the "forerunner of accidents to come." A patient in this condition may daily look for secondary local ulcerations of a rapid and destructive character, and constitutional symptoms of a more or less formidable kind. It, therefore, behoves him to adopt speedy means for the removal of the induration, which may be generally accomplished, and till that period arrives he cannot be considered safe. I could detail a number of cases of induration of this character which I have entirely succeeded in removing by the continuance of the plan just laid down for the treatment of the indurated chancre; a gentle and continued action of the remedies should be kept up till the induration has entirely disappeared. It is a rare circumstance for this plan of treatment to fail: should, however, the induration not appear to yield after two or three weeks' treatment by vapour and friction, mercury may be administered by the mouth. One preparation of mercury will succeed, occasionally, when another has failed; the plan laid down is applicable and successful in the great majority of cases, but exceptions will from time to time occur. Specific induration always remains for a time after the chancre has apparently healed, and in many cases, as I have already said, a secondary ulceration, and even a third, will take place as long as the induration remains. Should this not occur, the induration remains, more or less marked, for two or three months after the chancre has healed; sometimes much longer. Cases have been recorded where these indurations have remained for years. (See M. Puche's tables, quoted by M. Ricord in his Lectures on Chancre.) I have seen since then one case where a distinct induration on the seat of an old chancre has remained for several years; but in such instances the indurations appear to have lost all their specific character, for in two cases the subjects of them had been some time married, and both wives and children were in good health.

I wish here to make a few remarks on buboes in connection with primary sores, although I have devoted a separate chapter to this subject. Buboes form only in the glands which are placed on the course of the lymphatics in connection with the primary sore; and hence it is that buboes in the groin do not form as a consequence of ulcers confined to the glans penis, since the lymphatics of the glans penis do not pass

through the glands situated in the groin, but under the arch of the pubis, to open into glands placed within the pelvis. The lymphatics from the skin of the penis, from the angle between the glans and prepuce, from the crypts on the side of the frænum, and from the scrotum, all pass through the glands in the groin, and hence chancres situated in any of these localities are liable to be followed by bubo. When the chancre is soft or simple, no bubo may form, if the patient keep quiet, is properly treated, and the local applications used not of an irritating nature. Under other circumstances, a gland in one or both groins may be attacked with inflammation (adenitis), which may or may not run on to suppuration; in a great majority of instances suppuration does take place, and frequently the chancre has been long healed before the suppuration in the gland is complete. The cause of these buboes is either an extension of inflammation along the lymphatic to the gland, produced by ordinary non-specific causes, or by the absorption of a specific pus from the chancre itself.

Buboes are often much more formidable diseases than the chancres which cause them. The non-virulent bubo is often followed by a succession of abscesses, sinuses, and induration of the surrounding integument and cellular tissue, which are sometimes months disappearing; the non-virulent bubo is frequently produced by walking, riding, skating, or free living, whilst the patient has a primary sore still uncured: the local applications to the primary sore frequently disperse this kind of bubo; the use of escharotics frequently produces it, whatever may be said to the contrary.

The open virulent bubo becomes formidable from its liability to assume a form of ulcerative phagedena: the ulcerations run upwards over the abdomen, and downwards over the thigh; they preserve their virulence for weeks or even months after the chancre has healed; during which periods, if inoculated, they produce a virulent ulcer; they produce fearful mutilation, and occasionally terminate fatally, from the extension of the ulceration to the coats of the surrounding blood-vessels. I have seen the femoral artery opened by these ulcerations, and the patient die instantly from the hæmorrhage produced; the external iliac has been perforated in the same way.

The buboes which succeed to chancres specifically indurated are much less formidable as local diseases than the two forms just alluded to: they consist in a chain of enlarged and hard glands in one or both groins, generally in both, and in one more than the other; several glands are hard and tender, one generally more than the rest; they show no disposition to suppurate, and rarely do so. They are, literally, blind chancres in the groin, require no local measures, and are only to be dispersed by means of constitutional treatment.

CHAPTER IX.

OF CHANCRES OF THE URETHRA.

CASES of syphilitic ulcers in the urethra have been cursorily alluded to by many surgical writers. Hunter mentioned them; they are also noticed by Mr R. Carmichael in his Clinical Lectures on Venereal Diseases. The late Dr Wallace spoke of some discharges from the urethra of venereal origin which were only curable by mercury; but it has been left to modern surgical pathologists to demonstrate that primary venereal sores, precisely resembling in their nature and consequences chancres situated externally, may exist in the canal of the urethra itself, at variable points between the meatus urinarius and the bladder.

The most frequent seat of urethral chancre is the fossa navicularis. Here there is no doubt of the nature of the disease; but the chancre may be situated more deeply, where it can neither be seen nor felt, and where the only proof of its existence has been the successful inoculation of the discharge from the urethra, or the constitutional taint of which that discharge has been the only primary disease.1

Discharges from the urethra are due to more causes than one; and hence it is that we find Dr. Wallace saying, "that there occur cases of these discharges in which we find mercury to act in the most salutary manner; and others, again, in which the discharge will continue, and be, after a time, followed by induration and bubo, and most probably by secondary symptoms, unless this medicine be given."2 When we consider the

1 It is not improbable that too great prominence has been given to the fact that all discharges from the urethra followed by secondary symptoms are due to a chancre situated deep in the canal. I have elsewhere alluded to this. See a valuable paper, 'Du Chancre Larvé, ou Ulcération syphilitique primitive intra-uréthrale profonde, par Lagneau fils,—Archives Générales de Médecine,' March, 1856.

2 Op. cit., pp. 248-9.

generally powerless effect of mercury over pure gonorrhoea, we cannot but suppose that these remarks of Dr. Wallace must refer to chancres or venereal ulcerations of the urethra, which an imperfect diagnosis has confounded with gonorrhoea.

The symptoms of urethral chancre are, heat, itching, or irritation in the urethra, accompanied by discharge; pain or tenderness in a particular part of the urethra when it is rolled between the fingers; the presence of a distinct induration at the point where the pain is complained of; pain also increased during micturition, and referred to the same point. Discharge from the urethra occurs at various and at irregular periods after the setting in of the first symptoms already described. It is very different from the discharge of gonorrhoea; it may be sanious, bloody, or of a sloughy character, and commonly does not flow unless the indurated portion before described be pressed forcibly between the fingers.

A gentleman consulted me for a disease in the urethra, which had existed many months, and which he said consisted at first in a small sore, visible when the lips of the meatus were separated. This part had healed; but it was evident that the ulcer had extended its ravages down the urethra, since, on pressing an induration which existed behind the glans between the fingers, there escaped from the urethra a tenacious slough, precisely resembling that covering an indurated chancre in its first or ulcerating stage.

The only disease for which chancre of the urethra is likely to be mistaken is gonorrhoea. From this it is to be distinguished by the history of the case, the character and quantity of the discharge, the presence of a distinct circumscribed induration in some part of the urethra, most commonly seated in or immediately behind the glans penis. This circumscribed induration must not be mistaken for that general induration of the corpus spongiosum urethree which accompanies acute gonorrhoea, and results from an effusion of lymph into the cells of the spongy body. This state in gonorrhoea is generally accompanied by chordee, a symptom generally absent in chancre of the urethra.

When muco-purulent discharges from the urethra continue to resist the usual methods of treatment, we may resort to the