of this the gouty state is a
notable example, with a long list of secondary disorders.
But few realize, however, that cancer is another disease which is quite
as striking in its relation to faulty nitrogenous and sulphur
metabolism. In my former lectures I developed this subject pretty fully
and need not repeat it here, but could adduce more recent proof, did
time permit. Suffice to remind you that many independent observers have
recorded very important and significant errors in the nitrogen and
sulphur partition in cancer, both in its early and late stages, some of
which I have verified in hundreds of volumetric urinary analyses. As
these errors are made to disappear by proper dietary and medicinal
treatment the carcinomatous lesions have steadily improved, and in many
cases have disappeared entirely, as I hope to demonstrate in a later
lecture.
We must, therefore, accept the fact that cancer has very close relations
to the elaboration of protein in the system, and the rational deduction
of this is that an overconsumption of nitrogenous food has something, if
not everything, to do with the production of cancer. As yet we know
little or nothing in regard to actual cancer-genesis; no one has ever
demonstrated, and probably no one ever will demonstrate, the absolute
beginning of the change in some normal cell or cells, in the breast or
elsewhere, which eventuates in their taking on the rampant or malignant
feature which we call cancer. But this change does occur, and though the
exact alterations in the polarity of the cells and the disturbance of
their centrosomes and nuclei, which have been described, may not be
perfectly understood, there is some definite cause for their occurrence.
Some have suggested the hypothesis that the mononuclear leukocyte, by
conjugation with disturbed cells, gives them an abnormal reproductive
power by which they eventually develop the tumor and invade other
tissues. But back of all this there is still some activating cause,
which is found in the fluids which bathe every tissue, namely the blood
and lymph, which we shall see later are deranged in cancer.
The fact that with innumerable injuries occurring everywhere and at all
times cancer develops from them very rarely, should teach us something.
We must conclude, therefore, that there is some constitutional
condition, or rather some state of the blood, which nourishes the cells
and which favors this continued malignancy—some fuel which feeds the
malignant process and at the same time induces a progressive lowered
vitality, ending fatally. For we have already seen in these and former
lectures that the local lesion which we call cancer is but one
manifestation or result of a pernicious anemia, which, if not checked,
may end life in a relatively short time.
As cancer is not contagious or infectious, this anemia, with all its
concomitants, including the local trouble which we call cancer, must be
autotoxic, and evidence is strong that it is of a nitrogenous origin. We
look naturally, therefore, to see if there can be found any relationship
between an augmented consumption of protein-bearing food and the steady
increase in cancer mortality which is reported on every side.
England has furnished more fully and for a longer period than any other
country the mortality and dietary statistics of its population, and from
these we can learn a great deal of value in our study.
According to a carefully prepared table by W. R. Williams showing the
total population in England during the years from 1840 to 1905, cancer
deaths had increased from 17.7 per 100,000 population in 1840 to 88.5 in
1905, or five times in numbers, and in 1913 there were 105.5 deaths from
cancer in 100,000 population. During this time the meat consumption had
more than doubled, to 130 pounds per capita in 1904; so that, according
to Williams, it is estimated that among the adult well-to-do population
the per capita meat consumption was from 180 to 330 pounds per year, in
addition to large quantities of game, poultry, eggs, fish, etc.
The United States Report of the Meat Situation, 1916, also furnishes
some valuable information to aid in this inquiry.
The Argentine Republic stands next in the consumption of meat, with 140
pounds per capita, and with a cancer mortality of 91 per 100,000 in
1900.
The United States comes next, with a per capita consumption of meat at
201.1 pounds in 1909 and a death rate from cancer of 73.8 per 100,000 in
that year, which, as previously stated, was 79.4 in 1914 and 81.1 in
1915.
New Zealand exceeds the United States a little, with a meat consumption
in 1902 of 212.5 pounds per capita, and an increase in cancer mortality
from 32 in 1877‒1888 to 60 per 100,000 in 1900 and 71 in 1903. This
increase is mainly among British and other immigrants, whereas the
aborigines, living simple lives, are seldom affected.
Australia stands first in the consumption of meat, with the enormous
rate of 262.6 pounds per capita in 1902, and the increase of deaths from
cancer there is most striking. In 1851 the death rate per 100,000 living
was 14, in 1900, 62.6, and in 1913, 75 per 100,000 living. The most
striking difference is exhibited between those who are native born, who
in 1900 had a cancer death rate of only 22 per 100,000, while the
British born had a mortality from cancer of 203, or nine times as great;
a still higher ratio was found among immigrants of other nationalities.
Those who have written there on the subject ascribe this proclivity to
cancer to the gluttonous habits of immigrants, who have meat for
breakfast, lunch, dinner, tea, and supper (MacDonald, Williams).
Italy, consuming the least quantity of meat, 46.5 pounds per capita, in
1901, has the lowest cancer death rate, but the present meat consumption
cannot be learned. In Italy, however, the mortality from this disease is
steadily rising, from 50.9 per 100,000 in 1860 to 1900 to 63.6 per
100,000 from 1906 to 1910.
But, as I have tried to show you all along, it is some derangement of
metabolism which is at the bottom of neoplastic growths, and that
derangement is not necessarily due to any one single cause, as diet.
There are other elements of disturbance besides the nitrogenous
malassimilation which is due to the intake of an excessive amount of the
proteid of the animal kingdom; for cancer is said to have been seen in
vegetarians, although I have never met with such a case. We know,
however, that some or many articles from the vegetable kingdom, such as
the pulses and some nuts, contain a very large proportion of proteid;
thus dried peas contain 21 per cent, haricot beans 23, lentils 23.2,
dried lima beans 26.4, soy bean flour, 39.5, butternuts 27.9, black
walnuts 27.6, peanuts 25.8, and almonds 24 per cent of proteid, all more
than is contained in beef and mutton. Thus a large supply of any of
these might produce the same error in the blood stream as that induced
by meat.
In my former lectures I pointed out also that coffee and alcohol were
found by statistics and clinical experience to have a prejudicial effect
on cancer, and therefore must be considered as elements in its
production. In a later lecture I shall deal more specifically with these
matters, in reference to the prophylaxis and treatment of the disease.
At the present time I will only remind you of what I have so often said
before: that it is the complex of modern civilization, with all its
temptations and errors in regard to eating and drinking, and living,
including the nervous strain felt everywhere, that in some way produces
alterations in nutrition which account for many of our diseases. This
operates through the blood current, which ministers in such a way to the
tissues that under some slight provocation a heterologous growth of
certain tissue cells occurs, with malignant tendencies, instead of the
normal homogeneous and stabile structures which compose healthy tissues;
and this departure from normal cell action we call cancer.
LECTURE III
THE MORTALITY FROM CANCER; ANALYSIS OF SURGICAL STATISTICS
As has been already shown in these and previous lectures, the death rate
from cancer has been steadily and alarmingly increasing in almost every
locality, ever since statistics have been collected. The attempt has
been made from time to time to show that this increase is not real, but
is apparent, and that the error arises from three main causes. These
are: 1. The increased longevity in general, leading to the existence of
more people of the cancerous age; 2. Improved diagnosis; and 3. More
careful death certification.
Time does not allow us to go into this matter very fully, but this
erroneous impression is so widespread, and one so constantly meets it in
conversation, that it is desirable to present briefly the grounds and
proof for an absolute denial of the assertion that there has been very
little or no real increase in the mortality from cancer.
First, it may be stated that most of the arguments quoted against the
correctness of statements regarding the steadily rising death rate of
cancer date back to King and Newsholme, who, in 1893, some twenty-three
years ago, attempted a study of early statistics and drew certain
conclusions from them. This was long before the era of careful research
and reliable diagnosis and statistics, and can have little, if any,
weight. Bashford and Murray in the Second Scientific Report of the
Imperial Cancer Research Fund, in 1905, attempted to show the same
thing. But even this was eleven or twelve years ago, and the utter
fallacy of the sophistical arguments appears in the absolute, steady
increase in the death rate of cancer as shown by official tables from
many countries, and as especially collected and seen in the remarkable
book by Hoffman on “The Mortality from Cancer Throughout the World.”
It is impossible in a brief lecture to give even a faint idea of the
immense and valuable amount of research represented, and consequently
the most useful information furnished in this monumental work; the
material is taken from original documents with new information, freshly
obtained from original sources. All is given with an impartiality and
clearness which are refreshing when compared with some recent writings
on the subject. With the immense accumulated data on record, some of
which will be referred to, all showing a steady rise of mortality up to
the present time, and that during a period of especial study of cancer
such as the world has never known before, it is quite unreasonable and
impossible to believe that this advance is only apparent, and that it is
influenced by the three suppositions mentioned. While accuracy of
diagnosis may be important in early cancer, it is certain that in late
stages and at death, from which the various mortality tables are taken,
there is rarely any question as to the diagnosis. There is evidence,
however, to show that cancer is increasing even more rapidly than
appears from mortality statistics.
In 1900 the recorded mortality from cancer in the registration area of
the United States was 63 per 100,000 living, and in 1914 it had risen to
79.4, or an increase of 16.4 per 100,000 living, or over 26 per cent.
While in 1915 there were 54,584 deaths from cancer against 52,420 in
1914 in the registration area of the United States, or 2,164 more
deaths. The total number of deaths in the entire United States is
estimated at about 80,000 last year. The death rate in 1915 was 81.1 per
100,000, or a rise of over 28.7 per cent since 1910. The increase during
this past year has been 1.7 per 100,000 living, while the gross increase
for the preceding five years was but 5.6 per 100,000, or less than an
average of 1.2 per 100,000 each year. So that the great activity in
cancer education and in operative surgery during that year has succeeded
in raising the death rate from cancer by .5 per 100,000 over the average
of the preceding five years!
It is to be noted that this increasing mortality from cancer has been
steady and constant, though with slight diminution occasionally, some
years ago, before the great activity in cancer research, cancer control,
and cancer surgery. All this would certainly indicate some deep-seated
cause of the malady which had not been recognized; indeed the mortality
during the last five years was as follows: 1911, 74.3; 1912, 77; 1913,
78.9; 1914, 79.4; and in 1915, 81.1 per 100,000.
It may be of interest to know that the mortality from cancer varies very
greatly in different portions of the United States, and it would be
instructive to investigate the cause; but the data for this do not
exist. The highest death rate for 1914 was in Vermont, 109.9; Maine had
107.6; Massachusetts, 101.8; New Hampshire, 100.8; California, 97.9; all
against the general average of 79.4 per 100,000 inhabitants in the
registered area of the United States. The lowest among the registration
States was Utah, with 45.8 per 100,000 living. In New York State the
deaths from cancer in 1914 were 88 per 100,000 population in the cities
and 96.1 in rural districts.
Many cities, of course, show a higher death rate from cancer than the
average, owing in part to the number of patients coming for treatment,
and also to the more complex life of the cities, with the greater
temptations leading to the disturbances of metabolism causing cancer.
Thus, the average of twenty large cities gives a rise in death rate of
cancer from 48.6 from 1881 to 1885, to 89.3 per 100,000 living in 1913.
The following table gives the average cancer mortality from 1906 to 1910
per 100,000 in certain American cities:
San Francisco 102.5
Boston 99.4
Providence 96.9
Los Angeles 94.9
Cincinnati 93
Hartford 91.9
New Haven 89.8
Dayton 88.5
Rochester 88.2
Springfield 86.9
District of Columbia 86
Baltimore 85.8
Omaha 85.7
Buffalo 84
New Orleans 82.2
Philadelphia 81.9
Hoboken 80.7
Columbus 79.5
Manhattan and Bronx 78.4
St. Louis 78.4
Denver 77.9
Newark 76.9
Chicago 76.5
Greater New York 74.1
Richmond 73.9
Kansas City, Mo 71.1
St. Paul 71.1
Indianapolis 70.4
Borough of Brooklyn 68.9
Milwaukee 68.4
Nashville 68
Pittsburgh 66.4
Minneapolis 65.3
Detroit 64.5
Cleveland 62.9
Louisville 61.1
Jersey City 60.5
Charleston 53.6
Seattle 50.2
Augusta (Ga.) 49.1
Memphis 48.7
Savannah 47.1
In the city of New York, as given by the Board of Health Bulletin, there
were from July 1, 1915, to June 30, 1916, 4,672 deaths from cancer, or
an average of just 12.8 persons per day; in the last six months, July 1
to December 31, there were 2,264 deaths from cancer, 990 males and 1,274
females, with a daily average of a little higher than last year.
It is readily understood that many factors enter into the study and
proper understanding of the statistics of cancer, such as age, sex,
location of the lesion, etc., and the limits of a lecture do not permit
any adequate presentation of the subject, but a few points may be
mentioned.
Thus, in regard to age, the States which represented the greatest number
of deaths from cancer, Vermont with 109.9 and Maine with 107.6, show
that the proportion of individuals over 45 years of age was over 27 per
cent, compared with 17.7 per cent for Kentucky and 16.2 per cent for
Montana, which latter gave almost the lowest mortality from cancer.
The same is true somewhat in regard to sex, although sufficient data are
not at hand to show the relative number of living males and females in
the different States. We know, of course, that the great preponderance
of cancer in females is due to that affecting the breast and uterus, and
where females preponderate in the population the total cancer mortality
would be the highest.
The location of the lesion has also a bearing upon the understanding of
statistics. Thus in Norway, for some unexplained reason, cancer of the
stomach caused the great mortality of 60 per cent (66.9 males, 52.9
females) of all cancer mortality, while cancer of the breast caused but
7.6 and of the uterus 16.2 per cent of the whole, the general rate being
93.9 per 100,000 inhabitants. In the United States, in 1914, cancer of
the stomach and liver caused the deaths of 37.9, cancer of the breast
10, and cancer of the female genital organs 14.2 per cent of all deaths
from cancer.
There are other points also to be taken under consideration in
connection with cancer statistics which we cannot even touch on and can
only mention one, namely, the physical condition; for the disease is
known to be more frequent proportionately among the better nourished and
well-to-do classes, etc.
Turning to other countries, we find abundant confirmation of the
persistent and considerable increase in the mortality from cancer, in
many cases much greater than has occurred in the United States; and in
nearly all of them the increase can be recognized as commensurate with
the progress or advance of so-called civilization, especially as
emphasized in city life.
England and Wales afford us about the most satisfactory statistics in
this regard. W. R. Williams has given a valuable table, already referred
to in connection with food, showing the prevalence of cancer and its
relative increase in England and Wales from 1840 to 1905. In 1840 the
cancer death rate was 17.7 per 100,000 living, with a proportion of 1 to
129 of total deaths. The deaths from cancer increased with almost a
perfect regularity until in 1905 there was a mortality of 88.5 per
100,000 living, and 1 in 17 of the total deaths was due to cancer, as
against 1 to 129 in 1840. The total proportion of deaths from all causes
is given for each year, and while the population has only a little more
than doubled in these 65 years, the deaths from cancer have increased
from 2,786 to 30,221, or over ten times the number; the rate of cancer
deaths per 100,000 living had increased five times, while the ratio of
deaths from cancer to total deaths had multiplied more than seven times.
Since 1905 the cancer death rate in England and Wales has advanced to
99.3 per 100,000 in 1911, and to 105.5 in 1913, and in London the cancer
mortality is 114.9 per 100,000 population.
Statistics from other countries, collected by Hoffman, show the same
steady increase. I will not weary you with much more of statistical
detail, but it is interesting to record a few of the more striking
facts, illustrating the universal increase in the cancer death rate
during these later years of cancer research and active surgery. The data
are from 1896 to 1910, and the countries will be arranged according to
proportionate increase in the death rate per 100,000 population. Thus,
Ireland comes first, with an increase of 20.7, which is explained in
part by the emigration of younger persons, leaving more of the cancer
age; next comes Denmark, increased from 118.9 to 137.3, or 18.4 per
100,000 population; then the German Empire with an increase of 13.4;
Hungary, 12.9; Italy, 12.7; Holland, 11.6; Norway, 10.9; Austria, 9.4;
and France from 97.3 to 102.7, or only 5.4 per 100,000 population.
During this same period the deaths from cancer in the United States have
increased about 18 per 100,000, or almost as much as the highest of the
countries mentioned.
In regard to the bearing of all these figures upon the alleged apparent
and not real increase of cancer, I may quote from Hoffman: “The evidence
is so convincing” as to the reality of the increase of cancer “that it
may be safely maintained that no other statistical conclusion in
medicine is so concisely and incontrovertibly established as this: in
any event, no satisfactory evidence is available to successfully
contradict this conclusion at the present time. If all this evidence,
however, is inconclusive and worthless, then no alternative remains but
to discredit the statistical returns of every country in the world with
regard to any single disease or group of diseases, although the returns
are accepted as approximately accurate in regard to every other
important cause of death.”
[Illustration:
Death Rate per 100000 Population
From United States Mortality Statistics 1915
]