Skin Cancer | by Henry H. Hazen, A.B., M.D.
In this book an effort has been made to gather under one cover the latest views on malignant tumors of the skin, and to give the personal experience of the author, an experience gained in Dr. Blood-good's surgical pathological department of the Johns Hopkins Hospital, in Dr. Gilchrist's dermatological clinic at the same institution, and in the surgical, pathological, and dermatological departments of the Freedmen's and Georgetown University hospitals.
| Title | Skin Cancer |
| Author | Henry H. Hazen, A.B., M.D. |
| Publisher | St. Louis C. V. Mosby Company |
| Year | 1916 |
| Copyright | 1916, St. Louis C. V. Mosby Company |
| Amazon | Skin Cancer |
by Henry H. Hazen, A.B., M.D., Professor Of Dermatology In The Medical Department Of Georgetown University, Professor Of Dermatology In The Medical Department Of Howard University; Sometime Assistant In Dermatology In The Johns Hopkins University; Member Of The American Dermatologioal Association.
With Ninety-Seven Text Illustrations, And One Colored Frontispiece
To William Stewart Halsted A True Student Of Cancer
Preface- When one considers that epithelial growths of the skin, both benign and malignant, are so common, that they are usually so easily diagnosed, that the tissue from them is readily obtainable for histolo...
- Chapter I. General Considerations
- Definition And Conception In 1863 Virchow* stated that it was practically impossible to give a satisfactory definition of a tumor, and many writers since that time have unwittingly proven the truth...
- Classification of Skin Cancer
- A thoroughly satisfactory classification of epithelial tumors has not yet been made. For this there are many reasons; first and foremost, because until a few years ago the pathology was not thoroughly...
- Classification of Skin Cancer. Continued
- As Auspitz, Unna, and many others have pointed out, the term papilloma is, histologically speaking, a grave misnomer, for the real development is in the rete and the papilla are only secondarily affec...
- Structure of Skin Cancer
- All neoplasms consist of two main elements-the cells and the stroma. As has already been stated, the cells are derived from the various types of epithelial cells, and, with the exception of the tumors...
- Growth Of Tumors
- Many authors think that a carcinoma springs from one center, but Petersen's11 work would seem to show that the multicentric origin of malignant epithelial tumors is far from uncommon. As Bloodgood wel...
- Etiology
- The causative factor in cancer of the skin is that of cancer in any other portion of the body, and is still unsolved. Dermatologists have not done their share toward the elucidation of the carcinoma r...
- Incidental Factors
- Age Cancer of the skin usually occurs in those well past middle life. Sex The two sexes are almost equally affected, except in cancer of the mouth, which is very rare in women. Race The...
- Chapter II. Precancerous Dermatoses
- As Bowen* states in a recent article, various keratoses form the commonest cutaneous lesions that become cancerous. Certain of the soft nevi, however, especially the common pigmented moles, and scars ...
- Pigmented Moles
- For many years it has been well known by dermatologists, and to a somewhat lesser extent by surgeons, that the most virulent form of skin cancer (or sarcoma)-namely, the melanotic-always has its origi...
- Seborrheic Warts
- Clinical Course These lesions, also called senile warts and seborrheic nevi, are very common on the backs and faces of elderly persons. Upon the face they usually develop upon the temples, or sides...
- Simple Keratosis
- Clinical Course Solitary patches of keratosis may develop in the elderly, usually upon the face or the hands (Fig. 4). They start as papules from 1 to 3 mm. in diameter, and are of great surface ha...
- Arsenical Keratoses
- That arsenic may cause keratoses is not a particularly unfamiliar fact, but it has been within the past few years that it has become generally recognized that the internal administration of that drug ...
- Keratosis Follioularis
- Wende* has reported a remarkable ease where the keratotic lesions of Darier's disease become carcinomatous. It is only surprising that this condition has not occurred more frequently. ...
- Cutaneous Horn
- It is generally known that cutaneous horns often become malignant, the change taking place at the base, and being evidenced by ulceration, secretion, and induration (Fig. 5). . Fig. 6.-A cutane...
- Cancer Of Paraffin Workers
- Schamberg* has recently published a most complete paper on the prevalence of cancer in tar workers, paraffin workers, and chimney sweeps. The crude petroleum has a particularly irritating effect upon ...
- Xeroderma Pigmentosum
- Unna's description of the clinical course of this disease still remains classical, and but little has been added. He states that this disease was first recognized by Ruder and by Kaposi. Clinical C...
- Sailor's Skin
- This condition was originally described by Unna as occurring in sailors who were much exposed to weather and sun. The condition, as will be shown later, is not confined to seafaring men, but also occu...
- Farmer's Cancer
- The condition described by Unna as peculiar to seamen is also found in those who are much exposed to the sunlight, especially where the air is very dry. As it is fairly common in the western part of t...
- X-Ray Dermatitis
- Clinical Course This sad condition was much more frequent in the early days of x-ray therapy than it is at present. In those days the operators took no precautions to shield either themselves or pa...
- Introduction. Paget's Disease
- Paget's disease is often considered as a precancerous condition, but, as there is still dispute as to whether the cutaneous lesions may not be secondary to the cancerous changes the writer has felt it...
- Marjolins Ulcer
- Cancer frequently develops upon the scars of various dermatoses. Most prominent of these is the scar resulting from ordinary burns of the third degree. Cancer originating in such lesions is commonly c...
- Lupus Vulgaris
- Lupus vulgaris of many years' duration is not infrequently complicated by cancer. Sequeira* has recently published an excellent article on the prevalence of malignant change in lupus, and has reported...
- Leg Ulcers
- Chronic leg ulcers rarely become cancerous. Both Bloodgood* and Gottheil* have noted this, the former having seen but three cases, and the latter having been able to collect but ten cases from the lit...
- Lupus Erythematosus
- Lupus erythematosus scars occasionally become the seat of skin cancers. Dubreuilh and Petges* have collected all of the cases reported in addition to recording two of their own. In practically all of ...
- Syphilis
- Syphilitic ulcers are often referred to as undergoing malignant degeneration, but the condition is certainly unusual. The change may take place either in an ulcer or in the scar produced by suchan ulc...
- Inflammatory Dermatoses and Other Forms
- Eczema, lichen planus and psoriasis (Hartzell*, Bloodgood*) occasionally give rise to cancer of the skin, but in the vast majority of the cases reported it is probable that either arsenic or x-ray was...
- Chapter III. Epithelial Wakts
- There are, of course, two varieties of epithelial warts-the benign and the malignant. Benign Warts Both clinically and pathologically the benign warts may be divided into four main classes, each...
- Malignant Cutaneous Warts
- There are two varieties of malignant skin warts-the prickle- and the basal-celled. There is still a question as to whether the cancerous growths are malignant from the start, or whether they represent...
- Chapter IV. Basal-Celled Carcinomata
- The differentiation of the basal-celled group of tumors from the other epithelial neoplasms is really due to the excellent work of Krompecher,* and in America the attention of both dermatologists and ...
- Classification Of Basal-Celled Carcinomata
- According to the later clinical course, the basal-celled carcinomata may be divided into seven groups-1, the flat rodent ulcers; 2, the nodular; 3, the rolled-edge; 4, the depressed scar-like cancer; ...
- I. Flat Rodent Ulcers
- Clinical Course The flat rodent ulcers usually occur upon the face (Fig. 21), and much more rarely upon the back. It is the most frequent type encountered by the dermatologist and general prac-titi...
- II. Nodular Cancers
- Clinical Course The nodular cancers arise from a pre-existing lesion. A pearly nodule first forms, which slowly grows until in from six months*' to one year's time the growth has attained a diamete...
- III. Rolled-Edge Rodent Ulcers
- Clinical Course The rolled-edge rodent ulcer is very closely related to the two varieties just described, but more closely to the second type. It begins in the identical way that they do, but is fa...
- IV. Depressed Scar-Like Cancer
- Clinical Course The depressed scar-like cancers are comparatively infrequent, the author's series containing but one case. As they start as a very small subepidermal nodule and as the skin over the...
- V. Morphea-Like Cancer
- Clinical Course The morphea-like cancel's have recently been described in detail by Heidingsfeld.5 who has collected all of the reported cases in addition to describing one of his own. According to...
- VI. Fungating Tumors
- Clinical Course Fungous tumors are either large or small. Occasionally a basal-celled neoplasm may be fungating from the beginning, but this is rare, and this characteristic is usually of late deve...
- VII. Deep Ulcers
- Clinical Course Deep ulcers are rare, and in the majority of them it is probable that the growth consists primarily of cuboidal rather than of basal cells. They usually arise upon the face, grow ra...
- Chapter V. Cubo-Celled Carcinomata
- Origin It will be remembered that just above the cells forming the basal layer of the rete there is a layer of cuboidal cells, cells somewhat larger than the basal cells, and of a square rather tha...
- Chapter VI. Spino-Celled Carcinomata
- Occurrence In many ways this group of cancers forms the most important one from a clinical standpoint, for, when it is remembered that the lips, tongue, and penis are chiefly affected by this type,...
- Spino-Celled Carcinomata. Continued
- Prognosis Prognosis depends on the stage of the growth and the extent of the operation; even in fairly late cases the mortality should not be high if an extensive and thorough operation be done. Th...
- Chapter VII. Benign And Malignant Tumors Of The Cutaneous Appendages
- As has already been pointed out, the normal skin has the following appendages: hair follicles, both of the lanugo and deep hairs, with the adjoining sebaceous glands, and the sweat glands and ducts. F...
- Tumors Of The Hair Follicles
- The hair follicle has different layers, just as has the skin, and epithelial growths may originate from any of these layers. Krompecher* states that he has been able to recognize two tumors of the fac...
- Tumors Of The Sebaceous Glands
- At least four pathological types of tumors may arise from the sebaceous glands; first, simple hypertrophy, which clinically may give two different conditions-the well-known adenoma sebaceum and, in ad...
- Tumors Of The Sweat Glands
- Here, again, there are several possibilities: First, simple hypertrophy of the sweat glands: second, true adenoma of the sweat glands; third, basal-celled carcinoma of the sweat glands; and fourth, mo...
- Tumors Of The Sweat Ducts
- Here also there are several possibilities-first, benign tumors of the ducts, and, second, carcinomata arising from the ducts. Also, it must be remembered that the multiple syringocystadenomata spring ...
- Chapter VIII. Multiple Benign Tumors
- The three varieties of multiple benign tumors of epithelial origin -namely, the multiple benign cystic epithelioma, the syringocystadenoma, and adenoma sebaceum-have recently been thoroughly studied b...
- Multiple Benign Cystic Epithelioma
- These tumors were first studied histologically by Balzer and Menetrier* in 1885, but they failed to recognize the true nature of the growths. Brooke* in 1892 and Fordyce* in the same year independentl...
- Syringocystadenoma
- This group has likewise been well studied by Sutton, and his finding confirmed by Welch. For this group of tumors there have been many names proposed, largely because of the uncertainty as to the true...
- Adenoma Sebaceum
- According to Sutton, Rayer* was the first to describe adenoma sebaceum, calling it Vegetations vasculaires. A few years laterAddison and Gull* considered it to be a lichen. In 1890 Pringle* accurate...
- Chapter IX. Nevocarcinomata And Malignant Melanomata (Malignant Pigmented Moles)
- It is a rather curious fact that, although it has been known for many years that the most malignant of all tumors spring from the skin and are deeply pigmented, yet only within the last ten years has ...
- Nevocarcinomata And Malignant Melanomata (Malignant Pigmented Moles). Continued
- On the other hand, many pathologists hold that the nevoid cells, especially the chromatophores, have their origin in the mesoderm. On this side are grouped Virchow, Soldan,* Borst,* Kreibich, Rib-bert...
- Chapter X. Carcinoma En Cuirasse-Carcinoma By Extension- Metastatic Carcinoma-Paget's Disease
- Carcinoma En Cuirasse Pollitzer* has recently written an excellent article on carcinoma of this type, and the author has drawn freely from it. Just as in many other cancerous conditions, there a...
- Carcinoma By Extension
- Clinical Course Now that the public is beginning to more fully appreciate the danger of lumps or tumors in any part of the body, the surgeon does not often see a case with ulceration through the sk...
- Metastatic Carcinomata
- Clinical Course It is rare to find cancer of any of the organs metastasizing to the skin, but this does occasionally happen. Kauf-mann-Wolf* has recently written a very complete article on the subj...
- Paget's Disease
- This condition was first described by Paget* in 1874, and since that time has been the subject of much study. Especially has it been debated whether the cutaneous changes antedated or followed the dev...
- Chapter XI. Endotheliomata
- Among pathologists there is still much confusion regarding the status of endotheliomas, and what tumors should be called by this name. In a recent article Fick* contends that the pathological entity k...
- Nevo-Xantho-Endotheliomata
- McDonagh* has described several cases of small multiple, yellow tumors, present at birth, which were apparently distinct from xan-thomata in that the histological examination showed that the cells wer...
- Chapter XII. Benign Connective Tissue Tumors
- Before dealing with the sarcomata, it seems wise to say a few words concerning the benign connective tissue tumors, the sarcomata being the malignant connective tissue tumors. Cicatrix A cicatri...
- Keloid
- A keloid is a fibrous new growth that, to all intents and purposes, is simply a hypertrophic scar. They are not especially common in whites, but are very frequently encountered in the negro. In former...
- Fibroma
- True fibromas of the skin are rather rare tumors, even in the negro race. They do, however, occasionally occur, usually as solitary tumors in adults. They are occasionally found upon the abdomen, aris...
- Neuroma
- According to Heidingsfeld,* very few cases of neuroma cutis have been described. In the cases reported by this author and in others which he has gathered from the literature, the tumors were usually s...
- Myoma
- This rare tumor of the skin has been carefully studied by Heidingsfeld.6 The growths may take their origin from the muscle normally present in the walls of the vessels, in the arrector pili muscles, o...
- Lipoma
- Lipomas or fatty tumors are probably the commonest benign tumors that are encountered in surgical dispensaries. They sometimes develop in children, but much more commonly in adults. The solitary forms...
- Osteoma
- True bony tumors of the skin must be differentiated from calcareous deposits which are the result of chronic inflammatory processes. Heidingsfeld* has briefly reviewed some of these cases in addition ...
- Hemangioma
- A hemangioma or vascular nevus is a congenital new growth and hypertrophy of the blood vessels of the skin. Small telangiectases are frequently acquired, but the larger lesions are always congenital. ...
- Lymphangioma
- As Stelwagon* well points out, the subject of lymphangioma is still a rather confused one, inasmuch as no hard and fast dividing line has been drawn between actual new growths and lymphangiec-tases. ...
- Lymphangioma Circumscriptum
- This disease is characterized by a hypertrophy and new growth of lymph capillaries, characterized by circumscribed, elevated, crowded vesicles filled with lymph. As a general rule, the disease begins ...
- Chapter XIII. Sarcomata And Sarcoids. Sarcomata
- The subject of sarcomata of the skin is still in a greatly confused condition. It is not yet definitely known whether the multiple pigmented growths are derived from the epithelium or from the mesobla...
- Solitary Lesions
- Round-Celled The small round-celled sarcomata are extremely malignant; for it is a peculiarity of sarcomata that the nearer they approach the embryonic type of cell in structure the more malignant ...
- Multiple Lesions
- Round-Celled Sarcomatosis of the skin, except with melanotic growths, is very unusual. When this condition does occur, it is usually with the small round-celled type of neoplasm, for this is the mo...
- Transitional Lesions
- Spiegler-Pendt Type Tumors of the variety described by Spieg-ler,* Fendt,* Polland,* and others, and commonly called the Spiegler-Fendt type of sarcoid, seem to occupy an intermediate position betw...
- Sarcoids
- The rather lengthy articles by Fano* and Darier* are extremely helpful in dealing with the problem of the border line conditions between the sarcomata and sarcoids. Boeck Type The Boeek-1 type o...
- Chapter XIV. Lymphomata
- The subject of lymphoid and myeloid tumors has long confused not only dermatologists, but clinicians and pathologists as well. It seems to the author, however, that certain broad principles are now cl...
- Chapter XV. Differential Diagnosis
- In dealing with cutaneous neoplasms, there are two essentials- first, to decide whether the new growth is an inflammatory one or a true neoplasm, and, second, to decide whether, if it be a true tumor,...
- Microscopic Pathology
- The tissue can be preserved in any of the accepted fixing agents, although 50 percent alcohol or 10 percent formalin will usually suffice, and is then fixed, blocked, cut, stained, and mounted in the ...
- 1. Nodular Lesions
- There are, of course, many varieties of solitary tumors of the skin; there are found fibroids, fatty tumors, lymphoid tumors, neoplasms originating from the blood or lymph vessels, endotheliomata, wen...
- 2. Ulcerative Lesions
- The ulcerative lesions are usually easy to differentiate, for they too lack many of the physical characteristics of cancer-namely, the hard edge, with the pearly nodules therein. Lupus Vulgaris ...
- 4. Scar-Forming Lesions
- As already pointed out, cancer may heal spontaneously in the center, and have only a slight amount of ulceration at the edges: the most extreme example of this type is the morphea-like epithelioma. Th...
- Chapter XVI. Peognosis
- The prognosis in cancer of the skin depends on several factors- first, the type of cancer; second, the stage of the disease; third, the situation of the tumor; and last, the skill of the physician who...
- Chapter XVII. Peophylaxis
- Discovery Of Cancer Until the true cause of cancer is discovered it will be impossible to prevent it in a truly scientific and effective way, and hence it is very necessary that the etiology be com...
- Chapter XVIII. Treatment
- In dealing with the treatment of skin cancers, the following outline will be followed: Surgical. Knife. Actual or electric cautery. Curette, with or without the use of a caustic. Electrica...
- Surgical Treatment
- Knife At times it is difficult to decide which is the best form of treatment for a special case. The patient usually dreads the knife, and likewise dreads an extensive operation for a small growth,...
- Surgical Treatment. Continued
- Closing The Wound The question of the closing of the wound is a serious one. The writer has noticed that when a basal-celled cancer recurred, this recurrence almost invariably took place at the edg...
- Electrical Treatment
- Electrolysis By some the electric needle is used in one of two ways-either the entire lesion is removed by it, or numerous punctures are made into it, so that the body of the growth is destroyed. W...
- Actinic Treatment
- X-Rays In the employment of the x-rays for the treatment of cancer, three methods have been advocated; first, the treatment by fractional doses; second, the employment of three or four large doses;...
- Actinic Treatment. Part 2
- As apparatus and technic improved so that the number of exposures in a given case was reduced, the unfavorable results and the recidives were' correspondingly diminished numerically. In other words, ...
- Actinic Treatment. Part 3
- Many instruments have also been designed for the purpose of judging the penetration or quality of the ray. Most notable are the Benoist radiochrometer, the Benoist-Walter, the Wehnelt, and the Walter...
- Actinic Treatment. Part 4
- *Pusey: Jour. Amer. Med. Assn., 1907, xlix, 1215. 30 Pusey: Jour. Cutan. Dis., 1913, xxxi, 73. Radium-At the time of writing, radium* is receiving more than its share of notoriety, both in the dail...
- Caustics
- Caustic Potash Caustic potash* is a powerful caustic, and must be used with care, for it is extremely rapid in its action, and often this action is much deeper than was originally intended. The cau...
- Congelation Treatment
- Liquid Air And Carbon Dioxide Snow Congelation has been used in two forms-first in the form of liquid air,* which was always difficult to obtain and more difficult to keep, and in the form of carbo...
- Medication
- Arsenic Arsenic is still used internally by a few men, Sherwell, in particular, advocating it, and even Pusey seeming to think that it may have a slight inhibitive action. It is used either in the ...
- Treatment Of Complications
- Infections When an epithelioma has been in an ulcerative condition for any length of time, it is not unusual for it to become infected, and this infection may be with a simple pyogenic organism, ...
- Treatment Of Inoperable Cases
- The subject of the treatment of inoperable cases is not as painful a one as might appear, for much can frequently be done for them. In the first place, many so-called inoperable cases are strictly ...
- Repair Of Deformities
- Plastic Surgery When a patient has been cured of extensive cancer of the skin, so far as concerns the removal of the disease, there is often much to be done to replace the deformity. Plastic surger...
- Chapter XIX. Tumors According To Location
- Hertzler,* in his admirable book on tumors, deals with neoplasms according to their location, and for further details the reader is referred to his volume. Many of the epithelial tumors, however, vary...
- Tumors of Scalp
- The commonest new growths upon the scalp are of a benign variety; wens or warts are especially common. Malignant melanotic growths at times have their origin here. Cancer of the scalp is rather uncomm...
- Tumors of Forehead And Temples
- Btjsal-celled neoplasms are not as common here as upon the face, but are fairly frequently seen. Sequeira,* iii his series of 220 cases, saw nine upon the forehead and twelve upon the temples. In comm...
- Tumors of Eyelids
- Basal-celled growths are very prone to arise from the inner canthus of the eye, and to a slightly less extent from the outer canthus. Over thirty of Sequeira's cases had their origin in one of these l...
- Tumors of Nose
- Tumors originating from the naso-facial grooves (Fig. 74) are almost invariably of the basal-celled type, and are commoner here than upon any other part of the body. Bloodgood* says: 11 The basal-cell...
- Tumors of Ears
- Two distinct types of tumors arise from the ears-those having their origin upon the pinnae, which are mostly rodent ulcers, and those arising from within the auditory canal, which grow very rapidly, b...
- Tumors of Cheeks And Face
- Basal-celled tumors here are comparatively common. Bloodgood has seen fourteen out of a total of fifty-five cases of benign and malignant epithelial tumors. They usually arise about 2 cm. below the ey...
- Tumors of Chin
- Basal-celled tumors of the chin are rare. Sequeira has seen only two such cases. Prickle-celled tumors are also rare. Bloodgood has had two instances of so-called basal-celled tumors where metastases ...
- Tumors of Neck
- Considering the chronic irritation caused by collars, cancer of the neck is rare, although a few instances do occur. The neoplasms arising in this locality usually spring from moles, then forming nevo...
- Lips
- Appreciating the earnest efforts of various authors and members of committees to educate the laity and impress on the profession the methods which should be adopted to improve results in the treatment...
- Sarcomata
- In classifying the malignant tumors of the lips, mention must be made of sarcomata. Certain of the angiomata undergo malignant change, and must receive radical surgical treatment. More rarely, small r...
- Basal-Celled Tumors
- Under the basal-celled type we may clinically have nodular lesions, usually beneath the skin, ulcers, fungi, or warts. The vast majority of the so-called rodent ulcers are basal-celled carcinomata, bu...
- Spinocellular Tumors
- The spinocellular cancer of the lip commonly starts at the mucocutaneous border, and the first symptom is an area of induration, with slight ulceration. Both the induration and the ulceration tend to ...
- Metastases
- As already pointed out, the basal-celled growths do not metastasize to the lymph glands and arc cured by a local operation. On the other hand, the commoner prickle-celled tumors speedily metastasize, ...
- Malignant Warts
- The malignant wart, already mentioned, is a prickle-celled tumor. Papillary epithelial tumors may be malignant from the onset, or may develop malignancy from a benign growth, but, as a rule, metastase...
- Treatment to Tumors of the Lips
- As has already been stated, excision of the growth with a good margin of healthy tissue and repair of the lip-in other words, the local operation-is a justifiable and harmless procedure, provided the ...
- Treatment to Tumors of the Lips. Part 2
- *Beckman: Jour. Oklahoma State Med. Assn., Oct., 1913. In removing a section of lip which contains a basal-celled tumor or one of the malignant warts, or when the growth is small and recent, and th...
- Treatment to Tumors of the Lips. Part 3
- The avoidance of shock, hemorrhage, and infection is especially necessary in these cases. A preliminary dose of morphine and atropine, a carefully given anesthetic, a minimum of trauma from retraction...
- Tumors of Tongue
- Like all other cancers of the skin and mucous membranes, carcinomata of the tongue do not arise de novo, but from some preexisting lesion. There is first an ulcer or a little area of infiltration that...
- Treatment Tumors of Tongue
- Bloodgood* has recently written a short, but stimulating, article on treatment of cancer of the tongue. He states that in the very early cases-that is, where malignant change is just taking place- a ...
- Cancer of Trunk
- Cancer of the trunk is rather uncommon, although the most frequent site is around the shoulders. In this locality the majority of growths are of basal-celled origin, and do not metastasize. Upon other...
- Tumors of Extremities
- The following account is from a recent article by the author.26 Because of the failure to distinguish between the various types of cutaneous cancer, many of the older articles on carcinoma of the e...
- Tumors of Extremities. Part 2
- A study of these few figures should clearly show that prickle-celled cancer of the skin is comparable to cancer of the breast, tongue or lips, and, just as no good surgeon would think of treating a tr...
- Tumors of Extremities. Part 3
- The cuboidal-celled growths, as already stated, are formed from the transitional epithelium normally lying between the basal and prickle layers. They form either fungous tumors or ulcers. Treatment is...
