forty-six days, and probably is nearly always about twentyfour days. The reasons of its variation in different individuals are yet to be learned; but in this respect it is analogous to other contagious diseases where the incubation varies within certain limits.

When incubation is passed, some change always takes place at the site of inoculation. This change, the initial manifestation has three forms: 1, the elevated desquamating papule; 2, the superficial ulcer; 3, the indolent ulcer, with a hard base. These three forms are quite independent of any local irritation present with them. All varieties of the initial manifestation begin by forming a solid papule, which remains dry, losing the cuticle from its surface, without reaching ulceration. In the superficial ulcer or erosion, the induration of the tissue beneath the ulcerating surface is less abundant, and the surface secretes a thin discharge. In the third, induration is well marked, and also the ulceration, though the discharge is not copious or purulent. This is the most easily recognised form. When fully developed it has a hard, resisting base; the surface is covered by a scanty adhesive discharge; the edges are sloping, rounded; and the induration extends a little beyond the ulcer.

Effects of local Irritation on the point of Syphilitic Inoculation. If chancrous pus or matter from any irritable sore be inserted with the syphilitic secretion, immediate action of this irritant begins, the intensity and continuance of which depends on the source of the irritant. If it has been drawn from a suppurating ulcer, a similar ulcer is produced in a few days, which runs a course identical with that of the sore it sprang from. If the irritant matter be drawn from a feebly irritating source, the action is less violent, and subsides in the course of a few days. Similar effects ensue if the irritant be applied to a syphilitic ulcer after it is developed. Chancrous pus laid on the surface of an indurated ulcer, sets it

to suppurate freely, and to acquire the character of a suppurating chancre. This is the mixed chancre of Rollet. Sloughing action at the point of inoculation is no preservative against syphilis.

Syphilitic ulcers are usually single. Their seat is spread over any part of the surface of the body, the prepuce and glans penis being the most frequent. The induration at the point of inoculation varies, according to its situation and the sex of the patient: it is rarely, if ever, wholly absent. The stay of the induration is long-ninety days being commonly a short period. Its anatomical structure is like that of syphilitic productions of any other period of the disease; it consists of nucleated cells and ill-formed fibres massed together. These cells do not develope into a defined tissue, but degenerate into granules and pigment, especially when ulceration is going on. Copious induration at the seat of contagion is not always an indication of a severe course of the disease, though the two often go together.

In weakly per

The lymphatic glands connected with the point of contagion begin to enlarge, slowly and painlessly, about eleven days after the induration of the point of contagion itself. This enlargement results from general congestion and irregular hypertrophy of the glands. The cellular tissue around them remains unchanged, and they can be plainly felt as a group of enlarged glands beneath the skin. sons this local change is sometimes followed by enlargement of the lymphatic glands throughout the body, of which the most plainly affected are the nuchal lymphatic glands. This further change in the glands is accompanied by increase in the colourless corpuscles of the blood, pallor and languor. Enlargement of the lymphatic glands is sometimes ill marked, and escapes observation. When it departs, the glands shrink back to their original size, or even, by fatty and calcareous degeneration, lose their normal structure.

Suppuration in these glands, so common a complication of the local chancre, is unusual, and is the consequence of artificial irritation being applied to the sore; never dependent on the disease alone. The number of cases where the glands suppurate, is very small. The opinion once generally held, that suppuration of the lymphatic glands is protective against general infection, is quite devoid of foundation. The lymphatic vessels sometimes thicken as they run along under the skin to the glands.

The diagnosis of a syphilitic initial lesion depends on the incubation of the sore, the induration, the languid, superficial quality of the ulceration, should that be present, and the painless, general enlargement of the nearest group of lymphatic glands. In all venereal ulcers where the presence or absence of these characters cannot be ascertained, the diagnosis must be uncertain.

The prognosis is that of syphilis.

SYPHILIS.

CHAPTER IV.

ERUPTIONS ON THE SKIN.

Preliminary Period: Malaise, Fever-General Sketch and Points of resemblance of the eruptions: Macular, Papular, Vesico-pustular, Pigmentary, Tubercular: Gummy Nodules, Serpiginous Ulcers, Alopecia, Nails— Summary.

Period preliminary to the exanthematous Stage of general Eruption. When the initial lesion and the enlarged glands are developed, an interval commonly ensues before further phenomena of the disease appear. If this is counted from the first appearance of the papule to the first appearance of the general eruption, in sixteen of the cases of artificial inoculation detailed in page 62, the shortest interval was 19 days, the longest 131 days. In nine it was between 20 and 40 days. In cases of accidental inoculation, the period is reckoned to be between four and six weeks. (Sigmund.) This is about the average of those cases of experimental inoculation in which no uncertainty exists concerning the interval before the eruption. Lancereaux1 assigns, on the authority of Leudet, a space of 60 to 70 days after contagion, or 40 to 50 after the appearance of the primary manifestation. Zeissl has never seen the eruption appear before the eighth week after contagion. In ten cases of my own, where I was able to ascertain the date of contagion with probable exactness, the interval between contagion and 1 Lancereaux, loc. cit., p. 116. 2 Zeissl, loc. cit.,

2

p. 170.

eruption in the shortest was eight weeks, and in the longest fifteen after contagion. It may be concluded, then, that the first general eruption of the skin takes place about ten weeks after contagion, or seven after the commencement of induration of the initial lesion; and between five and six after the enlargement of the neighbouring lymphatic glands.

Febrile Disturbance.-The appearance of the rash is frequently, though by no means invariably, attended by general disturbance of the functions, such as inappetence, nausea, flying pains in the body, persistent frontal headache, depression of spirits, irritable temper, &c. In some, and probably most persons, the bodily temperature rises for a short time; still, this elevation may be entirely absent from first to last. Güntz, who has examined the temperature, finds that no rise takes place until the occurrence of general disturbance of the system and the eruption. It then rises to 100°-102° F. at night, falling in the morning to 99° F., and continues this alternation during a few days, or even weeks, while the rash is appearing. The degree of elevation depends on the amount of eruption, coryza, &c. present. Acceleration of the pulse also takes place, while the temperature is increased. A few observations of my own confirm the statements of Güntz concerning this elevation of temperature. In observations on six patients, taken at the outbreak of the eruption, I found the temperature rise in the evening to 100°-101° F., 100° F., and 102° F.; in two others, where the eruption was scanty, it did not reach 100° F., yet these patients complained of headache and dulness similar to that felt by the other four. In the morning the temperature of all was 98° to 983° F. I found also the temperature in two other cases of widely-spread rupial eruption to be raised to 100° and 101° F. while the eruption was extending, though these patients had suffered some years

2 Schmidt's Jahrbuch für 1863.