When the arm is broken Hippocrates makes the extension thus: he says,

“We must take an oblong piece of wood, such as that which is put into

the holes at the end of spades, and fastening ropes to its extremities,

suspend it transversely from some beam, and placing the man upon some

elevated object more erect than what is called the erect sleeping

posture, we pass his hand over the above-mentioned piece of wood, so that

the middle of the wood may be fitted to the armpit, and his arm being

bent at a right angle, an assistant stooping down takes hold of the hand,

and then some heavy object, such as a stone, a leaden ball, or the like,

is to be fastened to the elbow, and being allowed to hang suspended, in

this way you must set the fracture, or instead of a weight an assistant

may pull down the arm, and instead of the above-mentioned piece of

wood some use the step of a ladder.” Soranus, however, proceeds thus:

Having placed the man in a chair, or, which is better, as it occasions

less disturbance, in a supine posture, then having put a ligature round

the wrist and suspended it from the neck so as to preserve its angular

figure, we direct two assistants, the one to apply his fingers below

the fracture and the other above, and thus to make the extension. Or

if we require stronger pulling we apply two equal pieces of thong to

the arm, the one above the fracture and the other below, and giving one

of the pieces of thong to the assistant who stands above the patient’s

head, and the other to the one at his feet, we order them to make

counter-extension. If the fracture be near the top of the shoulder we

apply the middle of the thong to the armpit and direct the assistant

at the head to hold it, and, while the other pulls in the opposite

direction, we make the counter-extension as above. And when the fracture

is at the elbow, the ligature is to be applied there or at the wrist. The

bones of the fracture being properly set, the extension is to be relaxed,

and it is to be bound up according to the method of Hippocrates. When

the fracture is free from inflammation and recent, we must use linen

bandages of a proper length, and three or four fingers in breadth, which

have been soaked in water or oxycrate, but when there is inflammation,

thin soft pieces of wool steeped in oil are to be used. And if the

fracture be at the middle of the arm the bandaging must commence at the

fracture, and after two or three turns the bandaging is to be carried

upwards, in order, as he says, that the overflow of blood to the part

may be intercepted; and it is to terminate there. A second bandage is

then to be applied with its head at the fracture, and, having done as in

the former case, carry it from above downwards, and again reverting from

thence upwards let it terminate there. There should be a moderate degree

of tightness according to our own feeling and that of the patient. If the

fracture be near the top of the shoulder, the first bandage should take

in the acromion, scapula, and sternum, so as to form what is called the

crane bandage. The second one is to extend to the elbow, and reverting

from thence to the upper parts it is to take in, with the acromion, the

scapula and sternum, like the first bandage. If the fracture be at the

elbow, the fore-arm is to be taken in with the bandage, the figure of

the elbow-joint being preserved. And so in like manner with the other

members, such as the fore-arm, the thigh, and the leg; and when the

fracture is in any part near a joint, and not in the middle of the limb,

the joint is to be bound along with it. After the bandaging the moderns

immediately apply splints, in order to preserve the bones which have been

set in their proper shape, tightening them agreeably to the patient’s

feeling and the swelling occasioned by the inflammation. But the

ancients did not apply the splints until after the seventh day, within

which period, as the inflammation had declined, the limb had become

less swelled. Hippocrates orders the bandages to be loosed every three

days, lest, owing to the part being constantly covered up, distension

and pruritus should come on, and that the insensible perspiration might

not be obstructed after the bone has become firm; for that by these

means not only does a painful pruritus take place in certain cases, but

ulceration of the skin is occasioned by the acrimony of the sanious

humours. He directs us, therefore, to bathe with tepid water, so as to

dispel the humours, but after the seventh day to loose the bandages at

greater intervals, because the parts no longer require the expulsion of

the humours; the formation of callus thus goes on properly. The splints

are to be applied in this manner. Compresses, thrice folded and dipped

in oil, are to be put upon the bandages, and if the limb be of equal

thickness this is to be done even; but if it is of unequal thickness,

the hollow parts are to be filled up with the compresses so as to make

the arm of equal thickness for the application of the splints; then the

splints being wrapped with a moderate quantity of wool or flax, we apply

them around the fracture, being not more than a finger’s breadth distant

from one another, binding them moderately tight, and taking care, as

much as possible, that the splints do not come in contact with a joint,

and being more particularly careful of the inner part of the joint, for

there they sometimes occasion ulcers and inflammations of tendons. But

there the bandaging must be made slacker; and stronger, on the other

hand, where the fracture swells up. It is better that the chest should

be moderately bound with the arm, lest by its motions it should derange

the position. If inflammation should come on (which we know by the

swelling and redness around, and from the limb being more tightly bound

than formerly), or if the fracture become deranged, or if, without these

occurring, the bandages become slacker, or, on the other hand, tighter

than proper, the bandages are to be loosed and everything rectified.

The patient is to be laid in a supine position, with his hand upon his

stomach, and a soft pillow is to be placed under the arm having a skin

upon it to receive the embrocations which run from it. The part is to

be bathed with warm oil every day, more especially if inflammation be

present, and during the time of inflammation he is to be fed sparingly,

and afterwards moderately, to promote the growth of callus. He must

lie quiet until the callus is formed, which, in the arm and leg, takes

place about the fortieth day. After this the bandages are to be loosed,

and after using the bath he is to be treated with plasters suitable to

fractures. This mode of procedure is applicable in almost all cases of

fracture of limbs.

* * * * *

COMMENTARY. Hippocrates’s account of fracture of the os humeri, as quoted

by Paulus, is from the eighth chapter of his work ‘De Fracturis,’ but our

author has used considerable liberties in making the extract. The mode of

using the piece of wood for suspending the arm is easily understood, from

his own description without the commentary of Galen. (See p. 541, t. v,

ed. Basil.) In the edition by Littré it is, moreover, well illustrated

by a drawing. (T. iii, p. 445.) He directs the splints not to be applied

until the seventh day, in order to give time for the inflammation and

swelling to subside. He says, the bone gets consolidated in about forty

days. He justly remarks, that when distortion of the arm takes place it

is to the outside, that is to say, backwards. His method of bandaging

for fractures of the arm and fore-arm was the same. He directs us in the

first place to put a cerate to the part, and then to apply the first

bandage, beginning at the fracture, and carrying it two or three turns

upwards, so as to prevent the blood from falling down into the part. The

second bandage is to commence above the fracture, and is to be carried

downwards. Afterwards splenia or oblong compresses, spread with cerate,

are to be laid over them, and these are to be secured by strips of

linen cloth. These bandages are to be removed when they become slack,

generally about the third day. On the seventh the ferulæ or splints

are to be applied, the limb by that time having lost its swelling, and

they are to be allowed to remain until the 24th day after the accident.

When swellings arise on any part of a limb from pressure, they are to

be anointed with cerate or wine and oil, and wrapped in soft wool; and

if the splints be hurting the limb they are to be removed for a time.

(De Fract. 21.) When the bandages are taken off, he directs that hot

water should be poured upon the limb. He recommends a spare diet unless

there be a wound of the integuments. (De Fract. and Galen. Comment.)

It may be proper to give some more account of the splenia and ferulæ

(νάρθηκες), used by Hippocrates in fractures of the extremities. In his

work entitled ‘The Surgeon’s Shop’ (ἰήτρειον), he directs the length of

the splenia to be made proportionate to the part which they are applied

to, their breadth three fingers, their thickness three or four folds,

and their number such as to encircle the limb without doing either more

or less. It appears quite clear that they consisted of folded linen.

The intention of them was to give some support to the part. He directs

the splints to be smooth, even, concave, and somewhat shorter than the

length of the bandages, in order not to hurt the sound skin. It appears,

then, that the whole apparatus used by Hippocrates in the treatment of

fractures, consisted, 1st, of two under-bandages, 2d, of splenia or

folded compresses, 3d, of the ferulæ or splints, 4th, of an outer bandage

to secure the splints. With regard to the cerate used in the Hippocratic

system of bandaging, it is important to state that, from a passage in his

treatise, ‘Officina Medici,’ it would appear that the cerate was not only

applied to the skin, but that, for the sake of greater security, every

fold of the bandages was rubbed with it. See Galen’s Commentary on the

work, (T. v. p. 692, ed. Basil,) and Littré’s Hippocrates, (T. iii, p.

316.) It remains to be mentioned, that the bandages were secured by means

of a thread or with a needle. (Off. Med. 8.) Nothing can surpass the

judgment and precision with which Hippocrates lays down his rules for the

application of the bandages. (Ibid.)

Galen describes the splenia as being pieces of linen folded three or

four times, which are to be laid along the arm longitudinally. He

directs us to spread them with cerate. He says that they support the

limb. He says distinctly that all the folds of the bandages should be

rubbed with cerate in order to give greater support. All his directions

for the treatment of a broken limb are most judicious. When at first

there is much pain and inflammation, he recommends bleeding and purging;

but when the callus begins to form, he directs the patient to use a

nourishing diet. Spiculæ and scales of bone are in general to be allowed

to exfoliate of themselves, and not removed forcibly by the surgeon.

(Comment. and Fragment. ap. Nicetæ Collect.)

Celsus lays down the principles of treatment in fractures of the arm,

fore-arm, thigh, and leg so circumstantially, that we can afford room

only for an outline of them. He recommends no time to be lost in getting

the displaced parts properly reduced. For this purpose, if the limb be

strong, two assistants may be required to pull in contrary directions;

and if other means do not succeed, thongs of leather, or linen bandages,

may be attached to each end of the broken limb to make extension and

counter-extension with them. When the ends of the bone have been

adjusted, (which is known by the pain and deformity being removed,)

the limb is to be wrapped in linen cloths folded two or three times,

and dipped in wine and oil. Six bandages or rollers (fasciæ) are then

to be applied. The first is the shortest, which is to be three times

rolled round the limb upwards in a spiral direction, and three times

generally will be sufficient. The second must be one half longer, and is

to commence wherever the bone projects; or if there be no projection, at

any part of the fracture; and is to be carried first downwards and then

upwards, so as to terminate a little above the former. These are to be

secured by a broader linen cloth spread with cerate. The third and fourth

bandages are then to be applied upon the principle, that the latter is

to be put on in the contrary direction to the former; and further, it

is to be observed that the third bandage terminates below, whereas all

the others terminate above the fracture. Upon the whole, he adds, it

is better to secure the limb with many than with tight bandages, these

being apt to occasion mortification. When properly applied they ought

not to be loose on the first day, yet such as not to give pain; slacker

on the second, and loose on the third day. They are then to be removed

and again applied, and a fifth bandage is now to be superadded to them;

and again, these are to be taken off on the fifth day, and six bandages

put on, in such a manner that the third and fifth may terminate below,

and all the others above. Whenever the bandages are taken off, the limb

is to be bathed with hot water, and proper fomentations applied to allay

the inflammation, which will generally be found to have subsided about

the seventh or ninth day. Then the bandages are again to be put on as

directed above, and ferulæ or splints are also to be added, taking

care to put on a stronger and broader splint at the side to which the

fractured bone has a tendency to be protruded. These must all be rounded

where they come in contact with a joint, to avoid injuring it; they are

only to be secured with such tightness as to keep the bones in their

place, and when they get loose their thongs are to be tightened. The

bandages are to be removed gradually. These are his general directions

for all fractures of the extremities, and it is to be remarked that his

mode of treatment is essentially the same as that of Hippocrates. He

afterwards describes at considerable length the method of setting the

broken ends of the os humeri. After this is accomplished he directs us to

bind the arm gently to the side. With regard to the splints, he properly

recommends the longest to be applied externally; shorter ones on the

brawn of the arm (over the biceps muscle?), and the shortest under the

armpit. He advises us to remove them frequently when the fracture is

situated near the fore-arm; and at these times the arm is to be bathed

with hot water, and rubbed with a soft cerate.

It will be seen that the methods of Hippocrates and Celsus, although the

same in principle, differ in the following respects. Hippocrates uses

three bandages, Celsus six: Hippocrates uses small compresses, Celsus

large pieces of linen: Hippocrates uses cerate, Celsus wine and oil.

The Arabians conducted the treatment in much the same way as the Greeks.

In cases of fracture of the arm, Albucasis directs us to make the

bandages of soft, thin linen cloth; but of broader and firmer linen if

the thigh or leg is to be treated. Below them is to be applied a smooth

cloth spread with a suitable liniment. After the under bandages have been

put on in the manner already described, the splints are to be applied,

provided no swelling nor inflammation be present, for in that case they

are to be deferred for a few days. These splints are to be constructed

from the middle part of the alcanna, or of pine, or of the palm-tree, or

of a tree which he calls _calingi_.

Avicenna directs us to form the splints of the wood of alcanna, or of

oleander, or of pomegranate tree, or the like. The length of the splints

is to be made equal to that of the limb, and their greatest breadth about

three fingers. They are to be secured with another bandage and pieces

of tape made of linen cloth. There is to be an interval of a finger’s

breadth between each splint. He says, it is best to apply four splints of

such a length as to reach from joint to joint. They are to be smooth and

even so as not to injure any part. In cases of fracture of the os humeri

he directs us to surround the nearest joint with the bandages, and, if

the fracture be in the middle, to make them take in both extremities. He

recommends us to foment the limb with vinegar and water, or water alone.

The arm is to be fastened to the side and the hand laid on the stomach.

Haly Abbas, in giving directions for the treatment of fractures in

general, recommends the splints to be made of pieces of alcanna, or any

hard wood. Afterwards he directs the limb to be laid upon a table having

a pad (pannus) placed on it, which last is to be secured with fillets. He

gives particular directions not to apply the splints over the processes

of bones, and when inflammation comes on he forbids splints to be used

at all; in that case the patient is to be kept upon restricted diet. The

bandages are to be removed in the course of three days.

The directions given by the experienced Rhases about the bandages and

splints are very similar to our author’s, and therefore need not be

repeated.

See an account of the ancient splenia, or compresses, and of the ferulæ,

or splints, in Scultet’s ‘Arsenal de Chirurgie.’ (29, 30.) See also Van

Swieten’s ‘Commentary,’ (354.) Van Swieten remarks, that although the

eighteen-tailed bandage be supposed a modern invention, a similar one is

described by Hippocrates, (De Fract.) and by Galen in his commentaries on

the same.

Le Clerc gives a pretty full description of the Celsian method

of treating fractures. (Hist. de la Méd.) See also Fabricius ab

Aquapendente (Œuv. Chir. ii, 3, and i, 4). We are certain it will be

generally admitted that the waxed apparatus of the ancients in the case

of fractures was probably quite as efficacious as the starched bandages

which have been introduced of late years with so much advantage.

SECT. C.—ON THE ULNA AND RADIUS.

The ulna and radius are sometimes both fractured together, and sometimes

one of them only, either in the middle or at one end, as at the elbow or

wrist. The worst of all is when both are fractured together, after that

the ulna alone, but a fractured radius is, of all cases, the easiest

cured. For, although it be larger than the ulna, yet it has this bone

as a base and support to it. If only one be fractured, the extension

must be applied principally to it, but if both, they are to be stretched

evenly, the arm being put into an angular position, so that the thumb may

be higher than the fingers, and the little finger lower than any of the

others, for thus the ulna will be placed under the radius. If stronger

extension be required, especially when both are broken, we must apply

it not only with the hands but also with ligatures, as described when

treating of the arm; and everything relative to the bandaging and the

subsequent treatment, with the application of the splints, is to be done

as in that case until callus is formed. The bones of the fore-arm have

their callus formed in about thirty days at most. And the fore-arm is to

be otherwise arranged in the same manner as the arm, with the exception

of those things which are put under it.

* * * * *

COMMENTARY. Whoever would wish to see a full exposition of the principles

upon which these cases of fracture ought to be conducted may consult

the first part of Hippocrates’s work. (De Fracturis.) He shows, with a

singular precision, the disadvantages of the prone and supine positions

of the hand, both of which, it appears, had their advocates in ancient

times. The bandages, compresses, and splints are to be applied in the

manner described in the preceding section. He insists strongly on the

necessity of having the arm and wrist carefully suspended in a broad

soft sling, and that the hand be placed neither too high nor too low.

Hippocrates takes notice of fracture of the olecranon, as will be

explained afterwards.

Oribasius gives a description and drawing of a laqueus calculated to

retain the splints, and secure the fore-arm in cases of fracture. (De

Laqueis, 2.)

Celsus directs us to sling the arm, with the thumb a little inclined,

towards the breast, in a convenient napkin (mitella), the broad part

being applied to the arm, and the narrow ends tied behind the neck.

Albucasis treats of this case of fracture very accurately. He calls the

ulna the larger of the bones. He directs the arm to be suspended with the

thumb uppermost. When the fractured pieces of bone occasion irritation,

he advises us to make an incision and extract them. When a troublesome

pruritus seizes the arm, he recommends us to remove the bandages and

bathe with hot water.

Rhases gives proper directions about not applying the bandages too tight

or too slack. When the hand swells he recommends them to be slackened.

The accounts given by Avicenna and Haly Abbas are quite similar to our

author’s. Avicenna cautions us not to make the splints too long lest

they hurt the hand. None of the Arabians, we believe, have noticed the

fracture of the olecranon. Like most imitators, they often fall short of

their originals.

SECT. CI.—ON THE HAND AND ITS FINGERS.

The bones of the carpus, metacarpus, and of the phalanges of the fingers,

being of a spongy and porous nature, are often crushed but rarely

fractured. The patient then being placed on a high seat, we are to direct

him to lay his hand prone upon an even table, and the fractured pieces

being stretched by an assistant, we arrange them with two fingers, that

is to say, the thumb and the index-finger. A tight bandage is to be used

at the time that inflammation prevails, for, owing to the porous nature

of the bones, a redundance of callus is formed. If the phalanx or finger

be simply broken, and it be the large one, called also the thumb, after

suitable bandaging, it is to be bound to the palm that it may be kept

at rest; but if any of the others, as for example, the index or little

finger, it is to be bound along with the one next to it, or if one of

the middle, it may be bound along with that on either side, or all may

be bound altogether. For they are thus kept best at rest, as if the

fractured bones had been supported with splints.

* * * * *

COMMENTARY. Hippocrates recommends the general treatment applicable in

all cases of fracture, with the exception of the splint, which, as Galen

explains, is not admissible in these cases.

Celsus says, it will be sufficient when a finger is broken to bind it to

one piece of splint (surculum) after the inflammation has subsided.

Albucasis recommends one small splint to be applied upon the thumb when

it is fractured. If one of the fingers be broken, it is to be bound up

with the others, or one small piece of splint may be used. Avicenna,

Rhases, and Haly Abbas treat distinctly of these accidents, but supply no

additional information.

SECT. CII.—ON THE THIGH.

The case of a broken thigh is analogous to that of the arm, but in

particular, a fractured thigh is mostly deranged forwards and outwards,

for the bone is naturally flattened on those sides. It is to be set by

the hands, with ligatures, and even cords applied, the one above and

the other below the fracture. When the fracture takes place at one end,

if at the head of the thigh, the middle part of a thong wrapped round

with wool, so that it may not cut the parts there, is to be applied to

the perinæum, and the ends of it brought up to the head and given to an

assistant to hold, and applying a ligature below the fracture, we give

the ends of it to another assistant to make extension. If it is fractured

near the knee, we apply the ligature immediately above the fracture, and

give the ends to an assistant, with which to make extension upwards;

and while we put a ligature round the knee to secure it, and while the

patient lies thus, with his leg extended, we arrange the fracture.

Pieces of bone which irritate the parts, as has been often said, are to

be taken out from above; and the rest of the treatment we have already

described in the section on the arm. The thigh gets consolidated within

fifty days. The manner of arranging it afterwards will be described after

delivering the treatment of the whole leg.

* * * * *

COMMENTARY. Hippocrates has correctly stated the difficulty attending

the management of a fractured thigh-bone, and the disgrace which an

ill-managed case entails upon the surgeon. He directs him to make

extension and counter-extension, and to apply the bandages and splints

in the manner formerly described. He recommends a few turns of the

bandage to be brought about the loins, in order to prevent the skin at

the top of the thigh from being injured by the splints. He points out

the extreme importance of attending to the position of the heel, as if

improperly laid, it is capable of deranging the fracture entirely. It

gets consolidated, he says, in about fifty days. (De Fracturis.)

Celsus pronounces it impossible to heal a fractured thigh-bone without

deformity. The patient, he says, must ever afterwards tread upon his

toes; and yet, he adds, the case will be worse if neglected.

Albucasis holds forth greater encouragement. He describes the process

of treatment very minutely, directing the surgeon to stuff up all the

hollow places in the limb with soft pads before applying the splints. He

also recommends him to surround the whole limb with a bandage from the

heel to the nates. We are inclined to think, although the language of

his _barbarous_ translator is not sufficiently precise, that his splints

extended the whole length of the limb.

Rhases, and we believe, he alone of all the ancient authorities, directs

the thigh to be laid in a somewhat bent position, and for this purpose he

recommends something suitable to be put below it.

Haly Abbas and Avicenna, as usual, borrow everything from our author.

SECT. CIII.—ON THE PATELLA.

The patella is a porous bone kept firmly in its place by the parts above

and below, and is often crushed but seldom fractured. It undergoes

fracture also through its thickness, and is broken into small pieces,

with or without a wound. The symptoms are obvious,—a solution of

continuity, a hollow, and crepitation. The fracture is put in order by

extending the leg, for thus the divided portions may be brought together

with the fingers, until the lips of the fracture mutually touch, and are

united to one another, and fractured pieces, when separated, are thus

arranged together. For even if callus does not take place, owing to the

parts being drawn in different directions by the muscles and tendons from

the thigh and leg, which are inserted into it, yet the separation is much

diminished. But it occasions much lameness to the patients; for, when

they attempt to labour, the knee cannot sustain them long, and in walking

their ascent upwards is impeded; but in moving along a plain their

lameness is not perceptible. In ascending, however, as the knee cannot

bend in raising and setting down the leg, the lameness becomes apparent.

And in this case any bone that irritates is to be taken out where it

protrudes, and proper treatment applied.

* * * * *

COMMENTARY. None of the ancient authorities have given so full an account

of this accident as our author. Hippocrates and Celsus have omitted it

altogether. Soranus merely gives the symptoms, namely, a hollowness in

the part and crepitus.

Albucasis recommends us, after arranging the broken pieces of bone, to

apply a round splint over it if necessary. Rhases likewise speaks of

applying a well-stuffed splint. Haly’s account is distinct but similar to

our author’s, from which it is abridged. Neither he nor Avicenna makes

any mention of a splint.

SECT. CIV.—ON THE LEG.

The treatment of fractures of the leg corresponds with that of the

fore-arm, for it consists of two bones, the thicker of which bears

the same name (tibia), and the small one, from its resemblance, has

been called fibula. Its fractures also admit the same varieties, being

deranged on all sides when both the bones are broken together, and to

three when only one, namely, within, without, and the tibia backwards and

the fibula forwards. Wherefore it is to be set in the same manner by the

hands, or ligatures, sometimes applied to the leg itself, and sometimes

to the thigh, (for the knee being a strong joint can bear the extension

uninjured,) and ligatures are to be applied likewise below the fracture,

as we mentioned under the head of the fore-arm. The case is to be managed

otherwise, as described by us in the section on the arm.

* * * * *

COMMENTARY. Hippocrates has treated of this case at considerable length.

The bandages are to be applied as formerly described, and the leg laid on

a level board with a soft cushion under it. It is clear that he did not

approve of the bent position of the limb. The splints are to be applied

on the seventh or eleventh day. Of the fractures of a single bone, that

of the tibia, he remarks, is the worse, a fractured fibula being easily

managed. He gives particular directions to attend to the state of the

heel.

Celsus treats of these fractures in general terms, like those of the

fore-arm. Albucasis directs us to apply two splints made of the wood of

pines or palms, of moderate thickness, and of such length as to extend

from the knee to the feet. One of these is to be placed below the leg and

the other above; and they are to be tied in three places, namely, at the

extremities and in the middle.

The other Arabians treat of these fractures in more general terms.

SECT. CV.—ON THE FOOT.

The astragalus cannot be fractured by any means, being guarded by bodies

on all hands; by the tibia, the fibula, and the os cuboides. But the

scaphoides, the bones of the tarsus, and those of the toes, and the

cuboides itself, are fractured like those of the carpus, metacarpus, and

the fingers of the hand, so that what was said of them is applicable here

and need not be repeated.

* * * * *

COMMENTARY. Hippocrates remarks that these bones can only be fractured

by some sharp and heavy body. They are to be treated like fractures

in general, only that they do not require splints. He recommends the

recumbent position with the foot somewhat elevated, and states, in strong

terms, the mischief brought on by unseasonable attempts at walking. (De

Fracturis, 10.) Galen, in his Commentary, gives an accurate anatomical

description of the bones of the foot.

Celsus is very brief on this case. He conducts the treatment on general

principles. Albucasis directs us to make the patient put his foot on the

ground, the surgeon is then to place one of his feet on it and stand on

it. By this means the derangement of the bones will be rectified. He

approves of a splint to the sole.

We find nothing worthy of notice in the works of the other authorities.

SECT. CVI.—ON THE ARRANGEMENT OF THE LIMB.

When the thigh or leg is fractured, the manner of arranging the limb will

be as important a consideration to you as the other treatment. For the

evenness of the fractured parts is especially preserved by this means

when properly performed. Some, therefore, lay the fractured part upon a

canal, either of wood or of earthenware, or else they lay the whole limb

upon it; others apply it only in cases of fracture with a wound, because,

say they, these cannot be bound with splints. But the moderns altogether

reject the use of these canals for many reasons, but more especially on

account of the pressure occasioned by their hardness. Nor is it improper

to apply splints to fractured limbs with a wound, as we shall show

afterwards. Let the patient, then, lie upon his back, and let a thick

garment, equal to the limb in length, be laid under it, more especially

where the fracture is, and let both its ends be convoluted and wrapped

round so as to resemble the canal in its middle longitudinal cavity, and

let it be covered with a soft skin for receiving the embrocations; and

then let the limb be fitted to this canal-like cavity, and let other

garments or wool be applied on both sides to prevent the limb from being

moved to the sides. And let a small board, covered with rags for sake

of softness, be fastened to the sole of the foot; and, for the sake of

greater security, let the middle of two or three ligatures be applied

under this canal-like garment, and let the broken limb be lightly bound

along with it. But if the patient be unable to restrain himself from

drawing in his leg, his foot should be fastened to the board by means of

ligatures around the ankle, so that he may be prevented even from drawing

in his leg involuntarily in his sleep. Some likewise cut out a hole in

the middle of the bed, that the patient may void his urine and fæces by

it without requiring to be moved until the callus has become formed.

* * * * *

COMMENTARY. We have already mentioned that Hippocrates approved of the

straight position of the limb. With respect to the _canals_ (σωλῆνες)

mentioned also by our author he expresses himself in equivocal terms. He

says that they prove useful, but not to the extent generally believed. He

properly remarks that they do not prevent the body from being moved, and

that consequently they cannot be supposed capable of securing the limb

entirely from derangement. He is decidedly of opinion that unless they

extend from above the ham to the heel they do no good in fractures of the

leg. (De Fracturis, 16, ed. Littré.)

Celsus gives the following description of the _canals_: “Is canalis et

inferiore parte foramina habere, per quæ, si quis humor excesserit,

descendat: et a planta moram, quæ simid et sustineat eam, et delabi non

patiatur: et a lateribus cava, per quæ loris datis, moræ quædam crus

femurque, ut collocatum est, detineant.” Galen, in his Commentary on

Hippocrates (l. c.) describes these machines as being round externally

and hollow within, so as to inclose the limb all around:—περιλαμβάνει τὸ

σκέλος ὅλον ἐν κύκλῳ. From these words one might think that the canal of

which he speaks was a complete cylinder or cone. But from our author’s

direction to lay the limb upon the canal, it would appear that the

machine he speaks of was open above, and as such it is represented and

described by Scultet (Arsenal de Chirurg. xxii, 6.) His words are: “Il

faut que le canal embrasse plus de la moitié du membre;” this, therefore,

is a sort of _trough_. Sprengel calls it a box (_boîte_, Fr. edit.)

Littré translates it by _gouttière_, _l. c._ For an account of these and

other machines anciently used in fractures of the lower extremities, see

Van Swieten (Comment. 354), and Heister (Surgery, ix, 9.) Brunus and

Theodoricus make mention of these _canals_, but do not much approve of

them.

Galen informs us that the canals were made of different kinds of wood.

He speaks of a surgeon in his time who made them from the wood of the

phillyrea. He makes mention of a method of supplying their place by means

of a bolster laid below the limb and tied round it with fillets. (Nicetæ

Collect. and Comment. l. c.)

Avicenna and Albucasis take notice of these machines, but neither of

them with approbation. They also speak of securing the limb in the way

described by our author.

The canals would appear to be the machines which Rhases mentions by the

name of _barangi_. (Cont. xxix.)

SECT. CVII.—ON FRACTURES COMPLICATED WITH A WOUND.

When a fracture is attended with a wound, if there be a hemorrhage it

is to be first stopped; and if there be inflammation, we must use the

applications suitable to it; and if there be contusion of the flesh,

we must scarify the flesh to remove all apprehension of gangrene; or

if gangrene or any other spreading mortification has come on, we must

meet it with suitable remedies. The treatment of each of these cases you

have had delivered in the Fourth Book. When none of these symptoms is

present, nor much of the bone exposed, we may use hooks and sutures,

and effect the cure by the treatment for recent wounds, having first cut

out any broken pieces of bone which move about and produce irritation.

But if a large bone project, which, for its size, cannot be brought into

contact by the extension, it will require consideration. Hippocrates,

then, in fractures of the thigh and arm, dissuades from replacing at

once the protruding bones, predicting danger from it, owing to the

inflammation or perhaps spasm of the muscles and nerves which are apt

to be brought on by the extension. But time has shown that this attempt

will sometimes succeed. Of whatever bones, therefore, we endeavour to

replace the protruded ends, we must not meddle with them when in a state

of inflammation, but on the first day, before inflammation has come on,

or about the ninth day, when the inflammation has gone off. We may set

them by an instrument called the lever. It is an iron instrument about

seven or eight fingers’ breadth in length, and of moderate thickness

that it may not bend during the operation; with its extremity sharp,

broad, and moderately bent. Its sharp extremity, then, is to be put under

the protruding prominence of the bone, and by pushing at the other end

while moderate extension of the limb is made, we bring the extremities

of the fracture together; or, if we cannot do so, we must cut off the

projections by counter-perforators (chisels), or saw them off in the

manner described when treating of fistulæ. Having removed the spiculæ

of bones and set the limb aright, we cure the wound by dressing with

pledgets. But in those members which are double or in pairs, we must take

care when the bones of either of them are sawn off, that no contraction

of the limb take place, but that it be kept of its proper length by

extension. The bandaging is to be thus applied: the circular folds are

to be arranged on both sides of the wound, and oblique ones according to

the length of the sore, so that they may intersect one another in the

form of the Greek letter Χ, and prevent the lips of it from gaping. And

when the ulcer is foul, we must apply dressing with cleansing ointments;

but if clean, with incarnating, and the other articles of known efficacy.

Hippocrates used the pitch-plaster, which is said to have been the same

as the ointment, tetrapharmacon, called also basilicon. After the sore

has incarnated we apply splints. Some apply them from the first, taking

care not to hurt the parts about the ulcer, and tightening them according

to necessity, or again slackening them. When a scale of bone is going to

exfoliate, which we ascertain from the discharge being more copious and

thin, we must remove the loose fungous flesh about it, and the bandages

must be applied loose; but having removed the scale with a hook or some

such instrument, we must have recourse to tighter bandages. During the

whole time of the healing of the sore, the dressing called motophylax

with some of the anti-inflammatory medicines is to be laid over the

wound, to be kept on with a simple bandage, which is to be removed at

each dressing; everything else remaining the same as described in the

treatment of the arm.

* * * * *

COMMENTARY. Hippocrates treats of these cases at great length. His

method of rectifying the protruded ends of bones by means of a lever, is

described by our author. He says, it may be done on the first or second

day, but not on the third or fourth, after the inflammation is begun,

for fear of occasioning convulsions. Compresses dipped in wine and oil,

or soft bandages are to be used, but splints are not to be applied until

the sore puts on a healthy appearance. He mentions that some were in the

practice of bandaging the limb above and below the wound, and leaving it

bare, in order to allow the discharges to escape; but this practice he

greatly disapproves of, as tending to produce swelling in the place; and

he recommends the whole limb to be well secured with bandages, but then

not too tight. He states that all bones which are completely denuded,

must exfoliate and come out. When a bone projects and cannot be replaced,

he directs the surgeon to cut it off if it irritate the soft parts. No

splints are to be applied when there is a bone which it is seen will

exfoliate. If it be the summer season, the compresses applied to the

wound are to be frequently soaked with wine; but if it be winter, greasy

wool is to be dipped in wine and oil and applied. Compound fractures of

the thigh or arm, attended with protrusion of the broken bone, are said

to be peculiarly dangerous; for if replaced, they are apt to occasion

convulsions; and if let alone, they give rise to acute bilious fevers.

Some, however, he adds, recover when the bone is replaced. (De Fract. cum

Comment. Galeni.) Galen explains, that the danger in cases of fractured

femur and humerus arises from their vicinity to important blood-vessels

and muscles.

Celsus lays down the rules for conducting the treatment in these cases

with great precision. He states, that fractures complicated with a wound

of the skin are generally dangerous, especially when it is the humerus

or femur. In the latter case he directs us to saw off the ends of the

bone. The case of a fractured humerus is more easily managed. The danger

is greatly increased when the fracture is near a joint. He recommends us

to divide any muscle which may run across the wound, to let blood, and

put the patient upon a restricted diet. In other fractures the bones are

to be gently replaced. The wound is to be dressed with a pledget dipped

in wine, to which roses have been added. This application is borrowed

from Hippocrates. The bandages are to be put on somewhat slacker than

when there is no external wound. Neither splints nor canals must be used,

but broad bandages. The parts are to be fomented with hot oil and wine,

and the dressings renewed every day. When a small fragment of a bone

projects, if it be blunt, he recommends us to replace it; but if sharp,

he directs us to saw it off, and then replace the bones with the hands or

a suitable instrument. Sometimes fragments of bones die, and after a time

drop out; and sometimes sharp spiculæ irritate the soft parts, in which

case he recommends us to enlarge the wound and cut off the projecting

points.

The treatment recommended by Albucasis is very judicious. If inflammation

be present, he directs us to subdue it by bleeding; and, in that case,

reduction is not to be attempted until the ninth day; but in all other

cases it is to be done at first. When it cannot be reduced by the hands,

an iron instrument seven or eight fingers’ breadth in length, and two

fingers broad, is to be used as a lever for this purpose. When the ends

of the fracture are sharp and cannot be replaced, they are to be cut

off or sawed. His saw bears a considerable resemblance to that of the

late Mr. Hey, of Leeds. He recommends an astringent wine as a suitable

application, but condemns all cerates which contain oil. The bandages are

to be put on very slack. Splints are not to be applied while the wound is

irritable and ill-conditioned. When it does not heal, he says we ought

to suspect that it is prevented by spiculæ of bones, which are to be

sought out and extracted.

Avicenna and Rhases give very proper directions about removing spiculæ

of bones, and applying slack bandages, but they evidently copy from

Hippocrates and our author.

SECT. CVIII.—ON THE REDUNDANT CALLUS OF FRACTURES.

The superabundant callus of fractures occasions always a deformity, and

sometimes also lameness if it be formed near a joint. If, therefore, the

callus be newly formed, we use very astringent medicines, and bring it

to its form by bandages; and sometimes we effect our purpose by applying

a plate of lead to it. But if it is of a stony hardness we make an

incision, and pare it off, removing the prominent part by chisels, if

need be, and boring it with trephines.

* * * * *

COMMENTARY. Celsus directs us to rub the limb with oil, salt, and

nitre; to pour a great quantity of hot salt water upon it; to apply an

emollient ointment; to bandage it tightly, and to give an emetic. He

also recommends us to produce revulsion by the application of mustard to

another part.

Albucasis recommends nearly the same plan of treatment as our author.

When the case is recent, he directs us to make astringent applications,

such as aloes, olibanum, and myrrh, with an astringent wine or vinegar.

He also speaks of applying a plate of lead; and when the callus becomes

hard, he approves of scraping and sawing it off, as directed by our

author.

No additional information is to be got from the other Arabians.

Theodoricus, and the other surgical authorities of that age, describe the

treatment exactly as the ancients. When the callus is hard, they direct

us to scrape or saw it off.

SECT. CIX.—ON DISTORTION FROM THE UNION BY CALLUS.

When bones heal distortedly by callus, no little lameness takes place,

more particularly if in the feet. The method then of breaking them over

again is not at all to be admitted, as it may occasion the utmost danger;

but if the callus be newly formed, we must have recourse to the allusions

of a relaxing nature, and to cataplasms, such as those from fat olives

and pigeon’s dung, and the other medicines for dissolving callus; and

we also dispel it by friction with the hand, and bending it every way.

But if it be of a stony hardness, we make an incision of the skin with a

scalpel, and separate the union of the bones with chisels, and then cure

the fracture as formerly said.

* * * * *

COMMENTARY. Celsus approves of breaking the bones over again. With this

intention he directs us, in the first place, to bathe the limb with much

hot water, and rub it with liquid cerate; the callus is then to be moved

with the hands, and the ends of the bone properly set; or if that cannot

be thus accomplished, a rule is to be wrapped round with wool and bound

upon the part, so as to restore it to its proper shape.

Avicenna agrees with Celsus in speaking favorably of breaking the bone

over again. He also speaks favorably of the other treatment recommended

by our author.

Rhases recommends emollient applications, and gentle attempts to restore

the figure of the limb. Albucasis mentions the proposal of breaking the

bone again with disapprobation.

SECT. CX.—ON BONES WHICH HAVE NOT UNITED BY CALLUS.

Sometimes fractured bones remain without forming adhesions, beyond the

natural period, either owing to their being often loosed, or from too

frequent bathing of the part, or from having been moved unseasonably,

or from the number of the bandages, or from atrophy of the whole body,

by which means the limb becomes emaciated. Wherefore we must endeavour

to remove all the other causes, but more especially the atrophy, partly

by calefacient applications which attract nourishment to the place,

and partly by supplying a sufficiency of food and baths, and whatever

also is of a refreshing nature. Among the other symptoms which follow

the formation of callus, the bandages then become stained with blood,

although no wound be present, which probably takes place from the

substance about the callus, when it unites, squeezing out the drops of

blood which were distributed to the hollows of the bones.

* * * * *

COMMENTARY. When the fractured portions do not adhere after a certain

time, Celsus directs us to extend the limb, and rub the ends of the bone

together, in order to convert them again into the state of a recent

fracture, taking care, however, not to hurt the muscles and nerves. The

part is then to be fomented, and the splints applied on the fifth day.

Rhases recommends calefacient liniments, friction, and nutritive food.

SECT. CXI.—ON LUXATIONS.

We proceed to the treatment of luxations, which naturally follows that of

fractures. A luxation then (to give a definition of it) is a displacement

of a member from its proper cavity to an unusual place, by which means

the voluntary motion is impeded. We have no other differences of it to

mention, except that some are to a greater and some to a less degree.

When the bone of a member, therefore, is completely removed from its

place, the accident is called by the common name of luxation, but when

only moved a little, or brought only to the brim of the cavity, it is

called a subluxation.

* * * * *

COMMENTARY. Celsus gives several important remarks upon dislocations

in general, but as most of them may more properly be brought under

particular heads, we shall notice them here but briefly. He distinguishes

dislocations into two classes; the first consisting of a separation of

two bones naturally united, such as the scapula from the humerus, the

radius from the ulna, the tibia from the fibula, the os calcis from the

bones of the ankle, which last is of rare occurrence, and the second

being a removal of the bone of a joint from its proper place. When a

dislocation occurs, as he remarks, the finger discovers a cavity in the

part, and inflammation and fever come on, followed sometimes by gangrene

and convulsions. If not reduced, the limb wastes. In a person who is

lean, humid, and has weak nerves (muscles?) the dislocation is most

easily reduced, but is more difficult to retain. The inflammation is to

be reduced by the application of wool dipped in vinegar; by abstinence, a

spare diet, and drinking tepid water. Afterwards friction, exercise, and

a more generous diet are to be allowed. (viii, 11.)

See many curious remarks on this subject in Galen’s Commentary on

Hippocrates (de Articulis), and in Apollonii Citiensis Scholia in Hip.

et Galen.; also Avicenna (iv, 5, 1); Haly Abbas (Pract. ix, 101); Rhases

(Cont. xxix, 2.)

SECT. CXII.—ON THE LOWER JAW.

Beginning then again from the upper parts we shall treat of the lower

jaw. For the upper being immoveable does not admit of dislocation; but

the lower does not indeed readily admit of complete luxation, owing to

its heads being firmly fixed to the upper jaw, but it often undergoes

subluxation, for the muscles which are fixed to it being relaxed by

the constant exercise of mastication and speaking, the jaw is readily

slackened from the most common causes. For the term used by Hippocrates

signifies _slackened_. In these cases the part returns to its natural

place without trouble. With regard to the complete dislocation of the

lower jaw, it will be sufficient to deliver Hippocrates’s account,

being, at the same time, brief, complete and clear. He says thus: “The

jaw seldom falls out of the joint, but it is often slackened in yawning,

as many other irregular actions of muscles and tendons do this. When it

falls out of the joint it is marked principally by these symptoms; the

lower jaw projects forwards, and is inclined in an opposite direction

to the luxation; and the coronoid process of the bone swells out near

the upper jaw-bone, and it is with difficulty that they shut their jaws.

In these cases the suitable mode of reduction is apparent. For somebody

must hold the patient’s head, another grasps the lower jaw internally

and externally with his fingers at the chin, while the patient yawns

as much as he can conveniently; and we must first move the jaw with

the hand hither and thither for a certain time, and order the man to

relax the jaw and separate it; and then we must attend to perform three

evolutions at the same time, we must move the jaw from its distorted

shape to its natural; push the jaw backwards; and then shut the jaws

close, and prevent yawning. This is the mode of reduction, and it cannot

be performed by any other processes. Very little treatment will suffice

afterwards. Having applied a waxed compress, it is to be secured with

a loose bandage. But the surest process is to lay the man upon his

back, and supporting his head upon well-stuffed pillows, that they may

not yield, to get some person to hold the head of the patient. And if

both ends of the jaw be dislocated, the treatment is the same, only the

mouth cannot be so well shut, for then the jaw is more prominent, but

less distorted from the teeth of the upper and lower jaws corresponding

exactly together. Reduction is to be immediately performed, and the mode

of it has been already described. If it cannot be restored, there may be

danger of the life from continued fevers, torpor, and carus. For these

muscles being altered and stretched in a preternatural manner produce

carus. They frequently have evacuations by the belly, which are purely

bilious, and small in quantity; and if they vomit, it is pure bile.

These, for the most part, die on the tenth day.” This mode of reduction

we have often practised, having first used fomentations of warm water and

oil, by a sponge along the dislocated jaw, more especially when there

is any difficulty in restoring it to its position. Wherefore, having

placed the man upon the ground, we stand behind and operate in the manner

described by Hippocrates.

* * * * *

COMMENTARY. The account here given of Hippocrates’s method of reduction

is taken from his work, ‘De Articulis,’ (31.) When a few of his technical

terms are explained in the commentary of Galen, the description is

sufficiently distinct, and is upon the whole a very correct account

of the symptoms and treatment of this accident. The prominence of the

coronoid bone is well described by Hippocrates. Galen remarks that the

end of the jaw-bone slips under the zygomatic arch. It has been a matter

of dispute what Hippocrates means by slackening, or incomplete luxations

of the jaw. It is worthy of remark that such an accident is described by

Sir Astley Cooper. (See further Littré’s Hippocrates, t. iv, 29.)

Galen’s description of the method of reduction is given in the Collection

of Nicetas. (Chirurg. Vet. ed. Cocchius.) It is substantially the same as

that of Hippocrates.

A mode of reducing the dislocation by means of a machine is described by

Oribasius, in his work De Machinamentis, 30.

The account which Celsus gives of this accident is upon the whole

very accurate, and corresponds very well with modern descriptions. If

dislocated only at one end, the chin inclines to the opposite side, and

the teeth of the upper and lower jaws do not correspond. If at both ends,

the whole chin projects outwards, the lower teeth are more prominent, and

the muscles appear stretched. The patient being properly seated, and his

head held by an assistant, the surgeon having wrapped his thumbs with

linen cloths, is to put them into the patient’s mouth, while the fingers

are applied externally. The jaw being firmly grasped, the chin is to be

shaken, and then, at one and the same instant, the head is to be seized,

the chin moved, the jaw forced into its place, and the mouth shut. After

reduction, if pain in the eyes and neck has been brought on by the

accident, he recommends us to let blood from the arm. The patient is to

live upon liquids, and avoid talking.

Albucasis follows Hippocrates in distinguishing dislocations of the

lower jaw into partial and complete. In addition to the symptoms already

detailed, he mentions a flow of saliva from the mouth, and an inability

to speak. When the dislocation is partial or incomplete, he says, it soon

returns of itself to its proper place. When the luxation is complete, he

directs us to reduce it by introducing the thumbs into the mouth, and

grasping the jaw in the manner described by Hippocrates. He states that

when not reduced the accident often proves fatal by superinducing fevers

and coma. Avicenna, in like manner, affirms, that if not reduced, it

may bring on fatal consequences. His account is borrowed entirely from

Hippocrates. Rhases and Haly Abbas give exactly the same description of

the symptoms and mode of reducing as Albucasis.

Monteggia, Fabricius ab Aquapendente, Sir Astley Cooper, and Mr. Samuel

Cooper (the author of the well-known Surgical Dictionary) affirm that

there is no foundation for the prognostic of Hippocrates, that the

accident will prove fatal if the dislocation be not speedily reduced.

We can say, however, from our own personal knowledge, that such fatal

consequences do occasionally occur. We once knew a poor woman who was

very liable to dislocations of the lower jaw, which we reduced three

or four different times. At last, owing to circumstances which it is

unnecessary to explain, an interval of more than a day elapsed between

the accident and the reduction. By this time she was become seriously

indisposed, and died a few days afterwards with all the symptoms

described by Hippocrates. We may mention also that Heister states that

fatal consequences may result from the accident. (Chirurg. p. i, iii,

4.) The same thing is affirmed also by Brunus (Chirurg. Mag. i); by

Theodoricus (ii, 43); and by Guido de Cauliaco (v, 2.)

That species of sub-luxation described by Hippocrates, is mentioned

by Guy of Cauliac in the following terms: “Mandibula quandoque

mollificatur.” (v, 2.)

SECT. CXIII.—ON THE CLAVICLE AND ACROMION.

The clavicle, at its inner extremity, is not liable to dislocation, for

there it is articulated with the sternum, where it admits of no motion.

But if from any sudden and violent force from without, it should be

torn from its place, it is to be subjected to the same treatment as a

fracture. And its extremity which is articulated with the shoulder does

not readily fall out of the joint, being prevented by the biceps muscle

and the acromion. But neither does the clavicle admit any strong peculiar

motion of its own, being made solely for the expansion of the thorax, and

hence man is the only animal which has a clavicle. If it should sometimes

happen to be dislocated in wrestling, it is to be replaced with the hand,

assisted by the application of many-folded compresses, together with

convenient bandages. When the acromion is sub-luxated it may be restored

to its proper place by the same treatment. It is a small cartilaginous

bone connecting the clavicle to the scapula, which is not to be seen

in the skeletons. This, if moved a little from its place, exhibits

the appearance to inexperienced persons of the head of the arm being

dislocated; for the top of the shoulder appears sharper, and there is a

hollow from which it was removed; but the cases are to be distinguished

from one another by the symptoms about to be enumerated.

* * * * *

COMMENTARY. The dislocation of the outer end of the clavicle from the

acromion is treated of by Hippocrates, who gives a very distinct

account of the symptoms and mode of treatment. He warns the surgeon not

to confound this accident with dislocation of the humerus, as he had

frequently seen done. He directs the surgeon to push down the projecting

end of the bone; and then to secure it with compresses, and bind the arm

to the side. He holds that the accident always leaves some deformity. (De

Articulis, 15.)

Galen mentions that this accident happens most commonly to young persons,

and that when not reduced it occasions a wasting of the arm. The account

which Galen in this place and, copying from him, our author have given

of the accident to which they represent the acromion as being subject,

has been the subject of much controversy among modern authorities. See

Cocchi (Chirurg. Vet. 133); and Littré (Hippoc. iv, 12.) Hippocrates,

whom they both evidently had in view, (de Artic. 13), clearly refers

to dislocation of the scapular end of the clavicle; and probably Galen

alludes to the same, complicated with separation of the acromion from

the scapula in young subjects. We would beg leave to quote what Monro

says of the acromion: “This is an epiphyse in children; and in some old

subjects I have seen it joined by a cartilage to the spine.” (Anat. of

the Bones, p. 231.) Galen states decidedly that in young persons this

process is sometimes bent along with the clavicle, and in them that

replacement of the parts to their natural state is easily effected. He

adds, “as dry wood is not adapted for bending, but such as is sappy and

green bear this, in the same manner the bones of growing animals can be

bent by force, and more especially such as are porous and fistulous,

as the clavicle is.” Galen relates that in his own person he met with

the accident while wrestling in the Palestra, and that by using oily

fomentations and light bandages, a cure was at last effected. He says he

was then thirty-five years old, but adds, that he had never known another

person cured who was so far advanced in life. (Ibid. 134.) Avicenna gives

the same account of the acromion as the Greeks. (iv, 5,1, 10.)

Neither Celsus nor Oribasius has treated of this case of dislocation.

Rhases, Avicenna, Haly Abbas, and Albucasis agree that dislocations

occur more frequently at the acromial than at the sternal end of the

clavicle. Desault and Boyer, on the other hand, affirm that the accident

occurs oftener at the sternal extremity; but Sir Astley Cooper’s ample

experience confirms the correctness of the ancient statement. Mr. Liston

also agrees in stating that dislocation at the acromial end is much more

frequent than at the sternal.

SECT. CXIV.—ON DISLOCATION OF THE SHOULDER.

The head of the arm, which is articulated with the cavity of the scapula,

is often dislocated; but neither upwards, owing to the coronoid process

of the scapula, which prevents it, nor often backwards, owing also to

the scapula, nor forwards owing to the tendon of the biceps muscle

and the acromion. Sometimes, though rarely, it is dislocated inwards

and outwards, but frequently, and particularly in those who are lean,

downwards. In such persons, however, as it is readily dislocated, so is

it also reduced; but in those who are brawny, on the other hand, it is

not readily dislocated, and is reduced with difficulty. In some cases

from a blow suspicions of dislocation are formed, although none has taken

place, owing to the violent inflammation which supervenes. Wherefore,

dislocation downwards may be thus ascertained. The affected shoulder,

when compared with the sound one, appears very different, the upper part

of the arm, whence the dislocation took place, seeming hollow; and (as

mentioned with regard to the sub-luxation of the acromion,) the top of

the shoulder appears sharper than natural; and the dislocated head of

the arm is distinctly felt in the armpit. The elbow also is removed to

a distance from the ribs; or, if you attempt it, you can only bring it

to the ribs with difficulty; neither can the hand be raised to the ear,

owing to the stretching of the elbow; nor can any other varied motions be

performed with it. In children, then, and in recent and inconsiderable

displacements of the bone, it may be often reduced, as Hippocrates

remarks, by the protuberant knuckle of the middle finger of the clenched

hand of the surgeon, or of the sound hand of the patient, if he be not a

child. But the following are more effectual modes of reduction. Having

bathed the man and used relaxing affusions, let him be laid on the

ground in a supine posture, and apply a moderately-sized ball, either of

leather or some other soft thing to the armpit; and the surgeon being

seated with his face turned to the patient upon the affected side, if

the right shoulder he dislocated, let him put the heel of his right foot

upon the ball previously fitted to the armpit, or if the left, that of

the left foot; and seizing the hand of the affected arm, let him pull

down to the feet, at the same time making counter-extension by the heel

in the armpit, while an assistant, standing behind the head, pulls at

the other shoulder in an opposite direction, to prevent the body from

being dragged along. There is another mode of reduction, namely, by

suspending the patient upon a person’s shoulder. A young man taller than

the patient, or standing on some elevated object, by his affected side,

(the patient also being in a standing posture) is to apply his shoulder

below the patient’s armpit, while he stretches and pulls the patient’s

hand towards his own belly, so that the rest of the patient’s body is

suspended at the back of the person who supports him. But if the patient

be light, another light child is to be suspended from him. For while

the arm and the rest of the body are pulled downwards oppositely, the

shoulder put under the armpit, readily replaces the dislocated limb. And

the same thing may be done by means of the instrument called a pestle.

It is a long piece of wood which is erected on the ground upon some

other firm object. Its upper extremity, then, being rounded, and neither

very thick nor thin, is applied below the armpit of the patient, who

either stands or sits, according to the length of the pestle, and the

hand being stretched along the pestle and pulled downwards, while the

rest of the body is balanced on the opposite side and weighs downwards,

the reduction takes place either spontaneously, or with the assistance

of another person pulling down. And this may be done with the step of a

ladder, as we described when treating of the extension for a fractured

arm. Here some round body is to be fitted to the step of the ladder,

such as will suit the armpit of the patient, and propel the head of the

arm. But if, owing to the oldness of the accident, or the hardness of

the body, we find the reduction difficult, we must have recourse to the

method by the means of the instrument called ambe. The ambe is a piece

of wood about two cubits in length, of the breadth of three fingers, and

about two fingers’ breadth in thickness, having the one extremity round

and adapted for the hollow of the armpit, like the extremity of the

pestle. Having then wrapped its end with linen rags, in order that it

may be softer, we adjust it under the head of the humerus in the armpit,

and stretching the hand along the wood, we bind it at the arm, fore-arm,

and wrist; then bringing the hand with the wood over a transverse piece

of wood, fastened between two erect pedestals, or again over the step of

a ladder, so that the armpit may be fitted transversely to the step, we

draw the hand downwards, and allow the rest of the body to hang suspended

on the opposite side; for then the limb will return to its place. After

the reduction, we must apply to the armpit a secure and moderately-sized

ball of wool, which, if there is no inflammation present, is to be dry,

but if there is inflammation, it is to be dipped in oil. Around this, the

shoulder, and the other armpit, a bandage is to be put on in the form

of the Greek letter Χ, so that the decussation may take place above the

affected shoulder; and the arm is to be bound to the sides; and the elbow

and hand are to be slung by the neck, so that the limb may not fall out

again while the dislocation is recent. After the seventh day or later,

having loosed the bandages, we must have recourse to moderate friction,

so that the body being rendered firmer, the joint may become less liable

to luxations. But if the limb is often dislocated, either owing to its

humidity (flabbiness), or from its being long subject to the accident, we

must proceed to burning, as formerly described. But since sometimes the

fœtus in utero or the child, while growing, sustains a dislocation of the

part which is not reduced, the flesh upon the shoulder is nothing reduced

from the natural, nor is the hand obstructed in any of its operations,

but the bone remains shorter, not increasing in size; and such persons

are called weasel-armed. But in the case of the thigh, the bone does not

grow and the limb wastes; for, not being able to sustain the weight of

the body, it is not exercised. And with regard to all the other members,

if they remain unreduced the parts below are greatly impaired.

* * * * *

COMMENTARY. Hippocrates delivers his opinions respecting dislocations

at the shoulder-joint with singular modesty and a remarkable air of

truth. He says, that he had never met with a case in which the head of

the humerus was not lodged in the armpit, and expresses a doubt whether

in reality there be dislocations inwards or backwards. “I will not

affirm,” he adds, “whether or not dislocation forwards may take place,

only this I can say that I have never seen it.” (De Articulis.) Galen,

in his commentary on this work, mentions that he had seen five cases

of the uncommon kinds of dislocation, four of which were dislocations

forwards. They occurred mostly among the athletæ. In one case, of which

he relates the particulars, he effected the reduction with his heel

placed in the armpit. Galen states distinctly, that it is the retraction

of the muscles which proves the great obstacle to reduction. (Ed. Basil,

v, 585.) Hippocrates has described several methods of reduction, most of

which are mentioned by our author. By the fist placed in the armpit, as

described by our author. By the heel, as likewise described by him. He

adds one advice not distinctly given by our author, to apply the ball

placed in the armpit on the side within the head of the humerus, and

not upon it. The process by suspending the patient upon the shoulder

of another person is next described by him. Those by the pestle and

ladder are afterwards clearly described. He then describes the ambe and

the application of it to the reduction of dislocations in nearly the

same terms as our author. We may here mention, by the way, that the

description of the ambe given by Boyer, does not correspond exactly to

the instrument recommended by Hippocrates. See drawings of Hippocrates’s

ambe in Heister’s ‘Surgery’ (x, 4); in Scultet’s ‘Arsenal de Chirurgie’

(xxii, 1); and in Littré’s edition of Hippocrates (iv, 91.) Hippocrates

describes other less important processes of reduction with a Thessalian

chair, and a door. He remarks, that persons in a reduced habit of body

are most liable to dislocations, and illustrates this position by some

very acute observations on the occurrence of these accidents in cattle.

After reduction, he directs that a ball of soft wool should be placed in

the armpit and secured with a bandage and a sling; and he attaches great

importance to well-regulated friction afterwards.

Celsus mentions two kinds of dislocation at the shoulder-joint, namely,

downwards and forwards. He describes the methods of reduction by the

hand, and by a wooden instrument (spathula lignea) resembling the ambe of

Hippocrates. His description of the latter method is very distinct. His

mode of reducing dislocations inwards merits attention. The man is to be

laid on his back, and a strip of cloth or a thong of leather being placed

in the armpit, its two ends are to be brought behind the patient’s head

and given in charge to an assistant, while another takes hold of the arm;

the surgeon is then to push back the patient’s head with his left hand,

while with the other he raises the fore-arm and arm, and pushes the bone

into its place. After reduction the armpit is to be stuffed with wool,

and suitable bandages applied.

Oribasius treats of dislocations downwards, outwards, and forwards; and

gives a very elaborate description of complicated machines for reducing

them. Of these it is impossible to convey any correct idea without proper

plates. We must be content, therefore, with referring the reader to his

work. (De Machinamentis.)

Albucasis describes three kinds of dislocation at the shoulder, namely,

downwards, inwards, below the pectoral muscle, and upwards, about which

he expresses himself somewhat doubtful. He denies the possibility of

dislocations forwards and backwards, the former being prevented by the

muscles and latter by the scapula. His methods of reduction are exactly

the same as those mentioned by Paulus.

Avicenna expresses himself as being doubtful whether any dislocation

takes place at the shoulder except downwards, at least, he adds, he

had no experience of any other case. He gives the symptoms of it very

accurately, and describes all the methods of reduction mentioned by our

author. He approves of the cautery to obviate the tendency to repeated

dislocations.

Haly Abbas questions the occurrence of dislocations upwards, forwards,

inwards, or backwards. He appears, therefore, to agree with Hippocrates

in considering that downwards as the only unequivocal case of

dislocation. He recommends the processes of reduction described by our

author.

Rhases remarks, that owing to the shallowness of the glenoid cavity and

the weakness of the ligaments the bones at the shoulder are more subject

to luxations than those of any other joint. He describes the symptoms

very accurately. The top of the shoulder, he says, is sharper than

natural, the head of the humerus is felt in the armpit, the arm cannot

be brought to the sides without pain, nor raised to the head at all.

He remarks correctly that when the accident happens during delivery or

in childhood, the arm does not grow to its natural size. He mentions

that venesection is often of great use in reducing dislocations. He also

recommends the warm bath. He denies the possibility of a dislocation in

any other direction except downwards.

The ancient modes of reduction are recommended and described by Guy of

Cauliac (v, 2); and Theodoricus (ii, 47.)

SECT. CXV.—ON THE ELBOW.

Inasmuch as the elbow-joint is more complicated than that of the

shoulder, so, in like manner, are its dislocations more difficult to

manage; for they are less readily occasioned, and more difficultly

reduced, owing to the number of its processes and cavities. Sometimes

it undergoes sub-luxation only, but often it is completely dislocated

in every direction, and more especially forwards and backwards. It is

easily recognised even by the sight, and the dislocated bone may be

felt in the place to which it has been removed, while a hollow appears

in the place whence it was moved. A comparison with the sound arm

particularly discloses the nature of the accident. Reduction then must

be made immediately before inflammation comes on, for, if this has

supervened, it is difficult to cure, and some such cases become utterly

irremediable, more especially if the dislocation was backwards; for of

all the dislocations at the elbow-joint, that backwards is the most

painful and dangerous. Small displacements then may be restored by a

moderate degree of extension, the assistants keeping the hand extended,

pulling, and making counter-extension at the fore-arm and arm, while the

surgeon with the palm of his hand pushes the dislocated bone into its

natural place. Hippocrates rectifies the dislocation forwards by bending

the hand suddenly so as to force the palm straight to the shoulder of the

same side; and that backwards again by frequent and strong extension;

inasmuch as dislocations forwards are produced by violent extension, and

those backwards by violent flexion. If the dislocation has continued

long unreduced, we must have recourse to stronger extension, such in

particular as that described by Hippocrates for a fractured arm, where he

has recourse to the piece of wood adapted to a spade. Some of the moderns

manage the matter thus: Two assistants stretching the arm as aforesaid,

the one holding at the armpit, and the other below at the wrist, the

surgeon, standing opposite the patient, grasps the arm with the palms of

both his hands near the joint, and giving orders to bind a long folded

robe or broad swathe round his hands and the arm of the patient, and to

pull outwards and downwards towards the hand, whilst he, following the

same course, drags the parts with his hands thus secured until they pass

the articulation of the joint. The arm should be first anointed with

oil, to render the part slippery and easily moved with the palms of the

surgeon’s hands. Thus the dislocated parts being violently pulled by the

hands of the assistants will return to their proper place. After the

reduction the arm is to be bent to an angular position, and treated with

oblong compresses and suitable bandages.

* * * * *

COMMENTARY. No author, ancient nor modern, has given so complete a view

of the accidents to which the elbow-joint is subject as Hippocrates. In

his works (De Fracturis, De Articulis, and Mochlicus,) he has treated

of this subject with surprising accuracy and skill. He describes

the following injuries of the elbow-joint: 1st. Complete luxations,

laterally, anteriorly, and posteriorly. 2d. Luxations of the radius,

anteriorly, posteriorly, and laterally. 3d. Fracture of the olecranon.

4th. Fracture of the apophysis of the humerus. We must give his

description of the last-mentioned injury in his own words: “It sometimes

happens that the head of the humerus is broken at its apophysis; and

this, although it appear a more serious accident, is, in fact, less

so than many other injuries of the joint.” It is singular that this

distinct account of a very common injury of the joint should have been

overlooked or misunderstood by all his commentators and the surgical

authorities down to the present day. We have often met with it in our own

practice, and seen many instances in which it had been misapprehended in

the practice of other surgeons. It is only within the last five or six

years that it has been described in any modern work on surgery. Lateral

luxation of the radius is described by him under the name of _diastasis_.

(De Fracturis, 44; De Articulis, 20.) The Commentaries of Apollonius

Citiensis and Galen are worth consulting although they contain no new

matter. Galen remarks that in dislocations of the radius, the power of

flexion and extension is often not much impaired; and this, we may add,

is confirmed by modern observation. Galen’s account of fractures of the

olecranon is remarkable for its precision and accuracy. (Chirurg. Vet.

84.)

Celsus describes four different kinds of dislocation at the elbow,

namely, forwards, backwards, and to either side. He also mentions

that rare variety, in which there is a dislocation of the ulna, while

the radius remains in its place. (See Sir Astley Cooper’s Lectures.)

The other varieties are all well described, and suitable methods of

treatment recommended. When there is a dislocation forwards the arm is

extended, but cannot be bent; when backwards, on the contrary, it cannot

be extended, and is shorter than natural. When to either side, the arm

is somewhat bent towards that side from which the bone has been moved.

He lays it down as a general rule for treating all such dislocations,

to extend both the members concerned in different directions, until the

bones are separated from one another, and then to push them into their

right position. When the dislocation is forwards, he directs us to make

strong extension with the hands or with thongs, and then placing some

round body upon the anterior part of the arm, to push the fore-arm

over it suddenly to the shoulder. This method is well described by

Hippocrates, but rather indistinctly by Paulus. In all the other cases,

the best method, he says, is to make reduction in the same way that it is

performed for the replacement of fractures.

Oribasius mentions the four ordinary kinds of dislocation at the

elbow-joint, and describes methods of reducing them by machines. He

has likewise described the separate dislocation of the radius from the

humerus, and he is the only Greek authority, as far as we know, who has

described the separate luxation of the ulna, but which, as stated above,

had been noticed by Celsus. We need scarcely remark that a few cases of

this uncommon accident have been reported of late years.

Albucasis says that the fore-arm is dislocated in all directions, but

more especially backwards and forwards. His description of the mode of

reduction is evidently copied from Paulus. Avicenna likewise borrows his

whole account from our author.

Rhases and Haly Abbas describe the ordinary cases of complete luxation at

the elbow-joint, but we believe that neither they nor any of the Arabians

take notice of the dislocation of the radius from the ulna, nor the

abruption of the apophysis of the humerus.

SECT. CXVI.—ON DISLOCATIONS AT THE WRIST AND FINGERS.

Dislocations at the wrist and fingers are attended with no difficulty,

unless accompanied with a wound. This case, therefore, will be treated

of under the head of dislocations with a wound. Those without a wound

may be remedied by moderate extension and the anti-inflammatory plan of

treatment.

* * * * *

COMMENTARY. Hippocrates says that the hand is dislocated inwards and

outwards, but most frequently inwards. In the former case it is found

impossible to bend the fingers, and in the latter to extend them. He

also makes mention of dislocations to either side. He directs us to make

counter-extension upon a table, and to push down the projecting end

of the bone with the hand or the heel. He also describes the separate

dislocation of the radius and ulna; and, upon the whole, his account

is very little different from that given by Sir Astley Cooper in his

‘Lectures,’ and by Mr. Liston in his ‘Elements of Surgery.’

Celsus describes, in his usual elegant manner, the dislocations forwards

and backwards. He denies the possibility of the lateral dislocations,

and, in fact, it is now acknowledged that if ever they do occur they are

incomplete. Like Hippocrates, he directs us to replace dislocations of

the fingers by making extension upon a table. He does not make mention of

the separate dislocation of the lower end of the radius.

Oribasius mentions the dislocations forwards and backwards, and likewise

the separate dislocations of the radius and ulna. Sometimes, he says,

the radius is dislocated, while the ulna remains in its place, and

sometimes the ulna is dislocated while the radius remains. He describes

the process of reduction with machines.

Albucasis, Avicenna, and Haly Abbas describe very accurately the

dislocations forwards and backwards. They state that immediate reduction

is peculiarly required in the case of this accident. Avicenna recommends

a strengthening plaster to be put on the part before the splints are

applied. When the joint, after reduction, is found to have lost the power

of motion, Albucasis recommends us to pour hot water upon it and apply

friction.

Rhases states that the ulna is more apt to be dislocated separately than

the radius, which generally undergoes fracture rather than luxation. The

fingers, he says, are mostly dislocated inwards.

SECT. CXVII.—ON THE VERTEBRÆ OF THE SPINE.

The vertebræ of the spine, when completely dislocated by accident,

occasion instant death; for the spinal marrow undergoes extraordinary

compression; and even when one of its nervous processes is compressed,

it brings on dangerous symptoms. It often suffers sub-luxations, and

when this takes place forwards it gets the name of repandation; when

backwards, that of gibbosity; and when sideways, that of wry-neckedness.

When there is a small sub-luxation of many vertebræ together, the

distortion occasions a circular flexure of the spine, and in this case

some are apt to be deceived, and take it for a complete dislocation of

one spine, whereas a complete dislocation of one spinal vertebra does

not produce a circular but an angular flexure of the spine, which is

attended with more danger. When the dislocation is inwards, it cannot be

reduced because no counter-pressure can be made on the belly. But those

who imagine that they can effect anything in this case by stretching the

patients upon a ladder, by apply cupping instruments, or administering

sternutatories, or by producing coughing, or by inflation, are

sufficiently exposed by Hippocrates. But since, often the breaking off

of some of the small bones of the spine leaves a hollow appearance (as

has been mentioned when treating of fractures), some have taken this for

a dislocation forwards; and it being speedily healed, (for its callus is

soon formed,) they have given out that a dislocation forwards is readily

cured, although in fact it be wholly incurable, or difficult at least,

to cure. For retention of the urine and fæces takes place, with coldness

of the body; but this state is followed afterwards by an involuntary

discharge of the excrements. These symptoms arise from the nerves and

from muscular sympathy, and the patients soon die, more especially if the

upper parts and the vertebræ of the neck be affected. But that gibbous

state of the spine which mostly takes place from infancy, is a protracted

affection and not speedily fatal; but, as Hippocrates has shown, it

leads to disease and is incurable. But when this state occurs from an

accident, the contrivances to remedy it with a ladder, suspending the

patient erect, and inflation with a bladder, are altogether ridiculous.

But the method of rectifying it, recommended by Hippocrates, will be

alone sufficient. For, he says, a board, in length and breadth such as

to contain the man, or a bench equal to it, is to be placed near a wall,

being extended along the wall, and not more than a foot distant from it,

and some robes are to be spread over it to prevent the body from being

injured. Then the man, being bathed, is to be laid on his face along

the board or bench, and a thong is to be twice passed round his breast

by the armpits along the back; and the extremities of the thong are to

be fastened to a pestle like a piece of wood erected on the floor at

the extremity of the board or bench, and this to be given to a person

standing behind the patient’s head to hold, so that when the lower parts

are secured oppositely, and the upper pulled towards the head, extension

may be made at the proper time. Then another thong being bound round both

the feet above the ankles, and again another above the loins, so that its

two ends may meet upon the haunch-bone, the extremities of these thongs

are to be again united together, and bound to another pestle-like piece

of wood resembling that already described; and this pestle, like the

former, is to be erected near the extremity of the board or bench at his

feet; and then we are to order the assistants to make counter-extension

by these pieces of wood. Others effect this part of the operation by

what are called aselli. They are axles turned upon an erect piece of

wood, which is placed at each extremity of the large board or bench, at

the feet and head of the patient, and the thongs are to be wrapped round

them. While the extension is thus made, we press down the prominence of

the back with the palms of the hands, and if necessary we may sit upon

it without apprehension. If the spine is not thus made straight, and the

patient can endure pressure, we may scoop out from the adjoining wall a

furrow opposite the prominence of the back, so that the length of the

furrow may not be greater than a cubit, and it must be in a situation

neither much higher nor lower than the patient’s spine. But this furrow

ought rather to be prepared beforehand, and on this account we directed

the board at first to be placed near the wall. Then one extremity of

a board is to be introduced into the furrow, while we press the other

downward until it is clear that the spine is rectified. According to

Hippocrates, extension alone without the board, and again the treatment

with the board alone, is sufficient to accomplish the purpose. If this

be true it will not be improper, in cases of dislocation anteriorly and

laterally, to make the aforesaid extension without the compression. After

the reduction, a thin piece of wood three fingers in breadth, and of

such a length as to comprehend the dislocated part and some of the sound

vertebræ, is to be wrapped round with a piece of linen or some flax, on

account of its hardness, and applied to the spine with suitable bandages.

And the patient must be kept upon a spare diet. If afterwards any remains

of the protuberance are to be discovered, we must use relaxant and

emollient applications, with the pressure by means of the plate. Some use

a plate of lead.

* * * * *

COMMENTARY. Our author’s account of dislocations of the spine is entirely

condensed from Hippocrates’s work ‘De Articulis,’ and the commentary

of Galen on the same. The description of the methods of reduction is

so plain, that we need not take up time in illustrating it. It will be

remarked that he makes mention of a mode of reducing these dislocations

by means of axles or aselli. In the days of Hippocrates they were

acquainted with only three of the mechanical powers, namely, the lever,

the wedge, and the axis in peritrochio. The last mentioned is called by

him asellus. (See De Fracturis cum Comment. Galeni.) Hippocrates makes

mention of a mode of reducing dislocations of the spine, by succussion in

a ladder, but expresses himself unfavorably of it as being a procedure

which none but charlatans would practice. He speaks with becoming

contempt of those who have recourse to ostentatious modes of performance

_ad captandum vulgus_.

Celsus states very decidedly the fatal nature of dislocations of the

uppermost vertebræ. Even those below the diaphragm are designated as

highly dangerous. They happen either forwards or backwards. Those above

the diaphragm occasion paralysis of the hands, vomitings, contractions

of the tendons, difficulty of breathing, pain, and relaxation of

the ears. Those below the diaphragm produce paralysis of the lower

extremities, suppression of urine, or an involuntary discharge of it.

Even these cases, he adds, prove fatal within three days. He says, that

Hippocrates’s mode of reduction by counter-extension and pressure on the

part with the heel, applies only to cases of incomplete luxation.

Oribasius describes the method of reduction by means of a machine, as

mentioned by our author. It will readily be understood that the whole

process consisted in making counter-extension upwards and downwards,

and pressing upon the part which projects with a piece of wood. (De

Machinamentis.)

Albucasis explains the nature of the accident and the methods of

reduction in much the same terms as our author. The patient is to be

laid upon a board or bench of sufficient length, spread with some soft

thing to prevent him from being hurt. Then a pole or piece of wood is to

be fastened at each extremity of the bench; and a rope or swathe, being

carried round the patient’s body by the armpits and above his head, is

to be fastened to the upper pole, which is not to be fixed firm in the

ground; and another rope is to be brought round below the part affected,

and fastened to the pole at his feet. Powerful counter-extension may be

thus made, while the surgeon presses upon the protruded part with his

hand and pushes it into its place. If these means do not succeed, he

directs us to fasten a piece of wood into a hole in the wall opposite the

protuberant part of the patient’s back and to press down with it. Other

methods are also described by him. After reduction he directs us to

apply a splint with bandages, as recommended by our author.

Avicenna describes all the methods of reduction here mentioned; and

in the Latin edition of his works there are plates to illustrate his

descriptions. Judging from our own experience of such cases, however, we

would say that such contrivances can seldom be required to reduce these

dislocations, as there is much less difficulty in the reduction than in

keeping the parts in place afterwards.

Haly Abbas copies the description given by Hippocrates of the mode of

reduction. After the parts are restored to their place, he recommends

us to apply a board (tabula lignea) three fingers broad, and of such

a length as to comprehend the dislocated vertebræ and some of the

adjoining ones; and to bind it firmly on to prevent a recurrence of the

displacement.

The ancients were well acquainted with the curvature of the spine

occasioning paralysis of the lower extremities. Alsaharavius remarks that

it occurs most frequently in childhood, and arises from an inflammation

or collection of humours between the vertebræ. Sometimes, he adds, it is

occasioned by a gross flatus. This is the disease called _spina ventosa_.

When connected with a collection of blood in the part, he recommends

bleeding, clysters, and various emollient applications. When it arises

from flatulence he prescribes the hermodactylus. If the usual means do

not succeed he approves of the actual cautery. (Pract. xxviii, 9.)

But no ancient author has treated so fully of curvature of the spine

as Rhases. He states that it occurs most frequently in childhood, and

often proves fatal by occasioning pressure on the thoracic viscera.

The disease, he says, may arise from a fall, a blow, an abscess, or a

gross flatus contained in the vertebræ. In cases of paralysis of the

lower extremities connected with this disease, he approves of applying

the actual cautery to the back. (Cont. i.) He states correctly that

dislocations of the upper vertebræ often prove suddenly fatal. He directs

the surgeon to keep them reduced with a splint extending the whole

length of the spine. (Cont. xxix.) On the spina ventosa or gibbositas,

see further Serapion (v, 26.) For the cure of it, he recommends first

discutient plasters, and if these do not succeed he advises recourse to

the actual cautery. (v, 27.)

SECT. CXVIII.—ON DISLOCATION AT THE HIP-JOINT.

The other bones of the human body sometimes undergo subluxation, and

sometimes complete luxation, but the articulations at the hip and the

shoulder are subject only to complete luxation, more especially the

hip-joint, because it has a deep and round cavity which is further

strengthened by a strong brim. The limb, then, being subject to

displacement from its cavity by some great violence, many differences

arise according to the greater or less degree of the dislocation.

Dislocation at the hip-joint takes place in four ways, or rather places;

for it is dislocated either inwards, outwards, forwards, or backwards;

inwards and outwards frequently, more especially inwards; but forwards

and backwards very rarely. When the dislocation is inwards, the affected

leg, if compared with the sound one, appears longer, the knee is more

prominent, the patient cannot bend the leg at the groin, and a swelling

is clearly felt in the perineum, from the head of the thigh being lodged

there. When the dislocation is outwards, the symptoms are the contrary to

these; for the leg appears shorter, there is a hollow in the perineum,

a protuberance about the nates, the knee is turned inwards, and the leg

can be bent. When the dislocation is forwards, the patient can stretch

the leg without pain at the knee, but when he attempts to walk he cannot

turn the foot inwards; the urine is retained, the groin is swelled, the

buttocks appear wrinkled and destitute of plumpness; and in walking

he supports himself upon his heel. Those who experience a dislocation

backwards can neither extend the ham nor the knee, nor can they bend

the limb before bending the groin also. The leg appears shorter, the

groin looser, and the head of the thigh is to be felt at the buttock.

When, then, from infancy, or simply, when for a length of time the limb

has been neglected after being dislocated, and allowed to remain so,

the cure is impracticable, callus having been already formed. But when

the luxation is recent, it may be managed in the way recommended by

Hippocrates. We must, then, proceed immediately to the reduction, for

dislocations at the hip-joint, when allowed to remain long, are wholly

irremediable. In general, then, in all the four kinds of dislocation,

the reduction may be accomplished by rotating it, by bending the limb,

and by extension. For if the accident be recent and the patient young,

we may sometimes succeed in reducing the limb by grasping and rotating

the thigh this way and that. When the dislocation is inwards we may

sometimes accomplish our purpose by bending the limb at the groin inwards

frequently and strongly. If the dislocation does not yield to these

means we must have recourse to extension, first with the hands, certain

assistants grasping the thigh and leg and pulling the limb downwards,

while others grasp the body at the armpits and pull upwards. Or, if a

stronger extension be required, the leg may be bound with twisted cords

or thongs, above the ankle, and a little higher than the knee, lest it

suffer injury; but it is not necessary to secure the breast in this

manner, for, as has been said, the hands may be put under the armpits for

this purpose. And the middle of a soft and strong thong is to be applied

to the perineum, and brought up to the shoulders anteriorly by the groins

and clavicles, and posteriorly along the back, and the two ends are to be

given to an assistant to hold. Then, all pulling together so as to raise

the patient’s body, extension is to be thus made. This mode of extension

is applicable generally in all the four varieties of dislocation. But the

manner of replacement varies according to the nature of the dislocation.

If the bone has been dislocated inwards, let the patient be stretched by

having the middle of a thong applied to the perineum between the head

of the bone and the perineum, and let the thong be brought upwards by

the adjoining groin and the clavicle, and let a young man with both his

arms grasp the thigh which is affected in its thickest part, and pull

strongly outwards. This mode of reduction is easier than any of the

others. When the limb does not thus yield we must have recourse to other

contrivances more complicated but more efficacious than these. Let the

man be stretched upon a large board, or bench, like that upon which we

stretch those who have dislocation of the spine, and along nearly its

whole length let certain gutters be scooped out, in breadth and depth

not more than three fingers, and not more than four fingers distant from

one another, so that the extremity of the lever being inserted into

them may impel the limb wherever it is required. In the middle of the

board, or bench, let another piece of wood be fastened about a foot in

length, and in thickness like that which is inserted in the extremity of

a spade, so that when the man is pulled along, this piece of wood may

come between the perineum and the head of the thigh, so as to prevent the

yielding of the body when pulled by the feet, and thereby often obviating

the necessity of making counter-extension; and at the same time when

the body is extended this piece of wood will push the head of the thigh

outwards. The extension is to be made in the manner described above, more

particularly by the foot. But if it is not thus reduced, the erect piece

of wood is to be taken away, and two other pieces of wood fastened on the

sides of it like posts, not more than a foot in length, and let another

piece of wood be adapted to them like the step of a ladder, so that the

figure of the three pieces of wood may resemble the Greek letter Η; the

middle piece of wood being fixed a little below the upper extremities.

Then the man being laid on the sound side, we bring the sound leg between

the two posts below the piece of wood corresponding to the step of a

ladder, while the affected one is brought above it, so that the head of

the thigh is to be adapted to it; but a folded garment is to be first

wrapped about it to prevent the thigh from being bruised. Then another

board of moderate breadth, and of such a length as to extend from the

head of the thigh to the ankle, is to be bound along the inner side of

the thigh. Then extension being made either by the pestles mentioned in

treating of the dislocation of the vertebra, or some other instrument,

the leg is to be pulled downwards along with the board which is fastened

to it, so that by the force exerted the head of the thigh-bone may

return to its proper place. There is another mode of reduction without

making extension upon a board, which is much commended by Hippocrates.

The patient’s hands, he says, are to be bound loosely to the sides, and

a soft but strong thong put round both his feet at the ankles and above

the knees, four fingers distant from one another, so that the affected

leg when stretched may come two inches lower down than the other. The

man is afterwards to be suspended with the head two cubits distant from

the ground. Then an expert young man is to seize the affected thigh in

his arms, at its thickest part, where the head of the thigh is lodged,

and suddenly suspend himself from the man, by which means the joint

will readily return to its place. This mode of reduction is simpler

than any of the others, being performed without much apparatus, but

many now reprobate it as dangerous. If the dislocation is outwards, the

extension is to be made as above, but the thong at the perineum is to be

passed by the opposite parts, I mean the groin and clavicle. The surgeon

is to propel the limb from without inwards, the lever being fastened

into one of the furrows formerly prepared, and an assistant fixing the

sound nates that the body may not yield. In dislocations forwards, the

patient being stretched, a strong man is to apply the palm of the right

hand to the affected groin, and press down with the other hand, so that

the depressing force may be exerted downwards, and to the knee. In

dislocations backwards, the man is not to be stretched so as to raise

him up, but he is to lie upon a hard body as in dislocations outwards;

and, as we mentioned with regard to dislocations of the vertebra

backwards, the man is to be laid on his face upon a board or bench, and

the ligatures are to be applied, not to the loins, but to the leg as

mentioned a little above. But the depression, by means of a board, is to

be applied at the buttocks, where the dislocated bone is lodged. And thus

much respecting dislocations at the hip-joint occasioned by some external

cause. But since dislocation sometimes takes place at the hip-joint, as

at the shoulder, owing to a collection of humours, we must, in this case,

as we mentioned in the other, have recourse to burning.

* * * * *

COMMENTARY. Although the descriptions given by the medical authorities

who preceded and followed our author will be found in the main exactly

the same as his, we are induced to give a brief outline of them, in order

to illustrate by every means in our power a subject so important as the

one now on hand.

Every subsequent author is indebted to Hippocrates for his lucid and

correct exposition of dislocations at the hip-joint. He says truly that

the thigh-bone is dislocated in four directions, namely, inwards, which

occurs frequently; outwards, the most frequently of all; backwards and

forwards, both very rarely. The following are the symptoms of dislocation

inwards, as described by him. The leg is longer than natural, the

buttocks outwardly appear hollow; the knee, foot, and leg are turned

out; the patient cannot bend his thigh at the groin; and the head of the

thigh-bone occasions a tumour in the perineum. This appears evidently to

be the variety described by modern surgeons as the dislocation inwards

and downwards, the head of the bone being lodged near the thyroid

foramen. The symptoms described by modern authors are exactly the same

as those mentioned by Hippocrates. Having seen cases of it, we can bear

testimony to the correctness of Hippocrates’s description. The symptoms

of dislocation outwards as enumerated by Hippocrates are, shortening

of the limb, relaxation of the inner part of the thigh, and projection

at the buttock, inclination of the knee, leg, and foot inwards, with

inability to bend the limb. This case is described by modern authors as

a dislocation upon the dorsum of the ilium. From personal experience

we can also testify to the accuracy of the description of it given by

Hippocrates. The next variety is the dislocation backwards, which,

he remarks, is of rare occurrence. It is rather obscurely marked by

inability to extend the leg at the hip-joint and ham, relaxation of

the flesh in the groin, distension of the nates, a slight degree of

shortening and inclination of the limb. He states that the head of the

bone is situated below the flesh of the nates. This assuredly is the

dislocation backwards upon the tuber ischii, the symptoms of which are

admitted by Sir Astley Cooper to be sufficiently obscure. Hippocrates

describes with great accuracy the appearance which the limb puts

on afterwards when the dislocation is not reduced. (De Articulis.)

Reduction, he says, may be accomplished by the hands, with a bench, or

with a lever. All these modes of reduction are mentioned by our author,

and therefore we shall not take up time in describing them. (Ibid. and De

Vectiariis, 15.) The figure of the bench of Hippocrates, given by Littré,

would appear to us excellent, and it renders the description easily

understood. (Hippocrat. Op. t. iv, 44.) Littré also gives an excellent

figure of the reduction by suspension. (Ib. 291.)

Apollonius Citiensis gives a most elaborate and interesting commentary

on the methods of reduction recommended by Hippocrates in cases of

dislocation at the hip-joint. These methods, however, may be best learned

by examining the figures given in the Index Galeni, or in H. Stephens’s

Latin Translation of Oribasius (Ap. Med. Art. Princip.), or in Littré’s

Edition of Hippocrates (iii, and iv.) There is one curious passage

in the commentary of Apollonius, which we must not pass by. He says

that Hegetor, one of the followers of Herophilus, had maintained that

dislocation of the thigh being attended with rupture of the tendon fixed

into his head (ligamentum teres) it was impossible ever afterwards to

keep the ball of the femur in the acetabulum. This, Apollonius correctly

argues, is contrary to experience and the authority of the ancients. (Ed.

Dietz, p. 35.)

Celsus describes the different modes of dislocation at the hip-joint

in the following terms: “Femur in omnes quatuor partes promovetur,

sæpissime in interiorem; deinde in exteriorem; raro admodum in priorem,

aut posteriorem. Si in interiorem partem prolapsum est, crus longius

altero et valgius est: extra enim pes ultimus spectat. Si in exteriorem,

brevius varumque fit, et pes intus inclinatur; calx ingressu terram non

contingit sed planta ima; meliusque id crus superius corpus, quam in

priore casu, fert, minusque baculo eget. Si in priorem crus extensum

est, implicarique non potest; alteri cruri ad calcem par est, sed ima

planta minus in priorem partem inclinatur: dolorque in hoc casu præcipuus

est, et maximè urina supprimitur. Ubi cum dolore inflammatio quievit,

commodè ingrediuntur, rectusque eorum pes est. Si in posteriorem, extendi

non potest erus, breviusque est; ubi consistit, calx quoque terram non

contingit.” His statement, however, that dislocations inwards are of

most frequent occurrence of any is at issue with that of Hippocrates,

who more correctly states that the dislocations outwards are the most

common of all. He likewise describes clearly the methods of reduction. If

the muscles of the limb be weak, it will be sufficient to make extension

by means of thongs applied at the groin and the knee; but if strong, it

will be better to fasten them to the upper extremities of two sticks

loosely fixed in the ground, and to make counter-extension by pulling the

ends of the sticks in opposite directions. A more powerful method is by

stretching the limb upon a board having axles at both ends with thongs

fastened to them, by turning which such powerful extension could be made

as would be sufficient even to break the muscles and tendons. When these

are stretched, if the bone is dislocated forwards, some round body is

to be placed in the groin, and the knee is to be suddenly carried over

it, for the same reason and in the same manner as in dislocations at the

shoulder. In the other cases the surgeon is directed to push the bone

towards its place, while an assistant propels the hip-joint.

Oribasius mentions the four varieties of dislocation at the hip-joint.

In three of them, he says, the leg is extended and cannot be bent; but

in the dislocation backwards, it is bent and cannot be extended. He has

described the method of reducing these dislocations by machines, of which

he gives plates.

Albucasis describes the four varieties of dislocation and the methods of

reduction in much the same terms as Paulus. His modes of reducing them

are: 1st. By rotating the limb in all directions. 2d. By making extension

and counter-extension with the aid of two assistants. 3d. By suspending

the patient, and getting a strong assistant to grasp the affected leg

and swing himself by it. 4th. By making extension with ropes fastened

to two sticks or pieces of wood as recommended for dislocations of the

spine. When the dislocation is forwards, the surgeon is to press down the

prominent part with his hands; but if backwards, a board is to be used in

the manner described by our author.

Avicenna agrees with Hippocrates, in opposition to Celsus, that

dislocation outwards (on the dorsum of the ilium) is of more frequent

occurrence than the dislocation inwards (on the foramen ovale.) His

description of the modes of reduction is evidently taken from Paulus.

Haly Abbas describes the four varieties mentioned by Hippocrates, and

recommends much the same treatment. The account of them given by Rhases

is exactly the same.

The earlier modern writers on surgery, describe the four varieties

of dislocation at the hip-joint in the same terms as the ancients.

They evidently follow the Arabians. See Theodoricus (ii, 51); Guido

de Cauliaco (v, 2, 7.) From the contents of this section it will be

clearly seen how erroneous is the statement made by the late Sir Astley

Cooper, that the profession was entirely ignorant of the nature of these

accidents until within these last few years.

SECT. CXIX.—ON DISLOCATION AT THE KNEE.

The knee is dislocated in three ways: inwards, outwards, and towards the

ham; for it is prevented by the patella from being dislocated forwards.

Using, then, the same modes of extension, sometimes by the hands alone,

and sometimes by cords, we must have recourse to suitable bandages, and

the other suitable treatment, the part being in particular preserved free

from motion.

* * * * *

COMMENTARY. Hippocrates, like our author, mentions three directions in

which the bones of the knee-joint may be dislocated: namely, inwards,

outwards, and backwards. He has not noticed the dislocation forwards,

which is, in fact, a very rare case. Celsus mentions, however, that

Meges had related a case of dislocation forwards, which was successfully

treated by him. But most of the other authorities, he says, have denied

the possibility of such an occurrence. He directs the surgeon to reduce

dislocations at the knee upon general principles, by making extension and

counter-extension. Hippocrates represents dislocations at the knee as

being of more frequent occurrence, but less dangerous, than those of the

elbow.

Oribasius, like our author, treats only of three kinds of dislocation at

the knee. Albucasis denies the possibility of a dislocation forwards.

He directs the surgeon, in making reduction, to turn his back to the

patient, and take the limb out between his knees; then while an assistant

makes extension at the foot, he is to replace the bones with his hands.

This seems a very proper method of reduction.

Avicenna likewise mentions only three modes of dislocation. He has

described dislocation of the patella, a case omitted by our author. He

directs us after making reduction, to fill the hollows with compresses,

and then to apply splints and bandages. He says that the knee is often

dislocated in walking. He must surely allude to a species of sub-luxation

first well described by the late Mr. Hey, of Leeds; for a complete

luxation is a very rare occurrence, and is never occasioned but by great

violence.

Haly Abbas and Rhases describe only three kinds of dislocation at the

knee, and deny the possibility of a dislocation forwards. Both evidently

copy from our author.

The earlier modern surgeons, as usual, adopt the views of the Arabians,

and accordingly deny the possibility of a dislocation forwards. See

Theodoricus (ii, 52.) They would appear to have been wholly unacquainted

with the works of Celsus, and to have derived all their information from

the Arabians.

Dislocations at the knee-joint are now found to be of much rarer

occurrence than they are represented to be by the ancient authorities.

In fact only a very few cases have been reported in modern times. We

would beg, therefore, to refer our readers to a case related in the

‘Medical Gazette,’ Dec. 16, 1842, by the author of this Commentary. It is

necessary to remark, however, that several typographical mistakes occur

in the Report, which are partly corrected in a subsequent number of the

same periodical.

SECT. CXX.—ON DISLOCATION AT THE ANKLE, AND ALSO OF THE TOES.

The articulation at the ankle, if but a little displaced, is remedied by

moderate extension; but if completely dislocated, it requires greater

force. We may endeavour therefore, in this case, to make strong extension

by the hands; but if reduction does not take place, having stretched

the man on the ground in a supine posture, we are to fasten into the

floor a long and strong peg, between his two thighs, so as to prevent

the body from yielding to the extension by the foot; or rather let the

peg be fastened before the man is laid down; or if we have the large

board at hand on the middle of which, as we said, a wooden peg a foot

long is fastened, we may make the extension upon it. An assistant then

grasping the thigh, and making counter-extension, another assistant is

to pull the foot with his hands or by a thong, and the surgeon is to

rectify the dislocation with his hands, while some other person keeps the

other foot down below. After the reduction it is to be bound carefully,

some folds of the bandage being carried along the front of the foot,

and some towards the ankle; but we must take care not to include the

posterior tendon which is inserted into the heel. And the man is to be

kept from walking for forty days; for those who attempt to walk before

the cure is completed impair the actions of the part. If from a leap,

as commonly happens, the bone of the heel is moved from its place, or

if any inflammatory state is brought on, it is to be remedied by gentle

extension and reduction, anti-inflammatory embrocations and secure

bandages, the man being kept also in a quiet state until the part is

restored. And dislocation of the toes, as we said with regard to the

fingers, may be remedied without difficulty by moderate extension. In all

these luxations and sub-luxations, after the reduction, and rest for a

suitable number of days, any inflammation or swelling which may remain in

the joints, and occasion a protracted impairment of the function thereof,

is to be cured by emollient applications, the materials of which must be

known to every one who is conversant with the matters relative to our art.

* * * * *

COMMENTARY. Hippocrates states that dislocation at the ankle is generally

produced by leaping from a great height. He remarks that the accident

gives rise to excessive swelling of the part. When the parts have been

reduced, he directs us to apply a bandage to retain them properly in

position, which, he says, it requires some address to perform in a

suitable manner. He recommends us to reduce dislocations of the toes

and of the bones of the foot like those of the hand. His account of

dislocations of the astragalus and of the os calcis is curious, but there

is some difficulty in clearly apprehending his views. We need scarcely

say that it is a subject still requiring elucidation.

According to Celsus, dislocations at the ankle-joint may take place in

all directions. He recommends us to reduce them with the hands, by making

extension and counter-extension. He advises us to make the patient lie in

bed longer than in ordinary cases.

Oribasius makes mention of only three modes of dislocation at the ankle;

namely, inwards, outwards, and backwards.

According to Albucasis, dislocation at the ankle can only take place

inwards or outwards. When the bones of the tarsus are displaced, he

directs us to restore them by making the patient put his foot upon the

ground; and the surgeon, by placing his foot upon it and standing erect,

is to push them into their place. After reduction, a splint is to be

put under the sole, and secured with bandages. Rhases, Avicenna, and

Haly Abbas evidently copy from our author. They give the same account as

Hippocrates of dislocation of the astragalus.

Luxations of the tarsal bones are described in Sir Astley Cooper’s

‘Surgical Lectures,’ and other modern works. Modern authors are agreed

that dislocations may take place in all directions, and that they may be

complete or incomplete. It will be remarked that Paulus makes mention of

sub-luxations.

This is the place where we shall be expected to give some account of

the knowledge possessed by the ancients of the nature and treatment of

Club-foot. It is singular that Hippocrates is almost the only ancient

author who has treated of the subject in an interesting manner, and of

him one need have little hesitation in affirming, that he displays more

practical acquaintance with it than any other writer until the time

of Stromeyer. He states that there are more than one variety of this

_impediment_; that it is not, properly speaking, a _dislocation_, but

a _declination_ of the foot from its natural position; and that most

cases of congenital club-foot admit of cure, if it be attempted before

the limb is much wasted. He gives minute directions for restoring the

limb to its proper shape by the fingers, and for securing it with waxed

bandages and compresses, above which a piece of stout leather or a plate

of lead is to be bound. Over all a leaden boot, like the Chian shoes, may

be applied if necessary. By these means, he does not hesitate to declare

that the deformity may be generally overcome more readily than one would

have believed, “without cutting or burning, or any other complex mode of

treatment.” (De Articulis, 62.) Galen’s commentary on this chapter is of

use in illustrating the text of Hippocrates, but supplies no additional

information for any practical purpose. (v, 642, ed. Basil.)

SECT. CXXI.—ON DISLOCATIONS WITH A WOUND.

In the case of dislocations with a wound the utmost discretion is

required. For these, if reduced, occasion the most imminent danger,

and sometimes death, the surrounding nerves and muscles being inflamed

by the extension, so that strong pains, spasms, and acute fevers are

produced, more particularly in the case of the elbows, knees, and joints

above, for the nearer that they are to the vital parts the greater is

the danger they induce. Wherefore, Hippocrates, by all means, forbids

us to apply reduction and strong bandaging to them, and directs us to

use only anti-inflammatory and soothing applications to them at the

commencement, for that by this treatment life may sometimes be preserved.

But what he recommends for the fingers alone, we would attempt to do

for all the other joints: at first, and while the part remains free

from inflammation, we would reduce the dislocated joint by moderate

extension, and if we succeed in our object we may persist in using the

anti-inflammatory treatment only. But if inflammation, spasm, or any of

the afore-mentioned symptoms come on, we must dislocate it again if it

can be done without violence. If, however, we are apprehensive of this

danger (for perhaps if inflammation should come on it will not yield,)

it will be better to defer the reduction of the greater joints at the

commencement; and when the inflammation subsides, which happens about the

seventh or ninth day, then, having foretold the danger from reduction,

and explained how, if not reduced, they will be mutilated for life, we

may try to make the attempt without violence, using also the lever to

facilitate the process. We are to apply the same treatment to the ulcer

as recommended for fractures with a wound.

* * * * *

COMMENTARY. Hippocrates, as stated by our author, was decidedly averse

to immediate reduction in cases of dislocation complicated with an

external wound. Hence, in compound dislocations at the ankle, he forbids

us to interfere at first, as attempts at reduction will certainly bring

on convulsions or gangrene. Modern experience agrees with that of the

father of medicine as to the danger attending these accidents. Compound

luxations at the wrist, he says, prove fatal if reduced, but if let alone

they generally get better. (De Artic. 64.) Compound dislocations at the

knee are said to be particularly dangerous. (Ibid. 66.)

Celsus follows the line of practice recommended by Hippocrates. In cases

of compound dislocations at the shoulder and hip-joint, he states that

the danger is great if they are left unreduced, but pronounces death

to be certain if they are reduced. Like Hippocrates, he approves of

immediate reduction only in dislocations of the bones of the feet and

hands. Even these, however, are not to be interfered with while the

parts are in an inflamed state. He approves of bleeding, a spare diet,

and rest. When a naked bone protrudes and cannot be got restored to its

place, he advises it to be sawed off. (viii, 25.)

Galen gives his unqualified sanction to the practice of Hippocrates. See

his commentary on the work ‘De Articulis’ and ‘Nicetæ Collectio.’

Albucasis, like our author, recommends gentle attempts at reduction

before swelling and inflammation come on, and soothing treatment

afterwards.

The practice of Haly Abbas differs nothing in principle from that of

our author and Albucasis. If reduction has not been performed early, he

forbids it until the inflammation has subsided.

Rhases appears to have copied his rules of treatment from our author.

He recommends us, if possible, to replace the parts before inflammation

comes on, but forbids it while they are in that state, for fear of

occasioning convulsions and death.

SECT. CXXII.—ON DISLOCATION COMPLICATED WITH FRACTURE.

If a dislocation be attended with fracture without a wound we must apply

the common extension, and replacement by the hands, as described for

simple fractures. But if complicated with a wound, we must apply the

suitable treatment from what has been said of fractures with a wound, and

dislocations in particular.

* * * * *

COMMENTARY. Haly Abbas says that when a wound, a fracture, and a

dislocation are combined in one case, each is to be treated upon general

principles.

Albucasis directs us to remove any spiculæ of bone which may protrude in

such cases. He exhorts the surgeon to act cautiously but confidently, as

such conduct will prove most pleasing in the sight of his Creator, and

redound to his own glory.

END OF VOL. II.

C. AND J. ADLARD, PRINTERS,

BARTHOLOMEW CLOSE.