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By the continued presence of purulent matter, absorption, ulceration, caries, and even death, of bone, is frequently produced, all which might have been prevented by its evacuation. If pus collect in the neighbourhood of cavities or canals, it is of the utmost importance that it be early discharged; and the evil effects of negligent and dilatory treatment are well exemplified in the following cases:—A patient had been allowed to suffer, for a long time, under an extensive abscess at the lower part of the neck, beneath the origins of the sterno-mastoid muscles. The abscess at length gave way externally; but the patient was at the same time seized with profuse expectoration of pus, and during expiration the air escaped through the external openings in the neck. It was evident that the abscess communicated with the trachea, and it also appeared to have extended deeply into the mediastinum. The patient soon perished, but there was no opportunity of examining the parts. In another case of extensive abscess at the root of the neck, an opening was proposed, but delayed. At length, the abscess gave way spontaneously; and from the circumstance of portions of solid as well as fluid ingesta escaping by the external opening, it was evident that the œsophagus had ulcerated. The cure was very tedious, but ultimately complete, and apparently much accelerated by free counter openings.

In suppuration of the cellular substance in the neighbourhood of the anus, the matter may present itself externally, whilst it is making extensive progress internally; and if a free opening is not made, fistula ani is the result. The propriety of an early evacuation of purulent matter in important, or very sensible, organs, such as the eye and testicle, is very evident.

The larger arterial and venous trunks appear not to suffer from suppuration, for in purulent depôts we find them entire, and much thickened by copious effusion of lymph into their outer cellular coat and sheath; the nerves, however, are not so much protected, or do not appear to resist the pressure and insinuation of pus, and suffer along with the other tissues.

The most convenient and effectual mode of opening an abscess is with a sharp-pointed bistoury, and the incision should vary in extent according to the circumstances of the case. The straight instrument, used as described and represented in the “Practical Surgery,” p. 56, will be found to answer best in deep-seated collections; in the more superficial it may be slightly curved. It is used as here shown, only that the edge of the knife should be turned more downwards before the integument is divided by withdrawing it. The aperture must always be made at the most dependent part, which is also, generally, the thinnest; thereby a free exit is allowed to the matter. If the incision be not made in a dependent part, a considerable quantity of the matter will be retained within the abscess, and can only be evacuated at the time by squeezing the parts—at all times a very cruel and improper practice—applying compresses, &c., which produce much irritation and unnecessary inconvenience to the patient. The cavity of the abscess inflames, the discharge becomes bloody and putrid, and great constitutional disturbance is apt to follow. When, again, the opening is sufficiently large, properly placed, and the matter flows out through the elasticity of the coverings, no air enters, the cyst gradually contracts, and the cure is soon completed.

When the abscess has been deeply seated, and the incision made through a considerable thickness of healthy parts, it is sometimes, though very rarely, necessary to introduce a small piece of lint between the edges of the wound, otherwise they may speedily adhere, and the discharge of the matter be in this way prevented. In consequence of smart hemorrhage, also, it may be proper to stuff the wound with lint, and retain it for an hour or two; but in general the practice of stuffing abscesses, or the openings into them, is hurtful. After the incision, as already remarked, it is unnecessary and injurious to discharge the pus by forcibly squeezing the sides of the abscess; the application of a poultice will promote the evacuation of the matter, and allay the irritation. In chronic abscesses of large size, it is sometimes necessary to make a counter opening—that is, an opening in a part of the tumour opposite to the original opening, in order that the matter may be more completely discharged. Setons introduced into the cavity of phlegmonous abscesses some time after their evacuation, are highly injurious, as causing much irritation in parts which are already in a morbid state of excitement; but in chronic collections, which show no disposition to heal, their use may sometimes be followed by good effects, on the same principle that they were hurtful in the preceding case; if they should not cause a sufficient degree of excitement, they may be smeared with some stimulating ointment. In extensive collections, in which the matter is not sufficiently evacuated by the external aperture, injections are by some recommended, and, perhaps, occasionally employed: in those abscesses which are comparatively recent, and in which the surrounding parts are still in a state of over-excitement, they are quite inadmissible. The employment of setons and injections in any case of abscess is not much to be commended or trusted to. Caustic, the potassa fusa, may be frequently employed with advantage for opening chronic abscesses, especially when they are the consequence of glandular enlargement, and undermine the integuments, which show no tendency to adhere to the subjacent parts. The potass is best used in the solid form and well pointed; not in paste, as is sometimes practised. By its application the unhealthy surface is destroyed, and the surrounding parts are stimulated so as to assume a sufficient degree of action to throw off the portions which have become useless, and to form new and healthy granulations, whilst the surrounding effusion of lymph or serum is for the most part speedily absorbed. But it can never be employed in acute abscesses without aggravating the disease; and in collections which are deeply seated, it cannot be of much service, for in these a considerable thickness of healthy parts must be destroyed, and if the potass be applied, it will afterwards be necessary to cut through the slough, as was practised by the older surgeons, in order to evacuate the matter and give relief to the patient; or else to continue the application of the caustic for an inordinate space of time, which is a practice altogether unnecessary, extremely cruel, and productive of much irritation, constitutional as well as local.

A too common result of abscess, when inertly treated, is the formation of a Sinus; that is, a canal, the circumference of which is condensed by deposited lymph, and which furnishes a discharge of unhealthy purulent matter, frequently thin and gleety. Several sinuses frequently unite, and evacuate their contents by one opening. Previously to treating a sinus, its extent must be carefully examined by the probe; this requires considerable caution, for the full extent of the canal may not be discovered, in consequence of its tortuous course, or from its diverging into collateral branches; or the probe, by being used too forcibly, may pass into parts altogether unconnected with the morbid cavity. Thus, in exploring a sinus at the lower part of the leg, or in the foot, the probe may be pushed to a considerable extent beneath the tendinous sheaths of the muscles, and induce the surgeon to adopt treatment unnecessarily severe. In the treatment, we may at first employ setons, injections, and graduated pressure, as formerly explained; and if these fail, the canal must be freely laid open by the knife—a mode of practice much more effectual; then there is formed a cavity similar to that of a recent abscess, and to be treated accordingly. Incision is most frequently necessary when the sinus exists in adipose substance, in tendinous structure, in parts possessed of little vitality, and in patients of a sluggish and enfeebled constitution. In sinus, as well as in chronic abscess, the potass is of essential service; a stick of it may be introduced into the canal, and if the sinus is superficial, the integuments may be divided by this caustic as effectually as by the knife. The indolent and callous surface of the sore is thereby destroyed, and the effects are similar to those which have been already mentioned, when speaking of the use of potass in abscess; in fact, by its application the sinus is transformed into an acute and open abscess. Foreign bodies, such as diseased and dead portions of bones, must be early removed; for it is to be remembered that these are much more frequently the cause than the consequence of suppuration.

The healing of an abscess which has been opened closely resembles the process of union by the second intention in a flesh wound; granulations arise, attended by the secretion of pus, the cavity gradually contracts; the surrounding effusion is absorbed along with a portion of the adipose matter; and on the granulations reaching the surface, new skin is formed, and the parts coalesce.

After abscesses have been opened, the fomentations, poultices, or warm-water dressing, as recommended in the treatment of ulcers, are to be continued, but only for a limited time. The power of the system must be carefully supported by exposure to a pure atmosphere; by nourishing food; by the exhibition of wine, tonics, and such medicines as promote digestion. In cases where the system is unusually inert, it may be proper to administer stimulants. The most powerful stimulants are frequently necessary, and by steady perseverance in the use of them, patients have often been saved in very hopeless circumstances. Great attention must be paid to the bowels, and the secretions poured into them, for on the condition and quality of these the state of the constitution materially depends. The internal Use of cantharides is often advantageous in chronic suppurations and abscesses, but it is inadmissible in cases where enlarged glands occupy dangerous situations, either externally or internally; unless the tumours are in progress towards resolution, suppuration is certainly induced, and may be productive of the worst consequences. The glands not unfrequently become enlarged during the exhibition of this medicine; and such an occurrence must be watched attentively. In illustration of the good effects of stimuli in certain cases, it may be mentioned that the cavities of abscesses are often speedily effaced by granulations, and that obstinate sores frequently contract and cicatrise, after the occurrence of a febrile attack, though they had previously shown no disposition to heal.

In glandular swellings, Deobstruents, as they have been called, are used; and with this view, mercury is often had recourse to; this medicine, however, instead of producing a salutary effect, very generally tends still farther to impair the constitution. Preparations of iodine, exhibited both externally and internally, appear to be sometimes of use when the swellings have become stationary, or are inclined to subside. Iodine may be given in combination or not with iron. It is a medicine exhibited very generally and indiscriminately, and is very much more trusted to than it deserves to be. When the tumours are irritable, fomentations may be employed, and advantage taken of sea-bathing, warm or cold. The common adhesive or soap plaster, spread on soft leather, or the ammoniacal plaster, are often applied with advantage to indolent glandular swellings. Blistering is sometimes resorted to with good effect, and in some situations pressure may be usefully employed.

In the treatment of large indolent collections, it was proposed by Mr. Abernethy to make a small and indirect aperture, and to evacuate the contents of the abscess as often as the matter accumulated; but a degree of constitutional irritation frequently supervenes upon this proceeding, and the discharge becomes bloody, putrid, and mixed with a considerable quantity of gaseous fluid. The discharge of blood probably arises from the usual support being taken away from the vessels ramifying on the surface of the cavity, in the same way that blood is effused into the cavity of the abdomen, in consequence of the too rapid evacuation of the serum in ascites.

Suppuration, more especially when extensive and long continued, is attended with a peculiar species of fever, termed Hectic. This fever is the remote consequence of local injury, or disease, whereas symptomatic inflammatory fever is the immediate one. The incessant and long-continued addition of pus to the blood may be the cause of hectic fever. In cases of pulmonary consumption, pus globules are almost uniformly detected in the blood. This fact has been noticed by Dr. Davy and Mr. Gulliver. The pus is probably carried along the capillaries, where it is always forming in chronic abscesses: in short, all the pus formed is not separated from the blood. Hectic probably arises from the never-ceasing addition of a little pus to the blood, inflammatory fever from the sudden addition of a large quantity. In long-continued disease, particularly internal, the hectic occasionally occurs before the existence of suppuration is indicated; and it does not always supervene upon suppuration, even though extensive. Hectic has been supposed to arise from the absorption of pus; but pus cannot well be absorbed without disintegration of its particles (and then it would be no longer pus), for their diameter exceeds that of the more minute bloodvessels and absorbents. Abscesses occasionally disappear, without this event being followed by any unpleasant symptom.

Hectic fever is most apt to arise in constitutions originally weak; and usually either from some incurable disease of a vital organ, or from extensive affection of a part not essential to life; but it may also be induced without any local assignable cause.

The general symptoms are those of a low and gradual fever, attended with great debility; the pulse is frequent, unequal, small, and sharp; the general surface is pale; there is flushing of the face, hands, and feet; the skin, at one period, is cold and clammy, sometimes dry and rough—at another, it is bathed in profuse perspiration, especially towards evening; chills alternate with flushing; the appetite is much impaired; diarrhœa supervenes; pale-coloured urine is voided in great quantity, often with a lateritious sediment; there is want of sleep, and great anxiety; the eyes are sunk, and of a glassy hue; the features become changed; there is great emaciation; the patient, gradually more and more weakened, falls into a state of coma, and expires.

A condition, somewhat resembling sympathetic fever, occasionally supervenes in a constitution that has been suffering from hectic, when any additional irritation occurs, and this fever has been called Irritative. The sanguiferous system becomes more excited—the secretions are suspended—the sensorium is disturbed; but still the symptoms are accompanied with the peculiar debility characterising the state of hectic. It frequently follows the opening of large chronic abscesses by a minute aperture, in the manner formerly described and is relieved only by free evacuation of the confined matter.

In the treatment of hectic, the local disease giving rise to the symptoms, if it cannot be cured by other means, must be removed by operation. Thus, if hectic is consequent on long-continued, but not extensive, disease of bone, the affected portion is to be taken away; if from extensive chronic disease of an arm or leg, the limb must be amputated.

In general, the removal of the hectic cause is followed by immediate melioration of the symptoms, even though the patient has been reduced to an almost moribund condition: the feeble hectic pulse of 120 or 130 sinks in a few hours to 90, and becomes more full and strong; anxiety and restlessness cease, and a patient sleeps soundly the first night after the operation, who for weeks had scarcely closed his eyes; the cold sweats and colliquative diarrhœa immediately subside, and the urine loses its sediment; in effect, all the hectic symptoms disappear, and are succeeded by such as indicate a marked improvement in the power and energy of the constitution; and the rapidity with which these changes take place is in many cases truly astonishing. Nourishing food, wine, tonics, &c., must be given, in the first instance sparingly, and afterwards gradually increased in quantity, according as the stomach can bear them; for it is not to be overlooked, that incautious and too liberal use of them may be productive of irretrievable evils, as the action of the system may be increased beyond its resources, in the same way as the imprudent application of stimulants to a part debilitated by an excessive degree of cold causes its sphacelation, in consequence of the arterial action induced being greater than what the power of the part can support. The mineral acids may be useful in checking the inordinate perspiration; opium, astringents, and absorbents, in arresting the diarrhœa; but all are of little avail unless the exciting cause is removed, and to this latter circumstance the attention of the practitioner ought therefore to be chiefly directed. It is not always quite safe, however, to free the patient at once of a great suppurating drain. Upon the healing up of extensive and long-continued ulcers, it is often necessary, in order to prevent oppression of and congestion in the viscera of the chest, abdomen, or head, to insert an issue or seton, and gradually withdraw it. In amputations also, more especially in patients above the middle period of life, to rid them of disease which has caused hectic and wasting, in consequence of profuse discharge, it is often advisable to keep part of the wound open, so that it may suppurate, heal, and dry up slowly.

Mortification, or the death of a part, is also one of the results of inflammatory action, and the term has been subdivided into Gangrene and Sphacelus. Gangrene is that state in which the larger arterial and nervous trunks still continue to perform their functions; a portion of the natural temperature remains, and the part may be supposed still capable of recovery. Sphacelus, again, expresses complete death, when, putrefaction being no longer resisted, the part becomes black, cold, insensible, and fetid; but, in general, the distinction between the terms is not strictly attended to. A division of more importance is into humid and dry, or traumatic and chronic, gangrene; humid or traumatic being applied to mortification produced by external injury; dry or chronic to that resulting from a constitutional cause.

Mortification is not always a result of inflammation; it is sometimes preceded by incited action of the vessels, sometimes not. It follows as a matter of course that if inflammatory action is so violent as to cause stagnation of blood in most or all the vessels of a part, and this is continued, there must be a consequent failure of nutrition, which will terminate in mortification.

Humid or traumatic gangrene frequently occurs without previous inflammation, the injury being so severe as at once to deprive the part of its vitality. Dry or chronic mortification is often unpreceded by inflammatory action, or at least it is slight and of very short duration. It is preceded by stagnation, or is at all events coincident with this stagnation, not in the smaller vessels only, but in the trunks leading to the affected part. In humid gangrene, swelling with erethismus generally precedes the death of the parts; whereas in the dry, whether the surface change colour immediately or not, they shrink immediately. In the former they quickly lose their vitality, and consequently retain a considerable portion of their fluids; in the latter the process is much slower, and they become dry and shrivelled.

The most common remote cause of spontaneous mortification is a rigid state of the arteries, most frequently met with in the inferior extremities of elderly persons, in consequence of the deposition of calcareous matter between the internal and middle coat; this calcareous degeneration may be confined to a part of the limb, or may pervade the whole of it, and even extend throughout the arterial system. There are many cases in which disease of the arteries has existed, though no gangrene occurred; but this by no means invalidates the assertion, since, when arteries are thus affected, the part cannot withstand sphacelus when exposed to any of its immediate causes. An attempt has been made to connect mortification with an inflamed state of the arterial coats. This opinion is not confirmed by experience. Obstruction from coagulation of their contents, and inflammation of the venous trunks, sometimes precedes death of the extreme parts in old people, and seems to act as a direct cause. After wet seasons, spontaneous gangrene has prevailed as an endemial disease on the Continent, where rye is a principal article of food. The rye is subject to a disease called Ergot; the grains become large, black, and have a horny consistence; and the use of it, when thus diseased, is assigned as the cause of gangrene. The patients who have suffered from the use of this ergot or cockspur rye have experienced pain and heat, with swelling, generally in the lower limbs, though occasionally in the upper. These symptoms abating, the parts became cold, insensible, and discoloured, and were gradually separated from the body. The disease attacked patients of both sexes and every age, did not appear to be infectious, and was frequently fatal. It has occurred in this country from the use of unsound wheat. A tendency to mortification sometimes arises from a peculiar state of the atmosphere, want of cleanliness, poor and irregular diet, &c. Cancrum oris, for example, and sloughing of the pudendum in children, occur in those of the poorer classes who live in low, damp, and dirty situations; and little or no incited action precedes the sloughing. The same may be said of the phagedænic affections of the genital organs. Mortification and ulceration seem to differ merely in this,—in the latter, a part which, from any cause, is unfitted to remain a portion of the living body, is only prevented from dying by absorption just as it is about to lose its vitality; whilst in mortification the part perishes too soon, or in too great quantity, to admit of absorption. Sloughing phagedæna is a sort of connecting link.

Mortification, to a greater or less extent, may be produced in any constitution, and at any age, by the application of heated substances, caustics, acids, &c.; by the effusion of acrid matter into the cellular substances, as urine or putrid sanies; by the interruption of the circulation and nervous energy, as from ligatures or improperly applied bandages—or by natural strictures, as those in hernia and paraphymosis; by continued pressure, more especially in such patients as have, from long suffering and confinement, had the powers of the circulating system weakened; and by violent contusions, as in fractures, compound luxations, and gunshot injuries. A frequent source of mortification, in inclement seasons and climates, is exposure to extreme cold. In this case, the cold is not the direct, but the indirect cause; the power of the parts is very much weakened by exposure to the low temperature, and is thereby rendered incapable of resisting the incited action which follows the stimulus of sudden transition from cold to heat, even though the degree of increase in temperature should not exceed that of the natural standard. That cold is not the direct cause of mortification, has been undeniably proved by facts derived from military practice. No symptoms of inflammation or gangrene occur when the soldier is on duty, and continuously exposed to severe cold; but they speedily present themselves after a rapid thaw has commenced, or after the soldier has imprudently approached a fire. Soon after the half-frozen person has begun to feel a little more comfortable from sudden warmth, he becomes aware of pain, attended with a sensation of itching in the extremities, generally the lower, which are considerably swollen, and of a dull red colour; these, and other symptoms of inflammation, are of no long duration, the action speedily runs its course, and the part soon plainly indicates that gangrene has commenced.

When gangrene follows the tight application of a ligature, the death of the part seems to depend more on obstruction to the circulation of the blood, than on any diminution of the nervous energy, for we do not observe that paralytic limbs are peculiarly liable to gangrene. The surgeon frequently takes advantage of the fact that a part soon dies when its supply of blood is cut off, or its return in the veins interrupted; and has recourse to ligature for removal of parts, When he considers it inexpedient to employ cutting instruments.

Mortification may be produced by the above-mentioned causes, either immediately or consecutively; and it will occur in some constitutions, or states of constitution, at some periods of life, in some structures, and in some parts of the body, more readily than in others.

Inflammatory action is seldom so intense as to terminate in death of the part, unless the power of that part has been diminished by previous local or constitutional disease, or by injury; and the inflammation preceding gangrene is all along attended by symptoms of so well-marked debility, both local and general, that it is frequently designated the Inflammatio Debilis. Of inflammatory affections, the erysipelatous most frequently terminates in gangrene; in other words, the power of resisting incited action is not so great in the cellular tissue and skin as in other parts of the body.

The period at which the symptoms of gangrene appear after an accident varies, in general, according to the severity of the injury. As was already observed, the part may be immediately deprived of its vitality—if not, symptoms of gangrene sometimes appear within a few hours after reaction has taken place; while in other cases, tension, pain, and heat occur, and may continue for a longer or shorter time, according to the degree of power remaining in the part. Tension often exists to a great extent after severe injuries, from extravasation of blood or serum; the functions of the vessels are thereby interrupted, and gangrene is inevitable. As the action proceeds, the pain and heat often subside—the parts become flaccid—dark-coloured serum is effused beneath the cuticle, forming what are termed Phlyctenæ—the skin becomes dull and livid—dark streaks extend along the limb, perhaps from the colouring matter of the blood transuding, as in commencing putrefaction in the dead body—air is effused into the subcutaneous cellular tissue, causing a sense of crepitation when pressed by the finger—sloughs form, either black or of an ash colour—and the gangrene involves a greater or less extent of the limb. The mortification is here represented as attacking a limb that had suffered from compound fracture. The dark part around and above the protruded bone was in a state of sphacelus. The dorsum of the foot and the integument towards the knee were only gangrenous. The patient was advanced in life, and the state of the constitution such as to induce a belief that there was a predisposition to mortification. The removal of the limb was, under the circumstances, reckoned inexpedient. In some instances, the mortification is most towards the surface; in others, it is chiefly amongst the deeply seated parts. Sudden cessation of pain is generally regarded as an unequivocal sign of the occurrence of gangrene, especially in the internal viscera; but it not unfrequently happens that the painful sensations suddenly cease, whilst no gangrene supervenes, and that a part mortifies, whilst the pain continues but little abated.

In compound fractures, dislocations, or severe bruises of the soft parts, dark-coloured, prominent points occasionally appear, in consequence of the effusion of bloody serum beneath the cuticle; in these, however, the fluid is speedily absorbed, and the surface resumes its natural aspect, the cuticle exfoliating and being reproduced; and it is of consequence to know their real nature, for, if mistaken for the gangrenous phlyctenæ, the inexperienced practitioner may be alarmed, and, consequently, have recourse to very injudicious practice.

When the process of gangrene is checked, the skin immediately beyond the mortified part becomes of a brighter hue, and is affected by a more healthy species of inflammation, which ultimately terminates in ulceration, with purulent discharge, and thereby forms what is called the line of demarcation between the dead and the living parts; the process, commencing in the integuments, gradually extends to the deeply seated parts, so that the mortified portion is ultimately attached to the living merely through the medium of bone or ligament. Arteries appear more than any other texture to resist sloughing; and those leading to a mortified part are found contracted and filled with coagulated blood, so that the spontaneous separation of the sloughs, and even incisions for their removal, made in sound parts, are followed by little or no bleeding. This salutary change in the arteries may be accounted for by supposing, that the inflammatory action which leads to the separation of the dead substance from the living affects the arteries at that point as well as the other structures, causing adhesion of their internal surface, and obliteration of their cavities; and the natural result is, that the calibre of the artery above the obliterated point gradually diminishes in size, and the blood coagulates up to the nearest collateral branch: but in consequence of extension of the inflammatory action, the collateral branches may also be obliterated to a considerable extent upwards, and thus the contraction and coagulation in the larger trunk will also extend in proportion. Besides, before the line of separation has commenced, arteries cannot transmit their contents into the sphacelated part, any more than into an extraneous body; so that the circulation of the blood in them is as effectually obstructed as if a ligature were tightly applied; in this way, also, the contraction and coagulation may be accounted for.

Mortification is accompanied with great anxiety; coldness and clamminess of the face and extremities; weak, irregular, and hurried circulation; quick, short breathing; a cadaverous expression of countenance; hiccup (which, however, often occurs in very slight sloughing, or when no sloughing has taken place, in external or internal inflammations, extravasations, &c.); by diarrhœa, vomiting, and in hopeless cases, more especially of traumatic gangrene, by delirium and coma; in fact, almost all the symptoms of severe constitutional irritation are more or less fully developed. In some cases, the patients are restless and unmanageable; in others, low and dejected. The disease often proceeds with fearful rapidity to a fatal termination, the patient becoming comatose from effusion within the cranium; but in other instances, in which the vigour of the constitution is greater, and the extent of mischief less, the system bears up under the affection, and a separation is effected between the dead and living parts. The danger is in general to be estimated by a consideration of the size and importance of the part, and of the age and constitution. The destructive consequences of sphacelus arise both from a local and general cause; for the mere application of putrid animal substance to a part still alive—the infiltration, for instance, of dark serosity into the cellular tissue in the course of a limb—causes a sort of inflammation attended with symptoms of diminished power, and followed by constitutional disturbance; whilst the ultimate extinction of life may be imputed to the effect produced on the system by the part previously to its becoming sphacelated, and to the sympathy between the system and the parts which are left in a weak and moribund condition, and which seem endowed with a disposition to extend the disease.

In the treatment of mortification, no one would think of using any means, local or general, so long as the cause remained; and it therefore must in the first place be removed, otherwise the mischief may speedily become irreparable; thus, a stricture must be divided, irritating fluids evacuated, foreign bodies extracted, &c.

In chronic gangrene the cause is constitutional, and the means employed must be directed accordingly. In general, the power of the constitution requires support, though, in cases where much fever is present, it may often be necessary to keep the patient on low diet: exhibit salines and mild purgatives in the first instance. The effects of food should be attentively watched, and its quantity increased or diminished accordingly. On the subsidence of the fever, and when sphacelus has occurred, wine and animal food must be given abundantly. Stimulants, strictly so called, are not admissible until the line of separation be formed, and their exhibition must then be regulated by the circumstances of the case. Opium and other anodynes are found necessary during the progress of the disease, to allay irritation and produce sleep; opium has been recommended on very high authority, that of Mr. Pott, in mortification of the lower limbs. The bowels must be attended to. Peruvian bark was at one time supposed to be a specific in this disease, but experience has not born out the opinion; it seldom agrees in substance, and the decoction, with or without the compound tincture or sulphate of quina, will be found much more useful in supporting the power and tone of the digestive organs. After the line of separation has been formed, and not till then, the surgeon may interfere, and assist nature in her work, dividing the exposed bones or ligaments by which the dead parts still adhere to the living; or he may perform amputation immediately below the line of demarcation. Amputation in the sound parts cannot be recommended: for vitality is impaired throughout the system, and more particularly near and above the line of demarcation, where, though the structure seems entire, yet the incisions are made in parts really diseased, and which would almost certainly and speedily mortify. In fact, amputation above the line of separation, in whatever way performed, is seldom if ever productive of advantage in spontaneous gangrene.

In order to prevent the occurrence of gangrene after exposure to intense cold, the frigid part must be cautiously and slowly restored to its natural temperature; first by being either placed in very cold water, or rubbed with snow; afterwards, by the degree of warmth in the applications, and surrounding atmosphere, being gradually increased.

In acute gangrene, and in robust constitutions, when the affection arises from over-action, abstraction of blood is had recourse to with marked advantage. In some cases it may be employed, but with due caution, even after sphacelus to a slight extent has occurred. In gangrene, purging and bleeding must not be had recourse to but with the greatest circumspection; for it ought always to be remembered, that however strongly they may be indicated, the time is not far distant when they will be totally inadmissible, and when the weakening effects of depletion will prove highly prejudicial, particularly in cases where the mischief is proceeding rapidly.

The loss of blood is frequently beneficial in sloughing phagedena, as is exemplified on the occurrence of spontaneous hemorrhage in such cases.

When a portion of a limb, throughout the greater part of its substance, is so injured that it evidently cannot recover, it ought to be removed instantly, and before the constitution has suffered.

When gangrene follows inflammatory action, this is first to be moderated, and then the strength by all possible means supported.

When only a portion of the soft parts of a limb is destroyed by mortification, and it is likely that the member may be saved and prove useful to the patient, measures should be adopted to hasten separation of the dead parts, and reparation of the breach in the living.

After the separation of sloughs has commenced, the attention of the surgeon is chiefly to be directed towards the constitution; it must be supported and strengthened by nourishing food, wine, and tonics, or by stimulants, if necessary. Bark in substance, acids, and other supposed antiseptics, are of but little use.

The local applications which have been employed are numerous; poultices of all kinds, charcoal, carrot, and effervescing; various lotions to the surrounding parts, spirituous applications, such as several of the tinctures, liniment of turpentine, balsams, &c., with the view of correcting the fetor. But it is evident that such applications to a dead part can be productive of no effect; the only beneficial result that can be expected from such means is removal of the fetid smell, which can be effected, if need be, by sprinkling a solution of the chloride of soda on the body-linens and bed-clothes. Scarifications are sometimes used; when these are made merely into the sphacelated part, they can be productive of good only by allowing the escape of matter; when they extend more deeply, they are injurious. This practice, however, as will be hereafter noticed, is adopted with the best effects when mortification is threatened.7

When the sloughs become loose, they must be removed bit by bit with scissors; and when the sphacelated part has separated entirely, the healing of the breach is to be promoted by judicious dressing, bandaging, and by proper position.

In mortification of an extremity, in consequence of injury, removal of the part by incision in the sound substance was formerly as much dreaded as in chronic cases before the separation had commenced; but such fears have now subsided, and the practice of delay has been in a great measure relinquished,—amputation being performed in the sound part, at a considerable distance from the mortified or even gangrenous tissues, and during the progress of the disease, occasionally with a favourable result. If the surgeon defer the operation until a line of separation have begun to form, he will soon discover the danger of his delay; the constitution will, in the majority of cases, rapidly sink under the malady before the progress of the disease is in any measure checked, or any attempt is made to throw off the mortified parts. Two cases which lately occurred in my hospital practice, are here introduced from the “Lancet,” to show how different the progress is, and how opposite the practice ought to be. Both the patients made excellent and rapid recoveries.

“Sarah Arnold, æt. 75, was admitted on the 26th of January. She has been a person of great mental and bodily activity, and has enjoyed excellent health from her infancy, until her present illness, although necessarily exposed, from the nature of her occupation, a gatherer and hawker of watercresses, to all varieties of weather. About six weeks ago, without being more than usually exposed to cold, she was seized with severe rigors. Two days afterwards she began to complain of slight pain, with clinching of the fingers, which at the same time became discoloured at the tips, and were partially deprived of sensation. This at first did not give rise to much uneasiness, and no treatment was employed; and it was not until a week after the commencement of the disease, when the discoloration had passed the wrist, and the hand had become dry and shrivelled, and motion and sensation in it were completely lost, that a medical man was called in. Both internal and local remedies were then employed, but without in the least retarding the progress of the disease, which in about a fortnight from her seizure had extended a little way above the middle of the humerus, beyond which it did not pass. At present there is a well-marked line of separation between the living and the gangrenous parts, but there are two livid spots beyond it, on the outer side of the arm; on the inner side, where the disease has extended a little higher up than the outer, suppuration has already commenced. The integuments in the immediate neighbourhood of the diseased parts are slightly reddened and tumefied, and it is there only that she complains of some slight pain. The hand and wrist are dry and shrivelled, but above this the parts are soft and flaccid. Below the line of demarcation, the extremity is of a dark colour, resembling the skin of a negro, and completely deprived of the power of motion and sensation; but she complains of a disagreeable tingling, referred to the fingers. The discoloured parts are quite cold, and the pulse cannot be felt, even in the axilla. Though she complains much of debility, the system seems to be but little affected. The appetite is very good; the skin is moderately warm; the pulse is 98, and of good strength; the tongue is moist and clean. She sleeps little. ℞. Haust. c. Sol. M. Morph. gtt. xxv. M. Vini Rub. ℥iv. Water-dressing to the arm at the line of separation.

“27. She continues much the same as yesterday; slept little, bowels moved twice; tongue clean and moist; appetite very good; pulse as before; heat of skin natural; intellect clear; no expression of anxiety in the countenance. ℞. Haust. Con. Vin. Full diet.

“28. The suppuration on the inner side of the arm is more copious, and the discharge is more fetid. The livid spots on the outer side of the arm have not extended, and there is some slight redness around them. Pulse 104, of good strength; tongue clean and moist; heat of skin still natural; appetite good; bowels moved once since the last report. Continue. A little Sol. Chlor. Calcis to be added to the dressing.

“29. The dry and shrivelled state of the extremity has extended as high as the middle of the forearm. The discharge is much the same as before in quantity, but is more fetid. The separation between the gangrenous and the sound parts, which had begun on the outer side of the arm when she was admitted, is extending a little, both towards the inner and the outer side. Pulse 90, of moderate strength; skin natural; tongue clean and moist; bowels open; appetite excellent.

“30. Much the same as yesterday; sleeps a little better.

“31. The suppuration is more copious; the discharge extremely fetid. The dead parts on the inner side of the humerus are gradually becoming more detached. No change in the appearance of the livid spots beyond the line of separation; pulse 102, of pretty good strength; bowels continue regular, and the appetite is good. Cont. vinum et haust.

“Feb. 2. The separation of the gangrenous parts on the inner side of the arm has advanced a little more since last referred to. The livid spots have disappeared, with the exception of the largest, where a small superficial slough has formed. The diseased parts were removed to-day, the line of separation being fairly established, and suppuration having taken place in a great part of its extent. The soft parts were divided by means of a pair of scissors, cutting as near to the living parts as could be done with safety; the bone was then denuded as high up as possible, by passing a bistoury round it, and it was then divided by the saw. There was no bleeding from the soft parts, and only slight oozing from the bone, which was found to be alive where it was divided. Cont. vinum et haust.

“3. Continues in much the same state as yesterday; pulse 104, of good strength; tongue clean and moist; bowels moved once; skin natural; appetite good; suppuration very free. Cont.

“5. Suppuration copious; a portion of the dead parts left have separated, and left a healthy florid granulating surface. Continues much the same.

“6. Discharge copious, and much less fetid; bowels regular; pulse 100, of good strength; tongue clean; appetite good; wishes for more food. To have an additional chop. Cont. alia.

“8. The greater part of the sloughs have separated, and have left a healthy florid granulating surface; no change in the general symptoms. Continue.

“9. The stump looks well, and the posterior part of the cut end of the bone is covered by healthy granulations.

“In some notes of this case, kindly furnished me by the late Professor Fergus of King’s College, who had an opportunity of watching the appearances for some time before the admission of the patient here, it is mentioned that the flow of blood in the veins was exceedingly slow, and that hard knotty tumours could be felt in the parts before they became sphacelated. These swellings all along preceded the mortification. It is mentioned, besides, that the patient had a sort of fit, but that it could not exactly be ascertained whether or not she lost consciousness. Her left arm is said to have been motionless from and after that time. There is considerable discrepancy in the accounts of the mode of invasion, and of the duration of the disease, before the line of separation became apparent. A period of six weeks is stated in our case-book to have elapsed from the attack to the admission of the patient into this hospital. It would appear, however, from the other history, that not more than three weeks had passed over. The old lady is not very distinct in her account; at one time she makes a statement with great minuteness, and very soon after contradicts herself on almost every point. When pressed on the subject, she states that she got disgusted with her condition, became despondent and careless about everything, and that her recollection is not now very good.”

“S.W., aged 16, was admitted March 12, under the care of Mr. LISTON. She is a servant girl, of sanguine temperament and good constitution. On Friday, March 9, she was cleaning the outside of a parlour window, and stood on the sill. The window-sash, upon which she was depending for support, being suddenly drawn down by a person inside, she was precipitated into an area, a distance of fifteen feet. She was immediately picked up, and conveyed to the hospital. The house-surgeon detected a compound fracture of the ulna, and a fracture of the radius, both fractures being a little above the wrist-joint of the right arm. The fracture was adjusted, and the wound, which was inferiorly to, and behind, the wrist, dressed in the usual manner. A dose of house-medicine was administered; suitable directions were given in case of the occurrence of pain or swelling; she was sent home, and desired to remain quiet. The following morning (Saturday) she was visited by the house-surgeon, who found her comfortable, but she had passed a sleepless night. On Sunday morning the affected part became so intolerably painful that she tore off the splints and bandages, which one of the dressers of the hospital had a short time before readjusted; in the evening she was in great pain, and the arm was much swollen.

“12. To-day (Monday) she was admitted into the hospital; water-dressing was applied to the wound. The bandages were reapplied, and an anodyne administered in the evening, with the effect of producing some rest.

“13. The pain and swelling were so great during the night that the house-surgeon was called up to see her, and ordered the application of fomentations; this morning she is much more comfortable.

“14. On removing the whole of the apparatus this morning early, mortification was found to have taken place in the limb; at the time of Mr. Liston’s visit in the middle of the day, the limb was very swollen, the fingers were of a black colour, the forearm livid, there were vesications near the elbow with fetid discharge. There was a good deal of fever with slight delirium; pulse irregular, quick. Mr. Liston considered the only chance the patient had was the immediate amputation of the limb at the shoulder. The patient’s consent having been readily obtained, Mr. Liston proceeded at once to the

“Operation.—He first introduced a long double-pointed knife under the acromion, and brought the point out at the lower and posterior border of the axilla, by this means the joint was laid open; the flap thus formed of a portion of the deltoid was raised, and the head of the bone separated from its attachments. The other flap was formed from the integuments and muscles in front. The axillary, and one other vessel, required ligature. The edges of the wound were drawn together by three points of suture, and cold water-dressing applied. One grain of muriate of morphia was given. In the evening, several strips of isinglass plaster were applied, and the edges approximated. The delirium ceased after a short but refreshing sleep.

“15. Passed a good night; has had little pain; feels very comfortable this morning; she is cheerful, and has little fever; pulse 86, regular. The wound looks healthy.

“April 2. Since the above date, the patient has been gradually improving in her health and strength, and she is now able to walk about the ward.”

In gangrene occurring after exposure to cold, amputation should not be had recourse to till after the line of separation has formed; and in this case the constitutional symptoms are much less urgent, and the object of the operation might be frustrated by its being performed in parts, which would speedily become sphacelated. The amputation may be performed either at the line of separation by cutting the ligaments or bones, as was done in the case from which the accompanying sketch was taken, and when the line of separation is well declared; or, if by these means a good covering is not likely to be had for the exposed surface, the incisions may, in these cases, be with safety and propriety made in the living tissues, at the most convenient point.