Elements of Surgery

by Robert Liston

The injury is often so great as at once to demand removal of the limb. There is no alternative, when, from laceration of the soft parts, superficial, deep, or both—comminution of the bone to a great extent—rupture of large vessels—and opening of joints—either gangrene or an overpowering suppuration are rendered not only probable but almost certain. The period at which the operation is to be undertaken requires judicious selection. Some patients are not affected constitutionally even by great and violent injury, such as dreadful laceration of the limbs; whilst others, even after slight wounds, are seized with delirium, tremors, vomiting, lowness of spirits, depressed circulation, paleness of the surface, and appear on the eve either of rapid sinking or of immediate dissolution. In the first class of patients immediate amputation may be had recourse to with safety and advantage. In the second, the patient must be reassured, and stimulated both by external and internal means; in short, reaction must be brought about, and then let the surgeon operate. If he amputate before this, his patient will most probably die on the table, or very soon after his removal from it; reaction will never take place, and sinking of the vital powers be accelerated by the ill judged interference. A greater or less time is required for the occurrence of reaction in different individuals; the usual period is from two to six hours. Commencement of it is a sufficient warrant for operation; the surgeon must not delay till inflammatory fever has been lighted up, for then he will interfere with great disadvantage. He must then subdue the inordinate action as much as possible, and wait for the suppurative stage. When the patient has become hectic from profuse and long continued discharge, when, perhaps, no union has taken place—then also the limb must be removed. In civil practice, patients as often recover from secondary as from primary amputation. But according to the experience of military surgeons, the result is otherwise—many recover after primary and few after secondary; much may depend on the accommodation of the patient afterwards. A great deal must necessarily be left to the judgment, discretion, and conscientiousness of the surgeon.

Fractures of the cranium were treated of as connected with disturbance of the important organ which it protects.

The bones of the face are occasionally broken and displaced. The frontal sinus is sometimes opened by fracture of the external plate. No small degree of force is required to effect this injury:—I recollect an instance of it, with opening into the sinus, occasioned by an attempt at suicide; the man had struck his forehead violently with a large stone, wishing to knock his head to pieces. The integuments are generally divided, and, during expiration, blood, sometimes frothy, is poured out through the opening. When there is no wound of the integument, emphysema of the forehead and eyebrows has resulted from disruption of the bones that compose this cavity, or others connected with the nostrils.

The ossa nasi are fractured and displaced by direct violence. They may be broken and comminuted without much displacement, or separated from their connections and depressed without much fracture. Even slight cases are generally attended with laceration of the Schneiderian membrane, and with profuse hemorrhage from the nostrils. The soft parts over the bones are thin and tense, and consequently in many cases divided. Great swelling is apt to ensue, at first either bloody or œdematous. Inflammatory swelling to a great extent, both externally and internally, is to be dreaded and guarded against. Abscess of the Schneiderian membrane, frequently of the septum narium, occurs from slight injuries, if neglected; and, if not actively and properly treated, may terminate in loss of substance and consequent deformity of the features.

The existence of fracture of the ossa nasi is very readily ascertained; the part is distorted, being either uniformly depressed, or hollow at some points, and abruptly prominent and sharp at others. With the view of remedying deformity produced by displacement, and preventing the bad consequences already spoken of, the bones must be restored to their original position. They are to be raised by means of a strong probe or director, covered with lint, and introduced high into the cavity. Whilst, by means of this instrument, pressure outwards is made, the fingers of the surgeon are applied externally, so as to mould the organ into a proper shape. Unless force be again applied to the part, there is no risk of subsequent displacement; no apparatus is required to preserve the bones in situ.

In compound fracture the detached spiculæ are to be picked out, and the wound cleansed of blood and extraneous bodies; its edges are to be brought neatly together, and retained by one or more stitches, with slips of unirritating plaster. Inflammatory symptoms are to be warded off and combated by purgatives, antimonials, local abstraction of blood, and fomentations. Formation of matter in the nasal cavity is to be prevented, by scarification of the swollen membrane that fills the nostrils and precludes the passage of air; and if matter has been allowed to collect, it must be early discharged.

Opening into the frontal sinus, whether the result of accident or of exfoliation, may sometimes be closed by paring the edges of the integuments and bringing them together, or by covering the deficiency with a flap borrowed from a neighbouring part. Such measures should not be resorted to, in the case of opening from accident, till after all inordinate action has subsided, otherwise adhesion will fail.

Cases of fracture of the superior maxilla, os malæ, and zygoma, have been met with. Great displacement cannot occur, nor is any peculiarity of treatment required. If the fracture is compound, loose portions of bone may require removal.

The inferior maxilla is exposed to violence, but from its construction and consistence is capable of resisting a great degree of force. It may be broken at various points; the usual site of fracture is where the canine or the first small molar tooth is implanted; but it not unfrequently gives way at the symphysis, or near the angle. The alveolar processes are often detached, with loosening of one or more teeth. The fracture is frequently compound; being produced by a direct blow, as the kick of a horse. The bone sometimes breaks at a part not struck, as at the symphysis from a blow near the angle. The accident is easily recognised; in fact, the patient, if sensible, has himself discovered fracture before he applies for assistance. There is distortion of the part, and the broken extremities, when moved, are felt grating on each other; there is discharge of blood, perhaps of teeth, from the mouth; and in compound fracture the ends of the bone are visible. At the symphysis the parts are not much displaced; they are more so when the fracture is in the site of the first molar. In the latter situation it is occasionally difficult to replace the bone, and retain it in its proper position.

The face swells to a greater or less extent, according to the severity of injury done to the soft parts, and the time which has elapsed before reduction. The parts within the mouth swell; often there is great infiltration of the loose cellular tissue under the tongue. Sometimes extensive abscess forms, showing itself in the mouth or under the chin.