The _small ac.u.minated-pustular syphiloderm_ (_miliary pustular syphiloderm_) is an early or late secondary eruption, commonly encountered in the first six or eight months of the disease. It consists of a more or less generalized, disseminated or grouped, millet-seed-sized, ac.u.minated pustules, usually seated upon dull-red, papular elevations. The eruption is, as a rule, profuse, and usually involves the hair-follicles. The pustules dry to crusts, which fall off and are often followed by a slight, fringe-like exfoliation around the base, const.i.tuting a grayish ring or collar. Minute pin-point atrophic depressions or stains are left, which gradually become less distinct.

Scattered large pustules, and sometimes papules, are not infrequently present.

Describe the large ac.u.minated-pustular eruption of syphilis.

The _large ac.u.minated-pustular syphiloderm_ (_acne-form syphiloderm_, _variola-form syphiloderm_) is a more or less generalized eruption, occurring usually in the first six or eight months of the disease. It consists of small or large pea-sized, disseminated or grouped, ac.u.minated or rounded pustules, resembling the lesions of acne and variola. They develop slowly or rapidly, and at first may appear more or less papular. They dry to somewhat thick crusts, and are seated upon superficially ulcerated bases.

It pursues, as a rule, a comparatively rapid and benign course. In relapses the eruption is usually more or less localized.

How would you distinguish the large ac.u.minated-pustular syphiloderm from acne and variola?

In acne the usual limitation of the lesions to the face or face and shoulders, the origin, more rapid formation and evolution of the individual lesions, and the chronic character of the disease, are usually distinctive points.

In variola, the intensity of the general symptoms, the shot-like beginning of the lesions, their course, the umbilication, and the definite duration, are to be considered.

The presence or absence of other symptoms of syphilis has, in obscure cases, an important diagnostic bearing.

Describe the small flat-pustular eruption of syphilis.

The _small flat-pustular syphiloderm_ (_impetigo-form syphiloderm_) consists of a more or less generalized, pea-sized, flat or raised, discrete, irregularly-grouped, or in places confluent, pustules, appearing usually in the first year of the disease. The pustules dry rapidly to yellow, greenish-yellow, or brownish, more or less adherent, thick, uneven, somewhat granular crusts, beneath which there may be superficial or deep ulceration; where the lesions are confluent a continuous sheet of crusting forms. The eruption is often scanty. It is most frequently observed about the nose, mouth, hairy parts of the face and scalp, and about the genitalia, frequently in a.s.sociation with papules on other parts.

Are you likely to mistake the small flat-pustular syphiloderm for any other eruption?

Scarcely; but when upon the scalp, it may bear rough resemblance to pustular eczema, but the erosion or ulceration will serve to differentiate. Moreover, concomitant symptoms of syphilis are to be looked for.

Describe the large flat-pustular eruption of syphilis.

The _large flat-pustular syphiloderm_ (_ecthyma-form syphiloderm_) consists of a more or less generalized, scattered eruption, of large pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases of the lesions are a deep-red or copper color. Two types of the eruption are met with.

In one type--the superficial variety--the crust is flat, rounded or ovalish, of a yellowish-brown or dark-brown color, and seated upon a superficial erosion or ulcer. The lesions are usually numerous, and most abundant on the back, shoulders and extremities. It appears, as a rule, within the first year, and generally runs a benign course.

[Ill.u.s.tration: Fig. 55. Rupia. (_After Tilbury Fox._)]

In the other type--the deep variety--the crust is greenish or blackish, is raised and more bulky, often conical and stratified, like an oyster sh.e.l.l--_rupia_; beneath the crusts may be seen rounded or irregular-shaped ulcers, having a greenish-yellow, puriform secretion.

It is usually a late and malignant manifestation.

How would you differentiate the large flat-pustular syphiloderm from ecthyma?

The syphilitic lesions are more numerous, are scattered, are attended with superficial or deep ulceration, and followed by more or less scar-formation. Moreover, the history, and presence or absence of other symptoms of syphilis have an important diagnostic value.

[Ill.u.s.tration: Fig. 56. Ulcerating Tubercular Syphiloderm.]

Describe the bullous eruption of syphilis.

The _bullous syphiloderm_, (of acquired syphilis) is a rare and usually late eruption, appearing in the form of discrete, disseminated, rounded or ovalish, pea- to walnut-sized, partially or fully distended, blebs.

The serous contents soon become cloudy and puriform. In some cases the lesions are distinctly pustular from the beginning. The crust, which soon forms, is of a yellowish-brown or dark green color, and may be thick and stratified (_rupia_), as in the deep variety of the large flat-pustular syphiloderm. The erosions or ulcers beneath the crusts secrete a greenish-yellow fluid. It is a malignant type of eruption, and is usually seen in broken-down subjects.

It is not an uncommon manifestation of hereditary syphilis (_q. v._) in the newborn.

[Ill.u.s.tration: Fig. 57. Tubercular Syphiloderm.]

How is the bullous syphiloderm to be differentiated from other pemphigoid eruptions?

By the gravity of the disease, the accompanying ulceration, the course and history; and by other evidences, past or present, of syphilis.

Describe the tubercular eruption of syphilis.

The _tubercular syphiloderm_ (_syphiloderma tuberculosum_) may exceptionally occur within the first year as a more or less generalized eruption. As a rule, however, it is a late manifestation, at times appearing many years after the initial lesion; is limited in extent, and shows a decided tendency to occur in groups, often forming segments of circles and circular areas, clearing in the centre and spreading peripherally.

It consists (as a late, limited manifestation) of several or more firm, circ.u.mscribed, deeply-seated, smooth, glistening or slightly scaly elevations; rounded or ac.u.minated in shape, of a yellowish-red, brownish-red or coppery color and usually of the size of small or large peas. Several groups may coalesce, and a serpiginous tract result (_serpiginous tubercular syphiloderm_). The lesions develop slowly, and are sluggish in their course, remaining, at times, for weeks or months, with but little change. As a rule, however, they terminate sooner or later, either by absorption, leaving a more or less permanent pigment stain with or without slight atrophy (_non-ulcerating tubercular syphiloderm_), or by ulceration (_ulcerating tubercular syphiloderm_).

[Ill.u.s.tration: Fig. 58. Ulcerating Tubercular Syphiloderm.]

Describe the ulcerating tubercular syphiloderm.

The ulceration may be superficial or deep in character, and involve several or all of the lesions forming the group. The patch may consist, therefore, of small, discrete, punched-out ulcers, or of one or more continuous ulcers, segmented, crescentic or serpiginous in shape. They are covered with a gummy, grayish-yellow deposit or they may be crusted.

As the ulcerative changes take place, new lesions, especially about the periphery of the group or patch, may appear from time to time.

[Ill.u.s.tration: Tubercular Syphiloderm.]

[Ill.u.s.tration: Large-pustular Syphiloderm.]

In some instances, more especially about the scalp, the surface of the ulcerations becomes papillary or wart-like, with an offensive, yellowish, puriform secretion (_syphilis cutanea papillomatosa_).

From what diseases is the tubercular syphiloderm to be differentiated?

From tubercular leprosy, epithelioma and lupus vulgaris, especially the last-named.

What are the chief diagnostic characters of the tubercular syphiloderm?

The tendency to form segments, crescents and circles, the color, the pigmentation and ulceration, the history, and not infrequently marks or scars of former eruptions.

[Ill.u.s.tration: Fig. 59. Tubercular Syphiloderm.]

Describe the gummatous eruption of syphilis.

The _gummatous syphiloderm_ (_syphiloderma gummatosum_, _gumma_, _syphiloma_) is usually a late manifestation, showing itself as one, several or more painless or slightly painful, rounded or flat, more or less circ.u.mscribed tumors; they are slightly raised, moderately firm, and have their seat in the subcutaneous tissue. They tend to break down and ulcerate.