Part 3

For two thousand years people have speculated about the origin of cancer. Galen held a theory somewhat analogous to the present Chinese doctrine of the _yin_ and the _yang_; he taught, in essence, that some kind of “ch’i” had got at loggerheads with its fellow gases, and that the result was a general disturbance of bodily functions. Paracelsus thought that the salt balance of the body was upset, and textbooks still sometimes put this into modern medical terminology, saying that the balance of power between different types of cells is disturbed. This may or may not _describe_ what happens, but it is a long way from _explaining_ it.

In the sixteenth and seventeenth centuries cancer was often referred to as an “act of God” in punishment for sin. For instance, cancer of the tongue was said to afflict those who spoke against the Church, a view that the Church, not always strictly scientific in interpretation of phenomena, did not discourage.

Here is a translation which Sir D’Arcy Power has made from Paul de Sorbant, a German physician writing in 1672, in his _Universa Medicina_. “We saw”; he says, “an ulcer of the tongue degenerating into cancer in the noble baron Vertemali, which caused such a haemorrhage from destruction of the sublingual arteries and veins that the patient was suffocated. He recognised with great penitence that the cause of this cancer was a divine punishment because he had often abused the clergy.” Benetus, about the same time, in his book called _Medicinae Septentriniolanus Collatitia_, describes a case of what he calls “Tumor Linguae Miraculosa.” Here is a translation of part of it. “There was lately a certain baron who had a very poisonous tongue. He not only directed his jibes against all and sundry, but he kept his most venemous shafts for the clergy and those who devoted themselves to God’s service. He was caught at last in the very act, by a holy brother of good repute as he was pealing this cursed bell, who said to him: ‘Your foul tongue has overlong deserved that punishment from an offended God which it will shortly receive.’ The Baron went off undismayed, but a few days afterwards a small swelling began to grow on the side of his tongue. Little by little it increased in size until it became an inoperable cancer, and at length the tongue having become incurved, twisted and drawn back to his throat, miserably afflicted, but penitent and confessed, he was summoned before the Great Judge who calls his servants to a most strict account.”

This may all seem very far away and out of contact with our present-day thought, but only two years ago a dear old lady sent to the Cancer Hospital Research Department two pages of closely written typescript, the gist of which was that she was withdrawing her usual annual subscription, as, after giving the matter a great deal of thought, she had come to the conclusion that cancer was caused by the consumption of alcohol. So she proposed to forward her usual subscription to the local Temperance Society which really was striking at the root of the problem! The Secretary wrote and pointed out that cancer is very common in cats who are strict prohibitionists! The old lady did not reply!

Let us come back again from theory to fact, and consider some of the factors which we know constantly to be associated with cancer, and which we are justified in regarding as being, in many cases, more than predisposing causes.

The most important of these is chronic irritation. We find that almost every cancer is preceded for a longer or shorter period by what may be called a precancerous condition. The more our knowledge increases the more we are finding out that this holds good.

The commonest sites for cancer are the womb, the breast, and the stomach. These together account for more than sixty per cent. of all cancers, and far below them in frequency we find the tongue, the lip, and the bowel, and the various glands.

Cancer of the womb is constantly preceded for many years by disease, palpable and curable, often the result of childbearing, and the part where it occurs is one bathed in an acid medium.

Cancer of the breast also is constantly associated with preceding chronic inflammation, this condition itself producing, as one of its by-products, a highly acid substance, further to irritate the delicate cells already near the end of their tether. Mechanical irritation, beyond a doubt, is an important factor. Although in civilised countries the disease is distressingly common, in those countries where the breasts are habitually uncovered, cancer of this organ is extremely rare. The habitual friction of modern clothes predisposes cell-growth, infection from no matter what source is given a foothold, and after years of abuse, the cells lose the impulse to normal reaction and at last turn and slay their victim.

There is evidence that about two-thirds of all the cases of cancer of the stomach originate in an old gastric ulcer, and the constant eating of hot food is perhaps enough to account for the remaining third. The delicate gastric cells, more abused than any other cells in the body, are bathed in a highly acid medium. It is no wonder that departure from their appointed path accounts for thirty per cent. of all cancers in men, and in women as well, if we except the two conditions just mentioned.

In cancer of the kidney, the bladder, and the gall bladder, stones are nearly always present to initiate the irritation.

In cancer of the tongue, syphilitic or other preceding conditions are nearly always there, whether it be the irritation from raw alcohol, hot tobacco smoke, or a broken tooth. It is interesting to note that, until syphilis appeared in Europe, cancer of the tongue was practically unrecorded in the existing literature. We have no need to go any further for examples of these precancerous irritative conditions. They are all curable or removable, but, as they do not as a rule give rise to acute painful symptoms, severely inconveniencing the patient, they are difficult to treat, and the unfortunate patient is told to _wait and see_, and is given medicine which may for a while relieve, but which――alas!――seldom has a chance to cure, or to prevent the fate which is slowly overtaking him.

So far the evidence which has been brought before you, that chronic irritation has a causal connection with cancer, has been of a circumstantial nature: it has often enough been found in what we may call suspicious circumstances, but that does not prove that by itself it can directly cause the disease. If a man is seen hanging about the place where a burglary has been committed, it does not prove that he participated in it. He may be a burglar, or he may be what lawyers call an accessory before the fact, and before we can feel reasonably sure that he is a guilty party we must, unless we can actually see him committing the crime, find that whenever he is present, and he has a chance, a burglary takes place.

Now in scientific investigation we can do what in ordinary life is not possible; we can take our burglar, arrange a set of suitable circumstances and see what happens and with what degree of regularity thefts occur. In the last four or five years something like this has been done on a large scale with cancer, and a large body of evidence is accumulating which suggests that, given suitable circumstances, chronic irritation will produce cancer with a fair degree of regularity, at least in some places. If it will do so in some places there is no reason to doubt that, under circumstances which for the moment we do not quite understand, it will do so in all the places where cancer is found.

That this is so has not yet been completely proved, but I think there is a good deal of evidence along this line. It has been known for a great number of years that certain skin cancers are constantly found in people whose occupations necessitate their skin being in contact with certain chemical irritants. For instance, the workers in shale oil are often afflicted with cancer of the skin. In the spinning industry, when reaching over to deal with the machinery, a place on the worker’s leg is always rubbing up against an oily spindle. This process goes on for years at the same spot, and these people are found frequently to get cancer, beginning at the irritated place. Some aniline dyes are excreted in the urine, and growths of the bladder are very frequent in aniline workers. In India, some native tribes carry little metal boxes containing charcoal next to their skin in order to warm themselves, and the warmed spot frequently becomes the seat of a malignant ulcer. Further, in chimney-sweeps, whose skin is always more or less impregnated with carbon, we find that cancer frequently develops in those places where the soot is difficult to wash completely away and often is not cleaned off for years at a time. Finally, we have the well-known examples of skin cancer among X-ray workers, and mouth-cancer in those who chew betel nut.

Now it is just this type of cancer that we have the opportunity to imitate in the laboratory. Dr Leitch, of the Cancer Hospital, has taken rats, guinea-pigs and rabbits; and, day after day for months, soot, tar, oils and all the irritants he could think of were respectively painted on some selected part of their bodies. At the Cancer Hospital he started using tar to paint on the under surface of the bodies of white mice. This was done every morning for several months, and, in a large percentage of cases, small warts were produced. The fate of these warts varied; some of them disappeared, but others progressed to the formation of true cancer. The results of these experiments made it extremely probable that the irritants were the direct cause of the cancer. Of course it is not _proved_, for it is possible to assume that there is some ubiquitous “other cause”, only waiting till the tissue resistance is lowered enough by the irritants to get its chance to act. Another interesting fact, which transpired as the result of this work, is that some of the animals from whom the warts disappeared developed cancer a month or so subsequent to the disappearance, thus showing that the _predisposition_ to cancer formation is acquired long before the growth actually appears.

In human beings, the process of cancer formation in response to chemical irritants takes much longer (often twenty to thirty years), and is preceded by much the same sort of preliminary skin reaction as in animals.

In looking for a proximal cause for cancer production, we should not, I think, look for a common cause in all cases, but should try to find something or _anything_ which will produce the necessary previous irritation.

It has not, I think, been established beyond a doubt that chronic irritation is the _sole_ exciting cause of cancer――this in the nature of things would be very difficult to prove――but it has been shewn that its presence strongly predisposes to new growth formation.

The problem which now arises is that of how we are going to put this knowledge we have gained to practical use in the prevention of cancer. In order to solve this we will consider in some detail the three commonest cancers met with, namely cancer of the breast, the womb and the stomach, and we will see how the problem applies to them.

Now in cancer of the breast we have this outstanding fact that, almost all the cases show for some years beforehand obvious signs of chronic inflammation of the breast, and in nearly all of them this precancerous stage can be seen, when they are examined microscopically.

Obviously this is the time to deal with the disease; and the way to do so is systematically to examine microscopically (by a procedure in itself devoid of all risk, except the very small one due to the administration of a general anaesthetic), every _doubtfully_ malignant breast, afflicted by chronic inflammation. This may seem a revolutionary thing to say; but if we set ourselves to deal with this plague in the logical manner that we employ when we sit down to deal with any other pest, and, if we follow all the facts known to their inevitable conclusion, we are driven to it, and we shall see that there is no other course open to us but to _deal in a wholesale manner with the precancerous condition_. To do this we shall have to undertake a long campaign of education. One of the leading authorities on breast cancer in America, did undertake such a campaign in his own district, with the result that, from the enthusiastic propaganda of one man, the proportion of precancerous to fully developed malignant lesions which appeared at his clinic rose in six years by thirteen per cent. In twenty years the proportion of fully developed cancer to pre-malignant lesions dropped from ninety to seventy-eight per cent.

I am quite sure of the fact that the adoption of this proposal would mean operations upon a number of breasts which would never become cancerous, but, so far as I can see, we cannot help this, any more than we can help vaccinating a large number of people who will never have small-pox, or, when we isolate diphtheria contacts, can we help disturbing also a large number of people who will never get diphtheria. The public have been educated to regard these precautions as natural and proper, and as a rule raise no objections to their being carried out. Dr Bloodgood, to whose educational work I have just referred, states that if any woman could be kept under sufficiently close observation, she could be practically assured against death from cancer. I think every other surgeon of experience would agree with him.

So much for prevention and the precancerous lesions. Let us come to the question of the cure. Here we find that the chances of cure in any particular case simply depend on the stage at which the case appears for treatment. We can for convenience divide cases into two groups; those which have glands involved and those which have not. By this I mean those which have glands so grossly involved that they are appreciable to the touch. Again quoting Dr Bloodgood, it is found that of those cases with gland involvement, twenty-three per cent. only are cured after seven years but, of those without gland involvement, sixty-five per cent.

Now, here is the fact which ought to rouse us to action: the average duration of the disease in these cured cases was nine months――_nine precious months_ in which that remaining thirty, or forty, per cent. might have been cured _if they had only been treated earlier_. Or, if they had been properly examined still earlier by a trained person, the disease could have been dealt with earlier with a still better chance of ultimate cure, and it is Dr C. H. Mayo who has said that there is no reason on earth why about ninety-five per cent. of all cases of cancer of the breast cannot be permanently cured.

So far we have spoken in detail of cancer of the breast but, when we come to deal with cancer of the uterus, we shall find that the facts are almost exactly analogous, only that the results of indecision and delay are even more deplorable. We find that, by the time they come for treatment, about half the cases are quite incurable, and those which are operable are as a rule a great deal further advanced than those of cancer of the breast. In spite of this we find that out of two hundred consecutive cases no less than forty per cent. were cured; that is to say, had no recurrence within seven years. All the cases which were operated on had had quite definite symptoms for six months. In other words, the patient herself should have come for examination six months before she did, and if she had been examined in the course of a proper routine, the disease could have been discovered far earlier than was the case.

Quite recently, a report of a series of cases has been published by Professor Faure, a distinguished French gynæcologist, which so exactly illustrates my views that perhaps I may be forgiven for making use of it. Faure cut ninety-six cases of cancer of the uterus and has divided them into good cases, mediocre cases and bad cases. It is significant that there were only twenty-one “good” cases, thirty-five “mediocre” cases and forty “bad” cases. The good cases are what I have called early cases, the mediocre cases correspond to moderately advanced cancer, and the bad cases to those which are on the border line between operability and non-operability. His total results approximate very nearly to most other published lists but their analysis is very significant. Of the good cases there was one operative death; of the remainder seventy-five per cent. were cured and twenty-five per cent. recurred.

Of the mediocre cases there was an operative mortality of 8.57%. Of those surviving the operation 62.5% were cured and 37.5% recurred. In the bad cases there was a post-operative mortality of 22.5%: only six were cured and twenty-five recurred. That is to say, respectively, 19.35% were cured and 80.65% recurred. These figures tell their own tale.

With this hopeless condition of affairs it is no use saying that the results of surgery are bad. They are; but it is not the fault of doctors, or the methods at their disposal; it is the misfortune of the patient that her lack of proper education must bear the blame.

Cancer of the uterus is in many cases preceded by precancerous lesions, all amenable to various kinds of treatment. Again, the only way to deal with it is not to wait and see whether a woman has got cancer but to look and see that she has not. Until this is our attitude, the results are not likely to be much better, whatever the means at our disposal for its cure.

Finally, turning to another great group of cancers which make up thirty per cent. of all in men (and in women too, if we exclude the two previously mentioned types), we find exactly the same condition of affairs.

In two out of every three cases of cancer of the stomach there is evidence that it has arisen in an old ulcer, and Dr Mayo has suggested that eating hot food may account for the remaining third. It is moreover the experience of all surgeons who systematically submit all gastric ulcers upon which they operate to microscopic examination, that about twenty per cent. of them all are malignant.

We have before us the plain fact that from ten to twenty per cent. of all chronic ulcers which have come for surgical treatment are already malignant and can only be cured by a complete removal. Another fact also requires taking into the most serious consideration, and this is, that it is the considered opinion of by far the large majority of experienced surgeons that exploration and some form of operation is the best treatment for every case of chronic gastric ulcer which has recurred once, or at least twice, after a thorough course of medical treatment. (The term “chronic gastric ulcer” is here used in its strictest scientific sense, and by it is meant an ulcer whose diameter in any one direction is more than a centimeter, and whose edges are hard and thickened). In spite of this, a distinguished surgeon recently put on record that every case of gastric ulcer upon which he operated had on an average been “cured” nine times. Why is this? The reason is clear. In nearly every case the symptoms of gastric ulcer (and, remember! twenty per cent. are already cancerous) can be relieved for a time by palliative treatment, when once again the deluded patient thinks he is cured.

There is no need for me to point the lesson from this. I have put forward the facts, and every one can draw his own conclusions. There is only one gleam of hope that I can see on the horizon, and that is, in dealing with the disease in an early stage by radical measures, and, in twenty per cent. of the cases, thus combining prevention with cure.

Again, we must alter our attitude. We must look and see, not merely “dope” and see! Once symptoms of this disease have recurred after efficient treatment, there is only one good reason for not looking and making certain, and that is when the risks of looking exceed those of the lesion being malignant――that is to say, somewhere between ten and twenty per cent. At present, the risks of looking are about one in a thousand, and the risks of removal of a cancer about three per cent., taking all cases, most of which are at an advanced stage. The operative risks of earlier cases are less than this, and to this must be added about a two per cent. risk of a further operation being necessary――in all, not exceeding five per cent.

I realise that the adoption of this policy will mean a certain number of otherwise avoidable operations. I know that it will mean operating on a few cases that would otherwise get better by themselves, or by other means. But until it is adopted, there is, as far as I can see, no prospect of reducing the death-rate from cancer of the stomach. For so long as indiscriminate medicine-taking has precedence over exact methods of investigation and treatment, so long will cancer of the stomach continue to make up thirty per cent. of all cancers. Again the question is largely out of the hands of the doctors. As long as patients come to a doctor wanting “a bottle of medicine, doctor, just to help me carry on”, so long will they get it, as the doctor finds it hard to refuse. For he knows the patient will go from doctor to doctor till he gets what he wants.

I have dealt in some detail with the three commonest types of cancer, but the same arguments apply to all. The problem is not so much how to cure cancer――so much can, and is being constantly done by one method or another――but how to educate people so that we can get hold of cancer early. The problem is one of diagnosis, and is therefore to be solved by education and courage, not by hesitation and fear.

No statement of the cancer problem would be complete without some mention of two methods of treatment which have recently come much to the fore: namely, the use of X-rays and of radium.

To give any really useful account of these is very difficult, as no really satisfactory groups of cases have been published, and one can only speak from one’s own experience and that of colleagues who have been working with them.

The action of both these methods of treatment is in essence the same. It has been found that X-rays and radium have the power of destroying living tissue when such is exposed to their action for varying lengths of time. Fortunately, cancerous tissue is destroyed before normal healthy tissue, and it is the aim of the treatment to expose the growth to that dosage of rays which will kill the malignant tissue but just fall short of doing harm to the normal tissue. Sometimes this is more easily done with X-rays and sometimes with radium; it all depends on the position of the growth. This all sounds very attractive, and one would think that, on the surface of things, with such a weapon at our disposal, every case could easily be efficiently dealt with. But, like many other superficially attractive things, it is found on further examination to have its drawbacks. Although a proper dose of X-rays will kill cancer tissue, a smaller dose will stimulate it to further action. Further, these rays have, comparatively speaking, a very low penetrating power. They are absorbed and rendered inactive by thin layers of metal, of skin or of other tissue.