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Ministers in the several States.
speaking, the old men have nearly doubled in numbers in relation to the whole community, while the old women have far more than doubled. A large part of the increase in cancer is explained in this simple way.
The number of deaths attributed annually to cancer in Australia has risen in thirty years from 458 to 2,165, and in New Zealand in twenty years from 138 to 430, the registered deaths from 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 five years, 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 creased since 1870, although the tumours of third, 91 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 deAllowance 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 per recorded cancer rates per 10,000 living have sons; but, in 1900, estimated in the manner somewhat more than doubled in males, and just described, the sarcoma rates per 10,000 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, while the rates substantially 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 been a striking increase in the number of old people, of persons in the cancer period, both an absolute increase, and an increase in proportion to the whole population In 1871, if we exclude New Zealand, but include Western Australia, there were 6,392 persons of 75 and upwards in Australasia; whereas, in 1900, if we include New Zealand, but exclude Western Australia, it is estimated that there were 34,241 persons of 75 and upwards. If we consider the proportions which those living at the several age periods bear to the whole population, we find that the relative increase in favour of the elder folk begins with the decade from 55 to 65, and increases into old age; so that from 75 upwards, if we take the proportionate numbers of 1871 as 100, the old men have increased to 187, and the old women to 250; or, roughly
Reverting to our main argument, we find that in the age periods from 25 to 35 and from 35 to 45 the cancer rates (including sarcoma) have fluctuated from year to year, though there is no definite increase. While recorded cancer shows no definite increase in persons under 45, there is a progressive increase above that age by 42 per cent. between 45 and 55, by 86 per cent. between 55 and 65, the rates being more than doubled between 65 and 75, and nearly trebled from 75 upwards.
Comparing the sexes, we find that the total female rate was higher than the male in 187072 and in 1880-82, but lower than the male in 1890-92 and in 1900. At the present time the female rate is slightly above the male from 25 to 35, and double the male from 35 to 45, though not itself increasing in this decade. It is higher than the male from 45 to 55 in the
proportion of 17: 12, about equal to the male from 55 to 65, slightly less from 65 to 75, and eight per cent. less from 75 upwards.
But some startling figures appear when the male and female statistics of 1870-72 are compared with those of 1900. The male rate has increased much more rapidly than the female between the ages of 45 and 55, and slightly more rapidly in the two following decades; but, from 75 upwards, while the male rates have been multiplied by 2, the female rates have been multiplied by 44. If we concentrate our attention on persons of 75 and upwards, we find that the increase has been steaaily progressive. Here is the crucial question: Do these figures, and particularly those relating to females, represent a real increase in the prevalence of cancer, or a more regular recourse to medical advice, better diagnosis, and more explicit registration of the cause of death? Undoubtedly, with the material progress of these communities, the aged, and particularly the aged women, have better and more regular medical attendance, and the prejudice against a record of cancer in death certificates is decreasing. Further evidence, however, is however, is afforded by the comparative records of the several States, marked discrepancies in their cancer histories pointing to better diagnosis and more explicit registration as the chief causes of the apparent increase of the disease. Still further information is available in the details of organ incidence. In Australasia, as elsewhere, the most notable feature is the frequency of cancer in the uterus and female breast, which contribute 237 per cent. and 9.6 per cent. respectively to the total cancer mortality in females. Cancers of the tongue, pharynx, larynx, esophagus, stomach, pancreas, and urinary bladder are more common in males, while the intestine is affected almost equally in the two sexes. The liver suffers somewhat more often in women, doubtless, in the main, through secondary infection from the breast or elsewhere. The face, lip, jaw, and glands of the neck suffer much more in men. On the whole, in Australia men suffer slightly more often than women; but, if the generative and mammary systems be excluded, males suffer in great excess, the rates per 10,000 living being, approximately, 5.96 and 3·52.
If we study the apparent changes in prevalence during the past thirty years in the domain of organ incidence, we find that the stomach rate has doubled in both sexes, while the liver rate has trebled in has trebled in men and nearly quintupled in women. Cancer of the intestine (not including the rectum), has
quintupled in men and increased seven fold in women, the rectum rate having trebled in women, while in men it has increased tenfold. In men, also, the tongue rate has nearly doubled, the throat rate trebled, the bladder rate nearly quadrupled, and the pancreas rate multiplied seven fold. These rates of increase seem to bear some proportion to the difficulty of diagnosis. But, on the other hand, the face rate in males is less than it was twenty years ago. The lip rate in males has fallen from '068 in 1870-2 to 047 in 1900, though in females it has increased to one-third of the male rate. Infinitely more important; the uterus rate shows only a slight increase (from 113 to 1.29 per 10,000 females living), and the female breast rate, after increasing somewhat, now stands lower than in 1870.
But the meaning of these changes is not fully apparent till we study the organ and age incidence together. I have selected for special presentation (a) cancer of the head, face, nose, and lips in males; (b) cancer of the tongue in males; (c) cancer of the stomach in males and in females; (d) cancer of the liver in males and in females; (e) cancer of the breast in females; and (f) cancer of the uterus. It will be found that in the head, face, nose, and lip, the only notable increase is in persons of 75 and upwards. In the tongue there is a slight increase from 45 to 55, more decided from 55 to 65, and a slight increase from 65 upwards. the stomach there is a slight increase from 45 to 55, more decided from 55 to 65, especially in women, and very decided from 65 upwards, especially in women. In the liver the increase is greater than in the stomach, but affects the age period in much the same way. In the female breast there is a total decrease, but there is an increase by one-third between 55 and 65, and by less than a third from 65 upwards. In the uterus there is a decrease under 55, a slight increase from 55 to 65, a more than fourfold increase from 65 to 75, and also from 75 upwards. The uterine rates, which were peculiar in having an early maximum, have now assumed the usual cancer type, the rates per 10,000 increasing with every decade into old age.
General Conclusion.—While I am not prepared absolutely to deny that there has been any increase in the prevalence of cancer, I can state positively that malignant tumours in young people show no recent sign of increase; that among the external cancers, which are easily recognised, those of the face and lip in males appear to be less frequent than formerly, while cancer of the breast in women has also decreased; that uterine cancer has only slightly increased,
the rates for women under 55 being lower than they were thirty years ago; that the apparent increase of cancer is most marked in old people, and particularly in women of 75 and upwards; and I am strongly of opinion that most of this apparent increase is fictitious, being due partly to changes in the age distribution of the population, and partly to more regular medical examination, better diagnosis, and more explicit registration.
Comparison of Australasian with English Rates. If we finally compare the cancer statistics of Australasia with those of England and Wales, it is found that the Australasian rates are decidedly lower for male and for females, and this both for all ages, and at almost every period of life except for persons of 75 and upwards. The rates for England and Wales were higher in 1899 than ever before, the general rate being 8 29 per 10,000 living, the male rate 6.72 and the female rate 9-77. When the generative and mammary systems are excluded, the female rate in England and Wales is only slightly less than the male. These proportions between the sexes contrast strongly with those which obtain in Australasia, where the total female rate is less than the male, instead of being nearly half as large again; and where exclusion of the generative and mammary systems brings the ratio of the female rate to the male rate down to, approximately, as 10-17. In England and Wales, as in Australasia, the cancer rates increase from middle life into old age. While the total rates in England and Wales have increased from 4.46 in the period 1874-75 to 8.29 in 1899, the Australasian rates have increased from 2.75 in 1870-72, to 5.72 in 1900.
Dr. VERCO (Adelaide) read a paper on the South Australian statistics as to the disease; but explaining that when he prepared his paper he did not know that Professor Allen would deal with the statistics of all Australasia. As to the prevalence of the disease in South Australia, between 1874 and 1900 there had been 3,282 cases; average per million, 382 of all ages; the death rate was 60 per cent, during that period, of that of the old country. concluded that cancer rapidly increased with advancing age. New methods of comparison raised the percentage from 60 per cent. to 82 per cent. as compared with the old country. Among men the mortality in South Australia from cancer was slightly higher than in England and lower as to females. Up to date statistics showed a marked freedom from caneer among
South Australian women as compared with those of the old country. As to cancer on the whole, in that State there was a decrease in the number of deaths registered. Their statistics showed a rapidly increasing liability to cancer with advancing age. Many cases of cancer declared themselves to the laymen, but others could not be diagnosed by the most skilled of scientists. The more scattered a population the fewer were the cases of cancer registered. There was nothing to explain in connection with male mortality, unless the slightly increased rate was attributed to a greater accuracy in diagnosis; but what did require elucidation was the apparently marked freedom of women from cancer. A peculiar feature of statistics was the smallness of the death-rate from cancer among women in South Australia. At Frankfort-on-Maine, where the statistics were probably kept with accuracy, the death-rate among women was 50 per cent. higher than among men, and in Great Britain and Ireland 45 per cent. higher. What, then, did this low female mortality among women in South Australia mean? Whatever might be the solution of the low death-rate among women, the conclusion was forced upon them that South Australian women-and he was glad to find that it meant Australian women generally— enjoyed a decided immunity from cancer as compared with their sisters on the other side of the world.
Dr. W. CAMAC WILKINSON (Sydney) read a paper on the "Etiology of Cancer." The subject of cancer had a very melancholy interest for the physician as well as the layman. Whatever success might have been achieved in other fields of science, cancer was the one disease which baffled and set at defiance the efforts of the medical profession. In other diseases the greatest advances had been made by a closer study of the etiology of those diseases The best prospects of success in dealing with the important question of cancer, especially with regard to its treatment and prevention, was to obtain a better understanding of its origin and nature. Whether the increase in cancer was real or apparent, no one had the hardihood to assert that it was diminishing. The extent of cancer could be measured by the various deaths that took place. In Tasmania there had been very little increase since 1870. Females suffered more than men from cancer, between the ages of 55 and 60, but after the age of 60, males suffered more than females. Occupation appeared to have some effect on cancer, and clergymen occupied the best position, and chimneysweeps the worst. As he had
previously remarked, statistics showed that there was an increase in the number of cases of cancer. It was for them to consider if that increase was real or apparent. It was no use saying actuaries and statisticians were wrong; they were right according to their own methods. If they were wrong it was due to the fact that incorrect data were supplied to them. If medical men could not settle the question no body of men could settle it. Medical men blamed for not knowing more, but false, morbid sentiment often stood in the way of research. The view was now held that the growth of cancer was altogether independent of the tissue invaded. A proper system of research required not only post-mortem examination, but also histological investigation. He quoted the opinions of eminent authorities with regard to the cause of cancer. Benign tumours, although large, did not have a bad effect on the blood, but malignant tumours, no matter how small, did affect the blood. There were great gaps to be yet filled in before it would be possible to declare that cancer was due to a parasite. If it was found that cancer was due to a parasite, something might then be done to arrest its progress, and he hoped that the efforts of the scientists at present engaged in the work would be successful.
Dr. SYDNEY JAMIESON (Sydney) read a paper on "The part played by injury, chronic irritation, and inflammation, in the production of new growth." After dealing with the occupation of those attacked, Dr. Jamieson instanced cases in which cancerous growths attacked injured tissues; examples of new growth following upon chronic irritation and inflammation were then instanced, many examples being seen of tumours arising at points which were the seats of chronic inflammation; epitheliomata not infrequently were found growing in the edges of chronic ulcers Innumerable cases could be instanced where long continued irritation and inflammation had been associated ultimately with cancer formation. In conclusion, he said by taking means to prevent inflammatory attacks from becoming chronic; by adopting skin grafting to a greater extent in the healing of burns and ulcers, and by as far as possible relieving the tissues from the baneful effects of prolonged irritation, they would, he felt sure greatly reduce the incidence of new growth.
Dr. TODD (Adelaide), read a paper on desirability of removing the chain of glands near its growth." He believed the limits of curing cancer by the knife had been reached; yet at present the principal hope was that the surgical
treatment of cancer would not be regarded as a last resort, but as a means for actual cure. Professor ALLEN (Melbourne), read a paper prepared by Dr. F. D. Bird, of Melbourne, on "The general results of radical operation." He dealt with the disease from the point of view of the practical operating surgeon. He pointed out that the many varying forms of disease which are grouped under the term "cancer are so numerous, and so different in their structure and effects that it would be well-nigh impossible to describe them all within the limits of a single paper. The almost utter hopelessness of the surgeon of 50, or even 20 years ago, in the presence of this disease contrasts strongly with the confidence of the more sanguine surgeon of the present day. With regard to the prospect of the cure of cancer by operation, it lies, nowadays, somewhere between these two extremes. The older surgeon, with his crude, imperfect operations, undoubtedly cured some cases, whereas the modern surgeon, with all his latest improvements, fails to bring about a cure in a great many instances. Nevertheless, in few branches of the doctor's art have the chances of complete cure been advanced so much. Mr. Bird quoted Sir William Banks, who asks the question as to what would be the result if every cancer were operated upon when it was of very small size? To bring this happy result about, the public must be gradually educated up to the fact that a larger number of cancers are perfectly and permanently curable, if only surgical relief is sought at an early stage. It was pointed out that in some cancers, easily accessible to the surgeon's knife, the percentage of actual cures had lately been gradually rising from two or three to 20 and 30 and lately even to 55 per cent., and this, too, in spite of the fact that many cases are now operated upon which would formerly have been left to their fate. How many cases of cure can every operating surgeon call to mind, which, to all appearances, hardly justified an operation, owing to the advanced stage of the disease. On the other hand, the surgeon to-day is often persuaded to operate, when his surgical instinct tells him that surgery can scarcely avail anything. Sometimes, to his delight and that of his patient, even here he scores a genuine and unexpected success, To surgeons in the past, all cancer cases seemed almost hopeless; to-day there are cases-unpromising, truly-but far fewer cases can be labelled absolutely hopeless. This is a great and encouraging advance. surgeon can say decidedly whether a case is favourable or not. The only fear is that of
recurrence after removal. Sometimes, even when a cancer returns several times after removal, it can be ultimately cured by repeated operation. These are strange and rare instances of the disease, but every surgeon has seen many of them. The disease seems, in fact, after a time, to wear itself out. Now-a-days, the presence of what is known as the "Cancerous Cachexia" is not necessarily a bar to operation. On the contrary, it very often is an indication for it, and it is surprising how quickly a cancerous patient will regain health and strength after the focus, or poison centre, of his disease has been removed. Thus they had a number of rational inducements to operate, a number of subsidiary reasons for using the knife, but the grand inducement--the overpowering reason for operating is that, in a number of cases, they could cure the patient outright. The prominent note of the paper was one of hope for further successes from surgery in the near future, as the public becomes alive to the importance of applying for relief early in the disease. There was also hope for the surgeon, who must bear in mind the fact that, however unpromising the case may appear, he has a reasonable chance of curing his patient by a thorough and complete removal.
A paper, taken as read, on "Some Aspects of Cancer," was submitted by Dr. W. M. Stenhouse (Dunedin), contending that cancer was mainly a disease of old age, and was due to the loss of some power or property which, in earlier years, constituted a protection; instancing however, a case of sarcoma of the kidney in & young, healthy woman, with excellent family history, and no obvious cause. Dr. Stenhouse was not disposed to attach great importance to heredity, but laid great stress on nervous or moral shock, and quoted cases illustrating the rapid development of cancer in such circum
Dr. A. W. FINCH NOYES (Melbourne) submitted a paper, with statistics on cancer records for the principal hospitals of Victoria. His analysis comprehended 3,936 cases of carcinoma and sarcoma, extended over 20 years, and collected from the principal hospitals of Victoria. He showed that there was an increase in cancer, which exceeded the increase of population. The greater accuracy of diagnosis, helped by the more thorough microscopical examination of doubtful growths, and the greater frequency of post-mortem examinations, tend to swell the numbers. Many cases, too, are now admitted for surgical treatment, which in the past, would have been turned away as inoperable, but these factors alone cannot wholly account
for the increase of cancer cases. gave an interesting analysis of the sex, type of new growth, organ involved, and occupation of the victims of cancer.
A paper was taken as read, prepared by Mr. T. A. Coghlan, New South Wales Government Statistician, on "The causes of the increase or alleged increase in cancer, examined in the light of the statistics of New South Wales, since 1856." He discussed the question of the increase of cancer entirely from a statistical point of view, limiting observations to the statistics of New South Wales. As regards the alleged increase of cancer there has been much controversy. It is alleged that the increase in the cancer figures is due to an alteration in the age constitution of the people, and to the fallacious mode of referring cancer deaths to the whole population rather than to the age groups, cancer being mainly a disease of adult ages. This contention is disposed of by a comparison of the deaths in age groups with the number of persons exposed to risk in those same groups. By this the statistics unmistakably show that, taking a term of years for comparison, there has been an increase in the rate in each group. In the past ten years, a period during which it is not claimed that any great improvement in diagnosis has taken place, the increase of cancer has been very considerable for both sexes and for all ages, the only exception being for females in the age group, 25 to 34. In this group there has been a slight decline in the number of deaths compared with the population. Improved diagnosis does not, therefore, account for the increase of the cancer figures.
Professor ALLEN replied. He said it might seem strange that no free discussion should follow. But he thought that was one sign of the great truth that the work of a medical congress lay more in the private communications between members than in the public transactions of the Congress. They learned more by coming together, man to man, and comparing their thoughts and experiences than by getting upon the platform and making set speeches. He believed that the bringing up of the subject of cancer would not be a fruitless thing. It would bring forth fruit. If it stimulated investigation and led to the avoidance of difficulties and errors met and committed in the past they might arrive at some substantial results. He thanked the Congress for the attention given to his very long paper. And yet it was only in the nature of a sketch. He had much more material available than he had submitted to the Congress, but he had given his own main impressions. He had not seen any reason to