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male youth when not at their strenuous work are

largely addicted to football, while the miner isobliged to work in peculiar positions often far awayfrom the possibility of help. Thus a radical method ofdealing with a torn internal cartilage has been foundnecessary at Newcastle. It is Mr. Turner’s usualpractice to make a transverse incision on the innerside of the knee. Through this the cartilage is cutfrom its anterior and lateral attachments ; it is thendislocated forwards and cut through as far back aspossible. Only a small portion then remains, and thisslips back between the condyles, where its presence isharmless. Men are refused work in the mines forrecurrent synovitis, but not after a successful radicaloperation has been performed-a most practicaltestimonial to the method which has been evolved.Abdominal emergencies play a large part in the miner’slife, and here the pressure on the infirmary has grownsteadily in recent days, beds tending to become filledon account of earlier diagnosis by local practitioners-indeed, Mr. Turner has frankly admitted sending awaycases diagnosed outside the hospital as appendicitis,which cases had returned later with full-blownsymptoms. Exposure and changes of temperatureresult in the prevalence, not alone among the workingclass, of fibrositis in various forms, and Prof. Angushas given a particularly interesting demonstration ofDupuytren’s contraction for which he had performedTagliacotian grafting with results still remaining goodafter three to five years.The practitioners of the district are welcomed to the

teaching of the infirmary, their readiness to overfill theinstitution, however embarrassing, being counted tothem for righteousness. Teaching in clinical surgeryhas developed largely but independently on linescomparable to those of Theodor Kocher at Berne.In the intervals of operating Mr. Turner, for example,passes in review the various aspects of the case inhand by using a hanging ground-glass screen in theante-room of the theatre on which are projectedpictures from a lantern in the corridor outside. A recentclinical lecture on bhe tieatment of a deranged knee-joint, which lasted four minutes, began with portraitsof Lister and William Hey, with a picture of the latter’ssaw ; then followed a remark or two on asepsis asapplied to the knee-joint ; the anatomy of thecartilages was reproduced from Gray’s text-book, anddiagrams were given of the common types of tear in thecartilage. A diagram showed the incisions and theposition of the internal lateral ligament and now theinterrupted sutures in the capsule allowed of seepage offluid and avoidance of pain ; a schedule of the after-history of a series of 24 cases operated upon 9 to 13years previously brought the lecture to a conclusion,with a portrait of Sir Robert Jones as a pioneer in thisbranch of practice. At a recent demonstration tovisiting surgeons other subjects of interest broughtforward included a series of cases of cleft palate whichhad been operated upon at various ages and whichillustrated the facility with which the normal speechis acquired in direct proportion to the early restora-tion of the soft palate ; several cases of transplantationof ureters into the sigmoid colon for various irremediableconditions of the bladder in which rectal continence offluid was gradually acquired; and a case of completefacial paralysis with suture of the spinal accessorynerve into the facial nerve four years after itsocclusion. Eleven years after the operation the facialmuscles were mobile with little associated move-

ment, and the condition was still improving. Mr.Turner believas strongly in making an abdominalincision over the site of the lesion to be dealt with,rather than in using the median or paramedianincision commonly used by other surgeons. Severalcases were shown to illustrate this, none of thepatients having any sign of post-operative ventralhernia.

H.R.H. the Princess Royal has accepted thepresidency of the Queen Alexandra League, founded by thelate Queen to support the Lord Mayor Treloar Cripples’Hospital and College.

RECENT CANCER INVESTIGATION:STATISTICAL AND CLINICAL.

THE last few weeks ha,ve seen the publication of a-number of important reports dealing with cancer

statistics. Of these, the two volumes published by-an International Committee appointed by the HealthOrganisation of the League of Nations, are mostimportant, both from their authorship and the interestand magnitude of the problem treated. The problem-was presented by the mortality statistics of Englandand Wales, Holland and Italy. These three countries.were selected for two reasons by an authoritativecommittee, under the chairmanship of Sir GeorgeBuchanan, appointed by the Health Organisation.Their official mortality statistics are held to reach anequal standard of accuracy, but reveal a considerable-difference in the mortality of cancer of the breast anduterus. This is very much higher in England andWales than either in Holland or Italy. A detailedinquiry seemed, therefore, likely to yield information-on some of the factors which determine the incidence-of cancer in these organs. The problem is complicatedby the fact that the total mortality for women fromcancer of all organs is not the same in these threecountries. It is lower in Italy than in Holland orEngland and Wales. In England, Wales, and Hollandthe total mortality is nearly the same. This means,.of course, that the lower incidence of cancer of the-breast and uterus in Holland is compensated for bya higher incidence in other organs, and this compensat-ing increase falls mainly on the digestive tract. Cancer-of the digestive tract is much more frequent in Dutchwomen than in English women. Italian women do-not suffer from this compensating increase in cancer-of the digestive tract. They have, however, a higherincidence of cancer of the uterus than Dutch women,but this does not apply to England and Wales, where-cancer of the uterus is more frequent than in Italy.The statistical inquiry into these problems has beenentrusted to a subcommittee of statisticians composedof Dr. Major Greenwood and Dr. Janet Lane-Claypon(London), Prof. Deelman (Groningen), Prof. Methorst(The Hague), Prof. Niceforo (Naples), and Dr.Tomaneck and Prof. Pittard (Geneva). The com-position of the subcommittee is in itself a guaranteeof the soundness of the work done which is presentedin the two volumes in an exceptionally clear andsuccinct manner.

JJIortal1ty from Cancer of the Breast and Ilterus.The first volume is the report of the subcommittee

of statisticians. The second volume contains a numberof reports by Sir George Buchanan, Dr. A. Lutrario,Dr. N. M. J..Titta, and Prof. M. T. Deelman onthe results of clinical inquiries into the differencesof the mortality from breast cancer in the threecountries. The report of Sir George Buchanan isbased on the investigations of Dr. Janet Lane-Clayponwhich have been published in a separate report issuedby the Ministry of Health.2 Dr. Lane-Claypon hascollected by means of a questionnaire detailed materialconcerning the life-history of 508 cases of cancer ofthe breast and of 509 control cases who did not sufferfrom cancer. - The inquiry has been placed, therefore,on a very wide basis. It is probably the most extensivestatistical investigation on cancer which has as yetbeen undertaken, and both as regards the organisationand the care and labour involved in carrying it outrpfiects the greatest credit on those responsible for it.The material presented is very great and does not lenditself to brief summary.

Clinically it has long been known that cancer ofthe breast is less frequent in women who have nursed

1 League of Nations Health Organisation, Subcommittee onCancer. Vol. I. : Report on the Demographic Investigations inCertain Selected Countries. Vol. II.: Report on the Results ofCertain Clinical Inquiries relating to Differences of CancerMortality in Certain Selected Countries.

2 A Further Report on Cancer of the Breast, with specialreference to its Associated Antecedent Condition. 1926.London : H.M. Stationery Office. 3s. 6d.

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their children than in those who have not done so.’This clinical experience is confirmed by this report.It holds good for all the three countries. But thereport does not corroborate another clinical dictum.,concerning cancer of the uterus. Clinicians have heldthat childbearing predisposes to cancer of the cervix.The statisticians, however, conclude from theirmaterial that " the higher incidence of cancer of theuterus upon married women is a consequence of theimmediate effects of a single parturition " by whichis meant presumably the first childbirth, and thatwomen who have borne many children are less, ratherthan more, liable to cancer of the uterus in comparisonwith married women who have borne few children.The statistical data do not allow of a distinction being- made between cancer of the cervix and cancer of thebody of the uterus. Although this is pointed out in- the report as a possible objection, the statisticaldifferences are too definite to be invalidated by it.

Since, then, the incidence of cancer of the breast anduterus is to a certain degree affected by the physio-logical functions of these organs, it was to be expected-that one or more of the various factors connected withthe reproductive life of women might account for thegreat difference in the incidence of cancer of theseorgans in the three different countries. But this-expectation was not fulfilled by the statistical inquiry.None of the numerous factors, including surgical-treatment, which were made the subject of investiga-tion, was found to be.responsible for the difference inthe incidence of cancer of the breast in the threecountries. In place of a solution, cancer, with- characteristic elusiveness, presents the followingparadox. One statistical finding is that women whonurse their children are less liable to cancer of thebreast. Another is that the percentage of womenwho do not nurse their children is higher in Hollandthan in England. One would expect, therefore, tofind a higher incidence of cancer of the breast amongDutch women than among English women. But,.as already stated, the reverse is the case.

Another statistical puzzle is provided by the Italiandata on cancer of the uterus. Though cancer of thebreast.,.is less frequent in Italy than in either Hollandor England, Italian women are more liable to cancerof the uterus than Dutch women, but less liable thanEnglish women.

Local Predisposing Conditions.Though the inquiry has not solved the problem

which it set out to investigate, it would be a mistaketo write down this great effort as a failure. To haveestablished that those factors which are particularlyconcerned with the functional activity of the breastand uterus, and which are known to affect the liabilityof these organs to cancer, do not account for the greatnational differences in the incidence of cancer of thoseorgans is in itself a positive achievement. Its greatvalue lies in the definite elimination of these factors,so that we must now look elsewhere.

Dr. Lane-Claypon’s report deals very fully withthe local conditions which predispose to cancer ofthe mamma- Acute suppurative mastitis was found notto be a contributory cause to the later appearance of- cancer of the breast, but evidence of a previous injury,chronic non-suppurative mastitis, and hyperplasia-occurred more frequently in the history of the cancerseries than in the control series. In a detailed dis-cussion on the importance of hyperplastic changesin the breast as antecedents of cancer, Dr. Lane-Claypon accepts the teaching of *Sir Lenthal Cheatle,who has recently published further observationsconfirming his previous work in a very instructivepapery By a study of sections of the whole mammahe has been able to show that the various hyperplasticchanges which he has observed in the human breastand which, as he holds, find their termination incancer are identical in time and sequence with thechanges which can be induced experimentally in theskin of mice by tarring and which are known to endin cancer. The numerous excellent figures which

3 Brit. Jour. of Surgery, 1926, xiii., 509.

accompany the paper lend strong support to hisarguments.

Cancer in New Zealand.Anotlier report,4 which is geographically circum-

scribed, derives its chief interest from this very limita-tion. New Zealand offers certain exceptional featuresfor the statistical study of cancer. It is a self-contained country which has advanced during thepast 50 years from a community of pioneers to acommunity enjoying all the advantages of civilisationwithout its disadvantages. We mean that the peopleare prcsperous, possess all facilities of education andcommunication, and have an efficient and up-to-datemedical service, while the excessive urbanisationwhich characterises the civilisation of Western Europeis absent. The people are of Anglo-Saxon descentwithout much admixture by immigration, so thatby a comparison with the incidence oi cancer in thiscountry it is possible to test whether the differencein the climatic and social conditions has affected theincidence of cancer. The report shows that theincidence of cancer in New Zealand is exactly thesame as in this country.

During the last 50 years there has been a very rapidincrease in the recorded death-rate from cancer inNew Zealand. The increase is mainly an apparentone, as Mr. Butcher points out in an admirablesummary at the end of the report, due to the greaterefficiency of the medical service, which in New Zealand,as in all civilised countries, is gradually bringing, bybetter diagnosis and registration, the recorded death-rate from cancer more and more up o the level ofthe unknown actual death-rate from cancer. We findaccordingly the most rapid increase during the earlieryears 1875 to 1900, while during the last 15 years thedeath-rate has remained nearly on the same level.The increase affects men more than women, becausein men the organs chiefly liable to cancer are lessaccessible than in women, so that they escape diagnosismore easily.

Perhaps the most interesting data of this report arethose referring to cancer among the Maoris. Thepresence of a native population living under the sameconditons as Europeans, subject to the same systemof registration as regards birth and death, and havingthe same opportunities for medical treatment, offersexceptional facilities for the study of the vexedproblem of the incidence of cancer in native races.The statistics submitted give for Maoris a crudedeath-rate of only 2-60 per annum per 100,000 livingas against a corresponding rate of 8-80 for the restof the population. Mr. Butcher believes that, forvarious reasons, the rate for the Maoris is probablyunderstated, but " there is sufficient evidence onwhich to conclude that cancer is much rarer among theMaoris than among Europeans." If this differenceshould be confirmed by a careful and detailed investi-gation into the incidence of cancer among the Maoris,it would afford clear proof of the existence of racialdifferences in the susceptibility to cancer. There ishere a unique opportunity to gain importantinformation on this aspect of the cancer problem.

4 J. W. Butcher : Cancer in New Zealand. A Statistical Study.Published in the New Zealand Official Year Book, 1926.

HOSPITAL BEDS FROM TINFOIL.-The Committeeof the Tinfoil Fund of the Ancient Order of Druids reportsthat last year .81228 was realised by the sale of " silverpaper," making a total of .E6640 since the fund was startedin 1912. It is intended to endow three hospital beds thisyear, in addition to making small money grants to tenhospitals.WALTHAMSTOW HOSPITAL.-The Lord Mayor of

London, Sir William Pryke, on March llth laid the founda-tion-stone of the Thomas Worton Ward and the Leyton andLeytonstone War- Memorial Ward at the Walthamstow,Wanstead, and Leyton Children’s and General Hospital.The two new wards will each contain 16 beds, and, in addition,on each of the two floors there will be four single wards forpaying patients. Accommodation will also be provided fortwo resident house surgeons. The new additions will costabout z40,000.