Alexis Thomson and Alexander Miles - Manual of Surgery

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#Trigeminal Neuralgia.#--A severe form of epileptiform neuralgia occurs
in the branches of the fifth nerve, and is one of the most painful
affections to which human flesh is liable. So far as its pathology is
known, it is believed to be due to degenerative changes in the semilunar
(Gasserian) ganglion. It is met with in adults, is almost invariably
unilateral, and develops without apparent cause. The pain, which occurs
in paroxysms, is at first of moderate severity, but gradually becomes
agonising. In the early stages the paroxysms occur at wide intervals,
but later they recur with such frequency as to be almost continuous.
They are usually excited by some trivial cause, such as moving the jaws
in eating or speaking, touching the face as in washing, or exposure to a
draught of cold air. Between the paroxysms the patient is free from
pain, but is in constant terror of its return, and the face wears an
expression of extreme suffering and anxiety. When the paroxysm is
accompanied by twitching of the facial muscles, it is called _spasmodic
tic_.

The skin of the affected area may be glazed and red, or may be pale and
moist with inspissated sweat, the patient not daring to touch or wash
it.

There is excessive tenderness at the points of emergence of the
different branches on the face, and pressure over one or other of these
points may excite a paroxysm. In typical cases the patient is unable to
take any active part in life. The attempt to eat is attended with such
severe pain that he avoids taking food. In some cases the suffering is
so great that the patient only obtains sleep by the use of hypnotics,
and he is often on the verge of suicide.

_Diagnosis._--There is seldom any difficulty in recognising the disease.
It is important, however, to exclude the hysterical form of neuralgia,
which is characterised by its occurrence earlier in life, by the pain
varying in situation, being frequently bilateral, and being more often
constant than paroxysmal.

_Treatment._--Before having recourse to the measures described below, it
is advisable to give a thorough trial to the medical measures used in
the treatment of neuralgia.

_The Injection of Alcohol into the Nerve._--The alcohol acts by
destroying the nerve fibres, and must be brought into direct contact
with them; if the nerve has been properly struck the injection is
followed by complete anaesthesia in the distribution of the nerve. The
relief may last for from six months to three years; if the pain returns,
the injection may be repeated. The strength of the alcohol should be 85
per cent., and the amount injected about 2 c.c.; a general, or
preferably a local, anaesthetic (novocain) should be employed
(Schlosser); the needle is 8 cm. long, and 0.7 mm. in diameter. The
severe pain which the alcohol causes may be lessened, after the needle
has penetrated to the necessary depth, by passing a few cubic
centimetres of a 2 per cent. solution of _novocain-suprarenin_ through
it before the alcohol is injected. The treatment by injection of alcohol
is superior to the resection of branches of the nerve, for though
relapses occur after the treatment with alcohol, renewed freedom from
pain may be obtained by its repetition. The ophthalmic division should
not, however, be treated in this manner, for the alcohol may escape into
the orbit and endanger other nerves in this region. Harris recommends
the injection of alcohol into the semilunar ganglion.

_Operative Treatment._--This consists in the removal of the affected
nerve or nerves, either by resection--_neurectomy_; or by a combination
of resection with twisting or tearing of the nerve from its central
connections--_avulsion_. To prevent the regeneration of the nerve after
these operations, the canal of exit through the bone should be
obliterated; this is best accomplished by a silver screw-nail driven
home by an ordinary screw-driver (Charles H. Mayo).

When the neuralgia involves branches of two or of all three trunks, or
when it has recurred after temporary relief following resection of
individual branches, the _removal of the semilunar ganglion_, along with
the main trunks of the maxillary and mandibular divisions, should be
considered.

The operation is a difficult and serious one, but the results are
satisfactory so far as the cure of the neuralgia is concerned. There is
little or no disability from the unilateral paralysis of the muscles of
mastication; but on account of the insensitiveness of the cornea, the
eye must be protected from irritation, especially during the first month
or two after the operation; this may be done by fixing a large
watch-glass around the edge of the orbit with adhesive plaster.

If the ophthalmic branch is not involved, neither it nor the ganglion
should be interfered with; the maxillary and mandibular divisions should
be divided within the skull, and the foramen rotundum and foramen ovale
obliterated.

CHAPTER XVII

THE SKIN AND SUBCUTANEOUS TISSUE

Structure of skin--_Blisters_--_Callosities_--_Corns_--_Chilblains_
--_Boils_--_Carbuncle_--_Abscess_--_Veldt sores_--Tuberculosis of
skin: _Inoculation tubercle_--_Lupus_: _Varieties_--Sporotrichosis
--Elephantiasis--Sebaceous cysts or wens--Moles--Horns--New growths:
_Fibroma_; _Papilloma_; _Adenoma_; _Epithelioma_; _Rodent cancer_;
_Melanotic cancer_; _Sarcoma_--AFFECTIONS OF CICATRICES--_Varieties
of scars_--_Keloid_--_Tumours_--AFFECTIONS OF NAILS.

#Structure of Skin.#--The skin is composed of a superficial cellular
layer--the epidermis, and the corium or true skin. The _epidermis_ is
differentiated from without inwards into the stratum corneum, the
stratum lucidum, the stratum granulosum, and the rete Malpighii or
germinal layer, from which all the others are developed. The _corium_ or
_true skin_ consists of connective tissue, in which ramify the blood
vessels, lymphatics, and nerves. That part of the corium immediately
adjoining the epidermis is known as the papillary portion, and contains
the terminal loops of the cutaneous blood vessels and the terminations
of the cutaneous nerves. The deeper portion of the true skin is known as
the reticular portion, and is largely composed of adipose tissue.

#Blisters# result from the exudation of serous fluid beneath the horny
layer of the epidermis. The fluid may be clear, as in the blisters of a
recent burn, or blood-stained, as in the blisters commonly accompanying
fractures of the leg. It may become purulent as a result of infection,
and this may be the starting-point of lymphangitis or cellulitis.

The skin should be disinfected and the blisters punctured. When
infected, the separated horny layer must be cut away with scissors to
allow of the necessary purification.

#Callosities# are prominent, indurated masses of the horny layer of the
epidermis, where it has been exposed to prolonged friction and pressure.
They occur on the fingers and hand as a result of certain occupations
and sports, but are most common under the balls of the toes or heel. A
bursa may form beneath a callosity, and if it becomes inflamed may cause
considerable suffering; if suppuration ensues, a sinus may form,
resembling a perforating ulcer of the foot.

The _treatment_ of callosities on the foot consists in removing pressure
by wearing properly fitting boots, and in applying a ring pad around the
callosity; another method is to fit a sock of spongiopilene with a hole
cut out opposite the callosity. After soaking in hot water, the
overgrown horny layer is pared away, and the part painted daily with a
saturated solution of salicylic acid in flexile collodion.

[Illustration: FIG. 93.--Callosities and Corns on the Sole and Plantar
Aspect of the Toes in a woman who was also the subject of flat-foot.]

#Corns.#--A corn is a localised overgrowth of the horny layer of the
epidermis, which grows downwards, pressing upon and displacing the
sensitive papillae of the corium. Corns are due to the friction and
pressure of ill-fitting boots, and are met with chiefly on the toes and
sole of the foot. A corn is usually hard, dry, and white; but it may be
sodden from moisture, as in "soft corns" between the toes. A bursa may
form beneath a corn, and if inflamed constitutes one form of bunion.
When suppuration takes place in relation to a corn, there is great pain
and disability, and it may prove the starting-point of lymphangitis.

The _treatment_ consists in the wearing of properly fitting boots and
stockings, and, if the symptoms persist, the corn should be removed.
This is done after the manner of chiropodists by digging out the corn
with a suitably shaped knife. A more radical procedure is to excise,
under local anaesthesia, the portion of skin containing the corn and
the underlying bursa. The majority of so-called corn solvents consist of
a solution of salicylic acid in collodion; if this is painted on daily,
the epidermis dies and can then be pared away. The unskilful paring of
corns may determine the occurrence of senile gangrene in those who are
predisposed to it by disease of the arteries.

[Illustration: FIG. 94.--Ulcerated Chilblains on Fingers of a Child.]

#Chilblains.#--Chilblain or _erythema pernio_ is a vascular disturbance
resulting from the alternate action of cold and heat on the distal parts
of the body. Chilblains are met with chiefly on the fingers and toes in
children and anaemic girls. In the mild form there is a sensation of
burning and itching, the part becomes swollen, of a dusky red colour,
and the skin is tense and shiny. In more severe cases the burning and
itching are attended with pain, and the skin becomes of a violet or
wine-red colour. There is a third degree, closely approaching
frost-bite, in which the skin tends to blister and give way, leaving an
indolent raw surface popularly known as a "broken chilblain."

Those liable to chilblains should take open-air exercise, nourishing
food, cod-liver oil, and tonics. Woollen stockings and gloves should be
worn in cold weather, and sudden changes of temperature avoided. The
symptoms may be relieved by ichthyol ointment, glycerin and belladonna,
or a mixture of Venice turpentine, castor oil, and collodion applied on
lint which is wrapped round the toe. Another favourite application is
one of equal parts of tincture of capsicum and compound liniment of
camphor, painted over the area night and morning. Balsam of Peru or
resin ointment spread on gauze should be applied to broken chilblains.
The most effective treatment is Bier's bandage applied for about six
hours twice daily; it can be worn while the patient is following his
occupation; in chronic cases this may be supplemented with hot-air
baths.

#Boils and Carbuncles.#--These result from infection with the
staphylococcus aureus, which enters the orifices of the ducts of the
skin under the influence of friction and pressure, as was demonstrated
by the well-known experiment of Garre, who produced a crop of pustules
and boils on his own forearm by rubbing in a culture of the
staphylococcus aureus.

A #boil# results when the infection is located in a hair follicle or
sebaceous gland. A hard, painful, conical swelling develops, to which,
so long as the skin retains its normal appearance, the term "blind
boil" is applied. Usually, however, the skin becomes red, and after a
time breaks, giving exit to a drop or two of thick pus. After an
interval of from six to ten days a soft white slough is discharged; this
is known as the "core," and consists of the necrosed hair follicle or
sebaceous gland. After the separation of the core the boil heals
rapidly, leaving a small depressed scar.

Boils are most frequently met with on the back of the neck and the
buttocks, and on other parts where the skin is coarse and thick and is
exposed to friction and pressure. The occurrence of a number or a
succession of boils is due to spread of the infection, the cocci from
the original boil obtaining access to adjacent hair follicles. The
spread of boils may be unwittingly promoted by the use of a domestic
poultice or the wearing of infected underclothing.

While boils are frequently met with in debilitated persons, and
particularly in those suffering from diabetes or Bright's disease, they
also occur in those who enjoy vigorous health. They seldom prove
dangerous to life except in diabetic subjects, but when they occur on
the face there is a risk of lymphatic and of general pyogenic infection.
Boils may be differentiated from syphilitic lesions of the skin by
their acute onset and progress, and by the absence of other evidence of
syphilis; and from the malignant or anthrax pustule by the absence of
the central black eschar and of the circumstances which attend upon
anthrax infection.

_Treatment._--The skin of the affected area should be painted with
iodine, and a Klapp's suction bell applied thrice daily. If pus forms,
the skin is frozen with ethyl-chloride and a small incision made, after
which the application of the suction bell is persevered with. The
further treatment consists in the use of diluted boracic or resin
ointment. In multiple boils on the trunk and limbs, lysol or boracic
baths are of service; the underclothing should be frequently changed,
and that which is discarded must be disinfected. In patients with
recurrence of boils about the neck, re-infection frequently takes place
from the scalp, to which therefore treatment should be directed.

Any impaired condition of health should be corrected; when, there is
sugar or albumen in the urine the conditions on which these depend must
receive appropriate treatment. When there are successive crops of boils,
recourse should be had to vaccines. In refractory cases benefit has
followed the subcutaneous injection of lipoid solution containing tin.

#Carbuncle# may be looked upon as an aggregation of boils, and is
characterised by a densely hard base and a brownish-red discoloration of
the skin. It is usually about the size of a crown-piece, but it may
continue to enlarge until it attains the size of a dinner-plate. The
patient is ill and feverish, and the pain may be so severe as to prevent
sleep. As time goes on several points of suppuration appear, and when
these burst there are formed a number of openings in the skin, giving it
a cribriform appearance; these openings exude pus. The different
openings ultimately fuse and the large adherent greyish-white slough is
exposed. The separation of the slough is a tedious process, and the
patient may become exhausted by pain, discharge, and toxin absorption.
When the slough is finally thrown off, a deep gap is left, which takes a
long time to heal. A large carbuncle is a grave disease, especially in a
weakly person suffering from diabetes or chronic alcoholism; we have on
several occasions seen diabetic coma supervene and the patient die
without recovering consciousness. In the majority of cases the patient
is laid aside for several months. It is most common in male adults over
forty years of age, and is usually situated on the back between the
shoulders. When it occurs on the face or anterior part of the neck it is
especially dangerous, because of the greater risk of dissemination of
the infection.

A carbuncle is to be differentiated from an ulcerated gumma and from
anthrax pustule.

[Illustration: FIG. 95.--Carbuncle of seventeen days' duration in a
woman aet. 57.]

_Treatment._--Pain is relieved by full doses of opium or codein, and
these drugs are specially indicated when sugar is present in the urine.
Vaccines may be given a trial. The diet should be liberal and easily
digested, and strychnin and other stimulants may be of service. Locally
the treatment is carried out on the same lines as for boils.

In some cases it is advisable to excise the carbuncle or to make
incisions across it in different directions, so that the resulting wound
presents a stellate appearance.

#Acute Abscesses of the Skin and Subcutaneous Tissue in Young
Children.#--In young infants, abscesses are not infrequently met with
scattered over the trunk and limbs, and are probably the result of
infection of the sebaceous glands from dirty underclothing. The
abscesses should be opened, and the further spread of infection
prevented by cleansing of the skin and by the use of clean under-linen.
Similar abscesses are met with on the scalp in association with eczema,
impetigo, and pediculosis.

#Veldt Sore.#--This sore usually originates in an abrasion of the
epidermis, such as a sun blister, the bite of an insect, or a scratch. A
pustule forms and bursts, and a brownish-yellow scab forms over it. When
this is removed, an ulcer is left which has little tendency to heal.
These sores are most common about the hands, arms, neck, and feet, and
are most apt to occur in those who have had no opportunities of washing,
and who have lived for a long time on tinned foods.

#Tuberculosis of the Skin.#--Interest attaches chiefly to the primary
forms of tuberculosis of the skin in which the bacilli penetrate from
without--inoculation tubercle and lupus.

#Inoculation Tubercle.#--The appearances vary with the conditions under
which the inoculation takes place. As observed on the fingers of adults,
the affection takes the form of an indolent painless swelling, the
epidermis being red and glazed, or warty, and irregularly fissured.
Sometimes the epidermis gives way, forming an ulcer with flabby
granulations. The infection rarely spreads to the lymphatics, but we
have seen inoculation tubercle of the index-finger followed by a large
cold abscess on the median side of the upper arm and by a huge mass of
breaking down glands in the axilla.

In children who run about barefooted in towns, tubercle may be
inoculated into wounds in the sole or about the toes, and although the
local appearances may not be characteristic, the nature of the infection
is revealed by its tendency to spread up the limb along the lymph
vessels, giving rise to abscesses and fungating ulcers in relation to
the femoral glands.

#Tuberculous Lupus.#--This is an extremely chronic affection of the
skin. It rarely extends to the lymph glands, and of all tuberculous
lesions is the least dangerous to life. The commonest form of
lupus--_lupus vulgaris_--usually commences in childhood or youth, and is
most often met with on the nose or cheek. The early and typical
appearance is that of brownish-yellow or pink nodules in the skin, about
the size of hemp seed. Healing frequently occurs in the centre of the
affected area while the disease continues to extend at the margin.

When there is actual destruction of tissue and ulceration--the so-called
"_lupus excedens_" or "_ulcerans_"--healing is attended with
cicatricial contraction, which may cause unsightly deformity. When the
cheek is affected, the lower eyelid may be drawn down and everted; when
the lips are affected, the mouth may be distorted or seriously
diminished in size. When the nose is attacked, both the skin and mucous
surfaces are usually involved, and the nasal orifices may be narrowed or
even obliterated; sometimes the soft parts, including the cartilages,
are destroyed, leaving only the bones covered by tightly stretched scar
tissue.

The disease progresses slowly, healing in some places and spreading at
others. The patient complains of a burning sensation, but little of
pain, and is chiefly concerned about the disfigurement. Nothing is more
characteristic of lupus than the appearance of fresh nodules in parts
which have already healed. In the course of years large tracts of the
face and neck may become affected. From the lips it may spread to the
gum and palate, giving to the mucous membrane the appearance of a
raised, bright-red, papillary or villous surface. When the disease
affects the gums, the teeth may become loose and fall out.

[Illustration: FIG. 96.--Tuberculous Elephantiasis in a woman aet. 35.]

On parts of the body other than the face, the disease is even more
chronic, and is often attended with a considerable production of dense
fibrous tissue--the so-called _fibroid lupus_. Sometimes there is a
warty thickening of the epidermis--_lupus verrucosus_. In the fingers
and toes it may lead to a progressive destruction of tissue like that
observed in leprosy, and from the resulting loss of portions of the
digits it has been called _lupus mutilans_. In the lower extremity a
remarkable form of the disease is sometimes met with, to which the term
_lupus elephantiasis_ (Fig. 96) has been applied. It commences as an
ordinary lupus of the toes or dorsum of the foot, from which the
tuberculous infection spreads to the lymph vessels, and the limb as a
whole becomes enormously swollen and unshapely.

Finally, a long-standing lupus, especially on the cheek, may become the
seat of epithelioma--_lupus epithelioma_--usually of the exuberant or
cauliflower type, which, like other epitheliomas that originate in scar
tissue, presents little tendency to infect the lymphatics.

The _diagnosis_ of lupus is founded on the chronic progress and long
duration, and the central scarring with peripheral extension of the
disease. On the face it is most liable to be confused with syphilis and
with rodent cancer. The syphilitic lesion belongs to the tertiary
period, and although presenting a superficial resemblance to
tuberculosis, its progress is more rapid, so that within a few months it
may involve an area of skin as wide as would be affected by lupus in as
many years. Further, it readily yields to anti-syphilitic treatment. In
cases of tertiary syphilis in which the nose is destroyed, it will be
noticed that the bones have suffered most, while in lupus the
destruction of tissue involves chiefly the soft parts.

Rodent cancer is liable to be mistaken for lupus, because it affects the
same parts of the face; it is equally chronic, and may partly heal. It
begins later in life, however, the margin of the ulcer is more sharply
defined, and often presents a "rolled" appearance.

_Treatment._--When the disease is confined to a limited area, the most
rapid and certain cure is obtained by _excision_; larger areas are
scraped with the sharp spoon. The _ray treatment_ includes the use of
luminous, Rontgen, or radium rays, and possesses the advantage of being
comparatively painless and of being followed by the least amount of
scarring and deformity.

Encouraging results have also been obtained by the application of carbon
dioxide snow.

#Multiple subcutaneous tuberculous nodules# are met with chiefly in
children. They are indolent and painless, and rarely attract attention
until they break down and form abscesses, which are usually about the
size of a cherry, and when these burst sinuses or ulcers result. If the
overlying skin is still intact, the best treatment is excision. If the
abscess has already infected the skin, each focus should be scraped and
packed.

#Sporotrichosis# is a mycotic infection due to the sporothrix Shenkii.
It presents so many features resembling syphilis and tubercle that it is
frequently mistaken for one or other of these affections. It occurs
chiefly in males between fifteen and forty-five, who are farmers, fruit
and vegetable dealers, or florists. There is usually a history of trauma
of the nature of a scratch or a cut, and after a long incubation period
there develop a series of small, hard, round nodules in the skin and
subcutaneous tissue which, without pain or temperature, soften into
cold abscesses and leave indolent ulcers or sinuses. The infection is
of slow progress and follows the course of the lymphatics. From the
gelatinous pus the organism is cultivated without difficulty, and this
is the essential step in arriving at a diagnosis. The disease yields in
a few weeks to full doses of iodide of potassium.

#Elephantiasis.#--This term is applied to an excessive enlargement of a
part depending upon an overgrowth of the skin and subcutaneous cellular
tissue, and it may result from a number of causes, acting independently
or in combination. The condition is observed chiefly in the extremities
and in the external organs of generation.

_Elephantiasis from Lymphatic or Venous Obstruction._--Of this the
best-known example is _tropical elephantiasis_ (E. arabum), which is
endemic in Samoa, Barbadoes, and other places. It attacks the lower
extremity or the genitals in either sex (Figs. 97, 98). The disease is
usually ushered in with fever, and signs of lymphangitis in the part
affected. After a number of such attacks, the lymph vessels appear to
become obliterated, and the skin and subcutaneous cellular tissue, being
bathed in stagnant lymph--which possibly contains the products of
streptococci--take on an overgrowth, which continues until the part
assumes gigantic proportions. In certain cases the lymph trunks have
been found to be blocked with the parent worms of the filaria Bancrofti.
Cases of elephantiasis of the lower extremity are met with in this
country in which there are no filarial parasites in the lymph vessels,
and these present features closely resembling the tropical variety, and
usually follow upon repeated attacks of lymphangitis or erysipelas.