deaths from cancer for the census year. Philadelphia (2) has an average death-rate of 2.28 per cent., New York (2) of 2.78 per cent. and Boston has probably even more, since cancer is more prevalent in the New England States than in any other section of America.

No method of treatment has so far been able to stop the onward march of this dread disease. When, in isolated cases, medicine had apparently accomplished a cure of cancer, the result was simply to lull the symptoms for a time until they would burst forth with increased force. Surgery did little better, for the knife, as wielded until a very few years ago, did not go to the root of the trouble. Disappointed in this result, some of the best minds in the profession turned their attention to the cause of this formidable disease. Pathologists and surgeons have vied with one another to find the clue to a more rational treatment of cancer than has been in vogue heretofore. Bacteriology has offered a helping hand to fathom the cause of this dreadful disease. Since Nepven (4), in 1880, first made the statement that bacteria are found in cancer, and in 1889, Darier discovered psorospores in Paget's disease, Colmheim's embryonic theory of tumors has received its death-blow and the parasitic theory of malignant disease has gained a great many believers and ardent workers. Scheuerlen, Kubasoff, Verneuil (5) ascribe the etiology of cancer to bacteria. Adamkievicz (6) to the coccidium sarcolytus; Van Nissen (7) to the claspodium cancerogenes; Plimmer (8) to certain protozoa, which he had found in every instance in fifty-three cases. Many other investigators delved in the laboratory of cancer juices to discover the etiological agent. Some found granular bodies, like Thoma and Henklom, Podwyssocky and Sawtschenko (9); others found hyaline bodies, like Torok (9); others again saw plasmodia, like Browicz and Stroebe (9). Foa, Wickham, Ruffer, Soudakevitch, J. Jackson Clarke, and others. found parasitic organisms. Whether this babel of names is the natural result of different and apparently contradictory observations or whether these many names are so many denominations of one and the same thing, may be left for others to determine. It may also be an open question whether the diverging results are not due simply to optical illusions or to the yet insufficiently developed microscopical technique, but that this remarkable activity of men who have all the facilities for original microscopical work at their

(1) Philadelphia Medical News, 1894, p. 437.

(2) American Medical and Surgical Bulletin, 1894, p. 1457. (3) Warren, Surgical Pathology.

(4) Lemaine Medicale, No. 50, P, 599.

disposal denotes their firm belief in the parasitic nature of cancer, they leave no one in doubt. Prof. Schroen (10) studied phagocytosis in carcinoma, and he asserts that he could see the leucocytes penetrate into the epithelial cells and carry off the parasites they found there. And if we learn further from such an authority as Metschnikoff (11) of Paris, that there is in rabbits a peculiar parasitic disease known as coccydiosis, which resembles cancer in many respects, it seems almost a certainty that parasitic bodies exist in the cells of cancerous tissues.

The uninitiated ask us of what use are all these investigations and what difference it would make in the treatment of malignant disease if it should be finally settled that a microbe is at the bottom of cancerosis; but we know such a discovery would make all the difference between a vague groping in the dark and a fully recognized scientific fact that would stand the test of confirmation, and it is now a matter of common experience that if etiological factors do not influence the treatment of a full-grown disease the simple knowledge of its cause places it among the preventable diseases that attack the flesh of man. For when we know what causes a disease we have already learned how to prevent it. Only a few years ago, tuberculosis was regarded as a constitutional disease, sent into the dwellings of man as his most deadly foe, against which no effort was of any avail as soon as the disease had lodged itself in the delicate apices of lung-tissue, and with the exception of a few extremely fortunate cases one-sixth of the human race was laid in the grave, a sacrifice to the idea that the disease was constitutional, was therefore hereditary, and no drug, of course, could be found to eradicate the hereditary or inherited havoc in the human body. To-day, tuberculosis has come to be one of the preventable diseases. Why? Because it has been proved that a bacillus is at the bottom of it, that this bacillus finds a ready entrance into an injured mucous membrane and hence into the deeper tissues, that an injured mucous. membrane is often the consequence of a simple catarrhal condition, that the bacillus is finally expectorated and if such expectoration is carefully guarded from drying and evaporating, is, in short, sterilized, it will harm nobody and will be laid at rest with its victim. (5) Warren, Surgical Pathology.

(6) Wiener Medizinische Presse, February, 1894.

(7) Centralblatt fuer die Medizenischen Wissenschaften, No. 21, 1894.

(8) Medical Record, Feb. 4, 1863, p. 146.

(9) International Journal of Surgery, June 1893.

(10) Philadelphia Medical News, 1894, p. 437.

(11) Medical Record, Feb. 4, 1893, p. 146,

A few months ago, I was called to attend a young man in the third stage of consumption. A brother of his had died less than a year before, another a year previous to that. Father and mother were and are perfectly well, there was no consumption on either side of the family, and yet two children were dead, a third was only a few months more for this life, and what was still worse a sister and a younger brother were fast going the same road. When I entered the room on my first visit the patient sat on a couch and before him were spread two or three sheets of newspaper and on these every little while a lump of his bacillus teeming sputum was deposited in order, as his mother said in her inimitable shrewdness, to save the carpet. That explained the condition of the family. It was not necessary to describe the disease of these stricken people to a hereditary tendency in the children. The first boy had acquired his disease in a tin shop and, probably, from a fellow-workman, and the sputum on the newspaper sheets did the rest, for to my surprise not one of the attending physicians, before I saw the third boy at death's door, had thought that there was something else to be done than the saving of the carpet. But we know that in the proper disposal of the sputum lies the safety of those that surround a consumptive, and in this family alone the disregard of this most important rule cost practically the lives of five human beings. Tuberculosis is now properly classed among the acquired and, therefore, preventable diseases, and the idea that it is inherited fortunately belongs to the past, and though we may not be able to cure a tuberculous patient any more than before we are able to protect those that care for such patients and even the patient himself from re-infecting his body with the death-giving vegetable organisms he expectorates in his sputum. If this is the case with tuberculosis, the most dreadful foe to the flesh of man, why should not the knowledge of at cause do the same for malignant growths?

The idea of heredity has warped the mind of man too much and has too often staid the hand of the surgeon when he could have dealt out life so easily, and his inaction or insufficient action nursed the death-preparing growth. Mafucci (12) studied the question of embryonal susceptibility to infection and he came to this most significant conclusion concerning heredity: The embryo of a chick kills the bacilli of tuberculosis that threaten its life and though born marasmic as the result of the struggle, yet the chick has not inherited the disease of its parents, for after a long time it can die without tuberculosis of the organs. There is no similar experiment (12) Annals of Surgery, Vol. xx, No. 4, 1894.

with cancer, but if the experiments of Mafucci mean anything they mean that the fate of the embryo is not so much decided in utero as outside of it; that the life of the young depends on the care that is spent in their bringing up; on the surroundings, whether they are reared in plenty or in want, whether they are matured in sunshine or in damp cellars, whether nature sends her smiles on the nursling or condemns it to early senility.

Dr. Snow (13) who, in the Cancer Hospitals in London, has had as much experience with cancer as any other man, says that the belief in heredity is derived merely from popular traditions and is wanting in any sound basis of scientific proof. Sir James Paget (14), the most eminent believer in the constitutional origin of cancer, could trace heredity in only one out of every three cases; while Mr. Sibley (14) traced it in one out of every nine; and Thomas Bryant (14) declares that in 222 of his cases heredity was traceable in only one out of every ten instances. Of 534 miscellaneous cases, Daniel Lewis (15) traced 33 to heredity, i. e., six in a hundred; and Gross (16) found in 1164 cases of carcinoma mammæ only 55 or 4.72% of hereditary transmission. These are figures that tell a most important story. They tell with authority that heredity is not to be considered a decisive cause in the formation of cancer. Heredity is, perhaps, more an incident than a cause, for in many other affections, even the innocent affections of whose local infectious character none of us is in doubt, an equal proportion of near relatives may be found to have been ill, and this would be sufficient ground for easily convinced people to call such diseases hereditary. As physicians, however, it becomes us to stop a moment and consider the question, for extremely practical issues are involved and the views now common too often lead to unfortunate results.

If heredity exerts such a determining influence on the formation of cancer, how is it that cancer attacks with predeliction those structures of the body that are most subject to external irritation? There is the pylorus, over which the most irritating substances in the shape of indigested, badly masticated, badly digested food pass into the intestines; the portio vaginalis uteri with its accidents of married life, and parturition; the mammary gland with its incidents of lactation and friction; the rectum with its fissures and hemorrhoidal propensities; the lips, the tongue, the buccal tract, with their cracked and illy-cared-for mucous membranes; the scrotum with its liability to friction; the gall-bladder (17) with its gall-stones. How is it that an inveterate smoker of clay-pipes is especially prone to cancer of the lip, a stone-mason to cancer of the lung, a chimney-sweep to

cancer of the scrotum, a laundress (according to Dr. Snow) to cancer of the breast? Why is a married woman more liable to cancer than a virgin? Why will a jagged tooth plant its imprints on the tongue and cause this organ of speech to become cancerous? Simply because anything that will maintain a constant, though ever so slight a degree of undue vascularity of a part favors the development of a growth.

If heredity be such an imposing cause of cancer, how is it that cancer appears most often at a time of life when organs have passed their most active stage and the vitality of tissues has become conspicuously impaired? Because, as Dr. Snow so well says: "Malignant lesions are especially prone to attack degenerating organs and degenerating people" (18), and it is in the nature of things that we all degenerate physically sooner or later as our fathers have degenerated before us and their fathers before them. This physical degeneration also explains why cancer has increased to such a degree. If heredity were the determining factor in the causation of cancer, why did malignant disease wait these thousands of years to show itself in such a dangerous increase? Cancer, according to Picot (19), is a much less common disease among the aborigines in Asia, Africa, North America, than it is in Europeans and their descendants. It is easy to say why. First, because heredity as the cause of cancer has been too much exaggerated. Secondly, because our civilization with its life of competition, its malignant warfare for the bite of bread that is needed to keep up the strength of the body entails such a hardship, such a toil, such privation, such laborious and dangerous occupations, such anxiety and care, such mental distress, as the world has never known before. As a consequence of this ceaseless work and worry the organs that have by nature a certain time to run on and a certain to run back become old too young, and enter upon their stage of devolution before nature is ready to make this devolution a perfectly normal step.

In this stage of abnormal devolution, the tissues need only to be injured, or subjected to a continuous irritation, or be the seat of abnormal conditions in which the epithelial elements are in excess, and all the conditions are present for a growth to flare up in its worst (13) Medical Record, January 20, 1894, p. 93.

(14) Thomas Bryant, Surgery.

(15) Daniel Lewis, Cancer and its Treatment, p. 114.

(16) Warren, Surgical Pathology.

(17) Johns Hopkins Hospital Bulletin, 1894, V. No. 41, p. 74-Dr. Delano Ames says that gall-stones probably bear a causative relation to cancer of the gall-bladder: Gall-stones are found in 91-93% of cases of such cancer.