II VHHU མSU U IHOU SཅསS པ སྐྱུ ཀཔ་ད Vས༦ VV༦༦ས་vབ༥ ལསཡ ས་པས pཨvSy ཨམ་ those surrounding them become greenish and not hard; for this is a satisfactory proof in all cases of ecchymosis, that they are not to get worse; but when lividity is complicated with hardness, there is danger that the part may become blackened. And we must so manage the foot as that it may be generally raised a little higher than the rest of the body. Such a patient will get well in sixty days if he keep quiet.

12. The leg consists of two bones, of which the one is much more slender than the other at one part, but not much more slender at another. These are connected together at the foot, and form a common epiphysis,' but they are not united together along the line of the leg; and at the thigh they are united together and form an epiphysis, and this epiphysis has a diaphysis; but the other bone in a line with the little toe is a little longer. -Such is the nature of the bones of the leg.

13. Sometimes the bones connected with the foot are displaced, sometimes both bones with their epiphysis; sometimes the whole epiphysis is slightly moved, and sometimes the other bone.' These cases are less troublesome than the same accidents at the wrist, if the patients will have resolution to give them rest. The mode of treatment is the same as that of the other, for the reduction is to be made, as of the other, by means of extension, but greater force is required, as the parts of the body concerned are stronger in this case. But, for the most part, two men will be sufficient, by making extension in opposite directions, but, if they are not

Galen states expressly, that although the tibia and fibula are described as being connected together at the foot, it is not to be understood that they form one bone, but merely that they are in close contact together. It would seem, then, that by epiphysis our author, in this place, meant the malleolus externus. We shall find many examples of its occurring in this sense in the present and two following works.

* Galen states in explanation, that the epiphysis or protuberance here described belongs principally to the tibia. By diaphysis, he says, is meant a ligamentocartilaginous prominence connected with it; it appears therefore doubtful whether he applied it to the spinous process of the tibia, or to the semilunar cartilages, as Bosquillon supposed. M. Littre refers the term to the former; but Galen's description of the dinkysis, as being of a ligamento-cartilaginous nature, and not being to be met with in the skeleton, would seem to exclude this supposition.

*If by epiphysis we understand the outer malleolus, the meaning of this pasસપ્તક ૨, The bones of the leg at the ankle may be completely dislocated along with the outer maïlecius, or subluxated, in which case either the malleolus externus or the thia may be partially displaced.” This is pretty much the same interpretation as as given to this passage by Gardeil, as quoted by M. Littré Œcon. Hip, tom m. p. «N”, wha, however, does not at all approve of it, but enters into a very elaborate disqasini, a on thes pussure, yet without bringing it to any very satofactory occasion. I need scarely mention that partial dislocations Lave been frequently observed and described recently. See Sir Charles Bell's Surgery, A 16 and the an the luxations at the ankle given in the Argument.

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sufficiently strong, it is easy to make more powerful extension in the fol-
lowing way: having fixed in the ground either the nave of a wheel, or any
such object, something soft is to be bound round the foot, and then some
broad thongs of ox-skin being brought round it, the heads of the thongs
are to be fastened to a pestle or any other piece of wood, the end of which
is to be inserted into the nave, and it, the pestle, is to be pulled away,
while other persons make counter-extension by grasping the shoulders
and the ham. It is also sometimes necessary to secure the upper extremity
otherwise; this if you desire to effect, fasten deeply in the ground
a round, smooth piece of wood, and place the upper extremity of the piece
of wood at the perineum, so that it may prevent the body from yielding
to the pulling at the foot, and, moreover, to prevent the leg while
stretched, from inclining downward; some person seated at his side should
push back the hip, so that the body may not turn round with the pulling,
and for this purpose, if you think fit, pieces of wood may be fastened
about the armpits on each side, and they are to be stretched by the hands,
and thus secured, while another person takes hold of the limb at the knee,
and aids in thus making counter-extension. Or thus, if you prefer it:
having bound other thongs of leather about the limb, either at the knee,
or around the thigh, and having fastened another nave of a wheel in the
ground above the head, and adjusted the thongs to some piece of wood
adapted to the nave, extension may thus be made in the opposite direction
to the feet. Or if you choose, it may done thus: instead of the naves,
lay a moderate-sized beam under the couch, and then having fastened
pieces of wood in this beam, both before and behind the head, make
counter-extension by means of thongs, or place windlasses at this extrem-
ity and that, and make extension by means of them.
There are many

other methods of making extension. But the best thing is, for any phy-
sician who practices in a large city, to have prepared a proper wooden
machine, with all the mechanical powers applicable in cases of fractures
and dislocation, either for making extension, or acting as a lever.
this purpose it will be sufficient to possess a board in length, breadth, and
thickness, resembling the quadrangular threshing-boards made of oak.'

14. When you have made proper extension, it is easy to reduce the joint, for the displaced bone is thus raised into a line with the other. And the bones are to be adjusted with the palms of the hands, pressing upon the projecting bone with the one, and making counter-pressure below the ankle with the other. When you have replaced the bones, you

1 These descriptions are remarkably clear and easily understood when illustrated by drawings, as they are by Vidus Vidius and M. Littré. All our author's modes of making extension and counter-extension appear to be very judicious, The board or bench (scamnum Hippocratis) is described in the work On the Articulations. The text in the conclusion of the paragraph is in a doubtful state. I have adopted the emendation of M. Littré.

VOL. II.-4.

sibly can; but if prevented by the thongs, you must loose them, and make counter-extension until you get the bandages applied. The bandage is to be applied in the manner formerly described, the heads of the bandages being placed on the projecting part, and the first turns made in like. manner, and so also with regard to the number of compresses and the compression; and turns of the bandages are to be brought frequently round on this and on that side of the ankle. But this joint must be bound more tight at the first dresssing than in the case of the hand. But when you have applied the bandage, you must place the bandaged part somewhat higher than the rest of the body, and in such a position that the foot may hang as little as possible. The attenuation of the body is to be made proportionate to the magnitude of the luxation, for one luxation is to a small, and another to a great extent. But in general we must reduce more, and for a longer time, in injuries about the legs, than in those about the hands; for the former parts are larger and thicker than the latter, and it is necessary that the body should be kept in a state of rest, and in a recumbent position. There is nothing to prevent or require the limb to be bandaged anew on the third day. And all the treatment otherwise is to be conducted in like manner, as in the preceding cases. And if the patient have resolution to lie quiet, forty days will be sufficient for this purpose, if only the bones be properly reduced, but if he will not lie quiet, he will not be able to use the limb with ease, and he will find it necessary to wear a bandage for a long time. When the bones are not properly replaced, but there has been some defect in this respect, the hip, the thigh, and the leg become wasted, and if the dislocation be inward, the external part of the thigh is wasted, and vice versa. But for the most part the dislocation is inward.'

15. And when both bones of the leg are broken without a wound of the skin, stronger extension is required. We may make extension by some of the methods formerly described, provided the bones ride over one another to a considerable degree. But extension by men is also sufficient, and for the most part two strong men will suffice, by making extension and counter-extension. Extension must naturally be made straight in a line with the leg and thigh, whether on account of a fracture of the

1

1 According to Galen, the cause why dislocation inwards is more common than outwards is, that the end of the fibula extends lower down than the inner malleolus, and that has a tendency to prevent dislocation outwards. All our best authorities at the present day are agreed that dislocation of the astragalus inwards is the most frequent form of luxation at the ankle-joint. See Bransby Cooper's Lectures, where the same reason is assigned for the greater frequency of this mode of displacement as that given by Galen: "This is the most frequent luxation, in consequence of the malleolus internus not descending so low as the external." (Med. Gaz., 1069.)

2 The treatment of fractures of the bones of the leg, as given in this and the two following paragraphs, is deserving of much attention.

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bones of the leg or of the thigh. And in both cases they are to be bandaged while in a state of extension, for the same position does not suit with the leg and the arm. For when the fractured bones of the arm or forearm are bandaged, the fore-arm is suspended in a sling, and if you bind them up while extended, the figures of the fleshy parts will be changed in bending the arm at the elbow, for the elbow cannot be kept long extended, since persons are not in the custom of keeping the joint long in this form, but in a bent position, and persons who have been wounded in the arm, and are still able to walk about, require to have the arm bent at the elbow-joint. But the leg, both in walking and standing, is habitually extended, either completely or nearly so, and is usually in a depending position from its construction, and in order that it may bear the weight of the rest of the body. Wherefore it readily bears to be extended when necessary, and even when in bed the limb is often in this position. And when wounded, necessity subdues the understanding, since the patients become incapable of raising themselves up, so that they neither think of bending the limb nor of getting up erect, but remain lying in the same position. For these reasons, neither the same position nor the same mode of bandaging applies to the arm and to the leg. If, then, extension by means of men be sufficient, we should not have recourse to any useless contrivances, for it is absurd to employ mechanical means when not required; but if extension by men be not sufficient, you may use any of the mechanical powers which is suitable. When sufficiently extended, it will be easy to adjust the bones and bring them into their natural position, by straightening and arranging them with the palms of the hand.

16. When the parts are adjusted, you should apply the bandages while the limb is in a stretched position, making the first turns to the right or to the left, as may be most suitable; and the end of the bandage should be placed over the fracture, and the first turns made at that place; and then the bandage should be carried up the leg, as described with regard to the other fractures. But the bandages should be broader and longer, and more numerous, in the case of the leg than in that of the arm. And when it is bandaged it should be laid upon some smooth and soft object, so that it may not be distorted to the one side or the other, and that there may be no protrusion of the bones either forward or backward; for this purpose nothing is more convenient than a cushion, or something similar, either of linen or wool, and not hard; it is to be made hollow along its middle, and placed below the limb. With regard to the canals (gutters?) usually placed below fractured legs, I am at a loss whether to advise that they should be used or not. For they certainly are beneficial, but not

1 I have given a summary of all the information which I could collect respecting the canals or gutters, used by the ancients for greater security to a fractured leg, in my annotations On the Surgery, and in the Commentary on PAULUS ÆGINETA, Book VI., 106. Galen mentions, in his Commentary on this part, that

use

I suppose.

preserve the leg at rest as they suppose; nor, when the rest of the body is turned to the one side or the other, does the canal prevent the leg from following, unless the patient himself pay attention; neither does the canal prevent the limb from being moved without the body to the one side or the other. And a board is an uncomfortable thing to have the limb laid upon, unless something soft be placed above it. But it is a very useful thing in making any subsequent arrangements of the bed and in going to stool. A limb then may be well and ill treated or without the canal. But the common people have more confidence, and the surgeon is more likely to escape blame, when the canal is placed under the limb, although it is not secundum artem. For the limb should by all means lie straight upon some level and soft object, since the bandaging must necessarily be overcome by any distortion in the placing of the leg, whenever or to whatever extent it may be inclined. The patient, when bandaged, should return the same answers as formerly stated, for the bandaging should be the same, and the same swellings should arise in the extremities, and the slackening of the bandages in like manner, and the new bandaging on the third day; and the bandaged part should be found reduced in swelling; and the new bandagings should be more tightly put on, and more pieces of cloth should be used; and the bandages should be carried loosely about the foot, unless the wound be near the knee. Extension should be made and the bones adjusted at every new bandaging; for, if properly treated, and if the swelling progress in a suitable manner, the bandaged limb will have become more slender and attenuated, and the bones will be more mobile, and yield more readily to extension. On the seventh, the ninth, or the eleventh day, the splints should be applied as described in treating of the other fractures. Attention should be paid to the position of the splints about the ankles and along the tendon of the foot which runs up the leg. The bones of the leg get consolidated in forty days, if properl treated. But if you suspect that anything is wanting to the proper arrangement of the limb, or dread any ulceration, you should loose the bandages in the interval, and having put everything right, apply them again.

17. But if the other bone (fibula ?) of the leg be broken, less powerful extension is required, and yet it must not be neglected, nor be performed slovenly, more especially at the first bandaging. For in all cases of fract

the more ancient authorities sometimes made use of a mechanical apparatus which he calls glossocomum, a drawing of which is given in the Latin translation of Galen by Vidus Vidius (Venetiis apud Juntas, 1565); and still a better one in the Institutiones Chirurgica of Tagaultius (iv., 3). It would appear to me to be a most ingenious machine, and excellently adapted for the position required. It is so constructed, that extension and counter-extension are constantly kept up by a double set of pulleys.

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