In all forms of spontaneous gangrene there is marked improvement in the general health of the patient as soon as a distinct line of demarcation forms between the dead and living tissue. In old people diabetes is a fertile cause of gangrene of the toes and feet.

Treatment. It is only before the occurrence and during the spread of gangrene that the use of lowering remedies can be suggested. The constitutional conditions which predispose to gangrene, such as want of food, diabetes, fevers, feebleness of the heart's action, are all associated with debility; consequently, depressing remedies are to be avoided. Tonics, together with stimulants such as are recommended in acute gangrene, should early be had recourse to; if there be much depression, ether, ammonia and camphor are of material service. The administration of opium, in doses of from two to four grains during twenty-four hours, in cases where the drug does not disagree with the patient, is recommended by all authorities.

Locally, salicylic wool, or iodoform wool, or simple cotton wool, in thick layers around the foot and limb, covered with a silk handkerchief or thick stocking, must be used. The gangrenous part may be powdered with iodoform or left dry beneath the cotton wool.

Question of Amputation.-When the gangrene is the result of a severe injury, or when it arises from a wound or ligature of an artery, the rule is to amputate at once. The operation should be performed as soon as the gangrene has manifested itself, without waiting for the line of demarcation.

In spontaneous gangrene from disease of the arteries, the rule is not to amputate until the line of separation has formed.

HOSPITAL GANGRENE.

Hospital gangrene is a severe ulceration, in which there is copious exudation and infiltration of the affected part, together with rapid decomposition; it arises where a number of sick and wounded men are crowded in ill-ventilated apartments, who are deprived of nourishing food, and where there is no opportunity for separating the infected. It may affect any kind of a wound, or even a mere bruise.

Hospital gangrene may be divided into idiopathic and traumatic; it is idiopathic when it depends upon constitutional causes, and traumatic when it has its origin in an external injury.

Symptoms. When the disease ensues from a wound, an ulcer, or on the stump of an amputated limb, the part begins to be painful, the edges

inflame, the suppuration becomes less and of a serous character, the granulations assume a dark and foul appearance, and are rapidly destroyed; a quantity of lymph, of a grayish appearance, covers the sore; the wound increases in all directions; the edges become painful and oedematous, and the cedema spreads. The disease begins with pain, which is constant and excessive, being sharp and stinging; cavities are observed more or less deep, the edges being covered with pus. These ulcerous spots increase and run together; a bloody, ichorous fluid is secreted, and the surface enlarges in all directions. The destruction is often restricted to the cellular tissue, but frequently the muscles and all surrounding parts are destroyed. Bleeding sometimes occurs from the destroyed vessels. When suppuration takes place, the discharge is abundant and highly fetid.

These local symptoms are accompanied by loss of appetite, pain in the region of the stomach, nausea, costiveness, loss of sleep, quick and generally a weak pulse, hot skin, anxiety and restlessness.

Its characteristic is quick extension and decomposition of the tissues. The contagion develops itself usually in hospitals, where the air is deteriorated, where patients are huddled together, and where attention to cleanliness is not observed.

When the disease begins as a local affection, it commences as a vesicle, surrounded by dusky inflammation, with severe darting and stinging pains. When the pustule is ruptured, the ulcer displays a dirty, foul slough. The sore soon enlarges; the edges become everted, and the parts puffy and swollen; the surface is composed of gray or ash-colored sloughs, which may become brown, or resemble coagula of blood. These symptoms are accompanied by loss of sleep and exhausting diarrhoea, which, if continued, end in death in about three weeks.

Treatment. It is well to commence the treatment of the case with a free purge; a mercurial purge is to be preferred; calomel and jalap, or calomel with rhubarb, or compound extract of colocynth, will answer. During the course of the disease the bowels should be kept in a soluble condition.

When the patient begins to show evidence of flagging, tonics, in the shape of iron, quinine, together with wine, brandy, milk, nutritious broths, should be had recourse to. Muriated tincture of iron, in doses of twenty drops, every three or four hours, is probably the best ferruginous preparation. To allay pain and irritability, and produce sleep, opium should be given in large doses.

The diet should be highly nutritious, and if there is evidence of a scorbutic taint, oranges, lemon juice, potatoes, onions, tomatoes, etc., must be freely given.

The local treatment should be soothing; the exposed surface should be thoroughly cleansed and dried, and the parts freely bathed with a weak solution of acid nitrate of mercury, carbolic acid, nitric acid, sulphate of copper, etc., etc. The application of chloride of zinc or nitric acid should be followed by an antiseptic or deodorant poultices to receive the discharge and aid its escape.

Great care must be taken, not only to keep the parts clean, but everything surrounding the patient must be constantly cleansed, and changes in the dressing should be frequently made.

Bromine, permanganate of potassium, chloride of zinc, chlorinated sodium, creasote, nitrate of silver, etc., all have their advocates, and may be used in turn.

SEPTICEMIA.

By Septicemia is understood those forms of septic diseases which are unaccompanied by the development of secondary inflammation.

It is an infective disease, i. e., the chemical products which are poured out by the micrococci poison the blood, so that if a few drops are inoculated into a healthy animal the disease is reproduced. It is a grave form of septic disease which begins usually on the second day, ushered in by a severe chill. In a large majority of the cases the chills are repeated, although the temperature is high, ranging from 103° to 108°. The patient has sweats. The pulse rate increases remarkably. The symptoms become of the typhoid type; the emaciation is rapid and extreme. Death takes place in about eight days.

Under the heading of Septicemia there are two diseases: septic intoxication, non-infective, due to the absorption of chemical poison engendered in some putrefactive process external to the body, and septic infection, due to the entry of septic fungi into the blood and to their multiplication there. Septic infection may occur from the smallest wound, and there may be distinct evidence of inoculation of a poison.

Many of the products of putrefaction are pyrogenous. Bergmann succeeded in crystallizing, on fine needles, from putrid fluids, an alkaloidal body, which he calls sepsica, which possesses, in a high degree, the property of exciting fever.

PYÆMIA.

Pyæmia differs from Septicemia in this respect, that the absorption and dissemination of the poison give rise not only to a general disease, but also cause the formation of secondary foci of inflammation—the so-called

metastatic abscesses; that is to say, pyæmia is septicemia with the addition of certain abscesses. The abscesses are called secondary, because they are secondary to a primary inflammation. They are called embolic, because they originate from emboli. They vary in size from a seed to a large walnut; they are generally found in the lungs, liver, spleen, kidneys and brain, and are usually upon the surface of organs.

The symptoms of pyæmia present themselves within the first week after putrid or septic changes have begun in a putrid part; they are ushered on by a severe rigor, followed by profuse sweating. The temperature will vary from 103° to 105°. The skin will be dry, tongue coated, attended by sordes on the gums and teeth; the countenance becomes jaundiced; there will be nausea, diarrhoea, and all the symptoms of typhoid fever. There will be dull, heavy pain in the part where the abscess is forming. If the abscess is forming in any of the external tissues of the body, it will be known by fluctuation.

Prognosis. Serious; usually fatal. Repeated shiverings are the very worst omen. A temperature of or above 106° is very unfavorable.

The treatment of putrid or septic intoxication, septicemia and pyæmia is identical. These affections depend upon the entrance into the blood of putrid or septic materials, and there must be a point from which this material is derived; hence the wound must be rendered aseptic.

Lay open the abscess, wash it out with antiseptic solutions, and dress it with antiseptic dressings. Give opium to relieve pain if necessary. The indications are to remove the exciting cause of the disease, to purify the blood, and keep up the strength of the patient.

It may be well to begin with a calomel purge, when general indications warrant it. The attention of the surgeon should at once be turned to the necessity of keeping up the strength of his patient, and tonic treatment should be early resorted to. Quinine, with or without iron, should be administered. When suppuration is established Huxham's tincture of bark and aromatic sulphuric acid are the remedies, and sleep must be procured by opiates. Brandy or whiskey, port or sherry wine, beef tea, milk, eggs, and such articles as will keep up the strength of the patient, are early indicated. Cleanliness must be insisted upon, and great good will be attained by diligent and unfailing attention to the dressings.

Detergent lotions containing chlorinated sodium, carbolic acid or chloride of zinc, are serviceable.

The position of the part should be so arranged as to favor the escape of the secretions.

Should hemorrhage exist, muriated tincture of iron is a remedy to be resorted to; it should be given in doses of 20 to 30 drops, every four hours. Ergot or atropia, combined with the iron or given separately, will be found valuable in allaying the copious sweating that is apt to exist in this disease.

ANÆSTHESIA.

Anæsthetics are those agents which are employed for the prevention of pain, especially when used in surgical practice and during labor. They are likewise used to produce relaxation of muscles, when needed in reducing dislocations and hernia, or in setting fractured bones. They may be also resorted to in making diagnoses in cases of obscure abdominal tumors and in supposed malingering.

Anæsthesia may be produced by benumbing the part to be operated on by means of cold, by intercepting nervous communication, and by arresting the activity of the nervous centres concerned in sensation. They may be either local or general in their action.

Local Anæsthesia.-When anæsthesia is to be induced by cold, the most convenient plan is to throw a jet of anhydrous ether spray upon the part, and thus freeze it; or a mixture of equal parts of pounded ice and common salt contained in a bag may be applied to the part.

Muriate of cocaine, in solution, produces complete local anesthesia of mucous surfaces. Two or three applications at intervals of five minutes, will, in about ten minutes, produce local anesthesia of the part to which it is applied, and last for a quarter of an hour. Where it is desired to be employed in cases of amputation of fingers, or in removal of tumors, a solution of four per cent. strength should be injected into different parts of the affected organ in quantities of ten minims.

General anesthesia is obtained by inhalation.

Should the patient be debilitated, or should he be suffering from heart disease, it is well to administer hypodermatically a mixture of sulphate of morphia gr. %, whiskey m xx, an half hour before administering the anæsthetic.

Before commencing inhalation, the patient should have abstained from eating for at least four hours; it is important that the stomach be empty at the time that an anesthetic is administered, vomiting being almost sure to occur if the stomach contain food. He should lie comfortably in the horizontal posture, and the dress should be loose, especially about the neck and abdomen. If the vapor excites either swallowing or coughing, its strength must be diminished. After volition has been