GANGRENE—FOLLOWING CONTINUED FEVER- 
DOUBLE AMPUTATION—RECOVERY. 
V. W. P. BjJTLEK, M. A. Surgeon, U. S. A. * 
'i'he rarity of this form of gangrene has suggested to me the propriety 
of presenting this paper. In consulting the literature of this disease 
I notice that this kind of gangrene is only casually mentioned by most 
authors. The varieties of gangrene classified and put down in the 
latest works, are as follows: Moist, dry, senile, white, symmetrical, 
diabetic, diptheritic, noma and hospital. 
It would be useless to attempt to define each of these forms of this 
trouble, to this intelligent body of men. Authors differ in their defini- 
tions of gangrene. Liston, says, sphacelus is complete death of a part, 
and in gangrene the larger arterial and nerve trunks still perform then- 
respective functions. They differ as to whether or not gangrene and 
spacelus are synonymous, but any such synonyms are generally con- 
ceded to be obsolete now. It is evident to my mind now, after what l 
have read on the subject, that the true cause of the gangrene in my 
case was due to an endoarteritis which created a coagula, or a thrombus 
that cut off the circulation, which induced gangrene. Pepper in his 
extensive and elaborate work, says it is due principally to acute 
arteritis following the low forms of fever. Wood mentions very briefly 
this also. Obstruction of the veins very seldom causes gangrene. This 
inti amatory condition of the arteries, Pepper says, cause a thrombus, 
and he noticed that a thrombus is composed of fibrin and blood corpus- 
cles similar to a blood clot. The causes that produce a thrombus- 
induce a rapid destruction of the white corpuscles. 
Ilarie has called attention to the frequency with which acute inflam - 
matory arteritis follows fevers, typhoid especially. He says the arteries 
mostly affected are the femoral, posterior tibial, and the dorsal artery 
of the foot. In my case, the posterior, tibial and the dorsal were 
involved, which created a foreign body that brought on gangrene. 
Barie has classified two kinds of arteritis, namely, acute, obliterating 
arteritis, and acute parietal arteritis. The former characterized by 
embryonal infiltration of all the adjoining tissues, a secondary thrombus 
forms, and the muscles and skin lose their symmetry, become stink, 
and of a reddish black hue, with temperature much lowered and 
accompanied by pain. This form, he says, almost invariably termina- 
tes in gangrene. The acute parietal arteritis does not have such 
serious consequences. My case, when I first saw it, presented precisely 
* Head before S. C. Medical Association, April 21, 1889. 2 
Gangrene—Following Continued Fever—F. W. F. Butler, M. D. 
the same symptoms which Barie says follows acute obliterating arte- 
ritis. Therefore, I am led to conclude that the true cause of this case 
of gangrene was aoute obliterating arteritis, following a case of conti- 
nued fever, from which the patient was convalescing when I first saw 
him. 
Case.—On the morning of November 27th, 1888, I was called some 
miles into the country to see M. M. ..Ft. 2S Family history, as far as 
I could ascertain, was good, with probably two exceptions—his grand- 
mother and an uncle, I learned, had died with a trouble very much 
like the one from which he was now suffering. On entering the cabin, 
1 found my patient lying over in a dark corner; he was very much 
emaciated, weak and covered over with four or five heavy quilts. As 
soon as 1 entered the hut I recognized the characteristic gangrenous 
•odor. I uncovered the affected limb, and soon found that my olfactory 
had told the truth. For l discovered a cold, darkened leg, insensible 
to the touch of my hands, or to the prick of a pin. The line of de- 
marcation had first begun to be formed, and I should have amputated 
.then, but was compelled to endeavor to revive the dying leg. The 
family told me he had been sick two or three weeks, and had been 
attended by a physician in the neighborhood, who had given up the 
.case. 
I was certain 1 had a case of gangrene, with no lesion or traumatism 
to cause it. i really did not know the true cause then, but told them it 
was gangrene, and I would endeavor to save it, but thought it was too 
late, I dressed the leg antiseptically and with warm applications, and 
put the patient on tonic pills of iron, quinine and strychnia, for then he 
was suffering no bowel or stomach trouble, but was intensely weak and 
reduced, also ordered small quantities of milk punch regularly and 
often. I did my utmost to save the limb but told them, after the second 
visit, that on my next visit the leg would have to (mine off. for now the 
line of demarcation had fully formed and the odor was terrific, and I 
saw that, under the existing circumstances, pyaemia would soon set in. 
.So, on the 4th of December, 1888, accompanied by Drs. Hill and 
Tompkins, I repaired to the place to amputate. I forgot to mention, 
that when I first saw the man, I also found him suffering from an 
immense putrid black, nasty smelling bed-sore in the lower part of the 
back near the prominent portion of sacrum, this was protected as well 
as the circumstances would permit. I used as an anaesthetic half 
chloroform and half ether, and the patient took it well under Dr. Hill’s 
guidance. I amputated about six inches below the thigh joint, as 1 
was fearful of a recurrence of the gangrene, so did this to prevent, if I 
could, such an unfortunate state of affairs, i made part skin and part 
muscular flaps. The parts were brought together with wire, and a wet 
sublimated dressing (1-2000) and applied over the stump on top of the 
wet dressing carbolized gauze and borated cotton with bandages over 
all. The patient stood the operation well, notwithstanding his great 
weakness and depletion. I remained in the neighborhood that night, 
and he passed a tolerably good night. The whiskey and milk were 
increased, as was the quinine. The bed-sore mentioned above was Gangrene— Following Continued Fever—F. IF. P. llutler, M. D. 
3 
dusted over with iodoform and wheat flour and protected from the bed. 
This enormous bed-sore added to the magnitude and apparent hope- 
lessness of this terrible case. The patient was delirious, wandering 
and feverish for four or live days, pulse weak, quick and thready. I 
then put him on tincture of digitalis combined with the whiskey. 
Everything went on as well as I could expect until the fifth day, when, 
owing to a rise in the temperature and an unpleasant odor of the 
stump, I dressed it. Much to my regret, I found the femur had project- 
ed, then the flaps and the parts were in a complete state of suppuration. 
Evidently the man in his delirium and restlessness rolled over on the 
stump, and the bone pushed through the skin. I now determined 
to apply a dry dressing of sublimated gauze and did so. In the mean- 
time I did all i could to protect th * bed-sore, but found a hard job, 
for two more bed-sores of a gangrenous character now appeared on 
each hip-bone, to which I also applied iodoform and protected them 
with pillows as best we could. These bed-sores gradually sloughed off 
and began to granulate. 1 gave him as a nourishment bovinine and 
milk, with soup and light diet. Fortunately for me and my patient, 
his stomach never failed him once, and he took everything apparently 
with relish, lie was doing well, the bed-sores healing and the project- 
ting bone gradually disappearing by healthy granulating tissue. After 
the febrile state had subsided to some extent. I prescribed Rx-Sulph. 
s try eh. grs. j. sol. ferrous null ?i.. M. S. 15 gtts. ter in die. The 
quinine grs. iii, was kept up continually. 
I was just beginning to congratulate myself, as I now thought my 
patient was good to recover, but lo and behold, on the third week after 
the first amputation the other foot began to pain and get cold. I at 
once began warm applications, and tried every conceivable plan to save 
this leg. but all my efforts were futile. So soon as the line of separa- 
tion began to form, I determined to operate, and. in fact, the poor 
unfortunate negro begged me to do so. I saw that the dorsal artery 
was affected and that gangrene had begun. On the 7th of February, 
with the assistance of I)rs. Ileall and Nicholson, I amputated just 
below the knee, obtaining a good muscular flap. I concluded to dress 
this stump differently from the other, so I brought the flaps together 
with horse hair and applied a dry dressing of sublimated gauze made 
of cheese cloth. The man stood the operation well, took the same 
kind of anesthetic as given before, easily. The bed-sores were healing, 
and the patient from this on gained strength daily. The stump healed 
by first intention, and there have been no signs of a return of gangrene 
in any part of the body, lie is now doing well without his legs. 1 am 
led to conclude, from my experience with this case, though it is limited, 
and hardly enough to form opinions on, first, that, as soon as we noti- 
ce no signs of return of life to the part aflected, sometimes even before 
the line of separation, or demarcation forms, amputate high up above 
the, seat of trouble; second, that, judging from my meagre experience 
and that of my professional brethren in this town a dry dressing anti- 
septic gives the best results.