In some instances, more especially about the scalp, the surface of the ulcerations becomes papillary or wart-like, with an offensive, yellowish, puriform secretion (_syphilis cutanea papillomatosa_). #From what diseases is the tubercular syphiloderm to be differentiated?# From tubercular leprosy, epithelioma and lupus vulgaris, especially the last-named. #What are the chief diagnostic characters of the tubercular syphiloderm?# The tendency to form segments, crescents and circles, the color, the pigmentation and ulceration, the history, and not infrequently marks or scars of former eruptions. [Illustration: Fig. 59. Tubercular Syphiloderm.] #Describe the gummatous eruption of syphilis.# The _gummatous syphiloderm_ (_syphiloderma gummatosum_, _gumma_, _syphiloma_) is usually a late manifestation, showing itself as one, several or more painless or slightly painful, rounded or flat, more or less circumscribed tumors; they are slightly raised, moderately firm, and have their seat in the subcutaneous tissue. They tend to break down and ulcerate. The lesion begins usually as a pea-sized deposit or infiltration, and grows slowly or rapidly; when fully developed it may be the size of a walnut, or even larger. The overlying skin becomes gradually reddish. At first firm, it is later soft and doughy. It may, even when well advanced, disappear by absorption, but usually tends to break down, terminating in a small or large, deep, punched-out ulcer. [Illustration: Fig. 60. Tubercular Syphiloderm.] #Does the gummatous syphiloderm invariably appear as a rounded well-defined tumor?# No. Exceptionally, instead of a well-defined tumor, it may appear as a more or less diffused patch of infiltration, leading eventually to extensive superficial or deep ulceration. #From what formations is the gummatous syphiloderm to be differentiated?# From furuncle, abscess, and sebaceous, fatty and fibroid tumors. Attention to the origin, course, and behavior of the lesion, together with a history, must all be considered in doubtful cases. [Illustration: Fig. 61. Large Pustular Syphiloderm.] #What is to be said in regard to the character and time of appearance of the cutaneous manifestations of hereditary syphilis?# In a great measure the cutaneous manifestations of hereditary syphilis are essentially the same as observed in acquired syphilis. They are usually noted to occur within the first three months of extra-uterine life. The macular, papular, and bullous eruptions are most common. #Describe these several cutaneous manifestations of hereditary syphilis.# The _macular_ (erythematous) eruption begins as large or small, bright- or dark-red macules, later presenting a ham or cafe-au-lait appearance. At first they disappear upon pressure. The lesions are more or less numerous, usually become confluent, especially about the folds of the neck, about the genitalia and buttocks; in these regions resembling somewhat erythema intertrigo.