three, four, folds of the they are to onate to the ints are to be ess all along the fracture h are devoid n the splints ir shortness. t to occasion d be rubbed eaning of this the reading. ). Both Foës -y, the list or e compresses, to adopt this icenna, iv., 5, te 4, the aprings, is well of treating a may well be be a passage ch this surgithe ancient rom wax, in egarding the mited, being of Galen on orrupt state. the skin of fold of the e Chirurgici in this maned bandages purities, and scorides (ii., ess from the d to remark whom it is Fractures by their forezed Europe no.professes ion of ban 13. As to the temperature and quantity of the water used, its heat should be just such as the hand can bear, and it ought to be known. that a large quantity is best for producing relaxation and attenuation, whereas a moderate quantity is best for incarnating and softening. The limit to the affusion is, to stop when the parts become swelled up, and before the swelling subsides; for the parts swell up at first, and fall afterward.' 14. The object on which it (the limb?) is laid should be soft, smooth, and sloping upwards toward the protuberant parts of the body, such as the heel or hips, so that there may be no projection, nor bending inwards, nor turning aside.' The canal (spout or gutter?) should rather comprehend the whole limb than the half of it, attention being paid to the injury and to whatever else appears to create inconvenience.' 15. The presentation of the injured part to the physician, the extension, the arrangement, and so forth, are to be regulated according to nature. What is nature in these operations is to be determined by the accomplishment of the object which we have in view, and for this purpose we must look to the part in the state of rest, in its middle state, and to habit; in regard to the state of rest and relaxation, as in the arm, that it be in a line with the hand; and with regard to the medium between flexion and extension, that the forearm be at right angles to the arm; and with regard to habit, it should be considered that some limbs bear certain positions preferably, as, for example, the thighs extension; for in such attitudes the parts can best bear to be placed for a considerable time without a change of posture. And in the change from the state of distention, the muscles, veins, nerves, and bones, when properly arranged and dages to fractured limbs, takes no notice whatever of the use of cerate. Thus it is that we always pass by valuable things when we do not estimate the use of them properly. 1 The warm water, I may just mention, was applied upon the removal of the bandages. The objects for which it was applied are briefly noticed by our author, and are fully explained by Galen in his Commentary. Galen further alludes to the practice elsewhere. (Meth. Med., xiv.; and Hygiene, ii.) We shall find further mention of it in the work On Fractures. The meaning of this sentence, nothwithstanding the explanations furnished by Galen, is somewhat obscure. One can readily appreciate the propriety of the direction to lay the heel in particular on an elevated object, in order, as Galen remarks, to prevent a defluxion to the part. 3 The canal (called in French gouttière), although Hippocrates elsewhere ex presses himself regarding its usefulness in rather equivocal terms, appears to me to be one of the simplest and most ingenious contrivances imaginable for securing a fractured leg. For several years I have used in imitation of it a half boot made of the strongest pasteboard, and have found it the greatest improvement imaginable in the treatment of fractures. It appears to me preferable to any of the mechanical contrivances which are at present in use in the London hospitals. raised or placed.' 16. The extension should be most powerful when the largest and thickest bones, or when both are broken; next when the under-bone, and least of all, when the upper. When immoderate, it is injurious, except in the case of children. The limb should be a little elevated. The model by which we judge if the part be properly set is the sound part of the same name, or the part which is its pair. 17. Friction can relax, brace, incarnate, attenuate: hard braces, soft relaxes, much attenuates, and moderate thickens." 18. The following should be the state of matters on the first application of the bandage. The person to whom it has been applied should say that he feels the compression particularly at the seat of the injury, but very little at the extremities; the parts should be adjusted but not pressed together, and that rather by the number of the bandages than by the force of the constriction; and the tightness should rather be on the increase during the first day and night; but on the next it should be less, and on the third the bandages should be loose. On the next day a soft swelling should be observed in the extremities; and on the third day, 'There is not much of any practical importance in this paragraph which requires illustration. The best position for a fractured limb, as Galen remarks, is that in which it can be longest kept without producing pain; this, in the forearm, Hippocrates holds to be the state intermediate between pronation and supination, with the forearm at right angles to the arm, and in the leg complete extension. Galen pronounces decidedly in favor of the extended position during the treatment of a fractured thigh. 2 This paragraph, it will readily be perceived, relates to fractures of the forearm. There is little in it which requires illustration. Galen remarks, that the bodies of young persons, being of a softer and more humid nature, endure greater extension than those of the aged without being exposed to pain or more serious consequences. This is no doubt the fact, and it is equally true that aged persons can scarcely bear to be touched without experiencing most acute pain. 3 This subject is so fully treated of in the English edition of PAULUS ÆGINETA, Book I., 18, that I need not touch upon it in this place. See, in particular, Galen (De Sanit. tuend., ii., Comment. h. 1.), and Oribasius (Med. Collect., vi). 4 On this direction Verduc makes the following remark: "Hippocrates, who so often forewarns us of the danger of making the bandages either too tight or too slack, gives us a certain sign of the due tightness of the bandage, viz. the inflammation and rising softness of the lower extremity, whether the foot or hand. So that if the foot is not at all inflamed, you must immediately undo the dressings, for fear of a false callus. If the inferior extremities are very much inflamed, and have a hard tumor upon them, you must slacken the rollers."-On Fractures, Bandages, etc. It is well known that in modern practice the extremities are bandaged to prevent swelling from taking place in them. Whether or not this be in all cases a wise practice, I have my doubts; indeed I am inclined to think that the swelling below, relieves the swelling, and consequently the congestion, in the seat of the fracture. When the bandages are not too tight, nor the patient when the bandaging is loosed, the swelling should be found diminished in 19. The suspending of a fractured limb in a sling, the disposition of it, and the bandaging, all have for their object to preserve it in position. The principal considerations with regard to the position are the habits and the peculiar nature of each of the limbs: the varieties are shown in running, walking, standing, lying, action, repose.' 20. It should be kept in mind that exercise strengthens, and inactivity wastes." 21. Compression should be produced by the number of bandages, rather than by the force of the constriction. 22. In cases of ecchymosis, contusions, sprains, or swellings not attended with inflammations, blood is to be expelled from the wound, in greatest quantity to the upper part, and in smallest to the inferior; neither the arm nor the leg should be placed in a declining position: the head of the bandage should be placed on the wound, and there the greatest pressure should be made; the least at the extremities, and intermediately in the middle; the last fold of the bandage should be at the upper part of the body. As to binding and compression, these objects are to be in an unhealthy condition of body, the swelling below, to say the least of it, can, do no harm, and, besides serving as an index of the state of the bandaging above, may, and I think certainly in some cases does, relieve the tension in the seat of the injury. The contents of this chapter is an accurate résumé of the more ample directions which, as we shall see below, are given in the works On Fractures and On Articulations. 1 The splints, I believe, were secured by ligatures going round the limb in different places, care being taken to avoid the spot where the fracture was situated. See, in particular, Avicenna (iv., 5, 2, 7, 8). * The subject-matters contained in this passage are evidently pretty much the same as those contained in § 15. Galen insists strongly upon this being a clear proof that the present work is a mere rough sketch, and that it had never been completed by our author. In the course of his Commentary, he repeatedly insists that the original publisher must have used great liberties with the text. As a corollary to this proposition Galen remarks, that in surgical treatment an injured limb ought not to be too long kept entirely without motion, but that as soon as the inflammation has subsided, it should be cautiously moved after hot water has been poured upon it, etc. VOL. II.-2. striction; and moreover, in these cases the bandages should be thin, light, 23. Dislocations, sprains, diastases of bones, violent separation, abruption of the extremities of bones, and distrainings, so as to induce varus or valgus, in these cases we must apply the bandages so as not to compress the part whence the displacement took place, and that we may render them tight at the side to which the displacement was, and give the limb an inclination in the opposite direction, and that in an excessive degree. We employ bandages, compresses, suspension of the limb in a sling, attitude, extension, friction, rectification; and along with these the affusion of much water." 24. In treating parts which are atrophied, we must comprehend a considerable part of the sound limb with the bandage, so that by the influx thereby produced, the wasted part may acquire a supply greater than its loss, and may be thus disposed to growth and restoration of its fleshy parts. It is better also to bandage the parts above, as the thigh in the case of the leg, and also the thigh and leg of the opposite side, so that they may be placed in similar circumstances, and may both equally be deprived of motion; and that the supply of nourishment may be alike curtailed and open to both. The compression should be the effect rather of the number of the bandages than of their tightness. We relax first the part most requiring it, and have recourse to that kind of friction which will promote the growth of flesh, and to affusion. No splints." 1It is foreign to my purpose to enter upon a discussion of the different readings in this paragraph, as this would occupy too much time and space. See Galen, Foës, and Littré. As I have translated it, the meaning seems obvious, and the practice very rational. The subject herein treated will be found more fully discussed in the work On Fractures. ? This paragraph, as Galen remarks, contains an epitome of a variety of matters which are fully treated of in the treatises, On Fractures, and On the Articulations. Whatever is obscure in it will readily be understood upon reference to these works. I shall only notice a few of the terms which may be somewhat obscure to the modern reader who is not familiar with the two treatises now referred to. Diastasis is the separation of the two bones not connected together by diarthrosis, but in immediate connection, such as the separation of the radius from the ulna at the elbow-joint, and the separation of the cranial bones at a suture. Abruption applies to the snapping off of the extremity of a bone, such as that of the humerus. The distrainings, or distortions (diaστpéμμara), relate principally to cases of club-foot, and will come to be more properly treated of in the portion of the work on the Articulations, which relates to that subject. Upon reference to Galen, it will be seen that he bestows a very lengthy and elaborate Commentary on this paragraph, partly in illustration of the verbal meaning of the term here used, and partly in discussing the merit of the practical rules laid down by our author. By atrophied parts in this place, Hippocrates is and othe Chut the st without The appear to San bent of the oth zalan di wing here &t as direct There is no Galen's ( I affectio @bags filled m. It tton of dia ce of the conbe thin, light, purpose, even aration, abrupaduce varus or ot to compress we may render give the limb cessive degree. in a sling, attise the affusion prehend a cont by the influx greater than its n of its fleshy e thigh in the te side, so that both equally be t may be alike he effect rather e relax first the friction which ints." e different readand space. See ems obvious, and found more fully a variety of matOn the Articulareference to these mewhat obscure now referred to. er by diarthrosis, us from the ulna suture. Abrup ch as that of the e principally to in the portion of ery lengthy and on of the verbal t of the practical ace, Hippocrates 25. Those things which are for the purpose of giving support and strength to the part, as to the breast, side, head, and so forth, are used in such cases as the following: for pulsations, that there may be no motion in the part; and in separation at the sutures of the skull, in order to give support; and in order to strengthen the chest and head, in coughs, sneezings, and other movements. In all these cases the same measure of bandaging is to be observed, for where the injury is, there the bandage should compress most, and something soft is to be placed below that suits with the complaint; and we must not apply the bandages tighter than just to stop the pulsations from creating disturbance, and that the separated parts at the sutures may be brought into contact, they must not be such as absolutely to stop the coughs and sneezings, but so as to give support, and, without occasioning uneasiness,' prevent the parts from being shaken. would appear to allude to parts which have become wasted in flesh owing to the compression and want of exercise during their treatment for fractures. The treatment of emaciated parts is briefly laid down by PAULUS ÆGINETA, Book I., 59, and the other authorities. See the Commentary. It is remarkable that, as far as I can discover, none of the later authorities make mention of the loose bandaging here recommended by our author. Galen, however, states that he had used it as directed by Hippocrates, and with good effect. 1 There is not much in this paragraph which stands in need of illustration, but then Galen's Commentary is well deserving of being consulted. He explains that, in affections of the head and chest, it was customary to use small pillows and bags filled with millet to give support to the parts affected and stop motion in them. It will be remarked, that in this place our author makes distinct mention of diastasis or separation of the bones of the cranium at the sutures. See above. |