malignum_, a malignant growth of chorionic epithelium. Inasmuch as
this tumor also includes a syncytial layer it has been known as
_syncytioma_. Such tumors usually contain elements derived from both
layers of the chorion. They follow pregnancy, generally within a few
months, and are often preceded or accompanied by a _hydatidiform mole_.
This growth constitutes a malignant neoplasm. It pertains to ulcerating
uterine growths characterized by early extensive metastasis, which
prove fatal. It has been shown that similar growths occur not only in
the uterus but also in the testicle, and thus the scope of the term has
been much enlarged. In its biology it resembles the sarcoma; in its
histology, the carcinoma. It is more malignant than any other known
growth. (See Plate XXVIII.)
Occurring within the uterus its most important clinical feature is a
tendency to frequent and alarming hemorrhage. When occurring about the
testicle this trouble rapidly becomes fungoid, bleeding easily and
excessively, the lungs being among the first organs to show metastasis,
which takes place through the blood as well as the lymphatic vessels,
for the cells of these growths seem to penetrate the capillaries. By
the time a diagnosis is made a case is likely to be too far advanced
to admit of radical treatment. If scrapings could be examined early,
shreds of syncytioma would be found, and it might be possible that a
complete hysterectomy would be of use.
Metastatic nodules consist mostly of round, dark masses presenting a
more or less pronounced fibrous structure. These are generally found
in the lungs and cerebrum, where the vessels are large and the tissues
soft. There is usually a sharp contrast between such a tumor and the
surrounding tissues. The time which elapses between delivery and the
appearance of the growth is from three to ten weeks. The tumor rapidly
spreads to the upper portion of the vagina. The trouble probably begins
some time before delivery.
The latest tendency among pathologists is to refer a growth of this
kind to the teratomas. In women this tumor is particularly a teratoid
growth, some cells of the fecundated ovum giving rise to neoplasms,
while the ovum itself thus derived may misdevelop into a hydatidiform
mole. The tumor may be properly regarded as consisting in effect of
fetal cells; it is built up of these cells, without bloodvessels and
connective tissue, and so belongs to a class by itself. Occurring in
women it is almost always a consequence of pregnancy; occurring in
the testicle or in the ovary it should be regarded as proceeding from
ectodermal cells. For their treatment the earliest and most radical
measures only will suffice.
=Suprarenal Epithelioma; Hypernephroma.=--Grawitz has distinctly
established the right of these tumors to separate consideration, for he
first determined their origin and identity. Hypernephroma is a tumor,
found mainly in the kidney, composed of adrenal rests, or bits of
accessory suprarenal tissue imprisoned within the renal capsule. Their
minute structure is often that of the adrenals, with a tendency toward
the type of perithelioma. They have hitherto been considered examples
of sarcoma of the kidney, but are to be abruptly distinguished from it
in most instances. Tumors of this character have also been found within
the capsule of the liver and along the spermatic artery. In the kidney
the tumor portion is usually distinct from the renal tissue; it is
often enclosed within a sort of capsule, and rarely connects with the
pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely
escapes by the ureter. Hypernephroma is delicate in structure, and its
vessels give way readily. After this has happened a true hematoma may
result. (See Plate XXVIII.)
Similar neoplasms form in the adrenals themselves. These tumors vary in
degree of malignancy, some of them scarcely deserving the designation
malignant. They may be met at any age, but are more common in adult
life. Before removal they are not to be differentiated from other
tumors of the kidney. Their cells manifest this peculiarity in that
they contain a notable percentage of glycogen. It should also be added
that even in true sarcoma of the kidney proliferating adrenal elements
may be found.
[Illustration: PLATE XXVIII
FIG. 1
Hypernephroma Renalis. (Medium magnification.)
FIG. 2
Chorion Epithelioma.]
GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.
The following tables are here inserted, trusting that they may aid
the young practitioner in distinguishing in a general way between
benign and malignant tumors, and even in making a diagnosis between
sarcoma and carcinoma. I have also inserted a table differentiating
the clinical appearances of epithelioma and of lupus. In these tables
comprehensiveness has not been aimed at, rather simplicity, while
it is not denied that cases are met with in which diagnosis may be
exceedingly difficult, and in which the common signs herein mentioned
may be found either absent or misleading:
TABLE I.--DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT GROWTHS.
_Benign Growths._ _Malignant Growths._
Common at all ages. Rare in early life.
Usually slow in growth. Usually rapid in growth.
No evidences of infiltration or Infiltration in all cases,
dissemination. dissemination in many.
Are often encapsulated, nearly Never encapsulated, seldom
always circumscribed. circumscribed.
Rarely adherent unless inflamed. Always adherent.
Rarely ulcerate. Often ulcerate--nearly always when
surface is involved.
Overlying tissue not retracted. Overlying tissue nearly always
retracted.
No lymphatic involvement when not Lymphatic involvement an almost
inflamed. constant feature.
No leukocytosis. Leukocytosis often marked.
Elimination of urea unaffected. Deficient elimination of urea (?).
TABLE II.--DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA.
_Sarcoma._ _Carcinoma._
Occurs at any age. Rare before thirtieth year of
life.
Disseminates by the bloodvessels Disseminations by the lymphatics.
(veins).
Arises from mesoblastic Arises from glandular (epithelial)
structures. tissues.
Distant metastases are more Less so.
common.
Contains blood channels rather Contains vessels of normal type.
than complete bloodvessels.
Less prone to ulceration. More so.
Involvement of adjacent Almost invariably adjacent
lymphatics not common. lymphatics are involved.
Secondary changes and Degenerations not common; other
degenerations are more common. secondary changes rare.
(Sugar present in the blood?) (Peptone present in the blood?)
Differential diagnosis between epithelioma and ulcerating gumma will be
found in Chapter X.
TABLE III.--DIAGNOSIS BETWEEN EPITHELIOMA AND TUBERCULOSIS (LUPUS).
_Epithelioma._ _Tuberculosis (Lupus)._
Preceded usually by continued Irritation plays no figure. Preceded
irritation or warty growths. usually by nodules.
Diathesis plays no known part. Diathesis evident. Coincident
evidences of tuberculous disease
elsewhere.
Rarely multiple. Often multiple.
Area of thickening ahead of Extension of ulceration not preceded
ulceration. by thickening.
Ulceration advancing from a Various foci, which may coalesce.
central focus.
Border usually raised and Border abrupt, eaten, irregular,
everted, regular in outline. thickened, firm, often inverted,
irregular in outline.
Often assumes fungoid type. Never fungoid.
Base may be deeply excavated. Base nearly level with surface.
Usually painful. Seldom painful.
Bleeds easily. Seldom bleeds.
Never tends to cicatrize. As marginal ulceration proceeds
there is often cicatrization at
centre.
Most rare in the young. Common in the young.
Discharge is very offensive. Discharge rarely offensive.
Lymphatic involvement nearly Rarely.
always.
GENERAL CONSIDERATIONS CONCERNING CANCER.
Cancer is one of the most fatal of diseases, yet has no _symptomatology
of its own_. It produces no _symptoms_ which may not be produced by
other affections, and this lack of pathognomonic features constitutes
one of the great difficulties in diagnosis. It may disturb every
function of the part involved. Experimenters have sought in vain for
a distinctive feature by which the disease can be recognized; neither
in the blood nor in the various organic tissues have such changes been
found that can be explained only on the hypothesis of cancer. The
pain which it is supposed to cause is often lacking, and is extremely
variable and uncertain. The cachexia of its terminal stages is not
characteristic, no matter how pronounced, and may be explained by a
variety of conditions, all of which may accompany the disease. The
search for the suspected parasites cannot be made with such certainty
as to lead to any definite conclusions. It is known by a complex of
clinical conditions or by microscopic sections of tissues already
removed.
When the disease is superficial it is easily recognized, but when
deep-seated, recognition comes later.[15]
[15] Since the discovery of Spirochæta pallida in syphilis, Mulzer
and Loewenthal have found spiral organisms on the surface of
ulcerating tumors. Borrel also found spirochætæ in conjunction with
helminthia in two enclosed mouse tumors, and also in a large tumor
sent from Ehrlich’s laboratory. None of these authors attributed
any significance to the presence of these organisms, but recently,
through the publication of Gaylord, in the _Journal of Infectious
Diseases_, who has found a characteristic small spiral organism in
nine out of ten primary mouse tumors, and in all of the transplanted
mouse tumors of three distinct strains in the New York State Cancer
Laboratory, the subject has attracted new interest.
[Illustration: FIG. 95
Rat with primary cystosarcoma of thyroid; cage infection in
previously healthy animal kept in cage formerly occupied by rat with
same condition. (Gaylord and Clowes, Jour. Amer. Med. Assoc., January
5, 1907.)]
[Illustration: FIG. 96
Rat with tumor produced by transplantation from that represented in
Fig. 95. (Gaylord and Clowes, loc. cit.)]
Gaylord’s organism is best demonstrated by the Levaditi silver
method, but can be seen by experienced observers in the living
fresh state. It measures from 2.5 to 7.8 microns in length, and
the individuals have from four to thirteen closely packed abrupt
turns. The organism measures 0.6 micron in diameter. Thus far it has
been impossible to stain it with any of the aniline stains, which
characteristic appears to distinguish it from the organism described
by Borrel and Loewenthal. Calkins has also found this organism in a
spontaneous mouse tumor in New York. The distribution of the organism
in the growing periphery of the tumors, when considered in the light
of Fischer’s work with Scarlet-R, would make it appear not impossible
that the organism bears an etiological relation to the tumors in
which it occurs.
In the light of the well-authenticated cases of cage infection and
the evidence of immunity now definitely determined, the way should be
prepared for the discovery of the organism or organisms of cancer. At
present this organism would appear strongly in evidence as its cause.
The microscopic picture may explain considerable in regard to the
future as well as the past. For instance, in a case of sarcoma the
presence of small, round cells, and especially of pigment, bespeaks a
degree of malignancy which probably nothing yet known can baffle. A
chemical examination of the tumor after removal may make the surgeon
alert regarding the future of the case, according to the amount of
glycogen contained within the mass, since the glycogen content is in
direct proportion to its malignancy. For a while some reliance was
placed upon the percentage of urea elimination, but this is influenced
by so many factors as to have proved unreliable.
The _relations which cancer bears to other diseases_ are of
considerable interest. Those between cancer and trauma have been
discussed; tuberculosis perhaps is the condition which, next to pure
local irritation, predisposes to cancerous invasion. The transformation
of tuberculous into cancerous lesions can be best appreciated where it
can be most readily inspected, _i. e._, on the skin, and it is well
known that lupus lesions frequently undergo this change. This is also
true of large ulcers, which may undergo a direct transformation into
epithelioma, or pass through the intermediate stage of tuberculous
infection. Cancer in tuberculous lymph nodes is also a matter of
interest. Again, cancers and tuberculous lesions may exist side by side
in the same organ, as in the lung or the brain. Distinct sarcomatous
nodules have been found in infiltrated lungs and alongside of
tuberculous cavities, while cancer of the face will not infrequently be
found associated with tuberculosis of the cervical lymphatics. Lubarsch
has claimed that 4 to 5 per cent. of tuberculous patients suffer also
from cancer, and that about 20 per cent. of cancer patients suffer from
tuberculosis.
The _method of death_ in cancerous patients is as free from distinctive
characteristics as the course of the disease. It is usually associated
with two prominent features, malnutrition and some terminal infection.
At the last there is usually some toxemia, which renders the closing
hours free from actual pain, while if the toxemia be profound patients
may linger unconscious for several days.
GENERAL REMARKS ON THE TREATMENT OF CANCER.
Accepting the views expressed when discussing the nature of the
cancerous process, the following may be assumed to be true: _Cancer
begins as a local disease._ There is therefore a period in its
history when _if_ it be recognized in time, _if_ it be or can be made
accessible, and _if_ it be thoroughly removed, it can be frequently
cured. The “ifs” in the foregoing statement afford such insuperable
obstacles in so many cases that the difficulties in the way of
treatment are very great. It has been said that, “The resources of
surgery are rarely successful when practised upon the dying.” It
happens too often that these cases are not submitted to the surgeon
until long after the favorable period above indicated is past. This is
explained by the difficulties of diagnosis, by the inaccessibility of
many primary cancers, and by the unwillingness of patients to submit
to the knife. Nevertheless the best time to treat a cancer is when its
existence is first suspected, and the best way is the most radical, _i.
e._, by thorough extirpation.
While such extirpation should include a wide area of apparently
healthy tissue and of the entire organ which seems to be involved,
for instance, in the case of the liver, this last may be impossible;
and yet by removal of a considerable area of healthy liver around a
cancerous gall-bladder the writer has seen complete and apparent final
recovery follow. The principal direction is to be thorough.
That cancer so often returns after operative attack is largely due to
the fact that the general practitioner, under whose observation most of
these cases first come, is slow to recognize the malady, and timid to
advise radical methods.
It has been recognized that in cancer the internal administration
of arsenic has been beneficial. In order to obtain the best results
from its use, it must be pushed to the physiological limit and in
preparations of the most active and reliable kind.[16]
[16] The preparations of arsenic which have proved most satisfactory
are the imported cacodylate of sodium, which comes in capsules ready
sterilized for use, and the following solution, which is original and
needs to be made up in accordance with the formula herewith furnished:
(1) Dissolve 7 grains mercuric biniodide with 10 grains potassium
iodide in a little water. (2) Dissolve 48 grains arsenic bromide in a
little water with the aid of gentle heat. (3) Dissolve 24 grains gold
chloride in a small amount of water. (4) Mix the mercuric and the
arsenic solutions and then add the gold solution, which will cause
a whitish precipitate, becoming brownish in color. (5) Heat this
mixture and decant the clear portions, setting it aside. (6) Add 2
drachms nitromuriatic acid to the above precipitate and heat gently
until a clear red solution results. (7) Add to this the decanted
portion of 5, which will cause a reddish precipitate. Heat the whole
mixture up to the boiling point and until all residue is dissolved.
(8) Add sufficient distilled water to make 15 fluidounces. The
product should be bright, clear, and wine colored.
Of this solution 10 drops are supposed to represent ¹⁄₁₀₀ grain
mercuric chloride, ¹⁄₃₀ grain gold chloride, ¹⁄₁₅ grain arsenic
bromide. The commencing dose is 10 minims, which may be increased to
25 or more, taken in abundance of water.
=Treatment by Toxins of Erysipelas.=--A number of years ago Fehleisen,
calling attention to the fact that cancers had seemed to improve or
possibly even disappear after an attack of erysipelas, suggested
deliberate infection of the surface of such a growth from a case of
erysipelas. In this procedure he met with some success, but there were
numerous objections to it, one being the impossibility of controlling
the spread of the infection thus produced. Coley, of New York, then
undertook a much more systematic study of the relation between the two
diseases, and devised a method of injecting the toxins produced by the
streptococci of erysipelas and of reinforcing them, if necessary, by
those of the bacillus prodigiosus. The intent of this treatment is to
produce reasonable reaction in the hope of mitigating the rapidity of
the growth, checking its progress, or even causing its disappearance.
It has been on trial now for several years, and while in a few cases of
sarcoma, especially in the hands of its originator, the treatment has
apparently been of service, it has proved disappointing in the majority
of instances.
=Liquid Air.=--The application of liquid air to superficial malignant
growths has proved successful in a number of instances, but inasmuch
as this is practicable in only one or two of the largest cities of the
country, it is not a measure which need be discussed here at length.
The liquid seems to act as an almost painless escharotic, and its use
produces sloughing, or a drying up under a scab, which after a day or
two will loosen and be easily detached.
=Radium.=--This remarkable element has aroused within the past few
years an amount of scientific interest and experimentation with which
there is little else to compare. The enormous expense of a preparation
of any great activity, and the rather bewildering contradictory
statements which have been made by those who use the weaker
preparations, have caused it to occupy a doubtful position in any
list of reliable therapeutic agencies. It is undeniable that certain
rodent ulcers, tuberculous lesions of the skin, and a few carcinomatous
lesions have been much improved or apparently cured by its use. It
is ordinarily used in glass or aluminum tubes or capsules, which are
applied upon the surface of the growth to be treated. It has also been
used sprinkled upon a plaster whose surface has been prepared with
Canada balsam, and thus directly applied. Again, it has been enclosed
in a capsule to which a strong silk thread has been fastened so that
the former may be swallowed, retained in the stomach for a few hours,
and then withdrawn. These last means of using it are of questionable
value. Of still less value are the suggestions to dissolve it in water
or to administer water in which a receptacle containing radium has been
allowed to stand. There is much of interest and perhaps something of
value in _radiotherapy_, but nothing as yet of positive value in the
hands of the profession generally.
=Ultraviolet Light=, or, as it is often named after its promoter,
Finsen light, has proved of value in many cases of lupus, and in some
cases of superficial epithelioma. Its effects, however, can scarcely
be made to penetrate into the deeper tissues, and in its use it is
even necessary to make pressure upon the part treated with quartz
compressors, because ordinary glass shuts out a great proportion of
these rays from whatever source may produce them, and because it is
necessary to create a temporary anemia of the lesions, as the fluids
of the body have the same effect as does glass. For these reasons the
method, which is of but limited value, can be made serviceable in but a
small proportion of cases.
=X-ray Therapy.=--The Röntgen or cathode rays have played a large
part during the last few years in the therapy of cancer. Such varying
statements have been made concerning their value as to keep them
still on trial and nothing very positive can be said regarding their
efficacy. It may be said, however, that the nearer the malignant growth
is to the surface of the body the more promptly can their effects be
produced. The superficial growths, especially of the epitheliomatous
variety, often yield readily to their use; the deeper the lesion the
more vague the effect, both in character and permanence. It has been
the writer’s experience that they furnish the best method of relieving
pain, in a large number of these growths, short of the anodyne
effects produced by powerful drugs, which are in every other respect
undesirable. He holds that no one can predicate with certainty what may
be their effect in any given instance, but that they are worthy a trial
in every inoperable, painful, or otherwise hopeless case. Occasionally
improvement follows their use, while in the next, apparently a similar
case, one may be doomed to great disappointment. There are as yet no
indications by which the cases which are most amenable can be easily
recognized. Even in cases of extensive and disseminated abdominal
cancer marvellous improvement may follow, but never a cure. It is
indeed questionable whether deep cancer can ever be really cured by
these means. As against their undoubted and unchallenged value in some
instances, certain disadvantages are met in the difficulty of selecting
a proper vacuum tube, the frequency and duration of exposure, the
distance, etc. _Dermatitis_, sometimes mild, sometimes severe, has too
often followed the injudicious use especially of a “high” tube, and
more painful, irritable, or intractable ulcers are seldom seen than
some following so-called “_x_-ray burns” of the skin. Moreover this is
not the worst of these cases, for efforts intended for the best have
been in repeated instances turned into a travesty by the development
on surfaces thus burned of epithelioma, necessitating later mutilating
operation. A well-known American surgeon suffered amputation of one
hand and nearly all of the other as a penalty for inattention to the
destructive effects of too prolonged exposure of his hands. It has,
therefore, impressed itself upon the writer that the x-rays should not
be indiscriminately employed. Nevertheless in skilled hands and used
with great discretion they can be made a powerful instrument for good
in many cases, especially for the relief of pain. They should never be
regarded as a substitute for operation if operation be feasible, but
they may often be employed to advantage after operating, in serious
cases, where there is reason to fear recurrence.
The efficiency of the _x_-rays is apparently enhanced by the
_simultaneous administration of thyroid extract_; although the
explanation for this improvement is not known, it is, however, of
enough importance to be borne in mind. The extract should be given in
5-grain doses three or four times a day. All the remarks above made
may pertain as well to the employment of cathode rays in non-malignant
affections, _i. e._, tuberculous lesions, neuralgia, etc.
=Miscellaneous Measures.=--A large number of suggestions concerning
the treatment of cancer have emanated from various sources and from
men of widely different views. Beaston, of Glasgow, being impressed
by the physiological relationships and sympathies between the ovaries
and the mammary glands, has suggested the benefit of the _removal of
the ovaries in hopeless cases of mammary cancer_, holding that the
nutrition of the mamma being thus influenced there would be more or
less subsidence of pathological activity. He has reported instances in
which, apparently, this measure had the desired effect; nevertheless it
has not found general favor.
Based upon views concerning the hyperacidity of the blood and tissues
in the cancerous condition, it is believed that there is a pronounced
indication for the internal use of alkalies; and the hypodermic
injection of 5 minims of a 1 per cent. solution of a chemically pure
soap has been recommended by Webb, on the theory that it promotes the
separation of cholesterin from the living cell. He would increase the
dose until 60 minims are given at one time, every other day. A 20 per
cent. solution of Chian turpentine, dissolved in sterile oil, has
also been recommended to be used in the same way. These are recent
suggestions of unknown value.
In the general management of cancer patients, two things should be
kept in mind: (1) That they are entitled to _relief from suffering_
in the least harmful way in which it may be offered, and (2) there
comes a time in the history of many of these cases when all other
considerations may be set aside in favor of comfort and tranquillity.
Opium and other “drugs that enslave” have their disadvantages, but
these cannot outweigh the benefit which they may confer in the last
stages of cancer. _The terminal pains of malignant disease should he
assuaged at any necessary cost of other considerations._
But while all this is going on elimination must not be neglected.
Opiates are peculiarly liable to diminish secretions and peristaltic
activity. The skin, the kidneys, and the bowels should be kept active
by measures which serve this purpose, and if it be desirable to prolong
life, nutrition should be regulated and frequently administered, but it
is absolutely _necessary to maintain elimination_.
The latest suggestion, viz., to treat cancer by injections of
pancreatic ferments (trypsin and amylopsin), seems to the writer to be
based upon erroneous notions concerning the nature and causation of the
disease, and to hold out only specious hope of self-justification.
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.”
CHAPTER XXVIII.
SURGICAL DISEASES OF THE FASCIÆ; APONEUROSES; TENDONS AND TENDON
SHEATHS; MUSCLES AND BURSÆ.
Fasciæ and aponeuroses are such non-vascular and indifferent tissues
that they have practically no primary diseases, except such fibrous
and malignant tumors as have their origin in them; nevertheless they
suffer in a variety of morbid processes. They lose vitality and break
down under the influence of both acute and chronic septic infections.
By virtue of their resistant structure, when they slough they break
down slowly and the process ends usually with the help of scissors and
forceps. Many an old suppurating lesion, especially of the hand and
foot, is kept active by the fact that dense, fibrous tissue remains
concealed, which ought to have separated. Under these circumstances
free incisions should be made and all necrotic tissue trimmed away.
Pus which has formed beneath these fibrous investments will give
pain largely in proportion to the intensity of the process and the
unyielding character of the fasciæ; hence the urgency of early incision
in case of deep phlegmon. Moreover, the direction of least resistance
may cause pus when confined to travel where its presence is most
undesirable, as from the neck beneath the deeper muscle planes down
into the thorax. When pus escapes from beneath firm tissue it is
usually by a small opening, after which it may spread out again beneath
the skin before finally escaping. This condition has been called
“_collar-button abscess_.” Care should be exercised in opening the
superficial collection not to miss the small opening. The fascia must
be split sufficiently to permit of thorough cleaning out of whatever
collection there may be beneath it.
In the presence of cicatricial contraction of the skin, in
shortening of muscles by chronic spasm, as in wryneck, or in certain
deformities--for instance of the foot--numerous signs of a shortening
or contraction of fasciæ and aponeuroses are seen. In many instances of
club-foot it thus becomes necessary not merely to divide tendons but to
make extensive incisions through the plantar aponeurosis or elsewhere,
in order to release sufficiently the parts whose extension is desired.
Underneath the joint contractures which have been produced by burns and
their resulting scars similar conditions will be found, which in old
and extensive cases constitute bridles of dense tissue that make it
almost impossible to release the parts.
DUPUYTREN’S CONTRACTION.
Dupuytren’s contraction presents the most serious and insidious
appearance of slow but almost irresistible contraction of fibrous
elements which the human body presents. It is produced by contraction
of the palmar fascia, with its numerous minute prolongations, rather
than by flexor tendons. It is seen in the hands of men who from the
nature of their occupations are subject to much irritation of the
palmar surface. It begins nearly always in the fourth or fifth fingers,
but may spread to and involve all the digits and even the thumb.
The view held by Adams and others that it is a chronic hyperplastic
inflammation, with scar-tissue contraction of the palmar fascia and
of the adjoining connective and fatty tissue, which does not involve
them evenly, but only at certain points, is correct, at least when
small nodules may be felt in the palm which are the precursors of the
disease. Either hand may be affected, but generally both are involved.
It is found in from 1 to 2 per cent. of those who depend upon their
hands for their support. Deformity may proceed to pressure dislocation
and finally to ankylosis. Its causation then is very obscure; it is
rarely the result of definite injury, but follows continued irritation
of the surface. It seems to have a local origin, and yet it is
frequently associated with the gouty diathesis to such an extent that
the prolonged use of alkalies will relieve some cases. The first
significant sign of the condition is the formation of small nodules in
the palm of the hand, as stated, and this usually precedes the finger
contraction by a year or two.
[Illustration: FIG. 110
Dupuytren’s contraction. (Adams.)]
[Illustration: FIG. 111
Dupuytren’s contraction of palmar fascia, showing contracted fingers.
(Burrell.)]
=Treatment.=--There is considerable difficulty in treating these cases
satisfactorily. Cooper advised subcutaneous division of the tense bands
and forcible stretching of the fingers; this rarely proves sufficient.
Adams advocated multiple sections made with a small tenotome, which
is more effective. The best method is that of Kocher, which consists
in excision of the fascial bands by longitudinal incisions along the
cords, and the dissection of the skin from the underlying fascia. The
cord is carefully dissected, with its prolongations and then completely
removed, while the margins of the skin wounds are closed with sutures.
The more thoroughly the dissection is performed the more satisfactory
the result. The fingers should be straightened and kept from
contraction by the use of a mechanical device. In desperate cases the
entire skin of the palm has been removed, with the diseased fascia, and
a plastic operation made with skin taken from the thigh or the chest,
the flap being sutured in place but not detached completely for ten to
twelve days.
Two somewhat allied conditions involving the hand and the foot are the
so-called _lock_ or _trigger-finger_ and _hammer-toe_.
LOCK OR TRIGGER-FINGER.
Lock or trigger-finger implies a peculiar obstruction to free movement
of the finger, which requires extra effort and then is overcome
quickly, as if a knot had been slipped through a small opening. It is
supposed to be due to a thickening of the tendon at some point, as by a
small fibroma, which becomes entangled along the course of the sheath,
through which it is moved with difficulty. It is probably due to a
local irritation, as in the case of Dupuytren’s contraction. Injury to
the tendon sheath may also produce a similar condition.
=Treatment.=--Should it fail to respond to rest and massage the sheath
should be opened and the cause of the difficulty sought out and
removed.
HAMMER-TOE.
Hammer-toe produces deformity with more or less ankylosis. An angle
is formed between the first and second phalanges, and the tip of the
toe is made to bear more than its proportion of weight. This deformity
is in large degree due to the use of shoes which are too short. In
consequence there will develop over the protruding joint a corn or
bunion.
=Treatment.=--Should the trouble come on in childhood the toes should
be fastened to a straight splint and shoes for a time abandoned,
while later they should be properly adapted to the needs of the case.
In troublesome cases complete excision of the involved joint gives
satisfactory results.
SURGICAL DISEASES OF THE TENDONS AND TENDON SHEATHS.
TENDOSYNOVITIS.
Acute inflammation of a tendon sheath is known as _tendovaginitis_ or
_tendosynovitis_. It always implies an infection, and occurs about the
hands and feet. It is a frequent complication of felons. Many felons
begin in such a manner that it is difficult to decide which part of
the fibrous structures of the finger is first involved. Infection
having once occurred within a tendon sheath will travel rapidly until
it meets with a natural barrier. The frequency of these lesions makes
it important to recall here the anatomy of the tendon sheaths of the
hand. There is a common palmar tendon cavity, which connects with the
thumb and little finger and the space above the annular ligament, but
communication with the first, second, and third fingers is ordinarily
destroyed. This accounts for the apparent vagaries of cases where
infection beginning in the thumb spreads to the little finger before
the others are involved. It will also show the location where incisions
should be made.
[Illustration: FIG. 112
Cicatricial contraction and deformity resulting from consequences of
neglected phlegmon and osteomyelitis of hand. (Lexer.)]
=Suppurative Tendosynovitis.=--Suppurative tendosynovitis needs prompt
intervention, as adhesions may result from retention of exudate, or
lest necrosis of tendon occur from perversion of its nutritive supply.
Ordinarily it is the result of a local infection, perhaps through a
small, trifling surface irritation, but it results occasionally as a
metastatic expression of gonorrhea, or distinct septic infection. A
gonorrheal tendosynovitis is, however, less likely to suppurate, but
more likely to assume the plastic form and interfere with function by
producing adhesions between a tendon and its sheath. The combination
of virulent bacteria and susceptible tissues will produce local
destruction in almost as short a time as in the appendix. The pain is
intense, because of the inelasticity of the structures.
[Illustration: FIG. 113
Suppurative tendosynovitis (felon), with sloughing tendons and necrotic
bone. Unfortunately poulticed for two weeks. (Lexer.)]
=Treatment.=--Every appearance of this kind calls for early incision,
by which not only the skin but the tendon sheath as well should be
freely incised. An incision at either end of the involved sheath,
with flushing and drainage, may save a tendon and preserve function.
Incision should not be delayed, as destruction may have occurred and
deformity be the result. When the common palmar sheath is involved a
long incision from the base of the index finger, around the base of
the thumb and up the wrist to a point considerably above the annular
ligament, will afford considerable relief. It will, moreover, shorten
the time of ultimate restoration of function.
=Chronic Tendosynovitis.=--Chronic tendosynovitis may be the result of
rheumatism, in which case it assumes the plastic form, or of gonorrhea;
the same being true of a tuberculous invasion, which may vary much
in intensity. In the subacute forms the deposition of tubercles may
lead to a plastic outpour which, being detached by constant motion of
the parts, is broken into masses whose minute portions become rounded
off by friction and condensed by time, and appear as the so-called
“_melon-seed_ or _rice-grain_ bodies.” Some of the same material may
be found adherent to the walls of such a cavity. In slower forms there
is less tendency to plastic outpour, but much more to the formation
of granulation tissue, such as is seen in tuberculous lesions in all
parts of the body. When, therefore, a case of this general character
presents we have the signs of local tuberculosis, or of dropsy of the
tendon sheaths, with the fluctuation somewhat modified by the presence
in the fluid of rice-grain or melon-seed bodies. Should, in such a
case, an acute infection be added we will have the chronic symptoms
merged suddenly into acute. A tendovaginitis of this type appears as a
ridge or swelling along the course of one or more tendons. It will be
elastic and fluctuate in proportion to the distention of the sheath.
When the palmar bursa is involved there is usually, in the palm of the
hand, a bag of fluid which may be forced above the wrist by pressure,
while frequently the little bodies above described are recognizable by
the sensations (crepitus) which they produce. The plastic type rarely
proceeds to suppuration or ulceration unless secondarily infected. The
granulation type proceeds to ulceration and destruction.
=Treatment.=--Treatment of the rheumatic and gonorrheal forms is at
first rest, with later passive and forced motion, in order to break up
adhesions and prevent their re-formation. If one wait too long he meets
with great difficulty in these efforts and the cases become exceedingly
tedious. Forcible motion should be practised under nitrous oxide
anesthesia and should be repeated every two or three days. Meanwhile
massage should be employed. If pain or reaction be extreme ice-cold
applications should be applied. Extreme swelling may be combated by the
use of a rubber glove. If this be worn, ichthyol-mercurial ointment
should be used beneath it, in order to promote absorption.
Treatment of the tuberculous cases is often disappointing.
Non-operative measures afford but temporary benefit, while operation to
be effective should be thorough. It should consist of free incision,
with exposure in whole or in part of the affected channel or cavity,
thorough cleaning out of its contents, removal of all edematous or
tuberculous tissue or granulations, and the use of an antiseptic as
strong as it can be employed.
The new _opsonic_ serum treatment, now being placed on trial as this
work goes to press, promises much in the treatment of all these septic
affections, though detailed statements would be premature.
TENDOPLASTY.
It was a step in advance in surgical technique when Stromeyer and
Dieffenbach, in 1842, introduced the method of subcutaneous division of
tendons and aponeuroses, and showed how easily contracted tendons could
be lengthened by tenotomy. From their time until somewhat recently
tenotomy has held its place in the treatment of various deformities,
and until Anger, Gluck, Hoffa, and others have taught the surgical
profession what can be done by various plastic and suture methods
in overcoming defects and atoning for loss of function in paralyzed
muscles. To the surgery of tendons and muscle terminations have been
added the further resources of tendon suture, _i. e._, _tenorrhaphy_,
and _tendoplasty_, by which latter something more than the mere suture
is meant, _i. e._, the plastic rearrangement and grafting of tendons
one upon another.[20]
[20] The method of transplanting one tendon upon another is to be
credited to Nicoladoni, who perfected it in 1882. Later it fell into
disuse, but was revived in this country, especially by Goldthwait, of
Boston, in 1896.
[Illustration: FIG. 114
FIG. 115
FIG. 116
FIG. 117
FIG. 118
FIG. 119
FIG. 120
FIG. 121
Illustrating various methods of dealing with tendons in tendoplasty.
(After Vulpius.)]
_Tendon suture_ is practised as an emergency measure when one or more
tendons has been accidentally divided, this being considered now
as much a part of the surgeon’s duty as to close any other part of
the wound. No additional resource or expedient is needed, it being
necessary only to observe the principles of asepsis, which should be
maintained in every case. A tendon raggedly divided should be cleanly
cut and its edges brought together with formalin-gut or freshly boiled
silk. A series of divided tendons should be treated after the same
fashion, matching the ends as closely and completely as possible. After
uniting the tendon ends, if the case be clean, the tendon sheath should
be closed and the parts put at rest, in such a position that no tension
is made upon the injured sinew until it is seen to have united.
[Illustration: FIG. 122
FIG. 123
Shortening a tendon.]
It was a great service, in which perhaps Gluck figured most
conspicuously, to show that when tendon ends could not be neatly
coapted an animal material could be interposed in such a way as to
serve as a trellis along which cells could group, or around which
they might organize, and thus gradually and finally become a part of
the complete tendinous cord. Silk and catgut have best served this
purpose, and new tendons have gradually formed around these artificial
substitutes, to the length of 10 Cm. In every fresh case where there
has been such loss of original structure as to justify a measure of
this kind, or in certain old cases where tendons have long since
sloughed away, it may be possible to resort to these expedients.
It has been possible to _transplant fresh tendons_ from the smaller
animals and to see them serve the same purpose in a satisfactory manner.
Among these methods of tendoplasty is _tendon grafting_, by which a
part or all of the tendon of an active muscle is inserted into the
terminal portion of a paralyzed muscle and thus made to assume to a
greater or less extent the purpose and function of the latter; in other
words it assists in ingeniously diverting the activity and direction
of a given muscle to a purpose different from its original intent. By
this diversion a more equal or equable distribution of muscle force is
afforded the parts into which the affected muscles are inserted. For
its successful performance only those muscles which are still active
can be utilized. Among the simplest of cases where this expedient can
be used are those produced by traumatic and peripheral paralyses, or
traumatic loss of a given tendon or a set of tendons. It is rarely to
be practised as an emergency measure, but as an expedient to be availed
of later. It finds its greatest usefulness in cases of long standing.
It is equally applicable where muscles and tendons have been divided by
injury, or paralyzed by injury to their nerve supply, as well as where
deformities are produced by chronic neurotic disturbance, by scars, by
excessive callus, etc. It proves equally serviceable in paralyses of
spinal origin, particularly those due to anterior poliomyelitis.
Tendon grafting will serve both as a substitute in cases of lost
function and as a provision against future deformity. In cases of the
ordinary paralyses of children, tendoplasty should be deferred for
several months after the occurrence of the paralysis. In the case
of growing children it is desirable not to wait too long, as other
objectionable features may present themselves. In the congenital
and hereditary paralyses and in conditions like athetosis or the
dystrophies of syringomyelia, meningocele, etc., also in such
conditions as habitual dislocations of the patella, much can be
accomplished by a carefully planned tendoplasty. It will be easily seen
then how wide a field of usefulness lies before one who familiarizes
himself with the recent technique of tendon surgery.
[Illustration: FIG. 124
FIG. 125
Two methods of tendon implantation and fixation. (After Vulpius.)]
[Illustration: FIG. 126