Part 7

As these kind of wounds are liable of becoming ulcers, great care should be taken in the beginning to treat them properly.—Wounds in general should not be dress’d or look’d to too often; in general it aggravates the parts, and retards healing. A wound should not be opened the first three days after the first dressing: nature is very kind, and requires care only to replenish what is deficient.

When an ulcer has commenced, see the treatment under that head.

_Gun-shot Wounds._

These are the most terrible of all sorts of wounds; for it is not only the contusion that attends them, but frequently the ball forces strange things, as cloaths, &c. into the wound with it.

Gun-shot wounds at best are tedious in their healing, but very often, from their nature, liable to mortification, and thence become dangerous. Besides, it is seldom that the fleshy parts alone are wounded, but they frequently penetrate into the very bones themselves.

The first care in gun-shot wounds, is to extract the ball, or whatever is forced into the wound; in the next place, the wound should be dressed with _Yellow Basilicon_, (F) mixed with fine _Precipitate_ (O).

No. I

_Take Basilicon one ounce, fine Precipitate one scruple, and mix them._

The parts all round should be well fomented with warm claret, intermixed with _Spirits of Wine and Camphor_.

If the patient is full-bloody, and no blood lost by the wound, he should be blooded, and immediately treated as a patient in a fever.

If the pain in the parts become violent, eight or ten drops of _liquid laudanum_ (T), together with thirty or forty drops of _sweet spirit of nitre_ (D), should be given once, twice, or thrice a day. If the wound begins to discharge plenty of matter, it should be dressed with the same dressing often. But if the parts become black, very fœtid, the patient in great pain, and grows faint, a mortification is to be feared; which I shall treat of in its proper place.

When the suppuration is unkind, and the parts are much inflamed, a poultice will be very proper.

No. II

_Take oatmeal (15) or (if that is not on board) biscuit pounded about three spoonfuls, honey one spoonful, water a sufficient quantity to boil it into soft poultice; in which put of sweet oil about half a spoonful. This poultice should be renewed twice a day at least, and put on as warm as possible it can be borne._

As gun-shot wounds are apt to degenerate into malignant ulcers, I shall refer the reader to the treatment of ulcers in general.

SECT. III.

_Of Bruises._

Bruises, in whatever degree, have more or less some blood and other vessels torn and injured, and may properly be considered as wounds under whole skin. It is from the tearing to pieces blood vessels, whereby the blood extravasates from their natural channels, that occasions the swelling. If the bruise is but slight, the vessels are soon enabled to circulate the humours; but if the contusion is great, the extravasated humours are apt to corrupt, and make a collection of matter; thence an aposthume and ulcer must naturally follow.

Bruises on fleshy parts are not so bad by far, as on the joints, because the fibres in the muscles are more pliable, and sooner unite; the ligaments on the joints are very rigid, and extremely sensible; for which reason also, they are generally more painful and tedious in their cure.

The first intention is to disperse the extravasated humour, and to strengthen the tone of the injured fibres. To this intention the parts should immediately be bathed with _spirit of wine and camphor_ (A). But if the bruise is immediately on the joints, the _linament of soap_ (B) is still superior. A bandage over the part, so as to keep it in rest as much as possible, is also of great service. If, however, the part is so very much bruised, that there appears a collection of crumous blood, and that an aposthume is actually the consequence, recourse may be had to the above poultice in order to ripen it the more, and bring it the sooner to a head; and then treat it as a common ulcer. But that seldom is the case.

If the contusion is great, and the patient is full of blood, bleeding is necessary; for in such a case a fever is apt to ensue, which should be guarded against, and the patient treated accordingly.

SECT. IV.

_Of Dislocations_

There are many accidents by which a limb may become dislocated; the reduction of which is a material point in surgery. But if a surgeon is not at hand, a man ought nevertheless, not to remain in that painful and deplorable state, that endangers not only the limb of becoming useless, but even the loss of life itself.

I shall proceed therefore in my directions as plain as possible, avoiding every expression that may render this operation prolix.

It must first of all be remembered what was said of joints, articulations, and ligaments in the first lecture under that head. We must thence observe, that a dislocation of the upper arm with the shoulder is the most common that happens, because of the great variety of motion, and the flatness of the head of the arm-bone, and the cavity of the shoulder blade. Next to this is the thigh bone, with the hip. But this is done by much greater force, and therefore more troublesome in reducing. All other joints that are angular are seldom really dislocated, being stronger secured, and cannot be separated from their articulation, without first tearing the ligamentous capsula that surround them; yet nevertheless, some are subjected to be partly dislocated; and this is what is commonly called sprains.

Dislocations may be from two causes; first from violence, secondly from weakness of the ligament. In the latter case the reduction is the easiest, but the limb is apt to slip out again by the least accident.[11]

Footnote 11:

I remember a man who frequently had his shoulder dislocated, and was his own operator in reducing it again. The first time the accident happened in the ship I was surgeon of, I was naturally called to his assistance: “Stop Doctor,” (said Tom) “I have got a tackle in my chest, and I will soon bouse it in again;” and sure enough, he had a pully, with which he immediately reduced it.

I shall briefly consider each kind of dislocation, that an accident makes a man liable to.

_Dislocation of the Arm with the Shoulder._

The dislocation of that, may be two ways; (viz) downwards, and forwards; but it cannot be backwards nor upwards; except some part of the shoulder-blade be broke.——The best method to examine the patient what kind of dislocation it is, (especially to one unacquainted with these branches of surgery) is strictly to compare both shoulders, and the difference will be very plain, both to sight and touch.

If the dislocation is downwards that is, the head of the arm-bone, slipt in the arm-pit, there will be a cavity on the top of the shoulder, different from the sound arm, and the elbow will be drawn upwards, without being able to be moved either towards the body; or so, as the patient to put his hand out without the greatest pain.

When this is found to be the case, then, in order to reduce it, set the patient low, on a steady seat. Take a napkin or towel, of which make a girt; put one part over your neck, and the other part under the arm-pit. Let an assistant hold the patient steady, another take hold of the patient’s arm, with the elbow bent, and extend it gradually; then with both your hands take the arm, and whilst you lift up the arm by help of the napkin resting on your neck, you press gently down the arm with your hands like a lever; in the mean time the assistant extends, and thus you reduce it; which you will hear by its snapping: upon which the patient will be able to move his arm in all kind of direction, without much pain.

If the head of the arm-bone is dislocated forwards, there will be a cavity backwards on the shoulder, and the elbow will stick backwards, and remain motionless, with great pain. In this case, as before, let the patient sit low, and with the help of the napkin, and assistances, first extend the arm forwards; then like a lever bring the head of the bone in its cavity; which, like the former, will be perceived by a snapping, and the voluntary motion of the patient’s arm.

When the shoulder is reduced, secure the whole with a long double-headed bandage, cross-wide over the shoulders, and round the body. Foment it night and morning with _spirits of wine and camphor_ (A). Keep the arm close to the body, with the elbow bent, and wear it in a sling, that it may be free from motion till it is well.

_Dislocation of the Elbow, or the Knee._

The elbow, as I said before, is very seldom dislocated, unless fractured, and the ligament tore at the same time; and when so, the case is terrible. But very often those joints receive a wrench, which, though nothing out of its place, is often very painful, on account of the many tendons that surround the parts. The only thing in such wrenching, is to foment it with _spirit of wine and camphor_ (A), or else the _saponaceous linament_ (B). The same method should be observed with the knee, securing it well with a bandage, in order to give it rest to recover: For rest is a principal remedy.

_Of spraining the Wrist, or Ancle._

The wrist and ancle are complicated joints, and thence capable of a great number of motions, and subject to a variety of sprainings, but not a perfect dislocation; nevertheless, they are very painful, and sometimes tedious in getting well. Whatever be the matter, the sick part should be compared with the sound, and the difference is soon seen.

If it so happens, that there appears a perceivable difference, the parts should be gently extended, and reduced; and all that is to be done, is the securing it well with a bandage, and fomenting it with _Spirits of Wine and Camphor_, (A) or, what is yet better, _Linament of Soap_. (B)

The thumb, however, is liable to be dislocated, which is easily perceived; which should be immediately reduced, and secured with a bandage, and treated as already directed.

_Dislocation of the Thigh Bone._

The articulation of the thigh bone with the hip is similar to the shoulder, with regard to the head of the bone, and the pan in which it moves, except that it is much deeper. It must be a great force that drives it out of its articulation, and consequently very difficult to be reduced. It may either be dislocated inwards, or backwards.

If the dislocation is inwards, which is the most common, the toes will be turned outwards, and the whole leg and thigh will be somewhat shorter than the other; so likewise, if it is dislocated backwards, the leg and thigh will appear shorter, but the toes will be bent inwards. The best way of determining, as I have said before, is to make a just comparison of the sick and sound leg.

The reduction is somewhat difficult, and will sometimes baffle the most experienced surgeon, because the acting muscles are very strong; and when they have first begun to contract the parts, they will not easily suffer themselves to be relaxed. Nevertheless, lay the patient upon his back or on the sick side, upon a steady table; let an assistant hold him fast, another extend the thigh, so as to have the knee bent; the operator having a napkin resting on his neck, and under the thigh of the patient, similar to the method directed before by the shoulder; and then with both hands bend the thigh, as with a lever, into its socket again; when it will give a loud snap, coming into its proper place.

It very frequently happens in this heavy dislocation, that either the articulation is not reduced, or that it immediately slips out again when reduced; so that the patient will never recover the former use of that limb more. In this case nature is very kind, and the part where the bone slips into will become callous, and form as it were a new acetabulum; by which the patient in time comes to walk, though (as it may be supposed) but lamely. In the course of my practice I have met with but two perfect dislocations of the thigh, both of them perfectly recovered; but it must be remembered, they had youth on their side, and the greatest care joined to favourable circumstances.

At best however, it is an ugly accident, for it is not only that the ligaments that surround the joint are generally torn, but very often the thigh bone is fractured at the same time. It requires more skill than one would suppose, to determine which is the case, whether a fracture, dislocation, or both; and am apt to believe they are often confounded with each other.

When the dislocation is reduced it should be well secured with a long double-headed bandage; the patient kept still, the part well fomented, and if requisite, some blood taken away: a fever generally attends, which should be duely taken care of.

On the whole, dislocations when they proceed from violence, are sometimes attended with severe symptoms, the parts being very sensible, and it will require sometime for the patient to recover his strength again.—Care therefore should be taken to keep the parts warm, and give them as much rest as possible.

A strengthening plaister spread upon leather, and put for a constancy round the parts after the inflammation is gone of, will also prove of singular service.

SECT. V.

_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.