In any case repair cannot occur until the abnormal tissue is completely removed spontaneously or by treatment. Then healthy granulations appear on the floor of the ulcer, the thickened borders melt away and scar-tissue forms over the surface. This cicatrix is depressed and wide according to the depth and extent of the ulcers; it is usually smooth but may be uneven from fibrous bands or nodules, is often adherent, white in the center with a brownish hue at the periphery.
An early diagnosis of gummatous tumors is important in order to institute appropriate treatment to prevent ulceration and destruction of tissue and to distinguish them from other neoplasms which may require surgical removal. A clear history of primary syphilis or the occurrence of other syphilids is often wanting as an aid to diagnosis and chief reliance must be placed on the physical features and method of development of the gummatous lesions. All ulcerations or growths suspected of being syphilitic should receive specific treatment before resorting to radical operative measures.
In the stage of tumefaction it may be necessary to diagnose gumma from the following conditions: Enlarged glands and “scrofulous gummata” more often occur in young subjects than syphilis, are generally situated quite characteristically along the line of lymphatics and pursue an indolent, persistent course. No history of syphilis can be obtained and the signs of scrofula are usually present. Sarcomata do not have the favorite seats of gumma; they more frequently occur on the trunk and become attached to parts beneath; they are harder, painful, usually single and do not disappear by absorption. Lipomata are softer, more compressible and flatter than gummata. These growths are commonly single, located in regions unusual for the syphilid, and may remain little changed or slowly enlarging for years. Fibromata usually develop in childhood, persist through life without any tendency to ulceration.
Gummatous ulcers may resemble the following: Epithelioma presents different points which have just been discussed under the diagnosis of tubercular syphilid. Varicose ulceration is often located on the lower third of the leg with more or less varicosis, edema and eczematous inflammation. Chancroidal ulceration may closely resemble an ulcerating gumma. The history of slow infiltration and tumor before the ulceration, the absence of a history of an acute inflammatory course and glandular involvement would clearly distinguish the syphilid. Lupus vulgaris and its diagnostic points have been sufficiently described under tubercular syphilid.
Pigmentary Syphilid (syphilitic leukoderma) – Much difference of opinion exists regarding the real nature of this rare manifestation. The true pigmentary syphilid is primary in occurrence and independent of preceding eruptions. It may be due to extravasation of blood colouring matter (pigmentary syphilid) or to hemorrhage into the skin (purpuric syphilid). In either case, it is distinctly macular.
The pigmentary syphilid is usually found in the latter half of the first year but it may appear earlier or later. It may be the only form present or it may coexist with other lesions, and is usually located on the neck and shoulders. It more frequently affects females and is more often seen in brunettes. Its usual duration is from three to six months although it may persist for years. The patches are sometimes hyperemic but if so, this is a transient stage and the surface is not elevated or scaly. The peculiarity of this form is that it is uninfluenced by specific treatment, externally or internally. Taylor has been described three distinctive forms of this syphilid: (1) as brownish spots or patches of various sizes; (2) a diffused pigmentation which, after a time, becomes leucodermic taking the form of small spots which gradually increase in size (retiform pigmentary syphilid); (3) an abnormal and unequal distribution of pigment resulting in the interblending of lighter and darker colored spots giving the surface a dappled appearance (marmoraceous pigmentary syphilid, from its resemblance to a form of marble).
Diagnosis – In the formative stage the pigmentary syphilid may be confused with chloasma which is often situated on the face and presents none of the evidences of syphilis, and with tinea versicolor which is frequently present on the trunk in large patches which can easily be scraped or rubbed off. A microscopic examination of the causal fungus may be undertaken. When the lighter spots begin to disappear or the syphilid is in a stage of decline, it may be mistaken for leukoderma. This usually is located elsewhere than on the neck and has a narrow border of pigmentation around its white area. From the hypertrophy and atrophy of pigmentation of the other syphilids, the true pigmentary form may be always known by the history of its independent development.
Fig. 163 – Papulopurpuric syphilid. The purpuric macules appeared at the acme of the secondary papular eruption.
The purpuric syphilid occupies a doubtful place in the classification of syphilitic eruptions because hemorrhage into the skin, independently of other lesions, is exceedingly rare in acquired syphilis. Hemorrhage may occur with any of the early or late eruptions, but is more commonly associated with the macular or papular syphilids. The etiology of such effusions of blood relates probably more to the pathology of purpura than syphilis. With the macular syphilid, pin-point to millet-seed-sized, purpuric spots appear more or less generally distributed with the roseola, each lesion surrounded by the flush of the latter. When hemorrhage complicates the papular form it may surround the papule or occur in its substance. The same factors which produce non-specific purpura together with the altered blood of the syphilitic probably explains its occasional occurrence in the latter. It is more frequent among children who suffer from hereditary syphilis.
The presence of a syphilitic eruption in these cases will serve to diagnose them from all other purpuric lesions.
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