Elements of Surgery

by Robert Liston

The nature of the injury is at once known; and the displacement is easily remedied. But I have met with instances where, through ineffectual attempts at reduction, the unnatural position has been allowed to continue for many hours, to the great distress of the individual. The object in view is to depress the ramus—one or both, as may be—and to raise the chin. This is effected by pressure with the thumbs on or in the situation of the molar teeth, whilst with the fingers the jaw is moved upwards and backwards. The thumbs need not be protected by a glove, as is generally recommended; on the bone resuming its place, they are easily slipped into the space betwixt the jaw and the cheek. There is no necessity for bandaging, as retentive apparatus; the patient is not likely to yawn for some time after.

Luxation of the clavicle, at either end, is produced by force applied to the point of the shoulder. It is seldom that the sternal extremity is separated from its connexions. When this accident does happen, it is easily recognised; the end of the bone is prominent and loose, and is distinctly felt riding over the top of the sternum. Replacement is effected by bringing back the shoulder; but the bone is with difficulty retained in the proper position, and is long in becoming fixed; a certain degree of deformity is ever after present.

Displacement of the scapular extremity is by no means rare, and occurs to a greater or less extent, according to the laceration of the ligaments. If those only are torn which connect the end of the bone to the acromion, there is mere rising of the end. But if—as is often the case when the violence has been great, as in a fall either from a height or with great velocity—the conoid and trapezoid ligaments connecting the tuberosity of the bone with the coracoid process, have given way, then the end of the bone projects, pushes out the deltoid, and gives rise to considerable flattening of the shoulder. The arm falls forwards, and cannot be moved but with pain; nor is the patient able to raise it by its own muscular power. If the surgeon grasps the middle of the bone, he finds the end moveable; and the evident and deforming projection puts an end to any doubt regarding the nature of the case. The bone is readily reduced by raising the arm, and carrying the scapula backwards. The limb must be retained in the proper position for many weeks, if a cure without interruption, and with as little deformity as possible, is desired; but after the utmost care and patience, there still remains, in almost every case, some projection more than before the accident. The ligaments are slow in uniting, and the union is imperfect and weak. The requisite apparatus is the same as for fractured clavicle, but must be retained for a longer time. The patient experiences great relief from the limb being put up in this manner and maintained so; and inflammatory action, with much of the swelling, is averted.

The inferior angle of the Scapula occasionally escapes from under the border of the latissimus dorsi, usually with some laceration of the muscular fibres. The displacement is occasioned by raising the arm above the head to an unusual extent. The angle of the bone projects considerably, and the muscle is felt playing beneath it distinctly during motion of the parts; the movements of the limb are limited and painful. The parts may be brought into their original position by pressing the angle of the scapula towards the ribs, whilst the arm is much raised; and the bone is afterwards confined in its proper place by a broad bandage passed pretty tightly round the chest. The retentive apparatus must be continued for a considerable time, and in some cases a cure may be so effected; but in general the bone soon regains its former unnatural position, and continues to do so, however often and however easily it may be replaced. The parts gradually become accustomed to the change in relative position, and little inconvenience is experienced.

Luxation of the Shoulder-joint is prevented, by the arrangement and structure of the parts, from taking place in any direction excepting towards the axilla—downwards into the hollow of the armpit, downwards and forwards under the lower border of the pectoral muscle. Occasionally, though very rarely indeed, displacement occurs backwards. On the anterior and inferior aspects, the articulation is not supported, as at its other sides, either by muscular substance or by processes of bone. The accident is occasioned sometimes, though rarely, by direct violence, as by a blow on the back part of the shoulder; and of such I have seen a few examples. But, in almost every instance, the displacement is caused by force applied to the distal extremity of the humerus; either immediately, as by falling on the elbow, or through the forearm, as when a person endeavours to break a fall by stretching out the arm, and alights with the whole weight of the body on the palm. The accident may also result from forcible abduction of the extremity, particularly when the power is applied near the extremity of the limb. There is laceration, to a greater or less extent, of the capsule, and of the muscles immediately investing the fibrous tissue round the articulating cavity. Without disruption, complete luxation cannot exist—the articulating surfaces cannot be separated, nor can the head of the humerus be altered in position; subluxation, or, in other words, a sprain, may occur in such circumstances, but true luxation cannot.

Bruises of the shoulder, with or without fracture, either of the scapula or of the upper part of the humerus, must not be mistaken for dislocation, for the consequences of such a blunder are fearful. In both descriptions of accident, the appearances of the limb are somewhat similar, and hence the examination requires to be particularly accurate and careful. In both there is flattening of the shoulder, but in fracture there is crepitus, motion to an unnatural extent, though painful, and greater suffering during manipulation; in dislocation no crepitus at all resembling that in fracture can be perceived, the motions of the limb are very limited, and the displaced head of the bone can almost always be felt. The direction of the force, too, as already observed, when on the subject of fracture, is an important assistant in diagnosis; from falls or blows upon the shoulder we may expect fracture, from falls on the elbow or palm, luxation. In dislocation an indistinct feeling, sometimes amounting to obscure crepitation, is occasionally perceived during rotation of the limb; and this arises from one or more of the tendinous attachments of the muscles having, during their disruption, torn away a portion of their osseous attachment.

Great pain attends on dislocated humerus, from the head of the bone compressing and stretching the axillary plexus; and the interruption to the flow of the blood produces tingling at the points of the fingers, numbness of the whole limb, and after a time swelling of the hand and forearm. Flattening of the shoulder, and depression under the acromion, are the most prominent marks of displacement having occurred, and are at once apparent. They are more distinctly perceived on comparing the two shoulders; then the acromion on the affected side stands remarkably outwards. The projection is not so apparent when the immediate swelling from effused blood has been fully formed, but the hollow under the acromion can be felt through any quantity of extravasated blood. The arm admits of very little motion, is lengthened and abducted. The elbow cannot be brought close to the side, and attempts to do so are productive of great suffering. The patient has little or no muscular command over the upper arm. Rotation and elevation of the limb require considerable force, and are practicable only to a very limited extent; during attempts at the former, as already mentioned, obscure crepitus is sometimes perceived. The abduction is most remarkable in the dislocation directly downwards; and in this form of the accident, the fingers easily detect the head of the bone lying in the axilla, deep, yet distinct, particularly during attempted rotation. When the head of the bone lies forward by the coracoid process, and under the pectoralis major, it can be felt, and the prominence occasioned by it can be clearly seen in thin people, before swelling has occurred, and after its subsidence. The bone sometimes lodges in an intermediate situation, and then the signs peculiar to each form of displacement are mixed. When reduction is not accomplished, the bloody swelling first occurs to obscure the signs; this may in part subside, but then the inflammatory supervenes; both after a time disappear, the muscles waste, and then all the signs are very apparent. After some weeks, the motions of the limb become more extensive, not in consequence of the head of the humerus having changed its position, or returned into the glenoid cavity, but from the scapula moving on the ribs more freely, and to a greater extent than usual. At last, but not till after a long period, considerable motion betwixt the bones can be effected; the scapula, where the head of the humerus rests, having furnished an adventitious cavity, to which the latter has adapted itself. But free motion can never be regained, for the movements that are effected are chiefly produced by the action of the muscles of the scapula.

Replacement, even in very recent cases, sometimes is accomplished with difficulty in those whose muscles are fully developed. But in general a successful result will follow simple measures, particularly if the patient is taken unawares—as by rotating the arm with one hand whilst the fingers of the other are placed in the axilla, then suddenly lifting the head of the bone outwards, and at the same time performing abduction—the patient being all along assured that he will not be put to pain, and that there is no intention of attempting reduction. In this manner reduction may often be accomplished by the surgeon and one assistant; the trunk and scapula being fixed by the assistant, either grasping the patient in his arms, or holding a sheet or towel passed round the body, close to the axilla, whilst the surgeon extends and rotates the extremity, and at the same time lifts the head of the bone from its situation. The rotation is made by using the forearm, bent to a right angle, as a lever; thus considerable power can be exerted on the head of the bone, and the long head of the biceps muscle—the stretching of which, no doubt, affords an obstacle to reduction—is at the same time relaxed. In luxation downwards, there is no more successful method than that by counter-extension with the heel in the axilla, and extension by the surgeon grasping the wrist. The patient is placed recumbent, on a couch or on the floor, and the surgeon, sitting by his side, lodges his heel in the axilla, and with both hands extends the arm; after a short continuance of extension, he performs a sudden and powerful combination of both movements, and so jerks the bone into its natural position. In some recent, and in all old cases, it is necessary to apply considerable force, steadily, and for a long time, so as to tire out the muscles, and dislodge the head of the bone. An assistant effects this by means of pulleys. These are fixed to a laque, applied above the elbow with a clove-hitch, and to a ring fastened either in the wall or to a post; two small iron rings which can be screwed into a beam are useful in private practice, and should always accompany the pulleys. When all is prepared, the assistant pulls the end of the rope steadily, and with considerable power, whilst the surgeon rotates the limb, and endeavours to lift the head of the bone, at the same time regulating the degree of extension. The directing of the degree and continuance of the force is not the least difficult part of the procedure, for, when excessive, there is a risk of the axillary nerves and artery giving way; such accidents have happened, and been accompanied with serious and even fatal consequences; and from laceration of other tissues, the muscular, fibrous, or cellular, fatal inflammation and abscess have resulted. The surgeon is therefore called upon to exercise judgment and discretion—not to continue extension to a pernicious extent, and not to abandon attempts at reduction too soon, leaving his patient disabled for life. For making counter-extension to the extension by pulleys, a broad strong belt is useful, perforated near the middle for transmission of the injured arm; it is passed round the body so as to fix the trunk and scapula, coming under the axilla of the sound side, and being then fastened by means of a hook to a ring in the wall.

Luxations of the shoulder-joint may be, and have been, reduced after the lapse of two or three months; but the difficulty increases, and the chance of success diminishes, in proportion to the time which has elapsed since the date of the accident. And in deciding upon making the attempt, many circumstances are to be weighed and considered—the patient’s period of life and his occupations, the state of the parts, the degree of motion that has been acquired, and the treatment, if any, which has been previously followed. Perhaps the most important consideration is regarding the state of the parts, as indicated by the degree of motion. If the movements be to such an extent as to favour the supposition of the head of the bone having been furnished with a new recipient cavity, to which it has in a great measure accommodated itself, and that the glenoid cavity has, from disuse, become altered, the surgeon can scarcely hope for advantage to his patient from attempts to break up the new articulating apparatus, and reëstablish the old. The patient will, most probably, be put to a great deal of pain and some danger, without experiencing improvement to the limb; indeed the motions and power may prove less than before. In old men, too, force sufficient for reduction cannot be employed without great risk of laceration of nerves, bloodvessels, and muscles. But if the patient be young, the motions still limited, and the articulation apparently not changed by solid effusion, reduction may be attempted with a fair prospect of success, and without injury. In all such cases, however, the surgeon must watch every step of the proceedings, and have sufficient experience to stop short of inflicting irreparable mischief. No standard can be fixed for the degree of force that is necessary and safe; he may be foiled, even after the most powerful efforts, in a dislocation of two or three weeks’ duration; whilst, by the use of but slight force, he may succeed in one of as many months. Much assistance is obtained by the means formerly adverted to, as auxiliary, by weakening the muscular energy. Of these, nauseating doses of antimony are most generally employed, and being the most safe, may be recommended to be tried first; and if these fail to produce the desired effect, the patient may be bled freely, if he be young and robust, more especially since this will assist to avert the inflammatory action likely to follow the violent reduction. Tobacco produces the most complete prostration of muscular power, and may consequently be resorted to in extreme cases; but it ought, if possible, to be avoided, as its use is far from being void of danger. The warm bath cannot always be procured; when at hand, it merits adoption, being both safe and effectual, particularly if combined with antimony or bleeding. The extension should not be commenced till these means have begun to take effect, but everything should be prepared, so that it may be applied at a moment’s warning. After all attempts at reduction, whether successful or not, it is necessary to moderate the inflammation that ensues, by local bleeding and fomentation, combined, if necessary, with nauseating laxatives: general depletion is seldom required.