(7) Among the various cutaneous spots, it is particularly the liver-spots (ephelides hepaticae), and the spots in the faces of pregnant females, that may give rise to mistakes, and may induce a careless observer to diagnose a syphilitic affection, more specially since syphilitic and non-syphilitic spots frequently appear mixed up together. If these cases, in order to avoid mistakes, it may perhaps be sufficient to remember that all syphilitic spots, in this affection more perhaps than in any other syphilitic forms, are distinguished by their well known copper or brown-gray color, and their sharply circumscribed, round shape.
Secale 120. – continuation of the preceding Subject.
A FEW OTHER CHRONIC CUTANEOUS AFFECTIONS. – Besides the non- cutaneous affections mentioned in the preceding paragraphs, we still have (1) Eczema (eczema rubrum); (2) Scabies (itch); (3) Mercurial eruptions; (4) Lepra; and (5) the Elephantiasis of the Greeks; these eruptive diseases likewise deserve a more particular consideration, in order that they may not be confounded with analogous syphiloid exanthemata.
(1) Eczema, which a superficial inspection might lead one to diagnose as a simple eruption, where, on the contrary, we have a syphilitic exanthem before us, is distinguished from the latter by its much smaller, more numerous, and more confluent vesicles, by the pruritus with which it is always attended, and by its very frequently fiery red color; whereas the syphilitic eczema shows larger, less numerous, less frequently confluent and never- itching vesicles, which are, moreover, surrounded by copper- colored areolae. As regards the eczema impetiginosum, the syphilitic form which corresponds to it always exhibits besides its peculiar black crusts, ulcers and cicatrices, such as they never appear in the non-syphilitic variety.
(2) Scabies, with which a syphilitic affection has very frequently been confounded, is easily recognized, even if no acorns should be found by the microscope, by the nocturnal itching which no syphiloid, eruption has in the same degree; if the itch is mingled with syphiloids, the latter readily distinguish themselves from the itch-pustules as heterogeneous phenomena.
(3) Mercurial eruptions, which may not only take the form of vesicles, papules, and small tubercles, but upon the hairy scalp may break out in tolerably large ulcers, and form a sort of dark- brown crusts, resembling in color very nearly the syphilitic crusts, are distinguished from the latter both at their origin as well as during the period of desiccation, by the almost voluptuous itching by which invites the patient to scratch them open; and likewise by the fact, that they always appear singly, and never leave the characteristic cicatrices of syphiloid exanthems behind them. The surface of these mercurial ulcers, which are never very deep, looks as if it had been corroded by insects, of like a honey-comb, full of the fine perforations.
(4) Lepra is distinguished from its analogous syphiloid, for which it is often mistaken, by its border, which is not, as in the analogous syphiloid form, formed by a ring tubercles, with occasional interruptions, but by an interrupted circle, having a blackish rather than a copper-colored hue, and always detaching numerous scales, sometimes in such large quantities that a whole handful may be picked up in the patient’s bed, whereas in syphilitic lepra these scales are not very numerous, and frequently scarcely perceptible.
The elephantiasis of the Greeks (lepra ulcerosa), has likewise been confounded with syphiloid exanthems, although its tubercles never show the hardness of syphiloid tubercles, but consist of small, livid, soft, doughty and unequal swellings, which are frequently accompanied by a characteristic insensibility of the skin, and a horrid-looking hypertrophy of the affected limb; its ulcers resemble lupus rather than ulcerous syphiloid exanthems. Only at the commencement of the disease, when, as is well known, elephantiasis commences with the breaking out of spots, it may be possible to confound it with syphilitic spots, but scarcely even then, provided we remember that the skin, in the spots of elephantiasis, is perfectly insensible.
VI. PROGNOSIS AND TREATMENT OF SYPHILIDAE.
Secale 121.– Prognosis.
Rigorously speaking, the prognosis of these exanthems is the same as that of syphilis itself; where this is cured, the syphilidae will likewise disappear;, where syphilis is not cured, the prognosis of the syphilidae is neither more nor less favorable than that of chancre, bubo, mucous tubercles, and fig- warts, with or without gonorrhoea. Respecting syphilidae, the prognosis is in so far more dubious, as the existence of these exanthems implies a more or less general infection of the constitution with the syphilitic disease, and hence an increased difficulty of removing the eruption. So far as their dangerous character is concerned, not all syphiloids are of the same importance, since some of them seem tom be more transitory in their course, and almost disappear without leaving a vestige behind, where as others prove exceedingly inveterate, and cause the most horrid disorganizations of the face and other parts. Viewed in this light, the exanthematic, and perhaps also the papulous form, are the mildest exanthems, since they not only cause no pain, but do not leave a trace behind them. The squamous syphiloids, likewise, are not very dangerous in themselves. Notwithstanding they may sometimes spread over a large extent, and notwithstanding the occasional hardness of their scales, they never cause any destruction in the integuments, and never leave cicatrices, but always terminate in spots that never leave a vestige of disease behind. More or less dangerous are pemphigus and rhypia, not only because they always leave deep, disfiguring, and indestructible cicatrices, but likewise because they always show that the syphilitic poison has already begun to taint the very foundations of the constitution. Under certain circumstances, the vesicular from, and more specially the syphilitic impetigo, may become dangerous disorders, not only on account of their obstinate character, but likewise on account of the bone pains with which they are attended, and on account of the irregular, disfiguring cicatrices, which they leave behind. Among the pustulous exanthems, the syphilitic acne and there non-confluent eczema are not very dangerous, leaving only inconsiderable cicatrices; whereas the confluent eczema and the ecthyma constitute some of the worst forms of syphiloid exanthems, the former occasioning very extensive disfiguring cicatrices, more particularly in the face, in which respect it is in no degree behind the ecthyma, although, as a rule, it is less obstinate than the latter. The worst forms of any are, without contradiction, the tubercular, not only because their presence always implies a thorough poisoning of the organic tissues by the syphilitic virus, but likewise on account of the enormous destructions which their termination in ulceration, specially in the face, that seems to be their favorite site, may cause, leaving the most horrible cicatrices and disfigurements, which, in spite of a perfect eradication of the poison, remain unchanged during the whole life-time of the patient. However, it is not so much by the individual conduct of each single syphiloid, but, above, all, by the inclination of all syphiloids to break out afresh, and by the number, form, and locality of the accompanying ailments, that the amount of danger to the patient is to be determined, who may sink from misery, until finally death releases him from his sufferings. Death, however, is never the direct consequence of syphiloid exanthems, but is always superinduced by the destructive workings of cachexia depending upon the action of the syphilitic poison in the tissues of the organism. Viewing the matter from this point, the general prognosis of syphiloids will be found to depend: (1) upon the number of the existing syphiloids, and upon the frequency of their return: (2) upon the number, from, a nd locality of the simultaneously-occurring ulterior, secondary symptoms; (3) upon the more or less rational method of treatment of the original primary symptoms; and, (4) upon the constitutional condition of the patient generally.
Secale 122.–Treatment of Syphilidae.
It seems scarcely necessary to premise that the treatment should coincide perfectly with that of syphilis generally; all, therefore, that may be required at our hands, is to indicate the remedial agents that seem best adapted to these forms of the syphilitic disease. In this respect we have to observe, in the first place, that so far as the selection of a remedy is concerned, it makes very little difference to what dermatological form the syphiloid before us belongs; whether exanthematic, papulous or vesicular, pustulous, squamous or tubercular; the question will be more particularly under that what circumstances and conditions the syphiloid has become developed. In this direction, we have to consider three dealing points that should guide us in the selection of a remedy: (1) the manner in which the patient had been treated heretofore, whether with or without mercurial preparations; (2) the accessory, primary, or secondary ailments accompanying the syphiloid; and (3) the character of the prognosis as determined by the nature of the syphiloid itself; whether the exanthem is transitory, and may finally disappear without a vestige remaining, or whether it is inveterate and destructive.
