Concerning the flat tubercles, which Cazenave likewise ranges among his syphiloid, but which are, for the most part, primary phenomena, see mucous tubercles, 68-72.
Secale108. – Lepra Syphilitica, seu nigricans (Syphilitic Leprosy)
Several authors have not been willing to regard this eruption as an independent form, but maintain that the formation of scales is a termination peculiar to all syphiloid. This is indeed true, in most cases; but, inasmuch as there are some forms where the formation of scales plays as important part, and even constitutes the whole phenomena exclusively, as it were, a correct and easy diagnosis of syphilitic cutaneous eruptions would seem to render a more particular consideration of these scaly syphiloid eruptions indispensable. Cazenave, who is the most correct observer of all syphilitic forms, classes lepra under three different categories: (1) lepra nigricans, or syphilitic lepra; (2) psoriasis, or scaly tetter: and (3) psoriasis cornuta, or horny scales.
The first of these three kinds, lepra syphilitica, consists of an eruption of circular, violet-red spots of different sizes, somewhat raised at the edges, and rather depressed in the centre. These spots which never attain to the large size of common, non- syphilitic lepra spots, generally are of the size of a dime, sometimes even much smaller. When first breaking out, the spots are like little papules, raised above the skin, and looking like points of coppery-color, which spread and become pitted in the centre or rather raised at their edges, while gradually the spots assume a dark, dingy, violet red color, with a somewhat blackish tint, and become covered at their borders with gray, hard, dry scales. The eruption may continue in this condition for a long time, except that the scales fall off and become renewed again, or else do not return at all, in which case, these spots retrograde in the same manner as they had gradually developed themselves, leaving only dark vestiges, which continue to mark, for a long time after, the rounded form of the affected parts, and are darker at their edges than at the centre, which first loses its characteristic color. These spots can show themselves at every point of the surface of the body, but the extremities seem to constitute their favorite site; Cazenave has seen them scattered over the whole body. I have seen them, in the case of a rather careless woman, and whose face alone had remained free, covering the limbs, abdomen, chest and back, at the same time as they were associated with other syphilitic cutaneous forms in other parts of the same body. Their first appearance is sometimes preceded for some days by a general feeling of malaise, headache, sadness even bone-pains, all of which symptoms generally disappear in proportion as the eruption breaks out upon the skin. In the case of my woman, the patient had had a chancre two years previous, which had become cicatrized a long time ago; and the different syphilidae, which generally selected the skin for their locality, had already been out over a year, attended with a sort of sadness or joylessness, from the very moment when the eruptions first made their appearance, and which did not ceases until they had been completely removed.
Secale 109. – Psoriasis Syphilitica (Diffusa, Guttata of Cornuta)
That form of psoriasis which approximates most nearly the common, non-syphilitic psoriasis, is psoriasis diffusa; and more particularly the variety designated as psoriasis guttata. Psoriasis diffusa consists of rather large, round or irregular, yellowish pale-red, or copper-colored spots, that become covered with hard, brittle, faint-white scales, the centre of which frequently ulcerates and forms a blackish scurf; the scaly spot frequently shows slight cracks from which a clear serum oozes out, which may be succeeded by ulcerations and condylomatous growths. This form is most frequently seen in the face, though it may likewise break out on the hands and around the ankles, and according to some, even around the anus and on the scrotum.
Psoriasis guttata, which occurs much more frequently, is not, as some assert, confined exclusively to the hairy scalp; on the contrary, it may spread over the whole surface of the body. On the body it is seen in the shape of small, prominent spots, of the size of a three-cent piece, generally round or oval, not pitted in the centre, generally isolated and scattered in tolerably large numbers. These small spots, which are of a marked copper red, and retain this color for a long time before it changes to gray, soon become covered with a gray, rather firmly adhering scale, which, after it once drops off, is not apt to form again, and leaves a small, red, somewhat raised spot, surrounded by a narrow white border. These spots often remain a long time before they flatten down and grow paler; even after they have sunk to a level with the skin, the redness often persist for a long time and imparts to the spots an appearance of being elevated above the skin. After a time, their color changes to brown and then gray, and the eruption disappears without leaving a trace behind.
Psoriasis cornuta, also designated as palmaris and plantaris, because it breaks out almost exclusively in the palms of the hands and on the soles of the feet, may break out in two different forms. In one form it may assume the shape of small risings, of the size of a pea, somewhat wart-shaped, and, seated upon a red, not always distinctly perceptible base, with a hard, white, horny centre, that sometimes can be picked off with the nails, but in other cases seems to be sunk into the integuments, like a wedge. This horny elevation is generally surrounded by a ring, of one or two lines in width, having characteristic color but not always distinctly visible, if the hands are not clean, and becoming more prominent after the hands have been washed with cold water. I have seen this form break out, sometimes even after the lapse of fortnight, in individuals in whom a chancre had been suppressed by external means, without the use of Mercury; whereas the second variety has only been seen by me on persons who had taken a good deal of Mercury for chancre, and even after chronic mercurial poisoning, in cases where no syphilitic taint was present. This variety consists of a more or less board, scalp spot, or of several of them, on which the epidermis seems to become detached in large scarlet flaps, whose scales are sometimes so thick that it seems as though several layers might be torn away. These scales sometimes crack, forming painful rhagades having a very clean appearance, and being entirely devoid of any of the signs of similar rhagades at the anus, or between the toes. These scales are very often surrounded by a tolerably broad border of an unmistakably syphilitic color; in such cases a so-called mercurial syphilis, or a coalescing of syphilis and mercurial disease most likely prevails.
Secale110. – Syphilitic Affections of the Nails and Hair.
In order to facilitate their diagnosis, we will consider these affections more particularly.
1. Affections of the Nails. – In treating of the consecutive, and sometimes likewise protopathic ulcers of the primary period of syphilis, we have already made mention of syphilitic ulcerations of the nails (onychioe syphilitica), which often break out around the nails as irregular rhagades, with fungoid borders, and betray their syphilitic origin by their gray, bluish color, and by their secretion of a fetid ichor. Beside these ulcerations, in consequence of which the nails often drop off, these may likewise undergo important structural alterations, without any ulcerous disorganization, simply by the syphilitic virus diffused through the organism. In consequence of such alterations, they may likewise drop off the same as when they are destroyed by ulceration, although such structural alterations almost always involve the matrices of the nails. In most cases of this kind, the internal border of the nail secretes a sort of purulent fluid, sometimes in considerable, and, at other times, in scarcely perceptible quantities, the color of the skin remaining unchanged all the time. Very frequently the nail is more or less painful, the pain being, if not always, at least very often felt when pressing upon the ball of the finger or toe, and sometimes preventing the use of these parts. The affection is very often associated with other syphiloid eruptions.
2. Falling off the Hair. – The symptom is one of the most frequent accompaniments of secondary syphilis. I do not know of a single case of this disease, where the above-mentioned symptom did not occur. Three of my female patients, so far, not only lost their head-hair, but likewise their eyebrows, eyelashes, the hair of the private parts, so completely that no trace of it could be seen; although it grew again after a time, and the face became again invested with its noblest ornament. Older authors have attributed this sad result to the abuse of Mercury, which may indeed produce similar results; but in the case where I witnessed this spoliation, not a grain of Mercury had ever been taken. The pityriasis described by other authors as an affection of the hairy scalp that is said to precede the falling off the hair is likewise no permanent symptom; in many cases the loss of hair may indeed in most cases, this loss takes place without the least sign of a syphilitic affection of the scalp being perceptible. On the other hand, the hair may fall off in consequence of secondary, and even primary syphilis; sometimes even during the fungoid stage of protopathic chancres. The older the disease, the more remotely from the period of protopathic chancre the falling off of the hair takes place, the more unfavorable the prognosis. Among older patients the prognosis is likewise more unfavorable than among young people. Among young people, if the hair fell off shortly after the appearance of protopathic phenomena, and the disease was otherwise rationally treated, and cured with appropriate means, the hair grows again as thickly and as rapidly as if it never had been lost. It is only in place the roots of the hair had been completely destroyed by ulceration, that the most celebrated promatum, as well as any other remedy, will prove inefficient to restore it.
