in mind that in a certain proportion of men and in a
larger proportion of women, the patient has no knowledge of having
suffered from syphilis. Certain slight but important signs may give the
clue in a number of cases, such as irregularity of the pupils or failure
to react to light, abnormality of the reflexes, and the discovery of
patches of leucoplakia on the tongue, cheek, or palate.

The _general character of tertiary manifestations_ may be stated as
follows: They attack by preference the tissues derived from the
mesoblastic layer of the embryo--the cellular tissue, bones, muscles,
and viscera. They are often localised to one particular tissue or organ,
such, for example, as the subcutaneous cellular tissue, the bones, or
the liver, and they are rarely symmetrical. They are usually aggressive
and persistent, with little tendency to natural cure, and they may be
dangerous to life, because of the destructive changes produced in such
organs as the brain or the larynx. They are remarkably amenable to
treatment if instituted before the stage which is attended with
destruction of tissue is reached. Early tertiary lesions may be
infective, and the disease may be transmitted by the discharges from
them; but the later the lesions the less is the risk of their containing
an infective virus.

The most prominent feature of tertiary syphilis consists in the
formation of granulation tissue, and this takes place on a scale
considerably larger than that observed in lesions of the secondary
period. The granulation tissue frequently forms a definite swelling or
tumour-like mass (syphiloma), which, from its peculiar elastic
consistence, is known as a _gumma_. In its early stages a gumma is a
firm, semi-translucent greyish or greyish-red mass of tissue; later it
becomes opaque, yellow, and caseous, with a tendency to soften and
liquefy. The gumma does harm by displacing and replacing the normal
tissue elements of the part affected, and by involving these in the
degenerative changes, of the nature of caseation and necrosis, which
produce the destructive lesions of the skin, mucous membranes, and
internal organs. This is true not only of the circumscribed gumma, but
of the condition known as _gummatous infiltration_ or _syphilitic
cirrhosis_, in which the granulation tissue is diffused throughout the
connective-tissue framework of such organs as the tongue or liver. Both
the gummatous lesions and the fibrosis of tertiary syphilis are di