some other way (" choc en retour"); but this is not established beyond doubt.

There are also those who believe that syphilis may pass from father to child while the mother escapes. It is most probable, however, that the mother of a syphilitic child never really escapes, for under such circumstances she never catches the disease from her child after its birth (Colles' Law).

CHAPTER III.

THE INITIAL MANIFESTATION.

The interval between the introduction of the poison and the commencement of its activity is called the incubation. This period lasts most commonly about twenty-four days. The limits of incubation are between ten and forty-six days. The reasons of this variation in different individuals are yet to be learned.

When incubation is over, a change takes place at the site of inoculation. This change, the initial manifestation (initial lesion, primary syphilitic sore, hard or infecting chancre), has three forms: 1, the elevated desquamating papule: 2, the superficial hard ulcer; 3, the indolent ulcer, with a hard, widely extended base. These three forms are produced quite independently of any local irritation. In the first variety the hard deposit remains dry, losing the cuticle from its surface, without reaching ulceration.

In the second and commonest form, the induration of the tissue beneath the ulcerating surface is less abundant, and sometimes, instead of being developed in a mass, it is spread in a thin layer under the surface, which secretes a serous discharge; this form is called "parchment induration." In the third, induration is well marked, and also ulceration, but the discharge is not copious or purulent. This is the most easily recognized form, which is often called a "Hunterian chancre." When fully developed it has a hard, resisting base; the surface is covered by a scanty, adhesive discharge; the edges are sloping and rounded; and the induration extends beyond the ulcer.

Effects of Local Irritation.-If chancrous pus or matter from any irritable sore be inserted with the syphilitic secretion, immediate action of this irritant begins, the intensity and continuance of which depend on the acridity of the irritant. Similar effects ensue if the irritant be applied to a syphilitic ulcer after it is developed. Chancrous pus applied to the surface of an indurated sore incites it to suppurate freely, and to acquire some of the characters of a chancre, in which case the discharge becomes auto-inoculable. When the syphilitic virus and chancrous pus are inoculated together, the lesion which results is called a "mixed chancre," by Rollet. Sloughing action at the point of inoculation is no preservative against syphilis.

It

The initial manifestation is usually single. may be met with on any part of the surface of the

body, the prepuce and glans penis being the most frequent sites in the male, and the labia and nymphæ in the female. The induration at the point of inoculation varies, according to its situation and the sex of the patient; it may be scanty, and thus liable to be overlooked by a superficial observer, but it is rarely wholly absent. Copious induration is not always

an indication of a severe course of the disease.

The lymphatic glands connected with the point of contagion enlarge, slowly and painlessly, about eleven days after induration of the point of contagion. The cellular tissue around the glands remains unchanged, and they can be plainly felt as a group beneath the skin. This local change is sometimes followed by general glandular enlargement, those most plainly affected being the cervical glands. This further change is accompanied by diminution in the number of the red corpuscles of the blood, pallor and languor. Enlargement of the lymphatic glands is sometimes ill-marked, and escapes observation. When it subsides, the glands shrink back to their original size, or even, by fatty and calcareous degeneration, lose their normal structure. Suppuration in these glands, so common a complication of the local chancre, is unusual, and is the consequence of local irritation, never dependent on syphilis alone. puration is not protective against general infection. The lymphatic vessels, which connect the initial lesion with the glands, can often be felt as hard cords beneath the skin.

Sup

The diagnosis of a syphilitic initial lesion depends

on the incubation, the induration, the indolent superficial quality of the ulceration, should that be present, and the painless general enlargement of the nearest group of lymphatic glands.

The prognosis is that of syphilis.

CHAPTER IV.

AFFECTIONS OF THE SKIN.

After the development of the initial manifestation and glandular enlargement (primary symptoms), there is another interval before the appearance of the general or secondary symptoms; and this period of quiescence is sometimes called the "second incubation.'

The Period of General Eruption, when not influenced by specific treatment, begins about nine or ten weeks after contagion, six or seven after induration of the point of inoculation, and four or five after the lymphatic glands are perceived to have enlarged. Malaise, pains in the head, back and limbs, and pyrexia, may precede or accompany the outbreak of the rash. The febrile action and pain are sometimes intense, and the former may assume a periodic intermitting course. The fever generally subsides when the eruption is fully out.

General Remarks on Syphilides.—The various aspects of the rashes in syphilis resemble those of

the non-syphilitic eruptions in some degree. There are several characters common to all the earlier syphilides. 1. The Papular is the commonest eruption. All the others are usually mingled with papules, and thus the papule becomes the type or basis of syphilitic eruptions. The different rashes do not become typical examples of the eruptions among which they are classed; the vesicles, for example, are abortive, and the scaling patches desquamate but scantily. 2. Symmetry. In the earlier stages both sides of the body are beset with spots, because the virus producing them pervades all parts of the system. 3. Color. At first this is often bright red, but it usually changes to the hue of raw ham, or assumes a coppery tint. 4. Rarity of Irritation. Syphilitic rashes are almost always free from heat, itching, or smarting. 5. Favorite Localities. Most frequently the trunk, the forehead, especially along the border of the scalp, the margins of the nostrils, and the nape of the neck are chosen by the eruption. The outer aspects of the extremities often escape, and the backs of the hands and feet are rarely marked. The palms and soles are frequently attacked by syphilis— situations commonly avoided by non-syphilitic rashes. Again, simple macular eruptions prefer the extremities, while syphilitic maculæ often spare them. Common psoriasis always prefers the outer and rough aspect of the limbs. Syphilitic scaly eruptions show a preference for the flexor aspect. 6. The Form and Arrangement of the spots and patches in syphilis are often arches or circles, or segments of circles. 7.