gummatosa) consists in the formation of a rounded or flat, slightly
raised, moderately firm, more or less circumscribed tumor, having its
seat in the subcutaneous tissue, which later shows a tendency to break
down. As a rule, only one or two tumors are present. The growth is
variously known as a gumma, gummy tumor, and syphiloma. The lesion,
which is usually a late manifestation, begins as a small, pea-sized
deposit beneath the skin, which gradually increases in size; the
overlying skin, which is at first of a natural color, becoming pinkish
or reddish. It may eventually attain the size of a walnut or may be
even larger. It is firm or soft and doughy to the touch, is usually
painless, and tends to break down, disappearing by absorption or
ulceration, the ulcer being usually deep with perpendicular edges. It
is to be distinguished from furuncle, abscess, and fatty and fibrous
tumors. In most cases other symptoms of syphilis are present.
SYPHILODERMA BULLOSUM (syn., bullous syphilide, syphilis cutanea
bullosa, pemphigus syphiliticus) appears in the form of discrete,
disseminated, rounded or ovalish blebs, varying in size from a pea to a
walnut, and containing a serous fluid which rapidly becomes cloudy or
thick. In some cases the process is distinctly pustular from the
beginning. The blebs, which are, as a rule, partially or fully
distended, after a variable time dry to crusts of a yellowish-brown or
dark-greenish color, which may be thick and raised or conical and
stratified, the latter constituting rupia, as in the case of the large,
flat pustular syphiloderm. They are easily removed, and cover erosions
or ulcers which secrete a greenish-yellow fluid. It is a rare
manifestation, occurring late, is variable in its course, and is seen
usually in broken-down individuals. It is not infrequent in hereditary
syphilis in the new-born.[7]
[Footnote 7: For the cutaneous manifestations of hereditary syphilis
see article by J. William White on that subject in Vol. II. p. 254.]
ANATOMY.--Anatomically, the syphilitic deposit consists of a round-cell
infiltration. It is most typically shown in the papule and tubercle; in
the macule there is hyperæmia, with beginning tissue-cell
proliferation, but the specific cell-infiltration is not
distinguishable. The process usually involves the mucous layer of the
epidermis, the corium, and, in the deep lesions, the subcutaneous
connective tissue. The extent and depth of the infiltration depend upon
the size and form of the growth.
TREATMENT.--Cutaneous syphilis, as in the case of all other
manifestations of this disease, requires constitutional treatment, and
generally local medication also. In order that relapses may in a great
measure be obviated, prolonged treatment by appropriate remedies is
essential. Even with such management and under the best circumstances
relapses will frequently occur. The advantage of temperate and regular
living and hygienic influences in promoting a disappearance of the
manifestations and keeping the disease in abeyance cannot be too
strongly urged. In syphilitic subjects anæmia, dyspepsia, malaria, or
any similar condition is apt to render the syphilis more violent, and,
if present, should receive appropriate treatment. Ill health from any
cause predisposes to a relapse.
{706} The remedies which, in a sense, may be considered to exert a
specific action in syphilis are mercury and potassium iodide. They are
indispensable in the treatment of the disease. Both are important,
although the former is the more valuable. As a rule, mercury is the
remedy to be given in the first stages of the disease, and the cases
are exceptional in which its use is not permissible. In such instances
potassium iodide is to be prescribed. As the later stages of the
disease approach the iodide of potassium becomes relatively more
important. Even in the late syphilodermata, however, mercury in small
doses holds a prominent place in the treatment, as it seems to possess
a greater influence in preventing relapses. In the administration of
mercury salivation is to be carefully guarded against, as its
occurrence is detrimental to the health of the patient, and indirectly
as well as directly it exerts an unfavorable influence on the course of
the disease. Beyond slight tenderness of the gums its action should
never be pushed.
There are several methods of administering mercury, but that by the
mouth is for many reasons the best. For this purpose various
preparations, such as blue mass, calomel, corrosive sublimate, the
protiodide and biniodide, as well as other mercurials, are used. In the
average case the protiodide is one of the best, and is probably in most
general use. It is given in pill form in the dose of one-fourth or
one-half a grain three times daily. If gastric or intestinal
disturbance, such as pain and diarrhoea, is produced by its use, as is
occasionally the case with this and all other preparations of mercury,
a small proportion of opium may be added to each pill. Blue mass is an
important mercurial in the early syphilodermata, and is given in doses
of two or three grains three times daily. For bringing the system
rapidly under the influence of the mineral, an important consideration
in some cases, calomel in doses of one or two grains combined with
opium, three or four times a day, is the most active. Corrosive
sublimate is slow in its action, but is usually well borne and shows
but slight disposition to salivate. The dose is one-twenty-fourth to
one-eighth of a grain in pill or solution three times daily. It is
rarely employed in early syphilis, but is a useful mercurial for
long-continued administration, and also in the later stages of the
disease.
Inunction is another method of introducing mercury into the system, and
is especially useful in treating the disease in the infant. For this
purpose two preparations are used--blue ointment and oleate of mercury.
The latter, 5 to 20 per cent. strength, has lately been somewhat
extensively employed, but it is not comparable in value for this
purpose to the blue ointment. The sole advantage of the oleate is its
light color. The blue ointment may always be prescribed with confidence
as to its effect; the same cannot be said of the oleate. Various
regions are selected for the inunctions--the arms, axillæ, thighs,
abdomen, chest, and back being taken in turn, so as to obviate as far
as possible local irritation. About a drachm of the blue ointment
suffices for an inunction. For infants the preparation should be
weakened. By means of inunctions the system may rapidly be brought
under the influence of the remedy.
Another method of introducing mercury is by hypodermic injections.
Corrosive sublimate is the preparation commonly employed; about
one-tenth of a grain, with about the same quantity of morphia,
dissolved in fifteen minims of water, constitutes the average amount
for an {707} injection, one being made daily. The back, especially the
lateral regions, is the part usually selected. The method has the
advantage of rapidity of action, twenty to thirty injections sufficing,
as a rule, to remove the lesions. At the same time potassium iodide, if
indicated, may be given by the mouth. The method, however, is
objectionable, the injections producing pain, inflammatory swelling,
and induration, and not infrequently abscesses. Ptyalism, a possible
accident also, is to be guarded against.
The mercurial vapor bath is in many cases of value. Calomel or the
black oxide of mercury is commonly used, about thirty grains of either
to the bath. A vaporizing apparatus, containing the mineral and water
required, is placed beneath the stool or chair, and the patient
enveloped in a sleeveless flannel gown and covered over with a rubber
blanket, the bath lasting about thirty minutes. The patient remains
covered until cooled off, and then goes to bed in the flannel gown. The
plan has cleanliness and simplicity as well as effectiveness to commend
it. The corrosive-sublimate water bath is another method that is
useful, especially for infants--ten to thirty grains to the bath for an
infant, and two to four drachms for an adult. From fifteen minutes to
half an hour should be passed in the bath.
Potassium iodide is, as already stated, indispensable in the treatment
of late manifestations. The average dose is ten to twenty grains three
times daily, but in many obstinate cases much larger doses may be
necessary. It is usually given after meals, but it may be taken largely
diluted half an hour before eating to greater advantage. Mercury should
be, for reasons already stated, prescribed with it, the two remedies
constituting the so-called mixed treatment. Another remedy frequently
of use in the treatment of syphilis, especially in obstinate cases of
ulceration, is opium in the dose of one or two grains three times
daily, which in some cases possesses the power of arresting the
activity of the process.
Local treatment remains to be considered. In the macular and small
papular eruptions it is rarely called for, but in the more severe
syphilodermata their disappearance may be hastened by external
applications. The mercurial vapor and water baths already mentioned are
serviceable; also an ointment of ammoniated mercury, a drachm to the
ounce, a 5 to 20 per cent. oleate-of-mercury ointment, and citrine
ointment with two to four parts of lard, constitute excellent local
remedies. Mercurial plaster is frequently of value, especially in
reducing infiltrations. In the palmar and plantar syphilides strong
ointments are necessary, and should be well worked into the skin. Moist
papules always require treatment; cleanliness is of great importance.
Applications of solutions of chlorinated soda, corrosive-sublimate
lotion, and a lotion of carbolic acid, followed by a dusting-powder of
calomel, oxide of zinc, or starch, may be advised. The ulcerative
lesions, after the removal of crusts by means of hot water or oily
applications, are to be treated with the ointments or lotions named
above.
Epithelioma.
There are three varieties of epithelioma or skin cancer--superficial,
deep-seated, and papillomatous. The superficial, or flat, form begins
as a minute, firm, reddish or yellowish prominence, or it may begin as
an {708} aggregation of such lesions. The process may remain in this
stage for months or years; sooner or later, however, the summit of the
growth becomes slightly scaly and shows a softened or excoriated
centre. From this central point a small quantity of fluid oozes, which
forms a yellowish or brownish crust. This scale or crust becomes
detached from time to time, either intentionally or by accident, and is
followed by another similar in character, but possibly larger than that
which had preceded. At the same time the underlying nodule or nodules
slowly increase in size.
In this condition it may remain for months or years, but sooner or
later the process becomes more active. New nodules form about the edges
of the patch, and in a variable period go through the same steps as
those forming the original lesions. The excoriation or ulcer becomes
more marked, being as large as a pea or a dime, irregular in outline,
more or less crusted. It is defined against the surrounding healthy
skin by a flat or slightly elevated, more or less hardened, infiltrated
border. The ulcer, which has usually an uneven surface, secretes a
scanty, thin, viscid fluid, which dries to a firm, adherent crust. At
points there may be a disposition to spontaneous involution, the
epithelial growth being cast off by suppuration, depressed scar-tissue
taking its place. The ulcerative process, however, generally progresses
until often a sore of considerable size may form. The general health
remains unaffected. The superficial variety may form as described, and
may so continue its course, or it may at any stage pass into the more
malignant, deep-seated variety.
This latter variety may begin as a tubercle or nodule in the normal
skin, or it may, as already stated, start from the superficial or other
variety. Where it develops typically a pea-sized, reddish, shining
tubercle or nodule, or an area of infiltration, forms in the skin, or
even in the subcutaneous connective tissue, which grows slowly or
rapidly, usually from six months to a year or more elapsing before
exciting solicitude. Sooner or later, depending on the virulence of the
process, ulceration takes place, superficial or deep-seated in
character, depending upon the amount of infiltration. The surface of
the ulcer is granular and reddish and secretes an ichorous discharge,
and the edges are indurated and, as a rule, everted. As the
infiltration spreads the ulcer enlarges peripherally, and at the same
time involves the deeper parts, muscle, cartilage, and bone often
becoming implicated. The glands also become involved, burning or
neuralgic pains are felt, and the strength gradually declines, until
from septicæmia, marasmus, or implication of vital parts death results.
The third variety, the papillomatous, may arise in the form of a
papillary or warty growth, or it may develop, as is more commonly the
case, from either the superficial or the deep-seated variety. At an
advanced period its surface is papillomatous or warty, is ulcerated and
fissured, bleeds easily, and discharges an ichorous fluid, which dries
and forms a brownish crust.
Epithelioma is most frequently encountered about the face; the nose,
eyelids, and cheek all being favorite localities. The neck, the hands,
and the genitalia also suffer frequently. If seated about the genitals,
its course is apt to be more rapid and destructive. The predisposing
causes are not well understood. The disease rarely shows itself before
middle life, and is {709} much more common in men than in women. It is
not, as a rule, inherited. The exciting causes are frequently to be
found in long-continued alterations in the epithelial structures, such
as, for example, occur in warts. Any locally irritated tissue may be
the starting-point of the disease. The process consists in the
proliferation of epithelial cells from the mucous layer. The
cell-growth takes place downward in the form of finger-like
prolongations or columns, or it may spread out laterally, so as to form
rounded masses, the centres of which usually undergo horny
transformation, resulting in onion-like bodies, the so-called
cell-nests or globes. The rapid cell-growth requires increased
nutriment, and hence the blood-vessels become enlarged; moreover, the
pressure of the cell-masses gives rise to irritation and inflammation,
with corresponding serous and round-cell infiltration.
Epithelioma is to be differentiated from syphilis, wart, and lupus.
Occurring about the genitals, it may be confounded with chancre, but
the history, duration, character of the base and edges will serve to
differentiate the diseases. The syphilitic lesion, wherever occurring,
runs a much more rapid course than epithelioma. In tubercular syphilis
several points of ulceration are usually seen; in epithelioma usually
only one. The secretion from syphilitic ulcerations is generally
abundant and of a yellowish, creamy character; in cancer it is scanty,
viscid, stringy, and streaked with blood. The ulcer of syphilis rarely
has the elevated, infiltrated border usually seen in epithelioma. Warts
or warty growths must be distinguished by attention to their history
and course; observation extending over months may at times be necessary
before a positive opinion as to the existence of epithelial
degeneration is warrantable. In lupus vulgaris the deposits are
peculiar and are multiple, while in epithelioma the lesion is usually a
single formation. The former generally begins in early life; the latter
is a disease of the middle-aged and old. It remains to be stated that
occasionally cancer and lupus occur combined, the former usually
following the latter.
TREATMENT.--The variety, extent, and rapidity of the process are always
to be duly considered in the prognosis. The superficial form may exist
for many years without causing alarm. The deep-seated variety is always
to be viewed as a serious disease, and is often fatal. Relapses after
operation, even where this has been well performed, are frequent. The
treatment is in most cases--for the time, at all events--successful. If
the diseased tissue is thoroughly removed, the relief may be permanent
or may at the least extend over several years. If, however,
cauterization or operation is not thorough, the parts are scarcely
healed before symptoms of a recurrence manifest themselves. Internal
treatment does not seem to exert any beneficial effect upon the
disease. In regard to local treatment, whatever operation or remedy is
capable of removing or destroying the growth may be employed, caustics,
the curette, and the knife all being available for this purpose.
Among the caustic agents, potassa in stick or in solution is one of the
most valuable. Chloride of zinc in paste or stick form may also be
mentioned as being of service, but it is a painful caustic. Arsenical
pastes are efficient, and have the advantage of sparing the healthy
tissues; one consisting of equal parts of powdered acacia and arsenic,
to which a small proportion of morphia may be added, will be found
serviceable; {710} it should kept applied in the form of a plaster for
from six to twenty-four hours, or until the pain, which is apt to be
severe, becomes unbearable, and then poultices applied. Pyrogallic
acid, from one to four drachms to the ounce of resin cerate, is a very
valuable remedy. Its action is slow; it should be renewed twice daily,
and its application continued for a week or longer. As a rule, it is
painless.
One of the best plans of treatment is that with the dermal curette. The
diseased tissue is thoroughly scraped away, the wound dressed with some
simple ointment, and healing allowed to take place. Sometimes after the
use of the curette it is advisable to cauterize lightly with caustic
potash or to apply an ointment of pyrogallic acid for a few days to
ensure complete destruction of the disease. There are other cases in
which excision constitutes the most useful method of treatment. In
cases in which there is much loss of tissue a plastic operation may be
performed, being preceded by a thorough removal of the diseased
tissues. The galvano-cautery is another method which may be resorted
to.
Sarcoma.
Sarcoma cutis, or sarcoma of the skin, is a rare affection, consisting
of shot-, pea-, hazelnut-, or larger-sized, variously-shaped, discrete,
non-pigmented or pigmented tubercles or tumors. They are smooth, firm,
and elastic, are not markedly painful upon pressure, and show a
tendency to reach the surface and ulcerate. The overlying skin is at
first normal and somewhat movable, but as the lesions approach the
surface it becomes reddened and adherent, or if of the pigmented
variety the skin acquires a bluish-black color. The multiple pigmented
sarcoma (melano-sarcoma) appears, as a rule, first on the soles and
dorsal surfaces of the feet, and later on the hands, the lesions
manifesting a disposition to bleed.
The disease described by Geber and one of us (Duhring) under the name
of inflammatory fungoid neoplasm is doubtless a form of, or closely
allied to, sarcoma. It manifests itself by the formation of several
distinct kinds of lesions, the more important consisting of flat or
slightly-raised coin- to palm-sized, rounded or ovalish, superficial or
deep-seated, smooth, scaly, or crusted patches of a pale-pinkish or
deep-reddish color; and prominent, rounded, or ovalish, soft, firm, or
solid, furrowed or lobulated, tubercular or fungoid tumors, varying in
size from a pea to an egg, somewhat depressed in the centre, and
pale-red, deep raspberry-red, or violaceous in color. The flat patches
with involution assume a mottled or streaked purplish, yellowish, or
salmon color. The tumors may appear suddenly within a few hours or a
day, or gradually in the course of weeks or months. After reaching a
certain size they tend to soften, diminish in size, and undergo
spontaneous involution or ulcerate. Itching and burning are usually
complained of, but are variable. All regions may be attacked. It is
rare. The so-called lymphadenoma, lymphadénie cutanée, and mycosis
fungoide of the French may also, doubtless, be properly classified as a
variety of sarcoma.
The disease is to be distinguished from the papular, tubercular, and
gummative syphilodermata, lupus, leprosy, and carcinoma. As a rule,
sooner or later, a fatal termination takes place. Treatment is
palliative. Surgical interference may be of service in particular
situations. {711} Hypodermic injections of Fowler's solution in
increasing doses have, it is stated, influenced the disease favorably.
CLASS VII.--NEUROSES.
Dermatalgia.
Dermatalgia, or neuralgia of the skin, is characterized by pain having
its seat solely in the skin, unattended by structural change, and
associated usually with a morbidly sensitive condition of the part. The
symptoms are purely subjective, as in pruritus. The skin shows no
alteration. It is usually a local disorder, confined to a small area,
and is met with, as a rule, in adult age. It consists in a
highly-sensitive state of the integument, with a feeling of positive
pain having its seat in the superficial layers of the skin, which is
remarkably sensitive to external impressions; the touch, contact of the
clothing, and even the air, exciting more or less pain. In character
the sensation is burning, pricking or darting, or like electric shocks.
It is generally worse at night. The affection may exist idiopathically
or symptomatically, the latter being the more common and accompanying
lesions of the nervous centres. Its frequent connection with rheumatism
has been pointed out by Beau and other writers, from which fact it is
sometimes called rheumatism of the skin; but in other cases it occurs
in persons apparently in good health. Hysteria has also been noted as a
cause. The general treatment depends upon the exciting cause, but local
measures may be demanded to relieve the disagreeable or painful
sensations, among which the galvanic current, applications containing
belladonna, aconite, or iodine and blistering may be tried.
Pruritus.
Pruritus is a functional disease of the skin, characterized solely by
the sensation of itching, without the existence of structural change.
The affection must be clearly separated from the many other cutaneous
diseases accompanied by itching. In pruritus the single symptom is
itching, varying in kind and degree. There are no primary structural
lesions, but secondary lesions, resulting from scratching and local
irritation, are not infrequently present. The sensation is variously
described by the sufferers, being often likened to the crawling of
small insects over the surface. The desire to rub or scratch is
irresistible. In other cases the sensation is a tingling, or as though
some irritating substance, as flannel, was in contact with the surface.
It exists in all degrees of severity, and frequently proves a source of
great distress. It may occur at any age, but is most often met with in
middle life and in old age, constituting so-called pruritus senilis.
The itching may be constant or intermittent, but is usually the latter,
occurring in most cases paroxysmally, and being almost invariably worse
at night.
{712} The disease may be local or general, but it seldom invades large
portions of the surface at one time. In most cases it is a local
disorder, the common regions being the genitalia and anus. The trunk,
especially in elderly persons, is also not infrequently invaded.
Occurring about the female genital organs, it constitutes the pruritus
vulvæ of writers, having its seat in the labia or in the vagina. It is
a very distressing form of disease, and is met with, as a rule, in
middle life and old age. In the male the anus and the scrotum are the
regions generally attacked, the perineum sometimes also being involved
simultaneously. The anus in either sex is liable to invasion, the
disease occurring here in children as well as in adults. All of these
local varieties, as stated, are worse at night, and sometimes prove so
harassing as to interfere greatly with sleep.