been reported by Eiselberg, Bergmann, Israel, Mikulicz, Heidenhain, Keen, and Elliot.

4. In the fourth group are placed these cases where the ideal operation has been performed. In these cases the tumour has generally been pediculated, and the pedicle has been sufficiently fibrous to enable the surgeon to tie off the pedicle and then close the abdominal wound. Christopher Martin removed an accessory lobe of the liver in this way. Langenbuch tried this procedure, but the abdomen had to be reopened for secondary hæmorrhage from the pedicle. Wagner lost a case from hæmorrhage; but Keen, Vohtz, and Bruns have recorded successful cases.

The reason why partial hepatectomy is a comparatively uncommon operation, is because the parenchyma of the liver is of such a nature that ligatures introduced to control hæmorrhage cut through the liver-substance with great ease. Again, we cannot control the hæmorrhage by ligaturing the hepatic artery, for the liver differs from all other organs in the body, inasmuch as the blood entering it is chiefly venous; and in cutting the liver the hæmorrhage comes with a rush from the portal veins and oozes from the hepatic veins. But there is a great difference between the two, for the former have a sufficient amount of fibrous tissue surrounding them -derived from Glisson's capsule-to enable us to ligature them; while the hepatic veins are very thin-walled vessels, the hæmorrhage from which is controlled by gauze pressure or by the cautery.

From the above considerations it follows that any mass ligature that is introduced into the liver-substance will fail to control hæmorrhage, if that ligature is inserted in such a way that, as it is drawn tighter, it tends to form a circle. There can be no effectual hepatic ligature, unless the sides of the ligature remain parallel when drawn upon.

Terrier and Auvray advocate a ligature which, when introduced, divides the pedicle up into square compartments, and cannot cut through the upper surface of the liver because of an interlocking ligature which joins each loop as it emerges from the liver. But this method of ligature fails because there is nothing to prevent the strands cutting through the lower surface of the liver. In fact, these authors point out that each knot should be tied so tightly that the liver-substance is cut through; the large vessels, however, are not cut through, but are only compressed. The result is, that there is considerable oozing from the hepatic veins.

I wish, now, to suggest a method which I have

tried on pieces of liver with success, and which, I think, will overcome many of the difficulties of hepatectomy, and will enable us to extend the scope of the operation, particularly in cases of malignant disease of the gall-bladder, where a small area of the liver has become affected. The idea, no doubt, has occurred to others, but I am not aware that it has been tried on human beings. I propose that, previous to the operation, several discs of decalcified bone-say, lin. in length and in. in breadth-in which two holes have been drilled, should be threaded with three pieces of catgut (fig. 1). The central loop of gut (c) should be of a different colour to the side pieces (a and b), and this is easily managed by preparing the gut with the pink soloids of biniodide of mercury (Burroughs, Wellcome & Co.'s). The lower single free ends (a1, b1) of the gut may be caught by catch-forceps. After endeavouring to define the limits of the tumour, it is walled off by gauze sponges, and a blunt pedicle needle is pushed slowly from above downwards through the liver-substance until it emerges below, when it is threaded with one of the loops (a) attached to the bone-plate, and the needle is withdrawn, carrying with it the loop to the upper surface of the liver, where it is passed through a plate and caught by a pair of catch forceps. The uncoloured outer strand only should be seized (fig. 2), so that when all the loops have been drawn up and we are about to tie off, we may sever the strands of the coloured loop and thus leave the forceps attached to the uncoloured strands, and so avoid confusion (fig. 3).

The reason for tying the central coloured loops first is obvious, for we then have a series of fixed points, and we can now proceed to tie the lower strands (fig. 3, c1, d1) of the uncoloured gut, and then the upper portions of the same strands (fig. 3, c and d). The end strands (a and b) are left until the last, when they are tied so as to encompass the extremities of the base-a being tied to a1. As, however, the liver may be cut through if much force is used, it will be well to bring both these strands through a small curved plate and then to tie them (fig. 4).

It is well to bear in mind that a sharp needle, or a three-faced needle, should not be employed; for if the needle be sharp the large hepatic veins will be pierced and the blood will pour out of the needle-track. It is quite possible, after a little practice, in passing a blunt needle through a liver, to feel the resistance to its progress when we encounter a large portal vein. owing to the fibrous coat derived from Glisson's capsule. The needles

that I propose to use on the first opportunity are blunt Reverdin's needles, curved right and left. The tumour may now be removed, either by amputation or by slowly burning through the liver substance. The cautery should be heated only to a dull red, so as to char the tissues, and should be drawn across the liver tissue repeatedly, but little being burnt at a time. If the tumour be large, it will take at least halfan-hour to remove it in this way. I think, therefore, that it would be well to begin by making an incision into the liver on the distal side of the ligatures, and if we find that the hæmostasis is complete, to at once proceed to amputate. after which the large vessels may be seized and ligatured, and then, if necessary, the surface may be cauterised.

It must be borne in mind that the cautery is powerless to arrest hæmorrhage from a large portal vessel, and these should always be tied; the hepatic veins may ooze, but gauze pressure or the cautery will control this.

If possible, on excising the tumour, we should make a V-shaped incision, so that we may bring the surfaces together at the conclusion of the operation by a few mattress or single sutures (fig. 5).

If the surface left, after removing the tumour, is a broad one, then we should isolate the liver, by placing a sheet of iodoform gauze beneath the liver (fig. 6), and bring it into contact with the charred surface, because for days after, a free flow of bile usually takes place; the gauze may be renewed, or it may be allowed to remain in its original position. If, however, the compression has been sufficient to stop all hæmorrhage in the first instance, it is unlikely that the bile will escape in any quantity.

I can see no objection to leaving these decalcified sterile plates in the peritonal cavity. They will certainly do no harm, and they will not be so irritating as the three or four square inches of charred liver surface usually left

behind.

Should, however, there be any objection to them, we may remove them at the conclusion of the operation; but if we do so, we must be very sure that the large vessels have been sccured, and that the whole surface has been well charred.

On the other hand, they may be allowed to remain for a week and may then be removed, if we have taken the precaution to fix a strand

also be used in operating on cases of hydatid cysts situated an inch below the surface of the liver, when, in order to reach the cyst, we are compelled to cut through the parenchyma of the liver, and the wound becomes flooded with blood.

HEREDITY AND DISEASE.

By J. Flynn, M.B., Ch. M., R.U.I., Sydney.

of consangu

(continued).

(Continued from page 440, "Australasian Medical Gazette," October 21, 1901.) THE theory then that consanguinity has a The specific effect in the deterioration of the off- influence spring, by reason of the "non-renewal of the inity on the blood" rests on slender foundation. In-breeding offspring of animals implies a closeness of mating 25 that is out of the question in the human subject, and yet with proper precautions no deleterious consequences are observed in the offspring. If then such consequences follow in the marriage of relatives, they must be due to some other cause than the consanguinity. In comparing the marriages of near-of-kin and the in-breeding of animals, we must remember that while both classes have this in common-union of kindred

they have also this important difference, namely, that a careful artificial selection is practised in the one, which is conspicuous by its absence in the other. In other words we have consanguinity, pure and simple, free from any complication in the one; in the other we frequently have consanguinity intensifying and accentuating a common morbid heredity.

The practical breeder knows full well that the greatest objection to in-breeding, in fact, the only one of importance, is the difficulty of selecting animals free from constitutional defects, and the loss to him from the tendency of such defects to become dominant in the offspring. The untoward results arising from marriages of near of kin are almost invariably to be ascribed to similar constitutional defects inherited by the wedded descendants from some long-forgotten ancestor. When we reflect that cousins are descended from a common ancestry, and so possess a common heritage-of

(25) In-bred animals are generally produced by breeding in the direct line between a sire and his daughter or granddaughter, or between a dam and her son or grandson, though close breeding in the collateral line is also practised.

In a recent contribution to the Edinburgh Royal Society Professor Ewart, from experiment he conducted on the in-breeding (a) of pigeons, (b) of rabbits, (c) of horses, concludes that con

strand may be then brought out with the gauze at the conclusion of the operation.

These plates may be used for operating in cases of ruptured liver (fig. 7). They may

say.

or y loss of fertility, but that in the case of horses it refined the various tissues, increased the sensitiveness and led to irritability and loss of constitutional vigour, but why it did so he could not He also points out that while the offspring of second cousins might be small and deficient in vigour, the offspring of first cousins unusually vigorous. or of members of the same litter might be large, well-formed and

strength or weakness of constitution, of immunity or susceptibility to disease-it is easy to understand how their issue run a double chance of inheriting those qualities they possess in common, be they good or bad. If then, parents, though related, are heirs to a sound constitution, with no defects to transmit, their offspring have, as it were, a double guarantee against constitutional flaws; but if. on the other hand, cousins join in marriage possessing in common a depraved heritage-and most persons show some deflection from the normal orbit of well-being, a deviation which they share with their kindred-then there is a double chance of perpetuating in their offspring their weaknesses and susceptibilities, their tissue proclivities and disease tendencies.

The objection, then, to consanguineous marriages lies not in the consanguinity, as such, but in the danger of the partners possessing similar untoward qualities, but the same objection holds with all persons contemplating wedlock, even though they be not related who possess any morbific tendency in common. Perhaps the strongest argument against consanguinity being the cause of the defects usually ascribed to it, is the fact already referred to that deaf-mutism cannot, as a rule, be directly transmitted to the offspring, even in those cases in which both parents are deaf-mutes. It is chiefly by means of breeding-in that peculiarities of structure among the lower animals are perpetuated, and so easily and so certainly is their hereditary transmission effected that it would be difficult to assign a limit or to say what amount of abnormal development may not by this system be established as a permanent variety. It is, therefore, useless to con tend that the consanguinity is the cause of deaf-mutism, or of any of the other diseases or defects from time to time ascribed to it. The true cause is heredity, intensified and raised, as it were, to its second power. Some of the evils attributed to marriages of near of kin may be traced to similar defects in some immediate ancestor, which, descending by the related partners, met in their embrace and appeared in geometrical increase in the issue. Other maladies, such as retinitis pigmentosa and deaf-mutism, though not recognised in the ancestors in the same form, may, for all we know, be nearly allied to conditions apparently unlike and undergoing transformation in transmission through the wedded relatives, appear with such intensity in the issue that it became a family disease.

It does not, however, follow that relatives, even when there is no hereditary tendency to

deafness or other defects, are well advised in marrying, for, as Darwin forcibly remarks, no one knows with certainty, until towards the end of life, what ills may lie hidden in his edition of the family constitution.

We may not inappropriately conclude this portion of our subject in the words of the renowned author of the “Descent of Man: "

"Man scans with scrupulous care the character and pedigree of his horses, cattle, and dogs before he matches them; but when he comes to his own marriage he rarely, or never, takes any such care. Though he is in so far superior to the lower animals that he highly values mental charms and virtues, on the other hand he is strongly attracted by mere wealth or rank. Yet he might, by selection, do something not only for the bodily constitution and frame of his offspring, but for their intellectual and moral qualities. Both sexes ought to refrain from marriage if they are in any marked degree inferior in body or mind; but such hopes are Utopian and will never be even partially realised until the laws of inheritance are thoroughly known. Everyone does good service who aids towards this end. When the principles of breeding and inheritance are better understood, we shall not hear ignorant members of our legislature rejecting with scorn a plan for ascertaining whether or not consanguineous marriages are injurious to man.”

CANCER.

66

Diseases.

Widely divergent opinions are entertained by Heredity of authorities of standing as to the heredity of res cancer. On the one hand Herbert Snow states Cancer. that "the belief in the heredity of cancer is derived merely from popular tradition, and is wanting in any sound basis of scientific proof;" on the other, the late Sir James Paget was wont to state that we cannot over-estimate the importance of inheritance in the origination of cancer." And each of these distinguished authorities gave reasons for the faith that is in him. At a discussion on cancer at the Pathological Society some years ago Sir James Paget gave his experience on the heredity of cancer, as follows, namely, that "in his early practice, which was chiefly hospital work, he could reckon the proportion of cases with a family tendency to the disease as one in six; subsequently in private practice he found it one in four, and later still it became one in three." Some of his cases are very interesting. Thus, a lady who died of cancer of the stomach had seven children and thirty grandchildren; of these a daughter died with cancer of the stomach, two granddaughters with cancer of the breast, a grandson with cancer in the bladder, a grandson with cancer

in the rectum, and a grandson with cancer in the axillary glands. Similar instances could be easily multiplied. But the occurrence of cases in families is not denied even by those who deny the influence of heredity. The facts are admitted, but the inferences deduced from the facts are disputed. The disease often occurs in families in whom there is no hereditary predisposition. Thus, according to Snow, when the families of non-cancerous persons are compared with those of cancerous subjects there is little or no appreciable differences in the number of cancerous relatives. At the London Cancer Hospital, Herbert Snow inquired into the family history of 1,075 cases of carcinoma in different parts of the body. One hundred and sixty seven, ie 15.7 per cent., stated that the disease had already occurred in their families, it being understood that the transmission was not always direct18, but that it had affected more than one member of the family. On the other hand among 175 patients who were under treatment at the same institution for noncancerous affections, 46, i.e., 26 per cent. admitted that cancer occurred in their families; and in two other series of 78 and 79 respectively, the former consisting of healthy medical men and the latter of patients with pulmonary disease, the relative percentages were 19.2 and 11.3. It will be at once evident that statistics of this kind are very uncertain. In many cases the history is based upon the mere statement or belief of the patient, and is not supported by the evidence of those who have actual knowledge of the family history. In the case of the non-cancerous patients no one could tell, but that they may in after life have fallen victims to the disease. In a disease which occurs so frequently as cancer, coincidence must come largely into vogue. Perhaps the question might be summed up as follows: The predisposition of the organism is to revert to the normal type. Diseases are never reproduced in the offspring with the same constancy and regularity that normal conditions are. Hence, even in families where hereditary morbid tendencies are strongest, most of the members usually escape. This is true of tuberculosis and it is also true of cancer. On the other hand, it is equally true that when an individual in whom a morbid variation appears leaves offspring these offspring are cæteris paribus more likely to vary again in a similar

way than are persons whose ancestors never experienced such a variation.

In glancing over the statistics already on record on the influence of heredity in the causation of cancer two features stand out prominently. The first is that in a certain percentage of cases the evidence is of such a convincing nature as to leave little doubt that it is at least a powerful pre disposing cause. When we see families in whose members cancer develops in the same organs during several generations, and when the disease is exclusively confined to one side of the family, and even to one sex, it is difficult to exclude heredity. Thus Williams records the case of a woman, aged 53, with uterine cancer whose maternal grandmother, mother, mother's sister, and the patient's two sisters had all died of cancer of the uterus. Guttmann met with cancer of the uterus in three sisters. Atthill relates the case of a woman, aged 28, with uterine cancer whose mother and two sisters all died of cancer of the same organ. Then there is the historic instance of the Bonaparte family, four members of which, father, brother and two sisters of Napoleon, died like the Emperor himself of cancer of the stomach. In the family of a lady medical student her grandmother, mother, two maternal aunts and two sisters all died of cancer. An American physician's paternal aunt, father and son all died of cancer. Dr. Barker knew of a family where eight members died of cancer. The late Dr. G. H. Barlow mentions a case where a lady was the fifth victim of cancer of the liver in two generations. The last case we shall refer to is that related by Broca the mother died of cancer of the breast, of her four daughters two died of cancer of the liver, and two of cancer of the breast; of the third generation, ten members died of cancer. Similar cases could be easily cited; it is far more reasonable to attribute such cases to the influence of heredity than to mere coincidence.

:

(18) The cases of direct transmission were not numerous; of the 169 near relatives, the mother was stated to be cancerous in 57 instances, the father in 18, grandmother in 12, grandfather in four. There were only seven instances of more than one member of the family having been cancerous, and of these only two in which

disease.