for the various staining fluids to which they were submitted, showing that the cellular structures had undergone destructive (?) change. The papillæ could only be distinguished with difficulty, only mere traces could be seen. In place of the cellular connective tissues, appeared rather thick, slightly cloudy hyaline like beams, which inosculated with each other quite intimately. The spaces between these beams contained numerous pus-corpuscles. What appeared to be blood vessels,-transversely cut-were discovered, containing granular hyaline like masses. Lymphatic vessels could not be made out. The entire picture gave the appearance of all the tissues having undergone coagulation, and the diagnosis was accordingly made as coagulation necrosis.

All influences, that may disturb the circulation of a given part, that lead to an impeded circulation, in other words, to a permanent stasis: such as thrombus, embolus, a closure of the blood vessels in consequence of a diseased condition of the intima or the entire wall of the blood vessels, or following ligation; pressure upon the tissue, lead to necrosis, if the obstruction of the circulation exceed a certain limit of time. Compression of the vessels by extravasated fluids or exudations in the perivascular connective tissue, such as inflammatory products and hemorrhage, may lead to death of the parts. Cohnheim states, (Ziegler All. Th. 60) that integument, bone and connective tissue still live in very many cases after a complete obstruction has been continued for twelve hours. Tissues undergoing necrosis, following intense inflammatory disorder and due to a want of nutriment, because the channels for its conveyance have been obstructed—and exhibiting the appearance before described, are usually termed coagulation necrosis.

Necrosis with subsequent coagulation of the fluids and tissues, appears in two principal forms, which can both often be demonstrated in the same case. In the first form, there appear blood globules and lymph and other fluids, that have emigrated or transuded through the wall of the blood vessels; there may also be granular or fibrillary or homogeneous coagulated matter. In the second form there is coagulation of the cells and cell derivates, after their death, to homogeneous masses. The granular, fibrillary and hyaline masses, which appear with coagulation of blood are albuminous bodies, which are usually termed fibrin. They form flakes, and lumps, and membranes. Immense quantities of red blood globules

are sometimes included in the coagulum, forming soft dark red lumps.

Coagulation of blood and lymph can only take place when the white corpuscles of the blood or lymph undergo dissolution. According to Alex. Schmidt, the plasma of the blood contains a substance known as fibrinogen, which must be brought in contact with the fibrin-ferment and paraglobine, contained in the white corpuscles, before coagulation can take place. As soon as the circulation of a circumscribed part,-as in our case-has been suspended and deprived of its nourishment, through the influence of an erysipelatous inflammatory process, the white corpuscles contained in the blood vessels and those that have emigrated into the perivascular connective tissue and lymph canals, very soon undergo dissolution through the influence, in part, of the ptomaines-the products of micro-bacteria. The paraglobine and fibrin-ferment escaping from the white blood corpuscles, are brought in contact with the fibrinogen of the plasma, that exists, at least, to a slight degree extra as well as intra-vascular in inflammatory conditions-completing the coagulation.

Inflammatory transudations and exudations, as well as blood, coagulate and furnish abundant material for the formation of membranous masses; for example, the formation of false membranes on the surface of inflamed mucous surfaces, as in diphtheria or membranous croup. The fibrinous masses are composed of granules, fine thread like fibrilla, in part of rather thick inosculating beams and homogeneous masses. The connective tissues themselves, according to Cohnheim (Z. All. Th., page 62) undergo similar changes. The lymph which exists in moderate quantities in the tissues, contains a fibrinogenic substance which enters the connective tissue cells, combines with the fibrinoplastic material therein contained and produces coagulation," or to use the author's favorite term "coagulation necrosis," referred to by others as "hyaline necrosis." The different cells undergo different changes, the final outcome of which is always destruction.

AGE OF PATIENT.

Our fourth point relates to the extreme old age of the patient at the time of the operation. Before the introduction of antiseptics one would hardly have dared to hope for a successful recovery from an amputation near the shoulder in one so old. Under the present

method of wound treatment, age does not play that important role that it once did, as to the advisability of an operation. We do not speak so much of too low vitality in old age. Age enters very little into consideration, in the performance of a justifiable operation. Since we have learned to understand more thoroughly the cause of wound complications and the ways and means to avoid them, we feel ourselves justified in undertaking operations, with confidence of a successful issue, that could hardly have been countenanced in the pre-antiseptic period.

APPLICATION OF RUBBER BAND.

Our fifth point relates to the method of the application of the rubber band for the purpose of preventing loss of blood. I claim no originality for the method. The advantages are so apparent as

to require no further comment.

DID WE HAVE A TRUE CASE OF ERYSIPELAS TO DEAL WITH.

In the consideration of our sixth point, some doubt might be entertained as to whether we had to deal with a true case of erysipelas. Judging solely from the clinical manifestations in the early stages of our case, we are compelled to designate it as a true erysipelas. The inflammatory process of the integument began at a certain point, spread in different directions in a most characteristic manner. The case presented all the usual clinical appearances, viz: the typical redness; slight swelling; pain; a sharply defined and slightly elevated margin of the inflamed area, all contributing toward the formation of that well known and easily recognized picture, erysipelas. That the subsequent progressive necrosis was a direct outcome of the affection-as I have attempted to show-is very probable. This view, however, is strongly disputed by many at the present day, the opponents of this theory maintaining that a socalled "erysipelatous necrosis" is never an erysipelas in the beginning; that there must exist a specific and distinct poison which always terminates in a necrotic destruction of tissue; that a true erysipelas never brings about such changes as we observed in our case. It is not necessary to repeat here what I have already said in relation to the manner in which a necrosis of the tissues may follow a dermatitis such as is presented to us in the case in question. I am not ready to dispute that many of the so-called cases of erysipelatous gangrene or necrosis are not true erysipelas at their inception, for we

do sometimes observe cases in which characteristic erysipelas hardly becomes manifest before destructive changes, either of a phlegmonous or necrotic character, have begun. But I do maintain that we can have an erysipelas with a subsequent necrosis of tissues as its direct outcome, and I would prefer to speak of necrosis of tissues fol lowing erysipelas rather than make use of the well known terms, erysipelas gangrenosum, erysipelas phlegmonosum, etc.

TREATMENT.

In conclusion we will cast a hasty glance at the treatment. We will not discuss the various methods of treatment, as sublimate applications, subcutaneous injections of carbolic acid and the endless list of remedies that have been proposed from time immemorial. We will confine ourselves to, and sum up in the fewest possible words the indications in the cases in which we find extensive swelling and oedema. The common practice of the application of poultices, I believe to be wrong. I cannot conceive in what way they can ever be productive of benefit, on the contrary I can understand in what way they might be a factor of great evil. Every poultice containing, as it does, the very elements favorable for the propagation of micro-organic life, may be the means of precipitating the very condition we seek to avert. In many cases of œdematous inflammatory swelling, we have,sooner or later, a breach of the cuticle. If we apply over such a breach a warm poultice of a gelatigous nature, we add nourish.nent to the micro-organic life that has been the sole cause of the mischief. I cannot understand in what way, the engorged blood-vessels, the lymphatic channels and the cellular connective tissues can be relieved by a poultice of inflammatory pro ducts, especially in erysipelatous disorders. I believe the practice of extensive scarifications to be the most rational and one to be insisted upon in all cases. As soon as unusual swelling and oedema manifest themselves, we ought to scarify without delaying until the parts become threatened with death,-for then we have often remained expectant too long-before we resort to heroic means. We know of no line of treatment so effective as extensive scarification. These scarifications should be performed, to be effective, under every antiseptic precaution. A neglect of these might hasten the complication that we attempt to prevent. No one will dispute that numerous punctures, larger or smaller incisions are the most effec

tive means at our command for the relief of a part overburdened with the products of an erysipelatous inflammatory process. If an antiseptic gauze dressing be applied over the scarified parts, not only are the excessive exudatious absorbed but a portion of the antiseptic agent is taken up by the circulation and exerts an influence upon the bacterial life in the tissues involved.