are most enlarged where the primary manifestation approaches the typical papular form, and are least developed when induration is ill-marked or wanting at the point of contagion. I have myself now under my care a patient whose primary manifestation was never distinctly and satisfactorily indurated, and in whom the lymphatic glands of the groin have been unchanged, though his body is now marked with papular eruption. Bassereau, in his 380 cases, found that in 35 the glands were not enlarged at the time of observation, while the amount of enlargement varied much in those where it was distinctly present. This makes it probable that the glands in a small number of cases escape alteration.

One of the lymphatic vessels now and then forms a hard string, the size of a crow quill, along the penis; it is painless, and rolls under the fingers. The enlargement is due to thickening of the coats of the vessel very similar to that they undergo in leucocythemia; this chronic affection is distinguished from ordinary lymphangitis by absence of pain, and redness.'

Diagnosis of the Initial Manifestation.—This is usually easy notwithstanding the occasional confusion of the initial manifestation of syphilis with local venereal ulcers. It is made in ordinary cases by the presence of the four following characters :-First. The time of quiescence, usually about twenty-four days before induration begins at the point of contagion. Second. The presence of induration. Third. The superficial character of the ulceration; and, lastly, the painless general enlargement of the nearest group of the lymphatic glands speedily following the induration of the point of contagion. The discharge is viscid, adherent, and scanty, quite unlike the secretions of local ulcers; but if a syphilitic ulcer suppurate, its discharge is as purulent

1 See Zeissl, Die Constitut. Syph., and Bassereau, loc. cit.

as that of the local sore. The primary syphilitic ulcer is likely to be confounded with simple chancre, herpes preputii, excoriations and chafings, warts, and epithelial cancer. The distinctions between simple chancre and syphilitic sores, are given in the description of the Local Venereal Sore, and need not be recapitulated here. Herpes is distinguished by acute inflammation of an itching area and copious secretion, the irritation and traces of which subside in a few days with cleanly local treatment. Similar treatment brings the same result in excoriations also, which moreover show themselves in a few hours after the chafing that occasioned them. None of these have the induration, the viscid discharge, and the enlarged glands of the syphilitic ulcer. In such cases, nevertheless, whenever a risk of exposure to syphilis has occurred, a positive diagnosis must be reserved until time for the incubation is passed; as the induration may come on after the patient has shown his sore to the surgeon.

Epithelial growths are sometimes, by their obstinacy and long existence, mistaken for syphilitic sores. They are distinguished in their early stages by their margins being raised into prominent tubercles, and by being cracked and fissured; by the neighbouring glands not being enlarged, for they remain unaffected a long time unless the cancer progress rapidly, when the disease is not likely to be mistaken for an indurated sore. If the sore has existed a few weeks, other symptoms of syphilis will be present if the ulcer has a syphilitic origin; but induration alone of the syphilitic ulcer can by no means be trusted, for epithelial growths frequently extend into the surrounding tissue, and closely simulate syphilitic induration. Epithelial growths are most often taken for chancres when placed on the glans penis, or vulva, where they are far less common than syphilitic ulcers; on the other hand, a syphilitic initial papule is more frequently mistaken for an epithelial growth when

forming on the lower lip, where it is comparatively rare, and cancer very common; but attention to the distinctions just given usually renders the diagnosis clear, especially for a syphilitic induration of the lower lip, which is early accompanied by enlarged submaxillary lymphatic glands. To recapitulate the characters of the syphilitic ulcer:-They are, 1. The smooth, scanty, viscid secretion. 2. The sloping edges. 3. If induration be marked at the base of the ulcer, it is also evident in the neighbouring lymphatic glands. 4. In six to twelve weeks after infection, other symptoms of syphilis, papular eruption, sore throat, pallor, &c., appear.

Patches of the general eruption of syphilis are sometimes mistaken for initial ulcers, when situated in suspicious localities. Papular eruptions occasionally indurate on the penis, and if neglected even ulcerate, thus resembling the initial manifestations exactly. Dr. Hardie1 has seen this take place in two individuals, while they were under his care in hospital with general syphilis. In the lower class of prostitutes, who have been suffering with syphilis for years, tough indurated cicatrices are common at the entry of the vagina, and they closely resemble the ordinary commencing indurated sore of syphilis when irritated by neglect.

The fibroid gummy deposits beneath the surface, when occurring in the glans penis, or other parts of the pudenda of both sexes, after breaking on the surface, often assume an eroding action, which gives them very much the aspect of a sloughing chancre. They are distinguished by the unenlarged condition of the glands, by the absence of local congestion, the glairy discharge, and by the presence or traces of syphilitic disease elsewhere. Old scars of rupia, nodes on the shin, and nearly always the peculiar pallor that attends long-standing syphilis, also help the diagnosis.

1 Evidence before the Venereal Committee, 1865 (Q. 1896).

care.

When this kind of ulcer is seated on the tongue, it is also mistaken for the initial lesion. An instance recently came under my observation :-A woman, married some years, in whom there was no history of general syphilis, but a very distinctly syphilitic complexion, was treated with mercury for two months without benefit before she came under my When I saw her I found the ulcer to be on the right side of the tongue near the tip. It was not elevated above the surface in the least; on the contrary, it formed a ragged cavity in the muscular substance, with some thickening and hardness around it. The patient said that it had existed as a hard lump in the tongue for some months before it burst; some matter then escaped, and the hole remained open ever since. She recollected, moreover, that for the last two years she had had lumps in the tongue not exactly where this one was, and that one burst leaving a sore, which was very painful when she had hot or sharp tasting food in her mouth. No other symptom of syphilis had been observed; but though she had been married eight years she had no children. The earthy pallor of the face and soft palate was very distinct. This circumstance, with the history of the nodules in the tongue, induced me to diagnose them as gummy swellings of the muscular substance. She took iodide of potass, and in six weeks the cavity filled, and the thickening almost entirely disappeared.

The diagnosis is also uncertain, when the patient is ignorant of the date of infection, and shows a fresh sore which suppurates and has no multiple enlargement of the neighbouring glands. In this case even a positive opinion cannot be expressed until the ordinary incubation of syphilis is passed, and time allowed for the induration to develop, should it have been inoculated.

Comparison of Venereal Ulcers with their Source.-Some observers, at the time when it was believed that syphilis was

G

propagated only from indurated chancres, thought much would be gained by comparing a given indurated sore with the lesion from which it was contracted. Bassereau and Fournier showed by this plan, that whenever a person was infected with an indurated sore, the person whence he contracted his disease had syphilis; and vice versâ, whenever the sore was simply suppurating, the source of the contagion was free from syphilis.

Inoculation of the discharges of the sore on the bearer (the so-called auto-inoculation) was at one time upheld by Ricord as an unerring distinction between the simple chancre and the syphilitic sore. The simple ulcer is easily reproduced by inoculation, but the thin discharge of the syphilitic sore always fails to produce any effect when inoculated on its bearer. This distinction is now shown to be untrustworthy, for two reasons: first, the syphilitic virus may be present in a patient suffering with local ulcers also, and the pus of these ulcers might be inoculable, notwithstanding the presence of general syphilis; secondly, the thin discharge of the ulcerated papule of syphilis is not inoculable on its bearer; nevertheless, if the papule is made to suppurate by any kind of irritation, the pus from it sometimes becomes freely inoculable. Thus Ricord's test to distinguish venereal sores is a useless guide in diagnosis. This question is more fully discussed in the chapter on Syphilisation.

The prognosis is that of syphilis, and the patient must expect further development of the disease.

SUMMARY.

The interval between the introduction of the poison and the commencement of its activity is called the incubation. This period has an average of twenty-four days. In a series of cases where its length could be accurately marked, it was never shorter than ten days, nor longer than