cease and the slough be gradually thrown off. Then it is seen that not only have the skin and superficial fascia been destroyed, but that in bad cases possibly muscles, tendons, nerves, vessels, and even the periosteum of the bones, have shared in the gangrenous process. Fortunately in many instances the deeper structures are spared, the disease being relatively limited and superficial. Sometimes, however, important structures, including joints, bones, and large blood-vessels, are destroyed; in such cases, even if life be spared, great deformity may ensue from different forms of ankylosis, or from strangulation of a distal part by a contracting cicatrix.
When the disease attacks a pre-existing wound or sore, the granulating surface of this becomes dry, and rapidly assumes the appearance and characters of a slough.
In sloughing phagedæna the neighbourhood of the sore is somewhat congested and swollen, particularly so if the patient has been obliged to use the limb. Constitutional disturbance may be considerable and of an adynamic type. On the other hand, it occasionally happens that large sores are attended with singularly slight local or general reaction. In bad cases a sapræmic condition is apt to supervene and carry off the patient; or death may occur from bleeding from the opening of a large blood-vessel.
Treatment.—It is of the first importance to endeavour to correct any cachectic state which may be present. Thus good food, fresh vegetables, lime-juice, and quinine are almost invariably indicated. Opium in full doses, not merely to assuage pain, but on account of its special action on the phagedænic process, is usually of great service. Locally, an endeavour must be made effectually to destroy the germ by the application of some powerful and penetrating caustic to the diseased surface. With this view, on the strength of considerable experience, I recommend that the patient be put under chloroform and the slough thoroughly dissolved off by the free application of pure carbolic acid, a piece of lint on a stout stick being used as a mop for the purpose.
