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A DISCUSSION ON CANCER. always meet with our unflinching opposition. Introductory Address by H. B. Allen, M.D.,

I was greatly struck, and I am sure all of Professor of Anatomy and Pathology in you were, also, with an able article in a late the University of Melbourne, and Patholonumber of the Gazette on the suggestion of the gist to the Melbourne Hospital. A.M.P. Society, to introduce a system of half At the Sixth Intercolonial Medical Congress, Hobart. fees for examination for insurance of £250 and

(ABSTRACT.) under, and, as the writer stated, we can only regret that a society which divides a profit of Is Cancer a Parasitic Disease ?-Many facts nearly half a million a year, should seek to save


the belief that cancer is a parasitic the paltry sum of £1,200 a year by decreasing disease. The primary local manifestation, its the rate of fees paid to the profession. This is infiltrating nature, the tendency to disseminaonly another instance that assists to prove that tion throughout the body, and the ultimate if any body of men desire to retrench, and there cachexia, all bear some analogy to the phe

medical attendance at all connected with non ena of tubercle and other processes due to it, poor Pil Garlic always comes in for the first microbic invasion. Cancer, or some disease kick, and it further shows that we have no closely resembling it, has been successfully friends beyond ourselves. Needless to say, we inoculated in many cases from one laboratory are going to oppose this attempted imposition, animal to another; instances are sufficiently for it is an imposition, for an examination made numerous, though not so well attested, of transby a conscientious man must require the same fer from man to lower animals; and definite skill, time, and trouble whether for an assurance though guarded statements are made of sucof £100 or £1,000. I put the question to the cessful inoculation from man to man. Remanager when the secretary, Dr. Hankins, and peatedly after operations for cancer, the disease myself, as president, interviewed him at his re- has recurred in an obscure corner of a scar, or quest, on the subject, " Do the medical examina- in the track of a trocar used in exploratory tions pay the society." The answer was “Yes.” tapping, in such fashion as to convince the

Now, what lesson are we to learn from the surgeon that he had unintentionally induced a events of the past year. It is this -- that we fresh implantation. The so called parasites of have only ourselves to trust to, and that we can cancer have been brought prominently before obtain our reasonable objects only by the English readers by the work of Ruffer, Plimmer, thorough cohesion and mutual confidence of our and others. The parasitic theory of carcinoma members. Each man owes a duty to his pro- is singularly attractive, because it seems to fession, and is bound to see that at his hands at promise results in prevention and cure similar least the profession is not injured; nay, more, to those obtained in diphtheria and other each man is bound to do all that in him lies to microbic diseases. further the common interests of the profession, There are, however, reasons of great weight and he may rest assured that by so doing he is against it. Cancer is pre-eminently a disease most efficiently furthering his own interest. of declining life, occurring more and more The Council of this Association are your elected frequently from middle life into advanced age, representatives, entrusted by you with the and in this respect unlike all known parasitic management of the affairs of the profession. diseases. The primary growths themselves are They have a right to your confidence, they do often very unlike the results of parasitic nothing of importance without consulting the infection. For example, a columnar carcinoma members, and they have a right to your generous of the rectum may show an exaggerated system support on all occasions. Union makes strength, of tubular gland formation, extending in reguand if we are only united the attacks of our lar pattern through the muscularis mucosce, enemies will leave us unscathed.

and perhaps even through the main muscle In conclusion, I have to offer you my warmest coat before it tends to spread in looser irregular thanks for raising me to the position of presi. fashion. The disseminated growths of cancer dent of this Association, the highest position in bear the traces of the seat of the primary the gift of the profession, and the greatest com- growth in a manner and to a degree never pliment which it is in your power to pay, and I manifested in parasitic processes. The reason wish for the Association very many years of is simple. In the dissemination of tumours, a prosperity and success.

cell or group of cells is conveyed by blood or ACCORDING to the tables drawn up by the Registrar- lymph to a new site, and grows there by its General in connection with the census of London, there

own multiplication into a secondary tumour. are about 5,000 doctors and 16,000 nurses in London. In tubercle, on the contrary, the parasite itself

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is disseminated, and multiplies in a new site, epithelium from connective tissue, is there producing irritative lesions, the cells of satisfactory in practice; and the same may be which are not descended from those of the said of the consequent reference of carcinoma primary focus. Opinion is still divided con- to the epiblast or hypoblast, and of sarcoma to cerning the parasitic origin of cancer, but, the mesoblast. Difficulties were first found in though I cannot regard the question as settled, tumours arising from serous membranes, and my own opinion inclines decidedly to the therefore mesoblastic, but having the histological negative.

structure of carcinoma. For such cases, the The Intrinsic Theory. The whole body is group of endotheliomata was established. descended from a single original cell, and each Certain observers have been led to form a new part of the body inherits its qualities by con- section of archiblastic tumours derived from iinued descent from specialised offspring of that undifferentiated embryological elements, while single cell. In each part there is no anarchical others would divide endotheliomata into those mob of cells, but a federal society, with due re- akin to connective tissue and those akin to lations, restraints and provisions. Vessels, epithelial structures. Pathologists probably connective tissues and epithelial coverings are exaggerate the separation of one layer of the maintained in due relations to one another. embryo from another, forgetting their common The true marvel lies in the federal organisation descent from the original fertile cell. of each portion of the body, maintaining it in Increased Activity or Lessened Resistance.due size and due relation of parts, rather than in carcinoma, the question naturally arises, in the occasional aberrations that induce local whether the epithelial invasion is due to some over-growth or tumour formation. Carcinoma new power on the part of the epithelium, or some is a confused imitation of the embryonic pro lessened resistance on the part of the connective cess of gland formation, while sarcoma re- tissues. The epithelium is always active, sembles the act of repair, persisting at some sometimes with great intensity, sometimes with one stage or other, the growth in either case quiet persistence. The behaviour of the conbeing without obvious purpose, without limit, nective tissue varies. In certain cases scarcely unfederal, evil. Cohnheim's theory of per- any change occurs, beyond the mechanical sistent embryonic “rests of connective tissue results of the epithelial inroad; but in others, or epithelium, detached from their usual con- the connective tissue is as active as the epinections, will scarcely serve to explain the can- thelium, playing no passive part, but showing cers of advanced life. Ribbert's theory of de- itself an energetic partner in the tumour tachment of epithelium by activities of connec- development, sometimes indeed so as almost to tive tissue can seldom apply. The specialisa- confound carcinoma and sarcoma together. tion of the malignant elements is biologic and Plain thinking leads us to ascribe cancer formafunctional, not mechanical. Mere misplacement tion to a direct increase in the activities of of epithelium does not in itself induce carci cells, whether of epithelial cells in the case of

Epithelial “rests” in the ovary or carcinoma, or of connective tissue cells in the neck may remain inactive, or form dermoid case of sarcoma. This opinion may be held cysts. Cancer sometimes originates in such with equal strength by the advocates and critics “rests” or implantations, but there is the same of the parasitic theory. difficulty in explaining such an event as when The Increased Activity may be Controlled.cancer starts in normally-placed epithelium. In It must not be thought that all hopes for the any case, the explanation is not yet forth-control of cancer, apart from simple extirpacoming

tion, are bound up with the establishment of Cancer a Local Process.-Cancer growth is its parasitic origin. Curious cases are essentially a local process, due to loss or per- record of spontaneous retrogression of maligversion of the local controls, of the local fede- nant tumours. The occasional withering or ral bond. Now and then multiple primark even disappearance of carcinomata of the cancers occur, just as with innocent growths. breast after the menopause or the removal of Such multiples are more often sarcomata than the ovaries, the shrinking of some rodent carcinomata. It is clear that the loss or ulcers under the influence of the Röentgen perversion of control may be multiple, or may rays, and the rapid changes in the way of even be widely spread in some particular tissue, degeneration and absorption induced by Coley's such as bone or skin.

fluid in many sarcomata, especially of the Classification.-In general, the current spindle-colled type, prove conclusively that the classification of cancer into two groups, carci- special growing power of cancer elements can noma and sarcoma, according as it arises from 'be restrained. It is important to note that, in


on on


the three methods mentioned, the good results the breast. Sibley found cancer of the uterus are limited to definite varieties of malignant in a mother and her five daughters. But in growth; but, nevertheless, encouragement is general the power of hereditament is infinitely given to seek more sure and general controlling less. Paget found that one-fourth of 322 canpower over the progress of cancer, and to obtain cerous patients were aware of the occurrence of all the side-lights that such observations throw cancer in other members of their families, but

the vexed questions of its nature and that only one in 25 had a parent dead from causation.

Snow, in 1075 cases, found a family Dissemination. There is urgent need for history in 15.7 per cent., but in 78 healthy further study of the phenemena of dissemina- people he obtained a similar history in a rather tion, and of the conditions which encourage or higher percentage. Mr. Powys, of the Victorian forbid tho formation of secondary growths. Statist's Office, working from the standpoint of Why, for instance, should colloid cancer of the a mathematician, has minutely examined the rectum or rodent ulcer of the neck have such curves of mortality at the various ages, from enormous power of local growth, and so little phthisis and cancer in Victoria and in England tendency to disseminate? Why should a sar- and Wales. He finds that in phthisis, the age coma of the testis infect the inguinal glands, mortality curve is heterogenous, and may be while the axillary glands usually go free in resolved into two curves, an early curve, having sarcoma of the breast? Why are the secondary its maximum in England between 25 and 30, growths following carcinoma of the breast in Victoria between 28 and 33, and a late sometimes limited to the liver, and sometimes curve, having its maximum in England beto the bones? Why should the secondary tween 45 and 50, in Victoria between 55 and growths of sarcoma sometimes avoid the lungs, 63. Mr. Powys suggests that the early curve where they usually develop first? A very probably consists of deaths due to contact with practical question is afforded, when in one phthisical parents, the so-called hereditary woman a carcinoma of the breast grows to phthisis, while the late curve pertains to great size without infecting the axillary glands, phthisis acquired later in life from inhalod while in another case these glands are involved sputum, &c. In Victorian males the late curve in marked degree, while the breast itself has is so strong that the whole tracing, even withundergone but trifling enlargement. Some out adjustment, is markedly dicrotic. On the better explanation than accident is needed for contrary, Mr. Powys finds that the age curve delayed infection in one case, and early infection of cancer mortality is a homogenous curve, and in the other.

cannot be split into separate components, and Relation of Innocent to Malignant Tumours. he infers that the dominant cause of cancer is There is a wide-spread belief that innocent single, and not composite. These striking obtumours have a marked tendency to become servations and inferences have not yet been malignant. I am convinced that this tendency published, but will doubtless receive the careful is much exaggerated. I do not affirm that in consideration which they deserve. The influence nocent tumours have any exemption from can- of local irritation in favouring the evolution of cer, but merely that too much has been made cancer is beyond question, and fully recognised. of their supposed tendency to become can- As to general conditions, cancer may develop in

the young or the old, the robust or the feeble, Influence of Race, Hereditament, Irritation, the stout or the lean, the nervous or the placid, dc.--(ancer is rare among the Australian the idler or the overworked. In a large proaboriginals, many years often passing without portion of cases, it appears in persons who have a single case being registered among the blacks enjoyed a most healthy life; and patients with remaining in Victoria, though the blacks are cancer seldom suffer from any severe internot exempt from either external or internal current diseases, such as croupous pneumonia.

I am informed that cancer is also rare But, on the contrary, I could quote from my among the Maoris of New Zealand, a race of own experience cases of cancer developing in vastly higher type. By way of contrast, the patients with phthisis or with tuberculous Chinese in Victoria suffer severely from cancer. intestine, or with the scars of old tubercle. Great difficulties beset any attempt to estimate Prevalence of Cancer in Australasia.—The the influence of heredity in cancer. The statistical tables, which I now have the honour famous series of cases related by Broca shows formally to present to the Congress, have been how terrible this influence may be, the series prepared from data most kindly furnished by extending over seventy years, with fifteen cases, the Government Statists, with the gracious all descended from one woman with cancer of permission and countenance of His Majesty's



five years,

Ministers in the several States. The number speaking, the old men have nearly doubled in of deaths attributed annually to cancer in numbers in relation to the whole community, Australia has risen in thirty years from 458 to while the old women have far more than doubled. 2,165, and in New Zealand in twenty years A large part of the increase in cancer is explained from 138 to 430, the registered deaths from in this simple way. cancer in Australasia during 1900 including The study of age incidence gives other valu1,407 males and 1,188 females. If we take able information. Not only is the death rate 100 as the standard for Australia thirty years from cancer in persons under 25 very small, ago, and for New Zealand twenty years ago, but since 1880 it shows no increase, the rates the deaths in Australia have increased to 480 per 10,000 living beings 0:11 for 1870-72, 0·18 for males and 465 for females, and the deaths for 1880-82, 0:19 for 1^90-92, and 0:17 for in New Zealand to 367 for males and 260 for 1900. The rates for children under five have females. Hospital experience reflects this great decreased from 0 22 in 1870-72 and in 1880-82 increase. I have been Pathologist to the to 0.19 in 1890-92, and 0:17 in 1900. Thus Melbourne Hospital for slightly over twenty- the definite conclusion is reached that cancer in

and during that time have kept children and young people is not increasing. We notes of 4,459 post-mortem examinations. may turn aside for a moment to study the During the first five years, 6-8 per cent. of the history of sarcoma in more advanced life. deaths so recorded were due to cancer; during Sarcoma in males above 25 has slightly dethe second five years, 6.9 per cent. ; during the creused since 1870, although the tumours of third, 9.1 per cent. ; during the fourth, 10-2 old people have come to bulk more largely in per cent.; and during the fifth, 10.4 per cent. the schedule. In females there has been a de

Allowance must be made in the first place cided increase, to a rate slightly higher than for increase of population ; and it is then found that of males. But, evidently, there was some that the Australasian death-rate from cancer fault in the diagnosis of female cases in former for every 10,000 living has risen in the last time, and even more than with males there has, thirty years for persons from 2.75 to 5 72 ; for of late years, been more frequent recognition males, from 2.65 to 5 91 ; for females, from 2·86 of sarcoma in old people. The common belief to 5.50; or, if we take 100 as the standard that sarcoma is pre-eminently a disease of thirty years ago, to 223 for males, to 192 for childhood is very erroneous. It is the only females. In this short period, therefore, the form of malignant tumor affecting young perrecorded cancer rates per 10,000 living have sons ; but, in 1900, estimated in the manner

; somew:hut m re than doubled in males, and just described, the sarcoma rates per 14,000 somewhat less than doubled in females. The living in each age period were only 0 06 for female rate, which was the higher, has become males and for females under 25, wbile the rates substuntially the lower. While cancer may for those of 75 and upwards were 3 80 for occur in certain forms at any age, it is pre- males and 7:4 for females, and it may be noted eminently a disease of later life, increasing more that no case of ovarian cancer was recorded at and more in prevalence as age increases beyond this advanced age the middle term. In Australasia there has Reverting to our main argument, we find been a striking increase in the number of old that in the age periods from 25 to 35 and from people, of persons in the cancer period, both an 35 to 45 the cancer rates (including sarcoma) absolute increase, ard an increase in proportion have fluctuated from year to year, though there to the whole population In 1871, if we exclude is no definite increase.

While recordeu cancer New Zealand, but include Western Australia, shows no definite increase in persons under 45, there were 6,392 persons of 75 and upwards in there is a progressive increase above that age by Australasia ; whereas, in 1900, if we include 42 per cent. between 45 and 55, by 86 cent. New Zealand, but exclude Western Australia, between 55 and 65, the rates being more than it is estimated that there were 34,241 persons doubled between 65 and 75, and nearly trebled of 75 and upwards. If we consider the pro- from 75 upwards. portions which those living at the several age Comparing the sexes, we find that the total periods bear to the whole population, we find female rate was higher than the male in 1870that the relative increase in favour ef the elder 72 and in 1880-82, but lower than the male in folk begins with the decade from 55 to 65, and 1890-92 and in 1900. At the present time the increases into old age ; so that from 75 up- female rate is slightly above the male from 25 wards, if we take the proportionate numbers of to 35, and double the male from 35 to 45, 1871 as 100, the old men have increased to though not itself increasing in this decade. It 187, and the old women to 250 ; or, roughly is higher than the male from 45 to 55 in the


proportion of 17: 12, about equal to the male quintupled in men and increased seven fold in from 55 to 65, slightly less from 65 to 75, and women, the rectum rate having trebled in eight per cent. less from 75 upwards.

women, while in men it has increased tenfold. But some startling figures appear when the In men, also, the tongue rate has nearly

, male and female statistics of 1870-72 are com- doubled, the throat rate trebled, the bladder pared with those of 1900. The male rate has rate nearly quadrupled, and the pancreas rate increased much more rapidly than the female multiplied seven fold. These rates of increase between the ages of 45 and 55, and slightly seem to bear some proportion to the difficulty more rapidly in the two following decades; of diagnosis. But, on the other hand, the face but, from 75 upwards, while the male rutes have rate in males is less than it was twenty years been multiplied by 27, the female rates have been ago. The lip rate in males has fallen from .068 multiplied by 44 If we concentrate our at- in 1870-2 to .047 in 1900, though in females it tention on persons of 75 and upwards, we find has increased to one-third of the male rate. that the increase has been steaaily progressive. Infinitely more important; the uterus rate Here is the crucial question : Do these figures, shows only a slight increase (from 1:13 to 1.29 and particularly those relating to females, re- per 10,000 females living), and the female breast present a real increase in the prevalence of rate, after increasing somewhat, now stands cancer, or a more regular recourse to medical lower than in 1870. advice, better diagnosis, and more explicit But the meaning of these changes is not registration of the cause of death ? Un fully apparent till we study the organ and age doubtedly, with the material progress of these incidence together.

incidence together. I have selected for special communities, the aged, and particularly the presentation (a) cancer of the head, face, nose, aged women, have better and more regular and lips in males ; (b) cancer of the tongue in medical attendance, and the prejudice against males ; (c) cancer of the stomach in males and a record of cancer in death certificates is de- in females ; (d) cancer of the liver in males and creasing Further evidence, however, is in females ; (e) cancer of the breast in females ; afforded by the comparative records of the and (f) cancer of the uterus. It will be several States, marked discrepancies in their found that in the head, face, nose, and lip, the cancer histories pointing to better diagnosis only notable increase is in persons of 75 and and more explicit registration as the chief upwards. In the tongue there is a slight in. causes of the apparent increase of the disease. crease from 45 to 55, more decided from 55 to Still further information is available in the 65, and a slight increase from 65 upwards. In details of organ incidence. In Australasia, as the stomach there is a slight increase from 45 elsewhere, the most notable feature is the to 55, more decided from 55 to 65, especially in frequency of cancer in the uterus and female women, and very decided from 65 upwards, breast, which contribute 23.7 per cent. and especially in women. In the liver the increase 9.6 per cent. respectively to the total cancer is greater than in the stomach, but affects the mortality in females.

Cancers of the tongue, age period in much the same way. In the female pharynx, larynx, esophagus, stomach, pan- breast there is a total decrease, but there is an creas, and urinary bladder are more common increase by one-third between 55 and 65, and in males, while the intestine is affected almost by less than a third from 65 upwards. In the equally in the two sexes The liver suffers uterus there is a decrease under 55, a slight somewhat more often in women, doubtless, in increase from 55 to 65, a more than fourfold the main, through secondary infection from the increase from 65 to 75, and also from 75 breast or elsewhere. The face, lip, jaw, and upwards. The uterine rates, which were peculiar glands of the neck suffer much more in men. in having an early maximum, have now assumed On the whole, in Australia men suffer slightly the usual cancer type, the rates per 10,000 inmore often than women ; but, if the generative creasing with every decade into old age. and mammary systems be excluded, males General Conclusion. While I am not presuffer in great excess, the rates per 10,000 pared absolutely to deny that there has been any living being, approximately, 5.96 and 3.52 increase in the prevalence of cancer,

I can state If we study the apparent changes in preva- positively that malignant tumours in young lence during the past thirty years in the domain people show no recent sign of increase; that of organ incidence, we find that the stomach among the external cancers, which are easily rate has doubled in both sexes, while recognised, those of the face and lip in males the liver rate has trebled in men and appear to be less frequent than formerly, while nearly quintupled in women. Cancer of the cancer of the breast in women has also decreased ; intestine (not including the rectum), has that uterine cancer has only slightly increased,


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