rise to exacerbations, whether the tendency be to inflammation, to a foul condition of the sore, or to fevers. And if any piece of information be particularly valuable this is; to which of the most important cases in medicine does it not apply? and that not only in wounds but in many other diseases, unless one should call all other diseases wounds. And this doctrine is not devoid of a certain degree of plausibility, for they are allied to one another in many respects. But those who maintain that wool should be used until after the first seven days, and then that the parts should be extended and adjusted, and secured with bandages, would appear not to be equally devoid of proper judgment, for the most dangerous season for inflammation is then past, and the bones being loose can be easily set after the lapse of these days. But still this mode of treatment is far inferior to that with bandages from the commencement; for, the latter method exhibits the patient on the seventh day free from inflammation, and ready for complete bandaging with splints; while the former method is far behind in this respect, and is attended with many other bad effects which it would be tedious to describe.' 31. In those cases of fracture in which the bones protrude and cannot be restored to their place, the following mode of reduction may be practiced:-Some small pieces of iron are to be prepared like the levers which the cutters of stone make use of, one being rather broader and another narrower; and there should be three of them at least, and still more, so that you may use those that suit best; and then, along with extension, we must use these as levers, applying the under surface of the piece of iron to the under fragment of the bone, and the upper surface to the upper bone; and, in a word, we must operate powerfully with the lever as we would do upon a stone or a piece of wood. The pieces of iron should be as strong as possible, so that they may not bend. This is a powerful assistance, provided the pieces of iron be suitable, and one use them properly as levers. Of all the mechanical instruments used by men, the most powerful are these three, the axis in peritrochio, the lever, and the wedge. Without these, one or all, men could not perform any of 1 This mode of treating recent fractures and other injuries would appear to be now entirely lost sight of, and yet I can well believe that, under peculiar circumstances, as, for example, in military practice, it might be often found a very advantageous and useful method of treatment to bind a limb at first either, as our author mentions, with well-carded wool or with raw cotton. If disposed of in this way, and laid in the half-boot of pasteboard, which I have formerly mentioned as being used by myself in lieu of the ancient canals, I have no doubt but a fractured limb would lie very securely, and the patient in this state might be carried to a distance if required. ? Bis. 3 From the terms in which our author expresses himself, it has been supposed that these are the only mechanical powers which were known in his day. But, considering the advances in the arts which had then been made, it is not likely VALVAA lever is not to be despised, for the bones will be reduced in this way, or In 32. When you have reduced the bones to their place, the modes of treatment, whether you expect the bones to exfoliate or not, have been already described. All those cases in which an exfoliation of bone is expected, should be treated by the method of bandaging with clothɛ, beginning for the most part at the middle of the bandage, as is done with the double-headed bandage; but particular attention should be paid to the shape of the wound, so that its lips may gape or be distorted as little as possible under the bandage. Sometimes the turns of the bandage have to be made to the right, and sometimes to the left, and sometimes a double-headed bandage is to be used. 33. It should be known that bones, which it has been found impossible to reduce, as well as those which are wholly denuded of flesh, will be that the Greeks could have been entirely unacquainted with the screw, although our author omits to mention it here as not being of any application to surgical practice. The pulley (trochlea) is mentioned in the work On the Articulations, § 43, and, if I recollect right, in other parts of the Hippocratic treatises; but, as we have already stated, it does not appear that it was used anciently in the reduction of dislocations. 1 We recognize here two terms, the strictum and laxum, which formed the ground work of the whole system of the Methodists. See Cælius Aurelianus, passim. Quel ba of the bone elin some all it wil will sen rs, and som separati des, differe Et the bon akes place and is par a genera bercle of the dto sixty da zarate mor other sma ion of bone if it can red in ord can be tak the flesh. Cover, it b t With regar le sawed off Cas are com completely. Those that atoms that h 4. Such cas as former It avoid wett Gager of febril ed by cold t Co that the the bones have and in those cas tached. 35. Those c trades, do not e marrow; and n See Aphoris Cani ratione vita VOL reduction with the ced in this way, or ver the other dos but the protruding Il furnish a proper ension, may be la. y no means on the rbed on these days. will be excited, and apt to occur if I ese facts should be uction is effected, e the bones again he time when the sions and tetanus ally tense.' In the limb on the inflammation as But when seven and if the wound tempt at reduc t take and give e, the modes of not, have been ion of bone is with cloths, bes is done with be paid to the ed as little as bandage have sometimes a und impossiesh, will be ew, although n to surgical ticulations, § cises; but, as ently in the formed the Aurelianus, 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. 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. 66 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. ll be adm termen; and be stretched, b the wound. stated. do so ho *many; and be looked u int nearer 1. Latations putations ton to its ren confor and has ma p of the same an extent : 10 great marises fro erter is con protrude are attache The subject of Ce thought it n A few poin Dere is still great 1hree-joint, eve Hey of Leeds partial displ there appears is category ha des not appear qanted. Part anted with a ca sease usually ca ach impaired e disease have wrident: indeed I ted this mista arident as being stated elsewhere, host rarely meets the ligaments con n the Argument subject. 1 usually supervene ith singultus and - in those cases in ots made at redu ver, than those in will recover when rmodes of treaterence as to the a great differenc inside; for there aich, if wounded. less importance. t of the dangers, are compelled to Ehe bones do not tracted (for they advantageously 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. |