CHAPTER XXVII
.
THE SKIN.
It is proposed here to treat only of those diseases of the skin which may complicate surgical cases or call for surgical treatment.
_Dermatitis_ may be produced by chemicals, caustics, and various irritants; the former, for instance, by the use of strong antiseptics upon sensitive skins, and the latter as when fecal matter or urine is poured over unprotected skin or allowed to remain in contact with it. Ammoniacal urine will prove irritating, as will also that of diabetes. When carbolic acid was in general use it gave rise to great trouble upon the hands of many surgeons, while iodine, iodoform, and other such remedies, as well as the stronger mercurial preparations, will cause local symptoms similar to those produced by poison ivy.
This may be prevented, when the condition has occurred, by applying soothing lotions or mild astringents, with anodynes, in dry dusting powder or in ointment form. Cocaine in small amounts, or preferably orthoform with menthol, may be employed in either of these ways. When an acid discharge is expected the skin should be protected with an ointment or with collodion or rubber cement; the latter by drying will leave a thin film upon the surface. Thus around a fecal fistula the skin will be irritated and more or less macerated, and should always be thus protected when possible.
Between sixty and seventy drugs are known to produce distinct forms of dermatitis, such as copaiba, cubebs, the various preparations of iodine, bromine, and arsenic, some of the aniline preparations, quinine, etc.; while the various antitoxic serums, especially that of diphtheria, will sometimes produce a skin disturbance. In these cases it is only necessary to recognize the source of the trouble and remove the cause by stopping the drug. Should dermatitis produce such restlessness as to interfere with the physiological rest necessary for a wound or fracture an opiate should be administered.
DERMATITIS CALORICA.
_Dermatitis calorica_ means the varying degrees of irritation which may be set up by extremes of heat and cold, continuous or alternate, as in so-called _chilblains_. These are often seen upon the feet, but occur upon the hands and even the face, _i. e._, in places most exposed and least supplied with blood. The lesion occurs in patches, often with livid discoloration, and causes sensations varying from discomfort to acute pain, almost always aggravated by warmth; while the skin appears inflamed, though to the touch it usually seems cool.
=Treatment.=--Chilblains occur most frequently in the anemic and those with uric-acid diathesis, but may be met at any time. The constitutional treatment should not be overlooked. Much pertains to good care of the feet, especially after exposure. After wetting or chilling they should be dried and then rubbed with boric-acid talcum powder, containing 1 or 2 per cent. of menthol; this may be dusted upon the feet, before going outdoors, upon return, and when there is discomfort.
It will often give relief to immerse the feet in warm water containing sufficient tincture of iodine to give it a mahogany color; or the feet may be simply dipped in this and then allowed to dry without using a towel. The use of hydrogen dioxide diluted two or three times has been highly commended. If this proportion of dioxide be added to four or five parts of hot saturated solution of sodium bicarbonate the efficacy of the measure will be much enhanced. In extreme cases frequent use of the following formula will probably give more relief than anything else: Carbolic acid 1 part, ichthyol and tincture calendula each 4 parts, and glycerin 16 parts. With this the skin may be kept constantly moistened.
The expressions of dermatitis produced by heat may vary from an efflorescent rash to complete destruction, and will be treated of under the following head:
BURNS AND SCALDS.
The term “burn” is applied to lesions produced by flame or dry heat, while moist heat (_i. e._, boiling materials or steam) causes injuries known as “scalds.” Between the two there is but little essential difference, except that with the latter there is usually loosening of the hair of the part, and sometimes much loosening of the epidermis as well, so that it is easily detached in more or less large patches. Whether heat is relatively feeble but prolonged, or higher in degree and of shorter duration, the results of dry heat are about the same. Some differences will exist according to whether the part is exposed to actual flame or to hot or melted material, sufficiently hot perhaps to cause complete charring or carbonization of a part.
[Illustration: FIG. 97
Burn by electric current from “live wire” carrying 1200 volts. (Original.)]
Similar injuries are produced by concentrated caustics, acids, or alkalies, while such materials as phosphorus or sulphur produce deep burns. The burn produced by lightning is rarely deep, although it may be extensive (Fig. 97). Persons coming in contact with live wires sustain burns which partake much of the nature of the electric discharge, and are sometimes of a character to deserve the term “_brush-burn_.” Formerly burns were divided by Dupuytren into six or seven degrees, but this classification is too cumbersome and artificial to be acceptable. Morton’s classification is now everywhere accepted, by which they are divided into three degrees: (1) Dermatitis without vesication. (2) Vesication even to the formation of bullæ. (3) Destruction of the skin, with or without that of the deeper parts, which may include actual carbonization of a limb.
Burns may vary within the widest imaginable limits. To an extensive burn of the surface may be added the features produced by inhalation of smoke, steam, or flame; accordingly the eyes and the mucous membrane of the nose and mouth suffer, the parts becoming chemotic and disfigured, so as to make the individual unrecognizable. Burns constitute one of the most painful and distressing injuries known to the surgeon,
## particularly when the area is large and the case is complicated by
injuries which necessitate more or less prolonged rest in bed. When the body is burned completely around it is difficult to ensure rest without the use of anodynes.
_Shock_ is a marked feature of every serious case of burn or scald, and albumin quickly appears in the urine in these cases. _Ulceration of the duodenum_ may follow extensive injuries of this kind, and is occasionally the cause of death. It is to be attributed to a toxic
## action produced by absorption of putrid material connected with the
surface sloughing process. A temporary diabetes is sometimes noted. Laryngitis, bronchitis, and pneumonia may occur from inhalation of steam or smoke, while the inhalation of flame may bring about a rapid _edema of the glottis_, which may necessitate tracheotomy as an early and emergency measure. It is generally stated that a burn of the second degree, which even involves half of the surface of the body, may prove fatal; while this is not invariably the case, it is too frequently true, and may afford aid in prognosis.
Burns of the second degree are always followed by exudation with formation of blebs, usually within a few hours. In the more serious cases the exudate may be bloody. Burns of the third degree are necessarily followed by more or less gangrene, and this fact affords the reason for the radical treatment recommended.
=Treatment.=--By the time the surgeon is called to treat a burn the first indications are usually relief of pain, and perhaps stimulation for shock. The circumstances attending such injury generally leave the patient in an excited mental condition, and for several obvious reasons it would be well to use sufficient anodyne to tranquillize and give comfort. An excellent application in emergency cases is a saturated solution of sodium bicarbonate, or it may be dusted over the affected surface.
The unpleasant visceral complications that follow burns are due to absorption of decomposing fluids or tissues, so retained or so in contact with readily absorbing surfaces as to produce a more or less violent degree of toxemia. In this way are to be explained delirium, convulsions, or coma, as well as the ulcerative and toxic intestinal symptoms which constitute the distressing complications.[17] For this reason the radical method of prevention is the best; hence whenever there is any prospect of sloughing, or when even the epidermis is so burned as to make it appear that it will soon separate, the best method of treatment is to anesthetize the patient and then with a stiff brush and antiseptic soap scrub the part and remove everything that is at all loose, if necessary even using a wire brush, scissors, or a razor. Beneath every sloughing area toxic absorption will go on, and it will be far better to have fresh raw and bleeding surfaces than those which cover sources of danger; the resultant scar will not be any greater, while the subsequent course of the case will be favorably influenced. Exquisitely tender surfaces thus have their sensibility blunted, and the comfort of the patient is greatly enhanced by thorough cleansing and sterilization; moreover, dressings will not need to be so frequently changed. A soothing, antiseptic ointment should be applied; there are few better than the ordinary ointment of zinc oxide, to which may be added bismuth subnitrate and orthoform.[18] Treatment of this kind would probably not need to be repeated, and the duration of the trouble would be reduced to one-quarter or one-third of the time which would otherwise be required. When actual carbonization has occurred amputation is generally necessary. Diluted solutions of ichthyol have proved satisfactory, and the dressings should be covered with some impermeable material, so as to exclude the air. Another advantage is that the amount of subsequent discharge is limited, and thus there is less need for frequent change of dressings. In extreme cases there is no method which gives so much comfort and certainty as _continuous immersion in warm water_; to this may be added common salt or some other antiseptic, but the water alone is sufficient, if changed frequently. In burns covering a great part of the body this treatment is the most serviceable. It should be employed until the sloughs have separated and surfaces are granulating and ready for skin grafting. This implies, of course, immersion of the entire body in a bath-tub, the body lying on a sheet fastened to the sides of the tub. The advantage of brewers’ yeast dressing, when sloughs are present, has been previously emphasized in the chapter on Ulcers and Ulceration.
[17] _The Poisons Produced in Superficial Burns._--The intoxication which often proves fatal in from a few hours to a few days after an extensive burn of the surface, with its attendant delirium, albuminuria, hematuria, vomiting of blood, diarrhea, etc., is very similar to the acute intoxications produced by bacterial products. The sympathetic nervous system is seriously involved in both. These toxins are evidently the result of hemolysis, and it has been shown that they are slow poisons, especially for nerve tissue, apparently eliminated by the intestines and kidneys, which thus suffer during the process of elimination. This is a more rational explanation than the theories of thrombosis or of alterations in the red corpuscles, which would not account for duodenal ulcers, necroses in the Malpighian bodies of the spleen, etc. These poisons are formed in the burnt area and not externally; hence, if this burnt area be removed immediate death may be prevented, whereas if it be permitted to remain for a few hours it may be too late. The poisons seem to be produced in the skin, as the burning of the muscle is not followed by any such degree of intoxication. They seem to be neither ptomain nor pyridin derivatives, but rather resemble the poison of snake venom. Pfeiffer believes them to be derived from the splitting up of proteids altered in composition by the heat of the burn.
[18] Cargile membrane makes an excellent covering for burns whose surfaces have been cleaned of sloughs and which are granulating. It adapts itself perfectly to all irregularity of contour, may be snugly applied and not changed until necessity requires it.
The disfigurement caused by a superficial burn will fade after a few months. In cases where the skin has sloughed there is a tendency to cicatricial contraction as soon as granulations begin to form, and the tendency then is to the formation of _disfiguring scars_. About the limbs the flexor muscles will always overcome the extensors, and bridle-like deformities will be formed at flexures of the joints. These are to be prevented so far as possible by two measures--proper splinting and early skin grafting. About the face splints cannot be used, but one of the grafting methods should be used.
[Illustration: FIG. 98
Epithelioma following ulcer due to burn. (Lexer.)]
A tendency in the scars of old burns is to formation of _keloid_ (see below) and _epithelioma_. The writer has seen epitheliomatous ulcers covering at least an area of a square foot, which had formed upon the sites of burns received years previously. In one case of this kind it was necessary to remove the entire upper extremity; even then the disease recurred and finally destroyed the patient (Fig. 98).
Burns produced by _caustic acids or alkalies_ call for appropriate chemical antidotes at first and later essentially the same treatment as that already mentioned. In cases of severe burn there is danger of neglecting the ordinary rules of general treatment, which consist in maintaining elimination and nutrition.
FROSTBITE.
Effects similar to those produced by heat are caused also by cold, varying from a superficial dermatitis with its surface irritation, its possible vesication, and, later, desquamation, to complete freezing of an extremity or a part (_e. g._, the nose, or the ear), which may be followed by _gangrene_. Portions which are not frozen beyond the point of restoration of vitality undergo a marked reaction and become swollen and discolored, save in rare instances where they shrivel. Gangrene is not so immediate a process as in a severe burn, as it takes a number of hours, sometimes days, for the establishment of the so-called _line of demarcation_, by which the dead tissue is separated from the living. On one side of this line putrefaction goes on rapidly, as in moist gangrene from any cause; on the other side there is active circulatory disturbance, with phagocytosis, by which the line becomes more marked; no portion of tissue on the distal side of this dead line can be saved. The location of the lesion and the exigencies of the case will indicate where amputation should be made. (See chapter on Gangrene.)
=Treatment.=--A rapid restoration of warmth to the part is most undesirable. The thawing-out process in a case of severe freezing should be begun in cold or ice-cold water. Crude petroleum at a temperature of 60° F. has been recommended as a substitute for cold water, and immersion may be continuous for several hours. A rubbing with alcohol and water may be substituted for the cold water, and then a gradual restoration to the ordinary temperature of the air. Unless this treatment be skilfully managed there may be such a rapid reaction as to be painful and even injurious. By the time there is any active exudation, or putrefaction has begun, an absorbent dry dressing and suitable antiseptics may be used.
DERMATITIS OF RADIO-ACTIVE ORIGIN.
The common expression of this form of skin affection is called a burn. This is something more than its name implies, for it is understood that the active factors are the ultraviolet rays, or the rays beyond the color region of the spectrum; that it is not due to the heat rays is shown by the intense burning that is frequently seen in the Arctic regions. In the skin of the young and tender, _sunburn_ is sometimes followed by vesication and desquamation; ordinarily it simply produces the latter. Any soothing ointment or solution is usually sufficient for the _treatment of sunburn_, which should, however, include avoidance of the exciting cause.
[Illustration: FIG. 99
“_X_-ray burn,” result of nine exposures in nine days. Extensive necrosis and sloughing, with an intractable ulcer. (From collection of Dr. G. W. Wende.)]
Much more intense actinic effects are produced by the _x_-rays, leading sometimes to complete destruction of the skin. These phenomena are usually called _x-ray dermatitis_. They vary from local discomfort, with itching, loss of hair on hairy surfaces, and partial anesthesia, with later a glossy appearance, to edema of the cellular tissue, by which anatomical outlines are effaced. The natural color of the skin, owing to pigmentation, appears dark. If the exciting cause be stopped before or as soon as this stage is reached complete recovery is possible, save that hair does not always grow from the surface which has lost it. The _x_-ray treatment should be pushed up to this stage. Careful management is now necessary, especially should any surface irritation like chafing occur. That _x_-ray burn, so called, may result from _x_-ray exposure made some time previously seems to be established by a case reported to me by Dr. L. L. McArthur, of Chicago, where he had to do skin grafting upon a lesion of this kind which did not appear until fifteen months after the last exposure.
The stage of danger is characterized by extreme itching with multiform eruptions in successive crops, desquamation, formation of minute vesicles, and ulcers; or the process may be more acute and the skin begin to slough. Small lesions will become confluent, and large excavations may be formed. The sloughing process is usually slow, and by it are produced ulcers characterized by extreme pain and discomfort and a lack of tendency to heal.
These ulcers are exquisitely sensitive and applications intended for relief are of themselves most distressing. Everything about such an ulcer seems sluggish, while small areas which have apparently healed break down again; healthy scabs are not formed and granulations are extremely indolent.
=Treatment.=--In the treatment of these lesions, so long as they are mild, the surgeon should confine himself to soothing applications and rest; at the same time discontinuance of _x_-ray exposures and even avoidance of light seem to be essential. Any operator threatened with such trouble should wear thick rubber gloves during all his work. The local treatment of this lesion is not essentially different from that described in the chapter on Ulcers and Ulceration, but the surfaces are often so erethistic as to demand either anodyne applications, containing such remedies as orthoform, anesthesin, or even cocaine, or else they need radical treatment with a sharp spoon.
Sloughing surfaces should be treated with brewers’ yeast until the surface has become healthy. Picric acid in solution has been recommended, a saturated solution being diluted seven or eight times before using.
The writer has rarely seen any more distressing or obstinate lesions than presented in some of these cases. In speaking of epithelioma it has been stated that some of these ulcers are prone to thus degenerate. It seems an extreme contradiction in physics that the agent used so frequently in the treatment of superficial cancers should, when used to excess, produce lesions which themselves become cancerous. It has been the writer’s privilege to witness amputation of all of one hand and a large part of the other, in the case of a well-known colleague, who carried the x-ray treatment to excess, and until he suffered to this extent. Careful and discriminating judgment is therefore necessary in the management of vacuum tubes.
Since _radium_ has come into use it has been found to exercise a deleterious effect upon the skin. The radium emanations are known to influence living cells and tissues, and their inhibiting effect upon the growth of larvae has been well established. The prohibitive price of radium preparations will make these lesions rare. After exposure there appears an erythema followed by an active dermatitis, which so closely resembles lesions above described, in their early stages, that one description will suffice for both. Moreover, the treatment of a radium burn differs in no essential respects from that of an _x_-ray burn.
ACUTE INFECTIONS OF THE SKIN.
=Furuncle or Boil.=--A furuncle is a phlegmon having its origin in a hair follicle and involving a small area of skin and subcutaneous tissue. The infection is produced by one of the ordinary pyogenic organisms, which have easy access to the base of the follicles. Sometimes these organisms are of unusual virulence, but ordinarily there is a local condition which favors the infection, while it may be encouraged by a general diathetic condition, such as diabetes. The lesion is usually single, but may be multiple. Boils appear sometimes in groups or in crops, and when the condition has become chronic it is called _furunculosis_, which may be local or general. A boil commences as a tender papule, which rapidly enlarges into a conical swelling, sometimes of considerable size. Around it there is an area of dusky discoloration, while the apex becomes quite dark. Pus, travelling in the direction of least resistance, comes more or less readily to the surface, the apex of the boil yielding and pus finally escaping, if not evacuated by incision, usually with a small amount of necrotic tissue, which may be sufficiently large to justify the term “core.” With the escape of pus the throbbing pain is much relieved. A furuncle arising in tissues where swelling is not easily treated, as in the nose, the external meatus, and also in the axilla and the perineum, will produce an abnormal amount of pain.
=Treatment.=--The domestic treatment of boils consists of poultices, usually made of hot flaxseed. These are always nauseous applications, and tend to favor the development of similar trouble in adjoining follicles. An equally comforting application can be made with a piece of spongiopiline, or a compress, saturated in an antiseptic solution, and covered with rubber tissues, outside of which, if necessary, a hot-water bottle may be applied. Inasmuch as it is tension which produces pain, _early incision_, which can be made under a little freezing spray, or with cocaine, will give the greatest relief. This may be practised even before pus has appeared. After such incisions the same moist applications may be applied. Incisions should be made as soon as pus is shown to be present. The appearance of a whitish point at the apex of the furuncle will always indicate the presence of pus beneath.
_General furunculosis_ has almost always an underlying diathesis as a cause, and this should be sought out and treated according to its nature. In the absence of recognized constitutional conditions the writer has never found anything equal to aromatic sulphuric acid, given in 10 or 12-drop doses, with tincture of arnica in teaspoonful doses, to be freely diluted with water.
=Carbuncle.=--This differs from a furuncle in the extent of the local infection, involvement of subcutaneous tissue, and the amount of necrosis which it produces. It is in most instances a more serious affair, life often being destroyed by the extent of the resulting necrosis and the amount of toxins produced. It begins as a local process, but always with constitutional disturbance, and sometimes even with a chill. The affected surface rapidly assumes a brawny hardness, and the infiltration is often extensive; pain is severe and throbbing; the surface becomes more dusky in appearance, numerous pustules appear, development of all the features of a serious carbuncle usually taking place in a few days. Later it begins to soften and the skin gives way at several points, at each of which a small drop of pus is discharged, while after removing this there may be seen white necrotic tissue beneath. The sloughing process extends deeply, generally to the deep fascia, and this itself occasionally succumbs. A person may have a distinct carbuncular lesion where the area primarily involved is not much larger than that of a five-cent piece; on the other hand, in debilitated or dissipated subjects, a lesion of this kind may become as large as a dinner plate, while the sloughing process may expose the underlying bone. This is often the case on the back of the neck and trunk. A carbuncle may occur in any part of the body, but is usually seen on the back; when upon a limb it generally involves the extensor surface. It is especially serious and dangerous when occurring upon the face, as septic thrombosis may readily extend to a cranial sinus and rapidly kill. It was formerly believed that carbuncles of the lip always terminated fatally; while this is not necessarily true it will indicate the seriousness of the condition (Figs. 100 and 101).
[Illustration: FIG. 100
Carbuncle of the neck. (Lexer.)]
=Treatment.=--There are few lesions where both constitutional and local treatment need to be more judiciously combined. Many of these patients are diabetic, and then it assumes malignant tendencies. Others are syphilitics or alcoholics, whom dissipation has reduced to a condition of serious malnutrition. The urine should always be examined for sugar and albumin, and whatever indications it may afford carefully followed. Septic intoxication and infection may so rapidly depress the already weakened patient as to call for stimulants and tonics, and pain may be so severe as to justify the use of anodynes.
The _local treatment_ should consist of soothing applications until the extent of the plastic exudate has declared itself, after which it should be more radical. It is better, therefore, to excise under an anesthetic, the area which ordinarily would require days or weeks to slough. The most satisfactory treatment is the radical. The knife, the scissors, and the sharp spoon constitute the best means of combating this disease. In other respects the treatment was discussed when dealing with septic infection. Nothing will so hasten the sloughing and cleaning up process as brewers’ yeast. The writer’s custom is to make a thorough excision of the affected area and treat the part with yeast for some days. About the lip and face the sharp spoon should take the place of the knife, but even there, if the case be attacked early, tissue can be saved and disfigurement reduced to a minimum. The method used by some of injecting 5 per cent. carbolic solution is less satisfactory, although the measure above recommended is a rather severe operation and usually requires complete anesthesia.
[Illustration: FIG. 101
Anthrax carbuncle of forearm. (Lexer.)]
CHRONIC INFECTIONS OF THE SKIN.
=Tuberculosis.=--Most of the skin lesions formerly described as scrofulous are now known to be expressions of tuberculosis. So, also, are some of the papillomatous growths and the chronic ulcers, which do not assume distinctive form.
_Lupus vulgaris_ is perhaps the most common of these cutaneous lesions, especially in certain parts of the world. It is seen more often among the young than the old. The lesions begin with a papule, which becomes the well-known lupus, smaller nodules coalescing and forming eventually a brownish-red patch, whose borders are somewhat elevated and scaly. This lesion usually goes on to ulceration, particularly in those parts of the body where it is kept moist or frequently irritated. It is in these lesions that a healing or cicatrizing tendency is seen at one point and progressive ulceration in another. Ulceration does not always occur, but the papule just described sometimes undergoes spontaneous absorption, the tissue atrophying, losing its peculiar skin functions, and the scar being depressed and scaly.
Lupus vulgaris is to be distinguished from lupus exedens, referred to under Epithelioma. It is often mistaken for the latter, and a differential diagnostic table has already been given. (See p. 293.)
_Verruca necrogenica_, as it used to be called, is now known as _verrucose tuberculosis_. It consists of cutaneous warts, surrounded by an erythematous zone or patch, which tend to break down, and covered with scabs, intermixed with pustules. The lesion rarely proceeds to complete ulceration. It occurs especially upon the hands and exposed parts of those who handle cadavers or carcasses. The lesion is usually slow and sometimes disappears spontaneously.
On or about the mucocutaneous borders of individuals suffering from tuberculosis there appear small ulcers, secreting a thin, puruloid material. These are seen especially about the nose, the mouth, the anus, and the vulva. These lesions should be regarded as local infections from a constitutional source. They are often sensitive, show little tendency to heal, and are sources of danger to others. They should receive radical treatment.
Under the term _scrofuloderm_ are included a variety of subcutaneous tuberculous nodules which spread and involve the skin. They begin in the superficial lymph nodes. The overlying skin becomes bluish and gives way, while an ulcer remains which discharges more or less puruloid material. The edges of these ulcers are frequently undermined for a considerable distance. These are ordinarily chronic lesions, which sometimes undergo a spontaneous recovery, leaving disfiguring and discolored scars, usually irregular and more or less striped or banded.
Some of the scrofuloderms are included under the erythema induratum of Bazin, lesions which appear mostly on the calves of the legs of young women, consisting of deep-seated nodules, which break down into deep ulcers, having elevated and overhanging edges. Again, there is the so-called lichen scrofulosorum, _i. e._, a papular eruption seen in the young, especially those who show other evidences of tuberculosis. It consists of rounded groups of papules, usually on the sides of the trunk, at first bright in color, new papules appearing as the old ones fade. In addition there is the pustular scrofuloderm, which crusts over, heals, and leaves small cicatrices.
In all of these lesions the tubercle bacilli can be usually demonstrated. There are other skin lesions in which no bacilli can be demonstrated, which are supposed to be due to the toxins generated in tuberculous foci elsewhere. Hallopeau suggests calling all tuberculous skin lesions _tuberculides_ and to group them as follows: (_a_) Those in which bacilli are present, bacillary tuberculides, and (_b_) those arising from tuberculous toxins, toxic tuberculides.
[Illustration: FIG. 102
Lupus of skin (hypertrophicus et exulcerans). Finally healed by excision and plastic operation. (Lexer.)]
[Illustration: FIG. 103
Lupus vulgaris. (Hardaway.)]
Among the latter he describes what he calls _folliculitis_, _i. e._, small papules, firm, at first red, then elevated, becoming nodules, appearing on the extremities, and gradually producing crater-form ulcers covered with black crusts, leaving small pock-like scars. This condition is chronic, lasting years. In these patients the skin is furfurated, showing a sluggish circulation.
=Treatment.=--Inasmuch as tuberculous skin lesions tend to spread and to recur, they need radical treatment--_i. e._ the sharp spoon, the scissors, and caustic. Ordinarily it is best to scrape the affected surface, to trim away all unhealthy edges, and then to apply a strong caustic for a brief space of time, thereby sterilizing it and searing the mouths of the absorbents which may have been opened by the scraping. Treatment for two or three days with brewers’ yeast will usually suffice to put the surface in a healthy condition, after which it may be skin-grafted or treated by any of the ordinary plastic methods.
=Rhinoscleroma.=--The bacillus of rhinoscleroma was described in the chapter on Inflammation, under the heading Pyogenic Organisms. It is a specific infection, primarily of the skin, which appears invariably upon the nose. It begins either in the skin or mucous membrane, or both, and having once thoroughly invaded the tissues grows in all directions. It shows no tendency to heal, but gives to the tissues a distinctive brawny induration. From the nose it extends to the palate, pharynx, and antrum, making steady encroachment upon the parts which it affects, distorting the features, obstructing respiration, and often causing pain by pressure on the sensory nerves. Its first appearance is characterized by nodules, frequently covered with dilated bloodvessels. Unless it can be seen and recognized early it is a wellnigh hopeless condition with which to contend. Extirpation of the affected tissue is the only satisfactory method of dealing with it. It is a different disease from rhinophyma described elsewhere. (See Figs. 7 and 8, p. 55.)
=Mycosis Fungoides.=--This form of skin infection, of somewhat uncertain origin, is met in shape of fungoid nodules, and likely to involve the upper part of the body; they tend to increase in number and size, to infiltrate, often to ulcerate, sometimes to disappear by spontaneous absorption, but in severe cases cause death, either by malnutrition or sepsis. Tumors are thus formed which attain the size of a child’s head. As soon as surface infection or ulceration begins the breaking-down process is rapid; there is early involvement of the lymph nodes, and the general health begins to suffer. The tendency in almost every case is to fatal termination. Cases may run from a few months to fifteen years, however, before this stage is reached. By some authors the disease is considered as a peculiar form of sarcoma. It is, however, generally regarded as a granuloma, whose specific organism has not been ascertained.
[Illustration: FIG. 104
Ulcerating gumma of skin, cicatrizing in certain areas. (Lexer.)]
=Actinomycosis, Syphilis, Leprosy, and Glanders= should be included among the chronic infections of the skin, and have been described.
=Radesyge.=--Radesyge is a granulomatous involvement of the skin, peculiar to certain parts of Europe, particularly Norway, which has been by some considered to be an expression of leprosy, by others to be a disease by itself. It is generally held that the lesions which have passed under this name are really expressions of cutaneous syphilis.
=Framboesia; Yaws.=--This is an endemic tropical disease, of which we see our nearest specimens in the West Indies, and involves especially the negro and Oriental races. It begins with an eruption, papules maturing in fungoid form, being met with most often at mucocutaneous borders, but appearing anywhere upon the surface. It is specific and inoculable, having a period of incubation of about two weeks, and becoming generalized in from fifteen to twenty weeks. The papules increase in size, become covered with yellow crusts, which fall off and expose a rough surface which discharges an offensive puruloid material. After remaining in this condition for an indefinite time the lesions spontaneously improve and may disappear, leaving only pigmented spots to mark their previous sites. Beyond local cleanliness and antiseptic applications the lesions require but little treatment. If anything more is attempted it should be thorough and effected with the cautery or the sharp spoon.
=Mycetoma.=--Mycetoma is more commonly known as _Madura foot_, or sometimes _the fungus foot of India_. It prevails especially in Southern India and about Madras, and is apparently confined to that part of the globe. Nevertheless it has been reported from Algiers and from South America. It is a specific infection of the foot, beginning in the skin; it rarely occurs on the hands, the scrotum, etc. It leads to the formation of an infectious granuloma, which gradually destroys the texture and identity of the tissues, and finally demands amputation or ablation of the part.
Russian bacteriologists have discovered parasites resembling the protozoa which they have found in the granulations and ulcerations of the Delhi boil. They were also occasionally seen in the leukocytes. By these observers these parasites have been regarded as active agents and have been given the name ovoplasma orientale.
=Oriental Boil.=-This also is a slow infection of the skin, met with especially in Southern India, where it is known as the _Biskra button_ and the _Aleppo_ or _Delhi boil_.[19] It appears mainly on the unprotected parts of the body at first as a papule and then a nodule, which enlarges, ulcerates, usually tends to heal spontaneously, and leaves an ineffaceable scar. It is practically a granuloma of the skin, is auto-inoculable, and is best treated by complete excision.
[19] Delhi boil is now known to be another of the local infections of exposed surfaces, occurring especially about the lower extremities and the genitals, due to the invasion of one of the trypanosomas, its actual pathology having been only recently demonstrated.
=Guinea Worm, or Filaria Medinensis.=--This worm is about one line in diameter and two or three feet long, and is found generally throughout the tropics. The embryo is taken into the intestines with drinking water and migrates to the skin, beneath which it develops. The male worm has never been discovered. What is known of the evidence of its presence pertains only to the female. When fully developed it can be felt in a coil beneath the skin. It produces local inflammation, a vesicle forms, and the head of the worm then protrudes. When it is exposed it can be frequently extracted by gentle traction, removing as much each day as protrudes. Christie has suggested to destroy the worm by electrolysis, and others inject into the vesicle some antiseptic, by which the worm is killed, it being afterward absorbed without difficulty (Fig. 105).
[Illustration: FIG. 105
Guinea-worm bleb just cut off. (Bryant.)]
=Blastomycetic Dermatitis.=--This is a true protozoan infection of the skin, first described by Wernicke in 1892, which has now become quite generally recognized and described. The parasite is a very small, spheroid protozoan, and is found in the skin elements, as well as in the pus and debris discharged from the lesions. It has been successfully cultivated and inoculated. It is classed among the yeast fungi. It produces lesions very much like some of those met with in syphilis, tuberculosis, and mycosis fungoides. Indeed it may be necessary to use the microscope in order to complete the diagnosis, which is best accomplished by teasing a small portion of tissue on the slide in liquor potassæ (Hardaway).
The lesions begin usually as small papules, which may later coalesce and become covered with a fine scab. Around these there develop thickened borders, with fungus-like projections. Between the little elevations pus may form, or an exudate occur in sufficient quantity to dry into a large-sized crust. Here, as in lupus, cicatrization may be going on at interior points while the lesion is encroaching around the margin. The affection is slow, and the ulcer may attain a size of several inches in diameter.
The treatment consists in radical measures, _i. e._, strong caustics, curetting or complete extirpation with the knife, which may be followed by more or less plastic work, as required.
=Coccidioidal Granuloma.=--Under this name is described a rare form of granulomatous lesion of the skin, whose exciting cause is not one of the ordinary bacteria, but a form of mold--one of the varieties of _oidium_. The clinical manifestations of this lesion resemble those of blastomycetic dermatitis, save that in the latter the primary focus of infection is always found in the skin and remains there localized, whereas coccidioidal granulomas may occur as well in the deeper tissues or viscera as upon the skin; in fact, the skin lesions of the latter may be described as _oidiomycosis_ in distinction from blastomycosis. It produces miliary skin nodules which closely resemble tuberculous lesions, and may even caseate or assume an acute type and break down rapidly. The lesions are progressive, with a tendency to dissemination, both by the lymph and the blood currents. The lymph nodes are usually early affected and often suppurate.
=Cysticercus, or Tænia Solium=, may be found in the subcutaneous tissue in the shape of small nodules, covered by unaffected skin. When young these tumors are tense and elastic, but are subject to calcareous changes. They occur frequently on the back.
=Echinococcus Cysts= are also found in the skin, where they may attain a size which will make them fluctuate. The treatment for all such lesions is complete eradication.
=Trophoneuroses. Perforating Ulcer of the Foot.=--This has already been alluded to in the chapter on Ulcers and Ulceration. The lesion apparently begins as a thickening or callosity, usually beneath the head of the first metatarsal bone, at a point where much pressure is made, owing to the natural position of the foot. Beneath the thickened skin there develops an adventitious bursa, in which, or in the skin itself, the first degeneration may take place. The result is a deep ulcer, with overhanging borders, and a thin, often foul discharge. The lesion is not painful, and patients are less likely to spare the foot. It is usually associated with some central spinal disease, or with a peripheral neuritis. It is more common in those patients who have had disease leading to loss of sensation in the foot.
The treatment consists in excision of the ulcer down to healthy tissues, with careful protection. Skin grafting is often found successful.
=Ainhum.=--Ainhum is essentially a disease of the negro and of tropical climates. It usually begins in the little toe or little finger, and goes on to spontaneous amputation, the result of an anemia caused by the formation of a sclerotic ring, which encircles the digit and shuts off the blood supply. It is an annular scleroderma, or keloid, which produces the disturbance.
CYSTS OF THE SKIN.
The most common cysts of the skin are the _sebaceous_, known also as _steatomas_, which result from obstruction of the ducts of sebaceous follicles, and accumulation therein of sebaceous secretion. They are found where these glands abound, and may attain the size of a hen’s egg or larger. They are frequently infected and suppurate, or their contents may undergo slow change and lose their original characteristics by the time they are evacuated. Peculiar changes occur in rare instances, since they may calcify, or their bases serve even for the development of cutaneous horns, while in the other direction they not infrequently undergo malignant degeneration. In some of these cysts a small opening can be found, through which, on pressure, fatty or butter-like contents can be exposed. When their contents begin to putrefy the odor becomes offensive.
Another variety of the skin cyst is the so-called _atheromatous_, which is more allied to the cutaneous dermoid, and whose contents are often nearly pure cholesterin. Sometimes they contain hair or other epithelial products. They occur usually in the scalp. These are essentially inclusion cysts and purely epiblastic products. When infected their contents putrefy and smell badly. (See Fig. 88, p. 285.)
=Treatment.=--The treatment for any cysts of the skin consists in extirpation of the sac. It is sufficient to split them thoroughly with a sharp, curved bistoury, and then, on either side, to seize the edge of the divided sac with forceps and enucleate it. All this can be done under local anesthesia. The cavity should be thoroughly disinfected and not too tightly closed.
Under the name Cock’s peculiar tumor some English writers have alluded to the offensive ulcerated surface, with raised edges, which is left after the contents of these cysts have undergone putrefaction and escaped by breaking down of the surface. Such a lesion is on the border-land between mere ulceration and malignancy.
HYPERTROPHIES AND BENIGN TUMORS OF THE SKIN.
=Corns.=--_Clavi_, or _corns_, vary in density. A soft corn differs from a hard one only in that it is located where it is softened by moisture of the parts. A hard corn is a reduplication or callosity, conical in shape, representing great hypertrophy, with condensation of surface epithelium. Beneath old lesions of this kind will frequently be found small cysts, while nerve fibers become entangled, and these little lesions are sometimes exceedingly sensitive. They frequently become inflamed, the process proceeding to suppuration or ulceration.
=Bunions.=--When beneath such an indurated area of skin there forms an adventitious bursa, or a natural one becomes involved, the lesion is called a _bunion_. These are more frequent over the joints of the toes, where they sometimes cause intense discomfort. The bursæ sometimes connect with the joint cavity, and should one suppurate the other necessarily becomes involved. An infection of either of these lesions causes local and possibly fatal disturbance. I have seen death from pyemia follow infection of a bursa beneath a soft corn (Fig. 106).
[Illustration: FIG. 106
Distorted foot, from pressure and bunion. (Erichsen.)]
These lesions are not met with among the savage races or those who go barefooted. They are essentially products of the footwear affected in modern society. Were shoes made to fit the natural foot and not to constrain it in abnormal positions, corns and bunions would be practically unknown.
=Treatment.=--Preventive treatment is the most important and pertains to properly adapted footwear. Unfortunately the treatment of these minor lesions is too frequently left to charlatans and so-called chiropodists, who may give temporary relief in many instances, but have no knowledge of either the nature of the difficulty or its proper surgical treatment.
Soft corns will usually disappear if the parts can be kept clean and dry. Hard corns are essentially callosities, which should be pared down or trimmed off until the surface is almost ready to bleed. It may then be painted with a collodion containing 20 per cent. of salicylic acid and a little alcohol. If this mixture be applied to the surface of a clean and dry corn it can often be peeled away with the corn after a few days. When it is desirable to soften any callosity of this kind, previous to paring or trimming it, it can be done by applying for a few hours a mixture of equal parts of glycerin and liquor potassæ; this will so soften a callosity as, when applied over night, to make it endurable through the following day.
Bunions are so often associated with hypertrophy of the underlying bone as to entitle them to consideration under deformities of the feet. The most pronounced expressions are usually seen in connection with hallux valgus (_q. v._), and their treatment comprises excision of the bunion and its underlying bursal sac, along with exsection of the joint. By this radical local measure complete relief is usually afforded.
=Cutaneous Horns.=--These have the consistence of an ordinary nail, are epiblastic products, varying in size, length, color, and shape. They have been alluded to in the chapter on Tumors. Sutton has divided them into _sebaceous_, which occur most often upon the head and spring from an old sebaceous cyst (see above); _warty_ horns, which much resemble them; _cicatricial_ and _nail_ horns, which are instances of exaggerated growth of the finger-nails.
=Treatment.=--A simple excision of the growth with its base is all that is needed in these cases.
=Warts; Verrucæ.=--These constitute one variety of papillomas, the overgrowth having its original site in the prickle-cell layer of the rete. The most common form occurs upon young subjects on the exposed parts, as the face, hands, and feet. These are usually multiple; they frequently occur upon the surface, and retain dirt in such a manner as to be nearly always recognizable on the surrounding skin. They frequently disappear with as little known reason as that which caused their appearance.
Dilated papillary growths, like a fringe, are sometimes seen about the face and neck of elderly people. These have been known as _filiform warts_, while Unna gave them the name _fibrokeratomas_.
A form described as the _seborrheic wart_ occurs upon the face and elsewhere in elderly people. It is frequently pigmented, may itch intolerably, and is perhaps the form which most often undergoes malignant degeneration. To the acuminate form of wart, which is usually soft, and most often met with as a venereal wart about the genital region, has been given the name _condyloma_. These appear in either sex, grow rapidly, are covered with a puruloid secretion, bleed easily, and assume often such shape and resemblance as to give rise to expressions “strawberry growth,” “raspberry growth,” etc. They are always produced by irritation, usually in connection with one of the venereal diseases, and are generally due to lack of cleanliness. They may grow luxuriantly and over a considerable area, and, when appearing on the surface of the vulva, conceal completely the parts underneath. They also occur in connection with the mucous patches of tertiary or hereditary syphilis, but have essentially the same structure, no matter how produced.
=Treatment.=--In the treatment of ordinary warts nothing is better than absolute cleanliness. A dry wart touched daily with formalin solution, or covered with collodion containing 1 to 2 per cent. of corrosive sublimate, will usually shrink and become detached in a few days. Thorough excision of any true wart is sufficient to finally dispose of it. If the wart be cut through it is likely to bleed profusely, since its vessels are larger than those of the surrounding skin. Any growth of this kind can also be destroyed by the actual cautery, or by one of the strong caustic agents, which, however, should be used with great care.
_Venereal warts_, _condylomas_, are best treated radically, either with the actual cautery or with scissors and sharp spoon. Local anesthesia is always advisable in order that this may be thoroughly done. In instances of extensive growths of this kind a general anesthetic may be profitably given.
=Molluscum Contagiosum.=--Molluscum contagiosum, sometimes known as _epithelial molluscum_, is a name applied to small warty growths more or less embedded in the skin, from which, by pressure, some epithelial debris can be forced out. The lesions are rarely single and yet rarely numerous. They may be met upon any part of the body, especially upon exposed portions. They are doubtless results of skin infections by various organisms. The best treatment is excision, although they may be split and cauterized and thus made to shrivel, or the same effect may be produced by electrolysis.
[Illustration: FIG. 107
Keloid occurring in a laparotomy scar. (Lexer.)]
=Keloid.=--This has already been mentioned under the heading Fibroma, in the chapter on Cysts and Tumors. It deserves further mention here, however, because of the disfigurement produced by keloid scars, and because the spontaneous expressions of the disease may occasionally demand surgical intervention. In cicatricial tissue it often follows the scars left by burns or excision of tuberculous lesions. Since subcutaneous sutures have been introduced there is less keloid than there was years ago (Fig. 107).
[Illustration: PLATE XXIX
Keloid. (Hardaway.)]
=Treatment.=--The surface indication is always for excision or eradication, but one cannot give the slightest guarantee against recurrence in even worse form in the same scar. Electrolysis may have a beneficial effect on some of the lesions, but will only occasionally prove satisfactory. A number of years ago _thiosinamin_ was introduced, and has perhaps given a larger measure of success than any other remedy. It is used in 5 or 10 per cent. solution, which is injected into and around the growth, and may lead to gradual absorption of the hypertrophied tissue. The pain which the injection produces does not last long and I have seen many excellent results follow its use.
The same injections may be resorted to in general keloidal disease, which is seen most often in the colored race. In negroes it may follow traumatism of the skin surface, and attain the size of a saucer or plate. (See Plate XXIX.)
=Neurofibroma.=--Fibroma of the skin may happen at any time and is likely to develop in the finer branches of the cutaneous nerves, where it will constitute a small tumor, known as _painful subcutaneous tubercle_. These little tumors attain the size of a pea and appear between the skin and superficial fascia. Sometimes they are painful and are always tender. Unless thoroughly removed they tend to recur. Nevertheless complete removal is the only remedy.
=Fibroma Molluscum.=--A much larger, softer, and more complex tumor is that known by Virchow as _fibroma molluscum_. These tumors may attain large size, and may be single or multiple. Over four thousand of these lesions have been counted on one subject. They develop from the connective tissue of the cutaneous nerves, and involve later the globular and follicular structures of the skin, softening and undergoing such changes as to deserve the adjective molluscum. Changes analogous to these lead to what has been described as _dermatolysis_, _i. e._, hypertrophy of the skin, with loosening of the subcutaneous tissue, by which it is thrown more or less into folds. Another clinical expression of the same condition has been known as _pachydermatocele_, in which pendulous masses of skin hang from various parts of the body, especially the face and neck, and undergo pigmentation and other changes.
=Treatment.=--These lesions can be excised, always with temporary cosmetic improvement, but not always with a guarantee against recurrence of the trouble.
=Scleroderma.=--This name is given to a leathery induration of the skin occurring in circumscribed areas, which have been called “morphea,” or in diffuse patches, which shade off into surrounding normal skin. The first indication is a stiffening accompanied by some thickening and hardness. Sometimes the affection is painful, and the brawny hardening which it produces makes it irksome and uncomfortable. The skin thus affected can not be picked up between the fingers, and is more or less adherent to the tissues beneath. When the difficulty is pronounced the sweat and sebaceous glands cease to functionate. If it occur about a joint the movement of the latter may be interfered with, even to the extent of producing ankylosis. Wherever it appears there is impediment to motion and flexibility of the parts beneath. The tendency usually is to spontaneous disappearance with atrophy. While subsiding at one locality it may recur in another. Upon the hands it may effect such great disturbance of function as to produce what has been described as “sclerodactylia.” The skin over bony prominences, when irritated, may break down; ordinarily it does not go on to ulceration.
=Pathology.=--The pathology of scleroderma is very obscure. Whether it depend upon primary disturbances of circulation, both of blood and lymph, or whether it is produced by cellular hypertrophies has not been determined.
The characteristic induration of this disease is not imitated in other affections except _scleroma neonatorum_, but it may, nevertheless, be confused with the infiltration of tuberculosis, of syphilis, or of malignant disease. While the disease persists, in most cases it is not often fatal.
=Treatment.=--It is to be treated mainly by tension, the general and constitutional conditions by massage, and inunction with soothing oils or with the ichthyol-mercurial ointment. It has been successfully treated, as is keloid, by the subcutaneous use of a 10 per cent. alcoholic solution of thiosinamin. The ultraviolet rays and even the x-rays, used judiciously and carefully, may also be of service.
=Rhinophyma.=--This form of tumor is to be differentiated from rhinoscleroma, the latter being due to a peculiar specific bacillus, while rhinophyma is a filth disease, due to hypertrophy of the sebaceous structures of the nose from obstruction of the sebaceous ducts. It is often seen among alcoholics, perhaps less frequently at home than abroad. Pathologically it consists of enormous and irregular hypertrophy of the sebaceous gland elements and connective tissue of the skin of the nose. Each hypertrophied gland secretes in proportion to its increase in size, and even the vessels of the part become engorged. In consequence there results a lobulated, distorted, most disagreeable appearance, which often becomes exceedingly offensive. The tumors thus formed sometimes increase to a size sufficient to interfere with breathing and with feeding. The resulting nasal enlargement is usually trilobed. The first impetus to the overgrowth comes sometimes from such cutaneous irritation as frostbite, or local irritation of some kind.
=Treatment.=--The treatment of rhinophyma consists in the unrestricted use of scissors and the sharp spoon, with the preservation of so much of the integumentary structure as may serve to cover the reduced dimension of the nose. These lesions will bleed freely at first, but bleeding is usually easily checked. When a plastic covering of the defect is impossible, the surface may be left to granulate, with a certain feeling of security that the cicatricial contraction following will reduce the enlargement to normal proportions.
=Xanthoma.=--This name is applied to a macular lesion, papillary or tuberculous, marked by the appearance of yellowish spots, occurring singly or in groups, often about the eyelids, but seen anywhere upon the skin. When occurring in papules it is called _xanthoma planum_; when in nodules, _xanthoma tuberosum_. There is a variety met with in diabetes which is temporary and usually disappears spontaneously.
=Treatment.=--The _treatment_ for xanthomatous patches is either electrolysis or complete excision, under local anesthesia.
=Keratosis.=--Keratosis is a term applied to thickening of the normal epidermis, occurring in limited areas, the skin being transformed into tense or almost horny tissue. The form which occurs in elderly individuals is called keratosis senilis. It occurs upon the face, the hands, and forearms, but may be seen on any part of the body. The involved areas become discolored, sometimes by true pigmentation, more often by a deposit of dirt. As long as epithelial reproduction occurs away from the basement membrane the lesions are simple and innocent, but in elderly people it requires but little irritation to provoke a down-growth of epithelium, and then the development of epithelioma is rapid.
=Treatment.=--These reduplicated epithelial elements can be kept soft by an application of equal parts of glycerin and liquor potassæ. After being softened they may be easily scraped down to a normal level, but will later reform. If they begin to ulcerate they should be excised. Should excision be declined the area may be treated with the thermocautery or with one of the caustic pastes.
=Vascular Growths.=--These have already been mentioned in the chapter on Tumors, under the head of Angioma. So far as the skin is concerned they usually occur in the shape of nevi (called strawberry growths) or the more disseminated form, sometimes involving considerable areas, commonly known as “port-wine marks,” which are essentially cutaneous telangiectases, are almost always of congenital origin, and frequently appear in complete form even at birth. They may occur rapidly or slowly. An isolated nevus should be treated by complete excision. Large vascular areas, or port-wine marks, are best treated by repeated electrolysis. If treated early they are sometimes eradicated by the local use of sodium ethylate.
The so-called _nevus pigmentosus_, or pigmented mole, is generally of congenital origin, and may or may not be accompanied by vascular changes. It is not infrequently covered with hair, and sometimes forms a patch of considerable size, often upon the face. These lesions occasionally occur in such form as to entitle them to be styled nevus verrucosus or nevus pilosus. Occurring upon the back or trunk they are usually disregarded. When upon the face they should receive surgical treatment.
=Treatment.=--Excision is, of course, the best method of treatment unless a disfiguring scar be feared. This can usually be prevented by proper plastic methods. When excision seems inadvisable electrolysis is the next best method of attack. No matter how vascular may be the lesion itself, the vessels a short distance from the margin of these growths are rarely dilated, and hemorrhage is not a feature which need deter one from radical treatment.
=Lymphangioma.=--This has also been described in the chapter on Tumors. A circumscribed form is occasionally found in or beneath the skin. It occurs early in life, constitutes a more or less sessile tumor, which collapses on pressure, fills slowly, its surface being often irregular, warty, or horny. Should the surface be injured lymph will escape rather than blood. An extended form of it constitutes one kind of elephantiasis. (See chapter on Lymphatics.) Any septic infection of a growth of this character is likely to result seriously and at once.
=Treatment.=--The best treatment is excision under thorough aseptic precautions; next to this is destruction with the cautery, which will lead to resulting sloughing and cicatrization.
=Malignant Disease.=--All forms of cancer may appear, primarily, in or upon the skin. From the ordinary surface epithelium springs _epithelioma_; from the glandular elements possibly _round-cell carcinoma_; and from the mesodermic elements any of the radical varieties of sarcoma, while endothelioma is less common.
=Epithelioma.=--This is a frequent infection of the skin, which may arise primarily as an original lesion, usually following surface irritation, or secondarily, either as the extension of similar disease from other parts or of degeneration of previously innocent epithelial tumors. Epithelial outgrowth, so long as it be an _outgrowth_, and do not transgress the limits of the basement membrane, is essentially innocent in character; but so soon as growth in the downward direction begins we have the beginning of a skin cancer, which may proceed to fatal extent if not promptly recognized and properly treated. These growths vary very much in rapidity and malignancy. Occurring upon surfaces which are kept constantly moist and warm they develop more rapidly, as upon the tongue, within the vulva, rectum, etc. The slowest form of growth of this kind is the so-called rodent ulcer. Epithelioma which begins in or upon the skin or mucous membrane tends to spread to and involve everything in its neighborhood; even bone and cartilage succumb to its ravages, and, becoming involved, lose all their characteristics and melt away in the surrounding ulcer. This produces in the course of time hideous and serious developments. No tissue is exempt from its ravages, and yet life may be prolonged for many years, even when the face is almost entirely eaten away. Epithelioma and rodent ulcer have been described in the chapter on Tumors.
[Illustration: FIG. 108
Epithelioma.]
More deeply seated carcinomas of the skin infiltrate in both directions alike, and grow downward, sometimes in cylinder form, thus giving rise to a clinical type called _cylindroma_. Lenticular carcinoma is also described as differing from the ordinary epithelioma, in that it exhibits a true alveolar structure. This form is rare, and is distinguished from the common form by the absence of the so-called “pearly bodies,” which characterize common epithelioma. The lenticular form is most often seen in recurring cancer of the breast, or in the vicinity of scars showing where deep-seated cancer had existed.
=Diagnosis.=--Epithelioma in its various forms should be distinguished from skin lesions due to syphilis and tuberculosis. A diagnostic table has been given (see p. 293) by which diagnosis as between it and lupus may ordinarily be made. The lesions of syphilis are usually multiple and accompanied by other manifestations which stamp their character. There is, moreover, usually a history which will be suggestive if not actually helpful. In cases of actual doubt, as upon the tongue and elsewhere, the therapeutic test may be applied. If resorted to, it should be vigorously made. When mercurial inunction is thoroughly practised, and the internal administration of the iodides effects no improvement within three weeks, the hypothesis of syphilis may be abandoned.
All cancerous lesions tend to advance and to destroy in spite of all local measures. There never appears about them any indication of a tendency toward cicatrization, and, while the edges of malignant ulcers may be thickened and everted, the more central portions are always excavated. They cause, moreover, involvement of the adjoining lymphatics, although this may be said as well of syphilitic and tuberculous lesions.
=Treatment.=--Concerning the treatment of epithelioma and other malignant skin diseases there is little to be said which has not already been summarized in the general considerations concerning the treatment of cancer. Radical excision of the original lesion, in its early stages, will usually lead to final recovery. If there be involvement of the lymphatics the indication is made thereby more positive for cleaning out all infected areas, while, at the same time, the prognosis is rendered less favorable. There comes a time in the history of all these cases when excision can be recommended only as a palliative measure, _i. e._, when it may be regarded as useless. In the more hopeless cases benefit will but rarely be obtained from the use of _x_-rays, ultraviolet light, or radium.
=Paget’s Disease.=--Paget’s disease includes lesions now regarded as a _precancerous stage_, which appear upon the breasts and around the nipples of women during the middle decades of life. Something similar is seen in other parts of the body and in both sexes, but it is most common around the nipple on one side. For a long time it appears as an ordinary eczema, which, however, does not tend to heal but to spread, while the skin beneath becomes more or less infiltrated. A gradual retrocession of the nipple is usually seen. Certain discomfort accompanies the lesion, which may go on indefinitely until it becomes unmistakably cancerous. This is a precursor not so much of round-cell cancer (scirrhus) as of epithelioma. _Eczema of the nipple is to be regarded with suspicion_, especially when occurring after the menopause. Until diagnosis is fairly established it is best treated with soothing applications. So soon as the cancerous stage has been determined the breast should be removed. (See Plate XXVI.)
Other forms of malignant or border-land tumors which occur upon the skin are _chimney-sweeper’s cancer_, _paraffin cancer_, and that met with in _aniline workers_. Chimney-sweeper’s cancer was the name applied to epithelioma of the scrotum occurring among a class of laborers whose occupation is now almost entirely extinct. It began usually as papilloma and merged into epithelioma. Among workers in paraffin and coal-tar factories there is an analogous lesion, the result of surface irritation, the skin becoming dry, thickened, covered with acne-like pustules, and then with papillomas which ulcerate and frequently change over into true epitheliomas.
=Sarcoma.=--Only the outer layers of the skin are truly epiblastic. In the depths of the integument mesoblastic elements enter largely, and from these various forms of sarcoma may develop. These have already been treated in the chapter on Tumors. They may be single or multiple, and a general _disseminated sarcomatosis_ is occasionally observed. It corresponds to miliary tuberculosis, but presents many distinctive lesions in the skin, by which it may be easily recognized. A form of multiple pigmented sarcoma involving the hands is represented in Fig. 109. These growths are almost always tender on pressure and more or less painful. They coalesce and finally form fatal lesions.
=Melanoma.=--This term was introduced by Virchow, who made it cover all pigmented growths. By common consent it is today limited to tumors of the skin and uveal tract which contain pigment; metastases may occur in any or all of them. They occur as malignant degenerations of nevi, moles, and other small growths. Pathologists are still disputing as to whether they should be considered sarcomas or endotheliomas. The coloring matter which they contain is amorphous, finely granular material, lying between the cells in moles, but occurring free in the tissues and blood and even in the urine. It is soluble in strong alkalies, from which it can be recovered as melanic acid, containing a small proportion of sulphur. Of its origin nothing is positively known. It seems to be generally accepted that the deposit of pigment is not of itself a causative agent of the growth of the tumor, but that the growth of cells and their pigmentation are coincident processes. Johnston has offered much evidence lately to the effect that growths from nevi are really of endothelial origin. Hutchinson has described _melanotic whitlow_. (See below, the Nails.)
Melanoma is a pigmented ulcerating neoplasm, which possesses at first only a local malignancy like that of rodent ulcer; the more it assumes the endotheliomatous type of growth the more it tends to disseminate and to prove fatal.
The melanoma arising from a mole or nevus, thus known as melano-endothelioma, begins to increase in size and becomes more full, as well as to assume a darker tint. For a variable time it is a single, rather firm, gradually growing, flat tumor, rarely ulcerating, but sometimes exuding a thin dark fluid. Suddenly there appears rapid local spread as well as dissemination. The latter may be first noted in the adjoining lymph nodes. Thus numerous secondary tumors may be felt in and beneath the skin, at first colorless, becoming more or less rapidly pigmented. Metastasis may take place to every organ in the body, but usually the liver and lungs--less often the brain--are involved. In one case known to the writer the heart was a mass of nodules of this same secondary character.
Another expression of the same serious condition is seen in a lesion called by the French malignant lentigo, which also begins with pigmented spots, on the feet of old men, sometimes upon the face. These lesions cause thickening of the skin and early ulceration.
Rodent ulcer, which is one form of epithelioma, occasionally assumes the melanotic type, and is called melano-epithelioma.
[Illustration: FIG. 109
Fibrosarcoma of hands. (Hardaway.)]
The most marked collection of pigment in the human body, within small space, is along the uveal tract within the eye, and orbital melanomas are not infrequent. Beginning within the sclerotic they rapidly perforate this dense membrane and spread to adjoining tissues, while dissemination and metastasis occur early and rapidly.
=Treatment.=--For melanoma there is but one successful treatment, and this is successful only when practised early, _i. e._, complete excision or destruction. Every mole, nevus, or other skin lesion which shows the slightest tendency to changes noted above should be promptly excised, along with a wide area of its surrounding tissue. It _may_ be thus possible to make a radical cure. Neither _x_-rays nor any other less radical method of treatment will have the slightest effect. The treatment of any case left to itself until mistake in diagnosis is impossible will probably be of little avail.
SKIN APPENDAGES; HAIR AND NAILS.
The only lesions of the hair and hair follicles that concern the surgeon are those which have been described under the head of Syphilis of the Skin, or some of the congenital growths, such as plexiform neuroma, lymphangioma, etc., whose surfaces are frequently pigmented and hairy, and may call for excision, along with the underlying tumor.
=The Nails.=--Onychia implies any disturbance of the nail border and matrix. Simple onychia occurs frequently in the fingers of marasmic children. It is evidenced by softening and swelling of the skin around the nail, by more or less pain, disturbance of circulation beneath the nail, which becomes finally loosened, sometimes leaving a foul ulcer. This ulceration may extend and involve nearly the whole finger. It may occur in one or in several fingers. Lesions of this kind are regarded as local infections, occurring usually in vitiated constitutions. It is a common expression or complication of syphilis; when of such origin it yields readily to treatment; at other times it is often slow and tedious. Except in specific cases, where mercurials locally and internally will usually be sufficient, the treatment should be radical and should consist of thorough exposure of the ulcerating and fungous surfaces, thorough curetting, and the use of suitable caustics and antiseptic dressings.
=Onychia Maligna.=--Onychia maligna implies, according to some writers, a more distinctive type of phlegmonous lesion, while the term has also been applied to malignant ulcers, sometimes pigmented (see Melanoma above) and sometimes of more ordinary type. In either type of lesion granulation tissue may be exuberant and fungating, and it is possible that at times there will be doubt in diagnosis. The finger-tips, with their peculiar tactile sensibility, should never be sacrificed unnecessarily, yet any malignant lesion calls for amputation of the finger.
=Ingrowing Toenail.=--This is due almost invariably to ill-fitting footwear, the toes being crowded into too narrow shoes, with too high heels. The real lesion is not so much an excessive growth of the nail as overgrowth and overriding of the skin margin around the matrix. It is painful and annoying, sometimes even disabling. The maceration of a perspiring foot in a warm and tight shoe serves to aggravate the difficulty. Palliative treatment is afforded by chiropodists and quacks, who pack cotton beneath the edge of the nail and keep patients under treatment for indefinite periods, never remedying the footwear and never curing the case. In simple cases it is usually sufficient to excise a portion of reasonably healthy skin on either side of the terminal phalanx, in order that by cicatricial contraction the skin may be drawn away from the nail border. Serious and long-standing cases are best treated by avulsion of the nail, which may be usually performed under local anesthesia or by the aid of nitrous oxide gas. The blade of a knife or scissors is driven under the centre of the nail sufficiently to ensure its passing completely beneath the hidden matrix. The nail is then split in the middle, each half seized at its split border by strong forceps, and by a rapid movement torn loose from its bed. The border of the skin should be scraped, after which a simple dressing suffices, providing the operation has been performed with proper antiseptic precautions.
TATTOO MARKS.
Many an individual is tattooed in youth who would gladly be relieved of the discoloration later in life. Tattoo marks are difficult to erase. The following is a method attributed to Ohmann-Dumesnil: “Wash the skin with soap and water, then with eight or ten fine cambric needles, tied together and dipped in glycerole of papoid, tattoo the stained skin, driving the needles into the tissues so as to deposit the digestive in the corium, where the carbon is located. Repeat as necessary. The pigment is liberated by the digestant.”
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