SECT. CI.—ON THE HAND AND ITS FINGERS.
The bones of the carpus, metacarpus, and of the phalanges of the fingers, being of a spongy and porous nature, are often crushed but rarely fractured. The patient then being placed on a high seat, we are to direct him to lay his hand prone upon an even table, and the fractured pieces being stretched by an assistant, we arrange them with two fingers, that is to say, the thumb and the index-finger. A tight bandage is to be used at the time that inflammation prevails, for, owing to the porous nature of the bones, a redundance of callus is formed. If the phalanx or finger be simply broken, and it be the large one, called also the thumb, after suitable bandaging, it is to be bound to the palm that it may be kept at rest; but if any of the others, as for example, the index or little finger, it is to be bound along with the one next to it, or if one of the middle, it may be bound along with that on either side, or all may be bound altogether. For they are thus kept best at rest, as if the fractured bones had been supported with splints.
Commentary. Hippocrates recommends the general treatment applicable in all cases of fracture, with the exception of the splint, which, as Galen explains, is not admissible in these cases.
Celsus says, it will be sufficient when a finger is broken to bind it to one piece of splint (surculum) after the inflammation has subsided.
Albucasis recommends one small splint to be applied upon the thumb when it is fractured. If one of the fingers be broken, it is to be bound up with the others, or one small piece of splint may be used. Avicenna, Rhases, and Haly Abbas treat distinctly of these accidents, but supply no additional information.
SECT. CII.—ON THE THIGH.
The case of a broken thigh is analogous to that of the arm, but in particular, a fractured thigh is mostly deranged forwards and outwards, for the bone is naturally flattened on those sides. It is to be set by the hands, with ligatures, and even cords applied, the one above and the other below the fracture. When the fracture takes place at one end, if at the head of the thigh, the middle part of a thong wrapped round with wool, so that it may not cut the parts there, is to be applied to the perinæum, and the ends of it brought up to the head and given to an assistant to hold, and applying a ligature below the fracture, we give the ends of it to another assistant to make extension. If it is fractured near the knee, we apply the ligature immediately above the fracture, and give the ends to an assistant, with which to make extension upwards; and while we put a ligature round the knee to secure it, and while the patient lies thus, with his leg extended, we arrange the fracture. Pieces of bone which irritate the parts, as has been often said, are to be taken out from above; and the rest of the treatment we have already described in the section on the arm. The thigh gets consolidated within fifty days. The manner of arranging it afterwards will be described after delivering the treatment of the whole leg.
Commentary. Hippocrates has correctly stated the difficulty attending the management of a fractured thigh-bone, and the disgrace which an ill-managed case entails upon the surgeon. He directs him to make extension and counter-extension, and to apply the bandages and splints in the manner formerly described. He recommends a few turns of the bandage to be brought about the loins, in order to prevent the skin at the top of the thigh from being injured by the splints. He points out the extreme importance of attending to the position of the heel, as if improperly laid, it is capable of deranging the fracture entirely. It gets consolidated, he says, in about fifty days. (De Fracturis.)
Celsus pronounces it impossible to heal a fractured thigh-bone without deformity. The patient, he says, must ever afterwards tread upon his toes; and yet, he adds, the case will be worse if neglected.
Albucasis holds forth greater encouragement. He describes the process of treatment very minutely, directing the surgeon to stuff up all the hollow places in the limb with soft pads before applying the splints. He also recommends him to surround the whole limb with a bandage from the heel to the nates. We are inclined to think, although the language of his barbarous translator is not sufficiently precise, that his splints extended the whole length of the limb.
Rhases, and we believe, he alone of all the ancient authorities, directs the thigh to be laid in a somewhat bent position, and for this purpose he recommends something suitable to be put below it.
Haly Abbas and Avicenna, as usual, borrow everything from our author.
SECT. CIII.—ON THE PATELLA.
The patella is a porous bone kept firmly in its place by the parts above and below, and is often crushed but seldom fractured. It undergoes fracture also through its thickness, and is broken into small pieces, with or without a wound. The symptoms are obvious,—a solution of continuity, a hollow, and crepitation. The fracture is put in order by extending the leg, for thus the divided portions may be brought together with the fingers, until the lips of the fracture mutually touch, and are united to one another, and fractured pieces, when separated, are thus arranged together. For even if callus does not take place, owing to the parts being drawn in different directions by the muscles and tendons from the thigh and leg, which are inserted into it, yet the separation is much diminished. But it occasions much lameness to the patients; for, when they attempt to labour, the knee cannot sustain them long, and in walking their ascent upwards is impeded; but in moving along a plain their lameness is not perceptible. In ascending, however, as the knee cannot bend in raising and setting down the leg, the lameness becomes apparent. And in this case any bone that irritates is to be taken out where it protrudes, and proper treatment applied.
Commentary. None of the ancient authorities have given so full an account of this accident as our author. Hippocrates and Celsus have omitted it altogether. Soranus merely gives the symptoms, namely, a hollowness in the part and crepitus.
Albucasis recommends us, after arranging the broken pieces of bone, to apply a round splint over it if necessary. Rhases likewise speaks of applying a well-stuffed splint. Haly’s account is distinct but similar to our author’s, from which it is abridged. Neither he nor Avicenna makes any mention of a splint.
SECT. CIV.—ON THE LEG.
The treatment of fractures of the leg corresponds with that of the fore-arm, for it consists of two bones, the thicker of which bears the same name (tibia), and the small one, from its resemblance, has been called fibula. Its fractures also admit the same varieties, being deranged on all sides when both the bones are broken together, and to three when only one, namely, within, without, and the tibia backwards and the fibula forwards. Wherefore it is to be set in the same manner by the hands, or ligatures, sometimes applied to the leg itself, and sometimes to the thigh, (for the knee being a strong joint can bear the extension uninjured,) and ligatures are to be applied likewise below the fracture, as we mentioned under the head of the fore-arm. The case is to be managed otherwise, as described by us in the section on the arm.
Commentary. Hippocrates has treated of this case at considerable length. The bandages are to be applied as formerly described, and the leg laid on a level board with a soft cushion under it. It is clear that he did not approve of the bent position of the limb. The splints are to be applied on the seventh or eleventh day. Of the fractures of a single bone, that of the tibia, he remarks, is the worse, a fractured fibula being easily managed. He gives particular directions to attend to the state of the heel.
Celsus treats of these fractures in general terms, like those of the fore-arm. Albucasis directs us to apply two splints made of the wood of pines or palms, of moderate thickness, and of such length as to extend from the knee to the feet. One of these is to be placed below the leg and the other above; and they are to be tied in three places, namely, at the extremities and in the middle.
The other Arabians treat of these fractures in more general terms.
SECT. CV.—ON THE FOOT.
The astragalus cannot be fractured by any means, being guarded by bodies on all hands; by the tibia, the fibula, and the os cuboides. But the scaphoides, the bones of the tarsus, and those of the toes, and the cuboides itself, are fractured like those of the carpus, metacarpus, and the fingers of the hand, so that what was said of them is applicable here and need not be repeated.
Commentary. Hippocrates remarks that these bones can only be fractured by some sharp and heavy body. They are to be treated like fractures in general, only that they do not require splints. He recommends the recumbent position with the foot somewhat elevated, and states, in strong terms, the mischief brought on by unseasonable attempts at walking. (De Fracturis, 10.) Galen, in his Commentary, gives an accurate anatomical description of the bones of the foot.
Celsus is very brief on this case. He conducts the treatment on general principles. Albucasis directs us to make the patient put his foot on the ground, the surgeon is then to place one of his feet on it and stand on it. By this means the derangement of the bones will be rectified. He approves of a splint to the sole.
We find nothing worthy of notice in the works of the other authorities.
SECT. CVI.—ON THE ARRANGEMENT OF THE LIMB.
When the thigh or leg is fractured, the manner of arranging the limb will be as important a consideration to you as the other treatment. For the evenness of the fractured parts is especially preserved by this means when properly performed. Some, therefore, lay the fractured part upon a canal, either of wood or of earthenware, or else they lay the whole limb upon it; others apply it only in cases of fracture with a wound, because, say they, these cannot be bound with splints. But the moderns altogether reject the use of these canals for many reasons, but more especially on account of the pressure occasioned by their hardness. Nor is it improper to apply splints to fractured limbs with a wound, as we shall show afterwards. Let the patient, then, lie upon his back, and let a thick garment, equal to the limb in length, be laid under it, more especially where the fracture is, and let both its ends be convoluted and wrapped round so as to resemble the canal in its middle longitudinal cavity, and let it be covered with a soft skin for receiving the embrocations; and then let the limb be fitted to this canal-like cavity, and let other garments or wool be applied on both sides to prevent the limb from being moved to the sides. And let a small board, covered with rags for sake of softness, be fastened to the sole of the foot; and, for the sake of greater security, let the middle of two or three ligatures be applied under this canal-like garment, and let the broken limb be lightly bound along with it. But if the patient be unable to restrain himself from drawing in his leg, his foot should be fastened to the board by means of ligatures around the ankle, so that he may be prevented even from drawing in his leg involuntarily in his sleep. Some likewise cut out a hole in the middle of the bed, that the patient may void his urine and fæces by it without requiring to be moved until the callus has become formed.
Commentary. We have already mentioned that Hippocrates approved of the straight position of the limb. With respect to the canals (σωλῆνες) mentioned also by our author he expresses himself in equivocal terms. He says that they prove useful, but not to the extent generally believed. He properly remarks that they do not prevent the body from being moved, and that consequently they cannot be supposed capable of securing the limb entirely from derangement. He is decidedly of opinion that unless they extend from above the ham to the heel they do no good in fractures of the leg. (De Fracturis, 16, ed. Littré.)
Celsus gives the following description of the canals: “Is canalis et inferiore parte foramina habere, per quæ, si quis humor excesserit, descendat: et a planta moram, quæ simid et sustineat eam, et delabi non patiatur: et a lateribus cava, per quæ loris datis, moræ quædam crus femurque, ut collocatum est, detineant.” Galen, in his Commentary on Hippocrates (l. c.) describes these machines as being round externally and hollow within, so as to inclose the limb all around:—περιλαμβάνει τὸ σκέλος ὅλον ἐν κύκλῳ. From these words one might think that the canal of which he speaks was a complete cylinder or cone. But from our author’s direction to lay the limb upon the canal, it would appear that the machine he speaks of was open above, and as such it is represented and described by Scultet (Arsenal de Chirurg. xxii, 6.) His words are: “Il faut que le canal embrasse plus de la moitié du membre;” this, therefore, is a sort of trough. Sprengel calls it a box (boîte, Fr. edit.) Littré translates it by gouttière, l. c. For an account of these and other machines anciently used in fractures of the lower extremities, see Van Swieten (Comment. 354), and Heister (Surgery, ix, 9.) Brunus and Theodoricus make mention of these canals, but do not much approve of them.
Galen informs us that the canals were made of different kinds of wood. He speaks of a surgeon in his time who made them from the wood of the phillyrea. He makes mention of a method of supplying their place by means of a bolster laid below the limb and tied round it with fillets. (Nicetæ Collect. and Comment. l. c.)
Avicenna and Albucasis take notice of these machines, but neither of them with approbation. They also speak of securing the limb in the way described by our author.
The canals would appear to be the machines which Rhases mentions by the name of barangi. (Cont. xxix.)
SECT. CVII.—ON FRACTURES COMPLICATED WITH A WOUND.
When a fracture is attended with a wound, if there be a hemorrhage it is to be first stopped; and if there be inflammation, we must use the applications suitable to it; and if there be contusion of the flesh, we must scarify the flesh to remove all apprehension of gangrene; or if gangrene or any other spreading mortification has come on, we must meet it with suitable remedies. The treatment of each of these cases you have had delivered in the Fourth Book. When none of these symptoms is present, nor much of the bone exposed, we may use hooks and sutures, and effect the cure by the treatment for recent wounds, having first cut out any broken pieces of bone which move about and produce irritation. But if a large bone project, which, for its size, cannot be brought into contact by the extension, it will require consideration. Hippocrates, then, 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 this attempt will sometimes succeed. Of whatever bones, therefore, we endeavour to replace the protruded ends, we must not meddle with them when in a state of inflammation, but on the first day, before inflammation has come on, or about the ninth day, when the inflammation has gone off. We may set them by an instrument called the lever. It is an iron instrument about seven or eight fingers’ breadth in length, and of moderate thickness that it may not bend during the operation; with its extremity sharp, broad, and moderately bent. Its sharp extremity, then, is to be put under the protruding prominence of the bone, and by pushing at the other end while moderate extension of the limb is made, we bring the extremities of the fracture together; or, if we cannot do so, we must cut off the projections by counter-perforators (chisels), or saw them off in the manner described when treating of fistulæ. Having removed the spiculæ of bones and set the limb aright, we cure the wound by dressing with pledgets. But in those members which are double or in pairs, we must take care when the bones of either of them are sawn off, that no contraction of the limb take place, but that it be kept of its proper length by extension. The bandaging is to be thus applied: the circular folds are to be arranged on both sides of the wound, and oblique ones according to the length of the sore, so that they may intersect one another in the form of the Greek letter Χ, and prevent the lips of it from gaping. And when the ulcer is foul, we must apply dressing with cleansing ointments; but if clean, with incarnating, and the other articles of known efficacy. Hippocrates used the pitch-plaster, which is said to have been the same as the ointment, tetrapharmacon, called also basilicon. After the sore has incarnated we apply splints. Some apply them from the first, taking care not to hurt the parts about the ulcer, and tightening them according to necessity, or again slackening them. When a scale of bone is going to exfoliate, which we ascertain from the discharge being more copious and thin, we must remove the loose fungous flesh about it, and the bandages must be applied loose; but having removed the scale with a hook or some such instrument, we must have recourse to tighter bandages. During the whole time of the healing of the sore, the dressing called motophylax with some of the anti-inflammatory medicines is to be laid over the wound, to be kept on with a simple bandage, which is to be removed at each dressing; everything else remaining the same as described in the treatment of the arm.
Commentary. Hippocrates treats of these cases at great length. His method of rectifying the protruded ends of bones by means of a lever, is described by our author. He says, it may be done on the first or second day, but not on the third or fourth, after the inflammation is begun, for fear of occasioning convulsions. Compresses dipped in wine and oil, or soft bandages are to be used, but splints are not to be applied until the sore puts on a healthy appearance. He mentions that some were in the practice of bandaging the limb above and below the wound, and leaving it bare, in order to allow the discharges to escape; but this practice he greatly disapproves of, as tending to produce swelling in the place; and he recommends the whole limb to be well secured with bandages, but then not too tight. He states that all bones which are completely denuded, must exfoliate and come out. When a bone projects and cannot be replaced, he directs the surgeon to cut it off if it irritate the soft parts. No splints are to be applied when there is a bone which it is seen will exfoliate. If it be the summer season, the compresses applied to the wound are to be frequently soaked with wine; but if it be winter, greasy wool is to be dipped in wine and oil and applied. Compound fractures of the thigh or arm, attended with protrusion of the broken bone, are said to be peculiarly dangerous; for if replaced, they are apt to occasion convulsions; and if let alone, they give rise to acute bilious fevers. Some, however, he adds, recover when the bone is replaced. (De Fract. cum Comment. Galeni.) Galen explains, that the danger in cases of fractured femur and humerus arises from their vicinity to important blood-vessels and muscles.
Celsus lays down the rules for conducting the treatment in these cases with great precision. He states, that fractures complicated with a wound of the skin are generally dangerous, especially when it is the humerus or femur. In the latter case he directs us to saw off the ends of the bone. The case of a fractured humerus is more easily managed. The danger is greatly increased when the fracture is near a joint. He recommends us to divide any muscle which may run across the wound, to let blood, and put the patient upon a restricted diet. In other fractures the bones are to be gently replaced. The wound is to be dressed with a pledget dipped in wine, to which roses have been added. This application is borrowed from Hippocrates. The bandages are to be put on somewhat slacker than when there is no external wound. Neither splints nor canals must be used, but broad bandages. The parts are to be fomented with hot oil and wine, and the dressings renewed every day. When a small fragment of a bone projects, if it be blunt, he recommends us to replace it; but if sharp, he directs us to saw it off, and then replace the bones with the hands or a suitable instrument. Sometimes fragments of bones die, and after a time drop out; and sometimes sharp spiculæ irritate the soft parts, in which case he recommends us to enlarge the wound and cut off the projecting points.
The treatment recommended by Albucasis is very judicious. If inflammation be present, he directs us to subdue it by bleeding; and, in that case, reduction is not to be attempted until the ninth day; but in all other cases it is to be done at first. When it cannot be reduced by the hands, an iron instrument seven or eight fingers’ breadth in length, and two fingers broad, is to be used as a lever for this purpose. When the ends of the fracture are sharp and cannot be replaced, they are to be cut off or sawed. His saw bears a considerable resemblance to that of the late Mr. Hey, of Leeds. He recommends an astringent wine as a suitable application, but condemns all cerates which contain oil. The bandages are to be put on very slack. Splints are not to be applied while the wound is irritable and ill-conditioned. When it does not heal, he says we ought to suspect that it is prevented by spiculæ of bones, which are to be sought out and extracted.
Avicenna and Rhases give very proper directions about removing spiculæ of bones, and applying slack bandages, but they evidently copy from Hippocrates and our author.
SECT. CVIII.—ON THE REDUNDANT CALLUS OF FRACTURES.
The superabundant callus of fractures occasions always a deformity, and sometimes also lameness if it be formed near a joint. If, therefore, the callus be newly formed, we use very astringent medicines, and bring it to its form by bandages; and sometimes we effect our purpose by applying a plate of lead to it. But if it is of a stony hardness we make an incision, and pare it off, removing the prominent part by chisels, if need be, and boring it with trephines.
Commentary. Celsus directs us to rub the limb with oil, salt, and nitre; to pour a great quantity of hot salt water upon it; to apply an emollient ointment; to bandage it tightly, and to give an emetic. He also recommends us to produce revulsion by the application of mustard to another part.
Albucasis recommends nearly the same plan of treatment as our author. When the case is recent, he directs us to make astringent applications, such as aloes, olibanum, and myrrh, with an astringent wine or vinegar. He also speaks of applying a plate of lead; and when the callus becomes hard, he approves of scraping and sawing it off, as directed by our author.
No additional information is to be got from the other Arabians.
Theodoricus, and the other surgical authorities of that age, describe the treatment exactly as the ancients. When the callus is hard, they direct us to scrape or saw it off.
SECT. CIX.—ON DISTORTION FROM THE UNION BY CALLUS.
When bones heal distortedly by callus, no little lameness takes place, more particularly if in the feet. The method then of breaking them over again is not at all to be admitted, as it may occasion the utmost danger; but if the callus be newly formed, we must have recourse to the allusions of a relaxing nature, and to cataplasms, such as those from fat olives and pigeon’s dung, and the other medicines for dissolving callus; and we also dispel it by friction with the hand, and bending it every way. But if it be of a stony hardness, we make an incision of the skin with a scalpel, and separate the union of the bones with chisels, and then cure the fracture as formerly said.
Commentary. Celsus approves of breaking the bones over again. With this intention he directs us, in the first place, to bathe the limb with much hot water, and rub it with liquid cerate; the callus is then to be moved with the hands, and the ends of the bone properly set; or if that cannot be thus accomplished, a rule is to be wrapped round with wool and bound upon the part, so as to restore it to its proper shape.
Avicenna agrees with Celsus in speaking favorably of breaking the bone over again. He also speaks favorably of the other treatment recommended by our author.
Rhases recommends emollient applications, and gentle attempts to restore the figure of the limb. Albucasis mentions the proposal of breaking the bone again with disapprobation.
SECT. CX.—ON BONES WHICH HAVE NOT UNITED BY CALLUS.
Sometimes fractured bones remain without forming adhesions, beyond the natural period, either owing to their being often loosed, or from too frequent bathing of the part, or from having been moved unseasonably, or from the number of the bandages, or from atrophy of the whole body, by which means the limb becomes emaciated. Wherefore we must endeavour to remove all the other causes, but more especially the atrophy, partly by calefacient applications which attract nourishment to the place, and partly by supplying a sufficiency of food and baths, and whatever also is of a refreshing nature. Among the other symptoms which follow the formation of callus, the bandages then become stained with blood, although no wound be present, which probably takes place from the substance about the callus, when it unites, squeezing out the drops of blood which were distributed to the hollows of the bones.
Commentary. When the fractured portions do not adhere after a certain time, Celsus directs us to extend the limb, and rub the ends of the bone together, in order to convert them again into the state of a recent fracture, taking care, however, not to hurt the muscles and nerves. The part is then to be fomented, and the splints applied on the fifth day.
Rhases recommends calefacient liniments, friction, and nutritive food.
SECT. CXI.—ON LUXATIONS.
We proceed to the treatment of luxations, which naturally follows that of fractures. A luxation then (to give a definition of it) is a displacement of a member from its proper cavity to an unusual place, by which means the voluntary motion is impeded. We have no other differences of it to mention, except that some are to a greater and some to a less degree. When the bone of a member, therefore, is completely removed from its place, the accident is called by the common name of luxation, but when only moved a little, or brought only to the brim of the cavity, it is called a subluxation.
Commentary. Celsus gives several important remarks upon dislocations in general, but as most of them may more properly be brought under particular heads, we shall notice them here but briefly. He distinguishes dislocations into two classes; the first consisting of a separation of two bones naturally united, such as the scapula from the humerus, the radius from the ulna, the tibia from the fibula, the os calcis from the bones of the ankle, which last is of rare occurrence, and the second being a removal of the bone of a joint from its proper place. When a dislocation occurs, as he remarks, the finger discovers a cavity in the part, and inflammation and fever come on, followed sometimes by gangrene and convulsions. If not reduced, the limb wastes. In a person who is lean, humid, and has weak nerves (muscles?) the dislocation is most easily reduced, but is more difficult to retain. The inflammation is to be reduced by the application of wool dipped in vinegar; by abstinence, a spare diet, and drinking tepid water. Afterwards friction, exercise, and a more generous diet are to be allowed. (viii, 11.)
See many curious remarks on this subject in Galen’s Commentary on Hippocrates (de Articulis), and in Apollonii Citiensis Scholia in Hip. et Galen.; also Avicenna (iv, 5, 1); Haly Abbas (Pract. ix, 101); Rhases (Cont. xxix, 2.)
SECT. CXII.—ON THE LOWER JAW.
Beginning then again from the upper parts we shall treat of the lower jaw. For the upper being immoveable does not admit of dislocation; but the lower does not indeed readily admit of complete luxation, owing to its heads being firmly fixed to the upper jaw, but it often undergoes subluxation, for the muscles which are fixed to it being relaxed by the constant exercise of mastication and speaking, the jaw is readily slackened from the most common causes. For the term used by Hippocrates signifies slackened. In these cases the part returns to its natural place without trouble. With regard to the complete dislocation of the lower jaw, it will be sufficient to deliver Hippocrates’s account, being, at the same time, brief, complete and clear. He says thus: “The jaw seldom falls out of the joint, but it is often slackened in yawning, as many other irregular actions of muscles and tendons do this. When it falls out of the joint it is marked principally by these symptoms; the lower jaw projects forwards, and is inclined in an opposite direction to the luxation; and the coronoid process of the bone swells out near the upper jaw-bone, and it is with difficulty that they shut their jaws. In these cases the suitable mode of reduction is apparent. For somebody must hold the patient’s head, another grasps the lower jaw internally and externally with his fingers at the chin, while the patient yawns as much as he can conveniently; and we must first move the jaw with the hand hither and thither for a certain time, and order the man to relax the jaw and separate it; and then we must attend to perform three evolutions at the same time, we must move the jaw from its distorted shape to its natural; push the jaw backwards; and then shut the jaws close, and prevent yawning. This is the mode of reduction, and it cannot be performed by any other processes. Very little treatment will suffice afterwards. Having applied a waxed compress, it is to be secured with a loose bandage. But the surest process is to lay the man upon his back, and supporting his head upon well-stuffed pillows, that they may not yield, to get some person to hold the head of the patient. And if both ends of the jaw be dislocated, the treatment is the same, only the mouth cannot be so well shut, for then the jaw is more prominent, but less distorted from the teeth of the upper and lower jaws corresponding exactly together. Reduction is to be immediately performed, and the mode of it has been already described. If it cannot be restored, there may be danger of the life from continued fevers, torpor, and carus. For these muscles being altered and stretched in a preternatural manner produce carus. They frequently have evacuations by the belly, which are purely bilious, and small in quantity; and if they vomit, it is pure bile. These, for the most part, die on the tenth day.” This mode of reduction we have often practised, having first used fomentations of warm water and oil, by a sponge along the dislocated jaw, more especially when there is any difficulty in restoring it to its position. Wherefore, having placed the man upon the ground, we stand behind and operate in the manner described by Hippocrates.
Commentary. The account here given of Hippocrates’s method of reduction is taken from his work, ‘De Articulis,’ (31.) When a few of his technical terms are explained in the commentary of Galen, the description is sufficiently distinct, and is upon the whole a very correct account of the symptoms and treatment of this accident. The prominence of the coronoid bone is well described by Hippocrates. Galen remarks that the end of the jaw-bone slips under the zygomatic arch. It has been a matter of dispute what Hippocrates means by slackening, or incomplete luxations of the jaw. It is worthy of remark that such an accident is described by Sir Astley Cooper. (See further Littré’s Hippocrates, t. iv, 29.)
Galen’s description of the method of reduction is given in the Collection of Nicetas. (Chirurg. Vet. ed. Cocchius.) It is substantially the same as that of Hippocrates.
A mode of reducing the dislocation by means of a machine is described by Oribasius, in his work De Machinamentis, 30.
The account which Celsus gives of this accident is upon the whole very accurate, and corresponds very well with modern descriptions. If dislocated only at one end, the chin inclines to the opposite side, and the teeth of the upper and lower jaws do not correspond. If at both ends, the whole chin projects outwards, the lower teeth are more prominent, and the muscles appear stretched. The patient being properly seated, and his head held by an assistant, the surgeon having wrapped his thumbs with linen cloths, is to put them into the patient’s mouth, while the fingers are applied externally. The jaw being firmly grasped, the chin is to be shaken, and then, at one and the same instant, the head is to be seized, the chin moved, the jaw forced into its place, and the mouth shut. After reduction, if pain in the eyes and neck has been brought on by the accident, he recommends us to let blood from the arm. The patient is to live upon liquids, and avoid talking.
Albucasis follows Hippocrates in distinguishing dislocations of the lower jaw into partial and complete. In addition to the symptoms already detailed, he mentions a flow of saliva from the mouth, and an inability to speak. When the dislocation is partial or incomplete, he says, it soon returns of itself to its proper place. When the luxation is complete, he directs us to reduce it by introducing the thumbs into the mouth, and grasping the jaw in the manner described by Hippocrates. He states that when not reduced the accident often proves fatal by superinducing fevers and coma. Avicenna, in like manner, affirms, that if not reduced, it may bring on fatal consequences. His account is borrowed entirely from Hippocrates. Rhases and Haly Abbas give exactly the same description of the symptoms and mode of reducing as Albucasis.
Monteggia, Fabricius ab Aquapendente, Sir Astley Cooper, and Mr. Samuel Cooper (the author of the well-known Surgical Dictionary) affirm that there is no foundation for the prognostic of Hippocrates, that the accident will prove fatal if the dislocation be not speedily reduced. We can say, however, from our own personal knowledge, that such fatal consequences do occasionally occur. We once knew a poor woman who was very liable to dislocations of the lower jaw, which we reduced three or four different times. At last, owing to circumstances which it is unnecessary to explain, an interval of more than a day elapsed between the accident and the reduction. By this time she was become seriously indisposed, and died a few days afterwards with all the symptoms described by Hippocrates. We may mention also that Heister states that fatal consequences may result from the accident. (Chirurg. p. i, iii, 4.) The same thing is affirmed also by Brunus (Chirurg. Mag. i); by Theodoricus (ii, 43); and by Guido de Cauliaco (v, 2.)
That species of sub-luxation described by Hippocrates, is mentioned by Guy of Cauliac in the following terms: “Mandibula quandoque mollificatur.” (v, 2.)
SECT. CXIII.—ON THE CLAVICLE AND ACROMION.
The clavicle, at its inner extremity, is not liable to dislocation, for there it is articulated with the sternum, where it admits of no motion. But if from any sudden and violent force from without, it should be torn from its place, it is to be subjected to the same treatment as a fracture. And its extremity which is articulated with the shoulder does not readily fall out of the joint, being prevented by the biceps muscle and the acromion. But neither does the clavicle admit any strong peculiar motion of its own, being made solely for the expansion of the thorax, and hence man is the only animal which has a clavicle. If it should sometimes happen to be dislocated in wrestling, it is to be replaced with the hand, assisted by the application of many-folded compresses, together with convenient bandages. When the acromion is sub-luxated it may be restored to its proper place by the same treatment. It is a small cartilaginous bone connecting the clavicle to the scapula, which is not to be seen in the skeletons. This, if moved a little from its place, exhibits the appearance to inexperienced persons of the head of the arm being dislocated; for the top of the shoulder appears sharper, and there is a hollow from which it was removed; but the cases are to be distinguished from one another by the symptoms about to be enumerated.
Commentary. The dislocation of the outer end of the clavicle from the acromion is treated of by Hippocrates, who gives a very distinct account of the symptoms and mode of treatment. He warns the surgeon not to confound this accident with dislocation of the humerus, as he had frequently seen done. He directs the surgeon to push down the projecting end of the bone; and then to secure it with compresses, and bind the arm to the side. He holds that the accident always leaves some deformity. (De Articulis, 15.)
Galen mentions that this accident happens most commonly to young persons, and that when not reduced it occasions a wasting of the arm. The account which Galen in this place and, copying from him, our author have given of the accident to which they represent the acromion as being subject, has been the subject of much controversy among modern authorities. See Cocchi (Chirurg. Vet. 133); and Littré (Hippoc. iv, 12.) Hippocrates, whom they both evidently had in view, (de Artic. 13), clearly refers to dislocation of the scapular end of the clavicle; and probably Galen alludes to the same, complicated with separation of the acromion from the scapula in young subjects. We would beg leave to quote what Monro says of the acromion: “This is an epiphyse in children; and in some old subjects I have seen it joined by a cartilage to the spine.” (Anat. of the Bones, p. 231.) Galen states decidedly that in young persons this process is sometimes bent along with the clavicle, and in them that replacement of the parts to their natural state is easily effected. He adds, “as dry wood is not adapted for bending, but such as is sappy and green bear this, in the same manner the bones of growing animals can be bent by force, and more especially such as are porous and fistulous, as the clavicle is.” Galen relates that in his own person he met with the accident while wrestling in the Palestra, and that by using oily fomentations and light bandages, a cure was at last effected. He says he was then thirty-five years old, but adds, that he had never known another person cured who was so far advanced in life. (Ibid. 134.) Avicenna gives the same account of the acromion as the Greeks. (iv, 5,1, 10.)
Neither Celsus nor Oribasius has treated of this case of dislocation.
Rhases, Avicenna, Haly Abbas, and Albucasis agree that dislocations occur more frequently at the acromial than at the sternal end of the clavicle. Desault and Boyer, on the other hand, affirm that the accident occurs oftener at the sternal extremity; but Sir Astley Cooper’s ample experience confirms the correctness of the ancient statement. Mr. Liston also agrees in stating that dislocation at the acromial end is much more frequent than at the sternal.
SECT. CXIV.—ON DISLOCATION OF THE SHOULDER.
The head of the arm, which is articulated with the cavity of the scapula, is often dislocated; but neither upwards, owing to the coronoid process of the scapula, which prevents it, nor often backwards, owing also to the scapula, nor forwards owing to the tendon of the biceps muscle and the acromion. Sometimes, though rarely, it is dislocated inwards and outwards, but frequently, and particularly in those who are lean, downwards. In such persons, however, as it is readily dislocated, so is it also reduced; but in those who are brawny, on the other hand, it is not readily dislocated, and is reduced with difficulty. In some cases from a blow suspicions of dislocation are formed, although none has taken place, owing to the violent inflammation which supervenes. Wherefore, dislocation downwards may be thus ascertained. The affected shoulder, when compared with the sound one, appears very different, the upper part of the arm, whence the dislocation took place, seeming hollow; and (as mentioned with regard to the sub-luxation of the acromion,) the top of the shoulder appears sharper than natural; and the dislocated head of the arm is distinctly felt in the armpit. The elbow also is removed to a distance from the ribs; or, if you attempt it, you can only bring it to the ribs with difficulty; neither can the hand be raised to the ear, owing to the stretching of the elbow; nor can any other varied motions be performed with it. In children, then, and in recent and inconsiderable displacements of the bone, it may be often reduced, as Hippocrates remarks, by the protuberant knuckle of the middle finger of the clenched hand of the surgeon, or of the sound hand of the patient, if he be not a child. But the following are more effectual modes of reduction. Having bathed the man and used relaxing affusions, let him be laid on the ground in a supine posture, and apply a moderately-sized ball, either of leather or some other soft thing to the armpit; and the surgeon being seated with his face turned to the patient upon the affected side, if the right shoulder he dislocated, let him put the heel of his right foot upon the ball previously fitted to the armpit, or if the left, that of the left foot; and seizing the hand of the affected arm, let him pull down to the feet, at the same time making counter-extension by the heel in the armpit, while an assistant, standing behind the head, pulls at the other shoulder in an opposite direction, to prevent the body from being dragged along. There is another mode of reduction, namely, by suspending the patient upon a person’s shoulder. A young man taller than the patient, or standing on some elevated object, by his affected side, (the patient also being in a standing posture) is to apply his shoulder below the patient’s armpit, while he stretches and pulls the patient’s hand towards his own belly, so that the rest of the patient’s body is suspended at the back of the person who supports him. But if the patient be light, another light child is to be suspended from him. For while the arm and the rest of the body are pulled downwards oppositely, the shoulder put under the armpit, readily replaces the dislocated limb. And the same thing may be done by means of the instrument called a pestle. It is a long piece of wood which is erected on the ground upon some other firm object. Its upper extremity, then, being rounded, and neither very thick nor thin, is applied below the armpit of the patient, who either stands or sits, according to the length of the pestle, and the hand being stretched along the pestle and pulled downwards, while the rest of the body is balanced on the opposite side and weighs downwards, the reduction takes place either spontaneously, or with the assistance of another person pulling down. And this may be done with the step of a ladder, as we described when treating of the extension for a fractured arm. Here some round body is to be fitted to the step of the ladder, such as will suit the armpit of the patient, and propel the head of the arm. But if, owing to the oldness of the accident, or the hardness of the body, we find the reduction difficult, we must have recourse to the method by the means of the instrument called ambe. The ambe is a piece of wood about two cubits in length, of the breadth of three fingers, and about two fingers’ breadth in thickness, having the one extremity round and adapted for the hollow of the armpit, like the extremity of the pestle. Having then wrapped its end with linen rags, in order that it may be softer, we adjust it under the head of the humerus in the armpit, and stretching the hand along the wood, we bind it at the arm, fore-arm, and wrist; then bringing the hand with the wood over a transverse piece of wood, fastened between two erect pedestals, or again over the step of a ladder, so that the armpit may be fitted transversely to the step, we draw the hand downwards, and allow the rest of the body to hang suspended on the opposite side; for then the limb will return to its place. After the reduction, we must apply to the armpit a secure and moderately-sized ball of wool, which, if there is no inflammation present, is to be dry, but if there is inflammation, it is to be dipped in oil. Around this, the shoulder, and the other armpit, a bandage is to be put on in the form of the Greek letter Χ, so that the decussation may take place above the affected shoulder; and the arm is to be bound to the sides; and the elbow and hand are to be slung by the neck, so that the limb may not fall out again while the dislocation is recent. After the seventh day or later, having loosed the bandages, we must have recourse to moderate friction, so that the body being rendered firmer, the joint may become less liable to luxations. But if the limb is often dislocated, either owing to its humidity (flabbiness), or from its being long subject to the accident, we must proceed to burning, as formerly described. But since sometimes the fœtus in utero or the child, while growing, sustains a dislocation of the part which is not reduced, the flesh upon the shoulder is nothing reduced from the natural, nor is the hand obstructed in any of its operations, but the bone remains shorter, not increasing in size; and such persons are called weasel-armed. But in the case of the thigh, the bone does not grow and the limb wastes; for, not being able to sustain the weight of the body, it is not exercised. And with regard to all the other members, if they remain unreduced the parts below are greatly impaired.
Commentary. Hippocrates delivers his opinions respecting dislocations at the shoulder-joint with singular modesty and a remarkable air of truth. He says, that he had never met with a case in which the head of the humerus was not lodged in the armpit, and expresses a doubt whether in reality there be dislocations inwards or backwards. “I will not affirm,” he adds, “whether or not dislocation forwards may take place, only this I can say that I have never seen it.” (De Articulis.) Galen, in his commentary on this work, mentions that he had seen five cases of the uncommon kinds of dislocation, four of which were dislocations forwards. They occurred mostly among the athletæ. In one case, of which he relates the particulars, he effected the reduction with his heel placed in the armpit. Galen states distinctly, that it is the retraction of the muscles which proves the great obstacle to reduction. (Ed. Basil, v, 585.) Hippocrates has described several methods of reduction, most of which are mentioned by our author. By the fist placed in the armpit, as described by our author. By the heel, as likewise described by him. He adds one advice not distinctly given by our author, to apply the ball placed in the armpit on the side within the head of the humerus, and not upon it. The process by suspending the patient upon the shoulder of another person is next described by him. Those by the pestle and ladder are afterwards clearly described. He then describes the ambe and the application of it to the reduction of dislocations in nearly the same terms as our author. We may here mention, by the way, that the description of the ambe given by Boyer, does not correspond exactly to the instrument recommended by Hippocrates. See drawings of Hippocrates’s ambe in Heister’s ‘Surgery’ (x, 4); in Scultet’s ‘Arsenal de Chirurgie’ (xxii, 1); and in Littré’s edition of Hippocrates (iv, 91.) Hippocrates describes other less important processes of reduction with a Thessalian chair, and a door. He remarks, that persons in a reduced habit of body are most liable to dislocations, and illustrates this position by some very acute observations on the occurrence of these accidents in cattle. After reduction, he directs that a ball of soft wool should be placed in the armpit and secured with a bandage and a sling; and he attaches great importance to well-regulated friction afterwards.
Celsus mentions two kinds of dislocation at the shoulder-joint, namely, downwards and forwards. He describes the methods of reduction by the hand, and by a wooden instrument (spathula lignea) resembling the ambe of Hippocrates. His description of the latter method is very distinct. His mode of reducing dislocations inwards merits attention. The man is to be laid on his back, and a strip of cloth or a thong of leather being placed in the armpit, its two ends are to be brought behind the patient’s head and given in charge to an assistant, while another takes hold of the arm; the surgeon is then to push back the patient’s head with his left hand, while with the other he raises the fore-arm and arm, and pushes the bone into its place. After reduction the armpit is to be stuffed with wool, and suitable bandages applied.
Oribasius treats of dislocations downwards, outwards, and forwards; and gives a very elaborate description of complicated machines for reducing them. Of these it is impossible to convey any correct idea without proper plates. We must be content, therefore, with referring the reader to his work. (De Machinamentis.)
Albucasis describes three kinds of dislocation at the shoulder, namely, downwards, inwards, below the pectoral muscle, and upwards, about which he expresses himself somewhat doubtful. He denies the possibility of dislocations forwards and backwards, the former being prevented by the muscles and latter by the scapula. His methods of reduction are exactly the same as those mentioned by Paulus.
Avicenna expresses himself as being doubtful whether any dislocation takes place at the shoulder except downwards, at least, he adds, he had no experience of any other case. He gives the symptoms of it very accurately, and describes all the methods of reduction mentioned by our author. He approves of the cautery to obviate the tendency to repeated dislocations.
Haly Abbas questions the occurrence of dislocations upwards, forwards, inwards, or backwards. He appears, therefore, to agree with Hippocrates in considering that downwards as the only unequivocal case of dislocation. He recommends the processes of reduction described by our author.
Rhases remarks, that owing to the shallowness of the glenoid cavity and the weakness of the ligaments the bones at the shoulder are more subject to luxations than those of any other joint. He describes the symptoms very accurately. The top of the shoulder, he says, is sharper than natural, the head of the humerus is felt in the armpit, the arm cannot be brought to the sides without pain, nor raised to the head at all. He remarks correctly that when the accident happens during delivery or in childhood, the arm does not grow to its natural size. He mentions that venesection is often of great use in reducing dislocations. He also recommends the warm bath. He denies the possibility of a dislocation in any other direction except downwards.
The ancient modes of reduction are recommended and described by Guy of Cauliac (v, 2); and Theodoricus (ii, 47.)
SECT. CXV.—ON THE ELBOW.
Inasmuch as the elbow-joint is more complicated than that of the shoulder, so, in like manner, are its dislocations more difficult to manage; for they are less readily occasioned, and more difficultly reduced, owing to the number of its processes and cavities. Sometimes it undergoes sub-luxation only, but often it is completely dislocated in every direction, and more especially forwards and backwards. It is easily recognised even by the sight, and the dislocated bone may be felt in the place to which it has been removed, while a hollow appears in the place whence it was moved. A comparison with the sound arm particularly discloses the nature of the accident. Reduction then must be made immediately before inflammation comes on, for, if this has supervened, it is difficult to cure, and some such cases become utterly irremediable, more especially if the dislocation was backwards; for of all the dislocations at the elbow-joint, that backwards is the most painful and dangerous. Small displacements then may be restored by a moderate degree of extension, the assistants keeping the hand extended, pulling, and making counter-extension at the fore-arm and arm, while the surgeon with the palm of his hand pushes the dislocated bone into its natural place. Hippocrates rectifies the dislocation forwards by bending the hand suddenly so as to force the palm straight to the shoulder of the same side; and that backwards again by frequent and strong extension; inasmuch as dislocations forwards are produced by violent extension, and those backwards by violent flexion. If the dislocation has continued long unreduced, we must have recourse to stronger extension, such in particular as that described by Hippocrates for a fractured arm, where he has recourse to the piece of wood adapted to a spade. Some of the moderns manage the matter thus: Two assistants stretching the arm as aforesaid, the one holding at the armpit, and the other below at the wrist, the surgeon, standing opposite the patient, grasps the arm with the palms of both his hands near the joint, and giving orders to bind a long folded robe or broad swathe round his hands and the arm of the patient, and to pull outwards and downwards towards the hand, whilst he, following the same course, drags the parts with his hands thus secured until they pass the articulation of the joint. The arm should be first anointed with oil, to render the part slippery and easily moved with the palms of the surgeon’s hands. Thus the dislocated parts being violently pulled by the hands of the assistants will return to their proper place. After the reduction the arm is to be bent to an angular position, and treated with oblong compresses and suitable bandages.
Commentary. No author, ancient nor modern, has given so complete a view of the accidents to which the elbow-joint is subject as Hippocrates. In his works (De Fracturis, De Articulis, and Mochlicus,) he has treated of this subject with surprising accuracy and skill. He describes the following injuries of the elbow-joint: 1st. Complete luxations, laterally, anteriorly, and posteriorly. 2d. Luxations of the radius, anteriorly, posteriorly, and laterally. 3d. Fracture of the olecranon. 4th. Fracture of the apophysis of the humerus. We must give his description of the last-mentioned injury in his own words: “It sometimes happens that the head of the humerus is broken at its apophysis; and this, although it appear a more serious accident, is, in fact, less so than many other injuries of the joint.” It is singular that this distinct account of a very common injury of the joint should have been overlooked or misunderstood by all his commentators and the surgical authorities down to the present day. We have often met with it in our own practice, and seen many instances in which it had been misapprehended in the practice of other surgeons. It is only within the last five or six years that it has been described in any modern work on surgery. Lateral luxation of the radius is described by him under the name of diastasis. (De Fracturis, 44; De Articulis, 20.) The Commentaries of Apollonius Citiensis and Galen are worth consulting although they contain no new matter. Galen remarks that in dislocations of the radius, the power of flexion and extension is often not much impaired; and this, we may add, is confirmed by modern observation. Galen’s account of fractures of the olecranon is remarkable for its precision and accuracy. (Chirurg. Vet. 84.)
Celsus describes four different kinds of dislocation at the elbow, namely, forwards, backwards, and to either side. He also mentions that rare variety, in which there is a dislocation of the ulna, while the radius remains in its place. (See Sir Astley Cooper’s Lectures.) The other varieties are all well described, and suitable methods of treatment recommended. When there is a dislocation forwards the arm is extended, but cannot be bent; when backwards, on the contrary, it cannot be extended, and is shorter than natural. When to either side, the arm is somewhat bent towards that side from which the bone has been moved. He lays it down as a general rule for treating all such dislocations, to extend both the members concerned in different directions, until the bones are separated from one another, and then to push them into their right position. When the dislocation is forwards, he directs us to make strong extension with the hands or with thongs, and then placing some round body upon the anterior part of the arm, to push the fore-arm over it suddenly to the shoulder. This method is well described by Hippocrates, but rather indistinctly by Paulus. In all the other cases, the best method, he says, is to make reduction in the same way that it is performed for the replacement of fractures.
Oribasius mentions the four ordinary kinds of dislocation at the elbow-joint, and describes methods of reducing them by machines. He has likewise described the separate dislocation of the radius from the humerus, and he is the only Greek authority, as far as we know, who has described the separate luxation of the ulna, but which, as stated above, had been noticed by Celsus. We need scarcely remark that a few cases of this uncommon accident have been reported of late years.
Albucasis says that the fore-arm is dislocated in all directions, but more especially backwards and forwards. His description of the mode of reduction is evidently copied from Paulus. Avicenna likewise borrows his whole account from our author.
Rhases and Haly Abbas describe the ordinary cases of complete luxation at the elbow-joint, but we believe that neither they nor any of the Arabians take notice of the dislocation of the radius from the ulna, nor the abruption of the apophysis of the humerus.
SECT. CXVI.—ON DISLOCATIONS AT THE WRIST AND FINGERS.
Dislocations at the wrist and fingers are attended with no difficulty, unless accompanied with a wound. This case, therefore, will be treated of under the head of dislocations with a wound. Those without a wound may be remedied by moderate extension and the anti-inflammatory plan of treatment.
Commentary. Hippocrates says that the hand is dislocated inwards and outwards, but most frequently inwards. In the former case it is found impossible to bend the fingers, and in the latter to extend them. He also makes mention of dislocations to either side. He directs us to make counter-extension upon a table, and to push down the projecting end of the bone with the hand or the heel. He also describes the separate dislocation of the radius and ulna; and, upon the whole, his account is very little different from that given by Sir Astley Cooper in his ‘Lectures,’ and by Mr. Liston in his ‘Elements of Surgery.’
Celsus describes, in his usual elegant manner, the dislocations forwards and backwards. He denies the possibility of the lateral dislocations, and, in fact, it is now acknowledged that if ever they do occur they are incomplete. Like Hippocrates, he directs us to replace dislocations of the fingers by making extension upon a table. He does not make mention of the separate dislocation of the lower end of the radius.
Oribasius mentions the dislocations forwards and backwards, and likewise the separate dislocations of the radius and ulna. Sometimes, he says, the radius is dislocated, while the ulna remains in its place, and sometimes the ulna is dislocated while the radius remains. He describes the process of reduction with machines.
Albucasis, Avicenna, and Haly Abbas describe very accurately the dislocations forwards and backwards. They state that immediate reduction is peculiarly required in the case of this accident. Avicenna recommends a strengthening plaster to be put on the part before the splints are applied. When the joint, after reduction, is found to have lost the power of motion, Albucasis recommends us to pour hot water upon it and apply friction.
Rhases states that the ulna is more apt to be dislocated separately than the radius, which generally undergoes fracture rather than luxation. The fingers, he says, are mostly dislocated inwards.
SECT. CXVII.—ON THE VERTEBRÆ OF THE SPINE.
The vertebræ of the spine, when completely dislocated by accident, occasion instant death; for the spinal marrow undergoes extraordinary compression; and even when one of its nervous processes is compressed, it brings on dangerous symptoms. It often suffers sub-luxations, and when this takes place forwards it gets the name of repandation; when backwards, that of gibbosity; and when sideways, that of wry-neckedness. When there is a small sub-luxation of many vertebræ together, the distortion occasions a circular flexure of the spine, and in this case some are apt to be deceived, and take it for a complete dislocation of one spine, whereas a complete dislocation of one spinal vertebra does not produce a circular but an angular flexure of the spine, which is attended with more danger. When the dislocation is inwards, it cannot be reduced because no counter-pressure can be made on the belly. But those who imagine that they can effect anything in this case by stretching the patients upon a ladder, by apply cupping instruments, or administering sternutatories, or by producing coughing, or by inflation, are sufficiently exposed by Hippocrates. But since, often the breaking off of some of the small bones of the spine leaves a hollow appearance (as has been mentioned when treating of fractures), some have taken this for a dislocation forwards; and it being speedily healed, (for its callus is soon formed,) they have given out that a dislocation forwards is readily cured, although in fact it be wholly incurable, or difficult at least, to cure. For retention of the urine and fæces takes place, with coldness of the body; but this state is followed afterwards by an involuntary discharge of the excrements. These symptoms arise from the nerves and from muscular sympathy, and the patients soon die, more especially if the upper parts and the vertebræ of the neck be affected. But that gibbous state of the spine which mostly takes place from infancy, is a protracted affection and not speedily fatal; but, as Hippocrates has shown, it leads to disease and is incurable. But when this state occurs from an accident, the contrivances to remedy it with a ladder, suspending the patient erect, and inflation with a bladder, are altogether ridiculous. But the method of rectifying it, recommended by Hippocrates, will be alone sufficient. For, he says, a board, in length and breadth such as to contain the man, or a bench equal to it, is to be placed near a wall, being extended along the wall, and not more than a foot distant from it, and some robes are to be spread over it to prevent the body from being injured. Then the man, being bathed, is to be laid on his face along the board or bench, and a thong is to be twice passed round his breast by the armpits along the back; and the extremities of the thong are to be fastened to a pestle like a piece of wood erected on the floor at the extremity of the board or bench, and this to be given to a person standing behind the patient’s head to hold, so that when the lower parts are secured oppositely, and the upper pulled towards the head, extension may be made at the proper time. Then another thong being bound round both the feet above the ankles, and again another above the loins, so that its two ends may meet upon the haunch-bone, the extremities of these thongs are to be again united together, and bound to another pestle-like piece of wood resembling that already described; and this pestle, like the former, is to be erected near the extremity of the board or bench at his feet; and then we are to order the assistants to make counter-extension by these pieces of wood. Others effect this part of the operation by what are called aselli. They are axles turned upon an erect piece of wood, which is placed at each extremity of the large board or bench, at the feet and head of the patient, and the thongs are to be wrapped round them. While the extension is thus made, we press down the prominence of the back with the palms of the hands, and if necessary we may sit upon it without apprehension. If the spine is not thus made straight, and the patient can endure pressure, we may scoop out from the adjoining wall a furrow opposite the prominence of the back, so that the length of the furrow may not be greater than a cubit, and it must be in a situation neither much higher nor lower than the patient’s spine. But this furrow ought rather to be prepared beforehand, and on this account we directed the board at first to be placed near the wall. Then one extremity of a board is to be introduced into the furrow, while we press the other downward until it is clear that the spine is rectified. According to Hippocrates, extension alone without the board, and again the treatment with the board alone, is sufficient to accomplish the purpose. If this be true it will not be improper, in cases of dislocation anteriorly and laterally, to make the aforesaid extension without the compression. After the reduction, a thin piece of wood three fingers in breadth, and of such a length as to comprehend the dislocated part and some of the sound vertebræ, is to be wrapped round with a piece of linen or some flax, on account of its hardness, and applied to the spine with suitable bandages. And the patient must be kept upon a spare diet. If afterwards any remains of the protuberance are to be discovered, we must use relaxant and emollient applications, with the pressure by means of the plate. Some use a plate of lead.
Commentary. Our author’s account of dislocations of the spine is entirely condensed from Hippocrates’s work ‘De Articulis,’ and the commentary of Galen on the same. The description of the methods of reduction is so plain, that we need not take up time in illustrating it. It will be remarked that he makes mention of a mode of reducing these dislocations by means of axles or aselli. In the days of Hippocrates they were acquainted with only three of the mechanical powers, namely, the lever, the wedge, and the axis in peritrochio. The last mentioned is called by him asellus. (See De Fracturis cum Comment. Galeni.) Hippocrates makes mention of a mode of reducing dislocations of the spine, by succussion in a ladder, but expresses himself unfavorably of it as being a procedure which none but charlatans would practice. He speaks with becoming contempt of those who have recourse to ostentatious modes of performance ad captandum vulgus.
Celsus states very decidedly the fatal nature of dislocations of the uppermost vertebræ. Even those below the diaphragm are designated as highly dangerous. They happen either forwards or backwards. Those above the diaphragm occasion paralysis of the hands, vomitings, contractions of the tendons, difficulty of breathing, pain, and relaxation of the ears. Those below the diaphragm produce paralysis of the lower extremities, suppression of urine, or an involuntary discharge of it. Even these cases, he adds, prove fatal within three days. He says, that Hippocrates’s mode of reduction by counter-extension and pressure on the part with the heel, applies only to cases of incomplete luxation.
Oribasius describes the method of reduction by means of a machine, as mentioned by our author. It will readily be understood that the whole process consisted in making counter-extension upwards and downwards, and pressing upon the part which projects with a piece of wood. (De Machinamentis.)
Albucasis explains the nature of the accident and the methods of reduction in much the same terms as our author. The patient is to be laid upon a board or bench of sufficient length, spread with some soft thing to prevent him from being hurt. Then a pole or piece of wood is to be fastened at each extremity of the bench; and a rope or swathe, being carried round the patient’s body by the armpits and above his head, is to be fastened to the upper pole, which is not to be fixed firm in the ground; and another rope is to be brought round below the part affected, and fastened to the pole at his feet. Powerful counter-extension may be thus made, while the surgeon presses upon the protruded part with his hand and pushes it into its place. If these means do not succeed, he directs us to fasten a piece of wood into a hole in the wall opposite the protuberant part of the patient’s back and to press down with it. Other methods are also described by him. After reduction he directs us to apply a splint with bandages, as recommended by our author.
Avicenna describes all the methods of reduction here mentioned; and in the Latin edition of his works there are plates to illustrate his descriptions. Judging from our own experience of such cases, however, we would say that such contrivances can seldom be required to reduce these dislocations, as there is much less difficulty in the reduction than in keeping the parts in place afterwards.
Haly Abbas copies the description given by Hippocrates of the mode of reduction. After the parts are restored to their place, he recommends us to apply a board (tabula lignea) three fingers broad, and of such a length as to comprehend the dislocated vertebræ and some of the adjoining ones; and to bind it firmly on to prevent a recurrence of the displacement.
The ancients were well acquainted with the curvature of the spine occasioning paralysis of the lower extremities. Alsaharavius remarks that it occurs most frequently in childhood, and arises from an inflammation or collection of humours between the vertebræ. Sometimes, he adds, it is occasioned by a gross flatus. This is the disease called spina ventosa. When connected with a collection of blood in the part, he recommends bleeding, clysters, and various emollient applications. When it arises from flatulence he prescribes the hermodactylus. If the usual means do not succeed he approves of the actual cautery. (Pract. xxviii, 9.)
But no ancient author has treated so fully of curvature of the spine as Rhases. He states that it occurs most frequently in childhood, and often proves fatal by occasioning pressure on the thoracic viscera. The disease, he says, may arise from a fall, a blow, an abscess, or a gross flatus contained in the vertebræ. In cases of paralysis of the lower extremities connected with this disease, he approves of applying the actual cautery to the back. (Cont. i.) He states correctly that dislocations of the upper vertebræ often prove suddenly fatal. He directs the surgeon to keep them reduced with a splint extending the whole length of the spine. (Cont. xxix.) On the spina ventosa or gibbositas, see further Serapion (v, 26.) For the cure of it, he recommends first discutient plasters, and if these do not succeed he advises recourse to the actual cautery. (v, 27.)