Elements of Surgery

by Robert Liston

The prognosis is always unfavourable, as the patient dies either young, or remains permanently lame and deformed.

The treatment can be only palliative; and as the weight of the trunk is the main agent in aggravating the displacement, repose is obviously indicated: but it is not necessary to confine the patient to the recumbent posture; since, in the act of sitting, there is no stress on the femur, the body resting principally on the tuberosities of the ischia. Dupuytren thought favourably of the cold bath: it should be strongly impregnated with salt, and the body immersed for three or four minutes at a time. He was also in the habit of using a well-stuffed belt, about four inches wide, for surrounding the pelvis and fixing the great trochanters; thus binding the ill-adapted parts together, keeping them at the same height, and preventing that continued motion to which they are otherwise so much exposed.]

Luxation of the Bones of the Leg.—separation of them from the end of the femur—seldom occurs. It can be the effect only of great violence and great laceration. Most frequently fracture is concomitant, perhaps with wound; and such accidents require amputation, either primarily or secondarily. Subluxation, from laceration of the internal lateral ligament, is not so unfrequent. It is most common in females, the natural conformation of their thigh-bones disposing them to bend inwards; and from falling awkwardly, particularly if carrying a weight, the ligament is apt to give way. The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely; a sustaining apparatus, fitted on the outside, retained by straps, and with a joint opposite to the articulation, is required to be constantly worn when the patient wishes to use the limb.

Luxation of the Patella is spoken of by some as common. Others of much experience have not met with a single instance of it. I have never seen this accident. The bone, it is said, may be displaced outwards, inwards, or upwards. The first form of luxation is the most frequent, and is caused by a severe fall, with the foot twisted outwards and the knee inwards. Displacement inwards is produced by direct violence applied to the outer part of the bone, or by the foot being turned inwards in a fall. Displacement upwards can occur only after laceration of the ligamentum patellæ, the bone being then drawn up by the unresisted action of the muscles on the fore part of the thigh. In dislocation outwards, the bone has been found “resting with its inner edge upon the outer surface of the condyle, the fore part facing obliquely forwards and inwards.” In this last form of accident, sudden, forcible, and complete flexion of the limb is said to produce immediate reduction. In dislocation outwards or inwards, the muscles are to be relaxed by raising the heel, extending the limb, flexing the thigh, and then forcing the bone to its proper site by manipulation. In the dislocation upwards with rupture, the limb is to be kept extended and raised, and the bone is brought as nearly into its place as possible by bandaging. When a peculiar laxity of the apparatus about the joint exists, whether as a cause of luxation or not, the support of a well-made knee-cap is required.

As formerly stated, Dislocation of the Ankle cannot take place inwards or outwards, without fracture of the end of the tibia or of the fibula, either above the articulation, or where they project by the sides of the astragalus for the greater security and strength of the joint. Subluxation, however, or sprain, may occur without injury of the bones: in this accident, should the parts not have spontaneously resumed their original situation, no difficulty is experienced in putting them to rights; simple manipulation is sufficient. Occasionally, the foot is luxated forwards, by force applied either to the heel or to the fore part of the leg whilst the limb is fixed. The heel is shortened, the foot elongated; indeed, the marks of the injury are so distinct, that comparison of the limbs is sufficient for diagnosis. Luxation may also take place backwards; and in this case the heel is elongated and the foot shortened. In these accidents it is not unfrequently found that one or other malleolus has given way, or that the lower end of the tibia is split. Reduction is sometimes difficult. Extension is to be made by grasping the foot and pulling whilst the limb is fixed, at the same time making pressure either backwards or forwards, as may be required. To retain the bones in their proper situations, it is always necessary, at least prudent, to apply a paste-board or leathern splint to each side of the limb, particularly when fracture of the malleoli is conjoined.

Displacement of the Bones of the Tarsus may result from great force; for example, when the foot is squeezed under a heavy weight, one or more bones may escape from their connections, and project. Reduction of such displacement is exceedingly difficult at any period, and becomes almost impossible when inflammatory action is allowed to supervene previously to attempts being made. The astragalus is sometimes pushed out of its place; though it is difficult to conceive how, to a bone so hid and so firmly connected, such force should be applied as to cause protrusion of it from its natural situation. It has been found lying on the dorsum of the foot, causing swelling, lameness, great pain, shortening and deformity of the limb; and the shape of the bone can, in such circumstances, be distinctly felt and seen through the integument. As already observed, reduction is almost impracticable, and, with the view of remedying deformity, it has been proposed to cut out the displaced bone; but as to the expediency of such practice I can give no opinion.

I have seen but one instance of displacement of this bone backwards, and most probably another will never occur to me. A heavy young man, in a state of utter intoxication, fell backwards down a stair, and in the fall his foot became entangled in the railing. The astragalus was found lying betwixt the back of the tibia and the tendo-Achillis, its upper articulating surface facing forwards, the lower in contact with the tendon. All attempts to reduce the bone proved fruitless. Violent inflammatory action followed, but was reduced by active measures; and the limb ultimately became very useful; in fact, though not till after many months, little lameness or shortening was perceptible.

By Sprain is understood subluxation or partial displacement of a joint, with stretching, and more or less laceration of the articulating apparatus—ligaments, tendons, sheaths, and bursæ, being all involved in the injury. Sometimes small portions of the processes of bone are separated, being torn away, attached to ligament or tendon. All joints, both large and small, are liable to the accident. In the proximal, or in the middle joints of the finger, for example, one or other lateral ligament is stretched or torn; the finger is twisted to a side; the joint is swelled; and this swelling, with pain, is of long continuance, perhaps increased by repeated twists, or by imprudent use of the joint. The elbow and shoulder are frequently sprained, as also the hip and knee; but the injury most frequently occurs in the wrist and ankle. It is generally occasioned by a fall, the foot or hand coming awkwardly to the ground, the muscles being at the time relaxed and unprepared; by over-exertion in lifting heavy weights; by entanglement and twisting of the limb, &c. The ankle is often sprained by what is called a false step; the fore part of the foot comes in contact with an obstacle unexpectedly, the foot is twisted under the limb, the weight of the body is thrown on the apparatus of one side of the joint, and this is in consequence immoderately and unnaturally stretched. Violent pain immediately occurs, and the patient is sick and faint. Discoloration and rapid swelling take place from extravasation of blood into the cellular tissue, into the sheaths of the tendons, and perhaps into the synovial pouches, in consequence of laceration of the bloodvessels. Effusion of serum and increased secretion of synovia afterwards occur, from incited action of the vessels. Thus the joint is deformed. Attentive examination is required to guard against mistakes; the existence or non-existence either of displacement or of fracture must be at once ascertained by determined and perfect manipulation; the parts must be pressed and moved, to such an extent as is necessary, notwithstanding the pain thereby occasioned, and notwithstanding the resistance afforded by the patient. It has been already stated that luxation of the wrist is not uncommon; that separation of the one bone of the forearm from the other, and transverse fracture or splitting of the radius, at the distal extremity, are accidents by no means rare. Great disfiguration follows simple sprain, much swelling taking place on the fore part of the limb from effusion under the fascia, and there is also much serous and bloody infiltration of the cellular tissue on the back of the hand and forearm. In the ankle, the ends of the bones must be carefully examined, and also the fibula in its whole extent, that the existence or non-existence of fracture may be ascertained, and that the surgeon may be guided to a correct mode of treatment. If the joint is not put at rest immediately, the extravasation is increased, and, in consequence, the pain and inflammatory swelling also; and parts of the joint at first not involved in the injury may thus be made to suffer. Many diseases of synovial membrane and articulating cartilages are attributable, and can be traced, to badly managed sprains; and in some constitutions, but slight injury, combined with a little bad treatment, suffices to destroy a joint. When, the case is well managed, the pain is never great, and soon abates; the swelling after a few days slackens; the discoloration becomes greater, the serum being absorbed, and the effused blood shining through the skin; the integuments appear green, blue, red, purple—these hues either being present all at the same time, or occurring successively; the discoloration often extends far from the joint. The mobility and strength of the joint are recovered gradually.

Perhaps no injury is more frequently mismanaged, by those both in and out of the profession. Every old woman thinks she can cure a sprain; most absurd and hurtful measures are resorted to; the injured parts are kept in motion; cold lotions and cold effusions are employed, and at the same time stimulating frictions: probably attempts are made, either by leeching or by puncturing, to extract the effused blood; and many similar follies are committed. The proper treatment certainly appears to consist principally in absolute rest and position. If there is any displacement it must be rectified immediately. If there is any fracture; or if there is a tendency to redisplacement after reduction; or if the patient is restless either from folly or from insensibility, as when the head has been injured by the accident, when the patient is under the influence of strong liquors, or when he labours under delirium tremens,—a splint or splints must be applied to secure immobility of the parts, at the same time without such compression as may interfere with swelling from effusion; the effusion is a salutary process, and should be encouraged, not repressed. By absolute rest and elevation of the limb, the extent of the swelling is limited, and inflammation warded off. Fomentations, properly employed, afford much relief; at first they probably encourage the serous effusion. The integuments soon become relaxed, during the regular use of fomentation, and tension and vascular action subside, as also pain. The swelling then abates, and is no longer hard; it pits on pressure, and the skin has a puckered appearance. Then gentle friction becomes advantageous, and uniform support should be afforded by the application of a flannel roller. The longer the limb is disused, the more perfect and rapid is the recovery, provided the rest of the cure be properly conducted. In general nothing more than what has been stated is required. But if the limb be moved, or stimulated in any way, early, then necessity will arise for antiphlogistic measures—perhaps venesection, certainly copious and repeated abstraction of blood by leeches, accompanied with fomentations, and the internal exhibition of antimonials, purgatives, &c. When such is the case the cure is tedious, the joint long remains swelled and stiff, the patient is lame and incapable of exertion.

Leeching or puncturing at an early period, with the view of allowing extravasated blood to escape, is useless and hurtful. The effused and coagulated blood cannot be evacuated, and suppuration, followed by destruction of the cellular tissue, has often been the consequence of such ill-advised proceedings. Friction with stimulating liniments, or even simple friction, at an early period, is also hurtful, as tending to excite vascular action, and to convert simple swelling into inflammatory. The application of cold at any period is of little use, and ought certainly to be avoided immediately after the injury, as adding to the sufferings of the patient, and interfering with the natural processes which have commenced for the reparation of that injury.