proper local medication is very important. The ordinary micro-organisms,
finding a suitable nidus, very readily germinate and add greatly to the
suppuration, and consequent exhaustion 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, and shrinking up the
granulations. Ichthyol, 10 to 25 per cent. in water, and permanganate 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 solution, 1 to 2 per 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
elements they should never be neglected. Ichthyol ointment (℞ Ichthyol
ʒss-ʒi Zinc Oxid ʒss Unguent. Aquæ Rosæ ℥i) 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 week
in connection with other medical treatment; radium can also be of real
service 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
progress 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 question but that with the adoption of proper dietary
and medical treatment, even from the first suspicion of a malignant
growth, and before, as also after operation, the final results of
operative procedure will be even far better than have been yet attained.
LECTURE VI
CLINICAL CONSIDERATIONS AND CONCLUSIONS
The test of everything lies in the results obtained. Theories,
discussions, and arguments are all unavailing unless results show their
truth. In medicine, however, it is sometimes difficult to demonstrate
results until after the lapse of time, as was well illustrated by the
preposterous claims first put forth for “606,” which is gradually
attaining about its correct status. The same is true in regard to the
surgery of carcinoma, where operations which formerly were attended with
very 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 justified in any operation he had
performed on 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.
Murphy of Chicago, has also repeatedly expressed himself most
pessimistically in regard to the ultimate results of the surgical
treatment of carcinoma, especially in those patients who are fat, and
with lax tissue, that is, exhibiting evidences of imperfect metabolism.
Dietetic and medical treatment of cancer, 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 have recovered spontaneously,
that is, without surgical interference, and often really to the surprise
of the medical attendant: 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 believe that it is to be
found in what has preceded 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 latter light
would be thrown on the etiology of carcinoma, which, as we know, is a
disease of epithelial elements; and the earlier Report of the Hospital
shows but one department, including Cancer with Skin Diseases, with
operating surgeons and a gynæcologist to assist, whenever their services
were requested by the physicians in charge. Before long, however, for
reasons which cannot now be given, and against the judgment of the
present speaker, the plan was changed, and a separate cancer department
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 removal.
For thirty or forty years I have held very much the same views regarding
cancer which have been presented in these lectures, and have acted on
them more or less strongly, and in later years very stringently, and
have rarely seen cause for regret. 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, in which 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 private practice I find that I have
more or less complete records of 96 cases of carcinoma, 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
consultation, 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
number of cases of recurrent carcinoma in the New York Skin and Cancer
Hospital, which have been submitted to very careful laboratory study,
some of whom have exhibited 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 analysis 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 results. 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
medicinal measures of the character now being considered, and that it is
my custom to treat such in the same manner; for reason would seem to
show that the same causes would produce abnormal proliferation of
epithelial elements on the cutaneous surface 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
operated on surgically before adequate treatment had been employed; many
of these were earlier cases, or those seen in consultation. 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 naturally 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 a biopsy, even before surgical removal,
and manifestly improper where this is not undertaken; but in most of the
cases there was the independent diagnosis of one or more other medical
men, and many of the patients came to me on account of threatened
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 uncertain 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 average
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 the better the 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 process is well under way its cells
secrete a something which hastens the general depravement of the system,
and quickens the growth of the neoplasm, and naturally greatly increases
the difficulty of overcoming the dyscrasia.
Thus in the effort to get at and remove all possible or prospective
cancerous lesions, many innocent or non-malignant adenomata, etc., are
operated on, which are afterwards found to be such microscopically. 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 which have been excluded from the carcinoma 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 frequently have done, it
is a better and more desirable result than if they had been removed 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 accomplished toward checking the cause producing the
offending lesion. But the very fact of the frequent recurrences after
operation, 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 measure of success which has
followed the noble efforts of our distinguished surgeons, only it is to
be hoped that hereafter other measures will also be more commonly
adopted, looking towards a prevention of the recurrence 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
defined, 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, who pronounced the tumor as undoubtedly
cancer, and urged its instant removal; this I did not know until she
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 menopause, 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 absolutely no breast trouble, and for eight years
later, while he himself was under occasional treatment, I learned
repeatedly that she remained still perfectly well, over sixteen 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 cancer by three medical
men, and one of them, a surgeon of prominence, had arranged for
immediate surgical removal the next day. 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 entirely disappeared. A month or two later she had some
pain in the breast, in connection with the menstrual disturbance
accompanying 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 five 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 October 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 for some months, with also a numb,
shooting 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 palpation, 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 under great strain of work,
mental and physical, as a city missionary.
Another very similar case was in the person of Miss G. M., aged 44, who
has been under constant observation and treatment off and on for various
troubles from November 13, 1905, until yesterday. Fifteen 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
menstruation, which had continued until her visit, and for the last
months she had been kept from her work in school, the pain being severe
in the breast, and more recently in the axilla: in July there had been
bleeding from the nipple. She had seen a number 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 between two and three inches in
diameter, in the upper, inner segment of the left breast, 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
previous 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 almost 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 public 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 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
exhausting 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 carcinoma, after operation, of which I have had a
number of cases with varying results, according to the duration and
severity of the disease.
Miss H. M., aged 61, came to me June 21st, 1913, with the following
history: About two years previously a lump appeared in the outer, lower
segment of the left breast, which was removed in August, 1911; this
healed soon, leaving a good axillary scar, and there was no thought of
trouble until two months before her visit, when a small red spot
appeared near the edge of the sternum. This 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 center 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 new ones have formed, several of
which have been removed under local anæsthesia, 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 patient has lived comfortably and
without pain for almost sixteen months after coming under treatment,
and, although she has lost some flesh, the active cancerous process,
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 treatment, 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 recurrent cancer in the Hospital
which had been under active medical treatment during the past year, with
careful laboratory studies, but it is naturally too early to report
anything very definite in regard to them, especially as most of them
were desperate cases, which had advanced far beyond any possible
operative relief. Moreover 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 restraint seems also
very irksome and useless 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 healed and left a tumor
the size of a pigeon’s egg in the inner, upper 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 egg, 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 incision, from the second to the fourth rib, with many
nodules around it, averaging a third of an inch 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 enormously swollen and
helpless. When she left the Hospital, June 20th, 1914, the ulcer had
entirely closed, many of the cutaneous 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.
While in the Hospital careful laboratory investigations were made,
according to a definite schedule. The _blood_, studied weekly,
maintained a hæmoglobin 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 months to 4,282,000, then fell a little and rose again to
almost 4,000,000: the leucocytes 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 proportion of the
other forms remained about normal. The _urine_, volumetrically analyzed
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 normal, and sometimes above, the chlorides
were diminished, owing to the rather small amount of food taken, the
phosphates varied a little above and below normal, there was never any
indican, and the sulphates averaged a trifle below normal. The _saliva_,
tested before and after each meal, was acid at first, but became neutral
and alkaline off and on. The _weight_, taken weekly, fell a little from
the first, but maintained a good level, and rose a little before she
left the Hospital.
This was a very difficult patient to manage, as she was a very ignorant
Polish woman, who often rebelled at the diet, and wearied of the routine
and restrictions imposed; she left the Hospital June 20th, 1914, against
my wish, but with as great a change in her physical condition and
disease 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 operations, deserves mention, although it will be some time before
any decisive result can be reported.