or by migration of pus-corpuscles is unknown. Without chancroid. its existence is impossible. Virulent bubo is usually single, in one gland, on one side. It suppurates necessarily, but, until it is open, there is no diagnostic feature which can positively distinguish it from simple acute inflammatory bubo on the road to suppuration. This only can be said, that its course is more rapid, more acute, more inflammatory. Periadenitis occurs with virulent bubo also, the pus forming outside the gland usually ulcerating through the skin first. In such case the first pus that flows is simple, not poisonous, and the wound looks like that seen with simple bubo; but soon the deeper pus from the gland appears, poisons the wound, and gives it the wellknown chancroidal aspect, and now the pus is freely auto-inoculable. Virulent bubo may discharge by a single opening. This is large at first, and subsequently enlarges, but, if fortunately adhesive inflammation has agglutinated its edges to the surrounding underlying tissue, no further poisoning takes place, the abscess assumes all the character of a true chancroid (abrupt edges, pultaceous, irregular base), passes through its regular stages, and finally gets well. Matters do not, however, always eventuate so fortunately; the thinned skin over the suppurating gland may fail to become bound down by adhesive inflammation, or to give way speedily at a single point, then the pus undermines a certain extent of integument, and perforates it in a cribriform manner. Burrowings, more or less extensive, go on. Hard, sinuous, everted edges, overhanging flaps and bridges of thin, purplish skin, long fistulous tracts, and poisoned pouches full of pus, serve indefinitely to prolong the virulent bubo, making its duration a matter of months, perhaps years.

Finally, virulent bubo, like any other chancroid, may be attacked by phagedena, or any of the other complications set down for chancroid. Accidental auto-inoculation of the skin of the abdomen or thigh is not uncommon. The worst forms of phagedena are seen in connection with virulent bubo. The case which Fournier records as having lasted fourteen years and being still unhealed at the knee was phagedena of a virulent bubo. All the varieties of phagedeua are found, but the pultaceous, serpiginous variety is most common. It usually travels up over the abdomen, but if very extensive seems to prefer to turn the flank and go down the thigh, rather than advance upon the chest, that region shown by Boeck to be unfavorable soil for chancroid. Phagedena does occur on the chest, but not commonly.

The nature and character of phagedena have been described. phagedenic bubo does not necessarily, or indeed usually, exist in connection with a phagedenic chancroid, which latter may be attended by simple bubo, or leave the glands untouched nor is lymphangitis necessary, or indeed common. An insignificant-looking chancroid

may be attended by a phagedenic bubo, and phagedenic chancroid. may have no bubo at all.

*

Horteloup has a case going to show that the virus of chancroid. may be long retained in the glands of the groin before showing itself. A patient of twenty-six has chancroid in February, 1879, and shortly suppurating bubo. The latter is lanced, and the patient leaves hospital April 15th, with chancroid well and no swelling in either groin. Six months later, having meantime had no new sore, he returns with glands swollen in each groin, and three and a half months later he again entered hospital, both groins suppurating, one phagedenic. This case is so irregular as to need confirmation, in my opinion.

Diagnosis.-The diagnosis between simple, virulent, and syphilitic bubo will be found in the diagnostic table following syphilitic chancre. The bubon d'emblée does not exist in the sense originally attributed to the term; namely, a bubo without antecedent venereal ulcer, ushering in syphilis, and furnishing auto-inoculable pus. The absurdity of this is self-evident, for a virulent bubo never ushers in syphilis, nor indeed has it anything to do with that disease. It is nothing more or less than a chancroid. A bubo, however, may suppurate in the groin without necessarily any antecedent chancroid, as in connection with herpes, gonorrhoea, balanitis, an inflamed corn; or spontaneously, as may a gland in the neck or axilla; such a bubo, however, does not furnish poisonous pus. When a gland in the groin suppurates, and its pus is virulently and actively auto-inoculable, it has been preceded by a chancroid. The latter may have cicatrized before the patient presents himself, perhaps was situated in the urethra, or even in the rectum, but somewhere it is or certainly has been. The intelligence of the surgeon may occasionally be taxed to find it.

There are no diagnostic signs between a simple and virulent bubo at first. When opened spontaneously or by art, the outlet does not enlarge in simple bubo; in virulent bubo it does, and shows all the characteristic marks of chancroid. Again, if suppuration can be arrested in an inflamed gland, it must have been simple bubo (unless syphilitic); virulent bubo must necessarily suppurate.

Treatment of Bubo.-The preventive treatment of bubo is rest, and the avoidance of such causes as tend to inflame the chancroid. The most positive preventive treatment is the absolute destruction of the chancroid with caustic. In such a case if the simple ulcer left by the fall of the slough is still able to excite a simple bubo, yet virulent bubo and its attendant phagedena can no longer occur. Tincture of aconite and belladonna combined in equal parts are of some use locally, especially if combined with rest. Tincture of iodine I consider absolutely useless if not harmful in acute advancing bubo, and I no longer employ it. Rest in bed, aconite and belladonna, and a light poultice "Ann. de Derm. et de Syph.," January, 1880, p. 54.

will avert impending bubo (simple) more often than any means with which I am acquainted.

Besides rest, there are three other agents which may avert suppuration occasionally:

1. Blister, repeated as soon as the skin has re-formed.

2. Pressure, which, if applied early and judiciously in mild cases, is sometimes effective.

3. Leeches, plentifully applied around the swollen gland.

The latter treatment is only applicable in the early stages of bubo, for, should the swelling prove virulent, suppuration is inevitable, and, if the leech-bites are near the point of opening and have not cicatrized, they are pretty sure to become inoculated and form so many chancroids. If the tendency to suppuration advances very slowly, the bubo is certainly simple; if rapidly, large, hot poultices should be constantly applied to hasten it, and the abscess may be allowed to open itself; but, if from its very rapid course it is believed to be virulent, an opening should be made as soon as any fluctuation can be felt, to let out the poisonous pus, and save destruction of tissue. In this way burrowing may be averted, as it may also by properly applied pressure. It is a good rule to open early in any case. If it be simple bubo, no harm is done; if it be virulent, the chancroidal ulcer following is by so much less extensive. Small collections of pus should be punctured, large ones extensively laid open. If the skin does not appear to be adherent, some caustic paste may be preferred to incision. If any outside wounds exist (leech-bites) at the time of opening bubo, they should be carefully protected.

The question of attempting to abort the bubo after suppuration is imminent or has actually occurred is worth considering. Morse K. Taylor* gives a number of interesting cases of acute inflammation in lymphatic glands, in which he claims to have invariably aborted suppuration by injecting into their substance twenty minims of a solution of carbolic acid (gr. viij to the 3j). If suppuration has occurred, he aspirates the cavity, and washes on successive days with a carbolic-acid solution (gr. xij to j). There is certainly no objection to trying a means so simple.

When the knife is used, if the bloody, thinnish, unhealthy look of the pus suggest virulent bubo, the poultice should be discontinued, otherwise it is better kept up for some days. All cavities, if large, should be thoroughly cleansed several times daily with warm water, and then injected with a mild solution of carbolic acid or permanganate of potash, dilute alcohol, or some other detergent lotion. After virulent bubo becomes an open ulcer, its treatment is that of chan

* He used a solution of 1 in 30, and injected in this way at one sitting, in different parts of a single gland the size of a goose-egg, gr. xv of potassium iodide in 3j of water, and repeated the injections four times in two days, he says, with success.

croid. Where large glands lie out in the ulcer and have not suppurated, or if all the suppuration have come from periadenitis, in cases where the bubo was strumous, these glands should be removed. This is best done with the finger, tearing them away, or they may be tied off with a ligature. Even when cut away they rarely bleed much.

Burrowing and phagedena in the groin are treated in the same manner as when occurring with chancroid. The pastes, carbo-sulphuric and Vienna, are well suited to phagedena in this region. Where suppuration has been stayed, and in all cases of chronic bubo in which strumous degeneration of the gland plays a large part, resolution may be hastened by counter-irritants and pressure. The latter is conveniently applied, the patient being on his back, by placing a bag of sand or fine shot over the swollen glands, or by a spica bandage over compressed sponge laid upon the swelling, the bandage afterward being slightly moistened. Trusses are too irritating, but it has been noticed that persons wearing trusses and afterward getting chancroid rarely have bubo upon the side of the hernia, probably from previous atrophy of the gland through prolonged pressure (Ricord). If there has been periadenitis wth one or more fistulæ, or in any case of protracted trouble, it becomes a question for surgical judgment whether it is not better to terminate the matter at once by free incisions and scraping out all diseased tissue with the surgical spoon. Such a course is always successful, and, if antiseptic dressings are used, three weeks are usually enough for a cure even in very severe cases, or enough of a cure to let the patient get up and about.

If the symptoms never become sufficiently severe to justify surgical interference, among the counter-irritants repeated punctate cauterization with a Paquelin cautery or mild repeated blistering are perhaps best. Tincture of iodine has positive resolving power in this stage. Jacubowitz claims success from interstitial injections of iodide of potassium.

**

Internal remedies for chronic and phagedenic bubo are the same as for similar conditions of chancroid.

(0) LYMPHANGITIS, or inflammation of the lymph-vessel, never occurs without some accompanying inflammation of the connective tissue around the vessel, perilymphangitis. Its varieties are identical with those of bubo; namely:

1. Simple inflammatory lymphangitis, which may be found in connection with any inflammatory abrasion, simple, chancroidal (most common), or syphilitic (least common).

2. Virulent lymphangitis, only found in connection with chancroid.

3. Syphilitic lymphangitis, found only with syphilis.

The first two varieties are indistinguishable until they suppurate.

* "Der praktische Arzt," xvi, No. 7.

One or two hard, knotty cords are felt under the skin of the penis, usually at the side. They commence at the chancroid (or other lesion), extend for a greater or less distance up the penis, sometimes up to the glands in the groin. Occasionally they can be felt only toward the root of the penis. The integument over them, in mild cases, is unaltered; in severer cases their course is marked by a red line. They are painful to the touch, and during erection. The penis is often red, erysipelatous, swollen, oedematous, and, in severe cases, there are fever, sleeplessness, etc.

Lymphangitis terminates in resolution or suppuration. In virulent lymphangitis the latter is inevitable. In the simple form suppuration may occur in one or more spots, resulting in abscesses, which discharge and get well. In virulent lymphangitis similar abscesses form along the line of the vessel, open, furnish auto-inoculable pus, and remain as chancroidal ulcerations.

Either form may exist without bubo, with simple bubo, or with virulent bubo. The affection is not common, and bubo is most frequently encountered without it.

Treatment.-Rest, cooling lead-water or spirit lotions, collodion for excessive ædema, perhaps puncture, poultice for severe pain, and opening abscesses, when they form, comprise the treatment. Simple abscesses are best treated with water-dressings; virulent abscesses exactly like chancroids, which indeed they are. Internal treatment has no influence over lymphangitis.

CHAPTER III.

SYPHILIS.

Nature.-Unity and Duality.-Length of Time required for Absorption of Virus.-Analogy with Vaccine Virus.-Second Attacks of True Syphilis.-Transmissibility to Animals.--Incubation of Syphilitic Chancre.-Induration, parchment-like, split-pea, diffuse.-Ulceration.-Secretion.Pain.-Nature of Scar.-Auto- and Hetero-Inoculation.-Vaccinal Syphilis.-Multiple Inoculation.-Fluids capable of transmitting Syphilis by Inoculation.-Methods of Transmission of Syphilis. Duration of Chancre.-Number.-Size.-Situation.-Form.-Symptoms of Urethral Chancre. -Course of Chancre. - Complications. -"Mixed Chancre."- Transformation into Mucous Patch. - Phagedena and Gangrene. Treatment of Chancre. - Syphilitic Bubo. — Lymphitis.

SYPHILIS is a general dyscrasial blood-disease caused by the absorption of a peculiar virus into the circulation, manifesting itself primarily by the appearance of a poisonous sore at the point where the virus entered, and afterward by a succession of morbid manifestations occurring at longer or shorter intervals-manifestations which, in their totality, interest every organ and tissue in the body.

The virus is only known by its effects. Exactly what it is has not