An Ethical Problem Part 20

CHAPTER XVI

RESEARCH WITHOUT VIVISECTION

No phase of modern science so closely touches the welfare of humanity as the studies which concern the prevention of disease. Up to a very recent period, well within the lifetime of many now living, practically the entire energy of the medical profession was given up to the treatment of human ailments, with an almost complete disregard of problems of prevention or studies of origin. To-day, in great measure, all this has been changed, and the importance of preventing disease has come well to the front. It is permissible to doubt whether the "cure" of any of the princ.i.p.al infectious diseases is likely to be so thoroughly accomplished as to eliminate it as a cause of mortality, and we may regard with greater promise attempts to discover the mysterious causes of our diseases, and the best methods by which their spread may be prevented. It is certainly a great gain that during the last hundred years mankind has learned that deliverance must come through human activity, and has ceased to regard typhoid or consumption as a dispensation of Providence.

For the conquest of some of the princ.i.p.al maladies affecting the human race at the present time I have long questioned whether the laboratory for experimentation upon animals offers the opportunity for the surest results. The average man has his attention fixed upon mysterious researches which are being carried on in this or that "Inst.i.tute"; rumours of impending discoveries and almost certain cures are published far and wide; and gradually one gets the impression that notwithstanding abundant disappointments, it is only by yet more vivisection that the mystery will be solved. Is this a valid conclusion? In many cases, might not scientific research have a better chance to discover the secret of origin were it directed into other channels? I propose to suggest one method of scientific research with which vivisection is in no way concerned--an investigation into the cause of one of the most terrible and most threatening of human maladies--cancer, or malignant disease.

The subject is a vast one. Within the limits of a few pages it cannot be treated with any approach to the completeness which its importance demands. The utmost that can now be attempted is the suggestion of certain lines of research independent of animal experimentation, which, if carried out with completeness, might lead to results of incalculable benefit to humankind.

Outside the medical profession there are few who have the faintest realization of the facts pertaining to malignant disease. One reason for such ignorance is the lack of any organized system, in the United States, for recording the annual mortality. Except among barbarous or semi-civilized people, no such condition exists. When, during the autumn of 1912, Dr. Bashford, the Director of the Imperial Cancer Research Fund of England, was invited to lecture in New York, he confessed that he had tried in vain to obtain American statistics concerning cancer which might be compared to those of other nations; they simply did not exist. There are a few states and a few cities for which mortality records exist, but in some of the principle states of America there is no official record showing even the total number of deaths from murder, from accident, or disease. Once in ten years the Federal Government resents us the mortality report of the census year, but even here the information is not available until a considerable period after it is collated. There is, however, one nation whose official registers for many years have recorded the mortality from each cause of disease, for either s.e.x, and for each ten-year period of life. These records have no equal elsewhere, and are only approached by the mortality records of the Empire of j.a.pan.

The figures concerning cancer upon which we may chiefly depend are those which pertain to the English people. There can be no doubts but that the mortality from cancer in America exhibits the same phenomena, though the rate may be higher.

The first thing to impress the student is the immensity of the tribute of mortality exacted by this disease, from those in the maturity of life, and in large measure at the period of greatest usefulness.

During thirty years, from 1881 to 1910 inclusive, there perished in England and Wales from cancer no less than 703,239 lives. Figures like these, for the average intelligence, are practically incomprehensible; for this thirty-year tribute to malignant disease in a signle country represents more human being than all estimated to have perished on the battlefields of Europe for two hundred years.

And if we were able to add the mortality from this one disease on the Continent of Europe, it might represent a total of several millions.

Another significant circ.u.mstance is the uniformity of the tribute exacted by cancer, year after year. We can see that best by taking the actual number of deaths from this cause, in a single country, and observing with what slow, implacable, and ever-increasing steps the great destroyer advances.

DEATHS FROM CANCER IN ENGLAND AND WALES

----------------------------------------------- | Year. | Males | Females | |--------------------------|--------|---------| | 1905 .. .. .. | 12,470 | 17,761 | | 1906 .. .. .. | 13,257 | 18,411 | | 1907 .. .. .. | 13,199 | 18,546 | | 1908 .. .. .. | 13,901 | 18,816 | | 1909 .. .. .. | 14,263 | 19,790 | | 1910 .. .. .. | 14,843 | 19,764 | | 1911 .. .. .. | 15,589 | 20,313 | | 1912 .. .. .. | 16,188 | 21,135 | | | | | -----------------------------------------------

The terrible thing about these figures is their uniformity from year to year. With as great a degree of certainty as the farmer foretells the produce of his fields and the results of his seed-sowing, so the statistician can calculate the tribute that cancer will exact from the human race in future years. How many persons in England and Wales will die from some from of cancer during the year 1917? Unless some great catastrophe shall vastly lessen the total population, the number of victims destined to perish from malignant disease during that one year will hardly be less than 38,500, and in all probability will be more. And we have no reason to doubt that in the United States the mortality from cancer would be found equally uniform were it possible to know the facts.

Nor does uniformity pertain to numbers of either s.e.x only. Each period of life has to furnish its special toll. If we look at the mortality among men or women for a period of years, we shall see this phenomenon very clearly. In the following table we see the deaths of men from cancer, in England, at each ten-year age-period.

DEATHS FROM CANCER AT DIFFERENT AGE-PERIODS (ENGLAND): AGE-PERIODS OF MALES

-------------------------------------------------------------- |YEAR|Under|25-35.|35-45.|45-55.|55-65.|65-75.| Above |Total.| | | 25. | | | | | | 75. | | |----|-----|------|------|------|------|------|-------|------| |1906| 250 | 322 | 927 | 2,454| 4,087| 3,651| 1,566 |13,257| |1907| 305 | 277 | 921 | 2,392| 4,041| 3,675| 1,588 |13,199| |1908| 274 | 317 | 925 | 2,594| 4,147| 3,957| 1,687 |13,901| |1909| 262 | 296 | 921 | 2,581| 4,319| 4,174| 1,710 |14,263| |1910| 283 | 337 |1,001 | 2,778| 4,377| 4,315| 1,752 |14,843| |1911| 309 | 317 | 978 | 2,901| 4,627| 4,602| 1,855 |15,589| --------------------------------------------------------------

Precisely the same phenomenon is to be found in the cancer-mortality of women. Each ten-year period of life exacts its own proportion, with an increasing death-rate out of proportion to the increase of population.

Another fact, attainable only by the study of English statistics, is the singular regularity with which malignant disease selects different parts of the body year after year. If proclivity to this mysterious ailment were a matter of chance, or dependent upon the irregular action of certain forces, we should certainly fail to find such uniformity, or such approach to uniformity, as exists. One year, for instance, there would be, let us say, a preponderance of attacks upon the skin; another year the digestive organs would be the princ.i.p.al sufferers; a third year the joints and muscles would be chiefly involved. The actual experience proves that we are subject here to forces of incalculable stress, which nevertheless press steadily and uniformly upon humanity, where the habits and environment are the same. In the year 1901, for example, of the total number of fatal cases among men, the seat of the disease was the stomach in a little over 21 per cent. of the total number of cases. In 1910 the proportion was also 21 per cent. During the ten years 1901-1910, of the total mortality, the stomach was the organ involved in but a fraction over 21 PER CENT. OF THE TOTAL CASES.

Is cancer increasing? This is a question of vast importance to the human race. That in proportion to total population more die from the disease to-day than twenty or thrity years ago, is a fact about which there can be no doubt. Dr. Stevenson, in the Report of the Registrar- General for the year 1910, tells us that in "all countries from which returns have been received the mortality has shown a general tendency to increase in recent years." Speaking on the "Menace of Cancer," the statistician of the Prudential Insurance Company of America affirmed that "the cancer death-rate in the United States is increasing at the rate of 2.5 per cent. per annum, and a corresponding increase is taking place practically throughout the civilized world." The cancer- rate among men in the United States has increased, according to the same authority, 29 per cent. during the last decade. The steady increase of cancer year after year is strikingly shown by a curve diagram, based upon the English mortality for several years.

A significant ill.u.s.tration of the steady increase in the mortality from cancer is shown by its fatality among women in England between the ages of forty-five and sixty-five. In the year 1875, of all deaths of women at this period of life, one in ten (in round numbers) was due to some form of malignant disease. In 1890 the tribute exacted by the disease had become one in eight. Ten years later--in 1900--of all women dying in England during this period of middle life, the toll of cancer was one in seven; and in 1910 the corresponding proportion was one in five! At this rate of increase it will not be many years before a full third of all the deaths of women at this time of life will be due to malignant disease. There can be little doubt that the same phenomenon would be found to pertain to American experience, were it possible to disentangle the facts from the obscurity in which they are now permitted to lie. It is a curious fact that in England until the year 1900--and, so far as we know, for thousands of years--the death-rate from consumption among women was considerably higher than that of malignant disease; that in 1903, for the first time, the cancer-mortality of women exceeded that of phthisis; and that in 1910 it had so far surpa.s.sed it that they are not likely ever again to be equal, unless we shall discover the cause of the more fatal plague.

The theory has been put forth by certain writers that the increased death-rate from cancer is due, not to any increased frequency of the dissease, but rather to improved methods of detection. It is quite certain that fifty years ago, for instance, surgeons were less able and less willing to p.r.o.nounce judgment regarding obscure cases of internal tumours. But if the better diagnosis of to-day accounts for some part of this increase since 1860, it does not seem probable that it can explain the rising death-rate of the last ten or fifteen years. The medical pract.i.tioner of 1900 was certainly as well qualified to p.r.o.nounce upon the character of the disease as the surgeon or physician of to-day. Nevertheless, the cancer death-rate of England in 1910 had increased 16 per cent. above that of ten years before, and during the fifteen years 1895-1900 it had increased fully 28 per cent. Certainly in these last few years there has been no such increased ability to detect the disease as would account for all this. Yet another fact suggests doubt of this optimistic hypothesis.

If the increased cancer death-rate were due merely to the increased ability of the physician or surgeon to recognize the ailment, we should certainly find that the increase of cancer would be seen only in those parts of the system, such as internal organs, where some degree of doubt might perhaps be entertained; while, on the other hand, there would be little or no increase discernible in the mortality of cancers affecting parts of the body where its nature could not be mistaken by any intelligent physician or surgeon. Now, for a number of years, perhaps with this hypothesis in view, the Registrar-General in England has tabulated all deaths from cancer of either s.e.x, not only by different age-periods, but also by the part of the body affected by the fatal disease. A study of the facts thus made known is extremely suggestive. It is true that a marked increase in the death-rate has occurred in cancer affecting internal organs, as we should naturally suppose; but it is also true that malignant disease affecting parts of the body where little or no doubt of the character of the ailment could be entertained by the physician, exhibit in some instances as marked an increase in the death-rate as in some other cases, where doubt of malignancy might be justifiable.

For example, cancer of the tongue among men showed a death-rate of 32 per million population in 1897; it went up to 47 per million in 1910-- an increase of nearly 50 per cent. Cancer of the female breast showed a death-rate of about 142 per million population in 1897; it had arisen to a rate of 190 per million only thirteen years later; and here, a.s.suredly, the nature of the disease in fatal cases cannot be mistaken.[1] Cancer of the stomach in its final stages does not present insuperable difficulties in way of diagnosis, but the death-rate increased for men about 40 per cent. in fifteen years; and although some of this increase may be due to more careful discrimination between cases of malignant disease affecting the liver, yet this explanation cannot account for the increase when both organs are considered together. The subject is worthy of careful and extended investigation, but even a cursory examination of the facts now available indicate a real increase in the death-rate from cancer in England, and probably in every other civilized country in the world.

[1] "During fourteen years ... the mortality from mammary cancer has increased by about 29 per cent., NOTWITHSTANDING LIVES SAVED BY IMPROVED METHODS OF OPERATION."--Registrar-General's Report for 1910, p. 69.

But all these phenomena are of secondary importance compared with the great problem of medical science--the yet undiscovered cause of malignant disease. During recent years the study of cancer has been conducted with scientific enthusiasm in many laboratories. Vast sums of money have been given, in the hope that these studies may one day lead to the discovery of a cure. One whom I knew in his youth became the heir of great wealth; lived to see one whom he loved perish from the disease; was struck down himself, and dying, left a fortune for the purpose of promoting research concerning cancer. And yet to-day the problem, as attacked in the various laboratories of Europe and America, is apparently as far from solution as it was forty years ago. Sir Henry Butlin, ex-President of the Royal College of Surgeons, England, is said to have operated on as many cases of cancer as any surgeon of his day. Yet, speaking in October, 1911, he said:

"I have been a.s.sociated with the Imperial Cancer Research and in touch with its staff from the foundation of the Research, and have been a member of the publication committee of all its scientific reports. IT HAS DONE NOTHING ON THE LINES IN WHICH OBSERVATION HAS BEEN SO USEFUL. It has not unfolded the life-history of a single variety of cancer, so that we can base our operations on the information. It has not even discovered whether spontaneous cancer of a particular part of the body in the rat or mouse runs a similar course to spontaneous cancer of the same part of the body in the human subject. These problems are not suited for experimental investigation; they are determined by observation."[1]

[1] Lancet, London, October 7, 1911.

No "serum," no drug, no curative agency of any kind, has thus far been discovered upon which the slightest dependence may be placed. The only measure of relieve which medical science can now suggest is early and complete extirpation. Of what proportion of cases even this insures immunity we cannot tell.

Without decrying what has been done in the laboratory, may it not be that we have gone in that direction as far as there is any hope for success, and that all effort should now be directed TO THE DISCOVERY OF THE CAUSE OF MALIGNANT DISEASE IN HUMAN BEINGS? That great secret still eludes us, but until we can penetrate that mystery, it is difficult to perceive how we may hope to prevent the increasing prevalence of the great destroyer . Yet there is one method of investigation which (speaking from a study of cancer statistics for more than twenty-five years) seems to me to offer, more than all others, a reasonable hope of ultimate success. It is independent of all sacrifice of animal life. It involves, however, an expenditure far greater than is possible for any private investigator, and probably only by the co-operation of the Government can it be undertaken with any chance of success. Yet, if Society can once be aroused to a recognition of the need for the completest possible investigation concerning malignant disease, and particularly the reasons for its differing prevalence among people of different nationalities, habits, and general environment, that inquiry will take place, even though it cost the price of a battles.h.i.+p.

The subject is so vast and involved that it cannot be discussed with any approach to completeness in a single essay. Suppose, however, that we glance at the theory which regards cancer as due to a microbe which in some mysterious ways gains admission into the human body, lying for a time dormant, but liable under appropriate stimulation to be awakened into malignant activity. We know at the outset that if any such germ of disease exists, it has thus far escaped visual recognition. No human eye can be said with certainty to have seen it, even when aided by the most powerful microscope; but this may be due to the fact that, like the germ of certain other diseases, it is so minute that it lies beyond the range of human vision. There are, however, certain facts pertaining to the disease which have significance. We have already seen that in a given country there is a kind of uniformity in the number of those dying from the disease from year to year; but another phenomenon relates to the unequal pressure in difference countries of the causes of the disease.

1. THE DEATH-RATE FROM CANCER APPEARS GREATLY TO VARY ACCORDING TO RACE AND ENVIRONMENT.

CANCER DEATH-RATE IN DIFFERENT COUNTRIES PER 100,000 POPULATION

--------------------------------------------------------------- | Five-Year Periods. | Switzerland. | England. | Italy. | |--------------------------|--------------|----------|--------| | 1886-1890 .. .. | 114 | 63 | 43 | | 1891-1895 .. .. | 122 | 71 | 44 | | 1896-1900 .. .. | 127 | 80 | 51 | | 1901-1905 .. .. | 128 | 87 | 55 | ---------------------------------------------------------------

Here is the record of a period of twenty years. These differences of proclivity to cancer are exceedingly curious. Can the reader perceive why they exist?

The rate in England is quite 50 per cent. higher than that of Italy.

If we explain this by the hypothesis of greater skill in detecting the disease, what are we to say of the cancer-rate in Switzerland, which is 50 per cent. higher than that of England?

But here is another curious fact. The United States census of 1900 permits a contrast of the mortality of cancer according to the birthplaces of mothers of those attacked. Here, for instance, is the death-rate from cancer and tumour of persons of different nationality, calculated in three sections of the country--the rural districts of the registration area, the cities of the same section, and the cities outside the registration area.

DEATH-RATES IN THE UNITED STATES FROM CANCER AND TUMOUR PER 100,000 WHITE POPULATION, ACCORDING TO THE BIRTHPLACE OF THE MOTHERS OF PATIENTS

--------------------------------------------------------------- | | | | | | Registration Area. | Other | | COUNTRIES. |----------------------| Cities. | | | Rural | Cities. | | | | Districts. | | | |--------------------------|------------|---------|-----------| | Italy .. .. .. | 20 | 24 | 39 | | Russia and Poland .. | 26 | 30 | 26 | | England and Wales .. | 79 | 77 | 80 | | Ireland .. .. | 90 | 82 | 86 | ---------------------------------------------------------------

How are these facts to be explained? What is there about the habits, the environment, the dietetic peculiarities of the Italians in America, which tends to confer upon them a greater immunity from cancer than is possessed by those whose maternal ancestry goes to England or Ireland? a.s.suredly this immunity is not due to chance. It is governed by some law, even though that law be unrecognized to-day.

If the low cancer mortality of Italy made itself manifest only in that country, we might suspect it indicated a lack of skilled diagnosis; but here we find it just as prominent in three different section of the United States. Not only that, but the difference is seen in comparison of parts affected by cancer. For persons whose mothers were born in Ireland the death-rate in cancer of the stomach per million population was 184; the corresponding rate for Italians was 56.

Does the poverty of the people have anything to do with proclivity to cancer? In one way this is a probability. If we could compare the general prosperity of men and women whose parents were born in the United States with the entire population of which the parents were born in other countries, it seems to me that we should find the second cla.s.s, taken as a whole, to be financially less prosperous than the first. Now, in 1900, the census reveals that in the United States the cla.s.s to suffer chiefly from malignant diseasewas that which included THE FOREIGN-BORN POPULATION, alike in cities, in rural districts, within or without the registration area. This is certainly a fact of tremendous import. In America the population is a blend of every European nationality. Why, taken as a whole, should the native American suffer from one mysterious disease less than some of those who have come more recently to the United States?

In another work I have ventured to suggest that if we are to discover the cause of cancer, we must study the habits and customs of those still living who have become the victims of some form of this mysterious disease. A theory held by some is that cancer is due to the consumption of meat. If one means that the flesh of perfectly healthy animals is liable to cause cancer, the hypothesis is one for which it seems to me that the evidence is far from being sufficient to justify belief. But if, on the other hand, it is suggested that malignant disease may be due to germs derived from animals which were suffering from som form of cancer when they were killed for the food of human beings, then much that is otherwise obscure becomes plain.

We should expect in such cases to find cancer more prevalent among the poor than among the rich, and especially prevalent among those who, from carelessness, or ignorance, or seeming necessity, consume the cheaper kinds of meat. And since, both in their native land and in America, the Italian population consumes less meat than peoples of other nationalities, we should expect them to be less liable to be infected by the germs of malignant disease.

A few years ago a medical writer who has given much attention to this disease published some of his investigations into the cancer death-rate of Chicago. Taking the figures for a single year, he discovered that the "cancer death-rate among the Irish and German residents of Chicago is the highest in the world, being nearly 300 per cent. higher than in their native countries."[1] Of each 10,000 population of each nationality living at the age of forty years and over, he found that the deaths from cancer among the Germans was 76, among the Irish 70, among the Scandinavians 52, and among the natives of Italy 24. It was found that, while the staple diet of Italians in Chicago was macaroni and spaghetti, the people of other nationalities among whom the cancer-rate was exceedingly high, "consume large quant.i.ties of canned and preserved meats and sausages, OFTEN EATEN UNCOOKED." He discovered that a large part of the fresh meat prepared at the establishment of a certain slaughtering establishment in Chicago was derived from animals which had been condemned on the ante- mortem inspection, but the flesh of which was perimitted TO BE SOLD AS PURE FOOD AFTER THE DISEASED PARTS HAD BEEN REMOVED. Sold thus at a cheaper price, such meat was chiefly consumed by the poorer cla.s.ses of the foreign population. And while Dr. Adams does not adopt the hypothesis of the cancer-germ, he does not think there can be "the slightest question but that the increase in cancer among the foreign- born over the prevalence of that disease in their native countries is due to the increased consumption of animal foods, PARTICULARLY THOSE DERIVED FROM DISEASED ANIMALS."

[1] See article by Dr. G. Cooke Adams in Chicago Clinic of August, 1907, pp. 248-251.

A statement like this is calculated to induce serious reflections.

The average reader finds it difficult to believe that, according to the present interpretation of the law, the flesh of animals found to be suffering from cancer at the time of their slaughter would be permitted to pa.s.s into the world's food-supply. We are int the presence of a great mystery. We do not know how the gret plague originates. But no reflecting man or woman can be insensible to the significance of possibilities when he learns that cancer affects animals which are killed for food; that in the majority of cases the disease affects some part of the digestive tract; that it chiefly prevails among the very poorest cla.s.ses of the population, excepting only those like Italians, who use but little meat; and that, according to the official regulations of the United States Government in force to-day, THE FLESH DERIVED FROM CANCEROUS ANIMALS NEED NOT ALWAYS BE DESTROYED AS UNFIT FOR HUMAN CONSUMPTION. The cancerous tumour, the affected parts, must indeed be cut away, and carefully condemned. The disposition of the remainder of the meat is left to the decision of the inspector!

The regulation so far as it applies to meat of this kind, is as follows:

"ANY ORGAN OR PART of a carca.s.s, which is badly bruised, or which is affected by tumours, MALIGNANT or benign, ... shall be condemned; but when the lesions are so extensive as to affect the whole carca.s.s, the whole carca.s.s shall be condemned."[1]

[1] Regulations governing Meat Inspection, U.S.A. Regulation No. 13, section 23. See also Appendix VIII., p. 362.

The meaning of this regulation would seem to be perfectly clear.

There is no demand by the Government that the entire carca.s.s of an animal affected by malignant disease shall be utterly destroyed for food purposes, unless the disease has involved the entire body,--a condition as rarely found among domesetic animals, as among human beings. Otherwise than this, what is there in the official regulations of the bureau governing meat inspection to prevent such use of the flesh of diseased animals as the inspector may authorize?

It seems to me that if science is ever to discover the cause of malignant disease, there should be a careful study of all the conditions under which the disease now manifests itself. The mortality from cancer in the state of New York, in 1912, amounted to 8,234; in England, the number of those who perished from the disease in 1911 was nearly 36,000. By what figure must we multiply this mortality in order to ascertain the number of persons living who have been affected, or who now are suffering from cancer? n.o.body knows.