That the death-rate from carcinoma generally is steadily increasing in almost every part of the civilised world hardly admits of doubt. In the report of the Registrar-General for England for 1896, the statistics bearing upon this question are arranged in groups of five years, from 1861 to 1895 inclusive, and show the following deathrate from cancer per 100,000 living.
1 These include the various diseases of the oesophagus, stomach, intestines, liver, pancreas, and peritoneum which were treated in the medical wards. The figures were too complex to insert in the table.
2 The post-mortem material was derived from the records of hospitals in London, Paris, Berlin, and Prague, and the mortuary statistics from England (1899), Paris, New York, Geneva, Wurzburg, and Frankfort-on-Main.
Date. . .
In 1896 the death-rate per 100,000 living was 76.4, in 1897 78.3, in 1898 79.8, and in 1900 82.8. In other words, during the last thirty years the death-rate from this cause has been nearly doubled. J. D. Bryant, of New York, has shown that the disease is constantly on the increase in the United States, and that the mortality from it has been trebled between 1860 and 1890.
According to Kirchner, the death-rate from cancer in Prussia per 10,000 living had risen from 3.73 to 5.29 in the case of men, and from 4.45 to 6.03 in the case of women, during the period 1888 to 1897. Hirschberg's statistics for Berlin show an increase in the mortality from the disease per million living from 657 men and 1,126 women in 1876 to 1,537 men and 1,775 women in 1895.
In Australia, Mullins found that the death-rate from cancer had been trebled between 1857 and 1893 ; while in New Zealand, Macdonald states that it was twice as great in 1889 as in 1879.
The fact that until quite recently it was the custom in official returns to consider malignant disease in its entirety rather than as regards the organ that was primarily affected, renders it difficult to offer much statistical evidence as to the increase or otherwise of the gastric lesion. Haberlin was the first to point out that in Switzerland the frequency of gastric carcinoma is constantly increasing, and compiled the following table, which shows the death-rate from the disease per 1,000 inhabitants of that country from 1877 to 1886.
In the report of the Registrar-General for England for 1889 figures are given for certain areas in 1868 and 1888 respectively. The death-rate per million living of thirty-five years and upwards from cancer of the stomach was, in 1868, males 283.65, females 193.45. In 1888 it had risen to 346.15 in men and 277.75 in women. In other words, there was an increase of 22 per cent, in males and 44 per cent, in females.
According to the census returns of the United States for 1880, in certain groups, among 1,000 deaths from cancer where the seat of the disease was known there were 300.18 from cancer of the stomach. The total deaths from this cause were 2,133, which, in a population for the area of about 29,000,000, gives one death from the disease in every 13,595 living. In 1890 certain areas gave a rate of one death to every 9,761 living (Osier and McCrae).
Both in Hamburg and Helsingfors, and more especially in the latter town, the death-rate from the disease has greatly increased during the last twenty years (Reiche, Holsti).
From the following figures, supplied to us by Dr. Tatham, it will be seen that the death-rate from the disease in England has only slightly increased in both sexes during the last few years.
We have also collected statistics from three of the largest hospitals of London for two periods of five years each, the first being 1881 to 1885, and the second 1895 to 1899. The results, which are expressed in the following table, show that the percentage frequency of gastric carcinoma in the medical wards increased from 0-4 to 0-6, and the proportional death-rate from the disease from 1-42 to T82 per cent, in the course of fifteen years. It must be borne in mind, however, that the rapid advance that has taken place in abdominal surgery since 1885 has caused many cases to be transferred from the medical to the surgical wards, and at the same time has probably induced a larger number to seek hospital treatment; and since it is impossible to calculate the relative influence of these two factors, no absolute conclusion can be drawn from the figures.
Total medical admissions
Gastric cancers (diagnosed)
Proportional deathrate per 100 medical deaths
Newsholme and King consider that the increase of cancer is more apparent than real, and may be explained by the better methods of diagnosis that are now in vogue. For our own part, however, we believe that every advance which is made in practical medicine is more likely to diminish than to increase the apparent death-rate from carcinoma of the stomach. Thus, a medical man whose knowledge is deficient usually regards a fatal complaint accompanied by indigestion, vomiting, and loss of flesh, as cancer of the stomach; whereas another, who is better versed in the science of diagnosis, will often discover that the symptoms are due to simple ulcer, kidney disease, stricture of the bowel, phthisis, or to a tumour of the brain.1 Again, it was formerly the custom to regard carcinoma as the principal cause of pyloric stenosis, and in the absence of a necropsy almost every case which presented signs of dilatation of the stomach was recorded as ' cancer.' At the present time, however, it is universally recognised that the cicatricial contraction of a simple ulcer or adhesions to the gall-bladder are responsible for a large proportion of all strictures of the pylorus, and that the modern methods of diagnosis permit them to be distinguished from the malignant variety during life. Finally, the more ignorant the practitioner, the greater is the probability that he will regard all palpable tumours of the abdomen as ' cancerous ;' while the better his education, the more readily will he differentiate between visceral enlargements and true tumours, and between the malignant and benign varieties of the latter. For these several reasons we are strongly of opinion that with the growth of medical education the apparent mortality from abdominal carcinoma will exhibit a slower rate of increase than is observed in the case of the so-called ' accessible organs.'