COMMENTARY. Hippocrates directs us to pass a needle armed with a very

thick thread through the hemorrhoids, and tie them with it. Septic

applications are afterwards to be made to them. (De Victu Acut. 67.) The

author of another of the Hippocratic treatises recommends us to cure them

by burning with red-hot irons. (De Hæmorr.)

Celsus directs us when the base of a hemorrhoid is narrow to tie it with

a thread where it joins the anus, and to apply over it a sponge squeezed

out of hot water until it become livid, when it is to be scraped off

with the nail or a scalpel. Sometimes, however, he says, the ligature

occasions great pain and retention of urine. If the hemorrhoid be large

and its base broad, he directs us to seize it with a hook, and dissect

it out a little above its base: the part is to be secured with a thread.

When there are many hemorrhoids he advises us not to operate upon them

all at one time. When there is a discharge of blood it is to be stopped

by the application of a sponge. The day after the operation he recommends

us to use the tepid bath and catalapsms. (vii, 30.)

Aëtius approves of cutting off hemorrhoids, and describes the operation

minutely. He directs us to seize the pile with a hook, grasp it firmly,

and bind it with a thread, after which it is to be raised and cut off. To

stop the bleeding a piece of sponge bound round with a thread is to be

introduced into the anus. Suitable dressings and bandages are then to be

applied, (xiv, 6.)

In the ‘Isagoge’ ascribed to Galen, the method of treating hemorrhoids by

the ligature is particularly commended.

Albucasis prefers excision and burning, but if the patient will not

submit to these methods of cure he approves of having recourse to the

ligature. Excision is performed by seizing the hemorrhoid with a hook and

cutting it at its base, after which some styptic application is to be

made. The ligature is applied by transfixing the base of the hemorrhoid

with a needle armed with a thread. (Chirurg. ii, 81.) He gives particular

directions about the process of burning. (p. i, 37.)

When the hemorrhoid is internal Rhases directs us to evert the anus,

and having laid hold of the tumour to cut it out. He also describes

the process of tying them in the same terms as the other authorities.

(Contin. xxiv.) The directions given by Avicenna are quite similar.

Haly Abbas recommends excision or the ligature. (Pract. ix, 61.)

Fabricius makes mention of all these methods of treatment, but speaks

of the application of the cautery as being dangerous. Upon the whole

he appears to have entertained great apprehensions from stopping the

discharge of piles. (Œuv. Ch. ii, 94.)

Theodoricus and Brunus recommend excision, the cautery, and the

ligature, according to circumstances. Theodoricus also makes mention of

applications for consuming and drying them up.

SECT. LXXX.—ON CONDYLOMATA OR EXCRESCENCES, AND FISSURES.

Condyloma on the fundament differs in situation alone from that on the

female parts of generation, being a wrinkled excrescence of the anus,

either from a preceding inflammation or fissure. At first, then, it is

called an excrescence, but when it becomes callous, condyloma. These

also, like the former, are to be taken hold of with a forceps and cut

out, and the cure completed with escharotics. Fissures are occasioned

principally by hard fæces, and being slow of granulating owing to their

callosity, must be converted into recent ulcers by paring them with

the nails or a scalpel, when they may be made to granulate by proper

applications.

* * * * *

COMMENTARY. Celsus briefly directs us to seize the condyloma with a

forceps and cut it out by the roots. Should any fungous flesh arise it is

to be kept down with the squama æris. (vii, 30.)

Aëtius gives a fuller account of these affections than our author. The

condyloma, he says, is a tubercle which forms in the soft wrinkled skin

about the anus. When it becomes hard and callous he recommends us to

take hold of it with a forceps and cut it out by the roots. Old fissures

he directs us to treat by paring their edges and applying suitable

dressings. (xiv, 3.)

The same treatment is recommended by the Arabians. See Haly Abbas

(Chirurg. ix, 62); Albucasis (Chirurg. ii, 81, 82); Rhases (Contin. xxiv.)

SECT. LXXXI.—ON IMPERFORATE ANUS.

In new-born children the anus is sometimes found imperforate, being

blocked up by a membrane. If possible, then, the membrane is to be

ruptured with the fingers, but if not, we must cut it with the point

of a scalpel, and accomplish the cure with wine. And since often in

adults, owing to an ulcer not properly cured, a stricture takes place at

the anus, we must break it with a convenient instrument, and treat it

properly with a pipe of lead, or some wedge-shaped tent introduced into

the anus until the cure be completed, lest contraction should again take

place. The wedge-shaped tent is to be anointed with some healing ointment.

* * * * *

COMMENTARY. Soranus describes this operation in very distinct terms. (p.

164.)

Albucasis evidently copies our author’s account, recommending us to break

or divide the membrane, and introduce a canula of lead into the opening

to prevent adhesion. (Chirurg. ii, 79.)

Haly Abbas, in like manner, directs us to make an opening and introduce a

leaden tube or a piece of sponge. (Pract. ix, 63.)

SECT. LXXXII.—ON THE EXCISION OF VARICES.

The varix is a dilatation of a vein occurring sometimes in the temples,

sometimes in the hypogastric region below the navel, sometimes in the

testicles, but more especially in the legs. For the most part it derives

its origin from a melancholic humour. The operation for those of the

testicle we have already described when treating of cirsocele, and those

in the leg may be operated upon in a similar manner, making the attempt

upon those in the inner parts of the thighs, where they generally arise;

for below this, as they are divided into many ramifications, they are

more difficult to succeed with. Wherefore, having washed the man, and

applied a ligature round the upper part of the thigh, we are to direct

him to walk about, and when the vein becomes distended we are to mark its

situation with writing ink or collyrium, to the extent of three fingers’

breadth or a little more, and having placed the man in a reclining

posture with his leg extended, we apply another ligature above the knee;

and where the vein is distended we make an incision upon the mark with

a scalpel, but not to a greater depth than the thickness of the skin,

lest we divide the vein; and having separated the lips of the wound with

hooks, and dissected away the membranes with crooked specilla, like those

used in the operation for hydrocele, and laid bare the vein, and freed

it all around, we loose the ligatures from the thigh, and having raised

the vessel with a blind hook, and introduced under it a needle having

a double thread we cut the double of it, and opening the vein in the

middle with a lancet, evacuate as much blood as may be required. Then

having tied the upper part of the vessel with one of the ligatures, and

stretched the leg, we evacuate the blood in the limb by compression with

the hands. Then having tied the lower part of the vein, we may either

cut out the portion intermediate between the ligatures, or suffer it to

remain until it drop out of its own accord with the ligatures; then we

have to put a dry pledget into the wound, and apply over it an oblong

compress soaked in wine and oil, and secure them with a bandage, and

accomplish the cure by the treatment applicable in cases of suppuration.

I am aware that some of the ancients do not use ligatures, but cut out

the vessel immediately after it is laid bare, whilst others stretch

it from below and tear it out by force. But the mode of operating now

described is of all others the safest. Varices on the hypogastrium may

be treated in like manner, and those on the temples as described in the

operation of angiology.

* * * * *

COMMENTARY. Hippocrates directs us to make small punctures in varices

of the leg, but forbids to open them freely. (De Ulceribus, 16.) In the

Hippocratic treatise entitled ‘Hippiatrica,’ it is recommended to burn

varices in the legs of horses.

Celsus treats ingeniously of varices on the head (aneurism by

anastamosis) on the belly (cirsocele?), and on the leg. With regard to

the treatment, he says, in a word, that they are all either to be burnt

or cut out. If the varix be straight, or if, although transverse, it

consist of a single vein of moderate size, it will be better, he says, to

burn it. If crooked and convoluted, and if it consist of a multitude of

veins, it will be more useful to cut them out. He directs us, in burning

them, to make an incision in the skin, and having laid bare the vein to

touch it with a slender blunt piece of iron red-hot, taking care not

to burn the edges of the wound which are to be drawn aside with hooks.

This is to be done at intervals of about four fingers along the whole

extent of the varix, and then the dressings for burns are to be applied.

The varix is cut out in this way. The vein is to be exposed as above

directed, and dissected with a scalpel from the surrounding parts (care

being taken not to hurt it); a blunt hook is then to be introduced below

it; and the same thing is to be done at the same interval as mentioned

above. When this has been performed wherever there are varices, the

vein is to be cut asunder at one of the hooks, and drawn towards the

next hook, and then torn out. The leg being in this way cleared of the

varices, the lips of the wound are to be united, and an agglutinative

plaster applied above. (vii, 31.) It will be remarked that our author

makes mention of this method of treatment but disapproves of it.

Aëtius describes the excision of varices in exactly the same terms as our

author. He also makes mention of the treatment by the actual cautery.

(xiv, 84.)

The operation of extracting varicose veins is briefly described in the

‘Isagoge’ of Galen. Albucasis describes accurately the different modes of

operating upon varices. He says there are two methods of performing the

operation with the knife, that is to say, by incision or by extraction.

The former method is done by applying a piece of fillet round the

upper part of the thigh, and at the inferior part near the knee, and

then opening the vein in one, two, or three places, and evacuating the

blood in it: the limb is then to be bound up. In performing extraction,

the veins are first to be made to swell by putting the limb into hot

water, applying fomentations, and taking strong exercise; and then a

longitudinal incision is to be made in it, either at the knee or the

ankle. The vein is afterwards to be dissected from the neighbouring parts

and suspended with a blunt hook. The vein is to be laid bare in like

manner at the distance of three fingers’ breadth, and in more places if

required. At last, it is to be cut asunder at the ankle and drawn out.

Afterwards wool dipped in wine and rose-oil is to be applied. When the

varix consists of a congeries of tortuous vessels he recommends us to

dissect it out entire. (Chirurg. ii, 92.)

Haly Abbas briefly inculcates the same treatment as Albucasis. (Pract.

ix, 64.) Avenzoar considers the complaint nearly incurable.

Rhases directs us, in the first place, to bleed and purge, and then to

expose the vessel or cut it out. He also approves of compression. (Cont.

xxviii.)

It is related that the operation here described was performed upon the

celebrated Caius Marius. See Cicero (Tusc. Disput. ii.) Pliny (H. N. xi,

104); and Plutarchus (in Mario.) It seems to have been a very painful

operation, since it is mentioned as a proof of his fortitude that he

submitted to it without being bound. It would appear that the learned and

ingenious Aurelius Severinus used to perform it. (V. Mangeti Bib. Chir.

xvi.)

SECT. LXXXIII.—ON THE DRACUNCULI OR GUINEA-WORMS.

The treatment of dracunculi being principally accomplished by medicines,

we have given an account of it in the Fourth Book.

* * * * *

COMMENTARY. We have treated fully of this subject at the end of the

Fourth Book.

SECT. LXXXIV.—ON AMPUTATION OF THE EXTREMITIES.

Sometimes the extremities, such as a hand or a foot, having mortified,

so that the bones themselves are corrupted, either from having been

fractured by some external means, or from having become putrid owing to

some internal cause, it is necessary to saw them off; before doing which

the parts surrounding the bones must be divided. But since, when this is

done first, as a considerable time is required for the sawing, there is

danger of a hemorrhage taking place, Leonides properly directs us not to

divide all the parts at once unless they are completely mortified, but

first to cut the part where not many nor very large veins or arteries are

known to be situated, down to the bone quickly; then to saw the bone as

expeditiously as possible, applying a linen rag to the parts which have

been cut lest they be torn by the sawing and occasion pain, and then

having cut through what remains, to apply red-hot irons to the vessels

and stop the hemorrhage thereby with compresses of lint, and to apply

proper bandages with the dressings suitable to suppurations.

* * * * *

COMMENTARY. Hippocrates and Galen recommend amputation to be performed

in general at a joint. (De Articulis, Galeni Comment. t. v, p. 650, ed.

Basil.) Hippocrates says complete excision may be performed at the joints

of the hand and foot, and at those of the wrist and ankle, and generally

with safety, unless the patient be cut off by fainting, or continual

fever supervene on the fourth day. When gangrene attacks a fractured

limb, his rule of practice is to let the parts drop off, and he remarks,

many persons thus recover, even when the fracture is seated in the femur.

When gangrene comes on without being preceded by fracture, he directs the

soft parts, as soon as they have lost all sensibility, to be removed at

the nearest joint below, and the surgeon is to wait until the bone also

separates. He says he had seen the bone of the thigh thus separate on the

eightieth day; in that case the limb below had been removed at the knee

on the twentieth day. In a similar case of gangrene of the leg, the bones

separated on the sixtieth day. He pronounces gangrene of the extremities

to be more formidable in appearance than in reality. He recommends a mild

and anti-inflammatory treatment, and that the limb should be laid in an

elevated position as long as there is any fear of hemorrhage. Violent

attacks of dysentery are apt to come on, but do not generally prove

obstinate. (De Artic. 69.) It would appear from Thucydides and Lucretius

that it was not uncommon to amputate in cases of gangrene in the days of

Hippocrates. (See their Descriptions of the Plague of Athens.)

In cases of gangrene Celsus directs us to make an incision of the flesh,

between the sound and corrupted part, down to the bone, which is to

be sawed across, and after the asperities have been removed from the

end of the bone, the skin is to be brought over the stump. (vii, 33.)

He gives us no particular description, however, of amputation of the

extremities. We turn, therefore, to the celebrated fragments of the works

of Archigenes and Heliodorus, preserved in the collection of Nicetas,

published by Cocchius. (Chirurgici Græci, Florent. 1756.)

Archigenes begins by stating the circumstances which require recourse

to be had to amputation. They are, the presence of some intractable

disease, such as gangrene, necrosis, putrefaction, cancer, certain

callous tumours, and sometimes wounds inflicted by weapons, and the like.

Before attempting the operation he recommends us to consider well if

the patient’s strength will enable him to endure it. The operator must

then tie or sew the vessels which pass to the parts; in certain cases

a ligature is to be applied round the whole limb, cold water is to be

poured upon it, and some are to be bled. Amputation near the joints is

not to be attempted. In such as are of a full habit of body, a circular

band is to be put round the limb, to draw up the skin with, and to direct

the incision. After cutting down to the bone, the tendons are to be

retracted, and the bone scraped and sawn. When much blood is discharged,

red-hot irons are to be applied, and a double compress laid on the part

from which the blood proceeds. Having loosened the band, a cataplasm

of leeks, bread, and salt is to be applied to the stump; and the parts

about the jaw-bone are to be anointed with cerate of iris and old oil,

doubtless in order to obviate the danger from tetanus.

Heliodorus states that a limb may require to be amputated owing to

gangrene or any other cause that occasions the death of it. In the

extremities, then, he remarks, amputation may be performed with less

danger; but above the knee or elbow the danger of hemorrhage from the

great vessels being wounded is very considerable. Some, he says, from

too great anxiety for despatch, cut through all the bodies (the soft

parts?) at one incision, and then saw the bones. But this method of

removing the limb is not unattended with danger, as many vessels pour

forth blood at the same time. “Wherefore,” he adds, “it appears to me

better first to divide those parts of the limb where there is least

flesh, as on the anterior part of the leg, and then to saw the bone; and

I myself am in the practice of first applying a ligature above the part

of the limb which is to be sawn across, and then of operating in the

manner described. In sawing the bone the plate of the saw ought to be

applied even, in order that the sawing of the bones may be even. When the

bones are sawed the other parts which remain undivided are straightway

to be cut through with a scalpel, and large pledgets applied along with

suitable compresses. External to these, sponges with suitable bandages

are to be put on. After the third or fourth day, when all fear of

hemorrhage is over, suppuration is to be promoted by suitable dressings.”

In no other of the Greek medical works which have come down to us is

there any description of amputation of the extremities.

Avicenna mentions the operation of sawing off the bones of the

extremities, but in such general terms as gives us no information in what

manner it was performed. (iv, 4, 4, 10, 11, 12.)

The description given by Haly Abbas is more complete. A limb, he says,

is amputated thus. The operation is to commence with first cutting the

skin, and then when the bone of a limb is to be sawn, you must not cut

through the whole flesh at once, lest an immoderate discharge of blood

take place from the veins and arteries so as to occasion the death of the

patient and interrupt the process of sawing the bone; except the flesh of

the limb be wasted or putrid. But you ought first to divide that part of

the flesh where no great arteries and veins are situated, cutting them

down to the bone, which is to be sawn across as quickly as possible, the

fleshy parts in the mean time being retracted with a piece of linen, lest

the saw should tear them and occasion bleeding and pain; when the bone

is sawn across, whatever portion of the flesh remains undivided is to be

cut, and then the veins and arteries are to be burned. When the bleeding

is stopped a pledget with suitable bandages is to be applied. (Pract. ix,

65.)

Albucasis represents amputation as necessary in cases of mortification,

as indicated by the smell and discoloration. When the disease is seated

in the hand, he recommends us to amputate at the fore-arm; when in the

forearm, at the elbow; and if the arm itself be affected, he pronounces

the case to be hopeless. In like manner, with regard to the lower

extremities, he pronounces all cases incurable in which the disease is

seated above the knee. In performing the operation he directs us to apply

two bandages around the limb, the one above and the other below the

place at which it is to be cut off. These bandages are to be pulled, the

former upwards and the latter downwards, by two assistants, so as to put

the skin upon the stretch; the fleshy parts are then to be divided with

a large scalpel down to the bone, which is afterwards to be cut out, or

sawed across, and during this part of the process a piece of linen is

to be applied around all the fleshy parts, to prevent them from being

injured by the sawing. Should any hemorrhage occur during the operation,

he directs us to apply the cautery, or a styptic powder; and after the

operation he recommends us to bandage the limb in a suitable manner,

until the stump is healed. He relates a case, from which the timidity of

his own practice is rendered very apparent. A person who had a spreading

mortification in the foot, cut it off at the ankle-joint himself, and

was cured for the time. The disease next attacked the hand, upon which

he applied to Albucasis, requesting that he would cut it off in the same

manner, but this he refused to do, for fear that the man’s strength might

not be able to endure the operation. He afterwards learned that the man

had cut off his whole hand, and had recovered. (Chirurg. ii, 89.) The

history of this case proves decidedly that the operative surgery of the

Arabians, in the days of Albucasis, must have been very defective; this

he himself frankly confesses, for he declares that all knowledge of this

art had been lost, except what vestiges of it had been preserved in the

works of the ancient authors, whose descriptions, he complains, had been

mutilated and corrupted. (Prefatio.) We mention this, in order that the

ignorance which prevailed in his time may not be imputed to all preceding

ages, nor may be used as an argument against the genuineness of the

extracts from the works of Heliodorus and Archigenes, given above.

Rhases makes some interesting remarks on the sawing of bones. He directs

us to stretch the flesh upwards and downwards, with a piece of cloth,

so that it may not come in the way of the teeth of the saw. When it is

necessary to saw a rib or a bone, near any important membrane or organ,

he recommends us to use a plate (tabella), to protect the soft parts from

the saw. When the bone connected with a joint is diseased, he directs us

to extract it at the joint. When the os brachii, or tibia, is diseased,

he recommends us to extract it entire, but forbids to meddle with the

head of the femur or the vertebræ. In another place he declares it as his

opinion that when a joint is swelled, and the bone diseased, (in cases

of white swelling?) it will be impossible to effect a cure unless the

whole diseased portion of the bone be cut out. (Cont. xxix.) From these

passages it is quite obvious that the ancients practised excision of the

bones of joints. See also what our author says on this subject in the

seventy-seventh section of this book. A Cooper or a Liston could not

recommend a bolder plan of treatment in such cases.

Theodoricus, Guy of Cauliac, and the other surgical writers of that

age, follow closely in the footsteps of the ancients, especially of the

Arabians. When the mortified part is near to a joint, they recommend

amputation at it. In other cases they direct us to make an incision

between the sound and the dead parts, to saw the bone with a fine saw,

and to stop the bleeding with a heated iron. Theodoricus recommends

stupifying medicines, such as opium, hyoscyamus, mandragora, or cicuta,

before the operation. Ambrose Paré has undoubtedly the merit of

introducing the use of the ligature into modern practice in amputations,

and, in fact, Archigenes seems to be the only ancient authority who

mentions it in such cases. We have shown, however, in another place, that

the ligature was freely used by the ancients for stopping bleeding from

wounds.

SECT. LXXXV.—ON PTERYGIA ABOUT THE NAILS.

The pterygium is a fleshy excrescence about the nails, covering part

of the nail, and being commonly formed in the large fingers and toes.

But those in the feet arise most commonly from an accident, whereas,

those in the hands arise from whitlow, the inflammation being neglected

and turning to pus. For, the pus being allowed to remain, corrodes and

corrupts the root of the nail, and often destroys the whole of it, but

generally the one half, while a portion of it uncorroded is left at

the root of the nail, and sometimes the whole root is left uncorroded.

Sometimes, too, it corrupts the bone, when a disagreeable smell arises

from it, and the extremity of the finger becomes swelled and appears

livid. They are to be treated, then, by cutting and removing all the

remaining part of the nail with the point of a scalpel, and then burning

both the ulcerated and cut part with cauteries. For, the pterygium is a

spreading disease, and does not stop unless burnt, so that, if neglected,

it affects the whole finger. If, while the nail and bone remain sound,

the inner angle of the nail sink down and pierce the adjacent flesh, it

occasions inflammation; and in this case the irritating portion is to be

raised upon a thin probe, or some such thing put under it, and removed

with the point of a scalpel, and the excrescence eaten down with an

escharotic medicine. And most cases are cured by being treated in this

way. But if larger, it is first to be cut out with a scalpel, and then

the medicine is to be used.

* * * * *

COMMENTARY. We have given an account of the ancient treatment of pterygia

by medicines towards the end of the Third Book.

Celsus recommends excision with the knife and the application of

cauteries or strong caustics afterwards. (vi, 19.)

Aëtius and Oribasius trust to septic and caustic applications without an

operation. Antyllus (apud Rhasis Cont. xxxvi,) recommended excision and

burning when the discharge from the ulcer is fetid.

Albucasis, like our author, recommends us to cut off the piece of nail

that is attached, and then to apply a burning iron to the part. The

burning, he adds, is of great consequence. When the bone is diseased he

directs us to take it out, which generally may be done at the joint.

(Chirurg. ii, 9.)

Haly Abbas likewise directs us to cut off the piece of nail and apply

the cautery. He says, if this be neglected the bone is apt to become

diseased. When pus is seated below the nail, he recommends us to

introduce the head of a probe under it, and cut upon it with a knife;

after which a caustic medicine is to be applied to the flesh. (Pract. ix,

66.)

SECT. LXXXVI.—ON A BRUISED NAIL.

Since, owing to nails having been bruised by accidents, pains supervene,

which compel us to operate upon them, it will be sufficient to give

you Galen’s account of the matter. He says, then: “When the nails are

contused we have found the evacuation of the blood a palpable remedy for

soothing the pain, when it and the throbbings are very violent. But we

must make an oblique incision, not straight from above downwards, with a

sharp scalpel, so that when the blood is evacuated the divided part of

the nail may serve as a cover to the parts under it. But if you make a

straight incision from above down to the fleshy excrescence, as it is

called, another body is formed from the flesh below the nail shooting

out through the division of the nail, whence pains again invade, as in

the complaint we call paronychia, owing to the flesh under the nail

being compressed by it. Wherefore, one may see the patients immediately

relieved from pain by this section. On the following days we may gently

raise the divided part of the nail, and press the sanies from under the

nail, and then again, as I said, apply the nail as a cover to the flesh

below. The rest of the treatment of the finger should be soothing and

discutient.”

* * * * *

COMMENTARY. Avicenna and Rhases approve of the plan of treatment here

recommended, upon the authority of Galen. Rhases, in fact, gives the very

words of Galen. (Cont. xxxvi.)

Albucasis directs us, in the case of a bruised nail, first to have

recourse to venesection, and then to make a transverse (oblique?)

incision through it. (Chirurg. ii, 91.)

See our remarks in the sixtieth section of this Book on the confusion of

the terms _transverse_ and _oblique_ by the translators of the Arabians.

The same treatment is recommended by Haly Abbas. (Pract. ix, 67.)

SECT. LXXXVII.—ON CLAVI, MYRMECIA, AND ACROCHORDONES.

The clavus is a round callus, white, resembling the head of a nail, and

occurring in all parts of the body, but more especially on the soles

of the feet and the toes, occasioning pain and lameness in walking.

Wherefore, having scarified around the clavus or corn, and taken hold

of it with a forceps, we cut it out by the roots with a sharp-pointed

scalpel or lancet for bleeding. Some, in order that they may not grow

again, use heated cauteries. The myrmecia is a prominence of the skin,

small, callous, round, thick, spreading deep at the base, and, if rubbed,

occasioning a sensation like the bites of ants, and being formed in all

parts of the body, but more especially in the hands. Wherefore, some,

among whom is Galen, advise us to scarify around the myrmecia with the

stalk of a hard feather, such as those of old fowls, of geese, and of

eagles, and to push it down so as to remove the myrmecia from the root.

Others do the same thing with a copper or iron tube. The moderns are

satisfied to scarify around it, and, having seized it with a forceps, to

cut it out like corns with a scalpel. The acrochordon is a small rising

of the surface, free of pain, callous, for the most part round, and

having a narrow base so as to appear to hang. It is so called from its

resemblance to the end of a cord. Having stretched out the protuberance

then we may cut it out; or, otherwise, we may tie a thread or a hair

round it. I have known many who consumed this and all the afore-mentioned

protuberances with what is called the cold cautery.

* * * * *

COMMENTARY. We have already treated fully of these diseases towards the

end of the Third Book and in the Fourth, to which we refer the reader for

further information on this head.

Celsus recommends us merely to shave the clavus or corn. The others he

directs us to remove by caustics, such as the lees of wine (potass?), or

a mixture of alum and sandarach. The acrochordon, he says, when cut out

leaves no roots behind. (v, 28.)

Albucasis particularly recommends burning for the cure of clavus and

myrmecia. This may be accomplished either with fire or hot water. If the

former method is preferred, an iron proportionate to the size of the corn

is to be heated red-hot and applied to it, and the burning carried to

such an extent as to occasion suppuration. In the other method a funnel

of copper or iron, or else the quill of a vulture is to be applied to the

corn, and then filled with boiling water. By these means, he says, the

corn may be eradicated. (Chirurg. i, 55.)

See also Haly Abbas (Pract. ix, 12) and Rhases (Cont. xxxvi.) Rhases

does not state very distinctly the difference between the myrmecia and

acrochordon. He speaks of scraping them out with a hard pen, and of tying

them at the base; but upon the whole he approves most of taking hold of

them with a forceps and dissecting them out.

Avicenna recommends us to cut out the clavus and then apply a caustic

medicine to the part. (iv, 7, 4, 14.)

SECT. LXXXVIII.—ON THE EXTRACTION OF WEAPONS.

That the extraction of weapons is a most important department of surgery

is declared by the Poet Homer, when he says:

“The man of medicine can in worth with many warriors vie,

Who knows the weapons to excise, and soothing salves apply.”

We must first describe the different kinds of weapons. Warlike

instruments, then, differ from one another in material, figure, size,

number, mode, and power. In material, then, as the shafts are made of

wood or of reeds; and the heads themselves are either made of iron,

copper, tin, lead, horn, glass, bones, and of reeds, too, or of wood: and

such differences are found especially among the Egyptians. In figure,

inasmuch as some are round, some angled (as triangular), some pointed and

lance-shaped, as some have three points; some are barbed and some are

without barbs; and of the barbed, some have the barbs turned backwards,

so that in attempting to extract them they may fasten in the parts; and

some forwards, so that when pushed they may do the same thing: some

have them diverging in opposite directions like the forked lightning,

in order that whether pulled or pushed they may fasten in the parts.

Some missiles have their barbs united by a hinge, which being expanded

in the extraction, prevent the weapon from being drawn out. They differ

in size, inasmuch as some are three fingers’ breadth in size, and some

are as small as one finger, which are called _micca_ in Egypt, and some

are intermediate between them. In number, inasmuch as some are simple

and some compounded. For certain small pieces of iron are inserted

in them, which, in the extraction of the weapon, remain concealed in

deep-seated parts. In mode, as some have the sharp extremity fixed to

a tail and some to a shaft; and some have it carefully inserted in the

shaft, and some carelessly, so that in the extraction they may separate

and leave the head behind. In power, as some are not poisoned and some

are poisoned. Such are the differences of weapons. We now proceed to

treat of the extraction, both in cases of those who have been wounded in

war and those not in war, whether voluntarily and involuntarily, under

whatever circumstances, and of whatever materials they may be composed.

There are two modes of extracting weapons from fleshy parts; either by

pulling them backwards, or pushing them forwards. When the weapon is

fixed superficially the extraction is made by pulling it back, and in

like manner when it is lodged deep, but the opposite parts, if wounded,

would occasion danger from hemorrhage or sympathy. It is to be pushed

forwards when lodged deep, and the intervening substances between it and

the opposite side are of small size, and neither nerve, bone, nor any

such thing is an obstacle to the division. When a bone is wounded, the

mode of extraction is by pulling; if, therefore, the head of the weapon

be in sight, we make the extraction immediately; but, if it is hid, we

must, says Hippocrates, get the wounded person to put himself in the same

posture as when he received the wound, and thus make the examination; or,

if this cannot be done, he is to be placed in the nearest possible to it,

and thus it is to be examined with a sound. If the head of the weapon has

fixed in the flesh, it is to be drawn out with the hands, or by laying

hold of the appendage, which is called the shaft, if it has not fallen

off. This part is mostly made of wood. When it has fallen off, we make

the extraction by means of a tooth-extractor, or a root-extractor, or an

instrument for extracting weapons, or any other convenient instrument.

And sometimes we make an incision in the flesh around it in the first

place, if the wound do not admit the instrument. And if the head of

the weapon has passed to the opposite side, and it is found impossible

to extract it by the way in which it entered, having divided the parts

opposite we extract it through them, either drawing it out in the manner

mentioned, or we make a hole with the weapon itself, pushing it either

by the shaft, or, if it has come away, by an impellent instrument,

taking care not to divide a nerve, vein, artery, or any important part,

for it would be disgraceful if, in extracting the weapon, we should do

more mischief than the weapon itself had done. If the weapon has a tail,

which is ascertained by examination with the probe, having introduced

the female part of the impellent instrument and fixing it, we push the

weapon forwards, but if it has a shaft, the male part. And if the head

when extracted appear to have notches, so that other small pieces of iron

might be inserted in them, we make an examination again with the probe,

if we find them we extract them in the same manner. And if the weapon has

barbs in opposite directions, which do not yield to our pulling, we must

make an incision in the adjacent parts, if no important vessel or the

like lie there, and when the weapon is laid bare, we extract it without

trouble. Some apply a tube about the barbs, so that when they draw out

the weapon the flesh may not be torn by the barbs. If the wound does

not become inflamed, we may use sutures, and heal it up like a bloody

wound; but if it inflame we may remove the inflammation by embrocations,

cataplasms, and the like. If the weapon be poisoned we must, if possible,

cut off all the flesh which has imbibed the poison, which is known by its

being altered from the sound flesh, for it appears pale, livid, and as

it were dead. They say that the Dacians and Dalmatians touch the points

of their weapons with elecampane, called also _ninum_, and that when it

thus becomes mixed with the blood of the wounded animal it proves fatal,

although it is eaten by them with impunity. If, again, the weapon fix

in a bone, we make trial with the instrument, and, if flesh prevent the

extraction, we cut it off, or separate it; but if it be lodged deep in

the bone (which we know by its being so firm that it cannot be shaken

with a considerable force) we first remove the remaining part of the

bone with a cutting instrument, or bore it with trephines if it has

considerable thickness, and thus disengage the weapon. If a weapon be

lodged in any important part, such as the brain, heart, throat, lungs,

liver, stomach, intestines, kidneys, womb, or bladder, and fatal symptoms

have already shown themselves, as the extraction would occasion much

laceration we must decline the attempt, lest while we do no good we

expose ourselves to the reprobation of ignorant people. But if the result

be dubious, we must make the attempt, having first given warning of the

danger. For in many cases, when an abscess has formed in some vital part,

recovery has unexpectedly taken place; and the lobe of the liver, part of

the omentum and peritoneum, and the whole uterus are said to have been

taken away, and yet death was not the consequence. And we often open

the windpipe intentionally, in cases of angina, as we mentioned under

the head of Laryngotomy. To leave the weapon then as it is, occasions

certain death, and exhibits the art in an inhumane light, whereas by

extracting it we might possibly save a life. It is not difficult to

ascertain when an important part is wounded, this being discovered by

the peculiarity of the symptoms, the discharges, and situation of the

parts. When, therefore, the membranes of the brain are wounded, there is

intense pain of the head, the eyes are fiery, the tongue red, and there

is aberration of intellect; but if it is attended with a wound of the

brain, there is prostration of strength, with loss of speech, distortion

of the countenance, vomiting of bile, a discharge of blood from the

nostrils, an evacuation of a white and pultaceous fluid by the auditory

foramen, and of ichor, if it can find a passage by the wound. If the

weapon has penetrated to the cavity of the chest, and sufficient room is

left for it, the breath passes out. When the heart is wounded, the weapon

appears at the left breast, and feels not as if in a cavity, but as fixed

in another body, and sometimes there is a throbbing motion; there is a

discharge of black blood if it can find vent, with coldness, sweats, and

deliquium animi, and death follows in a short time. When the lungs are

wounded, if the opening be sufficiently large, a frothy blood passes out

at it; but if not, it is rather vomited up, the vessels of the neck are

swelled, the tongue changes colour, and there is an urgent desire of cold

things. When the diaphragm is wounded the weapon appears lodged about the

false ribs, there are large inspirations with pain, sighs, and heavings

of the parts about the shoulder-joints. If the viscera of the abdomen are

wounded, the nature of the injury will be apparent from the discharge,

if the wound be sufficiently large, or if the weapon be extracted, or if

the shaft be broken internally; for chyle is evacuated from the stomach,

and fæces from the intestines; sometimes the omentum or an intestine

protrudes. When the bladder is wounded urine is discharged. When the

membranes of the brain or the cerebrum itself is wounded, we extract

the weapon by trepanning the skull, as will be described presently in

fractures of the bones of the head. If the weapon is lodged in the chest,

and does not come out readily, it is to be extracted by means of a

moderate incision in the intercostal space, or by cutting out a rib with

the assistance of the instrument called meningophylax. In like manner,

when the stomach, bladder, and other deep-seated parts are wounded, if

the weapon come out readily it is to be extracted without more ado; but

if not, we must enlarge the wound, and afterwards use the dressings for

fresh wounds. In wounds of the abdomen, gastroraphé as formerly described

may be had recourse to, if necessary. But if the weapon has lodged in

any of the larger vessels, such as the internal jugulars or carotids,

and the large arteries in the armpits or groins, and if the extraction

threaten a great hemorrhage, they are first to be secured with ligatures

on both sides, and then the extraction is to be made. If parts have been

fastened to one another, such as the arm to the chest, or the fore-arm to

the other parts of the body, or the feet to one another, if the weapon

(as a spear) do not penetrate through both parts, we are to take hold

of the weapon externally and extract as if only one part were affected,

but if it has passed through both, having sawed the wood through the

middle, we extract each part singly, in the most convenient direction.

But since often stones or the sharp points of rocks, or pieces of lead,

or the like, are lodged in the body, either being impelled with force

from a sling, or happening to be acuminated, they are to be known by

the swelling being hard and irregular, and by the solution not being

everywhere straight, but larger than common, and having the skin bruised

and livid, and the pain being attended with a sense of weight. They

are, therefore, to be dislodged by means of suitable instruments, or

scraped out with the concave part of a specillum or of an ear-specillum

adapted for wounds; or, if they can be applied, a tooth-extractor or

a root-extractor may be used for pulling them out. In many instances

weapons lodged in the body lie concealed, and a long time after, when the

wounds are healed up, the part having suppurated bursts, and the weapon

drops out.

* * * * *

COMMENTARY. Hippocrates considered the extraction of weapons to be one

of the most important departments of surgery. It is to be fully learned,

he says, only by attaching oneself to a foreign army. (De Medico.) He

makes some interesting remarks on the subject in his treatise ‘De Capitis

Vulneribus.’

We must now attempt to give an abstract of Celsus’s very interesting

chapter on the Extraction of Weapons. Every weapon is to be extracted

either by the part at which it enters or by that to which it tends. If

it is not deep-seated, or if it has not passed any great vessels or

nerves, there is no better plan than to draw it out as it entered. But

if there is a greater space through which it must return than there

would be to push it out, and if it has already passed the vessels

and nerves, it will be better to open what remains undivided, and

extract it in this direction. If the weapon is to be drawn backwards,

the opening is to be enlarged by a scalpel, which will occasion less

inflammation and obstruction of the parts than if they are torn by the

weapon itself. In whichever way it be extracted great care ought to be

taken that no nerve, large vein, or artery be divided. If any of these

parts be detected in the wound they are to be drawn aside with a blunt

hook. These are his general directions. He then subjoins instructions

for extracting particular kinds of weapons. An arrow being a slender

body, and generally impelled with great force, is often lodged deep,

and is to be extracted for the most part rather by the opposite side to

which it entered, especially as it has barbs, which tear most if drawn

backwards. The flesh about the weapon is to be separated by means of a

suitable instrument, and then if the head (mucro) appear with the shaft

(arundo) fixed to it, the weapon is to be propelled until it can be laid

hold of at the opposite side and extracted; or if the shaft has fallen

out and only the iron remain lodged within, the head is to be seized

with the fingers or a forceps, and removed, and it is to be extracted

by the opening at which it entered, upon the same principles; for the

wound being enlarged, the weapon is to be drawn back by the shaft if it

remain, or otherwise by the iron itself. If there appear to be barbs

upon the arrow, and if short and small, they are to be broken off with

a pair of pincers; or, if larger and stronger, they are to be covered

with split writing-pens (fissis scriptoriis calamis) to prevent them from

tearing the flesh during extraction. And here we may mention, that the

common _calamus scriptorius_ of the ancients was made from an Egyptian

reed. See Montfauçon (Palæographia Græca, p. 3.) When the weapon which

is lodged in the body is large it must not be extracted by the opposite

side, as it would make the wound too large. He directs us to draw it

back by means of an instrument invented by Diocles, of which he gives a

description. Another class of weapons which must sometimes be extracted

are leaden balls, stones, or any such thing which breaks the skin, and

is buried within. In all such cases the wound, he says, must be enlarged

and the body extracted with a forceps. A complication which increases

the difficulty of extraction arises from the weapon being lodged in a

bone, or between two bones at a joint. When lodged in a bone it is to

be moved about until loosened, when it is to be grasped with a forceps

and extracted in the same way that a tooth is pulled out. It rarely

happens that the weapon cannot be removed in this way; but if it remain

fixed in the bone, it is to be struck with some iron instrument until

it be shaken from the place where it is lodged. When other means do not

succeed, the bone is to be perforated with a trephine. When the body is

lodged in a joint between two bones, the two members about the wound

are to be wrapped round with strips of cloth, or leathern thongs, and

thereby separated by pulling in opposite directions, by which means the

space between them will be slackened, and then the weapon may be removed

without difficulty. When the weapon had been poisoned, these things must

be done with all possible despatch, and the remedies applied which are

used when a poison has been swallowed, or a person has been stung by a

serpent. The wound from which a weapon has been extracted requires no

other treatment than what is applicable for ordinary injuries. (vii, 5.)

Albucasis borrows mostly from our author the account which he gives of

the construction of weapons and the symptoms occasioned by the wounds

which they inflict. He also relates some interesting cases of recovery

from very severe wounds. An arrow entered at the root of a man’s nose and

was extracted by Albucasis behind his ear; and the man recovered without

having sustained any injury to the eye. He extracted another large

arrow which had lodged deep below the eye of a Jew; and in this case

also the sight was not impaired. He extracted a barbed arrow which had

lodged in the throat of a Christian, by enlarging the wound, and the man

recovered. An arrow had lodged in a man’s belly, so that, at first sight,

Albucasis considered the case as hopeless; but, after thirty days, as no

mortal symptoms had supervened, he enlarged the wound and extracted the

weapon. He saw a man who had got an arrow lodged in his back; the wound

healed, but after an interval of seven years the weapon came out below

his buttocks. He knew a woman who had an arrow lodged in her belly, and

the wound healed, and the weapon never afterwards occasioned her any

inconvenience. He knew a man who had an arrow lodged in his face, and

the wound healed up, and never gave him much trouble. He relates that he

extracted an arrow which had been buried in the nose of a prince, after

making various fruitless attempts for the space of four months. He then

delivers general directions for the extraction of weapons, borrowing, as

usual, very freely from our author. When a weapon cannot readily be got

extracted at the time, he recommends us to let it alone until it become

loosened by the putrefaction of the surrounding parts. When impacted in a

bone, he directs us either to move it about until it is loosened, or to

perforate the bone with a trephine. When lodged in the cranium, it is to

be removed in like manner with a trephine, provided the dura mater is not

injured, for if it is wounded the case must not be interfered with. When

a weapon is lodged deep in any part of the body where there are no large

nerves, veins, or bones, he directs us to enlarge the wound and extract

the weapon; but if it has barbs, the fleshy parts about it must first be

carefully separated to prevent them from being torn. When a weapon passes

through a limb, or attaches one part of the body to another, he directs

us to cut off the part which projects, and then extraction may easily be

accomplished. If fastened in a bone, he advises us to turn it round so

as to loosen it; and if that does not suffice, he recommends us to leave

it for a few days, when it may be extracted without difficulty. If the

shaft or wooden part of a weapon be broken off, he directs us to apply to

the head an impellent instrument with a concave extremity, so as to adapt

itself to the form of the body which is to be extracted. When the weapon

is poisoned, he recommends us, if possible, to cut out the flesh around

it. When a weapon lodges in the breast, belly, bladder, or side, and can

be felt with a probe, he directs us to cut cautiously upon it, taking

care not to wound a vein or nerve. He concludes with giving drawings of

forcipes and impellents. (Chirurg. ii, 96.)

Rhases gives sensible directions for the management of these cases, but

they are so similar to those of our author that we need not dwell upon

them. If the size of the wound permit, he directs us to introduce a

forceps to the iron head and draw it out. If the opening be too small, he

recommends us to enlarge it. When the weapon has nearly passed through

the limb, he advises us to push it out at the opposite side. Thorns and

such like sharp things are to be removed by the application of extractive

plasters. (Ad Mans. vii, 25.)

Avicenna gives a literal translation of the present chapter of Paulus,

and supplies nothing additional of much interest. (iv, 4, 2, 10.)

The account given by Haly Abbas is full, but like that of Albucasis. He

mentions that he had seen cases in which an arrow had been lodged in the

intestines, and although fæces were discharged by the wound, the patient

recovered. He adds that others relate cases in which recovery took place

although the liver or omentum had been wounded. (Pract. ix, 15.)

The rules for the extraction of weapons laid down by Theodoricus and all

the earlier authorities are mostly copied from the ancient authors. (i,

22.)

It would be naturally expected that we should give some account in this

place of the surgery in the heroic ages, as far as it can be learned from

the poems of Homer and the Commentary of Eustathius. The Commentator

remarks that three methods of extracting weapons are mentioned by

Homer: 1. By evulsion or pulling the weapon backwards, as in the case

of Menelaus. (Iliad, iv, 214.) 2. By protrusion or pushing it forwards,

as in the case of Diomedes. (Iliad, v, 112.) 3. By enlarging the wound

and cutting out the weapon, as practised by Patroclus in the case of

Eurypylus. (Iliad, xi, 218.) He further remarks that it appears to have

been a common practice to suck a wound with the mouth; and, he adds,

that this method was still in use among a barbarous people in his days.

(Iliad, iv, 219.) The weapons used in the Trojan war were swords, spears

or javelins, stones flung by the hand or by a sling, hatchets or axes,

as used by the Trojans on certain occasions (Iliad, xii, 590), and

arrows. Eustathius remarks, however, that there would appear to have

been very few bowmen. In his Commentary on the Odyssey he states that

poisoned arrows were never employed in war, but only for killing wild

beasts. (Odyss. i, 260.) We believe that no weapons of iron were used in

the war of Troy, and that they were all made of copper. (See Jameson’s

Mineralogy, iii.) Little transpires from Homer with regard to the

internal treatment. In one place (Iliad, xi, 638) mention is made of a

mixture of wine and cheese having been given to a wounded warrior, which

practice, Eustathius says, had given rise to a variety of conjectures.

Some supposed that the wound in the case referred to was so slight as

not to render the administration of stimulants improper; others rather

believed that the loss of blood had been so great as to call for the use

of wine to support the strength. But many, he adds, were of opinion that

men in the heroic ages lived so temperately that their constitutions

readily bore things on extraordinary occasions, which in after ages

were reckoned to be of too inflammatory a nature. This explanation is

advocated by Athenæus. (Deipnos, i.) In the Odyssey, mention is made of

a hemorrhage being stopped by incantation, which shows, as Eustathius

remarks, that amulets and incantations were as ancient as the heroic ages.

SECT. LXXXIX.—ON FRACTURES AND THEIR DIFFERENCES.

Having described the surgical operations on the fleshy parts, we have

next to give an account of those which relate to the bones, I mean the

treatment of fractures and dislocations; for these also fall under

the department of surgery. And first, of fractures, beginning with

fractures of the bones of the head, because they hold an intermediate

place between the operations on the fleshy parts and the bones, and

because the cranium overtops all the other parts. In general terms,

then, a fracture is a division of a bone, or rupture, or excision of it,

produced by external violence. The differences of fractures are many.

A bone, then, is said to be fractured _raphanatim_, _scandulatim_, _in

unguem_, _polentatim_, and _per defractionem_. A fracture _raphanatim_

is a transverse one through the thickness of the bone, and is called

also _cucumeratim_ and _caulatim_, because cucumbers and cabbages break

in this way. _Scandulatim_ is a longitudinal fracture of a bone. _In

unguem_ is a fracture at one part straight, and at its extremity lunated,

and it is also called _arundatim_. _Polentatim_ is a fracture of a bone

into small pieces; and it is also called _nucatim_ by some: _Defractio_

or _præcisio_ is when part of a bone is taken away with tearing of the

skin, so that part is removed and is wanting. These are the differences

of fractures.

* * * * *

COMMENTARY. The following is a list of the ancient authors who have

treated of fractures and dislocations: Hippocrates (de Fracturis; de

Articulis; de Vulner. Capit.; Officina Medici); Galen (Comment. in

eosdem, Meth. Med. vi.); Celsus (viii); Oribasius (de Machinamentis,

&c.); Nicetæ Collectio ex Chirurg. Græc.; Apollonius Citiensis (Scholia

in Hippocrat. ed. Dietz); Avicenna (iv, 5, 23); Rhases (ad Mansor. vii,

26; Divis i, 140; Cont. xxix); Averrhoes (Collig. vii, 36); Avenzoar (ii,

6, 1); Haly Abbas (Pract. ix, ad finem.)

Hippocrates does not make use of the technical terms explained by our

author in this section, and Galen hints that he thinks his Master did

better in confining himself to words generally understood. Galen defines

only a few of these terms. He calls that kind of fracture in which the

end of a bone at an articulation is entirely taken away, _âbruptio_

(ἄπαγμα.) A transverse fracture with a complete separation of the broken

portions is called a fracture _caulatim_ (καυληδὸν.) A longitudinal

division not attended with an entire separation of the parts is called

_scandulatim_ (σχιδακηδὸν.) He thinks the later writers on the subject

who had introduced the use of such terms as _raphanatim_ (ῥαφανηδὸν) and

_polentatim_ (ἀλφιτηδὸν) had refined too much.

All the terms mentioned by our author occur in a fragment of Soranus,

preserved in the collection of Nicetas. They are also treated of very

elaborately in the fragments of Heliodorus, contained in the same

collection.

Celsus, who was studious of perspicuity and elegance, avoids all

technical terms as much as possible. He thus defines the varieties of

fractures. A bone, he says, may be split longitudinally like a piece of

wood, or it may be broken transversely or obliquely, and its ends may be

blunt or sharp, which last variety is the worst of all, as they cannot

be easily made to unite with the other parts, and are apt to wound the

muscles and nerves. Sometimes the bone is broken into fragments, and

in certain bones a fragment is occasionally separated entirely from the

broken bone.

The Arabians, especially Avicenna, Haly Abbas, and Albucasis, adopt

the terms used by our author. Albucasis remarks, that the fracture of

a bone is recognised by the derangement of the broken pieces, by their

projection, and the crepitus produced upon pressure. He says, however,

that there may be a fissure without derangement or crepitus.

SECT. XC.—ON FRACTURES OF THE BONES OF THE HEAD.

In particular, then, a fracture in the head is a division of the cranium,

sometimes simple and sometimes complex, occasioned by some external

violence. The differences of fractures of the head are these: a fissure,

an incision, an expression, a depression, an arched fracture, and, in

infants, a dent. A fissure, then, is a division of the skull, either

superficial or deep, when the inward bone is not removed out of its

place. An incision, or slash, (ἐγκοπὴ) is a division of the skull with

refraction of the fractured bone (if the injured bone be broken off some

call the affection _deasciatio_, i. e. as if done by a hatchet). An

expression is a division of a bone into many parts, with a sinking down

of the fractured pieces upon the membrane of the brain. A depression

(ἐγγίσωμα) is a division of a bone with a sinking downwards of the

fractured bone from its natural position towards the meninx. An arched

fracture (καμάρωσις), as Galen says, is a division of the skull attended

with elevation of the fractured pieces in the middle, and depression

around the edges of the sound parts, like as in expression. Such is

his opinion. Some enumerate also the capillary fracture, but it is a

very narrow fissure which eludes the senses, and therefore, being often

overlooked owing to the symptoms of it not being obvious, it occasions

death. An indentation is not a division of a bone, and, therefore, such

an injury is not properly called a fracture, but is, as it were, a

protrusion and bending of the skull inwardly, forming a hollow without

a solution of continuity, as when vessels made of copper, or the raw

hide of an ox, are struck on the outside. There are two different kinds

of indentation, for either the bone is depressed through its whole

thickness, so that often a separation of the membrane of the brain takes

place, or it is pressed upon by the skull throughout; or sometimes the

indentation does not affect the skull through its whole thickness but

only its outer plate down to the diploe. To these differences some also

add that by repercussion, which happens, say they, when a fracture of the

cranium takes place opposite to the part which received the blow. But

they are in a mistake, for what happens to glass vessels does not, as

they say, happen here; for, this happens to them from their being empty,

but the skull is full and otherwise strong. But when many other parts

of the head have been struck, as in a fall, and a fissure of the skull

takes place without a solution of continuity of the skin, an abscess

afterwards forms in it, and being opened, this fissure is discovered,

which appears to them to have been occasioned by the blow on the opposite

side; and this is to be cured like the fissure first mentioned. If a

fracture, then, occur in the head, it is discovered by the sharpness,

weight, hardness, or violent force of the body which struck it, and by

the symptoms which supervene upon the person who has been struck, such

as vertigo, loss of speech, and sudden prostration, more particularly if

it be a fracture with depression, or contusion, or expression, or the

internally-arched fracture, owing to the compression of the brain. It

is also discovered by its appearances to the senses; for if there be a

considerable division of the skin we ascertain the occurrence readily

thereby; but if there be no division, or a very narrow one, and we

suspect a fracture, we make an incision in the skin and ascertain it by

the sight, or by probing it with an instrument. If then it be any of the

other kinds of fracture it will readily be apparent, but if it is only

a narrow capillary fissure which eludes the sense, having poured on the

part some black liquid medicine, or the common writing ink, we scrape the

bone, for the fissure appears black, and we must go on scraping until

the symptoms of the fissure disappear; but if it extend to the membrane

we must desist from the scraping, and endeavour to ascertain whether

the membrane has separated from the bone or remains fixed. For if it

remain, the inflammation of the wound continues moderate, the patient

gets gradually freed from the fever, and the pus appears concocted. But

if the membrane has separated, the pains increase and the fever in like

manner, the bone changes colour, and then unconcocted pus is discharged;

and if the person who has the charge of it neglect the case, and has

not recourse to perforation, still more grievous symptoms will come on,

vomiting of bile, convulsions, disorder of intellect, and acute fever,

under which circumstances one must decline operating. But if these are

not present, and the membrane has not separated, and if the fracture be

a mere fissure, it may be cured by scraping alone, although it be of

considerable depth. If it extend to the diploe only it is to be scraped

down to it, or the broken bone removed, as will be described. If broken

into small pieces, these also are to be extracted with a convenient

instrument. And if the membrane separate, and you have treated the

patient from the commencement, and if it be winter, endeavour by all

means to effect the removal of the bone before the fourteenth day; but,

if in summer, before the seventh, while the afore-mentioned symptoms have

not come on you may operate in this way:

_The Operation._—Having first shaved the head about the wound, we make

two incisions intersecting one another at right angles like the Greek

letter Χ, one of them being the wound already existing; then dissecting

the four angles at the top, so that the bone about to be perforated may

be wholly laid bare, if there be bleeding we apply pledgets moistened

in oxycrate, but if not dry ones; and then applying a compress out of

wine and oil, we use a proper bandage; and next day, if no new symptom

supervene, we proceed to perforate the affected bone. Wherefore, having

placed the patient on a seat, or in a reclining posture suitable to the

wound, and stuffed his ears with wool in order to avoid the noise of the

perforation, we loosen the bandage from the wound, and having removed all

the dressings and sponged it, we direct two assistants with small twisted

bands to retract the four angles of the parts lying over the fracture,

and if the bone be weak, either naturally or from the fracture, we cut it

out with counter-perforators, beginning first with the broader ones and

changing to the narrower, and then using those which are of the form of

a specillum, striking gently with the mallet to avoid shaking the head.

But if the bone be strong it is to be first perforated with that kind of

perforators called abaptistæ, which have certain eminences projecting

a little above the point that prevent them from sinking down to the

membrane, and then, by using the chisels, we remove the fractured bone

not at once, but by pieces, if possible with the fingers, or otherwise

with a tooth forceps, or bone forceps, or hair-nippers, or some such

instrument. The space between the perforations should be as great as

the breadth of the largest head of a specillum, and its depth should be

until it is near the inner surface of the bone, taking care that the

perforator (trepan?) do not touch the membrane. Therefore, in order to

suit the thickness of the bone with the size of the perforator, several

ought to be previously prepared for the purpose. But if the fracture

extend only to the diploe the perforation should be carried no farther.

After the removal of the bone, having cleared away any asperity that

remained after the cutting of the bone with a carving instrument, or the

extremity of a perforator, using the meningo-phylax as a protector, and

bringing away carefully the small bones and spiculæ which remain, we

proceed to the application of the dressings. This is the more common,

and at the same time the easiest and least dangerous mode of operating;

but the method of performing it with a sort of incisor called lenticular

is greatly praised by Galen, being performed without perforation after

the part has been scraped all round with hollow chisels (κυκλίσκοι).

Wherefore he says thus: “If you have once laid bare the place, then

applying the incisor, which has a projection at the extremity like a

lenticular, blunt and smooth, but sharp longitudinally, when you apply

the broad part of the lenticular to the meninx, divide the cranium by

striking with the small hammer. For we have all that we require in such

operations; for the membrane, even if the operator were half asleep,

could not be wounded being in contact only with the broad part of the

lenticular, and if anything adhere to the cranium, the round part of the

lenticular removes its adhesion without trouble. And behind it follows

the incisor, or knife itself, dividing the skull; so that is impossible

to discover another mode of operating more free from danger or more

expeditious.” But the mode of operating with saws and the instruments

called chœnicides or modioli (trepans?) is condemned by the moderns as a

bad one, and the operation may be done as we described for fissure. The

same mode of removing bones will be applicable in the other fractures

of the cranium. But regarding the amount of bones requiring extraction

Galen informs us, writing thus plainly: “What parts of a fractured bone

are to be removed I will now explain to you in order. When it is greatly

bruised it is to be taken out entire, but if certain fissures extend from

it farther, as sometimes they appear to do, we must not pursue them to

their termination, well knowing that no harm will result from them if

everything else be properly done.” After the operation, having dipped

a simple linen rag of the size of the wound in oil of roses, we lay it

over the membrane as a cover, and in like manner, having dipped a small

ball of wool in oil of roses, we put it over the aforesaid rag, and then

having moistened a doubled compress in wine and oil, or in the same oil

of roses, we apply it to the whole wound, taking care that they be not

too heavy for the meninx. We then have recourse to a broad bandage, which

also must not be made tight, but so as merely to preserve the pledgets.

And the regimen is to be what is called anti-inflammatory and such as

is applicable for fevers, frequently bathing the membrane with oil of

roses. After the third day loosing them and sponging the part we pursue

the treatment applicable for recent wounds and the anti-inflammatory;

sprinkling upon the meninx some of the powders called cephalics until it

incarnate, and sometimes scraping the bone, if it require it, on account

of certain projecting spiculæ, or for the sake of incarnation itself. And

we may apply medicines of the ingredients recommended for wounds.

_On inflammation of the membrane of the brain._ Often after the operation

the membrane is inflamed, so as not only to rise above the skull but

likewise above the skin, and is attended with hardness, and obstructs

the natural pulsatory motion of the brain, in which case convulsions and

other severe symptoms, or death, for the most part supervene. It becomes

inflamed either from the irritation of some sharp projecting piece of

bone, or from the weight of the dressings, or from cold, or from eating

too much, or from drinking wine, or some other cause not apparent. If

then the cause be obvious it is to be speedily removed, or, if it is not,

it will be proper to contend strenuously against it, either by having

recourse to venesection, if nothing prohibit it, or to a diet suitable

for inflammation. We must also use topical remedies, such as warm

embrocations with hot rose-oil, and bathing the part with the decoction

of marshmallows, or of fenugreek, of linseed, of camomile, and such like,

and cataplasms of raw barley flour, or of linseed with the aforementioned

decoction and the grease of a fowl; and irrigations with wool to be

poured upon the head and occiput, and some anti-inflammatory oil is also

to be poured into the meatus auditorius. The viscera also are not to be

neglected, but suitable cataplasms are to be applied to them. And care is

to be taken of the whole body, putting the patients into warm baths and

anointing them. If the inflammation continues and nothing else prohibit,

Hippocrates directs us to purge them with cholagogue medicines.

_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.