Secale 93. Distinctive Characteristics of Syphiloid Eruptions.
So far we have indicated the diagnostic signs which characterize syphiloid eruptions whenever they show themselves; but circumstances may arise in consequence of which some of these signs become more or less obscured, and slight deviations from the main rule may take place. They may be owing to the age of the eruption, to its particular shape, and to the stage of development, when the physician is first consulted. In order to be sure of our diagnosis, it becomes indispensable that these differences, in the color, shape, and course, of the syphiloid, should be carefully considered; previously, however, we have to consider more particularly the different forms under which the syphilidae may appear. We have already stated that they may assume all the different forms of ordinary cutaneous diseases, from the simplest spots to the most hideous ulcers; on which account modern syphilographic writers have attempted to classify them in accordance with Willan’s and Bateman’s anatomical system as maculae, papulae, eczema, tubercles, etc. There could be no objection to such a classification, if these anatomical forms appeared in practice as rigorously delineated as they do in books, and did not occur more or less mixed, specially the higher, more perfectly developed forms; or, in other words, if several syphilidae did not appear upon the skin at one and the same time. Far from constituting as many idiopathic syphilitic diseases as they adopt various anatomical forms, these pretended varieties of syphiloid eruptions are in reality nothing but diversified manifestations of one and the same cutaneous action of the syphilitic disease, originating in a variety of unknown, accidental circumstances, or perhaps in different degrees of an inherent tendency towards outward growth: the differences being simply apparent, of an external nature, not, by any means, founded in any essential distinction. This classification has this great and sole advantage, to place before us a lucid and compact view of all the forms of cutaneous syphilis, and greatly to facilitate a correct appreciation of these forms in all possible cases. Viewed from this point of view, such a systematic arrangement, being a classification of the different symptoms of one and the same malady, has indeed a real value. Accepting this classification in this light, and in no other, we propose in the following chapters to consider the different syphilidae, so far as may be necessary for a correct diagnosis of these affections, under the following categories: (1) Maculae (2) eczema (3) pemphigus; (4) pustulous (5) papulous (6) scaly and (7) tuberculoid forms.
II. THE DIFFERENT FORMS OF SYPHILITIC ERUPTIONS.
Secale 94. Maculae.
The form which is described under the name of syphilitic roseola, consists of irregular, circular, more or less confluent, measle-shaped spots, raised but little above the skin; at first of a copper color, after a while changing to a yellowish red-gray appearance, and but slowly, and finally only imperfectly paling under the pressure of the finger. The outbreak of the spots is sometimes preceded by, and sometimes attended with, fever and a general feeling of indisposition. They run a chronic course, sometimes disappearing after a while spontaneously, either by scattering or after a bran-like desquamation, but always without ulceration or cicatrization; however, after disappearing in one locality, they are very apt to re-appear in another. They are generally located on the neck, in the posterior cervical region on the shoulders, breast, upper extremities, very frequently in the face, and sometimes around the sexual organs and on the inner surface of the thighs. Very frequently these spots break out during the second stage of the primary period, after the chancre has passed into the stage of fungoid growth; and it is at this period that their breaking out is attended with a general malaise, a feeling of weariness and lameness, headache, and pains in all the limbs. Sometimes these accessory affections are associated with pain in the throat, violet-redness of the mucous membrane of the mouth, the velum palati, and fauces, together with great dryness of the affected parts, and unusual sensation of heat and difficulty of deglutition; even superficial ulcers in the throat may be seen in some cases. This measle-shaped eruption may remain unchanged for days in the same locality; at times only its peculiar red color may seem more intense without ever being accompanied by pruritus or a feeling of heat. After a while this redness changes more and more to a light-brown, and afterwards to a gray color, until finally it becomes so imperceptible that it can only be seen when the parts are held against the light, when the skin has the appearance of being dirty and might easily be cleansed. This tint may remain unchanged for months, and even years; only in cold weather, and after washing, the color may sometimes become more marked.
Beside these smooth maculae, others describe a papulous redness (erythema papulosum). This eruption is distinguished from the former by its small spots, at most of the size of a dime, not very red, papulous, and supposed to break out only subsequent to gonorrhoea. But inasmuch as the first observer of this eruption, Dr. Cazenave of Paris, admits that he has only seen it on persons who had suppressed their gonorrhoea with large doses of Copaiva, and it is a well-known fact that Copaiva produces such an eruption, it is questionable whether this is justly chargeable to the disease, or ought not rather to be attributed to the action of the Copaiva. I have seen this eruption a number of times on individuals who had been dosing themselves with large quantities of Copaiva for gonorrhoea; but I have never seen it after gonorrhoea for which no Copaiva had been taken, notwithstanding that there has not been a week for the last ten years when two or three new cases of gonorrhoea have not presented themselves for treatment in my office, from every condition and class of society.
Secale 95. Syphilitic Eczema.
(2) a. This eruption, which, until recently, has been described only by Dr. Cazenave, according to some is very rare; according to others, on the contrary, occurs much more frequently, and remains unnoticed by most physicians for no other reason than because every vesicle is not surrounded by the characteristic bronze-colored areola, which is improperly regarded by many as the sole truly diagnostic signs of syphilitic eruptions. For a long time it has likewise been my opinion that this eczema had been seen only here and there by some of our hospital-physicians, until I met with a suspicious looking eruption in one of our homoeopathic dispensaries. The spots were more or less rounded, scattered over the thighs, pubes, abdomen, chest, and upper arm, some of them of the size of a hand, some of the size of a dime. They were covered with little vesicles, did not cause the least itching, but did not seem to be of a syphilitic character, for the reason that the copper or bronze redness was wanting, and the spots had a dirty pale-yellow look. The history of the case, however, and the still-existing primary phenomena of the second stage on the sexual organs, showed that this eruption might very properly be classed among the syphiloids. My attention having been once excited by this case, I did not fail afterwards to notice other similar cases. According to Cazenave this category not only comprehends the syphilitic eczema, but likewise the so- called syphilitic pustules and a sort of syphilitic vesicular herpes. These two last-named forms, however, will be described more minutely each in a separate paragraph; in this paragraph we confine ourselves to the syphilitic eczema. This syphiloid consists of small, transparent vesicles showing themselves in irregular, scattered groups more prominently than the common eczema, each of which vesicles, if examined through a glass, will be found surrounded with a red areola; sometimes the whole spot upon which they are seated, exhibits a faint redness, in which case the vesicles are somewhat larger, and feel harder and denser. They always persevere for a long time in the same condition; the fluid which they contain, remains transparent, scarcely ever becoming turbid; at last the vesicles appear wilted and shrivelled, the areola, or the whole spot upon which the group is located, becomes fainter, exhibiting a grayish tint, the raised epidermis becomes depressed, and in the place of the vesicle there remains nothing but a slight desquamation of the skin with a border that is generally more blanched than the original site of the vesicle. In some cases the eczema appears somewhat altered, in consequence of the vesicles becoming lacerated by the friction of the clothes, after which they appear covered with small, furrowed, lacerated crusts, of a tolerable degree of density, which are formed out of the sero-purulent fluid of several vesicles, among which ulcers are never found. In this case the specific copper-redness is more marked, and the whole eruption, whose true pathological nature can no longer be doubted, exhibits a mingling of the above-described original vesicles and crusts scattered here and there. In other cases the eruption may assume the forms of impetigo, when spots of different sizes, of a tolerably vivid redness and covered with vesicles, are seen; there vesicles, which are at first transparent, and afterwards become turbid and filled with a purulent serum, are soon replaced by crusts, and finally cicatrize at the same time that new vesicles start up, so that here, likewise, the different stages of the syphiloid may be witnessed at one and the same time. These crusts are much thicker than those of non-syphilitic impetigo, and like other syphilitic crusts, look black, coniform, furrowed, in superincumbent layers and firmly adhering; in a few rare cases, these crusts hide cup- shaped ulcers, which always leave a depressed cicatrix that remains visible for a long time. This syphiloid occurs very frequently during the existence of chancre or buboes.
