LESIONS PREDISPOSING TO CANCER.

BY M. B. HUTCHINS, M.D., ATLANTA.

It is difficult to avoid bringing into a paper of this kind the cause of origin of cancerous growths, since cause and prior lesion are so intimately related. Without some sort of stimulus, or disturbance of cell relation, many of the lesions would never become malignant. Whether a group of cells has been left out of place in fetal life and ready for aberrant growth, or gets misplaced later, can make no great difference for the purposes of this paper, but the latter occurrence seems best to harmonize with the facts. That mechanic, thermic, actinic, chemical, and perhaps local toxic influences, often seem the positive exciting cause of malignant development can not be doubted. What the element is in cell relations that holds the balance in so many cases and loses its control in a few we do not know.

Of all skin lesions tending to cancerous development there are none that rank so high as the rough horny, scalecrusted, irregular, pinhead to all sizes and shapes of points and patches seen on the face, neck and hands. These occur so frequently upon the thin, red, florid skin of people who are either red-haired, or have the "red-haired" type of skin, as to become a definite feature. The crusts are usually composed of small horny cell masses; the skin beneath may show a bit tender, or it may be slightly thickened, irregular. Later one or more points take on

typical epitheliomatous changes, cell-growth, infiltration, erosion, crusting, fissuring, ulceration. Often there are numerous epitheliomata on the one subject. But a majority of people go through life with their "scaly spots," better or worse, without reaching the malignant stage; hence radical treatment for these must await such development.

Closely related to the above, or occurring with it, is the cily, seborrhoeic skin with points, discs or patches developing in a greasy surface, and showing greasy scales; sooner or later, erosions, new growth, finally the epithelioma in full development. These two kinds of skins and lesions more frequently show multiple epithelioma. Warty, flat, roughened patches, as of the "senile skin," often form the starting-point of cancer. A persistent fissure of the lip may be the origin of epithelioma. Scars, as from burns, caustics, X-rays, incisions, boils, carbuncles and various injuries, present a condition of cell displacement favorable to malignant growth.

A lesion from the pinch of a cracked and foul pipe-stem has caused death from cancer of the lip. Phimosis, balanitis, at times result in epithelioma. An innocent looking epulis may prove not a fibroma, but a sarcoma.

Lupus erythematosus has been known to degenerate into cancer. Lupus vulgaris scars often so change. An apparently innocent wart may become malign, and keratoses from long continued arsenic. Keene, in his paper before the American Medical Association two years ago, insisted upon the latent dangers in, and the removal of all moles, but was convinced of the impossibility of getting the consent of the patient to such radical prophylaxis. My own observation is that few moles undergo cancerous change; but when they do, especially those of the

pigmented type, their malignance and metastases may be horribly complete; their termination fatal.

The pigmentary type of malignant disease is the product of many lesions. A mole accidentally burned, and so being transformed into malignancy, is recorded by Crocker. Johnston reports cancer developing in a mole on the thigh; another on the back; another on the shoulder, and one on the abdomen. Following injury near the nail, a swelling, dark fluid discharge, pigmentary deposit in the growth-melanotic whitlow.

"Malignant freckle" spot of the foot or leg may end in pigmentary cancer. Melanotic rodent ulcer or melanoepithelioma is another form. Melanoma of the eye has its usual beginning in a choroidal pigmentary spot.

The type of these growths is often impossible to diagnose accurately without the aid of the microscope. Metastases of pigmentary cells are often extensive, the lethal end certain. Early and free surgical removal offers the only cure.

Wilfred Fox considers most cases of melanoma as nevocarcinoma. Johnston found both types, nevo-carcinoma and nevo-sarcoma. Fox, at variance with Johnston, convicts the pigment of the chief activity in cancerous change.

Cases under X-ray treatment for epithelioma often show partial, possibly complete destruction of the original disease, with extension, or new development of disease in the scar or its borders. Skiagraphic X-ray burns and the burns of X-ray workers have time and again gone on to epithelioma and death. McLeod's case of a lupus X-ray scar with cancer forming in its middle is striking.

Suppurative, broken down sebaceous cysts, or even the unbroken cysts, may be transformed into cancer.

A small injury of the tongue from a jagged tooth, and the irritation continued, have sufficed to bring on cancer

of that organ.

A similar development may follow a syphilitic gumma. So with leukoplasia, the white spots and bands called "smokers' patches." In the same way may constant irritation of a tonsillary, pharyngeal or esophageal lesion terminate. Many cases of cancer of the stomach follow an ulcer; many of the gall-bladder succeed erosions from biliary calculi. Ovarian cysts may so degenerate. Uterine myoma is not always benign. Cervical scars from old lacerations frequently form the starting point of cancer. Leukoplasia of the vulva often undergoes malignant change.

No adenoma of the breast is safe to leave in its place. The cicatrix from abscess of the breast has been sufficient to furnish the origin of cancer. Paget's disease of the nipple, possible to be confused with eczema, is usually cancerous in nature and progression.

Sufficient examples have been given and time and space are already too far exhausted to permit of an extension of the list. In unnatural lesions and growths, in scars and irritated erosions, in parts subjected to continued injury, we have a loss of cell balance, an absence of normal restraint, and the scene laid for the entrance of the unknown element that determines the onset of carcinoma, sarcoma or endothelioma, all malignant.

Το urge upon people the dangers in lesions and growths not yet malignant will often be of no avail. In many cases the malignant change may never take place, but every effort should be made to cure irritated lesions and remove irritant agents in the simple cases; and no growth certainly progressing towards cancerous evolution should be left untreated. Upon the slightest occurrence of symptoms tending to these changes, instant and thorough treatment must be instituted. Often the simplest erosion, smallest scirrhus or most minute irritated mole or other

growth may liberate cells that wander away to form metastases of the most formidable character. It is proper to watch some cases without interference, and criminally negligent or ignorant to advise the patient to "let alone" any lesion or growth already showing signs of malig

nance.

I have used the term "cancer" in its broad sense, to cover all types of growth whose tendency is to progression, insidious diffusion, recurrence after treatment, certain death without treatment, often death in spite of treatment.

The following cases illustrate some of the results referred to above:

Case No. 1.-Mr. Q., age fifty-nine. Razor cut in large flesh-colored mole, left cheek, eight months before. Microscope showed epithelioma. Excised. Permanent

recovery.

Case No. 2.-Mr. C. Fungating and eroded pigmentary lesion top of left shoulder. Dark mole there for years. Irritated by suspenders. Got well after prolonged caustic treatment and protection.

Case No. 3-Mr. M., age sixty-six. Diag. Melanosarcoma of dorsum of right foot. Forty years before, a pin-head diameter, black dot just to right of great toe's extensor tendon. Slow peripheral growth for twenty-five or thirty years; then increasing, especially rapidly in past three or four years. When seen, a lesion two by two inches. Various shades and degrees of pigmentation, brown to black or bluish. Some thickening and in parts finely papular. Burning sensation when warm in bed. Declined excision. Received no treatment. About a year later part of patch elevated, exuding serum, and still no metastasis, but he died within a year or two of general diffusion of disease.