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.
197. The following cases may be considered conclusive:—
A private of the 5th division of infantry received a wound at the battle of Salamanca from a musket-ball, which passed across the back part of the right leg, from above downward and inward. It entered about two inches below and behind the head of the fibula, and passed out near the inner edge of the tibia. There was little blood lost at the time, and it was considered to be a simple wound; eight days after the injury, some blood flowed with the discharge; this increased during the night, and, on examining the limb on the morning of the ninth day, it was evidently injected with blood, which flowed of a scarlet color from both orifices. It being doubtful which vessel was wounded—whether it was the trunk of the popliteal artery, or the posterior tibial or peroneal after its division into these branches—it was thought advisable to place a ligature on the femoral artery about the middle of the thigh, which suppressed the hemorrhage. The case was now shown to me, as one in proof of the incorrectness of the opinion I had a few days before stated, of the impropriety of such an operation being done. The seeming success did not long continue; hemorrhage again took place from the original wound, and the limb was then amputated. The posterior tibial artery had been injured, and had sloughed. The man died.
Remarks.—A straight incision, directly through the back of the calf of the leg, of six inches in length, and two ligatures on the wounded artery, would have saved this man’s leg and life.