Fig. 25
Ulcers resulting from deep ecthymatous syphilide. (Fordyce.)
The Gumma of Syphilis.
—This is as characteristic of late syphilis as is the condyloma of the earlier stage. By this term is meant a new formation which may vary in size from a millet-seed to a large mass. Sometimes it is diffuse, or it may be circumscribed. It seems to originate from connective tissue, and may be met in all parts of the body. Microscopically it consists of a delicate stroma filled with small, round cells, the mass being furnished usually with bloodvessels, also of new formation. Such a gumma may pass through various stages of integration and disintegration. The cells sometimes undergo fatty changes by which the entire mass is softened, and its interior contains a puruloid material resembling pus. The gumma, as it increases, will replace other tissues and cause them to disappear, and thus it happens that when it disappears the region previously occupied by it seems to have diminished in size. Sometimes, however, cicatricial tissue takes its place and not only distorts an organ or part but impairs its function. Thus softening and melting may occur at one time and a dense scar or mass at another.
The degree of infectiousness of gummatous and other late syphilitic ulcerations is uncertain. The later they occur, the less infectious. It would be safe, however, to assume that they are all dangerous.
The Gummatous Syphilide.
—This begins, as a rule, as a subcutaneous gumma which quickly proceeds to and involves the skin. At first it appears as an induration, developing into a distinct tumor, becoming more indurated and firmly implanted as it grows, the overlying skin becoming reddened and swollen. After a time there occurs softening in the interior of the mass, and upon incision there will escape not pus but viscid, puruloid fluid, yellowish gray in color, which may contain corpuscles resembling those of pus. It is the content of such a tumor as this which has given it its peculiar name, gumma. Should proper treatment be rapidly pushed, it is possible for a softened gumma to disappear by absorption, but if ulceration or evacuation has taken place, there remains usually a permanent disfigurement at the site of the mass; like tuberculous gummas these growths may undergo caseous or even calcareous degeneration.
A gumma of the skin will open at one or several points, and, becoming thus secondarily infected, may give exit to sloughing tissue and foul discharge. If the skin directly overlies the bone, then the tumor may involve the latter as well; and when it ulcerates, the bone will be exposed. In the healing process, however brought about, deformity from cicatricial contraction may cause much disfigurement. When a gumma appears beneath the true skin and then disappears it may leave areas of depression, with more or less adherent, bleached-out scars, perhaps with a pigmented margin. The appearance of such scars is suggestive of the disease even without a definite history.
The gummas form the most important features of syphilis, at least from a surgical standpoint, since they frequently appear in the depths as well as on the surface of the body, without any other symptoms, and they often cause no little perplexity in diagnosis. Syphilomas, tuberculous gummas, phlegmons, innocent and benign tumors, as occurring especially in and upon the bone, in the muscles, tongue, the breast, the testicle, and elsewhere, may be difficult of diagnosis. Of course, a history of syphilis is a great help. Doubt frequently arises when such a history cannot be obtained. Scarcely any other disease will produce multiple lesions such as are seen in syphilis, and when multiple they are usually distributed, with some appearance of symmetry. Ulcers formed by their breaking down are often extremely sensitive, but do not bleed easily, nor show a tendency to exuberant granulation. In cases of doubt the most successful test is perhaps the therapeutic, and consists in giving mercurial or mixed treatment to the point of toleration and noting its effect.