to his brain. His breathing became stertorous, the right pupil widely dilated, the left contracted, and he died at 1:30 p. m. the next day, about forty-eight hours after the operation. Meantime, his temperature remained normal for the first twenty-four hours; after that it steadily rose till it reached 104.8; his pulse also increased from normal to 120, and his respiration to 32.

PATHOLOGIC REPORT.

BY DRS. COPLIN AND ELLIS.

These

Sections from the Tumor from the Neck.-These are composed largely of a new growth made up of cell masses and a fibrous stroma. The cells are rounded, polyhedral or fusiform in outline and are so placed as to form the enveloping wall of irregular spaces that are empty or contain a few degenerating cells. walls are very thick, including dozens or scores of layers of cells that have evidently been derived from the proliferation of the cells originally forming the boundary of the spaces, which are undoubtedly dilated lymph sinuses. The fibrous stroma of the tumor varies in amount and texture. Usually it is quite abundant and in some areas is dense in type; for the most part it is loose and cellular and at certain points shows a tendency toward myxomatous transformation.

Sections that include the artery and vein show the former to be attached to the tumor-bearing mass by fibrous adhesions; its wall is not penetrated by the new growth. The artery is the seat of pronounced atheroma, this lesion involving much more prominently one-half of the circumference of the vessel. The vein wall has been partially destroyed by the tumor which projects into and nearly obliterates the lumen.

Sections from the glandular mass of tissue are from a salivary gland that contains no demonstrable new growth. Perivascular accumulations of small round cells are present and a moderate degree of intralobular fatty infiltration is also a feature.

Sections from the large mole from the right side of the head show that the elevated area is made up mainly of an enormously thickened epidermis, though the papillæ of the corium are also prolonged upward as loose, cellular extensions. At many points the epithelial cells have undergone disintegrative changes with the resulting formation of variously sized cavities. Many of the cells, particularly those in the near vicinity of papillæ, contain a large quantity of dark brown pigment. This material is also present. mainly intercellular in location, in the extremities of the papilla. There is no evidence whatever of any abnormal extension of ep thelium into the underlying tissue or of the presence of malignant growth.

Sections from the small mole from the left side of the head present an appearance very like that of the larger one. The overgrowth of the papillæ is more pronounced and cysts in the epithelium are larger and more numerous.

Diagnosis.-Lymphangio-endothelioma of the neck; pigmented cystic papillomas of the head. We are not inclined to believe that there is any connection between the growths removed from the skin and the tumor from the neck.

I have included this case with the others chiefly because possibly it may be an exception to the rule which seems to exist, that as soon as a mole begins to enlarge it is already malignant. The pigmented mole of the right temple, which made its appearance when he was 42 years of age and began to grow and deepen in color when he was 65, would, probably, have caused a carcinoma or a sarcoma at a later period. The microscopic examination of this mole, however, shows no carcinomatous change. Yet, on the other hand, the patient at 69 years of age, four years after the mole began to grow, did develop apparently a glandular tumor under the lower jaw on the same side of the neck. Whether there was any nexus between these two growths is, of course, an open question. It is at least both curious and significant that after the growth of the mole the carcinoma developed on the same side of the neck. Whether, if this mole had been thoroughly extirpated before it began to enlarge, the carcinoma in the neck would not have appeared, of course one can not definitely determine. One thing, however, is certain, that if the mole had been removed before its growth began, it could not by any possibility have been responsible for the carcinoma in the neck. No other apparent cause for the up-springing of the carcinoma in the neck was discoverable.

CASE 10.-A Presternal Wart Appearing at 20 Years of Age, Becoming Malignant 36 Years Later; Removal; No Recurrence After 7 Years.

History. John Y. E., aged 56, Royersford, Pa., first consulted me April 3, 1897, at the instance of Dr. Brower. When he was 20 years of age he first noticed a small wart in front of the sternum. This underwent no change until a few months ago. It then began to grow, at first slowly, but within the last few weeks quite rapidly. He has suffered no pain until recently. On examination I found a tumor 3x5 cm. in diameter just to the left of the middle line over the sternum, between the level of the second and third ribs. It was a very dark blue or purple color and was ulcerated over a large part

of its surface. It was not attached to the sternum and there was no dissemination through the neighboring skin. No enlarged glands were perceptible. I removed it the same day without removing anything but the tumor and the tissues underneath it down to the sternum. He made an uneventful recovery and went home in a few days.

Dr. Kyle, who made the microscopic examination, reported as follows:

MICROSCOPIC EXAMINATION.

On section it was dark and granular in appearance, somewhat resembling an engorged spleen. From the cut surface a dark, thick fluid could be pressed out. Perpendicular sections directly through the center of the tumor showed embryonic connective tissue cells closely packed together, uniformly distributed, and held together by a homogeneous albuminous substance. The blood vessels were open channels without distinct walls. The cells varied in size and shape, some being round, others spindle-shaped, with here and there areas of pigmentation. Near the borders there was normal connective tissue.

Diagnosis.--Mixed cell sarcoma.

A letter from the patient dated March 15, 1904, reports him in excellent health, without any evidence of recurrence. CASE 11.-Callosity at the Ankle, Caused by a Shoe, Becoming Carcinomatous; Excision; No Recurrence After Seven and a Half Years.

History.-Mrs. B. R. S., aged 23, of Shenandoah, Pa., was first seen Nov. 19, 1896, at the request of Dr. J. B. Davis. Her family history is excellent. She was married a year ago, but has not been pregnant. About a year and a half ago she first noticed a small lump on the front of the ankle, where the shoe produced some pressure, which had caused a callosity of the skin. This began to grow, until at the present time it is as large as a large chestnut. It is sessile. Apparently it has no connection with the parts underneath the skin; it is quite dense to the touch, but is not painful. No glands are perceptible in the groin or in the saphenous region. Urine normal.

Operation.-Nov. 20, 1896. I excised the growth, which I found did not involve any of the tissues below the superficial fascia. The subcutaneous tissues were removed along with the skin down to the tendons, but without opening their sheaths. She made an uneventful recovery and went home in a few days. The tumor was examined by Dr. D. Braden Kyle, who reported as follows:

MICROSCOPIC EXAMINATION.

Sections perpendicular to the surface of the skin showed an inditration of epithelial cells downward into the tissue beneath, with distinct nestings of cells loosely adherent to the fibrous stroma. The fibrous stroma contained blood vessels with thickened walls and irregular lumen. Diagnosis.-Carcinoma.

I was rather surprised at the microscopic diagnosis, for clinically it had none of the external appearances of such a growth. On section it showed a mottled dark brownish yellow.

Her physician, Dr. J. Pearce Roberts, reported, on Dec. 5, 1896, that there was a small nodule the size of a split pea situated at the base of the first metatarsal, which was quite painful to touch. On March 5, 1904, he reports that the little nodule on the dorsum of the foot still remains without any change.

While this case is not strictly one of either wart or mole, yet the character of the growth, as shown by microscopic examination and the absence of recurrence for so long, in spite of the appearance of the little nodule at the base of the first metatarsal, which is entirely independent of the growth which I removed, seems to me to make it worth while to add it to the present list of cases.

CASE 12.-Congenital Hole of Umbilicus; Sarcomatous Degeneration After 45 Years; Immediate Excision; Recurrence in the Wall of the Abdomen; General Sarcomatosis.

History. Mrs. Dr. X., aged about 45, was first seen, with her husband, Dec. 12, 1902. As long as she can remember she has had a little mole just within the depression of the navel. In June, 1902, in consequence of its showing a tendency to grow, it was cauterized with nitrate of silver, and later a doctor attempted to remove it by electrolysis, transfixing it with needles. After rather prolonged treatment with the needles the mass dropped out, but soon recurred. When I saw her it was about the size of a pea, was ulcerated and discharging a small amount of pus. In addition to this, she had a fatty tumor the size of two fists in the left axilla.

few

Operation. On Dec. 18, 1902, I removed the fatty tumor and excised widely the entire umbilicus and the surrounding tissues with the wart down to the peritoneum, without opening the abdominal cavity. She recovered in a days. The umbilical tumor was given to Professor Coplin in the laboratory of the Jefferson. He reported that the little wart "was composed largely of nests of cells enclosed in a scanty fibrous stroma. The cells are chiefly of the small, round variety, though in a few areas they are somewhat spindle-shaped. Infiltration of these cells extends nearly half the length of the section, immediately beneath the skin margin. No distinct vessels are noted in the cell areas described. In other portions of the sections the vessels are practically normal. A small amount of pigment is present. Diagnosis: Alveola sarcoma, showing slight melanosis."

After the operation I saw her repeatedly and there has never been the slightest tendency to recurrence at the navel; but about the end of April, 1904, she noticed a small lump under the skin 5 cm. above and 3 cm. to the left of the former situation of the navel. From the age of 18 she has had some pelvic trouble, for which she has had various kinds of treatment, including a prolonged treatment by Apostoli in Paris. During the first week in May, 1904, her pelvic trouble seemed to be aggravated, and she had much pain in the right iliac fossa, together with some slight fever. For this Dr. James C. Wilson, the famliy physician, was called in. Her temperature rose to about 101, and examination of the blood at intervals of a few days showed a slowly increasing leucocytosis, beginning at 15,000, and on May 23 reached 19,000. There were no symptoms of appendicitis.

I was called in consultation on May 25, and concurred in Dr. Wilson's opinion that there was no evidence of an appendicitis or other suppurative process which we could discover. Examination of the uterus showed it to be enlarged to the level of the umbilicus and very adherent on the right side, and the seat of a number of myomata. She had marked and increasing pain on the outside of the right leg, especially above the external malleolus. No local reason for this could be discovered, and we were inclined to think that it was the result of pressure from the pelvic conditions. Meantime, however, bearing in mind the sarcomatous nature of the former umbilical tumor, we feared greatly a sarcomatous change either in the uterus or possibly in the iliac glands. Beside this, she manifested a distinctly cachectic appearance, which was very painfully evident to me when I saw her on May 25, after an interval of some weeks.

After a conference with her husband and Dr. J. M. Fisher it was decided that an abdominal section should be done, followed by such operation, including, if necessary, total hysterectomy, as the pelvic conditions indicated, and also that the tumor of the abdominal wall should be removed.

Second Operation.-On May 30, 1904, I did a hysterectomy. The uterus had a large number of myomata, with very dense adhesions on the right side. Other than the mechanical difficulty of the hysterectomy, there was nothing worthy of note. The tumor above and to the left of the umbilicus was removed. It was limited to the fatty tissue, which was rather abundant, and was about the size of a cherry. It had no adhesions either to the skin or the muscles. On section, the tumor was clearly

a sarcoma.

In view of the fact that no lymphatic gland exists at the point where this tumor arose, and, therefore, that it was not a direct lymphatic infection from the umbilical tumor, it naturally gives rise to great apprehension lest it prove to be the beginning of a general sarcomatosis.1

Dr. Charles A. Powers of Denver has kindly furnished me with the following cases to reinforce the lesson of this paper: CASE 13.-Mole Over the First Lumbar Vertebra from Earliest Recollection; at 35 Years of Age It Began to Grow; Very Wide Extirpation; Axillary Recurrence After Two Years and a Half;

1. June 25. She has suffered vague pains in the right leg and foot, right arm, shoulder and back. Within a few days there have developed three nodules on the right back, two on the right shoulder and one in the right great toe-all evidently sarcomata, and the earliest indications of a general sarcomatosis, which will soon terminate her life.

Second Operation; Death Three Months Later from General Sarcomatosis.

Eight or nine years ago Dr. S. G. Bonney brought to me a man of 35 years, who had a growing lump about the size of a filbert Не In the mid-line of the back over the first lumbar vertebra. said that since his earliest recollection there had been a mole at this place; that about two months before a little fluid had gathered in it. He had shown it to a physician in a small New England town, who had simply opened it. When I saw the man the little lump presented the appearance of sarcoma. I removed it in rather wide limits under ether, and a frozen section was made on the spot by Dr. H. C. Crouch, then professor of pathology in the University of Colorado. Dr. Crouch pronounced it melanosarcoma, whereon I removed tissue over an area 6 inches long by 4 inches wide down to the vertebræ. I saw the man frequently for two years, during which time nothing happened. He then disappeared for six months, when Dr. Bonney again brought him to me with an axillary mass the size of a small orange. This was removed as widely as possible and found to be melanosarcoma. Three months later the man died of general sarcomatosis. There was no recurrence in or about the original scar.

CASE 14. A Mole Over the Last Dorsal Vertebra; Sarcomatous Development; Removal; Recurrence; Second Operation 18 Months Later; Death Soon After.

About two years ago I saw, in consultation with Dr. J. M. Walker and the late Dr. Clayton Parkhill of Denver, a middle-aged woman who had enormous, rapidly-growing tumors of both axillæ. in examining her, I noticed a small scar over the last dorsal vertebra and was told that a mole had been removed under cocain 18 months before, and that the physician had put it in a bottle of alcohol and given it to her husband. It was found and examined by Dr. J. A. Wilder, professor of pathology in the University of Denver, who reported it to be alveolar sarcoma. Parkhill had removed a sarcomatous mass. The woman died six weeks after I saw her.

CASE 15.-Mole Over Second Lumbar Vertebra; Sarcomatous Degeneration in Middle Life: Removal; Recurrence in Situ in Three Months; Second Wide Removal; No Recurrence for Three Years.

About three years ago Col. Henry Lippincott of the United States Army, then chief surgeon of the Department of the Colorado, brought to me a lady in middle life, the wife of an officer, who gave the following history: Three months before the physician at an army post in Arizona had removed a small "growing mole" from over the second lumbar vertebra. He had sent this to Dr. L. A. Conner of the pathological department of the New York Hospital, who had pronounced it myxo-fibro-sarcoma. When I saw the patlent there was a return in the scar. The widest excision was made and the tissue sent to Dr. Connor, who pronounced it a "sarcoma. I heard recently from this lady. There is as yet no sign of relapse.

I have seen a number of cases in which epithelioma has followed long-existing warts. I can not give the exact number, but I definitely remember these:

CASE 16.-Epithelioma of Nose from Wart.

A year and a half ago I removed (at St. Luke's Hospital) a large epithelioma of the nose which developed from a wart.

CASE 17.-Epithelioma of the Vulva Developing from Long-Eisting Papilloma: No Recurrence After Four Years.

Some four years ago I removed a fair-sized epithelioma (Dr. J. A. Wilder) of the vulva which developed from a long-existing papilloma. The inguinal glands of both sides were hyperplastic, but not cancerous. The woman was a patient of Dr. B. P. Anderson of Colorado Springs, and remains well.

CASE 18.-Wart on the Scalp Developing into Epithelioma; Removal.

While at the New York Cancer Hospital, twelve years ago or more, I removed a very large epithelioma of the scalp following a wart which "often bled when the hair was combed."

CASE 19.-Wart at the Elbow Developing at the Age of 75 into Epithelioma: Death from Cancer of the Liver Two or Three Years Later.

Twelve or fourteen years ago I removed, under cocain, a very small epithelioma developing from a wart just above the elbow in an old gentleman of 75 years, the father of my friend, Dr. A. There was no return in the scar, but I think he died of cancer of the liver two or three years later.

Dr. E. Wyllys Andrews also has kindly furnished me with the following cases:

CASE 20.-Mole on the Cheek from Childhood; Malignant De generation at 70 Years of Age; Involvment of Submaxillary Glands. A man, aged 72, with hypertrophy of the prostate, sought Dr. Andrews' advice for the prostatic hypertrophy. He had lost weight in the previous few months. A mole on the left cheek, which had existed from childhood, became ulcerated and inflamed two years before Dr. Andrews saw him. A month later the submaxillary lymphatic glands on the same side began to enlarge. At the time when he consulted Dr. Andrews this tumor was about the size of an egg. On the left cheek where the mole had been there was a ragged ulcer 2 cm. in diameter, covered with a bloody crust; the base of the sore was hard and indurated, and the tumor in the neck was firmly attached to the deep structures, evidently a carcinoma. Suprapubic cystotomy by spinal anesthesia was performed in March, 1903, but the patient declined operation on the carcinoma and left the hospital at the end of March much improved in health. In December, 1903, his health was still much improved. The condition of the epithelioma has not changed.

CASE 21.-Wart on Temple for Over 30 Years; Eight Months After It Began to Enlarge; Section Showed a Carcinomatous Growth; Cure by X-Rays.

Mrs. McD., aged 67, had for over 30 years, and possibly much longer, a small warty tumor, the size of a small pea, near the outer angle of the right eye above the zygoma. In December, 1901, it began to enlarge. When seen first by Dr. Andrews, in August, 1902, it was 1.5 cm. in diameter, saucer shaped, slightly excavated, with an indurated base. A small section showed a typical epithelioma. The diagnosis made was rodent ulcer. The ulcer was entirely cured by 20 or 25 exposures to the -rays for from five to fifteen minutes at a distance of 10 to 30 cm.

CASE 22.-Pigmented Mole for Many Years in Front of Ear; Carcinomatous Change Coincident with Growth.

Man, aged 52. had a brownish mole 5 by 15 mm. in front of the left ear which had been noticed for many years. In the summer of 1903 it enlarged to a size of 2 cm., with an elevation of above 1 cm., with an indurated base and a sanious discharge. The whole growth and the skin from which it grew was removed. Microscopically, the tumor proved to be an epithelioma.

CASE 23.--Mole on Back of Neck; Irritation by Collar; Development of Carcinoma.

Man, aged 45, had a mole on the back of his neck, which was irritated by his collar and developed an epithelial cancer, as was verified by a microscopic diagnosis.

Dr. J. Chalmers DaCosta has given me the following brief history of a case of melanotic sarcoma:

CASE 24. Pigmented Mole on the Back of the Hand; After a Number of Years Malignant Degeneration and Axillary Involvment; Removal of the Mole and Cleaning Out of the Axilla; Recurrence in a Few Weeks, Followed by General Sarcomatosis; Death in Three Months.

The patient was a man nearly 50 years of age. For a number of years he had had on the back of his hand a pigmented mole. Some time before I saw him this began to enlarge. When I saw him the glands in the corresponding axilla also were enlarged. The mole was removed and the axilla cleaned out. The glands removed were filled with pigment. A few weeks after the operation the glandular growth recurred, and associated with its recurrence was the development of sarcomatous nodules containing pigment all over the body, and also of flattened pigmented areas. The man died within three months of the operation with general sarcomatosis. Dr. F. X. Dercum has kindly given me the notes of the following case:

CASE 25.-Mid-Scapular Mole Undergoing Malignant Degeneration; Death from Sarcoma of the Brain.

W. B. S., a man, aged 57, for many years had a mole between the scapulæ. He was admitted to the Jefferson Hospital Nov. 25, 1903, with symptoms of a brain tumor. Some time before his admission this mole had begun to grow and was removed by his fam

Fig. 5. Cerebrum, coronal section, anterior aspect; superior parietal lobule and posterior part of temporal lobe. Three-fifths natural size. Jefferson Medical College Hospital laboratories. No. 2538. Melanotic sarcoma of brain, secondary to primary growth in skin of back. A-Secondary nodule showing considerable hemorrhage in the interior of the new growth and a scanty irregularly distributed but narrow band of peripheral hemorrhage. B-Similar mass in opposite hemisphere. The hemorrhage in this area is around the growth which is considerably compressed. C-Bloodstained zone surrounding mass; it will be observed that the peripheral blood-tinging of the white matter is more marked on this side than the other, due to the more abundant hemorrhage and its peripheral distribution. D and E are also areas of hemorrhage containing varying quantities of neoplastic tissue; the latter, which in the absence of extravasated blood, is grayish-brown or nearly black, is further obscured by hemoglobin inhibition.

ily physician. In July, 1903, while driving, he was suddenly seized with an epileptic attack. This was followed by a number of others, and he died Nov. 30, 1903, five days after his admission to the hospital. The postmortem was made by Dr. W. M. L. Coplin, and Fig. 5 shows the sarcoma of the brain.

DISCUSSION.

DR. WILLIAM L. RODMAN, Philadelphia-My experience is very much like that of Dr. Keen, as I have seen more warts undergo epitheliomatous transformation than I have pigmented moles undergo sarcomatous change. I distinctly remember three well-marked instances of warts undergoing epitheliomatous change late in life. The first case was that of an elderly physician, who had a wart situated on the temple, about the size of a hazelnut, which had been there for many years. He believed it was due to the continual pressure of

A

one.

his hatband. It had ulcerated. I made the diagnosis of epithelioma, removed the wart, cauterized the base and the patient made a good recovery. There has been no recurrence. The second case occurred in a man 60 years of age, who had a wart on the dorsum of the left hand for many years, and when I saw him in 1898 it was about the size of a small walnut. I excised it, feeling sure that it had undergone epitheliomatous change. Parts of the growth were examined microscopically and the clinical diagnosis confirmed. The case is perfectly well at the present time. The third case was a most unfortunate The patient, a man, had an ulcer on the back of the hand which began as a wart and had been there for many years. On examination I found well-marked enlargement of the glands in the axilla, 'and when I cut into the axilla I found a mass almost as large as my fist, to which the axillary vein was adherent. I excised four or five inches of the vein along with the mass. He made a good operative recovery, but died about a year afterward from metastases. I have memory of a case occurring about ten years ago in the practice of Dr. Vance of Louisville and which was reported by him to the Louisville Surgical Society. The patient was a very prominent woman, age about 55, who had a pigmented mole on the inner aspect of the knee, which had undergone sarcomatous change. Dr. Vance operated; recurrence took place in the groin and pelvis, and death soon followed. It was undoubtedly melanotic sarcoma.

DR. GUSTAV FÜTTERER, Chicago-Dr. Keen has shown that mechanical factors will produce certain changes in warts and moles which will make them malignant, and I have specimens here by which I can demonstrate the sudden occurrence of such changes in epithelial cells of the stomach. These metaplasias I have produced in the stomach of rabbits by experiment. Columnar cells of the glands of the stomach have been completely transformed and perfect pegs of squamous epithelial cells have been formed which have grown down into the deeper tissues. They push everything aside and invade even the muscularis. In a late case that I have observed they even penetrated the wall of the stomach itself and had grown toward the liver. The literature of metaplasia shows a close relation between this and carcinoma. Such metaplasia with malignancy following has occurred in different organs and, as a rule, it does not exist very long before it becomes malignant. Mechanical factors play an important part in this change, but while there are other factors at work, we may in a general way say that the mechanical factors are the principal cause. In animals which have no teeth we find physiologic metaplasia in the stomach, because it is here where the hard food is broken up.

DR. ROBERT F. WEIR, New York-I think we should adopt the rule as to moles which is accepted in connection with tumors, both benign and malignant, which is that they should be removed early. Every mole and wart had better be destroyed at once, but while this is an easy thing to say to patients, it is not so easy to get their permission. They dread the knife, but if you can tell them that there will be only a small scar, and that effected without cutting, you may get their consent. I only wish to mention the fact that for many years and in many cases I have used the glacial monochloracetic acid with good results. I apply it until the mole becomes whitish and this is followed by a slight reaction. In a week the dry scab comes off and in a short time the wound heals. Occasionally one or two repetitions may be required. This is a very thorough way of removing moles and warts, as the scar is small in size, pliable and of a nearly normal color.

DR. ERNEST LAPLACE, Philadelphia-These cases always occur in tissues of diminished resistance. A great many people have warts and moles who never have cancers, but those who are for other causes prone to the development of cancer are very likely to develop cancer in warts and moles and other tissues of diminished resistance. Old age is also a prominent predisposing factor, and while the warning of Dr. Keen should be heeded and all warts and moles should be removed before any malignant tendency has manifested itself, in order to make assurance doubly sure, yet this will often be found to be impossible. As to the production of carcinoma and sarcoma, I

believe various points of pathology have a bearing on this. Warts proper are of a true epitheliomatous type, for they consist of a hypertrophy of the papillary layer of the skin. These become true epitheliomata; there are, however, moles with enlarged and proliferating blood vessels which later become sarcomata. Hence, it is safest to remove all such excrescences when it becomes apparent that they are growing.

DR. A. D. BEVAN, Chicago-A possibility that has impressed itself on me from an experience with a limited number of these cases is the danger of rapid general involvement apparently from infection of the wound in the operation itself. I have removed melanotic sarcoma and the operation has been followed almost immediately by general involvement. Before I remove another of these growths I shall make it absolutely dry with the Pacquelin cautery. Every pigmented mole is histologically a malignant growth, and it takes but a little stimulation to change a clinical benign into a clinical malignant growth. Recently my assistants and myself were discussing this matter, all having decided to have moles removed from our backs. We found that each had a great many to be removed and consequently we changed our minds. Doubtless one-half of this audience have moles and those who have a great many could not think of removing them all. At the earliest possible indication of any irritation a mole should be destroyed with the Pacquelin cautery and then widely extirpated with the knife.

DR. W. W. KEEN-A mole is a match which sets fire to a great conflagration. Dr. Bevan's point is a good one. One can not make any absolute rule, as there are so many exceptions. I remember the case of a man who had from 50 to 100 moles, but one would not think of advising extirpation of all of them, if, indeed, any in such a case. I do not recall any instance of malignant degeneration in a case having so many moles.

PATHOLOGIC IRREGULARITIES.*

M. H. FLETCHER, D.D.S., M.D.

CINCINNATI.

ENUNCIATION.

The terms orthodontia and irregularities of the teeth conventionally carry with them the idea of irregular teeth in children and youth, connected with their treatment for correction. The causes are usually hereditary, but may be acquired. One could quote from writers from Etruscan days down to the present time and give the opinion of more than fifty authors, but their definitions of the etiology would most likely each differ somewhat from the other.

There have been handed down to us such explanations as "She inherited large teeth from one parent and small jaws from the other," or "His baby teeth were not extracted soon enough," or "Were taken out too soon." "Lack of absorption of the roots of the temporary teeth, while the growth of the permanent set is rapid," etc. One author thinks "the development of the hind end of the jaw does not keep pace with the absorption of the front end."

Then there are a lot of platitudes, such as "The teeth are too large for the jaw," "Too many teeth for size of the jaws," "Projecting jaws," "Sleeping with the mouth open," "Enlarged tonsils," "Want of room in the jaws," etc., etc.

In summarizing the above opinions it would seem. that symptoms, or results, have been given in place of the real cause. Nevertheless, this is only another opinion.

ETIOLOGY.

Guilford divides the causes into hereditary and acquired, and Colyer into general and local.

Read at the Fifty-fifth Annual Session of the American Medical Association, in the Section on Stomatology, and approved for publication by the Executive Committee: Drs. E. A. Bogue, Alice M. Steeves and M. L. Rhein.

"Talbot has shown that irregularities of the teeth were often due to two factors. Those of constitutional origin, which develop with the osseous system, and those of local origin." "The deformity always commences at the sixth year and is completed at the twelfth." "Forward movement of the posterior teeth produce the same result as arrest of development of the maxillæ. It was also shown that the vault is not contracted by mouth breathing. That contracted dental arches are as common among low as in high vaults and that they simply appear high because of the contraction. That mouth breathing due to hypertrophy of the nasal bones and mucous membrane, deformities of the nasal bones, adenoids or any pathologic condition producing stenosis does not cause contracted jaws, but all these conditions are due to neuroses of development."

EFFECTS.

The ill effects of these deformities must be apparent to such an audience as this with a mere suggestion. The degree and extent of the ill effects have not only to do with the unsightliness of the patient, but Talbot has. done much to prove the connection of extreme cases with idiocy and crime.

Aside from uncomeliness, irregularities undoubtedly interfere with the proper care of the teeth and gums, and in this manner are a large factor in fostering diseases of the alveolar process, including the surrounding tissues; many times involving other parts of the jaws, the nose, eyes and ears, often inducing chronic disorders. of digestion and fostering the causes of zymotic diseases. Neuroses of many varieties may have their origin in diseased alveolar process and teeth.

TREATMENT.

As to treatment, our best men differ in their procedures. Cleft palate and hare lip are of course dealt with from a surgical standpoint. Prognathic cases, showing atavistic tendencies, with diastema behind the canines, are sometimes treated surgically by removal of bone from these spaces, but such treatment is rare. In the treatment of lesser deformities mechanics are almost entirely relied on. Some operators resort to the removal of one or more teeth in order to accomplish the desired end. On the other hand, Dr. Angle says: "The best balance, the best harmony, the best proportions of the mouth in its relation to the other features, require in all cases that there shall be the full complement of teeth, and that each tooth shall be made to occupy its normal position. And if we accomplish this we shall have satisfied the demands of art, so far as they are concerned in the relation of the mouth to the rest of the face."

To restore the features to harmony and the teeth to perfect position and usefulness requires mechanical skill of the highest order, coupled with an esthetic sense and artistic eye.

PATHOLOGIC IRREGULARITIES.

Definition. In contradistinction to the above, there is a class of irregularities not treated of in works on orthodontia, nor have they been considered under the head of dental orthopedies. In fact these cases seem in a way to be "the stones which the builders disallowed."

They are in many particulars the exact opposite of the others. 1. They do not appear until the age of mature years. 2. They are purely acquired. 3. They are entirely pathologic, in the sense that they are the result of disease, localized in the alveolar process. 4. They are only amenable to mechanical treatment by first removing the causes of the disease producing them.

Name.-In order to distinguish these from the previously described, the writer has called them pathologic irregularities.

Etiology. To describe all the causes of pathologic irregularities would be to give a treatise on interstitial gingivitis, known also as pyorrhea alveolaris and Rigg's disease.

To make the matter plain from my standpoint it will, however, be necessary to briefly describe the anatomy, the pathology and the causes, with treatment other than mechanical.

Anatomy. An intimate knowledge of the anatomy is of course necessary in order to comprehend the pathology, or to apply treatment intelligently. It is presumed this is understood.

Now, when we consider that a hard, unyielding substance like a tooth is not only supported and held in place by, but entirely dependent on, the thin, bony walls of the alveolar process, it is a marvel to realize what hard usage it withstands, and what enormous pressure and lateral strain it is continuously subjected to without displacement or injury. Let this bone become diseased, however, and ere long the teeth become tender and unusable, and vast numbers are finally lost without the least defect in the tooth itself.

In the last decade these diseases and their treatment have engaged the attention of the profession to a marked degree, much to its credit.

Terminology.-To Talbot is due the credit of having classified the various phases of this disease and described its different stages. He has given the name "interstitial gingivitis" to inflammation of the gums, alveolar process and peridental membrane. The term Riggs' disease and pyorrhea alveolaris were formerly applied to any or all the stages and conditions.

The term Riggs' disease is indefinite and is to-day obsolete. Pyorrhea alveolaris now indicates a flow of pus from the sockets about the roots of the tooth and is a terminal stage of inflammatory action. It is the result of previous inflammation known as interstitial gingivitis. Inflammatory action may continue, however, and exfoliation of the teeth result without pus infection. One termination of the inflammatory action is the tendency of the teeth to be expelled from their sockets, with the result that they become elongated, tilted to one side or pushed in or out of the normal arch.

To give a plan of arresting this process before it has gone too far and to replace the teeth into their normal position is the object of this paper.

Causes. In order to arrest or eradicate a disease its causes must first be found and removed. Talbot says: "The local causes which produce interstitial gingivitis are an accumulation of tartar about the necks of the teeth, decayed teeth producing hypertrophy of the gums, unfinished fillings, gold crowns and bridge work, artificial dentures, rapid wedging of the teeth, collections of food and everything that will produce irritation of the gum margin, setting up a chronic inflammation or gingivitis. This in turn extends to the deeper tissues (the peridental membrane and alveolar process), where it becomes interstitial in character. The constitutional causes which act locally, producing interstitial gingivitis, are the toxic effects of mercury, lead, brass, uric and other acids, potassium iodid and other agencies acting in a similar manner, such as scurvy,” etc.

He further says: "Autointoxication (meaning selfpoisoning due to a faulty metabolism), is the great cause of interstitial gingivitis resulting in pyorrhea alveolaris."

There seems no reason to believe that drug poisoning or other morbid systemic conditions can produce interstitial gingivitis without a lesion of the gum preexists. This lesion may be the merest break in the mucous membrane, caused by the smallest deposit of calcareous material, this local mechanical irritation. being one requisite of the etiologic moment. On the other hand, there may frequently be found in gingivitis the systemic disorders accompanying cases of sapremia and septicemia.

The continual pressure against the gum tissue of rough, irritating calcareous deposits, which continuously increase in quantity and insinuate themselves deeper and deeper beneath the soft tissues, are accompanied with all the products of repair by granulation or second intention, and may be accompanied by surgical fever. These deposits may be found wherever saliva can penetrate. It has never been my privilege to see deposits of tartar about the necks of teeth that were innoxious, but they are always irritating to some degree, and usually greatly so. This condition may exist in all stages, from that of being imperceptible to the naked eye up to a complete state of pyemia, and may result in death.

On the other hand, there is abundant evidence to show that autointoxication, or a low state of health from any cause, greatly favors the progress of the disease, and with this state of affairs present a chronic pus-forming condition may soon be found about one or more of the teeth where the local exciting cause exists, but that autointoxication or other systemic disorders cause this disease, without local irritation, does not appeal to the writer's reason any more than to say that the same disorders cause inflammation of the pleura or conjunctiva without a local point of least resistance from local cause.

Degeneracy or faulty development may bring the etiologic moment at a very early stage of the local irritation. This might be almost coincident with the initial lesion, whereas in normal and healthy individuals the pyorrheal stage, even in its mildest form, may be deferred indefinitely or never appear even where, calcareous deposits are excessive.

The fact that the tissues involved are transitory in nature does not seem an adequate factor in accounting for the disease, as suggested by Talbot, since they are as transitory in cases where the disease does not exist as where it does, and these tissues recover as readily as other structures which are not transitory.

There seems no question but that calcareous deposits about the teeth should be looked on as noxious foreign bodies and that the constant effort on the part of nature to extrude them, results in the progressive death of the surrounding tissues with the malposition of the teeth as one result. We find in this disease zones of granulation tissue with the result of destructive metabolism in the soft tissues and the creation of sequestra in the bone. This condition, however, is changed to constructive metabolism the moment the tartar, sequestra or other local irritants are removed.

The sinus in the pyorrheal stage of this disease is between the root and alveolar process, unless the lesion