the country so much, and the examples we have had of their practically stamping out typhoid and smallpox. The same position is evidenced in their actions with regard to medical benefit societies, which can never be entirely, and ought not to be merely a matter of £ s. d., and I cannot understand why the guiding spirits of these societies cannot take a broader view of the matter. There is no more certain thing in this world than that you never get thirteen pence for a shilling, and if you are going to cut down people in any walk of life who are serving you, you may be quite sure you get no more than the value of your money, and I should have thought that it would have been to the interests of the societies to obtain the best talent available (and they have some very good men), and that to ensure generous attendance they would not have scrupled to have paid them fairly; instead of this the chief aim seems to be to screw the doctor to the lowest possible rate, to be most exacting in their rules regarding his attendance, and then wonder why relations are so often strained. As a body there is no class of people on earth so easy to get on with as medical men, but to take advantage of their needs and the competition that necessarily ensues cannot be to the advantage of those who engage their services. See what has happened to this M.U.O. The able who attended them previously have resigned under circumstances of which you are fully aware, and they have now four medical officers who are not members of the British Medical Association. I need say no more.

Another of the petty troubles which beset us arises out of the action of a body known as the Australian Natives' Association. Whether this Association is an embryo Africander Bond, or whether its aims are the most philosophical and desirable in the world, has absolutely nothing to do with us as a profession, but when they claim medical benefits because they are a registered friendly society, it is in that respect, and in its medical aspect only, that we have a right to object, and that we do strongly object is evident from the decision not to enter into contract relations with them, which was unanimously carried at a meeting of the profession specially convened for the purpose of discussing it. It seems a strange thing that any society should arrogate to itself the right to say to a body of educated men-you will have to do this, or that, whether you like it or not. Surely we have a right to a say in the matter. Surely we may not unreasonably form our opinion as to whether any particular society is entitled to the benefits of contract practice. Who gave

these gentlemen the right to compel us to attend them as a society? This is a matter that can only be arranged by mutual agreement, and, although any society has a perfect right to say to our Association-we should like you to attend us, we, on our part, have an equal right to decline if we consider the conditions unsuitable. The concession of 258., instead of 16s. and 178., which they are so fond of quoting, reminds me of what took place in the birth-place of this society in Victoria, where the members, at the commencement of their career, made lots of promises, and gave their medical attendants 25s. a year instead of the ordinary rate. Now it is not yet a very old institution (I believe it has lasted about six years), but in that short period they have managed to sweat the profession in Victoria by reducing the payment to 12s. 6d, and, from what I can hear, if they try they will soon have no difficulty in reducing it still further. Here in New South Wales in our dealings with this Association we intend to take as our motto the old principle of "Principüs obsta," i.e., deal with an evil before it becomes confirmed, and we have not the slightest intention of delivering ourselves, bound hand and foot, to the tender mercies of the Australian Natives' Association, as our unhappy brethren in Victoria, from their own accounts, seem to have done. Let the Australian Natives' Association carry out their own ends, whatever they may be, but let them refrain from attempting to impose on us by masquerading in the guise of an honest benefit society. Their real aim is something very different, and they only pretend to the character of a friendly society in order, by their scheme of medical benefits, to attract shoals of members. It is not my province to comment on any actions of the medical profession in another State, but, if what one hears is true, and from letters written by members of the profession there, the Australian Natives' Association, in its dutiful friendly capacity, has taken control of the elections of the medical men in the different hospitals. which elections unfortunately are made by the subscribers generally, instead of through an intelligent committee. This has had the effect of practically silencing a great many voices in the profession in a manner which must be obvious to all of you, and what more pitiable sight can there be than that a body of educated gentlemen should be under the thumb of an organisation which is masquerading under the false pretence of being a friendly society, and at the same time using the medical benefits as the great inducement to members joining. This

is what happened in one of their art unions:Amongst other arguments used to induce membera to enrol themselves were some shouting out, "Here is a chance of a fortune for a bob, and medical attendance at 3d. a week." When the medical benefits were first mooted by the Australian Natives' Association our Secretary, Dr. Hankins, waited on their President and asked him if they proposed to have any wage limit. He replied, "No; they could not have any wage limit, otherwise they could not compete with the other benefit societies, who were not bound by any such limit. We are going to act on business principles, and we shall be guided by the law of supply and demand." And this reply was given by a protectionist M.P. But we often find that political principles, however strongly proclaimed, are only translated into action when great voting power is affected. The politicians think we have no such power. It is for you, gentlemen, to show they are mistaken. Some of the vapourings of the Australian Natives' Association are rather amusing than otherwise. They tell us, forsooth, that they mean to crush us by the aid of Parliament, and that they will get an Act passed compelling respectable members of the British Medical Association to meet in consultation the outsiders, whom they will be obliged to employ as their medical officers. It is said that an act of Parliament can do any thing except make a man a woman; but I think we must add another limitation to its power, for no Act of Parliament could bring a respectable practitioner to consult with a man who is outside the pale of decent practice Another threat which these gentlemen are good enough to use against us is to the effect that they will bring new medical men to the various country towns, and other places, to act as rivals to the men already established. We have often heard this kind of thing before. I have been told that nearly thirty years ago the same threat was used in Sydney when the societies endeavoured at that time to squeeze the medical men. They threatened to introduce young practitioners from England, and so crush the opposition of the established doctors; but their threats came to nothing, and so it will be with the Australian Natives' Association if they try it. "Surely in vain is the net spread in the sight of any bird," and he would be a very foolish bird who would set himself in opposition to his fellowpractitioners so as to bring the whole profession under the heel of the Australian Natives' Association. I think better of my fellow-practitioners, and I feel sure that no man of character would lend himself for a moment to such a suicidal

proposal. In fact, the threat is what the Americans call a "bugaboo," horrid in fancy, meant to frighten weak people, but when you take it by the throat there is nothing in it. Every sober, industrious practitioner can always make his way, and he is not the one to lend himself to such questionable ways. No, gentlemen, you need not fear the bugaboo. The organizer, or, as some would call him, the wire-puller, is fearfully and wonderfully made, and I advise you to beware of him. He toils not, neither does he spin, but he takes good care to live on the fat of the land, for he has the knack of making other people work for him. The latest work of his hands is known as the "Commonwealth Benefit Society," a worthy fellow of the notorious Peoples' Prudential, and I believe the offspring of the same brain. It is intended, as I am informed, to be a kind of cave of Adullam for the established benefit societies, where everyone who is discontented can take refuge. The prospectus promises mountains and marvels, but I strongly advise you to have nothing to do with it, or with any association except the bona fide benefit societies. We are determined not to enter into contract practice with any other society beyond those already existing, which were established solely for mutual help in time of sickness. For those who do not care to join one of these excellent institutions, there is the Sydney and Suburban Medical Society, where any one with an income of £200 or under can be attended by the best men in the profession, and where, if a consultation is necessary, it can be obtained at half-fees from any member of the British Medical Association. I must congratulate the Society on its success and the Secretary, Dr. O'Hara, is deserving of every praise.

I notice that at the Adelaide Congress of the Australian Natives' Association, the President said that if the medical profession desired to break up the friendly societies they would have to pay for it. How cleverly he tries to draw the public away on a false scent. He knows, or he ought to know, that there is no such intention; and, that there may be no excuse for any further misrepresentation, I state authori tatively that the profession not only has no idea of trying to break up a legitimate friendly society, but that we recognise their extreme usefulness, and that it is to the mutual advantake of persons with small incomes and of professional men that the club system should be maintained on just and proper lines. Every bona fide benefit society posseses our respect, and will always receive every assistance in our power; but sham benefit societies, whose real

objects are of a perfectly different character, will always meet with our unflinching opposition.

is

I was greatly struck, and I am sure all of you were, also, with an able article in a late number of the Gazette on the suggestion of the A.M.P. Society, to introduce a system of half fees for examination for insurance of £250 and under, and, as the writer stated, we can only regret that a society which divides a profit of nearly half a million a year, should seek to save the paltry sum of £1,200 a year by decreasing the rate of fees paid to the profession. This is only another instance that assists to prove that if any body of men desire to retrench, and there any medical attendance at all connected with it, poor Pil Garlic always comes in for the first kick, and it further shows that we have no friends beyond ourselves. Needless to say, we are going to oppose this attempted imposition, for it is an imposition, for an examination made by a conscientious man must require the same skill, time, and trouble whether for an assurance of £100 or £1,000. I put the question to the manager when the secretary, Dr. Hankins, and myself, as president, interviewed him at his request, on the subject, "Do the medical examinations pay the society." The answer was "Yes." Now, what lesson are we to learn from the events of the past year. It is this-that we have only ourselves to trust to, and that we can obtain our reasonable objects only by the thorough cohesion and mutual confidence of our members. Each man owes a duty to his profession, and is bound to see that at his hands at least the profession is not injured; nay, more, each man is bound to do all that in him lies to further the common interests of the profession, and he may rest assured that by so doing he is most efficiently furthering his own interest. The Council of this Association are your elected representatives, entrusted by you with the management of the affairs of the profession. They have a right to your confidence-they do nothing of importance without consulting the members, and they have a right to your generous support on all occasions. Union makes strength, and if we are only united the attacks of our enemies will leave us unscathed.

In conclusion, I have to offer you my warmest thanks for raising me to the position of presi dent of this Association, the highest position in the gift of the profession, and the greatest compliment which it is in your power to pay, and I wish for the Association very many years of prosperity and success.

}

ACCORDING to the tables drawn up by the RegistrarGeneral in connection with the census of London, there are about 5,000 doctors and 16,000 nurses in London.

A DISCUSSION ON CANCER. Introductory Address by H. B. Allen, M.D., Professor of Anatomy and Pathology in the University of Melbourne, and Pathologist to the Melbourne Hospital.

At the Sixth Intercolonial Medical Congress, Hobart. (ABSTRACT.)

Is Cancer a Parasitic Disease?-Many facts encourage the belief that cancer is a parasitic disease. The primary local manifestation, its infiltrating nature, the tendency to dissemination throughout the body, and the ultimate cachexia, all bear some analogy to the phenomena of tubercle and other processes due to microbic invasion. Cancer, or some disease closely resembling it, has been successfully inoculated in many cases from one laboratory animal to another; instances are sufficiently numerous, though not so well attested, of transfer from man to lower animals; and definite though guarded statements are made of successful inoculation from man to man. peatedly after operations for cancer, the disease has recurred in an obscure corner of a scar, or in the track of a trocar used in exploratory tapping, in such fashion as to convince the surgeon that he had unintentionally induced a fresh implantation. The so called parasites of cancer have been brought prominently before English readers by the work of Ruffer, Plimmer, and others. The parasitic theory of carcinoma is singularly attractive, because it seems to promise results in prevention and cure similar to those obtained in diphtheria and other microbic diseases.

Re

There are, however, reasons of great weight against it. Cancer is pre-eminently a disease of declining life, occurring more and more frequently from middle life into advanced age, and in this respect unlike all known parasitic diseases. The primary growths themselves are often very unlike the results of parasitic infection. For example, a columnar carcinoma of the rectum may show an exaggerated system of tubular gland formation, extending in regular pattern through the muscularis mucosa, and perhaps even through the main muscle coat before it tends to spread in looser irregular fashion. The disseminated growths of cancer bear the traces of the seat of the primary growth in a manner and to a degree never manifested in parasitic processes. The reason is simple. In the dissemination of tumours, a cell or group of cells is conveyed by blood or lymph to a new site, and grows there by its own multiplication into a secondary tumour. In tubercle, on the contrary, the parasite itself

is disseminated, and multiplies in a new site, there producing irritative lesions, the cells of which are not descended from those of the primary focus. Opinion is still divided concerning the parasitic origin of cancer, but, though I cannot regard the question as settled, my own opinion inclines decidedly to the negative.

The Intrinsic Theory.-The whole body is descended from a single original cell, and each part of the body inherits its qualities by continued descent from specialised offspring of that single cell. In each part there is no anarchical mob of cells, but a federal society, with due relations, restraints and provisions. Vessels, connective tissues and epithelial coverings are maintained in due relations to one another. The true marvel lies in the federal organisation of each portion of the body, maintaining it in due size and due relation of parts, rather than in the occasional aberrations that induce local over-growth or tumour formation. Carcinoma is a confused imitation of the embryonic process of gland formation, while sarcoma resembles the act of repair, persisting at some one stage or other, the growth in either case being without obvious purpose, without limit, unfederal, evil. Cohnheim's theory of persistent embryonic "rests" " of connective tissue or epithelium, detached from their usual connections, will scarcely serve to explain the cancers of advanced life. Ribbert's theory of detachment of epithelium by activities of connective tissue can seldom apply. The specialisation of the malignant elements is biologic and functional, not mechanical. Mere misplacement of epithelium does not in itself induce carcinoma. Epithelial "rests" in the ovary or neck may remain inactive, or form dermoid cysts. Cancer sometimes originates in such "rests or implantations, but there is the same difficulty in explaining such an event as when cancer starts in normally-placed epithelium. In any case, the explanation is not yet forthcoming.

Cancer a Local Process.-Cancer growth is essentially a local process, due to loss or perversion of the local controls, of the local federal bond. Now and then multiple primar cancers occur, just as with innocent growths. Such multiples are more often sarcomata than carcinomata. It is clear that the loss or perversion of control may be multiple, or may even be widely spread in some particular tissue, such as bone or skin.

Classification. In general, the current classification of cancer into two groups, carcinoma and sarcoma, according as it arises from

epithelium or from connective tissue, is satisfactory in practice; and the same may be said of the consequent reference of carcinoma to the epiblast or hypoblast, and of sarcoma to the mesoblast. Difficulties were first found in tumours arising from serous membranes, and therefore mesoblastic, but having the histological structure of carcinoma. For such cases, the group of endotheliomata was established. Certain observers have been led to form a new section of archiblastic tumours derived from undifferentiated embryological elements, while others would divide endotheliomata into those akin to connective tissue and those akin to epithelial structures. Pathologists probably exaggerate the separation of one layer of the embryo from another, forgetting their common descent from the original fertile cell.

Increased Activity or Lessened Resistance.In carcinoma, the question naturally arises, whether the epithelial invasion is due to some new power on the part of the epithelium, or some lessened resistance on the part of the connective tissues. The epithelium is always active, sometimes with great intensity, sometimes with quiet persistence. The behaviour of the connective tissue varies. In certain cases scarcely any change occurs, beyond the mechanical results of the epithelial inroad; but in others, the connective tissue is as active as the epithelium, playing no passive part, but showing itself an energetic partner in the tumour development, sometimes indeed so as almost to confound carcinoma and sarcoma together. Plain thinking leads us to ascribe cancer formation to a direct increase in the activities of cells, whether of epithelial cells in the case of carcinoma, or of connective tissue cells in the case of sarcoma. This opinion may be held with equal strength by the advocates and critics of the parasitic theory.

The Increased Activity may be Controlled.— It must not be thought that all hopes for the control of cancer, apart from simple extirpation, are bound up with the establishment of its parasitic origin. Curious cases are on record of spontaneous retrogression of malignant tumours. The occasional withering or even disappearance of carcinomata of the breast after the menopause or the removal of the ovaries, the shrinking of some rodent ulcers under the influence of the Roentgen rays, and the rapid changes in the way of degeneration and absorption induced by Coley's fluid in many sarcomata, especially of the spindle-celled type, prove conclusively that the special growing power of cancer elements can be restrained. It is important to note that, in

the three methods mentioned, the good results are limited to definite varieties of malignant growth; but, nevertheless, encouragement is given to seek more sure and general controlling power over the progress of cancer, and to obtain all the side-lights that such observations throw on the vexed questions of its nature and

causation.

Dissemination. There is urgent need for further study of the phenomena of dissemination, and of the conditions which encourage or forbid tho formation of secondary growths. Why, for instance, should colloid cancer of the rectum or rodent ulcer of the neck have such enormous power of local growth, and so little tendency to disseminate? Why should a sarcoma of the testis infect the inguinal glands, while the axillary glands usually go free in sarcoma of the breast? Why are the secondary growths following carcinoma of the breast sometimes limited to the liver, and sometimes to the bones? Why should the secondary growths of sarcoma sometimes avoid the lungs, where they usually develop first? A very practical question is afforded, when in one woman a carcinoma of the breast grows to great size without infecting the axillary glands, while in another case these glands are involved in marked degree, while the breast itself has undergone but trifling enlargement. Some better explanation than accident is needed for delayed infection in one case, and early infection

in the other.

Relation of Innocent to Malignant Tumours. There is a wide-spread belief that innocent tumours have a marked tendency to become malignant. I am convinced that this tendency is much exaggerated. I do not affirm that innocent tumours have any exemption from cancer, but merely that too much has been made of their supposed tendency to become can

cerous.

Influence of Race, Hereditament, Irritation, &c.-Cancer is rare among the Australian aboriginals, many years often passing without a single case being registered among the blacks remaining in Victoria, though the blacks are not exempt from either external or internal cancer. I am informed that cancer is also rare among the Maoris of New Zealand, a race of vastly higher type. By way of contrast, the Chinese in Victoria suffer severely from cancer. Great difficulties beset any attempt to estimate the influence of heredity in cancer. The famous series of cases related by Broca shows how terrible this influence may be, the series extending over seventy years, with fifteen cases, all descended from one woman with cancer of

the breast. Sibley found cancer of the uterus in a mother and her five daughters. But in general the power of hereditament is infinitely less. Paget found that one-fourth of 322 cancerous patients were aware of the occurrence of cancer in other members of their families, but that only one in 25 had a parent dead from cancer. Snow, in 1075 cases, found a family history in 15.7 per cent., but in 78 healthy people he obtained a similar history in a rather higher percentage. Mr. Powys, of the Victorian Statist's Office, working from the standpoint of a mathematician, has minutely examined the curves of mortality at the various ages, from phthisis and cancer in Victoria and in England and Wales. He finds that in phthisis, the age mortality curve is heterogenous, and may be resolved into two curves, an early curve, having its maximum in England between 25 and 30, in Victoria between 28 and 33, and a late curve, having its maximum in England between 45 and 50, in Victoria between 55 and 63. Mr. Powys suggests that the early curve probably consists of deaths due to contact with phthisical parents, the so-called hereditary phthisis, while the late curve pertains to phthisis acquired later in life from inhaled sputum, &c. In Victorian males the late curve is so strong that the whole tracing, even without adjustment, is markedly dicrotic. On the contrary, Mr. Powys finds that the age curve of cancer mortality is a homogenous curve, and cannot be split into separate components, and he infers that the dominant cause of cancer is single, and not composite. These striking observations and inferences have not yet been published, but will doubtless receive the careful consideration which they deserve. The influence of local irritation in favouring the evolution of cancer is beyond question, and fully recognised. As to general conditions, cancer may develop in the young or the old, the robust or the feeble, the stout or the lean, the nervous or the placid, the idler or the overworked. In a large proportion of cases, it appears in persons who have enjoyed a most healthy life; and patients with cancer seldom suffer from any severe intercurrent diseases, such as croupous pneumonia. But, on the contrary, I could quote from my own experience cases of cancer developing in patients with phthisis or with tuberculous intestine, or with the scars of old tubercle.

Prevalence of Cancer in Australasia.-The statistical tables, which I now have the honour formally to present to the Congress, have been prepared from data most kindly furnished by the Government Statists, with the gracious permission and countenance of His Majesty's