Drainage must be provided for all infected wounds. It is unwise, in most cases, to try to bring together with sutures the torn and ragged edges of a lacerated wound. Nevertheless, if the injury is one of the face or other exposed surfaces where a scar will cause much disfigurement an effort at coaptation should be made. Very often the edges of the wound may be held together with gauze wet with collodion along its margins; in other cases strips of adhesive plaster will do the work. Suture material is very likely to slough out, even when the wound is thoroughly cleansed, on account of the pressure which it exerts upon tissues whose vitality has been impaired by traumatism. In wounds of the extremities the parts can often be moulded into shape with the fingers and held in place with splints and bandages-not applied tight enough

to interfere with the circulation.

When there is great impairment of tissue, associated with infection, probably the best application is the moist or wet antiseptic dressing, kept in contact with the wound until there is healthy reaction and commencing granulation, when dry dressings may be substituted. If the wound is deep or there are sinuses which are not very accessible, or if there is considerable hemorrhage, it may be necessary to pack the wound

and let it heal from the bottom.

A DAILY MEDICAL PAPER.

A corporation composed entirely of physicians, which has acquired the Medical Critic of New York, announces, in the latter journal, that it will commence the publication of a daily medical paper about October 1. This journal will contain six four-column pages, will make a special feature of the medical and surgical news of the day, which will appear on the first page, and, in addition, will publish original articles, abstracts, editorials, reviews-in fact, everything to be found in a first-class medical journal. The publishers, as intimated in the prospectus, hope to secure 100,000 subscribers through a remarkably low subscription price. The profits (of course) are to be obtained from the advertising. With their enormous prospective circulation a correspondingly high rate is to be charged for space-$48,000 a year they think very reasonable for a page. On this basis they have no difficulty in figuring out an annual income of 25 per cent. from their $150,000 of capital stock.

With the best wishes in the world for the success of the estimable gentlemen engaged in this enterprise, we still have some misgivings. Even acknowledging, for argument's sake, that there is a burning demand for a daily medical paper, it would certainly show remarkable success if it could exhaust the whole field of possible sub

scribers from the very start-for there are probably not 100,000 physicians, of all schools, really engaged in active practice in the United States. The whole fabric rests upon this phenomenal subscription list and upon the willingness of subscribers to surrender $1,000 an inch for advertising space. The prospectus reads like one of "Uncle Jack's" in The Caxtons. Again, let us assure the new paper of our good will,-but "the best laid plans of mice and men gang aft aglee."

MUNICIPAL HOUSEKEEPING.

In a recent address Professor Charles Zueblin of the University of Chicago castigates the American who fills his home with bath-tubs and his alley with garbage," and very properly says that this is "a barbaric idea of cleanliness." Other indications of the innate barbarism of the native American are found in the fact that he expectorates on the sidewalks, throws refuse in the streets, allows the smoke from his chimneys to cover the land and looks with apathy upom muddy, unclean streets. Perhaps Professor Zueblin throws too large a portion of the responsibility for these things upon the native American. Chicago, which can safely claim the doubtful honor of being the filthiest large city in the country, is also the most foreign; and the oldfashioned New England village certainly leaves. little to be desired as regards cleanliness. But im the main the reproof is well deserved. Dirt in a city, as in a home, is inexcusable, disgraceful,— worse, a menace to the health of the community. Everyone admits the truth of this statement, but practical methods of dealing with the problem of municipal housekeeping are not forthcoming. Even Professor Zueblin is impractical when he suggests that "the task of cleaning the city and keeping it clean ought to be turned over to the housewives instead of being mismanaged by business men.'" The trouble is that the task is not managed by business men, but by political appointees, totally unfitted, by training or otherwise, to deal with problems requiring the joint services of skilled sanitary engineers and medically trained health officers. What can be done by such men was shown by Colonel Waring in New York. But anything that Professor Zueblin can do to arouse the sanitary conscience in his students and in the public deserves the hearty approval of medical men, who should work individually and collectively to the same end.

SOME "DISCOVERIES."

The usual crop of new discoveries and wonderful cures is being harvested by the newspapers-perhaps for lack of other news. Cancer is still the richest mine for the investigator. Some years ago we were electrified by the news

that this terrible disease was due to eating tomatoes; a little later the vegetarians announced that meat eating was the cause, and that its increase was coextensive with the increased consumption of meat; still later we learned that the overconsumption of saccharin substances was the reason for its continued spread; a year or two ago an English doctor charged the use of salt with the responsibility; since then another pundit has announced that it was the lack of salt which made the trouble; this summer's announcement, made by Dr. Alfred Wolff in the Nineteenth Century, leaves no doubt that beer drinking is what really does the work; Mr. Edison, however, does not agree with this and thinks it due to the destruction of the phogocytes or something of that kind. And here we rest-for the present.

New cures for tuberculosis are cropping out everywhere and all the time. "Sanosin" and Leininger's formaldehyd treatment are now attracting German attention. Even over on the West Side a new consumption "cure" is heralded this very month. Mathews, of the University of Chicago, has a cure for tetanus-a salt solution of course; while down in Mexico the medical faculty have definitely settled upon a cure for dropsy and found a method of restoring gray hair to its natural color. Dunbar's hay fever serum is now entering into active competition with Curtis' immunizing treatment. And so it

goes.

The wonder of it is, that with all these wonderful discoveries and more wonderful “cures”

Reople continue to get sick and die, just as they always have. The problems of cancer, of consumption, of tetanus, loom up as large as ever— and the search goes on. Things look a little "funny" sometimes, but, after all, that is the way of progress.

X-RAY DANGERS.

In the May number of the Medical Standard attention was called, editorially, to the danger of infecting X-ray burns, and a case was cited in which carcinoma, necessitating the amputation of a finger, was implanted upon such an injury. The experience of Mr. Edison and his assistants, as widely reported in the newspapers, gives new interest to this observation. As the result of a destructive cancerous process, set up by the X-ray, it was necessary to amputate the left arm and fingers of the right hand of one assistant, while the left hand of another assistant is also threatened. Mr. Edison, also, complains of "lumps in the stomach," which he attributes to the X-ray, because the tube was held close to the stomach while he worked. Reports of similar injuries are coming in from various sources,

and medical men are beginning to realize the necessity for care and discretion in the use of this powerful agent.

As regards the deleterious action of the X-ray upon the tissues, an interesting theory is advanced by Edison, i. e., that it is due to the destruction or injury of the phagocytes, thereby interfering with the normal reparative process. It will be remembered that the curative action of the X-ray has been attributed to stimulation of phagocytic action. It is possible that Mr. Edison's theory has some basis in fact that injury may really result from overstimulation of the disease-combating cells-phagocytes or whatever they may be. But this theory hardly holds out the hope of cure by the method proposed by Edison, i. e., the introduction of the serum of a healthy person into the body of the one afflicted with the degenerative process. This is, of course, pure speculation, and as Edison himself says, must be left for medical men to investigate.

ANOTHER AMERICAN "INVASION."

The following press dispatch from Berlin has recently made its appearance in the newspapers of this country. It will be news to some within our midst that the able Chicago alderman and amiable coroner's physician of Cook county has become an international authority upon tubercu

losis:

"Arrangements have been completed on behalf of Dr. George Leininger of Chicago which will enable him to visit the Berlin municipal hospitals during autumn in order to demonstrate his treatment of tuberculosis by means of solidified formaldehyd. This treatment is unknown here. The experiments will be conducted under the patronage of Prof. Fraenkel and Prof. Heyman, two leading specialists. Dr. Leininger's approaching visit is described here as a wholly new phase of the American invasion. When the project was first suggested one eminent medical man said petulantly: This Yankee business has reached the limit when American doctors have the presumption to come to Germany to teach medicine.'"'

Can it be possible that the fame of Dr. Leininger's justly celebrated Formaldehyde Cough Cure has preceded him across the Atlantic? It is little wonder that these German doctors dread this new American invasion.

The Medical World says that a dram of formaldehyd to a pint of water sponged about the genitals and axilla will remove the odor of perspiration. A stronger solution will check excessive perspiration and fetor of the feet.

Gentlemen: The subject which we shall take up for consideration to-day is interesting and important, not only because of the variety of its pathologic processes and its clinical manifestations, but also because of its frequent occurrence and the significance it has for the physician who attempts to give relief. Leg ulcers are met with frequently, especially by the physician who spends his life and labors among the common people, among the toilers. In fact, leg ulcers may be called a disease of the poor, and it will therefore not surprise you when you learn that we have in this hospital quite a number of cases of leg ulcers of which we can avail ourselves for purposes of demonstration. I will present several cases to you first, and will then follow the presentation with a general discussion of leg ulcers.

CASE I. This man is 46 years of age; formerly a bookkeeper, but for the last three years without any definite occupation. He is addicted to the use of alcohol. He has been suffering

even slight injuries cause a return of the ulcers. CASE II. This man, who is 74 years old, has had varicose veins and associated eczema for the last thirty years. Twelve years ago he was operated upon for the varicose veins; the vena saphena being excised. The ulcers as well as the eczema healed rapidly after the operation, but unfortunately the anastomotic veins soon enlarged and both the varicosities and the eczema returned. There is now one ulcer to be seen on the right foot just above the external malleolus and extending down to the heel. The borders of this ulcer are infiltrated considerably and of almost leathery consistency. The callous edge is sloping somewhat, but ends abruptly at the base of the ulcer. The base is covered with flat granulations of a pale color. There is but little secretion.

CASE III. This patient, colored, is 22 years of age. He says that he had a hard chancre and maculo-papular eruptions two years ago. About three months ago a hard nodule developed on his

from eczema for a number of years, and it has now developed into the erythemato-squamous variety. The skin over the tibia and the outer aspect of the leg is of a dark-red or even a bluish-red color; thickened, infiltrated and covered with plate-like scales. At the lower third of the leg, right over the tibia and laterally, are two ulcers, oval in shape, three-fourths and one and a half inch in length and about half an inch in width. The bases of these ulcers are flat, but covered with brownish granulations. The borders are soft, not thickened; the edges are somewhat infiltrated, but not much elevated, passing gradually into the floor of the ulcer. Although these ulcers have existed for a long time, yet they respond well to treatment; but

*A clinic held at the Cook County Hospital and especially reported for the Medical Standard.

and the edges undermined. The floor is uneven and covered with a thick purulent secretion. The surrounding tissues are edematous.

This patient will also serve to demonstrate another condition which has existed since his birth and, therefore, is not in any way connected with his present trouble. On inspection you will notice that his whole body is covered with large plate-like scales, which in some places, are partly detached. His skin also is very dry and furrowed. Some of the furrows are quite deep. This is a congenital condition known as ichthyOsis.

CASE IV. This woman, aged 27, contracted syphilis five years ago. She had a very severe attack of secondary syphilis and is now in the tertiary stage of the disease. She is emaciated, pale and cachectic. All over her body, especially on the upper portions of the thighs, you see very large, soft, wrinkled, quite typical, syphilitic scars. On the inner side of both feet, over the tarsal bones, are several large ulcerations, cir

niac. using the hypodermic needle many times a day. She has had several attacks of mania since the syringe was taken away from her by the nurse. It is interesting to note that all the small ulcers originated at points where the hypodermic needle was inserted. The larger ulcers developed spontaneously on the basis of large pustules.

SYPHILITIC SERPIGINOUS ULCER.

calar in shape and intersecting each other. Their borders are very hard and sharply defined; the edges of the ulcers are almost perpendicular. The floor of each ulcer is uneven and covered with a purulent mass. At the heel you see an aggregation of small tubercles, each broken down and excavated in the center.

CASE V. The initial lesion in this case dates back five months and an area of sclerosis is still visible in the vulva. The patient is 28 years of age. Her entire body, but especially her legs and arms, is covered with ulcers of different sizes and shapes. The borders are infiltrated, red in color; the floor of these shallow ulcers is covered with a thick, sticky mass; crusts are seen in a few. In some localities, especially on the thigh, are seen pigmented spots indicating healed ulcers. The patient is a cocainoma

All these varieties of ulcers, occurring from different causes, assuming different forms, may be grouped under the common name of "leg ulcers. Let us now discuss briefly their pathology.

An ulcer is usually defined as a loss of tissue, a defect in the cutis. But not every defect in tissue is an ulcer. Necrosis or suppuration of the deeper parts of the skin, or of any organ, is not an ulcer; it is an abscess. Neither is an injury of the surface of the skin an ulcer; it is a wound. Loss of substance and the localization of this loss are not, therefore, the attributes on which we may base the definition of ulceration. We must look for other symptoms which shall distinguish or differentiate an ulcer from other defects of tissue. Such a distinction may be found only in the development of the ulcer; in its pathology; in the factor of its evolution.

How does an ulcer originate? We see an ulcer originating from a very small point and spreading gradually peripherally, increasing in depth, by destruction of adjacent pre-existing tissue. tissue. This destruction, this breaking down and necrosis of tissue, is, therefore, a factor in ulceration; a distinctive feature.

What is another possibility in this process of ulceration? The ulcer may heal. We know from clinical observation that the healing process goes on continually at the borders and in the floor of the ulcer. New connective tissue is formed and it is transformed into a cellular tis

A

sue, the socalled granulation tissue. The surface of these granulations is covered by epithelium growing from the surrounding epidermis. The whole process is one of regeneration. And this is a second distinctive feature of ulceration. combination of these antagonistic factors or processes, necrosis and regeneration, make up the process of ulceration. "So long," says Unna (Histo-Pathology of the Diseases of the Skin), "as a loss of substance induced by trauma, gangrene, etc., does not granulate, it is not an ulcer; nor is it if it granulates well. It is called an ulceration only when there is an attempt made at healing, but scarring is hindered by the breaking down of the granulations, or a deficient cornification." Therefore, ulceration is granulation and necrosis; regeneration and destruction. If the destruction exceed the regeneration, the ulcer increases in size and depth. If both processes, regeneration and destruction, keep pace, the ulcer becomes stationary. If regeneration exceed destruction, then healing will take place.

But there is still a third factor concerned in the process of ulceration, and that is inflammation. You know that every necrotic process produces inflammation, which serves for separation and demarcation of the necrotic tissue. For this reason one or more of the symptoms of inflammation are always evident in every ulcer. The ulcer is named according to the prominence of one or the other of these factors in the ulcerative process. If the necrotic factor is in excess of the other two, then we have the necrotic, phagedenic, gangrenous or serpiginous ulcer. If the regeneration and formation of granulation tissue predominate, then we have the hypertrophic, exuberant ulcer. If both the processes, the necrosis and the regeneration, keep pace with each other, then we have the atonic, indolent ulcer. If in addition to these processes there exist a severe inflammation, we give the ulcer an appropriate name. For instance, the edematous ulcer, when there is stagnation or hypostatic edema; the suppurative ulcer, when there is a marked secretion of pus; the croupus ulcer, when its surface is covered with coagulated fibrin in the form of a membrane; or of the diphtheritic ulcer, when there occurs infection with the diphtheria bacillus and the coagulated fibrin is mixed with mortified tissue.

Why do ulcers occur by preference on the lower extremities? What factors or conditions exist there more than in other parts of the body to favor the development of an ulcer? What is it that retards the process of healing and favors necrosis, those making of ulcers of the leg a separate group of pathologic conditions? In other words, what is the etiology of leg ulcers?

One of the most prominent factors in the production of ulcers of the leg, and the one above all others that is instrumental in prolonging the condition, is venous stasis. The retardation of the returning current of venous blood, and the dilatation of the veins, prevent a sufficient amount of nutrition from reaching the skin, favor the death of tissue and prevent or retard the normal process of repair, granulation and cornification. The recognition of these conditions is not difficult. You can see the enlarged

and varicosed veins on the surface of the leg; if the deeper veins are involved, veins that cannot be seen, you can feel them as soft caverns by palpating carefully.

These varicosed veins also produce marked changes in the character of the skin. The skin is thin, stretched, scaling and eczematous, showing the eczema in its different stages and lesional varieties. We also often see a peculiar pigmentation of the skin of a bluish-red or dark-brown color. Venous stasis is the most essential factor in the production of leg ulcers. All other factors are accidental and of secondary importance. You will understand, therefore, why leg ulcers are a disease of the toiling masses; of working people who have to stand on their feet all day; and of women who in permanent fear of race suicide let their chronically pregnant uterus press upon the large veins of the pelvis and thus produce stasis of the lower extremities.

Other factors in the production of leg ulcers are traumata and constitutional diseases, especially syphilis. The varicosed leg with its degenerated skin is a locus minoris resistentiæ, the slightest injury producing a defect which, for the reasons mentioned, is slow to heal, and which favors and invites infection. Such an injury need not necessarily be of a gross mechanical character. Scratching, induced by the itching edematous skin may produce a slight abrasion which will finally develop into an ulcer.

Of the constitutional diseases which may produce ulcers, syphilis occupies the first place. Syphilitic ulcers occur mostly in the later stages of the disease. Only occasionally, in debilitated. individuals, or persons having low resisting powers, will syphilis assume an ulcerative form in the first year of the disease. This is seen in the case of the woman we have here, the cocainomaniac whose system is debilitated and her resistance lessened by chronic intoxication with cocain.

These ulcers of the secondary stage of syphilis, being mostly the consequence of rupia syphilitica, are not confined to the leg alone, but usually are disseminated. Those syphilicit leg ulcers which are confined to the legs belong to the tertiary gummatous stage and are the result of the breaking down of superficial gummatous nodules, or of subcutaneous and periostal gummatous nodules.

In uncomplicated cases the syphilitic ulcers are recognized easily. As a rule, they are not painful; their base is uneven, covered with a slightly transparent yellowish mass; the border infiltrated; the edges perpendicular; the surrounding tissue thick, edematous and of a darkbrown color. In tertiary syphilitic ulcers the form often is serpiginous or reniform. These are typical findings, but are not always present or they may be indefinite. Sometimes these symptoms may be obscured by those of the varicose ulcers. Syphilis has a predilection for weak spots, for a locus minoris resistentiæ, and gummata often develop on varicosed legs. In these the diagnosis is extremely difficult and often can be made only after the employment of antisyphilitic remedies.

One symptom only points positively toward