right scapula is of a bright, angry red, which partly disappears on pressure, and feels hot to the hand. The margins of this area are slightly raised above the surrounding skin, and a few immature vesicles are scattered over it. The skin is tender to the touch, though deep pressure over any part of chest causes no pain. There is no friction, rab, nor other adventitious sound heard upon auscultation. There is no temperature and the pulse is normal.

Subsequent course: During the next three days the eruption extended over the entire right chest behind, as far down as lower margin of 8th rib; around the side, and gradually narrowed to cover the 4th and 5th chondro-sternal articulations in front. The vessicles became confluent, the contents became purulent, and, on the fifth day, the involved area was covered with a dry, brown crust. As the eruption subsided the pain became less severe and the intercostal nerves became sensitive to pressure. Staphlococci were present in the vessicular fluid, but no streptoccoci were found. On the fourth day the area from lower border of eruption to the costal arch became the seat of a sudden painless swelling; the skin over this area was pink in color and pitted slightly on pressure. There was itching of the skin over the swelling. It was on this day that the vessicular eruption was at its height and the vessicles and edema subsided simultaneously. On the sixth day an acute arthritis developed in right shoulder and elbow joints. This subsided in two days.

Treatment: The pain required morphine. Salicylic acid four per cent was used locally, and salicylates given internallyfree elimination maintained with salts, and, as the attack subsided, cimifuga and gelsemium were exhibited.

Remarks: The points of interest in this case are two: First, the character of the pain, passing through the chest and not following the intercostal nerves, the eruption having no apparent relation to these nerves, and the nerves themselves not being tender, made an early diagnosis of intercostal neuralgia difficult. Erysipelas was ruled out on the absence of temperature and of streptococci. There was no chance for exposure to poison vak or ivy and these would not account for the intense pain and burning. The second point was the occurrence of acute localized edema during the course of a neuritis and in the absence of any gastro intestinal disturbance. Quinlee first described angioneurotic edema in 1882, and the condition was regarded by him as a vaso-motor neurosis under the influence of which the permeability of the vessels was suddenly increased, thus permitting a rapid effusion of fluid into the subcutaneous tissues This form of edema is frequently hereditary and runs through several generations. Its frequent occurrence with gastro-intestinal disturbences leads to the view that it is identical with the giant form of hives. In the case described the condition may be regarded as a reflex neurosis, either from the skin or from the intercostal

nerves, causing either an increased permeability of the vessel walls or a sudden interference with the circulation of the part.

THE USE OF PARAFFIN TO REPLACE DESTROYED BONE, WITH REPORTS OF CASES

E. F. BURTON, M. D. Tucson, Arizona

The reports of Morton of San Francisco, Connell of Leadville, Smith of New York, and others in regard to the use of paraflin in correcting deformities, and experiments showing the disposition made of the substance when injected into living tissue, led me to make use of it in the cases briefly described below:

The first case was a compound gunshot fracture of the right tibia, made by a .45 revolver bullet at close range, in which the anterior two-thirds of the bone was destroyed for 1 1-2 to 2 inches at about the middle of the bone, and the remaining third of compact bone broken into 8 to 12 pieces. The bullet lodged in the soleus muscle. (Entered slightly to the outer side of the crest from the fibular side, passing inward). Some of the fragments of the posterior third were still connected by periosteum and some were completely separated from each other. After as carefu! cleansing as the circumstances would permit, the leg was placed in a plaster cast and kept in extension with a window over the bullet hole, after most of the debris had been removed from the wound. The conditions made it practically certain that pus would develop, and such was the case. The cavity was kept drained as thoroughly as possible, with the result that the fragments of the posterior third united under the periosteum and formed a shell of bone corresponding to the posterior surface of the tibia. When this seemed fairly solid, the wound was curetted and made as nearly surgically clean as possible, packed with decalcified bone chips, periosteum from the bone above and below made to cover partially (although far from completely) the defect, and the wound closed. It became necessary within a few days to open it again, however, and the bone chips were thrown out gradually with the pus which formed. This experiment was repeated, with the same result. Then it occurred to me to try the experiment of filling the cavity with paraffin having a melting point 110 F., and it was again cleaned thoroughly and so filled, the opening of the sinns being covered with steril oiled paper simply. The day following it was found that it was possible to pour in about a dram more of the paraffin. This was done and the opening was covered as before. The wound closed gradually and remained closed for three weeks, at the end of which time the cast was removed and the patient allowed to attempt to walk with the use of a cane. The leg seemed strong and sound, with no more enlargement at the site of the fracture than would have

resulted had there been no compounding of the fracture. After some days of use--perhaps ten--there appeared a drop of pus at the old wound, and it was reopened, a cavity the size of a large hazelnut curetted, cleansed and refilled with paraffin. There is no shortening of the limb. which seems to be as strong as its fellow. There has been no opportunity to determine the nature of the tissue which has taken the place of the parallin, except that at the last operation of filling the small cavity it was evident that the tissue below, in the space filled by paraffin, was sensitive and did not correspond to any normal tissue in consistency, being harder than muscle and softer than cartilage and very slightly clastic. The wound remained closed, and to all appearances closed permanently, for a number of months, until recently, when it opened, and a particle of bone was thrown out, leaving a sinus discharging not more than a drop of thin pus daily. This is the condition at present. The patient has been working uninterruptedly at his trade, and I only discovered the present condition. when I looked him up to show the case at this meeting. I shall now clean up the sinus again and refill the cavity with paraffin, expecting it to close as before, although it is evidently possible for the same experience to be repeated in the future. I have no doubt, however, of the final favorable outcome and permanent healing, as the leg is even now just as serviceable and strong as the other one.

Since writing the above the wound has closed and there is no indication of any further trouble. The man recently carried a number of seventy-five pound rolls of binding paper up a ladder to the roof of a building, upon which he was working, without any feeling of weakness or lameness in the wounded leg.

The second case is that of a miner, upon the dorsum of whose right foot a timber fell. The man found himself unable to walk upon the foot, and was treated by Mexican physicians for three months, and at the end of that time told that he could go back to work, that there had been no fracture of any bones and that he would have no further trouble with the foot. He resumed. work, although there was considerable pain upon putting the foot to the ground, and he did not stop work until, at the end of two weeks, the pain and swelling were so great that he could no longer put on any kind of a shoe, or bear his weight on the foot. About this time he came under my care. I found an ununited fracture of the first metatarsal bone at about the junction of its anterior and middle thirds, the dorsum of the foot swollen and very tender, and a sinus at the base of the second toe, discharging thin sanious pus. Several conservative operations were done in the attempt to save as much bone as possible, but there were involved in the suppurative osteitis and removed the first, second and third metatarsal bones and first phalanx of the great toe.

As I have said, the operations were conservative and not all of these bones were removed at once, efforts being made to avoid

the sacrifice of so much bone. For instance, the ununited ends of the fractured first metatarsal were curetted and kept in position, with the result that union took place in spite of the unfavorable conditions, only to be followed, however, by pathological fracture later on, due to infection from the first phalanx, which did not seem to have been previously involved. The removal of all these bones and the soft parts involved left so little framework that it seemed that little had been gained by not doing a Lisfranc amputation. There were four drainage openings, one at the site of the sinus opening, present at the time I first saw the case, one over the site of the fracture of the first meatarsal, one on the plantar surface directly under this, and the last in the middle of the plantar surface. After several weeks of treatment in the endeavor to cause these wounds to close, the entire cavity was curetted, washed with antiseptic solutions and filled with paraffin, which had been given a melting point of 110° F. by the addition of a sufficient amount of olive oil. As in the first case, it was possible to inject more paralin on the day following, about two drachms being required to fill the cavity. The total amount required to fill the cavity was about an ounce and a half, a much larger amount than was used in any of the cases reported heretofore. The openings closed and remained closed for nearly a month, at the end of which time it seemed that there was pus beneath the surface, at the site of the original sinus opening. This was reopened, a small amount of pus evacuated, the wound made large enough to inspect and cut a small piece from the paraffin first injected. This was not examined microscopically, but from the gross appearance, as well as from the fact that it was sensitive, it appeared to be supplied with nerves, blood vessels and connective tissues, that is, organized. In appearance it resembled somewhat an inflamed cartilage, being mottled pink, with small blood vessels distributed throughout. Its consistency was softer than cartilage and firmier than muscle. It was very slightly resilient. Enough more paraffin was used to fill the smali cavity remaining, and the wound closed and so remained as long as the patient was under observation. At that time the foot was as nearly its normal shape as possible except for the depressions of the scars, the patient was walking without any aid, and returned to his work as a miner.

BLOOD POISONING

J. W. COLEMAN, M. D., Jerome, Arizona

I shall use the term "Blood Poisoning" in the sense of any infective disease caused by the absorption of septic products, without regard to the particular Cocei that cause it. I do not know, nor do I believe it is known, the number of varieties of pus producing germs. Sternberg describes 22 varieties of the Sireptococcus alone; even the Coli Communis has been found guilty of

causing Pyogenic infection. The point I wish to make is that I do not think it is absolutely necessary for successful treatment to know all varieties of Pyogenic germs that caused the infection, Lecause mixed infection is the rule. There is no specific, with the possible exception of pure Streptococcus infection (reports strongly indicate that the anti-Streptococcus serum is as near a specific for pure Streptococcus infection as diphtheritic antitoxine is for diphtheria).

Strange as it may appear, infection seems to be a self-limited disease; the germs that cause the disease seem also to generate an antixtoxine that cures it. What the old-time surgeons called "Laudable Pus," and in more recent years called by Keen "Damnable Pus," possibly was not so far wrong after all, because, while the germs of infection caused the trouble, they also made an antitoxine that helped to cure it. You who practiced surgery before the days of antiseptic and surgical cleanliness have seen many wounds suppuate and get well. Something stimulated the Phagocyte producing organs of the body, causing a great increase of white blood corpuscles which eventually destroyed the various forms of Pyogenic germs.

The body has a limited natural resistance to infection; when, however, infection occurs the natural resistance is increased by the antitoxine created by the pus-producing Cocci.

Now comes the question, Have we any remedies at our comnand capable of increasing the natural resistance of the body to infection, or, infection having occurred, can we give the patient anything that will act as a general systemic antiseptic? I believe we have such remedies, and they can be given safely.

To tell this method of treating Pyogenic infection, it is necessary to give the history and treatment of a few cases to illustrate method and action of remedies, and then draw conclusions.

Joe P., an Italian miner, was hit on back of hand by falling rock, making a wound possibly one-half inch deep; it bled freely. He went to his cabin and put on some raw potatoes. I saw him first about 36 hours later; hand, wrist and forearm badly swollen, intense pain, temperature 103, brownish serum oozing from wound, skin copper colored. Cleaned out the digestiv track, freely opened wound, cleansed with hot antiseptic, and ordered continuous hot application to hand and arm and ten drops of F. E. Echinacea every two hours. The next day the copper colored swelling had extended above the elbow, about midway to shoulder, following the lymphatics of the extensor muscles. I then, under a little chloroform, opened bursa on elbow and five other places on arm, the openings being down to the muscular tissue and from two to three and one-half inches long. No blood nor pus came from the openings, a little black blood came from the larger veins, but absolutely no cozing. The cuts exposed gelatinoid substances,