Secale 96. Syphilitic Herpes.
This form is not very rare; it is even more frequent than many suppose, but is more apt to be misjudged than any other syphiloid eruption, so much the more easily as it resembles herpes circinnatus. This syphilitic herpes generally breaks out in round, ring-shaped, elevated spots, of the size of a three-cent piece to that of a dime, and is distinguished from the non- syphilitic herpes circinnatus by the well-known syphilitic color, which from a copper-colored hue afterwards passes into the yellowish gray or pale brownish-gray tint. This form never terminated in ulceration, and hence never makes any scars. Usually this herpes is not very numerous; it seldom breaks out more than two or three at a time; the tettery spots are generally very distinct from each other, frequently breaking out simultaneously on opposite sides, for instance on the neck and thighs, etc. These herpetic eruptions seldom break out alone, but almost always mingled with other syphiloids, on which account it may be comparatively easier to diagnose them correctly.
Beside the herpes, there is another variety that might be designated as herpes furfuraceus or bran-shaped herpes; this variety is scarcely ever properly diagnosed being confounded either with the common non-syphilitic eczema, or with pityriasis. Like the simple squamous herpes circinnatus, the syphilitic herpes circinnatus like wise appears in the shape of extremely small, numerous scales, which generally are chiefly spread over the breast and extremities, and which, always perfectly circular, are at first no bigger than a pea, but may increase in size to that of a dime. The vesicles covering the herpes have very thin membranes, and shrink away so rapidly that there is scarcely time left for observation, so that these spots might be mistaken for pityriasis, if a closer inspection with a glass, during the first period of their existence, did not reveal on their border a multitude of small little points arranged in circles and surrounded by remnants of epidermis, which points remain until they coalesce in one general border that is more specially perceptible when the rings are of a larger size. The centre of this herpes is generally inflamed, and looks as if it had become raised by a rapidly absorbed and dried-up fluid, having become the seat of small scale which is sometimes sufficiently large to cover the whole surface of the herpes. This herpes which is distinguished from ordinary pityriasis only by its marked copper- color, as well as by its almost horny central scale, which resembles the scales of psoriasis, is one of the most frequently- occurring vesicular syphiloids, frequently mingled with other eruptions and even accompanied by bone-pains. It may likewise break out in various localities, even on the glans, where I have seen it, as a genuinely secondary symptom, show itself subsequent to the cure of a chancre which was effected years ago without a trace of a scar remaining behind. Hofrichter’s case (Allium hom. Zeit., 35, p. 135), of small brown spots at the anus, of the size of small split peas, which were accompanied by tubercles and disappeared after the detaching of small particles of epidermis, most likely belongs to this category, and, likewise, the spots described by Rummel (Allium hom. Zeit., vol. 18, p. 292), and resembling psoriasis, of which Rummel observes that they occur quite frequently in Magdeburg. This would seem to confirm my suspicion that the syphiloid in question is not so very rare, only it remains unnoticed in most cases.
Secale 97. Varicella Syphilitiea
This from exhibits tolerably large, transparent vesicles, which afterwards become torpid, and may either scatter or terminate in the formation of a blackish crust surrounded by a red areola. Generally for some time after the crust has become detached, the affected locality continues to exhibit a dirty-gray color. Very often, their breaking out is preceded for two or three days by a general feeling of malaise, with a sensation of weariness and lameness in the limbs and even febrile symptoms, after which the surface of the body becomes covered, either in isolated places, or successively all over with spots of a moderately vivid redness, which very speedily become raised throughout their whole extent and filled with a transparent fluid, so that little by little the whole crowd of these spots seems transformed into vesicles surrounded with a copper-colored areola which is in all respects like the areola of the original macula. These vesicles are circular, globular, prominent, and of different sizes, from that of a pin’s-head to the size of a pea, and even much larger. The spreading of the varicella takes place very slowly, not only with respect to the general spreading of the eruption, which is very gradual, but likewise with respect to the development of each single vesicle. Such a vesicle may sometimes remain unchanged for a whole week, on which account the eruption, after a certain period, may acquire a very peculiar appearance. We may see for instance, on the one hand, fresh, well-rounded, elastic, transparent, perceptibly raised vesicles, surrounded by not very dark, but perceptibly copper-colored areola; whereas on the other hand, older vesicles are seen by the side of the former, that have already become depressed, are rather broad than projecting, and only contain a small portion of the re-absorbed fluid; others again, though flattened, are thick and hard to the feel, and, contain a turbid fluid; whereas another set has become converted into thick, blackish crusts. All of them, however, exhibit in all their stages the specific color which marks all syphilitic products, although this color runs into a variety of tints, all of which, however, betray by their characteristic appearance the original color from which they spring. When first arising, for instance, the vesicles occupy the whole of the original spot, whose redness disappears entirely, but soon reappears again in the shape of a red areola by which the vesicle is surrounded. At first this areola has a coppery color, which vanishes away in the dirty, yellowish-brown, gray tint left behind by the vesicles, after its disappearance, so that these dirty-gray spots are much broader than the original vesicles. If this syphiloid is carefully examined and contrasted with the eruption which, according to some authors, constituted the first manifestation of syphilis, in the shape of a general protopathic cutaneous disease described as Variola venerea, it would seem as though the form of varicella, which we have just now delineated might be the first and true, though very badly degenerated, type of the whole disease. This syphiloid is frequently seen accompanied by angina syphilitica, or even by exostoses and bone pains.
Secale 98. Pemphigus Syphiliticus Rhypia.
This occurs in two distinctive forms; (a) as syphilitic pemphigus, and (b) as rhypia or rupia. The former of these forms, which is described in our books as pemphigus of new-born infants, has so far been only met with among this class, without the syphilitic nature of this disease having ever been suspected, until Professor Dubois of Paris demonstrated it by the most incontrovertible testimony. This pemphigus always shows itself in the form of several blisters in the palms of the hands, or on the soles of the feet, of the size, of a hazelnut, and generally broad, flat, not very extensive, regularly rounded, filled with a sero-purulent fluid, and surrounded by a copper or violet-colored areola. Sometimes, though rarely, this fluid dried up, forming a blackish-brown crust; in the majority of instances the bulla hursts, the fluids runs out, and the bulla ulcerates, which never happens with the non-syphilitic pemphigus. The syphilitic pemphigus is generally present already when the infant is born, or develops itself at any rate shortly after birth. It seems remarkable that this syphiloid should never be accompanied by any of the ordinary phenomena of secondary syphilis, as happens to so many other syphiloids; nor that the skin of these new-born infants should never exhibit the dryness and shrivelled appearance with authors consider as a diagnostic sign of congenital syphilis and which imparts to these infants the well- known appearance of old age. Wherever this form has been seen, the mother was either still affected with syphilis, or had had the disease at some former period. Up to the present time, as has already been stated, this pemphigus has only been noticed among infants, where it is not by any means a very rare occurrence.
The other form, known as syphilitic rupia, is somewhat less frequent. It consists of broad, flattened, not very full bullae, surrounded by areolae of a deep copper-color, and containing a blackish fluid which speedily dries up and becomes converted into a blackish crust whose centre is thicker than the circumference, forming, by this means, a cone which is considerably raised above the epidermis. The surrounding areola deepens in proportion as the crust is older; not infrequently an ulcer forms, which dips down to the subjacent textures sufficiently to be designated as a true ulcus consecutivum, round the crust, by which means the elevation of the crust over the skin becomes still more prominent; this is more particularly the case when the ulcer is somewhat advanced in age. The number of these bullae varies; at all events it is larger than in pemphigus, though even in the form of rupia they do not exceed fifteen to twenty in number. If with the larger bullae smaller ones are associated, these may become renewed several times, whereas the larger ones remain; these it is that may be changed to ulcers. If these bullae cover the whole body, as is sometimes, though rarely, the case, they are generally of the same size, and the eruption might easily be mistaken for ecthyma, from which it is almost only distinguished by its broader, more superficial bullae, by their coniform crust, and by the fact that the bullae continue to appear in successive numbers even while the process of ulceration is still going on in other localities. The course of rupia is always very slow; if the ulcers disappear, they always leave, without an exception, round scars which still retain for a long time their characteristic peculiarities.
