TO describe all the operations of surgery, and to point out the different diseases in which these operations are necessary, would extend this articIe far beyond the limits set to it: we must therefore confine our observations to such cases as most generally occur, and in which proper assistance is either not asked, or not always to be obtained.
THOUGH an acquaintance with the structure of the human body is indispensably necessary to qualify a man for being an expert surgeon; yet many things may be done to save the lives of their fellow-men in emergencies by those who are not adepts in anatomy. It is amazing with what facility the peasants daily perform operations upon brute animals, which are not of a less difficult nature than many of those performed on the human species; yet they seldom fail of success.
INDEED every man is in some measure a surgeon whether he will or not. He feels an inclination to assist his fellow-men in distress, and accidents happen every hour which give occasion to exercise this feeling. The feelings of the heart, however, when not directed by the judgment, are apt to mislead. Thus one, by a rash attempt to save his friend, may sometimes destroy him; while another, for fear of doing amiss, stands still and sees his bosom-friend expire, without so much as attempting to relieve him, even when the means are in his power. As every good man would wish to steer a course different from either of these, it would no doubt be agreeable to him to know what ought to be done upon such emergencies.
NO operation of surgery is so frequently necessary as bleeding; it ought therefore to be very generally understood. But though practiced by Midwives, Gardeners, Blacksmiths, &c. We have reason to believe that very few know when it is proper. Even physicians themselves have been so much the dupes of theory in this article, as to render it the subject of ridicule. It is, however, an operation of great importance, and must, when seasonably and properly performed, be of singular service to those in distress.
BLEEDING is proper at the beginning of all inflammatory fevers, as pleurisies, peripneumonies, &c. It is likewise proper in all topical inflammations, as those of the intestines, womb, bladder, stomach, kidnies, throat, eyes, &c. as also in the asthma, sciatic pains, coughs, head-achs, rheumatisms, the apoplexy, epilepsy, and bloody flux. After falls, blows, bruises, or any violent hurt received either externally or internally, bleeding is necessary. It is likewise necessary for persons who have had the misfortune to be strangled, drowned, suffocated with foul air, the fumes of metal, or the like. In a word, whenever the vital motions have been suddenly stopt from any cause whatever, except in swoonings, occasioned by mere weakness or hysteric affections, it is proper to open a vein. But in all disorders proceeding from a relaxation of the solids and an impoverished state of the blood, as dropsies, cacochymies, &c. bleeding is improper.
BLEEDING for topical inflammations ought always to be performed as near the part affected as possible. When this can be done with a lancet, it is to be preferred to any other method, but where a vein cannot be found, recourse must be had to leeches or cupping.
THE quantity of blood to be let must always be regulated by the strength, age, constitution, rnanner of life, and other circumstances relating to the patient. It would be ridiculous to suppose that a child could bear to lose as much blood as a grown person, or that a delicate lady should be bled to the same extent as a robust man.
FROM whatever part of the body blood is to be let, a bandage must be applied betwixt that part and the heart. As it is often necessary, in order to raise the vein, to make the bandage pretty tight, it will be proper in such cases, as soon as the blood begins to flow, to slacken it a little. The bandage ought to be applied at least an inch, or an inch and half from the places where the wound is intended to be made.
PERSONS not skilled in anatomy ought never to bleed in a vein that lies over an artery or a tendon, if they can avoid it, the former may easily be known from its pulsation or beating, and the latter from its feeling hard or tight like a whip cord under the finger.
IT was formerly a rule, even among those who had the character of being regular practitioners, to bleed their patients in certain diseases till they fainted. Surely a more ridiculous rule could not be proposed. One person will faint at the very sight of a lancet, While another will lose almost the whole blood of his body before he faints. Swooning depends more upon the state of the mind than of the body; besides, it may often be occasioned or prevented by the manner in which the operation is performed.
CHILDREN are generally bled with leeches. This, though sometimes necessary, is a very troublesome and uncertain practice. It is impossible to know what quantity of blood is taken away by leeches; besides, the bleeding is often very difficult to stop, and the wounds are not easily healed. Would those who practise bleeding take a little more pains, and accustom themselves to bleed children, they would not find it such a difficult operation as they imagine.
CERTAIN hurtful prejudices with regard to bleeding still prevail among the country people. They talk, for instance, of head-veins, heart-veins, breast-veins, &c. and believe that bleeding in these will certainly cure all diseases of the parts from whence they are supposed to come, without considering that all the blood vessels arise from the heart, and return to it again; for which reason, unless in topical inflammations, it signifies very little from what part of the body blood is taken. But this, though a foolish prejudice, is not near so hurtful as the vulgar notion that the first bleeding will perform wonders. This belief makes them often postpone the operation when necessary, in order to reserve it for some more important occasion, and when they think themselves in extreme danger they fly to it for relief, whether it be proper or not; bleeding at certain stated periods or seasons has likewise bad effects.
IT is likewise a common notion that bleeding in the feet draws the humours downwards, and consequently cures diseaes of the head and other superior parts; but we have already observed that, in all topical affections, the blood ought to be drawn as near the part as possible. When it is necessary, however, to bleed in the foot or hand, as the veins are small, and the bleeding is apt to stop too soon, the part ought to be immersed in warm water, and kept there till a sufficient quantity of blood be let.
WE shall not spend time in describlng the manner of performing this operation. That will be better learned by example than precept. Twenty pages of description would not convey so just an idea of the operation as seeing it once performed by an expert hand. Neither is it necessary to point out the different parts of the body from whence blood may be let, as the arm, foot, forehead, temples, neck, &c. These will readily occur to every intelligent person, and the foregoing observations will be sufficient for determining which of them is most proper upon any particular occasion. In all cases where the intention is only to lessen the general mass of blood, the arm is the most commodious part of the body in which the operation can be performed.
FROM whatever cause an inflammation proceeds, it must terminate either by dispersion, suppuration, or gangrene. Though it is impossible to foretel with certainty in which of these ways any particular inflammation will terminate, yet a probable conjecture may be formed with regard to the event, from a knowledge of the patient's age and constitution. Inflammations happening in a slight degree upon colds, and without any previous indisposition, will most probably be dispersed; those which follow close upon a fever, or happen to persons of a gross habit of body, will generally suppurate; and those which attack very old people, or persons of a dropsical habit, will have a strong tendency to gangrene.
IF the inflammation be slight, and the constitution sound, the dispersion ought always to be attempted. This will be best promoted by a slender diluting diet, plentiful bleeding, and repeated purges. The part itself must be fomented and, if the skin be very tense, it may be embrocated with a mixture of three-fourths of sweet oil, and one-fourth of vinegar, and afterwards covered with a piece of wax plaster.
IF, notwithstanding these applications, the symptomatic fever increases, and the tumour becomes larger, with violent pain and pulsation, it will be proper to promote the suppuration. The best application for this purpose is a soft poultice, which may be renewed twice a-day. If the suppuration proceeds but slowly, a raw onion cut small or bruised may be spread upon the poultice. When the abscess is ripe or fit for opening, which may easily be known from the thinness of the skin in the most prominent part of it, a fluctuation of matter which may be felt under the finger, and, generally speaking, an abatement of the pain, it may be opened either with a lancet or by means of caustic.
THE last way in which an inflammation terminates, is in a gangrene or mortification, the approach of which may be known by the following symptoms: The inflammation loses its redness, and becomes duskish or livid; the tension of the skin goes off, and it feels flabby; little bladders filled with ichor of different colour spread all over it; the tumour subsides, and from a duskish complexion becomes black; a quick low pulse, with cold clammy sweats, are the immediate forerunners of death.
WHEN these symptoms first appear the part ought to be dressed with London treacle, or a cataplasm made of lixivium and bran; should the symptoms become worse, the part must be scarified, and afterwards dressed with basilicum softened with oil of turpentine. All the dressings must be applied warm. With regard to internal medicines, the patient must be supported with generous cordials, and the Pervian bark exhibited in as large doses as the stomach will bear it. If the mortified parts should separate, the wound will become a common ulcer, and must be treated accordingly.
THIS article includes the treatment of all those diseases, which, in different parts of the country, go by the names of biles, imposthumes, whitloes, &c. They are all abscesses in consequence of a previous inflammation, which, if possible, ought to be discussed; but when this cannot be done, the suppuration should be promoted, and the matter discharged by an incision, if necessary; afterwards the sore may be dressed with yellow basilicum, or some other digestive ointment.
NO part of medicine has been more mistaken than the treatment or cure of wounds. Mankind in general believe that certain herbs, ointments, and plasters are possessed of wonderful healing powers, and imagine that no wound can be cured without the application of them. It is however a fact, that no external application whatever contributes towards the cure of a wound, any other way than by keeping the parts soft, clean, and defending them from the external air, which may be as effectually done by dry lint, as by the most pompous applications, while it is exempt from many of the bad consequences attending them.
THE same observations hold with respect to internal applications. These only promote the cure of wounds as far as they tend to prevent a fever, or to remove any cause that might obstruct or impede the operations of Nature. It is Nature alone that cures wounds; all that Art can do is to remove obstacles, and to put the parts in such a condition as is the most favourable to Nature's efforts.
WITH this simple view, we shall consider the treatment of wounds, and endeavour to point out such steps as ought to be taken to facilitate their care.
THE first thing to be done when a person has received a wound, is to examine whether any foreign body be lodged in it, as wood, stone, iron, lead, glass, dirt, bits of cloth, or the like. These, if possible, ought to be extracted, and the wound cleaned, before any dressings be applied. When that cannot be effected with safety, on account of the patient's weakness, or loss of blood, they must be suffered to remain in the wound, and afterwards extracted when he is more able to bear it.
WHEN a wound penetrates into any of the cavities of the body, as the breast, the bowels, &c. or where any considerable blood-vessel is cut, a skilful surgeon ought immediately to be called, otherwise the patient may lose his life. But sometimes the discharge of blood is so great, that if it be not stopt, the patient may die even before a surgeon, though at no great distance, can arrive. In this case, something must be be done by those who are present. If the wound be in any of the limbs, the bleeding may generally be stopt by applying a tight ligature or bandage round the member a little above the wound. The best method of doing this is to put a strong broad garter round the part, but so slack as easily to admit a small piece of stick to be put under it, which must be twisted, in the same as a countryman does a cart-rope to secure his loading, till the bleeding stops. Whenever this is the case, he must take care to twist it no longer, as straining it too much might occasion an inflammation of the parts, and endanger a gangrene.
IN parts where this bandage cannot be applied, various other methods may be tried to stop the bleeding, as the application of styptics, astringents, &c. Cloths dipped in a solution of blue vitriol in water, or the styptic water of the Dispensatories, may be applied to the wound. When these cannot be obtained, strong spirits of wine may be used. Some recommend the Agaric of the oak as preferable to any of the other styptics; and indeed it deserves considerable encomiums. It is easily obtained, and ought to be kept in every family, in case of accidents. A piece of it must be laid upon the wound, and covered with a good deal of lint, above which a bandage may be applied so tight as to keep it firmly on.
DR. TISSOT, in his Advice to the People, gives the following directions for gathering, preparing, and applying the agaric. - "Gather in autumn, says he, while the fine weather lasts, the agaric of the oak, which is a kind of fungus or excresence issuing from the wood of that tree. It consists at first of four parts, which present themselves successively: 1. The outward rind or skin, which may be thrown away. 2. The part immediately under this rind, which is the best of all. This is to be beat well with a hammer, till it become soft and very pliable. This is the only preparation it requires, and a slice of it of a proper size is to be applied directly over the bursting open blood-vessels. It constringes and brings them close together, stops the bleeding, and generally falls off at the end of two days. 3. The third part adhering to the second may serve to stop the bleeding from the smaller vessels; and the fourth and last part may be reduced to powder as conducing to the same purpose - Where the agaric cannot be had, sponge may be used in its stead. It must be applied in the same manner, and has nearly the same effects.
THOUGH spirits, tinctures, and hot balsams may be used, in order to stop the bleeding when it is excessive, they are improper at other times. They do not promote but retard the cure, and often change a simple wound into an ulcer. People imagine, because hot balsams congeal the blood, and seem, as it were, to solder up the wound, that they therefore heal it; but this is only a deception. They may indeed stop the flowing blood, by searing the mouths of the vessels; but, by rendering the parts callous, they obstruct the cure.
IN slight wounds, which do not penetrate much deeper than the skin, the best application is a bit of the common black sticking plaster. This keeps the sides of the wound together, and prevents the air from hurting it, which is all that is necessary. When a wound penetrates deep, it is not safe to keep its lips quite close: this keeps in the matter, and is apt to make the wound fester. In this case the best way is to fill the wound with soft lint, commonly called caddis. It however must not be stuffed in too hard, otherwise it will do hurt. The caddis may be covered with a cloth dipped in oil, or spread with the common wax plaster; See Appendix, Wax plaster; and the whole must be kept on by a proper bandage.
WE shall not spend time in describing the different bandages that may be proper for wounds in different parts of the body; common sense will generally suggest the most commodious method of applying a bandage; besides, descriptions of this kind are not easily understood or remembered.
THE first dressing ought to continue on for at least two days; after which it may be removed, and fresh lint applied as before. If any part of the first dressing sticks so close as not to be removed with ease or safety to the patient, it may be allowed to continue, and fresh lint dipped in sweet oil laid over it. This will soften it so as to make it come off easily at next dressing. Afterwards the wound may be dressed twice a-day in the same manner till it be quite healed. Those who are fond of salves or ointments, may, after the wound is become very superficial, dress it with the yellow basilicum; See Appendix, Yellow basilicum; and if fungus, or what is called proud flesh, should rise in the wound, it may be checked, by mixing with the ointment a little burnt alum or red precipitate of mercury.
WHEN a wound is greatly inflamed, the most proper application is a poultice of bread and milk, softened with a little sweet oil or fresh butter. This must be applied instead of a plaster, and should be changed twice a-day.
IF the wound be large, and there is reason to fear an inflammation, the patient should be kept on a very low diet. He must abstain from flesh, strong liquors, and every thing that is of a heating nature. If he be of a full habit, and has lost but little blood from the wound, he must be bled: and, if the symptoms be urgent, the operation may be repeated. But when the patient has been greatly weakened by loss of blood from the wound, it will be dangerous to bleed him, even though a fever should ensue. Nature should never be too far exhausted. It is always more safe to allow her to struggle with the disease in her own way, than to sink the patient's strength by excessive evacuations.
WOUNDED persons ought to be kept perfectly quiet and easy. Every thing that ruffles the mind, or moves the passions, as love, anger, fear, excessive joy, &c. are very hurtful. They ought, above all things, to abstain from venery. The body should be kept gently open, either by laxative clysters, or by a cool vegetable diet, as roasted apples, stewed prunes, boiled spinnage, and such like.
IN slight burns which do not break the skin, it is customary to hold the part near the fire for a competent time, to rub it with salt, or to lay a compress upon it dipped in spirits of wine or brandy. But when the burn has penetrated so deep as to blister or break the skin, it must be dressed with some of the liniment for burns mentioned in the Appendix, or with the emollient and gently drying ointment, commonly called Turner's cerate; See Appendix, Turner's cerate. This may be mixed with an equal quantity of fresh olive oil, and spread upon a soft rag, and applied to the part affected. When this ointment cannot be had, an egg may be beat up with about an equal quantity of the sweetest salad oil. This will serve very well till a proper ointment can be prepared. When the burning is very deep, after the first two or three days, it should be dressed with equal parts of yellow basilicum, and Turner's cerate mixed together.
WHEN the burn is violent, or has occasioned a high degree of inflammation, and there is reason to fear a gangrene or mortification, the same means must be used to prevent it as are recommended in other violent inflammations. The patient, in this case, must live low, and drink freely of weak diluting liquors. He must likewise be bled, and have his body kept open. But if the burnt parts should become livid or black, with other symptoms of mortification, it will be necessary to bathe them frequently with warm camphorated spirits of wine, tincture of myrrh, or other antiseptics, mixed with a decoction of the bark. In this case the bark must likewise be taken internally, and the patient's diet must be more generous.
AS example teaches better than precept, I shall relate the treatment of the most dreadful case of this kind that has occurred in my practice. A middle-aged man, of a good constitution, fell into a large vessel full of boiling water, and miserably scalded about one half of his body. As his cloths were on the burning, in some parts, was very deep before they could be got off. For the first two days the scalded parts had been frequently anointed with a mixture of lime-water and oil, which is a very proper application for recent burnings. On the third day, when I first saw him, his fever was high and his body costive, for which he was bled, and had an emollient clyster administered; poultices of bread and milk softened with fresh butter, were likewise applied to the affected parts, to abate the heat and inflammation. His fever still continuing high, he was bled a second time, was kept strictly on the cooling regimen, took the saline mixture with small doses of nitre, and had an emollient clyster administered once a-day. When the inflammation began to abate, the parts were dressed with a digestive composed of brown cerate and yellow basilicum; where any black spots appeared they were slightly scarified, and touched with the tincture of myrrh; and to prevent their spreading, the Peruvian bark was administered. By this course, this man was so well in three weeks as to be able to attend his business.
BRUISES are generally productive of worse consequences than wounds. The danger from them does not appear immediately, by which means it often happens that they are neglected. It is needless to give any definition of a disease so universally known; we shall therefore proceed to point out the method of treating it. In slight bruises it will be sufficient to bathe the part with warm vinegar, to which a little brandy or rum may occasionally be added, and to keep cloths wet with this mixture constantly applied to it. This is more proper than rubbing it with brandy, spirits of wine, or other ardent spirits, which are commonly used in such cases.
IN some parts of the country the peasants apply to a recent bruise a cataplasm of fresh cow-dung. I have often seen this cataplasm applied to violent contusions occasioned by blows, falls, bruises, and such like, and never knew it fail to have a good effect.
WHEN a bruise is very violent, the patient ought immediately to be bled, and put upon a proper regimen. His food should be light and cool, and his drink weak, and of an opening nature; as whey sweetened with honey, decoctions of tamarinds, barley, cream-tartar-whey, and such like. The bruised parts must be bathed with vinegar and water, as directed above; and a poultice made by boiling crumb of bread, elder-flowers, and camomile-flowers, in equal quantities of vinegar and water, applied to it. This poultice is peculiarly proper when a wound is joined to the bruise. It may be renewed two or three times a-day.
AS the structure of the vessels is totally destroyed by a violent bruise, there often ensues a great loss of substance, which produces an ulcerous sore very difficult to cure. If the bone be affected, the sore will not heal before an exfoliation takes place; that is, before the diseased part of the bone separates, and comes out through the wound. This is often a very slow operation, and may even require several years to be completed. Hence it happens, that these sores are frequently mistaken for the King's evil, and treated as such, though, in fact, they proceed solely from the injury which the solid parts received from the blow.
PATIENTS in this situation are pestered with different advices. Every one who sees them proposes a new remedy, till the sore is so much irritated with various and opposite applications, that it is often at length rendered absolutely incurable. The best method of manageing such sores is, to take care that the patient's constitution does not suffer by confinement, or improper medicine, and to apply nothing to them but some simple ointment spread upon soft lint, over which a poultice of bread and milk, with boiled camomile-flowers, or the like, may be put, to nourish the part, and keep it soft and warm. Nature, thus assisted, will generally in time operate a cure, by throwing off the diseased parts of the bone, after which the sore soon heals.
ULCERS may be the consequence of wounds, bruises, or imposthumes improperly treated; they may likewise proceed from an ill state of the humours, or what may be called a bad habit of body.
IN the latter case, they ought not to be hastily dried up, otherwise it may prove fatal to the patient. Ulcers happen most commonly in the decline of life; and persons who neglect exercise, and live grossly, are most liable to them. They might often be prevented by retrenching some part of the solid food, or by opening artificial drains, as issues, setons or the like.
AN ulcer may be distinguished from a wound by its discharging a thin watery humour, which is often so acrid as to inflame and corrode the skin; by the hardness and perpendicular situation of its sides or edges, by the time of its duration, &c.
IT requires considerable skill to be able to judge whether or not an ulcer ought to be dried up. In general, all ulcers which proceed from a bad habit of body, should be suffered to continue open, at least till the constitution has been so far changed by proper regimen, or the use of medicine, that they seem disposed to heal of their own accord. Ulcers which are the effect of malignant fevers, or other acute diseases, may generally be healed with safety after the health has been restored for some time. The cure ought not however, to be attempted too soon, nor at any time without the use of purging medicines and a proper regimen. When wounds or bruises have, by wrong treatment, degenerated into ulcers, if the constitution be good, they may generally be healed with safety.
WHEN ulcers either accompany chronical diseases, or come in their stead, they must be cautiously healed. If an ulcer conduces to the patient's health, from whatever cause it proceeds, it ought not to be healed; but if, on the contrary, it wastes the strength, and consumes the patient by a slow fever, it should be as soon as possible.
WE would earnestly recommend a strict attention to these particulars, to all who have the misfortune to labour under this disorder, particularly persons in the decline of life; as we have frequently known people throw away their lives by the want of it, while they were extolling and generously rewarding those whom they ought to have looked upon as their executioners.
THE most proper regimen for promoting the cure of ulcers, is to avoid all spices, salted and high seasoned food, all strong liquors, and to lessen the usual quantity of fresh meat. The body ought to be kept gently open by a diet consisting chiefly of cooling laxative vegetables, and by drinking butter-milk, whey sweetened with honey, or the like. The patient ought to be kept cheerful, and should take as much exercise as he can easily bear.
WHEN the bottom and sides of an ulcer seem hard and callous, they may be sprinkled twice a-day with a little red precipitate of mercury, and afterwards dressed with the yellow basilicum ointment. Some times it will be necessary to have the edges of the ulcer scarified with the lancet.
LIME-WATER has frequently been known to have very happy effects in the cure of obstinate ulcers. It may be used in the same manner as directed for the stone and gravel.
MY late learned and ingenious friend, Dr. Whytt, strongly recommends the use of the solution of corrosive sublimate of mercury in brandy, for the cure of obstinate ill-conditioned ulcers. I have frequently found this medicine, when given according to the Doctor's directions, prove very successful. The dose is a table-spoonful night and morning; at the same time washing the sore twice or thrice a-day with it. In a letter which I had from the Doctor a little before his death, he informed me, "That he observed washing the sore, thrice a-day with the solution of a triple strength was very beneficial."
A FISTULOUS ulcer can seldom be cured without an operation. It must either be laid open so as to have its callous parts destroyed by some corrosive application, or they must be entirely cut away by the knife; but as this operation requires the hand of an expert surgeon, there is no occasion to describe it. Ulcers about the anus are most apt to become fistulous, and are very difficult to cure. Some, indeed, pretend to have found Wards Fistula paste very successful in this complaint. It is not a dangerous medicine, and being easily procured, it may deserve a trial; but as these ulcers generally proceed from an ill habit of body, they will seldom yield to any thing except a long course of regimen, assisted by medicines, which are calculated to correct that particular habit, and to induce an almost total change in the constitution.