Reprinted from The Tri-State Medical Journal, St. Louis, Mo., February, 1896. 
RUPIA. 
By A. H. Ohmann-Dumesnil, 
Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, 
St. Louis. 
TO the serious student of medicine, there is no more interesting depart- 
ment than syphilology. The study of the various processes which 
are found in syphilis, is one which is always interesting, and it is 
withal of the highest utility in arriving at a correct diagnosis, and in for- 
mulating a successful plan of treatment. Many visceral diseases of an 
apparently obscure origin, and intractable to treatment, readily yield the 
most brilliant results when properly traced to their true origin-syphilis. 
It should always be borne in mind that this trouble may be a possible factor, 
for it is so widely disseminated, and, in many instances, its earlier stages 
are of such a mild character that the patient has either forgotten the 
circumstances, or looks upon the whole affair as of such a trivial nature that 
he does not look upon it as incumbent on him to make any mention of it. In 
addition to this, the generality of the medical profession have paid but com- 
paratively little attention to the subject, and unless confronted by an eruption 
often forget the fact that lues is a protean disease in its manifestations, and 
one requiring more than perfunctory treatment. It should be watched with 
care, and not, as too frequently happens, be met with neglect. And even 
eruptions are but too often mistaken for syphilitic when not so, and vice 
versa. Among the eruptions which are very apt to lead to error are those 
of the late period of syphilis. So-called tertiary syphilis is but too often 
supposed to be confined to gummata and affections of the bones when, in 
reality, it is replete with various eruptions of a most interesting nature. 
I do not intend entering into any lengthy dissertation upon syphilis 
and its nature and different manifestations as the subject is practically an 
inexhaustible one. But, it may not be inappropriate to call attention to the 
fact that syphilis is by no means a disease which has remained in statu quo. 
As a matter of fact, it has become a comparatively mild disease, if we are to 
place any reliance on history. In the fifteenth century it was most virulent, 
and deaths were by no means uncommon, and they followed infection in an 
incredibly short space of time. This virulence abated gradually, but no 
later than fifty years ago we find descriptions and plates of the disease 
representing it as much more severe than we are accustomed to find it 
to-day. However, we occasionally have occasion to observe cases which 
recall some of the older types, which have apparently disappeared. It is 
chiefly in neglected, imperfectly treated or generally depraved physical 
conditions that such reversals of type are met with, and they are of such a 
nature as to be markedly debilitating and rapidly destructive in their action. 
Rupia may be stated to be, in general terms, one of the cutaneous 2 
lesions characteristic of late syphilis. On the other hand, like other man- 
ifestations of this character it may appear comparatively early, and in 
precocious cases it is sometimes seen in the course of the first year of the 
trouble. Asa matter of fact, it is essentially a modification of the pustulo- 
crustaceous syphilide, the changed appearance being largely dependent upon 
the lowered state of the tissues of the individual. The evolution of the 
individual lesions is a slow one, and both progressive and destructive. To 
recognize it before its full development is impossible; to prevent its evolu- 
tion is comparatively an easy matter. The first manifestation which is 
observed is in the form of a dark red macule, which gives rise to little or no 
anxiety on the part of the patient, whilst the color has been described as 
copper-colored, cut-ham in tint, to my mind it is more of a red, slightly 
tinged with brown, nearly approaching a sepia on a red ground. This 
macule is succeeded by a small flat pustule, whose innocent appearance is 
very deceptive. It is, however, soon covered by a greenish-brown crust, 
which is never very large, possibly a quarter of an inch in diameter, and 
roundish or slightly ovalish in outline. A peculiarity of the crust is that 
it has quite a marked tendency to become thick, and this thickening 
increases as the disease progresses. The first appearance of the crust is 
not of a particularly alarming character, as it is not excessively thick and, 
at its inception, ordinarily gives rise to little or no suspicion of its true 
nature, unless in the mind of one well acquainted with it. 
Rupia, whose name is derived from riipos (dirt), is, in reality a 
superimposition of a series of dirty, greenish-brown or blackish-red crusts 
upon each other, and resting upon an ulcerated base, covered with a 
greenish-yellow, foul-smelling pus, occasionally streaked with blood or 
containing small portions of 'clotted blood. Directly a crust has formed 
and obtained a certain size (generally a quarter of an inch or so in diame- 
ter), another crust forms immediately underneath the. first, of the same 
general outline, but a little larger in area. This process, it must be under- 
stood, does not imply that the first crust is thin-on the contrary, it 
is thick and may be conical in form, its height being fully equal to the 
diameter of its base. The successive formation of crusts immediately 
underneath each other goes on steadily and rather slowly, and, as already 
mentioned, each one is larger than its predecessor, and the underlying 
ulceration becomes deeper. The process may go on for an indefinite period 
of time, and the crusts will remain as a whole, being rather firmly attached 
to the underlying tissues. It may be stated, as a general fact, that in an 
untreated case, the accumulation of crusts has notably increased the height 
of the lesion, the area of its base has become larger, and the underlying 
ulceration has become deeper with each successive lamination. Another 
point not to forget is that this progressive ulceration introduces the element 
of pain, and this increases pari passu with the extension of the process. 3 
Of course, this element of pain is only manifested upon pressure on the 
lesion. 
When a rupial crust is closely examined, it will be found that it is sur- 
rounded by a narrow band of pus, giving the impression that it is floating. 
Fig. i. Small Crusts of Rupia. 
External to this purulent zone there is an areola, more or less pronounced, 
of a dusky copper-red color, which gradually merges into the color of the 
normal integument. When the lesion has disappeared, the characteristic 4 
pigmentation is manifest in the scar, which marks the former site of the 
crust. The number of rupial crusts which may be observed in a case varies 
greatly. A peculiar fact which is noted is that, in some individuals, the 
crusts remain comparatively small in size, and never exceed a half inch in 
Fig. 2. Large Crusts of Rupia. 
diameter. A good example of this may be seen in Figure 1. Here it will 
be seen that an attempt at confluence has declared itself, but never succeeded 
in becoming established. On the other hand, the size of the individual 
lesions is made up by their number. For, in this, as in all other cutaneous 5 
involvements, the rule holds that the smaller the lesions, the greater the 
number, and vice versa. Rupial crusts may attain a size much larger than 
these just mentioned, and be as much as two inches in diameter, and as 
thick as an inch or more, with a more or less imperfect conical form. It is 
when they have attained this large size that rupial crusts present their 
characteristic form. It is then that we encounter the so-called "oyster- 
shell" appearance which is very well shown in Figure 2. As may be 
observed in this picture, the rupial eruption is in various stages, a circum- 
stance which is not unusual in such cases. The various sizes and degrees 
of evolution are quite typical of the successive manner of their appearance. 
The mode of growth by superimposition of crusts is also well shown in the 
largest lesion. 
It is true that rupia, even in its milder forms, is but infrequently seen 
in private practice. The most marked casesand the severer forms, are those 
met with in public hospitals, clinics and eleemosynary institutions. This is 
no doubt dependent upon the fact that those who are the carriers of such lesions 
are individuals who have been debilitated by exposure, lack of food, exces- 
sive drinking and deficiency of treatment. Filth and carelessness also add 
their quota to this general physical ruin and general break-down. Typical 
cases, however, are far from being rare in public hospitals, in both males 
and females, and constitute marked examples of the types of wretchedness, 
poverty and degradation which the shady quarters of large cities furnish. 
It may be laid down, as a general rule, that the lower extremities are 
not the seat of rupia. It seems to have a predilection for the arms and 
face, the trunk not being often attacked, and then it is the back which 
most frequently suffers. At least, such has been my experience. When 
the legs do become the seat of rupia, it is almost always certain that other 
portions have been affected. When the face becomes affected the crusts 
may be so thick as to make the physiognomy perfectly hideous, or if but 
one side is affected, sufficiently ugly to be repulsive as may be seen from an 
example in Figure 3. It is when lesions assume the size and proportions 
delineated in the accompanying figures that terror seizes upon the patient, 
and leads him to seek treatment. The crusts of rupia differ somewhat from 
the earlier syphilides in that they do not assume any symmetrical distribution. 
Unilateral disposal seems to be the rule, and the reason of this does not seem 
to be apparent. A strange coincidence which may be noted in the figures 
which accompany this article, is that the crusts appear on the left side. 
The natural termination of an untreated case of rupia is in one of two 
ways. In some cases the crusts drop off spontaneously and, in the course of 
time, and cicatrization finally occurs the scars being rather thick and corded 
and in many cases cribriform, that is, showing the perforations of the ducts 
of the sebaceous glands as well as sweat-pores. In other cases, the ulcera- 
tive process may take on a sudden impulse, and become deeper and deeper. 6 
This naturally leads to greater or less destruction, and a deep ulcer will 
ultimately manifest itself which will go deep down into the tissues to 
the extent of even involving the underlying bony structures. This is 
certainly a serious matter, and the fact, such may be the final- outcome of 
any case of rupia, should not only lead to the adoption of active curative 
measures, but should make a prognosis guarded; whilst proper care and 
attention to both nutritive and medicinal requirements are generally followed 
by excellent results, cases will arise which seem to stubbornly resist all 
measures. 
Fig. 3. Confluent Rupial Crusts of the Face. 
The diagnosis of this trouble should offer no difficulties whatever as 
there is no cutaneous affection which possesses lesions having the same 
characteristics as rupia. The peculiar form and progressive growth of the 
crusts as well as their dirty reddish-brown color should immediately awaken 
suspicions of its true character. The marked fetid odor is also a sign which 
is almost pathognomonic if it has been once experienced by the nostrils. 
The generally run-down condition and appearance are further confirmatory 
elements to form a diagnosis not to mention a history of syphilis which can 
always be obtained in such cases. Whilst the general broad lines of treatment may be easily laid down, 
it requires a certain amount of judgment to properly carry out the necessary 
details to obtain a successful issue. In the first place it is absolutely 
essential that good, nutritious food in sufficient quantity should be eaten 
by the patient. His surroundings should be clean and comfortable. If 
necessary to countereffect the stimulating effects of the alcoholics which 
have been previously taken, kola wine combined with bitter vegetable 
tonics should be administered. These will be found to be the best adjuvants 
to the more specific remedies which are given. So far as specific medication 
is concerned, it will be found that an active mixed treatment is the best to 
begin with. This is more especially valuable in those cases which are in 
the transition period between the secondary and tertiary periods. The 
following will be found quite an effective combination to use: 
R Hydrargyri bichloridi, gr. ij. 
Kali iodidi, § ij. 
Tinct. cinchonae co., 
Aquae destillatae, aa § iv. 
M. 
Sig. Half a tablespoonful iu milk, after each meal. 
In some instances, it will be found necessary to diminish the quantity 
of mercury, or to stop it altogether, keeping up the same dose of iodide of 
potassium. It should not be forgotten to administer the iodide in milk, in 
order to avoid any irritation of the gastric mucous membrane. Further- 
more, it will be found that the administration of teaspoonful doses of 
bicarbonate of soda in water (preferably aerated) between meals, or better two 
hours after each meal will prevent iodic intoxication. The size of the dose of 
iodide of potassium must be governed entirely by each individual case, and its 
effects should be carefully watched in order to determine this point accurately. 
The local treatment of rupia is of no small importance. To begin 
with, the crust should be removed, preferably with a bichloride poultice of 
a strength of about 1 in 1000. After this the floor of the ulcer, which is 
then exposed, should be cleansed with a 1 to 500 solution of bichloride. 
If the granulations be unhealthy in appearance, large and flabby, the walls 
of the ulcer everted and undermined, a good curetting will be of benefit. 
If the granulations appear sluggish, they should be stimulated with a 
solution of acid nitrate of mercury, one drachm to the ounce, lightly pen- 
cilled over the surface. If the granulations become too exuberant, they 
should be repressed, and for this purpose, there is no better means than by 
means of the caustic method. This is done by passing over the granulations 
a small, smooth, soft-pine paddle which has been dipped in. nitric acid, 
c. p. This will not only repress the granulations, but will also act as a 
stimulant, and prevent the ulcerative process from extending any deeper. 
In any event, the best dressing to use is a bichloride gauze dressing which 
should be renewed daily. The gauze should be saturated with a one to one 
thousand solution of bichloride, and not covered with an impermeable 
dressing. A much better plan is to have the patient keep the gauze moist 
by occasionally dropping on some of the solution. If the ulcer takes on a 
good action, the dressing may consist of campho-phenique powder, which 
will form an artificial crust and lead to complete healing underneath it. 
A careful attention to details and cleanliness is absolutely necessary. 
It may be found necessary to permit periods of rest in the course of the 
internal treatment, but it must never be forgotten that eternal vigilance is 
the price of a successful issue in every case of rupia. 
7