Thermodynamics

If a lowered oxygen pressure during cell growth may cause cancer, or, more generally, if any inhibition of respiration during growth may cause cancer, then a next problem is to show why reduced respiration induces cancer. Since we already know that with a lowering of respiration fermentation results, we can re-express our question: Why does cancer result if oxygen-respiration is replaced by fermentation?

The early history of life on our planet indicates that life existed on earth before the earth’s atmosphere contained free oxygen gas. The living cells must therefore have been fermenting cells then, and, as fossils show, they were undifferentiated single cells. Only when free oxygen appeared in the atmosphere - some billion years ago - did the higher development of life set in, to produce the plant and animal kingdoms from the fermenting, undifferentiated single cells. What the philosophers of life have called "Evolution créatrice" has been and is therefore the work of oxygen.

The reverse process, the dedifferentiation of life, takes place today in greatest amount before our eyes in cancer development, which is another expression for dedifferentiation. To be sure, cancer development takes place even in the presence of free oxygen gas in the atmosphere, but this oxygen may not penetrate in sufficient quantity into the growing body cells, or the respiratory apo-enzymes of the growing body cells may not be saturated with the active groups. In any case, during the cancer development the oxygen-respiration always falls, fermentation appears, and the highly differentiated cells are transformed to fermenting anaerobes, which have lost all their body functions and retain only the now useless property of growth. Thus, when respiration disappears, life does not disappear, but the meaning of life disappears, and what remains are growing machines that destroy the body in which they grow.

But why oxygen differentiates and why lack of oxygen dedifferentiates? Nobody would dispute that the development of plants and animals and man from unicellular anaerobes is the most improbable process of all processes in the world. Thus there is no doubt, that EINSTEIN descended from a unicellular fermenting organism - to illustrate the miracle, molecular O₂ achieved. But according to the thermodynamics of Boltzmann, improbable processes require work to take place. It requires work to produce temperature differences in a uniformly temperatured gas; whereas the equalization of such temperature differences is a spontaneous process that does not require work. It is the oxygen-respiration that provides in life this work, and dedifferentiation begins at once when respiration is inhibited in any way. In the language of thermodynamics, differentiation represents a forced steady state, whereas dedifferentiation - that is, cancer - is the true equilibrium state. Or, illustrated by a picture: the differentiated body cell is like a ball on an inclined plane, which, would roll down except for the work of oxygen-respiration always preventing this. If oxygen respiration is inhibited, the ball rolls down the plane to the level of dedifferentiation.

But why respiratory energy and not fermentation energy can differentiate, whereas in general, for example in growth, respiratory energy and fermentation energy are equivalent? Obviously, there would be no cancer if there were not this discrimination of fermentation energy, that is, if fermentation like respiration could differentiate. Then, when respiration is replaced by fermentation, fermentation would take over differentiation, and a high state of differentiation would be maintained even in the fermenting body cells.

Chemistry

Physics cannot explain why the two kinds of energy are not equivalent in differentiation; but chemistry may explain it. Biochemists know that both respiration energy and fermentation energy do their work as phosphate energy, but the ways of phosphorylation are different. If one applies this knowledge to carcinogenesis, it seems that only oxidative phosphorylation but not fermentative phosphorylation can differentiate, a result, that may in future explain the mechanism of differentiation.

Yet Biochemistry can explain already today why fermentation arises, when respiration decreases. Figure 4 shows that the pathways of respiration and fermentation are common as far as pyruvic acid. Then the pathways diverge. The endproducts of fermentation is reached by one single reaction, the reduction of pyruvic acid by dihydro-nicotinamide to lactic acid. On the other hand, the endproducts of the oxidation of pyruvic acid, H₂O and CO₂, are only reached after many additional reactions. Therefore, when cells are harmed, it is probable that first respiration is harmed.

In this way the frequency of cancer is explained by reasons of probability.

To sum up:

1. Impairment of respiration is frequent than impairment of fermentation because respiration is more complicated than fermentation.
2. The impaired respiration can be easily replaced by fermentation, because both processes have a common catalyst, the nicotinamide.
3. The consequence of the replacement of respiration by fermentation is mostly glycolysis, with death of the cells by lack of energy. Only if the energy of fermentation is equivalent to the lost energy of respiration, is the consequence anaerobiosis. Glycolysis means death by fermentation, anaerobiosis means life by fermentation.
4. Cancer arises, because respiration, but not fermentation, can maintain and create the high differentiation of body cells.

To conclude the discussion on the prime cause of cancer, the virus-theory of cancer may be mentioned. It is the most cherished topic of the philosophers of cancer. If it were true, it would be possible to prevent and cure cancer by the methods of virology; and all carcinogens could be eaten or smoked freely without any danger, if only contact with the cancer virus would be avoided.

It is true that some virus-caused cancer ^b) occur in animals, but no one sure human virus-cancer has been observed so far, whereas innumerable substances cause cancer without viruses in animals and man. Thus viruses do not meet the demands of Pasteur, that is must be possible to trace the prime cause in every case of the disease. Therefore science classifies viruses as remote causes of cancer, leading to anaerobiosis, the prime cause, that meets the demands of Pasteur.

b) The chicken Rous sarcoma, which is labeled today as a virus tumor, ferments glucose and lives as a partial anaerobe like all tumors. O. WARBURG, Bioch. Zeitschrift 160, 307, 1925; F. WIND, Klinische Wochenschrift, Nr. 30, 1926.

Many may remember how anaerobiosis as prime cause of cancer was recently disputed emphatically, when one single cancer - the slow Morris hepatomas - was believed (wrongly) to lack in fermentation. In contrast the virus theory is adhered to although all cancers of man are lacking in virus-origin. This means the surrender of the principles of Pasteur and the relapse into bygone times of medicine.

Applications

Of what use is it to know the prime cause of cancer? Here is an example. In Scandinavian countries there occurs a cancer of throat and esophagus whose precursor is the so-called Plummer-Vinson syndrome. This syndrome can be healed when one adds to the diet the active groups of respiratory enzymes, for example: iron salts, riboflavin, nicotinamide, and pantothenic acid. When one can heal the precursor of a cancer, one can prevent this cancer. According to ERNEST WYNDER 3) of the Sloan-Kettering Institute for Cancer Research in New York, the time has come when one can exterminate this kind of cancer with the help of the active groups of the respiratory enzymes.

It is of interest in this connection that with the help of one of these active groups of the respiratory enzymes, namely nicotinamide, tuberculosis can be healed quite as well as with streptomycin, but without the side effects of the latter ^c). Since the sulfonamides and antibiotics, this discovery made in 1945 is the most important event in the field of chemotherapy generally, and encourages, in association with the experiences in Scandinavia, efforts to prevent cancer by dietary addition of large amounts of the active groups of the respiratory enzymes. Since there can scarcely be overdosage, such experiments can do no harm.

c) V. CHORINE: C. R. sci. Paris, 220, 150 (1945). – H. FUST and A. STUDER, Schweizerische Z. für allgemeine Pathologie, Band 14; Fasc 5 (1951).

I would like to go further and propose always making dietary additions of large amounts of the active groups of the respiratory enzymes after successful operations when there is danger from metastatic growths. One could indeed never succeed in redifferentiating the dedifferentiated cancer cells, since during the short duration of human life the probability of such a back-differentiation is zero. But one might increase the respiration of growing metastases, and thereby inhibit their fermentation, and - on the basis of the curve of DEAN BURK and MARK WOODS obtained with the Morris hepatomas - thereby inhibit the growth of metastases to such an extent that they might become as harmless as the so-called "sleeping" cancer cells in the prostates of elderly men.

A Second Example of Application

The physicist MANFRED VON ARDENNE has recently attacked the problem of the therapy of cancer. ARDENNE discovered that cancer cells owing to their fermentation, are more acid – inside and on their surface – than normal cells and hence are more sensitive to high temperatures. On this basis, he and his medical colleagues have treated cancer patients, after surgical removal of the primary tumors, by raising the body temperature of the patients to about 109º Fahrenheit for an hour, in the hope that the metastases will then be killed or their growth so slowed up as to become harmless. It is not yet decided whether this idea can be described as a practical success. But the provisional work of ARDENNE is already of great significance in a field where hopes of conventional chemotherapy have been dimmed but might be brightened by combination with extreme or moderate hyperthermy.

A third application. According to an estimate by K. H. Bauer of the Cancer Institute in Heidelberg, at least one million of the now living twenty five million male inhabitants of West Germany will die of cancer of the respiratory tract; still more will die from other cancer. When one considers that cancer is a permanent menace, one realizes that cancer has become one of the most dangerous menaces in the history of medicine.

Many experts agree that one could prevent about 80% of all cancers in man, if one could keep away the known carcinogens from the normal body cells. This prevention of cancer might involve no expenses, and especially would require little further research to bring about cancer prevention in up to 80 percent ^*).

*) Since this estimate was published, some though 80% even to low. Yet prevention remained taboo and early diagnosis was the only consolation that was offered.

Why then does it happen that in spite of all this so little is done towards the prevention of cancer? The answer has always been that one does not know what cancer or the prime cause of cancer be, and that one cannot prevent something that is not known.

But nobody today can say that one does not know what cancer and its prime cause be. On the contrary, there is no disease whose prime cause is better known, so that today ignorance is no longer an excuse that one cannot do more about prevention. That prevention of cancer will come there is no doubt, for man wishes to survive. But how long prevention will be avoided depends on how long the prophets of agnosticism will succeed in inhibiting the application of scientific knowledge in the cancer field. In the meantime, millions of men must die of cancer unnecessarily.

Literature to Preface of Second Edition:

1. WILLSTAETTER, WIELAND and EULER, Lectures on enzymes at the centenary of the Gesellschaft Deutscher Naturforscher. Berichte der Deutschen Chemischen Gesellschaft, 55, 3583, 1922. The 3 lectures of the 3 chemists show that in the year 1922 the action of all enzymes was still a mystery. No active group of any enzyme was known.
2. OTTO WARBURG, Biochem. Zeitschrift, 152, 479, 1924.
3. OTTO WARBURG, Heavy Metals as prosthetic groups of enzymes, Clarendon Press, Oxford, 1949.
4. OTTO WARBURG, Wasserstoffübertragende Fermente, Verlag Werner Sänger, Berlin, 1948.
5. DEAN BURK, 1941. On the specificity of glycolysis in malignant liver tumors as compared with homologous adult or growing liver tissues. In Symposium of Respiratory Enzymes, Univ. of Wisconsin Press. pp. 235-245,1942. DEAN BURK, Science 123,314,1956. Woods, M. W., Sandford, K. K., Burk, D., and Earle, W. R. J. National Cancer Institute 23, 1079-1088, 1959. DEAN BURK, Burk, D., Woods, M. and Hunter, J. On the Significance of Glucolysis for Cancer Growth, with Special Reference to Morris Rat Hepatomas. Journ. National Cancer Institute 38, 839-863, 1967.
6. O. WARBURG und F. KUBOWITZ, Bioch. Z. 189, 242, 1927; H. GOLDBLATT und G. CAMERON, J. Exper. Med. 97, 525, 1953.
7. O. WARBURG, 17. Mosbacher Kolloquium, April 1966. Verlag Springer, Heidelberg, 1966.
8. O. WARBURG, K. GAWEHN, A. W. GEISSLER, D. KAYSER and S. LORENZ, Klinische Wochenschrift 43, 289, 1965.
9. O. WARBURG, Oxygen, The Creator of Differentiation, Biochemical Energetics, Academic Press, New York, 1966.
10. O. WARBURG, New Methods of Cell Physiology, Georg Thieme, Stuttgart, and Interscience Publishers, New York, 1962.

Literature to Preface of First Edition:

1. OTTO WARBURG, A. W. GEISSLER, and S. LORENZ: Über die letzte Ursache und die entfernten Ursachen des Krebses. 17. Mosbacher Kolloquium, April 1966. Verlag Springer, Heidelberg 1966.
2. Any book on vitamins, such as Th. Bersin. Biochemie der Vitamine. Akad. Verlags.-Ges. Frankfurt 1966.
3. ERNEST L. WYNDER, SVEN HULTBERG, FOLKE JACOBSSON, and IRWIN J. BROSS, Environmental Factors in Cancer. Cancer, Vol. 10, 470, 2057.