Tubercular Syphilide

This variety, as its name implies, is an eruption consisting of tubercles, ranging in size from a pea to a hazel-nut. Their summits are usually covered with a few fine scales. They may ap-pear as an early or as a late manifestation. In the former case, they occur as isolated lesions disseminated over the surface; but when occurring later, they are frequently associated in circumscribed groups. The tubercles disappear by absorption or by ulceration, in either case leaving a brownish mark behind, and a more or less evident cicatrix as an ultimate condition. When they ulcerate they become covered with a greenish or greenish-black crust, underneath which lies the ulcer. This form of eruption is not infrequent, but is more commonly met with in cases of neg-lected syphilis, than in those which have received careful and appropriate early treatment. It is usually a late lesion.

Vesicular Syphilide

This is a rare lesion, belonging to the secondary period, and usually consists of moderate-sized vesicles, scattered irregularly over the surface, or collected in little groups. Each vesicle is surrounded by a coppery areola; they break in a few days, and are replaced by thin crusts or scales. When the crusts are removed the surface beneath them is brownish red. This form of eruption usually lasts several months, and is maintained during this period by successive crops of new vesicles. The lesion is quite superficial, not involving the skin very deeply, but generally leaves brownish macules, which take some time to fade away. Occasionally, small vesicles develop upon the summits of papules in connection with the early papular lesions.

Bullous Syphilide

This is an exceedingly rare lesion in adults, but is quite common as a manifestation of hereditary syphilis in infants. It consists of large vesicles or bullae appearing shortly after birth, whose favorite seat is the hands and feet, but they may also appear upon the trunk and limbs. It is the so-called syphilitic pemphigus of infants.

Pustular Syphilide

Pustules occurring in connection with syphilis present several varieties, as regards their aspect, course, and termination, and are among the most important of the cutaneous lesions met with in this disease. They occur under three principal forms.

The first consists of small pustules disseminated over the surface, frequently in great number. Each pustule is found to rest upon a hard and raised base, as if the upper half of a papule had changed into a pustule. A hair frequently runs through its centre. The course of these pustules is usually indolent; each one, after lasting two or three weeks, bursts, and its contents dry into thin greenish crusts which adhere for a week or two longer. Upon the falling or removal of the crusts we find a coppery papule with a depressed and perhaps ulcerated summit. The papule slowly disappears, leaving behind a brown macule, which in turn gives place to a minute white cicatrix. This form of eruption is the so-called syphilitic acne.

In the second variety we find the pustules larger than the foregoing, and without the raised base, and, as a rule, less numerous. They are surrounded with a tawny areola, without marked induration. The pustules soon break, and their contents dry in greenish or sometimes dark crusts; on the removal of the crusts superficial circular ulcerations will be discovered. These heal readily, but always leave cicatrices. The eruption may persist for several months, being prolonged by the occurrence of fresh pustules. It usually appears during the latter portion of the secondary period, and may occur upon any portion of the cutaneous surface, including the scalp. This form is the syphilitic ecthyma of authors.

A third variety of pustule is met with occurring in the tertiary stages of syphilis. They are large, isolated, and scattered over the surface, and vary in number from a single one to thirty or forty. These pustules contain a mixture of pus and sanious fluid, and soon dry into thick, dark-colored crusts, covering a deep ulcer. The ulcer gradually enlarges and continues to secrete an ichorous and unhealthy pus, which likewise dries into a crust having a greater diameter than the first one, which still adhering, it pushes before it. This process continues, new crusts form, pushing forward the earlier ones, until in time we have a stratified cone, half an inch or more in height, projecting from the surface, upon the removal of which, a deep ulcer with abrupt margins and an unhealthy base is perceived. If the progress of the eruption is unchecked, a fresh crust, pos-sessing the characters of the former, soon forms, the ulcer meanwhile steadily enlarging. This form of eruption is sometimes called rupia.

Squamous Syphilide

We have already noticed the fact that papular and tubercular lesions frequently exhibit scales in connection with them. In some cases this commingling of characters is so decided that it is hard to say which predominates, or even to recognize the pre-existing lesions. These mixed forms may, with propriety, be termed papulo- or tuberculo-squamous. In addition to these, however, we may have lesions which are decidedly scaly from the beginning. These true squamous syphilides consist of brownish red patches, covered with a thin coating of scales. The patches are usually rounded or annular, forming circles, or segments of circles, and are very slightly elevated above the surrounding surface. The scales which cover them are of moderate size, but not imbricated, and do not form very thick layers. Usually, they do not completely cover the coppery base, but permit a little rim of it to appear at the edge. The scaly syphilide may appear upon any portion of the surface, frequently invading the scalp. It may also occur upon the palm of the hand and sole of the foot.

Syphilis Of The Connective Tissues

The gumma is the lesion most frequently developed in the connective tissues. Its principal features have been already described.