course of the disease and permit a provisional prognosis. Superficial and evanescent lesions, appearing infrequently during an early period point to a mild virulence, and to a speedy and complete recovery. The reaction of the syphilitic skin eruptions to specific treatment is a valuable guide to its efficiency. Their persistence and their progressive tendency for deeper structures should put the physician at once on his guard to push his drugs or use a more intense method of medication. Syphilis of the skin, including the mucous orifices, is furthermore responsible for nine-tenths of all infections, and for this reason alone requires more attention than when involving other parts of the body. An individual with a syphilitic eruption is a greater menace than one with smallpox, being by far more numerous, not enough incapacitated to seek seclusion and not as easily recognized and guarded against as the latter. By attending his daily business and social duties he may contaminate directly and indirectly any object with which he comes into contact, and scatter the infection broadcast. Here again the physician shoulders a great responsibility, if he does not perfect himself sufficiently in the knowledge of syphilis of the skin to recognize it early, so as to protect the community by proper measures. The other extreme is just as reprehensible, though more of an injury to the individual than to the public. It is the indiscriminate jumping at a diagnosis of syphilis at the very least suspicion. It should be remembered that syphilis is a great imitator of almost every pathological condition, and that at times it leads experts astray. To condemn an individual to social ostracism, possibly to break up family ties, and to subject him to mental and physical misery. for years is not permissible except upon the strongest evidence. As there are usually a group of symptoms present indicating syphilis, it is a good general rule never to rely on one feature alone for a definite diagnosis. The old fashioned classification of syphilis into a primary, secondary and tertiary stage has outlived its usefulness, except possibly for convenience only. It referred to the belief that certain manifestations were appearing at certain periods of the disease. It is known now, however, that such is not the case, that early and late manifestations merge into one another, preceed and succeed each other without any regularity, and are not dependent on any special period of the disease. The same classification also inferred the idea that the tertiary lesions were only consequences of the infection, but in themselves not capable of transmitting the infection. This theory has been completely upset by the proof of the presence of the spirochetae in every lesion of syphilis. It is desirable to abolish these old designations entirely, and name the lesions according to the pathological changes encountered. As already mentioned, syphilis of the skin, while closely simulating many dermatoses, always has some distinct features, which give it a character of its own. The early eruptions are more or less extensive and symmetrical, the latter few and found in limited areas only. No part of the skin is exempt but some localities are affected more frequently and by preference. The papules on the forehead, along the border of the hair, were known already to the Romans and called "corona veneris." The squamous affection of the palms and soles, the small white round spots on the neck or leucoderma, the moist papules or condylomata around the genitals and the anus are other wellknown examples. The color of the lesions become more characteristic as they grow older, or as new relapses occur, the tint changing gradually from a bright to a dark red, and even to brown, aptly compared to the color of raw ham or of copper. Frequently the early lesions have a tendency to group in circles and to form gyrate figures by coalescence. The later lesions, especially the ulcers, spread at the periphery with convex borders while healing at the center, producing circinate and serpiginous figures and assuming the shapes of horseshoes, kidney outlines, the letters S, C, etc. The resulting scars and pigmentations retain this characteristic appearance and for a long time present to the experienced eye an incontrovertible testimony to the past infection. Compared with other inflammatory affections of the skin the syphilitic eruptions develop slowly, and in successive crops. These last appear in the original type, while the older have already undergone changes, so that another feature, that of polymorphism, is added to the picture. Macules, papules, pustules, ulcers and crusts may be seen in the same subject, an association which is rarely seen outside of syphilis. One of the most peculiar and distinctive features of syphilis of the skin, with few exceptions, is the absence of subjective symptoms, such as itching, pain, etc. A macular eruption is often overlooked entirely on this account. It is a frequent experience to see a patient almost covered with ulcerations who seems to suffer very little inconvenience. The knowledge of pathology of syphilitic cutaneous tissue has been given a new impetus since the discovery of the spiro chetae. These micro-organisms have been successfully demonstrated in almost all lesions. The serous secretion from an untreated chancre contains a large number of them during the first few weeks. After eight weeks they are difficult to find. They are distributed irregularly in foci, and unless these are found the search may be disappointing. The bloodvessels are early invade, peri- and endarteritis being produced. In time all the tissues in the neighborhood of the primary lesion become involved, which in itself shows the futility of an extirpation with the hope of stopping short the disease. The constant appearance of the skin eruptions in syphilis is due to the preference of the spirochetae for certain structures, especially the epithelial cells. The pathology of all the cutaneous lesions of syphilis is essentially the same and only differs in degree. Its main element is infiltration of round cells in the connective tissues. In the macular, the mildest and most superficial eruption, hyperaemia predominates. In the syphilitic papule, which represents the characteristic type of a specific lesion, the infiltration involves the papillary layer; if the process extends to the deeper parts of the skin, and to the subcutaneous tissues tubercles and gummata are formed. These infiltrations have no vitality and undergo degeneration. Appreciating these changes, the clinical forms are easily explained; the papule is prominent on account of the filling up of the tissues with the cellular infiltration; is shiny on account of the tensity of the epidermis; hard, due to the density of the infiltration; if the epidermis breaks on account of the stretching, scaling results; the dark redness is produced by the blood coloring matter; the gumma is produced by a globular mass of cells, increasing at the periphery and undergoing necrosis in the center. It may be appropriate to say a few words in regard to treatment of syphilis of the skin. As a rule it needs no special attention, and will yield to the constitutional medication, except if very disfiguring or threatening important functions. Mercury and iodides are still the most valuable drugs in the treatment of syphilis, and are sufficient in all ordinary cases. Some syphilitic eruptions seem to be, however, very refractory to their action, and in such, happily, the salvarsan comes to the rescue. Mucous patches and old obstinate ulcerations, which at times resist all other treatment for months and years, often disappear rapidly after the administration of 606. Ehrlich and his followers have given up every other method of application except the intravenous. Whoever has given the muscular injections, and had experience with the intense pain, high temperature and the frequent sloughing, which followed it, will never return to it, after having acquired the necessary skill for the intravenous infusion. The objections to this, as the necessary stay at a hospital, the occasional difficulty in finding the vein and the possibility of some of the solution entering the peri-vascular tissues, are trifling and need not be considered. They are greatly offset by the absence of pain, the mild reaction and the quick results. A common occurrence after the administration of salvarsan is the Herxheimer reaction, which is very liable to scare those who are not acquainted with it. It is a sudden flaring up and exaggeration of all symptoms, and especially of the cutaneous manifestations during the first twelve hours, and is probably due to the increased action of the stirred up toxins. The lesions appear of a deeper color and involve larger portions of the body, but soon begin to show signs of retrogression, and disappear completely in a remarkably short time. In conclusion it might be said that with the advent of new therapeutics, the better knowledge of the disease and more accurate control of the treatment by the different tests, the general course of syphilis is becoming milder, and the aggravated cases of syphilitic eruptions rarer. The success of Noguchi in growing pure cultures of the spirochetae has already resulted in experiments to supplant the Wasserman test in the diagnostic work, and may be looked forward to as the most effective future weapon against syphilis. Syphilis With Special Reference to the Spinal Cord In the beginning it may be stated that the title of the present paper embraces so much territory that it is scarcely possible to give more than a brief outline of the syphilitic diseases involving the cord, a detailed discussion of almost any one of them would occupy the allotted time. The writer regrets the necessity of segregating the subject "syphilis." If there is any disease that should be considered in its entirety, it is syphilis. There is no disease with which we are acquainted that requires a *Read before the Nebraska State Medical Association at Lincoln, May 7-9, 1912. broader comprehension of the general principles of etiology, pathology, diagnosis, prognosis and treatment than syphilis. Gowers has well said, "To the surgeon the processes of syphilis are for the most part open and manifest, to the physician they are secret, its ways are obscure, its language is seldom unequivocal." The physician, therefore, treating syphilitic disease of necessity should possess a broad knowledge and comprehension of disease in general, for it is safe to say that no other disease is so widespread in its distribution or more multiform in its manifestations, and, as Gowers intimates, such a physician should be a surgeon as well as a medical man in the general and broadest acceptation of the term. The statement made by Hunter over a century ago, that "syphilis did not affect the internal organs", was not disputed for nearly fifty years later. Then Lollamand, and afterwards Dittrick, both demonstrated its fallacy, and still later the great Virchow proved that the central nervous system was subject to syphilitic changes, but upon more careful investigation, however, it has been found that it was the bloodvessels, lymphatics and neuroglia that were invaded to the greater extent rather than the essential nervous tissue itself. So firmly fixed in the mind of physicians had the Hunterian idea of this disease become that one of the greatest of modern observers and teachers in neurology when writing upon the relation of syphilis to the nervous system, entitled his work "Syphilis and the Nervous System" rather than "Syphilis of the Nervous System," showing to some extent, at least, that the theory of Hunter promulgated over a century before was still prominent to some extent in the minds of medical men. Reference to the foregoing broad statement by Hunter is not made in a spirit of criticism but rather to show how our knowledge of the disease has advanced as the years have passed and our methods of investigation have been improved. If a physician were capable in each instance of making a diagnosis and could secure for treatment every case of syphilis, as well as every case in which syphilis was a factor, in a given community and the community need not be very large, he would soon become independent and certainly would have his time fully occupied. It has been stated by Henchen that one out of every seven infected by syphilis develops at some time in the course of the disease some lesion of the nervous system, traceable directly or indirectly to the original infection. Fournier states "syphilis is |