But occasionally the nodules grow so luxuriantly that the epidermis develops furrows and clefts which may reach down to the nodules, and then a bloody fluid comes out of them which dries up on the surface to a reddish brown scab. Or it may happen that the upper horny layers of epithelium disappear, and that only a few rows of cells of the rete Malpighii remain. In this case the exuded fluid less often dries, the surface is usually blood-red and moist, and appears like an ulceration, though it is not really one. When this takes place on the face, particularly on the lips, or on the backs of the fingers, the sufferings of the patient are very much increased. After several years the nodules usually soften about the middle of their base, and the nodule may sink in over the softened part; or they burst, the softened part is thrown off, and now is developed the true ulceration by which the nodule may be completely eliminated and sunken stellate scars alone remain. The determination of the commencement of the disease is exceptionally difficult, indeed impossible, for it must always be founded on the statements of the patient, and the patients either observe themselves insufficiently, as may frequently be noted, or they conceal many facts. As a matter of fact we do not know the earliest symptoms of the disease. According to Danielssen and Boeck, the patients often suffer long and repeatedly, before the outbreak of the disease, from weakness, with rheumatoid pains and fever. This the patients frequently corroborate. But we are inclined to regard these attacks of fever as indications of the already existing disease. It appears to us more probable that the disease begins with some form of local affection which is so indistinct that the patient himself does not notice it, or at least lays no weight upon it, and that these local affections are analogous to others with which we are familiar, namely, the nodules which may last for years before new and such definite eruptions appear, that the disease cannot any longer be ignored or kept secret. We believe therefore, that the patients do not really know when they commence to be ill, and that they date the beginning of the disease from a later eruption. If at the commencement only the extremities are affected the patients may conceal their condition for years, and through this concealment become so accustomed to lie, that later it is impossible to receive from them correct information.