the patient unable to repair accidental injury to those organs, and thus, indirectly, frequently causes death.

Though the earliest manifestation is as much a part of the general disease as are the subsequent ones, it has been found convenient to arrange them in three groups. First, those developed at the point of contagion and in the nearest glands-the so-called primary symptoms; next, the widely spread affections, observed mainly on the surface of the body, called secondary; and lastly, those attacking usually a limited area, or a special organ, named tertiary affections. These sets of symptoms are usually separated by pauses. Not invariably; for now and then patients present simultaneously symptoms proper to all three periods. To such cases the term "malignant" or "galloping" syphilis has been applied. In the majority of cases, however, when the disease does not end with the secondary stage, tertiary symptoms do not appear earlier than five years after contagion.

Pathological Anatomy.-The changes produced by syphilis are of an inflammatory nature, and are chiefly due to the production of a morbid growth which undergoes certain processes of increase and degeneration. This change begins by the formation of small round cells embedded in a delicate stroma. The structure is at first similar to that of ordinary granulation tissue, and does not present any elements peculiar to syphilis. The growth may develop in a diffused, infiltrating form, or in the circumscribed

masses known as gummata. Probably no organ or part of the body is exempt from liability to be attacked; and though the new growth is essentially the same wherever and at whatever period of the disease it occurs, it of course varies according to the tissue or organ that is its seat. The gummy growth is at first highly organized and very vascular, but subsequently there is a marked tendency to plugging of its vessels and consequent degeneration. If disintegration take place the consequences vary according to the seat of the growth. If the skin is affected an irregular ulcerated surface remains, while in the case of internal organs a tough cicatricial fibrous tissue results, which by contraction may seriously, or even fatally, interfere with the functions of the affected viscus.

Contagion is not Repeated. By this it is meant that a man who has once suffered from syphilis, thereby gains immunity for the future, and further inoculations have no effect upon him. This law, commonly true, is not absolutely so; undoubted instances exist of patients who have had syphilis, and who after a lapse of years again contract the disease.

In the best recognized and undoubted cases of reinfection, a regular recurrence takes place, namely: incubation, indurated initial lesion, enlarged glands, and eruptions of the cutaneous and mucous surfaces. In the second mode in which syphilis is said to be repeated, the course is much modified. The earlier stages do not appear, but the disease advances at

once to the later forms; and nodes, rheumatic pains, affections of the liver, and other viscera, are the first signs of general infection. As such cases have no clear distinction from others which are simply revivals of a former attack, they are open to doubt.

Duration. This varies much in different persons. As a practical rule, one and a half or two years should be fixed as the probable period during which a patient may expect relapses of eruptions on the cutaneous or mucous surfaces. It must, nevertheless, be borne in mind that the disease is sometimes life-long, and the longer it lasts the more difficult it is to cure, though even in these cases success is often the reward of perseverance, for the number of incurable cases of syphilis lessens as our knowledge of the disease becomes more complete.

CHAPTER II.

CONTAGION.

The causes of syphilis are predisposing and exciting. Predisposing causes are conditions facilitating the spread or increasing the severity of the disease. Syphilis is more severe in cold than in temperate climates; and in hot ones for natives of cooler climates. Any cause which enfeebles the condition of the individual increases the severity of syphilis.

All races are subject to the disease. When it invades .a district not previously accustomed to it, its course, like that of other contagious diseases, is for a time Probably there are individuals insusceptible to syphilis, who escape that contagion as they escape contagion of other kinds.

more severe.

The sole exciting cause of syphilis is a subtle nonvolatile principle called the virus, which, except in the case of inheritance, enters only at a breach of surface. The essential nature of the virus is unknown. Certain observers, especially in Germany, claim the discovery of a bacillus peculiar to syphilis ; but the question at present remains unsettled:

The length of time which elapses between inoculation and absorption of the virus is also unknown. Excision of the initial lesion has hitherto failed to prevent general infection-indeed, cauterization within twelve hours after contagion has also failed.

The Vehicles of the Virus are-The secretions of all early syphilitic affections and the blood; but the fluids of the body usually cease to be contagious when only the so-called tertiary affections are left.

The physiological secretions of a syphilitic persone.g., saliva, sweat, tears, milk, semen-have not been proved to be inoculable when free from admixture with syphilitic secretions or with the blood.

The secretions of co-existing diseases in syphilitic persons should always be regarded as capable of conveying syphilis, though the evidence that they have done so, except under the conditions mentioned in the preceding paragraph, is imperfect.

Modes of Contagion.-Syphilis may be propagated by (1) direct contact; by (2) mediate com-. munication; or by (3) hereditary transmission.

1. Direct Contact.-Syphilis is most commonly communicated during coitus; but it is not necessarily a venereal disease, for it is sometimes conveyed by kissing, by suckling, by examining diseased persons, as in the case of doctors, students and midwives, and in various other ways.

2. Mediate Communication.—More rarely syphilis is conveyed through the medium of drinking vessels, spoons, pipes, towels, or other articles that have been used by syphilitic persons. Dentists' and surgeons' instruments have also acted as media of contagionas, for instance, in vaccination.

3. Hereditary Transmission.-Our knowledge is imperfect respecting the ways in which syphilis may be transmitted from parent to child. There is no doubt that if the mother be infected shortly before or at conception, the child will almost always receive the disease. The child will probably contract the disèase if the mother be infected in the early months of pregnancy. If she is infected after the seventh month the child often escapes. As the disease subsides in the mother, the chances of escape for the child greatly increase, and after the second or third year of the mother's infection the child is often healthy.

It is believed by many that the child may inherit the disease from the father, and may in turn infect the mother through the placental circulation, or in