Mortification frequently occurs in old age, in con sequence of calcareous depositions taking place in the arteries, a change of structure observed affect ing those of the brain, trunk, arms, and legs, espe cially the last. The arteries of the lower are more subject to this affection than those of the upper extremities. In general the patient complains of great uneasiness of the foot and ankle-joint, par ticularly during the night, before any disease mani fests itself in the toes, which then appear of a pur ple colour, have a cold feeling to the surgeon, while hot and painful to the patient ; but in some cases only a benumbed sensation is felt for some time. The disease usually begins on the inside or tibial aspect of the little toe, and not unfrequently in both feet ; from this it spreads either to the other toes or upper aspect of the foot, ankle, and even the leg ; and then produces so much febrile irritation as to carry off the patient. Soon after the purple colour manifests itself, more or less tumefaction ensues, with vesication or phlyctenx, a dark serous discharge, and a greenish black pulpy appearance of the textures affected. The treatment is by blood-letting, opiate fomentations and poul tices, the internal use of opium in small doses, and frequently repeated, but never to produce delirium or impair the appetite, and by the sulphate of quinine. The diet should be light and nutritive, with a moderate allowance of \vine. When the fomentations and poultices have subdued the acti vity of the disease, the toes may be dressed with simple ointment, and kept warm and comfortable with clothing, and on a level with the body. If any of them sphacelate, they ought to be allowed to drop off themselves, as they retain life for a longer period than sphacelated parts arising from active inflammation. This species of mortification, even if cured, is extremely liable to return, to pre vent which the diet must be nutritious, with a good allowance of wine, and the feet warmly clothed, in a moderate temperature, and kept as much as pos sible on a level with the body.
The same peculiar mortification, characterized by simple symptoms, sometimes supervenes to a generally diseased condition of the arteries and veins, in which they become plugged up with coag ula of blood interrupting the circulation. This re quires the same kind of treatment as the last; and in neither is amputation admissible.
In a few cases, mortification occurs from the ar terial circulation being too feeble, in consequence of some disease of the heart; and in others, from both the arterial and venous circulation being impeded by tumours growing around the aorta and versa cava.
Mortification sometimes ensues when the princi pal artery or a limb is secured by ligature in wounds, or in aneurism, in which case, the heel generally first affected from the pressure becomes black in colour, the cuticle vesicates, and the whole foot cold, lifeless, and of a leaden colour. The gangrene then extends rapidly along the leg, exci ting excruciating pain, profuse suppuration, and hectic fever, which soon put an end to the patient's sufferings. The same result occasionally takes place when the blood, in diffused false aneurism, presses on the contiguous nerves, arteries, veins, and lymphatics, or even in circumscribed false or true aneurism from the inosculation of the smaller arteries being unable to carry on the circulation; the two last cases are, however, extremely rare.
The treatment of mortification from these causes is to support the circulation by bandage and warmth; and when these fail, amputation is the only alterna tive. Mortification also occasionally follows gun shot wounds destroying the principal artery or vein, or artery and vein conjointly of a limb, and is evinced by a similar train of symptoms, only they advance with more rapidity, and require earlier amputation.
Mortification also occasionally occurs from long continuance in bed, in protracted fevers, in com pound fracture of the bones of the thigh and leg, and from the destruction of the spinal cord in con sequence of fracture of the vertebra:; in which cases, those parts of the body which sustain the greatest pressure, are affected, as in the region of the sa crum. To prevent pressure producing mortifica tion in such cases, various contrivances are resorted to; pillows of feathers, down, distended with air, and of various shapes, are employed.
The affections of the heart have been already treated of in the Article MEDICINE, Vol. XIII. p. 44, and the only one admitting of a surgical opera tion, is dropsy of the pericardium, which, when the diagnosis is certain, is performed as follows: an incision is made between the fifth and sixth ribs between the integuments, but in such a way that the skin may afterwards act as a valve, and ought therefore to be pulled upwards. The greater pec toral and intercostal muscles are then to be cau tiously divided, the operator keeping sufficiently distant from the sternum, so as to avoid the inter nal mammary artery. In this division of the mus cles, the pleura costalis will most probably have been divided, as the pericardium will be generally found adhering to it; the latter is now seen distend ed with fluid, and is to be opened carefully with a lancet or bistoury, making a small aperture, when the fluid will exude. If the pericardium does not adhere to the pleura costalis, the incision in the pleura must be enlarged so as to admit the finger, which, when introduced, will feel the distended pericardium, that can then be puctured with a bis toury, guided along the finger.
A most interesting case of aneurism of the heart occurred lately, wherein a gentleman cured himself, by injecting his own respired air into the left tho racic cavity, by which he has been perfectly cured, although the symptoms were most unequivocal. He took a common ox's bladder, to the neck or mouth of which he adapted a stop-cock, and very delicate silver tube, and having filled it with his respired air, he punctured his thorax on the left side, with the silver tube, between the fifth and sixth ribs, avoiding the internal mammary and intercostal ar teries, and then injected the air into his chest. This he repeated for upwards of seventy times, and several times in our presence. We have ourselves repeated it in other cases with advantage, and con sider that it might be employed in other affections of the chest.