COLUMBIA LIBRARIES OFFSITE HLAI IH SCICNCFS STANnAHrj HX641 59590 RC261 .H33 Skin cancer, by Henr RECAP iisif-. iKJ'S*;- ^#iv;i ■¥\e-:ie T^- tutbcCilPotJlrtuDcrk (Cnllrgr of IJIjiiHiriaitB anb ^urgrnna SrfprpurF ICtbrarg i Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/skin^cancerOOhaze SKIN CANCER Prickle-cellefl rancer originating in an old lupus vulgaris lesion. (Collection of Dr. M. L. Heiding.sfeld.) SKIN CANCER BY HENKY H. HAZEN, A.B., M.D. PROFESSOR OF DERMATOLOGY IN THE MEDICAL DEPARTMENT OF GEORGETOWN tTNI- VERSITY; PROFESSOR OF DERMATOLOGY IN THE MEDICAL DEPARTMENT OF HOWARD UNIVERSITY; SOMETIME ASSISTANT IN DERMATOLOGY IN THE JOHNS HOPKINS UNIVERSITY; MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION. WITH NINETY-SEVEN TEXT ILLUSTRATIONS, AND ONE COLORED FRONTISPIECE ST. LOUIS C. V. MOSBY COMPANY 1916 h -iq^ Copyright, 1016, by C. V. Mosby Company Press of C. V. Mosby Company St. Louis TO WILLIAM STEWART HALSTED A True Student of Cancer. PREFACE When one considers that epithelial growths of the skin, both be- nign and malignant, are so common, that they are usually so easily diagnosed, that the tissue from them is readily obtainable for histo- logical study, and that most of them are so amenable to proper treat- ment, it is surprising how much ignorance prevails concerning them, even among surgeons and dermatologists. In this country BUkxI- good has done much to correlate the clinical and pathological find- ings, and to point out how these different findings influence treat- ment, for the treatment of tumors of the skin must be conducted by different procedures according to their malignancy. In this book an effort has been made to gather under one cover the latest views on malignant tumors of the skin, and to give the per- sonal experience of the author, an experience gained in Dr. Blood- good's surgical pathological department of the Johns Hopkins Hos- pital, in Dr. Gilchrist's dermatological clinic at the same institu- tion, and in the surgical, pathological, and dermatological depart- ments of the Freedmen's and Georgetow^n University hospitals. The aim of the book is to be both scientific and practical — to give the correct pathology of the cutaneous neoplasms, and to point out hoAV this guides treatment. It is a pleasure to thank my friends for the help that they have given me, in the referring of cases for study, in the preparation of pathological material, and in furnishing me photographs. I\Iy thanks are due to Dr. Richard L. Sutton, of Kansas City ; Dr. 31. L. Heidingsfeld, of Cincinnati; Dr. C. J. White, of Boston; Dr. George M. MacKee, of New York; Dr. Perkins, of Kansas City; and Dr. Gilchrist for illustrations. Both Dr. Gilchrist and Dr. E. A. Bal- loch, of Washington, have allowed me to make free use of their ma- terial. Dr. Wm. B. Sowers, of Washington, for several years resi- dent surgeon at the Johns Hopkins Hospital, has written the en- tire subject of carcinoma of the lip, and Dr. H. A. Fowler, of Wash- ington, has helped me with the subject of cancer of the penis. Dr. Van Sweringen, pathologist to Freedmen's Hospital, has prepared many sections for me. H. H. Hazex. Washington, D. C. CONTENTS CHAPTF^R I. f'AOK General Coxsideuations 17 Definition and Concei^tion — Classification — Structure — Growtli of Tumors — Toxins — Tiiimiiiiity — J']tioIo;;y — Inciilontal Fact07'3. CHAPTER II. PUECANCEllOUS DERMATOSES 35 Pigmented Moles — Seborrheic Warts — Simple Keratosis — Arsenical Ker- atoses — Keratosis Follicularis — Cutaneous Horn — Cancer of Paraffin Workers — Xeroderma Pigmentosum — Sailor 's Skin — Farmer 's Cancer — X-Ray Dermatitis — Paget 's Disease — Marjolin's Ulcer — Lupus Vulgaris — Leg Ulcers — Lupus Erythematosus — Blastomycosis — Syphilis — Inflam- matory Dermatoses — Sinuses — Wens — jSTevi — Papillomas — Conclusions. CHAPTER IIL Epithelial Warts 52 Benign Warts — Malignant Cutaneous Warts CHAPTER IV. Basal-Celled Carcinomata 59 Classification of Basal-Celled Careinomata— Flat Rodent Ulcers — Xodular Cancers — Rolled-Edge Rodent Ulcers — Depressed Scar-Like Cancer — Mor- phea-Like Cancer — Fungating Tumors — Deep Ulcers — Diagnosis — Treat- ment. CHAPTER V. Cubo-Celled Caecinomata 81 CHAPTER A'l. Spino-Celled Carcinomata 84 CHAPTER VII. Benign and Malignant Tumors of the Cutaneous Appendages .... 92 Tumors of the Hair Follicles — Tumors of the Sebaceous Glands — Tumors of the Sweat Glands — Tumors of the Sweat Ducts. CHAPTER VIII. Multiple Benign Tumors 102 Multiple Benign Cystic Epithelioma — Syringocystadenoma — Adenoma Sebaceum. CHAPTER IX. NEVOCAKCINOilATA AND MALIGNANT MeLANOMATA Ill 11 12 CONTEXTS. CHAPTER X. PAGE Cakcinoma ek Cuikasse — Cakcinoma by Extension — Metastatic Cauci- NOMA — Facet's Disease 119 CHAPTER XI. Exdotheliomata 127 Xevo-xantho-ciulothcliomata CHAPTER XII. Benign Connective Tissue Tumors 132 Cicatrix — Keloid — Fibroma — Fibroma Molluscum — Neuroma — Myoma — Lipoma — Osteoma — Hemangioma — Lymphangioma — Lymphangioma Cir- cumscriptum. CHAPTER XIIL Sarcomata and Sarcoids 137 Sarcomata — Solitary Lesions — Multiple Lesions — Transitional Lesions — Sarcoids. CHAPTER XIV. Lympiiomata 14S CHAPTER XV. Differential Diagnosis 15-t CHAPTER XVI. Prognosis 169 CHAPTER X\T[I. Prophylaxis 173 CHAPTER XVIII. Treatment 1"8 Surgical — Electrical — Actinic — Caustics — Congelation — Medication — Treatment of Complications — Treatment of Inoperable Cases — Repair of Deformities. CHAPTER XIX. Tumors According to Location 207 ILLUSTIiMIONS Priokle-cellkd Cancer Frontispiece FIG. PAOE 1. Photomicrogruph of uu oidiuaiy pigmented mole 36 2. Common mole of the neck 3G 3. Fungous cancer 38 4. Horny growth upon the liaiid 40 5. Cutaneous horn 41 6. Xeroderma pigmentosum 43 7. Xeroderma pigmentosum 44 8. Lupus vulgaris 48 9. Photomicrograph of lesions of molluscum contagiosum 54 10. Diagram of sites of origin of 220 cases of basal-celled cancer . . . . o'J 11. Photomicrograph showing basal-celled carcinomata 60 12. Photomicrogra])h showing downgrowth of the epithelium 61 13. Photomicrograph showing a clubbing of the downgrowth 62 14. Downgrowth contracts, so that solid mass of basal cells is formed ... 62 15. Photomicrograph showing ulceration of epithelium 63 16. Photomicrograph showing section from a typical rolled-edge rodent ulcer of the shoulders 64 17. Photomicrograph demonstrating the manner in which a basal-celled cancer may be covered by normal epithelium 65 18. Photomicrograph of a basal-celled carcinoma 65 19. Basal-celled cancer of the chin 66 20. Multiple basal-celled cancers 67 21. Flat basal-celled carcinoma of the nose 68 22. Basal-celled cancer of many years' duration 69 23. Basal-celled cancer spontaneously healed in center 70 24. Early basal-celled carcinoma of the hand 71 25. Nodular basal-celled carcinoma of the cheek 72 26. Basal-celled cancer of the hand 73 27. Basal-celled cancer of the forehead 74 28. Eolled-edge rodent ulcer of the neck 75 29. Morphea-like epithelioma 76 30. Cuboidal-celled cancer 82 31. Deep prickle-celled cancer of cheek in a young man 85 32. Eapid growing cancer developing from within the ear 86 S3. Prickle-celled cancer originating in the mastoid following mastoid opera- tion 87 34. Photomicrograph of prickle-celled cancer 88 35. Epithelial pearls in a squamous-celled cancer 89 36. Carcinoma originating in hair follicles 94 37. Carcinoma of the buttock 97 38. Photomicrograph of adenoma of the sweat ducts 99 13 14 ILLUSTRATIONS. no. PAGE 39. PliotoiHifiugia|ih of ailommia of the sweat ducts 100 ■iO. Multiple lu'iiij,'!! cystic epithelioiua 103 41. riiotomicro^iaiili nf imiitipio benign cystic epitlielioma 10-1 4'2. SyringocystaileHoina 105 43. Photoniicrogiaph of syiingocystadenonia 10(5 44. Pliotoniicrogiapli of syringocystaileiionia 107 43. Adenoma sel>aceuni 108 ir.. Mdlluseum contagiosuin 109 47. Xevucaicinonui 11- 48. Malignant pignientetl nmle ll-'« 49. Photomicrograph of a malignant pigmented mole (nevocaicinoma) . .lit! 50. Photomiciogiaph of malignant mole 117 51. Caicinoma en cuiiasse 120 52. Extension of carcinoma of the breast 121 53. Histology of Paget 's disease 124 54. Histology of lymphangioendothelioma 130 55. Photomicrograph of small round-celled sarcoma of skin 139 50. Multiple sarcomata 142 57. Multiple hemorrhagic sarcoma 145 58. Mycosis fungoides 151 59. Hypertrophy of the epidermis 157 60. Chancre of the chin 158 (jl. Chancre of the lip 159 62. Gumma of the nose 160 03. Gummatous lesion of the lip IGl 64. Lupus vulgaris, showing spontaneous healing in center 162 65. Tuberculous ulceration 16.". {j(]. Diffuse papillomatosis of skin 164 67. Tuberculosis verrucosa cutis 165 68. Blastomycosis 166 69. Basal-celled epithelioma 190 70. Basal-celled epithelioma, after treatment 191 71. Endothelioma capitis 208 72. Ba.sal-celled carcinoma of the fureliead 209 73. Basal-celled cancer of eyelid 210 74. Basal-celled cancer of the nose 211 75. Seborrheic keratosis of the lip 214 76. Seborrheic keratosis of the lower lip 215 77. Ulcerated prickle-celled carcinoma of the lower lip 216 78. Prickle-celled carcinoma of the lower lip 217 79. Fungating carcinoma of the lower \\[> 218 80. FuJigating cancer of the lower lip 219 51. Prickle-celled cancer of the lower lii> 220 82. Prickle-celled cancer of the lower lip 221 83. Prickle-cellcd cancer of the upper lip 222 84. Relationship of the deep lymphatics to otiier structures of the neck . . 224 85. Method of repairing a defect caused by the excision of a V-shaped piece of the lip 225 ILLUSTRATIONS. 15 FIG. PAGE 8G. Same as Fig. 85 226 87. Mayo's method for rciiioving liiinor 227 88. Same as Fig. 87 22S 89. Plastic operation for repairing defects after removal of cancer of the lip 220 00. Same as Fig. 8!) 2.';0 91. Same as Fig. SO 2:jl 92. Crile's incision for removal of cancer of tiic lip ... 2'j2 93. Same as Fig. 92 2.33 94. Same as Fig. 92 234 95. Same as Fig. 92 2.35 9G. Same as Fig. 92 236 97. Cancer of the tongue 238 81vL\ CyVN( i:iJ CHAPTER I. GENERAL CONSIDERATI OXS. DEFINITION AND CONCEPTION. Ill 1863 Virchow^ stated that it was practically impossible to give a satisfactory definition of a tumor, and many -writers since that time have unwittingly proven the truth of that statement. In deal- ing with epithelial neoplasms we may, however, say that any auton- omous growth of epithelial cells, or of cells derived from the epi- thelium, constitute a neoplasm. We are not dealing with inflam- matory masses or with cysts, although either of these conditions can, and do, give rise to tumors, sometimes clinically indistinguishable from true neoplasms. CLASSIFICATION. A thoroughly satisfactory classification of epithelial tumors has not yet been made. For this there are many reasons ; first and fore- most, because until a few years ago the pathology was not thorough- ly studied, and no one recognized that a tumor showing one type of structure might, in the natural course of events, come to present a totally different histological picture, although the same cell type was always preserved. Then, too, the use of the terms "epithelioma" and "carcinoma," not to mention the rest of the nomenclature, has varied markedly at the hand of different writers, and even today there is no uniformity. The use of the term "papilloma" is a splen- did illustration of this, for the word is used to cover almost any tumor that projects at all above the surface of the skin or mucous membrane. According to Unna,- the first division of carcinomata of the skin was made by Hannover^ in 1852, when he made use of the termjs "flat" and "infiltrating," a diA"ision that was brought into popu- *Virchow:Die Krankhaften Geschwiilste, Berlin, 1S63. = Unna: Histopathology of Diseases of the Skin (Walker's translation). New York, 1S96. 5 Hannover: Das Epithelioma, Leipzig. 1S52. IS SKIN CANi'iaj. larity in the irront work ot' Thiersch' in iMi.'). And yet ThiiTsch ivcoiriiizoil that an ointholial canciM' »it" a llat cr appan-ntlx' bcniirn nature niiiilit coiiu' to inliltrate the tissues vei-y (K'eply. l-'oi- a fur- ther eritieisni of Thiei-seh's views the readier is referred to i)a<;es GG5 to GGS of .I'nna's hook. althoU'j:h it must l)e elea'.-ly understood tliat the autlior l»y no means coincides with all of I'nna's beliefs and eritieisins. To some extent Thiersch, and to an e\-en ijreater extent many suh- sotjuent writers, haxc attempted to classify cutaneous eareinomata aeeordinji; to the tissue from which ll)e.\ spran«r. Thei'e are, of eoui'se. the following ]>o.ssil)le coui'ses for epitln-lial tumoi's: 1. The various layers of the epidei'mis. 2. The hair follicles. 3. The scbaeeous jjlands. 4. The sweat glands, f). The sweat dnets. 6. C'ontrenitall\' misplaced t'pilhelial structures oi- cells. Unfortunately for this i)lan, none of its advoeates have been thor- oughly good pathologists, and hence there have been many glaring errors. For instance, any carcinoma with the cells arranged in a hollow cylinder at once had its (M-igin ascribed to the sebaceous glands, which notion, of course, is an absolutely erroneous one. For a more detailed account of these fallacies the reader is again referred to I'lma. I'nna's own classification deserves esjiecial notice because he is a thoroughly well-trained ])athologist, has studied the question care- fully, and has made an effort to give a satisfactory classifieation. An abridgement of his classification is as follows: I. Malignant new for))uilii/ns. A. Carcinoma vulgare. 1. Fungating forms. a. Fai)illai'y. b. Coarse reticular. 2. Cylindrical forms. a. Keticulai-. b. Simjde cylindrical. c. Acinous. d. Styloid. < Thiersch: Der Eijithelkrebs, Leipzig, 18C5. (;i;Ni':i{Aii (;()Xsii)i:kati().\s. 19 3. Alvc()];ir IVtriiis. a. L;ir}4(! jiJvcoljir. I). Siiuill alvoolnr. 4. ( 'iU'('iii(iiii;ili)iis lyiii|ili;it ic in l';i ret inns. a. ( "arciiioiiia -Jacob, i-odciit ulfor. b. ('jirf'inoiiiM of Ihc sjiiloc's skin. c. X(M'()(|('i'iii;i i)i<4ii)('ii1osiiiii. <1. Pajj^ct's ciU'ciiioiiia, of the iii|i[)lc. 0. Ncvo- and iiicbiiio-cai-fiiioDiala. //. Botif/u nvtv fornidlious. A. Tnmoi's propei". 1. Of the epidermis. a. Acanthoma, including Verruca vulgaris. Condyloma. Epithelioma (moUuscum) contagiosum. Acanthosis nigricans. 2. Glandular hypertrophy and adenoma, including a. Hypertrophy and adenoma of the coil gland ap- paratus. General hypertrophy. Spiradenoma. Syringoadeuoma. b. Hypertrophy and adenoma of the sebaceous glands. Sebaceous gland hypertrophy. Steadadenoma. B. Stagnatory tumors. 1. Of the epidermis. a. Keratoma, including Callus. Clavus. Cutaneous horn. Angiokeratoma. Onychogryphosis. b. Cysts, including Traumatic epidermis cysts. Follicular cysts. Horny cysts. Sebaceous cvsts. 20 SKIN CAXCKR. 2. Syriiigal cysts. a. Duct cysts. b. Porous cysts. ///. Malformations. A. Progressive disturbances of liutrition. 1. Proliferating tumors. a. Syringoadenoma (lymphangioma tuberosum multi- plex). b. Acanthoma adcnoidcs cysticum (multiple benign cystic epithelioma). 2. Stagnatory tumors. a. Dci'moids. b. Atheromata. Certain objections can at once be raised to this sclicmc. First, there is a mixture of clinical and pathological forms. Second, it treats of the less important tumors according to their origin, while it totally ignores the origin of the more important tumors. Third, it is doubtful if neoplasms can rightly be divided into "tumors proper" and "stagnatory tumors," using the latter expression, in Unna's sense, to mean that there is not an undue proliferation of tissue, but rather a lessened destruction of it. Fourth, Unna uses the term "acanthoma" to apply to the basal cells as well as to the priclde cells of the rete. This is incorrect, as "acanthoma" should apply only to the hoi'ny cells; the term "reteoma" Avould be more exact in many instances. Fifth, nor can the writer agree that the mul- tiple benign cystic epithelioma is a malformation, nor does he be- lieve that it should be called "acanthoma adcnoidcs cysticum," for the reason that it develops from basal cells. With these few excep- tions, however, Unna's classification is excellent, and a model for all future attempts. Ribbert's^ terminology is still very popular, especially among clin- icians, for it has the merit of simplicity. According to this author we have: Papillomas which comprise fibro-epithelial tumors. Epitheliomas which comprise tumors derived from the surface epi- thelium. Carcinomas wliioh comprise tumors derived from glandular epi- thelium. •Rlbbert: Geschwiil.«tlehre. Born, 1904. GENERAL CONSIDEKATIONS. 21 As Auspitz, Unna, and many others have jx^intcd out, the term papilloma is, histologically speaking, a grave misnomer, for the real development is in the rete and the papilla; arc only secondarily af- fected. If all tumors arising from squamous epithelium arc to be spoken of as cpithcliomata, we must call malignant epithelial tumors of the lip, tongue, pharynx, esophagus, and of certain portions of the genital tract, cpithcliomata. To the author this seems undesir- able for two reasons; first, because these tumors run the same course as the glandular careinomata; and, secondly, because the term car- cinoma means more to both physician and laity than does the word epithelioma, especially since the latter is sometimes used to desig- nate a benign growth. Krompccher,*' in his excellent monograph, "Der Basalzellenkrebs " adopts the following classifications: 1. Fibroepithelioma spinocellulare simplex, or keratodes. 2. Carcinoma spinocellulare simplex, or keratodes. 3. Fibroepithelioma basocellulare. / Solidum. . ri • 1 -,-.-. lAdenoides. 4. Carcinoma basocellulare<' ^ \ Cysticum. Hyalinicum, etc. Bloodgood," after a characteristic thorough search of the litera- ture, advocated the following scheme in his teaching and for his specimens : 1. Benign epithelial warts. a. Mixed epithelial warts. b. Spinocellular (horny) warts. c. Basocellular warts. 2. Malignant epithelial warts. a. Epithelioma spinocellulare malignum. b. Epithelioma basocellulare malignum. 3. Malignant basocellular tumors. a. Epithelioma basocellulare solidum malignum. b. Epithelioma basocellulare solidum et adenoides malignum. c. Epithelioma basocellulare solidum et adenoides cysticum malignum. d. Carcinoma basocellulare solidum stellatum. 4. Carcinoma cubocellulare. 'Krompecher: Der Basalzellenkrebs, Jena, 1903. 'Bloodgood: Progressive INIedicine, December, 1904. 11 SKIN lANli:i{. '). Epitlielioma spinocellulare inalij^num. 6. C'ai'cinoiiia .si)iiiuci'llulai'e inaliiriium. 7. AtleiuicarciiKtiiia of haii' t'ollicles. S. Adeiioc.-irciiiDina of sweat tilauds. Here the aiitlinr scridusly chjects to I UiukIltooiI "s dift'ei'i'iil iat ion of malignant tumors, haxiiii;- the same ori<>:in. into I'pitheliomata and earcinonmta aecoi-dinji; to sli}4:lit differenci's in ilicir histoloyieal pic- ture. l>lood<;ood uses the term epithelioma when the gi'owth has re- tained tlir picture of tlie tissue from wiiich it spranji'. and carci- noma when the picture of the original tissut- e.iii nn JDnger he dis- tiniruislied. In some tunn)rs certain sections will, how CNcr. I'csemhie epithelioma, anil nthei' sectiims. |)erhai>s mdy a shmt distance away, will resemble carcinoma, antl hence this diiVerentiation does not aj)- lieal to the wi-itei- as being ])ractical. The spiinx'cllulai' warts are not necessarily linmy warts; liei-e there seems to be some confusion with the kei'atomata. Othei'wise. howevei'. IJloodgood's ])athological classiHcation is exti'cnu'ly good. In addition to giving us a woi'king iliffereiit iatioii. liloodgood lijis also shown exactl\' how the pathology of a neoi)lasm agrees with its clinical course, and hence with its treatnuMit. lie has added a most important chapter to the study of the maligmint cutaneous tumors. In an attempt to give a simpler classilication. liloodgood has re- eently devi.sed the following classification: 1. Heiugn i)recancerous lesions. a. Warts, which include any e])ithelial h\pert rophy. i). Subepidermal nodules, often sebaceous gland infections. c. I leers, as tul)erculcus. syphilitic, etc. d. Sinuses, unhealed. '1. lOarly cancers. a. ^lalignant warts. 1). Adein)careiiu)mata. e. Epithelial hypertropli\' in ulcers, and sinuses. 3. Late cancel's. a. Spino-celled oaneers. b. ('ul)o-eelled cancers. c. Baso-eelle(l canc(M-s. Inasmuch as tiiis book is pi-imai'ily intemled for the clinician, it has seemed to the author to be l)est to give a clinical, rather than a j)atholouic;d. nomenclature, ami he has ado]ite<| the following: <;|':m:i;ai, (;(>nsii);;i{\'ii(>.\s. 23 1. I>('iii;is()-('cll('(l ('|)i1 licli.il tumors . ,,• , , / .Mull Ipic l)Mll<^ll. 2. Malif^iuiiit ('|)illi('li;il \v;ii'1s. a. Spiiio-f'cllcd. 1). I>as()-('(']1('(1. 3. Baso-celled carciiioinata. a. Flat rodcMit iilcci'. b. lUitloii-likc or iiodidiii' cjirciiKdii;!. ('. Ixollcd-cdjijc carcinoin;!. d. Depressed scar-like (vii-cinoina. e. Morphea-likc earciiioina. f. Fungatiiif? earcinoma. g. ITlcerative eareinonia. 4. C*ubo-eelled eareiiiomata. a. Ulcerative carcinoma. b. Fiingating carcinoma. 5. Spino-celled carcinomata. a. Ulcerative carcinoma. b. Fungating carcinoma. , (i. Tumors of hair follicles. a. Benign (multiiile benign cystic epithelioma of Jariseh). b. Carcinoma. 7. Tumors of sweat glands. a. Adenoma. b. Carcinoma. 8. Tumors of sweat ducts. a. Adenoma. b. Syringocystadenoma. 9. Tumors of sebaceous glands. a. Adenonui sebaceum. b. Adenoma. c. Adenocarcinoma. 10. Nevocarcinomata (and multiple pigmented carcinomata). 11. Paget 's disease. 12. Carcinomata by extension. 13. Metastatic carcinomata. 14. Carcinomata en cuirasse. 15. Endotheliomata capitis. 24 SKIN CANCER. Some authors, notably Adaiui^ and Hcrtzler,^ object to Krom- peeher's differentiation of skin carcinoniata into prickle and basal cellular types, pointing out tliat the prickle cells are simply a dif- ferentiation of the basal t-olls, and are not of a different origin. But to the author this elassilieation seems justified, for the two types of tumor run absolutely different clinical courses — courses even more distinct than the histological pictures. The basocellular tumor is usually of slow, or of comparatively slow, growth, and practically never metastasizes, thus differing markedly from the spinous-celled tumors, which grow rapidly, and usually form metastases. Krom- pecher also recognizes a basocellular glandular tumor, a neoplasm less malignant than the type of adenocarcinoma, in wliich the cell type is that of the superficial epithelial lining of the ducts. Blood- good is inclined to agree witli Kronipeeher in this assertion. STRUCTURE. All neoplasms consist of two main elements — the cells and the stroma. As has already been stated, the cells are derived from the various types of epithelial cells, and, Mith the exception of the tu- mors derived from the sebaceous glands, remain remarkably true to type unless flattened out by pressure. AVe can easily recognize the basal-celled and the spinous-celled type, and, with slightly more difficult}', the cubocelled type. The cells from the appendages of the skin maj' usually be recognized, although, of course, the tumors originating from the hair follicles may very soon come to absolutely resemble the neoplasms originating from the surface epithelium. The cell type of the sebaceous glands usually changes so promptly that it is impossible to prove that a tumor had its origin in these glands. This change consists in a loss of the fat. after which the cell is difficult to recognize. The criterion of malignancy is the breaking thi-ougli of the basal membrane by the epithelial cells. This basal membrane normally forms the limit of the epithelial cells, thus separating them from the fibrous tissue of the corium. Invasion, once the membrane is ruptured, may take place in any one of several ways, all carefully studied by Unna. The cancer cells may invade practically en masse, they may form more or less solid alveoli, they may push forward in long alveoli, or they may branch out like the branches of a tree, or they may invade singly or in small groups. The mode of in- vasion depends on at least two factors — one the inherent power of •Adami: Principles of Pathology, New York, 1908, i. •Hertzler: Treatise on Tumors, New York, 1912. GENERAL CONSIDERATIONS. 25 reproduction of the euiieer c(;l]s, Jiiid tlif; rjllici- the resisting power of the invaded tissue. Characteristic of cancer cells iire the atypical mitotic figures, a peculiarity so j)ronounc(!d that sonic authors have Jjcen inclined to believe that the atypical power of repj'oduction was the cause of the disease. It is now usually believed, however, that irregular mitosis is an effect and not a cause. The degenerations of cancer cells ha\e been carefully studied by several investigators, including Gilchrist^" and Unna. Both call par- ticular attention to the close resemblance of some of these degenera- tive bodies to parasites, and warn against the error of mistaking them for causal organisms. Unna states that the most connnon degeneration is the hyaline one, the so-called cancer pearls being one variety of this type of degenera- tio]x. The pearls are simply groups of cells arranged concentrically, and having a great affinity for acid dyes, due to the degenerative changes. Unna also describes eight forms of hyaline degeneration of the circumscribed variety. They are : 1. Eound balls of a size varying from 15 to 20 microns in diam- eter, and in the interior of which there exist the remains of a nu- cleus, always lying in a cavity. 2. Irregular, long twisted bodies are fairly common. 3. Small hyaline bodies, having a diameter of from 7 to 15 mi- crons, may lie in a nuclear cavity, but close to the nucleus. 4. The bodies described in the last heading may become elon- gated. 5. Hyaline rods or tendrils are sometimes found. 6. There may exist capsulated structures in which there is a well-preserved nucleus, lying in a ring-formed cell that has under- gone hyaline degeneration. 7. Flake or vesicle-like hyaline bodies Avith nuclear cavities may occur. 8. And, lastly, there may exist hyaline vesicles in which the nu- clear remains are inclosed by two hyaline capsules. There is a final group in which exist conglomerations which have arisen from the compression and coalescence of the individual ele- ments. There is another group of hyaline degeneration, even com- moner than the circumscribed changes, and that is the diffuse hy- aline change. This degeneration can be distinguished only in well- *» Gilchrist: Johns Hopkins Hospital Reports; Studies in DermatologA% 1S96. 2G SKIX CANCKR. staiu'Ml siK'ciiiU'Us. jiml is Irciiiu'iitly a pi-cciirsdr ol' tlir iiiori' cii'cum- scrihtnl cluuiiros. rnna states "tho liiiiitcil. dilTusi'd hyaliiio lU'iron- eration of tlio imuT ix'i'iiuiclcai- sultstaiicc of the ccll-hody is ox- traoi\liiiai'il\' coiinnon." Xi'xt in fi'eciuoncy to the liyaliiic (li'Liciu-ratioii is tlic simple soft- eniiii; and liquefaction of tlie ei)itlicrnini, which is often coin])ineil with the hyaline changes. A sinjxle cell may he attackeil. or a luv^v jiortion of the cancer may soften. This form of deuvnei'ation is not present in those forms of caiuH'r thai irrdw hy loii^-. sleii- formed. In some t\pes of neoplasm one prevails, while in other types of tumor the other ])revails. Of course thei'c is frequently a combination of tlie two. (^uite frequently the cancerous invasion of the corium induces a severe inllanuiiatory reaction, some authors fioinjjr so far as to claim that a cancerous downjrrowth of tissue never occurs without a C(>llular exudate forndny: around it. The cells usually found arc small i-ound cells, fixed tissue cells, mast cells and plasma cells, (iiant cells are occasionally found. Sometimes this reaction is so marked as to almost comi)letely obscure the cancerous process. I'n- na states that in twenty-four out of his seventy' cases an iidlamma- tory reaction was very considerable; the rodent ulcers. Pajret's can- cers, and the cancei-s of xeroderma ])iroc- e.ss of invadinj; cancel- walled in by an iidlammatory mend)rane, but some of them usually ai-e. Unna states that in ten of his cases there was no inflammatory reaction. The cellular iidiltration of the cutis is usually dii-ectly in ratio with the rapidity of infill i-ation by the neoi)lasm. Neoplasms have a comi)lete vasculai' cii-culalion. the blood ves- sels may pre-exist, or may be newly foi-med. but are usually derived from both sources. The newh-formed blood vessels consist of an en- (;i;xi:i;.\L roNsiDij; \'rio.\s. J( d()tlK'li;il liiiiii<^\ willi (('•ciisioti.illy ;i (ibroiis oiitr't- hiyor, Jiri'l vary ^'r(';i11y in size Accoi'diii^- 1o 1 1 ci't/.lcr ncilhcr ihtxcs nor lyhii»li;if ifs liav'f boon ,s;i1 isfjiclorily (Iciiioiisl r;itc(|. GROWTH OF TUMORS. Many aiitliors 1hini< thai a carcinoma sprin^'^s from one ccjitci', but rctoi-Keir.s" work would seem 1o sliow tlial llic mulliccntric orif^in of inalifi^nant opilhclial tumors is far from uncommon. As I»lood- good well observes, I'elei'sen's (b'moustrations appix- to l!ie basal- ccllcd type, a fonu of tumor tliat is frof|noiitly multiple. Fetei-seu's work appears to have been vvvy carefull\- done aftci- the "Platteu- modcllen-Methodc" of l>orn.'- The early tumors were cut into sc- I'ial sections, and from these seetions a wax model was ])uilt up. This is, of eourse, the only positive way in whieh the (juestion as to the unieentric or inultieentrie origin of cancer ca]i be settled. As Ijoar- ing on this point, rxib'hi'ist has reeently had a very early basal- celled earci)U)nia of the face, in whieh. at a distance of about 3 mm. from the main tumoi- mass, there was a distinct new and exceeding- ly early carcinoma developing. Serial sections showed that there was no connection between the two. If these tumors are really of multicentric origin, the point has a great practical beai'ing, foi" it means that a wider incision is necessary at the time of operation. This fact, or rather theory, may explain why basal-celled carcino- mata so often recur after operations in which but a small margin is given them. On the other hand, it must always be remembered that metastases may have taken place by a lymph channel, and that an apparently separate growth is in reality simply a metastasis. At first it was thought that cancer spread by a])position. that the cancer cell caused the neighboring cells to also become cancerous, and later observation has shown that to some extent this belief is correct. Hertzler says: ''In transplanted epithelial tumors in ani- mals the connective tissue has been stimulated to sarcoma forma- tion, showing that the power of growth may be transmitted to other kinds of tissue. Still more conclusive are the experiments of Bor- rel and Lewin, in which epidermis was stimulated to the formation of squamous epithelioma by the transplantation of glandular tumor beneath it, showing that the proliferating stimulus may be conveyed by cells possessed of the power of unlimited growth. In both these instances there can be no confusion between the normal and the "Petersen: Beitr. z. klin. Chir.. 1002. xxxii. 543. '=Born: Bohm-Oppel Taschenb. cl. Milvr. Technik.. 74. 28 SKIX CANCER. tumor cells. The proliferation excited by Scharlach R. and Sudan 111. likewise show clearly that epithelial cells can be made to pro- liferate and invade surrounding tissue by the action of certain ex- trinsic stimuli. It may be regarded as proven, therefore, that nor- mal epithelial cells, under certain conditions, may be made to pro- liferate by close contact with malignant cells or by other stimula- tion." And yet it is generally conceded that tumor growth comes from the multiplication of the tumor cells, rather than from the conversion of other cells to a malignant type. Gro^vth takes place by the cancer cells either invading between the connective tissue fibers through the lymphatics or otherwise, or by bodily pushing the connective tissue aside, or more usually by a combination of both methods. These invading cells may or may not retain connection with the main body of the tumor. In the more malignant types of tumors, cells may escape to the lymphatic glands, or may be carried by blood vessels to remote portions of the body, or they may spread out and form separate masses in the proximity of the parent neoplasm. In cancer the growth usually takes place through the lymph spaces and lymph vessels. On account of this spread through the Ijmphatic system, it is often impossible to dif- ferentiate between metastasis and local infiltrative growth ; in fact, it is desirable not to attempt to distinguish between them, for they are essentially the same. The superficial spread may be so great as to form cancer en cuirassc, where practically the whole subcutaneous tissue becomes cancerous. The lymph glands affected are usually the nearest glands draining the cancerous area, but rarely these are skipped and more remote ones are involved. Extension by contact is rarely seen in tumoi'S of the skin, and many excellent clinicians deny its existence. It is very important to note that cancer cells may lie dormant for many years, and then suddenly take on great activity. AVe no longer speak of cancer patients as cured when an intcr\al of three years has elapsed without recurrence. Occasionall}' adenomata of the su])i-aronal or thyroid glands form metastases, and the author has observed one case Avhere a histologi- cally benign adenoma of the sweat glands metastasized to the neigh- boring glands. It seems reasonable, however, to suppose that there are true area of malignancy in these neoplasms. Recurrence after operation depends on the factors already dis- cussed. Recurrence means that all tumor cells were not removed by the surgeon, either because they had escaped to other organs, or because of a wide local spread. (;kni;ral considkrations. 29 TOXINS. It has not been proven that epithelial tumors have a specific toxin. What absorption there is probably comes from the endotoxins of bacteria which are secondary invaders. IMMUNITY. There is probably ]io authentic instance where an epithelial neo- plasm, microscopically proven to be malignant, has spontaneously healed, mid failed io recur. The central x>ortion of a rodent ulcer may heal and form scar tissue, and may likewise scab over and ap- parently heal for a year or even more, but not permanently ; in fact, we know nothing of true iiiiiiinnity. ETIOLOGY. The causative factor in cancer of the skin is that of cancer in any other portion of the body, and is still unsolved. Dermatologists have not done their share toward the elucidation of the carcinoma rid- dle, although they have had better opportunities than any other type of clinician, inasmuch as they are sometimes able to trace the de- velopment of cutaneous cancer from the various precancerous der- matoses, of which xeroderma pigmentosum forms such a beautiful ex- ample. Ewing^"' has recently treated exhaustively of the different theories as to the etiology of cancer, and Loeb^'* has published a num- ber of excellent papers. Cohnheim's Theory. — Cohnheim^^ believed that cancer arose from congenitally displaced epithelium, beginning to grow riotous- ly. As Unna has well pointed out, this certainly takes place in the neoplasms arising from congenital moles and from other nevi. At least three objections may, however, be placed against this theory — first, that cancer often starts where no congenital rests can be dem- onstrated, and w^here it is extremely improbable that any such rests would exist; second, that the theory does not explain why the rests become malignant ; and, third, as pointed out by "Welch, that even in very deep burns, where all of the surface epithelium is destroyed, a carcinoma may later develop. It may be added that the known congenital malformations do not very frequently become malignant. Changes in Cell Type or Metaplasia.— AYhile an epithelial cell of one type may be changed into an epithelial cell of another type. " Ewing: Arch. Int. Med., 1908, i, 175. ^* Loeb and Sweek: Jour. Med. Research, 1913, xxiii, 2, July. "Cohnheim: Vorlesungen liber allg. Pathologie, Berlin. 1S77, 30 SKIN (ANCKK. there is no proof that one type of eell may liirn into a i-adically different type. It seems certain that metaphisia in ejiithelial tu- mors is conHiieil within narrow limits. Of course, it is known that a benifjn jJapiMoma. so-ealled. that has exi.sted foi- yeai's may later beeome maliijnant. But. a<;ain. this theory is not satisfyiii'r. for it jrives no explanation why these ehan«res take place. Regression. 1\\ tiiis term Rihhcrt indicated a condition of eell chancre where cells hecoine atavistic. (»r less differentiated. It is };en- erally stated by path(»lo»rists that tumors arisinj^ from the less dif- ferentiated cells and showing' the structure i>f the jtrimitive cells are the most mali^Miant. and yet in carcinoma of the skin we find that the basal-celled (or primary'' tumors are much less malijxnant than the tumors ai-isin*^' from the jirickle cells and to some extent retain- ing; their structure. It is true that in the latter the jirickles art- short, or entirely lost, and that the cells are .smaller than normal. but these ehanjjes ma\- lai-y:cly be due to i)i'essui'e. Atypical mit(»tic fi«rures have been studied by many, and by .some believed to l)e responsible for the abnormal proliferation of the cells. l)ut the majority of pathojofjists believe that these abnormalities are the result and not tlie cause of bewildered «rrowths. Changes in Tissue Balance. — Thiersch held that in carcinomata the i»rimai\\- chan^fc was in the connective tissue, that there was a weakeniuf? of it which allowed the epithelial cells to expand and penetrate into it. He thought that there was an antagonism between the epithelial cells and the connective tissue cells, a totally unjusti- fied assumption. It is well known that in many conditions, as in x- ray cancer, the primary change is in the connective tissue, but there are no facts to ju.stify the belief of Thiersch. Ilertzler has shown that in very early eases of cancer the connective tissue does not take acid stains in a normal way, but nothing practical has developed out of this interesting demon.stration. Microorganisms.— Ewing gives the following list of parasites that have at some time been held to be responsible for cancer: Bactkria. — Bacillus of Rappin, 1886; Scheui-len. 1887: Franckc. 1888; Lampiasi. 1888; Koubassof, 1889; Micrococcus ncofoi-mans. Doyen, 1902. CocciDiA. — Cocidium of Dariei-. 1889; Albarran, 1889; Thoma, 1889; Sjobring. 1890; Coecidium sarcolytuni, Adamkiewicz, 1892; Soudakiewitsch-Metchnikoff, 1892; Monsarrat, 1905. Sporozoa (unclassified). — Bii'dscye inclusion, Foa, 1891; Plim- mer's bodies. 1892; Sporozoiin. Ruffer, 1892; Sawtschenko, 1893; Ameba-sporidium, Pfeiffer. 1893; Rhopalocephalus canceromatosus. (;i;ni;k.\l coxsihKKA'iioNs. :jl KoroliicfC. In!)-!: S[)()r()/,(»(iii. Koui'lofC, ls;)4; Bosc. 1807; llomato- zo(")ii, l\;ili;inc, IM)4: ( ';iiicri;iiiicl)a iiificroj^losHa, Hiscii. 1000; Lcy- (lriii;i j4ciiiiiii|);ir;i, S('li;iiiiiiiiii. lsO(i: Intranuclear parasite, Schuller. 1 001 -I. Hi, AS'i'().MV(K'ii;s. — Sjiccliaromvccs ncolDriiKtns, Saiifelicc. 1806 : PliiHiiKM-, Leopold; Roiu-ali, F>ra ; Kusscli's fuehsin ho^K1X CANCKR. liaiidli' the crude tar. ami tliat in iicai-ly every factory a imniber of cases can be found. The lesions are usually situated \ipou the hands, and are associated with a marked folliculitis. In chimney sweeps the disease j?enerall\" appears ujion the scniluiii. i]nc to the collection of the soot in the skin ru fre(iuently leads to death, ('aii- cer is also re]ioi1ed in ^actlenei's who handle soot in the course of their work. The etiology of cancer of the sl^in is still siih judici. hut ^\"e t to devcloi) u])on othei- lesions of the skin, these being fully considered in the next chapter. The work of Smith in showinfij that a disease in i)lants that is certainly analogous to cancer is due to bacteria, the work of Rous and ]\Iuri)hy in demonstrating that chicken sarcoma can be inoculated from a tiltrate passed through a Berkfelt filtei-. Khi-lich's'-'- demonstrations that mouse cancer is rendered more virulent by being transmitted through several generations, and Gaylord's" experiences with in- fected cages, not to mention certain of Behla's-* statistics, would seem to show that cancer is probably due to an infecting organism of some sort. It is well known that a riotous proliferation of cells can be caused by external irritants, and the fact that cancer so fre- quently develops upon the site of an old injury or of a more re- cent break in the skin may simply mean that here is the chance for the infecting organism to gain foothold. The long periods of latency before a metastasis manifests itself is certainly in harmony with this theory. Against it speaks strongly the rarity of "cancer a deux." = Ehrlich: Zeit.schr. f. Aerztl. Fortbikl., 1906, 7. "Gaylord: Jour. Am. Med. A.ssn., 1907, xlviii, 15. ^Behla: Deut. n.ed. VVchn.schr., 1901, xxvii, 427. CUAVTKli II. rJih]CANCKIi(JlJS DKRAIATOSHS. As Bowcn' states in u rofeiit urticlo, various kcraloscH form Iho commonest cutaneous lesions that become caiicei'ous. Certain of the soft nevi, however, especially the common pif^menlcd moles, and scars resulting from var-iims causes, either infectious or Iraumatic, arc apt to l)ecome the seats of epithelial tiuuors, oflcii of an ex- tremely malignant nature. PIGMENTED MOLES. For nuuiy ycai's it has been well known l)y dei'inatologists, and to a somewhat lesser extent by sui'geons, that the most virulent form of skin cancer (or sarcoma) — namely, the melanotic — always has its origin in either congenital or acquired pigmented moles. In 1903, Bloocigood,- and a few months later Keen," two eminent American surgeons, showed how frequent and fatal these growths were. They further stated that not only all acquired moles, but all congenital moles, that began to grow, that showed any signs of ulceration, or that were subject to continuous irritation, should be removed as a prophylactic measure. Unfortunately, although this point is now conceded by all surgeons and dermatologists, neither the profession at large nor the general public is as yet educated up to it, but there are many signs of an awakening. Neither the large raised, hairy moles, nor the small hairy ones, are apt to develop into melanotic growths, and only rarely do they become the seat of basal-celled cancers. The almost flat, deeply pig- mented, common moles are the dangerous ones. Histology. — Histologically, these benign growths consist of more or less epithelial hj^pertrophy ; beneath the rete there is a thin layer of normal corium, and then come the characteristic large nevoid cells, closely grouped together, as shown in Fig. 1. Some of the pigment is in these cells, but may also occur in the neighboring corium. There is considerable discussion as to whether these cells are of mesoblas- tic or epithelial origin, the weight of evidence seeming to favor the latter view. This question will be fully discussed in the chapter devoted to the malignant melanotic gro"s^i:hs. ^Bowen: Jour. Cutan. Dis., 1912, xxix, 241. ^Bloodgood: Progressive Medicine, Dec, 1903, 149. ' Keen: Jour. Amer. Med. Assn., 1903. 3G ;K1N C'ANCKR. Fig. 1. — In this pliotoiniernKiaiih ^;iiR'iiu-il luuK- may bo seen the masses of nevoid cells eontainiiig pigment, and also pigment scattered through- out the neighboring corium. There is a layer of normal corium between the rete and the underlying masses of cells. (Author's collection.) Malignant Degeneration. — The liisl clinical eviclcut'os of nialij?- naney are often ^■cry slight ; tliere may be a slight growth or a slight ulceration, i)ossibly followed by the development of a tnmor (Fig. Fig. 2. — The patient shown in this illustration had a common mole of the neck, which he irritated while shaving. It was removed under local anesthesia, and promptly recurred with the result shown. There were many other growths both in the skin and glands. (Heidingsfeld's collection.) PUKCANCKKOIJS I)i;i{M A'I'OSKS. -H 2), but the C()ii') increase of pif^-nieiitntioii in the denn;!, loj^'flliec willi dilaljilion of the blood vessels, Jind a heavy infill r;i1(!, wilh round ov \)(i\yireti'()leum has a ])articiilarly irritatiiifj: effeet upon the skin, especially ai-ound the hair fdllicles. These are found to be filU'd with dark, spiii\- i)lu>is. Not iiifrecnu'iitly keratoses form, and later cancerous chan:ni/ed by IJiidei- and liy Kaj^osi. Clinical Course. — It usually beuins with an inllamniatoi-y liyi)er- emia and a freckle-like condition, the freckles doubtless being pro- tective in intent. As a «jeneral i-ule. oidy the exjiosed parts of the skin ai'c invoh'ed at fii'st, but later in the course of the disease the whole skin may be invoKi'd. The fii-st chanjj^es are noticed between the ages of five and ten months, and jjrogress but slowly. At a lit- tle later date it is noted that there are atrophic ai-eas in the skin, and also venous telangiectases (Fig. 6). Between the ajres of fifteen and twenty years kei'atoses usually manifest themselves, and from the eai'liest stages the skin is remarkably rough and dry. The eyes are exceedingly sensitive to li^ht. and thi' patient liangs his head and keeps the eyes closed when the illumination is at all bright. At about the age of twenty some of the keratotic patches become malignant, and the growth of these carcinomata is usually sIoav and typical of rodent ulcers. Occasionally the cour.se of the disease is much more rapid; in the patient illustrated in Fig. 7 large cancers had developed at the age of fourteen. Pathology. — Histologically, the lesions' have been studied by Un- na. KaiJosi,'' Fordyce,^* and others. The very earliest lesions have not as yet been sufficiently studied. l)Ut the second stage — that is, where there is a marked increase in the amount of pigment — is well known. The basal layer of the rete contains an abnormal amount of pigment, and the rete as a Mhole is thinned and atrophic. The papilla? are widened by congestion. The changes in the corium are found over the entire skin. The varices do not form under the pig- ment, but only where this is lacking. I'luia states that in the areas '"Kaposi: Twentieth Century Practice of Medicine, v. "Fordyce: Jour. Amer. Med. As.sn., 1010, Iv, 1624. J'RI'XJANCI'MtOIJS l)i;H.\lA'r()SKS. 43 ■of excessive pif^mcntation tlic pi^mciil is roiiml iiol only in the rete, but also in the papilhiry spjiccs, pjtrtly in llic lymph spar-eH and partly in the hyper'li'()|)hi(' H[)iii(ll<' fclls. Scjillcrf-d flnrnfts arc alHO found in 1ii<^ iii)|icr |»ri('kl(^ hiycr. Fig. 6. — This boy, aged 12, had .suffered from freckles since he was 2 years old. Atrophic areas, areas of pigmentation, and a keratotic lesion upon h's neck can be seen. Tlie condition is one of xeroderma p'gmentosum. (Case in the Johns Hopkins Hospital.) 44 SKIX CANCER. In the third stage there exists i,'reat thickcniiifj: of the horny layer, so as to form liorny ^varts or keratoses, beneath Avhieh the rcte is deformed in spaces corresponding: to the black areas. In the lower ]iricklc layer the prickles are lost, and the cells consequently arc misshapen, and there is considerable intracolhilar edema. In the retc are masses of closely packed epithelial cells loaded with pig- ment. At times collections of nevoid cells are fouml in the upper portion of the corium, all loaded with pigment. The white sclerotic spots arc due to an obliteration of the capillaries, caused by the sclerosis and hypertrophy of the connective tissue of the corium. There is usually some round-celled infiltration around the basal layer. The cancers developing in these patches are typical basal- celled carciuoiiiata. showing, however, an increase in pigment. Fig. 7. — The same patient illustrated in Fig. 6. Had a mnnbpr of will-ilcvelojied cancers arising from the Iteratoses. Microscopically, thoy were shown to be basal-celled. The condition is xeroderma pigmentosum. (Case in the Johns Hopkins Hospital.) The condition is believed to be due to a congenital lack of resist- ance to the rays of the sun, and the increased pigmentation, as avcII as the early erythema, is an attempt on the part of the body to protect itself against the actinic rays. It is not unusual to find a number of r-hildrcn in the same family similarly affected with lliis disease. Treatment. — The prognosis is always bad, the patients may be relieved for a short time, but eventually death results from carcinoma- tosis of the skin, occasionally complicated by visceral metastases. PRKCANCiiKOCS l));io cxposf^l to Hunlif^ht as little as possible, jiikI it would he Ixillcr il" Ihe windows of the room in whi(;h they are k(!j)t were of red j^lass, so as to filter out th(! actinje rays. In addition to tiiis, the e,\r)Osed portions of the body sliould either be covered by a, mask or by a 7"ed ointment or lotion, ealaniine beinj^ faii'ly s;i,tisfiu*toi'.\' lor 1liis purpose. Whenever a carcinoma a})peai-s, it slionld l)e rjidif-ally rcinovcd at onee, or, bet- ter yet, the keratoses should be excised as sor)n as they appear. In other respects the treatment is purely symptomatic, treating symp- toms as they develop. SAILOR'S SKIN. This condition was originally described by Unna as occurring in sailors who were much exposed to weather and sun. The condi- tion, as will be shown later, is not confined to seafaring men, but also occurs in farmers and those who are exposed to a dry climate and excessive actinic rays. In both of these groups of cases there is an acquired hypersusceptibility to actinic rays, as opposed to the congenital intolerance that appears to be the basis of xeroderma pig- mentosum. There first appears upon the exposed parts a diffuse cyanotic red- ness. Pigment spots soon appear, but the areas between these ''freckles" may or may not lose their pigment. Telangiectases ap- pear, and the skin becomes dry and hard, and keratoses usually re- sult. This condition may last for years, but usually there develop basal-celled carcinomata, that run the clinical coiu*se of rodent ul- cers. When this condition begins to develop, the patient should give uj) an out-of-door life, or at least protect himself from light. In the later stages the treatment consists of the surgical removal of the growths. FARMER'S CANCER. The condition described by Unna as peculiar to seamen is also found in those who are much exposed to the sunlight, especially where the air is very dry. As it is fairly common in the western part of the United States among those following agricultural pur- suits, it has been aptly named "farmer's cancer."' The condition commences with a deep bronzing of the skin, later the cutaneous covering becomes dry and rough and minute keratoses develop. 46 SKIN CAXCKR. Hyde^^ has thorouj?hly consitlcrcil this type of dermatosis, showing how frequently rodent uleers deveh)]^ upon these keratotie patches. More recently Lawrence-" has called particular attention to the ])rcv- alenee of this disease in Australia. Lawrence states that out of 6,000 consecutive cases at his clinic 1.8 percent, or 108 cases, showed this condition, a tigure y:reatly in excess of the pi'evalcnee of rodent uleers at the European skin clinics. He attributes the condition to the {jrcat nmouiit of sunshine and the low i-olativc humidity of the atmosphere. The treatment is the same as for "sailor's skin." X-RAY DERMATITIS.-' Clinical Course. — This sad condition was much more fi'e(iuenl in tlie early da\"s of x-ray therapy than it is at i)resent. In those days the oj^ei-ators took no pi-eeautions to shield either themselves or patients from long continued exposui'e to the soft rays, and the result was that there were vei-y many sufferers. The condition is in every way analogous to the conditions just described, and is un- doubtedly caused by the actinic i-ays of the Koentgon tube. The backs of the hands are well known to l)e the most susceptible i)or- tions of the body, and here it is that this condition is most often seen. Again, we see the developing of an excess of i)igment, usually in freckle-like spots, then there ai)i)ear superficial telangiectases; the skin becomes dry and rough, and loses its secretions, and the hairs fall out. The nails frequently become stunted and roughened. Small horny growths appear, usually upon the site of the freckles. These later develop int« either ulcers or carcinomata. The cancers may be either of the basal-celled or the prickle-celled type, or a mixture of the two. In the ease of the squamous-celled cancers the spread is usually rather rapid, and local removal nearly always followed by reeuri'ence, and at times by metastases. Even the basal-celled car- cinomata usually grow fairly fast. Pathology. — Pathologically it is conceded that the fii-st changes manifest themselves in the corium and not in the epithelium. The sweat and sel>aceous glands become atroi)hied. the blood vessels are dilated, and there are signs of an inflammatory ])i-occss, with round- celled infiltration. "Hyde: Amer. Jour. Med. Sc, 1006, cxxxi, 1. *» Lawrence: Trans. 7th Internat. Congress Dermat. and Syphil., Rome. 1912, 1219. "Porter and White: Ann. of Surg., 1907, xlvi, 649. 1'UI';(;an(;i;k()i:s I)i;ieutie remedy. The callosities should he renio\-ed either by the use of the knife or by the cautery and eui-ette. 'I'o tlu; author it seems il- logical to use either the I{oentg(!U tube or radium, for he cannot help feeling that there is grave danger of thereby aggravating the condition, recalling tlint \hc troubh; is caused jjy light. Whenever an ulcer appears, it should ix; (excised and skin-grafted, and cancei-s should be excised with an ample margin. ]f they are of the spino- cell type, amputation and I'cmoval of the neighborly glands should be seriously considered. PAGET S DISEASE. Paget 's disease is often considered as a precancerous condition, but, as there is still dispute as to whether the cutaneous lesions ma}* not be secondary to the cancerous changes the writer has felt it best to deal with this subject in a special chapter. MARJOLIN'S ULCER. Cancer frequently develops upon the scars of various dermatoses. Most prominent of these is the scar resulting from ordinary burns of the third degree. Cancer originating in such lesions is commonly' called Marjolin's ulcer. The first manifestation is almost invariably a superficial ulcer, with a considerable amount of rather foul dis- charge. A fungous overgrowth often results, with great indura- tion around the edges. At other times there is simply a deep ulcer, accompanied by induration. Cancers of this type are usually of the spinous-celled variety, necessitating wide local removal, and enu- cleation of the draining lymphatic glands. In severe cases situated upon the limbs amputation is usually necessary. LUPUS VULGARIS. Lupus vulgaris of many years' duration is not infrequently com- plicated by cancer. Sequeira-- has recently published an excellent article on the prevalence of malignant change in lupus, and has re- ported a number of very interesting cases. He concludes that the "Sequeira: Brit. Jour. Dermat., 1908, xx, 40. 48 SKIN CANCKR. cancorous dojifciieration devcloi)s only in long standing eases, and usually in persons about the prime of life. It is usually stated that about 2 pereent of all cases of lui)us become cancerous. Con- trary to the statement of most observers, Sequel ra In'lieves that this change is more common in men than in Momen. The change takes place more frequently u])on the faci- tlian elsewhere (Fig. 8). It is still questionable whether x-ray treatment of the lupus has been responsible for the malignant change, but apparently cancer is no more common in the cases treated by the x-ray than in the cases Fig. 8. — This woman had suffered from lupus vulgaris for years. A deep spino- celled cancer has developed and is invading her orbit. (Heidingsfeld's col- lection.) treated bj^ some of the older methods. At the same time it must be remembered that it is only within a comparatively few years that the ray has been persistently' used in lupus, so the future may hold many such cases in store for us. The tumors are almost invariably of the prickle-cell type, and spread rapidly and frequently met- astasize. Radical operation is indicated in all cases. Local re- moval and radiation of the base of the ulcer is not sufficient ; it may cure a few cases, but cannot give good results -when tested on many patients. PKJCCANCIOUOCS l)i;iCM,\'l(;SKS, 49 LEG ULCERS. Chronic leg ulcers rarely become euiiccrouH. T'olli I'.loof]«^oo(P^' and CJotthciP'^^ have noted this, the former havinj^ seen but three caHeH, and the latter having been able to collect Init ten cases from the literature. Most dermatologistH and surjifcons express surjirise tliat such a change docs not take place more frequently, but to the author it does not seem surprising when one considers that cancer prefers to originate from a dry sore and not from a moist one. In common with most carcinomata of the extremities, these growths are usually of the spinous-cclled type and hence are very malignant. Operation should consist of wide local removal, the glands likewise being taken out. Amputation is frequently necessary. In the case illustrated in Fig. 30 the growth was curetted and excised, and thoroughly cauterized with acid nitrate of mercury, and has escaped recurrence for three years. LUPUS ERYTHEMATOSUS. Lupus eryfliematosus scars occasionally become the seat of skin cancers. Dubreuilh and Petgcs-'' have collected all of the cases re- ported in addition to recording two of their own. In practically all of the patients the lupus had existed for many years, and the neoplasms originated upon the scar tissue. So far as can be judged from the rapidity of their growth, they were of the spinous-celled variety. More recently Janeway-*' has recorded another case occur- ring after the use of carbon dioxide snow. Gottheil, in discussing this case, held that previous x-ray treatment was probably the true factor. BLASTOMYCOSIS. That the lesions of hlastomycosis may become cancerous has been shown by Bloodgood-' in a case that the writer was fortunate enough to see with him. SYPHILIS. Sypliilitic ulcers are often referred to as undergoing malignant degeneration, but the condition is certainly- unusual. The change may take place either in an ulcer or in the scar produced by such ='Bloodgood: Progressive Medicine, Dec, 1904. =* Gottheil: Jour. Amer. Med. Assn., 1912, Ivix, 14. =5 Dubreuilh and Petges: Ann. de dermat. et de syphil., 1909, x, 106. ^''Janeway: Jour. Cutan. Dis., 1910, xxviii, 140. -■ Bloodgood: Progressive Medicine, Dec, 1907. 50 SKIN LANCLK. an ulecr. usually the latter. In the former instance it is noted that the j^ranulation tissue beeoines raised at some ]H)int. and that it bleeds very readily. The tissue is friable, and is sli<;htly pnlrr tlian the rest of the granulations. Induration ni;i>- he fell aituuid llie edf^es. The further course siiows eithei- a (lc(|ily i'atin>r ulcer or a funjjjous growth, or a combination of tlu' two. These lesions ari' usually of the more malignant type. ;iihl hciicc (Icniand extensive operative interference. INFLAMMATORY DERMATOSES. Eczi))i(i, licJiDt i)hi)uis ri(isis ( ll;ii1/.cll.-"' i-ih)odgood-") oc- casionally give rise to cancer of the skin. Iml in the \iist nia.)oi'it>' of the cases repoi'ted it is ])i'ol)al)le thai either arsenic or x-i-iiy was the true cause. SINUSES. Bloodgood frequently refers to .sintisis a)tf; may or'i{i;inu1,(; in the lesions of Ihe s<)-e;ille(| miihii.h- heni'rii eyslie. epitheIioiii;i1;i. He does not, ho\ve\(^r, jij^ree wilh lli-idinj^sreld,"-'- who believes that all f^i'owths of this tx'pe ;ire prenudif^njiiil in eharaeter. Both Moiitgoniciy''' and Sutloii'' h;i\-e sliown how i're(|nently can- cer of the lip stai'ts in seboi'i'heie patches, and I'dt \-eai's i1 has Ijeen known that cancer of the t(jnj;iie fi-c(iuenll\' originates in syphilitic lesions as well as in leukoplakia. Bloodgood''' states that every ease of cancer of th(! skin of whicli he has a complete record originated from, some abnormality of llie skin, and not from normal epidermis. He also states that out of forty cases of cutaneous sarcoma, thirty-tw'o originated from dis- tinct skin lesions, usually the scars of burns. These statements show that, if all apparently harmless cutaneous growths were removed, we should have fewer cancers. It also means that Ave should do our best to promptly heal all lesions, and not allow them to drag along. "Sutton: Amer. Jour. Med. Scien., 1913, cxlv, 819. == Heidingsfeld: Jour. Amer. Med. Assn., 1912, Ivix, 256. 33 Montgomery: Jour. Cutan. Dis., 191.3, xxx, 82. w Sutton: Jour. Amer. Med. Assn., 1913, Ix, 1774. 'SBloodgood: Progressive Medicine, Dec, 1912. CHAPTER IIT. EPITHELIAL WARTS. There are, of eoiirsc, two varieties of epitlielial warts — the be- nign and the malignant. BENIGN WARTS. Both clinically and i)athologically the benign warts may be di- vided into four main classes, each of which contains subdivisions. A. Keratoma t a. a. Simple keratoma. b. Clavus. c. CjiUus. d. Cutaneous horn, c. Angiokeratoma. B. Acanthoma (spino-celled tumor). a. Molluscum contagiosum. C. Mixed-celled tumors (rctcomata). a. Verruca vulgaris. b. Verruca digitata. c. Verruca filiformis. d. Condyloma acuminata. e. Semi globular wart. f. Pedunculated fibroreteoma. g. Seborrheic warts. h. Acanthosis nigricans. D. Basal-celled warts. a. Nevus-like warts. b. Multiple benign cystic epithelioma. In addition to tlie true Avnrt-like growths, certain infectious dis- eases of the skin frequently assume a papillomatous overgrowth, con- sisting of hypertrophied epithelium. Among these may be men- tioned lupus vulgaris, and various other forms of tuberculosis of the skin, frambesiform .s^-philis, blastomj'cosis, yaws, and occasionally ec- zema. The different growths mentioned above form a veritable hodge- 52 KI'I'l'IIKMAfj WAK'l'S. .0.5 podge, a set of tumors yory (lifTercnt in lliini>leted at a later date. In obtaining; material for seetions it is best to employ an eleetrie eautery. exeisiii^^ the tis.sue exactly as with a knife, but giving a wider margin, inasnuich as the heat ruins much of the tissue with wliich it comes in contact. Frozen sections cannot he unreservedly advo- cated, imismuch as it is very difficult to i)r(»ducc thin, well stained specimens, and hence a i)rop(i' diarobable that the ma.ioi'ity of malij>:nant wai'ts can be cured by means of ju-oper i-adiation. althoui^h at the ])i'esent time there are absolutely no statistics ujxju wliich to base this opinion. The lack of deep intiltration should inalu' these tumors ideal subjects for pi'op- crly administered x-ra\s. chapter iv. basal-cellp:d carcinoma 1^ a . The (lifrerentiaUon of llu; l)as;il-<'cllc(l i^roup of lumoi-s from the other epithelial neoplasms is really due to the exeellent work of KrompechciV aiul in America the attenlion of l)«)1li dcrmatoloj^ists and surgeons has l)een especially called to tlies(; {^I'owths l)y the ]>u\) lications of Bloodf^ood.- This very large and important group of tumors embi-aces the typi- cal Jacob's ulcers of the English author as well as of Unna, the Fig. 10. — Diagram of the sites of origin of 220 cases of basal-celled cancer. (After Sequeira.) cancroid of the early writers, and the rodent ulcers of the sur- geons and dermatologists. Owing to the varying clinical and patho- logical pictures presented by these tumors, they have been much confused by most writers, many men not recognizing that the histo- logical picture might vary, not only in different stages of the same growth, but also in sections taken from different parts at the same time. Some English authors have even gone so far as to speak of ^Krompecher: Der Basalzellenkrebs, Jena, 1903. ^Bloodgood: Progressive Medicine, Dec. 1904. 59 60 SKIN CANCKR. a rodent ulcer becoming mali«;nant, wlien in reality the basal cells were simply invading the tissue in a slightly different way. Krompecher has shown that even the glandular tumors may have a different picture and run a different course, according to which layer of the glandular epithelium from which they arise, but this need not now concern us, thougli it does seem wise to point out the analogy. Occurrence. — These tumors are usually situated upon the face, especially upon the nose, eyelids, and median portions of the check, but may occur upon any other part of the face, or upon the back or shoulders. They are extremely rare upon the limbs. Sequeira's^ composite illustration shows very clearly where they usually arise Fig. 11. — This illusUalion shows biisal-celled carcinomata arising from different portions of the rete. Serial sections showed that there was no connection be- tween the various growths. (Gilchrist's case.) (Fig. 10). They very rarely originate in people under thirty years of age, and are most common in the decade between forty and fifty. It is usually stated that males are much more frequently affected than are women, some authors even stating that 90 percent of the cases occur in men and the majority believing that at least 75 per- cent of the patients are of the male sex. Neither Krompecher 's nor the author's own statistics Avould seem to bear out this assumption, for Krompecher records nine in men and eight in women, and the author's figures give thirty-one in men and twenty-four in women. Pathology. — The neoplasms spring from the basal layer of the ' Sequeira: Brit. Jour. Dermat., 1913, xxv, 172. BASAL-CKLLKD CARCIXOMATA. 61 epithelium. Not, j)irrcf|iiciitlv' 1li(;y ;i,rc imiltifjlf;, OHpocially in the typo si)i'in}^in}^ from .sobori'luMc w;irts. Petersen'' lias deirionstrated that tlie growths may liave a iimltieeritrie orif^iii. In a reeerit ease i'lom the Joliiis ir()|)kiiis l)('iMii;itolof?ieal C'linie it foiild be dearly shown that in one nodule tliei-e wei-e a number of sejiaj-ate and dis- tinet plaees whei-e mali^-iiant i^roliferation w;is be-^'inninj^ (i'^if?- Hj. The whole j^'rowth was seetioned, and lliesc small iiodulcs had no connection with each other. From this section it was poHsible to demonstrate the very earliest changes, pliologi-aphs of which arc here Fig. 12. — The earliest lesion of cancer is a downgrowth of the epithelium. Some of the prickle cells have lost their nuclei. There is very little infiltration of the surrounding- corium. (Gilchrist's case.) reproduced. The first change noted is an unduly long do-oiiward growth of the intrapapillary process (Fig. 12). There is some de- generation of the rete, and many of the prickle cells have lost their nuclei. There is a slight invasion of the rete by round cells and fixed tissue cells; the subpapillary portion of the corium shows a slight increase in these same cells, and the blood vessels are dilated. The second stage (Fig. 13) shows a clubbing of this downward growth; the basal cells have begun to proliferate, and the death of the cell nuclei is very apparent. The fibrous tissue of the corium shows some signs of compression, and there is an increase in small < Petersen: Beitrage z. clin. Chir., 1902, xxxii, 543. 62 SKIN CAXL'KR, round and fixed tissue cells, some of which have invaded the rete. In the third staf?e (Fiiu'. 14) the cancerous lesion is distinctly seini- r ^ Fig. 13. — The secoml change in a developing basal-celled cancer is a clubbing of the downgrowth shown in Fig. 12. The basal cells are beginning to proliferate, and dejienerative changes may be plainly distinguished in the spinous cells. (Gilchrist's case.) Fig. 14. — The downgrowth contracts, so that a solid irass of basal cells is formed. (Gilchrist's case.) globular in shai)e. due entirely- to a lu'oliferation of the hasal cells, there niav oi- mav not be infill r;i1 ion of the coriuni l)y inflainniatoi-y BASAri-(;i;i-iii;i) (jAitcixo.viA'iA. (y.i cells, and ihc, iU';i\\\ of Ihc nuclei nC I lie [iilc|:lc fcllK friii ]>(■ floarly Hcen. Sonic nuclei cati he, (list iii^iiisli(<| lyin) the buHal- ccllcd f?rowtli h;is invfidcd the fctc, so tlint siirl;ifc ulfcration has taken X)l ace. At ;i later jx^ciod the l);is;il iiicnihiJine is Inoken tfirrtutrh, and the invasion of the corium Ix-^ins. After the invasion begins, Ihe piit holoj^iejil [ticliire vjiries. Al first there ai'c solid nuisses of the (lee[)ly-st;rniin<^ IkisjiI eells (F}^. 16), the Carcinoma haso<< Ihdare soIuIkvi of Kromix'eher ;inlood- good. The solid masses do nol, li()\\c\ci', lon^ rein;iin so. for they either degenerate in the cenlci-, forming e\s1s, or else ;in';intre llicin- Pig. 15.^ — A latei" development of nodule in basal-celled cancer of skin shows ulcera- tion of epithelium. (Gilchrist's case.) selves in solid finger-like downgrowtlis (Fig. 17). The cystic de- generations are often very extensive, and it is not nnusnal to find nnmerons large cavities, surrounded by two or three layers of can- cer cells. This stage is called Carcinoma hasocellularc (.'^olidum (t cysticam). The growth may have a distinctly acinous arrangement, there being many fine branches, somewhat like the limbs of a tree. This condition forms the Carcinoma hasocellularc adenoides of Krom- pecher, the glandular cpiflicliomata of the older Avriters. and the fuhular cpiflicliomata of the modern dermatologists. In some of the large fungating neoplasms there may occur large or small stellate alveoli of cancer cells imbedded in granulation or fibrous tissue, so 64 8K1X CAXCKK. as to somewhat i-osciublo scirrhus carcinoma of tlio breast. Ki'om- peehcr has no designation for this group, l)ut Hloodgood calls them Carcinoma hasocdlulare stcUatmn (Fig. 18). In this latter group the cells may be so flattened out ])y ])ressure as to be almost unrec- ognizable. l)ut they retain their affinity for the basic stains. Clinical Course.— Clinically, these growths start upon a pre-ex- isting dermatitis. Bloodgood states positively that in every case of which he has a complete history there was an antecedent lesion, how- ever small. The commonest of these dermatoses is the so-called seb- Fig. 16. — Thi.s section was from a typical rolled-edge rodent ulcer of the shoulders. The basal cells are arranged in solid masses. Notice the way that normal epi- thelium and some connective tissue cover the mass of cancer cells, while in other portions the growth may be seen springing from the surface epithelium. This invasive growth, without change in the overlying skin, is common In cancer and frequently leads to incomplete operations. (Author's collection.) orrheic wart, next come small subepidermal nodules, then keratoses of various kinds, and finally scars or minute ulcerations, often thought to be traumatic. The first stage of the cancer that is noted by the patient is usually a slight itching or burning sensation, and at that time a very slight increase in thickness of the skin can be felt. Very shortly after a minute ulceration takes place and there is a serous discharge (Fig. 19). Then a scab foi-ms, that drops off from time i5ASAri-CK[ii;i;i) (;ak(;i\om.\')'a. 65 .,r^2'.^v v'.Vv ■Vk^ Fig. 17. — This section also demonstrates the manner in which n li:i..'ii- celled can- cer may be covered by normal epithelium. This case had been treated by the x-ray and pronounced cured. Possibly too soft a tube was used. Fig. 18. — In this low-power photomicrograph of a basal-celled carcinoma it can readily be seen that the cells are lying in small strands and also singly be- tween connective tissue fibers. This histological picture is often seen in the large fungous basal-celled tumors, and at times makes them difficult to dis- tinguish from spino-celled neoplasms. (Author's collection.) 6G SKIX CANCER. to time, ami whenever this oeeurs it is noted that the ulcerated area is a triile lnr<;er. "When examined closely, a few minute, greyish, Fig. 19. — This man is suffering from two very early basal-celled cancers of his chin, proven by histological examination. They might be easily mistaken for benign growths at this stage, but slight crusting and oozing and a small amount of infiltration lead to their diagnosis. (Sutton's collection.) shiny masses can be seen at the edge of the open sore, and this edge is usually hard and slightly elevated (Fig. 20). The neoplasm may BASAL-CKfJ>KI) OAUCIN'OMATA. 67 then take any one; of sc,v('r;il coiii'scs, ;ill sliorlly to be y the (|cnn;i1ol(i^'ist ;iii(| !.'rii(r;il [irac- titioner. It l)Ofj''iiis ;is reddish or ]H'/dv\y-i^ycy smooth nodule. 2 1o .'' mm. in diamctci-. Siipcrlictiai ulceration takes phiee cnrly, owiuu:, to the invasion of the re1e by the cancerous tissue. The ider^ratcd area is covered by a fairly closely adhereid, hhiek or d;irkdjrown crust, which from time to time either drops off or is pieked off hy the patient. When this occurs, thei-e is sliMhl, hleedinj/. ;iiid it is no- ticed that the ulceration is larger. The {growth is always slow; it may take one year, oi- it may take five years, for a diametr'c of 1 ^ ^ 1 1 Rl i Fig. 22. — This basal- celled cancer is of many years' duration. Even more extensive ones occasionally come under observation. (Heidingsfeld's collection.) cm. to be reached. Slightly enlarged blood vessels may be noted ex- tending into the surrounding skin, and considerable induration is always present. On inspection, either with the naked eye or, if necessary, with a hand lens, a fevr pearly nodules can be seen just at the edge of the ulceration. The skin around the edge looks as though under great tension, is shiny and thin. The tissue beneath the scab resembles ordinary granulation tissue, but is less hemor- rhagic and more friable. Pathology. — If the groAvth be removed at this early stage and ro SKIN CANCCR. examined histologically, it is at once soon that tlic lu-w tissue con- sists entirely of basal cells, usually arrani;od in solid masses (Car- cinoma hasocilhihnr solid um). At times it will lie noted that these solid alveoli are sending out fingerdike dow ngrowtlis {Carcinoma hasociUularc adcnoidcs) , or that distinct cysts liave ])een formed {Carcinoma hasoccUuJarc cjisticum). Later Course. — U" the tumor be undisturbed or ineffectually treated, one of several things may happen. In the first place, there may be "widespread superficial ulceration, that may be so extensive as to cover half of the face (Fig. 22). In some of these cases it is remarkable how the mucous membranes arc spared. Usually, how- ever, the orbit is invaded, the eye destroyed, and death takes place Fig. 23. — This basal-celled (.-ancer has spontaneously healed in the center, but is spreading along the periphery. (Gilchrist's case.) from meningitis. Second, the ulceration may take place as just de- scribed, but there may be some f ungating masses, where the cancer cells are unable to rapidly invade the underlying tissue. Third, there may be considerable spontaneous healing, with the formation of a considerable central, w^hite, depressed scar (Fig. 23). How- ever, on at least one of the edges there is characteristic ulceration, or the formation of cancer nodules. In some of these cases the formation of scar tissue considerably distorts the features, pulling the eyelid downward, or the mouth upward as the case may be. BASAri-(;i';iJ;i;[) cakcinomata. 71 This, of course, is duo to llic; foiil racturcs that always take place in scar formation. l^Vmrth, th(! i'ofiiiation of dc(!p cavities, due to severe ulceration may occur. Secondary infection frefjuently occurs, some- times with i)us pi'oduciiif^ organisms, atid 'sometimes with putrefac- tive bacteria. The edf^e, even from a coinfinrntively early stage is slightly elevated and always veiy hard, nnd ;it times cancer plugs may be distinguished in it, nltliougli this is miicli foniinoner in the priclde-celled cancers. The iiidurution is due not oidy to the can- cer cells, but also to the innanimatory cells, and to fibrous tissue that is frequently formed. The surface of the tumors is cr»rnpara- Fig. 24. — This portrays an early basal-celled carcinoma of the hand. Cancers upon the hand are usually spino-celled and metastasize. (Sutton's collection.) tively smooth, resembling anemic granulation tissue, and. has not the rough, warty appearance, so characteristic of the squamous- celled tumors. The naked eye appearance of these neoplasma. upon section, is also characteristic ; infiltration is usually comparatively shallow, and the Avhite lines of invading epithelium are very fine. Histologically, in the large growths, the early solid structure of the cancerous alveoli is never retained. The general arrangement is in more or less irregular cylinders, often branching, or in the stel- late form described bv Bloodgood. There is often much fibrous tis- 72 SKIX CANCER. sue at the edtros. aiul usuallx' coiisidiTabU' intlanmiatory cxiulato. oc- casionally so severe as to obscure the cancerous ])icture. Diagnosis. — In the e.arly stajj:es tliese growths may Ijc confused with tlie iionmalignant keratotic conditions, or are rarely with sim- ple inflammations. After ulceration has taken place only syphilis, lupus vulgaris, or more infreciuently lupus crythematosis or even blastomycosis might simulate cancer. In the chapter on differential diagnosis there will l)o a full discussion of tlieso diseases. ^ BS|^.A=^^\"'' "^ i^H Fig. 25. — This nodular basal-celled carcinoma of the cheek arose from a sebor- rheic keratosis, a number of which may be seen upon the cheek. (Heidings- feld's collection.) II. NODULAR CANCERS. Clinical Course. — The nodular cancers arise froiu a pre-existing lesion. A pearly nodule first forms, which slowly grows until in from six months' to one year's time the growth has attained a diam- eter of 1 em. and an elevation above the skin of about the same. The lesion is roughly semiglobular in shape, may be .slightly um- bilicated, and is very hard and firm to the touch (Figs. 24, 25). The color is pinkish-white or grey, and there are dilated vessels running into the tumor. Later, ulceration may take place in the center (Figs. 20, 27), and the neoplasm run any of the courses al- IIAHAL-('KIj^jKI) carcixomata. (.'> ready (icHcrihcd iiihIci' IIk^ iic;i(lih»,' of 11k; i\:\i. rodent uW-ff. This type is in reality simply a, inodificatlnn of 1li(; loljcd fd^/c i-oddit ulcer type. Pathology.— Ilistolof^-ically, tln^ lesion at first shows the char- acteristics of the Carcinoma hasocdlidarc soLiduw, ])nt later chanf^cs to some of other types, as has already been descriljcd, the only dif- ference beinf? that the changes are comparatively slow, and 11. at cysts rarely form. Fig. 26. — This large basal-celled cancer of the hand sprang from a seborrheic kera- tosis. Notice a healed lesion upon the middle finger. This is an unusual tumor, for neoplasms of the hands are usually of the spino-celled type. (Sutton's collection.) Diagnosis. — Gnmmata and benign epithelial, fibroid, or cystic tumors must not be mistaken for this type of growth. III. ROLLED-EDGE RODENT ULCERS. Clinical Course. — The rolled-edge rodent ulcer is very closely re- lated to the two varieties just described, but more closely to the second type. It begins in the identical way that they do, but is fairly common upon the back and shoulders as well as upon the face. The tendency is for these tumors to grow much more rapidly than 74 SKIX CANCKR. the flat type, despite the fact that in many instances there is no surface ulceration for several years (Fig. 28). By the end of a year these tumors usually have a diameter of several centimeters. These growths have a distinctly semiglobular edge and a correspond- ing depression in the center, so that they resemble the crater of an extinct volcano. The edge is extremely hard, and the skin over it is tense, tliin. and shinv, and there arc numerous dilated blood vessels Fig. 27. — Tlii-s large ba-sal-celkd cancer, with a markedly elevated edge, arose from a seborrheic keratosis, numbers of which can be seen upon the face. (Heid- ingsfeld's collection.) extending out into the normal skin. The skin of the central por- tion may or may not show signs of ulceration. If ulcerated, there is usually but a slight crust. The surface of the exposed or cancer- ous tissue resembles granulation tissue, and is anemic and friable. The late course of these neoplasms is the same as that of the two preceding types, and the pathology is identical with that of the nodular lesions. IJASAIi-(Ji;M;i:i> CAKCINOMA'I'A. I'-) IV. DEPRESSED SCAR-LIKE CANCER. Clinical Course. — The depressed sear-like cancers are compara- tively iirl"re(|U(!iit, the author's series containing but one case. As they start as a very small subepidermal nodule and as the skin over them remains intact, they frequently remain undiscovered for some little time. They usually arise upon the cheeks or temples of those well past middle life. The nodule flattens out, and slowly spreads along the basal layer of the rete, or just beneath it, and as a result the appearance is identical with that of a depressed scar, except that the color is not so white, and that the normal lines of the skin are to some extent retained. While the skin is thinner than usual, yet to examination it simply looks sunken and feels bound down, just as morphea patches do. There is no dilatation of the surface Fig. 28. — This rolled-edge rodent ulcer of the neck has no ulceration, ered v/ith a crust. (Heidingsfeld's collection.) but is cov- blood vessels. The induration can be plainly distinguished, feeling somewhat like a small coin imbedded beneath the skin. These neoplasms grow very slowly, and ulceration does not take place until scA'cral years have elapsed. It is highly probable that tumors of this type may end in the morphea-like cancer shortly to be described. Pathology. — The histopathology is the same as in the preceding group. TO SKLX CANCER. Diagnosis. — Tl\e ditTei-iMitial iliatriiosis nmst lu> iiiado I'roiu de- pressed scars, and I'l'om iiu»ri)lioa. V. MORPHEA-LIKE CANCER. Clinical Course. — Tlie uKirplira-like cancers liave reeently heen described in detail by lleidinfjsreld.' ^vll() lias collected all of the reported cases in addition to describini; one of his own. According k U^' Fig. 29. — Thi.s morphea-like epithelioma showed upon histological examination typi- cal basal-celled structure. (Heidingsfeld's collection.) to Ilcidingsfeld, there are now ])nt eight eases of this variety of cancer on record, but he calls attention to the fact that many cases of so-called ulcerating morphea should undouljtedly be i)ut in this categoiy. Cases have now been described by Danlos/' Stelwagon,^ = Heidingsfeld: Jour. Cutan. Dis., 1913, xxxl, 370. •Danlos: Ann. de dermat. et de syphil., 1809, x, 656. ^Stelwagon: Trans. Amer. Deimat. Assn., 1899, 166. i{ASAri-(;Kiii>i:i) cakcinomata. ' ' ITartzcl],^ Fordycc," Pcnioi,^" and ir('i(liii<,'srcl:ro\vths whcM-e thoy are not fi-cely aeeossible, as in the naso-faeial fold, ov where it is important not to i)ro(luee a sear, as upon the eyrlid, the x-i-ay shouhl l)e tried. It is imi)ortant to j;ive one or two heavy exposures oi a measured dose, rather than to try many small dcuses. for reeurrenee follows many of the latter, and the ji;ro\vth is then resistant to further radiation. In aljsolutclx' inoper- able )j:ro\vths either the x-ray or radium nuiy be emj)loyed. However ;i small do.se of I'adium should never be employed, or marked stimu- lation of the neoplasm may occur. In the ease of extensive ji^rowth x-ray is the be.st method, for radium seems not to be ai)i)lieable ex- eept in small tumors. In some instances a combination of these meas- ui-es is to be advocated. For instance it is prol)abl\- well to radiate after every operation. In all instances it is hipfhly important not to employ measures that are insufficient, for such treatment is almost sure to result in the rapid spread of the cancerous process. Simple curetting, cauterization with silver nitrate, earl)olic acid or similar substances, and the use of carbon dioxide snow should not be em- ])loyed, as they usually do much more harm than good. CilAPTEIi V. CUBO-CELLED CARCINOMATA. Origin.- — It Avill be rciucnibcrcd that just above the cells fonn- iiig the basal layer of the rete there is a layer of cuboidal cells, cells somewhat larger than the basal cells, and of a square rather than a columnar shape, and yet with no prickles and not staining as in- tensely with the acid dyes as do the prickle cells. Epithelial tumors may arise from these cells, and when they do they possess characteristics of both the basal-celled and squamous- celled carcinomata, or, to be more exact, they form a connecting link between these two radically different types. They have many of the clinical characteristics of the former in that they grow rather slowly, and frequently run a course identical with that of the rodent ulcer, and yet they resemble the more malignant type in that they have a marked tendency to metastasize. At times it is practically impossible to distinguish them histologically from the basal-celled neoplasms, and Bloodgood^ thinks that there are undoubtedly many mixed cases. According to Bloodgood, these tumors were first recognized by Krompecher- in the course of his work on the histology of the basal- ccllcd carcinomata. Clinical Course. — Clinically, these growths arise from pre-exist- ing lesions of the skin, just as do the other varieties of cancer. They may form either fungous or ulcerative lesions, but more usually the former. The tumors often grow very slowly; in a case reported by Bloodgood it took eight years for a diameter of 12 cm. to be reached. In the author's case (Fig. 30) a diameter of 10 cm. was reached in about six months ; between these two extremes there are all stages of transition. The fungous neoplasms grow much more rapidly than the ulcers, and metastasis seems to take place sooner. The cancerous tissue resembles anemic granulation tissue, that bleeds easily and is very friable. There is always extreme induration about the edges. Pathology. — The gross pathology is similar to that of the squa- mous-celled cancers, for the alveoli are large, much larger than in 'Bloodgood: Progressive Medicine, Dec. 1004. = Krompecher: Der Basalzellenkrebs. SI 82 SKIN CAXCKK. basal-celled jirowths, aiul contain fine Mhite M:i';nuilar material (can- cer cells) that can readily be S(iueezed out. AVhen examined under the microscoix'. it is seen tliat at first the jrrowths are snlid. ])ut that they soon l)e<:iii to spi-cad out in Ion? finfrer-like acini, that bi-andi (Uit more or li-ss as tiu'\- Lrniw down- ward. The cells resemble larjje sciuare basal cells, ami at times are »is larfje as the prickle cells, but do not contain i)rickl('s. nor do they stain with eosin as well as the si)inous cells. In addition, there is no tendency for the formation of eilliei' whorls oi- tlu> moi-e ad- vanced e])ithelial pearls. Incidence. — Out of a total of DDT cases of epillielial tumoi-s. of which 820 were malignant, Bloodgood^ reports tliat tliere were 5 Fig. 30. — This cuboidal-celled cancer originattnl in a varicose ulcer of the leg:, and had been present about five months. It has remained well for three years since local removal and cauterization. It would have been safer to have re- moved the glands. (Author's collection.) percent of cuboidal-celled tumors. In location, tliese neoplasms are pretty Avell scattered. In a study of sixteen cases, Bloodgood states that three were on the lower lip, five on the face, three on the legs, and one each on the scalp, penis, tonsil, tongue, and neck. Diagnosis. — Tlie diagnosis must be made from Ixitli ]n'ickle- and basal-celled cancers, and in eases of a mixed type of tumor this may be very difficult. The naked eye diagnosis depends on the depth of the malignant infiltration, and the size of the alveoli, and the microscopic diagnosis on the size and character of the cells and the lack of whorls or pearls. 'Bloodgood: Amer. Jour. Med. Sc, 1914, cxlvii, 76. cubo-cj:lm;d carcincj.ma'i'a. 83 Treatment. — If caught yevy c-u'ly, siiii|)lc cxcisioii wiili ;i \\]<\(: niarg'iii wiJl usually suffice to '/wt- ;i i)cnii;iiicnl mrc, hut, if tlic tumor has existed for ;iiiy l(!ii}ftli of time, i1 is ;il)solutoly impera- tive to remove the ncif^hhoriiiji; lyinpli ^hiiiils. i''iir1li( r study of this group of tumors is needed, ms vvc ;irc not ,\(;t cJeai- as to when metastasis takes place, although ]i\U' work by Bloodgood seems to show that this is often ('oiiip;ii';i1i\'ciy ciirly. CHAPTER VT. SPINO-CELLED CAKCIXOIMATA. Occurrence. — In many •ways lliis ni-oup ol' cancers foi-nis Ihc most iiiipniiaut one from a clinical standpoint, for. Avhcn it is rc- meinberocl tliat the lii)s, tonjiuc. and ])ouis arc chiofly affected l)y this type, and that in addition a larj^e proportion of the growths upon tlic cutaneous surfaces are prielde celled, it will readily be seen tliat the more important of the surgical e])ithclial cancers be- long to this category. In a surgical service a])ont two of these growths are seen to one basal-celled neoplasm, ])iit in a dermatologi- cal service the reverse is the case. In the last forty cases of can- cer of the skin seen by the author, nine were of this kind. Ac- cording to the statistics of Bloodgood,^ these tumors are most fre- quently encountered upon the lip; secondly, upon the skin; thii-dly, upon the tongue ; and, fourthly, upon the penis. In his review- of GO cases from Bloodgood *s service the writer found that the neoplasm up- on the skin arose in the following localities: finger, 4 eases; hand, 11 cases ; wrist, 2 cases ; forearm, 2 cases ; elbow, 2 cases ; upper arm, 3 cases; foot, 2 cases; ankle, 3 cases; lower leg, 6 cases; knee, 2 cases; thigh, 3 eases; scalp, 3 cases; face, 8 cases; neck, 3 cases; trunk, f) cases; and scrotum, 1 case. Etiology. — For all practical purposes, the stndy of tlie i)recan- cerous lesions arc the most important. In this same series of 60 cases the preexisting maladies were as follows: scar of burn, 11 cases; scar of trauma, 5 cases; sinus, 1 case; senile keratosis, 4 cases; "wart," 14 cases; "pimple," 5 cases; blastomycosis, 1 case; x-ray dermatosis, 2 cases ; lupus vulgaris, 1 case ; ulcer, 3 cases ; scratch, 1 case; arsenic keratosis, 2 cases; uncertain, 10 cases. Upon the lips almost any variety of lesions may serve as the starting point, while upon the tongue lesions of leukoplakia or of syj)hilis are especially apt to become malignant. Varieties. — Bloodgood formerly divided the s])ino('ellular tumors into epithelioma spinocellulare and carcinoma spinocellulare, using the latter term when the typical arrangement of the benign proto- type was lost. From a clinical standi)oint there are but two types — 'Bloodgood: Progressive Medicine, Dec, 1D04. = Hazen: Jour. Cutan. Dis., 1915, xxxiii, 611. 84 SPINO-CKIJ.KI) (JAIiCINOMATA. 85 the Ofdiiiury oik; of f';uK'cr ;ui(] llu! oilier of IIh; iii;ilitrii;iiit wart that ncithcf inflliratcs nor inctastasizcH. Clinical Course. — Clinically, the truo cancors fits! appear as nodules that usually speedily ulcerate. They may then be either fungous or x>ure ulcers, or a combination of the two. The surface is usually rough and irregular, and is often papillary. The color is that of a dirty granulation tissue, with some whitish splotches. Around the edges there may be some cancer plugs, looking some- Fig. 31. — Deep prickle-celled cancer of cheek in a young man. (Sutton's collection.) what like comedones, from which masses of cancer cells can be squeezed. The tissue is friable and bleeds easily. The edge is usual- ly very hard, and there is often deep induration. Growth is usually comparatively rapid, and it is not unusual to see extensive involve- ment by the end of the first year. A tumor of nearly 15 cm. di- ameter may be developed by the end of two months. The most important thing to remember about this group of can- cers is that they frequently metastasize. The author made a special study of this point in the paper already referred to, and has found that out of the 60 cases reported, 38 were followed for three years or 86 SKIN CAXCKR. more, ami that out of these 38 cases. 2'-^ liad ilefmitc metastases. In certain of these cases the metastatic ^I'owths ajiparently formed at a very early date. 4 when the ])rimary iri-owtli uas of not more than one montli's duration. Spinocelled tumors of llic l)ody and heail seem to l)e rather more a])t to metastasize tlian tiiose n]>on the limbs, and those oi'i^rinatin^ from x-ray or arsenic keratoses seem especially dan^^crous in this respect. The spinocelk'd mali^'iiaiit warts first appear as wart-like growths, which develop rather slowly. I'licre is often a tendency toward ])e- iluiiculation. and llu're is no cancci'ous infiltrate at the base. As a result, these ^'rowths do not form metastases. .Jtttp^ l^SK> ^^M^ ^ ^Hfc^' ?a|fe ) ^^*' ■ ,. '^fjk L ^^^^^^T/^^^^l fc. ,^^^^^^^^^^ w^- Fig. 32. — Rapidly growing cancer devoloiiiiiK lioin within the eai collection.) (Heidingsfeld's Pathology. — -If one of these tumoi-s l)e excised and then cut into halves, a number of interesting? things may be seen by the naked eye — things that go a long way toward making an accurate diag- nosis. There is usually rather wide and deep invasion of the eorium ; pei'haps of the underlying muscle. Bloodgood states: "The epi- thelial alveoli are distinctly white in color, finely granular, and ar- ranged in a more or less uniform pa})illary shape. . . . The fine, branching white lines are composed of masses of spinal-celled epithelium on a connective tissue basis." These lines are very much coarser than the lines in basal-celled growths, for in this latter con- dition the alveoli are usuall\' Cdniparalivcly small. ,SPTNO-(;i;i.Iii:i) CAKf.'lXOMATA. 87 On luHtolo^'icuI examination ;i niiinlxr of - soTkI ; llicrc is ;i dippinj/ down of the rctc, the new growth consislin^' niniost cn1ircl\' of ftrifkle eells, but the basal membrane of cuboidal cells s1ill i'cni;iirnn(; intaet. Many oi" these prickle cells li;i\c lost llicir nuclei, in olliers Mty[)icjil kaiy- okincsis is K<>iiif? on; some; oi' \hv, cells lia\e undergone vjirious types of dcgenei-jition, already sufficiently discussed in chapter I, and there are eonsiderable spaces belwcen 1he cells. In ad(|ition to this, WSL ^ ^-^ ^Sa^^^K ^SH^^K m 9^ K^B L^^HU r-^ M 1 i ^^HP Fv^fiB wi ^ k ^ ,'Vf fl ffl^^n 1 1 1 1 i Fig. 33. — Prickle-celled cancer originating in the mastoid following mastoid opera- tion. (Heidingsfeld's collection.) the prickles are disappearing. Other descending alveoli appear, not at more or less distant places, as so fi'eqnently occnrs in the basal- celled growths, bnt as branches from the original downgrowth. The next appearance is where there are a nnmber of solid alveoli, side by side, serial sections showing them to be connected and not sep- arate and distinct. These solid alveoli may be large or they may be very small, so small as to be only four or five cells' diameter in thickness. In these early stages there is no tendency for whorl for- mation or the formation of epithelial pearls, bnt these changes may come very shortly, and are iisnally apparent abont the time that the growth begins to divide into numerous small alveoli. These small 88 SKIN canci:r. alveoli are, of course, the processes or buds that have been nipped off from the orijrinal parent growths. When one studies a com- paratively late squanunis-t'ollod cancer of the skin, he will see that it usually conforms to one of four different arrangements: First, where a more or less pa])illary structure is maintained, all of the alveoli bcinfi; about ccjual in size, and where tlic cuboidal basal cells are still found surronndinir tlie prickle cells. In tlic center of these alveoli the cells are often foinul ilattencd out in a concentric shape, forming the well-known whorls, and distinct pearl formation may take place. Second, tlicrc may lie very numerous small alveoli, each "^^ Fig. 34. — High-power pliMi'uiiicniKrapli uf prickle-celled cancer. lection.) (Author's col- composed of but a few cells, and separated from its fellows by con- nective tissue. In this form there arc usually no basal cells discern- ible, and there is a great tendency for whorl or the more advanced pearl formation. Third, the neoplasm has a distinctly tubular for- mation, the cells being arranged in long lines that have many branches, which are rarely bordered by basal cells. And, lastly, the cell arrangement may be more or less that of a scirrhous carcinoma — that is, small islands of cells are found, surrounded by connec- tive tissue. This type is analogous to the Carcinoma hasocellulare stellatum of Bloodgood, except that here we have prickle instead of basal cells. SPINO-CEIjLED C a RC I N M A 'J" A . 89 The cells thcrn,selv(!H deserve; study. They are lar^^e, iriore or 1c8H angular in outline, a,nd stain intensely with the Ji.ei' di-hix' usuallx" ri'sults in extensive jrlandular metastasis. Treatment. — In the t)])ininii of the wi-itei- Xlw t ri'alnient slioiikl be entirely surgieal, leavinir x-ra\ orst,'' l^lood!4'oo(V' Franz," P>()i'rniann,' Von Brunn,** Steincr," McGlannan,^" Volkmann,^' and iiiyself.^- ■•Boi'st: Die Lehre von den Geschwulsten, Wiesbaden, 1902. "Bloodgood: Progressive Medicine, Dec, 1907, 1908, 1912; Jour. Amer. Med. A.s.sn., 1906, xlvii, 1740; Amer. Jour. Med. Sc, 1914, cxlvii, 76. "FrsLUz: Beitrage z. klin. Chir., 1902, xxxv, 171. 'Borrmann: Deutsch. Zeitschr. f. Chir., 1906, Ixxxii, .36.3. 8 Von Brunn: Zentralbl. f. Chir., 1907, xxxiv, 550. "Steiner: Deutsch. Zeitschr. f. Chir., 1906, Ixxxii, 363. 1" McGlannan: Maryland Med. Jour., July and August, 1908. "Volkmann: Samml. klin. Vortr. Chir., 1889, No. 102. i-Hazen: Jour. Amer. Med. Assn., 1915, Ixiv, 658; Southern Med. Jour., 1915, viii, 577. CHAPTER YII. BENIGN AND .AIA[.IC;XAXT TUMORS OF THE CUTANEOUS APPENDAGES. As has already been pointed, out, the normal skin has the follow- ing appendages: hair follicles, both of the lanugo and deep hairs, ■with the adjoining sebaceous glands, and the sweat glands and duets. From all of these organs both benign and malignant tumors may arise. In addition, there is unquestionably the possibility of there being congenitally displaced epithelial or glandular tissue, and it now seems fairly certain that at least one clinical and pathological entity, the syringocystadenoma, springs from congenitally misplaced coil ducts. Dermoids, of cour.se, have their origin in congenitally dislocated tissue. OAving to the degenerative changes, as avcII as the modifications in cell type, that naturally take place during the lifetime of a neo- plasm, it is highly probable that a fair number of tumors originate from these appendages, and that they cannot be diagnosed as such under the microscope. In even a slightly advanced basal-celled car- cinoma, it is impossible to determine ■whether the origin was in the basal layer of the epithelium or in the hair follicle. As Unna^ well points out, the cells of the sebaceous glands so readily revert to sim- ple-appearing epithelial cells that one might never suspect a car- cinoma of having its origin in them. Fi'om these two illustrations it can be readily seen that it is often impossible to say in just ■what cells the malignant change first appeared. TUMORS OF THE HAIR FOLLICLES. The hair follicle has different layers, just as has the skin, and epi- thelial growths may originate from any of these layers. Krom- pecher- states that he has been able to recognize two tumors of the face as springing from the basal layers of the hair follicles, and various other pathologists have reported similar observations. It is certain that, as our knoAvledge and technic improve, we shall later be able to identify neoplasms as springing from some of the numer- ous lavers. 'Unna: Histopathology of Diseases of the Skin, New York, 1896. = Krompecher: Der Basalzellenkrebs. 92 BENIGN TUMOKS OF (JUTANKOCS AI'l'KNDAOKS. ')■'> At the present time two difrereiit cliiiifal and patholo^if'Jil vari- eties of tiiiiioi' ai'isinf^ ij-oiii tin; ha.sa] laycir have bee)i fliffer-eiitiated. The finst is the multiple benign cyslic epitheliomd , suhv;iri('1y of Von /ai'iseh, which is clinieally iiuliHliiif^tiishable from, the iriore common type known as the lirooke-l^'ordycfv"' variety, where the growth is from, the l)asal laA'crs oT 1h(! cpil lidiinn in'opci-. I'hesc tumors will be fully discussed in the ch;i|)1('r dcjiliii^ ui1li llic inul- tiplo benign tumoi-s. The second is the rodent ulcer type, or the irichoepilJidi.ovui of some authors. The case reported by Bloodgood* is a fair illuslrati(jn of this tyjtc. It occurred upon the cheek, just anterior to the angle of the jaw, in an elderly man, having been present for foui'teen j'ears as "a small elevated area covered with hair," probably a nevus of the hairy type. During the last year it had grown to about 7 or 8 cm. in diameter, and, as the result of the use of a caustic paste, there was a slight superficial ulceration, with considerable induration at the edge of the solid portion of the neoplasm. The tumor was freely movable over the cheek muscles. It was easily excised under cocaine, and it was then found that there was a zone of normal fat between the neoplasm and the underlying muscles. At the end of fourteen years there had been no recurrence. On section of the tumor the gross appearance showed large hair follicles, containing hairs in the depth of the tumor. Between the follicles the normal tissue was re- placed by "a firm, white, granular tissue, divided into alveoli by a firm connective tissue stroma. Here and there were a few ca\'ities, containing finely granular material — that is, the naked eye appear- ance of an epithelioma spinocellulare malignum. " Histologically, however, the cells w^ere not those of a prickle-celled carcinoma, but more nearly resembled basal or cuboidal cells, and in places could distinctly be seen springing from the hair follicles. In Bloodgood's laboratory the author had the opportunity of studying another case in which the tumors were of much slower growth, and in which the cells were distinctly basal in character. Recently the author has had a rather interesting case in his own practice. The patient was a man of 45, referred by Dr. Balloch, who had been struck upon the head two years previously, while on a fishing trip in the north woods. A, few months later there developed a nodule, which had slowly increased in diameter. "When se«n, there was on the right anterior quadrant of the scalp a large growth that ^ Sutton; Jour. Amer. Med. Assn., 1912, Iviii, 3o *Bloodgood: Prog. Med., Dec, 1904. 94 SKIN' CANCER. closely rosoinbled a typical rollcd-cdp:c roilcnt ulcer. It was at least 12 cm. ill (.liaiiu'tcr. the vd^xo was very hainl. and firmly attached to the skin, but not to the nnderlyinj? bone. No ulceration had taken place. The hair was si)arso. just as it was upon the remainder of his scalp. As oi)eration would liave been very difficult because of the size of the growth, it was dctenniued to try the x-ray. and the re- sults were very jzratifyiny:. for the jji-owth i)romi)tly healed and for over two years there has ])ecn no recun-ence. Ilistolo«j:ically, the Fig. 36. — Carcinoir.a originating in hair follicles. Low-power photomicrograph. (Author's collection.) picture was very similar to Bloodjjood's case (Fip:. 36). There were very large hair follicles extending deep into the tissues; practically the whole field was filled with them, packed so closely together that there was no room for any other tissues. The hypertroj)hy was al- most confined to the basal layers, and from some of them escaping strands of cells could readily be distinguished. The follicles con- tained no hairs. In addition to the various types of cases mentioned above, it must BENIGN 'I'lJMORS OK (JIITA N IXX "S A I'I'I NDACKS. 95 be borne in mind iliat, some of ilic lypicul I'odcnt uIcits. o)- [jasal- eellcd carcinoniatu, niidoiihlcdiy orif^inate in the, hair folliclcjH. TUMORS OF THE SEBACEOUS GLANDS. At leant four patlioloj^ical types of tunioi's may arise iJ'fjiii the sebaceous glands; (ii'st, simple hypertrophy, which clinically may give two different conditions — the well-known adenoma sebaceum and, in addition to this, irregular nodulations, often known as rhinophyma; second, true adenoma of the glands, which condition may also be found, in adenoma sebaceum according to Sutton \-' third, a basal- eelled carcinoma; and, fourth, an adenocarcinoma ar-ising from tlio inner and more differentiated layer of lining cells. Adenoma Sebaceum. — The sul)ject of adenoma sebaceum will be fully discussed in the following chapter. Simple hypertrophy of the sebaceous glands also appears at times as an accompaniment of other diseases, and at times as independent tumors. The independ- ent tumors are rare; they are isolated, grow slowly, are yellowish- white in color, opaque, and usually from 3 to 6 cm. in diameter, semiglobular in appearance, but globular to the palpating finger, and often show a gaping follicle. At times sebaceous material can be squeezed from them. Much more frequent are the hypertrophies associated with rosacea and histologically combined with prolifera- tion of the fibrous tissue. This condition usually occurs upon the nose, but may to a slighter extent involve the che^^ks and forehead. True Adenoma of the Glands. — True adenoma of the glands are practically unknown according to Unna. but Sutton thinks that in one of his cases of adenoma sebaceum he is justified in considering that this condition was present. Basal-Celied Carcinoma. — As Kronipeeher points out, the basal cells of the skin form an unbroken line with the basal cells not only of the hair follicles, but Avith those of the sebaceous glands as well, so that a priori there is reason to believe that basal-celled tumors may originate from them ; he offers no proof, however, that such neoplasms do exist. Thiersch thought that very many of the cyl- indroma (epithelioma basocellulare adenoides) had their origin in the sebaceous glands, but his deductions were founded entirely upon the fact that the arrangement of the cells in this condition resembled the arrangement of the cells in the sebaceous glands, and that the lobular shape of the two was somewhat alike : hence his views were speedily oveli:hroA^^l. It must be remembered that a tumor could 'Sutton: Jour. Cutan. Dis., 1911, xxix, 4S0. i)l) SKIX CANCER. easily originate fi'Diu these eells, and that after a slight period of time it would be inipossil)le to prove or even suspeet this fact. While this faet is by no means jirovcn. yet the author feels convinced that such must be the case. Adenocarcinoma. — Uinia states that one of his seventy-three cases arose from the sebaceous glands, and still retained the character- istics of the sebaeeous-eell type. He calls particular attention to the fact that in any inflammatory or neo])lastic condition the cells lose their fat, and revert to a simple cuboidal epithelial type, im- possible to differentiate from other epithelial eells. Bloodgood men- tions none of his tumors as of this class. Nor is any of the recent literature helpful on this class of tumors. Kecently the author has seen a remarkable case of adenocarcinoma of the sebaceous glands where the cell type was completely retained (Fig. 37). The patient was a middle-aged negress, admitted to the surgical service of the Freedmen's Hospital Ijecause of a f ungating tumor that had ex- isted upon her left buttock for one year. She stated that it had started as a nodule beneath the skin, which had rapidly grown and speedily ulcerated. On examination a large part of the buttock was involved by a deeply-seated tumor that had ulcerated through the skin and become markedly fungous. In the nearby skin were sev- eral similar smaller neoplasms. The left inguinal glands were mark- edly enlarged. On biopsy it was found that the tumor consisted en- tirely of enormously enlarged and dilated sebaceous glands, more or less filled with an albuminous material. The lining cells were but one or two rows thick, and had retained all of the characteristics of sebaceous gland cells. A few of the cells had, however, escaped through the ba.sement membrane. There were numerous mitotic fig- ures. All of the cells contained fat, and were of the same size and general characteristics as normal gland cells. Unfortunately the pa- tient refused operation and Avas lost sight of. TUMORS OF THE SWEAT GLANDS. Here, again, there are several possibilities: First, simple hyper- trophy of the sweat glands; second, true adenoma of the sweat glands; third, basal-celled carcinoma of the sweat glands; and fourth, more malignant carcinoma, springing from the lining cells of the sweat glands. Simple Hypertrophy of the Sv^reat Glands.— Simple hypertrophy of the sweat glands does not form tumors, so far as is now recog- nized. BKNIGN TUMOKS OV (MJTANKOI S A I'I'I;\I)A(;KS. 07 True Adenoma of Sweat Glands.-Uima stales IIimI do.iuuUt ad- enomata of the coil ^UuuIh -.uv. very rare, ami thai, most lurnors usually supposed to consist of these elements arc m reality derived from the sweat duets. As ., erilerio.., it is m^eessary to show th.d, lateral f^rowths spring from the ^hinds. tli-'se ;,rowths tending to Fig- 37 -This carcinoma of the buttock arose about one year ago. and is now practically inoperable, owing to a mass of glands in the grom. Histological examination showed that the neoplasm still retained the structure of the sebace- ous glands, from which it arose. This proves that an adenocai-cinoma of the skin may metastasize rapidly, and that the glands should be taken out at the earliest possible moment. (Author's collection.) 98 SKIN CANCKH. bend and roll up ; the presenec or absence of a lumen is of no par- ticular moment, but the basal membrane must be intact. The true cases of spiradenoma fall into two irroujis, according to uhether they form true independent tumoi's. or are sim])ly accoin])animents of other dermatoses. The former are rare, the latter fairly common. The latter type is most fre(iuently encountered in association with carcinomata and an«!:iomata. also in lupus .md uciirolihi'oinala, as well as varices of the leg. Unna has collected six cases wliicli he accepts as Irue spii-adcno- mata — the cases reported by Lotzbcck, Thierfelder, Knauss, Chande- lux, the llaggans. and one of his own. Most of these tumors arose as subcutaneous nodules, which grew either slowly or rapidly, but which were always encapsulated. Usually there W'as considerable ac- companying vascular dilatation. T'nna's review of tlies(> ca.ses is very complete. Adenocarcinoma of Sweat Glands. — Cai-eintniiala of llie sweat glands are coiiipara1i\ely rai-e tumors, and must usually be de- rived from the basal cells, for they are of comparatively slow growth. They arise as nodules beneath the skin, -which gradually be- come adherent to the surrounding tissues and eventually ulcei-ate. Bloodgood has seen but two cases. His second case is described as follows:" "It w^as observed in a colored Avoman aged 50 years. Two years ago attention was called to the back by itching; the patient felt a small nodule in the back, about the size of a bean, since which time there has been a steady growth, and the patient has abraded the surface by constant scratching. . . . The central ulcera- tion is very superficial, like an abrasion, and covered with a brown- ish crust. This ulceration occupied the center of an oval, with a slightly elevated area of induration not sharply outlined from the surrounding tissue. Clinically, it appeared like a diffuse fibroma of the skin, which is not an uncommon ol)servation, especially in the colored race. . . . On section l)etween the superficial ulcerated area and the surrounding zone of epidermis, one could see nothing but a diiYuse growth of fibrous tissue. Epithelial alveoli could not be distinguished with the naked eye; yet, when .studied mieroseopi- callj', this fibrous stroma was riddled with minute areas lined or filled by sweat gland epithelium, and in many places the long tubules of the sweat glands were preserved." With all due deference to the great authority of Bloodgood, the author feels tliat 1liis tu- mor is an exniiiple of an adenoma of the sweat/lucts, I'allici- than •Bloodgood: Prog. Med., Dec, 190-1. Bi<:Nf(JN 'J'lJMOKS OF rMITA NKOI 'S ,\ I'I'KXDAOKS. 09 H c;u'('.iii<)Mi;i, of the ,^l;iii(ls. In ;i I'cccnl ;irlic|c Wol riicim^ states that thcM'c Jii'c but fwd ccrlnin ciiscs of this disease mi I'eeoivl — a fiawc of Darier's ujkI ojk; of liis own. Wul I'lieim eonlends 1liai the fol- lowing criteria are necessary in orcler 1(» eslahlisd heyond all fjoubt this diagnosis: first, either a sure eoiin(;ction willi llie duels or coil glands; second, a nior})h(jl()gy vvliicli can ])e idenlifiefj without any doubt as normal or abnormal sweat glands; and 1liir.iA£a:iL>.-'i2. Fig. 38. — Low-power photomicrograph of adenoma of the sweat ducts. (Author's collection.) TUMORS OF THE SWEAT DUCTS. Here also there are several possibilities — first, benign tumors of the ducts, and, second, carcinomata arising from the ducts. Also, it must be remembered that the multiple syringocystadenomata spring from congenitally displaced sweat ducts. Benign Tumors of the Ducts. — The benign tumors, or syringo- adenomata, are usually solitary, or occasionally multiple tumors, and ■Wolfheim: Arch. f. Dermat. u. Syphil., 1907, Ixxxv, 277. sRlauber: Beitr. z. khn. Chir.. 1904. xli. 311. 100 SKIS' CANCKK. are apt to appoar iipun the face as seiiiiglulnilar nodules, wliich on palpation are easily ilistin^uished as fjlobular, but Mhieh arc not adherent to surrounding; tissue. They vary in diameter from 1 to 8 cm. llistolofjically, they consist of many latei-al branches from the ducts, the lumens of which may or may not be patent, but the basal membrane of which is never broken throuj^h. Besides the in- crease of epithelial tissue, there is an increase of fibrous tissue as McU (Figs. 38, 39). Petersen has described a case of clinical '■nevus nnius lateralis" which consisted chieflv of a true syringoadcnoma, and Unna has had X Fig. 39. — Adenoma of sweat ducts. High-power pliotomicrograph. (Author's collection.) a somewhat similar case, and which he dcscri])cd as "asphyxia reti- cularis multiplex." Carcinomata of the Ducts. — Carcinomata of the ducts have not been described, but doubtless occur. Treatment. — The treatment of all of these tumors is faii-ly def- inite. When a tumor is clinicallj'' benign, it may be treated by sim- ple excision, and, when clinically malignant, by broad local removal, usually without disturbing the lymph glands. If, however, micro- scopical examination shows a malignant type of carcinoma, the glands should be removed at once. If good frozen sections can be obtained BENIGN TUMORS OF CUTANKOUS AI'l'i;.\I).\GJ':.S. 301 at once, this furtlior operation may Ijc flonc ;i1, Uk: s;inic siHirif.', as otherwise a second operation is necessary. Jji jijf>[)ci;il»lc fases one might resort to radium, the x-ray, or the curette jukI (•;iiiir;ry. Ir- ritant pastes shoukl never ])e used, for tlu; ^mtiwHi is usiuilly loo deeply situated to ;i.l]ovv of curative results. MULTIPLE BENIGN TUIMORS. The thi'oo varieties of iiuiltiple hciiiuii liiiuoi's of ciiitliclial orif^nn — namely, the multii)le benign eystic ciiitlu lidiiia. Ilic syringoeyst- adenonia, and adenoma sebaceum — havi' i-i'ci'Utly been thoronf;hly studied l)y Sutton/ and the foHowinfj: account is hirgely derived from his ai'tieles. MULTIPLE BENIGN CYSTIC EPITHELIOMA. These tumors witc lii-st studied liistoh)iii<'all\ by bialzer and Menetrier- in 1885, but they failed to recoj;nizc the true nature of the {2:i-o\vths. Brooke^ in 1892 and Fordyee'' in the same yeai* inde- pendently investij;ated the lesions and arrived at a itroper solution of the problem. Clinical Course. — Clinically, the disease is more apt to oc- cur ill \vomen (Fig. 40), usually those past middle life, and there is a marked tendency for the disease to run in families, several members frequently being involved. The site of ])redilection is the face. The tumors are translucent and vary in size from 2 to 8 mm. ill diaiiieter. They vary in nuniber from six to twenty. I'sually the growths remain stationary for many years, a few new ones oc- casionally appearing, but the older ones showing no tendency to either enlargement or to spontaneous disappearance. In a few cases malignant change has taken place, this having occurred in the cases reported by J. C. White,"' Jarisch." Stclwagon,' Sutton and Dcnnie,"* and Strobel." Heidingsfeld'" is inclined to l)elieve that all tumors of this class are premalignant in both structure and character, but Sutton stronglv dissents from this view. 'Sutton: Jour. Amer. Med. Assn., 1912, Iviii, 333. Jour. Cutan. Dis., 1911, xxix, 480. Amor. Jour. Med. Sc, 1913, cxlv, 819. = Balzer and Menetrier: Arch. f. Physiol., 1885, 565. » Brooke: Brit. Jour. Dern:at., 1892, iv, 269. «Fordyce: Jour. Cutan. Dis., 1892, x, 459. 5 White: Jour. Cutan. Dis., 1894, xii, 477. •Jarisch: Arch. f. Dermat. u. Syphil.. 1892, 269. 'Stelwagon: Di-seases of the Skin, Phila., 1910. * Sutton and Dennie: Jour. Amer. Med. Assn., 1912, Iviii. 333. « Strobel: Personal communication. "Heidingsfeld: Jour. Amer. .Med. Assn.^ 1912. Ivix. 256. 102 MUJ/1'II'M: l<;.\ 'I I MOi;,-. lO:; Pathology. — TTistoloj,no;illy, llici-c ;itc two flisliiift, typos — the Brooke type, wlici-e the luinor is dcriviMl fiDMi thf Ijusal layers of the rete, and the .Ijiriscli tyfx;, where 1lic iifolilVrjiliori is from the hair follieles. In both types 1hc piciuic is soinewhat similar, for ^'extcndinf^ down into the foriiim rrom tlic l);is;il l;i>-f'r were numer- ous fine, long, slender cluiins of cftil liclinm, Iwo oi' 1hr(!e cells in width, whieh terminated in hiilh-like eysts, filled wilh folloid ma- terial and corneous niateriid." These collections of horny matter are undoubtedly snared off from the horny layer, as so well illus- trated by Krompechcr in examples of the basal-celled tumors. In Fig. 40. — Multiple benign cystic epithelioma. (C. J. White's collection.) some cases there is an additional subdividing of the downgro^^i:hs. In addition to these changes, cysts are found in the upper portion of the prickle layer, tilled with hornified material. There may be a considerable amount of small round infiltration in the corium (Fig. 41). Nomenclature. — Inasmuch as the cells are distinctly basal in char- acter, the author feels that the name proposed by Unna^^ and adopted by Sutton — namely, Aca)if]io})ia adcnoidcs cysfkum — is an unfor- tunate one, for the term acanthoma should refer entirelv to tumors ^^Unna: Histopathology of Diseases. of the Skin. 104 SKIN CANCER. derived from the prickle layer. The name BasoccUidomu adcnoidcs cysticum would be nearer the correct term, and only the disinclina- tion to further incumber the dermatological nomenclature prevents the author from adopting it. SYRINGOCYSTADENOMA. This group has likewise l)ceii well studied Uy Sutton, and his find- ing confirmed l)y Welch. For tliis group of tumors there have been many names proposed, largely l)ocause of the uncertainty as to the true pathological picture. It has been repeatedly confused Avitli the group just described. Biesiadccki^- and Kaposi^^ called these growths "Lymphangioma tuberosum multiplex;" Quinquad,'' "Cellulomc cpi- theliale eruptif;" Besnier," "Nevi epitheleaux cystiques;" AVald- heim,^^ "Hemangioendothelioma cutis papulosum;" and Gassmann," " Biesiadecki: Untersuchungen aus clem path. ii. anat. Inst, im Krakau, 1872, 2. "Kapo.si: Hebra's Lehrbuch der Hautkrankheiten, Enke. "Quinquad: Trans. Internat. Congr. Dermat., Paris, 1889, 412. "Besnier: Besnier and Doyen's Translation of Kaposi Pathol, u. Therapie der Hautkrankheiten, ii. 367. "Waldheim: Arch. f. Dermat. u. Syphil., 1002, 225. '•Gassmann: Arch. f. Dermat. u. Syphil., 1901, Iviii. 177. MiJi/i'iri,!'; iii:Ni(;.\ timoks. 105 "Ncvi cyst-ci)itli('li()in}ilo.si |»;i|>nl(isiiiii." In iidililion U) thoso names, many others have been ^iveii. from time to time. Clinical Course. — (Jlinieally, these tumors appear as numerous translucent scmiglobular j^n-owths (F'v^. 42), varying in diameter from 2 to 8 mm., and usually situated on oithei- the chest or face. Women appear to be more subjeet to them 1li;iii do men. They persist in- Fig. 42. — Syringocystadenoma. (Sutton's collection.) definitely, neither growing in size, nor tending to disappear. They do not undergo malignant change. Pathology. — Pathologically, the stratum corneum is unchanged (Figs. 43, 44), the granular layer is somewhat thinner than normal and is devoid of granules, and the basal layer is regularly arranged, but the cells are swollen and edematous, and the nuclei large and vesicular. The papillfe are flattened, or perhaps lacking. There is some cellular infiltration in the upper portion of the corium, but the blood vessels are lessened in number and show no iirflanimatory changes, the capillary endothelium being normal. The elastic tis- sue is reduced in amount, and an elastic membrane completely sur- 100 SKIN CANCEK. rounds the cysts. Hair follicles aiul scl)accous p:laiuls ai)poar to be iiorinal. The coil jilaiuls are well (levelo|)ed aiul exhibit no patho- logical changes. There is some coUnu^cnous degcnei'atioii of the con- nective tissue stroma. Scattercil tlirou^lmut the cutis, from the sub- papillary poi'tion of the corium to the subcutaneous fat, are num- bers of round or o\al masses of ei)itheliuiii niid e|)ithclial IIiumI # .-^ ^ •V- .^^ ■ ■>' -:> V«J> J*^ >fa ."' ■■ ' ' • Fig. 4.'?. — Low-power photomicrograph of syringocystadenoma. (Sutton's collection.) tubules. ]\lany of these cell collections ])osscss a stem-like api)eiidage of epithelial cells, two cells in thickness, which connect two or more of the gland-like masses. In many in.stances these epithelial tracts are found existing through the corium. The nuclei of the cells is large and stains deeply. In maeroscopically normal skin taken from the trunk Sutton has found similar strands of epithelial cells, and in one specimen several budding processes and a few cysts were pres- ent. That these cells still retain their function was proven by Sut- ton by administering pilocarpine to the patient, sweat appearing upon the surface of the tumors. MIJI/l'Il'l.i: HKNIOK 'J'U.VHMtS. 107 Origin. — There is still ;i qiicsiioii ;is 1o wiicllicr 1li(!S(; lunioi's spi'iti;^' fi'oin pi'eviously nonnnl s\\c;i1, (iiicts, or from congenital or ac([nir('(l defeets. Tiiriik'^ holds lli;it I he iihscnfc or rare occurrence of Kwcjil glands in tin; area, of Ihc, tiiiiior, conipared to the number in the adjoininfr normal skin, is indicative of the transformation of the preexisting sweat tiihnles in1o tumor elements. In favor of the congenital theory is the oeeiirrenee in so many instances of the tu- mor in early life, and especially in several members of the same family. Schidachi'-' has pioduccd similar cysts, even vv^ith epithelial strands, by occluding the sweat ducts. Stockmann-" has shown that the sweat tubules contain genuine secretion, and in one of Sutton's cases there was an enlai-gement of llie tumor following the use of Fig. 44. — Low-power photomicrograph of syringocj'stadenoma. (Strobel's case.) pilocarpine. Sutton strongly contends that the growths are derived from eongenitally misplaced sweat ducts. ADENOMA SEBACEUM. According to Sutton, Kayer-^ was the first to describe adenoma sebaceum, calling it "Vegetations vasculaires. ' ' A few years later isTorok: Monatshefte f. prakt. Dermat.. 1SP2. xiv. 1S5. 1" Schidachi: Arch. f. Dermat. u. Syphil.. 1907. Ixxxiii, 3. =» Stockmann: Arch. f. Dermat. u. Syphil., 1908, xlii. 145. =iRayer: Rayer's Treatise, 2d ed.. Willis's Translation. 996. 108 SKIN CANCKK. AJaison ami Gull-- consiaorea it to bo a liehou. In 1800 Prin^'lc=^ aceurately described the histolog:}' of the lesions, and 1yi)ical cases are often called the "Pringle type" of adenoma siliacciun. Clinical Course. — The lesions are not often seen in private prac- tice, and are only exceptionally encountered in the dispensary, but Crocker-* states that in insane asylums j^lenty of them can be ob- served. The lesions are discrete, red nodules, varying in size from 1 to 9 nun., and situated upon sides of the nose and the adjacent portions of the cheeks (Fig. 45). They may, however, be scattered Fig. 45. — Adenoma sebaceum. (Author".s collection.) upon any other portion of the face. The surface capillaries arc di- lated, thus giving the bright red color. The lesions tend to run in families, just as the above described conditions do. A low grade of mental development not infrequently accompanies the cutaneous condition. Poor considers that there is another type of adenoma se- baceum, in which the eruption is asymmetrical, and the lesions tend to coalesce. Krzystalowicz considers that there are two pathological varieties — one a true hypertrophy of the sebaceous glands, which =^ Addison and Gull: Guy's Hospital Reports, ser. 2, vii, 267. '^Pringle: Brit. Jour. Dermat., 1890, xii, 1. "Crocker: Diseases of the Skin. MUi/i'ii'Li'; j{i;ni(;,\ 'rtjMfjus. 109 may undergo deffoncrjilioii, jind ;i, scfoiid \viiic;h Hfcnis to iofludf; pathological deviations. Pathology.- — In a roccni cjisc! of SiiHon's, two tumors were ex- cised, and Ills report is iipitciidcd in a, soincwliat al)hr(!viated form. The smaller growth was jnHd(! up oT two iiriy)(',rf(!ctly formed and empty hair follicles, with subjoined masses of enormously hypei*- trophied sebaceous glands, the birger ol" wliieli eonneeltid direetly with the surface. The cells and uucl(;i stained cleai-ly and well. Two of the larger masses of glandular tissue were divided into sep- ai-ate lobules by fine, fibrous septa. The larger tumor more nearly Fig. 46. — MoUuscum contagiosum. (Author's collection.) fulfilled Unna's requirements for a true steatadenoma (a benign tu- mor-like growth of irregular formation, proceeding from the epi- thelium of the sebaceous glands, in the outgrowth of which fatty, but no colloid metamorphosis, takes place). Surrounding the lower third of an abortive hair follicle Avere numerous small, oval, or ir- regularly oval collections of sebaceous glands. No horny pearls or colloid substance was found. The individual cells in the sebaceous masses were smaller and less plump than those observed in the growth described above, and the number of the lobules was increased threefold. To sum up, in one growth there was a hypertrophy of 110 -KIN CANrl.H. the sebaceous tissiu\ and in the otlun- the formation of now fjhancls. In one case that tlio author lias ])orsonally studied the seliaceous ghinds were but very sliijlitly hypi-rtrophieil, tlu' blood vessels were dihited. and there was considciable ])erivaseular iiililt ration in the upper portion of the coriuiii. Atypical Multiple Growths.- The aixive ithelial orijjin. llartzcll-"' has reporteil a uniipic neoplasm which resembled both the niultii)le benign cystic epithelioma and the syringocystadenoma, and which may have been a combination of the two. Ormsby-'" has reported a case of comparatively large tu- mors in which spontaneous involution took place, and which clearly sprang from the sweat ducts, which were filled with and surrounded by thick masses of epithelial cells. Diagnosis.- — There are comjjaratively fe^v conditions wliidi sim- ulate these multipb' benign epithelial growths. One condition that nuist be excluded is molluscum contagiosum (Fig. 46) and another colloid milium. The former of these comes on suddenly, and often occurs in e]iidemies. There is a marked central depression, and, on opening, gelatinous material can be squeezed out. Colloid milium usually develops upon the upper part of the face, there is no dila- tation of the surface capillaries, and the lesions arc distinctly yel- lowish in color. Prognosis. — The prognosis is good so far as life is concerned, but tlie lesions persist indefinitely. Treatment. — All of these tumoi's can be i-emoved by the knife, curette, caustics, electrolysis, and at times by the x-ray. Personally, the author prefers the electric needle. " Hartzell: Brit. Jour. Derirat.. 19ii4, xvi, 3G1. =«Ormsby: Jour. Cutan. Dis., 1910, xxviii, 433. CIIAPTi:il IX. NEVOCARCINOMATA AN]) lAFALKIXAXT M KLAXO.M ATA ( MALIGNA NT PIG M KNT Kl) M o I > I-; S ) . It is a rathei.' curious fact that, Jilthouj^li it lias been kncnvn for many years that the most malignant of all tumors spring from the skin and arc deeply pigmented, yet only within the last ten years has the significance of that fact been generally recognized. In 1903 Keen^ and Bloodgood," independently, showed that these growths al- most always, if not invariably, spring fi-oin moles or nevi, and rec- ommended that such growths be removed as a prophylactic measure. In dealing with the clinical forms, it is wise to bear in mind the v/ords of Unna,^ who states: "Since the melanocarcinomata of the skin always take their origin in pigmented moles, and, on the other hand, there can hardly be nevocarcinomata completely without pig- ment, it is well to describe together these two gi'oups of tumors, which are combined by gradual transitions. And, further, in every other aspect, the character of the two is the same. In all cases we are dealing with rapidly growing, pigmented carcinomata, of alveolar structure, which soon lead to infection of the lymphatic glands, to more or less melanotic metastasis and a fatal termination." Clinical Course. — Clinically, these tumors have their origin in nevi, using the term in its broad sense, most frequently from either congenital or acquired, almost flat, deeply pigmented moles of the nonhairy variety. It is usually noted that a mole, usually one that has been subjected to trauma, begins either to grow or to ulcerate, these changes usually not being especially marked. ^letastases fre- quently develop before any change has been noted. The general im- pression among the profession seems to be that these metastases usual- ly involve the skin and the viscera, and that the lymph glands are spared, but this view is by no means the correct one. for in the vast majority of instances there is marked glandular involvement. Clin- ically there are four main courses, which, of course, grade off, one onto the other. First, it may be noted that, very soon after changes are noted in the mole (or nevus), numerous other pigmented spots make their appearance in the skin, looking very much like other iReen: Jour. Amer. Med. Assn., 1903. -Bloodgood: Progressive Medicine, Dec, 1903. 'Unna: Histopathology of Diseases of the Skin. Ill 112 SKIN r\Nrr:n. Fig. 47. — This figure show.s widespread cutaneous metastases from a malignant pigmented mole (nevocarcinoma). There were also visceral growths. (J. W. Perkin's collection.) moles (Figs. 47, 48). They usually, however, grow rather rapidly; some of the glands begin to enlarge ; a number of fairly large, more or less pigmented, tumors appear on or in the cutis, and signs of NEVOCARCINOMA'IA AND MALKiXANT .M l.l>A NO.M ATA. 11:5 viseci'jil (lisl iii'l);iii('(! jirlsc, i'roiw wliidi llic |»;ilicii1 s[)C(!flily dicH. Sec- ond, there may he; innrkcd evidence oi' inclasljisis in some of the iri- tern melanoendothelio- inata. whose capacity in this direction can hardly be exafj:{i:eratcd. (5) A histolojLijical diaj^nosis is the only ]iroper method of dif- ferentiation between the two. Adami says: "Pifjmented tumors of a i>ure cpitheliomatous ty]H^ are unknown/' but Fordycc thinks that he is mistaken in this. To the author the following conclusions seem irresistible: (1) Nevoid cells have a twofold origin, one from the basal cells of the epidermis, and another, not yet determined, po.ssil)ly from the endo- tlu'lium. {'2) ^lalignaiit iiu'lanoiuata of tlic skin spring directly Fig. 49. — Low-power photomicrograpli ui .i malignant pigmented mole (nevo- carcinoma). (Autlior'.s collection.) from these cells. (3) Melanotic sarcomata may spring from other organs, as from the choroid, the gall-bladder (Duval),-" adrenal (Orth),-^ and numy other organs. (4) Lymphangioendotheliomata arc not nearly so malignant as these tumors (see chapter on endo- thelial tumors). (5) Basal-celled carcinomata are certainly not as malignant as this group. The whole question, then, is still unset- tled, although it seems probable that some of these luiiiois are car- cinomata and some sarcomata. ^licro.scopically, a fully developed tumor (Figs. 49, 50) shows =" Duval: Montreal Medical Jour., 1008, xxxvii, 270. "Orth: Berlin klin Wclin.schr., lOOfi, xxvi. NI";VOCAI{(MN()MA'rA AM) M AI-KiN A N'l' M I :i- \ NO.M \T \ . 117 cither ail. alveolar ;i,rr;i;iif^'ctiiciil of \;w'/c or siii;ill '•dls, huiidlcs of Hpindlc- and oat-Hhaped cells, uv ;i coinhiii;!! ion of tlic two, the ]>]<:- turc varying in different j)or1ioiis of 1lic sjunc Imnor. The amount of chromatin varies; in sonu; fIrMs not only lln- ''(jl nucleus may be obscured, but even tlie <'eli sluipe, uliile in oilier liclds it is pres- ent in comparatively small amounts. J>orst has poinlcd out that there was more pigment nenr the great Ijlood vessels. The melanin, which is the pigment present, is in the form of fine amoi-phous gran- ules, varying in color from a golden yelloAV to a veiy deep brown. It is generally conceded 1o be 1lic (iii;il st;i.g(! of the cell, and, where Fig. 50. — High-power photomicrograph of malignant mole. (Author's collection.) there is most, the cell is the oldest or the best nourished. As re- gards the origin of the melanin, it is still undetermined whether it arises from the blood, or whether it orginates in the cutis or the epidermis. Diagnosis. — As a general rule, the diagnosis of these tumors is only too easy, for they are rarely seen before metastases have oc- curred. In the author's experience two conditions have proven troublesome, which may best be illustrated by case reports. In the first instance a young girl consulted him because of a jet-black tu- mor that had developed upon the edge of an old vaccination scar. Examination showed a tumor about the size of a pea. firmly adherent 118 SKIX CAXCKK. to the deeper layers of the skin, and witli dihUed lilood vessels ex- tending from it. It was completely excised with a wide margin, and microscopical examination showed that there had l)een a small venous angioma, into which hemori-hage had taken place .some time before, and that the blood pigment had remained. The other ease was somewhat similar. On the edge of the nostril there had de- veloped a ma.ss that was black in coloi-. and the diagnosis of melanoma was made. Histological examination, as well as the later course of the disease, showed that the growth was inflammatory tissue into which hemorrhage had taken place with the deposit of blood pig- ment. Histologically, this case was very difficult to distinguish from & true melanotic tumor, and was watched with a certain amount of suspicion for some montlis. ProgTiGsis. — Tlie prognosis is bad. Bloodgood-- states that he lias tht' ]\'eord of but one case that has survived — a case of Dr. Wain- "wright, of Scranton, who is alive seventeen years aftei- operation. The histological picture was such that the true melanotic nature of the tumor could not be doubted. Pringle-' has reported two cures, which Bloodgood-* does not accept. As a general rule, patients die inside of two years, but in a few instances life is prolonged well beyond that time. It is possible that in some few instances life might be saved by a very extensive early oiieration. an operation in- cluding the glands. Treatment. — Pi-evention is much better than cure. Every ac- quired mole should be removed, preferably with either the knife or actual cautery, so as not to irritate the nests of nevoid cells. Every congenital mole that is subjected to irritation should be removed. Whenever a mole begins to gi'ow, or to show any evidences of either irritation or ulceration, it is an imperative sign for immediate oper- ative interference, although this will often be too late. When skin or internal metastases have numifested themselves, treatment is use- less; neither Coley's serum, x-ray, nor radium Avill have the slightest influence. In the cases where the involvement is glandular only, either extensive block dissection of the glandulai- vessels and glands, or. if the growth be upon a limb, aini)utation might cure. == Bloodgood: Progressive Medicine. Dec, l!tl2. " Pringle: Edinburgh Med. Jour., June, 1008. =' Bloodgood: Progressive Med., Dec., 1909. CIIAPTEU X. CARCINOMA EN CUIRASSE— CARCINOMA BY EXTENSION— METASTATIC^ CARCINOMA— FACET'S DISIOASH. CARCINOMA EN CUIRASSE. Pollitzer^ has recently written an excellent article on carcinoma of this type, and the author has drawn freely from it. Just as in many other cancerous conditions, there are many de- grees of involvement, and the author can see no reason for not call- ing even minor involvement of the lymphatics of the skin, causing induration, by the name of cancer' en cuirasse, although many will not accept this view. Clinical Course. — This type of cancer Avas first described by Vel- peau about seventy-five years ago, and fully developed instances are very rare. The trouble probably always begins in the glands of the breast, notwithstanding the statements of Rodman and Besnier to the contrary. In a typical case Ave find a breast cancer, with re- traction of the nipple, and possibly all of the other signs of a typical mammary carcinoma, although the skin of the gland may be so in- durated that it is impossible to palpate the primary tumor. Begin- ning in the breast, and extending from it over the chest and back, to a greater or less extent the skin is reddened, very hard and firm to the touch and feeling like a sclerodermatous cutis (Fig. 51). There may or may not be very numerous small angular or round papules present, but there are usually a few. These papules may resemble the lesions of lichen planus to a marked extent. Pollitzer says that in his case the appearance Avas that of a lichen planus developing upon a sclerodermatous area. The glands may or may not be involved, and the disease usually runs a comparatiA-ely sIoav course, about that of a slow-growing scirrhous carcinoma. OAviug to the obstruction of the lymphatics, the arm may become markedly edematous. At times there is A-ery intense itching over the diseased area, and movement is usually greatly limited and at times painful. Pathology.— The pathology of the condition is comparatively sim- ple. Instead of passing through the lymph vessels, the cancer cells have groAA-n into them in long, finger-like projections, almost com- 1 Pollitzer: Jour. Cutan. Dis., 1909. xxvii. 143. 119 no SKIN CANCER. pletcly filling the luiuens. Very little of the eaneeroiis tissue is found outside of the lynii)haties. There is very little inilanunntory reaction in the cutis; the blood vessels. p:l!^»ds and connective tis- / .< »-..!?r\3 Fig. 51. — Carcii oiiia on cuira.- (Suttoii'.'^ coUfotion.) sue are unehaufjed. The lichenoid papules are due to a hypcracan- thosis over three or four of the papilla*, and not to the deposit of cancerous cells in the more superficial portions of the skin. The erythema is probably due to the effect of the toxins upon the vaso- motors in a region in which the flow of lymph is obstructed. Cer- (jAii(MN()MA in' i;x'ri;.\si()X. 121 tain of the nodules lluii <';iii (H'c;isi(iii;ill\ !)'• fdf (lcc[icr in Iho skiji arc duo to accuinuhillons ;iimI i^i'owIIi of cimicci' fdls llinl, havo ch- capcd from tli(! I,yiii|)li;i1 ics ;iiiil st;ir1ermanent cure are very slim, although x-ray treatment has appaixiit!\- rtiictl a few, and radium promises something. METASTATIC CARCINOMATA. Clinical Course. ^It is rare to iiud cancer of any of the organs metastasizing to the .skin, but this does occasionally happen. Kauf- mann-Wolf- has recently Avrittcn a very complete article on the sub- ject, and has collected all of the pul)lished eases, sixty-fi\e in num- ber. It is to this article that the author owes tlie following state- ments. The condition is very rare. Rieclielniann.'' in autopsies upon 711 carcinomatous subjects, did not once encounter this condition, Buday* found it three times in 366 cases, while Krasting' mentions .seven in- stances of cutaneous metastases in 1,078 carcinoma cases, four of these, however, being associated with mammary cancer. Out of the sixty-five cases that Kaufnumn-AVolf has collected, twenty-three followed cancer of the stomach ; three cancer of the liver; two, cancer of the pancreas; ten, cancer of the uterus; one, cancer of the ovary; six, cancer of the lung; two, cancer of the mediastinum; two, cancer of the esophagus, w^hile the remainder sprang from various other organs. Twenty-three of the patients were men; thirty-three were women, while in the other instances the sex was not stated. Many of the patients were extremely old, but some were comparatively young, so it is improba])lc that age is a factor. In onlv one or two instances was there a .solitary metastasis to the = Kaufmann-Wolf : Arch. f. Dermat. u. Syphil.. 1013, cxiv, 709. ' Riechelmann: Berl. klin. AVchn.schr., 1902, 728, 758. * Buday: Zeitschr. f. Kreb.';for.schung, vi, 26. "Krasting: Zeitschr. f. Krebsforschung. iv. 3.36. 1'Agi:t'w diskas'k. 123 skin; in the majority of instaiiwK tlif coiKlilioii was sirni)ly asHOoi- ated with a general carcinoinatoHis. In IIk; skin there are tlirce forms of tumors — solitary nodules, y'l-oups of nodnlfs, ;inr| ;i fl;if. infiltra- ing form of neoplasm. Tlu; tumors are i-ather pi-one to early ul- ceration, except in tliose cases where the })atholot,'y shfjwed Ihe eon- dition to be one of lymphatic infarction. In some of the instances the ]);itirii1 died very sooji jif'lcr the ap- pearance of the cutaneous manifesiaiiu)is, but the averaj,fe dui-ation of life after cutaneous metastases had taken place was about six months. One patient lived for one and a half years. As accompaniments or prodromal symptoms there were found edema, herpes zoster-like vesicles, erysipeloid erythema, lichenoid conditions, and urticarial phenomena. With lymphatic infarction the edema was rather constant. Itchinj^ was often complained of. Pathology. — The type of cancer found in the skin depends on the nature of the primaiy growth. Treatment. — Treatment consists in keeping the patient comfort- able. PAGET 'S DISEASE. This condition was first described by Paget'^' in 1874, and since that time has been the subject of much study. Especially has it been debated whether the cutaneous changes antedated or followed the development of a cancerous change, and even yet this question is not absolutely settled. Clinical Course. — Paget 's disease usually begins as a peculiar raw, granulating, weeping eczematous patch around the nipple of a woman past middle life. Later the breast is noted to be the seat of cancer, and there is the same fatal termination so common in other instances of this malady. The disease is, however, subject to many variations. In some in- stances, from a clinical standpoint, the cutaneous lesion is, very clearly, simply an example of a chronic, weeping eczema. In other instances the cancerous change undoubtedly antedates the skin changes. Hartzell" has collected nineteen illustrations of the occur- rence of Paget 's disease on other portions of the body than the breast. These extramammary cases are most common upon the penis, but, as Hartzell well shows, may develop upon almost any other portion of the body. In the discussion of Hartzell 's paper it was generally agreed that it is not at all unusual to find these extra- « Paget: St. Bartholemew's Hosp. Rep., 1874. v, 87. ■Hartzell: Jour. Cutan. Dis.. 1910, xxviii, 379. rj4 8K1X I'ANCr.R. manunary eases, and nearly every cleriuatolotrisl of wide ex])erienee has seen one or more. In the breast cases the dermatitis may exist for as nuu-h as eijjht or ten years before the cancer is clinically demonstrable, and. inas- mnch as cancer of the breast, when nntreated. almost invariably runs a nu»re rapid course than that, it is ])r()baltlc that the der- matitis is the original lesion, and is not secondary to the neoplasm, as Jacobeus"' ami others believe. The cancer does not, by any man- ner of means, always develop directly from the diseased skin, al- though it not infrecjucntly does so. l)ut in many instances it arises Fig. 53. — Hi-stology of Paget's di.sease. (Author'.s collection.) at a distant point, and from the glandular ci)ithclium and not from the cutaneous cells. In the extramammary cases the cancer develops from the skin cells, and usually in from two to three years after the dermatitis has manifested itself. It then runs the course of the more malignant prickle-celled neoplasms, not forming the typical rodent ulcers. Pathology. — Pathologically, the condition is extremely interest- ing, owing to the presence of the curious Paget's cells, about which there has been much discussion (Fig. 53). It has been thought by some that they were simply modified epithelial cells, by Jacobeus ^Jacobeu.": Arch. f. path. Anat. (Virchow's), cLxxviii. l'A(ii:'l''s DISICASK. 125 and others tliut they wei'e i)i i'(!;ility eaiieer ccWh ^rowinf^ iif) lowjuvl the skin from a decip-seated eareinoiiia,, atnl hy I);u-icr,'' Wickfiam,'" and othei'S to \h'. |»;ii';isilcs, llie soc;illc(| |»s(»ios[)(riii.s. I'ractJcally all patholo^'ists have now eoiicech'd 1li;il, IIk; (ii'st view was eorreet, and tluit tliey are simply modilied and (Jej^enerated j)i'if',kle eells, dc- riv(Ml from tiu! epidcnnis. Tli(5 inti'apapillaiw processes are much loiif^er 1lian nsiial, and are rounded rather than ])oiiited. The cells are often widely sepai-atcd, due to the presence of intraeellnlar edema, and have lost their l)ricklcs. Some of the cells are as much as 30 microns in diameter, and usually contain a very large nucleus, lying in a vesicle. Other cells show similar, but not so marked, changes, which have been very well described by Unna.^^ There is a very considerable cellu- lar infiltration, both of the rete and the adjacent portion of the cor- ium. These changes are true, not only of the typical breast changes, but of the cutaneous cases as well. Should the disease be regarded as a true pi-ecancerous condition, or as a disease sui generis, as maintained by Unna? In the extra- mammary cases it is probably an example of a true precancerous dermatosis, but, inasmuch as in the breast cases the cancer may de- velop at a distant site, it can hardly be assumed as a pathological precancerous change, but simply as a clinical entity that definitely warns that a deep cancer may follow. As a general rule, precan- cerous changes are dry and hard, and not moist and weeping as in Paget 's disease. Prophylaxis and. Treatment. — At any rate, there is one very im- ])ortant lesson to be learned, a lesson that has as yet not been suffi- ciently emphasized. Any patient with an intractable eczema of the nipple region should invariably have a biopsy performed, and. if the sections show the changes characteristic of Paget 's disease, that breast should be removed without any delay, for it will inevitably become cancerous. AVhether the glands should be removed depends probably on the stage at which the operation is performed. If there is the slightest clinical evidence of cancer, a complete operation must be done, but, if clinical examination and the careful examination of the breast when it has been excised show no naked eye appearances of cancer, then the simple removal of the breast will suffice. How- ever in all instances a microscopical examination of the removed tissue should be made. The cutaneous cases should be treated in the same way. If they » Darier: Soc. de Biologie, April 13. ISSn. ^"Wickham: iSIaladie de la peaii dite maladie de Paget. Paris, 1890. "Unna: Histopathology of the Diseases of the Skin. 12G SKIN CANCKK. are examples of extrainaniinary Pa-rt't 's. Iliey sluuilil lie cxcisotl with a fjoodly margin. Onec caneer has develoiieil. the prognosis is ii;ituiall.\ unfavorable. as only a very extensive oi>oi'ation Wdiild ^ivc tlu' paliciit a (light- ing ehanee for life. CIIAPTKR XT. ENDOTIIELIOMATA. Anionjjs' patholo^isls tliccc is slill miicli cont'iisioii \-f<^;wi\\u<^ llif; status of endotheliomas, and what Iiiiihus sImhiM he called by this name. In a recent ai-ticle Fick^ contends that the patholof^ical en- tity known as endothelioma never has and never can exist, and that the so-called endothelial cells are in reality cpiHiclijil in oi-ij^in, ]>er- haps derived from some of the fi^landnlar (sleinents. On the other hand, Zeit,- in an excellent article, maintains that many of the so- called alveolar sarcomata and carcinomata arc undoubtedly examples of endotheliomata. This confusion is undoubtedly due to the vari- ability of the cells. Zeit remarks: ''Morphologically, an endotheli- oma may resemble typical (adenoma) or atypical (carcinoma) or- ganoid structures, or t3^pical (fibroma) or atypical (sarcoma) histoid growths. It is extremely confusing for the student who has learned how to diagnose common atypical histoid growths, as sarcomata and atypical organoid tumors as carcinomata or endotheliomata, to read of the diagnosis of an at^^pical organoid tumor by Billroth as alveo- lar sarcoma; by Rindfleisch as sarcoma endotheliale ; by AValdeyer and Kolaczek as angiosarcoma ; by Fischer and Cramer as endothelial sarcoma." And the author much fears that it is not alone the stu- dent who is confused, but even some of these A-ery writers them- selves. Zeit goes on to say that a correct clinical diagnosis is of the great- est importance to the surgeon because endothelial tumors grow very much more slowdy than sarcomata, and do not produce metastases until they have existed for some years. At the same time, they are very prone to recur after operative removal. The following scheme of classification is usually adopted: 1. Lymphangioendothelioma. 2. Hemangioendothelioma. 3. Perithelioma. The perithelial tumors originate from the endothelium lining the perivascular lymph spaces, and hence there is some discussion as to iFick: Dermat. Wchnschr., 1012, liv, 4SS. = Zeit: Jour. Amer. Med. Assn., 1P06, xlvi, £67. 127 128 SKIN CANri'.R. wlu'ther thoy should be calkHl lK'iuaiijj:ii)eiulothelioiiias or lymjilian- }j:iiH'iuk)tholit)iniis. ai'i'ordin«r tn some authors.-' On the other hand, Zcit ein]>hatieally says: "The ])ei'ithelial inemln-aiie nuist be dif- ferentiated from tlie jierivaseuhir lyniidi spaees of His, whieh he found surroundinaces. 2. "Endothelial cells produce inti'accllular cement substance and are closely packed together, whereas the epithelial cells in carcinoma have no intercellular substance and form no compact layers. 3. "In endothelioma delicate fibrillar processes extend from the walls of the alveoli into the proliferated cell masses. They are ab- sent in carcinoma. 4. "In endothelioma the cell masses consi.st of a dense mosaic of many layers of cells, witk small skarply-outlined nuclei, sur- rounded by a broad envelope of clear, glassy perinuclear protoplasm. Carcinoma cells have large vesicular nuclei, witk a moderate amount of perinuclear ])rotoplasm, more or less granular. 5. "In endothelial tumors the cells are arranged in the form of cellular cords and cylinders (round masses in carcinoma), and may separate out hyaline material (cylindroma) or form lumina-likc masses (sieve-like) in the cellular cords, due to secretory processes of endotkelial cells. 6. "To distinguisk tkc endothelial tumors from sarcomata, it is to be remembei'cd that the former have an organoid, the latter a hi.s- *Adami: Principles of PathDlog.v. i. 758. * Bramlei.s and Pouget: Ann. de Derniat. ct de Syphil., 1910, 5th .ser., i, 506. KNDO'I'HIJJOMA'I'A. 129 toid, structure. Accordinf^ U) lliis <\ci\\\\\'\MN r\Mi:i{. NEUROMA. According to lleicliiigsfeld,^ very few cases of neuroma cutis liave been described. In the cases reported by this autlior and in others which he luis .}]:athered from the literature, tiie tumors were usually solitary, hut were I'arely multiple, and ai)peai'cd clinically as sub- cutaiu'ous nodules tliat could readily he mistaken for either fibromas or myomas. Pivssure upon these fjrowtlis. however, usually jiave rise to laiiciuat iiiLi' pains. 1 1 i.sloloLiically, cxamiiial itui I'cvcaled the presence of nerve tissue, sometimes associated with either muscle or endothelial tissue. Surgical intei'vention was curative. MYOMA. This rare tumor of the skin has Ijeen carefully studied l)y ITeid- ingsfeld.'' The growths ma>' take their origin from the nniscle nor- mally present in the walls of the vessels, in the arrector ])ili mu.scles, or in the musculai- attachments to the glands. Clinically, they are subcutaneous single or multiple tunuirs that are apt to be painful upon pressure. In some instances they are associated with cavern- ous dilatation of the blood vessels. They can be diagnosed with cer- tainty only by microscopical examination. Surgical intervention is curative. LIPOMA. Lipomas or fatty tumors arc probably the commonest benign tu- mors that are encountered in surgical dispensaries. They some- times develop in children, but much more commonly in adults. The solitary forms are much commoner than the multiple or diffuse. They may be found upon any portion of the body. They vary great- ly in size, from being almost microscopic to a weight of several pounds. They have their origin in the subcutaneous fatty tissue. There are several types — the solitary, the multijile, and the diffuse. The latter condition is often spoken of as "fatty neck." Lipomas do not become malignant, and are not dangerous in any sense. i)ut are rather unsightly. They may be easily removed ])y sui-gical in- terference, and do not recur if completely removed. OSTEOMA. True bony tumors of the skin must be differentiated from cal- careous deposits which are the result of chronic inflammatory proc- = Heiding.>- instance a fun- gous tumor develops, usually very rapidly. Clinical Course. — Clinically, there are two tyi)es of tunu)i- — (1) where a nodule ai)]iarently begins in the normal skin, and (2) where a nevus Ijreaks down. In the first type it is noted that a pale-red. rather vascular, nodule begins to ])rotrude from the skin, and that it bleeds very easily on injury. The lesion is usually round at the start, and may project above the skin, or may be be- neath it, according to the dei)th of the tissue from \\hich it sprang. Ulceration usually takes place, in the center of the growth at least. In the deep type there is considerable induration, but not of the stony character so typical of carcinonuita. Crowth nuiy be slow or very rapid, and metastasis to the glands often takes place within a few weeks after the first appearance of Ihe tumor is noted. It is not infi-eriuent to find a few metastases in the neighboring skin. Pathology. — Pathologically, the cells are either small oi' laige round cells (Fig. 55) that may or may not be divided into islands by fibrous tissue. ^Mitotic figui-cs are very common. Usually there is but little inflammatory exudate around the edges of the invad- ing gi'owth. Unna- has some very interesting ideas as to the origin of the sai-coma cells. He holds that the degeneration begins in the healthy tissue with a swelling of the spindle cells; these cells soon 'Bloodgood: Progressive Medicine, Dec, 1912. = Unna: Histopathology of Diseases of the Sliin. SARCOMATA. 139 withdj'aw thcii; proccsscis, hfi^oiiK; round (ti- (■\{\)]c;i\. ;iti(| often forin true ])];i.sina onlls. 3^^'oni 1li(;iii, iic.ar Ihf. Mi;ir<^in f)i' the mow j^rowlh, the ti'iio sai'C'onia ocIIh develop. 'JMiiis the fthiHina eells are a sta»^e ill tlie (h'velopnicnt ol' round-celled s;ireoin.a, frotn s[)in(|lcd-oelled niesoblastie structures. Diagnosis. — ^The sarcomata oI tiiis type must be distinj^uislied fj'oni cndotheliomata, granuloma pyogenicum, and various adenomata of the skin structures. In case of doubt the new gr-ovvth should be removed by a broad excision, and submitted to histological examina- tion. Usually, however, diagnosis is not difficult, for in sarcoma the growth is more rapid, and there may be early ulceration of the skin. The sarconuita, originating from nevi, resemble the group fir.st Fig. 55. — High-power ijhotomicrograph ui small round-celled sarcoma of skin. (Author's collection.) described, except in their origin and early appearance. At first it is noticed that the nevus is enlarging, and ulceration speedily takes place. Then a fungous tumor usually protrudes from the area of ulceration, and the further course is as already described. Prognosis and Treatment. — The prognosis is bad. Bloodgood states that only one of his six cases was cured by operation. Opera- tion should consist of Avide local excision, and removal of the neigh- boring glands at the same time, using a block operation, so that all tissue is taken out in one place. Spindle-Celled. — The spindle-celled sarcomata are much com- moner than are the round-celled neoplasms for the reason that mesoblastic tissue is normally composed of spindle cells. Different 140 SKIN CANCER. grades of malignancy exist, according to Mhethcr the tumor con- sists of fibro-spindle colls, or of the jnire oat-shaped or spindle cells. Incidence.— This group of tumors frequently arises from the scars of old wounds or burns, especially those that have healed slowly. Bloodgood states that he has never seen a nudignant neoplasm aris- ing from a wound that has healed by first intention. These tumors sometimes arise from preexisting fibromata. Clinical Course. — The tumors appear as firm "white or pinkish growths, lliat usually grow rather rapidly. There is usually con- siderable dilatation of the surface blood vessels, and idceration takes place early. The neighboring glands usually become involved with- in one year. At times, when a glandular enlargement is found, this is not due to metastases of the sarcoma cells, but to inflanmia- tion. Pathology. — Pathologically, the cells consist of various types of spindle colls. In some cases these approach fibrous tissue in char- acter, and in other cases are short and oat-shaped ; the latter are much more malignant. These cells are arranged in bundles that in- tersect the growth at all angles, and forming a sort of frame around the blood vessels, which are dilated. Some blood pigment may be deposited in the tissue, chiefly around the vessels. Mitotic figures are rarely seen. A few plasma cells are usually found scattered among the spindle cells, chiefly near the edge of the growth. The elastic tissue is lost at once and the normal lymphatics are obliterated. There is no inflammatory reaction as occurs in carcinoma. Certain of these tumors undoubtedly have their origin in the blood ves- sels, and hence deserve to be called angiosarcomata, but all tumors of this class do not arise in this way. For a fuller discussion of the pathology of these neoplasms the reader is referred to the work of Unna, which is very complete, and gives an excellent bibliog- raphy. Diagnosis. — This group of tumors is easy to diagnose, largcl.v because of the early ulceration. Prognosis. — The prognosis is much better than in the other va- riety of sarcomas, although by no means as good as might be de- sired. Bloodgood states that in nineteen cases six have remained well after operation, although most of these were fairly well ad- vanced cases. If the cases can be operated upon early, at least 50 percent should be saved. Treatment. — If seen early, a broad local excision, probably -with removal of the neighboring glands, should 1)0 the method employed. SAKCOMA'IA. 141 Neither radium, the x-j-ay, Jior any of the ffiii.slifs slioul'l he used, except ill. inoperable neoplasioH. Giant-Celled. — Giant-eelled sareonuis of the skin are extremely rare, although a few instances have been recorded. Unna reports a case where there was a small, bluish-red, angioma- like tumor of the face. Unna says: "The whole cutis was ti-aris- formcd into a tumor mass, witli niimerous cells and very little inter- cellular substance, over which tlie ('i)idei-niis was here and there thijincd, and in one place ulcei'ated. ... It was evident that the tumor cells developed from spindle cells, Avhich, by taking up protoplasm, at first around the nucleus, enlarged, and then assumed all ])ossible forms and dimensions. The cells are so multiform that it is hardly possible to describe them. . . . Almost all of them contain several nuclei. They passed very gradually into giant cells, with which every section swarmed." Pasini^ has recently reported a case of giant-celled sarcoma of the skin, and both Crocker* and Perrin and Leredde' have reported instances of sarcomatosis of the cutis from giant-celled neoxdasms. These last reports seem rather singular, for a priori one would hardly suspect that a growth showing the characteristics of a giant-celled sar- coma would be so malignant. In other regions they certainly are not. Treatment. — The treatment should consist of ample local excision, and not of caustics or x-rays, except perhaps as an adjunct to the knife. As regards the local treatment of extensive or inoperable sarco- mata, but little can be said. Wickham has had some really remark- able results with radium. Those who have seen the photogi'aphs that he exhibited at the International Dermatological Congress held at Eome in 1912 were wonderfully impressed wdth his success. A few good results from the x-ray have been reported, but they have not been constant. So far as general treatment goes, (.^ley's*^ serum should be tried, although Coley has had rather better results than others who have used the preparation. Coley 's serum consists of a vaccine made from the streptococcus of erysipelas and the bacillus prodigiosus. The rationale of the treatment is as follows : Some 3'ears ago it was noted that when a patient suffering from sarcoma w^as attacked by erysipelas, the result upon the neoplasm Avas most beneficial ; this led some clinicians to inoculate their hopeless sar- spasini: Gior. Ital. d. Mai. Yen. e. d. Pel., 1912, liii, 353. * Crocker: Diseases of the Skin. = Perrin et Leredde: Ann. de Dermat. et de Syphil., 1895, vi. 103S. « Coley: Amer. Jour. Med. Sc, 1893, cv, 4S7; 1906, cxxxi, 375. 142 SKIN CANCER. coma patients with erysipelas, but tlic results of the infeotion were fre(iuently so disastrous that Coley detei-mined to try vaecines, and in some instances his results were excellent. Coley himself does not advise the use of the serum upon operable cases. Fig. 56. — Multiple sarcomata. (C. J. White's collection.) MULTIPLE LESIONS. Round-Celled. — Sarconiatosis of the skin, except with melanotic growths, is very unusual. When this condition does occur, it is SARCOMATA. 143 UHUally with the; smnll roiind <'i'llcure sarcoma of a special type, the latter view predominating. Treatment. — Treatment is not satisfactory. According to Kob- ner,^^ Sherwell,^* and De Amicis, arsenic will cure some cases if given in large amounts and over a considerable space of time, Fowler's so- lution being the form generally employed. Possibly cacodylate of soda, used intramuscularly, might produce a better effect, and yet one must be inclined to agree with Fox and AVile, who believe that arsenic cures only sarcoids and not true sarcomata. X-ray is use- ful in certain cases, though probably not for any great length of time. One observer has reported the disappearance of the lesions following the local application of bichloride solutions. TRANSITIONAL LESIONS. Spiegier-Fendt Type. — Tumoi-s of the variety descri])ed by Spieg- ler,^" j.\.ji,]l !■■ l>()]laii(l,'' and others, and commonly called the Spieg- "Mariani: Arch. f. Dermat. u. Syphil., 1909, xcviii, 267. " Kobner: Berl. med. Wchnschr., 1883, No. 2. "Sherwell: Amer. Jour. Med. Sc, Oct., 1892. •- Spiegler: Arch. f. Dermat. u. Syphil., 1894, xxvii, 163. '■=Fendt: Arch. f. Dermat. u. .Syphil., 1900, liii, 213. 1" Polland: Arch. f. Dermat. u. Syphil., 1910, civ, 09; 1912, cxi, 69. SARCOMA 'I' A. 145 Icr-Fcndt 1\|m' of snrcoid, seem lo neeiipy ;iii i lit (■niierlijito position between tlie Kaposi ly|)e of iiiillli|ile s;ireoiii;i jiinl 1 he eoinfirirativcly hfiTtnless s;ii'e(»i(ls. Ill lliis ^Toilp of lesidiis ;ire |Hir|ilisli Vi'd liiinors, ii.sii;ill\- Iviiij? Fig. 57. — Multiple hemorrhagic sarcoma (Kaposi). (HeidingsfelcVs collection.) 14G SKIX CANCF.R. deep in the cutis, essentially chronic in course, showinfr no ulcera- tion, and almost invarialily ^i^nng no metastases, although Spiegler has reported one fatal ease. Histologically, there are more or less circiunscribed areas of small round-colled infiltration. These ag- gregations may be inclo.sed in a connective tissue caiisule. At times a few giant or eiiithclial cells may occur. Fox and AVile'^ very per- tinently remark: "It is highly probable that many, if not all. of the so-called cured cases of sarcomatosis cutis belong to this group, which is really distinguished from true sarcomatosis cutis by the extreme malignancy of the latter and its tendency to invade the inner organs." SARCOIDS. The i-ather lengthy ai-tidos by Fano'"' and Darior-° are extremely helpful in dealing with the problem of the border line conditions be- tween the sarcomata and sarcoids. Boeck Type. — The Boeck^^ type of sarcoid is probably the best known and the most often diagnosed. It may occur as one or more large nodules, as numerous papules, or in infiltrated placques, us- ually developing upon the face, back, shoulders, or arms. There are practically no subjective symptoms, and the general health is un- affected. The nodules are pink or purplish in color, and often show- dilated peripheral vessels, and there may be slight scaling. To the touch they are firm and elastic, but there is no deep infiltration. The lesions run a chronic course and never ulcerate. They may in- volute spontaneously. Histologically, the sections show sharply circumscribed, deep- seated nodules, composed of epithelioid cells, filling the perivascular lymph spaces. At the periphery one may observe lymphocytes and a few giant and plasma cells. There is no evidence of caseation ne- crosis, although Boeck considered the lesions to be tuberculous in origin. T1i(^ lesions iiivoluto nnd(M" proloimod administration of arsenic. Subcutaneous Type of Darier and Roussy. — The type of sarcoids described by Darier and Eoussy-- is rare and occurs only upon the trunk. There are found lesions of about 1 to 5 cm. in diameter, distinctly round or oval. The nodules are composed of epithelioid "Fox and Wile: Jour. Cut. Dis., 1911. xxix, 375. "Fano: Arch. f. Dermat. u. Syphil.. 1007, Ixxxiii, 33, 225, 427. '•Darie:-: Monat.sh. f. prakt. Dermat., 1910, 1, 419. « Boeck: Jour. Cutan. and Gen.-Urin. Dis., 1899, xvii. 543. Arch. f. Dermat. u. Syphil., 1905, Ixxiii, 71. "Darier et Rous.sy: Ann. de Dermat. et .Syphil., 1904, v. 144, 341 SARCOIDS. 147 cells and I yinpliocylcs and numerous jjiaiil '•(■lis. TIk; chanji^eM arc less circiiniscrihcd than in 1 he liocck- lypc, anri ;it linif-s Sf;f;m to be disliiK'tly infiltrating. Nodular Type on Extremities. Tlic last type, suggested by Darici-, i-csoinblcK the erythema indiiraluni of Bazin ; in fact, the following name has been su<,'f,'ested, "sai-eoides noin-uses et nodul- aires des membrcs." The lesions usually develop upon 1he le^s of adult women, and present reddish or i)ni'plish nodules or iiiflltra- tions. It is very diffieult to separate this ^ronp from true cases of erythema induratum, especially as this 1yp(' ol' sarcoids may occa- sionally ulcerate. Darier especially i)oiuts out that all cases of sarcoids do not run true to form, and that one case may show featui"es of several of these groui)s, either clinically or histologically. Etiology. — \n regard to etiology, there are two views — one that the affection is of tuberculous origin, and the other that it is not. In favor of the tuberculous etiology may be cited the microscopic findings, the epithelioid and giant cells, although the author by no means admits that the presence of giant cells makes a diagnosis of tuberculosis certain, for they can be found in almost any chronic infiannnatory condition of the skin, even down to acne vulgaris. Winckler,-'^ in an analysis of seventeen cases, found evidence of tu- berculous deposits in the body in six cases, and that about ten cases out of thirty-one reacted positively to tuberculin, a figure not much more than the general average of supposedly healthy persons. A positive inoculation experiment has been recorded by Morawitz.-* On the other hand, Kren and Weidenfeld" made inoculation experi- ments in two cases with negative results. Histologically and clin- ically, there is no evidence of caseation or necrosis, which fact is very unlike those usually observed in tuberculosis of the skin. Ar- senic will cure sarcoids and will not cure tuberculosis. Diagnosis. — From the standpoint of differential diagnosis, it is at times extremely difficult to exclude sarcomatosis cutis, only the course of the disease serving to do that. Leukemia cutis, leprosy, and syphilis can be differentiated by the various laboratory tests in case of doubt. Prognosis and Treatment. — The prognosis for both life and the local betterment is good. Arsenic has a remarkable effect, although it must frequently be used over a long space of time. Darier thinks that the x-rav, calomel, and tuberculin are also useful. =' Winkler: Arch. f. Dermat. ii. Syphil.. Ixxvii, 3. '* Morawitz: Arch. f. Dermat. u. Syphil., 1910. cii, 121. "•^ Kren and Weidenfeld: Arch. f. Dermat. u. Sj-phil., 1909. xclx, 79. CllAI'TKK XI\'. L^■.MI'1I('.M.\'I^\. The suhjoct of lyinplidid and mxcltiid Itiiiidrs has loiiti- confused not only clernuit()loatlu)l()^ists as well. It seems to the autlior. liowever, that eertain bi-oad juinciples aiv now clear, and that all that is needed is to study the details. Adanii's^ classification of the lynii)hoid and myeloid diseases is ])ossil>ly the most satisfactory one, inasmuch as it is the simplest and most com- prehensive, although he does not follow Tiirck- in dividin": lympho- matoses into leukemic and aleukemic, and pointing out that cer- tain of the former tyi>e should become convei-ted into the latter variety, which should always be Ixn-ne in mind. The followin<; grou]i of diseases is associated \\ith cutaneous tu- mors : Myelomata. ^lultiple myelomata. ^Myeloid leukemia. Chloroma. Lymphomata. Hodgkin's disease. Lymjdiatic leukemia. In addition to these jjeneral diseases, lymjihomatous processes may be at first localized in the skin and only later involve the other blood- producing organs. The primary lymphatic diseases involving the cutis are simple lymphomata, mycosis fungoides, and lymphodermia perniciosa. The general field has been reviewed by the author-' in two recent articles, one in association with Strobel,^ in which there is a full discussion of the problems here encountered as well as a complete bil)liography. Multiple Myelomata. — Two cases of multiple myelomata showed cutaneous manifestations. The ]iatient of Spiethoff's showed only an erythrodermia, but Bloch's'' case had definite tumors of 5 cm. size. 'Adami: Principles of Patholog.v, i. = Tiirck: Wien. klin. Wchnschr., 1903. x\ i, 1073. 'Hazen: Jour. Cutan. Dis., 1911. xxix, 521. < Strobel and Hazen: Jour. Cutan. Di.s., 1011. xxix, 117. J'Bloch: Arch. f. Derniat. u. Sypliil.. lOlO. xcix, 9. 148 I>^■\ll'll().\I.\•|■\. 149 Myeloid Leukemia. Oiil\ tlncc ciscs ol' myeloid (sploiioinyolot?- cnoiisj lciil<('iiii;i sliowffi liiiiiurs, ;ill lii)iiHervation fi woiiiJiii ;i^C(l 10 willi ;i w ell (|i\clo|)((| myeloid l(;ill)-am\vell, Ilitsch- mann, Paltauf,' and djicohjieiis. The nodules were usually of small size, and freely movabh' ui)ou the underlying tissues. The most characteristic thing was the greenish color. Hodgkin's Disease. — Hodgkin's disease still remains a fertile field for contention. After Reed's'* work appeai-ed it was thought for a time that this nudady was definitely established, and that it was characterized by a veiy definite histological picture. Cases have, however, been reported where a perfectly typical case of this trouble has developed into an equally typical leukemia, and AVarthin'-' has shown that certain cases have the pathology of simple iymphomata, and not of the type described by Reed. In this disease the com- monest skin manifestations are either bronzing or pruritus, but def- inite nodules or tumors may develop. Lymphatic Leukemia. — Lymphatic leukemia is fairly sharply di- vided into the acute and chronic forms, although thei-e are. of course, transitional stages between these two varieties. The patients suffering from acute leukemia frequently showed purpuric conditions of the cutis, a number of other cases showed either vesicles or urticaria, but seven cases showed either nodules or small tumors. These cases are described in the author's article as well as in the more recent one of Nanta." Patients suffering from the chronic form of lymphatic leukemia not infrequently show papules or vesicles upon the skin, but nine cases have shown either tubercular eruptions or fairly large tu- mors. As a rule, these lesions did not ulcerate, but one or two have done so. Thick subcutaneous infiltrations were not uncommon: these " RoUeston and Fox: Brit. Jour. Dermat., 1909, xxi, 377. " Paltauf: Mracek's Handbuch der Hautkrankheiten, Wien., 1909, v. sReed: .Tohns Hopkins Hospital Reports, 1902, x. 9\Varthin: Osier's Modern Medicine. Phila.. 1908. iv. 808. ^"Nanta: Ann. de Dermat. et de Syphil., 1912. iii, 572, 639, 694. 150 SKIX CANCKR. occurred usually u^on the face, and often iiiphodci'mia pei'- niciosa. Also, it should be remarked that the same remedies have a l)eneHcial effect here as in the otlier mend)ers of the frrouji — name- ly x-ray and arsenic — and also inteicunciit in feet ions, esjiecially ery- siju'las. They, therefore, feel that mycosis fnui^oidcs is ;i member of the j^rouj) of tliseases usually called lymphomatous. inid that, in the sense of Tiirck. it is an aleukemic l\iiiphomatosis, that may. how- ever, beconu^ leukemic. Diagnosis. — In this entire disease in any ol: the iiilcrnal oi-^aiis. I lislolo^ical examination of the lesions showed a Jiodule, well walled in and not invadinj^ the epidei'mis, llie cells lieinj^' of a small, round elm ivicter, greatly rc- seuil)]in^' those of a small round-celled sai'coma, or of a lympliosar- coiua; they were, however, later decided to he lyfdcal jymphfjid cells. Some of the f^rowths involuted under Ihc adminisi I'ation of arsenic. Newbcrfi^er reported a somewhat similar case in. 1802, Avhei'C there were likewise small, hai'd groAvths in the coriiim, without any other symptoms. Ill addition to the articles mentioned a1)ove, Arndt's'' sliouM be read by any one who is interested. « Arndt: Jour. Amer. Med. Assn., 1914, Ixiii, 1268. ('H.\rTi:ij x\'. i)iii'i:Ki:.\ri.\i. DiAdXOSiS. Ill (.lealinjr with cutaiu'ous iu'ui»lasins. there are two essentials — first, to deeide whether the new growth is an inflamniatory one or a true neoplasm, and, second, to decide whether, if it be a true tu- mor, if it be malignant or benign. If it be malignant, it is neces- sary to further decide whether it be a ])ri('kle-c('lU'(I tumor, or a basal-celled groAvth, or if it be a sarcoma. In order to decide this question accurately, it is often necessary to ai^proach the problem in three different ways — first, the clinical aspects of the new growth ; second, its gross pathology as seen by the naked eye; and third, its hi.stological .structure as seen by the microscope. The better the pathologist that the operator is the more frequently will he be able to make a diagnosis from the first two of these criteria, and hence the more promptly will the patient be dealt with and the necessity for second operations lessened. History.— The first point is to obtain a careful history from the l)atieut. The age must always be noted. It is rare for malignant epithelial tumors to arise before the age of thirty, except in the condition know^n as xeroderma pigmentosum. Nor does a mole often become malignant under the age of forty. Likewise sarcomata of the skin are not common in the young. The occupation of the jiatient must always be noted, for malig- nant tumors of the basal-celled variety not infrequently develop in those wlio have l)een much exposed to actinic rays, whether produced by the sun or by the riintgen tube. Those who are engaged in the manufacture of paraffin and tar arc especially liable to cutaneous cancer. Fui-thermore, it should be decided whether there was a precan- cerous dermatosis antedating the new growth. From the common senile warts we usually find a basal-celled carcinomata resulting; from an x-ray burn a prickle-celled neoplasm is much more likely to arise. If the growth be from a pigmented mole, we are usually dealing with either a nevocarcinoma or multiple melanomata, both very malignant. In the scars of old wounds prickle-celled growths or sarcomata may arise, while from vascular nevi we practically find only sarcomata. 154 DIKFKKIlNI'IAIi DIACiXOSIS. 155 The duration ol" syiiiploins Is lil<<'\visc of s|)ccl;il irrii-)ort, for the more malis'iifiiil, 1li<' tiiinor the more iMpIdly il <;r()\\s. A basal -cdlofl tumor may g'r()\v iiuirc iMpidly lli;iii ;i prieklc-collfd one, hut this is I'arc. With a deeply seated Jieophism il is always best to exclude syph- ilis, and, to deeide on this })oiiil, lln: y)atient's word should never be accepted, but tiie (liai?ii()sis coiiCinncd b\ 1he various laboratory tests, rememberjii<>' that botli the Wassei'inaiiii and luctin reactions may be negative in lonj^ standing cases of this malady, and hence not putting too iimch reliance in them. At times a superficial }^im- ma before idceration may almost exactly i-esemble a norlnlar- or rollcrl- edge rodent ulcer. The symptoms of onset must be noted, and what was the first, pain, itching, serous discharge denoting superficial ulceration, or the pres- ence of a nodule. It must always be remembered that pain is com- paratively I'are in skin tumors, whether malignant or benign. The later symptoms must be carefully asked for in order to de- termine as to the possibility of metastases. While cachexia is ex- tremely rare in skin cancers, yet metastases from them may cause these symptoms. In large ulcerating growths the a1)sorption of toxins from secondary bacterial infection may cause a picture of cachexia. The local signs and symptoms are much more important than the general ; we must always try to find out how rapidly the tumor grew when first observed, and how rapidly it has grown within the past few weeks. Examination. — In the examination of the growth, certain facts must be observed. First, we should note the relation of the tumor to the skin, for certain tumors arising from the appendages may not at first be adherent to the epidermis, while the basal- and prickle- celled growths almost invariably are attached to the skin from the incipiency. On inspection we must note the size of the growth — whether it is exuberant or Avhether it has formed a deep ulcer. The character of the surface must be observed, for prickle-celled neo- plasms usually have a very rough and irregular surface. The amount and character of the discharge is important, for absorption may cause many general symptoms. jMetastatic growth, either in the vi- cinity or in the glands, must be looked for. And especially impor- tant is the situation of the tumor, for growths on the face except the lips are usually comparatively benign, while those upon the ex- tremities are usually A^ery malignant. Likewise, if there be mul- tiple growths, they are probably of a basal-ceUed origin, if not ex- amples of multiple sarcomata. 156 SKIN OANCKK. On palpation the i-liarat'tor ul llu> induration is esitocially impor- tant, for the carcinoiiiata in\arial)l\' liavr an extroinoly hard cdfre. while in iiithmimatui-y lesions tliis is lackiiiir as a .ni'iieral rule. The (h'pth ot' the induration is liki-wisi' iini)oi-tant, for in the malitrnant •rrowths this it> usually eonsiderahh'. It must always be boi-ne in mind that there may hi' an inllannn;itoi'\" indui'ation that may sim- ulate a eaneerous one. The nei^hhorinj; ^dands shouhl always l)e ])ali>ated. aiiaiu rememherinir that an eidarjrement of them can de- note an inlhinniiatorx' condition. Gross Pathology.- After a tumor is excised, it sliiiuld be sec- tioned at once in order to determine its variety and the depth of its iniiltration. \n the s(iuamous-celled cancers the inliltration is com- paratively deep and wide. Tliese <::i-owths also sliow ;i chai-acteristic picture on section, for there can be observed fine uliite lines, about the size of fine sewin«? cotton, i-adiatin^ downward from them, a condition totally lacking in the inflammatory conditions, and usual- ly not marked in the ba.sal-celled gi-owths. wliere the cancerous al- veoli arc smaller. In obtaining material fen- microscopic study, ceiiain ]irecautions must always be observed. Among the majority of surgeons there is a strong feeling that it is freiiuently dangerous to excise a portion of a tumor for examination if that tumor be of a nudignant na- ture, for incision leaves a number of gaping l)lood vessels and lymi)hatics into which cancer cells might e.scai)e and thus cause metastases. At the same time, it is occasionally essential to examine such tissue, so the following scheme is usually adopted. If the tu- mor be upon the lip. (»!■ upon a part where it is })ossible to temporar- ily constrict the blood vessels by pressure, an assistant does this with his fingci"s, then a piece is excised under local anesthesia from the edge of the gi-owth. taking care to include a small portion of ap- parently normal skin, in order to determine th(> iidiltrative ]>owers of the cancer cells, and the wound is then thoroughly cauterized with either the actual cautery or a strong chemical one. In very eai'ly cases it is often im])ossit)l(^ to detei'iniiu^ from a clinical examination or from the naked eye ai)])earance of the tumor to what vai-iety it l)elongs, and then the whole growth may be re- moved and sections made from it. Microscopic Pathology. — The tissue can be presei-ved in any of tlic accei>ted lixing agents, although 7)0 ])ercent alcohol oi- ]0 per- cent formalin will usually suffice, and is then fixed. l)l()cked. cut. stained, and mounted in the usual manner. Probably, for routine examination, no stain is l)et1er than hematoxvlin and eosin. A com- I)II''|'i;k,i:\ti Ai- ui\(;s(y<\<. 157 potent Tni(M'()Sf()i)is1 cnii iisiuilly IImii di.ij^iiosc IIk; r-orulition wilhoiil trouble, fill lion j^li one should be sclictcil wlut knows tin; (Wfi'cvcwcc between tlic b;isiib ;im(1 prickle (M'llcd vni'idics. in fcrtain ^jrowths orif^'in;itin<4- from the {^'landiibir ;ipi)cnd;i;rvi\\ overj^rowl li of e[»itheli;d tissue Fig. 59. — In certain chronic infections of the skin, notably tuberculosis, of which this is an example, there is a marked hypertrophy of the epidermis, which may render it difficult to distinguish from cancer. Usually, however, the re- lationship between the basal- and spino-cells is not altered. (Author's collec- tion.) (Fig. 59), but this should not be mistaken for malignant hyper- trophy, for the papillary structure is better retained; the cells of the rete are normal in arrangement and in their relationship to one another, even though they be greatly increased in number. Xor is the basement membrane broken through. The microscopic differences between the scpiamous- and basal-celled types of cancer has already been fully discussed in the chapters dealing with those subjects. 158 SKIN CANCKR. In ireneral. it may be said that four classes of lesions nuist be differentiated from the various types of cutaneous cancer — first, those lesions causing nodules, as tlie benifzn tumors, cysts of various kinds. chancres, and fjummata; second, the ulceivitive variety of lesions, as luinis vuljjaris, sypliilis in the ])rimary or tertiary stage, tramnatie ulcers, and certain of the rare ^M-anuloinata. as sporotrichosis; third, the pajullary lesions, such as a more or less diffuse pai>illomatosis secondary to irritating disciiarges, exuberant granulation tissue, granulomata pyogenicum, tuberculosis verrucosis, blastomycosis, and very rarely framboesiform syphilis; fourth, lesions causing scarring, as lupus vulgaris, syjihilis. lui)us ci-Ntliematosis. and mor])hea. Fig. 60. — Chancre of the chin. (Gilchrist'.s collection.) 1. Nodular Lesions. — There are, of course, many varieties of solitaiy tumors of the skin; there are found fibroids, fatty tumors, lymphoid tumors, neoplasms originating from the l)lood or lymph vessels, endotheliomata, wens, dermoid tumors, sarcoids of various varieties, and a number of inflammatory conditions, of -which chancre and gummata are the more prominent. With the exception of the last two just named, the diagnosis is usually easy, for we find that nearly all of these growths present themselves as definitely encap- sulated, slowly growing tumors, that only rarely ulcerate through the skin, and then only after they have existed for many years. All of them lack the stony hardness at the edge that is characteristic of the carcinomata, and akso the firm attachments to the underlying DIPFERr:N'l'IAL I)IA(;XOSIS. ir/j and overlying strufliifcs. S;n'f'oinata nuiy morn rioarly rosfinhlt; these {growths, for at first tlicy iwv, often found to he prf;tty definite- ly cncapsnlatecl, nnd Iicik-c freely ino\;il)Ie. Chancre. — At times it is extremely difficult to make a differential di;i,f?iu)sis betAveen a chancre and a raxjidly {^rowing nodular cancer (Fififs. GO, 61), for both have the same cartilaginous resistance, and ulceration often takes jjlace in the center of each in about the same way. The observance of a number of facts will, hoAvcver, aid in making a diagnosis. In llie first place, the age of the patient is a great factor, for cancer is infrequent in the young, while chancre usually does not occur in the old, although it may, of course, do Fig. 61. — Chancre of the lip of one month's duration. (Author's collection.) SO. Second, the location of the growth is of some aid. for chancres are rare except upon the penis, lips, or fingers, although they may. of course, occur upon any part of the body. Cancer is rather rare upon the upper lip, and practically never occurs upon either lip in a woman. Third, the growth of a chancre is usually very much more rapid than that of a cancer, a diameter of 2 cm. being not in- frequently obtained in less than two weeks; and fourth, the neigh- boring glands usually swell within a month after the initial appear- ance of a specific lesion, which is not found in cancer. In cases of doubt, the spirochete should be searched for with the dark field il- luminator; this instrument is much more satisfactory than the ex- amination of stained specimens. AVhere none of these methods are IGO SKIN' CAXCKR. availaMo. salvarsan slioiild l)e adiuiuistoi-ctl intravoiioiisly, and. if tho irrowth ilisapi>oars. it was uiitldulilrtUy luolit-. Gumma.^ — Karoly a i;uiiiiiia iiia\- i)iH'siMit syiii])1()iiis llial make it pi-actically iinj^ossiblo to diffoiriitiato tioiii caiiciT. Tlu' autlior has recently seen two cases ot tumors ui)on the nose, hotli oecurrin^ in people past 40, wlm presented no other evidences of syphilis (Fig. G2). In both of these eases there was a raised, extremely hard edge, with dilated blood ve.ssels. no ulceration for a number of months, and no marked inthunmation i)resent. Hoth cases were considered to l)e cancerous. Imt in l)i>tli cases sect inns slmwcd ;i typically hilitic treatment. 2. Ulcerative Lesions. — The ulcei-itive lesions aie usually easy to differentiate, for tlicy too lack many of the ])hysical clmracteristics of cancer — namely, the hiii-d edge, with the pearly nodules therein. Lupus Vulgaris. — Lupus vulgaris (Fig. 64) usually originates in tht- young; it is very rare to find a case starting in a })atient over 20 years of age. The growth of the ulcer is slow, although not slower than that of a rodent ulcer. One characteristic of a tuber- i)iKi-"i';ui';N'riAi. I)IA(;nosis. 161 culoiis ii](*(!r is llic ovci'liJiiij^iii;^' cd^c of skin, tin \i\ccr iiul hcih^j cleanly putu^licd out ( ^''i^^ (ir)). In sdinc instances lif;ilint.' may take j)laee in tho center, Icjiviny' ;i ('i)ni|);ii-;it i\cly sii|)(rfici;il soft HCar. A section t;iken from tlie cd^c of ;i |i;it<-li of Iii|his will show that the condition is ;in in(l;iiiiin;itoi'y one, ;ind the prc.-seiice of {fiant, but more especially endolhelioid, cells may !»<■ y may l)eoonio c-ancoi-oiis untlor very oxcoptional oir- cunistam-cs. A i-a])id .i;rowth of jtaiiilloiuatoiis tissue rosombliii'; a dirty jjranulation tissue, but iimiv aiu'inic and less vascular, would inako one very suspicious of beginning malignant change. The .same hoMs true of varicose ulcers. Sporotrichosis. — The lesions of sporotrichosis^ arc usuall\' nud- tiple, and follow the cour.se of tlu^ lym])hatic ves.sels; in addition Fig. 64. — Lupus vulgaris, .showing spontaneous lu-aling in center, duration. (Author's colleition.) K\n]a years' the cau.sal oi'gauism can be demonstrated. Mosl of the otlier gran- ulomatous affections arc acfiuii'cd in tro])ical or .semitrojdcal coun- tries, and in persons Avho have lived in them such conditions must be excluded, which is u.sually not difficult, for the condition of the edge of the growth is a sure sign to guide one. 3. Papillary Lesions. — ^[ost of the papillary lesions should not "Hyde and Davis: Jour. Cutan. Dis., lOlO, xx\iii. :',2\ 1)||'|'i;i;i:n'ii \ii diagnosis. 163 (•juiKc. trouble, l)iii (K'cjisioiKilly IIk'V do, cspccinlls- to oiio who has jioi seen. iii;iiiy of I liciii. Diffuse Papillomatosis. Oik; coiidilioii 11i;i1 is uol ircuc rally rec- ognized oven ])y cxpcriciic'cd cliiiicians is tlic diffuse papillomatosis of the skin caused by an iri'itatiu*^ diseliarj^c. Fig. GO shows a very extreme form of it, but it is often seem in milder forms, especially around chronic leg nieers in wliieli thei-e has been mufh weeping. The common venereal wai-ts arc the most familiar examples of this condition; other illnsti-ations arc the so-called dermatitis vegetans and pemphigus vegetans, in both of whieh eonditions a discharge has set up a pi'olifcration of epithelial tissue. Fig. 65. — Tuberculous ulceration. (Randolph's case.) Exuberant Granulation. — Ordinary exuberant granulation tissue is occasionally mistaken, but should not be, for it is of a different color, lacking the dirty-white splotched appearance that cancerous tissue assumes, and also totally lacking the induration. Granuloma Pyogenicum. — The condition known as granuloma pyogenicum- is simply an excess of granulation tissue caused by an infecting microorganism, and might be confused with sarcoma, but = WMle: Jour. Cutan. Dis., 1910. xxviii. 663. 1G4 SKIN CANCRR. lU'viT with farc'iiionia ; tho rxtrcMiic toiulcnicss and lack of indura- tion in the irniuth shcuild sitvo to diflVrontiato it from cithor con- dition. Fig. 66. — Diffu.'se papillomato.sis of skin. (Author's collection.) Tuberculosis Verrucosa Cutis. — Tulierculosis vci-i-iu'osa cutis (f'iff. GTj could be nii.stakeu only by a tyi'o. foi-, as a general rule, the surface epithelium is almost intact, the lesions lack dej)th and in- duration, and are almost invarial)ly multii)le. i)ii'i'')';Ki;N'iiAL 1)IA<;n()Sis. k;.") Blastomycosis. — P>];iKtornycoHiH'' (V]^. GH) uKually chuhch a truo j);ij)ill()iiiiil()ii.s ovcr^i'owlli of the, skin; IicIvvj-cm IFic \cyv\icosc pro- jectioiiH }U'(! iniiiutc! abscesses eontirniiii^- pus, in wliidi il is usually easy to dernoiistratc the eausativ(! or^'anism. The eolor is often ])Ur- I)liKh, and ther(^ is a, laek of (\vv.\) infill rat ion, the eonditiori feelint,' S0f?{?y, I'Hi-her than indurated. 'I'lie lesions are nsnally hiulti|»le, and there may l)e a number of minute abscesses in the skin beyond the limits of" the lesions i)ro])er. Fig. 67. — Tuberculosis verrucosa cutis. (Author's collection.) Yaws and Syphilis. — In either yaAvs or framhesiform syphilis the lesions are invariably multiple and laek deep induration: they are apt to be most pronounced on the face and around the genitalia or axillae. 4. Scar-forming Lesions. — As already pointed out, cancer may heal spontaneously in the center, and have only a slight amount ' Stelwagon: Diseases of the SKin, 7th ed.. Phila., 1914. 166 SKl.N CA.\"Ci:U. of ulceration at the cdj^cs; the most extrenu' exaniiile of this ty])C is the luorpliea-like epithelioma. Tliere are a number of other (mui- ditions Avhieh likewise eause scarring', perhaps with veiy little ul- ceration, and they nuist be diagnosed from this variety of cancer. Lupus Vulgaris. — Lui)us vuljrari.s will often heal in the center, and show only a ('()ini)aratively narrow zone of ulceration at the margin. The overhanging edges of skin and tlic lack of deep in- duration would serve to distingui.sh this condition from cancer, even if the age of the patient did not, for lupus is extremely rare except in childhood. Syphilis. — The lesions of syphilis spread very much more rapidly tluui do those of superficial cancer, and the ulceration is usually clean and punched out in appearance, besides lacking hardness. Fig. 68. — Blastomyccsis. (Author's collection.) Lupus Erythematosus. — Lupus erythematosus causes scarring without ulceration; the surface of the skin is covered by closely ad- herent white scales, and the follicles gape widely; the color is pink- ish. The lesions are usually multiple, have a great tendency to be symmetrical upon the face, especially the nose, cheeks, and around the ears. This condition may be confused with syphilis, but not of cancer. Morphea. — ^MOriihea may siniulalc one ty])(' of caiu'ci-, already fully described under the heading of morphca-like epithelioma in the chapter on the basal-celled cancers. As pointed out at that time, the presence of ulceration or of a i-aised firm edge should suffice to differentiate between Ihoin. TJnrclv the caiu-ci- ot niirassc may diI''1''i;ki;x\'1'i.\l diaoxosis. KJT rescnil)lc a Hr-lcrodcnna, but cxjiiniiKilioti of llir; bi'nasl will iihii;i1I>' clear up tlie dijij^iiosis. Serodiag'nostic Methods. — Jt is iinpossihlf to concliKb; a chap- ter on the diagnosis of cancer without a word or two of reference to the attempts at laboratory diagnosis l)y iiuians of utilizing the changes in the bodily cells and fluids that have takc^n jjlaee because of cancer. The majority of these tests are satisfactorily described in the third edition of Miillci-'s "Scrodi;ignostic Methods," tivins- lated by Whitman.' The reaction of Freund and Kaminer^ depends on the observa- tion that the blood scrum of normal individuals has the power to dissolve cancer cells, the scrum of cancer patients lacking this power — indeed having the power to inhibit the desti-uclion of such cells by normal serum. Von Dungern" has attemi)ted tlie diagnosis by the well-kno"vvn principle of deviation of the complement, l)ut in tlie liands of others the I'esults have not been satisfactory. Kraus, Graff, and Ranzi^ have attempted to diagnose cancer by means of the cobra venom method, which depends on the principle that in certain conditions human blood serum possesses the ability to activate the hemolysis of horse's red blood cells by cobra venom. Marcus's^ modification of the method of Miiller and Joehmann^ depends on the fact that the digestive power of trypsin is neutral- ized by a certain amount of serum or blood. The method of Berg- mann and Meyer^° depends on the same principle. The meiostagmin reaction, as practiced by Ascoli and Izar^^ and others depends on the principle that, when diluted blood serum of patients is mixed with a homologous antigen and heated, there oc- curs a specific lowering of the surface tension. Elsberg, Neuhof, and Geist^- have described a skin reaction for carcinoma that has been investigated in this country by Lisser and Bloomfield^^ at the Johns Hopkins Hospital. The injection of 5 minims of a 20 percent suspension of washed human red blood cells * Miiller: Serodiagnostic Methods. 3d ed. (translated by "SVhitman). Phila., 1913. 5 Freund and Kaminer: Wien. kiln. Wchnschr., 1911, xxiv, 1759. 6 Von Dungern: :\Iunch. med. Wchnschr., 1912. lix, 65, 1098, 2854. •Kraus, Graff, and Ranzi: Wien. klin. Wchnschr., 1911, No. 28. s Marcus: Berl. klin. Wchnschr., 1909, No. 4. ° Miiller and Jochmann: Miinch. med. Wchnschr., 1909, Nos. 29, 31. " Bergmann and Meyer: Berl. klin. Wchnschr., 1908, No. 37. "Ascoli and Izar: Miinch. med. Wchnschr., 1910, Ivii, 62, 182, 392. 403, 842, 1170, 2129. " Elsborg, Neuhof, and Geist: Amer. Jour. Med. Sc, 1910. ^3 Lisser and Bloomfield: Bull. Johns Hopkins Hospital, 1912, xxiii, 356. 168 SKIN t\.\(i;K. just hc..u.;,tl. thr skin is l-oll..w,..l l.y a ..hara.-f.Tisli. n.H-tion in nn.nv cancer i)atioiits. Kxvn nuMv ro-ently it has h.vn ,.ropos...l to us. a nM,.lili..at inn of TiH' AbilerhaI«lon reaction for pref^nancy.'^ Fortunately, lumever. in .-an.-er of the skin it is not neeessarv i.. depen.l ,.n sueh n.etho.ls. f..,- ,h,. .lia.Mu.sis ran nsnallv be ma.i;. l,v mspect.on. and. if not. hy Uu- ..xaniinalion of tissur." whi.-h is -,1 ways readily ohtaincd. Editorial: .I,,ur. Arm-r. M.-d. A.>..mi.. v.n:i. l.xi. i 461. CTT AFTER XVi. PROGNOSIS. Thv i)r()er('eut. Cuboidal-Celled Cancer. In Hlondgood's sei-ios of culxtidal-celled growths the percentage of cures was only 33 percent, but this in- cluded many tumors of all stages and locations. If seen early, the ]>ercentage of permanent cures should be much higher than that of the squamous-celled neoplasms. Baso-Celled Cancer. — Of the baso-celled growtlis 70 pci- cent have been pennanontly cured, and these figures include even the inoper- able cases. AVhen the growth is not over 2 cm. in diameter. 100 percent should be cured by a sufficiently radical treatment. In the more advanced cases, or where there is invasion of some of the nat- ural openings of the face, the outlook is not so good. Init neverthe- less is not always ho])eless by any manner of means. Sarcoma. — In regard to sarcoma, Rloodgood furnishes us with some mo.st interesting .statistics. In six cases of "poritlu-linl angio- sarcoma" arising from a congenital nevus, there was but one cure; in eight similar cases, but arising dc novo, there was not one cure. Twenty cases of sarcoma developed in scars; of these eight were cured, five lost track of, and the reminder not cured. "In every one of these cases the growth in the scar had continued one or more years, so that in every case there was sufficient clinical indication for an earlier intervention. Now. if the probability of a cure be 50 percent in late intervention, we can l)e (|uite sure that it will be much greater in early intervention." In nine cases of sarcoma of the skin there was a history of a preexist iiiu- fi])i'onia. and only five of these cases have remained Avell. The multiple sarcomata vary in maligiumcy. In the small round- celled cases the outlook is hopeless. l)ut in the Kaposi and Spiegler- Fendt types the outlook is better, although most of the patients hav- ing the Kaposi variety eventually die. yet the patient may survive for a number of years. Nevocarcinomata. — Tlie nevocareinomala and tlie melanoniata are usually hoju'less from the onset, for metastases have usually taken place by the time the patient notices the finst change in the mole. Cancer of Cutaneous Appendages. — The prognosis in the cancers arising from the various appendages of the skin, as well as the en- dothelial group, is faii-ly good, for a sufficiently broad local incision will nsuallv cui'e l)oth of these conditions. PROONOSIS. 171 Development. — The stage of Hie disc'isc li;is, of coufsf, ;i most, important bearing, for an early prickhj-f^jllcd cancel- is mucli easier to treat and has a much lietter outlook th;in a, \cry advanced basal- celled neoplasm. With the exception of tlic nevocarcinoma group, the i)rognosis of all early tumors is good, for every tumor is cur- able in some stage of its existence. Even in fairly well-advanced growths of almost any variety the i)rognosis is not absolutely hope- less if the tumor is so situat('r;i1ion c;in be pci*- formed. Location.— 'JMic location of llic ncophisin is vcvy iiii])ortaiit in determining the outcome, as well as the utility of the organ involved. In c;incor of the face there is an unfortunate tendency to do too limited ;iii ()i)erati()n because of the fear of deformity. Upon the eyelids or ears a complete operation is not only difficult, but very deforming. Upon the lip the prognosis is genei-ally good, for, as alrcndy stated, the figures from Maj'os show that ovei- 80 percent of the early cases can be permanently cured, and about 70 percent of the late and recurrent cases give good results if submitted to a rad- ical operation. Tumors situated upon the limbs or body can usually be cured even at a fairly late stage, for here a large operation can be done Avith the more than fair chance of removing all of the cancerous tissue, even if some of it be in the lymphatic glands. Upon the penis the outlook is not so good, for cure demands the complete removal of that organ and of the neighboring lymphatic glands, and even then only about half of the early cases are cured. In the rare tumors of the basal-celled variety the outlook is much better, for local re- moval will generally cure. Operator. — The skill of the operator is essential. In the first place, the surgeon or dermatologist should be able to accurately diagnose his case before operation, preferably without the use of a biopsy, for, as already pointed out, a biopsy may be dangerous, in- asmuch as it may allow cancer cells to escape into the cut blood ves- sels or lymphatics. In some cases it is impossible to diagnose a growth until the time of operation, and then a surgeon should be sufficiently skillful as a gross pathologist to immediately tell what the character of the tumor is, and hence how extensive an opera- tion is necessary. ] Complete operations should be done in one sitting, for second operations are always dangerous for two reasons — first, because of the effect upon the general health of the patient, and sec- ond, there must of necessity be a In-eak in the chain of complete 172 SKIN CANCER. vomoval, aiul a fc^Y cells may Ite lol't at tlic (lividinroven or disiu'o\en as soon as the growth a])i)ears. and the ex- l)ectant plan of treatment usuall\- leads to very had results. For- tunately the ])rofession has awakened to the danj^^'r of the so-ealled l>i-eeaneerous eonditions. and the laity, as a result, are much hetter infoiMiinl than they I'oi'iiierly were. 10vei\\- surgeon has commented on the innnhei- of i)atients suffering from still heiiijiii aftli<'tions of the skin a])plyinji- for adviee and treatment. This oiu^ fact is the most hoi)eful siu,-n that we have today as to 1h(> ])ossil)ilities of jier- manent results in tlu> tii^ld of eaueer therapy. Cancer Quack. — The so-ealled cancer quack is one of the nien- aees that today faces the puhlic. The quack is in the field sim- ply for the money that he can secure from unfortunate patients, and in 99 percent of the cases he is ahsolutely without conscience as to the manner in which he secures this. He is ])erfectly w^illing to tell a patient that any kind of a lesion is cancer and needs immedi- ate and expensive treatment ; he is ahsolutely ignorant regarding pathology, and makes no attempt to keep track of his results, ex- cept in the hope of securing more money. It is surprising to see how many of the hospital patients have had treatment from this group of men. and then eventually submit to a grave operation be- cause of the loss of time. In conclusion, the results in the treatment of skin cancer are much better than they formei-ly wei-e, and will become much better as ad- vice is sought earlier. CHAPTER XVII. PROPHYLAXIS. Discovery of Cancer. I'ntil \\\c line cause ol' caucci- is discm'- crcd it will he impossible lo prcvcii! i1 in a truly scientifif and ef- fective way, and henec it is xcvy necessai-y that the etiolojry he coin- })lctcly worked out. Foi-tunately there are a nuinher of hihoi-atorics now established that are endeavoi-ing^ to solve this difficult problem, and there is no doubt that some day one of them will sueeecd. Sueh a research, however, reciuires funds, and it is absolutely necessary that these institutions be supported. The establishment of the various societies, both for educational purposes and for various types of cancer research, is one of the hopeful signs of the times, for the public must be educated to the point where they will seek advice before the cancerous stage is reached. Precancerous Dermatoses. — In a more or less general soi-t of way we know that cancers of the skin are almost invariably preceded In' some variety of precancerous condition, be it congenital, inflamma- tory, or neoplastic. In the first place, it is evidently necessary to prevent these precancerous dermatoses whenever possible, or at least to remove them if they be present. Chronic trauma of the skin or mucous membrane should be prevented, jagged teeth should never be allowed to remain, care should l)e taken to prevent burns of the lip resulting from the use of the pipe, cigar, or cigarette. This means that a fairly long stub should always be left if a holder is not used. There is no doubt that cigarette smoking can cause a precancerous dermatitis, although this fact is not dwelt on in the literature. Nor should the skin or any part of the body be chroni- cally irritated, either by articles of clothing or by any instrument of trade. One should not persistently rub his body against a de.sk or table ; those doing manual labor should protect themselves against trauma by suitable pads. A truss for hernia may cause cancer by its incessant friction and pressure. A suspender buckle may do the same thing; in fact, the possibilities are manifold. Occupation. — As already pointed out, certain industries more than predispose to cancer of the skin. Schamlierg^ and others have .shown 1 Schaaiberg:: Jour. Cutan. Dis., 1910, xxviii. 644. 173 174 SKIN CANCER. how prevalent this ooiulition is in those wlut are foreed to handle the various ]n-oduets of tar and ]H'troleuni. (hiinney sweeps were formerly liahle to cancer ol" the scrotum. ( 'tiiiii>lote eleanliness Avould doubtless save soine iiion from industrial cancer of this nature. The majority of industrial cancers are. liowever. undouhtcdly due to ex- cessive actinic rays, citlicr ol" the sun oi' ot' ihc x-ray. the latter be- in«; much the more daufxerous. Those who arc cxjKfsed to such dan- g:ers sliould take suitable iii'ccautions. lead bcinfj: the material easiest to liainlle th;il is iiii i>er\ ioiis 1o the l\(Hitjren rays, and some sort of a mask suflicieiit to i>i'otect from the sun's rays. Congenital Deformities. — While it is generally iccoiinizcd that cancer may follow in the wake of various eonsenital deformities of the skin, still there is a widespread feelinp: that operative interfer- ence of any kind as applied to such a congenital defect is very dan- gerous and apt to cause cancer. This is a grievous error. Blood- good- states that he has removed with the knife 175 clinically be- nign pigmented moles, some of which already showed signs of ir- ritation, and that there has not been the development of a single malignant tumor in this series; and this in spite of the assertions made by many surgeons and dermatologists that it is dangerous to excise a mole, and that it should always be removed Avith the cautery. As already stated, every pigmented mole that appears late in life, as well as every pigmented mole that begins to grow or that shows any sign of irritation, should be i-emoved at once ; in fact, every pigmented mole that is liable to chronic irritation should be elimi- nated. The large more or less pigmented nevi occasionally become malignant, giving rise to either sarcomas or carcinomas. The small ones, if excised, never give rise to malignant trouble, but in the mind of the author it is doubtful if the large ones should be touched ex- cept for cosmetic reasons. There is no way of removing these large growtlis and li;i\iim- the wound heal by first intention: tliey can be removed only by electrolysis, cauterization, or some similar method, and in these cases malignant change is ju.st as apt to develop upon the scar as in the old growth. Vascular nevi rarely become malignant, but when they do they give rise to a virulent type of sarcoma. Still, it is doubtful, for the reasons stated in the preceding paragraph, if it is wise to re- move them in order to prevent such malignant change taking place. The various types of benign Avarts, commonly but erroneously called papillomata, only exceptionally undergo malignant degenera- tion, but every one that is exposed to trauma should be excised. 'Bloodgood: Amer. Jour. Med. Sc, 1914, cxlvii, 76. riuji'JiVLAXis. 175 Benign Tumors. TIk^ vfirioiis Itciii^n liimors hcconu; uifilit.MiJint much oi'twicr tliiui is conimoiily .suf)poK('(l. JilofxJf^ood states that in the Johns Hopkins clinic there have been 406 cases of beni^cn connective tissiu; tumors oj)era,tecai'. In every instance, therefore, there had been the opjiortunity for an earlier complete local operation. Not (»ne of these ei^ht cases was cured. If we are to jxct better re- sults in dealinii' with the malijrnant luinoi's of the skin, we must .see and tivat our ])atients at an earlier date. The ])ublic must be tauo:ht to realize that nothing can be gained by delay. They should further be taught the danger of consulting men who are ignorant and mercenai'y. and absolutely Avithout conscience. Every physician should have at hand a few copies of the American ]\Iedical Associa- tion's expo.se of tho.se engaged in this nefari(ms trade. There are. of course, a number of ways in whicli the public can be I'cached in such nuitters. but in my judgnu'Ut none is so eft'ective as the ]H'i-sonal ])lea of the physician to a ])atient or household that Inis confidence in liim. Public lectures, and ai'licles conlributed to the daily papers ov to the juiblic nuigazines have but a transient ef- fect, and are usually speedily forgotten. And just foi- this reason it is necessary that every qualifiecl physician and every end)ryonic ])hysician shall have imiu'cssed on him the danger of ])i-ccancerous affections, and should be taught not only in his course in pathology, PKOI'lIYLAXIS. 177 but ;iJ.S() ill HUff^cry, iiicdicinc, ;iihI dcniuitoloj^y, the fact, l!i;i1 ;i can- cer iKjai'Iy alwuyH ariscH upon tlu; site; oi" an a})iionii;ili1y, ]>(■ it con- genital or ac(|iru'C(l. And in inany medical hcIkhiIs Ihis is not suffi- ciently well done. It is unjust to hlaiiK; the buHy practitioner for neglecting to keep up with these advances when he did not receive the proper instruction, but fortunately the ethicji! iiicdif;d Journals of today are teaching this very point, and emphasizing.'^ the neces- sity of recognizing cancer early. If the physician is in doubt, there is always an expert within call, a man who has the necessary ability and appai'atus to make a diagnosis. nrAPTKK XVTTT. TREATMENT. Tn (Icnliiiir witli llu' troatinont of skin cancers, the following out- line \vill 1)0 followed : Surfjical. Knife. Actual or electric cautery. Curette, with or wiilioiit the use of a caustic. Electrical. Electrolysis. Fulguration. Actinic. X-rays. Radium. Caustic. Nitric acid. Sulphuric acid. Acid nitrate of mercury. Chromic acid. Pyrogallic acid. Caustic potash. Arsenic. Silver nitrate. Zinc chloride. Congelation. Liquid air. Carbon dioxide snow. Medication. Arsenic. Methylene blue. Colloidal copper salts. Cancer vaccine. Immune sera. Supportative treatment. Analgesics. 178 TREATMKiNT. 179 Treatment of (•()ni|>lic;iii()iis. Tnreclioii. Ilc.iiiorrlin^c. Invasion of special organs. Repair of deformities. Plastic operations. Artificial organs. Treatment of inopci-aljlc cases. SURGICAL. Knife. — At times it is diflicult to decide uliicli is the best form of treatment for a special case. The patient usually dreads the knife, and likewise dreads an extensive operation for a small growth, and the physician must first gain the confidence of such a patient, and then point out the dangers incurred by doing an incomplete operation. But, in addition to the personality of the patient, the personality of the neoplasm must also be considered, and this the writer has endeavored to do in the chapters devoted to the special varieties of tumors. The author feels that excision with the knife is usually the preferable way in which to treat a tumor, for in this way a clean operation can be done with very little scarring, and it is possible to obtain a section of the tumor for microscopic study. This last should always be done, for in no other way have we a check as to w^hat we are doing. The treatment of cancer without microscopical study is about as satisfactory as trying to read with- out eyes. This is because epithelial tumors vary markedly in their malignancy according to the type of cell from which they spring, and it is not always possible to make a diagnosis from a naked eye appearance alone, at least not until it has been many times confirmed by the histological study of similar conditions. Next to the use of the x-ray, the knife is the least painful of all modes of attack. And lastly, the results are the best, so far as one can judge by the study of statistics. So far as the writer knows, no dermatologist has kept an accurate list of statistics of the cases of cancer that he has treated by the curette or the caustic, and but few have checked up their x- ray results. So at the present time we can say that, so far as statistics go. the results with the knife are infinitely superior to the results obtained in any other way. Furthermore, in all surgical clinics it is noted that nearly one-half of all patients Avho apply for treatment because of skin cancer give the history of having been treated by a caustic paste, or by the curette, and often by the x-ray 180 SKIN CANCER. or riuliuni. At the s;mu> tiiiio. it is difticult to use \\\v kuifo upon tumors that are situated uj)ou the nose, eyelids or oars, and here some other form of treatment must usually l)e devised. In the eases of the priekle-eellt'd cancers llu- knife is the only proper instrument, and this ])robahly ai)i»lies to the euhoidal-eelled neophisms as well. Sarcomata, endotheliomata. and the tiunors arisinjj: from the f?lands of the skin siiould he treated by no other method. Anesthesia. — llavini;- once tlecided thai tlie lesion is to be ex- cised, thi' form of anesthesia must next \)v det(M-mined. In the snuiller tumors it is usuall\' possihU' to oixTate umlcr local anesthesia, and for this i)urpose there is no better substance than the well- known Sehleich's solution, made without the addition of morphine. Sehleich's solution is essentially a one-tenth of one ])ei-cent solution of eoeaine in noi-mal salt solution. There is not the slightest neces- sity for using a stronger solution of cocaine, ])roviding that the sur- geon properly infiltrates the tissues. In fact, the use of more tlian one-third of a grain of cocaine at one sitting may be dangerous,^ the patient showing either excitement or depression. It is very con- venient to add a few drops of a 1 to 1,000 adicnalin solution to the cocaine mixture, for this will markedly lessen the amount of the bleeding. A fine needle should always be used, so that the solution will not escape through the needle track. The needle is inserted at a slight distance from the growth, usually about half an inch, and superficially just beneath the skin, so that the infiltration can be noted; if the injection be made deep into the corium, satisfactory in- filtration will not ensue. It should always be remcml)ered that it is very difficult to infiltrate scar tissue, and at times impossible, so eases showing much scarring are not suitable for local anesthesia. The injection of the anesthetic mixture must be kept \\]\ through several punctures, until not only the tissue in and beneath the tumor is thoroughly infiltrated, but also an area at least one-half an inch beyond its margins. Anesthesia will be coiui)lete at the end of two minutes, if not earlier. Before using a local anesthetic, it is well to make one or two little scratches of the skin to indicate the in- tended line of incision, for when the growth and surrounding tis- sues arc filled with fluid the original boundaries are often lost. In extensive cases it is usually necessary to employ general anes- thesia, and in growths around the mouth or nose there is great need for an expert anesthetist. Ether is usually oiiiplnyod for long opera- tions, while nitrous oxide and oxygen may suffice for a short one. Disinfection. — In tlie majority of cases it is best to disinfect the »Cushny: Ptiarmocology ami Therapeutics, New York, 1011, 313. TKKATMKNT. 181 Hkin will) iodine ;il)<)iit leu iniiiiilcs Ix-foi-cr bcj^iiiniii^' flic oiu;i-af ion. )'Cliiciu))(!i'iii^' tliJil 1li(' iddiiu' imisl ;ilw;iys Ix; Jipplicil \(t ;i 1 horfiUf/liIy dry surfacM' in order lo he cfdciciit. Operation. It is iisii;d lo l;d . although in cases of tension this may not be possible. At first the wound may be dressed with silver foil, over which a piece of sterile gauze is placed, and sealed with either collodion or adhesive. Or the wound may be painted with ioiline. smeai-eil with a little sterile ointment to prevent the adhesion of the gau/e that is ])laced next to it. Af- ter the stitches have been removed, a little more iodine may be add- ed, and the wound dressed with cotton and collodion. In the case of a small growth the wound should be entirely healed by the end of the tenth day, although it is well to leave collodion on for a few- days longer in order to remove strain and jirevont the j^ossihility of the edges separating. Actual or Electric Cautery. — l-'oi- many years some surgeons have felt that, when they employed the actual cautery rather than the knife, there was less danger of cancer recurrence in the edges of the scar. llaLsted. as well as many others, has noted this in cancer of the breast. Were it not that the electric cautery is liable to get out of order in the ordinary operating room, it would be the ideal one. but, as it is. the actual cautery is the moi-e i-eliable. Excision can be managed by the cautery as well as by the knife, although in the removed tissue it is imiiossible to determine the limits of the neo- plasm. As a conseciuenee, some surgeons prefer to excise Avith the knife and then immediately employ the cautery. It is generally considered somewhat dangerous to emi)loy the actual cautery in the presence of ether fumes. The cautery has the one great advantage over the knife of thoroughly searing the edges of the wound, so that no cancer cells can escape into the vessels or become iini)lanted along the line of incision. In extensive cases of cancer upon the limbs or body the cautery is excellent, although it cannot, for example, be used near the eye. The cautery should always be used when it is not possible to give a wide margin, as in lesions of the tongue. Curette, With or Without Use of a Caustic. — The use of the cu- rette without following it by a cau.stic of some kind is mentioned only to be condemned. An occasional case may be cured by the vigorous use of this instrument, but a brief recollection of the path- ologA' of a cancer will show that it cannot reacli the cells that are progressing into the still health}' tissue. If a wound is, however, thoroughly curetted and then efficiently cauterized, the results are often excellent. Sherwell- has elaborated 'Sheiwell: Jour. Cutan. Dis., 1010, xxviii, 487. TREATMENT, 1 83 a inctliod in which ho om])]oys tho acid nitrate of rnoi-fury a.s tho cautei'i/iiig agent, aiic] has liad (ixcclleiit results. Other dermatolo- gists, including th(! aiilhor,' h;ive likewise ()l)t;iine(l gofjd resiills fi'oiii its employment. Hie following ;iecoiiiit is 1;ikeii from the wj-itor'.s own artiele on the siibjeet. The aeiart under treatment, and the si)arks allowed to play upon the area. Fidguration (do Keatintr-Hart) is foumled upon the premise that the monopolar lonu.- sjtarl'; of hijjh frequenex" and hinh tension aets not only upon the neoplasm, but upon the soil on which the neojilasm has developed. Dc Keatin«;-ITart claims that the use of the high fre(iuency short spark at a low tension aets as a tissue stimulant, but that a spark of the minimum length of 8 em. applied for a suf- ficiently long space of time transforms a healthy area into a torpid wouml. which heals lai'gely by the contraction of the surrounding healthy tissue. It is considered that the same process that prevents the reformation of healthy epidermis after fulguration also retards or sui)presses the groAvth of cancer cells. As this method is the most important of the electrical ones before the medical jirofession today, it nuiy be well to describe the ap- jiaratus used. The generating ap])aratus consists of a large coil and a rapid interru])ter. which converts the street current of low volt- asre and high amperage into an interrui)ted current of high voltage an.l low amperage. The high frequency api)aiatus consists of an ( >udiu resonator, with spai'k gap and condensei's of gi'eat capacity. The sterilizing and cooling a]ii>aratus compi'ises an air pump, driven by an elective motor, which forces aii- thi'ough an electric sterilizer, and the air is tinally delivered at the elect i-ode cool and stei-ile. The electrode consists of a metal mandril within a rubl)er tube. The first step in the operation is i)ui'ely surgical, consisting of the removal of the diseased tissue as com])letely as jiossible, then the spark is used for a long time, using sparks of high fi'eciuency and high tension, and applying them to the entire wound. The electrode should be kej)t in steady motion, and no carbonization of tissue should result. '"Ten minutes of fulguration should be used on an area of ten square centimeters." Bainbridge wisely concludes his arti(lc by .stating that, although nt the present time the results seem good, still it is too early to draw TREATMENT. ]87 iiny too 0|)timiHtic f'oiK'liisioiis, ;i, sliilcnicni willi whifli ;ill f;iir ininflf;(l men must uj^rcc. ACTINIC. X-rays. — In tlic (•niployinciil of 1Im' x-f;i\s I'or llic t rent mciil of CcllH'CI", tlirCG luetliods Ikivc been ;i(|\()c;itc understand the capabilities of ])oth his ma- chine and tube; at tiist lie inust jiroeeed carefully until ho tests these instrunuMits out nimn each particulai- jtatient, and then he can i;ive numerous sitting's. The woik is prolouficd and )iecessarily rather expensive, and the i)atients often tire of it. < >f cdnrse. it is absolutely essential that all oi" the sui-iouiidiiiL:- skin he covered with lead foil, so that neillief nii acute liui-ii iioi' alroiiliy and telan<;i- ectases can follow. It was soon found that two exposui'cs of twenty minutes each, usinjj: the same tube and the same amount of curi'ent. were just as effective as nine oi* ten exjxjsures of five minutes each, jtrovided that the former were not too lonjf separated. These iigures arc, of coui'sc. merely jjiven in )'ound numbers — as illustrations and not as abso- lute facts. As a result, many men bcffan treatment alonj; these lines." and in ^'cnernl the I'csults wvw just as pjood as li>- lh(> older method. There has been a mai'ked shortcninfj: in the dui'ation of the treatment, and not as much liability to ati'ophy and telangiectasis, but some danfjer of an acute burn. Tlie use of th(^ penetrometer to measure the quality of the rays and of the Sabouraud-Xoire pastille to measure the (pjantity of the emanations has markedly lessened this danger, but it is still pi'esent. es])eci;illy witli the inexperienced operator. The natural sc(iuence of this treatment was to give one, or per- haps two, massive doses — doses measured accurately both as to quan- tity and quality. In America ]MacKee, of New York, has been the chief exponent of this idea, although, as he points out, the method is in common use abroad, and his results have been excellent (Figs. 69, 70). The following account is derived from his various papers on the subject, and from my own ]iorsonnl expoi-ience. which is iden- tical with MacKce's. ^lacKee and Kemer'' claim that an accurate measurement of the dose is as imi)o)-tant in Kontgen I'ay therapy as in any field of medi- cine; that the massive dos(\ carefully measui-ed, is both accuj'ate and scientific; that the patient is spared the necessity of many visits to the phy.sician's office; and last, that this foi-m of ti'catment is bct- ' I.iang(>: Jour. Amer. Med. A.s.'jn., 1913. Ixi, 556. " MacKee and Remer: New York Mert. Jour., March 20. 1913. Amer. Jour. RontBfnoIopy, Drc, 1913. TKKATMKxNT. 189 tcr llH^f;ip(Mi1ic;illy. In c.xpljiiiiiii^ the last point,, Ihcy Hay: "Sev- eral years ajjjo it was ciistoinary to ap})ly the x-i-;iy 1o ffjilhr-jionia in very small doses three times a week. It was tioI iinconimdn lo liear oi" ;>() to 150 01' more treatments l)cln/\\ct\ 1o one p;i1icn1. Thosf wlio a,re familiar with ])ast results will i-eeollcct tli;it ;i ff rtnin per- centage oi the patients were permanently furcd, while in ;iii nn- i'oiiiuiately ];\.y' hard border. Histopathology is that of a deep- seated basal-cell epithelioma. (MacKee's collection.) follows: A milliampercmeter is employed to ascertain the amount of current passing through the tube, the milliamperage employed being the same in every ti'catinoiit. Tho nnodo of the x-ray tube 'n;i;AT.\ii:x'r. 101 is always placed ;i1 ;i ^ixcii iniiiilx'i' of iiidics from Ihr; skin. Tho parallel spark ga]) (ov oilier iiislrmiK'iit;, uhicli rcj^istcrs the resist- ance in the circuit, is adjusted at a certain distance. By working with these eoiist;ints, lia\iii<^ liad a ji^reat deal of ox})ericnee, beinf? thorouf^'hly a,e(|n;iiii1ed wiili ;dl p;irts oP th()ssess the exaetiiiy: retiuireinents of the massive dose metliod. This view may have to he modified in the fntnre. hut. with the ex- eitinf^ apparatus and tubes a\aih-ihh' at present. \\i' d of measurement consists of utili/.iu'j: many of tlie factors of the iuilircct tcchnic willi llic aildilimi of cniiilov Imlt instruments designed for the ]>urposi' ol" dircctl\ t'stimatin<; the (pial- ity and ([uantity of the ray. Theri' ha\e been many t\j)es of ap- ])ai'atus and many sehenu's ad\anced with this object in \ie\\. There are, for instance, the lIol/,ioi'dier-( Jalimard units, the (iuiUeininot Ihioroinel ric (|uai>t iometer. the KienbocU i)hoto.Li-rapiiic (|uantiometer. the Sehwar/. i)iH'eii)itation radiometer, the llampson i-adiometer. and many devices and schemes ori^-inate 10 1ul)e— that is. a TIIKATMKNT, ]0.'> tubo lliiil: will iiicjisiii'c S (»!• 10 nulls l»\' tlu' I'.cnoisf sf-alc uIk'H U'sIrT] for ])en('trii1i()ii. The t('<*hiii(' \'*>\- iiiciisiii'iii;^' '|ii;iiili1y iiicfils ;i soiiicu li;it i'ullcr Ncript ion, r(»i- il is iiol <4ciicr;ill \' cm iiloycd in this country. Tin; jlol/knccht vjulioinclci- consists ol' ;i snilnhly tinted celluloid l);ind. the colors of which ^-radc from zero 1o S II units. The measurement ])ie('(\s consist ol' past.ils of plat inocyanide of Itarium. and the estima- tion is made by i)lacin^' a half pastil under the c(»lored hand. An- other half pastil is exposed to the eiimnations of the tube, while the patient is under treatment, c()vcre(| with eellidoid. and |ilaced in ccmtaet with the "index" half ])astil, but outside of the colored hand. The whole jiastil is now moved down the scale until the two halves match exactly in color, and a reading' is then made, somewhat as on a hemojU'lobinometer. As regards dosage, the Ilolzknecht units are now jd'etty generally known and used. As already stated, 1 unit ef|uals a dose that is one- third hirge enough to produce erythema of the face in an adult. The H units are accurate only when a ''medium" tube is employed — a B 6 tube, for instance. It is necessary to remember that 5 H with a hard tube may produce only a temporary alopecia, Avhile the same dose with a soft tube may cause permanent baldness, and hence it can be seen that the biological effects of the H units vary according to the quality of the ray. As a general rule, from 5 to 7 H units are employed at the first sitting, and, if necessary, four weeks later another dose of about the same size given. Regarding the "skin distance" and the "pastil distance," the au- thors say: ''It is customary to place the pastil exactly half way be- tween the anode and the skin. The reason for this is that the pastil, being closer to the anode, will assume a deeper color when in this position than when placed upon the skin, and, therefore, supposedly greater latitude is obtained in estimating the change in tint. Para- doxical as it may seem, the deep orange shades are harder to match than the paler colors. Not only are the green, yellow, and lighter orange tints easier to match, but they do not fade so rapidly when they are exposed to light and moisture. Contrary to what has been published, the color acquired' by an exposed pastil will fade almost as rapidly under the influence of strong artificial light as by the action of daylight, and the deeper orange tints will attenuate far more rapidly than will the paler colors. These are some of the reasons why we prefer the full 'skin distance' for the pastil. There are, also, other very important reasons. The numerals on the scale of units of the Holzkneeht instrument are not equally spaced. 194 SKIN CANCi:i{. One has more latitiule in conipariii«? the liy:hter than in cstimatinj^ the darker tints. The pastil must be placed at least one inch from the \v;dl of tlio tube to avoid the deleterious effect of heat, and hence the tulii' can be i)laced nearer the patient and the exposure shortened. With the pastil on the skin. re!?ardless of the distance of the aiKMk'. the H units must be multi- l)licd by foiw to conform Avith the law of inverse proportions to the .sciuare of the distance — that is to say, if 1 II unit is administered in this manner, it will equal 4 II units by the "half di.stance' method." The fresh pastil is of a glazed brilliant green color, and all ])astils should have this color, approximately at least. They shouhl ])e kept in a well-ventilated humidor that is kept in a cool room. A used pastil can l)e returned to almost normal color 1)\- the action of tlay- liglit and moisture. Either the English. Frencli, or (Jcrman ]nistils may be u.scd. for all seem about equally reliable. It is l)etter to use fresh pastils each time. Now a word as to the choice of method. Undoubtedly it is better in every particular to use as little x-ray as possible in the treat- ment of cutaneous affections, and this can best be done by a technie which approaches that just described. At any rate, we should make some attempt to measure our doses — this is just as important as to standardize the drugs that we administer by mouth. To the author it seems certain that in the next decade practically everyone will use instruments of precision in determining not only the quality. 1)ut the quantity of the rays that he uses. At the same time it must be remembered that very bad results are occasionally obtained when one attempts to use the massive dose. Most of these reports have come out of the dry states in the west, where there is a comparatively low humidity, and it seems possible that the lack of moisture may af- fect the sensitiveness of the pastils; at any rate, there have been a number of very bad burns reported. Also, it is more than possible that all skins do not act equally, and that wliat one skin will tolerate will prove very irritating to the next. The results of x-ray therapy in cancer of tlie skin liave usually been good in the liands of experienced men. Pusey" reports 72. .5- percent of successful I'csults in 111 unselected cases, com])rising lioth the basal- and prickle-celled variety of cancer. Still later Pusey^* admitted only two failures in thirty-five selected cases of cancer of the lower lip, mainly, however, of the rodent ulcer variety. Mac- Kee's results have been almost uniforndy good, and there can be •Pusey: Jour. Amer. Med. A.ssn.. 1907, xlix, 1215. "Pusey: Jour. Cutan. Di.s., 1013, xxxi, 7.3. TKKATMKNT. ] OO Tio doubt that the x-ray can aff'oinf)lish cuvch in vory many caHOM of cutaneous cancer, provided lliat no metastasis has taken plaf-e to the neighboring^' glands. Tlic results -.we nol, liowciver, as sure as they are with the knife, for we find a ccsrtain .pcrcoitage of cases that arc al)solutc]y intraetaljle to the rays, thf; treatment is usually more pi'olonged, and, if a, dcrnialilis b<' produced, the treatment is usually more paiirful. And, (inally, in the hands of an exf^ert sur- geon there is not a, great difTcrcnce in the scai'ring pi-oduced by the removal of a small tuiiioi-. The x-ray has, however, a great field of usefulness. It is the ideal treatment for l)asal-cel]ed cancers of the eyelids, of the naso-facial folds, and of the ears. In addition, it is useful in the very old, who cannot well sul)Miii 1o an operation, and in certain very extensive cases of cutaneous cancer. In some of these cases it will render the patient comfortable and prolong life, even if it will not cure. The general tendency is for the x-ray ex- pert to belittle surgery and for the surgeon to make light of the rays, whereas in reality each field of therapy has a great field of use- fulness. Radium — At the time of writing, radium" is receiving more than its share of notoriety, both in the daily press and before the va- rious medical societies, as a cure for cutaneous cancer. In fact, radium seems to be going through tjie same stages that the x-ray has — first, it has created wild enthusiasm, then deep disgust, and finally it has found its true place. The general trend of opinion is that radium must be used in large quantities and the application must be for a considerable period — that is to say, the present ten- dency is to use it in ''massive doses" just as in the case of the Rontgen rays. While the greater portion of the radium in the world is produced in America, it has been used much more abroad than at home; in fact, the majority of American dermatologists have been profoundly skeptical concerning its value, and this is hardly to be wondered at when one considers the undue enthusiasm with which it has been advocated by certain men on both sides of the Atlantic ocean. Eadium is usually employed in the form of the bromide. Its gen- eral action seems to be comparable to that of the x-rays, but rather more powerful. It is knoAvn that three classes of rays are given "Lawrence: Radium Therapy, Melbourne, I'Jll. Wickham: Arch. f. Dermat. u. Syphil., 1012, cxi, 161. Wickham et Degrais: Radiumtherapie, 2d ed., Paris, 1912. Newcomet: Internat. Clinics, 23d ser., ii, 268. WilUams and Ellsworth: Jour. Amer. Med. Assn., 1913, Ix, 1694. Simpson: Jour. Amer. Med. Assn., 1913, Ixi, SO. 196 SKIN CANCr.R. oft* l)y it, and those rays are eallotl the alpha (a), beta (fi), and •raniiiia (y). The ali)ha rays possess but little power of penetra- tion, and nw somewhat deviable by a ina^fnet. They ean be absorbed by an air c-ushion of three inehes thiekness. by ^dass, or thin alumi- num. The beta rays have mueh more i)enetrative i)o\ver, but are metre easily dcxiati'd by the malakia upon the tongue. The actual cautery can well replace this caustic. Pyrogallic Acid. — Pyi-ogallol is considerably used by some men, largely because it is suj^jiosed to have a selective action and to spare healthy tissue, while destroying the cancer cells. It is usually em- ployed in a 10 percent strength, but the author agrees with Stel- wagon^* that this is entirely too Aveak, and that, to expect any re- sults, a 25 percent strength must be used. The following i)rescrip- tion would be about correct : B Pyrogalloli ."ij Vasclini, EesinjB cerati, aa partes requalis ad 3j This mixture is s])read ujjou gauze and kept closely aj^plied to the cancer, changing the dressing twice daily. At tlie end of five to eight days a slough Avill form, which will shortly sc])arate, or which may be loosened by means of a poultice. The ]»art is then cleaiLsed, and the ti-eatment continued until the ])liysician thinks that sufficient tissue is destroyed. As a general rule, this method has one commendation — the lack of ])ain caused. "Pu.sey: Jour. Amer. Med. Assn., 101.3, Ix, 434. "Stelwagon: Diseases of the SIfiii, Phib.., 1914. TKKATMKNT. 1 Ijfj CAUSTICS. Caustic Potash. — (!;uis1ic poljisli'' is ;i iMtwcffnl cjnisli'-., aiicst obtained l)y loosely screwing- a small brass rylindiT 1o 1lic fnitlet valve of a coniinereial tube of the ^'as, wliidi is supplied to nil di-utr- gists for the purpose of ehai'jjjin^ theii- soda wa1 cr, and linn tit.ditly tying a piece of chamois over tlie end of the tube. In ihis way a molded i)eneil of the snow is obtained i-eady foi* use. Jt is best handled in a pair of heavy, lined automobile gloves, and is ajtpiied to the growth for from one to three minutes, making firm pressure. The action is essentially caustic, and is not very deep. The authoi- has seen it used in only four instances of cancer, and in all of them there was prompt recuri-ence; hence he does not advocate this form of treatment. Some other dermatologists, however, report suc- cesses from its use. MEDICATION. Arsenic. — Arsenic is still used internally by a few men, Sher- Avell, in particular, advocating it, and even Pusey seeming to think that it may have a slight inhibitive action. It is nsed either in the form of FoAvler's solution or as Donovan's solution, the maximum dose usually being employed. There is no doubt of the value of this form of treatment in sarcoid and in the border line cases between sarcoid and sarcoma, but there is very little evidence that it is of any value in true cancer of the skin, other than acting as a general tonic. Methylene Blue. — The internal use of methylene 1)lue has l)een advocated by no less an authority than Jacobi-^ in internal cancer, that author believing that, while it will not cure the disease, it will at least hold it in cheek for some time. So far as the author knows, the internal administration of this drug has never been sho^^^l to have the slightest effect upon cutaneous cancer. ^"Dade: Trans. 6th Inter. Dermat. Con., 1907, ii, 672. Whitehouse: Jour. Amer. Med. Assn., 1907, xlix, 371. =>» Pusey: Jour. Amer. Med. Assn., 1907, xlix, 1354. Jour. Cutan. Dis., 1909, xxvii, 32. Jour. Cutan. Dis., 1910. xxviii, 352. Low: Carbonic-acid Snow, New York, 1911. "Jacobi: Jour. Amer. Med. Assn., 190G, xlvii, 1545. 202 SKIN CANCKR. Colloidal Copper Salts. — Witliiii a short time preparations of col- Ktidal (M)i)j)er have been injeeted into eancer i)atient.s. Loeb, ]\Ie- Cliirg, and Sweek-- state that they "'ai'e now a])le to eausc the grad- ual retrogression of human oaneei*. whieh nntit now has withstood variousinodes of tn-atment ; ana]ier on the use of this method from the Cancer Keseareh Service of the Cornell I'liiversity ^ledical School, in wliich lie de- tails his experiments with and his elinieal use of this metliod, and decides that this form of treatment is ])robably without value. Weil finds that tlie injei-tions are not \\cll Ixinic. that 1hc\- ai-e followed by chills and rigoi's. and tliat nausea and vomiting are very common. In addition to these sym])toms. there is usually a progressive anemia. Locally, there may result cithei- ])li]ebitis or ])eripldfbilis. Immune Sera. — The various attempts to produce either an active or a passixe immunization against cancer is an extremely interesting one, but so far the results have been so contradictory that it would probal)ly be a waste of time to attempt a description of even a few of them. The literature is voluminous. l)ut speedily becomes obso- lete. A. E. Thayer,-'* of ^lo])ile. has recently written a very interesting paper on epitheliolysis against cancer. lie has worked on the as- sumi)tion, now well grounded, that the injection of cells from one animal into the body of another would make the scrum of the re- cipient animal lytic for such cells, and this was a specific reaction. In addition, the carcinoma cells are less resistant than normal cju- thelial cells; hence, if tlie lytic power of the serum could be raised, the cancer cells would be the first destroyed. In one case of in- operable cancer of the uterus, washed autolyosates of cancer were in- jected with apparently beneficial results. ]\Iore confirmation is nec- essary before we can be sure of our ground. At the Freedmen's Hospital we have tried to produce active im- munization against epithelial cancer in a few eases. This was done by making an extract of a cancer of a similar histological origin, splitting it into toxic and non-toxic parts as suggested by Vaughan, and using injections of the non-toxic part once a week. The results were negative, although one i)atient did state tliat tlie injections were distinctly stimulating. "Loeb, McClurg, and Sweek: Inter.slate Med. Jour., Iftl2, xix, Uil,'>. ='Weil: Jour. Amer. Med. Assn., 1913, Ixi. 1034. =» Thayer: .South. Med. Jmir.. 101.'?. vi. i>r.-. TREATMENT. 203 Mjuiy att,einf)ts have been made In IimIucc; p;i,ssi\(: inirtiudi/.jitjfni by llio iiijoclion of an imniimo scniin. As \\cvh-\cy aiul Bfclx/'^'' point out, tliis tlicorcl ically is an idcnl 1 i'c;il mcnl \'i>\- f-ancer, for it is .soluble in the ))lo()(l, transinissii)lc by liic l)loo4 SKIN CANll.H. TREATMENT OF COMPLICATIONS. Infections. W'lun an I'pit lu'lioina has \)v<.'\\ in an ulcei'ative oon- (litinn liii- any liiiiilh nf tiiiu'. it i.s not unusual for it to bocoiiio iu- t"fctt't|. and this int'i'dioii may he with a simple |iyoji:('nic oi-jranism, as tlif stapliylocofcus. or with sonu' sucli jit'i-ni as tlio protous. Jn tho i»utrc't'activo cases tho odor is often hori'ilile. In the former case, extension ma\- take jilace and death result from menin^ritis. The first essi'Utial in dealing; with an infection is to deternnne the ehar- actei' of tlie offeudinj; or^Muisin and the de|)th of the infection. In many ca.ses the use of antiscplic wet dressinir. 1a!licated. In some instances, as when the (irl)it is iiivade(l. there is always danger of meningitis developing, and when the mouth is invaded the patient may starve to death. Ti'oatment in all such cases must l)e according to tho general linos of surgery and modi- cine — at least give the patient comfort, and relieve as far as possible all of the symptoms. Here each case must be decided on its own merits — no specific rules can be laid down. TREATMENT OF INOPERABLE CASES. The subject of the treatment of inoperable cases is not as pain- ful a one as might ayipoar. for much can fref]Uontly be done for them. 1'ItKATMKNT. 205 In llic first ])l;i('(>, iiuiiiy so-c;ilIc»l iiioiicriihlc fjisfs iirf sli'ictly op(:r iiii>h glands should be removed at the onset. The one object in the treatment of cancer is to wipe out every last cancer cell-^not one must be left. To do this means the sacrifice of apparently healthy tissue, and the surgeon must school himself to do this, making the question of deformity an entirely secondary consideration. It is l)etter to learn a few modes of treatment and practice them well ratlier than to liave a superficial knowledge of all the varieties of attack; and, above all, tissue from each tumor should be submitted to competent histological examination, for in no other way can we increase our knowledge of the relationship between the pathology nnd llic clinical course of the disease. =«Bloodgood: Jour. Anier. Med. Assn., 1010. Iv, 1G15. CHAPTER XIX. TUMORS ACCORDING TO LOCATION. Hertzler/ in liis ;i(|iiiii';il)lc l)Of)k on limioi's, deals with neoplaHms according to tlicir location, and for further details the reader is re- ferred to his volume. Many of the epithelial tumors, however, vary in malignancy, and hence in their clinical course, according to the region of the skin from which they arise. Also, it is impossible to treat tumors of different localities in the same way; for instance, one cannot treat a basal-celled cancer of the eyelid as he would a similar tumor upon the back. Scalp. — The commonest neAV growths upon the scalp are of a benign variety; wens or w^arts are especially common. Malignant melanotic growths at times have their origin here. Cancer of the scalp is rather uncommon. According to Hertzler, von Bergmann found that out of 675 skin cancers in his clinic, 36 had their origin in the scalp. These tumors may be either basal-celled or prickle- celled, but the latter are probably the more common. Bloodgood states that out of 17 epithelial tumors, only 6 were basal-celled, and 2 of my own 3 cases were prickle-celled in character. In small basal- celled tumors, excision is the proper course, but in large neoplasms it is justifiable to try x-ray, because a plastic operation to repair the defect caused by extensive excision is very difficult. In the prickle- celled growths, broad local excision and removal of the neighboring glands is the best. Of course, in this location block dissection is im- possible. From time to time cases of malignant turban tumors have been re- ported. While these were given various names, and while the path- ological examinations differed somewhat, still all of these growths had many clinical characteristics in common, and the name ''endo- thelioma capitis" has been pretty generally applied. AncelP re- corded a case occurring in a 26-year old woman, and which was present for ten years. At autopsy metastases were found in the liver. Four relatives were similarly affected, but the disease re- mained local in all of them. Baker" reported another case in a man aged 24. Tumors developed shortly after traumatism, some of them ^Hertzler: Treatise on Tumors, New York, 1012. = Ancell: Quoted by Hoffmann and Friboes. 3 Baker: Quoted by Crocker. Diseases of the Skin. 207 208 .SKIN CAXCKK. luuk'rwent siioutaiu'ous involution, liut ono «ji-o\v until it ivaehocl a (lianiotri- of l(t inclu's. whon it was surjzically roinovod and roiiortod by the jiatlinliiirist tn lu' a liltrosarcoiiia. ('oiin' i'cikii'IimI an instance in a woman ajjoil i)'2. who had the inalaily \\)v twenty-six yeai's. One of her children had the same tronlilc Tlie patholotrit'al dia}j:nosis was "alveolar sarcoma of l>illi'. \vlio had liccn afl'ci-tcd foi- \\)y\v \cars. and whose ,.:^^ jl4^-^7^ffTjA^n^ ^!^%^^^M > St^^^^ ? L^^^ jm^y^ V ^^j^^/ "^k ^^' f' ■ ^ /■' Fig. 71. — Enduthelionia capiti.-^. (Aftc-i- Sijiegler.) daughter had a similai" condition. Ovt)'' saw a case wliidi developed after injury, and which was tlioujrht to he a si)indle-celled sarcoma. Barrett' saw the same condition in a mother and her two daughters. He called the growths "multiple sudoi-ipei'ous adenomata." Spieg- ler'' has carefullx- studicil the condition and decided tliat the condi- ♦Cohn: Jour. Cutan. and flenito-Urinaiy Di.s.. 1S:>:;, x, V.f.i. ' Kapo.si: Comptes Renrlus de ConK. Internat.. Rome. 1894, 135. *Oro: Giono. Ital. d. mal. Yen. e. d. Pelle. 180C, Fas.s. ii. 'Barr.'tt: Brit. Jour. Dermat.. Feb. 6, 1802. •Spiegler: Arch. f. Dermat. u Syphil., 1800, 1. 1G3. TUMORS AC(;()KI)IN(; TO I-OCATIOX. 20fi tion was really cndotliclioiiwiloiis. P()iif(;l'' li?]s dcsfribod another case, calling it a cylindronia of the scluiccoiis yjjinds. IfaHlnrul"* re- ported a ease in wlilcli metastases occuiic"!. I lofriiKiiiti and P^rihoes^' mention still oilier cases. Lawi'cncc lias s(;eu tlie disease in ;i mot her and daughter, and the |);i11iological reftort was endothcliojiia. Hoffmann and Frihocs li;ive described a ease which they consider to be a perfect illustration of a, ])enign basjd-cellcid tumor. They are inclined to believe that the vast m.ajority of these growths are basal- celled in character. Krompecher^- agrees in this view. It is prob- able that various types of malignant growth can give a similar clin- ical picture, and that treatment must depend entirely on tbo mifi-<-)- seopical findings. Forehead and Temples. — Basal-celled neoplasms are not as com- mon here as upon the face, but are fairly fi-equently seen. Seciue- Fig. 72. — Basal-celled carcinoma of the forehead. (Heidingsf eld's collection.) ira,^^ in his series of 220 cases, saw nine upon the forehead and twelve upon the temples. In commenting on those of the forehead. "Poncet: Quoted by Spiegler. ^"Haslund: Quoted by Hoffmann and Friboe-s. "Hoffmann and Friboes: Trans. 7th Inter. Con. Dermat. e. Syphil., Rome. 1012, 931. Hoffmann: Deutsch. Med. Wchnschr., 1010, 2365. Friboes: Beitr. z. Klin. u. Histopathol. der gutart. Hautepitheliome, Karger, Berlin, 1012. 1= Krompeeher: Der Basalzellenki-ebs. Jena. 1903. " Sequeira: Brit. Jour. Dermat., 1013. xxv, 172. 210 SKIN CANCER. he says: '"Here tho ulcers are usually of the superficial cicatrizing: type. They often start just above the rot)t of the nose and extend upward in the frontal region." Crocker, in his specially illustrated book, has a very good cut of a case of this variety. The tumors originating U])on the tenijjles seem In liavc a sj)ecial tendency to become fungating. Basal-celled tumors aiising in these localities are much coimnonci- than tlic itricklc-cellcd neoplasms (Fig. 72 V Eyelids. — Basal-eelled growtiis are very ])rone to arise from the inner eanthus of the eye, and to a sliglitly less extent from the outer canthus. Over thirty of Sequeira's cases had their origin in one of these locations. Tumors springing from other portions of the lids are comparatively infrequent, but nevertheless do occur, especially upon the lowoi- lid. Bloodgood says that out of twenty-four epi- Fig. ?3. — Basal-celled cancer of eyelid that has invaded the orbit. lection.) (Author's col- thelial tumors, benign and malignant, originating upon the lids, twelve were of the basal cellular variety. Hence it can readily be seen that the vast majority of malignant tumors arising from the lids are not of the prickle-celled type, and therefore are not especially malig- nant (Fig. 73). McDonagh'^ has recently Avritten an interesting article on the path- ology of the skin from the eyelids and naso-faeial gi'ooves, and con- eludes his article as follows : "Tumors affecting the orbito-facial and naso-facial grooves are of epithelial origin, and atavistic of l)oth the lower eyebrows and the "MoDonagh: Brit. Jour. Dfrniat., iril2, xxiv. 2'.n. TUMOKS A(j(;()i{i)iN(; TO ]j)<:.\-i\()S. 211 specialized f^larids CniiiKl in IIm'sc regions in iii;iMy of the mammalia. There is probably nol ;iii iii(li\ilvl.N CANCER. Operation'' is undoubtedly the best. Tiie majority of surfjeons and dermatolojrists ajrree with these conehisions, even the most enthu- siastic ojierators advisiny: x-ray first. Caustic i>astes must never be used. l)ecause of tlic itrdximily of the eye, ainl the iiial)ilil\- to cdii- trol their action. Nose. — Tumors oriirinalinLr from the naso-facial iirooves (Fiir. 74) arc almost in\iii'ial)l\' ol" the l»asal-ccllc(l tyi)c. niid arc coiimioiicr here than ujHm any othci- part of the body. Hh)ody:o()d"' says: "The basal-ccHcd tumor is situated most fi('(|uently ui>on the nose (50 percent. l-> out of 'J(i cases)." Tmnoi's uiuui the ln'iduc of the nose may be of any of tiie other tyi)cs of cancer, and the ])rickh^-celled variety the next most fi-e(iucntly encountered. It is usually a rule to consider that all tumors of the nose ai-e I'odeiil uleei's. but tiiis is a mistake. A short time aj^o the autlior removed from the l)i-i«lyre of the nose a small tumor that had been ])rcsent for over six months, auil was surprised to find it to be a tyi)ical sininiiioiis-celled carci- noma, h'ortunately tumors in this location <>;row slowly. Because of the diftieulty of excising a jjrowth in one of the j^i-ooves. it is better to use either the curette and cau.stic or to rely on the x-ray. In the spinocelled tunu)rs it is imi)ossible to do a l)lock operation. so the glands must be left. Ears. — Two distinct types of tumoi-s arise trom llu' eai's — those having their origin upon the piniur, which are mostly rodent ulcers, and those arising from within the auditory canal, which grow very rapidly, being of the iiioie malignant type, llcidingsfeld has had a very remarkable case where such a tumor arose from the mastoid region after an operation for an infection of this area. Tumors of the i)inna are not often met; the author has seen only one. and ]^>lood- good rei^oi'ts oidy three. The rodent ulcer variety should be treated with either the rontgen rays or curette and cau.stic l)ecausc of the deforniity that must of necessity follow an opei'ation with the knife alone. The dccji tumoi-s are ])robably hopeless fi-om the stai't, but radicnl suru-(-ry mi'z'lit save a few. Cheeks and Face. — Basal-celled tuinoi-s here are comparalively common. Bloodgood has seen fourteen out of a total of fifty-five cases of benign and nuilignant ei)ithclial tumoi-s. They usually arise about 2 cm. below the eyelids, but may occur elsewhere. Twenty- four of Sequeira's 220 cases had their origin upon the cheeks. "When seen early, these tumors should be excised and the scar closed by a linear suture; or, even better, after excision the edges should be "Sherwell: Jour. Cutan. Di.'<., 1910. xxviii, 487. '•Bloodgood: Propre.'^.sive Medicine. Dec, 1904. TUMOKS ACCOIUjINO 'I'O LOCATION. 2]') c';uit(!fi/.c(l, ;iii(l I;i1ci' ;i skin \>:n\i'\ done. In cxlciiHivc casoH, eithei' excision or ;i Slicrwcll (»|»('r;iti()n ni;iy \u' [teffoniiefl, or tbo x-ray or radium I ricd. Many of tiu; ]i(H)i)la.sinH ol' IIk; cheeks ;ii'(! of the ni;dij;n;inl jo'iekle- eelled variety, and ^row very r;if)idly. In sneh ejises it is iieeossary 1() do ii \'v\'y rjidicid oper;!! ion, ini-ludin^ tlic rcnio\;d of llie neij,'li- borinj^- lyinjdiaties. Chin. — Basai-cclled liiniors of llic fliin arc rare Sequeii'a has seen only two such cases. I'riekle-eelhMl iiuiioi's are also i-arc. Blood- good has had two instances of so-called basal-celled tumors whci'C metastases took i)lacc to the submental glands, but is inclined to re- gard them as cuboidal-celled growths. Excision is Ihe best treatment for growtbs in this locality. Neck. — C'onsidering the chi-onic iri'itation caused by collars, can- cer of the neck is rare, although a few. instances do occui-. The neo- plasms arising in this locality usually spring fi-oni moles, then form- ing nevocarcinomata, in the sense of Unna, or fi'om congenital fibro- epithelial outgrowths, then forming typical rodent ulcers, more rare- ly squamous-celled- neoplasms. Treatment is ahmg the lines already indicated. Lips. — Appreciating the earnest efforts of various authors and members of committees to educate the laity and. impress on the pro- fession the methods which should be adopted to improve results in the treatment of cancer, the author feels that he can best introduce the surgery of cancer of the lips by calling attention to certain facts which seem of special moment in cancer occurring in this situation. Precancerous Lesions. — The surgical importance of any abnor- mality appearing at the mucocutaneous junction of the lips, espe- cially the lower lip, at middle life or later, cannot be too much em- phasized. If the lesion persists for a few weeks or over a month, although it may be only a slight scab (Figs. 75, 76), wart, indura- tion, or little ulceration, it may be of the gravest significance, for this is exactly the way that cancer of the lip starts. There is al- ways a precancerous stage, and this is the ideal time for interfer- ence. Bloodgood rei)orts cases which show that a Avart situated ou the lower lip may become malignant within two months after its appearance. Cancer may develop in a pipe burn within two months, and a fully developed cancer with metastases to the glands of the neck is possible three months after the initial lesion is noted. The greatest risk is in the cases where there has been a delay of more than six months befoi'e operation. Hence these early persistent le- 2U SKIN CANCKU. sions should be excised with a inarfjfin of healthy tissue; {rcnerally a small wedjje-shaped excision will suflict'. This slires, it could not be i'ceoy:ni/.ed until the patient returned with glandular in\-olveineiit. AVheii the latter ai-e involved, the oj^era- tion is a serious one. anil the })ercentage of cures is very much lower than in the early ca.ses. If the tissue ]irove, on microscopical exam- Pig. 75. This patient is sufferirg from a seborrheic keratosis of the lip. It would probably have become iiuilignant had it not been removed. (Sutton'.s collection.) ination, to be cancerous, the cervical lymi)h glands should be at once excised. In early cases, before the lymph glands are involved, we can hope to cure about 95 percent of our cases, but after involvement of them has taken place the statistics show about 50 percent of cures. Our methods are improving, but two very vital factors in future success are cai-ly diagnosis and early operation. Incidence. — Cancer of the lips is comparatively comnion in men and very rare in women, and usually occurs upon the lower lip. Steincr^^ reports 140 cases of cancer of the lower lip and 12 of the »• Stelner: Deut. Zeitschr. f. Chir., 1009, xcvii, 243. TUMORS ACCOUDING TO LOCA'l'IOX. 215 upper, Judd"^ Ims Ii;ul \^)-\ of llic lower iind only Ihrct; oj" tlio up- per, while liowiil rc(i''' jii\c.s llic r;i1io ;is 2:1 1 1o 7, and also states that six times ;i,s nuiny oiiifers are found upon the side of the lip as upon the eeiiter. IJloodj^ood 's'-" s1;i1is1ifH sfiow U!l f'f)ithelial 1u- mors of the lower lip Jind "II of 1lic iiiipcr lip. CjuK-cr of liie lip appears about or aftei- middle life in the \;i,Ht majority of iustanees (Fig. 77), but may occjisionnlly (|e\clo|> in the younj^. Ilertzlcr shows a marked example in ;i l)oy of l(i, ;ind llie author illustrates a case in a man of 27 (Fifjf. 7S). (Jancer of the lip is mueli nioi-e common than ])oiii^n affections of Ihesc orfrnns. Fig. 76. — This man has a very extensive seborrheic keratosis of the lower lip. (Sutton's collection.) Etiology. — Irritation of the lips seems to be the most potent factor in the etiology. A smoker's burn of the lower lip is the commonest cause of irritation, but ragged teeth, or the habit of bit- ing or picking the lips may cause sufficient irritation. Cigarette smoking, where the paper stuck to the lips and left irritation when removed, was apparently the cause of one cancer under the writer's observation. The early abnormality may be a slight ulcer or loss of epithelium, or there may be an epithelial hypertrophy and a re- isjudd: Old Dominion Jour. Med. and Surg., 1908. vii, 399. I'Rowntree: Arch. Middlesex Hosp., 1908, vii. 119. -0 Bloodgood: Jour. Amer. Med. Assn.. 1910. Iv, 1537, 1615. Surg. Gynec. and Obst., April, 1914, 404. :iUi SKIN CANCr.R. sultiiiii: wart. Sitiue lesions may i)i'rsist as linii^ni Irsidiis lor sev- eral years, and then tie trene rate, but ^enei-ally the i'hanf»c is early anil (tftfU \ri\\' rapid, as lias already been slateil. Sarcomata. — In elassilyin*; the nialiirnant tnnioi-s oi" the lips, men- tion must be made of sareomata. ("ertain of the an radical sury:ieal treatment, ^lore rarely, snudl round or spindle-celled sarcomata oeeur upon the lip. !Markley-' has reeently rei)orted such a case and eollccted sev- eral others from tlie literature. His ])atient was 65 years of age, and. because of this fact and because of the involvenumt of the eervi- I-^ig. -Ulcerated prickle-celled carcinoma of the lower lip in a negro, of two years' duration. (Author's collection.) cal glands, diaj.jnosis of carcinoma was made, but the microscope showed the lesion to consist of small round cells, a typical sarcoma As the tumor had been present for six months before radical opera- tion was done, the prognosis was naturally bad. These tumors metastasize early, either through the blood stream or through the lymphatics, and operation must be done very eai-Iy in order to save the ])ationt. Carcinomata. — The epithelial tumors of the lip are the most im- portant for our consideration, for they are the common grow-ths that demand surgical treatment. The lip cancers may be grouped under "Markley: Jour. Amer. Med. Assn., lOl."?, 1x1, r.'A. TUiMoits A(.'(;()i;))iN(; ■[(> location. 217 two licadiiifijs — the k((u;iiih)IIs- or prickle (•(■lie. I 1y)H; jind llio l)asal- ciollcd vurjcty. ^riic iiialijiiuiiil \v;irls ;il.so dcscrvo r'ori.sid(!ration, al- though they arc |»r;ic( ic;ill\ ;il\viiy.s pricldc celled in orii^dii. This claHsificatioJi. is based on tiini of l\ roinpeclier. 'I'lie ciibocfiljed tu- mors are Ix^st incJiKhMJ with the s(pi;inioiis-cellcd neophisiiis, foi' thoy a.re of almost sinnhir ni;di^ii;incy, ;iiid hence re(|uire 1lie same treat- ment. Basal-Celled Tumors. 4:iider the hasal-celled type wc may clin- ically have nodular lesions, usually beneath the skin, ulcers, fungi. Fig. 78. — Prickle-celled carcinoma of the lower lip in a young man, which arose after treating a clinically benign lesion with caustic pastes. (Gilchrist's col- lection.) or warts. The vast majority of the so-called rodent ulcers are basal- celled carcinomata, but occasionally a prickle-celled, tumor may run a similar course, differing only in the fact that gland metastases re- sult. Microscopically, the difference is easy to detect, as has already been sufficiently pointed out. Usually the clinical difficulty in diag- nosis occurs only in the very early cases. The basal-celled growth has a greater tendency to appear as a subepidermal nodule, its growth is slow, and gradually a scab is formed : the latter comes away and an ulcer appears, or a fungous growth may develop. Spinocellular Tumors. — The spinocellular cancer of the lip com- monly starts at the mucocutaneous border, and the first symptom is 218 SKIN' CANCKH. an area of imluration. with slii^ht iik-erat'um. I'xitli tlu' iiuluration and the ulceration tcnil \o increase rai>idly. and the subniaxiUary lyini>h «rhinds soon beeoine hard and shot-like. This tjrowth often has the appearance of chancre, and the followin}? are the chief di- agnostic iH)ints. Chancre is comnioii in the younj;: cancer is coni- nnm in the old and rare in the young; cancer is very rare in wom- en; chancre equally connnon in the two sexes; chancre is almost as common upmi llic upi)er lip as upt)n the lower, whicli is not true of cancer; in chancre the growth is much moic i-ajiid than in cancer, and tiie lymph glands enlarge much earlier; the spiro- chete can l»c dcmonsti-ated in chancre, and the histological pic- Fig. 70. — Fungating carcinoma of the lower lip, of only five weel LOf.'A'l'IOX. 219 good's .stati.sticN coiiccniiii}^' iiiiiliuiiinil liitnois of llic lower lij), pub- lished in 1910, thei-e were 100 s(iiiioc(lliil;ii- liimors, 2 cuboeellular neoplasms (whieh av(! eaii include willi the preec^diiif^), and only 4 hasal-ccllcd growths. In eontrast, liis figui-es eoneei-iiing eancer of the upper lip showed 4 spino-eclled growths and 9 basal-celled ones. In determining the r('l;i1i\(' iii;ili<,ni;Mify of a tumor of tlie lip, certain general rules hold ;is for cpilliclijil lumors upon other poi-- tions of the body. Lon^' durjilioii, no liislory (»f ;iny active growth, Fig. 80. — Fungating cancer of the lower lip of five years' duration. (Heidingsfeld's collection.) absence of enlarged draining glands, tendency to remain peduncu- lated, a lack of definite induration at the base, all point in favor of a more benign type of growtli. Malignant Warts. — The malignant Avart, already mentioned, is a prickle-celled tumor. Papillary epithelial tumors may be malig- nant from the onset, or may develop malignancy from a benign growth, but, as a rule, metastases from these tumors do not take place. Bloodgood^*^ describes such a growth springing from the muco- cutaneous border of the lower lip in a feeble old man,, the tumor being of one year's duration. The tumor had a large papillary sur- face, which overhung normal skin, and was attached by a pedicle to the edge of the mucous membrane. There was no induration below !l!U SKIN canci;k. till' ]H'ilirlo. Hi'cause of the nhove I'lu-ts tlio oporator was able to coiu-liule itii (tpiM-atiun. that the tunuir was oithoi" l)onitrn or a v(M'\ I'aily papillary (.'pithelioiiia. L'iical I'xcisioii was iH-rforincd. and early caiu'crous chaiifjes. liinitoil to tht> wart, wore I'oiiiul. Fuillior (•poratiitu was dccniod iiiiiuH'ossary. and thorp was no i-ccurivnco. Bloodgood has ol)si>rv(>d st-vt-nlrrn iiudiLiuaut warls. and all hiit one has roniaiju'd ciiivd hy operation, and in that caso the local incision was not sufli('ii'ntl\' broad. In nine cases merely a wedtro-shai)ed piece was rcniovetl. and in eitrhl the cer\ ical i)f;)'a1.int( lablc, where llie diji^iiosis c;ui ]h' iii;i(1(! cillicr froin I lie, i^yoss jipiK;-'i ranee of the tissue oi' From ;i frdzcii scdion. ;iihI holti tlic iijilicnt ;iih1 (i]k-v- atof i)re|);u'e(l to Jiiiiii(Mli;i,1,ely j^o ;ilic;ise from, the central portion, and hence any bbjckinj^ of rej^ular drain- age, whether by cancer or iidlfunination, may cause the lymjth stream to flow in any direction. As a, result it is ])est to remove the glands upon both sides at the same sitting. The deep cervical group of lymph glands (Fig. 84), estimated to comprise from fifteen to thirty glands, extends from the tip of the mastoid and posterior belly of the digastric muscle to the junction of the internal jugular and subclavian veins. Some of these glands lie in front, but a larger number lie behind the internal jugular vein. This is a ver.y important group in surgery of the lip, because it forms the second glandular relay for the area -which drains the submental and submaxillary glands. Consequently, when the submaxillary glands are involved, it is necessary that the entire deep cervical group be removed. The author believes that the ideal treatment of cancer, in general, requires that the primary growth, along with the lymphatics drain- ing the part, should be removed in one piece ; there should be no division of lymphatics. It is not, however, necessary in most eases of cancer of the lower lip for the incision for the removal of the glands of the neck to be continuous with the incision in the lip. Witness the cases where the operation upon the lip has been done independently of that on the neck, and no appearance of cancer in the lymph vessels, which lie between the primary growth on the lip and the first relay of glands in the neck, has become manifest. Beckman,-* in his report of these cases from the Mayo clinic, states that he has not observed a cancer occurring in the lymphatic vessels betAveen the original growth and the lymphatics of the neck, and that cancer of the lip is either a local growth or a metastasis in the adjacent glands. Because of the danger of infection from the buc- cal cavity, it is of great importance that the local excision and the operation on the neck should be independent, and that the latter be done first, although both should be performed at the same sitting. ='Beckman: Jour. Oklahoma State Med. Assn., Oct.. 1913. 224 SKl.V CANCKK. In removing: a section of lip wiiidi coiitaiiis n basal-collod tumor 01* one of the inali},niant warts, oi- wlien tlie he found that not enough margin has been ^ixcn. r.croiv ninkin^'- llic inr-ision it is an advantage for hemostasis to liavc. Jin ;iHsiHl;in1, r-oni press the lip on each side Ijetwcen tliuiiil) and forefing(!r. The tissue removed is generally in the shape of a wedge, with the apex down in tumor of the lower lip and apex upward in the case of the upper lip. There is a divided coi'onaiy artery to ])e ligalcd on each side, catgut be- Fig. 85. — This figure and the following one show the common method of repair- ing a defect caused by the excision of a V-shaped piece of the lip. ing used. Careful approximation of the skin and mucous membrane with linear continuity of the vermilion border of the lip is, of course, desirable, and is perhaps best done with fine silk or horse hair for stitches, using interrupted sutures. Proper cleansing of the mouth and teeth 1)efore operation, giv- ing special attention to pyorrhea alveolaris (in which case the gums should be cleansed and swabbed with tincture iodine), are impor- tant for prompt and cosmetic healing. The sutures in the skin had best be removed early. Avithin two or three days, to prevent cross 226 SKIX CANCER. scars. TIk' \a\vv .spi-e;ulin«j: of the woiiiul o;in ho i)rcvi'iitO(l hy ad- hesive strips across the wound or a coHodion dressing. lU^eaii.se of the freciueney of tlie ])rickle-eclled eaneer, all sections thus removed shouM he exainini'd 1»\' an expert i)atholop:ist, and, if found to be true eaneer, unless of the liasal-celled ty]ie or of the non- intilt rating warty variety, the opei-ation upon llie neck should be done at an early date. Various plastic operations are used in rejiairinj; tiie lip after the removal of a section. The avoidance of tension and the cosmetic re- I Fig. 86.— See Fig. 85. suit should determine which of the chiloplastics is to be used in a fjiven case. That generally used when a small lesion has been ex- cised in the shape of a Avedgc is simple approximation of the edges. If the wedge removed has been a large one, and a great portion of the lip is missing, a horizontal cut can be made from the corner of the mouth upon one or both sides, carrying the incisions through the thickness of the cheek, and then the sides of the wedge drawn together without tension (Figs. 85, 86). ]\Iayo's method of remov- ing a quadrilateral section instead of a wedge is an improvement (Figs. 87, 88). In extensive growths, Avhich have invaded the lip or cheek extensivelv. there can be no hard and fast rules for the TUiMOns ACCOinx.Nw; ro i.ocatkjn'. 227 ehiloplasty (J^'i^s. S!), !)0, !)l). I1 is mosl, impoi 1;iii1 1o »/ivf Ihf growth a wide iiiai'i^in ;iiiil nol siicrilifc coiiiiilcfc rcuKJVJil 1o Ific rlr;- Kire for an cany closure As has l)(M.'ii s;ii(| iihovc, llicrc slioiiM ])vc\'cvi\\)\y lie no cowdcc^jou between the lines ol" incision i'nr removal of a growl h on the 11 f> and the incision on the neck Jor llic removal of the lymf»hatics. The older ingenious plastics, which combined (hips i'oi' 1lie closun; of gaps in the lij) and exposure of field for )'(;iiiovi)ig cei'vical lymithaties, are obviously not to ])v reconunended — first, ])ccHnsc of the risk of infecting the entire field of operation from the buccal cavity, and, second, because the operation upon the cervical lymfth glands can- not be complete enough. In the hands of those expert enough in the use of local anesthetics, especially novocaine, extensive o])crations can be done upon the neck Fig. 87. — This shows the incisions used at the Mayo clinic, both for the removal of the growth and the repair of the deformity. (Redrawn after Boeckman.) very satisfactorily without submitting the patient to the risk of a general anesthetic. The majority of surgeons, however, still prefer a general anesthetic for this part of the w^ork. If the lip is done first, the gloves should be changed and fresh instruments and towels used for the second part of the operation upon the neck. It is gen- erallj'' advantageous to do the radical operation upon the neck first, and, after the neck incisions have been closed and protected, excise the portion of the lip containing the growth and repair the lip. Extensive operations for cancer of the lip, as for cancer else- where — often in old men Avith arterial, renal, or myocardial changes — should never be undertaken without previous most careful exam- ination of the patient's general condition and preliminary treatment according to the demands of the system. The avoidance of shock, hemorrhage, and infection is especially necessary in these cases. A preliminary dose of morphine and atro- 22S SKIN CANCKR. I»ino. a carofully '^Won anostlit'tic a iiiiniiiiuin of Irauinn from re- traction ami throat dissection, will lessen the shock. The exclusion of nervous stimuli. accordin«:f to Ci-ile's ])rinciple of anoci-assoeia- tion. is an imi)ortant refinement in pi-cventing shock in weak or ner- vous individuals. The most ])ainstakini-evious (i])eration had been done upon tlie lip, or it hatl been ti'cated with a caustic jiaste. and a late radical operation was ])ei-foi-nu'd. the cures were TO ]iercent. Of this lat- ter grou]) showing ^Handular involvement. 33 1 '3 percent were cured. Crile stniiiLrly ui'<;es the iieclv (ii»eratinu as a I'outine in all eases Fig. 90.— Set- Fig. 89. of cancer of the lip. Where there ai'c no pali)al)le glands, he makes the small incision as illustrated in Fig. 92. Thi-ough this the re- gional lymphatic-bearing tissue is removed by block dissection. This includes both fat and glands of the submental and sulnnaxillai-y region on the side of the growth. The submaxillary salivary gland is not removed if there is certainly no in\(»lvement of the regional lymjdiatics. In cases with definitely involved enlai'ged lymphatic glands the entire lymphatic-bearing tissue of that side of the neck is removed. The carotid ai-tery is exposed as low down as possible by an intramusculai- se])aration of the stei'nomastoid muscle, and TIJM(M{S A(;C0I{1>IN(; '10 l-OCA'IION. 2'',] tornporary closure of 1liis ;i fiery is en'ccicd. The eoriiplele skin in- cision (Fi^. 9'>) is llieii Jiiade (iiKiliidinu phil \'sm;i j and the flaps extensively reflected. The sternomastoid is disided, llic external and internal jufi'uliir v(!ins are secured, douMy lied, ;iiid divided at the base of the U(U'i\. The dissection is Ihen f';iri'i(;(l from helow u[)\vard (Fif^^s. 94, 95) into the deKI)IN(J 'I'O IA)(:.\-\\()S. S-)'-> and histologically cxainincd in mnkf! sure of their cli;) rafter. None of the lesions should be tr-cnlcd Mk; way skin lesions may bo treated — that is, by eansties, eautery, ejirbon-dioxide snow, x-ray, radium, etc. The rarer l)iis;il-eelle(l liinMirs :\\\<\ the ni;ili!jn;iii1 warts do not require more tluui a, careful locjil exeision. All squaiiious-eelled eaueers should hnve not <)r\]y local removal, but also removjil of the ;Ul;inds of the neck. The local o[)era1ion e;in rejidily be done witli loejil anesthesia, and Fig. 93. — When the glands are clearly involved, this incision should be made. (Redrawn after Crile. ) under proper conditions the radical operation can be performed in the same way. The slight tendency for the growth to go beyond the cervical lymph glands and the accessibility of these glands should encour- age more radical and painstaking operations. Where the submaxillary glands are known to be definitely involved, the entire lymphatic chain on that side of the neck should be removed by block dissection, including the internal jugular vein. Tongue. — Like all other cancers of the skin and mucous membranes, carcinomata of the tongue do not arise de novo, but from some pre- existing lesion. There is first an ulcer or a little area of infiltration 234 SKIN CANCER. that should «rivo i>kMity of warniniyr. Tlieso precancerous lesions may arise in various ways; they may be due to the irritation caused by bad teeth, or they may result from tlie excessive use of tobacco, either smoked or chewed. The latter must jday some part, for cancer of this or^an is- very rare in women. ShimII ]>apill;iry outsjrowths of «*,V.;''-^vv'^''V \ / Fig. ;'4. — After the skin and i!Ubcutaneou.s ti.-!sue have been inci.sed, the stor- nocleidonia.stoid muscle is divided, the jugular veins ligated and cut, and the carotid artery is clamped. The skin and plat.vsma are then dissected back. (Redrawn after Crile.) the tip or tlie latci'nl ed liisldln^Mfjilly r(;S(;rn}>]c r-ar- ciiioina. Treatment, liloodij'ood-''^' liiis fcccntly wrillfii .-i short, but stim- ulating, article on 1 re;il iiienl of e;ine(-i' of the tnn^iie. lie states that in the very early cases — th;it is, where ni;ili<^ni;in1 ch;in^'e is just tak- ing place — a complete local removiil with the c;iu1ery will nf;arly always effect a cure. Iieferrin^' to the ];iter e;ises, iJloorJgood states: ■ "It has been demonstrated that the failure to eui'e when the can- cer of the tongue is fully developed is due to the neglect to remove the muscles of the floor of the mouth below the cancer. "The high mortality after operations for cancer of the tongue is chiefly due to the removal of the floor of the mouth without re- moving at the same time a section of the lower jaw. "When the operation is performed in one stage, it is impossible to remove the tongue, the floor of the mouth, the glands, and then close the opening in the mouth unless a section of the lower jaw is also removed. If the former operation is done thoroughly, the mor- tality is very high — almost 80 percent — from i)rimary or secondary pneumonia, or late infection from the oral fistula." For moderately early cases Bloodgood recommends an operation done along the following lines: The glands of the neck are first thoroughly removed, and the floor of the mouth above the glands, but below the tongue, thoroughly burned with the cautery, and the wound closed. At a little later date the affected portion of the ton- gue and the floor of the mouth below it are attacked from above with the cautery until the two areas of cauterization meet. The healed skin flap from the first operation forms the floor of the mouth and prevents infection from without. In very late cases it is still necessary to remove a section of jaw, the tongue, floor of the mouth, and glands in a block operation. Trunk, — Cancer of the trunk is rather uncommon, although the most frequent site is around the shoulders. In this locality the ma- jority of growths are of basal-celled origin, and do not metastasize. Upon other portions of the body prickle-celled growths predominate, and they should always be removed, together with the draining glands, by a block operation, as otherwise recurrence is very apt to follow. About the breast we may find Paget "s disease of the nipple or a "Bloodgood: South. Med. Jour. 1914, vii, 542. '24V SKIN CAXCKR. carcinoma tn cuirussc. The latt(M- is very rare, l)iit must be thought of when nodules appear upon the skin in the Aicinity of the mam- mary ffland. Extremities. — Tlie following account is from a i-ecent article by the author.-" Because of the failure to distinguish between the various tyjies of cutaneous cancer, many of the older articles on carcinoma of the extremities are practically worthless from a modern point of view. Howard Fox-" has recently rejiortcd an intei-esting case of cancer of the hand which metastasized to the mediastinal glands, and has reviewed the literature. After studying various articles, notably those by Hcimann,-^ Gurlt.-" von "Winiwarter,^" Neumann, ^^ Bulkley and Janeway,''- von Brunn,^^ Volkmann,^'* and Franz""' he comes to the conclusion that cancer of tlu' limbs is (Mniiparativi'ly a rare dis- ease as compared with cutaneous cancer in other jiortions of the body. Fox, referring to cancer of the hand, further says: "In spite of the malignancy of these cases from a microscopical standpoint, there can be no doubt that clinically they are relatively benign, gen- erally running a slow course, and only late, if at all, invading the hTTiphatic glands." On the other hand, in a discu.ssion^" of this paper, both Schalek and Corlett rei)orted cases in which metastases had occurred, while "Wile called attention to the fact that cancers originating in arsenical keratoses usually metastasized. Bloodgood^' has consistently contended that the lymphatic glands should be removed in all cases of prickle-celled cancer of the body, no matter where located, but especially on the limbs, for here is it always easy to remove the draining lymphatics. Steiner,^^ writing from the clinic of Dollinger, states that a routine practice is made of removing lymi)h glands in all cases of cancer of the extremities. A summary of the literature would seem to indicate that cutaneous cancers of the extremities are not especially common, that they are *«Hazeii: Jour. Amer. Med. Assn.. 1915, Ixv. 837. ''Fox: Jour. Cutan. Dis., 1015, xxxii. 22. ^Heimarn: Arch. f. klin. Chir., 1898. Ivii, 911. »Gurlt: Arch. f. klin. Chir., 1880. xxv, 421. "von Winiwarter: Beitrage zur Stati.stik der Carcinome, Stuttgart. 1878. •'Neumann; Bcitrag zur Kenntnis der Extrcniitaten-Krebse im Anschluss an zwei Falle der Freiburger Klinik, Inaug. Diss. Freiburg im Breisgau, 1911. "Bulkier and Janeway: Med. Record, New York, Ixiii, 465. "Von Brunn: Beitr. z. klin. Chir., 190.3, xxxvii. 227. "Volkmann: Samml. klin. Vortr., 1889. No. 102. "Franz: Beitr. z. klin. Chir., 1902, xxxv, 171. '•Discussion: Jour. Cutan. Dis., 1915, xxxiii, 29. "Bloodgood: Progressive Medicine. Dec. 1004. 1907, 1908. 1912. " Steiner: Deutsch. Ztschr. f. Chir., 1906, Ixxxii, 363. TtlMOKS A(J(,MJin)lN<; 'l(> I.Of.'A'l'ION. 2-11 more common on the lower th;iii on Ihe ujtjjer- limits, that they al- ways follow some ])i'(!('aneei'ous coiMlilions, th;i,t Ihoy are usually of the prickic-cclhul lypc, thiii tlu^y Jii-e j-;ire on tlic [uilins (jf the hands, and thai wiien occii yy\\\iniiipily recui-i-ed. Dui'ing the next five years there were a number of local operations. She then entered the hospital with a mass of inoj^erable glands in the axilla, l)ut with no signs of metastatic growl lis in the body. It is moi-e than ])rob- able that a complete early operation, including the axillai-y glands, would have resulted in permanent cure. The other in.stance oc- curred in a negro man, this being probably the only case on record of a malignant mole in one of his race. The jirimary growth was in the sole of the foot. There were metastases both to the glands and to the lungs, and death speedily ensued. Penis.'" — Cancer of the jienis is not especially common, although certain authors state that it constitutes nearly 1 percent of all can- cers, undoubtedly entirely too high an estimate. None of the text-books or articles that the author has read has given a correct account of the pathology of these cancers, which are analogous to those occurring upon the lip. In other words, there are three varieties — first, the common prickle-celled variety; second, the prickle-celled malignant warts; and third, the basal-celled growths. Cuboidal-celled tumors also occur veiy exceptionally, thus really making four varieties. The common malignant tumors are the squamous-celled ones, that usually originate on the glans penis or mucous mem])rane of the foreskin, and that speedily ulcerate and fungate. ]\Ietastases to the inguinal glands are nearly always present after a short time, and hence in dealing with these growths it is necessary not only to re- move the local growth, but also to do a complete dissection of the glands on both sides. This should be done as upon the lip, making a block dissection, first removing the glands and then ami)utating the penis. Where this is not done, there are ]»i;ic1ical]y no recov- eries, l)ut, where this opei-ation is performed in early cases, the per- centage of cure is above 3G pei'cent. The i)rickle-celled malignant warls may lie mistaken for venereal warts, l)ut speedily ulcerate. There is, however, no induration about the base, and an extensive local removal will result in a permanent »» Barney: Annal.s of Surg., in07, xlvi, 890. 244. TiiMoiJS A(;(;()Hi)iN(; to i>o(;a'1'ion'. 245 cure. In iiijui.v of llicsc f;isc.s it is iicc<'ss;i ry 1o ;i in put ale ifu! (•t\(\ of the j)cnis, but this is not alvvayH ncccissary. The basal-('('ll(;