Alexis Thomson and Alexander Miles - Manual of Surgery

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The part affected is enormously increased in size, and causes
inconvenience from its bulk and weight. In contrast to ordinary dropsy,
there is no pitting on pressure, and the swelling does not disappear on
elevation of the limb. The skin becomes rough and warty, and may hang
down in pendulous folds. Blisters form on the surface and yield an
abundant exudate of clear lymph. From neglect of cleanliness, the skin
becomes the seat of eczema or even of ulceration attended with foul
discharge.

Samson Handley has sought to replace the blocked lymph vessels by
burying in the subcutaneous tissue of the swollen part a number of stout
silk threads--_lymphangioplasty_. By their capillary action they drain
the lymph to a healthy region above, and thus enable it to enter the
circulation. It has been more successful in the face and upper limb than
in the lower extremity. If the tissues are infected with pus organisms,
a course of vaccines should precede the operation.

[Illustration: FIG. 97.--Elephantiasis in a woman aet. 45.]

A similar type of elephantiasis may occur after extirpation of the lymph
glands in the axilla or groin; in the leg in long-standing standing
varix and phlebitis with chronic ulcer; in the arm as a result of
extensive cancerous disease of the lymphatics in the axilla secondarily
to cancer of the breast; and in extensive tuberculous disease of the
lymphatics. The last-named is chiefly observed in the lower limb in
young adult women, and from its following upon lupus of the toes or foot
it has been called _lupus elephantiasis_. The tuberculous infection
spreads slowly up the limb by way of the lymph vessels, and as these are
obliterated the skin and cellular tissues become hypertrophied, and the
surface is studded over with fungating tuberculous masses of a livid
blue colour. As the more severe forms of the disease may prove dangerous
to life by pyogenic complications inducing gangrene of the limb, the
question of amputation may have to be considered.

[Illustration: FIG. 98.--Elephantiasis of Penis and Scrotum in native of
Demerara.

(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
illustrated by _elephantiasis nervorum_, in which there is an overgrowth
of the skin and cellular tissue of an extremity in association 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 masses consisting of leprous
nodules. It is also illustrated by _elephantiasis involving the scrotum_
as a result of prolonged irritation by the urine in cases in which the
penis 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 accumulated 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.

[Illustration: 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 shelled 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 associated 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 coarse skin an application of
one minute may be necessary, and it may have to be repeated.

#Horns.#--The _sebaceous_ horn results from the accumulation 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.

[Illustration: 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 _molluscum 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 buttock, 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 clusters 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 washing 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 sex, and may form large
cauliflower-like masses on the inner surface of the prepuce or of the
labia majora. Although frequently co-existing with gonorrhoea 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 masses are dissected from the labia;
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 masses 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.

[Illustration: 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 mass 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 dermatitis 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 arsenic
over long periods for medicinal purposes.

[Illustration: 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 foetal 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
shining. 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.

[Illustration: 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 succumb 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.

[Illustration: 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 illustrated 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.

[Illustration: 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.

_Contracted scars_ frequently cause deformity either by displacing
parts, such as the eyelid or lip, or by fixing parts and preventing the
normal movements--for example, a scar on the flexor aspect of a joint
may prevent extension of the forearm (Fig. 63). These are treated by
dividing the scar, correcting the deformity, and filling up the gap with
epithelial grafts, or with a flap of the whole thickness of the skin.
When deformity results from _depression of a scar_, as is not uncommon
after the healing of a sinus, the treatment is to excise the scar.
Depressed scars may be raised by the injection of paraffin into the
subcutaneous tissue.

_Painful Scars._--Pain in relation to a scar is usually due to nerve
fibres being compressed or stretched in the cicatricial tissue; and in
some cases to ascending neuritis. The treatment consists in excising the
scar or in stretching or excising a portion of the nerve affected.

_Pigmented or Discoloured Scars._--The best-known examples are the blue
coloration which results from coal-dust or gunpowder, the brown scars
resulting from chronic ulcer with venous congestion of the leg, and the
variously coloured scars caused by tattooing. The only satisfactory
method of getting rid of the coloration is to excise the scar; the edges
are brought together by sutures, or the raw surface is covered with
skin-grafts according to the size of the gap.

_Hypertrophied Scars._--Scars occasionally broaden out and become
prominent, and on exposed parts this may prove a source of
disappointment after operations such as those for goitre or tuberculous
glands in the neck. There is sometimes considerable improvement from
exposure to the X-rays.

_Keloid._--This term is applied to an overgrowth of scar tissue which
extends beyond the area of the original wound, and the name is derived
from the fact that this extension occurs in the form of radiating
processes, suggesting the claws of a crab. It is essentially a fibroma
or new growth of fibrous tissue, which commences in relation to the
walls of the smaller blood vessels; the bundles of fibrous tissue are
for the most part parallel with the surface, and the epidermis is
tightly stretched over them. It is more frequent in the negro and in
those who are, or have been, the subjects of tuberculous disease.

[Illustration: FIG. 106.--Recurrent Keloid in scar left by operation for
tuberculous glands in a girl aet. 7.]

Keloid may attack scars of any kind, such as those resulting from
leech-bites, acne pustules, boils or blisters; those resulting from
operation or accidental wounds; and the scars resulting from burns,
especially when situated over the sternum, appear to be specially
liable. The scar becomes more and more conspicuous, is elevated above
the surface, of a pinkish or brownish-pink pink colour, and sends out
irregular prolongations around its margins. The patient may complain of
itching and burning, and of great sensitiveness of the scar, even to
contact with the clothing.

There is a natural hesitation to excise keloid because of the fear of
its returning in the new scar. The application of radium is, so far as
we know, the only means of preventing such return. The irritation
associated with keloid may be relieved by the application of salicylic
collodion or of salicylic and creosote plaster.

_Epithelioma_ is liable to attack scars in old people, especially those
which result from burns sustained early in childhood and have never
really healed. From the absence of lymphatics in scar tissue, the
disease does not spread to the glands until it has invaded the tissues
outside the scar; the prognosis is therefore better than in epithelioma
in general. It should be excised widely; in the lower extremity when
there is also extensive destruction of tissue from an antecedent chronic
ulcer or osteomyelitis, it may be better to amputate the limb.