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.
FIG. 56.
Ulcerating Tubercular Syphiloderm.
Describe the bullous eruption of syphilis.
Thebullous 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.
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.
Thetubercular 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 formingsegments 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.
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
Tubercular Syphiloderm
Tubercular Syphiloderm.
Large-pustular Syphiloderm
Large-pustular Syphiloderm.
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.
FIG. 59.
Tubercular Syphiloderm.
Describe the gummatous eruption of syphilis.
Thegummatous 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.
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.
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.
Themacular(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.
Thepapulareruption is observed in conjunction with theerythematous 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 intomoist papules.
Thebullouseruption 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.
Inacquired 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.
Inhereditary 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; byinunction, in the form of blue ointment; byhypodermic injection, usually as corrosive sublimate solution. The method byfumigation, 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. viijAc. carbolici, ................................... gr. x-xxAlcoholis, ...................................... fʒivGlycerinæ, ...................................... fʒjAquæ, ................ 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.
(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 withoutpremonition, 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.
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-yellowishmacules 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.
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 irregularpemphigoid 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 apicture 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.
(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.
(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.
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 superficialulceration, 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 thedeeper-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 thex-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?
Thex-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 mildx-ray erythema; and in some instances benefit or cure onlyoccurs after more active exposure, sufficient to cause anx-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 thex-ray.
The much better plan, as already intimated, is to employ one of the several operative or caustic methods, and supplementing, while healing, with thex-ray.
(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 anddegenerated 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 thex-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.
(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.
Describe granuloma fungoides.
A rare form of disease, heretofore looked upon as sarcomatous, but now generally recognized as granuloma, and formerly described under the namesmycosis 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.
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.