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.