Elements of Surgery

by Robert Liston

The arm requires to be raised and supported by a sling.

Fracture of the Ribs.—One rib, or more, may be broken by injuries in various ways—by blows of the fist—falls on hard bodies—pressure on the chest by heavy bodies passing over or falling upon it. They generally give way anteriorly to the angles, at the most convex point; but sometimes near the spine or the sternum. At the same time they may be partially luxated at either of the extremities. The fracture is generally transverse; occasionally, and rarely, oblique. Sharp portions are seldom detached. The skin is sometimes divided, but more frequently the pleura and lungs are torn by the spiculæ projecting internally; hence effusion into the chest, and emphysema of the subcutaneous cellular tissue near the fracture, take place. The emphysema, if permitted, extends over the greater part of the chest, and even farther.

Fracture of the ribs is attended with pain, particularly during full inspiration; and if the injury is severe, the patient is incapable, without great pain and exertion, of accomplishing full inspiration. He uses his handkerchief, sneezes, and coughs, with the utmost difficulty. Crepitation is felt by the patient, and is easily detected by the surgeon, by placing the hand on the suspected point, and desiring the patient to attempt full inspiration so as to grate the surfaces on each other. Motions of the trunk, and often of the upper extremities also, are attended with aggravation of the symptoms. In some cases attentive examination is necessary to discover crepitus—in certain situations, and when perhaps one rib only has given way, especially if some time have elapsed betwixt the infliction of the injury and the application of the patient for relief.

In the slighter cases, it is sufficient to restrain the motions of the chest by a broad bandage applied firmly round it; and a split cloth, or a scapulary, may be passed over the shoulders and attached to the circular bandage to prevent its being displaced. Great and immediate relief is thus afforded. In those of a plethoric habit, blood may be taken from the arm, some hours after the injury, with relief and advantage; it may ward off an inflammatory attack—and it is absolutely necessary to adopt this practice on the slightest indication of such supervening. The appearance of the countenance, and the state of the pulse and respiration, must be watched; and on the first becoming anxious, the second strong and accelerated, and the third hurried and imperfect, active measures must be employed—venesection, antimony, purgatives, diaphoretics, anodynes—one or all according to circumstances. In the more severe injuries the same practice is pursued; and the symptoms are watched with great care. The air in the cellular tissue, if effused in great quantity about the neck and face, and interfering with the functions of the parts, is to be evacuated by punctures. If the emphysema is slight, and confined to the neighbourhood of the injured part, farther extrication is prevented by the timely and accurate application of a bandage; the air already in the cellular tissue speedily disappears. The effusion into the chest is also in general absorbed; but it may remain and increase, and from violence of action purulent secretion may be mixed with the serous. The breathing then becomes embarrassed, the chest swells, and the integuments are œdematous. The action of the lung is either much impaired or entirely arrested, as is ascertained by auscultation. In such circumstances, evacuation of the effused fluid may be required.

The Sternum is sometimes fractured, or, in young persons, the bones composing it disjoined; but the occurrence is exceedingly rare. The displacement is not great; and is rectified by changing the position of the trunk. The same treatment is required as for fracture of the ribs. Abscess has formed under the bone, as the result of the injury; but by antiphlogistic means, local and general, this may be in most cases prevented.

Fracture in the vicinity of the shoulder-joint requires to be most accurately examined, that a correct diagnosis may be formed, and the practice be judicious and decided.

Portions of the upper part of the humerus are torn off, along with the attachments of the short muscles, during violent exertions, particularly if the limb is in an awkward position. This is followed by want of power, great swelling, and considerable deformity. Some indistinct crepitation is perceived; the articulation is afterwards stiff, and the bone of an unnatural form. But these indications of the injury gradually disappear.

More extensive solution of the continuity of the bone takes place, generally in consequence of a direct and violent blow on the shoulder. The patient is unable to raise the arm, though with great pain it can be placed in any position that it occupies naturally; it can be abducted and raised, perhaps to a greater extent and more readily than when sound. The shoulder is flattened, and the limb apparently lengthened. The elbow is readily put to the side. On raising the humerus, rotating it, and moving it to and fro, crepitation is distinctly perceived—but not so readily after swelling has taken place. The swelling also obscures the appearances observed immediately after the infliction of the injury,—the flattening of the shoulder, and apparent elongation of the arm. By the fingers of one hand, pressed deep into the axilla, the head of the humerus can be discovered; and, on rotating the shaft of the bone with the other hand, grasping the elbow and pushing upwards at the same time, crepitation is perceived, and the upper portion of the bone is ascertained to be unaffected by the rotation of the shaft. The nature of the injury is then sufficiently apparent.

But the shaft of the humerus may, by such manipulation, be ascertained to be entire. Still, from the direction of the force which effected the injury, the flattening of the shoulder, the remarkable falling down of the arm, the loss of power, the free motion, and from the crepitation, though perhaps indistinct, it is evident that fracture has occurred. Then, by the fingers in the axilla, whilst the humerus is raised and moved in different directions, crepitation is recognised deeper and less distinct than in the former case; and the surgeon is warranted in believing that the glenoid cavity has suffered—that it is broken into fragments, or that it is separated from the body of the scapula by fracture of its neck; he is also warranted in adopting the means of cure suitable to such an accident. Many such injuries are supposed to occur, yet it is strange that preparations illustrative of it are scarcely to be met with in our collections of morbid specimens.

How both detachment and luxation of the head of the humerus should occur, can scarcely be explained. Luxation certainly cannot take place after fracture; no force can be applied to the head of the bone sufficient to displace it. It is barely possible, that after luxation, force may be applied to the bone so as to fracture its neck. This accident is of very rare occurrence, though by some supposed to be otherwise. I have had an opportunity of examining but one case, and that was very distinct; the head of the bone, completely detached from the shaft, lay in the axilla. Comminution of the head of the bone, with displacement of the fragments, is not uncommon.