V. COMMON DERMOID DISEASES, WITH WHICH SYPHILOIDS MAY BE CONFOUNDED.
Secale 117. – Rubeola, Varicella, Smallpox.
What we have said at the conclusion of the preceding paragraph, of the circular form as being common to some non-syphilitic and eruptions, applies equally to some other symptoms which both syphilitic and non-syphilitic exanthems have in common. In order, therefore to furnish all the means which nay assist in establishing a correct and discriminating diagnosis, we deem it indispensable to present a list of the non-syphilitic cutaneous affection with which the syphiloid are most easily confounded. These are, in general: (1) some exanthematic and epidemic eruptions; (2) certain dermoid affections of the face; (3) various herpetic eruptions; and (4) some forms of mercurial syphiloid eruptions, all of which we will consider more particularly in the following article.
1. Exanthematic and Epidemic forms. Under this head, rubeola varicella and varioloid deserve our first attention. As regards rubeola (roseola communis), with which, in case, the patient should deny the existence of any previous syphilitic infection, syphilitic spots (roseola syphilitica) might be confounded, we have to observe in the first place that the febrile motions with which the breaking out of this last-named exanthem may be attended, are never as violent as the fever accompanying acute exanthems. Moreover, the redness of the common roseola-spots pales off in proportion as the eruption runs its course, and disappears under the pressure of the finger; there final disappearance leaves nothing but a slight desquamation; whereas the spots of the syphilitic roseola are of a coppery-red, deepening and finally changing to a grayish-color as the spots run their course; moreover, they progress slowly, disappear but imperfectly under the pressure of the finger, and, long after their disappearance, leave brown, or dirty yellowish-brown tints which, though not very distinct, become more prominent in the cold or after washing in cold water. As regards varicella and variola, with which some syphiloids are likewise much more intense than the febrile motions attending analogous syphiloid; in addition to which, the syphilitic vesicles are always surrounded by a copper colored areola, which is wanting a simple varicella, whose vesicles moreover rapidly inclines to suppurate, whereas the syphilitic vesicles remain for a long time in the same condition, and finally become converted into blackish crusts which fall off, leaving dingy-gray spots behind. The absence of acute fever during the prodromic stage of the syphilitic ecthyma, where the febrile motions, as in the case of all other syphilitic eruptions, are much less marked than the fever accompanying the breaking out of an acute exanthem, may be sufficient to distinguish that ecthyma from common variola, though the syphilitic pustules may lead a superficial observer into error, as they indeed have done in many cases, for a few days at least. But even here all uncertainty will undoubtedly disappear after the lapse of a few days, were it only if we consider the slow course and the more circumscribed spreading of syphilitic pustules, not to speak of the different cicatrices and marks which these pustules leave behind.
Secale 118. – Continuation of the former Subject.
FACIAL ERUPTIONS. – The different eruptions in the face, more particularly acne, mentagra, lupus vorax, and even carcinoma, are much more readily confounded with syphilitic products than the ordinary exanthems, or any other febrile eruptive diseases. Errors of this kind having frequently taken place, we will give a full description of the diagnostic signs, a knowledge of which may prevent all misapprehensions.
As regards acne, and more particularly the indurated acne, acne indurata, nothing is easier than to mistake it for a pustulous syphiloid, or to mistake the latter for simple acne; a mistake that may occur so much more readily as the distribution of the pustules is about the same in either disease. What sheds light on the diagnosis if the fact that in syphilitic acne, besides the copper-colored areola which surrounds the tubercular indurated pimples, instead of a simple erythematous blush, the number of these pustules is much less, and the cicatrices they leave behind are round and pitted, whereas the cicatrices of simples acne are oblong, elevated, and lax, if folded upon themselves; a diagnostic sign which is the more important, since both forms break out more particularly in the face and on the forehead, and, on the shoulders, appear sometimes simultaneously. Beside these eruptions were have a kind of syphilitic tubercles on the nose and cheeks, that might likewise be confounded with the common acne indurata, if the former were not distinguished from the latter by their greater hardness, their coppery-red color and generally oval from, as well as by their larger size, their more deep-seated base in the integuments, and their disposition to ulceration and the formation of crusts, without mentioning the peculiar cicatrices they leave behind.
It is these last-mentioned signs that constitute the main difference between the so-called mentagra and syphilitic tubercles; in addition to which, mentagra is accompanied by a sort of hypertrophy of the whole of the subjacent cellular tissue, which is never perceived in the case of syphilitic products.
Lupus likewise, specially when seated on the nose, has been falsely mistaken for a syphilitic product; or, which is more frequently the case, syphilitic product have been mistaken for lupus, which, considering that the diagnosis is not very easy, is indeed not a very difficult matter. While in their tubercular condition, they can be distinguished from each other by this, that the tubercles of lupus are flatter, softer, more yellowish, and never shining at their surface, but always having a shrivelled appearance, with oedema of the subjacent cellular tissue, and pale lead-color of the skin; whereas syphilitic tubercles are always hard, copper-colored, shining and semi- globular, and moreover surrounded by a copper-colored areola. In addition to this, the ulcers of lupus are always superficial, soft, spongy, and resting upon a soft, oedematous base, whereas the syphilitic ulcers are deep-seated, having a lardaceous base and abrupt edges.
Almost the same diagnostic signs distinguish carcinoma of the face and lips from syphilitic tubercles; the former never has the characteristic hardness, nor the peculiar copper-color of syphilitic tubercles, not to mention the fact that cancer always arises from a scarcely ever salient induration (scirrhus) in the interior of the tissues.
Secale 119. – Continuation of the former Subject.
HERPETIC ERUPTIONS. – More frequently than with any of the preceding forms have syphilitic eruptions been confounded with herpes circinnatus, ecthyma simplex, impetigo, lichen, psoriasis, and pityriasis, and likewise with various spots on the skin. Let us, therefore, discriminate them with great care.
(1) Herpes Circinnatus has undoubtedly its annular shape in common with the analogous syphiloid, from which, however, it is distinguished by its fainter blush, whereas the color of the syphiloid is of a deep copper tint, and covers the whole spot, whereas in the simple herpes circinnatus the skin inside the ring preserves its natural whiteness.
(2) Ecthyma simplex is distinguished from the syphilitic ecthyma by the fact that the former only occurs among old people, has no succession of crops, only causes superficial ulceration, the skin between the pustules being neither wilted not dingy-looking; their cicatrices never are as round, pitted or deep as those of the syphilitic eczema.
(3) Impetigo simplex is readily confounded with the syphilitic impetigo, and vice versa. In the non-syphilitic impetigo the scurfs are never as green, as little raised, firmly adhering, and are never surrounded by as broad, copper-colored areolae as in the syphilitic form, nor is there any suppuration going on beneath the scurfs.
(4) Lichen simplex has a great deal in common with the syphilitic lichen; the vesicles of the non-syphilitic form are less elevated and more confluent, the skin preserving its natural somewhat rosy hue; the eruption is likewise attended with more or less itching; whereas the vesicles of the syphilitic lichen are of a copper color, raised, less confluent, of a peculiar lustre; they never ulcerate, as is sometimes the case with lichen agrius.
(5) Psoriasis, when appearing on the palms of the hands and soles of the feet, is almost always of a syphilitic kind, more particular if the spots are surrounded by a more or less copper- colored border.
(6) Pityriasis might mislead one by its more or less rounded, desquamating spots, specially if they have a reddish tint; nevertheless, with a little attention, the syphilitic form is easily distinguished by the absence of all pruritus, and by its brown copper-color, its more definitely rounded form, and the wilted, sallow appearance of the surrounding skin, from the well- known spots of the common pityriasis, which have mostly a yellow or vividly red color, and only show a very slight, scarcely perceptible mealy desquamation.
