to show here and on former occasions, all cancer will be inoperable, or
rather, not needing operations, when the principles I have tried to
develop are fully elaborated by the wide experience of others, and when
they are firmly established, and correctly carried out. For when it is
universally realized that it is the errors of life, determined and
accentuated by advanced civilization, so-called, which lead up to and
cause cancer, and when public education has been advanced along correct
lines, the tendency to cancer will diminish and there will be fewer
cases, either operable or inoperable. The former will melt away under
correct internal and external measures, and the latter will be helped
by, or slowly yield to the same, unless the malignant process has
already progressed beyond the possibility of retrogressive metabolism.
But, of course, it is too much to expect that such longed for results
will be fully attained within a generation or two.
INOPERABLE CANCER is truly a most distressing condition, especially
after it has become so after one or more surgical operations. The
hopelessness and despair of the patient when told that no operation is
possible is bad enough. But when with recurrence, time and again after
repeated operations, it is decided that no further relief by the knife
is possible, the despondency is indeed pitiful—especially as ordinarily
one can only look forward to a sure and most painful death, at a not
very distant day. It is very difficult to convince many of these
patients that medical treatment, including diet, can do any good, so
firmly fixed is the idea that an operation is the only possible remedy;
many, therefore, get weary of the restraint necessary when immediate
results are not seen. And yet in my previous lectures I gave several
such cases to show that much can be done medically along these lines,
even in these distressing cases, and later shall hope to narrate other
instances, similar to those reported in my lectures two years ago.
It is undoubtedly true that some of these cases which are inoperable
when first seen could have been operated on at a much earlier period,
with as much success as follows in those in which this is tried. But we
have already seen in the last lecture how small a proportion of these
selected cases survive a long time; for we have yet to find statistics
regarding those who have been traced even as long as ten years. In my
previous lectures I reported concerning two patients with undoubted
cancer of the breast who had been watched for sixteen years, with no
trace of the trouble remaining, and two others who had been seen each
for nine years; these latter have been watched since, and have been seen
recently, eleven years after beginning treatment, with the same results,
all without operation. These cases had all been diagnosed as undoubted
cancer by competent surgeons, some eminent, and had refused operation,
which had been urged. Later I shall hope to relate other similar
instances of early cancer.
Inoperable cancer, comprising at least 50 per cent of all cases applying
to the surgeon, presents many features of interest and worthy of
consideration. The reasons for inoperability may be grouped as follows:
1. Those occurring in regions quite inaccessible, as in the brain,
esophagus, liver, pancreas, etc.
2. Those otherwise accessible, but which have advanced too far before
seeking surgical relief, occurring in many locations.
3. Those in accessible regions where experience has shown that
recurrence is pretty sure to take place, such as advanced cases in the
oral cavity, bladder, prostate, etc.
4. Those which have recurred after repeated operations, with extensive
spreading of the disease, as in many cases of the breast, uterus, etc.
5. Those with already very great metastatic involvement, in many
regions, presenting a true carcinosis.
6. Those in close proximity to or involving vital organs, blood vessels,
ureters, etc.
7. Those in which there are other reasons, such as advanced age, lowered
vitality, great cachexia, etc.
8. Those who absolutely refuse to be treated with the knife.
There is no necessity of troubling you with details as to the character
or appearance of inoperable cancer, which are dwelt on in standard
works, as our study relates rather to the causes of the disease and the
means of arresting its progress.
Nor need I dwell much further on this distressing aspect of cancer, for
I believe that all see the necessity of seeking some other measures than
operative surgery to aid in solving the question of relieving the
present condition of affairs. It is for this mass of otherwise hopeless
cases that any reasonable method of treatment is worthy of serious
consideration, both for the measure of relief which may be secured along
many lines by exactly the proper care, and especially for the
possibilities of its value in regard to prophylaxis.
Unfortunately it must be acknowledged that many claims, quack and other,
have been put forth in times past for remedies and measures which would
control or remove, and even cure, the disease in all stages. But the
failure of each in turn has very naturally discouraged many from
accepting any new proposition, and the profession and laity have almost
given up the hope for a real cure of cancer.
In the present instance, however, there is no attempt to present or urge
any single means or measure as a cure-all for cancer. But there has been
an endeavor to study the fundamental causes of the disease along
biochemical lines, and to meet intelligently the errors found. We have
seen cancer developing more and more as the ill effects of modern
civilization have manifested themselves, and have found that its
increase has kept pace coincidently with and even exceeded that shown by
certain other diseases, cardiac, arterial, and renal, which are
recognized as due to errors of living; and there is every reason to
believe that cancer is of the same origin. In a later lecture I shall
hope to show how some of these errors may be overcome, with the
consequent cessation of the cancerous process and even the disappearance
of the malignant lesion already formed.
RECURRENT CANCER represents only the continuance and further operation
of the internal or systemic causes which induced the formation and
development of the first lesion, and are a natural sequence therefrom.
Otherwise why should there be such an almost universal tendency of the
disease to redevelop either in the same or other localities? It is
granted, of course, that the very complete ablation of an early tumor
and its surroundings removes a focus in which disease has started, and
from which is generated a hormone or poison which tends to further lower
the vitality of the blood. But this does not by any means reach the
basic cause, as we saw in the former lectures.
In estimating, however, the real value of an operative procedure, which
has seemed to be successful for some period of time, we must also
inquire if there has not been some other cause which may account for the
absence of further cancerous deposits? It is more than likely, in
successful cases, that the previous occurrence of the disease and the
fear of recurrence have so modified the life of the patient in many
respects, that the primal cause is more or less removed. It is
incredible to believe that the mere removal of the portion of tissue in
which the systemic disorder has localized can forever prevent a new
focus from developing. As well might we expect that the removal of a
gouty toe, a tubercular deposit, or a late syphilitic gumma would
inhibit further manifestations of the disease.
Recurrent cancer, then, is but the result of a continuance of the
operation of the same causes which produced the first local lesion, and
need surprise no one, if those causes are left entirely unchecked and
the system unchanged. Undoubtedly in many instances the recurrence, or
increased production of the disease, is made more certain by the
operation itself; it is also recognized that handling or manipulation
then or at any time may also contribute to this, as may be understood
from the following:
1. Cancer cells, which have a reproductive capacity, may be forced into
the adjoining tissue, or find entrance into blood vessels or lymphatics
severed during operation, and there continue their activity and produce
new lesions.
2. By implantation, cancer cells, already started on their reproductive
career, may be transferred to freshly cut surfaces, and there may
develop new lesions, favored by the continued derangement of the blood
current.
3. Cancer cells may have existed outside of the immediate area which was
removed surgically, and so may continue to develop new lesions, being
further stimulated thereto by the manipulations attending the operation.
4. We know, finally, that the occasional removal of lesions which are
afterwards shown microscopically to be benign, such as adenoma, cysts,
chronic mastitis, etc., will sometimes be followed by the development of
true cancer, which will then pursue a malignant course.
On the occurrence, therefore, of any lump or lesion which might possibly
be or become cancer, the greatest caution should be exercised to avoid
all manipulation, lest a spread of the disease should render it more
rebellious to treatment. For in the medical management of cancer it is
naturally more difficult to cure a patient when there are large numbers
of diseased cells, in one or various locations, which are already giving
forth their poisonous hormone, vitiating the blood stream.
The New York Board of Health has recently inaugurated a service for the
examination of specimens excised from suspected cancer, in order to
establish the diagnosis microscopically before surgical operation. There
could hardly be devised a more effective plan to increase the mortality
from cancer and to render many more cases really inoperable than this
one would surely be; for by thus cutting into cancerous tissue and
opening lymphatic channels and blood vessels, with the opportunity for
absorption of cancerous elements during the necessary delay, metastases
would certainly be induced which would render a surgical removal or a
dietary and medicinal treatment immeasurably less effective. It is to be
hoped that this scheme will be immediately abandoned.
Recurrence of cancer is far more common during the first year after
operation than in any other single year, but, as we shall see shortly,
there is no time limit when the disease may not manifest itself anew. It
is understood, of course, that recurrence depends also largely on the
previous duration, extent, and malignancy of the tumor, and exact
statistics are very few and imperfect in regard to these matters.
It is well known that not long ago three years was considered as the
time at which, if there had been no recurrence, the cancer could be
considered as cured, and very many statistics have been based on this
period. But with further experience and closer observation, and with
more diligent following up cases, it was found that recurrences did take
place more or less frequently at subsequent periods, and now the time
limit has been arbitrarily extended to five years. This is because the
very large proportion of recurrences are in the first year, varying for
different locations and conditions from as high as 50 to 80 per cent in
different statistics.
But as the patients who have lived out the five-year limit are followed
up more carefully, it is found that recurrences do happen all along the
following years, so that they are recorded as occurring 6, 8, 9, 20, and
25 years after operation; I have met with many after 3 or 5 years, and
even as late as 15 years after operation. The vast majority of cases,
however, are not thus accurately followed out, much less reported, and
thus far we have few data on which to make accurate statements as to the
actual permanent cure of cancer by the knife.
Recurrent cancer, as one constantly observes it, is most deplorable, and
many who have had much to do with these cases realize that the distress
is often far greater than in other cases in which the disease has run a
natural course, without operation and under good medical guidance. The
pain attending growths in scar tissue is generally intense and commonly
requires anodynes continually and increasingly; these in turn, by
disturbing digestion and locking up the secretions, seem to augment the
disease. Even with these patients, however, very much may be done to
relieve their suffering by proper dietary and medicinal means, with
suitable local medication, as I have constantly seen, so that opiates
need be but little used.
METASTASES form a very considerable and important element in inoperable
and recurrent cancer, and we will briefly consider these. They occur
mainly through three channels: 1. The lymphatic system; 2. The venous
system; and 3. The arterial system. The permeation theory of Handley
relates to direct extension laterally through lymphatic spaces, and
belongs to the first mentioned means of extension. It is also believed
that metastases may be formed in the peritoneal cavity, and likewise in
the pleural cavity, by direct contact of cancer cells or pieces of
malignant tissue which have gained access to those cavities and have
been carried down by gravity and movement of viscera. They then become
engrafted on healthy tissue and form metastases there.
While holding firmly to the belief that the original cancerous growth
and other foci of disease are developed from a vicious state of the
blood current, there seems to be no reason for doubting that the disease
may also be extended in the manner above indicated. Although cancer
material cannot be inoculated from one person to another, or from a
human being to animals, nor from one species of animal to another,
experience and observation show that the malignant process can be
transferred from one organ or structure of the same individual to
another part or structure, whether there has been a surgical operation
or not.
The lymphatic system is apparently the first means for the spread of the
malignant process, and all are familiar with the lymph nodes seen in the
neighborhood of cancerous masses. It is supposed that these are caused
by the lodgment of detached cells which have taken on the abnormal
reproductive action which characterizes cancer. As with other foreign
bodies, pus cocci, etc., the minute lymphatic glands seek to arrest
their passage into the circulation, and it is probable that some of them
are destroyed there, for the single enlarged gland will often remain for
a long time as the only manifestation of metastasis. In many cases,
where the original cancer has disappeared under dietary and medicinal
treatment, the enlarged glands also disappear, as I have seen many
times.
When the disease is unchecked, however, the glands fail in their
endeavor to protect the system and continue to enlarge one after another
along the line of the lymphatics, and the lymph stream then carries
certain cancer elements through the thoracic duct into the venous
circulation; thence they reach distant parts of the body, through the
arterial system, and, being lodged in capillaries, a more or less
general carcinosis results. Cancer elements can also proliferate along
lymphatic tracts, and, furthermore, they may enter the venous and
arterial systems directly by the invasion of a malignant growth.
All these and other points regarding the metastasis of cancer form a
very interesting study, but time does not permit of further elaboration.
All know that while primary carcinoma of the liver is very rare, its
secondary or metastatic involvement is very common. The bones, lungs,
spleen, kidney, and viscera generally are all often found to be the seat
of metastases, and in general carcinosis, which has lasted some time,
metastases will be found abundantly both in the lymphatics of many parts
of the body and in many organs and tissues. Metastases in the lungs are
not uncommon in breast cancer, as also metastasis in the bones of the
thorax. In the last lecture reference was made to the frequency of
metastases in the skeletal structures of the body, which probably have
much to do with the pernicious anemia which carries off the patient.
An interesting study relates to the extension of the carcinomatous
process in the skin; this occurs at first near, and then around, and
even at a distance from the site of an operation, especially after
removal of the breast. These nodules are at first small, and felt deep
in or below the skin, and are not colored. They steadily increase in
size, and when about that of a small pea, they become red and elevated a
line or so. Later they may appear more numerous and even involve a large
area, forming the so-called _cancer en cuirasse_, and may ulcerate.
Sometimes single lesions of some size may appear here and there, even
some distance from the site of the original tumor, and may not be
colored. While these may represent lymphatic infarctions, it is often
impossible to trace any direct connection with lymph ducts, and they
more probably arise from capillary deposits of cancerous elements. I
have frequently had these scattered cutaneous lesions excised, in cases
under medical treatment, with a view of removing mechanically some of
the foci from which the disease could be spread. The wounds have
invariably healed promptly and perfectly, and no carcinomatous process
has resulted.
The BLOOD IN CANCER has been studied mainly in reference to its solid
constituents, and very little in regard to its plasma; whereas it is
from the plasma that the blood corpuscles are formed, and this is the
principal agent in the development and nutrition of tissues, normal and
malignant. For it is to be remembered that the chyle is discharged
directly into the venous blood current, and the venous radicles absorb
much of the nutritive material directly from the abdominal organs. The
plasma, therefore, carries with it constantly a varying quantity of
partially assimilated material to be oxidized in the lungs, and slowly
purified by the agency of the kidneys; the serum albumen and serum
globulin are also active agents in the formation of tissue, malignant or
other. There is great need of laboratory studies along these lines, and
also on the alkalescence of the blood, which we found to have a marked
diminution in cancer.
We know also comparatively little in regard to the origin and
destruction of the cellular elements of the blood, and can only depend
on the microscopic examination of their forms and appearances in health
and in many conditions of disease. These have been abundantly studied
morphologically, but mainly in the more severe forms and later stages of
cancer, as detailed somewhat in my former lectures. Enough was there
quoted to show the continued degeneracy of the blood after a cancerous
growth had acquired some progress; there has also been observed some
improvement for a while after the removal of a tumor, evidencing the
deleterious effect of the hormone secreted by a cancerous mass.
The laboratory study of the blood from 22 of the cancer patients in the
New York Skin and Cancer Hospital under my care, has been instructive as
well as valuable along certain lines. In most of them it was made
weekly, and often over long periods of time, and the results tabulated
for easy comparison, in order to study closely the condition of the
patient and the effect of remedies. No very startling revelations were
made by these blood studies, they confirmed in the main the observations
of others, though some interesting facts were learned from an analysis
of the data. They referred to ten cases of cancer of the breast, four of
the stomach, two of the uterus, one of the rectum, one of general
abdominal carcinosis, and the rest in scattered locations.
The lowest hemoglobin index was 35, with 2,800,000 red blood cells, in a
woman aged 59 with cancer of the stomach. The next lowest hemoglobin
index was 45, with which the patient, aged 53, died, with inoperable
cancer of the right breast; the blood count showed 3,700,000
erythrocytes, and 10,400 white blood cells, 76 per cent of which were
polynuclear. During the course of observation, covering several months,
the red blood cells were once 2,100,000, but under careful treatment
rose to 4,110,000 not long before death. The next lowest red cell count
observed was 2,200,000, with 12,000 white blood cells, and 65 hemoglobin
index, in a man aged 52, with a terrible inoperative cancer of the cheek
and neck, of which he died.
The highest red cell count made was 5,400,000, in a case of cancer of
the uterus, in a patient aged 52, the count being 4,064,000 on entering
the hospital. The highest hemoglobin index was 90 in a number of severe
cases, and 100 in one case of sarcoma, to be detailed in the next
lecture. In one recurrent case of cancer of the left breast, which was
very distressing at first, the patient died peaceably and without pain,
with a hemoglobin index of 90, and 4,900,000 red cells, and 7,400 white
cells, of which 75 per cent were polynuclears, 17 per cent small
lymphocytes, and 7 per cent mononuclears. Her hemoglobin had been 70 per
cent on entering the hospital with 3,360,000 red cells. The highest
leukocyte count observed was 18,600 in a case of inoperable cancer of
the right breast, not long before death, in an unmarried female of 53;
but in the course of treatment it had fallen to 6,200, about normal,
from 10,520 before beginning treatment.
I will not weary you with more of these figures, which are interesting
and instructive as one studies them week by week in connection with the
physical condition of the patient. However much can be done for these
distressing and inoperable cases of cancer, one has to acknowledge that
when general carcinosis has set in we are still helpless in arresting
the lethal progress of the disease, although very much can be done in
prolonging life and alleviating suffering; and this does not mean with
morphia or codeia which in the end does harm, and was very seldom
administered to the patients referred to.
Forbes Ross, after ten years of constant microscopic clinical and
surgical research, has made some interesting observations, covering many
pages, on the blood of cancer patients, which have a close bearing on
our subject, and to which I can only briefly allude, and I do not know
if I can make it clear in the time I can give to the subject. By long
study of sections of carcinomatous tissue he claims that the mononuclear
leukocyte behaves in a very different manner from the polynuclear.
Briefly he charges the mononuclear white corpuscles with actually
producing the disease, by conjugating with certain epithelial cells,
thereby giving them the reproductive capacity which enables them to push
forward on their destructive career. The polynuclears seem to come up to
the defense of the body, but are overcome by the poison secreted by the
rapidly growing tumor cells.
The red blood cells he also finds, with other observers, nucleated more
frequently in cancer than in any other form of secondary anemia, and
subject to a change of composition, and deficient in lecithin and
nuclein. He shows the importance of potash, which we shall later find
clinically of such great value in cancer, and I cannot do better than
quote some of his words: “How vitally important potassium salts are to
the red corpuscles is shown by the following: One thousand parts of red
corpuscles are found to contain six hundred and eighty-eight parts of
water, three hundred and eight parts of organic solids, and eight parts
of mineral. Of these eight parts three and one half are of potassium
chlorid, two and one half are potassium phosphate, and decimal one
potassium sulphate; the remaining 1.9 parts are divided between the
iron, sodium, calcium, and magnesium, comprising the rest of the
corpuscles. More than three quarters of the total mineral ash of the red
corpuscles is, therefore, composed of potassium. This fact is an
important one, and the reader is earnestly requested to bear it in
mind.” Later we will again see some of the valuable clinical suggestions
which arise from his researches.