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CANCER:MEMORANDUM OF DEPARTMENTAL COM-

MITTEE OF MINISTRY OF HEALTH.

A REPRESENTATIVE committee was recentlyappointed by the Ministry of Health to draw up amemorandum on cancer for the guidance of localauthorities. The constituent members were: Sir GeorgeNewman (chairman), Dr. C. J. Bond, Sir GeorgeBuchanan, Dr. S. Monckton Copeman, F.R.S., Dr.Major Greenwood, Prof. F. Gowland Hopkins, F.R.S.,Prof. W. S. Lazarus-Barlow, M.D., Dr. J. A. Murray,Dr. T. H. C. Stevenson, Dr. S. Wyard, Lieut.-ColonelA. B. Smallman, M.D. (secretary). IThe terms of the memorandum are as follows :—-

Characteristic Featttres and Natural Course of Cancer..

In this memorandum the term " cancer " is appliedto a group of morbid conditions known to affect manand lower animals in all parts of the civilised world.The members of this group differ widely in naked eyeand microscopical appearances. They also differ inthe age of the individuals affected, in the rapiditywith which they run their course, and in their liabilityto become generalised throughout the body. Butthey all agree in that (i) they are manifestations ofdisordered overgrowth of some tissue of the body,(ii) they are at first local, (iii) they are not encapsuled,(iv) they progressively invade the deeper parts,(v) they readily undergo degenerative changes,(vi) they tend to become disseminated to distant partsof the body, (vii) they lead sooner or later to the deathof the individual in the vast majority of cases.From the standpoint of preventive medicine and

public health administration, there is a conspicuouscontrast between cancer and groups of other morbidconditions, such as the acute infectious diseases ortuberculosis, for which the fundamental principlesof prevention are well established. From the mass ofmedical experience and literature on cancer, old andnew, we have an extensive knowledge of its naturalcourse and pathological anatomy ; from mortalityand other records we know much about its occurrenceand geographical distribution. But knowledge usefulfor its prevention is still far from complete. The rootcause or causes on which the occurrence of cancerdepends remain obscure. We do not possess anyspecific means of producing immunity against cancer,as we have against small-por, nor have we any specificmeans of curing the disease analogous to quinine formalaria or arsenobenzol compounds for syphilis.In all these directions much valuable research workhaQ been undertaken, both within laboratories andoutside them, and such research is being furtherpursued. Study with this object ought to receiveevery possible support from central and local healthauthorities, from those responsible for hospitals andother institutions, from voluntary agencies, and fromthe general public.

Extent of Cancer JIortality and its Increase.In a population of 37,885,242 persons in England

and Wales in 1921, a total of 46,022 deaths wereattributed to cancer. These figures imply that outof each average million persons 1215, and out of eachthousand 1-21, died of cancer. The death-rate per1000 of the population attributed to cancer in Englandand Wales has gradually increased from 0-32 in1851-60 to 1-12 in 1911-20, and 1-21 in 1921. Tosome extent this fourfold increase is due to the factthat a larger proportion of the population thanformerly is now of those ages at which deaths fromcancer commonly occur; but when full allowancehas been made for this ageing of the population, theincrease is from 0-33 in 1851-601 to 0-97 per 1000 in

1 Another way of presenting the facts is this. In 1851—60the mean population living in England and Wales is estimated tohave been 18,996,916 of whom 60,196 (317 per million livingper annum) were recorded as dying of cancer. In 1911-20in an estimated mean population of 35,750,765 the number ofdeaths ascribed to cancer was 399,511 (1,117 per million livingper annum).

1911-20, and 1-01 in 1921, so that in the spaceof two generations the recorded mortality hastrebled.

It has long been matter for discussion to whatextent this increase has been due to improved diagnosisand more accurate certification of cause of death.There can be little doubt that these factors have beencontributory, but unfortunately it has now to berecognised that they will not account for the wholeof the recorded increase. Superficial cancers, such asthose of the tongue or the female breast, were readilyrecognisable as such even 60 years ago, by the timedeath occurred. Yet in the 20 years’ period 1901-21(after making allowance for the ageing of the popula-tion) the mortality of males ascribed to cancer of thetongue has increased from 38 per million living in1901 to 53 in 1921, and that of females from cancerof the breast from 148 in 1901 to 190 in 1921, increasesof 39 and 28 per cent., respectively, in 20 years.During the same period the mortality, similarly stated.of the total population from all forms of cancerincreased from 841 per million in 1901 to 1007 in1921, or by 20 per cent. There is only one part ofthe body frequently attacked by cancer, the womb,in respect of which significant increase in mortalityis not recorded during these 20 years-a fact whichmay in some degree be attributed to the fall in thebirth-rate.

’ During this period of 20 years, from 1901 to 1921,in which cancer increased by 20 per cent., the generaldeath-rate fell by 32 per cent., that of infants by 45per cent., and that from tuberculosis by 38 per cent.,while substantial declines were recorded with respectto most other causes of mortality.An increase of mortality attributed to cancer is

the common experience of modern civilisation.The frequency with which different parts of the

body are attacked by fatal cancer differs greatly indifferent countries ; it may differ over a period ofyears even in the same country ; and changes areoccurring not only in respect of the parts of the bodyattacked by cancer, but also in regard to the ages atwhich deaths occur. In this country the tendencyis for deaths from cancer to occur later in life thanformerly, and this change has been going on, at leastamongst females, for many years. The latest vail-able returns show that the death-rate from canceris not increasing for males up to 45 years of age, andfor females up to 60. The most rapid increase is

occurring in extreme old age.Great differences in regard to the parts of the body

attacked by cancer also exist between the sexes. Theexcess of deaths of females (over males) from canceris entirely due to malignant disease of the breastand generative organs ; in most other parts of thebody a considerable excess is recorded for males.There is a great difference between the relativefrequencies of different forms of cancer amongstmarried and single women. Cancer of the womb ismore fatal to married and widowed, and cancer ofthe breast and ovary to single women. In 1911-20,for every 100 deaths of single women from cancerof the breast, there were 392 deaths of married women,..for every 100 deaths of single women from cancerof the ovary there were only 272 deaths of marriedwomen, but for every 100 deaths from cancer of theuterus in the single women there were as many as1009 amongst the married women. During thisperiod there were 463 deaths of married and widowedfor every 100 deaths of single women, so the excessof deaths for the married is much larger than normalin the case of cancer of the womb, but smaller thannormal in those of the breast and ovary. The death-rates for 1911-20 corrected for age distiibution arenot yet available, but for the years 1911-13 we have ethe following figures, which are death-rates permillion women living corrected for age distribution :--Cancer of the womb : Unmarried women, 169 ;married and widowed. 293. Cancer of the breast rUnmarried women, 346 ; married and widowed, 238.Cancer of the ovary : Unmarried women, 60 ; marriedand widowed, 31.

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Proclivity to Cancer.The large majority of people go through life, even

to old age, without suffering from cancer, but thegeographical and social distribution of cancer-mortalityshows that the risk of being attacked by cancer isone which is widely disseminated. In a broad sense,liability to cancer is not an attribute of any particularsocial class, profession, or occupation. It is to beinferred, therefore, that the occurrence of cancer

depends, to an important degree, on personal predis-posing factors. For the purpose of this memorandumthere would be no advantage in detailing or summaris-ing studies or speculations on the nature of thosefactors, on the specific, general, or constitutionalantecedents of cancer, or on the meaning of " pro-clivity " to cancer. Knowledge is not far enoughadvanced. It is right, however, to point out thathereditary predisposition to cancer has not at presentbeen proved to be of any practical importance inman ; that it cannot be asserted with scientificauthority that the use of any particular article offood increases the liability to cancer, or prevents itfrom appearing ; that no known drug or preparationwill prevent its appearance or cure it when present;and that no danger of cancer has been proved to resultfrom inhabiting houses or districts in which cancerhappens to have been exceptionally common. Thereis no evidence to show that cancer is an infectious orcontagious disease.

Chronic Irritation as a Determining Factor in theAppearance of Cancer.

One certain fact about cancer is that it frequently and

follows on chronic and prolonged irritation. Not alltissues, however, are equally liable in this respect.The palm of the hand, for example, in spite of itsexposure to chronic irritation of all kinds, is probablynever the seat of cancer. In the female breastcancer occurs far more commonly in the deeper partsof the gland than in the nipple, which is more exposedto injury. Some tissues show a special liability todevelop cancer during chronic irritation, such as theskin of the face, the lips, insides of cheeks, tongue,lower part of bowel, neck of womb. Certain varietiesof chronic irritation, too, are more liable to be followedby cancer than others. Thus, in the lip, long continuedirritation by a clay pipe is particularly dangerous ;in the tongue, irritation by a jagged tooth or badlyfitting toothplate ; in the womb, the chronic ulcera-tion which may follow confinement. Again, syphiliticdisease affecting the tongue or female externalgenerative organs, or tuberculosis of skin (lupus)affecting the face, particularly if it has necessitatedprolonged treatment, is liable to end in cancer. Andlastly, workers in tar, such as briquette makers,workers with anilin or paraffin, chimney-sweeps, andmule-spinners are apt to suffer from cancer in specialparts of the body as a consequence of repeatedirritation by the particular agent concerned.

This liability of cancer to follow chronic irritation of so many different types is remarkable, and leadsto the supposition that beneath them all there liessome common factor--as yet unrecognised-which isfundamental to the passage of a chronic inflammatoryand non-cancerous condition into one that is definitelycancerous. In one variety of cancer (rodent ulcer)the distribution of the new growth is such that itsuggests a close relationship with the nerve-supplyof the affected part. How far this is true and howfar modifications of the body itself as distinguishedfrom the chronic irritant play a part in the ultimateproduction of the cancer it is impossible to say inour present state of knowledge.

Prophylaxis.While considerations such as those in the section

on Proclivity to Cancer show how far we are from beingable to say how cancer is to be avoided, those underthe heading of Chronic Irritation as a DeterminingFactor in the appearance of cancer indicate that thereare at least some provocative causes of cancer whichcan be guarded against. Since cancer occurs more

commonly in certain sites, it is prudent to notice andremove causes of chronic irritation in these sites.Apart altogether from cancer, people should attendto these conditions in the exercise of common carefor their general health and fitness.

In this category, for example, and for reasons justgiven, come the removal of rough stumps of teeth orreplacement of badly fitting dentures ; a change ofhabit if pipe-smoking is found to produce soreness onthe same spot of the lip or tongue ; an alteration ofclothing which causes irritation of particular regionsof the body-for example, the breast; the avoidanceof constipation and other like matters. On the samebasis the possibility of establishing a chronic irritationin a region liable to cancer gives an additional reasonfor obtaining advice and treatment in disorders ofthe stomach, bowels, or womb. Finally, specialprecautions, the nature of which is well known tothose concerned, must be adopted in certain occupa-tions (tar, &c.) known to entail superadded andspecialised risks of cancer.

Diagnosis of Cancer.For reasons that are indicated in the next section

(Treatment) early diagnosis is of the greatest import-ance. This means not only diagnosis of the actualexistence of cancer, but, even more, diagnosis of theexistence of abnormal conditions that are commonprecursors of cancer. Cancer itself in its early stagesis almost invariably unaccompanied by pain, and issometimes painless throughout. This painlessness ofcancer in its early stages is one of its most insidiousdangers, since it leads the patient to delay seekingmedical advice. Were cancer as painful in its earlystages as toothache, there would be far fewer of thosepitiable cases in which the patient first seeks advicewhen the cancer has reached a stage beyond all butpalliative treatment.

Early diagnosis obviously depends upon cooperationbetween the patient and the doctor. Medical adviceshould be sought at once, particularly if a tumour orlump is found in the breast, if an ulcerated conditionexists on the tongue, lip or skin which does not healin a few days, if there is persistent hoarseness, if amole or wart shows a tendency to grow, if blood ormucus is passed with the stools, if there is bloody oroffensive discharge at other than the normal monthlyperiods, especially at the change of life or after it haspassed. Even with the greatest care and skilldoubtful cases occur; but only after careful medicalexamination can it be decided whether such conditionsare or are not indicative of cancer, and those whoseek advice in these circumstances are taking a wisecourse quite apart from cancer possibilities. Anabnormality is there, and whatever it is due to itshould be treated and not nursed in secret.

r-eucneerec.

If a person has not recognised that something iswrong-and such cases occur-nothing more can besaid. But very many persons are aware that some-thing is wrong, fear it may be cancer and put offconsulting a doctor because they think that if cancerbe diagnosed an operation will be necessary. Quiteapart from the facts that anaesthetics and antisepticshave robbed operations of many of their terrors, andthat many such cases would not be cancerous at all,the chances of a patient must be better the earlierhe or she comes under treatment. Most medicalauthorities believe that in cancer early operationaffords the best chance to the patient, although theywould not feel justified in stating that all risk ofrecurrence is necessarily removed by operation, evenif undertaken in an early stage of the disease. Butthere is indubitable evidence that removal by opera-tion, though ultimately followed by recurrence,enables many people to live a natural life in comfortfor considerable periods, while in advanced cases suchremoval may relieve or prevent prolonged suffering.There are many cases, moreover, in which cancerousgrowths have been removed once and for all, thepatient has lived for years afterwards without recur-

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rence, and has ultimately died from an entirelydifferent cause.And. lastly, evidence is accumulating that in some

varieties of cancer, and in some situations, radium orX ray treatment, or diathermy, carried out by expertmedical practitioners, offers at least as good a chanceto the patient as surgery, without the attendantdisadvantages, and in other cases it may be triedwhen surgery is out of the question. The essentialpoint is that the patient should not postpone or delayseeking competent medical advice, and, above all, shouldnot waste time or money by trying quack remedies whichat best are useless, and at worst aggravate the disease.7H any condition in which cancer is suspected, immediateand decisive action is necessary.The actual prospect of length of life after measures

for the removal of cancer have been taken is not amatter for dogmatising, but without question theearlier these measures are adopted the better.

Local Health Authorities and Cancer Questions..Propc!<yam.&mdash;-Many local authorities, on the advice

of their medical officers of health, undertake invaluable" propaganda " in relation to certain diseases bymeans of public notices, advertisements, broadcastleaflets, lectures, cinemas and the like. The considera-tions set out above show how greatly cancer differs,in regard to the applicability of these methods, froma disease such as small-pox, for which there is a surepreventive to be proclaimed, from other diseases ofthe infectious class where individuals must be urgedto take precautions for the safety of their fellows, orfrom diseases such as the venereal group for whichspecial and gratuitous treatment is provided out ofthe public funds, and requires to be advertised.Much caution is obviously needed in announcementsto the public on cancer in order to avoid overstatement,the making of promises which are not warranted byevidence, or the production of needless and mischievousapprehension of cancer. If all this is realised, know-ledge of some of the main facts of cancer (negative aswell as positive)-such as are indicated in this Circular-may usefully be spread through the ordinaryagencies of public health departments, notably byinstruction at welfare centres, by midwives andmaternity nurses 2 and by social welfare workers. Itneed hardly be added that it is important for themedical officer of health in advising on these mattersto enlist the counsel and assistance of other medicalmen, whether specialists or general practitioners, inhis area.

Facilities for Diagnosis and Treatment.- It is notcontemplated or suggested that there should beestablished throughout the country a public cancerservice, analogous to the services for tuberculosis orvenereal diseases, or that for treating acute infectiousdiseases. Even if such a service were considereddesirable, it would be out of the question until othermatters, such as the improvement of undergraduateand post-graduate medical education in cancer

diagnosis and treatment, have been further developed.But public health authorities, insurance committees,boards of guardians, or other public bodies concernedshould not feel discouraged from individual actionwithin the competence of these bodies from assistingin securing better facilities for diagnosis or more

effective treatment of cancer in the areas or institutionsunder their jurisdiction. It has, for example, beensuggested that local authorities, in conjunction withthe local representative bodies of the medical profes-sion in suitable areas (acting through a special cancercommittee or otherwise) might periodically undertakea review of such questions as the following, consideringin each instance whether steps could and should betaken to meet the requirements of the area and themedical profession within it, and enlisting the help ofall who are likely to be of assistance :-

(1) Improving the local facilities for clinical con-sultations and for pathological examinations ;2 The Central Midwives Board issues an instructional note on

cancer to all midwives on registration, and includes questions oncancer in women in their examination for certificates.

(2) Improving the local facilities for cancer treat-ment (operative, or provision of X ray and radiumapparatus), and considering the adequacy of arrange-ments for this purpose at hospitals, local institutions,

&c., which serve the area ;(3) Improving the facilities for transport of

patients ;(4) Arranging locally for post-graduate demon-

strations, lectures, or courses on cancer for medicalmen practising in the area ;

(5) Arranging locally for the education of thepublic as indicated in the paragraph on propaganda.Should such local medical consideration of cancer

problems lead to applications for the assistance orcooperation of public health authorities as well as ofvoluntary agencies and individuals, the Minister isconfident that these applications will be consideredpractically and sympathetically by those to whomthey are addressed. The Department will be gladat any time to receive communications on the mattersabove outlined in cases in which it would appearthat its action would be helpful or its knowledge oflocal progress in dealing with cancer questions mightbe increased.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH.I THE following are some of the principal healthstatistics of 11 London boroughs taken from reportsfor the year 1922 :&mdash;

The lines indicate that the report did not give the information.

Chelsect.Dr. Louis C. Parkes. whose impending resignation

is announced, mentions in his report for 1922 that theborough council spent 2965 in subsidies to the ChelseaHealth Society, the Red Cross Babies’ Nursing Home,the Chelsea Day Nursery, the Chelsea Branch of theInvalid Children’s Aid Association, the ChelseaDistrict Nursing Association, and to convalescenthomes for nursing mothers, and his report shows thebenefits accruing. Half of the amount of the sub-sidies is recovered as a Ministry grant. Unfortunately,the Babies’ Nursing Home had to be closed in Julyon account of complaints of the noise of cryinginfants and it has not been possible to acquire otherpremises as yet. There were 40 deaths from influenzaand 53 notifications of acute primary pneumoniaduring the first quarter. Sixty per cent. of the deathsfrom pulmonary tuberculosis occurred in institutions.There were two deaths from puerperal fever and tenfrom other diseases, &c., of pregnancy. Of the latter,