Pellagra is a slow but usually progressive disease occurring chiefly in Italy, due, it is thought, to the continued ingestion of decomposed or fermented maize. It is characterized by cutaneous symptoms, at first upon exposed parts, of an erythematous, desquamative, vesicular and bullous character, and by general const.i.tutional disturbance of a markedly neurotic type. A fatal ending, if the disease is at all severe or advanced, is to be expected.

Treatment is based upon general principles.

Epithelioma.

(_Synonyms:_ Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)

What several varieties of epithelioma are met with?

Three--the superficial, the deep-seated, and the papillomatous.

Describe the clinical appearances and course of the superficial variety of epithelioma.

The superficial, or flat variety (_rodent ulcer_), begins, usually on the face, as a minute, firm, reddish or yellowish tubercle, as an aggregation of such, as a warty excrescence, or as a localized degenerative seborrh[oe]ic patch. The latter lesion (known also as keratosis senilis, old-age atrophic patches), consisting of a yellowish or yellowish-brown greasy or hardened scurfy spot or patch is quite frequently the starting-point of epithelial growths. Sooner or later, commonly after months or several years, the surface becomes slightly excoriated, and an insignificant, yellowish or brownish crust is formed.

The excoriation gradually develops into superficial ulceration, and the diseased area becomes slowly larger and larger. New lesions may continue, from time to time, to appear about the edges and go through the same changes.

[Ill.u.s.tration: Fig. 64. Epithelioma. (_After D. Lewis._)]

The ulcer has usually an uneven surface, secretes a thin, scanty, viscid fluid, which dries to a firm, adherent crust. It is usually defined against the healthy skin by a slightly elevated, hard, roll-like, waxy-looking border. In rare instances there is a disposition, at points, to spontaneous involution and scar formation; as a rule, however, the ulcerative action slowly progresses.

The general health is unimpaired, the neighboring lymphatic glands are not involved, and the local condition, beyond the disfigurement, gives rise to little trouble, unless, as occasionally happens, it pa.s.ses into the more malignant, deep-seated variety.

Describe the clinical appearances and course of the deep-seated variety of epithelioma.

The deep-seated variety starts from the superficial form, or it begins as a tubercle or nodule in the skin. When typically developed, a reddish, shining tubercle or nodule, or area of infiltration, forms in the skin or subcutaneous tissue. In the course of weeks or months superficial or deep-seated ulceration takes place; the ulcer having hardened, and, as a rule, everted edges. The surface is reddish and granular, and secretes an ichorous discharge. The infiltration spreads, the ulcer enlarges both peripherally and in depth--muscle, cartilage and bone often becoming invaded. The neighboring lymphatic gland may become implicated, pains of a burning or neuralgic type are experienced, and from septicaemia, marasmus, or involvement of vital parts, death eventually ensues.

Describe the clinical appearances and course of the papillomatous variety of epithelioma.

The papillomatous type usually arises from the superficial or deep-seated variety, or it may begin as a papillary or warty growth.

When fully developed, it presents an ulcerated, fissured and papillomatous surface, with an ichorous discharge which dries to crusts.

It is slowly progressive, and sooner or later may develop a malignant tendency.

Upon what parts is epithelioma commonly observed?

About the face, especially the nose, eyelids and lips; and also about the genitalia. It may involve any part.

At what age is epithelioma usually noted?

It is essentially a disease of middle and late life, although it is exceptionally met with in the young.

What is the cause of epithelioma?

The etiology is obscure. It is not, as a rule, inherited. Any locally irritated tissue may be the starting point of the disease.

State the pathology.

The process consists in the proliferation of epithelial cells from the mucous layer; the cell-growth takes place downward, in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded ma.s.ses, the centres of which usually undergo h.o.r.n.y transformation, resulting in the formation of onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the bloodvessels become enlarged; moreover, the pressure of the cell-ma.s.ses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration.

How would you distinguish epithelioma from syphilitic ulceration, wart, and lupus vulgaris?

From syphilis it is to be differentiated by the history, duration, character of the base and edges, its comparative slow progress, its usually slight, viscid discharge, often streaked with blood, and, if necessary, by the therapeutic test.

Wart or warty growths are to be differentiated by attention to their history and course. Long-continued observation may be necessary before a positive opinion is warrantable. The appearance of any tendency to crusting, to break down or ulcerate is significant of epitheliomatous degeneration.

In lupus vulgaris the deposits are peculiar and multiple, the ulcerations are of different character, the tendency to scar-formation constant; and, with few exceptions, it has, moreover, its beginning in childhood or early adult life.

What factors are to be considered in giving a prognosis in epithelioma?

The variety, extent, and rapidity of the process. The superficial form may exist for years, and give rise to no alarm; whereas the deeper-seated varieties are always to be viewed as serious, and are, indeed, often fatal. Involving the genitalia, its course is often strikingly rapid. Relapses, after removal, are not uncommon.

What is the special object in view in the treatment of epithelioma?

Thorough destruction or removal of the epitheliomatous tissue.

How is the destruction or removal of the epitheliomatous tissue effected?

By the use of such caustics as caustic potash, chloride-of-zinc paste, pyrogallic acid, a.r.s.enic, and the galvano-cautery; and by operative measures, such as excision and erasion with the dermal curette, and by the _x_-ray. (See treatment of lupus vulgaris.)

In small lesions the use of an a.r.s.enical paste is a most admirable method of treatment, although somewhat painful. The paste is made of one part powdered acacia and one to two parts a.r.s.enious acid; at the time of application sufficient water is added to make a paste. This is applied thickly, and a piece of lint superimposed. A good deal of pain and inflammatory swelling ensue; at the end of twenty-four hours the part is poulticed till the slough comes away; the ulcer is then treated as a simple ulcer, under which healing takes place. Occasionally a second application is found necessary.

Upon the whole, the best method in the average case is to curette thoroughly, and supplement with momentary cauterization, with caustic potash, or with several days' use of the pyrogallic acid ointment.

During the healing process, short exposures to the Rontgen ray--about every three to five days--is good practice.

The degenerative changes in the beginning of scurfy, seborrh[oe]ic spots or patches seen in old people can frequently be lessened or wholly stopped by the daily application of an ointment containing 5 to 10 per cent. of sulphur and 2 to 5 per cent. of salicylic acid.

What can be said of the value of the x-ray in epithelioma?

The _x_-ray method is now much in vogue, and proves curative in many superficial cases, and of benefit in some of the deeper-seated varieties. In most cases it must be pushed to the point of producing a mild _x_-ray erythema; and in some instances benefit or cure only occurs after more active exposure, sufficient to cause an _x_-ray burn of the second degree. The method is not attended with much risk if properly used. The healthy parts should be protected by lead-foil. Exposure should be two to five times weekly, at a distance of three to eight inches, and from five to twenty minutes, employing a tube of medium vacuum. Unfortunately the method is usually slow. The radium treatment is essentially similar to that by the _x_-ray.

The much better plan, as already intimated, is to employ one of the several operative or caustic methods, and supplementing, while healing, with the _x_-ray.

Paget's Disease of the Nipple.