_Of Fractures_
We come now to fractures. There is something terrible in the sound of
_broken bones_; and yet in common they are by far more easier managed
and healed than a dislocated joint: nature is very kind; from the
fractured parts of a broken bone, there exsudes a gelatenous matter
called _Callus_, that very soon glews them together again, and makes
them stronger than ever. As easy as a fracture is ruined, as easily it
may be well treated. I shall therefore lay down some few rules, which if
properly observed, will ever be attended with success, as they are
founded upon happy experience, in my own practice.
In the first place, a fracture should be reduced as soon as possible.
Secondly, the part should have as much rest as possible till the callus
is formed, or the bone knitted together again. Thirdly, bandages should
not be laid on too tight. Fourthly, camphorated fomentations should not
be too plentifully made use of. Fifthly, the habit of body should be
kept in a slate of health; and Sixthly, the diet during the time should
be wholesome and sparing.
With regard to the reduction, it was formerly a great error for a limb
to be stretched out in an extensive posture; for the extension of the
muscles contracted the limb, and made the reduction both painful and
troublesome.
I shall here recommend a better method; namely to have the muscles in a
flexible position, during the operation and the cure. But to proceed to
particulars.
_A Fracture of the Skull._
This accident is frequently attended with many bad symptoms, and often
requires the operation of the trepan; which I shall here pass over,
being too prolix for this place. I have only to observe, that we have
frequent instances of the patient doing well without any other help than
bleeding; and where there is no surgeon on board, this is the only
remedy first to fly to, and gives the greatest chance for the patient’s
life: next to this, shave the head, and treat him as circumstances shall
direct, without meddling with the fracture, any farther than applying
gentle fomentations, with _flowers of chamomile_ (11) boil’d in claret,
and some _linament of soap_ (B) added to it; and if there is any wound,
have it properly dressed as directed in the article of wounds.
_Fracture of the Arm._
If the upper arm is fractured, proceed in the following manner:
First of all be sure it is a fracture; to know this, put one hand on the
middle of the arm, and the other on the elbow, move it gently to and
fro, and if there is a fracture, you will find it crackle by the touch,
which sometimes is so distinct as to be heard. The arm at the same time
is somewhat swelled, and either the patient cannot move it, or else it
is attended with very great pain.
When the fracture is certain, then proceed in the following manner; Let
the patient sit upon a low chair, or chest, let an assistant hold him
steady, and let another lift up the arm, and extend it gradually,
horizontal to the shoulder, keeping the elbow bent somewhat all the
while.
Then with both your hands gently press the fractured bone, so that it
may feel perfectly joined again. Sometimes it happens that the ends of
the bones are somewhat slipt over each other; in which case, extension
is the more requisite.
When this is done, then take a bandage of about two yards long, first
rolled up, and wrung out of _spirit of wine and camphor_ (A.); begin
near the elbow, and lay it smoothly on, laping over a little; and
proceed gradually till it comes to the shoulder, and then return with it
back again till it is done.
This bandage should not be too tight, nor too slack, but so as
immediately to suit the arm exactly. Over this bandage again, lay a
double folded rag, called a compress, so as to cover the bandage; and
over this again two splints, one above, and another below; which tie
gently together with some tape in three places. Then put the arm into a
sling; cover up the whole arm and hand, and let the patient go to rest.
If the fracture is upon the under arm, the reduction is a little more
difficult; but only in the care it requires of reduction. As there are
two bones in the under arm, it should well be examined which it is, or
if both. In reducing of it, let the arm be bent as before; one assistant
to hold the patient, one to hold the elbow, and another the wrist;
gently extending, till the fracture is reduced, as before directed, and
the bandage, compress, and splints, put on according to the same Method.
In this fracture the wrist and hand should be kept from moving; as the
motion of their muscles will be apt in a great measure to hinder the
bones from uniting again.
_A fractured Thigh bone._
This is of very great importance; which, from its situation, and the
strength of the muscles, in general, even by the best method is very
difficult to reduce.
Let the patient lay on the opposite side, and with the knee bent; let
the limb be extended by assistances, and carefully set it according to
the situation, similar to the beforementioned method.
This limb requires a very long bandage, and very large splints. The
method of treatment must be as before, and the patient must be well
secured in bed. He should not lie constantly upon his back in a straight
posture, as formerly was practised; but most part upon either side, with
his knee bent, which should be kept bent as much as possible; if he can
lay chiefly upon his sick side, so much the better; he may also move a
little his joints, in order to prevent them from growing stiff.
_A fractured Leg._
This accident is more common, and therefore ought to be paid the
greatest attention to.
To know for certain whether the leg is fractured, let the patient lay on
his back or on either side, with his leg and thigh bent, so that the
muscles are entirely at ease, and out of action. Let an assistant hold
up the leg by the knee; then take with one hand the ancle, with the
other the middle of the leg, and move the ancle to and fro, holding the
other hand steady, and if you feel a crackling, and the patient feels
great pain in those parts, the leg is certainly fractured; particularly
if the patient could not stand upon it before. This being fully
discovered, we must next examine which bone is fractured, the _Tibia_ or
_Fibula_; and then proceed in the following manner.
Let the patient lie as before directed; one assistant holding the knee
in a bent position, another holding the leg near the foot, both
gradually extending.
Then with both your hands reduce the fracture, by gently pressing it
with the palm of your hand while it is extending. Then lay on a long
roller; or, what is still better, a many-tailed bandage, which is made
thus: Take nine or ten slips of linen, about two inches broad,
increasing from twelve to twenty inches in length, laying over each
other about half an inch. The whole bandage must be secured with a slip
of linen behind, so as to make the breadth of the bandage the length of
the leg; either of these must be previously wrung out in camphor
spirits.
If you make use of the roller, begin laying it on from the ancle, going
gradually upwards, folding each round over half an inch at a time; and
under the calf of the leg, give the bandage a single twist, by which it
will always suit. Continue this till the whole is finished.
Over this again put a compress, and then put on the splints, (previously
bolstered with some tow) which secure with tape, as before observed with
the fracture of the arm.
The many-tailed bandage is however superior to the roller, in the
fracture of the Leg. The method of laying it on is this: the patient
laying upon his back, with his thigh lifted upwards by the assistant,
put the bandage under the calf of the leg; then begin from the ancle
upwards, folding over alternately the tails of the bandage, so that they
secure each other. When this is compleated, put over the whole a
_Compress_, as before directed, as also the _Splints_; or in the room of
common splints, put on the new invented splints of Mr. Sharp; of which a
ship should have three or four pair of different sizes, both for the
right and left leg.
When this is performed, the patient should be put to rest as soon as
possible; and he will lay easiest upon the side where the fracture is,
with his thigh and leg bent forwards. This position suits not only best
on board a ship where the motion is continually apt to disturb the sick
part, but is also most natural both for ease, and for healing; as the
muscles are all at rest, and adds firmness and ease to the body.
_Compound Fractures._
When a fracture is attended with a wound, it is needless to observe,
that the case is of a more dangerous nature. If the contusion has been
so great, as to splinter the bones, such splints as are loose, and seem
to prick through the flesh, should by all means be removed. Violence
must however be avoided; for by a little patience, nature will of her
own accord separate and discharge them.
Gentleness should ever be observed in surgery, though not a timid
weakness, by being defective in dressing properly. The reduction of the
fracture should be conducted the same as before, with this difference,
that always a many-tailed bandage should be chosen, so that it may be
opened when requisite.
The dressing of the wound should be the simplest possible; for the
nature of bone is so delicate, that it will neither bear to be much
exposed to the air, nor suffer any greasy salve or ointment to come near
it; both are liable to corrode it, and bring on a carious, which is of a
most dangerous tendency. Dry lint therefore is the best, particularly
near the fractured bone.
In short, it is to be treated cautiously, like an ulcer, and the
greatest care to be taken, that the arm, leg, or whatever fractured part
it is, be kept steady, and no oftener dressed than what is absolutely
necessary.
_Conclusive Observations on Fractures._
In the obscure times of surgery, various medicines were applied to
broken bones, with a notion to unite them the sooner. This, however, is
entirely exploded from modern practice.
The inflammation that generally attends fractures requires however a
fomentation of _Camphor Spirits_ (A), in order to disperse the
obstructed humour; but if there is no inflammation, the part undoubtedly
is the better without such applications; as then there will be nothing
to hinder a free circulation; for which reason, fomentation should be
used as sparingly as possible.
It is well known too, with what difficulty the fractured bones were set
formerly, owing principally to the limb being stretched out in a
position that excited all the muscles to contraction. This is also here
obviated.
In reducing therefore a dislocation or fracture, the muscles should be
as much at rest as possible, both in the operation, as well as during
the whole time of the cure. It is for that very reason my direction in
this respect differs from what has been delivered to us by authors on
that subject, particularly such, as might be expected to fall into the
hands of a seaman.
Another error has been practised, namely, the laying on the bandage very
tight. It was supposed, that that would strengthen the limb, and make
the bone smooth; but it has sometimes prevented the bones from growing
together at any rate. The bandage to be sure should not be too slack,
for then we might as well lay it aside entirely. A bandage certainly is
necessary, but merely as a support, and it should never be tighter than
what the patient can well bear.
In simple fractures, the first dressing should be so permanent, as to
have no need for being removed, at least for six, seven, eight, nine
days, or more; if the patient don’t feel uneasy. For my own part, having
ever been successful in fractures, I have not opened the first dressing
for a fortnight, and sometimes three weeks.
The laying stretched upon the back when a leg is fractured, is
altogether needless, troublesome, and even a hindrance to the healing.
The patient should have a good wide cot, and so that it may swing pretty
easy; or else entirely confined, when the ship has much motion; and
having the leg well secured with splints, he may safely lay on what side
he pleases, provided he does not sit up in the bed (though he may out of
it) for the first three weeks; for that strains the muscles very much.
The diet should be sparing, the body kept open, and a temperate warmth
should be preserved, in order to promote perspiration. Drinking of
strong liquors should by all means be avoided, and the diet should be as
fresh as the circumstances will permit.
Six weeks is generally the time allowed for the cure; that however is no
certain rule. If the fracture is simple, and the constitution good, then
at a month’s time a small trial may be made by the help of crutches, or
a trusty mess-mate, in a calm day; but if it occasions the least pain,
it should be postponed.
This is then all I have of consequence to observe in simple fractures;
which holds good also with compound ones, except that the wound requires
to be dressed oftener; but the greatest care should be taken, that it is
done in a manner, so as not to disturb the knitting of the bone.
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