Chapter XXV: Book VI: Sect. I.—preface to the Surgical Part (11)

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.