Manual of Surgery Volume I Part 41

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

#Callosities# are prominent, indurated ma.s.ses of the h.o.r.n.y layer of the epidermis, where it has been exposed to prolonged friction and pressure.

They occur on the fingers and hand as a result of certain occupations and sports, but are most common under the b.a.l.l.s of the toes or heel. A bursa may form beneath a callosity, and if it becomes inflamed may cause considerable suffering; if suppuration ensues, a sinus may form, resembling a perforating ulcer of the foot.

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

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

#Corns.#--A corn is a localised overgrowth of the h.o.r.n.y layer of the epidermis, which grows downwards, pressing upon and displacing the sensitive papillae of the corium. Corns are due to the friction and pressure of ill-fitting boots, and are met with chiefly on the toes and sole of the foot. A corn is usually hard, dry, and white; but it may be sodden from moisture, as in "soft corns" between the toes. A bursa may form beneath a corn, and if inflamed const.i.tutes one form of bunion.

When suppuration takes place in relation to a corn, there is great pain and disability, and it may prove the starting-point of lymphangitis.

The _treatment_ consists in the wearing of properly fitting boots and stockings, and, if the symptoms persist, the corn should be removed.

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

[Ill.u.s.tration: FIG. 94.--Ulcerated Chilblains on Fingers of a Child.]

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

Those liable to chilblains should take open-air exercise, nourishing food, cod-liver oil, and tonics. Woollen stockings and gloves should be worn in cold weather, and sudden changes of temperature avoided. The symptoms may be relieved by ichthyol ointment, glycerin and belladonna, or a mixture of Venice turpentine, castor oil, and collodion applied on lint which is wrapped round the toe. Another favourite application is one of equal parts of tincture of capsic.u.m and compound liniment of camphor, painted over the area night and morning. Balsam of Peru or resin ointment spread on gauze should be applied to broken chilblains.

The most effective treatment is Bier's bandage applied for about six hours twice daily; it can be worn while the patient is following his occupation; in chronic cases this may be supplemented with hot-air baths.

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

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

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

While boils are frequently met with in debilitated persons, and particularly in those suffering from diabetes or Bright's disease, they also occur in those who enjoy vigorous health. They seldom prove dangerous to life except in diabetic subjects, but when they occur on the face there is a risk of lymphatic and of general pyogenic infection.

Boils may be differentiated from syphilitic lesions of the skin by their acute onset and progress, and by the absence of other evidence of syphilis; and from the malignant or anthrax pustule by the absence of the central black eschar and of the circ.u.mstances which attend upon anthrax infection.

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

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

#Carbuncle# may be looked upon as an aggregation of boils, and is characterised by a densely hard base and a brownish-red discoloration of the skin. It is usually about the size of a crown-piece, but it may continue to enlarge until it attains the size of a dinner-plate. The patient is ill and feverish, and the pain may be so severe as to prevent sleep. As time goes on several points of suppuration appear, and when these burst there are formed a number of openings in the skin, giving it a cribriform appearance; these openings exude pus. The different openings ultimately fuse and the large adherent greyish-white slough is exposed. The separation of the slough is a tedious process, and the patient may become exhausted by pain, discharge, and toxin absorption.

When the slough is finally thrown off, a deep gap is left, which takes a long time to heal. A large carbuncle is a grave disease, especially in a weakly person suffering from diabetes or chronic alcoholism; we have on several occasions seen diabetic coma supervene and the patient die without recovering consciousness. In the majority of cases the patient is laid aside for several months. It is most common in male adults over forty years of age, and is usually situated on the back between the shoulders. When it occurs on the face or anterior part of the neck it is especially dangerous, because of the greater risk of dissemination of the infection.

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

[Ill.u.s.tration: FIG. 95.--Carbuncle of seventeen days' duration in a woman aet. 57.]

_Treatment._--Pain is relieved by full doses of opium or codein, and these drugs are specially indicated when sugar is present in the urine.

Vaccines may be given a trial. The diet should be liberal and easily digested, and strychnin and other stimulants may be of service. Locally the treatment is carried out on the same lines as for boils.

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

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

Similar abscesses are met with on the scalp in a.s.sociation with eczema, impetigo, and pediculosis.

#Veldt Sore.#--This sore usually originates in an abrasion of the epidermis, such as a sun blister, the bite of an insect, or a scratch. A pustule forms and bursts, and a brownish-yellow scab forms over it. When this is removed, an ulcer is left which has little tendency to heal.

These sores are most common about the hands, arms, neck, and feet, and are most apt to occur in those who have had no opportunities of washing, and who have lived for a long time on tinned foods.

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

#Inoculation Tubercle.#--The appearances vary with the conditions under which the inoculation takes place. As observed on the fingers of adults, the affection takes the form of an indolent painless swelling, the epidermis being red and glazed, or warty, and irregularly fissured.

Sometimes the epidermis gives way, forming an ulcer with flabby granulations. The infection rarely spreads to the lymphatics, but we have seen inoculation tubercle of the index-finger followed by a large cold abscess on the median side of the upper arm and by a huge ma.s.s of breaking down glands in the axilla.

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

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

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

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

[Ill.u.s.tration: FIG. 96.--Tuberculous Elephantiasis in a woman aet. 35.]

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

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

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

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

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

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

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

#Sporotrichosis# is a mycotic infection due to the sporothrix Shenkii.

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

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

_Elephantiasis from Lymphatic or Venous Obstruction._--Of this the best-known example is _tropical elephantiasis_ (E. arab.u.m), which is endemic in Samoa, Barbadoes, and other places. It attacks the lower extremity or the genitals in either s.e.x (Figs. 97, 98). The disease is usually ushered in with fever, and signs of lymphangitis in the part affected. After a number of such attacks, the lymph vessels appear to become obliterated, and the skin and subcutaneous cellular tissue, being bathed in stagnant lymph--which possibly contains the products of streptococci--take on an overgrowth, which continues until the part a.s.sumes gigantic proportions. In certain cases the lymph trunks have been found to be blocked with the parent worms of the filaria Bancrofti.

Cases of elephantiasis of the lower extremity are met with in this country in which there are no filarial parasites in the lymph vessels, and these present features closely resembling the tropical variety, and usually follow upon repeated attacks of lymphangitis or erysipelas.

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

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

[Ill.u.s.tration: FIG. 97.--Elephantiasis in a woman aet. 45.]

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

[Ill.u.s.tration: FIG. 98.--Elephantiasis of p.e.n.i.s and s.c.r.o.t.u.m in native of Demerara.