Part 7

When considering the metabolism of cancer mention was made of derangement in the action of the ductless glands in this disease, and of the use and value of certain preparations of the internal secretions in its treatment. While a hormone therapy of cancer is still in its infancy, in spite of many books and innumerable journal articles on the internal secretions, it is quite possible that the future may demonstrate its efficacy in helping to control the disease: for, that the latter are efficient agents in carrying on the vital processes in the body, there can be no question, although as Biedl remarks, “Our knowledge of the chemistry of hormone formation is very slight.”

But considerable clinical evidence has been accumulated that one at least of the internal secretions, namely, that of the _thyroid_, has a definite beneficial effect upon cancer; this I have administered to many cancer patients, and have reason to believe that it contributed to the favorable results obtained. Sajous, believing that insufficiency of the adrenal secretion is an element in altered nutrition, advocates thyroid extract on the ground that it stimulates the activity of the adrenals: Vincent quotes Erlich as believing that “there may be substances circulating in the organism which may stimulate the body cells to resist the athreptic influence of cancer cells.” Shirlaw advises a tablet made of thyroid 6 grains, supra-renal ¾ grain, and pituitary 1/16 grain. While the treatment by these hormones from internal secretions is really in rather an experimental stage, it would seem more than probable that the correct use of these pluriglandular extracts, in combination with other proper dietary and medicinal treatment, would be of service in the prophylaxis and treatment of cancer. I have been a little cautious in the use of thyroid, beginning with two or three grains with meals, three times daily; for, as a promoter of catabolism it can disintegrate tissue faster than the emunctories can remove the effete products, and may thus poison the system.

Serum- and Vaccine-therapy are yet in a stage of development, and as I have had little or no personal experience with them I will not attempt to discuss their value, which time alone will demonstrate. While there have been many claims of success from treatment along these lines, unfortunately they have not been confirmed by later observations by others: I may say frankly that they have never appealed to me as rational, in consideration of the views and experience I have long had along other lines of thought and practice. If, however, future investigations shall confirm some of the remarkable reports which have been made, the latest of which is by Nowell, there may be opened a non-surgical line of treatment of cancer which would mean much to many otherwise hopeless cases.

The _local medical treatment_ of cancer is also an important matter which should receive careful attention. For many years in early cancer of the breast, under proper, general, dietetic, hygienic, and medicinal treatment, I have seen the lump vanish under the continued application of the iodide of lead, in Hebra’s diachylon ointment of the German Pharmacopœia (ʒss-ʒi ad ℥i), and in very many instances I have had the assurance of patients that its application relieved the pain and was of the greatest benefit also in axillary and other metastases. In other cases the continuous painting with ichthyol (50 p.c. in water) has seemed to be of great service, in combination with other proper treatment: all of this in earlier cases, before ulceration has occurred.

After ulceration has set in, either in primary or recurrent cases, 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.