Columbia ^ntberiStt|) ^tfnma Ktbrarg (&vven by /^^r-^JUVMIJ?^ v.. Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/cancerstudyofthrOOpark CANCER A STUDY OF THREE HUNDRED AND NINETY-SEVEN CASES OF CANCER OF THE FEMALE BREAST WITH CLINICAL OBSERVATIONS BY WILLARD PARKER, M.D. NEW YORK & LONDON G. P. PUTNAM'S SONS" Cfjc Enicfecrliocfter i|rcss 1885 COPYRIGHT BY P. PUTNAM'S SONS Press o£ G. P. Putnam's Sons New York PREFATORY NOTE. During the few years preceding his death, my father, relieved in large part from the arduous labors of active professional life, occupied himself in gathering together and classifying the cases of mammary cancer that had come under his observation, amounting in all to nearly four hundred. Before the work, however, had been completed to his satisfaction, his health and strength broke down, and he was able to do but little in its revision. As it was his wish that the record should be published, I give it to the public nearly in the form in which he left it, and would ask that it be regarded, not as an elaborate work, but as embodying some of the observations made and conclusions reached during a long and busy profes- sional life, by one who combined with an exceptionally large experience, strong, practical common-sense. WILLARD PARKER, Jr. New York, May 20, 1885. INTRODUCTION. The subject of cancer is one of the most interesting in medical science, and one which has received especial con- sideration by some of the ablest thinkers and writers in the profession. But notwithstanding all the study which has been given to both as regards its histology and its clinical characteristics, its etiology is still unsettled. More than half a centur}' ago, when I commenced the practice of surgery, the question w^as altogether in a crude state, and whatever positive opinions were held by the pro- fession, they could not be regarded as having the most ra- tional foundations. One reason for the unsettled state of opinion was the lack of subsequent histories of cases which had been operated on, and which were often wrongly reported as cures as soon as the patient had recovered from the operr^tion. Another cause of erroneous opinion was the lack of that histological knowledge which now shows that in most cases of cancer there is, at an early period, a degree of infiltration of the cancerous elements be3^ond what was formerly suspected. Errors also arose from the probable inclusion of cases of adenoid or other tumors, which had no malignant element in them. It was with a view of collecting information which 2 INTRODUCTION mio"ht at some time, combined with the observations of others, throw more Hght upon the treatment — and perhaps also on the nature and the causes — of cancer, that I began to record various points in the cases which came under my observation. Had it been possible to anticipate the ques- tions that have since arisen in regard to the conditions under which cancer is developed, I should, no doubt, be able to look back with greater satisfaction upon my work. I now offer my contribution, remarking, however, that whatever value it may have depends more upon the ob- servations of active practice than upon any elaborate re- search in the pathological laboratory. If it shall aid others in arriving at conclusions as to the treatment of cancerous patients, and as to the best mode of living to avoid possi- ble or probable causes of the disease, I shall feel that my labor has not been in vain. Of the records which I have kept, those which describe the disease as occurring in the female breast have been rather the more complete; and in treating of the subject. I confine myself to these cases, though the remarks I may have occasion to make will apply to cancer in general. It would be idle to discuss the symptomology of cancer, for that subject has been treated exhaustively by others. Let it suffice to say that we are here dealing — all doubts reo-ardino- diao-nosis being; laid aside — with cancerous tu- mors of the female breast, which may or may not implicate the tissues above and beneath it, which cause peculiar lan- cinating pains, which generally ulcerate at a later period, often involve other tissues and organs, and finally carry the patient off. Every organ or part of the system derives from the blood, and assimilates, the elements which are necessary to its own existence and growth; that is to say, bony tis- sue assimilates the material for bone, muscle assimilates A STUDY OF CANCER 5 the material of muscle, and connective tissue the material of connective tissue; and all these processes of assimilation are performed by virtue of the power which resides in the cells which form the distinguishing and principal portion of each tissue, to reproduce themselves by multiplication, under the normal influence of the nervous system. Under ordinar}' circumstances these assimilations go on without deviation from their normal types. But in consequence of certain influences which have a tendency to pervert the rela- tions between proliferating cells and the terminal nerves, it seems that those cells may assume an abnormal condition; in other w^ords, that they pass into cancer-cell prolifera- tion. The connective tissue, instead of forming connec- tive tissue from the indifferent cells and reproducing itself according to a normal type, undergoes a retrograde devel- opment, and is itself converted into indifferent cells, or into the group of so-called cancer-cells, found beyond the limit of true epithelial transformation. We may therefore regard the formation of cancer-cells as a process of mal-assimilation. The fact that cancer has alwa3^s, for a greater or less length of time, a merely local manifestation, only shows that the tissues of the part are the essential factors of the diseased growth. More- over, we never have a primary formation of cancer except in an organ whose function has been impaired or per- verted. After the formation of the primary tumor, how- ever, the blood becomes contaminated with infectinsf elements, which, being conveyed to other parts, cause the cells of these parts to assume that peculiar phase of devel- opment which is called malignant. Transportation of tissues is undoubtedly effected in the lymph current as well. The cancer cell probably has the power of producing its like by assimilating the nutritious elements of the 4 INTEODUCTION blood, as other tissues have, and it may be considered as having a life peculiarly its own. Not having, however, a normal function to perform, like other cellular tissues, it is not, like them, subject to wasting metamorphosis, and therefore it tends to keep adding to its bulk. Thus it has a double mode of growth in its type: (i) by reproducing itself, and (2) by causing, through infection, a growth similar to itself in adjacent healthy cellular elements. Malignant growths invade the surrounding tissues, and in general are to be distinguished by this peculiarity from tumors which displace the adjoining structures. This view of the subject inclines me to think that there is truth in several of the different theories which have been advanced as to the genesis of cancer. The doctrine of Virchow, that the connective tissue corpuscles are the starting-points of the new pathological formations, is, I believe, true just so far as connective-tissue cells may develop cancer cells. The theory of Thiersch and Wal- dyer that cancer cells are a development of the lower layer of the epidermis or of the epithelium of glandular struc- tures, and that this growth invades the connective tissue; or the further extension of the theory by Waldyer that cancer may proceed from any epithelial structure, I be- lieve to be perfectly true as far as these structures have the power, under certain abnormal circumstances, of tak- ing on cancerous development. But the theory is quite insufficient when it seeks to limit the cancerous prolifera- tion to the epithelium or to the connective tissue. Koster, of Boule, considers that the so-called " cancer cylinders " are sometimes produced by a multiplication of endothelial cells within the lymphatic vessels; while Classon thinks that the wandering white blood corpuscles, by passing through the walls of the blood-vessels into the lymphatics, are the elements from which cancer cells spring. Dr. A STUDY OF CANCER ^ E. W. Hoeber, of New York, has made some observa- tions " on the first development of the cancer elements," in which he claims to have demonstrated that their growth springs from the basis subtance of connective tissue. ANALYSIS OF THREE HUNDRED AND NINETY-SEVEN CASES OF CANCER OF THE FEMALE BREAST OCCUR- RING IN THE PRACTICE OF THE WRITER. In order to present the subject concisel}^ I have ar- ranged my cases in tables which will be found at the end of the volume; while, as the discussion progresses, I shall relate the histories of a few of the typical cases more in detail. The records begin in 1830 and are continued down to 1883. After discarding a number which do not present sufficient data to be of value, the whole number recorded is 397. For the sake of convenience, principall}" in examining conditions relating to etiology, they are divided into nine different groups; not according to any classification founded upon minute anatomical structure, but with re- gard to certain relations to physical constitution, dura- tion, course of the disease, etc. The nine groups, as I have classified them, are as fol- lows: Group I. Cases characterized by a tumor, small and generall}' painless for a number of years, which frequently came in the ;2/ want of vitality in a person of strumous tendency seems \ to arrest the rapid cell-development so characteristic of j cancer. The following case presents an additional char- 1 acteristic of cancer of the breast in women of consump- tive taint, that of a tendency to sloughing. Case 22. — A widow, forty-seven years of age, who had never had a living child, but had had a still-born child ten years before (at the age of thirty-seven). Soon after, a tumor made its appearance, during the involution of the mammary gland. It continued as an apparently benign tumor till about one year before amputating. It then began to grov/ rapidly, with inflammation in the region of the nipple, which was destroyed by sloughing. In Novem- ber, 185 1, the breast was removed at the College clinic, and the wound healed and remained in an apparently fair condition till the following Christmas, when it broke out and discharged as before, and had an intolerable stench. In March, 1852, a hard lump, resembling the core of a boil, was removed, and in the September following she returned to the clinic with the wound perfectly healed and in good condition. She had a consumptive taint, but had no relatives in whom cancer could be traced. She died several years afterwards, of cancer, at Bellevue Hos- pital ; the duration of the cancerous growth thus being, according to estimate, about ten years. Here we have a 1 6 GROUP IT typical case of sloughing cancer, where it would seem that the infiltration of the malignant growth was circum- scribed by inflammation and rapid suppuration, with partial sloughing. This tendency, according to my obser- vation, is more marked in persons who have strumous constitutions. The following may be taken as a typical case of chronic cancer, having a long benign period in a person free from consumptive taint. Case 32. — Nov. 21, 1855. I^ine years before this time, a single lady, thirty-eight years of age, discovered a small lump in the left breast. It developed rapidly during the six months previous to date. The tumor was .removed, and was found to be cancer of the .scirrhoiis variety. The wound healed kindly, and the patient was in good health, without any return of the disease, eighteen years after the operation, and twenty-seven years after the first appear- ance of the tumor. This lady, although well developed, was not as fleshy as the majority of subjects of cancer of the breast. Summing up these data: There are included in this group sixty cases, and of these seven can count ancestors who have had cancer; eleven have had ancestors who were consumptive; and three trace both cancer and phthisis in their families. About one half were fleshy or of full habit. Fourteen had received a blow or other injury. Two had been burnt by caustic. Twelve had been subjects of mammar}' abscess. Three had had mastitis, which did not suppurate. Four had dysmenorrhoea. Six had irritation and other uterine irregularities, and one a still-born child. Fourteen had been the subjects of great mental affliction. A STUDY OF CANCER 17 The average duration of the tumor in a benign condi- tion, in forty-two cases which permitted a fair estimate to be made, was 10.9 years; the average age at which the apparently benign tumor commenced was 34 years; at which cancerous development commenced, 46 years. The cancer became acute in seven of the cases; and the number of cases in which there was no injury or derange- ment of the reproductive system, or any assignable cause, was eleven. The average duration of cancerous growth in twenty- nine cases, in which it could be estimated with any exact- ness, was 6.3 years. The average duration of life after amputation in eigh- teen cases was 5.2 years. Group II. — Tumors -which assumed a malignant character very soon or immediately after their discovery., in case of ifijury., seeming to follow it immediately ', and ivhich., moreover^ had a tolerably long course. In this group there are thirty-eight cases. The chief difference between ni}^ first and second groups consists in the duration of the benign state of the tumor. Among the thirt3^-eight cases in Group II., five counted progenitors who were the subjects of cancer, and five had relatives with a phthisical history. About one half were fat or fleshy. Eleven had received blows or injuries in the seat of the cancer previous to its development. Three had had caustic applied, which may or may not have pre- ceded the malignant growth. Three had had mammary abscess, and four had had difficulty in nursing. Five of them had been the subjects of great mental affliction; while in the remaining cases no cause could be assigned. These ratios agree pretty well with those in the first group, and indicate a similar mode of development. 1 8 GROUP II The average age of the subject at the beginning was 45-9 3'ears, and the average duration of the tumor twelve, years. The average duration of life after amputation, in those cases where a fair estimate could be made, was 11.5 'years. In the thirty-eight cases comprising this group there were only five — or about one-seventh of the whole — who could point to relatives who were subjects of cancer. There were only five who had consumptive relatives. Regarding the cases in this group as not essentially dif- ferent in their origin and mode of development from those in the first group, we may 3^et assume that their earlier cancerous development was due to the lesser influence of tubercular diathesis. Attention is called to the small number who had " cancer relatives," the ratio being onl}'' about one ninth, which is below the ratio which we should expect to find if we were to estimate the number of persons in the community in general who could trace cancer amono^ their relatives. A much greater proportion of these cases than of those in Class I. were among persons in good circumstances. Many of them lived in luxury, and took but little exercise in the open air, living in overheated, and, as is not un- common, in poorly ventilated rooms. In brief, for six sevenths of the number comprising this group, there were causes enough that tended to produce cancer, without taking into consideration the influence of heredit}^, had such influence been traceable. Case 3. — June 3d, 1832. A married lady, 42 3^ears of age, the mother of several children. She had a tumor of the left ring-finger two years previous to this date. At the latter time she presented a scirrhous tumor of the left breast, which had all the characteristic symptoms of that disease. It was amputated. The wound healed kindly; A STUDY OF CANCER I9 she lived twelve years longer, and then died of secondary cancer of the liver, which weighed twelve pounds at the autopsy. This lad}^ had no relatives who were the sub- jects of either cancer or consumption, as far as could be ascertained. She was robust and healthy until the disease was far advanced. Case ^. — May 9th, 1835. A married lady, 38 years of age, and the mother of eight children. Tumor of righ^t breast; no involvement of axillary lymphatic glands. A maternal aunt died of cancer of the uterus; another, of cancer of the eye; and a sister, of cancer of the breast. Two cousins also, on the maternal side, had died of can- cer. The tumor was discovered eighteen months before the time when I first saw her. This breast had been the subject of suppurative inflammation during lactation, and had never performed its functions w^ell. I removed the tumor, and she made a good recovery. She called on me in New York City twentyjz&gyen years afterwards, and was feeling well, although a small cancerous tumor had appeared on the right side of the neck. Groii'p III. Cases tuhich ran an exceedingly rapid course^ sotnetimes ending" in death in seven or eight ?nonths from the discoveiy of the disease', and tvhich ivere as a rule of the soft, or encephaloid, variety of cancer. These I have called acute cases. They include sixty- two cases, of which six had relatives who were the sub- jects of cancer (viz.: cases Nos. 113, 136, 159, 174, 302, 349). Thus about one tenth of these cases had " cancer- relatives,"' if I may be allowed to use this term, signifying a cancerous history among ancestors. There were ten, or one in 5.5, who could point to consumptive relatives, and in three cases there was a family history of both can- 20 GROUP III cer and phthisis. Sixteen, or about one fourth, had re- ceived blows at the seat of the tumor, and in four the tumor developed in the situation of abscesses. One had been the subject of dysmenorrhcea, and one had had diffi- culty in nursing from the breast. Average age at com- mencement of disease, 43.5 years. Average duration of disease, 12.5 months. Average duration of life after operation, seven months. Case 7. — April 8th, 1841. This lad}^, forty-six years of age, discovered a tumor in the right breast five months before consulting me on the above date. It was growing rapidly, the lymphatics in the axilla were enlarged, and there were all the symptoms of a rapid development of cancer. The breast was removed, but the progress of the disease was not arrested. The patient was soon attacked by severe pain in the spinal cord; the cancerous growth returned in the cicatrix, and she died in less than five months after the operation, with secondary cancer in various parts of the body. She was very fleshy, belonged to a health}' family with no record of cancer or consump- tion, and lived rather sumptuously. There is no record of a blow, abscess, or other exciting cause. That there was some source of irritation in the mamma, however, is scarcely a matter of doubt. Under the present conditions of societ}', there are very few perfectly natural cases of lactation, and as a rule, women who have children have more or less irritation of the mammary apparatus. Case 191. — April 6th, 1868. A German lad}', the mother of several children, forty-three years of age, very fleshy and robust. No cancer or consumptive taint. Some years ago she had an abscess in the right breast. About two months ago a tumor began to grow in the seat of the abscess, and is now developing rapidly as a medullary cancer. The axillary lymphatic glands are involved. A STUDY OF CANCER 21 The entire breast, as well as the indurated Ij^mphatic glands, were removed, but the disease returned in the cicatrix and contaminated the whole system, and the pa- tient died in thirteen months from the discovery of the disease, and eleven months after the operation. Case 34. — February 2d, 1856. A lady, forty-two years of age, the motlier of eleven children, and belonging to a very healthy family, with no trace of cancer or consump- tion, discovered a tumor a short time before the birth of her 3'oungest child, which is now six months old. It pre- sented all the appearances of a rapidly developing medul- lary cancer. The axillary lymphatic glands were enlarged, yet an operation was decided upon. She died in four months afterwards, eleven months from the beginning of the disease. This patient was very fleshy, had good gen- eral health, a good appetite, and was generous in her habits of eating. A noteworthy fact in regard to these cases of acute cancer is that, in a great proportion of them, the Ij^mphatic system was very early involved; before, or, in other words, the operation was performed after, the lymphatic system had become implicated. Probabl}-', indeed, the lymphatic system had become involved in all of them, but the fact was not manifest. Whenever a case can be pro- nounced one of acute cancer, it is probable that an opera- tion, whether the axillary glands are involved or not, will be of no avail. Another remarkable fact to be noticed in this group is the great proportion of married to single women. But let us not be misled by supposing that married life favors the development of acute cancer. The more logical inference is, that women of greater vitalit}^ have acute cancer oftener than others, and these women are not so likely to remain single as those having less vitality. 22 GROUP III What significance is there in the fact that thirteen out of the fifty-five married -women and Avidows never had children, in other words, Avere barren, or in a condition not to conceive? Is it to be inferred that child-bearing lessens the tendency to cancerous development? By no means. On the contrary, in any individual, or number of individuals, pregnancy and child-bearing increase the risk; this is borne out by statistics and by common observation. , "What then is the meaning of this seeming paradox? Sim- plv, that a condition of the system not favorable to con- ception, that is, the existence of dysmenorrhcea, uterine displacement, epithelial irritation, uterine catarrh, presents the conditions which are favorable to the development of j cancer of the breast, because these are productive of mammarv irritation. Now the question arises, does pregnancy, in the case of uterine disease, increase or diminish the risk of ac- quiring cancer? Observe that this is a difierent question from that whether pregnancv increases the risk in a fe- m^ale. The answer, however, will probably be similar, that is, that the risk is increased, and to a greater degree than in the case of a healthy woman, because the irreg- ularities of function connected with child-bearing are greater than in a healthy woman. Yet pregnancy and child-bearing Avill not be frequent causative factors if the laws of nature are well observed, and if the patient re- ceives such treatment and care during the lying-in period as lessen the chances of irregularities of function. Group IV. — Cases of cystic cancer {cysto-scirrlius) . There were thirteen cases of this variety of cancer, and among them only one ('X0.32) who could point to a rel- ative laboring under the disease; and only one who had consum^ptive relatives. As a rule the patients in this A STUDY OF CANCER 23 to group enjoyed good general health. Seven are recorded as having received blows at the seat of the tumor; one had mammary abscess, one dysmenorrhoea, one had been operated on by caustic plasters, and one had had great mental affliction. Ten of the thirteen had a record of some exciting cause. The average age at the com- mencement of the disease was 52.5 years, and the aver- age duration of those cases that had a full history was 5.6 years. Two of the subjects are still living. All had borne children except No. 368. Whether the experience of others will indicate that the cystic form of cancer com- mences to develop rather later than other forms I do not know. Case 69. — March 16, 1861. A lady fifty-one years of age, the mother of several children, of strong constitu- tion and full habit of body, had several 3'ears before re- ceived a blow upon the right breast, which at the time gave much pain, and not long afterward developed into a cystic tumor. The tumor and the whole gland were extir- pated March 16, 1861, but the disease recurred in the cica- trix, and a second operation was performed in February, 1862. The axillary lymphatic glands were not involved at either operation. Nevertheless, the disease went on unchecked, and the patient died March 6, 1863, three years after its discovery, and two years after the first operation. This case was somewhat more rapid in devel- opment, and hastened to a termination rather sooner than the other cases of cysto-scirrhous tumors. The patient was, however, younger than most of the other subjects of this form of cancer, with the exception of Case 92, which was a cystic form occurring in a woman thirty-two years of age. Case 74. — July 6, 1862. A lady sixty-nine years old, very fleshy, the mother of several children, and having 24 GROUP V always enjoyed good general health, had received a blow upon the left breast three years previously, that is, at the ao;e of sixty-six, which was followed by a tumor that at the ao-e first named began to show signs of malignancy. It was another case of cysto-scirrhus; and the patient died after five years' malignant duration of the tumor, without an operation having been performed. Ten years after the death of this patient, a daughter became the subject of o-eneral cancer, in which the skin was extensively in- volved. Case 94. — May 5, 1S63. A lady seventy years of age, of full habit and of good general health, physically sound, with no cancerous or consumptive taint, and belonging to a lono--lived family, received a blow upon the breast which caused much pain. A cyst soon developed, which in about five years showed evidences of a malignant na- ture. No operation, however, was performed, and she died twelve years after receiving the blow, or seven — perhaps eio-ht — years after the commencement of the malignant growth. This I regard as a typical case of cysto-scirrhus in an old lady. From my own observations I am led to think that scirrho-cystic tumors generally develop at a later period than other forms of cancer, and are proved to follow blows, without which their occurrence would be doubtful. Group V. — Cases of ordinary sciri'hus of the breast -which have not been i?icluded in Group I. or in Group II.: including the cases having a benign period at their commencement. The cases placed in this group form the greatest num- ber; but they have comparatively little individual inter- est, from the fact that many of the most significant cases have been separated from them. They furnish — in com- A STUDY OF CANCER 25 mon, however, with the mass of the cases contained in all the other groups — evidence of the frequent commence- ment of cancerous tumors in the seats of injuries, and of a decided tendency towards an abnormal development of epi- thelial structures in persons of full ph3'Siqiie and of luxu- rious habits of living. There are 221 of these cases, among them 83 whose history is completed, and in which the duration of the malignant growth can be estimated. This is placed at 2 years and 10 months. Average age at commencement of growth, 47 3'ears and 5 months. The average length of life after operation, in 50 cases, was i year and 4 months. The number having " cancer rela- tives " was 28; having consumptive relatives, 34; and 4 furnish histories of both cancer and phthisis. Of these cases, 44 of the subjects were fat; 43 were fleshy in habit, and 29 well developed and strong, making in all 116, or over one half of the whole, who were persons of more than average physical development. There were 30 who were thin or delicate; while in the remaining cases no record of physical condition of the general system was preserved. The record shows that 53 had received blow^s at the seat of the tumor, and 12 had been the subjects of mammary abscess at the seat of the tumor. In 20 of the cases there had been miscarriage, or dysmenorrhoea. Caustic had been used in 4 cases, and 47 had had great mental affliction. There were 136 cases in which a rec- ord showed that the patient had received either a blow or an injury of some kind, had had an abscess, or had suf- fered great mental affliction. In several instances two or more of these exciting causes were present in one subject, but each case represents only one person. There are, therefore, only 85 cases in which no record of exciting causes had been made, but we have every reason to be- lieve that such causes did exist, unknown, in a majority — 26 GROUP V perhaps in all — of these remaining cases. The axillary lymphatic glands were involved at the time of observa- tion in 1 02, and not involved in 106 cases; and in 13 there is no record. Several of the cases, the subjects of which are now living, are placed in this group, as may be seen by referring to the table, but they are not counted in mak- ing up the average duration, and in time they might fall into other groups according to later history. Case 51. — Dec. 28, 1858. A lady thirty-nine years of age, strong, of full habit and good general health, the mother of several children, the youngest seven years of age. While nursing the youngest child she received a blow upon the left breast, which caused much pain, and resulted in the formation of a tumor which in about a year and five months afterwards developed a malignant growth. It then began to give trouble and to cause severe lancinat- ing pains. The axillary lymphatic glands were indurated at the time of observation, but an operation was decided upon, and the whole gland was removed. The wound healed kindly, and the disease made but little apparent progress for eight or nine months, when the Ij'mphatic system became more rapidly involved, and the patient died in a little over two 3^ears after the operation. An autopsy revealed cancerous development in the liver, as the principal seat. This patient had no cancerous or con- sumptive relatives, as far as could be learned. She had been a hearty eater, and had dyspepsia. Case 117. — June 18, 1864. An unmarried lady, forty- two years of age, well developed and strong, with good general health, and with no record of cancer or consump- tion among blood-connections, received a blow about eight months before date, which was followed by very severe pain. At the same time she was much distressed at occurrences which took place during the civil war. A STUDY OF CANCER 27 The tumor began to develop in about four months after she received the blow, and in its site. The axillary lym- phatic glands w^ere enlarged at the time she consulted me, but it v^as decided to amputate. The entire breast was removed; the wound healed; but, after six months, the disease returned in the cicatrix and skin, and the patient died in the spring of 1865, about one 3''ear and four months after the discovery of the tumor. Case 169. — April 14th, 1867. A lady, fifty-two years of age, who had lost her husband a month previously, had a painful tumor of the right breast, which had begun to give trouble three years previously. She consulted me for a diao^nosis, which was that the tumor was a cancer. She sailed for Europe in May, 1867, and consulted M. Nelaton, who amputated the breast in September of that year. The wound healed, and she returned to the United States the latter part of the following October. When she arrived home the disease had begun to return, and she died of general cancer in May, 1868, about eight months after the operation. The tumor was encephaloid, although its duration was about four years. The axillary lymphatic glands were involved at the time of the opera- tion — indeed, were affected when she consulted me, in April, 1867. Her health had always been good, except that the menstrual function was irregular and painful; and during this period the tumor swelled and gave her much pain. Her husband had been sick a long time, and her care and anxiety had been very great. She had never conceived, and I believe these were sufficient traceable causes for the malignant epithelial growth. Case 183. — November 9th, 1867. A lady, forty-eight years of age, the mother of five children, had, seven years ago, an induration of the uterus, accompanied by an ex- ceedingly fetid discharge, and the affection was pro- 28 GROUP VI nounced cancerous. The actual cautery was applied on six different occasions, and the disease receded. About ten months before the date given, a tumor appeared in the left breast. During the recession of the uterine disease, her health, which had been very good, became rather delicate, but she improved about the time of the appear- ance of the tumor in the breast. The axillary lymphatic glands were enlarged, and no operation was advised. The disease progressed in the usual manner, and the pa- tient died. in the fall of 1869 of general cancer. The dura- tion of the malignant growth cannot be estimated in this case, as it is uncertain whether the uterine disease was cancerous, or whether the irritation it gave to the mam- mary gland was a cause of the cancer in that organ. No cancer or consumption was traceable among her relatives. Group VI. Women U7tder 35 yeais of age. The epithelial tissues possess more vitality in young than in old persons, and it would be expected that can- cerous proliferation would be more rapid in the young than in the old. This has been verified by general observa- tion, and my cases point to the same conclusion. Sixteen — or about one third — of the patients belonging to this group were decidedly fat, and sixteen of the remainder were full or fleshy; all, or nearly all, of these were women of more than ordinary physical development. Sixteen were cases of acute cancer. Of the thirty-two married women and widows, six were barren, and several had only one or two children. For instance, Case No. 342 w^as that of a lady thirty-three years old, married several years, but having only two children, the youngest five years old. There is no record of menstrual irregularity or of uterine disease; yet notwithstanding the want of positive evidence it could scarcely have been otherwise, or she would have had A STUDY OF CANCER 29 more children. She lived generously and had dyspepsia, but was otherwise in very good health. A grandfather was said to have had cancer of the lip. Case No. 25. — July 17th, 1852. A lady twenty-eight years of age; large, fat, well-developed, and in good general health. She had, however, never been pregnant, but had suffered from dysmenorrhoea before marriage. The whole breast was infiltrated with the cancerous growth, and she had considerable lancinating pain. Case No. 98. — May 19th, 1863. A young woman, thirty-five years of age; another example of cancer asso- ciated with barrenness. She had a tuberculous inheri- tance, and the disease lasted six years. Case No. 103 is that of a lady, thirty-three years of age, with only two children, the youngest being six years old. It is another example showing the relations of irreg- ular uterine functions to cancer. She had labored under chronic uterine disease, of what character the record does not sufficiently indicate; but whatever may have been its nature, it had an irritating influence upon the nervous sys- tem and epithelial structures. The tumor commenced as benign four years before date, and followed a blow on the right breast. See the case in the table. Case No. 174 is an example of acute cancer in a young woman, thirty-five years of age, and barren. She was of full habit of body, a finely-developed woman of the nervous temperament. She had had great domestic affliction just previous to the appearance of the tumor, and this, I believe, was a cause of the disease, in addition to the rather luxurious habits of the patient. Case 250, August, 1872, offers another example of the development of carcinomatous disease in a lady thirty-five years of age, who had only two children, and whose fam- ily was consumptive. This was also a case of acute can- 30 GROUP VII cer, the duration being but fourteen months. The patient had been accustomed to indulge in luxurious food, and wore tight dresses, by which means constant irritating pressure was applied to a full bust. The axillary lym- phatic glands were implicated, and I advised against an operation, which I have very little doubt would have been of no avail had it been performed. Case No, 311 is another instance of cancer, where the patient had had only one child, then twelve years old. She was thirty-six years of age, was a fleshy and well developed woman, full of vitality, but irregular in the menstrual function. Her paternal grandfather died of cancer in the face, and her mother of consumption, this side of the famil}' being very tuberculous. The case was one which progressed rather slowly; it had begun in a tumor having a benign period of five or six years. No further history is recorded. Group VII.- Women of seventy years and over. There were eight cases in women who were over seventy years of age at the time of observation. Two of these, however, were cases of long standing; one. No, 29, having been the subject of mammary cancer at fifty-four years, which receded without an operation, the patient dying of cancer of the uterus at the age of seventy-six. The duration of the disease in this mstance is estimated at twenty-two years. Case 176, Aug. 3, 1867, is that of a lady who died of mammary cancer at the age of eighty-six, but who was first attacked at the age of forty-nine. She had never been preg- nant, although living a long time married. The develop- ment was in the site of a blow, and commenced soon after the accident. The breast was removed in 1834. At the time of observation in 1867, she was eighty-three years old, and had had a return of the disease for about one year. A STUDY OF CANCER 3 I No operation was advised, on account of her advanced age, although the axillary lymphatic glands w^ere not in- volved, but she survived three years longer, dying in 1870, at the age of eighty-six. The duration of the disease v^as, therefore, between thirty-three and thirty-four 37ears. The other eight cases began to develop at the following ages : Four of them at about sixty-nine years, one at sev- ent}^, one at sevent3-four, one at seventy-six, and one at seventy-nine. The greatest age attained was eighty-six years, viz., case 176, noticed, who carried the disease over thirty-three years. It should be noticed that her grand- mother died of cancer of the uterus. Case 74 had a duration of five years, and was cysto- scirrhous. The disease began in the site of a blow re- ceived three years previous to the discover}^ of the tumor, which was at the age of sixty-nine. She was then a strong, healthy, rather fleshy woman. She had a daughter, who died of oreneral cancer not lons^ after her own death. Case 91 began in the site of an abscess, and bad a benign period of several years. Case 94 began its malignant development at seventy years, in the site of a blow that had been re- ceived five years previously. Both of these cases, 91 and 94, occurred in women of full habit of body, who had always had good general health. They had each had six children, were in good circumstances, and, although I have no record of their manner of living, it is presuma- ble that it was not upon a spare diet. The only exciting causes are, in one case, an abscess, and in the other, a blow. Case 138 is noticed in Group IV., as is also case 74. In case 274 the disease began at the age of seventy-four in the site of an abscess in the right breast. The subject was a well-developed woman, of remarkably strong con- stitution, and with no trace of cancer or of consumption among her relatives. At the time of observation, at two 32 GROUP VIII years' development, her general health was still good, and she survived two years and five months longer, mak- ing the entire duration of the disease, as noted, four years and five months; but it may have been longer. Case 335 began, at the age of seventy-six, as a malignant tumor. There is no record preserved of a blow, abscess, or other exciting cause. The breast — the right one — was removed in September, 1876, at the age of seventy-seven. The wound healed, and she remained well till the latter part of October, 1877, when, having severe pain in the side, she was given eighteen drops of Magendie's solution of morphine, and she died of narcotic poisoning; whether with the seeds of cancer in her system or not cannot of course be stated. There had been no apparent involve- ment of the lymphatic system, and one would lean to the opinion that it was a case of permanent recovery after amputation. The tumor in case 340 also developed in the site of an abscess which formed while nursing her first child, when she was a 370ung woman. Six months previous to observation she fell and broke an arm, receiv- ing a blow on the site of the abscess; and the malignant growth immediately followed the blow. Her health was then feeble, and she died within a year from the com- mencement of the disease. This case goes to increase the number of those which, in my opinion, indicate that cancerous tumors have their origin in injuries or seats of irritation in constitutions pre- pared for the development of the disease, the constitutional condition being acquired by certain habits of living. Group VIII. — Cases 'which present a history of can- cer among ancestors or other blood-relatives. This group includes 56 cases, or one-seventh of my whole number. Ten of them had a tubercular inheritance A STUDY OF CANCER 33 as well. We fail to find the influence of heredity in six sevenths of the cases. It may be said that the prob- abiHty of there being cancer in the families of a much larger proportion of these patients is very great. But would it not be straining the matter to suppose that as many as one third of the number really had relatives affected with cancer — absolute evidence being wanted? And then how should we account causatively for the remaining, two thirds of the cases? They would have their causes, as I have elsewhere remarked, outside of that inheritance, and then we shall have to admit that those having "cancer relatives" were just as likely to be the subjects of the same causes. Let us, therefore, examine the record to see whether we have not the usual number of causes other than hered- ity — causes that have been supposed to be active by many acute observers — if we add to the predisposing constitutional cause, errors in diet, and accompanying digestive derangements, and epithelial irritability. In four cases there is a history of mammary abscess. In eight cases we have the record of a blow. In four cases pressure from stays is noted. In three cases we find bar- renness. In three cases we have defective functional action of the gland and of menstruation. In sixteen cases grief and anxiety are mentioned. In case 253 the breast had been operated on with caustic plasters before there was sufficient evidence of malignant disease. Here the caustic cannot be counted as an exciting cause, yet it may have been. In case 282 caustic was applied to the breast ten years previous to the time when the patient presented herself to me. The disease had then appeared in the cica- trix, and it is impossible, of course, to say with certainty that the malignant development was primarily in the cicatrix. But from the length of time which had elapsed between the 34 GROUP IX application of caustic and the condition when seen by me, the fair inference is that the caustic was applied to a be- nign tumor, if to any tumor at all, and that it preceded the cancer. This was developed in the wound, and in a pa- tient greatly alarmed by the belief that she had inherited a now inevitable disease which was to destroy her life. Thus, among these 56 cases of cancer which might be claimed as hereditary, we find no less than 38 Avhich have other assignable causes recorded; and these causes are quite as numerous as in those cases which have no " can- cer relatives." Upon a fair examination of these cases, therefore, heredity appears as a vanishing force, and can, not consistently be claimed as a proven cause of cancer. My chief object in view in bringing out this aspect of the subject is the practical one of calling the attention of the profession to those causes which can be avoided; and, if all the causes of cancer are more or less avoidable, and if heredity, contrary to the common opinion, is not cause, great good must result from the adoption of such a view. As I have remarked in another place, if we regard hered- ity as a potent element in the causation of cancer, we nat- urally neglect other and important causes; but if the idea is erroneous we allow ourselves to be led astray by a will- o'-the-wisp, and needlessly alarm many of our patients. This is not all; by leading them to fear that they will become patients, we apply to them one of the really active causes, as I believe, of cancer, — fear, and the resulting depressing mental excitement. Groitp IX. — Cases vjhich -present a histoiy of phthi- sis among ancestors or other blood relatives. There were 71 cases in which the subjects inherited phthisical tendencies or constitutions. Some remarks have already been made in regard to the relations of can- A STUDY OF CANCER 3 c cer to consumption, and they will suffice for all that might be said in this place. I may observe that the cases in- cluded in this group occurred in subjects who were in rather less prosperous circumstances than those having "cancer relatives," and for the very reason, as it would seem, that those who have '' cancer relatives " have rela- tives who live luxuriously, are wealthy, indulge in the pleasures of the table, and, in many instances, do not take enough outdoor exercise to remove the constantly accu- mulating effete materials from the system. II DEDUCTIONS DRAWN FROM AN ANALYSIS OF THE THREE HUNDRED AND NINETY-SEVEN CASES RECORDED. I WILL now endeavor to deduce from the foregoing cases the evidence they furnish as to the nature of cancer, par- ticularly in regard to its etiology; fortifying my data, either in passing or afterwards, b}* comparing them with the observations of others. I have already briefl}^ touched upon the views held by the leading histologists as to the development of carci- noma. But even if it could be proved that all cancer cells are developed from connective tissue exclusively, or from epithelium exclusive^, we should not thereby arrive at the etiology of cancer; we should only have discovered its histological nature, not its causes. These must be sought for — to a certain extent, at least — independently of histo- logical questions: We shall have to observe the habits of individuals, of communities, and of nations, and their surrounding circumstances. We shall be obliged to look for causes which exist in civilized communities, and which are absent, or almost entirely absent, among barba- rous or uncivilized communities, or among nations whose modes of life are essentially different from ours. For — and this is an extremely significant circumstance, — it has been found that barbarous and semi-civilized peoples are comparatively free — some tribes, indeed, are perfectly 36 A STUDY OF CANCER Z1 free — from cancer. Then again we shall find communi- ' ties among civilized nations who have certain peculiar habits, which somewhat resemble those of natural or rude peoples, who have very little cancer. i ^ Now is there any one habit which is common to civi- L^^ lized people, that is not practised by primitive people, — c^C^ as by the Egyptians or the Hindoos, — which can be thought to produce cancer? Can it be some peculi- arity of diet? That could scarcel}* be contended. Is it living in cities? But the inhabitants of India reside in densely populated cities. Are the germs of contamina- tion contained in the water which the inhabitants of civi- lized communities use as a beverao^e? The same nesfa- tion must be given to this as to the last question. If i drinking-water is anywhere rendered impure, it is in India. 1 In England and Wales, cancer is much the most prevalent among those who dwell upon the banks of rivers and on ; alluvial soils; but that such situations do not generate can- cer appears from the fact which has been stated, that cancer is almost unknown on the banks of the Nile. Does cancer belong to certain races? It is scarcely known among the native black population of Africa, but it is not uncommon among the negroes of this country; neither is it uncom-_. ^ mon among domestic animals. What explanation can be derived from these facts? They certainly do contain some clue, if we can but un- ravel it. Can the explanation possibly be in the doctrine of heredity? Has the negro, by dwelling among the white race, acquired a constitutional predisposition, which is transmitted? Has he contracted certain diseases by his transplantation from his native country, which have laid the foundation of such predisposition? This question is difficult of solution, but I think we shall have reason to believe the answer is not in the affirmative. 38 CAUSES OF CANCER When we take into consideration the comparative prev- alence of cancer among those who are addicted to certain habits, certain modes of living, among civilized peoples, and then compare these habits and modes of living with those of uncivilized communities, I think that a connecting link may be made out between cause and effect. Cancer is the most prevalent among peoples that are in the habit of living generously, and, as far as my observation has gone, amonof those individuals who are most addicted to luxu- rious habits, other things being equal, and more particu- larly those who are in the habit of eating highly-seasoned food, and who are more or less troubled with mal-assimi- lation, and consequent sympathetic irritation of the skin and mucous membranes. Is cancer more prevalent among those nations which are addicted to intoxicating drinks? As intoxicating drinks are used, as a rule, by civilized people, more than by people who live in a state of nature, the answer must be in the affirmative. But if the question is whether can- cer is more prevalent among individuals who are in the habit of freely using intoxicating beverages, we can hardly answer it in the affirmative. - Cancer is more frequent in Paris than in London, but it is a well-established fact that the inhabitants of London use strong alcoholic drinks more freely than those of Paris. Is cancer more prevalent among those nations whose people are immersed in the cares of life and in the accu- mulation of fortunes, and where anxiety and disappoint- ment are common? It must be admitted that although wealth brings its cares, and struggling to amass fortunes its disappointments and blighted hopes, these do not affect so much the female members of the community; nor is mental affliction so great among those who live gener- ously, as among the subjects of poverty and neglect. A STUDY OF CANCER 39 Why, then, is not cancer more prevalent among the poor? This is answered by the fiict that the other causes, such as idleness and luxur}-, do not operate. Is cancer more frequent among nations which have been exposed to constitutional diseases, such as syphilis? Surgeons have occasionally noticed the similarity of some of the characteristics of the two diseases, such as the primary local development, and the constitutional con- tamination which follows. From intermarriage and the endless mixing of families, how many have escaped the remote effects of a disease so widely spread as syphilis was during the i6th, 17th and i8th centuries. The disease then produced the most frightful constitutional ravages, in a great measure in consequence of the want of knowledge how to treat it. It is well-known how many and varied are the forms of that dread disease, and how its fruits often appear where its seed was never suspected of having been sown. The appearance of cancer in domestic ani- mals, however, that have never been known to be affected with syphilis, would seem to place the answer to the query regarding this disease as being causativel}^ allied to cancer in the negative. Walshe treats of the causes of cancer under three heads : specific, -predis-posing, and exciting. The specific are infection, contagion, inoculation, and venous injection; but as all these have been shown to be inoperative, his causes are reduced to two general heads — predisposing and exciting. The predisposing causes are considered as hereditary or acquired. In regard to heredit}^ he makes the following remarks: "Whatever be our theor}^ of hereditary influence, a satisfactory conclusion regarding its connection with cancerous disease can only be obtained by the well-advised application of the numerical method. The absolute demonstration of its realit}^ would be the 40 CAUSES OF CANCER discovery that, of a large mass of cancerous individuals, a very considerable majority v^ere born of parents similarly diseased." He adds: "Additional confirmation of the fact v^ould be had w^ere it proved that the mean period of manifestation of the disease was materially earlier among cancerous individuals born of parents similarly af- fected, than among persons of untainted parentage." ("The Nature and Treatment of Cancer," pp. 145, 146.) I presume that these remarks v^ill generally be regarded as just; and especially the last remark, that in patients inheriting a so-called cancerous taint an earlier appearance of the disease w^ould be noted than in those who were not so tainted. I shall have occasion to apply these remarks to some facts found in my own statistics. How they may be affected by the records of others remains to be seen. According to Walshe the predisposing acquired causes are age, marriage or celibac}', menstruation, lacta- tion, depraved habits, mental affliction, sustained intel- lectual labor, social condition, climate, and geographical location. Now, can anxiety be a predisposing cause? Will a long period of care, trouble, and sorrow alone disturb the balance between the nervous and cellular elements, so as to make the latter take on an abnormal, a cancerous, development? It is more than probable; but can it be demonstrated? Perhaps not; but must we on that ac- count reject the probability? Are we justified in rejecting every hypothesis which cannot be placed upon a demon- strated basis? Sometimes scientific truth is discovered by adopting hypotheses, and acting upon them as if they were established truths. Nor is a reasonable h3^pothesis in the case of so obscure a disease as cancer, which has baffled investigation for centuries, to be rejected unless we can point to a cause which is demonstrable. Are A STUDY OF CANCER 41 we to refuse to accept a probable cause because we do not find a demonstrated one? Then we may probably never arrive at a conclusion, and, therefore, lose the advantages of instituting a rational method of treatment. But if we believe mental affliction to be one of the pre- disposing causes of cancer, we shall advise those who have apparently benign tumors in their breasts of the advantage of being cheerful. If we believe that generous living, and particularly the habit of eating heartily of ani- mal food, is one of the causes of cancer, we shall advise the patients who consult us on the subject to live frugally; and if the community in general is warned by physicians that luxury and an unrestrained mode of living may en- courage cancerous growths in any person when he arrives at middle age, those who attend to the admonition will be more careful in their habits. If want of personal cleanli- ness, bad ventilation, or any habits by which effete matter is either produced too rapidly or retained in the system, are likely to induce a constitutional predisposition to can- cer, or to localize a predisposition already formed, then an avoidance of such causes will be more likely to follow the warnings of the physician than if such views of the causes are not held. These views, however, in regard to the etiology of cancer, are not founded on such prudential considerations, but on the great probabilit}' that it is in just these conditions that cancer has its origin. Upon this point I make the following quotation from Walshe (p. 155): "Much has been written on the influ- ence of mental misery, sudden reverses of fortune, and habitual gloominess of temper on the deposition of carci- nomatous matter. If systematic writers may be credited, these constitute the most powerful cause of the disease; and although the alleged influence of mental disquietude has never been matter of demonstration, it would be vain 42 CAUSES OF CANCER to deny that facts of a very convincing character, in re- spect of the agency of the mind in the production of this disease, are frequently observed. I have myself met w^ith cases in which the connection appeared so clear and deci- sive, that to question its reality v^'"0uld have seemed to struggle against reason." " But," again he says, as though not full}'- appreciating the physiological reason why, in fact, the influence of affliction must favor abnormal epithelial development, " the extent to which this works practically has doubtless been overestimated. It should be recollected that cancer is a very rare affection before the thirtieth 3'ear, and that the number of persons fortunate enough to reach that age without having suffered under disappointed hopes and wasting grief is in all probability comparatively small. Authors who dwell most strongly on this mode of causa- tion of the disease curiously enough fix on the middle ranks of society as those furnishing the least amount of cancerous disease; 3^et these are precisely the classes in which reverses of fortune most frequently occur, and in which mental anxiety, inseparable as it is from profes- sional and commercial pursuits, must be strongest and most constant" (pp. 155, 156). These words from perhaps the most satisfactory writer on cancer require careful consideration. For reasons that have been given, we cannot doubt the influence of grief in causing cancer. But, in the first place, it is not at all certain that the middle ranks of society suff"er the greatest amount of mental affliction or worry. On the contrary, the poverty-stricken have often the most over-burdening griefs: and, again, the wealthy and the powerful have imaginary or social griefs that are often quite as powerful in their influence, for they are fostered by nervous or hereditary excitability and by a heightened A STUDY OF CANCER 43 faculty of morbid feeling, and stimulated by their ways of living. On the other hand the middle classes are mostly exempt from the other most powerful cause — that of over-feeding. Many of them live well, some over-eat; and this class furnishes its quota of cancerous disease: but the majority of them are not luxurious livers, and more- over take considerable exercise and keep their bodies free? of effete matter. It therefore appears that these state- ''■ ments do not in the least affect the view that cancer has one of its causes in mental affliction, but rather uphold it In regard to heredity, there are some who believe that a certain state of the constitution may be transmitted as well as acquired, in which cancer is likely to be devel- oped; but the matter is exceedingly doubtful, and my own statistics point to the opposite conclusion. The belief is popular and widespread that cancer is an hereditary disease, and those who cannot trace a cancer- ous taint amono^ their relatives as a rule entertain no fear that they will ever become its subjects. On the other hand, acting upon the theory of heredity, those who have relatives who are the subjects of cancer are apt to be alarmed at the slightest appearance of any tumor what- ever, and causes other than hereditary are disregarded. The unfortunate descendant of a cancerous progenitor fears that he has the cancerous constitution, and that any tumor may take on a cancerous developm.ent; and thus he is kept in a state of constant alarm which favors the de- velopment of the very disease he dreads. Every wart or mole will be regarded with fear, and expected to begin at any moment a malignant warfare against the life of its hapless possessor. How much better, if it be possible, that we should re- gard cancer as an avoidable affection ! As long as we accept heredity as the most frequent cause of cancer, we 44 CAUSES OF CANCER are more or less deterred from searching for other causes. On the contrary, if we have well-founded reasons for ex- cluding heredity as a cause, we are impelled to make a more thorough search for others, and I believe much prac- tical benefit will follow from such a course. We must find the causes, if we find them at all, in the habits of the people. I believe that a full record of the circumstances, state of health, habits of living, and the accidents to the parts affected with the disease, in one thousand cases of cancer, would go far — perhaps, indeed, it would be suf- ficient — to furnish data for a solution of the question of etiology. An over-excited, injured, or weakened organ — a mam- mary gland, for example — may be the seat of the develop- ment, as well as an irritated primarily healthy organ. Cancer is, however, not a disease of early life, but of mature life. Among the 367 cases of cancer of the female breast, of which I have recorded a sufficient history upon this point, only four were among females under thirty years of age, and twenty-seven under thirty-five years of age. As the majority of cases are in subjects over forty-five years of age, it is not unusual to regard this as evidence that decadence of functional activity is a cause of cancer; but it may be only evidence that cancer requires, as a rule, a considerable period of time to produce that gradual change in the oro^anism which constitutes the cancerous diathesis. The derangement of the nervous system produced by the disturbance attending the discontinuance of such im- portant functions as those of reproduction is undoubtedly great; but I call attention to the frequent development of the disease several years before the subsidence of these functions. One circumstance strikes the surgeon in all the cases A STUDY OF CANCER 45 of cancer of the female breast; namely, that the disease develops, as a rule, during a state of low activity. Dur- ing the performance of the lacteal function the gland rarely takes on a cancerous development, and is not likely to do so during gestation. From the nature of the case this is what might be expected. An abnormal growth is not likely to take place in an organ during its period of activity; in fact, the performance must be so accompanied by healthy action that unnatural malignant development can find no place. There are a few cases, however, in which the growth takes place rapidly during lactation or during gestation, but they are rare; and it is more than probable that a commencement had already been effected in such cases, and that the excitement of functional activ- ity sometim.es acts as a stimulus to the abnormal growth. Ill THE DOCTRINE OF HEREDITY — THE GEOGRAPHICAL DISTRIBUTION OF CANCER — THE INFLUENCE OF CIV- ILIZATION IN THE PRODUCTION OF CANCER — SUM- MARY OF THE CAUSES OF CANCER. We are now in a position to sum up the evidence, as far as these cases can assist us, on the question of heredity in cancer. I approach this vexed question with diffidence, and with a feeling that it requires to be treated with the greatest candor, and with deference to the testimony of others, in order, as for as possible, to avoid falling into error. All the relations of cancer, its geological and geo- graphical distribution, its frequency among different races of mankind, its occurrence in different states of civilization, its relation to social habits and sanitary conditions, must be taken into account. I will endeavor to state briefly the chief points in the arguments both in favor of and against the doctrine of heredity; first considering the arguments deduced from data furnished b}^ others, and afterwards inquiring how far the conclusions thus derived are modi- fied by my own observations; and endeavoring, from a survey of the whole field, to find the direction which its investisration ouo'ht to take. It v/as stated by Sir James Paget, in a discussion on the subject, held by the Pathological Society of London in 1874, that when he was principally engaged in hospital practice he could trace the inheritance of the disease in 46 A STUDY OF CANCER 47 about one case in six. When he came to know something- more of private practice he says that he could count one in four. " Now I can," he says, " without difficulty, count, as actual facts, not less than one in three, of all my patients with cancer, in whose families the occurrence of cancer is well known. But this number does not nearly represent what we may very safely assume to be the predominance of inheritance in cancer. A large number of persons die of internal cancer, and convey it to their offspring, though it is never known that they themselves have been the sub- jects of cancer." (See report of discussion in the London Lancet^ March 21, 1874, and also in the Journal of the Pathological Society?) Now, without discussing the question as to how far we have a right to assume that persons often die of cancer without the fact ever being known, if we admit that one third have inherited the disease, let us ask how much probability there is that the remaining two thirds, who can trace no connection with cancer, have inherited it? That is to sa}', what probability is there that the two thirds who can trace no inheritance still have the disease by inheri- tance? How far are we to accept the statement of Sir James Paget that ''a large number of persons die of inter- nal cancer, and convey it to their offspring, though it is never known that they themselves have been the subjects of cancer? " Most cases of internal cancer are secondary, and follow a primary tumor whose existence is generally known, or pretty well made out, even in cancer of the stomach. The liver is the internal organ most often affected, but probably three fourths of the cases of cancer of the liver are second- ar}' (Rindfleisch). Admitting, now, that there are one sixth as many cases of primar}^ cancer of the liver as there are of the breast, and that there are one third as many 48 HEREDITY IN CANCER cases of primary cancer of internal organs, excluding the uterus and rectum, as there are of the uterus and breast, the number of cases in which such cancer patients have ancestors in whom cancer can be traced is much too small to admit the element of heredity. More than half of all jthe cases of cancer met with, if we give the element of heredity the widest possible influence, must therefore be accounted for in some other wa}'. In other words, it must be supposed that the disease has been acquired. But if we have the strongest reasons for believing that cancer has been acquired in half the number of cases, what rea- sons have we for believing that it has not been acquired in the other half of the cases also? The strongest advo- cates of heredity claim that it is associated with " cancer relatives^'' in only one third of the cases. How are those cases which are not transmitted (if any are transmitted) acquired? Certainly in the habits and circumstances of the patients. Now if one half of the cases may be ac- quired, all may. Note that we have here a question entirely difterent from that of the transmission of tubercle. A tubercular parent usually begets a child with a percepti- bly marked strumous constitution. If the exceptions to this rule were as frequent as they are in cancer, it would be difficult or impossible, even in this disease, to trace heredit}'^, although (and this is not the case in cancer) a constitutional tendency is earl}^ manifested. Of course there is a tendency in cases of tuberculosis to the return to a normal type of nutrition; and the other parent, if vig- orous, may impress a healthy tendency upon the offspring; still the strumous diathesis will generally be apparent in the organization of the child. In the transmission of syphilis we see more plainly still the marks of heredit}^, and when a child is born with syphilis, or shows symp- toms of the disease when no contamination has been pos- A STUDY OF CANCER 49 sible since birth, the disease can certainly be traced to a progenitor. To return to the question : What is the importance, as an evidence of heredity, of the fact that in a certain circle ' of a surgeon's practice he finds one third of his cases of cancer connected with other cases by blood relationship? Its importance is overestimated b}" reason of a simple numerical fallacy which is generally overlooked in the argument. Let us ask this question : What is the average number of persons belong to the family of one's ancestors, say, for four generations back? Assuming that the aver- age number of children of a married pair is four, then, in the families of immediate parents there would be eight individuals who must be counted as relatives. Every per- son would thus count among the families of their four grandparents, on an average, sixteen individuals, and the generation of the eight great-grandparents would num- ber, in the same proportion, thirty-two. In the fourth remove the number would be sixty-four, and in the fifth one hundred and twenty-eight. Adding these numbers together gives two hundred and forty-eight persons in- volved in the comparatively direct family connection of one person in the fifth degree of ascent. If we include A only four generations, that fe>m the families of great- nJT^ grandparents, the number involved will be one hundred and twenty, and, by including the descending relationships from these, the number would reach several hundreds. Now, according to reliable statistics, the proportion of deaths from cancer to that of all other diseases is about one in one hundred and twenty-five. Therefore it would seem to be quite in accordance with the laws of chance that there should often be found — certainly as often as once in three times — a person who could count one or more cases of cancer in the families of ancestors and blood 50 HEEEDITY lA^ CANCER relatives for three or four generations back, even taking j into account the possibility of the existence of unknown I cases of internal cancer. f Let us now remark further, that while we thus have one case of cancer connected with one or two cases among one or two hundred relatives, one or two hundred per- sons have relatives or ancestors who have died of cancer, but none of them are themselves the subjects of cancer. Lookino; at the incurable nature of the disease, w^hich in this respect presents a strong contrast to consumption and syphilis, and the time during which it has existed, we could hardly expect a single member of a civilized com- munity, were the disease hereditary, to have escaped it. Would not a disease that was at once hereditary and incurable have necessarily contaminated the whole race? Nevertheless, it is a fact which requires careful and candid consideration that in seme families there will be several cases of cancer, a fact strongly pointing to some powerful common cause; if not to inheritance, then to habits and modes of living, which have been practised by the members of the family, and which are sufficient to induce the disease. It is possible that in some cases per- sons may inherit constitutional tendencies b}' which they are liable to be influenced by external agents. They may inherit constitutional w^eakness of digestive organs, or irri- tability of the skin and mucous membranes, as w^ell as they may, by habits and circumstances, acquire such weak- nesses and tendencies; but this is not inheriting a disease in the way that scrofula and syphilis are inherited. It must be admitted that the investigation of the etiology of cancer is one of the most vexed and difficult subjects belonp-ing- to medical science. It has received more atten- tion, and that through a longer space of time, than an}'' other, and much diversit}^ of opinion still prevails. One A STUDY OF CANCER 51 of the latest contributions to the subject of cancer is that of Dr. Alexander von Winniwarter, a study from the cases of Prof. Billroth's private and clinical practice. Although he does not positively dispute the influence of heredit}', from an examination of his cases he la3"s but little weight upon it. He says, "The statements of some English authors who have taken up the subject are merely worth- less, because they are based upon entirely superficial diagnosis, and extracts from public death registers, which have been prepared by Ia3'men. Until we have more carefully prepared statistics we cannot tell Avhether the doctrine of heredity will be strengthened or weakened. Of 170 cases in which hereditary taint had been inquired into, two had ' cancer relatives,' or 5.8 per cent, or -jy of the whole." Again he says: "According to Paget and Velpeau, the number of cancer patients who have cancer relatives is as i to 3 to those w^ho have not. According to Sibley, there are 8.75 per cent, or one in about eleven cases, and that is nearly v^^hat is found in the cases in this book, or 8.8 per cent of cases of cancer of the breast. Among German surgeons there is not much information upon this point, and I do not think the hereditary disposi- tion is of as much consequence as is supposed by some." Now, what evidence is there that cancer is developed by habits and circumstances of living, by geographical and other causes, independent of hereditary influence? In regard to the geographical relations of cancer, much information has been collected, and the statistics thus fur- nished will be useful in making an inquiry as to what probable influences the habits of communities of the globe have had in the production or non-production of the dis- ease. "In St. Helena during ten 3'ears, between 1826 and 1835 inclusive, among the civil and military population of that island there were 552 deaths, only two of which were 52 HEREDITY IN CANCER attributed to cancer." This is only i in 276, or less than half the averasfe of cases in Great Britain. Here we have the statistics of a civilized European population, enjoying many of the luxuries of life, but at the same time living in a remarkably pure and salubrious atmosphere. " At Al- giers (from the Gazette Medicate d''Atgier), among the 5561 deaths which took place during the years 1852, 1853, and 1854, 37 deaths are recorded," or one in about 150, less than half the average (Yl3iW\\3.ndi,Geog7'apky of Heart Disease, Cancer, and Phthisis, p. 90). Walshe, in his classical book on cancer, as long ago as 1846, has the fol- lowing: " The maximum amount of cancerous disease occurs in Europe, as compared with other quarters of the globe. I have but few documents illustrating the relative frequency of the disease in different regions. The following table exhibits a most striking excess in Paris, over London: — *' Ratio per cent of deaths from cancer. , ^ > To total To popu- deaths. lation. " London (1841) 0.83 0.02 Paris 2.54 0.78 Verona 0.75 ..." (Walshe on the " Nature and Treatment of Cancer," Lon- don, 1846, p. 160). The author remarks that the first of these numbers is given by M. Tanchou, the second (for 1830 only) is calculated from a paper in Journal Comp. dii Diet, des Sc. Med. " In Asia the disease appears to be much less common. Of a total number of 30,102 cases admitted into the Ho- bart Tov/n Hospital in Tasmania during twelve years, there were but four cases of scirrhus. In the pages of the A STUDY OF CANCER 53 Calcutta Medical Journal^ a passing remark on the in- frequency of scirrhus and encephaloid among the Hin- doos is occasionally found; and their import is confirmed by some statistics recently published in the male and female hospitals at Calcutta (Appendix to Annual Report of Medical College of Bengal, session 1844-45). Among 4080 males admitted during a space of three years, three only were affected with cancer, and among 701 females admitted during two years, two only were cancerous — in both, the uterus was the organ affected" (ibid., p. 160). " In China," the author remarks, " the population suffers to a greater extent than this, and that the course and rav- ages of the disease are the same among the Chinese as ourselves is shown most graphically in a series of draw- ings (which I have now before me, from the museum of University College) ; executed by native artists from specimens occurring in their countrymen." " The inhab- itants of Africa appear to be specially exempt from this disease. Clot Bey dwells upon its rarity among the Egyptians, female as well as male, and curiously ascribes the infrequency of uterine cancer to the women's habit of wearing drawers, whereby the genital organs are protected from eddies of cold air. M. Hamon (who is said by M. Tanchou to have passed fourteen years in the service of Mehemet Ali), never observed the disease among the indigenous female population, and but very rarely among the Turkish. M. Bax (quoted by M. Tan- chou) met with no case of the disease either in Algiers or Senegal during a period of six years. Nor do the tables of mortality for Algiers for 1841 and 1842 attribute death in any instance to cancer. M. Ponzin treated about 10,- 000 native Arabs with not more than one case of cancer; the disease was of the breast of a female." (Walshe, p. 161.) He then gives American statistics of that time. 54 HEREDITY IN CANCER which I omit, and goes on to say, " The foregoing survey, imperfect as it necessarily is, suffices to show that certain regions of the globe are peculiarly exempt from the rav- ages of cancer. But is this exemption to be really referred to the special influence of climate, or of some concom- itant condition ? Wherever the disease is particularly rare it may be remarked that a low state of civilization prevails: wherever social organization is of a highly per- fect kind, there cancer flourishes. May we then infer, that, as has more than once been contended, cancer, like insanity, follows in the wake of civilization; and that as the ferment of a high state of social advancement is among the most active causes of destruction of intellect, so too, it plays a prominent part in generating one of the most ter- rible physical evils to which humanity is subject?" My own observations tend to corroborate this state- ment, for it is a noteworthy fact that a majority of my cases occurred among people in good circumstances, many of them wealthy, and living luxuriously, and that as a rule the most rapid and malignant cases were among those surrounded with the greatest comforts. Walshe remarks: "It is curious that even the lower animals ap- pear to acknowledge a somewhat analogous influence; it will presently be seen (p. 170) that they are much more subject to the disease when in a state of domestication than in their natural wild condition"' (ibid., p. 161). Now, what are some of the conditions present in a high, and absent in a low state of civilization? One of them is established wealth, and a state of luxury. The appetite for eating meat and highly seasoned food is indulged, and can be regularly and habitually indulged, only in a state of established civilization, with communities engaged in ac- cumulating fortunes and vicing with each other in sumptu- ous living. Savage and nomadic people, or people not A STUDY OF CANCER 55 addicted to regular and systematic industry, do not pro- duce enough food for a luxurious mode of life, and, as a rule, animal food is scarce. Hunting and fishing are pur- sued to a considerable extent by some wild or barbarous people, but they are only occasionally large eaters. They more often, and particularly the women, go for long periods with very frugal fare. The}^ often have, from ne- cessity, long fasting periods. The Hindoos live upon rice and have no cancer. The Chinese eat more animal food, are not cleanly, live in a way to retain much effete matter in the system, and they have cancer. The North American Indians are not subject to cancer. Among the Zulus, Dr. Lindley, who resided many years in their country, never saw a case. In regard to the lower animals, those in a wild state do not, as a rule, get enough to eat, and they do not live as well as domestic animals. Wild animals are, as a rule, half starved. The domestic dog and cat are over-fed. The wild animals do not have cancer, the domestic ani- mals do. These questions are pertinent, therefore: Does a low diet tend to alleviate cases of cancer? Has a low diet been known to prevent its development? The latter question is unanswerable, for no one can say when cancer has been prevented; but in regard to the ef- fect of abstemiousness on cancer I can speak with great pos- itiveness, that a vegetable, or at least a ver}- bland diet, does check the progress of the disease, and, in some cases now under treatment, has been attended by an alleviation of the symptoms; and, in a few instances, even by a reces- sion of the growth. It is well, and in fact indispensable, that the histology of cancer should be carefully studied, and the labors of minute anatomists have been of great service; but there has been a disposition to rely too much on working with S6 HEREDITY IN CANCER the microscope as a means of arriving at ultimate causes, and the consequence is that there has not been as much advance in the etiology and nature of the disease, as if more reliance had been placed upon the labors of older surg-eons. The following passage, written by Sir Astley Cooper, more than half a century ago, shows a broader and inore enlightened view of the subject than is contained in the writings of some more recent observers, who have sup- posed that they were working far in advance oi the great Eng:lish surgeon. '■''Cause of Scii'7'hus. — The cause of this disease is sup- posed to be some accidental blow, or the pressure of a part of the dress; but although a blow may produce a swelling on the bosom, yet that swelling will not be of a scirrhous nature unless some defective state of the constitution dis- poses to malignant action. If the constitution be good, the effects of a blow are speedily dissipated; but if the constitution be faulty, the swelling grows into a formida- ble disease. The complaint is in part constitutional, in part local. It is constitutional in so far as the disposition to malignant action is produced by the state of the habit. It is local also, because the action in the part is peculiar, and the result is a specific effusion different to that of com- mon inflammation." ( " Lectures on Surgery," Boston, 1825.) Now what are the effective causes of cancer? Hered- ity, as has been show^n, may be ruled out almost wholly. The system must be prepared for the disease, or else why is it that in one case at a given period a frequently exciting cause may be entirely inoperative, and at another time the disease may follow the cause? Why should the body, after being subjected through a number of 3'ears to blows, cuts and other forms of injury, resist the disease, A STUDY OF CANCER 57 and yet subsequently succumb to a cancer which suc- ceeded the same kind of cause? In my opinion the tis- sues must have undergone some unknown transformation which will permit the possibility of cancerous develop- inent, and it is at this period that an exciting cause may bring on the disease. This condition of the system de- pends upon the following circumstances: First. — Luxurious living, and particularly excess in animal food, increases the waste products of the body, and, if coupled with insufficient exercise, the waste products are retained in the system and have a tendency to produce abnormal growths. Whether living in a malarious atmos- phere would assist luxur}^ in producing cancer may be a question. Of itself it would of course be inoperative, as it is very rare among the Hindoos. Second. — Local irritation of an epithelial surface, as the pressure for a great length of time against the breast of the point of a corset, particularly if the glandular appa- ratus has been irritated by disordered function or inflam- mation. The presence of a cicatrix in the seat of a former abscess is probably one of the most powerful of the exciting causes of cancer; but it must be considered that the consti- tution requires to be brought into a certain condition before exciting causes will operate. It has been noticed by some observers that cancer patients are frequently the subjects of eczema: not that there is any relationship between the diseases, but that they love the same soil to grow in. There is probably a local relationship between rheumatism and cancer, in so far as rheumatism is an expression of faulty digestion or assimilation, which is more or less pro- ductive of epithelial and epidermic irritation. The cancer chart and the chart of heart disease of S. Haviland, show a certain degree of resemblance in the distribution of the two diseases, while consumption is shown to be moit 58 HEREDITY IN CANCER prevalent where cancer is the least so. Cancer, for in- stance, is common in London, and most frequent among those who live sumptuousl}^; it is present along alluvial bottom lands, where the soil is rich, and the air less fitted to remove waste material from the body, where the people live more indolently and luxuriously than upon the higher lands. In a more salubrious atmosphere, as in the moun- tains of Wales, in portions of Westmoreland and Lancas- ter counties, England, and on the island of Anglesey, there is a minimum of the disease. Third. — Mental affliction. This is a mooted question, but aside from the conclusions of some of the best thinkers and the evidence of statistics, there are the strongest physiological reasons for believing that great mental de- pression, particularly grief, induces a predisposition to such a disease as cancer, or becomes an exciting cause under circumstances where the predisposition had already been acquired. The nervous system is a controlling fac- tor in all the functions of the body, even in those of seem- ingly so mechanical a nature as perspiration. How often do we see the sweat stand out in great drops almost in- stantly under certain emotions! The connection between all epithelial cells and the termination of nerve-fibres is now known to be very intimate, and a disposition on the part of the nervous S3'stem to neglect its duty in that direc- tion must certainly allow of an easier departure of the epithelial cell in an abnormal direction. In a person of more than ordinary vitality, where the epithelial cells con- tain a full share of living matter, what great risk must there be of an abnormal proliferation in the direction of that growth which is known to be associated with surplus vitality — cancer! In fact it is a logical deduction from all that is known of the physiolog}^ of the system and of the pathology of cancer, that mental affliction must add to A STUDY OF CANCER 59 the chances of a development of cancer. It is a fact that grief is especially associated with the disease. If cancer patients were, as a rule, cheerful before the malignant development made its appearance, the physiological the- or}^, no matter how logical, must fallj but it is otherwise. The facts substantiate what reason points out. Fourth. — Dysmenorrhcea and other uterine irregulari- ties. If the theory that a withdrawal of the vigilance of the nervous system from the epithelial functions tends to allow them to take an abnormal development, then dysmenor- rhcea and disordered uterine function in general must be admitted as a factor in the causation of cancer. How much may the nervous system be disturbed, its controlling powers overthrown, the mind unhinged by the distracting influence of disordered uterine function, with hysteria, ecstacy, mania, and milder forms of insanity as the result! Let, however, the will of the person preserve the mental balance, and allow the great estrangement to take place between the nervous and epithelial functions, or let any circumstances allow of such estrangement, and how much more readily may the proliferation of epithelial cells take on an abnormal character! Many of the questions suitable to a systematic work on cancer have been left out in this inquir}'. The matters of diagnosis and prognosis have received adequate attention by many writers, and there is but little more to add about them. As to treatment, that I consider to have very prac- tical relations to the idea which has been brought promi- nently forward here, viz., that cancer is to a great degree one of the final results of a long-continued course of error in diet, and that a strict dietetic regimen is, therefore, a chief factor in the treatment, preventive and curative. I have in this inquiry avoided going into a discussion of the histo-pathological questions which are now being 6o HEREDITY IN CANCER pushed with great energy and industry by the younger members of the medical profession. I leave them to the pursuit of the ardent and enthusiastic students, who have already done much and will certainly do more to illustrate the protean powers of nature, particularl}' when under the impulse of morbid conditions. The question to which I have chiefly addressed myself lies behind these histo-pathological inquiries, and is. What are the conditions of the system, and what are the habits and circumstances that have brought about these condi- tions under which this abnormal development, this riotous formation of cancer cells, is possible? What can the in- dividual eat, and under what circumstances of assimila- tion, of nutrition in general, through what irritations, what imperfect processes of elimination of effete matter, can the individual pass to become the subject of cancer prolifera- tion? How long- must the normal cellular elements of the body be subjected to those influences before they will consent to take their " new departure? " Some very practical hints as to treatment may be taken from what has gone before. Avoid the so-called predis- posing causes, i.e.^ unnecessary luxury in mode of life. Especially abstain from eating food rich in nitrogen. Urge your patient to take sufficient exercise; point out to her the necessity of cleanliness, and of avoiding all articles of dress that would induce irritation of the skin by pres- sure. Persuade her to cultivate cheerfulness of dispo- sition, and regulate her various functions, particularly that of menstruation. All this will tend to forestall the development of the disease. But let it be supposed that we have a case of cancer to deal with. There is such a consensus of opinion as to the advisability of early removal of the growth, that a. discus- sion of this subject would be useless. So, then, in the first A STUDY OF CANCER 6 1 place, let us remove the tumor, and thoroughly. But after we have done so, after we have taken it out by the ver}'' roots, is this sufficient? No. We must then adopt the means stated above to prevent a second development. We must change the diathesis; we must seek to modify the patient's constitution so that it will be no longer prone to reproduce the disease; and then only may the surgeon be satisfied that he has done his duty. THREE HUNDRED AND NINETY-SEVEN CASES OF CANCER OF THE FEMALE BREAST. i A r^^vi: J. 'o 2-g i i •tf-a .S-- S.S o o-c s •c ^,-d: stic a [jratio tion dly. le ca :ar pi rt ;i.-.a .ri:|i!JI ° s'.s < M < H 1 to a This patient had had can ed about j years before op jout I year after applica ustic, began to develo]) rapi ly be questioned whether t r did not originate in the s ced. Died of cancer of liver i tcr. The diseased organ \ lbs. Had had tumor of r r, which was amputated 2 y re date. 11 IE; . ►5 = ? CO .s Tumor of $ years' stanc lich there had been frequei ting pain, after some growt IS a' tendency to atrophy, bu e last three months progres lopment with increased pai oved whole organ ; wound It had lancinating pain. No cord. Had severe pain in spinr icd of general cancer ; livei d other organs more or le ited with disease. c.< u S u-c "« 2 ;i2 5 S ^ p^rs > zjoli Q Si ■^l-l •asnB3 o -c r-=i.a b2 -0 Suijpxg pauSissy l.t o X V >'M s s -c~ c u J S.S a M o 5;8 o o o > o -g -a •UOI} -ipuoQ XK)isXq ^ "C 13 T3 ■« 13 •jaauEy jo X;auBj\^ rt r: ■uou + + s -E.isdo -lajjE paAi'j CC " ^ ■asEa + + c> M -SIfJ JO UOIlEjnQ " ■suoqEjadf) jo -o .-^ - - " " - - - ■uoijE.uasqQ jo „ i^ „ o uoijEJadQ }E aSy * CO ■i^ T "^ •jnatu ^ 1 -aaaauimo^ }e aSy n T •asnEdouaj\[ aajjE £i ^ a P " JO ajojaq asEasifj >5 ci JO uoqEjsajiuEi\; .ri .n ^ J J J ^ ■S . ■- •Xjojsih X[imEj u c died of canci of the uterus sister of cane of breast •p9A|0AUl EQIXy - o - o - i'S ^ _^ a'^ ^ •paApAoi iSEajg; ^-p o trj trj to o c •^ ■- c o - •aajpiiq^ jo 'OSt > CO " >1 i-a ^ •-■a d-c ;^-a •uoi}ipuo3 I1A13 rt a ?-.;i rt.H ~ " 5 i- •jaquin^ - " ^ -1- ^ o t^ 1/1 cyj „ u 00 OO a? o? CO € ^ - „- m J^ c? M ^■ ^ u >> >. i; ? < r^ ►^. S s S < -3 1 i 13= H o J. M 13" 3 O a C 3 1—1 00 )_ a, 13 a 13 3 E o 13' > o c te c o IS o c g -a c o 5 C re a a I? p d o a o H V a, Tj- yi o" ■5 5 E d 1 s >v3 i o be 13 ■d 3 « ■d o »-. u 3 O 13 E 5 E 5 13 S P. O u "re O g a 13 S S 13 2 3 ■a 13 a 8 o n, o >-• « o P •d 8 o o 1- 1- c _o a E < lis 00 13 '-3 •^ C r: 13 13 C 3 O o o 13 -a c 1 6 3 H „-Sil3 s & s ■* O m E E o o S 3 H rt 13 C rt S Ml 13 13 013 3^ U -3 c J2 "to t — < & a rt o 1 ■6 2 s o ,a vO 3 S « "1 J £ E >> ■♦-» > c (A" c .2 i o 13 -• M 4) 3 >^ O u o rt o u o .it r> ° .2 a 3 C E O o c ^ O ■2 a. o s o c o c ^ 3 E 3 1 2 N*H o c 13 13 "v t3 o -a TS TJ 13 13 o 13 O O > o o o o o o o be o o o o U) ^ tc J3 13 .J= w *-; Mj= tJOjS M _^ j3 •B bKji « ii ^ ^ ^^ X!~ ^ 43 ii ^ ;ii - ^ "3 03 •5 03 _J. >2 rt 5 ^ o -" in " -d 13 13 -a 13 ^ -d 13 13 ■a 13 u u n o !-• « u ^ ■^ — ^ J5 ^ X J3 03 j3 s O « ^D s o 00 NO ■* •* vO - ^ in ^ 00 SO ■d- ^ o ■«■ " in w ■^ o ■X3 i vO NO vd t^ NO NO ^ 13 ■d • CJ~ o~ oJ" v~ oT 57 (U ^ u u ^ 1^ 1- :-! .s >2 o > .S *-t3 O. au) E 3 > -1 c rt c « o 1) o'S u _K_ !l H n o o » H o n o O c ^ i'S ^ ^ ~ ^1 J3 *ii ;■« iti •E JS ^ ■C (Jh CO .s? bi3 b/3 •c " o c o o p "" 'C •E *"* •c *~^ Is *j~ 13 3 i ■o- a w c 3 o E vO " "2 O. s»> m o 13 "So .S T 1 ii E'S ■2 lil3 E-S n E ■d rt E 13 V u ^13 « -> bb 3 < 1 c 3 >— 1 3 1— > General Remarks. Has had a tumor in this breast 15 years. Commenced to grow and be painful during last 3 years. First operation Dec. 30, 1850; 3d operation May 2, 1854. Have no record of date of 2d operation. Died within i year after 3d operation. A remarkably well developed and apparently healthy woman, belong- ing to a healthy family with no trace of cancer. _ A person of remarkably fine phy- sique, with an excellent family record in every particular. 2d operation Jan., 1853. No further record. In the beginning of 1S50 the right breast sloughed, destroying the nip- ple, producing intolerable stench. Amputation Nov., 1S50. Thewound healed and remained pretty well until Christmas, 1857, when it again ulcer- ated. In March, 1858, a mass was removed, and in the September fol- owing she returned to the clinic ap- parently well. Died more than 3 years afterwards, precise date cannot be given. Noretraction of nipple. Did not conceive until 12 years aftcrmarriago. 6 opf;rations. 5lh operation. May iS, i85-i, removing some hard noclules from skin. Three varieties of cancer : scirrhns, colloid, and enccphaloid, each grading into the other. ■asn-Ef) Suppxg pauSi'ssy dysmenor- rhea, did not nurse last 3 children -s c still-born child 10 yrs. before operation ; in- flammation dysmenor- rhcea ; blow 3 mos. before discovery •uotj -ipuo3 lBO!sX'q T3 _ well devel- oped, good health, now anxmic 1 I -dnojQ - ^ 10 M 1 U33UB3 JO XjaUE^ •s n ■a 'e 1 1 -uou 1 -BjadQ J33JE paAi'j 5 after 1st, 1 after 2d vO + 00 : -asBa ■ "^!C[ JO uoijBjnQ; " + •suopBjado JO -0^ r-, " N « >o 1 -uopEAjasqQ JO 1 uoiJEjado IE aSy •jnaui -aDuauiuio^ je aSy ^ S) ■«■ ■«■ 6- t ^0 00 •T ■asnEdouaj\[ ja;iE JO ajojaq asEasiQ JO UOtJBJSajIUEJ^ 1 J3 rt J3 U .a •^lOJSIfJ XlIUIEjJ > si 8'2 > P. 01 E aj u 2; ■paApAUT Bjiixy •0 - •paAjoAui jsEajg 2 % .to ."3) ■n3-»PIH3 JO 'ON ^ > Si a N •U0nTpU03 J1AI3 5I E'C 15 -S E-c E'C •iaquin^ - S s f? H h < 00 Q 00 in 3 < 00 > 00 i^M >i^ p MOO — .= tt ^ 6 is iH M ?; ^ s (i2 » ^ .„ Ml '-• V c: o c o >,^ > o •a + + « j; a> o-^.a p ^ c u ■•3 "3 E-E < < K m z M O J} 3 ja ■a c: CD 2 o c "3. "S -a c X •a S^ c c •^^ •m M .s'o C I, bca ^-§ O I. c.S •2 3 O . 00 u ^ ^- . 2 o -go '^< o» .2 r re O, o s ^ o imenced during lactation. 2 after operation had hepatalgia; ing of 1870 had epithelioma of uteri. Died Nov., 1870. rteen years before had a small in skin of breast ; commenced dop rapidly i year ago. No r record. :? "« > -a > . •a" re fj-a ^■3 -a' 3 p. ;3&e 12 -5 u « " £ S 5^ fe E-at: &n '~ ^■a ■^1 , ■d -a •a •a 13 ■a ■a •a .5"° S Suppxg p3u3l3SV S ^ u ;-• ^ o o o o ^ § >. o p c B c ^ mX> a C c ■a •a ■a •a •a o -ipuo3 p3isAi{£ I a^ i^^ o _ ^•5 a^ &6 ^ •SS OJ o 5.c "dnojQ ^ « ^ C- vo q- CO ^ " " in .0 ^ ^ •a -a -a 'a _^ TJ -a •J3DUB3 JO X}3UE^ o o re « re « o re « n re w w t/i — •uoi; o E CO d E vO o -EJ3do -isiJB paAiq " " •3SE3 CO d P. vO vO vO -SIQ JO UOTJB.inQ; ■^ « fO " ■SUOni3.l3dO JO -OKI " - " N « M " - " - ■UOI)EAJ3SqO JO „ M m t^ ^ N „ t^ fo „ ^ uoiJEiado IE aSy "^ " •* ^ m m ■^ to •JU3UI O CO -3DU3UIUI03 ;e sSy •«}• -I- ^ "^ " ■^ -^ " •3SnBd0U3J\[ .I3JJB a ^ Ji t JO 3J0J3q aSESSIQ a rt O o «2 JO U0UB1S3}IUEI\[ J3 XI J2 ja ^ ^ ,Q ^ ^ s* u u C ■jCjOJSIfJ XJIUIE.J ri O o aw §1 s c 3 rt ■S ■§ c •paApAui E^iixy ""w ^ o " H ■^ ^ ^ ■paAioAui jsEajg "53 ■« J3 •s •S -a "u "5) "m " ^ ■«3-'PlHD JO 'ON t^ ** vO ■<■ > 1 « > ^.'53 it! 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"^ ■« " rt 1 3 % •a o S is S « ^ G > ■a o o 'g'c 5 Q 1 a, o Si >. ■ S'c-S '^ g g- Si 4) Q, B •§■ o* o CO J2 ■ii o t; 3 1 P S S 2 S o ill % o u o .5 1 •a S 5|| fa •a 5 1*1 121 i O.S'^ - ^ Mi ^ - S ; --c M^ --'°-5 J= 2-p --■d^ -o a p..^ s l&^ <-M t^ •n^ ^^^ •Sj: ^^^ ^^^ a^ « ^ ^ o vO ^ q> ^ ^o m o - "H ? ? ?! *. ■d •g •a u4 "^ •H •H J5 ^ J3 •^ -== j: m vO J3 00 " ;i B o t^ vO N vO " •" « " M H M - M N - - - o " S) s ■ " vO .S E-E "m E'»^ tLT3 5 "3) ^ m 1^ o „ N m -f »o -* "j- ^ ■«- U1 in m lO m tN. t^ t^ 00 00 oo o 0^ ov W' oo 00 00 00 > o c U o rt o. ov ■g w o 15 ^ O 1—1 < a s w o 1 < 1 859; advised t to a "cancer ed with caustic 3, aged 50. 80 -a covered small lich soon com- 3w as large as a > in axilla in- ecord. peration after sease returned 1 organs, and eration. 3 ■a" S 3 a Pi J < 1 fall of she wen was treat led in 186 ; ago die jreast_, w. ow ; is n nd gland further r ■3'^ 1—1 . from Delas. D d interna r after op 2 13 Z. -;n^ "■£0 OJ to ^ii CJ u: nf V E p •5^ O c« S " rt St3 ^"^ "^ to 00 £ > 3j2 - ■3.0 3 ■« S;-3 0. a 1 'w yj •3snE3 c •r 3 Sui}i3X3 pguSissy 8 O, ' tn u CJ £^ ^ ^.j-. & iS m a rt c c 0.3 ^ /3 ■uotj -ipao3 |e3IsXiIjJ T3^ rt OJ tJO-C > 1. (U Is — OH >a E.a ■§1 E.S rj V iOJ= il 13 3« -•s| •dnojQ in fO ^ m ir, m m " m •0 *•» •4-» •d "O 13 •a •d T3 13 •isouEj JO XjauE^ rt .2 CO >-• >< X « '^ E ~ ~ E E ,C •uoij s l-E.iadoJslJE paAii E i i ssus + 6 E >o i £ i -SIQ JO UOUBJnQ « •suoqEJsdojo -Of^ ■^ " - - M N - ■uoijEAjasqo JO sO ^ vo r-l N uoiJEJadQ }E sSy '^ ^ .0 •" •JU3UI vO ^ t-> -33USUHU03 IB aSy "^ ■«■ CO ■* ■«• " »n •3snEdou3j\[ iajjE ^ u JO 3J0J3q 3SE3Sip PS n rt « rt JO uoue;s3JIuej\[ J3 J3 J3 J3 S •XjOJSIIJ XlJlUEjJ III. §•2 = 3 1.1 8 £; •paAjoAui Er[ixy - w - ^ ^ ^ ■paApAUl 1983^3 to *1J to (^. *CLJ ^ 1" 1-i " .^ 1-1 •c _ e a ^_^ ^_^ •usjpiiqo JO -OM > f^i 2 IS N 3 1 > s i-o l!.T3 & i-a & i-fl l!.T3 iii iTj « •U0ptpu03 I1AI3 £•= £'^ ■5 g-n ►0 ■5 E'S tS w S'S .S •jaqiun^ ^ t^ CO c^ 5 vO ^o M ■* ■■o - w g .^ *> .^ ^ CO < « *^ „ ^ Tf to > ji 5 5 .^ ^ iz; b 1—. l-> M M ^ fi c 5 ^• ^ ni ^., M ^• >, ^ c re Sfi 1- 13 1) J> vO 3 13 u, V o nl ■^ 3 <5 13 p ii S ,C •a »J 13 re C o re o 5 3 -a 13 > o c *> o -0 o 1 Ot3 si fa C re S S O 1 2 re 0) 1 fa T3 1 i E 3 "re c 2 13 o o c re s Ml "re s 13' re 3 1 "0 13 a. c £ o s t3 3 ■6 3 5 5 .9 "^ p >< o 01 T3 > .2 O T3 g E >, O T3 t3 C re 1 > O v 3 re E o i Mi g re < 3 £ "i^re "S M ^ ->Q ^ rt u '^ X c o ^ O > •3 X >- >, 3 >, .52 .s^ E E o O 13 aji ■a P3 > o o U c 3 O ■a U rt T3 c o C3 T3 > < 3 > "p. re ■c "re "re > 'S •S-J 3 O fa 13 re 2 o re 1 13 ^ 3- u a ^ :z; ;- >> Q u M) O 5 j: Si O o u >, *13 -a .a Si •5 "1 3 e -s fi c t 8 tr fi ^-^ o £ « o ^ fr, ■a niiS > is u y f a> fc u o !F o ff= FR £ .Q Vr. Z^'C C JJ a c re o o 3 ^ rt > -a O o o £ O O c r2 o > « 1) 1 13 O E ■re —"re 13 o o re re 13 o o MJ3 --■^ 3 Ji re ■a o g j= 13 O O r- jj-'re O o t^ 00 00 r;; m m ■* c^ M M in * " - ^ •O 13 f O ^ ■M •o •H o i- o •a 13 •g b J3 E C:^ ,a j= C^ J3 j; O « o E n £ E NO 2 o E u. T) 6 6 «v. « m E E m ,v. " ^. M N N " o N o ^^ ^^ in „ ^ o ^ lo cr, "^ m Ul ■* "»" ■«- vO "'■ ^ ^. 5- vO S. 00 (7. ^. ■*• i j: % rft ,. Tl •n ^ T3 T3 tL T3 ji^ TI S u S t^ ■a & rt*^ n C £ ^ S S E E = E n T3 .s 13 E = 13 C'C M „ „ ■* m vO t^ o \D VO r- ^ M ^ ^ N N ^ ^ ^ 00 00 N ^ 00 ^ ^ sf) ^ N .^ o" o C m fO •^ M *^ ^ ^ vO S s s o g ^ fa < "3 "3 —> ►-1 bo" r! s.a = = . i? 3 " rt i? i" c J. ^ ^ -cScrt .S -J X g-rt "a 5 III J8& J <: z a O "■' = OJ >-, "III "III •=- 2 .2: :- M if:- p a ^ ■->,S •3sm33 ■w -a ^n N c - u „ ^:2J^^ Snijpx^ psuSissy E "-S ■ 0— 4J .2 ^iS^ 2 ^ ilU - P rt r: ll 1 s T3 "S •n "So -a •UOT} -!PU03 l^otsXqj J-S w^ &6 SJ a=5 "^ g 3 S rt ^ 3"| II " c,S =3 3 •dnojQ - - - vO OD ^ ■H « •J33nB3 JO jC}3UB^ ■g •s -H "o -y '9 •H -H •uoij d -EJadQ -isiJE psAiq a •3SE3 -siq; jo uouBJnQ " pi 6 S c> vO ■suoiiEasdo }o 'o^ - N •uoijE.uasqo -lo 10 n 10 N UOUBJadQ IE 3§v io ^ -^ ■^ '*■ m •JU31U -aonsuiuio^) je aSy ■* ^. i ■asnEdou3j\[ jaijE £ 9 « u :-. JO 3JO}3q sseasiQ ^. *^ rt d rt JO U0l}E}S3JIUEI^ J M .:2 13 u « ti ■5-^ •Xjoisijj X|Ture£ U I/} "3 J feo •3^ •p3A|OAUI BJpCV " " " gg « » _^ „ •paAioAui jsESjg u) Ml "o "sj 'S u J ■c ^ -n n 1 'as-JPnqO JO 'ON > 1 •X- « « " •uoi}tpno3 I1A13 Is-g «■? i-s 5 y; ^?^ 2 -p-Tl - *" ^=£ " ■" " $ ^ ='~ uaqumj^ CO M « c? 00 TO ^ N M a " ■^ ■* co" c^ M «> « - _-d i2 -^ >. -o re re 4 i: -re S M c ^ C o 5 p. 2 S o " Si — > o "a o •T3 >. > ■♦J E o c o g SI o g o T3 ■■3 a is f is ■— 1 re ^ op = re 1^5 • - o ■c.g J-l - 1) E 3 "5 > - o "^ % . > E o 1 re E c o 2 ! 1 o *'.•-; E = 5 o 'c So'a, . c a o — i -0 o >, i « •" d c o re re X O .St: re ^ o Ji uu o 1^ tl E g o 're £ o in o E S So >.T3 C ") I- rt <«S3 s o § s. c J= ."2 o « = uQ re re *i,Ji< . o ^ Tl U1 ^ 13 •n s ■* o cox j: re TS -o o ^ ,, o o ^i H C OJ '" E >» s o u n.« u Z r S!i 11 o ^ ^ " o X O c .5 J s c nxi re >. *-> X l-i X >. -o ^ ■o •a "O -o '2 r- ^- 3 o UJ3 S:j3 ?rx k'r.a k'r^ fex &^ 13 O o p § rt ^ "^ s "3 Ji "3 :=^ lE II 3 H X v^ J= 00 «i. o< t^ m \r% Ul ■^ M N * lO ■^ A r, -rt "H 13 •a •d -rt -o -o X X, E S J5 rt ■§ >. j: •D ^ £ X - " vO t^ - n.. vO - -* ^. . O o t^ " t.. - M - N ^ t^ CO ^ ^ ^ t^ ^ to to <0 -t ■^ ■*■ ^o E^ ro to "^ "'' o_ o .n o rL. 0^ r^. ^ o '^ -^ xn u i" OJ u ^ V Si u S-i ^. o ■2, .ri •in O o ■a re « XI Si « re X X X c c c u c m 3 •a o '-' re "c D. > V. ^ (^ tT H S M) ■Si ^ ■^•^ 4) X tj rt 5: 3 11 O P) u E^o "S S JD o o o O - - O _^ ^ ^ ^ ^ t" m to o XI .tn ^ .iP — — _ ii M « ■^ ^ N vO > > , , "m g Id E-n E-C i- a E o re E "Vd o •a re E T3 E-fi M „ M to ^ !/■ vO CO c> 0^ IJ o O o kO vO o" CO ■O S ^0 m" O N uS .; Wj O > o fi >-> 5 < re > >. § 5 '^ U ^ oui III III E-g .3 rr.;,3'~-^.n S rt ^-B.^ >>^ "_>,„• •^Jg-a -a . 2-3 £ ^ «i— 1 1) < S bl U Z H o 3 ■" t^ ■g ^ o i ^ c 3 iscovered lump in 184 ced to give trouble in 184 tion in 1846, in Aberdee . Reappeared in i year give much trouble till Fe n a mass as large as a gc removed. No axillary ^ ed at that time. Healed 11 for 18 mos. remained sta with pain. It then, Oc rated; axillary glands ii . 1852. Died in spring as had a tumor in left br ars, which remained nea iry till tlie last 18 mont ler record. enses ceased 18 month; lopment, prognosis slow ration not advised. C Skin and axilla involv cin involved and adheren year. Saw it i year ag had existed some 4 ye ntly benign. Operation Recovered from op urther record. a.a '^■S E pJH c ? & > S^'sOT -aO^r Xi ? ra 00 1^ •3snE3 •H •2 a ■E g c .S Suui3X3 p3u3issv 1 ^ t3 SSS o o fH £ e 3 c rt e a n ^"O 3 •a -a -O ■a -a •a ■uoij -ipuo3 jESis^iqci S>S a^ o &5 V ^ ^ M.3 &5 >s.S « ji *B " •a ^^ .2^ rt Ji •dnojg o^ ^ " ^_ .« vO_ ■a •a -a -a -a -a •a •JI33UE3 }0 Xj3LIE^ 3 a n n !3 « •X ^^ J3 E ■UOl} -Bjado -isiJB p3Ai';[ - 0" - ■3SE3 -StQ JO UOpBjnQ ■SUOI}EJ3dQ JO -ON - o o N " •uouEAassqQ so ^ C-) ro UI r-> -* fo uopBJado }E 33^ M "^ m in r-j in fo •juaiu „ o VO »o N -aDU3uiui03 }E sSy m « m « m CO ■3SnEdOU9p\[a3}JE u 1-1 Wi ^ S JO 3J0J3q 3SE3SIQ rt rt ^ JO uoi}EisajiuBj\i .Q J3 ^ - J2 •jQojSlJJ XlIUIEjJ a, ■p3AJOAUI E^IXy - - - " - -M „ ^ ■paAjoAui iSESjg M) ^0) OJ to ■E " " ■" '- ■"3-IPIR3 JO 'OiSE 00 - « " « N •3T3 »!■ -a '3 -a i'^ i"^ i'^ jj-a ■U0pipU03 JIAI^ £■2 £■;: £'C E'C B-c E-S £-n 00 ^ M f.) fo ■jsquinf^ O o <^ t-> « f^ ^ m ■» "2 vO h c? . N _ -■■ r^ •■* Q >^ a S a c j4 :>, 3 3 m ^ >—, 1—1 1— > >-> >— ) . 1 tA c M] C > i -a* gan growing one year iction of nipple. When :came cancerous cannot stated. No further , 1-4 J; -d-d m'-d ■■3 g « 5 •* S 0) ra , - 5 ° > § " .5 -^ g B C 4S a.-a a o ;-< 1 £ g E JJ.S 3 1^.= -ego c s P.o5 ^ )-• .S 3 c S vO a '0 || "3 C ^ >, C 2 1 1^3 " 3 tS ■Kc/2'bj s « 1 ■3 c u 1m > ^^; ^ C P, ^6^1i .£. iz; "O ^ Ji2 P„'H S2 'So -d 13^ n ? >^i. +J '— E q 4) "H £:^ u O B 3 >. Si 'H o S E " 3 la.! ^-g n ■" "O c S c o o 11 2 o c C ^ rt >. ■ "2 °^ &.2 la J3 rt •d •a tj -d -d ^- -d o a5 &£ J3 a^ _ MJ3 < ■d "o 1 ^ J3 JS J3 J3 E E - ^ " - J3 " .. t^^ ^ t^ ^ - " /v. NO - M - " - M m vO ^ „ ,s m \ri -«• -'J' -5- rt- ro " in ■* ■«■ "*" •2 O ^ ^ >2 "3 -Q -Q XI J3 Xi J2 ^ i •s 1) h •S ■5 -.3 1^ E^ p. p< a. o " O " - lo +^ t+-( •a *J In fn t+H "o £ M •c ^ — — ' "^ i-. ■ ^ T3 -* ro m > 3! r"^ ^t 13 T3 D ^t3 ^-n rt (1) rt'B ■u "3) E-n E-S E-a _C E-C E-C e-n E-C _0 E-n ^ tn t^ 00 M N M ^ o CO NO NO ^ vO ^ VD 00 vO ^ NO oT "2 s -■ !7 CO 0- N S-. >-. >i ^ >. c -Q -Q J3 J3 ,Q 3 1—1 3 1—1 1—. 1—1 1—1 1—1 h fx< [K h \^ ulcer- arged. overed ly dur- of ma- d. teadily caused ration, volved V "^ A, . -Si SIS . < s a ■ Pi infiltrated ; nds much en Tumor disc s grown rapic Duration nnot be statt progressed s cement, and 1 from idee dy became ii it t to!" li 42 «J-C3 < a Id z 3 Whole breast ated ; axillary gla Died in 3 months 7 years ago. Ha ing the last yeai lignant growth CE The disease from the commei much exhaustio Axillary glands near termination. « £.5 oil 5S — ^1 .2 3 S.2 55 1^ If .S it ?^ r- « ■lU 111 1 p^ E g-si „ "g^ 0. :asnB3 3ui}iDX3; pauSissy .0 •a o| ■0 8 •s 1 0. = « ii 5 r^ ct) ■■^ E-" £ 2 ^ - n ;>,o a = .s c XI -i-a ■a •a •0 (U u > •s ■0 •s •uou _ (U 60 -ipuo3 IwisXqj M.5 "0-3 tJifl £> i •5 j= H^ S.S y li-^ > >5 J •dnojQ - ~ ^ ^ •* CO ^ ^ " ■a •0 •0 ■a 60 •0 -0 •a •a •jaouE3 JO XjauE^ "a ^ a •|l a >< rt s ■UOI} V V -•EiadQ JajJB paAiq -■^ •aSE3 ^ -SI(J JO UOUE.inQ - ^ M "■ t^ •suoqEJadQ jo -o^ - - M - N •uoijEAjasqo JO t^ „ „ »n t-^ \n uoijEjado IE a3y "* vO '^ ? "" ■juam CO ^ 00 -a3nauiiiio3 ie aSy * "'' t^ '»• r^ •asnEdouaj\r .tajjE ^ ;.■ •„ t-, Si u JO ajojaq asBasiQ S B *^ ^ JO uoi}EisajTaEj\[ ^ J a rt ^ ^ rt u -^ XlOJSIJJ X[IU1EJ C n! u J3 •Si is •paAjOAui E^itxy " - " - -0 Is ^ ^ •paApAui ;sBaja *fij tfl ^ in tn "o SO i-> :-• ^ i« P rt rt s ■uajpiTq3 JO -o^ 2 ■^ > S 1/1 ^ 1 S > l^ i-Tl & J ^ y-^ •nonipuo^ 11A13 ^ 5. Si M •§ i=.2i p.-i 3-7- " ■« " ? " xn ^ ^ ro ^ 2 2 2 ■.^ ^ ^ < •^ S 0" " 1^ iS Q C 1 S ^■ „• >, ■K „■ ^ s ►-> >— 1 3 M PS ?M 3 O .a 1 o ■a c .2 1 3 C ■-3 1 -a ii c rt •a I ■5 rt ■3 > an. 11. 1S65. 2d 66. Died Sept. rof No. 54. At ew ganglia were illary developed tumor. Com- ant growth can- in May, 1867, a ved from a part a n V ■O £ >. 1^ ^ ■o p rt li cc — t- c> _, "" c^ III o o o U Si J2 r; o E 3 O O o > i| •5 ? « 1 3 i 3 S rt >, rt £ rt K rt* O 5 o 1 J3 S _rt rt 2 ^- - -^ rt « =.£.« . 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J0 340J3q3SE3SIQ; rt a rt £ JO uoijEjsajiuEjM Si Si J2 J ■Xjojsijj A\wck^ "E "o. •i •paAJOAUl Eiip^v " « - " ^ ^ _ •p3A]0AUI }SE3Jg "u t! to "o "oj "a CO '" 1 » ■- ' "* ""* ■ ' - s •a3ipi!q3 JO -ok^ N i« ■<• CO > •uonrpao3 PA13 •i-g 1 a% N ^'C b"^ # §"3 c'S ^ = u c n C t- ? vO „ f^ ro ^ •J3quinj>j M • f^ t*i r^ trt ro ro M Vj CO CO CO m " CO . f* co" • < l-« ^ Q Q 6 1-^ C r! >— > ►-^ rt >-> ^ (^ ' 2 ~o i< 2S S > -^ -s: ~ £Z ^-S ^ ^ 5 i'i< ^" i— 2 o S o* y M o .^3 E-E: .'"cCi'o ^"] o^ §_, C c « " O ^ >>-5£ „ o-r; ■§£.:: y^= 5 2 S.-C =^ so 2--'S ■S-P i: o n ■?^--^ "-K-o H c w.-^ ■■S'E .2 ^ ^s K 11 ^ " c g » - ^ II ^ ^ ~ - O „ in o CO U1 o m t^ •^ o \0 «1 ^ l4 i) 1-1 u ^ 0) 3 ^■ J Si J - - " o - - To To S jj CJ o /3 2 2 t> 1 il "I ■5 o o o t^ o CO so a r^ r^ t^ ^;2 J, bo r M .^"S r;;^ J: i >>i-' tf o"S 2 u c aj 00 OJ ■S !U"St3 P^ 2 Is'^'-i- Hj§ 1 ii'EcJ HS-reE ^ ^ *u 3 jr a. cj aj re D a« . .2 a ^1 " ' '^ .a- roT3 - 1^5 bibrj'a. .^ rt 3 « < m PS J 5-5'§-5 "o jr, > ° Oj ^'.5 ii>JS - s iii--5 «a EO BJ= X E^Z •i' •3snE3 3 c c" •H -d u "S Suqpxg pauSissy 1 ^ = .2.0 « a u c: C « re u c C c J.'O _ QJ > bo _tf "UOTJ OJ bO ^ ^ IH -ipuoQ lEOisXqj ^ --£ •3 •£ S w ^ S ^ j= 5 S1..C 3 ■S c "3 '■s •dnojr) t^ « o> « in m ^ t3 •.I3DUB3 JO XjSUBjV 1 "2 .^ "o 13 u re re ^ .« e .fl ^ ■S •uoii II -Baado -layE paAiq •3SE3 m II *v. -SIQ JO UOIJBinQ "'■ _ •suoiiEJsdo JO o^ * - - - •UOIJBAJSSqO -to o> ^ in OS t^ uoijEjadQ }E sSy t^ -f 10 -^ \o •JU3UI 00 00 „ - t^ z N -33U3U1U103 jB aSy t-N ■<■ ■^ t^ m •asnBdou3i\[ jajjE u u « u JO aaojaq asBasijj *; H 4-» .S .2 ra £ rt JO UO!}B}SajlUBJ\[ « c^ ^ " is V •a C n •iCioisiH XiiuiEj sum n I. > I- 5!"5 •a 1 S2 •= S rt t- 3 J3 j: ^^ « a a. ■3 •paAioAui Enjxy - " - - ^ ^ .5 „ j3 ^ •paAjoAut jsEajg "^ *a3 Ul 2 .M *3J ^ •c •"^ •c ^ *n *"* *"* r-3 __ 2 rt •«3-«PnHD P -ON ■*■ « <«• ^ % vO > 1 1 i-o 1 i-d ■s-O 1 iIt3 •UOpipitO^ IJAQ •0 '0 E-n •a rt V ^ ir. \0 1^ CO c> M •jaquin^ t^ t^ 1^ h. 00 00 tn «*> CO ro •^ t^ fo t% t^ t^ ^ (^ CO r^ 00 00 00 00 H -1 00 M M H oo" 0" M cT ->! fO M 00 N M fO -r a c s ^ Ul J ji ,a 3 3 "3 ■< Q £ £ lo B in f ill " ^ " « "■'- 1 o o S 5- E o S || c o ^ > T3 i 1 CO a g = 13 — •a •2-d S c .- '^ Is, 8 v.. u •B o ii "S. .£■ -o" 12 ■a c « "3; "3 m -a a. O >-■ Patient weighs 250 lbs. Tumor ry painful, nipple retracted. Su- rficial ulceration around nipple. further record. i -a 13 W s c £ 3 8 c re tr m & re >. E 3 B 'c m r| « _o £ >. -at 1-1 :h ■c 3 E 1-1 13 -a <: c S "3 § A U if 00 _o re H, E «!; 00 .a" re 1 re 3 13 > ■3 g 3 H If - D „ ■a re ^ « P. S3 4M _re re 3 13 CO J= >-. i QO E >. h t! - o s s ^ 2; > S.Z ■^ 2; B U S<^ s 'S Q ^ ^ Tl d Ml •a >. o 13 „ ^ a -a u r. E P 2 o o 3 1 E ifi h. ._o 3 1- >> h- rt Xi c c -Q .3 „ O to 13 ;:^ > .t. •.;^ MJS n v3 ^ a fH rt _ S3"« T3 ft" 2^ ^ 'B > Sj.C 3 ^^ & a, > « 00 ^ ^ ^ u, « - .0 .. 1 13 13 "E 'H •T3 •H 13 "^ ^" ^ J3 J3 ^ E O S II c o< .IJ — - . « *v. II " vO - * - O H n m o \D vO fO 10 n ^ m .n '^ u^ VO "^ vO ■9- * m 1- - ? 4- vO a> vO ^ /*-. ^. t^ -*■ 1) u . 00 ro PO PO .^ „ „ •^ *- •1 M HI M ro PO (S 13 a < 3 1— I g "—1 i 5 0" 1^ i o"— 1 s3 0, ? 5 •5 g c" 3 -a .& a Pi < a 2 M > p w >> S ?i S o< 5. _ £=►£.2.^ - ^a OS s 00 E 3 H|| U ^2 P a > '^ -a •0 -a •a 13 «"o 13 - bJ] Suijiaxg pauSissy 8 S « V >> 2 £ >-• ;- u 1 2^ ;-< X3 2 c c c p « >. r! 0) bO _i •uoij c > .^ >2 3 IS- 3^ S)5 ig.=l £ ■dnojQ « vD ■ > " c c k" 6 ^ iz; P Q •-> >— 1 <* "^ aJ re" ^•- §"0 ffi-?„= 2 !a^«. re "7 "S *^ >> -S^< |.| ^ p T3 ^/^ O E Oi OS c.= « •— ^o-a = ■7 re c .£ rr^ t; re r^ S fr d c-M re ir-H luJreTJ > (U E.-sS-p -0 re ^ ^ ^ ^0 1^ Oj i.^ (/! ^-^^^ ■a 3 're '^^ c c = u p r^; IJP"^ ? ises w re died No ij a, A-%h Me Die no sister are. pa 1 HWi s-s g s - O -^ OJ P^ re >, ^.--c^^^ n' cj J2 ^ ^ o ■-3 s t. o on. 'o D, 5) ^ ffiS c P i^ lo ^ to "5 a, P o III «a " vO t^ 10 " "^ - " ^. - ^. vO r^ in to M ^ n- r^ 0-. ^ m ■" t^ " vO cQ u u :_ Ji £ ;.< '^ J2 XI J3 re -2 >S.y "a. .2 u a 3 g -a g TO U5 " " ^ ^ ^ _^ ^ ^ _^ To "si "bhl fcO <^ j= "v « ■5 -Q ^ ■- ^ ^^ '~^ '^ •c & s D S , V 5 & , S to re"^ re"^ re's E"S "S 5 _-2 Id E-S to -t to r^ OD M N ro ?j ?) M It < years ago. Ampu- ago. Has a numb t, as if standing on returned m cicatrix, studded with tuber- little more than a on. ed. Tumor size of , pain. No further ■T3-- CI. «i . cs-3 = 12 B;^ of mor 8 months ago, eaning child. Nip- d. Advised opera- r record. of cancer of tongue, jf uterus. Father other to 80. Was 2>^ years after the a — M). < "^'s & ■■"s = &-g_S u .i:s^ *j c 5 OS a z a O ■-3 g II c s^ i 3 ■21 0^ U >'2 "^ 8 •£ ■- St 1"^ 4->ui(jcCcjX t-v.. bJ30 vO C1.-43 I. « •3snB3 S =• C •0 •s 1 13 2 3uiji3X3 pauSissy S y 8 y M ■ Sn IM ji a ^ & „ E i ^ S?o M « CH s S 1 ■n -§ •uon .J3 bOJ3 1 c •S Mj3 .="'3 ■5^ •dnojQ ^ ^ ^ c- ^ ^ ^ .n -a T3 T) T3 ■d 13 •J3DaB3 JO XjSUE^ *!«. is J5 '^ ^ 13 J3 ^ •uoij + II -BJado JSJJB paAjT « ■asB3 + II -siq; jo uoijBJnQ •SUOTJBjadQ JO '0^ « - - •uoqBA.iasqo Jo N W in „ N uoijEjadQ ;b aSy 10 m '^ ^ ■* ^ in •n •juaui s> <> Ov ■«• '? -aonaiuuio^ k aSy m 'i- ? * -* •^ m .n •asnBdouajAj jajjE ■u u io aiojaq asEasiQ; « « >2 « CS 13 CS ij JO uoi}EjsajiuBj\[ .2 J3 , .2 ■.3 •XiOJSIfJ XjIUIEJ If s E g a. .2 !2 B ■ .2 fc" 9 53 •paA|OAui Bljixy H - - " ^ ^ ^ „ ^ •paA|OAui jSBajg ■a « !2 2 .■y) .a M-l ■rt •u3-tPlFl3 JO -ON 'i- M M " > Ul N 5 .S b'^ i-o •ao;}ipao3 11A13 E-S £■= E-c ■5 S-n E-n .c S-C E-C HT N !^ fi ^ ^o vO CO OD 00 CO CO '^ *^ t^ !> N - ^o" Q 3 fe. a C a 4) c 3 ■g ■jj S < — 1 "-g P- oj 5 °2 ^ ^ Is -a "2 c S ^x« t^l =-'^ g>.S> S^ S = £ I c .;- o- -5 £■ ;i^i ■ s . I. u ' o— ' ^ 1) O " - '-^ «-■ --,;.« 2 "n t/3 g a" g. aT-C |i '^ o ^U "a, a . •c« o c c s - o M „ "■ O M .— 'O 4J 6-3 O rt & C j:.£ 13^ "O^ ■^ S O « O o rt h o 11 .S''rt 6 E ^ /v. " * - » „ M ^ m „ in vO * xn "^ vO ■ •0 ^ -^ ■* S u u s s rt "o rt rt *QJ Ji ^ ^ ^ j_. ^ "u To "u •s •^ T ^^ ^^ Xi •s •c E-c 3 3 3 re cj.H cca- ter, s in ins. ous ch, in '3, -p Er ■— o.S.ii « 5 re ™/5 w fe g M B..S -a ? = c.:= ^ 3 ^ s|l Mp:|fa < a < <5 U O 3 B Amputation Septem ealed and remained eeks ago; when, hav le, she was given 18 di ndie's solution morp lich she died. 8 S -o-g" _S rt ^ K Si « ■-353 'm ^ OQ c c _o re 0. E "3 . «T3 re Fell and broke her ruck her breast at point months ago. Died of tie less than i year. Pain at time of blow, anal twinges, about 4 n ere appeared four littl east, which gave lancin ley increased, and r owth resulted. Aniputat 77 ; second operation f ovember; third operati W ^-S So? ■S iz; 2; Vio-^ •i:55H &'^2;-£ a ^ m •asnE--) re 4-. •g 'S ? ^ '^2 re Sujipxg; pauSissy It'' li .9 u " 5 ?o FF ^ Z° ^ a a S ■n •uon -ipuo3 IE3IS,iqsi ■a •5 C^ w •dnojg « « m ^ ^ N. 00 •0 •a •0 ■n T3 ua3UE3 JO XjauB^ re "o rt ""■ JS *v. S re •UOI} -B.i3doaa}JE paAi-j •asEa (•» 1 -SIQ JO UOqBJHQ " •suoiiBJadQ JO -Ofi - - •uoi}EAa3sqo -"^ r-> CO uoi}BJ3do }E aSy VO t^ "" r.. >o •}naui t^ t^ -a3u3umio3 }e aSy t^ ^ ^ •asnEdouai\r ja}jB u u k4 ^ ^ >.. I, JO ajojaq asEssip a Si a a ■^ .t; rt d £ JO U0I}E}S3JUIBJ\[ re re c Si CJ3 •XjO}SIJJ ^[IIIIB_J E 1 3 1. rt sfi c -S j= w ■pSAJOAUI B[[ixy - " " " .^j ^ ^ ^ •paAjoAui }SEa.ig .a" " _bp - " _M1 - .2i •rt t^ "s •uajpnqD JO -o^M > " > >o s & & s « , & -> 1—1 1— > (^ 1 T3 O O be "? jT J) J3 3 J-. "go 3 3 E<1 E s 1 t3 P S're b/) ^2- 4-. O "re -a o o ■^Ji •^ E-S ■t;; > re ° ■— .« Mo .3 o M o i^ TS 1-. «3 Kg O u u S o < >< OJ 3 T3 O u li .. <^ ■ S a. US' - la « S Si:; 6^ - >. 60 >^ - o " ^ > 5-c J3 5 to tjO g 2i ai o :-< >> CI >. " O e ■y 2 -g "H re^ -s o^i: ■* w « n cfi t- ^ o S n is ,, u V4 5 ^ u o 2^ !^ 3 r* E o o 3S JriJ^n 2 s o !P o 3 ° rt >Q rt rt >-. -Q"S c !« 3 3'i; JD s ho a, uT C g '3 3 '0 o o ■a 3 ~ O 15 bo 3 -a § « 15 li > 3 5 > 3-Cii pore i o 00 ir, n N in fO f ■«■ u, U1 ro ^ m oo ^o vO vO o" ■i- t^ ■" m " "■ -a- OJ Vo aj 1 C 3 1—1 "3 1-1 "3 1—1 •Sli = a"^ ■ Sis 1) ^ SiJ "o ^s J^ ^ _: pa °> > a ^1 rt2 Kgg; c .2 « 5 11 re ui -a S g" r:-"" . i-< '3 -j^ Is^ re "•- •d S ^-^ s a| re 3S° SI 05 < "_5J S bjO 13—0 2m, -gHg i^ '^'A o 1. a " H z re a. y !- Jf3 i ° r y ■5 E"^ o^re "t3 o -1 o re «>I7 ■« o art OJ £ :j- . "■a ^1 O c JJ c «-□ . re oj M re"^ CT3 re = «=1 -^ re -0 c = 3 'S ^11 •^1 03 •3snB3 t^ ^ O C ^ re v-O"^ E S a E <" u c Suiipxg psuStssy w "^ "'-= «.2 M rt nl ^Jjrt.O .2 "2'^ ■" S jHsl la s Ss ^£"3 E M £ re 5 ? 2 n >, njtc >% re ^ re -Q re >, J3 >, re .3 O S -o T3 •uoi; fc/j-S 9 « .tpno3 iEDisAl[j S •dnojQ " ^ o o ^ ^ -a _j_, ^ •d ^ U3DUB3 JO XjSUB^ n.. rt. ^ o o s j; O o.. ■uoij -BjadQ J3JJE paAiq •SSB3 -StQ JO UOtJBjnQ •suoijEaado Jo ojij O «■ o o o •UOHBA43sqO -to N „ 1^ uotiBjado ;b s3y -i- ^ •^ '4- •}u3ai N O o vO N « -33U3unno3 je aSy ^ •o ^ XT, o ^ ■^ c> ■3SnEd0U3J\[ J9JJE >-• u ^ u " ^ v^ JO aaojsq 3se3si(J a •in o re re JO uoi}e;s3jiuej\[ J3 ^ re J2 J3 Si C a •a o o •Xjoisijj X|tuibjJ c S'S. £ S a, £ 3 5 •paAioAui Enixy - - o o ^ ^ ^ ^ •paApAui iSEajg ^ .M ^ ^ ^. - .bO .to •usipiiii3 JO -ojsi 1 O O ■«• o> - t^ i.13 ^ re ""^ ? i.-a ? b'« b^iS E-c S-c -3 E-c -o ■? E-C £-^ £■= U-) oo M N m fO irj m vO oo CO oo CO TO 00 CO H m i:^ tf (> ■* ■«^ i vK t^ Q >• bJD ^ ^■ > o > o > o O OJ '—> < o o ■^ :2; ^ fi « CO p G CO ^ ^ 1.S ° ■a B p.( "-T-r s o o^ = > 5 5 0) . 8 E e^ .S ■" to -a ^ o E >.g u ^ S g-a « § I § a-s = « t-.s-'-s g « w'C cS S.S go, o « I. c „^ Ml rt u « V -^ a ra t^ S «J3 O^ iT3 O 00 <^r^ P C !U 8 nd I- c t^ 3 re o 0) -rj-^i ttj a J2 (u 3 Jo S^ ^ c ^ S^ C g eg" « -3 S So Mg S-'^ " S C 'O^ -^ C . £-2 ■^ O-O i; e « Q Ji >= 00 X o^.Sc c.i! -o O + o ^. s s " " - - - - - ao 00 vS o s, o s, o o^ . o oo A.. Ov fN. t^ irl lO ■«• lO « u w I. u JJ "^ o 01 J3 Is rt Is "« •2 o-. O O J2 E^ o H O - - O _^ _^ ^ J3 ^ ^ *S ba M S bJJ *"• '~* •c •c "" 1-1 >-■ s , & ? 4) o 1 E-C } E-C re o E-C c'C O o -a 1 fo ^ u^ 00 o M N >o vO vO kO M) 5" 00 si ozr^ 6 ii 1) . M •aSHE^ T3 - „ >,_= g'3 i t •p 'P Saijiaxg; pauSissy 5.2 " P >■« "rt i^ ^ " 5 u S 33 s „- "c.^ S ;-, ii .SS e o'^ 3 u^ .a -3.i3 M s c c . C 1> 4-» « its C4 to c^ c> ■dnojg j; "- to " ■^ X " °°~ '^ -d 13 ti ■T3 -C uaanE3 jo Ajaire^v s rt « rt rt ■uoij -EjadQ JajJE pa-'ii'l •asEa ^ -ST(J JO UOUEJnQ ::= •suoijEJado JO ox 1 •uoijE.'aasqo Jo n ^ ^j PO uoijEJadQ jB aSy ^ 1^ ■^ 10 ^ •juaui ^N -aoaainmo^ je a§v ro •a- 1^ " m ■a3nEdoaaj\: jajjE U « g 'd •_ ■ P 10 ajojaq aseasiQ i; 0- n- ;o nonE5sajtuEj\- ^ .a .0 J3 .2 ^ S a " ^J: .2 .15 = ^ _- '/J *S 'd s« i§-i £'2 ■5 rt ■jtio;siji ^Cjtnrej .2 ^ ■''S CS __^"^ t- ^ i^ :i j; ^ "ti " 2 ^ ij .. P C — ■^ s £!• S >, "m a, 13 = a -i2 .^ •paAJOAUI EIJIXY - - ^ ^ ^ „ •pa.vjOAut jsEajg CJ ^tfj - 0- .W '^ _c/] '^ ■"S-iPimO JO 'OX " - „ - , ^ S 1 u s •noqipaoQ ^tAQ " j:-? S.'l ■^ M _o K? s? •0 '" " " - ? w S " ^ ai to » fo ^ Ifi CO M S s r^ t^ t^ E; t^ 00 o> a H < J ^ 1 oT CO - 00 00 Q ^ >> >-. > > > o- i==i < s s 1—1 . "— > ^ ^ iz; 1 o r; £ c i o 3 b> 5 1 5 o u 1 1 g c ^ o ti t> > -3 o ca C o r; ^ •3 c <; = U IS S > 3 . a >. tl 1 r: s ,5 rt 2 a = 2 3 O <-> •c o c •c o 1 i ^ >i V c >> rt 5 T! o 25 u OJ IS 1 3 5 eg =0 rt - -o > c ir o -3 St) s -c ■a 1) K -a >. -3 ■a rt s >. u ■p > "■ ^ c > .'i. ,, a - V a a. J ■J5 !_- 1^ z j; c >, ^ "^ — ■J fa ^ o > o p o 0) fa >< 5 CJ U & J < 2. X t^ t^ > o "3i J3 3 .2 O 5 ■3 3 f3 Eg 2Z t£> -a rt J 1 O OJ O "5 o OJ G O o" ^ O 2 ■-5 "c - ? ■^ - "ii = 5 = ^ 2 Q 2 CO ■— 1 « •a ^ >> 3 o 5 >. ■H o § "2 o 3 3 E CO o f^ « ^ % ^ ^ ^ r> =* ^ •^ .:i )-• £J s „ p =: o c t£ >i o o g o o o o o 9 1^0 o w^ r: J r: .1^ .n >. c rt s 5 rt' > •a •d % a, « 5 ^ ^ t^ c^ O o o ^ ^ ^ ^ m *^ " ^ T! T) TJ T! T! T! Tl ■X3 Tl •a T3 - - - — — — rt - g - rt ■a — rt J5 JS 5 rt - - — rt H — — — — — — _ — — — — — _ — — b^ ^ t-> ns lO si o vO iO ^ "l- ^ £) "^ ^ lO o ^ ,n ^ '^ u^ i) ■i- ■ o u-1 " > _1> , S S S ^ S V ZJ , , ^"S s o O o p-3 ■--a Tl Tl •a c -n S'S g- J "O •w s S S S •w •s - E'S S f.] ro -* m -o r^ CO o n HH r) ^ % « ■ft O O o^ o o O Q n o o n o eg o CO CO CO ■^ '-' "-" "-■ '-' CO "■ '-' « ?> N f? IT ^ „- 00 o ~ CO O co" o" = J ^ ^ V- u ■- >> >> >. n. ^- „• •— > Cx. rt fa s < < s >^ •^ OJ o O < S a < a u z Id O Never pregnant. Constipation and hxmorrhoids, dysmenorrlioea and uterine, enlarged glands above clavi- cle, nodules in skin over breast, liver enlarged, tender ; constant cmesis. Lump discovered two years ago. Breast enlarged five weeks ago. Lump discovered almost immedi- ately after blow. Grew continually, and in December, 1880, ulcerated. Advised amputation. ■asnB3 Smjpxg; pauSissy no record pressure from stays blow 3 years agOj affliction at tune of injmy ■no;} -tpno3 lEDjsAiid: good flesh fat, for- merly thin well devel- oped •dnojQ «n CO - • J30UB3 JO XjauE^ hard soft hard •uoij -BjadQ JajJE paAi'j •asBa -siQ JO uot;EjnQ[ •suoi^EjadQ }0 'Of^ ■uoqBAjasqo -lo uoiJEJadQ }E aSv Z ^ ? •4uaui -aDuaaiuio^ jb aSy 5- % ^ •asnBdoua j\j jajjE io ajojaq asEasiQ JO uoiiE3sajiuBj\[ before before ■Xl0}SIJJ X|IUIBjJ cancer and phthisis phthisis •paAjoAui Eiipcv H >-l •paA|0Aui }SBajg right right ■°3-'Pim3 JO 'ON r^ « •U0I}ipu03 IfAlQ mar- ried inar- ried single uaqum^ 00^ a h < 1 i eg c 13 "2 -^ S