Secale99. – Syphilitic Pustules.
All syphilitic pustules have this in common, that they may break out in all parts of the body, and that they are frequently accompanied by the worst secondary phenomena, such as secondary chancres, exostoses, bone pains etc., or that they have become evolved with other syphilidae as a final consummation. According to Cazenave, they may break out as a truly protopathic product immediately after infection has taken place. But the case upon which he bases his opinion was an infection, not contracted by sexual connection, but by innoculation. The victim was a physician with a sore finger, who assisted to woman who had a chancre, in confinement. Two or three months after infection, red spots broke out, followed by numerous pustules on the lower and upper extremities, shoulders, and head, which were at first mistaken for varioloid, but afterwards revealed their syphilitic character by chancrous ulcers, whose aspect reminded one of the descriptions of syphilis from the times when syphilis was an epidemic disease. Be this as it may, it our day these pustules, if we except inoculation by the skin, do no longer occur as protopathic products of impure connection. Upon examining such cases as Cazenave’s more closely, we shall see that, where inocculation results in the formation of pustules, the ulcers arising from them, in which the original characteristics of chancre are found slightly altered in form, not in essence, nevertheless exhibit essential differences from the syphilitic pustules, notwithstanding all their apparent similarity with this syphiloid. He who, after the fashion of Willian, deems the anatomical form equivalent to the essence of the eruption, and from analogous form infers an identity of pathological essence, may readily be induced to conclude that protopathic chancres, if occurring in different forms, may not only be represented by protopathically appearing pustules as products in all respects identical with chancre, but likewise by any form of syphiloid ulcers. Admitting that the ulcers in Cazenave’s case were not a pustulous, syphiloid, but true chancres, we shall insist upon our proportion; that all pustulous, ulcerated eruptions, which have been observed hitherto, never have been protopathic products, but can never have been any thing else than secondary eruptions. In the following paragraphs, we shall see, from a description of each particularly form of these syphilitic pustules, in how far they are essentially distinguished from chancres by their course, and even by their frequently spontaneous disappearance, after having run through all their different stages, not to mention other distinctive signs, which every attentive reader can readily discover for himself. The best descriptions of these eruptions has been given by Cazenave. But it is not only by this description that he has facilitated the diagnosis of this syphiloid, and its distinction from other similar non-syphilitic eruptions, but by rigidly arranging this syphiloid in accordance with its external forms, which had hitherto been imperfectly and obscurely described by authors under the common name of syphilitic pustules, under three distinct heads; (a) Acne syphilitica; (b) Impetigo syphilitica; and (c) Ecthyma syphiliticum. Let us adopt this arrangement in considering each of these forms.
Secale100 – Acne Syphilitica.
This is the most frequent of all the pustulous forms of syphilis, and is more frequently overlooked than any other. It always occurs in the shape of isolated, scattered pimples of the size of a small lentil, that are irregularly scattered over various portions of the surface of the body, not very prominent, but of characteristic color, suppurating more or less imperfectly, and finally changing to crusts that are smaller than the original pimples. This acne may affect every part of the body, the face, back, chest, and extremities, but assumes a somewhat different from according as it breaks out in one place or another. In the face, on the chest and back, it resembles most generally the common non-syphilitic acne; the pimples are rather large, prominent, and rounded, one half of a pimple being in a state of suppuration; they are usually covered with a small, more or less thick scurf, which, after it falls off, leaves a rather broad and depressed scar, often resting for a long time upon a tubercular base. On the limbs, these pimples are flat, specially at their base, which is broader, and not so round, and surrounded by a rather deep copper redness. The pimples themselves first have the shape of not very much elevated and sometimes painful spots of the size of small split peas; afterwards their centre becomes raised, after which a small collection of pus is perceived at its point, which disappears in two or three days, either in consequence of being absorbed, or the point behind accidentally lacerated; or else it may become converted into a small, not very firmly adhering scurf. In this condition, the pimple forms a small papulous, copper-red elevation, offering but a slight resistance to the pressure of the finger, and showing a small depressed cicatrix at its point; sometimes the centre is perforated and surrounded for some time by remnants of epidermis. The longer this eruption lasts, the more it loses its pustulous form, and approximates the form of papules, for which it might easily be mistaken. Here, too, as in most other syphilitic eruptions, successive crops of new pimples make their appearance while the old ones are still running their course, so that these different and simultaneously occurring formations offer great facilities for studying the whole course of the eruption; though, after all, in spite of the great importance which Cazenave seems to attach to it, it matters very little whether this form is considered as of the pustulous or papulous variety, provided we are sure that it is a syphilitic disease. In this respect, it frequently happens that this acne is confounded with eruptions of an entirely different kind, even with the itch, more particularly if the pimples are scattered in great numbers over the extremities. I have met with a case where the flexor-surface of both arms were covered with these pimples, and where the nocturnal itching of which the patient, a very unclean woman, complained, and which was caused by vermin, made me doubt for a while the true nature of the disease, until I administered a dose of Mercurius 12, after which the pimples rapidly disappeared, leaving only spots of the characteristic, unmistakable syphilitic color. This acne always runs a chronic course; its pimples, which are always isolated, nerve terminate in ulceration; their base almost always becomes indurated, until gradually the whole disappears, leaving only a small scar, which remains forever.
Secale101. – Impetigo syphilitica.
This syphiloid may present itself in two different forms, according as the pustules either remain isolated or become confluent. In the former variety, the tolerably large pustules remain isolated, or, if they become confluent, it is mostly by accident, and never more than two or three at a time. When first appearing, they look like copper-colored spots of a tolerably vivid redness, the epidermis on which becomes raised in its whole extent, without showing a hardened base. When perfectly formed, they are small, soft, rather closely congregated pimples, filled with a purulent fluid, are surrounded by a red border; as to the characteristic copper color, however, it is confined to the portions of skin between the pimples rather than to a definitely circumscribed areola around each pustule, the color of which areola at first even is very faint, but becomes more distinct in proportion as the pustules are more completely formed. The first appearance of this impetigo is very frequently preceded by a general feeling of malaise and of weariness and lameness in the limbs; the eruption may, moreover, spread over a more or less extensive surface. It is most usually seen on the abdomen, nates, and on the inner surface of the thighs, less frequently on the upper extremities, and still less frequently on the face. If once fully formed, these pustules, unless they are accidentally lacerated, may remain for several days at the same point of development; in every case, however, the purulent fluid which they contain coagulates, resulting in the formation of a small, brownish scurf, which is broader than the original pustules increase in size, the purulent fluid becomes more copious, and raises the epidermis in a larger circumstance, in which case, several of these pustules approximate and run together under one crust, beneath which an ulcer may form which, although not very deep, may leave a cicatrix, that is larger and more depressed than the cicatrix formed by an isolated pustule.
The second or confluent form of this impetigo, which, in reality, is nothing more than a pustulous eruption setting in at the very commencement with an increased pathological activity, is, in every respect, more virulent. The confluent pustules, by their union, cause a suppuration which, although superficial, results in the formation of broad and more or less scattered cicatrices. This form is not often seen on the the lower limbs, but more specially on the chest, neck, and, which is much more worse in the face and on the forehead. This form, likewise is preceded by a general feeling of malaise, attended with more or less marked febrile motions; after which, the eruption itself is ushered in with a more or less vivid redness and swelling of the parts, upon which small pustules soon break out, and run into each other the more rapidly the more inflamed they are at their base, soon after forming broad scurfs, surrounded by copper- colored areolae, whose crusts are unequal, raised, greenish, soft to the feel and arched at their centre, deeply adhering to the surrounding skin, and betraying, by their very sight, the existence of a subjacent ulcerated surface, which, after the scurfs have fallen off, is found transformed into more or less disfigured cicatrices. This syphiloid may break out in the several localities at once; if once formed, it does not spread further, like serpiginous tubercles, for instance, but remains located where the original redness had first made its appearance.
