Part 136

_Broken bones._--Never move a patient with a broken bone till it has been suitably bandaged. Broken bones (fractured) are of three kinds--(_a_) simple fracture, when the bone is simply broken in one place; (_b_) compound fracture, when there is a wound in the flesh communicating with the broken ends of the bone; (_c_) comminuted fracture, when the bone is broken into pieces. The occurrence of a fracture may almost always be learned from the history of the accident, the patient having generally felt or heard the bone snap; other indications are deformity of the limb, such as shortening or bending, and on taking hold of the limb, you will find there is increased movability, and will hear and feel a peculiar grating caused by the broken ends of the bone rubbing against each other, called “crepitus”; also pain and loss of power in the limbs.

It is not imperatively necessary to do anything to a broken limb before the arrival of a doctor, except to keep it perfectly at rest, unless the patient must be moved; then, to prevent further mischief, the broken ends of the bone _must_ be put in position and kept there. The first step is to pull the limb till the sinews and muscles stretch sufficiently to let the two ends of the bone meet each other. When this has been done, splints and bandages must be applied to keep the ends from shifting again.

The treatment of a broken bone then consists of (1) carefully removing or cutting away, if more convenient, any of the clothes which are compressing or hurting the injured parts; (2) very gently replacing the bones in their natural position and shape, as nearly as possible, and putting the part in a position which gives most ease to the patient; (3) applying some temporary splint or appliance, which will keep the broken bones from moving about and tearing the flesh, for which purpose you may use pieces of wood, stick, tin, pasteboard, wire, straw, or firmly folded cloth, taking care to pad the splints with some soft material, and not to apply them too tightly, while the splints may be tied by loops of rope, string, pockethandkerchiefs, pieces of cloth, or any kind of cord; (4) conveying the patient home or to a hospital, meanwhile examining the loops to see that they do not become too tight by rapid swelling of the part.

To get at a broken limb or rib, the clothing must be removed, and it is essential that this be done without injury to the patient. The simplest plan is to rip up the seams of such garments as are in the way. Boots must be cut off.

In a fracture of a leg bone, after setting the broken limb and putting it in splints, it should be bound to the sound leg at the knee and ankle, with rolled up coat for the sides and a piece of thin board or other substance for the front of the thigh. A broken arm, when in splints, requires the support of a sling, which may be made of a handkerchief fastened round the neck.

Bandaging can hardly be learned from a book--some practice is essential. Bandages are made of unbleached calico, flannel, linen, &c., and are used as supports to the different parts of the body, as means of applying pressure, for fixing splints, dressing, &c., and for allaying muscular action. The chief kinds are the roller and the triangular bandages.

Roller bandages commonly have the following dimensions: Finger, 1 yd. by ¾ in.; arm, 3-6 yd. by 2½ in.; leg, 6-8 yd. by 3 in.; chest, 8-12 yd. by 4-5 in.; head, 4-6 yd. by 2½ in. To roll one of these bandages, first fold one end 2 or 3 times, as tightly as you can, making it into a small roll; take hold of this by the fingers of both hands, both thumbs being placed on the top of it, the rest of the bandage being held by another person, who keeps it moderately strained; by alternate movement of the thumbs make the roll revolve on its own axis, the fingers at the same time holding it in position between the hands; fasten the end by a stitch or pin, to prevent unrolling.

Roller bandages are applied in 3 different ways: (1) simple spiral, (2) reverse or recurrent, (3) crucial or figure-of-8. When first applying the bandage, leave the end a little long, so that when the first turn is made, by laying this end under, and bandaging over it again, it is prevented from slipping. The application of the simple spiral is shown in Figs. 112, 113, each turn overlapping the preceding one to the extent of about ⅔rds the width of the bandage. This simple spiral is generally replaced by the reverse spiral, Fig. 114, which differs from it in that the bandage is turned back upon itself each time it is carried round the limb; it is not easily learnt, and requires practice before it can be done well; the thumb or forefinger of the hand not holding the bandage should be laid upon the limb at the point where the turn of the bandage is to be commenced, the other hand turning the bandage back upon itself. The crucial or figure-of-8 form is generally used at the joints, and always when going over the ankle-joint in bandaging from the foot up the leg. Carry the bandage over the upper part of the joint, then down, under, and across the lower part, and then up over the upper part again. Remember always to bandage from within outwards; commence from below and work upwards; let the pressure be evenly and uniformly applied, but not too lightly; avoid all wrinkles in your bandage; reverse or turn a bandage over always on the fleshy side, and not over a bone; fasten it with a few stitches.

The triangular bandage may well be represented in every-day life by an ordinary large pockethandkerchief folded from corner to corner. Its application is almost endless and simplicity itself. A few examples of the manner in which it may be used are shown in Figs. 115, _a_, _b_, _c_, _d_; it is fastened merely by tying the ends in a double knot.

Broken ribs are of common occurrence, and give rise to great pain, because every time the injured person breathes, the ribs, rising and falling, allow the broken ends to grate against each other. A temporary method of relieving this pain and keeping the broken ends in apposition, is to roll a wide flannel or calico bandage tightly round the chest 3 or 4 times.

_Burns and Scalds._--(_a_) In all but very slight cases of burns and scalds, the patient should be seen by a doctor at once, as the constitutional symptoms consequent upon these accidents require skilled attention. With regard to the immediate local applications. The clothes having been most gently and cautiously removed (being cut in all places where they adhere to the burnt and scalded skin) and any blisters having been simply pricked, the surface should at once be covered with some unirritating substance which excludes the air and keeps up a good heat. For this purpose many things are advocated, such as flour, starch, a mixture of collodion and castor oil, and “carron oil” (equal parts lime-water and linseed oil). A smooth, thick layer of cotton wool should be laid over this, or failing that a blanket, but do not let the blanket touch any raw place without the intervention of a piece of fine linen rag soaked in oil, or it would stick, causing great pain when removed.

(_b_) Linen dipped in a solution of carbonate of soda or potash relieves the pain sooner than anything. The best form is a saturated solution of bicarbonated soda in either plain water or camphorated water; if applied speedily it is most effectual in immediately relieving the acute burning pain; and when the burn is only superficial, or not severe, removing all pain in the course of a very short time, and preventing the usual consequences--a painful blistering of the skin, separation of the epidermis, and perhaps more or less of suppuration. For this purpose, all that is necessary is to cut a piece of lint, or old soft rag, or even thick blotting-paper, of a size sufficient to cover the burned or scalded parts, and to keep it constantly well wetted with the soda lotion so as to prevent its drying. By this means, it usually happens that all pain ceases in ¼-½ hour. Where the main part of a limb, such as the hand and fore-arm or the foot and leg have been burned, it is best to plunge the part at once into a vessel filled with the soda lotion, and keep it there until the pain subsides.

(_c_) The matter given off from burnt surfaces soon emits a very offensive odour. Therefore it is wise to mix an antiseptic substance with the remedies--e.g. carbolic acid or thymol, which not only prevent the bad odour from the suppuration, but also tend to alleviate the suffering. It would be well to always keep ready mixed an ointment for burns containing 1 per cent. thymol.

(_d_) The free use of soft soap upon a fresh burn will remove the fire from the flesh in very little time. If the burn be severe, after relief from the pain, use linseed oil, and then sift upon it wheat flour. When this is dried hard, repeat the oil and flour until a complete covering is obtained. Let this dry until it falls off, and a new skin will be formed without a scar.

(_e_) Take ice well crushed or scraped, as dry as possible, into the finest division; then mix it with fresh lard until a broken paste is formed. The mass is put into a thin cambric bag, laid upon the burn or scald, and replaced as required. So long as the ice and lard are melting there is no pain from the burn; return of pain calls for the repetition of the remedy.

(_f_) Whether the skin is broken or not, apply soft cotton or linen rags, dipped in a solution of Epsom salts, 1 oz. to the pint of cold water, and lightly bound over the burnt part or parts, the bandages to be kept constantly moist with the solution, and never removed till a cure is effected, which will be in 2-3 hours to 2-3 days, according to the severity and extent of the burning. While this application in all cases gives instant relief from pain, it is especially useful in removing the tendency to collapse and nervous dread.

(_g_) Cover the place over at once with the preparation of chalk, called common kitchen whiting, mixed, either with sweet oil or water--oil is preferable--into a thick paste. Plaster it gently on with a brush or a feather about ⅛ in., or more, thick; taking care, if possible, not to break the blister, or blisters. Then cover the part affected with a piece of flannel, to keep the moisture in, and damp the layer of whiting from time to time with oil or water. If kitchen whiting cannot be procured, use flour instead; and if neither can be had, then cover the scalds or burns with bits of rag dipped in sweet oil, and lay plenty of cotton wool outside them. Change the dressings only often enough to keep the places clean, and then wash them off with a weak solution of carbolic acid.

(_h_) A method in use in the public hospitals of the city of New York, known as “glue burn mixture” is composed as follows 7½ troy oz. white glue, 16 fl. oz. water, 1 fl. oz. glycerine, 2 fl. dr. carbolic acid. Soak the glue in the water until it is soft; then heat on a water-bath until melted; add the glycerine and carbolic acid, and continue heating until, in the intervals of stirring, a glossy, strong skin begins to form over the surface. When wanted for use, heat on a water-bath, and apply with a flat brush over the burned part. Pour the melted mass into small delf extract jars, cover with paraffin-paper and tin-foil before the lid is put on, and afterwards protect by paper pasted around the edge of the lid. In this manner, the mass may be preserved indefinitely.

(_i_) Saturate a soft piece of fabric with alcohol, lay it over the burn, then cover it with cotton or finely picked oakum: it will allay the pain. Subsequently disturb the dressing as little as possible; wet the dressing occasionally with alcohol. In burns from strong nitric acid, copious application of cold water, and even of such powerful bases as ammonia, potash, and lime in water, have no perceptible effect, except perhaps to increase the violence of the inflammation. But the effect of a dilute solution of sulphurous acid is astounding. In a very few minutes the blister will be reduced; the oxidising process of the acid will be completely arrested, the painful irritation removed, and in a short space of time the wound will heal. (A. Irving.)

In bad burns with lime, soap lye, or any caustic alkali, wash abundantly with water (do not rub), and then with weak vinegar or water containing a little sulphuric acid; finally apply oil as in ordinary burns.

(_j_) To recover a person in a state of insensibility from the effect of smoke, dash cold water in the face, or cold and hot water alternately. Should this fail, turn him on his face, with the arms folded under his forehead. Apply pressure along the back and ribs, and turn the body gradually on the side; then again slowly on the face, repeating the pressure on the back. Persevere with these alternate rolling movements about 16 times in a minute, until respiration is restored, A warm bath will now complete the recovery.

(_k_) In scalding by boiling water or steam, cold water should be plentifully poured over the person and cloths, and the patient then be carried carefully to a warm room, laid on the floor or carpet, or on a table, but not put into bed (as there it becomes difficult to attend further to the injuries), to await the doctor. If the patient complains of thirst, a warm, stimulating drink (such as tea) should be given, as after severe burning the temperature of the body is sure to fall. Children sometimes receive serious scalds of the mouth and throat by swallowing hot fluid or steam from a spout. Medical assistance should be obtained without delay, as an immediate operation may be required to prevent death from suffocation. Until the arrival of the doctor the patient should inhale warm vapour, to relieve the fits of choking; the best way to make a person inhale vapour is to construct a kind of tent of blankets around the patient, and allow the steam from a kettle, to puff into it.

_Carrying injured persons._ (_a_) By Bearers.--If no conveyance can be procured or improvised, you can transport an injured person a short distance by human bearers. If only one is available, and if the patient can stand up, let him place one arm round the neck of the bearer, bringing his hand on and in front of the opposite shoulder of the bearer. The bearer then places his arm behind the back of the patient and grasps his opposite hip, at the same time catching firmly hold of the hand of the patient placed on his shoulder with his other hand. Then by putting his hip behind the near hip of the patient much support is given, and, if necessary, the bearer can in this way lift him off the ground, and, as it were, carry him along. This is an admirable way of helping an invalid to walk up stairs. If the patient cannot stand, the only way in which one person can remove him is by getting him on his back; this is not practicable in a case of broken thigh (Fig. 116).

When 2 bearers are available, the patient may be carried several different ways:--(1) In a sitting position, by the bearers joining two of their hands underneath his thighs, close to the buttocks, while their other two hands are placed round his loins and clasped together. The patient, if able, can help to support himself by clasping the bearers round their necks. (2) By 2 of the bearers’ hands forming a seat and the other 2 arms a back support (Fig. 117). (3) By 3 of their hands forming a seat, while a back support is made by the remaining arm (Fig. 118). (4) A seat may be made with all 4 hands, and especially if the patient is able to sit up and help support himself by placing his arm over the shoulders of the bearers, he may be carried a long distance by this method. Fig. 119 shows another plan, and Fig. 120 indicates how the hands should grasp each other.

(_b_) By Stretcher.--To place an injured person on a stretcher and convey him properly requires 3 bearers, unless the distance be very great; 2 carry the stretcher, and a third attends to the patient, and changes place with one of the bearers if necessary. To lay a patient on it, put the foot of the stretcher at his head in a line with his body; 2 bearers then place themselves one at either side, join hands underneath the back and hips of the patient, raise him up, lift him backwards over the stretcher, and lower him on to it. The third bearer takes charge of the injured portion (limb or head), and steadies it with a hand on either side. The two bearers now take their places at the head and foot of the stretcher, lift it up, and carry it off; while the third walks at the side of it, as a safeguard to the patient. Observe the following rules in carrying a stretcher: (1) Carry it with the hands, or suspended by straps over the bearers’ shoulders, never place it on the shoulders, because the patient might fall off, or even die, without the bearer observing it. (2) Do not keep step, i.e. do not put the same foot forward, then the motion of the stretcher remains even. The pace must be short (about 20 in.) and without a spring; the knees must be rather bent, and the hips moved as little as possible. Jolting, hurrying, crossing ditches, &c., are to be avoided. Choose bearers of the same height, arrange the shoulder-straps so that the head may be carried a little higher than the feet.

_Convulsions._--Till medical aid can be procured, put the child into a warm bath, in which you can bear your elbow. Sponge him well over, and put a sponge of cold water on his head.

_Cuts and Wounds._--Wounds may be “incised” (made by a clean-cutting instrument), “punctured” (when the depth exceeds the breadth, as in stabs), “lacerated” (torn, and the lips of the wound irregular), and “contused” (effected by bruising). The chief points to be attended to are:--(_a_) Arrest the bleeding. (_b_) Remove all foreign bodies as soon as possible. (_c_) Bring the wounded parts in apposition, and keep them so, best done by means of strips of adhesive plaister, first applied to one side of the wound, and then secured to the other; these strips should not be too broad, and space must be left between the strips to allow any matter to escape; wounds too extensive to be kept together by plaister, must be stitched by a surgeon. For punctured and severely lacerated or contused wounds a surgeon should be sent for.

For washing a wound, to every pint of water add either 5 gr. corrosive sublimate or 2½ teaspoonfuls carbolic acid. If the acid is used, add 2 tablespoonfuls glycerine, to prevent its irritating the wound. If there is neither of these articles in the house, add 4 tablespoonfuls borax to the water. Wash the wound, close it, and apply a compress of a folded square of cotton or linen. Wet it in the solution used for washing the wound, and bandage down quickly and firmly. If the bleeding is profuse, a sponge dipped in very hot water and wrung out in cloth should be applied as quickly as possible. If this is not available, use ice, or cloths wrung out in ice water.

Wounds heal in two ways.--(_a_) Rapidly, by primary union without suppuration, and leaving only a very fine scar; this only when the sides of wound can be accurately brought together, are not displaced by bleeding or exudation of matter, and when the wound is left quiet, protected from outward injury, and kept perfectly free from impurity. (_b_) Slowly, with suppuration, and the formation of granulations, and leaving a large red scar, as when so much skin has been destroyed that the edges of the wound cannot be brought together, or so lacerated and bruised that life is destroyed in them, or separated by blood or exudation of matter, or if the injured parts have been disturbed, or the wound has not been properly cleaned and disinfected. Want of cleanliness leads to putrefaction and the formation of matter, which separates the sides of the wound.

_Drowning, Choking, and Suffocation._--The fatal termination to be avoided in all these cases is suspension of breathing, hence they may be classed under one head.

Drowning.--This is perhaps the most common, and embraces in great measure the remedies adapted to the other forms of suffocation. The first step is to send immediately for medical assistance, blankets, and dry clothing; but proceed to treat the patient _instantly_ on the spot, in the open air, with the face downward, whether on shore or afloat; exposing the face, neck, and chest to the wind, except in severe weather, and removing all tight clothing from the neck and chest, especially the braces.

The points to be aimed at are--_immediately_ the restoration of breathing; and, after breathing is restored, promotion of warmth and circulation. Efforts to restore breathing must be commenced immediately and energetically, and persevered in for 1-2 hours, or until a doctor has pronounced life extinct. Efforts to promote warmth and circulation, beyond removing wet clothes and drying the skin, must not be made until the first appearance of natural breathing; for if circulation of the blood be induced before breathing has recommenced, the restoration to life will be endangered.

To restore breathing, place the patient on the floor or ground with the face downwards, and one of the arms under the forehead, in which position fluids can more readily escape at the mouth, and the tongue will loll out, leaving the entrance to the windpipe free. The tongue may be easily kept extended by simply passing a small rubber band round it and the chin. The mouth and nose must be thoroughly wiped and cleaned from obstructions.

If breathing has quite or almost failed, means must be used to restore it; if not, proceed at once to promote warmth. There are several ways of inciting suspended respiration. The best, as requiring only one person, is Silvester’s method, as follows: Place the apparently dead person flat on his back, raising his head and shoulders slightly by means of a folded article of dress. Standing behind him, grasp his arms just above the elbow, and draw them gently and steadily upwards over the head, keeping them in that position for 2 seconds; by this means the chest expands and air is drawn into the lungs (Fig. 121). Then carry the arms back again in the same way and press them gently and firmly against the sides of the chest for 2 seconds; by this means the air is pressed out of the lungs again (Fig. 122). These movements are repeated carefully and perseveringly, about 15 times in a minute, till natural respiration begins. The first evidence of this is a sudden flush of colour in the face.

When 2 persons are present, Francis’s plan may be adopted, thus: The body of the patient is laid on the back, with clothes loosened, and the mouth and nose wiped; 2 bystanders pass their right hands under the body at the level of the waist, and grasp each other’s hands, then raise the body until the tips of the fingers and the toes of the patient alone touch the ground; count 15 rapidly; then lower the body flat to the ground, and press the elbows to the side hard; count 15 again; then raise the body again for the same length of time, and so on, alternately raising and lowering. The head, arms, and legs are to be allowed to dangle down quite freely when the body is raised.

When 3 or more persons can assist, Marshall Hall’s method is available. To excite breathing, turn the patient quite on the side, supporting the head, and induce inspiration and expiration by alternately rolling the body over on its face, and back again, at 15 seconds intervals, as shown in Figs. 123 and 124.