Definition, description, and histology.* - Epithelioma of the skin is a tumor originating in the stratum Malpighii, and characterized by a tendency to increase in size, to invade adjacent tissues, both superficially and deeply, and to destroy them, and ultimately to destroy the life of the individual that bears them. The growth commences, generally speakias a proliferation downward of the cells of the interpapillary portions the stratum Malpighii. These downward roots or shoots assume various forms. After a time the rapid increase in the number of new cells and the circumferential pressure of the surrounding connective tissue compels them to occupy the least possible amount of space. This they seek to ac-complish by arranging themselves in concentric and stratified layers, constituting the stratified cell-nests, or "epidermic globes" of histological writers. Thus firmly compressed they form little microscopic masses, which, when a number of them are aggregated, give rise to a tubercle or nodule, the peculiar characteristic of which is hardness. After a time, probably as the result of pressure and deprivation of nutrient material, these nodules "break down," that is, undergo a necrobiotic process, which leads to ulceration. This process continues, and the amount of tissue-d<-struction is limited only by the degree of vital endurance possessed by the patient.

We confine that which follows to epithelioma of the skin proper, and do not include in the description the epitheliomata of mucous membranes or glandular organs.

Epitheliomata, however, are not all alike, either in their behavior or mode of origin. Sometimes they appear to arise spontaneously and without apparent cause, sometimes, on the other hand, they are secondary developments arising as sequels to chronic and long-continued local irritation. Some epitheliomata invade the tissues deeply and infect the neighboring lymphatic glands, others confine their ravages to the cutaneous tissues proper. Some run a rapid course, others exist for years before acquiring a very large size. They vary also as regards the grade of malignity exhibited in different cases, slowly corroding superficial ones, possessing this feature to a much slighter degree than the others.

Diagnosis

As a rule, the diagnosis in most cases of epithelioma will be easy. Occasionally, however, a question will arise as to whether a certain lesion is an epithelioma, a lupus, or a sarcoma, on the one hand, or a more innocent papilloma on the other. The distinctions between epithelioma and lupus will be considered in connection with the latter disease. From sarcoma of the skin it is to be distinguished by its greater consistence, less sharply defined infiltration, and lesser vascularity and tendency to hemorrhage.

Prognosis

The prognosis of epithelioma is unquestionably bad, not so, however, to the extent asserted by Kaposi, who says: "No matter whether an epithelial cancer has been removed by the knife or by cauterization, recurrence always takes place within a shorter or longer period of time." This statement is so extraordinary that I give his original words below.* Perhaps this has been Kaposi's experience, but almost every other surgeon can recall cases in which extirpation of the growth has been followed by complete immunity in the future. These cases, however, it must be admitted, are in the minority. Ceteris paribus, the earlier the nature of the disease is recognized, and the sooner it is removed, the better the prognosis.

Etiology

There is too little known concerning the causes of epithelioma to permit any definite or dogmatic statement to be made concerning them. While in some cases the morbid growth first shows itself at points of the skin that previously appeared to be normal, in others, the cancerous development appears on the site of some long-existing and presumably innocent growth, as a simple wart or papilloma that has been subjected to frequent irritation. It also not unfrequently appears as a sequel to the graver forms of lupus, and has even arisen upon a patch of chronic eczema.

* Ob der Epithelialkrebs mittels Exstirpation oder Aetzung entfernt worden ist, immer kommen in kurzeren oder langeren Intervallen recidive Eruptionen." 97, 2:

Treatment

Extirpation is the first thing to be thought of, provided the case is not so far advanced that ultimate recovery is hopeless. or even temporary alleviation improbable. If an operation is admissible it should be performed as early and as thoroughly as possible. When the lesion is conveniently situated and fairly circumscribed, excision, including broad margin of surrounding tissue, appears to me to be the most judicious procedure. When more diffuse or irregular, caustics may be employed, or excision of a part or the whole followed by the caustic application. The caustic employed may be either Vienna paste, sulphuric acid paste, one or more of the caustic chlorides, or arsenic. The former are act; destroyers of tissue, but exert no poisonous influence on the system. The last is energetic to a degree, exceedingly painful, and in a number of instances its application has been followed by fatal poisoning. Of the various modes of using Arsenic that of Marsden * is perhaps the best. 1 method is as follows: "A thick paste of arsenic is made according to the following formula:

Arsenious acid...............................

Mucilage of gum acacia.......................

To be well mixed together, and made into a thick paste.

"The patient's health having been attended to, the whole of the cancerous surface is to be spread over with this paste, provided it is not more than a square inch, and the paste must be sufficiently thick not to run; a piece of dry lint is then pressed on to the part, overlapping the paste half an inch all round; this must be left for a short period, say ten minutes, by which time any superabundant paste will have been taken up bv the extra lint, which is then to be carefully cut away with a sharp pair of scissors; in an hour, or at most two, the lint covering the paste will have become dry and hard, and it will adhere closely and firmly to the cancer. In the course of twenty-four hours the surrounding parts will commence to swell, become red, and to a certain extent inflamed, and the patient will experience a drawing pain. In general, this is by no means severe, and does not last more than one or two days. At the expiration of from forty -eight hours to three days, according to circumstances, bread and water poultices are to be constantly applied and changed every two or three hours; the pain, redness, and swelling will by this time have subsided, and a distinct line of demarcation be seen extending entirely around the cancerous mass: the skin ulcerates, and a fissure is formed, separating the slough from the healthy tissues; the fissure continues to deepen, until the entire cancer comes away, leaving a healthy cuplike depression vat ing in size and depth according to the mass removed. Healthy granulations will now commence, and it will be well to continue the poultices for some time; indeed it often happens that no other application need be used."

As regards the use of internal remedies little can be said. Besides tonics and roborants to improve the general condition, arsenic, as a specific remedy, is almost the only one that need be considered. This drug cer-tainly appears to have been useful, and in fact curative in a few cases of presumably malignant disease, but whether these cases were genuine epi-theliomata cannot be determined.

* A New Successful Mode of Treating Certain Forms of Cancer. 3d edition. Loo-don, 1874, p. 83.

Besides the drugs mentioned the following may be considered: Acidum Citricum, 8; Alumen, 13; Bals. Gurg.,30; Carota, 40; Clematis Erecta, 45; Conium, 47; Galium, 56; Onoperdon, 80; Phytolacca, 86; Potass. Chloras, 92; Sedum Acre, 105; Silica, 105; Sodii Silic., 107; Thuja, 25;

Xanthox, 116; Zinci Nitras, 117, and Zinci Sulph., 117.