On rhinophyma or the Hammer-nose / by Balmanno Squire.

  • Squire, Balmanno, -1908.
Date:
1889
Catalogue details

Licence: Public Domain Mark

Credit: On rhinophyma or the Hammer-nose / by Balmanno Squire. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    skin. It is in fact a pseudo-hypertrophy of the skin. The new-for- mation consists, in its earlier stages, principally of embryonic connec- tive-tissue, which later on \mdergoes development into mature con- nective-tissue. As a result of this localized increase of connective tissue, both within, and also immediately beneath, the substance of the corium; a considerable thickening of the skin, and of the sub- cutaneous connective tissue is produced. With this thickening of the skin is associated, dilatation of the smaller bloodvessels of the skin, and also new formation of small bloodvessels. Furthermore there is a notable dilatation of the sebaceous follicles, which are distended with solid sebum, and are also greatly hypertrophied. The epidermis how- ever remains unchanged. The thickened skin contains many connective tissue cells, as well as migratory cells derived from the multiplied and dilated bloodvessels, and ftirthermore numerous embryonic cells with nuclei. Many of the embryonic cells are i;ndergoing conversion into connective tissue. The embryonic cells are arranged in groups. The bloodvessels of the afected skin are much more numerous, and of much greater size, than is proper to the normal condition. The sebaceous glands are notably enlarged, some of them in only a moderate degree, but others acquire, a very considerable increase of size. Their ducts also are greatly dilated. Thus to the considerable thickening of the skin and of the sub- cutaneous connective tissue, induced by the new formation of connec- tive tissue: there is added a further potent cause of increase of sub- stance, namely the great increase in size of the sebaceous follicles imbedded in these structures. The sebaceous glands are, however, not only greatly enlarged. They also possess a greater number of lobules, which are separated from one another by strong bundles of connective tissue. The distension of the glands, produced by the undue proliferation of their epithelial constituents, is still further contributed to by the abnormally solid nature of their contents, which escape sluggishly and so cause a further expansion of the cyst-like structure. On examining the epithelial contents of the sebaceous glands, it is found that the cells remain nucleated nearly up to the commencement of the duct, where their contour fades and their nucleus disappears. The duct contains a greasy, dingy-coloured, finely granular mass, interspersed with darkly pigmented particles. This mass consists of the debris of the gland-cells. The dark particles in it are derived from the debris of the layers of pigmented epithelium with which the wall of the duct is lined. The treatment of Ehinophyma is in most instances a imrely surgical matter. When the disease is only recently developed it is possible to obtain resorption of the new connective tissue. But when the tumour is of long standing, as it generally is by the time that it comes under obser- vation, one cannot count on producing absorption of the now mature and long-established connective-tissue-growth which is the chief cause of the enlargement. Nevertheless, even in its fully developed condi- tion, the ‘ hammer-nose ’, or even the ‘ pound-nose ’, is capable of being rendered less unsightly, and even of being somewhat diminished in size without having recourse to very radical measures. That is to say the redness may be diminished and with it so much of the enlargement as may be due to increased vascularity. When the disease is in its earlier stages, it is possible to reduce the dilatation and hypertrophy of the sebaceous glands by repeatedly kneading the enlarged nose between the fingers and thumb so as to express the sebaceous accumulation, and by applying various stimu- lating applications, for example an Ointment of the Bed Iodide of Mercury (15 grs. to I oz.), or a Lotion of Perchloride of Mercury (1 gr. dissolved in I fl. oz. of Eectified Si)ii'it). Such api)lications, moreover, assist materially in promoting absorption of the new connective tissue formed in the substance of the corium and of the subcrrtaneous areolar tissrre. When by such means the thickening and, coincidently, the pitting of the nose have become materially lessened, the skin will then have become srrfficiently prepared for attacking the teleangiectases at the best advantage. This may most conveniently be done by means of the process of multiple linear scarification as first devised by myself. For this purpose my multiple linear scarifier, which I have recently figured elsewhere,' offers many advantages. In obliterating the dilated bloodvessels by means of scarification care should be taken that so far as possible the incisions be made in a direction transverse to the direction of the larger branches, and not as is sometimes done in a direction parallel with them. It will be found that on the alae and tip of the nose the direction of the larger twigs is vertical, that is to say parallel with the length of the nose. Accordingly the direction of the little cuts should be horizontal. In executing them it will be an advantage to insert the forefinger of the left hand, for some little dis- tance, into the nostril of the side on which the incisions are being made. The pulp of the finger introduced into the nostril should face outwards. There is a three-fold reason for this precaution. Not only is the wing or tip of the nose, as the case may be, supported firmly while it is pressed on by the instrument; biit the jjart operated on is also flattened out so that the numerous incisions, which are made at one sweej) of the instrument, are all of fairly uniform depth; moreover the operator’s sense of touch is employed not only in his hold of the instrument but also in the counterpressurc he makes on the part that is being operated on. The obliteration of the teleangiectases is not the only advantage obtained by multiple linear scarification: it also ensures, and that in a very marked degree, a still further subsidence of the thickening of the skin. I find it advantageous to defer the ' On Lujius vulgaris. LenJon, 1888. Fig. 4. employment of scarification (in the treatment of early Ehinophyma) until after the distension of the sebaceous glands and the pitting of the skin have been somewhat reduced by ‘ massage ’ and the use of stimulating applications. Otherwise the incision of the hregular sur- face, and of the distended folhcles opening on to it, is apt to pro- duce a conspicuous and very odd-looking burrowed jiitting of the skin which it is impossible to remedy. When the enlargement of the nose is of long standing and has acquired notable dimensions, when for example it is in the condition reiiresented in the coloured illustration, the treatment that I have described as effective in the earlier stages of the growth will still be of some avail in moderating the disfigurement; that is to say it is capable of diminishing in some tangible degree the enlargement, the redness, and the coarsely pitted aiipearance of the nose. Nevertheless, when once the disease has attained a fairly consider- able development, the most speedy, the most effective, and on the whole the best means of treating it is to deal with it surgically. As regards the pedunculated or fig-shaped excrescences, when such are present, the best means of abolishing them is to snijD them off at their narrowed base with a pair of curved scissors. It is excrescences which are developed on the wings of the nose that, as a rule, lend themselves most to this easy way of riddance. But in dealing with sessile or hemispherical lobes of the tumoiu’, and more par- ticularly with the snout-like enlargement of the tip of the nose, the surgeon has to elect between two distinct methods of operation. The one is to attempt an opera- tion of the so-called ‘ plastic ’ land, or, if need be, several small operations of this character; in other words, to excise in one or more places a wedge-shaped piece of the thickened skin: the base of the wedge being formed by the surface of the skin, and the thin end of the wedge by the line of junction, deep in the tumour, of the two converging incisions. The outline of the base of the wedge must be spindle-shaped. After the wedge- shaped ihece has been removed, the sides of the wound are brought together. The other method of operation is of a more sweeping kind: sessile lobules are shaved off, and, in the case of the snout-like enlargement of the tip and indeed of the enlarged alje as well, the nose has to be literally carved out anew from the tumour in which it is concealed. The former method, which perhaps may be regarded as somewhat of the nature of a compromise, has the advantage of leaving the nose covered with skin: bub has the disadvantage of leaving a raised linear scar, or a retracted cicatricial cleft, as the case may be, at the line of junction of the api^osed raw surfaces: moreover, ‘at the best, the operation can never produce a wholly satisfactory result from the point of view of shape. It is not like a matter of excising, and uniting the cut edges of, skin which is thin and glides readily over the subjacent structures; as, for instance, in the operation performed on the skin of the orbit for one of the kinds of entropion. In the case of Ehinophyma all skin that is left on either side of the removed wedge is enormously thick- ened, and so the result obtained is necessarily far short of a complete abolition of the growth. Now the more thorough method, that of complete ablation, has it is true the disadvantage of leaving the nose with a cicatricial covering in the i:)lace of true skin; but, if neatly performed, it restores the nose perfectly to its original shai^e. In performing this operation considerable assistance is afforded by the fact that as a rule, even in very adxanced cases, the actual margin of the nostrils is quite unaffected by the growth : so that an accurate starting point is afforded around the margin of each nostril. Then again, at the upjier margin of the tumour, the swelling rises abruptly so that an accurate line of departure is presented there also. Still further assistance can be gained by introduc- ing the forefinger of the left hand far up the nostril of the side that is being operated on, the pulp of the finger-tip being held outwards. Tlie reasons for this manoeuvre are much the same as in the case of multiple linear scarification. It is perhaps scarcely neces- sary to say that some familiarity with the art of drawing is a con- siderable assistance in a procedure of this kind. The bleeding, which is apt to be copious, is readily arrested by adjusting the coimavity of a small sponge over the nose, and by making pressure on tne sponge for some time. The raw surface heals quite speedily owing to the considerable number and the deep situation of the sebaceous glands in the fleshy jiart of the nose. The remains of these glands, which are left after the operation, afford numerous starting points of epithelium so that the wound soon skins over. The form of knife most suitable for performing the operation of complete ablation of a Ehinophyma is figured in the text. F. v. Hebra' records a case in which the con- siderably elongated tip of the nose was removed by the elastic ligature devised by Bittel but such a method is not very well suited for the performance of a iilastic operation. B. S. 21, Weymouth Street, Portland Place, 1889. The Author’s Ablation- knife. ' ‘ Zur Therapie der Acne rosacea,’ Wiener naedizinische Wochenschrift, Nr. 1 1878.