ON THE ARTICULATIONS
by Hippocrates
translated by Francis
Adams
ON THE ARTICULATIONS.
I am acquainted with one form in which the
shoulder-joint is
dislocated,
namely, that into the armpit; I have never seen it take
place
upward nor outward; and yet I do not positively affirm whether
it
might be dislocated in these directions or not, although I have
something
which I might say on this subject. But neither have I ever
seen
what I considered to be a dislocation forward. Physicians,
indeed,
fancy that dislocation is very apt to occur forward, and
they
are more particularly deceived in those persons who have the
fleshy
parts about the joint and arm much emaciated; for, in all
such
cases, the head of the arm appears to protrude forward. And I
in
one case of this kind having said that there was no dislocation,
exposed
myself to censure from certain physicians and common people on
that
account, for they fancied that I alone was ignorant of what
everybody
else was acquainted with, and I could not convince them
but
with difficulty, that the matter was so. But if one will strip the
point
of the shoulder of the fleshy parts, and where the muscle
(deltoid?)
extends, and also lay bare the tendon that goes from the
armpit
and clavicle to the breast (pectoral muscle?), the head of
the
humerus will appear to protrude strongly forward, although not
dislocated,
for the head of the humerus naturally inclines forward,
but
the rest of the bone is turned outward. The humerus is connected
obliquely
with the cavity of the scapula, when the arm is stretched
along
the sides; but when the whole arm is stretched forward, then the
head
of the humerus is in a line with the cavity of the humerus, and
no
longer appears to protrude forward. And with regard to the
variety
we are now treating of, I have never seen a case of
dislocation
forward; and yet I do not speak decidedly respecting it,
whether
such a dislocation may take place or not. When, then, a
dislocation
into the armpit takes place, seeing it is of frequent
occurrence,
many persons know how to reduce it, for it is an easy
thing
to teach all the methods by which physicians effect the
reductions,
and the best manner of applying them. The strongest of
those
methods should be used when the difficulty of reduction is
particularly
great. The strongest is the method to be last described.
2. Those who are subject to frequent dislocations
at the
shoulder-joint,
are for the most part competent to effect the
reduction
themselves; for, having introduced the knuckles of the other
hand
into the armpit, they force the joint upward, and bring the elbow
toward
the breast. The physician might reduce it in the same manner,
if
having introduced his fingers into the armpit on the inside of
the
dislocated joint, he would force it from the ribs, pushing his own
head
against the acromion, in order to make counter-pressure, and with
his
knees applied to the patient's elbow pushing the arm to the sides.
It
will be of advantage if the operator has strong hands, or the
physician
may do as directed with his head and hands, while another
person
brings the elbow toward the breast. Reduction of the shoulder
may
also be effected by carrying the fore-arm backward to the spine,
and
then with the one hand grasping it at the elbow, to bend the arm
upward,
and with the other to support it behind at the articulation.
This
mode of reduction, and the one formerly described, are not
natural,
and yet by rotating the bone of the joint, they force it to
return.
3. Those who attempt to perform reduction with
the heel, operate
in
a manner which is an approach to the natural. The patient must
lie
on the ground upon his back, while the person who is to effect the
reduction
is seated on the ground upon the side of the dislocation;
then
the operator, seizing with his hand the affected arm, is to
pull
it, while with his heel in the armpit he pushes in the contrary
direction,
the right heel being placed in the right armpit, and the
left
heel in the left armpit. But a round ball of a suitable size must
be
placed in the hollow of the armpit; the most convenient are very
small
and hard balls, formed from several pieces of leather sewed
together.
For without something of the kind the heel cannot reach to
the
head of the humerus, since, when the arm is stretched, the
armpit
becomes hollow, the tendons on both sides of the armpit
making
counter-contraction so as to oppose the reduction. But
another
person should be seated on the other side of the patient to
hold
the sound shoulder, so that the body may not be dragged along
when
the arm of the affected side is pulled; and then, when the ball
is
placed in the armpit, a supple piece of thong sufficiently broad is
to
be placed round it, and some person taking hold of its two ends
is
to seat himself above the patient's head to made counter-extension,
while
at the same time he pushes with his foot against the bone at the
top
of the shoulder. The ball should be placed as much on the inside
as
possible, upon the ribs, and not upon the head of the humerus.
4. There is another method of reduction performed
by the shoulder of
a
person standing. The person operating in this way, who should be
taller
than the patient, is to take hold of his arm and place the
sharp
point of his own shoulder in the patient's armpit, and push it
in
so that it may lodge there, and having for his object that the
patient
may be suspended at his back by the armpit, he must raise
himself
higher on this shoulder than the other; and he must bring
the
arm of the suspended patient as quickly as possible to his own
breast.
In this position he should shake the patient when he raises
him
up, in order that the rest of the body may be a counterpoise to
the
arm which is thus held. But if the patient be very light, a
light
child should be suspended behind along with him. These methods
of
reduction are all of easy application in the palestra, as they
can
all be performed without instruments, but they also be used
elsewhere.
5. Those who accomplish the reduction by forcibly
bending it round a
pestle,
operate in a manner which is nearly natural. But the pestle
should
be wrapped in a soft shawl (for thus it will be less slippery),
and
it should be forced between the ribs and the head of the
humerus.
And if the pestle be short, the patient should be seated upon
something,
that his arm can with difficulty pass above the pestle. But
for
the most part the pestle should be longer, so that the patient
when
standing may be almost suspended upon the piece of wood. And then
the
arm and forearm should be stretched along the pestle, whilst
some
person secures the opposite side of the body by throwing his arms
round
the neck, near the clavicle.
6. But the method with a ladder is another
of the same kind, and
still
better, since by it the body can be more safely counterpoised on
this
side; and that, while in the method which the piece of wood
resembling
a pestle, there is danger of the body tumbling to either
side.
But some round thing should be tied upon the step of the
ladder
which may be fitted to the armpit, whereby the head of the bone
may
be forced into its natural place.
7. The following, however, is the strongest
of all the methods of
reduction.
We must get a piece of wood, five, or at least four
inches
broad, two inches in thickness, or still thinner, and two
cubits
in length, or a little less; and its extremity at one end
should
be rounded, and made very narrow and very slender there, and it
should
have a slightly projecting edge (ambe) on its round
extremity,
not on the part that is to be applied to the side, but to
the
head of the humerus, so that it may be adjusted in the armpit at
the
sides under the head of the humerus; and a piece of soft shawl
or
cloth should be glued to the end of the piece of wood, so as to
give
the less pain upon pressure. Then having pushed the head of
this
piece of wood as far inward as possible between the ribs and
the
head of the humerus, the whole arm is to be stretched along this
piece
of wood, and is to be bound round at the arm, the fore-arm,
and
the wrist, so that it may be particularly well secured; but
great
pains should be taken that the extremity of this piece of wood
should
be introduced as far as possible into the armpit, and that it
is
carried past the head of the humerus. Then a cross-beam is to be
securely
fastened between two pillars, and afterward the arm with
the
piece of wood attached to it is to be brought over this
cross-beam,
so that the arm may be on the one side of it and the
body
on the other, and the cross-beam in the armpit; and then the
arm
with the piece of wood is to be forced down on the one side of the
cross-beam,
and the rest of the body on the other. The cross-beam is
to
be bound so high that the rest of the body may be raised upon
tip-toes.
This is by far the most powerful method of effecting
reduction
of the shoulder; for one thus operates with the lever upon
the
most correct principles, provided only the piece of wood be placed
as
much as possible within the head of the humerus, and thus also
the
counter-balancing weights will be most properly adjusted, and
safely
applied to the bone of the arm. Wherefore recent cases in
this
way may be reduced more quickly than could be believed, before
even
extension would appear to be applied; and this is the only mode
of
reduction capable of replacing old dislocations, and this it will
effect,
unless flesh has already filled up the (glenoid) cavity, and
the
head of the humerus has formed a socket for itself in the place to
which
it has been displaced; and even in such an old case of
dislocation,
it appears to me that we could effect reduction (for what
object
would a lever power properly applied not it move?), but it
would
not remain in its place, but would be again displaced as
formerly.
The same thing may be effected by means of the ladder, by
preparing
it in the same manner. If the dislocation be recent, a large
Thessalian
chair may be sufficient to accomplish this purpose; the
wood,
however, should be dressed up as described before; but the
patient
should be seated sideways on the chair, and then the arm, with
the
piece of wood attached to it, is to be brought over the back of
the
chair, and force is to be applied to the arm, with the wood on the
one
side, and the body on the other side. The same means may be
applied
with a double door. One should always use what happens to be
at
hand.
8. Wherefore it should be known that one constitution
differs much
from
another as to the facility with which dislocations in them may be
reduced,
and one articular cavity differs much from another, the one
being
so constructed that the bone readily leaps out and another
less
so; but the greatest difference regards the binding together of
the
parts by the nerves (ligaments?) which are slack in some and tight
in
others. For the humidity in the joints of men is connected with the
state
of the ligaments, when they are slack and yielding; for you
may
see many people who are so humid (flabby?) that when they choose
they
can disarticulate their joints without pain, and reduce them in
like
manner. The habit of the body also occasions a certain
difference,
for in those who are in a state of embonpoint and fleshy
the
joint is rarely dislocated, but is more difficult to reduce; but
when
they are more attenuated and leaner than usual, then they are
subject
to dislocations which are more easily reduced. And the
following
observation is a proof that matters are so; for in cattle
the
thighs are most apt to be dislocated at the hip-joint, when they
are
most particularly lean, which they are at the end of winter, at
which
time then they are particularly subject to dislocations (if I
may
be allowed to make such an observation while treating of a medical
subject);
and therefore Homer has well remarked, that of all beasts
oxen
suffer the most at that season, and especially those employed
at
the plow as being worked in the winter season. In them,
therefore,
dislocations happen most frequently, as being at that
time
most particularly reduced in flesh. And other cattle can crop the
grass
when it is short, but the ox cannot do so until it becomes long;
for,
in the others, the projection of the lip is slender, and so is
the
upper lip, but in the ox the projection of the lip is thick, and
the
upper jaw is thick and obtuse, and therefore they are incapable of
seizing
short herbs. But the solidungula as having prominent teeth
in
both their front jaws, can crop the grass and grasp it with their
teeth
while short, and delight more in short grass than in rank;
for,
in general, short grass is better and more substantial than rank,
as
having not yet given out its fructification. Wherefore the poet has
the
following line:
As when to horned cattle dear the vernal season
comes,*
because
rank grass appears to be most sought after by them. But
otherwise
in the ox, this joint is slacker than in other animals, and,
therefore,
this animal drags his foot in walking more than any
other,
and especially when lank and old. For all these reasons the
ox
is most particularly subject to dislocations; and I have made the
more
observations respecting him, as they confirm all that was said
before
on this subject. With regard, then, to the matter on hand, I
say
that dislocations occur more readily, and are more speedily
reduced
in those who are lean than in those who are fleshy; and in
those
who are humid and lank there is less inflammation than in such
as
are dry and fleshy, and they are less compactly knit hereafter, and
there
is more mucosity than usual in cases not attended with
inflammation,
and hence the joints are more liable to luxations;
for,
in the main, the articulations are more subject to mucosities
in
those who are lean than in those who are fleshy; and the flesh of
lean
persons who have not been reduced by a proper course of
discipline
abounds more with mucosity than that of fat persons. But in
those
cases in which the mucosity is accompanied with inflammation,
the
inflammation binds (braces?) the joint, and hence those who have
small
collections of mucosities are not very subject to
dislocations,
which they would be if the mucosity had not been
accompanied
with more or less inflammation.
*There
is no such line in the works of Homer as they have come down to
us.
9. In cases of dislocation those persons who
are not attacked with
inflammation
of the surrounding parts, can use the shoulder
immediately
without pain, and do not think it necessary to take any
precautions
with themselves; it is therefore the business of the
physician
to warn them beforehand that dislocation is more likely to
return
in such cases than when the tendons have been inflamed. This
remark
applies to all the articulations, but particularly to those
of
the shoulder and knee, for these are the joints most subject to
luxations.
But those who have inflammation of the ligaments cannot use
the
shoulder, for the pain and the tension induced by the inflammation
prevent
them. Such cases are to be treated with cerate, compresses,
and
plenty of bandages; but a ball of soft clean wool is to be
introduced
into the armpit, to fill up the hollow of it, that it may
be
a support to the bandaging, and maintain the joint in situ. The
arm,
in general, should be inclined upward as much as possible, for
thus
it will be kept at the greatest possible distance from the
place
at which the head of the humerus escaped. And when you bandage
the
shoulder you must fasten the arms to the sides with a band,
which
is to be carried round the body. The shoulder should be rubbed
gently
and softly. The physician ought to be acquainted with many
things,
and among others with friction; for from the same name the
same
results are not always obtained; for friction could brace a joint
when
unseasonably relaxed, and relax it when unseasonably hard; but we
will
define what we know respecting friction in another place. The
shoulder,
then, in such a state, should be rubbed with soft hands;
and,
moreover, in a gentle manner, and the joint should be moved
about,
but not roughly, so as to excite pain. Things get restored
sometimes
in a greater space of time, and sometimes in a smaller.
10. A dislocation may be recognized by the
following symptoms:-Since
the
parts of a man's body are proportionate to one another, as the
arms
and the legs, the sound should always be compared with the
unsound,
and the unsound with the sound, not paying regard to the
joints
of other individuals (for one person's joints are more
prominent
than another's), but looking to those of the patient, to
ascertain
whether the sound joint be unlike the unsound. This is a
proper
rule, and yet it may lead to much error; and on this account it
is
not sufficient to know this art in theory, but also by actual
practice;
for many persons from pain, or from any other cause, when
their
joints are not dislocated, cannot put the parts into the same
positions
as the sound body can be put into; one ought therefore to
know
and be acquainted beforehand with such an attitude. But in a
dislocated
joint the head of the humerus appears lying much more in
the
armpit than it is in the sound joint; and also, above, at the
top
of the shoulder, the part appears hollow, and the acromion is
prominent,
owing to the bone of the joint having sunk into the part
below;
there is a source of error in this case also, as will be
described
afterward, for it deserves to be described; and also, the
elbow
of the dislocated arm is farther removed from the ribs than that
of
the other; but by using force it may be approximated, though with
considerable
pain; and also they cannot, with the elbow extended,
raise
the arm to the ear, as they can the sound arm, nor move it about
as
formerly in this direction and that. These, then, are the
symptoms
of dislocation at the shoulder. The methods of reduction
and
the treatment are as described.
11. It deserves to be known how a shoulder
which is subject to
frequent
dislocations should be treated. For many persons owing to
this
accident have been obliged to abandon gymnastic exercises, though
otherwise
well qualified for them; and from the same misfortune have
become
inept in warlike practices, and have thus perished. And this
subject
deserves to be noticed, because I have never known any
physician
treat the case properly; some abandon the attempt
altogether,
and others hold opinions and practice the very what is
proper.
For physicians have burned the shoulders subject to
dislocation,
at the top of the shoulder, at the anterior part where
the
head of the humerus protrudes, and a little behind the top of
the
shoulder; these burnings, if the dislocation of the arm were
upward,
or forward, or backward, would have been properly performed;
but
now, when the dislocation is downward, they rather promote than
prevent
dislocations, for they shut out the head of the humerus from
the
free space above. The cautery should be applied thus: taking
hold
with the hands of the skin at the armpit, it is to be drawn
into
the line, in which the head of the humerus is dislocated; and
then
the skin thus drawn aside is to be burnt to the opposite side.
The
burnings should be performed with irons, which are not thick nor
much
rounded, but of an oblong form (for thus they pass the more
readily
through), and they are to be pushed forward with the hand; the
cauteries
should be red-hot, that they may pass through as quickly
as
possible; for such as are thick pass through slowly, and occasion
eschars
of a greater breadth than convenient, and there is danger that
the
cicatrices may break into one another; which, although nothing
very
bad, is most unseemly, or awkward. When you have burnt through,
it
will be sufficient, in most cases, to make eschars only in the
lower
part; but if there is no danger of the ulcers passing into one
another,
and there is a considerable piece of skin between them, a
thin
spatula is to be pushed through these holes which have been
burned,
while, at the same time, the skin is stretched, for
otherwise
the instrument could not pass through; but when you have
passed
it through you must let go the skin, and then between the two
eschars
you should form another eschar with a slender iron, and burn
through
until you come in contact with the spatula. The following
directions
enable you to determine how much of the skin of the
armpit
should be grasped; all men have glands in the armpit greater or
smaller,
and also in many other parts of the body. But I will treat in
another
work of the whole constitution of the glands, and explain what
they
are, what they signify, and what are their offices. The glands,
then,
are not to be taken hold of, nor the parts internal to the
glands;
for this would be attended with great danger, as they are
adjacent
to the most important nerves. But the greater part of the
substances
external to the glands are to be grasped, for there is no
danger
from them. And this, also, it is proper to know, that if you
raise
the arm much, you will not be able to grasp any quantity of skin
worth
mentioning, for it is all taken up with the stretching; and also
the
nerves. which by all means you must avoid wounding, become exposed
and
stretched in this position; but if you only raise the arm a
little,
you can grasp a large quantity of skin, and the nerves which
you
ought to guard against are left within, and at a distance from the
operation.
Should not, then, the utmost pains be taken in the whole
practice
of the art to find out the proper attitude in every case?
So
much regarding the armpit, and these contractions will be
sufficient,
provided the eschars be properly placed. Without the
armpit
there are only two places where one might place the eschars
to
obviate this affection; the one before and between the head of
the
humerus and the tendon at the armpit; and then the skin may be
fairly
burned through, but not to any great depth, for there is a
large
vein adjacent, and also nerves, neither of which must be touched
with
the heat. But externally, one may form another eschar
considerably
above the tendon at the armpit, but a little below the
head
of the humerus; and the skin must be burned fairly through, but
it
must not be made very deep, for fire is inimical to the nerves.
Through
the whole treatment the sores are to be so treated, as to
avoid
all strong extension of the arm, and this is to be done
moderately,
and only as far as the dressing requires; for thus they
will
be less cooled (for it is of importance to cover up all sorts
of
burns if one would treat them mildly), and then the lips of them
will
be less turned aside; there will be less hemorrhage and fear of
convulsions.
But when the sores have become clean, and are going on to
cicatrization,
then by all means the arm is to be bound to the side
night
and day; and even when the ulcers are completely healed, the arm
must
still be bound to the side for a long time; for thus more
especially
will cicatrization take place, and the wide space into
which
the humerus used to escape will become contracted.
12. When attempts to reduce a dislocated shoulder
have failed, if
the
patient be still growing, the bone of the affected arm will not
increase
like the sound one, for although it does increase in so far
it
becomes shorter than the other; and those persons called
weasel-armed,
become so from two accidents, either from having met
with
this dislocation in utero, or from another accident, which will
be
described afterward. But those who while they were children have
had
deep-seated suppurations about the head of the bone, all become
weasel-armed;
and this, it should be well known, will be the issue,
whether
the abscess be opened by an incision or cautery, or whether it
break
spontaneously. Those who are thus affected from birth are
quite
able to use the arm yet neither can they raise the arm to the
ear,
by extending the elbow, but they do this much less efficiently
than
with the sound arm. But in those who have had the shoulder
dislocated
after they were grown up, and when it has not been reduced,
the
top of the shoulder becomes much less fleshy, and the habit of
body
at that part is attenuated; but when they cease to have pain,
whatever
they attempt to perform by raising the elbow from the sides
obliquely,
they can no longer accomplish as formerly; but whatever
acts
are performed by carrying the arm around by the sides, either
backward
or forward, all those they can perform; for they can work
with
an auger or a saw, or with a hatchet, and can dig, by not raising
the
elbow too much, and do all other kinds of work which are done in
similar
attitudes.
13. In those cases where the acromion has been
torn off, the bone
which
is thus separated appears prominent. The bone is the bond of
connection
between the clavicle and scapula, for in this respect the
constitution
of man is different from that of other animals;
physicians
are particularly liable to be deceived in this accident
(for
as the separated bone protrudes, the top of the shoulder
appears
low and hollow), so that they make preparations as if for
dislocation
of the shoulder; for I have known many physicians,
otherwise
not inexpert at the art, who have done much mischief by
attempting
to reduce such shoulders, thus supposing it a case of
dislocation;
and they did not desist until they gave over mistake of
supposing
that they had reduced the shoulder. The treatment, in
these
cases, is similar to that which is applicable in others of a
like
kind, namely, cerate, compresses, and suitable bandaging with
linen
cloths. The projecting part must be pushed down, and the greater
number
of compresses are to be placed on it, and most compression is
to
be applied at that part, and the arm being fastened to the side
is
to be kept elevated; for thus the parts which had been torn asunder
are
brought into closest proximity with one another. All this should
be
well known, and if you choose you may prognosticate safely that
no
impediment, small or great, will result from such an injury at
the
shoulder, only there will be a deformity in the place, for the
bone
cannot be properly restored to its natural situation, but there
must
necessarily be more or less tumefaction in the upper part. For
neither
can any other bone be made exactly as it was, which having
become
incorporated with another bone, and having grown to it as an
apophysis,
has been torn from its natural situation. If properly
bandaged,
the acromion becomes free of pain in a few days.
14. When a fractured clavicle is fairly broken
across it is more
easily
treated, but when broken obliquely it is more difficult to
manage.
Matters are different in these cases from what one would
have
supposed; for a bone fairly broken across can be more easily
restored
to its natural state, and with proper care the upper part may
be
brought down by means of suitable position and proper bandaging,
and
even if not properly set, the projecting part of the bone is not
very
sharp. But in oblique fractures the case is similar to that of
bones
which have been torn away, as formerly described; for they do
not
admit of being restored to their place, and the prominence of
the
bone is very sharp. For the most part, then, it should be known,
no
harm results to the shoulder or to the rest of the body from
fracture
of the clavicle, unless it sphacelate, and this rarely
happens.
A deformity, however, may arise from fracture of the
clavicle,
and in these cases it is very great at first, but by and
by
it becomes less. A fractured clavicle, like all other spongy bones,
gets
speedily united; for all such bones form callus in a short
time.
When, then, a fracture has recently taken place, the patients
attach
much importance to it, as supposing the mischief greater than
it
really is, and the physicians bestow great pains in order that it
may
be properly bandaged; but in a little time the patients, having no
pain,
nor finding any impediment to their walking or eating, become
negligent;
and the physicians finding they cannot make the parts
look
well, take themselves off, and are not sorry at the neglect of
the
patients, and in the meantime the callus is quickly formed. The
method
of dressing which is most appropriate, is similar to that
used
in ordinary cases, consisting of cerate, compresses, and
bandages;
and it should be most especially known in this operation,
that
most compresses should be placed on the projecting bone, and that
the
greatest pressure should be made there. There are certain
physicians
who make a show of superior skill by binding a heavy
piece
of lead on the part in order to depress the projecting bone; but
this
mode of treatment does not apply to the clavicle, for it is
impossible
to depress the projecting part to any extent worth
mentioning.
There are others who, knowing the fact that the bandages
are
apt to slip off, and that they do not keep the projecting parts in
their
place, apply compresses and bandages like the others, and then
having
girt the patient with a girdle, where it is usually applied
with
most effect, they make a heap of the compresses upon of the
compresses
upon the projecting bone when they apply them, and having
fastened
the head of the bandage to the girdle in front, they apply it
so
as to bring the turns of it into the line of the clavicle, carrying
them
to the back, and then bringing them around the girdle they
carry
them to the fore part and again backward. There are others who
do
not apply the bandage round the girdle, but carry the rounds of
it
by the perineum and anus, and along the spine, so as to compress
the
fracture. To an inexperienced person these methods will appear not
far
from natural, but when tied, they will be found of no service; for
they
do not remain firm any length of time, even if the patient keep
his
bed, although in this position they answer best; and yet even when
lying
in bed, should he bend his leg, or should his trunk be bent, all
the
will be displaced; and, moreover, the bandaging is inconvenient,
in
as much as the anus is comprehended by it, and many turns of the
bandage
are crowded there in a narrow space. And in the method with
the
girdle, the girdle cannot be so firmly girt around, but that the
turns
of the bandage force the girdle to ascend, and hence of
necessity
all the other bandages must be slackened. He would seem to
me
to come nearest his purpose, although after all he effects but
little,
who would take a few turns round the girdle, few turns round
the
girdle, but would use the bandage principally to secure the former
bandaging;
for in this manner the bandages would be most secure, and
would
mutually assist one another. Every thing now almost has been
said
which applies to fracture of the clavicle. But this also should
be
known, that in fractures of the clavicle, it is the part attached
to
the breast which is uppermost, and that the piece attached to the
acromion
is the lowermost. The cause of this is, that for the most
part
the breast can neither be depressed nor raised, there being but a
slight
movement of the joint at the breast, for the sternum is
connected
together on both sides with the spine. The clavicle admits
of
most motion at the joint of the shoulder, and this arises from
its
connection with the acromion. And, moreover, when broken, the part
which
is connected with the sternum flies upward, and is not easily
forced
downward; for it is naturally light, and there is more room for
it
above than below. But the shoulder, the arm, and the parts
connected
with them, are easily moved from the sides and breast,
and,
on that account, they admit of being considerably elevated and
depressed.
When, therefore, the clavicle is broken, the fragment
attached
to the shoulder inclines downward, for it inclines much
more
readily with the shoulder and arm downward than upward. Matters
being
as I have stated, they act imprudently who think to depress
the
projecting end of the bone. But it is clear that the under part
ought
to be brought to the upper, for the former is the movable
part,
and that which has been displaced from its natural position.
It
is obvious, therefore, that there is no other way of applying force
to
it (for the bandages no more force it to than they force it
from);
but if one will push the arm when at the sides as much as
possible
upward, so that the shoulder may appear as sharp as possible,
it
is clear that in this way it will be adjusted to the fragment of
the
bone connected with the breast from which it was torn. If one then
will
apply a bandage, secundum artem, for the purpose of promoting a
speedy
cure, and will reckon everything else of no value, except the
position
as described, he will form a correct opinion of the case, and
will
effect a cure in the speediest and most appropriate manner. It is
of
great importance, however, that the patient should lie in a
recumbent
posture. Fourteen days will be sufficient if he keep
quiet,
and twenty at most.
15. But if the clavicle be fractured in the
opposite manner (which
does
not readily happen), so that the fragment of bone connected
with
the breast is depressed, while the piece connected with the
acromion
is raised up and rides over other, this case does not require
much
management, for if the shoulder and arm be let go, the
fragments
of the bone will be adjusted to one another, and an ordinary
bandage
will suffice, and the callus will be formed in the course of a
few
days.
16. If the fracture be not thus, but if it
incline either forward or
backward,
it may be restored to its natural position, by raising the
shoulder
with the arm as formerly described, and brought back to its
natural
place, when the cure will be speedily accomplished. Most of
the
varieties of displacement may be rectified by raising the arm
upward.
When the upper bone is displaced laterally or downward, it
would
favor the adaptation of the parts if the patient would lie on
his
back, and if some elevated substance were placed between the
shoulder-blades,
so that the breast may be depressed as much as
possible
upon the two sides; and if, while another person raised the
arm
extended along the sides, the physician, applying the palm of
the
one hand to the head of the bone, would push it away, and with the
other
would adjust the broken bones, he would thus reduce the parts
most
readily to their natural position. But, as formerly stated, the
upper
bone (sternal fragment?) is rarely depressed downward. In most
cases,
after the bandages have been applied, that position is
beneficial
in which the elbow is fixed to the same side, and the
shoulder
is kept elevated; but in certain cases, the shoulder is to be
raised,
as has been directed, and the elbow is to be brought forward
to
the breast, and the hand laid on the acromion of the sound side. If
the
patient has the resolution to lie in bed, something should be
placed
so as to support the shoulder, and keep it as much elevated
as
possible. But if he walk about, the arm should be slung in a shawl,
which
embraces the point of the elbow, and is passed round the neck.
17. When the elbow-joint is displaced or dislocated
to the side or
outward,
while its sharp point (olecranon?) remains in the cavity of
the
humerus, extension is to be made in a straight line, and the
projecting
part is to be pushed backward and to the side.
18. In complete dislocations toward either
side, extension is to
be
made as in bandaging fracture of the arm; for thus the rounded part
of
the elbow will not form an obstacle to it. Dislocation, for the
most
part, takes place toward the sides (inwardly?). Reduction is to
be
effected by separating (the bones) as much as possible, so that the
end
(of the humerus) may not come in contact with the olecranon, and
it
is to be carried up, and turned round, and not forced in a straight
line,
and, at the same time, the opposite sides are to be pushed
together,
and propelled into their proper place. It will further
assist
if rotation of the fore-arm be made at the elbow, sometimes
turning
it into a supine position, and sometimes into a prone. The
position
for the treatment consists in keeping the hand a little
higher
than the elbow, and the arm at the sides; then it may either be
suspended
or laid at rest, for either position will answer; and nature
and
the usage of common means will accomplish the cure, if the
callus
does not form improperly: it is formed quickly. The treatment
is
to be conducted with bandages according to the rule for bandaging
articulations,
and the point of the elbow is to be included in the
bandage.
19. Dislocations at the elbow give rise to
the most serious
consequences,
such as fevers, pain, nausea, vomitings of pure bile,
and
more especially when the humerus is displaced backward from
pressure
on the nerve, which occasions numbness; next to it is the
dislocation
forward; the treatment is the same; reduction in
dislocation
backward is by extension and adaptation; the symptom of
this
variety-loss of the power of extension; of dislocation
forward-loss
of the power of flexion, and in this case reduction is to
be
accomplished by placing a hard ball (in the bend of the elbow), and
bending
the fore-arm about it, along with sudden extension.
20. Diastasis of the bones may be recognized
by examining the part
where
the vein that runs along the arm divides.
21. In those cases callus is quickly formed.
In congenital
dislocations
the bones below the seat of the injury are shorter than
natural,
and, mostly, those nearest to the place; namely, the bones of
the
fore-arm, next those of the hand; and, third, those of the
fingers.
The arm and shoulder are stronger, owing to the nourishment
which
they receive, and the other arm, from the additional work
which
it has to perform, is still more strong. Wasting of the flesh
takes
place on the inside if the dislocation be on the outside; or
otherwise,
on the side opposite the dislocation.
22. When the elbow is dislocated either inward
or outward, extension
is
to be made with the fore-arm at a right angle to the arm; the
arm,
suspended by means of a shawl passed through the armpit, and a
weight
attached to the extremity of the elbow; or force may be applied
with
the hands; when the articular extremity has been cleared, the
displaced
parts are to be rectified with the palms of the hand, as
in
dislocations of the hands. It is to be bandaged, suspended in a
sling,
and placed while in this attitude.
23. Dislocations backward are to be rectified
by the palms of the
hands,
along with sudden extension; the two acts are to be performed
together,
as in other cases of the kind. But in dislocation forward
the
arm is to be bent around a ball of cloth of proper size, and at
the
same time replaced.
24. But if the displacement be on the other
side, both these
operations
are to be performed in effecting the adjustment. For
conducting
the treatment, the position and bandaging are the same as
in
the other cases. But all these cases may be reduced by ordinary
distention.
25. Of the methods of reduction, some operate
by raising up the
part,
some by extension, and some by rotation: the last consists in
rapidly
turning the fore-arm to this side and that.
26. The joint of the hand is dislocated either
inward or outward,
most
frequently inward. The symptoms are easily recognized: if inward,
the
patient cannot at all bend his fingers; and if outward, he
cannot
extend them. With regard to the reduction,-by placing the
fingers
above a table, extension and counter-extension are to be
made
by other persons, while with the palm or heel of the hand on
the
projecting bone one pushes forward, and another from behind on the
other
bone; some soft substance is to be applied to it, and the arm is
to
be turned to the prone position if the dislocation was forward, but
to
the supine, if backward. The treatment is to be conducted with
bandages.
27. The whole hand is dislocated either inward
or outward, or to
this
side or that, but more especially inward; and sometimes the
epiphysis
is displaced, and sometimes the other of these bones is
separated.
In these cases strong extension is to be applied, and
pressure
is to be made on the projecting bone, and counter-pressure on
the
opposite side, both at the same time, behind and at the side, with
the
hands upon a table, or with the heel. These accidents give rise to
serious
consequences and deformities; but in the course of time the
part
gets strong, and admits of being used. The cure is with bandages,
which
ought to embrace both the hand and fore-arm; and splints are
to
be applied as far as the fingers; and when they are used they
should
be more frequently unloosed than infractures, and more
copious
affusions of water should be used.
28. In congenital dislocations (at the wrist)
the hand becomes
shortened,
and the atrophy of the flesh occurs, for the most part,
on
the side opposite to the dislocation. In an adult the bones
remain
of their natural size.
29. Dislocation at the joint of a finger is
easily recognized.
Reduction
is to be effected by making extension in a straight line,
and
applying pressure on the projecting bone, and counter-pressure
on
the opposite side of the other. The treatment is with bandages.
When
not reduced, callus is formed outside of the joint. When the
dislocation
takes place at birth, during adolescence the bones below
the
dislocation are shortened, and the flesh is wasted rather on the
opposite
than on the same side with the dislocation. When it occurs in
an
adult the bones remain of their proper size.
30. The jaw-bone, in few cases, is completely
dislocated, for the
zygomatic
process formed from the upper jaw-bone (malar?) and the bone
behind
the ear (temporal?) shuts up the heads of the under jaw,
being
above the one (condyloid process?), and below the other
(coronoid
process?). Of these extremities of the lower jaw, the one,
from
its length, is not much exposed to accidents, while the other,
the
coronoid, is more prominent than the zygoma, and from both these
heads
nervous tendons arise, with which the muscles called temporal
and
masseter are connected; they have got these names from their
actions
and connections; for in eating, speaking, and the other
functional
uses of the mouth, the upper jaw is at rest, as being
connected
with the head by synarthrosis, and not by diarthrosis
(enarthrosis?):
but the lower jaw has motion, for it is connected with
the
upper jaw and the head by enarthrosis. Wherefore, in convulsions
and
tetanus, the first symptom manifested is rigidity of the lower
jaw;
and the reason why wounds in the temporal region are fatal and
induce
coma, will be stated in another place. These are the reasons
why
complete dislocation does not readily take place, and this is
another
reason, because there is seldom a necessity for swallowing
so
large pieces of food as would make a man gape more than he easily
can,
and dislocation could not take place in any other position than
in
great gaping, by which the jaw is displaced to either side. This
circumstance,
however, contributes to dislocation there; of nerves
(ligaments?)
and muscles around joints, or connected with joints, such
as
are frequently moved in using the member are the most yielding to
extension,
in the same manner as well-dressed hides yield the most.
With
regard, then, to the matter on hand, the jaw-bone is rarely
dislocated,
but is frequently slackened (partially displaced?) in
gaping,
in the same manner as many other derangements of muscles and
tendons
arise. Dislocation is particularly recognized by these
symptoms:
the lower jaw protrudes forward, there is displacement to
the
opposite side, the coronoid process appears more prominent than
natural
on the upper jaw, and the patient cannot shut his lower jaw
but
with difficulty. The mode of reduction which will apply in such
cases
is obvious: one person must secure the patient's head, and
another,
taking hold of the lower jaw with his fingers within and
without
at the chin, while the patient gapes as much as he can,
first
moves the lower jaw about for a time, pushing it to this side
and
that with the hand, and directing the patient himself to relax the
jaw,
to move it about, and yield as much as possible; then all of a
sudden
the operator must open the mouth, while he attends at the
same
time to three positions: for the lower jaw is to be moved from
the
place to which it is dislocated to its natural position; it is
to
be pushed backward, and along with these the jaws are to be brought
together
and kept shut. This is the method of reduction, and it cannot
be
performed in any other way. A short treatment suffices, a waxed
compress
is to be laid on, and bound with a loose bandage. It is safer
to
operate with the patient laid on his back, and his head supported
on
a leather cushion well filled, so that it may yield as little as
possible,
but some person must hold the patient's head.
31. When the jaw is dislocated on both sides,
the treatment is the
same.
The patients are less able to shut the mouth than in the
former
variety; and the jaw protrudes farther in this case, but is not
distorted;
the absence of distortion may be recognized by comparing
the
corresponding rows of the teeth in the upper and lower jaws. In
such
cases reduction should be performed as quickly as possible; the
method
of reduction has been described above. If not reduced, the
patient's
life will be in danger from continual fevers, coma
attended
with stupor (for these muscles, when disordered and stretched
preternaturally,
induce coma); and there is usually diarrhea
attended
with billous, unmixed, and scanty dejections; and the
vomitings,
if any, consist of pure bile, and the patients commonly die
on
the tenth day.
32. In fracture of the lower jaw, when the
bone is not fairly broken
across,
and is still partially retained, but displaced, it should be
adjusted
by introducing the fingers at the side of the tongue, and
making
suitable counter-pressure on the outside; and if the teeth at
the
wound be distorted and loosened, when the bone is adjusted, they
should
be connected together, not only two, but more of them, with a
gold
thread, if possible, but otherwise, with a linen thread, until
the
bone be consolidated, and then the part is to be dressed with
cerate,
a few compresses, and a few bandages, which should not be very
tight,
but rather loose. For it should be well known that in
fracture
of the jaw, dressing with bandages, if properly performed, is
of
little advantage, but occasions great mischief if improperly
done.
Frequent examinations should be made about the tongue, and
prolonged
pressure should be applied with the fingers, in order to
rectify
the displaced bone. It would be best if one could do so
constantly,
but that is impossible.
33. But if the bone be fairly broken across
(this, however, rarely
happens),
it is to be set in the manner now described. When
adjusted,
the teeth are to be fastened together as formerly described,
for
this will contribute much toward keeping the parts at rest,
especially
if properly fastened, and the ends of the thread secured
with
knots. But it is not easy to describe exactly in writing the
whole
manipulation of the case; but the reader must figure the thing
to
himself from the description given. Then one must take a piece of
Carthaginian
leather; if the patient be a younger person, it will be
sufficient
to use the outer skin, but if an adult the whole
thickness
of the hide will be required; it is to be cut to the breadth
of
about three inches, or as much as will be required, and having
smeared
the jaw with a little gum (for thus it sticks more
pleasantly),
the end of the skin is to be fastened with the glue
near
the fractured part of the jaw, at the distance of an inch or a
little
more, from the wound. This piece is to be applied below the
jaw;
but the thong should have a cut in it, in the direction of the
chin,
so that it may go over the sharp point of the chin. Another
piece
of thong like this, or somewhat broader, is to be glued to the
upper
part of the jaw, at about the same distance from the wound as
the
other thong; this thong should be so cut as to encircle the ear.
The
thongs should be sharp-pointed at the part where they unite, and
in
gluing them, the flesh of the thong should be turned to the
patient's
skin, for in this way it will be more tenacious; then we
must
stretch this thong, but still more so the one at the chin, in
order
to prevent the fragments of the jaw from riding over each other,
and
the thongs are to be fastened at the vertex, and then a bandage is
to
be bound round the forehead, and a proper apparatus is to be put
over
all, to prevent the bandages from being displaced. The patient
should
lie upon the sound side of the jaw, not resting upon the jaw,
but
upon the head. He is to be kept on a spare diet for ten days,
and
then nourished without delay. If there be no inflammation during
the
first days, the jaw is consolidated in twenty days; for callus
quickly
forms in this, as in all the other porous bones, provided
there
be no sphacelus (exfoliation?). But much remains to be said on
the
sphacelus of bones in another place. This method of distention
with
glued substances is mild, of easy application, and is useful
for
many dislocations in many parts of the body. Those physicians
who
have not judgment combined with their dexterity, expose themselves
in
fractures of the jaws, as in other cases, for they apply a
variety
of bandages to a fractured jaw-bone, sometimes properly, and
sometimes
improperly. For all such bandaging of a fractured jawbone
has
a tendency rather to derange the bones connected with the
fracture,
than to bring them into their natural position.
34. But if the lower jaw be disjointed at its
symphysis in the
chin
(there is but one symphysis in the lower jaw, but there are
several
in the upper; but I am unwilling to digress from the
subject,
as these matters will have to be touched upon in other
kinds
of disease)-if, then, the symphysis be separated at the chin, it
is
the work which anybody can perform, to rectify it; for the part
which
protrudes is to be pushed inward by pressure with the fingers,
and
the part that inclines inward is to forced outward by pushing with
the
fingers from within. It is after having applied extension to
separate
the fragments that this is to be done, for they will thus
be
more easily restored to their natural position, than if one
should
bring them together by using force. This is proper to be
known
as applying to all such cases. When you have set the parts,
you
must fasten the teeth on both sides to one another, as formerly
directed.
The treatment is to be accomplished with cerate, a few
compresses,
and bandages. This part, in particular, requires a short
but
complex (?) bandaging, for it is nearly cylindrical, though not
exactly
so; but the turn of the bandage is to be made, if the right
jaw
was dislocated, to the right hand (that is said to be to the right
hand
when the right hand conducts the bandaging); but if the other jaw
be
the seat of the dislocation, the bandaging is to be made in the
other
direction. And if matters be properly adjusted, and the
patient
keep quiet, there will be a speedy recovery, and the teeth
will
be uninjured; but if not, the recovery will be more protracted,
the
teeth will be distorted, will give trouble, and become useless.
35. Of fractures of the nose there are more
than one variety, but
those
who, without judgment, delight in fine bandagings, do much
mischief,
most especially in injuries about the nose. For this is
the
most complex of all the forms of bandaging, having most of the
turns
of the bandage called "ascia," and rhomboidal intervals and
uncovered
spaces of the skin. As has been said, those who practice
manipulation
without judgment are fond of meeting with a case of
fractured
nose, that they may apply the bandage. For a day or two,
then,
the physician glories in his performance, and the patient who
has
been bandaged is well pleased, but speedily the patient
complains
of the incumbrance of the bandage, and the physician is
satisfied,
because he has had an opportunity of showing his skill in
applying
a complex bandage to the nose. Such a bandaging does
everything
the very reverse of what is proper; for, in the first
place,
those who have their nose flattened by the fracture, will
clearly
have the part rendered still more flat, if pressure above be
applied
to it; and further, those cases in which the nose is distorted
to
either side, whether at the cartilage or higher up, will
evidently
derive no benefit from bandaging above it, but will rather
be
injured; for it will not admit of having compresses properly
arranged
on either side of the nose, and indeed, persons applying this
bandage
do not seek to do this.
36. This bandaging would appear to me to answer
best when the skin
surrounding
the bone is contused on its ridge near the middle, or if
the
bone itself have sustained some injury, but not a great one, in
such
cases, redundant callus forms in the nose, and the part becomes a
little
too prominent; and yet, even in these cases, the bandaging need
not
require much trouble, if, indeed, any bandage be applied at all;
for
it is enough if one lay a waxed compress on the contusion, and
then
apply the double-headed bandage, thus taking one turn with it.
The
best application to such accidents is a small cataplasm of wheaten
flour,
washed, and mixed up into a viscid mass. If the flour be made
from
good wheat, and if it be glutinous, it should be used alone for
all
such cases, but if it be not very glutinous, a little of the manna
of
frankincense, well pulverized, is to be moistened with water, and
the
flour is to be mixed up with it, or a very little gum may be mixed
in
like manner.
37. In those cases in which the fractured portions
are depressed and
flattened,
if it is depressed in front at the cartilage, something may
be
introduced into the nostrils to rectify the parts. If not, all such
deformities
may be restored by introducing the fingers into the
nostrils,
if this can be managed, but if not, a thick spatula is to be
introduced
with the fingers, not to the fore part of the nose, but
to
the depressed portion, and the physician is to take hold of the
nose
externally on both sides, and at the same time raise it up. And
if
the fracture be much in the fore part one may introduce into the
nostrils
as already stated, either caddis scraped from a linen
towel,
or something such wrapped up in a piece of cloth, or rather
stitched
in Carthaginian leather, and moulded into a shape suitable to
the
place into which it is to be introduced. But if the fracture be at
a
greater distance, it is not possible to introduce anything within,
for
if it was irksome to bear anything of the kind in the fore part,
how
is it not to be so when introduced farther in? At first, then,
by
rectifying the parts from within, and sparing no pains upon them
from
without, they are to be brought to their natural position, and
set.
A fractured nose may be readily restored to shape, especially
on
the day of the accident, or even a little later, but the physicians
act
irresolutely, and touch it more delicately at first than they
should;
for the fingers should be applied on both sides along the
natural
line of the nose, and it is to be pushed downward, and thus,
with
pressure from within, the displacement is to be rectified. But
for
these purposes no physician is equal to the index-fingers of the
patient
himself, if he will pay attention and has resolution, for they
are
the most natural means. Either of the fingers is to be placed
firmly
along the whole nose, and thus it is to be gently held, and
steadily,
if possible until it become firm, but if not, he himself
is
to hold it for as long a time as possible, or if he cannot, a child
or
woman should do it, for the hands ought to be soft. Thus may a
fracture
of the nose, attended with depression, and not with
displacement
to the side, but in a straight line, be most properly
treated.
I have never seen a case of fractured nose which could not be
rectified
when attempted, before callus is formed, provided the
treatment
be properly applied. But although men would give a great
price
to escape being deformed, yet at the same time they do not
know
how to take care, nor have resolution, if they do not
experience
pain, nor fear death, although the formation of callus in
the
nose speedily place, for the most part is consolidated in ten
days,
provided sphacelus do not take place.
38. When the fractured bone is displaced laterally,
the treatment is
the
same, but it is obvious that the reduction is to be made, not by
applying
equal force on both sides, but by pushing the displaced
portion
into its natural position, and pressing on it from without,
and
introducing something into the nostrils, and boldly rectifying the
fragments
which incline inward, until the whole be properly
adjusted,
well knowing that if you do not restore the parts at once,
it
is impossible but that the nose must be distorted. But when you
restore
the parts to their natural position, either the patient
himself,
or some other person, is to apply one finger or more to the
part
which protrudes, and keep it in position until the fracture be
consolidated;
but the little finger is, from time to time, to be
pushed
into the nostril, to rectify the parts which incline inward.
When
any inflammation supervenes, dough must be used, but attention
must
still be equally paid to the application of the fingers, although
the
dough be on the part. But if the fracture be in the cartilage,
with
lateral displacement, the end of the nose must necessarily be
distorted.
In such cases some of the aforementioned means of
reduction,
or whatever suits, is to be introduced into the nostril;
but
there are many convenient things to be found which have no
smell,
and are appropriate in other respects; thus, on one occasion, I
introduced
a slice of sheep's lung, as it happened to be at hand;
for
sponges, if introduced, imbibe humidities. Then the outer skin
of
Carthaginian leather it to be taken, and a piece of the size of the
thumb,
or what will answer, is to be cut off and glued to the
outside
of the nostril which is turned aside, and then this piece of
thong
is to be stretched to the proper degree, or rather a little more
than
what will be sufficient to make the nose straight and regular.
Then
(for the thong must be long) it is to be brought below the ear
and
round the head, and the end of the thong may either be glued to
the
forehead, or a still longer one may be carried all round the head,
and
secured. This is a natural mode of setting the nose, is of easy
application,
and is calculated to enable the counter-extension on
the
nose to be made greater or less, as you may incline. In a case
where
the fractured nose is turned to the side, the treatment is to be
conducted
otherwise, as already described; and in most of them the
thong
ought to be glued to the end of the nose, in order to make
extension
in the opposite direction.
39. When the fracture is complicated with a
wound, one need not be
troubled
on that account, but pitch-cerate or any of the
applications
for fresh wounds is to be applied to the sores; for, in
general,
they admit of easy cure, even when there is reason to
apprehend
that pieces of bone will come out. The parts, at first,
are
to be adjusted fearlessly, taking care that nothing is omitted,
and,
subsequently, they are also to be adjusted with the fingers; more
softly,
indeed, but still it must be done; and of all parts of the
body
the nose is modeled with the greatest ease. And there is
nothing
to prevent us from having recourse to the practice of gluing
on
the thongs, and drawing the nose to the opposite side, even if
there
be a wound or the parts be inflamed, for these thongs give no
pain.
40. In fractures of the ear all sorts of bandages
do harm. For one
would
not think of applying it quite loose, and if applied more
tightly,
it only does the more harm, for even the sound ear, when
confined
with a bandage, becomes painful, throbs, and gets into a
febrile
state. With regard to cataplasms, the heaviest, on the
whole,
are the worst; but almost all kinds are bad, form abscesses,
occasion
an increase of humors, and afterward troublesome
suppurations;
and a fractured ear stands in less need of such
applications
than any other part; the most ready, if required, is
the
paste of meal, but neither should it have weight. It should
touch
as little as possible; for it is a good sometimes to apply
nothing
at all, both to the ear and to many other cases. Attention
must
be paid to the patient's position during sleep. And the body must
be
reduced, more especially if there be danger lest the ear suppurate;
it
will also be better to open the bowels, and if the patient can be
readily
made to vomit, this may be accomplished by means of the
syrmaism.
If the part come to suppuration, it should not be hastily
opened;
for often when matter appears to be formed it is absorbed
again,
even when no cataplasm is applied. But if forced to open it,
the
part will get soonest well if transfixed with a cautery, and yet
it
should be well understood that the ear gets maimed, and is less
than
the other if burned through. If not burned through, an
incision,
and not a very small one, should be made on the upper
side;
for the pus is found to be surrounded with a thicker covering
than
one would have supposed; and it may be said, in general, that all
parts
of a mucous nature and which form mucus, as being all viscid,
when
touched, slip from below the fingers to either side; and on
that
account the physician, in such cases, finds that he has to pass
his
instrument through a thicker substance than he supposed; and in
certain
ganglionic cases, when the skin is flabby and mucous, many
physicians
open them, expecting to find a collection in them; here the
physician
forms a wrong judgment, but by such a procedure no great
harm
results to the patient from having had the part opened. But
with
regard to watery parts, and such as are filled with mucus, and
which
are situated in regions where every one of the parts, if opened,
will
occasion death or some other injury, these will be treated of
in
another work. When, therefore, incision is made in the ear, all
sorts
of cataplasms and pledges should be avoided, and it is to be
treated
either with applications for recent wounds, or anything else
which
is neither heavy nor will occasion pain, for if the cartilage be
laid
bare and abscesses form, the case will be troublesome; this
happens
from such modes of treatment. In all aggravated cases, the
most
effectual remedy is the transfixing of the part with a hot iron.
41. The vertebrae of the spine when contracted
into a hump behind
from
disease, for the most part cannot be remedied, more especially
when
the gibbosity is above the attachment of the diaphragm to the
spine.
Certain of those below the diaphragm are carried off by varices
in
the legs, more especially by such as occur in the vein at the
ham;
and in those cases where the gibbosities are removed, the varices
take
place also in the groin; and some have been carried off by a
dysentery
when it becomes chronic. And when the gibbosity occurs in
youth
before the body has attained its full growth, in these cases the
body
does not usually grow along the spine, but the legs and the
arms
are fully developed, whilst the parts (about the back) are
arrested
in their development. And in those cases where the
gibbosity
is above the diaphragm, the ribs do not usually expand
properly
in width, but forward, and the chest becomes sharp-pointed
and
not broad, and they become affected with difficulty of breathing
and
hoarseness; for the cavities which inspire and expire the breath
do
not attain their proper capacity. And they are under the
necessity
of keeping the neck bent forward at the great vertebra, in
order
that their head may not hang downward; this, therefore,
occasions
great contraction of the pharynx by its inclination
inward;
for, even in those who are erect in stature, dyspnoea is
induced
by this bone inclining inward, until it be restored to its
place.
From this frame of body, such persons appear to have appear
to
have more prominent necks than persons in good health, and they
generally
have hard and unconcocted tubercles in the lungs, for the
gibbosity
and the distension are produced mostly by such tubercles,
with
which the neighboring nerves communicate. When the gibbosity is
below
the diaphragm, in some of these cases nephritic diseases and
affections
of the bladder supervene, but abscesses of a chronic
nature,
and difficult to cure, occur in the loins and groins, and
neither
of these carries off the gibbosity; and in these cases the
hips
are more emaciated than when the gibbosity is seated higher up;
but
the whole spine is more elongated in them than in those who have
the
gibbosity seated higher up, the hair of the pubes and chin is of
slower
growth and less developed, and they are less capable of
generation
than those who have the gibbosity higher up. When the
gibbosity
seizes persons who have already attained their full
growth,
it usually occasions a crisis of the then existing disease,
but
in the course of time some of them attack, as in the case of
younger
persons, to a greater or less degree; but, not withstanding,
for
the most part, all these diseases are less malignant. And yet many
have
borne the affection well, and have enjoyed good health until
old
age, more especially those persons whose body is inclined to be
plump
and fat; and a few of them have lived to beyond sixty years of
age,
but the most of them are more short-lived. In some cases the
curvature
of the spine is lateral, that is to say, either to the one
side
or the other; the most of such cases are connected with tubercles
(abscesses?)
within the spine; and in some, the positions in which
they
have been accustomed to lie cooperate with the disease. But these
will
be treated of among the chronic affections of the lungs; for
these
the most suitable prognostics of what will happen in these cases
are
given.
42. When the spine protrudes backward, in consequence
of a fall,
it
seldom happens that one succeeds in straightening it. Wherefore
succussion
on a ladder has never straightened anybody, as far as I
know,
but it is principally practiced by those physicians who seek
to
astonish the mob-for to such persons these things appear wonderful,
for
example, if they see a man suspended or thrown down, or the
like;
and they always extol such practices, and never give
themselves
any concern whatever may result from the experiment,
whether
bad or good. But the physicians who follow such practices,
as
far as I have known them, are all stupid. The device, however, is
an
old one, and I give great praise to him who first invented this,
and
any other mechanical contrivance which is according to nature. For
neither
would I despair, but that if succussion were properly gone
about,
the spine, in certain cases, might be thereby rectified. But,
indeed,
for my own part, I have been ashamed to treat all such cases
in
this way, because such modes of procedure are generally practiced
by
charlatans.
43 Those cases in which the gibbosity is near
the neck, are less
likely
to be benefited by these succussions with the head downward,
for
the weight of the head, and tops of the shoulders, when allowed to
hang
down, is but small; and such cases are more likely to be made
straight
by succussion applied with the feet hanging down, since the
inclination
downward is greater in this way. When the hump is lower
down,
it is more likely in this case that succussion with the head
downward
should do good. If one, then, should think of trying
succussion,
it may be applied in the following manner:-The ladder is
to
be padded with leather lined cushions, laid across, and well
secured
to one another, to a somewhat greater extent, both in length
and
breadth, than the space which the man's body will occupy; he is
then
to be laid on the ladder upon his back, and the feet, at the
ankles,
are to be fastened, at no great distance from one another,
to
the ladder, with some firm but soft band; and he is further to be
secured,
in like manner, both above and below the knee, and also at
the
nates; and at the groins and chest loose shawls are to be put
round
in such a fashion as not to interfere with the effect of the
succussion;
and his arms are to be fastened along his sides to his own
body,
and not to the ladder. When you have arranged these matters
thus,
you must hoist up the ladder, either to a high tower or to the
gable-end
of a house; but the place where you make the succussion
should
be firm, and those who perform the extension should be well
instructed,
so that they may let go their hold equally to the same
extent,
and suddenly, and that the ladder may neither tumble to the
ground
on either side, nor they themselves fall forward. But, if the
ladder
be let go from a tower, or the mast of a ship, fastened into
the
ground with its cordage, it will be better, so that the ropes
run
upon a pulley or axle-tree. But it is disagreeable even to enlarge
upon
these matters; and yet, by the contrivances now described, the
proper
succussion may be made.
44. But if the hump be situated very high up,
and if succussion be
by
all means to be used, it will be better to do it with the feet
downward,
as has been said, for the force downward will be the greater
in
this case. The patient is to be well fastened to the ladder by
cords
at the breast, at the neck by means of a very loose shawl so
as
merely to keep the part properly on the ladder, and the head is
to
be fastened to the ladder at the forehead, the arms are to be
stretched
along and attached to the patient's body, and not to the
ladder,
and the rest of the body is not to be bound, except so as to
keep
it in place by means of a loose shawl wrapped round it and the
ladder;
attention, moreover, should be paid that these ligatures do
not
interfere with the force of the succussion, and the legs are not
to
be fastened to the ladder, but should be placed near one another,
so
as to be in line with the spine. These matters should be thus
arranged,
if recourse is to be had at all to succussion on a ladder;
for
it is disgraceful in every art, and more especially in medicine,
after
much trouble, much display, and much talk, to do no good after
all.
45. In the first place, the structure of the
spine known, for this
knowledge
is requisite in many diseases. Wherefore, on the side turned
to
the belly (the anterior?) the vertebrae are in a regular line,
and
are united together by a pulpy and nervous band of connection,
originating
from the cartilages, and extending to the spinal marrow.
There
are certain other nervous cords which decussate, are attached
(to
the vertebrae?), and are extended from both sides of them. But
we
will describe in another work the connections of the veins and
arteries,
their numbers, their qualities, their origin, their
functional
offices in particular parts, in what sort of sheaths the
spinal
marrow is inclosed, where they arise, where they terminate, how
they
communicate, and what their uses. On the opposite side
(behind?)
the vertebrae are connected together by a ginglymoid
articulation.
Common cords (nerves?) are extended to all parts, both
those
within and without. There is an osseous process from the
posterior
part of all and each of the vertebra, whether greater or
smaller;
and upon these processes there are cartilaginous epiphyses,
and
from them arise nervous productions (ligaments?), akin to the
external
nerves (tonoi). The ribs are united to them, having their
heads
inclined rather to the inside than the out, and every one of
them
is articulated with the vertebrae; and the ribs in man are very
curved,
and, as it were, arched. The space between the ribs and the
processes
of the vertebrae is filled on both sides by muscles, which
arise
from the neck and extend to the loins (?). The spine,
longitudinally,
is a straight line slightly curved; from the os sacrum
to
the great vertebra which is connected with the articulation of
the
femur, the spine inclines backward, for the bladder, the organs of
generation,
and the loose portion of the rectum, are situated there.
From
this, to the attachment of the diaphragm, the spine inclines
inward,
and this portion alone, from the internal parts, gives
origin
to muscles, which are called psoae. From this to the great
vertebra
(seventh cervical?) which is above the tops of the shoulders,
it
is convex behind lengthways; but it is more in appearance than it
really
is, for the spinous processes are highest in the middle, and
less
so above and below. The region of the neck is convex before.
46. In cases of displacement backward along
the vertebrae, it does
not
often happen, in fact, it is very rare, that one or more vertebrae
are
torn from one another and displaced. For such injuries do not
readily
occur, as the spine could not easily be displaced backward but
by
a severe injury on the fore part through the belly (which would
prove
fatal), or if a person falling from a height should pitch on the
nates,
or shoulders (and even in this case he would die, but not
immediately);
and it also would not readily happen that such a
displacement
could take place forward, unless some very heavy weight
should
fall upon it behind; for each of the posterior spinal processes
is
so constructed, that it would sooner be broken than undergo any
great
inclination forward from a force which would have to overcome
the
ligaments and the articulations mutually connecting them. And
the
spinal marrow would suffer, if from the displacement of a vertebra
it
were to be bent even to a small extent; for the displaced
vertebra
would compress the spinal marrow, if it did not break it; and
if
compressed and strangled, it would induce insensibility of many
great
and important parts, so that the physician need not give himself
any
concern about rectifying the displacement of the vertebra,
accompanied,
as it is, by many other ill consequences of a serious
nature.
It is evident, then, that such a case could not be reduced
either
by succussion or by any other method, unless one were to cut
open
the patient, and then, having introduced the hand into one of the
great
cavities, were to push outward from within, which one might do
on
the dead body, but not at all on the living. Wherefore, then, do
I
write all this? Because certain persons fancy that they have cured
patients
in whom the vertebra had undergone complete dislocation
forward.
Some, indeed, suppose that this is the easiest of all these
dislocations
to be recovered from, and that such cases do not stand in
need
of reduction, but get well spontaneously. Many are ignorant,
and
profit by their ignorance, for they obtain credit from those about
them.
These are deceived in this way, for they suppose the spinous
processes
to be the vertebrae themselves, because every one of them
appears
round to the touch, not knowing that these bones are processes
from
the vertebrae, as formerly stated; but the vertebrae are at a
considerable
distance before them; for of all animals, man, in
proportion
to his bulk, has the belly (internal cavity?) the narrowest
from
behind to before, especially at the breast. When, therefore,
any
of these processes are severely fractured, whether one or more,
the
part there appears lower than on either side, and for that
reason
they are deceived, supposing that the vertebrae are displaced
inward.
And the patient contribute also to deceive them; for if they
attempt
to put themselves into a bent position, they are pained,
from
the skin being stretched at the seat of the injury, and at the
same
time the fragments of the bones wound the skin still more; but if
they
bend forward, they feel easier, for the skin at the wound is thus
relaxed,
and the bones are less disposed to hurt them; and if touched,
they
shrink and bend forward, and the part which is touched appears
empty
and soft. All the circumstances now mentioned contribute to
deceive
the physician. Such patients speedily get well without any bad
effects,
for callus readily forms in all such bones as are porous.
47. There are many varieties of curvature of
the spine even in
persons
who are in good health; for it takes place from natural
conformation
and from habit, and the spine is liable to be bent from
old
age, and from pains. Gibbosities (or projections backward) from
falls
generally take place when one pitches on the nates, or falls
on
the shoulders. In this case some one of the vertebrae must
necessarily
appear higher than natural, and those on either side to
a
less degree; but yet no one generally has started out of the line of
the
others, but every one has yielded a little, so that a considerable
extent
of them is curved. On this account the spinal marrow easily
bears
such distortions, because they are of a circular shape, and
not
angular. The apparatus for the reduction in this case must be
managed
in the following manner: a strong and broad board, having an
oblong
furrow in it, is to be fastened in the ground, or, in place
of
the board, we may scoop out an oblong furrow in the wall, about a
cubit
above the floor, or at any suitable height, and then something
like
an oaken bench, of a quadrangular shape, is to be laid along (the
wall?)
at a distance from the wall, which will admit of persons to
pass
round if necessary, and the bench is to be covered with robes, or
anything
else which is soft, but does not yield much; and the
patient
is to be stoved with vapor, if necessary, or bathed with
much
hot water, and then he is to be stretched along the board on
his
face, with his arms laid along and bound to his body; the
middle,
then, of a thong which is soft, sufficiently broad and long,
and
composed of two cross straps of leather, is to be twice carried
along
the middle of the patient's breast, as near the armpits as
possible,
then what is over of the thongs at the armpits is to be
carried
round the shoulders, and afterward the ends of the thong are
to
be fastened to a piece of wood resembling a pestle; they are to
be
adapted to the length of the bench laid below the patient, and so
that
the pestle-like piece of wood resting against this bench may make
extension.
Another such band is to be applied above the knees and
the
ankles, and the ends of the thongs fastened to a similar piece
of
wood; and another thong, broad, soft, and strong, in the form of
a
swathe, having breadth and length sufficient, is to be bound tightly
round
the loins, as near the hips as possible; and then what remains
of
this swathelike thong, with the ends of the thongs, must be
fastened
to the piece of wood placed at the patient's feet, and
extension
in this fashion is to be made upward and downward, equally
and
at the same time, in a straight line. For extension thus made
could
do no harm, if properly performed, unless one sought to do
mischief
purposely. But the physicians, or some person who is
strong,
and not uninstructed, should apply the palm of one hand to the
hump,
and then, having laid the other hand upon the former, he
should
make pressure, attending whether this force should be applied
directly
downward, or toward the head, or toward the hips. This method
of
applying force is particularly safe; and it is also safe for a
person
to sit upon the hump while extension is made, and raising
himself
up, to let himself fall again upon the patient. And there is
nothing
to prevent a person from placing a foot on the hump, and
supporting
his weight on it, and making gentle pressure; one of the
men
who is practiced in the palestra would be a proper person for
doing
this in a suitable manner. But the most powerful of the
mechanical
means is this: if the hole in the wall, or in the piece
of
wood fastened into the ground, be made as much below the man's back
as
may be judged proper, and if a board, made of limetree, or any
other
wood, and not too narrow, be put into the hole, then a rag,
folded
several times or a small leather cushion, should be laid on the
hump;
nothing large, however, should be laid on the back, but just
as
much as may prevent the board from giving unnecessary pain by its
hardness;
but the hump should be as much as possible on a line with
the
hole made in the wall, so that the board introduced into it may
make
pressure more especially at that especially at that spot. When
matters
are thus adjusted, one person, or two if necessary, must press
down
the end of the board, whilst others at the same time make
extension
and counter-extension as along the body, as formerly
described.
Extension may also be made with axles, which may either
be
fastened in the ground beside the bench, or the post of the axles
may
be attached to the bench itself, if you will make them
perpendicular
and overtopping (the bench?) a little at both ends, or
at
either end of the bench. These powers are easily regulated, so as
to
be made stronger or weaker, and they are of such force, that if one
were
to have recourse to them for a mischievous purpose, and not as
a
remedy, they would operate strongly in this way also; for by
making
merely extension and counter-extension longitudinally,
without
any additional force, one might make sufficient extension; and
if,
without making extension at all, one were only to press down
properly
with the board, sufficient force might be applied in this
way.
Such powers, then, are excellent which admit of being so
regulated,
that they can be made weaker and stronger as required.
And
the forces are applied in the natural way; for the pressure
above
forces the displaced parts into their place. Natural extension
restores
parts which have come too near one another to their natural
position.
I, then, am acquainted with no powers which are better or
more
appropriate than these; for extension along the spine downward
has
no proper hold at the bone called the os sacrum; and extension
upward,
along the neck and head, has indeed a hold; but extension thus
made
is unseemly to behold, and, besides, if increased, may occasion
much
mischief otherwise. I once made trial of the following plan.
Having
placed the patient on his back, I put below the hump a bladder,
not
inflated, and afterward introduced air into the bladder by means
of
a brass pipe connected with it. But the experiment did not succeed;
for,
when the man was fairly extended, the bladder yielded, and the
air
could not be forced into it; and, besides, the hump of the patient
was
apt to slip off the distended bladder when they were pressed
together.
But when I did not extend the man strongly, the bladder
was
swelled up by the air, and the man became more bent forward than
proper.
I have written this expressly; for it is a valuable piece of
knowledge
to learn what things have been tried and have proved
ineffectual,
and wherefore they did not succeed.
48. In curvatures forward of the vertebrae
from a fall, or from some
heavy
body falling upon them, in general no one of them is displaced
far
beyond the others, but if one or more be so displaced, the case
proves
fatal; but, not withstanding, as formerly stated, the
displacement
is circular, and not angular. In such cases, then, the
urine
and faeces are more apt to be retained than in displacement
outward,
the feet and the whole inferior extremities are colder, and
the
symptoms are more fatal than in the former case; and if they do
survive,
they are more subject to retention of the urine, and to
loss
of strength, and to torpor in their legs. But if the displacement
be
in the upper part, they experience loss of strength and torpor of
the
whole body. I know no mechanical contrivance by which such a
displacement
could be reduced, unless that one might be benefited by
succussion
on a bladder, or any other similar plan of treatment,
such
as extension, as formerly described. I am not aware of any mode
of
pressure which might be applied along with the extension, like that
of
the board in displacement backward; for how could one apply
pressure
from before through the belly? (internal cavity?) The thing
is
impossible. But neither coughing nor sneezing has any power so as
to
cooperate with the extension, nor would the injection of air into
the
bowels have any effect. And to apply large cupping instruments
with
the view of drawing back the vertebrae which have protruded
forward,
shows a great error of judgment; for they rather propel
than
attract, and those who apply them are not aware even of this
fact,
for the greater will be the inclination forward the greater
the
instrument applied, the skin being forcibly drawn into the
cupping-instrument.
I could tell of other modes of succussion than
those
formerly described, which one might fancy would be more
applicable
in such an affection; but I have no great confidence in
them,
and therefore I do not describe them. On the main, it should
be
known, respecting the accidents which I have briefly described,
that
displacements forward are of a fatal and injurious nature; but
that
displacements backward, for the most part, do not prove fatal,
nor
occasion retention of urine nor torpor of the limbs, for they do
not
stretch the ducts leading toward the intestines, nor occasion
obstruction
of the same; but displacements forward produce both
these
bad effects, and many others in addition. And truly they are
more
apt to lose the power of their legs and arms, to have torpor of
the
body, and retention of urine, who experience no displacement
either
forward or backward, but merely a violent concussion along
the
spine, while those who have displacement backward are least
subject
to these symptoms.
49. And one might observe many other instances
in medicine, of
considerable
injuries not proving serious, but producing a crisis in
some
affection, while less considerable injuries prove more serious,
give
rise to chronic diseases, and extend their effects to the whole
system.
Now something similar may happen in fracture of the ribs;
for
in fracture of one or more ribs, in general, if the fractured
bones
are not driven inward, nor are laid bare, fever rarely
supervenes,
neither does it often happen that there is haemoptysis,
empyema,
and suppurating sores, which require treatment with pledgets,
nor
necrosis of the bones; and in these cases the ordinary regimen
is
sufficient. For, unless they be seized with continual fever, a
strict
diet does more harm than good, by inducing inanition, and
increasing
the pain, fever, and cough; for moderate fullness of the
intestines
has a tendency to replace the ribs, while evacuation
leads
to suspension of the ribs, and suspension induces pain. Ordinary
bandaging,
externally, is sufficient in such cases; the bandages
should
be applied moderately tight, along with cerate and
compresses,
or a pad of wool may be applied. The rib is consolidated
in
twenty days, for callus soon forms in such bones.
50. But when there is contusion of the flesh
about the ribs,
either
from a blow, or a fall, or a bruise, or any like cause, there
is
often copious vomiting of blood, for there are canals stretched
along
the vacuity of each rib (intercostal space?), and nerves
proceeding
from the most important parts of the body have their origin
there.
Many of these, therefore, are troubled with coughs,
tubercles,
empyema, external suppurations, and sphacelus of the
ribs.
And even when no such symptoms supervene from contusion of the
skin
about the ribs, still in such cases there is, generally, more
combined
pain than in fractures of the ribs, and relapses of pain in
the
seat of the injury are more apt to occur. Wherefore some
physicians
pay much less attention to such injuries, than where the
rib
is fractured, whereas, if they were wise, they would treat such
cases
with far greater care than the other; for it is proper that
the
diet should be restricted, that the patients should remain at rest
as
much as possible, and abstain from venery, from fat articles of
food,
from such as excite cough, and from everything strong; they
should
be bled in the arm, speak as little as possible, should have
the
contused part bound round with folded compresses, plenty of
bandages,
broader than the contusion, and which should be smeared with
cerate;
in applying the bandages, broad and soft shawls should be
used,
and they should be put on moderately firm, so that the patient
will
say that they are neither too tight nor loose, and the
bandaging
should commence at the seat of the injury, and be made
more
particularly tight there, and the bandaging should be conducted
as
is done with a double-headed roller, so that the skin about the
ribs
may not be ruffled, but may lie smooth, and the bandaging
should
be renewed every day, or every alternate day. It is better also
to
open the bowels with some gentle medicine, so as just to produce an
evacuation
of the food, and the diet is to be restricted for ten days,
and
then the body is to be recruited and filled up; while you are upon
the
reducing system, the bandaging should be tighter, but when you are
making
him up again, it must be looser; and, if he spit blood from the
commencement,
the treatment and bandaging should be continued for
forty
days; but if there be no haemoptysis, treatment for twenty
days
will generally be sufficient; but the length of time must be
regulated
by the magnitude of the injury. When such contusions are
neglected,
if no greater mischief result there from, at all events the
bruised
part has its flesh more pulpy than it had formerly. When,
therefore,
any such thing is left behind, and is not properly
dissipated
by the treatment, it will be worse if the mucosity be
lodged
near the bone, for the flesh no longer adheres to the bone as
formerly,
the bone becomes diseased, and chronic sloughings of the
bone
in many cases arise from such causes. But if the mischief be
not
upon the bone, but it is the flesh itself which is pulpy, relapses
and
pains will return from time to time, if there happen to be any
disorder
in the body; wherefore proper bandaging, and for a
considerable
time, must be had recourse to, until the extravasated
blood
forming in the bruise be dried up and absorbed, and the part
be
made up with sound flesh, and the flesh adhere to the bone. The
best
cure is the cautery in those cases which, from neglect, have
become
chronic, and the place turns painful, and the flesh is pulpy.
And
when the flesh itself is pulpy, the burning should be carried as
far
as the bone, but the bone itself should not be heated; but if it
be
in the intercostal space, you need not make the burning so
superficial,
only you must take care not to burn quite through. But if
the
contusion appear to be at the bone, if it be still recent, and the
bone
has not yet become necrosed, if it be very small, it is to be
burned
as has been described; but if the rising along the bone be
oblong,
several eschars are to be burned over it. Necrosis of the
rib
will be described along with the treatment of suppurating sores.
51. There are four modes of dislocation at
the hip-joint: of which
modes,
dislocation inward takes place most frequently, outward, the
most
frequently of all the other modes; and it sometimes takes place
backward
and forward, but seldom. When, therefore, dislocation takes
place
inward, the leg appears longer than natural, when compared
with
the other leg, for two reasons truly; for the bone which
articulates
with the hip-joint is carried from above down to the
ischium
where it rises up to the pubes, upon it, then, the head of the
femur
rests, and the neck of the femur is lodged in the cotyloid
foramen
(foramen thyroideum?). The buttock appears hollow
externally,
from the head of the thighbone having shifted inward,
and
the extremity of the femur at the knee is turned outward, and
the
leg and foot in like manner. The foot then being turned outward,
physicians,
from ignorance, bring the sound leg to it and not it to
the
sound leg; on this account, the injured limb appears to be much
longer
than the sound one, and in many other cases similar
circumstances
lead to error in judgment. Neither does the limb at
the
groin admit of flexion as in the sound limb, and the head of the
bone
is felt at the perineum too prominent. These, then, are the
symptoms
attending dislocation of the thigh inward.
52. When, then, a dislocation has not been
reduced, but has been
misunderstood
or neglected, the leg, in walking, is rolled about as is
the
case with oxen, and the weight of the body is mostly supported
on
the sound leg, and the limb at the flank, and the joint where the
dislocation
has occurred is necessarily hollow and bent, while on
the
sound side the buttock is necessarily rounded. For if one should
walk
with the foot of the sound leg turned outward, the weight of
the
body would be thrown upon the injured limb, but the injured limb
could
not carry it, for how could it? One, then, is forced in
walking
to turn the leg inward, and not outward, for thus the sound
leg
best supports its own half of the body, and also that of the
injured
side. But being hollow at the flank and the hip-joint, they
appear
small in stature, and are forced to rest on a staff at the side
of
the sound leg. For they require the support of a staff there, since
the
nates inclines to this side, and the weight of the body is carried
to
it. They are forced also to stoop, for they are obliged to rest the
hand
on the side of the thigh against the affected limb; for the
limb
which is injured cannot support the body in changing the legs,
unless
it be held when it is applied to the ground. They who have
got
an unreduced dislocation inward are forced to put themselves
into
these attitudes, and this from no premeditation on their part how
they
should assume the easiest position, but the impediment itself
teaches
them to choose that which is most conformable to their present
circumstances.
For persons who have a sore on the foot, or leg, and
cannot
rest upon the limb, all, even children, walk in this way; for
they
turn the injured limb outward in walking, and they derive two
advantages
therefrom, to supply two wants; the weight of the body is
not
equally thrown upon the limb turned outward, as upon the one
turned
inward, for neither is the weight in a line with it, but is
much
more thrown upon the one under the body; for the weight is in a
straight
line with it, both in walking and in the shifting of the
legs.
In this position one can most quickly turn the sound limb
under
the body, by walking with the unsound limb outward, and the
sound
inward. In the case we are now treating of, it is well that
the
body finds out the attitudes which are the easiest for itself.
Those
persons, then, who have not attained their growth at the time
when
they met with a dislocation which is not reduced, become maimed
in
the thigh, the leg, and the foot, for neither do the bones grow
properly,
but become shortened, and especially the bone of the
thigh;
and the whole limb is emaciated, loses its muscularity, and
becomes
enervated and thinner, both from the impediment at the
joint,
and because the patient cannot use the limb, as it does not lie
in
its natural position, for a certain amount of exercise will relieve
excessive
enervation, and it will remedy in so far the deficiency of
growth
in length. Those persons, then, are most maimed who have
experienced
the dislocation in utero, next those who have met with
it
in infancy, and least of all, those who are full grown. The mode of
walking
adopted by adults has been already described; but those who
are
children when this accident befalls them, generally lose the erect
position
of the body, and crawl about miserably on the sound leg,
supporting
themselves with the hand of the sound side resting on the
ground.
Some, also, who had attained manhood before they met with this
accident,
have also lost the faculty of walking erect. Those who
were
children when they met with the accident, and have been
properly
instructed, stand erect upon the sound leg, but carry about a
staff,
which they apply under the armpit of the sound side, and some
use
a staff in both arms; the unsound limb they bear up, and the
smaller
the unsound limb, the greater facility have they in walking,
and
their sound leg is no less strong than when both are sound. The
fleshy
parts of the limb are enervated in all such cases, but those
who
have dislocation inward are more subject to this loss of
strength
than, for the most part, those who have it outward.
53. Some tell a story how the Amazonian women
dislocate the joints
of
their male children while mere infants, some at the knee, and
others
at the hip-joint, that they may be maimed, and that the male
sex
may not conspire against the female, and that they use them as
artisans
to perform any sedentary work, such as that of a shoemaker or
brazier.
Whether these things be true or not I do not know, but this I
know,
that matters would be such as is represented, provided their
children,
while infants, were to have their joints dislocated. The
consequences
of dislocation inward at the hip-joint are much greater
than
of dislocation outward at the hip-joint, but at the knee,
although
there be some difference, it is less; but the mode of
either
impediment is peculiar, their legs are more bandied when the
dislocation
is outward, but those who have dislocation inward stand
erect
on their feet with less freedom. In like manner, when the
dislocation
is at the anklejoint, if outward they become vari (their
toes
are turned inward?), but they can stand; but if the dislocation
be
inward they become valgi (their toes are turned outward?), but they
have
less freedom of standing. The proportional growth of their
bones
is as follows: in those cases in which the bone of the leg is
dislocated,
the bones of the feet grow very little, as being very near
the
injury, but the bones of the leg increase in size, and with very
little
defect, but the fleshy parts (muscles?) are wasted. But when
the
ankle-joint is in its natural state, but the knee is dislocated,
in
these cases the bones of the leg do not grow in like manner, but
become
shortened, as being nearest the seat of the injury, and the
bones
of the feet also are atrophied, but not in the same
proportion;
because, as was said a little while ago, the ankle-joint
is
safe, and if they could use it, as in the case of club-foot, the
bones
of the foot would be still less atrophied. When the
dislocation
takes place at the hip-joint, the bone of the thigh, in
this
case, does not generally grow in like manner, as being the one
nearest
the seat of the injury, but becomes shorter than the sound
one;
but the growth of the bones of the leg is not arrested in like
manner;
nor of those of the feet, for this reason, that there is no
displacement
between the bones of the thigh and leg, nor between those
of
the leg and foot; in those cases, however, the fleshy parts of
the
whole limb are atrophied; but if they could make use of the
limb,
the growth of the bones would be still more developed, as
formerly
stated, only the thigh, although its flesh would be much less
wasted,
would still be by no means so fleshy as the sound limb. The
following
observations are a proof of this: those persons who are
weasel-armed
(galiancones) from birth, owing to dislocation of the
humerus,
or when the accident has happened to them before they have
attained
their full growth, such persons have the bone of the arm
shortened,
but those of the fore-arm and hand are little inferior in
size
to the sound, for the reasons which have been stated, because the
humerus
is the bone nearest to the joint affected, and, on that
account,
it is shorter than natural; but the fore-arm is not equally
affected
by the accident, because the joint at which the bones of
the
arm and forearm are articulated remains in its natural
condition,
and the hand is still further distant than the fore-arm
from
the seat of the injury. Such are the reasons why certain of the
bones
in this case increase in growth, and certain do not. The
laborious
office of the hand contributes much to the development of
the
flesh in the fore-arm and hand, for whatever work is done by the
hand,
these weasel-armed persons strive to do no less effectually with
the
other hand than with the sound; for the arms do not support the
weight
of the body like the legs, and the work performed by them is
light.
From exercise, then, the fleshy parts on the hand and
fore-arm
are not atrophied in weasel-armed persons, and by these means
the
arm, too, gains flesh. But in dislocation inward at the hip-joint,
whether
from birth or from childhood, the fleshy parts, on that
account,
are much more atrophied than those of the hand, because the
patients
cannot exercise the leg. Another proof will be given in the
observations
which will be presently stated, that these things are
such
as I things are such as I have represented.
54. When the head of the femur is dislocated
outward, the limb in
these
cases, when compared with the other, appears shortened, and this
is
natural, for the head of the femur no longer rests on a bone as
in
dislocation inward, but along the side of a bone which naturally
inclines
to the side, and it is lodged in flesh of a pulpy and
yielding
nature, and on that account it appears more shortened.
Inwardly,
the thigh about the perineum appears more hollow and flabby,
but
externally the buttock is more rounded, from the head of the thigh
having
slipped outward, but the nates appear to be raised up, owing to
the
flesh there having yielded to the head of the thigh-bone; but
the
extremity of the thigh-bone, at the knee, appears to be turned
inward,
and the leg and foot in like manner, neither does it admit
of
flexion like the sound limb. These, then, are the symptoms of
dislocation
outward.
55. When such a dislocation is not reduced
in adults, the whole limb
appears
to be shortened, and in walking they cannot reach the ground
with
the heel, but they walk with the ball of the foot on the
ground,
and the points of their toes incline a little inward. But
the
injured limb, in this case, can support the body much better
than
in dislocation inward, both because the head of the femur and the
neck
of its articular extremity, being naturally oblique, have
formed
a bed under a considerable portion of the hip, and because
the
extremity of the foot is not forcibly turned outward, but is
nearly
in a line with the body, and is even inclined more inwardly.
When,
then, the articular extremity of the femur has worn out a socket
for
itself in the flesh where it was lodged, and the flesh is
lubricated,
it ceases to be painful in the course of time, and when it
becomes
free from pain, they can walk without a staff, if so inclined,
and
they can support the body on the injured limb. From usage then, in
such
cases, the fleshy parts are less enervated than in those which
have
been mentioned a little before, still, however, they lose their
strength
more or less; but in general there is more enervation when
the
dislocation is inward than when it is outward. Some of them, then,
cannot
wear their shoes, owing to the unbending state of their leg,
and
some of them can. But when this dislocation takes place in
utero,
and when the dislocation having occurred at any time before
manhood,
from violence, has not been replaced, or when from disease
the
articular extremity has started from its socket, and is
displaced
(for many such cases occur, and from some of them, if the
femur
become necrosed, obstinate suppurations requiring the use of
tents
are formed, and in certain of them the bone is laid bare),
whether
the bone become necrosed or not, the bone of the thigh is much
shortened,
and does not usually grow like the sound one, the bones,
too,
of the leg, become shorter than those of the other, but in a
small
degree, for the same reasons that were formerly stated; such
persons
can walk, some of them in the same fashion as adults having an
unreduced
dislocation, and some of them walk with the whole foot on
the
ground, but limp in walking, being obliged to do so by the
shortness
of the limb. Such is the result, even though they be
carefully
and properly trained in the attitudes before they have
strength
for walking, and in like manner also, after they have
acquired
the necessary strength; but those persons require the most
care
who were very young when they met with the accident, for, if
neglected
while children, the limb becomes entirely useless and
atrophied.
The fleshy parts of the entire limb are more wasted than
those
of the sound limb, but this is much less apt to happen in
their
case than in dislocation inward, owing to usage and exercise, as
they
are speedily able to make use of the limb, as was stated a little
before
with regard to the weasel-armed (galiancones).
56. There are persons who, from birth or from
disease, have
dislocations
outward of both the thighs; in them, then, the bones
are
affected in like manner, but the fleshy parts in their case lose
their
strength less; the legs, too, are plump and fleshy, except
that
there is some little deficiency at the inside, and they are plump
because
they have the equal use of both their legs, for in walking
they
totter equally to this side that. Their nates appear very
prominent,
from the displacement of the bones of the joint. But if
in
their case the bones do not sphacelate (become carious?) and if
they
do not become bent above the hip-joint, if nothing of this kind
happen
to them, they become otherwise sufficiently healthy, but the
growth
of all the rest of the body, with the exception of the head, is
arrested.
57. In dislocations of the head of the femur
backward, which
rarely
occur, the patient cannot extend the leg, either at the
dislocated
joint, or at the ham, to any extent, and of all the
dislocations,
this is the variety in which the patients have the least
power
of making extension at the groin and the ham. But, moreover,
this
also should be known (for it is a valuable piece of knowledge,
and
of much importance, and yet most yet most people are ignorant of
it),
that persons in health cannot extend the joint at the ham, if
they
do not extend the joint at the groin at the same time, unless
they
raise the foot very high, for in this way they could do it;
neither
also could they bend the joint at the ham, but with much
greater
difficulty, if they do not bend the joint at the groin at
the
same time. There are many other things in the body which have
similar
connections, both with regard to the contractions of nerves
(ligaments?),
and the positions of muscles, and many of them more
worthy
of being known than is generally supposed, and with regard to
the
nature of the intestine and that of the whole internal cavity, and
with
regard to the displacements and contractions of the uterus; but
all
these things will be treated of elsewhere, in a work akin to the
present
one. But with regard to the matter on hand, they cannot make
extension,
as has been already stated; and the limb appears shortened,
for
two reasons-first, because it cannot be extended, and also because
the
bone has slipped into the flesh of the nates; for the head and
neck
of the femur, in this dislocation, are carried downward from
their
natural situation, to the outside of the nates. But yet they can
bend
the limb, unless prevented by pain, and the leg and foot appear
pretty
straight, and not much inclined toward either side, but at
the
groin the flesh, when felt, appears looser, from the bone of the
joint
having slipped to the other side, but at the nates the head of
the
femur may be felt to be more prominent than natural. Such are
the
symptoms accompanying dislocation of the thigh backward.
58. When this dislocation occurs in an adult,
and is not reduced, he
can
walk, indeed, after a time, and when the pain has abated, and when
he
has been accustomed to rotate the articular bone in the flesh; he
finds
it necessary, however, to make strong flexion at the groin in
walking,
for two reasons, both because the limb, for the causes
already
stated, becomes much shorter, and he is far from touching
the
ground with his heel, and he can barely reach it with the ball
of
his foot, and not even thus, unless he bend himself at the
groins,
and also bend with the other leg at the ham. And in this case,
he
is under the necessity of supporting the upper part of the thigh
with
his hand at each step: this also contributes, in a certain
degree,
to make him bend the body at the groins; for, during the
shifting
of the feet in walking, the body cannot be supported on the
unsound
be supported on the unsound limb, unless it be pressed to
the
ground by the hand,-the end of the femur not being placed properly
under
the body, but having slipped backward to the nates; and if he
should
try to rest the weight of his body for a little, upon the foot,
without
any other support, he would fall backward, for there would
be
a great inclination in this direction, from the hips having
protruded
backward far beyond the line of the foot, and the spine
inclining
toward the hips. Such persons can walk, indeed, without a
staff,
if so accustomed, for because the sole of the foot is in its
old
line, and is not inclined outward, they do not require anything to
balance
them. Such, however, as, instead of grasping the thigh, prefer
resting
their weight upon a staff introduced into the armpit of the
affected
side, these, if they use a longer staff, will walk, indeed,
more
erect, but will not be able to reach the ground with the foot, or
if
they wish to rest upon the foot, they must take a shorter staff,
and
will require to bend the body at the groins. The wasting of the
fleshy
parts is analogous to what happens in the cases formerly
described,
for the wasting is greatest in those cases in which the
patients
keep the limb up, and do not exercise it, whilst those who
practice
walking, have the least atrophy. The sound leg, however, is
not
benefited, but is rather rendered more deformed, if the injured
limb
be applied to the ground, for it is forced to cooperate with
the
other, being protruded at the hip, and bent at the ham. But if the
patient
does not use the injured limb by applying it to the ground,
but
carries it up, and rests upon a staff, the sound leg thereby gains
strength,
for it is employed in its natural position, and further, the
exercise
gives it strength. But it may be said, these things are
foreign
to medicine; for what is the use of enlarging upon cases which
are
already past remedy? This is far from being the case, for it
belongs
to the knowledge of medicine to be acquainted also with these,
and
they cannot possibly be separated from one another; for to such as
are
curable, means are to be used to prevent them from becoming
incurable,
studying how they may best be prevented from getting into
an
incurable state. And incurable cases should be known, that they may
not
be aggravated by useless applications, and splendid and creditable
prognostics
are made by knowing where, how, and when every case will
terminate,
and whether it will be converted into a curable or an
incurable
disease. When then, from birth, or during one's youth,
this
dislocation backward occurs, and is not reduced, whether it be
connected
with violence or disease (for many such dislocations occur
in
diseases, but the nature of the diseases in which dislocations take
place,
will be described afterward); if, then, the dislocated limb
be
not reduced, the bone of the thigh becomes shortened, the whole
limb
is impaired, is arrested in its growth, and loses its flesh
from
want of use; the articulation at the ham is also impaired, for
the
nerves (ligaments?) become stretched, from cases formerly
stated,
wherefore those who have this dislocation, cannot make
extension
at the knee-joint. In a word, all parts of the body which
were
made for active use, if moderately used and exercised at the
labor
to which they are habituated, become healthy, increase in
bulk,
and bear their age well, but when not used, and when left
without
exercise, they become diseased, their growth is arrested,
and
they soon become old. Among these parts the joints and nerves
(ligaments?),
if not used, are not the least liable to be so affected;
they
are impaired, then, for the reasons we have stated, more in
this
variety of dislocation than in the others, for the whole limb
is
wasted, both in its bones and in its fleshy parts. Such persons,
then,
when they attain their full growth, keep the limb raised and
flexed,
rest the weight of the body on the other leg, and support
themselves
with a staff, some with one, and others with two.
59. In dislocations of the head of the thigh-bone
forward (they
are
of rare occurrence), the patients cannot extend the leg
completely,
but least of all can they bend it at the groin; they are
pained,
also, if forced to bend the limb at the ham. The length of the
leg,
if compared at the heel, is the same as that of the other; but
the
extremity of the foot inclines less to project forward. But the
whole
limb has its natural direction, and inclines neither to this
side
nor to that. These cases are particularly attended with severe
pain,
and they are more apt to be accompanied with retention of
urine
at first than any of the other dislocations; for the head of the
thigh-bone
is lodged very near to important nerves. And the region
of
the groin appears swelled out and stretched, while that of the
nates
is more wrinkled and flabby. The symptoms now stated are those
which
attend this dislocation of the thigh-bone.
60. When persons have attained their full growth
before meeting with
this
dislocation, and when it has not been reduced, upon the
subsidence
of the pain, and when the bone of the joint has been
accustomed
to be rotated in the place where it is lodged, these
persons
can walk almost erect without a staff, and with the injured
leg
almost quite straight, as it does not admit of easy flexion at the
groin
and the ham; owing, then, to this want of flexion at the
groin,
they keep the limb more straight in walking than they do the
sound
one. And sometimes they drag the foot along the ground, as not
being
able to bend the upper part of the limb, and they walk with
the
whole foot on the ground; for in walking they rest no less on
the
heel than on the fore part of the foot; and if they could take
great
steps, they would rest entirely on the heel in walking; for
persons
whose limbs are sound, the greater the steps they take in
walking,
rest so much the more on the heel, while they are putting
down
the one foot and raising the opposite. In this form of
dislocation,
persons rest their weight more on the heel than on the
anterior
part of the foot, for the fore part of the foot cannot be
bent
forward equally well when the rest of the limb is extended as
when
it is in a state of flexion; neither, again, can the foot be
arched
to the same degree the limb is bent as when it is extended. The
natural
state of matters is such as has been now described; and in
an
unreduced dislocation, persons walk in the manner described, for
the
reasons which have been stated. The limb, moreover, is less fleshy
than
the other, at the nates, the calf of the leg, and the whole of
its
posterior part. When this dislocation occurs in infancy, and is
not
reduced, or when it is congenital, in these cases the bone of
the
thigh is more atrophied than those of the leg and foot; but the
atrophy
of the thigh-bone is least of all in this form of dislocation.
The
fleshy parts, however, are everywhere attenuated, more
especially
behind, as has been stated above. If properly trained, such
persons,
when they grow up, can use the limb, which is only a little
shorter
than the other, and yet they support themselves on a staff
at
the affected side. For, not being able to use properly the ball
of
the foot without the heel, nor to put it down as some can in the
other
varieties of dislocation (the cause of which has been just now
stated),
on this account they require a staff. But those who are
neglected,
and are not in the practice of putting their foot to the
ground,
but keep the limb up, have the bones more atrophied than those
who
use the limb; and, at the articulations, the limb is more maimed
in
the direct line than in the other forms of dislocation.
61. In a word, luxations and subluxations take
place in different
degrees,
being sometimes greater and sometimes less; and those cases
in
which the bone has slipped or been displaced to a much greater
extent,
are in general more difficult to rectify than otherwise; and
if
not reduced, such cases have greater and more striking impairment
and
lesion of the bones, fleshy parts, and attitudes; but when the
bone
has slipped, or been displaced to a less extent, it is easier
to
reduce such cases than the other; and if the attempts at
reduction
have failed, or have been neglected, the impairment in
such
cases is less, and proves less injurious than in the cases just
mentioned.
The other joints present great differences as to the extent
of
the displacements which they are subject to. But the heads of the
femur
and humerus are very similar to one another as to their
dislocations.
For the heads of the bones are rounded and smooth, and
the
sockets which receive the heads are also circular, and adapted
to
the heads; they do not admit then of being dislocated in any
intermediate
degree, but, not withstanding, from their rounded
shape,
the bones slip either outward or inward. In the case we are now
treating
of, then, there is either a complete dislocation or none at
all,
and yet these bones admit of being displaced to a greater or less
extent;
and the thigh is more subject to these differences than the
arm.
62. Wherefore, then, some of these congenital
displacements, if to a
small
extent, may be reduced to their natural condition, and
especially
those at the ankle-joint. Most cases of congenital
club-foot
are remediable, unless the declination be very great, or
when
the affection occurs at an advanced period of youth. The best
plan,
then, is to treat such cases at as early a period as possible,
before
the deficiency of the bones of the foot is very great, and
before
there is any great wasting of the flesh of the leg. There is
more
than one variety of club-foot, the most of them being not
complete
dislocations, but impairments connected with the habitual
maintenance
of the limb in a certain position. In conducting the
treatment,
attention must be paid to the following points: to push
back
and rectify the bone of the leg at the ankle from without inward,
and
to make counter-pressure on the bone of the heel in an outward
direction,
so as to bring it bring it into line, in order that the
displaced
bones may meet at the middle and side of the foot; and the
mass
of the toes, with the great toe, are to be inclined inward, and
retained
so; and the parts are to be secured, with cerate containing a
full
proportion of resin, with compresses, and soft bandages
insufficient
quantity, but not applied too tight; and the turns of the
bandages
should be in the same direction as the rectifying of the foot
with
the hand, so that the foot may appear to incline a little
outward.
And a sole made of leather not very hard, or of lead, is to
be
bound on, and it is not to be applied to the skin but when you
are
about to make the last turns of the bandages. And when it is all
bandaged,
you must attach the end of one of the bandages that are used
to
the bandages applied to the inferior part of the foot on the line
of
the little toe; and then this bandage is to be rolled upward in
what
is considered to be a sufficient degree, to above the calf of the
leg,
so that it may remain firm when thus arranged. In a word, as if
moulding
a wax model, you must bring to their natural position the
parts
which were abnormally displaced and contracted together, so
rectifying
them with your hands, and with the bandaging in like
manner,
as to bring them into their position, not by force, but
gently;
and the bandages are to be stitched so as to suit the position
in
which the limb is to be placed, for different modes of the
deformity
require different positions. And a small shoe made of lead
is
to be bound on externally to the bandaging, having the same shape
as
the Chian slippers had. But there is no necessity for it if the
parts
be properly adjusted with the hands, properly secured with the
bandages,
and properly disposed of afterward. This, then, is the
mode
of cure, and it neither requires cutting, burning, nor any
other
complex means, for such cases yield sooner to treatment than one
would
believe. However, they are to be fairly mastered only by time,
and
not until the body has grown up in the natural shape; when
recourse
is had to a shoe, the most suitable are the buskins, which
derive
their name from being used in traveling through mud; for this
sort
of shoe does not yield to the foot, but the foot yields to it.
A
shoe shaped like the Cretan is also suitable.
63. In cases of complete dislocation at the
ankle-joint, complicated
with
an external wound, whether the displacement be inward or outward,
you
are not to reduce the parts, but let any other physician reduce
them
if he choose. For this you should know for certain, that the
patient
will die if the parts are allowed to remain reduced, and
that
he will not survive more than a few days, for few of them pass
the
seventh day, being cut off by convulsions, and sometimes the leg
and
foot are seized with gangrene. It should be well known that such
will
be the results; and it does not appear to me that hellebore
will
do any good, though administered the same day, and the draught
repeated,
and yet it is the most likely means, if any such there be;
but
I am of opinion that not even it will be of service. But if not
reduced,
nor any attempts at first made to reduce them, most of such
cases
recover. The leg and foot are to be arranged as the patient
wishes,
only they must not be put in a dependent position, nor moved
about;
and they are to be treated with pitched cerate, a few
compresses
dipped in wine, and not very cold, for cold in such cases
induces
convulsions; the leaves also of beet, or of colt's foot, of
any
such, when boiled in dark-colored austere wine, form a suitable
application
to the wound and the surrounding parts; and the wound
may
further be anointed with cerate in a tepid state. But if it be the
winter
season, the part is to be covered with unscoured wool, which is
to
be sprinkled from above with tepid wine and oil, but on no
account
is either bandage or compress to be applied; for this should
be
known most especially, that whatever compresses, or is heavy,
does
mischief in such cases. And certain of the dressings used to
recent
wounds are suitable in such cases; and wool may be laid upon
the
sore, and sprinkled with wine, and allowed to remain for a
considerable
time; but those dressings for recent wounds which only
last
for a few days, and into which resin enters as an ingredient,
do
not agree with them; for the cleansing of the sores is a slow
process,
and the sore has a copious discharge for a long time. Certain
of
these cases it may be advantageous to bandage. It ought also to
be
well understood, that the patient must necessarily be much maimed
and
deformed, for the foot is retracted outward, and the bones which
have
been displaced outward protrude: these bones, in fact, not
being
generally laid bare, unless to a small extent; neither do they
exfoliate,
but they heal by thin and feeble cicatrices, provided the
patient
keeps quiet for a length of time; but otherwise there is
danger
that a small ulcer may remain incurable. And yet in the case we
are
treating of, those who are thus treated are saved; whereas, when
the
parts are reduced and allowed to remain in place, the patients
die.
64. The same rule applies to dislocations at
the wrist, attended
with
a wound and projection of the bone, whether the bones of the
arm
be displaced inward or outward. For this should be well
understood,
that the patient will die in the course of a few days,
by
the same mode of death as formerly described, if the bone be
reduced,
and allowed to remain so. But in those cases in which they
are
not reduced, nor any attempt made to reduce them, the patients,
for
the most part, recover; and the same mode of treatment as has been
described
will be applicable; but the deformity and impediment of
the
limb must necessarily be great, and the fingers of the hand will
be
weak and useless; for if the bones have slipped inward, they cannot
bend
the fingers, or if outward, they cannot extend them.
65. When the os tibiae, having made a wound
at the knee, has
protruded
through the skin, whether the dislocation be outward or
inward,
in such a case, if the bone be reduced, death will be even
more
speedy than in the other cases, although speedy also in them. But
the
only hope of recovery is if you treat them without reduction.
These
cases are more dangerous than the others, as being so much
higher
up, as being so much stronger joints, and displaced from
bones
which are so much stronger. But if the os femoris form a wound
at
the knee, and slip through it, provided it be reduced and left
so,
it will occasion a still more violent and speedy death than in the
cases
formerly described; but if not reduced, it will be much more
dangerous
than those cases mentioned before, and yet this is the
only
hope of recovery.
66. The same rule applies to the elbow-joint,
and with regard to the
bones
of the fore-arm and arm. For when these bones protrude through a
wound
which they have made in the skin, all cases in which they are
reduced
prove fatal; but if not reduced, there is a chance of
recovery;
but to those that survive there is certain impediment. And
if
in any instance the bones of the upper articulations
(shoulder-joint?),
should be dislocated, and project through a wound
which
they have made in the skin, these, if reduced, are followed by
more
speedy death; and if not reduced, they are more dangerous than
the
others. But the mode of treatment which appears to me most
suitable
has been already described.
67. When the joints of the toes or hands are
dislocated, and the
bones
protrude through a wound which they have made, and when there is
no
fracture of the bone, but merely displacement of the joint, in
these
cases, if the reduction be made and allowed to remain, there
is
some danger of spasms (tetanus?) if not properly treated, and yet
it
may be worth while to reduce them, having warned the patient
beforehand
that much caution and care will be required. The easiest,
the
most efficient method, and the one most conformable to art, is
that
by the lever, as formerly described when treating of bones
which
have been fractured and protruded; then the patient must be as
quiet
as possible, lie in a recumbent position, and observe a
restricted
regimen. And it will be better also that he should get some
gentle
emetics. The sore is to be treated with dressings for fresh
wounds,
which permit of allusions, or with the leaves of camomile,
or
with the applications for fractured bones of the head, but
nothing
very cold must be applied. The first (most distant?) joints
are
least dangerous, but those still higher, are more so. Reduction
should
be made the same day, or the next, but by no means on the third
or
fourth, for it is on the fourth day that exacerbations especially
attack.
In those cases, then, where immediate reduction cannot be
accomplished,
we must wait until after the aforesaid days; for
whatever
you reduce within ten days, may be expected to induce
spasm.
But if the spasm supervene on its being reduced, the joint
should
be quickly displaced, and bathed frequently with warm water,
and
the whole body should be kept in a warm, soft, and easy condition,
and
more especially about the joints, for the whole body should rather
be
in a bent than in an extended state. Moreover, it is to be
expected,
that the articular extremities of the bones of the fingers
will
for this generally happens, if even the least degree of
inflammation
take place, so that if it were not that the physician
would
be exposed to censure, owing to the ignorance of the common
people,
no reduction should be made at all. The reduction of the bones
of
joints which have protruded through the skin, is attended with
the
dangers which have been described.
68. When the articular bones of the fingers
are fairly chopped
off,
these cases are mostly unattended with danger, unless deliquium
come
on in consequence of the injury, and ordinary treatment will be
sufficient
to such sores. But when resection is made, not at the
articulations,
but at some other point in the bones, these cases
also
are free from danger, and are still more easily cured than the
others;
and the fractured bones of the fingers which protrude
otherwise
than at the joint admit of reduction without danger.
Complete
resections of bones at the joints, whether the foot, the
hand,
the leg, the ankle, the forearm, the wrist, for the most part,
are
not unattended with danger, unless one be cut off at once by
deliquium
animi, or if continual fever supervene on the fourth day.
69. With regard to the sphacelus of fleshy
parts, it takes place
in
wounds where there are large blood-vessels, which have been
strongly
compressed, and in fractures of bones which have been bound
too
tight, and in other cases of immoderate constriction, when the
parts
which have been strangulated generally drop off; and the most of
such
patients recover, even when a portion of the thigh comes away, or
of
the arm, both bones and flesh, but less so in this case; and when
the
fore-arm and leg drop off, the patients readily recover. In
cases
then, of fracture of the bones, when strangulation and
blackening
of the parts take place at first, the separation of the
dead
and living parts quickly occurs, and the parts speedily drop off,
as
the bones have already given way; but when the blackening
(mortification)
takes place while the bones are entire, the fleshy
parts,
in this case, also quickly die, but the bones are slow in
separating
at the boundary of the blackening, and where the bones
are
laid bare. Those parts of the body which are below the
boundaries
of the blackening are to be removed at the joint, as soon
as
they are fairly dead and have lost their sensibility; care being
taken
not to wound any living part; for if the part which is cut off
give
pain, and if it prove not to be quite dead, there is great danger
lest
the patient may swoon away from the pain, and such swoonings
often
are immediately fatal. I have known the thigh-bones, when
denuded
in this manner, drop off on the eightieth day; but in the case
of
this patient, the parts below were separated at the knee on the
twentieth
day, and, as I thought, too early, for it appeared to me
that
this should be done more guardedly. In a case which I had of such
blackening
in the leg, the bones of the leg, as far as they were
denuded,
separated at its middle on the sixtieth day. But the
separation
of denuded bones is quicker or slower, according to the