In my lectures given here two years ago I considered, as far as I could in the time allowed, the nature of cancer,^[1] and the evidence in favor of its being a medical rather than a purely surgical disease; and in order that the trend of what shall follow may be clearly understood, brief reference may be made to some of the principal points studied and developed in the preceding lectures. To this end I may restate the conclusions presented at their close, as developed in the lectures, perhaps with some alterations or additions which two years’ further study, observation, and treatment of cancer may suggest.

1. Cancer is but a deviation from the normal life and action of certain of the ordinary cells of the body, which, for some reason, difficult to understand, take on an abnormal or morbid action: with this there is a continued tendency in them to a malignancy which invades contiguous tissue, associated with a pernicious anemia which in the end tends to destroy life.

2. There is some reason to believe that this diseased action first takes place in what are known as “embryonic rests” or pre-natal, wrongly placed tissue elements. These latter, however, are now shown to exist in every individual in many localities, but the reason why at some particular time they take on this malignant action, and form cancer, has not yet been satisfactorily explained.

3. Cancer is not wholly due to traumatic causes; although these may play a not inconsiderable part in its occurrence in certain localities and cases.

4. It is pretty conclusively decided that cancer is not caused by a microörganism or parasite; although various forms of these have been found in connection with the disease, and each has been claimed as the cause of cancer.

5. It is known clinically and experimentally that cancer is not contagious.

6. Nor is it hereditary in any appreciable degree; although certain rare instances have been reported in which such seems to be the case, and though some tendency in that direction has been demonstrated in certain strains of mice.

7. Occupation has not any very great influence on the occurrence of cancer; although it is more frequent in some pursuits than in others.

8. Cancer is not altogether a disease of older years; although its incidence is greatly increased with advancing age.

9. Cancer does not especially belong to or affect any particular sex, race, or class of persons. It is, however, more frequent in females than in males, although of late years the proportion in the latter is steadily rising.

10. Cancer is not confined to any climate, location, or section of the earth, but has been observed in all countries and climates, though with different frequency.

11. No single cause of cancer has yet been demonstrated; nor is it likely that this will ever be the case, as experimental and other investigations have covered almost every possible line of research, with only negative results.

12. The exclusion of almost every other possible cause of cancer, as well as its pathological history and biochemical studies, all lead, therefore, to deranged metabolism as the only remaining possible etiological element. This latter acts by inducing changes in nutrition, and these in turn depend on diet and the proper or improper action of the secretory and excretory organs; these latter may, still further, be affected by nervous influences.

13. While the biochemistry of cancer does not as yet throw very great light on its true nature and cause, enough has been determined to show that the morbid changes in the cells are largely associated with deranged metabolism.

14. The blood in advancing cancer manifests changes which indicate vital alterations in the action of the organs which form blood and control the nutrition of the body and its cells.

15. Clinical and experimental evidence demonstrate that the secretions and excretions of the body exhibit departures from normal; these, while not wholly pathognomonic of cancer, still indicate metabolic disturbances which involve the nutrition of the cellular elements, and these disturbances are of importance.

16. The evidence seems certain that the cancer mass, when fully developed, secretes a hormone or poison which tends to augment its own growth, and hastens the lethal progress of the disease.

17. The mortality from cancer is undoubtedly on the increase in every portion of the globe, in spite of the assiduous activity of the laboratories and the immense advances in surgical procedure.

18. This increase in mortality is seen to vary inversely, and in about the same proportion, with the steadily diminishing mortality of tuberculosis, under recent careful medical guidance.

19. The increase of cancer mortality is found to follow closely along the lines of modern civilization.

20. The extension of cancer appears to depend largely upon the altered conditions of modern life, particularly along the lines of self-indulgence in eating and drinking, and indolence.

21. The augmentation in the consumption of meat, coffee, and alcoholic beverages in civilized communities is seen to be coincident with the great and proportionately greater augmentation of the mortality from cancer.

22. The nerve strain of modern life seems to be an element of importance, both through disturbance of metabolism and by direct action on morbidly deranged cells.

23. No single remedy for cancer has been, or will probably ever be, discovered, since it is conceded that there is no single cause for the disease. The history of cancer abounds in the heralding of various vaunted remedies, quack and other, including sera, whose employment has only ended in the disappointment of medical men and in the deluded hopes of innumerable sufferers.

24. Modern surgery has materially improved the statistics relating to the immediate results of operative procedures; but the total achievements along this line are insignificant when compared with the steadily rising death rate, and ultimate mortality of about 90 per cent of those once afflicted with cancer.

25. Surgery has had, and may yet have, its function to perform in removing some of the products of the constitutional state causing cancer, more or less efficiently, curing some patients and prolonging the life of others; but from past experience it can never hope to lessen the morbidity of cancer. The reason for this is that it attacks a symptom only, and not the underlying cause.

26. The X-ray and radium, as also caustics, are in the same position as surgery, and can do little more than cause to disappear, more or less temporarily, some of the lesions which have developed from causes which they cannot reach.

27. With all these means the measure of success, aside from the technical skill of the operator, depends largely on the duration and the extent of development of the malignant growth before treatment: the earlier such local treatment is undertaken, other things being equal, the greater the possibilities of success.

28. The same is true in regard to the treatment of cancer by dietary and medical means. The earlier the morbid constitutional process, or state, leading to tumor formation is attacked by proper dietetic, hygienic, and medicinal measures, the greater the promise and expectation of success, present and permanent.

29. The cure and prevention of cancer, therefore, and the checking of its increasing occurrence and mortality, depend largely upon the early adoption of such measures as will limit the agencies which induce the formation of the new growth: these are certain derangements of the body juices which tend to bad nutrition and disturbance of the action of the body cells.

30. The simple life, with the avoidance of the dietetic and other causes which have been found to induce cancer in nations and individuals, promises the best hope for the arrest of its rapidly increasing development and mortality throughout the world.

31. It is more than possible, however, that the long continued operation of many baneful causes has produced such a degeneration of tissue in the human race that it will take a generation or more of proper living to make the beneficial impression on the general occurrence and mortality of cancer which is so longed for.

It is quite impossible and unnecessary to elaborate again the facts upon which these conclusions are based, which were given very fully in my previous lectures and book; but we may briefly consider some of the features just presented, and some of the evidence why cancer should be considered from a medical rather than a surgical standpoint. For it must be conceded that both the general medical profession and the laity still regard the disease as belonging to surgery, and look only to the knife for any hope in its treatment. In spite of all that has been done the present outlook for the checking of its rising mortality by this means, and for the prevention of cancer, is bad indeed, as will be shown in a later lecture.

But, gentlemen, many great surgeons, in past and present time, as quoted in my former lectures, have acknowledged verbally and in writing their inability to cope with cancer as a disease, and have recognized time and again that they operated only because they knew of nothing better to do. Often it is acknowledged that the operation is only palliative, in the hope, alas, how often futile, that some good might result from it, in the chance that the dread disease would not return. We shall see later, when we come to study the mortality of cancer in various locations, and an analysis of surgical statistics, how slight the foundation is for such hopes.

Both in the past and present times many surgeons of eminence, well acquainted with the disease, whom I quoted in my former lectures, have also more or less casually expressed the conviction that there was some deep-seated constitutional cause of cancer which baffled recognition, but which must have to do with the diet or mode of living of those afflicted. The most recent of these is Dr. William J. Mayo, who has spoken in no uncertain terms along this line, in a recent address as President of the American Surgical Association. And yet how relatively little intelligent effort has been put forth to discover and amend these conditions, and to remove the bodily derangement which eventuates in the formation of the foci of disease which later become malignant and form what is called cancer, or to modify the blood changes which ultimately destroy life!

In a long experience I have seldom, if ever, come across a patient with cancer who had had any intelligent and prolonged attempt to check its development by dietary, hygienic, and medicinal means; invariably the knife, X-ray, and radium have been the only measures under consideration. Also, after an operation the patient is dismissed, or watched for a recurrence and again operated on, with no prolonged effort to so modify the constitution that the same causes shall not reproduce the malady in the same or other localities. And yet I have narrated to you cases of undoubted cancer, verified by competent surgeons, who urged instant removal, which had entirely disappeared without operation under the line of treatment detailed, and who remained in perfect health for many years, sixteen in two instances. I also reported cases illustrating the beneficial result of dietary and medicinal measures in cases recurrent after operation. This matter will be more fully considered in a later lecture, with further illustrations.

We may now consider some general matters bearing on the question of a medical rather than an exclusively surgical aspect of cancer.

The founders of the Index Medicus placed cancer among the diseases of metabolism, along with gout, obesity, chronic rheumatism, diabetes, and a few conditions of minor importance. This grouping of cancer in no wise interferes with the idea that a chronic local irritant may be the exciting cause of the local development of the tumor, which becomes malignant, in any particular situation; any more than what is observed in the case of late syphilis, where a gummy tumor or a bone lesion may appear at a point of injury, or where gout will develop in a joint which has been bruised.

But it does show that broad medical thought has long recognized that cancer is not a purely local disease, but that it arises from some disturbance of nutrition, tending to localize in some particular spot, even as a neuralgia will occur in some special nerve and be reached, not by local measures, but by those of a general nature. Repeated casual observations have often been made by clinicians, and even by surgeons of prominence, of the apparent relations between cancer and gout or rheumatism, and also diabetes, and all recognize the rebelliousness of cancer when it occurs in connection with obesity. The late Dr. John B. Murphy was very strong in regard to this latter point. The constant occurrence of cancer in rheumatic individuals is a very striking feature, which I observe almost daily.

It is worthy of remark that cancer begins to appear at a wholesale rate at the age when metabolism begins to slow up, and some time after the body growth has become fully established. At this period people are apt to lose the balance between physical effort and the intake of food, eating as much as ever, perhaps more, while becoming more sedentary. At the same time the emunctories become less active. The various affections of metabolism now tend to appear and are associated with imperfect oxidation, or diminished tolerance toward certain ingesta. It is interesting to note that in a study of many thousand cases of eczema I found the disease to be actually more frequent, in proportion to those living, between the ages of 50 and 55 than at any other period of life after the infantile period, or the first five years of life; just about the same time when cancer is most common. And the constitutional conditions at the bottom of eczema are very much the same as those in cancer.

Patients with a cancer just beginning will often, or even generally, seem to be in excellent health. It is indeed remarkable to observe how commonly patients with beginning breast cancer will seem to be in a splendid condition of health. They are ruddy and blooming in appearance, and when the lump is first discovered it is hard indeed to believe that if the erroneous life processes which caused the cancerous lesion to develop are not checked, the patient will before long succumb to the direful disease. Williams remarks that “such types are indications of hypernutrition.”

But a most careful study of these patients in every particular will so constantly reveal such errors of life and derangements of metabolism that these must be looked upon as contributing causes, at least, to the development of the local condition which later becomes malignant; in the same way as the patient will appear to be in blooming health just before an attack of acute gout. For when these conditions are rectified by proper dietary and medicinal measures the local cancerous condition not only ceases to develop but actually disappears without surgical removal, as I have repeatedly shown you. These errors and derangements are not commonly evident on a superficial examination, and often are recognized only after very painstaking search, and re-search.

We have not yet arrived at such a clear knowledge of metabolism as to understand just where the fault lies in these cases of seeming perfect health, with the beginning of a neoplasm which may eventuate so disastrously. But we do know that what passes for good health is often fictitious, and is quite compatible with even grave disorders of various kinds. It is more than possible that the apparent well-being of the patient with beginning cancer, which is often observed to be associated with uricacidemia, points also to the correctness of our thesis in regard to its internal causation. As remarked in one of my former lectures, quoting Ribert, “no one has ever seen the beginning of mammary cancer” and no one will ever see the beginnings of cancer of internal organs.

But, whatever may be thought of Haig’s theories or statements regarding uric acid, there is no question but that many maladies of many kinds have their origin in the concatenation of processes which has long been recognized clinically as lithemia. Personally I believe that sooner or later it will be generally recognized that the starting point of cancer occurs in some cell or cells, previously normal, probably as the result of local irritation, in which there is a deposit of some of the elements of faulty nitrogenous partition, induced by undue ingestion of animal protein: and that the malignant, reproductive process in the cells is kept up by a continuance of the same supply of imperfectly disintegrated nitrogenous matter.

The condition of the urine furnishes a most invaluable indicator and guide as to the systemic derangements and their correction. This has not reference to the presence of sugar, albumin, or casts, but rather to other features, reflecting the manner in which metabolism is performed. This subject was gone into pretty thoroughly in my former lectures, but must be briefly considered here, because of the great importance of the subject.

It is well known that, while the products of the digestion and disassimilation of carbohydrates and fats pass off by the lungs, generally without harm, those of protein and salts are eliminated by the kidneys, and may be the cause of various systemic derangements. The urine, therefore, when most carefully analyzed volumetrically, exhibits in the clearest possible manner how the metabolism is carried on and where the error lies.

From a study of hundreds of complete volumetric analyses of urine in dozens of cancer patients, both in the very early and late stages of the disease, I have found that this excretion almost invariably exhibits departures from normal which are significant.

First to be mentioned is the relation of the total solids excreted daily to the body weight of the individual; for it is evident that a person weighing 200 pounds should pass off more than a smaller person. The following table represents fairly well the total solids that should pass daily in order to maintain a healthy equilibrium:

These figures do not represent much active exercise, and with increased bodily exertion the solids passed should be more. Men excrete about one-tenth more than women; there are also less urinary solids passed with advancing age, and about five per cent may be deducted for each ten years after forty.

The estimation of the total solids is easy with Haines’ modification of Hasser’s method. Multiply the last two figures of the specific gravity of the urine by the number of ounces voided in 24 hours, and add ten per cent to the product. Thus, if the amount passed in 24 hours was 36 ounces with a specific gravity of 1.021, it would be 36 × 21 = 756 + 10 per cent = 832 grains of solids in the whole amount of urine excreted that day. By comparing this with the table it can be readily ascertained if the amount is above or below the normal standard for the body weight of the patient. For many years I have employed this method of determining the urinary output in hundreds of patients with various diseases of the skin and cancer, and have found it of inestimable value. It is understood, of course, that by dietary and medicinal measures the urinary solids are to be brought up to and maintained at normal.

The actual acidity of the urine, as measured by the oxalic acid and phenolphthalein test, is also of the greatest importance. This is not difficult of application and is daily used in my laboratory; the litmus paper test is of relatively little value in comparison with an actual chemical measurement. Thus, with an average standard of 300 we not infrequently find an acidity of 500 or 600, or even 1000 or more, or it may sink to 200 or 100, or even be strongly alkaline. In cancer I have striven, by diet and remedies, to keep it a little below normal, as it has been shown that the blood in this disease exhibits a constantly increasing tendency to diminished alkalescence, or, wrongly called, increased acidity.

But further and very careful volumetrical urinary analysis is very important to determine and maintain the metabolism in its proper condition. Time does not permit such an elaboration of this subject as might be desired, and I can only call your attention briefly to some of the points brought out in my former lectures.

Many observers have found the nitrogenous disintegration very imperfect in cancer cases, and oxyproteic acids are increased and even that in very early cancer. An increase of amino-acid nitrogen was found by Reid in practically every case studied. Others have found an increase in colloid nitrogen, to more than double the normal amount, and also increased elimination of xanthin and urinary ammonia; so that all observers testify to a disturbed nitrogen partition in cancer. The elimination of urea is certainly greatly diminished, even in early stages and when on a full diet, as I have almost invariably observed.

The sulphur partition is also found to be imperfect, in new and old cancer cases, and even a great increase in the urinary discharge of sulphates is constantly noticed in my analyses. Associated with these errors in the nitrogenous and sulphur element is the very common and persistent increase of indican, showing stasis in the small intestine, with bacterial putrefaction.

Imperfect intestinal elimination is constantly observed in cancer cases, both habitually and in the very early, formative period, and also later, even before any recourse to morphin, which, of course, heightens the trouble. In recording the statements of these patients I have been so struck with the almost invariable history of constipation before the first appearance or suspicion of the cancer that I cannot help feeling very strongly the possibility that the toxins produced by the millions of microörganisms, generated through intestinal stasis and fecal putrefaction, play a great part in the production of that blood dyscrasia which culminates in the formation of the malignant new growth.

I mentioned to you last year that in hundreds of tests of the saliva in cancer patients the reaction was found to be acid almost invariably, until corrected by dietary and other treatment. I have this test made and recorded daily, half an hour before meals and half an hour after meals, on my cancer patients in the New York Skin and Cancer Hospital. I have also the urine volumetrically analyzed each week, and the results all tabulated in columns on the history sheet, so that the changes may be compared weekly, in regard to each constituent, as treatment progresses. The same is done with the weekly studies on the blood, which I hope to present in full before long.

I think, gentlemen, that from what I have said you can see that the medical aspects of cancer loom up pretty large, and yet we are only beginning to study the disease along these lines. We see, thus, that cancer is not primarily a surgical affection, and that the mere ablation of an offending portion of the body which has become diseased can never preclude a new portion from becoming affected, or prevent a recurrence in the same location; indeed, this often seems to be stimulated and increased by the trauma and by the deranged lymphatic and vascular circulation caused by the operation and the dissemination of actively growing cancer cells through these channels. This will appear more fully later when we come to study the increasing mortality of cancer during these later years of active surgery, and when we come to analyze the actual reports of operative procedures.

I hope, gentlemen, that by these lectures I may succeed in satisfying your minds that if anything is to be done towards staying the steadily rising frequency and increasing mortality of cancer, it must be by carefully wrought out medical means, and not by the knife.