CONSTITUTIONAL SYIHILIS. 763 



more intractable than the maculous, and several weeks usually elapse 

 before it yields even to an energetic treatment. 



The scaly syphilitic eruption (psoriasis syphilitica) often com- 

 mences as a syphilitic roseola or lichen. The spots are discrete, and 

 rarely become large, although they may be very numerous. The color 

 of a specific psoriasis is generally darker than non-specific, and the 

 scaly layer is usually thin. Not unfrequently cracks form in the infil- 

 trated skin, which lead to ulceration. As we have already remarked, 

 the knees and elbows are hardly ever affected in syphilitic psoriasis. 

 Palmar and plantar psoriasis, which always is of syphilitic origin, 

 begins with the formation of small, round; or oval callous spots of a 

 pale-red or yellowish color. After the thickened cuticle has become 

 detached from these spots, or has been scratched off by the patient, 

 the copper-colored, infiltrated cutis is exposed to view, surrounded by 

 concentric circles of dried desquamating epidermis. This circle en- 

 larges, while sometimes the centre begins to heal, or covers itself 

 afresh with a coat of horny cuticle. Now and then the efflorescences, 

 which at first were separate, afterward coalesce, causing great thick- 

 ening of the epidermis, which cracks readily, forming extremely painful 

 fissures or rhagades. 



The pustulous syphilide is called impetigo, or ecthyma, according 

 as it produces small and pointed or large and flat pustules. They are 

 sometimes solitary, sometimes formed in groups, and appear upon the 

 face and scalp as well as upon the body and extremities. They are 

 surrounded by a coppery areola, and dry up into scabs, which, when 

 situated upon the scalp, are very annoying, owing to their liability to 

 be torn off by the comb. Beneath the scabs of the ecthyma pustules, 

 and more rarely under those of impetigo, there are ulcers, which eat 

 more or less deeply into the cutis. The color of the scars, which 

 always remain after the healing of ecthyma, is at first a coppery-red, 

 and afterward remarkably white. Syphilitic impetigo and ecthyma 

 are more serious affections, and appear at a later stage of the disease 

 than any of the exanthemata hitherto described. In spite of the most 

 careful treatment, many months often elapse ere they begin to heal. 

 The pustulous syphilides are quite intractable, and sometimes outlast 

 all the other symptoms of the disease. 



There is an eruption known as varicella syphilitica, and which, in- 

 deed, bears a great resemblance to varicella. It is almost always pre- 

 ceded by febrile disturbance. The vesicles, which are numerous, and 

 scattered more or less over the whole body, spring from red maculae. 

 The liquid contained in them is at first slightly turbid, afterward 

 purulent, and finally dries up into round, blackish crusts, which, when 

 they fall, leave brownish stains behind. This, also, is an obstinate 



