The lesion begins usually as a pea-sized deposit or infiltration, and grows slowly or rapidly; when fully developed it may be the size of a walnut, or even larger. The overlying skin becomes gradually reddish. At first firm, it is later soft and doughy. It may, even when well advanced, disappear by absorption, but usually tends to break down, terminating in a small or large, deep, punched-out ulcer.

[Ill.u.s.tration: Fig. 60. Tubercular Syphiloderm.]

Does the gummatous syphiloderm invariably appear as a rounded well-defined tumor?

No. Exceptionally, instead of a well-defined tumor, it may appear as a more or less diffused patch of infiltration, leading eventually to extensive superficial or deep ulceration.

From what formations is the gummatous syphiloderm to be differentiated?

From furuncle, abscess, and sebaceous, fatty and fibroid tumors.

Attention to the origin, course, and behavior of the lesion, together with a history, must all be considered in doubtful cases.

[Ill.u.s.tration: Fig. 61. Large Pustular Syphiloderm.]

What is to be said in regard to the character and time of appearance of the cutaneous manifestations of hereditary syphilis?

In a great measure the cutaneous manifestations of hereditary syphilis are essentially the same as observed in acquired syphilis. They are usually noted to occur within the first three months of extra-uterine life. The macular, papular, and bullous eruptions are most common.

Describe these several cutaneous manifestations of hereditary syphilis.

The _macular_ (erythematous) eruption begins as large or small, bright- or dark-red macules, later presenting a ham or cafe-au-lait appearance.

At first they disappear upon pressure. The lesions are more or less numerous, usually become confluent, especially about the folds of the neck, about the genitalia and b.u.t.tocks; in these regions resembling somewhat erythema intertrigo.

The _papular_ eruption is observed in conjunction with the erythematous manifestation, or it occurs alone. The lesions are but slightly elevated, and seem to partake of the nature of both macules and papules.

They are usually discrete, and rarely abundant; they may become decked with a film-like scale, and at the various points of junction of skin and mucous membrane, and in the folds, they become abraded and macerated, developing into _moist papules_.

The _bullous_ eruption consists of variously-sized, more or less purulent blebs, and is usually met with at or immediately following birth. It is most abundant about the hands and feet. Macules and papules are often interspersed. There may be superficial or deep ulceration underlying the bullae.

What other symptoms in addition to the cutaneous manifestations are noted in hereditary syphilis in the newborn?

Mucous patches, and sometimes ulcers, in the mouth and throat; hoa.r.s.eness, as shown by the peculiar cry, and indicating involvement of the larynx; snuffles, a sallow and dirty appearance of the skin, loss of flesh and often a shriveled or senile look.

What is the pathology of cutaneous syphilis?

The syphilitic deposit consists of round-cell infiltration. The mucous layer, the corium, and in the deep lesions the subcutaneous connective tissues also, are involved in the process. The infiltration disappears by absorption or ulceration. The factor now believed to be responsible for the disease and the pathological changes is the Spirochaeta pallida, discovered by Schaudinn and Hoffmann, and usually found in numbers in the tissues.

Give the prognosis of cutaneous syphilis.

In _acquired syphilis_, favorable; sooner or later, unless the whole system is so profoundly affected by the syphilitic poison that a fatal ending ensues, the cutaneous manifestations disappear, either spontaneously or as the result of treatment. The earlier eruptions will often pa.s.s away without medication, but treatment is of material aid in moderating their severity and hastening their disappearance, and is to be looked upon as essential; in the late syphilodermata treatment is indispensable. In the large pustular, the tubercular and gummatous lesions, considerable destruction of tissue may take place, and in consequence scarring result. Ill-health from any cause predisposes to a relapse, and also adds to the gravity of the case.

In _hereditary infantile syphilis_, the prognosis is always uncertain: the more distant from the time of birth the manifestations appear the more favorable usually is the outcome.

How is cutaneous syphilis to be treated?

Always with const.i.tutional remedies; and in the graver eruptions, and especially in those more or less limited, with local applications also.

What const.i.tutional and local remedies are commonly employed in cutaneous syphilis?

_Const.i.tutional Remedies._--Mercury and pota.s.sium iodide; tonics and nutrients are necessary in some cases.

_Local Remedies._--Mercurial ointments, lotions and baths, and iodol in ointment or in (and also calomel) powder form.

Give the const.i.tutional treatment of the earlier, or secondary, eruptions of syphilis.

In secondary or early eruptions mercury alone in almost every case; with tonics, if called for. If mercury is contraindicated (extremely rare), pota.s.sium iodide may be subst.i.tuted.

How is mercury usually administered in the eruptions of secondary syphilis?

By the mouth, chiefly as the protiodide, calomel and blue ma.s.s, in dosage just short of mild physiological action; by _inunction_, in the form of blue ointment; by _hypodermic injection_, usually as corrosive sublimate solution. The method by _fumigation_, with calomel or bisulphuret, is now rarely employed.

The method by the mouth is the common one, and it is only in rare instances that any other method is necessary or advisable.

What local applications are usually advised in the eruptions of secondary syphilis?

If the eruption is extensive, and more especially in the pustular types, baths of corrosive sublimate ([dram ii-dram-iv] to Cong. x.x.x) may be used; and ointment of ammoniated mercury, twenty to sixty grains to the ounce, blue ointment, and the ten per cent. oleate of mercury alone or with an equal quant.i.ty of any ointment base.

The same applications or a dusting powder of calomel may also be used on moist papules.

How long is mercury to be actively continued in cases of early (secondary) syphilis?

Until one or two months after all manifestations (cutaneous or other) have disappeared, and then, as a general rule, continued, as a small daily dose (about one-quarter to one-third of that prescribed during the active treatment) for a period of two or three months; then another cycle of the active dosage for a period of four to six weeks; then a resumption of the smaller daily dose for another two or three months; and so on, for a period of at least two years.

(Almost all authorities are agreed as to the importance of prolonged treatment, but differ somewhat on the question of intermittent or uninterrupted administration.)

Give the const.i.tutional treatment of the late, or localized, syphilodermata.

Mercury always, usually in small or moderate dosage, as the biniodide or corrosive chloride, and pota.s.sium iodide; the latter in dose varying from two grains to two drachms or more, t.d., depending upon its action and the urgency of the case.

How long is const.i.tutional treatment to be continued in cases of the late syphilodermata?

Actively for several weeks after the disappearance of all symptoms, and then (especially the mercury) continued in smaller dosage (about one-third) for several months longer.