From the time the chancre begins to form the spread of the disease begins by invasion of the lymphatics. By the time the chancre is well developed enlargement of the neighboring lymph-nodes can be observed. This continues even after the chancre has disappeared, and the enlarged nodes are found to be hard, free from inflammation, painless, and movable. They also do not suppurate. The nodes most commonly involved are the postcervical, sternomastoid, sub-8 maxillary, epitrochlear, axillary, and inguinal. Enlargement of the epitrochlear is particularly suspicious, as it is seldom attacked except in syphilis.

There then appear skin eruptions, polymorphic in character, accompanied by fever, constitutional symptoms, and a rapid decrease in the erythrocytes, with a moderate leukocytosis, usually of the lymphocytes. The skin lesions are generally symmetric, do not itch, and are coppery in appearance. May be some loss of hair, due to inflammation of the hair-follicles. The patches are irregular and have a "moth-eaten" appearance.

The mucous patch or condyloma latum appears on the mucous membrane and the contiguous skin surfaces, particularly those that are naturally warm and moist. It is a slightly elevated, moist, grayish lesion, covered by a thin pseudomembrane. In these there is round-cell infiltration of the skin, with superficial necrosis and edema. There may be one or more patches.

Fig. 37. - Upper Median Incisors in Hereditary Syphilis (Cornil and Ranvier).

Fig. 38. - Serrations in Normal Teeth (Cornil and Ranvier).

Although the chancre and the secondary lesions are highly contagious, the mucous patch is probably the most so.

The chief tertiary lesion is the gumma. It is found most commonly in the nose and nasal septum, scalp, iris, shoulders, arms, and internal organs. The gumma develops as a nodular mass composed of great numbers of embryonic connective tissue and lymphoid cells with a very small amount of tra-beaulae. Blood-vessels, most of them showing thickening of their walls, are numerous and may be found even during necrotic changes of the tissues. This would indicate that the breaking down processes are probably due largely to the syphilitic poison and not to obstruction of the vessels. It usually undergoes a caseous or other form of degeneration, with ulceration or absorption and subsequent cicatrization. It is hard, dense, and elastic.

When the growth of the gumma ceases, the younger peripheral cells become organized into connective-tissue cells, forming an envelope for the cheesy and gummatous center. This envelope shrinks, the semifluid portions are absorbed, and finally a scar, possibly calcareous, is left.

The blood-vessels show an endarteritis which closes or narrows the lumen. The remains of broken-down cells and particles of fat are present, and giant cells may be found. As the Treponema pallida have been found in gummata, and inoculations into apes have caused syphilis, the tertiary lesions must be considered infectious.

Congenital syphilis may result from disease of the ovum, spermatozoon, or both, or it may be transmitted through the placenta after conception has taken place, this being the most probable.

The mother, although showing no signs of syphilis, cannot be infected by nursing her child that is suffering from the disease (Colles' law).

Whether this immunity is real or whether the mother acquires it by being herself affected, although so lightly as to cause none of the usual symptoms, is still an unsettled question. As the Wassermann reaction is generally positive with the mother's serum, it would seem that she is usually infected.

An apparently healthy baby born of a syphilitic mother cannot be infected by her (Profeta's law). This apparent immunity may indicate that the child has received a true but latent infection, one that may not make its appearance until later in life.

The fetus may die in utero and be aborted, the child may be born dead, or it may be alive, but die shortly after birth.

The primary lesion does not occur in the hereditary form, but the secondary and tertiary manifestations may be evident, such as skin eruptions and mucous patches or even gummata. The characteristic lesion of congenital syphilis is pemphigus. There are present on the palms or the soles blister-like elevations of the skin containing a bloody or a greenish fluid.

The upper incisors of the second dentition are frequently conical and peg shaped, with deep notches at the free edge (Hutchinson's teeth).

There also frequently occurs a "white" pneumonia, cirrhosis of the liver, spleen, and pancreas, osteochondritis, and interstitial keratitis.