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^^ ■ Hu i\ct-S^ 
 
 ■ H clzi^nni ^ J. if. 
 
 ON THE 
 
 STAGES AND FORMS OF SYPHILIS 
 
 WITH MORE ESPECIAL REFERENCE TO THE 
 
 HEPATIC MANIFESTATIONS OF THE DISEASE. 
 
 BY J. G. ADAMI, M.A., M.D., F.R.S.E., 
 
 PROFESSOR OF PATHOLOGY, McGILL UNIVERSITY, MONTREAL 
 
 ri:phinti;i) fiiom ihk montri;ai. mkuuai, .iovhnai., junk, 1s08, 
 
 V 
 
 ^"R#A^ 
 
 1 
 
ON THE STAGES AND FORMS OF SYPHILIS 
 
 WITH MORE ESPECIAL REFERENCE TO THE HEPATIC 
 
 MANIFESTATIONS OF THE DISEASE/ 
 
 BY 
 
 J. G. Adami, M.A., M.D., F.R.S.E,, 
 
 Professor of Pathology, McGill University, Montreal. 
 
 It is remarkable how during all these centuries, syphilis has 
 remained sharply distinguished from all other forms of human disease, 
 constituting a class apart. There are many other contagious maladies, 
 not a few chronic infectious disorders, and, now-a-days, we are able 
 to group these together ; we can recognise common principles govern- 
 ing their course and effects upon the organism, and can see, or think 
 we see, a common principle underlying the morbid changes in one or 
 other tissue from the onset of the disease to its culmination— a prin- 
 ciple identical in the infant and in the aged. So we can with syphilis 
 only habitually we do not. We treat and regard it as a something 
 
 distinct. 
 
 Take for instance that disease which in its chronicity as in the 
 lesions which characterise it, most closely resembles syphilis— tuber- 
 culosis. From the onset to the end, at every stage, from the primary- 
 lesion to the most extensive generalisation of the process, we see one 
 morbid change at work, namely, the focal multiplication of the bacilli 
 leading to the development of tubercles. It is true that according to 
 circumstances these tubercles may vary in their characters from a 
 condition in which small cell infiltration is so extensive as closely to 
 approximate to miliary abscess formation, through conditions of so- 
 called epithelioid cell overgrowth to a state in which fibroid connec- 
 
 1 Delivered at the meeting of the Ontario Medical Association at Toronto, June 
 1st, 1898. 
 
2 
 
 tive tissue development is so excessive as to iimsk everything else, 
 save, perhaps, necrosis and caseation. But the fact remains that we do 
 not sharply diH'erentiate successive stages of the disease, or consider 
 that the successive stages are characterised by the development of 
 specific manifestations. At the most, in one organ, the lungs, we 
 trace such succe.ssive stages of the tubercular process, but we never 
 think of laying down that what is to be made out in the lungs obtains 
 for other organs, and for the body in general. On the contrary, a 
 study of pulmonary phthisis alone has convincetl us that the course 
 of tuberculosis varies so greatly according to the interaction of two 
 factors — the condition or reactive power of the tissues, and the viru- 
 lence of the bacilli — that to attempt to plot out the course of the dis- 
 ease in each case into well tletined stages is an impossibility. 
 
 With syphilis it is quite another thing. From llicord onwards a 
 primary, secondary, and tertiary stage have been clearly distinguished, 
 and not only this, but according as to whether the disease is acquired 
 in post-natal life, or has seized upon the individual while in the 
 mother's womb, so do we recognise two difterent types of the disease . 
 
 There is, I take it, no more firmly ' fixed idea ' in the whole of 
 medicine than that of the absolute existence of these different stages 
 and forms of syphilis. To-day, I do not want to pose as a revolution- 
 ist and an iconoclast, for speaking broadly, and regarding the bulk 
 of the evidence before us, I, like all others, must acknowledge the 
 utility of the divisions. But there is a danger in these fixed ideas, 
 in medicine as in all sublunary affairs, and, to say the least, it is of 
 benefit occasionally to enquire whether what is accepted of all men is 
 so absolutely and entirely fixed and assured as we are accustomed to 
 regard it. 
 
 What I am about to say is not novel. The unity of syphilitic 
 lesions has been preached for now more than thirty years, in fact, 
 ever since Wagner pointed out that all such lesions might be referred 
 to the developments of a specific neoplasm. Perhaps Wagner went 
 too far, for there are generalised fibroid conditions, which, as I shall 
 have to point out in connection with the liver, are not directly due to 
 the development of circumscribed neoplasms ; but it must be acknow- 
 ledged that neoplasms or infective granuloinata are to be recognised 
 in each stage and form of the disease. Nevertheless, the idea of the 
 sharp demarcation of the difterent forms and stages of the disease 
 seems to be as firmly planted to-day as it was prior to 1864, and the 
 admirable protest of Ncvins Hyde' and the writings of others do not 
 seem as yet to have inHuencod the profession in general. 
 
 • Morrow's System of Genito- Urinary Diseases, Vol. II., 18!)3, p. 20, et seq. 
 
8 
 
 At the outset, I must point out that it is not even necessary to have 
 any recognisable rtrst stage or cutaneous chancre. We know well, 
 that in evciy case of infection, the infectious agent must make an 
 entry from without into the tissues, and in a great number of cases 
 we can discover the point or points of entry, and at such point or 
 points we find evidences of primary local infection, whether on the 
 skin or mucous membranes, and this local infection is strictly com- 
 parable with the cutaneous syphilitic chancre. But we also come 
 across cases in which there is a complete lack of evidence of such 
 superficial primary infection ; we may find, for instance, the cervical 
 or mesenteric lymph glands affected with tuberculosis without a sign 
 of tuberculosis of the pharynx or tonsils or intestinal mucosa, cases 
 which usually, though mistakenly, are spoken of as ' ci'yptogenetic' 
 What occurs in other diseases must at times occur in syphilis, and in 
 going over my post-mortem records, in which to each case, I have 
 subjoined a record of the clinical history of the case, I have been 
 struck several times by observing that where well marked tertiary 
 syphilis has been present in the organs, there has not been a sign of 
 old penile or other chancre,' and more than once, in following up the 
 clinical history, by finding that while the patient has freely admitted 
 that he has led a loose life and suffered, it may be several times, from 
 gonorrhoea, he has denied ever having suffered from chancre (vide 
 case III). Now presumably an individual who had had a hard sore 
 would not wholly forget the circumstance, nor is it rational to urge 
 that a hospital patient who admits without constraint that he has led 
 a life of excess and suffered from other venereal diseases, would con- 
 ceal the previous existence of a chancre. Either then the chancre 
 was so small and inconsiderable as to cause no inconvp^ '-^nce, or the 
 virus gained entry into the system without causing •,- cutaneous 
 disturbance. 
 
 In the female this absence of any superficial or recognisable first 
 stage is especially noticeable ; time after time the disease only mani- 
 fests itself in the secondary stage. I would go so far as to say that 
 the ' fixed idea ' that there must be a chancre developed at the region 
 of primary infection, has led to a thorough and general misunder- 
 standing as to the nature of congenital syphilis. It is a popular fall- 
 acy to regard a considerable number of cases in which the father of 
 
 ' In some at least of these cases without doubt, the same process has happened 
 as occurs occasionally in connection with vaccinal cicatrices, namely, there has been 
 so complete absorption of the cicatrical tissue, that the part becomes in the course 
 of years absolutely normal in appearance. This complete absorption I need scarcely 
 say, is characteristic of primary lesions of mucous surfaces, and is very frequent in 
 the female. 
 
4 
 
 syphilitic offsprinf,' is syphilitic, anil the iTiothcr is apparently free 
 from the disease, as due to the sperm heinjj syphilised, or if this view 
 be carried to its logical conclusion, it is supposed that the spermato- 
 zoon bears with it the syphilitic virus, be it bacillus or whatever the 
 nature of the specific microbe, and introduces it into the ovum at the 
 monjent of conception, and thus the oH'sprin}^ develops, syphilised 
 from the start, the mother bein<if and remaininjf absolutely free from 
 taint. This, as I say, is a popular fallacy. But it is incredible that the 
 germ gain entrance into the spermatozoon, for the spermatozoon being 
 nucleus and Hagellum, and scarce anything more, has not the means 
 of ingesting foreign bodies, while we have not a shred of evidence 
 that the syphilitic germ is amiKboid and capable of making its way 
 into the spermatozoon. 
 
 It is likewi.se outside the limits of credibility that a virulent organ- 
 ism could be within the minute almost yolkless segmenting human 
 ovum, lying latent in one or other of the cells, the products of 
 segmentation. Such passages of pathogenic microbes on to the sur- 
 face, and possibly into the eggs, may occur in insects, as Pasteur 
 demonstrated, but the insect's egg contains relatively abundant yolk, 
 and segmentation then may be little influenced by the presence of the 
 micro-organism, provided that this be in the yolk. Even then, I 
 doubt whether the embryo could develop properly, and ani inclined to 
 consider that a more reasonable explanation of Pasteur's observations 
 upon the silk worm's eggs is, that at a relatively late period of their 
 development those which come to maturity Ijecome tainted either 
 from the surface or from other eggs which have been killed by the 
 multiplication of the germs within them. 
 
 If the syphilitic virus gained entry into the unsegmented human 
 ovum, its effects would surely be to lead to the destruction of the 
 ovum. FcKtal syphilis must originate at a later date, and although 
 syphilis in tlie pai'ents may doubtless have its effects upon the ovum 
 and spermatozoa of the same, and lead to constitutional disturbances 
 in the offspring, progressive syphilitic lesions, the true .syphilomata, 
 in the foetus and infant are not inherited, but are congenital, that is 
 to say, acquired in utero after conception. Or in other words, inherited 
 and congenital .syphilitic lesions are two very different things. Thus 
 to return to the main point, if the mother be without sign of .syphilis, 
 and the child be .syphilitic, the only satisfactory explanation is, that 
 the syphilitic virus has entered into the maternal organism and 
 tissues, and has failed to induce any characteristic lesion at the point 
 of entry, but has, nevertheless, through the placenta and chorionic 
 villi gained an entrance into the tVietal tissues ; the process arrested 
 
in th(» mother has betin •leveloped in the Husceptihle tissutis of the 
 clilM, iind we have here an interestinj^ example! oi' tlie variahility in 
 the manifestations of the disease dependent npon the reactiv*^ powers 
 of the tissues. 
 
 Were any further word necessary in support of this contention it 
 would be found in the significant way in winch the liver is affected 
 in congenital syphilis. Extensive specific lesions of the liver in the 
 acquired disease are relatively uncommon They are the most 
 common of all lesions in the congenital affection. As Chiari has 
 pointed out, out of 144 cases of congenital syphilis examined by him, 
 the liver was diseased (and that extensively) in 128 cases or nearly 
 nine-tenths. Were the ovum infected it would be difficult to explain 
 why the liver should thus be especially singled out. When we re- 
 member that this oi'gan is the first to receive the blood coming by the 
 umbilical vein, then if the infection originates from the placenta 
 hepatic implication is the natural sequence. 
 
 The essential difference between such congenital, or ante-natal, and 
 ' acquired,' or post-natal syphilis is, that in the former the virus passes 
 innnediately into the blood and so becomes <Jisseminated through the 
 organism, in the latter, the dissemination is delayed. The second 
 stage of acquired syphilis, is tJie first stage of the congenital disease. 
 
 Again, although as a pathologist not in practice, I have not met 
 with and am little likely to come across the condition, continuing the 
 analogy between tuberculosis and syphilis' we must, I hold, admit the 
 inherent probability of Kaposi's statement that it is possible to have a 
 primary cutaneous syphilitic lesion, a true specific indurated chancre, 
 not followed by any secondary effects. And further it is well estab- 
 lished that women who have borne syphilised children and have 
 themselves shown not a sign of primary or secondary manifestations 
 may, years after, present unmistakable tertiary lesions.^ 
 
 Up to this point, therefore, it may be laid down : 
 
 (1) That from analogy, as from clinical history and absence of any 
 indications of the same, in sundry cases there may be an absence of 
 the primary cutaneous or epithelial manifestations of syphilis. 
 
 (2) That individuals may fail to present either primary or second- 
 ary' symptoms that are recognisable, and yet eventually develope 
 definite tertiary lesions of the disease. 
 
 (8) That where the subject is relatively insusceptible, it is possible 
 
 ' Every pathologist knows, many from personal experience, liovv frequent among 
 those performing autopsies are casea of strictly localised cutaneous tubercles not 
 followed by extension. Such primary cutaneous tuberculosis is characterised by its 
 tendency to remain localised. 
 
 •^ Vide Finger, Arch. f. Dermat. u. Syph. 18!K), p. H31. 
 
that the disease may he limited to the primary cutaneous manifesta- 
 tion not followed by secondary lesions.. 
 
 (4) That as with tuhi-rculosis so with syphilis, tlie congenital form 
 of the disease begins at what may he termed the secondary stage of 
 the acquired disea.se, i.e., the stage of general dissemination of the 
 virus through the organism. 
 
 The Relationship between Secondary and Tertiary Syphilis. 
 
 I would now pass on to consider the relationship between the 
 secondary and tertiary stages of syphilis. 
 
 Where in any infectious diseases we have widespread eruptions, 
 affecting both skin and mucous membranes, we now feel a.ssured that 
 such eruptions are due either to the irritation set up by the actual 
 presence and growth of the specific germs of that disease in the sub- 
 cutaneous and submucous layers, or to the irritation produced by the 
 products of the.se germs growing in other parts of the system. 
 And the more we study infections of which we can isolate the specific 
 microbes (.streptococcus and pyococcus infections, typhoid, &c.), the 
 more we find the first of these alternatives in force, and in the case of 
 syphilitic eruptions, the fact that the cutaneous eruptions are infective, 
 affords clear evidence that the specific virus is present in them. 
 
 Such generalised infections of the skin and mucus membranes can 
 only be brought about through the agency of the blood stream, or, 
 otherwise, what is termed the secondary stage of post-natal, acquired 
 syphilis, is the stage of general dissemination of the virus through 
 the system by the blood stream, and of the more immediate results of 
 such dissemination. What has been described as the second period of 
 incubation (the interval elapsing between the development of the 
 chancre and the appearance of syphilodermiae) is the period requisite 
 for the virus to infect and traverse the lymphatic system on its way 
 from the primary lesion into the blood stream, and then to proliferate 
 in the cutaneous and other tissues up to such a point that eventually 
 it produces a reaction. 
 
 It is usually held that the syphilitic virus now especially affects the 
 skin and mucosae, and that the abundant and varied crop of syphil- 
 ises — of syphilodertni:e — are the peculiar sign of the second .stage 
 gummatous and more fibrous growths being characteristic tertiary 
 developments. Certainly the eruptions are the prominent features of 
 the secondary stage, but it is too much left out of account that in the 
 early stages of generalisation of the disease, the internal organs may 
 be, and perchance often are, affected. And what I wish more especially 
 to bring before you this evening is this lack of sharp definition 
 
between the unatoinical chanj^ea in early and late jjeneralised syphilis. 
 This lack is well shown by a study t»f the syphilitic liver ; indeed, it 
 is a study ut* several cases (jf syphilitic hepatitis which have been 
 revealed in the post-mortem theatre at the Royal Victoria Hospital 
 during the last four years, which has prompted me to select this more 
 general treatment of the stages and forms of syphilis to bring before 
 you this evening. 
 
 The I'eason why tertiary and secondary syphilis are regarded as so 
 widely distinct is not difficult to comprehend. The disease is rarely 
 directly fatal, especially now-a-days, and it ij rarely that we obtain 
 an opportunity to study the viscera during the earlier stages. As 
 Jonathan Hutchinson has pertinently remarked : "The visceral 
 pathology of the secondary stage might form a chapter in the his- 
 tory of syphilis which has not yet been written, and for which we 
 possess few data. It is however, I feel sure, a great mistake to state 
 that there are none to be obtained." In the address from which I 
 take these words, an address which opened a celeV)rate(l discussion at 
 the Pathological .Society in London in 1876, he pointed out that abun- 
 dant facts are on record to disprove the assertion that large gunnnata 
 are not to be seen in the secondary stage. He noted that two cases 
 of death from syphilitic disease of the heart which had come under 
 his notice, had both occurred during the secondaiy stage and presented 
 myocarditis with gummata, and in one of the two there were also 
 distinct gummata in the spleen and in the testes, while he went so far 
 as to state that the best example of gumma in the liver which he had 
 encountered was in an infant. 
 
 To bring forward the evidence presented by the liver as to the 
 identity of the anatomical lesions in the two stages, and as to the 
 continuity or unity of the disease, it will be well to discuss the ways in 
 which the liver is affected in syphilis and run over the different forms 
 of specific hepatic lesions. 
 
 It is difficult to realise that scarce fifty years have elapsed since it was 
 first clearly established that tlie liver is affected in any form of syphi- 
 lis. The chapter in medical history bearing upon the liver in relation 
 to syphilis is of some interest. Hutten and Fallopius and many of 
 the earliest writers upon the morbus gallicus, held that syphilitic 
 ulcers wherever appearing were the result of a corruption of the 
 humours, the origin of which was to l)e looked foi* in the liver which 
 had become diseased from the action of a volatile contagion. Others 
 held that this organ was tlie first to l)e affected consecutively to dis- 
 ease i)f the genital organs. This was when every disease was regarded 
 as (hie to a disturbance of the humours, and the liver being large and 
 
8 
 
 of unknown functions, the severity of the disease almost naturally 
 led to the liver being seized upon as the guilty party in syphilis. 
 When autopsies became more frequent the implication of the liver 
 became seriously disputed : Paracelsus denied that it had any r61e in 
 disease, stating that he had frequently found other organs affected 
 but had rarely met with any disturbance of the liver. Morgagni 
 again in the middle of the eighteenth century, but expressed the 
 views of his contemporaries when he denied any relationship between 
 syphilis and hepatic disorders. 
 
 The Liver of Congenital Syphilis. 
 
 Only in 1848,' or according to Hutinel and Hudelo in 1847, was there 
 published any serious study of the liver, in syphilis, and then it was 
 not the characteristic gummatous liver of the acquired disease, but 
 the enlarged liver of the congenital condition to which attention was 
 called. In that year and yet more fully in 1852, Gubler described 
 the liver of congenital syphilis, pointing out its enlargement, its firm- 
 ness and elasticity. He noted that the changes were often in circum- 
 scribed spots only, and here in these very earliest careful studies upon 
 the subject, he pointed out that while the other lesions in the infant 
 were of a secondary nature, the changes in the liver were of tertiary 
 type and allied to the gummatous developments. 
 
 Time forbids that I should describe minutely the histological 
 changes occurring in the liver of congenital syphilis. You will find 
 them clearly stated in an article upon diseases of the liver by your 
 distinguished confrere Dr. Graham, in the recently published Loomis- 
 Thompson System of Medicine, an article which is far and away the 
 best treatise on hepatic disorders by a single individual that has 
 appeared in our language for many years. SuflSce it to say that the 
 affected portions of the organ present a combination of the develop- 
 ment of minute, somewhat ill-defined collections of small round cells, 
 which we know as miliaiy gummata, together with a wide-spread 
 development of fibrous tissue, not only along the portal sheaths, but 
 also spreading between the groups of liver cells which present more 
 or less atrophy, in short, a condition of pericellular fibrosis. This 
 fibrosis is in itself what we are accustomed to regard as a peculiarity 
 of tertiary syphilitic manifestations. Yet here it occurs within a very 
 few months of the primary lesion, when cutaneous eruptions and other 
 secondary symptoms are abundant. And not only this, but at times 
 we have appearances more closely resembling the gummata of the 
 acquired disease. 
 
 ' Gubler, Gaz. des Hop. Jan. 1H4H, and Gaz. Med. de I'aris, 1852, p. 2(52. 
 
"What is the meaning of this general interstitial fibrosis, or more 
 correctly, what is the series of changes which leads to its formation ? 
 It is difficult to state with precision. At times it appears to be wholly 
 in excess of any development of the above mentioned miliary gummata. 
 Indeed, it looks as though it had not been preceded by any charac- 
 teristic syphilomatous lesion, and the peculiar manner in which 
 the connective tissue development extends between the rows of 
 the liver cells, and becomes pericellular, and pari passu the liver 
 cells show evidences of atrophy, would seem to indicate that here 
 we are dealing with, not so much the results of the productive granu- 
 lomatous inflammation, as with a process of tissue disturbance set 
 about by the diffusion throughout the system of the toxic substause 
 generated by the virus. These toxines lead to the atrophy of the liver 
 cells with synchronous development of connective tissue ; in short, the 
 appearances are largely, but by no means entirely, those of a replace- 
 ment fibrosis. 
 
 A somewhat similar condition is occasionally to be met with in the 
 kidney and that in the earlier stages of the disease. The only further 
 point I need impress upon you here is that this generalised fibroid 
 change may be developed in the earliest stage of the generalised 
 disease, and by no means necessarily indicates a tertiary condition. 
 
 In some rare cases this extensive fibroid condition appears to be 
 present with very little evidence of syphilomatous or granulomatous 
 change in the organ. Marchand' has recently described and collected 
 together about half a dozen examples of this condition. Curiously 
 enough, this form of cirrhotic liver with atrophy in most of the cases 
 has occurred in one of a pair of twins and that one still-born. It is 
 also associated with evidences of profound hepatic disturbance in 
 the shape of icterus. Marchand's cases are not wholly satisfactory 
 so far as regards the history of syphilis in the parents, but, as he states, 
 it is difficult to explain this remarkable condition of atrophy of the 
 organ with extreme fibrosis, save on the supposition that tlie cases 
 were syphilitic. 
 
 Coming now to the presence of gummata, Oubler noted in his 
 earliest communications that scattered through the cirrhotic areas in 
 the infantile liver were numerous fine paler flecks, which he likened to 
 grains of semolina, and Virchow, studying these, spoke of them as 
 miliary gummata. More and more evidence has accumulated as to 
 the relationship between these minute, ill-defined tubercles or collec- 
 tions of small round cells, and the caseous gummata seen in the 
 acquired disease. The relationship is identical with that between 
 
 1 Ctbl. f. Allgem. Path., Vol. VII., 1806, p. 273. 
 
10 
 
 miliary tubercles in the lung, and encapsuled tubercular caseous 
 nodules in the same. In the great majority of cases, the liver of con- 
 genital syphilis presents the admixture of a diffuse pericellular 
 cirrhosis and scattered miliary gummata. Sometimes the whole of 
 the organ is aftected, at other times the process is observed <mly in 
 parts, either at the edges or in a portion of one lobe. In this latter 
 case, one has circumscribed yellow masses sharply defined from the, 
 in general, congested, but otherwise unaffected hepatic tissue. Sydney 
 Coupland,' indeed, goes so far as to regai'd these circumscribed masses 
 as enormous gummata. It is, however, open to doubt whether these 
 masses strictly conform to our idea of gummata, although I must 
 confess that it is difficult to define with precision what we include 
 under this term. For myself I am inclini^d to regard them as more 
 nearly resembling the large nodular syphilomata occasionally to be 
 met with in the adult liver, where they may be so well defined as 
 time and again to lead to the erroneous diagnosis of non-infective 
 neoplasms. 
 
 There are frequent cases on recoi'd in which true gummata have 
 been recognised in the liver within a few weeks after birth. Several 
 French cases will be found quoted by Hutinel and Hudelo^ in 1890, 
 while Cohn in 1896 quotes several German authorities.' In English 
 literature, I have found cases described by Canton,* (in an infant of 
 two weeks, with numerous small gummata), Barlow"' and Hutchin- 
 son (loc. cit.) 
 
 In Barlow's case the cMld showed no syphilitic symptoms until it 
 was seven weeks old ; it died five weeks later, and upon the upper 
 surface of the liver were several depressed areas, varying in size from 
 that of a pea to that of an almond, one having a slight tail-like pro- 
 longation ; there were a few also upon the under surface. As he 
 points out, froui the.se depressions it is clear that the gummata were, 
 as he terms it, receding, although it would seem clear that they pre- 
 sented no central caseous change. 
 
 From the above description it would seem that in the liver of the 
 new born infant, presenting externally evidence of what is known as 
 as the secondary stage of the disease, there may be several varieties 
 of syphilitic manifestations : 
 
 1. Well defined gummata. 
 
 2. Admixture of miliary gummata, with generali.sed fibroid change 
 
 1 Trans. I'atli. Soc- London, Vol. XXVII., 1870, p. 'Mi. 
 •' Arch. (If Med. Experiint, 18!K), Vol. II., p. .lO!). 
 :' Vircho\v'.s Arch., Vol. 140, 181K5, p. 468. 
 * Trans. Path. Soc , Vol. XIII;, 1802, p. 113. 
 ' Trans. Path. Soc, Vol. XVII., 1876. p. 292. 
 
11 
 
 not affecting the whole organ but forming relatively large circum- 
 scribed areas. 
 
 3. Admixture of miliary guramata and generalised fibrosis affect- 
 ing the whole organ, which is in consequence enlarged. 
 
 4. Generalised " atrophic " cirrhosis without much evidence of 
 gummata, but associated with icterus, cedema, etc., the organ being 
 granular and definitely contracted. 
 
 In other words all the changes seen in congenital syphilis ai'e those 
 which ordinarily are considered to characterise the tertiary rather 
 than the secondary stage of the disease. 
 
 There is yet another form of congenital syphilis which has to be 
 noted ; the form termed " Syphilis hereditaria tardiva " or more cor- 
 rectly, delayed congenital syphilis. Several examples of this delayed 
 syphilis are on record ; it is to be made out from them that frequently 
 the cutaneous changes may not show themselves for years after birth. 
 Taking up more especially the English literature upon the subject, 
 Henry Morris ' has described a case of a girl aged 20 with marked 
 syphilitic family history and evidences of interstitial keratitis, who 
 had suflPered from sore throat at 12, enlargement of the liver at 18, 
 ascites at 19, and at the autopsy, the liver was found much puckered 
 and deeply fissured as well as altered in shape, while there were 
 several large gummatous nodules imbedded in different parts of the 
 organ. Wills* records a case that seems somewhat more definite, in 
 which a male, aged 22, presented a small dense liver with thickened 
 capsule, which was constricted into lobules by numerous thickened 
 bands of connective tissue, a condition which he could only explain as 
 being due to congenital syphilis. Bristowe describes a condition of 
 gummata in the liver of a boy of 15 which gave way to treatment 
 with potassium iodide, a condition which he couM only regard as an 
 excellent example of the results of delayed congenital .syphilis ; and 
 Osier, in his well known Lectures on the Diagnosis of Abdominal 
 Tumours, gives two cases which are similar, one of his own, the other 
 which had been recorded by Dr. A. C. Wood, in the University Medi- 
 cal Magazine, Vol. II. Both of these cases were in boys of 13, pre- 
 senting clear evidence of congenital syphilis ; in both there was the 
 enlarged irregular liver which diminished un<ler the action of potas- 
 sium iodide. A further case in a male, aged 22, has just been pub- 
 lished by Post and Councilman.' 
 
 It is clear then that congenital syphilis, like the acquired disease, 
 can manifest a tertiary stage long years after infancy, and that the 
 
 ' Trans. Pdth. Soc. Vol. 21, 1870, p. 214. 
 
 - Liverpool MedicoOhirurgical Journal, July, 1892. 
 
 3 Boston City Rep., 1808, p. 233. 
 
12 
 
 tertiary symptoms when thus delayed are liable to be of the gum- 
 matous type with cicatricial contraction. In other words, congenital 
 syphilis may in every respect follow a course identical with that seen 
 in the acquired. 
 
 The Liver of Acquired Syphilis. 
 
 Passing on now to consider the syphilitic manifestations in the 
 disease of post-natal acquirement, it is very interesting to notice that 
 whether we are dealing with cases in which death has occurred 
 within the first year after the disease has been communicated to the 
 individual, or whether we obtain the liver long after the acquirement 
 of the disease, the morbid changes are of the same order, the only 
 recognisable difference being that the longer the time that has elapsed 
 after infection, the greater is the tendency to the development of 
 cicatricial changes with contraction and deformity of the organ. 
 
 Taking up the hepatic disorders in series, perhaps the earliest dis- 
 turbance that has been noticed with common frequency is the develop- 
 ment of icterus in the early secondary stage. The association has 
 been noticed by several writers. Hilton Fagge, writing in 1867, was 
 able to quote Portal, Ricord, Gubler and Lancereaux upon this point, 
 and noted that Lancereaux alone had collected 21 other descriptions 
 of the connection, and, intermittently, observers have since described 
 the association which is now generally recognised. The last writers 
 upon the subject are Neumann, Joseph, and Uhlmann. 
 
 Inasmuch as patients have very rarely died in this stage, it is 
 impossible to state with precision what is the condition, but by 
 analogy with what occurs in the infantile liver, it may be suggested 
 that there is here a generalized toxic disturbance of the organ, with 
 catarrhal hepatitis, which may or may not lead on to the generalised 
 fibroid state which has been described in connection with the infantile 
 Kver. Indeed, Hilton Fagge' has recorded a very interesting case of 
 what he terms yellow atrophy of the liver consecutive to a diffuse 
 change in the organ due to acquired syphilis. The case is that of a 
 female of 23, in which there was a history of syphilitic rash with 
 falling off of hair, and macular syphilides. Jaundice appeared to be 
 of the obstructive nature. The patient became drowsy, then uncon- 
 scious and comatose. At the autopsy, the liver weighed 46 oz., and 
 was of an opaque bright yellow colour, and of dense consistence. The 
 surface was mottled, the left lobe resembled very closely that of the 
 infantile syphilitic liver; it was pale and semi-pellucid, and the 
 parenchyma was replaced by connective tissue ; there was no amyloid 
 rea^stion. 
 
 7 
 
 Trans. Path. Soc, Vol. XVIII., 1807. 
 
18 
 
 7 
 
 Here then we have the jaundice, associated witli the generalised 
 atrophic condition of the organ, which in the absence of full micro- 
 scopical description, may be taken to be either closely allied to the 
 atrophic form already mentioned in the infant, or to the general 
 pericellular fibrosis with miliary gummata seen in same. Without 
 deciding positively to which form this case belongs, I would point out 
 that generalised change in the organ is more common than I think is 
 generally recognized. 
 
 The gummatous syphilitic liver is so characteristic and so well- 
 known a form of hepatic disease, that novv-a-days, it is rarely 
 described, save from previous authorities, and thus in general, once 
 gummata are recognized in the liver not much further interest is 
 taken in the case ; thus the old classic descriptions and ideas are per- 
 petuated. 
 
 It is generally laid down that in tertiary syphilis affecting the liver, 
 guunnata, whether well marked and caseous, or the cicatrised remains 
 of such with well-formed stellate surrounding of fibrous bands are 
 the characteristic changes in the organ, while a condition of generalised 
 and pericellular cirrhosis is wanting. It nmst, however, be remem- 
 bered that even years after the primary infection such cirrhotic 
 change may be recognisable, and not a few cases are on record of 
 such a condition. 
 
 In three out of eight cases of tertiary sj'philis affecting the liver 
 which have come to the post-mortem room at the Royal Victoria Hos- 
 pital during the past four years, there was clear and fairly extensive 
 pericellular fibrosis along with gummatous change. The fibrosis, it is 
 true, was not generalised over the whole liver, the condition more 
 nearly resembled a condition of circumscribed fibroid change seen in 
 the infantile liver. 
 
 These three cases are of some interest as throwing light upon the 
 
 hepatic changes. In one case there was no clear history given of the 
 
 date of infection. 
 
 Case I.— Male, iBt. 35. The patient became amemlc and emaciated in April, 1895, 
 oedema and ascites supervening, and death occurred early in July. There was albu- 
 minuria and the cedema of the legs had been complicated with an erysipelatous 
 condition which seems to have been directly caused by the hepatic disturbance, for 
 the heart was fairly normal, and the kidneys although large and white, showed 
 scarce any sign of interstitial change. The liver showed numerous large deep stel- 
 late cicatrices with some diaphragmatic adhesions. The organ in general was soft 
 with advanced fatty nutmeg condition. Sections through the cicatrices showed a 
 characteristic gummatous appearance with large bands of fibrous tissue running 
 deeply. Microscopically, there was a considerable amount of pericellular cirrhosis 
 jn the neighbourhood of the gummata with much small-celled infiltration. The 
 spleen was large, firm and congested. The stomach presented diffuse submucous 
 hiemorrhages. 
 
14 
 
 I shall return later to consider this condition of small celled infil- 
 tration. Case v. to he referred to later showed a similar condition. 
 
 In another patient of Di". Stewart the condition was more wide- 
 spread. 
 
 Cask II.— The patient aged about thirty-seven, was infected 14 years before his 
 death, and, although himself a medical man, had never untlergone proper antisyp- 
 hilitic treatment, on account of the intense gastric disturbance induced l)y mercury 
 and potassium iodide. Four years after infection he su/lered from gastritis and 
 diarrha'a altei'nating nitli constipation and a condition of gastric disturbance and 
 general malaise which continued at intervals for the rest of his life. It is to be 
 noticed that there was a frecjuent development of a febrile temperature. Ascites 
 and jaundice supervening in the middle of October he was tapped ; the tluid collected 
 again, and he died in the beginning of November. 
 
 At the autopsy, there was no sign of old ulceration or chancre ; there was well 
 marked jaundice ; the heart was healthy in appearance, though there was moderate 
 atheroma of the aorta. There were dense bands of adhesions between the diaphragm 
 and the abdominal wall, and the liver was profoundly contracted and small, scarcely 
 passing beyond the middle line. It had a puckered and coarsely nodular surface. 
 The right lobe was especially contracted presenting fretiuent and well-marked gum- 
 mata with surrounding cicatrices so that the surface was broken up into numerous 
 small nodules of the large hobnailed type. On section there were numerous white 
 gummata from two to four mm., in diameter scattered through the liver substance, 
 and in addition there were relatively large areas of fibrosis here and there through- 
 out the organ. The spleen was large, turgid and smooth, weighing 57(( grammes. 
 
 Upon microscopical examination the organ showed well-formed caseousfgummata 
 with a zone of surrounding congestion together with a very general advanced inter- 
 stitial fibrosis, somewhat irregularly distributed, in addition to the ordinary fibroid 
 bands of tertiary syphilis. The bile capillaries were richly injected with inspissated 
 bile, and the kidney showed a condition of parenchymatous nephritis. 
 
 The interest in this is, that here we have presented to us a progres- 
 sive syphilitic distui-bance not arrested to any extent by .specific treat- 
 ment. The amount of change in the liver was extreme, and as above 
 mentioned, consisted in the development of numerous gummata, peri- 
 cellular fibrosis and catarrhal hepatitis, with jaundice. Indeed, we 
 have here an example of syphilitic infection of the liver in an active 
 stage fourteen years after primary infection. The appearance of the 
 liver in this case appears to throw light upon what is the true nature 
 of so-called tertiary syphilis. This is not by any means a receding 
 process. While the tendency of the disease is, as it were, to burn 
 itself out, and while in the majority of cases, if properly treated, the 
 virus is completely destroyed in the secondary stage, nevertheless 
 there may be persistence of the virus, and under favourable conditions 
 the disease may light up again. Here, in this case, the patient 
 enjoyed very fair health from 1888 to 1893. Gastric and intestinal 
 functions were well performed ; he increased in weight, and led an 
 active life. During this time the process was certainly arrested, then 
 the malaise and indigestion returned, and the ascites and jaundice 
 which supervened can only be ascribed to the progressive development 
 of syphilitic disturbance in the liver. 
 
15 
 
 The analogy between syphilis and tuberculosis in this respect is 
 perfect. In about 30 per cent of our autopsies we come upon evi- 
 dences of old tubercular cicatrices in the lungs, and in the majority of 
 these cases the process is undoubtedly wholly arrested ; thus we are 
 dealing with healed tuberculosis. In some however, we see that the 
 virus is still present in the encapsuled caseous masses, for we can in a 
 certain number of cases cause the disea.se in guinea pigs by inocu- 
 lating into them the caseous contents of the old tubercles, and again 
 in some cases we can recognise that these tubercles have been 
 obsolescent and not obsolete, for around them we can make out pro- 
 gressive tuberculosis evidently originating from them. Speaking of 
 these cases in the language which we employ to syphilis, we might 
 de.scrilie them as being eiiamples of tertiary tuberculosis, or to put it 
 otherwise, we include under the term tertiary syphilis, two conditions: 
 
 1. The cicatrices and fibroid chanjies which are indications of a 
 previous syphilis now healed and obsolete. 
 
 2. The lighting up again of an obsolescent syphilis from old foci in 
 which the virus has remained latent. 
 
 The two cases just recorded are examples of the latter condition, 
 while the case which follows is one of several examples of the former : 
 
 Cask III.— Male, set. 40, who had led a wandering life in the South American 
 States, Pacific Islands, and over the world since 25. Had snflfered from all the dis- 
 eases of childhood, gonorrhci'a at 18, stricture five years later, yellow fever while 
 serving in an American Army, sniall-pox and malaria when he was 19, had chronic 
 dysentery about six years ago, was a heavy drinker of spirits, and had been a soldier, 
 a sailor, and of late a backwoodsman ; he denied having had a chancre. The cause 
 of death was acuu 'obar pneumonia of the upper lobe of the right lung with purulent 
 peritonitis. 
 
 The liver was deformed, weighed 19(50 grammes, and showed four large areas of 
 puckering on the upper aspect of the right lobe. A rounded mass 3 cm., broad and 
 2..T cm. long projected from the lower end of the right lobe, the truncated end of 
 which was characteristically puckered ; the appearance of the organ was typically 
 syphilitic. The intestines showed no signs of previous dysentery. 
 
 In this case, the section through the puckerings showed singularly 
 little fibrous tis.sue despite the extreme contraction and deformity of the 
 region where they were present. There were no proper gummatous 
 areas to be made out, and the oidy .satisfactory explanation is that in 
 this liver which presented so obviously the appearance of tertiary 
 syphilis there had been complete or almost complete absorption of the 
 syphilitic deposits. 
 
 It may be suggested that the resemblance between tuberculosis and 
 syphilis which I have thus emphasised is imperfect, in that when 
 tul)erculosis caiee allicts the organ, the virus always remains latent in 
 that organ, and there is not the complete absorption which we must 
 acknowledge takes place in the majority of cases in syphilis. For 
 
16 
 
 it is admitted that at the most (and that in untreated cases) only 30 
 per cent, of those infected sliow tertiary symptoms. Among those 
 treated the percentage is only about 10 per cent. But this is another 
 modern popular fallacy : there may be complete cure of tuberculosis 
 and complete disappearance of the tubercles even when they have 
 become distinctly fibrous. This is proved by the experimental infection 
 of dogs with peritoneal tuberculosis and arrest of the process by re- 
 peated laparotomy. I need .scarce remind you that it also has been 
 recogni.sed in some cases that there may be arrest of tubercular 
 peritonitis in man by similar means. Definite cases are on record 
 in which there has been a complete disappearance of well marked 
 fibroid tubercles from the .serous coats of the intestines. The analogy, 
 therefore, between tuberculosis and syphilis nmst be regarded as com- 
 plete in this re.spect. 
 
 Rarely we come across a syphilitic liver showing very clear evi- 
 dence of the progressive development of the hepatic condition. 
 
 Cask IV.— Such a case have I met with in a male of 28, who entered the Royal 
 Victoria Hospital under Dr. Stewart with a rupture of one or more branches of the 
 middle cerebral artery, and who had two years before been treated by Dr. James 
 Bell for syphilis. Whether the syphilis then was primary, secondary, or of later 
 manifestations I cannot ascertain, for the patient died before his history could be 
 elicited. In this case there was syphilitic inflammation of the ventricles of the brain, 
 and early atheroma of smaller arteries. The liver showed three or four puckered 
 scars, and microscopically, fairly frequent gummata, with fiiant cells and small local- 
 ised infiltrations of leucocytes. There were no signs of tuberculosis anywhere, and 
 the sections of the liver stained with carbol-fuchsin did not show any tubercle 
 bacilli. In this case, the puckered scars indicated guumiata which had undergone 
 cicatrisation and fairly complete absorption. The small infiltration of leucocytes can 
 only be regarded as miliary gummata resembling in every respect those seen in the 
 infantile liver of congenital syphilis. The case nmst be regarded as one in which, as 
 shown in the ventricle of the brain and in the liver, the active syphilitic process had 
 been rekindled or had progressed with rapidly fatal results. 
 
 Case I. was probably an example of the same condition. 
 
 The only manifestation of syphilis in connection with the liver 
 which is to be found in the acquired and not in the congenital form, 
 is the condition of perihepatitis. I have not come across or met with 
 in literature any indications of the development or presence of such a 
 condition in the newly born child ; in the adult, more especially at 
 the late stages, it is not very uncommon. 
 
 Out of the eight cases, I came upon it in a fairly extensive con- 
 dition in a female of 62, in which syphilis must have dated back for 20 
 years, more or less, for she gave a history of liaving seven cliildren, of 
 which five were miscarriages, and the other two died in infancy. Here 
 the most extensive syphilitic changes were in the neighbourhood of 
 the longitudinal fissure and round the gall-bladder. An interesting 
 point was the fact that a mistaken diagnosis was made of atrophic 
 
17 
 
 cirrhosis with ascites. The capsule of the organ was throughout 
 thickened, the upper surface very smooth, the abnormal lobulation and 
 puckering. Near to the gall-bladder in the right lobe was a caseous 
 nodule, the size of a filbert, showing some calcification on section. 
 
 Upon section, the organ showed a thickened fibroid capsule, many 
 small central scars, caseous gummata, anil more or less ditt'use and 
 apparently recent fibroid change. Here it should be added that during 
 the last five months of her life, she had been repeatedly tapped, and 
 following upon tapping, there was found at the autopsy a condition of 
 sub-acute peritonitis with inflammatory lymph covering the intes- 
 tines. Thus the perihepatitis might not have been entirely syphilitic 
 indeed I am a little doubtful whether syphilis pure and simple will 
 lead to the condition of generalised perihepatitis. 
 
 Case V.— Female, set. 62, with a history of having had seven children, of which 
 five were miscarriages and the other two died in infancy. The husband said to be 
 phthisical. In 1895, Dr. Roddick removed an epithelial wart, which on examination 
 was found to be non-malignant. Suddenly upon July 31st, 1895, while the patient 
 was feeling in good health she had an attack of hwmatemesis which was repeated 
 next day and again two days later. It was accompanied by meleena and great 
 weakness. 
 
 Upon admission to the hospital in August, 1895, under Dr. Stewart, the patient 
 was sallow and there were dilated venules on the face. The liver extended from 
 the fifth rib, two and a half inches downwards ; it was not palpable nor could the 
 spleen be felt ; there was a low systolic murmur. The urine was high coloured with 
 a trace of albumin. While in hospital epistaxih occurred once or twice. This his- 
 tory together with the progressive loss of flesh, the sub-icteroid tinge, the abdominal 
 swelling with epigastric pain, the slight u'dema of the legs, led to a diagnosis of 
 atropic cirrhosis of the liver ; 270 ozs. of fluid were removed from the abdomen, and 
 after removal the fulness In the epigastrium was found to be due to the hard large 
 mass passing down to within 8 cm. of the navel. This mass, hard and rounded, 
 was continuous with the right lobe of the liver. The fluid re-accumulated and the 
 patient underwent numerous tappings. Slie became progressively weaker, and the 
 hepatic tumour appeared to be undergoing progressive diminution. 
 
 After having left the hospital she was re-admitted early in January 189(5, dying 
 upon January 24th. The condition was thought to be one of atrophic cirrhosis with 
 enlargement of the left lobe. 
 
 Autopsy.— (Edema of the legs ; extensive ascites with distended abdomen. 
 Upon opening, the visible intestines were found coated with lymph ; the omentum 
 which was fatty and oedematous was adherent to the parietes in several places. 
 The liver presented numerous adhesions, especially to the intestines and surround- 
 ing organs, specially in the region of gall-bladder. The right lobe did not reach the 
 costal margin, the left extended just below the xyphoid. The organ weighed 1425 
 grammes, its greatest breadth was 22 cm., the right lobe especially being contracted 
 (breadth 10 cm.) ; this lobe was also diminished from above downwards, its length 
 being 15.5 as compared with 19 cm., of the left lobe. The capsule was thickened ; 
 the upper surface fairly smooth with, however, linear indentations, but the under 
 surface presented extensive abnormal lobules especially in the region of the gall- 
 bladder and upon the right lobe, so that several small lobules of liver tissue were pro- 
 duced, and near to the gall-bladder a caseous nodule the size of a Albert showed some 
 calcification upon section. The under surface of the left lobe showed numerous 
 cicatrices, some distinctly stellate. The largest was close to the longitudinal fissure 
 and was ;i em. in diameter. 
 
16 
 
 Upon section the organ showed many small central scars, caseous gummata and 
 more or lena diffuse and apparently recent fibroid chanye. There was further a 
 moderate (iiiiount of chronic (iassive congestion and cholelithiasis with obstruction 
 of the cystic duct. The organ gave no amyloid reaction, and the spleen was large, 
 firm and tense, with thiclcened capsule. In addition there was fat necrosis uf the 
 pancreas, brown atrophy of the heart, moderate atheroma of the aorta, slight chronic 
 pachymeningitis, emphysema and bronchitis. 
 
 It will be noticed that the most extensive syphilitic change was in the neigh- 
 bourhood of. the longitudinal fissure and round the gall-bladder. 
 
 Yet another case of syphilitic liver with great thickening of the 
 capsule showed this saiiie complication of peritonitis. In this case (a 
 patient under Dr. James Bell) there had been recurrent attacks of 
 appendicitis during the last four years, with much chronic fibroid 
 typhlitis, and the patient died of acute peritonitis following opera- 
 tion. Although the liver showed numerous stellate scars with abnor- 
 mal lobulation, these were on the upper surface and there had been 
 no signs of hepatic disturbance. There were in addition moderate 
 arterio-sclerosis and fibroid syphilis of the left testicle. 
 
 Case VI.— The patient, a male, entered for recurrent appendicitis and died of 
 acute peritonitis following the operation Feb. 27th, 1896. Four years previously had 
 had illness with symptoms of appendicitis., For five or six weeks before admission 
 had dyspepsia, followed by right iliac pain beginning about Feb. 7th, kept at work 
 till the 12th. Operation : Purulent appendicitis with perforation, followed by gen- 
 eral peritonitis and death. 
 
 ^M<oj9sj/.— Acute peritonitis with evidence of much chronic fibroid typhlitis. 
 Liver large, surface very irregular, owing to great irregular thickening of capsule. 
 Weight 2(X)0 grams, numerous large superficial stellate scars with abnormal lobula- 
 tion ; greatest thickening about longitudinal ligament in front. On section, fairly 
 firm, a few small internal cicatrices ; portal vein and vena cava free ; peripoital 
 glands free. Liver showed large periportal fibrous glands with thickened arteries 
 and atrophy of some liver cells. Spleen, large 153 grams, 12.5 x (J.5 x 3 firm, soft and 
 rather pale. Pancreas, hapmorrhages and necrosis. Other organs showed evidences 
 of the acute febrile disturbance with moderate arterio-sclerosis and its eflfects ; 
 there was in addition fibroid syphilis of the left testis. 
 
 In the case of a male, oat. 75, the organ had the characteristically 
 puckered appearance and showed upon the anterior surface of the 
 right lobe a large convex cartilaginous plate, 9.5 x 7.5 cm., or about 4 
 X 5 inches, associated with chronic thickening of the capsule, together 
 with numerous small cartilaginous plates elsewhere ; the left lobe did 
 not show much thickening of its capsule. The spleen, however, as is the 
 rule in chronic perihepatitis, presented a much thickened capsule. (In 
 this case there was very extensive gummatous hepatitis with practi- 
 cally no clinical evidence of affection of the organ.) 
 
 Case VII.— Of this patient, a male, H»t. 70, under Dr. .Tas. Bell, with cancer of 
 the tongue and general arterio-sclerosis, there is no history bearing upon the date Of 
 infection. 
 
 i4M^ops»/.— Emaciation ; rheumatoid arthritis of fingers ; slight icterus; retracted 
 .abdomen, abdominal cavity dry ; liver 1335 grams, 21 x 16 x 8 cm, right lobe anteriorly 
 and inferiorly broken up into scvrral small lobules ; at hilus five or six small acces- 
 sory lobules Ijetween a bean and a walnut in size. On anterior surface of right lobe. 
 
19 
 
 left superior angle, large convex cartilaginous plate 9^ by 7} cm. aHsociated with 
 chronic thickening of capsule. Numerous small uuitilaginous platen elsewhere on 
 the right lobe, the left also broken up into several lubulcs. On section, organ fairly 
 friable with here and there small tlbrous strands of tissue intersecting collections 
 of lobules. Spleen, capsule very much thickened, weight 24U, enlarged 1U.5 c 7.5 x 
 5 cm. On section, soft, with slight tibrosLs. Other conditions : Cancer of tongue, 
 arterio-sclerosis, sclerosed heart valves and coronary arteries, hypertrophy of pros: 
 tate, hydronephrosis, chronic interstitial nephritis, etc. (This case again shows 
 very extensive gummatous hepatitis with singularly little clinical evidence of the 
 liver disease.) 
 
 In two other cases, there were localised adhesions between the organ 
 and the diaphragm. These adhesions, however, bore no clear rela- 
 tionship to the areas of cicatrisation in the organ. 
 
 On the whole therefore I am inclined to regard diftuse chronic 
 perihepatitis as more a complication, than a direct syphilitic mani- 
 festation. 
 
 There is one further condition of syphilitic disturbance of the liver 
 in the adult to which I have only referred in passing, and that is the 
 development of large tumour-like outgrowths of the organ which are 
 80 sharply defined that clinically the erroneous diagnosis may easily 
 be made of malignant neoplasm. These growths are distinct from 
 the bosses pi'oduced by the cicatrices of old gummata and subsequent 
 deformity of the organ, and under the action of potassium iodide, they 
 appear to undergo fairly rapid absoption. Osier in the work already 
 cited has described very clearly one of these cases. So far as 
 I know, in the coarse lesion produced, there is nothing quite similar 
 to this seen in congenital syphilis. Microscopically however, the mass 
 shows a condition not unlike that seen in the circumscribed areas of 
 fibrosis in the infantile liver. There may or may not be caseous or 
 gummatous change in the centre. There is however, much central 
 fibroid change with complete destruction of hepatic parenchyma, and 
 towards the periphery there is a more vascular connective tissue area 
 in which strands of liver cells are to be made out. The nature of the 
 growth and the presence of these liver cells would appear to indicate 
 that what we have to deal with in such cases is a focal syphi- 
 lomatous change in which, as the process extends from the centre, 
 there is, at the same time, a constant proliferation of the liver tissue, 
 and thus gradually, there is the development of a localised mass of new 
 tissue, in the main fibroid, but at the periphery, where the change is 
 not so extreme, there is growing liver tissue. 
 
 With this I have, I believe, mentioned the main manifestations of 
 syphilis as they occur in the infant and in the adult, and it will be 
 seen: 
 
 In the first place that the lesions occurring in the congenital and 
 
the acquired disenso, are identical, and brought about by the same 
 process or processes. 
 
 That whether we liave to d(uil vvitli the disease in the secondary or 
 in the tertiary stage, the same processes are at work. That, if we 
 except those cases as truly tertiary in which we have to deal merely 
 with the fibroid remains of obsolete gummata, and again those cases 
 in which there is perihepatitis (which perihepatitis appears to be a 
 complication rather than the genuine and direct result of syphilis), 
 then we are bound to admit that the study of the liver alone would 
 indicate that no sharp boundary line can be made out between secon- 
 dary and tertiary syphilis. No more can we make out such a bound- 
 ary between secondary and tertiary tuberculosis. 
 
 While I and all others must admit the utility of recognising these 
 two stages, from an anatomical and histological standpoint one is 
 forced to acknowledge that progressive syphilis is charactei'ised by 
 the same succession of phenomena whether it be studied but a few 
 months or long years after the primary infection. Anatomically and 
 histologically there is no valid distinction to be drawn between 
 secondary and tertiary syphilis. 
 
 It may be asked whether such a conclusion is not wholly at var- 
 iance with clinical opinion and experience ? Upon the face of it, it is 
 — but if the subject be looked into carefully, I think that such a view 
 will reconcile not a few of the divergencies existing among syphilolo- 
 gists. We have those (and they are the majority) who .state that 
 tertiary syphilis is non-infectious, and those who bring forward clear 
 examples of the production of infection five or ten years after primary 
 inoculation of the disease. This difference can be reconciled if we 
 agree upon the following points : 
 
 1. That now-a-days, under proper treatment, syphilis, if not a self- 
 limiting disease, is at least a disease which can be healed, so that 
 many of the lesions recognised as being tertiary syphilis, are truly 
 the indications of the old healed syphilis, and not signs of progressive 
 or latent disease. 
 
 2. If the disease has not completely died out and remains latent, 
 the resistance of the tissues of the organism is such that in the 
 majority of cases if it does not tend to light up again; there is so con- 
 siderable a local reaction, that the infection and consequently the 
 spread of the process tend to remain strictly localised, and the germs 
 (which are probably of bacillary nature) do not become disseminated 
 through the blood. Thus neither the blood nor the secretions contain 
 the virus. 
 
 3. In a vei*y small number of cases, the reaction on the part of the 
 
21 
 
 tissues may ha so Itjb ned, and the virus retain or gain so high a 
 virulence that either it cause?* ulcijration, or in other ways becomes 
 ilisseminated and capabl*' of cad.^in^^ infection even late in the ter- 
 tiary stage.' 
 
 ' After raiding this pa|t..«', Dr. C. A. Ti'iiipl»! of Toronto, brought to my notice 
 (in intero8tlng cxainplo illii,str«*ing this point wliioh hf very kindly permltH me to 
 note here. The patient, ii vlgoroUM M'>n<le, contriicted the n itifil lesion five years 
 before marrlHge, underwent mercurial Irciitnu-nt for four year.s, imd later was 
 treated by Kournier's Int "mlttent method, generally for from nix to eight weeks 
 twice a year. His wife a highly educated and cultiind woman never showed any 
 symptom of syphilis. In tlie (Ifth year of marriage she iHciuiie pregnant for the first 
 time, and, ten years after the primary infection of the husband, she aborted at the 
 seventh month, the fcetus showing the typical facial characteristics and a greatly 
 enlarged liver. The husband had always tended to have syphilitic eruptions if he 
 neglected treatment, and when last Dr. Temple saw him, after the abortion, there 
 were scaling circinate lesions on t lie abdomen and groins and ulcerating patches, 
 some ecthymatous, others healing, on both legs from the knee downwards.