VOL. XXXIX, No. 267

WHOLE 931

Original Articles

SYPHILITIC CUTANEOUS SCARS.

BY A. H. OHMANN-DUMESNIL, St. Louis. HERE is probably no single one of the secondary lesions of the skin which possesses more general interest than the scar, unless it be the ulcer. The scar is not only full of interest from a morphologic point of view, but also from a pathologic point of view. As an etiologic teacher it is of the highest value. For a proper understanding of the various and diverse differences connected with the different kinds of scars is replete with points of the highest importance to aid, from a diagnostic point of view, in the sometimes difficult task of accurately determining what the anterior original condition was in a pathologic sense. In the observation of scars there always exists a certain number of points which should always be taken into consideration. Thus a scar may be thick or thin, smooth or rough, firm or soft, or varying in these qualities. The color may vary, and, if there be a number, the distribution may be peculiar, symmetrical or in regular figures. Again, there are corded scars, such as follow deep ulcerations, burns and other traumas. Lupus is very apt to leave stellate scars, and so are ulcerations of mucous membranes, more especially of the pharynx. Linear scars follow cuts, whether accidental or surgical, and unless care be taken in their treatment they are very apt to become puckered. The thickness of a scar is usually a good index of the amount of destruction of tissue which has taken place, and its form will also furnish a very good idea of the manner in which that destruction occurred. This is more especially the case in those instances in which former ulcers have occurred, as they furnish a clear indication of their former size and distribution, and from these very points quite a distinct idea may be formed of the causative condition which existed anteriorly.

The peculiar characteristics which accompany scars are also of much value and constitute a good index of their derivation. The hypertrophic scar reveals some general condition which leads to the peculiarity in size. Thus, the scars resulting from destructive suppuration of tuberculous glands are always of this

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nature. And the peculiar scars which follow injuries in those prone to develop keloid should also be borne in mind. And thus we note certain peculiarities of some value even in such lesions as scars. Another instance which may be cited is the vaccine scar, which once seen can hardly ever be mistaken if ever observed again. Its peculiarity in contour and surface, as well as the degree of paleness it exhibits, are sufficient to make its cause easily recognized. So it is with variola, the scars of which, the so-called "pits," possess not only morphological peculiarities, but have such a distribution as immediately stamps. them as derived from the destructive action of smallpox pustules. But we will turn our attention to syphilitic scars and some of their peculiarities.

In syphilis scars are the result of either superficial or deep destructive lesions. This is one reason why the chancre should not be followed by a scar. Whilst it is true that we occasionally meet with one which is phagedenic this is rather the exception than the rule. The reason that scars follow chancres is that patients, druggists or even physicians are too prone to employ caustics directly they see a suspicious sore upon the genitals. As the chancre is essentially a small-cell infiltration such methods are irrational; and if the primary lesion be properly managed no scar will result. In this respect it differs materially from the chancroid, which is always a destructive lesion, as manifested by the pain and suppuration which accompany it. Emphasis is laid upon these points for the reason that a physician is not justified in concluding that a patient has had syphilis, or a chancre, because he observes a scar upon the genitals. The destructive lesion produced by a caustic is not essentially syphilitic, and for this reason the scar does not possess any particularly well-marked or distinguishing signs. So that it may be concluded that scars upon the genitalia furnish no presumptive evidence of some anterior venereal trouble. In destructive syphilitic lesions the scars may occur spontaneously or as the result of the treatment adopted. When treatment is radical and effective the scars which occur will never be of so marked a character as if the case be but incompletely treated or permitted to recover almost spontaneously, as many will, although the improvement observed is only temporary. In any case, when the scar first forms, it is quite slow in its evolution

and is very delicate in its texture, so much so that it is prone to break down upon the slightest external ir. ritation. On the other hand, it has a tendency to limit itself quite exactly to the contours of the original destructive lesion. Like all cicatrices and similar processes of a reparative nature, its first beginnings are manifested at the periphery, the action being a centripetal one, which is exactly the reverse of the destructive action, which was centrifugal. Cicatrization, beginning at the periphery, spreads rather slowly towards the center, and it is not an unusual thing to see it stop short in its progress. It then requires some stimulation in order to continue its course. This may or may not be necessary until the entire surface of destroyed tissue is covered by the scar tissue. When this latter has been effected it is usually necessary to afford the new tissue some protection. This is necessary in order that a good result may follow without the disagreeable interruption attendant upon a breaking down of the cicatrix. This latter contingency may occur with the best of protective treatment, and it is on account of the possibility of this occurring that effective internal treatment is always necessary. If all these conditions are fulfilled we see a good, firm scar result, and one which will form an efficient and a lasting substitute for the destroyed tissues. Another condition which will be noted is that the scar will be of sufficient density, without being malformed, and, as a natural result, will not arouse or lead to any particular attention on the part of others.

The first change observed in a syphilitic scar after it has become formed is a marked and deep pigmen. tation. This pigmentation is one which is of a pe. culiar nature, such as is usually observed in all similar changes of color in syphilitics. While it is usually of a dark brown color it is yet of such a peculiar brown as to greatly suggest the hue of bronze. It is a shade of color which it is a very difficult matter to describe, and which, once seen, is indelibly fixed in the memory. Of course, this peculiar brown color is observed in Caucasians; in negroes, instead of brown, it is black, on account of the great preponderance of pigment in their skin. The brownish tinge is more marked in those of dark complexions, whereas in blondes it more nearly resembles what it has been compared to by some-the color of old copper. Other writers again describe it as similar to the surface of cut ham, which has been exposed to the air. To the writer it has a greater resemblance to a brownish tinge in which a certain preponderance of dark red manifests itself. Be this as it may, the pigmentation of the scar is sharply defined against the unaffected skin. The line of dermarcation is so well and positively defined that it frequently gives the impression that the integument has been stained with. some coloring matter. This resemblance is still more

marked when, as occasionally happens, the scars are not thick, so that the apparent stain is not elevated above the general level of the integument, nor can any depression be made out, either by the touch or by simple inspection. It is in this class of cases that much care must be exercised, either not to mistake the condition for one of syphilitic pigmentation pure and simple, or not to mistake it for a non-specific pigmentation, such as may be brought on by the process which produces the large freckles or small chloasmata.

In the normal evolution of the syphilitic scar the color gradually fades away in the course of time. This bleaching process begins at the center of the lesion in a point which gradually takes on a peripheral movement which is slowly progressive. The paleness is much more marked at the center and becomes even intense to such a degree that the periphery presents a much darker tinge. In time this becomes so prominent that the periphery is transformed into a distinct and marked dark-brown ring, which is slow to grow lighter in hue. This peculiar ring is quite interesting to observe, and it often puzzles those who are unacquainted with the peculiar development and evolution of syphilitic pigmentation of scars. The dark ring we have just mentioned slowly disappears, to assume the same hue as that shown by the rest of the lesion. Then a process, which may be looked upon as a continuation of the one just described, sets in. It is not only a continuation, but it may be looked upon as an intensification. The loss of the pigment which has accumulated is not only accomplished until the normal color of the skin is attained, but there comes on an actual loss of the pigment which is natural. This loss is one which is very similar to that observed in some cutaneous troubles and, as in them, it becomes permanent. The color, however, does not resemble that of vitiligo, which has a milky-white hue. On the contrary, it is of a dead-white hue, but with a surface which is somewhat glistening, though not with that sheen observed in psoriasis, which reminds one of motherof-pearl.

The condition which may be regarded as a common peculiarity of some syphilitic scars is that they are apt to be smooth and glabrous, and almost on a level with the skin. Such are well represented in Figure 1. They are thin and pliable, this being due to the fact that the ulceration was quite superficial. In the patient whose arm is figured the treatment was not only of short duration, but quite inefficient. She did not suffer from any extensive secondary symptoms, having had but a few disseminated papules and a few scattered pustules. Later on some syphilitic ulcerative lesions came on and, whilst some were quite deep and severe, quite a number were very superficial. At the time the picture, from which Figure 1 was made,

but have led to the formation of very small pits or depressions in the scar, such as are observed in cicatrices following vaccination, and which might be aptly called vacciniform scars. In this form there is invariably a depression below the general level of the skin, although in syphilis very small cords occasionally run across the field of the cicatricial tissues.

On the other hand, if the ulcers have been active and extended through the skin, and efficient treatment neglected or only partially carried out, the resulting scars will be found distorted, thick and corded as well as hypertrophic in character, giving rise to a very unsightly appearance, as shown in Fig. 2. The patient in this case had a small ulcer of the prepuce and adjoining neighborhood, which was inclined to be destructive, and, as is often the case in negroes, the ulcers rapidly spread. Being frightened at the increase in the number and severity of the ulcerations he consulted friends who recommended various washes and ointments, whose sole action was to aggravate the trouble. He finally arrived at such a deplorable condition that he applied and was admitted in a public hospital, where he was properly treated and the ulcers healed. It will be seen from the illustration that the ulcerative process had gone down deep into the integument of the scrotum and mons veneris and the scars retracted to such an extent as to produce deep fur

rows.

FIG. 1. SUPERFICIAL SCAR (Syphilitic).

was taken, it had already been several years since the scars had formed and she was then suffering from visceral involvements. As can be seen, the scars were quite smooth, although slightly elevated, as shown by the one occurring on the radial side of the arm, and of a marked white color.

A peculiar variety of syphilitic scar is the cribriform, from its fancied resemblance to a sieve. In this form the scar has destroyed the skin down to the cutis or true skin, and involved a portion of it. In consequence of this the glands of the integument and the bulbs of the hair have not been destroyed. In the reparative process which takes place the healing seems to occur about and around the openings of the follicles, and the majority remain more or less patulous, giving rise to the peculiar appearance which has given its name to this variety of scar. Moreover, one or two hairs may be seen, here and there, apparently projecting from the scar, whereas, as a matter of fact, they occur in little islets which have escaped destruction. It is also to be noted that the openings of the ducts of the glands frequently do not persist,

FIG. 2. DEEP SCAR (Syphilitic). When deep ulcers occur in syphilis, in which there is an extensive destruction of the subcutaneous structures, the reparative efforts of nature, even under the best treatment, will not succeed in supplying the destruction which has been accomplished. As a natural result of this the scars of deep ulcers assume a crateriform shape, or the form of a reversed cone. this is not the only condition which is observed. The cicatrix is thick, corded, and not infrequently it is traversed by cords radiating from the centre, making it stellate in appearance. It is particularly in this

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variety that the scars are hypertrophic in character and present a very unsightly appearance. When the ulcers are located in the neighborhood of joints they are very apt to be followed by scars which will seriously interfere with the function of motion, and in that manner add to the discomfort of the patient. If the ulcer has been very deep and situated over a bone it is not unusual for the cicatrix to become attached to the osseous structure, and, on account of its unyielding nature, it will add still further to the inconvenience. This interference is of such a marked character that it produces great dissatisfaction in patients, who will often express themselves as of the opinion that the cure of the ulcer was worse than the lesion itself.

In this class of individuals the appear

ance of the trouble cuts but a small figure in comparison with the inconvenience caused by the scar, more especially as, in the case of men especially, it hinders them from gaining a livelihood as easily as they otherwise would.

FIG. 3. SCAR OF ENTIRE SCALP (Syphilitic).

There is another variety of syphilitic scar which is, fortunately, not as prevalent as those which have been described. This is the scar which follows confluent serpiginous ulcerations of the scalp and those occurring over subcutaneous bones. In this form the scar is firmly attached to the bone, and often it dips down into the depressions which have resulted from caries or necrosis. An example of such a condition is shown in Figure 3. In this case the patient, a woman, had been treated intermittently and not actively enough. Her whole osseous system was involved. She had lost her vomer and nasal bones, had perforation of the palate, necrosis of various bones, and had her body literally covered with thick scars,

which had followed deep and extensive ulcerations. The alveolar processes had all disappeared. A reference to Figure 3 will show a characteristic picture of the condition presented. As will be noted the scar is quite smooth, with the exception of a rather irregular depression near the vertex, due to a necrosis of the outer table of the skull. Upon the left side and at the occiput up to the left ear there is a fringe of hair; whilst, upon the right side, not a vestige remains. The line which may be observed at the occiput was caused by the pressure of the elastic which aided in holding the wig which was worn. At the time the patient presented herself she was no longer troubled by any superficial lesions, but was suffering from syphilis of the nervous system, with the accompaniment of a few visceral lesions, notably gummata of the rectum. A peculiarity of the scar of the skull is one which can be noted in these formations over subcutaneous bones. They are usually adherent and rather thin, although not cribriform. The adherence would seem to produce so much tension that a greater or less amount of pressure atrophy takes place in the cicatrix.

It may not be out of place to call attention to certain scars which, by their size and distribution, point to the prior existence of syphilis. In pustular syphilides of a marked character, such as the varioliform, each lesion leaves a rounded scar of the size of the base of the original lesion. These scars are apt to be slightly depressed and always assume a markedly white color. They may be scattered upon the limbs; but upon the trunk and face they are more apt to be distributed in the curved lines of the segments of circles or complete circles. This is characteristic of syphilis and should always awaken suspicion to its having affected the subject presenting them. In the pustular diseases which are followed by scars, such as acne, herpes zoster, or variola, it will be noted that the cicatrices are very irregularly distributed. They do not assume any particular distribution, nor are they disposed in circular lines or in the form of the arcs of circles.

Another point which should always be borne in mind is that symmetry, in its absolute sense, is not an invariable rule so far as syphilitic lesions are concerned. Whilst it may be true that analogous areas will be affected, the lesions will not occur in corresponding parts of them, and on this account too much symmetry must not be expected. As a necessary corollary of this proposition it naturally follows that symmetry in the distribution of scars is not to be expected. Moreover, the scars affecting symmetrical areas are not necessarily of the same nature. That is, they will not be of the same degree of thickness and, consequently, the thicker ones will not bleach as rapidly as those which are thinner, even though the primary destructive lesions may have appeared simultaneously. The whole subject is perhaps deserving of more attention than has hitherto been paid to it, and whatever time is devoted to it will be amply repaid by the returns it will give in the way of directing attention to a possible prior condition which can explain what would otherwise appear to be very obscure or puzzling symptoms.

With this number we close Volume XXXIX of the REVIEW. Eleven weeks ago the present management in assuming charge of the publication accepted the task as significant of earnest work rather than of airy promises. We were willing to postpone extravagant claims until the commendations of our patrons made them unnecessary. We still submit our efforts to the verdict of the medical public, content in the knowledge that the commendations have come and are coming, and we are sure they will come in direct proportion to the value which the REVIEW establishes for itself.

THE DISPLACEMENT OF COCAINE IN LARYNGOLOGY BY NEWER DRUGS.

As year by year passes in succession, we are forced to admit the fallacy of what was a fondly cherished belief that in certain specialties, at least, medicine approaches the exactness of a science. In fancy, the mastery of the subject seemed to be simply a matter of study, application and mind. In reality, we reach the topmost round when, behold! someone adds another and another, thus confirming the thought that there is no rest without enforced retrogression. While we tarry the ladder lengthens and attainment of the heights becomes impossible.

Many have thought that progress in laryngology and its associated specialties would soon be impossible in view of the refinements of manipulative dexterity made possible since the introduction of cocaine as an anesthetic fifteen years ago.

The medical world welcomed cocaine with an enthusiasm that indicated a feeling that the summum bonum had been attained. To be able to render the field of operation anesthetic without the loss of con

sciousness on the part of the patient was certainly a tremendous advance over the methods before in vogue.

We are much inclined to agree that there is great truth in the sophomoric title of the essays of our school days, "The age calls; the hero comes." Observe how, when cocaine was found to cause unexpected toxic symptoms in idiosyncratic and debilitated patients, eucaine was added to our anesthetics— an agent having practically the same formula but differing from cocaine mainly in that it is manufactured artificially from coal tar, while the latter is prepared from coca leaves, etc. Eucaine up to the present time at least has upheld the claim that it has but slight if any disposition to affect the heart, and for this reason is largely utilized in nasal and laryngeal surgery.

Apart from the necessity for increasing the strength of the solution and the uncomfortable dryness, which both cocaine and eucaine occasion, they are sovereign remedies for the relief of pain in laryngeal tuberculosis and cancer. The "age called" for another remedy and, presto! orthoform came into view as an anesthetic for such cases-non-toxic, easy of application, producing no uncomfortable dryness, and inducing anesthesia which remains longer, even if it is not quite so complete.

For years we have sought a vaso-motor constrictor whose action was equal to that of cocaine without its evil effects in the way of exhilaration, habit and heart depression. Just as we were beginning to despair, organo-therapy, coming to our relief, gave us the supra-renal gland, so-called. When a solution of this agent is applied to a mucous membrane, the constricting effect upon the muscular portion of the arterioles is so marked that the mucous membrane becomes almost absolutely bloodless. Thus far no pernicious effects, constitutional or local, have been reported, although it has sprung into extended use. That it finds a happy indication in all affections in which the vascular system of the nose is surcharged with blood, goes without saying. Its value in hay fever will be amply tested during the present summer, and we are confident that it will be found of decided value. Thus the world goes on, for soon this last product, in the light of modern chemical methods, will be relegated to the rear, when some one discovers and isolates the peculiar constituent which gives to it this vaso-constricting power.

THE VALUE OF EMPLOYMENT IN THE TREATMENT OF THE NERVOUS.

A. GROHMANN, in the Psychiatrische Wochenschrift, June 3, 1899, describes briefly his attempt to procure for people nervously affected an employment suitable for them. He believes that a certain part of the