CANCER OF THE BREAST RECURRENT FIVE TIMES IN 30 YEARS.

909 Too clear a view of the rationale of this grim universe would have driven whole generations of men to despair and to suicide, as it drove that strange materialist, John Davidson, not many years ago. Davidson, a most amiable and gentle writer, drowned himself deliberately because he had come to the conclusion that mankind, a terminable and evanescent phenomenon, is God in process of evolution. Swift devotes many pages to the effects of the vapour of madness upon mankind. Every species of it proceeds from a redundancy, but it is always produced in the same way-by a rising of the ingenious particles with the vital liquor, producingan abstraction of the rational part of the soul, which, we commonly call madness." Swift’s correspondent, Henley, notes that talking to oneself is esteemed a sign of madness.’’ Pray, doctor, let me know whether writing letters be talking to oneself." Swift, however, quotes an Irishman as saying that the difference between the sane and the insane in conversation lies in this, that the lunatic blurts out whatever comes into his mind "just in the confused manner as his imagination presented.the ideas." The sane, on the other hand, he said, weigh their utterances. Swift writes of the madness of nations and its causes, and cites what he believed to be the long insanity of the Puritan Revolution, but his own diseases he cannot diagnose. His deafness, believed to have been caused by disease of the semicircular canals, he attributed to his excessive eating of apples, of which he once consumed about 120 in a day. He notes in his "Journal to Stella"his almost daily struggle to eat fewer apples. His deafness was doubtless contributory to his insanity. He was stone deaf for a year or so before he died, and at the same time utterly silent. During his last period of mental gloom the Earl of Orrery writes to a friend bewailing the overclouding of the once brilliant intellect, and notes with what horror Swift, himself persecuted at the last, had always regarded the madness that in individuals has been the result of persecution. Perhaps with premonition of his own fate Swift left his fortune to endow a madhouse.

good over evil.

As might be advanced cases the most were numerous. fairly expected, The general practitioner will doubtless take an increased interest in tuberculosis if his aid is cordially invited, and as time goes on the disease may then become recognised in a more incipient condition. The term " early case" has gradually become almost synonymous with "a favourable case," and this is to be regretted, since an "early case" may be an acute case and quite unsuited for treatment in a sanatorium, a hospital being the more suitable institution. We recommend Dr. Macfie’s paper to the careful attention of those responsible for the institution of The want of "sanatorium benefit"in other counties. is greatly accommodation and sanatorium proper hospital accentuated in some districts. The reason for this is to a large extent financial, and time alone can show whether existing institutions can come to the aid of district authorities in a satisfactory manner.

duties, and not attempt any overlapping. the

CANCER OF THE BREAST RECURRENT FIVE TIMES IN 30 YEARS. " UNDER the title "Non-malignant Cancer of the Breast we discussed recently an Australian case of cancer of the breast with a duration the greatest on record-47 years.l No operation was ever performed. In the Edanburglt Medical Journal for February Mr. David M. Greig has reported a case of cancer of the breast of remarkably long duration, though far short of the period just mentioned, in which The patient recurrence took place no fewer than five times. was a widow, aged 71 years at the time of death, October, 1903. She was unable to give details of family history. Her only child died at the age of 40 years from jaundice, the history strongly suggesting a malignant origin. Except for the breast trouble she had always been strong and healthy, a splendid type of hardy Highlander. In 1872 she was struck on the left breast by a cow’s horn. Eighteen months later a little hard nodule appeared at the inner quadrant. Towards the end of 1873 this was excised by the late Professor Annandale. In 1881 the growth had recurred and he removed the entire breast. She remained free for seven years, but in 1888 recurrence had again taken place, and Professor Annandale SANATORIUM BENEFIT IN EAST ESSEX. removed the growth. She stated, and the scar indicated IN another column we publish a report of the first 100 that she was correct, that the axilla was never included in cases recommended for sanatorium benefit in East Essex ;; of the operations. In 1889 a third recurrence was it is written by Dr. James D. Macfie, tuberculosis officer to any removed by Professor D. MacEwan and Dr. Templemore. In the Essex county council. After describing the manner in 1894 a nodule appeared in front of and below the clavicle. which the county of Essex is divided for the purposes of In 1898 she first came under Mr. Greig’s observation. She administration, Dr. Macfie proceeds to give a brief account was a healthy, hearty-looking woman able to do house of the work which has been accomplished. The report is work and attend to lodgers whom she kept as a chiefly of value in drawing attention to the difficulties means of livelihood. An oval tumour, measuring 6 inches which arise under the scheme as illustrated by the expein its longest diameter, projected above the middle riences of the three officers appointed by the Essex county of the left clavicle, and extended down to the lower council. In the first place, it was found that the three The overlying skin border of the pectoralis major. areas were much too large, thus thoroughly justifying the showed some telangiectasis and several large veins. The original report of Dr. J. C. Thresh, the medical officer to tumour was soft, and in places suggested fluctuation. It the Essex county council, who had advised that there should It was excised in had all the appearances of a sarcoma. be nine areas in all. It is to be hoped that other county and was found to consist of two parts, each 1898, May, councils will take warning from this error and assure themsoft and encapsulated and slightly lobulated. Though selves that the number of tuberculosis officers appointed being was no evidence of involvement of the axillary glands there will be in satisfactory proportion to the insured population and the manner in which that population is dis- they were removed, as the original tumour was described as The wound healed by first tributed. Dr. Maone points out that a great difficulty hard, suggesting carcinoma. Five intention. months later she was complaining of pain is found in dealing effectively with thinly populated in the left shoulder. About inches from the outer 1 districts, and unless this is borne in mind a partial failure end of the clavicle a vaguely defined soft swelling had may follow. Attention is also drawn to the paramount above the bone, which seemed to be inimportance of the complete cooperation between the medical appeared volved. Both the tumour and the clavicle were removed officer of health and the tuberculosis officer. For the smooth It was found necessary to remove also the working of the sanatorium benefit, however, it is essential together. coracoid process of the scapula, as it was obviously that, whilst cordially supporting each other, these officers should confine themselves each to their own particular 1 THE LANCET, Feb. 22nd, 1913, p. 552.

910 :affected. The tumour had extended underneath the pecto- through gardens and yards in which it is exposed to faecal ralis major. Complete eradication was impossible. This pollution and receives slop-water from houses. The stream operation was followed by much greater relief than could supplies only a small portion of Ringwood with water, but ,have been expected. The wound healed well and movements the ordinary sources of supply are by no means free from of the arm appeared to be limited only by the cicatrix of the danger, as they consist usually of shallow wells into which operation of 1898. She continued well for several months, soakage takes place from the surface and which may also .but towards the summer of 1900 recurrence again took place. receive polluting matters from neighbouring cesspools and It is surprising, as Dr. Macewen observes, As the growth increased she became more and more incapa- leaky drains. citated for house work. In November she was admitted to that a place of the consequence of Ringwood has not the Royal Hospital for Incurables, where she died in long ago been provided with a suitable water-supply of October, 1903. The immediate cause of death seemed satisfactory quality. In this and other matters, however, to be debility, which was accompanied by marked emacia- the report shows very serious defects in the proceedings tion, and was doubtless hastened by recurring haemorrhage which have passed for sanitary administration in the locality. The tumour re- Dr. Macewen ascertained that the first case of enteric fever from several small ulcerating patches. mained soft until the end. For some weeks before death in the town occurred on July 18th, and that by Sept. lst there were pains in the chest and lower limbs, suggesting 48 cases had occurred without any adequate measures having -vertebral involvement, but the necropsy showed that the been taken to investigate the circumstances and check the growth had perforated the chest wall and extended on to spread of the disease. On August 31st, when the official the pleura and along the line of the ribs, while down the inquiry was ordered, the Local Government Board had been spine were many secondary growths. In consequence of unable to obtain any statement of what was happening, the nature of the recurrence, the appearances of the beyond the bare figures of notified cases, from the district tumours, their softness, the rounded bases, the encapsula- council or its medical officer of health. Some hospital tion in the earlier stages, and the absence of glandular accommodation of an unsatisfactory kind was improvised involvement, Mr. Greig had no doubt that the condition in August and some tardy steps were taken to secure was sarcoma. However, Professor L. R. Sutherland, who safety in the disposal of excreta from infected houses, examined the specimen, pronounced it to be alveolar but as a whole the facts given in the report cannot be -carcinoma. regarded as creditable to the local public health service. We read that the attitude of the district council has caused much A DANGER TO HEALTH IN THE NEW local dissatisfaction, and it is to be hoped that the sanitary IN years past, when elementary considerations of public authority of this historic and picturesque little town will now health were less understood than they now are, the reports of put their work into better order and provide a proper waterthe medical inspectors of the Local Government Board very supply without delay. They have not only their own populaoften related to towns and villages which had been attacked tion to consider, but the health of the numerous visitors to by epidemics of enteric fever in consequence of the pollu- this part of the New Forest, by whom the publication of this tion of local shallow wells or other sources of report should be taken as a warning against the conditions at ____

FOREST.

water-supply,

and of the neglect of the sanitary authority concerned to take necessary precautions with respect to the early cases from which the wholesale infection had been derived. Such instances, though less common at the present day, may still be met with, and a striking example will be found in the ,report recently made to the Local Government Board by Dr. Hugh A. Macewen1 on an outbreak of enteric fever in Ringwood which occurred last autumn. In the small town -of that name, with a population of some 3000, as many as 77 cases of enteric fever occurred during the months of July, August, and September, several of which were fatal. Dr. Macewen gives an admirable account of a very thorough investigation into all the circumstances of the epidemic, which presented some unusual features. The majority of those attacked were children of school age, and suspicion first fell on the schools they attended and on - certain school treats which seemed to have been connected with the spread of infection. The facts set out in the report, however, show that the first of these must be eliminated, and that although there was some reason to implicate ice-creams consumed at the school treats, infection in this way could only have played a, minor part, if any, in the production of the outbreak. The key to the causation was found in the fact that a quite disproportionate number of those attacked obtained their drinking water from an open stream which crosses the centre of the town, and the evidence that many of the children who had to cross the stream on their way to school were in the habit of drinking from it. The stream in question crosses ground which is used as a place of deposit for rubbish of all kinds, and then

1 Reports to the Local Government Board on Public Health and Subjects (New Series, No. 74). London: Wyman and Sons ; Edinburgh : H.M. Stationery Office ; Dublin : E. Ponsonby. Price 9d. Medical

present existing.

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INTRATHORACIC INJECTIONS IN

PHTHISIS.

IN the Rivista Medica (Vol. XX.) Dr. V. D’Amico gives details of 22 cases in which he practised the special method of treatment initiated by him. This method consists in injecting an iodised fluid through the intercostal spaces, with the object of bringing it into direct contact with the diseased focus in the lung, whether a cavity or area of tuberculous infiltration. As the 22 recorded cases derived very distinct benefit from this procedure, bearing in mind also the fact that they were in more or less advanced stages in which other methods of treatment give but little scope for encouragement, Dr. D’Amico’s method seems certainly deserving of further trial. More especially is this the case since in none of the patients treated by him did any untoward result seem to follow the injections, which were well tolerated, nor did there seem to be any danger of haemorrhage even when the case was one of haemoptysis ; moreover, two cases were in children aged 4 and 10 years respectively. Two solutions were used by Dr. D’Amico, either singly or alternately, but he seems to have a decided preference for the first, which consists of iodoform 1. grm., camphor 2 grm., guaiacol 5 grm., essence of mint 30 drops, and olive oil 20 grm. ; the other preparation used by him was Zambeletti’s iodised serum. The needle, preferably of platino-iridium, should be of fine calibre and from 3 to 5 em. long. In adults from 20 to 60 injections had to be given according to the extent of the disease, while in the two cases of children already mentioned 10 sufficed. 1 c.c. was the usual amount injected, but as much as 4 to 6 c. c. was required in cavities. In choosing a spot for the puncture, while it is, of course, necessary to avoid the cardiac area and large vessels, the object is to slowly inject