Gummatous syphilide, with ulceration and necrosis of frontal bone

If you’ve ever wondered how someone could live with a skull like this one.

Tertiary syphilis would arise between three to 15 years after infection, and emerged as “gummatous” (forming gummas, soft tumor-like nodules, like what caused this lady’s ulcer) about 15% of the time. If the inflammatory nodules didn’t form on an important organ or blood vessel (as they could, and did, form anywhere in the body), gummatous syphilis wasn’t in and of itself fatal. Death from infected ulcers was not uncommon, however.

Interestingly, you could have gone to town with this lady and not gotten syphilis from her, despite her having been infected for probably more than half her life - tertiary syphilis is no longer transmissible.

A Practical Treatise on Diseases of the Skin. John V. Shoemaker, 1892.

Happy Columbus Day, US residents! Let’s celebrate with one of his greatest achievements!

Top: Gummatous ulcer of left nipple - Patient 24 years of age, drummer, suffering from syphilis for 6 months. Has been under continuous mercurial treatment during that time but in spite of that has broken out in ulcers across body, 74 in number. Patient emaciated and anemic. Broad scar from syphilitic sclerosis at base of penis.

Bottom: Gumma of the breast - Patient 41 years of age, noticed tumerous growth on side of breast one year ago, recently began ulcerating with gummatous lesions forming nearby. Reports being otherwise healthy. Examination showed scarring from old papules around breast, labia majora, and anus. Swelling of inguinal and axillary glands.

Atlas of Syphilis and the Venereal Diseases. L. Bolton Bangs, 1899.

Gummatous nipple (a.) and breast (b.)

A. The nipple was of a 29-year-old man who’d been afflicted with syphilis for 6 months. He’d been treated the entire time with a mercurial solution (the typical and most effective treatment of the day), but his entire body had still developed syphilitic ulcers over that time. The left nipple was completely replaced by an ulcerating sore, and he even had pustular sores with extensive crusts on his scalp. There was a pustulous ulcer within the nose and partially-healed sores all over the body. Patient was very emaciated and anemic.

B. The breast was of a 41-year-old woman who had 4 children, and had never breast-fed. She noticed a gradually-increasing tumor in the left breast appx one year before she was seen by this doctor. It began ulcerating approximately 6 months before admission. Upon examination, there were scars of healed papules around the anus, perineum, and labia majoris, and swelling of the inguinal glands. Her mouth, nose, and throat were all clear.

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The differences in the two cases point out the unexpected ways people can react to the same disease. An able-bodied male can be incapacitated faster than an older mother of multiple children who was known to have had health problems in the past, even when he receives treatment from the first obvious signs of disease.

Some of the reason behind why that can happen has to do with the strength of the immune system of a given patient (affected by previous diseases, living conditions, and heredity), but just as much has to do with what strain or mutation of a disease was acquired, and sometimes reasons that we can’t explain even with modern medicine.

From Atlas of Syphilis and the Venereal Diseases, edited by L. Bolton Bangs, M.D., 1899.

Two gummatous syphilitic lesions, from advanced stages of infection.

From Bockenheimer’s Iconograms Illustrating Interesting Surgical Conditions. 1913.