Complete Text (Part 6)

the matrix ; in this latter case they are thickened and incurvated (onychogryphosis), and appear as if raised from their bed by a laminated mass. Sometimes a double nail, especially on the thumb, is met with, and even a double terminal phalanx. c. The cutaneous glands, apart from new formations, pre- sent little of importance. The most common affection to which they are subject is purulent inflammation about the sebaceous glands, especially of the face (acne). If this be associated with considerable redness and inflammatory swell- SKIN ÄND SUBCUTANEOUS TISSUE. 25 ing of the surrounding skin it is called acne rosacea, and is met with chiefly on the nose. If the inflammation start from the glands belonging to the hair of the beard, it is called acne mentagra or sycosis, but must not be confounded with sycosis parasitica, which depends on a vegetable growth. 7. Morbid growths in the skin. («.) Hypertrophy of the skin, involving sometimes chiefly the epidermis, sometimes chiefly the connective tissue, forms the connecting link be- tween those affections which we have considered above, and tumors of the skin and subcutaneous cellular tissue. Many of the forms of hypertrophy are of so little importance, and so easy of diagnosis, that their mere mention almost suffices. Such are : callus (tyloma^, corn (^clavus') — both mere thickenings of the epidermis. Ichthyosis, which is gen- erally of considerable extent, consists in increased formation of, and horny change in, the epidermis, and transforms the skin into a sort of horny coat of mail which breaks off in scales and plates. A similar, but local process, leads to the formation of horny excrescences (^cornua cutanea^. Common hard warts (yerruccB), which consist chiefly of epithelium, although they involve also increase in the papillary layer, and the so- called vegetations (especially common on or near the geni- tals), in the formation of which the papillary layer plays a great part, the papillse becoming very long, pointed, and even giving off branches, condyloma acuminata, also belong in this class. The epidermis does not increase enough to cover over all these papillary outgrowths, the result of which is that some of the papillse project from the surface. These growths sometimes are of considerable extent, particularly when seated at the outlet of a canal lined with mucous mem- brane, papilloma. Elephantiasis Arahum is rather an affection of the true skin and the subcutaneous tissue, and is chiefly met with in the feet, legs, and genitals. In well-marked cases the foot and leg are much enlarged, the angle between them is more or less effaced, the surface of the skin is sometimes smooth, 26 DIAGNOSIS IN PATHOLOGICAL ANATOMY. sometimes studded with nodules and excrescences, and often pours out a secretion, which may have a milky appearance. The secretion is more often met with where flat superficial ulcers with brawny bases are present. Sometimes, especially on the genitals, elevations of variable size are met with, from which this fluid exudes in enormous quantities. On section cavities appear which are easily recognized as en- larged lymph spaces Qp achy der mia lymphangieetaticd) . On cutting into the extremities the enlargement is found to consist of a tough, firm, whitish tissue, which has re- placed the true skin and in great measure also the subcu- taneous tissue, and may even penetrate the intermuscular spaces as far as the bone (the diffuse fibroma of Virchow). The microscope shows a great increase in the number of ves- sels, and an enlargement of the papillge, especially at the seat of the warty protuberances. Bundles of dense connective tissue cross each other in all directions, and the more com- plex structures which are inclosed between them, as fat, muscle, and nerves, are gradually destroyed ; the bone shows signs of extensive, irregular ossifying periostitis (hyperos- tosis). The rare affections sclerema neonatorum and scleroderma of adults also belong in this class. They are characterized by fibrous thickening of the skin, which, in its later stages, gives rise to atrophy and retraction of the same. The skin then is smooth, shiny, and so tense as to distort the joints in various ways. Soft warts or wholes, when congenital, are called mother's marks (noevi materni) and belong almost exclusively to the true skin. They are more or less sharply elevated above the surface of the skin ; are seen on section to consist of a soft gray tissue, which is strongly contrasted with the structure of the skin ; extend to a variable depth into the cutis, and sometimes even into the subcutaneous tissue ; and are cov- ered by an epithelial layer which is but little, if at all, thicker than normal. They are often pigmented, the pig- ment lying partly in the lower layers of epithelial cells, but SKIN AND SUBCUTANEOUS TISSUE. 27 chiefly in the richly cellular connective tissue of which the mole is composed. These formations are interesting chiefly from the frequency with which sarcomatous tumors spring from them. b. Of the actual tumors which are found on the skin, cystic tumors (1) first demand our attention. Some of these are due to retention of the secretion of the hair folli- cles and sebaceous glands. The simplest form of these is the small yellow nodule, very common on the nose, called comedo, which on pressure allows the escape of a little yellow wormlike body with a black head (dirt) from the dilated hair follicle. This little body consists of epithelial cells and fat, and is merely retained secretion. Milium is a rather larger yellow nodule (the size of the head of a pin) ; it has no external opening like the comedo, which it resembles, however, in structure, and occupies the deeper portion of the hair follicle. The largest of these retention-cysts is the wen (^atheroma) which is ordinarily from the size of a pea to that of a hazel-nut, but may, in rare instances, reach the size of the head. Its contents consist sometimes of soft, thick, yellow, glistening plates of Cholesterine, sometimes of a but- tery or even chalky mass, and are inclosed by a membrane of connective tissue, the cyst wall, which contains but few vessels, and often has points of cretification. When of a cer- tain size they remain seated in the cutis, but on further growth encroach upon the subcutaneous tissue, and become entirely imbedded in it. Under the microscope the contents are resolved into horny epithelial cells, fatty degenerated cells, free fat drops, and crystallized fat, particularly Choles- terine. The so-called dermoid cysts resemble wens closely, but are much more rare. They range from the size of a walnut to that of a hen's egg, and consist of a sack, containing a soft, yellowish, greasy mass of fat, Cholesterine, epidermis, etc. Sometimes hair or even more organized structures are found in them. The wall is not, as in a wen, a simple fibrous in- vestment, but contains all the elements of the outer skin, — 28 DIAGNOSIS IN PATHOLOGICAL ANATOMY. epidermis, cutis richly supplied with vessels, hair, and seba- ceous glands, which are not always distributed uniformly throughout the circumference but may be confined to more or less limited portions of it. The whole skin is thus here represented, and the contents are only retained sebum and cast-off epidermis. The formation of sebum predominates over that of epidermis — the reverse is the case in wens — and hence a large cavity containing chiefly sebum or a honey- like matter may nearly always be classed as a dermoid cyst (Virchow). Other cystic formations are met with in the subcutaneous and intermuscular tissue, and even by the side of the bones, which are distinguished from those already described, in that they do not contain retained glandular secretion but a clear, highly albuminous fluid, varying in consistency from that of water to that of honey (meliceris). The hygromata, the most common of which is hygroma praepatellare (housemaid'' s hnee)., also belong in this class, and are dilatated normal or newly formed bursse. They form ill-defined cavities in the connective tissue, sometimes with prolongations, and are often traversed by bands and septa of connective tissue, or are rough on their inner surface. Another subdivision includes those accumulations of syno- vial fluid in the sheaths of the tendons called ganglion., or weeping sinew. They are chiefly found on the wrist and ankle. If the secretion is thick, they are called meliceris cysts, or cysts with honey-like contents. Sometimes a sort of papillary growth takes place on the inner wall. These growths may become pedunculated and then detached, thus forming those small, flattened, grayish-white free bodies which are sometimes found in large numbers in these cysts. There is still another form of cyst which results from the dilatation of lymph spaces. They are commonly seated on the neck (Jiygromata eolW), and are sometimes congenital. 2. Vascular Tumors (Ängiomata') . These are very com- mon on the skin. We do not mean to include under this SKIN AND SUBCUTANEOUS TISSUE. 29 head aneurismal dilatations of the arteries or varicosities of the veins, which may also cause prominence of the skin, and will be described under disease of the vessels, but refer here to dilatation, and, what is still more common, new formation of the capillaries (telangiectasis). These tumors project but little above the surface of the skin, are either bluish or bright red in color, are sometimes of large extent, and often congenital (jicevi vasoulosi'). Cavernous tumors., so called, are much less common, and depend on the new formation of vessels larger than capillaries ; they generally spring from the subcutaneous fat tissue. 3. Lipomata (fatty tumors) are often met with on the skin and are to be regarded as local hyperplasias of the sub- cutaneous fat tissue. They are distinctly lobulated, the lobules are separated by vascular connective tissue, and the fat cells are plainly visible to the naked eye. These tumors are more or less elevated above the surface, and sometimes, indeed, are only connected with it by a small pedicle (lipoma pendulum). If the interstitial connective tissue be abundant and dense, the tumor is harder, and white bands are seen running through it (lipoma fibrosum or durum) ; if the tis- sue softens — this is more liable to occur at the centre — the fat escapes from its limiting membrane, and a cavity is formed, filled with an oily mass. Telangiectasis is often associated with these tumors (lipoma telangiectodes) : this form is congenital. A remarkable formation of fatty tissue often takes place about old hernial sacs. A growth of mucous tissue is sometimes found in lipomata, especially at the centre (lipoma myxomatodes or myxoma lipomatodes, according as either structure predominates). The myxomatous portion is somewhat transparent, gelati- nous, and becomes white on the addition of acetic acid, as can be seen with the naked eye. Under the microscope — a bit snipped off with the scissors will generally answer the purpose — one sees a perfectly transparent substance, in which the addition of acetic acid produces a filamentous or granular opacity, which does not disappear on adding an ex- 30 DIAGNOSIS IN PATHOLOGICAL ANATOMY. cess of the reagent, and whicli contains a network of star and spindle-shaped cells with anastomosing processes. 4. Pure myxomata also occur, both in children (connected with the umbilicus) and adults. Their origin, in the latter, is often in the deeper tissues, and their presence in the skin is only secondary. 5. The same remark applies to enchondromata, which generally spring from the bones or their vicinity. They may attain great size, may cause ulceration of the skin, and consequent exposure of the bluish-white cartilaginous tissue of which they are composed. Like the lipoma they are lobu- lated, and the lobules are surrounded by connective tissue. Sections may readily be prepared for the microscope, which shows their structure to be that of hyaline cartilage, except that sometimes, particularly near the edges of the smallest lobules, the cells are star-shaped (star-celled cartilage). The various structures of the enchondroma, the myxoma, and the lipoma are often combined in the same tumor. True bony tumors of the skin (osteomata) are very rare. 6. Three forms of granulomata (granulationsgeschwiilste, Virchow) occur in the skin, the lupous, the leprous, and the syphilitic. (a.) The microscopic appearances of lupus are very varied. The typical form consists of multiple bluish-red nodules, from the size of a hemp-seed to that of a pea, springing from the cutis and projecting above the surface of the skin (lupus tuberculosus or nodosus). An earlier stage in which the nodules have not as yet become raised above the surface, but appear only as brownish-red stains, from the size of the head of a pin to that of a lentil, is called I. maculosus. If the nodules have become confluent and thus an extensive new formation project above the surface, it is called I. hyper- tropMcus ; if the skin over the infiltration be covered with epithelial scales, it is called I. exfoliativus ; and, lastly, if the nodules have burst and formed an ulcer or ulcers, it is called I. ezulcerans. According to that view of the subject which is now prevalent, a nodular small-celled growth in the co- SKIN AND SUBCUTANEOUS TISSUE. 31 rium extending outward into the papillary, as well as in- ward into the cellular layer, constitutes the histological base of these changes. Ulceration depends on a disintegration of these cells, and heals, leaving scars and great contraction. All the stages of the process (growth, ulceration, and cicatri- zation) may be found near each other in the same subject. According to Rindfleisch, lupus is to be regarded as adenoma of the cutaneous glands ; according to Friedländer as local tuberculosis. The name lupus erythematodes or erythematosus has been given to an affection which is not attended by either the formation of nodules or by ulceration, but by the formation of minute cellular masses in the cutis. This growth is very apt to involve the sebaceous glands (causing enlargement of the glands and milium), and often starts from them; it is al- most strictly confined to the face, and when it extends from the nose symmetrically over either cheek forms a figure very like a butterfly. Lupus of long standing with its attendant cicatrices is much more commonly met with on the dead body than the recent form. The favorite seat of the disease being the face, it is here that its ravages are most marked ; all the prominent parts of the face, the tip of the nose, the lips, the eyelids, may be destroyed ; the skin of the face is smooth, tense, and glistening ; the nostrils are mere apertures in the face ; the mouth is transformed into a more or less rounded hole sur- rounded by cicatricial tissue ; the eyeballs are exposed, ulcer- ated, or destroyed, having been deprived of the protection of the lids. There is one point in regard to the distortion of the nose which is of special importance. Lupus attacks first the anterior portion (the soft parts and cartilages), while syphilis attacks the bone first and allows the bridge of the nose to sink in. (5.) Leprosy (^elephantiasis Crrcecorum'), only sporadic in Middle Europe, is characterized by much larger nodules, from the size of a hazel-nut to that of a walnut, the chief seats of which are the face and extremities. The nodules occupy 32 DIAGNOSIS IN PATHOLOGICAL ANATOMY. the corium, though they may extend into the subcutaneous tissue, and consist of richly celhilar granulation-tissue, which, according to Virchow, evidently springs from the cells of the connective tissue. The condition of the nodules remains unchanged for a long time, though, when old, their cells may undergo fatty degeneration and thus the nodules diminish in size. Ulceration is rare, and is always dependent on exter- nal influences. ((?.) Syphilis may be the cause of tumor-like growths in the skin, as well as of more inflammatory processes (psoriasis, pemphigus, rupia, etc.). These growths are called gummata and consist of a soft, small-celled tissue with an intercellular substance soaked in a sticky fluid, which fluid exudes from the cut surface on pressure. The nodules may soften in con- sequence of fatty degeneration of the cells, and open ulcers result from the destruction of the superficial tissues. The base of such ulcers is formed by gummy tissue, which is con- stantly breaking down ; it thus acquires a yellowish, brawny appearance, and becomes dense and indurated to the touch. Many authorities class here the primary syphilitic sore, the so-called hard chancre, which has exactly the character we have just described. A, «econd form is the mucous patch (condyloma latum, plaque muqueuse'), which is attended by growth of the individual papillse, the epidermis covering which is thinned, softened, and moist, thus resembling that covering mucous membranes. A third form is the so-called lupus syphiliticus, especially common on the extremities. In this form numerous nodules, varying in size from that of a hemp-seed to that of a pea, are seated in the cutis or even in the subcutaneous tissue ; in their early stages they are dense, but later they become softer (much more rapidly in the skin than elsewhere), and form open sores partly through fatty degeneration and partly through suppuration. These ulcers are at first round, but becoming confluent, they as- sume all sorts of irregular shapes, and in healing leave scars which are remarkable for the degree of contraction which they may undergo. SKIN AND SUBCUTANEOUS TISSUE. 33 (<;?.) Glanders or farcy {inaliasmus) is also classed here by Vircliow. This disease is attended by the formation of nodules in the skin which diiEfer from those before described in that they tend to break down by suppuration, but like them consist of a small-celled growth. The nodules on breaking down leave ulcers which likewise, by becoming con- fluent, may acquire an irregular contour. There is an acute as well as a chronic form, the formation of nodules