EMBOLISM OF THE ARTERIES 
OF THE EXTREMITIES. 
by 
SAMUEL B. WARD, A. M., M. D„ 
ONE OF THE SURGEONS TO THE PRESBYTERIAN HOSPITAL, NEW YORK, AND PROFESSOR OF 
SURGERY AT THE WOMAN'S MEDICAL COLLEGE OF THE NEW YORK 
INFIRMARY. 
[.REPRINTED FROM THE NEW YORK MEDICAL JOURN&. h. MARCH, is^_ 
NEW YORK: 
D. APPLETON AND COMPANY. 
549 & 551 BROADWAY. 
1874. PKOSPECTUS FOR 1874. 
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D. APPLETON & 00., 549 & 551 Broadway, N. Y. EMBOLISM OF THE ARTERIES 
OF THE EXTREMITIES. 
”1 
SAMUEL B. WARD, A. M., M. D., 
ONE OF THE SURGEONS' TO) THE PRESBYTERIAN HOSPITAL, NEW YORK, AND PROFESSOR OF 
SURGERY AT THE WOMAN'S MEDICAL COLLEGE OF THE NEW YORK 
INFIRMARY. ' 
[REPRINTED FROM TEE NEW TORE MEDICAL JOURNAL, MARCH, 1S74 ] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1874. EMBOLISM OF THE ARTERIES OF THE 
EXTREMITIES. 
The following case occurred in the writer’s practice last 
summer; and the rarity of such, together with the poverty ot 
the literature of our own language on the subject, are his rea- 
sons for offering this paper for publication. 
Case I. Heart-Disease of Sixteen Years’ Standing ; Sud- 
den Occlusion of Right Popliteal Artery, after an Attack of 
Endocarditis/ Apparent Improvement, and Attempt at Col- 
lateral Circulation for Two Days; Secondary Thrombosis of 
Femoral Artery, extending as high up as Pouparfs Ligament, 
at least, and occluding all the Collateral Branches ; Gangrene 
of Leg on Fourth Day • Double Diaphragmatic Pleurisy 
and Trismus on Eleventh Day ; Death on Twelfth.—D. P., 
aged thirty-two, Irish, married, plasterer by trade; has never 
had rheumatism, syphilis, or any serious illness, except inter- 
mittent fever about fifteen years ago, and diphtheria eight 
years ago. When sixteen years old he was first told by his 
physician that he had heart-disease, the character of which 
was not stated, and was advised to give up hard work and 
avoid excitement. The diagnosis has been frequently verified 4 
EMBOLISM OF TIIE 
by others, and be lias been obliged to quit work for an hour 
or two at a time, but no longer, on two or three occasions. 
August 6, 1873.—Was first called to see this patient, and 
found his stomach largely distended with gas, bowels some- 
what tympanitic, pulse 150, irregular, and intermittent. He 
was belching up a great deal of wind, and suffered slightly 
from dyspnoea. As he had undergone no unusual exposure, 
exertion, or excitement, and had been drinking freely for some 
time of lager-beer, which had disordered his stomach, and in- 
terfered with his appetite, it was thought that the derange- 
ment of digestion was, perhaps, the main cause of his trouble, 
and a mixture of hydrocyanic acid, pepsine, and bismuth, was 
ordered. 
7th, Morning. — Felt much better until latter part of 
night; stomach in better condition, but bowels constipated; 
pulse 120, and stronger. Examination of heart revealed hy- 
pertrophy of left ventricle, with dilatation, and some valvular 
disease, of the exact nature of which 1 could not be certain, 
on account of the rapid and irregular action of the organ. 
Prescribed cathartic of rhubarb and magnesia, and ten drops 
of tincture of digitalis every four hours. 
Evening.—Bowels have moved, and feels more comfort- 
able. 
8th.—Extreme suffering from dyspnoea during past night. 
Urine examined and found normal; no oedema of lower ex- 
tremities at any time. This morning Prof. A. L. Loomis saw 
him in consultation; confirmed the previous diagnosis, and 
added, as the nature of the valvular trouble, aortic obstruc- 
tion, aortic regurgitation, and mitral regurgitation, and endo- 
carditis was also supposed to exist. A purge was ordered of 
ten grains each of calomel and rhubarb, with five grains of 
quinine.* For the tincture of digitalis we substituted tea- 
spoonful-doses of the infusion of the fresh leaves, with eight 
grains of bitartrate of potash, every two hours. 
11th.—Patient has improved steadily since last date, and 
ate, with relish, a beefsteak for his dinner at 12 m. to-day. 
Bowels quite loose. At 1.30 p. m. I was sent for in haste; but, 
beino; out at the time, did not see him till 2.45. In the mean 
time Dr. Cole had been called in. I found, on reaching his AETEEIES OF THE EXTEEMITIES. 
5 
bedside, that at half-past one, while walking across the floor, 
he had experienced a sense of numbness in the right leg, re- 
marking that he had no control over it. This was followed, 
almost immediately, by exceedingly acute pain in the muscles 
of the calf, compelling him to lie down. Dr. Cole at once di- 
rected the limb to be bathed in hot mustard-water and vigor- 
ously rubbed, and had given him twenty drops of Magendie’s 
solution, and twenty grains of bromide of potassium, with the 
effect of only partially easing the pain. 
Examination of the limb on entering the room showed me 
that the muscles were perfectly flaccid; the skin was white as 
marble, and apparently as bloodless; and the surface, from a 
hand’s breadth above the knee to the extremity of the toes, 
perfectly cold. Pulsation could be felt in both tibials of the 
left limb ; on the right side no pulsation could be felt below 
the opening in the adductor magnus, for the passage of the 
femoral. The popliteal could not be felt on either side, on ac- 
count of the muscularity and fatness of the patient. Dr. Cole 
says that, when he first examined the limb, the muscles of the 
calf were hard and contracted, and that there were well- 
marked muscular twitchings. These disappeared after the 
first dose of morphine. The limb lay on its outer aspect, was 
flexed at the knee, and at certain points the epidermis had 
been separated by the friction. Sensation was very much di- 
minished, if not absolutely destroyed; and it was only after 
repeated efforts, and with considerable pain, that the patient 
was able to make the least movement of any portion of the 
limb below the knee. An effort to straighten the limb caused 
excessive pain. The patient’s general condition was indica- 
tive of acute suffering. His head and upper extremities were 
bathed in perspiration, and he tossed about the bed inces- 
santly, begging some one to shoot him to put him out of his 
pain. 
The diagnosis was made of embolism of the right popliteal 
artery by a clot or vegetation, from the valves of the heart. 
The immediate indication was, to relieve the pain; the danger, 
that of gangrene and its complications. 
To ease the patient, it was necessary to give two grains of 
morphine, hypodermically, in the course of two hours, in fif- 6 
EMBOLISM OF THE 
teen-drop doses at intervals of twenty minutes. The limb was 
wrapped in cotton-wadding, bottles of warm water placed near 
it, and the patient directed to keep as quiet as possible. 
Dr. Loomis saw the patient again at 9 f. m., confirmed the 
diagnosis, and suggested that the morphine might be supple- 
mented from time to time with hourly doses of thirty grains 
of bromide of potassium. Weak milk-punch was ordered, 
and, as he was fully under the influence of morphine, as indi- 
cated by itching and contracted pupil, no more was given, 
though he had not yet slept. 
12th, Morning.—Comfortable night, sleeping most of the 
time, ate some breakfast; no headache or nausea. Natural 
warmth has extended down as far as the knee-joint, and there 
is great tenderness on pressure in the popliteal region. No 
redness, swelling, or tenderness, over the femoral vessels. In 
testing the sensibility of the skin, the line limiting it was 
found to pass irregularly around the leg, at an average of 
about four inches below the knee; slight purplish discolora- 
tion of the skin, corresponding pretty accurately with the in- 
sensible portion, and caused apparently by extravasated blood. 
Moving the limb caused great pain ; but the patient could 
himself raise the whole extremity without much inconvenience, 
and without moving any joint below the hip. 
Evening.—Patient lias eaten moderately during the day 
and been comfortable. No marked change in limb. 
loth, Morning.—Passed a good night. This morning nat- 
ural warmth has extended down about four inches farther 
than yesterday; sensation is extending slowly downward, and 
the discoloration is fading a little above. In other words, 
there is every appearance that collateral circulation is being 
established. No arterial pulsation can be felt at a lower point 
than previously. General condition good; eats well; and 
sleeps well with the aid of morphine. 
At 1 o’clock p. m. Prof. H. B. Sands saw the patient in 
consultation, and we concurred in a favorable prognosis as to 
the salvation of the limb, grounded on the facts above stated. 
llth.—Condition of limb slightly worse. Discoloration 
deepening and extending, and above it is a zone, about six 
inches wide, of liypercestliesia. General condition good in 7 
ARTERIES OF THE EXTREMITIES. 
every respect. No pulsation can 1)C felt in the femoral be- 
low the middle of the thigh. Heart’s action less regular and 
weaker. Morphine again; and prescribed digitalis, and two 
grains of quinine every two hours. Ordered plenty of strong 
beef-soup, or mutton or chicken broth, milk and eggs, and half 
an ounce of brandy every two hours. 
15th.—Patient worse, weaker and delirious. No pulsation 
can be felt in the femoral even at the groin. There seems to 
be thrombosis of the artery extending upward from the occlu- 
sion. Dr. Sands saw the patient again, and it was found that 
a surgical needle could be run its entire length into the calf of 
the leg without the patient’s knowledge, and that no blood 
followed its withdrawal. The prognosis had therefore to be 
modified; the patient must necessarily lose his limb, and little 
hope was entertained of his recovery. A proposition for im- 
mediate amputation was unhesitatingly rejected. Carbolic- 
acid ointment to combat gangrenous odor. 
16^.—Little change; delirium less. Phlyctenulas appear 
on gangrenous skin, tilled with dark-colored serum. Urine 
again found normal. 
11th.—Worse; incessant incoherent talking, and picking at 
the bedclothes. Tongue coated, but not dry; no sordes. 
Limb about the same. Seemed for the first time to have 
fever; temperature 99.6° in axilla. Brandy increased to an 
ounce and a half every two hours, and all the nourishment 
ordered that he could take. 
V&th.—Stronger and less delirious. Bowels have moved 
well. Temperature 99.2°. 
19<th.—Ho important change. Line of demarcation indi- 
cated by enlarged blood-vessels at a hand’s-breadth below the 
knee. Slight erysipelatous blush on outer side of knee, which 
was painted with iodine, and five drops of the tincture ferri 
chlor. was ordered every two hours. 
20?A.—Ho change. 
21 it.—Yery restless night; delirium worse; pain more 
severe, and met by morphine. Erysipelas disappearing. 
22d.—Miserable night on account of pain. Delirium 
worse, and of lower type. Detected a commencing pleurisy at 
base of left lung. At noon he was unable to open his mouth, 8 
EMBOLISM OF THE 
or protrude liis tongue in the usual manner; respiration 60 
per minute and shallow; temperature 104.5°. At 5 o’clock 
p. m. Dr. J. It. Learning saw him in consultation, and found 
diaphragmatic pleurisy on both sides ; confirmed the diag- 
nosis of aortic obstruction and regurgitation, but could find no 
mitral disease. Agreed to give him thirty grains of calomel; 
but when an efiort was made to do so it was found impossible 
on account of trismus. At 9 o’clock p. m. he could recognize 
no one, was restless, but not suffering. 
23d.—At 2 o’clock a. m. he died, perfectly quietly. 
On account of the feelings frequently expressed by the pa- 
tient during his lifetime, it was impossible to obtain permis- 
sion to make any post-mortem, examination whatever—a cir- 
cumstance much to be regretted. The symptoms, however, are 
so clear that there can be no reasonable doubt of the diagnosis. 
For the history of the literature of this subject the reader 
is referred to M. Dumaz’s “ Thesis for the Degree of Doctor 
of Medicine,” Paris, 1872; and to a paper by Dr. John A. 
Lidell, of this city, in the American Journal of Medical 
/Sciences, January, 1873, page 37. Those who have contrib- 
uted most to elucidate it, and the kindred subject of throm- 
bosis, are Dupuytren, Cruveilhier, Yirchow, Carswell, Le- 
groux, Billroth, and Colmheim. 
Etiology.—There is no doubt that disease of the left side 
of the heart is the principal cause of embolism in the systemic 
circulation. We have only been able to find one case re- 
corded as the latter, in which the former was not known 
to exist, and in every ease in which an autopsy was made the 
diagnosis was verified. In the exceptional case 1 the occlud- 
ing body was a portion of an atheromatous patch on the ab- 
dominal aorta, which lodged at the bifurcation of that artery, 
and occluded the left primitive iliac. 
Now, rheumatism is recognized as being the chief cause of 
heart-disease; but it will be noticed that, in the case wlich is 
the foundation of this paper, there had been no previous at- 
tack of this nature; and the comparison of some twenty-five 
published cases shows that chronic endocarditis is more likely 
to cause the accident than the acute form which accompanies 
1 *• These deM. Ch. Benni,” Pari*, 1867. ARTERIES OF TIIE EXTREMITIES. 
9 
rheumatic fever. After chronic endocarditis, the result of no 
special disease, follows acute rheumatism ; then the puerperal 
state; and lastly gout, pleurisy, and the abuse of alcoholic 
drinks. 
In this connection an interesting question arises: AVhy does 
gangrene so frequently follow embolism, while ligature of the 
same artery at the same point is comparatively free from this 
danger ? The explanation is, that in the case of ligature the 
thrombus, which immediately forms, extends no farther than to 
the nearest collateral branch; while in a case of embolism the 
previously diseased and weakened heart propels the blood with 
so much less velocity, and under so much less tension, that the 
collateral arteries are not well dilated; and again, the throm- 
bus, which forms above the occlusion, extends upward, consti- 
tuting what is known as secondary arterial thrombosis, and 
occludes the collaterals. In the case here reported, the prog- 
ress of this complication, and its direct influence on the con- 
dition of the limb, were plainly noted at the time. 
Embolism occurs more frequently in females than males; 
is most common between the ages of twenty and forty, but by 
no means restricted to that period; and is more frequent in 
the lower extremity than the upper, and somewhat more so on 
the left side than the right. 
Pathological Anatomy.—Virchow, Panum, Weber, Bill- 
roth, and Cohnheim, have taught us most on this head. The 
researches of the latter1 are the most recent that have been 
published. They confirm previous conclusions in many re- 
spects ; but show, on the other hand, that haemorrhagic infarc- 
tion is due, not to collateral arterial fluxion, as Virchow and 
Bindfleisch teach, but to a retrograde movement of the blood 
in the veins of the affected district; and, further, that the 
escape of blood takes place through the mechanically intact 
walls of the vessels, and not subsequent to a rupture of the 
latter. The result of embolism is shown to be serious if the 
occluded vessel is a terminal one; and may be slight if it re- 
ceives collateral branches beyond the point of occlusion. 
An autopsy in case of death, soon after embolism, shows 
the light-yellow, firm, fibrinous clot which caused the obstruc- 
1 “ Urtersuclmngen liber d'e ercboliscbcn Processe,” Berlin, 1872. 10 
EMBOLISM OF THE 
tion, situated usually, though not always, at the bifurcation of 
an artery. Above and below this, the vessel is filled with a 
soft, dark-colored clot, the length of which depends upon cir- 
cumstances. If circulation has been reestablished, it extends 
in both directions to the point where a collateral branch is 
given otf or received; if no attempt at collateral circulation 
has been made, it extends downward to the termination of the 
artery, and upward to an indefinite distance; frequently, in the 
lower extremity, as far as the bifurcation of the common iliac, 
or of the aorta itself. The vein corresponding to the obliter- 
ated artery i&sometimes filled with coagula, sometimes free. 
An autopsy mouths after embolism, and when the vitality 
of the limb has been preserved, will show the same conversion 
of the vessel into a fibrous cord which follows the ligature. 
It is also possible1 that, “if the embolus consists of pure 
fibrine,it may be dissolved; ” in which event no lesion would 
be found to show that the accident had ever occurred. 
One important step in the organization of the embolus, 
and the conversion of it, together with the wall of the vessel, 
into a fibrous cord-, is acute secondary endarteritis. In autop- 
sies, made some days after the embolism or thrombosis, this 
condition is frequently found, and was formerly supposed to 
be the cause of the trouble; it is now shown to be part of the 
process which Nature adopts to remedy the mischief. 
Diagnosis*.—This is usually easy. The symptoms are, first, 
an unusual sensation in the limb, suddenly developed, gen- 
erally amounting to pain so acute as to be the prominent symp- 
tom ; occasionally it is described as simply an itching, prick- 
ing, formication, or numbness. Frequently this comes on in the 
midst of apparent good health. In one case M. Legroux a 
noticed the disappearance of a bellows-murmur in the heart at 
the time of the occurrence of the embolism; in our own case 
the mitral-regurgitant murmur seems to have disappeared. It 
is suggested that the same explanation may be offered for 
both; viz., that the fibrinous accretion which gave rise to the 
murmur became, by its detachment, the embolus. 
To this unusual sensation is added paralysis, more or less 
1 American translation of Billroth’s “Surgical Pathology,” pp. 325, 326. 
2 “ Thfcse pour le Doctorat en MGdecine,” quoted in Dumaz’s thesis. 11 
ARTERIES OF THE EXTREMITIES. 
complete, of the limb, and to this also the patient usually calls 
attention. 
The third symptom is decrease or abolition of sensatior. 
All of these symptoms might occur with paralysis from dis- 
ease or injury of the nervous centres. 
When one adds to these, however, the three symptoms de- 
pendent on mechanical obstruction in the vessel—paleness, 
coldness, and absence of arterial pulsation ~below the affected 
point—we have a group of phenomena which belong to embo- 
lism and nothing else. As occasional symptoms we may also 
add nausea, vomiting, and muscular twitchings. The physiog- 
nomy of the patient is usually indicative of a serious lesion. 
The after-history of the case depends, of course, upon the 
result. If death ensues, the paleness of the limb gives place 
in from two to six days to violet discoloration, and the rest 
of the history is simply that of gangrene. The line of demarca- 
tion is rarely situated at the level of the embolus, but usually 
much lower down. It is not uncommon, with gangrene ex- 
tending only to the knee, to find occlusion at the bifurcation 
of the common iliac. Another point well worthy of note is 
that the constitutional symptoms are for many days so slight 
as to delude the patient and his friends into the belief that 
the lesion is not nearly so serious as the physician knows and 
states it to be. From ten to fifteen days frequently elapse 
before the thermometer indicates any constitutional disturb- 
ance, and during this period appetite and digestion are usually 
good. 
If recovery follows embolism, all the symptoms gradually 
disappear as collateral circulation is established ; and pain is 
spontaneously developed in the course of the affected artery, 
due to the arteritis already mentioned. Sometimes, however, 
circulation returns much more rapidly than would be possible 
through collaterals. M. ITallopeau records a case in which 
this occurred while he happened to be examining the affected 
limb. The color returned as rapidly as if a fine injection had 
been thrown into the main artery, an hour and a quarter after 
embolism had taken place, accompanied by natural warmth 
which soon became excessive; and at the end of three hours 
all the symptoms had disappeared. Disintegration and solu- 
tion of the clot could alone account for this. 12 
EMBOLISM OF THE 
Many mistakes in diagnosis in tliis affection have been 
made, due in part to the fact that the pathology of the lesion 
lias only recently been made out. A no less celebrated man 
than Cruveilhier1 admits having fallen temporarily into error. 
The subject which he is discussing is gangrene by cadaveriza- 
tion, and the first paragraph reads as follows: 
uIn this form of gangrene the dead parts present the ap- 
pearance of a fresh cadaver, or of a recently-amputated limb. 
It is observed particularly in the case of the death of a limb 
by sudden and complete interception of arterial blood. Such 
was the case of a female, aged forty, suffering with cancer of 
the breast, who was suddenly seized with paralysis of sensation 
and motion in the whole left lower extremity. I thought at 
first that I had to deal with a case of paralysis, and therefore 
had the limb warmed with hot linens, and friction made with 
spirits. But soon afterward, struck with the death-like cold- 
ness of the limb, with its cadaverous paleness, which extended 
to the groin and ceased abruptly with the paralysis; and hav- 
ing noticed, besides, that, at certain points, the friction had 
detached the epidermis, I at once recognized my error, and 
diagnosticated the form of gangrene which I have thought 
proper to call gangrene by cadaverization ; which the result 
was not long in confirming.” 
Cruveilhier, then, recognized that this form of gangrene 
was due to obstruction of the main artery of the limb; but 
the migration of the occluding embolus from the heart was an 
important point in the history of the disease which had not 
then been grasped. 
The records of the bTew York Pathological Society, and 
the medical journals of a few years past, both in this country 
and Europe, afford a number of cases that would be of interest 
in this connection did they not occupy so much space. 
One more point must be noticed, which is, the frequency 
of relapse; or, more correctly speaking, the probability that, 
after one artery has become the seat of an embolus, others 
will share the same fate. Schutzenberger2 records an extreme 
instance of this kind, in which there occurred, first, embolism 
1 “ Anatomie Pathologiqne,” Paris, 1862, p. 252. 
2 Gazette Medicate de Strasbourg, 1857, p. 110. ARTERIES OF THE EXTREMITIES. 
13 
of the left brachial, followed by restoration of the circulation ; 
forty days afterward, obliteration of the bifurcation of the 
aorta, followed by establishment of collateral circulation ; 
fifty-four days later, hemiplegia; and, six days after that, sud- 
den death, which was found to depend on softening of the 
brain, the result of plugging of the right internal carotid. 
Infarctions were also found in the liver and spleen. 
Prognosis.—From what has been already said, it is clear 
the prognosis is bad. The physician must always be sure that 
the heart is restored to a healthy condition before the patient 
can be pronounced out of danger. The writer has been able 
to find but one recovery in thirty published cases. It is prob- 
able that other cases have recovered, the histories of which 
have never been published, owing to the doubt that has al- 
ways been supposed to hang over the diagnosis. To the kind- 
ness of our friend Dr. "VVm. M. McLaury we owe one such : 
Case II.—Mrs. M., American, aged thirty-one, married, 
having always enjoyed fair health, went through her first and 
second pregnancies and confinements without any unusual oc- 
currence. Had never had any heart-disease. Twenty-four hours 
after her second labor, which occurred on January 10, 1865, 
she had a severe chill, and two or three hours later was sud- 
denly seized with intense pain in the right leg, which soon 
amounted to perfect agony. On examination the foot and leg 
were found to be very pale up to a line about three inches 
below the knee, and through the same extent coldness, with a 
very great diminution, if not total absence, of sensation, was 
noticed. Unfortunately, the arteries were not examined with 
reference to their pulsations. The power of voluntary motion 
was abolished, and there was a single purplish streak from the 
knee down the outer side of the leg on to the foot. 
Two days later, phlyctenulae made their appearance on the 
skin, which had then become gangrenous, and the integument 
sloughed off until the muscles, tendons, ligaments, and bone, 
were all exposed from two or three inches below the knee 
down to the line of the metatarso-phalangeal articulations, 
leaving only a narrow strip of skin with irregular borders, cor- 
responding to the previously-mentioned purplish line. The 
limb was kept covered with yeast-poultices and lying in a bed 14 
EMBOLISM OF THE 
of bran. The internal treatment was supporting and stimu- 
lating, the patient’s daily allowance being four pounds of 
fresh, lean beef made into strong broth; three eggs and a suffi- 
cient quantity of milk made into punch; and, as stimulants, 
one quart-bottle of brandy, one-half pint of sherry, and one 
pint of champagne—the latter to control nausea. The patient 
also frequently took as much as four ounces of laudanum in 
the twenty-four hours to relieve pain. 
One month after the accident the slough had separated and 
granulations appeared ; at the end of three months she was 
able to leave her bed ; at the end of five months began to go 
out-doors; gradually her health was fully restored; and at 
present a large scar is to be seen, and a granulating surface, 
rather smaller than a silver dollar, which has never healed. 
The lodgment of an embolus at the bifurcation of the 
popliteal, so disposed as to entirely occlude the anterior tibial, 
and diminish the flow through the posterior, would account 
for just what took place in this case. 
Treatment.—When embolism of the main artery of an ex- 
tremity has taken place, it has been proposed to make an effort 
to break up the clot by kneading the affected part, and thus 
allow the fragments to pass into vessels of less importance and 
facilitate their solution. The writer cannot find that success 
has ever attended such efforts. 
It has also been recommended to administer carbonate of 
ammonia in pretty large doses, with a view of dissolving the 
coagulated fibrine; and Dr. Kichardson claims that he has 
met with considerable success in thus effecting solution of 
emboli of the pulmonary artery. 
At all events, the warmth of the limb must be maintained 
in order to assist the formation of collateral circulation, except 
in those cases in which, as Otto Weber points out, there is 
danger from venous hypersemia and thrombosis; then cold 
and astringent lotions should be resorted to, first among which 
he classes lead-water. 
At the same time we must not forget the great importance 
of the heart complication which usually exists, and impart to 
the contractions of that organ additional strength and tone 
by whatever means each may consider most expedient. Digi- AETEEIES OF THE EXTEEMITIES. 
15 
talis and alcohol will probably occupy the first rank among 
these in the estimation of all. 
If all these means have failed to maintain the vitality of 
the limb, the question of amputation comes up. The danger 
of septic poisoning stares us in the face, so long as the dead 
parts are in contact with the living; and, if our patient is for- 
tunate enough to escape that, there follows the exhaustive 
process of ulceration and suppuration by which Nature removes 
the gangrenous limb, and cicatrizes the stump. For these 
reasons M. Dumaz advises the amputation of the extremity 
just as soon as gangrene declares itself by the appearance of 
violet marbling on the previously pale limb. 
We are unable to find any case recorded in which amputa- 
tion has been performed at this early period, before the line of 
demarcation is formed. 
The two latest works on surgery which are supposed to 
contain, in a comparatively small compass, the results of all 
past experience, as well as of the most recent scientific re- 
search, are Pitha and Billroth’s “ Handbuch der Chirurgie,” 
and Holmes’s “ System of Surgery.” In the first of these 
Otto Weber says,1 “ The amputation of gangrenous parts 
should, as a rule, never be undertaken until the line of demar- 
cation of the gangrene is plainly marked out by Nature; even 
then it consists often in only an unimportant assistance, in 
that one only divides the firmer tissues.” The reason given 
for this rule is, that the flaps are so very apt to slough. 
In Holmes’s “ System of Surgery,” Chas. H. Moore, in 
an article on “ Gangrene from Occlusion of Arteries,” 2 asks, 
“Should the gangrenous limb be amputated?” and answers, 
“ Surgical experience and reasoning both prompt a general 
reply in the negative.” His reasons are, that the occlusion is 
frequently at a point higher than the proposed amputation, 
that gangrene is very apt to occur in the flaps, and that the 
result of amputation is in general fatal. The vast majority 
of our American surgeons entertain precisely similar views in 
regard to gangrene in general. 
The best argument in favor of very early amputation in 
1 Op. cit., I. Band, I. Abth., I. Abschnitt, S. 566. 
2 Yol. iii., p. 407. 16 
EMBOLISM OF THE 
this particular case is, that the great danger in waiting lies in 
the extreme probability of secondary arterial thrombosis occur- 
ring, with the embolus as a starting-point; and that by remov- 
ing the limb early, and at a point sufficiently high to include 
the embolus, this may be averted. The theoretical reply would 
be, that a thrombus would immediately form at the point of 
ligation of the vessel in the amputation, and would be just as 
likely to extend upward to a fatal distance as that which 
started from the original embolus, under the given conditions 
of a weakened and diseased heart. If, in reply, it be urged 
that nothing can be supposed to diminish the chances of recov- 
ery after gangrene has fairly set in as a consequence of embo- 
lism in a patient with chronic heart-disease, we have nothing to 
say, except that in many cases where the occlusion exists at 
the bifurcation of the common iliap or of the aorta, it will be 
impossible to include the embolus in the amputated limb. 
That delay is not necessarily fatal, is shown by the fact that 
Bryant, of Guy’s Hospital, has twice successfully amputated 
the leg, in consequence of gangrene from embolism occurring 
in the course of scarlet fever, after the line had formed. 
To condense into a single paragraph the conclusions which 
may fairly be drawn from what has preceded, we may say that 
arterial embolism may be looked for especially in patients who 
have long been suffering from heart-disease, and generally 
between twenty and forty years of age; that the diagnosis is 
generally easy, paleness, coldness, and absence of arterial pul- 
sation in an extremity, being added to the symptoms which 
usually accompany paralysis; that the prognosis is very bad ; 
and, finally, that the treatment consists in an effort to break 
up the clot, if the artery be superficial, or effect its solution, 
to favor the formation of collateral circulation, and to omit no 
measures tending to strengthen and regulate the heart’s action,- 
and nourish and support the patient. Amputation is unad- 
visable until the line of demarcation has formed and extended 
deep into the soft parts, unless the attempt be made to thus 
save the patient’s life, just at the time when gangrene is evi- 
dently impending, and secondary arterial thrombosis has not 
yet extended upward to the point where the artery would be 
divided in the operation. ARTERIES OF THE EXTREMITIES. 
17 
In concluding this paper, the writer would like to call 
attention to the differential diagnosis between arterial throm- 
bosis and embolism. The symptoms of the latter have been 
already clearly set forth ; the history of the former can be read 
in any well-marked case of senile gangrene, accompanied by 
degeneration of the inner arterial coat, rendering it so rough 
that it readily affords attachment to fibrinous clots. 
There are, however, many other cases of arterial occlusion, 
followed by gangrene, on record, occurring after confinement; 
during an attack of scarlet fever, with heart-complications; in 
cancerous patients; during the course of a typhoid or other 
low form of fever; in cholera; in goitre; in peritonitis, and 
other diseases—most of which have been reported as cases of 
thrombosis. The histories of most of these cases read just like 
those of embolism, and where death has ensued tho,post-mortem 
examination has usually shown a clot of lamellated fibrine, 
situated often at the bifurcation of an artery, and no lesion of 
the arterial walls of such nature as to render probable its exist- 
ence prior to the occlusion. M. Dumaz puts the argument 
concerning the point of origin of the clot very clearly, though 
he was not the originator of it. Considering the pressure of 
blood in the arteries (amounting to about six feet of water), and 
the rapidity of the circulation (blood passing from the pulmo- 
nary radicles to the extremities in four or five seconds), it is 
almost impossible to conceive that a clot could form on the 
healthy wall of an artery ; having no inflamed or roughened 
surface to which to attach itself, it must be washed along in 
the current. It seems much more probable that the clot forms 
and grows in the heart, “ where every thing is favorable for 
the production of a fibrinous clot, the chordee tendinese, the 
columnse carnese, the play of the valves, the anfractuosities, 
the irregularity of the contractions, their lack of strength in 
the puerperal condition, typhoid fever, goitre, and other dis- 
eases.” He supposes, then, that the clot having begun to form 
behind one of the valves, protected in a little eddy, or in a 
fossa between two columnse carnese, grows until, by its increased 
size, it projects into the cavity of the heart far enough to be 
detached from its moorings, or a part of it broken oft by the 
current, and carried into the circulation. 18 
EMBOLISM OF THE ARTERIES OF THE EXTREMITIES. 
Dr. B. W. Richardson1 claims that fibrinous coagulation in 
the heart is of comparatively common occurrence before death, 
especially in diphtheritic croup, gives the diagnostic signs of 
the accident, and points out the course of treatment to be pur- 
sued. 
Dr. Barnes2 has given us a table of cases of puerperal gan- 
grene, by the remarks appended to which it is clear that he is 
not decided whether they ought not to be considered as cases 
of embolism, rather than thrombosis, at least in some instances. 
Dr. Beverly Robinson,3 of this city, in a very fair discus- 
sion of the probability of the ante-mortem formation of heart- 
clot, supports Richardson’s view, and strengthens it by the 
relation of post-mortem examinations in which its character 
was carefully observed. 
So far as we can ascertain, no one has attempted to prove 
that a fibrinous clot ever forms in the calibre of a healthy 
artery; it has simply been the custom to report the cases, to 
which we now refer, as instances of thrombosis, depending on 
extreme coagulability of the blood. If, however, they be 
classed as cases of embolism, the prognosis previously given 
must be modified, and made to depend very greatly on the 
presence or absence of heart-disease of long standing. In 
twenty-three cases which we have been able to collect, where 
it was absent, we have ten recoveries ; while, in thirty cases in 
which it was known to exist, we have but one. 
1 British Medical Journal, December 14, 1872. 
2 “ Obstetrical Transactions,” vol. iv., p. 31. 
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