instrument numerous closely-set punctures are made, and repeated from
time to time, usually with the same action and result as from linear
scarification.
_Erasion._--The parts are thoroughly scraped with a curette, and a
supplementary caustic application made, either with caustic potash or
several days' use of the pyrogallic-acid ointment. The result is usually
satisfactory.
The dental-burr is also useful in breaking up discrete tubercles.
_Excision._--This is an effective method if the disease consists of a
small pea- or bean-sized circumscribed patch.
Of these various operative methods those now most favored are erasion
and excision, punctate and linear scarification methods are now rarely
employed.
#Tuberculosis Cutis.#[D]
(_Synonym:_ Scrofuloderma.)
[Footnote D: The most important clinical variety of this class is lupus
vulgaris, which is considered above, separately, at some length.]
#What do you understand by tuberculosis cutis?#
The term is applied to those peculiar suppurative and ulcerative
conditions of the skin due to the tubercle bacilli.
#How does the common type of tuberculosis cutis begin?#
The most common type of tuberculous ulceration or involvement of the
skin usually results by extension from an underlying caseating and
suppurating lymphatic gland; or it may have its origin as subcutaneous
tubercles independently of these structures. It tends to spread, and may
involve an area of one or several inches.
[Illustration: Fig. 48. Tuberculosis Verrucosa Cutis (Negro).]
#What are the clinical appearances and behavior of this type of
tuberculous ulceration?#
It is usually superficial, has thin, red, undermined edges of a
violaceous color, and an irregular base with granulations covered
scantily with pus. As a rule, it spreads gradually as a simple
ulceration, with but slight, if any, outlying infiltration. Subjective
symptoms of a painful or troublesome character are rarely present. Its
course is usually progressive but slow and chronic.
Other symptoms of tuberculosis are commonly to be found.
#Are other forms of tuberculosis cutis met with?#
A papulo-pustular eruption is sometimes observed, especially on the
upper extremities and face; sluggish and chronic in character and
leaving small pit-like scars; has been known as the _small pustular
scrofuloderma_.
[Illustration: Fig. 49.
Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary
tuberculosis).]
An ulcerative papillomatous or verrucous tuberculosis of the skin
(tuberculosis verrucosa cutis) is also occasionally noted, most commonly
seated upon the lower leg or the back of the hand. It may be slight or
extensive. Its mildest phase is the so-called verruca necrogenica.
#Describe verruca necrogenica.#
Verruca necrogenica is a rare, localized, papillary or wart-like
formation, occurring usually about the knuckles or other parts of the
hand.
It begins, as a rule, as a small, papule-like growth, increasing
gradually in area, and when well advanced appears as a pea, dime-sized
or larger, somewhat inflammatory, elevated, flat, warty mass, with
usually a tendency to slight pus-formation between the hypertrophied
papillae; the surface may be horny or it may be crusted. It tends to
enlarge slowly and is usually persistent, but it at times undergoes
involution.
[Illustration: Fig. 50.
Tuberculosis Cutis (Verruca Necrogenica). (_After Model in Guy's
Museum._)]
#State the etiology.#
Heredity, insufficient and unwholesome food, impure air, and the like
are predisposing. The tubercle bacillus is the immediate exciting cause.
The disease usually appears in childhood or early adult life, and not
infrequently follows in the wake of some severe systemic disease.
Etiologically it is identical in nature with lupus.
#How is the tuberculous ulcer to be differentiated from syphilis?#
By the peculiar character of the tuberculous ulceration, the absence of
outlying tubercles and infiltration, together with its history, course,
and often the presence of other tuberculous symptoms.
#State the prognosis.#
These various types of tuberculosis cutis are, as a rule, more amenable
to treatment than that form known as lupus vulgaris (_q. v._).
#What is the treatment of these forms of tuberculosis cutis?#
Constitutional remedies, such as cod-liver oil, iodide of iron or other
ferruginous tonics, together with good food and pure air; phosphorus
one-hundredth to one-fiftieth of a grain three times daily is also of
benefit in some cases.
The local treatment consists in thorough curetting and the subsequent
application of a mildly stimulating ointment. The several other plans of
external treatment employed in lupus (_q. v._) are also variously
practised. In recent years the _x_-ray and Finsen light plans have, in a
measure, supplanted the previous methods of treatment. They are slow,
however, and might be, especially the _x_-ray, more satisfactorily
employed as a supplementary measure.
#Ainhum.#
#Describe ainhum.#
Ainhum is a disease of the African race, met with chiefly in Brazil, the
West Indies, and Africa, and consists of a slow but gradual linear
strangulation of one or more of the toes, especially the smallest,
resulting, eventually, in spontaneous amputation. The affected toes
themselves undergo fatty degeneration, often with increase in size, and
are, when strangulation is well advanced, considerably misshapen. The
nature of the disease is obscure.
_Treatment_ consists, in the early stages, of incision through the
constricting band; when the disease is well advanced, amputation is the
sole recourse.
#Mycetoma.#
(_Synonyms:_ Fungous Foot of India; Madura Foot; Podelcoma.)
#Decribe mycetoma.#
It is a disease involving usually the foot, and is met with chiefly in
India. It is characterized by swelling and the formation of tubercular
or nodular lesions which break down and form the external openings of
sinuses which lead to the interior of the affected part. These
discharge, and are studded with, whitish granules or black, roe-like
masses, mixed with a sanious or sero-purulent fluid. The whole part is
gradually disintegrated, the process lasting indefinitely. Its nature is
obscure; it is thought to be due to a fungus.
_Treatment_ consists in the early stages, when the disease is limited,
of thorough curetting and cauterization; later, after the part is more
or less involved, amputation, at a point well up beyond the disease,
becomes necessary. Potassium iodide internally may exert a favorable
influence.
#Perforating Ulcer of the Foot.#
#Describe perforating ulcer of the foot.#
Perforating ulcer of the foot is a rare disease, consisting of an
indolent and usually painless sinus leading down to diseased bone. The
external opening, which is through the centre of a corn-like formation,
is small, and may or may not show the presence of granulations. The
affected part is commonly more or less anaesthetic and of subnormal
temperature. One or several may be present, either on one or both feet.
The most common site is over the articulation of the metatarsal bone
with the phalanx of the first or last toe. The disease is dependent upon
impairment or degeneration of the central, truncal or peripheral nerves.
#What is to be said in regard to the prognosis and treatment?#
Treatment, which is, as a rule, unsatisfactory, consists in the
maintenance of absolute rest, and the use of antiseptic and stimulating
applications. Amputation is also resorted to, but even this is at times
futile, as a new sinus may appear upon the stump.
#Syphilis Cutanea.#
(_Synonyms:_ Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)
#In what various types may syphilis manifest itself upon the integument?#
Syphilis may show itself as a macular, papular (rarely vesicular),
pustular, bullous, tubercular and gummatous eruption; or the eruption
may be, in a measure, of a mixed type.
#In what respects do the early (or secondary) eruptions of syphilis
differ from those following several years or more after the contraction
of the disease?#
The early or secondary eruptions are more or less generalized, with
rarely any attempt at special configuration. Their appearance is often
preceded by symptoms of systemic disturbance, such as fever, loss of
appetite, muscular pains and headache; and accompanied by concomitant
signs of the disease, such as enlargement of the lymphatic glands, sore
throat, mucous patches, falling of the hair and rheumatic pains.
#State the distinguishing characters of the late eruptions.#
The late eruptions (those following one or more years after the
contraction of the disease) are usually of tubercular, gummatous or
ulcerative type; are limited in extent, and have a marked tendency to
appear in circular, semicircular or crescentic forms or groups. Pain in
the bones, bone lesions and other symptoms may or may not be present.
#What is the color of syphilitic lesions?#
Usually, a dull brownish-red or ham-red, with at times a yellowish cast.
#Are there any subjective symptoms in syphilitic eruptions?#
As a rule, no; but in exceptional instances of the generalized
eruptions, more especially in negroes, there may be slight itching.
#Describe the macular, or erythematous, eruption of syphilis.#
The _macular syphiloderm_ is a general eruption, showing itself usually
six or eight weeks after the appearance of the chancre. It consists of
small or large, commonly pea- or bean-sized, rounded or
irregularly-shaped, not infrequently slightly raised, macules. When well
established they do not entirely disappear under pressure. At first a
pale-pink or dull, violaceous red, they later become yellowish or
coppery. The eruption is generally profuse; the face, backs of the hands
and feet may escape. It persists several weeks or one or two months; as
a rule, it is rapidly responsive to treatment.
#How would you distinguish the macular syphiloderm from measles, roetheln
and tinea versicolor?#
Measles is to be differentiated by its catarrhal symptoms, fever, form
and situation of the eruption; roetheln, by its small, roundish,
confluent pinkish or reddish patches, its precursory pyrexic symptoms,
its epidemic nature, and short duration; tinea versicolor by its
scaliness, peripheral growth, distribution and history.
And, finally, by the absence or presence of other symptoms of syphilis.
[Illustration: Fig. 51. Macular Syphiloderm.]
#What several varieties of the papular eruption of syphilis are met with?#
There are two forms of the papular eruption--the small and large; those
of the latter type may undergo various modifications.
#Describe the small-papular eruption of syphilis.#
The _small-papular syphiloderm_ (_miliary papular syphiloderm_) usually
shows itself in the third or fourth month of the disease, and consists
of a more or less generalized eruption of disseminated or grouped, firm,
rounded or acuminated pin-head to millet-seed-sized papules, with smooth
or slightly scaly summits, and in some lesions showing pointed
pustulation. Scattered minute pustules and some large papules are
usually present. The eruption is profuse, most abundant upon the trunk
and limbs; and in the early part of the outbreak is of a bright- or
dull-red color, later assuming a violaceous or brownish tint. It runs a
chronic course, is somewhat rebellious to treatment, and displays a
tendency to relapse.
[Illustration: Fig. 52. Moist Papules. (_After Miller._)]
#How would you distinguish the small-papular syphiloderm from keratosis
pilaris, psoriasis punctata, papular eczema, and lichen ruber?#
The distribution and extent of the eruption, the color, the grouping,
with usually the presence of pustules and large papules and other
concomitant symptoms of syphilis, are points of difference. Pustules
never occur in the several diseases named, except in eczema.
#Describe the large-papular eruption of syphilis.#
The _large-papular syphiloderm_ (or _lenticular syphiloderm_) is a
common form of cutaneous syphilis, appearing usually in the first six or
eight months, and consists of a more or less generalized eruption of
pea- to dime-sized or larger, flat, rounded or oval, firmly seated,
more or less raised, dull-red papules; with at first a smooth surface,
which later usually becomes covered with a film of exfoliating
epidermis. The papules, as a rule, develop slowly, remain stationary
several weeks or a few months, and then pass away by absorption, leaving
slight pigmentation, which gradually fades; or they may undergo certain
modifications. In most cases it responds rapidly to treatment.
[Illustration: Small-papular Syphiloderm.]
[Illustration: Fig. 53. Palmar Syphiloderm.]
#What modifications do the papules of the large-papular syphiloderm
sometimes undergo?#
They may change into the moist papule and squamous papule.
#Describe the moist papule of syphilis.#
The change into the moist papule (also called _mucous patch, flat
condyloma_) is not uncommon where opposing surfaces and natural folds of
skin are subjected to more or less contact, as about the anus, the
scroto-femoral regions, umbilicus, axillae and beneath the mammae. The
dry, flat papules gradually become moist and covered with a grayish,
sticky, mucoid secretion; several may coalesce and form large, flat
patches. They may so remain, or they may become hypertrophic, warty or
papillomatous, with more or less crust formation (_vegetating
syphiloderm_).
[Illustration: Fig. 54. Annular Syphiloderm. (_After I.E. Atkinson._)]
#Describe the squamous papule of syphilis.#
This tendency of the large-papular eruption to become scaly, when
exhibited, is more or less common to all papules, and constitutes the
_squamous_ or _papulo-squamous syphiloderm_ (improperly called
_psoriasis syphilitica_). The papules become somewhat flattened and are
covered with dry, grayish or dirty-gray, somewhat adherent scales. The
scaling, as compared to that of psoriasis, is, as a rule, relatively
slight. The eruption may be general, as usually the case in the earlier
months of the disease, or it may appear as a relapse or a later
manifestation, and be limited in extent.
As a limited eruption it is most frequently seen on the palms and
soles--the _palmar and plantar syphiloderm_. Occurring on these parts it
is often rebellious to treatment.
[Illustration: Maculo-papular syphiloderm.]
#How are you to distinguish the papulo-squamous syphiloderm from
psoriasis?#
In psoriasis the eruption is more inflammatory, and usually bright red;
the scales whitish or pearl-colored and, as a rule, abundant. It is
generally seen in greater profusion upon certain parts, as, for
instance, the extensor surfaces, especially of the elbows and knees. It
is not infrequently itchy, and, moreover, presents a different history.
In the syphilitic eruption some of the papules almost invariably remain
perfectly free from any tendency to scale formation; there is distinct
deposit or infiltration, and the lesions are of a dark, sluggish red or
ham tint; and, moreover, concomitant symptoms of syphilis are usually
present.
#Describe the annular eruption of syphilis.#
The _annular syphiloderm_ (_circinate syphiloderm_) is observed usually
in association with the large-papular eruption, and consists of several
or more variously sized, ring-like lesions, with a distinctly elevated
solid ridge or wall peripherally and a more or less flattened centre. It
is commonly seen about the mouth, forehead and neck. The lesion appears
to have its origin from an ordinary, usually scaleless or slightly
scaly, large papule, the central portion of which has been incompletely
formed or has become sunken and flattened. The manifestation is rare,
and is seen most frequently in the negro.
#What several varieties of the pustular syphiloderm are met with?#
The small acuminated-pustular syphiloderm, the large acuminated-pustular
syphiloderm, the small flat-pustular syphiloderm, and the large
flat-pustular syphiloderm.
#Describe the small acuminated-pustular eruption of syphilis.#
The _small acuminated-pustular syphiloderm_ (_miliary pustular
syphiloderm_) is an early or late secondary eruption, commonly
encountered in the first six or eight months of the disease. It
consists of a more or less generalized, disseminated or grouped,
millet-seed-sized, acuminated pustules, usually seated upon dull-red,
papular elevations. The eruption is, as a rule, profuse, and usually
involves the hair-follicles. The pustules dry to crusts, which fall off
and are often followed by a slight, fringe-like exfoliation around the
base, constituting a grayish ring or collar. Minute pin-point atrophic
depressions or stains are left, which gradually become less distinct.
Scattered large pustules, and sometimes papules, are not infrequently
present.
#Describe the large acuminated-pustular eruption of syphilis.#
The _large acuminated-pustular syphiloderm_ (_acne-form syphiloderm_,
_variola-form syphiloderm_) is a more or less generalized eruption,
occurring usually in the first six or eight months of the disease. It
consists of small or large pea-sized, disseminated or grouped,
acuminated or rounded pustules, resembling the lesions of acne and
variola. They develop slowly or rapidly, and at first may appear more or
less papular. They dry to somewhat thick crusts, and are seated upon
superficially ulcerated bases.
It pursues, as a rule, a comparatively rapid and benign course. In
relapses the eruption is usually more or less localized.
#How would you distinguish the large acuminated-pustular syphiloderm from
acne and variola?#
In acne the usual limitation of the lesions to the face or face and
shoulders, the origin, more rapid formation and evolution of the
individual lesions, and the chronic character of the disease, are
usually distinctive points.
In variola, the intensity of the general symptoms, the shot-like
beginning of the lesions, their course, the umbilication, and the
definite duration, are to be considered.
The presence or absence of other symptoms of syphilis has, in obscure
cases, an important diagnostic bearing.
#Describe the small flat-pustular eruption of syphilis.#
The _small flat-pustular syphiloderm_ (_impetigo-form syphiloderm_)
consists of a more or less generalized, pea-sized, flat or raised,
discrete, irregularly-grouped, or in places confluent, pustules,
appearing usually in the first year of the disease. The pustules dry
rapidly to yellow, greenish-yellow, or brownish, more or less adherent,
thick, uneven, somewhat granular crusts, beneath which there may be
superficial or deep ulceration; where the lesions are confluent a
continuous sheet of crusting forms. The eruption is often scanty. It is
most frequently observed about the nose, mouth, hairy parts of the face
and scalp, and about the genitalia, frequently in association with
papules on other parts.
#Are you likely to mistake the small flat-pustular syphiloderm for any
other eruption?#
Scarcely; but when upon the scalp, it may bear rough resemblance to
pustular eczema, but the erosion or ulceration will serve to
differentiate. Moreover, concomitant symptoms of syphilis are to be
looked for.
#Describe the large flat-pustular eruption of syphilis.#
The _large flat-pustular syphiloderm_ (_ecthyma-form syphiloderm_)
consists of a more or less generalized, scattered eruption, of large
pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases
of the lesions are a deep-red or copper color. Two types of the eruption
are met with.
In one type--the superficial variety--the crust is flat, rounded or
ovalish, of a yellowish-brown or dark-brown color, and seated upon a
superficial erosion or ulcer. The lesions are usually numerous, and most
abundant on the back, shoulders and extremities. It appears, as a rule,
within the first year, and generally runs a benign course.
[Illustration: Fig. 55. Rupia. (_After Tilbury Fox._)]
In the other type--the deep variety--the crust is greenish or blackish,
is raised and more bulky, often conical and stratified, like an oyster
shell--_rupia_; beneath the crusts may be seen rounded or
irregular-shaped ulcers, having a greenish-yellow, puriform secretion.
It is usually a late and malignant manifestation.
#How would you differentiate the large flat-pustular syphiloderm from
ecthyma?#
The syphilitic lesions are more numerous, are scattered, are attended
with superficial or deep ulceration, and followed by more or less
scar-formation. Moreover, the history, and presence or absence of other
symptoms of syphilis have an important diagnostic value.
[Illustration: Fig. 56. Ulcerating Tubercular Syphiloderm.]
#Describe the bullous eruption of syphilis.#
The _bullous syphiloderm_, (of acquired syphilis) is a rare and usually
late eruption, appearing in the form of discrete, disseminated, rounded
or ovalish, pea- to walnut-sized, partially or fully distended, blebs.
The serous contents soon become cloudy and puriform. In some cases the
lesions are distinctly pustular from the beginning. The crust, which
soon forms, is of a yellowish-brown or dark green color, and may be
thick and stratified (_rupia_), as in the deep variety of the large
flat-pustular syphiloderm. The erosions or ulcers beneath the crusts
secrete a greenish-yellow fluid. It is a malignant type of eruption, and
is usually seen in broken-down subjects.
It is not an uncommon manifestation of hereditary syphilis (_q. v._) in
the newborn.
[Illustration: Fig. 57. Tubercular Syphiloderm.]
#How is the bullous syphiloderm to be differentiated from other
pemphigoid eruptions?#
By the gravity of the disease, the accompanying ulceration, the course
and history; and by other evidences, past or present, of syphilis.
#Describe the tubercular eruption of syphilis.#
The _tubercular syphiloderm_ (_syphiloderma tuberculosum_) may
exceptionally occur within the first year as a more or less generalized
eruption. As a rule, however, it is a late manifestation, at times
appearing many years after the initial lesion; is limited in extent, and
shows a decided tendency to occur in groups, often forming segments of
circles and circular areas, clearing in the centre and spreading
peripherally.
It consists (as a late, limited manifestation) of several or more firm,
circumscribed, deeply-seated, smooth, glistening or slightly scaly
elevations; rounded or acuminated in shape, of a yellowish-red,
brownish-red or coppery color and usually of the size of small or large
peas. Several groups may coalesce, and a serpiginous tract result
(_serpiginous tubercular syphiloderm_). The lesions develop slowly, and
are sluggish in their course, remaining, at times, for weeks or months,
with but little change. As a rule, however, they terminate sooner or
later, either by absorption, leaving a more or less permanent pigment
stain with or without slight atrophy (_non-ulcerating tubercular
syphiloderm_), or by ulceration (_ulcerating tubercular syphiloderm_).
[Illustration: Fig. 58. Ulcerating Tubercular Syphiloderm.]
#Describe the ulcerating tubercular syphiloderm.#
The ulceration may be superficial or deep in character, and involve
several or all of the lesions forming the group. The patch may consist,
therefore, of small, discrete, punched-out ulcers, or of one or more
continuous ulcers, segmented, crescentic or serpiginous in shape. They
are covered with a gummy, grayish-yellow deposit or they may be crusted.
As the ulcerative changes take place, new lesions, especially about the
periphery of the group or patch, may appear from time to time.
[Illustration: Tubercular Syphiloderm.]
[Illustration: Large-pustular Syphiloderm.]