Municipal action to reduce the cancer mortality

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PUBLIC HEALTH.

M U N I C I P A L A C T I O N TO REDUCE THE CANCER MORTALITY.* B-~- A. MEARNS FRASER, M.D., Medical Officer of Health, Portsmouth. may prove of interest to describe briefly to I T the members of the Southern Branch the municipal action that is being taken in Portsmouth to reduce the cancer mortality. Evidence of the necessity for something being attempted to control the death-rate from cancer is provided by a study of the returns of the Registrar-General, from which it will be seen that the death-rate from cancer is now closely approaching that from tuberculosis. Whether cancer is actually increasing as rapidly as is indicated by the death-returns is a matter that need not.be discussed at present ; the fact that it causes a death.rate of nearly I per I,OOO living in the kingdom affords sufficient justification for municipal action in the matter. Up to the present time I am not aware that local authorities have directed much attention to cancer. The reason for this is obvious. The particular branch of the medical profession to which we belong has in the past concerned itself principally with the prevention of disease; it is rather difficult, however, to take steps for the prevention of a disease until we know what is the cause of that disease, and in a case of cancer out of the enormous number of causes that have been suggested not one (except in some cases chronic irritation) stands upon any scientific basis. Medical officers of health have therefore not been in a position to advise their authorities as to measures which will reduce the prevalence of cancer. Although, however, local authorities have been unable to adopt any measures to reduce thebrevalence of cancer, it was suggested to the Portsmouth Health Committee by its vicechairman, Mr. Childe, who is also senior surgeon at the Royal Hospital, that the committee could and should adopt measures that might reasonably be expected to be successful in reducing the number of deaths from cancer. From his experience Mr. Childe was able to convince the Health Committee that a very large number of persons lost their lives from cancer for the sole reason that they put off applying for treatment until too late. The common experience of surgeons is that patients, and especially women, pay no attention to the first symptoms, what may be called * Read before the Southern Branch of the Society of Medical Officers of Health on March 6th, x9I4,

JuLy,

the warning signals of the onset of cancer. In the public mind cancer is associated with excruciating pain ; therefore, unless symptoms are accompanied by pain no suspicion is aroused that anything serious is the matter. The result of this association of cancer with pain in the mind of the public is that it is not until pain is a predominant symptom that a person attacked by cancer seeks medical advice, anit by this time, unfortunately, the cancer has often advanced beyond the stage when any hope of a cure can be entertained. I am told surgeons throughout the country can give examples ad nauseam of patient after patient who consult them suffering from cancer who, on being questioned as to when they first noticed, it may be, the lump in the breast or the irregular loss of blood at the menopause, show by their replies that they had noticed the first symptoms six months to a year previously. When asked why they had not seen a doctor before, the invariable reply is that as there was no pain or discomfort it was not thought to be anything serious. Evidence points to the fact that it was not so much the dread of an operation that prevented these persons consulting a doctor before compelled to by the pain, as the fact that they were ignorant of the significance of the symptoms. In most cases it is ignorance on one of two points that prevents patients consulting a doctor until too late to secure relief. The first one I have mentioned--ignorance of the significance of the early symptoms; the second is ignorance that cancer in its earliest stages is a curable disease. A woman over 4 ° with a lump in the breast may possibly b e suspicious that it is cancer, but she has the idea that cancer is incurable, and if there is no troublesome symptom she postpones consulting her medical man for fear that he will pronounce what she regards as a sentence of death. The reason for this attitude toward cancer is that members of the public generally only come across cases of cancer that result fatally, also they frequently hear of the cases that are operated on only to die a year later from a recurrence of the disease, and, as is only natural, they take an absolutely despondent and hopeless view of their case. It is to dispel the ignorance of the public on these two points that the Portsmouth Health Committee are at present directing their attention. All the available evidence goes to show that cancer is at first a local disease, and in the majority of positions in which it occurs may

1914.

PUBLIC

be removed, and if removed early will not recur. / : We wish, therefore, to make the individual members of the public aware of the vital importance of at once consulting a doctor if, after the age of 4 ° , certain symptoms should appear; to point out to them what these symptoms are which should arouse suspicion of cancer; to impress on them the fact that taken early cancer is curable; and to warn them of the fatal results from delay. To accomplish this, steps have been taken in three directions. First, an address on the subject was given by Mr. Childe to all nurses, midwives, health visitors, social workers and others brought into intimate relationship with the poor. This address was given in the Town Hall and was attended by most of those in the town whom it was hoped to reach. Second, leaflets, a copy of which is appended, have been prepared and are issued to the public. These give the early symptoms of cancer in some of its commonest positions, point out that cancer is curable, and urge the importance of acting promptly in seeking medical advice if fatal results are to be avoided. These leaflets are issued to all nurses, midwives and social workers, and can also be had at the Health Department on application. Third, a similar notice is inserted in a prominent position in the local Press on the first Monday in each month. In addition to the above, in order to assist poor persons in obtaining a correct diagnosis, arrangements are being made by which the services of a competent pathologist will be at the disposal of all practitioners in the borough to examine and report free of charge upon material taken from any morbid growth. The foregoing are briefly the lines upon which we are working, and a commencement was made at the beginning of this year. It will be noticed that our action is solely directed to endeavouring to prevent patients from postponing seeking medical advice until the disease has passed beyond the surgeon's aid. We are going on the assumption, which I believe is correct, that at the present time the only cure for cancer is early removal. There is no other method of treatment that has been pro,/ed successful. Whether the use of radium will take the place of the knife has yet to be proved, for although very encouraging results have been published these have not yet stood the test of time. But even if radium proves as successful, as everyone hopes it will, its

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HEA LTH.

success, too, will probably be largely dependant upon the patient submitting himself for treatment in the early stage of the disease, so that although we may have to modify the statement that early removal is the only cure for cancer, there will still remain the necessity for educating the public as to the early symptoms of cancer and urging them not to delay seeldng medical advice. In conclusion, I would like to say that I am very glad of this opportunity of being able to submit a short account of what the Portsmouth Health Committee are doing in regard to cancer, because I am anxious to have the views of other medical officers on the subject. So far as I am aware, the action we are taking is somewhat new to sanitary authorities, and I feel certain that a discussion of our procedure must prove beneficial, and I trust will lead to suggestions of other means that may be adopted to lessen the present terrible cancer mortality. I would only add that evidence is forthcoming that the action that is being taken has not been without effect, and already several medical men have informed me that patients with early carcinoma, cases probably curable, have consulted them, and have stated that they should not have done so had not their suspicions been aroused by the notice in the press. BOROUGH OF PORTSMOUTH. ~NOTICE IN REGARD TO CANCER.* It has been brought to the notice of the Health Committee that of the n u m b e r of persons who die each year from cancer many could have been cured if they had applied earlier for medical advice. On quesiioning patients as to w h y they did not apply to a doctor earlier, the reason almost invariably given is that as the early symptoms were unaccompanied by pain, it was not thought that anything serious was the matter. I n order therefore to call the attention of the public to the significance of certain symptoms and conditions, and to the vital importance of acting promptly on the occurrence of these, it has been decided to make the following facts public. The only cure for cancer, at present known, is its early and complete removal. Cancer, if removed early, has been proved conclusively to be a curable disease. If neglected, and not removed in its earliest stage, it is practically invariably fatal. The p a r a m o u n t importance of its early recognition and early removal is therefcre evident. F o r this purpose the assistance both of the public and the medical profession is requisite, and a grave responsibility rests on both. It is only by their m u t u a l co-operation that the ravages of this terrible disease can be lessened. The following information should be of vital assistance to the public. It is no exaggeration to say that, if acted upon, the result would be the saving annually of many hundreds of lives, which at present are inevitably lost, i . - - C a n c e r , in its early and curable stage; gives rise to no pain or symptom of ill-health whatever. 2.--Nevertheless, in its commonest situations, the signs of it in its early stage are conspicuously manifest. To witness : 3 . - - I n case of any swelling occurring in the breast of a w o m a n after 40 years of age, a medical man should at once be consulted. A large proportion of such swellings are cancer. *This notice is issued in leaflet form to nurses, midwives and others, and is published in th~ local press oa the first Monday in each month.

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4 . - - A n y bleeding, however trivial, occurring after the change of life means almost invariably cancer, and cancer which is then curable, If neglected till pain occurs, it means cancer which is almost always incurable. 5---Any irregular bleeding occurring at the change of life should invariably be submitted to a doctor's investigation. It is not the natural method of the onset of the change of life, and in a large number of cases means commencing cancer.

6 - - A n y wart or sore occurring spontaneously on the lower lip in a man over 45 years of age is almost certainly cancer. I f removed at once the cure is certain, if neglected the result is inevitably fatal. 7.--Any sore or swelling occurring on the tongue or inside of the mouth in a man after 45 years of age should be submitted to investigation without a moment's delay, and the decision at once arrived at by an expert microscopical examination whether it is cancer or not. A very large proportion of s u c h sores or swellings occurring at this time of life are cancer, and if neglected for only a few weeks the result is almost inevitably fatal, If removed at once the prospect of cure is good. 8.--Any bleeding occurring from the bowel after 45 years of age, commonly supposed by the public to be " piles," should be submitted to investigation at once. A large proportion of such cases are cancer, which at this stage is perfectly curable. 9 . - - W h e n warts, moles, or other growths on the skin are exposed to constant irritation they should be immediately removed. A large n u m b e r of them, if neglected, terminate in cancer. i o . - - A v o i d irritation of the tongue and cheeks by broken jagged teeth, and of the lower lip by clay pipes. Many of these irritations, if n @ e c t e d , terminate in cancer. i L - - A h h o u g h there is no evidence that cancer is communicable under ordinary circumstances it is desirable that rooms occupied by a person suffering from cancer should be cleaned and disinfected from time to time. A. MEARNS FRASER, M.D., Health Department, Medical Officer of Health. Town Hall, Portsmouth.

APPOINTMENTS. DR. JOHN ALLEN has been appointed clinical tuberculosis officer and assistant medical officer of health of Bury. DR. FREDERICK J. C. BLACKMORE has been appointed chief medical officer to the V¢oolwich Tuberculosis Dispensary. DR. C. G. H. CA~IPBSLL has been appointed a junior assistant medical officer in the infectious hospitals service of the Metropolitan Asylums Board. DR. G. DAVlDSON has been appointed a junior assistant medical officer in the infectious hospitals service of the Metropolitan Asylums Board. DR. A. HoGG has been appointed medical officer of health of Monk Bretton U.D. DR. J. DICKINSON LEIGH has been appointed an assistant tuberculosis officer to the D u r h a m C.C. DR. R. T. MEADOWS has been appointed medical officer of health to the Saltash Town Council. DR. PEF.K, of Regent's Park, London, has been appointed assistant sehoot medical efficer to the Flintshire Education Committee. DR. S. S. R~NDALL has been appointed medical officer of health to the Boston R.D.C. DR. ROI~ERT E. ROBER'rs, Cwmfelinfach, has been appointed medical officer of lfealth of Mynyddislwyn U.D. DR. H. C. SNSLL, of Sheffield, has been appointed school medical officer for Retford. DR. EDWARD F. STEPHENSON, medical officer of Dunmore, Co. Waterford, has been appointed a medical inspector under the Irish Local Government Board. DE. E. F. SYRETT has been appointed medical officer of health of the Borough of Harwich. DR. RALPH P. WILLIAMS,school medical officer for Sheffield, has been appointed senior assistant medical officer to the Board of Education.

JULY,

ILEAL TH.

RECENT STATISTICAL WORK THE CANCER PROBLEM. BY M A J O R G R E E N W O O D ,

ON

J u N . , M . R . C . S . , L.R.C.P.

A N experienced

city man once told me that chess had ruined many a promising clerk; there is a fascination exercised by its initially simple and ultimately complex technique which lures the beginner on until he wakes from dreams of Morphy and Lasker to the reality of a lost situation. Much the same may be said of cancer research. Great are the prizes to be claimed by him who discovers the " cause " of Cancer and its " c u r e , " while data for a solution seem abundant. W e have statistics of every description, records of autopsies, reports of operations, medical opinions and theories in profusion. Surely with so much grist, the statistical mill must grind out something of value! This is the thought which has inspired many who are endowed with enthusiasm, leisure, some familiarity with arithmetic and a hearsay knowledge of the clinical Proteus we name cancer. It is to be feared that the outcome of their labours is not always satisfactory. Thus, The Times in a recent article directed public attention to Mr. C. E. Green's book, The Cancer Problem, in language which might lead its readers to attribute importance to Mr. Green's theory that the products of coal combustion are a factor in determining the geographical incidence of cancer. It is sufficient to remark that Mr. Green's statistical method is a comparison of the proportions of cancer deaths to deaths from all causes in various districts, that the effects of varying age and sex constitutions are not noticed, and that figures based upon large cities such as Glasgow, and sparsely populated rural districts, such as the Shetland Islands, are compared in the same table. This is still a free country, and Mr. Green has a perfect right to publish any statistical results he pleases, however inadequate one may think them, but whether a leading journal should, without the least attempt at critical analysis, give these notions a wide currency, is a more disputable point. In the same article, The Times refers to another recent statistical paper more deserving serious notice ; this is Professor Karl Pearson's analysis of some data collected by the late Dr. T. L. Webb.* Dr. Webb's data consisted of a record of deaths from *Btometri~a, Vol. viii., 430 and ix., 28.