in the non-syphilitic. But if a fresh syphilitic scar is cut into, it will occasionally be transformed into an ulcer. The union of fractures is sometimes retarded by the syphilitic diathesis in syphilitic persons. Mechanical or chemical irritations are liable to produce, on the irritated places, inflammatory products analogous to the phase of luetic lesions from which the patients happen to be suffering at the time. Cauterizations. performed on persons afflicted with a recent or latent form of the disease do not furnish such results as would justify one in inferring from their appearance the character of the syphilis present (cauterisatio provocatoria of Tarnowsky).

Succession and Phases of Syphilitic Affections.

Not only the manner of succession in which syphilis attacks the different tissues, but the local morbid phenomena and their metamorphoses display a certain degree of regularity. First of all, the lymphatic glandular system, the common integument, with its appendages, and the mucous membrane, become diseased. The affection of the periosteum, of the bones, of the subcutaneous and submucous connective tissue, follows later. The affections of the viscera belong to this category. In consideration of this well-nigh constant succession of attacks, Ricord divided them into three groups, and designated them as primary, secondary, and tertiary syphilis. In the primary stage he placed the Hunterian sclerosis and glandular indolent swelling; in the secondary, the disease of the upper layer of the general skin and the mucous membranes; in the tertiary, the affection of the subcutaneous and submucous connective tissues, the bones, the serous and fibrous membranes, and the parenchymatous organs.

But no such distinct division as was made by Ricord really exists. Thus, there are often seen syphilitic affections of the bones in the early period of the disease, and, conversely, ozæna syphilitica frequently occurs in connection with those eruptions of the skin which Ricord places among the secondary phenomena. It seems to us that the classification adopted by II. Zeissl, namely, the stage of moist papules, or condylomata, and the stage of gummatous adventitious growths, is much more correct, because the appearance of the first gummatous

node upon the skin, or in any of the visceral organs, almost excludes the presence of moist papules. The morbid processes of the condylomatous stage may be regarded as lesions of irritation, those of the gummatous stage as new growths. The first group embraces the affections of the lymphatic system, of the skin and its appendages, of some parts of the mucous membranes, and of the iris. The second group includes the diseases of the subcutaneous and submucous cellular tissues, of the fibrous membranes, of the bones and cartilage, of the muscles and viscera.

Development, Course, and Duration of Constitutional Syphilis, and its Mortality.

The development and dissemination of syphilis do not go on steadily and uninterruptedly; apparent recoveries (stages of latency) occur periodically, and are followed by new eruptions, which may be more severe even than the preceding ones. The intervals of apparent recovery may last many months, even many years. On carefully examining such a patient, traces of latent syphilis, such as swelling of the lymphatic glands, opacity and hypertrophy of the epithelial cells of some parts of the mucous membrane, discolored cicatrices, hypertrophies or nodes on the bones, etc., will always be found. The slow or rapid succession, as also the speedy or tardy development and resolution of some of the morbid lesions, varies exceedingly, and depends chiefly upon the congenital or acquired individual peculiarities of the constitution, and upon the age of the patient; sometimes, however, also upon various accidental causes and influences. In syphilis, the law of partium minoris resistentia is seen everywhere exemplified. The phenomena of the first stage, as a rule, display a certain degree of activity, while the symptoms of inveterate syphilis (gummatous phase) run a tedious course. In some cases the different phases of the disease follow each other rapidly and violently (syphilis galopant), while in others, months, and even years pass before a new eruption follows, or more serious effects of an almost forgotten disease appear. In the first phases of syphilis the dry eruptions of the skin usually disappear by resolution; in the later periods, however, ulcers form.

The duration, like the course of syphilis, varies exceedingly, according to the individual peculiarities, the age, and the conduct of the patient, and the various complications that may occur. If the natural course of the disease is not interfered with by therapeutical measures, a complete spontaneous cure may take place at the end of a certain length of time; but, conversely, in patients who undergo no treatment, the most serious forms of syphilis may develop. Treatment exercises a most important influence over the course and duration of the disease. Syphilitic patients who are mercurialized very early, especially before general phenomena have appeared, are oftener attacked by grave lesions of syphilis (cerebral and visceral), and they are oftener subject to relapses than those who, for a long time, were not treated at all, or first with iodine, and later on with mercury. A cure of the disease may indeed be brought about in any of its stages; the most rapid and permanent is achieved in those most recently attacked. In the most favorable cases, to be sure the rarest, a cure may be accomplished in from three to four months; in most instances, however, it takes two, three, or more years. Under unfavorable conditions and unsuitable treatment, the disease, now improving, and then again becoming aggravated, will drag along many years till finally some serious lesions of the tissues, or disturbance in the functions of important organs, ensue, resulting in paralysis and chronic invalidism that terminate in death.

Syphilis itself rarely causes death; and, when this happens, it is generally in consequence of gangrene, profuse hæmorrhage from arterial branches that are difficult to ligate, or necrosis of the bones of the skull. In some cases, suffocation, in consequence of hæmorrhage into Morgagni's cavity of the larynx, or œdema of the vocal cords (laryngostenosis syphilitica) puts a sudden end to the patient's existence; while in equally rare cases the patients succumb to albuminuria (Bright's disease), syphilitic affections of the liver, of the nervous centers, of the cardiac muscle, to marasmus, or, finally, to tuberculosis generated by syphilis, or an improperly managed mercurial treatment.

Development of Lymphatic Glandular Swellings originating in the course of Syphilis (Multiple Adenitis).

In about five or six weeks after the indolent buboes have formed in the immediate vicinity of the primary syphilitic induration, other chains of lymphatic glands enlarge in various regions of the body at a distance from the indolent buboes. We think we are justified in offering the following physiological explanation of the syphilitic swelling of the lymphatic glands, viz.: The syphilitic virus is absorbed by the lymphatic vessels, and the first pathological sign that absorption has taken place is the appearance of an indolent bubo. The syphilitic contagion is not retained in this primary swollen lymphatic gland, but is conveyed with the lymph to other tissues and glands.

The chains of lymphatic glands that swell up most markedly are those situated in the neck at the posterior border of the mastoid process and sterno-cleido-mastoid muscle, the jugular and subclavicular, the axillary, and the remainder of the inguinal glands which were not primarily affected, the cubital and the submaxillary glands. In the syphilitic cadaver, the lymphatic glands situated upon the inner surface of the sternum, the bronchial, the abdominal, and the pelvic glands, are also found greatly enlarged.

The enlarged syphilitic glands at first are only as large as a pea, bean, or hazel-nut, and, as a rule, swell up without any inflammation, and are not sensitive; but, like the primary indolent buboes, they may subsequently become greatly enlarged in consequence of scrofula or tuberculosis, and undergo suppuration, in part at least, if they absorb purulent material from any ulcerating sore in the vicinity.

Multiple adenitis is an almost constant attendant upon all the other syphilitic lesions, and generally keeps pace with them in their aggravation and improvement. In doubtful cases it is a most valuable sign regarding the nature and character of the morbid lesions situated in other tissues of the body; and even in those cases in which a partial cure has caused the other effects of the disease to disappear, it is often the only evidence that the syphilitic diathesis is not entirely extinguished (latent syphilis).

The syphilitic glandular hypertrophies, in persons who are in other respects well, never attain such large proportions as the scrofulous hypertrophies. The former are smooth on their upper surface-the latter nodular and uneven. Syphilitic swellings of the glands, under favorable conditions, gradually grow smaller and disappear, or they undergo fatty, calcareous, or amyloid degeneration. Scrofulous glandular hyperplasiæ frequently become inflamed from very slight external causes, and pus forms in several places. The pus becomes inspissated, fatty, calcareous, or degenerates into a cheesy substance; but in the end the tumor ruptures at several points, and torpid ulcers of the skin, with livid undermined edges, originate, which now secrete a thin, sticky, adhesive matter, and then again an inspissated cheesy discharge, and heal by the formation of contracting, radiating cicatrices.

Morbid Lesions of the Skin caused by Syphilis (Syphilitic Diseases of the Skin-Syphilides).

Syphilis produces on the skin the first and the most frequent morbid alterations. Alibert has included them all under the common name of "syphilides." The nature of the morbid process upon the skin, like all syphilitic forms of disease, is due to chronic, circumscribed inflammations and circumscribed formation of new connective tissue. Active granular and cellular proliferations take place at the affected places. The granules and cells are either reabsorbed, or they degenerate into puscorpuscles, or become transformed into connective-tissue cells and fibers. These processes produce either dry or purulent eruptions. The dry eruptions are represented by the maculæ, papules, nodules, and tubercles; the purulent by vesicles, pustules, and rupia. These eruptions, however, are also produced by the most varying morbid conditions not allied to syphilis. Hence, there are no eruptions that belong exclusively to syphilis; the latter imitates all eruptions of the ordinary affections of the skin.

The resemblance of the syphilides to the non-specific diseases of the integument, the form and the kaleidoscopic appearance of the eruptions, as also the variable degree of the metamorphoses they undergo, always make the diagnosis of syphi