high, so, within certain limits and somewhat reduced it may still remain.

Now you may ask what I should set down as the things to be done for a carbuncle. These boards, nearly bare as they are, may tell you. In local treatment one of the best things you can do, if the carbuncle is small, is to cover it with emplastrum plumbi spread upon leather, with a hole in the middle through which the pus can exude and the slough can come away. That, occasionally changed, is all the covering a small carbuncle will need. It is difficult thus to cover the whole surface of a large carbuncle, and to keep it clean; therefore, I think that the best application for that is the common resin cerate. This should be spread large enough to cover the whole carbuncle, and over it should be laid a poultice of half linseedmeal and half bread. And, if you want to exercise your skill, learn to make that poultice well, and to put it on well, and to keep it in its place well. That mode of dressing the carbuncle, so far as the materials are concerned, will last through its whole course: but whilst the carbuncle is making progress and discharging its slough, you will find plenty of room for the exercise of considerable skill in dressing it, and filling up the cavities with soft substance spread with this ointment. Besides this, the carbuncles are to be carefully washed, and especially with some deodorising substance, as Condy's fluid, or weak carbolic acid, and the cavities may be syringed out with it. The importance of cleanliness is very great. You noticed in the man I showed you just now the spots of acne and boils round the edges of the carbuncle. This points out the necessity of care, which I suppose had not been taken there, to keep the surface of the skin adjacent to the carbuncle perfectly dry, and free from any contact with the discharge, which seems really to have the power of infecting the neighbouring skin, and so producing the boils which are apt to arise, sometimes in clusters, around the carbuncle. Of diet I have already spoken to you. Of medicines I say nothing. Quinine, bark, and other medicines of that class, may be given if you please, or in case of evident need, and so many aperients; but there is really no need of them in an ordinary case of carbuncle. But there is one medicine which you may find very valuable, and that is opium, especially in all the earlier painful stages of carbuncle, in which it relieves the suffering as thoroughly as incisions, or any thing I know. After the early stages, even that is unnecessary, except for some patient who may be unable to sleep. But there is one measure in the treatment of carbuncle which is seldom employed, and yet is of great importance, and that is letting the patient have very free air. The general idea that carbuncles are very dangerous diseases has commonly led to the

patients being entirely confined to bed and kept shut up in their rooms. There is in that an unnecessary care; and this, too, I learned from a patient who refused to comply with injunctions a gentleman with a large carbuncle on the back of his head, who would not keep his bedroom. He had been accustomed to an active life, and after seventy or eighty years of that custom he was quite indisposed to remain in his room. So with that carbuncle he daily came down stairs, changing his room and moving about the house as well as the pain and weakness would allow him. No carbuncle could go on better; all the stages were passed through without any risk or trouble, it healed with unusual speed. After that I had a yet more striking case. A lady came to London "for the season, as she called it; and she had not been here more than a week or ten days before a carbuncle came out on the back of her head, just under her hair. It was a great vexation to her that she had to give up all her amusements; and so, as she did not mind the pain, she would go out. And it was then that, for the first time and last, I saw any value in a "chignon." She dressed her carbuncle under the chignon, and she went to the park, to the theatre, and to dances unharmed, and with her carbuncle quite unseen, and no trouble whatever followed. It healed up after the ordinary fashion and in about the ordinary time. But, indeed, you may see cases of this description on a much larger scale if you watch the carbuncles that come to us in the out-patients' room. There we often see them of considerable size, and they do as well among the out-patients as among the in-patients; and yet these out-patients are freely in the air all day, and many of them continue at their work. So you may set it down as one point to be attended to in the management of carbuncles that patients should not be confined to their room. They should at least have change of air in their own house; and, unless they are too low, they should not avoid exposure to the fresh open air.

Treating your cases of carbuncle upon this plan, I believe you will find that the great majority will pass through their course well.-Lancet, Jan. 16, 1869, p. 73.

SYPHILITIC DISEASES.

84. OBSTINATE CASES OF ACUTE AND CHRONIC GONORRHEA, SUCCESSFULLY TREATED BY INJECTIONS OF GLYCERINE OF TANNIN.

From cases under the care of J. D. HILL, Esq., at the Royal Free Hospital, London.

Perhaps no surgical disease is so frequently observed in hospital (out-patient) practice as gonorrhoea, and the treatment which is

advocated by surgical authorities cannot in many instances be surpassed; occasionally, however, troublesome cases will arise, both in the acute and chronic form of the disorder.

In these cases, previous to the employment of any kind of local or constitutional treatment, whether alone or in combination, several circumstances, Mr. Hill thinks, have to be considered.

First, it is necessary to determine the occupation, habits, and constitutional peculiarities of the patient; or, in other words, what assistance, both from within and without, can be brought to bear upon a purely local affection. Secondly, to overcome local difficulties, which are both physiological and mechanical in character; and these may be briefly said to consist in the mobility of the affected part, its dependent position, and the occasional contact of an irritating fluid-the urine.

The treatment which Mr. Hill tells us he has extensively employed in hospital and private practice was, he believes, first introduced by Dr. Ringer, of University College, who has kindly favoured him with the following remarks:-"For some time past I have been making observations with an injection of glycerine of tannin in chronic gonorrhoea and gleets, and have found it of great use, especially in gleets, which I believe may be removed more quickly with this injection than perhaps any other. In the acute stage of the disease a little care is necessary, or great pain is caused. This may be prevented by diluting the glycerine of tannin with equal parts of mucilage. Another point to attend to is that the injection should not be injected too far, or it causes a great and frequent desire to make water."

Mr. Hill is therefore enabled to support the experience of Dr. Ringer, not only by recent cases, but also by observations on the treatment of gonorrhoea by tannin and mucilage injections extending over some years. These injections he first used in the proportion of ten grains to the ounce, but latterly, as suggested by Dr. Ringer, he found the glycerine of tannin more serviceable, slightly modified, however, as to the diluting agent.

The precaution alluded to as to injecting is probably a most important one, whatever be the lotion employed; for although in some few instances the fluid may be injected too far, in the larger number it will not be injected far enough. Now in either case the surgeon is blamed for a fault which in reality rests with the patient; and here it may not be out of place to describe the method which Mr. Hill recommends to all patients using injections:

"The bladder having been first emptied, the bottle containing the lotion is to be well shaken, and about two drachms of it briskly poured into a saucer. This must be quickly drawn into a glass syringe with a bore in the nozzle equal to a No. 6 catheter.

The penis is then to be held in the left hand, with the thumb and little finger respectively ylaced upon the superior and inferior portions of that organ close to the symphysis pubis, and the fore and middle fingers resting in like manner upon the superior and inferior surfaces of the glans close to the meatus urinarius. The syringe, with the piston withdrawn, is now to be taken up with the right hand, and the nozzle as far as its shoulder carefully passed into the urethra. Previous to injecting, the thumb and little finger of the left hand must compress the root of the penis, in order that the urethra be closed against the passage of any fluid beyond this point. When a sense of tension is felt, the syringe may be withdrawn; but the front fingers must previously be so applied as to compress the glans, and thus prevent any escape of fluid from the meatus. Next, with the thumb and forefinger of the right hand the fluid in the urethra is to be set in motion, and so kept for four or five minutes. This will be attended with a gurgling noise from the mixture of air and fluid. Thus, when the injection has so insinuated itself within the folds and lacunæ of the urethra as to saturate the openings of the follicles and mucous glands, and permeate the whole of the affected structure, it is allowed to escape.'

وو

It is conceived that by these means the bladder is protected on the one hand, and on the other there is a certainty of the fluid being applied to the affected surface of the urethra.

Mr. Hill has furnished us with the notes of six cases in which the glycerine of tannin would appear to have been of great service. In several, injections of zinc, lead, and alum had been employed without much benefit. The formula employed was the following:-Glycerine of tannin, three ounces; olive oil and mucilage, of each one ounce.-Lancet, March 20, 1869, p. 398.

VOL. LIX.