Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (17)

Linear or punctate scarification is another method of treatment that is 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.

SYPHILODERMA GUMMATOSUM (syn., gummatous syphilide, syphilis cutanea 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.

The causes which give rise to the affection are varied. Thus it is sometimes called forth by gestation and by the various disorders of menstruation, and in other instances, in either sex, by organic diseases of the genito-urinary tract. Diseases of the kidney and of the liver, especially jaundice, are frequently accompanied by pruritus. The nervous system is not infrequently at fault. Gastro-intestinal derangement, the ingestion of certain medicines (as opium), intestinal parasites, and hemorrhoids, are all well-known causes. The disease is strictly functional in nature, and is due to reflex nervous action.

The diagnosis rests with the subjective symptoms as given by the sufferer. There are no primary lesions; the secondary lesions, however, are sometimes so extensive as to suggest other diseases, especially prurigo and eczema, but there should be no difficulty in differentiating these diseases if their clinical features are kept in mind. Prurigo--a disease, practically speaking, unknown in this country--it will be remembered, is characterized by well-defined papules, and moreover shows predilection for the lower extremities. The subjective symptoms of pruritus often simulate those due to the presence of lice. In all cases these parasites, whether of the head, body, or pubes, should be carefully excluded in the diagnosis, for it sometimes happens that pediculosis is looked upon and treated as pruritus, the true nature of the affection being unsuspected. Pediculosis, it must not be forgotten, is occasionally met with in the upper walks of life, where it is at times extremely difficult to account for the source of contagion. Inspection of the skin and of the underclothing should be made in all suspected cases.

The treatment naturally varies with the determined or probable cause. The local origin of the affection should, in the first place, be inquired into. The internal remedies are to be selected with the view of meeting the requirements of the case. The various functions of the body should receive due attention, the bowels, in all cases tending to constipation, being kept open by laxatives, preferably saline preparations. The diet should be directed, all stimulating or injurious food and drink being interdicted. Quinine, arsenic, belladonna, strychnine, carbolic acid, tincture of gelsemium, and pilocarpine are remedies which may be tried in obstinate cases. In all cases the cause should be diligently sought for, for until this is discovered and removed there can be but little hope of complete recovery. External remedies, though extremely grateful to the patient, and of course very useful, as a rule are only palliative. There are cases, however, in which they prove curative. Water in the form of very hot or {713} cold douches, and alkaline and sulphur lotions and baths, are sometimes serviceable, employed either alone or in connection with other remedies. In the local varieties of the disease antipruritic and stimulating lotions are especially serviceable. One of the most valuable remedies is carbolic acid, in the strength of from fifteen to forty grains to the ounce, to which may be added small quantities of glycerin and alcohol. A strong lotion consists of carbolic acid, one drachm and a half; potassa, twenty grains; water, eight ounces. The tarry preparations considered in eczema, especially liquor carbonis detergens and liquor picis alkalinus, are useful, as are likewise thymol, a few grains to the ounce of glycerin and alcohol, and oil of peppermint. The latter remedy, pure or mixed with glycerin, may be applied with a brush. Sometimes a simple chloral lotion is efficacious. In like manner lotions of acetate of lead, ten to thirty grains to the ounce; dilute hydrocyanic acid, a few drachms to the pint; hyposulphite of sodium; chloroform; chloroform and alcohol; diluted acetic acid; diluted ammonia-water; diluted nitric-acid; and corrosive sublimate,--may be tried. R. W. Taylor recommends the following:

Rx. Fol. belladonnæ,
Fol. hyoscyami, aa. drachm ij;
Fol. aconiti, drachm ss;
Acidi acetici, fluidounce j. M.

This may be diluted with water a drachm to the ounce, or may be used with equal parts of glycerin, painted on the skin or in the form of an ointment, a drachm or two to the ounce. Tobacco, used as an infusion, two or three drachms to the pint, is often efficacious, especially in pruritus vulvæ. The fluid extract of conium, applied with a brush, and iodoform in ethereal solution, applied as a spray, may likewise be resorted to where the disease involves this region. Camphor and borax may be mentioned as being sometimes of service, as in the following formula:

Rx. Sodii boratis, drachm ij;
Glycerinæ, fluidrachm iv;
Spts. camphoræ, fluidounce ss;
Aquæ rosæ, ounce v. M.

Another lotion, containing borax and morphia, may be given:

Rx. Sodii boratis, drachm iv;
Morphiæ sulph., gr. xv;
Glycerinæ, fluidounce ss;
Aquæ, q. s. ad fluidounce viij. M.

In some cases ointments prove more acceptable than lotions. Tar, carbolic acid, thymol, and the mercurials are all valuable used in this form, varying in strength with the locality and amount of surface to be treated. The smaller the area, as a rule, the stronger the remedy. Chloroform, chloral, and camphor also may be used in the form of ointments. About one drachm each of chloral and camphor to the ounce constitutes a good antipruritic remedy; the active ingredients are to be rubbed together and then added to the ointment.

In pruritus of the anus one of the most valuable and neatest remedies is carbolic acid with glycerin or olive oil, in the strength of from fifteen to forty grains to the ounce. Very hot water applied with a soft linen compress or sponge will usually afford temporary ease, and may be employed from time to time in connection with other more active {714} remedies. In some cases we have had rapid and good results from an ointment of balsam of Peru, a drachm and a half to the ounce. Equal parts of belladonna ointment and mercurial ointment, and a solution of corrosive sublimate, about a quarter of a grain to the ounce, may also be mentioned; and where there are fissures occasional pencilling with a solution of nitrate of silver will afford relief, the latter application, made with a piece of sponge fastened on a stick, being also useful in pruritus vulvæ.

A long list of formulæ have been vaunted for the relief of pruritus of the female genitalia, a few of which may be given. In addition to the remedies already mentioned the following formulæ will sometimes prove valuable. The fluid preparations may be used as vaginal injections or may be applied by means of a brush, tampon or cloth, according to their nature. Hyposulphite of sodium, a drachm to the ounce; sulphurous acid, sufficiently diluted; alum, sulphate of zinc, tannic acid, acetic acid, borax, and boric acid, may all be made use of in the form of injections. In this variety of the disease, as well as in pruritus of the anus, a 6 per cent. solution of cocaine, applied with a brush, or the oleate used as an ointment in the same strength, may be prescribed.

The prognosis should in all cases be guarded, the ability to relieve the disorder depending mainly upon the nature of the cause. The majority of cases, due to no evident cause, prove obstinate. But in all instances the patient should be encouraged to persevere in the treatment, and the hope of an ultimate cure extended to him.

* * * * *