An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White.
- William Williams Keen
- Date:
- 1899
Licence: Public Domain Mark
Credit: An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White. Source: Wellcome Collection.
Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.
![While tliore is a possiliility of error in diagnosis between a chancre and an epithelioniatous ulcer when a niaerosco])ical examination alone is made, there is, on the contrary, no such ap})reliension when a microscopical examination of the lesions is instituted. The histological structure and arrangement are so very distinct and unlike in these lesions that a mistake cannot well occur. In the e})itlielioma we have the ingrowing of the interpapilhuy layers of epithelial cells, the branching or budding outgrowths from the sebaceous glands which consti- tute the very characteristic ej)itheliomatous pegs, and the formation of the cell-nests or pearls upon these pegs, which are all so strikingly different, when contrasted with the histological structure of a chancre, that no doubt as to diagnosis remains. Upon the sides of the tongue ulcerations, produced by the continual contact of that organ with rough and carious teeth, have been mistaken for chancres. This error should ])e guarded against, but is not so serious in its results as the failure to recognize the specific lesion when it is situated at the point of the tongue, the possibility of its communication to innocent people being, in such cases, an element of unusual importance.^ In the first five or six days it is impossible to diagnosticate it, but if the original little inflamed papule enlarges and extends, becoming elevated above the surrounding parts; if its epithelial covering drops off and its surface becomes diphtheritic; if superficial cauteri- zation with crayons of nitrate of silver, which so rapidly cure the common small painful papule of the tongue, have no effect upon it,—there is a strong presump- tion that it is chancre. This will be confirmed later by the appearance of submaxillary glandular enlargement and induration of the sore. Of all the chancres of the cephalic region, however, that of the tonsils or of the isthmus of the fauces presents the greatest diagnostic difficulties, on account of the effacement of its characteristics by the surrounding inflam- mation. If in a case of prolonged sore throat there be an appearance resembling a single mucous patch, and there be no history of antecedent syphilitic poison- ing, it becomes probable that the trouble is chancrous; and this probability is greatly increased if any induration can be felt by palpation with one finger in the pharynx and another external to its walls ; if enlargement of the glands above the angle of the jaw occurs; or, of course, if the patient confesses to having been peculiarly exposed to contamination. The sore is much more common in this region in females than in males, Mackenzie noting the fact that out of 7 cases of primary syphilis of the ton- sils Avhich he had met with, 6 were women. (6) Superior- and Inferior Extremities.—Chancres of the hands are often seated at the margin of the nail and closely resemble simple whitlows. They may be diagnosed by their long duration, their abrupt limitation, the hardness of the tissues around and beneath them, and the consecutive engorgement of the epitrochlear ganglion. Upon the dorsal face of the phalanges the initial lesion at first simulates an inflamed papule or boil, but is less painful, dis- charges no core, and is elevated, not excavated. The anterior face of the forearm in both sexes, the anterior surface of the thigh in men and the posterior surface in women, are the parts most exposed to contagion. The chancre of vaccino-syphilis occurs after the evolution of the vaccine sore. It can only be confounded with the ulcerations described by Blot under the name of vaccinal phagedenism, which are rounded with abrupt borders and indurated bases, and are often accompanied with engorgement of the axil- ^ The same remark applies to mucous patches of the tongue and lips with even more force, &o they are so much more frequent than primary sores.](https://iiif.wellcomecollection.org/image/b21217014_0183.jp2/full/800%2C/0/default.jpg)
