that "it is somewhat too heroic for English surgeons"-is both unsound and insufficient; unsound, because, if properly performed, it is the very reverse of "heroic," being both painless and bloodless; insufficient, because, even if heroic as the author erroneously supposes, it would be much less so than others resorted to by English surgeons for the purpose of curing this obstinate complaint, as, for instance, the slashing, and starring, and cross-cutting of certain great operators, or the application of strong nitric acid by others. This allusion to the ancient operation affords decisive evidence that the operation and the object proposed to be effected have alike become obsolete in the English school of surgery.

The excision of the callous margin is performed with the express immediate intention of removing the ring of indurated cuticle, without injuring or interfering with any other tissue. Bearing this in mind, the operator, with a sharp scalpel, carried nearly horizontally, or on a plane with the surface of the ulcer, pares or shaves off layer after layer of cuticle, till he reaches that which immediately covers the cutis; this last layer he will find very thin and transparent, through which is seen the bright red cutis beneath, bearing some resemblance to the florid margin of the lips. Beginning with about half-an-inch of the margin, and proceeding cautiously till he reaches the cutis, he is enabled to form an estimate of the varying depth of accumulated cuticle, which is always greater at the inner margin than outwardly, where it passes off insensibly into the sound skin. Having ascertained this depth, he can then proceed more boldly and rapidly to the complete removal of the margin round the whole circumference of the ulcer. If the operator is very careful, very steady, and very dexterous, he may accomplish his object without drawing blood; but the probability is, that in a few points he may wound the cutis.

The operation being completed, he will then see how very little of the apparent excavation was due to the "surrounding congestion and morbid deposit" upon which, according to most modern writers, not only the appearance of depression, but also the ulceration, depends. If he has had the manual treatment of many cases of this class of ulcers, he will be surprised at the light thrown upon their nature and treatment. He will, I think, be able to understand why some of the numerous modes of treatment have succeeded, and why others have failed,-why even precisely the same mode has sometimes succeeded, and at other times failed. He may, in my opinion, also understand why "some forms of callous ulcer are very difficult to cure by support, or any other method," where this preliminary operation, or an equiva lent treatment effecting the same end, directly or indirectly, has not been adopted. The after-treatment should be that usually employed to promote granulation. The patient should be confined to bed, and a linseed poultice applied during four to seven days. By this time the ulcer will usually be covered with the small, firm, conical, florid granulations which characterise the reparative process, and from the

margin will be seen the bluish-white film of new skin and cuticle passing over the new granulations; while already the size of the sore will be diminished by the contraction which takes place almost simultaneously with the re-establishment of the healthy process of reparation.

The ulcer is now in a fit state for the employment of the treatment adapted for healthy ulcers, on which I need not at present dwell.

The operation described appears to date its origin at least as far back as the days of Hippocrates. The indefatigable translator of the Sydenham Society's edition of the works of that author and of Paulus Ægineta, the learned Dr. Adams, of Banchory, has, in both works, shown that it was advised and practised by them, and by a long succession of great authorities, down to a comparatively recent period.

[To the close of the last century the callous ulcer was treated by excising its margins. In 1780, Mr. Benjamin Bell recommended the application of the nitrate of silver instead. Mr. Baynton, however, not long afterwards drew the attention of the profession most forcibly to this disease.]

The views of Mr. Baynton diverted the attention of the Profession from the real primary obstacle to the healing of a large proportion of callous ulcers; from what may be styled the "previous question" to all plans of treatment. No doubt, many even of this class of sores. recovered under Mr. Baynton's plan, because the indurated cuticle, being hermetically sealed from the action of the air, became softened by infiltration of the secretions, and peeled off with the plaster on changing the dressings, so that it ceased to exercise a compressing and constricting power on the living structures. But those who have had the manual treatment of these ulcers, must acknowledge that they have not unfrequently been almost disheartened at the utter failure of all their careful and laborious bandaging. Mr. Critchett, while strongly advocating Mr. Scott's plan, candidly acknowledges that some such cases resist the employment even of the measures he advises, based as they are on what he considers the only sound principle. I have, however, some ground for stating that the late Mr. Scott, of Bromley, in his own practice, occasionally resorted to a measure which effectually removed the callous edges, and stimulated the surrounding integument to new and vigorous action. Many years ago, one of the surgeons of St. Thomas's Hospital, mentioned publicly in the wards, that he had been told by a patient who had been under the care of the elder Mr. Scott, that the strapping and bandages, having been applied in the accustomed manner, were allowed to remain untouched for about ten days, exercise being enjoined from the commencement. When removed, at the end of that time, it was found that, not only the callous edges were removed, but the ulceration had apparently extended over a large portion of the leg; the acrimony of the retained discharge

from the sore, and of the secretions from the sound and unsound skin, having occasioned extensive excoriation. It was stated, that after this preliminary step, the usual mode of applying his bandages was employed by Mr. Scott, with the gratifying result of the rapid healing of an old and obstinate ulcer. Now, after making every allowance for the unintentional departure from strict accuracy in the reports of treatment given by a non-professional patient, we may, I think, perceive a certain amount of truth in the above account; especially when we recollect the admitted success of the blister, as recently advised by Mr. Syme, and in ancient days by Hippocrates, and by most systematic writers in all subsequent ages. The operation of a blister is similar to the mode said to have been pursued by Mr. Scott, though more rapid. In each case sound and unsound cuticle would be removed at the same time, and with it the solid ring forming the callous margin. Mr. Syme's plan is another instance where a remedy proposed for one purpose actually effects another, and in that way proves beneficial. Objections have been raised, as that the blister is very painful, and that patients are unwilling to submit to the application, an objection which must be deemed valid when a painless substitute is offered, and that more efficient. Another still stronger is, that it is apt to produce permanent irritability of the skin. A third objection can scarcely be deemed admissible; it is said to be "insufficient of itself to effect a cure." The same objection would avail against any single mode of treatment. As I understand Mr. Syme's proposal, he intends the blister as preparatory to other treatment. Now, in point of severity, the treatment by excision will bear a most favourable comparison either with that said to be Mr. Scott's, acting by the acrimony of the retained secretions, or with Mr. Syme's blistering plan, or with the recent method, by applying nitric acid; while, as to safety and rapidity, I think not a question can be raised. Mr. B. Bell's proposal to substitute arg. nitr., with the direct view of removing the callous edge, I tried extensively in conjunction with the plan of Mr. Higginbotham, of Nottingham, but in this class of ulcers, without a single instance of success.

The more indirect plan, as that by filling up the wound to the level of the margin with melted wax, I have seen to fail, even in the hands of the proposer's friends and fellow-students. Where it has succeeded, the cause has probably been, that the wax, when cold and firm, took off the pressure of the solid ring of cuticle from the vessels of the cutis.

Mr. Skey's treatment by small doses of opium I have known to be followed by occasional success, even in other hands, though many have been greatly disappointed. Having practised in a district where opiumeating is not uncommon-where the white poppy is commonly grown in the peasant's garden, in order that the cottage may always have a supply of poppy-tea for the infant, while the mother goes out stonepicking or weeding, or other field-work-I have met with old ulcers

among habitual consumers of opium; and here of course Mr. Skey's proposal fails us. Perhaps the true explanation of the success which has followed many plans in hospital practice, may, in some instances, be found in the improved health which attends on rest from labour, on regularity of hours of meal-time and repose, and on a regulated diet. On one occasion I determined to put these influences to the test in the case of a prisoner for theft. He had had an ulcer over the front surface of the tibia for seven years. The sore was about the size of a half-crown, with elevated edge, and smooth glassy surface. He was put on the ordinary prison diet, which was ample or even liberal, but not allowed beer, wine, or spirits. Of course he was not permitted to work on the tread-wheel, but other work in-doors and out was provided, and he had at least two hours out-door exercise daily. The only applications were lint to the wound, and simple ointment, to prevent evaporation, care being taken thoroughly to cleanse the surrounding skin, and to prevent the patient from wiping the surface of the sore, which had been his previous habit. The improvement was was steady. In about six weeks the ulcer was firmly healed, and continued so during the term of his imprisonment. As usual, he again committed an offence which brought him under my notice some months afterwards, when I had the opportunity of ascertaining that the cure was permanent.

I have thus hastily and imperfectly reviewed the opinions entertained in ancient and modern days of the circumstances which occasion the acknowledged difficulty in the treatment of the old callous ulcer. I have endeavoured to show that the primary obstacle to all successful treatment is the presence of a solid ring of compact and indurated effete cuticle; that the necessary preliminary curative measure is the removal of this ring; and that the safest, the mildest, and yet the most speedy and efficacious method of attaining this end is the excision of the callous margin, strictly confining this operation to the paring or shaving off the accumulated cuticle without wounding the cutis.

For a practical knowledge of this operation, I am happy to acknowledge my obligation to Mr. Hewson, one of the surgeons of the Lincoln County Hospital, who told me, that he had acquired his familiarity with it from a House-surgeon of that institution, whose thirty years' tenure of office dated from the commencement of the current century.

[Mr. South declares the success of this mode of treatment to be admirable. Here are the notes of some cases at one time under him.] David Brooks, aged 30, labourer, was admitted into Henry's Ward, St. Thomas's Hospital, Aug. 14, 1853. He has an ulcer on the right leg, consequent on an injury sustained ten years ago, since which time it has never entirely healed. He has lived very badly, being at times half starved. Has usually worked among the barges on the

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the river, being often a considerable time in the water and mud. Numerous remedies were applied to the sore with little or no effect, the hardened cuticle appearing to form a barrier to the cicatrization. At last, Mr. South determined to try the effect of paring the edges of the ulcer. This was done several times, and the sore soon showed a healing margin. Before the sore was quite healed, the patient was discharged, in consequence of a deficiency of beds. He then became an out-patient, and then was again admitted into the hospital; but of subsequent progress no notes were taken. There was no doubt of the benefit ensuing on the paring of the edges while he was in Henry's Ward.

Timothy Driscol, aged 40, an Irish labourer, was admitted into George's Ward, St. Thomas's Hospital, on Tuesday, September 13, 1853. He has had, on the front of the right leg, an ulcer for the last sixteen years. It is now about the size of a man's hand; the edges are raised and callous, and the surrounding cuticle is much thickened; the surface of the sore is glassy, but at the edges are a few unhealthy granulations. He suffers little or no pain, unless from injury; the discharge is scanty, thin, and unhealthy. Mr. South directed the application of linseed poultice and the dilute nitric acid lotion. After a little time the granulations became more numerous and healthy, but the edges showed little inclination to heal, the white callous ridge remaining as on admission. About three weeks after admission, Mr. South directed the edges to be pared. Hardened cuticle, in many parts of some thickness, was removed; this was done with little or no pain to the patient, and the bleeding was inconsiderable. In some parts, where the edges were not so hard, simple scrapings were required. At the end of a week a manifest improvement had taken place; a thin healing margin extended towards the centre of the sore; the same applications were continued. The paring process was repeated several times at intervals of about eight or ten days. As soon as the granulations rose to the level of the surrounding healthy parts, simple ointment and bandage were applied, the edges being now perfectly natural. The sore healed rapidly, and, when the patient left the hospital in December, was not larger than a half-crown. He afterwards attended as an out-patient, bandages being applied till the sore was entirely healed.-Med. Times and Gazette, Jan. 28, 1854, p. 81.

124.-On a New Mode of Treating Ulcers from Irritation of the Nails. At a meeting of the Harveian Society, MR. URE related the following case of a young woman aged 23, who was under his care at St. Mary's Hospital.]

Four months before admission, the great toe of the right foot became uneasy and swollen, the patient having pared the nail the day preceding. Ere long, a painful and irritable sore made its appearance by the side of the nail, which discharged from time to time a quantity