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THE WAR AGAINST CANCER Interesting Address Given by John W.S.McCullough, M.D., D.P.H., in Colborne Town Hall, Tuesday Afternoon, March 5th, 1935 INTRODUCTION Thirty or forty years ago there were a few diseases which inspired despair, if not terror, among the public. Of these, diphtheria, consumption, and typhoid fever may be taken as examples. Diphtheria In my early days of medical practice, in the early 90's, diphtheria killed in about one-half of the cases. In this period there were about 1200 deaths a year from diphtheria in Ontario. There = no r and effective arrived about that time, =>sult that the scourge of dr taken ! eatment fith the iphtheria, a disease chiefly of ei under ten years, has become s-ntly controlled that last year | arHj were but 56 deaths from this cf ion, and death-rate had dropped | unti the 57.5 of 1895 to 4 per 1000 of I the ation. This "terror" of mothers , the jeen removed, and if the public | eith work has become team work. It is no longer the work of the general practitioner; it has become a highly specialized branch of treatment. Delay in Diagnosis In every country there is 'a lamentable complaint that most of the cases of cancer come too late for effective results in treatment. This sistuatlon is being met with abroad by well-trained campaigns of public education and by better training of medical students and of those proposing to specialize in cancer work. sary as prevention in other diseases. Much can be done In this direction by education and by periodical examination of persons after 35 years of age. Follow-up of Cases Another matter of imiportance is the follow-up of cases. In every clinic an should be I folkn r of 1 the lead o diph- luch with patients hack to the place itervals for years of the return of In some countries rnment or by the umin were literally filled with cases of typhoid fever. The victims of the disease were from the strong .adult population; usually there were a couple of hurley policemen among them, and the death-rate was high. Typhoid fever is a self-limited disease; it runs its course apparently uninfluenced by treaatment other than careful nursing; its incidence depends Advance in Cancer Control During the last century medicine las won signal victories over many Mseases. Most of the victories have jeen in connection with germ-caused liseases. Cancer is a disease, of an-rther category. Its actual cause is mknown and it levies a 10% toll upon idult humanity. It is no respector of jerson. Never has the problem of the ilk, the keepirfg e of cant widely and scientifically a to-day. The surgeon and gist are collaborating wit success in its treatment, out the whole world oi search there blows 'a nev and expectancy. Inucrease of Car There seems to be littl r beer are ready to divide in their turn. The process of further division depends upon a number of circumstances many of which are unknown, but In part it depends on the nature of the cell. Thus the skin is constantly being renewed by division of the deepest layer of cells, whereas nerve ceils are never renewed once they have been formed. Although cells typically are of spherical form, they may, from' pressure, become flattened, columar, polyhedral or irregular in shape. The cancer cell is a normal cell of the body, but for some unknown reason this cell departs from the ordinary habit, and not only divides, but continues to subdivide indefinitely. Under the microscope one cah observe the birth and growth of the cancer cell, can see it spread, invade-and destroy the healthy tissues; -one; can distinguish cancer cells from the ordinary tissue cells, and classification of the different types of cancer and tumour growth can be made. Cancer seems to be a local rebellion of a group of cells against the established order. The rebellious cells are unrestrained in their action; they are "bolshevlsts," and if the local riot, is not properly checked it may deve-: The cause of this untoward action! on the part of the errant cell is un* known. Cancer is non-infectious; it ;s not hereditary; it Is not introduced from without; it is gemerated within duce cancer. The surface of the body and the alimentary canal are among the chief sites of cancer. These regions aiso are the most subjeot to irritation. Many chemical and physical agents are known to excite cancer, irritation is the commonist "cause" of cancers of parts of the body sup-jeet to injurious influences. Knowledge of this fact is of assistance in the prevention of cancer. Avoidance of Irritation or the removal of irritating agents are the potent measures in the reduction of cancer. Biochemical Stimuli The human body is a complex chemical laboratory. The growth of glandular cancer, and perhaps of other forms, is prolbably excited by the influence of the chemical processes of the body. In this field research may possibly" uncover the real cause of Since < alike i vegp- cer can be ascribed. Cancer itself is a parasite grafted upon the human organism upon which it acts structive fashion. Cancer may be a combination of diseases. Fifty years ago fever was5 a term used to cover a large variety, of affections. The cause of most of these fevers having been discovered,, they are now clarified as typhus and typhoid fever, pneumonia, malaria, i tc. Many phvsicians believe that can1; cp,- is similanlv :: general term that' It riety of i tat there using a mixed diet, the kind of food consumed has probably no effect in originating cancer. No diet will predispose to, nor prevent cancer in the individual. But the manner In which 'food is used may cause irritation, and thus excite a malignant growth. Foods taken too hot or bolted without proper mastication may act as irritants or cause indigestion, and so provoke cancer of the stomach or intestines. iviilization justly be blamed ductlon of cancer. Certain civilized habits, higher life development and the greater average age of may account for the pos-of the cancer of civilizes { e over that of primitive people. | It is obviously impossible to disown the advantages of civilized life and nine primitive habits. The remedy rather to gain control of cancer. by research and application of scien-j tific knowledge. the opinion that its lim: peutic measure have f its cells to I reached. Surgery stil cells and that fieI<i in cancer treat" a de- civilization ifcible -- The Growth the disease is too far gone for curative measures, wiuld be relieved of their troubles and cured of their dis- Modern Method of Treatment of Cancer The chief resources in the treatment of cancer are: Surgery, X-rays and Radium. Of these resources, that of surgery has long held the field, and surgery remains the most potent agent of treatment in dancer of the stomach, cf the intestines, the fundus of the uterus, and other abdominal organs, though this field is being somewhat invaded by irradiation either as an active or an auxiliary to surgical treatment; it is still the best resource in cancer of the iarnyx and oesophagus, but in these fields also radium Is taking a part. In the treatment of cancer of the breast, surgery holds the chief place. Here again radium and X-rays are widely used in auxil-ia.iy treatment. In cancers of the surface of the body, the lips, buccal cavity, the jaws and throat, and the uterine cervix, radium and X-rays afford very satisfactory results, especially if cases are seen early, a requisite that widely enhances the opportunity of cure by any method. It appears, therefore, that for the largest numlber of cancers of the human body, surgery is still the method of choice, but it Is equally apparent that both radium and X-rays are powerful and effective methods of treatment, and that facilities for treatment of cases should include the best in all three lines. Surgery In an address of this nature it is unnecessary to dilate upon the value of surgical treatment. This form of treatment since the days of the immortal Lister has shown an extraordinary development, and some of atbout the growth, the time employed and the quantity used constituting the dose. In a little less than four days .he emanation (radon) loses half its strength. The effect of radium element, of the emanation and of X,rays, is much the same, and preference for one or the other is chiefly a mattr of convenience, accessibility of the growth, and perscnal experience. For^ the •reatmer.t of tumours, the hard or gamma rays are used, the softer rays being cut off by a filter of iead, platinum or other metal. The reason why these r£.ys, in appropriate dose, destroy cancer cells, and at the same time have a minimum effect upon normal cells of the body, is largely because the cancer cells are in a" constant state of division, and are, consequently more sensitive to the rays than the normal cells. In addi- | tion to this, the rays are believed to have an effect upon the surrounding * tissues which contributes to the cure of < Both sdve do? the gre* dosage both v ; as a thei i food, and t thi In thei an War, more soldiers died rid than from all other together. A generation or j s death-rate from typhoid was 50 to 60 per 1000 of population. | To-day the rate Is only one or two. j The other'day I saked a young doc-1 tor who was graduated in 1929, "How ; many cases of typhoid did you see' during your course?"., "Just one," he answered; and teachers in the medical | schools tell me they can scarcely find enough cases of typhoid to show their | students. Forty years ago we practically ignorant of the me preventing typhoid. To-day it i ily prevented, and has become ligible affection among us. The better records of to-day. The greater skill in diagnosis. The increase in the number of people of tbe cancerous age. The better education of the pirblic'in preventive medicine of all kinds, which enables the layman and woman to appreciate the earlier signs of the With i i of, and £ Consumption or Tuberculosis A generation Ago there was general This disease shows itself chiefly among young adults. The beautiful fair-haired girl, a keen student school, suddenly develops a cough, weariness, and loss of appetite. The doctor announces, "she has tuberculosis." The anxious mother feels that the death-warrant of her beautiful daughter has been sfcqgd. But thanks to the combined applieS^i of rest, good food, outdoor life andsunshine, consumption is usually checked and often cured, so that the death-rate of 145 per 100,000 has been cut in three and tuberculosis, instead of ranking-second in the list of "killing" diseases, now occupies fifth place. Tuberculosis is prevented by the use of better living quarters., the avoidance of crowding, by the separation of children from their tuberculous parents, brothers and sisters by the use of pasteurized milk (thus avoiding the bovine type of the dis- public health education, of j particularly among children to-day, id-! the future men and women will detect the early signs of cancer more readily and offer themselves to the doctor for earlier diagnosis and treatment. , Speaking at Chicago recently, Dr. Bloortvoc! said: "A lailimi *.,„„. In addition to the are other forms of known as benign tu all more or iess malignant of Growths, rue cancer'the™ -regular growtraj lours. These ar» associated wgji tumours but aS comparatively harmless in themselves. There are cell processes which precede true cancer and which are knowotf as pre-cancerous conditions. Th-ejl pre-cancerous reactions of tissue cel» appear to be due to the influence o\ some external irritant or of son " ternal stimulus-. Some of thesf growths result in cancer, and cancers develop from some such pri-< cancer spreads through invasion of .adjacent tissue by the cancer cells *x by their dissemination through the lymphatic vessels and blood vessels -to distant parts. The spread of original giowth to other parts of the body is known as metastasis. The trreat danger in cancer comes from this invasion. The Tate of this invasion and the destructive effect of the invading cells vary greatly in different cancers and thus some dancers are much more dangerous than others. The for ssful doesn't have cancer of the face. Why Because with the first blemish on he face she goes to a physician. That -i a valuable lesson for men to learn. "Women smoke, but they do not develop cancer of the mouth. The reason'--they keep their teeth free from nicotine. That's another lesson for their husbands and brothers. But after all this, there is a real increase in the incidence of cancer. If we take our own country alone, the mortality from cancer has shown a successive and steady rise over a long period, one must admit that cancer is increasing. Statistics of Can( lity the >ntrol of flies, and j 1929 the I suppose you are not fond of statistics, and I shall burden you with only sufficient to convince you that there is an alarming increase in this affection. Beginning with 1:914 the mortality rate for cancer in Ontario 69 per 100,000 of pupulation general sanitary measures. .-'After over 26 years of public health ■ sometimes discouraged i 104, and last year ivith the slow progress (1933). During the last decade the rate of has been nearly 20 per 100, i the i 000 °f population, or a relati-control of disease. When I recollect! crease of 31%. For certain regions of that 311 millions are spent on sick-, tne body, the stomach, the intestines, -.n*3r in Canada every year and that and the female organs of generation, the increase has been particularly marked and is in comparative accord with that found in most countries. The annual loss of life from cancer in Ontario has, in the aggregate now reached 4,000 and the total numiber of cases cannot fail short of 12,000. The increase in cancer mortalit; growth, while a departure from the normal, is not actually cancer. Exam pies of this axe seen In the pearl; appearance the lip in smokers, li the white spots on the tongue or Inside the cheek, or in the scaly cumulations of epidermis on the fa of elderly persons. These are ; cancer; they are pre-cancerous c ditions which may and frequently do, become cancerous. The Origin and Cause of Cancer As already pointed oujt, no re: cause of cancer has so far been discovered. All the causes which know of are predisposing or exciting conditions which appear to be related to the origin of cancer. Thesi il. Hereditary predispositions. 2. Age. 3. Embryologicai faults. 4. Irritation and injury. 5. Biochemical stimuli. 6. Diet and civilization. ies despair of the eventual control disease. But the facts to which I ve just referred give me comfort I I thank God and take courage, i.t the future may bring, in resepect other di ined in diphtheria, typhoid I sener Cancer ;ent day despair and terror to cancer is similar to the Id terror which 30 or 40 existed in respect to diphtheria. While there is today no perfect cure for cancer, yet the measures for the treatment of cancer are infinitely superior to those for the treatment of diphtheria before the year 1895. While there is no eomi treatment of cancer, research into this affection is far more advanced and the prospects for a cure infinitely better than the corresponding spects for diphtheria, typhoid and tuberculosis forty years ago. The War Against Cancer In the campaign against cancer many things must be considered, such, for example, as centres tarj treatment, delay, in diagnosis, follow-up cases, methods of prevention, and re- Centres for Treatment In most of the countries Of North America and in Europe, there are centres for cancer treatment with well-equipped staffs of pathologists, physicists, physicians and surgeons, all trained to carry on their work with the closest co-operation. Cancer Canada, the rate be-1930, or an increase of 5 over that of 1929, and of 470 in the number of deaths. The newer section of the country, Alberta, Manitoba and Saskatchewan, with fewer people of the cancer age, have the lower rates, for the reason that these provincs have a younger population than the older provinces. The records for England and Wales since 1847, show an ever-increasing tide of cancer mortality. During this period the rate has risen from 27.4 per 100,000 to 152.6 (1933). The United States, and particularly the continent of Europe, show an equal or greater increase, and all over the civilized world there is the biggest interest in research as to the cause of cancer, and experiments in treatment designed to control' this mighty The Ni The huma miHlons of cells, cells thi seen only when magnified about 5.00 times, when they appear to be of the •:ize of a small pin's head. In its simplest form the cell is a spherical Ibody with a definite wall, and semi-solid contents in the middle of which is a smaller spherical body known as the nucleus, and upon which the life of the whole cell depends. In its normal life history the nucleus and subsequently the cell itself divides. The cells grow to full size and those whos is stronger with other; ? tlia: Heredity aim a Is and men i susceptibility »r weaker than ii affections the the disease is limited. Diagonosis he satisfactory, must be applied at the Earliest possible opportunity. Destruction of a small cancer at beginning, or removal of irritation and continued observation or pre-cancer-nus states would do much to limit the fefcrtality of this dangerous disease. '"ak« v is at first a local disease, and if removed in the early stage is Decline and Death of Cancer ■ A cancer is a living thing, and all living things it cannot last ever. Dr. David Arthur Welsh, CP., Edin,, writes in a fascinating manner of this and other epochs of the life history of cancer. I "A few cancers reach the their natural life before they kill the patient. Every doctor who has had much experience of cancer can recall instances where a cancer appears to have been checked in its malignant career, where it has ceased to grow and where it has died out. What sametimes happens is this: the doctor declares with truth that an advanced cancer is hopelessly inoperable, and that he can do no rrfore; the patient in desperation tries some quack remedy. Then the incredible thing hap-r begins to die and the patient begins tafcllro again. Not ie In 1000 cancers, perhaps not one 10,000 is so obliging as to die here its human host." But the incredible fact has happened through the cancer possessing a ality or because of <j4jj8f, the body, and mraging in that his fact irch ] ! Of auistiion of i casing hod ily astonishingly high degree of skill; he is confident of himself, and it will only be a discovery of newer, more exact, and simpler method® that he will be dethroned. The limited time in this, address given to the consideration of the surgical treatment of cancer, fails to indicate the Immense value of surgery as a therapeutic agent in malignant growths. The surgical treatment of cancer is also well-known botn within and without the profession that it seems out of place to say more than lhat, in our present state of knowledge surgery still holds the premier position; it is stil lthe line of approach in the majority of cancers. Opinion of the value of early surgical measures in cancer is given by Lord iMoynihan, one of the most di painted screen--were found to hi "No better illustration of the value of early surgical interference in cases, for example of cancer of the breast could be given than the statistics published three years ago by our Minister of Health. Very briefly was found that when the operation for cancer of this origin was performed in the early stage of the disease, 91.1% of women were alive and well ten years after operation, whereas if tlu disease were very advanced, 94.4% were de'ad within this period, The nature of the disease was -the same, the operation the same; the stage of the disease made all the difference. It is true to say that every single case of cancer where the ease is accessible to the surgeon, curable in the early stage, for cancer is at first a local disease. It is quite cfctvious, therefore, that the futu: success of surgery very largely r] pends upon the education of the pu lie in these matters and of a very clear recognition of the fact that thei] only fear should be the fear of delay.' X-rays and radium in excesses "are very dangerous, so charge of treatment must use test care in prescribing the used, and in adopting safe-lecessary to the protection of irkers and patients. The use of irtadia-ion, whether from X-rays or radium, demands prolonged experience and meticulous care. It is a form of treatme-nt that can only be successfully and safely carried out in an institution for the purpose, in the,* hands of skilled operators; it is not■ for the general practitioner. Everywhere this fact must be stressed. The rays of rsdium and the Roentgen rays are visible, potent agents , for %ood when properly used; they are dangerous in the hands of persons unskilled in their use. Roentgen or X-rays On November 8, 1895, a new kind of Tay was discovered in Wurzburg, Bavaria, Germany, by Prof. Wllhelm Conrad Roetgen, Professor of Physics in the University, a Doctor of Philosophy. For the first time was seen a light never before observed on land or sea. It was a faint, greenish illumination upon a bit of cardboard, painted over with a- fluorescent chemical preparation. Upon the faintly luminous surface was seen the line of dark shadow. The experiment was carried on in a darkened room from which every known kind of ray had ibeen scrupulously excluded. A Crooke's tube stimulated internally by sparks from an induction coil was provided and carefully covered by' a shield' of black cardboard impervious to' every known kind of light. Nothing' was visible until the hitherto unrecognized rays, emanating from the Crooke's tube and penetrating the cardboard shield, fell upon the luminescent screen, thus revealing the new ray3. The visible rays--they were visible •eptio There parent to child. Aga Age is a definite factor in the onset of canceir. While malignant growths may originate at any age, the liability to cancer increases with the years of life. The work of preventive medicine has extended the length of life of the individual. Through this extension there is provided an additional number of potential cancer victims. The newer countries with a younger population have less cancer than the rider civilizations. As the population becomes of more advanced age, the mortality of cancer increases. - fre- fih : of Cancer body is- comiposed The hun .vonderfui a I Faults Its elements ;le cell. As i Any of these faults. On growths are dangerot are innocent. The g the body, as a rule, should be of these regarded with the I, and every oppor-ove or disprove their cancer. Neither pa-:an afford to gamble at any single one of innocent one. Noth-ft to chance. Every of diagnosis, under ss, should be resort-tvestigation of such pursued until the Radium Radium is a radio-active substance derived from pitch-plende, the chief of which hitherto has been the i Congo. A couple of years ago extensive deposits of pitchblende were discovered in the Great Bear Lake region. of N.W. Canada and radium (refined from thi|s material has been produced and is now in use in our clinics. In 1806 Becquerel discovered that the element uranium, the importent constituent'of pitchblende, emit'.ed rays capable of passing j through material substances, and in i 1898 M. and Mme. Curie proved that i these rays were produced by the dis-on I integration of the uranium atom, '•re that a new element which they called fly radium was formed,' and that this in ot its turn was subject to continuous !re disintegration, during which similar >m j rays were emitted. Radium is used in two forms, first as the element which in appearance resembles white pepper, and second, in solution from which an emanation or gas called radon, is produced. The dose in each form can be accurately measured and is usually referred an enormous penetrative power, pas-siing through cardboard, cloth and wood with ease. They would go through a thick plank or book of 2000 pages. But copper, iron,'lead, silver and gold were less penetrable, the densest of them being practically opaque. While flesh was very transparent, bones were fairly opaque, and so ' the discoverer, interposing his hand between the source of the rays and the luminescent cardboard, saw the bones of his living hand projected on the screen. The X-rays have much the same ■ effect as the rays from radium. They are really the same thing 'but can be used where the local situation of the growth prevents the ready application of radium,. Both the rays of radium and X-rays can be accurately measured, there being an international "yardstick" for this purpose, thus allowing of the dose in one country being the same as in another. Neither radium nor X-rays are cure- alls; thej ixilia •gery r and the" brynlogic It is not known h5w irritation a n exciting the growth of cancer, here is no doubt that injury ; ihronic irritation of a part often Pain Not an Early Sign It is a very great misfortune for the human race that cancer in its early stages is not often accompanied by pain. If cancer were only as painful as a toothache from the start, thousands of those who procrastinate until rany lillisn of radiu element. In treatment the radium clement is contained in hollow need1; of platium iridium which are placed in or about the growth or part to be treated. The disintegration of radium is a slow process, one-half disappearing in a period of 1690 years. Its Anal disposition is lead. During the process of disintegration energy is liberated in the form of alpha, beta and gamma rays. The emanation of radium is a gas which will be lost unless the radium from which it arises is kept in a sealed receptacle. In the sealed container radium emanation gradually accumulates in an increasing amount, and it is used chiefly in the form of "seeds," which are tiny sealed receptacles of gold or other materia;, and which may be inserted into or ith the fortunate exception that in cancers of the mouth, throat, lips, skin and the uterine cervix, they ar^ probably better methods of treatments .than surgery. Hopes for the Cancer Patient Thousands of reports of cancer have been accumulated all tending to show that this disease of humanity is almost never hopeless; that cures nave been obtained in seemingly the most futile cases, rnd that the greatest obstacle to the in?] i; vi d treatment of the disease is tin mental lethargy and the hopeless atttude of the genera! Prevention of Cancer This public condition can be changed only by education, by the use of the true facts about, cancer, by the spread of knowledge as to newer and improved methods of treatment and by urging the pubiic to present themselves to the physician not when the earliest signs appear, but yearly after 35 years of age, just as they visit the dentist. Prevention of cancer may be achieved to a considerable degree by the education of the public and of doctor", nurses, and dentists in the early signs-' of the disease. It is a lamentable fact that, all over the world, one sees the majority of cases coming too late for treatment. There is a fear of cancer. The only fear should be the fear of delay. Education in the early signs of cancer will be of service; the great hope is the public health education of the child. In this work every professional unit can assist; the doctor, the dentist, the teacher and the nurse. There must be wide publicity, through the press, by radio, by exhibits, by lectures, pamphlets, and by personal contact. These will cost money, but no money could be more wisely spent. The periodical health examination, like the yearly visit to the dentist, wuld save many lives.