Chapter 16

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.

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.

#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.

#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.#

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.

#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.

#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.

#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 ([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 Glycerinæ, ........................... f[dram]j Aquæ, ............ 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 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.

#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.

#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, 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 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?#