intemperance. The foetor of the breath, often unendurable when there is cough without expectoration is characteristic.

The matter expectorated is at first grayish white or greenish, resembling portions of gangrenous lung found after death. Later the matter is purulent, and less offensive in odor. The breath and expectoration furnish the diagnostics; the gangrenous fœtor is not sufficient. If the expectoration suddenly assume a gangrenous foetor, at the same time becoming copious and presenting the appearances characteristic of decomposed pulmonary substance, the existence of gangrene is quite certain; especially if prior to the eruption of this peculiar matter the expectoration has been slight or altogether wanting. The case is clearer if there had been previously ascertained circumscribed solidification, and if cavernous signs afterwards appear in the same locality. If peculiar fœtor occur in the course of bronchitis it rarely ever becomes so intense as in gangrene; it has been developed less suddenly little or no gangrenous matter ever appears in the expectoration; no sign of solidification preceded, none of cavernous excavation follows it. An abscess following pneumonitis may furnish purulent expectoration, sometimes foetid, but never so intensely so. The matter discharged is not the dark, sanious, liquified gangrenous lung-substance above described.

Small portions of lung substance within a tuberculous cavity may communicate a gangrenous odor to the expectoration, but not to the true gangrenous extent. The previous history may distinguish the

two cases.

Pneumo hydrothorax may be distinguished by the symptoms given under that head. Gangrene of the lungs occurs oftenest in children, next in adults, then in aged persons.

Summary of Physical Signs.-" Dullness on percussion, varying in degree and extent, unless the gangrenous portion be quite limited, and deeply-seated. Bronchial respiration, or suppression of respiratory sound within the area of dullness on percussion; increased vocal resonance or bronchophony and fremitus occasionally present; mucous or subcrepitant rales in the vicinity of the gangrenous portion; possibly, a true crepitant rale; subsequent to the occurrence of fetid expectoration, cavernous respiration, gurgling, and in some cases pectoriloquy." Remedies: Laches., Phos., Arsen.

4. GANGRENA SENILIS.-Spontaneous Gangrene.-A form of gangrene which generally commences in the feet of aged persons, or at least those past the middle age of life, though younger persons have been attacked by it.

But it generally occurs in aged persons in whom the arteries have become ossified, more or less contracted, sometimes obliterated. The ossification generally extends well up the leg. In some cases the femo

ral artery, instead of being ossified, has become converted into an impervious gristly cord; the change in all these cases seems to be the effect of a gradual degeneration of the tissue, without previous inflam

mation.

Premonitory Synptoms of Senile Gangrene.-There is for some months or years before gangrene is perceived, occasional pain of the toes and lower limbs, followed with numbness and some difficulty of keeping the feet warm. After the feet have been cold and are become warm again they become quite painful with a sense of weakness in the muscles. The patient can walk quite well for a short distance, but is soon exhausted; after one or two years he finds little blood in the feet, the heart is easily excited to unwonted action by running, walking upstairs, lifting weights, by excitement of passion; the circulation is obstructed, the action of the heart is liable to stop, and syncope will follow. These premonitory symptoms may continue for years, and then the mortification will suddenly follow on some trifling inflammation. A corn may have been cut too deep till it bleeds, and inflammation and gangrene follow. Or the foot has been too cold, and then placed too near the fire to warm it; the toes inflame slightly and then mortify. Small blisters resembling those of severe erysipelas soon burst and expose dead cutis vera. The flesh though dead has not the usual black appearance of mortification; from not being supplied with blood, the dead portions often appear quite white, thus deceiving by this appearance the careless observer.

The gangrene may be confined to one toe or may extend to several, or to the foot. The pain sometimes slight, at other times excruciating. When mortification begins, a little line of inflammation appears at the margin of the gangrene which slowly creeps over the toes and up the foot, and the mortification follows it; the patient feeling all the time quite well in all other respects.

In the course of some months the disease begins to progress more rapidly; the inflammation followed by the gangrene extends farther up the toes and feet; a fresh attack of inflammation affects the general system; the morbid fluids existing in the diseased part begin to be absorbed; the pulse becomes feeble and rapid; the appetite fails; the skin is more hot, the patient sinks into a state of stupor, and, in a few days more he dies.

TREATMENT.-The first idea of the old surgeons was amputation; but this was long ago given up. The only efforts now relied upon are: 1, to check the inflammation by general and local measures. 2, to relieve the pain, support the strength till the dead portions can slough off, leaving the stump to heal by granulation.

Good diet, such as can be digested, must be furnished; digestion, assimilation and exertion must be kept in as healthy a condition as

possible. Stimulants, as ale, porter, beer, &c., must be used as far as they can be made agreeable. The patient must be confined to bed, warmly covered, first with some mild ointment, after which the best covering for diseased limbs is carded wool, as recommended by Mr. Vance, surgeon at the Greenwich Hospital. It was also tried by Sir B. Brodie with success in many cases. It should be applied in large quantities over the whole limb as high as the hip, sewing a silk hand kerchief loosely over it to keep it in place, and kept on several days. This application ensures the quiet of the limb, protects it from changes of temperature; and even the diseased arteries gradually assume a more healthy condition under its influence. It should be continued till full recovery; and then a soft woolen stocking and drawers should still be worn next the skin.

When the progress of mortification is arrested the line of demarcation is seen separating between the living and dead parts. The separation generally progresses till the flesh is entirely detached, and after a time even the bones become loose. The tendons and ligaments may need to be cut, but neither the flesh nor the bones should be severed by an operation. Cutting off a portion of the dead flesh does no good, and an incision into the live flesh is almost certain to be followed by a spread of the mortification.

To control the offensive odor of the dead flesh, employ a wash of chloride of lime, or chloride of zinc, though carefully guarding against wetting with it the living parts. A good disinfectant is a dry powder prepared by rubbing together 100 parts of plaster of Paris with 5 parts of coal tar. This may be applied to gangrenous surfaces, or to any other that is offensive, as it makes a good dressing spread on lint. Tar water, which contains Kreosote, is also a good disinfectant. When the gangrene spreads rapidly and the life of the patient is in danger, it is advised to destroy the vitality of the surface parts of the limb in advance of the inflammation and to consolidate the dead flesh of the sloughs while they are separating, so as to allow a distinct line of separation to be established between the dead and live flesh. Strong nitric-acid appears to answer this purpose better than any thing else, though the operation is very painful. First dip a piece of wool in the acid, wipe its surface, and apply the wool to all the surface for some distance beyond the gangrene. After one or two applications of strong acid, usually, the dead portion will begin to slough off; the acid should afterwards only be reapplied where the slough does not appear readily to separate from the living flesh.

When the spontaneous gangrene attacks the extremities of young persons, the arteries of the legs or feet having become plugged up with fibrinous exudations, the brain is quite liable to be simultaneously affected. The treatment consists in, horizontal position, quietude,

·

calming arterial excitement with Aconite, avoiding mental agitation. and anxiety. Aconite alternated with Belladonna will control the febrile and cerebral excitement better than any thing else. Hitherto the reliance has generally been on Opiates to quiet the pain and irritation, stimulants, as Ammonia and lemon-juice, China, Lach., Arsen., &c. The application of a large quantity of wool around the limb with proper internal treatment, and good diet will sustain the vital powers till the dead parts have time to separate.

5. GANGRENE OF THE MOUTH. GANGRENOPSIS. GANGRENA ORIS.

The recent order of Surgeon-General Hammond, prohibiting the use of calomel in the United States Army, recalls to our recollection the observations of former years, in which this disease as a poisonous effect of mercury was more common than it appears to be now. It does not indeed occur as a common effect of mercury in good constitutions, even when that article is injudiciously used, but is almost always preceded by some other constitutional disease, as intermittent fever, scarlatina, or some epidemic. It is peculiarly liable to attack children over two years of age, or between the periods of the first and second dentitions, who are much reduced by protracted fevers, or mucous inflammations. It has long been known that children are with difficulty salivated, hence it has been common to prescribe calomel recklessly in trifling diseases; and very often, instead of an ordinary ptyalism the physician finds on his hands a case of gangrenous inflammation. Professor Dugas of Augusta, Ga., (in the Southern Medical and Surg. Journal, Oct. 1850,) says: "there are few communities in this section of the country in which there may not be found some living evidences of the havoc of mercury upon the face."

Symptoms.-The disease ordinarily appears in patients who have suffered from ague or some pernicious fever. When the original disease is subsiding a foul sloughing ulcer is observed on the gums near some decayed tooth, or in points which have shown effects of mercury. The local disease extends by a process of sloughing rather than by ulceration. The surface of the ulcer is jagged, covered with dark offensive cream-colored sloughs. In some children, previous to the commencement of this disease, there is general ill health for weeks; derangement of the digestive organs; alternate constipation, bilious diarrhoea; abdomen swollen and general emaciation. The patient is suspected to be suffering from the effects of worms, and one dose after another of calomel is given. The worms are not discovered, but after some days the mouth is observed to be sore. The epithelium is sound, except in one spot, perhaps adjoining a single tooth, which has been partially decayed before. At this point the gum is converted into a

grayish, cineritious slough, slightly receding from the body of the tooth which is becoming loose, and the investing membrane is found diseased. The case is not considered alarming, and an astringent wash is thought sufficient; but, in a few days the friends begin to be alarmed. There is now fever, pulse 100 per minute; no appearance of exhaustion, the eye is clear, and the intellect undisturbed. But the cheek and eyelid of the affected side are swollen and red over a large surface, but with a round grayish patch in the centre; and this, on looking closely, is black at the edge, and the circumference surrounded by a circle of brighter red. The centre is ashy or tawny in color, soft and slightly depressed. This circular spot is already gangrenous; it penetrates the whole thickness of the cheek, the dark slough extends to the diseased part of the jaw where the first ulcer appeared, and is seen to be gradually extending on every side. Caries is extending from the tooth along the jaw. The teeth become loose and the patient sometimes plucks them out with his fingers. "I saw a child at my first visit watched by an attendant to keep it from pulling out its teeth. If not cured the disease progresses to an early termination in death; the mind remaining clear, and the child continuing to take food and drinks while the power of swallowing remains."

In adults the course of the affection is about the same. It begins in persons whose health is already broken by previous disease. They have generally taken much medicine, have perhaps had mercurial sore mouth more than once to cure bilious fevers and supposed chronic hepatitis, quinine to cure agues, and hydragogue purgatives to cure dropsical affections. The physician finds the patient in a case of this kind in a slight chill, or after imperfect reaction. Some pain in the head; tongue coated, edges red. He gives one or two purging doses of Calomel, with common accompaniments. The fever seems better; but all is not right; the strength does not return. The mouth is observed slightly sore, and the ptyalism is expected to finish the cure. But it does not the breath is found very offensive; further purgatives are given, and strong astringent lotions are used for the mouth. The case goes on for some days, and all is thought to be improving. But the breath has a peculiar fœtor, and some certain spot is pointed out as painful. The cheek is swollca, pale at first, then red, glossy; eyelid oedematous, nearly closing the eye. The mouth within shows a black or grayish eschar, either on the gum or inside of the cheek. Gangrene has already commenced; and it slowly but certainly extends towards the orbit, along the jaw, soon perforating the cheek. Death is on the march, though the patient says, he feels "pretty well;" the pulse is good, the fever is scarcely perceptible, and he takes sufficient food. Under any common treatment he will die in a few days.

CAUSES. All the malarious fevers, scarlatina, measles, and other VOL IL-23.