195. The gangrene, mortification, or sphacelus, consequent on a wound
of the main artery of the lower extremity, is, in the first instance,
_local_ and _dry_, unless putrefaction be induced by heat. (See
_Aphorism_ 28.) The following case is a good example of this and of all
the other points laid down as principles or facts:--
A gentleman received an injury in the upper part of the left thigh,
parallel to but a little below Poupart’s ligament, from the shaft of
a van. The late Messrs. Heaviside, Howship, and Chevalier were sent
for immediately, and my attendance was desired next day. I called the
attention of these gentlemen to the _tallowy-white_ and _mottled_
appearance of the foot and lower part of the leg, and assured them that
the femoral artery was injured, and the femoral vein in all probability
also, from the rapid appearance of the first signs of dry gangrene. In
this they would not believe, until the shrinking and drying of the foot
and leg became obvious, the course of the tendons on the instep and
toes being marked by so many dark-red lines under the drying skin above
them. The amputation I recommended below the knee they would not hear
of, although they reluctantly admitted the fact of the mortification.
On the eighteenth day after the accident, blood flowed from the wound
in quantity, of a dark-venous color. This bleeding I pronounced to be
from the lower end of the artery. My three friends, in whose hands
the case was, could not understand this, and placed a ligature on
the external iliac artery, which did not arrest the bleeding. They
now, although too late, saw their error, and desired me to do what I
pleased, and a ligature secured the lower end of the artery from which
the blood flowed. The man died exhausted a few days afterward.
This is a remarkable case, deserving the most serious attention.
According to the principle laid down at first as a general rule, the
thigh should have been amputated at the seat of injury the morning
after the accident, when the signs of mortification of the foot
were obvious. But it must be borne in mind that amputations at the
trochanter major or hip-joint are most formidable and not generally
successful operations; in consequence of which I have recommended
another course, deserving, in such cases, of the most deliberate
consideration and trial. (See _Aphorism_ 29.) The leg should have been
amputated immediately below the knee, as I had ordered it to be done
in the case of Turnbull, (page 202,) because that is the part in all
such cases at which nature seems capable of arresting the progress of
the mortification, if the constitution and powers of the sufferer are
good, and equal to the calls upon them. The impairing, the destructive
influence a mortified leg exerts on the whole system is removed, and
an amputation substituted for it of comparatively little moment. When
the hemorrhage took place, the lower end of the artery should have
been tied. The upper end never bled, and the ligature on the iliac
artery was useless. In this case, it is probable, as the vein was also
injured, that the life of the part at and above the knee might not have
been preserved, and the patient would have died.
In a case of the kind in which the artery was wounded at the _lower_
part of the thigh instead of the _upper_, amputation at or just
below the wound may be the proper course; this amputation, although
dangerous, being much less so than one at the upper part of the thigh
or hip-joint. Nevertheless, amputation should not be had recourse to
unless the extension of the mortification is beyond a doubt.
196. In Aphorism 29, it is strongly recommended not to amputate a thigh
when mortification has stopped just below the knee, and a line of
separation has been formed between the dead and the living parts--an
opinion formed on a principle laid down in opposition to those usually
received by the profession at large, and which have been entertained
from the fact that amputations done under these circumstances are
commonly fatal.
Richard Cook, aged fifty, a mason, while sitting on a square block
of stone, on the 23d of February, was struck by another, which drove
the popliteal space or ham against the edge of the block on which he
sat, causing him great pain, and otherwise greatly bruising the leg,
although no bones were fractured, nor was the skin torn. The limb, on
his admission into the Westminster Hospital half an hour afterward,
was much larger than the other, and of a dark reddish-blue color,
evidently from the bruise or extravasation of blood, which appeared
to be still issuing from the vessel or vessels, as the limb continued
to increase in size, until it became at last greatly swollen. The
pulsation of neither the anterior nor the posterior tibial artery could
be distinguished through the swelling the next morning. The bowels
were opened, and a cold spirit lotion was applied to the calf and
around the leg, and the swelling somewhat subsided, the limb becoming
quite a blue-black, which, with the tenseness of the parts, distinctly
indicated the effusion of a large quantity of blood. It was soon
obvious that greater mischief had occurred than had been expected;
and on the 2d of March, as vesications, filled with a bloody fluid,
were formed on the outside of the leg, over the fibula, and the whole
limb was manifestly about to pass into a state of gangrene, if it had
not already done so, I prepared everything for tying the popliteal or
other arteries, if found necessary, and made a long and deep incision
on the outer and back part of the leg, through the integuments and
muscles posterior to the fibula, and removed a considerable quantity of
coagulated blood from between the muscles and from a large cavity which
extended upward into the ham, without causing further hemorrhage; in no
part of that cavity could an artery be felt. The patient’s countenance
and body had assumed a jaundiced hue; the pulse was very quick; the
tongue foul; the countenance sunken; the skin hot; the head wandering.
Poultices of linseed-meal and stale beer were applied, with gentle,
stimulating applications. Brandy and wine were ordered in proper
quantities every hour or two, with sufficient doses of the muriate of
morphia at night to allay irritation and induce sleep. The incision,
together with these remedies, gave great relief, and on the 7th the man
seemed to have been saved from a state of the most imminent danger.
On the 8th the pulse was 112, the tongue clean, the skin of a whiter
color, the bowels opened by injections; eight ounces of brandy were
given in the twenty-four hours; wine, with sago, arrow-root, jelly,
oranges, and anything he chose to ask for. The greatest cleanliness was
observed, and the chloride of lime was used in profusion all around
him. The mortification of the limb was complete; a line of separation
formed about four inches below the knee in front, and extended behind
toward the ham. On the 26th, the dead parts having almost entirely
separated from the bones all round, those which remained were cut
through where dead, the bones were sawn about five inches below the
knee, and the lower part of the limb removed, leaving an irregular,
and, in part, a granulating stump, with an inch of bone projecting from
it. On the 24th of May this portion was found to be loose; diluted
nitric acid had been applied to its surface, and on the 20th of June
it separated. On the 16th of August Cook left the hospital in good
health, with a very good stump, having cost the hospital £57 in extra
diet. In this case, there can be little doubt of the popliteal artery
having been torn; and if the incision made on the 2d had been had
recourse to during the first two or three days, and the artery sought
for, and secured if found bleeding, it is possible the mortification
might have been prevented; although it is probable, from the pressure
arising from the great extravasation and coagulation of blood, that
the collateral circulation was so much impeded as not to have been
able to maintain the life of the limb below even during that time. The
incision made on the 2d saved the life of the patient, by taking off
the tension of the part, and relieving thereby in a remarkable manner
the constitutional irritation which hourly appeared likely to destroy
him; indeed, no one expected anything but his dissolution. When the
line of separation had formed, he was evidently unequal to undergo the
operation of amputation, in order to make a good stump, without great
risk, and the dead parts were therefore merely separated for the sake
of cleanliness and comfort. Experience has demonstrated in too many
cases of the kind that the formal operation of amputation at this time,
as recommended by most modern surgeons, would in all probability have
cost him his life.
The application of powdered charcoal, particularly that made from bog
earth, or of areca wood, or Macdougall’s disinfecting powder, or of the
disinfecting liquids now in use, such as the chlorides of lime, sodium,
and zinc, removes in a great degree the intolerable odor which renders
the room of the sufferer unbearable, and essentially interferes with
his amendment. Incisions should be made into the dead parts to allow
the evacuation of the fluids contained within them, while the parts
themselves may be removed from time to time; so that when the period
arrives at which an amputation is considered advisable, the bones, if
of the leg, may be sawn through at or below the line of separation,
and nearly the whole of the mortified soft parts removed, so as to
leave little of those which are dead and offensive. This operation is
done without the patient feeling it; it gives rise to no irritation,
inconvenience, or danger; Nature is not interfered with in her
operations; and in due time the parts which remain are separated and
fall off, leaving a stump more or less good, but which will always bear
the application of a wooden leg; and thus the knee-joint is saved--a
saving of no small importance to the patient, and a new precept in
surgery.