Secale114. – Non-syphilitic Eruptions accompanying the Syphiloids
Another point, which cannot be sufficiently attended to in a case of syphiloid eruption, is the fact that not only several of them may appear together, mixed up indiscriminately one with the other, but that they likewise manifest themselves associated with other, non-syphilitic exanthems, on which account the diagnosis of the existing combination may become very difficult, and the physician may find it a hard task to make up his mind regarding the true nature of the case before him. for this reason, it is important and useful to know what eruptions may possible appear together; this knowledge may enable us to see light even in obscure and dubious cases. In respect to these combinations, which may really be regarded as true complications, we have to distinguish two possibilities: (a) a syphiloid may supervene while some other cutaneous disease is already present; or, (b) this disease may break out while the syphiloid is already developed. The former of these two cases, where the syphiloid supervenes during the presence of an already existing exanthem, can only properly refer to chronic cutaneous diseases, since all acute diseases temporarily suspend the course of syphilis, which, even if actually and full developed in the organism, would not break out until the acute disease had run its course. As regards chronic exanthems, the syphiloids may indeed become associated with them, either by coalescing with them, and imparting to the former a syphilitic appearance; or else both exanthems may co- exist independently of each other, in which case, syphilitic and non-syphilitic scales, scabs, tetters, lichen, eczemata, etc., may be observed and contrasted on one and the same patient with considerable interest and advantage. Such cases, however, are not very frequent; whereas other cases, where syphilitic pustules, for instance, are seated on old, large liver-spots, occur much more frequently. As regards the other case, where a new exanthem became associated with an existing syphiloid, this new exanthem must always be one of an acute form, such as measles, small pox, scarlatina, etc., inasmuch as the organism being saturated with the chronic syphilitic miasms, the existing diathesis does not leave room for the development of another chronic eruption; though I have seen more than one patient who, even while affected with a chronic syphilitic exanthem, was, at the same time, attacked with the itch. If acute exanthems supervene during the presence of syphiloid eruptions, the former may assume a very malignant form, specially if the syphiloid had already shown symptoms of malignancy, and had become deeply rooted in the tissues. On the other hand, if the syphiloid and the other symptoms of secondary syphilis were but slight, I have seen every syphilitic sign become suspended, and utterly disappear, in consequence of the supervention of an acute exanthem, and not appear again until this exanthem had run its course without the least untoward result. As to the assertion, that the syphilitic diathesis may be completely extirpated by the supervention of typhus, smallpox, etc., I am unable to confirm it. I have seen two such cases; in both of them the syphilitic symptoms were indeed suspended during the course of the acute disease; in both of them, however, though the disease ran a very favorable course, the final convalescence was attended with malignant syphilitic ulcerations, as a last sequela.
IV DIAGNOSIS OF SYPHILITIC EXANTHEMS
Secale115. – General Observation.
One who has carefully perused our description of the different syphiloids, but has not observed them in practice, might be led to imagine that nothing is easier than to recognize their true character at first sight whenever they occur. This is indeed true in many cases, specially if other primary or secondary symptoms of syphilis are present at the same time. Even in cases where these accessory symptoms are wanting, the characteristic color; the rounded form of single pimples, or whole groups of them, which always approximate to the circle; the successive croups in which these eruptions appear; in one word the whole look of such a syphiloid, and above all, its contrast with a similar, non-syphilitic exanthem, together with a knowledge of the previous history of the case, will lead the physician, if not to the positive conviction, at least to the supposition that he is dealing with a syphiloid in the present case. A mere supposition is of course no certainty; and if it is necessary in any disease to have certainly, it is in syphilis; not only on account of the danger involved in a misapprehension of its true nature, the danger of increase and aggravation of the symptoms, but likewise on account of the inconvenience to which a physician might be exposed, if in a case of obscure and chronic exanthem, but perfectly free form all syphilitic taint, he should allow himself to express the suspicion that the exanthem might possibly betray the presence of some hidden syphilitic infection. But how is the physician to acquire certainty in the absence of all other syphilitic signs, or if the patient out of modesty or in consequence of other important considerations, should insist upon never having been affected with syphilis; or if he should even have remained ignorant of the fact in consequence of drying up an incipient chancre-vesicle with lead-water, or suppressing it with some cauterizing agent, and if the rapid disappearance of this primary sign of the syphilitic infection should have led him to overlook the danger and to mistake this first manifestation of the disease for something unimportant and perhaps a mere accident? But supposing we discover symptoms of a former syphilitic infection, would this justify us to pronounce the existing exanthem of a syphilitic character, even if the absence of all positive signs of syphilis should be calculated to excite a doubt in our minds? We have already stated (No. 85), that in cases where syphiloids break out years after the primary phenomena have disappeared, we shall discover a continued series of syphilitic phenomena from the first moment of manifestation of the syphilitic infection down to the appearance of the present exanthem. It is to this circumstance that we desire to direct the special attention of practitioners in cases where a careful inquiry into the previous history and origin of the case neither reveals present infection, nor any other, unless perhaps one that had been forgotten for years. If we can find out that the patient, who pretends never to have been infected with syphilis, has had several exanthems, (the nature, form, color, and course of which the physician cannot investigate with too much care), and if the character or the nature of these exanthems corresponds to that of analogous syphilitic exanthems, we may almost rest assured that the present eruption, if some of its leading appearances resemble the symptoms of one of the former series, is of a syphiloid character. And vice versa, if a patient who had not been exposed to any new infection for the last three years, and had been treated rationally for the former infections, applies for treatment, and the eruption, according to all appearances, is decidedly of a dubious character, no other secondary symptoms being present, and the patient having been perfectly exempt, during this period of three years, from all suspicious eruptions from all equivocal spots upon the chest, face, or hands, we may as safely conclude that the existing exanthem is non-syphilitic, as it was fair to conclude in the former case that it was of an opposite nature.
Secale 116. – Certain local Diagnosis Signs.
As has already been stated, these are: (1) the peculiar color; (2) the disposition inherent in the isolated sports, pustules, or pimples, or in whole groups of these eruptions to assume a circular form; and above all, (3) the succession of crops, which is never seen as significantly in any other dermoid disease, and which gives us an opportunity of observing a syphiloid eruption in all its different stages at one and the same time. This sign is of the utmost significance. It alone, if fully present, together with the other characteristic symptoms, is sufficient to decide the diagnosis even when no other syphilitic phenomena are present. These exanthems, however, are not always seen at this period; very frequently they present themselves during the first stage of their existence, when no succession of crops has as yet taken place, and the color and form of the eruptions have to be the sole guide of the physician. In relation to these two characteristics, we shall therefore offer a few suggestions. As regards color, we have already stated a number of times that the characteristic color of syphilitic eruption is the color of copper; but we have likewise seen that this red, during the course of these eruptions, passes from the simple red through a bluish brown or yellow to the dark reddish-gray color of venison, and to a dingy gray-yellow, through so many shades, that it requires a well-practised eye to recognize, amidst so many different shades, the peculiar syphilitic color, which, nevertheless, can never remain unrecognized by any one who has once had a chance to observe it. In as much as not every practitioner has seen all these different shades, and the general definition of coppery-red might easily lead to wrong conclusions, the question will be, under what general appellation these different shades should be comprehended so that they may be recognized even by a physician who has never seen them. The solution of this problem has been vainly attempted by most of the older as well as modern writers on syphilis; fortunately, however, this question admits of a ready answer at the period when the characteristic succession of crops has not yet taken place, and when the color of the eruption is to decide its syphilitic character. For it is during this period, when the exanthems first make their appearance, that the copper color is most deeply marked, and only vanishes at the time when the period of the succession of crops set in, when with every new crop the deep copper-red will again appear; so that the peculiar copper- red, whether of the whole exanthem or only of parts of it, is and always will be the characteristic diagnostic sign which, in addition to the tendency to the circular form, will almost always be sufficient to determine the syphilitic nature of the eruption. At all events, this color is a safer diagnostic sign than the mere form, although this will likewise prove a valuable indication provided we do not look at the eruption in a one sided manner; but view it as a whole, as we see it simultaneously on the face, chest, back, limbs, etc.; if seated on the fingers, for instance, we tell the patient to place them close together, so that we may have a chance of observing the full shape of the exanthem, whether pustules, spots, or pimples. The difficulty, in this respect, is not, however, limited to a recognition of these circular forms; for, as we shall see in the subsequent paragraph, there are other, non-syphilitic eruptions that assume a round form, such as herpes circinnatus (ring-worm), etc.
