ON THE SURGERY
by Hippocrates
Translated by Francis
Adams
IT IS the business of the physician to know,
in the first place,
things
similar and things dissimilar; those connected with things most
important,
most easily known, and in anywise known; which are to be
seen,
touched, and heard; which are to be perceived in the sight,
and
the touch, and the hearing, and the nose, and the tongue, and
the
understanding; which are to be known by all the means we know
other
things.
2. The things relating to surgery, are- the
patient; the operator;
the
assistants; the instruments; the light, where and how; how many
things,
and how; where the body, and the instruments; the time; the
manner;
the place.
3. The operator is either sitting or standing,
conveniently for
himself,
for the person operated upon, for the light. There are two
kinds
of light, the common and the artificial; the common is not at
our
disposal, the artificial is at our disposal. There are two modes
of
using each, either to the light, or from the light (to the
side?).
There is little use of that which is from (or oblique to the
light),
and the degree of it is obvious. As to opposite the light,
we
must turn the part to be operated upon to that which is most
brilliant
of present and convenient lights, unless those parts which
should
be concealed, and which it is a shame to look upon; thus the
part
that is operated upon should be opposite the light, and the
operator
opposite the part operated upon, except in so far as he
does
not stand in his own light; for in this case the operator will
indeed
see, but the thing operated upon will not be seen. With
regard
to himself when sitting, his feet should be raised to a
direct
line with his knees, and nearly in contact with one another;
the
knees a little higher than the groins, and at some distance from
one
another, for the elbows to rest upon them. The robe, in a neat and
orderly
manner, is to be thrown over the elbows and shoulders
equally
and proportionally. With regard to the part operated upon;
we
have to consider how far distant, and how near, above, below, on
this
side on that side, or in the middle. The measure as to distance
and
proximity is, that the elbows do not press the knees before, nor
the
sides behind; that the hands be not raised higher than the
breasts,
nor lower than so as that when the breast reposes on the
knees
he may have the hands at right angles with the arm: thus it is
as
regards the medium; but as concerns this side or that, the operator
must
not be beyond his be beyond his seat, but in proportion as he may
require
turning he must shift the body, or part of the body, that is
operated
upon. When standing, he must make his inspection, resting
firmly
and equally on both feet; but he must operate while
supporting
himself upon either leg, and not the one on the same side
with
the hand which he makes use of; the knee being raised to the
height
of the groins as while sitting; and the other measures in
like
manner. The person operated upon should accommodate the
operator
with regard to the other parts of his body, either
standing,
sitting, or lying; so as that he may continue to preserve
his
figure, avoid sinking down, shrinking from, turning away; and
may
maintain the figure and position of the part operated upon, during
the
act of presentation, during the operation, and in the subsequent
position.
4. The nails should be neither longer nor shorter
than the points of
the
fingers; and the surgeon should practice with the extremities of
the
fingers, the index-finger being usually turned to the thumb;
when
using the entire hand, it should be prone; when both hands,
they
should be opposed to one another. It greatly promotes a dexterous
use
of the fingers when the space between them is large, and when
the
thumb is opposed to the index. But it is clearly a disease when
the
thumb is impaired from birth, or when, from a habit contracted
during
the time of nursing, it is impeded in its motions by the
fingers.
One should practice all sorts of work with either of with
either
of them, and with both together (for they are both alike),
endeavouring
to do them well, elegantly, quickly, without trouble,
neatly,
and promptly.
5. The instruments, and when and how they should
be prepared, will
be
treated of afterwards; so that they may not impede the work, and
that
there may be no difficulty in taking hold of them, with the
part
of the body which operates. But if another gives them, he must be
ready
a little beforehand, and do as you direct.
6. Those about the patient must present the
part to be operated upon
as
may seem proper, and they must hold the rest of the body steady, in
silence,
and listening to the commands of the operator.
7. There are two views of bandaging: that which
regards it while
doing,
and that which regards it when done. It should be done quickly,
without
pain, with ease, and with elegance; quickly, by despatching
the
without pain, by being readily done; with ease, by being
prepared
for everything; and with elegance, so that it may be
agreeable
to the sight. By what mode of training these accomplishments
are
to be acquired has been stated. When done, it should fit well
and
neatly; it is neatly done when with judgment, and when it is equal
and
unequal, according as the parts are equal or unequal. The forms of
it
(the bandage?) are the simple, the slightly winding (called ascia),
the
sloping (sima), the monoculus, the rhombus, and the
semi-rhombus.
The form of bandage should be suitable to the form and
the
affection of the part to which it is applied.
8. There are two useful purposes to be fulfilled
by bandaging:
(first,)
strength, which is imparted by the compression and the number
of
folds. In one case the bandage effects the cure, and in another
it
contributes to the cure. For these purposes this is the rule-
that
the force of the constriction be such as to prevent the adjoining
parts
from separating, without compressing them much, and so that
the
parts may be adjusted but not forced together; and that the
constriction
be small at the extremities, and least of all in the
middle.
The knot and the thread that is passed through should not be
in
a downward but in an upward direction, regard being had to the
circumstances
under which the case is presented; to position, to the
bandaging,
and to the compression. The commencement of the ligatures
is
not to be placed at the wound, but where the kriot is situated. The
knot
should not be placed where it will be exposed to friction, nor
where
it will be in the way, nor where it will be useless. The knot
and
the thread should be soft, and not large.
9. (Second.) One ought to be well aware that
every bandage has a
tendency
to fall off towards the part that declines or becomes
smaller;
as, for example, upwards, in the case of the head, and
downwards,
in the case of the leg. The turns of the bandage should
be
made from right to left, and from left to right, except on the
head,
where it should be in a straight direction. When opposite
parts
are to be bandaged together, we must use a bandage with two
heads;
or if we make use of a bandage with one head, we must attach it
in
like manner at some fixed point: such, for example, as the middle
of
the head; and so in other cases. Those parts which are much exposed
to
motion, such as the joints, where there is a flexion, should have
few
and slight bandages applied to them, as at the ham; but where
there
is much extension, the bandage should be single and broad, as at
the
kneepan; and for the maintenance of the bandage in its proper
place,
some turns should be carried to those parts which are not
much
moved, and are lank, such as the parts above and below the
knee.
In the case of the shoulder; a fold should be carried round by
the
other armpit; in that of the groin, by the flanks of the
opposite
side; and of the leg, to above the calf of the leg. When
the
bandage has a tendency to escape above, it should be secured
below,
and vice versa; and where there is no means of doing this, as
in
the case of the head, the turns are to be made mostly on the most
level
part of the head, and the folds are to be done with as little
obliquity
as possible, so that the firmest part being last applied may
secure
the portions which are more movable. When we cannot secure
the
bandaging by means of folds of the cloth, nor by suspending them
from
the opposite side, we must have recourse to stitching it with
ligatures,
either passed circularly or in the form of a seam.
10. The bandages should be clean, light, soft,
and thin. One
should
practice rolling with both hands together, and with either
separately.
One should also choose a suitable one, according to the
breadth
and thickness of the parts. The heads of the bandages should
be
hard, smooth, and neatly put on. That sort of bandaging is the
worst
which quickly falls off; but those are bad bandages which
neither
compress nor yet come off.
11. The following are the object which the
upper bandage, the
under
bandage, or both aim at: The object of the under bandage is
either
to bring together parts that are separated, or to compress such
as
are expanded, or to separate what are contracted, or to restore
to
shape what are distorted, or the contrary. It is necessary to
prepare
pieces of linen cloth, which are light, thin, soft, clean,
having
no seams nor protuberances on them, but sound, and able to bear
some
stretching, or even a little more than required; not dry, but
wetted
with a juice suitable to the purpose required. We must deal
with
parts separated (in a sinus?) in such wise, that the parts
which
are raised may touch the bottom without producing pressure; we
must
begin on the sound part, and terminate at the wound; so that
whatever
humor is in it may be expelled, and that it may be
prevented
from collecting more. And straight parts are to be
bandaged
in a straight direction, and oblique obliquely, in such a
position
as to create no pain; and so that there may be no
constriction
nor falling off on a change of position, either for the
purpose
of taking hold of anything, or laying the limb; and that
muscles,
veins, nerves, and bones may be properly placed and
adjusted
to one another. It should be raised or laid in a natural
position,
so as not to occasion pain. In those cases in which an
abscess
is formed, we must act in a contrary way. When our object is
to
bring together parts which have become expanded, in other
respects
we must proceed on the same plain; and we must commence the
bringing
together from some considerable distance; and after their
approach,
we must apply compression, at first slight, and afterwards
stronger,
the limit of it being the actual contact of the parts. In
order
to separate parts which are drawn together, when attended with
inflammation,
we must proceed on the opposite plan; but when without
inflammation,
we must use the same preparations, but bandage in the
opposite
direction. In order to rectify distorted parts, we must
proceed
otherwise on the same principles; but the parts which are
separated
must be brought together by an underbandage, by
agglutinants,
and by suspending it (the limb?) in its natural
position.
And when the deformities are the contrary, this is to be
done
on the contrary plan.
12. In fractures we must attend to the length,
breadth, thickness,
and
number of the compresses. The length should be that of the
bandaging;
the breadth, three or four fingers; thickness, three or
fourfold;
number so as to encircle the limb, neither more nor less;
those
applied for the purpose of rectifying a deformity, should be
of
such a length as to encircle it; the breadth and thickness being
determined
by the vacuity, which is not to be filled up at once. The
upper
bandages are two, the first of which is to be carried from the
seat
of the injury upwards, and the second from the seat of the injury
downwards,
and from below upwards; the parts about the seat of the
injury
being most compressed, the extremities least, and the rest in
proportion.
The upper bandages should take in a considerable portion
of
the sound parts. We must attend to the number, length, and
breadth
of the bandages; the number must be such as not to be inferior
to
what the injury requires, nor occasion compression with the
splints,
nor prove cumbersome, nor occasion any slipping of them,
nor
render them inefficient. As to length and breadth, they should
be
three, four, five, or six cubits in length, and as many fingers
broad.
The folds of the strings (selvages?) should be such as not to
occasion
pressure; they are to be soft and not thick; and all these
things
are to be proportionate to the length, breadth, and thickness
of
the part affected. The splints are to be smooth, even, and
rounded
at the extremities; somewhat less all along than the upper
bandaging,
and thickest at the part to which fracture inclines.
Those
parts where there are tuberosities, and which are devoid of
flesh,
such as the ankles or fingers, we must guard from the splints
which
are placed over them, either by position, or by their shortness.
They
are to be secured by the strings in such a manner as not to
occasion
pressure at first. A soft, consistent, and clean cerate
should
be rubbed into the folds of the bandage.
13. As to the temperature and quantity of the
water used, its heat
should
be just such as the hand can bear, and it ought to be known
that
a large quantity is best for producing relaxation and
attenuation,
whereas a moderate quantity is best for incarnating and
softening.
The limit to the affusion is, to stop when the parts become
swelled
up, and before the swelling subsides; for the parts swell up
at
first, and fall afterward.
14. The object on which to (the limb?) is laid
should be soft,
smooth,
and sloping upwards toward the protuberant parts of the
body,
such as the heel or hips, so that there may be no projection,
nor
bending inwards, nor turning aside. The canal (spout or gutter?)
should
rather comprehend the whole limb than the half of it, attention
being
paid to the injury and to whatever else appears to create
inconvenience.
15. The presentation of the injured part to
the physician, the
extension,
the arrangement, and so forth, are to be regulated
according
to nature. What is nature in these operations is to be
determined
by the accomplishment of the object which we have in
view,
and for this purpose we must look to the part in the state of
rest,
in its middle state, and to habit; in regard to the state of
rest
and relaxation, as in the arm, that it be in a line with the
hand;
and with regard to the medium between flexion and extension,
that
the forearm be at right angles to the arm; and with regard to
habit,
it should be considered that some limbs bear certain
positions
preferably, as, for example, the thighs extension; for in
such
attitudes the parts can best bear to be placed for a considerable
time
without a change of posture. And in the change from the state
of
distention, the muscles, veins, nerves, and bones, when properly
arranged
and secured, will preserve their relations to one another
while
the limb is raised or placed.
16. The extension should be most powerful when
the largest and
thickest
bones, or when both are broken; next when the under-bone, and
least
of all, when the upper. When immoderate, it is injurious, except
in
the case of children. The limb should be a little elevated. The
model
by which we judge if the part be properly set is the sound
part
of the same name, or the part which is its pair.
17. Friction can relax, brace, incarnate, attenuate:
hard braces,
soft
relaxes, much attenuates, and moderate thickens.
18. The following should be the state of matters
on the first
application
of the bandage. The person to whom it has been applied
should
say that he feels the compression particularly at the seat of
the
injury, but very little at the extremities; the parts should be
adjusted
but not pressed together, and that rather by the number of
the
bandages than by the force of the constriction; and the
tightness
should rather be on the increase during the first day and
night;
but on the next it should be less, and on the third the
bandages
should be loose. On the next day a soft swelling should be
observed
in the extremities; and on the third day, when the
bandaging
is loosed, the swelling should be found diminished in
size,
and this should be the case every time the bandages are removed.
At
the second application of the bandage, it should be ascertained
whether
the dressing has been properly done, and then greater
compression
should be made, and with more bandages; and on the
third,
still greater, and still more. On the seventh day from the
first
dressing, when the bandages are loosed, the limb should be found
slender
and the bones mobile. We must then have recourse to the
splints,
provided the limb be free of swelling, pruritus, and
ulceration,
and allow them to remain until twenty days after the
accident;
but if any suspicions arise, the bandages must be loosed
in
the interval. The splints should be tightened every third day.
19. The suspending of a fractured limb in a
sling, the disposition
of
it, and the bandaging, all have for their object to preserve it
in
position. The principal considerations with regard to the
position
are the habits and the peculiar nature of each of the
limbs:
the varieties are shown in running, walking, standing, lying,
action,
repose.
20. It should be kept in mind that exercise
strengthens, and
inactivity
wastes.
21. Compression should be produced by the number
of bandages, rather
than
by the force of the constriction.
22. In cases of ecchymosis, contusions, sprains,
or swellings not
attended
with inflammations, blood is to be expelled from the wound,
in
greatest quantity to the upper part, and in smallest to the
inferior;
neither the arm nor the leg should be placed in a
declining
position: the head of the bandage should be placed on the
wound,
and there the greatest pressure should be made; the least at
the
extremities, and intermediately in the middle; the last fold of
the
bandage should be at the upper part of the body. As to binding and
compression,
these objects are to be attained rather by the number
of
the bandages than the force of the constriction; and moreover, in
these
cases the bandages should be thin, light, soft, clean, broad,
sound,
so that they may effect their purpose, even without splints.
And
we must use affusions.
23. Dislocations, sprains, diastases of bones,
violent separation,
abruption
of the extremities of bones, and distrainings, so as to
induce
varus or valgus, in these cases we must apply the bandages so
as
not to compress the part whence the displacement took place, and
that
we may render them tight at the side to which the displacement
was,
and give the limb an inclination in the opposite direction, and
that
in an excessive degree. We employ bandages, compresses,
suspension
of the limb in a sling, attitude, extension, friction,
rectification;
and along with these the affusion of much water.
24. In treating parts which are atrophied,
we must comprehend a
considerable
part of the sound limb with the bandage, so that by the
influx
thereby produced, the wasted part may acquire a supply
greater
than its loss, and may be thus disposed to growth and
restoration
of its fleshy parts. It is better also to bandage the
parts
above, as the thigh in the case of the leg, and also the thigh
and
leg of the opposite side, so that they may be placed in similar
circumstances,
and may both equally be deprived of motion; and that
the
supply of nourishment may be alike curtailed and open to both. The
compression
should be the effect rather of the number of the
bandages
than of their tightness. We relax first the part most
requiring
it, and have recourse to that kind of friction which will
promote
the growth of flesh, and to affusion. No splints.
25. Those things which are for the purpose
of giving support and
strength
to the part, as to the breast, side, head, and so forth,
are
used in such cases as the following: for pulsations, that there
may
be no motion in the part; and in separation at the sutures of
the
skull, in order to give support; and in order to strengthen the
chest
and head, in coughs, sneezings, and other movements. In all
these
cases the same measure of bandaging is to be observed, for where
the
injury is, there the bandage should compress most, and something
soft
is to be placed below that suits with the complaint; and we
must
not apply the bandages tighter than just to stop the pulsations
from
creating disturbance, and that the separated parts at the sutures
may
be brought into contact, they must not be such as absolutely to
stop
the coughs and sneezings, but so as to give support, and, without
occasioning
uneasiness, prevent the parts from being shaken.
-THE END-
