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disputed question of the causation of cancer. list in each, whereas the stomach comes second If we accept the parasitic theory of cancer- in both21. Have we any explanation of the formation, then the “ malignant predisposition " extraordinary liability of these organs to cancer. would correspond with the " tubercular pre- Let us take the uterus and mammary gland first. disposition.” But it must be admitted that What strikes us from biologic point of view in none of the so-called discoveries of “cancer considering these organs, is that they decay in germs "19 have so far been able to withstand the human female or functionally die long destructive criticism. In the words of Hanse- before her organism dies.

All her other organs mann, they are all “ degenerated cells, kary: may be enjoying their pristine vigour, she okinetic figures, white and red corpuscles, and may herself be

may herself be well-preserved," while her

. finally normal carcinomatous cells,” and he uterus and mammary gland, as it were out of speaks of the parasitic theory as "already be harmony with their environment, shrivel and longing to history." And Professor Adami in decay. Now Herbert Spencer has shown that his recent address concludes that the parasitic the entire organism holds in check the natural theory has yet to justify the pre-eminence it reproductive powers of the fixed cells of the has lately attained, even though cancerous body tissue, so that they never go beyond that growths are produced by the irritation of point that is of greatest utility to the organism. bilharzia ova. The embryonic tissue presup- When however from any cause that controlling posed in Cohnheim's theory may, like an ordi- influence is weakened, the primitive powers of nary malformation, be transmitted. Indeed it the cells assert themselves. Nowhere in the was the transmission of malformations that nature is better illustrated the condition of first suggested to Cohnheim his brilliant em- weakened control than in these two organs, in bryonal theory But although Cohnheim's the female at the menopause. Both uterus and theory is generally accepted as explaining cer- breast have played their part in the economy. tain homologous tumours, vg., myoma of the They have lived their life. They are no longer uterus, 20 and such heterologous ones as chon in harmony with the other portions of the dromata of the testicle and parotid, and organism. Is it any wonder that they take on although the theory is practically verified in action for themselves; perhaps the wonder is one class of tumours, namely, dermoids and in they do not do so oftener. many forms of cysts, still it can hardly be said There is another point it is well to recall to be applicable either to sarcoma or cancer; to mind, that both the uterus and the on the contrary, the more closely we reflect on mammary_gland are comparatively recent the matter the more convinced we become that organs. The fusion of the Müllerian ducts the cancer cell is rather an adult cell that has that produces the uterus does not occur till lost its specialisation and reverted to a primi- we arrive at our own order.

The maiomary tive form, rather than that it is one endowed gland appears for the first time in the mamwith persistent embryonic characteristics.

Now, Darwin has shown that The essence of the cancer process, the organs that have been recently acquired are

heredity of which we are here principally apt to vary widely and to be in a state of unof the organ concerned in, is perverted gland formation, stable equilibrium. Even in the individual

Now, as we glance over the records of cancer the uterus and mammary gland are like some importance in different organs, we note there is a well-flowers, the latest to bloom and the first to fade,

marked regional tendency. Two organs in the so that individually they are short lived, and i livianale female, the breast and uterus, and what we ancestrally they are recent. It is scarcely any

may call the mouth parts in the male, head the wonder then if with their function extinguished.

malian group

The history

life anul ancestral

attackel of mire

influence afecting 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 (Mülerian) tubes fused together, which remain separate as the "horus" of all other uteri. As it is precisely this region which is the site of myompata 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 boly.

(21) According to statistics compiled by Williams from tbe 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 created 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) Accordir g 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 glaods 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 statisticschow both in man aud animals alike that the longer life and vigour are maintained after the cessation of the reprowuctive powers, the greater is the liability to cancer.






their food supply lessened, themselves decaying, proximity or within its borders. Altogether
while the remainder of the organisms enjoys its it is structurally variable and morbidly
pristine vigour they would take an aberrant susceptible. And there some who see
action And if we consider the close resemb- in this region, with its thick muscular coat,
lance there is between what takes place in in excess of present requirements, its bulgings,
cancer formation and the early for mation of its folds, and pouches, the remains of the “gastric
the mammary gland itself in embryo life, and mill” of our crustacian ancestors, which still
its subsequent enlargement at puberty and at persists in the gizzard of birds and in the
lactation, we will cease to wonder that this grinding stomach ” of certain edentate mam-
aberrant action results in cancer. The only mals, i.e., the Great Ant-eater23 and some
difference is that in the one case the process is Armadillos.
held in check for the good of the organism, in The male mouth-parts (tongue, lip, cheek,
the other it runs riot, and against the organism. jaw) also figure high in cancer statistics, 40 per
We may conclude, then, that in the uterus and cent. of all cases in men being attributed to
mammary gland there is a special morphological them. It is well to bear in mind that this
liability for their acini to revert to a more region in the male is notably modified by
primitive condition. The property that stands secondary sexual developments. The mouth-
out most conspicuously in primitive epithelium parts of the female are but an enlargement
is that of dipping down and branching through of the same structures in the child. As
the mesoblast.
No wonder, then, that | Darwin24


“Throughout the animal cells returning to this condition should kingdom, when the

differ in display the


though ternal appearance, it is with rare exception perverted In their reckless proliferation the male, which has been the more modified, there is, however, always an attempt, however for generally the female retains a closer resemabortive, to form a gland.

blance to the young of her own species.” In the other organs which have gained At puberty the general contour

this a bad pre-eminence in liability to cancer, region changes in the male. The angles of the there is generally some developmental reason jaw become more prominent; the chin becomes for structural variability. Thus, let us take square and deep, not only by increased growth the stomach. When we speak of

of the alveolar part, but also by thickening of of the stomach we to all intents and purposes the subdental portion, which enables the jaw to mean cancer of the pylorus and neighbouring withstand the action of the masticatory region. Ewald states nearly all the statistics muscles. These muscles themselves become agree that in about one-half of the cases the now more prominent and stand out beneath pylorus is involved ; according to Brinton 60 the skin in bolder relief; so that, in a way, the per cent, Lebert 59.6 per cent., Katzenel male jaw is almost as characteristic as the male lenbogen 58.3 per cent., Luton 57 per cent." | pelvis. Again, at this time, the vocal Wilks and Moxon state that the district to the cords elongate in the male. Before puberty right of a line drawn from the cardiac opening the vocal cords

two-thirds the to a point four inches below the pylorus will length of adult cords. The female larnyx include the starting point of the vast majority resembles the larynx of boys’ While the of cancers. The pyloric region is specially larynx is undergoing the changes of subject to stenosis of various kinds from the puberty,


boy's voice is said to thickness of its muscular bands, from projection crack. In eunuchs who have been deprived of its mucous folds, or there may be a congenital of the testes before puberty the voice does not constriction. As Ewald says, there may be a undergo this change. The pomum Adami proround or slit-like contraction of the ostuim jects. The resonance cavities of the mouth and pylori, or the muscular portion of the pylorus pharynx undergo a corresponding change to may be hypertrophied, and the pyloric portion match the voice, the chin and lips become may project into the duodenum like the cervix clothed with beard; in fine, the male face aputeri into the vagina. The region is one of pears. After fifty years of age a retrograde transition from the secretive epithelium of the change in all these characters sets in, so that stomach to the absorptive epithelium of the the voice, lips and jaws of the old man become intestine. There are traces of a second chamber as infantile as that of the old woman, the teeth in the bulging along the greater curvature fall out, the lips and cheeks fall in, the alveolar kuown as the antrum pylori. The region is

Elementary Anatomy, "The Alimentary also specially liable to ulcers; nearly 80 per cent. of gastric ulcers are situated either in close

(24) - Descent of Mau," page 221.




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(23) See Srstem."

process is absorbed, the jaw itself becomes ob- chimney-sweeps' cancer and smokers' cancer, does lique, the angle obtuse. All these changes affect not the irritation theory seem played out. the old man relatively much more than they do When we reflect that epithelioma of the lip the old woman, and some see in this relative occurs in non-smokers who are relatively few change a reason why many areas of this region, in any community, that it attacks the opposite richly supplied with both mucous and sebaceous side of the mouth to that in which the pipo glands, are placed in that condition of detached- was held, that cigarette and cigar-smokers are ness from the rest of the organism, which is so not exempt, is it not reasonable to conclude favourable for cancer formation. At any rate that the pipe is at best but the proverbial last we have these facts, that in the human female straw ? three-fourths of cases of cancer that occur in her are to be attributed to two organs, the

CLINICAL AND PATHOLOGICAL uterus and mammary gland, and that in the male 40 per cent. of all cases of cancer that

NOTES, affects him is to be attributed to the mouth parts—that these two regions, in many ways dissimilar, resemble each other in these-(a) Case of Unusual Size of Fætus, and that they are both modified by the sexual funct- Occipito-posterior Position. tion, one set (uterus and mammary gland) primarily, the other, namely, mouth parts (tongue, On December 17th, 1901, I was called to Mrs. lips, cheek, jaws) secondarily; (b) that C., at 9.30 am. they both undergo marked atrophy dur- Previous History.Seven children born ing

the life time of the individual ; living, two miscarriages. One precipitate lastly, that the stomach (practically the pylorus) labour in which the placenta was born with the comes next in each sex—in the cancer role child and cervix lacerated. and we have seen that though there is here no Labour had begun at 1 a.m the same day. extinction of function or any notable atrophy The os was almost fully dilated and the head of structure, yet that it (the pylorus) is anato- not engaged in the pelvis. The abdomen was

. mically variable and pathologically susceptible, very large. I ruptured the membranes, and and there is some reason for considering it a after waiting an hour and a half, as little "degenerate gizzard.” The deductions to be progress was made, applied the forceps. After drawn from these reflections, while not con- trying at intervals for an hour I made little clusive, are suggestive and tentative, that while progress, and so removed the forceps and any gland-bearing epithelium may become the introduced my hand. I found the occiput was starting point of cancer, yet this is far more turned to the sacrum, so rotated the head with likely to occur in regions where there is special my hand with no difficulty, and then again morphological change, or where there is an applied the forceps, and after a hard pull ancestral basis ; that cancer is perverted gland succeeded in delivering the head. The shoulders formation favoured by senile changes ; that it then refused to move, so I again introduced is the question of senility of glands themselves my hand and found one arm doubled behind rather than of the organism ; that the source

the back. I tried in vain to rotate the of danger is not in the simultaneous decay of shoulders towards this arm so as to bring it to the glands and the organism, but of one before the front, so then hooked a finger into the the other; that nowhere is this condition better axilla, and with great difficulty brought down complied with than in the decay of uterus and the posterior arnı from behind the back. The breast in the "well-preserved” female. This child was then easily delivered, but was dead. would be quite in keeping with what has been It weighed 14lbs , waz 22 inches in length, the stated in an earlier portion of this paper, that it chest measured 16 inches in circumference, and is not improbable that inborn structural peculia- the head 19. rities exercise a wider sway in the causation of The perinæum was not lacerated, and the disease than is generally believed and that these mother has not had a bad symptom since inborn peculiarities having perhaps a morpholo delivery, but had paresis of one leg for some gical or ancestral basis tend to be transmitted to days afterwards. I record the case the offspring. Again since cancer depends so correct treatment in rectifying the occipitomuch upon the age of the individual and history posterior position lead to another difficulty in of the organ attacked, does it not seem im- displacing the arms. probable that infection can be the only factor

ARTHUR H. CLARKE, M.R.C.S. in its production. And if we except Hobart.

as the

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Abdominal Aneurism-Paraplegia- Extensive retroperitoneal hæmorrhage had

occurred, but the exact site of rupture of sac was

not ascertained, nor was the exact section of the J. R., aet. about 48, was seen by me for the aorta affected located, further than that it was first time on 13th September, 1898. He com-close below the diaphragm. Ly proper post

. plained of sudden loss of power in his legs. mortem an excellent and instructive specimen He had had syphilis, and had worked hard as of the results of aneurism might have been teamster and contractor. He had had an secured. aneurism of popliteal artery, which had been

J. A. Tuyne, M.B., C.M. Edin. cured, by ligature of the femoral artery, in the Millicent, S.A. Melbourne Hospital about year 1883. There was no trace of the aneurism in popliteal region, but a linear scar over the position MIRROR OF HOSPITAL PRACTICE of the femoral artery, at the apex of Scarpa's

IN AUSTRALASIA. triangle, was in evidence.

I gave him some potass. iodide. On September 20th he seemned

CRAIGEND PRIVATE HOSPITAL, fairly well. On October 2nd he was complain

SYDNEY. ing more of a pain in epigastric region, and on this occasion attention was specially directed

(UNDER THE CARE OF A. MacCORMICK, to this locality.

F.R.C.S. Eng.) I made an examination, and informed him that he might have an aneurism there. A hard Case I.—Renal tumour, with symptoms remass or tumour could be felt with pulsation sembling renal calculus ; Nephrectomy; X Ray communicated but non-expansile ; no thrill

thrill | burn. could be felt, and no bruit could be heard.

Male, aged 43, was admitted to Craigend This pain troubled him a good deal. He House on August 16th, 1901. Patient had thought relief would be obtained by an aperient, had repeated attacks of pain in the right so I ordered him 2 or 3 pills containing 5 kidney resembling renal colic. A skiagram grains of calomel. I advised him to rest. had been taken which apparently shewed the He took the aperient referred to, but not shadow of a renal calculus. On August 17th, getting any or much result there from, he, in under anæsthetic administered by Dr. Maitland addition, took eight or ten Beecham's Pills, and Gledden, the kidney was exposed through the also went into country against advice. When at usual incision in the right flank, and brought his place in country he became exceedingly up into the wound. A distinct tumour the faint, and his companions thought he was size of half a mandarin orange was found occudying. He was brought back to Millicent over pying the anterior and lower half of the kidney, a rough road, in bottom of a spring cart. apparently a sarcoma. No calculus was found. When seen he presented the appearance of Nephrectomy was decided upon. profound shock, face and conjunctivæ pallid, was completely freed from its bed, and the pulse frequent and feeble, legs completely vessels and the ureter were separately ligatured paralysed, and he had most distressing pain in with catgut, and the kidney removed. A them. I believed him to be dying from rupture drainage tube was inserted into the pouch, and of the abdominal aneurism. He died about kept in for 48 hours. The patient made a 6 a.m. next day. A post mortem examination slow recovery; there was no constitutional was obtained, but performed under difficulties. disturbance, nor any discharge of pus, but the

On opening abdominal cavity a large tissues were of low vitality, and the wound aneurism was found about size of a cricket ball, healed slowly, leaving a sinus for many weeks. apparently entirely filled with firm laminated At the time of the operation there was a large clot. I attempted removal of the aneurism, red patch, looking like a patch of eczema, on the but this ended by pulling it off the spinal front of the abdomen, mostly to the right of column, which formed the posterior wall of the the middle line, which slowly progressed until

a patch of the true skin, several inches in The vertebral column had been croded to diameter, became involved.

The outer porthe extent of penetration of the spinal canal, tion of this slowly cicatrized, but there is still with subsequent paraplegia and accompanying (five months afterwards) a large ulcer on the sensory phenomena from pressure on cord by abdominal wall to the right of the umbilicus. blood. The finger could be placed in the hole covered with a parchment-like surface, and in the spine caused by the aneurism.

with callous edges, which shews little tendency

The organ



to heal. The patient is in a neurasthenic con- presented in the skiagram. That again led to dition, with lowered vitality. He has been the decision to remove the kidney, which was reading all the literature he can get on “X Ray safer in a feeble old man, with a partially burns," and has made up his mind that he will damaged kidney, than to undertake the more not be well for eleven months. He complains conservative measure of uretero-plasty. of pain of a burning, itching character in the abdomen, which interferes with appetite and


Case II.-A “Kink” in the right ureter; AN INDEX OF SYMPTOMS AS A CLUE TO DIAGNOSIS. symptoms resembling renal calculus; nephrec- By R. W. Leftwich, M.D., late Assistant Physician

to the East London Hospital for Sick Children. tomy ; recovery.

Second edition. Smith, Elder and Co., London, 1901. A man, aged 62, was admitted to Craigend This small work has reached a second edition, and we House on October 12th, 1901. The patient must confess some surprise that a book of this nature was a thin, wiry man, and looked as if worn

should command the attention of so large a number of with pain. He had had frequent attacks of book of this kind will not tend to elevate the scientific

medical practitioners. In our opinion, the use of a pain in his right kidney, and a skiagram shewed standing of students or practitioners of medicine. The a shadow resembling that of a calculus. On concluding part of the work on the methods of October 13th an anæsthetic was adninistered diagnosis is much too brief to be of any real assistance by Dr. Jenkins, and the right kidney exposed. one who has received a careful training

at the bedside

to students, and certainly will not be of service to any Some difficulty was experienced in bringing it in the principles of physical examination and diagnosis. up into the wound. No calculus could be felt The multiplication of books of this class is not to be

G.E.R. and the pelvis was explored through an incision commended. in the convex border, with negative results. SYPHILIS AND OTHER VENEREAL DISEASES. By H. An attempt was made to pass a bougie through de Méric, M.R.C.S. Eng. Surgeon to the French the ureter into the bladder, but failed. Further

Hospital, London, etc., etc. London : Bailliere,

Tindall and Cox. Price 5s, net. exploration revealed a sharp “kink” in the

This work of 132 demy octavo pages is divided into upper end of the ureter. The question of trans- fifteen chapters. It is chiefly an elaboration of the planting the ureter to another part of the pelvis author's “ Notes on Venere al Diseases,” published in was discussed. and considering the fact that the 1889; but the two important chapters on the “ Prokidney had been split in the search for a calcu- phylaxis of Syphilis," and the “ Contagious Diseases

Acts,” are new. The author, in the preface, expresses lus, and also considering the patient's age and surprise at the diffidence of medical men in England enfeebled condition, it was thought that removal in publishing works on venereal diseases, and at the of the organ gave him the best chance, es

half-apologetic tone in which they write on them ;

especially when it is considered how much the future pecially as the other kidney was healthy, The health of the individual depends upon a proper vessels and the ureter, below the “ kink,” were treatment. The author has endeavoured to set down separately ligatured with catgut, and divided. in as concise and practical a manner as possible the After removal the kink remained

results of his observations on venereal diseases, both in distinct. very

private practice and at the French Hospital in London, A drainage tube was kept in for twenty-four and it may be said he has succeeded in his efforts. In hours, and the patient made an uninterrupted the first chapter the diagnosis between “bard” and recovery, leaving the hospital in three weeks “soft” chancres, or as he prefers to call them “simple'

or “ local ” chancres, and “syphilitic” chancre; the quite free from his old pain.

former almost always multiple, the latter almost Remarks. In the Annals of Surgery for invariably singie. The author does not lay so much January, 1902, Huntingdon, of San Francisco, stress upon the frequency of a “mixed infection” as reports a case of X-Ray burn which he success- appears necessary, judging from the very large profully treated by excision, and quotes Rudis- portion of apparently simple” chancres (with

suppurating buboes), that is followed by secondary Jacinski, who says that “X-Ray burn is coming syphilis, met with in the out-patient departments of our to be regarded as a misnomer, as the lesion con- Sydney Hospitals. The chapters on treatment will be sists in an acute, sub-acute or chronic necro- found very practical. As to the “ Prophylaxis of biosis depending upon irritation of the peri of preventing the spread of this disease is the rigorous

Syphilis,” the author thinks that the only efficient way pheral sensory nerves with secondary paralysis application of the Contagious Diseases Acts in garrison of the vaso-motor system of affected areas.” and sea-port towns. The experiments of Perry, Laval, It is evident from the low vitality of the Auzias Turenne, Sperino, Vieviorovsky and others

are discussed, and for the most part condemned, as operation wound, in the first case, that the

the author thinks “ that any project of serum therapy deeper parts were affected similarly to the skin

in the direction of immunizing healthy persons against and subcutaneous tissues. The skiagram syphilis had perhaps better be left severely alone.” in each of these cases shewed a distinct shadow In discussing the Contagious Diseases Acts, the author

advocates the establishment of large venereal hospitals as of a calculus, and in the second case induced

near large centres of population where prostitutes could one to split the kidney, as one naturally

go for treatment, and where they would be treated expected to find a stone from the appearances I kindly.


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