Manual of Surgery Volume I Part 42

(Mr. Annandale's case.)]

Belonging to this group also is a form of _congenital elephantiasis_ resulting from the circular constriction of a limb _in utero_ by amniotic bands.

_Elephantiasis occurring apart from lymphatic or venous obstruction_ is ill.u.s.trated by _elephantiasis nervorum_, in which there is an overgrowth of the skin and cellular tissue of an extremity in a.s.sociation with neuro-fibromatosis of the cutaneous nerves (Fig. 89); and by _elephantiasis Graecorum_--a form of leprosy in which the skin of the face becomes the seat of tumour-like ma.s.ses consisting of leprous nodules. It is also ill.u.s.trated by _elephantiasis involving the s.c.r.o.t.u.m_ as a result of prolonged irritation by the urine in cases in which the p.e.n.i.s has been amputated and the urine has infiltrated the scrotal tissues over a period of years.

#Sebaceous Cysts.#--Atheromatous cysts or wens are formed in relation to the sebaceous glands and hair follicles. They are commonly met with in adults, on the scalp (Fig. 99), face, neck, back, and external genitals.

Sometimes they are multiple, and they may be met with in several members of the same family. They are smooth, rounded, or discoid cysts, varying in size from a split-pea to a Tangerine orange. In consistence they are firm and elastic, or fluctuating, and are incorporated with the overlying skin, but movable on the deeper structures. The orifice of the partly blocked sebaceous follicle is sometimes visible, and the contents of the cyst can be squeezed through the opening. The wall of the cyst is composed of a connective-tissue capsule lined by stratified squamous epithelium. The contents consist of acc.u.mulated epithelial cells, and are at first dry and pearly white in appearance, but as a result of fatty degeneration they break down into a greyish-yellow pultaceous and semi-fluid material having a peculiar stale odour. It is probable that the decomposition of the contents is the result of the presence of bacteria, and that from the surgical point of view they should be regarded as infective. A sebaceous cyst may remain indefinitely without change, or may slowly increase in size, the skin over it becoming stretched and closely adherent to the cyst wall as a result of friction and pressure. The contents may ooze from the orifice of the duct and dry on the skin surface, leading to the formation of a sebaceous horn (Fig. 100). As a result of injury the cyst may undergo sudden enlargement from haemorrhage into its interior.

Recurrent attacks of inflammation frequently occur, especially in wens of the face and scalp. Suppuration may ensue and be followed by cure of the cyst, or an offensive fungating ulcer forms which may be mistaken for epithelioma. True cancerous transformation is rare.

Wens are to be _diagnosed_ from dermoids, from fatty tumours, and from cold abscesses. Dermoids usually appear before adult life, and as they nearly always lie beneath the fascia, the skin is movable over them. A fatty tumour is movable, and is often lobulated. The confusion with a cold abscess is most likely to occur in wens of the neck or back, and it may be impossible without the use of an exploring needle to differentiate between them.

[Ill.u.s.tration: FIG. 99.--Multiple Sebaceous Cysts or Wens; the larger ones are of many years' duration.]

_Treatment._--The removal of wens is to be recommended while they are small and freely movable, as they are then easily sh.e.l.led out after incising the overlying skin; sometimes splitting the cyst makes its removal easier. Local anaesthesia is to be preferred. It is important that none of the cyst wall be left behind. In large and adherent wens an ellipse of skin is removed along with the cyst. When inflamed, it may be impossible to dissect out the cyst, and the wall should be destroyed with carbolic acid, the resulting wound being treated by the open method.

#Moles.#--The term mole is applied to a pigmented, and usually hairy, patch of skin, present at or appearing shortly after birth. The colour varies from brown to black, according to the amount of melanin pigment present. The lesion consists in an overgrowth of epidermis which often presents an alveolar arrangement. Moles vary greatly in size: some are mere dots, others are as large as the palm of the hand, and occasionally a mole covers half the face. In addition to being unsightly, they bleed freely when abraded, are liable to ulcerate from friction and pressure, and occasionally become the starting-point of melanotic cancer. Rodent cancer sometimes originates in the slightly pigmented moles met with on the face. Overgrowths in relation to the cutaneous nerves, especially the plexiform neuroma, occasionally originate in pigmented moles. Soldau believes that the pigmentation and overgrowth of the epidermis in moles are a.s.sociated with, and probably result from, a fibromatosis of the cutaneous nerves.

_Treatment._--The quickest way to get rid of a mole is to excise it; if the edges of the gap cannot be brought together with sutures, recourse should be had to grafting. In large hairy moles of the face whose size forbids excision, radium or the X-rays should be employed. Excellent results have been obtained by refrigeration with solid carbon dioxide.

In children and women with delicate skin, applications of from ten to thirty seconds suffice. In persons with coa.r.s.e skin an application of one minute may be necessary, and it may have to be repeated.

#Horns.#--The _sebaceous_ horn results from the acc.u.mulation of the dried contents of a wen on the surface of the skin: the sebaceous material after drying up becomes cornified, and as fresh material is added to the base the horn increases in length (Fig. 100). The _wart_ horn grows from a warty papilloma of the skin. _Cicatrix_ horns are formed by the heaping up of epidermis in the scars that result from burns. _Nail_ horns are overgrown nails (keratomata of the nail bed), and are met with chiefly in the great toe of elderly bedridden patients.

If an ulcer forms at the base of a horn, it may prove the starting-point of epithelioma, and for this reason, as well as for others, horns should be removed.

[Ill.u.s.tration: FIG. 100.--Sebaceous Horn growing from Auricle.

(Dr. Kenneth Maclachan's case.)]

#New Growths in the Skin and Subcutaneous Tissue.#--The _Angioma_ has been described with diseases of blood vessels. _Fibroma._--Various types of fibroma occur in the skin. A soft pedunculated fibroma, about the size of a pea, is commonly met with, especially on the neck and trunk; it is usually solitary, and is easily removed with scissors. The multiple, soft fibroma known as _mollusc.u.m fibrosum_, which depends upon a neuro-fibromatosis of the cutaneous nerves, is described with the tumours of nerves. Hard fibromas occurring singly or in groups may be met with, especially in the skin of the b.u.t.tock, and may present a local malignancy, recurring after removal like the "recurrent fibroid" of Paget. The "painful subcutaneous nodule" is a solitary fibroma related to one of the cutaneous nerves. The hard fibroma known as _keloid_ is described with the affections of scars.

#Papilloma.#--The _common wart_ or verruca is an outgrowth of the surface epidermis. It may be sessile or pedunculated hard or soft. The surface may be smooth, or fissured and foliated like a cauliflower, or it may be divided up into a number of spines. Warts are met with chiefly on the hands, and are often multiple, occurring in cl.u.s.ters or in successive crops. Multiple warts appear to result from some contagion, the nature of which is unknown; they sometimes occur in an epidemic form among school-children, and show a remarkable tendency to disappear spontaneously. The solitary flat-topped wart which occurs on the face of old people may, if irritated, become the seat of epithelioma. A warty growth of the epidermis is a frequent accompaniment of moles and of that variety of lupus known as _lupus verrucosus_.

_Treatment._--In the multiple warts of children the health should be braced up by a change to the seaside. A dusting-powder, consisting of boracic acid with 5 per cent. salicylic acid, may be rubbed into the hands after was.h.i.+ng and drying. The persistent warts of young adults should be excised after freezing with chloride of ethyl. When cutting is objected to, they may be painted night and morning with salicylic collodion, the epidermis being dehydrated with alcohol before each application.

_Venereal warts_ occur on the genitals of either s.e.x, and may form large cauliflower-like ma.s.ses on the inner surface of the prepuce or of the l.a.b.i.a majora. Although frequently co-existing with gonorrha or syphilis, they occur independently of these diseases, being probably acquired by contact with another individual suffering from warts (C. W. Cathcart). They give rise to considerable irritation and suffering, and when cleanliness is neglected there may be an offensive discharge.

In the female, the cauliflower-like ma.s.ses are dissected from the l.a.b.i.a; in the male, the prepuce is removed and the warts on the glans are snipped off with scissors. In milder cases, the warts usually disappear if the parts are kept absolutely dry and clean. A useful dusting-powder is one consisting of calamine and 5 per cent. salicylic acid; the exsiccated sulphate of iron, in the form of a powder, may be employed in cases which resist this treatment.

#Adenoma.#--This is a comparatively rare tumour growing from the glands of the skin. One variety, known as the "tomato tumour," which apparently originates from _the sweat glands_, is met with on the scalp and face in women past middle life. These growths are often multiple; the individual tumours vary in size, and the skin, which is almost devoid of hairs, is glistening and tightly stretched over them. A similar tumour may occur on the nose. The _sebaceous adenoma_, which originates from the sebaceous glands, forms a projecting tumour on the face or scalp, and when the skin is irritated it may ulcerate and fungate. The treatment consists in the removal of the tumour along with the overlying skin.

The exuberant ma.s.ses on the nose known as "rhinophyma," "lipoma nasi,"

or "potato nose" are of the nature of sebaceous adenoma, and are removed by shaving them off with a knife until the normal shape of the nose is restored Healing takes place with remarkable rapidity.

#Cancer.#--There are several types of primary cancer of the skin, the most important being squamous epithelioma, rodent cancer, and melanotic cancer.

[Ill.u.s.tration: FIG. 101.--Paraffin Epithelioma.]

#Epithelioma# occurs in a variety of forms. When originating in a small ulcer or wart-for example on the face in old people--it presents the features of a chronic indurated ulcer. A more exuberant and rapidly growing form of epithelial cancer, described by Hutchinson as the _crateriform ulcer_, commences on the face as a small red pimple which rapidly develops into an elevated ma.s.s shaped like a bee-hive, and breaks down in the centre. Epithelioma may develop anywhere on the body in relation to long-standing ulcers, especially that resulting from a burn or from lupus; this form usually presents an exuberant outgrowth of epidermis not unlike a cauliflower. An interesting example of epithelioma has been described by Neve of Kashmir. The natives in that province are in the habit of carrying a fire-basket suspended from the waist, which often burns the skin and causes a chronic ulcer, and many of these ulcers become the seat of epithelioma, due, in Neve's opinion, to the actual contact of the sooty pan with the skin.

The term _trade epithelioma_ has been applied to that form met with in those who follow certain occupations, such as paraffin workers and chimney-sweeps. The most recent member of this group is the _X-ray carcinoma_, which is met with in those who are constantly exposed to the irritation of the X-rays; there is first a chronic dermat.i.tis with warty overgrowth of the surface epithelium, pigmentation, and the formation of fissures and warts. The trade epithelioma varies a good deal in malignancy, but it tends to cause death in the same manner as other epitheliomas.

Epithelial cancer has also been observed in those who have taken a.r.s.enic over long periods for medicinal purposes.

[Ill.u.s.tration: FIG. 102.--Rodent Cancer of Inner Canthus.]

#Rodent Cancer# (Rodent Ulcer).--This is a cancer originating in the sweat glands or sebaceous follicles, or in the ftal residues of cutaneous glands. The cells are small and closely packed together in alveoli or in reticulated columns; cell nests are rare. It is remarkably constant in its seat of origin, being nearly always located on the lateral aspect of the nose or in the vicinity of the lower eyelid (Fig. 102). It is rare on the trunk or limbs. It commences as a small flattened nodule in the skin, the epidermis over it being stretched and s.h.i.+ning. The centre becomes depressed, while the margins extend in the form of an elevated ridge. Sooner or later the epidermis gives way in the centre, exposing a smooth raw surface devoid of granulations.

[Ill.u.s.tration: FIG. 103.--Rodent Cancer of fifteen years' duration, which has destroyed the contents of the Orbit.

(Sir Montagu Cotterill's case)]

The margin, while in parts irregular, is typically represented by a well-defined "rolled" border which consists of the peripheral portion of the cancer that has not broken down. The central ulcer may temporarily heal. There is itching but little pain, and the condition progresses extremely slowly; rodent cancers which have existed for many years are frequently met with. The disease attacks and destroys every structure with which it comes in contact, such as the eyelids, the walls of the nasal cavities, and the bones of the face; hence it may produce the most hideous deformities (Fig. 103). The patient may succ.u.mb to haemorrhage or to infective complications such as erysipelas or meningitis.

Secondary growths in the lymph glands, while not unknown, are extremely rare. We have only seen them once--in a case of rodent cancer in the groin.

_Diagnosis._--Lupus is the disease most often mistaken for rodent cancer. Lupus usually begins earlier in life, it presents apple-jelly nodules, and lacks the rounded, elevated border. Syphilitic lesions progress more rapidly, and also lack the characteristic margin. The differentiation from squamous epithelioma is of considerable importance, as the latter affection spreads more rapidly, involves the lymph glands early, and is much more dangerous to life.

_Treatment._--In rodent cancers of limited size--say less than one inch in diameter--free excision is the most rapid and certain method of treatment. The alternative is the application of radium or of the Rontgen rays, which, although requiring many exposures, results in cure with the minimum of disfigurement. If the cancer already covers an extensive area, or has invaded the cavity of the orbit or nose, radium or X-rays yield the best results. The effect is soon shown by the ingrowth of healthy epithelium from the surrounding skin, and at the same time the discharge is lessened. Good results are also reported from the application of carbon dioxide snow, especially when this follows upon a course of X-ray treatment.

#Paget's disease# of the nipple is an epithelioma occurring in women over forty years of age: a similar form of epithelioma is sometimes met with at the umbilicus or on the genitals.

#Melanotic Cancer.#--Under this head are included all new growths which contain an excess of melanin pigment. Many of these were formerly described as melanotic sarcoma. They nearly always originate in a pigmented mole which has been subjected to irritation. The primary growth may remain so small that its presence is not even suspected, or it may increase in size, ulcerate, and fungate. The amount of pigment varies: when small in amount the growth is brown, when abundant it is a deep black. The most remarkable feature is the rapidity with which the disease becomes disseminated along the lymphatics, the first evidence of which is an enlargement of the lymph glands. As the primary growth is often situated on the sole of the foot or in the matrix of the nail of the great toe, the femoral and inguinal glands become enlarged in succession, forming tumours much larger than the primary growth.

Sometimes the dissemination involves the lymph vessels of the limb, forming a series of indurated pigmented cords and nodules (Fig. 104).

Lastly, the dissemination may be universal throughout the body, and this usually occurs at a comparatively early stage. The secondary growths are deeply pigmented, being usually of a coal-black colour, and melanin pigment may be present in the urine. When recurrence takes place in or near the scar left by the operation, the cancer nodules are not necessarily pigmented.

[Ill.u.s.tration: FIG. 104.--Diffuse Melanotic Cancer of Lymphatics of Skin secondary to a Growth in the Sole of the Foot.]

To extirpate the disease it is necessary to excise the tumour, with a zone of healthy skin around it and a somewhat large zone of the underlying subcutaneous tissue and deep fascia. Hogarth Pringle recommends that a broad strip of subcutaneous fascia up to and including the nearest anatomical group of glands should be removed with the tumour in one continuous piece.

#Secondary Cancer of the Skin.#--Cancer may spread to the skin from a subjacent growth by direct continuity or by way of the lymphatics. Both of these processes are so well ill.u.s.trated in cases of mammary cancer that they will be described in relation to that disease.

#Sarcoma# of various types is met with in the skin. The fibroma, after excision, may recur as a fibro-sarcoma. The alveolar sarcoma commences as a hard lump and increases in size until the epidermis gives way and an ulcer is formed.

[Ill.u.s.tration: FIG. 105.--Melanotic Cancer of Forehead with Metastases in Lymph Vessels and Glands.

(Mr. D. P. D. Wilkie's case.)]

A number of fresh tumours may spring up around the original growth.

Sometimes the primary growth appears in the form of multiple nodules which tend to become confluent. Excision, unless performed early, is of little avail, and in any case should be followed up by exposure to radium.

AFFECTIONS OF CICATRICES

A cicatrix or scar consists of closely packed bundles of white fibres covered by epidermis; the skin glands and hair follicles are usually absent. The size, shape, and level of the cicatrix depend upon the conditions which preceded healing.

A healthy scar, when recently formed, has a smooth, glossy surface of a pinkish colour, which tends to become whiter as a result of obliteration of the blood vessels concerned in its formation.

_Weak Scars._--A scar is said to be weak when it readily breaks down as a result of irritation or pressure. The scars resulting from severe burns and those over amputation stumps are especially liable to break down from trivial causes. The treatment is to excise the weak portion of the scar and bring the edges of the gap together.