ulcerations becomes papillary or wart-like, with an offensive,
yellowish, puriform secretion (_syphilis cutanea papillomatosa_).
#From what diseases is the tubercular syphiloderm to be differentiated?#
From tubercular leprosy, epithelioma and lupus vulgaris, especially the
last-named.
#What are the chief diagnostic characters of the tubercular syphiloderm?#
The tendency to form segments, crescents and circles, the color, the
pigmentation and ulceration, the history, and not infrequently marks or
scars of former eruptions.
[Illustration: Fig. 59. Tubercular Syphiloderm.]
#Describe the gummatous eruption of syphilis.#
The _gummatous syphiloderm_ (_syphiloderma gummatosum_, _gumma_,
_syphiloma_) is usually a late manifestation, showing itself as one,
several or more painless or slightly painful, rounded or flat, more or
less circumscribed tumors; they are slightly raised, moderately firm,
and have their seat in the subcutaneous tissue. They tend to break down
and ulcerate.
The lesion begins usually as a pea-sized deposit or infiltration, and grows
slowly or rapidly; when fully developed it may be the size of a walnut,
or even larger. The overlying skin becomes gradually reddish. At first
firm, it is later soft and doughy. It may, even when well advanced,
disappear by absorption, but usually tends to break down, terminating in
a small or large, deep, punched-out ulcer.
[Illustration: Fig. 60. Tubercular Syphiloderm.]
#Does the gummatous syphiloderm invariably appear as a rounded
well-defined tumor?#
No. Exceptionally, instead of a well-defined tumor, it may appear as a
more or less diffused patch of infiltration, leading eventually to
extensive superficial or deep ulceration.
#From what formations is the gummatous syphiloderm to be differentiated?#
From furuncle, abscess, and sebaceous, fatty and fibroid tumors.
Attention to the origin, course, and behavior of the lesion, together
with a history, must all be considered in doubtful cases.
[Illustration: Fig. 61. Large Pustular Syphiloderm.]
#What is to be said in regard to the character and time of appearance of
the cutaneous manifestations of hereditary syphilis?#
In a great measure the cutaneous manifestations of hereditary syphilis
are essentially the same as observed in acquired syphilis. They are
usually noted to occur within the first three months of extra-uterine
life. The macular, papular, and bullous eruptions are most common.
#Describe these several cutaneous manifestations of hereditary syphilis.#
The _macular_ (erythematous) eruption begins as large or small, bright-
or dark-red macules, later presenting a ham or cafe-au-lait appearance.
At first they disappear upon pressure. The lesions are more or less
numerous, usually become confluent, especially about the folds of the
neck, about the genitalia and buttocks; in these regions resembling
somewhat erythema intertrigo.
The _papular_ eruption is observed in conjunction with the erythematous
manifestation, or it occurs alone. The lesions are but slightly
elevated, and seem to partake of the nature of both macules and papules.
They are usually discrete, and rarely abundant; they may become decked
with a film-like scale, and at the various points of junction of skin
and mucous membrane, and in the folds, they become abraded and
macerated, developing into _moist papules_.
The _bullous_ eruption consists of variously-sized, more or less
purulent blebs, and is usually met with at or immediately following
birth. It is most abundant about the hands and feet. Macules and papules
are often interspersed. There may be superficial or deep ulceration
underlying the bullae.
#What other symptoms in addition to the cutaneous manifestations are
noted in hereditary syphilis in the newborn?#
Mucous patches, and sometimes ulcers, in the mouth and throat;
hoarseness, as shown by the peculiar cry, and indicating involvement of
the larynx; snuffles, a sallow and dirty appearance of the skin, loss of
flesh and often a shriveled or senile look.
#What is the pathology of cutaneous syphilis?#
The syphilitic deposit consists of round-cell infiltration. The mucous
layer, the corium, and in the deep lesions the subcutaneous connective
tissues also, are involved in the process. The infiltration disappears
by absorption or ulceration. The factor now believed to be responsible
for the disease and the pathological changes is the Spirochaeta pallida,
discovered by Schaudinn and Hoffmann, and usually found in numbers in
the tissues.
#Give the prognosis of cutaneous syphilis.#
In _acquired syphilis_, favorable; sooner or later, unless the whole
system is so profoundly affected by the syphilitic poison that a fatal
ending ensues, the cutaneous manifestations disappear, either
spontaneously or as the result of treatment. The earlier eruptions will
often pass away without medication, but treatment is of material aid in
moderating their severity and hastening their disappearance, and is to
be looked upon as essential; in the late syphilodermata treatment is
indispensable. In the large pustular, the tubercular and gummatous
lesions, considerable destruction of tissue may take place, and in
consequence scarring result. Ill-health from any cause predisposes to a
relapse, and also adds to the gravity of the case.
In _hereditary infantile syphilis_, the prognosis is always uncertain:
the more distant from the time of birth the manifestations appear the
more favorable usually is the outcome.
#How is cutaneous syphilis to be treated?#
Always with constitutional remedies; and in the graver eruptions, and
especially in those more or less limited, with local applications also.
#What constitutional and local remedies are commonly employed in
cutaneous syphilis?#
_Constitutional Remedies._--Mercury and potassium iodide; tonics and
nutrients are necessary in some cases.
_Local Remedies._--Mercurial ointments, lotions and baths, and iodol in
ointment or in (and also calomel) powder form.
#Give the constitutional treatment of the earlier, or secondary,
eruptions of syphilis.#
In secondary or early eruptions mercury alone in almost every case; with
tonics, if called for. If mercury is contraindicated (extremely rare),
potassium iodide may be substituted.
#How is mercury usually administered in the eruptions of secondary
syphilis?#
By the mouth, chiefly as the protiodide, calomel and blue mass, in
dosage just short of mild physiological action; by _inunction_, in the
form of blue ointment; by _hypodermic injection_, usually as corrosive
sublimate solution. The method by _fumigation_, with calomel or
bisulphuret, is now rarely employed.
The method by the mouth is the common one, and it is only in rare
instances that any other method is necessary or advisable.
#What local applications are usually advised in the eruptions of
secondary syphilis?#
If the eruption is extensive, and more especially in the pustular types,
baths of corrosive sublimate ([dram ii-dram-iv] to Cong. xxx) may be
used; and ointment of ammoniated mercury, twenty to sixty grains to the
ounce, blue ointment, and the ten per cent. oleate of mercury alone or
with an equal quantity of any ointment base.
The same applications or a dusting powder of calomel may also be used on
moist papules.
#How long is mercury to be actively continued in cases of early
(secondary) syphilis?#
Until one or two months after all manifestations (cutaneous or other)
have disappeared, and then, as a general rule, continued, as a small
daily dose (about one-quarter to one-third of that prescribed during the
active treatment) for a period of two or three months; then another
cycle of the active dosage for a period of four to six weeks; then a
resumption of the smaller daily dose for another two or three months;
and so on, for a period of at least two years.
(Almost all authorities are agreed as to the importance of prolonged
treatment, but differ somewhat on the question of intermittent or
uninterrupted administration.)
#Give the constitutional treatment of the late, or localized,
syphilodermata.#
Mercury always, usually in small or moderate dosage, as the biniodide or
corrosive chloride, and potassium iodide; the latter in dose varying
from two grains to two drachms or more, t.d., depending upon its action
and the urgency of the case.
#How long is constitutional treatment to be continued in cases of the
late syphilodermata?#
Actively for several weeks after the disappearance of all symptoms, and
then (especially the mercury) continued in smaller dosage (about
one-third) for several months longer.
#What applications are usually advised in the late, or localized,
syphilodermata?#
Ointment of ammoniated mercury, twenty to sixty grains to the ounce;
oleate of mercury, five to ten per cent. strength; mercurial plaster,
full strength or weakened with lard or petrolatum; a two to twenty per
cent. ointment of iodol; resorcin, twenty to sixty grains to the ounce
of ointment base; and lotions of corrosive sublimate, one-half to three
grains to the ounce.
The following is valuable in offensive and obstinate ulcerations:--
[Rx] Hydrarg. chlorid. corros., ........... gr. iv-gr. viij
Ac. carbolici, ....................... gr. x-xx
Alcoholis, ........................... f[dram]iv
Glycerinae, ........................... f[dram]j
Aquae, ............ q.s. ad ........... [Oz]iv. M.
Ointments are to be rubbed in or applied as a plaster; lotions, employed
chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and
usually supplemented by the application of an ointment. Iodol may also be
applied to ulcers as a dusting-powder, usually mixed with one to several
parts of zinc oxide or boric acid.
#Give the treatment of hereditary infantile syphilis.#
It is essentially the same (but much smaller dosage) as employed in
acquired syphilis. Attention to proper feeding and hygiene is of first
importance.
Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij,
t.d.); as calomel (gr. 1/20-gr. 1/6, t.d.); and as a solution of
corrosive sublimate (gr. ss-[Oz]vj, [dram]j, t.d.). If mercury is not
well borne by the stomach, it may be administered by inunction; for this
purpose, blue ointment is mixed with one or two parts of lard and spread
(about a drachm) upon an abdominal bandage and applied, being renewed
daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive
sublimate is, at times, a serviceable method.
Potassium iodide, if exceptionally deemed preferable, may be given in
the dose of a fractional part of a grain to two or three grains three
times daily.
#What local measures are to be advised in cutaneous syphilis of the
newborn?#
If demanded, applications similar to those employed in eruptions of
acquired syphilis, but not more than one-third to one-half the strength.
#Lepra.#
(_Synonyms:_ Leprosy; Elephantiasis Graecorum.)
#What do you understand by leprosy?#
Lepra, or leprosy, is an endemic, chronic, malignant constitutional
disease, characterized by alterations in the cutaneous, nerve, and bone
structures; varying in its morbid manifestations according to whether
the skin, nerves or other tissues are predominantly involved.
#What is the nature of the premonitory symptoms of leprosy?#
In some instances the active manifestations appear without premonition,
but in the majority of cases symptoms, slight or severe in character,
pointing toward profound constitutional disturbance, such as mental
depression, malaise, chills, febrile attacks, digestive derangements and
bone pains, are noticed for weeks, months, or several years preceding
the outbreak.
#What several varieties of leprosy are observed?#
Two definite forms are usually described--the tubercular and the
anaesthetic. A sharp division-line cannot, however, always be drawn; not
infrequently the manifestations are of a mixed type, or one form may
pass into or gradually present symptoms of the other.
[Illustration: Fig. 62. Tubercular Leprosy. (_After Stoddard._)]
#Describe the symptoms of tubercular leprosy.#
The formation of tubercles and tubercular masses of infiltration,
usually of a yellowish-brown color, with subsequent ulceration,
constitute the important cutaneous symptoms. Along with, or preceding
these characteristic lesions, blebs and more or less infiltrated,
hyperaesthetic or anaesthetic, pinkish, reddish or pale-yellowish macules
make their appearance from time to time; subsequently fading away or
remaining permanently (_lepra maculosa_).
When well advanced, the tubercular or nodular masses give rise to great
deformity; the face, a favorite locality, becomes more or less leonine
in appearance (_leontiasis_). The tubercles persist almost indefinitely
without material change, or undergo absorption or ulceration; this last
takes place most commonly about the fingers and toes. The mucous
membrane of the mouth, pharynx and other parts may also become involved.
[Illustration: Fig. 63. Anaesthetic Leprosy.]
#Describe the symptoms of anaesthetic leprosy.#
Following or along with precursory symptoms denoting general systemic
disturbance, or independently of any prodromal indications, a
hyperaesthetic condition, in localized areas or more or less general, is
observed. Lancinating pains along the nerves and an irregular pemphigoid
eruption are also commonly noted. There soon follows the special
eruption, coming out from time to time, and consisting of several or
more, usually non-elevated, well-defined, pale-yellowish patches, one or
two inches in diameter. As a rule, they are at first neither
hyperaesthetic nor anaesthetic, but may be the seat of slight burning or
itching. They spread peripherally, and tend to clear in the centre. The
patches eventually become markedly anaesthetic, and the overlying skin,
and the skin on other parts as well, becomes atrophic and of a brownish
or yellowish color. The subcutaneous tissues, muscle, hair and nails
undergo atrophic or degenerative changes, and these changes are
especially noted about the hands and feet. These parts become crooked,
the bone tissues are involved, the phalanges dropping off or
disappearing by disintegration or absorption (_lepra mutilans_). Sooner
or later various paralytic symptoms, showing more active involvement of
the nerve trunks, present themselves.
#State the cause of leprosy.#
Present knowledge points to a peculiar bacillus as the active factor,
while climate, soil, heredity, food and habits exert a predisposing
influence.
#Is leprosy contagious?#
The consensus of opinion points to the acceptance of the possible
contagiousness of leprosy; probably by inoculation, but only under
certain unknown favoring conditions.
#What are the pathological changes?#
The lesions consist essentially of a new growth, made up of numerous
small, more or less aggregated round cells, beginning in the walls of
the bloodvessels. In this way the tubercular masses and various other
lesions are formed. As yet, positive involvement ot the central nervous
system has not been shown, but some of the nerve trunks are found to be
inflamed and swollen, with a tendency toward hardening.
#What several diseases are to be eliminated in the diagnosis of leprosy?#
Syphilis, morph[oe]a, vitiligo, lupus, and syringomyelia.
When well advanced, the aggregate symptoms of leprosy form a picture
which can scarcely be confused with that of any other disease. In
doubtful cases microscopical examinations of the involved tissues, for
the bacilli, should be made.
#State the prognosis of leprosy.#
Unfavorable; a fatal termination is the rule, but may not be reached for
a number of years. The tubercular form is the most grave, the mixed
variety next, and the anaesthetic the least. Patients are not
infrequently carried off by intercurrent disease. Proper management will
often delay the fatal ending, and exceptionally, in the anaesthetic
variety, stay the progress of the disease.
#What is the treatment of leprosy?#
Hygienic measures are important. Chaulmoogra oil and gurjun oil
internally and externally are in some instances of service. Strychnia
alone, or with either of these oils, is ofttimes beneficial. Ichthyol
internally, and external applications of the same drug, and of resorcin,
chrysarobin, and pyrogallic acid, have been extolled. Change of climate,
especially to a region where the disease does not prevail, is often of
great advantage.
#Pellagra.#
(_Synonym:_ Lombardian Leprosy.)
#Describe pellagra.#
Pellagra is a slow but usually progressive disease occurring chiefly in
Italy, due, it is thought, to the continued ingestion of decomposed or
fermented maize. It is characterized by cutaneous symptoms, at first
upon exposed parts, of an erythematous, desquamative, vesicular and
bullous character, and by general constitutional disturbance of a
markedly neurotic type. A fatal ending, if the disease is at all severe
or advanced, is to be expected.
Treatment is based upon general principles.
#Epithelioma.#
(_Synonyms:_ Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)
#What several varieties of epithelioma are met with?#
Three--the superficial, the deep-seated, and the papillomatous.
#Describe the clinical appearances and course of the superficial variety
of epithelioma.#
The superficial, or flat variety (_rodent ulcer_), begins, usually on
the face, as a minute, firm, reddish or yellowish tubercle, as an
aggregation of such, as a warty excrescence, or as a localized
degenerative seborrh[oe]ic patch. The latter lesion (known also as
keratosis senilis, old-age atrophic patches), consisting of a yellowish
or yellowish-brown greasy or hardened scurfy spot or patch is quite
frequently the starting-point of epithelial growths. Sooner or later,
commonly after months or several years, the surface becomes slightly
excoriated, and an insignificant, yellowish or brownish crust is formed.
The excoriation gradually develops into superficial ulceration, and the
diseased area becomes slowly larger and larger. New lesions may
continue, from time to time, to appear about the edges and go through
the same changes.
[Illustration: Fig. 64. Epithelioma. (_After D. Lewis._)]
The ulcer has usually an uneven surface, secretes a thin, scanty, viscid
fluid, which dries to a firm, adherent crust. It is usually defined
against the healthy skin by a slightly elevated, hard, roll-like,
waxy-looking border. In rare instances there is a disposition, at
points, to spontaneous involution and scar formation; as a rule,
however, the ulcerative action slowly progresses.
The general health is unimpaired, the neighboring lymphatic glands are
not involved, and the local condition, beyond the disfigurement, gives
rise to little trouble, unless, as occasionally happens, it passes into
the more malignant, deep-seated variety.
#Describe the clinical appearances and course of the deep-seated variety
of epithelioma.#
The deep-seated variety starts from the superficial form, or it begins
as a tubercle or nodule in the skin. When typically developed, a
reddish, shining tubercle or nodule, or area of infiltration, forms in
the skin or subcutaneous tissue. In the course of weeks or months
superficial or deep-seated ulceration takes place; the ulcer having
hardened, and, as a rule, everted edges. The surface is reddish and
granular, and secretes an ichorous discharge. The infiltration spreads,
the ulcer enlarges both peripherally and in depth--muscle, cartilage and
bone often becoming invaded. The neighboring lymphatic gland may become
implicated, pains of a burning or neuralgic type are experienced, and
from septicaemia, marasmus, or involvement of vital parts, death
eventually ensues.
#Describe the clinical appearances and course of the papillomatous
variety of epithelioma.#
The papillomatous type usually arises from the superficial or
deep-seated variety, or it may begin as a papillary or warty growth.
When fully developed, it presents an ulcerated, fissured and
papillomatous surface, with an ichorous discharge which dries to crusts.
It is slowly progressive, and sooner or later may develop a malignant
tendency.
#Upon what parts is epithelioma commonly observed?#
About the face, especially the nose, eyelids and lips; and also about
the genitalia. It may involve any part.
#At what age is epithelioma usually noted?#
It is essentially a disease of middle and late life, although it is
exceptionally met with in the young.
#What is the cause of epithelioma?#
The etiology is obscure. It is not, as a rule, inherited. Any locally
irritated tissue may be the starting point of the disease.
#State the pathology.#
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 the formation of onion-like bodies, the
so-called cell-nests or globes. The rapid cell-growth requires increased
nutriment, and hence the bloodvessels become enlarged; moreover, the
pressure of the cell-masses gives rise to irritation and inflammation,
with corresponding serous and round-cell infiltration.
#How would you distinguish epithelioma from syphilitic ulceration, wart,
and lupus vulgaris?#
From syphilis it is to be differentiated by the history, duration,
character of the base and edges, its comparative slow progress, its
usually slight, viscid discharge, often streaked with blood, and, if
necessary, by the therapeutic test.
Wart or warty growths are to be differentiated by attention to their
history and course. Long-continued observation may be necessary before a
positive opinion is warrantable. The appearance of any tendency to
crusting, to break down or ulcerate is significant of epitheliomatous
degeneration.
In lupus vulgaris the deposits are peculiar and multiple, the
ulcerations are of different character, the tendency to scar-formation
constant; and, with few exceptions, it has, moreover, its beginning in
childhood or early adult life.
#What factors are to be considered in giving a prognosis in epithelioma?#
The variety, extent, and rapidity of the process. The superficial form
may exist for years, and give rise to no alarm; whereas the
deeper-seated varieties are always to be viewed as serious, and are,
indeed, often fatal. Involving the genitalia, its course is often
strikingly rapid. Relapses, after removal, are not uncommon.
#What is the special object in view in the treatment of epithelioma?#
Thorough destruction or removal of the epitheliomatous tissue.
#How is the destruction or removal of the epitheliomatous tissue
effected?#
By the use of such caustics as caustic potash, chloride-of-zinc paste,
pyrogallic acid, arsenic, and the galvano-cautery; and by operative
measures, such as excision and erasion with the dermal curette, and by
the _x_-ray. (See treatment of lupus vulgaris.)
In small lesions the use of an arsenical paste is a most admirable
method of treatment, although somewhat painful. The paste is made of one
part powdered acacia and one to two parts arsenious acid; at the time of
application sufficient water is added to make a paste. This is applied
thickly, and a piece of lint superimposed. A good deal of pain and
inflammatory swelling ensue; at the end of twenty-four hours the part is
poulticed till the slough comes away; the ulcer is then treated as a
simple ulcer, under which healing takes place. Occasionally a second
application is found necessary.