disease. Thus, the chancre of the urethra lies just where the stream of urine several times in the day necessarily passes over its entire face, and, this fluid being in a high degree irritating in consequence of the urinary salts it contains, the chancre often secretes quite freely, and may leave an odd-looking scar at the tip of the glans penis, this organ, after all is healed, looking as though it had lost its apex, while the external urinary meatus has for a distance of perhaps half an inch or more a "reamed-out" aspect. Deeply-cauterized and filthy chancres, as well as those of "mixed" type, may leave small cicatrices. It follows that in making examinations for the army and navy and for life insurance, the non-discovery of scars upon the progenital region of men does not prove that they have not had a preceding syphilis, and the actual discovery of such scars in the progenital region is by no means conclusive that the subjects of the same have been syphilitic.

Diagnosis.-The diagnosis of the initial lesion of syphilis is made chiefly by a careful study of the symptoms already detailed. By the recognition of these special characters, rather than by the exclusion of the symptoms of other diseases, is the end best reached.

The chancroid or "soft chancre" is usually a pustular lesion, and is represented either by an unbroken pustule surmounting its characteristic sharply-cut ulcer, or, after the rupture of the pustule, by the pus-bathed ulcer itself, circular, oval, stellate, or linear in outline. However engorged its base, the latter is never indurated save in the "mixed" variety. There is no period of incubation, and, though at times single, the lesions are usually multiple and often exceedingly numerous, scores forming in extreme cases. The adenopathy of chancroid is represented usually by a single though occasionally by a double bubo. Rarely many buboes occur of a distinctly inflammatory type, with a tendency to suppuration and the production in the lips of the wound, when there is spontaneous bursting of the gland-abscess, of a

chancroid by secondary infection. The purulent secretion of the chancroid is practically indefinitely autoinoculable-a fact accounting for the multiplicity of the lesions in many cases. Chancroids are usually genital in situation; rarely are they extra-genital, with the exception, particularly in filthy women, of the anus. The floor of the chancroidal ulcer is usually covered with a more or less tenacious slough resembling wet chamois-skin, and presenting in this particular a marked contrast with the shallow, scantily secreting, indurated, and sloping edges and floor of the initial lesion of syphilis. Lastly, the accidents of sloughing, phagedena, and enormous involvement of the skin and the subcutaneous tissues of the thigh in ulcerative and burrowing sinuses are almost unknown in syphilis of the cleanly, and are by no means of very rare occurrence in chancroids of all classes of patients.

The lesions of herpes progenitalis are very readily differentiated from syphilitic chancres. The former are transitory, lasting at the longest for but a few days-a feature of prime importance in establishing a diagnosis, for any so-called "herpetic lesions" followed by ulcers lasting for ten days are probably not such, and should be viewed with great suspicion. Herpetic lesions in the progenital region are essentially vesicular, and are visible either as vesicles or as the relics of vesicles in the form of very superficial reddish plaques, where delicate and lightly-tinted crusts appear, or as slightly raw and tender, finger-nail-sized spots, furnishing a serum sufficient in quantity to moisten an applied bit of cotton. Their cause, further, may often be determined without great difficulty (venery, pollutions, gastro-intestinal derangements such as constipation, chills, gouty attacks, etc.).

Balanitis. In this affection, as in herpes progenitalis, the disease, as distinguished from all varieties of chancre, is always short-lived and yields readily to treatment. In typical lesions the mucous membrane of the sac of the

prepuce and of the glans penis becomes reddened, tumid, and in extreme cases of a deep purplish hue, with superficial excoriations of the external layer of the membrane. in plate-like, finger-nail-sized plaques, which can be studied best in a well-marked case of blennorrhagia of the conjunctival membrane. There are distinct sensations of itching and burning in the part, and the odor of the secretions is usually nauseous in consequence of the altered character, in this part, of the secretion from the glands of Tyson. There is no induration, no glandular complication, and never ulceration. The disorder is usually relieved, when not complicated, in the course of a few days by the application of a stimulating vinous lotion aided by astringents, a thin layer of absorbent cotton being interposed between the two folds of membrane in contact.

Verruca Acuminata (“Venereal warts," Moist warts, Condylomata, etc.).-Filiform, papilliform, single or multiple, often numerous, vegetations may develop, for the most part in the progenital region of the two sexes. These warty growths are usually pedunculated, but at times are flattened. They secrete a mucoid fluid of offensive odor; this fluid in syphilitic subjects is highly contagious. The growths vary in size from a pin-head to compound masses as large as the fist and even larger. As distinguished from chancres, they are never indurated, they rarely ulcerate, they are not accompanied by adenopathy, and they survive for periods of time far outlasting the life-history of even persistent initial lesions of syphilis. They may occur in virgins, but they are more common in the subjects of venereal disorders, as also in those suffering from leucorrhoeal and other pathological fluids bathing the genital region. Rarely they have an extra-genital site, such as the face. In males they are apt to form in the sulcus behind the corona glandis, about the frænum, in the external orifice of the urethra, and over the scrotum; in women, chiefly about the fourchette and the labia. They are readily recognized by

their resemblance to the comb of a cock, by the absence of ulceration and of induration of the base, and, when wiped clean, by their florid aspect and their readiness to bleed when scraped or cut away.

Epithelioma of the genital organs occurs most commonly after the middle periods of life in both sexesages when chancres are decidedly of less frequent occurrence than at others. In men the most frequent site of the disease is the glans penis, where a circumscribed, flattened papule, verrucous elevation, or shallow erosion. may occur. The period of duration of these lesions is for most cases far greater than that of either chancre or gumma. The base of one or two of these primary growths may become indurated and the neighboring glands may enlarge; but the inactive, often slightly hemorrhagic or crusted papule or warty growth seated upon an infiltrated tissue, with an ulcer forming only after a long evolution of the primary symptom of the disease, is not to be mistaken for a chancrous lesion. When actually ulcerating, the resulting ulcer is of the type of the epitheliomata of the skin in general, with serous, scanty, or bloody secretion, everted edges, and excavated, often eroded, floor. For women the region of preference in the progenital forms is the clitoris, where the lesions above described may occur occasionally with striking deformity of the parts. The noninflammatory, often scarcely colored thickenings, erosions, warty growths, etc. of both labia and clitoris, in women past the menopause, are all to be separated from chancrous changes.

Molluscum epitheliale of the genital region in young persons, especially those of the male sex, is characterized by the occurrence, on the scrotum chiefly, of split-peasized, yellowish-white, waxy-looking, and imbedded or projecting bodies, usually exhibiting at one point or another of their globular surface a whitish or blackish punctum representing the occluded orifice of a sebaceous gland. They may be few in number, but often they are

exceedingly numerous, studding the region affected with isolated but closely approximated lesions. They are never ulcerated, indurated, inflammatory, nor the seat of evidence of any acute process. It is impossible for the trained physician to mistake them for chancres, but the error is occasionally made by young and timid lay patients, who, having for good reasons become anxious about exposure to disease of the affected part, discover for the first time, on careful scrutiny, the molluscous bodies, and are filled with terror at the sight. There is never any glandular complication of these simple lesions, and in any doubtful case the expression of the cheesy mass from the orifice of the gland would establish the diagnosis.

Lichen planus of the genital region, particularly in the male sex, is at times liable to be mistaken for chancre. But the lesions are always papular, dry, and flattened at the apex, with a singularly characteristic polygonal outline, often very sharply defined. They are never seated on an indurated base, are not accompanied by glandular enlargement, are not eroded nor ulcerated, and are usually multiple, with at times marked invasion of the skin of the lower belly and the adjacent region of the thighs. An interesting feature of lichen planus of the genital region is the grouping of the lesions in lines, so that at times half a dozen or more of the small crimson, reddish, purplish, or dull leaden-hued papules stretch in a direct line from one point to another over the dorsum of the glans penis, in the skin of the organ. Angular as well as rectilinear figures, and even odd-looking cockades, may thus be formed. Lichen planus lesions of the genital region are often the seat of intense itching, and may be well scratched with the evidences of such traumatism upon and about them.

They comlonger than

monly persist for a period of time much that limiting the continuance of chancres. The usual occurrence of typical lesions elsewhere than in the genital region (forearms, abdomen, thighs) is of value in establishing a correct diagnosis.