The form of eruption that I have designated as late pemphigus has the same localization as the early forum which is present. at birth, or within a few days after birth, but appears more frequently superimposed on an area of diffuse skin infiltration (see Plate 29).
Histologically there is in both forms a uniform inflammatory cell proliferation of the papillary portion, following the blood vessels. There is a striking broadening and a serous imbibition, on the part of the papillie and a separating from them of the rete mucosum, so that within the area covered by the bleb there is a complete denudation of the papillfe of their epidermal covering (see Fig. 119). At the same time there occurs splitting of the horny layer itself.
The remaining early exanthemata of hereditary syphilis differ but little from those of acquired syphilis. The following forms of erup tion may be distinguished: 1. Maculopapular Syphilide.—(Figs 117, 120, 122 and Plate 28).
This occurs as a rule after a period of incubation lasting several weeks, and consists of more or less numerous disc-shaped spots, slightly rased above the general skin level, varying in color from an early rose red, to a later brownish, or ham color, or after persisting for some time. to an ochre yellow. The locations of predilection are the lower extremities, the flexor surfaces of the upper extremities, the neck, chin and face. Palms and soles, too, are frequently affected. The papules may be absorbed from the centre leaving pigmented spots, or they may undergo desquamation, or in the presence of mechanical irritation they may grow extensively in all directions, and form the so-called condy lomata lata. The latter never appear as the first eruption of congenital syphilis, but are always an expression of a relapse. They occur usually in places where two opposing skin surfaces rub together as in the cir cumanal and genitocrural regions, in the interdigital folds and about the navel. They are easily eroded and then show a lardy yellow, or diphtheroid, surface. When the secretion ceases and the condylomata dry up, the color becomes lighter, the centres become depressed and the growths are covered with a layer as if they had been painted with collodion.
In early congenital syphilis the roseola of the acquired type is never found. Likewise the trunk is usually wholly free from eruption
in the congenital variety.
The papular eruption may be the first exanthem in congenital syph ilis or may represent a relapse of the disease. In the latter case it has been preceded either by diffuse skin affections, or simply by visceral and osseous manifestations.
Occasionally vesicles and pustules arise from broad papules by elevation of the epidermis.
The favorite, location of tnaculopapular eruptions is the forehead and the hairy scalp, usually after the diffuse skin infiltration has pre ceded it. A dense crown of papules is frequently formed on the fore head in relapses.
Most of the papules disappear ultimately by simple absorption, those that are larger and more elevated after a preceding desquama tion, the oozing forms after a preceding crust formation.
When crust formation has taken place extensively on the face and on the hairy scalp, there is an appearance that greatly resembles the stages of crust formation in impetiginous eczema. But the brownish yellow borders of the infiltrate with their glued appearance, as well as the crust-free infiltrated skin areas with their almost metallic lustre, the peculiar stiff, reactionless character of the whole inflammatory pic ture, and the absence of serous discharge between the scabs point to the fact that back of this crust formation there is not an eczema-, but a syphilitic infiltration.
2. Papulopustular Syphilide.—This form of eruption has a rela tively short incubation period. Pustules with thin purulent contents, not unlike the pustules of smallpox, appear on deep red flattened papules about the size of a lentil. Usually they appear only as scattered lesions. Through drying of the contents of the pustule cupshaped crusts frequently are formed (rupiaform syphilide). Frequently deeper ulcer ation takes place with the formation of crusts that resemble oyster shells (ecthyma syphiliticus). These forms belong to the severe mani festations of infantile syphilis and give an unfavorable prognosis. One must not confuse with these pustular syphilides secondary septic, or pyternic skin lesions in children that have hereditary syphilis.