When a part highly inflamed is on the verge of becoming gangrenous, the pain is violently in creased, the colour becomes deeper and extends farther, the tumefaction increases from the effusion of serum, communicating a doughy feeling, the cuticle is raised up into blisters, and the part ap pears erysipelatous. The pulse at this period is small and rapid, the tongue brown and crusted, and every symptom of typhus fever. This may be con sidered the gangrenous stage, which if not arrested ends rapidly in sphacelus. The pain and sensibility then cease, the part becomes edematous, emphy sematous, cold, black, and fetid; a profuse watery and dirty-coloured discharge is poured out, the pulse scarcely perceptible, the accompanying fever having as it were ceased, which often takes place suddenly and carries off the patient ; but a low typhoid fever more frequently continues for some days, attended with hiccup, subsultus tendinum, low delirium, and diarrhoea. This typhoid fever is supposed by some to arise from the absorption of the fetid matter, but as typhus supervenes to synochus or synocha, if severe and of long duration, we are entitled to ascribe it in this case to the same cause, viz, the violence of the inflammatory fever.
The treatment of the gangrenous or first stage is by applying large anodyne poultices in the hope of subduing the inflammatory action still present, and which is the cause of the gangrene; by keeping the patient quiet, on low diet, and administering pur gatives. The constitution is generally too exhaust ed to bear general blood-letting, but leeches or cup ping may be applied to the part. A large opiate should be given at bed-time. Should the part sphacelate, the yest or charcoal poultice should be used, or hot dressings applied, and the strength of the patient supported with beef-tea, animal jellies, and wine, together with the opiate at bed tune. If the mortified part is to recover by sphacelation, red line appears on the sound skin at the point of separation, between the living and the dead por tions, which line denotes the adhesive inflamma tion, soon forming the ulcerative, which producing suppurative papillae or granulations, secrete puru lent matter, so that the whole forms an ulcerated surface. Consequently, in a _limb which sphace lates, no hemorrhage takes place; a circumstance also dependent on the arteries being plugged up with coagula of blood.
Whenever the sphacelated parts have been thrown off and ulceration fairly established, the part should be dressed as a simple ulcer. The sphacelated por tions may be cut away with scissors or scalped at each dressing.
In cases of mortification occurring from mechan ical causes, as severe contusions, or traumatic gan grene, amputation may be with safety performed at any period; but in mortification arising from constitutional causes, as a general diseased condi tion of the arteries or veins, amputation proves fatal.
Mortification occurs occasionally from excessive cold. Acute pain is experienced in the part affect ed, with numbness, weight, and a tingling sensa tion in the legs; the feet of an obscure red colour, and slightly swollen. Sometimes a light red is
perceptible at the base of the toes and patellar as pect of the foot; at others, they are deprived of motion, sensibility and heat, and appear black and withered. The treatment is by applying snow or ice cold water to the part in order to thaw it, then camphorated spirit of wine or poultices. When the mortification is superficial, the dead parts com monly separate between the ninth and thirteenth clay, and leave an ulcerated surface, which requires the same treatment as ulcers. When a whole limb is affected with mortification, a slow typhoid fever, accompanied with diarrhoea carries off the patient; or the grangrenous portion becomes bounded by the circular line of adhesive inflammation, which suppurates and throws off the mass. Amputation in such cases should be resorted to, for it is morti fication from an external cause, the same as that from an external contusion. The operation ought to be deferred until the constitution has rallied from the benumbing effects of the cold, and the reaction of the nervous and circulating systems is fairly es tablished. This mortification from congelation or frost-bite, and also that from ergot, is named by some surgical writers dry gangrene, and by others chronic gangrene.
The eating of ergot, or unsound or diseased rye, or mildewed wheat, has an effect on the constitu tion not unlike that which the living exclusively on animal food has in producing scurvy. The rye so Impairs the nervous and circulating systems, that they become unable to perform their functions, consequently mortification takes place, first, in such parts of the body as are most remote from the cen tre of the circulation, an event that occurs in all kinds of gangrene. This variety of mortification commonly begins in the toes, which become red, painful, and hot, as if scalded with boiling water ; in a few days these symptoms suddenly cease, when the toes feel cold and insensible, become dry, hard, withered, and black as charcoal. The gangrenous action now extends gradually upwards along the foot, leg, and thigh, to the trunk, and is accompa nied with fever and delirium. In one instance, the lower extremities were separated at the hip joints from the trunk. This singular species of mortifi cation has occurred chiefly in France, and become occasionally epidemic, sometimes in Switzerland, and once in England. Its treatment naturally con sists in at once relinquishing the diseased rye or damaged wheat, and substituting the finest and best wheat, with nourishing diet. The gangrened parts to be treated by hot dressings, and when the spha celated portions are separated, the ulceration to be dressed with simple ointment, dry lint, or other ap plications, according to the appearance of the sore. Amputation is inadmissible while the constitution is under the influence of the ergot; but afterwards, it might be necessary to form a better stump.