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.
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.