The etiological and constitutional treatment of Lupus vulgaris will be much the same as that already considered, except that Dr. Anderson does not recommend the iodide of starch in this connection. As regards the influence of internal treatment I must frankly confess that I have never succeeded in curing a case of Lupus by this means alone, nor have I ever seen a case that was so cured. It does not follow, however, that others may not have succeeded better; or that internal medication is without influence in this disease. It is well, therefore, to consider a few of the drugs that have been recommended and used in this connection. Among these Arsenic was recommended by Home, during the last century, and by many authors since, and cases of cure by it are on record; cases in which we have no right to doubt either the accuracy of the diagnosis or the veracity of the reporter. Personal experience leads me to credit the drug with some power, more especially in the ulcerative forms.

Mercury and Iodide of Potassium appear to have been used with benefit in a few cases of Lupus, although there is a faint suspicion that the cases may not have been genuine Lupus, but, in reality, cases of syphilis, presenting features that caused them to resemble the former disease. The internal treatment being provided for, the external claims attention. This, in principle, is the same as that mentioned in connection with the treatment of erythematous lupus, namely, to remove the lesion as quickly and thoroughly as possible. Temporizing with either sedative or so-called "stimulating" applications are worse than useless. They do more harm than good, the lesion must be destroyed, not petted or simply chastised. When the lesion is of moderate size, and conveniently located, the most effective treatment is excision. When, however, this is impracticable, other measures must be adopted. Hebra speaks so enthusiastically of arsenical applications that I give his method in detail. He uses an ointment consisting of one part of arsenic, three parts of cinnabar, and twenty-four parts of ointment. This should be thinly spread upon linen, which is cut in narrow strips and accurately applied to the affected part. It is then covered with lint and held firmly in place with adhesive plaster. It is left in position for twenty-four hours, when a fresh application is made . without previous washing. At the end of another twenty-four hours it is again applied. 1 hiring the first day the parts to which the application has been made present very little alterations, and are not very painful.

At the end of the second day of treatment. however, the pain increases, and when the plater is removed the tubercles are found to have a grayish color and macerated aspect After the third application the pain becomes still more severe, and the integument surrounding the lupus patch becomes the seat of considerable oedema. On removing the plaster at the end of the third day all the tubercles, both large and small, are found reduced to the condition of a brownish black eschar and covered with a thin pus. The eschars correspond to each tubercle, and are sharply defined by the intervening healthy skin. The pain ceases quickly and completely, and the oedema disappears in two or three days.

The great advantage, according to Hebra, of this arsenical treatment consists in its not injuring or even excoriating the healthy skin, while the morbid tissue is safely and thoroughly destroyed.

The little sloughs, which are as numerous as the pre-existing tubercles, are loosened by suppuration, and removed in five or six days, leaving small holes separated from each other by islets of healthy skin. Cicatrization is rapid, and the resulting scar not very noticeable.

Sometimes two applications are sufficient; or, on the other hand, if the tubercles are large and covered with thick epidermis, two or more courses may be necessary.

There are two serious objections to this arsenical treatment, the effi-cacy of which, however, is conceded. These are the excruciating pain, and the danger of arsenical poisoning.*

Arsenic, however, is not the only caustic that can be employed. The biniodide of mercury, the Vienna paste, chloride of antimony, Llandolfi's paste, and other compounds may be used. Whichever one of these is chosen should be used with a bold hand, as success will be proportional to the activity of the caustic and the thoroughness of the application.

The actual cautery has also been advised, but when dependence is placed on this agent alone, success need not always be expected. I cannot, however, quite coincide with the sentiments expressed by Green (66, 253), who writes: "The actual cautery is now generally agreed to be the least advisable of all the modes ever recommended for checking diseased, and inducing new and more healthy actions in Lupus. This means, indeed, often appears to be positively injurious instead of beneficial. I very lately saw the actual cautery applied, at seven different times, in a case of Lupus, under the direction of two eminent surgeons, and certainly the practice was followed by no good effect." Rayer (86, 2: 211) is of a similar opinion. In other words, the actual cautery has often failed to check the progress of the disease, and, besides, has often done more harm than good. A little thought will enable us to understand why this has been the case. I presume it will be conceded without question that if a large quantity + of heat be employed, and the cauterizer kept in contact with the tissues sufficiently long, that any Lupus may be destroyed, but together with it in all probability a large amount of healthy tissue that should have been preserved. A red or a black heat coming from a cautery of large size will penetrate deeply, slowly destroying the surface with which it is in contact, and half killing the more distant tissues. A white heat, however, instantly kills the tissue to which it is applied, forming a carbonized eschar that acts as a non-conductor of heat, and protects the deeper parts. With the dull heat, then, we will have deeper action than we desire, followed by more or less pain and inflammation, a thick slough slowly separating, an ulcer not disposed to heal kindly, and a retractile scar. On the other hand, with the white heat, superficial action with insufficient destruction of the deeper portions of the lupous tissue, and, as a natural consequence, relapse of the disease. The successful use of the cautery, therefore, necessitates such an adjustment of the heat and period of contact that the whole of the lupous infiltration is destroyed without the infliction of unnecessary injury on the healthy tissues. This requires extended experience in the use of the cautery, and the exercise of good judgment in its application, and readily explains the unsatisfactory results that have so often followed its use.

* Hebra states that poisoning did not occur in any of the cases treated by him. + The differences between the quantity and the intensity of heat should be clearly appreciated. A large cauterizer at a red heat may give off a larger cuantity than a small one at a white heat, but the latter will possess the greater intensity.

The actual cautery, however, is not without its uses in the treatment of Lupus Vulgaris, as I have elsewhere (143, June, '77, 449, and 143, April 5, '79, 313) endeavored to show, but its application is secondary to other measures. If the lesion be a suitable one for excision, subsequently apply the cautery at a white heat if any doubt exists as to the thoroughness of the cutting operation. When, however, excision is impracticable, the lesion should be scraped with the curette, with the view to remove as much of the infiltration as possible, and then cauterized. After the scraping, a chemical caustic may be employed instead of the actual cautery. I have used both, but the latter has given me the most satisfactory results. Relapse, however, will sometimes occur, and render a second or even a third operation necessary.*