a period as possible, before the deficiency of the bones of the foot is very great, and before there is any great wasting of the flesh of the leg. There is more than one variety of club-foot, the most of them being not complete dislocations,' but impairments connected with the habitual maintenance of the limb in a certain position. In conducting the treatment, attention must be paid to the following points: to push back and rectify the bone of the leg at the ankle from without inward, and to make counter-pressure on the bone of the heel in an outward direction, so as to bring it into line, in order that the displaced bones may meet at the middle and side of the foot; and the mass of the toes, with the great toe, are to be inclined inward, and retained so; and the parts are to be secured, with cerate containing a full proportion of resin,' with compresses, and soft bandages in sufficient quantity, but not applied too tight; and the turns of the bandages should be in the same direction as the rectifying of the foot with the hand, so that the foot may appear to incline a little outward. And a sole made of leather not very hard, or of lead, is to be bound on, and it is not to be applied to the skin but when you are about

'I need scarcely remark now that our author has here exactly hit the true character of this impediment, which, as he says, is not a dislocation, but, originally, a mere declination of the foot.

2 Having lately gone through the process of curing congenital varus in both feet of a child a year old, I can attest to the general accuracy of the directions here given. From the nature of the case, it will readily be understood that the foot is to be pushed outward, and the leg inward, so as to bring the foot into a line with the leg. The only difficulty which one encounters in the description, is the direction that "the mass of the toes, with the great toe, should be inclined inward, and retained so." M. J. Guerin, so well known for his skill in orthopedy, gave M. Littré the following explanation of this manœuvre: “Quant à Ego ¿ykhívei, il faut le traduire par abaisser, incliner tous les orteils en dedans (par un mouvement d'arc de cercle sur l'axe antéro-postérieur du pied). C'est là le sens littéral et il exprime parfaitement ce qu'il faut faire pour la réduction du varus. Dans cette variété du pied-bot, le pied étant renversé sur la face externe; la rangée des orteils est, comme le pied, située verticalement et regarde en dehors; il convient donc d'inclineur ou d'abaisser les orteils en dedans et les fixer dans cette position." By the way, there is some mistake in this quotation, for the reading in the text is not έξω έγκλίνειν (although I humbly think ἔξω ἐκκλίνειν would be the most suitable reading), but ἐς τὸ είσω μέρος ἐγκλίνειν. The only way in which I can attach any proper meaning to the common reading, is by supposing that it refers to a very aggravated case of talipes varus, in which the foot is fairly turned round on its axis. In such a case, no doubt the toes would have to be pushed inward and downward, in the first place. But, however we may understand this clause, there can be no doubt that Hippocrates understood properly the principles upon which the treatment ought to be conducted.

No doubt, as is remarked by Galen in his Commentary, the addition of resin to the cerate would give the bandages a greater degree of firmness and stability. 4 That is to say-agreeably to the Hippocratic rule, contraria contrariis curantur-the abnormal inclination inward is to be cured by producing for a time an inclination outward.

to make the last turns of the bandages.' And when it is all bandaged, you must attach the end of one of the bandages that are used to the bandages applied to the inferior part of the foot on the line of the little toe; and then this bandage is to be rolled upward in what is considered to be a sufficient degree, to above the calf of the leg, so that it may remain firm when thus arranged. In a word, as if moulding a wax model, you must bring to their natural position the parts which were abnormally displaced and contracted together, so rectifying them with your hands, and with the bandaging in like manner, as to bring them into their position, not by force, but gently; and the bandages are to be stitched so as to suit the position in which the limb is to be placed, for different modes of the deformity require different positions. And a small shoe made of lead is to be bound on externally to the bandaging, having the same shape as the Chian slippers had. But there is no necessity for it if the parts be properly adjusted with the hands, properly secured with the bandages, and properly disposed of afterward. This, then, is the mode of cure, and it neither requires cutting, burning, nor any other complex means, for such cases yield sooner to treatment than one would believe. However, they are to be fairly mastered only by time, and not until the body has grown up in the natural shape; when recourse is had to a shoe, the most suitable are the buskins, which derive their name from being used in traveling through mud; for this sort of shoe does not yield to the foot, but the foot yields to it. A shoe shaped like the Cretan is also suitable.

63. In cases of complete dislocation at the ankle-joint, complicated with an external wound, whether the displacement be inward or outward, you are not to reduce the parts, but let any other physician reduce them if he choose. For this you should know for certain, that the patient will die if the parts are allowed to remain reduced, and that he will not survive more than a few days, for few of them pass the seventh day, being cut off by convulsions, and sometimes the leg and foot are seized with gangrene. It should be well known that such will be the results; and

S

1 The benefit of this leather sole is in reality very marked in the treatment of infantile club-foot. This I can attest from personal experience.

2 of the Chian slippers or sandals, and the buskins for traveling through mud or clay, Galen can give no account. See further the editors of Erotian. They were, no doubt, composed of stout and unyielding materials. It is well known that such a boot is very useful to keep the foot in position after it has been rectified.

3 Galen, in his Commentary, states that the danger of reduction consists partly in the additional violence inflicted on the muscles, and partly in their being then put into a stretched state, whereby spasms or convulsions are brought on, and gangrene as the result of the intense inflammation which ensues. Galen explains the term gangrene to mean the intermediate state between intense inflammation and sphacelus, the latter term being applied to the complete corruption, that is to say, death of a part. Celsus uses "cancer" as being synonymous with the term "gangrene." (viii., 25.)

2

it does not appear to me that hellebore will do any good, though administered the same day, and the draught repeated, and yet it is the most likely means, if any such there be; but I am of opinion that not even it will be of service. But if not reduced, nor any attempts at first made to reduce them, most of such cases recover. The leg and foot are to be arranged as the patient wishes, only they must not be put in a dependent position, nor moved about;' and they are to be treated with pitched cerate, a few compresses dipped in wine, and not very cold, for cold in such cases induces convulsions; the leaves also of beet, or of colt's foot, of any such, when boiled in dark-colored austere wine, form a suitable application to the wound and the surrounding parts; and the wound may further be anointed with cerate in a tepid state. But if it be the winter season, the part is to be covered with unscoured wool, which is to be sprinkled from above with tepid wine and oil, but on no account is either bandage or compress to be applied; for this should be known most especially, that whatever compresses, or is heavy, does mischief in such cases. And certain of the dressings used to recent wounds are suitable in such cases; and wool may be laid upon the sore, and sprinkled with wine, and allowed to remain for a considerable time; but those dressings for recent wounds which only last for a few days, and into which resin enters as an ingredient, do not agree with them; for the cleansing of the sores is a slow process, and the sore has a copious discharge for a long time. Certain of these cases it may be advantageous to bandage. It ought also to be well understood, that the patient must necessarily be much maimed and deformed, for the foot is retracted outward, and the bones which have been displaced outward protrude: these bones, in fact, not being generally laid bare, unless to a small extent; neither do they exfoliate, but they heal by thin and feeble cicatrices, provided the patient keeps quiet for a length of time; but otherwise there is danger that a small ulcer may remain incurable. And yet in the case we are treating of, those who are thus treated are saved; whereas, when the parts are reduced and allowed to remain in place, the patients die."

1 Celsus translates this clause of the sentence as follows: "tantum (membrum) ne moveatur, neve dependeat." (viii., 25.)

? It will be remarked that our author only forbids the use of "very cold" applications, from which Galen justly infers that he did not disapprove of moderately cold things. Galen here gives some interesting observations on the distinction between things which are cold to the senses, and those which are possessed of cold or congealing qualities, such as cicuta, mandragora, and the like. The ancient authorities all held that narcotics are of a cold or refrigerant

nature.

3 Our author, it will be remarked in this and the succeeding paragraphs, lays down his own views respecting the treatment of compound dislocations. That he must have been familiar with the treatment of them there can be no doubt, from the precise and well-defined manner in which he describes all the phenomena re

64. The same rule applies to dislocations at the wrist, attended with a wound and projection of the bone, whether the bones of the arm be displaced inward or outward. For this should be well understood, that the patient will die in the course of a few days, by the same mode of death as formerly described, if the bone be reduced, and allowed to remain so. But in those cases in which they are not reduced, nor any attempt made to reduce them, the patients, for the most part, recover; and the same mode of treatment as has been described will be applicable; but the deformity and impediment of the limb must necessarily be great, and the fingers of the hand will be weak and useless; for if the bones have slipped inward, they cannot bend the fingers, or if outward, they cannot extend them.'

65. When the os tibiæ, having made a wound at the knee, has protruded through the skin, whether the dislocation be outward or inward, in such a case, if the bone be reduced, death will be even more speedy than in the other cases, although speedy also in them. But the only hope of recovery is if you treat them without reduction. These cases are more dangerous than the others, as being so much higher up, as being so much stronger joints, and displaced from bones which are so much stronger. But if the os femoris form a wound at the knee, and slip through it, provided it be reduced and left so, it will occasion a still more violent and speedy death than in the cases formerly described; but if not reduced, it will be much more dangerous than those cases mentioned before, and yet this is the only hope of recovery.'

garding them. The danger of such accidents he has fairly stated, but probably not exaggerated. I need scarcely say that, with the modern surgeon in these unfortunate cases, the first consideration is, whether or not the limb is to be taken off at once; and that, even with this frightful alternative, the results have been by no means satisfactory. We have discussed this subject, however, in the Argument, where we have given an abstract of the other views of practice entertained by subsequent authorities.

That is to say, whether the bones of the fore-arm protrude before or behind. It is obvious from the text, and is made still more clear from Galen's Commentary, that, in this case, Hippocrates understands the bones of the fore-arm to be the parts displaced, and not those of the hand, as is usually understood in modern works on surgery. Sir Astley Cooper, however, like Hippocrates, considers the hand as the part in position, and the bones of the fore-arm as those which are displaced. But whether our author is always consistent with himself in regard to this, and the dislocations of the other joints, may be doubted. It is well known, that early writers, however remarkable they may be for originality of thought and vigor of expression, are seldom so distinguished for precision in the use of terms as succeeding authors are. That Hippocrates is not exempt from this defect must be admitted, nor is this to be wondered at, since he lived before the age of Aristotle, who first brought logic and criticism to perfection.

I need scarcely say that recent authorities give the symptoms very differently. See the Argument.

3 As remarked by Galen, our author in this paragraph makes a distinction in

66. The same rule applies to the elbow-joint, and with regard to the bones of the fore-arm and arm. For when these bones protrude through a wound which they have made in the skin, all cases in which they are reduced prove fatal; but if not reduced, there is a chance of recovery; but to those that survive there is certain impediment. And if in any instance the bones of the upper articulations (shoulder-joint ?), should be dislocated, and project through a wound which they have made in the skin, these, if reduced, are followed by more speedy death; and if not reduced, they are more dangerous than the others. But the mode of treatment which appears to me most suitable has been already described.

67. When the joints of the toes or hands are dislocated, and the bones protrude through a wound which they have made, and when there is no fracture of the bone, but merely displacement of the joint, in these cases, if the reduction be made and allowed to remain, there is some danger of spasms (tetanus?) if not properly treated, and yet it may be worth while to reduce them, having warned the patient beforehand that much caution and care will be required. The easiest, the most efficient method, and the one most conformable to art, is that by the lever, as formerly described when treating of bones which have been fractured and protruded; then the patient must be as quiet as possible, lie in a recumbent position, and observe a restricted regimen. And it will be better also that he should get some gentle emetics. The sore is to be treated with dressings for fresh wounds, which permit of affusions, or with the leaves of camomile,' or with the applications for fractured bones of the head, but nothing very cold must be applied. The first (most distant?) joints are least dangerous, but those still higher, are more so. Reduction should be made the same day, or the next, but by no means on the third or fourth, for it is on the fourth day that exacerbations especially attack. In those cases, then, where immediate reduction cannot be accomplished, we must wait until after the aforesaid days; for whatever you reduce within ten days, may be expected to induce spasm. But if the spasm supervene on its being reduced, the joint should be quickly displaced, and bathed frequently with warm water, and the whole body should be kept in a warm, soft, and easy condition, and more especially about the joints, for the whole body should rather be in a bent than in an extended state. Moreover, it is to be expected, that the articular extremities of the bones of the fingers will exfoliate, for this generally happens, if even the least degree of inflammation take place, so that if it were not that the physician would be exposed

dislocations at the knee-joint, according as it is the end of the tibia or of the femur which protrudes through the skin. Galen adds, that at the ankle it is only the bones of the leg, and at the wrist only those of the fore-arm, which are protruded.

Probably the Anthemis valentina. See the Appendix to Dunbar's Greek Lexicon, under πολυόφθαλμον.