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-ʒivGlycerinæ, ....................................... ♏ivAquæ, ........................................... 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 thex-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 diseasemaydisappear in course of time spontaneously, and occasionallywithout 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.
FIG. 43.
Single Scarifier.
Fig. 44.
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.)
(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 afirm and fibrouscharacter, results.
Fig. 45.
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.
Lupus Vulgaris
Lupus Vulgaris.
Lupus Vulgaris
Lupus Vulgaris.
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 bestreaked 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.
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.
FIG. 47.
Double Curette.
Of the milder methods, those most in vogue to-day are theFinsen lightandx-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, ................................. ʒijEmplast. plumbi, ................................. ʒjCerat. 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. xxHydrarg. sulphid. rub., .......................... gr. lxUngt. 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.
(Synonym:Scrofuloderma.)
[D]The most important clinical variety of this class is lupus vulgaris, which is considered above, separately, at some length.
[D]The most important clinical variety of this class is lupus vulgaris, which is considered above, separately, at some length.
What do you understand by tuberculosis cutis?
The term is applied to those peculiar suppurative and ulcerative conditions of the skin due to the tubercle bacilli.
How does the common type of tuberculosis cutis begin?
The most common type of tuberculous ulceration or involvement of the skin usually results by extension from an underlying caseating and suppurating lymphatic gland; or it may have its origin as subcutaneous tubercles independently of these structures. It tends to spread, and may involve an area of one or several inches.
Fig. 48.
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 thesmall pustular scrofuloderma.
Fig. 49.
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.
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 thex-ray and Finsen light plans have, in a measure, supplanted the previous methods of treatment. They are slow, however, and might be, especially thex-ray, more satisfactorily employed as a supplementary measure.
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.
Treatmentconsists, in the early stages, of incision through the constricting band; when the disease is well advanced, amputation is the sole recourse.
(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. Thewhole part is gradually disintegrated, the process lasting indefinitely. Its nature is obscure; it is thought to be due to a fungus.
Treatmentconsists 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.
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.
(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.
Themacular syphilodermis 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.
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.
Thesmall-papular syphiloderm(miliary papular syphiloderm) usually shows itself in the third or fourth month of the disease, andconsists 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.
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.
Thelarge-papular syphiloderm(orlenticular 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,
Small-papular Syphiloderm
Small-papular Syphiloderm.
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.
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 calledmucous 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 themammæ. 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.
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 thesquamousorpapulo-squamous syphiloderm(improperly calledpsoriasis 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—thepalmar and plantar syphiloderm. Occurring on these parts it is often rebellious to treatment.
Maculo-papular syphiloderm
Maculo-papular syphiloderm.
How are you to distinguish the papulo-squamous syphiloderm from psoriasis?
In psoriasis the eruption is more inflammatory, and usually bright red; the scales whitish or pearl-colored and, as a rule, abundant. It is generally seen in greater profusion upon certain parts, as, for instance, the extensor surfaces, especially of the elbows and knees. It is not infrequently itchy, and, moreover, presents a different history.
In the syphilitic eruption some of the papules almost invariably remain perfectly free from any tendency to scale formation; there is distinct deposit or infiltration, and the lesions are of a dark, sluggish red or ham tint; and, moreover, concomitant symptoms of syphilis are usually present.
Describe the annular eruption of syphilis.
Theannular 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.
Thesmall 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 exfoliationaround 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.
Thelarge 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.
Thesmall 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 andscalp, 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.
Thelarge 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.