SPONTANEOUS KELOID. 
CLINICAL LECTURE DELIVERED AT THE ST. LOUIS COLLEGE OF PHYSI- 
CIANS AND SURGEONS. 
Professor of Dermatology, St. Louis College of Physicians and Surgeons; Consulting 
Dermatologist to the St. Louis City Hospital, St. Louis Female Hospital; Der- 
matologist to the Alexian Brothers Hospital, to the Pius Hospital, to 
the St. Louis Polyclinic and Emergency Hospital, etc. 
A. H. 0HMANN-DUMESN1L/A.M., M.D., 
[Reprinted from International Clinics, Vol. II., Second Series.] SPONTANEOUS KELOID. 
CLINICAL LECTURE DELIVERED AT THE ST. LOUIS COLLEGE OE PHYSICIANS AND 
SURGEONS. 
A. H. OHMANN-DUMESNIL, A.M., M.D., 
Professor of Dermatology, St. Louis College of Physicians and Surgeons ; Consulting 
Dermatologist to the St. Louis City Hospital, St. Louis Female Hospital; Der- 
matologist to the Alexian Brothers Hospital, to the Pius Hospital, 
to the St. Louis Polyclinic and Emergency Hospital, etc. 
The case that I wish to present to-day is one which is interesting 
on account of two reasons : first, because it is a rare manifestation of the 
disease; secondly, because it presents a distribution over so extensive 
an area that such examples are but rarely seen. If you will remember, 
keloid is generally limited to the colored race. It is a connective-tissue 
new growth, which may occur either as the result of some traumatism 
or spontaneously. The cases most commonly seen are traumatic, and 
are the results of burns, cuts, lashes, operations, or any condition which 
may cause a traumatism, the keloid occupying the place which would 
have been occupied by a scar had the traumatism healed as it does 
under ordinary circumstances. Cases, however, of the second variety, 
or of spontaneous keloid, occasionally occur, and these are compara- 
tively rare. Plicque says that spontaneous keloid is not only rare, 
but a condition whose etiology is hard to establish. He states that 
Wilson, Kaposi, Vidal, and Schwimmer altogether have seen but 
seventy-two cases. Van Harlingen states that he never saw one, and 
authors in general do not claim that they have had much experience 
so far as seeing cases of spontaneous keloid is concerned. 
In the present case you see before you an individual who has been 
kindly referred to me by Dr. W. F. Thornton, of this college, who 
has gone to the further trouble of supplying the following notes in 
regard to the history of the case: 
Case.-Sylvester C., aged thirty-one, a mulatto, musician by occu- 
pation, applied to him for treatment on November 15, 1891. 
352 Fig. 2.-Spontaneous keloid (back view). 
Fig. 1.-Spontaneous keloid (front view). SPONTANEOUS KELOID. 
353 
Family History.-The mother alone is alive, the father having died 
of pneumonia. The mother is well and strong, forty-seven years of 
age. The father's history, so far as could be ascertained, is good. Three 
brothers and one sister are living, all being healthy and strong, and 
there is no history in any of constitutional trouble of any kind. 
Syphilis or tuberculosis does not exist in any of the parents' relatives 
or ancestors, so far as the subject knows. 
Anamnesis.-The patient was vaccinated on the right arm when 
three years of age. When the vaccination healed it left a small tubercle 
on the site of the scar, and at eight years of age the tubercle began to 
enlarge, and continued to do so until it became the size of a silver 
dollar in circumference. Then new tubercles began to appear upon 
the right arm only, and they continued to enlarge until they have 
reached the size shown at present. They next appeared upon the 
breast as they did upon the arm, and followed the same course. Then 
they appeared upon the hips, next upon the left arm, then upon the 
face. Small tubercles would appear while these were enlarging. 
Status Prcesens.-The patient is of medium height, well built, 
inclined to be muscular; is active, and complains of no discomfort, 
except so far as it may be connected with his cutaneous trouble. Upon 
inspection, he presents the following appearance. Upon the left cheek 
there is a tumor of the size of a walnut, rather flattened and glistening, 
traversed by enlarged blood-vessels of an arterial character. Upon 
the right arm he has a large, flattened tumor, rather depressed at the 
centre, occurring at the apex of the shoulder. Lower down we find 
four others, of varying sizes, rather paler than the normal integument, 
existing upon the outer aspect of the arm down to the elbow. On the 
right forearm there are two other tumors, which are also rather large 
and projecting, like the others, being slightly depressed at the centre. 
The apex of the left shoulder is also occupied by a keloidal tumor, 
while upon the left arm there are three more, one situated rather 
anteriorly, the two others being upon the exterior aspect of the 
arm, the forearm not being implicated. Upon the chest a broad, 
irregular keloid occupies the site of predilection of ;his disease,-viz., 
the sternal surface,-encroaching laterally upon each breast. Upon 
the right breast there are two small tumors, situated about an inch and 
a half internally to the nipple, one of these tumors being slightly 
smaller than the other. Upon the left breast we find a very small 
tubercle, external to and about an inch and a quarter from the 
left nipple. Below and between the breasts, about two inches either 
way, there is another tumor, about an inch long and half an inch 
Vol. II. Ser. 2-23 354 
INTERNATIONAL CLINICS. 
in breadth. The lower border of the scapula as on the left side 
one or two small nodules, and on the right two well-defined keloidal 
tumors; while below this, throughout the surface of the back, there 
are numerous small nodules distributed. Upon the buttocks there are 
upon the right two large tumors, of rather irregular shape, and upon 
the left one, in which the shape is such as to suggest that there were 
several tumors which have coalesced. As you see, the distribution is 
quite extensive, and the small subcutaneous nodules which are seen at 
present are gradually growing larger, and promise to become keloidal 
tumors in their turn. 
When we come to look at the morphology of these growths, we 
find that many of them-in fact, nearly all which have attained any 
size-are depressed at their centres, and, while roundish or ovoid in 
character, none of them are pedunculated, a peculiarity which was 
pointed out long since by Plicque. Upon inquiry, the following facts 
are elicited : 
The patient states that while never particularly uncomfortable, so 
far as their size and distribution are concerned, he has found that occa- 
sionally, sometimes frequently, a great deal of pain is felt in some or 
several, this pain being very much allied to neuralgia in its character; 
that is, there is a sharp, shooting pain, which spreads in various direc- 
tions, and seems to acknowledge the keloidal tumor as a centre for the 
ramifications of the different areas through which these lancinating pains 
are distributed. In addition to this, there is itching, which at times 
is very marked; and besides that, we find the remains of suppura- 
tion, not very extensive in character, but rather deep. The patient 
states that these tumors have suppurated at times and the process lasts 
for some little time, and it is this destructive action occurring in the 
central portion of the tumors which produces the apparent umbili- 
cation observed. Upon feeling the tumors themselves, it is found 
that they have peculiar characteristics. They seem to have a doughy 
feel and to be freely movable upon the subjacent connective tissue; in 
fact, they seem to be entirely unconnected with the fascia of the muscles, 
and to be independent of the intimate connective tissue which binds 
this fascia to the overlying structures. Handling the keloid does not 
seem to elicit any particular pain; indeed, the patient would not be 
aware of the fact that the tumors were being handled were it not for the 
general sensation which is imparted by palpation. When, however, 
the neuralgic pains are present, the mere act of touching them in- 
creases this pain and renders the patient uncomfortable. 
Now, to recur to keloid. As I have mentioned to you, it is a SPONTANEOUS KELOID. 
355 
connective-tissue new growth, and it is one which is most often observed 
in the colored race, although it is sometimes seen in the white. As 
a rule, it is a traumatic variety which we meet with, but care should be 
taken not to mistake traumatic or spontaneous keloid for so-called 
hypertrophic scar. This latter is a condition which follows trauma- 
tisms, and consists simply of an hypertrophy of the scar-tissue and 
hyperplasia of the elements of repair, which, instead of taking the 
place of the destroyed tumor, take on an increased growth of a low 
character, and form tumor-like masses of a low grade of vitality, and 
are very apt occasionally to be painful, and thus to simulate to a cer- 
tain degree keloid. In traumatic keloid you will find this peculiarity 
present in the growth. It always assumes the general configuration 
of the scar upon which it grows or which has occasioned its appear- 
ance. You will find, for instance, that where the traumatism has been 
caused by the lash, where we have parallel destructive lines occurring 
in the skin, the keloid will assume this same parallel longitudinal 
appearance. Where the keloid has been occasioned by an operation, 
you will find that it occurs in the lines or along the scar of the lines 
of incision ; and where the keloid has been caused by a burn, it will follow 
the configuration of the scars produced by that traumatism. Another 
peculiarity, which is found not only in traumatic but also in sponta- 
neous keloid, is, that the keloidal tumor, which in the beginning is 
roundish or oval in shape, changes with time. After a certain 
period it begins to throw out prolongations from the periphery of the 
original growth, and, as it occurs most frequently upon the chest, the 
prolongations have, as a rule, been observed to take place laterally, 
giving a fancied resemblance to the entire mass of a crab, whence it 
derives its name,-kelis, a " crab." In hypertrophic scar you will find 
that there is not this peculiarity of conformation. While the growth 
naturally follows the form of the traumatism which has occasioned it, 
it still participates in the general characteristics of scars, and limits 
itself to the traumatism which was produced either by the surgeon's 
knife or by the accident which caused the injury. You will find that 
there is no tendency whatever to prolongations being thrown out, as 
there is in keloid in general, nor is it limited so much to the colored 
race, being found with equal frequency in the white and in the African. 
No particular pain or neuralgic hypersesthesia can be foujid in it, and, 
as a rule, we do not find that suppuration ever takes place spontaneously, 
as occurs in both the traumatic and the spontaneous keloid. 
To make a differential diagnosis between spontaneous keloid, trau- 
matic keloid, and hypertrophic scar you will find sometimes a dififi- 356 
INTERNATIONAL CLINICS. 
cult matter, unless you can rely implicitly upon the history furnished 
by the patient. If the subject be reliable, the fact of a traumatism 
will immediately establish a differential diagnosis, so far as spontaneous 
keloid is concerned, and that can be immediately eliminated or adopted. 
Then, as between traumatic keloid and hypertrophic scar, you will find 
that the characteristics of keloid which I have already mentioned will be 
present to a greater or less degree, and entirely absent from the hyper- 
trophic scar. But cases occasionally occur in which no reliance what- 
ever can be placed upon the history of the patient, and where the 
number of the tumors is not sufficient to enable the diagnostician to 
state positively from their appearance as to whether the growth is 
spontaneous or traumatic, or is positively keloidal in character. Upon 
palpation, it will be found that keloidal tumors, whether they be 
spontaneous or traumatic in character, have a certain doughy feel and 
are slightly lighter in color than the surrounding integument. In 
the blacks you will find that the color is much paler than that of 
the normal skin, and in the white race that it has a pinkish appear- 
ance. Furthermore, you will find that there is a tendency for the 
appearance of new arterioles and for a thinning of the skin to exist, 
whereas in hypertrophic scar if it does exist for any length of time 
it partakes of all the characteristics of scar-tissue. It is white, even 
glistening in appearance. It has no skin upon it, since it is scar- 
tissue, and if any arterioles do exist they will be distributed about 
the border of the new tissue, and will not occur over the surface, 
as you find them in keloid. Moreover, the hypertrophic scar does not 
grow after a certain time : it remains stationary and never throws out 
prolongations. Keloid has a tendency to grow, and to grow for many 
years, and after it has apparently attained its growth you will then find 
that it suddenly begins to throw out offshoots, the so-called crab-like 
prolongations, which, in their turn, partake of the character of the 
original tumor. 
So far as the pathology of this trouble is concerned, there is but 
little known up to the present, except as regards its microscopic appear- 
ance. You will find that some authors contend that so-called scrofula 
is the cause, and is always present in those affected by the trouble; but 
in many cases no constitutional cause can be found at all, and, as in 
the instance .which is before you, the individual seems to be in as 
healthy a condition as could possibly be desired. Others, again, have 
stated that the trouble was a fibrous sarcoma, and yet a microscopical 
examination of this growth fails to demonstrate the presence of any 
element which would make one suppose that there was any sarcomatous SPONTANEOUS KELOID. 
357 
process taking place within the growth. If we compare keloid, false 
or cicatricial, and a hypertrophic scar microscopically, we shall find 
that there is one characteristic, which, to state it roughly, is about as 
follows, differing in each one. In true or spontaneous keloid the 
papillae of the skin remain, showing that there has been no destruc- 
tion of the cutis vera. It shows that the process is not a destructive 
one, but a neoplasm. We find that the fibrous tissue which is present 
is distributed in a vertical manner, as a general trend of the process. 
Now, if we take spurious keloid we find here a condition which 
immediately differentiates it from the spontaneous. While the con- 
nective tissue has the same general direction, and is distributed in about 
the same manner, in bundles having a vertical direction, the papillae 
are not present. The papillary layer of the true skin has disap- 
peared, and this can be easily explained if we reflect but for a moment 
upon the origin of the growth. It is traumatic in origin, and the 
skin has been destroyed in that portion where it took its origin. 
In the same manner you will find that in hypertrophic scar the 
papillae are also destroyed, for, as you are well aware, no papillae 
can exist in scar-tissue, because its very existence implies that there 
has been a destruction of the skin, and that it is simply a substitute 
for the destroyed portion, the substitute consisting of fibrous tissue, 
and this fibrous tissue is disposed, too, in bundles of white fibres, 
whose general direction is horizontal. So that if we take these 
three conditions into consideration, we have a very easy method of 
making a differential diagnosis by means of the microscope, and also 
of arriving at a safer conclusion in regard to the pathological pro- 
cess which has taken place in these various neoplasms. To assume 
that the trouble is one due to scrofula is entirely misleading, for we are 
aware now that scrofulosis in general is merely a term to imply a 
particularly localized form of tuberculosis. Now, in the examination 
of spontaneous keloid, the tubercle bacillus and other evidences of 
tubercular infiltration are entirely absent, and hence we cannot conclude 
that this is a tuberculous growth, nor can we suppose that because an 
individual is affected with tuberculosis, and has keloid, the latter is 
necessarily dependent upon his general condition. In the case which 
you see before you, we have an individual whose lungs are healthy, 
whose sputum contains no bacilli, in whom no evidence of either gen- 
eralized or localized tuberculosis can be found. The only point to 
establish is that it is spontaneous and not traumatic in character. The 
history might lead one to suppose that it was traumatic, from the fact 
that he states that the first tubercle began at the site of the vaccination ; 358 
INTERNATIONAL CLINICS. 
but had it been traumatic in character it would have been limited to 
that site,-that is, to the upper portion of his right arm,-whereas it 
is distributed over his trunk and limbs; and if we examine his chest 
and back we find tubercles of all sizes, from those which are barely 
perceptible to the touch to others which are as large, probably, as a 
hazel-nut, all of them growing, as he states to us, some having 
appeared without his knowledge, and at none of the sites where these 
exist can the slightest evidence of any traumatism be found. In 
addition to that, he states that in every portion, except that where he 
was vaccinated, he never received any injury whatever, nor was he cut 
or scratched, neither did he suffer any solution of continuity of the 
integument. Taking these facts into consideration (and there seems to 
be no reason for doubting the patient's statement in this regard), we 
must come to the conclusion that these tuberculous growths and tumors 
have appeared spontaneously, as they seem to be doing now, without 
any apparent cause, and this is certainly proof positive that the trouble 
under consideration is one of spontaneous keloid. There can be no 
doubt whatever as to its being keloidal in character, and as there is no 
doubt as to its causation, we must conclude that it is spontaneous 
keloid. Such a marked case as the present one is a rarity, and it 
presents, in addition, almost all the phases which may be observed in 
the evolution of this neoplasm. We find the barely perceptible 
tubercle, the one which is larger, the various degrees of size, until we 
arrive at the extremely large one, which has undergone the further 
metamorphosis of becoming flattened and assuming more of a scar-like 
aspect than you observe in the tumors on the arms, for instance, which 
appear almost sessile, and which have a doughy feel, whereas that upon 
the chest is rather firmer in consistency. We can see at present certain 
small suppurating points, such as upon the left side of the keloid of 
the chest. We can see sears existing in others, such as that upon the 
right arm, showing where suppuration has taken place before. At 
present he is not complaining of neuralgia, although he had that and 
itching a few days since. If there be any cause for this growth, a 
neurotic disturbance would probably account for it better than any 
other, and the general distribution would seem to favor this, were it 
not for the fact that the one occurring upon the chest crosses the median 
line, and thus immediately nullities any theoretical considerations 
which might be connected with nervous trunks, and consequently 
destroys any supposition that might attach, or any importance which 
we might give, to a neurotic origin for this growth. 
Now, the treatment is something which so far has proved entirely SPONTANEOUS KELOID. 
359 
ineffectual, not only in spontaneous keloid, but in the traumatic form 
as well. Every method imaginable has been employed, and always 
unsuccessfully. One of the cardinal qualities which this neoplasm 
seems to possess is that it will always recur. If, for instance, you take 
spontaneous keloid and destroy it with a caustic, cut it out with a 
knife, decompose it by electrolysis, or use any other method for its 
extirpation, you will find that as a natural result a scar will be pro- 
duced, and you will not have succeeded in destroying the keloid, but 
you will have a change taking place, in this: that instead of a spon- 
taneous keloid, you will have given rise to the development of a trau- 
matic keloid, which may or may not become larger than the original 
tumor was. There seems to be a certain predisposition existing in the 
individual which results in the regeneration of this peculiar neoplasm. 
In the case of the traumatic keloid you will find that, as in the spon- 
taneous, no matter what methods you may employ in order to secure 
its disappearance, the effect will be only temporary, and the ultimate 
result will be a recurrence of the original growth. In the same 
manner as in hypertrophic scar, if you cut out the scar you will 
find that in the majority of cases another hypertrophic scar will 
form. This shows that there must be some predisposition of the 
tissues which leads to a regeneration of the process, how or why we 
cannot explain, but that it does exist is confirmed by the practical ex- 
perience of those who have endeavored to procure the disappearance 
of these growths. In the present case it wotdd be rather difficult to 
eliminate the growths, as you see the involvement of the integument 
is so great that it would be dangerous to remove all these keloidal 
tumors. The patient is satisfied so far as cosmetic appearances are 
concerned. All the tumors, with the exception of the one on his 
left cheek, are covered by his clothing, and that one, although it is 
steadily growing, incommodes him but little. Still, he is willing to 
have that extirpated, and the only hope which can be held out to him 
is that of an operation which will be comparatively extensive, which 
will dip down into the normal tissue and go wide of the tumor, a 
scar being formed which in comparison with the growth will amount 
to practically very little. At the same time, it will give us an oppor- 
tunity of being able to examine this tumor microscopically, and 
perhaps of establishing some point which may have been overlooked. 
To sum up. The case is a unique one. As a case of spontaneous 
keloid, it is the most extensive that has ever been figured, probably, and 
one which is seen but once in a lifetime. It is instructive, from the 
fact that it demonstrates very clearly the fact of spontaneous keloid, INTERNATIONAL CLINICS. 
360 
the manner of its growth, the manner of its evolution, the phases 
through which it passes, the various processes which it may undergo, 
and the amount of surface which may be involved without distress- 
ing the subject of such It inconveniences the 
so little that he plies his vocation, that of a Violinist, without ever 
being incommoded, and whenever he has attacks of neuralgic pain 
his right arm suffers no more than his left, and sometimes it is 
neither one, but those portions which would naturally be supposed to 
offer the least opportunity for the development of such subjective 
symptoms,-viz., the facial tumor or that upon the chest. 
The patient will be kept under observation, and if any new de- 
velopments should appear, he will be presented to you again, in order 
to show them, although it is very probable that nothing of that char- 
acter will occur, except so far as the enlargement and growth of the 
tubercles, which are now apparent, are concerned.