Elements of Surgery

by Robert Liston

The course of a ball in the body is often very strange, depending on the force with which it is projected, or the resistance which is opposed to it, and on the position of the struck part. Balls often pass under the integument almost completely round the head or chest, having first struck the bone at a very oblique angle. Frequently they remain, lodged along with part of the clothing which they thrust before them. In such cases, they may be immediately removed, their exact situation being previously ascertained by external examination, or by means of a probe. They can generally be extracted through the aperture by which they entered; but if situated superficially, and at a distance from the opening, this will be more readily accomplished through an incision made upon them; if allowed to remain, suppuration will occur in the neighbourhood, the surrounding cellular tissue will be condensed, an abscess will be formed containing the foreign body, and by the process of absorption proceeding in the parts external to the abscess, the ball will at last reach the surface, and be discharged. The track is often so extremely tortuous, as to render it impossible to ascertain the situation, or even the existence of the foreign body, which greatly impedes the operation; and, in other instances, it may be necessary to allow the ball to remain undisturbed, on account of its being placed near important parts, which might be injured by any attempt at removal. Foreign bodies often remain lodged in fleshy or membranous parts for years, having become enveloped in a dense cyst, and having ceased to produce any great irritation. In consequence of the force with which they have been projected, and the resistance which has been opposed to their progress in the body, musket-balls, when extracted, either immediately after the infliction of the injury, or after a considerable time has elapsed, are seldom found to retain their globular form, but are flattened and ragged, and not unfrequently completely divided by the bones on which they have impinged. A bullet may be divided into numerous fragments on a bone, and part may enter into the osseous substance, whilst other portions penetrate in all directions into the soft parts, and, though sharp and irregular, may remain long in the dense cellular cyst which forms over them, without producing pain or inconvenience. There will necessarily be suppuration, and generally discharge of dead matter, from gunshot wounds, in consequence of the bruising of the parts by the ball, which may be expected to injure the superficial layer of parts in its tract so severely, that it must slough more or less.

Besides, the bones are often splintered by the force with which they are struck, and loose portions of them lodge amongst the muscles; then they are the cause of much mischief, for, on account of their long, sharp, and irregular form, they occasion great irritation, suppuration ensues in various parts, sinuses form, and the cure is rendered very tedious. In other cases, the bone is split in a longitudinal direction, and, in the cylindrical bones, these fissures are often of great extent.

Considering the nature of the body which inflicts the injury in a gunshot wound, and the velocity with which it is impelled, it is evident that the cure must be in all cases tedious, in consequence of the sloughing and suppuration which is induced, particularly at the aperture through which the ball passed. The foreign body ought always to be removed as early as possible, provided it can be accomplished without much violence, or injury to the parts. Dilatation of gunshot wounds is now had recourse to only to facilitate the removal of balls, splinters, &c., and even with this view, it ought to be employed but to a very slight extent, if at all; for foreign substances, when deeply seated, can be much more easily taken out when the sloughs are separating, and the parts relaxed by suppuration; then, too, they can be more readily reached through a counter-opening, when their situation renders this expedient. In short, the surgeon is not justified in cutting for balls, unless they are easily felt, and not deeply lodged. In order to discover the foreign body, probes will sometimes be required; the finger often answers the purpose best, unless when the wound is of considerable depth. If, on examination, the ball cannot be discovered, and if there is reason to think that it has followed an indirect course, the surgeon will, sometimes, be assisted in his search by placing the patient in that position in which he received the wound, and then judging of the circumstances most likely to affect the foreign body in its passage. In many cases, extraction can be accomplished by means of the finger alone; in others, forceps and scoops, various in length and size, are indispensable. Afterwards, light dressings are to be employed; and in the first instance, cold applications may prove advantageous in keeping down the inflammatory action; but when inflammation has commenced, and to encourage suppuration, warm fomentations and poultices are to be preferred; they will in many cases be both more grateful to the patient and more beneficial in their results, when used even from the commencement. Afterwards, it will be necessary to afford sufficient support to the parts by bandaging, and to change the applications according to the particular circumstances:—soothing, if the wound be irritable, stimulating, if inert, and gently escharotic, if the granulations be exuberant.

In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c., in deciding on the removal of the part by amputation,—or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to delay till suppuration occur, is now scarcely a matter of dispute. When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly performed,—delay is inadmissible. In comminution of the hard, with contusion and laceration of the soft parts—where limbs have been shattered and completely detached, or nearly so—in lacerations of parts, including the principal bloodvessels and nerves—fractures of the heads of bones, with openings into the joints—and in bad compound fractures, more especially of the thigh (for all compound fractures of the upper part of the thigh are dangerous), amputate at once. When the limb has been retained, and gangrene arises in consequence of the external injury, and when there is no reason to suppose that any internal cause is also in existence; or when the violence of inflammatory action has subsided, and the patient is become hectic, with profuse purulent discharge, and with disunited bones, then amputate. But, in this latter case, the chance of recovery is not so great, and the proportion of recoveries small; whereas, in the immediate or primary operations, the very reverse holds true. Such is the experience of the greater number of military surgeons. In civil practice, the results are somewhat different; a greater proportion of primary amputations are unsuccessful, and the secondary turn out more favourably than the statements of military surgeons would lead one to believe. In all cases, the judgment of the surgeon must guide him in his determination. The circumstances of the case, and the probable contingencies, must be all duly considered, and he must not proceed with his knife where there exists even a slight chance of preserving the limb.

Paralysis occasionally follows wounds of the arm, forearm, face, &c., inflicted by accident or operation, and this arises from an important nerve, or set of nerves, being divided. In cases of simple division, without much separation of the parts, reunion of the nerves may take place, and their functions be restored. If the limb remains paralysed, after cicatrisation of the wound, tepid effusions, friction, dry or with liniment, stimulating applications, &c., may sometimes be advantageously employed.

TETANUS

Is a disease which occasionally follows a wound, but rarely in this country. It is a spasmodic contraction, with rigidity, of the voluntary muscles, in some cases involving the whole body, in others the upper part of it only, and in some it is confined to a certain class of muscles. When the extensors are affected, the disease is termed opisthotonos; when the flexors, emprosthotonos. Complete tetanus is said to exist when the flexor and extensor muscles exactly balance each other, and the body is thereby kept straight and rigid. But when the affection is confined to the muscles of deglutition, and chiefly to those moving the lower jaw, it is called trismus. The disease has besides been divided into acute and chronic, and into traumatic and idiopathic; the one following wounds, the other arising from internal causes, or circumstances not connected with the læsion of the surface. The disease supervenes at various periods; sometimes, though rarely, not long after the infliction of the injury, in other instances after the lapse of eight or ten days, and often when the wound is healing, or nearly cicatrized. In warm climates, where it is of very frequent occurrence, it occasionally seems to be caused by exposure to damp and changeable weather; in children, it supervenes on the slightest irritation. It is often induced by the presence of splinters, or rather bodies of an irritating nature, and by the partial division of nerves. Not unfrequently it occurs after clean wounds, as amputation or venesection; in the former it may perhaps arise from a nerve being included in the same ligature with an artery, in the latter, from a nervous twig being partially divided. The more prominent symptoms are, stiffness of the back of the neck, and contraction of the features; difficult deglutition supervenes, and the efforts to accomplish it are attended with violent spasms of the muscles of the pharynx and œsophagus. Spasms of the injured limb often precede those of the muscular system generally; the muscles of the lower jaw become rigid and spasmodically contracted, and by a continuance and increase of the spasmodic action, the mouth is at last completely and immovably shut. The muscles of the trunk and limbs become affected, and there are violent spasms of particular sets of them, most generally of those situated posteriorly; thus the body is bent violently backward, so that its whole weight is supported on two points only, the heels and the occiput. These symptoms are not constant; relaxation occurs, and the patient enjoys a cessation of the malady: but this is only temporary; the painful feelings and the spasms soon return. A symptom of the most distressing nature is pain and spasmodic twitching of the diaphragm, impeding respiration, and imparting a shock to the whole system. Occasionally, emprosthotonos occurs, but, so far as my experience goes, the body is much more frequently bent backward; the muscles are sometimes ruptured by the violence of their own action. The circulating system and sensorial functions are often not much disturbed; but during the whole course of the disease, the bowels are much constipated. In most cases of traumatic tetanus, after four or five days, all the symptoms become aggravated; the countenance is horribly distorted, the spasms of the diaphragm are more frequent and violent, and the patient dies convulsed. Sometimes, though rarely, the fatal termination does not take place till the eighteenth or twentieth day. On dissection, the pharynx is found contracted, and bearing marks of acute inflammation. In one case, which fell under my observation, there was ultimately great difficulty in breathing and expectorating; and on examination, the trachea, as well as the pharynx, bore evident marks of inflammation, and were filled with a viscid mucus. In some instances, there are evident marks of inflammation of the spinal chord; the vessels, more especially at the lower part, are found enlarged, tortuous, and engorged with blood; portions of lymph are seen deposited on the arachnoid covering, and a serous fluid is effused, not unfrequently mixed with blood. Such appearances, however, are not observed in every case of fatal tetanus, and therefore it cannot be asserted as a fact, that the disease is dependent on a morbid condition of the spinal chord, though in certain cases the two affections coexist. By some it has been supposed, that in consequence of the distended and engorged state of the spinal arteries, the origins of the nerves are stimulated, and that a morbid affection of them ensues, giving rise to the tetanic symptoms; but want of uniformity in the morbid appearances prevents such a cause from being generally set down as the origin of tetanus.

This disease is one of the most intractable with which the surgeon has to contend. In the acute form, time is scarcely allowed for remedies; and in the advanced stage, it is with much difficulty that medicine can be received internally. Of course all irritations must be removed, both local and general, as far as that can be accomplished. If the patient be robust, and if the tetanic symptoms be ushered in with arterial incitement, general depletion ought certainly to be practised; and if the symptoms be such as to render the propriety of general bleeding dubious, blood may be abstracted locally, from the back of the head, or along the spine; and this may be followed by such counter-irritants as act rapidly. At the same time, powerful purgatives must be given, so as to bring the bowels into a better state; for, as already observed, obstinate constipation is a constant attendant on this disease. But the most important indication is to alleviate and prevent, if possible, the spasms; and for this purpose, opium is to be administered in large doses, either by itself, or combined with camphor or other antispasmodics. By such means, the disease has in some cases been arrested, but in the majority it has proceeded unabated. Some practitioners recommend and employ cold affusion and immersion, whilst others prefer the warm bath; and the latter appears to be the safer application, though neither can be considered as efficacious. Great relief and benefit seem to have accrued from the frequently repeated use of a warm bath, with some drachms of the tart. antimonii dissolved in it. I have had only two opportunities of trying this practice; one a chronic ease, where, after the division of the nerves proceeding from the wound, this remedy, with others, seemed to allay the spasms in a very remarkable manner: the patient recovered. In the other, a very acute case, after the extraction of a splinter from betwixt the thumb and forefinger, the bath was tried; the patient felt much comforted by it; but suddenly expired in a violent convulsion, whilst being replaced in bed. Great relaxation follows this remedy, profuse perspiration, and subsidence of the rigidity and convulsive action of the muscles. The practice was recommended to my notice by my excellent friend Dr. Stevens, Professor of Surgery at New York. In some cases, it would be worth trial to produce instant vesication by the acetic solution of cantharides or ammonia, and then try the effect of the application to the blistered surface of some of the alkaloids, such as morphia, aconitine, &c., or belladonna might be applied.

Some practitioners have used mercurial frictions along the spine, or on other parts of the surface; while others administer stimulants, and enemata with tobacco and turpentine. When there is reason to apprehend that the symptoms arise in consequence of laceration or partial division of a nervous trunk, it has been recommended to complete the division of it; and the practice is worthy of adoption, as in some cases it appears to have been successful. Little good can result from scarification of the wound. Amputation of the wounded member has also been proposed, particularly in chronic cases, and in one or two it has succeeded. I have made trial of it in but one instance, and in that it failed. Acute tetanus had followed a lacerated wound betwixt the thumb and forefinger; amputation of the forearm was performed, and immediately after the operation the spasms abated; but they soon returned, notwithstanding the free use of opium, and other remedies, and the patient died. In this case, the branch of the median nerve was found partially divided, and its cut extremities were thickened and inflamed. During the operation, I wished to abstract a considerable quantity of blood, but the arteries seemed to be so spasmodically contracted, as to permit the flow of a small quantity only. On examination after death, the median nerve was of its natural appearance, excepting at the bend of the arm, where it was of a bright-red colour. No change could be perceived in the brain or spinal chord, though the examination was conducted with the utmost care.