straining of sensible parts, the presence of the pus, or even its reabsorption, appears to be innoxious to the system; unless, indeed, the stagnant collection, by exposure to the atmospheric air in an open bubo, should generate carburetted and sulphuretted hydrogen gas, when the altered qualities of the pus become the exciting cause of serious disorder in the constitution.

Of the Progress and Termination of Buboes generally, and their exciting Causes.

To form any certain prognosis of the termination of a bubo in its early stage seems to be impossible, so variable is its general character and appearance. When active and irritable, it will suddenly become passive and stationary; or, when to outward view indolent, it will occasionally suppurate quickly, without stretching the integuments, and thus creating no pain or irritation.

I am unaware of any specifically marked signs by which the terminations are to be prognosticated, until the eve of their occurrence, either local or constitutional. The agency by which the changes are affected lie concealed, and the vicissitudes which buboes go through have, in consequence, a capricious appearance. These changes do not seem to depend directly on the gland itself, for, throughout the different stages of buboes, the glands remain much in the same state and size. The changes seem to be rather referrible to the integuments and cellular substance over the inflamed gland, and these run into inflammation more or less extensively, assuming different shades of redness, sometimes having a rosy, sometimes a bluish, and at others a brownish tint, probably from constitutional peculiarities rather than any which may be connected with the ultimate exciting cause.

From whatever source a bubo may originally proceed, we seem to have no proof that its progress and termination are influenced by it. A mild gonorrhoea of short duration, accumulation of viscid mucus behind the glans, a phymosis, an injury of the foot or toe, &c. are followed by buboes, similar in their appearance, continuance, and termination, to those arising from the most virulent gonorrhoea, or the inoculation of poisonous matter. I should imagine the buboes of the plague itself to be influenced by the state of the constitution, and not by the virus supposed to be imbibed. When, therefore, we hear of the malignant, the mild, the sympathetic, the syphilitic, or the strumous bubo, I should be disposed to refer all these characteristic distinc

tions equally to constitutional influence, to the disorders of health, and not to the nature and properties of the ultimate exciting cause; and, as such peculiarities are not usually pre-evident, the prognosis of bubo is seldom certain,

Of the Treatment of Buboes generally.

The foregoing views of the pathology and exciting causes of bubo have been introduced with the view of adapting the treatment of this tumor to the principle suggested. Accordingly, the first indication seems to be to remove the irritation derived from the presence of an enlarged and indurated gland in the groin or axilla; the means most suited to which end appear to be such as at once diminish and sooth the swollen parts, and these are of a topical kind. If pain and fever exist, local applications will thus tranquillize the system, in conjunction with repose in a recumbent position. The choice of local remedies must be governed by the state of the parts. The active and irritable state requires one species of application, and the indolent, sluggish, and insensible state, another. The secondary state of bubo, that of established suppuration, may be considered in the same light, and requires its treatment to be adapted to its immediate condition. Great attention seems to be necessary to the secondary state, as upon the choice of remedies depends much of its subsequent condition and duration.

Treatment of Bubo in its primary State.

If the incipient bubo be active and irritable, the remedies should be directed to the tranquillizing of the parts, and the adoption of such measures as may best secure the end in view. The inflammation of cellular surfaces seems to be beneficially treated with cooling, astringent, and evaporating lotions; but, ia glandular inflammation, such remedies appear to be insufficient, if not injurious. They are not calculated to relax and soothe the indurated and irritable gland, to check its swelling and suppuration, or diminish pain, although they lessen the inflammatory action of the softer and more yielding parts around, and contract the limits of inflammation within the sphere of the tumor, which advances in about the same ratio. The application, also, of leeches in the incipient state appears to aggravate the condition of the tumor, so that the advantages of abstracting blood seem to be counterpoised by the irritation of the leechbites. Experience has led me to discard the use of cold lotions and leeches, as inadequate to

secure the fulfilment of the objects in view, and rather tending to increase than relieve the existing symptoms, and promote the advancement of the tumor, instead of its repulsion, ultimately. A moderate and equable degree of warmth, combined with moisture, is more calculated to soothe the parts, repress their activity, relax the induration, and finally disperse the tumor. To this end, fomentations thrice a day, succeeded by light, warm, and moist poultices of linseed meal, or finely grated bread, or both mixed together, and soaked in boiled milk and water, may be advantageously applied; and, if these be insufficient to allay pain, the fomentations and poultices may be made of the decoction of poppyheads and conium. The first appearance of enlarged glands will often yield merely to fomentations, if the body be kept in repose. The result of such a principle of treatment, when the tumor subsides, is not attended generally, as in cases after the use of cold applications, with a kind of marble-like ball left in the groin or axilla, and liable to subsequent relapse. The dispersion in one case is more complete than in the other. Where the tumor is not active and irritable, its advance may sometimes be checked by cold washes; but it is then liable to become stationary and indurated; an effect not resulting from the use of fomentations and poultices.

With regard to constitutional remedies, such as tend to diminish the action of the heart and arteries, to cool the system, and assist the suppression and dispersion of the tumor, are indicated; and, in doses proportioned to the heat of the skin and fever, the invaluable remedy of tartarised antimony, with saline mixture and Epsom salts and senna, I have always found to be highly useful adjuncts, and far preferable to the use of narcotics, where pain attends the incipient advance of bubo, excepting as local applications. And, where plethora is present, bleeding from the arm will always tend to check the inflammatory stage, with general advantage to the system. But, when fever does not exist, and the tumor is not actively inflamed, I see no advantage in the use of antimony, &c.: on the contrary, in sluggish cases, the reducing plan may perhaps be injurious rather than beneficial.

It occasionally happens that the incipient stages of bubo are not attended with tension of the superincumbent integuments, which lay more loosely over the surface of the tumor. But this state of the parts may soon become altered, if repose be not enjoined, and the case thus become prolonged and more complicated. This passive state is

also more aggravated by cold applications and leeches; but it is less likely to be completely reduced by mild, moist, and warm applications, than the more irritable and active tumor. When these, therefore, have apparently brought the tumefied parts into a perfect state of passiveness, and the induration and swelling yield no further, blisters repeatedly applied, or cautious and gentle friction with the Linimentum olei camphorati, to which the Unguentum hydr. may be usefully added, often tend to the gradual removal of this chronic state. Should too much action be excited, the fomentations and poulticing may be resorted to again beneficially. If the first intention of stimulating remedies be not fulfilled, they have this advantage, that they bring the tumor forward to suppuration, and thus afford the means of destruction, if we cannot disperse it, and so prevent the inconvenience and liability to relapse which belong to indurated and enlarged glandular tumors situated in the groin or axilla. With labourers and soldiers, I have in such cases generally recommended a return to labour and duty until active inflammation be excited, and a chance thus afforded of the permanent removal of a troublesome and inconvenient affection.

Treatment of Bubo in its secondary State.

When the measures which I have recommended to be pursued in the primary state of bubo do not succeed in preventing its advance to the secondary state, and suppuration is inevitable, whether cold or warm applications, mild or stimulating, are to be preferred, cannot then be come a question. The same treatment which is calculated to disperse the tumor will now facilitate and concentrate the process of suppuration, diminish pain, and often tend to produce a speedy, favorable, and spontaneous discharge of the matter formed. Perhaps, when such is the termination indicated, it is best not to interpose with an artificial opening, and, with careful and judicious attention and management, the abscess will not long continue to be trou. blesome afterwards, where the constitution is in good order. The accumulation of stagnant matter should be avoided while the original aperture remains open, and a mild emollient poultice applied thrice a day, accompanied with gentle and gradually increased pressure, is well calculated to promote the discharge of the pus, prevent the formation of sinuses, and encourage the adhesion of the parietes of the sac; and, when this cannot be brought about, but a

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weeping orifice continues, the sac may be irritated, or even destroyed, by stimulants or escharotics.

In this stage of the secondary state, a generous diet, regular mode of life, and good air, are as essential to the patients as are a low diet and reducing measures in the primary state. But, if the progress of suppuration has not been accompanied by high inflammatory action of the parts involved, spontaneous discharge is either procrastinated or altogether avoided, and a soft fluctuating feel is presented to the touch, on applying the fingers to the surface of the bubo. We have then an opportunity of fairly employing surgical skill; and, in the choice of several means in our power, will probably depend the permanence and celerity of the cure. In some cases the quantity of pus becomes gradually diminished while poultices are being applied, but rarely entirely removed, although I have seen this effected. In such cases, where a languid state of the parts around exists, I have known the dispersion of the pus accelerated by repeated blistering. The same result may also be sometimes produced by the cautious and gradually increased pressure of a flannel bandage, passed across the tumor, and round the loins and thigh. I have also used, in similar cases, poultices mingled with mercurial ointment and soft soap, with benefit. But if there seems to be no indications of such measures effecting the removal of the pus, (and if the skin over the tumor be very thin, and the accumulation below large, these will not succeed, and the integuments will let out their contents,) it appears preferable to make an artificial opening in one of these modes, either by a simple puncture, a long incision, or the application of caustic so as to form a deep and wide eschar. Of these methods experience has taught me, certainly in general, to reject the first; for, though sometimes speedily successful, it most frequently entails a long continuance of the abscess in a state of secretion and discharge, requiring some trouble to manage. The two latter operations appear to be greatly preferable; and of these, perhaps, the formation of an eschar by caustic is the most effectual of the two, and the readiest mode of ensuring an entire and permanent destruction of the bubo, usually not long after the casting off of the slough. The manner in which I prefer applying the caustic is to rub the skin covering the bubo with the Kali purum dipped in a drop of water, till the parts to the extent of about a shilling are sufficiently affected to ensure the destruction of their vitality. An emollient poultice,