Surgery, with Special Reference to Podiatry Part 19

Back pressure upon the matrix from a short shoe upon a thick unresisting nail, is frequently the cause of onychia.

+Palliative Treatment of Hypertrophy.+ When the deformity seriously interferes with the wearing of shoes, or shows a tendency to cut into the lateral fold, it becomes necessary to establish normal dimensions either with the knife or drill.

The total removal of the nail; including the matrix, is the only permanent cure. Excision of the cutting edge of the nail, as in radical operation of ingrown nail, eliminates only that element of discomfort.

The thinning of the nail, by sc.r.a.ping or with the drill, can also be accomplished with sodium sulphide. A sufficient quant.i.ty of the sulphide is added to starch paste to make it swell; this, when applied (use a wooden applicator) to the thickened nail, will cause the nail to disintegrate. By touching the surface with the applicator, one can determine the depth of nail destroyed before was.h.i.+ng off the excess sulphide.

+Radical Treatment of Hypertrophy.+ When the thick nail has cut into the lateral fold and actual ulceration has occurred, it becomes necessary to remove the down-curved edge.

Under local anesthesia, an incision is made through the nail, a little to the side of the inflamed area, and is carried well back through the matrix. A curved incision, outside of the infected fold, meets the first incision in front and back of the nail. All the tissue between is removed in one piece, including the offending portion of nail with its matrix and the nail fold with all granulation tissue.

This wound may be brought together by catgut sutures, or may be allowed to heal by granulation.

This operation suffices to prevent further trouble at the nail edge, but does not prevent the discomforts due to a long, distorted, h.o.r.n.y nail. Total removal of the nail with its matrix is the only radical cure. (See "_Local Anesthesia"_).

+Inflammation of the Matrix (Onychia).+ As a result oftraumatism in unhealthy individuals, inflammation and suppuration sometimes occur at the root of a nail and in the contiguous portion of matrix ("run-around"), and often stubbornly continue unless the loosened, sharp edge of the buried nail be carefully trimmed away from time to time, and a little iodoform gauze be employed to press back the inflamed tissues.

From lateral hypertrophy of a toe-nail the sharp lateral edge becomes imbedded in the lateral fold, or from improper lateral compression of the toes, the same portion of soft tissues is forced up against the margin of the nail. In either case, inflammation, suppuration, and ulceration ensue, resulting in the formation of red, exuberant, excessively painful granulations, const.i.tuting the condition called _ingrowing toe-nail_, though more correctly it should be termed "up-growing pulp." Sometimes both edges, or even the whole matrix, become involved, producing pain on any movement of the member.

When inflammation and ulceration of the whole matrix occur, especially where a finger is involved, the condition is termed _onychia maligna_, which attacks only those in depressed health.

+Treatment.+ The palliative treatment suggested for ingrown nail is indicated for all inflammations of the matrix, as far as the disinfection or removal of the portion of nail producing irritation is concerned, but in onychia maligna the whole nail usually requires removal under local anesthesia, with destruction of the matrix by caustics, or by curetment.

Chapter XV

+TUMORS AND CYSTS+

+TUMORS+

+Definition.+ A tumor is a circ.u.mscribed ma.s.s of tissue made up of cells of the same kind as the tissue from which it grows.

There are two distinct types of tissue in the body: epithelial and connective, and therefore two types of tumors: the _epithelial tissue tumors_ and the _connective tissue tumors_.

Tumors may also be cla.s.sified as _typical_, and _atypical_. A typical tumor is one in which the cells are identical to those in the tissue from which it springs, and also has the same arrangement of cells.

They may be of epithelial or connective tissue origin. The tissue is identical in all respects and the growth is benign. An atypical tumor is one of epithelial or connective tissue origin in which, though the cells are the same as those in the tissue from which it grows, their arrangement is quite different. They are malignant.

The most important cla.s.sification of tumors is that into _benign_ and _malignant_.

A _benign tumor_ is one in which there is no tendency to rapid growth; the symptoms are purely local, and the general health is not affected, except indirectly.

On the other hand a _malignant tumor_ is one which takes on a rapid growth with a tendency to infiltrate or adhere to surrounding tissues; recurs when removed, and is accompanied by great pain and a rapid loss of weight and strength. These are commonly known as cancerous.

Malignant growths are of two types, carcinomatous and sarcomatous, dependent upon the tissue from which they emanate.

The _carcinomata_ spring from the epithelial type of tissue while the _sarcomata_ emanate from the connective tissue type.

+Origin.+ Tumors originate from many causes. Some are congenital and others grow in later life from an inherited tendency.

Any continued irritation which acts mechanically or chemically so as to maintain a constant, though slight, degree of undue vascularity of a part, such as the hot, rough stem of a clay pipe or a jagged tooth, favors the development of a malignant growth. Certain benign growths, such as warts or moles, are especially p.r.o.ne to malignant change. Age and s.e.x also predispose to tumor formation.

Thus carcinoma is a rarity under thirty years of age; the mammary gland of the female is more liable to carcinoma than the male; while on the other hand the esophagus, lip and tongue of the male are more liable to attack.

The possibility of certain malignant growths being of germ origin is thought to be evident (though not yet proven) from many facts. The fact that where there are malignant growths present, lymphatic glands, quite distant from the original growth, become secondarily infected, through the lymphatic vessels, seems to carry out this view.

Particles of a carcinoma (metastasis) floating in the blood stream, finding lodgment elsewhere also establish new growths (metastatic).

Tumors are named according to the tissues from which they arise, thus:

CONNECTIVE TISSUE TUMORS

Fibrous tissue---Fibroma Fatty tissue---Lipoma Mucous tissue---Myxoma Muscular tissue---Myoma Cartilage---Chondroma Bone---Osteoma Blood vessels---Angioma Lymphatics---Lymphangioma Lymphatic glands---Lymphoma

EPITHELIAL TISSUE TUMORS

Warty---Papilloma Glandular---Adenoma Skin---Epithelioma

+CYSTS+

+Definition.+ Cysts are hollow tumors filled with fluid or semi-solid contents. They are cla.s.sified according to their mode of development:

1. Cysts formed in already existing s.p.a.ces such as sebaceous cysts in the sebaceous glands of the skin; mucous cysts in mucous glands, and distension cysts in ducts of large glands like the salivary, lacteal, hepatic, etc.

2. Cysts of new formation into the tissue s.p.a.ces from the effusion of blood or plasma.

3. Congenital cysts known as dermoids.

4. Cysts of parasitic origin.

The only cyst with which the chiropodist ordinarily comes in contact is of the sebaceous variety.

+Sebaceous Cyst.+ A sebaceous cyst is a tumor resulting from retained seb.u.m (secretion of the sebaceous glands).

They sometimes, though rarely, are found on the soles of the feet.

They range in size from a millet seed to the size of an egg or larger; they may be globular or flattened. They may be single or multiple; the skin over them is normal in color and smooth, or white if distended, red if inflamed. They grow very slowly and ordinarily persist indefinitely, but calcareous changes are common. Not infrequently they break down and ulcerate. The wall is made up of connective tissue lined with epithelium and the secretion if chemically altered, becomes fluid, semi-fluid, cheesy or purulent.

+Treatment.+ Spontaneous cure often occurs when a cyst becomes inflamed and suppurates. The pus is evacuated either spontaneously or by incision, following which the walls of the sac adhere and its cavity is obliterated.

Treatment directed toward the obliteration of the sac is the only procedure which gives promise of permanent cure; mere puncture and evacuation will effect only temporary relief, the sac soon filling again.

Incision followed by dissection and removal of the sac, either intact or punctured, is radical and efficient.