This diffuse specific skin infiltration can arise under many different conditions: (1) by confluence of a number of disc-like areas the size of a. penny to that of a dollar, of pale rose color, not raised above the general surface of the skin; (2) on top of a diffuse uniform erythema; (3) by the rapid confluence of very rapidly arising, small, pale red, closely packed,. individual effloreseences; (4) by the confluence of real lenticular papules..
This diffuse hereditary-syphilitic lesion is most frequently found during the first three months of life and, according to our investigations, is never present at birth. It is a very frequent, but by no means con stant skin affection of hereditary syphilis that ushers in the period of cutaneous manifestations, but can also reappear at any time during the first year as a recurrence.
A special form of this diffuse skin infiltration in hereditary syphilis is found in specific paronychia, which is accompanied by trophic dis turbances of the nails (see Plate 26). Two forms are distinguishable: paronychia sicca, and paronychia ulcerosa. The skin adjacent to the bases of the nails of both fingers and toes appears brownish-red, thick ened and glossy, and covered with scales, or with crusts. As soon as this specific involvement of the matrix of the nail has persisted for some time, it is noticed that the nail is divided by a whitish transverse furrow into two parts which seem separate from one another and have very different characteristics. The proximal portion is thinner and marked by longitudinal furrows while the distal portion appears normal, "or at least a somewhat increased brittleness." Very frequently the nails are completely softened or disintegrated.
This diffuse syphilide of infancy has a special predilection for the hairy scalp. Whenever a hairy portion of the body is involved this leads at first to a marked increase in desquamation and in sebaceous secretion. Masses of sebum are rapidly formed—much more rapidly than in a simple nonspecific seborrhcm The scalp secretion always becomes thicker and tougher, it rapidly dries up with the scales into a hard crusty mass that covers the head completely like a hood. These masses do not, however, as a rule show the straw yellow color of the crusts of simple seborrhcea, but rather are light brown, with a base of infiltrated, copper-colored skin, not one that is bright red, swollen and oozing. At the same time the scales are always less firmly united to the skin than in eczema with crusts, and can usually be picked off without causing bleeding.
It is also very significant that the affection almost never moistens the scalp, as opposed to the condition in eczema. Under these masses
of sebum there is usually found in these cases of diffuse syphilide of the scalp, a perfectly intact epidermis, while in seborrineal infantile eczema of the scalp, when the crusts are lifted, the bared rote Malpighii is exposed, or if still more intensely inflamed, the bleeding papillary layer.
This same process manifests itself in a very similar manner in the region of the eye-brows. In many cases an early diffuse involvement of all the hairy regions leads to complete alopecia. The characteristic absence of hair on the scalp and on the eye-brows and eye-lashes in older infants afflicted with hereditary syphilis is explained in this same Occasionally there is a facial eczema implanted upon the diffusely infiltrated skin of hereditary syphilis (Fig. 11S). On the borders of the eyelids, the nostrils, and the lips, the infiltrated skin easily cracks and so leads to crust formation. Apart from the rhagades the whole skin of the face may be covered with reddish-brown or brownish-yellow crusts. In severe cases a rupiaform syphilide results.
The Circumscribed Exanthemata of Early Hereditary Syphilis.— These appear either upon a diffuse skin infiltration or upon a pre viously unaltered skin.
Peinphigus Syphiliticus Neonatoram.—In the majority of cases this is present at birth, occasionally it. appears during the first week, rarely during the second to the fourth week. If present at birth, or occurring during the first few days, it has an ominous significance, less so if it. occurs later. Essentially there is no difference between these two forms of pemphigus, which would be more properly designated by the terms papulo-bullotts, or papulo-pustular, syphilitic. In pemphigus of the newborn we have an eruption composed of vesicles or blebs, varying in size from that of a pea to that of a penny, filled with purulent or bloody fluid, and located on disc shaped brownish red spots. The blebs are surrounded by an infiltrated border. They always appear first on the soles of the feet and on the palms of the hands, but can later invade other regions of the body, not, however, without. being preceded by an infiltration of the skin (Figs. .118a and 119, and Plate 2S). As a result of the confluence of several blebs and the destruction of their roofs, ulceration takes place, and in rare cases circumscribed gangrene of the skin may supervene. Streptococci and staphylococci are found in great numbers in the secretion within the blebs. Schaudinn's spirochtete pallida, too, has recently been found repeatedly.