Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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The Medical Aspect of Cancer

Into any discussion of the problem of cancer there are immediately projected three human factors, the patient, the patient's physician and the specialist.

The great objective of the present campaign against cancer is the patient, actual or perspective. Never before has knowledge been more generally the property of the people. Nevertheless, ignorance and superstition still sway many minds. Avarice, fear, and credulity have not been eradicated from human nature. As long as "cancer cures" can be advertised from sea to sea or hawked from door to door, as long as cancerous and quacks abound, just so long will there be found persons to believe their cruel claims. The public must be educated. They must be shown the need and value of frequent physical examinations. They must know that any chronic ulceration or any abnormal tumor or swelling is pathological, will probably not disappear, and is a source of danger. They should be taught that any unnatural discharge from the nipple or from a body cavity, or any persistent or recurrent abdominal symptom must be investigated. Women must learn that a lump in the female breast eight times out of ten is, or will become, malignant; that any irregular uterine bleeding, especially intermenstrual or post-climacteric, however slight, is a signal to be heeded. It must be emphasized that cancer is not loss or weight. Bloodgood claims that benign tumors of the breast are more painful than malignant ones. As a matter of fact, pain and cachexia are late rather than early signs in cancer. Twenty p.c. of breast tumors occur under 40, and over five p.c. of all cancers under 35 years of age. The public must be instructed in at least the rudiments of scientifically correct anatomy and physiology, and in the early signs of cancer. All must realize that cancer in its incipiency is strictly a local disease, usually in an accessible area, that in a degree it can be prevented, and if taken early can be cured. About forty p.c. of all cancers have a recognizable precancerous stage or lesion. Cancer is a dangerous, insidious, rapidly increasing foe, and procrastination in beginning the end of cancer that should be feared.

How is this instruction and education of the public to be accomplished? It is, unfortunately, true that the medical profession is distrusted and discredited generally. The discussion of the causes thereof is beyond the scope and bounds of the present paper. We can only slowly retrieve our position as leaders. This we are accomplishing. Meanwhile, in the campaign for the control of cancer, all possible legitimate means should be employed to reach the public eye and ear. The education afforded by the relations of physician with patient or groups of patients may be very valuable but must necessarily be very limited in its scope. The fight against consumption has given us many lessons. Dr. Winters of Koenigsberg in Prussia was one of the pioneers in publicity about cancer, and his reports are favorable. Newspapers are the greatest hope and aid, and the attitude of the best on all medical subjects is most encouraging. Pamphlets', magazines, nursing journals, women's club, and societies should be used as a means to the end in view. Nurses, midwives, druggists, social workers, and spiritual advisers should be enlisted as missionaries of the gospel of prevention and early treatment.

What has the medical profession done to educate its own members about cancer and to disseminate this knowledge? As early as 1792 a cancer ward was opened at the Middlesex Hospital in London. In 1804 John Hunter started a medical society for the investigation of the cause of cancer. The present great movement began in England and Germany early in this century. The first International Association for Cancer Research has headquartered in Berlin. In Germany Ehrlich's and Wasserman's Laboratories and Czerny's Cancer Institute, and the Imperial Institute for Cancer Research under Dr. E. F. Bashford in England are known to you all. In Germany there are, or at least were, nine medical organizations and elven special societies entered in the fight. There is scarcely a so-called civilized nation of either hemisphere that is not now organized against the scourge. In the United States the American Medical Association, the Clinical Congress of Surgeons of North America and many other medical organizations have cancer committees. The American Society for the Control of Cancer was organized in 1913 to "disseminate knowledge concerning the symptoms, diagnosis, treatment and prevention of cancer, to investigate the conditions under which cancer is found, to compile statistics in regard thereto". Its ambition is to coordinate all existing forces into a single nation-wide effort to reduce the cancer death rate. It has interested the United States Census Bureau to publish a special cancer mortality report of the registration area for 1914. The best men of this country are associated with it and its influence will be felt. The Caroline Brewer Croft Fund for Cancer Research at Harvard, the Huntington Cancer Research Fund at Cornell and the George Crocker Laboratory in New York City are well known in the East. The Institute for the Study of Malignant Disease at Buffalo was started in 1899 and was formally placed under State control in 1901. No physician in New York State need lack pathological report on tissue. Twenty-six states are attacking cancer. Since 1909 the Pennsylvania Medical Society has been most active in this work. Through the influence of Dr. J. M. Wainwright of Scranton, Chairman of its Cancer Committee, sixty-six medical journals devoted the last July number, wholly or in part, to the subject. These workers in the field of purely scientific research are organized as the American Association for Cancer Research. The literature on cancer is vast. Of special journals, there are Cance in English, Krebsforschung in German, and Tumori in Italian.

What can the medical profession tell the public about cancer? The study of malignant growths has passed through various stages clinical, pathological, osteological and experimental. The experimental methods were made possible by the discovery of mouse tumors in 1902, and by the growth of cancer cells in vitro. What have men and methods and the years taught us?

1. How prevalent is cancer? Cancer causes about 5 B.C. of all deaths and about 8.6 p.c. of deaths above the age of forty-five. Not less than half a million dies of it every year throughout the civilized world. 75,000 succumb to the disease in the United States annually, of which about 40 p.c. are of the stomach and liver, 14 p.c. of the female generative organs, 12 p.c. of the intestines, 8 p.c. of the female breast, and 2-4 p.c. of the mouth and skin lesions are cancerous. It has been stated that one woman in eight and one man in eleven over the age of thirty-five years die of cancer. After forty years cancer is more of a menace than consumption. In the year 1913, there occurred in the United States in round numbers 45,000 deaths from cancer and 29,000 deaths from pulmonary tuberculosis over the age of forty.

2. Is cancer increasing? Sarcoma has probably changed but little, but carcinoma and epithelioma have practically doubled in the last thirty years. The annual death rate from cancer in Holland in 1875 was about 50 per 100,000 inhabitants; it is now over 100 per 100,000. In England and Wales in the decade 1851-60 there were 6000 deaths from cancer; in 1890-99, 30,000 deaths. The figures for the United States, New York States, the counties comprised by the Sixth Districts Branch and the city of Elmira are shown on the chart. Of course, it is only the figures of the more recent years that are of much value, but the absolute increase is very evident. In the United States, the death rate has increased to more than 25 p.c. in the past fifteen years. In the others, the rate has more doubled in the past quarter of a century. In the city of Elmira in 1913 more person were reported dying of cancer than of pulmonary tuberculosis. This increase has been general throughout the world, more marked in the cities than in the country, and more in the male than in the female. The gastrointestinal tract gas been the part of the body most affected by the increase. Such an increase cannot be entirely explained by better diagnoses, by more truthful reports, by more careful statistics nor by increased average human life.

3. Is cancer a disease of civilization? It would appear to be, though reliable figures are naturally lacking. In African negroes' cancer is said to form less than .33 p.c. of all tumors: among Europeans about 5.18 p.c. In this country, cancer is much less common in the colored race. In 1913 in the United States, the cancer death rate per 100,000 living was so for whites and 57.3 for colored. Japan is said to have a cancer death rate of 83-93 per 100,000.

4. Is cancer hereditary? Without question, the predisposition to cancer is to some degree transmissible. Clinicians record its possible influence in from 10 to 20 p.c. of their cases. Miss Maud Slye of the Sprague Memorial Institute of Chicago has shown that cancer can be bred in and out of mice at will and that resistance to cancer is a dominant Mendelian characteristic. Heredity influence cancer by determining the character of cell reaction to certain injury.

5. Is cancer infectious or contagious? All reliable evidence, clinical and experimental, speaks against it. Those most exposed are not more subject to it. It presents none of the picture of infection or immunity. The so-called houses have a better explanation on the basis of their usually poor and shifting inhabitants or heredity. The so-called cancer areas are not proof of infection. It is interesting to note, however, that while so called "cancer islands" occur in districts otherwise free from cancer, "cancer-free islands" do not occur in districts presenting a general diffusion of cancer. The fowl neoplasm of Rous is surely not a carcinoma if it is true malignant tumor at all.

6. What is the cause of cancer? An age-old question, to which still we can give no answer. Senile tissue changes are not an adequate cause. The theories of Cohnheim and Ribbert cannot explain all, cancer. We have no proof that it harbors a microorganism, though many have been called but none have been chosen. Even the earthworm has been maligned as the intermediate host. Green of Edinburgh believes that the smoke and combustion products of coal play an important role in cancer production and cities proof of his claims in comparative figures from the coal and wood burning districts of Great Britain and France. It is worthy here to note the possible part that soot may play in the chimney sweep's cancer and in the Kangri basket cancer. Barth claims that there is more cancer where the soil is chalky and less where silicates abound. This is reminisced of Zeller's treatment with silicates and arsenic. Lane of London believes that cancer is a late result of intestinal stasis. Some believe that civilized man has malignant growths because his food has been deprived of its natural mineral constituents. Laboratory workers have observed that an excessive carbohydrate diet seems to favor the development of experimental cancer, while Bulkery is firmly persuaded that forage protein is the crux of the matter. Dr. W.J. Mayo in an address before the American Surgical Association asks, "It is not possible, therefore, that there is something in the habits of civilized man, in the cooking or other preparation of his food, which acts to produce the precancerous condition".

Chronic irritation or oft-repeated trauma play some part in cancer production in many instances. Fibiger of Copenhagen beautifully demonstrated the action of parasites in tumor growth in the rat's stomach. We are all familiar with the occurrence of cancer in scar tissue, in leucoplakia, in ulcers, especially of the stomach. Five per cause cancer of the gallbladder. We all know the relative frequency of cancer at the narrowed angulated portion of the gastrointestinal tract. The public itself is acquainted with the smoker's cancer and the dangers of the X-Ray. The chimney sweep's cancer of the scrotum in England, the bladder cancer of the anillin worker and of the forearm of paraffin worker in Germany, the check cancer of the buoy chewer of the Far East, and Kangri basket cancer of the thighs and abdomen of Kashmir are notable example of chronic irritation causing cancer in unusual locations. We do not know how or where the chronic irritation acts, but the evidence of its influence in cancer production is overwhelming.

The real facts are few, the results of the year are meager. We can say that cancer arises from predispositions plus chronic irritation. The predisposition, as well as the reaction to cancer, seems to be local. It is, however, perfectly reasonable that some general body condition or condition, call it metabolic if we will, may render possible or facilitate the transformation of normal or of a congenitally deficient or abnormal cell into a cancer call, under the influence of some irritant. The balance between a living cell and its host is very delicate. Irritation, mechanical, thermal, chemical, infectious the deciding factor. We do not know the method or the agent that upsets the equilibrium between cell growth and cell restraint. As a matter of fact, we haven't yet answered the simple question why any cell grows. Dr. Wood says that the problem is to be attacked by clinical medicine, experimental pathology and general biology. 7. And, finally, can cancer be cured? Though a few spontaneous recoveries from cancer are on record, for all practical purpose the mortality of cancer, interfered with or treated "medically; is 100 p.c. Surgery is the only treatment worthy of the name that we possess. Its success depends entirely on prevention and early diagnosis. In superficial cancer, it should be 100 p.c. efficient. Postoperative results for five years vary greatly, but it is claimed that 80 p.c. of cancers of the lip, 20 p.c. of cancers of the tongue, 40 p.c. of cancers of the colon 30-50 p.c. of cancer of the uterus can be cured if the axilla is not involved, an only 25 p.c. if this has taken place. Probably less than 1 p.c. of cancer of the stomach remains well for five years after the operation, though the Mayo Clinic, Wertheim and a host of other operators report not satisfying but encouraging results. It is a far cry back to the statement of Dr. Agnew in 1890 who said that he had never cured a cancer of the breast. It is only the uninformed and the pessimist that says that a person with cancer has only one chance in ten, or in other words that cancer today has a mortality of ninety percent.

The second human factors in the cancer problem is the patient's physician. He must prevent cancer, he must recognize precancerous lesions, he must diagnose cancer, he must be honest about cancer. Any chronic inflammation, irritation or lesion of any kind anywhere in the body should be remedies. This is especially true of the skin, of the junction of skin with a mucous membrane or of mucous membrane with mucous membrane, and at the orifices a point of constriction of the gastrointestinal tract. 98 p.c. of women with cancer of the cervix have borne children. The physician must take cognize of an irritating pipe, a jagged tooth, an ulcer of the stomach. Moles, ulceration, tumors anywhere are a source of the danger. A digital rectal or vaginal examination may save a human life. No symptom is too slight not to merit recognition. Indigestion, flatulence, abdominal pain, hemorrhoids, diarrhea's, and constipation need investigation first and treatment afterward, such diagnoses, as well as dyspepsia, colic, metrorrhagia, change of life tumor and many others belong to the limbo of the past. They are symptoms of diseases, not disease itself. Tuberculosis, syphilis, and cancer should always be considered as cause of the symptoms in any given case.

It is the duty of the medical observe to observe and to record and to impart the results of his observations honestly to the patient or the patient's family or friends.

Two years ago, last November a woman of 52 came to me with a history of serval months of increasing constipation and localized paroxysms of cramp-like abdominal pain. Examination revealed localized visible peristalsis. An exploratory operation was advised and was refused. From that November till the following April another physician treated he constipation, by toniest for her anorexia and wasting, and gave her morphine for her pain. He then gave her up to die. She drifted back to me and was explored. She had a carcinoma at the hepatic flexure of the colon with extensive metastases. The tumor was inoperable.

None is infallible, every one of us errs in judgment, but we can at least make the efforts to be honest. If we do know and are sure, the course is clear. If we do not know, if we are not sure, an appeal for help and counsel is imperative, not to someone, however, who can bluff better than we or who gives lip-service only. The writer of this paper has not been in the practice of medicine as long as the most of those present here today, but he is fully persuaded that the policy of honesty in the long run pays. By honesty is not meant lack of tact or lack of gentleness. The patient comes to the physician in trouble and fear for advice. He or she naturally shrinks from disagreeable truth and prefers an agreeable falsehood. Your patients will honor and respect you for an honest opinion, and though you may be reviled and deserted your reward is sure.

The medical profession itself is largely responsible for much of the present attitude of the public toward operative procedures. The family doctor has been apathetic, skeptical, overconfident, grossly careless and incompetent. 18-25 p.c. of breast tumors are inoperable when they come to the surgeon, 26-39 p.c. of cancers of the stomach. Or the cancers of the uterus that Peterson saw through a period of ten years only 23.4 p.c. were operable. Kelly through a period of twelve years saw only about 54 p.c. that were operable. Dr. Howard Taylor reported that in New York City not one case in twenty of cancer of the uterus is operated on in time, and that of all dying of the disease only 25 p.c. had the benefit of a hysterectomy. The Cancer Committee of the Pennsylvania State Medical Society has published some illuminating and humiliating facts. of 382 cases of cancer investigated only 68 p.c. of superficial and 48 p.c. of deep cancer were operable when they reached the surgeon. In cancer of the cervix, the patient waited an average of four months before consulting a physician and then an average of eight months were allowed to elapse before any operative procedures were undertaken. In all cancers one year or more was allowed to pass between the discovery of the tumor a surgical aid. 3 p.c. of breast cancers were not examined, and 13 p.c. were given salves or told to wait. 9 p.c. of stomach cancer was not examined. 10 p.c. of cancer pf the cervix was not examined, and 20 p.c. was told to wait. Deaver found in 200 cases of breast cancer that an average of three years had elapsed between the discovery of the lump and the time of operation. I am not to be wondered at that both patient and physician have become skeptical about the surgical treatment of cancer. The best surgery is important in the face of such condition Such delay. On Part of patients and advisor, is criminal. The record of the general practitioner is pretty black. But there is another cause for the public's distrust. Too many prolapsed kidneys and uteri have been needlessly suspended. Too many appendices, innocent of wrongdoing, have been removed. There has been too much outing, too little conservatism. Hospital has been made synonymous with operation. The knife has been the magic wand invoked to heal all ills. Please do not misunderstand me or my intended meaning. Modern surgery has brought great benefits, but it has not been unmixed blessing. The public has keenly come to recognize the need of certain operative procedures, but they mistrust operations for conditions not obvious to themselves, and as they believe often not obvious to their medical advisor. They are therefore prone to refuse operation form a crack on the lip, a mole on the skin, a lump in the breast, or an exploratory laparotomy. Confidence in medical advisors must be restored. The laity must know that the only treatment of cancer worthy of the name is early wide excision.

The third human factor in the cancer problem is the specialist. There are many of them. No, one today questions the value of radiograph in diagnosis or lesion of the gastrointestinal tract, and no one knows its limitations better than those skilled in its use. It is a valuable aid, but never quite so valuable as the cystoscope, the proctoscopy, and the gastroscopy. The pathologist, in the very broadest sense, is a very important factor. Microscopic examination to tissue is the foundation stone of malignant tumor diagnosis. The research worker has not evolved any thoroughly reliable diagnostic test for cancer, but the hope of the world will probably be realized in some laboratory. The relative position of internal medicine and surgery presents today a curious picture contrasted with former times. Surgery has abrogated to itself the chief place in the world of medicine. Anything that is interesting in the whole realm has been claimed as its own province. The surgeon wants to be everything but the drug therapist, and he is usually a drug nihilist. The best brains for a decade or two of physicians have entered this field because of the gain and glory attached thereto. Surgery has scorned medical opinion and has demanded as its right to remove anything that it pleases. But internal medicine is today asserting its independence, claiming its rightful place, coming back into its own again. The surgical treatment of cancer is a failure, a makeshift, the best we have today, but far from what we want and what the world demands.

One world in regard to the relations between the practitioner of internal medicine and the specialists named. No one can successfully cover the field of modern medical science. It is too broad. The practitioner should not, must not be content to be a routine, a grinding drudge, living poorly on skim-milk while someone else gets fat on the cream. The family physician is often a team of endearment, but just as often it conveys a veiled idea of incompetency. The fate of the practitioner of medicine rests in his own hands. he should be an internist, a diagnostician, make himself worthy to stand with the elect. The specialist should not be a being of a superior world, whose judgement and opinion is always the last word. All should be members of the same class on the same level, equals in the field and fight.

Finally, what is the attitude of the medical profession toward the cancer problem? What is our creed, what are our articles of faith?

We acknowledge our ignorance and our helplessness but are cheered by the advances accomplished under great leaders. We regret that there are millions for research, but scarcely a cent for clinical medicine, for through the one or the other shall eventually come the solution of the problem. We believe in public education, in prophylaxis, in early diagnosis. We strive to discover cancer producing habits, to avoid chronic irritation, and to remove precancerous lesions. We believe that good history and a careful examination are still the very best means of diagnosis. We realize that medical treatment is absolutely futile. Ferments, serums, and vaccines have disappointed. Chemotherapy offers yet but little. The glory of electricity, the X-Ray and radium have largely faded. Surgery is the best that we have to offer. And, finally, we anticipants the day when that last statement shall not go unchallenged, when someone shall stand up and say, "This is the cause and here is the cure".

Binghamton, N.Y.

October 3, 1915


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