sore. When used at all they should be strong enough to produce an eschar at once. Creeping sluggish sores are often induced to granulate freely by dressing them with a lotion of 5 to 10 grains of tartarated iron to the ounce of water. This application is very effectual even in the most obstinate sores, causing them to granulate and cicatrise rapidly when many other remedies have failed. When the sore is very indolent, neither spreading nor healing, calomel or red precipitate may be dusted over the surface; or an ointment of half a grain of bisulphuret of mercury and two drachms of lard laid on for one or two hours. When the ointment is removed, a two grain solution of sulphate of zinc may be used to dress the sore. If means of this kind fail to excite cicatrisation, it is better to destroy the surface thoroughly with caustic to procure fresh granulations when the eschar separates.

Caustic should be used in the following cases :-It may be employed on the very first appearance of a sore, to shorten its duration, and to prevent the danger of inflammation, sloughing, multiplication by consecutive inoculation, or bubo. At this time the sore is also very small, and the pain accompanying its extirpation not very great. But when the patient has had the ulcer a week or ten days before he comes under treatment, the chancre has generally assumed the character it means to preserve; if it appears little prone to spread and inflame, it may be managed by astringent lotions without resorting to caustics. If the sore, on the other hand, be spreading, with sharply-cut edges, or if it has lasted a long time, and resists other treatment; or, again, if its presence prey upon the patient's spirits, cauterisation is the best remedy to prevent further mischief. In the rapidly sloughing chancre with inflammation, complete cauterisation with hot irons is the most effectual remedy, but it must be followed by soothing applications to allay the

pain and inflammation, when the sloughing surface is destroyed.

As chancres may excite bubo at any period of their existence, destruction of their surface with caustic may prevent this consequence whenever it is employed. Still this advantage is not sufficient in practice to require the invariable use of caustics, as the chance of a particular sore not being accompanied by bubo is two to one, even when left to run its course. Besides this, it is often exceedingly difficult to destroy several sores thoroughly by one application of caustic; hence the patient, after having undergone all the suffering and inconvenience of cauterisation, may be disappointed on finding, in a few days, the sore to assume its original character. In the section on Syphilis the propriety of using caustics to prevent general constitutional infection has already been discussed and shown to be valueless for that purpose. Thus caustics are useful to extirpate the sore on its first appearance, to check it when spreading, and to arrest its progress when sloughing rapidly. In other conditions the use of caustic has disadvantages which often outweigh the advantages.

Several preparations are used to destroy the ulcerating tissue. Whichever caustic is selected it should always be thoroughly applied, and it is better to cauterise a little more deeply than is absolutely necessary, that complete destruction of the sore may be ensured. Among the most effectual caustics is one Ricord prefers. He makes a paste of powdered charcoal and strong oil of vitriol, which he lays on and rubs into the chancre. In a few minutes the surface is destroyed, and forms an eschar or crust which falls off in a week, leaving the sore a simple granulating surface. It is a very effective remedy, being not liable to overflow the sides of the ulcer and attack the healthy skin, as is the case with liquid caustics. But it is not always at

hand, hence less convenient than another-the strongest nitric acid. The best way to use this is to dab it with a glass brush over the floor and edges of the ulcer, and allow it to soak well into the surface of the sore for a few minutes before the excess of acid is neutralised with a little carbonate of soda dissolved in water. The skin surrounding the ulcer should be protected by grease, but the edges may be left clear for the action of the caustic. The chloride of zinc and caustic potash are slower in action, and must be left longer in contact with the sore, or they will not penetrate deeply enough to destroy it altogether. The actual cautery by hot iron or galvanic wire are at times very useful when a large amount of tissue has to be destroyed, otherwise they are not preferable to chemical caustics, while they alarm the patient much more than the latter. When the caustic has done its work and the excess washed away with cold water, the sore should be wrapped in wet lint, and the pain, which often lasts several hours, can be assuaged by the constant application of ice-cold water. The eschar usually separates in four or five days, and leaves a clean granulating surface.

These applications are all very painful, and the fortitude of the patient seldom affords the surgeon full leisure for the complete destruction of the sore, and unless this is attained, the suffering will be in vain, whence it is best to render him insensible by chloroform or ether spray. The latter remedy is exceedingly painful if the part is at all inflamed; in such cases it is best to use chloroform, which has the additional advantage of rendering the patient unaware of what is going on around him and prevents the disagreeable consciousness of the nature of the operation.

Caustic must be withheld in inflamed chancres, except when the destruction of tissue is very rapid, and thick layers are necrosing one after another. If, however, the

chancre is simply inflamed, that is, painful, hot, secreting much pus, and the skin round the sore red and tense, but the ulcerating action does not threaten a great loss of tissue, it is better to allay the inflammation by rest, moderate diet, and cold lotions.

When the destruction of tissue is so rapid as to cause sloughing phagedena, the sloughing must be arrested by destroying the surface of the sore, beyond the limits of the morbid action which causes the mortification. The patient should be put under chloroform, and the surface of the sore cleared of the loose sloughs by snipping them away with scissors and wiping the surface dry. Then the red-hot iron should be passed evenly over the sore and along its edges till all the inflamed and ulcerating tissue is charred. This should be done deliberately and carefully, or the sloughing will begin again in a few hours. The pain of the cauterisation may be allayed by wrapping the part in rags dipped in ice-cold water for the first few hours after the operation. When the aching has subsided, a warm linseed poultice may be applied to hasten the separation of the eschar and cleaning of the surface.

The poultices and dressings should be mixed with weak solutions of chlorinated lime or soda, or of permanganate of potash, in the proportion of one to twenty of water, when the discharge is offensive. Carbolic acid mixed with forty parts of water is also very effective, and the sores may be covered with lint soaked in the solution. The carbolic acid lotion is often used without poul

arresting the progress of

tices, and is very efficient in inflamed or foul sores. The solution of carbolic acid in glycerine of the British Pharmacopoeia diluted with six or eight times its bulk of water is a very useful lotion in such cases. When the inflammation is less intense, the poultices can often be advantageously replaced by warm

dressings. Warm lead lotion on strips of lint frequently changed, may be used instead of the disinfectants, when there is little disintegration and putrefaction going on. Now and then the tension of the skin around an inflamed chancre may require incisions. They should be carried through the skin at the borders of the sore until the parts are relaxed; there is often smart bleeding if the skin is much congested. This is beneficial if it does not continue too long, but the patient should not be suffered to lose much blood, and the bleeding must always be arrested before it goes too far.

Patients with sloughing phagedena are usually exhausted and in a depressed nervous irritable condition; they need rest in bed, quiet, and occasional sedatives, such as 10 to 20 drops of tincture of opium with 30 drops of aromatic spirit of ammonia and half an ounce of brandy every four hours, or a smaller dose in proportion with the patient's habits. The diet should be nourishing-strong beef-tea, eggs, soups, and when the tongue is clean, more substantial food. When the sloughing is produced by contagion in over-crowded wards, plenty of fresh air is absolutely necessary, and separation of the patients attacked with sloughing. Intercurrent complications, as diarrhoea, bronchitis, or pleurisy, must be treated in the ordinary manner, if they arise.

Chancre within the urethra requires salines, and copious diluent draughts, such as linseed tea, decoction of barley, &c., to render the urine less scalding. A solution of a half grain of sulphate of zinc to the ounce should be injected once or twice daily into the urethra, into which a shred of lint is also inserted till the chancre heals, and a catheter should be occasionally passed, lest a stricture develope from the cicatrix.

Chancres in the rectum or anus are very difficult to keep clean. The anus and rectum should be well washed with a