often valuable. It is of most service in the non-ulcerating forms.
Linear scarification is the more satisfactory. The parts are thoroughly
cross-tracked and a simple ointment applied. If the bleeding is marked,
cold compresses may be applied. Anæmia of the parts results, the
papules are disturbed, and the new growth rapidly undergoes
retrogressive changes. If the area to be operated upon is large, the
patient should be anæsthetized. Charging the knife, or if punctiform
scarifications are practised the pointed instrument, with iodized
glycerin (one part iodine to twenty of glycerin) has been advised, as
rendering a successful result the more certain. The scar following the
curette and linear and punctate scarification is usually soft and
white, much less disfiguring, as a rule, than that following the action
of the stronger caustics. Destruction of the new growth by means of the
galvano-cautery or by the actual cautery has from time to time had its
advocates. Piercing the individual lesions with a platinum needle-point
heated to dull red by means of the battery has been strongly advised;
comparative absence of pain, rapidity, and good results are claimed for
it.
Scrofuloderma.
Scrofuloderma is a term employed to designate certain morbid conditions
of the skin which are dependent upon that state of the system known as
scrofula, or struma. The most common form of the cutaneous
manifestation is that which has its beginning in one or more of the
lymphatic glands. The gland slowly increases in size, without any of
the ordinary signs of inflammation, and after reaching the dimensions
of an almond may so remain or undergo fatty or cheesy degeneration. As
a rule, however, sooner or later the gland grows much larger, the
new-cell growth breaks down, the superjacent skin becomes hyperæmic,
thin, sensitive, and of a violaceous or purplish color. Finally, the
tumor breaks, and a thick, cheesy pus mixed with blood is discharged;
sinuses are apt to form, the skin ulcerates, and the process may so
continue for months, partial cicatrization taking place, and then again
breaking down. The resulting ulcers are irregular or ovalish in shape,
with undermined edges, and the surrounding thin and chronically
inflamed skin of a violaceous color. Their bases are uneven and covered
with pale, unhealthy-looking granulations. If there is crust-formation,
it is seen to be thin, grayish or brownish. The process is slow and
chronic. The scars are irregular, knotty, contracted, and often
hypertrophic. The affection is seen most frequently about the neck,
especially under the lower jaw. Other evidences of scrofula are usually
present.
A less frequent cutaneous manifestation consists of one or several
large, rounded, ovalish or irregularly-shaped, flat pustules upon an
inflamed or violaceous base. The crust forms slowly, is thin and flat,
and of a brownish color. The ulceration beneath has the peculiar
scrofulous characters. The scars which follow are soft, flat, and
superficial.
{699} A scrofuloderm occasionally met with consists of one or several
papillary or fungoid growths of a bright or dull violaceous red color,
with an ulcerated and discharging surface. They occur perhaps most
frequently about the hands, are chronic, and often lead to deep-seated
ulceration, which may involve the bones and give rise to deformity. The
disease resembles the verrucous and hypertrophic varieties of lupus
vulgaris.
Another variety of disease, seen usually in scrofulous subjects,
described by one of us (Duhring), manifests itself as small pinhead- to
pea-sized, disseminated, yellowish, flat papulo-pustules upon a red or
violaceous base, which slowly dry to crusts, and leave
punched-out-looking scars resembling those of variola. The lesions are
irregularly distributed, occurring for the most part about the face and
extremities. The process may continue for years. The lesions resemble
those of the small pustular syphiloderm.
The manifestations of scrofula are at the present time supposed to be
due to the specific infecting agent, the bacillus. Other conditions
which have been considered influential, and which are unquestionably
important predisposing causes, are heredity, blood-marriages,
insufficient and unwholesome food, continued exposure to wet and cold
and impure air. It generally develops in childhood, often after
measles, scarlatina, and similar diseases. Negroes are especially
predisposed to it. The scrofulodermata are, as a rule, readily
distinguished by their peculiar clinical characters. Other symptoms of
scrofula are, moreover, usually present and aid in the diagnosis. It is
to be differentiated from the gummatous ulcerations of syphilis by its
history, course, locality, the absence of the specific infiltration at
the borders of the ulceration, and the violaceous tint.
The constitutional treatment is the same as employed in other
scrofulous affections--cod-liver oil, syrup of the iodide of iron,
sulphide or muriate of lime, phosphorus, and iodine preparations being
the most reliable remedies. The diet should be liberal, consisting of a
large proportion of animal food. Hygienic measures are active
adjuvants. The external treatment of scrofulous ulcerations consists in
the use of stimulating applications. Mercurial ointments, corrosive
sublimate in alcohol, one-fourth to one grain to the ounce, and yellow
wash, are serviceable applications. Iodoform, in powder or ointment, is
often of benefit. A 1 or 2 per cent. nitrate-of-silver-ointment may
also be mentioned. Curetting, as in lupus vulgaris, is one of the most
valuable methods of treatment, especially useful in the fungoid
variety. Milton has had good results with calomel or gray powder, taken
at night two or three times weekly for a few weeks, and a saline every
morning in sufficient dose to produce a daily evacuation. The mercurial
is then intermitted for two or three weeks. Bitters and mineral acids
are given if the appetite fails. A simple ointment is used locally.
Syphilis Cutanea.
Syphilis (syphiloderma, dermatosyphilis, syphilis of the skin)
manifests itself in various forms upon the integument. Preceding or
ushering in the early eruptions there is sometimes considerable
systemic {700} disturbance, such as slight fever, loss of appetite,
muscular pains, and headache. In the greater number of cases, however,
general symptoms are wanting. Along with the cutaneous manifestations
there are usually other signs of the disease. In the early eruptions
the lymphatic glands are enlarged, and sore throat and mucous patches
may exist. Sometimes there is loss of hair. In the later syphilodermata
pains in the bones, bone lesions, and other symptoms may be observed.
The early eruptions are generalized; the later manifestations are
usually limited in extent, and have a tendency to appear in circular,
semicircular or crescentic forms. There are rarely any subjective
symptoms. The color of established syphilitic lesions is usually a dull
brownish-red or yellowish-red.
Syphilis may show itself as a macular, papular, vesicular, pustular,
bullous, tubercular or gummatous form of disease. In many instances,
although a particular efflorescence may predominate, lesions of other
varieties may be found intermingled.
SYPHILODERMA ERYTHEMATOSUM (syn., exanthematous syphilide, syphilis
cutanea maculosa, roseola syphilitica, macular syphiloderm) is a
general eruption, showing itself usually six to eight weeks after the
appearance of the chancre. The appearance of the eruption is retarded
by treatment. It consists of macules of various sizes and shapes, for
the most part the size of a pea or small bean and rounded, on a level
with the surrounding skin or slightly raised, giving the skin a mottled
or marbled look. At first the spots disappear under pressure, but
later, owing to the presence of more or less pigmentation, they
persist. Their outline, which is ill defined, is usually brought out
more distinctly on exposure. They vary in color from a pale pink to a
dull violaceous red, depending upon their duration and also upon the
natural complexion of the individual, and as they fade away become
yellowish or coppery. As a rule, they exist in profusion, so much so as
to cover not infrequently almost the entire surface, appearing without
order of distribution; exceptionally they exist sparsely and faintly,
in which case the eruption may be overlooked. The face, backs of the
hands, and feet frequently escape. Subjective symptoms are wanting. The
efflorescence may appear with or without systemic disturbance, but
malaise and slight fever frequently precede it. The chancre or its
scar, enlarged inguinal and cervical glands, erythema of the fauces,
rheumatic pains, and more or less falling of the hair usually accompany
its development. It may manifest itself slowly and insidiously, a week
or two elapsing before its height is reached, or the invasion may be
sudden, taking place in the course of twenty-four or forty-eight hours.
This syphiloderm probably occurs in the majority of cases of syphilis,
but in many instances is so faint as to escape observation. As a rule,
it responds rapidly to treatment.
It is to be distinguished from measles, rötheln, urticaria, simple
erythema, tinea versicolor, and certain medicinal eruptions. The
catarrhal symptoms, the fever, form, and situation of the eruption of
measles; the rapid formation and disappearance of the patches of simple
erythema; the wheals and intense itchiness of urticaria; the slight
scaliness, peripheral growth, and distribution of tinea versicolor; the
small roundish, confluent pinkish or reddish patches, precursory
pyrexic symptoms, the epidemic nature, short duration of rötheln; and
the history, fever, form, {701} and duration of the medicinal
rashes,--are points of difference which serve to distinguish these
diseases from the syphiloderm.
So-called Syphiloderma Pigmentosum, or pigmentary syphilide, may here
be referred to. It is a rare manifestation, and is characterized by
rounded, ovalish or irregularly-shaped, variously-sized, discrete or
confluent, pale grayish, yellowish, or brownish, usually ill-defined
faint macules. It occurs most frequently about the neck, is seen almost
exclusively in women, and is encountered during the latter half of the
first and in the second year of the disease. It develops slowly, and
may continue one or two months or as many years, and is uninfluenced by
antisyphilitic treatment. It is a simple pigmentary affection, similar,
apparently, to chloasma, from which and tinea versicolor it is to be
differentiated.
SYPHILODERMA PAPULOSUM (syn., syphilis cutanea papulosa, papular
syphilide, papular syphiloderm) is characterized by the formation of
variously-sized papules. The lesions are small or large, and in some
cases undergo various modifications.
The Small Papular Syphiloderm (syn., miliary papular syphiloderm,
lichen syphiliticus) consists in an eruption of disseminated or
grouped, more or less confluent, firm, small or minute, rounded or
acuminated papules, the size of a pinhead or milletseed. Their summits
may be smooth or covered with fine scales, or may show pointed
pustulation; this last symptom occurring especially in those through
which a hair protrudes. Miliary pustules, scattered here and there over
the surface, may also be present. At first the eruption is bright- or
dull-red, but later it generally assumes a violaceous or brownish tint.
In some cases the lesions are numerous and grouped, forming patches.
The eruption is seen most frequently about the trunk and upon the
limbs. It may appear during the third or fourth month or later. Large
flat papules or moist papules may exist simultaneously. It has a
chronic course, with a tendency to relapse, and is usually rebellious
to treatment. It is to be distinguished from keratosis pilaris, lichen
scrofulosus, psoriasis punctata, papular eczema, and lichen ruber. The
extent of the eruption, the color, grouping, with usually the presence
of pustules and large papules and other concomitant symptoms of
syphilis, are points of differentiation.
The Large Papular Syphiloderm (syn., lenticular syphiloderm) is
characterized by the formation of large, flat, circular or ovalish,
firmly-seated, more or less raised pale- or dull-red papules, varying
in size from a small split pea to a dime. In their early stage they are
usually smooth, but they subsequently become covered with exfoliating
epidermis. The forehead, region of the mouth, neck, back, flexor
surfaces of the extremities, scrotum, labia, perineum, and margin of
the anus are all favorite localities. The lesions, as a rule, develop
slowly, and, having attained various sizes, remain for weeks or months.
It is one of the commonest forms of cutaneous syphilis; it may be an
early or late eruption, and shows a disposition to relapse. As a rule,
it yields readily to treatment. The lesions may undergo more or less
modification, due either to the locality in which they exist or to
other influences. Ordinarily, they persist as typical papules, and
gradually pass away by absorption. At times they become soft and
spongy, while occasionally they become excoriated, with slight moisture
and crusting. This latter condition is {702} usually observed about the
junctures of the mucous membrane and the skin.
A common change is into the Moist Papule (syn., mucous papule, mucous
patch, broad, or flat, condyloma; _Fr._ plaques muquese). This takes
place upon those regions where opposing surfaces and natural folds of
skin are subjected to more or less contact, as about the nates,
umbilicus, axillæ, beneath the mammæ, etc. The lesions are more or less
moist, covered with a grayish, sticky, mucoid secretion consisting of
macerated epidermis. They are usually flat, and may coalesce, and so
form large patches. They may become hypertrophic, warty, and papillary,
constituting the vegetating syphiloderm (syphilis cutanea vegetans). In
this form the lesions become elevated, more or less circumscribed, and
may assume a warty character, resembling the cauliflower formation,
with a contagious secretion which dries to yellowish-brown crusts.
Heat, moisture, friction, and uncleanliness favor their development.
They usually disappear rapidly under local treatment.
Another modification which the papule frequently undergoes is into the
squamous papule, forming the Papulo-squamous Syphiloderm (syn. squamous
syphiloderm, syphilis cutanea squamosa, psoriasis syphilitica). The
papules become somewhat flattened, and are covered with dry, grayish,
adherent scales. The scaling may be slight or relatively abundant, but
is rarely as luxuriant as in psoriasis. On removing the scales the
papular character of the lesion may readily be detected. As a rule, the
eruption is not extensive; it may show itself on any part, and is
exceedingly persistent. It is most frequently encountered on the palms
and soles, where, on account of the peculiarities in the structure of
the skin, the lesions are somewhat modified. Occurring on these parts,
it is known as the palmar or plantar syphiloderm. The lesions partake
more of the nature of macules than papules; they are slightly raised
and are irregular in outline, and, as a rule, ill defined, varying in
size from a pea to a finger-nail. They may coalesce and form roundish
serpiginous or crescentic patches covered with dry, scanty,
semi-detached, grayish flakes of epidermis, which are most abundant
about the edges; at times the exfoliation is marked, and then the
patches are distinctly squamous, as in psoriasis. It is, as a rule,
symmetrical, and is frequently observed in the centre of the palms or
soles and upon the ball of the thumb and about the volar surfaces of
the fingers. It is rebellious to treatment. It may be an early or late
manifestation, but is usually the latter.
The papulo-squamous form of the syphiloderm may resemble eczema and
psoriasis. In eczema heat, itching, and sometimes discharge, together
with the history and course, will be sufficient points of distinction.
Psoriasis upon the palms rarely occurs except as a part of a general
eruption; the character and abundance of the scales, their lamellar
arrangement, the red rete beneath, and the absence of infiltration are
diagnostic. The differential diagnosis of the papulo-squamous
syphiloderm and psoriasis when occurring on the other parts of the body
are fully given in treating of the latter disease.
SYPHILODERMA VESICULOSUM (syn., vesicular syphilide, syphilis cutanea
vesiculosa) is an exceedingly rare form of cutaneous syphilis, and in
the majority of cases may be more properly classed under {703} the head
of the pustular variety. The lesions vary in size from a pinhead to a
split pea. If small, they are more or less acuminated, disseminated, or
grouped, usually involving the hair-follicles; if large, semiglobular
or flat, with or without a tendency to umbilication. The vesicles, as a
rule, pass into pustules. It is an early eruption, occurring usually
within the first six or eight months; is rarely extensive, pursues a
rapid course, and is generally associated with other symptoms of the
disease.
SYPHILODERMA PUSTULOSUM (syn., pustular syphilide, syphilis cutanea
pustulosa) is an important manifestation, although not so common as the
macular and papular varieties. The lesions assume one of several forms,
although not infrequently they are found intermingled.
The Small Acuminated Pustular Syphiloderm (syn., miliary pustular
syphiloderm) is characterized by the formation of milletseed-sized
acuminated pustules, usually seated upon minute reddish papular
elevations. The puriform contents dry to crusts, which fall off and are
followed by a slight fringe-like exfoliation around the base,
constituting a grayish ring or collar. The lesions commonly involve the
hair-follicles, are present in great numbers and scattered over the
whole surface, and may be either disseminated or in groups; in relapses
the eruption is usually localized. Variously-sized larger papules are
sometimes seen scattered sparsely over the surface. It may be an early
or a late secondary eruption. Minute pinpoint atrophic depressions and
stains are left, which gradually become less distinct. Other symptoms
of syphilis are usually present. The diagnosis is rarely difficult.
The Large Acuminated Pustular Syphiloderm (syn., acne-form syphiloderm,
acne syphilitica, variola-form syphiloderm) consists of small or large
split-pea-sized pustules, more or less acuminated, resembling the
lesions of simple acne or variola. The resulting crusts are yellowish
or brownish, usually thick and bulky, and are seated upon ulcerated
bases. The lesions may develop slowly or rapidly, with or without
malaise or febrile symptoms, are disseminated or grouped, at first
looking more or less papular. In the subacute or relapsing cases the
eruption is apt to be localized. It pursues a rapid and usually a
benign course, and is to be distinguished from acne, from the
potassium-iodide eruption, and from variola. The usual limitation of
acne lesions to the face and shoulders, their rapid formation, and the
chronic character of the disease, together with the absence of the
concomitant symptoms of syphilis, are points which may be utilized in
the diagnosis. Variola differs in the intensity of the general
symptoms, the umbilicated pustules, and the definite duration of the
disease. The acute character, bright color, course, and history of the
potassium-iodide eruption are generally sufficiently characteristic.
The Small Flat Pustular Syphiloderm (syn., impetigo-form syphiloderm,
impetigo syphilitica) shows itself in the form of pea-sized, flat or
raised, discrete, irregularly-grouped, or confluent pustules. The
crusts, which form rapidly, are a yellow, greenish-yellow, or
brownish-yellow color, more or less adherent, thick, bulky, uneven,
with a tendency to become granular and to crumble. Where the lesions
are confluent there results a continuous sheet of crust. Beneath the
crusts there may be superficial or deep ulceration. The eruption is
most frequently {704} observed about the nose, mouth, and hairy parts
of the face, on the scalp, and also about the genitalia. When upon the
scalp it is apt to resemble pustular eczema; the erosion or ulceration
beneath, however, will serve to differentiate it.
The Large Flat Pustular Syphiloderm (syn., ecthyma-form syphiloderm,
ecthyma syphiliticum) appears in the form of large pea- or dime-sized,
flat pustules, with a deep red base. Crusting usually follows
immediately. There are two forms of the lesion--a superficial and a
deep. In the superficial variety the crust is flat, rounded, or
ovalish, yellowish-brown or dark brown, and seated upon a superficial
erosion or ulcer, having a grayish or yellowish secretion. It may occur
upon any region, but is most common on the back, shoulders, and
extremities; the lesions are sometimes numerous. It appears, as a rule,
within the first year and runs a benign course. In the deep variety the
crust is raised and more bulky, dark-greenish or blackish, inclining to
become conical and stratified, like an oyster-shell, constituting what
is designated rupia. A crust of the same character occurs in the
bullous syphiloderm. If the crust is removed, an excavated ulcer is
seen, having a defined or irregular outline and a greenish-yellow,
puriform secretion. It is a late and a malignant manifestation, and is
not infrequently met with in hospital and dispensary practice.
SYPHILODERMA TUBERCULOSUM (syn., tubercular syphilide, syphilis cutanea
tuberculosa) is characterized by one or more firm, circumscribed,
rounded, acuminated, or semiglobular, deeply-seated, smooth, glistening
or slightly scaly elevations, yellowish-red, brownish-red, or coppery
in color, varying in size from a split pea to a hazelnut. They rarely
occur in great numbers, and are, as a rule, confined to certain
regions, and show a decided tendency to occur in groups, often forming
segments of circles. When several such groups coalesce, the result is a
serpiginous tract, the so-called serpiginous tubercular syphiloderm.
The face, back, and extremities are favorite localities. The lesions
develop slowly, are unaccompanied by subjective symptoms, and usually
occur as a late manifestation, at times appearing many years after the
initial lesion. A history of earlier symptoms of the disease is usually
obtainable.
The eruption terminates or disappears either by absorption or by
ulceration. If the former, a pigment-stain, which is usually
persistent, and in some cases slight atrophy, mark the site of the
lesions, and there may be also a slight amount of exfoliation. If
ulceration results, it may be superficial or deep, more frequently the
latter. It begins on the summit or in the interior, and the result is a
deep, punched-out, more or less crescentic ulcer with a gummy,
grayish-yellow deposit or covered with a crust. If the ulcerative
process takes place in a patch of grouped tubercles, an extensive
excavated ulcer may result. Sometimes the ulceration occurs in a
crescentic or serpiginous course. In some instances from the ulcerating
surface spring up papillary, wart-like, or cauliflower excrescences,
with a yellowish, offensive, puriform secretion, the so-called syphilis
cutanea papillomatosa. This condition is most frequently encountered
upon the scalp.
Tubercular syphiloderm is to be differentiated from lupus vulgaris,
leprosy, and cancer--especially the first, to which it at times bears a
close resemblance. In syphilis the lesions are firmer and deeper, and
form more rapidly, than in lupus; moreover, the disease is usually one
of {705} adult life and middle age, whereas lupus appears, as a rule,
first in childhood.