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FIBROMA Synonyms.—Molluscum simplex; Molluscum fibrosum; Fibroma molluscum;

Molluscum pendulum; Molluscum non-contagiosum; Fr., Fibrome; Nævus mollus-

coide; Molluscum vrai; Ger., Fibrom. Definition.—Fibroma is a connective-tissue new growth, appear­

ing as one or more sessile or pedunculated, pea- to egg-sized or larger,

soft or firm, rounded, sometimes flattened, painless tumors, seated be­

neath and in the skin. Symptoms.—The tumors appearing in this disease show varia­

tions as to size, shape, and numbers. There may be but a single growth

or they may be numerous. Occurring as a single tumor, which is the

more common, it is usually more or less pedunculated, and, when

reaching any great size,—and it quite frequently attains considerable

dimensions,—it becomes pendulous (fibroma pendulum). In the mul­

tiple cases the growths may be somewhat scanty in number, or may exist 694 NEW GROWTHS in great profusion, as in the instances observed by Octerlony,1 Hewson,

and others; in extreme examples they may be present in such abundance

as to crowd the surface, as in the case reported by Dunn.2 In these

extensive cases the growths vary from a pea to an egg or larger, and may

be almost all more or less rounded and sessile, although usually some show

a trifling or moderate tendency to narrowing at the base, giving the tu­

mors a pear shape, and such, when the narrowing is at all marked and

the growths moderately large, are generally slightly pendulous. Others

may be sausage shaped, and exceptionally show a tendency to lobulation.

In other cases the tumors will be, for the most part, as just described;

but one or several extremely large pedunculated growths (fibroma pen­

dulum) will be present, with a comparative small pedicle and a variously Fig. 156.—Fibroma (front and back view of the same patient) (courtesy of Dr. Addinell Hewson). sized, pear-shaped, often somewhat flattened, pendulous mass, which

hangs down and often covers up some of the smaller tumors. In these

general cases the upper part of the back seems to be a favorite region

for the pendulous growth, as in Tappey‘s and Iurkewicz‘s3 patients.

The smallest tumors project but slightly, in some instances appearing 1 Octerlony, Arch. Derm., 1875, P- 300, having 2333 growths (with illustrations);

Wigglesworth, in the same journal for 1876, p. 193, also records a similar case (with

illustration), having 1193 tumors; Hashimoto, Sei-I-Kwai Med. Jour., Dec, 1888, p.

197 (with illustration), described a case with 4503 growths; Pooley, Jour. Cutan. Dis.,

1894, p. 117, has also published an extensive case (with illustrations). 2 Dunn, Med. Press and Circular, 1890, p. 623 (with good illustrations); a plate of

this remarkable case, credited to Hutchinson, will also be found in Morrow‘s System,

vol. iii (Dermatology), op. p. 478. 3Tappey, Jour. Cutan. Dis., 1889, p. 179 (with illustration); Iurkewicz, Meditzin-

koië Obozrenië, No. 21, 1891, p. 738 (with drawing)—abs. in Brit. Jour. Derm., 1891, p.

367. FIBROMA 695 to be practically subcutaneous, although in other cases they are inti­

mately associated with the skin proper and are more elevated. In the

moderate and larger sized growths the elevation is conspicuous, and when

narrowing of the base is present, they are essentially situated wholly

above the surrounding level. The skin over the tumors is generally normal, but it may be tense or

lax, and of a natural pinkish or reddish color. The reddish color is

generally seen in those growths which develop rapidly, the slowly grow­

ing tumors—the usual course—remaining more or less normally colored.

In some tumors, more especially those of larger size, the openings of the

sebaceous glands are enlarged and hypertrophied, and sometimes con­

tain blocked-up secretion or plugs. In other instances, usually in those

lesions in which the skin is tense and distended, the follicles may be

atrophied and the integument somewhat thinned. To the touch they usu­

ally feel soft or doughy and slightly elastic, and are painless. They do

not undergo destructive change, although with the heavy, pendulous

formations, as a result of weight or pressure, surface abrasion and ulcera-

tion may occur; and when crowded together, owing to their number,

size, and location, as a result of interference with motion or by accidental

injury, the larger growths may occasionally become inflamed, and ex­

ceptionally undergo ulceration and even become gangrenous. In some

of the rapidly developing tumors the skin, which becomes red and vas­

cular, may later become excoriated and even ulcerated. Gangrenous de­

struction also occasionally occurs in the growths with extremely thin

pedicle. Ordinarily, however, such accidents do not occur, and except

for the disfigurement and discomfort of their presence, they give rise to

no serious condition. In the course of time, but usually slowly, some

lesions continue to increase in size, new ones may arise, while others,

having obtained variable dimensions from small to large, remain more or

less stationary, so that there are usually to be seen, in a given case,

tumors of all sizes from that scarcely larger than a pin-head or small

pea to that of considerable proportions; the latter, especially the large

pendulous tumors, sometimes reaching huge size, and weighing many

pounds. The greatest size and weight are observed in the single fibroma,.

although in the multiple cases sometimes one or two tumors also attain

enormous development. In the average case there seems to be a steady,

usually slow, increase in the number of the growths, although after a time

the malady is apt to remain stationary; exceptionally, however, there

are seen to be periods of active increase, and this has been more especially

noticed in women and in connection with pregnancy (Hirst1). Indeed,

there is a peculiar small type growth observed occasionally in pregnant

women, presenting about the fourth to the sixth month of pregnancy,

gradually increasing, as a rule, in numbers (rarely exceeding 50) up to

full term, and then slowly, in the course of a few months disappearing

(Brickner2); they are usually only seen about the neck, breast and sub-

mammary region. 1 Hirst, “A Note on the Etiological Influence of Pregnancy upon Molluscum Fibro-

sum,” Amer. Jour, of Obstetrics, 1911, lxiii, p. 256. 2 Brickner, “Fibroma Molluscum Gravidarum,” Amer. Jour, of Obstetrics, 1906,

liii. p. 191 (with histologic report by Pollitzer). 696 NEW GROWTHS Occasionally the tumor growths are ill defined, consisting of irregular

and nodular, confluent, wrinkled, and fold-like masses, and when such

formations are numerous and of gigantic size, they give the patient in

regions an elephantine appearance—the extreme development, which

seems really a combination of fibroma, elephantiasis, and dermatolysis,

giving rise to the appellation “elephant man,”1 In this instance there

were also some exostoses. Occasionally a growth, usually those of mod­

erate size, undergoes partial involution or absorption of the interior por­

tion, and hangs like a flaccid, partly filled pouch or sac This absorption

exceptionally takes place in the large pedunculated or sessile growths,

and when more or less complete, results in a soft mass of pendant, vari­

ously hypertrophied skin—dermatolysis (q. v.). This same change is

also at times noted in the small pea-sized, isolated fibromata, and fleshy

moles, soft warts, or solid, warty-looking growths, in the skin of those

advancing in years (see Atrophia senilis), which are often pedunculated,

and which result in small, pendulous sacs; to these the name of fibroma

simplex, or acrochordon, is sometimes given, although the term fibroma,

when employed, usually refers to the more pretentious growths, which

have been described, but which, as remarked, may undergo similar invo-

lutionary changes.2 Occasionally, in a pea- to cherry-sized growth, more

especially the smaller, when such absorption or involutionary change

takes place, there remains a slight projection, seemingly hollow and read­

ily compressible, and sometimes of a bluish tinge. In some instances neurofibromata have coexisted, as in the cases

recorded by Atkinson,3 von Recklinghausen,4 Payne,5 Brigidi,6 Briquet,7

and others.8 In some cases, as Recklinghausen and some others believe,

the lesions are doubtless all neurofibromata (Recklinghausen‘s disease,

neurofibromatosis). Other lesions sometimes associated are brownish,

pigmentary stains, sometimes freckle-like, small or large areas, and

occasionally more or less diffused discoloration. While, as Wickham9 1 Editorial report of an extreme example in Brit. Med. Jour., 1886, ii, p. 1188 (with

illustrations); an abbreviated account, with illustrations, also in Jour. Cutan. Dis., 1887,

p. no. 2 See Taylor‘s paper, “Molluscum fibrosum and its Relation to Acrochordon and

other Cutaneous Outshoots,“ Jour. Cutan. Dis., 1887, p. 41; and to “Keloid,” ibid., p. 161. 3 Atkinson, New York Med. Jour., 1875, vol. xxii, p. 601 (2 cases in family). 4 Von Recklinghausen, Ueber die multiplen Fibrome der Haut, und ihre Beziehung

zu den multiplen Neuromen, Berlin, 1882 (a résumé of fibroma cases; 5 plates, 2 of case

illustrations and 3 histologic). 5 Payne, Brit. Med. Jour., 1889, i, p. 592. 6 Brigidi, Monatshefte, 1894, vol. xix, pp. 190 and 237 (with histologic cuts and

bibliography). 7 Briquet, Jour. med. cutan., 1898, p. 219 (with bibliography). 8 Whitfield, Lancet, Oct. 31,1903, p. 1230 (newly formed nerve-fibers were found in

the growth); Krzystalowicz, Monatshefte, 1903, vol. xxxvi, p. 421 (case report, histologic

review, and bibliography to date); Piolett, Hospital Gazette, 1902, No. 137, brief ab­

stract in Jour. Cutan. Dis., 1905, p. 363 (with more than 600 tumors), Benaky, Annales,

1905, p. 977; Merk, Archiv, 1905, vol. lxxiii, p. 139. 9 Wickham, Paris letter, Brit. Jour. Derm., 1890, p. 151; Parkes-Weber, Brit. Jour.

Derm., 1909, p. 49, reviewing the subject, calls attention to the fact that cases of Reck-

linghausen‘s disease occur in which decided pigmentation of the skin is developed long

before neurofibromata of nerve-trunks or molluscum tumors of the skin are observed;

Ravogli, “Fibroma Molluscum, or Universal Neurofibromatòsis,” Jour. Cutan. Dis.,

Feb., 1911 (records a case; illustrations, review of the subject in general, with good

bibliography); Friedlander, “Multiple Neurofibromata” Jour. Cutan. Dis., 1910, p.

497, reports a case and gives review, based on 262 cases reported in the literature

(good bibliography). FIBROMA 697 states, some authors touch upon this feature, present in many cases, by

others it is entirely ignored. In Wickham‘s 8 generalized cases such

pigmentary conditions were present in all; and in addition there were

small, violaceous, compressible prominences, already noted, but which

Wickham apparently considers arise as such, and not necessarily as a

result of involutionary changes. Any part of the surface may be the seat of fibromata, but, as a rule,

the tumors are most numerous and largest on the trunk, both front

and back. The scalp1 and other parts of the head are also favorite

localities, and the extremities usually show the smallest number. The

palms and soles are rarely invaded, and, when so, the growths are small

and flattened. In some instances they have also been found on the mu­

cous membranes, as on the lips, gums, hard palate, and tongue. Another form of fibroma, called hard fibroma,2 or desrnoids, in con­

tradistinction to that which is ordinarily met with and just described

(sometimes called soft fibroma) is in many respects similar to the more

solid small growths already referred to as fibroma simplex. They

are rarely larger than a pea, occur usually singly, or as several

scattered solid growths, covered by normal skin; are sharply defined,

round or oval, smooth and compact, and movable. Their appearance

is insidious and their growth slow, and they may appear at any age, and

are even present, in some instances, at birth. Etiology.—The affection is not a common one in our own

country, England, or the Continent, but is, according to Hashimoto,

quite frequent in the eastern countries. Its etiology is obscure, although

it is known, from the observations of Virchow,3 Konigsdörf,4 Octerlony,5

Atkinson,6 and others, to have occurred in several successive generations,

or sometimes in more than one member of the same family. Heredity

or family tendency must, therefore, be considered a factor. It occurs

in both sexes, in all nationalities, and usually begins in childhood and fre­

quently in early infancy; in some instances it is congenital (Hahn, Tap-

pey, Hallopeau, and others).7 In early life the lesions are, however,

small and relatively scanty, and the increase in size and number takes

place very slowly, as a rule, not developing to any extent until much

later. In the cases of single fibroma its appearance is, as a rule, later in

life. The subjects of the malady, as Hebra pointed out, and also shown

in those of Pooley, Pringle,8 Iurkewicz, and many others, are often of 1W. G. Smith, Brit. Jour. Derm., 1896, p. 115, describes and illustrates a case of

extensive, somewhat lobulated fibroma, seated upon the scalp, with no tumors else­

where. 2 Synonymous with Unna‘s “ Fibroma simplex.” Recently, under the name of

“Noduli cutanei,” Arning and Lewandowsky (Archiv, 1911, cx, p. .3) reported a series

of cases (20 occurring among 5000 patients) which histologic examinations indicated

to be the same formation; evidently this form is not so uncommon as thought, but

from their benign and painless character often overlooked. 3 Virchow, Virchow‘s Archiv, 1847, vol. i, p. 226 (according to the patient‘s state­

ment his grandfather, father, brother, and sister had the same disease). 4 Königsdorf, “Ein Fall von Fibroma Molluscum Multiplex,” Dissertation, Würz-

burg, 1889 (quoted by Jarisch). 5 Octerlony, loc. cit. (a brother also had it). 6 Atkinson, loc. cit. 7 Hahn, “Beiträge zur Casuistik des Fibroma Molluscum,” Dissertation, Würzburg,

1888; Hallopeau, Annales, 1889, p. 707 (case demonstration and histologic examination). 8 G. L. K. Pringle, Edinburgh Med. Jour., 1900, vol. xlix, p. 260 (with plate). 698 NEW GROWTHS weak physical and of defective mental development, but while so in the

larger number of cases, it by no means obtains in all. Moreover, it

is not improbable, as Hutchinson1 suggests, that the mental apathy is

the indirect result of the gross disfigurement, the patient holding himself

aloof and shunning his fellows. Traumatism is thought a possible

determining factor in their production, or, more probably, only in in­

fluencing their location, more especially in the single fibroma developing

later in life. Schwimmer, Taylor, and Recklinghausen, as well as a

few others, have noted this, the last calling attention to the fact that those

parts of the body most subject to friction, pressure, etc, usually show

the most numerous growths. In some instances in women pregnancy

seems, directly or indirectly, of some etiologic influence (Brickner,

Hirst). Pathology.—According to the investigations of Rokitansky,

Virchow, Neumann, Sangster, Duhring, Crocker, and others, the growth

is due to a hyperplasia of the connective tissue, although there is not

the same unanimity as to its exact starting-point, whether from the con­

nective tissue of the corium, of the frame­work of the fat-globules, or

of the walls of the hair-follicles and sebaceous glands. As to what gives

rise to this hyperplasia is unknown. Recklinghausen, from his investi­

gations of multiple fibromata, believes that they are really neurofibro-

mata, and that they are formed primarily by proliferation of the con­

nective-tissue sheaths of the nerves, and subsequently added to by pro­

liferation of the same tissue of sweat-glands, sebaceous glands, and blood-

vessel sheaths. The admixture of neurofibromata in some cases is

generally recognized, but that fibromata, as commonly met with, are

all of the same origin or nature is negatived by the collective investiga­

tions of others. Both Pringle2 and Anderson3 have also called attention

to the fact that there is sometimes an association of fibromata with ade­

noma sebaceum, and it is not at all impossible, therefore, as these several

gentlemen suggest, that certain tumors of different origin and character,

which are sometimes found together, may have some common pathologic

relationship. Crocker suggests that the growth may be due to obstruc­

tion of the superficial lymphatics, and that this, as well as other, anatomic

analogies bring it into pathologic relationship with elephantiasis. As the beginning lesions grow and extend the skin is pushed upward,

and they finally project as simple or lobulated, sessile or pendent tumors;

they are adherent to the skin only at their base, and may thus be easily

enucleated (Heitzmann). Crocker states that a sebaceous gland or hair-

follicle forms the center in many of the small tumors, while these struc­

tures in the larger or older growths have undergone atrophy or disap­

peared. According to Taylor, in their very earliest stage the tumor con­

sists of a gelatinous structure, which, under the microscope, is found

composed of a succulent, edematous, wavy connective tissue with many

cells, while in the older growths the fibers are firm and not edematous, 1 Hutchinson, “Molluscum fibrosum,” Rare Diseases of the Skin, p. 205. 2 Pringle, “Case of Congenital Adenoma Sebaceum,” Brit. Jour. Derm., 1890, p. 1. 3 Anderson, “A Case of Adenoma Sebaceum Intermingled with Mollusca Fibrosa,”

ibid., 1895, p. 316. FIBROMA 699 and the cells are less numerous. On cutting through a well-formed

tumor of some duration, quoting chiefly from Crocker and Heitzmann,

it is found to consist of a white, fibrous mass, inclosed in a dense con­

nective-tissue capsule, with the central portion soft and pulpy, and from

which a small quantity of clear yellow fluid can be pressed out. The

fibrous tissue is firmest and most developed at the base, the fibers becom­

ing less firm and softer as the interior is approached. Connective-tissue

cells with large nuclei are found between the fibers, being most numerous

in the gelatinous central portion. The vascular supply consists of large

afferent and efferent vessels, readily demonstrable at the base, and which

spread peripherally, terminating in fine capillaries. The epidermis

remains unchanged, although the sebaceous gland-ducts are sometimes

hypertrophied, patulous, and plugged with comedones. Diagnosis.—In a large single and pedunculated fibroma, and in

cases of multiple, scattered, variously sized growths, most of which are

sessile, and possibly a few with a narrowed neck or pedicle, a correct

diagnosis is a matter of no difficulty. Confusion is most likely to occur

with multiple lipoma, but in this latter they are commonly lobular,

somewhat flattened, rarely present in numbers, and never pedunculated.

From multiple neuromata they are to be distinguished by the absence

of pain, as well as usually by their more general distribution. A mistake

has sometimes been made with molluscum contagiosum, but the growths

of the latter are much smaller, rarely numerous, most commonly seated

about the face, especially about the eyelids, and, moreover, are super­

ficial, have a central depression or aperture, and are covered by skin,

which is usually thin, stretched, and which has a semitranslucent appear­

ance. There might also be a possibility of confusing fibroma with the

early tumor stage of granuloma fungoides, but the usual preceding and

accompanying eczematoid symptoms of the latter, as well as the tend­

ency, in some growths, toward the formation of fungoidal ulcerating

masses, and the late development and sometimes capricious behavior

of the tumors,—appearing and disappearing,—are wholly different from

the features of fibroma. The soft and warty moles, sometimes congenital

and sometimes developing later in life, can scarcely be confounded with

fibroma, as commonly understood, although such growths, usually small

and few in number, and generally more or less pigmented, are to a great

extent to be placed in the same category. In the similar lesions observed

in old people about the face and back, the surface is, as a rule, dark col­

ored, often warty, and frequently covered with a greasy scale or crust.

It is scarcely likely that fibromata could be confused with the nodules

of leprosy, sebaceous cysts, or gummata. Prognosis.—The outlook, so far as life is concerned, is always favor­

able, but as to the growths themselves they are persistent, and usually

add gradually to their size and also increase in numbers. While not

therefore, involving the general health, still, by their presence, they often

give rise to inconvenience and discomfort by interfering with freedom of

motion and through accidental injury, besides being the source of mental

worry, which sometimes leads to an apathetic or neurasthenic condition.

Exceptionally, in some growths, a tendency to spontaneous involution 7oo NEW GROWTHS is exhibited. In single fibroma, and also in moderate multiple cases,

there may be relief or comparative freedom brought about through

operative procedures. Unfortunately, the malady is not influenced by

constitutional treatment, although one instance of great improvement,

to be later referred to, has been recorded. Treatment.—Surgical measures alone are of any reliance, and

the method, whether by ligation, écraseur, galvanocautery, or excision,

depends upon the size and character of the growths. Large pendulous

tumors can always be removed readily, and with great relief to the pa­

tient. The smaller tumors also admit of removal if not too numerous

and if done a few at a time. The huge, flabby growths, approaching the

nature of dermatolysis, have also been excised with success. Whatever

the method, the tumor should be thoroughly extirpated or a regröwth

is probable. Electrolysis has proved serviceable for the small tumors. In multiple cases, in view of the favorable influence from the long-

continued administration of arsenic exceptionally observed in other

multiple tumor growths, this drug might also be tried in fibromata,

more especially so now in view of the favorable influence apparently

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