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minute and back again to 140 in a minute, in another case from 204 to 65.5, and back again to 157, and so on. The general result may be stated as follows: A diminution of pulse rate, brought about by lowering the temperature of the blood flowing into the heart, causes an increase in the quantity of blood thrown out from the ventricle at each systole, and consequently an increase in the work done at each systole, and vice versa. The changes in the outflow from the ventricle at each systole are not, however, inversely proportional to the changes in the pulse-rate. The total outflow and the total work done during any given period of time decreases with a diminished pulse-rate, and increases with an increased pulse-rate.

POINTS

ON CERTAIN PRACTICAL POINTS IN THE PATHOL

OGY, CLINICAL HISTORY AND TREAT

MENT OF CANCER.

BY GEORGE H. RоHÉ, M. D.,

Prosessor of Hygiene and Clinical Dermatology, College of Physicians and Surgeons, Baltimore; Member of the American Dermatological Association; of the American Public Health Association; of the Medical

and Chirurgical Faculty of Maryland, etc.

The exact significance of the appellation cancer, both in its clinical and in its pathological sense, is frequently misunderstood. Not only by the laity, but by many physicians likewise, is the term often misapplied, or used in a singularly loose and indefinite manner. On the one hand the most innocent growths and ulcerations are called, believed to be, and often treated as cancers, while on the other, unquestionable cancerous affections are treated as non-malignant diseases of various kinds. The first error here mentioned accounts for the greater proportion of the widely-heralded successes of cancer-curing quacks by whom the country is overrun, while in the latter category are to be classed, the many deplorable mistakes which bring suffering and early death to many individuals stricken with malignant disease. Members will recall the report of cases of cancer of the rectum made to this Faculty two years ago by Dr. L. McLane Tiffany, where the usual diagnosis, either lay or medical, had been "the piles." Similar errors of diagnosis occur when cancer affects other organs or structures, and Billroth mentions the fact that very many cases of mammary cancer are diagnosticated as "chronic mastitis," and thus appropriate treatment is deferred until it is too late to accomplish any good result.

Although absolute certainty in diagnosis is not to be hoped for, I think we may unhesitatingly subscribe to the statement of Prof. S. D. Gross, that "just in proportion as our knowledge of morbid structure is positive, accurate and comprehensive, will be the probability that we will become skilled diagnosticians." *

While the origin of cancerous growths cannot yet be referred with certainty to any special tissue, since most eminent observers still hold very contradictory views upon this point, it may be considered as definitely established that the invariable anatomical condition present is epithelium out of place; or, stated a little more fully, all forms of cancer are characterized by the presence of a connective-tissue stroma, in the meshes of which are packed epithelial cells in abnormal arrangement, in places where they do not normally belong.

Whether these epithelial cells are derived from the skin, mucous membranes, and the secreting surfaces of glands as asserted by Thiersch, Waldeyer, Billroth and Ziegler; or, whether they are primarily developed out of connective tissue or white blood corpuscles, as held by Virchow, Stricker, Klebs, Rindfleisch and others; or whether, finally, as Köster believes to have demonstrated, they are an outgrowth of the endothelia of lymph-vessels, is of little moment from a purely clinical point of view. The doctrine of Waldeyer, that cancer is always developed from pre-existing epithelial tissue, that is to say, from those structures which are built up out of the upper and lower germinal layers of the embryo, seems to have the weight of authority and of clinical evidence in its favor.+

However we may regard these differences of opinion, there is now no disagreement upon the point that the essential histological condition is the presence of epithelial cells, confined, or infiltrated in a stroma of connective tissue. All other histological

*Proc. Am. Surgical Association. N. Y Med. Record, June ç, 1883. p 639. The latest theory of the genesis of tumors that has gained many adherents is that of Cohnheim. This pathologist believes that all tumors are the result of an excess of primary germ-material, which is called into activity by some local irritation or impulse to growth. This would not invalidate Waldeyer's theory, since all epithelial tumors would result from an excess of germ-epithelium.

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conditions found in cancer are either not peculiar, not constant, or unimportant.

The ultimate cause of morbid growths seems to lie in an undefinable constitutional predisposition. The white and black races show a marked difference in this constitutional tendency: in the former, epithelial degenerations are frequent, while in the latter the degenerations of connective tissue predominate. There can, I think, be no doubt that the same differences prevail among different individuals. Thus, we see this daily in practice, when one individual after a slight irritation of the skin is attacked by an eczema or a psoriasis, while another of perhaps similar habits and health is not affected by the irritation. So, I conceive, an individual may have epithelial tissues especially liable to degenerative action, and any prolonged irritation may, in such a case, cause cancer. That cancer is ever, either primarily or secondarily, a constitutional disease, in the same sense that syphilis is, I do not believe. Assuming the constitutional tendency above referred to, the local irritation is alone needed to cause the disease. This is seen in cancer of the lips, where the growth nearly always attacks the part irritated by the pipe of the smoker; in the chimney-sweep's cancer, where the constant irritation of the scrotum with soot, defines the situation of the morbid process; in cancer of the breast, which so often follows inflammation and abscess of the breast glands* and eczema of the nipple, and, as has been demonstrated by Dr. Emmett for cancer of the cervix uteri, which, according to his statistics, nearly always follows unhealed laceration of the cervix and the constant irritation of the epithelium of the cervical canal consequent thereupon.

I venture to call your attention also to the fact that morbid growths of an epithelial nature, but ordinarily innocent, may under certain circumstances become malignant. Doubtless most of those present have seen such cases. Pigmented nævi, warts, keratoses, papillomata, especially of the penis, cutaneous horns and similar growths are liable to become atypical, as Waldeyer

*Winiwarter, A. von (Beiträge Z. Stat. d. Carcinom 2), found that 21.05 per cent. of cases of carinoma of the breast, had had an attack of mammitis. The proportion of mammitis to delivered women is only 6 per cent. (Winckel).

cancer.

calls it, that is to say, the interpapillary prolongations of the rete Malpighii are extended downward into the connective tissue layer of the derma and so constitute the anatomical condition of Sebaceous tumors not unfrequently terminate in this manner. I have notes of several cases in which malignant disease followed simple epithelioma of the skin. One case was a single woman, aged 40, who had a mole upon the forehead. Being annoyed by its presence, she attempted to destroy it with various caustics. The inefficient application of these agents produced a chronic irritation of the spot, which finally eventuated in cancer, when she came under my treatment. This was in the early part of 1878. I scraped out the morbid tissue, and afterward cauterised the base thoroughly with nitrate of silver. A pliable flat scar resulted, but the patient afterward passed from my notice, and her subsequent history is unknown to me.

In another case, the primary growth was a cutaneous horn upon the cheek. I removed it, scraped out the base, which was friable and from which many villous papillæ penetrated the horny growth, and finally cauterised the spot with nitrate of silver. In a few weeks-in fact before the sore had healed-hard infiltrations were noticed, which were evidently malignant in character. The growth was several times destroyed with caustics, using in turn Cosme's paste, potassa fusa, and Marsden's arsenical mucilage, with no permanent effect. The Marsden's mucilage seemed to give the best result Having left the city in the autumn of 1878, I lost sight of the patient, but since my return have learned that she died in 1879 from an extension of the disease. As she had removed in the meanwhile to Pennsylvania. and entered a hospital there, I was not able to learn the particulars of her final illness.

The pathological features of cancer shed some light upon its clinical history, and certain facts in the latter may with profit be considered a little more in detail.

One of the symptoms popularly believed to be a constant accompaniment of cancer is pain. In the majority of cases it is a prominent symptom, but I find in my case-book, notes of four cases of undoubted cancer (ulcerating epithelioma of the skin), in

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