The cure of cancer is now ceasing to become a purely medical problem,
to be solved by biologists, pathologists and surgeons, and is becoming
a problem in psychology, and education, to be solved by publicists,
schoolmasters, and perhaps, when enough people are alive to the facts
of the situation, by legislators and statesmen.
This may sound a bold thing to say, but I hope to be able to bring
forward evidence proving that it is at present possible to cure
seventy-five per cent. of cancer cases with a mortality of under five
per cent.
Possibly the response to this essay will be that of one of the most
enlightened persons of my acquaintance who, on seeing my title, said,
“Of course this is perfectly absurd”, but it was a favourite saying of
Dr Maguire, a great American surgeon of the nineteenth century, that
the most useful thing one man can do for his fellows is to see a thing
clearly, and to say it plainly.
Here is a plain statement, susceptible of the fullest proof. Out of
every hundred people in our community, ten will in all probability die
of cancer; and, of those ten, seven or eight could be cured, or their
disease prevented with the present methods at our disposal. All that is
required is an intelligent facing of the facts concerning this disease,
and efficient medical attention.
The average annual deaths during the last eleven years in the United
Kingdom were 466,000,――nearly half a million people. Of these, 43,000
were due to cancer; 19,000 males and 24,000 females. Moreover, although
taken altogether ten per cent. of the population die of cancer, a
greater proportion of adults so die. I say again that a large proportion
of these cases is either preventable or curable.
The Executive Committee of the British Empire Cancer Campaign have
recently published a statement based on the last census. They say that,
during the year 1921, in Great Britain, of persons over 30 years of
age, one out of every seven died of cancer.
These figures make it plain that the question is not merely one of
interest to doctors and scientists; it is of concern to every one of
us, and to one person in every ten it has direct and very personal
interest.
Surgery and medicine have very little further to advance along
technical lines, so far as the type of case we see at present is
concerned. It is nearly impossible to make operations more extensive
and thorough than they are at present; and it is unlikely that the
operative mortality in the average good risk will fall much lower
than its present very small figure. Other methods of curing cancer do
not at the moment show promise of producing anything so good as the
present surgical results. We have therefore to resort to an educational
campaign for its victims before we can get much further on.
This brings me to the first point to be brought home before any more
is said――that _early_ cancer and _late_ cancer are, so far as results
and cures are concerned, two entirely different diseases. A well-known
English authority, speaking of cancer of the tongue, says: “An early
superficial cancer on the free part of the tongue should be, and
is, curable in practically all cases. The general conviction of the
incurability of cancer is founded on the results of operation on the
average fairly advanced case and, until this conviction is shaken, I
fear the public will remain relatively indifferent and pessimistic as
to the advantages of early treatment. Every surgeon of any experience
is aware that, as regards its accessibility to treatment, early cancer
is a totally different disease from even moderately advanced cancer,
but I am very doubtful as to whether we shall be able to enforce the
fact by direct statement so long as the treatment of advanced cases
furnishes the public with so many terrible object lessons in the
apparent intractability of the disease.”
The problem we have before us, then, is that of changing the whole
attitude, not only of the physician, but of the patient, to cancer.
Here is an example of the present point of view:――I have frequently
heard it said that such and such a patient has a lump, or some
disquieting symptom or other, but she won’t go to the doctor as she
is afraid he will say it is cancer. What we have to do is to strip
this disease of its fear-complex and bring all the facts about it into
the open. We have to change the attitude of the patient, and often,
unfortunately, of his doctor, from one of “wait and see” to one of
“look and see.” Then, and only then, shall we be on the way to curing
cancer.
The results of the present-day and popular point of view are appalling.
Somewhere about half the cases of cancer are far too advanced for
us to think about curing them at the time the patients appear. Of
the remaining half, approximately two-thirds have about a thirty
per cent. chance of cure, and the remainder about a sixty per cent.
chance. These figures are rough estimates based on impressions formed
in hospital out-patient work, but they will not be found far wrong.
The heart-breaking part of it is that it is all the result of fear,
carelessness and crooked thinking, which could be avoided in a large
percentage of the cases.
Yet there are signs that we are entering on a new phase, and that a
realisation of the importance of early diagnosis is slowly permeating
through the medical profession. In America we see an increasing
insistence on the use of detailed and specialised laboratory methods
for exact diagnosis; and in Great Britain there is in existence, at
St. Andrew’s University, a complete medical unit, under the supervision
of Sir James Mackenzie, for the investigation of the early symptoms of
disease. The establishment of this institute is, I think, one of the
most important advances that medicine has made in the last twenty-five
years, for it is a milestone on the road to progress, a concrete and
tangible expression of a changed point of view.
Let us for the moment leave generalities and give some few minutes to
more detailed consideration of the disease; first in outline, and then
in respect of some particular cases.
Cancer is a degeneration. It most often occurs at that period of life
when our biological work is done, and, as far as Nature is concerned,
we are of no use. From _her_ point of view we are on this planet to
reproduce our kind and, when we are past doing that, our tissues begin
to lose their firm hold on their appointed form, and stray from their
former habit of exactly reproducing _their_ kind when attempting to
recover from any kind of injury. Cancer is commonest in those organs
which have soonest finished their work――the reproductive organs of
women; and, after these, it appears most often in that organ so much
more abused than any other――the stomach.
The greatest number of cases appears at or after fifty, and therefore
at that age it behoves us, not to _wait and see_ whether we shall get
it or not, but to _look and see_ that we have not got it, for of people
who survive till the age of fifty, a great many more than ten per cent.
die of cancer.
From the biological point of view cancer presents another interesting
feature. It used to be generally stated by biologists that acquired
characteristics cannot be transmitted. In cancer we see a cell taking
on foreign characteristics in response to some environmental stimulus
and transmitting these to its offspring until the organism from which
it sprang is destroyed.
To sum up, the tissues from which cancer grows, in their normal
process of repair tend to reproduce themselves more or less exactly,
or if the injury is too gross, they are replaced by scar tissue; but
when we reach the age at which their biological work is done, there
is a tendency to atypical reproduction, in which an atypical cell
continues to reproduce itself atypically and grows at the expense of
the organism, eating into or eroding it as it enlarges, till it finally
kills the host on which it preys.
This will serve as a general definition, but, if we wish to be a little
more concrete, we must plunge for a while into the realms of pathology,
in order to get a clearer idea of what cancer means.
Our body is made up of three layers of tissues; each of these has its
separate function, and, within small limits, its own way of reacting
to long continued injury. Early in our prenatal development, these
three layers can be distinguished, and each of these later produces
its own type of tissue, and under appropriate conditions, its own
type of malignant tumour. From the outer and inner layers develop the
cells which actually touch the outside world, that is to say, which
cover the exterior of our body and provide our inner lining, or mucous
membranes. From the inner layer is developed glands which are, so to
speak, ingrowths from this layer, and it is the tumours arising from
this latter tissue layer which mostly concern us now, and which are the
cause of so much human suffering.
These Carcinomata, as they are called, all have something in common,
alike from the point of view of their recognition, pathology and
onset. They begin in some tissue which has previously been the seat
of disease, usually some chronic inflammatory process which has
been present for years, and which may have healed up and broken
down many times. When this occurs on open surfaces, such as the
tongue, intestinal mucous membrane, or lip, we can watch the gradual
transformation of the disease from a simple chronic inflammatory
process to that of a malignant growth.
Let us take, for instance, the case of cancer of the lip. We see an
old man who for years has been smoking a clay pipe. The stem of the
pipe gets shorter as the years go by, and consequently, as he smokes
it, hotter and hotter. One day he notices that his lip is cracked, the
crack being just on that part with which he habitually holds his pipe.
If we were to look at this under the microscope we should just see
that the mucous membrane was broken at this point. Perhaps he stops
smoking for a day or two till his lip has healed, and then continues
to smoke again. Soon, from force of habit, the pipe returns to its
old comfortable spot; and again the lip cracks. This time it is not
so painful, and takes longer to heal. This cracked lip may be present
for years, and if, after some time, we were to look at it again
under the microscope, we should see a very different kind of thing.
All round the crack would be congregated thousands of white blood
cells, trying vainly to assist the sore to heal, but, as well as this,
we should notice that, in their efforts to bridge the gap of broken
mucous membrane, the delicate epithelial cells which line our lips had
increased in number and thickness. We might also see that they had a
tendency to grow down to the deeper layers of the lip.
If we were to persuade our friend to give up his clay pipe and indulge
in some other form of smoking, or even to have a few teeth extracted
so that his pipe was more comfortable in some other position, the
small ulcer would, given time and a little attention, heal up quite
satisfactorily. But, with all the perversity of human nature, he will
not; he only has a small sore: it doesn’t hurt him, or anyone else, so
why should he worry?
We pass on another few years, and our friend reappears. This time his
sore has a more permanent appearance about it. It is hard, and somehow
looks as if it goes deep, and has a tendency to bleed. We look at it
and tell him that he ought to let us cut out that small sore, but as
a rule he won’t allow this procedure; he wants medicine to take for
it, an ointment to put on it. If we were again to have a microscopical
section at our disposal we should see a very different state of things.
Those epithelial cells which before were just thickened, and a little
angry looking, have at last wakened up and begun to grow. They have
branched out and grown deeper into the lip; there is nothing to check
them since they have thrown aside all the restraints imposed by the
necessity of keeping to their original form, and have, so to speak, got
out of the control of the usual mechanisms which the body possesses
for keeping cells in their proper place. The only thing we can do for
the patient is either to find some means to kill them――an end which
has not yet been achieved, as what will kill them will also kill the
patient――or to cut away the tissue in which they have grown, leaving a
wide margin around the farthest palpable edge of the ulcer. If this is
done, the patient can be assured of a permanent cure. But if he will
not believe you, as he often will not, possibly because you are not
willing to stake your reputation on the ulcer being malignant, or the
_certainty_ of its cure by surgery, he will go away for another year
or so. One day he appears again because his ulcer has been showing a
tendency to bleed and has got a bit bigger lately; also he has noticed,
while shaving, a small hard lump in his neck which he feels as the
razor goes over it. He still has no pain and no discomfort whatever.
We look at this and tell him that he has to undergo an operation, both
on his lip and on his neck, and that he has got cancer. We remove the
ulcer and every gland that we can find in a large area around, but
we can only assure him that he has a one in five or three chance of a
permanent cure whereas, if he had taken our previous advice, we could
have promised him a permanent cure in between ninety and one hundred
per cent. of chances, according to the age of the disease.
If we now use our microscope, we see that the undisciplined epithelial
cells have penetrated the lymphatic capillaries which are present
in all our tissues, and have followed them until they reach their
destination, the nearest glands. What will happen next depends on time.
The growth may spread to more glands, or even outside the glands, and
the only course we have open to us is to remove the primary growth,
again with a wide margin, irrespective of what disfigurement may
result, together with its corresponding lymphatic glands, trusting to
radium or X-rays to kill any stray cells that may be set free or missed
during the operation. The chances of cure simply depend on whether it
is possible to remove the disease completely or not.
The figures I have given are taken from a recent analysis of more
than five hundred cases of cancer of the lip carefully followed up.
Of cases in which there were no glands involved, ninety-one per cent.
were cured: of those with glands only eighteen per cent. were cured.
Now here is the point I want to emphasize. The average duration of
all these cases was two and a half years before operation. It is
impossible to devise any more radical operation, with a much lower
death-rate than we at present obtain, and there is no other method
which as yet produces better results than I have just quoted, but it
_is_ possible to do away with that two and a half years of waiting and
medicine. There is no reason for it but ignorance, neglect, stupidity,
self-deception and fear.
The example which I have just quoted is not an unusual one, nor, as I
hope to show you later on, do the figures materially differ for cancer
arising in other parts of the body. Cancer of the lip merely happens to
be a convenient, and easily understood, peg upon which to hang my text.
Cancer is practically always preceded by chronic irritation of some
kind or other. There may be, and in fact are, other factors which enter
into the problem, but there can be no doubt that in nearly all cases
there is what may be called a precancerous stage, which, if adequately
dealt with, will often prevent cancer appearing at all. It is moreover
a longstanding chronic condition which, as a rule, gives rise to very
little inconvenience on the part of the patient.
After this _precancerous_ stage there appears what may be called _early
cancer_, often indistinguishable to the naked eye from the original
precancerous lesion, but giving rise to great suspicion in the eyes of
the initiated on account of its hardness, and tendency to be fixed,
and its resistance to treatment. Cancer in this stage can be cured,
with results which will compare favourably with the cure of any other
known disease (i.e., in about ninety per cent. of all cases) its cure
simply depending on early diagnosis. This is a fact neither known nor
appreciated by the general public, and until it is known by everybody,
and these early stages are radically dealt with, we shall still be
spending our time and money looking for new and miraculous cures for a
condition which, in its very nature, is unlikely to be susceptible to
any method of cure when its late stages are reached.
The third stage is that in which the neighbouring lymph glands are
involved. In this stage about thirty per cent. are incurable, but these
figures are not of much help or comfort to any particular sufferer as
they depend on the degree of involvement and the rapidity of growth.
There is, in the vast majority of cases, no reason why it should ever
reach this stage other than those causes which are within the control
of the patient and his doctor.
Lastly we get to a stage in which the disease is frankly inoperable,
and generally speaking, only capable of relief by one palliative
measure or other. About forty to fifty per cent. of all cases which
reach the surgeon have already arrived at this stage, and it is to
this fact that the generally hopeless attitude of everybody is to be
attributed. It is only when this stage is reached that the patient
has pain and symptoms which “wake him up,” and that he realises the
calamity which has befallen him.
The early signs of cancer may now be summed up as those of a lesion
of some kind, extending over a number of years, giving rise to very
little trouble or inconvenience, and followed by a small hard lump or
ulcer. If the latter is present, it is often characterised by bleeding.
Again, practically no symptoms. To find it we must _look and see_;
often an operation involving practically no suffering and a very small
mortality is necessary. But the penalties of failure to do this at the
proper time are that ten per cent. of the population die of cancer.
There are certain popular misconceptions about cancer which require
correction. The first is that cancer is necessarily painful. This is
responsible for much of the late diagnosis, operative mortality and the
bad results. Only late cancer, and it would not be far wrong to say
only _incurable_ cancer, gives rise to pain. If only pain were an early
sign of cancer the whole aspect of the cancer problem would be changed.
Another very widespread delusion productive of great harm is that
cancer is constantly associated with _wasting_, and makes _rapid
progress_. These two symptoms are constantly associated with the
disease in its latest stages but are not seen at all in early cases.
One frequently hears people say that cancer is contagious, and also
that it is hereditary. These two popular conceptions probably have
the same basis. As we have seen, cancer is a very common disease, and
it would be strange indeed if, putting all question of relationship on
one side, we were not to see it quite commonly occurring in one or more
members of the same family, and if occasionally we did not find a house
in which each successive occupant for some years had cancer. I will
leave it to the mathematicians to work out the probability of cancer
occurring more than once in any given family. The necessary figures are
easily obtained from the Registrar-General’s office. As far as I know,
there is nothing truly in the nature of what may be called _evidence_
in support of either of these notions.
Time after time people have described parasites of some kind as
associated with cancer, but none of them has yet been made to answer
to any of the tests necessary to establish anything more than a
casual correlation. It may turn out to be that the causal agent in
cancer formation is a parasite either visible under the microscope,
or, what is more likely, belonging to the group of ultravisible, or
filter-passing, organisms; but even if this be so, there are two
other factors of immense importance, found so constantly associated
with the disease, that their significance cannot be underestimated by
anyone whose outlook is any wider than that of the mere purveyor of
prescriptions.
These two factors may be considered in a little more detail, as they
are of importance with regard to the question of prevention. They are
(1) the presence of an acid environment, and (2) what, for want of
a better term, may be called chronic irritation. Whatever the prime
cause may turn out to be, these can never be left out of account in any
consideration of aetiology, and even if some specific cause is found,
the discovery will not shake the validity of my thesis.
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.
Now, as has already been explained, a malignant growth, as well
as extending superficially, tends to spread very deeply and also
to involve neighbouring structures, and when X-rays or radium are
applied to it, we find that in some cases it will deal with the more
superficial parts of the growth but leave the deeper parts untouched,
or even more active than before. All kinds of methods have been tried
to get over this, such as burying radium in the substance of the
growth, and using very big doses, applied to various aspects of the
growth, but, so far, although there have been some very encouraging
results, the problem has not been solved.
As has been said, it is extremely difficult to estimate the exact value
of this treatment, as no figures are of any value till _seven years_
at least have elapsed after treatment, and no such figures have been
published. There can be no doubt, however, that an occasional case has
been cured, but it is the experience of all that the results of radium
treatment do not approximate in any way to the percentage of cures
obtained by surgery, even in those types of cancer which react best to
X-rays or radium.
Dr Knox, of the Cancer Hospital, London, who has had much experience
of high tension X-rays, says that the treatment of malignant disease
by X-rays has not yet reached that stage where it ought to be given to
any operable case instead of an operation. I think this opinion may be
regarded as an authoritative statement of the situation as it is at
present.
This is not all, however; X-rays and radium have a very important place
in the treatment of cancer, and as far as we can see at present, the
future hope lies in a judicious combination of one or the other of
these with surgery, for early operable cases, and their prolonged and
intensive use in those advanced cases which cannot be removed by other
means. A few advanced cases have even been rendered operable by this
means.
In combination with surgery this method has its very greatest use in
the prevention of superficial recurrences. In every operation, in
spite of the greatest care, it is impossible to avoid the setting free
into the tissues of a few cancer cells which may grow later into a
recurrence. Post-operative radiation bids fair to abolish this type
of recurrence, which formerly accounted for a good percentage of all
recurrences.
From time to time many methods have been brought forward which have
for a little while promised well, but so far none of them has produced
results in any way comparable with those obtained by complete removal
of the growth by surgical means.
I have not dealt with these in any detail here because, whether
ultimately we use drugs, surgery, violet leaves or any of the recently
popularised methods of “taking thought” to cure the disease, the main
point of my thesis will still hold good, and that is, that by far the
most important factor in the cure of the disease is that of _early
diagnosis_. This lies in the hands of the public far more than in those
of the medical profession. If the public want early diagnosis they will
get it, when they insist on it, just as they get anything else they
insist on, from self-government to prohibition, no matter how good or
bad it may be for them.
Briefly stated, most cases of early cancer are curable, and the
diagnosis of early cancer is only to be made by _looking_ instead of
_waiting_. On these facts, certain constructive proposals can be based.
They are so simple that they are not likely to be heeded for some time
to come, for the public has always preferred Abana and Pharpar, rivers
of Damascus, to washing in Jordan, and I suppose always will do, till
we reach a more enlightened age.
Nevertheless I believe it is true, and without exaggeration, to say
that about ninety per cent. of all cases could be cured or prevented if
the following statements were accepted.
If all persons over forty years of age were routinely examined once
every six months to see that they had not cancer, or a precancerous
condition, and if these when found were promptly dealt with, then
cancers of the rectum, tongue, lip, breast, skin and uterus would cease
to be the plagues they are at present.
Similarly, if every patient who had taken more than a pound of bismuth
to relieve gastric pain were routinely explored to see that cancer
or gastric ulcer did not exist, the large majority of growths in this
region would be either prevented or cured. Similar rules can easily be
devised to deal with cancers arising in other parts. What is wanted
is a change of attitude on the part of everyone concerned. After all,
a fortnight in bed, with forty-eight hours of discomfort, is not too
great a price to pay for freedom from this disease, and, with proper
examination, even this would be unnecessary in most cases.
Every intelligent person is aware that, in order to ensure freedom
from dental disease, it is necessary to have his teeth examined every
six months, and to have small lesions dealt with in their very early
stages. All have come to this conclusion because they know that
neglected dental disease means pain; and they now look to see that
their teeth are normal, instead of waiting for a toothache to come.
It is true that there are still some of our weaker brethren who still
wait till they get toothache before they visit the dentist; and for
them there is nothing to be done. In the same way, if we wait for the
advanced signs of cancer to develop, the position with regard to its
cure will remain approximately what it is to-day.
The education of the public up to this pitch is by no means an
impracticable proposal. The position with regard to appendicitis is
very much the same as that of cancer. What has been done in the case
of appendicitis? The mortality is in proportion to the number of hours
during which the disease has existed. Twenty years ago appendicitis
was responsible for a large number of deaths. During 1919 and 1920
there was, in a large London General Hospital, only one death from
appendicitis, and yet there were at least 5 cases dealt with every
week. This improvement is entirely the result of education of the
public and their doctors. They know that to be cured operation must be
early, and so we no longer wait to see whether the patient is going to
die; if we suspect it, we look and see whether it is present or not.
True, we remove unnecessarily a fair number of appendixes but, by so
doing, we purchase, for a much larger number of people, immunity from
death by this disease. When exactly the same principle is applied to
cancer we shall be in a position to be a great deal more satisfied than
we are at present.
One of the most successful ways of treating a patient with
fixed ideas is by the use of _explanation_ combined with strong
_counter-suggestion_. This is the method of psycho-analysis and
hypnotism. No patient is more susceptible to this kind of treatment
than that capricious lady, Public Opinion. If we want to realise the
ideals put forward in the early part of this essay, we must mobilise
all our resources: the Press; the Platform; the Consulting Room: for
a prolonged and intensive campaign against this black spot on our
civilization.