ENLARGEMENT 
OF 
SUBCUTANEOUS LYMPHATIC GLANDS 
IN 
TERTIARY SYPHILIS. 
By D. W. MONTGOMERY, M. D. 
Professor of "Pathology and Clinician for Diseases of the Skin, Med. Dept, of 
University of Cal., and Clinician for Diseases of the Skin, 
San Francisco Polyclinic. 
Enlargement of the lymphatic glands in tertiary syphilis may 
concern either the superficial or, more frequently, the deep 
ganglia. When it affects the superficial glands, those of the 
neck and of the groin are usually attacked.* 
The importance of remembering syphilis as a cause of chronic 
glandular enlargement cannot be overestimated, as it may simu- 
late Hodgkin’s disease so closely as to defy all attempts at a 
differential diagnosis except by the results of treatment, and 
in the meanwhile valuable time may be lost. A syphilitic his- 
tory, which might be expected to help in reaching a conclusion, 
very often leaves us in the lurch, as the primary and secondary 
lesions may have been so slight or have occurred so long before 
as to have escaped either the patient’s observation or memory. 
Hodgkin’s disease is very fatal, and its medical treatment con- 
sists in the administration of large doses of arsenic; tertiary 
syphilitic enlargement of the lymphatic glands, although per- 
haps not so fatal, still aids in bringing on the cachexia, and its 
treatment consists in the administration of large doses of iodide 
of potash, sometimes very large doses, and for long periods of 
time, for these enlargements are not among those syphilomas 
that are easily absorbed. 
*E. Lancereaux. Traite d'Anatomie Pathologique. Tome Deuxieme, page 
526. 2 
Enlargement of Glands in Tertiary Syphilis. 
The following is an instance of the syphilitic variety of gland- 
ular enlargements: 
On November 12th, 1889, Rudolph L.; a German; age thirty- 
one; a baker; came to my department of the San Francisco 
Polyclinic, giving the following history: His parents are still 
alive and healthy, and he has a brother and sister both healthy. 
No tuberculosis in the family. At twenty-one years of age, that 
is ten years before I saw him, he acquired a sore on the penis, 
which appeared about two weeks after exposure. He was then 
treated for syphilis, and did not notice any secondary symptoms. 
Five years afterwards, swellings, similar to those he had when 
he came under my care, appeared on both sides of the neck, 
which went away in about two weeks under anti-syphilitic treat- 
ment. Again swellings appeared in both armpits, about three 
years ago, which were also successfully treated antisyphilitically. 
He could not say what drug had been used either time, but to 
both medical men he had given the same history, and he said 
they had treated him for syphilis with good results. 
The swellings began again in the neck about five months ago. 
About two months ago he had malarial fever in Portland, Ore- 
gon. 
He was pale, but he said he had always been so, and there 
was no marked palor of the mucous membranes; he was weak, 
but fairly well nourished. There was a large, oval, subcutan- 
eous tumor, flattened from before backwards, extending from 
about two inches above the left clavicle, to about the same dis- 
tance below it. Dulness on percussion over the left apex was 
caused by the tumor, for, later on, when the tumor disappeared, 
resonance became normal. One enlarged gland could be felt 
above the right clavicle, which, on being pressed, gave rise to 
pain in the right axilla, probably from impinging on one of the 
cervical plexus of nerves. The glands in both axillae were much 
enlarged, some being as big as a pigeon egg. The increase in 
size was most marked in the left armpit. Sigmund’s gland on 
the right side was enlarged, and there was some induration and 
swelling of the glands in both groins. 
All the tumors were freely movable, with the exception of the 
very large one on the left side of the neck extending down over 
the chest. All were firm. The only tumor painful on pressure 
was that over the right clavicle, and there the pain was not at 
the point of pressure, but in the axilla. There were some hy- Enlargement of Glands in Tertiary Syphilis. 
3 
persemic patches on the skin; one about the size of a silver dol- 
lar, just above the line of liver dulness on the right side, had a 
play of colors between bright red at the periphery through 
purple to blue in the center, with slight desquamation. A 
similar patch was beginning to appear on the left side of the 
chest, and there was a slight hypersemia over the large tumor 
on the left side of the neck—this hypermmia did not strike one 
as that over a point of suppuration, but was a slight diffuse, 
even redness. Just above the hyperaemic patch on the right 
side of the chest, there was a firm, freely movable, painless gland, 
or subcutaneous gumma about the size of a bean. There were 
also some small desquamating patches on the back between 
the shoulders, which looked a little like patches of psoriasis. 
In no instance was the skin attached to the tumor beneath. 
There was no noticeable increase of white blood corpuscles, and 
the red blood corpuscles were regular in shape and size. The 
urine was normal. There was no demonstrable enlargement of 
the spleen, and no pain or tenderness of the bones. There were 
no indications of enlargement of the deep glands either of the 
abdomen or of the thorax. On account of the insurmountable 
difficulty of making a diagnosis between Hodgkin’s disease and 
tertiary syphilitic enlargement of the subcutaneous lymphatic 
glands, also of the history of what was probably an infecting 
sore, although no history of secondary symptoms could be 
elicited, and the previous good results on two separate occa- 
sions, of antisyphilitic treatment, it was decided to put the pa- 
tient upon large doses of iodide of potash, long continued. The 
hypersemic patches were simply painted with ichthyol, from 
which, of course, no result was expected, and internally we 
began with five grains of iodide of potash three times a day, in- 
creasing one grain each dose. In two days I saw the patient 
again, and the outlook was not very reassuring, for a new gland 
was discovered above the left clavicle, also the epitrochlear gland 
on the left side began to swell; and in a week, although he felt 
stronger, another tumor was discovered in front of the left 
sterno-cleido muscle, at the level of the angle of the jaw. It is 
worthy of note, that during the rapid increase in the size of the 
glands, there was no elevation of temperature. He was now 
taking eighteen grains of iodide of potash three times daily. 
About the end of the first month’s treatment while he was tak- 
ing one hundred and five grains of iodide of potash a day, im- 4 
Enlargement of Glands in Tertiary Syphilis. 
provement set in rapidly; all the glands decreased in size, and 
the large tumor on the left side of the neck and the hypersemic 
and scaley patches on the skin disappeared entirely. He began 
to suffer somewhat from the effects of the drug, and as the 
pressing indications for treatment were past, the dose was re- 
duced. 
Since then the amount of iodide of potash has been increased 
and decreased several times, and intermissions of one or two 
weeks made in the treatment when thought advisable. 
On December 9th, 1890, thirteen months after commencing 
treatment, he was in good health, and only two small glands were 
demonstrable, one about the size of a pea, round and hard, 
could be felt in the left axilla; the other, the right epitrochlear, 
was a little larger, and soft. His skin was free of all eruption, 
with the exception of a little acne between the shoulders. 
Jonathan Hutchinson recently in discussing a similar case 
reported by McCall Anderson, in his work on Syphilitic Affect- 
ions of the Nervous System, objects to considering them syphi- 
litic simply because the tumors disappeared on the exhibition 
of large doses of iodide of potash, for the reason, as he truly 
remarks, that this drug first won its place in our estimation by 
its success in reducing glandular enlargements, and was not 
used for syphilis till long after.* But might not reasoning like 
the following hold equally well, that the glandular swellings 
which it was found to reduce were syphilitic, non-syphilitic 
glandular enlargements not budging under its influence ? It 
made little matter whether the correct diagnosis were made, as 
long as the correct drug was used. Additional weight is given 
to this side of the argument by the views expressed in an able pa- 
per read by von Esmarch before the German Surgical Congress of 
1889. According to him a large number of tumors which are 
diagnosed and extirpated as sarcomas, are really syphilomas, 
and can be cured by a well directed treatment without which 
they run a markedly malignant course, returning in loco, and 
appearing to give rise to metastases. He even says all sarcomas 
may be the expression of syphilitic taint, one of the principal 
effects of luetic virus being connective tissue overgrowth.f 
* Archives of Surgery, July, 1889, page 73. 
+Fried. von Esmarch. Ueber die AStiologie und die Diagnose der bosarti- 
gen geschwulste, insbesondere derjenigen der Zunge und der Lippen. Cen- 
tralblatt fur Chirurgie, 1889, No. 29.