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.