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in the plight of the rejected students; while thewaste of time in dealing with unsuitable materialhas occurred before the sentences of banishment arepronounced. Progress lies between too much exami-nation and too little examination-and this is alikethe essential message of a clear and simple report,and a question of importance to America and Great

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Britain and to the other countries which have fallen Iunder the notice of the commission. For those whoregard union between the medical professions of eachnation as a vital factor in the development of inter-national amenities, it is satisfactory to hold thatbetween the great English-speaking countries it is amatter not of principle but of degree, that calls for.adjustment, when a fusion of interests can be secured.

PAPILLOMA AND CARCINOMA.THERE are three main aspects of the cancer problem :

a clinical or diagnostic, a surgical or therapeutic,and a biological, which concerns causation. It isfor his work on the second of these that the name ofSAMPSON HANDLEY will be lastingly remembered,since by his classical researches on the paths ofdissemination he placed the surgical treatment ofcancer upon a more scientific foundation-a founda-tion which is not likely to be shaken until we candispense with mechanical methods of destroyingmalignant tumours. In the ninth of his Hunterianlectures, which we publish in our present issue,Mr. HANDLEY definitely passes to a considerationof setiological factors and enunciates a new theory,which’by reason of its extreme simplicity is boundto arouse universal interest and, as he has doubtlessforeseen, not a little criticism. On page 1389 heays:—

" Any given consequence such as cancer springs from achain of previous events stretching back to infinity, andnot from a single cause. But if among those events onecan be detected which for a given consequence is veryfrequently present, and has never been proved absent,the clue to the problem of causation has been obtained,.and this event may be provisionally and loosely spokenof as the cause. In this sense I am bold enough to claimthan lymphatic obstruction is the cause of cancer, thoughthe labours of generations may be required to trace theintermediate steps."’The claim is, indeed, a bold one, and coming from any- other pen might receive scant consideration. Exam-ination of the steps that have led him to form thetheory is not-at least at first sight-very convincing.It is claimed, for instance, that " papillomatosisprecedes "every variety of carcinoma," and whenthis quotation is taken out of its context it is onewhich the dermatologist-who has the most frequentopportunity of studying malignant neoplasms of allkinds in their earliest stages-will find it hard to

accept. Quite early in the argument we are dogmati-cally informed that internal warts are much morecommon and much more important than those ofcutaneous origin. The second assertion may be correct,but every,skin department demonstrates the extremefrequency of verruca vulgaris among the dermatosesand infections of the epidermis and, what is of greatimportance in this connexion, their complete immunity,independent of their duration, from malignant change.What may possibly apply to papillomata in ductscannot with any regard for truth be applied to thesurface variety. Mr. HANDLEY might find thelaryngologists equally opposed to the statement that" it is the rule for laryngeal cancer to begin as apapilloma." The Emperor Frederick’s case whichlie quotes was the basis of an international inquiry,inaugurated by the Oentral Blatt in 1888, to determine

whether benign laryngeal growths could becomemalignant or be so converted by intralaryngealoperations. Of 2531 cases in the first category only12 (one in 211) were asserted by their reporters tohave become malignant, and in the second, whichincluded no less than 8216 intralaryngeal operations,33 (one in 249), were presumed to have taken on acancerous tendency as a result of operative irritation.Though figures are notoriously misleading, the viewthat papillomatosis precedes every variety ofcarcinoma will not be readily accepted in face ofsuch cumulative evidence.

If credence be given to the second part of the

theory even greater difficulties seem likely to arise,for it is claimed that lymphatic obstruction-the firststage of, and quite possibly a factor in, the productionof the duct papilloma-is the cause of cancer. In

support of this contention the lecturer gives a detailedand interesting account of the lymphatic supply ofthe skin, and follows it with his observations on theorigin of lupus carcinoma, from whose study originatedhis ’theory of lymphatic aetiology. The hypothesisis applied to the genesis of tar cancers, and evento those which have their origin in moles and nsevi.But if lymphatic obstruction in its ordinary sense isa factor in the production of cancer, then why does notthe disease arise more commonly from chronic ulcersof the leg, with which lymphatic obstruction is sooften associated ? And why are there no premonitorysymptoms suggesting lymphatic obstruction in

squamous epitheliomata and rodent ulcers originatingin such delicate structures as the eyelid ? It is curious,too, that Mr. SAMPSON HANDLEY passes so rapidlyover the results of the experimental investigationof cancer. Here the " absences of the relationshipbetween papilloma and carcinoma " on which Mr.HANDLEY relies finds a simple explanation. Accordingto the published work the appearance of a carcinomaafter tar painting is not necessarily preceded by thatof a papilloma. When an area of skin is subjectedto chronic irritation by tar painting a carcinomamay arise either alone or together with a papilloma,or a papilloma may appear first at the base of whicha carcinoma arises subsequently. Papilloma andcarcinoma have, therefore, a close relationshipbecause they have the same aetiology of chronicirritation. The appearance in man of a papillomain a tissue or organ indicates, therefore, that the tissueand organ may have been subjected to chronicirritation, and this in itself accounts for the subsequentappearance of a carcinoma.

These are some of the objections which are instinc-tively provoked by Mr. HANDLEY’s arguments, andin their turn are open to confutation. Meanwhile,his lecture should receive the careful considerationof those who have found their life-work in the studyof cancer.

A COURSE IN RADIUM.

THERE have long been centres in this country atwhich individuals have done notable work withradium in one form or another, but hitherto studentsrequiring a comprehensive course of study haveresorted to Paris or Stockholm. The want is now to befilled by setting up a National Post-graduate Schoolof Radiotherapy in London. Not long ago MountVernon Hospital obtained its enabling Act to investi-gate and treat cancer, and the Radium Commission,charged with the distribution of relatively largequantities of radium, encouraged the hospital and theRadium Institute to collaborate on a common basis