constitution at all. Their further consequences are buboes, rapid sloughing, or slow serpiginous ulceration. Under these circumstances they cause severe pain and constitutional disturbance to the patient, and may endanger life.

Bubo, or inflammation and abscess of the adjoining lymphatic glands. In 207 cases of simple sore collected by Ricord,1 65 had bubo. In Dr. Beith's table, about half of the ulcers not connected with syphilis were complicated with bubo. This is probably an unusually large proportion, and it is more exact to expect one third of the patients with simple sores to have inflammation of the lymphatic glands.

The enlargement of the glands takes place in two ways. The first and commoner variety called sympathetic bubo, is simply inflammation of the lymphatic glands and their surrounding cellular tissue from the irritation of the chancre. This bubo differs in no respect from the inguinal abscess sometimes occurring in gonorrhoea, or from that following an irritating blister of the foot or other part of the lower limb, except slightly in position, because different glands. are attacked.

The sympathetic bubo may occur at any time during the progress of a chancre, though most frequently in the first fortnight. The gland which first receives the lymphatics swells and grows very tender, rendering walking, and even standing, painful. In the early stage it can be distinctly felt under the skin, but soon it is masked by congestion and inflammation of the cellular tissue surrounding it, and thus forms an oval tumour lying over Poupart's ligament. The skin over the swelling assumes a dusky red tint, and grows soft and doughy to the touch. Pus forms in the congested

'Fournier: Ricord's Leçons sur le Chancre, p. 40.

2 Evidence before the Committee on Venereal Disease in the Army and Navy, 1865, p. 152.

A A

cellular tissue round the gland, and presently the abscess bursts through the skin, its contents escape, and the cavity heals by granulation in the ordinary way. The duration of the bubo in this case will be a month or six weeks, but it is often prolonged by the obstinate sinuses which are left under the skin. In one form, called the phlegmonous bubo, the enlargement is much slower; the whole group of glands are attacked, and produce a doughy, ill-defined, somewhat tender swelling, in which the separate glands cannot be distinguished from each other. The skin, after some weeks' chronic congestion, becomes dark reddish purple. In course of time fluctuation can be detected at several points, from suppuration beginning at the same time in different parts of the cellular tissue. The pus thus formed makes its way to the surface, and tunnels several sinuses in a mass of illorganised cellular tissue, which last many months before they heal. This variety of bubo has been also called scrofulous bubo, from its occurring in scrofulous persons, and from resembling other scrofulous lymphatic abscesses. Abscesses of this kind usually extend outwards towards the iliac spine, as well as towards the perinæum. Their duration much depends on the patient's general health, and kind of treatment pursued. When the bubo is healed, it leaves a small shrunken cicatrix, at first dark in colour, but subsequently turning white.

In the virulent bubo suppuration is excited in the gland itself by the contagious matter being conveyed direct from the chancre along the absorbents. The inflammatory action inside the gland quickly extends to the cellular tissue, forming an abscess round the gland, which is inoculated by the absorbed contagious matter that is set free when the gland breaks up or is punctured. The abscess thus itself becomes a chancre, and resembles the original sore in all its characters, though much exceeding

it in size. Ricord, in his "Letters on Syphilis," describes an experiment to prove that the matter of an abscess formed about a gland is not contagious until mixed with the pus from the interior of the gland. He opened a bubo, inoculated its pus without effect; he then punctured the gland lying at the bottom of the abscess, and let out a drop of pus; this was inoculated with success, and, moreover, the pus of the abscess itself became inoculable after mixture with that formed within the gland. Further corroboration. of this transport of the contagious matter from the chancre along the lymphatics to the gland is gained by the fact that the original sore may heal completely before the bubo suppurates, and accidental inoculation from the surface of the sore becomes impossible. Yet, on the escape of the pus from the interior of the gland, the abscess becomes a huge chancre, and furnishes inoculable pus. It is still uncertain what determines this absorption of pus into the gland; it takes place in only a small proportion of the suppurating buboes, and there is no fixed period for its Occurrence. Puche's case1 shows that it may take place in chancres which have long existed. He remarked that a serpiginous chancre, which had existed more than four years, suddenly produced a bubo with inoculable pus.

In its course the virulent bubo is very similar to the sympathetic bubo. It is not so frequent as the former, and it is uncertain in the time of its appearance; its duration is commonly a few weeks, but it may last much longer. Usually one gland only is attacked, and that acutely. There is considerable pain in the part, and general disturbance. When the abscess is opened and inoculated with the matter within the gland, the surface becomes irregular and worm-eaten; the borders hardened, eroded, and often

1 Fournier: Ricord's Leçons sur le Chancre, note viii.

much undermined; the undermined skin grows dull violet in colour, now and then an isolated bit sloughs off; the discharge is puriform, plentiful, thinner than that of the original abscess, but contagious and inoculable on the patient himself. The abscess, thus converted into a very large chancre, may become phagedenic or serpiginous, and before it heals may spread over a wide surface, and cause a considerable loss of tissue. The fascia is sometimes laid bare in the floor of the ulcer, and the other lymphatic glands lying on it are exposed. The veins around may ulcerate and be troublesome, even dangerous hæmorrhage occurs, or a great part of the skin of the groin, thigh, or abdomen, may be destroyed. The duration is ordinarily three to four months, but the chancre lasts until the power of secreting contagious pus is exhausted, a result not reached sometimes for one or two years. Healing takes place slowly, and leaves a wide hard cicatrix, at first tightly adhering to the fascia beneath, but gradually becoming free and pale white.

Bubo without chancre, or Bubon d'emblée. It has been supposed possible by some authors that venereal matter can enter a breach of surface and pass along the lymphatics to the glands without producing a sore at the point of contagion. There seems little doubt that this is a mistake. The records of cases of venereal bubo without chancre, though few and imperfect, show that they occur in young weakly persons, that they invariably cause a good deal of constitutional disturbance, and that they do not form until some time after the coitus supposed to have given them origin. Further, these abscesses do not secrete a contagious pus as they ought to do if they were occasioned by the transmission of virulent matter, that being the way the virulent bubo is produced. Again, these abscesses are never the premonitory signs of general syphilitic eruptions.

venery.

Thus, these buboes have but a single character to support the theory that the inflammation of the gland is excited by the conveyance of venereal matter from the surface of the body to their interior; namely, that they are a sequence of But it is not difficult to find a more obvious explanation. Follin suggests Follin suggests they are caused, not by venereal contagion, but by the fatigue of violent intercourse, just as severe exercise in walking, or running, will produce an abscess of the lymphatics; an opinion which is probably correct. Diday, also, though withholding a decided opinion, is doubtful if they are ever caused by direct absorption of matter into the gland, when no chancre is produced at the point of contagion. Recently I have had two cases among my hospital patients, young men, or rather growing lads, in whom acute abscess formed in the groins on each side in one, a week, in the other, ten days after sexual intercourse. These young men, during the three months that one of them, and the ten weeks that the other was under my observation, had no ulcer on any part of the territory whence the lymphatic glands of the groins receive their vessels. In the cases of this kind of bubo that I have seen, the patient has always been young and of unknit frame, one more likely than a full-grown vigorous man to be attacked by acute inflammation of the lymphatic glands after over-straining himself.

Beside the foregoing varieties of irritation and inflammation of the lymphatic glands, the lymphatic vessels leading to the glands are themselves sometimes inflamed, if the sore be placed on the prepuce or skin of the penis. The symptoms are a ridgy swelling, like a knotty string on the back of the penis, tender and often red; this lasts ten or fourteen days, and then subsides. Occasionally little

1 Nouvelle Doctrine de la Syphilis.