Class Vi.—New Growths

Keloid.

(Synonyms: Keloid of Alibert; Cheloid.)

Give a descriptive definition of keloid.

Keloid is a fibro-cellular new growth of the corium appearing as one or several variously-sized, irregularly-shaped, elevated, smooth, firm, pinkish or pale-reddish cicatriform lesions.

Describe the clinical appearance of keloid.

The growth begins as a small, hard, elevated, pinkish or reddish tubercle, increasing gradually, several months or years usually elapsing before the tumor reaches conspicuous size. When developed, it is one or more inches in diameter, is sharply defined, elevated, hard, rounded or oval, fungoid or crab-shaped, and firmly implanted in the skin. It is usually pinkish, pearl-white, or reddish, commonly devoid of hair, with no tendency to scaliness, and with, usually, several vessels coursing over it. In some instances it is tender, and it may be spontaneously painful.

The breast, especially over the sternal region, is a favorite site for its appearance. One, several or more may be present in the single case.

What course does keloid pursue?

Chronic; usually lasting throughout life. In rare instances spontaneous involution takes place.

State the etiology of keloid.

The causes are obscure. The growth usually takes its start from some injury or lesion of continuity; for instance, at the site of burns, cuts, acne and smallpox scars, etc.—cicatricial keloid, false keloid; or it may also, so it is thought, originate in normal skin—spontaneous keloid, true keloid.

What is the pathology of keloid?

The lesion is a connective-tissue new growth having its seat in the corium.

Is there any difficulty in the diagnosis of keloid?

No. It resembles hypertrophic scar; but this latter, which is essentially keloidal, never extends beyond the line of injury.

Give the prognosis.

The growth is persistent and usually irresponsive to treatment. In some cases, however, there is eventually a tendency to spontaneous retrogression, up to a certain point at least.

What is the treatment of keloid?

Usually palliative, consisting of the continuous application of an ointment such as the following:—

℞ Acidi salicylici, ................................ gr. x-xx
Emplast. plumbi,
Emplast. saponis, ....................āā.......... ʒiij
Petrolati, ....................................... ʒij. M.

An ointment of ichthyol, twenty-five per cent. strength, rubbed in once or twice daily, is sometimes beneficial.

Operative measures, such as punctate and linear scarification, electrolysis and excision, are occasionally practised, but the results are rarely satisfactory and permanent; not infrequently, indeed, renewed activity in the progress of the growth is noted to follow. The x-ray can be tried with some hope of improvement. The administration of thyroid has been thought to have a possible influence in some instances.

Fibroma.

(Synonyms: Molluscum Fibrosum; Fibroma Molluscum.)

What do you understand by fibroma?

Fibroma is a connective-tissue new growth characterized by one or more sessile or pedunculated, pea- to egg-sized or larger, soft or firm, rounded, painless tumors, seated beneath and in the skin.

Describe the clinical appearances of fibroma.

The growth may be single, in which case it is apt to be pedunculated or pendulous, and attain considerable dimensions; as a result of weight or pressure surface-ulceration may occur. Or, as commonly met with, the lesions are numerous, scattered over large surface, and vary in size from a pea to a cherry; the overlying skin being normal, pinkish or reddish, loose, stretched, hypertrophied or atrophied.

The tumors are painless. The general health is not involved.

Fig. 41.

Fibroma. (After Octerlony.)

What is the course of fibroma?

Chronic and persistent.

What is the etiology of fibroma?

The cause is not known. Heredity is often noted. The affection is not common.

State the pathology of fibroma.

The growths are variously thought to have their origin in the connective tissue of the corium, or in that of the walls of the hair-sac, or in the connective-tissue framework of the fatty tissue. Recent tumors are composed of gelatinous, newly-formed connective tissue, and the older growths of a dense, firmly-packed, fibrous tissue.

From what growths is fibroma to be differentiated?

From molluscum contagiosum, neuroma and lipoma; the first is differentiated by its central aperture or depression, neuroma by its painfulness, and lipoma by its lobulated character and soft feel.

Give the prognosis of fibroma.

The disease is persistent, and irresponsive to all treatment save operative measures.

What is the treatment of fibroma?

Treatment consists, when desired and practicable, in the removal of the growths by the knife, or in large and pedunculated tumors by the ligature or by the galvano-cautery.

Neuroma.

Describe neuroma.

Neuroma of the skin is an exceedingly rare disease, characterized by the formation of variously-sized, usually numerous, firm, immovable and elastic fibrous tubercles containing new nerve-elements, and accompanied by violent, paroxysmal pain. Their growth is slow and usually progressive. Later they are painful upon pressure. They are limited to one region.

The tumors are seated in the corium, extending into the deeper structure, and consist of nerve-fibres, yellow elastic tissue, blood vessels and lymphoid cells.

In the two cases reported, excision of the nerve-trunk gave, in one instance, permanent relief; in the other the effect was only temporary.

Xanthoma.

(Synonyms: Vitiligoidea; Xanthelasma.)

What is xanthoma?

Xanthoma is a connective-tissue new growth characterized by the formation of yellowish, circumscribed, irregularly-shaped, variously-sized, non-indurated, flat or raised patches or tubercles.

Name the two varieties met with.

The macular or flat (xanthoma planum) and the tubercular (xanthoma tuberculatum or tuberosum). In some instances both varieties (xanthoma multiplex) are seen in the same individual.

Describe the clinical appearances of xanthoma planum.

The macular or flat variety is usually seen about the eyelids. It consists of one, several or more small or large, smooth, opaque, sharply-defined, often slightly raised, yellowish patches, looking not unlike pieces of chamois-skin implanted in the skin.

Describe the clinical appearances of xanthoma tuberosum.

The tubercular variety is commonly met with upon the neck, trunk and extremities. It occurs as small, raised, isolated, yellowish nodules, or as patches made up of aggregations of millet-seed-sized or larger tubercles. The lesions may be few or they may exist in great numbers.

What is the course of xanthoma?

Extremely slow; after reaching a certain development the growths may remain stationary.

State the etiology of xanthoma.

The causes are obscure. Jaundice not infrequently precedes and accompanies its development, especially in the tubercular variety. The disease is uncommon, and is usually seen in middle and advanced life, and more frequently in women. In some cases (xanthoma diabeticorum) of general xanthoma diabetes is the causative factor.

What is the pathology of xanthoma?

It is a benign, connective-tissue new growth, with concomitant or subsequent, but usually partial, fatty degeneration.

Give the prognosis of xanthoma.

The condition is persistent, and usually irresponsive to all treatment save destructive or operative measures.

What is the treatment of xanthoma?

Treatment consists, in suitable cases, of excision; in some instances, electrolysis is serviceable. Applications of trichloracetic acid cautiously made are sometimes of value. In that form of general xanthoma due to diabetes the treatment of this latter condition will materially and sometimes completely remove the eruption.

Myoma.

(Synonyms: Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)

Describe myoma.

The disease is rare, and consists usually of one or several (exceptionally numerous), variously-sized tumors of the skin, made up of smooth muscular fibres. They are flat, rounded, oval or pedunculated, and have a smooth surface and a pale-red color; as a rule, they are painless.

The growth is benign, and consists essentially of a new formation of unstriped muscular fibres; but it may also be composed largely of connective tissue (fibromyoma); or it may contain an abundance of bloodvessels (myoma telangiectodes, angiomyoma); or there may be lymphatic involvement (lymphangiomyoma).

Angioma.

(Synonyms: Nævus Vasculosus; Nævus Sanguineus.)

Give a definition of angioma.

Angioma is a congenital hypertrophy of the vascular tissues of the corium and subcutaneous tissue. Exceptionally it makes its appearance a few weeks or a month after birth.

Into what two classes may angiomata be roughly grouped?

The flat (or non-elevated) and the prominent (or elevated).

Describe the flat, or non-elevated, variety of angioma.

The flat, or non-elevated, angioma (nævus flammeus, nævus simplex, angioma simplex, capillary nævus) may be pin-head- to bean-sized; or it may involve an area of several inches in diameter, and, exceptionally, a whole region. It is of a bright- or dark-red color, and is met with most frequently about the face. In some instances it extends after birth, reaches a certain size and then remains stationary; occasionally, when involving a small area, it undergoes involution and disappears.

The so-called port-wine mark is included in this group.

Describe the prominent, or elevated, variety of angioma.

The prominent variety (venous nœvus, angioma cavernosum, nœvus tuberosus) is variously-sized, often considerably elevated, clearly-defined, compressible, smooth or lobulated, and of a dark, purple color; it may, also, be erectile and pulsating. The growth is usually a single formation, and is met with upon all parts of the body.

What is the pathology of angioma?

It is a new growth, consisting of a variable hypertrophy of the cutaneous and subcutaneous arterial and venous bloodvessels, with or without an increase of the connective tissue.

Give the treatment of angioma.

In some instances, especially in infants, painting the parts repeatedly with collodion or liquor plumbi subacetatis will act favorably. For well-established, small, capillary nævi electrolysis or puncturing with a red-hot needle or with a needle charged with nitric acid may be employed; for “port-wine mark” frequent and closely contiguous electrolytic punctures are occasionally followed by a slight diminution in color. For the prominent growths, vaccination, the ligature, puncturing with the galvano-cautery, and excision are variously resorted to.

In recent years applications of liquid air and carbon dioxide have proved of service in some cases.

Telangiectasis.

Describe telangiectasis.

Telangiectasis consists of a new growth or enlargement of the cutaneous capillaries, usually appearing during middle adult life, and seated, for the most part, about the face.

To what extent may telangiectasis develop?

It may be limited to a red dot or point, with several small radiating capillaries (nævus araneus, spider nævus), or a whole region, usually the face, may show numerous scattered or closely-set capillary enlargements or new formations (rosacea). The latter is frequently associated with acne (acne rosacea).

The etiology is obscure.

What is the treatment of telangiectasis?

Destruction of the vessels by electrolysis or by the knife. (See treatment of acne rosacea.)

Lymphangioma.

(Synonym: Lymphangiectodes.)

Describe lymphangioma.

Lymphangioma is a rare disease, consisting of localized dilatations of the lymphatic vessels, appearing as discrete or aggregated pin-head or pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish or faint lilac color, and occurring for the most part about the trunk. It is of slow but usually progressive development, and is unaccompanied by subjective symptoms.

A rare condition, Kaposi described as lymphangioma tuberosum multiplex, characterized by more or less solid, somewhat cystic, pearly to pinkish red, sometimes crowded lesions, is now known to be “benign cystic epithelioma”; its most common site is the face. While called “benign,” ulcerative action may eventually ensue.

Treatment, when demanded, consists of operative measures.

Rhinoscleroma.

Describe rhinoscleroma.

Rhinoscleroma is a rare and obscure disease, slow but progressive in its course, characterized by the development of an irregular, dense and hard, flattened, tubercular, non-ulcerating, cellular new growth, having its seat about the nose and contiguous parts. The overlying skin is normal in color, or it may be light- or dark-brown or reddish. Marked disfigurement and closure, partial or complete, of the nasal orifices gradually results. It is met with chiefly in Austria and Germany.

Treatment, consisting of partial or complete extirpation, is rarely permanent in its results, the disease tending to recur.

Lupus Erythematosus.

(Synonyms: Lupus Erythematodes; Lupus Sebaceus; Seborrhœa Congestiva.)

What is lupus erythematosus?

Lupus erythematosus may be roughly defined as a mildly to moderately inflammatory superficial new-growth formation, characterized by one, several, or more circumscribed, variously sized and shaped, pinkish or dark red patches, covered slightly, and more or less irregularly, with adherent grayish or yellowish scales.

Upon what parts is lupus erythematosus observed?

Its common site is the face, usually the nose and cheeks, with a tendency toward symmetry; it is often limited to these parts, but may occasionally be seen upon other regions, more especially the lips, ears, and scalp. In rare instances a great part of the general surface may become involved.

Describe the symptoms of lupus erythematosus.

Usually the disease begins as one or several rounded, circumscribed, pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and of a pinkish, reddish or violaceous color. They slowly, or somewhat rapidly, increase in area, and after attaining variable size remain stationary; or they may progress and coalesce, and in this manner sooner or later involve considerable surface. The patches are sharply defined against the sound skin by an elevated border, while the central portion is somewhat depressed and usually atrophic. More or less thickening and infiltration are observed. There is no tendency to ulceration. The scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous or plugged with sebaceous and epithelial matter.

The subjective symptoms of burning and itching are usually slight and often wanting.

What course does lupus erythematosus pursue?

As a rule, the disease is persistent, although somewhat variable. At times the patches retrogress, involution taking place with or without slight sieve-like atrophy or scarring.

State the causes of lupus erythematosus.

The etiology is obscure. Some observers believe it to be a variety of cutaneous tuberculosis. It is essentially a disease of adult and middle age; is more common in women, and more frequent in those having a tendency to disorders of the sebaceous glands. It may, in fact, begin as a seborrhœa.

What is the pathology?

It was formerly considered a new growth, but recent opinion tends toward regarding it as a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. Variable œdema of the prickle layer and of the cutis is found. There is no tendency to pus formation.

Fig. 42.

Lupus Erythematosus.

Is there any difficulty in the diagnosis of lupus erythematosus?

As a rule, not, as the features of the disease—the sharply circumscribed outline, the reddish or violaceous color, the elevated border, the tendency to central depression and atrophy, the plugged up or patulous sebaceous ducts, the adherent grayish or yellowish scales, together with the region attacked (usually the nose and cheeks)— are characteristic.

State the prognosis of lupus erythematosus.

The disease is often capricious and extremely rebellious to treatment; some cases, up to a certain point at least, yield readily, and occasionally a tendency to spontaneous disappearance is observed; a complete cure is, however, it must be confessed, rather rare. The disease in nowise compromises the general health. In those rare instances of generalized disease the patient has usually died from an intercurrent tuberculosis.

How is lupus erythematosus to be treated?

The general health is to be looked after and systemic treatment prescribed, if indicated. As a rule, constitutional remedies exert little, if any, influence, but exceptionally, cod-liver oil, arsenic, phosphorus, salicin, quinine, or potassium iodide proves of service.

Locally, according to the case, soothing remedies, stimulating applications and destruction of the growth by caustics or operative measures are to be employed. (Try the milder applications first.)

Mention the stimulating applications commonly employed.

Washing the parts energetically with tincture of sapo viridis, rinsing and applying a soothing ointment, such as cold cream or vaseline.

A lotion containing zinc sulphate and potassium sulphuret thoroughly dabbed on the parts morning and evening:—

℞ Zinci sulphatis,
Potassii sulphurati, ................āā........... ʒi-ʒiv
Glycerinæ, ....................................... ♏iv
Aquæ, ........................................... f℥iv. M.

The calamine-and-zinc oxide lotion used in acute eczema is also often extremely valuable.

Lotions of ichthyol and of resorcin, five to sixty grains to the ounce; ichthyol in ointment, five- to twenty-per-cent. strength, is also useful.

Painting the patches with pure carbolic acid; repeating a day or two after the crusts have fallen off.

The continuous application of mercurial plaster. Sulphur and tar ointments, officinal strength or weakened with lard, and also the following:—

℞ Ol. cadini,
Alcoholis,
Saponis viridis, ..................āā............. ʒiiss. M.

(This is to be rubbed in, in small quantity, once or twice daily, and later a soothing remedy applied.)

In recent years both the x-ray and Finsen light have been used with variable success. Repeated applications of the high-frequency current, with the vacuum electrode, have also proved serviceable. Cautious applications of liquid air or carbon dioxide have also been used with some success in the past few years.

When are destructive and operative measures justifiable?

In obstinate, sluggish, and long-persistent patches, and then only after other methods of treatment have failed. (Remember that a patch or patches of the disease may disappear in course of time spontaneously, and occasionally without leaving a scar.)

State the methods of treatment commonly used in obstinate, sluggish and persistent patches of lupus erythematosus.

Cauterization—with nitrate of silver, with applications of pyrogallic acid in ointment or in liquor gutta-perchæ, fifteen to thirty per cent. strength, and with solutions (cautiously employed) of caustic potash, and exceptionally with the galvano-cautery.

Fig. 43.

Single Scarifier.

Fig. 44.

Multiple Scarifier. (As modified by Van Harlingen.)

Operative—scarification, either punctate or linear, and erosion with the curette. (See treatment of lupus vulgaris.)

Lupus Vulgaris.

(Synonyms: Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

What do you understand by lupus vulgaris?

Lupus vulgaris is a cellular new growth, characterized by variously-sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring.

Upon what region is lupus vulgaris usually observed?

The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former.

At what age is the disease noted?

In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age.

Describe the earlier symptoms of lupus vulgaris.

The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis.

What changes do the lupus tubercles or infiltrations undergo?

The lesions, having attained a certain size or development, may remain so for a time, but sooner or later retrogressive changes occur: the matured papules or tubercles, or infiltrated patches, slowly disappear by absorption, fatty degeneration, and exfoliation, leaving a yellowish or brownish pigmentation, usually with more or less atrophy or cicatricial-tissue formation—lupus exfoliativus; or disintegration and destruction result, terminating in ulceration—lupus exedens, lupus exulcerans. This latter is the more usual course.

Describe the clinical appearances and behavior of the lupus ulcerations.

They are rounded, shallow excavations, with soft and reddish borders. In exceptional instances exuberant granulations appear— lupus hypertrophicus; or papillary outgrowths are noted—lupus verrucosus. The ulcerations secrete a variable amount of pus, usually slight in quantity, which leads to more or less crust formation; later, however, cicatricial tissue, generally of a firm and fibrous character, results.

Fig. 45.

Lupus of Arm.

In what manner does the disease spread?

The patches spread by the appearance of new tubercles, or infiltrations at the peripheral portion. New islets and areas of disease may continue to make their appearance from time to time, usually upon contiguous parts.

Are the mucous membranes of the mouth, throat and larynx ever involved?

In some instances, and either primarily or secondarily.

Is the bone tissue ever involved in lupus vulgaris?

No.

What course does lupus vulgaris pursue?

It is slowly but, as a rule, steadily progressive. Several years or more may elapse before the area of disease is conspicuous.

What is the cause of lupus vulgaris?

It is now known to be due to the invasion of the cutaneous structures by the tubercle bacillus; in short, a tuberculosis of the skin. It is not infrequently observed in the strumous and debilitated. It is entirely independent of syphilis.

What is the pathology of lupus vulgaris?

According to recent investigations, the infiltrations of lupus are due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the bloodvessels and lymphatics. The fibrous-tissue network, vessels and a portion of the cell infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth (Robinson).

State the diagnostic features of lupus vulgaris.

In a typical, developed patch of lupus are to be seen:—cicatricial formation, usually of a fibrous and tough character; ulcerations; the yellowish-brown tubercles and infiltration; and the characteristic soft, small, yellowish or reddish-brown, cutaneous and subcutaneous points and tubercles.

How does the tubercular syphiloderm differ from lupus vulgaris?

The tubercular syphiloderm is much more rapid in its course, the ulceration is deeper and the discharge copious and often offensive; the scarring is soft, and, compared to the amount of ulceration, but slightly disfiguring; and it is, for obvious reasons, a disease of adult or late life. The history, together with other evidences of previous or concomitant symptoms of syphilis, will often aid in the differentiation.

How does epithelioma differ from lupus vulgaris?

The edges of the epitheliomatous ulcer are hard, elevated and waxy; the base is uneven, the secretion thin, scanty and apt to be streaked with blood; the ulceration usually starts from one point, and is often painful; the tissue destruction may be considerable; there is little, if any, tendency to the formation of cicatricial tissue; and, finally, it is usually a disease of advanced age.

In what respects does lupus erythematosus differ from lupus vulgaris?

Lupus erythematosus has no papules, tubercles or ulceration.

How does acne rosacea differ from lupus vulgaris?

Acne rosacea is characterized by hyperæmia, dilated vessels, papules, pustules, the absence of ulceration, and a different history.

State the prognosis of lupus vulgaris.

Lupus vulgaris is always a chronic disease, often exceedingly rebellious to treatment, and one that calls for a guarded opinion. Relapses are not uncommon.

Fig. 46.

Galvano-cautery Needle, Knife and Spiral Points. (As devised by Bésnier.)

The general health usually remains good, but in some instances death by tuberculosis of the lungs has been noted.

Is external or internal treatment called for in lupus vulgaris?

Always external, and not infrequently constitutional also.

What is the constitutional treatment?

The general health must be cared for; good, nutritious food, fresh air and out-door exercise, together with, in many cases, the administration of such remedies as cod-liver oil, potassium iodide, iron and quinine, are of therapeutic importance. Tuberculin may be tried in severe and obstinate cases, but its use is not without danger.

State the object of local treatment.

The destruction or removal of the diseased tissue.

May milder methods of treatment sometimes prove beneficial and even curative?

Exceptionally, mercurial plaster, corrosive-sublimate lotion and ointment (gr. j to ℥ j), a plaster containing five to fifteen per cent. of salicylic acid and creasote, repeated paintings with carbolic acid, and the constant application of lead plaster containing twenty per cent. of ichthyol, are valuable.

Fig. 47.

Double Curette.

Of the milder methods, those most in vogue to-day are the Finsen light and x-ray. Either proves extremely valuable in some cases, but the Finsen method is the favorite method.

What methods are commonly employed for the rapid removal or destruction of lupus tissue?

Cauterization, scarification, erasion and excision are variously practised; the particular method depending, in great measure, upon the extent of the disease, the part involved, and other circumstances.

Name the several caustics, and state how they are employed.

Pyrogallic acid, used as an ointment:—

℞ Ac. pyrogallici, ................................. ʒij
Emplast. plumbi, ................................. ʒj
Cerat. resinsæ, .................................. ʒv. M.

It is applied for one or two weeks. Every several days the parts are poulticed, the slough thus removed, and the ointment reapplied, and so on until the diseased tissue has been destroyed. It is useful in those cases in which a mild and comparatively painless caustic is advisable. In most cases several repetitions of this plan are necessary. Arsenious acid, employed as an ointment—

℞ Ac. arseniosi, ................................... gr. xx
Hydrarg. sulphid. rub., .......................... gr. lx
Ungt. aquæ rosæ, ................................. ℥i. M.

It is painful but thorough; it is spread on lint and renewed daily. The action is usually sufficient in three days, and the parts are then poulticed until the slough comes away, after which a simple dressing is employed. Its application is advisable for a small area only—not more than four square inches—as absorption is possible.

Galvano-cautery.—The diseased tissue is destroyed by numerous punctures with a red-heated point or by linear incision with a red-heated knife. It is often a practicable and satisfactory method. The Paquelin cautery and liquid air and carbon dioxide also have their advocates.

Describe the operative measures employed in the removal of lupus tissue.

Linear Scarification.—The parts are thoroughly cross-tracked, cutting through the diseased tissue, and subsequently a simple salicylated ointment applied. The operation is repeated from time to time, and as a result the new growth undergoes retrogressive changes, and cicatrization takes place.

Punctate Scarification.—By means of a simple or multiple-pointed 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.

(Synonym: Scrofuloderma.)

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.

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.

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 papillæ; 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.

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.)

Describe 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 anæsthetic 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, rötheln and tinea versicolor?

Measles is to be differentiated by its catarrhal symptoms, fever, form and situation of the eruption; rötheln, 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.

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.

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.

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, axillæ and beneath the mammæ. 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).

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.

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.

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.

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.

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).

Describe the ulcerating tubercular syphiloderm.

Fig. 58.

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.

In some instances, more especially about the scalp, the surface of the 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.

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.

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.

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 café-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 bullæ.

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 Spirochæta 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 (ʒii-ʒiv] 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:—

℞ Hydrarg. chlorid. corros., ....................... gr. iv-gr. viij
Ac. carbolici, ................................... gr. x-xx
Alcoholis, ...................................... fʒiv
Glycerinæ, ...................................... fʒj
Aquæ, ................ q.s. ad. .................. ℥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-℥vj, ʒj, 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 Græcorum.)

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 anæsthetic. 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.

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, hyperæsthetic or anæsthetic, 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.

Fig. 63.

Anæsthetic Leprosy.

Describe the symptoms of anæsthetic leprosy.

Following or along with precursory symptoms denoting general systemic disturbance, or independently of any prodromal indications, a hyperæsthetic 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 hyperæsthetic nor anæsthetic, 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 anæsthetic, 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, morphœa, 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 anæsthetic the least. Patients are not infrequently carried off by intercurrent disease. Proper management will often delay the fatal ending, and exceptionally, in the anæsthetic 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

Fig. 64.

Epithelioma. (After D. Lewis.)

aggregation of such, as a warty excrescence, or as a localized degenerative seborrhœic 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.

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 septicæmia, 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.

Upon the whole, the best method in the average case is to curette thoroughly, and supplement with momentary cauterization, with caustic potash, or with several days' use of the pyrogallic acid ointment. During the healing process, short exposures to the Röntgen ray—about every three to five days—is good practice.

The degenerative changes in the beginning of scurfy, seborrhœic spots or patches seen in old people can frequently be lessened or wholly stopped by the daily application of an ointment containing 5 to 10 per cent. of sulphur and 2 to 5 per cent. of salicylic acid.

What can be said of the value of the x-ray in epithelioma?

The x-ray method is now much in vogue, and proves curative in many superficial cases, and of benefit in some of the deeper-seated varieties. In most cases it must be pushed to the point of producing a mild x-ray erythema; and in some instances benefit or cure only occurs after more active exposure, sufficient to cause an x-ray burn of the second degree. The method is not attended with much risk if properly used. The healthy parts should be protected by lead-foil. Exposure should be two to five times weekly, at a distance of three to eight inches, and from five to twenty minutes, employing a tube of medium vacuum. Unfortunately the method is usually slow. The radium treatment is essentially similar to that by the x-ray.

The much better plan, as already intimated, is to employ one of the several operative or caustic methods, and supplementing, while healing, with the x-ray.

Paget's Disease of the Nipple.

(Synonyms: Malignant Papillary Dermatitis; Paget's Disease.)

What do you understand by Paget's disease of the nipple?

Paget's disease is a rare, inflammatory-looking, malignant disease of the nipple and areola in women, usually of advancing years, eventually terminating in cancerous involvement of the entire gland.

Describe the symptoms of Paget's disease.

The first symptoms, which usually last for months or years, are apparently eczematous, accompanied with more or less burning, itching and tingling. Gradually, the diseased area, which is sharply-defined, and feels like a thin layer of indurated tissue, presents a florid, intensely red, very finely-granular, raw surface, attended with a more or less copious viscid exudation. Sooner or later retraction and destruction of the nipple, followed by gradual scirrhous involvement of the whole breast, takes place.

What is the pathology of Paget's disease?

Although it was thought at one time to be a cancerous disease resulting from a continued eczematous inflammation of the parts, there is now but little doubt that it is of malignant nature from the earliest stages. The psorosperm-like bodies found, to the presence of which the disease has by some authorities been attributed (psorospermosis), are now known to be merely changed and degenerated epithelia. The morbid changes consist of an inflammation of the papillary region of the derma, leading to œdema and vacuolation of the constituent cells of the epidermis, followed by their complete destruction in places and their abnormal proliferation in others (Fordyce).

State the diagnostic features of Paget's disease.

The age of the patient; the sharp limitation; the well-defined, indurated film of infiltration; the peculiar, red, raw, granulating appearance; and, later, the retraction of the nipple; and, finally, the involvement of the deeper parts.

What is the prognosis?

If the disease is recognized early, and properly treated, a cure may be anticipated; later the outlook is that of scirrhus of the breast.

What is the treatment of Paget's disease?

Thorough cauterization by means of caustic potash or the galvano-cautery; or, its extirpation by means of the curette or excision. After extirpation or cauterization, supplementary treatment by the x-ray is advisable as an additional measure of precaution against relapse.

Until the diagnosis is thoroughly established, soothing applications, such as are employed in acute eczema, are to be advised.

Sarcoma.

(Synonyms: Sarcoma Cutis; Sarcoma of the Skin.)

Describe the several varieties of sarcoma.

Sarcoma of the skin is a more or less malignant new growth, of rapid or slow progress, characterized by the appearance of single or multiple, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors, of size varying from that of a shot to a hazelnut or larger. As a rule the growths are smooth, firm and elastic, somewhat painful upon pressure, and exhibit a tendency to ulcerate. The overlying skin is at first normal and somewhat movable, but as the growths approach the surface it becomes reddened and adherent; or, if the disease is of the pigmented variety, it acquires a bluish-black color. It is now generally believed that the most of the pigmented cases formerly thought to be of sarcomatous nature are really carcinomatous in character.

The multiple pigmented sarcoma (melano-sarcoma) appears first, usually on the soles and dorsal surfaces of the feet, and later on the hands. There is more or less diffuse thickening of the integument. The lesions themselves manifest a disposition to bleed.

State the prognosis and treatment of sarcoma.

The disease is always more or less malignant and, as a rule, sooner or later a fatal termination takes place. It is usually slow in its course.

Excision or extirpation, x-ray exposures, and the administration of arsenic in increasing dosage (preferably by hypodermic injection) now are generally considered the most promising in this usually hopeless malady.

Granuloma Fungoides.

Describe granuloma fungoides.

A rare form of disease, heretofore looked upon as sarcomatous, but now generally recognized as granuloma, and formerly described under the names mycosis fungoides, inflammatory fungoid neoplasm, and several others. It is characterized usually by symptoms of an eczematous, urticarial, and erysipelatous nature, and by the sudden or gradual appearance of pinkish or reddish, tubercular, nodular, lobulated, or furrowed tumors or flat infiltrations, which may disappear by involution or may be followed by ulceration; several or a larger number of the growths present a mushroom, papillomatous, or fungoid appearance, sometimes roughly resembling the cut part of a tomato. In most cases the tumor stage of the malady is not reached for two or more years; in exceptional instances, however, they appear in the first few months. The lesions, especially in their early stages, are, as a rule, accompanied with more or less burning and itching.

State the prognosis and treatment of granuloma fungoides.

The malady may last for several years or much longer, a fatal termination, with rare exceptions, sooner or later taking place. After the tumor stage is well established, the patient usually succumbs in from several months to one or two years.

Fig. 65.

Granuloma Fungoides.

Treatment consists of tonics, if indicated, and the administration of arsenic, preferably hypodermically, and Röntgen-ray exposures, along with the application of mild antiseptics, and operative interference when necessary or advisable.