which are almost always confounded by most syphilographists. You can convince yourself of this deplorable confusion, by reference especially to certain recent treatises.

The first variety of the mediate or consecutive bubo is that which succeeds to the non-indurated chancre and its different phagedænic varieties. This bubo of absorption does not invariably take place. Every non-indurated chancre does not inevitably give rise to it. It may even be said that more non-indurated chancres exist without it than with it. These buboes are essentially the terminations of the direct lymphatics, the orifices or extremities of which open into the chancre, either at the same side, or at the opposite side, when the vessels cross the median line. This relation is an essential one, and when it does not exist, buboes are not to be found. I can thus explain their frequency after chancres of the frænum, for example, and understand why I have never seen them supervene after the numerous inoculations which I have made at the upper part of the thigh.

The bubo which is observed in connection with the non-indurated chancre is not only never developed previous to this chancre, which ought not to be the case, if it could occur independ ently of the latter, but it ordinarily does not show itself until after the lapse of some time-often the first week, in the course of the second, and in certain circumstances at a much later period; and, if the primitive ulcer obstinately remains at the specific period, it does not manifest itself until after the lapse of months, or even years. In a patient of my colleague, M. Puche, a serpiginous chancre existed for three years before it occasioned a virulent bubo. It is only when the ulceration happens, sooner or later, to meet the desired relations, or when it has not counteracted them in its progress, that its virulent pus passes into the lymphatic vessels, which convey it directly to the ganglia, without themselves becoming infected.

With the non-indurated chancre, which is patent, or concealed in the urethra, in the anus, in the vagina, or in the mouth, the adenites, provided the chancre is unique, is most frequently mono-ganglionary. It affects only the superficial ganglia, so that the division of buboes into superficial and profound can in nowise be applicable to the virulent sort. The adenitis of viru

lent absorption, symptomatic of non-indurated chancre, is inflammatory, and usually very acute; it must inevitably tend to suppuration. Whether the virulent pus furnished by the chancre at the specific period be arrested in a lymphatic vessel, or reaches a ganglion, it produces a kind of inoculation which, owing to individual dispositions, gives rise to accidents analogous to those from which it emanates; that is to say, to chancres of the lymphatics or of the ganglia, with a progressive and suppurative tendency. But in this intra-lymphatic and absorbent inoculation, if I may so express myself, there supervenes, as in cases of inoculation on the skin and mucous membranes, a common inflammation of the neighborhood or of the periphery. And while the infected lymphatics and ganglia suppurate specifically, their phlegmonous atmosphere only furnishes simple pus. The existence of these two layers, at first so distinct and independent, and so easy to understand, was for some time unknown. You remember that one of your recent correspondents, who is so apt to confound everything, was astonished that they should be distinguished. Well! these two concentric layers have the various properties with which you are already acquainted, and which explain the reason why some experimenters, such as MM. Cullerier, the uncle and nephew, were enabled to assert that the pus of buboes is never inoculable. In fact, if, on the day we open a bubo in which the pus has not remained too long a time, we inoculate with the first pus which escapes-that is to say, with the pus of the phlegmonous layer-the result is negative; while, if we happen to take the pus from the deeper layers-that is to say, the virulent pus furnished by the ganglia -the result is positive.

I have observed cases in which the infected ganglia, a kind of virulent cysts, were dissected and laid bare by the peripheric phlegmonous suppuration; I then inoculated the pus in their neighborhood without result; and on opening afterwards the ganglion, I obtained a pus which produced a specific action. When we have for a time long delayed to open a virulent bubo, so that the ganglionary pus is effused into the phlegmonous pus, and has had time to mix with it, as well as when the bubo has already been opened a given time, all the pus is inoculable.

Hunter had already shown that the virulent pus of the bubo of absorption is identical with that of chancre, and, like it, is inoculable; the bubo in this case being a ganglionary chancre, contagious after the manner of other chancres. It was even the pus of a virulent bubo which he compared to that of a reputed secondary accident, cited among the cases recorded by the Société de Chirurgie, and from which the end was so conveniently disarticulated.

But it is a remarkable fact that the virulent, primitive pus is never met with, beyond the first ganglia, in direct relation with the chancres from which the contagion originated. Inoculable pus is never found in the deep ganglia, in the lymphatics which emanate from them, or in their termination. There is a barrier which the primitive pus has never passed. It is experiment, artificial inoculation, my dear friend, which taught me this fact, with due submission to those who, after having so much calumniated it, are so ready, at the present time, to acknowledge its value. Now, if it should happen that we are in doubt concerning the matter; if the effects of the pus from the base of the ulcer upon the lips of the spontaneous or artificial opening of a bubo do not enable us to establish, in the great majority of cases, a certain diagnosis, the incontestable pathognomonic signs will be negative inoculation in cases of inflammatory and scrofulous buboes, and POSITIVE IN THE SINGLE CASE OF VIRU

LENT BUBO.

Yours,

RICORD.

LETTER XXVII.

MY DEAR FRIEND: The second variety of the mediate, consecutive bubo is that which succeeds the indurated chancre. This form of symptomatic adenopathy merits the greatest attention and should be studied with care. It differs as much from the preceding variety, as the indurated chancre itself differs from the other varieties of the primitive ulcer.

The engorgement of the ganglia, in this variety, is, perhaps,

generally more precocious than that which succeeds a non-indurated chancre. It generally manifests itself before the lapse of the first week; and it may be said that its appearance is almost never delayed beyond the second week. If it has not been perceived within this period, it is because the observer has not known how to seek it. In cases of indurated chancre, the adenopathy is inevitable from the commencement. It is never tardily developed—which, as I have stated, is occasionally the case with the other forms of the primitive accident.

I have never observed a case of specifically indurated chancre which has not been attended by the symptomatic engorge ment of the neighboring ganglia. This engorgement is so regular and characteristic, that it may serve to indicate the nature of the chancre which has preceded it, when the latter has already disappeared, or when it is concealed in some profound regions, or when its base is very indistinctly marked.

By those who are well acquainted with this form of adenopathy, the seat of the primitive accident-an obligatory door of entrance, so to speak, to constitutional pox-can always be found with ease, provided we see the case in time, for chancre alone is its cause. Any one may easily convince himself of the truth of this statement by observing patients in whom secondary accidents are developed, and in whom this variety of ganglionary engorgement is perceived only in the neighborhood of the primitive accident. An acquaintance with the fact enables us to recognize certain transformations in situ, which are complicated, as it were, with certain secondary accidents, and thus to find their true starting-point; as, for example, in certain cases of papules, or mucous patches, which are considered primitive, and which have succeeded chancres in situ. I can now affirm that it is from want of rigorous appreciation and precise analysis, and because the physician has not seen the disease from the commencement, or because he has allowed himself to be deceived by simple coincidences, that mucous tubercle (a secondary accident) has been thought capable of giving rise to an engorgement of the neighboring ganglia. Whenever this accident, like all other secondary accidents, develops itself in many regions at the same time, we may easily convince our

selves that it is only where chancre has existed, that the ganglionary engorgement, which I have just described, is found.

As may be observed with respect to the acute, virulent adenopathy, symptomatic of the non-indurated chancre, a lymphangitis may precede and accompany the ganglionary engorgement in question. Here, the lymphatic cord is hard, indolent, sometimes knotted over the valves; it can easily be raised and circumscribed, when it is seated upon the dorsal face of the penis. At the corona glandis, under the præputial conjunction, the cords are found flexuous and serpentine; and, if the semimucous membrane be slightly stretched over them, it is discolored, and the cords remain whitish, a circumstance which does not occur in inflammatory lymphangites. This state of the lymphatic vessels, as a result of indurated chancre, might be confounded with other lesions of these vessels, if the indurated chancre whence the diseased vessels emanate, and the affection of the ganglia in which they terminate, did not enable us to recognize it. Moreover, in this species of lymphatic angiopathy, the neighboring skin, without changing color, is frequently œdematous; but it is a variety of oedema in some respects gelatiniform, on which the finger leaves no impression.

The ganglia, as in the other varieties, are much more tumefied on the side corresponding to the chancre, when but one accident exists; this side alone may remain affected, or the opposite also may be seized. Whether the one or both sides be affected, the infection is very rarely limited to a single ganglion. In the very great majority of cases, the adenopathy is multiple. As a very general, if not an absolute rule, what may be called ganglionary pleiades may be seen to form in the lymphatic radiation of indurated chancres.

At first, it is a simple indolent tension which almost always escapes the notice of the patient, and even of the physician, as may be proved by the observation of M. Boudeville, which was called in question at the Société de Chirurgie. Unless in a marked lymphatic temperament, or where there is strumous complication, it is rarely that the swelling exceeds the size of a small nut. Apart from accessory causes of inflammation, wholly foreign to the nature of indurated chancre, the ganglia remain