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From the Nutrition Laboratory, Copenhagen. Ciiiicer Statistics - CiifikWr r~ld Diet.’ BY M. HINDHEDE. What has especially -led me to study the etiology of cancer has been the uncanny fact that of a11 countries Denmark takes the lead as regmcls the dcath rate from cancer, and that, more- over, the disease is increasing apace. 1.n 1900 the death rate from cancer was 1.20 per 100,000 inhabitants in Danish towns, but in 1915 and 1916 it was 151. In Swedish towns in the same period it fluctnatecl between 1.00 ancl 108. I n 1908-1.91 2 it was, accor- cling to Hoffman, 112 in London, 111 in Paris, 77 in New Pork, 12 in Calcutta. In the whole of Denmark about 17 yo of all the persons that have completed their 45th year have every prospect of dying of cancer; a dismal thought considering that it is the disease most dreaclecl by all of us. It is beyond doubt that the fact of our being clistingiiishecl in such a sac1 manner must have a cause. But what? When through my investigations into people’s mode of living in various couutries 1 have come to the restilt that Denmark probably is the country in the world where the daily fare ist ))best!), ancl where consequently the greatest number of fat people are to be met with; when it is further known that stout people are particularly liable to die of cancer, it is but reasonable to suppose that here may be a causation. Preparatory to my investigations I have gone over the literature2 to learn what is known about Paper read before the Xedical Association of Copenhagen at its meeting 19t$ Februnry, 1924. - See Jonrnal of Cancer Research, Rnlletin de 1’Association franyaise poor 1’8tnde do Cancer, %eit,schrift fiir Krebsforschung, Scientific Reports of the Imperial Cnncar Research Fund, the books of Roger Williams, Rollo Russell, Hotfman, Jakob Wolf, etc., etc. (For further information I refer to 20. Beret- 27-250381. dela med. Scatbdinav. I.b/. LA’rI.

Cancer Statistics—Cancer and Diet

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Page 1: Cancer Statistics—Cancer and Diet

From the Nutrition Laboratory, Copenhagen.

Ciiiicer Statistics - CiifikWr r ~ l d Diet.’ BY

M. HINDHEDE.

What has especially -led me to study the etiology of cancer has been the uncanny fact that of a11 countries Denmark takes the lead as regmcls the dcath rate from cancer, and that, more- over, the disease is increasing apace. 1.n 1900 the death rate from cancer was 1.20 per 100,000 inhabitants in Danish towns, but in 1915 and 1916 it was 151. In Swedish towns in the same period it fluctnatecl between 1.00 ancl 108. I n 1908-1.91 2 i t was, accor- cling to Hoffman, 112 in London, 111 in Paris, 77 in New Pork, 12 in Calcutta.

In the whole of Denmark about 17 yo of all the persons that have completed their 45th year have every prospect of dying of cancer; a dismal thought considering that i t is the disease most dreaclecl by all of us. It is beyond doubt that the fact of our being clistingiiishecl in such a sac1 manner must have a cause. But what? When through my investigations into people’s mode of living in various couutries 1 have come to the restilt that Denmark probably is the country in the world where the daily fare ist ))best!), ancl where consequently the greatest number of fat people are to be met with; when i t is further known that stout people are particularly liable to die of cancer, i t is but reasonable to suppose that here may be a causation. Preparatory to my investigations I have gone over the literature2 to learn what is known about

’ Paper read before the Xedical Association of Copenhagen at its meeting 19t$ Februnry, 1924. - See Jonrnal of Cancer Research, Rnlletin de 1’Association franyaise poor 1’8tnde do Cancer, %eit,schrift fiir Krebsforschung, Scientific Reports of the Imperial Cnncar Research Fund, the books of Roger Williams, Rollo Russell, Hotfman, Jakob Wolf, etc., etc. (For further information I refer to 20. Beret-

27-250381. dela med. Scatbdinav. I.b/. LA’rI.

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3so A I . IlIh’DHEDE.

the death rate from cancer throughout the world. A s is well known, this question is ninch disputed, and the conclusions arrived a t differ widely. I caniiot enter on discussions here, but shall content myself with giving a short summary of the results a t which I have arrived.

It appears that natives of the torrid zones who live on a mild unspiced vegetarian diet have practically no cases of cancer of the internal organs. Cancer of the stomach and of the intestinal tube especially, which occur so very frequently in civilized count- ries, are almost unknown among those people. The same applies to ulcers of the stomach and intestines, catarrh of the siuall and large intestines, ailments which often lie a t the root of cancer. Rut when uncivilized peoples become ))civilized)) and adopt the European mode of living their cancer death rate also becoiiies ))normal)). I n all civilized countries during the Last 50 years this disease has been very greatly increasing. Attempts, which to me appear entirely unsuccessful, have indeed been made to es- plain away these uncanny facts. As regards the uncivilized peoples i t has been proposcd that the apparently slight diffnsion of the disease was not due to its non-esistence, but to its not coming to the knowledge of the physicians. English ancl Ciernian cancer-students have made every effort to find cases of cancer among uncivilizecl peoples. They have succeeded in finding a few, but the figures are so very small that they not only do not refute but on the contrary eminently support thc assertions re- garding the slight diffusion of cancer with the peoples in question. To this rule the Japanese are an exception; with them cancer of the stomach is of rather common occurrence. 13ut the esplana- tion is not far to seek: the Japanese use large quantities of very pungent spices and, to a great estent, half decayed plant pro- ducts. The increase of the disease in civilized countries has also been qiiestioned, comfort having been taken in the thought that the probable cause of $he apparent increase was the growing ability of medical men to diagnose the disease. Rut this suppo- sition far from explains the whole increase, and is Besides con- tradicted by the fact that the increase is as high for thc external easily recognizable varieties as for the internal ones.

We now pass on to our revision of the Danish cancer statistics. The results are represented in the charts I-T7, which show deaths

iiing fra 11. Hindhedes Kontor for Ernsringsnndersegelser, Kaheiihnvii 1924, Jakoh h i n d ; this paper being only a short extract, froni this I):ioish report.)

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CANCER srATimcs - C A S C E ~ ~ AAD DIET. 38 1

from cancer per every 100,000 individuals past the age of 35. The figures are standardized according to standard population 1901. Each figure represents the average for 5 years.

))la shows a11 deaths from cancer. For men the crude as well as the standardized figures are stated. For women only the latter. It shows the heavy increase succeeded by decrease during the last 5-10 years.

~110 shows in the lower section deaths from cancer of the sto- mach. It will be noted that the death rate of men here exceeds that of women by far. In the upper section are shown deaths from all other varieties of cancer. For women, cancer of the uterus and cancer of the breast are, however, not included.

01110 shows deaths from cancer for men in Copenhagen and provincial towns. Noticeable is the considerably higher death rate in the capital.

DIVD shows death from cancer ventriculi and all other varieties of cancer (cancer uteri and cancer mammz excluded) in pro- vincial towns. The bottom curves show deaths from cancer of the uterus in the capital and the provincial towns. Here is no increase, but neither is there any decrease, which it would have been reasonable to expect from the fact that surgeons during the last 20 years very probably have saved many of these patients from death by radical operations.

eVo shows deaths from cancer of the breast. Noticeable is the heavy increase despite the increasing number of radical operations. This increase of an external variety of cancer which the physicians 40 years ago could have had no difficulty in diag- nosing, shows with great certainty that the increase must be a real fact.

Now, what may be deduced from these figures? Do they tend to prove that the rich daily diet (over-feeding) by which Denmark ist distinguished, not only as regards the upper classes but, as compared with other countries, even more among the working classes, can be in any way connected with the cancer death rate? It seems to me that they point strongly that way. If cancer of the particular female organs be excepted, women have a far lower death rate than men. And there can be no doubt that men fare richer than women, and that men in Copenhagen indulge in richer fare than men in the provincial towns. We know that during the last 50 years the population has increasingly turned from vegetable diet to animal foodstuffs. The causes may be

Page 4: Cancer Statistics—Cancer and Diet

3eeeR,fw,w% C-c- pao. .100000.

age 35-100.

w 00 ka

Fig. I. Fig. 11.

Page 5: Cancer Statistics—Cancer and Diet

CAXCER GTATISTICS - CANCER AND DIET. ;3S8

Page 6: Cancer Statistics—Cancer and Diet

3S-l M. IIIXDIIEDE.

partly the higher wages, partly the medical profession’s vigorous agitation for a ))stronger)) fare, one richer in protein. Only in the last 10-15 years the tide has begun to turn owing to tlie intense agitation, more intense here, probably, than in any other country, against the prevalent over-feeding and for a return to tlie old, plainer diet. During the time of the rationing 1917-1919, i t mas left t o the champions of the new doctrine to calculate tlie dietary of the Danish population with the result that tlie stock of pigs was reduced to one-fifth while the normal nutrients of the pig, barley and potatoes, were reserved for man. That medical me11 here raised no objection to this change of fare goes to show the recently changed views on the matter. The highly improved

9& p&%. &M. .re=. 100.000.

&y 35*-400. &.t&n45.

Pig. V.

sanitary conditions’ also, in those classes of the population where the restriction on alcohol could be of no con~ec~uence,’ made a strong impression, and are presumably the reason why a great many people have gone on using more vegetables than formerly. The consumption of potatoes, particularly, has nnclonbtedly much increased. The decrease of deaths froin cancer especially during the last 5 years accords very well with the theory of over-feeding as its cause. That the restric- tion on alcohol cannot be its sole cause is also provcd by the marked increase during the last 30 years before tlie war despite the steadily decreasing consumption of alcohol.

Copenhagen. and 382

12th 192-2.

11. Ihndhede, The effect of fond restrictiou during w:ir nil mortality in The Jouriial of the Am. Jled. Ass.. Fc’Jr. 7 1920. Vol. 74, pp 351

Brit . Ned. Joorttal, Augttst 41. Hindhede. Alcohol restriction ntid iiiortality.

Page 7: Cancer Statistics—Cancer and Diet

CAXCER STATISTICS - CAXCER AS]) DIET. 385

sVIe shows the death rate from cancer per 100,000 individuals (for a11 ages) in all Swedish and Danish cities. Here the figures are not standardized. It is shown that the death rate is by far the higher in Danish cities although the statistics in the two related, neighbouring countries must be presumed to be equally exact. I n the cities all the death certificates are made out by qualified doctors. What can be the cause of this difference? The esplanatioii will probably be found in the two following charts.

O T T O gives an account of the general death rate in Stockholm arid Copenhagen. It will be seen that before the war the death rates from all diseases were about equal, but the Swedish death

rate from tuberculosis was about twice as high as the Danish. If the figures €or tuberculosis (and from 1916 also those for in- fluenza) be deducted, the death rate from, all other diseases up to 1918 was far lower in Stockholm. How is this contrast to be explained? As regards the tuberculosis, one would naturally seek the cause in a lower standard of living, poorer habitations, extre- mely spare diet-factors which empirically cause .higher death rate from tuberculosis, but often a lower death rate from other diseases. This surmise becomes almost certainty when it. is con- sidered that during the rationing, when we were put on poor man's fare, our death rate decreased to the level of that of Sweden. But, of course, to this resuIt the restriction on alcohol has been emi- nently conductive.

Page 8: Cancer Statistics—Cancer and Diet
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CANCER STATISTICS - CASCER AND DIET. 3 7

))YlII)) Here the figures for the death rate from all diseases escept influenza and tuberculosis are repeated. Below is stated the simultaneous consumption of strong spirits in liter per in- habitant. It is curious to watch the very different effects of the restriction on spirits in Sweden and Denmark. I n the latter country the death rate decreased strongly while in Sweden at the same time a slight increase was observable. Is i t reasonable to suppose that the two neighbouring peoples can react so differently on the same poisons? Hardly! The explanation is probably this, that the Swedish food-rationing failed. The Swedes were actually unclerfeed; therefore the death rate rose. If real underfeeding hacl not frustrated the plan the Swedish death rate would prob- ably also have been considerably lower during the time of the rationing.

Finally 1 have drawn a parallel with England. Directly from the official statistics' 1 have taken the following figures for stan- dard death rate in 18 typical professions, arranged in sequence according to the rate of cancer mortality. At the same time is stated the aggregate death rate, and the death rates from alco- holism, phthisis and apoplexy.

Tdde I.

tS'tandard ilfortnlity, Men, A g e 15-'65.

I. L o w C a n c e r ? J o r t a l i t y .

England 1910-1912.

Al l ranses Alcoholism Phthisis Apoplexy Cancer

Priests . . . . . . . . . . 443 1 45 30 45 Agricnltnral Labourers . . . 470 1 i l 16 5 4 'l'cnchers . . . . . . . . 506 4 70 27 57 Farmers . . . . . . . . . 495 3 57 23 58 Coal Nincrs . . . . . . . 727 2 i 6 51 61

Average 528 2.2 64 29 55 -____

' Morta1it:p of nicn in certain occupations. Supplement to the 75th Annual Report of the Registrar General for England and Wales.

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388 31 . IIIXDLIEDE .

T I . 3 I e d i u m C a n c e r M o r t a l i t y .

1'hysici:iiis . . . . . . . . Cotton iiiaiinfacturers . . . Shopkeepers . . . . . . . Shoemakers . . . . . . . . Lron goods ninkers . . . . . Carpenters . . . . . . . . Clerks . . . . . . . . . .

Average __-

All caiises Alcoholisin I'lithisis Apoplcsy Caiicer

693 51 1 70s s20 s37 694 742

763

3 65 J 120 3 117 3 222 3 131 2 1;'s 4 154

S.6 140

0

37 T O 4s 71 33 7 2 39 79 43 so 30 52 35 83

40 7S

I11 . High C a n c e r N o r t a l i t y .

Inn-keepers . . . . . . . 1. 265 39 19s 6s S5 Dock Labourers . . . . . . 1. 127 14 "2 39 9 s Inii-servauts . . . . . . . 1. 173 21 294 47 99 13utchers . . . . . . . . . SS5 10 127 45 I05 Chimney-sweeps . . . . . 1. 018 10 'LO2 41 107 Brewers . . . . . . . . 1.023 I0 1s1 50 125 H8er-bottlers . . . . . . 96s 12 201 47 12s

Average 1. 065 17 207 4s 107

All men . . . . . . . . . 790 4 143 36 7s

Copen hagen 190s . 191 2 .

All men . . . . . . . 993 81 1s1 39 139

Copenhagen 1877-1923 . A11 inen, Age 25-66 .

1s77.. 1ss1 . . . . . . . . 1, 2421 60 363 41 90 ISS7-lS91 . . . . . . . . 1, 16'2' 66 320 33 112 1895-1902 . . . . . . . . 1. 025' 5 2 212 41 119 1908-1912 . . . . . . . . 993' 51 1s1 39 139 1918-1922 . . . . . . . . 653' 4 107 24 111 .....

All canace excopt inflnenza .

Page 11: Cancer Statistics—Cancer and Diet

CANCER STATISTICS - CANCER AND DIET. 3S9

The figures tell their own tale. iI comparison of group I with group 111 leaves a strong impression of the high cancer death rate among professions the members of which indulge in abundant food and alcoholic drink.

--It the foot of the chart I have stated the corresponding figures for Copenhagen, calculated and standardized in the same way as the English figures. Of course, i t is misleading to compare the figures for one Danish city with those of a whole country, the death rate always being lower out in the country; but as 80 yo of the English population live in the towns, the deviations is not very wide. If 20 % of the population have a cancer death rate

of only ~ 5 4 + "'= 56, the death rate for the remaining 80 yo 2

will be 85, which means that the death rate in Copenhagen is 65 % higher than in English towns. How explain this? Well, seeing the huge difference as regards the alcoholism death rate one might be lead to think that the explanation lay here. But this will harclly bear investigation. The English figures here must be false. In 1906-1910 the aggregate consumption of pure alcohol in gin, beer, and wine per individual and year was 6.82 L. for Denmark, but 9.67 L. for Great Britain. The explanation is probably that English physicians are less inclined than the Danish to put this diagnosis into the death-certificate.

13elow I have stated the corresponding figures for death rates from causes which probably i t would be justifiable to term nutri- tion death-causes, most physicians being presumably willing to admit that they are likely to be closely connected with wrong nutrition (food and drink)., If we look a t the average figures2 in the charts for the three groups we find a conscpicuous agreement between the figures for 1 i- 2 + 3 and those for cancer. This would indicate that if 1 + 2 + 3 can be termed nutrition death- causes, cancer must be put under the same head.

,; ' Agricultmal laborers iind farmers. I' ' ' Of course, there are exceptions. Nost strikiiig is the euormorlsly high death rnt,e from thc three nntrit.ion death-causes among iun-keepers, whereas the death rate from cancer is not correspondiugly high. May uot the explanation to some esteut be sought in erroneous diagnosis, I woiider. The death rate from :dl known causes of death is so high among inn-keepers th:Lt the death rate from caucer to some extent may he obscnrcd. When a physician finds a tuinour in the abdomen of a highly nlcoholiscd inn-keeper, be may not unnaturally fecl :I certain incliriatiou to write >cirrhosis hepatis, (observe the very high figures for this cause), whereas i t may be cancer bepatis or ventriculi.

Page 12: Cancer Statistics—Cancer and Diet

390 M . HINDIIEDE .

Standard Uortulily. M e n . Aye ?5--G5 .

Ihglaild 1910-1912

1 3 :I Ot. li er

Cirrhosis diseases Bright's + -t 'ht"'er of liver of digestive disciisc

syster11

I'riests . . . . . . . . . . . 3 42 27 72 4 :i Agriciiltural lisboitrers . . . . 4 25 15 42 54 Tcachers . . . . . . . . . . 6 30 2 i 65 57 Farmers . . . . . . . . . . 11 29 22 62 55 Coal Blioers 7 2s 20 rt5 61

Average 7 30 22 59 55 . . . . . . . . .

Physicinns . . . . . . . . . . . 60 Cotton ...................... 33 . . . . . . . . . . . . . . . . . . . . . 33 ....................... 33 .......................... i ) 0 .. i . . . . . . . . . . . . . . . . . . . . . . 33

Average 14 37

Clerks . . . . . . . . . . . . . 37

44 136 4 1 tis 43 94 34 77 29 $1 33 7 3 36 ss 37 YS

Inn-keepers . . . . . . . . 117 Dock Lahourern . . . . . 16 Inti-servants . . . . . . . . 30 Rntchers . . . . . . . . . . 34 Chininey-sweeps . . . . . . . 31 Brewers . . . . . . . . 39 Beer-bottlers . . . . . . . . 46

Average 45

57 39 RS 35 26 40 42

40 ~

79 2.53 40 9.5 52 120 47 119 49 106 35 114 32 120

4s 113

$0 71 73 79 so 52 53 '75 .

55 95 !19

105 107 125 125

107 .

A11 men . . . . . . . . . . I3 34 33 so 7s

Copenhngen 1911 .

. . . . . . . . . . A11 men 20 33 52 105 133

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CAXCIIR STATISTICS - CAXCEH. AXD DIET. 39 1

To me the figures for the English farm labourers have been of special interest. Rowntree' has made a close study of their mode of living. He finds here a pronounced under-nourishment. I shall content myself with quoting a few of his closing remarks:

))Meat of some description figures in all bu t one of the dietaries but as already explained, i t often represents a flavouring rather than a substantial course. 'For the man only' is a remark found in niany of the menus.))

))Of milk, again, the under-consumption, especially in the households with many small children, is very serious. . . o After showing that the deficiency was not great as regards

the whole food-energy value, but that i t was the protein - especially the aninial protein - which was mostly wanting, Rowntree continues:

))But as a n adequate supply of protein is a n essential of phy- sical efficiency, i t is not incorrect to say that on the average the forty-two families investigated are receiving not nauch inore than three- fot~rtlis of the nourishment necessary for the maintenance of pliysical health.)) l3ut of all professions, these poor, underfed labourers have by

far the lowest figures for the aggregate death rate from the three nutrition diseases. Medical men's death rate from the same di- seases is exactly three times higher. It would hardly be possible better to illustrate the falsity of the old nutrition theories. Ac- cording to these facts i t looks as if the high protein-standard is not only unnecessary but directly harmful, not only in general but also as regards the development of cancer.

On the basis of all facts here stated, 1 beg to conclude that there is a probability of the main causes of cancer being:

1. Irritation of the digestive tube. (Decayed, strongly salted and spiced nutrients, alcoholic drinks, tobacco, etc.)

2. Over-nourisliment, most frequently caused by a too varied, too savoury food.

3. A food too rich in animal protein. To escape cancer, we must return to the more frugal habits

of our ancestors.

b sons. ' B. Seebohni Ronntree, Hnw the Labourer Lives, JAondoii 1913, Nelson