Secale102. – Ecthyma Syphiliticum
This syphiloid is distinguished from the former by the longer size of its pustules, not unlike the pustules of the common non- syphilitic eczema. The eruption is formed by a rising of the epidermis, underneath which pus is secreted; at their base, the pimples are more or less hardened, and very soon are transformed into thick crusts, which, when falling off, leave depressed cicatrices. According as these ulcers are either superficial, or more deeply penetrating to the subjacent tissues, we distinguish a superficial and a deep-seated eczema. Each of these varieties again admits of different forms.
In the former of these two varieties, the superficial ecthyma, the pustules, though more voluminous than those of impetigo, are never larger than a dime; they are perfectly round, run to a point like a cone; are filled with a thick, yellow fluid, and surrounded by copper-colored areolae, without, however, any induration of their base. Offering but little resistance to the pressure of the finger, they generally break very easily, and very soon changes to brown, round, not very firmly adhering scurfs, with raised edges and a uniform thickness throughout, and always resting upon a very superficial ulcerated surface. These superficial pustules are generally scattered over large portions of the surface of the body, although they occur most frequently on the hairy scalp, yet they likewise show themselves in other localities, and even in several places at one and the same time. In most cases, they come out isolatedly, but they may likewise form clusters, in which case, the crusts arising from them are larger, thicker, not unlike the scurfs of the above-mentioned impetigo, from which they differ in this, that the scurfs of ecthyma are always perfectly round, not raised in the centre like a cone, but depressed and raised at the edges, not very firmly adhering to the skin, and never exceeding a common dime in size.
In the second form, the deeply-penetrating ecthyma, we have larger pustules of an oval form, which, when first breaking out, look like violet-red spots, soon become filled with a bloody pus and surrounded by bluish areola, around which the skin has a copper colored appearance. Where the epidermis ceases to be tense, a swelling is perceived which causes these pustules to appear somewhat flattened. If these pustules tear and gradually pour out their contents, this bloody matter finally forms a scurf that increases in size during the first days of its existence, but finally dries up more and more and almost resembles the scurf of a burn. This crust, which has the form of the original pustule, is thicker in its centre than that of the superficial ecthyma, and sometimes is even arched. If the crust is removed before it becomes detached of itself, a deep ulcer is seen with grayish, small granulations at the bottom, abruptly circumscribed edges, close to which a whitish border is raised above it, composed of remnants of the epidermis. If the crusts runs its course unimpeded, it dries up more and more, becomes pitted at the centre, shrinks, and, after falling off, leaves, like all other syphiloids, a round and more or less depressed scar behind, which retains for a long time the characteristic color. The pustules, in this form of the ecthyma, are rather scanty, five or six, scattered at large intervals from each other, and most frequently seen on the arms and legs.
Secale 103. – Lichen Syphiliticus, Venereal Itch
Syphilitic papules are hard, firm, full, little blotches, and solid to the feel; containing neither pus or any other serous fluid, irregularly scattered over large surfaces, and, in their totality, exhibiting the characteristic syphilitic color. They may break out on almost every part of the body, but are most generally observed on the extensor surface of the extremities; likewise on the back, shoulders, and nape of the neck, where they usually have the appearance of thin, small coniform, numerously- scattered pimples which may likewise occur in groups, but may likewise appear less numerous and of larger size, even of the size of a small split pea. Hence we distinguish two kind (a) the syphilitic rash, and (b) the syphilitic papules.
The former, more specially known under the name of lichen syphiliticus, or venereal itch, has very small, sometimes innumerable, pimples that almost run into each other, and show a sort of lustre, which, in addition to the copper color, imparts to them a very peculiar appearance. This form, specially when it breaks out in the second stage of the primary, during the presence of protopathic phenomena, may be attended with all the symptoms that generally precede common, non-syphilitic exanthema; such as headache, weariness and lameness of the limbs, and more or less fever. In this case the eruption is generally all over; not only on the back and extensor surface of the extremities, but likewise and more particularly, in the face and on the neck. If very acute, this form of eruption does not last longer than a fortnight; in a few days the pimples begin to decay, break up in fragments and disappear, leaving only short-lasting spots, but never any scars. Sometimes their breaking is followed by slight desquamation. This eruption does not always appear in an acute form, but, after the complete disappearance of all protopathic products, may likewise break out as a true secondary syphiloid, of indefinite more really chronic duration. It is only this chronic form that I have had an opportunity of witnessing.
The other papulous form of this eruption has larger and broader pimples, which mostly arising from small spots of a dirty-yellow color, are rounded, never appear in groups, but always singly, scattered over large surfaces, which they invade gradually, not all at once. Hence this eruption may be observed, in all its stages, on persons afflicted with it, at one and the same period; in one locality we may observe firm, raised, copper-colored papules, whereas in another locality they appear shrunk, soft and less red; and in other places we only see yellowish-red spots on the point of changing to papules; and still in other parts, spots of grayish color, and more depressed, being remnants of former papules; the skin between all these different appearances exhibits a vivid color. These larger papules are generally located on the extremities, shoulders, nape of the neck, specially on the forehead, where they form the so-called corona veneris. They always run a chronic course; like the former, they never change to ulcers, crusts, or scales, but frequently appear intermingled with other syphiloids, and not unfrequently simultaneously with ulcers in the throat, exostoses, etc.
Secale 104. – Tubercular Eruptions
This syphiloid generally assumes the form of small, firm, dense, raised blotches, resisting the pressing of the finger, and, like the papules, containing neither pus nor any serous fluid. These tubercles are somewhat raised above the skin, sometimes scattered, and sometimes less numerous and limited to small blotches; sometimes combined in more or less regular groups, and in other cases scattered over a large portion of the surface of the body. The same diversified appearance exist in regard to their form, size and general course. Some have scarcely the size of a pea, are round, shining, copper colored; others are broad, flattened, globular, round, or oval, and as if seated within the layers of the integuments; whereas in other cases they are raised a few lines above the skin, as if placed upon it. Some of them are smooth and even, scaly, and even ulcerated and covered with scurfs; in some patients the disappearance of the tubercles is followed by nothing but like grayish spots that gradually disappear, whereas in other cases they cause inextinguishable, uneven cicatrices. Some, finally, achieve their whole course, together with all the disorganizations of which such tubercles are capable, without extending beyond the boundaries of their original limits, destroying the integuments in their course. Moreover, they may attack every part of the body; their favorite localities, however, are the face, nose, ears, eyebrows, and hairy scalp; though they have been known to spread over the whole surface of the body. The same differences are perceived in regard to the course they pursue, as in regard to their form. At times appearing slowly and by degrees; at times suddenly and unexpectedly; they frequently announce their advent by a general sensation of malaise, or supervene in company with syphilitic affections of the mucous membranes and bones; and, in almost every case, their appearance is superinduced by some accidental circumstance, such as an emotion, fever, etc. Sometimes they are accompanied by a considerable swelling and painfulness of the affected parts; very frequently they remain perfectly indolent, without affecting the surrounding parts. In other respects they may remain unchanged for months; but, starting from a given point, be it dispersion or ulceration, they may either disappear in an incredibly short space of time, or they may cause the most terrible disorganization. In accordance with these different characteristics, Cazenave has enumerated the following five kinds of tubercular syphiloid eruptions: (a) grouping (b) scattered; (c) perforating; (d) serpiginous, and (e) flattened. We will examine them more closely in their order.
