4. The Atypical Manifestations of Syphilis.-The organs of syphilitics are usually indurated from hyperplasia of the interstitial fibroconnective tissue. This is probably a manifestation of the syphilitic poison, though it must not be forgotten that alcoholism is frequently associated with syphilis and may be responsible for the cirrhosis of the liver and other indurations observed.

Cellular infiltrations beneath the mucous membranes, especially in the larynx, are common in syphilis, and may lead to ulcerations or indurations. In all probability the indurations of the internal organs follow such cellular infiltrations.

Endarteritis is common in syphilis in and about the specific lesions. This form of endarteritis does not, however, differ essentially from others.

Various skin eruptions occur in both secondary and tertiary syphilis. A few, because of their distribution, are characteristic, but the majority are with difficulty differentiated from similar non-syphilitic lesions, except the history of the case be taken into account.

Syphilitic bone diseases are common. Periostitis, ostitis, and osteomyelitis

Occur. These lesions have a selection for the upper third of the tibia, the sternum, and the skull. They may become very destructive, especially when affecting the septum nasi or the bones of the cranium. (See Diseases of the Bones.)

Hereditary Syphilis.-Hereditary syphilis may depend upon disease of the ovum, of the spermatozoön, or of both; or it may be caused by placental transmission, if contracted by the mother subsequent to conception. It can be inherited from the father only through the medium of the spermatozoön, hence the father of the infected child must be syphilitic at the time of conception. As the mother may infect the child either through a diseased ovum or by blood infection through the placenta, she may either be syphilitic at the time of conception or may contract the disease during pregnancy.

When, as sometimes happens, conception follows the union of a syphilitic spermatozoön and a normal ovum in a woman not infected with syphilis, it is not possible for her to become infected through the placenta from the fetal blood. This immunity of the mother of a syphilitic child is the foundation.

of "Colles' law" that a syphilitic child born of an apparently healthy mother is incapable of subsequently infecting her. The converse of this is also true, and forms the foundation of "Profeta's law," that an apparently healthy child born of a syphilitic mother cannot be subsequently infected by her.

FIG. 225.-Upper median incisors in hereditary syphilis (Cornil and Ranvier).

FIG. 226.-Serrations in normal teeth (Cornil and Ranvier).

The transmission of syphilis from parent to child rarely occurs subsequent to the lapse of four years from the time of original infection. Acquired syphilis of the mother may be transmitted to the child in utero as late as the seventh month of gestation.

Hereditary syphilis differs from acquired syphilis only in being without the initial lesion. It is contagious, and can be transmitted to others, just as any case of secondary syphilis.

For reasons already made plain, the hereditary form of the disease lacks the primary stage. Instead of virus reaching the child through some external focus where it first forms a chancre, and then invades the lymphatics, the poison, entering from the germinal cells, grows and multiplies simultaneously with the developing embryo, or in case of later infection of the mother, having produced its early manifestations in the body and invaded her blood, passes through the placenta and enters the circulation of the offspring.

Prenatal infection with syphilis is a very serious obstacle to the proper development of the embryo. Exactly how it will interfere with its progress will depend upon the time at which the infection of the embryo occurs and

the activity of the disease in the parents.
Thus, if the parents suffer from active
and malignant secondary syphilis at the
time of procreation, the disease in the
embryo is usually so active as to cause
its death and lead to abortion. The
aborted embryo is apt to show exagger-
ated lesions, such as palmar pemphigus
and disease of the internal organs.
the activity of the disease is more mild,
the fetus dies later, and is born dead and
macerated. It is said that at least one-
third of syphilitic children are born
dead.

If

If the virus is still less virulent, the children may be born alive with evidences of the disease, when they usually die shortly, or without evidences of its presence, to develop the symptoms and fall into an unhealthy condition shortly after.

Of these healthy appearing children, it is said that about 25 per cent. die in the first six months. Even if they survive longer, the dangers are overwhelmingly against the subsequent attainment of health and freedom from deformity. The newly born child of syphilitic parents usually shows no symptoms of the disease for from one to three weeks. About 30 per cent. show manifestations within a month, 66 per cent. of the remainder within three months.

The appearance of the syphilitic child, whether the syphilis be hereditary or accidentally acquired through contact with mucous patches in the maternal tissues during delivery, is about the same, the effect of the disease being a marked impairment of nutrition and growth.

The child appears small, withered, and weazened. Its features are senile or simian. It has a hoarse cry, and suffers from catarrh of the nasal mucous membrane, which causes the characteristic "snuffles." Cutaneous eruptions are frequent, and changes in the bones and joints are partly characteristic.

If the child lives, its life is apt to be a continued succession of morbid processes-pemphigus, coryza, cirrhosis of the liver, osteochondritis, dactylitis, interstitial keratitis, etc.

All its physiologic processes are disturbed and its structure morbidly modified. Thus, the teeth of the first dentition are irregular in development, opaque, chalky, deficient in enamel, with soft friable dentin, inequality in size, and proneness to decay. The permanent teeth are characterized by a peculiarity of the upper central incisors, known as "Hutchinson's teeth," the fang of each tooth being short, thick, and deeply notched at the edge.

As the child grows, various cellular infiltrations, superficial and deep ulcerations, make their appearance, with corresponding cicatrizations and more or less marked disfigurement and deformity.

PART II-SPECIAL PATHOLOGY.

CHAPTER I.

THE BLOOD.

GENERAL REMARKS.

THE blood is the circulating, life-sustaining fluid of the body. It receives the products of digestion in an assimilable and utilizable form, and conveys them to the various cellular laboratories for refinement. It carries appropriate nutriment to all the cells of the organism, absorbs effete products from the metabolic tissues, and carries them to the excretory organs. Through the hemoglobin contained in its corpuscles it is the means of tissue respiration, oxygen being absorbed in the lungs and carried to the cells, and the carbon dioxid eliminated by the cells taken back for elimination.

The blood consists of fluid-liquor sanguinis-and corpuscles.

Physiologically, blood is divided into the arterial, or freshly aërated, bright-red blood, the venous, or vitiated dark-blue blood, and the capillary, or intermediate blood. For purposes of study the blood is sometimes obtained by opening an arterial or venous vessel, either at the surface or in the organs of the body, but in nearly all cases studies of the blood are made from a drop obtained from a small puncture made in the ball of the finger or tip of the ear, and represents the capillary blood of the peripheral circulation. Whenever statements concerning the structure and composition of the blood are made, it should always be borne in mind that they refer not to the total blood or to the blood in the great vessels, but to this easily accessible blood of the peripheral circulation.

This blood used for study is a dark-red, heavy fluid. It is alkaline in reaction, from the presence of disodic phosphate (Na,HPO,) and sodium carbonate (NaHCO,). The alkalinity expressed in terms of sodium hydrate, according to different authors, varies as follows:

These variations seem to indicate that no reliable method of determining the alkalinity has yet been devised, and it is safe to follow von Limbek, Cabot, and others in saying that it is not correctly known.

For clinical purposes one can determine whether the blood be alkaline or acid, in spite of its red color, by the use of glazed litmus-paper, allowing it to remain in contact with the paper for about one-half minute, then carefully washing it off. In this way the corpuscles which give it the red color will be removed and the paper will show the reaction.

The specific gravity of the blood depends upon the number of corpuscles and their percentage of hemoglobin. In children it varies from 1.054 to 1.052. For women, the specific gravity approximates 1.054; for men. 1.055. It is safe to adopt 1.055 as the normal standard for healthy adults.

A simple method of estimating the specific gravity is that of Hammerschlag. It is done by making a mixture of chloroform and benzol of exactly the same specific gravity as a drop of blood permitted to fall from the punctured finger into it. If the drop of blood tends to sink, chloroform must be added; if it tends to float, benzol must be added. As soon as the drop of blood remains suspended, tending neither to rise nor to sink, the specific gravity of the mixture can be determined with a hydrometer and the reading will apply both to the blood and to the chloroform-benzol mixture. The hydrometer used for the purpose must be specially and correctly graduated for measuring the specific gravity of the chloroform-benzol mixture. The blood has a characteristic odor, which in different animals resembles the pulmonary exhalations.

It is somewhat difficult to make a correct chemic analysis of blood, because of the rapid formation of fibrin when it is shed. According to C. Schmidt, the following calculation represents the chemic composition with fair accuracy:

Hoppe-Seyler and Hammarsten give the composition of horse's plasma as

Simon introduces the following table, showing the marked difference existing in the mineral ingredients between serum and red corpuscles, the latter being relatively rich in potassium salts and phosphorus and poor in sodium salts and chlorin.

In addition to the composition given, which may constitute the invariable or slightly variable composition of the blood, there are a number of compounds which occasionally present themselves. Among these may be mentioned fat, varying from 0.01 to 0.015 per cent. after rich meals; soaps, cholesterin, lecithin, dextrose, normally about 0.01 to 0.015 per cent., and sometimes even 0.03 per cent., urea, uric acid, kreatin, kreatinin, carbamic acid, sarcolactic acid, glycogen, hippuric acid, and, under pathologic conditions, xanthin, hypoxanthin, paraxanthin, adenin, guanin, leucin, tyrosin, lactic acid, cellulose, 3-oxybutyric acid, acetone, and biliary constituents.

The gaseous interchange that takes place in the lungs and tissues causes venous and arterial blood to differ widely in gaseous ingredients; thus we