Cancer of the Breast 
WITH A STUDY OF TWO HUNDRED AND FIFTY 
CASES IN PRIVATE PRACTICE 
BY 
L. DUNCAN BULKLEY, A.M., M.D. 
SENIOR PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL. CONSULTING 
PHYSICIAN TO THE NEW YORK HOSPITAL, LATE MEMBER OF THE AMERICAN 
ASSOCIATION FOR CANCER RESEARCH, MEMBER OF THE AMERICAN 
ASSOCIATION FOR THE STUDY AND CURE OF CANCER, ETC. 
WITH FORTY ILLUSTRATIONS 
PHILADELPHIA 
F. A. DAVIS COMPANY, Publishers 
1924 COPYRIGHT, 1924 
BY 
F. A. DAVIS COMPANY 1 
Copyright, Great Britain. All Rights Reserved 
PRINTED IN U. S. A. 
PRESS OF 
F. A. DAVIS COMPANY 
PHILADELPHIA. PA. PREFACE. 
To write another book on Cancer of the Breast 
would seem to many superfluous, with the dozen or 
more good surgical books on the subject, now before 
me. But the aim of the present book is quite differ- 
ent from any which have preceded it. The latter 
have aimed only at the physical removal of certain 
lesions which may appear in various parts of the 
body, without any attempt to reach the real cause of 
their production, or to provide any means of pre- 
venting their recurrence, which so frequently hap- 
pens after surgical procedures. Moreover, the ulti- 
mate results in cancer, in general, from the present 
methods of treatment have been so unfortunate, the 
mortality in this country rising so steadily and alarm- 
ingly, with an acknowledged mortality of 90 per 
cent, of those once affected, that all are hoping for 
some relief. 
The attempt has here been made in the following 
pages to study the disease along entirely different 
lines, and to present a course of treatment which 
has been followed out for over forty years and which 
has yielded far better end results than those ordinar- 
ily observed under other plans of treatment. 
III IV 
PREFACE. 
In order to properly understand and follow this 
line of treatment it is necessary to look at cancer 
from an entirely different standpoint than is common. 
True, internal cancer is not a purely local disease, 
and has never been shown to be such, in spite of re- 
peated challenges asking for proof. Whereas, it has 
repeatedly been shown, by the clearest proofs, that 
the lesions commonly called cancer are only the ex- 
pressions, results, or products of a systemic or con- 
stitutional condition, or disorder, to which the name 
of carcinosis is given, as tuberculosis is the general 
title for the various expressions of disease caused 
by the tubercle bacillus. 
To properly understand the correct medical treat- 
ment of cancer of the breast, it was necessary to 
study and present carefully the evolution and invo- 
lution of this interesting gland of the skin, as well as 
its anatomy, physiology, and pathology, all of which 
have so much to do with the pathogenesis of mal- 
ignant neoplasms, as we shall see later. Lymphatic 
permeation is also a most important subject, very 
little considered but which explains fully the futility 
of expecting a cure of the disease by surgery, x-ray, 
or radium, and to this serious question a good deal 
of importance and space is given. 
The clinical portion of the work has been elabor- 
ated quite extensively, in order to present the vari- 
ous aspects of cancer in this region, as Thomas Bry- PREFACE. 
V 
ant detailed many dozen cases in his most excellent 
treatise on Diseases of the Breast so many years ago. 
The results of medical treatment will seem to be 
incredible to many who have not had the opportun- 
ity of studying large numbers of these cases in pri- 
vate practice, where the intelligence and faith and 
devotion of patients aids so greatly in the proper 
carrying out of the minute details of treatment, 
which are such an important element in securing 
success. While large hospital experience may aid 
greatly in regard to diagnosis and in perfecting sur- 
gical skill, it cannot take the place of painstaking 
and persevering study of the individual patient in 
private practice, and ministering to the various per- 
sonal peculiarities which often contribute materially 
to the success of treatment. 
The caution which has been given in former writ- 
ings may be repeated here. Namely, that this medi- 
cal treatment is not to be entered upon lightly or 
without due consideration. For, although when 
rightly carried out long enough, the results obtained 
far exceed any that can be otherwise secured, on the 
other hand, a lax or careless or too brief employ- 
ment of the measures enjoined can only end in dis- 
appointment. It takes a great deal of time, patience, 
and careful thought, as well as resolute will to fully 
succeed along this line of practice. Also such a per- 
fect acquaintance with, and confidence in, the prin- VI 
PREFACE. 
ciples upon which it is based, as will beget a like 
confidence in the patient, to enable one to pursue the 
tedious treatment sufficiently long to secure the re- 
sult desired. 
To grasp and understand fully the significance of 
all that has been here indicated, the author feels that 
one should read and study every word within these 
pages, and begs that no criticism will be made until 
everything is fully comprehended. The text has been 
illumined by illustrative figures borrowed from many 
good books, with kind permission. It has been hard 
to make selections, there is such a wealth of material 
in various text books and journals. 
With the hope that this work, which has necessi- 
tated the reading and study of thousands of pages of 
surgical, pathological, and other books, and journals, 
and the laborious study of many hundreds of sheets 
of case histories, may be of practical service in re- 
lieving much of the misery caused by cancer, the 
writer leaves the book (with all its imperfections) to 
the kindly indulgence of his fellow practitioners. 
L. Duncan Bulkley, M.D. 
5 East Fifty-third Street, 
New York City. CONTENTS 
CHAPTER I. PAGE 
Tumors in General 1 
CHAPTER II. 
Evolution and Involution of the Breast 16 
CHAPTER HI. 
Anatomy and Physiology of the Breast 31 
CHAPTER IV. 
Lymphatics and Lymphatic Permeation 39 
CHAPTER V. 
Carcinoma of the Breast and Paget's Disease 60 
CHAPTER VI. 
Sarcoma of the Breast 105 
CHAPTER VII. 
Diagnosis 114 
CHAPTER VIII. 
Prognosis 137 
CHAPTER IX. 
Medical Aspects of Cancer 155 
VII VIII 
CONTENTS. 
CHAPTER X. 
PAGE 
Treatment of Cancer of the Breast 180 
CHAPTER XI. 
Analysis of 250 Cases of Cancer of the Breast in Private 
Practice 240 
CHAPTER XII. 
Conclusions 321 
Index 327 ILLUSTRATIONS 
FIG. PAGE 
1. Diagrammatic representation of evolution of the breast 17 
2. Horizontal section of mamma 19 
3. Dissection of the lower half of the female breast, during lactation 21 
4. Section of human mammary gland during lactation 25 
5. Mammary gland in quiescence 27 
6. Cooper's ligaments in the breast 33 
7. Mammary lobule near the resting stage 35 
8. Lymphatic plexus, main highway for permeation in breast cancer 41 
9. Subdiaphragmatic lymphatics 44 
10. General plan of cervical and axillary lymphatic system 46 
11. Active infiltration occurring at the edge of the rapidly growing 
mass of primary breast cancer 49 
12. Typical lymphatic infiltration in breast cancer 49 
13. Scheme to illustrate the advance of permeation along a small 
lymphatic 51 
14. Thoracic duct, receptaculum and some lymph nodes 53 
15 and 16. The growing cancer cells stretch and finally rupture the 
lymphatic 55 
17. Strip of skin and underlying tissue, to demonstrate centrifugal 
spread of permeation, from left to right 57 
18. Diffuse proliferation of atypical cells in ducts in chronic mastitis 65 
19. Section through a cancerous breast 67 
20. Histological section of cancer, showing the roots 69 
21. Cancerous breast in section showing retraction of nipple 71 
22. Mammary cancer. Advanced carcinoma simplex 73 
23. Puckering of skin in recurrent carcinoma 74 
24. Mammary cancer. Postoperative recurrence 75 
25. Cancer en cuirasse, recurrent, with lymphedema of arm 77 
26. Fibro-adenoma surrounded by carcinoma 79 
27. Intra-cystic papilloma of the breast 81 
28. Mamary cancer 84 
IX X 
ILLUSTRATIONS. 
FIG. PAGE 
29. Mammary carcinoma arising on chronic mastitis and involving 
nipple and ducts 87 
30. Pathogenesis of cancer 88 
31. Chronic cancer of right breast 91 
32.- Paget's disease. Early stage 93 
33. Paget's disease, 5 years' duration 95 
34. Section through Paget's eczema 97 
35. Two layer lymphatic ducts from Paget's disease choked by neu- 
rotic epithelium 98 
36. Paget's disease of right nipple in a male 99 
37. Vertical section through edge of Paget's disease in male 100 
38. Fat necrosis of the breast 133 
39. Traumatic fat necrosis of breast 134 
40. Traumatic fat necrosis of breast 135 CHAPTER I. 
TUMORS IN GENERAL. 
Oncology is an enticing study, but thus far it 
seems to be very fruitless in its practical applications, 
especially in regard to cancer. It seems like Living- 
stone's search in trackless Africa, when a newspaper 
man, Stanley, had to find the explorer. Deaver, in 
the most recent work on cancer,1 says: "The nature 
of carcinoma is unknown. . . . Thus, a generation 
of workers have labored with great intelligence and 
patience, and a mass of information has been col- 
lected, but when it is carefully sifted, we find our- 
selves very much where our forefathers were, so far 
as any clear idea of the cause and nature of cancer 
are concerned. But what is more disappointing, we 
are precisely where they were as far as the treat- 
ment of the disease is concerned. All that they 
knew was, that the proper thing to do for cancer of 
the breast was to remove it. All that we know is 
to remove it. We do it with less pain than they, 
thanks to anesthetics; we do it with greater safety 
than they, thanks to antiseptics and asepsis; we do 
it with less probability of recurrence than they, 
1 Deaver and McFarland: The Breast, Its Anomalies, Its Diseases, 
and their Treatment, Philadelphia, 1918, p. 476. 
1 2 
CANCER OF THE BREAST. 
thanks to better technic; but we still do nothing to 
cure it." 
From the single lucubrations of the tyro in path- 
ology in the medical journals, or the elaborate re- 
search work in special journals, to the masterly 
works of Virchow, Wolff, and Ewing, we get little 
or nothing to help in the successful treatment of 
cancer, in spite of the millions of money and thous- 
ands of animal lives expended by the various re- 
search laboratories. 
While the reasearch laboratories have taught us a 
great deal as to the actual structure of neoplasms, 
and the innumerable varieties of size and shape of 
their cells, after they have become diseased and re- 
moved from the human body, or from those of ani- 
mals ; still, all students agree that they are only trans- 
formations of ordinary body cells, which were once 
healthy, or started from such and took on these ab- 
normal forms from some "unknown influence." 
Research workers agree that there is practically 
little or no difference, which they can determine, in 
the chemical composition of diseased cells from those 
which are normal, other than could be explained by 
metabolic activity of the tumor cells, its source being 
the blood hydrocarbonates and probably the proteins. 
Ewing2 has devoted a chapter to this subject from 
which we shall freely quote: "The conception that 
2 Ewing, James: Neoplastic Diseases, Philadelphia, 1919, p. 89. TUMORS IN GENERAL. 
3 
tumor proteins must differ in essential respects from 
those of normal tissues has not been demonstrated by 
chemical methods. The nature of the problem in- 
volved appears to have presented itself in different 
forms in the minds of investigators who have at- 
tacked the problem. A different distribution of nor- 
mal proteins from that in normal tissues has been 
demonstrated by Petry, Wolff, and Beebe, who found 
a higher content of nucleo-protein, more uncoagu- 
lable protein, and less globulin and albumin. It is 
probable that these results depend on the overgrowth 
of cell nuclei, degenerative and autolytic processes, 
and edema. Nucleohiston is present only in lymph- 
nodes among normal tissues, and its presence in 
lymphatic metastases of tumors originally free from 
this protein, indicates that metastatic tumors receive 
chemical impress from the tissues in which they are 
growing. Although nucleohiston is absent in prim- 
ary carcinoma of the breast and in the testes, Beebe 
found this substance in lymphnode metastases of 
mammary cancer; and Bang in the lymphatic metas- 
tases of testicular carcinoma. 
"Direct chemical analysis of the split-products of 
cancer proteins by Wolff, yielded a high proportion 
(35 Per cent.) of glutaminic acid, while Bergel and 
Dorpinghaus found excess of alanin, phenylalanin, 
asparaginic acid, and diamino acids. Yet these re- 
sults conflicted with those of Petry, Neuberg, and 4 
CANCER OF THE BREAST. 
Beebe. Resistance to peptic, and susceptibility to 
tryptic digestion, was said by Blumenthal and Wolff 
to distinguish tumor from normal tissues. Yet their 
results were not uniform and were probably deter- 
mined by the increased amount of nucleoproteid in 
some of the tumors. 
"Excess of potassium and deficiency in calcium 
in rapidly growing tumors free from necrosis, and 
the opposite relations in slowly growing and old or 
necrotic tumors have been demonstrated by Beebe 
and by Clowes. 
"Pentose was greatly increased in a fibro-carcin- 
oma of the breast, in comparison with the amount in 
the normal breast, in cases studied by Beebe and 
Shaffer. These authors also found that the pentose 
content in different tumors varied, and bore no rela- 
tion to the nucleoprotein, or to the presence of de- 
generation. 
"Lactic acid appears in tumors, according to Fulci, 
in considerable quantities. It is more abundant in 
epithelial than in connective tissue formations, and 
increases in the more malignant, actively growing 
tumors. Its formation is dependent on metabolic ac- 
tivity of the tumor cells, its source the carbohydrates 
and possibly the proteins. It appears to have no re- 
lation to cachexia. 
"Of the total phosphorus of the normal liver, B. 
Wolter found 24.68 per cent, as phosphatid phos- TUMORS IN GENERAL. 
5 
phorus, in the tumor-free portions of a liver with 
primary carcinoma 22.04 Per cent., and in the tumor 
nodules 16.28 per cent., while the protein phosphorus 
in the same materials ran 20 per cent., 25.5 per cent., 
and 26.70 per cent. In 0.0634 Gm. of dried tumor 
substance he found 1.40 per cent, of cholesterin. 
"Tryptophan was markedly increased in an epider- 
moid carcinoma of the skin and in an hepatic car- 
cinoma, over the normal proportions found in normal 
skin and liver, in cases studied by Fasal, but this 
substance was absent in a mammary fibro-carcinoma. 
"The chemistry of tumor fats has been studied ex- 
tensively in renal and adrenal tumors. In general it 
appears from Bossart's work that actively growing 
tumors, free from degeneration, contain little fat and 
much lecithin, while with degeneration and necrosis 
free fats replace lecithin. 
"Turin bodies were found by Wells and Long in 
about the same form and amount as in normal tis- 
sue, and less abundantly than the nuclear content 
would suggest. The purin enzymes were also iden- 
tical with those of normal tissues, guanase being con- 
stantly present and adenase absent. 
"Autolysis is often observed to proceed more rap- 
idly in certain tumor tissues than in normal tissues, 
but it is possible that all such differences depend upon 
the more cellular character, and presence of degen- 
erating tissue, edema, leucocytes, and bacteria. It 6 
CANCER OF THE BREAST. 
is extremely difficult to obtain normal tissue which 
may be safely compared with tumor-tissue in this 
respect. 
"The increased activity of autolysis is well illus- 
trated in Yoshimoto's experiments in which an hep- 
atic carcinoma yielded 7.2 Gm. of nitrogen in the 
split-products, as compared to 4.8 Gm. in equivalent 
units of normal liver. With a mammary carcinoma 
the difference was even greater. In the tumor auto- 
lysate purin nitrogen was reduced, while that of 
diamino-acids, peptone, and ammonia was increased 
in proportion. Blumenthal and Wolff have reported 
that when measured amounts of tumor-tissue and of 
normal tissue are autolyzed separately in one series, 
and conjointly in another, the autolysis is always 
greater in the conjoined series. They conclude that 
the tumor ferments attack the normal tissues and ex- 
hibit a heterolytic property. On this basis rests the 
claim that infiltrative growth and cachexia depend on 
the heterolytic activities of the tumor ferments." 
We may now discuss the chemical composition and 
the metabolism of the cancer cell. Individual anal- 
yses have shown a greater variability in the kind of 
tissue-protein found in the cancer cell, one or more 
members of the amino-acid group being present, per- 
haps in great excess. But if we pursue the subject 
further there is a fair amount of agreement in re- TUMORS IN GENERAL. 
7 
gard to the proteins of cancer and normal proteins. 
Variations depend upon a number of factors, such as 
the proteins in the tissue from which the growth 
arises, the age of the cancer-for in the older ones 
autolytic products are added to those of ordinary 
metabolism, etc. As far as possible we are writing 
of young and rapidly growing cancer cells. Of fresh 
cancer cells we only know from experiments in vitro 
that amino-acids are excreted in double the amount 
found in ordinary tissues: this apparently explains 
the presence of the acid medium said to occur in the 
field of proliferation. Another reason for different 
results in protein analysis is said to be the retention 
of this product in the veins, owing to sluggish circu- 
lation. In young cancer cells the product of kata- 
bolic substances is too slight to be readily appreci- 
able by ordinary tests, so that considerable amounts 
of amino-acids, along with proteoses, speak for auto- 
lysis. Cancer protein is attacked by trypsin, while 
normal tissues are practically immune. 
An extraordinary number of active substances 
have been described as cancer products. Fresh can- 
cer extract contains a variety of enzymes such as are 
found in ordinary tissue cells, and some show marked 
proteolytic powers with normal tissues, which sug- 
gests the old belief that cancer digested its way to 
some extent through sound tissues. Loeper claims 
that the proteolytic enzyme enters the blood and can 8 
CANCER OF THE BREAST. 
lower the azotemic co-efficient of the same. Cancer 
juice can digest more peptone, or rather produce 
more amino-acid than other and normal tissues. The 
products of autolytic enzymes have been summed up 
as autolysates, and some of these are doubtless toxic, 
as shown by their ability to produce hemolysis. 
While no specific or definite information, leading 
to a knowledge of the true nature of cancer is af- 
forded by these or other accessible researches, there 
runs through many of them a thread of thought 
which is important. 
It will be noticed how many of these studies relate 
to the disintegration of protein, to proteolytic fer- 
ments, to nuclein, to lymphocytosis, to autolytic ac- 
tion, etc., all of which go to confirm the thesis of an 
internal or constitutional nature of cancer, and the 
autonomous action of the body cells: for Quevli3 has 
so clearly demonstrated the intelligence of cell life. 
We have always held that errors in the blood con- 
tent are the cause of carcinosis, and indeed of all 
tumors, and it is quite understandable that the cells, 
which have ordinarily gone through their normal 
life, being destroyed and renewed by katabolism and 
anabolism, and have performed their duties of secre- 
tion of milk, etc., have mutinied,4 having rebelled, as 
3 Quevli, Nels: Cell Intelligence. The Colwell Press, Minneapo- 
lis, 1917. 
4 Bulkley: Cancer a Mutiny of Body Cells, Medical Record, Oct. 
1, 1921. TUMORS IN GENERAL. 
9 
soldiers would at bad food or other causes of discon- 
tent ; and being still possessed of the power of growth 
and multiplication, they form a useless and harmful, 
vicious mass, and spread as they choose in the tis- 
sues and lymphatics, and ultimately destroy life. 
Ewing5 says: "Tumor cells exhibit a wide variety 
of alterations which have been subjected to close 
scrutiny, but which it is difficult to interpret and 
classify. These changes affect both the nucleus and 
the cytoplasm. In the highly developed tumor cell 
the nucleus may be distinguished by five elements: 
(i) Nuclein, a nucleo-proteid, composing the chrom- 
atin, which appears in deeply staining clumps, nor- 
mally arranged along the periphery of the nucleus, 
or as an intra-nuclear network. (2) Paranuclein, 
an acidophile substance, composing the nucleoli. (3) 
Linin, or plastin, an achromatic substance, forming 
an intra-nuclear network. (4) Amphipyrenin, which 
some authors describe as constituting the nuclear 
membrane. (5) Nuclear fluid, filling the meshes of 
the nuclear network. 
"As compared with normal cells, all these nuclear 
structures may be much more abundant in tumor 
cells. In giant cells, especially those of myogenous 
origin, and in various sarcomas and epitheliomas, 
the nuclei reach enormous proportions from hyper- 
trophy, chiefly of nuclein. In epitheliomas great ex- 
5 Ewing, James: Neoplastic Diseases, Philadelphia, 1919, p. 46. 10 
CANCER OF THE BREAST. 
cess and multiplicity of paranuclein bodies are some- 
what characteristic, while in endotheliomas the nu- 
clei are relatively small. 
"Shrinkage and pyknosis of nuclei occur in degen- 
erating and necrosing areas of many tumors. Wide 
distention, from imbibition of fluids may accompany 
hydropic degeneration of the cytoplasm. Rarefica- 
tion of nuclein masses may result in a pale, diffuse 
stain of the thickened chromatic network. Or the 
chromatin may appear in very thin strands, eventu- 
ally disappearing in complete karyolysis. A common 
appearance in carcinomas is the presence of several 
distinct blocks of chromatin, lying irregularly in a 
nucleus devoid of chromatic membrane. The various 
stages of karyorrhexis may be followed in degener- 
ating or necrosing cells. The fragments of chrom- 
atin thus resulting may be scattered in the cytoplasm, 
and remain pyknotic or become dissolved. Extrusion 
of chromatin into the cytoplasm may result in the 
appearance of many basophile granules in the cell. 
The chromatin or linin may break up into many fine 
rings within the nucleus, and then be discharged into 
the cytoplasm." 
It is unnecessary to follow this interesting study 
further, to which the author devotes many pages, 
but enough has been given to show how the active 
properties of the cells change and how they become 
distorted when they take on their mutinous and riot- TUMORS IN GENERAL. 
11 
ous action. All of this points very clearly to sys- 
temic disorders of nutrition. 
The question arises, what is the cause of this dis- 
astrous, wild, unnatural behavior of living cells in 
the breast, which should be performing their normal 
functions of secretion of milk, mitosis, and reproduc- 
tion of healthy cells to take their place in the tis- 
sues? Why do they persist in their mad career, in- 
ducing many other cells to join in riotous action? 
Why does the process go on until a pernicious anemia 
destroys life? The reasons will appear in later pages, 
but a single, simple answer may first be given here. 
All the cells of the body depend for their constant 
nourishment on the circulating blood and lymph, and 
perform their functions thereby, as directed by 
nervous impulses. 
The cancer cell was originally a normal cell which 
has rebelled against the persistent ill usage to which 
it has been subjected. In consequence of this it has 
gradually parted with its loyalty to those physiologi- 
cal laws which have hitherto regulated its cycle of 
life. Is it to be wondered at, then, that a cell or 
cells may, and frequently do, throw off allegiance to 
those laws which govern healthy cell metabolism and 
take up a new role of existence, which they do 
when they develop into cancer cells? Now, if the 
various cells and organs of the body for a length- 
ened period have derived their nourishment from a 12 
CANCER OF THE BREAST. 
vitiated blood supply, no matter what the pollution 
consists of, is it reasonable to expect that they will 
be able to continue in healthy vigor, and be compet- 
ent to carry on their various functions satisfactor- 
ily ? They then cease to depend wholly upon a 
normal source of nourishment, obedient to a normal 
physiologic nerve influence, but attack and prey upon 
their neighbors, invading their domain and spread- 
ing destruction, as mutinous soldiers might do. 
Eventually they penetrate the lymphatic vessels, and 
thus reach the neighboring glands, setting up new 
colonies of cancer cells there, some of which make 
fresh inroads into more distant tissues. 
From all this we see that cancer is never a purely 
local disease, but that the carcinosis, of which the 
lesions which we call cancer are but the result or 
product, is a systemic or constitutional affair, going 
on and producing new lesions until the basic cause 
is removed: thus, what are often called recurrences 
are but the new developments of the disease, carcin- 
osis, even as the continued and even late appearances 
of syphilitic lesions are the sign that the original mal- 
ady has not been overcome. It is as unreasonable to 
expect to cure carcinosis by excising its first manifes- 
tations in the breast as it would be to claim to cure 
gout by excising the great toe where its first indica- 
tion may occur; and yet there are many who still TUMORS IN GENERAL. 
13 
claim otherwise, although the early and late recur- 
rences show the truth of this. The difference of 
opinion may be accounted for by mistaken diagnoses, 
for even pathologists acknowledge that the micro- 
scopic diagnosis of tumor tissue is often puzzling, 
and instances are known to us all where there 
have been half a dozen, more or less, different diag- 
noses of excised specimens by as many microscopists, 
often the best. 
Tumors are recognized clinically as benign or in- 
nocent, and malignant, according to observation of 
their ultimate effects, but thus far we have learned 
little or nothing from the laboratory as to the reason 
of their being one or the other, though microscopi- 
cally they are pretty well defined. Later they will 
both be considered in the diagnosis of cancer of the 
breast, when we will see that certain tumors, primar- 
ily benign, may be transformed into malignant, when 
the systemic conditions arise which produce the 
change. White6 has given about the best study on 
the formation of benign and malignant tumors, with 
microphotographic illustrations, all of which is. too 
technical to introduce here. Speaking of chorio-epi- 
thelioma, Sutton7 says: "This disease is instructive, 
because the erosive action of the trophoblast is the 
6 White, Charles Powell: Lectures on the Pathology of Cancer, 
Manchester, Eng., 1908. 
7 Sutton: Tumors, Innocent and Malignant, 7th Edition, p. 11. 14 
CANCER OF THE BREAST. 
physiological type of the invasiveness so character- 
istic of many varieties of cancer." 
H. C. Ross,8 and his co-laborers have thrown 
great light upon the real cytogenesis of cancer, which 
may lead to a much clearer understanding of the 
disease. The matter is far too intricate to introduce 
here, but by their patient and prolonged studies on 
induced cell reproduction, they have demonstrated 
by innumerable microphotographs the mitosis of 
cells, leading to their outrageous action in cancer; 
these changes are induced by various substances, 
including the products of putrefaction, and kreatin, 
xanthin, hemoglobin, etc. The latter, which are 
called auxetics, are produced in the cytolysis of cells, 
during their catabolism, especially after their death, 
from slight injury or internal influence. 
Finally, that astute and successful surgeon, Dr. 
Thomas Bryant,9 quotes and endorses Creighton, on 
the "Physiology and Pathology of the Breast," who 
has shown that "the investigation of breast tumors 
reveals merely the workings of the physiological 
law of healthy mammary activity under altered 
circumstances, that various degrees of disordered 
function may result in various kinds of tumors" and 
that tumor disease of the breast is "essentially a 
8 Ross, H. C.: Induced Cell Reproduction and Cancer, Vol. I, Phila., 
1911; Vol. II, London, 1912; Vol. Ill, London, 1913, pp. 21, 24. 
9 Bryant, Thomas: The Diseases of the Breast, London, 1887, pp. 
73, et seq. TUMORS IN GENERAL. 
15 
disorder of the function." These views support 
strongly my position that "cancer is a mutiny of 
body cells," due to deranged nutrition, and excited 
to erroneous action by some irritant, physical or 
neurotic. CHAPTER II. 
EVOLUTION AND INVOLUTION OF THE BREAST. 
The evolution of the normal breast has been very 
carefully studied by Deaver,1 with immense biblio- 
graphy and reference to original articles, and this 
and other material we shall freely use, condensing 
it, without necessarily indicating exact quotations. 
The breast is developed from the tissues of the 
skin, which are derived from the epiblast. The ear- 
liest indication of the future breast is formed in the 
embryo as a slight ectodermal ridge along each side 
of the body from the axillae to the groins. Later, 
about the fourth month, the ectoderm begins to send 
down into the mammary area, long exaggerations of 
the epithelial pegs of the rete mucosum. This down- 
ward process of the epiderm consists of solid cylin- 
ders, and first occurs in the area that is later to form 
the areola. The central cylinders are large and rap- 
idly grow broader and longer, to form the milk ducts, 
from which the mammary parenchyma is to form. 
As the parenchyma is thus forming in the cutis, 
unstriped muscular tissue appears in small quantity 
about the primary depression, and being for the most 
1 Deaver and McFarland: The Breast, Its Anomalies and Diseases, 
London, 1918. 
16 EVOLUTION AND INVOLUTION OF BREAST. 
17 
Fig. 1.-Diagrammatic representation of evolution of 
the breast. (Leaf.) 18 
CANCER OF THE BREAST. 
part circularly arranged, is soon followed by a cir- 
cular contraction that causes the central part of the 
mammary area to project slightly beyond the general 
surface. Thus the foundation of the nipple is laid. 
At the time of birth the human breast consists of 
a slightly depressed, rounded area over each pectoral 
region, in the center of which there is a tiny rounded 
node. When examined microscopically, it is found 
that the epithelium of the surface descends through 
the nipple in the form of slender, solid cylinders 
which spread out in the cutis, the ends being ex- 
panded and rounded. 
A few days after birth the mammary glands of 
both male and female infants show signs of internal 
activity. They swell to a varying extent, become 
slightly reddened, and are tender to the touch. After 
this period of infantile activity has subsided, the 
breasts are a little larger than before, and are com- 
monly changed in their minute structures; for when 
sections are examined with the microscope it is 
found that the parenchyma no longer consists of solid 
cylinders of epithelial cells but of hollow tubes with 
caecal, expanded terminations, and that instead of 
single dichotomous branchings, there are now sev- 
eral, so that the quantity of parenchyma has materi- 
ally increased. 
The sebaceous and sweat glands of the skin are 
similarly formed from the deeper prolongations of EVOLUTION AND INVOLUTION OF BREAST. 
19 
the rete Malpighii, and the mammary glands are in- 
cluded among the glands of the skin, and were for- 
merly looked upon as enlarged and specialized 
sebaceous glands. But later and special study has 
identified them with the sweat glands, a view which 
is supported not only by their histological structure, 
Duct 
Ampulla ' 
Nipple 
Areola 
..-Duct 
Fat 
Pyramidal process 
'Retinaculum cutis 
- " Pyramidal proci 
Skin 
Skin 
Retinaculum cutis » / 
-Superficial fascia 
✓Retromammary tissue 
' Sixth rib 
\ .^Intercostals 
Sternum' 
Pectoral Plane of fig. 82 
fascia 
Fig. 2.-Horizontal section of mamma. (Morris, Rodman.) 
as Creighton2 has pretty clearly shown, but also by 
their method of functioning. The lining cells of the 
sebaceous glands are completely destroyed in the 
process of secretion, and are converted into oily 
matter, while the lining cells of the mammary glands 
are not so destroyed, but secrete, like those of the 
2 Creighton, Charles: Cancer and Other Tumors of the Breast, 
London, 1902. 20 
CANCER OF THE BREAST. 
kidney, a point of importance in understanding the 
pathogenesis of cancer of the breast. 
From the first year to the advent of puberty the 
changes in the breasts are slight and unimportant, 
and consist chiefly in an added number and complex- 
ity of the tubules, which become more numerous in 
the breasts of girls than in those of boys. 
With the advent of puberty come developmental 
changes in the breasts of both sexes. These are com- 
paratively unimportant in boys but are striking in 
girls; they are believed to be related to the action of 
internal or endocrinous secretions; up to puberty it 
is stated that it is not possible to differentiate micro- 
scopically between male and female glands: subse- 
quent to puberty the male breast consists of tubules 
or ducts, with no acini; after the thirtieth year the 
male gland seems to regress. The female gland un- 
dergoes a remarkable development at puberty. The 
activity of growth usually begins about the tenth 
year, very gradually, but about the fourteenth and 
sixteenth year it increases rapidly, then again there 
is slow progress until about the eighteenth year when 
the gland becomes mature, all varying somewhat ac- 
cording to race, climate, heredity, etc. But the full 
development of the alveoli in the breast does not oc- 
cur until the first pregnancy has terminated and lac- 
tation begun; forming what is known as the axillary 
prolongation of the gland in several directions. EVOLUTION AND INVOLUTION OF BREAST. 
21 
Microscopically the first developmental changes in 
the completed breast consist in division and exten- 
sion of the glandular parenchyma beneath and be- 
yond the areola, and a deposition of fat tissue be- 
tween the forming lobules of glandular tissue. As 
Fig. 3.-Dissection of the lower half of the female breast, 
during lactation. (Luschka.} 
this goes on the gradual growth and extension of 
the mammary parenchyma, with a simultaneous in- 
crease in the adipose tissue, causes the growing gland 
to increase in diameter and elevation, until its max- 
imum size is attained, and a hemispherical shape is 
assumed. Later there is a developmental, firm union 
between the overlying skin and the milk ducts, and 22 
CANCER OF THE BREAST. 
the perfected nipple and areola appear. The mature 
male breast is rudimentary. Beneath the minute 
nipple and areola there is a gland of such inconsider- 
able size as to cause little if any elevation, and so 
embedded in the superficial fascia as to elude palpa- 
tion. It is a mistake to speak of only nipples in 
men, for glands are there, and in them are latent 
potentialities that may lead to cancer, of which seven 
instances will be mentioned in a later chapter. 
Involution. 
Involution, as well as evolution, of the breast has 
much to do with both benign or innocent, and malig- 
nant neoplasms. In its ordinary meaning involution 
indicates the attempt of the return of the gland from 
its size and complexity as a perfect organ to a smaller 
and simpler structure, without pathological changes; 
but some of these latter are dependent upon the 
changes which occur normally in most women. A 
certain amount of involution occurs after each lac- 
tation, but only to a certain degree: the vascularity 
diminishes, the function of secretion ceases, the inac- 
tive cells shrink, and their cytoplasm becomes less 
distinct: the acini flatten out and disappear: the glan- 
dular tissue, of which the whole breast seemed full, 
returns to a bulk contained in small scattered lobules: 
adipose tissue reappears as the glandular tissue dis- 
appears, and something approximating the original EVOLUTION AND INVOLUTION OF BREAST. 
23 
condition, is regained. But it is never a perfect re- 
turn to the original condition, for the involutional 
process is not infrequently complicated by the reten- 
tion of the products of secretion. Such retained 
milk undergoes slow inspissation, and the ducts be- 
come filled with a residuum that is partly fatty, partly 
protein in composition. Its presence is the exciting 
cause of an infiltration of mononuclear cells-lympho- 
cytes and plasma cells-and occasional, small giant 
cells into the periductal tissues. 
When the breast, the seat of post-lacteal involution, 
is examined microscopically a very varied picture is 
presented, by no means all parts of it appearing the 
same. Thus, all the lobules of mammary tissue may 
not have engaged in the function of lactation, so that 
it is not unusual to find occasional areas of tissue pre- 
senting virginal appearance. Some of the ducts are 
empty and collapsed: in others a certain amount of 
secretion may have been retained in the form of a 
creamy inspissation, or transformed into a trans- 
lucent, amorphous substance, in which are many cells 
whose partial disintegration makes their exact his- 
togenesis difficult or impossible to determine. In 
some lobules the appearance of mammary hyper- 
trophy may be retained: in others the acini have dis- 
appeared, but the peri-ductal tissue contains abund- 
ant lymphocytes, and perhaps some foreign-body 
giant cells; more diffuse fatty deposits are found 24 
CANCER OF THE BREAST. 
than in the virginal breast. The precise order and 
duration of the involutional changes following lacta- 
tion, and their completeness or incompleteness in the 
various details, appear not to have been determined. 
It is certain that they may extend over months or 
even years, when not interrupted by recurrence of a 
lactational hypertrophy incidental to the recurrence 
of pregnancy. 
Such are some of the changes in structure which 
have been discovered which show what marvelous 
transformations take place continually in a perfectly 
normal manner. But undoubtedly there are many 
which have been overlooked, while some of those re- 
ported approach what are called the pathological 
changes of approaching carcinoma, as has been re- 
peatedly remarked by observers. 
Senile involution of the breast. The final changes 
which occur in the mammary gland come in connec- 
tion with the menopause, and the microscopic appear- 
ances vary according to the past activities or quies- 
cence of the mammary tissue. In the breasts of vir- 
gins, and those of women who have borne no child- 
ren for years before the occurrence of the menopause, 
the changes are comparatively simple. In general, 
senile involution is characterized by progressive 
atrophy and disappearance of the alveolar structure 
of the parenchyma, progressive destruction of the EVOLUTION AND INVOLUTION OF BREAST. 
25 
lobular tissue, increase in the density of the fibrillar 
tissue, and by a deposit of adipose tissue throughout 
the breast; the breasts may feel corded. 
The changes which characterize senile involution 
are not difficult to recognize. In some, many or all 
Fig. 4.-From section of human mammary gland during lacta 
tion. X 50. (Stohr.) a, Branch of excretory duct; b, inter 
lobular connective tissue; c, alveoli. (Bailey.) 
of the lobules of the parenchyma, alveoli can be seen, 
whose smaller size and disappearing cells indicate 
that they are the seat of progressive atrophy. In 
lobules in which the atrophy has progressed to a 
marked degree, the intra-lobular connective tissue no 
longer shows a clear separation from the inter-lobu- 
lar stroma or matrix, but more and more blends 26 
CANCER OF THE BREAST. 
with it. When the disappearance of the lobule is 
complete the lobules may actually cease to exist, be- 
cause the peri-ductal tissue has so thoroughly blended 
with the inter-lobular stroma, or may appear as 
partly differentiated fibrous nodes in a slightly dif- 
ferent matricial tissue. Vestiges of alveoli are 
sometimes to be found in such fibrillar nodes, appear- 
ing as epithelial-lined tubules devoid of a basement 
membrane, and so deformed as not to be classed as 
alveoli or ducts. 
Prior to the alveolar atrophy the peri-ductal tissue 
sometimes shows increase in quantity and density: 
neighboring alveoli may be drawn upon and caused 
to coalesce. Approximated and closely related alve- 
oli dilate and coalesce to form minute cavities with 
incomplete partitions, then small, epithelial-lined 
cavities, with wrinkled or puckered walls, and finally 
minute cysts. The atrophy is progressive but how 
long it continues, how regularly it advances, and to 
what final change it eventually reaches, appear not 
to have been definitely followed: that senile involu- 
tion ever leads to complete extinction of the mam- 
mary tissue is extremely doubtful. 
In the senile mamma epithelial proliferations of 
the parenchyma, and degenerative changes in the 
stroma may be found; such form an immediate evi- 
dence of transformation from the physiological to 
the pathological state (chronic cystic mastitis, car- EVOLUTION AND INVOLUTION OF BREAST. 
27 
cinoma). But the epithelium of the alveoli may show 
appearances still more suggestive of pathological con- 
dition, in the form of alveoli with dilated lumina 
lined with a single layer of epithelium, whose cells 
differ conspicuously from those of the mammae else- 
Fig. 5.-Mammary gland in quiescence. (Bailey.') 
where. They are of cylindrical form, with pale cyto- 
plasm, large nuclei and nucleoli, whose size is two 
to four times that of the normal mammary epithe- 
lium, and remind one of the atypical elements of large 
cell carcinoma, without any actual malignant change 
having taken place. Some think that these repre- 28 
CANCER OF THE BREAST. 
sent a transformation of the cells leading to carcin- 
oma, but they are not malignant through prolifera- 
tion. 
The elastic tissue makes itself evident in the senile 
breast as contrasted with the breast of earlier age. 
It is found in greatest quantity in the circumference 
of the larger milk ducts, where it forms a thick fibril- 
lar layer. In such cases when the epithelium is gone, 
the lumina may close and nothing remain but a ring 
of elastica. Similar obliteration occurs in carcin- 
oma. In such cases there is no proliferation of epi- 
thelium, but on the contrary, a pressure atrophy 
caused by the connective tissue. In some cases dis- 
ease of the blood-vessels has been found, endarter- 
itis, sometimes accompanied with extensive calcifica- 
tion, sometimes with sub-endothelial internal prolif- 
eration, sometimes with thrombosis and thrombo- 
arteritis obliterans. Such changes can scarcely occur 
without inducing changes in the structural integrity 
of the tissues, both parenchymatous and interstitial, 
and it may be assumed that some of the retrogressive 
changes that have been already pointed out, as well 
as the frequent hyaline and calcareous changes of the 
inter-lobular tissue of the breast, may be thus ex- 
plained. : 
Abnormal or perverted involution. While the pro- 
cesses which have been considered are really a part 
of the normal cycle of life of the female breast, EVOLUTION AND INVOLUTION OF BREAST. 
29 
abnormal involution, from one cause or another, is 
constantly observed. As Deaver puts it : "The 
breast is restless; it is acted upon by a variety of 
agencies (hormones, etc.), is stimulated to grow or 
its growth is inhibited according to circumstances 
known or unknown. The result is disturbance of 
structure and function, whose extreme departures 
from the normal constitute abnormal involution, and 
are supposed to prepare the way for, if not directly 
lead into, the epithelial invasion of the malignant 
character that we know as cancer." We know also 
that it may result in other breast troubles, which will 
be mentioned incidentally later, as chronic interstitial 
mastitis, diffuse fibro-adenoma, cysts, etc. 
We thus see that what are recognized, by subse- 
quent results, as malignant neoplasms, are only ex- 
aggerated and distorted cells, originally normal, 
which having mutinied and having lost their nervous 
control, and having thrown off physiological allegi- 
ance, no longer perform their former secreting func- 
tion, but having still the power of growth, multiply 
and form the useless and ultimately harmful masses 
which we call cancer. Later we shall see that this 
perversion of action depends upon a perverted or er- 
roneous condition of the blood from which they re- 
ceive nutrition, the actual mutinous action being ex- 
cited by an external agent, as a local injury, surgical 30 
CANCER OF THE BREAST. 
interference, or a pus-forming microbe, or possibly 
from an internal irritating cause, such as an uric 
acid disturbance, as Haig3 has shown, and mentioned 
in later chapters. The wonderful studies of Creigh- 
ton4 furnish much to confirm this view. 
3 Haig, Alexander: Uric Acid a Factor in Disease, 7th Edition, 
Phila, 1908, pp. 420-426. 
4 Creighton, Charles: Some Conclusions on Cancer, London, 1920. CHAPTER III. 
ANATOMY AND PHYSIOLOGY OF THE BREAST 
While a good knowledge of the anatomy of the 
breast is essential for the surgeon, it is also very 
desirable for the physician who would wholly grasp 
the subject of cancer in this region, for an adequate 
conception of the mode of development, and the ex- 
tent and effects of the neoplasms which affect it, 
and also for diagnosis. 
The breast is described as a flattened hemispheri- 
cal, glandular mass, about 5 inches wide and 4 to 
4^ inches vertically, and of a thickness of about two 
inches, lying in front of the great pectoral muscles, 
one at each side of the front of the chest, extending 
from the second or third rib above, to the sixth or 
seventh below, and laterally from the outer side of 
the sternum to near the anterior border of the axilla. 
But this description by no means accurately defines 
the limits of the organ, for it has been shown that 
prolongations of glandular substance may extend 
upwards toward the clavicle, downwards toward the 
external oblique muscle, inwards to the sternum and 
outwards into the axilla. All this is very important 
to the surgeon, who may in operating leave certain 
portions of diseased breast tissue, leading to recur- 
31 32 
CANCER OF THE BREAST. 
rence. It is also important to the physician in diag- 
nosing obscure cases. 
The mass of the breast is composed of: I. The 
parenchyma, a group of secreting glands which open 
on the nipple by separate ducts. 2. The connective 
tissue forming the stroma and dividing the breast 
up into compartments. In this stroma run the blood- 
vessels, nerves, lymphatics, and ducts. 3. Fat, which 
forms more or less of a cushion behind the breasts, 
covers the outside, and embeds the lobules of glandu- 
lar tissue. This latter is important to recognize in 
making a diagnosis, for a small tumor in a thin 
breast is readily recognized, whereas in a fat one 
it is sometimes very difficult of recognition. 
The parenchyma, or gland itself is a conglomerate, 
racemose or compound organ, composed of from fif- 
teen to twenty distinct lobes, each of which is a 
distinct gland, subdivided into lobules of varying 
size, which in their turn are made up of an aggre- 
gation of alveoli, each alveolus being a terminal se- 
creting unit. Each lobe is held together by firm 
fibrous tissue, and yet at times is separated by fat: 
each lobule is surrounded by connective tissue for 
support, as also are the smaller lobules and secret- 
ing acini of the gland. The connective tissue also 
attaches the secreting mass to the outer skin, by what 
is known as suspensory, or Cooper's ligaments, and 
it is the contraction of these that causes dimpling ANATOMY AND PHYSIOLOGY OF BREAST. 
33 
of the skin and retraction of the nipple, when a can- 
cerous mass is beneath it. The blood-vessels and 
nerves which run in the skin and connective tissue 
are of special interest to the surgeon, but the lym- 
phatics are particularly important for the physician 
to recognize and know thoroughly, and will be con- 
sidered more particularly later. 
Fig. 6.-Cooper's ligaments in the breast. (Bryant) 
The ducts which lie in the connective tissue are an 
important feature in connection with cancer of the 
breast. Minute canals, lined a single layer of spher- 
oidal cells are in intimate connection with the alveoli. 
These little channels form the commencement of the 
excretory ducts, and after uniting with the corre- 
sponding tubules from neighboring alveoli form a 
common excretory duct for each lobule. They 34 
CANCER OF THE BREAST. 
then unite with similar ducts from other lobules to 
furnish each lobe with a common galactophorus duct. 
Then the latter, which, as stated, are fifteen to 
twenty in number, run upwards to open on the nipple 
by separate orifices. Beneath the nipple each duct 
is dilated into a lacteal sinus or ampulla, which 
serves as a temporary reservoir for the milk. These 
ducts are very important clinically in connection with 
cysts, galactocele, and duct carcinoma. 
Physiology. 
Physiologically the breast is a secreting organ be- 
longing to the reproductive system, and character- 
ized by periodical phases of activity, which are most 
pronounced during the era of sexual life. But the 
secreting power of the gland often manifests itself 
slightly for a brief period soon after birth, as already 
mentioned. Rodman and also Deaver have made 
such admirable studies of the physiology of the breast 
that a description of it may be profitably compiled 
from them. 
The rapid growth of the breast at the approach 
of puberty, when it attains approximately its normal 
size, does not reach its highest degree of develop- 
ment until pregnancy, parturition, and lactation have 
taken place. Thus, although there are formed and 
developed alveoli, which are the physiological units 
of the organ, these structures are not completely ANATOMY AND PHYSIOLOGY OF BREAST. 
35 
developed until the first pregnancy has terminated 
and lactation begun. At puberty they develop only 
at the periphery of the gland. Structure and func- 
tion are inseparably connected, as one might sup- 
pose, and the microscopical appearances of the cells 
in their structure are materially different in the non- 
lactating and the lactating breast. 
At about the eighth week after conception the 
Fig. 7.-Mammary lobule near the resting stage. 
(Creighton, Williams.') 
breasts begin to increase in size, and continue to en- 
large until the termination of pregnancy, and for 
some days thereafter. There is an increase in all the 
constituent structures. The alveoli become larger 
and more numerous, the blood-vessels distended, the 
areola larger and darker in color, and the nipples 
swollen and sore. The tubercles of Montgomery en- 
large, and striae form in the skin, owing to the 
stretching excited upon it by the distended gland. 
If the alveoli be examined microscopically at this 
period it will be found that they are in reality solid 36 
CANCER OF THE BREAST. 
cylinders composed of cells. Toward the close of 
pregnancy or soon after delivery some of these cells 
are cast off, leaving a single mosaic layer to line the 
walls of the alveoli. These cast-off cells form the 
colostrum found the first day or so after delivery, 
being rejected as not possessed of the secreting power 
required for milk. The fluid portion of the colos- 
trum is said to be merely a serous exudation, and in 
no wise a specific secretion of the mammary gland. 
The exact mode of secretion is differently inter- 
preted by different authors. It does not begin until 
two or three days after parturition, when some sud- 
den stimulus upon the perfected glandular structure 
causes a copious formation of fluid rich in proteins, 
sugars, and fats. The sources of the proteins and 
sugars cannot be determined by morphological stud- 
ies, but the origin of the fat compound may readily 
be observed in appropriate material. All observers 
agree that the fat appears in molecular form in the 
central half of the secretory cells, from which it 
enters the fluid in the lumen. 
To account for the development of the mammary 
glands, and the activities which take place at birth, 
puberty, pregnancy, and lactation, and the final 
changes described as coinciding with the climacteric, 
is a difficult matter for the physiologist. Many fac- 
tors must be considered, the most important of which 
are, without doubt, the influence of the hormones, ANATOMY AND PHYSIOLOGY OF BREAST. 
37 
or the internal secretions. Whether one internal 
secretion regulates all of the activities of the glands 
or not, is at present problematical. The conditions 
are so complex that we are prone to believe that 
many internal secretions engage in the process, 
either directly or indirectly. 
Menstruation is actively connected with mammary 
activity, as may be constantly observed, when many 
women can foretell its coming by the feeling in the 
breasts, slight swelling and tenderness, and even con- 
siderable lactation at each period. Experimental evi- 
dence also illustrates this, for when the ovaries are 
removed before puberty, sexual development does not 
occur, and the mammae fail to develop. In cretinism 
with infantilism there may be no production of the 
reproductive organs nor of the mammae, so that fail- 
ure of mammary development may be indirect and 
referred to the failure of the ovarian function, which 
in turn may be referred to failure of the thyroid 
secretion. 
The nervous system has intimate relations with the 
mammary secretion, as shown by experimentation 
and clinical observation. The influence of fright and 
anxiety is well known: it is not at all uncommon for 
complete, temporary arrest of secretion to occur in 
women who have been exposed to either of these 
emotions. It is also well known among parturient 
women that putting the child to the breast, stimu- 38 
CANCER OF THE BREAST. 
lating the sensory nerves of the nipple, results in a 
more profuse flow of milk. Remarkable cases have 
been reported in which the male breast was stimu- 
lated to secretion in this manner. 
It is thus seen that the physiological activities of 
the mammary gland are by no means simple and that 
the mechanism by which it is controlled is compli- 
cated. If the normal activities of the cells compos- 
ing the mammary glands are so involved we can 
readily understand that the pathological activities 
are likewise much the same. So, when the cells 
composing the glands find themselves not supplied 
with exactly the correct pabulum in the blood, and 
not controlled by proper innervation, and arc then 
subjected to undue irritation, as by a blow, a biopsy, 
or surgical interference, they will take on the ab- 
normal activities which result in the histological 
changes described as carcinoma or sarcoma, when 
excised long after their formation into neoplastic 
tumors. CHAPTER IV. 
LYMPHATICS AND LYMPHATIC PERMEATION. 
The surgical books are more and more filled with 
studies and diagrams of the lymphatic distribution 
and of the connection of various lymphatics with 
those in the breast, and one wonders how the sur- 
geon can ever hope or expect to cure the disease, 
carcinosis, by cutting out its original manifestation in 
that locality. The researches of Handley,1 Leaf,2 
Stiles, Lockwood, Deaver, and others have made this 
pretty clear, and we will endeavor to present as 
briefly as possible the present state of knowledge 
concerning this matter. For, while it is desirable 
for the surgeon to know what he has to face, it is 
equally so for the clinician, in order to advise whether 
a surgical operation is at all likely to be of any per- 
manent service in each particular case. It will be 
quite impossible in the space proper for this book 
to present the matter as fully as could be desired, 
and a compilation from authorities must suffice, the 
more full details being sought for in the originals. 
It is too generally considered that it is quite sufficient 
1 Handley: Cancer of the Breast, etc., 2d Edition, London, 1922, 
p. 206. 
2 Leaf: Cancer of the Breast, etc. London, 1912, p. 78. 
39 40 
CANCER OF THE BREAST. 
to investigate the condition of the axillary glands, 
but in "clearing out" the axilla alone it is readily 
understood that often very little is accomplished to- 
ward curing the disease. The x-ray examination of 
the chest, even in early cancer, will sometimes reveal 
an invasion of lymph glands within, which quite ex- 
cludes the possibility of a cure by surgical interven- 
tion. I will quote in full from Handley in regard 
to "the anatomy of the axillary glands." 
"All attempts to give an absolutely precise descrip- 
tion of the axillary glands are defeated by the great 
variations in number and arrangement which they 
present. 
"(A) A chain of six or more glands, lying close 
to the axillary vessels, which extends from the lower 
border of the pectoralis major and receives the lym- 
phatic vessels ascending from the limb. The highest 
of these glands (sometimes called the subclavian 
glands) lie in the space of Mohrenheim, under cover 
of the clavicular part of the pectoralis major, behind 
the costo-coracoid membrane. These glands, situ- 
ated high up at the apex of the axilla, have a special 
importance for two reasons, firstly, because they are 
sometimes found cancerous even when the pectoral 
glands have escaped; and secondly, because they are 
very likely, owing to their sheltered position, to es- 
cape removal during the operation, unless special at- 
tention is directed to them. It is almost impossible to LYMPHATICS AND LYMPHATIC PERMEATION. 
41 
reach them unless the greater part of the pectoralis 
major is removed. The late C. B. Lockwood3 redi- 
rected attention to these so-called subclavian glands, 
which, as Grossmar has pointed out, in io per cent, 
of all cases receive a tributary from the breast, which 
Fig. 8.-Lymphatic plexus, in deepest layers of cutaneous fat, main 
highway for permeation in breast cancer. (Sappey, Handley.') 
reaches them directly by piercing the pectoralis major 
muscle. This lymphatic channel is depicted in 
Poirer's work on lymphatic anatomy. 
"(B) A group of pectoral glands placed along 
the lower border of the pectoralis major and on the 
3 Lockwood: Cancer of the Breast, etc. London, 1913, p. 116. 42 
CANCER OF THE BREAST. 
inner wall of the thorax, in the angle between the 
pectoral muscles and the serratus magnus, which 
are joined by lymphatics from the mammary gland 
and from the front of the chest. 
"(C) A group of subscapular glands situated 
along the lower border of the subscapularis muscle, 
on the posterior wall of the axilla, into which the 
lymphatics of the back pour their contents. This set 
of glands is not as a rule affected in breast cancer, 
but may be cancerous in very advanced cases. 
"(D) Leaf has described a 'central' set of glands 
sometimes lying superficial to the axillary fascia, 
sometimes just deep to it. 
"(E) The uppermost glands of the chain which 
sometimes extends from the bicipital gland to the 
axilla, may be affected in breast cancer (Lockwood). 
"Besides the larger lymphatic glands, obvious to 
the naked eye on dissection, the axillary lymphatics 
present in their course innumerable nodules of lym- 
phoid tissue, each of which is a lymphatic gland in 
miniature." 
Deaver4 has also made a very careful study of the 
lymphatics in connection with breast cancer, and we 
may follow his presentation with advantage. He 
says: "In addition to the lymphatics of the organ 
proper, the adjacent lymphatic plexuses must also 
4 Deaver and McFarland: The Breast, Its Anomalies, Its Diseases, 
etc. London, 1918, p. 37. LYMPHATICS AND LYMPHATIC PERMEATION 
43 
be considered, as malignant disease sooner or later 
transgresses the confines of one to involve other lym- 
phatic systems. The lymph nodes of adjacent sys- 
tems that frequently become involved in carcinoma 
of the breast are, in the order of their importance: 
(a) Supraclavicular, deep cervical. 
(b) Axillary, opposite side. 
(c) Diaphragmatic. 
(J) Hepatic. 
(c) Supraxiphoid. 
(/) Upper brachial. 
(g) Intercostal. 
(A) Inguinal. 
He gives several diagrams of these, including one 
of the diaphragm and one showing connections of 
lymphatics of serratus magnus and intercostal mus- 
cles. He also calls attention to "lymph nodes fre- 
quently involved in carcinoma of the breast but in- 
accessible to the knife. The retro-sternal and in- 
ternal mammary, intercostal, subdiaphragmatic, hep- 
atic, and supraxiphoid group of Sappey may be 
arbitrarily included under the above heading. 
"The retro-sternal group consists of four or six 
nodes lying in front of the internal mammary artery, 
and arranged in a chain which lies near and runs 
parallel to the lateral border of the sternum. Its af- 
ferent vessels come from the mammary integument 
of the pre-sternal region, the anterior portion of the 44 
CANCER OF THE BREAST. 
intercostal spaces, and the superior portion of the 
recti abdominal muscles from the upper surface of 
the liver and from the diaphragm. The hepatic ele- 
ments run in the falciform ligament, to the dia- 
Ent. mammary chain. 
.Ant.mediastinum; 
Ant. diaphragmatic glands 
Gland in front of 
inf. vena cava.. 
, .Lymphatics from teat 
Mid. mediastinunv 
I 
Post, mediastinum, 
Central diaphragm 
alioglands. J 
Post, mediastinal 
k glands 
Inf. ven a cava. 
Esophagus. 
Aorta 
Post, diaphragm ate gland' 
Fig. 9.-Subdiaphragmatic lymphatics. {Leaf, Deaver.) 
phragm, which they pierce near the lateral border of 
the xiphoid process, to enter into the supra-xiphoid 
plexus of Sappey which is tributary to the internal 
mammary plexus. The mammary tributaries of this 
plexus are minute twigs which arise in the paren- 
chyma or inner segment of the breast, and follow LYMPHATICS AND LYMPHATIC PERMEATION. 
45 
the perforating branches of the internal mammary 
artery. These twigs suffer atrophy in senility, so 
that direct cancerous involvement of the retro-ster- 
nal nodes is less frequent than the close association 
between the two would lead one to expect. 
"The intercostal lymphatic plexus is found in as- 
sociation with the intercostal blood-vessels. It anas- 
tomoses in front with the internal mammary plexus 
and behind with the para-vertebral plexus. It con- 
tains two groups of small nodes, one at the point of 
origin of the lateral cutaneous branches of the ar- 
teries, the other in relation with these vessels at 
the angles of the ribs posteriorly. Efferent vessels 
from the latter communicate with vessels of the ver- 
tebral lymphatic plexus. This communication ex- 
plains metastatic involvement of the vertebral bodies 
in some cases of cancer of the breast. 
"The lymphatic distribution as given above is 
founded on anatomical investigation. Clinical and 
pathological evidence indicates that the dissemination 
of mammary cancer principally occurs by way of 
lymphatics contained in the deep fascia. Langhans 
originated this view, with which Heidenhain agreed, 
and Stiles in confirmation of their observations div- 
ides mammary lymphatics into five groups, viz.: 
"(a) Superficial, including those of the nipple, 
areola and surrounding skin. 
"(b) Sub-areolar (Sappey). 46 
CANCER OF THE BREAST. 
"(c) Tntra-mammary. 
"(d) Lymphatics of the circum-mammary adipose 
tissue. 
Fig. 10.-General plan of cervical and axillary lymphatic system. 
(Bonamy, Beau.) 
"(e) Retro-mammary. 
"These systems are intercommunicative, and Stiles 
says: 'The retro-mammary lymphatics receive all 
the efferent mammary lymphatics which leave the LYMPHATICS AND LYMPHATIC PERMEATION. 
47 
posterior surface of the gland.' In this way, there- 
fore, the efferent lymphatics of the corpus mammae, 
of the adipose tissue around it, and of the nipple, 
areola, and skin over it, open directly or indirectly 
into the lymphatics of the deep fascia. Carcinoma- 
tous dissemination, frequently an embolic process, 
primarily depends, as Handley has shown, upon cen- 
trifugal growth from the original focus along fascial 
planes, by a process of peri-lymphatic permeation. 
Therefore, the direction of the lymph current, or the 
convergence of lymphatic trunks at one particular 
point does not absolutely determine the location of 
secondarily involved lymph nodes, which depend 
rather upon the situation of the primary focus and 
the physical characteristics of its surroundings. Ar- 
gument for or against a certain direction of the 
lymph current is not apropos of the question from a 
pathological standpoint." 
Space does not permit of a further consideration of 
the distribution of the lymphatics, which could cover 
many pages more, and we will examine the profound 
researches of Handley into the now thoroughly ac- 
cepted theory, or rather proof, of lymphatic permea- 
tion. His theory seems to depend upon what he calls 
a parasitic character of the epithelial cells, or, in his 
words: "The Epithelial Cell an Obligate Parasite 
upon the Connective Tissue Cell." 5 
5 Handley: Loc. cit., p. 188. 48 
CANCER OF THE BREAST. 
"Certain of the cells of the body-the leucocytes, 
for example, and probably the hemal epithelium-are 
nourished directly from the blood plasma. Others, 
including most, if not all, of the cells of the con- 
nective tissue are fed by the diluted blood plasma, 
which is known as lymph. But the epithelial cells, 
in the course of their specialization, would appear to 
have lost this power of taking up nourishment di- 
rectly from the body fluids. Epithelium appears to 
depend for its nourishment upon the products of the 
connective tissue cell conveyed to it, either by actual 
contact, or at least by close contiguity. The inability 
of the epithelium to nourish itself from the fluids of 
the body is not mere theory. I have shown in previ- 
ous chapters that immersion in the blood stream is 
nearly always fatal to cancerous epithelium. . . . 
"It would take too long to marshal the facts of 
normal histology which support this view that the 
epithelial cell is an obligate parasite upon the con- 
nective tissue cell. The many layered epithelium of 
the skin which appears at first sight to contradict, in 
reality forms one of the best proofs of its truth. The 
deeper layers of skin epithelium are penetrated by a 
network of branching processes, easily visible in the 
negro because pigmented, derived from the under- 
lying connective tissue cells. The superficial layers 
of the epithelium, from which those nutritive proc- 
esses are absent, are continually dying and being cast LYMPHATICS AND LYMPHATIC PERMEATION. 
49 
Fig. 11.-Active infiltration occurring at the edge of the rapidly 
growing mass of primary breast cancer. (Handley.) 
Fig. 12.-Typical infiltration in breast cancer. Lines of cancer 
cells are seen in the tissue interspaces. (Handley.) 50 
CANCER OF THE BREAST. 
off." He then goes on to report work done by his 
colleague, Mr. Bonney, which showed that "a local 
increase in the cellularity of the sub-epithelial connec- 
tive tissue, accompanied also by a destruction of the 
elastic tissue, invariably precedes the appearance of a 
carcinoma. This increased cellularity is due to a 
precedent chronic inflammation. . . . 
"From my point of view, the pre-cancerous in- 
creased cellularity of the sub-epithelial connective 
tissues, which Mr. Bonney has demonstrated, ac- 
quires additional significance. If the epithelial cell, 
normal or cancerous, can live only as a parasite on 
the connective tissue cell, an abnormal aggregation 
of connective tissue cells beneath an area of epithel- 
ium will obviously tend to promote epithelial activ- 
ity, and will provide a body of hosts or caterers who 
will supply the needs of any epithelial cells which 
penetrate into the rarified connective tissue." 
Working along this thought, Handley6 has devel- 
oped his now accepted theory of lymphatic permea- 
tion in a most convincing way, with many illustra- 
tive plates, in a book of 400 pages, to which refer- 
ence should be made, for the subject is one of such 
immense size and importance that it can be but im- 
perfectly presented in the space which can be here 
given. As far as possible the words of the author 
6 Handley: Loc. cit., p. 189. LYMPHATICS AND LYMPHATIC PERMEATION. 
51 
Fig. 13.-Scheme to illustrate the advance of permeation along a small lymphatic; longitudinal sec- 
tion above, transverse section, below. No. 1. Normal lymphatic. No. 2. Permeated by cancer cells. 
No. 4. Ruptured by growing cancer cells, causing inflammatory action. No. 5. False capsule of newly 
formed fibrous tissue. No. 6. Cancer cells strangled by contraction of fibrous capsule, and lymphatic 
converted into a thread of fibrous tissue. {Handley.) 52 
CANCER OF THE BREAST. 
will be given, without actually indicating the loca- 
tion of the quotations. 
Having shown pretty conclusively that the former 
hypothesis of the disease being spread, and caused 
to recur, exclusively or even principally, by embolic 
process could no longer be held, he demonstrated by 
large numbers of microscopic studies that this is 
accomplished mainly by what he has designated 
lymphatic permeation. Put very briefly it means 
that, just as long experience has shown cancer to 
grow and extend widely, attacking and destroying 
any and all tissues, even bones, which it comes across, 
but as a rule following the line of least resistance; so 
having gained access to the lymphatics it travels 
along them, even against the current of lymph, until 
it has converted those attacked into fibrous strings, 
over wide areas, thus rendering them incapable of 
performing the work of the system which belongs 
to them, and leading to the pernicious anemia which 
ultimately destroys life. Following Handley we will 
endeavor to describe the method in which this takes 
place. 
"To the process of actual cancerous growth along 
the fine lymphatic vessels I have ventured to attach 
the name lymphatic permeation, or simply permea- 
tion. It appears to me to be the master process of 
dissemination. For whereas in attempted embolic 
dissemination via the glands, the emigrating cells Fig. 14.-Thoracic duct, receptaculum, and some lymph nodes. 
All permeated with cancerous materials, secondary to cancer of 
rectum. (Hillier, Sutton.') 
53 54 
CANCER OF THE BREAST. 
are cast away in the blood, cancer cells which migrate 
by way of the peripheral anastomatic plexuses sim- 
ply pass into the lymphatic vessels of adjoining areas 
without changing their conditions of life. Advanc- 
ing in this way, slowly and centrifugally from one 
lymphatic area to the next, permeation may conceiv- 
ably bring about the impregnation of the entire 
lymphatic system with cancer. An approximation 
to this condition is seen in the cases where subcu- 
taneous nodules or bone deposits spare only the dis- 
tal portions of the limits." Speaking of the differ- 
ence of injecting the lymphatics with mercury and 
studying the permeation of them by cancer he says: 
"The process of permeation is rather one of tendril- 
like cancerous growth along the vessels. It is inde- 
pendent of the current of lymph and proceeds with 
almost equal facility, either in the direction of or 
against the lymph stream, a fact which affords the 
key to the clinical puzzle that cancer is often seen to 
spread in a direction contrary to the lymph stream." 
The anatomic plexuses which divide the lymphatic 
system of the body into separate areas, and form ef- 
fective barriers against retrograde embolic dissemin- 
ation are powerless to check the advance of permea- 
tion. In fact so far as this process is concerned the 
whole lymphatic system is a single network of acces- 
sible channels and the slow centrifugal extension of 
permeation proceeds insidiously and relentlessly until LYMPHATICS AND LYMPHATIC PERMEATION. 
55 
Figs. 15 and 16.-The growing cancer cells stretch and finally 
rupture, the lymphatic and inflammatory reaction results. 
{Handley.} 56 
CANCER OF THE BREAST. 
it is often checked only by the death of the 
patient. 
The avenues through which permeation takes place 
are given by Handley as: 
i. The skin and subcutaneous fat. 
2. The deep fascia. 
3. The bones. 
Space does not permit of presenting the details of 
Handley's study of these lines of permeation, which 
he illustrates by figures and narration of cases, and 
statistics, but a few points may be noticed. He 
shows how cutaneous nodules are commonly distri- 
buted in a more or less circular area about an affected 
breast, before or after removal; with enlarged supra- 
clavicular glands and those in the neck, and cutane- 
ous nodules appearing also low on the sides and on 
the back, and sometimes even on the abdomen. The 
most interesting portion is that in which he demon- 
strates permeation by means of the deep fascia, which 
had not before been sufficiently recognized in con- 
nection with surgical procedures, and which ac- 
counted in a measure for the numerous recurrences. 
This deep fascial permeation was particularly shown 
in a study of melanotic sarcoma, a disease which is 
generally supposed to be disseminated through the 
blood-vessels. He states: "In sarcoma of the testis 
and of the tonsils, in lympho-sarcoma, and in mel- 
anotic sarcoma, wherever it is situated, the lymphatic LYMPHATICS AND LYMPHATIC PERMEATION. 
57 
glands are frequently involved. In the latter the 
demonstration is more easily effected, owing to the 
pigmentary character of the cells, and he gives a very 
striking plate illustrating the same. He gives also a 
valuable table showing the frequency with which the 
bones in different localities are affected in breast 
cancer. In the sternum and ribs they were found 
affected in 9 and 8 per cent, respectively, among 329 
cases at the Middlesex Hospital, but there were no 
Fig. 17.-Strip of skin and underlying tissue, to demonstrate 
centrifugal spread of permeation, from left to right. A, Skin; 
B, Subcutaneous fat; M, Muscle. {Handley.) 
instances where the radius, ulna, fibula, or bones of 
the foot were involved, and in only one instance the 
tibia, where it was associated with disease in the 
whole femur. All of this corresponds to about that 
which I have seen, except that once, at the Memorial 
Hospital, I saw a metastasis from the breast on the 
top of the right foot, which was demonstrated micro- 
scopically after amputation. Handley explains this 
deep fascial permeation as follows: 
"Besides the small tributaries (of lymphatics) 
which dip down vertically into the fascial plexus from 58 
CANCER OF THE BREAST. 
the surface of the body, there are running upwards 
to the deep aspect of the fascial plexus numerous ves- 
sels by means of which it communicates with the 
lymphatics of the subjacent tissues. I have fre- 
quently observed such vessels passing to the deep 
fascia from the muscles, and the special liability of 
the subcutaneous areas of the skeleton to cancer ap- 
pears to show that the fascial plexus anastomoses in 
a similar way with the periosteal lymphatics wher- 
ever they approach the surface." 
It is impossible in this place to go further into this 
most important subject, but enough has been said to 
show its immense importance, and the insuperable 
difficulties attending any purely surgical considera- 
tion of cancer. If in cancer of the breast, an ex- 
posed region, which has been the subject of such 
great observation and study by so many earnest, 
true, and able investigators, skillful operators, and 
intelligent writers, has still yielded such ultimately 
unsatisfactory results, as surgical statistics show, it 
is high time to seek if there is not some better way 
to approach the subject, and some better means of 
accomplishing desired results than have heretofore 
been commonly used. For even with the addition of 
x-ray and radium the death rate from cancer in 
general has steadily risen, as already stated, nearly 
33 per cent, under surgical dominancy, since 1920, LYMPHATICS AND LYMPHATIC PERMEATION. 
59 
while tuberculosis under careful medical supervision 
has fallen 43 per cent., as the United States mortal- 
ity tables show: and during 1921 the cancer mortal- 
ity has risen still 5 per cent., which is more than the 
increase in any year for a long time. In later pages 
I shall show that exactly proper dietetic, hygienic, 
and medicinal treatment does, not only check the ad- 
vance of breast cancer but, in time actually removes 
all traces of the neoplasm there; and not only this but 
that lymphatic nodes in the axilla, neck, and else- 
where may all thereby entirely be made to disap- 
pear. In other words the proper treatment of the 
carcinosis, of which all these are but products or 
manifestations, can and does, in early cases which 
have not been previously tampered with by any of 
the measures commonly employed, cease, and the 
mutiny of body cells is overcome, and they return to 
their normal state and function, as would mutinous 
soldiers when all the sources of their rebellion were 
removed. CHAPTER V. 
CARCINOMA OF THE BREAST AND PAGET'S DISEASE. 
As is well known, cancer of the breast is a disease 
of middle life, many statistics giving the greatest 
number of cases developing between the ages of 45 
and 50. But well authenticated instances, micro- 
scopically proven, have been seen as young as 16 and 
as old as 85 or older. It occurs both in males and 
females, but in the ratio of about one to one hundred. 
Cancer of the breast stands very high in the list 
of fatal diseases throughout most of the civilized 
world, and is increasing steadily; thus, in year 
1920, it destroyed 9.2 persons in each 100,000 as 
shown in the adjusted United States Mortality Re- 
ports, against 5 per 100,000 in 1900, in spite of the 
active and intelligent application of surgery, x-rays, 
and radium. During 1921, as shown by advanced 
report from Washington, the total number of deaths 
from all forms of cancer had risen from 82 per 
100,000 in 1917, to 86 per 100,000 of population, 
while in New York State it rose from 97.3 to 105.7 
per 100,000; and in Massachusetts, the highest state 
rate, it rose from 109.7 in 1917, to 118 per 100,000 
in 1920. The lowest death rate from cancer of all 
kinds in 1921 was 34.4 per 100,000 in South Carolina, 
60 CARCINOMA OF BREAST AND PAGET'S DISEASE. 
61 
43-6 for the white population and 25.5 for the colored, 
which latter had fallen from 29.1 per 100,000 in 
1917. In 1914 the total number of deaths from 
breast cancer in the United States was 5423, out of a 
mortality of 52,420 from cancer in general, something 
over 10 per cent, of the whole, and 17.4 per cent, 
of the total deaths from cancer in women. 
Cancer of the breast has very naturally been the 
object of histological study more than that of any 
other organ, and a mass of matter has been written 
about it in journals and many very able surgical 
books, which will be quoted from later, as surgeons 
of late years have monopolized the disease, and very 
little has been written upon it medically; one finds 
also considerable diversity of opinion expressed in 
regard to many points concerning it, which can- 
not be entered upon here. It is interesting to real- 
ize, as Ribbert says, that "No one has ever seen a 
beginning carcinoma of the breast." Undoubtedly 
it begins with the rebellion of one or more individual, 
previously healthy, body cells, which have mutinied1 
against the condition in which they find themselves 
in regard to nutrition, including nervous or physio- 
logical control. The immediate or exciting cause 
may have been in some local injury or unjust treat- 
ment, just as it would be in soldiers whose conditions 
1 Bulkley: Cancer, a Mutiny of Body Cells, Medical Record, 
October 1, 1921. 62 
CANCER OF THE BREAST. 
of normal life had become intolerable but who needed 
a personal injury to incite them to mutiny. Many 
writers now acknowledge that local injury cannot be 
recognized as the sole cause of breast cancer. 
Deaver says:2 
"Most surgeons and pathologists are of the opinion 
that injury by external violence or internal disease 
is the chief cause of cancer. Quite a collection of 
cases of cancer following injury and disease can be 
gathered together in support of this theory, but when 
they are carefully sifted they are not entirely con- 
vincing." He then cites very many such claims con- 
cerning cancer in other parts of the body, doubting 
many of them, and then regarding cancer of the 
breast he continues: "But conceding the general 
facts to be true, how can they be connected with the 
occurrence of cancer of the breast? The breast is 
an external organ, and therefore subject to trauma- 
tism, but although there be more cases of cancer 
among those who have met with a traumatic injury, 
there are still great numbers who have no recollection 
of such, and if traumatism were a factor of great 
importance, how about the latter? Again, the breast 
is one of the most frequently diseased viscera, pyo- 
genic inflammation during lactation being very com- 
mon and very destructive, but cancer is not strikingly 
more frequent among those who have thus suffered 
2 Deaver : Loc. cit., p. 477. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
63 
than among others. The hypertrophy and involution 
before and after lactation are striking examples of 
epithelial modifications and might serve as starting 
points for epithelial misbehavior, but the percentage 
of incidence is not much, if any, more frequent 
among women that have borne and nursed children 
than among those that have not. We are, there- 
fore, obliged to admit that mechanical and chemical 
injuries, whether by external violence or internal dis- 
ease, have not yet been shown to be very potent fac- 
tors in the occurrence of cancer of the breast." But 
when we come to speak under etiology of the true, 
basic, or predisposing cause it will be seen that un- 
doubtedly the immediate exciting cause of the mutiny 
may have been, and probably was sometimes, a severe 
injury or a biopsy or a surgical operation, which 
precipitated the formation of a cancer; even as a 
spark does in contact with combustible matter, the 
result depending upon the nature of the latter, rather 
than upon the spark itself; for it is recognized that 
even the irritation produced by the excision of a 
tumor, found microscopically to be only an adenoma, 
has been followed sooner or later by a true, malig- 
nant carcinoma, shown microscopically. 
True carcinoma as now recognized is essentially 
of epithelial origin and character throughout, as sar- 
coma is of connective tissue, with its round and spin- 
dle cells. But sarcoma is a relatively rare disease in 64 
CANCER OF THE BREAST. 
the breasts, forming only from 2 to 3 per cent, of 
breast tumors; still more rarely may sarcoma occur 
in connection with carcinoma in the same breast. 
This will be treated of more fully when considering 
diagnosis. Sarcoma of the breast is also still more 
rare in males. 
Carcinoma, as already stated, begins with the mal- 
formation of a group of glandular cells, which gradu- 
ally increase in number until a small mass is found 
accidentally, which represents the primary neoplasm. 
In very rare cases, however, its first obvious manifes- 
tation is not a nodule, but a diffuse infiltration of the 
whole of one or both breasts. It is recognized that 
chronic mastitis is closely associated with the inci- 
dence of cancer. Sutton3 says of this abnormal con- 
dition of the mammary gland, chronic mastitis: 
"The leading feature of this change is an increase in 
the fibrous tissue of the breast in close association 
with the acini and their ducts: the tissue specially 
concerned is often called the peri-acinous tissue, and 
when the change is widely diffused the gland shrinks 
and resembles the atrophic condition of the breast 
characteristic of old age. Both breasts are usually 
affected. In another form the increase is accom- 
panied by epithelial activity, the ducts of the acini are 
distended with fluid, become lobulated, and on section 
3 Sutton: Tumors, Innocent and Malignant, 7th Edition, London, 
1922, p. 315. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
65 
present a number of cystic spaces which appear to 
be independent, but are really sections of the same 
convoluted duct. Chronic mastitis has been studied 
for many years, with great care, not only on account 
Fig. 18.-Diffuse proliferation of atypical cells in ducts in 
chronic mastitis. A precancerous lesion. (Ewing.') 
of its simulation of the clinical signs of cancer, but 
also from its constant association with this disease." 
Ewing,4 agreeing with former studies of the disease, 
4 Ewing: Neoplastic Diseases, Philadelphia, 1899, p. 476. 66 
CANCER OF THE BREAST. 
says: "It is therefore clear that chronic mastitis is 
a very important predisposing condition to mammary 
cancer. It appears also, from histological evidence, 
that many causes arising in the chronic mastitis do 
not represent wholly new processes but on the con- 
trary are the result of steadily increasing epithelial 
overgrowth which is originally inflammatory and 
affects not embryonal or misplaced tissues, but the 
normal and adult glandular epithelium." All this 
will be considered more fully under diagnosis. 
Cancer is commonly first developed or recognized 
as a small lump in one breast, and it is generally 
stated that the left breast is rather more frequently 
affected than the right, which agrees with our statis- 
tics; of the 250 patients with breast cancer the right 
breast was affected 92 times, the left breast 96 times, 
and 57 not recorded, and both breasts 13 times. 
Among the patients there were 7 with typical Paget's 
disease. This is a larger proportion than in most 
statistics, but this is accounted for by their coming 
to me as dermatological cases. 
Different parts of the breast are more prone to 
develop cancerous tumors than others. Williams,5 
an accurate observer and profound student, very 
much quoted by all later writers, says: "Its peri- 
phery, for instance, is a much commoner seat of the 
5 Williams: A Monograph on Diseases of the Breast, London, 
1894, p. 154. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
67 
disease than its central part. Of 132 cases under my 
observation, in 90 (68 per cent.) the tumor was peri- 
Fig. 19.-Section through a cancerous breast, a, Nipple, d, 
Body, of gland, k, Cancerous mass. I, Cancerous infiltration of 
adjacent tissues, m, Cancerous axillary glands. (Williams.) 
pheral, and in 42 (32 per cent.) central. This agrees 
with what I have elsewhere pointed out, that the 68 
CANCER OF THE BREAST. 
majority of mammary neoplasms arise in the seats 
of the greatest post-embryonic developmental activ- 
ity, where cells still capable of growth and develop- 
ment most abound: that is to say, in the immediate 
vicinity of the acini, which are much more numerous 
in the peripheral than in the central part of the 
gland. 
"Most of the peripheral tumors are met with in 
the upper and axillary segments. Thus in 90 cases 
under my observation the disease was situated in the 
upper segment in 46, in the axillary in 20, in the 
lower in 20, and in the sternal in three. This coin 
cides with the results arrived at by Winiwarter and 
Gross: the latter's analysis of 256 cases gives 90 for 
the upper, 83 for the axillary, 51 for the lower, and 
32 for the sternum segment. A considerable number 
of these peripheral cancers are situated quite outside 
of the mammary gland, from outlying sequestrated 
mammary structures. This happened in 9.8 per 
cent, out of 132 consecutive breast-cancer cases under 
my observation. Of 29 neoplasms that originated in 
this way, 15 were in situation axillary, 8 sternal, and 
6 were found above the breast." 
The small groups of mutinied cells may or may 
not remain long in the same condition, though the 
rapidity of development of the cancer may vary 
greatly in different patients, according to the degree 
of systemic carcinosis, as we shall see later on; while CARCINOMA OF BREAST AND PAGET'S DISEASE. 
69 
in some cases, especially during lactation, the disease 
is frightfully rapid, resulting in death in a few 
months, in other instances a carcinomatous lesion in 
the breast has remained 20 years or more, giving 
little or no inconvenience. 
Fig. 20- Histological section of cancer, showing the roots. 
(Waldeyer, Williams.) 
But as we have seen in regard to lymphatic per- 
meation, the lump or mass itself is often but a small 
part of the neoplastic process. As long ago as 1830 
Astley Cooper0 wrote as follows: "I would observe 
6 Cooper, Astley: Lectures on Surgery, London, 1839, p. 386. 70 
CANCER OF THE BREAST. 
that the scirrhous tumor is not all of the disease, there 
are roots which extend to a considerable distance, and 
those who gave the disease the name of cancer prob- 
ably knew more of its nature than we are disposed 
to give them credit for. It is supposed by some that 
this name was given on account of the appearance 
of the surrounding veins. I should rather say that 
it was from the appearance on dissection than from 
anything without. When you dissect a scirrhous 
tumor you see a number of roots proceeding to a 
considerable distance, and if you remove the tumor 
only, and not the roots, there will be little advantage 
from the operation." This accords remarkably with 
what we know so well, both clinically and by labora- 
tory studies. 
There are some clinical features in cancer of the 
breast, connected with its pathology which are of 
importance to consider, but whose value requires to 
be weighed in each case before being accepted as 
conclusive. 
i. Retraction of the nipple. This varies greatly in 
different cases and depends on a definite mechanical 
cause, and may be induced by any neoplastic or in- 
flammatory disease of the breast which tends to cause 
a shortening of the milk ducts and peri-ductal con- 
nective tissue and Cooper's ligaments. Tumors cen- 
trally located are more likely to produce retraction 
than those that occupy the periphery of the breast. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
71 
There is no greater fallacy than the very general 
assumption that the retraction of the nipple is an es- 
sential symptom of cancer of the breast; and no 
Fig. 21.-Cancerous breast in section showing retraction of 
nipple. Dotted line shows extent of retraction of nipple and 
areola. (Sutton.) 
greater error than that with this symptom alone the 
diagnosis of cancer of the breast is confirmed, and 
that without it the disease must be of another kind. 
The nipple is often congenitally retracted, but this is 
generally bilateral. It may be caused by any neo- 
plastic or inflammatory disease which tends to short- 
ening of the milk ducts and peri-ductal connective 
tissue. Deaver says that 5 per cent, of benign growths 
cause the nipple to retract, and that it is relatively 
more frequent in tuberculosis than in carcinoma. 
The truth is that retraction of the nipple is only an 72 
CANCER OF THE BREAST. 
accidental symptom of cancer of the breast, met with 
when the disease is so situated that the ducts of the 
gland are drawn on by the infiltrating process, and, 
as a consequence the nipple is pulled, as it were, to- 
wards the infiltrated lobe; by itself it is of no special 
value. Again, should the infiltrating lobule be placed 
at the periphery of the gland, where, by its contrac- 
tion the ducts are but little affected, the nipple may 
be only slightly drawn, and sometimes to one side 
or the other. 
2. Attachment to the skin, and dimpling and puck- 
ering. This also is a mechanical affair, which, how- 
ever, is of much more importance when it is well 
marked and clearly associated with other definite 
clinical signs. It is due to the contraction of Coop- 
er's ligaments which attach the breast tissue to the 
skin and support it in place. Lockwood7 remarks: 
"A carcinoma which has puckered the skin, or re- 
tracted the nipple, is sure to have been growing for 
a long period and to have had plenty of time to in- 
vade the lymph vessels." The earliest manifesta- 
tion of this is the appearance on the skin, some- 
where, of a more or less wrinkled appearance, over 
an area of an inch or so, and on gentle palpation it 
will be found that that portion differs from the ad- 
joining skin, in that it cannot be pinched up like the 
normal skin; it will be a little depressed. 
7 Lockwood: Cancer of the Breast, London, 1913, p. 132. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
73 
Another form of skin disturbance is described, and 
pictured, as dimpling of the skin, in which over a 
greater or less area there are many minute depres- 
sions, giving to the tissue what is called a "pig skin" 
appearance, like the material often used in making 
horse saddles. I cannot say that I have often recog- 
nized it clinically, but it is frequently referred to. 
Fig. 22.-Mammary cancer. Advanced carcinoma simplex. 
Retraction of nipple; dimpling of skin. {Ewing.) 
Puckering of the skin, however, is a very com- 
mon condition, found especially in late cases of scir- 
rhus, where it often forms a very striking feature. 
The skin will be very firmly drawn in, occasionally in 
very curious manners, making deep fissures, at the 
bottom of which slight ulceration may begin. The 
skin is firmly attached, and cannot be moved by 
manipulation. 74 
CANCER OF THE BREAST. 
Exaggeration of the involvement of the skin is 
seen in the "brawny arm," so well known to occur 
after surgical removal of the breast. With the arm, 
Fig. 23.-Puckering of skin in recurrent carcinoma. (Handley.) 
even including the hand and fingers, intensely swol- 
len and hard, the skin is found to be infiltrated, and 
often of a firm, dense structure, which cannot be 
pinched up, and often of a darkened, brawny color. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
75 
Cutaneous nodules are a well-known expression, 
both in fairly early as well as in recurrent cancer, 
after surgical operations. They express lymphatic 
permeation, and as a rule are an indication against 
the possibility of advantage from further surgical 
Fig. 24.-Mammary cancer. Postoperative recurrence. (Ewing.) 
procedures. These cutaneous nodules generally ap- 
pear first near the original focus, or in the neighbor- 
hood of scars from previous operations. They com- 
monly begin beneath the skin, and can be felt as 
shotty papules with the skin of natural color over 
them. They soon redden and increase in size and 
may later ulcerate, although they may also remain 
simply as reddened nodules of varying size for a long 
time. 76 
CANCER OF THE BREAST. 
Cancer en cuirasse is a rare condition of acute or 
chronic dissemination of cancerous elements in the 
skin, whereby the whole integument, even over a 
large area is affected, producing a hide-bound condi- 
tion, ultimately resulting in compression of the chest, 
and fatal, sometimes, in a few months. Commonly 
this begins with the formation of the cutaneous nod- 
ules just described, which develop in larger and 
larger numbers and more or less fuse together; in 
other cases there is an erythematous condition of the 
skin, spreading almost like erysipelas, often in 
patches, which also fuse together until there is a large 
area. Velpeau,8 who originally described this condi- 
tion, related a case where the disease thus extended 
from the umbilicus on to the neck, in which the suf- 
fering was so great that she begged for a lethal dose 
of-opium. The cause of all this is understood in con- 
nection with lymphatic permeation, and Handley has 
studied it microscopically, under the name of pachy- 
dermia, in connection with breast cancer. 
3. Axillary adenopathy has long been recognized 
as an important diagnostic sign in breast cancer, and 
when well pronounced is undoubtedly an invaluable 
aid. But it is well known that axillary adenopathy 
may arise from many causes, and is not necessarily 
pathognomonic, except when accompanied by other 
8 Velpeau: A Treatise on Diseases of the Breast, Translated by 
Henry, London, 1856, p. 340. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
77 
unmistakable signs. From what has preceded, in 
regard to the very wide dissemination of carcinoma 
of the breast through other lymphatic channels and 
the recurrence of lymph nodes, often very small, in 
other and inaccessible situations, and from the state- 
ments of many reliable observers, that axillary adeno- 
Fig. 25.-Cancer en cuirasse, recurrent, with lymphedema 
of arm. {Deaver.) 
pathy was not discoverable in cases of cancer of the 
breast, found to be such microscopically after opera- 
tion, this sign is not to be absolutely relied on with- 
out other substantiating evidence. The matter will 
be again considered under diagnosis. 
The nomenclature of cancer of the breast has been 
put to a hard test, according to special views of dif- 
ferent writers, and Deaver9 has made a list of fifty- 
9 Deaver and McFarland: Loc. cit., p. 481. 78 
CANCER OF THE BREAST. 
four different names which have been given to this 
malignant neoplasm, many of them to represent clin- 
ical features and others regarding pathological char- 
acters, etc. But he narrows them down to six, which 
he gives, including most of the others in groups, 
which need not be here specified: 
"i. Scirrhous or hard cancer, in which the prevail- 
ing cell nests are small and the quantity of connec- 
tive tissue between them considerable, and in which 
the tumor usually appears small and hard. 
"2. Encephaloid, medzdlary, or soft cancer, in 
which the prevailing nests are large, and the quan- 
tity of connective tissue between them relatively 
small, and in which the tumor tends to be large and 
soft. 
"3. Carcinoma simplex, an intermediate form, 
characterized by cells packed together in more or less 
solid masses, without enough connective tissue to cor- 
respond to scirrhus or enough cellular elements to 
correspond to encephaloid. 
"4. Adeno-carcinoma. By this term is meant 
those forms of cancer in which the growing and ex- 
tending cancer nests and extensions maintain a more 
or less distinctly glandular appearance, through an 
arrangement of the cells by which hollow cylinders 
are continually formed. The arrangement obtains in 
both the primary tumors and their metastatic second- 
aries. It is unfortunate that the term adeno-carcin- CARCINOMA OF BREAST AND PAGET'S DISEASE. 
79 
oma has been used by many to signify that the can- 
cer has developed from glandular tissue, and not 
from surface epithelium. Such is not the usage of 
the term employed here. 
Carcinoma. 
- Adenoma. 
Fig. 26.-Fibroadenoma surrounded by carcinoma, original 
tumor existed twenty years. (Sutton.) 
"5- Gelatinous carcinoma. This is any form of 
carcinoma, in which the stroma or matrix, together 
with the cancer cells, is transformed, with great regu- 
larity, into a mucous jelly. The conditions are com- 
mon to the primary tumor and to its secondaries as 
well. 80 
CANCER OF THE BREAST. 
"6. The squamous cell carcinoma. A form of can- 
cer that may arise from the squamous epithelium of 
the skin or nipple, areola or surface of the breast, 
or from the squamous epithelium of the terminations 
of the larger milk ducts in the nipple. It is some- 
times pigmented, when the tissue from which it 
springs contains pigmented cells. 
"When carcinoma follows the invasive growth of 
the intra-cystic papilloma, it is in no way peculiar, 
except that it is associated with its parent lesion." 
Such is a clinical study of the disease. He also rec- 
ognizes cysts in a separate section, including cancer 
cysts, which Bloodgood has described, of which he 
says: "The name is hardly justified pathologically, 
as no particular kind of cyst is indicated. Cancer 
and cysts may occur in relation to one another in 
two ways: First, both morbid conditions occurring 
in the same breast and in close juxtaposition to one 
another, the cancer invades the inner wall of the ex- 
isting cyst and forms a projecting, reddish, more or 
less polypoid excrescence from its wall. Second, a 
small cancer by obstructing and irritating a duct may 
occasion the formation of a cyst, in the wall of which 
it subsequently appears." 
From a pathological standpoint Ewing10 says: 
"While there are several well defined anatomical 
forms of mammary cancer, the specific features char- 
10 Ewing: Neoplastic Diseases, Philadelphia, 1919, p. 491. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
81 
acterize chiefly the early stages of the disease. Aris- 
ing under markedly different conditions of a wide 
variety, the anatomical distinctions are often obliter- 
ated when the disease is fully established and the 
local lymphatics invaded. On chiefly anatomical fea- 
Fig. 27.-Intra-cystic papilloma of the breast. (Deaver.) 
tures the disease may be considered under the fol- 
lowing forms: 
"i. Adenocarcinoma, arising chiefly in cysts of 
ducts or sweat glands. 
"2. Duct carcinoma, arising from the lining cells 
of ducts. 
"3. Acinar carcinoma, arising from the epithelium 
of the acini. 82 
CANCER OF THE BREAST. 
"Of these main groups there are several subdivis- 
ions, such as gelatinous or mucous carcinoma, fibro- 
carcinoma, and carcino-sarcoma, while striking clin- 
ical features stamp certain cases of the disease as 
highly specific. . . . Not until the anatomical struc - 
ture and histogenesis of these tumors is more fully- 
understood can any significant knowledge be ob- 
tained of their etiology, prognosis, and the value of 
treatment. . . . Clinical features seem to be a less 
satisfactory basis of nomenclature and classification 
of cancer of the breast than with many other organs. 
The condition of the breast at the time of the devel- 
opment of the tumor has a prominent influence on 
the anatomical and clinical course of the disease. 
In elderly subjects various forms of cancer develop, 
but the disease is usually of slow course, and fibrosis 
and cicatrization are prominent. In small, atrophic 
breasts, at any age, glandular tissue being deficient, 
carcinoma usually takes the form of duct cancer, of 
the comedo type, and often affects the sweat glands." 
Following Ewing, and others, we will briefly consider 
the main divisions and description, without many ac- 
tual quotations. At the best, the clinical features of 
various forms are often greatly mixed up by syste- 
matic writers. 
i. Adeno-carcinoma. This represents the first step 
in the deviation from typical epithelial proliferation, 
and is one of the rarer forms of carcinoma. It dif- CARCINOMA OF BREAST AND PAGET'S DISEASE. 
83 
fers from adenoma proper in that it has no definite 
capsule but the small carcinomatous processes gradu- 
ally extend into the adjoining connective tissue, as in 
all cancers. 
It is claimed that the majority of these tumors 
arise in the cysts of chronic mastitis, and they 
are frequently multiple, and simple cysts or cysts 
with papillary adenomas may accompany the main 
tumor. Beginning small, they grow comparatively 
slowly, but steadily, to a rather large size, when the 
skin breaks down and a fungating mass is formed. 
The lymph nodes are rarely invaded until late in the 
disease, when the tumor has been converted into one 
of the other forms of carcinoma, after they have 
broken through the capsule, invading the breast and 
lymphatics. 
"Secondary changes are relatively frequent in ad- 
vanced tumors. Fatty degeneration is often ob- 
served, and considerable areas of necrosis may ap- 
pear in gross section. Over-development of blood- 
vessels produces a vascular tumor, prone to hemor- 
rhage, infarction, and necrosis. Repeated hemor- 
rhages may leave much pigment and give the appear- 
ance of a secondary melanoma." 
The simplest structure is a papillary'adenoma with 
carcinomatous foci. The papillae are low, and freely 
anastomosing bands of stroma tend to yield an alveo- 
lar structure, with many sacculations. The cells are 84 
CANCER OF THE BREAST. 
cuboidal or low and cylindrical, granular, opaque, but 
usually over-nourished and atypical. A more mal- 
ignant form shows little evidence of papillary struc- 
ture in the gross, but is solid and opaque. Every- 
where epithelium predominates over stroma. 
Fig. 28.-Mammary cancer. Bulky fungating adenoma 
malignum. {Ewing.} 
The most malignant forms of adeno-carcinoma, de- 
veloping in cystadenoma, produce bulky tumors in- 
vading most of the breast, perforating the skin as 
fungating masses, and early involving the lymphatics 
in various directions. The gross appearance, transi- 
tional types, and minute structure point clearly to the 
origin of these tumors from the papillary ingrowths 
of mammary cysts. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
85 
Mucoid carcinoma is usually an adenocarcinoma 
with mucous degeneration of stroma or cells, and 
owes its slow course both to its comparatively adeno- 
matous structure and to the mucous changes in its 
stroma, which greatly interfere with nutrition. 
2. Duct carcinoma. Carcinoma arising in the in- 
tralobular and large ducts produces tumors of char- 
acteristic gross and microscopical structure and some- 
what peculiar clinical course. The tumor usually be- 
gins near the nipple and affects the central portion 
of the gland, or it may appear in any portion of the 
breast. In the more malignant forms the organ may 
be considerably enlarged by diffuse growth, in which 
case the typical gross features may be lost. This 
form of tumor frequently develops in breasts which 
are the seat of diffuse chronic mastitis. In such 
cases the uniformly smooth section of the fibrosed 
organ shows at one or more foci a more dense and 
cicatricial appearance which is the result of the des- 
moplastic quality of the carcinomatous process. At 
the same time grayish yellow points appear from 
fatty changes in groups of tumor-cells, or from ac- 
cumulation of fatty matter in ducts. The tumor 
often takes the form of fibro-carcinoma with vary- 
ing cell content, but in many cases the typical small 
cystic types are observed. The structure presents 
marked proliferation of the lining cells, first of the 
larger, then of the smaller ducts, or vice versa. The 86 
CANCER OF THE BREAST. 
walls of the ducts are thickened, fibrous, or hyaline, 
and the lumen moderately dilated. 
The origin of this form of mammary carcinoma 
has been satisfactorily traced to the lining cells of 
the inter-lobular ducts. That the acini themselves 
may become involved and contribute to the sources 
of these tumors is indicated by minute examination 
of early cases. 
3. Acinar carcinoma. There are, however, mam- 
mary carcinomas which are derived chiefly or exclus- 
ively from the acinar epithelium. They occur under 
several dififerent conditions, but their total number 
is distinctly less than that of duct carcinomas. Aci- 
nar carcinoma, in this restricted sense develops in 
the malignant transformation of fibro-adenoma, it 
occurs in rare cases of small alveolar carcinoma, and 
it produces a type of fibro-carcinoma. These tumors 
are characterized in general by a dififuse growth and 
lack of encapsulation, by absence of the specific gross 
features of many duct cancers, by a structure in 
which small alveoli predominate, while the cells are 
usually small, and lack the pavement form and clear 
cytoplasm of the duct epithelium. In some cases of 
productive mastitis, and possibly in otherwise unal- 
tered breasts, the acinar epithelium may give rise to 
a malignant form of scirrhus or fibro-carcinoma. 
About the unaltered larger and the intralobular ducts, 
the acini become increased in number and break up CARCINOMA OF BREAST AND PAGET'S DISEASE. 
87 
into many small groups of atypical cells with hyper- 
chromatic nuclei. The connective tissue is much in- 
creased, and soon becomes fibrous, while the tumor 
cells are compressed into narrow rows, or small 
groups. Many cases of primary scirrhus develop in 
this manner. 
Fig. 29.-Mammary carcinoma arising on chronic mastitis and 
involving nipple and ducts. (Ewing.) 
Although Ewing discusses cancer mainly from a 
pathological standpoint he is an able clinician, as 
many remarks in his monumental work demonstrate. 
In regard to the Clinical varieties of cancer of the 
breast, he says:11 
11 Ewing: Loc. cit., p. 513. 88 
CANCER OF THE BREAST. 
"The clinical course of mammary carcinoma is in- 
fluenced by the condition of its origin, and the struc- 
ture of the tumor; by the age, susceptibility and phy- 
siological condition of the patient; and by many in- 
Fig. 30.-Pathogenesis of cancer. Enlarged acini packed with 
polymorphic cells. At a and c the epithelial cells1 are invading 
the stroma. (Gross, Williams.) 
tercurrent factors. Most prominent is the influence 
of structure and conditions of origin, and most cur- 
rent clinical classifications show a definite relation 
to these features. Age has a most pronounced influ- 
ence on most anatomical varieties. The relatively 
malignant course of most structural types of the dis- CARCINOMA OF BREAST AND PAGET'S DISEASE. 
89 
ease in growing subjects is uniformly recognized. 
The cellular varieties belong to the early decades, 
the scirrhous forms to late periods: yet there are 
imany exceptions to this general rule. Cystic adeno- 
carcinoma and colloid tumors are of relatively late 
occurrence. The very marked aggravations of the 
disease produced by gestation and lactation are com- 
monly observed. Cancer may apparently arise dur- 
ing gestation and prove fatal before its termination. 
While there are doubtless marked variations in the 
susceptibility of patients to the progress of the dis- 
ease, the nature of this constitutional element is as 
obscure here as elsewhere." We shall hope in later 
pages to show that "this constitutional element" is 
by no means obscure, and that, acting upon even our 
present knowledge the disease carcinosis, upon which 
all of these multitudinous cell changes depend, can 
be overcome, and the patient remain free from the 
manifestations for many years or indefinitely. 
Clinically he recognizes several varieties of mam- 
mary cancer. These are (i) Cyst-adenoma, (2) 
Medullary or encephaloid cancer, (3) Acute carcin- 
osis, (4) Scirrhus carcinoma, cancer en cuirasse 
only a phase of many forms, (5) Fibro-carcinoma, 
(6) Mucoid carcinoma. But when one comes to 
study carefully the dozen or more books treating of 
mammary cancer there is an amount of confusion as 
to terms and description which is appalling. We 90 
CANCER OF THE BREAST. 
will endeavor in later pages to make the matter as 
clear as it can be under the circumstances. 
Williams12 has made an interesting study on "The 
question of the origin of malignant from non-malig- 
nant neoplasms." He says: "Important practical 
issues are involved in the solution of the question as 
to the alleged liability of non-malignant neoplasms 
to become malignant." He himself does not believe 
this to be often the case, although he admits the pos- 
sibility, with Astley Cooper who said: "I believe that 
if a person has a tumor of the breast which is not 
malignant, and that it remains so until the change of 
life takes place, that then an undue action may be 
excited in the part, and the tumor becomes scir- 
rhous." Williams agrees that "since innocent neo- 
plasms may inflame, suppurate, ulcerate, necrose, and 
degenerate, just like other physiological parts of the 
body, it seems not unreasonable to suppose, on a 
priori grounds, that they may also become the seats 
of malignant disease." But on critical examination 
he rather excludes it, saying that in many instances 
it is perfectly evident that the association of the two 
is a mere coincidence, each neoplasm having origin- 
ated from the gland independently, and gives in il- 
lustration five instances from those prominent in can- 
cer surgery. Of 254 consecutive cases of mammary 
12 Williams: A Monograph on Diseases of the Breast, London, 
1894, p. 310. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
91 
cancer of which he had made a detailed examination, 
the disease was associated with fibro-adenoma in only 
two, of which he gives the details: but the relative 
Fig. 31.-Chronic cancer of right breast. (Nunn.) 
frequency with which fibro-adenomatous and cancer- 
ous neoplasms arise in the female breast, he showed 
was in the proportion of one to five. Ewing agrees 
that "the development of an epithelial tumor from 92 
CANCER OF THE BREAST. 
fibro-adenoma is rare." Undoubtedly in the many 
instances one meets with, where operations on breast 
tumors called cancer by surgeons at large, when 
there was no recurrence after removal these were 
only benign affairs, such as cysts, adenoma, fibro- 
adenoma, etc. For, unfortunately, of the large num- 
ber of operations, except in large hospitals and by 
prominent surgeons, in relatively few instances are 
the removed tissues pronounced upon by skilled 
pathologists. 
Paget's Disease. 
There has been much discussion in regard to this 
interesting form of carcinoma of the breast, ever 
since Sir James Paget13 first published his clear de- 
scription of it in 1874, based on 15 cases, all of 
which developed deep carcinoma later. Although 
Velpeau in 1840 described it as a "scabby degenera- 
tion of the nipple," he did not attach importance to 
it as a forerunner of cancer. Ewing14 describes it 
as "a specific, chronic progressive disease of the epi- 
thelium of the mammary nipple and adjoining skin, 
which is closely related to and almost invariably fol- 
lowed by carcinoma." 
Deaver15 discusses the matter pretty thoroughly, 
13 Paget, Sir James: St. Bartholomew's Hospital Reports, 1874, 
pp. 87, 89. 
14 Ewing: Loc. cit., p. 805. 
15 Deaver: Loc. cit., p. 686. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
93 
and gives references to 197 publications concerning 
it; Handley devotes 34 pages to the subject, and in 
1904 called it " a mysterious entity standing by it- 
self," but in the last edition of his book10 he studies 
it very fully and demonstrates well the serious char- 
acter of neglected cases, with which most surgical 
writers agree. Sutton17 in his usually clear style 
Fig. 32.-Paget's disease. Early stage. (R. L. Sutton.) 
summarizes the studies of Handley thus: "He makes 
it clear that the thickened eczematous condition of 
the nipple is not the precursor but the result of a 
subjacent cancer, commencing near the nipple. For 
example, a carcinoma starts in the smaller ducts of 
the breast, and, without producing a palpable tumor, 
permeates the breast lymphatics widely. The rich 
plexus of lymphatics around the ducts forms an easy 
16 Handley: Loc. cit., pp. 338-372; p. 363. 
17 Sutton, Sir John Bland: Loc. cit., p. 320 94 
CANCER OF THE BREAST. 
and convenient channel for permeation, and the lym- 
phatic block extends along them to the subareolar 
plexus beneath the nipple, causing edema and ne- 
crosis of the overlying cutaneous structures." 
When first seen by the physician the lesion com- 
monly presents the appearance of an ordinary eczema, 
and is generally wrongly treated as such too long, 
until its rebelliousness to all usual remedies proves 
the contrary, and ordinarily by that time lymphatic 
permeation has already taken place. There are cer- 
tain features, however, which distinguish it from 
simple eczema, which if very carefully observed 
should suffice to differentiate it. The lesion is al- 
ways almost circular, involving and surrounding the 
nipple, with a sharply defined and often slightly 
raised border, different from the indefinite edge, 
merging into the healthy skin, seen in eczema. There 
is also generally a little hardness, unlike the leathery 
infiltration felt in chronic eczema. The color also is 
more brilliant, intensely red, and the surface more 
raw and granular than found in eczema, even with- 
out scratching, for there is rarely any amount of 
itching. There is never much discharge, but a sticky, 
viscid, exudation from the abraded surface, which 
may glaze over, if properly treated, and does not 
seem to form much of a crust, but is very rebellious 
to heal. It is often, for a while, an indolent lesion, 
giving relatively little annoyance. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
95 
Fig. 33.-Paget's disease, 5 years duration. Patient aged 61. 
Outer lesion cleared up under X-ray, but mamma involved 
early. Death 18 months after. (Sequira.) 96 
CANCER OF THE BREAST. 
Handley's own description of the origin and char- 
acter of the changes belonging to Paget's disease are 
as follows, for we need not describe the various stud- 
ies of others, which he gives, all of which lead up to 
his conclusions. "A carcinoma starts in the smaller 
ducts in the breast, perhaps exceptionally from the 
acini or the larger ducts. Usually, without produc- 
ing a palpable tumor, it permeates the breast lym- 
phatics widely. The cutaneous lymphatics about the 
nipple are now dammed up so that lymph cannot re- 
turn from them. Later they are themselves perme- 
ated, but possibly this is not always the case. At 
this stage and before any lump has appeared in the 
breast, the skin of the nipple and mucosa of the 
ducts begin to show changes dependent upon lym- 
phatic obstruction. The epithelium shows disintegra- 
tion and degeneration of its superficial layers, with 
proliferation of the deeper layers. The dermis be- 
comes thickened by solid lymphatic edema, etc." 
Paget's disease is almost uniformly unilateral, I 
do not know of both breasts being affected at the 
same time, and have never seen it so, though it has 
been reported, also that it may spread extensively, 
covering a wide area. It is rarely connected with 
lactation, although cracked nipples and ordinary ec- 
zema in that region are not uncommon and often 
troublesome. It is a rare disease. Thomas Bryant18 
18 Bryant, Thomas: The Diseases of the Breast, London, 1887, p. 
167. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
97 
states that he had recorded but three instances in 600 
consecutive cases and quotes Gross and Oldekop's 
tables as 5 in 370 cases, and Henry Morris two out of 
305 cases, and Deaver mentions only one case among 
575 which formed the basis of his pathological stud- 
Fig. 34.-Section through Paget's eczema. On right epithe- 
lium disappearing, at A, a round cell infiltration, at zone of 
origin of lymphatic vessels, at B, a deep lymphatic invasion. 
(Handley.) 
ies. There were 7 instances among my 250 patients, 
the larger proportion being explained by their com- 
ing to me during my dermatological practice. The 
ages were 32, 44, 48, 59, 67, 76, 76 years when first 
observed. It is stated that several years, even five, 
may elapse before a demonstrable carcinoma in the 
breast may appear, though in some of Paget's own 98 
CANCER OF THE BREAST. 
cases such occurred in one or two years, while in 
those reported by others the outer breast eruption ex- 
isted 5, io, and even 20 years, before a deep cancer- 
ous lump developed, as in the case reported by 
Jamieson.19 
The axillary glands are not involved in Paget's 
Fig. 35.-Two layer lymphatic ducts from Paget's disease 
choked by necrotic epithelium. {Handley.') 
disease, certainly not in its early stages, and may not 
be even in instances where it has long existed, or 
until a mass is found deep in the breast. Nor does 
the affected surface become ulcerated, as in ordinary 
carcinoma, although in one of the two oldest patients, 
aged 76, there was a fungating mass 28 years after 
its first appearance at the nipple, and 11 years after 
19 Jamieson: Diseases of the Skin, Edinburgh, 4th Edition, p. 537. CARCINOMA OF BREAST AND PAGET'S DISEASE. 
99 
Fig. 36.-Paget's disease of right nipple in a male. (Handley.) 100 
CANCER OF THE BREAST. 
it was so diagnosticated by one of the leading sur- 
geons in New York, as learned by a letter written by 
him. When the tumor appears later in the breast, 
this may run the usual course and be ulcerated. 
While what is called Paget's disease belongs prim- 
Fig. 37.-Vertical section through edge of Paget's disease in 
male. Anatomical arrangement of permeated lymphatics well 
shown. Narrowed lymphatic vessel running diagonally to 
deeper plexus. (Handley.) 
arily to the breast of women, reliable observers have 
reported its existence on the male breast, and also in 
other locations, especially about the penis and scro- 
tum. The surgical books all urge early and complete 
operation, with which the dermatologists agree, but 
as far as I can find there is no record of the end 
results, whether this measure has resulted in a per- CARCINOMA OF BREAST AND PAGET'S DISEASE. 
101 
manent cure of the cancer. From what we have 
learned from Handley, lymphatic permeation has 
probably proceeded so far before this is done, that 
there is little prospect of ultimate success. I have not 
been able to follow my cases long enough to speak 
confidently in regard to the matter, as so many pa- 
tients are lost sight of; I know some of them have 
resorted to surgery, but cannot learn the late results. 
In one instance, at least, in a very intelligent lady 
aged 48, a perfectly characteristic eruption disap- 
peared, with no breast tumor, or axillary nodes, after 
most careful local measures, combined with her 
assiduous attention to complete dietary, hygienic, and 
medicinal measures, over a period of two and a half 
years, after having existed two years before coming 
under treatment; and she is still under observation at 
stated intervals. 
Studying over the changes in tissue which belong 
to the normal evolution and involution of the mam- 
mary cells, both in respect to advancing age and lac- 
tation, one does not wonder at the multitudinous al- 
terations from the normal which have been described 
by various investigators in connection with what is 
called cancer in general, as found by the microscope 
in those cells which have long mutinied. There is a 
great similarity and dissimilarity in them, and very 
considerable difference in both the clinical and patho- 102 
CANCER OF THE BREAST. 
logical features which have been described and pic- 
tured, so that the uninitiated must be puzzled. But 
in all of them there is an irregular, atypical, abnor- 
mal development which results in a malignancy, tend- 
ing to perpetuate itself and extend until, if not 
checked, the process destroys life. But to the think- 
ing mind all this seems natural enough. 
The reason for this malignant action, which must 
first start in some individual cell, or cells, has never 
been explained, and it is universally stated that we 
do not know the cause of cancer. But there is no 
mystery in the disease. Everything has a cause. 
And when one has seen and watched, for years, hun- 
dreds of patients, both with the primary disease and 
recurrent, postoperative cases, and has studied their 
individual lives, and has seen the local lesions of car- 
cinosis disappear, or improve under careful and pro- 
longed medical guidance, and the progressive ad- 
vance of the disease when this has been neglected, 
it seems impossible that any rational being could 
doubt the relation of cause and effect. The results 
of laboratory, and experimental research are 
acknowledged to be negative, and one is forced by 
them, and by many positive reasons to turn to faulty 
metabolism as a cause for the erroneous actions of 
the cells. Ewing and others repeatedly mention 
"atypical, over-nourished cells" in connection with 
cancer. The fact is that in practically every part of CARCINOMA OF BREAST AND PAGET'S DISEASE. 
103 
the human frame where epidermic cells are found, 
there is a liability for them to become diseased, either 
primarily or secondarily whenever there is a proper, 
or improper, common, systemic or constitutional 
cause capable of reaching every cell in the body. 
This, of course, is formed in the blood, from which 
they take their nourishment, which is profoundly af- 
fected in cancer, as Price-Jones,20 Gruner,21 and 
others have so clearly shown. The blood has been 
studied too much, perhaps, in regard to its cellular 
elements, and too little in regard to its plasma, in 
which the cells are bathed, and from which they re- 
ceive their right or wrong pabulum. 
It is granted, of course, that local irritation of 
some kind or another has started a cell or cells in 
their mutinous action,22 and destructive tendency, 
throwing off their allegiance to physiological control, 
even as soldiers who had long been dissatisfied with 
their food and surroundings would be incited to open 
rebellion by rough or unjust treatment by subordi- 
nate or other officers. So, a prolonged irritation in 
the mouth, a blow on the breast, a former inflamma- 
tory disease, a biopsy, or a surgical operation, weak- 
ens the tissues of the breast and starts the cells on 
20 Jones, Price: Blood Pictures, etc., New York, 1921, p. 56. 
21 Gruner, O. C.: The Exact Diagnosis of Latent Cancer, Phila., 
1919; pp. 61, 72. 
22 Bulkley: Cancer a Mutiny of Body Cells, Medical Record, Oct. 
1, 1921. 104 
CANCER OF THE BREAST. 
their riotous and destructive career. And many sur- 
geons and even pathologists acknowledge in their 
writings that there must be something back of it all, 
some "susceptibility or constitutional" element which 
predisposes the cells to take on the pernicious, disas- 
trous, and malignant action which we call cancer. If 
this erratic and malignant behavior of the originally 
normal cells of the mammary organ, resulting in can- 
cer, does not come from faulty metabolism, producing 
erroneous nutrition, as accomplished by anabolism 
and catabolism, what other reasonable explanation 
can be offered? CHAPTER VI. 
SARCOMA OF THE BREAST. 
As carcinoma is the result of faulty and malignant 
action of the epithelial cells, so sarcoma is a like 
disorder due to "abnormal vegetative activity of the 
connective tissue" cells. The points of dissimilarity 
between carcinoma and sarcoma are numerous and 
often striking, although the two were formerly con- 
fused, and both are still included under the designa- 
tion, "Cancer, Malignant Tumor," as No. 16, in the 
weekly lists of mortality by the New York City 
Board of Health. In the Index Medicus, however, 
carcinoma is classed among the metabolic and dia- 
thetic diseases, while sarcoma is placed among tum- 
ors, as a surgical affection. 
Sarcoma in general differs essentially from carcin- 
oma in many respects. Multiple primary sarcoma is 
not uncommon, while multiple carcinoma, except 
upon the skin is almost a curiosity. Carcinoma has 
more stroma than sarcoma, and is often organoid in 
character, while sarcoma is poor in stroma and 
mostly histioid. Cancer manufactures its stroma 
from the connective tissue which it invades, while 
sarcoma is said to form its stroma from its own cells. 
Early sarcoma may show little or no tendency to in- 
105 106 
CANCER OF THE BREAST. 
vade the surrounding tissues while carcinoma invades 
from the very outset. Sarcoma is more apt to 
metastasize by the blood route, and carcinoma by the 
lymphatics. The two growths attack by preference 
different structures; with sarcoma it is the bones and 
periosteum, fascias, ligaments, and tendons, and next 
to these the brain, gonads, and skin. With carcin- 
oma it is where epithelial elements predominate, as in 
the female breast and uterus, the stomach and colon, 
the mouth and skin. Each is rare in structures in 
which the other is common. Carcinoma seems able 
to provoke the formation of sarcoma, in rare cases, 
through the intense connective tissue reaction: while 
sarcoma is not known to produce carcinoma. When 
serially transplanted in the laboratory, mouse cancer 
has eventually resulted in sarcoma, but the opposite 
has not been noted. 
Carcinoma often causes the tissues around it to 
put up a defensive reaction, but such behavior is 
much less in evidence in sarcoma. Sarcoma at times 
follows upon a pronounced injury, like a blow: this 
is rarely seen in carcinoma, if at all, only in the 
breast. Carcinoma often follows chronic irritation, 
while sarcoma exhibits no such behaviour. Sarcoma 
shades into conditions like lymphoma and leucoma, 
and granulation tumors, while carcinoma shows no 
such affiliations. Sarcoma naturally agrees histo- 
logically with the tissues developed from the meso- SARCOMA OF THE BREAST. 
107 
blast, while carcinoma, developing from the epi- and 
hypo-blast, is akin to the benign epithelial growths. 
Carcinoma causes the cachexia which bears its name, 
while in sarcoma it is said that only a high degree 
of anemia results. 
Sarcoma of the breast has been carefully studied 
by Williams, also by Deaver,1 with an immense bibli- 
ography, which studies we shall largely follow. 
Deaver says that the taxonomic difficulties of har- 
monizing the various reports which have appeared 
are very great, and gives a list of no less than 16 
different names which have been applied to this dis- 
ease in the breast, among 838 cases, as far as it was 
possible to determine from the names given by the 
reporters on the detailed histological structure. 
Sarcoma is a rare mammary tumor. According to 
Roger Williams2 the percentage of 13,824 primary 
neoplasms analyzed gave the following table: 
Neoplasms in General 
Per Cent 
Breast Neoplasms 
Per Cent 
Cancers 
54.5 
77.7 
Sarcomas 
9.4 
3.9 
Non-malignant tumors 24.7 
15.7 
Cysts 
11.4 
2.7 
Rodman, analyzing 5000 cases of breast tumors 
collected from entirely trustworthy sources, found 
only 2.78 per cent, of sarcomata, while 80.02 per 
1 Deaver and McFarland: Loc. cit., p. 372. 
2 Williams, W. Roger: Loc. cit. Deaver and McFarland: Loc. cit., 
p. 414. 108 
CANCER OF THE BREAST. 
cent, were carcinoma. The disease is even more 
rare in the male sex, only 30 cases having been found 
in literature, and it is stated that women are affected 
approximately thirty times as often as men. 
All agree that little or nothing is known as to the 
cause of sarcoma except that traumatism plays a 
more important part in its production than it does in 
other mammary tumors. It is also thought that 
some mammary carcinomata owe their origin to mis- 
placed embryonal tissue elements, which assume ac- 
tive growth in adult life, while sarcoma in general 
may occur at any period of life, being seen frequently 
in the young; but in the breast all observers agree 
that it is most frequent between the ages of 45 
and 55. 
No definite knowledge has been presented in regard 
to the etiological significance of child bearing, lacta- 
tion, and pyogenic mastitis in sarcoma of the breast, 
though it seems that the changes incident to the 
menopause are rather more important. 
Three forms of sarcoma of the breast are com- 
monly spoken of. 1. Adeno-sarcoma, 2. Adeno-cys- 
tic or peri-ductal sarcoma, and 3. Pure sarcoma. 
According to Williams about 80 per cent, are of the 
first class. Histologically the matter seems to be a 
good deal mixed, and Ewing says: "the situation 
today is much as it was in 1894, when Williams 
found it impossible to write the history of pure sar- SARCOMA OF THE BREAST. 
109 
coma, because of the absence of requisite data." 
Williams says, "What gives a certain peculiarity to 
sarcomata of the breast is the frequency with which 
glandular elements are incorporated in its structure. 
Although there is every reason to believe that this 
admixture makes no essential difference in the nature 
of the disease, yet it often causes the form assumed 
by the neoplasm to be strangely modified, through 
the development of cysts and intra-cystic growths. 
This close association of the disease with the glandu- 
lar elements seems to indicate, that it is in some way 
an outcome of functional aberration. The question 
has been much discussed as to whether the glandular 
structures met with under these circumstances are of 
neoplastic origin, or whether they are merely the out- 
come of the mechanical distortion of pre-existing 
structures." 
Histologically, according to Ewing,4 "Adeno-sar- 
comas represent the malignant form of adeno- 
fibroma, but their many striking clinical and anatomi- 
cal features render them a rather specific form of 
mixed tumor of the breast. . . . The structure pre- 
sents considerable variations. Most tumors are com- 
posed of spindle cells, large or small, surrounding 
gland acini or ducts, either growing within distended 
channels, or spreading diffusely. The glands may 
participate for a time in the overgrowth but in ad- 
4 Ewing: Loc. cit., p. 484. 110 
CANCER OF THE BREAST. 
vanced cases they usually disappear, or are found in 
isolated instances. Round cells are less numerous and 
rather more malignant. Such cells show traces of a 
spindle or polygonal form, and sometimes an alveolar 
arrangement. Myxomatous changes may appear in 
large areas of bulky tumors. Giant cells of myeloid 
type occur in spindle- and round-cell growths." 
The question as to the nosological relation of what 
is spoken of as pure sarcoma of the breast, seems 
even more mixed than that of sarcoma in general 
in this organ; round cells and spindle-celled sarcoma 
are recognized in certain cases, but "A definitely 
alveolar structure points at once to an atypical epi- 
thelial tumor process. Not a few such tumors are 
included in the lists of sarcoma: they are difficult 
to distinguish in the gross from medullary carcin- 
oma." 
Sarcoma is occasionally found in connection with 
carcinoma in the breast, but is of very rare occur- 
rence, under the name carcino-sarcoma, Deaver stat- 
ing that literature contains reference to at least 20 
cases in which sarcoma and carcinoma occur in the 
same breast, or in which both are mixed together in 
the same tumor. Naturally these are rather micro- 
scopic curiosities than clinical entities. But some of 
the clinical histories are interesting, the sarcomatous 
change developing in a long existing, more or less 
benign tumor, in one instance for fourteen years. SARCOMA OF THE BREAST. 
111 
Looked at in a broad light sarcoma presents no 
more of a riddle than does carcinoma, as far as the 
cell changes show. If we study the microscopic de- 
scriptions given, it will be seen that they vary rela- 
tively little from those which occur naturally in the 
normal evolution and involution of the mammary 
gland, as in the case of carcinoma. As the disease 
relates to the connective tissue it is quite natural that 
their appearances should be different from those of 
the epithelial tissue composing the glands, and when 
they are, and have been submitted to a faulty nutri- 
tion or innervation, it is quite natural that they 
should mutiny and throw off physiological control, 
and thus become what we call malignant. 
But the epithelial cell everywhere in the body is a 
much more active and intelligent cell than the con- 
nective tissue cell, which is more stationary. In 
many parts of the body the epithelial cell is continu- 
ally changing, in performing its various duties of 
secretion and excretion, and is constantly being ex- 
foliated, as on the skin and mucous membranes. 
Consequently, when it has ceased to be in a normal 
state of existence, and retains only its power of 
growth, it multiplies rapidly and forms the destruc- 
tive, almost parasitic masses called carcinoma, whose 
still intelligent elements, the cells, push here and 
there, invading lymphatics and adjoining tissues of all 
kinds, and like a parasite live in the vital fluids, 112 
CANCER OF THE BREAST. 
without contributing anything to the welfare of the 
body, but only doing harm. 
The connective tissue elements are quite different. 
Their function everywhere is a more quiescent, sta- 
tionary one, forming the framework only of the 
breast, and having little active function, but only to 
"stand and wait." Consequently they are less dis- 
turbed by imperfect or disturbed nutrition or inner- 
vation, and do not so easily mutiny and go on a riot 
or rampage; and when they do so it is a relatively 
milder form than that of the cells of carcinoma. So 
the masses of adeno-sarcoma remain long encapsuled, 
while those of carcinoma almost at once penetrate the 
adjoining spaces, reach the lymphatics and involve 
the glands. Sarcoma does not penetrate its capsule 
until later, or may long remain quiescent, until a blow 
or injury of some kind starts them on their mutinous 
career, as a spark kindles a mass of combustible 
material, and the destructive behavior begins. But, 
as sarcoma travels more through the blood-vessels, 
the lymphatic glands are more slowly, if at all, af- 
fected, and the progress of the disease is slower than 
that of carcinoma, though we all know that when 
fully started sarcoma is capable of terrible ravages. 
Like carcinoma the earlier stages of sarcoma of the 
breast are commonly painless and, like carcinoma, 
much of the later painful and destructive features are 
largely the result of the advent of external micro- SARCOMA OF THE BREAST. 
113 
organisms. Sarcoma is seldom diagnosed in its very 
early stages, and often not until surgical removal has 
afforded an opportunity for microscopic investiga- 
tions, and even then several writers speak of the un- 
certainty which often attends this line of study of the 
disease. CHAPTER VII. 
DIAGNOSIS. 
The diagnosis of carcinoma of the breast is some- 
times very easy and often most difficult, and, perhaps, 
in some cases can only be absolutely determined by 
the microscope. When the disease is recurrent, after 
operation, or when the tumor has ulcerated, and 
especially when the lymphatics are largely involved, 
there is commonly no question as to the true nature 
of the case. But as we shall see, in regard to very 
early or little pronounced cases, the real nature of 
the trouble may be the cause of much doubt, and a 
correct diagnosis requires the most careful attention 
to every possible diagnostic point. 
One should also, always, bear well in mind the 
various affections of the breast of which the differen- 
tiation from carcinoma, or sarcoma, must be made, as 
will appear shortly. It is also important to remem- 
ber that the disease should not be neglected until 
symptoms appear which have long been considered 
classical. This is insisted on in surgical works with 
a view to radical operation, but it is even more im- 
portant in connection with proper medical treatment; 
for long experience has demonstrated that if the lat- 
ter is most carefully carried out, and for a sufficient 
114 DIAGNOSIS. 
115 
length of time, early breast lesions which were either 
already distinctly cancerous, or such as, if neglected 
would become so, almost invariably disappear en- 
tirely, and remain absent indefinitely under exactly 
the correct dietetic, hygienic, and medical treatment, 
carried out for a sufficient length of time. 
It is to be observed that many patients with quite 
innocent conditions of the breast, or with any un- 
pleasant sensations, often fly to the surgeon because 
of the fear of cancer, engendered by the death of 
some acquaintance or relative from that disease, or 
from the terror incited by the repeated crusades 
which have been made of recent years in regard to 
the control of this disease. Astley Cooper1 did well 
when he so clearly mapped out the affections of the 
breast which were not malignant. 
In regard to the differential diagnosis of cancer of 
the breast, surgical and pathological writers rightly 
give a long list of possibilities, which will be men- 
tioned in perhaps the order of their importance: 
i. Deranged evolution and involution. 
2. Benign tumors (adenoma and fibro-adenoma). 
3. Mastitis, acute and chronic. 
4. Cysts. 
5. Sarcoma. 
6. Tuberculosis. 
7. Cold abscess. 
1 Cooper, Sir Astley: Lectures on Surgery, London, 1839, p. 392. 116 
CANCER OF THE BREAST. 
8. Syphilis. 
9. Lipoma, chondroma, osteoma. 
10. Inflammatory conditions. 
First, it may be remarked that many writers state 
that carcinoma forms about 80 per cent, of all breast 
tumors, but it is important not to make a mistake in 
regard to the other 20 per cent., and undoubtedly 
many a breast has been taken off unnecessarily and 
often shamefully, which had no cancer; and some 
statistics as to the successful and permanent cure of 
cancer by surgical removal have probably been im- 
paired by the inclusion of non-cancerous tumors. 
Too much emphasis cannot be laid upon the im- 
portance and necessity of studying each patient most 
carefully, and getting clearly in mind and in writing 
a perfect history of the very beginnings of the 
trouble, when the mass was first noticed, and a per- 
fect subsequent history. Also for the medical treat- 
ment of cancer a thorough record of the patient's 
general condition, the digestive and intestinal action; 
the kidney excretion, daily amount, with volumetric 
estimation of solid excretion, character, urgency, noc- 
turnal passage; sleep, etc. 
In regard to the method of examining the breast 
trouble, Leaf2 has presented the matter so clearly 
that I cannot do better than quote his statements, 
2 Leaf: Cancer of the Breast, Clinically Considered, London, 1922, 
p. 61. DIAGNOSIS. 
117 
with slight changes: "In the first place it is absolutely 
essential that while being examined the patient be 
stripped to the waist, in order that the two breasts 
may readily be compared. She should sit upright in 
a moderately high chair, and any difference in the 
size and relative position of the breasts is at once 
apparent. The medical man should then stand be- 
hind the patient and by placing one hand flat on each 
breast will more readily appreciate the presence or 
absence of a tumor. If a tumor be discovered, it is 
then necessary to determine its degree of mobility in 
the surrounding breast tissue by both hands together. 
The tumor is fixed by one hand, the breast by the 
other, and the fixity of the one to the other is read- 
ily estimated. 
"If the tumor is fixed in the breast, the pectoral 
muscles must be put on the stretch and the degree of 
mobility of the breast over the underlying structures 
then determined. 
"The next point, and it is of the very greatest 
importance, is the question of implication of the skin. 
This is sometimes only too obvious, but in doubtful 
cases of carcinoma the demonstration of slight dimp- 
ling when an attempt to pick up the skin between the 
forefinger and the thumb is a very important diag- 
nostic sign. 
"Examination of the contents of both axillae should 
be carried out with the utmost care. The axilla CANCER OF THE BREAST. 
118 
should be examined both when the arm is in the pos- 
ition of adduction and abduction, as the presence or 
absence of any opening in the axillary fascia may 
materially influence the ease with which a group of 
enlarged central glands is felt. It will generally be 
found that enlarged glands can be most easily felt 
when the patient's arm hangs down by her side and 
the examiner's fingers are pressed against the thor- 
acic wall of the axilla. 
"Too much stress must not be laid on the detec- 
tion or non-detection of enlarged axillary glands, for 
in women who have much axillary fat it is often- 
times quite impossible to feel moderately enlarged 
glands, and in early stages of carcinoma there is 
often no perceptible alteration in the structures, while 
in some soft and rapidly growing cancers the glands 
never become obviously enlarged at all. 
"The consistency of enlarged axillary glands is 
perhaps of greater importance than the mere fact of 
enlargement. The presence of one or more hard 
enlarged glands is distinctly in favor of the growth 
being carcinomatous. On the other hand, the ab- 
sence of such glands by no means proves that can- 
cer is not present." 
In this connection it is well to go over Chapter 
IV, on the lymphatics and lymphatic permeation, 
where we saw that even in early cancer there is an 
involvement and permeation of deep vessels and in- DIAGNOSIS. 
119 
volvement of minute glands, even in places where 
they could not be detected with the finger. 
"Of all the signs of carcinoma the degree of hard- 
ness of the growth in the breast is of the utmost 
importance, for the vast majority of malignant breast 
tumors are notably hard. However, too much reli- 
ance must not be placed on this sign, for in the case 
of small growths, deeply set in the breast, the over- 
lying fat may entirely conceal the unyielding nature 
of the neoplasm. Moreover, there is a certain small 
percentage of cases of cancer of the mamma (medul- 
lary cancer, so-called) characterized by an almost 
diffluent constituency: while, on the other hand, a 
small cyst or a small abscess may be so tense that 
the impression of a very hard, solid tumor is ob- 
tained. It is probable that a small, deeply situated, 
tense cyst is the condition most frequently mistaken 
for carcinoma. 
"Very great difficulty is met with in those rare 
cases where a cyst or some other condition co-exists 
with a malignant growth and masks its charac- 
teristics. 
"The shape of the mass is of some significance: 
malignant disease usually occurs as a single more or 
less rounded nodule-a useful point of distinction 
from chronic interstitial mastitis, which often forms 
a somewhat triangular mass, with the apex towards 
the nipple. But occasionally a cancer is of such ir- 120 
CANCER OF THE BREAST. 
regular shape that it gives the impression of two or 
three masses closely set together. In rare instances 
two foci of growth are met with." 
In all this examination of the breast the caution 
must be urgently thrown out in regard to the harm 
which often results from rough handling or squeez- 
ing of tumors suspected to be carcinomatous. There 
is no need of this, and a tactus eruditus in a skilled 
clinician is a priceless treasure. If the mass should 
prove to be cancer harm is pretty certainly done by 
rough or repeated handling: cancer elements are 
squeezed into the lymphatics and many a case has 
thus been rendered hopeless. Many of my patients 
have complained sorely of the pain they have had 
from the rough handling of some surgeons. This is 
quite useless and harmful. 
A word may be said with advantage in regard to 
pain, or its absence as a diagnostic feature. Cancer 
is often thought of as a very painful affection, but 
those who know most about the disease realize that 
pain is not an essential element of cancer, when left 
to itself, although it is often most frightful in recur- 
rent cases, after surgical removal. Many a patient 
properly treated passes away as peaceably as a tuber- 
culous subject, or more so, simply exhausted by the 
cachexia, without any amount of pain, and not re- 
quiring a particle of morphine or other hypnotic. 
Pain is rarely complained of in the early stages of DIAGNOSIS. 
121 
cancer, when the diagnosis may be difficult, although 
as it progresses there may be occasional twinges, or 
darting pain in the lump radiating to the axilla, 
especially at the time of menstruation. So the com- 
plete absence of pain in early cases is no diagnostic 
sign against cancer. As the disease advances there 
may be, and often is, some pain on rather rough 
handling, or shortly after, which should be accur- 
ately noted. 
Deaver has studied the initial symptoms of cancer, 
and gives the following table: 
Initial Symptoms in Cancer (Deaver). 
Symptoms 
No. of Cases 
Per Cent. 
Lump 
156 
78.0 
Pain 
18 
9 0 
Eczema of nipple 
3 
1.5 
Bleeding from nipple 
2 
1.0 
Ulcer of nipple 
3 
1.5 
Soreness of nipple 
3 
1.5 
Retraction of nipple 
2 
1.0 
Increase in size of breast 
2 
1.0 
Lump in axilla 
2 
1.0 
Stinging sensation 
2 
1.0 
Tender axilla 
1 
0.5 
Dimpling of skin 
2 
1.0 
Sinus 
1 
Pigmented mole 
1 
Pain in upper right abdomen 
1 
A biopsy has been decided by almost every one to 
be a dangerous procedure in all cancer, and should 
not be practiced, of course, especially not in cases 122 
CANCER OF THE BREAST. 
which are to be treated medically. In many an in- 
stance it has been the means of rendering the case 
hopeless in which there had before been hope and 
expectation of a cure. Sufficient careful study and 
examination, and record, by an experienced person, 
should be sufficient to warrant a correct diagnosis 
without such a dangerous measure, although it is 
repeatedly stated by surgeons that in certain in- 
stances the true diagnosis cannot be established until 
after a microscopic study of the excised breast by a 
competent pathologist. Unfortunately all so-called 
pathologists are not equally skilled, any more than 
are the other members of the medical profession. 
We will now take up the differential diagnosis of 
carcinoma of the breast from the other conditions 
which have been mentioned. 
i. Erroneous evolution and involution of the 
breast. During the normal evolution of the breast at 
puberty and thereafter, as we know, there is a very 
material increase in the mammary tissue, the acini 
and lobules increase in size, and push out into the ad- 
joining tissue, and occasionally quite innocent small 
masses form, which naturally give anxiety to patient 
or parent, lest it be the beginning of cancer: but 
with careful attention to diet, hygiene, and action of 
the bowels these pass away. During the breast activ- 
ities connected with lactation there may be irregular 
lumps, as well as inflammatory masses, to be con- DIAGNOSIS. 
123 
sidered later, which may cause anxiety, but which as 
a rule are harmless, though it is well recognized that 
when true cancer exists it is greatly aggravated by 
lactation. 
Involution of the breast, both after lactation and 
in the senile state, is attended with many changes in 
the parenchyma as well as in the stroma, which give 
rise to conditions which both may be mistaken for 
carcinoma and which actually do produce the dis- 
ease; and it is often most difficult to distinguish with 
certainty which is the case. More or less definite 
masses of medium hardness may form in connection 
with the evolution and involution of the breast, and 
it is not unreasonable to suppose that deviations from 
the normal method of metamorphosis furnish a basis 
for the development of the morbid processes to which 
the organ is subject. But not too much haste must 
be exercised to call them malignant, for they often 
disappear under carefully directed and faithfully car- 
ried out medical treatment. The subject will again 
be considered under mastitis, acute and chronic. 
2. Benign tumors. Simple adenoma, fibro-aden- 
oma, and cystic adenoma, are benign, fibre-epithelial 
growths, most common in young unmarried people, 
in whom breast secretion is in a state of nascent ac- 
tivity. They represent rather a hypertrophic action 
of the cell elements, the epithelial cells appear to be 
normally arrayed upon their special basement mem- 124 
CANCER OF THE BREAST. 
brane, with a kind of regularity in their arrange- 
ment, and not atypical, as in carcinoma: but in cer- 
tain cases carcinoma forms from them, which breaks 
through the capsule by which they are surrounded. 
In some cases the fibrous element predominates, and 
in some of them cysts form, often several, giving the 
tumor a lobulated feel. Clinically they are rather 
hard to certainly differentiate, but by exclusion they 
can generally be recognized; there is, of course, no 
adenopathy, except when a carcinomatous process 
has attacked them. 
3. Mastitis. One often wishes, when examining 
a breast or breasts, that he could see by x-ray or 
otherwise, just what lesions exist in the lumpy tissue, 
with its worm-like masses and uncertain lumps, one 
or more of which perhaps have a firm consistence, 
suggesting carcinoma. And if perchance there be an 
axillary gland felt in either side it is sometimes hard 
to know just what to believe in the light of what has 
been already said about lymphatic involvement, as to 
the real character of the lesion found. Many writers 
attest the great difficulty in deciding in certain of 
these cases, while almost every one admits that mas- 
titis is a forerunner of cancer, in many instances, 
but just what the relation between the two is, is not 
clear; although Billroth argued strongly for inflam- 
matory action being the beginning of cancer, and 
this should always be borne in mind. DIAGNOSIS. 
125 
Mastitis may be acute or chronic, the latter often 
following on the former, but more often being of in- 
dependent nature. , 
Acute mastitis, seen especially during lactation, and 
probably due to microbic irritation, and commonly 
ending in suppuration, should give no difficulty in 
diagnosis from cancer; but chronic mastitis, often 
following the acute variety, and possibly also due to 
microbic action is quite different, and often presents 
great difficulties. 
Chronic mastitis. Chronic inflammation of the 
breast may include the whole organ (diffuse), or it 
may be limited to the vicinity of the glandular struc- 
tures (peri-ductal), or only a small segment of the 
organ may be affected (circumscribed). All of these 
may be seen in young or older persons, and confuse 
the study of cancer not a little. 
A. Diffuse mastitis, which is very rare, results in 
a fibrosis which in certain cases has been known to 
cause a shrinking or cirrhosing of the breast, some- 
times producing cysts, on account of its obstructing 
the ducts; or shrinking it down into a knotty mass, 
hardly distinguishable from cancer cured spontane- 
ously. 
B. The peri-ductal form of chronic mastitis, which 
one constantly sees, is essentially a peri-canicular 
chronic inflammation, limited to the vicinity of the 
glandular structures, causing a sclerosing fibrosis. 126 
CANCER OF THE BREAST. 
This 'latter gives rise to the worm-like masses often 
found in old and young breasts, and may also cause 
cysts, from obstructed ducts, which are often confus- 
ing in diagnosis, and will be more fully considered 
later. In a breast thus affected, multiple hard nod- 
ules, freely movable, although obviously connected 
with the mamma itself, can be felt: they seldom ex- 
ceed the size of a walnut, and may be a little painful 
alone or on handling, with possibly a little axillary 
adenopathy. 
C. Chronic circumscribed mastitis. This some- 
times offers the most difficulty in diagnosis. Occa- 
sionally there will be one or more tumors, of a 
rounded or ovoid shape, or a flattish plaque. This 
will feel hard and nodular, with some tenderness on 
pressure, and sometimes darting pain is complained 
of, and possibly some axillary adenopathy. Litera- 
ture contains reports of the excision of breasts for 
this condition, when microscopically they were com- 
posed mainly of dense, white fibrous tissue, contain- 
ing numerous nuclei, in which a few acinous and 
tubular gland structures were here and there em- 
bedded. Microscopically the mass resembled cancer, 
but there were no signs of cancer elements found, 
even in the axillary glands. This form of mastitis 
may also give rise to cysts, and also to chronic 
abscess. This condition should give no difficulty if 
sufficient care is exercised in the study of the case. DIAGNOSIS. 
127 
4- Cysts. These have been already considered in 
connection with various other conditions, but writers 
speak of idiopathic cyst, not so connected. It is 
hardly worth while to waste time and space describ- 
ing this, as they are so rare, forming only 2.6 per 
cent, out of 2397 consecutive mammary tumors 
analyzed by Williams, and reference must be made 
to surgical books. Galactocele must always be re- 
membered as a possibility. 
5. Sarcoma. This has already been fully discussed, 
and is mentioned here only as one of the conditions to 
be differentiated from carcinoma. It is repeatedly 
stated in surgical books that the diagnosis is seldom 
made, certainly of early cases, before surgical 
removal. 
6. Tuberculosis. The diagnosis of early tubercu- 
losis of the breast may be difficult; when fistuke, axil- 
lary adenopathy, and other signs of tubercular infec- 
tion are present, it is less difficult. The caseous tum- 
ors are apt to be multiple and tough to the feel, not 
having the definite hardness of carcinoma. There 
may also be numerous, rather small, pseudo-inflam- 
matory nodules. Deaver places tuberculosis of the 
breast at only 1.31 per cent, out of 1830 cases of 
benign tumors of the breast, collected by Sidney 
Scott. 
7. Cold abscess. While this is often spoken of in 
connection with tuberculosis, and may result from 128 
CANCER OF THE BREAST. 
this, in combination with the action of a pus bacillus 
-for we are told that the tubercle bacillus alone does 
not produce pus-cold abscess is also seen independ- 
ently of demonstrated tuberculosis. It may result 
from the remains of a previous acute inflammation, 
but in some instances, where it has been mistaken 
for carcinoma, and the breast incised, the contents 
of the abscess were found to be of a thick creamy 
consistence, like inspissated milk, possibly from an 
old galactocele, irritated by a blow. They usually 
originate in the acini. I well remember seeing Sir 
Jonathan Hutchinson diagnose a deep cold abscess, 
and empty it with a thrust of a bistoury. 
8. Syphilis. The only syphilitic lesion which could 
be mistaken for carcinoma is a late gummy tumor, 
and several writers on syphilis have described it in 
this location: it may occur in one or both breasts. 
It appears as a dense, knobby tumor, causing lancin- 
ating pains, even extending as far as the axillary 
region, along a chain of glands, equally hard and 
knobby. Careful clinical study, with the history and 
often the presence of other syphilitic symptoms 
should suffice for a differential diagnosis. Of course, 
a Wassermann may aid in diagnosis. 
9. Lipoma, chondroma, osteoma. Although rare, 
lipoma may occur in the breast, both as a general dif- 
fuse fatty deposit, and as a single encapsulated tumor, 
or as a mass behind the mamma. More commonly DIAGNOSIS. 
129 
both breasts are affected. The soft, flabby feeling 
should distinguish it from the hardness of carcinoma. 
Chondroma and osteoma are also great rarities, but 
are sometimes observed, both alone and developing in 
malignant tumors, owing probably to the sequestra- 
tions of small portions of the evolving thoracic skel- 
eton during an early stage of development. The 
differentiation of sarcoma from all these must be 
based on the same lines as in carcinoma. 
We have thus seen that it is no easy matter, in 
many cases, to determine with certainty the existence 
of a carcinoma. Although occurring in such an ac- 
cessible region there is no means of knowing just 
when the diseased process has begun, or how long it 
has lasted before being seen. For the tendency to 
cancer, or carcinosis, has existed long before there 
is any definite, recognized lesion: the process has 
unquestionably begun in a single cell or cells of micro- 
scopic character, days or weeks before any tumor 
has formed which can be discovered by palpation. 
The first symptom of carcinoma which attracts the 
attention of the patient, and sooner or later leads one 
to seek medical advice, is a tumor, in three-quarters 
of the cases. This is discovered accidentally by the 
patient, often in bathing, and may be very small, or 
even of some size before it is noticed. Quite com- 
monly, perhaps in one quarter of the cases, there is 130 
CANCER OF THE BREAST. 
a little darting pain running from the breast to the 
shoulder or down the arm, just enough to call at- 
tention to the developing lesion; later, of course, 
when there is pressure on nerves, or edema of the 
arm, the pain may be a troublesome feature, and 
when ulceration occurs, or in recurrent cancer, after 
operation, the pain is often most agonizing. In rare 
cases the patient will first notice an axillary adeno- 
pathy, and this may be detected by careful manipu- 
lation, in perhaps one-half of the cases when first 
coming for treatment. In a few cases retraction of 
the nipple will be the first sign noticed, and, still more 
rarely, discharge from the nipple. 
When ulceration occurs, later in the disease, the 
diagnosis, of course, is not so difficult, although the 
amount and character of the ulceration varies consid- 
erably in different cases. In some it may be soft and 
luxuriant, while in others there is a hard or brawny 
ridge around it, with a larger or smaller area of raw 
surface; when the ulceration is extensive the odor is 
commonly very offensively characteristic. It must 
not be forgotten, however, that much of the ulcera- 
tion, and pus discharge in advanced cancer is largely 
due to the action of the omnipresent pus cocci, which 
find a suitable nidus for their development and 
operation. 
It is remarkable, however, that almost all patients 
with beginning cancer, and even some in whom it DIAGNOSIS. 
131 
has far advanced, appear and seem to be in such 
rugged health. Their color is good, the appetite and 
sleep normal, most of the functions are well per- 
formed, and it is hard to convince them of the seri- 
ousness of their trouble, even as with patients ex- 
hibiting the early signs of tuberculosis. This sub- 
ject will be fully considered later. But many are sb 
terrorized by the word cancer, and the overzealous 
propagations concerning the disease, that if con- 
vinced of the correctness of the diagnosis they are 
often only too willing to carry out faithfully the pro- 
longed dietetic, hygienic, and medical treatment nec- 
essary for a cure. 
Even when there is an ulcerative tumor the diag- 
nosis is not always so easy, for ulceration occurs in 
the various forms of sarcoma, and in the lesions of 
syphilis and tuberculosis. But there is always a 
hardened edge in carcinoma which is quite charac- 
teristic, and the protrusion of fungous sarcomatous 
masses differs from what is seen in carcinoma. In 
syphilitic gummata which have ulcerated there is a 
depression, with undermined edges and a peculiar 
fetid odor, while in ulcerated tubercular masses there 
is a soft edge, pretty sharply cut or pouting, and gen- 
erally not as much offensive discharge as in the 
other affections. 
But, as already stated, a most careful, written 
clinical history and study of each individual, in all 132 
CANCER OF THE BREAST. 
respects, is of the first importance in recognizing and 
treating cancer. Laboratory agencies and physical 
methods of investigation and treatment have, as 
many recognize, wrongly minimized the relative im- 
portance and necessity of intense clinical study of the 
individual patient; and, in the eyes of some, have sup- 
planted that acumen derived from large experience, 
which belonged to the old school of medicine and 
gave such insight into the real nature of disease as 
was possessed by the leaders of thought and practice 
of some time ago. This is well seen in the writings 
of such men as Abernethy, Sir Astley Cooper, Sir 
James Paget, Thomas Bryant, and others. Until 
we go back to their laborious methods of personal 
study and observation, and record, no real progress 
will be made in the understanding and proper treat- 
ment of carcinosis. The minute researches upon the 
pathological products of the disease and experimental 
studies on animals have not aided practically in un- 
derstanding its true nature, nor in arresting its 
acknowledged ever-increasing death rate, as the mor- 
tality statistics so clearly demonstrate. Diagnosis 
largely depends upon clinical, or bedside, acumen. 
The art of medicine seems to be largely lost. 
Fat Necrosis of the Breast. 
In the issue of Surgery, Gynecology, and Obstet- 
rics, April, 1922, there is an article with gross and DIAGNOSIS. 
133 
microscopical illustrations, by Lee and Adair, which 
deserves especial notice and record. This is particu- 
larly so as there is no mention of the condition in 
any of the many books on cancer of the breast which 
Fig. 38.-Fat necrosis of the breast. Microscopical 
appearance. 
we have read, and the authors state that they could 
find no reference to it in literature other than their 
previous publication in the Annals of Surgery, 1920, 
Ixxii., 188-195. 
Fat necrosis closely resembles carcinoma, in many 
respects, and credit is given to Dr. James Ewing for 
clearly outlining the important features of the gross 134 
CANCER OF THE BREAST. 
and microscopic pathology, which had been given in 
their previous report. Most of the cases had been 
mistaken and operated on for carcinoma; for the 
disease is not so very rare, as it formed 4.2 per cent, 
of 283 cases diagnosed as operable and inoperable 
breast cancer, and approximately in 7 per cent, of 
benign breast tumors, analyzed at the Memorial 
Plospital. "Concerning the difficulties of pathological 
Fig. 39.-Traumatic fat necrosis of breast. 
Gross lesion. 
diagnosis, Dr. Ewing has pointed out that the micro- 
scopic picture may be a difficult one to interpret, if 
the diagnosis by frozen section is relied on. Paraffin 
sections give a very much clearer microscopic 
picture." 
Clinically also the diagnosis may be difficult, as 
the disease occurred between ages of 36 and 54. 
In all but one of the five cases there was definite fixa- 
tion of the tumor to the overlying skin, and in one 
of the cases the nipple was retracted, while in two 
of the cases there was deep attachment; in one of DIAGNOSIS. 
135 
the cases there were neighboring nodes, but they 
were exceedingly soft, and gave no suspicion of 
malignancy. In every one of the five cases the mass 
itself showed a consistency sufficiently hard to lead 
one toward the diagnosis of a malignant tumor. 
"One of the chief diagnostic points is a bona Ude 
Fig. 40.-Traumatic fat necrosis of breast. Note heavy 
type of breast 
accurate history of trauma; unfortunately, although 
a history of trauma is too easily obtained from 
patients suffering from breast carcinoma, it is fre- 
quently indefinite and inaccurate. In three of the 
cases hypodermoclysis was a traumatic factor." Cor- 
pulency seemed to be an important factor, as there 
were no thin individuals, and every patient had more 
than the average of subcutaneous tissue, none weigh- 136 
CANCER OF THE BREAST. 
ing less than 152 pounds, and one weighed 211 
pounds. In every one the breasts were large and 
full. There was no pain, except in one patient who 
complained of slight transient pain at irregular inter- 
vals. The authors think that more careful scrutiny 
will discover many more cases, as Ewing is said to 
have found the disease twenty-five times. CHAPTER VIII. 
PROGNOSIS. 
The prognosis of cancer depends upon many fea- 
tures and factors, some of which are difficult to un- 
derstand and realize. It is strange that in five prom- 
inent surgical books on cancer of the breast now 
before me, the word prognosis does not occur in the 
index, nor can I find the word in their pages. One 
other special book1 (advocating only surgery, as 
they all do), says in its pages: "Untreated cancer of 
the breast will almost invariably result in the de- 
struction of the patient within three years. The 
percentage of patients living after this time is so 
small that it may practically be disregarded. That 
the disease is strictly local in its beginning, and 
therefore amenable to early and radical surgical 
treatment, is a fact which I wish most strongly to 
emphasize." Another,2 and perhaps the most prom- 
inent work on cancer of the breast, says: "It is im- 
possible to give an accurate prognosis in any individ- 
ual case of carcinoma of the breast after operation. 
We know, on the other hand, that, with very few ex- 
ceptions, patients afflicted with the disease die within 
1 Rodman: Diseases of the Breast, Philadelphia, 1908, p. 253. 
2 Deaver and McFarland: Philadelphia, 1917, p. 543. 
137 138 
CANCER OF THE BREAST. 
a few years if not operated upon." We shall see 
later how true these statements are. 
The last author gives several pages to statistics 
of results from many prominent surgeons, and his 
own statistics, but they are far from encouraging in 
regard to the real cure of the disease by surgical 
measures. He claims that the operative mortality 
has fallen from 23.1 per cent, by Billroth, 1867-1875, 
to less than 1 per cent., at the present time, under 
the hands of more and more experienced operators. 
But what of the cases operated on by the ordinary 
surgeon, with little experience? 
In regard to the percentage of cures, he says: 
"Even if a patient remains free from cancer three 
or more years after operation, we cannot be sure 
that a recurrence will not take place." Of 175 opera- 
tive cases from the Philadelphia Lankenau Hospital, 
whose histories were traced, 62 or 35.5 per cent, died 
of recurrent cancer, 20 of them in less than one year 
after operation. He quotes several writers who show 
that about 30 per cent, of patients who are alive and 
well three years after operation for carcinoma of the 
breast, die of the disease, while only 21 per cent, are 
alive and free of recurrence at the end of the fifth 
year after operation. He further states: "The opera- 
tion itself, we believe, has about reached the limit 
of perfection," and finally says: "In prognosing the 
individual case of carcinoma of the breast, the fol- PROGNOSIS. 
139 
lowing facts must be taken into consideration: i. 
Age of the patient. 2. Sex of the patient. 3. Malig- 
nity of the tumor. 4. The duration of the disease. 
5. The local condition of the disease. 6. The com- 
parative probability of local, regional, and metatastic 
recurrence. 7. The method of treatment employed. 
8. Complications that increase the malignity of the 
tumor, such as lactation, etc." 
Rodman,3 while claiming that "surgery should 
cure one-half of all cases, provided that they can be 
subjected to the complete operation early in the 
course of the disease," still quotes from a compila- 
tion of cases made by Ransohoff in which recur- 
rence took place after seven or more years. These 
reports were made by well-known surgeons of cases 
which had occurred eight, nine, eleven, twelve, thir- 
teen, fifteen, seventeen, twenty, and even twenty-five 
years after operation. 
Watson Cheyne,4 a distinguished English surgeon, 
is far from being optimistic in regard to the surgical 
removal of cancer of the breast, and says: "In look- 
ing back over old literature one is very much struck 
by the great rarity of cure, and the very desponding 
view which surgeons took of the chances of perman- 
ent freedom after operation. Velpeau knew of only 
8 Rodman: Loc. cit., p. 256. 
4 Cheyne, Watson: The Object and Limits of Operations on Can- 
cer, London, 1896. 140 
CANCER OF THE BREAST. 
20 cases that had been cured . . . and Billroth's 
results were 8 cures in 143 cases. . . . As the re- 
sult of these researches, we now know that by the 
older methods of operating, and indeed by any 
method which does not take proper cognizance of the 
facts which recent researches have brought to light, 
the patient never really has a chance of cure, properly 
speaking, and the wonder is not that recurrence so 
constantly takes place, but that in any cases appar- 
ent cure follows." Coming down to recent times and 
methods, within two or three years a very prominent 
surgeon, aged 60, fully up to modern ways, remarked 
in a full medical meeting of several County Societies: 
"I am done with cancer surgery. I hope that none 
of you gentlemen will ever again ask me to operate 
on cancer, for I do not know that I have ever done 
sufficient good to warrant the operation." 
The breast, which is the most accessible region of 
the body both for the recognition and treatment of 
a malady, should afford, perhaps, the best field for 
estimating the prognosis of cancer, but unfortunately 
such has not been the case, as far as the best ultimate 
results are concerned, and here we may abstract 
from Ewing,5 an unprejudiced scientific student and 
observer. After quoting reported statistics of recur- 
rences of cancer, happening from seven to twenty- 
five years after operation, and referring to the oc- 
5 Ewing: Neoplastic Diseases, Philadelphia, 1919, pp. 521, 522. PROGNOSIS. 
141 
casional later appearance of the disease in the other, 
unoperated breast, and the statement that the aver- 
age life in untreated cases was placed by Paget at 
four years, and by Oldekop at twenty-nine months 
and by Sprangel at twenty-seven months, he says: 
"i. The figures (4 years and 27 months) are too 
divergent to permit accurate conclusions regarding 
the natural duration of mammary cancer. The at- 
tempt to establish an average duration of this dis- 
ease should be replaced by the systematic classifica- 
tion of cases, according to the factors known to in- 
fluence prognosis. 
"2. The comparison of operated and unoperated 
cases is sophistical. The choice of operable cases 
tends to throw into the untreated cases the majority 
of rapid and unfavorable cases. 
"3. Statistics favor the conclusion that operation 
on the whole shortens life in recurrent cases, al- 
though sometimes rendering it more tolerable. 
Handley's recurrent cases lived 29.6 months, while 
in the above series the duration of life was twenty- 
seven, twenty-nine, thirty-four, and forty-eight 
months respectively. This conclusion is strength- 
ened by theoretical considerations, as well as by ob- 
servations on the rapid course of many recurrent 
cases. It is clearly proven in many instances by 
the increasing anaplasia exhibited in the structure of 
recurrent cases. 142 
CANCER OF THE BREAST. 
"4- The high proportion of the clinical cures from 
the modern operation has resulted largely from the 
earlier recognition of cancer, and the inclusion of a 
large number of minute carcinomas or precancerous 
lesions in the operated class. 
"5. The choice of therapeutic measures should 
not be made under the impression that the duration 
of untreated cases is twenty-seven months, and that 
40 per cent, of the cases are cured. Since the dura- 
tion of the disease may vary from six weeks to 
twenty-five years, and the favorable results of opera- 
tion from o to 100 per cent., the first essential in 
treatment is accurate diagnosis and prognosis in 
each individual case. 
"6. In estimating the economic importance of the 
surgical treatment of mammary cancer there must be 
charged up the cost of acquiring surgical skill, and 
the deplorable conditions following recurrence. 
There can be no doubt that operation shortens life, 
and aggravates the terminal suffering in the great 
majority of recurrent cases. Most of those who 
deal with the great number of these unfortunate pa- 
tients would welcome 'a judicious limitation of the 
scope of operability in this disease. 
"From clinical and pathological studies I have 
drawn the impression that in dealing with mam- 
mary cancer surgery meets with more peculiar dif- 
ficulties and uncertainties than with almost any other PROGNOSIS. 
143 
form of the disease. The anatomical types of the 
disease are so numerous, the variations in clinical 
course so wide, the paths of dissemination so free and 
diverse, the difficulties'of determining the actual con- 
ditions so complex, and the sacrifice of tissue so 
great, as to render impossible in a majority of cases 
a reasonably accurate adjustment of means to ends. 
"The scope of the operative field having appar- 
ently reached a limit, the chief hope for a reduction 
in the mortality from mammary carcinoma lies in its 
prevention and earlier diagnosis." Most of us who 
have had the best opportunity of watching cancer 
for many years, especially its recurrences, will, I 
think, agree with this pathologist in his judgment. 
We have already referred to the study of Dr. Aebly,6 
based on a tabulation of cancer mortality in Switzer- 
land for many years, where there are some renowned 
surgeons and where the mortality records are well 
known for their accuracy. He tabulated those pa- 
tients who had been operated, on, and those left under 
ordinary medical, not special care, and treatment, and 
found that "operative procedures either lessen the life 
expectancy or have such a slight influence in pro- 
longing life, that it may be regarded as negligible." 
How far a properly guided medical treatment may 
affect prognosis will be seen later. 
6Aebly: Schweitz. Med. Wochenschr., Oct. 14, 1900. 144 
CANCER OF THE BREAST. 
We will now attempt to deal more concretely with 
prognosis. 
We have already seen that Deaver gives nine 
points to be considered in connection with the sur- 
gical prognosis of cancer, some of them pertain also 
to the medical treatment of the disease, but not all, 
if our conception of carcinosis is correct. If the 
lesions which we call cancer are only the results or 
products of this state of carcinosis, and if by most 
careful dietary, hygienic, and medicinal measures we 
remove the fundamental or basic cause of the mutiny 
and malignity of the cells, it does not matter so very 
much as to what the exact shape of them has become, 
as revealed by histological study after the mass has 
been excised, any more than it would to examine the 
brains or bodies of soldiers who had been shot be- 
cause they mutinied. Just as, when the mutinied sol- 
diers have had their reasonable demands satisfied 
they will return to their usual duties and obedience, 
so the body cells, which we have seen to be intelli- 
gent, will return to their normal state and function, 
and respond to proper physiological control, when 
their reasonable demands as to nutrition and nerve 
control have been satisfied, however far they may 
have departed from their previous normal shape. 
Deaver gives twenty-odd large pages to tables 
and matter relating to the cure of cancer by many 
different observers, the unfortunate part of which is PROGNOSIS. 
145 
that they are all largely based on a 3-year limit of 
recurrences; whereas we have seen that large num- 
bers are so affected even many years after the 3- 
year limit, so much so that some recent writers have 
thought that an 8-year limit should be made, whereas 
some are frank enough to state that no limit of a 
cure can be honestly made. We will see how differ- 
ent this is from what can be said concerning pro- 
longed, proper medical treatment. For, when the 
diseased mass has melted away, the enlarged lym- 
phatics have disappeared, and the patient is clinically 
well, there will be no recurrence, since the cause 
which produced the first trouble has been removed; 
provided the patient continue indefinitely to live the 
proper life in all respects. This has long been recog- 
nized in regard to tuberculosis, why can it not be 
understood in regard to cancer? 
It would seem that the following points should be 
considered in regard to the prognosis of cancer of 
the breast when treated medically in the very best, 
intelligent manner, with the full co-operation of the 
patient: 
1. Age of the patient. 2. Physical condition of 
the patient. 3. Duration of the disease. 4. Previous 
treatment. 5. Local condition of the original lesion. 
6. Character of the original lesion. 7. Lymphatic 
involvement. 8. Complicating features. 9. Relative 
faithfulness to all details of proper treatment. These 146 
CANCER OF THE BREAST. 
will be considered in turn; a combination of several 
of them naturally make the prognosis less favorable: 
i. Age of the patient. Carcinoma of the breast is 
said to be most fatal in young subjects, but this has 
not been my experience, as I cannot learn of the 
death of a single one of the patients under 35 years 
of age, who had not been operated upon previously. 
Primary cases yield unusually well, but, of course, as 
we shall see, recurrences are difficult to overcome. 
The following table gives the data regarding all the 
deaths in the 250 cases, which could be ascertained 
after most diligent attempts with many hundred, 
personally written follow-up letters, with return, ad- 
dressed envelopes. Of course, there must have been 
many more, especially among the advanced cases 
seen in consultation. 
Table of Deaths and Ages. 
Ages 
Primary 
175 Cases 
Post-operative 
75 Cases 
Total 
250 Cases 
Under 30 
0 
0 
o 
30 to 34 
0 
1 
1 
35 " 39 
1 
3 
4 
40 " 44 
3 
3 
45 " 49 
1 
8 
o 
Q 
50 " 54 
2 
2 
y 
55 " 59 
0 
2 
4 
9 
60 " 64 
0 
2 
o 
65 and over 
4 
2 
6 
Total cases 
11 
23 
34 PROGNOSIS. 
147 
2. Physical condition of the patient. In the early 
stages of cancer most patients exhibit often an in- 
creased state of good health, and if by a proper ad- 
justment of the measures employed, this can be main- 
tained the prognosis is correspondingly favorable, 
and many do maintain it until the difficulty has been 
entirely removed. When the disease has lasted 
longer, and more or less cachexia has set in, owing 
to lymphatic involvement, the prognosis is less favor- 
able, but great patience has sometimes worked sur- 
prising results even in such bad cases. Rather lean 
persons generally do better than those with much 
adipose tissue, and in the latter it is often desirable 
to take off some of the fat by diet, laxatives, and the 
free use of thyroid with other remedies. While loss 
of weight is often considered as one of the indications 
of advancing cancer, and if the disease is left alone 
it certainly does tend to reduce and weaken the pa- 
tient, early in the medical management of carcinosis 
it is often desirable to reduce the flesh of stout pa- 
tients. The patients should be weighed, on the same 
scales, and in the same clothes, frequently, even once 
a week, and it is best to keep the weight a trifle be- 
low that given in the insurance tables for the age and 
height of the individual. Details in regard to mat- 
ters relating to the physical condition of the patient 
will be considered in the next chapter, on "The 
Medical Aspects of Cancer." 148 
CANCER OF THE BREAST. 
3. Duration of the disease. This, of course, must 
influence the prognosis, as does also the previous 
treatment, as we shall see next. Early recognition 
and treatment of cancer of the breast has been so 
strongly emphasized by the surgeons that it is hardly 
necessary to speak of it. But while they insist on it 
so hopefully, all of us have seen plenty of cases 
where the breast was excised within a day or a week 
after a lump was discovered by a patient, and yet 
where frightful recurrence and even death followed 
from the disease. Still the earliest possible recogni- 
tion of a cancerous lesion, and the promptest possible 
employment of proper dietetic, hygienic, and medic- 
inal measures are of the utmost importance in the 
medical treatment of breast cancer. As stated be- 
fore, early cases, diagnosed by able surgeons as un- 
doubted cancer, and condemned to and even pre- 
pared for an immediate operation, can recover com- 
pletely and remain well indefinitely under proper 
medical management, as will appear in Chapter XII. 
Even those where the original tumor has attained 
very considerable size, with enlarged axillary glands, 
may also yield to proper treatment, but naturally 
it will take a long time for the effect to be produced. 
A three-year freedom from cancer is claimed as a 
cure by the surgeons, and it may take that long for 
an advanced cancer to disappear entirely; even as in 
tuberculosis prolonged treatment and "eternal vigi- PROGNOSIS. 
149 
lance'' is the only price of liberty. Patience and 
perseverance, with intelligent treatment are the price 
in cancer. And when the disease has completely dis- 
appeared by these means, it is in reality a cure, and 
unless the patient relapses into the mode of life which 
produced the carcinosis, there will, of course, be no 
recurrence of its local manifestations. 
4. Previous treatment. As may be judged by 
what has preceded, this has very much to do with the 
prospects of a cure. Recurrent cancer, which we 
have seen to be so common after operations, and 
which tends to shorten life when repeated, is cer- 
tainly often a desperate proposition. But, as was 
quoted from Abernethy: "It is after an operation 
that, in my opinion, we are most particularly incited 
to regulate the constitution, lest the disease should 
be revived or renewed by its disturbance"; so, with 
great care, much may be accomplished for these sad 
cases, which are indeed hopeless if left alone or 
wrongly handled, and I have seen plenty of them. I 
have already reported in a recent book7 the case of 
a lady aged 53, who had had four surgical operations 
by the same prominent surgeon within 19 months. 
The last wound had not healed and many cutaneous 
nodules developed around the open area, which was 
8 inches long by 3 inches wide, and the arm was 
7Bulkley: Cancer and Its Non-surgical Treatment, New York, 
1921, p. 345. 150 
CANCER OF THE BREAST. 
hard, tense, and useless. Under rigid treatment she 
improved very greatly, the wound almost healed, the 
arm became smaller, flabby, and useful. In five 
months her friends thought her quite well, but about 
that time she fell and broke her hip, possibly from 
bone metastasis, neglected her treatment, and died 
not long after. For these five months she suffered 
no pain, never taking an opiate, was happy and well, 
travelling frequently from a somewhat distant home 
to the office. There were 71 patients who had had 
one, two, three, or four operations, and of those 23 
are known to have died, while many others were lost 
sight of. 
X-ray and radium had been used in many of the 
cases before coming under treatment, and I have 
never seen any permanent benefit from them, but on 
the contrary they seemed7 even more intractable to 
medical treatment than the run of other cases. 
Whether this was from the well-known capillary 
changes induced thereby cannot yet be stated. 
5. Local condition of the original lesion. As may 
be inferred from what has preceded, it may be 
readily understood that the smaller the mammary 
lesion is the quicker it will probably yield, while a 
great scirrhous mass will take months or even years 
to disappear. When there is much ulceration it is of 
course very slow to heal while the cancerous tissue 
remains beneath it, but the way in which it may PROGNOSIS. 
151 
cover itself over with healthy epidermis under a 
proper dressing, to be mentioned later, is often very 
surprising. Cutaneous nodules, from diffuse lymph- 
atic involvement, are slow to yield, but in many in- 
stances they also disappear entirely, with the aid of 
proper local treatment, although it may take months 
to accomplish this. 
6. Character of the original lesion. If we accept 
the statements of pathologists in regard to the struc- 
ture of what are called the different forms of mam- 
mary cancer, as learned from excised breasts, we 
must believe that some forms are much more mal- 
ignant than others. Thus Ewing8 says, "cancer may 
apparently arise during gestation and prove fatal 
before its termination," and many writers speak of 
acute carcinosis, where there is very rapid progress, 
with local inflammatory signs (but none of these 
have happened to fall under my observation). Nor 
have I chanced upon the medullary or encephaloid 
form, "soft, cellular tumor which pursues the course 
of very malignant mammary cancer." I can under- 
stand how some of these virulent changes in the cells 
of the breast, verging on true inflammatory altera- 
tions, may occur in subjects who have a profound 
carcinosis, from accentuation or aggravation of the 
disordered metabolism of cells in the carcinosis dys- 
crasia, even as mutinous soldiers might go to any 
8 Ewing: Loc. cit., p. 513. 152 
CANCER OF THE BREAST. 
extent of malicious action if their reasonable de- 
mands were not attended to. 
7. Lymphatic involvement. Most modern writers 
now agree that when the supraclavicular glands are 
largely involved the case is inoperable and practi- 
cally hopeless, as far as any cure can be expected 
from surgical operations, x-rays, or radium. But we 
have already seen that lymphatic permeation pro- 
ceeds almost from the first, and that multitudes of 
lymphatic glands are infected in various regions, 
which cannot be discovered by palpation, and a study 
of Handley will show any intelligent and honest in- 
vestigator the uselessness of hoping that any meas- 
ures short of eradicating the basic cause of carcinosis 
can ever cure the disease permanently. But under 
correct, faithful, and persistent, internal treatment 
we have seen in many cases nodes all disappear, as 
in the instances to be detailed later; the lymphatics 
which may not have been already destroyed by per- 
meation or new ones, then perform their function 
again, as the patient steadily advances toward health. 
This, of course, takes a long time, even as recovery 
in tuberculosis, rheumatic arthritis, and other chronic 
affections requires much time. 
8. Complicating conditions. Diabetes, chronic 
nephritis, chronic heart disease, chronic rheumatism, 
tuberculosis (a rare complication), etc., all interfere 
seriously with the proper cure of cancer and compli- PROGNOSIS. 
153 
cate the prognosis of individual cases. Diabetes in- 
terferes with the proper dietary regulations, and 
sometimes carries off the patient long before the car- 
cinosis would do so, as in some of the cases to be 
mentioned. Chronic nephritis thwarts the proper 
elimination of waste nitrogenous products, which is 
such an important element in medical treatment, and 
chronic heart disease keeps the patient in a condi- 
tion of lowered vitality, hindering proper reconstruc- 
tive measures. Chronic rheumatism, a common ac- 
companiment of carcinosis, requires active measures 
to counteract the acidity accompanying cancer, and 
by interfering with proper exercise impedes the de- 
sired progress of the case. Tuberculosis, which, for- 
tunately rarely, though occasionally, is seen in con- 
nection with cancer, frustrates in a measure the at- 
tempts to carry out a proper dietary, for the dietetic 
principles of the two conditions are quite different 
and antagonistic: but with great care this obstacle 
can be overcome in some cases. 
We have thus seen that the prognosis of cancer is 
a difficult problem to solve in many instances. Each 
patient has to be most carefully studied, in every re- 
spect, and a careful written account is to be made of 
elements which can have any bearing on the case. 
Carcinosis as a disease is a most interesting and at- 
tractive study, and the results obtained are often 154 
CANCER OF THE BREAST. 
most gratifying, when sufficient labor, patience, and 
medical acumen are devoted to it. All this is quite 
different from simply making a surgical diagnosis, 
and then employing surgery, x-ray, or radium, in the 
hope that good may be accomplished. The Mortal- 
ity Reports will soon show the difference, when in- 
telligent medical treatment has been put to a suf- 
ficiently long test, and in ample and adequate num- 
bers of patients, to convince the medical profession 
and the public of the correctness of the position taken 
in these pages. CHAPTER IX. 
MEDICAL ASPECTS OF CANCER. 
The medical aspects of cancer loom large, when a 
sufficiently minute, accurate, and careful study of 
them is made and recorded. Cancer of the breast 
differs in no essential particulars from cancer in 
other locations, except, that, of course, the enormous 
activity and remarkable changes which take place in 
its cells, both in its normal evolution from birth and 
involution during senility, as well as before and after 
lactation, which we have already studied, render 
them more susceptible to the pathologic changes, 
which, from subsequent observation, we call malig- 
nant. Having some profound cause for mutiny the 
cells have thrown off all physiological control, and 
ceasing to activate in their proper secretory or other 
manner, and yet retaining their power of mitosis and 
growth, they multiply inordinately and form the use- 
less and harmful mass called cancer, with destruc- 
tive powers. Just as the soldiers in the Chinese 
armies now and then mutiny and throw off govern- 
mental control and become bandits; but they have 
been repeatedly known, after a while, to be again 
absorbed into the regular army, and become obedient 
soldiers; the same takes place with body cells form- 
ing cancer. 
155 156 
CANCER OF THE BREAST. 
The basic trouble, carcinosis, is the same in what- 
ever organ its products or manifestations may ap- 
pear, and the medical features belonging to them are 
not difficult to discover and realize, if sufficient study 
and medical acumen are applied. Therefore the 
studies and observation in regard to carcinosis in 
general apply equally well in cancer of the breast, 
and in that light we shall consider them. 
In order that this may receive more serious con- 
sideration I want first to cite some authorities to 
show that it is no new or hastily conceived idea upon 
which I have been acting satisfactorily for the last 
forty years and more. Reference has already been 
made to the celebrated English surgeon, Abernethy,1 
who, from experience, over a hundred years ago 
came out so strongly in favor of this conception of 
cancer, and to the most recent exponent of this line 
of thought, Sauerbruch,2 the famous German pioneer 
in thoracic surgery, who declared that the accepted 
idea of a local nature of cancer was wrong, and that 
what is called cancer was a local manifestation of a 
constitutional disease. Hochnegg, a celebrated rectal 
surgeon in Germany, is likewise a convert to the 
constitutional nature of cancer, as is also Pauchet, a 
well-known abdominal surgeon in Amiens, France. 
1 Abernethy: Surgical Observations on Tumors, 4th Edition, 1826, 
p. 93. 
2Sauerbruch: Deutsch. Med. Wochenschr., Jan. 19, 1922. MEDICAL ASPECTS OF CANCER. 
157 
Speaking of the prophylaxis of cancer, mainly 
from its surgical aspects, in regard to early opera- 
tion, Dr. Wm. J. Mayo,3 in a recent Presidential ad- 
dress before the American Surgical Association, said: 
"Is it not possible, therefore, that there is something- 
in the habits of civilized man, in the cooking or other 
preparation of the food which acts to produce the 
pre-cancerous condition? . . . Where cancer in the 
human is frequent, a close study of the habits of 
civilized man, as contrasted with primitive races and 
lower animals, where similar lesions are conspicu- 
ously rare, may be of value." 
Walshe, in 1844, in his classical work on cancer, 
gives numerous references to the constitutional na- 
ture of the disease, original or quoted from recog- 
nized authorities, as well as expressions in regard to 
the futility of expecting that surgical interference 
could cure cancer, in any great proportion of cases. 
He says: "It would in theory appear that the local 
removal of a tumor cannot of itself cure the disease, 
as the local formation is but a symptom of the gen- 
eral vice of the economy . . . This tissue being, 
as the normal textures, the seat of nutrition, is, like 
them, susceptible of its disordered conditions." 
Lambe,4 in 1815, wrote clearly in regard to the 
3 Mayo, Wm. J: Annals of Surgery, June, 1914, p. 805. 
4 Lambe: Additional Reports on the Effects of a Peculiar Regimen 
for Cancer, London, 1815. 158 
CANCER OF THE BREAST. 
causation of cancer from luxurious living, and ad- 
duced strong proof to show the effect of diet in cur- 
ing cases of undoubted cancer of the breast and 
uterus, the diagnosis of which had been confirmed 
by prominent surgeons of the day, several of whom 
endorsed the vegetarian diet. 
Sir Astley Cooper,5 a great English surgeon, said 
in 1825: "The cause of the disease (cancer of the 
breast) is supposed to be some accidental blow or 
the pressure of part of the dress: but although a 
blow may produce swelling of the bosom, yet that 
swelling will not be of scirrhous nature unless some 
defective state of the constitution disposes to malig- 
nant action. If the constitution is good the effects of 
the blow are speedily dissipated; but if the constitu- 
tion be faulty, the swelling grows into a formidable 
disease." 
Velpeau,6 a surgeon par excellence, basing his 
work on "over 2000 original cases bearing on the 
subject," said clearly, in 1856: "If instead of being 
a local disease, cancer is the result of a constitutional 
condition, the extirpation of cancerous tumors must 
be useless, and ought to be rejected as dangerous. 
It cannot be denied that a vast number of facts and 
considerations unite to compel us to admit cancer as 
5 Cooper, Sir Astley: Lectures on Surgery, London, 1835. 
G Velpeau: Diseases of the Breast, English Edition, London, 1856, 
pp. 462-472. MEDICAL ASPECTS OF CANCER. 
159 
a constitutional disease." And he gives several per- 
sonal cases in which medical measures affected a 
cure in scirrhous cancer. And yet he persisted in 
advising and practicing operations, so hard it is for 
surgeons to yield to medical considerations. 
Sir James Paget,7 that prince of surgeons and 
pathologists, in 1854 came out very strongly for the 
constitutional origin of cancer, when he says in his 
"Lectures on Surgical Pathology," that "Cancers 
are local manifestations of certain specific morbid 
states of the blood . . . the existence of the mor- 
bid material in the blood, whether in the rudimental 
or effective state, constitutes the general disposition 
to cancer." 
The late Dr. Willard Parker,8 an astute physician, 
and one of New York's great surgeons, in a study of 
397 cases of cancer of the breast, observed from 1830 
to 1880, wrote very strongly in regard to the consti- 
tutional relations of cancer. In considering its eti- 
ology he places first, luxurious living and particularly 
excess in animal food. He says: "Cancer is to a 
great degree one of the final results of a long con- 
tinued course of error in diet, and a strict dietetic 
regimen, is, therefore, the chief factor in the treat- 
ment, preventive and curative." He further says: 
7 Paget, Sir James: Lectures on Surgical Pathology, New York, 
1854. 
8 Parker, Willard: Cancer, Analysis of 397 Cases of Cancer of the 
Breast, New York, 1885. 160 
CANCER OF THE BREAST. 
"In regard to the effect of abstemiousness in cancer 
I can speak with great positiveness, that a vegetable, 
or at least a very bland diet, does check the progress 
of the disease, and in some cases, now under treat- 
ment has been attended by an alleviation of symp- 
toms, and in a few cases even by a recession of the 
growth." 
Even a pure pathologist, Charles Powell White,9 
feels that the medical aspects of cancer are import- 
ant. While presenting a synopsis of 22 points re- 
garding the pathology of cancer, and considering the 
principles on which its treatment should be based, 
and acknowledging that the cells of which the tumors 
are composed are identical with normal cells, and 
mentioning metabolism, he says: "It is much to be 
regretted that the writers and compilers of text 
books of medicine seem to habitually ignore the sub- 
ject of cancer. Cancer, however, has its medical 
aspects as well as its surgical, and we require more 
clinical observations on cancer from the medical 
point of view." 
The enormous and marvelous researches of H. C. 
Ross10 and collaborators on "Induced cell reproduc- 
tion and cancer," also show conclusively that there 
is something in the blood stream or tissues them- 
9 White, Chas. Powell: Lectures on the Pathology of Cancer, 
Manchester, 1908, p. 61. 
10 Ross, H. C.: Induced Cell Reproduction and Cancer, Vol. I, 
Philadelphia, 1912; Vol. II, London, 1912; Vol. Ill, London, 1913. MEDICAL ASPECTS OF CANCER. 
161 
selves which causes the normal cells to take on the 
erratic and destructive action which characterize the 
disease process which we call cancer, or properly, 
carcinosis. 
Many more strong declarations to like effect could 
be quoted from literature, from those well experi- 
enced in cancer, with books such as those of Forbes 
Ross and Robert Bell; and dozens, perhaps hundreds 
of personal letters have been received, confirming the 
position now taken; and there has now been formed 
an American Association for the Study and Cure 
of Cancer, with over sixty enrolled members from 
all over the United States and outside. 
The trend of all this study and observation is to 
settle positively that cancer never is a purely local 
disease, even at its beginning, and surgeons and path- 
ologists are challenged to demonstrate positively that 
it is such. It has been abundantly shown that it is 
the final result of a disturbance of equilibrium in the 
system, generally of long continuance. This induces 
certain cells, first in some particular locality, perhaps 
from some local injurious force, to take on an abnor- 
mal, vicious action, which is perpetuated by the con- 
tinuance of the same erroneous systemic condition 
which induced the first aberration from a normal 
state of life and function. 
But these fugitive and other observations and 
studies have never attracted the attention they de- 162 
CANCER OF THE BREAST. 
serve, and it would sometimes seem as if they were 
deliberately ignored, and that scientists and patholo- 
gists had conspired together to recognize only the 
local nature and treatment of cancer. The truth is 
that very little serious effort has ever before been 
made to assemble all the evidence of the constitutional 
elements involved in the ultimate causation, continu- 
ance, increase, and recurrence of the cancer lesions; 
and by induction and deduction to form a concrete 
idea of carcinosis as a disease, and its proper treat- 
ment, although many strong and prominent medical 
men, and even surgeons, had so stated. 
The glamour of surgery, and latterly of x-ray and 
radium, have, during the last two decades excluded 
from the minds of the medical profession and laity 
much thought of the medical aspects and treatment 
of cancer: and the reasons for this are not difficult 
to discover. 
Under previous medical care, with no sound rea- 
son advanced, and with no definite plan of treatment 
evolved, cancers of the breast and elsewhere had 
commonly been seen to go from bad to worse, until 
the disease was regarded as incurable, and the pa- 
tient was then left to die under morphia, which only 
increased the carcinosis, by further deranging and 
checking the secretions and excretions. As the local 
manifestation of the disease appeared to be the first 
real seat of the trouble, from which it'spread through MEDICAL ASPECTS OF CANCER. 
163 
adjoining glands which could be recognized, it was 
very natural that the surgeons believed that by re- 
moving the offending tumor early the malady could 
be checked; and they soon learned, or thought they 
did, that by also extirpating the neighboring en- 
larged glands the work would be more effective. 
But they forgot, or did not know, as the researches 
of Handley and others have so clearly demonstrated, 
and as has been described in a previous chapter, that 
the elements of the disease lingered in the deeper 
lymphatic vessels and glands, which could not be 
discovered and were not removable. 
Thus, while the immediate results of well con- 
ducted surgical operations seemed to be favorable, 
for a time at least, but with the possible expectation 
of a recurrence of the malady, there was still hope 
that further operations might succeed in eradicating 
the disease. But we have already quoted from 
Ewing, from the observation and view of a scientific 
student of very wide experience, as saying that he be- 
lieved that secondary operations on cancer of the 
breast only shortened life, and we all know that after 
them the pain and distress of recurrent lesions are 
excessive, and the case generally hopeless. However, 
for the last twro decades surgery has had full sway, 
and the medical man has practically kept his hands 
off from cancer, and referred all these cases at once 
to the surgeon, with the result often mentioned, that 164 
CANCER OF THE BREAST. 
90 per cent, of those once affected, die of the disease. 
While by the practice of great patience and acumen 
the mortality of tuberculosis has been reduced 43 per 
cent, since 1900, the death rate of cancer has ad- 
vanced about 36 per cent., under surgery. It is cer- 
tainly time for the medical man, in view of what has 
preceded and will follow, to see if great patience 
and a similar acumen will not enable him to 
check this constantly rising mortality, and effect 
something in connection with the management of 
cancer which will be commensurate with what has 
been accomplished in tuberculosis by medical means. 
On the mortality chart furnished each year by the 
United States authorities, there are three other 
chronic diseases, whose steadily rising death rate 
may well excite alarm, and stimulate the medical 
profession to more intelligent and earnest efforts to 
control their morbidity and mortality. These are 
heart disease, kidney disease, and apoplexy. The 
deaths from the first of these-heart disease-now 
exceed those from tuberculosis, and now for the last 
two years the deaths from cancer in New York City, 
have also forged ahead, so that there have been ac- 
tually more deaths from cancer than from tubercu- 
losis; and the three others have risen also about 15 
and 25 per cent, since 1900. All these diseases are 
recognized as having much to do with the diet and 
mode of living of modern civilization, and it is rea- MEDICAL ASPECTS OF CANCER. 
165 
sonable to suppose that cancer, whose advancing 
death rate has outstripped that of these other four 
chronic diseases, should be of somewhat the same 
nature and cause. 
There could hardly be a more eloquent argument 
for the application of medical perspicacity and acu- 
men to the study and treatment of cancer than the 
results of the same which have been applied to tuber- 
culosis, with such wonderful results, in spite of the 
ever present tubercle bacillus. Because science and 
clinical study have not been able thus far to point 
to a single and definite cause of cancer, for parasit- 
ism has been eliminated, or to lay out a treatment 
which will be surely successful in every case, however 
bad, there is no reason for doubting that we are on 
the right track when every sign points that way. 
Nor is there any wisdom or sagacity, but only mis- 
conception, error, and obstinacy, in questioning the 
medical aspects and cause of carcinosis, whose local 
lesions we call cancer, simply because we are con- 
strained to admit that local irritation or injury may 
act as exciters or coadjutors in producing the local 
lesions of the disease. We have always been taught 
that there are primary or basic causes of many affec- 
tions, and also secondary or exciting causes, and we 
have already mentioned the relative frequency of the 
latter in regard to the development of cancerous 
lesions in many localities. A remarkable confirma- 166 
CANCER OF THE BREAST. 
tion of the fact that cancer is not solely the result of 
traumatism is found in the extreme rarity of the dis- 
ease on the extremities, which are so often injured, 
or after the damage to tissues caused by surgical in- 
juries in general. Also carcinoma is unknown as 
the result of skin grafting, although these same epi- 
dermic cells which are employed in this procedure 
are the original seat of cancer. There must, there- 
fore, be an occult process going on in the system, 
which lays the foundation for the morbid response of 
the cells to some internal or external irritant; a 
something which so alters their nutrition that dis- 
turbance in their integrity results, and instead of pur- 
suing their normal course of homologous reproduc- 
tion, or fulfilling their natural secretory powers, they 
take on a new, heterologous formation, and begin, 
and continue a wild, unrestrained, and destructive 
course, with its well-known results. The same inter- 
nal causes which induced the original wrong cell ac- 
tion perpetuate the same with increasing severity, till 
death ends the struggle. 
These causes of a disturbed and perverted meta- 
bolism we will now study: they relate, of course, to 
the individual affected, and to the elements which go 
to make up the lowered integrity of the blood current, 
upon which the bad nutrition and growth of the cells 
depend in the disease which we are now considering. 
The elements which enter into this deranged condi- MEDICAL ASPECTS OF CANCER. 
167 
tion of the system are many, as careful and untiring 
clinical study will demonstrate in patients with can- 
cer of the breast; these have been elaborated exten- 
sively elsewhere,11 but they may be briefly consid- 
ered under the following heads: 
i. Food and mode of life. 
2. Faulty metabolism. 
3. Imperfect blood stream. 
4. Erroneous body elimination. 
5. Nervous disturbances. 
1. Food and mode of living. Not only personal 
experience but facts and figures, which have been 
presented abundantly elsewhere, show plainly that 
food and mode of living have much to do with the 
genesis and continuance of carcinosis, and that the 
disease is largely the result of evils attending so- 
called civilization. Sometimes this occurs in the way 
of an entirely wrong food, sometimes from an exces- 
sive quantity of tolerably correct food, and sometimes 
from a deficiency of proper elements for the perfect 
construction and functioning of body cells. This is 
an immense subject, which could occupy many pages 
and cannot be developed here. The errors at work 
are largely concerned with excessive meat eating, 
coffee, and alcohol. Luxurious living and indolence 
as factors are shown by the fact that in England, 
11 Bulkley: Cancer and Its Non-surgical Treatment, New York, 
1921. 168 
CANCER OF THE BREAST. 
in one decennium, cancer mortality was more than 
twice as great among the well-to-do men, having no 
specific occupation, as it was among occupied males 
in general, the ratio being 96 to 44. The indolence 
pervading this country, the disinclination to hard 
physical work, the automobile, and ease of transpor- 
tation, all contribute to produce the imperfect blood 
current which leads up to cancer: several observers 
have remarked that athletes are not subject to the 
disease, which I have found to be true. One writer 
remarks that "Cancer is essentially a disease super- 
vening upon a persistent neglect of hygienic laws." 
2. Faulty metabolism. The direct medium through 
which the above and other elements combine to pro- 
duce cancer, is through a deranged or faulty meta- 
bolism-with its two divisions, catabolism and anabol- 
ism-which fails to furnish a perfect blood stream 
from which the body cells may secure the proper 
nourishment for their growth, renewal, and function. 
Metabolism is obviously affected by the food and 
drink introduced into the system, and by the faulty 
operation of the various glands or organs which 
break them up and change them into substances 
which can be assimilated by the cells and converted 
into their structure. The right or wrong action of 
these organs will be considered later. 
The human body is composed of some fifteen dif- 
ferent primary elements, which are found in the MEDICAL ASPECTS OF CANCER. 
169 
composition of what enters the mouth and lungs: of 
these oxygen forms about 65 per cent. Throughout 
all nature it is recognized that plants and animals 
must have the right food and oxygen, in order to 
have healthy and vigorous life, and man is no ex- 
ception. There must be a proper balance in the vari- 
ous elements of nutriment on which they feed; this 
ordinarily is found in their surroundings or is sup- 
plied by human intelligence. Wild animals, guided 
by instinct, select their proper food and are seldom or 
never sick when in a state of nature; but with man 
matters are different. He does not seem to be 
guided so much by instinct as by taste, whim, or 
fancy, or by the influence of others, and so will often 
indulge in tickling the palate and gratifying the taste 
instead of simply satisfying the appetite; and the 
temptations to this, in modern life, are increasingly 
great. Thus it happens that gross errors are con- 
tinually committed, leading to various diseases, as 
we all know. It is to be remembered that man 
is the only animal that cooks its food, often very 
wrongly, or attempts to alter or refine it from the 
natural state, often very disadvantageously. 
3. Imperfect blood stream. The results of dis- 
ordered or faulty metabolism are shown in the blood, 
from which the body cells receive their nutriment. 
Although little or no changes can be discovered in 
the blood which are absolutely pathognomonic of 170 
CANCER OF THE BREAST. 
cancer, by the ordinary or simple methods com- 
monly employed, certain intensive workers, as Price- 
Jones,12 Ross,13 and Gruner14 have carried their 
studies much further and claim to have demon- 
strated blood changes which are characteristic of 
the disease: Gruner lays stress on the character of 
the plasma, which has heretofore been too much neg- 
lected, and also on certain changes in the leuco- 
cytes, all of which is too technical to introduce here. 
All are familiar with the later changes in the 
blood, as the disease progresses and cachexia occurs, 
the great reduction which may be seen in the hemo- 
globin, and the diminution of the red cells, even to 
1,000,000 instead of the normal 5,400,000. I am not 
aware of any great studies on the chemical composi- 
tion of the blood, except that the alkalescence may be 
greatly diminished, indicating cancer to be an aci- 
dosis. The lessening of the hemoglobin shows a re- 
duction in the iron in the blood and Forbes Ross has 
shown that the potash constituent of the red cells, 
which forms "more than three-fourths of the total 
mineral of the red corpuscles" in health, is also much 
diminished. The studies of these and other re- 
searches are very extensive and illuminating, but 
cannot be further developed here. 
12 Price-Jones: Blood Pictures, etc., New York, 1921, p. 56. 
13 Ross, Forbes; Cancer, The Problem of its Genesis and Treat- 
ment, London, 1-912, p. 51. 
14 Gruner: The Exact Diagnosis of Latent Cancer, Philadelphia, 
1919, pp. 50, 72. MEDICAL ASPECTS OF CANCER. 
171 
4. Erroneous elimination. The disintegration of 
foodstuffs and the processes of metabolism are car- 
ried on by the aid of the many organs of secretion 
and excretion with which the body is provided, which 
must always be considered in connection with the 
medical treatment of cancer of the breast, as they 
are often more or less at fault. 
i. Salivary Secretion. The first secretion which 
has to do with the proper digestion and assimilation 
of food products is the saliva, which is too often 
slighted. While the secretions of the mouth are 
partly for the purpose of aiding deglutition, this is 
principally effected by the mucous glands, while the 
large salivary glands have the function of digesting 
starchy products, which cannot be properly handled 
by the acid stomach; these, if ineffectually altered by 
the saliva are passed on for the action of the pan- 
creas, an enlarged salivary gland, one of whose en- 
zymes, amylose, digests starch. In both early and 
late cancer I have found the salivary secretion almost 
invariably acid, generally strongly so, as I have had 
hundreds of tests made and recorded in hospital pa- 
tients, a quarter of an hour before and a quarter of 
an hour after each meal. This means an imperfect 
transformation of starchy matter into dextrose or 
glucose, and shows the importance of perfect and 
prolonged mastication, which will be considered 
again later. The normal saliva is alkaline or neu- 172 
CANCER OF THE BREAST. 
tral, and the daily amount has been variably placed 
at from 1000 to 1500 c.c., while that of the daily 
average secretion of the pancreas is 650 c.c. 
2. Pancreatic Secretion. This mingles with the 
alkaline bile and endeavors to complete the digestion 
of food products. We can understand how the same 
vitiated blood stream which causes certain body cells, 
as in the breast and elsewhere, to rebel entirely and 
cease their normal work, can and does affect every 
cell in the body to a greater or less degree; and as 
the salivary secretion is disordered and imperfect, 
so that of the pancreas, liver, stomach, etc., all may 
do their work imperfectly, as dissatisfied soldiers 
would, before they broke out into open mutiny. But 
it is hard to tell much about these deeper secretions, 
except by the result of their supposed clinical mani- 
festations in their imperfect or disordered action. 
3. Endocrinous Secretions. The last remark ap- 
plies especially to the secretions of the ductless 
glands, about which so much has been written, with 
so little real knowledge. Unfortunately also we 
know very little as to how to effect their secretion, 
indeed we hardly comprehend much as to whether 
the claimed error from their disturbance is from ex- 
cessive, deficient, or faulty secretion, in many in- 
stances. Enough is recognized, however, for us to 
know and realize that they have functions to perform, 
and that errors in their action may cause certain dis- MEDICAL ASPECTS OF CANCER. 
173 
orders or diseases: such are Addison's disease from 
suprarenal disorder, gigantism from pituitary dis- 
turbance, cretinism, and myxedema from dysfunction 
of the thyroid. That there is some connection be- 
tween thyroid action and cancer is apparent from the 
advantage shown by several writers who report bene- 
fit after its use in this disease, which I have also seen, 
when given alone or used in conjunction with other 
proper treatment: it has been claimed that pituitary 
extract is also valuable. But it is understood that 
these glands may also suffer in their functional activ- 
ity from improper nutrition or bad nerve influence, 
quite as much as the cells forming the breast. 
4. Imperfect Intestinal Elimination. Many writ- 
ers have called attention to the important part which 
this feature plays in connection with cancer in gen- 
eral, and, as I have also seen it, especially in cancer 
of the breast; Dr. Robert Bell, of London, once a 
surgeon, operating largely on cancer, is most strong 
on this subject. He says: "During a period extend- 
ing now over 20 years that I have devoted especial 
attention to this subject, with ample opportunity at 
my command for observation, I have never met with 
a single instance where constipation did not co-exist, 
and, moreover, where it had not been in existence 
for a lengthened period prior to the manifestation of 
the disease," and he dwells at some length, and elab- 
orates with a great deal of force and logic, on the 174 
CANCER OF THE BREAST. 
necessity of a daily and complete evacuation of the 
bowels. 
I am even more strenuous in regard to the matter, 
and have been so for over forty years of observation. 
The action of the bowels, in regard to their true elim- 
inative function is often a difficult matter to discover 
and handle, and yet from long observation I am con- 
vinced that it plays a most important part in connec- 
tion with cancer. This is constantly observed in 
patients with mammary cancer, both before the re- 
currence of a lesion after surgical operation, and in 
the early, formative period, and likewise later, even 
before any recourse to morphine, which, of course, 
heightens the trouble. Recently, Victor Pauchet,15 
one of the leading abdominal surgeons of France, 
has come out strongly upon intestinal intoxication as 
the cause of cancer of the breast. 
In questioning these patients closely, and record- 
ing their statements at each visit I have been so 
struck with the almost invariable history of consti- 
pation, intestinal stasis with colonic engorgement, or 
at least imperfect intestinal elimination, that I can- 
not help feeling very strongly the probability that 
the toxins, produced by the millions of micro-organ- 
isms generated through intestinal stasis and fecal 
putrefaction, play a great part in the production of 
that blood dyscrasia which culminates in the forma- 
15 Pauchet, Victor: Journal de Med. de Paris, 1921. MEDICAL ASPECTS OF CANCER. 
175 
tion of the malignant growth, as Sir Arbuthnot Lane 
emphasized not long ago. While this is only a clin- 
ical conclusion it is hoped that laboratory research 
turned in this direction will confirm the finding. All 
this will be further considered under Treatment. 
5. The Liver. The liver has been shown by many 
researches to exhibit departure from normal action 
in connection with cancer. Reid,16 from the Re- 
search Laboratory in Manchester, England, reports 
that "In cancer, the liver, while not involved in the 
disease, is still unable, for some reason, to perform 
its functions in synthetizing urea. The organ is 
functionally injured, no lesions having been found 
to explain its insufficiency . . . cancerous subjects 
form proteids which the liver is unable to deal with, 
so that they are secreted unchanged, or nearly so." 
Degres17 has made confirmatory researches along 
these lines. Blumenthal18 states that urobilin is in- 
creased in a large proportion of cases of cancer, and 
others have confirmed hepatic functional disorders in 
connection with this disease. It is not surprising that 
the cells of the various organs of the body should 
share in perverted action from the deranged blood in 
carcinosis, and manifest greater or less alterations in 
structure, although many of them may not rise to 
16 Reid: Cancer Research Lab., Manchester, Med. Chron., Nov., 
1912; Apr., 1914. 
17 Degres: Gaz. med. de Paris, 1913, p. 400. 
18 Blumenthal: Handl, d. Spezial Path. d. Harns. 1913, p. 263. 176 
CANCER OF THE BREAST. 
the point of a mutiny resulting in the lesions of 
cancer. 
6. Imperfect Kidney Elimination. The urine in 
cancer has been investigated by very many observers, 
and although no definite and specific changes have 
as yet been demonstrated which are surely indicative 
of the disease, very many departures from the nor- 
mal have been reported which are of significance, and 
under complete volumetric analysis the urine of a 
subject of cancer is rarely if ever that of health. 
Many observers agree that there is a disturbance of 
protein metabolism manifested in the urine, and an 
increase in colloid nitrogen to more than double the 
normal amount; there has also been reported a dis- 
turbance in the sulphur output, and an increased 
elimination of xanthin, oxyproteic acid, and urinary 
ammonia. The urea in the urine is almost invariably 
diminished, often very greatly, as I have verified 
time and again in many cases. 
The urinary secretion will constantly be found to 
be extremely deficient, both as to the actual quantity 
passed in the twenty-four hours, and in its total solid 
elimination, which latter is, of course, the true indica- 
tion as to the efficiency of the excretion. In many 
cases, even of very early cancer, in which the urinary 
secretion has been measured and recorded every day 
for weeks, or months, I have found the elimination of 
solids often less than one-half the amount called for MEDICAL ASPECTS OF CANCER. 
177 
by the body weight of the patient. As the tumor 
has melted away under proper dietary, hygienic, and 
medical treatment the kidneys have often brought 
up the removal of waste material to or above a 
normal standard. So constantly have I observed this 
faulty urinary elimination early and late in these 
subjects, that I cannot but believe that it indicates 
some defect in metabolism which has a bearing upon 
the genesis and rebelliousness of cancer. 
5. Nervous disturbances. Tuke,19 fifty years ago, 
showed very clearly the influence of the mind upon 
the body in health and disease, and Cannon,20 quite 
recently, has made intensive studies, with immense 
bibliography, showing the same. Instances of these 
are familiar to all, such as sudden falling and grey- 
ing of the hair from fright, great anxiety, etc., loss 
of appetite, nausea, vomiting, etc., from bad news, 
loss of weight from anxiety and sorrow, blanching 
of the face from fear, blushing from emotion, red- 
dening of the face from rage, and even "cold sweat" 
from fright, and dryness of the mouth from excite- 
ment, etc. All the illustrations that could be given 
show clearly that nerve influence may affect any and 
all the cells of the body, just how we know not, ex- 
cept that it is largely through the sympathetic and 
19Tuke: Influence of the Mind upon the Body in Health and 
Disease, London, 1872. 
20 Cannon: Bodily Changes in Pain, Hunger, Fear and Rage, New 
York and London, 1915. 178 
CANCER OF THE BREAST. 
vasomotor nerves, and that they can equally affect 
those of the breast. Several writers on cancer have 
acknowledged nervous influence in the production 
of cancer, and that astute and successful surgeon, 
Thomas Bryant, of London,21 speaking of mental 
anxiety as a cause of cancer says: "To say that it 
is an antecedent of many cases of carcinoma is a fact 
which most surgeons would support." There can 
be no doubt but that the strain and stress of modern 
life, with all its rush and anxieties has a not incon- 
siderable influence in producing the changes of tis- 
sue which lead up to cancer. Even Gibson,22 study- 
ing cancer from a statistical standpoint of occupa- 
tions, and an adherent of the local nature of the dis- 
ease says: "It is undoubted that worry and anxiety- 
nerve depressing influences-predispose to cancer." 
That peculiarly wise and accurate surgeon, Sir 
Astley Cooper,23 in 1835, remarked: "I should 
have observed just now, when speaking of the cause 
of this complaint (breast cancer), that one of the 
most frequent is grief or anxiety of mind. How 
often have I seen, when a mother or nurse has been 
watching night after night, with anxious solicitude, 
21 Bryant, Thomas: The Diseases of the Breast, London, 1887, p. 
169. 
22 Gibson, W. T.: The Etiology and Nature of Cancerous and 
Other Growths, London, 1909, p. 94. 
23 Cooper, Sir Astley: Lectures on the principles and practice of 
Surgery, Eighth edition, London, 1835, p. 341. MEDICAL ASPECTS OF CANCER. 
179 
the pangs and suffering of a child, and she had the 
comfort and gratification of seeing its recovery, that 
in a short time after this she came to me with an 
uneasiness of the breast, which, on examination, I 
discovered to be a scirrhous tubercle. Fully three- 
fourths of these cases arise from grief and anxiety 
of mind." 
We have thus seen that cancer is certainly never a 
purely local disease, to be cured by the cutting or 
burning out of the original local product or mani- 
festation of its presence, or even by causing its tem- 
porary disappearance by x-ray or radium, but it is a 
constitutional affair, a carcinosis, with many con- 
tributing factors. In other words, it is the result of 
a long continued breaking of the laws of normal, 
simple life; for early in this writing we have seen 
the many things cancer is not, and any one who has 
carefully studied and recorded the histories of very 
many patients with cancer of the breast, each over a 
long period of time, will find that the medical aspects 
connected therewith are many and important. All 
this shows that cancer is not due to any one single 
cause, so that there is not and cannot be any single 
measure or remedy that can always cure it. But 
long experience demonstrates that the most diligent 
attention to its medical aspects, with most careful 
medical treatment accomplishes far more for it than 
the methods of treatment in vogue of late years. CHAPTER X. 
TREATMENT OF CANCER OF THE BREAST. 
The successful treatment of all cases of cancer 
of the breast is no easy matter, as the exact measures 
necessary to employ will often tax the wisdom, ex- 
perience, judgment, and patience of the physician to 
the utmost, for there are so many points to con- 
sider. As has been seen under Prognosis, success 
varies according to many features and factors. 
Early and simple cases are one thing, while advanced 
and recurrent cases are quite another, as may be 
judged by what has preceded, and what will follow. 
Success in the treatment of breast cancer relates 
to three features: I. The removal of the disease so 
that there is no further manifestation of it, not only 
for three years, the original, false limit, nor for five 
or even eight years, as suggested by Rodman, but 
permanently. 2. Extension of life. 3. Relief from 
pain, which is the fear of all cancer patients. These 
points have been or will be sufficiently dwelt upon 
elsewhere, and need not be elaborated here. 
We may conveniently discuss the possible methods 
of treatment under the following heads: 1. Surgery. 
2. X-rays. 3. Radium. 4. Caustics. 5. Chemical re- 
moval. 6. Bio-therapy. 7. Diet. 8. Hygiene. 9. Medi- 
cal, internal and external. 
180 TREATMENT OF CANCER OF BREAST. 
181 
I. Surgery. Any one who has thoroughly mas- 
tered Handley's remarkable study and demonstration 
of the lymphatic permeation of dissemination in can- 
cer, and is familiar with the many and able surgical 
books and writings upon cancer of the breast and 
their narration of cases, and fully grasps their state- 
ments of final results, as briefly recorded under Prog- 
nosis, must wonder how the surgeon can ever ex- 
pect to cure the disease in this region by the knife, 
although remarkable claims have occasionally been 
made. If more cases were followed up for years, and 
the results compared with the death record of pa- 
tients left without surgical excision, the statistics 
would be very different. No doubt many of the fav- 
orable reports are due to faulty diagnosis, such as 
the excision of benign tumors, cysts, adenoma, adeno- 
carcinoma, fibroma, and even tuberculous and syph- 
ilitic lesions, etc. If full and perfect microscopic 
diagnosis, by surely competent pathologists, were 
given of every excised mass, there would be fewer 
claims of the cure of true carcinoma by the knife; 
and if the patients were watched longer, with care- 
ful records, there would be more recurrences found. 
The rapidity, extent, and progress of lymphatic per- 
meation are such that it would seem almost an im- 
possibility to circumvent it by surgical procedure, and 
experience seems to warrant this conclusion, as has 
been abundantly shown. 182 
CANCER OF THE BREAST. 
In regard as to when to advise excision, I am per- 
haps not a good judge, as I have personally seen 
mainly the darker side. For benign growths in the 
breast, when annoying, it is unquestionably reason- 
able, although adenoma, when excised, has been 
known to be followed by true carcinoma, as proved 
by the microscope. But when there is good reason 
to believe that there is malignity, the surgeon and 
patient must take the responsibility of deciding. 
The more this process of lymphatic permeation is 
studied, the more does it seem to point clearly to a 
systemic or constitutional nature of carcinosis, which 
best explains the rapid involvement of the lymphatic 
system, damaging it so greatly that life processes 
cannot be carried out, and the patient succumbs. 
For Handley pretty clearly demonstrates that the 
embolic theory of dissemination as a principal cause 
of cancer recurrence is no longer tenable, although 
it has still many supporters. 
2. X-ray. The same reasoning applies to the use 
of the x-ray, which is equally helpless in reaching 
the real, systemic cause of the disease, carcinosis, as 
it can only seek to remove its product or manifesta- 
tion. It is recognized that the x-ray may and often 
does produce constitutional effects, as evidenced by 
prostration and vomiting after long and severe ex- 
posure, but I have not yet personally seen great 
benefit from it, much less a cure of mammary can- TREATMENT OF CANCER OF BREAST. 
183 
cer, although I have observed its employment in 
many dozen patients; and I have seen most grievous 
burns, which, as all know, may be impossible to heal, 
and in some cases its improper use seems to increase 
the tumor and adenopathy. 
3. Radium. A similar line of thought and obser- 
vation applies to radium. While this agency is of 
probably equal value with the x-ray in curing the 
localized disease, epithelioma of the skin, I have yet 
to know of its actual cure of breast cancer, though 
I have long watched its use in very many cases. I 
have seen some distressing results: I have had three 
patients in private practice with uterine cancer who, 
soon after the application of radium, and not before, 
had a vagino-rectal fistula, and defecated through the 
vagina, until they died miserably. 
4. Caustics. These have long been used by quacks 
and also by some regular practitioners, but have not 
received general endorsement. As commonly em- 
ployed they are very tedious and painful, with very 
slow healing, and dubious final results, although it 
must be acknowledged that sometimes there seems 
to be a permanent cure. They have this advantage 
over surgery that the caustic seals the blood-vessels 
and lymphatics, so that there is not the danger of 
infection in a cut wound and of recurrence of the 
disease. While I have seen some or many patients 
who have been thus treated, I have never felt willing 184 
CANCER OF THE BREAST. 
to advise or sanction it, except in the manner or 
method to be next described, in cancer of the breast. 
Local epithelioma on the skin is often very satis- 
factorily treated with a caustic, Marsden's arseni- 
cal paste, which I used with perfect results in many 
cases, years ago; but nitrate of silver should never be 
used in any form of cancer. 
5. Chemical removal. Especially for far advanced 
and otherwise inoperable cancer of the breast, this 
method, which has been developed and perfected by 
Dr. Strobel is of real service, as I have observed in 
a good many instances; although when there has al- 
ready occurred great lymphatic enlargement there 
can hardly be expected permanent results. In early 
cases it has hardly yet been tried, but when active 
surgical intervention is refused, and when one is not 
willing to submit to the prolonged and sometimes an- 
noying course of medical treatment (even with its 
cheering ultimate results) and when it seems impera- 
tive to the physician and patient to have the offend- 
ing mass removed at the earliest possible moment, 
this chemical removal is to be much preferred to sur- 
gical excision. The reason for this is that this 
method seals the blood and lymphatic vessels, and 
there is far less danger of a recurrence. The method 
is such an advance in the treatment of mammary 
cancer in general, that it merits a more full con- 
sideration here. TREATMENT OF CANCER OF BREAST. 
185 
The technique evolved by Dr. Strobel makes this 
procedure both painless and thorough, and with no 
operative dangers. The anesthetic employed almost 
exclusively is by the hypodermic injection of a tablet 
of scopolamine-morphine or hyoscine-morphine, an 
hour before the operation is begun, and again half 
an hour later; sometimes a sniff of an inhalant is 
required at the beginning of the operation; nothing 
is necessary after the skin is removed, nor at subse- 
quent applications of the caustic paste, about every 
other day, when also the resulting slough is trimmed 
off. This I can verify, as I have watched the whole 
treatment repeatedly. 
He divides the operation into four stages: (i) De- 
nuding the skin, down to the breast tissue, first with 
a liberal application of pure carbolic acid, and then 
by the very free use of stick caustic potash, dampened 
frequently. (2) The caustic paste of chloride of zinc 
and flour, equal parts, with water, darkened with 
powdered charcoal, spread on the wooly side of can- 
ton flannel, cut in pieces to fit, is laid over the whole 
denuded area. As this is removed about every other 
day there is found a slough which is trimmed off, and 
a new application of the paste is similarly laid over 
the denuded area. As I have repeatedly witnessed 
this procedure, patients say there is no pain. (3) 
When the chest level is reached, generally in about 
two weeks, there is a large area, with reddened, in- 186 
CANCER OF THE BREAST. 
flammatory edges, and an adherent slough, which is 
kept covered with an emollient ointment, spread on 
lint, changed several times daily, until it is shed, 
and a raw, healthy granulation surface is presented. 
This is then skin-grafted thoroughly, and properly 
cared for. Great care must be exercised in confining 
the chloride of zinc paste to the area to be destroyed, 
by proper protection of adhesive plaster or ointment, 
and careful nursing, for there is pain indeed if it 
gets on the skin, which is the reason for darkening 
it with charcoal. 
This method of removal of a cancerous breast 
seems to be the most rational possible, when com- 
bined with thorough and intensive medical measures, 
to prevent the further development of the manifesta- 
tions of the products of carcinosis in other places, 
idiopathically or from the result of deep lymphatic 
infection. For there is certainly not the recurrence 
of the disease about the healed surface which com- 
monly appears after surgical procedures, nor the 
swollen arm, so frequently resulting from the latter, 
and, of course, no operative mortality. When there 
is already much involvement of the axillary or supra- 
clavicular glands there is, of course, danger of a 
fresh outbreak of the disease somewhere else. This 
I have seen in a couple of cases. But when there is 
only slight axillary involvement of the gland, or a 
few glands, they can be destroyed or enucleated by TREATMENT OF CANCER OF BREAST. 
187 
the very careful use of the stick caustic potash, while 
the employment of any cutting instrument vitiates 
the whole proceeding, opening the lymphatics and 
inviting recurrence. 
While I have dwelt so long on this procedure, to 
make it very clear, I wish to say that I do not com- 
mend it wholly, or approve of it to the exclusion of 
proper dietetic, hygienic, and medicinal treatment. 
For it is exclusively a local measure, like operative 
surgery, aimed, like surgery, at the local manifesta- 
tion or product of carcinosis; and, as already quoted 
from Abernethy, of 100 years ago, "The best timed 
and best conducted operation brings with it nothing 
but disgrace, if the diseased propensities of the sys- 
tem are active and powerful. It is after an opera- 
tion that, in my opinion, we are most particularly in- 
cited to regulate the constitution, lest the disease 
should be revived or renewed by its disturbance." 
So, while this method has the advantage over the 
knife, it must not be looked on as a real cure of a 
disease which has such large medical aspects, and 
these must be met rightly and thoroughly if we ex- 
pect really to cure many cases. 
6. Bio-therapy. The next method of the treatment 
of cancer approaches, in a measure, the basic idea 
promulgated in these pages, namely, the employ- 
ment of something which shall modify the cyto- 
genesis, from within, in such a manner that the cells 188 
CANCER OF THE BREAST. 
will not stray away from physiological control, and 
go on a mutinous, disorderly, and destructive course. 
There is no reason why ultimately such treatment 
may not confirm and support the thesis of the con- 
stitutional nature and medical treatment of cancer 
of the breast, and why it may not, when perfected, 
be a rational and efficient aid in the treatment advo- 
cated in these pages. 
The lines along which attempts have been made 
for what has been called the biological treatment of 
cancer are many and varied, and need not concern 
us here. Trial has been made, largely unsuccessfully, 
of various substances, on different theories of the 
disease, and claims made of gain and improvement 
from them, which others could not verify, so that, 
with a few exceptions, this plan of treatment has 
been largely abandoned. Those plans that have been 
tried may be grouped under three headings: (i) 
bacteria; (2) serous, including human and animal 
substances; and (3) cytolytic, from vegetable sub- 
stances. To these should perhaps be added (4) 
organotherapy, employing preparations of the endo- 
crinic glands, generally by the mouth, though often 
otherwise. This is a large subject and it is not 
necessary to enter upon it here, but there are two 
methods which may be of service in breast tumor. 
One is Coley's fluid in sarcoma, and the other is a 
proteal injection for carcinoma, as advocated by Dr. TREATMENT OF CANCER OF BREAST. 
189 
H. S. Williams, of New York. I have used this lat- 
ter somewhat, but not long enough to express a de- 
cided opinion about it. The use of endocrinous 
gland products has been already spoken of. 
7. Diet. There can be no question with intelligent 
minds but that diet, proper or improper, plays a very 
important part in health and disease, and this has 
been especially shown in connection with cancer of 
the breast, in the cases considered in this book. As 
erroneous diet and a wrong mode of life are un- 
doubtedly the prime or basic cause of the disturb- 
ance in cell action which results in carcinosis, or 
what we call cancer, so the exact proper regulation 
of the same, providing proper nutrition and efficient 
nerve control of the cells of the body, certainly does 
tend to their return to a normal state, when aided 
by proper medication, as shown in the cases to be 
related later. 
Since first writing on the subject under considera- 
tion, medical reviewers, and many others, including 
the daily press, have spoken as though I regarded 
meat eating as the sole cause of cancer, and that en- 
forced abstinence therefrom was the single element 
necessary for its prevention and cure. This is in- 
deed a very narrow view of the subject, and from 
what has already been written it is readily seen that 
this is by no means the case. But that I regard ani- 
mal protein and its faulty partition as a fertile cause 190 
CANCER OF THE BREAST. 
of the derangement of metabolism which leads up to 
and fosters the growth of cancer, both the first lesion 
and its extension, and recurrences, is most certainly 
true. The question of diet, however, is a much 
broader one than that, for without this being correct 
in all respects, all other measures are of no avail. 
For, as in gout, the continuance of over-indulgence 
in port and Madeira wine would invalidate any at- 
tempt to cure the trouble permanently, so in cancer 
an excess of animal protein, or even a large amount 
of vegetable protein, militates against any effort to 
cure the disease permanently: this appears to be true 
also of coffee and alcohol. The influence of alcohol 
in inducing cancer has recently been shown statis- 
tically by Gibson,1 and confirmed by Sir Alfred 
Pearce Gould,2 Dr. Tatham, Dr. Newsholme, and 
others. 
As exactly proper diet is the basic element upon 
which the cure of cancer of the breast rests, it is all 
important that the physician and patient come to a 
perfect understanding as to how the proper diet can 
be secured and maintained. Moreover, it is well to 
remember that there is no definite period during 
which a rightly directed diet is to be carried out or 
continued; or rather that there is no fixed time when 
1 Gibson, W. T.: Etiology and Nature of Cancerous and other 
Growths, London, 1909. 
2 Gould, Sir Alfred Pearce: The Bradshaw Lecture on Cancer, 
London, 1910, p. 53. TREATMENT OF CANCER OF BREAST. 
191 
it may be discontinued, lest errors should induce a 
recurrence of the disease; and my patients are made 
to understand that it is at their own risk that it is 
to be stopped. For safety from recurrence of can- 
cer the proper diet should be persisted in indefinitely 
or even permanently; for if the original errors in diet 
and mode of life are returned to, there is no reason 
why the disease should not return. But if this is 
done faithfully there is certainly no probability of a 
recrudescence, as the cases to be narrated abundantly 
show. Even as in tuberculosis we know that a pa- 
tient may overcome the disease by fulfilling all the 
necessary conditions, dietetic, hygienic, and medic- 
inal, but that the disease may, and probably will, re- 
cur when the patient resumes exactly the same life 
as before 
It is often difficult to make sure that the patient 
will adopt and follow faithfully all the necessary pro- 
cedure for a period long enough to secure perfect re- 
sults, so obsessed is the medical profession and the 
laity with the idea that surgery offers the only hope in 
cancer. But with repeated and long, careful watch- 
ing by the physician this can certainly be accom- 
plished, and I have many, many patients whom I 
have watched for years, and who have been faithful, 
even indefinitely. Some of these, whom I have fol- 
lowed for a very long time, and who remain entirely 
freed from undoubted cancer of the breast, which 192 
CANCER OF THE BREAST. 
had been previously so diagnosed by prominent sur- 
geons, and were actually prepared for a surgical 
operation, have told me that they had suffered much 
more distress from the persistent warnings and solici- 
tations of their misguided physicians, surgeon, or 
friends, urging an operation, than they had from the 
diet, or from the disease itself, as it slowly vanished 
under treatment. 
At first the idea of an absolutely vegetarian diet is 
distasteful and seemingly impossible to many pa- 
tients, but when it is carefully and patiently ex- 
plained, and the reasons for its employment made 
clear, and the very great benefit to be derived there- 
from is fully understood, it is readily acquiesced in 
and carried out faithfully. Indeed many patients 
have asserted that they are more than pleased with 
the general good feelings resulting from it, and have 
no desire whatever for animal food or products; in 
some instances I am told that the whole family had 
adopted the same diet. At each visit I am particular 
to inquire about the matter, and have patients bring 
their diet card with them, and make sure, by repeated 
questioning, that everything is carried out exactly. 
Among the poorer classes, especially, it has some- 
times been hard to make matters perfectly clear, and 
to secure a correct and proper diet for those attend- 
ing my Medical Clinic for Cancer, at the New York 
Skin and Cancer Hospital. Therefore, some years TREATMENT OF CANCER OF BREAST. 
193 
ago I prepared a dietary card, or folder, with a 
daily menu, which has long been used most satisfac- 
torily by hundreds of patients in private and public 
practice, and which is here reprinted, still further 
modified and improved. 
To make the whole matter of this line of treatment 
perfectly clear, certain statements in regard to can- 
cer have been presented on the first page, and on the 
last page some directions as to diet and mode of life, 
of a practical character were added, with the daily 
menu on the inside pages to all of which particular 
attention is always directed. At first there were 
printed one thousand of this "Green Card Slip," 
which were given to patients and interested physi- 
cians, and when these were exhausted the card was 
somewhat revised, and five thousand were issued, 
which supply is now gone. These have been used in 
practice and distributed to inquiring physicians all 
over the country, who have made good use of them 
for cancer patients: 
DIRECTIONS FOR CANCER PATIENTS 
1. Cancer is a serious disease which should receive constant 
medical care from the time it is first suspected, and even long after 
all manifest symptoms have disappeared. 
2. "Cancer Specialists," who advertise, should be avoided. 
3. Cancer is not contagious, and there is no danger of communi- 
cating the disease to others. 
4. Cancer is not a disgraceful disease, and there is no reason 
for being ashamed of it or hiding it. 
5. As soon as cancer is suspected, whether there be a lump, or 
sore, or other symptoms, it should be at once cared for by a 194 
CANCER OF THE BREAST. 
competent medical man, as the earlier it is rightly treated the more 
prospect there is of its being cured. 
6. Anything suspected to be cancer should not be handled or 
squeezed, but should be kept from all irritation, as this increases 
and spreads the trouble, and renders the cure more difficult. 
7. If it is decided that a surgical operation is desirable and wise, 
this should be done very completely at the earliest possible moment; 
delay is dangerous. 
8. The proper medical treatment of cancer should never be 
neglected, both at the very beginning, and also for a long time 
after an operation has been performed, to prevent recurrence. 
9. It is rarely necessary or best to operate on cancer; x-ray and 
radium, rightly used, are often of value, but the disease can be made 
to disappear and remain absent under careful and efficient dietetic, 
hygienic, and medical measures alone, without an operation. 
10. This treatment consists in an absolutely vegetarian diet, with 
continous proper medication, for a long time. 
11. To get favorable ultimate results this treatment must be kept 
up faithfully and strictly until discontinued by the physician. 
To assist in carrying out a strictly vegetarian diet, a diet list 
for cancer is here given, which should be closely adhered to. 
Coffee, chocolate and cocoa, as also alcoholic drinks, even beer, 
are harmful and must be avoided. The rules given at the end of 
this card are also to be strictly observed. 
DIET FOR CANCER. 
Breakfast. 
Baked apple 
4 ounces rice 
3 " corn bread 
1% " butter 
^2 " sugar 
postum 
First Day. 
Dinner. 
5 ounces tapioca soup 
3 " baked potatoes 
3 " stewed celery 
3 " string beans 
1 " graham bread 
1% " butter 
1 raw apple 
Supper. 
4 ounces Ralston's food 
2 " white bread 
1% " butter 
4 " stewed prunes 
J4 " sugar 
Very weak tea TREATMENT OF CANCER OF BREAST. 
195 
Breakfast. 
Orange 
4 ounces hominy 
2 " graham toast 
1% " butter 
y2 " sugar 
postum 
Second Day. 
Dinner. 
5 ounces pea soup 
3 " macaroni 
3 " peas, corn 
3 " carrots, turnips 
2 " bread 
1% " butter 
dates 
Supper. 
4 ounces cream of wheat 
% " sugar 
1% " butter 
2 " crackers 
1% " baked apple 
2 " white bread toast 
Very weak tea 
Third Day. 
Breakfast. 
Banana 
4 ounces oatmeal 
2 " baker's rolls 
1% " butter 
" sugar 
postum 
Dinner. 
5 ounces corn soup 
3 " sweet potatoes 
3 " squash, beets 
3 " boiled onions 
2 " bread 
1^ " butter 
raisins 
Supper. 
4 ounces farina 
4 " stewed figs 
2 " graham crackers 
1% " butter 
% " sugar 
Very weak tea 
Breakfast. 
Raw apple 
4 ounces cornmeal mush 
2 " graham bread 
1% " butter 
% " sugar 
postum 
Fourth Day. 
Dinner. 
5 ounces vegetable soup 
4 " baked beans 
3 " cauliflower 
3 " asparagus 
2 " bread 
1% " butter 
figs 196 
CANCER OF THE BREAST. 
Supper. 
4 ounces rice 
4 " stewed prunes 
2 " graham crackers 
1% " butter 
% " sugar 
Very weak tea 
Fifth Day. 
Breakfast. 
Orange 
4 ounces rolled wheat 
3 " corn muffins 
1% " butter 
y2 " sugar 
postum 
Dinner. 
5 ounces okra soup 
4 " spaghetti 
3 " oyster plant 
3 " lima beans 
2 " bread 
1% " butter 
dates 
Supper. 
4 ounces cream of wheat 
sliced orange 
2 ounces oatmeal crackers 
1% " butter 
" sugar 
Very weak tea 
Sixth Day. 
Breakfast. 
Fried apple 
4 ounces pettijohn 
2 " graham toast 
1% " butter 
/2 " sugar 
postum 
Dinner. 
5 ounces celery soup 
4 " baked potatoes 
3 " egg plant 
3 " spinach 
2 " bread 
1J4 " butter 
orange 
Supper. 
4 ounces wheatena, wheatlets 
4 " stewed figs 
2 " saltine biscuit 
1% " butter 
% " sugar 
Very weak tea 
Repeat this bill of fare on successive days. TREATMENT OF CANCER OF BREAST. 
197 
Some interchange of the different articles may be made according 
to the season and to suit the appetite or convenience of patients; 
but in the main this bill of fare should be followed strictly, with 
occasional substitutions of similar articles, if necessary. 
Bread at least 24 hours old may be taken as desired. 
A little old cheese may be grated on the macaroni and spaghetti, 
but not cooked with it. 
One boiled or poached egg may be taken for breakfast every 
other day, and very fat bacon on the alternate days, unless other- 
wise directed by the physician. 
It is desirable to eat the skin of potatoes, baked or boiled. Veg- 
etable and fruit salads may be taken with each dinner, as desired. 
Each and every meal should be eaten very slowly, for at least 
half an hour, with long chewing. 
One tumbler of water, not iced, is to be taken with each meal, 
but not when food is in the mouth; also a tumbler full of hot water, 
one hour before breakfast and supper. 
No milk is to be taken unless specially ordered. 
The vegetable soups are all to be made from a stock composed 
of the water in which all vegetables for the family, including pota- 
toes, have been boiled, added to, day by day, kept hot, and allowed 
to evaporate; a portion of this is each day thickened with cooked 
cereals, rice, oat meal, barley, hominy, farina, sago, macaroni, 
vermicelli, etc., and flavored as desired. No meat stock of any kind 
is allowed in the soup. 
The cereals are to be boiled with water, three or four hours, and 
may be cooked in the afternoon and re-heated in the morning, 
adding more water. Rice, farina, and cream of wheat require only 
an hour. Chopped dates, figs, raisins, or currants may be added 
to cereals when desired. 
All the cereals are to be served very hot, on hot plates, and eaten 
with butter and salt to taste (not milk and sugar). They are to be 
eaten very slowly, with a fork, and very well chewed. 
The crackers with supper may be varied to suit the taste; they 
should be eaten dry, with butter, and chewed very thoroughly. 
Nothing should be taken between meals, unless especially directed, 
and the life should be as simple and healthful as possible, with early 
and long bed hours. 
L. Duncan Bulkley, M.D. 
This diet card was prepared with the assistance 
of the dietitian of the hospital, and represents an 
average of 2100 calories per day, with 140 of vege- 198 
CANCER OF THE BREAST. 
table protein. This is calculated for a person of 
about 150 pounds, either in bed or not taking much 
active exercise. The actual weight of different 
articles is put down for scientific purposes, but prac- 
tically the food need not be weighed, but the amount 
regulated by the desires of the patient, provided the 
appetite and personal will are correct. The quantity 
of each article may be increased or diminished for 
lighter or heavier individuals, but in the main this 
menu has sufficed, so that fat persons have come to 
near normal weight and thin persons have gained in 
weight. One hospital patient with postoperative, re- 
current sarcoma weighed 89^2 pounds on entering 
the hospital and some months later, on this diet alone, 
with proper medication weighed 130 pounds, per- 
fectly well and remained so. 
It is not expected, or even necessarily desired, that 
the patient should rigidly follow the menu each day, 
as given, the only idea is to keep perfectly within the 
limits of alimentation which are directed on the diet 
card, even substituting or adding other articles of 
just the same vegetarian elements. 
On the last page of the folder there are certain 
directions which are necessary to be carefully and 
perfectly carried out, and about which I question 
patients, often at each visit. An important one is 
that with regard to slow eating and always perfect 
masticating and insalivating the food at each meal, TREATMENT OF CANCER OF BREAST. 
199 
even cereals, for at least half an hour. Note also 
that the cereals are to be eaten hot, with salt and 
butter melted on them, and not with milk and 
sugar; and also surely with a fork, and not with a 
spoon, to encourage slow eating and chewing. All 
food is to be "Fletcherized." It is to be remembered 
that, in an earlier chapter the salivary secretion was 
mentioned as faulty, even in early cases of cancer, 
and this perfect mastication is intended to stimulate 
the salivary glands and facilitate the transformation 
of starch food into dextrose or glucose, the first step 
in digestion, without which later processes must be 
defective; for the rapid eating of modern days is 
one of the contributing causes of the perverted nu- 
trition leading up to cancer. 
Attention is called likewise to the preparation of 
the vegetable soup, which is to be employed in place 
of the meat stock as ordinarily used; this latter con- 
tains the most poisonous extracts of meat (with 
which dogs have been killed in the laboratory), or 
with milk, which is not desirable. This vegetable 
stock (made from the water in which all the vege- 
tables used by the family are boiled) contains all 
the salts and other valuable extracts from the vege- 
tables, which are usually thrown away to the great 
detriment of nutrition; for these mineral salts play 
an important part in the constitution of the body and 
its cells. It is well to pour out this mixture, saving 200 
CANCER OF THE BREAST. 
and replacing it, adding to it every day, and scald 
the porcelain-lined vessel in which it is collected, 
every other day, to keep it sweet. A portion of this 
vegetable stock for soup is to be taken out each day 
and thickened and flavored as desired, some butter 
being added, as also cooked and chopped vegetables, 
various cereals, rice, macaroni, vermicelli, tapioca, 
sago, okra, etc.: the more rice that can be used in this 
and other ways the better, for pure rice eaters have 
no cancer. I may add that many patients in private 
practice have declared that their families have pro- 
nounced this soup the best they had ever tasted. 
Attention has already been called to the great loss 
of nutritive elements in the modern or common mode 
of preparation of many articles of food. The loss of 
vitamins and minerals in the refinement of wheat 
flour is also serious, and whole wheat preparations 
should be more freely used in these cases; the old- 
fashioned, stone ground wheat flour, adding some 
mineral powder, was better, and possibly the change 
to modern, steel rolling methods may partly account 
for the increase of cancer of late years. 
Some one has called attention to the loss of min- 
eral and other substances in the refinement of sugar, 
and, therefore, brown sugar, old-fashioned molas- 
ses, and honey are more desirable. The United 
States Experimental Bureau tells us that 30 per 
cent, of the nutritive value of potatoes is ordinarily TREATMENT OF CANCER OF BREAST. 
201 
wasted by the common, careless method of peeling, 
soaking, and cooking them; the inner skin contains 
a large amount, if not all of the mineral content and 
most of the proteins. Hutchinson tells us that: "If 
a bushel of potatoes were peeled and soaked before 
being boiled, the loss of nutrients would be equiva- 
lent to the amount contained in a pound of beef- 
steak." For this reason I have advised that the skin 
of potatoes, boiled or baked, should be eaten. 
It will be noticed in the menu that the use of but- 
ter is encouraged, a quarter of a pound being given 
daily, divided into three portions, one at each meal. 
This quarter of a pound contains 840 calories, or 
one-third of the total calories ordinarily required, 
and is easily digestible. Hutchinson3 says: "There 
is no likelihood of this quantity surpassing the ab- 
sorptive powers of the intestine." Sugar is also pre- 
scribed in a reasonable quantity, affording an addi- 
tional carbohydrate, which is completely oxidized 
under favorable conditions. 
It is realized, of course, that this bill of fare can, 
and undoubtedly will, be improved upon. But it has 
been compiled, and added to, with considerable care 
and thought, and an experience with it now for 
many years in hundreds of cases of cancer and other 
diseases, shows that it is workable, and it has ac- 
3 Hutchinson: Food and the Principles of Dietetics, New York, 
1911, p. 12. 202 
CANCER OF THE BREAST. 
complished results which are often surprising and 
most gratifying both in my private and public prac- 
tice, and in the hands of many other physicians. It 
was prepared primarily for hospital, out-patient prac- 
tice, among the poor and uneducated classes of all 
nationalities, and perhaps there are other articles 
similar to those named which might be taken with 
advantage. 
Heretofore I have not advised the use of many 
fruits, especially raw, fearing the acid element in 
them, but I am now inclined to believe that they are 
beneficial; as also more of raw vegetable products, 
lettuce, cabbage, tomatoes, carrots, and nuts, if they 
are most thoroughly chewed. I also allow cream 
cheese, and some milk, given blood warm, pure and 
alone, without a particle of food with it, a full hour 
before meals, to those who seem to need more nour- 
ishment ; but it should never be taken with food. The 
yolks of eggs and bone marrow are also often service- 
able. 
In a former chapter, I have mentioned the rarity 
of cancer among vegetarian nations, and may give 
my own personal experience in the matter. During 
a rather extensive trip through the Far East I was 
unable to see or hear of any case of cancer, although 
I met a large number of medical men, and made 
diligent inquiry regarding the same. Wishing to 
verify my views in regard to the rarity of the occur- TREATMENT OF CANCER OF BREAST. 
203 
rence of cancer among those who lived on rice or 
other vegetarian diet, I visited many civil, military, 
and missionary hospitals, with a total of many thous- 
ands of patients, and ministering to many millions of 
population, in Japan, Korea, China, The Philippines, 
India, Siam, and Egypt. I met with the same re- 
sponse, that cancer was rarely seen among these 
vegetarian nations; although, as the natives came to 
the large cities, where they mingled with, and lived 
largely as foreigners did, cancer was not so very un- 
common. Thus all experience shows unquestionably 
the connection between diet and cancer, and the im- 
mense importance of having it correct in every re- 
spect, if we wish to cure cancer of the breast by 
any measure which may be tried. 
8. Hygienic adjustment. By this is understood, 
such a regulation of the various habits or conditions 
of the patient's life as will conduce to restore the 
blood to such a perfect or ideal condition that mu- 
tinous and disorderly body cells will return to their 
former normal condition of life and function, and re- 
main so. We know what this will do for tubercu- 
losis, but strangely enough, practically no attention 
to this is ordinarily applied to cancer. 
The details to be mentioned may seem simple and 
homely, but as close attention to details is most im- 
portant in antiseptic or aseptic surgery, so in cancer 
no detail is too small to consider, which can have a 204 
CANCER OF THE BREAST. 
good or bad effect on the state of the blood current 
inducing the wrong action of the cells of the 
breast, and favoring their erratic and destructive 
course. 
As the human body is composed of about 65 per 
cent, of oxygen, and as uncontaminated oxygen is 
essential to give the tuberculosis patient the power 
to resist the inroads of the tubercle bacillus, so im- 
perfect oxygenation of the material which enters and 
composes the blood is injurious to cancer. Attention 
should, therefore, be paid to ventilation and drain- 
age, and every source of contamination surrounding 
these patients should be removed. 
Sunlight we know is essential for perfect animal 
and vegetable life, and must have its effect on can- 
cer patients. Unfortunately, many of the poor crea- 
tures who have to go to some hospitals or cancer 
retreats, are not always fully and perfectly minis- 
tered to correctly in regard to either oxygen or 
sunlight. 
Sleep is nature's sweet restorer, and attention 
should be paid to this, both in the early and late 
stages of cancer. I always inquire about it at each 
visit. All know that errors in regard to this, of late 
years, are very gross. The normal eight hours of 
sleep, at the least, should be secured, and the avoid- 
ance of late hours should be insisted on, the patient 
being in bed and lights out by 10: 30 p. m. Early TREATMENT OF CANCER OF BREAST. 
205 
sleep is certainly more refreshing and re-creative 
than that begun late and prolonged into the morning 
hours. 
Morphine and all opiates and even most sedatives 
given to secure sleep, are surely harmful in cancer, 
as I have long observed, and they only increase the 
carcinosis by interfering with the action of the endo- 
crinous and other glands, and by checking the secre- 
tions and excretions, thereby vitiating the blood 
stream. When exactly proper treatment of all kinds 
is perfectly and carefully carried out they are seldom, 
if ever, required, and it is the rarest thing for any of 
my patients ever to require or have opiates, even up 
to a fatal culmination of the disease; I have known 
plenty of patients with cancer too advanced to save, 
to die peacefully, without an ache or pain, and no 
opiate, if every detail of treatment has been perfect. 
In very many instances I have known opiates, previ- 
ously ordered by others, to have been abandoned vol- 
untarily and entirely, soon after getting under proper 
treatment, and I cannot recall ever ordering or sanc- 
tioning morphine for a cancer patient. 
Regularity in habits conduces to perfect health 
and a healthy blood current, as is exemplified in 
those training as athletes, as also in those in the 
army and navy, among whom cancer is seldom seen. 
I insist on absolute regularity of meal hours, rest, 
sleep, and recreation. Eating between meals, of 206 
CANCER OF THE BREAST. 
sweets or of any thing is conducive to more or less 
disturbance of digestion, assimilation, and perverted 
metabolic action, and must be prevented. 
Recreation is a much misunderstood matter, and 
should be looked into and directed. For instead of 
its being a rc-creation of the vital powers, it is too 
often a wrec/e-creation of them. Excessive fatigue 
without question can interfere with perfect digestion 
and assimilation, and consequently with the bodily 
powers, and can lower cell vigor. Dissipation is de- 
fined as a wasting, scattering, or squandering any- 
thing, and many a person's health is dissipated by 
"pursuing pleasure to excess," as the dictionary 
has it. 
Mental and nervous states have likewise much to 
do with good or bad digestion and assimilation, and 
several writers have insisted that great nerve strain 
and fright have induced cancer of the breast. This 
is quite possible, both by their influence in arresting 
or delaying digestion, and so inducing intestinal fer- 
mentation, and autointoxication, and also by direct 
innervating influence on cell life, through the sym- 
pathetic and nervous systems, all of which I have 
seen. The effect of nerve influence on digestion was 
observed a while ago, in a laboratory, upon some 
cats under x-ray examination. When well fed and 
happy, and purring, the intestinal peristaltic action 
as watched by the fluoroscope, progressed perfectly, TREATMENT OF CANCER OF BREAST. 
207 
but when the same cats were then greatly irritated, 
purposely, all intestinal movements ceased. 
In attempting, therefore, to control early or late 
cancer, every possible element which can in any way 
influence assimilation and disassimilation, or cata- 
bolism and anabolism badly, must be guarded against 
hygienically, if we would place the system in a con- 
dition to resist the inroads of the disease. All these 
matters may seem homely and trite, but long experi- 
ence, more or less verified by other observers, has 
convinced me, from the results obtained in master- 
ing cancer, that they are all of importance. The 
tuberculotic patient undergoes any amount of priva- 
tion and discomfort in the endeavor to overcome the 
disease, and experience also shows that patients with 
cancer of the breast will gladly follow whatever 
course is necessary, when they know the nature of 
their trouble, and its usual course, and when they 
fully understand the importance and value of this line 
of treatment; and .especially when they see the bene- 
fits arising therefrom, in the gradual disappearance 
of malignant tumors. 
9. Medical treatment, internal and external. In 
the first place it must be clearly appreciated and 
understood that there is not, and probably never will 
be, any one single or individual remedy, or any abso- 
lute and fixed course of treatment, which is to be in- 
variably followed, or is always successful in every 208 
CANCER OF THE BREAST. 
case of cancer. This would appear to be self-evident 
from all that has preceded. Each case is a profound 
study of itself. Unfortunately the historical path of 
cancer is strewn with the wrecks of blasted hopes 
regarding various remedies, quack and other, whose 
virtues for the cure of the disease have been heralded 
for a while, only to sink into oblivion, to the sad 
disappointment of trusting sufferers from the dire 
malady. But after more than forty years experience 
with it I can speak unequivocally in regard to the 
line of treatment mapped out in these pages. 
In a disease about which there seems to be such 
uncertainty of opinion as to the absolute, final, and 
basic cause of the particular deviation from normal 
tissue-growth in the breast, and the production of 
such vicious, destructive cells as in cancer, the rem- 
edies which may be required in different cases, to 
meet the varied conditions, may have to be as varied 
as are the peculiarities of each individual. The treat- 
ment, therefore, or it might be called the manage- 
ment of cancer, requires the utmost diligence and at- 
tention to details on the part of both the physician 
and patient, and over a length of time which it may 
be difficult to secure. This is quite different from 
simply performing a relatively brief surgical opera- 
tion, after which the patient is dismissed, with the 
vain hope that the disease will not return, but with 
no precautions against its recurrence. TREATMENT OF CANCER OF BREAST. 
209 
Patience and perseverance, with much thought and 
medical acumen are the first requisites-but with and 
before this there must be a'firm'and thorough belief 
and confidence in the statements made by the writer, 
the correctness of the theory, and the value of the 
methods advised. With this there must be also an 
optimism on the. part of the physician which begets a 
confidence- on the part of the patient, which will as- 
sist much toward carrying out every detail and reach- 
ing the desired' result. Unless much time, thought, 
study, and effort can be given, to each case of cancer 
of the breast, I should deprecate any attempt to treat 
it medically, and rather risk at once the chances of 
the best surgery, poor as they are. 
From what has preceded it will be seen at once 
that rational and right internal treatment must pro- 
ceed and continue along the lines indicated, relating 
to the bio-chemistry of cancer as a disease, carcin- 
osis, as already explained; and not simply with refer- 
ence to its products, or local manifestations, as they 
may appear in various parts of the body, either prim- 
arily or. as the result of its spreading by metastasis. 
The idea is to be clearly understood and acted upon, 
that the patient is to be treated and not only the can- 
cer. The errors of life must be found and corrected 
if we are to cure the carcinosis, which is only thus 
possible; and it can be done. Some tissue cells have 
broken loose from their normal physiological state, 210 
CANCER OF THE BREAST. 
and have taken on a wrong and rampant action, of a 
reproductive character, which has been induced by a 
deranged or disordered blood current. This de- 
ranged metabolism has, in turn, been produced by 
a multiplicity of causes, including dietary errors, 
aided by faulty action of some of the organs of the 
body; and consequently measures are to be devised 
and carried out to restore the bodily functions to a 
normal state. 
The first and continued line of treatment, there- 
fore, after the prevention of the. introduction into 
the system of harmful elements, and the providing 
of suitable material for the building up of healthy 
breast cells, by dietary measures and by the removing 
of wrong hygienic features, is to seek by medicinal 
agents to restore the bodily secretions and its tissues 
to a normal state. This is accomplished by the con- 
stant recognition of the various medical aspects of 
cancer which have been presented, and acting intel- 
ligently in finding and forcibly rectifying any pos- 
sible errors which might contribute to the diseased 
action. And this is often not an easy task. 
Constipation, or rather, imperfect intestinal excre- 
tion, from intestinal stasis, as already mentioned, has 
long been recognized by many as an important ele- 
ment in the causation of cancer; this results in a 
failure to remove excrementitious matter, and leads 
up to an autointoxication resulting from its fermen- TREATMENT OF CANCER OF BREAST. 
211 
tation, mostly in the large intestines. This condi- 
tion I have found to exist almost invariably in the 
subjects of cancer, even long before any special harm 
therefrom was suspected, and also in the very early 
stages of the disease, and long before any such a 
derangement has been induced by opiates given for 
pain. 
Imperfect intestinal excretion is a large subject, 
about which much has been written, and it is diffi- 
cult to compass what should be said in regard to it 
in a brief space. But it is so very essential in the 
medical treatment of cancer of the breast, in order to 
secure what is really an ideal action of the intestinal 
canal, that some attention must be now given to this 
homely subject. 
Long experience has taught me that it is not at 
all enough simply to ask a patient if the bowels act 
regularly, which will often be answered in the af- 
firmative, when this is far from being the exact truth. 
Repeatedly it is found, on most careful and repeated 
inquiry, that patients endeavor to keep them so by 
some mineral water or oil, or with some advertised 
remedies, or perhaps by correctives advised by an- 
other practitioner, and it often requires no little skill 
and patience to discover the exact mode, and qual- 
ity and quantity, of the intestinal excretion. And 
often it occurs that there is not that complete empty- 
ing of the rectum which belongs to perfect health. 212 
CANCER OF THE BREAST. 
Dr. Bell is even more positive than I am, in regard to 
the invariable occurrence of imperfect or incom- 
plete intestinal excretion, or intestinal stasis, in can- 
cer patients, he says:4 "I am convinced that con- 
stipation constitutes a most potent predisposing cause 
of cancer, and is invariably present when cancer 
crops up. A complete evacuation every twenty-four 
hours must be insisted upon, for many are under 
the impression that if their bowels are moved once 
or twice a day, no matter what the character of the 
stool is, everything is satisfactory in this respect; 
whereas, on close questioning I have ascertained, in 
innumerable instances which I have come across, 
that the bowel has by no means been thoroughly re- 
lieved or emptied at the time. In these instances the 
inspection of the stool has been quite sufficient to 
prove that the feces have been retained for an undue 
length of time within the colon, the result being 
that the greater part of the liquid has been absorbed 
into the blood, and we know that this cannot occur 
without interfering sadly with its purity." I myself 
am equally positive about all this, and have found 
many patients with cancer of the breast who have 
had pain in it when the bowels were at all consti- 
pated; and in dozens of instances I have found that 
the cure progressed far more surely and rapidly 
4 Bell: Cancer, Its Cause and Treatment Without Operation, 
London, 1913, p. 97. TREATMENT OF CANCER OF BREAST. 
213 
when there were two or three good movements from 
the bowels daily, and this I often try to secure. Of 
course, much judgment must be exercised not to 
overdo the matter, for to cure cancer of the breast 
the patient must be brought to and kept in the best 
state of health. 
Colonic absorption is being more and more recog- 
nized as the source of various diseases, and the pos- 
sibilities of fecal retention in this location was most 
remarkably demonstrated in a case which recently 
came under my observation in one of the hospitals 
in New York City. A great solid mass was found 
in a woman's upper abdomen, and, suspecting that 
it might be cancerous, an exploratory incision was 
made, which revealed only an enormously distended 
transverse colon, between 4 and 5 inches in diam- 
eter. This was removed and was said to contain 
nearly 2 quarts of impacted feces, with an opening 
through the center, by means of which the bowels 
were said to have had regular action, as also free 
movement induced before the operation. 
It is not enough to give general directions to 
patients in regard to the action of the bowels, or to 
leave the matter of therapeutic measures to their dis- 
cretion, or rather, indiscretion. Definite and careful 
instructions should be given, and the actual remedies 
ordered to be used, together with explicit directions 
as to their employment, according to the requirement 214 
CANCER OF THE BREAST. 
of each patient, and careful inquiry should continu- 
ally be made as to the results. Lorand5 is very clear 
and strong upon the ill results from the retained ex- 
cretive products in the large intestine. He says: 
"The bacteria of the intestines exert their decompos- 
ing action upon the albumin, and, in fact, upon any 
constituents of the food which have escaped diges- 
tion by the gastric and intestinal juices. When a 
person has ingested a large quantity of meat it may 
happen that a portion of it will reach the large in- 
testine still undigested, and here the bacterial action 
will very decidedly come into play. The body, how- 
ever, cannot derive any nutritive benefit from the 
action of the decomposing bacteria upon the albumin 
in the large intestines, for even though the result- 
ing products may be absorbed, they are not assimil- 
ated in the same manner as other albuminoid nutri- 
ents, but, on the contrary, may exert an injurious 
and even poisonous action. Indeed the general symp- 
toms occurring after long continued constipation, 
such as headache, nausea, mental depression, loss of 
appetite, etc., may be referred to the absorption of 
such poisonous products. 
"During their progress through the intestine, all 
the fluids and such other portions of the food as are 
capable of being absorbed are taken up, and the far- 
6 Lorand, Arnold: Health Through Rational Diet, Philadelphia, 
1916, p. 44. TREATMENT OF CANCER OF BREAST. 
215 
ther the mass progresses downwards, the more its 
liquid contents are given up, until only dry feces re- 
main. The longer the feces remain in the intestine 
the harder they become. When the diet consists 
principally of meat, the feces tend to become dry, but 
with more carbohydrates, especially in the form of 
sweets, they are more liquid." The absorptive power 
of the lower intestine is recognized by all, when we 
remember that patients may be fed by the bowel for 
weeks, and even months, and that medicines, alcohol, 
and even ether are effective when thus administered. 
Kidney action, good or bad, has repeatedly been 
mentioned as an element of great importance in con- 
nection with the development, continuance, and re- 
currence of cancer, and this is a matter which should 
receive constant and serious attention in attempting 
to control cancer of the breast. As we recognize that 
the kidneys are only filters, seeking to remove ob- 
noxious material from the arterial blood, their se- 
cretion should be watched with frequently repeated 
volumetric analyses, and agencies should be employed 
to make it that of health, which is seldom the case. 
I have had many cases of cancer of the breast in 
which all the urine was saved each day, measured 
and recorded, for weeks, months, and even a year 
or two, with careful volumetric analyses made and 
recorded weekly, or at stated periods; for as already 
mentioned sometimes the actual solid ingredients 216 
CANCER OF THE BREAST. 
will be all wrong, and the total not one-half of that 
proper for the body weight of the patient. It is in- 
teresting to note how the kidney secretion improves 
as the cancerous condition improves under most care- 
ful medical guidance. And the saliva, deranged as 
already mentioned, also regains its normal alkalinity 
under exactly correct measures, with sufficient mas- 
tication. 
This matter of exactly the proper amount of elim- 
ination by the kidneys of the solid excretory matter 
is so important practically, in the cure of cancer of 
the breast that I must dwell on it a bit longer; for 
evidently a patient weighing 200 pounds should pass 
proportionally more urinary solids than one weighing 
100 pounds. In one very interesting case of breast 
cancer in a stout, flabby lady, aged near 55, in pri- 
vate practice, the total quantity of the urine, meas- 
ured daily for weeks, was always far below the nor- 
mal amount for her weight; and for some time it 
seemed almost impossible to raise the total solids ex- 
creted daily in the urine to more than one-half of 
that called for by her body weight, but it was finally 
successful. In cancer I seek to have the daily out- 
put somewhat in excess of the normal, and find the 
disease improve accordingly. 
The following table represents fairly well the total 
solids that should pass daily in order to maintain a 
healthy equilibrium: TREATMENT OF CANCER OF BREAST. 
217 
Body Weight 
Total Urinary 
Body Weight 
Total Urinary 
Pounds 
Solids, Grains 
Pounds 
Solids, Grains 
90 
500 
150 
920 
95 
535 
155 
955 
100 
570 
160 
990 
105 
605 
165 
1025 
110 
640 
170 
1060 
115 
675 
175 
1095 
120 
710 
180 
1130 
125 
745 
185 
1165 
130 
780 
190 
1200 
135 
815 
195 
1235 
140 
850 
200 
1270 
145 
885 
205 
1305 
These figures do not represent much active exer- 
cise, and with increased bodily exertion the solids 
passed should be more. 
The estimation of the total solids is easy with 
Haines' modification of Haser's method. Multiply 
the last two figures of the specific gravity of the total 
daily urine by the number of ounces voided in twenty- 
four hours, and add io per cent, to the product. 
Thus, if the total amount passed in twenty-four 
hours was 36 ounces, with a specific gravity of 1021, 
it would be 36X21=756+10 per cent. = 832 
grains of solids in the whole amount of urine ex- 
creted that day. By comparing this figure with the 
table it can be readily ascertained if the amount is 
above or below the normal standard for the body 
weight of the particular patient. For many years I 
have employed this method of regulating the urinary 218 
CANCER OF THE BREAST. 
output of solids in hundred of patients, and have 
found it of inestimable value. 
The acidity of the urine, as measured volumetri- 
cally by the oxalic acid and phenophthalein test, is 
also of the greatest importance as a constant guide 
to treatment. This is not difficult nor tedious of 
application, and has been used daily in my laboratory 
for years: the litmus paper test is of relatively little 
value in comparison with actual chemical measure- 
ment. Thus, with an average normal standard of 
285 to 300, we not infrequently find an acidity of 500 
or 600, or even 1000, and I have known it 1200: or 
it may sink to 200 or 100, or even be strongly al- 
kaline. As this urine comes directly from the various 
substances circulating in the arterial blood, which the 
kidneys are striving, often in vain, to keep at a nor- 
mal standard, it most surely must make a difference 
to the nutrition of the cells whether the alkalescence 
of the blood is normal, as reported by the urine at 
300, or whether the acid-element is doubled or even 
quadrupled. In cancer I have striven by diet and 
remedies to keep the urinary acidity a little below 
normal, and see the disease improve accordingly. 
There are still many other items relating to the 
kidney excretion which cannot be entered upon here, 
but which should ever be borne in mind and acted 
upon. This does not refer to albumin or casts, which 
are not ordinarily seen in cancer, except in its later TREATMENT OF CANCER OF BREAST. 
219 
stages, but to the volumetric excretion of phosphates, 
chlorides, and sulphates, the latter indicating dis- 
turbed sulphur partition, common in cancer, also the 
exact amount of urea, indican, urates, uric acid, etc., 
marking mainly the disturbed, or imperfect, partition 
and elimination of nitrogenous and sulphur products. 
In regard to the actual medical measures to be em- 
ployed, it is difficult to speak clearly and briefly, for 
during a prolonged course of treatment there may be 
any number and variety of remedies and measures 
required to reach the varied condition of the patient; 
but all the elements mentioned must be well borne in 
mind and acted upon definitely and intelligently, and 
the treatment may be required to be changed very 
often to meet arising conditions of the system. For, 
it is to be remembered, as before stated, that there 
is not and probably never will be, any one cure-all 
remedy for cancer, as may be judged from what has 
been said in regard to the contributing causes of the 
disease, although, from long experience, it appears 
that potassium, in one form or another, seems to be 
of the greatest service in most cases. 
It is interesting to note that Dr. Forbes Ross,6 a 
London cancer surgeon, whose untimely death has 
deprived us of a valuable scientific worker along our 
present lines, was an ardent advocate of potassium 
6 Ross, Forbes: Cancer, the Problem of Its Genesis and Treat- 
ment, London, 1912. CANCER OF THE BREAST. 
220 
in the treatment of cancer, whose value he established 
on bio-chemical as well as on clinical grounds: and 
he was even more positive in regard to the actual con- 
trol of the disease by potassium than the present 
writer has cared to express himself; although I have 
long seen the good results of this remedy, for 40 and 
more years. This was long before Forbes Ross be- 
gan to practice surgery. When he had been oper- 
ating much on cancer, for some years, he realized the 
inefficiency of surgery to cure the disease, and wrote 
very severely in regard to cancer surgery in the 
opening chapter of his book. 
After realizing this, he spent "ten years of con- 
stant microscopic, clinical, and surgical research," 
and advanced the hypothesis that "cancer is due to 
a want of balance in particular mineral salts of the 
body, and that the disturbance of this balance leads 
to the disorderly and malignant growth of epithelial 
cells (epiblastic and hypoblastic) known as carcin- 
oma," and claimed that the main disturbance is in 
regard to the potash balance in the body. By very 
careful deductive and inductive reasoning, and by 
actual experimentation and practice, he shows how 
this answers and explains more of the puzzles and 
intricacies of the cancer problem than any other 
hypothesis, and the experience of many others has 
certainly borne this out in practice. I have for 
many years realized it. TREATMENT OF CANCER OF BREAST. 
221 
Dr. Ross makes three references which in a meas- 
ure support the theory and actual experience of the 
value of potassium in cancer: 
"i. The old physiological adage, 'potassium is the 
salt of the tissues and sodium the salt of the fluids 
of the body,' still holds good as an absolute physio- 
logical truth. 
"2. Animal physiology teaches us that the whole 
range of the animal creation, from an ameba to man, 
follows the same law, 'potassium is the salt of the 
tissue cell.' 
"3. Examination of the botanical world brings us 
face to face with the same identical statement, 'potas- 
sium is the salt of the chemical physiology of the 
vegetable cell.' " 
In regard to the blood cells, about which he had 
studied and written much, Dr. Ross wrote of potash 
in the following language: "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 688 parts of water, 308 parts 
of organic solids, and 8 parts of mineral. Of these 
8 parts of mineral substances, 3.5 are of potassium 
chloride, 2.5 are of potassium phosphate, and 0.1 po- 
tassium sulphate: the remaining 1.9 parts are divided 
between the iron, calcium, and magnesium, compris- 
ing the rest of the red corpuscles. More than three- 
quarters of the total mineral ash of the red corpuscles 222 
CANCER OF THE BREAST. 
is, therefore, composed of potassium." Later he re- 
marks how constantly in anemia and cachexia, the 
patient improves much more rapidly when potassium 
is given conjointly with iron, a fact which I have 
noticed and called attention to for many years. 
In the cure of cancer, however, Dr. Ross pushes 
the administration of a salt of potassium far in excess 
of that which I have commonly found to be neces- 
sary in cancer of the breast, although in certain in- 
stances I have not hesitated to give very large quan- 
tities. This is probably because he had not yet 
reached fully the point of the influence of an exactly 
correct diet in this disease; the strong vegetable soup 
or extract, which I have already spoken of, made 
from the water in which all the family vegetables are 
boiled, contains a large percentage of potash, per- 
haps in a better combination than can be otherwise 
devised. Dr. Ross prefers potassium citrate and po- 
tassium phosphate combined, of which he gives from 
90 to 180 grains daily. I have generally used the ace- 
tate, and sometimes the nitrate in less quantities. He 
has related instances of advanced, inoperable cancer 
in which the results were remarkable, and one of 
them, a case of cancer of the uterus, in a widow aged 
59, which was quite a counterpart of one which I 
have observed and reported. 
It is not a little satisfactory to find from a surgeon 
such a microscopic, biochemical, and clinical explana- TREATMENT OF CANCER OF BREAST. 
223 
tion and support for a line of treatment which I have 
followed successfully for so many years, solely on 
clinical grounds. Dr. Ross makes the interesting 
statement that, having used enormous quantities of 
potash salts in his practice for 15 years, for various 
complaints, not one single case of cancer had ever to 
his knowledge occurred among the clientelle of his 
own practice: he had, however, constantly been en- 
gaged in operating on patients with cancer sent to 
him by other medical men. I made much the same 
remark in regard to the absence of cancer among 
the skin patients whom I had treated, often with ace- 
tate of potassium, in one of my lectures, long before I 
had seen the book or writings of Dr. Ross. It was 
the disappearance of lumps in the breast of patients, 
which had been diagnosticated by surgeons as can- 
cer, urging immediate surgical removal, and who 
were taking the mixture which I shall mention, for 
some skin complaint, that first directed my atten- 
tion to this disease very many years ago: this led to 
my adding Cancer in the name of the New York Skin 
and Cancer Hospital, as already mentioned, when I 
founded it over forty years ago. 
The first, or basic treatment, therefore, in addition 
to proper dietetic and hygienic measures, is a full 
amount of a potassium salt, of which I prefer the 
acetate (but Dr. Ross the citrate, phosphate and 
sometimes the carbonate) in combination with other CANCER OF THE BREAST. 
224 
remedies which experience has demonstrated have a 
salutary effect on cancer. For years in private prac- 
tice, and later also, when I started my Medical Clinic 
for Cancer in the New York Skin and Cancer Hos- 
pital, these patients have been given, almost always, 
first a mixture about as follows: 
B Potassii acetatis 5i 
Tinct. nucis vomic $ss 
Fid. ext. cascara 3j-3iv 
Fid. extr. rumicis radios ad $iv 
Misce. 
Sig.: Teaspoonful in water half an hour before eating. 
The amount of cascara is varied according to 
the action of the bowels, which should move at 
least twice daily. This mixture commonly acts also 
somewhat on the urine, but the acetate of potassa 
may be increased, and other diuretic ingredients 
may be added, if needed, such as sweet spirit of 
nitre, digitalis, scoparius, etc. The mixture acts 
best when given on an empty stomach half an hour 
to an hour before meals, in one-third tumbler of 
water. Latterly, I have been substituting a good 
fluid extract of clover for the rumex, 2 ounces in 
the mixture, with water up to 4 ounces. I have 
gotten equally good results with this mixture, and 
can hardly tell which is the best, though the rumex 
has had a trial of over forty years. One cannot tell 
how either of them acts; they are both claimed to 
be alteratives, whatever that means, and the whole 
matter rests on a clinical basis. TREATMENT OF CANCER OF BREAST. 
225 
But it must not be imagined that this is the only 
treatment necessary in these cases, although I have 
had cancer patients who have taken this mixture, 
with little variation, for months, or even years, per- 
haps with the occasional addition of other remedies, 
or alternation with them, with the result of the com- 
plete cure of the disease, as will be seen later. 
Patients with cancer of the breast, just beginning, 
will often, or even generally seem to be in excellent 
health. They are robust and often blooming in ap- 
pearance, and when the lump is first discovered and 
diagnosed it is hard to believe that, if the processes 
which caused the cancerous lump to develop are not 
checked, that patient will probably before long suc- 
cumb to the disease. Williams7 says that "such 
types are indications of hypernutrition." This re- 
mark is true only in a certain sense. One can hardly 
be overnourished, if rightly nourished in the proper 
manner. Many are, indeed, often wrongly nourished 
and overfed, without the proper muscular activity 
to properly oxidize or burn up the often wrong or 
excessive nutriment taken. Such cases often show 
great benefit from thyroid feeding, and Bell8 reports 
many instances with surprising results from this 
remedy, with the entire disappearance of a tumor in 
7 Williams, W. Roger: The Natural History of Cancer, New York, 
1908, p. 66. 
8 Bell, Robert: Loc. cit., London, 1913, p. 279. 226 
CANCER OF THE BREAST. 
a short time. I often give thyroid, after eating, alone, 
and also with the potassium and rumex mixture, 
with good result. In patients who are at all obese, 
and who as a rule do so badly after operation, it is 
frequently desirable to reduce the flesh by thyroid 
at the beginning of treatment. Williams,9 in his 
work on Diseases of the Breast, remarks "Cancer pa- 
tients are usually of a coarse physical type. Those 
recently attacked never present a cachectic appear- 
ance. The small, ill-nourished women of the type 
so familiar in Lancashire and other large industrial 
centers are seldom the victims of the disease. Of 75 
consecutive cases, when they first came under obser- 
vation, 8 were emaciated (primary 6, recurrent 
2) and 14 pale (primary 10, recurrent 4), the re- 
maining 49 (primary 39, recurrent 10) were all well 
nourished and healthy looking, 7 of them being 
obese." Of course when the carcinosis or cancerous 
habit has already been under way for some time 
before medical observation, cachexia and loss of 
weight are often prominent symptoms, as the can- 
cerous and lymphatic lesions themselves also aid in 
disturbing the processes of metabolism and nutri- 
tion, as already explained. 
But a most careful study, in every particular, of 
patients affected with cancer of the breast, seen in 
9 Williams, W. Roger: A Monograph on Diseases of the Breast. 
London, 1894, p. 286. TREATMENT OF CANCER OF BREAST. 
227 
very early stages, and probably some time before, 
will so constantly reveal such various errors of life 
and derangement of metabolism that these must be 
looked upon at least as contributing causes to the 
development of the local condition which later be- 
comes malignant. In the same way, before an at- 
tack of acute gout, a patient may appear to be in 
blooming health, but sufficient study and analysis for 
some time before the real acute attack would reveal 
a .condition of system which an experienced eye 
would recognize as a forerunner of that disease. 
For when these erroneous conditions in cancer, 
whether early or late, are recognized and efficiently 
remedied by proper dietetic, hygienic, and medicinal 
measures, the mass in the breast, or local cancerous 
condition not only ceases to develop but actually dis- 
appears without surgical removal, as I have re- 
peatedly shown; and no one doubts but that the 
threatening attack of gout or apoplexy could be 
warded off in the same manner. We all know that 
what passes for good health may be entirely ficti- 
tious, and is quite compatible with even grave dis- 
orders of various kinds. 
It will be readily seen, therefore, that no absolute 
directions can be given here as to all of the internal 
medicinal treatment of cancer of the breast, other 
than has been already said. As remarked before, 
there is no one single remedy, not even potassium, 228 
CANCER OF THE BREAST. 
nor even any single course of treatment, which is to 
be invariably followed, or is always successful in 
every case of cancer. Nor will there ever be such, 
for the palpable reason that the true nature and 
cause of the carcinosis, as heretofore developed, pre- 
cludes the possibility of such a thing. But many 
articles of the materia medica may at times very 
materially assist in overcoming the cancerous state, 
and they should be employed with a broad minded 
perspicacity and medical acumen, sufficient to dis- 
cern and remove the offending cause, whether it be 
by dietetic, hygienic, or medical measures. 
The nuclei of all cells, upon which their activity 
depends, are in close chemical association with phos- 
phorus, and, as Forbes Ross says, this "needs care- 
ful consideration in dealing with the cancer prob- 
lem;" and in certain cases I have seen far greater 
improvement when phosphatic preparations were 
added to or substituted for other treatment, as 
seemed indicated by the nervous condition of the 
patient. Phosphoric acid may be given with the 
meals, or Horsford's acid phosphates, taken freely, 
whenever needed for neurasthenic symptoms, or 
phosphate of iron, three to five grains in capsules, 
during the meals. 
Iron is very often of great service, when properly 
used, both in early cases, raising the integrity of 
the blood, and in meeting the cachexia as it develops, TREATMENT OF CANCER OF BREAST. 
229 
and I commonly give the dialyzed iron in pretty full 
doses, in the middle of the meal, also the tincture of 
the chloride of iron, in the same way. 
Cancer of the breast is continually found to be 
connected with rheumatic symptoms of various kinds, 
and neuritis, often very severe, is not uncommon, 
even far away from the neighborhood of the local 
disease: so that from first to last I may use aspirin 
very freely in many cases, and it seems to do the 
local cancerous lesion good also. I always give it 
in powder form, five grains in capsules, with hot 
water, and have it repeated in one or two hours, or as 
often as necessary. This is also my main reliance in 
connection with the pain of actual cancerous lesions, 
and it is generally sufficient, when the patient is 
under full dietetic, hygienic, and medicinal measures. 
Morphia is practically never needed then, as the 
case records to be given later abundantly show, and 
it is the very rarest thing for me ever to sanction its 
use; as it always in the end aggravates the disease, 
carcinosis: many patients have voluntarily discon- 
tinued its use, and I have taken it away from many 
patients without complaint. 
A word more in regard to the bowel action, which 
should be watched with the greatest care, and kept a 
little more active than normal, as already stated, even 
as I strive to keep the urinary excretion somewhat 
above the normal amount of solids for the weight 230 
CANCER OF THE BREAST. 
of the individual. At the beginning of treatment I 
very commonly give a certain old pill, the supreme 
value of which is known to many; it is as follows: 
It Extract! colocynth. comp., 
Massas hydrargyri aa gr. x 
Pulv. ipecac gr. ij 
Misce. 
Div. in caps. no. iv. 
Take two at bedtime and two on the second night 
after. In many cases, especially in full-blooded per- 
sons, I have these capsules repeated each week, on 
exactly the same nights, for weeks perhaps, but never 
more frequently; for I continually find on percussion 
that there is evidence of intestinal stasis, in spite of 
daily movements. In the interval between the sets of 
capsules other laxatives should be taken, if still 
needed, and for years I have employed a tablet, now 
made by several firms, as follows: 
B Podophyllin, 
Cascarin, 
A loin aa gr. % 
Misce. 
Sig.: Take one to three at bedtime. 
In some instances, where there is great, and often 
general abdominal dullness, I have had castor oil 
taken in a free dose every night, for even a week or 
so, with great benefit even to the cancerous tumor. 
All this is often done while the patient is under the 
potassium and rumex mixture, when the varying TREATMENT OF CANCER OF BREAST. 
231 
amount of cascara put in it does not seem to be 
thoroughly effective. 
A word about the potassium. In giving potassa 
very freely many fear a bad action on the heart, as 
the older books say, but I have never found any 
trouble of this kind; there is not the slightest 
objection, however, to administering digitalis or 
strophanthus at the same time. 
Mention was made of the value of thyroid extract 
in cancer of the breast, and some of the other endo- 
crinous extracts, alone or in combination, have been 
employed with reported advantage, by a number of 
observers. While from my personal experience along 
this line I am not in a position to speak strongly, ex- 
cept in reference to thyroid, I cannot but believe that 
rightly used they can have a beneficial action in can- 
cer. From my reading and studying I am convinced 
that all of them do have some, as yet almost mysteri- 
ous action on the nutrition and behavior of the cells 
of the body, as mentioned in regard to myxedema, 
cretinism, Addison's disease, and gigantism. It is 
quite possible that with a blood stream vitiated by 
dietary or other errors of life or by derangement or 
failure of the ordinary secretory and excretory glands 
of the body, which occur in cancer, the ductless 
glands, in common with other structures, may suffer 
and so be unable to do their part (whatever that may 
be) in balancing or equalizing the general metabolistic 232 
CANCER OF THE BREAST. 
powers of the system. In this case the introduction 
of the normal endocrinous tissue from healthy ani- 
mals may supply quite the element wanted in the 
human system, just as ox bile has long been of ser- 
vice in medicine, while the effect of adrenalin on 
the blood-vessels is well known. I think, therefore, 
that the evidence is very strong that preparations 
from some of the ductless glands of animals may, and 
probably will in some future time, when we have 
more reliable knowledge of them, be an established 
element in the treatment of cancer of the breast, in 
conjunction, of course, with proper dietetic and other 
measures. But this matter is still sub judice. 
It is quite impossible in the present writing to indi- 
cate in the slightest degree the many remedies and 
measures which may be necessary to carry any par- 
ticular case to a permanent cure, which can be cer- 
tainly done in a very considerable proportion of cases; 
for in the extended treatment often necessary an un- 
limited number may be required to meet varied con- 
ditions. It must, therefore, be left to the wisdom 
and experience of the individual physician to dis- 
cover and rectify any and all errors of life or func- 
tion which can in any manner influence metabolism 
and nutrition. The patient with cancer of the breast 
should be carefully studied-not only watched as is 
so often the case-over a long period of time, and 
at intervals sufficiently frequent to detect and correct TREATMENT OF CANCER OF BREAST. 
233 
any and every defect in the working of the system 
which may possibly have any effect in retarding the 
cure. This unquestionably requires a great deal of 
courage, pertinacity, and optimism on the part of the 
physician, patient, and friends, but it assuredly pays 
in the end. 
Local Treatment. 
The proper local medical treatment of cancer of 
the breast is very important, both as to the comfort 
afforded the patient and the measure of benefit to 
the diseased part. Time and again I have seen the 
agony suffered in removing the surgical dressings 
previously used, and have heard the expressions of 
comfort and joy when otherwise dressed; and have 
seen the progressive healing of raw, cancerous sur- 
faces, when another proper dressing has been substi- 
tuted for the harsh gauze so commonly employed. 
In the early stages of breast cancer, with unbroken 
cutaneous surface, the keeping of the part painted, 
night and morning, with equal parts of true, imported 
ichthyol and water, appears to help in the disap- 
pearance of the lesion, and even enlarged lymphatic 
glands, as I have observed in dozens of cases, and 
have thought that it aided also in dispelling the dart- 
ing pain common in some of them. In the case of 
late cutaneous nodules, developing thickly in patients 
with the disease, recurrent after operations, I have 234 
CANCER OF THE BREAST. 
seen them fade away, almost magically, under the 
constant painting with thiol and olive oil, of each 50 
per cent., as in one of the cases, with practically a 
cancer en cuirasse, to be reported in a later chapter. 
Sometimes I have used the tincture of iodine, with 
glycerine, a dram to the ounce with equally good re- 
sults, on unbroken surfaces in early mammary cancer. 
I have also seen lumps disappear more quickly when 
kept covered with a thick layer of cotton, on which 
was spread Hebra's diachylon ointment, in which a 
dram of iodide of lead to the ounce, was incorpor- 
ated. All of this- local treatment is, of course, only 
really valuable in conjunction with complete internal 
treatment as already indicated, for certainly these or 
any other local measures are incapable alone of cur- 
ing cancer. 
When ulceration has occurred, even in the terrible, 
ulcerating surfaces often seen in cancer recurrent 
after surgical operations, the very greatest relief and 
benefit is continually seen, when the harsh surgical 
dressing with gauze is replaced by a soothing oint- 
ment thickly spread upon very thin layers of absorb- 
ent cotton, and gently laid on so as to cover the en- 
tire denuded area. This may be covered with a 
single layer of gauze or flannel, held in place by ad- 
hesive strips, if necessary, but I deprecate any thick 
mass of cotton or much bandaging and never allow 
an impermeable dressing, such as oiled silk or gutta TREATMENT OF CANCER OF BREAST. 
235 
percha. The ointment, softened by a little heat, if 
necessary, is easily spread on thin portions of ab- 
sorbent cotton, perhaps 3 inches each way, held on 
the hand and applied with a steel spatula or an ordi- 
nary table knife. The relief and happiness expressed, 
especially by hospital patients, when this change of 
dressing is made is very gratifying. The ointment 
layer should be pretty thick, and so well spread that 
the fibers of cotton shall not touch the sore. This is 
generally changed twice in the twenty-four hours, 
or oftener if desired. Being gently removed, and 
fresh portions of spread cotton being prepared in ad- 
vance, these are quickly replaced, without there being 
much exposure to the air. If any of the ointment 
adheres to the sore, I have it gently removed with a 
dull spatula or a dull table knife, but if there is not 
much discharge this is not always necessary, for all 
irritation must be avoided; if there is much moisture 
or suppuration on removing the dressing, the surface 
may be very gently sopped with a bit of dry absorb- 
ent cotton, and the new application quickly made. I 
do not have the raw surfaces washed or treated much 
otherwise than as described, except under certain 
circumstances to be mentioned later. 
The ointment almost invariably used in the Hos- 
pital, and generally in private practice, is that of 
calamine and zinc, which I introduced many years 
ago, and now is well known: 236 
CANCER OF THE BREAST. 
B Acidi carbolici gr.x 
Pulvis calaminse prep 9 ij 
Zinci oxidi 3j 
Unguenti aquae rosae 3U 
Misce. 
Sig.: Spread thickly on absorbent cotton. 
When there is much pain, a dram or more of a 
4 per cent, solution of cocaine is incorporated in the 
ointment. Sometimes a few grains of acetate of 
morphia, in solution, worked into the ointment serves 
better. When the healing is slow, and the granula- 
tions sluggish, a half to one dram of true, imported 
ichthyol in the ointment helps greatly. It is sur- 
prising to see how a diseased surface will improve 
under this method of handling, and often, with all 
other treatment properly carried out, evidence of nor- 
mal epitheliation will appear in places and increase 
steadily. Occasionally there will be itching over the 
breast, or elsewhere, which is relieved by the free and 
repeated sopping on, with a bit of linen handker- 
chief, of a calamine and zinc lotion: 
It Acidi carbolici 3ss 
Pulv. calaminae prep. 3j 
Zinci oxidi 5ij 
Glycerinae 3iij 
Aquae calcis 3iv 
Aquae rosae ad $iv 
Misce. 
Sig.: Sop on freely and repeatedly as desired. 
A very considerable share of the suppuration and 
pain in raw cancerous surfaces is undoubtedly due 
to the presence and operation of the omnipresent pus TREATMENT OF CANCER OF BREAST. 
237 
organisms, which find a proper nidus for their de- 
velopment, for it is out of the question to keep these 
raw surfaces aseptic. Practically I do not attempt 
asepsis, for the carbolic acid, which may be increased 
with caution, generally suffices to effect this purpose. 
Most antiseptics seem to irritate the sore, and even 
increase the disease, for these mutinous cells are very 
irritable and rebellious. I have used the peroxide 
of hydrogen with good effect in some instances, ap- 
plying it thus: pouring it out on a saucer, very thin 
portions of absorbent cotton are thoroughly soaked 
in it, and being lifted carefully are made to lie over 
all the affected surface. In five minutes they are 
replaced by a second set, remaining on for five 
minutes, and on their removal the portions of cot- 
ton, ready beforehand with the thick layer of the 
proper ointment, as already described, are quickly 
laid on, without attempting to dry the surface. This 
may be done twice daily. Latterly I have been us- 
ing in the same manner chinosol, one tablet in a pint 
of water with half a teaspoonful of salt in it, often 
with good effect, possibly better than with the perox- 
ide. Sometimes the chinosol solution seems a little 
strong, and it may be diluted a little. 
Permanganate of potassium often proves very 
serviceable. I make a saturated solution which is 
used greatly diluted thus: One teaspoonful, more or 
less, in half a tumbler of water, and applied by very 238 
CANCER OF THE BREAST. 
thin layers of absorbent cotton soaked in it, and 
left on for a few minutes, followed by the ointment 
on cotton. It should be so diluted that the applica- 
tion is not at all painful. 
When there is much pain in a raw, cancerous sur- 
face, a 4-per cent, solution of cocaine may be applied 
in the same manner or may be sprayed on; when 
there is bleeding a i: 1000 solution of adrenalin may 
be applied in the same manner. 
Such are the lines of treatment, in the main, 
which have been successfully employed in the cases 
of cancer of the breast, about to be reported. It is 
recognized that methods of treatment in every dis- 
ease are subject to change and improvement with the 
more extended experience of the practitioner; but 
when everything has been carried out punctiliously, 
for a sufficient length of time, the results have 
generally been satisfactory, and so incomparably 
better than those observed or known to follow 
other lines of treatment, as will be seen later, that I 
am content to proceed along them until I can learn 
better. I am so old-fashioned that I am disinclined 
to give much heed to the many new suggestions and 
recommendations found in literature or flaunted by 
drug firms, or often by persons of very little experi- 
ence. I have from time to time made changes and 
improvements in some of the details of treatment, but TREATMENT OF CANCER OF BREAST. 
239 
in the main have followed the lines of management 
outlined above, for many years, and seldom with 
regret. 
The more I have studied literature and observed 
cancer practically, in my own hands and those of 
others for these many years, the more I am firmly 
convinced of its constitutional origin and nature, and 
of the correctness of the principles set forth in these 
pages. Cancer is never a local disease, not even in 
the development of its first lesion, although undoubt- 
edly the actual appearance of the first manifestation 
of the carcinosis may have been called forth or deter- 
mined by some local injurious influence. CHAPTER XI. 
ANALYSIS OF 250 CASES OF CANCER OF THE 
BREAST IN PRIVATE PRACTICE. 
Several times I have written, "The test of every- 
thing lies in the results obtained. Theories, discus- 
sions and arguments are unavailing unless results 
show the truth of them," and I have repeatedly re- 
ported many undoubted cases of cancer occurring in 
the breast and elsewhere, which should convince the 
unprejudiced observer of the truth of what has pre- 
ceded. 
There can be no question as to the earnestness or 
honesty of the endeavors to mitigate the ravages of 
cancer by surgery, x-ray, radium, etc., nor of the 
occasional advantages from the same, which are too 
often only temporary. But there can be still less 
question, from a consideration of the results, as al- 
ready studied, that little or no progress toward either 
prevention or cure has been obtained therefrom, in- 
deed the contrary is seen in the constant rise in its 
mortality; and when one considers the futility of at- 
tempting to cure a general disease by lopping off its 
local expression, some explanation becomes evident 
of the steadily increasing progress of cancer death 
rate. 
240 ANALYSIS OF CASES. 
241 
The criticism has sometimes been made in medical 
discussions, and in print, that in the majority of in- 
stances the diagnosis of the cases here presented has 
rested solely on clinical grounds, without microscopic 
proof of its correctness; and in view of the remark- 
ably favorable results reported, the question of the 
accuracy of the diagnosis is by no means unjustifi- 
able. 
But to this may be answered: (i) That in the re- 
current, postoperative cases there could be no doubt 
as to diagnosis. (2) That it is now pretty generally 
agreed that a biopsy in cancer is always a very ques- 
tionable procedure, as it tends to spread the disease, 
and to render the prognosis unfavorable; and it 
would be especially perilous in such cases as are to 
undergo medical treatment, and would be not all jus- 
tified, simply to satisfy so-called scientific curiosity 
or doubt. (3) The vast majority of cancer opera- 
tions are performed without previous competent 
microscopical evidence as to diagnosis. (4) In al- 
most every one of the cases here reported, if not in 
all of them, there had already been the definite opin- 
ion of other competent physicians and surgeons, that 
the disease was cancer, and an immediate surgical 
operation had been urged, as the only hope of saving 
life; and in a number of instances this had been fully 
arranged for, but escaped. (5) Constant study, ob- 
servation, and contact with cancer patients for forty 242 
CANCER OF THE BREAST. 
years or more, should warrant the present writer in 
claiming some authority in diagnosing the disease. 
Moreover, the minute observation and close study of 
thousands of dermatological patients, for over fifty 
years, has fitted him to diagnose and treat cancer 
of the breast, as that organ is essentially a group of 
cutaneous glands, altered to serve a special purpose. 
(6) It is claimed of stated by the surgeons that 80 
per cent, of tumors, other than abscesses, appearing 
in the breast in persons over 30 years of age, either 
are, or certainly will become, cancerous, and fatal 
within 5 years, if not surgically removed. The 
soundness of this latter opinion may be judged by 
the number of cases recorded later, in which such 
tumors have disappeared and remained absent for 
very many years, under careful medical management 
alone, without surgical interference. 
It has been a difficult task to analyze the histories 
of these 250 consecutive cases in'private practice and 
to prepare the data presented. For years full records 
of every patient have been kept, each on a separate 
sheet or sheets, with notes at each visit, solely for the 
purpose of carrying out treatment, and not with any 
expectation of such a study as this. Long analytical 
schedules have been made, and the data counted care- 
fully, with tables constructed, presenting the different 
features and data, which are referred to. All these 
case papers are preserved with the data. ANALYSIS OF CASES. 
243 
There were actually more than this number of 
cases of cancer of the breast observed and recorded, 
but the earlier ones were thrown out, as the notes 
were often meagre and incomplete, and also the 
many new ones seen since January I, 1923, are ex- 
cluded. Among the excluded cases are likewise a 
number observed casually in earlier years, in patients 
who were being treated for various dermatological 
affections. In a number of instances a mass had 
been discovered in the breast and diagnosed as cancer 
by prominent surgeons, who had urged immediate 
surgical removal, but the tumor had vanished in 
some months, without surgical interference, under 
the regimen and medication given for some chronic 
skin trouble. It was this observation that led me to 
study upon cancer and to specially treat the disease, 
as also to include the name in that of the New York 
Skin and Cancer Hospital, when I founded it over 
forty years ago; for I was powerfully impressed 
then with the constitutional nature of cancer, and 
wished every one to take advantage of this very 
desirable plan of treatment. Each year has more and 
more confirmed me in the vision. 
It was thought best, likewise, to exclude the very 
many cases seen in the Hospital, and casually else- 
where, as it is very difficult to obtain and record 
reliable data in regard to such cases. Moreover, 
patients seen in private practice are apt to be more 244 
CANCER OF THE BREAST. 
reliable in carrying out the medical measures to a 
successful end, and their case records are more valu- 
able in a study like this. There were also excluded, 
of course, many cases of breast trouble which were 
feared to be cancerous, but proved not so, such as 
adenoma, cysts, acute and chronic mastitis, etc. 
Many of the histories of patients here presented 
have appeared in previous writings, and are repeated 
here for the sake of completeness. These will be 
recorded first, with subsequent notes, and later others 
which are of interest, as illustrating certain points 
or features in connection with our subject. 
As mentioned before, the 250 cases of breast can- 
cer to be analyzed are not selected, but are those seen 
consecutively, first in the practice of dermatology, 
and latterly in one devoted exclusively to cancer. 
The following table presents a list of the total 
number of neoplastic growths of all kinds, observed 
and treated in private practice in over fifty years, up 
to December 31, 1922. This, of course, does not in 
any way represent their relative frequency or loca- 
tion, as would be shown in large hospital or mortal- 
ity statistics, but only the line of cases which come 
to one especially interested in this line of work. The 
great preponderance of breast cases will be readily 
understood. ANALYSIS OF CASES. 
245 
Cases of Neoplastic Disease to December 31, 1922. 
Males 
Females 
Total 
Carcinoma, breast 
7 
299 
306 
uterus 
36 
36 
digestive tract 
137 
36 
173 
genito-urinary tract 
13 
3 
16 
" other localities 
25 
26 
51 
total carcinoma 
182 
400 
582 
Epithelioma of the skin (epidermoid 
carcinoma) 
493 
276 
769 
Sarcoma 
25 
26 
51 
Total 
700 
702 
1402 
Graph I, which follows, shows the distribution of 
the actual number of breast cases in age intervals of 
five years; the peak of the graph, or the greatest 
number of cases, falls in the 45-49 year interval, and 
the next highest points, or the next greatest number 
of cases fall in the 50-54, 40-44, and 55-59 year in- 
tervals, respectively; that is 158 cases, or 63.20 per 
cent, of the 250 cases under observation were ob- 
served when the patients were between 40 and 60 
years of age. 246 
CANCER OF THE BREAST. 
As to location, the affection was as follows: In 88 
cases the disease was located in the right breast 
alone, in 90 cases in the left breast alone, in 15 cases 
in both breasts, and in 57 of the earlier cases no 
particular location is given. 
Graph I.-Age Distribution of Cancer of the Breast Cases. 
AGES 
24and 
OVER 
25-29 
30-34 
35-39 
40-44 
45-49 
50-54 
55-59 
60-64 
65-69 
70-74 
75 AND 
OVER 
60 
50 
40 
30 
20 
10 
0 
NUMBER OF INDIVIDUALS 
AVERAGE - 51 YEARS^ 
Most writers state that the left breast is more 
often affected than the right, for reasons unknown, 
although they are often differently explained. One 
married lady, aged 30 years, who was never preg- 
nant, had cancer in both breasts consecutively at an 
interval of four years. The right breast was first 
affected and under rigid, proper treatment this 
cleared up within about a year, when she became 
very careless, eating outrageously, and drinking ANALYSIS OF CASES. 
247 
Age and Location Distribution Table. 
Right Breast 
Left Breast 
Both Breasts 
Location 
not Given 
Total No. 
of Cases 
Years 
Age 
OF 
Female 
| Male 
Total 
Female 
Male 
Total 
Female 
Male 
Total 
Female 
Male 
Total 
Female 
Male 
Total 
Under 20 
20 to 24 
25 " 29 
30 " 34 
35 " 39 
40 " 44 
45 " 49 
50 " 54 
55 " 59 
60 " 64 
65 " 69 
70 " 74 
75 and 
1 
1 
4 
5 
9 
9 
17 
10 
12 
6 
8 
1 
1 
1 
1 
1 
4 
5 
10 
10 
17 
10 
13 
6 
8 
1 
4 
9 
7 
14 
22 
11 
4 
6 
4 
4 
1 
1 
1 
4 
9 
8 
14 
23 
11 
4 
6 
4 
4 
3 
8 
2 
1 
1 
3 
8 
2 
1 
1 
5 
9 
6 
15 
12 
5 
1 
2 
1 
5 
9 
6 
15 
12 
5 
1 
3 
1 
2 
8 
14 
21 
35 
53 
38 
29 
17 
14 
6 
2 
1 
1 
1 
1 
1 
2 
8 
14 
23 
36 
54 
38 
30 
17 
14 
7 
over 
Age not 
obtainable 
1 
2 
1 
2 
2 
2 
1 
1 
4 
1 
1 
4 
2 
Totals F. 
Totals M. 
85 
3 
88 
2 
15 
56 
1 
243 
7 
Totals. 
88 
90 
15 
57 
250 
whiskey, and about five years later the left breast 
developed a characteristic tumor, which also van- 
ished when she again returned to a proper life and 
careful medical treatment; this was eighteen years 
ago, and when seen recently she remained free from 
cancer. 
As to sex, there were seven cases in males, aged 
and located as follows: 248 
CANCER OF THE BREAST. 
Age Location 
37 years left breast. 
39 years right breast. 
41 years right breast. 
46 years right breast. 
48 years left breast. 
55 years right breast. 
72 years not given. 
Among these 250 cases there were 95 recorded as 
primary, 74 postoperative, and 85 not stated; of the 
whole number 183 had been under surgery, x-ray, 
Graph II.-Age and Location Distribution of Cancer 
Cases of the Breast. 
ACTUAL 
NUMBER 
30 
20 
10 
5 
o 
24 2529 30-34 40'44 50'54 60-64 70-74 
AGE IN 
YEARS 
35-39 45-49 55-59 65-69 
'75 
AND OVER 
■■LEFT BREAST RIGHT BREAST BOTH BREASTS 
or radium, ineffectually, alone or combined. It is 
needless to say that the last mentioned cases were 
often very difficult to treat medically, owing perhaps 
to the arterial or lymphatic changes already produced 
by radio-activity: I have seen some terrible burns 
from the latter two agents. 
The duration of the disease, from its first mani- 
festation until the time of coming under observation 
and treatment, has varied greatly, from a few days ANALYSIS OF CASES. 
249 
to a considerable number of years, ten to twenty; 
and even forty years in one instance, when a lump, all 
this time, lying dormant and possibly benign previ- 
ously, had begun to give serious annoyance. An 
analysis of these dates is not given, as it does not 
materially affect our study, and the exact time of 
onset is often difficult for the patient to determine. 
In a few cases the time of recognized existence 
has been very short, only a day, or a few days or 
weeks before the tumor was noticed. These cases 
have naturally yielded the best results under treat- 
ment, as the group of mutinied cells have not multi- 
plied beyond control. There had been comparatively 
little lymphatic permeation in this class of cases, and 
the cells were quite easily persuaded, by kind atten- 
tion to their complaints, as to nutrition and innerva- 
tion, to return to their former state, without metas- 
tasing greatly. With recurrence after operation, in 
some instances after from one to four operations, 
the task of the cells becomes, of course, much more 
difficult; but even in these cases the results of proper 
therapeusis have often been most gratifying, notably 
in the prolongation of life, and in relief from pain, 
without opiates, which latter only heighten the car- 
cinosis. 
The duration of medical treatment has varied 
greatly. Unfortunately there have been quite a num- 
ber, 167, who were seen only once or twice, in con- 250 
CANCER OF THE BREAST. 
saltation or otherwise; many patients, perhaps, 
wearied of the necessary restrictions, and the pros- 
pect of a long treatment, and by the influence of 
misguided friends or medical advisers have been 
lured away, to take the spectacular chances of the 
knife, x-ray, or radium, or quacks. Cases seen once 
or twice in consultation have naturally not done so 
well, for it is difficult to secure from physicians or 
surgeons such a close adherence to the minute de- 
tails of treatment as are necessary to secure perfect 
success. Many of these patients have also been seen 
in very late stages, when there was absolutely no 
hope, and some died almost immediately. 
The final or end results of medical treatment are 
difficult to express in large figures, as so many pa- 
tients come from distant points, and in spite of hun- 
dreds of follow-up letters there have not been the re- 
sponses, good or bad, which could be desired: many 
letters have been returned marked "unknown," or 
"removed." But large numbers have been heard 
from, or are being watched, and, judging from the 
records studied of patients who have done excellently 
well up to the last visit, when the mass had steadily 
decreased or was almost gone, and the health greatly 
improved in every respect, it is fair to suppose that 
the improvement has progressed to a cure, as in the 
many cases which have been watched for a long time 
without recurrences; but cases not heard from have ANALYSIS OF CASES. 
251 
not been counted as cured. As a rule almost all 
early and non-operated cases have gotten well, that 
is, those who have been absolutely faithful to all 
directions as to treatment, for a long enough time to 
enable one to speak thus. 
It will be noticed that no time limit of cure is set, 
as in the old surgical period of three years, which 
has been found so erroneous. But the three-year 
limit is quite correct in regard to the medical treat- 
ment of cancer of the breast, for, if all signs of the 
disease have disappeared by or before that time we 
may be reasonably certain that the disease is cured. 
That is, there can be no more manifestations of car- 
cinosis if the basic cause is overcome, and if it can 
be secured that the patient, by most careful living 
and any necessary medication, can be kept in the non- 
carcinosis state of the system; and this is possible 
with due wisdom and vigilance on the part of both 
the physician and the patient, working well together, 
as the cases to be narrated will show. For I can 
find only one or two exceptions among the patients 
with primary cancer who were really faithful in 
every particular during long enough periods, as will 
appear later. Of course, far advanced cases and 
those which have been operated on, in one way or 
another, are difficult to reach; and too much should 
not be expected, but even in these there have been 
some results which were most gratifying. The re- 252 
CANCER OF THE BREAST. 
suits of treatment and life extension are shown in the 
following diagrammatic table: 
Graph III.-Percentage Results of Treatment of 
Cancer of the Breast. 
Per Cent 
CURED 
WELL WHEN LEFT 
। DIED 
A- POST-OPERATIVE CASES 
B- PRIMARY, MEDICAL FIRST THEN 5UR6ERY 
C- PRIMARY, MEDICAL TREATMENT ONLY 
The total number of deaths which most diligent in- 
quiry, over months, with hundreds of letters, has re- 
vealed is most remarkable and hardly believable; only 
34 (n primary, 23 postoperative); the larger share 
of these were in very late conditions, or in postopera- 
tive and consultation cases. There were undoubtedly 
more deaths which were unaccounted for, but at the 
utmost the mortality was small indeed compared with ANALYSIS OF CASES. 
253 
that commonly expected; even if this number were 
doubled it would fall far short of the 90 out of 100, 
or ninety per cent., which is generally reckoned as 
the ultimate fate of those once affected with cancer 
in general. The following table presents the ages at 
which both primary and postoperative cases suc- 
cumbed : 
Table of Deaths and Ages. 
Ages 
Prim. 
Post-op. 
Total 
Under 30 
0 
0 
0 
30 to 34 
1 
1 
35 " 39 
1 
3 
4 
40 " 44 
2 
2 
4 
45 " 49 
2 
7 
9 
50 " 54 
2 
4 
6 
55 " 59 
0 
3 
3 
60 " 64 
0 
2 
2 
65 and over 
4 
1 
5 
Total deaths 
11 
23 
34 
" ■ cases 
95 
74 
The eleven deaths in unoperated cases were as 
follows: 
Case I. Primary, far advanced carcinoma of the right 
breast. Mrs. M. B. J., widow, aged 68, with four child- 
ren, was sent to me, Feb. 17, 1914. Two years previ- 
ously she had noticed a lump in the upper part of the 
right breast, after great and repeated mental distress from 
the death of a number of very near relatives, and a sis- 
ter's mental derangement, the great nervous strain having 
been attended with various bilious attacks and nervous 254 
CANCER OF THE BREAST. 
indigestion. The mass increased steadily in size, but was 
kept concealed even from her family, until the day before 
she called. Her family physician then recognized that it 
was far beyond hope from any operation, in which view 
a prominent surgeon concurred, and sent her to me. 
When first seen the whole breast was involved, double 
the size of the other, like a very large half melon, hard 
and immovable. There was a rather thick crust, several 
inches in diameter, adhering to an ulcerating surface, be- 
neath which came a moderate discharge. The axillary 
glands were enormously enlarged as also the supraclavicu- 
lar, and she was strongly cachectic. She was placed under 
very complete dietetic and medical treatment, and the 
whole area painted with a 50-per cent, ichthyol in water, 
the crust not being disturbed. In a very short time the 
discharge ceased, the adherent crust not being disturbed 
until she passed away peacefully, from exhaustion and 
pulmonary edema, on September 9, 1914. On August 5th 
it was recorded that the breast had done very well, was 
soft and movable, and not larger than the other breast, 
with no discharge, and no pain since a short time after 
beginning treatment. The axillary glands had diminished 
three-quarters in size, and the supraclavicular glands were 
much smaller. She never required or took a particle of 
morphine nor any opiate. 
The peace and comfort experienced by this lady during 
seven months, with an enormous inoperable cancer and 
great cachexia when first seen, was certainly very different 
from the generally conceived and observed course of 
cancer. 
Case II. Primary carcinoma of the left breast. Mrs. 
Dr. S., aged 85, seen September 16, 1918. After an ANALYSIS OF CASES. 
attack of grip two years previously, she noticed a small 
lump in the left breast, the size of a pea, which grew 
steadily and was treated with x-ray for over a year, and 
then with radium tube for four hours. There had been 
ulceration for several weeks. When first seen there was a 
mass three by four inches in the center of the breast, with 
a raw surface just above the nipple an inch in diameter, 
with a foul odor; she had much stabbing pain. She was 
placed upon an absolutely vegetable diet, with the acetate 
of potassa and rumex extract mixture half an hour before 
meals, and a calamine and zinc ointment. On December 
29, 1918, her physician wrote that she had "gotten along 
remarkably well." And while there was much discomfort 
and some pain she was able to go about the house and do 
much knitting for the soldiers. There was later a good 
deal of sloughing, but the whole mass had a less angry 
appearance since starting treatment. She was fairly com- 
fortable, without an opiate, until she collapsed suddenly 
in the bathroom after a dressing, and died peacefully, Sep- 
tember 2, 1919, at 86 years of age. This case was also 
most satisfactory, as she lived nearly a year after first 
seen, in reasonable comfort about the house, and died 
rather from old age than from cancer. 
Case III. Primary carcinoma of the left breast. Mrs. 
L. H. G., aged 68, a frail widow, weighing 80 pounds, 
first seen November 18, 1920. In June she noticed the 
left breast larger than the right, which increased until seen. 
She had had great tribulation, and really came to me for 
an x-ray burn in the right iliac region, which was occa- 
sioned by treatment of Bright's disease, a number of years 
previously. On April 18th, after a funeral of a dear 
friend, she received a blow on the chest from some rough 256 
CANCER OF THE BREAST. 
boys, by which she was greatly shaken, and a lump ap- 
peared in the left breast which increased until seen. Her 
physician sent her to a prominent surgeon who urged an 
immediate operation, as did her physician, which was 
refused. 
When first seen there was a hard mass two by three 
inches in diameter, nodular, with a skin node just above the 
nipple and considerable axillary adenopathy. Living alone, 
out of town, in spite of doubtfully proper diet and internal 
measures of various kinds, she did not do well, being sub- 
jected to great financial and other annoyance, and the 
breast developed a cauliflower excrescence from which she 
had many hemorrhages, until she passed away peacefully 
in a sanitarium, May 30, 1922, eighteen months after 
being first seen, and two years after the violent blow on 
the breast, having had no opiates. During this period she 
had severe herpes zoster down the right leg to the toes, 
and two months before her death most frightful general 
pruritus, which was shortly relieved by local treatment. 
The results were all that could be expected under the con- 
tinual nervous strain she was under, from household and 
financial difficulties. 
Case IV. Primary carcinoma of the left breast, with 
enormous adenopathy. Miss T. E., aged 54, seen first 
March 9, 1922. Four and a half years previously there 
was a small lump in the left breast, from a bruise, which 
remained and increased until her call. She had seen many 
physicians and surgeons, and had had considerable x-ray 
on the breast and also on the large axillary lump which 
formed, and on the greatly swollen left arm, without avail. 
When first seen there was a large, hard mass three by 
four inches, beneath the nipple, which was retracted, and ANALYSIS OF CASES. 
257 
enormous supraclavicular adenopathy and in the neck, with 
a greatly swollen, hard left arm; there was also supra- 
clavicular and axillary adenopathy on the right side. The 
x-ray showed great involvement of the chest. With such 
immense lymphatic complications it was evident that not 
much could be done, but she lived three months and a half, 
and passed away peacefully in sleep, on June 23d. Al- 
though she suffered considerably with the swollen arm, 
her troubles were relieved largely by the free use of aspirin 
and she took no opiate. Under full and proper diet and 
various medication it seemed at times as if the lymphatic 
derangement might be overcome. At times the arm swell- 
ing and that of the hand was decidedly less, and softer, 
under continual painting with ichthyol and water, half and 
half, and some of the glands were smaller, softer, and 
movable, but the lung involvement was too great to be 
overcome. She went home, to the country, and the travel 
being too much for her, she died five days later. 
Case V. Cancer en cuirasse of the right breast. Miss 
V. B. A., aged 46, was first seen May 14, 1918. Two years 
previously she noticed irritation about the nipple of the 
right breast, and a few months later it began to draw in and 
a small mass formed just below. This increased slowly 
but gave little trouble until about three months previous 
to her visit when there was pain, and about two months 
later the arm became swollen and very painful down to 
the fingers. With such a history one was hardly prepared 
for the condition discovered; on examination the right 
side, from the sternum to the post-axillary line, and down- 
ward half way to the umbilicus there was a very hard, 
malignant process, a cancer en cuirasse, which had con- 
tracted the right breast to one-sixth its natural size, and 258 
CANCER OF THE BREAST. 
the arm was swollen down to the fingers, and was one- 
third greater in size than the left, with much pain, since 
two months treatment with x-ray. There was, moreover, 
a mass in the left breast two by three inches in size. The 
patient had been always very constipated, with scanty 
urine and frequent micturition, and it was exceedingly 
difficult to make any headway with her. As the disease 
increased, away from me, in another city, the breast ulcer- 
ating, she suffered terribly, could not sleep, and was ner- 
vous and hysterical, crying and screaming. I learned by 
letter that later she took to morphine every three hours, 
and died October 20, 1918, five months after her first visit. 
I have seen several cases of cancer en cuirasse, but never 
one developing so rapidly and so rebellious to all treatment. 
Case VI. Carcinoma of both breasts. Mrs. W. C. L., 
aged 40, was referred to me by her physician on December 
26, 1918. Three months previously a lump was discovered 
in the right breast, which had disappeared entirely under 
my diet given by her physician. She had always been a 
very hearty eater, consuming very much meat. One week 
before her visit she noticed a mass in the left breast which 
was increasing; she had long been a sufferer from rheu- 
matism and neuritis which also ceased with the diet and 
anti-rheumatic remedies. On February nth she reported 
as feeling very well, the lump in the breast softer, the 
right breast continuing normal. On March 13th it was 
recorded that she was doing very well, nothing could be 
found in either breast, the arm pain had ceased, and she 
had gained in flesh. On April 25th I learned by tele- 
phone from her physician that she had just died very sud- 
denly from heart failure caused by indigestion. After 
much correspondence I finally learned from the county ANALYSIS OF CASES. 
259 
medical examiner that she died of diabetes mellitus, and 
that there was no "internal evidence of malignant disease 
found in the viscera." The connection between diabetes 
and cancer is beginning to be recognized, and I have had 
several cancer patients who died thus, the disease being 
undoubtedly aggravated by the diet prescribed. 
One case, really primary, not operated on surgically, but 
treated by "chemical removal," died from neglected medical 
treatment. 
Case VII. Late, inoperable carcinoma of the left breast. 
Mrs. L. H., aged 36, was seen in consultation September 
20, 1918. For fourteen months there had been a tumor in 
the left breast, first the size of a marble, which had in- 
creased gradually, and for the previous six weeks she had 
had darting pain, following a blow on the breast; this 
pain was more pronounced during menstruation. She 
had been having electrical treatments three times a week 
for nine months, also drinking a glass of radium water 
three times daily, and had been under vegetable diet. 
When first seen the left breast was greatly enlarged, 
with a hard mass two by three inches in diameter, with 
some adherent, reddened skin, and some axillary adeno- 
pathy, and several physicians and surgeons declared the 
case inoperable. Under careful diet and medication she 
seemed to do well for a while. The breast was less swol- 
len and red, and she gained a little flesh, to even more than 
her normal weight. But on October 22d the supraclav- 
icular glands were a little enlarged, and the axillary glands 
possibly a little larger. As she and her husband were rest- 
less and wanted an operation I consented to have Dr. 
Strobel do his "chemical removal," which went off well, 
except that the axillary glands were hard to reach, on 260 
CANCER OF THE BREAST. 
November ist, and that area was not skin grafted until 
December 13th. During all this time the dietetic and 
medicinal measures were neglected. The grafts on the 
breast and in the axilla did not take very well, and by 
December 26th there was still some rawness and a swell- 
ing of the left arm. 
After this, resuming my treatment, she picked up, and 
on March ist I recorded that she felt very well, pulse 80 
and good, regaining some flesh, almost her former weight, 
and went to her country home, being under my treatment. 
She then went West for several weeks, probably neglecting 
treatment, and several cutaneous nodules developed near 
the original site and on the back, with some supraclavicu- 
lar adneopathy. For this she received some radium treat- 
ment, with needles, by Dr. Janeway, and had repeated 
x-ray applications, and later right axillary adenopathy 
developed. She then went again to her country home and 
I lost sight of her, and later heard that she died July 12, 
1919. In this case the medical treatment, which was ir- 
regularly followed out, failed to check the lymphatic per- 
meation, and its extension put an end to her life. 
Three other fatal primary cases, which are here re- 
corded, were seen in consultation, or only once. 
Case VIII. Inoperable primary carcinoma of the right 
breast. Mrs. S. R., aged 68, seen in consultation May 20, 
1919, had had a lump in the right axilla for two years, re- 
maining much the same till March, 1919, when she noticed 
a mass in the breast, which had since ulcerated. When 
seen, the right breast was the size of a half melon and 
very hard, with numerous ulcerated areas; she had always 
been very constipated, with no movement for a week at a 
time. She was advised thorough dietetic and medicinal ANALYSIS OF CASES. 
261 
treatment, which may not have been carried out; her 
physician wrote me that she died about November 30th. 
Case IX. Primary carcinoma of both breasts, follow- 
ing uterine cancer. Mrs. W. A. C., aged 52, seen Febru- 
ary 9, 1922. For two years she had lost flesh, looking 
grayish, with obstinate constipation and indigestion. The 
uterus was then found to be enlarged and bound down, and 
at the same time both breasts were attacked, and axillary 
and supraclavicular adenopathy appeared. Then, two 
years ago, having uterine bleeding, she saw Dr. Kelly in 
Baltimore, who found extensive uterine disease, and curet- 
ting the cervical canal, diagnosticated adeno-carcinoma, 
giving her not six months to live. Several others gave the 
same diagnosis and prognosis. She then had radium in 
the uterus twenty-four hours, and the uterus was reported 
softer and movable, and the bleeding stopped; she also 
had x-rays fifty minutes each week for a while. Later 
she had swelling of the abdomen and legs, and a leading 
New York surgeon opened the abdomen, removing about 
a gallon of fluid and found all the peritoneum a mass of 
matted glands. I saw her but once, and she died April 
26, 1922. 
Case X. Primary carcinoma of the right breast, subse- 
quently operated on. Mrs. S. S., aged 43, came to me 
December 29, 1921, with a mass three by four inches in 
the right breast, hard and adherent to the skin, with the 
nipple much retracted. She was greatly constipated, de- 
pending on medicine, and with scanty and red urine, 
passed at night. She was given appropriate dietetic and 
medicinal treatment, but I never saw her again, and I do 
not know if she carried it out; on inquiry I learned that 262 
CANCER OF THE BREAST. 
she was soon operated on surgically in a hospital, and died 
on May 30th, after weeks of.great pain. 
Case XI. Inoperable carcinoma of the left breast. Mrs. 
D. L., aged 44, came to me December 22, 1920, with a 
curious history. She had had one child, a son, 19 years 
of age whom she had nursed ten months normally, no 
abscess. She had always been healthy and active until 
about a year previous to her visit when she became weak 
and heavy, with no ambition. Seeing her physician he ad- 
vised the teeth to be inspected and x-rayed, and as a 
result all the upper teeth and lower back teeth were ex- 
tracted, quite interfering with perfect mastication, which 
is such an important element in impending cancer. 
Four or five months previous to her visit she had pain 
in the left breast, which was relieved by witchhazel, and 
shortly after she noticed a lump in the breast, and an 
operation was urged, but rejected. The bowels were al- 
ways sluggish, requiring laxatives several times a week, 
the urine was urgent in the daytime and passed two to 
four times at night, and she had rheumatism; the menses 
were still quite regular, lasting three days, but recently she 
had them twice in a month. 
When first seen the left breast, especially the outer lobe, 
was involved in a great, hard mass, making it double the 
size of the other, it was painful, but not on light hand- 
ling; on the lower aspect there were two ulcerated cutane- 
ous nodules, and many small red points on the side; the 
axillary glands were greatly enlarged, low down. She 
was placed upon appropriate dietary and medical treat- 
ment, and on December 29th it was recorded that there 
was material improvement in the feeling of the breast, 
it was not so tense, and the cutaneous nodules were less ANALYSIS OF CASES. 
263 
red and smaller. She had slept much better, taking none of 
a former sleeping medicine, the urine was not so urgent, 
and not passed till 5 a. m., whereas formerly it had been 
two to four times at night. I did not see her again, but 
heard by telephone that she had gone to a hospital for a 
surgical operation, and later, upon inquiry, I learned from 
her husband that she died, November 19, 1921, eleven 
months after I first saw her. I had expected that the dis- 
ease would yield, as others had done, to careful and 
prolonged medical treatment. 
It is not necessary to go into detail regarding many of 
the 23 deaths which diligent inquiry and large corres- 
pondence have discovered in the 74 postoperative cases, 
for they all have about the same sad story; but some 
of them were of peculiar interest, on account of the 
good fight which was put up; a few illustrative cases may 
suffice. There were undoubtedly many more deaths than 
these, among the desperate cases which I saw in consul- 
tation, but my repeated letters have failed to elicit any 
more reports of deaths. 
Case XII. Postoperative carcinoma of the right breast. 
Mrs. B. E., aged 49, weighing 159 pounds, mother of three 
children, aged 21, 20, 13, was sent to me on January 25, 
1917, by a leading surgeon four months after he had per- 
formed a very perfect surgical operation, clearing out the 
axilla, on September 27, 1916. This was for the removal 
of a lump in the right breast, with axillary adenopathy, 
which was first noticed five or six weeks.before the opera- 
tion; the breast tumor was then the size of a large walnut, 
and was reported microscopically to be an adeno-carcin- 
oma. She had long been persistently constipated, depend- 
ing on cathartics all the time, the digestion was poor, with 264 
CANCER OF THE BREAST. 
continued flatulence, and she had insomnia to 2 or 3 a. m. ; 
the menses had ceased five years. 
When seen there was a good scar, from a complete 
operation, including the axilla, but there were some small, 
enlarged glands still there, and she complained of pain and 
aching, and the arm, which was enlarged, had some tender 
areas. She was placed on rigid diet and medication, but a 
month later it was recorded that there were cutaneous 
nodules around the surgical scar, with an area of redness 
nearby, such as is often seen in recurrent cases, and within 
two months all these, and the axillary adenopathy had in- 
creased. The urinary secretion from the first was found 
to be very deficient in the solids called for by the body 
weight, only one-quarter of the normal amount, and the 
urea was very low; this was more or less the condition 
for some months, but by very active treatment all this was 
restored to normal. 
She was a very intelligent and faithful patient, coming 
weekly from a neighboring town, and for some time 
seemed to do well under varied treatment to meet existent 
conditions, while maintaining the proper dietetic, hygienic, 
and medical measures. But in spite of all our efforts the 
cutaneous nodules kept appearing, although very slowly, 
as also some adenopathy, which painting with 50-per cent, 
ichthyol and x-rays seemed to markedly control. On 
October 25th, it was recorded that she felt very well, had 
a great appetite (for the "green card diet") and "sleeps 
wonderfully with no nocturnal urination," with which she 
had been formerly troubled; she never took morphine or 
any opiate. On November 28th, there was still "very 
great improvement," the cutaneous nodules had gone, also 
certain areas of diffuse redness which had appeared had ANALYSIS OF CASES. 
265 
vanished, and the enlarged gland in the axilla was less, 
and on January 8, 1918, it was "hardly perceptible." 
But the fatal lymphatic permeation persisted, and by 
April 16, 1918, a new enlarged gland was found low, 
behind the axilla, and a bony infiltration appeared by the 
sternal end of the incision, with considerable pain in the 
right shoulder and arm. She had kept her weight pretty 
well up to this time, but began to lose. However, under 
change of treatment she picked up, the urine improved 
materially the urea rising up to normal, and it seemed as 
if she might pull through. But slowly the supraclavicular 
nodes became involved, and those in the neck and back, 
for which radium tubes were inserted by Dr. Janeway, 
without appreciable benefit, but causing much pain. By 
November 15th signs of intrathoracic invasion appeared, 
with shortness of breath, cough, and distress, and the chest 
was tapped several times, and large amounts of fluid re- 
moved, up to 72 ounces. She finally passed away on 
January 19, 1919, two years after her first visit, and two 
years and four months after the operation. 
While the ultimate result was not such as was hoped for, 
or even expected by the surgeon who performed the rela- 
tively early operation and referred her to me, the case il- 
lustrates well the distressing features of the disease, and 
the practical impossibility of surgery reaching all the in- 
vaded lymphatics, and also the spread of the disease by the 
traumatism of lymphatics and blood-vessels during opera- 
tion. From long experience it seems that most careful 
dietetic, hygienic, and medicinal measures might have re- 
moved the first small tumor without operation, as in the 
many successful cases to be mentioned later, and thus the 
life saved. It was, however, a comfort to have her hus- 266 
CANCER OF THE BREAST. 
band, an unusually intelligent gentleman, write to me 
when announcing her death, "I am fully convinced that 
you have added considerable to her life, in comfort and 
length of days." 
Case XIII. Postoperative carcinoma of the left breast. 
Mrs. G. C., aged 46, with three children, 23, 22, 17, 
noticed a small lump in the left breast, three years before 
being first seen, October 5, 1918. This was removed surgi- 
cally in February,- 1917, the wound not healing for ten 
months. Four months before she came to me axillary 
adenopathy occurred, and a small, hard mass appeared in 
the middle of the operative scar. She had always been 
constipated, depending on medicine, and the saliva was 
found to be acid; the menses were still regular and normal. 
When first seen there was a flat, hard mass, one inch 
and a quarter by one inch, with darting pain in it, with 
two almond-size glands in the axilla, and some indefinite 
nodes in the pectoral fold. Being placed on full dietary 
and medical treatment, in a month it was recorded that 
she "felt much better," and the axillary nodes were 
smaller and movable. On December 21st, it was recorded 
that she "feels better all the time," the mass which was 
in the middle of the scar was gone, and the axillary nodes 
were smaller, and she had no pain. On February 13th, 
1919, she still felt very well, except some neuralgic pain 
in the left shoulder to the elbow, and the axillary gland 
had enlarged some; the saliva was still acid. After this 
she failed some, and on June nth she complained of 
great pain in the right side of the sternum up into the 
shoulder and neck, which was relieved considerably by 
aspirin and x-ray. On October 30th it was recorded that 
she "felt fine this week," the sternal lump was smaller and ANALYSIS OF CASES. 
267 
softer, as also the axillary gland. She had had several 
profuse menstrual periods, and then the menopause oc- 
curred and she began to run down. The sternal mass 
ulcerated and gave distress and the axillary nodes in- 
creased in size, and she failed in strength; before this she 
had been up and very active on account of a daughter's 
illness. Soon she could not come to the office, from her 
home in New Jersey, and a friend reported often that 
she was steadily failing. On September 10th I was sent 
for and found that she had considerable jaundice, but there 
was no enlargement or hard edges of the liver; there was 
still considerable ulceration on the chest. I afterwards 
learned that she had morphia hypodermically for the last 
three weeks of her life, which ended October 24, 1920, 
two years after I first saw her. While the disease was 
fatal in this instance, life was undoubtedly prolonged long 
after the time when it would be expected to end, while the 
comfort and activity of the patient during those two years 
was most gratifying to all. 
Case XIV. Postoperative carcinoma of both breasts. 
Miss S. M., aged 37, fell in May, 1916, striking the right 
breast. Three months later she noticed a lump the size 
of a pea, which increased, with the development of enlarged 
axillary and supraclavicular glands, and attacks of shoot- 
ing pains. On October 1, 1917, there was a very com- 
plete operation performed; the mass, the size of a large 
English walnut, including the axillary and supraclavicular 
glands were removed. When first seen, January 28, 1918, 
the operative area was still denuded over a large area, the 
grafts not having taken; this was being dressed surgically 
every other day, which dressing was continued by her 
surgeon for two weeks, with very great discomfort. 268 
CANCER OF THE BREAST. 
Being placed on a complete medical treatment, and the 
surface covered with a calamine and zinc ointment, spread 
on thin absorbent cotton, changed twice daily, the relief 
experienced was immense, and within three weeks it was 
recorded that the ulceration had completely healed. But 
some small cutaneous nodules had appeared, around the 
scar, which subsided under the continuous application of 
thiol, and occasional x-rays. But the supraclavicular 
glands again appeared, as also an axillary gland, though 
on June 26th it was recorded that the enlarged glands had 
gone down. She had been very nervous since the opera- 
tion, and various remedies had been employed, and in spite 
of a very hot summer, on August 28th she looked and felt 
very well. But on September 12th, it was recorded that 
the left breast was involved, with an irregular, nodular 
mass 1 by 2 inches in diameter, with also pain in the 
right breast and side, and some cutaneous nodules around. 
By September 6th, the left breast was more involved, with 
axillary adenopathy; iodide of lead in diachylon ointment 
was kept over the left breast, on absorbent cotton, and 
on October 10th it was much softer. I then lost sight of 
her for a while, and in response to a letter from me she 
wrote on December 22d, that she had been so much better 
and so busy that she kept putting off the appointment, and 
promised to call shortly, being sure that I "will be pleased 
to see how much better I look, gaining quite a few 
pounds." 
But she did not call, neglected treatment, and under- 
went some proteal injections, and took some quack rem- 
edies, and on February 22, 1919, I was asked to see her 
at her home. I found that she had been in bed for a 
month, since she had waked at midnight with a spasm in ANALYSIS OF CASES. 
269 
the right leg for which she had had morphine hypodermi- 
cally and had suffered much since; the sole of the right 
foot was very painful to the touch. The cancer had made 
bad progress. The left side had multiple cutaneous nodules, 
while the right breast was large and solid, with cutaneous 
nodules and much erythematous redness over and around it 
in patches. The right and left axillary nodes were large, 
and also right supraclavicular, and she died shortly there- 
after. While the ending of this case was unfortunate, for 
over twelve months she was comparatively well, carry- 
ing on a very active business of her own, as a hair dresser, 
and it was only when she neglected treatment and tried 
other measures that in two months the fatal lymphatic per- 
meation carried her off. 
Case XV. Postoperative carcinoma of the left breast. 
Mrs. F. L. E., aged 62, was first seen October 20, 1917. 
Two years previously, in June, a small lump, the size of a 
walnut, was noticed in the left breast, close to the nipple, 
which was drawn in within a week. The breast was 
amputated almost immediately, early in June, 1915, with 
a thorough, axillary operation, which showed microscopi- 
cally a carcinoma. In July, 1917, a lump appeared over 
the left clavicle the size of a bean, which was removed the 
next day, and shown to be carcinoma, under the micro- 
scope. There was no trouble until October 1st, when there 
were sharp pains in the left shoulder, and in the left 
clavicular region, from the joint to center; she had had 
rheumatism off and on for years, and the pain was disre- 
garded, until shortly two glands were discovered to be en- 
larged, above the clavicle, and I was consulted, with a 
hope of averting serious recurrence. 270 
CANCER OF THE BREAST. 
On examination a very good scar from the operation 
was found, extending into the axilla and along the arm, 
also the scar from the removal of the supra-axillary glands 
in July previous. There were two enlarged glands dis- 
covered above the clavicle, and a small one in the left 
axilla. She had always been greatly constipated, depend- 
ing on medicine, and had bad digestion, with gas; the 
sleep had been bad for years, with long periods of wake- 
fulness, and disturbed by frequent urination, the saliva was 
very acid. She was said to have diabetes, but no sugar 
was discovered, after several analyses. The urine was 
strongly acid, specific gravity 1018, 1020, and scanty, aver- 
aging 25 to 28 ounces, by measure, daily. 
Being placed on complete treatment, in two weeks she 
felt better, with less pain in the left arm, but had a short- 
ness of breath on ascending stairs, and a mitral mur- 
mur was discovered. A later analysis revealed almost 
3 per cent, of sugar in the urine, and she left for the 
Pacific Coast a month after; subsequently I learned that 
she died of diabetes, fostered possibly by the carbonaceous 
diet given for the cancer, in August, 1920, nearly three 
years after I first saw her. 
It would be useless to narrate further cases showing 
the results in the 74 postoperative cases, but a brief 
mention may be made of the duration of life after 
operation in the cases which have passed under my obser- 
vation, where the date of the final result could be ascer- 
tained. 
Of the 74 cases 1 died within one year thereafter, 
2 within eighteen months, 1 within two years, 2 within 
two and one-half years, 3 within three years or longer, 
and in 49 cases the time could not be determined. ANALYSIS OF CASES. 
271 
Turning now from this discouraging side of the cancer 
problem we will consider what can be accomplished by 
intelligent, faithful and prolonged treatment along medi- 
cal lines. Unfortunately, I cannot report that the actual 
number of satisfactory cases is as great as could be desired, 
for it has been found impossible to trace the many patients 
who have come from all parts of the country; many 
follow-up letters have been returned by the Post Office, 
as "unknown" or "moved," and in many cases no re- 
sponse came, even when doctors, families, or relatives were 
addressed. But in carefully studying the recorded his- 
tories there were found a relatively large number which 
were observed, remaining entirely well five, ten, sixteen, 
eighteen, and even up to twenty-nine years after first 
being seen. The most striking case, representing the last 
mentioned period, over twenty-nine years, may be men- 
tioned first. ■ This case was reported in my last book, as 
having been carefully watched for over sixteen years, and 
when examined thoroughly at the last visit, the breast 
was absolutely normal. Recently I got trace of her, thir- 
teen years later, well at the age of 74, she having re- 
mained free from cancer twenty-nine years after her 
first visit. 
Case XVI. Large primary ulcerating carcinoma of the 
left breast, patient well for twenty-nine years. Miss B. 
M. L., aged 45, was sent to me January 4, 1894, with a 
well defined carcinoma of the left breast, so diagnosed by 
several good medical men, one of them a surgeon of great 
prominence, who urged an immediate operation; this was 
to have been performed by him on the day following that 
on which she came to me, but escaped. The mass had 
been noticed for a month or so, and had steadily enlarged 272 
CANCER OF THE BREAST. 
and had begun to ulcerate, with slight axillary adenopathy. 
When first seen there was a hard mass, nearly two inches 
in diameter, in the upper outer quadrant of the breast, well 
defined, not painful on moderate handling, but subsequently 
she experienced pain in it; there was some adherence to the 
skin, which was ulcerated, near the center of the mass. 
Being placed on full dietary and medical treatment, two 
months later the lump was recorded as less distinct and 
flatter, and much healed, and within eleven months it had 
entirely disappeared. A month or two later she had some 
pain in the breast with the menstrual disturbance connected 
with the menopause, but careful examination revealed no 
trace of the tumor and no adenopathy. On November 
8, 1905, she called, bringing a relative for treatment, and 
careful examination showed the breast perfectly normal; 
again five years later she called, with another trouble, and 
the breast was found to remain perfectly well, sixteen years 
after first coming for treatment. Lately she sent me an- 
other patient with a breast tumor, and I learned her ad- 
dress, and called, and the breast was found to be normal. 
She is now 74 years of age and it is over twenty-nine 
years since she first came under my care. 
Case XVII. Primary carcinoma of the right breast, 
well for eighteen years. Mrs. H. R., aged 30, had been 
under my care for acne, off and on for some time, when 
on October 26, 1904, she called my attention to a char- 
acteristic lump about an inch in diameter, just below the 
nipple of the right breast, for which she had consulted her 
family physician, as she had had pain in it since July. 
She was a nervous, excitable lady, under great strain, 
eating freely and indulging in a good deal of liquor. 
Not being willing to have the operation urged, she con- ANALYSIS OF CASES. 
273 
suited me, and was placed on a strict diet, and thorough 
medical treatment, and on January 6, 1905, it was re- 
corded that the breast was normal, with no trace of the 
tumor, and with absolutely no pain; and being seen for 
several months after, it was constantly recorded that the 
breast remained normal. 
About four years after the disappearance of the mass 
in the right breast, when she had neglected treatment 
for some time and had lived pretty high, using liquor 
freely, a characteristic tumor developed in the left breast, 
with more or less pain, the right breast, originally affected, 
remaining free. Under careful dietetic and medical treat- 
ment this subsided, and within a few months both breasts 
were perfectly normal. She was a very difficult patient 
to manage, with a systolic blood-pressure from 200 to 250, 
and diastolic, no to 130; she had never been pregnant and 
her menses continued until after 47 years of age. Seen 
quite recently the breasts remained normal, fully eighteen 
years after her first visit. Experience teaches what 
would have been the result had the right breast been 
removed surgically, as advised, at that time. 
Case XVIII. Primary carcinoma of the left breast, 
well for seventeen years. Miss J. M. A., aged 45, a hard- 
working city missionary, under great mental and physical 
strain, was referred to me October 12, 1905, for a tumor 
in the left breast, above the nipple, which had existed for 
some months, awaking her at night with pain, and also 
with numb, shooting pain in the day time. She had seen 
many medical men and surgeons, all diagnosing cancer, 
but had declined the operation constantly urged. Under 
rigid dietetic and medicinal treatment, within two months 
the pain had entirely ceased and there was very little of the 274 
CANCER OF THE BREAST. 
trouble left in the breast. On January 5, 1905, it was 
recorded that both breasts were the same, with no trace of 
the former tumor in the left breast. She was repeatedly 
seen for nine years, always in active work, and the case 
then reported in my last book as cured. Recently she 
was seen again, still in perfect health, and rather stout, 
with absolutely no remains of the tumor, fully seventeen 
years after her first visit. 
Case XIX. Primary carcinoma of the right breast, well 
for over sixteen years. Mrs. B. E. C., aged 44, was first 
seen on account of trouble in the right breast on Septem- 
ber 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 my 
diagnosis of cancer, and hesitating at the thought of pro- 
longed medical treatment, she consulted a well-known, 
very prominent surgeon, who pronounced the tumor un- 
questionably 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 med- 
ical treatment. I saw her at frequent intervals for six 
months, and the breast became entirely normal. Four 
years later she was seen again, in regard to the menopause, 
which she was undergoing, and the breast was found yet 
to be normal; she was still 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 my 
occasional medical care, I learned repeatedly that she con- 
tinued still perfectly well, with no trouble of the breast. 
Thus, she remained entirely free from cancer over sixteen ANALYSIS OF CASES. 
275 
years after beginning treatment, with no metastases or 
recurrence of the breast tumor. They live in a neighbor- 
ing town in New Jersey and if there had been any re- 
currence I should certainly have known of it, as her hus- 
band is a distant relative, and overjoyed at her escape from 
the knife. 
Case XX. Primary cancer of the breast, well over 
seventeen years. Miss G. M., aged 44, a hard-worked 
public school teacher, first seen November 13, 1905, had 
struck the breast in a fall sixteen years before, but the 
effects passed off, and there were no sensations for seven 
or eight years, when she began to have pain, aggravated 
at menstruation. During the past year there was a lump 
formed, with constant pain, also recently pain in the axilla, 
which kept her from school. A number of medical men 
had always diagnosed cancer, and a surgeon of prominence 
in one of the large hospitals had strongly pressed for 
immediate operation, as the only hope, which was refused. 
When first seen there was a tumor two or three inches 
in diameter, sharply defined and nodular on the surface, 
in the upper segment of the left breast, with enlarged 
glands in the axilla. She had long been constipated and 
passed only about 60 per cent, of the amount of urinary 
solids proper for her weight and age. Under very active 
treatment it was recorded, four weeks later that there had 
been hardly any sensation in the breast during the previous 
week, whereas for the last months she had been kept from 
her work in school by the severe pain in the breast, and 
lately in the axilla. The tumor had already diminished 
materially in size, with only moderate hardness, and she 
had been out of doors every day, and was feeling very 
much better. One month later it was recorded that the 276 
CANCER OF THE BREAST. 
breast was very well, and on examination it was found 
to be 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 disap- 
pear for a month or two later, but on April 7th it was 
recorded that the left breast was the same as the other, 
and that no glands could be felt in the axilla. 
From that time to the present she has had a variety of 
troubles, rheumatic and others, and it has been difficult 
to keep up a correct action of the bowels and kidneys, but 
in spite of strenuous and often exhausting work as a 
New York City public school teacher, she had had no 
return of the breast trouble up to the time of my first 
report of the case in 1915, that is, for over nine years. 
A sister, aged 60, had then just died with cancer of the 
stomach, in a distant country town. It is now over eight 
years since then, and from friends I learn that the patient 
remains still entirely well and free from cancer, making 
over seventeen years from the date of her first visit. 
Case XXI. Primary carcinoma of the left breast, still 
•well nearly nine years. Mrs. J. T. T., a farmer's wife, 
aged 38, was seen in Norfolk, Conn., on August 11, 1914. 
She had been confined with her first child four months 
previously, but had not nursed the child, and had no 
trouble with the breast. Four weeks before her visit she 
had noticed a tumor in the upper, outer segment of the 
left breast, increasing steadily, with considerable pain. 
She had seen an excellent surgeon in a neighboring city, 
who diagnosed cancer, and urged instant operation. ANALYSIS OF CASES. 
277 
When first seen there was a mass the size of an egg, 
hard and well defined, tender on pressure, and with en- 
larged axillary glands. Under very active dietetic and 
medical treatment, including thyroid, and iron, and 50 
per cent, ichthyol locally, with Hebra's diachylon oint- 
ment later, the lump disappeared slowly, and just a year 
subsequently it was recorded that the breast was perfectly 
normal, with no trace of the tumor or axillary adenopathy. 
She was again confined of a healthy child in June, 1916, 
and the surgeon who made the original diagnosis of cancer, 
and urged immediate surgical removal, reported the breast 
perfectly normal. Seen very recently she still remains 
perfectly well and free from cancer, over nine years after 
her first visit. 
Case XXII. Primary carcinoma of the right breast, 
well six years. Mrs. S. J., aged 33, first noticed a lump 
in the right breast two months previous to her first visit, 
at my hospital medical clinic for cancer, February 28, 
1917. This steadily increased in size until seen, when it 
was fully an inch and a half in either direction, in about 
the middle line above the nipple, with sharp, rather hard 
edges, and a palpable gland in the axilla; she had been 
having sharp pains, radiating from the breast to the axilla. 
For future reference I called in the surgeon in attendance, 
who at once recognized it as carcinoma and urged im- 
mediate removal, as the only hope for the patient. 
She was extremely constipated, the mouth dry and the 
saliva acid. Being placed on strict dietetic and medicinal 
measures, it was recorded in two weeks that she felt better 
than for a year. The lump was materially smaller, though 
the edges were still sharp and nodular. There was no 
pain except on extreme exertion, in doing her own house- 278 
CANCER OF THE BREAST. 
work and caring for two small children, who always ac- 
companied her. She was very faithful to treatment, gen- 
erally coming every week, and six months later it was 
recorded that the mass had markedly diminished, it being 
about an inch in diameter, very shallow, and with abso- 
lutely no pain. Six months later practically nothing could 
be felt, and no adenopathy. 
A little over a year after her first visit, a physician vis- 
iting my clinic was told that she had cancer, and was 
asked to tell which breast had been affected. After care- 
ful examination he decided that it must have been the 
left breast, instead of the right, as there was slight chronic 
mastitis there. At intervals later four other physicians and 
surgeons made the same mistake in diagnosis. One of 
my assistants reported to me a similar case, where the can- 
cerous mass had disappeared under the same treatment, 
and after a year a doctor had made the same error, after 
examining both breasts. Within the first year my patient 
had been again pregnant, the child dying soon after birth. 
She reported for observation and some treatments for 
four years, and still nothing could be found in either 
breast, and no adenopathy; it is now nearly six years 
from her first visit; she has given birth to still another 
living child. 
It is unnecessary to go into much more detail regarding 
the very many cases of breast cancer which have passed 
under my observation and more or less faithful treatment. 
As already stated, it is very difficult to secure loyal obedi- 
ence to the necessary and often tedious details of the cura- 
tive measures, for a time sufficiently prolonged to secure 
the desired results. With the general view of the hopeless- 
ness of cancer, and the still prevailing view accepted by ANALYSIS OF CASES. 
279 
the laity, that cancer is a local disease, and that surgical 
removal offers the only hope, many patients after a brief 
period of treatment yield to the lure of the spectacular 
features of surgery, x-rays, or radium, even with the pos- 
sible expectation of recurrence, and are lost sight of, often 
after one, two, or a few visits. Of our cases there were 
151 who were seen but once, 16 twice, and 13 three or 
four times, when they ceased coming. There were 173 
who were under treatment for one month or less, 12, two 
months, 4, three months, and 26 for less than a year. 
On the other hand, 17 have been faithful for eighteen 
months, 19 for two years, and as already indicated, a 
very considerable number who have remained until dis- 
charged cured, and some of these return at specified 
intervals, for inspection, now even for many years. 
Cancer is such an insidious disease that while surgeons 
formerly considered freedom from recurrence for three 
years after operation a cure, this was lengthened to five 
years, and now those who are honest will not set any 
time, but rather look for recurrence, which is often seen 
ten, fifteen, twenty, twenty-five, or even more years there- 
after, as many of us can testify. When, however, the most 
careful, systemic treatment of carcinosis has been carried 
out conscientiously for some years, recurrence does not 
happen, and is hardly possible, inasmuch as the cause 
which produced the first tumor has been overcome. When, 
however, this is relaxed, and the bad habits of living are 
returned to, as in Case XVII, the disease reappears, in this 
instance in the other breast, soon to yield again to exactly 
the proper treatment. But this is quite a different story 
from what happens after surgery, when the patient is 280 
CANCER OF THE BREAST. 
simply watched for the return, without any intelligent 
effort being made to overcome the pernicious condition of 
system which originated the trouble. For true cancer 
is never, even at the first, a wholly local disease, although 
local irritation may cause its lesion to appear first in some 
particular place. In the same manner gout is rightly re- 
garded as a systemic disease, although its first manifesta- 
tion may occur when the great toe is stepped on, also 
while syphilis is a constitutional disease, its late lesions, or 
gummata, often arise at the site of an injury. So it is 
unreasonable to assert that the removal by the knife, x-ray, 
or radium, of the primary lesion will cure the disease. 
All of us have seen plenty of cases of breast cancer where 
the lesion was excised immediately after its discovery and 
yet there was recurrence or fresh development of the dis- 
ease in a longer or shorter time. 
A single interesting case still under observation and 
treatment may aid in a clearer understanding of the 
subject. 
Case XXIII. Advanced primary cancer of the right 
breast. Miss B. C. M., aged 52, a hard-working and 
ambitious school teacher, came to my office September 14, 
1920. Three years before a small lump appeared in the 
upper, outer segment of the right breast, which had been 
treated two years by an osteopath. A year before coming 
it had opened spontaneously, and a surgeon wished to re- 
move the breast, which was declined. Since then the mass 
had increased, with active and deep ulceration, which has 
been treated with disinfectants, but with no other 
measures. 
When first seen the whole breast was firm and immov- 
able, presenting a deep ulcerating area of about two by ANALYSIS OF CASES. 
281 
three inches, with hard, characteristic edges and profuse, 
offensive discharge. There were several enlarged axillary- 
glands, somewhat movable. She could bear no ordinary 
clothing, but came with a loose wrap over the affected 
breast. She was depressed and anxious, although hope- 
ful and confident that proper systemic treatment would 
overcome the trouble, which is half the battle in handling 
these cancer cases. She was of good color yet, and 
weighed more than that called for by her height and age, 
namely, one hundred and sixty pounds, which was reduced 
by treatment to one hundred and forty-four pounds when 
seen February 5th. 
She had always been constipated and had piles and an 
anal fissure, the saliva was very acid, and the sleep very 
bad from the great pain in the breast. Being placed on 
very strict diet, and thorough internal and external medical 
treatment the change recorded in two weeks was remark- 
able; she slept perfectly, with no pain, no opiate, and the 
breast appeared better and the discharge lessened; soon 
after this the hardened edges flattened down, with signs 
of cicatrization here and there. She was then given small 
doses of thyroid after eating, but this soon disagreed with 
her, and was changed to a capsule of apiol, five grains 
after eating and at bedtime, and from time to time various 
remedies were required to meet digestive, rheumatic, ner- 
vous, and other symptoms. 
She has now been over two years and a half under per- 
sistent and faithful medical treatment, and the change in 
her whole condition from first to last has been most re- 
markable, in comparison with the previous and usual 
progress in such cases; under ordinary circumstances, as 
she would undoubtedly have been in her grave a year or 282 
CANCER OF THE BREAST. 
more ago, while the misery and suffering involved would 
have been indescribable. She was certainly inoperable by 
any intelligent surgeon when first seen. 
The disease still exists in the breast, but is hardly a 
shadow of that when first seen, and it will require some 
months yet of diligent treatment to have it all healed and 
gone, which result she and a very intelligent sister, 
who has nursed her believe and expect. During all this 
time, from first to last, there has been still a steady gain 
week by week. The whole change in this almost two and 
a half years is certainly remarkable, and shows conclusively 
that the carcinosis can be checked, and the mutinous cells 
can be dispersed by dietetic, hygienic, and medicinal treat- 
ment, even in a thoroughly inoperable case. She has been 
cheerful and happy, going out as she pleased, and travel- 
ling to Florida for some weeks, and one can hardly be- 
lieve that it is the same person who, on September 24, 
1920, first came, a perfect wreck, who would not be given 
six months to live. She has not had a particle of pain, 
never requiring an opiate or sedative from the first, and 
as the sister said, "wants to do too much." It is well 
indeed that she has had such fortitude and patience and 
perfect obedience in following out all the necessary details 
of treatment. She has used many, many pounds of cala- 
mine and zinc ointment, and no doubt even gallons of 
internal remedies of one kind or other. 
She has been good enough to present herself twice at 
the weekly conference in the Memorial Hospital, once in 
May, with the great ulcerating mass, and in December, 
1921, with the mass much shrunken, the ulceration dimin- 
ished by one-third, and signs of epithelial healthy growth 
in many places. At this second visit I said that I expected ANALYSIS OF CASES. 
283 
to present her again in a year with the lesion healed. This 
visit has not yet been accomplished, as she is lame and 
lives a long distance from the hospital, and the weather 
bad. When I called on her January 24th, she said, "Why 
did you not wait a week longer, until all was perfectly 
healed over?" But unfortunately to report, as this goes 
to press, she had a fall a few weeks ago, and broke the 
right hip, at the trochanter, probably from lymphatic per- 
meation, and she is laid up, and possibly the end is not 
far off, even before the breast cancer has entirely disap- 
peared. But the results of treatment are conspicuous, in 
the length of life, over five and a half years from the 
beginning of the trouble, and in the perfect comfort she 
has had during the last two and a half years, until her 
accident. 
Many more cases could be cited which had been well 
two, three, five, and more years, in which the cancer could 
be spoken of as really cured, with absolutely no expectation 
of a recurrence, provided the patient lived in such a man- 
ner that there should be no more mutiny of the body cells. 
All this may seem very optimistic, but I have always been 
an optimist in medicine, believing that for everything, 
including cancer, there is a cause, and that while there is 
life there is hope. That the cause of cancer has not been 
earlier determined is a sad reflection on medical genius, 
but is partly explained by the fact that it has been sought 
for by experimentation in the laboratory on lower animals, 
and with the test-tube and microscope, and not enough 
in human beings and at the bedside. 
It may be interesting and instructive to have brief men- 
tion of more recent cases, many of which are still under 
treatment or close observation at stated intervals of weeks 284 
CANCER OF THE BREAST. 
or months. I will, therefore, present them concisely, in 
the consecutive dates of their first coming under treat- 
ment, up to January I, 1923, omitting unnecessary details. 
I want to say again, that without exception, to my knowl- 
edge, the diagnosis has been verified by other competent 
physicians and surgeons. 
Case XXIV. Primary cancer of the left breast. Mrs. 
I. T. G., aged 43, had just noticed a lump in the left breast 
two weeks before her visit on May 7, 1905. This had 
been diagnosed as cancer by at least four medical men, one 
of them a prominent surgeon in Hartford, Conn., who had 
urged immediate operation. When first seen there was a 
hard, sharply defined mass, one and one-half inches in 
diameter, which gave darting pain at times, and was 
painful on light handling. 
With vigorous treatment the change in the tumor was 
remarkable, and at the end of eight weeks it was re- 
corded that there was no trace of the tumor, and that 
both breasts were alike. She was a large, flabby woman, 
weighing two hundred and seven and one-half pounds, 
of the kind that do so badly after operation. With absolute 
faithfulness to treatment she weighed one hundred and 
ninety pounds, two years later, with no return of the 
breast trouble. She was last seen, for another difficulty, 
five and one-half years after her first visit, and both breasts 
were found perfectly normal. 
Case XXV. Primary carcinoma of the left breast. 
Miss T. M. M., aged 37, consulted me on March 23, 1916, 
for a mass in the left breast, which a surgeon of great 
eminence had diagnosed as cancer, urging most strenu- 
ously an immediate operation, saying that from its rapid 
development, she would die within six months if not oper- ANALYSIS OF CASES. 
285 
ated on. She had had a neurasthenic breakdown during 
the previous autumn, and now for some months had 
been under very great nervous strain with a father, aged 
71, slowly dying of Bright's disease. Two years previ- 
ously she had suffered from severe uricacidemia. The 
lump in the upper, inner quadrant of the left breast was 
noticed only a month or two before her visit, and had 
increased rapidly. 
When first seen there was a tumor about two inches in 
diameter, attached to the puckered skin over an area of 
an inch, there was considerable pain, increased much by 
the rather hard handling of the surgeon just referred to. 
There were a number of enlarged axillary glands. 
Under very active treatment, with constant observa- 
tion, and change of remedies as needed, in eight months 
the improvement in her general condition and in the breast 
tumor was very marked. When she then kindly appeared 
at my lecture, at the hospital, she told the audience that 
she "felt a thousand times better." Her color was ex- 
cellent, she had held her weight, one hundred and fifty- 
three pounds, a trifle above that called for by her height 
and age, and all this in spite of heavy daily office work, 
and very great trouble and anxiety about her father, who 
died in October. 
The breast was then soft, with still a lump, hardly one- 
half the original dimensions, the area of attached skin had 
diminished in size, with only a slight dimpling, and the 
enlarged glands had disappeared. She went on a trip to 
Chicago, by auto, slept perfectly, and had no pain. Ten 
months after her visit she had a very severe attack of 
grippe, being in bed three weeks in another city, and this, 
with many weeks of neglect of treatment set her back a 286 
CANCER OF THE BREAST. 
little, and she was lost sight of fourteen months after she 
had been given but six months to live by the surgeon, she 
being healthy and happy all the time, and never missed a 
day's office work. 
Case XXVI. Primary cancer of the right breast. Miss 
C. M. S., aged 35, was first seen January 15, 1917. Six 
months before she had had a hard blow on the right breast, 
which soon enlarged and was painful; it had been poul- 
ticed and iodex applied. 
When first seen there was a lump the size of an English 
walnut, quite well defined, with darting pain; no axillary 
glands were discovered, though small enlargements devel- 
oped two weeks later, when she had neglected treatment. 
Two months later the right breast was almost the same as 
the left, though there was still a sharp margin in one 
place. When last seen, about eighteen months after the 
first visit, the right breast was normal, but there was some 
caking in the left breast, and a little feeling in both breasts 
during menstruation. This was a difficult case to handle, 
as she had much care, work, and worry running a boarding 
house, with her mother sick at times. She had gastric dis- 
turbance and was much constipated before treatment. 
Case XXVII. Primary carcinoma of the left breast, 
rebellious to treatment. Miss G. D., aged 45, was under 
treatment for eczema, which about disappeared, when on 
January 22, 1917, she called my attention to a large mass 
in the middle of the left breast, just above the nipple, 
which had existed for six months or more. It was the 
size of an egg, hard, with sharp edges, with some adher- 
ence to the skin, and occasionally a sharp, darting pain, 
with moderate axillary glands detectable. She had been 
constipated for many years, depending on a laxative every ANALYSIS OF CASES. 
287 
day, her menses had ceased naturally nine years before at 
the early age of 36; her father had died of cancer of the 
stomach. 
Although she was an intelligent and presumably faith- 
ful patient, under frequent observation, the progress was 
slow, and on October 15th it was recorded that the lump 
was only a little smaller, but still well defined, rather 
sharp edges, and the adenopathy was slight. On January 
31, 1918, the tumor was recorded as smaller, and on 
February 14th that it had much diminished in size. On 
March 21st the mass was less hard, and much less pucker- 
ing of the skin above the nipple. On February 14, 1919, 
the lump was still softer, and no axillary glands could be 
discovered, though there were some small ones in the pec- 
toral fold, and the darting pains had ceased; the saliva 
was yet acid, and the urine still showed a considerable 
diminution in the amount of solids demanded by her 
weight, and the urea was not half the normal. She had 
had an attack of grippe, which pulled her down. August 
27th the breast was softer, and the tumor more movable, 
and no glands could be felt in the axilla. She had been 
complaining of backache low down, for some time, but 
there was no uterine trouble to account for it, and she 
had also been having darting pains in the breast, for 
which she was given x-rays for some weeks, under which 
the lump in the breast seemed to increase, and on Febru- 
ary 27th a very distinct gland the size of a small chestnut 
was found in the axilla. 
She was shortly thereafter given a six weeks' course of 
repeated injections of Williams' proteal treatment1 but 
without any appreciable effect, and I lost sight of her after 
1 Williams: The Protomorphic Theory, etc., New York, 1918. 288 
CANCER OF THE BREAST. 
her last visit, July 26, 1920, after a three and a half years' 
good fight on her part, and have not been able to trace 
her, after repeated letters. I could never find the reason 
for the rebelliousness in this case, which was so excep- 
tional, but it only shows that we have not yet fully reached 
the desired end. 
Case XXVIII. Postoperative carcinoma of the left 
breast, after removal of right breast. Miss H. K., aged 
45, first seen December 17, 1917, had noticed a lump in 
the right breast in April, 1915, which was removed sur- 
gically within three months, with a good axillary opera- 
tion. About the middle of June, 1917, she noticed a lump 
in the left breast, in the outer, lower segment. 
When seen there was a tumor the size of an egg, hard 
and with some irregular nodosities, the glands along the 
pectoral muscle were enlarged, with some doubtful axil- 
lary adenopathy. She was always constipated, and the 
saliva was acid, the menopause had not yet occurred. 
Placed on strict, proper diet and medication, she was very 
faithful, and though living in a distant city coming many 
times to New York for treatment, within a few months 
the tumor was recorded as materially smaller and softer, 
and no adenopathy could be detected. Later letters stated 
that she "felt very well indeed" and remained free from 
her breast trouble. 
Case XXIX. Recurrent carcinoma in the left breast 
two years after complete operation on the right. Miss H. 
K., aged 45, was sent to my office by Dr. Skiff, of Falls 
Village, on December 17, 1917. In April, 1915, a lump 
appeared in the right breast, which was very thoroughly 
removed, with a good axillary scar on July 14, 1915. 
About the middle of June, 1917, she noticed a lump in the ANALYSIS OF CASES. 
289 
left breast, for which she was sent from a distant town 
to me, six months after the mass was found, although 
several surgeons had urged an immediate and radical 
operation, and had given only some months to live unless 
operated on. 
On examination there was found a tumor the size of 
an egg, hard, a little irregular, with some nodosities, in 
the outer upper segment of the left breast, with enlarged 
glands along the pectoral fold, and some doubtful, small 
glands in the axilla. She was in poor condition, weighing 
one hundred and eighteen and one-half pounds, pulse, 
112 and weak, and very constipated, depending on a 
daily laxative, the saliva moderately acid; the menses 
were still regular, every four weeks. Under full treat- 
ment, at occasional visits to the city, there was found 
steady improvement and on June 12, 1918, the mass was 
less hard, and no enlarged glands could be found. On 
January 16, 1919, the tumor was less in size, no glands 
could be detected, and she "has not been so well for years," 
the same note being made on November 20th. On Febru- 
ary 3, 1921, she weighed more than at her first visit, the 
breast was normal, with no trace of the tumor or of lym- 
phatic nodes. When last seen, June 23, 1921, the condi- 
tions were the same, she has remained perfectly well, and 
free from cancer, nearly five years after she was given a 
few months to live. For, in answer to a letter she wrote 
on September nth, 1922, that she was still perfectly well. 
There is, of course, no possibility of further trouble, as 
she is a very sensible person and obedient patient, follow- 
ing all directions perfectly, for six years. 
Case XXX. Primary carcinoma of the left breast 
Mrs. K. S., aged 28, August 14, 1918, no children. Mass 290 
CANCER OF THE BREAST. 
size of an egg existed below the left nipple, which was 
retracted. No axillary glands were found, but some nodes 
in the pectoral fold. She was a very intelligent and obedi- 
ent patient, and under very strict and complete treatment 
it was recorded on December 16th that nothing could be 
felt in the breast, and no lymphatic glands, and on May 
28, 1919, a surgeon visiting in the office could not decide 
which breast had been affected. She has been seen repeat- 
edly at stated intervals, with moderate treatment, and 
when she last called, March 14, 1923, she was in fine 
condition, and over four and one-half years after her first 
visit there was absolutely no trace of the lump, no adenitis, 
though the right breast had some chronic mastitis; she 
weighed one hunderd and one and one-half, her weight at 
the first visit being ninety-seven and one-half pounds. 
Case XXXI. Primary carcinoma of the left breast. 
Mrs. G. K. L., aged 59, the wife of a physician, was first 
seen August 30, 1918. Four years previously a lump was 
noticed in the inner upper quadrant of the left breast, 
after a slight blow some time before. Since then the breast 
has felt heavy, and gradually the tumor has increased in 
size, until it was about three and one-half inches in diam- 
eter, hard and characteristic, with some enlarged glands 
in the axilla. Under very strict diet, with medication, in 
three months the mass had diminished one-half in size and 
was much softer; she had gained four pounds, was of good 
color, and felt better than for a long time. Seen rather 
recently the breast was entirely normal and the adeno- 
pathy gone, three years after the first visit, and there is 
no reason why she will not remain cured of her trouble, 
as she is a very intelligent and faithful patient. ANALYSIS OF CASES. 
291 
Case XXXII. Primary carcinoma of the right breast, 
Mrs. C. W., aged 40, no children, was first seen April 18, 
1919, for a tumor in the right breast, which had been 
developing for a year, beginning with soreness and aching, 
but no sharp or shooting pains. When seen there was a 
flat, sharp-edged mass across the middle of the right 
breast, three by four inches in diameter, not adherent to 
the skin; in the left breast there was some general chronic 
mastitis, with no axillary adenopathy on either side. On 
July nth the mass was much softer, and more indistinct, 
on September 4th the breast was still softer, and she was 
"feeling particularly well," and when last seen, October 
yth, there was still further improvement and she had 
gained several pounds. Since that time I have seen her 
husband frequently up to present writing, at a bank trus- 
tees' meeting, and he always reports her as very well, and 
without any breast trouble, after four and a half years. 
Case XXXIII. Primary carcinoma of the right breast. 
Mrs. C. B. G., aged 35, seen November 13, 1919, three 
children, thirteen, ten, and six. Ten days before her visit 
she felt pain in the right breast, running down the arm, 
and a lump the size of a small nut, in the upper, outer 
segment. It was fairly hard but moveable, and no axillary 
glands could be discovered, but about 2 months later a 
small, moveable gland was detected below the right axilla. 
Under active treatment the mass gradually softened but 
did not entirely pass away until October 1, 1921, when 
nothing could be found in the breast or axilla. Seen re- 
peatedly and examined, to the present time, she remains en- 
tirely free from all manifestation of the disease, and 
weighed one hundred and ten pounds, not long ago, her 292 
CANCER OF THE BREAST. 
previous weight being one hundred and a quarter; well 
three years and more after her first visit. 
Case XXXIV. Primary carcinoma of the left breast. 
Miss M. H. M., aged 45, seen March 20, 1920, had had 
an operation for uterine fibroid in February of the pre- 
ceding year. In June, 1919, a mass the size of a bean 
was discovered in the left breast, which disappeared under 
some non-surgical treatment, but leaving a generally lumpy 
condition of the breast, with a definite mass beneath the 
nipple, for which her surgeon sent her to me. An immedi- 
ate operation was advised by several physicians and sur- 
geons, but declined. 
When first seen the left breast was markedly larger than 
the right, with a* well defined mass, about one and three- 
quarter inches in diameter, quite hard, fairly movable, and 
an axillary enlarged gland, the size of a split almond. 
Under full treatment the lump in the breast became con- 
tinually smaller, as also the axillary gland, and on Septem- 
ber 9, 1920, it was recorded that the breast was normal, 
and no trace of the axillary gland could be found. Being 
seen repeatedly there was sometimes found more or less 
diffused chronic mastitis in both breasts, but no trace of a 
tumor nor any adenopathy. Her weight rose from ninety- 
five pounds, in January, 1921, after a hard school year, to 
one hundred and seven in March, and on August 25, 1922, 
in answer to a letter, she wrote that she remained well, 
with absolutely no breast trouble, almost two and one-half 
years. 
Case XXXV. Primary carcinoma of the right breast. 
Mrs. R. R., a widow, aged 52, who had had six children, 
whose menses had ceased three or four years ago, noticed ANALYSIS OF CASES. 
293 
a small lump, with twinges of pain, in the right breast 
three weeks previous to her first visit, April 12, 1920. 
On examination a tumor about three by four inches, 
fairly hard, was found above the right nipple, for which 
she expected to go to the hospital for immediate surgical 
removal as had been urged. On July 22d it was recorded 
that the breast was almost normal, with no painful sen- 
sations, as at first, and no adenopathy, as also on June 
10th. She kept her weight and strength excellently, and 
when last seen, July 14, 1922, she had gained much flesh, 
weighing one hundred and ninety-one and a* half pounds, 
felt excellently well, and with no trace of the tumor or 
adenopathy. 
Case XXXVI. Primary ulcerative carcinoma of the 
right breast. Mrs. F. I. G., aged 58, seen first October 6, 
1920, no children, menses ceased in 1907. Nine years ago 
she fell and struck the breast, but had no trouble for years, 
although latterly small lumps developed, which continued 
and opened up six months ago, and discharged since, with 
some pain but no great distress. When seen the right 
breast, in the lower middle, was the seat of a hard mass, 
about three by four inches in diameter, with a greatly 
retracted nipple and axillary adenopathy. In three months 
there was very material change in the breast, the hardness 
was gone from above, the ulceration much decreased, and 
the adenopathy decidedly less, as noted by a surgeon who 
watched the case with me. Six months later she looked 
the picture of health, with bright eyes and excellent color, 
and soon it was recorded that the breast had greatly im- 
proved, and as she said "wonderfully soft." 
As she lived some distance from the city I could not 
see her as often as wished, and with a sick daughter and 294 
CANCER OF THE BREAST. 
husband the treatment was probably neglected somewhat, 
and the disease increased some, with more ulceration and 
increased axillary involvement, with swelling of the arm. 
But under renewed activity of treatment there was again 
improvement, the arm became of normal size and the 
breast softened more. Again, however, with household 
trouble she became nervous and run down, and the solids 
in the urine diminished to one-third the normal for her 
body weight, though later they rose to considerable above 
normal, under caffein. But household troubles were prob- 
ably too much for her, and when last seen January 19, 
1920, she showed signs of lymphatic involvement within 
the chest, and disturbance in several directions, though the 
breast was still softer. While adverse circumstances pre- 
vented the full and expected benefit from medical treat- 
ment, she has had over two years of real comfort and 
great activity, with no pain, and no opiate, whereas under 
the usual course of the disease she would probably have 
been in her grave some time ago. 
Case XXXVII. Postoperative carcinoma of both 
breasts. Mrs. G. E. K., aged about 47, first consulted me 
late in 1920, on account of a mass in the right arm 
which developed some months after the removal of both 
breasts for cancer. This mass had been excised several 
months after its appearance, but soon returned. She had 
had trouble with the left breast, called mastitis, for over 
11 years, and late in 1916, a right hard lump appeared, 
and early in 1918, both breasts were removed, as a similar 
condition had developed in the right breast shortly before ; 
the breast lesions were determined microscopically to be 
carcinomatous. Since the last operation she had had much 
pain in the recurrent mass, and in the whole right arm, ANALYSIS OF CASES. 
295 
preventing sleep. She had been on my "green card" diet 
for some time before consulting me, which had the result 
of overcoming the chronic constipation and relieving the 
pain, so that she slept. Being placed under full dietetic, 
hygienic, and medicinal treatment she wrote a month later 
very enthusiastically that she had been more comfortable 
then than for a long time, and a later letter from Los 
Angeles states that she "has not been so well for many 
years." 
Case XXXVIII. Postoperative carcinoma of both 
breasts. Mrs. F. D. J., aged 48, November 9, 1920. For 
ten years she had had trouble with the left breast, said to 
be mastitis, until a bullet-like lump appeared in November, 
1916; this was pronounced cancer, when the lump became 
hard as a stone, and the breast grew much larger, and 
shortly the right breast became like the left. Then in 
May, 1918, both breasts were amputated, after apparently 
a biopsy confirming the cancerous nature. Eight months 
after the operation a lump appeared in the right axilla, 
near the operation scar, which was removed surgically six 
months later, but recurred, with great pain in the arm. 
Under very active treatment it was recorded, on Janu- 
ary 19, 1921, that there was a very great change in her 
condition, which "all thought wonderful." The pain had 
ceased, so that no more aspirin was needed, and the mass 
was smaller and softer. She then went far west for 
two months, and her letters were almost foolishly enthusi- 
astic; on her return home she had gained eight pounds, 
and on May 26th it was recorded that the lump had de- 
creased in* size rapidly, but was not quite gone, she had 
absolutely no pain. To make a long story short, on Octo- 
ber 10th it was recorded by a letter "Happy to tell you that 296 
CANCER OF THE BREAST. 
I am well, never pain at any time and all lumps have 
disappeared," and again in answer to my letter she wrote, 
on January 4, 1923, enthusiastically, "I remain perfectly 
well." She still continues her diet and right mode of 
living, sleeps like a healthy child and is very active, weigh- 
ing one hundred and thirty-eight pounds. She calls it 
"a miracle," when she looks back on what she had gone 
through, and the perfect comfort during the twenty-six 
months since treatment first began. 
Case XXXIX. Primary carcinoma of the left breast. 
Mrs. M. R. B., aged 46, a very cultivated lady school 
teacher, was first seen March 22, 1921, weighing one hun- 
dred and ten pounds. About February 8th, while bathing, 
she noticed a small lump in the lower segment of the left 
breast, which had remained and increased steadily, until 
when first seen it was the size of half a lemon, hard and 
nodular; the bowels were habitually constipated, requiring 
a laxative, and the saliva acid. On rigid treatment it was 
recorded that the mass grew steadily softer and smaller, 
until on June 27th it was not one-quarter the size. Dur- 
ing the very hot weather, and with hard school work the 
weight ran down tor one hundred and three and one-half 
on August 8th, but under reconstructive treatment it rose 
to one hundred and seventeen and one-half on December 
5th, and on January 26, 1922, it was one hundred and 
eighteen, and the record made that no trace of the tumor 
could be found. On June 9th, in answer to a letter she 
wrote that she was very well, better than ever at the close 
of a school year, and on October 26th it was recorded that 
there was no trace of the disease and she weighed one 
hundred and thirty-one. Seen recently, March 8th, 1923, 
the breasts were perfectly normal, she weighing one hun- ANALYSIS OF CASES. 
297 
dred and thirty-one and one-half pounds, more than ever 
in her life, and on December 4th she was still perfectly 
well. There can be no question as to an absolute cure in 
such a case, if she persists in doing the right thing. 
Case XL. Primary carcinoma of right breast, with 
chemical removal. Mrs. H. A. E., aged 48, seen first, 
May 20, 1921, struck the breast eight or nine months 
previously, and it had felt sore off and on since. Four 
months before her visit she noticed a depression in the 
skin and a hardness below. When first seen there was a 
"pig skin" area an inch in diameter, in the middle, three 
inches above the nipple, and a hard mass two inches in 
diameter, in either direction, flat and somewhat nodular 
on the edges and with some aching pain, but no adeno- 
pathy could be detected in either axilla or supraclavicular 
region. Her sister had a malignant sarcoma, and a 
grandmother died of breast cancer. 
Under proper treatment, and painting the breast with 
ichthyol, 50 per cent., the pain ceased shortly, as also 
the sick headaches, which she had had since a child, and 
the mass became softer, by August 18th, the puckering 
remaining. In spite of faithful treatment, with changes of 
remedies to meet varied conditions the breast ulcerated a 
little, and a few cutaneous nodules appeared, showing 
lymphatic permeation; she had also occasional, moderate 
pains, running up to the axilla, but no enlarged glands 
could be found. Wearying of the prolonged treatment, 
and yielding to the persuasion of others, she and her hus- 
band desired operative interference, and I finally consented 
to have the chemical removal done by Dr. Strobel; but as 
he had just gone abroad another person performed it, in 
July, without my permission, and with great pain and 298 
CANCER OF THE BREAST. 
slow healing. During quite a long period in the hospital 
the diet and internal treatment were omitted, and presum- 
ably since, as I have, not seen her medically since he 
captured the- case, as the surgeon who did the Strobel 
removal does not believe in my treatment. Writing to her 
I learned, on January 17, 1923, that she seemed very well, 
but that the arm still gave her great pain, making it hard 
to write; for this she had been taking x-ray exposures, 
but with apparently little effect. 
Case XLI. Primary carcinoma, of the left breast. Mrs. 
B. A. L., aged 42, came first, June 25, 1921. About seven 
weeks previous she noticed a depression on. the outer side 
of the left breast, and three weeks later a hardness. She 
had seen several surgeons, all of whom advised surely an 
operation, but'her brother, a physician, sent her to me; she 
had been dieting from the "green card" for three weeks 
and felt better in every way, with some diminution- in the 
lump. The urine was acid, specific gravity, 1010, with 
low urea, and only one-half the proper amount of solid 
excreta, and the saliva acid. The tumor in the middle 
segment of the right breast was two by three inches, and 
with moderate axillary adenopathy. 
Under active treatment she improved greatly in her 
general condition, losing her great nervousness, never tak- 
ing an opiate or sedative, and the tumor steadily softened 
and diminished in size, and though still adherent to the 
skin was less so by September 20th. On March 23, 1922, 
the mass was smaller and no adenopathy could be discov- 
ered, though later a slight, movable gland was detected; 
there was no pain, and she "felt ten years younger." 
When last seen, February 13, 1923, the mass had become 
much softer, with a lump only at the upper, outer aspect, ANALYSIS OF CASES. 
299 
still a little hard and protuberant, but less so, and the 
axillary gland hardly perceptible. She. was much worried 
about a swelling on the upper part of the scapula, which 
proved only to be a lipoma. 
Case XLII. Primary carcinoma of the left breast. 
Mrs. T. J., aged 24, first seen July 7, 1921. While nurs- 
ing her second child, five weeks old, she had had a sore 
nipple three or four weeks before her visit, when an abscess 
formed which- was freely lanced, leaving an open sore. 
When, first seen most of the left breast was red, hot, 
tender, with an acute mastitis, with' an ulcerative opening 
beneath the nipple, from the incision, stuffed with gauze, 
dressed' by the doctor daily. The relief expressed was 
very great when the wound was covered with the calamine 
and zinc ointment, spread on a thin layer of absorbent 
cotton, and the inflammation soon subsided and the wound 
healed, under proper internal measures as well. 
Some months later, when the inflammation had en- 
tirely subsided, and the baby was nursing from both 
breasts, a- small hard mass developed in the left breast, 
below the nipple, not at all inflammatory, and a decided 
lymphnode in the left axilla, as recorded on December 5, 
1921. Being placed on rigid treatment a note was made 
on March 20, 1922, that the tumor was smaller and softer, 
and the axillary node had disappeared. She weighed one 
hundred and thirty pounds, as against one hundred and 
fifteen for her height and age. Written to twice she did 
not respond and. presumably remained well. 
Case XLIII. Primary carcinoma of the left breast. 
Mrs. L. W., aged 23, first seen August 23, 1921. For a 
year she had had a lump in the upper outer segment of the 
left breast, remaining about the same, with dragging pain CANCER OF THE BREAST. 
300 
all the time. She had one child, five years old, and had 
no trouble with the breasts in nursing for a year. A 
maternal aunt had cancer of the breast, operated on three 
years ago, with a recurrence in the neck a year later. 
Another aunt had the breast removed for cancer four 
years ago, and has been under radium since, and was 
about to have another operation for recurrence. The 
patient had long had serious family trouble, together with 
prolonged sickness and death in the family, but has borne 
the nervous strain nobly. 
When first seen there was a tolerably hard, well defined 
lump about an inch and a half by one inch in diameter, 
with moderate adenopathy in the left axilla and pectoral 
fold, and some chronic mastitis in both breasts. Under 
active treatment it was recorded on November 9th- that 
the lump in the breast had disappeared, but the slightly 
enlarged gland in the axilla was still present, and some 
chronic mastitis in both breasts. By March 15, 1922, the 
axillary node could not be detected, nor the original tumor, 
though there was still some general mastitis in. both breasts, 
and when last seen, September 12, 1922, all was the same. 
Her weight when first seen was one hundred and sixteen 
and one-quarter pounds, and it had risen to one hundred 
and twenty-three and one-half, on March 15th. 
Case XLIV. Primary carcinoma of the left breast. 
Miss L. G. (colored), aged 40, first seen November 2, 
1921, had begun to have strange feelings in the left breast 
in July, with uncomfortable but not severe pain. On 
examination there was a sharply defined tumor below the 
nipple of the left breast, about two inches in both diam- 
eters, not painful on moderate manipulation, and with 
some doubtful axillary adenopathy, which shortly became ANALYSIS OF CASES. 
301 
more definite, and with some irregular mastitis lumpiness 
of both breasts. On June 9, 1922, it was noted that the 
breast was almost normal, but a very slight node could yet 
be detected low in the axillary space. On October 5th the 
tumor was recorded as smaller, though still characteristic, 
and the axillary gland discernible. In spite of treatment, 
which she claimed to carry out faithfully, a hard mass 
developed in the right breast, but all had entirely cleared 
up when last seen, in- December, 1923. 
Case XLV. Primary carcinoma of the left breast, sub- 
sequently excised. Mrs. R. E., aged 41, a stout and flabby 
lady, seen first November 17, 1921, had noticed a lump 
in the left breast for a year and a half, which had grown 
steadily larger; it has been seen by several physicians and 
surgeons, one especially a cancer surgeon, all advising an 
operation which had been arranged for about the time 
she called, but avoided. She had not been feeling well for 
three years, and ten years previously had passed gall- 
stones, with terrific pain. She had constant indigestion, 
with diarrhea, and very bad sleep, with long periods of 
wakefulness. 
On examination a hard mass, fully three inches in diam- 
eter, was found in the outer middle segment of the left 
breast, adherent to the skin, with nipple drawn in, and 
adenopathy in the anterior axillary fold. I presented her 
at the conference in the Memorial Hospital, and the diag- 
nosis was, of course, confirmed, but I was criticized 
severely for attempting to treat an "operable case." But 
the better judgment of her doctor brother, also a surgeon 
of another hospital, and her uncle, a prominent professor 
of medicine in Budapest, prevailed, and she was placed 
under vigorous treatment. On February 17, 1922, it was 302 
CANCER OF THE BREAST. 
recorded that the tumor was softer and reduced fully one- 
third from the first, the pain had left, and no axillary 
glands could be felt. All went well until she sailed for 
Europe on May 17th, and presumably was unable to carry 
out the dietary restrictions, and neglected the internal medi- 
cation all the time until her return. On her return from 
Europe I was called to see her March 2, 1923, and learned 
that on June 12th the breast had been removed in Vienna 
by Dr. Schmitzer, a very prominent surgeon, with slow 
recovery, and great pain in the healed wound and shoulder. 
Lately she had had much neuralgic pain in the left hip and 
knee, which was possibly from bone metastasis, as it 
turned out to be the fact by an x-ray picture. A sad illus- 
tration of the result of long neglecting proper internal 
measures. 
Case XLVI. Primary carcinoma of the right breast. 
Mrs. S. H. C., aged 48, sent by her family physician and 
surgeon, on December 9, 1921. In the spring she no- 
ticed the right nipple being slowly drawn in, but no medi- 
cal man saw it until her doctor accidentally discovered the 
condition, during an attack of scarlatina, found the mass 
in the breast and sent her to me. 
On examination the right nipple was found greatly re- 
tracted, with a hard, irregularly nodular mass, three inches 
in diameter above it, which was even visible, and a moder- 
ate axillary adenopathy; there was not much pain in the 
breast, but a hot feeling of late. On March 17, 1922, it 
was recorded that the tumor had materially improved, was 
softer and smaller, and the glands in the axilla were 
hardly discernible. The improvement continued, and on 
June 1st the lump was still softer, and hardly one-half its 
former size, and the axillary nodes very small and mov- ANALYSIS OF CASES. 
303 
able, and hardly felt. The mass had begun to ulcerate 
slightly at its upper margin, and a crust had formed, which 
was removed on October 27th, leaving a small, raw sur- 
face, and a small supraclavicular gland had developed. 
On January 18, 1923, there was still a little discharge from 
the raw surface, which was smaller, but the tumor was 
softer all around, and no axillary node could be discov- 
ered, but still some little supraclavicular enlargement. 
When last seen, March 15th, 1923, the mass was still 
softer^ and she was feeling well, and in good spirits. In 
this case the lymphatic permeation persisted in spite of 
treatment, but with increased medication it is expected 
that the disease will yield, as in other cases, for she is 
a very faithful and intelligent lady. 
Case XLVII. Inoperable primary carcinoma of the 
right breast. Mrs. S. E. M., aged 55, with a daughter 
aged 36 and a son 28 years old, first seen December 22, 
1921. Five years previously, after dislocating the right 
foot, she used a crutch which irritated the breast, and 
shortly had a blow over the same. A doctor gave her 
three injections of serum into the breast, and ulceration 
soon occurred, which had been worse the last six months, 
with drawing in of the nipple and sharp, stinging pain. 
She had always had bad digestion, with great constipa- 
tion, depending on a daily enema for many years. She had 
the grip badly two years ago, and asthma since, disturbing 
sleep; and muscular rheumatism for years. The menses 
had been normal until the menopause, four or five years 
previously. 
On examination the outer portion of the right breast 
was found to be drawn down by a hard mass, obliterating 
the nipple, with a hard, immovable gland rather low in the CANCER OF THE BREAST. 
304 
axilla, the size of a large chestnut. She was shown at the 
Memorial Hospital conference on January 19th, and ex- 
amined by Drs. Ewing, Lee, Stone, and others. Being 
placed on rigid treatment, on February 20th the breast 
was softer and the axillary gland smaller, but the right 
arm and hand were somewhat swollen, the urine was 
scanty and dark, and the saliva very acid still; she had 
long had high blood-pressure. On April 24th it was 
recorded that the breast was softer, and the mass some- 
what broken up, and there was no pain, the arm was less 
swollen, also the axillary gland smaller, and she "looked 
and felt better than in two years." 
On June 19th the breast was smaller and softer, the 
gland in the axilla materially smaller and movable, and the 
arm smaller and soft, instead of being hard and swollen 
as before. On August 2d it was recorded that she "hardly 
knows that she has any breast trouble," but has some in- 
crease in her rheumatism, in the knee, which prevented 
her from coming from a neighboring city. When last 
seen, at her home, on January 5, 1923, she was confined 
to a roller chair, but had not relaxed the dietary or other 
treatment for her breast, to which, however, she paid 
little attention, as it gave her no annoyance, although there 
was, of course, still a more or less hard mass in the breast, 
with great retraction of the skin, and some movable adeno- 
pathy in the axilla. 
Case XLVIII. Primary carcinoma of the right breast. 
Miss P. E. M., aged 42; seen first, April 12, 1922, was 
said to have first noticed a lump in the right breast ten 
years previously, which had remained, slowly increasing, 
but causing no uneasiness. She had long been consti- 
pated, with hemorrhoids, depending on nujol, and sleeping ANALYSIS OF CASES. 
305 
badly, with much wakefulness. When first seen there 
was moderate chronic mastitis in both breasts, and a hard, 
characteristic mass one by two inches in diameter in the 
lower, outer middle portion of the right breast, with some 
glandular enlargement, along the anterior fold of the axilla, 
later a small movable node was discovered in the axilla. 
Under full treatment, on August 3d, all pain in the right 
breast had ceased without any opiate, nothing could be 
found in either axilla, but a small gland had developed in 
the left side of the neck. On October 17th the right 
breast was apparently normal, but a hard mass one inch 
and a half in diameter had developed in the left breast, 
with some little biting pain. When last seen, March 3, 
1923, a little of the hard mass could be felt in the right 
breast, but there was no axillary adenopathy anywhere, 
she had kept her weight, as at first, one hundred and 
thirty-three and one-half pounds, and had been actively 
engaged in teaching a rather troublesome class. 
Case XLIX. Primary carcinoma of the left breast. 
Mrs. H. M. J., aged 48, with no children, was sent to me 
by her brother, a doctor, April 17, 1922. She had acci- 
dentally noticed a lump in the left breast only the day be- 
fore, having had a blow on the breast in November. She 
had always been constipated, depending daily on medi- 
cines, had had inflammatory rheumatism as a child, and 
chronic rheumatism off and on all the time since; the 
saliva was very acid, and she was much troubled with 
headache; the menses were still regular but diminishing 
in quantity. 
When seen there was a hard, sharply defined mass, two 
inches in diameter, beneath the nipple, which was not yet 
retracted, and a moderate sized, movable node in the 306 
CANCER OF THE BREAST. 
axilla, with some glandular enlargements in the pectoral 
muscle fold. The urine was fair in quantity, but the 
solids excreted were considerably less than called for by 
her weight. Later the average daily quantity was in- 
creased, but it was hard to bring the solids up to a normal 
standard. On June 16th it was noted that the tumor was 
certainly smaller and softer, and had lost some of the 
nodular edges; the axillary node was hardly detectable, 
but there were still some very small nodes in the pectoral 
fold. On September 6th it was recorded that the mass in 
the breast was hardly one-third the size at first, and the 
axillary gland could hardly be discovered. On January 23, 
1923, the lump in the breast seemed still smaller, and 
rather irregularly broken up; no axillary adenopathy could 
be discovered, but a questionable node had developed in the 
sixth rib, a little tender on pressure, which was relieved 
by painting continually with 50-per cent, ichthyol. When 
last seen, March 20th, the mass seemed smaller, a very 
small, movable gland could be detected in the left axilla, 
and also one in the pectoral fold. Her menses had ceased 
for two months. She is a very intelligent lady, perfectly 
faithful to treatment, and is still under observation at 
stated intervals, and from experience there is no doubt 
but that all the trouble will be gone in some months more, 
not to return if she is faithful. 
Case L. Primary carcinoma of the left breast. Miss 
M. S. A., aged 63, an old acne indurata patient, not seen 
for many years, came on May 6, 1922, on account of a 
lump in the left breast which had existed for a good many 
years, but which gave no trouble until three months previ- 
ously, when she had pain under the arm. She had been a ANALYSIS OF CASES. 
307 
great meat eater, had been very constipated, depending on 
medicine and a bad sleeper. She had long had high blood- 
pressure, 200 systolic. 
When first seen there was a mass two by three inches, 
hard, and with nodular edges, in the lower segment of the 
left breast, and darting pains, like needles, here and there; 
there were no axillary nodes but some in the pectoral fold. 
On July 29th it was recorded that the tumor was smaller 
and softer, and no glands could be felt; the right breast 
had still considerable chronic mastitis. On September 
23d there was hardly a trace of the tumor and no adeno- 
pathy ; her weight was one hundred and sixty-three 
pounds, which was more than that called for by her 
height and age. When last seen, on March 3, 1923, there 
was still a little infiltration in the lower part of the left 
breast, not hard, but no adenopathy could be discovered. 
Case LI. Postoperative carcinoma of the left breast, 
recurring in the right breast. Mrs. W. M., aged 40, who 
had had three children, 17 to 5 years, and no miscarriages, 
and whose menses were still regular and normal, first 
noticed a lump in the left breast, eleven months previous 
to her visit; this was removed September 22, 1921, and 
the disease appeared in the right breast nine months later, 
when another operation was urged by her surgeon, but 
refused, and I saw her six weeks later. 
On examination, June 1, 1922, there was a good scar of 
a complete operation on the left side, but with still some 
slight remaining left axillary adenopathy. The right 
breast was the seat of several hard masses, with much ir- 
regular mastitis, and axillary adenopathy. There was a 
large area of telangiectasia over the left upper chest and 
neck triangle, caused by x-ray, with some breaking down 308 
CANCER OF THE BREAST. 
points in it. On August 8th it was recorded that there 
was still a hard lump in the right breast, above the nip- 
ple, and moderate adenopathy still in the left axilla. On 
November 15th there was still a node the size of an 
almond in the left (operated) axilla, and two were found 
on February 8, 1923, when her weight was one hundred 
and fifty-two and one-half pounds, more than at her first 
visit, and considerably more than called for by her height 
and age. When last seen, March 21st, there was still a 
little sticking pain in the right breast, but the tumor was 
really gone, as also the chronic mastitis, although there 
was yet a movable gland, low in the right axilla, as also 
one in the left axilla. She was in fine health and spirits, 
and the telangiestatic condition and local degeneration on 
the left chest had greatly improved under local treatment. 
Case LII. Primary carcinoma of the left breast. Miss 
H. L., first seen July 6, 1922, after rather violent exertion 
noticed a small lump in upper outer quadrant of the left 
breast, which remained, slowly increasing until her visit. 
She had always been constipated, depending on medicine, 
with frequent bilious attacks and irregular and painful 
menstruation. On examination there was a flat mass, an 
inch in diameter, hard, and slightly adherent, and some- 
what painful on handling; some doubtful adenopathy. On 
October 30th the mass was softer and smaller and no 
adenopathy could be detected. On February 13, 1923, it 
was recorded that the mass was not one-third its first size, 
there were no sensations in it, and no adenopathy could be 
detected; she weighed one hundred eleven and one-quarter 
pounds, more than ever before. When last seen, March 
26, 1923, the mass was softer and more irregular in shape,. ANALYSIS OF CASES. 
309 
with no .adenopathy. Seen several times to date there 
was steady improvement in every direction. 
Case LIII. Inoperable primary carcinoma of the left 
breast. Mrs. G. J., aged 48, seen first September 14, 1922. 
In March she had noticed a small lump in the left breast 
and went to the Memorial Hospital in March, when an 
operation was advised, and repeated pre-operative x-ray 
exposures made up to June; after this she experienced 
much pain, with bad general feelings, and the mass in- 
creased steadily in size. As far as I could learn nothing 
more was done until she came to see me six months after 
beginning the x-ray. She had had three children, two are 
living, aged 25 and 23 years, one died between; they were 
nursed about three months when the nipple failed. She 
had been habitually constipated and had taken medicine 
every other day, for twenty years, she was a bad sleeper, 
and always nervous; the menses had been regular, but 
always two weeks late, and they were still the same. 
On examination the outer, middle segment of the left 
breast was occupied by a hard mass, two inches in diameter 
in each direction, the skin, adherent and puckered over it, 
with several cutaneous nodules, and the nipple retracted; 
an enlarged gland in the left axilla was recorded. On 
October 14th it was recorded that the tumor was smaller 
and softer, and had lost some of its hard, nodular margin, 
and the gland in the axilla seemed smaller. On December 
16th the mass was about the same, but the gland in the 
axilla was small and movable, the nipple seemed less re- 
tracted, but she had some pain in it and a little crusting, 
which later disappeared, under local treatment, by her 
next visit. On January 27, 1923, the lump was recorded 
as less hard, and the axillary adenopathy the same. When 310 
CANCER OF THE BREAST. 
seen, March io, 1923, the mass was less in size, still 
adherent to the skin, and with two movable glands in the 
axilla. She weighed one hundred and thirty-six and one- 
half pounds, which was more than that called for by her 
height and age. When first seen she was stout and flabby, 
and the weight was purposely reduced somewhat, to the 
great improvement in her general feelings; her sleep has 
become good during these six months, and in a year more 
she will probably overcome her disease entirely, for she is 
a very good patient, adhering strictly to every detail of 
treatment. 
She was sent for, and presented at the conference of the 
Memorial Hospital, on March 28th, without my permission, 
she being my private patient, and medical treatment was 
criticized, as the small mass of a year ago had become an 
inoperable cancer; whereas the real truth was that the small 
tumor observed there in March, 1922, was increased by 
the x-ray exposures until she came to me on September 
14th, six months later, entirely inoperable, since which 
time there had been great improvement. When last seen 
on March 30th, there was still greater improvement. 
Case LIV. Rebellious ulcerative primary carcinoma of 
the right breast. Mrs. A. D. R., aged 49, who had had 
two children, 16 and 10 years of age, and two miscarriages, 
and whose menses were recently becoming irregular, was 
sent to me by her physician, October 27, 1922. For ten 
months there had been a lump in the right breast which 
had been increasing fast until seen. She had always been 
constipated and with bad digestion, and poor sleep. 
On examination, in the outer, upper quadrant of the 
right breast there was a mass two by two and one-half 
inches in diameter, with a large lymph node on the side, ANALYSIS OF CASES. 
311 
three or four inches below the vault of the axilla, and 
also in the pectoral muscle. Upon the upper and outer 
portion of the tumor there was a raised, red area, about an 
inch in diameter, which afterwards was the base of much 
ulcerative trouble. On December 26th, the main tumor 
was possibly a little larger, but the edges were softer and 
less conspicuous, while the originally ulcerated area had 
broken down more. By February 6th, a nodule of some 
size, painful on pressure, had developed on the sternum, 
also a little metastasis in one of the upper ribs, both of 
which subsided slowly under ichthyol, 50 per cent, solu- 
tion. On March 6th, it was found that the breast tumor 
had hardened at its lower portion, and there was still the 
inflamed and ulcerated upper mass, which bled some. But 
it was recorded that she "feels wonderfully well," she 
weighed ninety-two and one-quarter against eight-nine at 
her first visit, and eighty-two pounds at her marriage; her 
color was excellent, and friends remarked that she looked 
better than for years; she was active in home and charit- 
able affairs, and yet in some directions the disease seems 
to be increasing by lymphatic permeation. On April 3d 
she was seen, when the breast was a little worse, with 
more redness at the side and hardness below, but she was 
still in good spirits, trying to forget her trouble, but 
adhering faithfully to the remedial measures. She has 
never had much pain in the breast, and of course has 
never had an opiate. 
The future of this case cannot be prognosticated; it is 
certainly a great exception to the mass of primary cancers 
of the breast which have been seen, and corresponds to 
some of the acute or fulminating carcinomas described in 
the pathological books, ending life within six months, and 312 
CANCER OF THE BREAST. 
shows that we have not yet quite reached the goal in con- 
trolling this dire disease. But there is no question that 
the course has been far different from what it would have 
been without proper medical attention, for during these 
over six months it has made relatively slow progress, and 
when last seen, May ist, she was in far better condition, 
weighing more than when she began treatment; she is the 
picture of health, bright and happy, with a very good color, 
sleeping perfectly, active in household and philanthropic 
work, nearly a year after the commencement of a disease 
which is said to end life in six months. 
Case L.V. Primary carcinoma of the left breast. Mrs. 
W. N., aged 40, whose mother and maternal uncle both 
died of cancer, was sent to me from Stamford by her 
physician, on November 1, 1922. On October 20th she 
had noticed a lump in the upper segment of the left 
breast, with also some sticking pains in the right breast. 
She was in poor condition, from long continued indiges- 
tion and constipation, taking laxatives every day, pulse 92, 
and the saliva was moderately acid. 
On examination there was a tumor three-quarters by 
one and one-half inches in diameter, with some skin at- 
tachment and dimpling, but no adenopathy could be dis- 
covered in the axilla, though there was an enlarged in- 
guinal gland, the size of a walnut, for which no cause 
could be found. Living in another city she did not return, 
and in response to a letter to her physician I learned that 
she consulted a surgeon, who removed the breast with 
axillary glands, contrary to his advice, and since then the 
patient had been "suffering very badly with a swollen 
arm, which is very troublesome." ANALYSIS OF CASES. 
313 
Seen again on April 14, 1923, there was a good scar 
from a complete operation, including the axilla, performed 
in a hospital on November 12th. But there was still an 
enlarged gland in the same left axilla and pain in the 
supraclavicular regions, with some swelling, but no dis- 
tinct glands could be discovered. The left arm was much 
swollen and painful, measuring twelve inches, against 
nine and one-quarter of the right arm. She had neglected 
the diet and medicine, following them only a few days 
after her visit, as the surgeon did not believe in them. 
She was still much constipated, with deranged menstrua- 
tion. Realizing the situation she gladly returned to active 
treatment, and consequent improvement along every line. 
Case LVI. Ulcerative primary carcinoma of the right 
breast. Miss K. A. E., aged 54, was seen first, November 
15, 1922. For two years and two months she had had a 
small lump in the right breast, with mild, transient, shoot- 
ing pain for two years, without any history of injury; but 
for four months there had been a raised mass on it, which 
had ulcerated during the last two or three months. Eight 
days previous to her visit a surgeon had advised an opera- 
tion, and another surgeon the same, the day before her 
visit. 
On examination there was a hard, characteristic nodular 
tumor, three by three and one-half inches in diameter, in 
the upper, outer quadrant of the right breast, with a 
raised, ulcerating and bleeding mass an inch and a half 
in diameter, with a retracted nipple, and one almond-sized 
node high up in the axilla; she had occasional shooting 
pain in the neoplasm; the saliva was very acid; the meno- 
pause had occurred ten years ago. Under proper internal 
and local measures, on December 15th, it was recorded 314 
CANCER OF THE BREAST. 
that she was feeling very well, there was no more bleed- 
ing and the raw surface was glazed over, and the axillary 
gland was possibly smaller and very movable. On January 
12, 1923, the tumor was reduced in size and movable, not 
adherent to the tissues below, nipple still retracted, and 
the axillary gland smaller and movable. On February 
23d, the whole tumor was smaller and softer, with still 
the protuberant mass, which had bled several times, and 
with the axillary gland smaller and very movable, and she 
was in very good health and spirits. 
When last seen, April 3d, she had just returned from 
Florida, and a partial neglect of dietary and other treat- 
ment had resulted in a little more trouble, in the way of 
bleeding, and some nodular condition of the tumor. She 
is a very intelligent lady, and generally faithful to direc- 
tions, and will undoubtedly again respond to the change 
of treatment given. 
Case LVII. Carcinoma of the right breast, after re- 
moval of the left. Mrs. F. A. A., aged 52, first seen 
November 20, 1922, had had a lump in the left breast for 
three months, when it was removed on November 20, 
1920, by a complete axillary operation. In March, 1922, 
a mass the size of a hickory nut developed in the right 
breast. She was placed on my diet by her medical attend- 
ant on April 10th, and the lump grew smaller until it 
was gone by the end of July. She had a son very sick 
for a long time, causing her to forget her trouble until 
six weeks before her visit when she had great soreness 
in the right breast, which passed off on resuming treat- 
ment, until a week before her call, when there was sore- 
ness to the touch, the nipple became painful, and the right 
arm aching. ANALYSIS OF CASES. 
315 
On examination there was a good operative scar into 
the axilla, on the left side, with no signs of recurrence. 
But on the right breast just above the nipple there was 
a tolerably characteristic mass with nodular edges, not 
then painful on moderate handling. Being seen several 
times there was a steady improvement in the tumor, and 
when last seen January io, 1923, it was recorded that the 
mass was better, softer and smaller, and no adenopathy. 
There was still pain in the left shoulder from the opera- 
tion, the arm having become swollen a year after the 
operation. 
Case LVIII. Paget's disease of the right nipple. Mrs. 
I. W. I., aged 48, was sent to me by her physician, Sep- 
tember 25, 1919. For about two years she had noticed 
soreness about the right nipple, with rawness, which had 
gradually increased, until there was an area affected the 
size of half a dollar, and an immediate surgical removal 
had been urged by a New Haven surgeon. 
On examination there was found a red, raw area, circu- 
lar, about one and one-half inches in diameter, a little 
raised, and glazed over in some places. There was no deep 
lump in the breast, but some chronic mastitis in the left 
breast, and no axillary adenopathy on either side. Under 
dietetic and medicinal treatment, including thyroid and 
the continued application day and night, first with the 
calamine and zinc ointment, later with the addition of 
ichthyol, half a dram to the ounce, the lesion soon largely 
subsided. On January 26, 1920, it was recorded that the 
breast looked better than ever, quite dried up, with only 
a few small raw points, and the day before there had been 
no rawness on changing the dressing. On October 18th, 
as there was still some rawness in places, and she was 316 
CANCER OF THE BREAST. 
restless and wanted radium; this was applied, by a col- 
league, with a patch seven-eighths inch square, with 25 
mg. of radium element in shellac, filtered through % mm. 
of platinum, for ninety minutes, over four areas, so as to 
cover the entire patch. The result was a perfect healing, 
with only a little redness, and no rawness for over four 
months. On October 27th she was seen by a surgeon, and 
it was recorded that the breast was normal; redness was 
gone, and the original area was only a little brown, no 
lump in either breast, nor adenopathy in either axilla. 
When seen October 19, 1922, the condition was the same, 
she was looking very well, weighing one hundred and 
eighty-nine pounds, much more than normal, and by 
letter I learned later that she remained perfectly well, and 
in excellent health, having passed the menopause over a 
year ago, still following fairly well the dietary and other 
treatment. When last seen by me, with a visiting surgeon, 
November 27, 1923, over four years after her first visit, 
and more than six years after the first sign of the dis- 
ease, the breast was normal, with only a brown stain, and 
no lesions in either breast, nor any adenopathy. 
Case LIX. Paget's disease of the right nipple. Mrs. 
T. F., aged 32, childless, was sent to me from a hospital, 
on October 18, 1919. For a year there had been soreness 
about the right nipple, beginning as a "small pimple," and 
then had gradually formed a diseased surface, which 
scaled over at times, and then exuded a little. She had 
always been very nervous, with a severe nerve shock six 
years ago, followed by some eczema, which still existed on 
the right thigh. She was continually under much nerve 
strain, teaching forty high school pupils, for forty-minute ANALYSIS OF CASES. 
317 
periods, nine hundred in a week. She had had repeated 
attacks of grippe, sometimes very severe. 
On examination there was found a circular patch about 
the right nipple, fully an inch in diameter, largely scaly, 
but with raw surface when the crust was removed. There 
was no tumor in the breast, nor axillary adenopathy. Be- 
ing placed on a thorough dietary and medicinal regime, on 
November 15th the breast had largely healed over and she 
had improved marvelously in general health, so that on 
November 29th it was recorded that she "felt like a differ- 
ent person, as though she were 18 years old." But later, 
lymphatic permeation seemed to have taken place, the 
surface became a little moist, and a node appeared on the 
sternum, and on two ribs. Soon she had grippe again and 
the breast enlarged with chronic mastitis, but no definite 
tumor and no axillary adenopathy. The breast lesion 
showed some attempt at epitheliation, here and there, but 
still with some scar surface, on March 16th. She then 
became restless and saw three surgeons who urged opera- 
tion or radium, and the breast was removed during the 
middle of July, 1920. In reply to a letter of inquiry she 
reported, on August 22, 1922, that she still remained well. 
Case LX. Paget's disease of the right nipple, of long 
duration. Mrs. T. M., aged 76, was seen in consultation 
with Dr. Sossnitz on December 22, 1922. Twenty-eight 
years previously she noticed trouble on the right breast 
which has continued ever since. On December 11, 1911, 
she saw a very prominent New York surgeon, whose let- 
ter, which was seen, confirmed the diagnosis of Paget's 
disease, which had not been troublesome until these last 
two years, when there had been considerable bleeding. 318 
CANCER OF THE BREAST. 
On examination there was a red, circular, flattened, 
fungating mass about three inches in diameter, raised 
nearly half an inch, some of the surface glazed over, and, 
perhaps one-third of it raw and discharging, with a little 
bleeding on removing the dressing; there was no lump 
in the breast and no adenopathy. The breast gave very 
little pain, and the patient, in bed looked the picture of 
health, and hardly showed her years. The bleeding was 
at once checked by the local application given, and re- 
peated reports from the doctor show that all is going on 
well, twenty-eight years after the beginning of the trouble. 
Case LXI. Postoperative cancer of the right breast, in 
a male. Dr. G. J., aged 46, had been under my care five 
years previously, for a greatly furrowed tongue, with some 
leucoplakia, fearing epithelioma, which did not exist, and 
the condition improved under treatment, so that I lost 
sight of him until October 20, 1919, when he called re- 
garding a recurrent carcinoma of the right breast. He 
had been operated on April 1, 1912, for suspected gall- 
stones, but none were found, and he was said to have 
pancreatitis. Twenty-seven months before his visit he 
began to have tense and inflamed nipples of both breasts, 
and the right nipple began to discharge. In October, 1917, 
two years before his visit, a prominent New York surgeon 
removed the right breast, but not the axillary contents. 
Eighteen months later the axillary glands enlarged, and an- 
other prominent New York surgeon removed the axillary 
contents, and he had been having x-ray and radium treat- 
ment ever since, with no relief to the great pain in the 
arm, which prevented sleep. 
On examination there was an enormous scar, from the 
arm, across the axilla, down the chest on to the abdomen, ANALYSIS OF CASES. 
319 
with also a scar in the neck above the clavicle. Very 
many cutaneous nodules had developed around the axilla, 
and on the chest wall, and the right arm was greatly 
enlarged, measuring 15 inches, the left being eleven and a 
half. The saliva was very acid. He was placed under 
complete treatment, but was soon lost sight of and nothing 
has been learned as to the result of the treatment 
prescribed. 
There have now been presented 60 and more his- 
tories of patients with cancer of the breast, in many 
of whom a very carefully directed medical treatment 
has yielded results which must be acknowledged as 
satisfactory when compared with those usually ob- 
served ; and did space and time permit, diligent search 
would probably reveal many more, while the many 
patients first seen since January 1, 1923 may be said 
to be all doing very well, at least I know of no ex- 
ceptions. There is little to add. These and other 
patients have been watched by hundreds of physicians 
or surgeons, and dozens of them are still under treat- 
ment, or observation. In dozens of instances of 
primary cancer of the breast the cure has lasted over 
three years, the period formerly, but wrongly, 
considered safe surgically, and some of them five, 
ten, fifteen, eighteen, and one even twenty-nine 
years. And when the carcinosis has been over- 
come, and the local lesion and metastases have 
all vanished under proper medical measures, it 
is reasonable to expect that there will be no recur- 320 
CANCER OF THE BREAST. 
rence, unless the patient again violates the laws of 
hygiene and health. 
Whether we are yet working along the very best 
lines of treatment remains to be seen, when many 
other workers report more fully in regard to their 
experiences. There are now hundreds of physicians 
all over the country and abroad who have accepted 
and adopted the systemic or constitutional nature of 
carcinoma or rather, carcinosis, and have, more or 
less, diligently acted thereon, and over sixty are en- 
rolled as members of the American Association for 
the Study and Cure of Cancer. With the new jour- 
nal, "Cancer" there will be a forum for the presenta- 
tion of the relative values of various forms of treat- 
ment, and the end results obtained by surgery, x-ray, 
radium, biotherapy, chemical, electrical, and other 
physical agencies, and the claims of these will be 
fairly represented and compared. The world is 
waiting anxiously for a satisfactory solution of the 
therapeutic problem of cancer, which can only be 
secured by the co-operation of many earnest and 
true scientific workers. 
Time will show a material improvement in the 
general mortality from cancer when the correct 
principles of treatment are more widely advocated 
and employed, even as in the case of tuberculosis. CHAPTER XII. 
CONCLUSIONS. 
Why is it that the medical profession and the laity- 
are so reluctant and slow to accept and act upon the 
unquestionably proper conception of cancer, as it has 
been repeatedly set forth and accepted by so many? 
All that has been here stated, and much more, has 
been presented before many scientific medical soci- 
eties, and the claims have never been refuted, and 
seldom even disputed, except by some surgeons, who 
still claim that operative interference alone offers any 
hope for cancer; they all seem to ignore the subject, 
from ignorance of what has been written. And we 
again challenge investigators of all kinds to seriously 
consider the matters here set forth and to criticise 
scientifically their correctness. 
We have seen that the breast is formed and devel- 
oped from prolongations into the deeper tissues, of 
epithelial cells from the lower layers of the skin, the 
rete Malpighii; and also that the lining cells of the 
acini and ducts thus formed continually undergo 
changes in the evolution of the gland, and during the 
involution which takes place after lactation and the 
menopause, which all very readily lead up to the ab- 
normal changes found in disease. We learned also 
321 322 
CANCER OF THE BREAST. 
that some of these changes were often hardly dis- 
tinguishable under the microscope from those seen in 
malignant affections. We know that all those nor- 
mal alterations in the cells depend on constitutional 
conditions, such as direct and reflex nerve influences, 
nutrition, and the influence of endocrinous and other 
secretions. Why should it not be accepted, then, that 
the later changes in the mammary cells, which form 
what is known as carcinoma and sarcoma, are caused 
by the same or other derangements of the system, 
the particular locality of the development of the neo- 
plasm being decided by some local injury or irritant, 
just as is the case in gout, syphilis, tuberculosis, 
rachitis, etc? Able and conscientious observers and 
investigators claim that they are such. 
Our study of metabolism, and the medical aspects 
of cancer, based on close clinical observation in very 
many cancer patients, for years, have shown a large 
number of departures from normal systemic condi- 
tions which are constantly observed in those affected 
with this disease. It is continually observed that 
the evidences of the malady, carcinosis, disappear as 
these systemic conditions are rectified by correct 
dietetic, hygienic, and medicinal measures. And we 
have seen, further, that when the manifestations of 
cancer are thus removed, the general health, vitality, 
weight, etc., of the patient also improve. Finally, 
when all this has been accomplished by the means CONCLUSIONS. 
323 
mentioned, we have found that there are no recur- 
rences or metastases, provided the patient still main- 
tains the same correct mode of life for an indefinite 
period, even as is known to be the case in tubercu- 
losis or gout. Why then is not this logical concep- 
tion of the nature and treatment of cancer accepted 
and universally acted upon? Hundreds of intelligent 
and conscientious physicians and surgeons all over 
the world have done this, and the whole profession 
and the laity will believe and accept it when their 
leaders in the medical profession have more widely 
promulgated it; as a few have already boldly pro- 
claimed it, dating back one hundred years and even 
up to the present day. 
All this is vastly different from the narrow view, 
developed mainly during the last twenty years, that 
the local tumor, which is but the first external mani- 
festation or product of the carcinosis, is truly a local 
affair, the destruction or removal of which by various 
local measures, will end the disease. Whereas, uni- 
versal experience, acknowledged by the surgeons, as 
we have seen in the chapter on Prognosis, shows 
that there will probably be a recurrence of the 
trouble, sooner or later, with increased suffering, and 
that under the measures in common use 90 per cent, 
of those once affected with cancer in general die of 
the same. Also reliable statistics show, beyond 324 
CANCER OF THE BREAST. 
doubt, that cancer mortality is steadily increasing all 
over the civilized globe. 
As has been repeatedly indicated in what has pre- 
ceded, the medical treatment of cancer is no facile 
or easy proposition. The most serious nature of the 
affection must be fully recognized, and its proper 
management is not to be lightly or loosely entered 
upon; for it will often tax the acumen and patience 
of the intelligent, thoughtful, and conscientious prac- 
titioner to the utmost, to carry out certain cases to 
a successful issue. But that this can be accomplished 
has been abundantly shown by the cases reported. 
Truth is often stranger than fiction, and the very 
simplicity of the ideas put forth in the preceding 
pages, as contrasted with the mystery which has so 
long hung over the cancer problem, is hard for some 
minds to accept; but truth will conquer in the end, as 
it always has done. But, as Sir Janies MacKenzie1 
says, "The bonds of tradition are difficult to shake 
off." 
1 MacKenzie, Sir James: Diagnosis and Treatment of Heart Af- 
fections. BIBLIOGRAPHY* 
Abernethy: Surgical Observations on Tumors, 4th Edition, 
London, 1826. 
Bailey, F. R.: Text Book of Histology, 3d Edition, New York, 
1910. 
Bell, Robert: Cancer, Its Cause and Treatment, 2d Edition, 
London, 1913. 
Brand, A. T.: Cancer, Its Cause, Treatment and Prevention, 
London, 1922. 
Bryant, Thomas: The Diseases of the Breast, London, and Paris, 
1887. 
Cheyne, Watson: Objects and Limitations of Operations for 
Cancer, London, 1896. 
Cooper, Sir Astley: Lectures on the Principles and Practice of 
Surgery, 8th Edition, London, 1835. 
Creighton, Charles: Cancers and Other Tumors of the Breast, 
London, 1902. 
Ibid.: Some Conclusions on Cancer, London, 1920. 
Deaver, John B.: The Breast, Its Anomalies, Diseases, etc., 
Philadelphia, 1917. 
Ewing, James: Neoplastic Diseases, Philadelphia, 1919. 
Gibson, W. T.: The Etiology and Nature of Cancerous Growths, 
etc., London, 1909. 
Gould, Sir Alfred Pearce: The Bradshaw Lecture on Cancer, 
London, 1910. 
Gray: Anatomy, Description and Surgical, 13th Edition, New 
York, 1910. 
Greene, R. H.: Cancer, Its Nature, Causes, etc., New York 1918. 
Gruner, O. C.: The Exact Diagnosis of Latent Cancer, Philadel- 
phia, 1919. 
Handley, W. S.: Cancer of the Breast, 2d Edition, London, 1922. 
Leaf, C. H.: Cancer of the Breast, London, 1912. 
Lockwood, C. B.: Cancer of the Breast, London, 1913. 
Mortality Statistics, U. S., 1914, 1921, 1922. 
Nunn, Thomas W.: Cancer of the Breast, London, 1882. 
Parker, Willard: Cancer, a Study of 395 Cases of Cancer of the 
Breast, New York, 1885. 
phia, 1919. 
* This is not presented as a complete bibliography, but only of the 
books now before me, read or consulted in the preparation of this work. 
325 326 
BIBLIOGRAPHY. 
Price-Jones: Blood Pictures, 2d Edition, New York, 1921. 
Quevli, Nels: Cell Intelligence, etc., Minneapolis, 1917. 
Robson, A. W. Mayo: Cancer and Its Treatment, Bradshaw 
Lecture, London, 1905.* 
Rodman: Diseases of the Breast, Philadelphia, 1908. 
Ross, Forbes: Cancer, the Problem of Its Genesis and Treat- 
ment, London, 1912. 
Ross, H. Campbell, and others: Induced Cell Reproduction and 
Cancer, 3 Vols., 1911, 1912, 1913. 
Shield, A. Marmaduke: A Clinical Treatise on Diseases of the 
Breast, London, 1898. 
Snow, Herbert: Cancers and the Cancer Process, London, 1893. 
Sequira: Diseases of the Skin, St. Louis, 1916. 
Sutton, Sir John Bland: Tumors Innocent and Malignant, 7th 
Edition, London, 1922. 
Ibid.: Cancer Clinically Considered, London, 1909. 
Sutton, R. L.: Diseases of the Skin, St. Louis, 1911. 
Taylor, H. Canning: Cancer, Its Study and Prevention, Philadel- 
phia, 1915. 
Velpeau, S.: A Treatise on the Diseases of the Breast, London, 
1856. 
Von Winiwarter, Von Alexander: Beitrage zar Statistik der Car- 
cinome, Stuttgart, 1828. 
Wells: Chemistry of Tumors, Chemical Pathology, 2d Edition, 
1919. 
White, Charles Powell: Lectures on the Pathology of Cancer, 
Manchester, 1908. 
Williams, W. Roger: The Natural History of Cancer, New York, 
1908. 
Ibid.: A Monograph on Diseases of the Breast, London, 1894. 
Wolff, Jacob: Die Lehre von der Krebskrankeit, Vols. 1, 2, 3, 
1907, 1911, 1913. INDEX 
Abernethy, John, 149, 156, 187 
Abnormal involution of breast, 
28 
Abscess, cold, 115, 127 
Absence of cancer in patients tak- 
ing potassium, 223 
Acetate of potassium in cancer, 222 
Acidity, urinary and cancer, 218 
Acinar carcinoma, 81, 86 
Acumen, medical, necessary for 
cancer treatment, 209 
Acute carcinosis, 89 
mastitis, 124 
Adair and Lee, 133 
Adeno-carcinoma, 78 
Adeno-cystic sarcoma, 108 
Adenopathy/ axillary, 76 
Adeno-sarcoma, 108 
Adrenalin locally in bleeding can- 
cer, 238 
Advanced cancer of breast, 253 
Advantages of chemical removal, 
185 
Aebly, J., 143 
Age and location in patients with 
breast cancer, 247, 248 
influencing prognosis, 146 
of male patients with breast can- 
cer, 248 
Ages and deaths of breast cancer 
patients, 253 
of cancer of breast patients, 60, 
245 
Agony from wrong local treat- 
ment, 233 
Analysis of 250 cases of breast 
cancer, 240 
Anatomy of breast, 31 
Animal protein and cancer, 189 
Animals, wild, and cancer, 169 
Anxiety and grief causing cancer, 
178 
Apoplexy, deaths from, compared 
to cancer, 164 
Arterial changes from radio-activ- 
ity, 248 
Asepsis impossible in cancerous 
ulceration, 237 
Aspects, medical, of cancer, 155 
Aspirin, value in cancer, 229 
Athletes, absence of cancer in, 205 
Attachment of the skin in breast- 
cancer, 72 
Auto-intoxication causing cancer, 
214 
Autolysis in tumor tissue, 5 
Avoid irritating cancerous ulcera- 
tion, 235 
Axilla, examination of, 117, 118 
Axillary adenopathy, 76 
glands, 40 
Bailey, F. R„ 25, 27 
Bell, Dr. Robert, 161, 173, 212, 225 
Benign breast lesions excluded 
from analysis, 243, 244 
tumors, 123 
Bibliography, 325 
Billroth, Th., 124, 138, 140 
Bio-chemistry of cancer, 209 
Biopsy in cancer dangerous, 121, 
241 
Bio-therapy, 187 
327 328 
INDEX. 
Blood cells, red, in cancer, 170, 221 
potash content in, 221 
stream, imperfect, and cancer, 
167, 179 
Blumenthal on urobilin in cancer, 
175 
Body elimination, erroneous, and 
cancer, 167 
weight and urinary excretion, 
216 
Bones, lymphatic involvement of, 
56 
Both breasts, cancer of, 258, 261, 
267, 294, 314 
Bowel action, definite instruction 
necessary, 213 
in cancer, 229 
Bowels, two or three evacuations 
daily, 213 
Brachial glands, upper, 43 
Breast, anatomy of, 31 
cancer, surgery in, 181 
lesions, benign, excluded from 
analysis, 243, 244 
physiology of, 31, 34 
Bryant, Thomas, 14, 96, 178 
Butter, value of, in cancer, 201 
Cachexia in cancer, 107, 170,* 226 
Calamine and zinc lotion, 236 
ointment, 235 
Calories required for cancer pa- 
tients, 197, 201 
Cancer cachexia, 226 
caused by luxurious living, 159 
cn cuirasse, 76, 234, 257 
management of, 208 
never a local disease, 12, 156, 
159, 161, 178 
specialists, 193 
Cannon, Walter B., 177 
Carcinoma of the breast, 60 
proportion among breast tumors, 
116 
Carcinoma, simplex, 78 
with sarcoma, 110 
Carcinosis as a disease, 153, 156, 
209 
to be treated, 228 
Card, green, diet slip, 193 
Care in handling cancer, 194 
Castor oil in cancer, 230 
Cases, histories of breast cancer, 
253-319 
Cause, no single cause of cancer, 
179 
of cancer, 11 
Caustics, advantage over surgery, 
183 
in breast cancer, 183 
objects of, in breast cancer, 183 
Cell intelligence, 8 
Cells, red blood, in cancer, 170 
Cereals important in cancer, 199 
Challenge of scientific correctness 
of systemic theory, 321 
Character of lesion influencing 
prognosis, 151 
Chemical removal of breast can- 
cer, advantages of, 184 
of advanced cancer, 184 
of cancerous breast, 259, 297 
Chemistry of tumors, 2 
Cheyne, Watson, 139 
Chlorides in urine in breast cancer, 
219 
Chinosol, diluted, in ulcerative 
cancer, 237 
Chondroma, 116, 128 
Chronic cancer, 91 
circumscribed mastitis, 126 
mastitis, 124 
mastitis and cancer, 64 
Clinic, medical, for cancer, 192 
Clinical study and history of can- 
cer, 131 
varieties of breast cancer, 87 INDEX, 
329 
Cocaine locally in ulcerative can- 
cer, 237 
Cold abscess, 115, 127 
Coley's fluid in sarcoma, 188 
Colloid nitrogen and cancer, 176 
Colostrum, nature of, 36 
Complete evacuation of bowels 
necessary in cancer, 212 
Complicating conditions, 152 
Composition of human body, 168 
Comparison of results of medical 
and surgical treatment, 
251 
Conclusions, 321 
Confidence on part of cancer pa- 
tient, 209 
Connective tissue versus epithelial 
cells, 111 
Constipation causing cancer, 173, 
210 
Constitutional effects from X-ray, 
182 
nature of cancer, 155-167 
Contagious, cancer is not, 193 
Cooper, Astley, 69, 90, 115, 158, 
178 
Cooper's ligaments, 70 
Cotton, absorbent, soothing to 
cancer, 234 
Courage in cancer treatment, 233 
Creighton, Charles, 14, 19, 30, 35 
Cuirasse, cancer en, 76 
Cures of breast cancer, 138 
Cured cancer of the breast, 283 
Cyst adenoma, 89 
Cysts of the breast, 115, 117 
Daily bowel action and cancer, 174 
Deaths and ages of breast cancer 
patients, 253 
in 250 private breast cancers, 252 
Death-rate of cancer, 164 
Deaver, John B„ 1, 16, 42, 62, 77, 
92, 97, 107, 121, 133, 146 
Deficient urine solids in cancer, 
176 
Degres on liver changes in car- 
cinosis, 175 
Deranged evolution of breast, 115 
involution of breast, 115 
metabolism in cancer, 227 
salivary secretion in cancer, 171 
Details, importance of in cancer, 
203, 207 
Diabetes complicating cancer, 152 
Diagnosis, faulty, in breast cancer, 
116. 181 
by careful study of case, 122 
of breast-cancer, 114 
of cases reported, 241 
microscopic proof of, 181 
Diachylon ointment, Hebra's, in 
cancer, 234 
Diaphragmatic glands, 43, 44 
Dietary treatment, duration of, 190 
Diet for cancer, 194 
in cancer, 189 
vegetarian, for cancer, 192 
Diffuse mastitis, 125 
Dimpling of the skin in breast- 
cancer, 72, 117, 121, 177 
Directions for cancer patients, 193, 
198 
Disturbances, nervous, causing 
cancer. 177 
Duct carcinoma, 81, 84 
Ductless glands and cancer, 232 
Duration of breast cancer, 248 
dietary treatment, 190 
disease influencing prognosis, 
148 
medical treatment, 249 
Early cancer, excellent health in, 
225 
Eczema of nipple, 121 330 
INDEX, 
Elimination, body, erroneous, and 
cancer, 167, 171 
Emaciation in cancer, 226 
Encephaloid cancer, 89 
Endocrinous secretions and cancer, 
172, 231 
End results of medical treatment, 
250 
of surgical treatment, 138 
Epithelial versus connective tissue 
cells, 111 
Epithelioma, Marsden's arsenical 
paste in, 184 
Erroneous body elimination and 
cancer, 167, 171 
evolution of breast, 122 
involution of breast, 122 
Errors of life to be corrected in 
cancer, 232 
Evolution of breast, 16 
of breast, erroneous, 122 
Ewing, James, 2, 9, 65, 73, 75, 80, 
87, 91, 92, 109, 133,140,151 
Examination of breast, 116 
Excellent health in early cancer, 
225 
Excision of breast cancer, 182 
External cause of breast cancer, 
62 
Far East, rarity of cancer in, 202 
Fascial permeation of lymphatics, 
56 
Fat necrosis of the breast, 132 
Fatal cases of post operated breast 
cancer, 263-270 
unoperated breast cancer, 
253-263 
Faulty diagnosis, 116, 181 
metabolism and cancer, 167, 
168 
Fear element in cancer, 180 
Fecal putrefaction and cancer, 174 
Fibro-carcinoma, 89 
First symptom of breast cancer, 
128 
"Fletcherizing" in cancer, 199 
Following up cancer cases, 181 
Food and mode of life, 167 
wrong or excessive, and cancer, 
167 
Fright causing cancer, 206 
Fruits in cancer diet, 202 
Fulminating cancer of breast, 311 
Gauze, surgical, irritating in can- 
cer, 234 
Gelatinous carcinoma, 79, 82 
Gentleness requisite in handling 
breast cancer, 120 
Gibson, W. T„ 178, 190 
Glamour of surgery, 162 
Glands, axillary in breast cancer, 
118 
Good health of cancer patients, 130 
Gould, Sir Alfred Pearce, 190 
Gratifying taste, and cancer, 169 
Green diet card for cancer, 193 
Grief and anxiety causing cancer, 
178 
Gross, S. W., 68, 97 
Gruner, O. C., 103, 170 
Habits, regularity of, in cancer 
treatment, 205 
Haig, Alexander, 30 
Haines' estimation of urinary 
solids, 217 
Handley, 39, 41, 47, 50, 96, 141, 
181 
Handling, rough, of breast can- 
cer very harmful, 120 
Hard cancer, 78 
Hardness of breast, 119 
Harmful results from X-ray, 183 
radium, 183 
over-zealous propagations con- 
cerning cancer, 131 INDEX, 
331 
Health excellent in early cancer, 
225 
Heart disease influencing prog- 
nosis, 164 
Hebra's diachylon ointment in 
cancer, 234 
Hepatic glands, 43 
Histories of cases of breast can- 
cer, 253-319 
Hochnegg on constitutional nature 
of cancer, 156 
Hutchinson, Jonathan, 128 
Robert, on diet. 201 
Hydrogen peroxide in ulcerative 
cancer, 237 
Hygienic adjustment, 203 
Hypernutrition and cancer, 225 
Imperfect blood stream and can- 
cer, 167, 169 
intestinal elimination in cancer, 
173 
kidney elimination and cancer, 
176 
Increase in size of breast, 121 
Index, 327 
Indican in urine in cancer, 219 
Individual peculiarities in cancer 
patients, 208 
Indolence a factor in cancer, 167 
Inflammatory conditions of breast, 
116 
Inguinal glands, 43 
Initial symptoms in cancer, 121 
Injury causing breast cancer, 62 
Insalivation important in cancer, 
171, 198 
Intestinal elimination, imperfect in 
cancer, 173 
intoxication and cancer, 174 
stasis and cancer, 174, 210 
Intoxication, intestinal, and cancer, 
174 
Intelligence of cells, 8 
Intercostal glands, 43, 45 
Intra-mammary glands, 46 
Involution, abnormal, of breast, 28 
of breast, 16, 22, 24 
of breast, deranged, 115, 122 
senile, changes in, 123 
Involvement, lymphatic, in breast 
cancer, 152 
Iron of value in cancer, 228 
Irritation to be avoided in treat- 
ing breast cancer, 235 
Jones, Price, 103, 170 
Kidney action and cancer, 215 
disease, mortality from, com- 
pared with cancer, 164 
elimination, deficient in cancer, 
176 
Laboratory studies, value of, 132, 
283 
Lactation, breast in, 21, 25 
resting stage of lobule after, 21, 
25 
irregular, lumps during, 122 
Lambe, Dr., on diet in breast can- 
cer, 157 
Lane, Sir Arbuthnot, intestinal in- 
toxication causing cancer, 
175 
Laxative remedies for cancer, 
230 
Lee and Adair on fat necrosis of 
breast, 133 
Leaf, C. H., 39 
examination of breast, 116 
Life of patient with breast cancer 
shortened by second oper- 
ation, 141, 143 
Ligaments of Cooper, 70 
Lipoma, 116, 128 
Liver, derangement of, in cancer, 
175 332 
INDEX, 
Local condition of lesion influenc- 
ing prognosis, 150 
disease, cancer is never local, 
12,156, 159, 161, 179, 239, 
280 
treatment of breast cancer, 233 
Location of lesion in breast cancer, 
246 
Lockwood, Charles B., 41, 72 
Long duration of Paget's disease, 
317 
Lorand, Arnold, 214 
Lotion, calamine and zinc, 236 
Lump in axilla, 121 
Luxurious living a cause of can- 
cer, 159, 167 
Luschka, anatomy of breast, 21 
Lymphatic absorption, prevented 
by chemical removal, 184 
involvement, 152 
permeation, 39, 49, 52, 181 
Lymphatics and the breast, 39 
Male, Paget's disease in, 99 
Males with breast cancer, 247 
Malignant adenocarcinoma, 84 
tumors developed from non- 
malignant, 90 
Management of cancer, 208 
Marsden's arsenical paste in epi- 
thelioma, 184 
Mastication, prolonged, impor- 
tant in cancer, 171, 198 
Mastitis, acute and chronic, 124, 
175 
chronic, cancer in, 66, 87 
chronic circumscribed, 126 
diffuse, 125 
periductal, 125 
Materia medica, many articles in, 
may be needed in cancer, 
228 
Mayo, Wm. J., on systemic cancer, 
157 
Meal hours, regularity of, in can- 
cer, 205 
Meat eating and cancer, 167, 189 
Medical aspects of cancer, 155, 179 
measures, various in cancer, 219 
versus surgical treatment, 153 
Medullary cancer, 89 
Menstruation and mammary activ- 
ity, 37 
Mental disturbances causing can- 
cer, 206 
Metabolism faulty in cancer, 167, 
169, 227 
proteid, disturbed in cancer, 176 
Metastasis, 209 
Metastases and recurrences rare 
after sufficient medical 
treatment, 323 
Microscopic proof of diagnosis, 181 
Milk, how to take in cancer, 202 
Mineral salts in blood, disturbed 
in cancer, 220 
Mistakes in diagnosis, 116, 181 
Mixture used in cancer, 224 
Mode of life and food, 167 
Mohrenheim space, 40 
Morphia practically never needed, 
229 
Morphine, harmful in cancer, 205 
Mortality of cancer, 164 
in 250 private breast cases, 252 
Mucoid carcinoma, 82, 89 
Mutinous cancer cells very ir- 
ritable, 237 
Mutiny of body cells causing 
cancer, 8, 155 
Necrosis, fat, of the breast, 132 
Neoplastic growths seen in pri- 
vate practice, 244 
Nerve influence on cancer, 206 
strain causing cancer, 178, 206 
Nervous disturbances causing can- 
cer, 167, 177 INDEX. 
333 
Nervous states and cancer, 206 
system and mammary secretion, 
37 
Neuritis common in cancer, 229 
Newsholme, Dr., influence of al- 
cohol in causing cancer, 
190 
New York Skin and Cancer Hos- 
pital, 192, 223, 243 
Nipple, Paget's disease of, 92 
retraction of, 70, 134 
No absolute single treatment for 
cancer, 227 
Non-malignant tumors becoming 
malignant, 90 
No one course of treatment in 
cancer, 207 
Normal body cells and cancer, 11 
No single remedy or course of 
treatment for cancer, 207 
Nutrition, proper, to be restored 
in cancer, 232 
Obedience, perfect, important in 
cancer, 207 
Occupied males and cancer, 168 
Ointment, calamine and zinc, 235 
Oldekop on duration of cancer, 
141 
Oncology, 1 
Operations, surgical, shorten life 
in breast cancer, 141 
Opiates harmful in cancer, 205 
unnecessary during full medical 
treatment, 229 
Optimism necessary for medical 
cancer treatment, 209, 
233 
Osteoma, 116, 128 
Overzealous propagations concern- 
ing cancer harmful, 131 
Oxygen, importance of, in cancer, 
203 
in body, 169 
Paget's disease, 60, 92, 95 
in a male, 99 
of the nipple, 315, 317 
Paget, Sir James, 141, 159 
Pain in breast cancer when con- 
stipated, 212 
in cancer, 120, 121, 130 
in sarcoma, 112 
in upper right abdomen, 121 
Pancreatic secretion, amount of, 
172 
Papillary adenoma, 83 
Parker, Willard, on luxurious liv- 
ing causing cancer, 159 
Patience in treatment of cancer, 
209, 233 
Pauchet, Victor, intestinal intoxi- 
cation causing cancer, 156, 
174 
Pectoral glands, 41 
Peculiarities, individual, in cancer 
patients, 208 
Periductal mastitis, 125 
Perverted involution of breast, 28 
Permeation, lymphatic, in breast 
cancer, 39, 49, 52, 181 
Peroxide of hydrogen in ulcerative 
cancer, 237 
Perseverance in medical treat- 
ment of cancer, 209 
Personal attention to constipation, 
211 
Pertinacity in medical treatment 
of cancer, 233 
Physical condition of patient influ- 
encing prognosis, 147 
Physiology of the breast, 31 
Phosphates in the urine of can- 
cer patients, 219 
Pigmented mole, 121 
Phosphates for carcinoma, 228 
Phosphate of iron in cancer, 228 
Plasma of blood, in cancer, 170 334 
INDEX, 
Postoperative cancer of breast, in 
male, 318 
Potash element of blood cells, 170 
in the blood, 221 
Potassium acetate in cancer, 222 
in cancer, 219, 231 
Potatoes, skin of, in cancer, 197, 
201 
Previous treatment influencing 
prognosis, 149 
Primary cancer of breast, favor- 
able private cases, 271-314 
Prognosis influenced by age, 146 
by character of lesion, 151 
by duration of disease, 148 
by local condition of lesion, 
150 
by physical condition, 147 
by previous treatment, 149 
by X-ray previously, 150 
of breast cancer by surgical 
treatment, 137-143 
Prostration after X ray, 182 
Proteid treatment for breast can- 
cer, 287 
Protein, animal, and cancer, 189 
Proteins in tumors, 7 
Puckering of the skin in breast 
cancer, 72 
Punctilious observance of cancer 
rules necessary, 238 
Pure sarcoma, 108 
Pus organisms causing ulceration 
in cancer, 236 
Quevli, Nels, cell intelligence, 8 
Radium, harmful results from, 183 
in breast cancer, 183 
influencing prognosis, 150 
Rapid eating to be avoided in can- 
cer, 199 
Rarity of cancer in vegetarian 
natives, 202 
Raw vegetables in cancer, 202 
Recovery for 29 years from ul- 
cerative breast cancer, 271 
Recreation, importance of correct, 
in cancer, 206 
Recurrence of cancer after chemi- 
cal removal, 184 
Recurrences and metastases rare 
after medical treatment, 
319, 323 
Recurrent cancer in other breast, 
after operation, 288, 307 
in other breast, from neglected 
treatment, 272 
Red blood-cells in cancer, 170 
Reid, Dr., cancer research, 175 
Relief from proper local treat- 
ment, 233 
Remedies varied for individual 
cases, 208 
Removal, chemical, of advanced 
carcinoma, 184 
Repeated surgical operations in- 
jurious in breast cancer, 
149 
Rest, importance of, in cancer, 205 
Resting stage of breast lobule 
after lactation, 35 
Restoration of proper bodily 
functions in cancer, 210 
Results, end, of medical treatment, 
250, 252 
the test of theories, 240 
ultimate, in breast cancer, 138 
Retraction of nipple, 70, 121 
Retro-mammary glands, 46 
Retro-sternal glands, 43 
Rheumatism and cancer, 229 
chronic, complicating cancer, 152 
Ribbert, D., 61 
Rice, importance of in cancer, 200, 
203 
Robust appearance in early cancer, 
225 INDEX 
335 
Rodman, William L., 133, 139 
Ross, Forbes, 161, 170, 219, 228 
H. C., 14, 160 
Rugged health of patients with 
early cancer, 131 
Rough handling of breast cancer 
very harmful. 120 
Saliva acid in cancer, 171, 216 
Salivary secretion deranged in 
cancer, 171, 199 
Sarcoma, 105, 108 
Sarcoma, adeno-, 108 
differential diagnosis, 105 
of breast, frequency of, 105, 107 
with carcinoma, 110 
Sauerbruch on systemic cancer, 
156 
Scirrhous or hard cancer, 78 
Scirrhus carcinoma, 89 
Secretion of milk, 36 
Sedatives for sleep, harmful in 
cancer, 205 
not required with proper in- 
ternal treatment, 205 
Senile involution, changes in, 123 
of breast, 24 
Sequira, J. H., Paget's disease, 95 
Sex of patients with breast cancer, 
247 
Shape of cancerous mass, 119 
Simple life and cancer, 179 
Simplex carcinoma, 78 
Skin and Cancer Hospital, 223, 
243 
Sleep, importance of, in cancer, 
204, 205 
Solids of urine and cancer, 176, 
217 
Soreness of nipple, 121 
Soup, vegetable, for cancer, 197, 
199 
Squamous cell carcinoma, 80 
Statistics of breast cancer, 60, 138 
Stiles, Harold J., 45 
Stinging sensation, 121 
Stream, .blood, imperfect, and can- 
cer, 167 
Strobel, Charles, 185 
Sub-areolar glands, 45 
Subscapular glands, 42 
Success in treatment of breast 
cancer, 180 
Sugar, value of, in cancer, 200, 201 
Sulphates in urine, in cancer, 219 
Sunlight, importance of, in cancer, 
204 
Suppuration due to pus organisms, 
236 
Supra-scapular glands, 43 
Supra-xiphoid glands, 43 
Surgery in breast cancer, ineffici- 
ency of, 136, 181^ 220 
Surgical gauze irritating to can- 
cer, 234 
operations, repeated, shorten life 
in breast cancer, 141 
time limit of cure, 251 
Sutton, Richard L., 93 
Sir John Bland, 13, 53, 64, 93 
Sympathetic nerve influence in 
cancer, 177 
Symptoms, initial in cancer, 121 
Syphilis, 116, 128 
Systemic nature of cancer, 155 
Taste, gratifying, and cancer, 169 
Tatham, Dr., influence of alcohol 
causing cancer, 190 
Technique of chemical removal, 
185 
Tender axilla, 121 
Theories tested by results, 240 
Thiol locally in cancer, 234 
Thyroid and cancer, 173 
extract in cancer, 225, 231 
Time limit of cure by medical 
treatment, 251 336 
INDEX. 
Time limit of cure after surgery 
of breast cancer, 251, 279 
Traumatism not real cause of can- 
cer, 166 
Treatment of breast cancer, 180 
Tuberculosis, 115, 127 
Tuberculotic patient obedient to 
instructions, 207 
Tuke, Hake, influence of the mind 
on body, 177 
Tumors, benign, 123 
of breast, carcinoma in 80 per 
cent., 242 
in general, 1 
Twenty-nine years recovery from 
ulcerative breast cancer, 
271 
Ulcer of nipple, 121 
Ulceration, cancerous, avoid irri- 
tating, 235 
in cancer, 131, 234 
Ultimate results in breast cancer, 
138 
Unoccupied males and cancer, 168 
Urates in urine in cancer, 219 
Urea, scanty excretion in cancer, 
175, 219 
Uric acid in cancer, 30 
Urinary solids and cancer, 215, 216 
deficient in cancer, 176 
Urine in cancer, 215 
Urobilin increased in cancer, 175 
Varied remedies for individual 
cases, 208 
Vaso-motor influence in cancer, 
178 
Vegetable soup for cancer, 197, 
199 
Vegetarian diet for cancer, 192 
nations, rarity of cancer in, 202 
Velpeau, A., 76, 158 
Volumetric analysis of urine, 215 
measurement of urinary acidity, 
218 
Walshe, constitutional nature of 
cancer, 157 
Weight of body and urinary excre- 
tion, 216 
White, Charles Powell, 13, 160 
Wild animals and cancer, 169 
Williams, H. S., 189 
W. Roger, 35, 66, 90, 107, 109, 
225, 226 
Worm-like masses in chronic 
mastitis, 126 
Xanthin increased in cancer urine, 
176 
X-ray, harmful effects from, 183 
in breast cancer, 182 
influencing prognosis, 150 
Zealous, over, propagations con- 
cerning cancer, harmful, 
131