Elements of Surgery

by Robert Liston

The bone is to be brought to its former shape by pressure of the fingers on the outside, and of the thumbs placed within the mouth on the corners of the teeth. Motion is prevented, and the parts are retained in their proper situation, by a wedge of cork or wood interposed on each side of the jaw, and grooved so as to receive the teeth both above and below. The wedges are placed with their thick ends anteriorly, and are retained by the lower jaw being firmly bound towards the upper; sufficient space for the introduction of food must be left between the wedges at the fore part of the mouth. Pasteboard or leather is applied externally, cut so as to fit exactly the fractured bone; it is previously softened in warm water, that it may adapt itself to the shape of the parts, and form a case over them; a thin layer of tow or wadding is placed between it and the skin, and the whole is retained by a roller, which is preferable to split cloths. The patient should not talk, or in any way attempt motion of the injured bone, and the food given should not require mastication. Inflammation is to be kept down by the usual means, and abscesses, if they form, must be early evacuated. Detached teeth and splinters of the jaw are to be extracted at the first; if teeth loosen much during the cure, they should be considered as foreign bodies, and removed, otherwise they will keep up the discharge, and tend to prevent union.[61] From three to six weeks is generally sufficient time for consolidation of the fracture. In severe cases union may be prevented by necrosis of part of the bone; or, though the bone unite, the external wounds may not heal, and the discharge may continue till the dead portions separate and are discharged.

Fracture of the Spinal Column is attended with alarming symptoms, and often terminates fatally, from the pernicious effects necessarily produced on the spinal chord, either immediately or consecutively, when the bones forming the column are disjoined to any great extent. The injury is effected by great violence—by the body being projected and alighting awkwardly—by a fall on the breech from a height, the head and trunk being bent forcibly forwards—by direct blows on the spine.

Displacement of the bones forming the spine, seldom takes place without fracture to a greater or less extent. Pure dislocation of the spine, from the rupture of ligaments and fibro-cartilage, is a very rare accident; few cases of it are on record, and in them the injury was in the cervical region; I have only met with two instances of complete and pure dislocation. The ligaments are of great strength, and the bones yield sooner than they do; and in the greater number of severe injuries of joints this is the case more or less.

A very well marked specimen of luxation, without the slightest fracture of the fourth from the fifth cervical vertebra is delineated on the next page. The injury was occasioned by the person falling backwards over a high paling, on which he was sitting, and alighting on the back of the head: along with the proper ligaments, the spinal chord is seen to be torn. The patient, of course, did not survive many days, being almost perfectly paralysed.

In general, either the bodies or the processes of the vertebræ are broken, and sometimes comminuted; occasionally the bodies are broken entirely through, with considerable displacement, the upper or lower end, as may be, projecting. There is twisting or bending of the trunk or neck, the articulating processes on one side only being displaced, whilst the ligaments on the other remain pretty entire. In some cases, either the spinous processes, or the articular, are separated without yielding of the bodies of the vertebræ, or of the interposed substance; then there is bending of the trunk forwards.

The symptoms vary according to the site of the injury, and the extent of violence inflicted on the spinal chord. This important organ may suffer concussion without fracture or displacement of the bones; its functions may be consequently more or less disturbed, and paralysis occasioned of those parts that are supplied with nerves from below the injured point. Without fracture, too, vessels may give way within the canal, and by compression from effused fluid urgent symptoms will be produced.

The power of motion may be lost whilst sensation is retained, and vice versâ; but in general both are either impaired or destroyed. In one case that came under my care, there was power of motion in one limb and no sensation, whilst in the other there was no motion but the usual sensation.

Patients may recover from the effects of a severe blow on the spinal column and consequent concussion of the chord, but very frequently they do not. Changes may take place at a late period in the chord or its membranes, in consequence of the injury—as thickening of the coverings—bloody, serous, or lymphatic purulent effusion—disorganisation and softening of the medullary matter. Inflammation of the membranes, or of the chord itself, may supervene, either very soon after the accident, or long afterwards; its intensity and period of accession will depend on the extent of the injury, and on the treatment. The muscles act spasmodically, the circulation is excited, the sensorium and nervous system are disordered, delirium ensues, and is followed by paralysis and coma.

In some cases of displacement, even to no small extent, the spinal chord escapes being bruised, torn, or compressed; no bad symptoms may ensue; or paralysis to a greater or less degree occurs and gradually goes off, probably occasioned by bloody effusion, which is afterwards absorbed. This I have witnessed in several instances—in a boy who fell from a high rock—in a woman who fell from a window; both lighted on the breech, and the trunk was bent forwards. The lad remained stout, but his trunk was somewhat deformed by an excurvation; the woman recovered perfectly. In these cases there was evidently laceration of the interspinal ligaments, though probably not of the ligamenta subflava, for the spinal chord must be stretched or otherwise injured when these are torn.