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of the clavicle, may be taken as guiding points for the operation.
When the tumor is very large, dislocating the stemo-mastoid mus-
cle, Wolfler makes the incision along the outer border of the
tumor. The necessity of pushing the tumor toward the median
line during the operation causes at times pressure on the trachea.
Drobeck*^ proposes to make the incision along the posterior border
of the stemo-mastoid muscle. Ligation of the two thyroid arteries
of one side by Wolfler was followed in one case by shrinkage of
the goitre on both sides. Dr. Bayer, our Prague Corresponding
Editor, reports that in a case of cancer, the operation failed from
deficiency of the collateral circulation.^ ObaUnski, of Krakow,
ligated in one case of parenchymatous goitre the two arteries of
one side, and in another the four arteries. The results were
satisfactory.** Weinlechner ligated successfully the two supeiior
thyroids.** Some operators have combined the ligation of the
arteries with removal of portions of the tumor, or with the opera-



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340 DISEASES OF THE THYROID GLAND. [ Goitre.

tion for enucleation. Eugene Hahn,*° after exposing the tumor,
ligated the two superior thyroids, and appUed the compression
artery forceps to the inferior, thus making a bloodless operation
of the removal of a portion of the gland. The forceps were
removed twenty-four hours later.

The operation of enucleation, first appUed to solid tumors of
the thyroid by Socin, of Basle, has met with general acceptation.
Albert Heydenreich,^^ of Nancy, contributes a full resume of this
subject. The majority of parenchymatous goitres, Socin found to
consist of capsulated tumors. The glandular tissue is often spread
out over these nodules. Several incisions may be necessary to
remove separate tumors. Compression is generally sufficient to
arrest parenchymatous haemorrhage. If a deep layer of gland tissue
has to be tmversed, it is best to guard against haemorrhage by the
use of the haemostatic forceps. A drainage-tube is subsequently
introduced and the wound in the gland closed with catgut.

The results obtained by Socin are reported by Grarr6" and
S. Kescr.*^ The number of patients operated on is 59. Total
extirpations 5, with 1 death. 17 partial extirpations, 17 enuclea-
tions of cystic, and 20 of parenchymatous tumors, without a single
death. A summary of the dificrcnt operative procedures is given
by J. L. Reverdin.^ Enucleation has been performed by ObaUn-
ski,** Hahn^'^ and Wblif,*''^ who has obtained imion by first inten-
tion in 11 out of 12 cases. Wolff ^^ reports that the removal of
one half of the gland has been invariably followed by atrophy of
the rest of the tumor. Cases of partial and total extirpation are
i-eported by Rubio,' Hofstetter,"" Morris,'* Terrillon," Wolff,""
Poncet,^^ and Weideman,^® who gives the results of 25 operations
performed at the Augusta Hospital.

The removal of the isthmus, as recommended by Sidney
Jones, was performed with marked relief of urgent symptoms by
Jackson.^^ Mayo Robson^^ treated successfully a cystic goitre by
incision, scraping of the walls, stitching of these to the skin, and
packing with zinc lotion. Tracheotomy was performed by J. B.
Ilurry*'^ and Terrillon.^^ In a case of Dr. Rubio^ there was a
diffuse enlargement, with ulcerated, bleeding surface, and exten-
sive adhesions that made extirpation impossible. Cauterization by
various means failed, until chromic acid was used with remarkably
good effect. The acid acted as a haemostatic without producing



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Bor^M^^ema.] DISEASES OF THE THYROID GLAND. 341

eschars. A few applications brought about the development of
healthy granulations, and a complete recovery in six weeks.

OPERATIVE OR SURGICAL MTX(EDEMA.

All surgical interference with the thyroid gland may be fol-
lowed by a more or less marked development of this condition.
This was first pointed out by the Reverdins, of Geneva, and by
Kocher. The latter has given it the name of cachexia strumipriva.
The disease is more frequent and more intense when the gland has
been removed in its totahty. The symptoms are identical with
those of myxoedema, and with those following the experimental
extirpation of the gland in the lower animals. In children the
operation may be followed by an an-est of development. A similar
condition may occur idiopathically, and has been described by
Boumeville and Bricon, under the name of " Idiocy complicated
with the pachydermic cachexia. ''^^ The opinion of Horsley as to
the nature of these symptoms has been given. Gruzner*^ advances
a similar theory. Kocher believes that there is a primary arrest
of the growth of the trachea, and a consequent deficiency of the
supply of oxygen. A case of Hans Schmid'*^' confirms this view
as relates to changes of the trachea. Our Bologna Corresponding
Editor, Dr. Albertoni, and Tizzoni, found a diminished amount of
oxygen in the blood.

J. L. Eeverdin*^ gives a resume of the results obtained by
different surgeons. Of 95 cases of the various operations men-
tioned in this paper, 30 were followed by surgical myxcedema.
Trombetta, of Messina, who has gone over the literature of the
subject, finds a percentage of 27. On the other hand, no cases are
reported from the Vienna clinic, and Bottini has operated on 52
cases without having a single case of surgical myxoedema. The
conclusions of Reverdin are: (1) That the accidents following the
operation are identical with the disease called myxoedema. (2)
Operative myxoedema is observed in adults as well as in children.
(3) There are different grades of operative myxoedema ; one pro-
gressive, with or without intermissions, another attenuated and
susceptible to improvement, if not cure, and a third which may be
called the light or abortive form. (4) Long intermissions may
occur, even if the extirpation was total ; and in two cases at least,
this has amounted almost to a cure. In these two, however,



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342 DISEASES OF THE THYROID GLAND. [sar^SaM?3[iSma.

tumors have appeared in the thyroid region. (5) The partial
extirpation may be followed by abortive forms of myxoedema. (6)
The extirpation of one lobe may be followed by atrophy of the
other, and symptoms of myxoedema. It will be seen, tlierefore,
that, whereas in tlie experiments upon the healthy gland, a partial
extirpation is apt to be followed by a compensatory hypertrophy
of the opposite lobe, in diseased conditions the opposite is apt to
happen. (Bergmann.)

In deciding as to the propriety of extirpation, we should
endeavor to determine what the functional capacity of the gland
may be in each individual case. Dr. Rubio,^ of Madrid, classifies
the cases as follow : —

There may be (1) integrity of function, with anatomical
integrity, complete or partial ; (2) abolition of function, by total
atrophy or total anatomical alteration ; (3) perturbation of function,
by hypertrophy or partial disorganization.

In the first class, the rapid suppression of the organ would
produce the same results as the experiments of Horsley on monkeys,
namely, a myxocdemic cachexia. In the second class, if there is
total atrophy, of course, no one will think of extirpation. These,
he thinks, must be the cases of primary myxoedema developing
spontaneously. If, on the other hand, the abohtion of the function
depends on a total anatomical alteration, the organism is more or
less modified, according to the degree of accommodation that it has
reached. If the compensation has been sufficient, the operation is
advisable, if not, it can do neither good nor harm. In the third
class, when the function is disturbed by a considerable hypertrophy
or partial disorganization, not only is the mucin allowed to remain
in the blood, but probably other deleterious materials are added to
it. In such case the extirpation is beneficial.

Our knowledge of the morbid anatomy of surgical myxoedema
is imperfect. A case is mentioned by Bnins ^^ of a man who died
at the age of 24 with symptoms of myxoedema, having been operated
on when he was 10 years old. The autopsy revealed the presence
of leptomeningitis with involvement of the cortical substance.

The Myxoedema Committee of the London Clinical Society
has sent out circulars requesting those who have extirpated the
thyroid gland to give their experience as to the effects of the
operation. The circular is accompanied with a description of the



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1IVX4

byder



;<Bdeina or



Paoby dermic Cachexia.



] DISEASES OF THE THYROID GLAND.



343



disease, from Ord's article in Qnaiu's Dictionary of Medicine, and
a photograph of which is reproduced on the next page.

MYXCEDEMA (ORD) OR PACHYDERMIC CACHEXIA (CHARCOT).

All the new material concerning the pathogenesis and morbid
anatomy of this disease has been given in the preceding pages.
An interesting summary, based on the observations of Horsley,
will be found in Virchow's address, already referred to. The
experiments of Horsley, and the contributions of the Reverdins
and Kocher, have awakened great interest in the subject of
idiopathic myxoedema. The disease, first described by English
physicians (Gull, 1874), has been recognized at different places on
the Continent, and during the year numerous cases have been
reported. The cases collected during the year are briefly tabulated,
as follow : —

CASES OF MYXCEDEMA.



REPORTER AND
REFERENCE.


HATIVITY.


SEX.
F


AGE.


tKieUan*'


Norway


41


tKiellan"


Norway


F


85


Zielewicz**




M

M
F
M
F


61
30
47
19


Bavill"




Paton'»

Warfoinffe'*

Hxuidfleld Jones^


Scotland
Sweden
England


Erb"


Germany


M


29


Erb'»


Germany


F


85


Senator'*


Germany


F


65


Landau"


Germany


F


85


Rosenbcrjc'*
Campana''
Stewart"


Germany

Italy
Canada


F

m"


"ii"


BoaiaK>n'*


France


M


47


Bhel8wen»<»


Engbuid








\ Scrofula. Congenital heart disease. Menorrhagia.
( Improvement. Pregnancy. Abortion.
\ Sister of above. Scrofula. Improved by residence
I in Alps of Norway.

Sclerosis of liver, spleen and kidney.

Prostatic hiemorrhage. Thyroid gland atrophied.

First case reported from Scotland (?).

Cured in about 8 months by arsenic and hot baths.

I'receded by long-standing menorrhagia.
$ Second case reported in Germany, after one of
I Dr. Reiss.

} Tlilrd case in Germany. Menopause at 28. First
\ symptoms of the disease at 30.

S Fourth case in Germany. Began 2 years after
menopause, which occurred at 45. No thyroid
gland i^een. A sister with similar symptoms.
JAmenonhoea. Atrophy of uterus. Frequent
i attacks of facial erysipelas. Syphilis.
Metrorrhagia. Removal of both ovaries.
First case reported in Italy, in the Italia Medico,
Tetany of hand muscles preceding myx oedema.
5 Obese. At 30 bad right hemiplegia. Brain found
\ parencephalic, as in idiots and cretins.
{ Reports two eases with tendency to bleed, and col-
) lects several other cases with the same symptom.



• All these cases had the characteristic symptoms of mvxcedema. Unusual features only are
mentioned in the table, or such as refer to the etiology, t Reported by Dr. Ecklund, Stockholm,
C'orresponding Editor.

Cancer of (lie TJiyroid. — One case, remarkable for the
absence of pain and cachexia, is reported by Aigre ;^^ another by
Augier,** in a man who died of tuberculosis. A case of sarcoma
is reported by Ransonhoff ;^ two cases of tuberculosis, one miliary,
the other of caseous degeneration, resembling goitre, by Frankel/*



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344 DISEASES OF THE THYROID GLAND, [2S2^



grave's disease.

Pathogenesis, — The recent contributions to this subject are
not conclusive. There is a concurrence of opinion as to the exist-
ence of some disturbance of the central neiTous system. It is
generally admitted that Brown-Sequard, Benedikt, and Fox were
right in locaUzing this disturbance in the medulla oblongata and
upper cervical cord. J. Mitchell Clark^ observes that we have
here in close relation the cardio-inhibitory, the vaso-motor and the
glycogenic centres, all of which may be affected in Grave's disease.
According to Dr. Clark, the disturbances are probably of the



Case of Myx(i:dema.

(From photograph kindly sent by Dr. Felix Semon, London.)

(ForUchHUe de» Medicin.)

molecular processes of nutrition, induced by changes in the met-
aboUsm of the thyroid gland. The case reported by him favors
the theory of an original and general nutritive disturbance, in that
the abdominal viscera were found to be of small size, and the
thymus gland persistent. The theory of a central nervous disturb-
ance is also advocated by Snell,^® Durdufi,®' and Jendrassik.** The
latter observer believes that the disease is a pohomyelencephalitis,
or inflammation of the gray substance, between the origins of the
third and twelfth pairs of nerves. He reports the case of a child



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SJSii?.] DISEASES OF THE THYROID GLAND. 345

six years old who had nuclear paralysis of the third, fourth, fifth
and seventh pairs of cranial nerves, and who presented the symp-
toms of Grave's disease. The acceleration of the heart's action,
and the eye symptoms were produced experimentally by Durdufi^^
by punctures of the medulla. These observations are very inter-
esting, and may lead to important rcsidts, but they are nothing
more than explanations of the difierent symptoms. The starting
point of the chain of phenomena remains unknown. P. G.
Mobius®* very ingeniously contrasts the symptoms of Grave's dis-
ease with those of myxoedema, and suggests that the former may
be the result of an excitation, and the latter of an arrest of the
functions of the thyroid gland. Weideman,^ in his report on the
results of extirpation of the thyroid, cites a case of goitre with
symptoms of Grave's disease. The latter disappeared after the
removal of the tumor. This is certainly not sufficient ground for
the opinion that Grave's disease is simply the manifestation of
mechanical disturbance of the sympathetic by tumor of the thyroid ;
because we may have Grave's disease without enlargement of the
thyroid; and because that form of enlargement of the thyroid
which is most apt to affect the neighboring structures, namely,
cancer, is not followed by Grave's disease. C. C. Haase®^ reports
a case of supposed laceration of the carotid artery into the cavern-
ous sinus, from a fall, followed in seven days by the appearance
of the symptoms of Grave's disease. These were relieved by liga-
tion of the common carotid. Exposure to cold and syphilis are
mentioned as the causes in two cases of Bristowe's.^^

Morbid Anatomy. — Higgens®^ foimd thickening of the cervical
sympathetic in one case, and Clark^ reports the following results
of a post-mortem examination : The emaciation was extreme. The
exophthalmos had disappeared. The thyroid was large, firm and
vascular. The heart was small, but the left ventricle was relatively
hypertrophied. The thymus was large, but normal in appearance.
The liver weighed only 28 oz. The pancreas was smalL A
microscopic examination of portions of the central nervous system
and the sympathetic revealed nothing abnormal. The thyroid
gland contained less connective tissue than normally. The epi-
thelial elements were increased. There were evidences of rapid
proliferation and decay of the latter. The extent of the colloid
degeneration of the vesicles was less than normal. In a case of



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346 DISEASES OF THE THYROID GLAND. [Beferenw».

Debreuilli,^ the improvement of the symptoms of the disease
was followed by the development of tuberculosis and multiple
neuritis. Sclerotic changes were found in various regions of the
cord.

Symptoms, — R. Norris Wolfenden®^ confirms the observation
of Charcot to the effect that the body resistance to electric
currents is lowered in Gmve's disease. Whereas in health the
average resistance is of 4-5000 ohms, it may be here reduced to
500. In a case reported by Vigouroux^*^ there was paraplegia
with some atrophy, but without recto- vesical trouble; in another
there was atrophy, without paralysis, of the sterno-mastoid muscles.

The pigmentary changes in the skin receive special attention
in the reports of cases by R. H. Lucy,^^ Drummond,®* West.^
Special mention of the eye symptoms is made by Katsaras,'^ Fitz-
gerald,'' SneU,^'^ Mobius,^"^ West.'« The pecuharities of the mental
disturbances are described by Drummond,®^ Peterson,^^ Collins,^"
and others.^*^^ Intermittent albuminuria, oscillations of temperature,
and enlargement of the tonsils are reported by Hutchinson,®* West***
and Petcrson.^^^

Treaiment, — R. Vigouroux'^ gives directions for the use of the
faradic current. One large electrode is applied to the lower part
of the neck posteriorly. The other electrode, olive-shaped, cor-
responds to the negative pole. It is appUed to the carotids, eye-
Uds, brow, and upper branches of the facial. In so doing the
motor point for protrusion of the eyeball should be avoided.
This the author has found to be situated one centimetre behind and
below the outer end of the eyebrow. A flat electrode is now used
in place of the olive pointed, and is applied to the thyroid gland,
and to the motor points of the sterno-thyroid and sterno-hyoid
muscles. The positive pole shoxdd now be applied to the precordia
for two or three minutes. On two occasions only has the faradiza-
tion of the carotid given rise to unpleasant symptoms. Galvanism
was very generally recommended at a meeting of the Detroit
Academy of Medicine.*®^ Cases successfully treated by electricity
are reported by Hadden^®^ and Nichols.'^ The latter observer
attaches importance also to the treatment of uterine lesions. Drs.
Hack, of Freibui^, and Chiari,^*^ of Vienna, report that a decided
improvement of the symptoms has followed the cauterization of
the hypertrophied mucous membrane of the middle and inferior



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B«ferenc«i.] DISEASES OF THE THYROID GLAND. 347

turbinated bones. In two cases of Fritch,"*^ complicated with
diabetes, the symptoms were relieved by dieting and the use of
nitrate of uranium. Bristowe"^ reports a complete success from the
removal of the isthmus by Sidney Jones. A partial extirpation
performed by Lister was followed by immediate rehef; but the
subsequent history of the case, as given by Fraser, is not satis-
factory."^ The patient has been since subject to convulsions, and
is now consumpti^'e.

REFERENCES.

1. Berlin Klin. Woch. 2. Deut. Med. Woch. 3. Cent f. Chir. 4. Dcut. Med.
Wocli. 5. Cent. f. Klin. 31ed. 6. Lancet. 7. Berlin Klin. Woch. 8. Rep. of Dr.
Angel Pulido, Madrid. 9. Berlin Klin. Woch. 10. La Semaine Med. 11. I'Union
Med. 12. Med. and Surg. Rep. 13. Provincial Med. Jour. 14. Lancet. 15. Brit.
Med. Jour. 10. Lancet. 17. Lancet. 18. Lancet. 19. Maryland Med. Jour. 20.
Wien. Med. Woch. 21. Le Progres Med. 22. London Med. Rec. 23. Weekly Med.
Review. 24. Goitre et Medication Interstitielle, Paris, 1886. 25. Le Progres Med. 26.
Arch, de M6d. 27. Lancet. 28. Gaz. des Hdpitaux. 29. Lancet. 80. Med. Press.
31. Deut. Med. Woch. 82. Bull. d. 1. Soc. Anat. 33. Le Progres Med. 34. Thera-
peutic Gaz. 35. Weekly Med. Review. 36. Indian Med. Gaz. 37. London Med.
Rec. 38. Brit. Med. Jour. 39. Jour, de Laryng. 40. Pacific Rec. 41. Wien. Med.
Woch. 42. Cent. f. Chir. 43. Deut. Med. Zeit. 44. Rep. of Dr. Bayer, ot Prague.
45. Wien. Med. Blatter. 46. Deut. Med. Zeit. 47. La Semaine M6d. 48. Cent. f.
Chir., 1886. 49. Revue Med. d. 1. Suisse Romande. 50. La Semaine Med. 51.
Deut. Med. Woch. 52. Deut. Med. Zeit. 53. Brit. Med. Jour. 54. Lancet. 55.
Bull. d. 1. Soc. Anat. 56. Deut. Med. Zeit. 57. Lyon Med. 58. Med. and Surg.
Rep. 59. Med. and Surg. Rep. 60. Provincial Med. Jour. 61. Lancet. 62. Ann.
des mal. de TOreille. 63. Revue Med. d. 1. Suisse Romande. 64. Deut. Med. Woch.
65. Provincial Med. Jour. 66. Deut. Med. Woch. 67. Rep. of Dr. Ecklund,
Sweden. 68. Berlin Klin. Woch. 69. Lancet. 70. Glasgow Med. Chir. Jour. 71.
Cent., f. Chir. 72. Brit. Med. Jour. 73. Berlin Klin. Woch. 74. Deut. Med. Zeit.
75. Berlin. Klin. Woch. 76. Deut. Med. Zeit. 77. London Med. Rec. 78. Med.
News. 79. Bull. d. 1. Soc. Anat. 80. Lancet. 81. Revue Mens, de Laryng. 82.
Jour, des Sci. Med. 83. Cinn. Lancet-Clin. 84. Deut. Med. Woch. 85. Brit. Med.
Jour. 86. Lancet. 87. Cent. f. Laryng. 88. Arch. f. Psychiatric. 89. Dcut. Med.
Zeit. 90. Med. and Surg. Rep. 91. Deut. Med. Zeit, 92. Revue de Laryng. 93,
Revue de Laryng. 94. Gaz. Heb. des Sci. M6d. Bordeaux. 95. Practitioner. 96. Le
Progres M6d. 97. Brit. Med. Jour. 98. Brit. Med. Jour. 99. Revue de Laryng.
100. Med. Rec. 101. Lancet. 102. Am. Jour. Med. Sci. 103. Med. Rec. 104.
Lancet. 105. Gaz. des Hdpitaux. 106. Am. Lancet. 107. Lancet. 108. Jour. Am.
Med. Assoc. 109. N. Y. Med. Jour. 110. Med. Press. 111. Revue de Laryng,
112. Edinburgh Med. Jour.

rUndated references apply to Jonmals publiahed hi 1887, and original articles cau be foacd by
consoltiDg the hidexes of the respective publications.]



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DISEASES OF THE LUNGS AND PLEURA.

By JAMES T. WHITTAKER, M.D.,



CINCINNATI.



PHYSICAL EXPLORATION.

Dr. J. R, Leaming* contributes to the literature of this sub-
ject a paper entitled " Diagnostic Areas over the Human Chest,"
read at the annual meeting of the New York State Medical Asso-
ciation. The author first presents a brief review of the anatomy,
internal and external, of the thorax, with especial reference to the
acoustic properties of the various regions. He describes the
human chest as an acoustic chamber mathematically adapted
m its interior form for the reflection and consonation of sound
waves originating in the larynx. He claims that the lungs
fill the chest cavity with expansive force even after expiration,
and press against the chest wall. With reference to the
acoustic importance of the pulmonary vesicles, he says: "Each
air-sac, distended with compressed air, is a resonator, and is in
direct connection with the outer air during inspiration." The
author evidently refers to the compression of the air due to
partial closure of the glottis in phonation. The natural respir-
atory murmur is composed of the vibrations in the convective
air-tubes, the friction sound of the tidal air, and the susurrus
of the muscles covering the sacs themselves, consonated in the
air-cells and transmitted to the ear through the chest-wall.
The importance of the "multitudinous resonance and sound-
conduction " of the lungs to the power, compass and infinite mod-
ulation of the human voice, is not omitted. " Those who listen
with delight to the music of the voice of a great singer like Patti
must stand in awe at the divine mechanism." . . . Wonder
is also expressed that this nicety of mechanism can be so long
preserved in persons exposed to all the vicissitudes of climate and
the nervous depression incident to a life of anxiety and worry.
(348)



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Ex^YjSluin.] DISEASES OF THE LUNGS. 349

The foUomng statement will doubtless strike some of our
readers as extreme, and it certainly indicates extreme shrewdness
on the part of the diagnostician : " We are told that autopsies
frequently reveal organized adhesions of the lungs to the chest
wall, or of the lobes to each other, or to the pericardial sac, which
had not been suspected during life, but each attachment is an
opening for sound leakage, both of the voice and respiratory
murmurs, and constitutes a diagnostic area which should have
been discovered by the carefid auscultator.** Such acumen can
hardly be expected of the general practitioner, however carefid.
Without questioning the truth of the author's statement, we are
reminded by it of the nomadic auscultator of our Western frontier,
with hearing so aCute as to be able to recognize the sound of the
growing gmss.

Auscidtation, however, is not physical diagnosis, and we are
reminded of certain conditions which are apt to be misleading.
The attachments of the pleura to the chest wall are likely to so
greatly exaggerate the pulmonary sounds as to lead to the suppo-
sition of pathological conditions in the lung. Still more misleading
are the signs where adhesions bind together the chest wall and a
portion of the lung which has undergone fibroid induration,
extending down to a dilated bronchus. The area over the adhe-
sion is depressed and there may be a cracked-pot percussion note,
with cavernous respiration. The spoken and whispered voice tests
seem to conoborate the cAidence of the existence of a canity, the



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