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my care one year prior thereto. She gave the following fragmentary history: Some seven years previously a large wart on the forehead, which she had had for a long time, commenced to annoy her. An attempt was made by a medical practitioner to remove it by caustic. As a result

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an ulcer formed, which, in spite of the application of ointments and various treatments by different surgeons, slowly extended, but with an accelerated rate during the past year. The condition at that time, January, 1902, was as follows: The upper part of the face was occupied by an immense open ulcerated wound, which had entirely

destroyed the skin, muscles and bone of the frontal region. It was bounded below by the lower eyelids and a sharply cut margin dividing the integuments and bones of the upper third of the nose. Superiorly it was limited by the sharply cut edge of the frontal bone above the frontal cells. Laterally it extended to the outer edge of the orbits. Within this space everything was destroyed down to the surface of the dura mater. The brain bulged into and pulsated freely in the upper part of this cavity. The dura at

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that time seemed thin, but exhibited no evidence of disease. Below the brain a portion of the roofs of the orbits were still intact, and beneath these the eyes lay semi-detached in their cavities, the globes semi-flaccid and the cornea opaque, but the patient was conscious of light and darkness, and remained so until the end. The surface of this great cavity was bathed in pus, contained many small greenish sloughs, and was fairly sensitive. The edges were not raised or hardened as they usually are in rodent ulcer, nor did they give the least indication of an advance line of infiltration, the skin immediately beyond the edge appear

ing healthy and quite devoid of inflammation. In addition, there existed two minor and completely detached areas of ulceration around the base of each ear. In the case of the ear the tissue beyond the zone of ulceration exhibited a waxy and thickened condition, and of all the tissues involved it alone suggested the existence of a neoplasm preceding the necrosis. In addition to these lesions, there existed partial deafness and a paralysis of the left half of the orbicularis oris. The sense of smell was destroyed, but taste was existent though unreliable. The age of the patient, and the immense destruction, excluded the hope of

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Partially developed cell nest in rete. x200.

benefit by surgical means. The X-ray was considered but the prospect did not seem to warrant the risk; experience having shown that while beneficial in the earlier stages of rodent ulcer, advanced cases are often made worse thereby. The surface was therefore dressed with an ointment consisting of equal parts of ung. zinci and vaseline, to which was added twenty grains each of lysol and calomel. Under this treatment the local condition greatly improved, the sloughs separated and an abundant granulation tissue formed on the exposed dura. The patient's health, considering her age, was excellent, appetite good, and pulse strong. So matters remained for nine months, the disease progressing but slightly. At the end of this period it commenced

again steadily to advance, and continued to do so until death. The deafness grew almost complete, but the nutrition was maintained; and when her demise finally came, in March, of this year, it could not be said to be especially the result of the disease, but rather from general senile asthenia. At the time of death the tissue destroyed included the whole of the frontal bone, part of the malar, and almost all of the ethmoid and nasal bones. The anterior lobes of the brain bulged out into this space, but there was never any evidence of envolvement of that organ or its membranes. The ulcerated areas, around the ears, participated in this final extension, and the one on the left

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exposed the masseter muscle freely. I was unable to obtain permission to make a proper dissection of the tissues involved, but I removed portions of the same, including the left ear. As before noted, this latter was the only area that presented any appearance of infiltration outside of the immediate edge of the ulcer. I cut some sections at right angles to the surface and made therefrom the photomicrographs that are here presented.

An examination of this section will disclose the following conditions: The rete mucosum is hypertrophied and lobulated, and at various points is semicontinuous with masses of cuboidal cells that penetrate the corium in columnar

formation. While not exhibiting fully formed epithelial pearls, there are several places where the epithelial cells assume a distinctly concentric arrangement, and one such mass is visible in the network of yellow elastic fibers that forms the stoma of the lobe. In addition to these eccentric epithelial hypertrophies, the whole tissue is infiltrated with an abundant small-celled growth.

Certain facts are illustrated by this case that are worth. bearing in mind. First, as to etiology, the wart with which this, and most cases of rodent ulcer commence, would, in the opinion of Butlin, not develop into a malignant ulcer unless irritated. Secondly, if completely excised it does not recur. Thirdly, the areas round the ears were quite distinct from the main ulcer. At the time the case came into my hands, the dressings had been greatly neglected, and it is difficult to avoid the conclusion that the presence of these areas was due to a secondary skin infection from the discharges which would naturally collect at these points. If so, they are corroborative of the opinion expressed by Dr. Jonas in his paper at the recent session of the American Medical Association as to the infectiousness of cancerous discharges.

The slight systemic effects of such an immense lesion are very remarkable. Notwithstanding the advanced age of 87, the patient was clear minded, strong in voice, and only bedridden because deprived of her eyesight and hearing. No cancerous cachexia or any blood changes were present. The absence of these usual accompaniments of carcinoma led the earlier surgeons to doubt the malignant nature of the growth, until the same was established by the labors of Thiersch, Charles, Moore, and Collins Warren.

The photomicrographs here presented show that the case under consideration partook of the characters of both the lobulated or squamous and the tubular varieties of epithelioma. Montgomery says that rodent ulcer is a superficial carcinoma of the tubular variety, and Dacosta asserts that rodent ulcer contains no cell nests. Nevertheless this was essentially a rodent ulcer, and it does contain cell nests.

A better knowledge of the nature of cancer is ever becoming of greater importance, and engaging more earnest attention. A condition such as the one under consideration,

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