Download Clinical Diagnosis of Nodular Syphilis: A Review and more Lecture notes Medicine in PDF only on Docsity!
CALIFORNIA AND WESTERN MEDICINE
THE LATE NODULAR SYPHILIDE By DOUGLASS W.^ MONTGOMERY,^ M. D. DISCUSSION by Harry E. Alderson, San Francisco; Anstruther Davidson, Los Angeles; Thomas J. Clark, Oakland.
S tigma^ monumenti^ revocans^ in memoriam^ iniqui- tatem, a memorial stigma bringing iniquity to remembrance. The (^) efficiency of the Wassermann reaction in detecting the presence of syphilis, and the success of arsphenamine in clearing up luetic lesions of the skin and mucous membranes is so marked that the im- portance of the clinical diagnosis of these interesting manifestations would seem to be diminished. Nu- merically this is so, as between 80 and 90 per cent of those afflicted with late (^) lesions of the skin give a positive reaction. The very success of the Wasser- mann reaction, however, makes it all the more desir- able to be able to make the diagnosis clinically when it fails. In practice we find it more and more fre- quent for both the physician and the patient to rely unqualifiedly on the laboratory diagnosis, which is a great evil. Not long ago we had a patient with late active lues in the nose, in the roof of the mouth, and in a toe, and yet her serum reaction was negative. As practicing physicians we all are aware of the moral value of a positive, unshakable diagnosis as a support in carrying out an efficient, continuous line of treat- ment, and this^ support may be obtained^ equally well from the clinical manifestations as from the labo- ratory findings. Then there are cases in which the patient mav suffer from two different lesions, and^ it becomes eminently desirable to be able^ to^ say that^ one^ of th--. will heal expeditiously under the^ treatment, while the other will not do so. iiere (^) is still another weighty reason for rehears- ing the clinical features of the late syphilides at every convenient opportunity. The success of ars- phenamine in clearing up the lesions of the skin and mucous membranes, or in preventing their appear- ance, is so great that the (^) occasions for seeing them have become quite infrequent. Even in large clinics teachers complain of the paucity of material for demonstration. (^) It is therefore desirable to make the best use of the few chances available, and one can only do so by being prepared for the event. The late (^) nodular syphilide used to be called the tubercular syphilide because it was usually larger than the (^) early papule and more sluggish in its course, but since so (^) many nodular cutaneous affections have been (^) recognized as appertaining to tuberculosis, the epithet "tubercular" has been dropped from the spirochetal affections entirely, as leading to confusion. The late (^) syphilitic papule, or nodule, both anatomically and^ etiologically, is the^ same as the early papule of the widespread papular or papulo- pustular rash. I well remember how surprised I was in sectioning a papule from a patient with a rare early miliary syphilide in the old (^) Polyclinic to find that (^) anatomically it was a minute gumma, even to the presence of (^) giant cells, and a (^) gumma is nothing more than a large, deeply situated, solitary nodule. The greatest incidence of the late nodular syphilide is about the third year of the disease, but it may
occur even in the first year, and it has been known
to appear as late as fifty-five years after the primary lesion (Fournier). The nodule of syphilis is a little tumor, and this should always be borne in mind in considering a diagnosis. It is generally about the size of a small pea, and it has the substantiality of a tumor, both to the eye and to the finger. It looks to be, and really is, well set in the true skin, and may extend below it into the subcutaneous tissue. Its surface may be intact, rounded and^ smooth, and^ its characteristic color is deep red or that of raw (^) ham, but it (^) may be bright red. If it occurs as one sole (^) lump or (^) nodule, or a few such widely scattered, I do not know how to make the diagnosis (^) clinically, but it seldom (^) so occurs, except as a very large node, when it tends to central (^) liquefaction and on opening discharges a glairy pus, and is called a gumma. Even here the resemblance between a (^) syphilitic gumma and a (^) tuber- cular gumma may be too close to differentiate. The course of the tubercular lesion is usually slower than that of (^) syphilis, and the infiltration is (^) usually softer. We have such a case under observation at present.
The late nodular syphilide usually occurs as one of
a group, and then its characteristics may be so dis-
tinctive that any well-trained physician may make
the diagnosis. Like everything organic the luetic
nodule grows to a size limited by its nature and
then recedes. The nodules of any group are all of different ages and therefore of different sizes, and their general appearance also differs with their age. An individual
nodule may pass through its whole life cycle in^ or
under a^ superficially intact^ skin, or possibly only give
rise to some desquamation as an evidence of its
inflammatory nature, and may disappear, leaving no
surface evidence of its previous existence, or it may
cause a scar. The presence of these scars in a
nodular patch is of great diagnostic value. Individual
nodules will almost certainly liquefy in the center,
and in opening on the surface give rise to small steep-edged ulcers with a dirty grey base.
Instead of appearing as individual papules the
late nodular syphilide may develop as a solid, con-
tinuous infiltration with a smooth, even surface and
a definite border, just as tuberculosis may develop
as an infiltration instead of separate tubercles. This
type is rare, however.
THE ARRANGEMENT OF THE PAPULES
Notation of the arrangement of the papules is
often most important, as on it may depend the
diagnosis.
In contrast to the early papular eruption, which is
bilateral as becomes a disease scattered universally
by the blood current, the late nodular eruption often
shows decided bilateral asymmetry.
We have before spoken of grouping as another
peculiarity of^ diagnostic value, but the papules in
the bunch (^) may be numerous and well set apart, and
may exhibit no arrangement whatever, constituting
what may be called a "buckshot group." Many of
the papules may break down into small circular
steep-edged ulcers, some of which may be covered
either with a yellow or with a black tightly adherent
crust, while others will have healed, leaving white or
3s56 Vol. (^) XXV, No. 3
CALIFORNIA AND WESTERN^ MEDICINE
Circular ulcer^ of^ late^ syphilis. A^ band of^ epithelialization may be seen extendint, from about 5^ o'clock^ on^ the^ circle toward the central nub, which will presently transform the circular ulcer into a kidney-shaped one.
reddish brown scars. The variegated appearance of the field may be imagined. A nodular syphilide may begin as a single nodule, and then others may arise immediately around it, so spreading out continuously from the original center. The spread, however, does not usually take place in an even circle; only a segment remains active, form- ing an advancing wall, invading the normal skin. Ulceration follows the wall, so that a crescentic lesion is formed with an advancing bow-shaped in- durated wall, within which there is a crescent-shaped ulcer, in the hollow of which there is scar tissue. This is the typical syphilitic horseshoe-shaped ulcer with the indurated border of raw ham^ color. This is the lesion so often mistaken for either lupus or epithelioma, but which is so much more rapid in its course than either of them. In the development of such a patch quite a variety of grotesque figures may be formed. For instance, Gougerot recently showed a photograph in which
two bows joined, forming the letter "S," as^ if^ the
disease were trying to write its own signature, and recently I saw a crescentic ulcer in^ which^ the^ two horns of the crescent had met, forming^ a^ circular ulcer with a nub of sound skin in^ the center.^ Subse- quently the healing began at^ one point on^ the^ edge and extended toward the central nub, as may be seen in the photograph. This circular ulcer will presently, therefore, again become a crescent-shaped one, THE (^) SITUATION OF THE LATE NODULAR SYPHILIDE These (^) syphilides have their favorite situations, and in their order of (^) frequency they occur on the face,
especially on^ the^ wings^ of^ the^ nose,^ about^ the^ mouth, and on the forehead. On the forehead they may occur along the hair line, causing the corona veneris of the tertiary period. Next^ in^ frequency^ of location comes the palmar^ and^ plantar^ surfaces,^ the^ thighs, nape of the neck, posterior surface^ of the^ forearms, and the scapular and lumbar regions of the back.
They may^ occur^ on^ any^ part^ of^ the^ cutaneous^ sur-
face, but it is apparent from the above that the
trained observer will pay particular attention to any
destructive lesion about the nares, mouth or fore- head, to see if by chance any additional signs of syphilis may be discovered.
SUPERINFECTION AND CRUSTING
The tissue of a late syphilitic nodule is diseased
and of low resistance, and it is situated near the
surface, and therefore^ is^ readily^ attacked^ by^ pyogenic
bacteria. Under these conditions desquamation,
ulceration and crusting are natural consequences.
THE ULCER RESULTING FROM^ THE SOLITARY NODULE
The solitary nodule may break^ down^ into^ an^ ulcer
with a definite indurated border, on^ the^ surface^ of
which the pus tends to dry, forming a crust.^ The
spirochete is strongly inclined^ to^ attack the blood
vessels, and I suppose it is because of this^ that^ the^ pus
is so frequently mixed with blood. The admixture of
blood makes the crust dark brown or^ black, and
very tough. It is also very adherent and fits within
the border of the ulcer like a watch crystal in^ its
setting. As the ulcer extends the crust becomes larger, and at the same time rises above its base, and
so takes on a roughly pyramidal shape, resembling
an oyster shell. The indurated border and the black
tightly adherent, accurately fitting, thick, rough
pyramidal crust^ form^ a^ striking^ and^ characteristic
picture.
THE DESQUAMATION AND CRUSTING OF THE GROUPED NODULAR SYPHILIDE
The nodules, as before remarked, may be^ grouped,
but irregularly scattered. They^ may,^ however,^ be
closely agglomerated so as to form a continuous
desquamating surface, in which case the diagnosis
may be impossible to make. I remember well^ an
incident in the old Toland Clinic^ at^ North^ Beach
that made a great impression upon me. A woman had what appeared to be an indurated eczema on the
side of the nose near the eye, for which I prescribed
ammoniated mercury ointment.^ At the^ next^ visit,^ a
week later, the lesion had so cleared up as to show
plainly its nodular character, and then I^ discovered
several other stigmata of lues that had^ previously
escaped my^ notice.^ It^ was a^ good^ illustration^ of^ the
clinic axiom that one finds what one^ looks^ for.
The crusting may be impetiginous, and so thick
as to completely hide the subjacent definite luetic
symptoms, and so give rise to an^ erroneous^ diagnosis
of impetiginous eczema, or^ of^ impetigo. In^ any
doubtful case nodules and scars should be sought for.
One must also remember that it is impossible to
tell beforehand how much real loss of substance has
taken place under a^ crusted^ syphilide, and^ it^ is^ often
September, 1926 357
September, 1926 CALIFORNIA AND^ WESTERN MEDICINE^359
tertiary lesions the percentage of^ positive^ blood^ findings drops sharply, so it is very important to recognize the disease by its clinical characteristics. Doctor Montgomery's broadminded attitude of using these cases of tertiary syphilis to educate the younger medical men is commendable.
QUANTITATIVE ESTIMATION OF ALBUMIN
IN URINE
By A. M. MOODY AND^ LOUISE STOCKING (From the Laboratory of St. Francis Hospital, San (^) Francisco) T (^) HIS paper relates the details of an accurate and rapid method for the quantitative^ estimation of
albumin in urine. The discussion is limited, first, to
a brief review of the inaccuracy and delays en-
countered in using the ordinary textbook procedures
and, second, to the technical aspect of the test, with- out any consideration of the pathological significance of albuminuria.
In February, 1925, a patient in whom we were
especially interested developed an albuminuria of
such a high degree that^ it was^ impossible^ to^ obtain
a (^) reading on the Esbach tube without diluting the
original specimen. This^ was^ done^ with^ water,
although most^ textbooks simply^ state^ "to^ dilute,"
but do not specify the diluent. Our readings seemed
somewhat large, so we set up a series of dilutions
and found that as the dilution increased we obtained
greater estimations of albumin. The results when
compared with gravimetric determination on the same specimens proved the inaccuracy of diluting urine with water. Those interested in laboratory
analyses are aware of the fact that the Esbach deter-
mination of albumin in urine gives only an approxi- mate estimation, requires twenty-four hours' time, and is influenced by many factors, yet it is probably the most widely used method.
Since we now know that diluting urine with water
increased the inaccuracy of albumin determinations
by the Esbach test, and since we did not think that
the gravimetric or other known accurate quantita-
tive methods were practical as routine procedures,
we set out to find something which could be relied
on to dilute urine without disproportionately altering
the albumin content.
Many fluids were tried, including the^ following:
Albumin free urine, Tsuchya's reagent, 2 per cent
acetic acid, various strengths of alcohol, sodium
chloride solutions (2 per cent to .85 per cent), and
others. In brief, all the above^ solutions as diluting
fluids were found to yield inaccurate results.
Tsuchya's reagent or alcohol used as diluting fluids
decreased disproportionately the albumin estimation.
Beginning with 2 per cent sodium chloride and
decreasing to a concentration of .85 per cent, in-
accurate results were obtained similar to those when
water was used as diluent. We noted, however, that
2 per cent sodium chloride yielded results which
were more promising.
At this point in our work we discovered that
Doctor Wykoff of Stanford University Hospital was
working independently on the same problem, and
that he began at 2 per cent sodium chloride and,
working with increasing concentrations, found that
2.5 per cent sodium chloride was the desired strength to be used. He was also working with a standard
control of egg albumin, using a modified Purdy
technique for the test.
With these facts we now felt that our difficulties
were about over, but believed that a standard made
from human blood serum would perhaps be more
nearly ideal, since urinary albumin so closely re-
sembles the coagulable proteins in the blood serum.
Then, too, Folin, in his laboratory manual, gives the
details of a test, using a standard made with hemo- globin free sheep's blood serum, so you see the idea
is not new. Sheep's blood serum is not as readily
obtained in our laboratory as is human serum, so
it seemed quite logical to use the latter as a standard.
It was found that 5 mls. of pooled human serums
diluted to 100 mls. with 2.5 per cent sodium chloride
solution yielded by gravimetric determination an
average albumin content of 6 grams per liter. With this standard solution we then proceeded to shorten
the time element from twenty-four hours^ to^ fifteen
minutes by adopting a modified Purdy test instead
of the Esbach.
The procedure as now used is as follows: Place in a 15 mls. capacity graduated centrifuge tube 10 mis. of urine to be tested, and in another similar tube 10 mls. of standard serum solution; thenaddtoeach tube 5 mls. of Tsuchya's reagent (phosphotungstic acid 15 gms. hydrochloric acid 50 mls., and make up to 1000 mls. with alcohol 95 per cent); mix thor- oughly by inverting back and forth, and let stand for ten minutes; then place the tubes in the centrifuge and centrifugalize for three to five minutes. Record the amount of precipitate in each tube and calculate the result.* The standard tube reading equals 6 gms. albumin per liter.
We have made over one thousand determinations,
using the^ above^ technique as^ routine, with^ frequent
checks by the gravimetric method. The average
difference was 3 per cent higher by the centrifugc
method. In many determinations identical results
were obtained, figuring to one decimal. No attempt
has been made to estimate closer with one decigram.
Slight errors^ may readily occur in reading amounts
between the graduations on the centrifuge tube, and also in the (^) gravimetric method, if the sediment is not properly dried to a constant weight.
When using the above method it must be remem-
bered that the standard is set up at the same time
as the unknown, and that all solutions are kept under
the same temperature conditions at all times until the
final reading is made. In this way only is one justi-
fied in comparing results. If it is necessary to dilute
the unknown, do so with 2.5 per cent sodium
chloride solution, a stock bottle of which is kept
under the same temperature conditions as the
standard and unknown. In this laboratory it has
been practical to keep our standard solutions at room
temperature.
The standard solution is made fresh each week,
oftener only when the stock has been used. A small
amount of preservative (chloroform 1 to 1.5 mls.
per 100 mls. of serum solution) can be added to
prevent bacterial growth or other determination. In
- (^) The supernatant fluid should be water clear after centrifuging. If there is the slightest turbidity then the concentration of^ albumin is too great for complete precipitation, and the original specimen must be diluted. This necessitates repeating the entire pro- cedure.
