Secale105. – Simple Grouping and scattered Tubercules.
Inspite of apparent difference of form, these two kinds have so many points in common that they may be very properly ranged in one class.
(a) Grouping Tubercles. – These tubercles are generally of inconsiderable size; they do not seem very much inclined to ulcerate, and the characteristic copper-color is not very marked, although it may show itself in two different ways. In most cases these groups are regular, perfectly rounded, and composed of more or less tubercles of the size of a large pea, in such a manner that each adjoining group forms, as it were, a ring with an elevated border, which is interrupted again by every subsequent tubercle, leaving an intermediate copper-colored space. According as the tubercles which form this ring are more or less in number, the length of its diameter varies. These tubercles, which are often covered with small, hard, grayish scales, never ulcerate, run a slow course, and generally disperse without leaving the least scar. They break out most frequently on the arms, sometimes on the forehead and neck. On the other hand, irregular groups of tubercles appear on the cheeks and lips; they are ranged close to each other without order, generally shining, but small and resembling papules, occupying, however, a much broader base than these latter. They are of a genuine copper- color with often extends beyond the locality where the tubercles are seated, specially in the face; moreover, the tubercles are hard, projecting, and resisting the pressure of the finger, like large-size pin’s heads. Although they never become moist, nor easily ulcerate, yet, after having stood a long while, they may become inflamed, run into each other, and cause a swelling of the part, which may break out in more or less deep ulcers; in the majority of cases, however, they pass away by dispersion after a certain period, decreasing at the same time in size as well as in color, and finally disappearing without leaving a trace behind. Whenever these grouping tubercles appear, they always constitute a symptom of fully developed secondary syphilis.
(b) Scattered tubercles. – These tubercles pretty generally break out at considerable distances from each other; the intermediate skin looks wilted and dingy; they are more prominent, more raised, and have a broader and more hardened base than the former variety; they are irregular, imperfectly rounded, oval; they are of a bright copper-redness; the epidermis that covers them is tense and shining. Being perfectly indolent, they appear to be the result of a slowly progressing inflammation; they never become either scaly or ulcerated, but remain shining, without every secreting a moisture. Sometimes, though rarely, the appearance of the eruption is preceded by headache and nocturnal bone-pains; they appear principally in the face and on the limbs, but may show themselves on almost any other part of the body, and even appear in company with grouping tubercles, although in different localities. They run a slow course; after they have gradually grown to the size of an olive, they may remain stationary for a long time, until, in consequence of some accidental cause, they become inflamed and afterwards ulcerate, which, however, is a rare occurrence; at the end of two or three weeks they generally disperse without scarcely ever leaving a spot behind, the color of which never continues longer than a month after the eruption has disappeared. A small scar is sometimes seen on their original site.
Secale 136. – Perforating Tubercles
This form, so named from the destruction which these tubercles may cause by ulceration, is distinguished by the production of large papules or deep-seated indurations in the integuments that at first are inconsiderable, but soon increase in size. They are not usually very numerous, and break out in the face, specially on the lips, alae nasi, and in front of the ear near the meatus; even if they appear in other localities, they are always present in the face. In most cases they are broad and semi-globular; their base looks as if it were grown together with the integuments, and penetrated deeply into the cellular tissue which they show a great tendency to perforate by ulceration. Very often they remain stationary for a long period, even for a whole year; after this period they begin to look red and, for sometime, change their color; sometimes they appear of a coppery-red, sometimes gray, and then again of a simple red color, until, the suppurating process begins at the outermost point of the tubercles. As soon as suppuration has set in, the ulterior course of the tubercles may take two different directions. Most frequently the course is slow and almost painless; the tubercles gradually softens at one or more circumscribed points which sometimes coalesce, and, either after or even before the complete discharge of the pus, change to a thick, not very humid and lightly adhering crust which, after falling off, forms again until the tubercle is completely destroyed, cicatrization not taking place until the last remnant of the indurated tubercles has passed away by suppuration. If cicatrization should take place at an earlier period, the process of suppuration will again recommence sooner or later until the whole tubercles is gone. Not always, however, the softening takes such a slow course. Very often the tubercles at once become tense, painful, and are surrounded by an inflamed, red areola, after which the ulcerative process, beginning at the internal point, rapidly penetrates through the whole thickness of the induration, and a black, dry, thick crust forms, that soon falls off and reveals a cup-shaped ulcer having all the characteristic signs of a syphilitic sore. New crusts keep forming, with new destruction, until the whole tubercular mass is removed and a final cicatrix has formed. In every case this cicatrix is pitted, of a violet color, with abrupt edges, and always retains the indestructible traces of a former tubercle. If these tubercles break out on the lips, nose, and on other parts, it frequently happens that these organs are irremediably lost. Even if the destruction should not be complete after a first ulceration, it will certainly result in the entire loss of the parts after a second or third renewal of the ulcerative process, and we can never be sure of having achieved a perfect cure until a long period elapses after the last cicatrization without any new outbreak taking place. This syphiloid is most frequently seen already towards the end of the second stage of the primary period of syphilis, it being a not very remote sequela of protopathic products. This syphiloid is most likely the most hideous of all, which, if occurring in the face or on the nose, might easily be confounded with lupus, carcinoma, or even with elephantiasis, where this disease prevails, if it were not that here, too, the previous history of the case, and the characteristic signs which are peculiar to all syphiloid eruptions render the diagnosis all but certain.
Secale 107. – Serpiginous and Flat Tubercles.
The first of these two forms, the so-called serpiginous or creeping tubercles, and distinguished from the former by this, that, in their case, the suppurative process does spread downward to the subjacent textures, but onwards over the adjoining surface. As its appearance, this form is known by large, red, rounded, hard papules, breaking out irregularly, here and there; they are not very numerous at first, do not exceed the size of a hazelnut, and sometimes are no bigger than a pea. Though they can occasionally be seen on other parts of the body, yet they break out most frequently on the back, chest, and in the face, whence they afterwards spread over the whole body, except the palms of hands and soles of the feet; their favorite locality, however, is the forehead, hairy scalp, nape of the neck and shoulders, and no less the hairy parts of the body, or the parts adjoining the hair, such as the temples, eyebrows, inguinal regions, and sexual parts. The tubercles themselves are smooth, shining, of a copper-red and never covered with scales; very frequently they remain indolent for a long time, without changing; suddenly, however, after a longer or shorter period, they commence to inflame, and to suppurate at their terminal point, after which the tubercles are rapidly destroyed, and become converted into thick, hard, coniform, sometimes black, at times gray, and always firmly-adhering crusts. If these crusts are removed before they become spontaneously detached, a rather superficial ulcer becomes visible, which soon covers itself with a new crust, which is neither as black nor as thick as its predecessor, but continues to be thicker at the centre than at the edges. As soon as this ulceration commences, new tubercles form by the side of the former, or on the borders of the cicatrices of former tubercles. By coalescing into one, these new tubercles form extensive sores, or else a number of smaller ulcers may arise in succession, at short intervals from each other. The destruction of neighboring parts, arising from this continued formation of new tubercles, may extend over a large surface of a few inches in diameter, or may give rise to several ulcer s of a rounded shape, and separated from each other by free intervals. It seems as though the process of ulceration would have a spontaneous termination, if it were not fed by new tubercles starting up in proportion as their predecessors are removed by ulceration. Hence it is that they may cicatrize at one end, after the fashion of the serpiginous chancre, while the ulcerative process continues at the other end, where it, is fed by the formation of successive crops of new tubercles, whose cicatrices continue for a long time to betray their origin by their form and peculiar distribution. Moreover, we may observe on every patient the different stages which this syphiloid runs through, at one and the same time. In this way, we may see at one place more or less numerous, prominent, copper-colored, irregularly-scattered tubercles, more particularly within the limits of the affected parts; whereas, at some other places, we see more or less thick and broad hard, centrally-raised, and somewhat dry crusts, the intermediate space between which is occupied by gray ulcers, with raised, abrupt edges, some of these ulcers being round, other irregularly-shaped, or spirally contorted, beside which, we witness the most diversified cicatrices, the older of which appear white and fibrous, whereas the more recently formed are violet-red etc. This syphiloid runs a very slow course; it generally does not make its appearance until a long time after the primary syphilitic phenomena have disappeared.
