skin when seen on section is found permeated with nucleated cells massed together by proliferation of the cells of the deeper part of the corium, which pass between the papillæ, and lift them up above the general level. These cells have no further development, no defined tissue results from their production; but they quickly degenerate, and are mingled with oil globules, granules, and pigment. The last is especially abundant at the point where ulceration is going on. Virchow finds the structure of these primary indurations to be identical with the so-called gummy tumours of the viscera and other parts of the body in cases of long standing syphilis. Lately an attempt has been made to consider this morbid deposit peculiar to syphilis, and Wagner1 has given it the name of syphiloma. He looks upon this hard, elastic, transparent structure to be as much a peculiarity of syphilis as tubercle of tubercular, or cancer of cancerous disease. His views have not at present found much favour with pathologists.

Complete absence of induration.-In considering this still much disputed point, it must be borne in mind that induration of the primary manifestation is only a symptom of the general disease, and not a necessity for the absorption of the poison, therefore, being nothing more than a symptom, it may be absent or vary in intensity like any other symptom of the disease. Luckily for the diagnosis it very rarely indeed is wanting. Excellent authorities believe such want of development is sometimes met with, others again, searching for it carefully, have always found it. Clerc, who believes in the occasional absence of induration, met with, in two years and a half, ten cases of early syphilis where he could find no primary manifestation whatever; but he also

Wagner: Das Syphilom. Archiv der Heilkunde. 1863-4-5. 2 Loc. cit., pp. 78, 98.

records a case where induration disappeared completely in twelve days. Consequently, it is probable that the induration, when supposed to be absent, is unobserved.

The exceptions are so few, even if they exist at all, that practically, induration is constantly formed at the point of contagion. Bassereau,1 in 170 cases of syphilitic initial manifestation, found 157 plainly indurated; in 13 it was doubtful; but he did not pretend to say induration had been absent throughout in any of these.

It is often thought that much induration of the initial papule is a sign of a severe course of syphilis. Bumstead,2 who is of this opinion, quotes Babington, Bassereau, and Diday, to support this view. I have notes of nine cases of severe protracted syphilis, where I had the opportunity of observing the condition of the initial manifestation. The induration was extensive in six; in two it was moderate, but they were weakly lads of eighteen to twenty. And in the last, the induration was so ill-marked, that I waited till the roseola showed itself before I could be sure syphilis had been contracted. Again, I have notes of two more cases where induration was great, and in one a lump formed on the prepuce as big as a horse-bean, and in the other, a woman, the induration extended deeply over an area as big as a shilling, on the right labium majus. The male patient usually showed himself twice a-week for six months, never allowing a longer interval than a week between his visits. His syphilis was confined to this copious induration, to enlarged inguinal glands, and to superficial ulceration of the tonsil, with inflammation of the fauces. The woman had sore throat, papular eruption on the shoulders, and some mucous tubercles. The general health of both these

1 Bassereau, p. 130.

2 Venereal Diseases, p. 415. 1864.

persons remained excellent the whole time. They were infected in January and March, 1865, and they have been free from relapses since August and December of the same year until the present time, end of 1867.

Indolent Enlargement of the Lymphatic Glands (Indolent bubo, chronic adenopathy, Pleiade ganglionnaire), communicating with the infected locality. This symptom comes next after the formation of the initial manifestation. This change is a most important one for the diagnosis when the characters of the commencing papule do not decide whether syphilis is present. The glands begin to alter shortly after induration commences at the point of contagion. In the cases of artificial inoculation, where the changes of the glands were closely observed, ten or eleven days1 elapsed before the glands began to enlarge. They continue to increase slowly until they have doubled their original size. No pain accompanies the enlargement, at most only little passing tenderness, which soon ceases. The skin retains its natural colour and suppleness, because it is not implicated in the changes going on in the glands beneath, and there is complete absence of inflammatory action. The anatomical alteration consists in irregular hypertrophy of the cellular tissue that composes the framework of the gland. This change is essentially the same as the induration of the primary manifestation. On section the gland is firm, dense, and pale, unless very recently enlarged, when it has a pinkish hue. The cellular tissue around the gland is unaltered. The gland of the group affected, which is nearest to the point of contagion, begins the enlargement, and attains a greater size than the others. If the inoculation take place near the middle line, on the frenum, for

1 Fournier, Incubation de la Syphilis, p. 20, et alibi; Follin, Pathologie externe, vol. i. p. 736; Zeissl, loc. cit. S. 51; Bärensprung, Annalen des Charité Krankenhauses, Bd. 9, 1tes heft.

instance, glands in both groins enlarge, being influenced by the lymphatics running from this point to each side.

Swelling of the glands is not always confined to those immediately connected with the primary manifestation, it extends often to the superficial glands of the back of the neck and other parts. This general enlargement of the lymphatic glands occurs in young persons of lymphatic temperament, before, or during the evolution of the papular eruptions. Marked anæmia, or leucocythemia, from the great increase of the colourless blood-corpuscles, accompanies this change in the glands, and gives the complexion a muddy or pasty hue. After a while, the glands resume their usual size, and the white-cell condition of the blood diminishes. Malaise, pallor and indisposition to exertion sometimes accompany swelling of the lymphatic glands, and to these are often joined flying rheumatic pains in the head, shoulders, limbs, or along the course of a particular nerve. Such are usually all the constitutional disturbances complained of by patients, but the febrile action which accompanies the appearance of the eruption on the skin is occasionally present here too; the headache at this time may be even agonising. Usually the glands of different regions change only when eruption exists on the parts with which their different ducts are connected. Early anæmia is not always present; patients often retain a flourishing appearance through the whole course of the disease. And malaise is often absent; the patients are so far as their sensations go in excellent health. The swelling of the glands continues three or four months, after that they commonly regain their natural size. Sometimes they even shrink from atrophy, fatty degeneration, and calcification, and their function is more or less completely prevented.

Suppuration of these enlarged glands occurs, but probably never through the influence of syphilis alone. In young,

weakly, or strumous persons, after violent exercise or fatigue, abscess may form in these indurated glands, as it does when syphilis is not present. The gland which enlarges first is that which usually suppurates, but the pus it secretes is not inoculable, for the bubo is sympathetic and never virulent. In 1400 cases of venereal disease, Mr. Henry Lee1 found 98 of secondary symptoms with suppuration of the inguinal glands. Still, in all but 6 of these, some cause presumably distinct from syphilis occasioned the suppuration. At the Midi Hospital of Paris in 1856, there were in Ricord's wards three cases of suppuration of the glands accompanying constitutional syphilis, but they were scrofulous patients. Bassereau gives 380 cases of constitutional syphilis where he could mark the condition of the glands. Of these 19 had suppurating buboes, and 323 had general enlargement; in 35 no enlargement was observed. At the Royal Naval Hospital, Plymouth, in the years 1861-2-3-4, 1600 cases of venereal ulcer were admitted. Of these 209 were complicated with suppurating bubo, and followed by syphilis; but as no mention is made of the nature of these chancres, it is fair to conclude that many were simple chancres co-existent with syphilis.

3

It is not yet quite agreed if enlarged glands are always present in syphilis. Ricord asserts they are a necessary phenomenon. Bumstead does not know of an exception. Sigmund believes them to be the only unfailing pathognomonic sign of syphilitic infection. Clerc, on the other hand, says, that in rare exceptions the lymphatic glands undergo no alteration at any period of the disease; he says, moreover, that the glands

1 Medical Association Journal, Dec. 7, 1865.

2 Fournier: Leçons sur le Chancre, p. 157.

3 Bassereau: loc. cit., pp. 147, 301, 378, 398, 445.

Dr. Beith's evidence before Committee on Venereal Disease in the Army and Navy, 1865, p. 152.