occurred mostly in elderly people, the clinical diagnosis being as follows: in six, ulcer or cancer; in two, syphilis of the stomach or cancer; in two, organic stricture of the cardia, probably cancer; one, adhesions or cancer.

In spite of the assurance which the writer feels is often warranted in making a positive statement as to the absence of malignant disease of the stomach, it is a striking observation that röntgenologists rarely diagnose an early carcinoma of the stomach. It is probably very rare indeed that a case of truly early carcinoma is seen at operation. That the application of the diagnostic points described in the foregoing pages is adequate is attested by the fact that not once in the hundreds of operated patients already mentioned was carcinoma found by the surgeon when the pre-operative Röntgen examination had failed to find an organic lesion; yet not more than a dozen of the gastric malignancies could really be considered as early. With malignant disease of the stomach, the morbid sensations produced by the affection are of such indefinite nature that the patient seeks medical advice only when it is too late for an early diagnosis. And, as Huerter says, even if during the first examination the suspicion of a malignant tumor is forced upon the average examiner, he is seldom willing to express a positive opinion until the programme of watchful waiting has been pursued too long for an early diagnosis. Why not make the Röntgen test a routine procedure in the examination of every case presenting gastro-intestinal symptoms?

As a matter of fact, the majority of cases of gastric cancer do not submit themselves for examination in the early stages of the disease. In the writer's experience, as in that of White and Leonard, most of the patients examined for suspected cancer of the stomach showed either a well-developed lesion, readily found, or else a normal röntgenologic behavior of the stomach, warranting a negative diagnosis of cancer. It is very striking that in the large series of cases reported by White and Leonard, as well as in the writer's own extensive experience, not a single case presenting normal Röntgen stomach findings has proved to be cancerous, although most of them have been followed to operation or to autopsy, or have been watched for at least six months after the examination, in order to verify the results.

Although it is obvious that a very small malignant lesion on the anterior or posterior wall might escape observation, nevertheless it

appears that a carcinoma of the stomach may be almost positively ruled out in patients whose symptoms are of long standing, but whose stomach is röntgenologically normal. With the very careful technic now possible, röntgenologic failures do not occur in the negative diagnosis of carcinoma, but in cases where carcinoma is diagnosed and does not exist. As White has put it, our mistakes have been errors of commission rather than errors of omission. The moral is to recognize the limitations of X-ray evidence. Even in cases where the X-ray examination is not required to establish an already obvious diagnosis of malignancy it renders great aid in locating the lesion and in showing its size and extension to neighboring tissues. At times the X-ray evidence will demonstrate that a carcinoma is small, free from adhesions, and distinctly operable in a case which, clinically, presents such signs as would lead one to expect a large inoperable lesion.

EPITHELIOMA: ITS EARLY DIAGNOSIS AND AN

EXCELLENT METHOD OF TREATMENT

BY WM. H. BEST, M.D.

Assistant Visiting Physician, Department of Cutaneous Diseases and Syphilis,
Kings County Hospital; Attending Physician, Polhemus
Dispensary, Brooklyn, New York

ALTHOUGH metastasis and glandular involvement are not so early in epithelioma as in carcinoma elsewhere in the body, its early recognition and immediate thorough removal prevent what is frequently supposed by the patient to be an inoffensive lump in the skin, or an insignificant ulceration, from becoming later the cause of a major operation, with much disfigurement and even loss of life.

Epitheliomata are due to a proliferation of the cells of the stratum mucosum (rete Malpighii), which is the lowermost of the four layers making up the epidermis. The lowermost cells of this stratum are columnar with oval nuclei, and are sometimes spoken of as the basal cells. Each superimposed row of cells, however, is less columnar, becoming polygonal with concentrically-placed, round nuclei. The cells of the rete contain fine fibrilla which radiate outward from the nuclei and go beyond the cell margin, crossing the intercellular spaces, and appear to interlock with fibrilla of other cells. These fibrilla have been variously called spines or prickles, and the name "prickle cell" has been given to the flat, polygonal cells containing these fibrillæ.

There are two types of epitheliomata, depending upon the type of cells that constitute them, which differ enough in their clinical appearance as well as in their histologic structure to be worthy of separate description. The essential pathologic process in both these types of epitheliomata, however, is a down-growing of the epiderm, with a proliferation of the cells of the stratum mucosum.

The squamous cell or prickle cell type of epitheliomata is made up of cells which correspond to the flat, polygonal, fibrillated, prickle cells of the stratum mucosum. In its earliest manifestations it is a

small, pearly thickening of the skin, covered with a scale. This scale, when at first picked off, leaves a moist surface, but soon the removal of the scale causes bleeding. Its course is then various. It may become elevated above the surrounding skin; it may spread peripherally without much elevation, giving the appearance of a flat disk; or it may grow into the subcutaneous tissue, making a small, irregularly-shaped tumor. In any case, ulceration soon starts, making an ulcer with a dark-red floor, from which spring minute epithelial projections. The margins are hard, indurated, and elevated. There is a slight mucosanguineous discharge. Except where ulceration extends deeply from the beginning, lymphatic involvement is not, as a rule, very early, but in this variety of epithelioma metastasis to the lymph-nodes takes place sooner or later. It is therefore more malignant than the type of epithelioma about to be described.

The rodent ulcer or basal cell type of epithelioma is composed chiefly of columnar epithelium (the inner cells of the mass being frequently oval), which correspond to the cells of the basal portion of the stratum mucosum. However, the lining cells of the hairfollicles, sweat and sebaceous glands may be a possible origin for this type of epitheliomata. The rodent ulcer first appears as a small, hard, faintly yellow or brown tubercle, with dilated blood-vessels running over its surface. It may remain so for years, but eventually ulceration starts. The ulcer is covered with a crust, which loosens and falls off, another crust forming. With the falling off of each subsequent crust the ulcer becomes larger. The process here appears to be more one of ulceration than one of new growth. The ulceration is peripheral as well as downward, and the margins do not show the same elevation and infiltration as is seen in the squamous cell epithelioma. The discharge is of a bloody character. After a time the ulceration spreads deeply, involving the subcutaneous tissue and even the bone. The lymphatics are rarely involved in rodent ulcer, and metastasis to the lymph-nodes (unless very late in the course of the disease) is a rarity.

In the diagnosis epithelioma must be differentiated from tubercular syphilid, lupus vulgaris, tuberculosis verrucosa cutis, and verruca. The following table brings out the salient points in their differentiation:

Epithelioma

Tubercular syphilid

Lupus vulgaris

Tuberculosis verrucosa cutis

Verruca

Progress slow.

Progress rapid.