Syphilis is a disease that expends much of its energy on the skin, but as it is one that pervades the entire system, it must be considered as a whole and not in its cutaneous relations alone. I shall therefore present its principal features in detail, and as briefly as is consistent with clearness.

History And General Considerations

It was during the last decade of the fifteenth century that this disease first attracted notice Whether it existed before, and whence it came, are questions which cannot be defi-nitely answered. Appearing first in Southern Europe, it spread rapidly through other portions of the continent and to the adjacent islands, and soon became recognized as an important and formidable affection, in its symptoms and consequences rivalling leprosy, with which it was later con-f'ounded. From that time until the present the disease has continued to exist, and has spread to every country penetrated by the footsteps of civilised man. Although the main features of the disease are the same as those which it presented in the beginning, it has, in certain respects, been somewhat modified. It is more especially as regards its general severity that we are more fortunate than our predecessors. Although we occasionally find isolated cases which fully realize the descriptions given in the past, they certainly are very rare. As the severe cases of the present day are chiefly those which have been neglected or improperly treated, it is not improbable that these causes were the principal factors concerned in the production of the state of affairs described by the older writers. On the other hand, the comparative mildness of the disease as at present seen is undoubtedly due to the more general attention and more judicious treatment that it now receives. The wide diffusion of the disease, however, and its ever readiness to assume, under favoring influences, the most malignant and destructive phases, render it worthy of the most serious study. It is, in fact, the most important of the affections which receive attention in this volume. In consequence of the varied phenomena presented by the disease, we are compelled to consider it from several points of view, more particularly its modes of propagation, its lesions, its course and variations, its diagnosis, prognosis, and treatment. Modes of contagion and propagation. - Syphilis is usually conrracted during sexual intercourse, but this is not the only medium by which it may be propagated; it may be also communicated by kissing, and through vaccination, and by certain unnatural practices. It may also be given by syphilitic wet-nurses to their nurslings, and vice versa, as well as by drinking-vessels, table utensils, pipes, etc.

Manifestations

The manifestations of syphilis are so numerous and multiform that the disease can only be comprehended in its entirety by a careful analysis of its phenomena from several different points of observation. We shall therefore consider its lesions and stages, and the tissues and organs liable to be affected.

Lesions

The principal lesions of syphilis are macules, papules, tubercles, vesicles, bullae, pustules, gummata, and diffuse infiltrations, and, dependent upon some of the foregoing, ulcerations, crusts, and scars. The definitions given of the lesions met with in non-syphilitic affections of the skin apply equally to those of syphilis. It is necessary, however, to define the term gumma, a lesion which plays an exceedingly important part in connection with this disease. The name is applied to certain circumscribed nodules located in the subcutaneous connective tissue, or within the substance of various deeper organs. These nodules consist mainly of collections of closely packed small round cells, which preserve their form and vitality for a certain length of time; but which ultimately become the seat of degenerative processes, and undergo cheesy metamorphoses, or disappear by means of suppuration and ulceration. These gummata rarely appear in the early stages of syphilis, but, as a rule, play their role in connection with the later developments of the disease.

Stages

Three stages of syphilis are usually described, namely, the primary, secondary, and tertiary. We must admit, however, two others, to wit, a stage of incubation which is present from the time the disease is contracted, and lasts until the appearance of the first visible manifestation of the disease. When this latter, to which the name of chancre is given, develops, we have the beginning of the so-called primary stage. This lasts until the appearance of certain general symptoms announce the secondary stage. This in turn is followed by the tertiary; but between the two there is usually a stage or condition characterized by the appearance of lesions which, under the usual definitions, we hesitate to term either strictly secondary or strictly tertiary. To this period the term intermediary may, with propriety, be applied.

The Stage Of Incubation

This period varies from two to five weeks, but its usual duration is from three to four weeks. Its commencement dates from the entrance of the syphilitic virus, but during its continuance there is not the slightest symptom or visible lesion that can be recognized as pertaining to the disease about to be developed. If the contagion gains entrance through an abrasion this latter heals just the same as it would have done if there had been no inoculation; if the disease is conveyed with vaccination, the vaccine vesicle pursues its early course unmodified. At the end of the period of incubation we find arising at the point where the virus has entered a small, somewhat tawny red, indolent papule. This papule is called a chancre, or the initial lesion of syphilis, and marks the commencement of the " primary stage."

The Primary Stage

The papule may, in its further course, undergo several modifications. If situated upon the skin, as in artificial inoculations, it usually remains as a dry papule over which the stratum corneum is seen tightly stretched; later this layer separates, and is perceived at the summit of the papule as a thin scale. If the tissues lying directly underneath the papule be delicately grasped between the thumb and index finger a certain amount of resistance is perceived. This resistance is due to the presence of a layer of hard infiltrated tissue constituting the so-called induration. The induration may be confined to a lamina not much thicker or stiffer than a piece of parchment, or it may approach the size of a split pea, or even the half of a small cherry. It is this induration which constitutes the fundamental characteristic of the true or hard chancre as distinguished from the chancroid. After an uncertain period, varying from two weeks to two months, the chancre undergoes retrogressive changes, which consist in the subsidence of the papule and disappearance of the induration. In many cases of cutaneous chancre the above-described course is not strictly followed. The epidermis, instead of remaining as a tense membrane stretched over the papule, gives way, and a superficial ulcer results. The secretion from this ulcer is scanty in amount, and unless irritated contains but little pus.