Operative Treatment.—This consists in the removal of the affected nerve or nerves, either by resection—neurectomy; or by a combination of resection with twisting or tearing of the nerve from its central connections—avulsion. To prevent the regeneration of the nerve after these operations, the canal of exit through the bone should be obliterated; this is best accomplished by a silver screw-nail driven home by an ordinary screw-driver (Charles H. Mayo).

When the neuralgia involves branches of two or of all three trunks, or when it has recurred after temporary relief following resection of individual branches, the removal of the semilunar ganglion, along with the main trunks of the maxillary and mandibular divisions, should be considered.

The operation is a difficult and serious one, but the results are satisfactory so far as the cure of the neuralgia is concerned. There is little or no disability from the unilateral paralysis of the muscles of mastication; but on account of the insensitiveness of the cornea, the eye must be protected from irritation, especially during the first month or two after the operation; this may be done by fixing a large watch-glass around the edge of the orbit with adhesive plaster.

If the ophthalmic branch is not involved, neither it nor the ganglion should be interfered with; the maxillary and mandibular divisions should be divided within the skull, and the foramen rotundum and foramen ovale obliterated.



CHAPTER XVII

THE SKIN AND SUBCUTANEOUS TISSUE

Structure of skin—Blisters—Callosities—Corns—Chilblains —Boils—Carbuncle—Abscess—Veldt sores—Tuberculosis of skin: Inoculation tubercle—Lupus: Varieties—Sporotrichosis —Elephantiasis—Sebaceous cysts or wens—Moles—Horns—New growths: Fibroma; Papilloma; Adenoma; Epithelioma; Rodent cancer; Melanotic cancer; Sarcoma—AFFECTIONS OF CICATRICES—Varieties of scars—Keloid—Tumours—AFFECTIONS OF NAILS.

Structure of Skin.—The skin is composed of a superficial cellular layer—the epidermis, and the corium or true skin. The epidermis is differentiated from without inwards into the stratum corneum, the stratum lucidum, the stratum granulosum, and the rete Malpighii or germinal layer, from which all the others are developed. The corium or true skin consists of connective tissue, in which ramify the blood vessels, lymphatics, and nerves. That part of the corium immediately adjoining the epidermis is known as the papillary portion, and contains the terminal loops of the cutaneous blood vessels and the terminations of the cutaneous nerves. The deeper portion of the true skin is known as the reticular portion, and is largely composed of adipose tissue.

Blisters result from the exudation of serous fluid beneath the horny layer of the epidermis. The fluid may be clear, as in the blisters of a recent burn, or blood-stained, as in the blisters commonly accompanying fractures of the leg. It may become purulent as a result of infection, and this may be the starting-point of lymphangitis or cellulitis.

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

Callosities are prominent, indurated masses of the horny 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 balls 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 horny layer is pared away, and the part painted daily with a saturated solution of salicylic acid in flexile collodion.



Corns.—A corn is a localised overgrowth of the horny 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 constitutes 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.



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 capsicum 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 buttocks, and on other parts where the skin is coarse 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 circumstances 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 albumen 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.



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 association 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 mass 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.



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 scraped 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 scraped 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 potassium.

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. arabum), which is endemic in Samoa, Barbadoes, and other places. It attacks the lower extremity or the genitals in either sex (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 assumes 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.



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



Belonging to this group also is a form of congenital elephantiasis resulting from the circular constriction of a limb in utero by amniotic bands.

Elephantiasis occurring apart from lymphatic or venous obstruction is illustrated by elephantiasis nervorum, in which there is an overgrowth of the skin and cellular tissue of an extremity in association with neuro-fibromatosis of the cutaneous nerves (Fig. 89); and by elephantiasis Graecorum—a form of leprosy in which the skin of the face becomes the seat of tumour-like masses consisting of leprous nodules. It is also illustrated by elephantiasis involving the scrotum as a result of prolonged irritation by the urine in cases in which the penis has been amputated and the urine has infiltrated the scrotal tissues over a period of years.

Sebaceous Cysts.—Atheromatous cysts or wens are formed in relation to the sebaceous glands and hair follicles. They are commonly met with in adults, on the scalp (Fig. 99), face, neck, back, and external genitals. Sometimes they are multiple, and they may be met with in several members of the same family. They are smooth, rounded, or discoid cysts, varying in size from a split-pea to a Tangerine orange. In consistence they are firm and elastic, or fluctuating, and are incorporated with the overlying skin, but movable on the deeper structures. The orifice of the partly blocked sebaceous follicle is sometimes visible, and the contents of the cyst can be squeezed through the opening. The wall of the cyst is composed of a connective-tissue capsule lined by stratified squamous epithelium. The contents consist of accumulated epithelial cells, and are at first dry and pearly white in appearance, but as a result of fatty degeneration they break down into a greyish-yellow pultaceous and semi-fluid material having a peculiar stale odour. It is probable that the decomposition of the contents is the result of the presence of bacteria, and that from the surgical point of view they should be regarded as infective. A sebaceous cyst may remain indefinitely without change, or may slowly increase in size, the skin over it becoming stretched and closely adherent to the cyst wall as a result of friction and pressure. The contents may ooze from the orifice of the duct and dry on the skin surface, leading to the formation of a sebaceous horn (Fig. 100). As a result of injury the cyst may undergo sudden enlargement from haemorrhage into its interior.

Recurrent attacks of inflammation frequently occur, especially in wens of the face and scalp. Suppuration may ensue and be followed by cure of the cyst, or an offensive fungating ulcer forms which may be mistaken for epithelioma. True cancerous transformation is rare.

Wens are to be diagnosed from dermoids, from fatty tumours, and from cold abscesses. Dermoids usually appear before adult life, and as they nearly always lie beneath the fascia, the skin is movable over them. A fatty tumour is movable, and is often lobulated. The confusion with a cold abscess is most likely to occur in wens of the neck or back, and it may be impossible without the use of an exploring needle to differentiate between them.



Treatment.—The removal of wens is to be recommended while they are small and freely movable, as they are then easily shelled out after incising the overlying skin; sometimes splitting the cyst makes its removal easier. Local anaesthesia is to be preferred. It is important that none of the cyst wall be left behind. In large and adherent wens an ellipse of skin is removed along with the cyst. When inflamed, it may be impossible to dissect out the cyst, and the wall should be destroyed with carbolic acid, the resulting wound being treated by the open method.

Moles.—The term mole is applied to a pigmented, and usually hairy, patch of skin, present at or appearing shortly after birth. The colour varies from brown to black, according to the amount of melanin pigment present. The lesion consists in an overgrowth of epidermis which often presents an alveolar arrangement. Moles vary greatly in size: some are mere dots, others are as large as the palm of the hand, and occasionally a mole covers half the face. In addition to being unsightly, they bleed freely when abraded, are liable to ulcerate from friction and pressure, and occasionally become the starting-point of melanotic cancer. Rodent cancer sometimes originates in the slightly pigmented moles met with on the face. Overgrowths in relation to the cutaneous nerves, especially the plexiform neuroma, occasionally originate in pigmented moles. Soldau believes that the pigmentation and overgrowth of the epidermis in moles are associated with, and probably result from, a fibromatosis of the cutaneous nerves.

Treatment.—The quickest way to get rid of a mole is to excise it; if the edges of the gap cannot be brought together with sutures, recourse should be had to grafting. In large hairy moles of the face whose size forbids excision, radium or the X-rays should be employed. Excellent results have been obtained by refrigeration with solid carbon dioxide. In children and women with delicate skin, applications of from ten to thirty seconds suffice. In persons with coarse skin an application of one minute may be necessary, and it may have to be repeated.

Horns.—The sebaceous horn results from the accumulation of the dried contents of a wen on the surface of the skin: the sebaceous material after drying up becomes cornified, and as fresh material is added to the base the horn increases in length (Fig. 100). The wart horn grows from a warty papilloma of the skin. Cicatrix horns are formed by the heaping up of epidermis in the scars that result from burns. Nail horns are overgrown nails (keratomata of the nail bed), and are met with chiefly in the great toe of elderly bedridden patients. If an ulcer forms at the base of a horn, it may prove the starting-point of epithelioma, and for this reason, as well as for others, horns should be removed.



New Growths in the Skin and Subcutaneous Tissue.—The Angioma has been described with diseases of blood vessels. Fibroma.—Various types of fibroma occur in the skin. A soft pedunculated fibroma, about the size of a pea, is commonly met with, especially on the neck and trunk; it is usually solitary, and is easily removed with scissors. The multiple, soft fibroma known as molluscum fibrosum, which depends upon a neuro-fibromatosis of the cutaneous nerves, is described with the tumours of nerves. Hard fibromas occurring singly or in groups may be met with, especially in the skin of the buttock, and may present a local malignancy, recurring after removal like the "recurrent fibroid" of Paget. The "painful subcutaneous nodule" is a solitary fibroma related to one of the cutaneous nerves. The hard fibroma known as keloid is described with the affections of scars.

Papilloma.—The common wart or verruca is an outgrowth of the surface epidermis. It may be sessile or pedunculated hard or soft. The surface may be smooth, or fissured and foliated like a cauliflower, or it may be divided up into a number of spines. Warts are met with chiefly on the hands, and are often multiple, occurring in clusters or in successive crops. Multiple warts appear to result from some contagion, the nature of which is unknown; they sometimes occur in an epidemic form among school-children, and show a remarkable tendency to disappear spontaneously. The solitary flat-topped wart which occurs on the face of old people may, if irritated, become the seat of epithelioma. A warty growth of the epidermis is a frequent accompaniment of moles and of that variety of lupus known as lupus verrucosus.

Treatment.—In the multiple warts of children the health should be braced up by a change to the seaside. A dusting-powder, consisting of boracic acid with 5 per cent. salicylic acid, may be rubbed into the hands after washing and drying. The persistent warts of young adults should be excised after freezing with chloride of ethyl. When cutting is objected to, they may be painted night and morning with salicylic collodion, the epidermis being dehydrated with alcohol before each application.

Venereal warts occur on the genitals of either sex, and may form large cauliflower-like masses on the inner surface of the prepuce or of the labia majora. Although frequently co-existing with gonorrhoea or syphilis, they occur independently of these diseases, being probably acquired by contact with another individual suffering from warts (C. W. Cathcart). They give rise to considerable irritation and suffering, and when cleanliness is neglected there may be an offensive discharge.

In the female, the cauliflower-like masses are dissected from the labia; in the male, the prepuce is removed and the warts on the glans are snipped off with scissors. In milder cases, the warts usually disappear if the parts are kept absolutely dry and clean. A useful dusting-powder is one consisting of calamine and 5 per cent. salicylic acid; the exsiccated sulphate of iron, in the form of a powder, may be employed in cases which resist this treatment.

Adenoma.—This is a comparatively rare tumour growing from the glands of the skin. One variety, known as the "tomato tumour," which apparently originates from the sweat glands, is met with on the scalp and face in women past middle life. These growths are often multiple; the individual tumours vary in size, and the skin, which is almost devoid of hairs, is glistening and tightly stretched over them. A similar tumour may occur on the nose. The sebaceous adenoma, which originates from the sebaceous glands, forms a projecting tumour on the face or scalp, and when the skin is irritated it may ulcerate and fungate. The treatment consists in the removal of the tumour along with the overlying skin.

The exuberant masses on the nose known as "rhinophyma," "lipoma nasi," or "potato nose" are of the nature of sebaceous adenoma, and are removed by shaving them off with a knife until the normal shape of the nose is restored Healing takes place with remarkable rapidity.

Cancer.—There are several types of primary cancer of the skin, the most important being squamous epithelioma, rodent cancer, and melanotic cancer.



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.



Rodent Cancer (Rodent Ulcer).—This is a cancer originating in the sweat glands or sebaceous follicles, or in the foetal residues of cutaneous glands. The cells are small and closely packed together in alveoli or in reticulated columns; cell nests are rare. It is remarkably constant in its seat of origin, being nearly always located on the lateral aspect of the nose or in the vicinity of the lower eyelid (Fig. 102). It is rare on the trunk or limbs. It commences as a small flattened nodule in the skin, the epidermis over it being stretched and shining. The centre becomes depressed, while the margins extend in the form of an elevated ridge. Sooner or later the epidermis gives way in the centre, exposing a smooth raw surface devoid of granulations.



The margin, while in parts irregular, is typically represented by a well-defined "rolled" border which consists of the peripheral portion of the cancer that has not broken down. The central ulcer may temporarily heal. There is itching but little pain, and the condition progresses extremely slowly; rodent cancers which have existed for many years are frequently met with. The disease attacks and destroys every structure with which it comes in contact, such as the eyelids, the walls of the nasal cavities, and the bones of the face; hence it may produce the most hideous deformities (Fig. 103). The patient may succumb to haemorrhage or to infective complications such as erysipelas or meningitis.

Secondary growths in the lymph glands, while not unknown, are extremely rare. We have only seen them once—in a case of rodent cancer in the groin.

Diagnosis.—Lupus is the disease most often mistaken for rodent cancer. Lupus usually begins earlier in life, it presents apple-jelly nodules, and lacks the rounded, elevated border. Syphilitic lesions progress more rapidly, and also lack the characteristic margin. The differentiation from squamous epithelioma is of considerable importance, as the latter affection spreads more rapidly, involves the lymph glands early, and is much more dangerous to life.

Treatment.—In rodent cancers of limited size—say less than one inch in diameter—free excision is the most rapid and certain method of treatment. The alternative is the application of radium or of the Rontgen rays, which, although requiring many exposures, results in cure with the minimum of disfigurement. If the cancer already covers an extensive area, or has invaded the cavity of the orbit or nose, radium or X-rays yield the best results. The effect is soon shown by the ingrowth of healthy epithelium from the surrounding skin, and at the same time the discharge is lessened. Good results are also reported from the application of carbon dioxide snow, especially when this follows upon a course of X-ray treatment.

Paget's disease of the nipple is an epithelioma occurring in women over forty years of age: a similar form of epithelioma is sometimes met with at the umbilicus or on the genitals.

Melanotic Cancer.—Under this head are included all new growths which contain an excess of melanin pigment. Many of these were formerly described as melanotic sarcoma. They nearly always originate in a pigmented mole which has been subjected to irritation. The primary growth may remain so small that its presence is not even suspected, or it may increase in size, ulcerate, and fungate. The amount of pigment varies: when small in amount the growth is brown, when abundant it is a deep black. The most remarkable feature is the rapidity with which the disease becomes disseminated along the lymphatics, the first evidence of which is an enlargement of the lymph glands. As the primary growth is often situated on the sole of the foot or in the matrix of the nail of the great toe, the femoral and inguinal glands become enlarged in succession, forming tumours much larger than the primary growth. Sometimes the dissemination involves the lymph vessels of the limb, forming a series of indurated pigmented cords and nodules (Fig. 104). Lastly, the dissemination may be universal throughout the body, and this usually occurs at a comparatively early stage. The secondary growths are deeply pigmented, being usually of a coal-black colour, and melanin pigment may be present in the urine. When recurrence takes place in or near the scar left by the operation, the cancer nodules are not necessarily pigmented.



To extirpate the disease it is necessary to excise the tumour, with a zone of healthy skin around it and a somewhat large zone of the underlying subcutaneous tissue and deep fascia. Hogarth Pringle recommends that a broad strip of subcutaneous fascia up to and including the nearest anatomical group of glands should be removed with the tumour in one continuous piece.

Secondary Cancer of the Skin.—Cancer may spread to the skin from a subjacent growth by direct continuity or by way of the lymphatics. Both of these processes are so well illustrated in cases of mammary cancer that they will be described in relation to that disease.

Sarcoma of various types is met with in the skin. The fibroma, after excision, may recur as a fibro-sarcoma. The alveolar sarcoma commences as a hard lump and increases in size until the epidermis gives way and an ulcer is formed.



A number of fresh tumours may spring up around the original growth. Sometimes the primary growth appears in the form of multiple nodules which tend to become confluent. Excision, unless performed early, is of little avail, and in any case should be followed up by exposure to radium.

AFFECTIONS OF CICATRICES

A cicatrix or scar consists of closely packed bundles of white fibres covered by epidermis; the skin glands and hair follicles are usually absent. The size, shape, and level of the cicatrix depend upon the conditions which preceded healing.

A healthy scar, when recently formed, has a smooth, glossy surface of a pinkish colour, which tends to become whiter as a result of obliteration of the blood vessels concerned in its formation.

Weak Scars.—A scar is said to be weak when it readily breaks down as a result of irritation or pressure. The scars resulting from severe burns and those over amputation stumps are especially liable to break down from trivial causes. The treatment is to excise the weak portion of the scar and bring the edges of the gap together.

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

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

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

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

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



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

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

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

AFFECTION OF THE NAILS

Injuries.—When a nail is contused or crushed, blood is extravasated beneath it, and the nail is usually shed, a new one growing in its place. A splinter driven underneath the nail causes great pain, and if organisms are carried in along with it, may give rise to infective complications. The free edge of the nail should be clipped away to allow of the removal of the foreign body and the necessary disinfection.

Trophic Changes.—The growth of the nails may be interfered with in any disturbance of the general health. In nerve lesions, such as a divided nerve-trunk, the nails are apt to suffer, becoming curved, brittle, or furrowed, or they may be shed.

Onychia is the term applied to an infection of the soft parts around the nail or of the matrix beneath it. The commonest form of onychia has already been referred to with whitlow. There is a superficial variety resulting from the extension of a purulent blister beneath the nail lifting it up from its bed, the pus being visible through the nail. The nail as well as the raised horny layer of the epidermis should be removed. A deeper and more troublesome onychia results from infection at the nail-fold; the infection spreads slowly beneath the fold until it reaches the matrix, and a drop or two of pus forms beneath the nail, usually in the region of the lunule. This affection entails a disability of the finger which may last for weeks unless it is properly treated. Treatment by hyperaemia, using a suction bell, should first be tried, and, failing improvement, the nail-fold and lunule should be frozen, and a considerable portion removed with the knife; if only a small portion of the nail is removed, the opening is blocked by granulations springing from the matrix. A new nail is formed, but it is liable to be misshapen.

Tuberculous onychia is met with in children and adolescents. It appears as a livid or red swelling at the root of the nail and spreading around its margins. The epidermis, which is thin and shiny, gives way, and the nail is usually shed.



Syphilitic affections of the nails assume various aspects. A primary chancre at the edge of the nail may be mistaken for a whitlow, especially if it is attended with much pain. Other forms of onychia occur during secondary syphilis simultaneously with the skin eruptions, and may prove obstinate and lead to shedding of the nails. They also occur in inherited syphilis. In addition to general treatment, an ointment containing 5 per cent. of oleate of mercury should be applied locally.

Ingrowing Toe-nail.—This is more accurately described as an overgrowth of the soft tissues along the edge of the nail. It is most frequently met with in the great toe in young adults with flat-foot whose feet perspire freely, who wear ill-fitting shoes, and who cut their toe-nails carelessly or tear them with their fingers. Where the soft tissues are pressed against the edge of the nail, the skin gives way and there is the formation of exuberant granulations and of discharge which is sometimes foetid. The affection is a painful one and may unfit the patient for work. In mild cases the condition may be remedied by getting rid of contributing causes and by disinfecting the skin and nail; the nail is cut evenly, and the groove between it and the skin packed with an antiseptic dusting-powder, such as boracic acid. In more severe cases it may be necessary to remove an ellipse of tissue consisting of the edge of the nail, together with the subjacent matrix and the redundant nail-fold.

Subungual exostosis is an osteoma growing from the terminal phalanx of the great toe (Fig. 107). It raises the nail and may be accompanied by ulceration of the skin over the most prominent part of the growth. The soft parts, including the nail, should be reflected towards the dorsum in the form of a flap, the base of the exostosis divided with the chisel, and the exostosis removed.

Malignant disease in relation to the nails is rare. Squamous epithelioma and melanotic cancer are the forms met with. Treatment consists in amputating the digit concerned, and in removing the associated lymph glands.



CHAPTER XVIII

THE MUSCLES, TENDONS, AND TENDON SHEATHS

INJURIES: Contusion; Sprain; Rupture—Hernia of muscle—Dislocation of tendons—Wounds—Avulsion of tendon. DISEASES OF MUSCLE AND OF TENDONS: Atrophy; "Muscular rheumatism"—Fibrositis; Contracture; Myositis; Calcification and Ossification; Tumours. DISEASES OF TENDON SHEATHS: Teno-synovitis.

INJURIES

Contusion of Muscle.—Contusion of muscle, which consists in bruising of its fibres and blood vessels, may be due to violence acting from without, as in a blow, a kick, or a fall; or from within, as by the displacement of bone in a fracture or dislocation.

The symptoms are those common to all contusions, and the patient complains of severe pain on attempting to use the muscle, and maintains an attitude which relaxes it. If the sheath of the muscle also is torn, there is subcutaneous ecchymosis, and the accumulation of blood may result in the formation of a haematoma.

Restoration of function is usually complete; but when the nerve supplying the muscle is bruised at the same time, as may occur in the deltoid, wasting and loss of function may be persistent. In exceptional cases the process of repair may be attended with the formation of bone in the substance of the muscle, and this may likewise impair its function.

A contused muscle should be placed at rest and supported by cotton wool and a bandage; after an interval, massage and appropriate exercises are employed.

Sprain and Partial Rupture of Muscle.—This lesion consists in overstretching and partial rupture of the fibres of a muscle or its aponeurosis. It is of common occurrence in athletes and in those who follow laborious occupations. It may follow upon a single or repeated effort—especially in those who are out of training. Familiar examples of muscular sprain are the "labourer's" or "golfer's back," affecting the latissimus dorsi or the sacrospinalis (erector spinae); the "tennis-player's elbow," and the "sculler's sprain," affecting the muscles and ligaments about the elbow; the "angler's elbow," affecting the common origin of the extensors and supinators; the "sprinter's sprain," affecting the flexors of the hip; and the "jumper's and dancer's sprain," affecting the muscles of the calf. The patient complains of pain, often sudden in onset, of tenderness on pressure, and of inability to carry out the particular movement by which the sprain was produced. The disability varies in different cases, and it may incapacitate the patient from following his occupation or sport for weeks or, if imperfectly treated, even for months.

The treatment consists in resting the muscle from the particular effort concerned in the production of the sprain, in gently exercising it in other directions, in the use of massage, and the induction of hyperaemia by means of heat. In neglected cases, that is, where the muscle has not been exercised, the patient shrinks from using it and the disablement threatens to be permanent; it is sometimes said that adhesions have formed and that these interfere with the recovery of function. The condition may be overcome by graduated movements or by a sudden forcible movement under an anaesthetic. These cases afford a fruitful field for the bone-setter.

Rupture of Muscle or Tendon.—A muscle or a tendon may be ruptured in its continuity or torn from its attachment to bone. The site of rupture in individual muscles is remarkably constant, and is usually at the junction of the muscular and tendinous portions. When rupture takes place through the belly of a muscle, the ends retract, the amount of retraction depending on the length of the muscle, and the extent of its attachment to adjacent aponeurosis or bone. The biceps in the arm, and the sartorius in the thigh, furnish examples of muscles in which the separation between the ends may be considerable.

The gap in the muscle becomes filled with blood, and this in time is replaced by connective tissue, which forms a bond of union between the ends. When the space is considerable the connecting medium consists of fibrous tissue, but when the ends are in contact it contains a number of newly formed muscle fibres. In the process of repair, one or both ends of the muscle or tendon may become fixed by adhesions to adjacent structures, and if the distal portion of a muscle is deprived of its nerve supply it may undergo degeneration and so have its function impaired.

Rupture of a muscle or tendon is usually the result of a sudden, and often involuntary, movement. As examples may be cited the rupture of the quadriceps extensor in attempting to regain the balance when falling backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in jumping or dancing; of the adductors of the thigh in gripping a horse when it swerves—"rider's sprain"; of the abdominal muscles in vomiting, and of the biceps in sudden movements of the arm. Sometimes the effort is one that would scarcely be thought likely to rupture a muscle, as in the case recorded by Pagenstecher, where a professional athlete, while sitting at table, ruptured his biceps in a sudden effort to catch a falling glass. It would appear that the rupture is brought about not so much by the contraction of the muscle concerned, as by the contraction of the antagonistic muscles taking place before that of the muscle which undergoes rupture is completed. The violent muscular contractions of epilepsy, tetanus, or delirium rarely cause rupture.

The clinical features are usually characteristic. The patient experiences a sudden pain, with the sensation of being struck with a whip, and of something giving way; sometimes a distant snap is heard. The limb becomes powerless. At the seat of rupture there is tenderness and swelling, and there may be ecchymosis. As the swelling subsides, a gap may be felt between the retracted ends, and this becomes wider when the muscle is thrown into contraction. If untreated, a hard, fibrous cord remains at the seat of rupture.

Treatment.—The ends are approximated by placing the limb in an attitude which relaxes the muscle, and the position is maintained by bandages, splints, or special apparatus. When it is impossible thus to approximate the ends satisfactorily, the muscle or tendon is exposed by incision, and the ends brought into accurate contact by catgut sutures. This operation of primary suture yields the most satisfactory results, and is most successful when it is done within five or six days of the accident. Secondary suture after an interval of months is rendered difficult by the retraction of the ends and by their adhesion to adjacent structures.

Rupture of the biceps of the arm may involve the long or the short head, or the belly of the muscle. Most interest attaches to rupture of the long tendon of origin. There is pain and tenderness in front of the upper end of the humerus, the patient is unable to abduct or to elevate the arm, and he may be unable to flex the elbow when the forearm is supinated. The long axis of the muscle, instead of being parallel with the humerus, inclines downwards and outwards. When the patient is asked to contract the muscle, its belly is seen to be drawn towards the elbow.

The adductor longus may be ruptured, or torn from the pubes, by a violent effort to adduct the limb. A swelling forms in the upper and medial part of the thigh, which becomes smaller and harder when the muscle is thrown into contraction.

The quadriceps femoris is usually ruptured close to its insertion into the patella, in the attempt to avoid falling backwards. The injury is sometimes bilateral. The injured limb is rendered useless for progression, as it suddenly gives way whenever the knee is flexed. Treatment is conducted on the same lines as in transverse fracture of the patella; in the majority of cases the continuity of the quadriceps should be re-established by suture within five or six days of the accident.

The tendo calcaneus (Achillis) is comparatively easily ruptured, and the symptoms are sometimes so slight that the nature of the injury may be overlooked. The limb should be put up with the knee flexed and the toes pointed. This may be effected by attaching one end of an elastic band to the heel of a slipper, and securing the other to the lower third of the thigh. If this is not sufficient to bring the ends into apposition they should be approximated by an open operation.

The plantaris is not infrequently ruptured from trivial causes, such as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain like the stroke of a whip is felt in the calf; there is marked tenderness at the seat of rupture, and the patient is unable to raise the heel without pain. The injury is of little importance, and if the patient does not raise the heel from the ground in walking, it is recovered from in a couple of weeks or so, without it being necessary to lay him up.

Hernia of Muscle.—This is a rare condition, in which, owing to the fascia covering a muscle becoming stretched or torn, the muscular substance is protruded through the rent. It has been observed chiefly in the adductor longus. An oval swelling forms in the upper part of the thigh, is soft and prominent when the muscle is relaxed, less prominent when it is passively extended, and disappears when the muscle is thrown into contraction. It is liable to be mistaken, according to its situation, for a tumour, a cyst, a pouched vein, or a femoral or obturator hernia. Treatment is only called for when it is causing inconvenience, the muscle being exposed by a suitable incision, the herniated portion excised, and the rent in the sheath closed by sutures.

Dislocation of Tendons.—Tendons which run in grooves may be displaced as a result of rupture of the confining sheath. This injury is met with chiefly in the tendons at the ankle and in the long tendon of the biceps.

Dislocation of the peronei tendons may occur, for example, from a violent twist of the foot. There is severe pain and considerable swelling on the lateral aspect of the ankle; the peroneus longus by itself, or together with the brevis, can be felt on the lateral aspect or in front of the lateral malleolus; the patient is unable to move the foot. By a little manipulation the tendons are replaced in their grooves, and are retained there by a series of strips of plaster. At the end of three weeks massage and exercises are employed.

In other cases there is no history of injury, but whenever the foot is everted the tendon of the peroneus longus is liable to be jerked forwards out of its groove, sometimes with an audible snap. The patient suffers pain and is disabled until the tendon is replaced. Reduction is easy, but as the displacement tends to recur, an operation is required to fix the tendon in its place. An incision is made over the tendon; if the sheath is slack or torn, it is tightened up or closed with catgut sutures; or an artificial sheath is made by raising up a quadrilateral flap of periosteum from the lateral aspect of the fibula, and stitching it over the tendon.

Similarly the tibialis posterior may be displaced over the medial malleolus as a result of inversion of the foot.

The long tendon of the biceps may be dislocated laterally—or more frequently medially—as a result of violent or repeated rotation movements of the arm, such as are performed in wringing clothes. The patient is aware of the displacement taking place, and is unable to extend the forearm until the displaced tendon has been reduced by abducting the arm. In recurrent cases the patient may be able to dislocate the tendon at will, but the disability is so inconsiderable that there is rarely any occasion for interference.

Wounds of Muscles and Tendons.—When a muscle is cut across in a wound, its ends should be brought together with sutures. If the ends are allowed to retract, and especially if the wound suppurates, they become united by scar tissue and fixed to bone or other adjacent structure. In a limb this interferes with the functions of the muscle; in the abdominal wall the scar tissue may stretch, and so favour the development of a ventral hernia.

Tendons may be cut across accidentally, especially in those wounds so commonly met with above the wrist as a result, for example, of the hand being thrust through a pane of glass. It is essential that the ends should be sutured to each other, and as the proximal end is retracted the original wound may require to be enlarged in an upward direction. When primary suture has been omitted, or has failed in consequence of suppuration, the separated ends of the tendon become adherent to adjacent structures, and the function of the associated muscle is impaired or lost. Under these conditions the operation of secondary suture is indicated.

A free incision is necessary to discover and isolate the ends of the tendon; if the interval is too wide to admit of their being approximated by sutures, means must be taken to lengthen the tendon, or one from some other part may be inserted in the gap. A new sheath may be provided for the tendon by resecting a portion of the great saphenous vein.

Injuries of the tendons of the fingers are comparatively common. One of the best known is the partial or complete rupture of the aponeurosis of the extensor tendon close to its insertion into the terminal phalanx—drop- or mallet-finger. This may result from comparatively slight violence, such as striking the tip of the extended finger against an object, or the violence may be more severe, as in attempting to catch a cricket ball or in falling. The terminal phalanx is flexed towards the palm and the patient is unable to extend it. The treatment consists in putting up the finger with the middle joint strongly flexed. In neglected cases, a perfect functional result can only be obtained by operation; under a local anaesthetic, the ruptured tendon is exposed and is sutured to the base of the phalanx, which may be drilled for the passage of the sutures.

Subcutaneous rupture of one or other of the digital tendons in the hand or at the wrist can be remedied only by operation. When some time has elapsed since the accident, the proximal end may be so retracted that it cannot be brought down into contact with the distal end, in which case a slip may be taken from an adjacent tendon; in the case of one of the extensors of the thumb, the extensor carpi radialis longus may be detached from its insertion and stitched to the distal end of the tendon of the thumb.

Subcutaneous rupture of the tendon of the extensor pollicis longus at the wrist takes place just after its emergence from beneath the annular ligament; the actual rupture may occur painlessly, more frequently a sharp pain is felt over the back of the wrist. The prominence of the tendon, which normally forms the ulnar border of the snuff-box, disappears. This lesion is chiefly met with in drummer-boys and is the cause of drummer's palsy. The only chance of restoring function is in uniting the ruptured tendon by open operation.



Avulsion of Tendons.—This is a rare injury, in which the tendons of a finger or toe are torn from their attachments along with a portion of the digit concerned. In the hand, it is usually brought about by the fingers being caught in the reins of a runaway horse, or being seized in a horse's teeth, or in machinery. It is usually the terminal phalanx that is separated, and with it the tendon of the deep flexor, which ruptures at its junction with the belly of the muscle (Fig. 108). The treatment consists in disinfecting the wound, closing the tendon-sheath, and trimming the mutilated finger so as to provide a useful stump.

DISEASES OF MUSCLES AND TENDONS

Congenital absence of muscles is sometimes met with, usually in association with other deformities. The pectoralis major, for example, may be absent on one or on both sides, without, however, causing any disability, as other muscles enlarge and take on its functions.

Atrophy of Muscle.—Simple atrophy, in which the muscle elements are merely diminished in size without undergoing any structural alteration, is commonly met with as a result of disuse, as when a patient is confined to bed for a long period.

In cases of joint disease, the muscles acting on the joint become atrophied more rapidly than is accounted for by disuse alone, and this is attributed to an interference with the trophic innervation of the muscles reflected from centres in the spinal medulla. It is more marked in the extensor than in the flexor groups of muscles. Those affected become soft and flaccid, exhibit tremors on attempted movement, and their excitability to the faradic current is diminished.

Neuropathic atrophy is associated with lesions of the nervous system. It is most pronounced in lesions of the motor nerve-trunks, probably because vaso-motor and trophic fibres are involved as well as those that are purely motor in function. It is attended with definite structural alterations, the muscle elements first undergoing fatty degeneration, and then being absorbed, and replaced to a large extent by ordinary connective tissue and fat. At a certain stage the muscles exhibit the reaction of degeneration. In the common form of paralysis resulting from poliomyelitis, many fibres undergo fatty degeneration and are replaced by fat, while at the same time there is a regeneration of muscle fibres.

Fibrositis or "Muscular Rheumatism."—This clinical term is applied to a group of affections of which lumbago is the best-known example. The group includes lumbago, stiff-neck, and pleurodynia—conditions which have this in common, that sudden and severe pain is excited by movement of the affected part. The lesion consists in inflammatory hyperplasia of the connective tissue; the new tissue differs from normal fibrous tissue in its tendency to contract, in being swollen, painful and tender on pressure, and in the fact that it can be massaged away (Stockman). It would appear to involve mainly the fibrous tissue of muscles, although it may extend from this to aponeuroses, ligaments, periosteum, and the sheaths of nerves. The term fibrositis was applied to it by Gowers in 1904.

In lumbago—lumbo-sacral fibrositis—the pain is usually located over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar muscles on one or both sides. The amount of tenderness varies, and so long as the patient is still he is free from pain. The slightest attempt to alter his position, however, is attended by pain, which may be so severe as to render him helpless for the moment. The pain is most marked on rising from the stooping or sitting posture, and may extend down the back of the hip, especially if, as is commonly the case, lumbago and gluteal fibrosis coexist. Once a patient has suffered from lumbago, it is liable to recur, and an attack may be determined by errors of diet, changes of weather, exposure to cold or unwonted exertion. It is met with chiefly in male adults, and is most apt to occur in those who are gouty or are the subjects of oxaluric dyspepsia.

Gluteal fibrositis usually follows exposure to wet, and affects the gluteal muscles, particularly the medius, and their aponeurotic coverings. When the condition has lasted for some time, indurated strands or nodules can be detected on palpating the relaxed muscles. The patient complains of persistent aching and stiffness over the buttock, and sometimes extending down the lateral aspect of the thigh. The pain is aggravated by such movements as bring the affected muscles into action. It is not referred to the line of the sciatic nerve, nor is there tenderness on pressing over the nerve, or sensations of tingling or numbness in the leg or foot.

If untreated, the morbid process may implicate the sheath of the sciatic nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A similar condition may implicate the fascia lata of the thigh, or the calf muscles and their aponeuroses—crural fibrositis.

In painful stiff-neck, or "rheumatic torticollis," the pain is located in one side of the neck, and is excited by some inadvertent movement. The head is held stiffly on one side as in wry-neck, the patient contracting the sterno-mastoid. There may be tenderness over the vertebral spines or in the lines of the cervical nerves, and the sterno-mastoid may undergo atrophy. This affection is more often met with in children.

In pleurodynia—intercostal fibrositis—the pain is in the line of the intercostal nerves, and is excited by movement of the chest, as in coughing, or by any bodily exertion. There is often marked tenderness.

A similar affection is met with in the shoulder and arm—brachial fibrositis—especially on waking from sleep. There is acute pain on attempting to abduct the arm, and there may be localised tenderness in the region of the axillary nerve.

Treatment.—The general treatment is concerned with the diet, attention to the stomach, bowels, and kidneys and with the correction of any gouty tendencies that may be present. Remedies such as salicylates are given for the relief of pain, and for this purpose drugs of the aspirin type are to be preferred, and these may be followed by large doses of iodide of potassium. Great benefit is derived from massage, and from the induction of hyperaemia by means of heat. Cupping or needling, or, in exceptional cases, hypodermic injections of antipyrin or morphin, may be called for. To prevent relapses of lumbago, the patient must take systematic exercises of all kinds, especially such as bring out the movements of the vertebral column and hip-joints.



Contracture of Muscles.—Permanent shortening of muscles results from the prolonged approximation of their points of attachment, or from structural changes in their substance produced by injury or by disease. It is a frequent accompaniment and sometimes a cause of deformities, in the treatment of which lengthening of the shortened muscles or their tendons may be an essential step.

Myositis.—Ischaemic Myositis.—Volkmann was the first to describe a form of myositis followed by contracture, resulting from interference with the arterial blood supply. It is most frequently observed in the flexor muscles of the forearm in children and young persons under treatment for fractures in the region of the elbow, the splints and bandages causing compression of the blood vessels. There is considerable effusion of blood, the skin is tense, and the muscles, vessels, and nerves are compressed; this is further increased if the elbow is flexed and splints and tight bandages are applied. The muscles acquire a board-like hardness and no longer contract under the will, and passive motion is painful and restricted. Slight contracture of the fingers is usually the first sign of the malady; in time the muscles undergo further contraction, and this brings about a claw-like deformity of the hand. The affected muscles usually show the reaction of degeneration. In severe cases the median and ulnar nerves are also the seat of cicatricial changes (ischaemic neuritis).

By means of splints, the interphalangeal, metacarpo-phalangeal, and wrist joints should be gradually extended until the deformity is over-corrected (R. Jones). Murphy advises resection of the radius and ulna sufficient to admit of dorsiflexion of the joints and lengthening of the flexor tendons.

Various forms of pyogenic infection are met with in muscle, most frequently in relation to pyaemia and to typhoid fever. These may result in overgrowth of the connective-tissue framework of the muscle and degeneration of its fibres, or in suppuration and the formation of one or more abscesses in the muscle substance. Repair may be associated with contracture.

A gonorrhoeal form of myositis is sometimes met with; it is painful, but rarely goes on to suppuration.

In the early secondary period of syphilis, the muscles may be the seat of dull, aching, nocturnal pains, especially in the neck and back. Syphilitic contracture is a condition which has been observed chiefly in the later secondary period; the biceps of the arm and the hamstrings in the thigh are the muscles more commonly affected. The striking feature is a gradually increasing difficulty of extending the limb at the elbow or knee, and progressive flexion of the joint. The affected muscle is larger and firmer than normal, and its electric excitability is diminished. In tertiary syphilis, individual muscles may become the seat of interstitial myositis or of gummata, and these affections readily yield to anti-syphilitic remedies.

Tuberculous disease in muscle, while usually due to extension from adjacent tissues, is sometimes the result of a primary infection through the blood-stream. Tuberculous nodules are found disseminated throughout the muscle; the surrounding tissues are indurated, and central caseation may take place and lead to abscess formation and sinuses. We have observed this form of tuberculous disease in the gastrocnemius and in the psoas—in the latter muscle apart from tuberculous disease in the vertebrae.

Tendinitis.—German authors describe an inflammation of tendon as distinguished from inflammation of its sheath, and give it the name tendinitis. It is met with most frequently in the tendo-calcaneus in gouty and rheumatic subjects who have overstrained the tendon, especially during cold and damp weather. There is localised pain which is aggravated by walking, and the tendon is sensitive and swollen from a little above its insertion to its junction with the muscle. Gouty nodules may form in its substance. Constitutional measures, massage, and douching should be employed, and the tendon should be protected from strain.

Calcification and Ossification in Muscles, Tendons, and Fasciae.—Myositis ossificans.—Ossifications in muscles, tendons, fasciae, and ligaments, in those who are the subjects of arthritis deformans, are seldom recognised clinically, but are frequently met with in dissecting-rooms and museums. Similar localised ossifications are met with in Charcot's disease of joints, and in fractures which have repaired with exuberant callus. The new bone may be in the form of spicules, plates, or irregular masses, which, when connected with a bone, are called false exostoses (Fig. 110).



Traumatic Ossification in Relation to Muscle.—Various forms of ossification are met with in muscle as the result of a single or of repeated injury. Ossification in the crureus or vastus lateralis muscle has been frequently observed as a result of a kick from a horse. Within a week or two a swelling appears at the site of injury, and becomes progressively harder until its consistence is that of bone. If the mass of new bone moves with the affected muscle, it causes little inconvenience. If, as is commonly the case, it is fixed to the femur, the action of the muscle is impaired, and the patient complains of pain and difficulty in flexing the knee. A skiagram shows the extent of the mass and its relationship to the femur. The treatment consists in excising the bony mass.

Difficulty may arise in differentiating such a mass of bone from sarcoma; the ossification in muscle is uniformly hard, while the sarcoma varies in consistence at different parts, and the X-ray picture shows a clear outline of the bone in the vicinity of the ossification in muscle, whereas in sarcoma the involvement of the bone is shown by indentations and irregularity in its contour.

A similar ossification has been observed in relation to the insertion of the brachialis muscle as a sequel of dislocation of the elbow. After reduction of the dislocation, the range of movement gradually diminishes and a hard swelling appears in front of the lower end of the humerus. The lump continues to increase in size and in three to four weeks the disability becomes complete. A radiogram shows a shadow in the muscle, attached at one part as a rule to the coronoid process. During the next three or four months, the lump in front of the elbow remains stationary in size; a gradual decrease then ensues, but the swelling persists, as a rule, for several years.



Ossification in the adductor longus was first described by Billroth under the name of "rider's bone." It follows bruising and partial rupture of the muscle, and has been observed chiefly in cavalry soldiers. If it causes inconvenience the bone may be removed by operation.

Ossification in the deltoid and pectoral muscles has been observed in foot-soldiers in the German army, and has received the name of "drill-bone"; it is due to bruising of the muscle by the recoil of the rifle.

Progressive Ossifying Myositis.—This is a rare and interesting disease, in which the muscles, tendons, and fasciae throughout the body become the seat of ossification. It affects almost exclusively the male sex, and usually begins in childhood or youth, sometimes after an injury, sometimes without apparent cause. The muscles of the back, especially the trapezius and latissimus, are the first to be affected, and the initial complaint is limitation of movement.



The affected muscles show swellings which are rounded or oval, firm and elastic, sharply defined, without tenderness and without discoloration of the overlying skin. Skiagrams show that a considerable deposit of lime salts may precede the formation of bone, as is seen in Fig. 111. In course of time the vertebral column becomes rigid, the head is bent forward, the hips are flexed, and abduction and other movements of the arms are limited. The disease progresses by fits and starts, until all the striped muscles of the body are replaced by bone, and all movements, even those of the jaws, are abolished. The subjects of this disease usually succumb to pulmonary tuberculosis.

There is no means of arresting the disease, and surgical treatment is restricted to the removal or division of any mass of bone that interferes with an important movement.

A remarkable feature of this disease is the frequent presence of a deformity of the great toe, which usually takes the form of hallux valgus, the great toe coming to lie beneath the second one; the shortening is usually ascribed to absence of the first phalanx, but it has been shown to depend also on a synostosis and imperfect development of the phalanges. A similar deformity of the thumb is sometimes met with.

Microscopical examination of the muscles shows that, prior to the deposition of lime salts and the formation of bone, there occurs a proliferation of the intra-muscular connective tissue and a gradual replacement and absorption of the muscle fibres. The bone is spongy in character, and its development takes place along similar lines to those observed in ossification from the periosteum.

Tumours of Muscle.—With the exception of congenital varieties, such as the rhabdomyoma, tumours of muscle grow from the connective-tissue framework and not from the muscle fibres. Innocent tumours, such as the fibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumours may be primary in the muscle, or may result from extension from adjacent growths—for example, implication of the pectoral muscle in cancer of the breast—or they may be derived from tumours situated elsewhere. The diagnosis of an intra-muscular tumour is made by observing that the swelling is situated beneath the deep fascia, that it becomes firm and fixed when the muscle contracts, and that, when the muscle is relaxed, it becomes softer, and can be moved in the transverse axis of the muscle, but not in its long axis.

Clinical interest attaches to that form of slowly growing fibro-sarcoma—the recurrent fibroid of Paget—which is most frequently met with in the muscles of the abdominal wall. A rarer variety is the ossifying chondro-sarcoma, which undergoes ossification to such an extent as to be visible in skiagrams.

In primary sarcoma the treatment consists in removing the muscle. In the limbs, the function of the muscle that is removed may be retained by transplanting an adjacent muscle in its place.

Hydatid cysts of muscle resemble those developing in other tissues.

DISEASES OF TENDON SHEATHS

Tendon sheaths have the same structure and function as the synovial membranes of joints, and are liable to the same diseases. Apart from the tendon sheaths displayed in anatomical dissections, there is a loose peritendinous and perimuscular cellular tissue which is subject to the same pathological conditions as the tendon sheaths proper.

Teno-synovitis.—The toxic or infective agent is conveyed to the tendon sheaths through the blood-stream, as in the gouty, gonorrhoeal, and tuberculous varieties, or is introduced directly through a wound, as in the common pyogenic form of teno-synovitis.

Teno-synovitis Crepitans.—In the simple or traumatic form of teno-synovitis, although the most prominent etiological factor is a strain or over-use of the tendon, there would appear to be some other, probably a toxic, factor in its production, otherwise the affection would be much more common than it is: only a small proportion of those who strain or over-use their tendons become the subjects of teno-synovitis. The opposed surfaces of the tendon and its sheath are covered with fibrinous lymph, so that there is friction when they move on one another.

The clinical features are pain on movement, tenderness on pressure over the affected tendon, and a sensation of crepitation or friction when the tendon is moved in its sheath. The crepitation may be soft like the friction of snow, or may resemble the creaking of new leather—"saddle-back creaking." There may be swelling in the long axis of the tendon, and redness and oedema of the skin. If there is an effusion of fluid into the sheath, the swelling is more marked and crepitation is absent. There is little tendency to the formation of adhesions.

In the upper extremity, the sheath of the long tendon of the biceps may be affected, but the condition is most common in the tendons about the wrist, particularly in the extensors of the thumb, and it is most frequently met with in those who follow occupations which involve prolonged use or excessive straining of these tendons—for example, washerwomen or riveters. It also occurs as a result of excessive piano-playing, fencing, or rowing.