The tubercular syphilids commence as deep-red papules which gradually enlarge in all dimensions until they reach the size of a split-pea to a hazel-nut. The lesions appear as round, smooth, firm, deeply seated, pinkish-red, brownish-red or ham-colored nodules. They are more frequently noted upon the forehead, ears, nose and chin or, less commonly, upon any surface. This eruption presents no subjective symptoms. Its course is usually very slow due to the development of new tubercles and the indolent involution of the old ones. The behavior of the lesions varies widely in different cases according to their mode of evolution and involution. They seldom ulcerate, they may coalesce and form variously sized and shaped patches with elevated borders, depressed and clearing centers, constituting a variety of the annular syphilid. When the process of extension and resolution is rapid, little damage may be inflicted on the skin; if slow, more or less atrophic scarring is left. The joining together of several tubercles may produce patches of serpentine shape (serpiginous tubercular syphilid). In a large number of cases the eruption has a circumscribed, circular or crescentic outline which extends by new papules appearing at the periphery. On the non-hairy part the patches are comparatively smooth, on the hairy surfaces they may be uneven from the greater involvement of the follicles and papillae, even becoming papillomatous or vegetative (vegetating tubercular syphilid). From the presence of pus, crusts may form between the elevations or a general exudation of serum will form crusts all over the surface. On the palms and soles the tubercles may become scaly and form circles with a fringed border and a coppery areola.
Fig. 161 – Serpiginous tubercular syphilid.
When treated early it is possible for this syphilid to disappear without injury to the skin but nearly always some scarring results. In neglected cases there may be considerable loss of tissue without a sign of ulceration; thus the lobes of the ear and the alae of the nose have been destroyed by the atrophic process.
In a few cases some part of the tubercle may ulcerate (ulcerative tubercular syphilid). This form only differs from the non-ulcerative in that the tubercles, softening in the center, break down the epidermis and become covered with a thick yellowish crust which slowly turns to greenish-black and is surrounded by a deep-red or purplish areola. The size of the crust represents the area of the ulcer which it covers. When the crust is removed, the ulcer is usually found to be deep with a thick border, sharply cut and sometimes slightly undermined edges, a smooth floor and secreting an irritating pus. The subsequent course of these lesions varies with their location, the general and tissue health of the patient and the intensity of the inflammatory process. In the cachectic, debilitated and alcoholic, the ulcers are apt to spread and join together in large patches. In the well nourished they may remain circumscribed and ultimately leave no greater cicatricial blemish than in the resolutive tubercles.
The more common location of this syphilid is upon the face, shoulders and neck and less often on the extremities and trunk. On the face it may be attended with considerable inflammatory swelling and hypertrophy, and sometimes pursues a rapidly destructive course. This is especially marked when the process becomes phagedenic or gangrenous in character. In extreme cases the nose may be penetrated and its entire structure, with the soft parts about, destroyed in a few weeks. These ulcerations may advance by peripheral infiltration and consecutive breaking down, or by new individual tubercles forming near their border; in either way they tend to maintain circinate shapes. Wherever their location they often assume a serpiginous method of growth by new tubercles developing at the margin, while progressive cicatrization goes on in the center. The latter mode of combined evolution and involution, as well as the exceptional appearance of keloidal tubercles in the cicatrices of syphilis, may present a close objective analogy to lupus vulgaris (syphilitic lupus).
Fig. 162 – Ulcerative tubercular syphilid.
The ulcerative tubercular syphilid heals very slowly, as a rule. When repair is sufficiently advanced, crusts cease to form and an irregular, reddish cicatrix is left, which finally fades to a shining white color often surrounded by a narrow coppery areola for some time. Such scars are usually depressed relatively to the depth of the preceding ulceration and, in some cases following deep ulceration, they are traversed by fibrous bands. Sometimes keloidal growths appear in the cicatrix and the superficial scars may be perforated by the minute openings marking the seat of follicles.
It may be necessary to diagnose the tubercular syphilid from the following conditions: Lupus vulgaris usually begins in early life; is often limited to one region; is much slower in its development and progress; has less regular lesions; is surrounded by a redness which merges gradually into the sound skin; its tubercles are pinkish or violet, of apple-jelly consistency; its ulcers are not so sharply cut or regular as in the syphilid; its crusts are irregular and not greenish-black; its scars are hard, uneven, more adherent and less depressed than the smooth, thin, flexible and sunken scars of syphilis.
The tubercles of leprosy are larger, softer, usually accompanied by large yellowish-brown pigmentations, white anesthetic spots and other disturbances of sensation in or about the lesions. The item of residence in a leprous country and the duration of the disease will help to clear up the diagnosis.
Epithelioma is common after the fiftieth year of life; its lesion is usually single with an infiltrated, everted or roll-like border; often presents pearly- looking tubercles adjoining or surrounding; is much slower in its progress; its discharge is not very profuse or very offensive but is often mixed with a little blood.
The tubercles of rosacea arise in the congested and thickened skin of the middle third of the face, often after a history of long persisting redness, accompanied or followed by permanently dilated capillaries. There is no tendency to destruction or ulceration.
Psoriasis and eczema of the palms and soles may be differentiated from the tubercular syphilid of the same regions in the same way as described in the papulosquamous form.
Gummatous Syphilid (gumma; syphiloma; gummy tumor) – This is usually a late or tertiary manifestation and rarely occurs before the fourth year, often after the twentieth. It always begins in the subcutaneous tissue unlike the tubercular syphilid but, like the latter, is composed of solid cell infiltration. It is characterized by one or several, slightly raised or flat, pea- to egg-sized, circumscribed, round, painless tumors. Their shape is governed to a certain extent by their location; thus, it may be globular when situated in the loose tissue, flattened when beneath the scalp and oblong when there is a lateral obstruction as along the fingers. The union of several lesions may cause a growth of large extent but generally they remain isolated. The favorite seats of gumma are the middle and upper third of the legs, about the ankles, the scalp and forehead. They may, however, occur upon any part of the body but only with extreme rarity on the palms or soles. On the leg they are apt to be attended with edematous, hypertrophic and inflammatory complications, sometimes destroying the deep tissues to the bone. On the scalp they are prone to coalesce, involve the entire integument, become adherent to or damage the bone. It is convenient to describe gummatous growths in three stages, those of infiltration, ulceration and repair.
The first period presents the slow growth of one or more tumors. The number is usually in inverse ratio to the lateness of occurrence. Even in the early years they are rarely numerous, not often exceed eight or ten, though cases have been recorded where there were many more. Exceptionally, they may develop symmetrically and quite rapidly with accompanying general symptoms of the secondary period. In the later period they are asymmetrical, unattended by general or local disturbance beyond a moderate soreness in restricted or exposed situations, and tend to invade the skin rather than the deeper tissues. The deeper involvement is shown when the skin loses its suppleness, becomes thickened, reddened and attached to the tumor. Soon a hyperemic areola appears around the coppery red and perhaps elevated center. The lesions may remain stationary for a time and under treatment even disappear without ulceration.
The stage of ulceration usually succeeds that of infiltration. The softened and undermined skin breaks in the center and gives exit to a thick, viscid discharge mixed with blood. Gradually the slough-like substance is eliminated through one or several openings, leaving exposed a gummatous ulcers. This is more or less deep and wide according to the extent of the original tumor; it is round, oval or irregular (from the fusion of several small lesions), with thickened borders surrounded by an extensive areola, undermined walls, an uneven greenish-red or blackish floor covered with broken down tissue and bathed by a sanious, fetid, purulent secretion. The course of such ulcers varies with their location, the care they receive and the intercurrence of inflammatory, gangrenous or other processes. They may pursue a phagedenic course, involving extensive areas and producing a severe or alarming cachexia. In a few cases, they may remain indolent with considerable swelling of the adjacent tissues and an offensive discharge. Located on the face gummatous ulcers may not only destroy the soft parts, cartilages and bones, but even in the less severe cases may result in disfiguring scars which in some cases interfere with the functions of the eyes, nose or mouth. Such results are rare, however, in recent times, since few cases among the poor now fail to receive careful treatment.
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