The objective manifestations of acquired syphilis may appear at any period in its course and, while no strict consecutive order is always observed, each lesion has its favorite period of occurrence. Thus, the chancre and associated constitutional symptoms present the primary stage; the macular, papular, vesicular and pustular eruption before to the secondary period; while the tubercular, bullous, gummatoma and ulcerative are found in the tertiary or late stage.
General Symptomatic and Diagnostic Features of the Syphilids. – The pathological processes of hyperemia and cell-infiltration alone or together with various subsequently induced changes give origin to numerous and varied forms of eruption; so much so that some one has described syphilis as an “imitator of other diseases.” The resemblance to other eruptive diseases is natural, inasmuch as the same anatomical parts are involved in all by an inflammatory process, but which in the case of syphilis (and some others) is dominated by a specific cause. The imitation therefore is hardly more than objective and is usually over-balanced by distinct differences. These characteristic differences, each alone of little diagnostic value, together form a significant clinical group, and may be studied in general contrast with the simple eruptions of other diseases.
Course and Duration – Syphilids of the active or secondary stage usually appear rapidly and attain full development in one or two weeks, although it is not uncommon for a few new lesions to show irregularity for some time afterward. Their disappearance is gradual although the papular eruption is prone to relapses for some months. On the other hand, the tertiary eruption shows little tendency to spontaneous disappearance. The eruption of the early period may be attended with pronounced systemic reaction, fever and may closely resemble an exanthem, but the apparent acuteness of the syphilid soon resolves itself into a subacute course. The behavior of these lesions may be hastened, interrupted or modified by some intercurrent disease which, however, will not affect the syphilitic diathesis sufficiently to prevent ultimate relapses. Acute febrile attacks of various origin, scabies, miliaria, furuncles, eczema, seborrhea, a scrofulous and lymphatic tendency, idiosyncrasy, age, climate, alcoholism and, in fact, any general or personal defects in hygiene, all of which influences are not peculiar or syphilis, may act to modify or aggravate the behavior of the syphilids. These influences give individuality to each case and afford a scientific basis for treatment.
The polymorphism of the early syphilids is present in the majority of cases and the lesions have a tendency to appear in crops. Thus, macules, papules, pustules and scaly lesions may coexist in all stages of evolution and decline or successively exhibit their varied phases in the transit of one form into another.
The order of evolution of the syphilids, while not absolute, is quite characteristic and the skin is usually involved from without inward or from the more superficial to the deeper parts. At an interval averaging about six weeks after the development of the characteristic primary sore, the so-called secondary eruptions begin to appear. Of these the macular is the first to occur, followed by the deeper but still superficial papular, then by the pustular and so on until the lesions present are indicative of the age of the disease. The papule is the most typical of the secondary lesions and occurs in varied forms to be described later. Although the eruptions of this period are supposed to last about two years, they are seldom constant because of the tendency to disappearance and recurrence at variable intervals. The tubercle is the typical lesion of tertiary syphilis, as the papule is of the earlier stage. The tertiary syphilids in comparison with the so-called secondary lesions are characterized as follows: they are much less constant in occurrence; when they do appear they are without order of succession; they are asymmetrical, localized, deep-seated, tend to persist and spread; cause local destruction of the tissue and leave permanent scars; and, though they may recur during the patient’s life, they are at no time contagious or inoculable.
The foregoing applies more or less accurately to the typical evolution of the syphilids, which may vary greatly in intensity, in the number and extent of the lesions and in their duration and succession. Rarely there may be an almost complete reversal of the law of syphilitic evolution and deeper lesions common to the tertiary period may antedate the superficial eruptions of the secondary period (retrogressive syphilis). In another irregular type, the usually late and deeper tubercles and gummata develop before the early and superficial macules, papules and pustules subside, or follow closely their decline and pursue an acute non-destructive course (rapid benign syphilis). Less often the rapid, violent and extensive involvement of the deeper tissues assumes a malignant destructive course (precocious malignant syphilis). Lesser irregularities in the evolution of the syphilids, such as the predominance or persistence of one kind of lesion, the moderate occurrence of the early lesions in the late or tertiary period, or lesions of the latter within the limits of the secondary stage, are not uncommon.
Distribution – In location, the syphilitic eruptions of the secondary stage resemble the exanthemata in being more or less generalized and symmetrical, but they seldom appear in such areas as the sternal, supra and infraclavicular regions, or on the dorsal surfaces of the wrists, hands and feet where other inflammatory eruptions are common. The form of the eruption determines the location to some extent. Thus, the macular syphilid is commonly found on the chest, trunk and flexor surfaces, while the papular favors the forehead, margin of the hairy scalp, neck, extremities and trunk. The pustular is often found on the hairy parts of the scalp, face and other regions well supplied with sebaceous glands and hair-follicles. Moist papules or mucous patches occur almost exclusively on the warm or moist regions of the body. The later syphilids, including the tubercular, may develop almost anywhere but the erythematous and rupial forms, like non-specific lesions of the same type, prefer the legs.
Configuration – The early eruptions exhibit little if any tendency toward special grouping or configuration but are usually round or oval and occasionally irregular. However, maculopapular lesions, especially in negroes, around the mouth, lower part of the face and neck are often distinctly annular. The later secondary outbreaks may show segmental, circinate or serpiginous tendencies, but ordinarily these manifestations are found in the later or tertiary period where this tendency is almost diagnostic.
The color and pigmentation of the syphilids are not so characteristic as generally supposed. At first the lesions are a bright pinkish-red and later they become a brownish-red, yellowish-brown or coppery tint which finally amounts to a brownish pigmentation which may eventually disappear. Rarely, pigmentation occurs independently of other lesions (pigmentary syphilid).
The scales of syphilis are thin, superficial, scant, dull white or yellowish in color and non-adherent compared with the same product of similar eruptions.
The crusts of syphilitic pustules and ulcers are quite distinctive. They are grayish, brownish or greenish-black in color, rest upon an indurated base and are easily detached; they are thicker than the crusts of simple lesions and are built up in layers from the secretions formed beneath. If of large size (ecthymatous or rupial), they may seem to almost float upon a base of liquid pus; and the conical, laminated brownish-black crusts of the rupial type, which may slowly attain a large size, are pathognomonic. The brownish-black, rough, dirty, oyster-shell-like crusts of late syphilitic ulcers are also characteristic.
Fig. 148 – Annulopapular syphilid, a common form in Negroes (courtesy of Dr. Howard Fox).
The ulcers of syphilis may be round, oval, crescentic or horseshoe in shape, due to both the enlargement and the subsequent healing which takes place more or less regularly form within outwardly. Hence, the margins are generally regular and their edges perpendicular. The floors may be grayish or present a membranous appearance, bathed with a sanious pus. The ulcer is often bordered by a reddish areola.
Fig. 149 -Syphilitic scars following a pustular syphilid.
The scars of syphilis are often diagnostic. They are distinctly round or oval in shape; at first reddish brown in color, they gradually fade from the center to the periphery until when mature there is left a white, smooth, shining, more or less depressed pliable surface, bounded by a narrow areola of brown pigmentation, which is usually persistent. Near the joints syphilitic scars may be traversed by fibrous bands, more often they are smooth or only minutely perforated at the follicular opening.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war