A system of practical medicine. By American authors. Vol. 4

by Unknown

Of late years the mechanical removal of the lupus deposits has been largely practised. In small patches excision of the entire diseased area has been recommended, but as considerable healthy tissue is necessarily removed with it, and the resulting scar is deep and disfiguring, it is not to be advised. Excision followed by transplantation of healthy skin has also been advocated. An excellent method of removal is by means of the dermal curette, or scraping-spoon. It is one that answers well in many cases. The diseased tissue should be thoroughly scraped out. It is painful, and it is often necessary to operate under ether. The healthy tissues are unyielding and cannot be readily scraped away, so that only the morbid deposit is removed. As it is difficult to remove the new growth from the interstitial spaces, we are in the habit of supplementing the operation with a caustic, either cauterizing lightly with caustic potash, or, what is advisable in the greater number of cases, applying the pyrogallic-acid ointment for several days following the curetting. This method—the curetting and subsequent cauterization—has, on the whole, proved satisfactory.

Linear or punctate scarification is another method of treatment that is often valuable. It is of most service in the non-ulcerating forms. Linear scarification is the more satisfactory. The parts are thoroughly cross-tracked and a simple ointment applied. If the bleeding is marked, cold compresses may be applied. Anæmia of the parts results, the papules are disturbed, and the new growth rapidly undergoes retrogressive changes. If the area to be operated upon is large, the patient should be anæsthetized. Charging the knife, or if punctiform scarifications are practised the pointed instrument, with iodized glycerin (one part iodine to twenty of glycerin) has been advised, as rendering a successful result the more certain. The scar following the curette and linear and punctate scarification is usually soft and white, much less disfiguring, as a rule, than that following the action of the stronger caustics. Destruction of the new growth by means of the galvano-cautery or by the actual cautery has from time to time had its advocates. Piercing the individual lesions with a platinum needle-point heated to dull red by means of the battery has been strongly advised; comparative absence of pain, rapidity, and good results are claimed for it.

Scrofuloderma.

Scrofuloderma is a term employed to designate certain morbid conditions of the skin which are dependent upon that state of the system known as scrofula, or struma. The most common form of the cutaneous manifestation is that which has its beginning in one or more of the lymphatic glands. The gland slowly increases in size, without any of the ordinary signs of inflammation, and after reaching the dimensions of an almond may so remain or undergo fatty or cheesy degeneration. As a rule, however, sooner or later the gland grows much larger, the new-cell growth breaks down, the superjacent skin becomes hyperæmic, thin, sensitive, and of a violaceous or purplish color. Finally, the tumor breaks, and a thick, cheesy pus mixed with blood is discharged; sinuses are apt to form, the skin ulcerates, and the process may so continue for months, partial cicatrization taking place, and then again breaking down. The resulting ulcers are irregular or ovalish in shape, with undermined edges, and the surrounding thin and chronically inflamed skin of a violaceous color. Their bases are uneven and covered with pale, unhealthy-looking granulations. If there is crust-formation, it is seen to be thin, grayish or brownish. The process is slow and chronic. The scars are irregular, knotty, contracted, and often hypertrophic. The affection is seen most frequently about the neck, especially under the lower jaw. Other evidences of scrofula are usually present.

A less frequent cutaneous manifestation consists of one or several large, rounded, ovalish or irregularly-shaped, flat pustules upon an inflamed or violaceous base. The crust forms slowly, is thin and flat, and of a brownish color. The ulceration beneath has the peculiar scrofulous characters. The scars which follow are soft, flat, and superficial.

A scrofuloderm occasionally met with consists of one or several papillary or fungoid growths of a bright or dull violaceous red color, with an ulcerated and discharging surface. They occur perhaps most frequently about the hands, are chronic, and often lead to deep-seated ulceration, which may involve the bones and give rise to deformity. The disease resembles the verrucous and hypertrophic varieties of lupus vulgaris.

Another variety of disease, seen usually in scrofulous subjects, described by one of us (Duhring), manifests itself as small pinhead- to pea-sized, disseminated, yellowish, flat papulo-pustules upon a red or violaceous base, which slowly dry to crusts, and leave punched-out-looking scars resembling those of variola. The lesions are irregularly distributed, occurring for the most part about the face and extremities. The process may continue for years. The lesions resemble those of the small pustular syphiloderm.

The manifestations of scrofula are at the present time supposed to be due to the specific infecting agent, the bacillus. Other conditions which have been considered influential, and which are unquestionably important predisposing causes, are heredity, blood-marriages, insufficient and unwholesome food, continued exposure to wet and cold and impure air. It generally develops in childhood, often after measles, scarlatina, and similar diseases. Negroes are especially predisposed to it. The scrofulodermata are, as a rule, readily distinguished by their peculiar clinical characters. Other symptoms of scrofula are, moreover, usually present and aid in the diagnosis. It is to be differentiated from the gummatous ulcerations of syphilis by its history, course, locality, the absence of the specific infiltration at the borders of the ulceration, and the violaceous tint.

The constitutional treatment is the same as employed in other scrofulous affections—cod-liver oil, syrup of the iodide of iron, sulphide or muriate of lime, phosphorus, and iodine preparations being the most reliable remedies. The diet should be liberal, consisting of a large proportion of animal food. Hygienic measures are active adjuvants. The external treatment of scrofulous ulcerations consists in the use of stimulating applications. Mercurial ointments, corrosive sublimate in alcohol, one-fourth to one grain to the ounce, and yellow wash, are serviceable applications. Iodoform, in powder or ointment, is often of benefit. A 1 or 2 per cent. nitrate-of-silver-ointment may also be mentioned. Curetting, as in lupus vulgaris, is one of the most valuable methods of treatment, especially useful in the fungoid variety. Milton has had good results with calomel or gray powder, taken at night two or three times weekly for a few weeks, and a saline every morning in sufficient dose to produce a daily evacuation. The mercurial is then intermitted for two or three weeks. Bitters and mineral acids are given if the appetite fails. A simple ointment is used locally.