elapsed after infection, unless the general progress of the disease be very rapid. Here the pustule quickly shrinks and the contents dry into a crust, the skin ulcerates under the crust, the fresh secretion dries into a layer wider than the first, while ulceration extends beneath, until a thick scab of several layers, of a brownish-green hue, is formed. Sometimes, though rarely, the vesicle is well developed. The crops may succeed each other for several months. Rheumatoid and periosteal pains and debility ordinarily accompany this eruption.

Pemphigus is of exceeding rarity in adults. When it attacks a child with inherited syphilis it is frequently fatal. It is one of the earliest of all syphilides, being in most cases present at birth. It develops on the palms and soles, and extends up the arms and legs.

Tubercular Syphilide.-This consists of solid rounded elevations of the skin. Being a late affection, it appears usually in persons infected at least three or four years. The nodules are prominent, coppery or purple-brown in color, collected commonly into groups, and most frequent on the face. This eruption is never widely spread. The tubercles are very liable to ulceration, and then leave indelible white The course is slow, for fresh tubercles may appear as the old ones subside, and the eruption recur again and again.

scars.

The Serpiginous Syphilide.-Creeping ulceration may attack a tubercle. Where this takes place little tubercles develop at the margins of the first deposit,

and merge into each other. The original tubercle soon ulcerates and a scab is formed under which an ulcer creeps, healing where the tubercle first began to melt away, and spreading by the destruction of the tubercles at the margin of the ulcer. The course of the affection is indefinite unless controlled by treatment.

Gummata of the cellular tissue, more rare than the last, are usually met with only in cases of longstanding syphilis. At first they form solid nodules beneath the skin. Presently the skin over the tumor becomes adherent to it, thin, bluish-red in color, and breaks down by slow ulceration. The contents then escape and a ragged interior is left, which heals with a depressed scar. Under proper treatment the mass is often absorbed before ulceration is reached. The gummy swelling is found oftenest on the limbs, but may form on any part of the surface; it is identical with the gummy tumor of internal organs.

The Hair. The hair frequently becomes dry and withered during the course of the cutaneous eruptions. It often falls partially from the scalp (alopecia), and the eyebrows, lashes, and down of the body occasionally fall too, causing complete baldness. In a few weeks new woolly hairs grow, and, commonly, in the course of a few months the hair is completely restored.

The ulcerating eruptions which beset the scalp sometimes destroy the follicles; the hair then comes away in patches and permanently bald spots are produced.

The Nails, in syphilis, may be atacked primarily (onychia) or by extension from the surrounding parts (perionychia).

Onychia. In the commonest form, the nail first loses its healthy lustre, becomes dull, brittle, and notched at the free edge. In some cases, also, the nail gradually separates from the matrix. The separation is usually limited to the distal portion; but sometimes the whole nail falls off, and when reproduced, is often grooved and irregular. In rare cases again, the nail becomes hypertrophied and greatly increased in thickness.

Perionychia.-One form arises from the extension of a papular syphilide to the nail matrix, producing dull spots and subsequently chipping and irregularity of the nail itself. An inflammatory form of perionychia begins with indolent, dull red swelling of the parts surrounding the nail and of the matrix. The nail often necroses, and ulceration is produced.

Syphilitic affections of the nails are distinguished by their multiplicity, chronicity, and the presence or history of syphilitic signs elsewhere.

CHAPTER V.

THE ALIMENTARY SYSTEM.

The Tongue is very commonly attacked in the first and second years after contagion, most frequently by excoriations and fissures along the borders and tip. Mucous patches also are not infrequent ; they accompany the papular eruptions of the skin. At a later period the mucous membrane and submucous tissue sometimes indurate in broad patches. In such cases, sinuous fissures and ulcers often form, from accidental irritation; and when they heal, white, shining scars remain. Lastly, gummy nodules may develop in the substance of the tongue; when superficial they break on the surface, and leave large, ragged, ulcerating cavities. Irritated syphilitic ulcers on the side of the tongue may be confounded with the simple ulcer set up by chafing the organ against ragged teeth, or with cancer; the first is distinguished by the rapidity of its healing when the cause is removed; the second by the hard everted edges, the shooting pain, and by the enlargement of the sublingual lymphatic glands. Nevertheless, the diagnosis is often difficult.

The Mouth and Pharynx.-At the time of roseolous rash on the skin a similar redness often spreads over the throat, lasting a few days, and never

going beyond very superficial excoriation. Small, round, sharply cut ulcers of a superficial kind, and mucous patches, are seldom absent from the fauces and tonsils during the early papular eruptions of the skin. They never sink deeply or leave contracted

scars.

Deep ulcers are the consequence of gummata in the submucous tissue, which, reaching the surface, rapidly disintegrate to a grayish adherent slough that gradually escapes and leaves a deep cavity with sharply cut edges. When ulceration follows the diffused form of infiltration, instead of destroying deeply, it sometimes migrates over the surface of the palate and pharynx, which becomes indurated widely before it ulcerates. Usually the action is confined to the mucous and submucous tissues; at times it extends to the base of the skull and vertebræ, through which it may reach the brain or spinal cord, and produce epilepsy or paralysis. Asthenic fever often accompanies this ulceration. dry, parched, and brown; any attempt at swallowing is most painful, and the voice is hoarse and nasal; cough and expectoration of viscid mucus increase the sufferings. When the disease is checked the ulcers heal, and tough unyielding scars bind down the fauces and greatly impede deglutition and speaking.

The throat is

The Esophagus.-Stricture of the oesophagus now and then occurs among the later consequences of syphilis. It results from gummy infiltration of the submucous tissue, followed by contracting cicatrization.