there is general poisoning from absorption, constitutional treatment should begin promptly, as in syphilis, scurvy, etc. In the local treatment of the compara. tively recent ulcer, where the granulations have come to a standstill, the sharp spoon or curette will stimulate them to renewed efforts.

A healthy ulcer is covered with small, bright red granulations. They do not bleed on touching; they are painless, and their growth rapid. Their edges are soft and show the characteristic opalescent blue line of proliferating epithelium. The entire portion involved is movable, the discharge is purulent and yellow, and the adjacent parts are not inflamed.

The great object to be kept in view, with regard to the management of ulcers, is that of ascertaining with accuracy their true nature. Too much attention can not be paid to this investigation.

In foul ulcers, with offensive discharges and much inflammation, hot flax-seed meal poultices, applied every fifteen minutes, for four or five hours at a time, facilitate the separation of the sloughing masses. When this has been accomplished these ulcers should be treated surgically, and physiological rest should be insisted on.

As the greatest objection to poultices, in most instances of this kind, is their weight, it becomes an object of attention, wherever it can be done, to let the limb rest upon the poultice, and not the poultice upon the limb.

The inflammation that generally accompanies ulcers is met by absolute rest, elevation and hot fomentations, when indicated. In ulcers whose edges are calloused employ radiating incisions, or completely cut the edges away. In an immovable ulcer when the parts are

adherent and anchored to structures beneath it, an ef-fective method is to partly or completely surround theulcer with several incisions through the deep fascia which sets it free from its anchorage and permits it to contract. Excessive or superfluous granulations (proud flesh) should be scraped away with a curette or cut away with scissors. Absence of granulations means a deficient blood supply. In these cases the lunar causticstick will prove sufficiently stimulating usually for the granulations to retain their vitality and be utilized in the reparative process.

The truly irritable ulcer is, perhaps, as distressing a complaint as any in surgery, and is a condition due to: the exposure of nerve filaments and the destruction of nerve-sheaths. Find the exquisitely sensitive granulation with the point of a probe, then divide it with a tenotome, or curette, or burn it with the solid stick of silver nitrate. If it fail to heal, skin-graft. Among the most common sites for irritable ulcers are near the ankle, in the matrix of the nail (in-growing nail), overthe tibia, and in the anus (fissure).

Phagedenic ulcers, commonly venereal, are the result of profound microbic infection of tissues whose vitality is below par. Their surfaces present no granulations, and are covered with sloughs; their edges are thin and undermined, and they rapidly spread in all directions. This type of ulcer should be touched with pure nitric acid or the actual cautery in selected cases. Moist antiseptic dressings and fomentations should be included in the treatment.

In ulcers of the leg, which are frequently accom-panied by much swelling, the result of passive congestion, the first step in the treatment is to reduce the swelling. This can be most effectively done by the application of wet bandages with uniform pressure, begun

at the base of the toes, and carried almost as high as the knee. If cotton bandages are used, they should first be wrung out in water, otherwise they will stretch and fail to accomplish the purpose desired. The best time to apply these bandages is in the morning before the patient gets out of bed. Advise the patient to keep the leg elevated higher than his body, on pillows, the night before you intend to apply your bandages, and gravity will aid you largely in reducing the passive congestion. Martin's rubber bandages are also useful, but the patient can not bear these long at a time.

After the passive congestion is thoroughly reduced, an excellent plan frequently employed is to substitute. for the bandages an adhesive rubber plaster boot. This, of course, necessitates shaving the leg before the boot can be applied. Begin at the base of the toes with strips about six-eighths of an inch in width, allowing them to overlap, and extend them with uniform pressure nearly as high as the ulcer, and discontinue encircling the limb with the plaster just before reaching this point. This complication having been met, you have only the ulcer and its cause to deal with. Such an appliance gives the structures a uniform and steady support; and is on the same principle that Wiseman recommended so strongly, more than two centuries ago, by means of the laced stocking.

In varicose ulcers of the leg the cause can be removed. if only the superficial veins are involved. Consequently resection of the saphena veins fails to give good results when the deeper veins are varicosed. These veins are accompanied by nerves, the internal saphenous being joined by its companion nerve about the level of the knee-joint. Much of the pain in varicose veins of the leg is to be attributed to this fact.

John Hunter was probably the first among the older

surgeons to practice taking up veins; so this is not new. In those days they only took up the dilated branches without obliterating the trunk, and it could not succeed; hence the practice fell into disuse. To-day we obliterate the entire trunk, and if the deeper veins are not involved we get pretty results. The longest incision the writer ever saw was one to obliterate the internal saphenous vein, nearly four feet long.

These radical methods are only objectionable because they carry with them a certain degree of dread to the mind of the patient; and any mode of treatment, however tedious and uncertain, is preferred by many patients to an operation, notwithstanding the sufferings, when carefully estimated, are too often ten times greater in the attempt to cure by palliative treatment than by the radical method. It is only under this prejudice that surgical operations are considered abstractedly, and when the disease for the relief of which they are performed is carefully considered, and the pain and distress of the one is balanced against the other, the prejudice will be completely removed; and that which from a superficial view was regarded cruel will be found to be humane.

It is an absolute waste of time to be temporizing with these conditions when one can accomplish in two or three weeks, by the radical method, what six or eight months fail to do by the other methods.

The most effective method for handling old and chronic ulcers is to anesthetize the patient, make a clean incision of the entire infected and affected area. As a result you have a clean aseptic wound to deal with; and the next step is that of skin-grafting, preferably Thiersch's method.

THE NECESSITY OF A STATE BOARD OF EXAMINERS FOR TRAINED NURSES IN GEOR GIA.

BY EUGENE B. ELDER, M.D., MACON.

A State organization, examination and registration of trained nurses is by far a more important subject than may appear at a glance, a subject that should interest every one in the State, not especially the professional man of to-day. Why shouldn't the Georgia Medical Association call upon the lawmakers of our State to formulate an appropriate law to govern trained nurses? To practice medicine, to become a pharmacist, and even to become an undertaker, you are compelled to pass a State board of examiners in order to practice your vocation, which is universally approved. Akin to the physician and druggist is the trained nurse when it comes to a point of preservation of life. Doubtless the first question to arise in the minds of the lawmakers would be, what are the reasons of a certain number of individuals to ask for such a law, and who would be benefited by such a law? There is no doubt but that the question could be answered to the satisfaction of every member of the legislature. It will of course first benefit the patient who is under the care of the nurse, a benefit to the community as well as to adjoining communities; it will benefit as well all who are worthy to be called trained nurses, elevating the standard of the professional nurse an·l compelling the inefficient nurse to qualify herself to proficiency or leave the ranks. Let Georgia do as many other States have done and have such a law, then we will have