Printed in Great Britain byF. Robinson & Co., at The Library Press, Lowestoft
Printed in Great Britain byF. Robinson & Co., at The Library Press, Lowestoft
THE CONQUEST OF CANCERINTRODUCTION
THE CONQUEST OF CANCER
The phrase “Conquest of Cancer”, though perhaps emotive rather than scientific, nevertheless implies the existence of a very real and important problem. And this problem, it may be confidently affirmed, is one that will never be solved, in action, by the efforts of the medical professionalone. Whatever be the future, and as yet reserved, revelations of Science, and whatever the further developments of Art, cancer will not cease to exact its toll unless medical science and art obtain the intelligent co-operation of an instructed public. It is for this reason that it has been thought useful to place before the public this little book, written by a practical surgeon who has given special attention to the problems of thelaboratory. The book itself, which not only states in simple language the essential points that should be comprehended by the public, but puts forward a plan for concerted action, is based upon one of a series of University Extension lectures given during the winter of 1922–23, at the Shantung Christian University, Tsinan, China, where Mr Wright is actively engaged in the Surgical Department of the School of Medicine.
The task of prefacing this essay by some words of introduction has devolved upon the present writer, not because he either has, or desires to present, any claim to speak with special authority concerning Cancer, but by reason of a close personal and professional friendship that has led him to appreciate very warmly the knowledge, the sincerity, and the disinterestedness that characterize Mr Wright’s thought and work. And he is confident that we may accept what has been said about Cancer atShantung as an honest and candid attempt to instruct and to construct, in detachment from the pribbles and prabbles that have sometimes confused discussion nearer home.
Now, although the public has the undoubted right to demand information on this subject, and although, as has been suggested, without admission of the public to the arena of discussion little can be done to diminish the present mortality from Cancer, yet is there real difficulty in communicating knowledge, without engendering unnecessary fear and alarm and sending the hypochondriac to those quacks and charlatans who diagnose non-existent disease in order that they may reap reward by announcing its cure.
Some weaker minds there will always be: so, whenever attention is directed towards some public danger, there are those who adopt the possible contingency as a peg on which to hang some ragged vestment of distracted emotion or thought. Thirty years ago, theinsane feared the telephone: during the Boer War, many thought that the “scouts were after them”; now-a-days lunatics babble of persecution by wireless, by Bolsheviks, or even by psycho-analysts. So, in Victorian times, themalades imaginaireswho then thronged consulting rooms spoke with bated breath of Bright’s disease: to-day, the hysterical secretly hope to hear the blessed word “Colitis”, and the hypochondriac as secretly dread the verdict of “Cancer”!
The task of the medical profession is to enlighten the laymen, that their help may be enlisted, and yet to avoid alike exaggeration and smooth sayings, false hopes and false fears. Macaulay, in a familiar passage, once said that there is nothing more ridiculous than the British public in one of its periodical fits of morality. At present, the British Public is less concerned than formerly with questions of morality, but is very much concerned with questions of health. Perhaps it is notso much health that is sought and desired as absence of pain and avoidance of death—which is not quite the same thing. But, though there is nothing intrinsically ridiculous in seeking the “advancement of morality” or the “conquest of disease”, the one, no less than the other, may be pursued in a ridiculous and dangerous manner.
The adoption of ill-conceived measures, designed to improve morals or to abolish disease, may, and often does entail consequences that are even less desirable than the evils it is hoped to combat. While the prohibition of the consumption or sale of alcoholic drinks may diminish certain ills, it has yet to be shewn that the casting out of devils in the name of Beelzebub may not be followed by possession with others yet more violent. A few years ago we were adjured to boil all milk, lest we became poisoned by certain microbes: we are now told that, if all milk be boiled, we are as if deprived of vitamines, and must suffer accordingly.Instances might be multiplied; but it should be obvious that moral and physical health must be considered, not as physical objects, but as relations, or states of equilibrium. Like all states of adjustment or equilibrium, they are the result of accommodation: of poise and counterpoise. They are not always and everywhere to be secured by the throwing of a certain weight into one or other scalepan, or by the cutting-off so many inches from the table-leg that seems the longest. So much, at least, should be recognised by a seriously disturbed public told by the daily press that so many more people than formerly now die of cancer; that science has not yet discovered the “cause of cancer”; but that all may be well if only we live on Nebuchadnezzar food washed down by paraffin.
Mr Wright’s essay, combining as it does a well-balanced and sufficient statement of what is known, with the outline of a constructive proposition that merits careful consideration, and atleast indicates to the public the kind of way in which relative safety may be obtained under present conditions, seems one that is eminently suitable for what may be called general reading. The problem is fairly and lucidly presented: the resources of surgery are quietly and reasonably demonstrated: and the advantages are shown of exhibiting that kind of prudence which leads the business man to seek auditing of his accounts and the sportsman to enquire how his score stands. But some words may perhaps be added from the standpoint of one who is a physician, and no surgeon.
Cancer is a class name given to certain kinds of growths, otherwise spoken of as tumours (or swellings) and ulcers, which are, as we say, characterised by malignancy. A growth, tumour, or ulcer which isnotmalignant isnotcalled a cancer. By malignancy we mean a tendency to spread, by local and direct extension (as spreads afire), or by convection, as when sparks fly from a locomotive to a haystack. Malignant tumours or ulcers tend to recur when removed, and, in the long run, to destroy life.
These general features are associated with certain microscopical characters found in the tumours or ulcers, so that the nature of any growth—whether malignant or otherwise—can be sometimes determined by the surgeon or physician, and sometimes by the pathologist or microscopist alone, but, as a rule, is most certainly settled by the physician or surgeon acting in conjunction with the microscopist. Yet, and this is important, not every cancer does actually destroy life. Surgeons of the greatest experience, such as the late Sir Alfred Pearce-Gould, have affirmed that undoubted cancers do occasionally undergo spontaneous cure, or at least arrest of growth,even in the absence of any treatment. Again, if excision is practised early, and sufficiently extensively, recurrence doesnot happen, in a certain proportion of cases. Finally, pain is no necessary or inevitable concomitant of cancer. In many cases pain is absent, or almost so; death may be due to mechanical consequences entailed by the growth rather than to destruction of any vital or sensitive part.
Now, medical men are in the habit of splitting up the group or class of malignant growths (or “cancers”) into two subsidiary groups or classes. One of these is named Sarcoma; the other Carcinoma. Sarcoma is the name given to a group of malignant growths taking origin in the structures and tissues developed from the “middle layer” of the embryo: the growths themselves—sarcomata—partake the nature of the tissues formed from this middle layer. The other group, of carcinomata, consists of growths taking origin in, and partaking the nature of one or other of the two remaining embryonic layers and the structures developed from them.
These two layers form respectively:
(1) The skin and related structures, and
(2) The lining of the tube passing through the body; its backwaters, out-growths and appendages.
It is these two layers which, as Mr Wright so aptly remarks, are in direct contact with the outer world. Now, while the carcinomata (which constitute the class of cancers chiefly discussed in this book) in general affect people who have passed the midpoint of life—those for whom, as Rabelais says, it ismidi passé—the sarcomata, which are less common than the carcinomata, are rather more frequently, yet not exclusively, found in young people; in those indeed, who have not reached life’s apogee. It is important that these facts should be borne in mind, for generalisations founded upon the study of carcinomata alone cannot be necessarily true in respect of all Cancer, unless the use of the term cancerberestrictedto the class technically known as carcinoma. To say that Cancer can be prevented if constipation is avoided is clearly misleading, when we remember that quite young children, nay, infants, may be the subject of sarcoma; unless of course we define cancer, as some would do, as the kind of growth that,ex hypothesi, is prevented when constipation is avoided. It is confusion of this sort, bred by slovenly expression out of loose thinking, that is in great part responsible for the present bewilderment of the public.
Another fertile source of confusion is the obscurity that attends both the popular and the professional use of the words “cause”, “causation”, and the like. The public demands that “the” cause of cancer be discovered, and is prepared to pay generously that this discovery be made. Unfortunately neither the public, nor men of science, care overmuch to discuss what they mean by cause and causation. This is no place in which to trench upon aprovince unsuccessfully explored by Locke, by Hume, and by Kant. Yet it is of vital importance that all doctors, scientists, and laymen should recognise two differentusesof these words.
When we speak about “the” cause of a “disease”, in a generalised or conceptual sense, as when we say that Koch’s bacillus is “the cause of tuberculosis”, we are really defining our concept of the disease in terms ofonecorrelative. We are saying that tuberculosis is a disease in which Koch’s bacillus is invariably present. Acirculus in definiendois only just escaped because we happen to know that, if Koch’s bacillus is injected into certain animals, the “disease” as we say, develops. Koch’s bacillus is the one constant correlative found in all cases of the kind that we agree to call tuberculous, by reason of certain clinical and pathological signs that we find. Possibly even this statement is not to be taken as absolutely true; though it represents what we find it convenient to say. But,when we thus declare Koch’s bacillus to be “the” cause of tuberculosis, we have by no means exhausted the study of all the correlations that may be called causal in respect ofparticularcases. Of ten cases of tuberculosis, each one exhibiting Koch’s bacillus, we may say thatfor each particular case“the” cause of the illness is different.
Thus:
A. is tuberculous because he was gassed in France;
B. is tuberculous because he was infected by his sick wife;
C. is tuberculous because he drank tuberculous milk;
D. is tuberculous because he worked in an ill-ventilated factory;
E. because he was exposed to wet and cold; and
F. because he drank and was dirty.
The difference between a medical cause in the generalised sense, (where cause means a defining correlative for a concept), and a medical cause in theparticular sense (when we seek to find out or state the antecedent without which this man would not be as he is here and now) is one of enormous importance, and one that should be constantly borne in mind when discussion is commenced. It is true that it involves the oldest of logical and metaphysical problems in respect of scientific thought—the question of universals and particulars; but that does not make it any the more easily shirked. Its relevance to the question of cancer is this: that the proof of the production of cancer in men or in animalsunder one set of circumstancesdoes not warrant us in saying that that set of circumstancesas known to usinvolvesallthe factors without which cancer cannot occur. And, even if research work demonstrated that, in every case now called cancer, some parasite or growth-form, some irritating factor that can be isolated, does actually obtain,unless it could be shewn that this parasite or factor is never found exceptwhere there is cancer as we now define it, we should have to proceed to investigate why and how cancer does not always occur when this factor is present. Just so are we at present seeking to explain why and how, of so many persons exposed to infection by Koch’s bacillus, only certain ones do become diseased. If we find that only those persons who possess a character that we may call “X” become infected, we shall then have to say that, not Koch’s bacillus, but the character “X” is “the” cause of tuberculosis. It is thus that science progresses: not by making the absolute and positive discoveries that the public is taught to expect, but by arranging and rearranging our experiential knowledge, as such grows, in terms of so-called laws and generalisations, that are foundprogressively convenient. But such laws and generalisations are not necessarily the one more “true” than the other,except in relation to the knowledge that they summarize. If such considerationsas these were more frequently borne in mind, there would be less unconscious deception, less disappointment, and greater economy in work and thought.
Explanations of the causation of cancer have been sought in many directions; and three chief theories have been set out. The most important, and the most interesting from the point of view of the practising physician, is that which considers cancer as provoked by long continued irritation under certain circumstances. This doctrine seems more “true” in respect of the Carcinomata—the cancers of the adult and the old, and of tissues in contact with the extra-personal world—than it is in respect of the Sarcomata—the cancers of the young, and of those inner parts not exposed to irritation by contact with the world. Yet sarcomata in real life do often seem to followinjury, and the tissues in which they formmaybe obnoxious to injurious influences of which we know nothing.
Another view is that cancer may bedue to a parasite of some kind or another. Certainly, so far as some lower animals are concerned, this is true, for certain rat and mice cancers are now known definitely to be associated with parasites. But then we may say, and properly, that in such cases the parasites are merely acting as do other irritants, and are not “specific” causes of cancer.
The third doctrine, or set of doctrines, regards cancers as arising when parts of the body (or rather, elements in the tissues of certain parts) no longer act in due subordination to the needs of the whole organism, but comport themselves “anti-socially”: developing irregularly; propagating themselves illegitimately; and so becoming parasitic to the commonwealth of the body. Those who hold this will admit that, in many cases, this revolutionary tendency is one provoked by irritation and the like: that sometimes it is a mere manifestation of irregular decay; and that, when it occurs in youngsubjects, it is because some islets of tissue have become misplaced, tucked away, ill-formed, and hampered in development, and so liable to provoke trouble later under stress of greater or less urgency. Such a view has much plausibility; there are flaws in a steel girder; there are tucked-in edges in even the best bound book, and there are developmental errors in most of us.
Moreover, there is Dr Creighton’s doctrine of physiological resistance. A part not put to its proper use is more apt than another to become cancerous. Certainly, unmarried women are more liable than are married to suffer cancer of the breast or ovary. Yet married women are more apt than unmarried to suffer cancer of the womb. Are we to say that in these latter there has been physiological misuse, or irritation produced by unhealthy child-bearing? So far is the problem removed from simplicity!
On the other hand, it is certainly as true as ever, that the gods still cancela sense misused, and, if we leave out of account for the moment the cases in which cancer seems due to developmental error—and who can say whether even then a child does not suffer vicariously for some physiological transgression by its parents?—the doctrine that cancer is due to irritation, whether produced by a clay pipe, hot drinks, constipation, or crude paraffin, does not really tell us much more thanthat. The difficulty is this:Howto walk in the way of physiological righteousness, andhowto preach it, without falling into a dogmatism as stupid as unbelief? Mr Wright tells us how, in medieval times, the Church declared cancer of the tongue to be sometimes a judgment on sinners for their blasphemy. Well, I for one, am not prepared to limit the “misuse” that entails physical disease and suffering to misuse in the material, or physiological sense. Organs, through the nerves of the “sympathetic”, are directly connected with the play ofemotions and of feeling-states. I am not sure that investigation would not shew a correlation—sometimes—between certain persistent and voluntary mental states (morbidmental states, that is) and the development of cancer in certain organs. The “argument” that cancer is infrequent in lunatic asylums, where the majority are mindless rather than wrongly thoughtful, evades the question.
The quest for a single causal factor, whose “discovery” will lead us to “abolish cancer”, is then, it would seem, just one more hunt for the philosopher’s stone. Yet, to use the formula of “right living” does not seem to be merely a verbal solution of the difficulty.
If we agree that to live rightly is the best insurance we can make against cancer, we are probably stating, as compendiously as possible,allwe do and shall ever know, in respect of the causation of cancer. It is then our duty to ascertain how to live rightlyin every sense of the word, and we may so come to realise that almost every one of what we call the blessings of civilisation has been purchased at the expense, in some respect, of right living. For this, heavy interest has to be paid, and even the efforts of science to put matters right seem too often not more than the borrowing of fresh capital to pay off old debts. It is right to call attention to the fact that certain “uncivilised” races, who live healthily and naturally in respect of food, drink, and sexual activity, do not suffer from cancer. But it is wrong to suggest that therefore we should adopt either their dietetic or their sexual customs. What is one man’s meat is another man’s poison. Adjustment to our surroundings, right livinghere and nowis what we need. Though Papuans and Sikhs may be very properly adjusted intheircontexts, it is not their adjustments that may best suit our cases.
This problem—that of right living—is the problem of prevention of cancerput upon the broadest basis. But, until or unless we work this out, we have to consider how best to avail ourselves of the knowledge already in our possession. Herein is one merit of Mr Wright’s plan. He tells people what, in his judgment, they can best do,here and now. It is a plan to be discussed; but, let it be clearly understood, it is one submitted by the author for individual consideration and action. Supposing it to be found, on analysis and trial, of real value, a cry might at once be raised for its putting into execution by central or local provision of the necessary facilities: at first for voluntary acceptance, then for compulsory adoption. Nothing could be a greater error. In matters of health what is advantageous for the individual is often not so, or even grossly disadvantageous, for the State.
Let every member of the State have the opportunity to avail himself or herself of what Science and Art can do for him: let none who has the willsuffer because he has not the means. But the too easy provision of means for the avoidance of consequences of neglect does, very seriously, put a premium on neglect and penalise those who themselves make effort in the right direction. Again: hard on individuals though it would seem, there is a very real racial advantage in the elimination—natural and inevitable, unless we interfere—of those whowill nottake advantage of opportunities offered them. We are not automata: we exercisechoice; when the opportunity of choosing rightly is offered us, if then we choose wrongly, we have no right to demand escape from the consequences,at the expense of others.
At any rate, if the facts relating to Cancer are plainly stated, every man has but himself to blame if he shrink from obtaining such diagnosis and treatment, as is now available, at the earliest moment. It were better still that he avoid from the beginning all what we know to be predisposingcauses of cancer: all the errors of omission and commission in respect of the physiological and spiritual—or physical and psychical—functions and relations of his Self.
It is the principle, the pursuit of the unattainable ideal, that really counts. The simple injunction to eat greens and take paraffin is the physiological counterpart of seeking to make people moral by act of Parliament, religious by church-going, and intelligent by attendance at evening lectures. But even if we make all possible effort, we cannotallhope to escape, and the necessity for seeking early diagnosis when things go not well is as imperative as is true the maxim that “A stitch in time saves nine”.
There is perhaps one more question that may be touched upon: that of the so-calledincreaseof cancer. It is commonly stated that cancer is increasing: it is as commonly asked if this is really so. As a matter of fact, the question (which we are usuallytold can be only answered by statisticians) is one that statisticians can only answer when we have agreed what they are to understand by it. And that is not so easy as may be at first thought.
It is certainly true that, in the British Isles, the number of deaths certified each year as due to cancer of one form or another is gradually and steadily increasing, both absolutely and relatively to the population. But then we have in the first place, to consider whether cancer is not diagnosed more frequently in ratio to the cases seen than was formerly the case, and, in the second, to remember that cancer is, on the whole, a disease suffered during the second half of life. Now, our population is an older one than it was: the birth-rate is falling: so many youths who would now be vigorous men of thirty-five to forty lost their lives in the war; and lives are, on the whole, longer than they were, owing to a diminishing liability to suffer from certain ailments other than Cancer.
Supposing that children ceased to be born, at the same time that the Ministry of Health succeeded in “abolishing” all diseases except cancer, and the Home Office and Police reduced the probability of death from accident, from homicide, and from suicide, to vanishing point. Would we not then all die from either “old age” or from “cancer”? If so; should we be justified in declaring that cancer had “enormously increased” since the successful institution of control of our own deaths and other peoples’ births?
We are, indeed, again confronted with the old problem of the one and the many, under one of its numberless aspects. From the point of view of the statistical bureaucrat, cancer is increasing. That is to say, an increasing number of deaths, and an increasing proportion of deaths, are every year presented to him, both absolutely and in relation to the population. And so many more perforated cards are inconsequence manipulated by his counting machine.
Can it be said that, for any one reader of these pages, the chances of death from cancer are year by year increasing, as are the chances of being run over in the London streets? Who can say?
But this is true. We must all die. We are, for the most part, anxious to postpone the day of death, and many of us dread, more than aught else, a death from cancer.
Effort in the path of right living—if steadily pursued—and the intelligent utilization of what Science and Art and Experience have to teach, will undoubtedly make for healthier and longer lived communities, and will lessen,for each individual, the probability of dying otherwise than in the fashion thought of by the doctor when he ascribes death to “old age”. The problem we are considering becomes indeed swallowed up by a still greater one; but, those who profit by whatMr Wright has had to say about Cancer, will profit in respect of this greater problem as well. Therein, so it seems, lies its greatest value.
F. G. CROOKSHANK
London, 1925