having continued still cold, he returned to his work, and for five hours during the afternoon was engaged cutting off the horns from the hides, whilst he held the latter in his left hand. Towards the latter part of the afternoon he felt cold all over, and, when he had returned home, feeling his left hand very cold, and being unable to straighten his fingers, which had stiffened as he held the skins; but neither the fingers nor hand were yet discoloured. He put his hand into lukewarm water; but could not bear it immersed on account of the great pain excited, which was also brought on by holding the hand to the fire. Indeed, he was only easy when the hand was cold, and could not even bear it beneath the bed-clothes, but was obliged to keep it out upon the counterpane. Before putting his hand and arm into warm water, there was not any apparent change in colour; but, after the first and every succeeding dipping into warm water, the hand became red and redder, and more painful.

On the 25th ult., when he awoke in the morning he noticed the nails were blackening about their roots; but he was free from pain, though the hand was very cold and numb, and was not prevented going about a little job.

On the 26th he again tried immersion in warm water; but the pain recurred, and the terminal joints of all the fingers and thumb had now become black. The mortification continued spreading; repeated applications of warmth always excited pain, and he was more easy in proportion to the part being kept cold.

On the 30th the mortification, having continued along the fingers, just entered the palm, and he began to suffer constant pain.

On Feb. 2, the hand had mortified up to the wrist; the pain was so gnawing and severe that he could not rest, and was accompanied with severe head-ache. He applied to a medical man, who bled him twice in the same day from the ailing arm, but did not get more than a pint of blood, and ordered warm applications.

Feb. 3. During the last night the gangrene had extended about one-third of the forearm upwards; has a dark colour, which terminates abruptly; is perfectly cold and insensible. He complains of pain in the head, aching and weariness of the limb, loss of rest at nights, general weakness, and failing appetite; he suffers much from thirst; his tongue covered with white fur, and the bowels confined; pulse 120, regular and weak, but perceptible at both wrists. A dose of infusion of senna with sulphate of magnesia was ordered forthwith; meat, and a pint of porter daily; warm fomentations and linseedmeal poultice to be applied to the hand.

Feb. 4. Altogether more comfortable. The bowels have been freely relieved; his tongue is cleaner, and the head-ache lessened. Is to have four ounces of brandy and two pints of porter daily.

Feb. 5. Is much the same; but feels very weak, though his appetite is improving. No pulsation can to-day be felt in the wrist of the ailing arm. The heart was carefully examined to-day, and its action and sounds ascertained to be natural. Is to have a mutton chop and two eggs, with three pints of porter, daily. R tinct. opii mxx. sp. ammon. comp. 3j. ex mist. camph. 6tis.

Feb 15. The gangrene has not spread since the last report; the line of demarcation between the living and dead parts is now apparent, and some vesication has occurred round the arm. The ulcerative process has continued steadily, and has now,

March 8, completely passed through the soft parts down to the bones, forming a regular well-shaped stump, the whole of which is granulating kindly. The gangrenous part has much the appearance of brown paper, and, though a little shrivelled, keeps its form, but is very offensive. It was therefore thought advisable to saw through the dead bones and remove it, which was done accordingly. His health has been steadily improving; he has scarcely had an untoward symptom, his head only aching occasionally; he sleeps well, and enjoys his food.

March 31. Wound cicatrizing, and there seems every prospect of his doing well.}

105. If a part frozen or benumbed by cold be too suddenly warmed, severe inflammation is the result; the part swells, becomes red and blue, and active throbbing pain ensues-chilblains; pouring out of fluid into the cellular tissue, suppuration, and, in actually frozen parts, gangrene. Corresponding appearances occur on the whole body if warmth be applied after exposure to severe cold; the skin swells, becomes red and painful, red spots, gorging with blood in different parts, and, in consequence, swimming of the head, swooning, spitting of blood, inflammation of the lungs, and so on. The hasty warming of a thoroughly benumbed body produces death and rapid putrefaction.

VOL. I.

K

[ASTLEY COOPER observes on this point:-" Great care must be taken in these cases not to apply heat very suddenly; even the common heat of the bed frequently occasions inflammation, which is extremely liable to gangrene, in consequence of the diminished nervous influence of the part:" and he mentions the case of a person who "had been shooting, and had exposed himself to severe cold; and finding his feet benumbed on his return, he immediately put them into warm water. The consequence was that a gangrene took place, of which, notwithstanding every care, he died." (p. 216.) LARREY also observes that those soldiers who had been exposed to severe cold, and had opportunities of warming themselves, suffered most. The cases just related confirm these statements.]

106. In reanimating a frozen person we must always commence with the lowest degree of warmth. The frozen person should be brought into a cold room and covered up (after he is undressed) with snow or with clothes dipped in ice-cold water; or he may be laid in cold water, so howIever that his mouth and nose are free. When the body is somewhat thawed, there is commonly a sort of icy crust formed around it; the patient must then be removed, and the body washed with cold water mixed with a little wine or brandy. When the limbs lose their stiffness and the frozen person shows signs of life, he should be carefully dried; put into a cold bed in a cold room; scents, and remedies which excite sneezing, are to be put to his nose; air is to be carefully blown into the lungs if natural breathing do not come on; clysters of warm water with camphorated vinegar, tickling the throat with a feather, dashing cold water upon the pit of the stomach. He is to be brought by degrees into rather warmer air; mild sudorifics, elder and balm tea, with solution of acetate of ammonia, warm wine and so on, are to be given, in order to cause gentle perspiration.

107. In a similar way a frozen limb is to be thawed; it is to be rubbed with snow or dipped in cold water, till sensation and motion return, when it may be washed with camphorated spirit, brandy, petroleum or essence of amber; cold, mild sudorific tea may be given to the patient, who is to be put to bed in an unwarmed room, with a view to keeping up a gentle perspiration for several hours.

Frozen parts must always be handled with care, and no violence used, because they easily break.

108. When by hasty warming a frozen limb becomes much swollen, painful, red, blue, or in some parts even black and shrivelled like a mummy, and to outward appearance is mortified, it may, however, still be oftentimes recovered by the application of cold, and by gradual transition to warmth. But, if mortification have already taken place, its usual treatment must be employed. If superficial, the slough separates; but, if the whole mass of the limb be affected, so soon as the mortification is defined, amputation must be performed.

In many cases the mortified limb drops off, of itself, or the bone only has to be sawn through at the point of demarcation. It does not, however, follow that in this mortification amputation is to be rejected. My own opinion as to the fortunate results of amputation performed at the proper time, and the disadvantage of delaying it, agree with those of LARREY (a).

109. Chilblains (Perniones, Lat.; Frostbeulen, Germ.; Engelures, Fr.) are erysipelatous inflammations of the skin, which, according to their degree, are accompanied sometimes with slight swelling and sensation of heat and pricking, which after a little time often subside of themselves. Sometimes they are connected with considerable dusky-red or bluish swellings and severe pain; sometimes with excoriation, arising from

(a) As above, 72.

little blisters or risings of the skin, and are often converted into widespreading obstinate sores. Chilblains may also, by great neglect, become mortified. They produce, only in winter, especially in change of weather, annoyances which are often great, and even interfere with the use of the limb; but, in summer, they subside. In any dyscracy of the body they often assume a corresponding character.

[HUNTER mentions "another inflammation very like chilblains, which is not very lively and is often in blotches, some the breadth of a shilling, others of the breadth of half-a-crown, and even broader, &c. This inflammation certainly arises from irritable debility; the blotches look more of a copper colour, and the skin over them is often diseased." (p. 265.) I have seen this appearance several times, and, in two or three instances, long streaks in the course of the superficial veins of the same character.J. F. S.]

110. Chilblains usually occur in young weakly persons, and women who are not accustomed to cold, have a sensitive and delicate skin, most commonly on the feet, hands, ears, nose, and lips, by a sudden alternation of cold and heat, especially if the part be moist and sweating. In many persons there seems a peculiar disposition for their production.

111. The treatment of chilblains of a mild kind consists in frequently rubbing them with snow, in repeated washing with ice-cold water, with brandy and water. camphorated spirit, lead wash, vinegar, acetate of ammonia, solution of hydrochlorate of ammonia, tincture of amber, diluted hydrochloric or sulphuric acid, petroleum, oil of turpentine, a mixture of rectified spirit of ammonia and laudanum, nitric acid with cinnamon water, solution of chloride of lime and so on. If they are very painful, more soothing remedies must be employed, leeches on the diseased part, cocoa, butter, deer-suet, poultices of chamomile and elder flowers, of rotten apples,bruised houseleek, various softening ointments, smearing with warm glue, and so on. Rubbing in soap liniment with a portion of tincture of cantharides upon the chilblain once or twice a day and keeping it warm, and, if it be ulcerated, the rubbing is to be applied in the immediate neighbourhood (a). The diseased part must be kept warm and quiet during the employment of these remedies.

[One of the best stimulants for chilblains is our hospital mustard liniment, consisting of one ounce of flour of mustard to a pint of turpentine.-J. F. S.]

112. Ulcerated chilblains require drying salves, lead oinment, zinc ointment, with myrrh, camphor, opium and Peruvian balsam, red precipitate of mercury ointment, and, if the flesh fungates, it must be touched with lunar caustic. In old sores of this kind, issues must be employed before they close, and, if connected with any general disease, it must be properly counteracted. Many speak favorably of electricity.

Gangrenous chilbains must be treated after the general rules.

113. The occurrence, as well as the recurrence of chilblains, must be guarded against by accustoming oneself to the cold, by avoiding warm coverings, and all hasty warming of cold parts, by frequently washing with cold. water, and afterwards brushing and carefully drying them.

(a) WARDROP; in Medic.-Chirug. Trans., vol. v. p. 142.

IV. OF BOIL OR FURUNCLE.

BERLEN, Dissert. de Furunculo. Gottinga, 1797.

HEIM, Erfahrungen über die Furunkeln; in HORN's Neuen Archiv., vol. vii. p. 151. JOURDAN,-Article, Furoncle; in Dictionn. des Sciences Médicales, vol. xvii.

ALIBERT, Nosographie des Dermatoses, vol. i. p. 221. Paris, 1832. folio.

DUPUYTREN; in Leçons Orales, vol. iv. p. 109.

COPELAND, JAMES, M.D.,-Article, Furuncular Diseases; in his Dictionary of Practical Medicine, vol. i.

114. The Boil or Furuncle (Furunculus, Lat. ; der Blutschwär oder der Furunkel, Germ.; Furoncle, Fr.) is a hard, bounded, deep red, raised and very painful swelling, situated in the sebaceous follicles of the skin, occurring on all parts of the body, and usually terminating in suppuration.

A slight pain first attacks some one part of the skin, and a little swelling appears, which, as the pain increases, becomes elevated, hard, and of a deep red colour, and attains various degrees of size, rarely, however, exceeding that of a pigeon's egg. In delicate persons, and in children, or, if the boil be seated in a sensible part, febrile symptoms often arise, loss of sleep, want of appetite, convulsions and so on. The swelling becomes white at the top, it breaks, some pus mixed with blood is discharged, and then the bag of the gland together with the destroyed cellular tissue is thrown off like a grayish-white core, or set-fast, as it is vulgarly called, (Eiterpropf, Germ.; Bourbillon, Fr.,) after which the surrounding hardness

subsides.

The sebaceous glands of the skin are not contingently attacked by the inflammation in boil, if the furuncular inflammation of the cellular tissue occur in its neighbourhood (WALTHER); but the sebaceous glands are originally the seat of the inflammation, and from them the inflammation spreads into the surrounding cellular tissue, as is proved by the little hard knot out of which the boil is always developed. The boil is only one link in the changes of the sebaceous glands, produced by inflammation, and only a gradual variation from the pimples and red spots so frequent on the face. These pimples, the mere inflammation of the excretory ducts of the sebaceous glands, may be always easily removed and their passage into a little pustule prevented, if they be squeezed early, which discharges a tallow-like substance from the duct. As the pimples are connected with the boil, as inflammatory affections of the sebaceous glands and their ducts, so also the maggots (commedones) are plugs in the excretory ducts, and the little pearl-like, almost transparent vesicles, which often occur in great numbers on the face of persons with tender skin, and which, if cut into or pulled out, present a tallowy substance enclosed in a bluish-white bag beneath the skin, to the sebaceous tumours-as chronic changes of the sebaceous glands.

[GENDRIN (a) denies that cores are sloughs, but says they are morbid secretions or pseudo-membranes, the product of the inflammation of the inter-areolar cellular processes; and that they consist of a viscid semi-transparent homogeneous yellowish-white substance without any vessels and without the least trace of organization. (p. 19.)

Boils are divided by ALIBERT (b) into four kinds, each presenting special characters. 1. The Common Boil (Furoncle Vulgaire or Clou) described above. 2. The Wasp's-Nest Boil (Furoncle Guépier) is also called by some the Malignant Boil, and by others the Mild Carbuncle, though they only described Malignant Carbuncle: the two diseases, however, appear to ALIBERT decidedly distinct, and justify their separation and the arrangement of the so-called mild carbuncle with boils, of which, indeed, it is merely an agglomera tion, indicated by a hard tumour surrounded with a red and inflamed zone, and having its top covered with one or more vesicles which shew its serous character: the pain is severe, the heat pungent and burning; pulsation and fluctuation are soon felt; the skin thins, and, numerous perforations being formed, a kind of grayish sanious skin separates in flakes, or may be removed in pieces, and the tegument covering the tumour separates during its course. This form of boil generally attacks the nape and region of the neck, (a) Above cited, vol. i. (b) Quoted at the head of the article.

sometimes extends to the back and rump, and even occasionally attacks the upper limbs. When the parts confining it are set at liberty, large ulcerations occur. It is generally critical; specially occurs after gastric and adynamic affections; rarely attacks other than elderly persons, and hence has been called Old People's Boil. According to MALVANI, its course is less quick than that of the common boil; it suppurates more slowly, for vesicles do not appear on it till the third or fourth week. 3. The Pustular Boil (Furoncle Panulé) is a slightly elevated but wide swelling similar to a pustule. It is acccompanied with pain, distension, and often with slight fever. It proceeds very slowly, requiring many months, and even a year to bring it to perfection. The aperture on its top resembles that of a weaver's shuttle; subsequently the boil dries up, and, if scratched, falls into powder. It occurs in all parts of the body, and, on its subsidence, leaves an ecchymosed spot, similar to that which ushers in its appearance. Its tip is generally red, hard, very shining, and gives place to a slight serous exudation, which ceases for some time, is repaired at intervals, but the hardness continues and is only resolved by furfuraceous scales. 4. The Asthenic Furuncle of Dr. COPELAND (a) (Furoncle Atonique of GUERSENT) (b) was described in the spring of 1823 by both those physicians. They agree in having observed it in children previously much weakened by disease; in persons who are subject to gastro-enteritis with adynamic symptoms; in latent pneumonia, during the course of small pox, and so on, according to GUERSENT, and where the weakness has been caused by chronic disorder of the bronchi, or asthenic inflammation of the substance of the lungs, according to COPELAND, who adds that coma generally comes on before death, in addition to the well-marked symptoms of adynamia noticed by him and GUERSENT. The eruption appears chiefly on the trunk, the lateral parts of the neck and thighs, but, GUERSENT says, more rarely on the limbs. COPELAND states, that in the cases he has observed, "the number of furuncles has been considerable, not fewer than five or six, and in two cases they were about twenty. GUERSENT's paper, however, does not lead to the supposition that in his cases the furuncles were numerous. Both describe them to begin as circumscribed swellings, of little extent, but resistant to the touch, of a livid violet colour, but sometimes without any remarkable change in the colour of the skin. In the second stage, a very small purulent phlyctæna appears on the top of the swelling, and, when it tears, the true skin shows beneath a little grayish patch, softened and perforated through and through like a common boil. At first a bloody serous fluid exudes, the swelling softens, and the aperture in the skin enlarges, which in two or three days, and sometimes even in twenty-four hours, forms a perforation from five to six lines in diameter, completely round, and exactly like a hole which has been made with an auger. During this time the swelling rapidly subsides. The cellular tissue does not separate like a core, and rarely detaches some fragments. The bottom of the ulcer presents a grayish sanious and dryish appearance, and whilst its edge is well defined, the surrounding skin, paler and softer than natural, is entirely separated from the cellular tissue to the extent of several lines. This atonic furuncle very commonly follows leech-bites; the perforation in the skin then seems to have been made with a trocar, but this triangular form soon rounds as it spreads, and becomes completely circular, as if it had arisen spontaneously. If the leech-bites have been grouped together, and each bite have given rise to a little furuncle, the skin after a few days appears perforated at every bite, and resembles a suppurating carbuncle, but with this difference that there is neither fulness nor swelling, and that the holes are larger and more regular than in carbuncle, such as might be made by small shot. The ulceration, which is the third stage of atonic boil, is generally indolent; in some cases, however, it is painful. It remains stationary for eight or ten days, more or less, according to the general condition of the patient. When the ulcer is disposed to heal, the cellular tissue becomes moist, brightens, and becomes slightly reddened, the skin gradually attaches itself to the subcutaneous tissue; some fleshy granulations rise from the bottom of the ulcer; the aperture in the true skin diminishes a little, and, as in all ulcers of the skin, a soft scar, slightly depressed, is produced, and which, in its extent only may be compared to that succeeding a large vaccine pustule." (pp. 337, 8.) In addition to these observations of GUERSENT, it is noticed by COPELAND that the cellular tissue is destroyed by rapid ulceration or phagedenic absorption; that the ulcers have no discharge nor any tendency to scab; that, in the two cases he examined after death, no attempts at reparation were visible in the ulcerated perforations, nor any injections nor inflammatory appearances in the margins: the chief alterations were moderate emaciation, congestion, and injection of the membranes of the brain with slight serous effusion, congestion of the substance of the lungs, with limited hepatization in an early (a) Above quoted.

(b) Du Furoncle Atonique; in Archives Générales de Médecine, vol. i. Jan., 1823.