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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 Röntgen 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.
Fig. 104.—Diffuse Melanotic Cancer of Lymphatics of Skin secondary to a Growth in the Sole of the Foot.
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.
Fig. 105.—Melanotic Cancer of Forehead with Metastases in Lymph Vessels and Glands.
(Mr. D. P. D. Wilkie's case.)
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 CicatricesA 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.
Fig. 106.—Recurrent Keloid in scar left by operation for tuberculous glands in a girl æt. 7.
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 NailsInjuries.—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 hyperæmia, 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.
Fig. 107.—Subungual Exostosis growing from Distal Phalanx of Great Toe, showing Ulceration of Skin and Displacement of Nail.
a. Surface view. b. On section.
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
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