This scale of frequency corresponds very well for most of the organs in my experience. But as regards the uterus and ovaries, I must be some what sceptical; probably some small superficially situated " fibromas" were taken for " scirrhus." According to the experience of all patho logical anatomists and surgeons, whom I have consulted on this subject, metastatic carcinoma of the uterus and ovaries scarcely occurs.
In Zurich I observed metastatic nodules: in the liver, 15 times; lungs and pleura, 6; brain, 2; bones, 2.
Von Winiwarter mentions metastatic tumors in the liver, 12 times; pleura and lungs, 10; bones, 7; dura mater and brain, 2; muscles of the back, 2.
At all events this much is apparent from these statistics, that metasta ses are by far most frequent in the liver, and then in the lungs, bones and brain.
As regards the bones it is doubtful whether we may regard the (not any too frequent) cases of carcinoma of the humerus, occurring on the same side as carcinoma of the axillary glands, as true metastases; they belong perhaps to the carcinomas arising by contiguous development. I have frequently seen cases of carcinoma of the vertebral column, though much more frequently in private than in hospital practice (in Zurich one case, and in Vienna four cases are noted in my clinic). I estimate the num ber of cases which I have seen at from twelve to fifteen. As it is not infrequent that kyphosis is thus developed, it must be assumed that the seat of the disease is principally in the bodies of the vertebrae; but the carcinomatous affection must more frequently and more rapidly invade the spinal nerves than do the suppuration and tubercle-formation in Pott's dis ease, for the most fearful neuralgic pains and paralyses are the rule in carcinoma of the vertebral column while they are the exception in caries of the vertebrae. I certainly know of no condition in which the severity of the pains is by any means so great, and particularly because it lasts for months, and even indeed for a year. I do not know whether it is an ac cident or whether it is due to some intimate connection, that the carci nomas of the vertebral column, which I saw, occurred especially in patients in whom the carcinoma of the breast belonged to the exquisite retracting form, and sometimes appeared so insignificant that it was first noticed by the physician. Even to-day I saw a case of this kind. Mrs.
X., about 48 years old, very well nourished; for two years there have been nodules in the inner, lower quadrant of the left mamma, which are now scarcely as large as a hen's egg, painless, with the overlying skin markedly retracted. In the axilla, the glands are swollen to the size of a walnut, movable, not wrinkled; the patient cannot give any informa tion as to the duration of their existence, as she was not aware of them. Pains for two months in the thoracic portion of the vertebral column; band-like sensation about the thorax; present inability to sit or to stand; continual pains—such are the symptoms. The fearful drama is just begun.
A few words regarding the infrequent metastases in the intestine (v. Winiwarter) and regarding the, by me not so infrequently observed, later invasion of the second mamma. Von Winiwarter very appropriately re marks: " We assume at present, at least tacitly, that an existing car cinoma secures the body against a second invasion of carcinoma." As we formerly acted upon the view that a cancer originates always in conse quence of an already previously existing latent dyscrasia, we could not wonder if cancerous tumors appeared gradually in many of the organs of the body. Now we act upon the view that cancer is in the beginning a purely local disease, which appears solitarily, and thence infects the whole body. Von Winiwarter rightly reminds us that we must not en tirely forget that the same individual may be afflicted with a second tumor, in another place, from the same (unknown) cause from which the first tumor originated. Metastatic tumors and metastatic abscesses in the mamma, for example, are such exceedingly great rarities, that we can scarcely compare invasion of the second mamma by carcinoma to them. A continuous extension from one mamma to the other is excluded in many cases of this kind. One is obliged indeed to think of a kind of sympathetic affection, such as has been proved to occur almost only in the eyes, sometimes in the ears, and then only by inflammatory processes. Tumors of both ovaries are certainly not very infrequent; tumors in both testicles, on the ether hand, do not occur frequently. There are still many problems to be solved.