[Reprinted from The Tri-State Medical Journal and Practitioner, St. Louis, Septembep-jSg?.] 
KELOID. 
By A. H. Ohmann-Dumesnil, Saint Louis. 
VERY dermatologist knows that there are 
many skin diseases which are but rarely 
I or never observed in Caucasians but wdiich 
f nevertheless, are seen rather frequently in 
l otherraces. This is said to be dependent 
upon susceptibility; but this is really 
beggingthe question, as it is merely stat- 
' ing the original proposition in another 
War & & form. It is an attempt at an explanation 
gsF which, in reality, does not explain. So 
Fl we must, perforce, remain contented 
with the mere statement of a bald fact 
v until some more satisfactory reason can 
11 pe brought forth. Under these circum- 
stances it may be simply stated as a fact 
that among the cutaneous affections which are not commonly observed in 
white persons, but which seem and actually do occur rather frequently in 
negroes, may be mentioned keloid. This disease, as most frequently seen, is 
known as the traumatic variety, and is the result of burns, cuts, lashes, 
operations, or of any other condition which may cause a traumatism, the 
keloid occupying the place which would have been occupied by a scar had 
the trauma healed as it does under ordinary circumstances. The variety 
which is much rarer is that known as "true" or spontaneous keloid. 
Plicque makes thestatement that true keloid is not only rare,butis a condition 
whose etiology it is very difficult to establish. He goes on further to state 
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, who have had a large dermatalogical experience, do not 
claim such, so far as having observed cases of spontaneous keloid is con- 
cerned. The disease is one of more than ordinary interest, not only from 
its morphological peculiarities and unusual pathology and pathogeny, but 
from the further fact that it is one which, up to the present, has seemed 
to resist all forms of treatment, even such as are thoroughly radical in 
character. It is seemingly incurable, but this is certainly only due to the fact 
that the methods hitherto employed are inadequate; and there is no doubt 
that some method, very probably simple in character, will be discovered 
which will solve this therapeutic riddle in a satisfactory manner. 
Keloid, whose name is derived from the Greek word Kelis, signifying a 
crab (to which it has been said to bear a fancied resemblance), is essen- 
tially a neoplasm of the fibrous variety . The disease occurs in the form of 
tumor-like formations, which are rather flattened, and which may or may not 
have narrow prolongations. The lesions occur about the chest and back 
for the most part, although the arms, legs and face may also be involved. 
The color is usually not so dark as that of the surrounding normal in- 2 
tegument, and here and there upon the surface there may be observed fine 
blood vessels ramifying in a somewhat stellate form. This latter, how- 
ever, is not an invariable accompaniment and is frequently absent. To the 
feel the lesions of keloid have a sort of doughy resistance, which, whilst 
it is perhaps firmer than that offered by a lipoma, is still not as marked as 
that offered by a fibroma. It is something very difficult to define, and yet 
when once it has been felt it is never forgotten and is easily recognized 
when felt again. The integument covering the keloidal tumor is smooth, 
sometimes tense and glistening, and not very freely movable or even 
attached. 
Before proceeding further with the general characteristics of keloid it 
may not be inopportune to give the history of a case of the spontaneous 
variety which I had occasion to observe some few years ago. S. C., a 
mulatto, aged 31, and a musician by occupation, gave a good family history. 
His father died of pneumonia, and his mother, still living, as well as three 
brothers and one sister, never had any disease. So far as the patient knew, 
neither syphilis nor tuberculosis ever existed in any of his ascendants. The 
patient states that he was vaccinated on the right arm at the age of three. 
When the vaccination healed it was followed by a small tubercle at the 
site of the scar, and when he was eight years old the tubercle began to en- 
large. It continued to do so until it attained the size of a silver dollar in 
circumference. It was then that new tubercles began to appear upon the 
right arm only, and they continued to enlarge until they reached their 
present size. They next appeared upon the chest, as they had done upon the 
arm, and they followed the same course. Then they made their appearance 
upon the hips, and then upon the face. Whilst these were enlarging small 
tubercles would be appearing. The back shows a number of these latter. 
When examined the patient was found to be of medium height, well 
built, inclined to be muscular. He is active and complains of no discom- 
fort, except so far as it is connected with his cutaneous trouble. He 
presents the following appearance, which is well shown in Figure 1, his 
back only being shown: Upon the left cheek there is a tumor of the size 
of a walnut, rather flattened and glistening and traversed by enlarged ves- 
sels of an arterial character. Upon the right arm, at the apex of the 
shoulder, there is a large, flattened tumor, rather depressed at the center. 
Hower down four other tumors exist on the outer aspect of the arm down 
to the elbow. These are of various sizes and rather paler than the integu- 
ment. On the right fore-arm there are two other tumors, also large and 
projecting, slightly depressed at the center. The apex of the left shoulder 
is also the seat of a keloidal tumor, three more being upon the left arm, one 
anteriorly. The left fore-arm is not implicated. Upon the chest a broad, 
irregular mass occurs over the sternal region, encroaching upon each 
breast laterally. Upon the right breast there are two small tumors to the 
left of and about an inch and a half from the nipple, one being slightly 
larger than the other. Upon the left breast there is a very small tubercle, 
external to and about an inch and a quarter from the nipple. Below and 
between the breasts, about two inches either way, is a tumor about an inch 
long and half an inch in breadth. At the lower border of the left scapula 
are one or two small nodules, and on the right two well-defined keloidal 
tumors. Below this numerous small nodules are distributed over the back. 3 
Upon the right buttock there are two large, irregular tumors; aud upon the 
left, one whose shape would seem to suggest that several, which formerly 
existed, have coalesced. When these tumors are examined it will be found 
that they are all depressed at their centers, roundish or ovalish in contour, 
and none pedunculated, a peculiarity to which Plicque called attention long 
since. 
Fig. i. Keloid 
The patient states that whilst the tumors are not particularly uncomfort- 
able, so far as their location and size is concerned, they do occasionally 
elicit a great deal of pain, this being very much allied to neuralgia in its 
character. The pain is sharp and shooting, spreading in various direc- 
tions, audit seems to recognize a keloid as a center of distribution for all of 
its ramifications over an affected area. There is added to this a certain 
amount of itching, which may become very marked. In addition to these 4 
subjective symptoms, suppuration is to be found. It is not of a marked 
character, but rather deep. According to the patient's statement, these 
tumors have suppurated at times, and the process last for a certain period. 
It is this destructive action occurring at the center which produces the ap- 
parent umbilication which is observed. Handling the keloid does not 
seem to produce any particular pain under ordinary conditions; but, when 
the neuralgic pains are present, the mere act of touching it makes the pain 
more acute. 
The history of this case is certainly most instructive, so far as obtain- 
ing a good idea of the objective and subjective symptoms of keloid is con- 
cerned. There are, however, some points in connection with the disease 
which are not brought out in the above. The number of keloids observed 
in different subjects varies greatly. In many there is but one, situated upon 
the chest, in the form of a flattened mass, extending horizontally and termi- 
nating at each extremity in small, narrow prolongations, having much the 
appearance of thickened scars. This peculiarity of prolongations from the 
central mass is rather a common one. The chest is certainly the site of 
predilection of keloid. The back is another locality for this peculiar 
growth, and here it is most often found in the form of parallel stripes or 
bars looking very much like scars. Another form is where it occurs as a 
single roundish or ovalish tumor. A very common locality is the lobes of 
the ears which have been pierced for earrings. But there is no locality in 
particular which is immune to keloid. Again, we find cases in which there 
exists a number of keloids, and they are of different sizes, much depending 
upon the length of time each one has existed, the older ones naturally being 
the larger. It may also be generally observed that it is a common occur- 
rence for a more or less flattened or extensive keloid to become depressed to a 
certain degree at its center, and suppuration may declare itself at one or at 
several points. This process subsides spontaneously, but is followed by the 
formation of scars, which are plainly perceptible upon the surface of the 
growth. The objective symptoms which have been briefly outlined are so 
easily recognized as to render a diagnosis of a case a comparatively simple 
matter. This recognition is rendered still easier by a due consideration of 
the history and of the subjective symptoms which are noted by the patient. 
These subjective symptoms, when they manifest themselves, are of 
quite a marked character. At times there is some itching,which manifests 
itself, but it is not very marked and really amounts to very little when we 
take into consideration another symptom, which is a most prominent one 
and occurs in all forms of the disease and all cases. This symptom con- 
sists in a sharp, lancinating, neuralgic and almost unbearable pain, which 
occasionally becomes excruciating in character, causing the patient to writhe 
in anguish. It is so acute in its intensity, and persists for such a compara- 
tively long period of time, that the one subject to it becomes positively 
frantic. It is most irregular in the periods of its manifestations, and it is 
this very uncertainty as to its appearance that keeps the subject in a con- 
stant state of fear and terror at the mere thought of the possibility of its 
sudden and unexpected appearance. It may be readily surmised what a 
serious condition such can be in a neurotic, or one whose nervous system 
has the slightest susceptibility to such psychic disturbances. There is the 5 
further terror added of the possibility of new keloids forming and, in their 
turn, adding to the agony of the condition already existing. 
False keloid is occasionally observed, but it is not to be confounded 
with the true variety, although it resembles it in no small degree. It is 
always due to traumatism and greatly simulates scar tissue, It is rarely, 
if ever, as extensive as true keloid, and it is devoid of the subjective symp- 
toms noted in the latter. In addition to this, it will yield to radical treat- 
Fig. 2. False Keloid. 
ment, something which the true form has never been known to do. It is 
for this reason that more than ordinary care should be taken to recognize 
such cases, on account of the important bearing this has in formulating a 
prognosis and in procuring successful treatment, where such is indicated. 
A good example of this peculiar form of pseudo-keloid is shown in Figure 
2. The patient, a young, white adult, suffered from tuberculous glands of 
the neck. He was advised to have them excised, which was accordingly 6 
done by a very competent surgeon. The incisions were quite slow to heal, 
but finally cicatrization occurred. It was, perhaps, but natural to expect 
a corded scar, which showed itself. In a comparatively short time, however, 
small prolongations from the scar made their appearance. This condition 
is very well shown in the picture. Observing this peculiar condition, the 
patient applied for relief, fearing that these prolongations would increase in 
both size and number. The final outcome of the case was all that could 
be desired. The cicatricial masses were excised, and after two years no 
recurrence had taken place. An interesting point to note, in connection 
with the case, is the fact that the patient was white, with no possible ad- 
mixture of black blood. He never complained of any itching or pain, and 
requested an operation for purely cosmetic purposes. 
Keloid is a growth which has been observed to occur after the age of 
puberty, in early adult life, as a rule. It does manifest itself during middle 
age,- but those who have escaped it and arrive at old age do not manifest 
the disease. If they be prone to it, an operation or a traumatism will be 
followed either by a hypertrophic scar or by a false keloid, which will cause 
but very little or no trouble beyond that caused by its ugly appearance. 
The disease itself seems to exercise no predilection for either sex, for it is 
seen to occur in females as frequently as it does in males. The size of the 
keloidal tumor seems to bear some relationship to the comparative intensity 
of the darkness of the skin. It would seem that the more pigment there 
is in the skin the larger the keloid is, other things being equal. Thus, in 
the darker negroes keloid seems to be larger than in those who are lighter; 
and in the white-skinned races it is quite small, as a rule, and never 
attains a large size. It is such an unusual thing to observe in Caucasians 
that its presence is accounted almost a rarity. 
The essential cause of keloid is unknown. So far as the origin of 
spontaneous keloid is concerned, nothing at all is known. The most 
common cause of the more frequently seen form, so far as can be deter- 
mined from the histories furnished, is traumatism. Such injuries as are 
caused by burns, cuts, strokes of the lash, blows inflicted with whips, iron 
bars, pieces of wood, and similar exciting causes, are followed by keloid in 
those individuals as are susceptible to the disease. The keloid occurs 
along the whole track of the traumatism, no matter in what portion of the 
body it may occur, and this new growth presents all the peculiarities and 
symptoms inherent to the disease. There is no doubt, whatever, that a cer- 
tain susceptibility exists; but in what this peculiar and strange suscepti- 
bility consists, essentially, has never been explained. All that can be 
predicated when it makes its appearance is that it exists. In the sponta- 
neous form of keloid we have the disease manifesting itself without any 
apparent cause or reason. It suddenly makes its appearance in the form 
of a small tumor, somewhat elevated, and it gradually enlarges until it 
reaches its limit of growth, where it remains stationary. In the meantime 
other keloids may be developing, so that it is not unusual to find a number 
of tumors in various stages of growth. As in the traumatic form, there 
exist marked subjective symptoms of a most painful and disagreeable 
character. 
The histopathology of the various forms of keloid and pseudo-keloid 
cannot be entered into at this time, as the subject is one whose thorough 7 
consideration would require much more space than could be spared at this 
juncture. Suffice it to say that it is a connective-tissue new growth which 
differs essentially from true scar, hypetrophic scar, or fibroma, in the 
peculiar distribution of the fibers of connective tissue. 
The treatment of keloid is as yet an odium medicines. All the various 
methods which have been devised up to the present time have proven ab- 
solute failures, with the possible exception of one, and this is only claimed 
to have produced fair results in but a few exceptional cases. Excision is 
totally powerless, and is invariably followed by a relapse. The same is the 
result of the employment of the actual cautery, galvano-cautery, or chem- 
ical caustics. Each and every one produces a wound which, as soon as it 
cicatrizes, is again the seat of a keloidal tumor. Electrolysis is reported to 
have cured a few cases, but as there have been no reports forthcoming 
detailing the condition of the so-called cured patients, one or two years 
later, no positive reliance can be placed in such reports, more especially in 
view of the fact that the authors have noted relapses in patients treated by 
this method. For this reason the physician whose aid is sought in such 
cases should always be careful not to make promises or even hold out any 
marked encouragement to patients afflicted with keloid. 
What may be done is to allay or mitigate the intense pain which mani- 
fests itself, and this may be accomplished by causing cocaine to traverse 
the tumor by means of cataphoresis. If this is not possible, a good 
application is the following, to be rubbed in frequently: 
ft Cocaini muriat gr. xv 
Ung. aquae rosse5 U 
Lanolini5 VJ 
M. 
Hypodermics of cocaine will also help to a marked degree and do much 
to allay the pain. 
The prognosis in every case is always bad, and no hopes of ultimate 
recovery from keloid should ever be held out in the present condition of 
our knowledge of its therapeutics.