Manual of Surgery - Alexis Thomson (read me a book txt) 📗
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Recurrent attacks of inflammation frequently occur, especially in wens of the face and scalp. Suppuration may ensue and be followed by cure of the cyst, or an offensive fungating ulcer forms which may be mistaken for epithelioma. True cancerous transformation is rare.
Wens are to be diagnosed from dermoids, from fatty tumours, and from cold abscesses. Dermoids usually appear before adult life, and as they nearly always lie beneath the fascia, the skin is movable over them. A fatty tumour is movable, and is often lobulated. The confusion with a cold abscess is most likely to occur in wens of the neck or back, and it may be impossible without the use of an exploring needle to differentiate between them.
Fig. 99.—Multiple Sebaceous Cysts or Wens; the larger ones are of many years' duration.
Treatment.—The removal of wens is to be recommended while they are small and freely movable, as they are then easily shelled out after incising the overlying skin; sometimes splitting the cyst makes its removal easier. Local anæsthesia is to be preferred. It is important that none of the cyst wall be left behind. In large and adherent wens an ellipse of skin is removed along with the cyst. When inflamed, it may be impossible to dissect out the cyst, and the wall should be destroyed with carbolic acid, the resulting wound being treated by the open method.
Moles.—The term mole is applied to a pigmented, and usually hairy, patch of skin, present at or appearing shortly after birth. The colour varies from brown to black, according to the amount of melanin pigment present. The lesion consists in an overgrowth of epidermis which often presents an alveolar arrangement. Moles vary greatly in size: some are mere dots, others are as large as the palm of the hand, and occasionally a mole covers half the face. In addition to being unsightly, they bleed freely when abraded, are liable to ulcerate from friction and pressure, and occasionally become the starting-point of melanotic cancer. Rodent cancer sometimes originates in the slightly pigmented moles met with on the face. Overgrowths in relation to the cutaneous nerves, especially the plexiform neuroma, occasionally originate in pigmented moles. Soldau believes that the pigmentation and overgrowth of the epidermis in moles are associated with, and probably result from, a fibromatosis of the cutaneous nerves.
Treatment.—The quickest way to get rid of a mole is to excise it; if the edges of the gap cannot be brought together with sutures, recourse should be had to grafting. In large hairy moles of the face whose size forbids excision, radium or the X-rays should be employed. Excellent results have been obtained by refrigeration with solid carbon dioxide. In children and women with delicate skin, applications of from ten to thirty seconds suffice. In persons with coarse skin an application of one minute may be necessary, and it may have to be repeated.
Horns.—The sebaceous horn results from the accumulation of the dried contents of a wen on the surface of the skin: the sebaceous material after drying up becomes cornified, and as fresh material is added to the base the horn increases in length (Fig. 100). The wart horn grows from a warty papilloma of the skin. Cicatrix horns are formed by the heaping up of epidermis in the scars that result from burns. Nail horns are overgrown nails (keratomata of the nail bed), and are met with chiefly in the great toe of elderly bedridden patients. If an ulcer forms at the base of a horn, it may prove the starting-point of epithelioma, and for this reason, as well as for others, horns should be removed.
Fig. 100.—Sebaceous Horn growing from Auricle.
(Dr. Kenneth Maclachan's case.)
New Growths in the Skin and Subcutaneous Tissue.—The Angioma has been described with diseases of blood vessels. Fibroma.—Various types of fibroma occur in the skin. A soft pedunculated fibroma, about the size of a pea, is commonly met with, especially on the neck and trunk; it is usually solitary, and is easily removed with scissors. The multiple, soft fibroma known as molluscum fibrosum, which depends upon a neuro-fibromatosis of the cutaneous nerves, is described with the tumours of nerves. Hard fibromas occurring singly or in groups may be met with, especially in the skin of the buttock, and may present a local malignancy, recurring after removal like the “recurrent fibroid” of Paget. The “painful subcutaneous nodule” is a solitary fibroma related to one of the cutaneous nerves. The hard fibroma known as keloid is described with the affections of scars.
Papilloma.—The common wart or verruca is an outgrowth of the surface epidermis. It may be sessile or pedunculated hard or soft. The surface may be smooth, or fissured and foliated like a cauliflower, or it may be divided up into a number of spines. Warts are met with chiefly on the hands, and are often multiple, occurring in clusters or in successive crops. Multiple warts appear to result from some contagion, the nature of which is unknown; they sometimes occur in an epidemic form among school-children, and show a remarkable tendency to disappear spontaneously. The solitary flat-topped wart which occurs on the face of old people may, if irritated, become the seat of epithelioma. A warty growth of the epidermis is a frequent accompaniment of moles and of that variety of lupus known as lupus verrucosus.
Treatment.—In the multiple warts of children the health should be braced up by a change to the seaside. A dusting-powder, consisting of boracic acid with 5 per cent. salicylic acid, may be rubbed into the hands after washing and drying. The persistent warts of young adults should be excised after freezing with chloride of ethyl. When cutting is objected to, they may be painted night and morning with salicylic collodion, the epidermis being dehydrated with alcohol before each application.
Venereal warts occur on the genitals of either sex, and may form large cauliflower-like masses on the inner surface of the prepuce or of the labia majora. Although frequently co-existing with gonorrhœa or syphilis, they occur independently of these diseases, being probably acquired by contact with another individual suffering from warts (C. W. Cathcart). They give rise to considerable irritation and suffering, and when cleanliness is neglected there may be an offensive discharge.
In the female, the cauliflower-like masses are dissected from the labia; in the male, the prepuce is removed and the warts on the glans are snipped off with scissors. In milder cases, the warts usually disappear if the parts are kept absolutely dry and clean. A useful dusting-powder is one consisting of calamine and 5 per cent. salicylic acid; the exsiccated sulphate of iron, in the form of a powder, may be employed in cases which resist this treatment.
Adenoma.—This is a comparatively rare tumour growing from the glands of the skin. One variety, known as the “tomato tumour,” which apparently originates from the sweat glands, is met with on the scalp and face in women past middle life. These growths are often multiple; the individual tumours vary in size, and the skin, which is almost devoid of hairs, is glistening and tightly stretched over them. A similar tumour may occur on the nose. The sebaceous adenoma, which originates from the sebaceous glands, forms a projecting tumour on the face or scalp, and when the skin is irritated it may ulcerate and fungate. The treatment consists in the removal of the tumour along with the overlying skin.
The exuberant masses on the nose known as “rhinophyma,” “lipoma nasi,” or “potato nose” are of the nature of sebaceous adenoma, and are removed by shaving them off with a knife until the normal shape of the nose is restored Healing takes place with remarkable rapidity.
Cancer.—There are several types of primary cancer of the skin, the most important being squamous epithelioma, rodent cancer, and melanotic cancer.
Fig. 101.—Paraffin Epithelioma.
Epithelioma occurs in a variety of forms. When originating in a small ulcer or wart-for example on the face in old people—it presents the features of a chronic indurated ulcer. A more exuberant and rapidly growing form of epithelial cancer, described by Hutchinson as the crateriform ulcer, commences on the face as a small red pimple which rapidly develops into an elevated mass shaped like a bee-hive, and breaks down in the centre. Epithelioma may develop anywhere on the body in relation to long-standing ulcers, especially that resulting from a burn or from lupus; this form usually presents an exuberant outgrowth of epidermis not unlike a cauliflower. An interesting example of epithelioma has been described by Neve of Kashmir. The natives in that province are in the habit of carrying a fire-basket suspended from the waist, which often burns the skin and causes a chronic ulcer, and many of these ulcers become the seat of epithelioma, due, in Neve's opinion, to the actual contact of the sooty pan with the skin.
The term trade epithelioma has been applied to that form met with in those who follow certain occupations, such as paraffin workers and chimney-sweeps. The most recent member of this group is the X-ray carcinoma, which is met with in those who are constantly exposed to the irritation of the X-rays; there is first a chronic dermatitis with warty overgrowth of the surface epithelium, pigmentation, and the formation of fissures and warts. The trade epithelioma varies a good deal in malignancy, but it tends to cause death in the same manner as other epitheliomas.
Epithelial cancer has also been observed in those who have taken arsenic over long periods for medicinal purposes.
Fig. 102.—Rodent Cancer of Inner Canthus.
Rodent Cancer (Rodent Ulcer).—This is a cancer originating in the sweat glands or sebaceous follicles, or in the fœtal residues of cutaneous glands. The cells are small and closely packed together in alveoli or in reticulated columns; cell nests are rare. It is remarkably constant in its seat of origin, being nearly always located on the lateral aspect of the nose or in the vicinity of the lower eyelid (Fig. 102). It is rare on the trunk or limbs. It commences as a small flattened nodule in the skin, the epidermis over it being stretched and shining. The centre becomes depressed, while the margins extend in the form of an elevated ridge. Sooner or later the epidermis gives way in the centre, exposing a smooth raw surface devoid of granulations.
Fig. 103.—Rodent Cancer of fifteen years' duration, which has destroyed the contents of the Orbit.
(Sir Montagu Cotterill's case)
The margin, while in parts irregular, is typically represented by a well-defined “rolled” border which consists of the peripheral portion of the cancer that has not broken down. The central ulcer may temporarily heal. There is itching but little pain, and the condition progresses extremely slowly; rodent cancers which have existed for many years are frequently met with. The disease attacks and destroys every structure with which it comes in contact, such as the
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