When the chancre appears upon the mucous surface of the penis, it may present the characters of the dry papule above described. More frequently, however, erosion or ulceration occurs, owing to the more delicate character of the epithelium. When the lesion is situated at the preputial reflexion we not uncommonly find an excessive degree of induration.

When the chancre appears upon the female genitals, it rarely presents more than the slight parchment induration, and sometimes even this is absent or inappreciable. In a very considerable number of cases in females, the chancre passes through its various stages, and disappears without having awakened the attention of the patient.

Extra-genital chancres, as those situated upon the lips and the mammae, generally exhibit marked induration.

Chancre is usually painless, unless irritated by excessive venery or other causes. Under these circumstances it may become inflamed and painful, and covered with a free purulent exudation, and be with difficulty distinguished from a chancroid.

Chancre is not, as a rule, inoculable upon a person bearing it, or upon another who is already syphilitic.

Adenitis

Within a week or ten days after the appearance of the chancre we usually find other symptoms arising, which are highly characteristic of syphilis. These are indolent and indurated tumefactions of certain lymphatic elands. When the chancre is located upon the genitals the inguinal glands are first affected. The increase in size may occur upon one side alone, but more frequently upon both. As a rule, several glands upon each side are involved. They may vary from the size of a Easel-nut to that of a pigeon's egg, and, as a rule, are painless; more rarely they become inflamed and suppurate after the manner of the chancroidal bubo. The enlargement and induration persist for months, and sometimes for years. In addition, certain ganglia at the back of the neck become affected in the same way, though they rarely attain the size of the glands in the groin. Besides these, certain glands situated above the inner humeric condyle, the so-called epitrochlear or cubital glands, frequently become involved upon one or both sides. When the chancre appears upon the finger in consequence of an accidental inoculation, the cubital glands are first involved, and subsequently the axillary.

Diagnosis Of Chancre

When a suspicious sore exhibits the charac-ters peculiar to chancre, and especially marked induration, together with involvement of the inguinal and post-cervical glands, the diagnosis is effected without difficulty and absolutely. If, however, induration is absent, and ganglionic involvement has not yet occurred, or the sore is inflamed and suppurating, the diagnosis may be exceedingly difficult, in fact, impossible.

Secondary Stage

After the primary stage has lasted from one to two months, additional phenomena arise, and usher in the so-called secondary stage. The earlier manifestations of secondary or constitutional syphilis include general febrile action, called syphilitic fever, flat moist papules upon the mucous membranes and the integument surrounding the genital organs, called mucous patches, and a general eruption or efflorescence upon the skin. These symptoms do not always follow each other in the same order, and one or more of them may be absent.

Syphilitic Fever

This is simply a febrile attack more or less sharp, and accompanied with general malaise, gastric disturbance, headache, etc. It usually lasts for a few days only, and then passes off, and may be quickly followed by the cutaneous eruption. There is nothing distinctive in the character of the fever that will enable it to be recognized as syphilitic, except its previous history or subsequent developments. The mucous patches and special eruptions will be considered in subsequent pages. The lesions mentioned, especially the early cutaneous eruption, may disappear spontaneously, to be followed by fresh outbreaks of eruption, in which the lesions present a somewhat graver aspect. The cutaneous trouble may be papular or squamous. As a rule the eruption is extremely superficial, and when it disappears leaves a temporary stain, without scar. During this period, also, the hair may fall out, producing a more or less complete, but also temporary alopecia. The eyes, too, may become involved, and variously situated pains may torment the unfortunate victim.

Intermediate Stage

After the occurrence of various secondary symptoms which have disappeared spontaneously, or have been removed by treatment, it is not uncommon to have a lull lasting a few weeks or months, or even years. During this period we may have absolutely no symptoms or signs indicative of syphilis; or, perhaps, the occasional ap-pearance of an isolated lesion, which may partake of the superficial character of the usual secondary lesions, or, on the other hand, may be but a foretaste of graver trouble yet to come.

Tertiary Stage

If the disease has not been definitely and permanently arrested in its development during the preceding stages, it may pass on to the condition known as tertiary syphilis. During this period we encounter profound modifications, not only of the superficial, but also of the deeper tissues and organs. The mucous membranes may become in-volved in extensive and destructive ulceration. The integument becomes the seat of tubercles, pustules, and ulcers, the periosteal membranes inflame, and the bones are affected with caries or necrosis. The vital organs also may become involved in the syphilitic processes. Not only the lungs, liver, intestinal tract, and kidneys, but the nerves, spinal cord, and brain may be invaded, with ultimately a fatal issue.

In the tertiary stage the patient may suffer greatly from debility, and the establishment of a general cachectic condition.

We see then, from this general review, that syphilis is a disease capable of affecting the entire organism, and often in a disastrous manner; we see that few, if any, of the tissues or organs are exempt from its ravages, and we are forced to the conclusion that it is a disease which invites our earnest attention and most careful consideration. To gain a proper comprehension of its varied character we must study it from several points of view, and we will commence with its effects upon the different tissues.