readily understood, the accompanying chart (now hanging before you) has
been copied from that given in the volume of the United States Mortality
Statistics for 1914, and it will help to visualize what has just been
stated. The data for 1915 have been added through the courtesy of Mr.
Rogers, Director of the Census, in a personal communication.
The striking fact brought out in this chart is the comparison between
the steadily diminishing death rate of tuberculosis, through careful
medical supervision, and the steadily increasing death rate of cancer,
under surgical care. While the mortality of tuberculosis has fallen from
201.9 persons in 1900 to 145.8 in 1915, or 56.1 less deaths in each
100,000 population, or over 27.7 per cent, the cancer death rate has
risen in the same time from 63 to 81.1 per 100,000, or over 28.7 per
cent. They have therefore approached each other by 56.4 per cent, and
unless this rate of progression is changed in some way, the lines will
have crossed one another in less than fifteen years more, even as that
for organic heart disease has already crossed that of tuberculosis, it
having risen almost 27 per cent.
Another interesting lesson to be drawn from this chart is that the death
rate from organic heart disease, nephritis, and apoplexy have all risen
coincidently with that of cancer, only that the rate of the latter has
outstripped them all. If we accept the fact that the increasing death
rate of these three diseases is largely the result of modern
civilization, especially from erroneous eating and drinking, it would
appear that cancer is due to the same cause.
Realizing, then, that the mortality of cancer is materially and steadily
rising, in spite of most diligent research by innumerable honest and
capable scientists, with the expenditure of vast sums of money and
countless animal lives, and in spite of the work of ardent, earnest, and
capable surgeons, who have failed to stay the terrible progress of the
disease, let us briefly study some of the reported statistics in regard
to the results of operative interference in cancer.
It may be first stated that this is a most difficult task, so different
are the reports from different surgeons. There are many elements which
affect the statistics relating to the surgery of cancer. First of these
is, perhaps, the stage of the disease at which the operation is
performed. Second, the results vary, of course, immensely with the
knowledge and skill of the operator and the excellence of the technique.
Third, the class of cases operated on has much to do with favorable or
unfavorable results reported. Fourth, the length of observation after
operation is always to be considered in connection with surgical
statistics. Finally, the optimism of the reporter must be regarded in
weighing the true value of reports as to ultimate results. We will
briefly consider these points.
First, as to the stage of the disease at which the operation was
performed. We have seen in this and previous lectures that the lesion
which we call cancer is but a _result_ of a deranged blood state, and is
not a purely local process, a something simply to be removed surgically
in order to have the patient get well and remain well. For one sees
plenty of cases where there were recurrences even after the very
earliest operations possible. But the claims put forth that favorable
results are conditioned on very early operations are so strenuous and
persistent that we must believe that a measure of the favorable results
can be thus accounted for. We know, of course, that very late in the
disease operations are out of the question. It is a little curious,
however, that most of the pictures shown, statistics presented, and
arguments adduced by these ardent advocates of early operation relate to
cancer of the skin, especially about the face, which cause hardly 2 per
cent of all the deaths from cancer in various countries; whereas those
who see much of cutaneous epithelioma know that if properly handled it
is generally a comparatively mild affair and relatively easily cured
without surgical operation, as you have so constantly seen in this
clinic in past years. But mortality statistics are greatly influenced by
the class of cases which the operator takes, and so if epithelioma of
the skin is included, the ratio of cures will be high. Selected cases
also always give more favorable statistics.
Second, the knowledge and skill of the operator and the perfection of
technique undoubtedly influence surgical statistics. The ordinary
practitioner or surgeon cannot hope for as favorable results in many
operations on cancer as can those who are past masters in this line, and
these latter are the ones who furnish the favorable statistics.
Third, the class of cases operated on affects surgical statistics very
greatly. While epithelioma of the face, and even of the lip, when well
removed, may yield most favorable statistics, cancer of the breast,
uterus, stomach, intestines, gall bladder, etc., yield increasingly
unfavorable statistics, as will be presently seen.
Fourth, the duration of observation after operation affects very
seriously the validity of statistics. Not long ago three years’ freedom
from disease was considered the time to regard a cancer as permanently
cured; but this time has been lengthened more and more, by the
observation of any number of cases where the disease has recurred even
long afterwards, and reliable observers are now very chary in expressing
an opinion as to the final cure of a cancer. This will be more fully
considered in another lecture.
Finally, the optimism of the reporter seems often to have something to
do with the reliability of surgical statistics. This need hardly be
discussed. The older and more experienced the surgeon the less confident
he is of having actually cured cancer with the knife. At a discussion in
the New York Academy of Medicine, some years ago, Dr. Robert F. Weir
said that the late Dr. Agnew, a celebrated surgeon of Philadelphia, had
remarked, just before his death, that he doubted if he had ever been
justified in an operation upon cancer, and he, Dr. Weir, stated that he
could almost say the same.
Turning now to the actual statistics of operative surgery on cancer, we
will find that the percentage of reported cures varies very greatly, in
accordance with the points just stated. It is understood, of course,
that no accurate statements can be made from statistics in reference to
the actual mortality of cancer in any location, partly owing to the
paucity of figures, and partly because the stages and extent of the
disease differ so greatly, and the results vary with the previous
duration of the lesion and the period of observation after the
operation.
Cancer of the skin presents the best operative statistics of any region,
and the claim is made that all cases are curable if operated on early
enough and rightly. While this is not wholly true, it is certain that if
all lesions which one chooses to call “pre-cancerous” are thoroughly
extirpated very early, and included in the statistics, the percentage of
cures can be reported as very high. So that it may be said that, taking
all statistics together, including very small as well as large lesions,
the favorable results, that is permanent cures of lesions which can be
truly called cutaneous epithelioma, may run as high as 75 per cent. But
against this is to be set the fact that a very large share of these
cases, taken early and by competent persons, are equally amenable to
cure by lighter measures, without the horrible disfigurement which one
sometimes sees after purely surgical procedures.
Cancer of the lip, when taken early and treated radically, including
gland extirpation, also yields a fairly satisfactory result, depending,
of course, on the stage of the disease, or amount of involvement of
tissue and glands, and the completeness of the operation. But while some
operators have claimed 75 per cent of cures, Hertzler makes the
percentage of permanent cures not much over 25 per cent. And here again,
if taken very early and treated correctly, many of these cases yield
without the knife, whereas very late cases may be practically
inoperable.
When, however, we come to cancer within the mouth, the tongue, etc., it
is quite a different story, and the end results of surgery are commonly
unsatisfactory. Certain European surgeons have reported an operative
mortality in cancer of the tongue as high as 36 per cent, while
recurrences are the rule, and really permanent cures the very great
exception.
As before stated, it is extremely difficult to give any true and
accurate estimate of the real end results from operative surgery as
ordinarily performed in cancer affecting various regions. The obvious
reason of this is that most of our statistics are from those who are
especially occupied with the disease under most favorable hospital
facilities, and also certain statistics may be from selected cases;
moreover, operators are naturally inclined to report mainly satisfactory
results, while the other aspect of the case is seldom presented. Aside,
then, from superficial epitheliomata, about the only locations in which
there is even a fair chance for the patient under the knife are the
breast, uterus, and rectum, and for these large statistics are
available; but again these are unsatisfactory, as they vary so greatly.
The reported statistics of cancer of the breast are very provoking.
Individual operators have claimed as high as 50 and even 70 per cent of
cures (Rodman). Murphy, on the other hand, on a basis of end results
states that the plump woman invariably succumbs, and that Paget’s
disease ends fatally in 90 per cent of cases. Hildebrand mentions 606
operations in which the percentage of permanent cures varied from 15 to
23 per cent; late recurrence is not uncommon in cancer of the breast. He
thinks that 35 per cent is the maximum possibility for permanent cures.
He would be very suspicious of any higher figure. Judd reports that of
266 cases of carcinoma of the breast in the Mayo Clinic, which could be
traced, 39.8 per cent were reported as alive at the end of five years,
although there was recurrence in 6 cases.
Lubhardy, in an article on recurrence, in 1902, states that 1,321
recurrences were known to have occurred after 2,107 operations, or
nearly 63 per cent, 4 per cent of which were late recurrences; he does
not mention the number “cured” nor the number of patients untraced.
Unfavorable results in breast cancer are seldom published. Dr. H. C. Coe
in a discussion quotes the experience of a friend who had operated on
between 200 and 300 cases of cancer of the breast with exactly 13
recoveries.
Levin (_Med. Record_, Jan. 27, 1917, p. 175) has recently made some
startling statements in regard to the recurrence of carcinoma after
breast operations. While granting that early cases without lymphatic
involvement yielded good results, he states that these represented at
the utmost only 25 per cent of the cases operated on: 75 per cent were
advanced cases with involvement of the skin and lymph glands. Of these
barely 25 per cent could be cured by radical operation, and in 52 per
cent of the advanced cases operated on metastases appeared in distant
organs without local recurrences. The longer the period after the
operation the greater was the number of recurrences.
He quoted Heurtaux, a French surgeon, who had followed up 284 cases
which he himself had operated on during the previous 20 years. H. stated
that four years after operation 43 per cent remained free of the
disease, eight years after only 16 per cent, and 20 years after only 2.5
remained free from the disease. There were a great many cases of
carcinoma of the breast reported in which the patient died from
metastasis in different organs without local recurrence 10, 15, and 20
years after the operation. The late metastases most frequently took
place in the skeleton, which was due to the fact that skeletal lesions
might continue a long time without causing clinical symptoms.
Dr. Levin confirmed the skeletal involvement by roentgenograms of ten
cases of carcinoma of the breast observed during the last two years, in
which it was found that the metastases must have been present at the
time of operation.
Dr. Willy Meyer in the discussion said that physicians had long been too
prone to consider carcinoma a local disease, and when he found signs of
metastatic infection he never felt that he could expect anything from an
operation.
We can only state with Hartwell and others that every especially
favorable series of cancer cases, and this applies particularly to the
breast, should be subject to close scrutiny. Why did this or that
operator get marvelous results and an equally efficient man get very
poor ones?
There are also many factors to be considered. How many cases were of the
senile or scirrhous type? How many of the tumors removed were proved
microscopically to be cancer? If one operates radically on every tumor
or swelling in the breast, however small, the end results will, of
course, be more favorable; for undoubtedly many innocent lesions,
chronic mastitis, adenoma, cystic tumors, etc., are often removed
unnecessarily. The question also arises as to what was the after care,
and what steps were taken to prevent recurrence? In view of the
statement of Hildebrand, just quoted, that 35 per cent is the maximum
possibility for permanent cure, and considering the terrible pain and
miserable death one so constantly sees in recurrences, it really becomes
a question as to the advisability of surgical interference.
The opinion has been expressed more than once by those who have watched
the disease, that if left alone, with ordinary medical care, the entire
average of 100 cases would be better, as to length of life and
suffering, than if submitted to operation. I shall hope to show you in a
later lecture that a greater proportion of breast tumors, diagnosed as
cancer by competent surgeons, have recovered completely for years, under
proper dietary and medical care than the percentage yielded by operative
procedure.
There is a wealth of statistics regarding operations for cancer of the
cervix uteri. Despite the figures obtained by radical operators like
Wertheim, the vast majority of those surgeons who practise either
vaginal or abdominal hysterectomy have obtained far inferior results to
those of Byrne, with his cautery, which is still in use. Wertheim once
reported the astonishing figure of 61 per cent of 5‒year recoveries. In
a later report, however, Wertheim stated that only about one half of the
cases that come to him are operable, and of these about one half are
cured by operation, that is, about 25 per cent of all cases. But
experience shows that if these cases could be followed up there would be
very many late recurrences. The claims of Wertheim and others must be
offset, however, by the high operative mortality reported by many; as
the cases must have been incipient in order to be operable, it is
possible that Byrne with his cautery could have done nearly as well, and
Byrne never lost a patient. But Klein of Munich, by circular letters
compiled many statistics, and concluded that the percentage of cure was
but 4.5 per cent, and Klein himself obtained only 3.6 per cent. Reinecke
asserted that only 10 per cent of cases of cancer of the cervix can be
cured.
Fredrick (_Trans. Gynæcol. Soc._, 1905, p. 136) collected the records of
500 hysterectomies for cancer of the cervix performed by prominent
colleagues and himself. Of this entire material there had been but 13
five-year cures. In discussion Henrotin stated that he had practically
given up abdominal hysterectomy. Currier stated that surgery was a
failure as a cure for cancer.
At an earlier session of the Society, 1900, in a discussion of Pryor’s
paper, Van de Warker asserted that surgery had done nothing for cancer;
Lapthorne Smith said that many women did better if left alone. J. Byrne
stated that hysterectomy for cancer was a crime. Engleman thought that
cancers left alone may insure a longer survival than those treated
surgically.
In a discussion before the same Society in 1896 (on Byrne’s paper)
vaginal hysterectomy was discussed. While Boldt, Dudley, and Baldy
claimed excellent results, Segond is known to have had but 5 relative
cures (2‒5 years) in 80 cases. Mundé saw a rapid return in all his 25
cases. Polk had recurrence in every one of 50 cases. Byrne collected
notes of 283 operations by ten men, and the results were as follows:
died, 7 per cent; life prolonged, 11 per cent; and became worse, 82 per
cent.
In the Transactions for 1912 (Discussion of Neal’s paper, Wertheim’s
operation) Bovee stated that only 10 per cent of cancers of the cervix
were operable. Polak had no survivors from operations, although four
were living from Byrne’s cautery method. Chalfant had 3 cures (6 years)
in 30 cases. In general the saving of life was offset by the high
operative mortality. Later I shall report two remarkable cases of very
extensive cancer of the cervix which have entirely recovered, with
normal cervix, without operation.
In regard to operative results in cancer of the stomach there are
relatively few satisfactory statistics. W. J. Mayo reported recently
(Levin, Hoffman “Statistics of Mortality,” etc., 1915, p. 210) on 996
cases of carcinoma of the stomach. Of these 344 cases only were operable
and of the latter 25 per cent remained cured five years and over, after
operation. In other words, about 9 per cent of cases of carcinoma of the
stomach can be cured by surgery at the hands of Mayo, how much less in
the hands of most other surgeons? Against such success must be opposed
the analysis of 1,000 cases of cancer of the stomach by Friedenwald
(_Amer. Jour. Med. Sci._, November, 1914). He states “of the entire
number, operations were performed in 266 instances; of these there is
not one patient living.” But few lived more than a year after operation;
the majority died within the first six months.
In cancer of the gall bladder several good operators have reported that
there have been absolutely no good results.
In cancer of the rectum there is a high operative mortality and very
questionable ultimate curative results; indeed, there are very few
reliable statistics in regard to this. In 27 perineal and sacral
operations Mayo reports 7 per cent primary mortality, and in 44
abdominal and combined abdominal and perineal operations 20 per cent
operative mortality. Tuttle reports a higher operative mortality. While
there are no available data in regard to the duration of life after
operation, it is well known that the disease usually recurs, and in many
a colostomy is performed, with all its distressing features and very
intangible results.
Time does not admit, nor is it necessary for me to go further into the
brave but futile attempts which have been made by surgeons to cure such
cases of cancer as can be reached by the knife, which, as we have seen
by the testimony of many foremost in their ranks, has been found
ineffective to a very great degree. In addition to the locations just
mentioned there are many others where the attempt has been made to
eradicate the disease surgically, but either with results quite as
unsatisfactory as those mentioned, or much worse. Thus cancer of the
tongue, palate, esophagus, cardiac orifice of stomach, liver, gall
bladder, pancreas, small intestine, bladder prostate, etc., also of the
brain and spinal cord, are most unfavorable, and both the operative
mortality and end results are disheartening. All surgeons agree that at
least 50 per cent of all cancers are inoperable, so that in all the
reports concerning the results of operations this must be taken into
consideration, and the real percentage of cures of cancer by surgery
must be divided into at least one half. Thus, if operative surgery
yields an average of 25 per cent of apparent cures in all cases operated
on, this would mean only 12.5 per cent of all cases of cancer. This,
considering the late recurrences often not traced, bears out the
commonly received opinion that about 90 per cent of all patients once
attacked by cancer die of the disease.
Surely the outlook for surgery, borne out by the steadily rising general
mortality from cancer, is most unpromising, and one naturally turns to
medicine, to know if there is not some means of modifying the system so
that there shall not be this tendency to malignant tissue change, so
destructive to life. In my former lectures I attempted to show that all
experience and biochemical laboratory studies looked this way, and in a
later lecture I shall hope to show that by dietary, hygienic, and
medicinal measures the disease can be and has been checked repeatedly,
and cancer cured without surgical operation. The permanence of the cure
depends, of course, upon the continued faithful adherence of the patient
to the means and measures which caused the dissipation of the tumor. For
no one can doubt but that, if the real cause is met and kept in check by
prolonged proper measures, the disease will not and cannot redevelop.
Do not misunderstand me and think that I claim that each and every case
of cancer, in any stage, can be cured. Alas, my sad experience with the
many deaths from recurrent and inoperable cancer, especially in the New
York Skin and Cancer Hospital, has taught me the contrary, and I have
often been appalled at the impotence of human endeavor; although even
these patients have often been grateful for the amount of benefit and
relief afforded by proper measures, and in my former lectures I reported
to you several such cases. But I do assert that the total percentage of
cures in reasonable cases is far, far greater under the line of
treatment I am presenting to you than under that most commonly employed.
LECTURE IV
INOPERABLE AND RECURRENT CANCER; METASTASIS; THE BLOOD IN CANCER
We saw in our last lecture that surgery had failed to check the rising
mortality of cancer, and that during the year 1915, in the United States
Registration Area, the death rate had augmented from 79.4 to 81.1, or an
increase of 1.7 persons in every 100,000 living; this was a greater
increase than the average rise in the death rate for the preceding five
years which was only 1.2 points. This, moreover, occurred during a still
active period of laboratory research, with wide publicity as to cancer
control, by education as to the benefit of early operation, and with
active and skilful surgery.
We saw that fully 50 per cent of all cases of cancer were quite
inoperable when first seen by competent surgeons, while the average end
result, or cure, in the cases operated on, for all kinds together, good
and bad, slight and severe, did not total as much as 25 per cent; this
makes but 12.5 of the entire number who applied for surgical relief. We
quite naturally asked, therefore, if some form of medical treatment,
including diet and hygiene, could not afford a better prospect of
arresting this fearful mortality. It is especially in regard to the
large number of inoperable and recurrent cases, comprising over 60 per
cent of the whole, that this inquiry is particularly important. We will
briefly consider these latter sad conditions.