A system of practical medicine. By American authors. Vol. 4

by Unknown

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 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 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 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.