the hemlock poultice, and such like, are usually resorted to; and as stimulants, a vast number of means have been used, varying in quality from the moderate excitement of a mixture of a resinous tincture with water, to the destructive agency of the potential or actual cautery.

In general, I imagine that gentle stimulants only should be used. It ought to be remembered that their influence is intended solely for the living parts: if too much excitement is produced by strong stimuli, possibly gangrene may be encouraged, and, at all events, more pain is occasioned by their use than the circumstances warrant. No harm can result from the application of caustics or the heated iron, provided the living parts are not touched by them; the stimulus of their qualities conveyed to these parts, through the medium of the slough, may induce favourable excitement in the living textures; but when they touch the latter, they will kill, and thus produce further mischief. It is good practice, on many occasions, to rub the surface of a sloughing, illconditioned, languid ulcer, freely with caustic, or even with the heated iron; but here, be it remarked, there is a slough already present, or it is intended to convert the surface into one by this direct and killing measure, for in the latter case the application seems to have the effect of causing nature to bring the disease to a crisis, as it were, and no longer to leave all the parts in a half-dead state, the surface being thus killed outright, and the adjacent vessels excited to a more healthy action. It is customary in the instance of carbuncle to cut freely into the gangrenous and mortified textures, but the object of doing so is apparently not understood by some. The incision in such cases should never penetrate beyond the actual gangrene and sphacelus: it should, however, be close upon those parts where the separation is expected to take place; for, under these circumstances, stimulating applications influence the living tissues much more readily than when conveyed through the whole thickness of a slough.

I

Stimulants in these cases are most commonly applied through the medium of poultices and lotions. A bread and water poultice, with a little tincture of myrrh, oil of turpentine, port wine, or such irritating fluids, poured over its surface, may suffice, or the common fermenting poultice may be used with benefit. Sometimes resinous ointment, by itself, or mixed with turpentine, is spread over the surface of such poultices. At the periods of dressing great care is taken to wash away all foul discharges, and no fluid answers better for such purpose, think, than a mixture of tincture of myrrh and water, of the strength of half a drachm, or a drachm to the ounce, or according to the stimulus supposed to be necessary. Of late years it has been much the custom to use solutions of chlorine or of carbolic acid for such purposes; and the solution of permanganate of potash has recently been much in requisition, chiefly, however, to correct the offensive smell of the slough. By such means, and by time, a slough will at last become entirely detached, and may then be lifted away, or if it be left by a few shreds only, these may be cut across with the scissors, and when the large mass has been removed, the small remaining portions of these shreds may be left to separate afterwards. The surface, at the period of the

removal of a slough, is usually covered by healthy granulations inclined to heal over, and no particular treatment is required further than that already referred to in the chapter devoted to granulation and cicatrization.

Perhaps the most troublesome cases of partial mortification which the surgeon has to deal with, are those which occur over the sacrum, in persons who are long confined to bed from fevers, chronic diseases, or fractures. As pressure seems in all such cases to be the immediate cause of the affection, the exposed parts, such as the skin on the back of the pelvis, over the prominences of the scapula, the great trochanters, and the heels, should be defended by soap plasters spread on felt; and when, unfortunately, sloughing occurs (or ulceration, for, as in many respects the conditions are analogous, the treatment of either case should be nearly alike), poultices will, besides their other good qualities, act as soft cushions for the injured parts, and if a water bed (Dr. Arnott's) can be procured, it will be found of the utmost utility.

CHAPTER XV.

QUESTION OF AMPUTATION IN GANGRENE AND MORTIFICATION.

THE remarks in the preceding chapter are applicable chiefly to instances of partial affection of some region: but it will happen sometimes that the gangrene seems so extensive, in either the upper or lower extremity, or that mortification has committed such ravages, as to preclude the hope of saving the limb, or even the life of the individual, if such a source of irritation is allowed to remain. The surgeon will seldom do his duty properly here, if he leave the case so much to nature, as in the instance of a partial slough; for, although there is ample experience to prove that a portion of a hand or foot, fore-arm or leg, may drop off, or that either member may be separated at its articulation with the trunk, by the disjunctive absorption, it is equally certain that the work is done in a tedious, painful, and unsatisfactory manner. Months may elapse ere a part is entirely separated; and when this has at last occurred, months more may pass over ere the sore cicatrizes. There cannot be a doubt that the surgeon is justified in many of these cases, in performing amputation, and the only ditficulty in some of them is to determine the proper period for such a proceeding.

In the instance of spreading gangrene, as has already been stated, it is difficult, if not impossible, to say where the disease is to end,-where there is to be a separation between the dead and living parts,-and hence it has been the prevalent custom to wait until a line of demarcation has formed, though, from the examples of Larrey, Lawrence, and some other modern surgeons, the practice of operating at an early period has been strongly advocated. Although educated in these latter

doctrines, and strongly prepossessed in their favour, I feel bound to say, that, after having acted upon them repeatedly, and seen others do the same, the success has been very different from what I anticipated. I have in my recollection six cases in which I amputated during spreading gangrene, four times in the thigh (one of them being for a simple fracture of the leg, another for compound; both close upon the ankle; the third following spontaneous obstruction of a popliteal aneurism, and the fourth after ligature of the femoral artery for a similar disease); once (being the fifth) in the leg for severe lacerated wound of the foot, and once (the sixth) at the shoulder-joint for extensive injury of the arm. None of these ultimately survived. I might possibly in future resort to a similar practice, but should feel greatly inclined to wait for a line of demarcation, although even here I should not be very sanguine as to the result. Numerous cases might be brought forward, however, to prove the success of such practice, yet I believe that, in many instances, the surgeon will best show his judgment, by amputating, in severe injuries, before sufficient time has elapsed for gangrene to come on, or by waiting, in the event of such an occurrence, until it is seen how far, and to what degree, the affection is likely to proceed, and, in addition, to what extent the constitution sympathizes with the local disease. The latter circumstance is, indeed, often remarkable; but whether it is from the wound or the gangrene, it is difficult to say. I once saw an amputation in the leg performed by a surgeon of great experience, for a severe compound fracture: the calf of the leg, when the incisions were made, was in a slightly suspicious condition, but not sufficient to deter from selecting this part for the operation: unequivocal gangrene, however, attacked the stump, and within eight-and-forty hours amputation was performed in the thigh: again the disease appeared in the stump, and at the same time in the skin over one of the scapula, where there was no suspicion even, that the slightest injury had been inflicted. Although I am satisfied that the operator did what the best rules of surgery dictated in this case, it is nevertheless exceedingly probable, that if delay had been given, in hopes of a line of demarcation forming, the condition near the shoulder would have been sufficient to have deterred from an operation at all.

If amputation during gangrene be decided upon, a question may arise as to the site of the operation. In the early stages, when it is impossible to determine how far the disease may extend, the incisions should, if possible, be made in a part where there is no indication of disease-even the slightest swelling or discoloration should induce suspicion. Dr. Norris has advised that "a joint had better be interposed between the injured part and the point of incision;" but I cannot here see any good reason for such a practice excepting as regards distance, for a joint can evidently have no influence in checking the progress of a disease which spreads solely along the skin and other soft parts; and it is worthy of remark that in three of the cases out of the six above alluded to amputation was done in the thigh while the gangrene began in two of them in the lower part of the leg, and in the

other actually on the foot. If the affection has already implicated the greater part of the member, the proceeding must then be effected close upon the trunk-possibly at the shoulder; and although the prospect is always most unfavourable when the knife is used upon parts already inflamed and swollen-perhaps gorged by infiltration resulting from diseased action, the surgeon need not utterly despair, for even then success may result, as was the case when Sir William Lawrence amputated at the shoulder-joint under such circumstances. Every experienced practitioner must have seen examples where wounds in parts so affected have healed most kindly,-such union, however, being, as might be expected, chiefly by the second intention. The incisions occasionally required in severe forms of erysipelas are examples of the kind.

If the line of demarcation has become visible, then the operator will choose the site of his proceedings chiefly with reference to the formation of a proper stump. He will of course cut above the line on the skin, but ought to bear in mind that possibly the affection may have extended further up in the subjacent textures; and on that account he should be cautious both in his diagnosis and prognosis.

It will often happen, in spreading gangrene and also in mortification, that the surgeon does not feel warranted in resorting to amputation; yet, such is the tenacity of life in some individuals in the latter affection, that a large portion of an extremity may be converted, after the lapse of weeks or months, into a shrivelled, dry, black mass, attached to the body only by means of bone, which undergoes disjunctive absorption more slowly than the soft textures. In such a case it will be but charity to assist nature with the saw, by applying it close to the living part, where, if no dead bone be left, granulations will spring up, and a tolerable, nay often an excellent stump will be the result. It may sometimes be a question in such cases, whether it will be best to cut in the line of demarcation, or perform a regular amputation a little higher up; the latter should certainly be preferred in some instances, although, as a general rule, particularly in persons advanced in life and of debilitated constitution, I believe it will be best to follow the indications of nature, and confine the manipulations to the parts where separation is already in progress.

SUCH a disease as that once familiarly known under the name of Hospital Gangrene is now rarely seen, although from time to time, both in hospitals and in private, cases are met with, which resemble in many respects those of former years, when the disease committed such ravages among our soldiers and sailors, and when in civil hospitals also, so

great was its prevalence and proneness to attack all open surfaces, that it became altogether impossible to calculate with any degree of certainty on the results of surgical practice. It rarely happens now-a-days that a slight abrasion of the skin, or the wound of an amputation, is attacked with sudden and severe inflammation which speedily assumes a gangrenous character, and then rapidly terminates in mortification; yet such cases do occasionally occur, although not with the frequency of former times, when, as was said of the Hôtel Dieu, a student might learn how to perform amputation by seeing it done on the living body, but could never learn how to treat the stump from the same field of observation, as the patients operated on invariably died of this destructive malady.

The term Phagedænic Gangrene is frequently used for this disease, too. Often there seems to be a mixture of erysipelas, gangrene, mortification, and ulceration, in the same case, as exemplified thus: on a trifling-looking sore on the glans penis, for instance, the proportionably slight inflammation which is present suddenly becomes more active; the surrounding redness assumes a darker hue; then it becomes blue and gangrenous, and the parts thus affected are converted into a slough, underneath which the process of ulceration goes on so rapidly, that as the dead part becomes loose, the space behind is evidently larger than under ordinary circumstances: moreover, on the comparatively more healthy surface left after the detachment of the slough, similar actions may again speedily ensue, and thus, in the course of a very few days, according to the extent of the attack, one half of the glans or one half of the penis, or more, may be destroyed. Sometimes the patient's constitution seems but little affected; generally the pulse is rapid and full at first, but feeble as the destruction makes progress, the mouth dry, tongue foul, and indeed there are most of the symptoms of that kind of fever which usually attends severe local inflammation, particularly great prostration of strength. In hospital practice I have seen many such cases; but the patients have generally been admitted with the malady upon them; neither the air of the hospital, nor any other supposed contagious influence about such establishments, has been the cause of the disease. Occasionally, however, I have known instances where sores and wounds have assumed similar aspects spontaneously in the hospital. During several seasons in Edinburgh, thirty years ago, without any apparent cause, many sores in the hospital became affected with actions which, in some respects, resembled those of Hospital Gangrene. Healthy-looking ulcers suddenly lost their red colour, and became of an ashy hue,-the granulations having seemingly lost all vitality: then several patches sloughed, whilst ulceration extended and widened the breach of surface. I have, within the above date, seen similar results repeatedly in King's College Hospital, and have reason to think that like conditions have often occurred even in the healthiest of the London hospitals.

There are few remedies, either external or internal, which have not been made use of in these phagedænic sores, but their effects have been very equivocal. As local applications, caustics seem to have been