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lying districts which are traversed by sluggish streams and are
liable to periodic inundations, and in support of this view he
instanced the Thames and its tributaries, which run through
districts that are markedly cancerous. That there is probably

1 A similar statement made by Cantlie of Hong Kong is cited by Eoger
Williams.



92 CANCER OP THE STOMACH

a good deal of truth in this contention is shown by the follow-
ing remarks of the Registrar-General in his report for 1890 : —

' Crude death-rates show that in and around Huntingdon-
shire and Cambridgeshire there is a well-defined area in which
cancer is exceptionally prevalent. It comprises the districts of
Stamford, Bourn, Spalding, and Holbeach in Lincolnshire,
Oundle and Peterborough in Northamptonshire, and most
of the counties of Huntingdon and Cambridge. In 1881-
1890 this area had a mean population of over 300,000, its
crude cancer-rate being 859 per million, or 46 per cent, above
the average for the country in general ; in the preceding
decennium the excess was 44 per cent.' On the other hand, as
Roger Williams has pointed out, many islands that have no
rivers, that are not low-lying and are not of alluvial formation,
such as the Scilly, the Channel Islands, and the Isle of
"Wight, have nevertheless a very high cancer mortality. In
Norway also cancer occurs for the most part in the moun-
tainous districts and at considerable elevations ; while in Mexico
the high table-land is more subject to the disease than the low-
lying plains (Hirsch). It follows, therefore, that whatever
influence a special district may exert upon the development
of cancer, geological configuration is by no means the sole
factor in its production.

It has frequently been noticed that the inmates of certain
houses are especially liable to carcinoma, which appears among
successive tenants who are neither related to one another nor
possess any hereditary predisposition to the disease (Arnaudet,
Fabre, Webb, Fiessinger). In Webb's case a man died of
cancer of the rectum in a certain house at the age of twenty-
six. Of the next tenants, the husband died of gastric cancer
and the wife of cancer of the rectum ; while of the three ladies
who next inhabited the house, one died from malignant disease
of the stomach and another from a similar affection of the
uterus. Mason has also shown that in the district of Leaming-
ton the disease is quite common in houses situated in certain
rows or upon one side of a row, while in other streets it is con-
spicuous by its absence. This writer has also remarked that
about 17 per cent, of these cancer houses were placed at the end
or at the corner of a street, were of old construction, and were
built upon a porous subsoil. In this connection it may be
noted that both husband and wife not infrequently fall victims



ETIOLOGY 93

to carcinoma of the digestive organs if the survivor continues
to reside in the same house, while occasionally the disease
occurs almost simultaneously in both.! Thus we have
known a man to be attacked by cancer of the stomach while
his wife was dying from a similar affection of the duodenum ;
and also a man and his two daughters to develop malignant
disease of the stomach or colon within a period of twelve months.
These several phenomena occur too frequently to be regarded
as mere coincidences, and probably depend upon the operation
of some well-defined local cause/ the nature of which, however,
is still obscure.

6. Race

Want of evidence^renders it difficult to determine the exact
influence of race upon the inception of the disease, but all
the information we possess seems to indicate that savage
peoples enjoy a comparative immunity. In Central Africa the
negroes appear to be seldom affected, while in the southern
portion of that continent the coloured inhabitants rarely fall
victims to the disease, which, however, is very rife among the
white population and the crossbreeds. Landry found cancer
to be rare among the aborigines of Canada, and it is also said
to be infrequent among those of New Zealand. According to
the Tenth Census Report of the United States, the cancer death-
rate was 27-96 per 100,000 whites and 12-17 per 100,000 blacks.

In India both Mohammedans and Hindoos are equally
affected, while among the Chinese superficial carcinomata are
common, but the gastric lesion is comparatively rare. It is in-
teresting to observe that in civilised countries the aliens usually
suffer more from malignant growths than those born in the
country. Thus, among the entire population of Australia over
twenty-one years of age, Mullins found that the death-rate from
cancer of those born in Germany was one in 538, of those born
in the United Kingdom one in 748, and of those born in
Australia one in 2,738. From these and other similar facts he
concluded that about three-fourths of the total mortality from
the disease was borne by the immigrant population. The
researches of Osier and McCrae at the Johns Hopkins Hospital
point to a similar conclusion, for they found that the native-born,
who constituted 78-3 per cent, of the patients, supplied only
57*3 per cent, of the cases of gastric cancer, while the foreign-



94 CANCEE OF THE STOMACH

born element, which formed only 21/7 per cent, of the patients,
contributed no less than 42-7 per cent, of the cases of that
disease. They also draw attention to the fact that, according to
the census of 1880, the death-rate from cancer per 100,000 living
was 20 - 08 for the native-born and 53 - 3 for the foreign-born.
Finally, they make the interesting statement that ' a lower death-
rate (from carcinoma of the stomach) is found in children of
mothers born in the United States, the highest being in those of
mothers born in Germany. This is most marked in the cases over
sixty-five years of age, being 42-72 in children of native-born
mothers and 123-62 in the children of mothers born in Germany.'
It has been asserted, although upon what authority we have
been unable to discover, that the Jews are seldom affected by
gastric cancer. Our own experience has convinced us that far
from being comparatively immune, the Jewish race is particu-
larly prone both to cancer and to simple ulcer of the stomach ;
while according to Billings the death-rate from cancer among
the Jews of the United States is the same as that of the rest of
the white population.

7. Heredity

Statistical inquiries relative to an hereditary predisposi-
tion to cancer *have shown that in 13-22 per cent, of all
cases of the disease some relative of the patient had died
from a malignant growth. With regard to carcinoma of the
stomach, Lebert found a family history of cancer in 7 per cent,
of his cases, Haberlin in 8 per cent., Brautigam in 12 percent.,
Schiile in 6-5 per cent., and Osier and McCrae in 7*3 per cent.
In our own series, one or other parent had died of cancer in
6 per cent., and a brother or sister in 2 per cent. It must
be remembered, however, that all these figures relate to hospital
patients, the majority of whom are profoundly ignorant of their
family history. In private practice a cancerous history is
obtained in about 16 per cent. The mere fact that a patient
with gastric carcinoma was related to some one who died of
cancer has little bearing upon the question of the hereditability
of the disease, since one in every twenty-one men and one in
every twelve women who attain the age of thirty-five die of some
malignant affection. What is of importance is the occurrence
of carcinoma of the same organ in successive generations.
This homotypic transmission of the complaint has so often been



ETIOLOGY 95

pointed out that a few examples will suffice to illustrate it.
In the Bonaparte family, Napoleon the First, his father, his
brother Lucien, and two of his sisters, Caroline and Pauline,
all died of carcinoma of the stomach. Manichow has recorded
that twenty-three families resident in one district had sixty-nine
cancerous members between them, of whom fifty-seven died of
gastric cancer and four others of malignant growths of the
intestine or liver. Among our own cases, the gastric complaint
appeared in one instance in three generations, while in another
three brothers, their father and a sister, all succumbed to it.
It is interesting to observe that the predisposition is usually
most marked in children of the same sex as the cancerous
parent. Thus, if the mother is affected, the daughters will
exhibit the greatest liability, while in the case of a cancerous
father it is the male issue that are principally attacked. It is
often stated that a family predisposition to cancer favours its
precocious development ; but we are personally of opinion that
the gastric disease has a curious tendency to appear at the same
age in each generation, and that the popular superstition upon
this point has, consequently, a solid groundwork of fact. It is
occasionally observed that the tendency to the disease is trans-
mitted through some member of the family who had personally
escaped. Thus we find it appearing in several members
of a family whose uncles, aunts, and perhaps grandparents,
had been affected in a similar manner, while the parent had
lived to a great age. Less frequently a grandparent will
transmit the disease to grandchildren, while all the immediate
offspring remain free from cancer. In 18 per cent, of our cases
one or both parents were stated to have died at a very advanced
age, and in several instances the grandparents had also exceeded
the usual span of life. This curious longevity among the pro-
genitors of cancerous families has often been the subject of com-
ment (Eoger Williams), and serves to emphasise the fact that
malignant disease is particularly apt to attack those who are con-
sidered to be constitutionally healthy. Lastly, it may be noted
that persons who die from gastric cancer are often endowed with
great reproductive fecundity, and are themselves members of
large families. In our series the average number of children
was 6-6, whereas in the general community the average number
of a family is 4-6 (Fan). Conversely, it is rare to find an only
child attacked by carcinoma of the stomach.



96



CANCEE OF THE STOMACH



8. Occupation

The most careful inquiries have failed to show that occupa-
tion exercises any material influence upon the development of
gastric carcinoma, while the fact that married women suffer
from the complaint equally with men seems to point to a
similar conclusion. The following table, which is taken from
the Fifty-fifth Annual Report of the Registrar- General of
England, indicates the relative incidence of cancer in males
engaged in different forms of employment, but since the
primary seat of the disease is not specified its conclusions are
not entirely relevant to the gastric lesion.

Table 19. — Cancer Deaths in Males. Highest and Lowest Mortality for
certain Occupations, showing the Comparative Figure to 1,000 Deaths
from all Causes (England) '



Above the average
[47 per mil.]
Occupations


Comparative
figure


Below the average
[47 per mil.]
Occupations


Comparative
figure


Chimney-sweeps

Copper-miners

Brewers ....

Innkeepers (London)

Inn servants .

Commercial travellers

Plasterers

Barristers and solicitors .

Merchant seamen .

Innkeepers (industrial

districts)
Milk-sellers .
General labourers

(London)
Butchers.


156
86
70
70
67
63
62
60
60

58
58

58
57


Medical profes
Miners, all cla
Farmers .
Agricultural la
Gardeners
Coalminers
Clergymen
Potters .
Grocers .
Hosiery-rnakei
Lace-makers
Lead- workers
Coalminers (S.
Paper-makers


sion .
sses .

bourers

s
Wales)




43
37
36
36
36
36
35
35
34
30
28
27
26
22


Occupied males (London)
Occupied males (indus-
trial districts)


59

48


All occupied males .
All occupied males (agri-
cultural districts)


44
40



9. Diet

The inordinate frequency with which carcinoma attacks
the alimentary canal naturally suggests that the infective
agent, if such there be, is usually introduced into the

1 In this table the mortality of all males from twenty-five to sixty-five years of
age from all causes is taken as a standard = 1,000. Out of this number the deaths
from cancer in all males amount to forty-seven. The table gives the comparative
numbers for males in different occupations, these numbers having only a relative,
and not an absolute, value.



ETIOLOGY 97

body with the food. It is therefore necessary to inquire
whether indulgence in or abstinence from some particular
article of diet exerts any decided influence upon its development.
Eeclus and others appear to have convinced themselves that
those who live upon vegetables are practically exempt from
the disease, but the evidence upon which this belief is founded
is somewhat obscure. On the other hand, there are strong
reasons for believing that the exclusive use of vegetables does
not prevent the inception of cancer. Hendley states that out
of 102 patients who were operated upon for carcinoma at
Jeypore between 1880 and 1888, sixty- one were lifelong
vegetarians ; while nearly 3 per cent, of oar cases of gastric
carcinoma denied that they had eaten meat for many years.
In private practice we have also frequently observed the
disease in people who had long abstained from animal food.
The popular superstition that tomatoes give rise to cancer is
probably founded upon some fancied resemblance between
the interior of the vegetable and a fungoid growth. Other
authorities attribute the increase of carcinoma to the greater
consumption of meat by the population during the last half-
century. It can hardly be denied that the tendency to
luxurious living has increased in almost every country in the
last fifty years, but that excessive indulgence in meat is a
primary factor in the production of the disease has yet to be
proved. It may be noted that the liability to cancer of the
stomach increases with age, whereas the appetite for meat
usually diminishes after middle life. Moreover, it is almost
unknown among savage tribes, who live by hunting, and among
the Esquimaux, while it is common both in hospitals and
infirmaries, whose sick inmates have seldom enjoyed oppor-
tunities for over-indulgence in meat.

Again, there is no evidence to show that any special variety
of animal food promotes the development cf the complaint.
Dried and tinned foods are apparently harmless, and Bauby
has shown that pork-eaters are not more prone to the disease
than others. It has been suggested that the importation of
frozen mutton might be responsible for the increasing prevalence
of malignant disease in Europe ; but the comparative immunity
enjoyed by the native populations of Australia and Argentina,
and the uniform increase of the disease hi all parts of the
civilised world, are sufficient to negative this supposition.

H



98 CANCEE OF THE STOMACH

Fishermen in England are unduly prone to cancer, but this
can hardly be ascribed to their diet, since the disease is very
common in the Black Forest and other parts of Central Europe
where fish is a rare article of food.

It is often asserted that teetotalers are seldom affected by
carcinoma, but we are not aware of any authentic evidence in
support of this view. On the contrary, we find that nearly 40
per cent, of our cases at the London Temperance Hospital
were total abstainers ; while at the London Hospital, where
patients are very seldom given to abstinence, no less than
4 per cent, of the cases of gastric cancer affirmed that they
had been lifelong abstainers from alcohol. It may also be
noted that malignant disease is very common among the
Mohammedan population of India, who never indulge in
alcohol ; while the British Medical Association's report upon
the etiology of cancer indicates that the alcoholic habit is,
if anything, antagonistic to the development of carcinoma.
Lastly, Boger Williams has laid great stress upon the tendency
of the complaint to attack people who have led sober and in-
dustrious lives, and upon the comparative immunity of those of
debauched and dissolute habits. We are also convinced that
the gastric lesion is extremely rare among persons affected with
alcoholic gastritis, cirrhosis of the liver, and nervous com-
plaints due to chronic alcoholism. Although, therefore, it is
possible that the abuse of stimulants may so diminish the
natural resistance of the tissues as to favour the inception
of cancer, as it undoubtedly does that of tubercle, we do not
believe that it is in any way an important factor. Cloquet has
attributed the prevalence of cancer of the stomach in certain
parts of Normandy to the consumption of acid cider, while
Brunon and Rebulet regard the frequent admixture of sea
water with that local drink as the deleterious agent. Neither
of these views, however, has been endorsed by the committee
appointed to investigate the subject, which seems to have
considered that heredity was the principal cause of the pre-
valence of the complaint.

Although indulgence in meat or alcohol does not appear to
favour the inception of carcinoma, it is quite possible that the
mischief may be due to the inordinate consumption of some other
article of diet. A comparative study of the food of savage and
civilised communities at once indicates that at least two
common articles of diet are usually wanting among those who



ETIOLOGY



99



appear to be naturally exempt from malignant disease. The
first of these is bread made with yeast, and the other beer. It
is also a curious fact that among the poorest agricultural popu-
lations, where these two products of civilisation are rarely
employed, carcinoma is supposed to be rare, while in those
districts where one or other is taken in excess the complaint is
exceptionally common. 1 It is also interesting to observe that
modern pathologists are inclined to regard the cell-enclosures
met with in carcinoma as more closely allied to yeast than to
protozoa, and should this identity be established it will cer-
tainly be advisable to ascertain whether all or only a portion of
the fungus employed in the preparation of bread and beer is
really killed in the process of manufacture.

10. Hygiene
The frequent occurrence of carcinoma of the stomach in old
houses and in those whose drainage systems are defective has
led to the belief that insanitary conditions either predispose
to or excite the disease. 2 It would appear, however, from
the reports of the Eegistrar-General that the death-rate from
cancer is comparatively low in densely populated districts,
where the hygienic arrangements are imperfect and where the
mortality from infectious complaints is the greatest. It is
also less among those engaged in industrial employments
than among the professional classes and shopkeepers; while
m most of the large cities it is more prevalent in the wealthy
quarters than in those of the poorer section of the population.
These facts have induced certain authorities to regard luxuri-
ous living as an important factor in the etiology of malignant
disease, but it might also be argued that the lesser mortality
m early life among the rich permits a greater proportion to
attain the age at which cancer is usually met with.

11. Traumatism and Mental Conditions

Carcinoma of the stomach occasionally follows a severe
blow upon the epigastrium, just as an injury to the breast

1 Table 19 indicates that brewers, inn-servants, innkeepers, and commercial
travellers are unduly prone to cancer; while the prevalence of the. disease among
those exposed to soot and the products of copper-smelting suggests the possible
influence of arsenic as a predisposing cause.

z Mason found that defective drainage existed in 25-7 per cent, of the houses
where the disease occurred.



n 2



100



CANCER OF THE STOMACH



sometimes forms the starting-point of the disease in that organ.
It is probable, however, that in both cases the effect of traumatism
is to determine the location of the growth rather than actually
to produce it, much in the same way that an injury in a tuber-
culous subject is apt to be followed by a local manifestation
of the complaint. There are also a few instances on record in
which a cancerous tumour of the stomach was found to contain
a pin, a spicule of bone, or some other foreign body that had
become embedded in the gastric wall and had given rise to
chronic irritation of the tissues.

The older writers were wont to regard grief and mental
trouble as important factors in the production of cancer, but of
recent years these and similar views seem to have fallen into
disrepute. No practitioner, however, who has had much
experience of cancer of the digestive tract can fail to have
been struck by its extreme frequency in men who have been
subjected to great domestic trouble ; and, for our own part,
we are so convinced that continued mental worry is a pre-
disposing cause of the disease that we make it a subject of
inquiry in every case, and regard its existence as a fact of clinical
importance.



12. Influence of Seasons

In the following table we have arranged 154 cases of carci-
noma of the stomach according to the month in which the
disease terminated and that in which it was supposed to have
commenced.

Table 20



Fatal cases Percentage



December

January

February

March

April

May

June

July

August

September

October .

November



Admissions
to hospital



9 ,
6 ' 22

V

10,

13 - 37
14)

14 I

18 '- 42

10'

18 )

19 53

16)



14-3


10 - 22




V




18,


24


15 , 41




8 1




16,


27-2


19 - 45




io)




15,


344


18 44




11'



14-4
27
29-6
29



26 [ 53
19 J

2 I
25-30

3 J

13 r 26
8 1
12
11' 30

1)



38
21-6
18-7
21-6



ETIOLOGY 101

We have given preference to the lethal event because the
accuracy of the figures upon this point is beyond dispute,
whereas those that refer to the commencement of the complaint
are always open to doubt. It will be observed that the death-
rate varies at different times of the year, being lowest during
December, January, and February, and highest in September,
October, and November ; or if the months be grouped according
to seasons, that over 60 per cent, of the total deaths take place
between June and November. These figures are, of course, too
small to warrant any absolute conclusions being drawn from
them, but at the same time they are too striking to be ignored,
more especially as both Yirchow and d'Espine noticed, fifty
years ago, that persons affected with malignant disease die more
frequently in the summer than in the winter. This fact is of
itself somewhat curious, since one would have supposed that a
disease which reduces the vitality to such a low ebb, and so
often terminates by pneumonia, would be more likely to prove
fatal to the poor inhabitants of London during the cold and wet
winter months than in the more genial weather of the summer
and autumn. At first sight it would seem as if an increase of the
temperature of the air might stimulate the growth of a malignant
tumour, in the same way that it does that of plants, and by
accelerating its progress curtail the period of existence. That
an increased rapidity of growth really does take place during
the spring and summer is more than probable, for not only do
cases succumb more quickly between April and August, but, as
will be seen from the table, only about one-seventh of the total
number were admitted into hospital during December, January,
and February. Personally, however, we are strongly of opinion
that carcinoma obeys certain laws of epidemiology, like enteric
fever, acute rheumatism, and other infective diseases, and is
consequently more rife at certain seasons than at others. If it
be allowed that the usual duration of the gastric complaint
varies from nine to twelve months, we should expect from the
facts already noted that in the majority of the cases it would
commence between September and February; and in this
connection the last part of the table becomes instructive, for it
will be observed that in 60 per cent, of the entire number the
first symptoms of illness showed themselves within that period.
We venture to believe that further investigation upon these lines
will throw an important light upon the etiology of carcinoma.



102 CANCEE OF THE STOMACH

13. Influence of Other Diseases

(a) Gastric Ulcer. — Cruveilhier was the first to point out
that carcinoma is apt to attack the edge or scar of a simple
ulcer, and the subsequent confirmation of this fact by Eoki-



Online LibrarySamuel FenwickCancer and other tumours of the stomach → online text (page 9 of 33)