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presence of buboes is one of the most constant and at the same time one of the characteristic phenomena of certain types of the disease, yet when we review the whole history of plague as a dreadful "pest," it is found that so-called bubonic plague is by no means the most horrible manifestation of the disease, and never occasions such devastation of life as other prominent forms of disease, such as primary pneumonic plague. In fact, one might go so far as to describe ordinary bubonic plague as more the benign type of plague, the malignant type being represented by primary pneumonic plague.
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Much has been written in regard to these bubonic swellings, and from the voluminous literature on the subject, one would conclude that almost the last word had been spoken in regard to this pathological lesion. Taking up the question from the standpoint of our present day conceptions of bubonic plague, however, there would appear to be still many points wanting, to complete the chapter dealing with such manifestations of plague, and the true interpretation of their presence.
For the past two years, I have had considerable insight to the presence of buboes, and noted many interesting points in regard to their pathological history and endeavoured to adduce certain evidence in regard to their presence in plague.
It is not my intention to enter into a deeply scientific description of the pathological appearances of buboes. Such is already well known.
I wish to bring forward my experience in regard to the anatomy of such swellings, the time of their appearance, their growth. their situation, their number, and subsequently to offer certain considerations regarding their origin in the disease.
(1.) Anatomy.—The neck, axilla and the region of the groin are the com- monest sites of these bubonic swellings. Their anatomy varies in these situations according to their severity. Occasionally it is only an enlarged gland with cortical injection; in other cases, however, the lesion may be widely spread, affecting structures placed at some distance from its focus of origin.
(a.) The Neck.-Buboes occur most frequently in the submaxillary, sub- mental, supra and infra-clavicular, sub and retro-auricular, and the parotic regions. The skin over the swollen mass is thickened aud covered frequently with petechiæ. On section, the mass is cedematous. The hæmorrhagic appearance is not equally intense throughout. The glauds are swollen, edematous, and injected. They are embedded in a densely infiltrated bæmorrhagic mass of connective tissue. The hæmorrhagic infiltration extends along the connective tissue spaces, and surrounds the neighbouring muscles and other structures.
(b.) The Axilla.-The lymphatic glands are periglandular connective tissue form a soft, cedematous mass of varying size. The super adjacent skin is fre- quently covered with petechia. The edema and hemorrhage extends into the surrounding tissues to the scapular muscles, the pectoral muscles, the intercostals, down the arm, and up into the region of the neck. The breast in females inay also participate and form part of the bubonic swelling. (Bubo paramammario- axillaris).
(c.) The firoin. The swelling may be femoral, inguinal, or both, with exten- sions to the iliacal and lumbar regions. The latter is common. The skin over the swelling is frequently covered with petechia. The hæmorrhagic infiltration may extend down the thigh to the popliteal region, or upwards over the lower part of the abdominal wall, into the scrotum, under Poupart's ligament into the pelvis. and spread over the belly of the ileo-psoas embedding the iliac glands, and the lymphatic duct and cystema chyli, with extensions to the kidneys, pancreas and even the diaphragm.
Rarer situations for the presence of buboes are the region of the tonsil, the popliteal space, the cubital gland, the sacral region, the mesentery, and the glands situated posterior to the liver and about the pancreas.
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Date of Onset.—This varies extremely. Buboes may be one of the earliest signs of the disease. In my opinion, they do not appear until certain prodromal symptoms have showed themselves. Many appear within 48 hours of the onset of the fever. In other cases their appearance may be delayed for several days.