contribute to 10,000 deaths from cancer in males and females respectively in England and Wales. Thus out of 10,000 deaths from cancer of males, 148 are due to cancer of the penis and testis, 926 to cancer of the lip, tongue, buccal mucous membrane, and cheek. In females in every 10,000 deaths from cancer, 2,259 are due to cancer of the uterus, 1,656 to cancer of the breast, and only 83 to cancer of the lip, tongue, cheek, etc. Similar mortality statistics for India do not exist, but we are in the fortunate position of possessing records of over 10,000 cases of cancer from males and females together, which have been subjected to complete pathological examination and reported from English hospitals. These selected cases show a quite different frequency of attack on the organs mentioned, and while indicating the necessity for great reservations, they furnish a transition to the much less numerous data from hospitals in India. In English hospitals, cases of cancer of the testis and penis are twice as frequent as in the mortality returns, and cases of cancer of the lip, etc., are nearly three times more numerous. In females, although cancer of the uterus is only half as frequent, cancer of the breast is more than three times as frequent in the hospital cases, while cancer of the lip, etc, is nearly four times more abundant than in the national statistics. Several factors probably combine to cause these discrepancies, because, while a certain proportion of the cases operated on recover completely, an enormous number of the cases of cancer which swell the mortality returns have only been recognised after they were beyond hope of surgical relief. The reversal in the figures for hospital practice, of the relation obtaining between the number of cases for the breast and uterus respectively in the national statistics, illustrates the important share easy examination plays in the early selection of cases suitable for treatment in hospitals.

When every possible weight has been given to such considerations, the figures from Indian hospitals present a very striking result. While cancer of the testis and penis is nearly ten times as frequent as in English hospitals, cancer of the lip, tongue, cheek, etc, contributes nearly the same proportion. Among females the same correspondence is found, cancer of the uterus being slightly more frequent than in English hospitals, and cancer of the breast equals more than threefifths of the English hospital figures. Cancer of the lip, tongue, cheek, etc., is on the contrary more than six times as frequent in Indian female hospital patients as in the corresponding English group.

The slight differences between the figures for English and Indian hospitals of the frequency of cancer of the breast and uterus make it

at least possible that the mortality in India from cancer of these organs may not be markedly different from the English mortality as indicated in the statistics of the Registrar General.

Dr. K. S. Wise records the great frequency of carcinoma of the penis in British Guiana among coolies, and also draws attention to frequency of carcinoma of the cervix uteri.

Attention may now be directed to the close correspondence of the frequency of cancer of the lip, tongue, cheek, and buccal mucous membrane in male English and Indian hospital patients, and the discrepancy between the corresponding figures for females among whom in India cancer of the lip, tongue, etc., is seen far more frequently. The association of certain forms of chronic irritation (clay pipes) with the development of cancer of the lip in this country, is well known and is generally held responsible for the higher incidence of cancer at these sites in males than in females. An analogous form of chronic irritation is found in India, in the form of chewing a mixture of betel leaves, areca nut, tobacco, and slaked lime, which is practised extensively by both sexes. The report of Dr. A. J. Chalmers and Dr. Perry on the incidence of cancer in Ceylon shows this association very clearly. In Ceylon more than half of the total number of cases are recorded for sites in or around the mouth.

Similar conclusions are arrived at by a consideration of the occurrence of cancer of the penis, which is extremely frequent in some races and very rare in others living side by side with them. The frequency of cancer of the penis is apparently associated with chronic irritation due to the accumulation of dirt and secretion under the prepuce, whereas it is practically unknown in Mohammedan races which practise circumcision.

The occurrence of epithelioma of the anterior abdominal wall in Kashmir with a frequency met with nowhere else is also most instructive. Some years ago Dr. Neve drew attention to the development of squamous-celled carcinoma in Kangri burns. The Kangri is a small earthenware vessel enclosed in basket-work variously decorated, and used to contain a charcoal fire. The Kangri is suspended round the waist under the flowing robes to assist in maintaining warmth by the natives of the cold hills of Kashmir. Repeated burns and long continued chronic irritation of the skin of the abdomen are the consequences. A common sequel to this long continued chronic irritation is the development of squamous celled carcinoma with metastases in adjacent lymph glands. We are indebted to Drs. Neave and Rawlence for a specimen of the "Kangri" as well as for photographs of natives using it.

We

have examined a large number of "Kangri cancers" in all stages of development. Their characteristic structure leaves no doubt that they are epitheliomata, the accompanying figures (figs. 7 & 8) obviating any need for a detailed description.

In the case of Egypt the apparent association of cancer of the bladder and penis with infection by Bilharzia hæmatobia illustrates the

FIG. 7.---Kangri ulcer which has become carcinomatous. From
anterior abdominal wall. X.

45

development of the disease as a sequel to a different form of chronic irritation.

The relation of these different forms of chronic irritation to the development of cancer in different parts of the world helps us to comprehend better the part played by other forms of chronic irritation whose association with cancer has long been observed. These irritations

may be mere direct physical injury as in fracture of bone or in the "horn core" of cattle in India *, chemical as in paraffin, petroleum, arsenic, and aniline cancer, actinic as in the case of the short hot clay pipe, the Kangri, the X-ray, or brand cancers (of cattle). Woodhead has observed several cases of squamous celled carcinoma develop in

60

FIG. 8.-Metastases in lymph gland from same case as that illustrated in fig. 7. x engine-drivers over the shin where the skin had been exposed for years to the direct action of heat. They may be of an infective nature as in

*This is a most interesting and instructive form of malignant new growth to which our attention was directed by Capt. Brodie-Mills of Bombay. Squamous cell carcinoma develops at the root of the right horn with great frequency in cattle used for draught purposes-the right horn being used by the natives to attach the animals to agricultural implements or draught-waggons.