Chapter XXVII: The Skin (2)

=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.

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.

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.”