Neoplasmata are essentially characterized by the formation of new kinds of tissue in the skin. Neoplasms are observed in many different diseases of the skin, and under a variety of circumstances, but those diseases only are included in this chapter in which a neoplasm forms the entire disease. The new tissue in neoplasms has been regarded as originating in, and therefore an hypertrophy of, already existing; but it is certainly not a pure hypertrophy, and it is new in regard to its character and behavior. On this account it is impossible to include the neoplasmata in any but a special group.
There are three principal forms of this disease-the superficial variety, commonly spoken of as lupus erythematosus; the deeper, or lupus vulgaris; and the deeply destructive form, or lupus exedens.
These three varieties present certain features in common, and their color is peculiar. It is neither the frank red of an active congestion nor the brownish ham-color of syphilis, but rather the vinous color that derives its hue from chronic venous congestion; mingled with a certain amount of red. The lesions are few in number; often but a single lesion may be present, but quite frequently we may find two or three-rarely more. Their course is chronic, years being devoted to their development. They almost always leave scars, even in the absence of ulceration. The local symptoms are insignificant, as there is rarely either pain or itching, at most a slight burning sensation, to which the patient becomes habituated and ceases to notice. In the patient`s family history, pulmonary phthisis is an almost constant feature.
Several years ago Bazin and Hardy gave the name of scrofulides to these affections, recognizing at that time their dependence on the general constitutional condition that predisposes to tuberculosis. Quite recently, the bacillus tuberculosis has been found to be a constant accompaniment of the lesions, thus demonstrating the soundness of the opinions advanced by the eminent dermatologists above mentioned.
In this variety the lesion commences as a reddish macule, barely elevated above the level of the surrounding skin. As it slowly but gradually increases in size, the elevation slightly increase, and small, closely adherent scales form upon the surface. The extension is peripheral, and after many months, or perhaps years, may attain the size of a coin. When it has reached a diameter of, say one-half quarters of an inch, the central and older portions begin to lose their infiltrated character, sink to the level of an and even beneath the level of the skin, at the same time losing their color. This continues until we find a white depressed scar, surrounded by a still infiltrated raised ring. During the progress of the lesion as described, other similar ones may have appeared on neighboring or on distant parts; but, as a rule, their number is limited. When two patches have appeared in close proximity, they may join by mutual peripheral extension. In this way the greater portion of one side, or even both sides, of the face may become involved by the disease. Such extensive invasion, however, is the result of years, as cases are met with in which the lesions have been gradually extending in this manner for twenty years or more, the older portions of the lesion undergoing the retrogressive changes we have noticed.
The favorite seat of all varieties of lupus is the face, although other parts may be attacked as well as, and even to the exclusion of the face.
Epithelioma may develop upon the site of a long-existing erythematous lupus, or in the neighborhood of lupus lesions.
Lupus vulgaris is characterized by the development of tubercles within or projecting to a greater or less degree above the surface of the skin. It rarely appears as an isolated tubercle, but more frequently in groups of six or a dozen tubercles, quite close to but not touching one another, little bands of apparently healthy skin intervening, thus forming a patch. As the disease progresses, however, the tubercles may unite by mutual extension and the entire patch present a lupous character. There may be one or more of these patches. The tubercles themselves are soft, sometimes almost jelly-like, in appearance and consistence. The extension of the lesions is slow, years intervening before the patches attain any notable size.
Just as in the erythematous variety, the lesions of lupus vulgaris may undergo resolution, leaving a depressed cicatrix, or else they may ulcerate superficially. The ulcerative action is exceedingly slow, and appears to involve only the upper portion of the derm-more rarely its entire thickness. The exudation from the surface of the ulcer is exceedingly scanty, and forms a crust adhering somewhat closely to the sore. The scars that result are of a reticulate character, not unlike those produced by a severe burn, and naturally cause more or less disfigurement. Lupus vulgaris, after ulceration takes place, may be succeeded by epithelioma at the margins of the ulcer.
This form of lupus was recognized by all the older writers; but those of recent times seem disposed to deny it a place in nosology, or declare that the cases described under this name were not lupus at all, but were epitheliomata. This is not in accord with Dr. Piffard`s observations, and he describes in this place a variety of lupus characterized by the development of usually a single good-sized soft tubercle. This slowly increases in size, until after a lapse of years, perhaps, ulceration sets in, which extends both in width and depth, involving the tissues beneath the skin. The margins of the ulcer are uneven, ragged, and burrowed under. The edges, however, are soft, not presenting any hardness or induration. After an indefinite period, however, at one or more points on the periphery of the ulcer hard nodules may and usually do develop, and which can easily recognize as unmistakable epithelioma. This epitheliomatous process may extend until the greater part of the ulcer is involved. The only contention concerning the nature of this disease is whether it is a true epithelioma from the beginning, or whether it is an epithelioma ingrafted on a lupous basis. Whatever may be the true pathology of the disease, the practical outcome is the same, and this is usually a fatal termination, unless the lesions be early vigorously dealt with.
Lupus may occur in the throat, and may make its appearance at any time of life. It occurs in men oftener than in women. It may occur in any constitution but seems to prefer the lymphatic temperament. Inheritance has nothing to do with it. Sometimes the mucous membrane assumes a purplish color, swells up and become granular and one or two of the granulations develops so much as to reach the size of a pea, or even that of a hazel-nut. Occasionally, the tubercles become prominent in the throat previous to alteration in the mucous membrane, and without differing from its normal color. They may be either superficial or deep. Their surface is smooth and brilliant, but if several of them become intimately united they appear as a single mass, round, cloven, and anfractuous. When the tubercles develop exuberantly in the larynx, breathing becomes embarrassed, and even stridulous. There is no alteration in the sensitiveness of the affected parts. Finally, the tubercles soften and become ulcerated. This melting down does not take place in a complete manner. In some cases, only the surface of the tumor becomes fissured or excavated as a margin to simple excoriations. IN others, the destructive process attacks a greater or smaller portion of the tubercle in its entire depth, producing ulcers which dip out of sight in the midst of the tissues. The cure of these cases is difficult and is followed by indelible scars. In some cases, the ulcers are developed in a slow but fatal manner; in others, they spread with astonishing rapidity; while in some others, they stop in the beginning, but how far their ravages may extend it is impossible to predict.
Instead of appearing in its usual idiopathic form, lupus, at times, develops subsequent to other skin lesions, for instance, a traumatism. In such case it affects one or more localities, but always where formerly an injury, ulceration or scar has been.
If the disease attacks the fingers it can completely destroy them, but never the nails or the matrix. As the finger is shortened by the disease the nail maintains its position at the end of the stump, and may finally reach a position over the head of the metacarpal bone, where it remains in apparently as healthy a condition as in its normal condition.
The family history of the great majority of patients suffering from lupus reveals the important fact that phthisis pulmonaris is met among the near relations to a surprising extent, and we are forced to the conclusion that the same constitutional condition that predisposes one subject to the invasion of tuberculosis of the skin; but the exact role played by the tubercle bacillus is not more known to us in the one case than in the other.
The diagnosis of lupus is in general easy. When we consider the location of the disease, the color of the lesions, their slow development, the absence of subjective symptoms, the presence of cicatrices in cases of long standing and the repeated relapses after even vigorous attempts at treatment, we ought not to be often led astray. A question may sometimes arise as to whether certain tubercles or ulcerations are lupous or syphilitic. The length of time they have existed will usually settle this, when we remember that syphilitic lesions may reach a degree of development in a few weeks that might hardly be accomplished by lupus in years. The single tubercle of lupus exedens is to be distinguished from sarcoma and epithelioma. In sarcoma the development of the lesion is much more rapid, while in epithelioma, the tubercle is hard, but in lupus exedens it is soft.
In no disease of the skin is the prognosis more dependent on the character of the treatment. In early cases it is absolutely good if sufficiently vigorous treatment be instituted, while lack of appreciation or lack of vigor on the part of the physician is responsible for most of the extensive and long-standing cases that we meet with.
Treatment.- Lupus erythematosus may sometimes be cured by the induction of an artificial eruption produced by the action of irritants. This method however, is not to be commended. It is much better to destroy it with an active caustic, provided the extent of the eruption does not contra-indicate this method. When the lesion is quite small, excision may be practiced; or thorough scraping with the dermal curette, followed by nitric acid, or the actual cautery. Lupus vulgaris demands the same treatment as the other form. In lupus exedens thorough removal with the knife of the diseased portions, including a portion of the surrounding apparently healthy tissue is the better plan.
Dr. Mackay reports two cases of lupus healed after a few weeks of treatment by twenty per cent. Ointment of resorcin, applied after scarification. The application of resorcin was attended with but comparatively little pain.
Sulphurous acid, in the form of a lotion or an oil, or in the gaseous state has been employed as remedial agent in lupus. The gaseous form may readily be obtained by burning in a jar, and allowing the fumes free contact with the surface to be treated. This can only be used upon parts removed from the respiratory organs. As a rule two applications daily, each for about twenty minutes, will be found best. The lotion is best obtained by the use of the pharmacopoeical preparation of the acid diluted in strengths of one in two, or one in three. This can be applied to any part of the face without producing disagreeable effects. The oil is preferred by some and is prepared by dissolving the anhydrous acid in castor or olive oil. Satisfactory results frequently follow this method of treatment.
Alveloz has lately been recommended as a local application for lupus and cancer. Cases have been reported where brilliant cures were effected by the use of the drug. I have had no opportunity of testing its virtues.
The application of ice will frequently relieve the severe pain that is sometimes the accompaniment of lupus; some authors claim curative effects from the use of ice.
Arsenicum alb. and Hydrocotyle, are the main internal remedies.
Others may be indicated as follows.
Aurum mur.- When starting from the nasal mucous membrane; a discharge from the nares very offensive; absorption of the bones of the nose melancholia.
Cistus.- Lupus on the face worse from cold air.
Graphites.- Lupus on the nose; obstruction of the mares dry, cracked skin; every injury tends to ulceration.
Guarana.- Lupus of an ochre-red color, yellow spots on the temples.
Hepar.- Lupus on the elbows; ulcers with burning or stinging edges; nodosities on the head sore to the touch; swelling of the upper lip.
Hydrastis.-Ulcers on the legs exfoliation of the skin; purulent discharge from the nostrils; faint, sinking feeling at the stomach.
Kali bichrom.- Ulcers painful to the touch; worse in cold whether; ulceration of the nasal septum; loss of appetite; all the secretions are tenacious and stringy.
Lycopod.- In recent cases; hunger with constant feeling of satiety; arms and fingers go to sleep easily; purulent discharge from the ears; weakness of memory; melancholia.
Nitric ac.- Lupus on the nodules of the ears; offensive purulent discharge form the ears; dry scaly skin; affections of the bones and glands; in dark complexions.
Oleum jec. ass.- A valuable remedy.
Staphysagria.- Ulcers on the alae of the nose; weary pains in the limbs as if bruised; teeth turn black and decay; in scrofulous subjects.
Epithelioma, or epithelial cancer of the skin, is characterized by the appearance of a hard tubercle or nodule, slowly increasing in size until ulceration sets in, which ulceration may extend both laterally and deeply and destroy all tissues with which it comes in contact. As its name implies, it is an outgrowth from the epithelial tissues, in which a more or less extensive and exuberant proliferation of epithelial cells occurs. The typical epithelioma may be said to take its origin in the Malpighian layer, the cells of which increase in number and seek accommodation in the deeper layers of the skin. As they increase however, some of them, from the pressure of the neighboring connective tissue are forced to occupy a smaller space than they would if permitted of this to multiply compression, small rounded bodies are formed in which the cells assume a stratified arrangement, constituting the epithelial cell-nests well-knows to every microscopical observer. Coincident with this extension of the disease inward there is a greater or less projection outward, forming a distinct sessile tubercle, or a more flattened growth.
Primary cancer of the skin is a rare condition while epithelioma, involving both cutaneous and mucous surfaces- as ordinary cancer of the lip – is sufficiently common. Cancer of the skin however, which has developed secondarily to some pre- existing morbid growth is the variety most frequently found in practice.
Epithelioma is distinctly the product of irritation not an acute and transient irritation, even if frequently repeated, but rather one that is hardly if at all, appreciable to the senses, and which is persistent and active through a lengthened period. Thus we may find that a purely innocent and benign growth like a simple wart, may after a lapse of years become the seat of an epithelioma, which would not otherwise have appeared. A localized seborrhoeic condition, which of itself implies an irritation of the epithelial lining of the glands, may, and not infrequently does, become the starting point of cancer. Lupus offers an inviting field for the development of the disease; and in general it may be said that an ulcerating lupus, if left to itself, will almost invariably in time become supplanted by epithelioma. Sarcoma. Sarcoma more rarely is followed by epithelioma, and this rarity may be explained by the fact that sarcoma usually runs its course and has destroyed the patient before the cancerous affection has had time to develop the irritation produced by the sarcoma being more active than that which ordinarily leads to the occurrence of the other disease.
Epithelioma is met with clinically in two distinct forms, in one of which the cutaneous involvement is more superficial than in the other. In the superficial variety, which is less frequently met with than the other the patient attention is first attracted to a little crust-usually on some part of the face. This he picks off, and gives little further attention to the matter. A new crust forms and this is in turn picked off and reveals perhaps, an slightly excoriated surface. He consults a physician, who, failing to recognize the gravity of the condition, prescribes some salve or other or lightly touches the part with caustic. The lesion extends, and perhaps rarely reaches the hands of a surgeon until it has advanced to the stage of frank ulceration. We now find a sharp-cut ulcer extending through the entire thickness of the skin but not involving the subcutaneous tissues. This ulceration advances at its borders, or sometimes in one direction only, while reparative changes may some times occur in the other, much after the manner of some cases of lupus. The progress of the ulceration is exceedingly tardy, and years may elapse before the ulcer has attained any considerable size and when it does, we will sometimes find that cicatricial tissue now occupies a portion of the territory that had been the early seat of the cancerous lesion.
The other or tuberous form of epithelioma, will be recognized at the beginning as a hard tubercle occupying the seat of what may have been previously the situation of a wart, mole etc. This tubercle increases in size, and the tissues beneath it are palpably involved in the morbid process. The skin surrounding the tubercle is also involved to a certain, or, rather, uncertain extent, as is evident to sight and touch. later ulceration appears, and the margins of the ulcer are everted and hard. As the ulcer spreads laterally so also does it become deeper and the process continuing unchecked leads in time to a fatal termination.
The diagnosis of epithelioma, when actually existing is surrounded with very few difficulties as the induration of the tissues is hardly to be met with in any other chronic cutaneous lesion; but the physician should be prepared as well to recognize conditions which will probably become epitheliomatous in time. It is this failure to diagnosticate an impending epithelioma that leads more frequently than it should be inefficient treatment and the sacrifice of lives that might otherwise have been saved. The face is the most frequent seat of purely cutaneous epitheliomata; and if a physician can not make up his mind as to whether a certain hard tubercle or a chronic ulceration is cancerous or not, his plain duty is to take his patient to some one who can.
The prognosis of cutaneous epithelioma is good, provided the lesion is seen in its early stages, and its locality permits of suitable and efficient local treatment. On the other hand, it is distinctly bad if the disease has gained much headway or involves an extensive surface.
The treatment of epithelioma will depend firstly on whether the particular lesion in question is or is not in a curable condition. This is in reality the most serious question that the surgeon has to determine, and to its solution he should being his best judgment, based on his knowledge and experience. If he decides that it is incurable, any operation would be a barbarity, and suggestive of charlantry; but if there is a good prospect for the thorough removal of the neoplasm, no time should be lost in carrying it into effect.
The removal of epitheliomata may be effected in two ways. One of the these is with the knife, and, when this is practicable, it is the best way; and there is but one rule to follow-cut widely and cut deeply. If for any reason the knife is impracticable, the diseased tissues may be destroyed by a sufficiently active chemical agent; and experience has shown that arsenic properly used is probably the most efficient means at our command. Now, there are two ways of using arsenic; one is to use it strong enough to destroy the cancer and the other is to use a weaker preparation and destroy your patient by arsenical poisoning. The stronger the arsenial preparation the greater its local action while the weaker it is the less is its topical action and the greater the probability of systemic absorption. Take anhydrous chloride of zinc and mix it with an equal of water to this add sufficient arsenic to make a moderately stiff paste. This should be applied to the diseased parts in a reasonably thick layer with a little absorbent cotton as a top dressing. To this treatment there is one objection, namely, the severe pain that the arsenic will cause which can only be mitigated by the free use of morphine. If the lesion be of moderate size, and the application thorough the falling slough will, in a week or two, reveal a healthy ulcer, which only requires a little time for complete healing.
If the case has progressed the period when a cure may reasonably be expected the prudent surgeon will seek only to mitigate the patient’s sufferings until death brings its release.