SO-CALLED 
MYCOSIS FONGOIDE. 
BY , 
GEORGE H. TILDEN, M.D., 
Physician, Department of Diseases of the Skin, Boston City 
Hospital. 
[Reprintedfrom the Boston Medical and Surgical Journal 
of October 22, 1885.\ 
BOSTON : 
CUPPLES, UPHAM & 00., Publisiikks, 
©10 Cornrr Book Storf. 
1885. SO-CALLED MYCOSIS FONGOIDE.1 
BY GEORGE H. TILDEN, M.D., 
Physician, Department of Diseases of the Skin, Poston City Hospital. 
Syn., Beerschwamahnliche multiple Papillargesch- 
wiilste der Hunt, Inflammatory fungoid neoplasm, 
Granuloma sarcomatodes cutis, Granuloma fungoides 
cutis, Sarcoma cutis, Lymphadenie cutanee. 
One of the twigs on the topmost brancli of Alibert’s 
arborescent classification of cutaneous diseases bears 
the name Mycosis Fongo'ide, employed by that Derma- 
tologist to designate an uncommon affection of the 
skin, which has since been described by various authors 
under half a dozen different titles. An instance of 
this disease came under my observation at the Boston 
City Hospital, in August of last year, having been 
sent to me by Dr. Vincent Bowditch. 
The patient was twenty-eight years of age, a man of 
robust build, whose family history gave no information 
of importance in connection with his malady, and 
whose condition had always been one of uninterrupted 
good health until his twenty-fifth year, when the "first 
manifestations of the disease appeared. These con- 
sisted in the development of several small, red and 
desquamating spots, situated about the elbows and 
attended by intermittent attacks of pruritus, which 
affected principally the outer sides of the arms, and 
were a source of much annoyance. The skin, in general, 
however, retained its normal aspect for several months, 
at the end of which time there appeared, irregularly 
distributed over the face, abdomen and arms, many 
1 Read at the Annual Meeting of the American Dermatological As- 
sociation, August 27, 1885. 2 
erythematous spots and patches of various sizes and 
individually of a fugitive character, which were at- 
tended and followed by desquamation and severe itch- 
ing, the latter being aggravated by any exposure of 
the skin to the air, by the influence of perspiration 
and by indulgence on the part of the patient in alco- 
holic liquors. According to his account, there was 
never anything like the formation of vesicles in con- 
nection with these lesions, which always retained then- 
dry and scaly character. 
This condition of the skin obtained with periods of 
remission and relapse, for about a year and a half, the 
general condition of the patient, meanwhile, remaining 
perfectly good. It was not until nearly two years 
after the beginning of the disease that there appeared 
several small cutaneous nodules of a red color, situated 
upon the left cheek and throat, the attention of the 
patient being first called to them by their interference 
with the act of shaving. Some of these nodules spon- 
taneously disappeared and no others became manifest 
until two or three months later, when there appeared 
upon the inner and lower part of the right thigh, a 
small red papule, which increased with slow and con- 
stant growth until it was represented by a cutaneous 
tumor the size of an orange. In consistence this tumor 
was moderately firm and its upper surface was denuded 
of epidermis, of a dirty yellowish color, and exuded a 
thin fluid, which, upon exposure to the air, readily 
dried to a thin crust. 
Shortly after the first appearance of this growth, 
there showed themselves in both groins, many papules 
of a like nature, which remained quiescent for several 
months, but eventually those in the left inguinal region 
developed with great rapidity, forming a mass of 
thickly crowded fungous excrescences of a reddish 
brown color, irregular shapes, lobulated and fissured in 3 
appearance, and covered with epidermis, the largest of 
them being the size of an English walnut. During 
the six months previous to the time I first saw the 
patient, numerous lesions in the shape of papules of 
various sizes had appeared on different parts of the 
body, more abundantly in and about the axillas and 
upon the neck and scalp than elsewhere, and many of 
them had developed into tubercles and some into tumors. 
Upon the back of the head there was a large oblong 
patch of irregular outline, composed of fiat tumors, 
measuring five by three inches in extent, and elevated 
nearly one-half an inch above the cutaneous level, the 
surface, uneven, fissured and covered for the most 
part with epidermis. The color of this patch was pale 
red and its consistence soft and doughy, although at 
the time of their first appearance, these tumors were, 
according to the patient’s account, much harder than 
when I saw them. The scalp, with the exception of 
the area taken up by this group of tumors, was thickly 
covered with hair. 
The forehead presented a collection of several large, 
flat, red papules, which were combining to form a large 
circular lesion of slight elevation and covered with 
epidermis, but of harder consistence than those upon 
the scalp. Upon the right cheek, near to the angle of 
the mouth, was a tumor, circular in outline, elevated 
nearly an inch above the level of the surrounding skin 
and somewhat larger than a silver half dollar. Its 
upper surface was slightly convex, deprived of epider- 
mis, of a pink color with shadings of yellow, studded 
with numerous red points and covered with a thin 
glaze, which was easily removed by friction or by the 
influence of warmth and moisture, thus allowing the 
escape of a reddish fluid, which upon exposure to the 
air again dried to a thin crust. In consistence this 
tumor was firm, being much more dense than those 4 
upon the scalp, the softness of which approached fluc- 
tuation. 
Almost surrounding the neck of the patient was a 
broad collar of a dusky red color and nodulated sur- 
face, formed by the coalition of papules and tubercles, 
extending upwards, as far as the jaw, and below, drap- 
ing itself with irregular outline upon the breast and 
shoulders. Just above the elbow joint, on the outer 
side of the left arm, was a moist tumor, similar to but 
smaller than the one upon the cheek, and immediately 
below it was a patch of combined papules and tuber- 
cles resembling those upon the neck. Upon the upper 
part of the back over the apex of the right scapula, on 
the right thigh below the fold of the nates, on the 
back of the left thigh and in the right popliteal space, 
were battened tumors and groups of tubercles of vari- 
ous grades of consistence and covered with epidermis 
of a pale red color. There were many papules and 
tubercles isolated and in groups, in and about the axil- 
lae and groins, while the abdomen, thighs and arms 
were covered with erythematous spots and patches, 
interspersed with papules and tubercles, which varied 
in size from that of a small pea to that of a filbert. 
None of these lesions were pedunculated or connected 
with the skin by a narrow neck, but all were attached 
by a base as large or larger than their tops. On the 
right thigh and in the left groin were tumors which 
have already been described. 
Although they presented much diversity in size and 
appearance, these lesions began as erythematous spots 
from which were gradually developed papules, at first 
of small size, of pale red color and covered with 
smooth epidermis. Simple increase in the size of these 
lesions had transformed many of them into tubercles 
the size of a filbert, and several of them into veritable 
tumors. Wherever large numbers of such papules This plate is merely intended to show in a general way, the distri- 
bution of the eruption on the back. 6 
and tubercles came into contact with one another, they 
coalesced, forming patches of greater or less extent, 
irregular outline, with nodulated and fissured surface, 
and of a darker, more violaceous color than the pri- 
mary and isolated nodules. For the most part these 
patches of conjoined lesions were covered with epider- 
mis and only here and there were they excoriated 
and oozing. In none of the cutaneous lesions was 
there any retrograde change represented by the 
formation of pus or by deeply destructive ulceration, 
although the softness of some of the tumors suggested 
a fluid or semi-fluid contents, and one of them having 
been incised, discharged a dark red, almost black, 
grumous fluid. The large and protuberant tumors 
were luxuriant growths, from the surface of which, in 
some instances, the epidermis had been cast off, expos- 
ing to view the pathological tissue of which they were 
composed, and from some of these excoriated tumors 
there had been occasional haemorrhage of moderate 
amount. They resembled very much in appearance, 
although they greatly exceeded in size, the moist, fun- 
gous, oozing tubercles, which are sometimes met with 
in connection wtth parasitic sycosis. When exposed 
to the air the thin, slightly bloody fluid exuded from 
their surface, dried to a thin crust, which was easily 
removed by friction or moisture. Decomposition of 
this fluid caused the patient to oftentimes emit a strong 
and peculiar odor, which resembled the united smells of 
sour cabbage and Parmesan cheese, being exceedingly 
offensive. 
Within two years there had been apparent to the 
patient painless enlargement of the lymphatic glands 
in the groins and axillie. The inguinal glands of both 
sides were much enlarged, having attained the size of 
large almonds, while along the outer edges of the pec- 
torales muscles and behind the ears over the mastoid 7 
processes, lymphatic glands were to be felt as large as 
good sized peas. This enlargement of the lymphatic 
glands was of indolent and painless nature and they 
were unattached to the surrounding tissues, forming 
subcutaneous tumors over which the skin was freely 
movable. 
The patient suffered no pain, and the cutaneous 
lesions were not sensitive to pressure but were, how- 
ever. attended with severe and widely spread itching, 
causing him to scratch vigorously, secondary lesions 
due to energetic use of the finger nails being manifest 
in several parts of the body. The patient was anasmic, 
the skin and mucous membranes being pale and the 
skin in general dry and rough. He complained of an 
unwonted feeling of weakness and easy loss of breath 
from slight exertion, together with violent beatings 
and palpitation of the heart, and the' most trivial 
occurrence was oftentimes sufficient to throw him into 
a state of nervous excitement. There had been a loss 
of thirty pounds from the normal weight of one hun- 
dred and eighty pounds, but there was no emaciation, 
the patient’s appetite was good, and there was fairly 
good performance of the digestive and excretory func- 
tions of the body. There were nowhere any cicatrices 
or atrophic spots on the skin, no cutaneous anesthesia, 
no deafness nor failure of vision, and there had been 
no hemorrhages from any of the mucous membranes, 
and no cough nor hemoptysis. The result of the phy- 
sical examination was as follows : 
The opthalmoscope detected nothing abnormal. 
The heart presented a systolic murmur heard over its 
base which was probably caused by anemia, and there 
was sometimes irregular and rapid action of the organ, 
very likely due to the same cause. 
The lungs were normal and the liver and spleen 
were not enlarged. The urine was found to be nor- 8 
mal. Examination of the blood by Dr. Gannett 
showed the number of red globules in a cubic millime- 
ter to be 3,722,000, and the number of white corpuscles 
23,333, that is, moderate anaemia together with increase 
in the number of white corpuscles, giving1 a ratio of 
one white corpuscle to one hundred and fifty-five red, 
the normal ratio being about one white to five hundred 
red. 
August 6th. The patient entered the hospital on 
the surgical side in the service of Dr. G. AT. Gay, who 
kindly turned the case over to me. lie was placed in 
one of the hospital tents, given the tincture of the 
chloride of iron, extra diet and received subcutaneously 
once a day, four minims of Fowler’s solution of arsenic. 
Under this treatment he gained fourteen pounds in 
weight and rapidly improved as to his general condi- 
tion, although no noteworthy change took place in the 
state of the skin. The liberal use of an ointment con- 
taining one per cent, of carbolic acid gave him the 
most relief from the intolerable itching with which he 
was afflicted, more especially during the night, lie 
left the hospital August 18th, but remained under 
observation until November. 
August 30. Since leaving the hospital many of the 
erythematous spots which were upon the abdomen, 
thighs and arms had developed into papules. 
September 5. Much of the diffuse erythematous 
redness about the chest had entirely disappeared, the 
restored whiteness of the skin contrasting in a striking 
manner with the red and violaceous color of the nu- 
merous papules and tubercles which were scattered 
about. 
September 18. There was some improvement in 
the general condition, but no marked change on the 
part of the skin. 
November 3. The patient complained of increasing 9 
weakness and shortness of breath upon exertion, which 
constrained him to remain quiet. A most striking 
change had taken place in several of the cutaneous 
lesions. The large tumor on the cheek near the cor- 
ner of the mouth had entirely disappeared and its 
original site was covered with epidermis, while the 
largest tumor of all, that upon the right thigh, was 
also covered with epidermis and had diminished in size 
by nearly one-third. There was excessive desquamation 
all over the body and the inner surface of the thighs had 
assumed an eczematous condition, oozing in places and 
covered with yellow, honey-like crusts. There was 
also remarkable alteration in the appearance of the 
face which within a week had become extensively in- 
filtrated, the skin being of a dull copper color and the 
countenance one of swollen rigidity, with effacement of 
the lines of expression. 
This was the last time I saw the patient, as he after- 
wards disappeared, probably on account of the fatal 
and hopeless prognosis which he received in reply to a 
request for information as to his prospects. I after- 
ward heard indirectly that he died in March of the 
present year, that is, about three years and eight months 
after the beginning of the malady. Before death he 
had been affected with gradually increasing exhaustion 
and diarrhoea. Two of the smaller nodules were ex- 
cised while he was in the City Hospital and given to 
Dr. W. W. Gannett, pathologist to the hospital for 
examination, and the following is his report of their 
histological structure: 
“ Report on two nodules sent for examination by 
Dr. G. II. Tilden, August 13, 1884. 
“ Both nodules were hardened in Midler’s fluid and 
later in strong alcohol. After the hardening process 
had been completed, the larger nodule measured 14 
mm. in diameter, and was elevated 5 mm. above the 10 
level of the surrounding skin; the smaller nodule had 
a transverse diameter of 10 mm. and an elevation of 
5 mm. The epidermis was intact upon them. 
“ A series of vertical sections was made with the 
microtome and then examined, stained and unstained, 
in various media. Sections were also brushed. 
“ Sections of the smaller nodule showed the follow- 
ing appearances:— 
“All the layers of the epidermis, from the horny 
layer to the rete, were intact and showed no variation 
from the normal. 
“ The superficial parts of the corium, including the 
papillae, showed the presence of masses of small round 
cells arranged in groups of varying size and form, 
some being nearly circular, others irregular, others 
branching. In the centre of many of them a blood- 
vessel was to be made out. After brushing, these 
masses were found to be made up of a very delicate 
connective-tissue stroma, in the form of a fine mesh- 
work of connective-tissue fibres enclosing spaces. Each 
of these spaces enclosed one or two small round cells, 
having a large distinct nucleus with very little proto- 
plasm about it. 
“ These cells correspond, njorphologically, to lymph- 
corpuscles ; their arrangement in the mesh described, 
makes this a cytogenous or lymphoid tissue. 
“ Where the above described patches were small and 
isolated the interlying connective-tissue of the corium 
showed nothing unusual. Where they were larger and 
in closer proximity, the intervening tissue of the co- 
rium was found to be converted into bundles of well- 
marked spindle-cells lying parallel to one another. 
“ In the deeper layers of the corium nothing remark- 
able was observed beyond a slight degree of round-cell 
infiltration of the adventitiae of some of the blood-ves- 
sels. In the sub-cutaneous connective-tissue no ap- 
pearances varying from the normal were discovered. 11 
“Sections of the larger nodule showed appearances 
varying from those in the smaller nodule as follows:— 
“ The epidermis was intact. 
“The papilla; on the peripheral parts of the nodule 
were distinct; those in the central part, however, were 
very small; the rete Malpighi presenting a wavy line. 
This change was undoubtedly due to the pressure of 
the growing tissue beneath. 
“ The upper half of the corium was at least three 
times the usual thickness and was wholly occupied by 
a cytogenous tissue like that described in connection 
with the smaller tumor. 
“This large area of lymphoid tissue was subdivided 
into smaller ones by narrow bundles of parallel-lying 
spindle-cells, which by anastomosis formed a coarse 
reticulum, having much the same relation to the lym- 
phoid tissue that the reticulum of a lymph-gland has 
to its follicles. 
“ In parts of the lymphoid tissue were to be seen nu- 
merous red blood-corpuscles which from their arrange- 
ment were evidently contained in vessels, that is, in 
capillaries. 
“ The lower half of the corium, that portion border- 
ing on the subcutaneous connective-tissue, showed many 
patches of lymphoid tissue, large and small, and of the 
greatest variety of form. Where this tissue was not 
present in patches one could make out round-cell infil- 
tration in the spaces between the larger connective- 
tissue bundles and elastic fibres. 
“In the subcutaneous fat-tissue the adventitia of the 
blood-vessels showed here and there round-cell infiltra- 
tion. 
“ The process in the larger nodule is evidently the 
same in character as in the smaller one, only more ad- 
vanced. One has to do in both nodules with the de- 
velopment of a true lymphoid tissue in the corium; 
that is, a lymphoma. 12 
“ In neither of the nodules was any evidence of a ne- 
crotic or degenerative change discovered. 
“ Several months after the histological examination 
of the above specimens had been made, RindHeisch and 
Auspitz announced their discovery, in lymphomata 
like the above, of micrococci, which they claim are 
the specific micro-organisms of this affection. 
“Although the nodules now described had been har- 
dened in Muller’s fluid and alcohol and were conse- 
quently much less adapted than fresh specimens or 
those hardened in absolute alcohol for demonstrating 
micro-organisms, yet the attempt was made to find 
them. 
“ Thin microtome sections were stained in Ehrlich’s 
gentian-violet solution, then treated by Gram’s method 
and examined in benzol balsam with an Abbe illumi- 
nating apparatus and a Zeiss 1-12 oil-immersion, but 
with a negative result. 
“ Sections were kept in alcohol for two months, then 
stained with an aqueoyis solution of methyl-blue, par- 
tially decolorized in alcohol and examined as before, 
but with a like negative result. 
“ Of course no special weight is to be attached to 
negative evidence in specimens hardened as the above 
were.” W W. GANNETT, M.D. 
The first description of this disease by Alibert, was 
published more than fifty years ago, and since that 
time a sufficient number of cases have been placed on 
record to furnish us with a good picture of its clinical 
aspects. There is no instance of the malady having 
occurred in more than one member of the same family, 
and as a rule, the sufferers therefrom have been healthy 
individuals, free from venereal disease and of good 
family history, so that the elements of heredity, conta- 
gion, and syphilis may be eliminated from consideration. 13 
In addition to the case reported in this paper. I have 
been able to find accounts more or less complete, of 
twenty-nine instances of this malady. The deaths of 
Portion of brushed section showing the fine network of connective 
tissue fibres present in the tumors, and the character of the cells of 
whichthe latter were composed. Drawn with the help of a camera 
lucida, Hartnack ocular iii, objective vii. 
sixteen of these cases have been recorded, and the re- 
sults of eleven autopsies have been published. One 
case of recovery is mentioned by Bazin as having taken 
place after an attack of migrating erysipelas, the pa- 
tient remaining well for several years afterward, and 
the other cases were lost sight of, many of them in a 
condition which gave no hope of recovery. 
Of these thirty instances of this disease, twenty-three 
occurred in males and seven in females, a remarkable 
disproportion in the matter of sex. The malady shows 
a tendency to develop in late adult life, more than one- 
half of the whole number of patients being forty years 
of age or over, at the time of the appearance of the dis- 14 
ease. Of the remaining cases, one-half occurred in 
individuals of over thirty years of age, so that in only 
about one-quarter of all the cases, has the affection de- 
veloped before the thirtieth year. The most advanced 
age at which the disease has been known to occur is 
sixty-eight years, which was the age of Demange’s pa- 
tient ; and there is no instance of its having developed 
before the twentieth year, if we exclude the case of an 
infant, reported by Landouzv to the Soc. de Biologie, 
which case has not been included in the above collec- 
tion on account of its doubtful and exceptional charac- 
ter. The duration of the disease is usually from two 
to four years, with the extremes of two, four and five 
months in the cases reported by (halliard, Naether, and 
Debove, respectively ; and of eight years, in one of 
Hardy’s cases, mentioned by Kobner, and twelve years, 
in a case of Bazin’s, reported by Guerard and Lorda. 
In a remarkable instance of this malady published by 
Port, there had been for thirty years, beginning with 
the fifth year of life, an almost continual manifestation 
of various kinds of inflammatory, cutaneous lesions, 
and it was not until the patient’s thirty-fifth year, 
about six months before his death, that the charac- 
teristic fungous excrescences of mycosis fongoide began 
to show themselves. 
The disease usually begins with the appearance on 
any and all parts of the body, of cutaneous lesions, 
which present no special characteristics by which they 
may be distinguished from changes which are met with 
in other and common affections of the skin. They may 
either be erythematous and urticarial in nature; may 
resemble eczema in being vesicular, moist, and covered 
with crusts, or may simulate psoriasis and lichen, by 
reason of their dry, infiltrated, and scaly character. At 
first, of a more localized and temporary nature, these 
lesions in the course of time, become more numerous 15 
and more tenacious of place, attended with greater 
thickening of the skin, and accompanied by pruritus of 
extreme severity, which is the only subjective symptom 
of which the patients complain. There are, however, 
exceptions to the above general rule, and the affection 
may begin with the immediate appearance of the 
tumors which are peculiar to it. Such was the case in 
the instances of this affection published by Demange, 
Galliardand Debove, which seem to have been of more 
acute development and shorter duration than usual. In 
two of these three cases, the tumors appeared first upon 
the breast, in the other upon the head ; and in two of 
them there took place very early in the malady, exten- 
sive infiltration of the skin of the face, giving to the 
countenance the so-called leonine expression, seen in 
leprosy and scleroderma. After a longer or shorter 
period of time, during which the patients suffer from 
these apparently inflammatory changes in the skin and 
the attendant pruritus, and during which time there 
not infrequently occurs temporary cessation of symp- 
toms, there appear the strange growths which are pe- 
culiar to mycosis fongo'ide, which foreshadow its fatal 
termination, and before the arrival of which, a diagno- 
sis is impossible. 
These tumors may arise either from preexisting path- 
ological patches in the skin, or they may develop in 
cutaneous regions which have hitherto been unaffected 
by disease. They consist in well-defined, rounded ele- 
vations of the skin, at first moderately firm and elastic 
in consistence, covered with smooth epidermis, of a pale 
red color, and their attachment to the skin by a pedicle 
or narrow neck is very exceptional. They remain con- 
fined to the skin and are always movable with it, even 
in the most advanced stage of their development. 
After they have attained a certain size, which, as in the 
present case, may be considerable, they remain un- 16 
changed for a long period of time; but there takes 
place in some of them, sooner or later, a change which 
is one of the most notable features of the disease, 
namely, their disappearance by absorption, which may 
coincide with the appearance and growth of similar 
tumors in other parts of the body. When these growths 
have reached a large size, the epidermis may be cast 
off, as in several tumors of the present case, and super- 
ficial erosion occur; this process, however, not being 
inconsistent with the integrity of the tumors affected 
by it, which retain their size and shape, constituting 
the moist, fungous excrescences peculiar to mycosis fon- 
goide. This form, characterized by superficial loss of 
substance, is the more common variety of retrograde 
change, but there may also occur rapid and extensive 
destruction of these tumors, in which case they soften 
and open externally, thus forming large, suppurating, 
cutaneous ulcers. 
In most of the cases, there has been painless enlarge- 
ment of many of the lymphatic glands to a greater or 
less extent, and like the cutaneous tumors, this lym- 
phatic enlargement may disappear by absorption. As 
a rule, the general condition of the patient is unaffected 
until after the appearance of the tumors; but eventu- 
ally they become anaemic and debilitated, toward the 
end appear fever and diarrhoea, which together with 
increasing exhaustion, and in some cases, the formation 
of extensive and suppurating ulcers of the skin, close 
the scene, death generally taking place from marasmus. 
Such is the clinical course of a malady, the patho- 
logical nature of which has given, and still offers suffi- 
cient opportunity for speculation, and the information 
furnished by the microscopic and post-mortem exami- 
nations remains to be considered. The results of mi- 
croscopic examination of these tumors agree in show- 
ing the epidermal layers of the skin to be in a normal 17 
condition, but sometimes thinner than usual; the pa- 
pillae flattened and broadened, but well defined in most 
cases; and an infiltration of the connective tissue of 
the corium with round, granular, nucleated cells, resem- 
bling leucocytes in appearance. These cells may be 
disposed in groups and gathered around the blood-ves- 
sels, an arrangement which is more apparent in sections 
taken from tumors before they have reached an 
advanced stage of development, in which latter event, 
the cellular infiltration may extend as deep as the snb 
cutaneous fat-tissue, in some cases replacing entirely 
the normal structure of the corium. Blood-vessels, 
hair follicles, and cutaneous glands may sometimes be 
seen imbedded in this collection cells, and their 
sheaths infiltrated with similar elements. Ranvier was 
the first to detect and call explicit attention to the exis- 
tence in these tumors of delicate, connective-tissue 
fibres, anastomosing so as to enclose spaces nearly cir- 
cular in form, in which lie the lymphoid cells, a structure 
such as was found by I)r. Gannett in the specimens 
from the present case, and which is considered to be 
characteristic of cytogenous tissue. The existence 
of this meshwork has been remarked by all of the 
French observers, and the fact that careful brushing of 
thin sections is necessary to determine its presence, 
may account for its having been overlooked by several 
investigators. 
The most noteworthy fact to be derived from the 
autopsies is the negative one of the absence in any of 
the internal organs, of metastatic growths similar to 
those in the skin. The nearest approach to such a 
condition of things was found in the autopsies reported 
by Duhring and Galliard, in each of which was detected 
in the walls of the bladder, beneath the mucous mem- 
brane, round-cell infiltration resembling that in- the 
skin, while in addition to this Galliard describes the 18 
presence in the heart, lungs, liver and testicles, of 
small circumscribed collections of leucocytes, apo- 
plexies lymphatiques,” the character of which was de- 
termined by the microscope. In one case only, that 
of Debove, were the tonsils the seat of ulceration, fol- 
lowing an enlargement of these glands which had 
been apparent during life. In the great majority of 
cases there was found increase in size of the lymphatic 
glands in various parts of the body, a change which the 
microscope has shown to be of the nature of hyper- 
plastic enlargement. In two instances some of these 
enlarged glands were found to contain small collec- 
tions of pus and there was also purulent infiltration of 
the surrounding connective tissue. In only two cases 
was the spleen notably enlarged, in three cases it was 
slightly increased in size, and in the rest, of normal 
dimensions. The details with regard to changes in 
the other internal organs are slight and possess no 
special significance. 
The theories with regard to the pathological nature 
of mycosis fongo'ide are three in number: 
I. That it is generalized sarcoma of the skin. 
II. That the new formation of lymphoid tissue in 
the skin renders the disease a variety of pseudo-leuk- 
aemia. 
III. That the new growths are so-called infective 
granulomata of the skin, that is, young connective-tis- 
sue tumors associated with the presence of special 
microorganisms. 
As to the first hypothesis, the weight of evidence is 
against the disease being sarcomatous in nature. The 
clinical course of the disease and the appearance of its 
cutaneous lesions are unlike the same factors in the 
cases of multiple sarcoma of the skin as described by 
Kobner and Kaposi. The curiously unstable charac- 
ter of the pathological products of mycosis fongo'ide, 19 
their comparatively rapid appearance and subsequent 
disappearance by absorption and by necrosis, are con- 
ditions not usually observed in connection with sarco- 
mata which, generally speaking, are permanent and 
stable growths. The microscopic structure of the 
tumors of mycosis fongo'ide is that of a lymphoid 
tissue rather than that of typical sarcoma, while the 
absence of so-called metastatic growths is the absence 
of what is one of the most marked tendencies of some 
varieties of sarcoma. 
With regard to the affection being leukremic or 
pseudo-leukaemic in nature, this theory is based solely 
upon the microscopic structure of the tumors of myco- 
sis, more particularly upon the presence therein of a 
finely-meshed cell-holding reticulum, such as is found 
in lymphatic glands and in cytogenous tissue, generally 
so called. So little is known as to the true nature of 
leukaemia and pseudo-leukamiia that speculation as to 
their possible relationship with mycosis fongo'ide is 
rather barren of definite conclusions, but it may be 
said that something more than a knowledge of the 
minute structure of pathological products at any one 
stage of their development, is necessary to render evi- 
dent their pathogenesis. In none of the very few 
cases of mycosis fongo'ide, in which the blood has been 
examined, has there been found sufficient increase in 
the number of the white corpuscles to constitute typical 
leukaemia, while in only two of the autopsies has there 
been found notable enlargement of the sjdeen, an en- 
largement which together with that of the lymphatic 
glands is an essential feature in pseudo-leukiemia. 
A remarkable case, which demands attention in this 
connection, has recently been published by Kaposi, as 
a hitherto unrecognized form of disease, under the 
name “ Lympho-dermia perniciosa.” Up to a certain 
point the features of this case bear some likeness to 20 
those of mycosis fongoide. There was the same pre- 
liminary manifestation of chronic inflammatory changes 
in the skin attended with pruritus and lasting a year, 
followed by the development of numerous cutaneous 
tumors and enlargement of the lymphatic glands. The 
tumors in this instance, however, did not disappear by 
absorption or form the typical, moist, fungous excre- 
scences of mycosis fongoide, but simply softened, 
opened and formed suppurating ulcers. 
In addition to the above phenomena, these ulti- 
mately developed undoubted evidence of leukaemia, 
which was confirmed bv the autopsy. 
There was marked increase in the number of the 
white blood corpuscles, the spleen was found after 
deatli to he four times its normal size, and nodules 
were detected in the lungs, pleura and medullary cavi- 
ties of the bones, which together with the cutaneous 
lesions were shown by the microscope to be composed 
of cytogenous tissue. The only other instance in which 
the development of lymphoid tumors in the skin ac- 
companied the course of typical leukaemia was in a 
case reported by Biesiedecki, in which case there is no 
mention of retrograde change in any of the tumors, 
the appearance of which was preceded by the develop- 
ment of the general leukaemic condition, and not as in 
Kaposi’s case, followed by it. 
Within the year Rindfleisch and Auspitz have each 
described the existence in the pathological products of 
mycosis fongoide, of microorganisms, the presence of 
which is considered characteristic of the so-called in- 
fective granulomata, represented by tubercle, lupus, 
leprosy, rhinoscleroma, and most recently of all, syph 
ilis. Rindfleisch describes them as streptococci, which 
he expressly states are to be seen only within the 
blood vessels, the plugging of whose calibre by these 
microorganisms is sufficient in his opinion to give rise 21 
to the cellular infiltration of the surrounding tissues, 
while their removal by the force of the blood current, 
is supposed to account for the peculiar disappearance 
by absorption of the lesions of mycosis fongoide. 
Auspitz, on the other hand, using the same methods of 
staining, states that there exist large numbers of 
micrococci in the pathological tissue outside of the 
blood vessels. It is impossible to avoid the suspicion 
that the presence of these micrococci, mentioned by 
Auspitz, is simply accidental. I here is nothing to be 
said concerning the latest theory, except to remark the 
discrepancy between these observations, and bearing in 
mind the prevalent rage for the detection of micro- 
organisms, to await further developments. It is possi- 
ble that these observations point in the wrong direct- 
ion ; it is not impossible that therein may eventually 
be found the answer to the naive question of Demange 
with regard to mycosis fongoide. “ N'y a-t-il done pas 
la quelque chose de special qui nous echappe encore ? ” 22 
Alibert. — Monographic des Dermatoses. Tome ii, p. 423. Paris, 
1836. 
Hardy. —Maladies de la peau. 1802. 
Bazin. — Lemons theoriques et eliniques sur les affections 
cutanees artificielles, etc. p. 375. Paris. 1802. 
Lorda. — Mycosis fongoides accompagnes d’une eruption gener- 
alisee, par placques rougeatres. Gaz. des hopitaux. No 01, 
1802. 
Guerard. — Du mycosis fongo'ide generalise. Paris, 1803. 
Kobner. — “ Ueber Beerschwamahnliche multiple Papillargesch- 
wiilste der Haut.” Klinische und experimentelle Mittheilun- 
gen aus der Dermatologie und Syphilidologie. p. 37. Er- 
langen, 1804. 
Virchow. —Die Krankhaften Geschwiilste. p. 53.8. 1804—5. 
Kaposi. — “Ueber die sogennante Framboesia.” Arcliiv fiir 
Dermat. und Syph. 180!). 
Gillot. — Etude sur une affection de la peau, decrite sous le nom 
de mycosis fongo’ide. These de doctorat. Paris, 180!). 
Landouzy.—Memoiresde la Soc. de Biologie. Dec., 1871. p. 184. 
Cliarpy. — De la nature du lichen hypertrophicus. Annales de 
Derm, et de Syph. Vol. iv, p. 27. 1872-73. 
Debove. — Societe Anatomique, p. 420. Oct., 1872. 
Ranvier. — Bull, de la Soc. Anatomique, p. 477. Paris, 1872. 
Demange. — Du Mycosis fongo'ide ou Lymphadenie cutanee. 
Annales de Derm, et de Syph. No. 2, p. 121. 1873-1874. 
Port.—Ein Fall von multiple Sarcombildung der Haut unter 
dem Bible der Mycosis (Alibert) Deutsches Arcliiv fiir Klin- 
ische Med. Band xii. s. 134. 1874. 
Hebra. — Artztliches Bericht des K. K. Allg Krankenhauses 
zu Wien vom Jalire, 1874, s. 213. Wien, 1875. 
Hebra. — Arcliiv fiir Derm, und Syph. 1875. 
Biesiadecki. — “ Ueber einen Fall von leuksemischen Tumoren 
in der Haut ” Mittheil. des Ver. der Aerzte in Nieder-Oesterr- 
eich. 1875-1870. Band ii, p. 30. 
Bazin. — “Mycosis” Dictionnaire Encyclopedique des sciences 
Medicales. 2m Serie, Tome xi. 1870. 
Tanturini. — “ Tre casi clinici liuovi di mycosis fongoides di 
Alibert ” 11 Morgagni. 1877. Nos. 1 and 2, p. 1 and p. 81. 
Bracket. — “ Observation de mycosis fongo'ide ” Mem. de Med. 
et de cliir. Militaires. 3d Se'rie, vol. 33, p. 020. 1877. 
Geber.—“Ueber eine entzundliche fungdse Geschwulstform 
der Haut.” Deutsches Archiv fiir Klin. Med. Band xxi, 
Heft, 2 w. 3 Min. 1878. 
Duliring. — “ A case of inflammatory fungoid neoplasm.” Ar- 
chives of Dermatology. Jan., 187!) and Jan., 1880. 
Fabre.—“ Des manifestations cutanees de lymphadenie cutanees 
a propos d’un cas de mycosis fongo'ide.” Bulletin de l’acad. 
Med. No. 44, p. 1135. Nov., 1879. 
LITERATURE OF THE SUBJECT. 23 
Hillaret. — Un cas mycosis fongoide debutant pas un urticaire. 
Acad, de Med. Paris, Dec. 7, 1880. 
Besnier.—Annales de Derm, and de Syph. Tome ii,-No. 4, p. 037. 
Oct 25, 18X1. “ Sur un cas de tnmeurs de la pean, etc ” 
Vidal.—Lymphadenie cutanee, Transactions of the Interna- 
tional Medical Congress- London, 1881. 
Hillaret. — Ditto. 
Oscar Simon. —Ditto. 
De Amiciis. — Contribuzoine clinica ed Anatomo-patologica 
alio studio del Dermo-linfoadenoma fungo'ide micosi, fung- 
oi'de di Alihert Naples. Tipografia Trani, strada Medina, 
25. 1882. Ref. in Annales de Derm, et de Syph Tome iii, 
No. 7, p. 452. 1882 
Galliard.—“ Contribution al’etude de la lymphadenie cutanee.” 
Annales de Derm, et de Syph. Tome iii, No. 3, p. 145 1882. 
Mannino. — “ Sur le Mycosis Fongoide d’Alibert Giorn. Ital. 
delle mal. vener. p. 348. 1882. 
Naether — “Granuloma sarcomatodes cutis” Deutsches Ar- 
chiv fur Klin. Med. 1883, xxxiii. 470-5X4. 
Kobner.— “ Beerscliwamahnliche multiplen Papillargeschulste 
derHaut.” Berlin Klin. Wochenschrift. No. 27, p. 417. 1883 
Hyde. — Study of a case of multiple sarcoma of the skin. Edin- 
borougli Medical Journal 1883-1884. xxix, 502—GOG. 
Auspitz.—Vierteljahreschrift fur Derm, and Syph. 1885. Heft. 
1,p 123 
Rindfleisch.—Deutsche Med. Woclienschrft. No. 15, p. 233. 1885. 
Kaposi — Uebereine neue Form von Hautkrankheit, Lympho- 
dermia perniciosa, etc. Separat-abdruck aus der Med. Jahr- 
biiclier der K.K. Gesellscliaft der Aertze in Wien, 1885.