Reprinted, from the New York Medical Journal 
for '^y 21, 1892. 
SENILE GANGRENE OB' THE TOES; 
AMPUTATION AT THE LOWER THIRD OF THE THIGH; 
RECOVERY. 
By M. S. KAK ELES, M. I)., 
NEW YORK. 
Last March (1891) I was called to see a lady, seventy 
years of age, who had been confined to her bed for three 
months. It was on the 19th of the month when I first saw her 
and received from her the following history : For twelve years 
she suffered with pains in the lower left extremity, which she 
supposed were due to a varicose ulcer situated a little above the 
external malleolus which now and then healed over, but oftener 
was in an open condition. During the latter part of the three 
months that she was bedridden the ulcer had healed, but the 
pains persisted around the ankle joint and foot. She had been 
treated for rheumatism until a small dark spot appeared on the 
big toe, about a week before I first saw her. The physician 
then had diagnosticated commencing gangrene, and ordered 
poultices to the parts; this had been kept, until I was called in. 
On examining the patient, one would, from her appearance, 
have judged her to be ninety years old instead of seventy. 
Anaemic, haggard, and in a debilitated condition. Appetite 
poor. The pulse fairly good, and evidenced sclerotic condition 
of the vessels. The heart was weak. No murmurs. Lungs 
normal. There was no rise of temperature. The urine, from re- 
peated examination, contained neither sugar, albumin, nor casts. 
Copybight, 1892, by D. Appleton and Company. 2 
SENILE GANGRENE OF THE TOES. 
The skin was wrinkled and in a flabby condition. Over the 
sacrum there was an abrasion of epidermis and cutis about the 
size of the palm of ihe hand, as result of continual pressure. 
The left big toe was entirely gangrenous, the second in an in- 
cipient stage of mummification. From her general appearance 
and debilitated condition, and from the character of the gan- 
grene, there seemed to me at the time no hurry to amputate the 
foot, or even the toes, until the nature of the progress of the 
disease was well established and the patient been put in a better 
condition, although I had in view at the time that an amputa- 
tion above the middle of the leg would give better results than 
removal of the toes or even the foot. 
The first indication to be met was the extreme weakness of 
the patient, and I resolved to stimulate her for a few days with 
tonics and good nourishment, in order that she could better be 
able to withstand the shock of an amputation. The gangrenous 
toes were treated antiseptically, and the course of the disease 
carefully watched until it commenced to spread to the back of 
the foot. 
As my patient had reacted well to the tonics (strychnine, 
iron, etc.), which had been given for two weeks, and the bed- 
sore taken on a healthy granulation, it then seemed that the 
time had arrived when amputation was imperative. The ques- 
tion was at what place. 
Koenig, in his Surgery, gives three causes of senile gangrene. 
1. As consequence of inflammatory stasis, resulting from 
some slight injury, in such patients who have exhibited symp- 
toms of impoverished nutrition of parts-such as coldness and 
insensibility of toes, fingers, etc. 
2. Less frequently as a consequence of marasmic thrombus 
of the capillaries without preceding inflammation which leads 
to localized mrfromification of skin and gradual spreading. 
3. Still less frequently gangrene as result of embolus or 
localized thrombus in a large arterial branch. 
I attributed in my patient the cause of the gangrene to that 
class due to thrombus in the capillaries, and, on account of the 
unhealthy condition of skin above the ankle, due to her chronic 
ulcer, thought to amputate above the seat of the ulcer-namely, SENILE GANGRENE OF THE TOES. 
3 
the middle or upper part of the leg; but still the fear that my 
flaps might slough deterred me from taking this seat of election. 
The popliteal artery was also much sclerosed, which also led me 
to believe that the higher I would amputate (without forgetting 
the serious risks taken in removing so much of an extremity) 
the better chance 1 would have of avoiding a recurrence of the 
gangrene. I decided, therefore, after careful deliberation, that 
the prognosis would be far better by amputation above the knee 
than below, through a skin which in all likelihood, from its ap- 
pearance, would have sloughed, and thus endangered my pa- 
tient's life through septic infection. 
On April 2d, as careful an aseptic operation (under a nar- 
cosis with the A. C. E. mixture) as could possibly have been 
done was performed through the junction of the middle and 
lower thirds of the femur. The circular method was used ; the 
flaps sewed with silkworm gut, and three small drainage-tubes 
inserted-one at each end, and one in the middle of the wound. 
The stump dressed, and patient put to bed with a good pulse. 
She rallied well and primary union obtained, except where 
drainage-tubes were inserted. After four weeks the patient 
was walking around on crutches, and said she felt better than 
she had in the last twelve years. She left the city perfectly 
happy that she could once more walk about. 
I report this case to confirm the value of Haidenhain's con- 
clusions that amputation through the thigh, when once senile 
gangrene has commenced in the toes and spreads to the foot, is 
far better (barring contra-indications) than running the risk of 
rapid sloughing of flaps in a lower operation.