The adoption of radical measures must be regulated by the progress of the case and the nature of the primary disorder present.
When amputation is determined upon, the anatomical distribution of the vascu lar supply of the part must clearly be borne in mind and an effort made to leave in the flaps, not only unobstructed vessels, if arteriosclerosis or thrombosis be present, but also a sufficient supply to insure proper nutrition. Stephen Smith. of New York (Phila. Med. Jour., Oct. 29, 'PS), recommends the following amputation when gangrene of the foot is present, and when it is decided to am putate at the knee or through the thigh. There being eight arterial branches in this region, if the incisions and flaps are suitably planned this arterial supply need not be seriously interfered with. Bis method of amputation is as follows: A straight incision is made from two inches above the upper border of the pa tella downward over the centre of that bone to the tuberosity of the tibia. From the lower extremity of this per pendicular incision two curved incisions are made, having their convexity down ward, and extending, respectively, in the direction of the external and inter nal borders of the limb. These two in cisions having been united posteriorly by a straight incision across the upper border of the calf, the flaps are dissected up from the tibia and fibula, the patella is removed, and the knee-joint is dis articulated.
It is generally thought advisable not to interfere with the reparative efforts of Nature when the line of demarkation is clearly established. When, however, in the ease of an extremity, there is no line and the morbid process ascends here and there or evenly and the patient shows evidences of impending constitu tional disturbances, the question of am putation is in order. In arriving at a decision in this connection the various reasons for an amputation should be carefully computed, namely: The nature of the causative disorder; the probabili ties as to spontaneous resolution; the subsequent deformity involved, both without and with amputation based upon the parts (muscles, nerves, vessels) already destroyed; and last, but not least, the general health of the patient. These may all prove useful in case of subsequent controversy. Severe injuries followed by gangrene warrant amputa tion if the tendency to spread is evident. When a putrescent mass, however, though the line of demarkation be present, exposes the patient to general toxemia, amputation is also warranted as soon as the signs of septictumia ap pear. Especially is this true in "trau matic gangrene." All surgeons agree that a high ampu tation is to be preferred, and the knee or thigh is usually selected because the profunda femoris is rarely obstructed by thrombi.
In SENILE GANGRENE a conservative line of treatment is indicated, since meddlesome surgery here is liable to be followed by extension of the morbid process. Attention to the healthy tis sues of the entire surface is necessary, since a minute abrasion, a slight blow, may become a gangrenous area. As taught by Thomas Jones (Med. Chron icle, Jan., 'PS), when the gangrene is limited to one or two toes and the pa tient's condition is satisfactory, the sur geon should be content with the expect ant plan of treatment, taking precau tions to lessen or prevent the effects of local septic infection. When, however, the gangrene has reached the metatar sus, he should be prepared to perform the high operation; that is, amputation above the knee. The local treatment in limited forms of gangrene should con sist in thorough cleansing of the foot and leg, free dusting of the immediate vicinity of the dead part with iodoform, and the application over this powder of sublimate or salicylic wool. The use of artificial heat in the form of poultices and fomentations is positively mischiev ous. Pain may be relieved by the inter nal administration of opium and the local application of a powder composed of boric acid, sublimate of bismuth, and hydrochlorate of morphine.
Case of synchronous amputation of both thighs for gangrene of the feet under special cocainization. The patient was a man of 6S years. Twenty minims of 2-per-cent.. solution of cocaine hydro chlorate were employed, the needle be ing entered between the fourth and fifth lumbar vertebra. The result was in every way satisfactory. G. G. Hopkins (Amer. 'Medicine, June 15, 19011.
In the treatment of DIABETIC GAN GRENE no special features are indicated. I [cidenhain, who has given the subject special attention, states that, as in senile gangrene, as long as the gangrene is confined to one or two toes the line of demarkation should he awaited and the dead tissues allowed to separate of themselves. Removal of the gangrenous portion with forceps and scissors may lead to gangrene of the parts above, al though the line of demarkation has been fully established. As soon, however, as the gangrene attacks the sole or the dor sum of the foot, an amputation of the thigh should be made as close above the eondyles as possible. Amputation below the knee is nearly always followed by gangrene of the flaps. In 11 cases of diabetic gangrene 6 were saved by thigh amputation. Two of the 3 fatal cases had large quantities of sugar in the urine (S per cent, and 5 per cent.), while the remaining 2 showed much albumin in addition to sugar. Such cases should avoid even insignificant injuries, which in them may assume seri ous proportions—precisely as in senile gangrene.