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(scirrhus) as of epithelioma. Eczema of the nipple is to be regarded
with suspicion, especially when occurring after the menopause. Until
diagnosis is fairly established it is best treated with soothing
applications. So soon as the cancerous stage has been determined
the breast should be removed. (See Plate XXVI.)
Other forms of malignant or border-land tumors which occur upon
the skin are chimney-sweeper’s cancer, paraffin cancer, and that
met with in aniline workers. Chimney-sweeper’s cancer was the
name applied to epithelioma of the scrotum occurring among a class
of laborers whose occupation is now almost entirely extinct. It began
usually as papilloma and merged into epithelioma. Among workers in
paraffin and coal-tar factories there is an analogous lesion, the result
of surface irritation, the skin becoming dry, thickened, covered with
acne-like pustules, and then with papillomas which ulcerate and
frequently change over into true epitheliomas.
Sarcoma.—Only the outer layers of the skin are truly epiblastic. In
the depths of the integument mesoblastic elements
enter largely, and from these various forms of sarcoma may develop.
These have already been treated in the chapter on Tumors. They
may be single or multiple, and a general disseminated sarcomatosis
is occasionally observed. It corresponds to miliary tuberculosis, but
presents many distinctive lesions in the skin, by which it may be
easily recognized. A form of multiple pigmented sarcoma involving
the hands is represented in Fig. 109. These growths are almost
always tender on pressure and more or less painful. They coalesce
and finally form fatal lesions.
Melanoma.—This term was introduced by Virchow, who made it
cover all pigmented growths. By common consent it is
today limited to tumors of the skin and uveal tract which contain
pigment; metastases may occur in any or all of them. They occur as
malignant degenerations of nevi, moles, and other small growths.
Pathologists are still disputing as to whether they should be
considered sarcomas or endotheliomas. The coloring matter which
they contain is amorphous, finely granular material, lying between
the cells in moles, but occurring free in the tissues and blood and
even in the urine. It is soluble in strong alkalies, from which it can be
recovered as melanic acid, containing a small proportion of sulphur.
Of its origin nothing is positively known. It seems to be generally
accepted that the deposit of pigment is not of itself a causative agent
of the growth of the tumor, but that the growth of cells and their
pigmentation are coincident processes. Johnston has offered much
evidence lately to the effect that growths from nevi are really of
endothelial origin. Hutchinson has described melanotic whitlow. (See
below, the Nails.)
Melanoma is a pigmented ulcerating neoplasm, which possesses
at first only a local malignancy like that of rodent ulcer; the more it
assumes the endotheliomatous type of growth the more it tends to
disseminate and to prove fatal.
The melanoma arising from a mole or nevus, thus known as
melano-endothelioma, begins to increase in size and becomes more
full, as well as to assume a darker tint. For a variable time it is a
single, rather firm, gradually growing, flat tumor, rarely ulcerating, but
sometimes exuding a thin dark fluid. Suddenly there appears rapid
local spread as well as dissemination. The latter may be first noted in
the adjoining lymph nodes. Thus numerous secondary tumors may
be felt in and beneath the skin, at first colorless, becoming more or
less rapidly pigmented. Metastasis may take place to every organ in
the body, but usually the liver and lungs—less often the brain—are
involved. In one case known to the writer the heart was a mass of
nodules of this same secondary character.
Another expression of the same serious condition is seen in a
lesion called by the French malignant lentigo, which also begins with
pigmented spots, on the feet of old men, sometimes upon the face.
These lesions cause thickening of the skin and early ulceration.
Rodent ulcer, which is one form of epithelioma, occasionally
assumes the melanotic type, and is called melano-epithelioma.
Fig. 109
 Fibrosarcoma of hands. (Hardaway.)

The most marked collection of pigment in the human body, within

small space, is along the uveal tract within the eye, and orbital
melanomas are not infrequent. Beginning within the sclerotic they
rapidly perforate this dense membrane and spread to adjoining
tissues, while dissemination and metastasis occur early and rapidly.
Treatment.—For melanoma there is but one successful treatment,
and this is successful only when practised early, i. e., complete
excision or destruction. Every mole, nevus, or other skin lesion which
shows the slightest tendency to changes noted above should be
promptly excised, along with a wide area of its surrounding tissue. It
may be thus possible to make a radical cure. Neither x-rays nor any
other less radical method of treatment will have the slightest effect.
The treatment of any case left to itself until mistake in diagnosis is
impossible will probably be of little avail.

SKIN APPENDAGES; HAIR AND NAILS.

The only lesions of the hair and hair follicles that concern the
surgeon are those which have been described under the head of
Syphilis of the Skin, or some of the congenital growths, such as
plexiform neuroma, lymphangioma, etc., whose surfaces are
frequently pigmented and hairy, and may call for excision, along with
the underlying tumor.
The Nails.—Onychia implies any disturbance of the nail border
and matrix. Simple onychia occurs frequently in the
fingers of marasmic children. It is evidenced by softening and
swelling of the skin around the nail, by more or less pain,
disturbance of circulation beneath the nail, which becomes finally
loosened, sometimes leaving a foul ulcer. This ulceration may extend
and involve nearly the whole finger. It may occur in one or in several
fingers. Lesions of this kind are regarded as local infections,
occurring usually in vitiated constitutions. It is a common expression
or complication of syphilis; when of such origin it yields readily to
treatment; at other times it is often slow and tedious. Except in
specific cases, where mercurials locally and internally will usually be
sufficient, the treatment should be radical and should consist of
thorough exposure of the ulcerating and fungous surfaces, thorough
curetting, and the use of suitable caustics and antiseptic dressings.
Onychia Maligna.—Onychia maligna implies, according to some
writers, a more distinctive type of phlegmonous lesion, while the term
has also been applied to malignant ulcers, sometimes pigmented
(see Melanoma above) and sometimes of more ordinary type. In
either type of lesion granulation tissue may be exuberant and
fungating, and it is possible that at times there will be doubt in
diagnosis. The finger-tips, with their peculiar tactile sensibility, should
never be sacrificed unnecessarily, yet any malignant lesion calls for
amputation of the finger.
Ingrowing Toenail.—This is due almost invariably to ill-fitting
footwear, the toes being crowded into too narrow shoes, with too
high heels. The real lesion is not so much an excessive growth of the
nail as overgrowth and overriding of the skin margin around the
matrix. It is painful and annoying, sometimes even disabling. The
maceration of a perspiring foot in a warm and tight shoe serves to
aggravate the difficulty. Palliative treatment is afforded by
chiropodists and quacks, who pack cotton beneath the edge of the
nail and keep patients under treatment for indefinite periods, never
remedying the footwear and never curing the case. In simple cases it
is usually sufficient to excise a portion of reasonably healthy skin on
either side of the terminal phalanx, in order that by cicatricial
contraction the skin may be drawn away from the nail border.
Serious and long-standing cases are best treated by avulsion of the
nail, which may be usually performed under local anesthesia or by
the aid of nitrous oxide gas. The blade of a knife or scissors is driven
under the centre of the nail sufficiently to ensure its passing
completely beneath the hidden matrix. The nail is then split in the
middle, each half seized at its split border by strong forceps, and by
a rapid movement torn loose from its bed. The border of the skin
should be scraped, after which a simple dressing suffices, providing
the operation has been performed with proper antiseptic precautions.

TATTOO MARKS.
 Many an individual is tattooed in youth who would gladly be
relieved of the discoloration later in life. Tattoo marks are difficult to
erase. The following is a method attributed to Ohmann-Dumesnil:
“Wash the skin with soap and water, then with eight or ten fine
cambric needles, tied together and dipped in glycerole of papoid,
tattoo the stained skin, driving the needles into the tissues so as to
deposit the digestive in the corium, where the carbon is located.
Repeat as necessary. The pigment is liberated by the digestant.”
 CHAPTER XXVIII.
SURGICAL DISEASES OF THE FASCIÆ;
APONEUROSES; TENDONS AND TENDON
SHEATHS; MUSCLES AND BURSÆ.
Fasciæ and aponeuroses are such non-vascular and indifferent
tissues that they have practically no primary diseases, except such
fibrous and malignant tumors as have their origin in them;
nevertheless they suffer in a variety of morbid processes. They lose
vitality and break down under the influence of both acute and chronic
septic infections. By virtue of their resistant structure, when they
slough they break down slowly and the process ends usually with the
help of scissors and forceps. Many an old suppurating lesion,
especially of the hand and foot, is kept active by the fact that dense,
fibrous tissue remains concealed, which ought to have separated.
Under these circumstances free incisions should be made and all
necrotic tissue trimmed away.
Pus which has formed beneath these fibrous investments will give
pain largely in proportion to the intensity of the process and the
unyielding character of the fasciæ; hence the urgency of early
incision in case of deep phlegmon. Moreover, the direction of least
resistance may cause pus when confined to travel where its
presence is most undesirable, as from the neck beneath the deeper
muscle planes down into the thorax. When pus escapes from
beneath firm tissue it is usually by a small opening, after which it
may spread out again beneath the skin before finally escaping. This
condition has been called “collar-button abscess.” Care should be
exercised in opening the superficial collection not to miss the small
opening. The fascia must be split sufficiently to permit of thorough
cleaning out of whatever collection there may be beneath it.
In the presence of cicatricial contraction of the skin, in shortening
of muscles by chronic spasm, as in wryneck, or in certain deformities
—for instance of the foot—numerous signs of a shortening or
contraction of fasciæ and aponeuroses are seen. In many instances
of club-foot it thus becomes necessary not merely to divide tendons
but to make extensive incisions through the plantar aponeurosis or
elsewhere, in order to release sufficiently the parts whose extension
is desired. Underneath the joint contractures which have been
produced by burns and their resulting scars similar conditions will be
found, which in old and extensive cases constitute bridles of dense
tissue that make it almost impossible to release the parts.

DUPUYTREN’S CONTRACTION.
Dupuytren’s contraction presents the most serious and insidious
appearance of slow but almost irresistible contraction of fibrous
elements which the human body presents. It is produced by
contraction of the palmar fascia, with its numerous minute
prolongations, rather than by flexor tendons. It is seen in the hands
of men who from the nature of their occupations are subject to much
irritation of the palmar surface. It begins nearly always in the fourth
or fifth fingers, but may spread to and involve all the digits and even
the thumb. The view held by Adams and others that it is a chronic
hyperplastic inflammation, with scar-tissue contraction of the palmar
fascia and of the adjoining connective and fatty tissue, which does
not involve them evenly, but only at certain points, is correct, at least
when small nodules may be felt in the palm which are the precursors
of the disease. Either hand may be affected, but generally both are
involved. It is found in from 1 to 2 per cent. of those who depend
upon their hands for their support. Deformity may proceed to
pressure dislocation and finally to ankylosis. Its causation then is
very obscure; it is rarely the result of definite injury, but follows
continued irritation of the surface. It seems to have a local origin, and
yet it is frequently associated with the gouty diathesis to such an
extent that the prolonged use of alkalies will relieve some cases. The
first significant sign of the condition is the formation of small nodules
in the palm of the hand, as stated, and this usually precedes the
finger contraction by a year or two.
 Fig. 110 Fig. 111

Dupuytren’s contraction. (Adams.) Dupuytren’s contraction of palmar fascia,

showing contracted fingers. (Burrell.)

Treatment.—There is considerable difficulty in treating these

cases satisfactorily. Cooper advised subcutaneous
division of the tense bands and forcible stretching of the fingers; this
rarely proves sufficient. Adams advocated multiple sections made
with a small tenotome, which is more effective. The best method is
that of Kocher, which consists in excision of the fascial bands by
longitudinal incisions along the cords, and the dissection of the skin
from the underlying fascia. The cord is carefully dissected, with its
prolongations and then completely removed, while the margins of the
skin wounds are closed with sutures. The more thoroughly the
dissection is performed the more satisfactory the result. The fingers
should be straightened and kept from contraction by the use of a
mechanical device. In desperate cases the entire skin of the palm
has been removed, with the diseased fascia, and a plastic operation
made with skin taken from the thigh or the chest, the flap being
sutured in place but not detached completely for ten to twelve days.
Two somewhat allied conditions involving the hand and the foot
are the so-called lock or trigger-finger and hammer-toe.

LOCK OR TRIGGER-FINGER.
Lock or trigger-finger implies a peculiar obstruction to free
movement of the finger, which requires extra effort and then is
overcome quickly, as if a knot had been slipped through a small
opening. It is supposed to be due to a thickening of the tendon at
some point, as by a small fibroma, which becomes entangled along
the course of the sheath, through which it is moved with difficulty. It is
probably due to a local irritation, as in the case of Dupuytren’s
contraction. Injury to the tendon sheath may also produce a similar
condition.
Treatment.—Should it fail to respond to rest and massage the
sheath should be opened and the cause of the difficulty
sought out and removed.

HAMMER-TOE.
Hammer-toe produces deformity with more or less ankylosis. An
angle is formed between the first and second phalanges, and the tip
of the toe is made to bear more than its proportion of weight. This
deformity is in large degree due to the use of shoes which are too
short. In consequence there will develop over the protruding joint a
corn or bunion.
Treatment.—Should the trouble come on in childhood the toes
should be fastened to a straight splint and shoes for a
time abandoned, while later they should be properly adapted to the
needs of the case. In troublesome cases complete excision of the
involved joint gives satisfactory results.

SURGICAL DISEASES OF THE TENDONS AND

TENDON SHEATHS.

TENDOSYNOVITIS.
Acute inflammation of a tendon sheath is known as tendovaginitis
or tendosynovitis. It always implies an infection, and occurs about
the hands and feet. It is a frequent complication of felons. Many
felons begin in such a manner that it is difficult to decide which part
of the fibrous structures of the finger is first involved. Infection having
once occurred within a tendon sheath will travel rapidly until it meets
with a natural barrier. The frequency of these lesions makes it
important to recall here the anatomy of the tendon sheaths of the
hand. There is a common palmar tendon cavity, which connects with
the thumb and little finger and the space above the annular ligament,
but communication with the first, second, and third fingers is
ordinarily destroyed. This accounts for the apparent vagaries of
cases where infection beginning in the thumb spreads to the little
finger before the others are involved. It will also show the location
where incisions should be made.
 Fig. 112

Cicatricial contraction and deformity resulting from consequences of neglected

phlegmon and osteomyelitis of hand. (Lexer.)

Suppurative Tendosynovitis.—Suppurative tendosynovitis

needs prompt intervention, as
adhesions may result from retention of exudate, or lest necrosis of
tendon occur from perversion of its nutritive supply. Ordinarily it is
the result of a local infection, perhaps through a small, trifling surface
irritation, but it results occasionally as a metastatic expression of
gonorrhea, or distinct septic infection. A gonorrheal tendosynovitis is,
however, less likely to suppurate, but more likely to assume the
plastic form and interfere with function by producing adhesions
between a tendon and its sheath. The combination of virulent
bacteria and susceptible tissues will produce local destruction in
almost as short a time as in the appendix. The pain is intense,
because of the inelasticity of the structures.
—Every appearance of this kind calls for early incision, by which not
only the skin but the tendon sheath as well should be freely incised.
An incision at either end of the involved sheath, with flushing and
drainage, may save a tendon and preserve function. Incision should
not be delayed, as destruction may have occurred and deformity be
the result. When the common palmar sheath is involved a long
incision from the base of the index finger, around the base of the
thumb and up the wrist to a point considerably above the annular
 Fig. 113 Treatment.ligament,
will afford
considerable relief. It
will, moreover,
shorten the time of
ultimate restoration of
function.
—Chronic
tendosynovitis may
be the result of
rheumatism, in which
case it assumes the
plastic form, or of
gonorrhea; the same
being true of a
tuberculous invasion,
which may vary much
in intensity. In the
subacute forms the
deposition of
tubercles may lead to
a plastic outpour
which, being
detached by constant
motion of the parts, is
broken into masses
Suppurative tendosynovitis (felon), with sloughing whose minute
tendons and necrotic bone. Unfortunately poulticed
for two weeks. (Lexer.)
portions become
rounded off by friction
Chronic Tendosynovitis.and condensed by time, and appear as
the so-called “melon-seed or rice-grain
bodies.” Some of the same material may be found adherent to the
walls of such a cavity. In slower forms there is less tendency to
plastic outpour, but much more to the formation of granulation tissue,
such as is seen in tuberculous lesions in all parts of the body. When,
therefore, a case of this general character presents we have the
signs of local tuberculosis, or of dropsy of the tendon sheaths, with
the fluctuation somewhat modified by the presence in the fluid of
rice-grain or melon-seed bodies. Should, in such a case, an acute
infection be added we will have the chronic symptoms merged
suddenly into acute. A tendovaginitis of this type appears as a ridge
or swelling along the course of one or more tendons. It will be elastic
and fluctuate in proportion to the distention of the sheath. When the
palmar bursa is involved there is usually, in the palm of the hand, a
bag of fluid which may be forced above the wrist by pressure, while
frequently the little bodies above described are recognizable by the
sensations (crepitus) which they produce. The plastic type rarely
proceeds to suppuration or ulceration unless secondarily infected.
The granulation type proceeds to ulceration and destruction.
Treatment.—Treatment of the rheumatic and gonorrheal forms is at
first rest, with later passive and forced motion, in order to break up
adhesions and prevent their re-formation. If one wait too long he
meets with great difficulty in these efforts and the cases become
exceedingly tedious. Forcible motion should be practised under
nitrous oxide anesthesia and should be repeated every two or three
days. Meanwhile massage should be employed. If pain or reaction
be extreme ice-cold applications should be applied. Extreme swelling
may be combated by the use of a rubber glove. If this be worn,
ichthyol-mercurial ointment should be used beneath it, in order to
promote absorption.
Treatment of the tuberculous cases is often disappointing. Non-
operative measures afford but temporary benefit, while operation to
be effective should be thorough. It should consist of free incision,
with exposure in whole or in part of the affected channel or cavity,
thorough cleaning out of its contents, removal of all edematous or
tuberculous tissue or granulations, and the use of an antiseptic as
strong as it can be employed.
The new opsonic serum treatment, now being placed on trial as
this work goes to press, promises much in the treatment of all these
septic affections, though detailed statements would be premature.

TENDOPLASTY.
 It was a step in advance in surgical technique when Stromeyer
and Dieffenbach, in 1842, introduced the method of subcutaneous
division of tendons and aponeuroses, and showed how easily
contracted tendons could be lengthened by tenotomy. From their
time until somewhat recently tenotomy has held its place in the
treatment of various deformities, and until Anger, Gluck, Hoffa, and
others have taught the surgical profession what can be done by
various plastic and suture methods in overcoming defects and
atoning for loss of function in paralyzed muscles. To the surgery of
tendons and muscle terminations have been added the further
resources of tendon suture, i. e., tenorrhaphy, and tendoplasty, by
which latter something more than the mere suture is meant, i. e., the
plastic rearrangement and grafting of tendons one upon another.[20]
[20] The method of transplanting one tendon upon another is to be
credited to Nicoladoni, who perfected it in 1882. Later it fell into disuse, but
was revived in this country, especially by Goldthwait, of Boston, in 1896.
 Fig. 114 Fig. 115

Fig. 116 Fig. 117 Fig. 118

 Fig. 119 Fig. 120 Fig. 121

Illustrating various methods of dealing with tendons in tendoplasty. (After Vulpius.)

 Tendon suture is practised as an emergency measure when one
or more tendons has been accidentally divided, this being
considered now as much a part of the surgeon’s duty as to close any
other part of the wound. No additional resource or expedient is
needed, it being necessary only to observe the principles of asepsis,
which should be maintained in every case. A tendon raggedly
divided should be cleanly cut and its edges brought together with
formalin-gut or freshly boiled silk. A series of divided tendons should
be treated after the same fashion, matching the ends as closely and
completely as possible. After uniting the tendon ends, if the case be
clean, the tendon sheath should be closed and the parts put at rest,
in such a position that no tension is made upon the injured sinew
until it is seen to have united.
Fig. 122 Fig. 123

Shortening a tendon.