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come detached. In some cases the upper part of the bone is laid bare, and in others the flesh dies all around; and, from a sore of long standing, certain of the bones become carious, and some not, some more, and some less; and in some the small, and in others the large bones. From what has been said it will be seen, that it is impossible to tell in one word when the bones will separate. Some come away more quickly, owing to their smallness, and some from being merely fixed at the point; and some, from pieces not separating, but merely exfoliating, become dried up and putrid; and besides, different modes of treatment have different effects. For the most part, the bones separate most quickly in those cases in which suppuration takes place most quickly, and when new flesh is most quickly formed, and is particularly sound, for the flesh which grows up below in the wound generally elevates the pieces of bone. It will be well if the whole circle of the bone separate in forty days; for in some cases it is protracted to sixty days, and in some to more; for the more porous pieces of bone separate more quickly, but the more solid come away more slowly; but the other smaller splinters in much less time, and others otherwise. A portion of bone which protrudes should be sawn off for the following reasons: if it cannot be reduced, and if it appears that only a small piece is required in order that it may get back into its place; and if it be such that it can be taken out, and if it occasions inconvenience and irritates any part of the flesh, and prevents the limb from being properly laid, and if, moreover, it be denuded of flesh, such a piece of bone should be taken off. With regard to the others, it is not of much consequence whether they be sawed off or not. For it should be known for certain, that such bones as are completely deprived of flesh, and have become dried, all separate completely. Those which are about to exfoliate should not be sawn off. Those that will separate completely must be judged of from the symptoms that have been laid down.

34. Such cases are to be treated with compresses and vinous applications, as formerly laid down regarding bones which will separate. We must avoid wetting it at the beginning with anything cold; for there is danger of febrile rigors, and also of convulsions; for convulsions are induced by cold things, and also sometimes by wounds.' It is proper to know that the members are necessarily shortened in those cases in which the bones have been broken, and have healed the one across the other, and in those cases in which the whole circle of the bone has become detached.

35. Those cases in which the bone of the thigh, or of the arm, protrudes, do not easily recover. For the bones are large, and contain much marrow; and many important nerves, muscles, and veins are wounded at

1 See Aphorism v., 17, 20. Celsus renders this sentence as follows: "Frigus omni ratione vitandum," etc., (viii., 10.)

VOL. II.-5.

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their works which require great force. Wherefore, res lever is not to be despised, for the bones will be reduce not at all. But if the upper fragment which rides ov not furnish a suitable point of support for the lever, 1 part is sharp, you must scoop out of the bone what wil place for the lever to rest on. The lever, along with ext recourse to on the day of the accident, or next day, but third, the fourth, and the fifth. For if the limb is distu and yet the fractured bones not reduced, inflammation this no less if they are reduced; for convulsions are mor duction take place, than if the attempt should fail. T well known, for if convulsions should come on when re there is little hope of recovery; but it is of use to displ if this can be done without trouble. For it is not at parts are in a particularly relaxed condition that con are apt to supervene, but when they are more than the case we are now treating of, we should not distr aforesaid days, but strive to keep the wound as free fi possible, and especially encourage suppuration in it days have elapsed, or rather more, if there be no feve be not inflamed, then there will be less to prevent tion, if you hope to succeed; but otherwise you nee

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32. When you have reduced the bones to their treatment, whether you expect the bones to exfolia1 already described. All those cases in which an e expected, should be treated by the method of band ginning for the most part at the middle of the banate should not the double-headed bandage; but particular attention shape of the wound, so that its lips may gape or be possible under the bandage. Sometimes the turns

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5 anything cord: for 33. It should be known that bones, which it heons; for convitadal. ble to reduce, as well as those which are wholly derby wounds.'


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per part of the bone is laid bare, and, from a sore of long standing. is, and some not, some more, and some hers the large bones. From what mpossible to tell in one word when e away more quickly, owing to their fited at the point; and some, from ---15, ating, become dried up and putrl; atment have different effecta,

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kly in those cases in which suppawhen new flesh is most quexy for the flesh which grows up below in vers of bone, It wil be well if the in forty days; for in some cases it is proto more; for the more porous pieces of : the more wood come away more sow FI much less time, and others otherw m. ** should be sawn off for the fo. and if it appears that or va **** 28 buk into its | see; and if it less a

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r course of medinent of the sores the body should to relax the parts acted, as also was ch cases, provided re small, and the he fractured bones them he will bring

ch milder accidents the knee-joint, in f the arm, and has a joint of the arm is bones of the leg are rtops the other to so oned, and therefore nerve (ligament?) at arm are unequal, and and the more slender , and to it (the olecrah go downward to the

-joints is so important, that discussion of it in the Arguconsideration in this place. he nature of subluxations at hich the subject has received and Mr. Bransby Cooper. No ibia do take place occasionally; he accidents generally referred emilunar cartilages; with these of the ancient authorities was have frequently seen, I am acbackward of the tibia, from the range to say, the limb is still not These cases of displacement founded with subluxations from ncient surgeons must have comwould not have represented this ey describe it to be. As we have ody this perhaps is the one which iption which our author gives of s so curious, that I have inserted ry ingenious observations on the

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the same time. And if you reduce them, convulsions usually supervene; and, if not reduced, acute bilious fevers come on, with singultus and mortification. The chances of recovery are not fewer in those cases in which the parts have not been reduced, nor any attempts made at reduction. Still more recover in those cases in which the lower, than those in which the upper part of the bone protrudes; and some will recover when reduction has been made, but very rarely indeed. For modes of treatment and peculiarity of constitution make a great difference as to the capability of enduring such an injury. And it makes a great difference if the bones of the arm and of the thigh protrude to the inside; for there are many and important vessels situated there, some of which, if wounded, will prove fatal; there are such also on the outside, but of less importance. In wounds of this sort, then, one ought not to be ignorant of the dangers, and should prognosticate them in due time. But if you are compelled to have recourse to reduction, and hope to succeed, and if the bones do not cross one another much, and if the muscles are not contracted (for they usually are contracted), the lever in such cases may be advantageously employed.


36. Having effected the reduction, you must give an emollient draught of hellebore the same day, provided it has been reduced on the day of the accident, but otherwise it should not be attempted. The wound should be treated with the same things as are used in fractures of the bones of the head, and nothing cold should be applied; the patient should be restricted from food altogether, and if naturally of a bilious constitution, he should have for a diet a little fragrant oxyglyky sprinkled on water; but if he is not bilious, he should have water for drink; and if fever of the continual type come on, he is to be confined to this regimen for fourteen days at least, but if he be free of fever, for only seven days,

1 Modern experience has amply confirmed the opinion here expressed by our author as to the danger there is in all cases of compound fracture of the femur or humerus from tetanus and gangrene. In whatever way treated, whether the parts be let alone at first, or reduced, or amputation be practiced, such cases commonly prove fatal.

2 Paulus Ægineta, in reference to this passage, says: "Hippocrates, in fractures of the thigh and arm, dissuades from replacing at once the protruding bones, predicting danger from it, owing to the inflammation, or perhaps spasm of the muscles and nerves, which are apt to be brought on by the extension. But time has shown that the attempt will sometimes succeed." (VI., 107.) For the practice of the other ancient authorities in this case, see the Commentary, 1. c.

3 Even Galen confesses himself unable to determine what is the exact meaning of the term (ua20aкòç) here applied by our author, but supposes it probable that he means some gentle method of administering the hellebore. He mentions that he was in the practice of giving an infusion of radishes in oxymel with a few branches of hellebore in such cases, and that when thus administered the purgative operation of the hellebore was mild. The reader will remark our author's partiality to hellebore in all cases of spasmodic nature, such as tetanus.

and then you must bring him back by degrees to a common diet. To those cases in which the bones have not been reduced, a similar course of medicine should be administered, along with the same treatment of the sores and regimen; and in like manner the suspended part of the body should not be stretched, but should rather be contracted, so as to relax the parts about the wound. The separation of the bones is protracted, as also was formerly stated. But one should try to escape from such cases, provided one can do so honorably, for the hopes of recovery are small, and the dangers many; and if the physician do not reduce the fractured bones. he will be looked upon as unskillful, while by reducing them he will bring the patient nearer to death than to recovery.

37. Luxations and subluxations at the knee are much milder accidents than subluxations and luxations at the elbow.' For the knee-joint, in proportion to its size, is more compact than that of the arm, and has a more even conformation, and is rounded, while the joint of the arm is large, and has many cavities. And in addition, the bones of the leg are nearly of the same length, for the external one overtops the other to so small an extent as hardly to deserve being mentioned, and therefore affords no great resistance, although the external nerve (ligament?) at the ham arises from it; but the bones of the fore-arm are unequal, and the shorter is considerably thicker than the other, and the more slender (ulna?) protrudes, and passes up above the joint, and to it (the olecranon?) are attached the nerves (ligaments?) which go downward to the

1 The subject of dislocations at the knee and elbow-joints is so important, that I have thought it necessary to enter into a pretty full discussion of it in the Argument. A few points, notwithstanding, will require consideration in this place. There is still great diversity of opinion respecting the nature of subluxations at the knee-joint, even after all the investigations which the subject has received from Hey of Leeds, Sir Astley Cooper, Mr. Liston, and Mr. Bransby Cooper. No doubt, partial displacements of the femur from the tibia do take place occasionally; but there appears good reason for suspecting that the accidents generally referred to this category have been displacements of the semilunar cartilages; with these it does not appear that Hippocrates or any other of the ancient authorities was acquainted. Partial dislocations from diseases I have frequently seen, I am acquainted with a case of nearly complete luxation backward of the tibia, from the disease usually called white swelling; and yet, strange to say, the limb is still not much impaired either in its strength or motions. These cases of displacement from disease have probably been sometimes confounded with subluxations from accident: indeed I cannot but think that the ancient surgeons must have committed this mistake sometimes, otherwise they would not have represented this accident as being of so frequent occurrence as they describe it to be. As we have stated elsewhere, of all the joints of the human body this perhaps is the one which most rarely meets with dislocation. The description which our author gives of the ligaments connected with the elbow-joint is so curious, that I have inserted in the Argument to the next work Beclard's very ingenious observations on the subject.

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