The Toner lectures. Instituted to encourage the discovery of new truths for the advancement of medicine. Lecture 1. On the structure of cancerous tumors and the mode in which adjacent parts are invaded

The "Toner Lectures" have been instituted atWashington byJosephM.Toner,M.D.,whohas pUxcedincharge of aBoard of Trustees, of which the Secretary of the Smithsonian Insti- tution is one, a fund, "the interest of which is to be applied for at least two annual memoirs or essa^-s relative to some branch of medical science, and containing some new truth fullyestablishedby experimentor observation.". Gentlemen:—Aftermuch hesitation astoa subjectsuitable forsuchan occasion asthis, I determinedto inviteyouratten- tion to certainconsiderations with regardtoCancer, a disease which merits study both because of the considerable mor-. The causes of the specific characteristics of individual growths were then naturally sought in the blastemata, and the pecu- liarities attributed to the blastemata were accounted for by supposing them to depend on special morbid conditions or dyscrasiaeof the blood.

The great name of Rokitanski,atwhose hands itfound its ripestdevelopment and most masterlyexpression, induced the general acceptanceof this hypothesis, andit waslong the pre- vailingdoctrineinthe schools of Europe and America, inspite of the circumstance that the most eager and searching inves- tigationsof the physiological chemistsutterly failed todiscern. Nor wasit strange that under the influence of the doctrine of dyscrasice, thenotion shouldarise thatthe specialized blas- tematamust express their specific natures bygiving birth to peculiarelementary forms, or that the histologistsof the day, very imperfectly acquainted with the normal structure of the body, and bewildered by the multiplicity of forms they ob- servedin morbid growths, should too hastilyhave adopted the plausibledoctrine of specificcancer cells,whichmoreextended observation speedily renderedquite untenable. 5, largenumberofcasestohave preceded thedevelopmentof the disease, and thoughfrequently the patient had lost all recol- lection of the original harm, yet it was in this direction we oughttolook, ratherthanseektoexplainawaytherealdifficul- ties byinvokingthe aidof an imaginary cachexia.

In consequence of the multipli- cation oforiginal investigators throughout Europe, and of the introduction of improved methods of histological research,. His general conclusion was quite adverse to the doctrine of Virchowthat cancers originate bythe multiplica- tion of the connective tissue corpuscles. So far from this being the case, in cancers of the skin at least,Thiersch de- clares that the essence of the morbid processisacell multi- plication in the lowersoft layers of the epidermis, andin the epitheliumof theglandularappendages of the skin,especially thesebaceousfollicles.

Atthe mai'gins, ontheotherhand, singlesmall slices,suchas areusuallymadeformicroscopicalexamination,areapt todis- playnumeroustransverse oroblique sections of individual cancer cylinders, which have beenerroneously interpreted asout- lying independent foci, and supposed to originate from the corpuscles of the connectivetissue inwhichthey areembedded.

CANCEROUS TUMORS. 7 only apparently a separate existence, and that everywhere the

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CANCEROUS TUMORS, 9 the muscle of the mucous membrane into the submucous con-

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11of thecirculation in the tortuousveins, whichinproperly pre- of thecirculation in the tortuousveins, whichinproperly pre- pared sections are found, as might be expected, to contain great numbers of white corpuscles.. first appears in the connective tissue stroma immediately around the blood-vessels.. cells and the large epithelial forms of the cancer cylinders every transition can be observed. When we remember the structure of connective tissue, and the manner in which Von Recklinghausen hasshown its little cavities and passages to openinto the lymphatic capillaries, weshall not be surprised thatitisin these,the nearest available cavities, that the new elements accumulate and develop into the cancer cylinders. As to the assertions of Thiersch and Waldeyer that the cancer cells are essentially epithelial elements, and therefore can only be the progenyof the horny layer of the embryo and of its derivatives, it .. appears tohim a generalization which the facts donot justify. . "Ifear," he cries, "that in this way we shallattain a cellular . mythologybeforewe shall havea cellularpathology.".

And hereIpauseforamoment tosay,that in thelatter part of the year 1871,my own studyof thin sectionsledmeto the conclusion that themigration of thewhite corpuscles played a great role in the developmentof cancerous growths, and that, at least in certain cases, the cancer cylinderswere formed by the transformation of these corpuscles, which first accumulated inthe lymphatic capillaries and the passages leadingtothem.

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CANCEROUS TUMORS. 13

CANCEROUS TUMORS. 15 The larger epithelial cells bore a striking resemblance to the

CANCEKOUS TUMORS. 17 growth are so similar in their microscopical appearances to

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CANCEKOUS TUMOKS. 21

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23in the cicatrix and destroj-cd tlie patient.* Tlie secondaiy in the cicatrix and destroj-cd tlie patient.* Tlie secondaiy grovvtlis liad no doubtful anatomy. I next draw your attention to some views from a case of cancer of the left breast, removed in March, 1871. Inthiscase portions of the growth presented the ordinary anatomyof scirrhus of thebreast, butother portions were ina conditionverysimilartothat describedinthe last case,except that many of the gland vesicles were dilated into cysts.

Such a growth would be called cysto-sarcoma if the whole tumor had the structure represented in these photographs, but a large part of it had the ordinary anatomyof scirrhus,.

CANCEROUS TUMORS. 25 posed of a net-work of nucleated cancer cylinders lying in a

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27transformationsaboutwhich there can beno question,namely, transformationsaboutwhich there can beno question,namely, the occasional conversion of the gland vesicles into C3'sts. But there isanother alteration in those of the gland vesicles which are most nearly normal, that can be seen in the sec- tionsfrom whichthese photographs were taken, and that has been shown in one or two of the photographs; namely, an increased number of epithelial cells in the interior of the vesicles, so that they form several layers, instead of one, whichis allthatexists in the normalvesicle.* Iam inclined to believe that this increase of the number of the epithelial elements may go on until the vesicles and ducts are so dis-. On the contrary the study of the marginal portions of growing breast-cancers inclines me more and moreto the opinion that the small-celled brood, accumu- lating in the lymph spaces, is transformed into cancercylin- ders.

That this takes place even in skin cancers I have endeavored to show, and it appears to me that the process plays even a more important role in cancers of the breast, forming probably the greater part of tumors which haA^e at- tained any considerable size, and the whole of those which develop as secondary growthsafterthe complete extirpation of theglandfor cancerousdisease. A studyof themode in whichcancers of the breast invade the adjacent fat is verysuggestive in this connection, and I willgive a short accountof the process asI have observedit.

CANCEKOUS TUMORS. 31

CANCEROUS TUMORS. 33 regular cells with large nuclei, that the older descriptions of

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On the other hand if a tumor be extirpated which does not possess the anatomj'^of cancer; in whichno proper cancer cylindershave been formed; as forex- ample in thefirst case ofmammary tumor to whichI alluded this evening, canwe be sure that the growth would not have ultimatelyacquired the cancerous anatomyif it had been let alone. Can we be sure that itwill not, in spiteof its timely extirpation, recurand prove fatal. Nevertheless it maynot be amiss to state that the general tenor of surgical experience would seem to give a negative answertoboththese important questions.

It implies amore or less confident belief in the local significance of the primary lesion, and it is not inconsistent withthecircumstance that practicallythe majority of tumors, whichonextirpation prove tohavethe anatomyof cancer,do. Onthe otherhandthe negativeanswertothesecondquestion might have been anticipated on purely anatomical grounds, since it would seem that in every cancer there miTst be a period when the small-celled infiltration of the connective tissue, and perhaps someincrease inthe numberof theepithe- lial elements of any glandular part involved, is all that has taken place, and whenever this process commencessimultane-.

CANCEROUS TUMORS. 35 ously in a comparatively large area instead of in a small one

LIST OF PHOTO-MICEOGRAPHS