3. Ulcerative Syphilide.—In locations that are naturally exposed to maceration and are not kept clean, ulcers arc formed through the destruction of papules. These are characterized by a peculiar basin like, sunken surface, by a dry, shining coat, and by its infiltration wall and absence of reaction. The site of predilection is the genito anal region. But in other regions too papules may become eroded and ulcerated when exposed to mechanical and chemical irritation. Fur thermore, all forms of vesicular and pustular syphilides may lead to ulceration. These ulcers are all distinguished from nonsyphilitic ulcers by the absence of inflammatory reaction, by the small amount of pain, by the presence of peculiar, dry, firmly adherent crusts and by their central depression. Probably all pustular and ulcerative syphilitics depend upon a double infection, i.e., with the specific germ of syphilis and with pyogenic bacteria.
4. Small Popular Syphilide.—This is extremely rare in infants and according to my observation occurs only as a manifestation of a relapse in hereditary syphilis during the second half of the first year. It greatly resembles tubercle of the skin (tuberculides), but is distinguished by the b r ow ni sh color, the peculiar glossiness, and the hardness of the individual papule. I have seen it on the nape of the neck, the back, the forehead, and on the extremities, partly scat tered, partly arranged in groups. At most the papules are but few in number. Exceptionally I have seen this form of eruption arise as late as the second or third year. This syphilide is very intractable from a therapeutic standpoint.
Lesion of the Mucous Mem branes.—Apart from nasal affec tions that have already been dis cussed, involvement of the mucous membranes in hereditary syphilis during infancy is a rare occurrence. Diffuse infiltration and papule formation, it is true, favor, as already indicated, the regions about the openings into the body, thus bordering on the adjacent mucous membranes without however invading the latter. Occasionally a stubborn hoarseness amounting even to aphonia indicates an involvement of the laryngeal mucous membranes, but only exceptionally during or soon after the first eruption. Usually this is one symptom among others of a relapse in which, as a result of oedema of the glottis and periehondritis, severe attacks of suffocation can occur that may even necessitate tracheotomy.
In spite of the intimate connections between the nasal mucous membrane and that of the middle ear, and in spite of the rather frequent attacks of middle ear disease in infancy, discharge from the ear is a rare affection in early hereditary syphilis.
A typical involvement of a mucous membrane is to be found in Mracek's syphilis annularis intestini localized in Peyer's patches. This, together with diffuse thickenings of the gastro-intestinal mucous brane that are a result of inflammatory cell tration areas accompanied by partial disappearance of the glandular elements, is perhaps the cause of intestinal disturbances in infants with congenital syphilis, although other factors doubtless play a part.
In children that are born healthy the first evidence of syphilis is nearly always to be found in symptoms of disturbed general health, with nervous unrest, increased tension in the fontanelle, rise of temperature, and deficient gain in weight. The appearance of diffuse skin infiltration and papular eruption is accompanied in my experience by only slight rise of temperature, while the eruption of pustular syphilides always brings out a temperature up to 39° C. (102° F.) lasting for a number of days, and frequently lasting many days longer than the eruption itself, probably due to a mixed infection.
Changes in the blood picture are always found soon after the eruption begins, but very frequently also before that time. They consist in a diminution in the amount of haemoglobin and in the number of erythrocytes together with the appearance of many nucleated red blood corpuscles and an increase in the number of white blood cells, especially the myelocytes and eosinophiles.
From a diagnostic standpoint it must be remem bered that lesions of the skin and of the mucous membranes may be very insignificant and that the diagnosis of early hereditary syphilis must not depend upon the presence or absence of skin lesions.
Bone Lesions in Early Hereditary osseous system is involved at least as frequently as the skin in hereditary syphilis. Involvement of the bones that are preformed in cartilage nearly always begins in intrauterine life, while that of the bones that form in mem branes usually occurs after birth. In fact Wegner's osteochondiitis which occurs at the epiphyscal borders of the hollow bones is a foetal manifestation, while the hyperostoses of the cranial bones usually do not arise until after birth.