Surgical cases : with observations / by James Spence.

  • Spence, James, 1812-1882.
Date:
1854
Catalogue details

Licence: Public Domain Mark

Credit: Surgical cases : with observations / by James Spence. Source: Wellcome Collection.

    8/18 (page 8)
    burgh, I saw him with Dr Hislop ; there had been no recurrence of the bleed¬ ing. I was stiJ 1 suspicious, however, from the amount of blood lost, and the long-continued diffuse suppuration which had previously existed, that the fibu¬ la r artery might have been disorganized and given way from sloughing. I accordingly came back from town as soon as I could, and on reaching Linton I found that bleeding had just recurred to a considerable amount. Assisted by Dr Hislop and my friend Dr Littlejohn, who had accompanied me, I again ex¬ amined the wound. The extent of the incision enabled me to see the whole deep part of the wound ; on clearing which of coagula, I found the textures generally covered with firmly adherent lymph, but some of the deeper parts looked sloughy and unhealthy. The bleeding welled up from the surface of the wound, but not in a jet. The patient’s state demanded that some decided measures should at once be adopted, since direct graduated compression had failed. As to direct ligature on the bleeding point, although I suspected the fibular artery, yet, though the large incision exposed the surface of the wound fully, there was no jet or distinct indication of bleeding from any one point, whilst the disorganised sloughy condition of the deep surface of the wound rendered it more than doubtful that a vessel, even if discovered, wrould have held ligatures. There remained, therefore, only the alternatives of ligature of the femoral artery, or amputation. The latter, from the state of the patient, and the extensive suppurating surface, might ultimately be necessary even for other reasons ; but I was very unwilling to sacrifice the limb, and, more¬ over, from the faint condition of the patient at the time, he would not have been able to bear the operation. I therefore determined to tie the superficial femoral, in order to control the general circulation of the limb, and to assist it by moderate graduated pressure directly applied to the wound. The patient having been brought under the influence of chloroform, I at once proceeded to tie the vessel, which was readily accomplished without removing the patient from bed. All oozing from the wound ceased immediately. Some lint was placed over the wound, supported by a thin flannel roller lightly applied. On the second day after tying the vessel, I saw him again. He was much better, the wound looked healthy, and everything seemed to promise well, as the cir¬ culation in the anterior and posterior tibial arteries was fully re-established. All went on well till the 21st September, when I was sent for in the afternoon, as bleeding from the leg had again occurred. I found the patient recovered some¬ what from the first effects of loss of blood, which had not been to a large amount; but I felt I could no longer persevere in attempts to save the limb, as any farther bleeding might have proved fatal, since the deep part of the wound was still sloughy, a portion of the necrosed fibula close to the knee had still to separate, and the patient was exceedingly debilitated from the previous ex¬ hausting disease, as well as from the hemorrhage. It was decided to amputate the limb at the lower part of the thigh. I had foreseen that this usually simple operation would be complicated in this case, both on account of the greater number of vessels which would require ligature in consequence of the enlarge¬ ment of the collateral branches after ligature of the femoral, but especially from risk to the deligated artery itself, from any traction exercised on it during the operation, as it was about the period when the ligature begins to separate by ulceration, and accordingly had obtained the assistance of my friends Dr Handyside and Dr Littlejohn. Dr Hislop administered chloroform, and as soon as the patient was under its influence, he was carefully turned round, and drawn towards the edge of the bed, and the limb steadily supported. Dr Handyside having compressed the common femoral, I removed the limb by double flap above the knee. The mouth of the superficial femoral was readily recognised, but I first secured the enlarged collateral branches, which could not be so completely commanded by compression. Before tying the superficial femoral, Dr Handyside, at my request, relaxed the compression somewhat, and blood flowed from its mouth, but, as might be expected, not in a jet. It was then tied ; the flaps were approximated by sutures, and the