avoid discharge from the already gangrenous area reaching the operation
wound. An assistant or nurse, who is to take no other part in the
operation, is told off to carry out the preliminary purification, and to
hold the limb during the operation.

#Malignant Oedema.#--This form of acute gangrene has been defined as
"a spreading inflammatory oedema attended with emphysema, and ultimately
followed by gangrene of the skin and adjacent parts." The predominant
organism is the _bacillus of malignant oedema_ or _vibrion septique_ of
Pasteur, which is found in garden soil, dung, and various putrefying
substances. It is anaerobic, and occurs as long, thick rods with
somewhat rounded ends and several laterally placed flagella. Spores,
which have a high power of resistance, form in the centre of the rods,
and bulge out the sides so as to give the organisms a spindle-shaped
outline. Other pathogenic organisms are also present and aid the
specific bacillus in its action.

At the bedside it is difficult, if not impossible, to distinguish it
from acute infective gangrene. Both follow on the same kinds of injury
and run an exceedingly rapid course. In malignant oedema, however, the
incidence of the disease is mainly on the superficial parts, which
become oedematous and emphysematous, and acquire a marbled appearance
with the veins clearly outlined. Early disappearance of sensation is a
particularly grave symptom. Bullae form on the skin, and the tissues
have "a peculiar heavy but not putrid odour." The constitutional effects
are extremely severe, and death may ensue within a few hours.

#Acute Emphysematous# or #Gas Gangrene# was prevalent in certain areas
at various periods during the European War. It follows infection of
lacerated wounds with the _bacillus aerogenes capsulatus_, usually in
combination with other anaerobes, and its main incidence is on the
muscles, which rapidly become infiltrated with gas that spreads
throughout the whole extent of the muscle, disintegrating its fibres and
leading to necrosis. The gangrenous process spreads with appalling
rapidity, the limb becoming enormously swollen, painful, and crepitant
or even tympanitic. Patches of coppery or purple colour appear on the
skin, and bullae containing blood-stained serum form on the surface. The
toxaemia is profound, and the face and lips assume a characteristic
cyanosis. The condition is attended with a high mortality. Only in the
early stages and when the inf