SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 39 



labia, feet, and occasionally the fingers, that is, in parts sup- 

 plied by no one large vascular trunk, but by many smaller 

 branches ; not only in parts distant from the centre, such as 

 the feet, but in parts which lose their heat most readily by 

 reason of their thinness and small size ; and parts irritated, it 

 may be by local discharges. Very probabl\', also, it may be 

 due to the fatty degeneration of the smaller arteries as 

 observed b^"^ Hoffman, Zenker, and Ponfick. Raymond (and 

 following him, Fischer and Estlander) ascribes it to a spastic 

 ischsemia, from contraction of the arterioles. The frequent 

 bilateral or symmetrical character of this variety, to which 

 Ka^-mond has called especial attention, would indicate, at least, 

 the probability of some such central cause. Whether, if it 

 exist, it be the direct result of irritation of the nerve-centres, 

 as is seen in the other nervous phenomena of fever, or whether 

 it be a reflex spasm caused by the circulation of a deteriorated 

 blood, similar to that to which Dr. George Johnson has 

 attached so much importance in Bright 's disease, we can at 

 present only surmise. 



The symi)toms of gangrene are marked and characteristic. 

 Towards the end of the fever, especially in the third week, or 

 earl}' in convalescence, as weakness is giving place to strength, 

 and the brightest hopes of speedy recovery are cherished, 

 sudden, severe, and persistent pain is felt. Usually it is at 

 the seat of the impending gangrene, though not uncommonly at 

 the clot itself, radiating thence to the peripher3^ In the lower 

 extremities it is often felt in the ball of the great toe or in tiie 

 heel. It is followed by numbness, coldness, loss of sensation, 

 and sometimes of motion, and in a short time discoloration 

 and all the other usual evidences of gangrene appear. Some- 

 times, but not usually, these local symptoms precede the pain. 

 If the distal vessels be examined, the pulsation will be found 

 feeble or utterly extinguished, while higher up at the seat of 

 the obstruction they will l)e changed into moderately firm but 



