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Lectures ON CLINICAL SURGERY,
APRIL
7,
1855.
divided into two branches at that part, and of them one was torn across, like the artery, while the other was much stretched and completely obstructed. Above the situation of this injury to the vessels the veins were empty up to the part where they had been divided at the amputation, but below the injury the was
Lectures ON
CLINICAL
SURGERY,
DELIVERED DURING ,
THE WINTER SESSION OF
BY JAMES
1854-5.
SYME, ESQ.,
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.
LECTURE XIV. TRAUMATIC
GANGRENE.
to be mentioned to-day is that of James L——, who was brought into the hospital four twenty-seven, aged days ago, suffering from a severe railway injury. He was leading a horse drawing a truck into the station, when he stumbled and fell on the rails, and the wheels of the truck passed over both legs and both hands, breaking the left leg, and bruising the right knee, and causing such contusion of one hand as to require immediate amputation of three fingers with
THE first
case
parts of their metacarpal bones. sion that the left foot was cold,
It was observed on his admisand that there was no pulsation in the tibial arteries, and these circumstances, together with the presence of a large swelling in the ham from effused blood, led to the suspicion that the popliteal artery was ruptured. The limb was placed on a M’Intyre splint, and some contused wounds on the leg were dressed with water-dressing. Next day the foot and lower part of the leg remained cold, and the ecchymosis extended some distance up the thigh. I then saw the case for the first time, and had little doubt that the popliteal vessels were injured -I say vessels, for obstruction of either alone would hardly be sufficient to cause gangrene, which was evidently coming on in this case; although it is true that if there be much bruising, obstruction of the artery by itself may lead to death of the limb. As I had little doubt that the popliteal artery and vein were both injured, I should have amputated at once at a part where I could be sure the vessels were sound-viz., in the middle of the thigh, had the patient not been in such a state of prostration that there was clearly no prospect of anything but immediate death resulting from the operation, if performed then. He has since rallied to some extent, but is still so weak, that I think that even now amputation would but accelerate his death. In the meantime the foot has exhibited unequivocal signs of gangrene, in the discoloration of the integument, its total insensibility, and the want of action in a wound that exists on the dorsum. I hope that by to-morrow his pulse, and other general symptoms may be in a condition to enable us to perform the operation with some hope of success. [Next day, (Feb. 6,) the patient being decidedly improved in general condition, Mr. Syme amputated the thigh at the middle by an anterior and a posterior flap, formed by transfixion. Very little blood was lost, and the patient being under chloroform, little or no change was produced upon his pulse by the operation. He went on well for some days, his appearance, strength, and appetite improving, and the stump showing considerable union by first intention ; but the bruise which the right knee had sustained at the time of the accident gave rise to extensive abscess of the thigh, communicating with the knee-joint, and he sank on the 19th of February, under the profuse discharge which occurred when the abscess opened. On examination of the limb after the operation, considerable ecchymosis was found beneath the integuments of the ham and lower part of the thigh ; the tibia was the seat of a very i oblique fracture, extending from about six inches below the upper end of the bone, on the inner side, obliquely upwards and outwards to immediately below the articular surface for the ’I fibula on the outer side; the upper fragment was splintered
longitudinally,
I
and two long narrow pieces were separated from the rest. The fibula had been torn away from its connexion with the tibia, in the violence of the accident, and displaced some inches upwards, along with the lower fragment of the latter bone. Opposite to the upper margin of the lower fragment of the tibia, which projected backward as a sharp ridge, the popliteal artery was torn completely across, with its ends separated an inch and a half ; the popliteal vein i
I
No. 1649.
veins of the leg were extremely turgid. Mr. Syme, in speaking in a lecture of these appearances, said-] The amount of blood found effused in the limb will strike you as being very small, considering the large size of the vessel that furnished it. It is, however, well known that arteries that have been torn across bleed but to a small extent. In Cheselden’s " Anatomy" you recollect the account of a miller who had one arm torn completely off along with the scapula, yet with scarcely any haemorrhage. Various explanations have been given of the fact. Some have ascribed it to laceration of the internal and middle coats, but this is unsatisfactory. The late Sir Charles Bell, supposing that the living vessels were prevented by their vitality from opposing friction to the progress of the blood through them, accounted for the arrest of the flow in a lacerated vessel by considering it killed by the injury, and therefore opposing friction to the blood like a tube of dead matter. Finding, long ago, such difference of opinion, I endeavoured to ascertain by experiment the actual condition of a torn vessel by gradually stretching a dead artery, when I found that at a certain point the internal and middle coats gave way with a snap, leaving the external coat, which, after stretching to a considerable extent, gave way also, and the result was that each end of the torn artery was of a conical form, the part consisting of external coat alone being drawn out into a funnel-shaped process, covering the end of the tube formed by the internal and middle coats. Having since taken every opportunity that has presented itself of examining torn vessels, I find this condition never absent, and you see it is present in the parts before you. In connexion with this case, I wish to make some remarks on the subject of mortification through the effects of external violence. The injury may be so severe as to kill the part directly, by putting an end at once to circulation and nervous energy ; or, the injury being less severe, the part may have its vitality so much weakened that inflammation coming on would destroy it: inflammation thus running on to gangrene is called " gangrenous inflammation." Thirdly, external violence may cause gangrene by cutting off the supply of blood completely through its action on the main vessels of the limb. I was once asked to see a patient who had met with an accident at a paper-mill, where a wound had been inflicted on the inner side of the arm, midway between the shoulder and elbow, cutting completely through all the vessels and nerves. I saw the patient thirty hours after the accident, when the arm below the injured part had exactly the same appearance as if it had been amputated. I removed the limb close to the shoulder-joint, and the patient made a good recovery. More frequently, however, inflammation comes on and passes into gangrene; but, as I had occasion to remind you lately, when speaking of the subject of popliteal aneurism, if the principal arterial and venous trunks of a limb are both obliterated, the death of the limb is certain and rapid the intervention of inflammation; and this is what without occurred in the case which forms the subject of these remarks. So far all is easy to be understood, but the next point presents
difficulty. Gangrenous inflammation, coming
some
on in a limb that has suffered from external violence, is not always limited to the injured part, but sometimes spreads on and on, and being attended with a corresponding degree of constitutional disturbance, proves fatal to the patient. This is a very important fact. The first question to be asked is,-How far can this spreading gangrene be arrested by amputation ? You may say, this matter is settled; that cases have proved it. It may be so, but I must say that the cases ordinarily brought forward in support of this opinion are very unsatisfactory. In many cases where it has been supposed that the spread of gangrene has been checked by amputation, it has, I believe, been not gangrene, but only inflammation that was spreading. When a contused part has inflamed, and the inflammation spreads, it is impossible while the inflammation is present to distinguish between that which will prove gangrenous and that which will afterwards subside, and time alone can decide the point, which therefore must remain doubtful if amputation be performed while this state of things is present. During my short residence in London, my then excellent house-surgeon, Mr. Clover, came for me in order that I might amputate the leg in a case of spreading gangrene. The patient had been admitted into University College Hospital two days before, with his leg severely injured by compression between
356 buffers at the Euston-square station. When I saw too early, you must remember that waiting far the line of dcall below the knee was dark-coloured, and redness with marcation may take away the only chance of the patient’s life. swelling extended up the thigh; his pulse was very quick, and I am aware this subject is usually considered one of the mo:;t he was in a most uufavourable state for operation. I said that difficult in surgery, but I confess I could never see this. It is if amputation were performed then, death would be next to certainly one that you should often reflect on, that you may certain; but that, on the other hand, I was not sure that the be prepared to act without delay on the principles which should guide you, reruembering that you may not always case was really one of spreading gangrene, and therefore I judged it right to wait in hope of a more favourable opportunity. In have the opportunity of consulting your more experienced the course of a few daysit appeared that the mortification was brethren. The principles are simple and easy to be understood, not extending, and in the meantime the patient’s pulse had and if once fairly comprehend 1 will conduct you safely * come down, and he was in a fit state for amputation, which I through all difficulties. with success. accordingly performed I do not mean to deny, however, that in cases where the ganSTRICTURE OF THE Tire RECTUM. RECTUZ. grene does spread, amputation may have the effect of arresting it. Some time ago I was called into the country to see a citizen Of all the departments of specialism, certainly the most of Edinburgh, who had fallen from a stage coach, and, in addi- degraded and degrading is that which has its appropriate seat tion to a severe injury of the head, with fracture of the arm in the rectum. The derangements of this part are involved and ribs, had experienced compound dislocation of the ankle. in darkness and obscurity; they are hidden from observation Mortification had taken place on the front and lower part of and discussion, and known only to the patient and his medical the leg, which was dark-coloured and vesicated, and redness attendant. The former is, therefore, completely in the power was extending up to the knee. There were six medical men in of the latter, who may dogmatize to any extent without fear attendance, who were unanimously of opinion that the case of contradiction, and practise in any way he pleases without fear of detection. Even when the patient dies, the was desperate if left to itself; but as some of them thought there was just a chance for him in amputation, I performed it death is attributed easily to dysentery, gout, fever, or anyat the middle of the thigh, and he recovered. I am satisfied thing, in short, rather than the real cause-the effects of that that patient would have died but for the amputation; and bad practice. We occasionally get behind the scenes, and hence, while I do not deny that amputation may save a learn from the patients themselves the extraordinary liberties patient’s life in spreading gangrene, yet I would have you re- that have been taken with their purses and persons. In hosmember that the grounds upon which this opinion is generally pital practice, however, such opportunities are comparatively based are not conclusive, and that the cases in which it has rare; and I, therefore, think it right to place before you a really happened are probably much fewer than is commonly patient whose simple story will ten sufficiently plainly what supposed; and hence you ought not to be led by dread of spread- incredible proceedings take place in this department. Before ing gangrene to amputateindiscriminately while the patient is the man is brought in, however, I may remark, that the rectum in an unfavourable state for the operation, but wait, if possible, is liable to stricture of two kinds ; the one a mere simple induunder such circumstances, till either the patient’s condition is ration of the coats of the bowel, which is a rare affection; the improved, or the danger to life from spreading of the gangrene other, a thickening from malignant deposit, which I am sorry is made apparent. As a general rule, the more the gangrene to say is very common. Malignant stricture of the rectum has depends on local causes, the greater is the benefit to be anti- one feature that distinguishes it from malignant disease genecipated from amputation. In some patients the disposition to rally-viz., that it is often very slow in its progress. Its course gangrenous inflammation is so strong, that the slightest injury, is certainly sometimes rapid; but it may go on for twenty or such as a mere scratch, will induce it; and hence in case of thirty years before causing the death of the patient, as it always wounds inflicted on such persons leading to a fatal issue, a does in the end, in spite of remedies, unless he be carried off question in medical jurisprudence may arise; for while the in some other way. Both of these forms of stricture exist in patient’s death is no doubt due in one sense to the injury, yet the same situation-viz., between two or three inches from it appears unfair that the party who inflicted it should be re- the anus, where the rectum makes its turn backwards; and it sponsible for the disposition of the patient’s constitution. Just may be said, that whenever stricture exists in the rectum, it is as delirium tremens may occur independently of any injury; within reach of the finger. There is no rule without excepand hence in case of death from delirium tremens after tion: and so it is possible that stricture may occur, in rare injury, it becomes a fair subject of inquiry, how far the fatal cases, higher up; but I never met with an instance of it durresult is attributable to the violence sustained. An officer ing a practice of thirty years, in which I have had pretty good of rank, apparently in good health, entered a railway opportunities for observing this class of diseases. It is quite carriage, and had not long taken his seat before he true that it is often believed that stricture occurs at the disbecame much excited through the disagreeable conduct of a tance of four or five inches from the anus; but this depends fellow-passenger—in other words, he flew into a violent passion. on a deception. A bougie passed into a healthy rectum goes up After he had been a little while in this state, his head was ob- pretty easily till it reaches the promontory of the sacrum, served to fall forwards, and he was dead! There could be no when its progress is apt to be arrested; and the medical man, reasonable doubt that the disagreeable conduct of the other unless aware of this source of fallacy, may be led to suppose passenger was the cause of death; but at the inquest, my very that a contraction of the bowel is the cause of obstruction. I much respected friend, Sir John Liddle, stated on examina- might mention many instances of this; but one, which is partion that he had long known the deceased to be affected with ticularly striking, will suffice. It took place in the case of an disease of the exposed him to peculiar risk from old lady, whom I was asked to see by Dr. Begbie : she had mental emotion, and the jury returned a verdict of "death been between two and three years under the care of two defrom natural causes," whereas, if he who injures another is servedly-distinguished practitioners of this city, now deceased, liable for constitutional disposition, the person in fault should on account of supposed stricture of the rectum. On entering have been tried for manslaughter. You, therefore, see that in her room, I saw a large tray covered with bougies of every these criminal cases allowance must be made for the constitu- possible size and consistence. On examination, however, I tional tendency of the patient; you will also be prepared to found all the bowel, within reach of my finger, sound; and, give due weight to that predisposition in determining your con- therefore, expressed a decided opinion, that no stricture was duct in regard to practice. present. Some months afterwards, the patient died; and Dr. It is an important rule that you should be guided in choosing Begbie, and one of the other gentlemen, were present at the the time for amputating, not by the formation of the line of de- examination of the body; in which the rectum, like the rest marcation, which has been too much insisted on, and which I of the intestinal canal, was found free from contraction. The have, perhaps, myself, too often waited for, but by the general gentleman expressed great surprise, and said that not less condition of the patient. For instance, in the man whose case we than three hundred hours had been spent in introducing have been considering, we saw from the first that both the bougies, and how it was that no stricture existed he could pot popliteal vessels were in all probability obstructed, and that understand; so he proceeded to make an experiment by inthe foot must die, but he was then too weak for amputa- troducing the bougie in the same way as he had been accustion. I therefore waited till he became stronger, but not till tomed to do during life, and found, that when it had reached the formation of a line of demarcation. Had we waited a few the height of the supposed stricture, it was stopped by the days longer, such a line would no doubt have formed, but the promontory of the sacrum. When you consider the duration patient would then, in all probability, have been weaker in- of the deception, and the high standing and eminent talent of stead of stronger. As it was, he went on perfectly well, as far the gentlemen thus deceived, you will allow that this case as we can judge, until suppuration of the knee-joint of the other proves, in a very striking manner, the risk of being misled by But that any man can maintain the exsource of fallacy. leg unfortunately carried him off. While, therefore, you must of a stricture at a still higher point-for example, not let the dread of spreading gangrene induce you to operate
railway him,
-
heart, which
this istence
357 or thirteen inches up-or still more, profess to cure I say, is what I cannot understand any one capable of, unless he be extremely ignorant, or, still worse, intentionally deceiving the patient. Unhappily, however, it has long been a practice with specialists, in this class of diseases, to employ treatment directed to strictures alleged to exist in such situations. I will now show you a patient, in whom this has been done, although I firmly believe he never had anything wrong with his rectum. [The patient, W. C-, aged forty-two, residing at York, was now brought in, and stated that ten years ago he suffered from some bowel complaint, accompanied with a mucous discharge from the rectum, and that he was then sent up to London to consult a certain rectum doctor, who told him that he had a stricture of the bowel, and passed very long bougies for a distance of about thirteen inches. He remained nine weeks under his care, the bougies being introduced about four times a week. He was, however, no better, and returned to York with some medicine and a bougie which he had purchased in London by the doctor’s direction, and which he has passed himself two or three times a week during the ten years that have since elapsed. The man having left the theatre, Mr.
twelve
SOME REMARKS ON
it,
THE
AZTECQUE
AND BOSJIEMAN
CHILDREN, NOW BEING EXHIBITED IN
LONDON,
AND ON THE
,I
RACES TO WHICH THEY ARE PRESUMED TO BELONG.
BY
ROBERT
KNOX,
M.D.
NATURAL HISTORY, like other branches of knowledge, must have its philosophy; but whether owing to the extreme difficulty of investigating the laws of life, or from the circumstance that the natural history of man, as part of the animal creation, is of necessity included in the inquiry, or from both circumstances, certain it is that natural history still rests upon no philosophic basis. Aristotle’s views were more practical than theoretical; and he was no anatomist, for descriptive anatomy had not then been discovered. The fossil remains, moreover, Syme said :-] Had l told you such a tale as this myself, you might perhaps had not been disinterred, and the history of the globe was in have supposed me to be romancing; but you have now heard consequence a mystery. Leibnitz and Newton simultaneously it from the patient’s own lips. But you may say that this is threw out generalizations in respect of the living animal world an old story, and that the light has perhaps shone in upon this worthy of their great names. They discovered and formuled practitioner during the last ten years, and shown him the error the unity in form and construction and materials of all that of his ways; but not long ago, I was consulted by a gentleman lives. But bound down by teleological laws, now proved to from England, who had been just before under the charge of be absolute fictions, they fancied the appearance of life on the the same person, and treated in the same way, although his globe to be the affair of yesterday, instead of comprising within rectum was as sound as any man’s in Edinburgh. Such prac- its infinite range millions and millions of years. The bright tices should be made fully known to the public as well as to the ray of truth which lighted up their minds to a just view of profession. It may be difficult to do this in London, from nature was but a sunbeam compared to the glorious luminary a natural unwillingness to incur the hostility of vindictive itself: and yet it was the first grand step. Buffon followed, Cuvier first, neighbours, but not being influenced by any such fear, I am andLinne; next Goethe and Cuvier; or rather for although Goethe preceded him in time he did not in pub.resolved to do what may be in my power. licity ; lastly, Oken, Spix, and Geoffroy. Thus gradually have grown up sounder views of life, of the FISSURE OF THE ANUS. forms of life on the globe, of their affiliations to each other. A man, about thirty years of age, next presented himself, Something like philosophy begins to show itself in works on complaning of pain at stool, and especially for some time natural history. Still there are numerous problems which afterwards. Mr. Syme, on examination of the rectum, dis- remain quite unsolved, of which not the least difficult have a covered a fissure of the anus, with a small external pile at reference to man. As I have of late years given much attenits base. He remarked, that on looking superficially at the tion to this part of the inquiry, I have ventured to apply some -anus, there was nothing to be seen but’ a small external of the physiological laws connected with species and natural pile, which might be supposed of no importance, but which, families to two specimens of the great human family now extaken in connexion with the patient’s symptoms, induced a hibiting in London-the Aztecque and Bosjieman children. careful examination of the part, when it was found that an 1st. Mankind is composed of one great natural family, comulcerated fissure ran up from it. Mr. Syme, having introduced prising many distinct species, unalterable and unaltered by the point of the forefinger of the left hand into the rectum, time or circumstances. In this respect, as in many others, the .pushed a small curved knife into the verge of the anus, where human natural family is subjected to the physiological laws tha external pile was situated, and brought out the point of which regulate the powers of life in other natural families. the instrument into the rectum, above the upper extremity of Man forms no exception to these laws, excepting in this, that the fissure, as felt by the finger, and then drawing out the as each natural family has its peculiarities, so man also has his ’knife and finger together, divided the mucous membrane along distinct natural history. the whole course of the fissure; he then cut off the small pile, 2ndly. The originating or determining cause of species is not remarking, that if left it was apt to be troublesome. Having known; but it has continental relations-that is, each continent placed a small piece of lint in the anus, and dismissed the possesses species distinct from those of other continents. The Asiatic lion differs from the African, and the spotted panthers patient, he said :-] This case again reminds me of the rectum specialists. During and leopards of Asia, Africa, and America, are all specifically my residence in London, I was consulted by an officer, who distinct. On the vast plains of Africa roams the two-toed ’had been absent six months from his regiment in Ireland, ostrich; a three-toed analogous bird is found on similar plains under the treatment of one of them, without obtaining any of South America; the emeu of Australia differs from both, relief from the agony produced by a fissure of the anus, from and the gigantic birds of New Zealand and Madagascar, now which he was relieved in an instant by the small operation you extinct, wandered, no doubt, over plains now immerged beneath have just witnessed. This disease, though often productive of the ocean. The Asiatic elephant differs specifically from the extremely severe symptoms, might readily pass unnoticed by African, and both from the extinct mammoth, but still an one whose attention had not been directed to the subject. elephant; nevertheless, as I shall show presently, they agreed We are indebted to the distinguished French surgeon, M. generically. Now, as regards man, he also is obviously affected Boyer, for pointing it out; but his treatment, though effectual, by continental influences; for the zebra differs not more from was unnecessarily severe, consisting in complete division of the the horse than the Saab from the European, the Jew from the sphincter; after which, several months’ confinement was re- Negro, the Mongol from the Italian. quisite for recovery. So the treatment continued, till I hap3rdly. In Nature’s great scheme there is probably no such pened to discover, many years ago, that the slight incision I thing as species, every conceivable link being filled up in time; have shown you was sufficient. If the pain produced by but as this does not occur simultaneously, so gaps appear, and examination with the finger is very agonizing, chloroform the species which ought to fill them up are not to be found. gives you a ready means of overcoming the difficulty. Very When such gaps are wide, the differences are called generic. frequently the external sphincter is tightly contracted in these All this is probably an error. If we place the living species cases; if so, it is expedient to divide the inner fibres of the and the extinct together these gaps disappear; species held muscle as well as the mucous membrane, and by doing this you to be very remote approximate by means of others, until at last hardly extend the incision. No confinement or subsequent specific distinctions all but disappear. In this way the species dressing is necessary, and I do not know any operation in composing the natural families of the rhinoceros, elephant, &c., surgery where so great an amount of relief is given with so fossil and recent, have, by being placed in juxtaposition, ittle trouble, either to the patient or the surgeon. the distinctions between the ancient and present
obliterated
7,
1855.
divided into two branches at that part, and of them one was torn across, like the artery, while the other was much stretched and completely obstructed. Above the situation of this injury to the vessels the veins were empty up to the part where they had been divided at the amputation, but below the injury the was
Lectures ON
CLINICAL
SURGERY,
DELIVERED DURING ,
THE WINTER SESSION OF
BY JAMES
1854-5.
SYME, ESQ.,
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.
LECTURE XIV. TRAUMATIC
GANGRENE.
to be mentioned to-day is that of James L——, who was brought into the hospital four twenty-seven, aged days ago, suffering from a severe railway injury. He was leading a horse drawing a truck into the station, when he stumbled and fell on the rails, and the wheels of the truck passed over both legs and both hands, breaking the left leg, and bruising the right knee, and causing such contusion of one hand as to require immediate amputation of three fingers with
THE first
case
parts of their metacarpal bones. sion that the left foot was cold,
It was observed on his admisand that there was no pulsation in the tibial arteries, and these circumstances, together with the presence of a large swelling in the ham from effused blood, led to the suspicion that the popliteal artery was ruptured. The limb was placed on a M’Intyre splint, and some contused wounds on the leg were dressed with water-dressing. Next day the foot and lower part of the leg remained cold, and the ecchymosis extended some distance up the thigh. I then saw the case for the first time, and had little doubt that the popliteal vessels were injured -I say vessels, for obstruction of either alone would hardly be sufficient to cause gangrene, which was evidently coming on in this case; although it is true that if there be much bruising, obstruction of the artery by itself may lead to death of the limb. As I had little doubt that the popliteal artery and vein were both injured, I should have amputated at once at a part where I could be sure the vessels were sound-viz., in the middle of the thigh, had the patient not been in such a state of prostration that there was clearly no prospect of anything but immediate death resulting from the operation, if performed then. He has since rallied to some extent, but is still so weak, that I think that even now amputation would but accelerate his death. In the meantime the foot has exhibited unequivocal signs of gangrene, in the discoloration of the integument, its total insensibility, and the want of action in a wound that exists on the dorsum. I hope that by to-morrow his pulse, and other general symptoms may be in a condition to enable us to perform the operation with some hope of success. [Next day, (Feb. 6,) the patient being decidedly improved in general condition, Mr. Syme amputated the thigh at the middle by an anterior and a posterior flap, formed by transfixion. Very little blood was lost, and the patient being under chloroform, little or no change was produced upon his pulse by the operation. He went on well for some days, his appearance, strength, and appetite improving, and the stump showing considerable union by first intention ; but the bruise which the right knee had sustained at the time of the accident gave rise to extensive abscess of the thigh, communicating with the knee-joint, and he sank on the 19th of February, under the profuse discharge which occurred when the abscess opened. On examination of the limb after the operation, considerable ecchymosis was found beneath the integuments of the ham and lower part of the thigh ; the tibia was the seat of a very i oblique fracture, extending from about six inches below the upper end of the bone, on the inner side, obliquely upwards and outwards to immediately below the articular surface for the ’I fibula on the outer side; the upper fragment was splintered
longitudinally,
I
and two long narrow pieces were separated from the rest. The fibula had been torn away from its connexion with the tibia, in the violence of the accident, and displaced some inches upwards, along with the lower fragment of the latter bone. Opposite to the upper margin of the lower fragment of the tibia, which projected backward as a sharp ridge, the popliteal artery was torn completely across, with its ends separated an inch and a half ; the popliteal vein i
I
No. 1649.
veins of the leg were extremely turgid. Mr. Syme, in speaking in a lecture of these appearances, said-] The amount of blood found effused in the limb will strike you as being very small, considering the large size of the vessel that furnished it. It is, however, well known that arteries that have been torn across bleed but to a small extent. In Cheselden’s " Anatomy" you recollect the account of a miller who had one arm torn completely off along with the scapula, yet with scarcely any haemorrhage. Various explanations have been given of the fact. Some have ascribed it to laceration of the internal and middle coats, but this is unsatisfactory. The late Sir Charles Bell, supposing that the living vessels were prevented by their vitality from opposing friction to the progress of the blood through them, accounted for the arrest of the flow in a lacerated vessel by considering it killed by the injury, and therefore opposing friction to the blood like a tube of dead matter. Finding, long ago, such difference of opinion, I endeavoured to ascertain by experiment the actual condition of a torn vessel by gradually stretching a dead artery, when I found that at a certain point the internal and middle coats gave way with a snap, leaving the external coat, which, after stretching to a considerable extent, gave way also, and the result was that each end of the torn artery was of a conical form, the part consisting of external coat alone being drawn out into a funnel-shaped process, covering the end of the tube formed by the internal and middle coats. Having since taken every opportunity that has presented itself of examining torn vessels, I find this condition never absent, and you see it is present in the parts before you. In connexion with this case, I wish to make some remarks on the subject of mortification through the effects of external violence. The injury may be so severe as to kill the part directly, by putting an end at once to circulation and nervous energy ; or, the injury being less severe, the part may have its vitality so much weakened that inflammation coming on would destroy it: inflammation thus running on to gangrene is called " gangrenous inflammation." Thirdly, external violence may cause gangrene by cutting off the supply of blood completely through its action on the main vessels of the limb. I was once asked to see a patient who had met with an accident at a paper-mill, where a wound had been inflicted on the inner side of the arm, midway between the shoulder and elbow, cutting completely through all the vessels and nerves. I saw the patient thirty hours after the accident, when the arm below the injured part had exactly the same appearance as if it had been amputated. I removed the limb close to the shoulder-joint, and the patient made a good recovery. More frequently, however, inflammation comes on and passes into gangrene; but, as I had occasion to remind you lately, when speaking of the subject of popliteal aneurism, if the principal arterial and venous trunks of a limb are both obliterated, the death of the limb is certain and rapid the intervention of inflammation; and this is what without occurred in the case which forms the subject of these remarks. So far all is easy to be understood, but the next point presents
difficulty. Gangrenous inflammation, coming
some
on in a limb that has suffered from external violence, is not always limited to the injured part, but sometimes spreads on and on, and being attended with a corresponding degree of constitutional disturbance, proves fatal to the patient. This is a very important fact. The first question to be asked is,-How far can this spreading gangrene be arrested by amputation ? You may say, this matter is settled; that cases have proved it. It may be so, but I must say that the cases ordinarily brought forward in support of this opinion are very unsatisfactory. In many cases where it has been supposed that the spread of gangrene has been checked by amputation, it has, I believe, been not gangrene, but only inflammation that was spreading. When a contused part has inflamed, and the inflammation spreads, it is impossible while the inflammation is present to distinguish between that which will prove gangrenous and that which will afterwards subside, and time alone can decide the point, which therefore must remain doubtful if amputation be performed while this state of things is present. During my short residence in London, my then excellent house-surgeon, Mr. Clover, came for me in order that I might amputate the leg in a case of spreading gangrene. The patient had been admitted into University College Hospital two days before, with his leg severely injured by compression between
356 buffers at the Euston-square station. When I saw too early, you must remember that waiting far the line of dcall below the knee was dark-coloured, and redness with marcation may take away the only chance of the patient’s life. swelling extended up the thigh; his pulse was very quick, and I am aware this subject is usually considered one of the mo:;t he was in a most uufavourable state for operation. I said that difficult in surgery, but I confess I could never see this. It is if amputation were performed then, death would be next to certainly one that you should often reflect on, that you may certain; but that, on the other hand, I was not sure that the be prepared to act without delay on the principles which should guide you, reruembering that you may not always case was really one of spreading gangrene, and therefore I judged it right to wait in hope of a more favourable opportunity. In have the opportunity of consulting your more experienced the course of a few daysit appeared that the mortification was brethren. The principles are simple and easy to be understood, not extending, and in the meantime the patient’s pulse had and if once fairly comprehend 1 will conduct you safely * come down, and he was in a fit state for amputation, which I through all difficulties. with success. accordingly performed I do not mean to deny, however, that in cases where the ganSTRICTURE OF THE Tire RECTUM. RECTUZ. grene does spread, amputation may have the effect of arresting it. Some time ago I was called into the country to see a citizen Of all the departments of specialism, certainly the most of Edinburgh, who had fallen from a stage coach, and, in addi- degraded and degrading is that which has its appropriate seat tion to a severe injury of the head, with fracture of the arm in the rectum. The derangements of this part are involved and ribs, had experienced compound dislocation of the ankle. in darkness and obscurity; they are hidden from observation Mortification had taken place on the front and lower part of and discussion, and known only to the patient and his medical the leg, which was dark-coloured and vesicated, and redness attendant. The former is, therefore, completely in the power was extending up to the knee. There were six medical men in of the latter, who may dogmatize to any extent without fear attendance, who were unanimously of opinion that the case of contradiction, and practise in any way he pleases without fear of detection. Even when the patient dies, the was desperate if left to itself; but as some of them thought there was just a chance for him in amputation, I performed it death is attributed easily to dysentery, gout, fever, or anyat the middle of the thigh, and he recovered. I am satisfied thing, in short, rather than the real cause-the effects of that that patient would have died but for the amputation; and bad practice. We occasionally get behind the scenes, and hence, while I do not deny that amputation may save a learn from the patients themselves the extraordinary liberties patient’s life in spreading gangrene, yet I would have you re- that have been taken with their purses and persons. In hosmember that the grounds upon which this opinion is generally pital practice, however, such opportunities are comparatively based are not conclusive, and that the cases in which it has rare; and I, therefore, think it right to place before you a really happened are probably much fewer than is commonly patient whose simple story will ten sufficiently plainly what supposed; and hence you ought not to be led by dread of spread- incredible proceedings take place in this department. Before ing gangrene to amputateindiscriminately while the patient is the man is brought in, however, I may remark, that the rectum in an unfavourable state for the operation, but wait, if possible, is liable to stricture of two kinds ; the one a mere simple induunder such circumstances, till either the patient’s condition is ration of the coats of the bowel, which is a rare affection; the improved, or the danger to life from spreading of the gangrene other, a thickening from malignant deposit, which I am sorry is made apparent. As a general rule, the more the gangrene to say is very common. Malignant stricture of the rectum has depends on local causes, the greater is the benefit to be anti- one feature that distinguishes it from malignant disease genecipated from amputation. In some patients the disposition to rally-viz., that it is often very slow in its progress. Its course gangrenous inflammation is so strong, that the slightest injury, is certainly sometimes rapid; but it may go on for twenty or such as a mere scratch, will induce it; and hence in case of thirty years before causing the death of the patient, as it always wounds inflicted on such persons leading to a fatal issue, a does in the end, in spite of remedies, unless he be carried off question in medical jurisprudence may arise; for while the in some other way. Both of these forms of stricture exist in patient’s death is no doubt due in one sense to the injury, yet the same situation-viz., between two or three inches from it appears unfair that the party who inflicted it should be re- the anus, where the rectum makes its turn backwards; and it sponsible for the disposition of the patient’s constitution. Just may be said, that whenever stricture exists in the rectum, it is as delirium tremens may occur independently of any injury; within reach of the finger. There is no rule without excepand hence in case of death from delirium tremens after tion: and so it is possible that stricture may occur, in rare injury, it becomes a fair subject of inquiry, how far the fatal cases, higher up; but I never met with an instance of it durresult is attributable to the violence sustained. An officer ing a practice of thirty years, in which I have had pretty good of rank, apparently in good health, entered a railway opportunities for observing this class of diseases. It is quite carriage, and had not long taken his seat before he true that it is often believed that stricture occurs at the disbecame much excited through the disagreeable conduct of a tance of four or five inches from the anus; but this depends fellow-passenger—in other words, he flew into a violent passion. on a deception. A bougie passed into a healthy rectum goes up After he had been a little while in this state, his head was ob- pretty easily till it reaches the promontory of the sacrum, served to fall forwards, and he was dead! There could be no when its progress is apt to be arrested; and the medical man, reasonable doubt that the disagreeable conduct of the other unless aware of this source of fallacy, may be led to suppose passenger was the cause of death; but at the inquest, my very that a contraction of the bowel is the cause of obstruction. I much respected friend, Sir John Liddle, stated on examina- might mention many instances of this; but one, which is partion that he had long known the deceased to be affected with ticularly striking, will suffice. It took place in the case of an disease of the exposed him to peculiar risk from old lady, whom I was asked to see by Dr. Begbie : she had mental emotion, and the jury returned a verdict of "death been between two and three years under the care of two defrom natural causes," whereas, if he who injures another is servedly-distinguished practitioners of this city, now deceased, liable for constitutional disposition, the person in fault should on account of supposed stricture of the rectum. On entering have been tried for manslaughter. You, therefore, see that in her room, I saw a large tray covered with bougies of every these criminal cases allowance must be made for the constitu- possible size and consistence. On examination, however, I tional tendency of the patient; you will also be prepared to found all the bowel, within reach of my finger, sound; and, give due weight to that predisposition in determining your con- therefore, expressed a decided opinion, that no stricture was duct in regard to practice. present. Some months afterwards, the patient died; and Dr. It is an important rule that you should be guided in choosing Begbie, and one of the other gentlemen, were present at the the time for amputating, not by the formation of the line of de- examination of the body; in which the rectum, like the rest marcation, which has been too much insisted on, and which I of the intestinal canal, was found free from contraction. The have, perhaps, myself, too often waited for, but by the general gentleman expressed great surprise, and said that not less condition of the patient. For instance, in the man whose case we than three hundred hours had been spent in introducing have been considering, we saw from the first that both the bougies, and how it was that no stricture existed he could pot popliteal vessels were in all probability obstructed, and that understand; so he proceeded to make an experiment by inthe foot must die, but he was then too weak for amputa- troducing the bougie in the same way as he had been accustion. I therefore waited till he became stronger, but not till tomed to do during life, and found, that when it had reached the formation of a line of demarcation. Had we waited a few the height of the supposed stricture, it was stopped by the days longer, such a line would no doubt have formed, but the promontory of the sacrum. When you consider the duration patient would then, in all probability, have been weaker in- of the deception, and the high standing and eminent talent of stead of stronger. As it was, he went on perfectly well, as far the gentlemen thus deceived, you will allow that this case as we can judge, until suppuration of the knee-joint of the other proves, in a very striking manner, the risk of being misled by But that any man can maintain the exsource of fallacy. leg unfortunately carried him off. While, therefore, you must of a stricture at a still higher point-for example, not let the dread of spreading gangrene induce you to operate
railway him,
-
heart, which
this istence
357 or thirteen inches up-or still more, profess to cure I say, is what I cannot understand any one capable of, unless he be extremely ignorant, or, still worse, intentionally deceiving the patient. Unhappily, however, it has long been a practice with specialists, in this class of diseases, to employ treatment directed to strictures alleged to exist in such situations. I will now show you a patient, in whom this has been done, although I firmly believe he never had anything wrong with his rectum. [The patient, W. C-, aged forty-two, residing at York, was now brought in, and stated that ten years ago he suffered from some bowel complaint, accompanied with a mucous discharge from the rectum, and that he was then sent up to London to consult a certain rectum doctor, who told him that he had a stricture of the bowel, and passed very long bougies for a distance of about thirteen inches. He remained nine weeks under his care, the bougies being introduced about four times a week. He was, however, no better, and returned to York with some medicine and a bougie which he had purchased in London by the doctor’s direction, and which he has passed himself two or three times a week during the ten years that have since elapsed. The man having left the theatre, Mr.
twelve
SOME REMARKS ON
it,
THE
AZTECQUE
AND BOSJIEMAN
CHILDREN, NOW BEING EXHIBITED IN
LONDON,
AND ON THE
,I
RACES TO WHICH THEY ARE PRESUMED TO BELONG.
BY
ROBERT
KNOX,
M.D.
NATURAL HISTORY, like other branches of knowledge, must have its philosophy; but whether owing to the extreme difficulty of investigating the laws of life, or from the circumstance that the natural history of man, as part of the animal creation, is of necessity included in the inquiry, or from both circumstances, certain it is that natural history still rests upon no philosophic basis. Aristotle’s views were more practical than theoretical; and he was no anatomist, for descriptive anatomy had not then been discovered. The fossil remains, moreover, Syme said :-] Had l told you such a tale as this myself, you might perhaps had not been disinterred, and the history of the globe was in have supposed me to be romancing; but you have now heard consequence a mystery. Leibnitz and Newton simultaneously it from the patient’s own lips. But you may say that this is threw out generalizations in respect of the living animal world an old story, and that the light has perhaps shone in upon this worthy of their great names. They discovered and formuled practitioner during the last ten years, and shown him the error the unity in form and construction and materials of all that of his ways; but not long ago, I was consulted by a gentleman lives. But bound down by teleological laws, now proved to from England, who had been just before under the charge of be absolute fictions, they fancied the appearance of life on the the same person, and treated in the same way, although his globe to be the affair of yesterday, instead of comprising within rectum was as sound as any man’s in Edinburgh. Such prac- its infinite range millions and millions of years. The bright tices should be made fully known to the public as well as to the ray of truth which lighted up their minds to a just view of profession. It may be difficult to do this in London, from nature was but a sunbeam compared to the glorious luminary a natural unwillingness to incur the hostility of vindictive itself: and yet it was the first grand step. Buffon followed, Cuvier first, neighbours, but not being influenced by any such fear, I am andLinne; next Goethe and Cuvier; or rather for although Goethe preceded him in time he did not in pub.resolved to do what may be in my power. licity ; lastly, Oken, Spix, and Geoffroy. Thus gradually have grown up sounder views of life, of the FISSURE OF THE ANUS. forms of life on the globe, of their affiliations to each other. A man, about thirty years of age, next presented himself, Something like philosophy begins to show itself in works on complaning of pain at stool, and especially for some time natural history. Still there are numerous problems which afterwards. Mr. Syme, on examination of the rectum, dis- remain quite unsolved, of which not the least difficult have a covered a fissure of the anus, with a small external pile at reference to man. As I have of late years given much attenits base. He remarked, that on looking superficially at the tion to this part of the inquiry, I have ventured to apply some -anus, there was nothing to be seen but’ a small external of the physiological laws connected with species and natural pile, which might be supposed of no importance, but which, families to two specimens of the great human family now extaken in connexion with the patient’s symptoms, induced a hibiting in London-the Aztecque and Bosjieman children. careful examination of the part, when it was found that an 1st. Mankind is composed of one great natural family, comulcerated fissure ran up from it. Mr. Syme, having introduced prising many distinct species, unalterable and unaltered by the point of the forefinger of the left hand into the rectum, time or circumstances. In this respect, as in many others, the .pushed a small curved knife into the verge of the anus, where human natural family is subjected to the physiological laws tha external pile was situated, and brought out the point of which regulate the powers of life in other natural families. the instrument into the rectum, above the upper extremity of Man forms no exception to these laws, excepting in this, that the fissure, as felt by the finger, and then drawing out the as each natural family has its peculiarities, so man also has his ’knife and finger together, divided the mucous membrane along distinct natural history. the whole course of the fissure; he then cut off the small pile, 2ndly. The originating or determining cause of species is not remarking, that if left it was apt to be troublesome. Having known; but it has continental relations-that is, each continent placed a small piece of lint in the anus, and dismissed the possesses species distinct from those of other continents. The Asiatic lion differs from the African, and the spotted panthers patient, he said :-] This case again reminds me of the rectum specialists. During and leopards of Asia, Africa, and America, are all specifically my residence in London, I was consulted by an officer, who distinct. On the vast plains of Africa roams the two-toed ’had been absent six months from his regiment in Ireland, ostrich; a three-toed analogous bird is found on similar plains under the treatment of one of them, without obtaining any of South America; the emeu of Australia differs from both, relief from the agony produced by a fissure of the anus, from and the gigantic birds of New Zealand and Madagascar, now which he was relieved in an instant by the small operation you extinct, wandered, no doubt, over plains now immerged beneath have just witnessed. This disease, though often productive of the ocean. The Asiatic elephant differs specifically from the extremely severe symptoms, might readily pass unnoticed by African, and both from the extinct mammoth, but still an one whose attention had not been directed to the subject. elephant; nevertheless, as I shall show presently, they agreed We are indebted to the distinguished French surgeon, M. generically. Now, as regards man, he also is obviously affected Boyer, for pointing it out; but his treatment, though effectual, by continental influences; for the zebra differs not more from was unnecessarily severe, consisting in complete division of the the horse than the Saab from the European, the Jew from the sphincter; after which, several months’ confinement was re- Negro, the Mongol from the Italian. quisite for recovery. So the treatment continued, till I hap3rdly. In Nature’s great scheme there is probably no such pened to discover, many years ago, that the slight incision I thing as species, every conceivable link being filled up in time; have shown you was sufficient. If the pain produced by but as this does not occur simultaneously, so gaps appear, and examination with the finger is very agonizing, chloroform the species which ought to fill them up are not to be found. gives you a ready means of overcoming the difficulty. Very When such gaps are wide, the differences are called generic. frequently the external sphincter is tightly contracted in these All this is probably an error. If we place the living species cases; if so, it is expedient to divide the inner fibres of the and the extinct together these gaps disappear; species held muscle as well as the mucous membrane, and by doing this you to be very remote approximate by means of others, until at last hardly extend the incision. No confinement or subsequent specific distinctions all but disappear. In this way the species dressing is necessary, and I do not know any operation in composing the natural families of the rhinoceros, elephant, &c., surgery where so great an amount of relief is given with so fossil and recent, have, by being placed in juxtaposition, ittle trouble, either to the patient or the surgeon. the distinctions between the ancient and present
obliterated