. Syphilis : a treatise on etiology, pathology, diagnosis, prognosis, prophylaxis, and treatment . have ex-pired from the date of the initial infection. When they appearthey are apt to be numerous and roughly symmetrical, but whenthey develop later, they are usually asymmetrical and few innumber. As already pointed out gummata may appear in anyportion of the body: upon the skin they are most apt to occurupon the upper half of the lower leg, upon the face, trunk, armsand scalp, but may appear anywhere. There is a tendency among 138 SYPHILIS students and many practitioners to regard a lesion as
. Syphilis : a treatise on etiology, pathology, diagnosis, prognosis, prophylaxis, and treatment . have ex-pired from the date of the initial infection. When they appearthey are apt to be numerous and roughly symmetrical, but whenthey develop later, they are usually asymmetrical and few innumber. As already pointed out gummata may appear in anyportion of the body: upon the skin they are most apt to occurupon the upper half of the lower leg, upon the face, trunk, armsand scalp, but may appear anywhere. There is a tendency among 138 SYPHILIS students and many practitioners to regard a lesion as gummousonly after it has broken down and produced an ulcer, but ofcourse this is incorrect, inasmuch as ulceration is simply a laterstage of the gummous process. A gumma develops as a firm,circumscribed, mildly inflammatory nodule in the corium, al-though, of course, a periosteal gumma may ulcerate through theskin. There is usually but little pain and but a slight amount oftenderness associated with its development. The nodule slowlyincreases in size, although at times this growth may be very. Fig. 65.—Solitary gummata are usu-ally larger than are multiple ones. Notea ringed lesion just beneath the lip. Fig. 66.—The scalp is a frequent siteof gummata: they usually spring fromthe bone. (Courtesy of Dr. John ) rapid, until a diameter of from one-half to nearly two inchesis reached. Then central softening usually develops, and fol-lowing the course of least resistance breaks through the skin,so that a deep punched-out ulcer is formed. When the lesionruptures, a thick gummy fluid is discharged, and it is from thecharacter of this discharge that the name gumma is secondary infection occurs, the discharge may be franklypurulent. The resultant ulcer is usually characteristic: it iseither round, oval or kidney-shaped, deep, with the walls de-scending at right angles from the skin so that the namepunched-out is given. The base is covered by a thick tena-cious se
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