The history

ancestral

attacked is

6.

disputed question of the causation of cancer.
If we accept the parasitic theory of cancer-
formation, then the "malignant predisposition"
would correspond with the "tubercular pre-
disposition." But it must be admitted that
none of the so-called discoveries of "cancer
germs
"19 have so far been able to withstand
destructive criticism. In the words of Hanse-
mann, they are all degenerated cells, kary-
okinetic figures, white and red corpuscles, and
finally normal carcinomatous cells," and he
speaks of the parasitic theory as "already be-
longing to history." And Professor Adami in
his recent address concludes that the parasitic
theory has yet to justify the pre-eminence it
has lately attained, even though cancerous
growths are produced by the irritation of
bilharzia ova. The embryonic tissue presup- |
posed in Cohnheim's theory may, like an ordi-
nary malformation, be transmitted. Indeed it
was the transmission of malformations that
first suggested to Cohnheim his brilliant em-
bryonal theory. But although Cohnheim's
theory is generally accepted as explaining cer-
tain homologous tumours, vg, myoma of the
uterus,20 and such heterologous ones as chon-
dromata of the testicle and parotid, and
although the theory is practically verified in
one class of tumours, namely, dermoids and in
many forms of cysts, still it can hardly be said
to be applicable either to sarcoma or cancer;
on the contrary, the more closely we reflect on
the matter the more convinced we become that
the cancer cell is rather an adult cell that has
lost its specialisation and reverted to a primi-
tive form, rather than that it is one endowed
with persistent embryonic characteristics.

The essence of the cancer process, the -life and heredity of which we are here principally of the organ concerned in, is perverted gland formation, of mere Now, as we glance over the records of cancer importance in different organs, we note there is a wellinfluence marked regional tendency. Two organs in the indivianal. female, the breast and uterus, and what we may call the mouth parts in the male, head the

than any

anecting the

(19) Some investigators thought they discovered bacteriaothers, especially modern ones, had it that it was a coccidium-the latest is that it is a yeast (myxomycete). Peiffer, after making a special study for fifteen years of the obligate cell parasites of the sporozoa group and of the growths caused by such sporozoa, declares that "among them was not numbered the true and exact cause of cancer." As to the parasites in human cancer and sarcoma, described by Max Schüller, it is well to recall that in all the growths which he has been able to produce so far, by inoculating animals with their cultures, the remarkable infiltrative character of true carcinoma has been conspicuous by its absence and a better case could be made ont for their granulomatous character.

(20) The body of the human uterus, as we know, is composed of two (Müllerian) tubes fused together, which remain separate as the "horns" of all other uteri. As it is precisely this region which is the site of myomata the Fallopian tubes being almost exempt, Sutton thinks it extremely probable that these growths spring from embryonic remnants during the fusion of the tubes to form the body.

list in each, whereas the stomach comes second in both21. Have we any explanation of the extraordinary liability of these organs to cancer. Let us take the uterus and mammary gland first. What strikes us from biologic point of view in considering these organs, is that they decay in the human female or functionally die long before her organism dies. All her other organs may be enjoying their pristine vigour, she may herself be "well-preserved." while her uterus and mammary gland, as it were out of harmony with their environment, shrivel and decay. Now Herbert Spencer has shown that the entire organism holds in check the natural reproductive powers of the fixed cells of the body tissue, so that they never go beyond that point that is of greatest utility to the organism. When however from any cause that controlling influence is weakened, the primitive powers of the cells assert themselves. Nowhere in the nature is better illustrated the condition of weakened control than in these two organs, in the female at the menopause. Both uterus and breast have played their part in the economy. They have lived their life. They are no longer in harmony with the other portions of the organism. Is it any wonder that they take on action for themselves; perhaps the wonder is they do not do so oftener.

There is another point it is well to recall to mind, that both the uterus and the mammary gland are comparatively recent organs. The fusion of the Müllerian ducts that produces the uterus does not occur till we arrive at our own order. The mainmary gland appears for the first time in the mammalian group. Now, Darwin has shown that organs that have been recently acquired are apt to vary widely and to be in a state of unstable equilibrium. Even in the individual the uterus and mammary gland are like some flowers, the latest to bloom and the first to fade, so that individually they are short lived, and ancestrally they are recent. It is scarcely any wonder then if with their function extinguished.

(21) According to statistics compiled by Williams from the four London Hospitals, St. Thomas', St. Bartholomew's, University College and Middlesex, the breast was the starting point of cancer in 40.3 per cent. and the uterus in 34 per cent. of all cases in the female. That is the two organs together are to be credited with 74.3 per cent. In the male the mouth-perts (tongue, lips, cheek, jaw) head the list with 40 per cent. of all cases that occur in him. The stomach comes a good second in both, with 18 per cent. in the female and 32 per cent. in males.

(22) According to the same authority cancer is not a disease of "completed" senility. After reaching its maximum in both sexes between 45 and 55 it shows a rapid decline. This would seem to show that a disturbance of the relation between the glands from which cancer originates and the organism itself takes place at this time, that is, while the glands decay the organism maintains a certain vigour and a certain amount of succulence. At any rate statistics show both in man and animals alike that the longer life and vigour are maintained after the cessation of the reproductive powers, the greater is the liability to cancer,

their food supply lessened, themselves decaying, while the remainder of the organisms enjoys its pristine vigour they would take an aberrant action And if we consider the close resemblance there is between what takes place in cancer formation and the early formation of the mammary gland itself in embryo life, and its subsequent enlargement at puberty and at lactation, we will cease to wonder that this aberrant action results in cancer. The only difference is that in the one case the process is held in check for the good of the organism, in the other it runs riot, and against the organism. We may conclude, then, that in the uterus and mammary gland there is a special morphological liability for their acini to revert to a more primitive condition. The property that stands out most conspicuously in primitive epithelium is that of dipping down and branching through the mesoblast. No wonder, then, that cells returning to this condition should display the same powers though now perverted. In their reckless proliferation there is, however, always an attempt, however abortive, to form a gland.

In the other organs which have gained a bad pre-eminence in liability to cancer, there is generally some developmental reason for structural variability. Thus, let us take the stomach. When we speak of cancer of the stomach we to all intents and purposes mean cancer of the pylorus and neighbouring region. Ewald states nearly all the statistics agree that in about one-half of the cases the pylorus is involved; according to Brinton 60 per cent, Lebert 59.6 per cent., Katzenellenbogen 58.3 per cent., Luton 57 per cent." Wilks and Moxon state that the district to the right of a line drawn from the cardiac opening to a point four inches below the pylorus will include the starting point of the vast majority of cancers. The pyloric region is specially subject to stenosis of various kinds from the thickness of its muscular bands, from projection of its mucous folds, or there may be a congenital constriction. As Ewald says, there may be a round or slit-like contraction of the ostuim pylori, or the muscular portion of the pylorus may be hypertrophied, and the pyloric portion may project into the duodenum like the cervix uteri into the vagina. The region is one of transition from the secretive epithelium of the stomach to the absorptive epithelium of the intestine. There are traces of a second chamber in the bulging along the greater curvature known as the antrum pylori. The region is also specially liable to ulcers; nearly 80 per cent. of gastric ulcers are situated either in close

proximity or within its borders. Altogether it is structurally variable and morbidly susceptible. And there are some who see in this region, with its thick muscular coat, in excess of present requirements, its bulgings, its folds, and pouches, the remains of the "gastric mill" of our crustacian ancestors, which still persists in the gizzard of birds and in the "grinding stomach" of certain edentate mammals, i.e., the Great Ant-eater23 and some Armadillos.

The male mouth-parts (tongue, lip, cheek, jaw) also figure high in cancer statistics, 40 per cent. of all cases in men being attributed to them. It is well to bear in mind that this region in the male is notably modified by secondary sexual developments. The mouthparts of the female are but an enlargement of the same structures in the child. As Darwin24 says, "Throughout the animal kingdom, when the sexes differ in external appearance, it is with rare exception the male, which has been the more modified, for generally the female retains a closer resemblance to the young of her own species."

At puberty the general contour of this region changes in the male. The angles of the jaw become more prominent; the chin becomes square and deep, not only by increased growth of the alveolar part, but also by thickening of the subdental portion, which enables the jaw to withstand the action of the masticatory muscles. These muscles themselves become now more prominent and stand out beneath the skin in bolder relief; so that, in a way, the male jaw is almost as characteristic as the male pelvis. Again, at this time, the vocal cords elongate in the male. Before puberty the vocal cords are not two-thirds the length of adult cords. The female larnyx resembles the larynx of boys'. While the larynx is undergoing the changes of puberty, the boy's voice is said to crack.

In eunuchs who have been deprived of the testes before puberty the voice does not undergo this change. The pomum Adami projects. The resonance cavities of the mouth and pharynx undergo a corresponding change to match the voice, the chin and lips become clothed with beard; in fine, the male face appears. After fifty years of age a retrograde change in all these characters sets in, so that the voice, lips and jaws of the old man become as infantile as that of the old woman, the teeth fall out, the lips and cheeks fall in, the alveolar Elementary Anatomy, "The Alimentary

(23) See Mivart System."

(24) Descent of Man," page 221.

process is absorbed, the jaw itself becomes oblique, the angle obtuse. All these changes affect the old man relatively much more than they do the old woman, and some see in this relative change a reason why many areas of this region, richly supplied with both mucous and sebaceous glands, are placed in that condition of detachedness from the rest of the organism, which is so favourable for cancer formation. At any rate we have these facts, that in the human female three-fourths of cases of cancer that occur in her are to be attributed to two organs, the uterus and mammary gland, and that in the male 40 per cent. of all cases of cancer that affects him is to be attributed to the mouth parts-that these two regions, in many ways dissimilar, resemble each other in these (a) that they are both modified by the sexual functtion, one set (uterus and mammary gland) primarily, the other, namely, mouth parts (tongue, lips, cheek, jaws) secondarily; (b) that they both undergo marked atrophy during the life time of the individual; lastly, that the stomach (practically the pylorus) comes next in each sex-in the cancer roleand we have seen that though there is here no extinction of function or any notable atrophy of structure, yet that it (the pylorus) is anatomically variable and pathologically susceptible, and there is some reason for considering it a "degenerate gizzard." The deductions to be drawn from these reflections, while not conclusive, are suggestive and tentative, that while any gland-bearing epithelium may become the starting-point of cancer, yet this is far more likely to occur in regions where there is special morphological change, or where there is an ancestral basis; that cancer is perverted gland formation favoured by senile changes; that it is the question of senility of glands themselves rather than of the organism; that the source of danger is not in the simultaneous decay of the glands and the organism, but of one before the other; that nowhere is this condition better complied with than in the decay of uterus and breast in the "well-preserved female. This would be quite in keeping with what has been stated in an earlier portion of this paper, that it is not improbable that inborn structural peculiarities exercise a wider sway in the causation of disease than is generally believed and that these inborn peculiarities having perhaps a morpholo gical or ancestral basis tend to be transmitted to the offspring. Again since cancer depends so much upon the age of the individual and history of the organ attacked, does it not seem improbable that infection can be the only factor in its production. And if we except

chimney-sweeps' cancer and smokers' cancer, does not the irritation theory seem played out. When we reflect that epithelioma of the lip occurs in non-smokers who are relatively few in any community, that it attacks the opposite side of the mouth to that in which the pipe was held, that cigarette and cigar-smokers are not exempt, is it not reasonable to conclude that the pipe is at best but the proverbial last straw?

CLINICAL AND PATHOLOGICAL NOTES.

Case of Unusual Size of Fœtus, and
Occipito-posterior Position.

ON December 17th, 1901, I was called to Mrs. C., at 9.30 a.m. born

Previous History-Seven children living, two miscarriages. One precipitate labour in which the placenta was born with the child and cervix lacerated.

Labour had begun at 1 a.m the same day. The os was almost fully dilated and the head not engaged in the pelvis. The abdomen was very large. I ruptured the membranes, and after waiting an hour and a half, as little progress was made, applied the forceps. After trying at intervals for an hour I made little progress, and so removed the forceps and introduced my hand. I found the occiput was

turned to the sacrum, so rotated the head with my hand with no difficulty, and then again applied the forceps, and after a hard pull succeeded in delivering the head. The shoulders then refused to move, so I again introduced my hand and found one arm doubled behind the back. I tried in vain to rotate the shoulders towards this arm so as to bring it to the front, so then hooked a finger into the axilla, and with great difficulty brought down the posterior arm from behind the back. The child was then easily delivered, but was dead. It weighed 14lbs, was 22 inches in length, the chest measured 16 inches in circumference, and the head 19.

The perinæum was not lacerated, and the mother has not had a bad symptom since delivery, but had paresis of one leg for some days afterwards. I record the case as the correct treatment in rectifying the occipitoposterior position lead to another difficulty in displacing the arms.

Hobart.

ARTHUR H. CLARKE, M.R.C.S.

Abdominal Aneurism-Paraplegia—

Rupture.

J. R., aet. about 48, was seen by me for the first time on 13th September, 1898. He complained of sudden loss of power in his legs. He had had syphilis, and had worked hard as teamster and contractor. He had had an aneurism of popliteal artery, which had been cured, by ligature of the femoral artery, in the Melbourne Hospital about year 1883. There was no trace of the aneurism in popliteal region, but a linear scar over the position over the position of the femoral artery, at the apex of Scarpa's triangle, was in evidence. I gave him some potass. iodide. On September 20th he seemed fairly well. On October 2nd he was complaining more of a pain in epigastric region, and on this occasion attention was specially directed to this locality.

I made an examination, and informed him that he might have an aneurism there. A hard mass or tumour could be felt with pulsation communicated but non-expansile; no thrill could be felt, and no bruit could be heard.

He

This pain troubled him a good deal. thought relief would be obtained by an aperient, so I ordered him 2 or 3 pills containing 5 grains of calomel. I advised him to rest. He took the aperient referred to, but not getting any or much result there from, he, in addition, took eight or ten Beecham's Pills, and also went into country against advice. When at his place in country he became exceedingly faint, and his companions thought he was dying. He was brought back to Millicent over a rough road, in bottom of a spring cart. When seen he presented the appearance of profound shock, face and conjunctivæ pallid, pulse frequent and feeble, legs completely paralysed, and he had most distressing pain in them. I believed him to be dying from rupture of the abdominal aneurism. He died about 6 a.m. next day. A post mortem examination was obtained, but performed under difficulties. On opening abdominal cavity a large aneurism was found about size of a cricket ball, apparently entirely filled with firm laminated I attempted removal of the aneurism, but this ended by pulling it off the spinal column, which formed the posterior wall of the

clot.

sac.

The vertebral column had been eroded to the extent of penetration of the spinal canal, with subsequent paraplegia and accompanying sensory phenomena from pressure on cord by blood. The finger could be placed in the hole in the spine caused by the aneurism.

Extensive retroperitoneal hemorrhage had occurred, but the exact site of rupture of sac was not ascertained, nor was the exact section of the aorta affected located, further than that it was close below the diaphragm. Ey proper post mortem an excellent and instructive specimen of the results of aneurism might have been secured. J. A. THYNE, M.B., C.M. Edin.

Millicent, S.A.

MIRROR OF HOSPITAL PRACTICE IN AUSTRALASIA.

CRAIGEND PRIVATE HOSPITAL, SYDNEY.

(UNDER THE CARE OF A. MACCORMICK, F.R.C.S. ENG.)

CASE I.-Renal tumour, with symptoms resembling renal calculus; Nephrectomy; X Ray burn.

A

Male, aged 43, was admitted to Craigend House on August 16th, 1901. Patient had had repeated attacks of pain in the right kidney resembling renal colic. A skiagram had been taken which apparently shewed the shadow of a renal calculus. On August 17th, under anæsthetic administered by Dr. Maitland Gledden, the kidney was exposed through the usual incision in the right flank, and brought up into the wound. A distinct tumour the size of half a mandarin orange was found occupying the anterior and lower half of the kidney, apparently a sarcoma. No calculus was found. Nephrectomy was decided upon. The organ was completely freed from its bed, and the vessels and the ureter were separately ligatured with catgut, and the kidney removed. drainage tube was inserted into the pouch, and kept in for 48 hours. The patient made a slow recovery; there was no constitutional disturbance, nor any discharge of pus, but the tissues were of low vitality, and the wound healed slowly, leaving a sinus for many weeks. At the time of the operation there was a large red patch, looking like a patch of eczema, on the front of the abdomen, mostly to the right of the middle line, which slowly progressed until a patch of the true skin, several inches in diameter, became involved. The outer portion of this slowly cicatrized, but there is still (five months afterwards) a large ulcer on the abdominal wall to the right of the umbilicus. covered with a parchment-like surface, and with callous edges, which shews little tendency