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.
Lupus.
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.
Lupus Erythematosus.
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.
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.
Lupus Exedens.
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.
