On blackness of the meninx. When the meninx turns black, if the blackness be superficial, and has been brought on by medicines which have that property, we may remove it by applying three parts of honey with rose-oil upon pledgets, along with the other suitable treatment. But if the blackness has come on spontaneously, more particularly if deep-seated, and be attended with other dangerous symptoms, then we must refrain from using them, for these appearances indicate a dissolution of the natural heat. I knew a person who had his skull trephined a year after the accident, and recovered. The fracture was from a weapon, and was situated on the bregma, and the discharge having an outlet, the meninx was thereby preserved free from injury.
Commentary. Hippocrates very properly lays it down as a rule that no injuries of the head are to be considered as trifling, since wounds affecting only the integuments will sometimes prove dangerous if neglected. He treats distinctly of fissures, contusions, and fractures of the cranium, which is an excellent arrangement of these accidents. Our limits, however, will not allow of our entering minutely into an explanation of his modes of treatment. In fractures of the head he forbids liquid applications, especially wine. He calls the trephine by the name of τρύπανον; and makes mention of a raspatory (ξυστὴρ). It would appear that his object in applying the trepan was altogether preventive; that is to say, that he had recourse to the operation in order to prevent inflammation and swelling of the brain, and not to remove the effects of them. He holds that severe contusions without fracture and fissures are more dangerous than injuries attended with depression and considerable separation of the fractured portions, and it is in the former class of cases that he recommends trepanning. When the bone is broken into several pieces, he says it stands in no need of the trephine. One of the varieties of fracture, which he describes with surprising accuracy, is the separation of the bones at a suture. It, he adds, seldom requires the use of the trephine. He remarks, that convulsions often occur in consequence of injuries of the head, and that the convulsions are in the opposite side to that in which the injury of the brain is seated. He gives an excellent account of erysipelas of the face supervening upon injury of the head, and recommends it to be treated with cholagogues. Altogether, his work ‘On Injuries of the Head’ bespeaks extensive acquaintance with the subject, and we need have little hesitation in pronouncing it to be one of the most valuable relics of antiquity. In one of his aphorisms, he states that concussion of the brain occasions loss of speech; that is to say, as Galen explains his meaning, superinduces apoplectic symptoms.
Galen mentions three sorts of instruments for operating upon the cranium, namely the cyclisci, the lenticulars, and the narrow raspatories. Fractures are classed by him into those which extend only to the diploe, and those which penetrate to the inner surface of the bone. He likewise divides them into simple fissures, contusions, and depressions inflicted by the body, which occasioned the injury. When the fissure extends down only to the diploe, he directs us to scrape down the bone with raspatories, and then to apply the medicines called cephalics, consisting of Illyrian iris, the farina of tares, manna, birthwort, and panacea. Of the fractures which extend to the meninx, if a simple fissure, it may be treated in the same manner by raspatories; but if attended with contusion, by perforating it all round with an auger (trepan?), and then using the scalpel, or by means of the cyclisci at once. Some, he says, instead of these instruments, use the abaptista, which had a circular border projecting a little above the sharp extremity of the perforator. Some, he says, from timidity, use only the instrument called chœnix (modiolus). Of all modes, however, he prefers that by the lenticular, as stated by our author. He then defines the engeisoma and camerosis, which we have translated the depressed and the arched fractures, the former being attended with depression, and the latter with elevation in the middle of the fracture. These are to be taken out entire by means of a lenticular or bone forceps. This, by the way, was the practice of the celebrated Heliodorus, of whose opinions on this subject we will give a short abstract below. (Nicetæ Collectio.) Such is Galen’s general treatment of fractures of the skull. In a word, he lays it down as a rule, that parts which are greatly comminuted, must be entirely removed; but that fragments, which extend far, must not be followed to their extremities. He forbids the use of bandages. He mentions having trepanned the head occasionally, but states that he generally left this task to the Roman surgeons. Sprengel remarks, that Galen was averse to the use of the trepan, and preferred the two instruments called by him φακωτὸς and κυκλίσκος. The latter, he remarks, was, properly speaking, a hollow chisel (un ciseau creux), which he drove in with a hammer. The former was a true lenticular-knife, resembling that described by Petit and Bell (Hist. de la Méd., 18.)
We will now attempt an abstract of Celsus’s lengthy account of these accidents. When the skull has been struck, he recommends us in the first place to inquire whether the person has vomited bile, has experienced dimness of vision, with loss of speech, or a discharge of blood from the nose and ears; whether he fell down at the time, and if he lay in a comatose and senseless state. These symptoms, he says, indicate a fracture of the bone, and the accident is to be looked upon as serious. But if torpor has come on, with mental aberration, paralysis, or contraction of the tendons, it is probable that the membrane of the brain has been injured, and little hopes of recovery need be entertained. In order to ascertain whether or not the bone be fractured, nothing answers better, he says, than making an examination with a specillum (sound), that is neither too sharp nor too blunt. If the bone is felt to be everywhere smooth, we are certain that it is sound; but if roughness is detected, we know that it is occasioned by a fracture. He warns us, however, not to mistake a suture for a fissure, as was once done by Hippocrates, upon whom he bestows a merited eulogium for this frank confession of his own blunder. When this method of inspection does not succeed, he advises us to pour writing ink on the part and to scrape the bone, which will appear black when there is a fissure. Sometimes, however, he adds, the blow has been sustained on one part of the skull, and the fissure occurs in another. This is the case of fracture by repercussion, of which we will make further mention afterwards. Celsus says, we ought to suspect the existence of it when symptoms of fracture have occurred without our being able to detect one in the part which received the blow. He also recommends us, if softness and swelling be detected in any part, to examine it, as it is likely that a fissure of the bone may be found there. (By the softness and swelling, of which he speaks, he probably meant the puffy tumour, described by Mr. Pott, in his work on ‘Injuries of the Head.’) Sometimes, he adds, but rarely, although the skull be safe, a vessel in the membrane of the brain bursts and pours forth much blood, which, becoming coagulated, occasions great pain and dimness of sight. In such a case, he says, the pain will point out the seat of the extravasation, and if an incision be made in the skin, the bone will be found to be pale—“eo loco cute incisâ, pallidum os reperitur.” (Heliodorus, in like manner, states that when extravasation has taken place within the cranium, the bone will be found to be pale—Nicetæ Collectio.) The fact that in cases of extravasation below the skull the bone is pale, that is to say, does not bleed, is pointed out by Mr. Abernethy as an unerring guide to practice in such cases. He says, “unless one of the large vessels of the dura mater be wounded, the quantity of blood poured out will probably be inconsiderable; I believe that a bone so circumstanced will not be found to bleed.” Celsus then proceeds to the description of the operation. If the injured portion of the bone is not sufficiently exposed, he directs us in the first place to enlarge the wound of the integuments. The periosteum is then to be scraped away with a raspatory. The form of the incision, if made solely by the operator, is to consist of two cross lines intersecting one another like the letter Χ, from the extremities of which the skin is to be dissected away. If there be a discharge of blood it is to be stopped by a sponge dipped in vinegar, or by compresses, while the head is elevated. In cases of fracture and fissure of the cranium, the ancient surgeons, he says, had immediate recourse to instruments for cutting out the part; but he recommends the surgeon, in the first place, to try the effect of applications for allaying the irritation, such as suitable plasters, with wool soaked in vinegar, proper bandages, and the like. This treatment is to be continued for five days, and on the sixth the part is to be fomented with a sponge soaked in warm water. If the skin begin to heal, and the fever to abate, and if the appetite return, with sound sleep, he recommends perseverance in the use of these applications. In this manner, he adds, fissures will often be filled with callus; thus, also, bones more extensively fractured may become united with callus, which forms a much better cover to the brain than the common integuments after a piece of bone has been cut out. But if, on the other hand, fever set in at the first with disturbed sleep, a copious discharge from the wound which shows no appearance of healing; if the glands of the neck swell, or if violent pain comes on, with loathing of food, the surgeon must proceed forthwith to the operation. Dangerous consequences, he adds, may arise either from a fissure or a depression. A fissure may allow fluids to descend to the membrane of the brain, and thereby give rise to pain and inflammation. A depression in like manner may occasion irritation, and spiculæ of bones by wounding the brain may prove particularly troublesome. As a general rule, he recommends as little of the bone as possible to be removed. If the one edge overtop the other, it will be sufficient to remove with a raspatory the prominent part; for when it is taken away there will be a sufficient opening for the cure. If the edges are firmly compressed together, a hole is to be bored with a wimble (terebra) on its side, at the distance of a finger’s breath, and from it two lines are to be cut to the fissure with a raspatory (scalpel), in the form of the letter V, so that its vertex may be at the hole, and its base at the fissure. If the fracture be long, more of these holes must be cut out. In cases of depression the whole depressed portion must be removed. In whatever way the pieces of bone are cut they are all to be removed by means of a suitable forceps. But we will not occupy more space in explaining his method of operating, as we have been already more than usually prolix. Enough has been said to show that the practice of Celsus was sensible, and in many respects not very different from that which is now followed in such cases. It will be seen that he was not forward to perforate the skull, and that many of the rules of treatment lately laid down as new discoveries are distinctly mentioned by him. For a description of the instruments used by him, namely, the modiolus, terebræ, and scalper excisorius, we must refer the reader to the original work. (viii, 3.)
The different kinds of fracture to which the skull is subject, and the treatment of them, are given very minutely in the Fragments of Heliodorus, published by Cocchi (Ch. Vet. 100, &c.); but as the views of the subject there laid down are nearly the same as our author’s, we shall only give a few specimens of the doctrines he inculcates. He describes very distinctly the species of fracture called diastasis, namely, the separation of two bones of the head at a suture. He directs that the head should be moulded into its former shape, and secured with compresses and tight bandaging. When matter forms he recommends it to be cut down upon. When depression of the bone without fracture occurs in children, it is not to be much interfered with, if no untoward symptoms come on. But if any collection take place, it is to be evacuated, even if trepanning should be required for this purpose. He says, in the treatment of simple injuries of the scalp, that the cure by the first intention is the quickest, but the suppurative the safest. In the same Collection there are a few fragments of Archigenes, containing some curious and important matter. He describes diastasis of the bones with more minuteness than any other ancient author, but does not touch upon the treatment. He appears to treat of hernia cerebri under the name of hypersarcosis, and recommends the excrescence to be removed, with septic medicines or the scalpel, down to the membrane (dura mater); after which a light dressing dipped in rose-oil is to be applied, and the part surrounded with a circular bandage. (Chirurg. Vet. p. 119.) Effusion of blood within the cranium is indicated by fevers coming on with chills, inordinate heat, disturbed sleep, eyes glossy, muddy, and red, loss of flesh, &c. In such cases, he remarks, if operated upon speedily, they exhibit promises of recovery, but generally soon die. (Ibid. 117.)
Albucasis enumerates the same varieties of fracture as our author, and his description of the operation is little different. The drawings which he gives of the surgical instruments used by the ancients in operations on the head are interesting, as they tend to illustrate the descriptions of Paulus and the other authorities. We may remark, by the way, that his abaptista, which he calls terebra non profundantia, are a sort of spear-shaped instruments, having a globular ball a short way above their extremity. They, therefore, had no resemblance to a modern trephine with a conical crown.
Avicenna gives a very full account of injuries of the head, but it is taken almost word for word from Galen and our author. Nearly the same may be said of Haly Abbas.
Avenzoar states that trepanning the skull will be proper when there is fracture with depression; but laments that in his time it would be difficult to find a surgeon capable of performing the operation. Averrhoes likewise intimates that he did not know a surgeon who could trepan the skull. This is an additional proof to what we have mentioned in the section on amputation that the Arabians in general were very timid operators.
Rhases strongly inculcates the propriety of having recourse promptly to the operation, when the bone is fractured and depressed, before dangerous symptoms have come on. Unless there be pressure on the brain, however, he does not approve of having immediate recourse to the operation.
It will be remarked that Celsus affirms, and our author denies, the occurrence of fracture by repercussion. It is the same as la fracture par contre-coup of the French medical authors, or the counter-fissure, namely, the fractura per resonitum of the earlier authorities. Soranus, who, like Celsus, believes in its occurrence, defines it to be a fissure which takes place in the part of the cranium opposite to that which received the blow. (Nicetæ Collectio.) Hippocrates himself makes mention of the counter-fissure, and pronounces it to be incurable, as the surgeon has no certain data to discover its existence. (Vul. Cap. viii.) Tulpius, Paré, and Van Sweiten have related cases of the counter-fissure. (See Comment. in Boerhaav. Aph. 254.) Heister also believed in its occurrence. (Chirurg. i, 1, 14.) For cases of it he refers to D. Wagnerus, (Dissert. de contra-fissura,) and Le Maire (De resonitu.) He is mistaken, however, when he quotes Ægineta as an authority for it. Sabatier relates a case of fracture par contre-coup in the sternum occasioned by a fall on the back. (Mémoires de l’Institut Natural, ii, 120.) See also Sprengel (Hist. de la Méd. 17.) Garengoit further relates various cases of the contre fissure. Bertaphalia defines it in much the same terms as Soranus. (v, 5.) Mr. Guthrie treats learnedly of this subject; but although he quotes many instances from the earlier authorities of fracture on one side of the head from a blow on the other, he states that in later years there is little proof of such an occurrence taking place. He admits, however, as indisputable the occurrence of fracture at the base of the skull from a blow on the vertex or back of the head. (Injuries of the Head, 65.) He also states that the term ἀπήχημα of our author, and that of ‘resonitus,’ as used by Latin authors, was applied to that species of fracture when the inner plate of the skull is knocked in or fractured, without the outer one being injured. (Ibid.) It does not appear, however, that the ancients applied the term in this sense. Thus Soranus, as stated above, defined it to be a fissure produced in the parts of the skull opposite to those which have received the blow. See the learned note of Cocchi. (Ap. Chirurg. Vet. 47.) Galen’s definition is to the same effect. (Ibid. 107.)
The treatment here recommended for inflammation of the membranes of the brain is so judicious, that even at the present day scarcely any improvement could be made on it. Our late authorities have shown the utility of cholagogue purgatives in such cases, and it will be remarked that they are recommended by our author and Hippocrates. (De Cap. Vuln. 27.)
Celsus directs us, when the dura mater gets inflamed and swelled, to pour tepid rose-oil upon it; and if it rise above the bone to apply lentil or vine leaves pounded with fresh butter or the grease of geese. He enjoins us to avoid all kinds of food requiring mastication, also smoke and sternutatories. When the brain projects beyond the bone (a case called hernia cerebri by modern surgeons), he advises us to sprinkle it with squama æris, and to use cicatrizing applications. A person who has sustained a fracture of the skull is advised to avoid the sun, wind, frequent baths, and the free use of wine until the wound is healed.
Aëtius recommends bleeding and laxative clysters. (vi, 47.)
Heliodorus recommends abstinence at first, and afterwards spare diet, water for drink, bleeding, when the inflammation is violent and the patient full, light dressings, cataplasms of melilot, linseed, and oil, and fomentations with decoctions of fenugreek or mallows. Archigenes directs us when there is a fungous tumour projecting above the bone, to remove it with septics or the scalpel, and then to apply pledgets. (Nicetæ Collect.)
Avicenna and Albucasis repeat our author’s directions. Haly Abbas follows in the same strain, recommending us to remove any cause of irritation, to pour refrigerant oils on the place, and to have recourse to venesection. (Pract. ix, 85.)
Our author having alluded to the pulsatory motion of the brain, we will state briefly the opinions of the principal ancient and modern authorities on this matter. Besides our author, Hippocrates, Galen, Oribasius, and Aëtius, among the ancients, mention a certain movement of the brain, namely, a swelling up during expiration, and a falling down during inspiration. Fallopius, Vesalius, Voltherus, Coiter, and Boerhaave maintained that this opinion is unfounded. But Columbo, Piccolomini, Dulaurens, Riolan, Littré, and more recently, Schliting, Lamure, Haller, Lorri, Vic d’Azyr, and Dumas, have reproduced this ancient truth. We once had an opportunity of observing the pulsatory motion of the brain in the case of a poor boy who had lost a considerable piece of the skull by exfoliation.
This would appear to be the most suitable occasion which we shall have to introduce an account of the osseous tumour, nearly all the information regarding which is derived from a fragment of Heliodorus. He describes it as a hard resistent tumour, immoveable, without pain, or change of colour. He says it occurs on all parts of the body, but more especially on the head, about the temples, when if one is formed on each side they are called horns. He directs that the tumour should be cut out from the very base, and the bone scraped with a raspatory. The wound is to be healed by glueing (the first intention?), if possible, but otherwise by suppurative applications. (Ch. Vet. 124.)
SECT. XCI.—ON FRACTURE AND CONTUSION OF THE NOSE.
The under part of the nose being cartilaginous does not admit of fracture, but it is liable to be crushed, flattened, and distorted; but the upper part being of a bony substance is sometimes fractured. In such cases Hippocrates prohibits bandaging, which only increases the flatness and distortion, unless when from a blow the parts about the middle of the nose protrude. For in these cases he applies a suitable bandage with medicines, in order to give the nose its proper shape. When, therefore, the nose is fractured in its under parts, having introduced the index or little finger into the nostril, push the parts outwards to their proper position. When the fracture is of the inner parts this is to be done with the head of a probe immediately, during the course of the first day, or not long afterwards, because the bones of the nose get consolidated about the tenth day. But they are to be put into the proper position with the index-finger and thumb externally. In order to prevent the bones from changing their position, two wedge-like tents, formed of a twisted linen rag, are to be applied, one to each nostril, even if but one part of the nose be deranged, and these are to be allowed to remain until the bone or cartilage gets consolidated. And some sew the quills of the feathers of a goose into the rags, and thus introduce them into the nose, in order that they may preserve the parts in position without obstructing the respiration; but this is unnecessary, as respiration is carried on by the mouth. If the nose become inflamed we may use some anti-inflammatory application to it, such as that from juices (diachylon), the one from vinegar and oil, and such like; or a cataplasm of fine wheaten flour boiled with manna or gum may be applied, both for the sake of the inflammation and in order to keep the nose in position. When the nose is distorted to either side, Hippocrates directs us, after it has been restored to its proper position, to take a piece of leather of a finger’s breadth, and having spread one of its ends with taurocolla or gum, to fasten one extremity of it on that side of the nose to which it inclines, and after it dries to bring the thong by the opposite ear to the occiput and forehead, and to fix the other end of the thong firmly there, so that the nose being drawn sideways may take the proper position in the middle. This practice, however, is not much approved of by the moderns. If the bones of the nose are broken into small pieces we must make an incision or enlarge the wound, and having removed the small bones with a hair forceps, unite the divided parts with sutures, and use the applications for recent wounds and those of an agglutinative nature. If there be a sore within the nose it is to be cured with the pledgets called lemnisci, spread with suitable ointments. Some also use leaden tubes until it cicatrize, lest a fleshy excrescence should arise from the ulcer.
Commentary. Some account of Hippocrates’s practice is given by our author. As here mentioned, he strongly disapproves of bandages which, he says, never fail to disappoint the expectations of both surgeon and patient. He directs us to replace the broken parts, either with the fore-finger or a specillum. He also describes the application of the piece of thong; a distinct account of which is given by our author. (De Articulis, 30.)
Galen, in his ‘Commentary,’ explains the obscurities in the text, but supplies no additional facts or views of practice. He greatly disapproved of agglutinative applications and bandages. (Fragmentum ap. Nicetæ Collect.)
Celsus gives a full account of fractures of the nose, but as he follows the plan of treatment recommended by Hippocrates, it will be unnecessary to dwell long upon it. When the cartilages are fractured, the pieces are to be replaced with a specillum, or with two fingers pressing on both sides; then oblong tents sewed round with a thin soft skin are to be introduced into the nostrils; or a large quill smeared with gum, or artificers’ glue may be applied in like manner. He speaks of the leathern thong, but uses it under somewhat different circumstances than those for which our author recommends it. He directs us to fasten the middle of it to the nose, and the extremities to the temples on either side. When any fragment of a bone does not coalesce properly with the rest, he recommends us to extract it with a forceps. The case, he properly states, is more dangerous when there is an external wound; but in this case he recommends us to apply one of the plasters adapted for recent wounds; like the others he disapproves of bandages.
Rhases, Avicenna, Haly Abbas, and Albucasis lay down exactly the same rules of practice as Hippocrates and our author.
The recent authorities consider the introduction of the tents into the nostrils unnecessary, and even prejudicial. (See Bell’s Operative Surgery; Cooper’s Surgical Dictionary.) But the earlier modern writers adopt exactly the practice of the ancients. Theodoricus recommends us to turn the nose to its proper shape when distorted, by means of a strip of linen fastened to its extremity with ichthyocolla, or the gluten of hides, as directed by the ancients. (ii, 29.)
SECT. XCII.—ON FRACTURE OF THE LOWER JAW, AND CONTUSION OF THE EAR.
We have treated of contusion of the ear in the Third Book, as this affection is not of the nature of a fracture. But the lower jaw is fractured from many causes. If, then, it be only fractured externally, and is not divided into two, as it occasions a curvature inwardly, the symptoms of it are obvious. Wherefore, having introduced the index and middle fingers of one hand—of the right, if the right jaw be fractured, and of the left, if it is the left—we push outwards the internal curvature of the fracture, which is to be secured with the other hand externally. The bones of the jaw are ascertained to be set straight by the equality of the teeth. When the jaw is fractured completely across, (that is to say, caulatim,) it is to be set by making extension and counter-extension, with the aid of an assistant; and the teeth, separated at the broken part, are to be fastened together, as Hippocrates says, and bound with gold, namely, with a ligature or thread of gold. But since this is not readily procured by everybody, a strong flaxen thread, a piece of fine linen, horse-hairs, or the like, may be substituted. If the fracture be attended with an external wound, we must examine with a probe and ascertain whether a piece of bone be broken off, and if this be found to be the case, and the wound is small, it is to be enlarged and the broken piece or pieces removed with some suitable instrument, and the lips of the wound united with sutures; then dressings suitable to recent wounds with bandages are to be applied. If there be no wound, a simple cerate is to be applied to the jaw along with suitable bandages. In applying the bandage, the middle of it is to be placed on the occiput, and the fold of it brought along by the ears on both sides to the chin, and then from the chin to the occiput again, and then again to the chin, and thence by the cheeks to the bregma, and then again to below the occiput, where the bandage must terminate. Upon these again a cover, that is to say, another bandage, is to be applied to the forehead and fastened behind the head, in order to secure the aforementioned bandages. Some, also, apply a light splint, or a piece of leather of proper size, to the jaw, and bandage it as we have described. Others use the bandage called a muzzle. If both sides of the jaws are separated at the symphysis, having removed them a little asunder with both the hands, adapt them again to one another, and having fastened the teeth together as aforesaid with a ligature, and applied the proper bandages, order the patient to be nourished with thin soups, because mastication is hurtful in this case. And, if you suspect that it has been deranged from its position, loose the bandages on the third day, and apply them again, and do in like manner until the callus be formed. The callus of the jaw-bone is generally formed within three weeks at most, because it is spongy and full of marrow. If any inflammation come on, we must not neglect the embrocations and cataplasms suitable to it; which practice is to be observed in all cases.
Commentary. Our author’s account of fractures of the lower jaw is taken almost word for word from Hippocrates. (De Articulis.) He divides them into external fractures, and fractures caulatim (or cauledon), which, agreeably to the explanation of this term, given in the 89th section, Galen interprets to be a complete separation of the fractured portions. He directs us to fasten the teeth with a gold thread; and in other respects also his practice is exactly the same as our author’s. His account of fracture at the symphysis is very correct.
Soranus gives a very sensible account of this subject. A transverse fracture, he says, often takes place, but a longitudinal one seldom, and in certain cases it is not attended with any distortion. It is to be recognized by examination with the fingers, when any displacement of the parts and crepitus will be recognized. Fracture in the ramus may be distinguished from dislocation, by there being mobility in the former case, whereas there is none in the latter. (Chirurg. Vet. p. 49.)
Celsus says, that in fractures of the jaw-bone the separated portions are never completely disjoined. When the bone is fairly broken transverse, the tooth at the fractured part protrudes, and is therefore to be secured to the adjoining one with a hair. He then recommends us to apply a double compress, moistened in wine and oil, with agglutinants; and afterwards a bandage or soft piece of leather is to be put on with its middle at the chin, and its extremities fastened above the head. In this, as in every other species of fracture, he recommends at first abstinence, and afterwards, liquid food; not allowing a full diet until the inflammation has subsided. He says, a fractured jaw-bone gets consolidated between the 14th and the 21st day.
Albucasis evidently copies from our author; and Avicenna and Rhases do so avowedly.
Haly Abbas gives a similar account, recommending us to secure the teeth with a thread; and then to apply bandages, and occasionally a compress, as directed by our author.
By the first variety, described by all the ancient authorities, was meant, we suppose, a fracture of the condyle.
SECT. XCIII.—ON FRACTURE OF THE CLAVICLE.
The clavicle in its natural position is united to the sternum at its inner extremity, and at its outer it is articulated with the acromion; and, therefore, as it supports the shoulder and the arm itself, if it undergo a fracture in any part whatever, the portion of it united to the shoulder sinks down, being dragged along with the arm. It is better, then, that the fracture be transverse, and not longitudinal, or partly straight with a lunated extremity, according to the opinion of most surgeons. For that which is fractured transversely, can, by extension and compression with the fingers, be readily restored to its proper position; but the other kinds of fracture have prominences not easily arranged. If, therefore, it be broken in any way through its whole thickness, let one assistant take hold of the arm connected with the fractured clavicle, pulling it at the same time outwards and upwards; and let another pull the opposite shoulder, or at least the neck, and let them make counter-extension. The surgeon then, with his fingers, is to set the fracture, pushing down what is prominent, and drawing outwards what is situated too deep. If more counter-extension be required, a ball of rags, wool, or something such, may be applied below the armpit, and the elbow brought to the rib adjoining to it; and the other things may be done as described already. But if it is found impossible to raise up the end of the clavicle connected with the shoulder that is lodged down below, having laid the man on his back, and placed a moderate cushion under his back, let an assistant push the shoulders downwards, so that the bone of the clavicle which is lodged below may be bent upwards, and then set the fracture with the fingers. But if part of the clavicle be broken off and unconnected, and if we find it irritating the parts, we must make a straight incision with a scalpel and remove the broken portion, and smooth the remainder with chisels, taking care that the instrument called meningophylax, or another chisel be put under the clavicle to make it steady; and if no inflammation is present, we may use sutures, but otherwise, pledgets. And having prepared various splenia (compresses), we must apply the larger and thicker to the projecting part of the bone; and these, when inflammation is present, are to be dipped in oil, but otherwise they are to be applied dry. And having put a moderate ball of wool under the nearer armpit, we apply a suitable bandage round by the armpits, the fractured clavicle and the scapula, bringing the folds in a proper direction; and if the part of the clavicle connected with the shoulder fall downwards, the middle of a broad thong is to be put under the elbow of the same side, and the whole arm suspended by the neck, and the hand is to be slung in another bandage as in cases of bleeding at the elbow. But if, which rarely happens, the outer part be uppermost, we must not have recourse to this arrangement of the arm. The patient must lie in a supine position, and live upon a spare diet, and if necessary, embrocations and other suitable applications are to be made until the callus is formed. The callus of the clavicle is formed in about twenty days at most.
Commentary. Hippocrates gives such an account of this accident as clearly bespeaks his intimate acquaintance with the subject. Transverse fractures, he says, are easily healed, whereas such as are oblique prove more difficult to manage. He justly remarks, that the deformity occasioned by this injury appears at first very great, and annoys both the patient and his physician, but that it gradually becomes less, and the patient, feeling little inconvenience from it, grows careless, and the physician, seeing no evil consequences result from this neglect, acquiesces in it, and presently it is found that proper callus is formed. Hippocrates further exposes the mistake of those who endeavour to push down the projecting bone, which, he justly remarks, cannot be effected. The part which projects, as he states, is almost universally the extremity attached to the sternum, the other portion being dragged down by the weight of the arm; and hence the mistake is obvious of those who attempt to push down the upper extremity. He recommends the patient to lie in bed until adhesion takes place, which generally occurs between the fourteenth and twentieth day. (De Articulis, 16.)
Galen directs us to apply four splenia or oblong compresses intersecting one another like the letter Χ. (Comment, et Fragment, apud Nicetæ Collect.) When the fracture is near the shoulder, Galen recommends the spica bandage (De Fasciis), for a drawing and description of which, see Heister’s ‘Surgery,’ (p. iii, c. 4, §1, c. 3.)
Celsus agrees entirely with the account of the matter given by Hippocrates. When the bone is broken transversely, he says, it will sometimes unite readily without the application of a bandage. In general, as he explains, the upper end of the fractured portions is the part attached to the sternum, the other being attached to the shoulder and dragged down along with the arm. He mentions that this is so generally the state of the parts, that some great masters of the art had declared that they had never seen a case in which the end attached to the shoulder projected, but that Hippocrates, who is rich in information upon these subjects, had affirmed upon his own authority that such an occurrence is to be met with. In setting the fracture he properly directs us to raise the shoulder; and his mode of bandaging would seem to have been little different from that now generally followed. He directs us to fill the armpit with wool, and to apply over the fractured portions of the bone a compress three times folded, and moistened in wine and oil; or, if the bone is broken into many fragments, a splint formed of cane (ferula). If the bones incline to the common position, the arm is to be fixed to the side, but if the outer end has a tendency upwards, the arm is to be tied to the neck. The man is to be laid on his back. All spiculæ of bones are to be cut out, if it is found that they are wounding the flesh.
Albucasis follows our author closely. He particularly enjoins the surgeon when there are any projecting spiculæ, to make an incision and cut them out; after which, a suture may be used to heal the integuments, provided the wound is large. A compress, soaked in rose-oil, vinegar, and wine, is to be applied to allay inflammation. He directs the patient to sleep on his back with a pillow under his armpit.
Rhases, Avicenna, and Haly Abbas give exactly the same account of the accident as Albucasis and our author.
SECT. XCXIV.—ON THE SCAPULA.
The scapula is not fractured in its broad and tabular part, but a fracture may sometimes take place at its spine. The fracture being sometimes what is called by expression, sometimes a simple fracture, and sometimes a piece is broken off. The expression, then, is ascertained by the touch, exhibiting a hollow, and occasioning torpidity of the adjacent arm and a throbbing pain. Simple fracture is known by its roughness and local pain. Both are to be managed according to the anti-inflammatory plan of treatment. When a piece is broken off, which also may be ascertained by the touch, if it gives no disturbance it may be fixed by a convenient bandage, but when it moves about and produces irritation, it is to be removed by an incision, and sutures used, as described above. Bandages like those for the clavicle are to be applied, and the patient is to be laid on the opposite side.
Commentary. Hippocrates has not treated particularly of this fracture.
Celsus treats in general terms of the cheek-bone, breast-bone, the broad bone of the scapula, the spine, os sacrum, &c. If there be an external wound, it is to be healed with suitable dressings; after which the fissure or hole in the bone will fill up with callus. If the skin be entire, he merely enjoins rest, a suitable cerate, and gentle bandages.
Albucasis and Avicenna, as usual, copy from our author. The former states that fractures of the scapula are healed in twenty or twenty-five days. Haly Abbas, like the others, directs us to remove any spiculæ which occasion irritation, to apply soothing cataplasms, and suitable bandages. Rhases remarks that the body of the bone is little subject to fractures, but that its extremities may be broken off. A fracture of the hollow portion of it is ascertained by a rising in the part; fissures are recognized only by the local pain.
SECT. XCV.—ON THE BREAST-BONE.
The middle of the sternum is fractured by simple division and by expression, and the extremity of it is broken off. When, therefore, the fracture is deranged, pain and inequality of the place follow, and there is crepitus upon pressure with the fingers. When by expression, there is violent pain, dyspnœa, and cough, owing to the pleura being irritated; and rarely there is vomiting of blood, a hollow in the fractured place, and yielding thereof. The same treatment is to be applied as that recommended for the scapula. When the fracture is by expression, we may practise Hippocrates’s mode of setting which he recommended for the clavicle when it inclines inwards, having recourse to the supine posture, the application of a cushion upon the back, pressing down the shoulders, and drawing the sides together with the hands. The sides being covered with wool, we apply a circular bandage, having first put on two thongs straight from the shoulders, so that afterwards the two ends may be united in a proper manner, and prevent the circular bandage from falling off.
Commentary. Hippocrates holds injuries of the sternum to be more dangerous than those of the ribs. He recommends in this case a light diet, rest, silence, bleeding at the arm, and so forth. (De Artic. 50.)
Celsus directs this fracture to be treated upon general principles, as explained in the preceding section.
The Arabians evidently follow our author. Albucasis speaks of applying thin splints.
The reader will find, upon reference to the ninetieth section, that a fracture by expression is a comminuted fracture with depression.
SECT. XCVI.—ON THE RIBS.
Of the ribs, called also spathæ, those which are long admit of a fracture in any part, but the false only at the spine, because there only they are of a bony nature; for at their anterior part they are cartilaginous, and are liable to be crushed, but not fractured. The diagnosis is not difficult, for an inequality presents itself to the fingers of the examiner, and there is crepitus with derangement at the fractured part. When the fractured parts incline inwards there is a violent pungent pain, more severe than that in pleurisy, from the pleura being wounded as with a sharp instrument; there is difficulty of breathing, cough, and often vomiting of blood. The other modes of displacement, then, may be rectified by the fingers, but in that inwards this cannot be done, owing to the difficulty of applying distension. Wherefore, some direct us to give much flatulent food, in order that by the inflation and distension occasioned by it the fracture may be propelled outwards. But this is not necessary, for there is no communication between the chest and the organs of nutrition, and besides, the inflammation will be augmented by repletion. Others apply a cupping instrument, which is not amiss, unless a collection of humours should be occasioned by the suction, and the fracture be thereby pushed more inwardly. Wherefore, Soranus says, “Let the parts be covered with wool dipped in hot oil, and let the intercostal space be filled with compresses, in order that the circular bandage applied, as in the case of the sternum, may lie smooth. And let everything be done, as in pleurisy, according to the degree of accident. But if any great necessity compel us, owing to the pleura being irritated, we must divide the skin and lay bare the broken part of the rib; and then putting the instrument for protecting membranes under, to prevent the pleura from being wounded, cut off properly, and remove the irritating pieces of bone. After this the parts which are not inflamed are to be united and cured as recent wounds; but such as are inflamed are to be covered with pledgets dipped in oil. The diet and treatment must be anti-inflammatory, and the patient is to be laid in the easiest posture.”
Commentary. Hippocrates gives a full and accurate account of this accident. He remarks that when the broken ends of the bone are not pushed inwards, it seldom happens that fever or any unpleasant symptoms supervene. When fever is not present he thinks that abstinence by occasioning an emptiness of the belly, proves rather prejudicial by removing what otherwise tends to support the part affected, which is thereby made to hang unsupported. In this case a slight bandage will be sufficient. The ribs, he says, become united in about twenty days. When the skin about the ribs is bruised by a blow or any other such cause, much blood, he says, is often vomited up. Galen, in his commentary on this passage, states that when the vessels of the pleura are wounded and blood effused into its cavity, a spitting of blood may take place although the lungs themselves have not been injured. The treatment recommended by Hippocrates consists of bleeding at the elbow, enjoining silence, applying folded compresses with broad bandages, neither too tight nor too loose. He directs us to use a double-headed bandage, and to commence at the seat of the fracture. He approves of gentle aperients and restricted diet for ten days, after which period nourishing food is to be given. He adds, that when the proper treatment is neglected, even if no other inconvenience should result from it, a viscid collection is sure to form in the part. When, in addition to this swelling, a chronic pain gets seated in the part, he advises the actual cautery to be applied. (De Articulis.)
Celsus, with his characteristic elegance and terseness, expounds the rules of practice delivered by Hippocrates. He directs us to apply a bandage, to bleed from the arm, to open the belly; to avoid noise, speaking, tumultuous passions, smoke, dust, and whatever is calculated to excite coughing and sneezing. Gruels only are to be taken before the seventh day, after which bread may be used. When the pain is violent he directs us to apply a cataplasm made from darnel, or barley with fat figs. Should a collection of matter take place it is to be opened with a red-hot iron. When mucus forms about the fracture, he recommends the application of the cautery. The above is but an imperfect outline of his admirable chapter on fractures of the ribs.
Avicenna professedly copies from our author. Haly Abbas, Rhases, and Albucasis give nearly the same account, without the slightest addition of any importance. They all approve of making an incision and extracting the pieces of bones which may happen to be irritating the pleura. Albucasis gives a drawing of the meningophylax, or instrument for protecting membranes during the sawing of bones.
SECT. XCVII.—ON THE BONES OF THE HIPS AND PUBES.
The bones of the ischium or hips are rarely fractured indeed, but admit of the same varieties as those of the scapula. Their extremities, then, are sometimes broken off; there may be fracture along their length, and the middle may be fractured by expression. They are attended with a local pain, a pungent and throbbing sensation, and torpor of the leg on that side if from expression. It is to be set in the same way as that of the scapula, only it does not admit of the extraction of broken pieces by an operation on account of the external parts. If necessary, it is to be set by the fingers, and afterwards we must apply the other convenient treatment, using embrocations, and filling up the hollows of the loins with compresses, in order that the circular bandages which are put on may lie even. The same things may be said with respect to the bones of the pubes, for we have nothing more particular to say of them.
Commentary. The other authorities do not treat of these cases so minutely as our author, whose account of them is sufficiently accurate.
Celsus merely directs us to treat them upon general principles.
Albucasis recommends the same plan of treatment as our author, with the addition of splints made of wood or leather. These, however, cannot be very much required. He directs the patient to lie on his back or on the sound side.
Avicenna does not treat of these cases of fracture. Haly Abbas and Rhases abridge our author’s account.
SECT. XCVIII.—ON THE VERTEBRÆ, SPINE OF THE BACK, AND OS SACRUM.
The round bodies of the vertebræ may sometimes be crushed, but rarely undergo fracture, in which cases the membranes of the spinal marrow or the marrow itself being compressed, sympathetic nervous affections take place, and death speedily follows, more particularly if the vertebra of the neck be affected. Wherefore, having first given warning of the danger, we must, if possible, attempt to extract by an incision the compressing bone, or if not we must soothe the part by the anti-inflammatory treatment. But if any of the processes of the vertebræ, of which the spine, as it is called, consists, be broken off, it will readily be felt upon examination with the finger, the broken piece yielding and returning again to its position, and, therefore, we must make an incision of the skin externally and extract it, and having united the wound with sutures, pursue the treatment for recent wounds. When the os sacrum is fractured the index-finger of the left hand is to be introduced into the anus, while with the other we manage as we best can the fractured bone; or if we feel any piece broken off, we make an incision and lay hold of it, and apply bandages and suitable treatment.
Commentary. Celsus remarks that when a piece of one of the vertebræ is broken off a hollow is felt in the place, it is attended with pain, and the person is compelled to bend inwards. The treatment is to be conducted upon general principles, as explained under fractures of the scapula.
Albucasis lays it down as a rule that when a fracture of the cervical vertebræ produces paralysis and insensibility of the arms, the case may be abandoned as hopeless. When, after a fracture of the dorsal vertebræ, it is remarked that there is paralysis and insensibility of the lower extremities, and that the alvine and urinary discharges are passed unconsciously, he, in like manner, pronounces the case to be desperate. When a piece of bone is broken off and occasions great irritation, he recommends us, like our author, to make an incision and take it out.
Haly Abbas and Avicenna borrow everything from Paulus.
Rhases gives many curious remarks upon injuries of the spine, but several of them are borrowed from Galen. (De Locis Affectis.) Galen relates many cases to show that retention of the urine and fæces is a common effect of an injury of the spine. He also mentions that loss of speech is sometimes the consequence of the upper part of the spine being injured. Rhases relates the case of a man who lost the sensibility of his arms from an injury of the last vertebra of the neck, produced by a fall from a horse. He states, that when the injury is below the neck the respiration is never affected. He inculcates that whenever there is paralysis of the limbs, or of any part after a fall, it arises from some injury of the spine. (Cont. i.)
When the sacrum or os coccygis is fractured, he directs us to replace the parts by introducing the finger per anum. (Cont. xxix.)
SECT. XCIX.—ON THE ARM.
When the arm is broken Hippocrates makes the extension thus: he says, “We must take an oblong piece of wood, such as that which is put into the holes at the end of spades, and fastening ropes to its extremities, suspend it transversely from some beam, and placing the man upon some elevated object more erect than what is called the erect sleeping posture, we pass his hand over the above-mentioned piece of wood, so that the middle of the wood may be fitted to the armpit, and his arm being bent at a right angle, an assistant stooping down takes hold of the hand, and then some heavy object, such as a stone, a leaden ball, or the like, is to be fastened to the elbow, and being allowed to hang suspended, in this way you must set the fracture, or instead of a weight an assistant may pull down the arm, and instead of the above-mentioned piece of wood some use the step of a ladder.” Soranus, however, proceeds thus: Having placed the man in a chair, or, which is better, as it occasions less disturbance, in a supine posture, then having put a ligature round the wrist and suspended it from the neck so as to preserve its angular figure, we direct two assistants, the one to apply his fingers below the fracture and the other above, and thus to make the extension. Or if we require stronger pulling we apply two equal pieces of thong to the arm, the one above the fracture and the other below, and giving one of the pieces of thong to the assistant who stands above the patient’s head, and the other to the one at his feet, we order them to make counter-extension. If the fracture be near the top of the shoulder we apply the middle of the thong to the armpit and direct the assistant at the head to hold it, and, while the other pulls in the opposite direction, we make the counter-extension as above. And when the fracture is at the elbow, the ligature is to be applied there or at the wrist. The bones of the fracture being properly set, the extension is to be relaxed, and it is to be bound up according to the method of Hippocrates. When the fracture is free from inflammation and recent, we must use linen bandages of a proper length, and three or four fingers in breadth, which have been soaked in water or oxycrate, but when there is inflammation, thin soft pieces of wool steeped in oil are to be used. And if the fracture be at the middle of the arm the bandaging must commence at the fracture, and after two or three turns the bandaging is to be carried upwards, in order, as he says, that the overflow of blood to the part may be intercepted; and it is to terminate there. A second bandage is then to be applied with its head at the fracture, and, having done as in the former case, carry it from above downwards, and again reverting from thence upwards let it terminate there. There should be a moderate degree of tightness according to our own feeling and that of the patient. If the fracture be near the top of the shoulder, the first bandage should take in the acromion, scapula, and sternum, so as to form what is called the crane bandage. The second one is to extend to the elbow, and reverting from thence to the upper parts it is to take in, with the acromion, the scapula and sternum, like the first bandage. If the fracture be at the elbow, the fore-arm is to be taken in with the bandage, the figure of the elbow-joint being preserved. And so in like manner with the other members, such as the fore-arm, the thigh, and the leg; and when the fracture is in any part near a joint, and not in the middle of the limb, the joint is to be bound along with it. After the bandaging the moderns immediately apply splints, in order to preserve the bones which have been set in their proper shape, tightening them agreeably to the patient’s feeling and the swelling occasioned by the inflammation. But the ancients did not apply the splints until after the seventh day, within which period, as the inflammation had declined, the limb had become less swelled. Hippocrates orders the bandages to be loosed every three days, lest, owing to the part being constantly covered up, distension and pruritus should come on, and that the insensible perspiration might not be obstructed after the bone has become firm; for that by these means not only does a painful pruritus take place in certain cases, but ulceration of the skin is occasioned by the acrimony of the sanious humours. He directs us, therefore, to bathe with tepid water, so as to dispel the humours, but after the seventh day to loose the bandages at greater intervals, because the parts no longer require the expulsion of the humours; the formation of callus thus goes on properly. The splints are to be applied in this manner. Compresses, thrice folded and dipped in oil, are to be put upon the bandages, and if the limb be of equal thickness this is to be done even; but if it is of unequal thickness, the hollow parts are to be filled up with the compresses so as to make the arm of equal thickness for the application of the splints; then the splints being wrapped with a moderate quantity of wool or flax, we apply them around the fracture, being not more than a finger’s breadth distant from one another, binding them moderately tight, and taking care, as much as possible, that the splints do not come in contact with a joint, and being more particularly careful of the inner part of the joint, for there they sometimes occasion ulcers and inflammations of tendons. But there the bandaging must be made slacker; and stronger, on the other hand, where the fracture swells up. It is better that the chest should be moderately bound with the arm, lest by its motions it should derange the position. If inflammation should come on (which we know by the swelling and redness around, and from the limb being more tightly bound than formerly), or if the fracture become deranged, or if, without these occurring, the bandages become slacker, or, on the other hand, tighter than proper, the bandages are to be loosed and everything rectified. The patient is to be laid in a supine position, with his hand upon his stomach, and a soft pillow is to be placed under the arm having a skin upon it to receive the embrocations which run from it. The part is to be bathed with warm oil every day, more especially if inflammation be present, and during the time of inflammation he is to be fed sparingly, and afterwards moderately, to promote the growth of callus. He must lie quiet until the callus is formed, which, in the arm and leg, takes place about the fortieth day. After this the bandages are to be loosed, and after using the bath he is to be treated with plasters suitable to fractures. This mode of procedure is applicable in almost all cases of fracture of limbs.
Commentary. Hippocrates’s account of fracture of the os humeri, as quoted by Paulus, is from the eighth chapter of his work ‘De Fracturis,’ but our author has used considerable liberties in making the extract. The mode of using the piece of wood for suspending the arm is easily understood, from his own description without the commentary of Galen. (See p. 541, t. v, ed. Basil.) In the edition by Littré it is, moreover, well illustrated by a drawing. (T. iii, p. 445.) He directs the splints not to be applied until the seventh day, in order to give time for the inflammation and swelling to subside. He says, the bone gets consolidated in about forty days. He justly remarks, that when distortion of the arm takes place it is to the outside, that is to say, backwards. His method of bandaging for fractures of the arm and fore-arm was the same. He directs us in the first place to put a cerate to the part, and then to apply the first bandage, beginning at the fracture, and carrying it two or three turns upwards, so as to prevent the blood from falling down into the part. The second bandage is to commence above the fracture, and is to be carried downwards. Afterwards splenia or oblong compresses, spread with cerate, are to be laid over them, and these are to be secured by strips of linen cloth. These bandages are to be removed when they become slack, generally about the third day. On the seventh the ferulæ or splints are to be applied, the limb by that time having lost its swelling, and they are to be allowed to remain until the 24th day after the accident. When swellings arise on any part of a limb from pressure, they are to be anointed with cerate or wine and oil, and wrapped in soft wool; and if the splints be hurting the limb they are to be removed for a time. (De Fract. 21.) When the bandages are taken off, he directs that hot water should be poured upon the limb. He recommends a spare diet unless there be a wound of the integuments. (De Fract. and Galen. Comment.) It may be proper to give some more account of the splenia and ferulæ (νάρθηκες), used by Hippocrates in fractures of the extremities. In his work entitled ‘The Surgeon’s Shop’ (ἰήτρειον), he directs the length of the splenia to be made proportionate to the part which they are applied to, their breadth three fingers, their thickness three or four folds, and their number such as to encircle the limb without doing either more or less. It appears quite clear that they consisted of folded linen. The intention of them was to give some support to the part. He directs the splints to be smooth, even, concave, and somewhat shorter than the length of the bandages, in order not to hurt the sound skin. It appears, then, that the whole apparatus used by Hippocrates in the treatment of fractures, consisted, 1st, of two under-bandages, 2d, of splenia or folded compresses, 3d, of the ferulæ or splints, 4th, of an outer bandage to secure the splints. With regard to the cerate used in the Hippocratic system of bandaging, it is important to state that, from a passage in his treatise, ‘Officina Medici,’ it would appear that the cerate was not only applied to the skin, but that, for the sake of greater security, every fold of the bandages was rubbed with it. See Galen’s Commentary on the work, (T. v. p. 692, ed. Basil,) and Littré’s Hippocrates, (T. iii, p. 316.) It remains to be mentioned, that the bandages were secured by means of a thread or with a needle. (Off. Med. 8.) Nothing can surpass the judgment and precision with which Hippocrates lays down his rules for the application of the bandages. (Ibid.)
Galen describes the splenia as being pieces of linen folded three or four times, which are to be laid along the arm longitudinally. He directs us to spread them with cerate. He says that they support the limb. He says distinctly that all the folds of the bandages should be rubbed with cerate in order to give greater support. All his directions for the treatment of a broken limb are most judicious. When at first there is much pain and inflammation, he recommends bleeding and purging; but when the callus begins to form, he directs the patient to use a nourishing diet. Spiculæ and scales of bone are in general to be allowed to exfoliate of themselves, and not removed forcibly by the surgeon. (Comment. and Fragment. ap. Nicetæ Collect.)
Celsus lays down the principles of treatment in fractures of the arm, fore-arm, thigh, and leg so circumstantially, that we can afford room only for an outline of them. He recommends no time to be lost in getting the displaced parts properly reduced. For this purpose, if the limb be strong, two assistants may be required to pull in contrary directions; and if other means do not succeed, thongs of leather, or linen bandages, may be attached to each end of the broken limb to make extension and counter-extension with them. When the ends of the bone have been adjusted, (which is known by the pain and deformity being removed,) the limb is to be wrapped in linen cloths folded two or three times, and dipped in wine and oil. Six bandages or rollers (fasciæ) are then to be applied. The first is the shortest, which is to be three times rolled round the limb upwards in a spiral direction, and three times generally will be sufficient. The second must be one half longer, and is to commence wherever the bone projects; or if there be no projection, at any part of the fracture; and is to be carried first downwards and then upwards, so as to terminate a little above the former. These are to be secured by a broader linen cloth spread with cerate. The third and fourth bandages are then to be applied upon the principle, that the latter is to be put on in the contrary direction to the former; and further, it is to be observed that the third bandage terminates below, whereas all the others terminate above the fracture. Upon the whole, he adds, it is better to secure the limb with many than with tight bandages, these being apt to occasion mortification. When properly applied they ought not to be loose on the first day, yet such as not to give pain; slacker on the second, and loose on the third day. They are then to be removed and again applied, and a fifth bandage is now to be superadded to them; and again, these are to be taken off on the fifth day, and six bandages put on, in such a manner that the third and fifth may terminate below, and all the others above. Whenever the bandages are taken off, the limb is to be bathed with hot water, and proper fomentations applied to allay the inflammation, which will generally be found to have subsided about the seventh or ninth day. Then the bandages are again to be put on as directed above, and ferulæ or splints are also to be added, taking care to put on a stronger and broader splint at the side to which the fractured bone has a tendency to be protruded. These must all be rounded where they come in contact with a joint, to avoid injuring it; they are only to be secured with such tightness as to keep the bones in their place, and when they get loose their thongs are to be tightened. The bandages are to be removed gradually. These are his general directions for all fractures of the extremities, and it is to be remarked that his mode of treatment is essentially the same as that of Hippocrates. He afterwards describes at considerable length the method of setting the broken ends of the os humeri. After this is accomplished he directs us to bind the arm gently to the side. With regard to the splints, he properly recommends the longest to be applied externally; shorter ones on the brawn of the arm (over the biceps muscle?), and the shortest under the armpit. He advises us to remove them frequently when the fracture is situated near the fore-arm; and at these times the arm is to be bathed with hot water, and rubbed with a soft cerate.
It will be seen that the methods of Hippocrates and Celsus, although the same in principle, differ in the following respects. Hippocrates uses three bandages, Celsus six: Hippocrates uses small compresses, Celsus large pieces of linen: Hippocrates uses cerate, Celsus wine and oil.
The Arabians conducted the treatment in much the same way as the Greeks. In cases of fracture of the arm, Albucasis directs us to make the bandages of soft, thin linen cloth; but of broader and firmer linen if the thigh or leg is to be treated. Below them is to be applied a smooth cloth spread with a suitable liniment. After the under bandages have been put on in the manner already described, the splints are to be applied, provided no swelling nor inflammation be present, for in that case they are to be deferred for a few days. These splints are to be constructed from the middle part of the alcanna, or of pine, or of the palm-tree, or of a tree which he calls calingi.
Avicenna directs us to form the splints of the wood of alcanna, or of oleander, or of pomegranate tree, or the like. The length of the splints is to be made equal to that of the limb, and their greatest breadth about three fingers. They are to be secured with another bandage and pieces of tape made of linen cloth. There is to be an interval of a finger’s breadth between each splint. He says, it is best to apply four splints of such a length as to reach from joint to joint. They are to be smooth and even so as not to injure any part. In cases of fracture of the os humeri he directs us to surround the nearest joint with the bandages, and, if the fracture be in the middle, to make them take in both extremities. He recommends us to foment the limb with vinegar and water, or water alone. The arm is to be fastened to the side and the hand laid on the stomach.
Haly Abbas, in giving directions for the treatment of fractures in general, recommends the splints to be made of pieces of alcanna, or any hard wood. Afterwards he directs the limb to be laid upon a table having a pad (pannus) placed on it, which last is to be secured with fillets. He gives particular directions not to apply the splints over the processes of bones, and when inflammation comes on he forbids splints to be used at all; in that case the patient is to be kept upon restricted diet. The bandages are to be removed in the course of three days.
The directions given by the experienced Rhases about the bandages and splints are very similar to our author’s, and therefore need not be repeated.
See an account of the ancient splenia, or compresses, and of the ferulæ, or splints, in Scultet’s ‘Arsenal de Chirurgie.’ (29, 30.) See also Van Swieten’s ‘Commentary,’ (354.) Van Swieten remarks, that although the eighteen-tailed bandage be supposed a modern invention, a similar one is described by Hippocrates, (De Fract.) and by Galen in his commentaries on the same.
Le Clerc gives a pretty full description of the Celsian method of treating fractures. (Hist. de la Méd.) See also Fabricius ab Aquapendente (Œuv. Chir. ii, 3, and i, 4). We are certain it will be generally admitted that the waxed apparatus of the ancients in the case of fractures was probably quite as efficacious as the starched bandages which have been introduced of late years with so much advantage.
SECT. C.—ON THE ULNA AND RADIUS.
The ulna and radius are sometimes both fractured together, and sometimes one of them only, either in the middle or at one end, as at the elbow or wrist. The worst of all is when both are fractured together, after that the ulna alone, but a fractured radius is, of all cases, the easiest cured. For, although it be larger than the ulna, yet it has this bone as a base and support to it. If only one be fractured, the extension must be applied principally to it, but if both, they are to be stretched evenly, the arm being put into an angular position, so that the thumb may be higher than the fingers, and the little finger lower than any of the others, for thus the ulna will be placed under the radius. If stronger extension be required, especially when both are broken, we must apply it not only with the hands but also with ligatures, as described when treating of the arm; and everything relative to the bandaging and the subsequent treatment, with the application of the splints, is to be done as in that case until callus is formed. The bones of the fore-arm have their callus formed in about thirty days at most. And the fore-arm is to be otherwise arranged in the same manner as the arm, with the exception of those things which are put under it.
Commentary. Whoever would wish to see a full exposition of the principles upon which these cases of fracture ought to be conducted may consult the first part of Hippocrates’s work. (De Fracturis.) He shows, with a singular precision, the disadvantages of the prone and supine positions of the hand, both of which, it appears, had their advocates in ancient times. The bandages, compresses, and splints are to be applied in the manner described in the preceding section. He insists strongly on the necessity of having the arm and wrist carefully suspended in a broad soft sling, and that the hand be placed neither too high nor too low. Hippocrates takes notice of fracture of the olecranon, as will be explained afterwards.
Oribasius gives a description and drawing of a laqueus calculated to retain the splints, and secure the fore-arm in cases of fracture. (De Laqueis, 2.)
Celsus directs us to sling the arm, with the thumb a little inclined, towards the breast, in a convenient napkin (mitella), the broad part being applied to the arm, and the narrow ends tied behind the neck.
Albucasis treats of this case of fracture very accurately. He calls the ulna the larger of the bones. He directs the arm to be suspended with the thumb uppermost. When the fractured pieces of bone occasion irritation, he advises us to make an incision and extract them. When a troublesome pruritus seizes the arm, he recommends us to remove the bandages and bathe with hot water.
Rhases gives proper directions about not applying the bandages too tight or too slack. When the hand swells he recommends them to be slackened.
The accounts given by Avicenna and Haly Abbas are quite similar to our author’s. Avicenna cautions us not to make the splints too long lest they hurt the hand. None of the Arabians, we believe, have noticed the fracture of the olecranon. Like most imitators, they often fall short of their originals.