153 
The chronicity of the condition is sufficiently well shown by the 
histories. The rate of progress varies a good deal in different 
cases, but is slow in all; the channel of infection is probably 
through the skin, for it appears almost exclusively on uncovered 
parts, i.e., the limbs and face rather than the trunk. 
As regards the constitutional condition of the patients, they 
none of them gave any constant or important medical history, and 
their general health was clearly unaffected. In those cases in 
which we examined for enlargement of liver or spleen, it was absent. 
I. WARTY FORM 
These masses begin as small painless tubercles and may 
gradually attain a diameter of three or four inches. The skin 
round their edge is usually healthy, but it may be reddened from 
sepsis, or show a definite areola marked by loss or increase of 
pigment. They have a very definite, raised, even overhanging 
edge, and may rise nearly an inch abruptly from the level of the 
surrounding skin. The surface of the growth, by the time it is 
seen, is often ulcerated in whole or part, but typically is covered 
by hard whitish epithelium, and presents a warty cauliflower-like 
appearance. It is intersected by clefts lined with foul decomposing 
epidermis; indeed, where bacterial infection has occurred, it is 
possible to express masses of dead epithelium with pus from 
numerous apertures under the overhanging edge. In places where 
movement naturally takes place, as on the front of the ankle, 
some of these clefts deepen and appear as transverse fissures which 
extend through the skin and give rise to pain on movement. With 
this exception, the disease appears to be painless. 1 here is 
occasionally some local oedema and enlargement of lymphatic 
glands, but these depend on secondary sepsis and ate not an 
essential part of the disease. 
Most of these growths become septic in course of time, and ful 
of mixed infection. Most of their offensive smell and fou 
appearance is due, however, to decomposition of epithelial masses 
on the surface and in the clefts, outside the substance o 
growths altogether. If they could be kept clean, which of course 
