Data Entry
- -This pointer pattern extracts section.
It's 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;
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.
- 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
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
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.
-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.
-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 work; 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.
- 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
(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
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.
- 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,
- the limb?) in its natural position. And when the
- deformities are the contrary, this is to be done on the contrary plan.
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 tuber-
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.
- 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.
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.
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.
-Friction can relax, brace, incarnate, attenuate: hard braces, soft relaxes, much - attenuates, and moderate thickens.
-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.
- 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
It should be kept in mind that exercise strengthens, and inactivity wastes.
-Compression should be produced by the number of bandages, rather than by the - force of the constriction.
-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.
-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.
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,
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.
-It’s 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;
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.
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 (
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
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.
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.
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 work; 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.
There are two useful purposes to be fulfilled by bandaging: (
(
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.
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 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 (
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.
The object on which to (
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.
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.
Friction can relax, brace, incarnate, attenuate: hard braces, soft relaxes, much attenuates, and moderate thickens.
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.
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
It should be kept in mind that exercise strengthens, and inactivity wastes.
Compression should be produced by the number of bandages, rather than by the force of the constriction.
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.
Dislocations, sprains, diastases of bones, violent separation, abruption of the extremities of bones, and distrainings, so as to induce
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,
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.
Data Entry
+This pointer pattern extracts section.
It’s 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;
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.
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 (
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
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.
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.
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 work; 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.
There are two useful purposes to be fulfilled by bandaging: (
(
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.
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 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 (
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.
The object on which to (
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.
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.
Friction can relax, brace, incarnate, attenuate: hard braces, soft relaxes, much attenuates, and moderate thickens.
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.
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
It should be kept in mind that exercise strengthens, and inactivity wastes.
Compression should be produced by the number of bandages, rather than by the force of the constriction.
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.
Dislocations, sprains, diastases of bones, violent separation, abruption of the extremities of bones, and distrainings, so as to induce
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,
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.
Data Entry
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In treating fractures and dislocations, the physician must make the extension as - straight as possible, for this is the most natural direction. But if it incline - to either side, it should rather turn to that of pronation, for there is thus - less harm than if it be toward supination. Those, then, who act in such cases - without deliberation, for the most part do not fall into any great mistake, for - the person who is to have his arm bound, presents it in the proper position from - necessity, but physicians who fancy themselves learned in these matters, are - they who commit blunders. There is no necessity for much study, then, in order - to set a broken arm, and in a word, any ordinary physician can perform it; but I - am under the necessity of giving the longer directions on this subject, because - I know physicians who have the reputation of being skilled in giving the proper - positions to the arm in binding it up, while in reality they are only showing - their own ignorance. But many other things in our art are judged of in this - manner, for people rather admire what is new, although they do not know whether - it be proper or not, than what they are accustomed to, and know already to be - proper; and what is strange, they prefer to what is obvious. I must now state - what the mistakes of medical men are, which I wish to unteach, and what - instructions I have to give as to the management of the arm; for what I have to - say regarding it, will apply to the other bones in the body.
-The arm, then, for that is the subject we were treating of, was presented in the
- prone position to be bound, but the physician forced his patient to hold it as
- the archers do when they project the shoulder, and in this position he bound it
- up, thinking withintendons?) were thus put in their natural position, and he appealed to
- what happens in archery, as a proof of this. And so saying, and so doing, he is
- looked up to as a sage; and yet he forgets that in all the other arts and
- performances, whether executed by strength or dexterity, what is reckoned the
- natural position is not the same, and that in the same piece of work it may
- happen that the natural position of the right arm is not the same as that of the
- left. For there is one attitude in throwing the javelin, and another in
- slinging, another in casting stones, another in boxing, and another in a state
- of repose. And whatever arts one examines, it will be found that the natural
- position of the arms is not the same in each, but that in every case the arms
- are put into the attitude which suits best with the instrument that is used, and
- the work to be performed. In practicing archery, no doubt this is the best
- attitude of the left arm, for gingly-moid extremity of the humerus being fixed
- in the cavity of the ulna, in this position, throws the bones of the forearm and
- arm into a line, as if they constituted a single bone, and all flexion at the
- joint is prevented in this position. It is no doubt certain that the member is
- thus put into the most unbending and extended position possible, so as not to be
- overcome or yield when the string is drawn by the right arm, and thus will the
- archer be enabled to draw the string farthest, and discharge his arrow with the
- greatest force and rapidity, for arrows thus discharged have the greatest
- swiftness and force, and are carried to the greatest distances. But there is
- nothing in common between the binding up of an arm and archery. Moreover, if
- having thus bound up the arm, the physician direct the patient to keep it thus,
- he will occasion him greater pain than he had from the wound itself; and thus
- also, if the physician order him to bend the arm, neither the bones, the nerves,
- nor the flesh will any longer be in the same condition, but will be arranged
- differently, having overcome the bandaging. What use, then, is there of the
- archer's attitude?
But another physician putting the arm into the state of supination, gives orders
- to extend the arm thus, and bandages it in this position, reckoning it the one
- according to nature, judging thus from the skin, and also fancying the bones to
- be thus in their natural position, because the bone which protrudes at the
- wrist, where the little finger is, appears to be in a line with the bone from
- which people measure the bone of the fore-arm. These things he brings forward as
- proofs that the parts are in their natural state, and he is supposed to speak
- correctly. But, indeed, if the arm be kept stretched in a supine position, it
- will become very painful, and this fact any one may ascertain by extending his
- own arm in this attitude. And also a weaker man grasping with his hands a
- stronger man whose arm is turned in a supine position, could lead him wherever
- he chose, and neither, if a man held a sword thus in his hand, could he make any
- proper use of it, so constrained is this position. And, moreover, if, when a
- physician has thus bound up the arm, he allow it to remain in the same position,
- the patient will endure greater pain if he walk about, but considerable, even if
- he remain at rest. And thus, too, if he shall bend the arm, the muscles and the
- bones must necessarily assume a different position. But, in addition to other
- mischief, he is ignorant of these facts regarding the position, that the bone
- which protrudes at the wrist, close to the little finger, belongs to the
- fore-arm, whereas the one at the joint, from which people measure the fore-arm,
- is the head of the humerus. He fancies that both these belong to the same bone,
- and many others are of this opinion. The latter, in fact, is the same part as
- that which is called the elbow, upon which we sometimes rest, and when he holds
- the arm thus in a supine position, in the first place the bone appears
- distorted, and in the next place the tendons which extend from the carpus along
- the inner side and from the fingers become distorted while the arm has a supine
- position; for these tendons proceed to the bone of the humerus, from which the
- fore-arm is measured. Such, and so
In cases of fracture in either of the bones of the forearm, it is easier to
- effect a cure if the upper bone be broken, although it be the thicker one, both
- because the sound bone is situated below, and forms a support to it, and because
- the deformity is more easily concealed, there being a thick mass of flesh on the
- upper side, except near to the wrist. But the lower bone is without a covering
- of flesh, is not easily concealed, and requires stronger extension. If it is not
- this bone, but the other which is broken, a more feeble extension proves
- sufficient, but if both be broken, a more powerful extension is required. In the
- case of a young person I have known the extension made more strong than was
- necessary, but in general the extension made is less than what is required. And
- when they are extended, the physician should apply the palms of the hands, and
- adjust the fractured parts and then having rubbed the parts with cerate, but not
- in large quantity so that the bandages may not come off, it is to be bound up in
- this state, care being taken that the hand be not lower than the elbow, but a
- little higher, so that the blood do not flow toward the extremity, but may be
- determined to the upper part; and then it is to be secured with the bandage,
And these are the signs that the patient has been well treated and properly
- bandaged: if you ask him if the arm feels tight, and he says it does, but
- moderately so, and especially about the fracture; and this reply he should make
- all along, if the bandage be properly applied. And these are symptoms of the
- bandaging being moderately tight; if for the first day and night he fancies that
- the tightness does not diminish, but rather increases; and if on the next day
- there be a soft swelling in the hand, for this is a sign of moderate
- compression, but at the end of the second day the compression should feel less,
- and on the third day the bandaging should appear loose. And if any of
When the third day arrives, that is to say, the seventh from the first dressing,
- if properly done, the swelling in the hand should be not very great; and the
- part which has been bandaged should be found more slender and less swelled at
- each time, and on the seventh day the swelling should be quite gone, and the
- broken bones should be more readily moved, and admit of being easily adjusted.
- And if these things be so, you should,
If, then, you see that the bones are properly adjusted by the first dressings,
- and that there is no troublesome pruritus in the part, nor any reason to suspect
- ulceration, you may allow the arm to remain bandaged in the splints until after
- the lapse of more than twenty days. The bones of the fore-arm generally get
- consolidated in thirty days altogether; but there is nothing precise in this
- matter, for one constitution differs from another, and one period of life from
- another. When you remove the bandages, you must pour hot water on the arm and
- bind it up again, but somewhat slacker, and with fewer bandages than formerly:
- and again on the third day you undo the bandages, and
When the arm is broken, if one stretch the fore-arm and adjust it while in this
- position, the muscle of the arm will be bound while extended; but when the
- dressing is over, and the patient bends his arm at the elbow, the muscle of the
- arm will assume a different shape. The following, then, is the most natural plan
- of setting the arm: having got a piece of wood a cubit or somewhat less in
- length, like the handles of spades,
The human foot is composed of several small bones like the hand. These bones - therefore are scarcely ever broken, unless the skin at the same time be wounded - by some sharp and heavy body. The treatment of such injuries, therefore, will be - delivered under the head of wounds. But if any bone be moved from its place, or - a joint of the toes be luxated, or any of the bones of the part called the - tarsus be displaced, it must be forced back again to its place as described with - regard to the hand; and is to be treated with cerate, compresses, and bandages, - like the fractures, with the exception of the splints; and is to be secured - tightly in the same way, and the bandages renewed on the third day; and the - patient thus bandaged should return the same answers as in fractures, as to the - bandages feeling tight or slack. All these bones recover perfectly in twenty - days, except those that are connected with the bones of the leg, and are in a - line with them. It is advantageous to lie in bed during the whole of this time; - but the patients, thinking light of the complaint, have not perseverance to do - this, and they walk about before they get well; wherefore many of these do not - make a perfect recovery. And often the pain puts them in mind of the injury; and - deservedly, for the feet sustain the weight of the whole body. When, therefore, - they walk about before they are whole, the joints which have been luxated are - cured incompletely; and, on that account, while walking about, they have pains - in the leg from time to time.
- But those bones which are connected with the bones of the leg are larger than
- the others, and the cure of them when luxuated is more protracted. The mode of
- treatment then is the same; but we must use more bandages and more splints, and
- the bandage is to be carried round to this side and to that, and pressure is to
- be made as in the other cases, particularly at the seat of the luxation, and the
- first circles of the bandages are
In persons who jumping from any high object pitch upon their heel with great
- force, the bones are separated, and the veins pour forth their contents, owing
- to the contusion of the flesh surrounding the bone, and hence a swelling and
- much pain supervene. For this bone (os calcis) is not a small one, protrudes
- beyond the line of the leg, and is connected with important veins and tendons;
- for the back tendon of the leg is inserted into this bone. Such cases are to be
- treated with cerate, and with compresses and bandages; and hot water is to be
- used in large quantity; and they require many bandages, which ought to be
- particularly good and appropriate. And if the patient happen to have a tender
- skin about the heel, nothing is to be done to it; but if, as some have it, the
- skin be thick and hardened, it is to be pared down smoothly and thinned, but
- without wounding it. It is not everybody who can apply the bandage properly in
- such cases; for if one shall bind the parts, as in other accidents about the
- ankle, sometimes bringing a fold round the foot and sometimes round the tendon,
- these turns leave out the heel, which is the seat of the contusion, and thus
- there is danger that the os calcis may sphacelate; and if this should take
- place, the impediment may endure for life and also in all the other cases of
- sphacelus, not proceeding from such a cause as this; as when, from being
- carelessly allowed to lie in a certain position during confinement to bed, the
- heel becomes black, or when a serious wound has occurred in the leg and it is
- long of healing, and is connected with the heel, or when the same thing happens
- in the thigh, or when in any disease a protracted decubitus takes placeoxyglyky (a
- composition from vinegar and honey?). But if the case be not going to get worse,
- the ecchymosed and livid parts, and those surrounding them become greenish and
- not hard; for this is a satisfactory proof in all cases of ecchymosis, that they
- are not to get worse; but when lividity is complicated with hardness, there is
- danger that the part may become blackened. And we must so manage the foot as
- that it may be generally raised a little higher than the rest of the body. Such
- a patient will get well in sixty days if he keep quiet.
The leg consists of two bones, of which the one is much more slender than the - other at one part, but not much more slender at another. These are connected - together at the foot, and form a common epiphysis, but they are not united - together along the line of the leg; and at the thigh they are united together - and form an epiphysis, and this epiphysis has a diaphysis; but the other bone in - a line with the little toe is a little longer. Such is the nature of the bones - of the leg.
- Sometimes the bones connected with the foot are displaced, sometimes both bones
- with their epiphysis; sometimes the whole epiphysis is slightly moved, and
- sometimes the other bone. These cases are less troublesome than the same
- accidents at the wrist, if the patients will have resolution to give them rest.
- The mode of treatment is the same as that of the other, for the reduction is to
- be made, as of the other, by means of extension, but greater force is required,
- as the parts of the body concerned are stronger in this case. But, for the most
- part, two men will be sufficient, by making extension in opposite directions,
- but, not withstanding, if they are not sufficiently strong, it is easy to make
- more powerful extension in the following way: having fixed in the ground either
- the nave of a wheel, or any such object, something soft is to be bound round the
- foot, and then some broad thongs of ox-skin being brought round it, the heads of
- the thongs are to be fastened to a pestle or any other piece of wood, the end of
-
When you have made proper extension, it is easy reduce the joint, for the
- displaced bone is thus raised into a line with the other. And the bones are to
- be adjusted with the palms of the hands, pressing upon the projecting bone with
- the one, and making counter-pressure below the ankle with the other. Whenvice versa. But for the
- most part the dislocation is inward.
And when both bones of the leg are broken without a wound of the skin, stronger
- extension is required. We may make extension by some of the methods formerly
- described, provided the bones ride over one another to a considerable degree.
- But extension by men is also sufficient, and for the most part two
When the parts are adjusted, you should apply the bandages while the limb is in
- a stretched position, making the first turns to the right or to the left, as may
- be most suitable; and the end of the bandage should be placed over the fracture,
- and the first turns made at that place; and then the bandage should be gutters?) usually placed below fractured legs, I am at
- a loss whether to advise that they should be used or not. For they certainly are
- beneficial, but not to the extent which those who use them suppose. For the
- canals do not preserve the leg at rest as they suppose; nor, when the rest of
- the body is turned to the one side or the other, does the canal prevent the leg
- from following, unless the patient himself pay attention; neither does the canal
- prevent the limb from being moved without the body to the one side or the other.
- And a board is an uncomfortable thing to have the limb laid upon, unless
- something soft be placed above it. But it is a very useful thing in making any
- subsequent arrangements of the bed and in going to stool. A limb then may be
- well or ill arranged with or without the canal. But the common people have more
- confidence, and the surgeon is more likely to escape blame, when the canal is
- placed under the limb, although it is not secundum artem.
- For the limb should by all means lie straight upon some level and soft object,
- since the bandaging must necessarily be overcome by any distortion in the
- placing of the leg, whenever or to whatever extent it may be inclined. The
- patient, when bandaged, should return the same answers as formerly stated, for
- the bandaging should be the same, and the same swellings should arise in the
- extremities, and the slackening of the bandages in like manner, and the new
- bandaging on the third day; and the bandaged part should be found reduced in
- swelling; and the new bandagings should be more tightly put on, and more pieces
- of cloth should be used; and the bandages should be carried loosely about the
- foot, unless the wound be near the
But if the other bone (fibula?) of the leg be broken, less
- powerful extension is required, and yet it must not be neglected, nor be
- performed slovenly, more especially at the first bandaging. For in all cases of
- fracture this object should be attained then as quickly as possible. For when
- the bandage is applied tight while the bones are not properly arranged, the
- properly arranged, the part becomes more painful. The treatment otherwise is the
- same.
Of the bones of the leg, the inner one, called the tibia, is the more
- troublesome to manage, and requires the greater extension; and if the broken
- bones are not properly arranged, it is impossible to conceal the distortion, for
- the bone is exposed and wholly uncovered with flesh; and it is much longer
- before patients can walk on the leg when this bone is broken. But if the outer
- bone be broken, it causes much less trouble, and the deformity, when the bones
- are not properly set, is much more easily concealed, the bone being well covered
- with flesh; and the patients speedily get on foot, for it is the inner bone of
- the leg which supports the most of the weight of the body. For along with the
- thigh, as being in a line with weight thrown upon the thigh, the inner bone has
- more work to sustain; inasmuch as it is the head of the thigh-bone which
- sustains the upper part of the body, and it is on the inner and not on the outer
- side of
When the thigh-bone is broken, particular pains should be taken with regard to
- the extension that it may not be insufficient, for when excessive, no great harm
- results from it. For, if one should bandage a limb while the extremities of the
- bone are separated to a distance from one another by the force of the extension,
- the bandaging will not keep them separate, and so the bones will come together
- again as soon as the persons stretching it let go their hold; for the fleshy
- parts (muscles?) being thick and strong, are more powerful
- than the bandaging, instead of being less so. In the case then which we are now
- treating of, nothing should be omitted in order that the parts may be properly
- distended and put in a straight line; for it is a great disgrace and an injury
- to exhibit a shortened thigh. For the arm, when shortened, might be concealed,
- and the mistake would not be great; but a shortened thigh-bone would exhibit the
- man maimed. For when the sound limb is placed beside it, being longer than the
- other, it exposes the mistake, and therefore it would be to the advantage of a
- person who would be improperly treated that both his legs should be broken,
- rather than either of them; for in this case the one would be of the same length
- as the other. When, then, proper extension has been made, you must adjust the
- parts with the palms of the hands, and bandage the limb in the manner formerly
- described, placing the hands of the bandages as was directed, and making the
- turns upward. And the patient should return the same answers to the same
- questions as formerly, should be pained and recover in like manner, and should
- have the bandaging
But this also should be known, that the thigh-bone is curved rather to the - outside than to the inside, and rather forward than backward; when not properly - treated, then, the distortions are in these directions; and the bone is least - covered with flesh at the same parts, so that the distortion cannot be - concealed. If, therefore, you suspect anything of this kind, you should have - recourse to the mechanical contrivances recommended in distortion of the arm. - And a few turns of the bandage should be brought round by the hip and the loins, - so that the groin and the articulation near the perineum may be included in the - bandage; and moreover, it is expedient that the extremities of the splints - should not do mischief by being placed on parts not covered with the bandages. - The splints, in fact, should be carefully kept off the naked parts at both ends; - and the arrangement of them should be so managed, as that they may not be placed - on the natural protuberances of the bone at the knee-joint, nor on the tendon - which is situated there.
-The swellings which arise in the ham, at the foot, or in any other part from the - pressure, should be well wrapped in unscoured and carded wool, washed with wine - and oil, and anointed with cerate, before bandaging; and if the splints give - pain they should be slackened. You may sooner reduce the swellings, by laying - aside the splints, and applying plenty of bandages to them, beginning from below - and rolling upward; for thus the swellings will be most speedily reduced, and - the humors be propelled to the parts above the former bandages. But this form of - bandaging must not be used unless there be danger of vesications or blackening - in the swelling, and nothing of the kind occurs unless the fracture be bound too - tight, or unless the limb be allowed to hang, or it be rubbed with the hand, or - some other thing of an irritant nature be applied to the skin.
- More injury than good results from placing below the thigh a canal which does
- not pass farther down than the ham,
The extremity of the heel should be particularly attended to, so that it may be - properly laid, both in fractures of the leg and of the thigh. For if the foot be - placed in a dependent position, while the rest of the body is supported, the - limb must present a curved appearance at the forepart of the leg; and if the - heel be placed higher than is proper, and if the rest of the leg be rather too - low, the bone at the forepart of the leg must present a hollow, more especially - if the heel of the patient be naturally large. But all the bones get - consolidated more slowly, if not laid properly, and if not kept steady in the - same position, and in this case the callus is more feeble.
- These things relate to cases in which there is fracture of the bones without
- protrusion of the same or wound of any other kind. In those cases in which the
- bones are simply broken across, and are not comminuted, but protrude, if reduced
- the same day or next, and secured in their place, and if there be no reason to
- anticipate that any splintered bones will come away; and in those in which the
- broken bones do not protrude, nor is the mode of fracture such that there is
- reason to expect the splinters will come out, some physicians heal the sores in
- a way which neither does much good nor harm, by means of a cleansing
There are others who treat such cases at first with bandages, applying them on
- both sides of the seat of the injury, but omit them there, and leave the wound
- uncovered, and afterward they apply to the wound some cleansing medicine, and
- complete the dressing with compresses dipped in wine and greasy wool. This plan
- of treatment is bad, and it is clear that those who adopt this mode of practice
- are guilty of great mistakes in other cases of fracture as well as these. For it
- is a most important consideration to know in what manner the head of the bandage
- should be placed and at what part the greatest pressure should be, and what
- benefits would result from applying the end of the bandage and the pressure at
- the proper place, and what mischiefs would result from applying the head of the
- bandage and the pressure otherwise than at the proper place. Wherefore it has
- been stated in the preceding part of the work what are the results of either;
- and the practice of medicine bears witness to the truth of it, for in a person
- thus bandaged, a swelling must necessarily arise on the wound. For, if even a
- sound piece of skin were bandaged on either side, and a part were left in the
- middle, the part thus left unbandaged would become most swelled, and would
- assume a bad color; how then could it be that a wound would not suffer in like
- manner? The wound then must necessarily become discolored and its lips everted,
- the discharge will be ichorous and without pus, and the bones, which should not
- have got into a state of necrosis, exfoliate; and the wound gets into a
- throbbing and inflamed condition. And they
As a general rule it may be said, that in those cases in which a separation of
- bone is not expected, the same treatment should be applied as when the fractures
- are not complicated with an external wound; for the extension, adjustment of the
- bones, and the bandaging, are to be conducted in the same manner. To the wound
- itself a cerate mixed with pitch is to be applied, a thin folded compress is to
- be bound upon it, and the parts around are to be anointed with white cerate. The
- cloths for bandages and the other things should be torn broader than in cases in
- which there is no wound, and the first turn of the bandage should be a good deal
- broader than the wound. For a narrower bandage than the wound binds the wound
- like a girdle, which is not proper, or the first turn should comprehend the
- whole wound, and the bandaging should extend beyond it on both sides. The
- bandage then should be put on in the direction of the wound, and should be not
- quite so tight as when there is no wound, but the bandage should be otherwise
- applied in the manner described above. The bandages should be of a soft
- consistence, and more especially so in such cases than in those not complicated
- with a wound. The number of bandages should not
The treatment of the sores is the same in those cases of fracture in which there
- was no wound of the skin at first, buttendon?)
- become black, it will fall off; for such sores are not to be treated with acrid,
- but with emollient applications, like burns. The bandages are to be renewed
- every third day, and no splints are to be applied, but rest is to be more
- rigidly maintained than in the former cases, along with a restricted diet. It
- should be known, that if any piece of flesh or tendon be to come away, the
- mischief will spread much less, and the parts will much more speedily drop off,
- and the swelling in the surrounding parts will much more completely subside,
- under this treatment, than if any of the cleansing applications be put upon the
- sore. And if any part that is to come away shall fall off, the part will
- incarnate sooner when thus treated than otherwise, and will more speedily
- cicatrize. Such are the good effects of knowing how a bandage can be well and
- moderately applied.
If you are deceived with regard to a recent wound, supposing there will be no - exfoliation of the bones, while they are on the eve of coming out of the sore, - you must not hesitate to adopt this mode of treatment; for no great mischief - will result, provided you have the necessary dexterity to apply the bandages - well and without doing any harm. And this is a symptom of an exfoliation of bone - being about to take place under this mode of treatment; pus runs copiously from - the sore, and appears striving to make its escape. The bandage must be renewed - more frequently on account of the discharge, since otherwise fevers come on; if - the sore and surrounding parts be compressed by the bandages they become wasted. - Cases complicated with the exfoliation of very small bones, do not require any - change of treatment, only the bandages should be put on more loosely, so that - the discharge of pus may not be intercepted, but left free, and the dressings - are to be frequently renewed until the bone exfoliate, and the splints should - not be applied until then.
- Those cases in which the exfoliation of a larger piece of bone is expected,
- whether you discover this at the commencement, or perceive subsequently that it
- is to happen, no longer require the same mode of treatment, only that the
- extension and arrangement of the parts are to be performed in a manner that has
- been described; but having formed double compresses, not less than half a fathom
- in breadth (being guided in this by the nature of the wound), and considerably
- shorter than what would be required to go twice round the part that is wounded,
- but considerably longer than to go once round, and in number what will be
- sufficient, these are to be dipped in a black austere wine; and beginning at the
- middle, as is done in applying the double-headed bandage, you are to wrap the
- part around and proceed crossing the heads in the form of the bandage called
- "ascia." These things are to be done at the wound, and on both sides of it; and
- there must be no compression, but they are to be laid on so as to give support
- to the wound. And on the wound itself is to be applied the pitched cerate, or
- one of the applications
In such cases as do not admit of bandaging according to any of the methods which
- have been described, or which will be described, great pains should be taken
- that the fractured part of the body be laid in a right position, and attention
- should be paid that it may incline upward rather than downward. But if one would
- wish to do the thing well and dexterously, it is proper to have recourse to some
- mechanical contrivance, in order that the fractured part of the body may undergo
- proper and not violent extension; and this means is particularly applicable in
- fractures of the leg. There are certain physicians who, in all fractures of the
- leg, whether bandages be applied or not, fasten the sole of the foot to the
- couch, or to some other piece of wood which they have fixed in the ground near
- the couch. These persons thus do all sorts of mischief but no good; for it
- contributes nothing to the extension that the foot is thus bound, as the rest of
- the body will no less sink down to the foot, and thus the limb will no longer be
- stretched, neither will it do any good toward keeping the limb in a proper
- position, but will do harm, for when the rest of the body is turned to this side
- or that, the bandaging will not prevent the foot and the bones belonging to it
- from following the rest of the body. For if it had not been bound it would have
- been less distorted, as it would have been the less prevented from following the
- motion of the rest of the body. But one should sew two balls of Egyptian
- leather, such as are worn by persons confined for a length of time in large
- shackles, and the balls should have coats on each side, deeper toward the wound,
- but shorter toward the joints; and the balls should be well stuffed and soft,
- and fit well, the one above the
Moreover, the greater part of physicians treat fractures, both with and without
- an external wound, during the first days, by means of unwashed wool, and there
- does not appear to be anything improper in this. It is very excusable for those
- who are called upon to treat newly-received accidents of this kind, and who have
- no cloth for bandages at hand, to do them up
In those cases of fracture in which the bones protrude and cannot be restored to
- their place, the following mode of reduction may be practiced:- Some small
- pieces of iron are to be prepared like the levers which the cutters of stone
- make use of, one being
When you have reduced the bones to their place, the modes of treatment, whether - you expect the bones to exfoliate or not, have been already described. All those - cases in which an exfoliation of bone is expected, should be treated by the - method of bandaging with cloths, beginning for the most part at the middle of - the bandage, as is done with the double-headed bandage; but particular attention - should be paid to the shape of the wound, so that its lips may gape or be - distorted as little as possible under the bandage. Sometimes the turns of the - bandage have to be made to the right, and sometimes to the left, and sometimes a - double-headed bandage is to be used.
- It should be known that bones, which it has been found impossible to reduce, as
- well as those which are wholly denuded of flesh, will become detached. In some
- cases the upper part of the bone is laid bare, and in others the flesh dies all
- around; and, from a sore of long standing, certain of the bones become carious,
- and some not, some more, and some less; and in some the small, and in others the
- large bones. From what has been said it will be seen, that it is impossible to
- tell in one word when the bones will separate. Some come away more quickly,
- owing to their smallness, and some from being merely fixed at the point; and
- some, from pieces not separating, but merely exfoliating, become dried up and
- putrid; and besides, different modes of treatment have different effects. For
- the most part, the bones separate most quickly in those cases in which
- suppuration takes place most quickly, and when new flesh is most quickly formed,
- and is particularly sound, for the flesh which grows up below in the wound
- generally elevates the pieces of bone. It will be well if the whole circle of
- the bone separate in forty days; for in some cases it is protracted to sixty
- days, and in some to more; for the more porous pieces of bone separate more
- quickly, but the more solid come away more slowly; but the other smaller
- splinters in much less time, and others otherwise. A portion of bone which
- protrudes should be sawn off for the following reasons: if it cannot be reduced,
- and if it appears
Such cases are to be treated with compresses and vinous applications, as - formerly laid down regarding bones which will separate. We must avoid wetting it - at the beginning with anything cold; for there is danger of febrile rigors, and - also of convulsions; for convulsions are induced by cold things, and also - sometimes by wounds. It is proper to know that the members are necessarily - shortened in those cases in which the bones have been broken, and have healed - the one across the other, and in those cases in which the whole circle of the - bone has become detached.
- Those cases in which the bone of the thigh, or of the arm, protrudes, do not
- easily recover. For the bones are large, and contain much marrow; and many
- important nerves, muscles, and veins are wounded at the same time. And if you
- reduce them, convulsions usually supervene; and, if not reduced, acute bilious
- fevers come on, with singultus and mortification. The chances of recovery are
- not fewer in those cases in which the parts have not been reduced, nor any
- attempts made at reduction. Still more recover in those cases in which the
- lower, than those in which the upper part of the bone protrudes; and some will
- recover when reduction has been made, but very rarely indeed. For modes of
- treatment and peculiarity of constitution make a great difference as to the
- capability of enduring such an injury. And it makes a great difference if the
- bones of the arm and of the thigh protrude to the inside; for there are many and
- important vessels situated there, some of which, if wounded, will prove fatal;
- there are such also on the outside, but of less im-
Having effected the reduction, you must give an emollient draught of hellebore
- the same day, provided it has been reduced on the day of the accident, but
- otherwise it should not be attempted. The wound should be treated with the same
- things as are used in fractures of the bones of the head, and nothing cold
- should be applied; the patient should be restricted from food altogether, and if
- naturally of a bilious constitution, he should have for a diet a little fragrant
- oxyglyky sprinkled on water; but if he is not bilious,
- he should have water for drink; and if fever of the continual type come on, he
- is to be confined to this regimen for fourteen days at least, but if he be free
- of fever, for only seven days, and then you must bring him back by degrees to a
- common diet. To those cases in which the bones have not been reduced, a similar
- course of medicine should be administered, along with the same treatment of the
- sores and regimen; and in like manner the suspended part of the body should not
- be stretched, but should rather be contracted, so as to relax the parts about
- the wound. The separation of the bones is protracted, as also was formerly
- stated. But one should try to escape from such cases, provided one can do so
- honourably, for the hopes of recovery are small, and the dangers many; and if
- the physician do not reduce the fractured bones he will be looked upon as
- unskillful, while by reducing them he will bring the patient nearer to death
- than to recovery.
Luxations and subluxations at the knee are much milder accidents than
- subluxations and luxations at the elbow. For the knee-joint, in proportion to
- its size, is more compact than that of the arm, and has a more even
- conformation, and is ligament?) at the
- ham arises from it; but the bones of the fore-arm are unequal, and the shorter
- is considerably thicker than the other, and the more slender (ulna?) protrudes, and passes up above the joint, and to it (the olecranon?) are attached the nerves (ligaments?) which go downward to the junction of the bones; and the
- slender bone (ulna?) has more to do with the insertion of
- the ligaments in the arm than the thick bone (radius?). The
- configuration then of the articulations, and of the bones of the elbow, is such
- as I have described. Owing to their configuration, the bones at the knee are
- indeed frequently dislocated, but they are easily reduced, for no great
- inflammation follows, nor any constriction of the joint. They are displaced for
- the most part to the inside, sometimes to the outside, and occasionally into the
- ham. The reduction in all these cases is not difficult, but in the dislocations
- inward and outward, the patient should be placed on a low seat, and the thigh
- should be elevated, but not much. Moderate extension for the most part
- sufficeth, extension being made at the leg, and counter-extension at the
- thigh.
Dislocations at the elbow are more troublesome than those at the knee, and, - owing to the inflammation which comes on, and the configuration of the joint, - are more difficult to reduce if the bones are not immediately replaced. For the - bones at the elbow are less subject to dislocation than those of the knee, but - are more difficult to reduce and keep in their position, and are more apt to - become inflamed and ankylosed.
- For the most part the displacements of these bones are small, sometimes toward
- the ribs, and sometimes to the outside; and the whole articulation is not
- displaced, but that part of the humerus remains in place which is articulated
- with the cavity of the bone of the forearm that has a protuberance (ulna?). Such dislocations, to whatever side, are easily
- reduced, and the extension is to be made in the line of the arm, one person
- making
The end of the humerus at the elbow gets displaced (subluxated?) by leaving the cavity of the ulna. Such luxations readily
- yield to reduction, if applied before the parts get inflamed. The displacement
- for the most part is to the inside, but sometimes to the outside, and they are
- readily recognized by the shape of the limb. And often such luxations are
- reduced without any powerful extension. In dislocations inward, the joint is to
- be pushed into its place, while the fore-arm is brought round to a state of
- pronation. Such are most of the dislocations at the elbow.
But if the articular extremity of the humerus be carried to either side above
- the bone of the fore-arm, which is prominent, into the hollow of the arm (?),
- this rarely happens; but if it does happen, extension in the straight line is
- not so proper under such circumstances; for in such a mode of extension, the
- process of the ulna (olecranon?) prevents the bone of the
- arm (humerus?) from passing over it. In dislocations of
- this kind, extension should be made in the manner described when treating of the
- bandaging of fractured bones of the arm, extension being made upward at the
- armpit, while the parts at the elbow are pushed downward, for in this manner can
- the humerus be most readily raised above its cavity; and when so raised, the
- reduction is easy with the palms of the hand, the one being applied so as to
- make pressure on the protuberant part of the arm, and the other making
- counter-pressure, so as to push the bone of the fore-arm into the joint. This
- method answers with both cases. And perhaps this is the most suitable mode of
- reduction in such a case of dislocation. The parts may be reduced by extension
- in a straight line, but less readily than thus.
If the arm be dislocated forward- this rarely happens, indeed, but what would a
- sudden shock not displace? for many other things are removed from their proper
- place, notwith-olecranon?) which passes above the
- prominent part of the bones is large, and the stretching of the nerves (ligaments?) is intense; and yet the parts have been so
- dislocated in certain cases. The following is the symptom of such a
- displacement: the arm cannot be bent in the least degree at the elbow, and upon
- feeling the joint the nature of the accident becomes obvious. If, then, it is
- not speedily reduced, strong and violent inflammation, attended with fever, will
- come on, but if one happen to be on the spot at the time it is easily reduced. A
- piece of hard linen cloth (or a piece of hard linen, not very large, rolled up
- in a ball, will be sufficient) is to be placed across the bend of the elbow, and
- the arm is then to be suddenly bent at the elbow, and the hand brought up to the
- shoulder. This mode of reduction is sufficient in such displacements; and
- extension in the straight line can rectify this manner of dislocation, but we
- must use at the same time the palms of the hands, applying the one to the
- projecting part of the humerus at the bend of the arm for the purpose of pushing
- it back, and applying the other below to the sharp extremity of the elbow, to
- make counter-pressure, and incline the parts into the straight line. And one may
- use with advantage in this form of dislocation the method of extension formerly
- described, for the application of the bandages in the case of fracture of the
- arm; but when extension is made, the parts are to be adjusted, as has been also
- described above.
But if the arm be dislocated backward (but this very rarely happens, and it is - the most painful of all, and the most subject to bilious fevers of the continual - type, which prove fatal in the course of a few days), in such a case the patient - cannot extend the arm. If you are quickly present, by forcible extension the - parts may return to their place of their own accord; but if fever have - previously come on, you must no longer attempt reduction, for the pain will be - rendered more intense by any such violent attempt. In a word, no joint whatever - should be reduced during the prevalence of fever, and least of all the - elbow-joint.
- There are also other troublesome injuries connected withradius?) is
- sometime partially displaced from the other, and the patient can neither perform
- extension nor flexion properly. This accident becomes obvious upon examination
- with the hand at the bend of the arm near the division of the vein that runs up
- the muscle. In such a case it is not easy to reduce the parts to their natural
- state, nor is it easy, in the separation of any two bones united by symphysis,
- to restore them to their natural state, for there will necessarily be a swelling
- at the seat of the diastasis. The method of bandaging a joint has been already
- described in treating of the application of bandages to the ankle.
In certain cases the process of the ulna (olecranon?)
- behind the humerus is broken; sometimes its cartilaginous part, which gives
- origin to the posterior tendon of the arm, and sometimes its fore part, at the
- base of the anterior coronoid process; and when this displacement takes place,
- it is apt to be attended with malignant fever. The joint, however, remains in
- place, for its whole base protrudes at that point. But when the displacement
- takes place where its head overtops the arm, the joint becomes looser if the
- bone be fairly broken across. To speak in general terms, all cases of fractured
- bones are less dangerous than those in which the bones are not broken, but the
- veins and important nerves (tendons?) situated in these
- places are contused; for the risk of death is more immediate in the latter class
- of cases than in the former, if continual fever come on. But fractures of this
- nature seldom occur.
It sometimes happens that the head of the humerus is fractured at its epiphysis; - and this, although it may appear to be a much more troublesome accident, is in - fact a much milder one than the other injuries at the joint.
- The treatment especially befitting each particular dislocation has been
- described; and it has been laid down as a rule, that immediate reduction is of
- the utmost advantage, owing to the rapid manner in which inflammation of the
- tendons supervenes. For even when the luxated parts are immediately reduced, the
- tendons usually become stiffened, and for a considerable time prevent extension
- and flexion from being performed
In bandaging, the head of the first bandage should be placed at the seat of the
- injury, whether it be a case of fracture, of dislocation, or of diastasis (separation?), and the first turns should be made there, and
- the bandages should be applied most firmly at that place, and less so on either
- side. The bandaging should comprehend both the arm and the fore-arm, and on both
- should be to a much greater extent than most physicians apply it, so that the
- swelling may be expelled from the seat of the injury to either side. And point
- of the fore-arm should be comprehended in the bandaging, whether the injury be
- in that place or not, in order that the swelling may not collect there. In
- applying bandages, we must avoid as much as possible accumulating many turns of
- the bandage at the bend of the arm. For the principal compression should be at
- the seat of the injury, and the same rules are to be observed, and at the same
- periods, with regard to compression and relaxation, as formerly described
- respecting the treatment of broken bones; and the bandages should be renewed
- every third day; and they should appear
In treating fractures and dislocations, the physician must make the extension as straight as possible, for this is the most natural direction. But if it incline to either side, it should rather turn to that of pronation, for there is thus less harm than if it be toward supination. Those, then, who act in such cases without deliberation, for the most part do not fall into any great mistake, for the person who is to have his arm bound, presents it in the proper position from necessity, but physicians who fancy themselves learned in these matters, are they who commit blunders. There is no necessity for much study, then, in order to set a broken arm, and in a word, any ordinary physician can perform it; but I am under the necessity of giving the longer directions on this subject, because I know physicians who have the reputation of being skilled in giving the proper positions to the arm in binding it up, while in reality they are only showing their own ignorance. But many other things in our art are judged of in this manner, for people rather admire what is new, although they do not know whether it be proper or not, than what they are accustomed to, and know already to be proper; and what is strange, they prefer to what is obvious. I must now state what the mistakes of medical men are, which I wish to unteach, and what instructions I have to give as to the management of the arm; for what I have to say regarding it, will apply to the other bones in the body.
The arm, then, for that is the subject we were treating of, was presented in the prone position to be bound, but the physician forced his patient to hold it as the archers do when they project the shoulder, and in this position he bound it up, thinking within
But another physician putting the arm into the state of supination, gives orders to extend the arm thus, and bandages it in this position, reckoning it the one according to nature, judging thus from the skin, and also fancying the bones to be thus in their natural position, because the bone which protrudes at the wrist, where the little finger is, appears to be in a line with the bone from which people measure the bone of the fore-arm. These things he brings forward as proofs that the parts are in their natural state, and he is supposed to speak correctly. But, indeed, if the arm be kept stretched in a supine position, it will become very painful, and this fact any one may ascertain by extending his own arm in this attitude. And also a weaker man grasping with his hands a stronger man whose arm is turned in a supine position, could lead him wherever he chose, and neither, if a man held a sword thus in his hand, could he make any proper use of it, so constrained is this position. And, moreover, if, when a physician has thus bound up the arm, he allow it to remain in the same position, the patient will endure greater pain if he walk about, but considerable, even if he remain at rest. And thus, too, if he shall bend the arm, the muscles and the bones must necessarily assume a different position. But, in addition to other mischief, he is ignorant of these facts regarding the position, that the bone which protrudes at the wrist, close to the little finger, belongs to the fore-arm, whereas the one at the joint, from which people measure the fore-arm, is the head of the humerus. He fancies that both these belong to the same bone, and many others are of this opinion. The latter, in fact, is the same part as that which is called the elbow, upon which we sometimes rest, and when he holds the arm thus in a supine position, in the first place the bone appears distorted, and in the next place the tendons which extend from the carpus along the inner side and from the fingers become distorted while the arm has a supine position; for these tendons proceed to the bone of the humerus, from which the fore-arm is measured. Such, and so
In cases of fracture in either of the bones of the forearm, it is easier to effect a cure if the upper bone be broken, although it be the thicker one, both because the sound bone is situated below, and forms a support to it, and because the deformity is more easily concealed, there being a thick mass of flesh on the upper side, except near to the wrist. But the lower bone is without a covering of flesh, is not easily concealed, and requires stronger extension. If it is not this bone, but the other which is broken, a more feeble extension proves sufficient, but if both be broken, a more powerful extension is required. In the case of a young person I have known the extension made more strong than was necessary, but in general the extension made is less than what is required. And when they are extended, the physician should apply the palms of the hands, and adjust the fractured parts and then having rubbed the parts with cerate, but not in large quantity so that the bandages may not come off, it is to be bound up in this state, care being taken that the hand be not lower than the elbow, but a little higher, so that the blood do not flow toward the extremity, but may be determined to the upper part; and then it is to be secured with the bandage,
And these are the signs that the patient has been well treated and properly bandaged: if you ask him if the arm feels tight, and he says it does, but moderately so, and especially about the fracture; and this reply he should make all along, if the bandage be properly applied. And these are symptoms of the bandaging being moderately tight; if for the first day and night he fancies that the tightness does not diminish, but rather increases; and if on the next day there be a soft swelling in the hand, for this is a sign of moderate compression, but at the end of the second day the compression should feel less, and on the third day the bandaging should appear loose. And if any of
When the third day arrives, that is to say, the seventh from the first dressing, if properly done, the swelling in the hand should be not very great; and the part which has been bandaged should be found more slender and less swelled at each time, and on the seventh day the swelling should be quite gone, and the broken bones should be more readily moved, and admit of being easily adjusted. And if these things be so, you should,
If, then, you see that the bones are properly adjusted by the first dressings, and that there is no troublesome pruritus in the part, nor any reason to suspect ulceration, you may allow the arm to remain bandaged in the splints until after the lapse of more than twenty days. The bones of the fore-arm generally get consolidated in thirty days altogether; but there is nothing precise in this matter, for one constitution differs from another, and one period of life from another. When you remove the bandages, you must pour hot water on the arm and bind it up again, but somewhat slacker, and with fewer bandages than formerly: and again on the third day you undo the bandages, and
When the arm is broken, if one stretch the fore-arm and adjust it while in this position, the muscle of the arm will be bound while extended; but when the dressing is over, and the patient bends his arm at the elbow, the muscle of the arm will assume a different shape. The following, then, is the most natural plan of setting the arm: having got a piece of wood a cubit or somewhat less in length, like the handles of spades,
The human foot is composed of several small bones like the hand. These bones therefore are scarcely ever broken, unless the skin at the same time be wounded by some sharp and heavy body. The treatment of such injuries, therefore, will be delivered under the head of wounds. But if any bone be moved from its place, or a joint of the toes be luxated, or any of the bones of the part called the tarsus be displaced, it must be forced back again to its place as described with regard to the hand; and is to be treated with cerate, compresses, and bandages, like the fractures, with the exception of the splints; and is to be secured tightly in the same way, and the bandages renewed on the third day; and the patient thus bandaged should return the same answers as in fractures, as to the bandages feeling tight or slack. All these bones recover perfectly in twenty days, except those that are connected with the bones of the leg, and are in a line with them. It is advantageous to lie in bed during the whole of this time; but the patients, thinking light of the complaint, have not perseverance to do this, and they walk about before they get well; wherefore many of these do not make a perfect recovery. And often the pain puts them in mind of the injury; and deservedly, for the feet sustain the weight of the whole body. When, therefore, they walk about before they are whole, the joints which have been luxated are cured incompletely; and, on that account, while walking about, they have pains in the leg from time to time.
But those bones which are connected with the bones of the leg are larger than the others, and the cure of them when luxuated is more protracted. The mode of treatment then is the same; but we must use more bandages and more splints, and the bandage is to be carried round to this side and to that, and pressure is to be made as in the other cases, particularly at the seat of the luxation, and the first circles of the bandages are
In persons who jumping from any high object pitch upon their heel with great force, the bones are separated, and the veins pour forth their contents, owing to the contusion of the flesh surrounding the bone, and hence a swelling and much pain supervene. For this bone (os calcis) is not a small one, protrudes beyond the line of the leg, and is connected with important veins and tendons; for the back tendon of the leg is inserted into this bone. Such cases are to be treated with cerate, and with compresses and bandages; and hot water is to be used in large quantity; and they require many bandages, which ought to be particularly good and appropriate. And if the patient happen to have a tender skin about the heel, nothing is to be done to it; but if, as some have it, the skin be thick and hardened, it is to be pared down smoothly and thinned, but without wounding it. It is not everybody who can apply the bandage properly in such cases; for if one shall bind the parts, as in other accidents about the ankle, sometimes bringing a fold round the foot and sometimes round the tendon, these turns leave out the heel, which is the seat of the contusion, and thus there is danger that the os calcis may sphacelate; and if this should take place, the impediment may endure for life and also in all the other cases of sphacelus, not proceeding from such a cause as this; as when, from being carelessly allowed to lie in a certain position during confinement to bed, the heel becomes black, or when a serious wound has occurred in the leg and it is long of healing, and is connected with the heel, or when the same thing happens in the thigh, or when in any disease a protracted decubitus takes place old man of Cos,
twenty-two centuries ago, understood the nature of this accident better than many of us did not many years since.
The leg consists of two bones, of which the one is much more slender than the other at one part, but not much more slender at another. These are connected together at the foot, and form a common epiphysis, but they are not united together along the line of the leg; and at the thigh they are united together and form an epiphysis, and this epiphysis has a diaphysis; but the other bone in a line with the little toe is a little longer. Such is the nature of the bones of the leg.
Sometimes the bones connected with the foot are displaced, sometimes both bones with their epiphysis; sometimes the whole epiphysis is slightly moved, and sometimes the other bone. These cases are less troublesome than the same accidents at the wrist, if the patients will have resolution to give them rest. The mode of treatment is the same as that of the other, for the reduction is to be made, as of the other, by means of extension, but greater force is required, as the parts of the body concerned are stronger in this case. But, for the most part, two men will be sufficient, by making extension in opposite directions, but, not withstanding, if they are not sufficiently strong, it is easy to make more powerful extension in the following way: having fixed in the ground either the nave of a wheel, or any such object, something soft is to be bound round the foot, and then some broad thongs of ox-skin being brought round it, the heads of the thongs are to be fastened to a pestle or any other piece of wood, the end of
When you have made proper extension, it is easy reduce the joint, for the displaced bone is thus raised into a line with the other. And the bones are to be adjusted with the palms of the hands, pressing upon the projecting bone with the one, and making counter-pressure below the ankle with the other. When
And when both bones of the leg are broken without a wound of the skin, stronger extension is required. We may make extension by some of the methods formerly described, provided the bones ride over one another to a considerable degree. But extension by men is also sufficient, and for the most part two
When the parts are adjusted, you should apply the bandages while the limb is in a stretched position, making the first turns to the right or to the left, as may be most suitable; and the end of the bandage should be placed over the fracture, and the first turns made at that place; and then the bandage should be
But if the other bone (
Of the bones of the leg, the inner one, called the tibia, is the more troublesome to manage, and requires the greater extension; and if the broken bones are not properly arranged, it is impossible to conceal the distortion, for the bone is exposed and wholly uncovered with flesh; and it is much longer before patients can walk on the leg when this bone is broken. But if the outer bone be broken, it causes much less trouble, and the deformity, when the bones are not properly set, is much more easily concealed, the bone being well covered with flesh; and the patients speedily get on foot, for it is the inner bone of the leg which supports the most of the weight of the body. For along with the thigh, as being in a line with weight thrown upon the thigh, the inner bone has more work to sustain; inasmuch as it is the head of the thigh-bone which sustains the upper part of the body, and it is on the inner and not on the outer side of
When the thigh-bone is broken, particular pains should be taken with regard to the extension that it may not be insufficient, for when excessive, no great harm results from it. For, if one should bandage a limb while the extremities of the bone are separated to a distance from one another by the force of the extension, the bandaging will not keep them separate, and so the bones will come together again as soon as the persons stretching it let go their hold; for the fleshy parts (
But this also should be known, that the thigh-bone is curved rather to the outside than to the inside, and rather forward than backward; when not properly treated, then, the distortions are in these directions; and the bone is least covered with flesh at the same parts, so that the distortion cannot be concealed. If, therefore, you suspect anything of this kind, you should have recourse to the mechanical contrivances recommended in distortion of the arm. And a few turns of the bandage should be brought round by the hip and the loins, so that the groin and the articulation near the perineum may be included in the bandage; and moreover, it is expedient that the extremities of the splints should not do mischief by being placed on parts not covered with the bandages. The splints, in fact, should be carefully kept off the naked parts at both ends; and the arrangement of them should be so managed, as that they may not be placed on the natural protuberances of the bone at the knee-joint, nor on the tendon which is situated there.
The swellings which arise in the ham, at the foot, or in any other part from the pressure, should be well wrapped in unscoured and carded wool, washed with wine and oil, and anointed with cerate, before bandaging; and if the splints give pain they should be slackened. You may sooner reduce the swellings, by laying aside the splints, and applying plenty of bandages to them, beginning from below and rolling upward; for thus the swellings will be most speedily reduced, and the humors be propelled to the parts above the former bandages. But this form of bandaging must not be used unless there be danger of vesications or blackening in the swelling, and nothing of the kind occurs unless the fracture be bound too tight, or unless the limb be allowed to hang, or it be rubbed with the hand, or some other thing of an irritant nature be applied to the skin.
More injury than good results from placing below the thigh a canal which does not pass farther down than the ham,
The extremity of the heel should be particularly attended to, so that it may be properly laid, both in fractures of the leg and of the thigh. For if the foot be placed in a dependent position, while the rest of the body is supported, the limb must present a curved appearance at the forepart of the leg; and if the heel be placed higher than is proper, and if the rest of the leg be rather too low, the bone at the forepart of the leg must present a hollow, more especially if the heel of the patient be naturally large. But all the bones get consolidated more slowly, if not laid properly, and if not kept steady in the same position, and in this case the callus is more feeble.
These things relate to cases in which there is fracture of the bones without protrusion of the same or wound of any other kind. In those cases in which the bones are simply broken across, and are not comminuted, but protrude, if reduced the same day or next, and secured in their place, and if there be no reason to anticipate that any splintered bones will come away; and in those in which the broken bones do not protrude, nor is the mode of fracture such that there is reason to expect the splinters will come out, some physicians heal the sores in a way which neither does much good nor harm, by means of a cleansing
There are others who treat such cases at first with bandages, applying them on both sides of the seat of the injury, but omit them there, and leave the wound uncovered, and afterward they apply to the wound some cleansing medicine, and complete the dressing with compresses dipped in wine and greasy wool. This plan of treatment is bad, and it is clear that those who adopt this mode of practice are guilty of great mistakes in other cases of fracture as well as these. For it is a most important consideration to know in what manner the head of the bandage should be placed and at what part the greatest pressure should be, and what benefits would result from applying the end of the bandage and the pressure at the proper place, and what mischiefs would result from applying the head of the bandage and the pressure otherwise than at the proper place. Wherefore it has been stated in the preceding part of the work what are the results of either; and the practice of medicine bears witness to the truth of it, for in a person thus bandaged, a swelling must necessarily arise on the wound. For, if even a sound piece of skin were bandaged on either side, and a part were left in the middle, the part thus left unbandaged would become most swelled, and would assume a bad color; how then could it be that a wound would not suffer in like manner? The wound then must necessarily become discolored and its lips everted, the discharge will be ichorous and without pus, and the bones, which should not have got into a state of necrosis, exfoliate; and the wound gets into a throbbing and inflamed condition. And they
As a general rule it may be said, that in those cases in which a separation of bone is not expected, the same treatment should be applied as when the fractures are not complicated with an external wound; for the extension, adjustment of the bones, and the bandaging, are to be conducted in the same manner. To the wound itself a cerate mixed with pitch is to be applied, a thin folded compress is to be bound upon it, and the parts around are to be anointed with white cerate. The cloths for bandages and the other things should be torn broader than in cases in which there is no wound, and the first turn of the bandage should be a good deal broader than the wound. For a narrower bandage than the wound binds the wound like a girdle, which is not proper, or the first turn should comprehend the whole wound, and the bandaging should extend beyond it on both sides. The bandage then should be put on in the direction of the wound, and should be not quite so tight as when there is no wound, but the bandage should be otherwise applied in the manner described above. The bandages should be of a soft consistence, and more especially so in such cases than in those not complicated with a wound. The number of bandages should not
The treatment of the sores is the same in those cases of fracture in which there was no wound of the skin at first, but
If you are deceived with regard to a recent wound, supposing there will be no exfoliation of the bones, while they are on the eve of coming out of the sore, you must not hesitate to adopt this mode of treatment; for no great mischief will result, provided you have the necessary dexterity to apply the bandages well and without doing any harm. And this is a symptom of an exfoliation of bone being about to take place under this mode of treatment; pus runs copiously from the sore, and appears striving to make its escape. The bandage must be renewed more frequently on account of the discharge, since otherwise fevers come on; if the sore and surrounding parts be compressed by the bandages they become wasted. Cases complicated with the exfoliation of very small bones, do not require any change of treatment, only the bandages should be put on more loosely, so that the discharge of pus may not be intercepted, but left free, and the dressings are to be frequently renewed until the bone exfoliate, and the splints should not be applied until then.
Those cases in which the exfoliation of a larger piece of bone is expected, whether you discover this at the commencement, or perceive subsequently that it is to happen, no longer require the same mode of treatment, only that the extension and arrangement of the parts are to be performed in a manner that has been described; but having formed double compresses, not less than half a fathom in breadth (being guided in this by the nature of the wound), and considerably shorter than what would be required to go twice round the part that is wounded, but considerably longer than to go once round, and in number what will be sufficient, these are to be dipped in a black austere wine; and beginning at the middle, as is done in applying the double-headed bandage, you are to wrap the part around and proceed crossing the heads in the form of the bandage called ascia.
These things are to be done at the wound, and on both sides of it; and there must be no compression, but they are to be laid on so as to give support to the wound. And on the wound itself is to be applied the pitched cerate, or one of the applications
In such cases as do not admit of bandaging according to any of the methods which have been described, or which will be described, great pains should be taken that the fractured part of the body be laid in a right position, and attention should be paid that it may incline upward rather than downward. But if one would wish to do the thing well and dexterously, it is proper to have recourse to some mechanical contrivance, in order that the fractured part of the body may undergo proper and not violent extension; and this means is particularly applicable in fractures of the leg. There are certain physicians who, in all fractures of the leg, whether bandages be applied or not, fasten the sole of the foot to the couch, or to some other piece of wood which they have fixed in the ground near the couch. These persons thus do all sorts of mischief but no good; for it contributes nothing to the extension that the foot is thus bound, as the rest of the body will no less sink down to the foot, and thus the limb will no longer be stretched, neither will it do any good toward keeping the limb in a proper position, but will do harm, for when the rest of the body is turned to this side or that, the bandaging will not prevent the foot and the bones belonging to it from following the rest of the body. For if it had not been bound it would have been less distorted, as it would have been the less prevented from following the motion of the rest of the body. But one should sew two balls of Egyptian leather, such as are worn by persons confined for a length of time in large shackles, and the balls should have coats on each side, deeper toward the wound, but shorter toward the joints; and the balls should be well stuffed and soft, and fit well, the one above the
Moreover, the greater part of physicians treat fractures, both with and without an external wound, during the first days, by means of unwashed wool, and there does not appear to be anything improper in this. It is very excusable for those who are called upon to treat newly-received accidents of this kind, and who have no cloth for bandages at hand, to do them up
In those cases of fracture in which the bones protrude and cannot be restored to their place, the following mode of reduction may be practiced:- Some small pieces of iron are to be prepared like the levers which the cutters of stone make use of, one being
When you have reduced the bones to their place, the modes of treatment, whether you expect the bones to exfoliate or not, have been already described. All those cases in which an exfoliation of bone is expected, should be treated by the method of bandaging with cloths, beginning for the most part at the middle of the bandage, as is done with the double-headed bandage; but particular attention should be paid to the shape of the wound, so that its lips may gape or be distorted as little as possible under the bandage. Sometimes the turns of the bandage have to be made to the right, and sometimes to the left, and sometimes a double-headed bandage is to be used.
It should be known that bones, which it has been found impossible to reduce, as well as those which are wholly denuded of flesh, will become detached. In some cases the upper part of the bone is laid bare, and in others the flesh dies all around; and, from a sore of long standing, certain of the bones become carious, and some not, some more, and some less; and in some the small, and in others the large bones. From what has been said it will be seen, that it is impossible to tell in one word when the bones will separate. Some come away more quickly, owing to their smallness, and some from being merely fixed at the point; and some, from pieces not separating, but merely exfoliating, become dried up and putrid; and besides, different modes of treatment have different effects. For the most part, the bones separate most quickly in those cases in which suppuration takes place most quickly, and when new flesh is most quickly formed, and is particularly sound, for the flesh which grows up below in the wound generally elevates the pieces of bone. It will be well if the whole circle of the bone separate in forty days; for in some cases it is protracted to sixty days, and in some to more; for the more porous pieces of bone separate more quickly, but the more solid come away more slowly; but the other smaller splinters in much less time, and others otherwise. A portion of bone which protrudes should be sawn off for the following reasons: if it cannot be reduced, and if it appears
Such cases are to be treated with compresses and vinous applications, as formerly laid down regarding bones which will separate. We must avoid wetting it at the beginning with anything cold; for there is danger of febrile rigors, and also of convulsions; for convulsions are induced by cold things, and also sometimes by wounds. It is proper to know that the members are necessarily shortened in those cases in which the bones have been broken, and have healed the one across the other, and in those cases in which the whole circle of the bone has become detached.
Those cases in which the bone of the thigh, or of the arm, protrudes, do not easily recover. For the bones are large, and contain much marrow; and many important nerves, muscles, and veins are wounded at the same time. And if you reduce them, convulsions usually supervene; and, if not reduced, acute bilious fevers come on, with singultus and mortification. The chances of recovery are not fewer in those cases in which the parts have not been reduced, nor any attempts made at reduction. Still more recover in those cases in which the lower, than those in which the upper part of the bone protrudes; and some will recover when reduction has been made, but very rarely indeed. For modes of treatment and peculiarity of constitution make a great difference as to the capability of enduring such an injury. And it makes a great difference if the bones of the arm and of the thigh protrude to the inside; for there are many and important vessels situated there, some of which, if wounded, will prove fatal; there are such also on the outside, but of less importance.
Having effected the reduction, you must give an emollient draught of hellebore the same day, provided it has been reduced on the day of the accident, but otherwise it should not be attempted. The wound should be treated with the same things as are used in fractures of the bones of the head, and nothing cold should be applied; the patient should be restricted from food altogether, and if naturally of a bilious constitution, he should have for a diet a little fragrant
Luxations and subluxations at the knee are much milder accidents than subluxations and luxations at the elbow. For the knee-joint, in proportion to its size, is more compact than that of the arm, and has a more even conformation, and is
Dislocations at the elbow are more troublesome than those at the knee, and, owing to the inflammation which comes on, and the configuration of the joint, are more difficult to reduce if the bones are not immediately replaced. For the bones at the elbow are less subject to dislocation than those of the knee, but are more difficult to reduce and keep in their position, and are more apt to become inflamed and ankylosed.
For the most part the displacements of these bones are small, sometimes toward the ribs, and sometimes to the outside; and the whole articulation is not displaced, but that part of the humerus remains in place which is articulated with the cavity of the bone of the forearm that has a protuberance (
The end of the humerus at the elbow gets displaced (
But if the articular extremity of the humerus be carried to either side above the bone of the fore-arm, which is prominent, into the hollow of the arm (?), this rarely happens; but if it does happen, extension in the straight line is not so proper under such circumstances; for in such a mode of extension, the process of the ulna (
If the arm be dislocated forward- this rarely happens, indeed, but what would a sudden shock not displace? for many other things are removed from their proper place, notwithstanding
But if the arm be dislocated backward (but this very rarely happens, and it is the most painful of all, and the most subject to bilious fevers of the continual type, which prove fatal in the course of a few days), in such a case the patient cannot extend the arm. If you are quickly present, by forcible extension the parts may return to their place of their own accord; but if fever have previously come on, you must no longer attempt reduction, for the pain will be rendered more intense by any such violent attempt. In a word, no joint whatever should be reduced during the prevalence of fever, and least of all the elbow-joint.
There are also other troublesome injuries connected with
In certain cases the process of the ulna (
It sometimes happens that the head of the humerus is fractured at its epiphysis; and this, although it may appear to be a much more troublesome accident, is in fact a much milder one than the other injuries at the joint.
The treatment especially befitting each particular dislocation has been described; and it has been laid down as a rule, that immediate reduction is of the utmost advantage, owing to the rapid manner in which inflammation of the tendons supervenes. For even when the luxated parts are immediately reduced, the tendons usually become stiffened, and for a considerable time prevent extension and flexion from being performed
In bandaging, the head of the first bandage should be placed at the seat of the injury, whether it be a case of fracture, of dislocation, or of diastasis (
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In treating fractures and dislocations, the physician must make the extension as straight as possible, for this is the most natural direction. But if it incline to either side, it should rather turn to that of pronation, for there is thus less harm than if it be toward supination. Those, then, who act in such cases without deliberation, for the most part do not fall into any great mistake, for the person who is to have his arm bound, presents it in the proper position from necessity, but physicians who fancy themselves learned in these matters, are they who commit blunders. There is no necessity for much study, then, in order to set a broken arm, and in a word, any ordinary physician can perform it; but I am under the necessity of giving the longer directions on this subject, because I know physicians who have the reputation of being skilled in giving the proper positions to the arm in binding it up, while in reality they are only showing their own ignorance. But many other things in our art are judged of in this manner, for people rather admire what is new, although they do not know whether it be proper or not, than what they are accustomed to, and know already to be proper; and what is strange, they prefer to what is obvious. I must now state what the mistakes of medical men are, which I wish to unteach, and what instructions I have to give as to the management of the arm; for what I have to say regarding it, will apply to the other bones in the body.
The arm, then, for that is the subject we were treating of, was presented in the prone position to be bound, but the physician forced his patient to hold it as the archers do when they project the shoulder, and in this position he bound it up, thinking within
But another physician putting the arm into the state of supination, gives orders to extend the arm thus, and bandages it in this position, reckoning it the one according to nature, judging thus from the skin, and also fancying the bones to be thus in their natural position, because the bone which protrudes at the wrist, where the little finger is, appears to be in a line with the bone from which people measure the bone of the fore-arm. These things he brings forward as proofs that the parts are in their natural state, and he is supposed to speak correctly. But, indeed, if the arm be kept stretched in a supine position, it will become very painful, and this fact any one may ascertain by extending his own arm in this attitude. And also a weaker man grasping with his hands a stronger man whose arm is turned in a supine position, could lead him wherever he chose, and neither, if a man held a sword thus in his hand, could he make any proper use of it, so constrained is this position. And, moreover, if, when a physician has thus bound up the arm, he allow it to remain in the same position, the patient will endure greater pain if he walk about, but considerable, even if he remain at rest. And thus, too, if he shall bend the arm, the muscles and the bones must necessarily assume a different position. But, in addition to other mischief, he is ignorant of these facts regarding the position, that the bone which protrudes at the wrist, close to the little finger, belongs to the fore-arm, whereas the one at the joint, from which people measure the fore-arm, is the head of the humerus. He fancies that both these belong to the same bone, and many others are of this opinion. The latter, in fact, is the same part as that which is called the elbow, upon which we sometimes rest, and when he holds the arm thus in a supine position, in the first place the bone appears distorted, and in the next place the tendons which extend from the carpus along the inner side and from the fingers become distorted while the arm has a supine position; for these tendons proceed to the bone of the humerus, from which the fore-arm is measured. Such, and so
In cases of fracture in either of the bones of the forearm, it is easier to effect a cure if the upper bone be broken, although it be the thicker one, both because the sound bone is situated below, and forms a support to it, and because the deformity is more easily concealed, there being a thick mass of flesh on the upper side, except near to the wrist. But the lower bone is without a covering of flesh, is not easily concealed, and requires stronger extension. If it is not this bone, but the other which is broken, a more feeble extension proves sufficient, but if both be broken, a more powerful extension is required. In the case of a young person I have known the extension made more strong than was necessary, but in general the extension made is less than what is required. And when they are extended, the physician should apply the palms of the hands, and adjust the fractured parts and then having rubbed the parts with cerate, but not in large quantity so that the bandages may not come off, it is to be bound up in this state, care being taken that the hand be not lower than the elbow, but a little higher, so that the blood do not flow toward the extremity, but may be determined to the upper part; and then it is to be secured with the bandage,
And these are the signs that the patient has been well treated and properly bandaged: if you ask him if the arm feels tight, and he says it does, but moderately so, and especially about the fracture; and this reply he should make all along, if the bandage be properly applied. And these are symptoms of the bandaging being moderately tight; if for the first day and night he fancies that the tightness does not diminish, but rather increases; and if on the next day there be a soft swelling in the hand, for this is a sign of moderate compression, but at the end of the second day the compression should feel less, and on the third day the bandaging should appear loose. And if any of
When the third day arrives, that is to say, the seventh from the first dressing, if properly done, the swelling in the hand should be not very great; and the part which has been bandaged should be found more slender and less swelled at each time, and on the seventh day the swelling should be quite gone, and the broken bones should be more readily moved, and admit of being easily adjusted. And if these things be so, you should,
If, then, you see that the bones are properly adjusted by the first dressings, and that there is no troublesome pruritus in the part, nor any reason to suspect ulceration, you may allow the arm to remain bandaged in the splints until after the lapse of more than twenty days. The bones of the fore-arm generally get consolidated in thirty days altogether; but there is nothing precise in this matter, for one constitution differs from another, and one period of life from another. When you remove the bandages, you must pour hot water on the arm and bind it up again, but somewhat slacker, and with fewer bandages than formerly: and again on the third day you undo the bandages, and
When the arm is broken, if one stretch the fore-arm and adjust it while in this position, the muscle of the arm will be bound while extended; but when the dressing is over, and the patient bends his arm at the elbow, the muscle of the arm will assume a different shape. The following, then, is the most natural plan of setting the arm: having got a piece of wood a cubit or somewhat less in length, like the handles of spades,
The human foot is composed of several small bones like the hand. These bones therefore are scarcely ever broken, unless the skin at the same time be wounded by some sharp and heavy body. The treatment of such injuries, therefore, will be delivered under the head of wounds. But if any bone be moved from its place, or a joint of the toes be luxated, or any of the bones of the part called the tarsus be displaced, it must be forced back again to its place as described with regard to the hand; and is to be treated with cerate, compresses, and bandages, like the fractures, with the exception of the splints; and is to be secured tightly in the same way, and the bandages renewed on the third day; and the patient thus bandaged should return the same answers as in fractures, as to the bandages feeling tight or slack. All these bones recover perfectly in twenty days, except those that are connected with the bones of the leg, and are in a line with them. It is advantageous to lie in bed during the whole of this time; but the patients, thinking light of the complaint, have not perseverance to do this, and they walk about before they get well; wherefore many of these do not make a perfect recovery. And often the pain puts them in mind of the injury; and deservedly, for the feet sustain the weight of the whole body. When, therefore, they walk about before they are whole, the joints which have been luxated are cured incompletely; and, on that account, while walking about, they have pains in the leg from time to time.
But those bones which are connected with the bones of the leg are larger than the others, and the cure of them when luxuated is more protracted. The mode of treatment then is the same; but we must use more bandages and more splints, and the bandage is to be carried round to this side and to that, and pressure is to be made as in the other cases, particularly at the seat of the luxation, and the first circles of the bandages are
In persons who jumping from any high object pitch upon their heel with great force, the bones are separated, and the veins pour forth their contents, owing to the contusion of the flesh surrounding the bone, and hence a swelling and much pain supervene. For this bone (os calcis) is not a small one, protrudes beyond the line of the leg, and is connected with important veins and tendons; for the back tendon of the leg is inserted into this bone. Such cases are to be treated with cerate, and with compresses and bandages; and hot water is to be used in large quantity; and they require many bandages, which ought to be particularly good and appropriate. And if the patient happen to have a tender skin about the heel, nothing is to be done to it; but if, as some have it, the skin be thick and hardened, it is to be pared down smoothly and thinned, but without wounding it. It is not everybody who can apply the bandage properly in such cases; for if one shall bind the parts, as in other accidents about the ankle, sometimes bringing a fold round the foot and sometimes round the tendon, these turns leave out the heel, which is the seat of the contusion, and thus there is danger that the os calcis may sphacelate; and if this should take place, the impediment may endure for life and also in all the other cases of sphacelus, not proceeding from such a cause as this; as when, from being carelessly allowed to lie in a certain position during confinement to bed, the heel becomes black, or when a serious wound has occurred in the leg and it is long of healing, and is connected with the heel, or when the same thing happens in the thigh, or when in any disease a protracted decubitus takes place old man of Cos,
twenty-two centuries ago, understood the nature of this accident better than many of us did not many years since.
The leg consists of two bones, of which the one is much more slender than the other at one part, but not much more slender at another. These are connected together at the foot, and form a common epiphysis, but they are not united together along the line of the leg; and at the thigh they are united together and form an epiphysis, and this epiphysis has a diaphysis; but the other bone in a line with the little toe is a little longer. Such is the nature of the bones of the leg.
Sometimes the bones connected with the foot are displaced, sometimes both bones with their epiphysis; sometimes the whole epiphysis is slightly moved, and sometimes the other bone. These cases are less troublesome than the same accidents at the wrist, if the patients will have resolution to give them rest. The mode of treatment is the same as that of the other, for the reduction is to be made, as of the other, by means of extension, but greater force is required, as the parts of the body concerned are stronger in this case. But, for the most part, two men will be sufficient, by making extension in opposite directions, but, not withstanding, if they are not sufficiently strong, it is easy to make more powerful extension in the following way: having fixed in the ground either the nave of a wheel, or any such object, something soft is to be bound round the foot, and then some broad thongs of ox-skin being brought round it, the heads of the thongs are to be fastened to a pestle or any other piece of wood, the end of
When you have made proper extension, it is easy reduce the joint, for the displaced bone is thus raised into a line with the other. And the bones are to be adjusted with the palms of the hands, pressing upon the projecting bone with the one, and making counter-pressure below the ankle with the other. When
And when both bones of the leg are broken without a wound of the skin, stronger extension is required. We may make extension by some of the methods formerly described, provided the bones ride over one another to a considerable degree. But extension by men is also sufficient, and for the most part two
When the parts are adjusted, you should apply the bandages while the limb is in a stretched position, making the first turns to the right or to the left, as may be most suitable; and the end of the bandage should be placed over the fracture, and the first turns made at that place; and then the bandage should be
But if the other bone (
Of the bones of the leg, the inner one, called the tibia, is the more troublesome to manage, and requires the greater extension; and if the broken bones are not properly arranged, it is impossible to conceal the distortion, for the bone is exposed and wholly uncovered with flesh; and it is much longer before patients can walk on the leg when this bone is broken. But if the outer bone be broken, it causes much less trouble, and the deformity, when the bones are not properly set, is much more easily concealed, the bone being well covered with flesh; and the patients speedily get on foot, for it is the inner bone of the leg which supports the most of the weight of the body. For along with the thigh, as being in a line with weight thrown upon the thigh, the inner bone has more work to sustain; inasmuch as it is the head of the thigh-bone which sustains the upper part of the body, and it is on the inner and not on the outer side of
When the thigh-bone is broken, particular pains should be taken with regard to the extension that it may not be insufficient, for when excessive, no great harm results from it. For, if one should bandage a limb while the extremities of the bone are separated to a distance from one another by the force of the extension, the bandaging will not keep them separate, and so the bones will come together again as soon as the persons stretching it let go their hold; for the fleshy parts (
But this also should be known, that the thigh-bone is curved rather to the outside than to the inside, and rather forward than backward; when not properly treated, then, the distortions are in these directions; and the bone is least covered with flesh at the same parts, so that the distortion cannot be concealed. If, therefore, you suspect anything of this kind, you should have recourse to the mechanical contrivances recommended in distortion of the arm. And a few turns of the bandage should be brought round by the hip and the loins, so that the groin and the articulation near the perineum may be included in the bandage; and moreover, it is expedient that the extremities of the splints should not do mischief by being placed on parts not covered with the bandages. The splints, in fact, should be carefully kept off the naked parts at both ends; and the arrangement of them should be so managed, as that they may not be placed on the natural protuberances of the bone at the knee-joint, nor on the tendon which is situated there.
The swellings which arise in the ham, at the foot, or in any other part from the pressure, should be well wrapped in unscoured and carded wool, washed with wine and oil, and anointed with cerate, before bandaging; and if the splints give pain they should be slackened. You may sooner reduce the swellings, by laying aside the splints, and applying plenty of bandages to them, beginning from below and rolling upward; for thus the swellings will be most speedily reduced, and the humors be propelled to the parts above the former bandages. But this form of bandaging must not be used unless there be danger of vesications or blackening in the swelling, and nothing of the kind occurs unless the fracture be bound too tight, or unless the limb be allowed to hang, or it be rubbed with the hand, or some other thing of an irritant nature be applied to the skin.
More injury than good results from placing below the thigh a canal which does not pass farther down than the ham,
The extremity of the heel should be particularly attended to, so that it may be properly laid, both in fractures of the leg and of the thigh. For if the foot be placed in a dependent position, while the rest of the body is supported, the limb must present a curved appearance at the forepart of the leg; and if the heel be placed higher than is proper, and if the rest of the leg be rather too low, the bone at the forepart of the leg must present a hollow, more especially if the heel of the patient be naturally large. But all the bones get consolidated more slowly, if not laid properly, and if not kept steady in the same position, and in this case the callus is more feeble.
These things relate to cases in which there is fracture of the bones without protrusion of the same or wound of any other kind. In those cases in which the bones are simply broken across, and are not comminuted, but protrude, if reduced the same day or next, and secured in their place, and if there be no reason to anticipate that any splintered bones will come away; and in those in which the broken bones do not protrude, nor is the mode of fracture such that there is reason to expect the splinters will come out, some physicians heal the sores in a way which neither does much good nor harm, by means of a cleansing
There are others who treat such cases at first with bandages, applying them on both sides of the seat of the injury, but omit them there, and leave the wound uncovered, and afterward they apply to the wound some cleansing medicine, and complete the dressing with compresses dipped in wine and greasy wool. This plan of treatment is bad, and it is clear that those who adopt this mode of practice are guilty of great mistakes in other cases of fracture as well as these. For it is a most important consideration to know in what manner the head of the bandage should be placed and at what part the greatest pressure should be, and what benefits would result from applying the end of the bandage and the pressure at the proper place, and what mischiefs would result from applying the head of the bandage and the pressure otherwise than at the proper place. Wherefore it has been stated in the preceding part of the work what are the results of either; and the practice of medicine bears witness to the truth of it, for in a person thus bandaged, a swelling must necessarily arise on the wound. For, if even a sound piece of skin were bandaged on either side, and a part were left in the middle, the part thus left unbandaged would become most swelled, and would assume a bad color; how then could it be that a wound would not suffer in like manner? The wound then must necessarily become discolored and its lips everted, the discharge will be ichorous and without pus, and the bones, which should not have got into a state of necrosis, exfoliate; and the wound gets into a throbbing and inflamed condition. And they
As a general rule it may be said, that in those cases in which a separation of bone is not expected, the same treatment should be applied as when the fractures are not complicated with an external wound; for the extension, adjustment of the bones, and the bandaging, are to be conducted in the same manner. To the wound itself a cerate mixed with pitch is to be applied, a thin folded compress is to be bound upon it, and the parts around are to be anointed with white cerate. The cloths for bandages and the other things should be torn broader than in cases in which there is no wound, and the first turn of the bandage should be a good deal broader than the wound. For a narrower bandage than the wound binds the wound like a girdle, which is not proper, or the first turn should comprehend the whole wound, and the bandaging should extend beyond it on both sides. The bandage then should be put on in the direction of the wound, and should be not quite so tight as when there is no wound, but the bandage should be otherwise applied in the manner described above. The bandages should be of a soft consistence, and more especially so in such cases than in those not complicated with a wound. The number of bandages should not
The treatment of the sores is the same in those cases of fracture in which there was no wound of the skin at first, but
If you are deceived with regard to a recent wound, supposing there will be no exfoliation of the bones, while they are on the eve of coming out of the sore, you must not hesitate to adopt this mode of treatment; for no great mischief will result, provided you have the necessary dexterity to apply the bandages well and without doing any harm. And this is a symptom of an exfoliation of bone being about to take place under this mode of treatment; pus runs copiously from the sore, and appears striving to make its escape. The bandage must be renewed more frequently on account of the discharge, since otherwise fevers come on; if the sore and surrounding parts be compressed by the bandages they become wasted. Cases complicated with the exfoliation of very small bones, do not require any change of treatment, only the bandages should be put on more loosely, so that the discharge of pus may not be intercepted, but left free, and the dressings are to be frequently renewed until the bone exfoliate, and the splints should not be applied until then.
Those cases in which the exfoliation of a larger piece of bone is expected, whether you discover this at the commencement, or perceive subsequently that it is to happen, no longer require the same mode of treatment, only that the extension and arrangement of the parts are to be performed in a manner that has been described; but having formed double compresses, not less than half a fathom in breadth (being guided in this by the nature of the wound), and considerably shorter than what would be required to go twice round the part that is wounded, but considerably longer than to go once round, and in number what will be sufficient, these are to be dipped in a black austere wine; and beginning at the middle, as is done in applying the double-headed bandage, you are to wrap the part around and proceed crossing the heads in the form of the bandage called ascia.
These things are to be done at the wound, and on both sides of it; and there must be no compression, but they are to be laid on so as to give support to the wound. And on the wound itself is to be applied the pitched cerate, or one of the applications
In such cases as do not admit of bandaging according to any of the methods which have been described, or which will be described, great pains should be taken that the fractured part of the body be laid in a right position, and attention should be paid that it may incline upward rather than downward. But if one would wish to do the thing well and dexterously, it is proper to have recourse to some mechanical contrivance, in order that the fractured part of the body may undergo proper and not violent extension; and this means is particularly applicable in fractures of the leg. There are certain physicians who, in all fractures of the leg, whether bandages be applied or not, fasten the sole of the foot to the couch, or to some other piece of wood which they have fixed in the ground near the couch. These persons thus do all sorts of mischief but no good; for it contributes nothing to the extension that the foot is thus bound, as the rest of the body will no less sink down to the foot, and thus the limb will no longer be stretched, neither will it do any good toward keeping the limb in a proper position, but will do harm, for when the rest of the body is turned to this side or that, the bandaging will not prevent the foot and the bones belonging to it from following the rest of the body. For if it had not been bound it would have been less distorted, as it would have been the less prevented from following the motion of the rest of the body. But one should sew two balls of Egyptian leather, such as are worn by persons confined for a length of time in large shackles, and the balls should have coats on each side, deeper toward the wound, but shorter toward the joints; and the balls should be well stuffed and soft, and fit well, the one above the
Moreover, the greater part of physicians treat fractures, both with and without an external wound, during the first days, by means of unwashed wool, and there does not appear to be anything improper in this. It is very excusable for those who are called upon to treat newly-received accidents of this kind, and who have no cloth for bandages at hand, to do them up
In those cases of fracture in which the bones protrude and cannot be restored to their place, the following mode of reduction may be practiced:- Some small pieces of iron are to be prepared like the levers which the cutters of stone make use of, one being
When you have reduced the bones to their place, the modes of treatment, whether you expect the bones to exfoliate or not, have been already described. All those cases in which an exfoliation of bone is expected, should be treated by the method of bandaging with cloths, beginning for the most part at the middle of the bandage, as is done with the double-headed bandage; but particular attention should be paid to the shape of the wound, so that its lips may gape or be distorted as little as possible under the bandage. Sometimes the turns of the bandage have to be made to the right, and sometimes to the left, and sometimes a double-headed bandage is to be used.
It should be known that bones, which it has been found impossible to reduce, as well as those which are wholly denuded of flesh, will become detached. In some cases the upper part of the bone is laid bare, and in others the flesh dies all around; and, from a sore of long standing, certain of the bones become carious, and some not, some more, and some less; and in some the small, and in others the large bones. From what has been said it will be seen, that it is impossible to tell in one word when the bones will separate. Some come away more quickly, owing to their smallness, and some from being merely fixed at the point; and some, from pieces not separating, but merely exfoliating, become dried up and putrid; and besides, different modes of treatment have different effects. For the most part, the bones separate most quickly in those cases in which suppuration takes place most quickly, and when new flesh is most quickly formed, and is particularly sound, for the flesh which grows up below in the wound generally elevates the pieces of bone. It will be well if the whole circle of the bone separate in forty days; for in some cases it is protracted to sixty days, and in some to more; for the more porous pieces of bone separate more quickly, but the more solid come away more slowly; but the other smaller splinters in much less time, and others otherwise. A portion of bone which protrudes should be sawn off for the following reasons: if it cannot be reduced, and if it appears
Such cases are to be treated with compresses and vinous applications, as formerly laid down regarding bones which will separate. We must avoid wetting it at the beginning with anything cold; for there is danger of febrile rigors, and also of convulsions; for convulsions are induced by cold things, and also sometimes by wounds. It is proper to know that the members are necessarily shortened in those cases in which the bones have been broken, and have healed the one across the other, and in those cases in which the whole circle of the bone has become detached.
Those cases in which the bone of the thigh, or of the arm, protrudes, do not easily recover. For the bones are large, and contain much marrow; and many important nerves, muscles, and veins are wounded at the same time. And if you reduce them, convulsions usually supervene; and, if not reduced, acute bilious fevers come on, with singultus and mortification. The chances of recovery are not fewer in those cases in which the parts have not been reduced, nor any attempts made at reduction. Still more recover in those cases in which the lower, than those in which the upper part of the bone protrudes; and some will recover when reduction has been made, but very rarely indeed. For modes of treatment and peculiarity of constitution make a great difference as to the capability of enduring such an injury. And it makes a great difference if the bones of the arm and of the thigh protrude to the inside; for there are many and important vessels situated there, some of which, if wounded, will prove fatal; there are such also on the outside, but of less importance.
Having effected the reduction, you must give an emollient draught of hellebore the same day, provided it has been reduced on the day of the accident, but otherwise it should not be attempted. The wound should be treated with the same things as are used in fractures of the bones of the head, and nothing cold should be applied; the patient should be restricted from food altogether, and if naturally of a bilious constitution, he should have for a diet a little fragrant
Luxations and subluxations at the knee are much milder accidents than subluxations and luxations at the elbow. For the knee-joint, in proportion to its size, is more compact than that of the arm, and has a more even conformation, and is
Dislocations at the elbow are more troublesome than those at the knee, and, owing to the inflammation which comes on, and the configuration of the joint, are more difficult to reduce if the bones are not immediately replaced. For the bones at the elbow are less subject to dislocation than those of the knee, but are more difficult to reduce and keep in their position, and are more apt to become inflamed and ankylosed.
For the most part the displacements of these bones are small, sometimes toward the ribs, and sometimes to the outside; and the whole articulation is not displaced, but that part of the humerus remains in place which is articulated with the cavity of the bone of the forearm that has a protuberance (
The end of the humerus at the elbow gets displaced (
But if the articular extremity of the humerus be carried to either side above the bone of the fore-arm, which is prominent, into the hollow of the arm (?), this rarely happens; but if it does happen, extension in the straight line is not so proper under such circumstances; for in such a mode of extension, the process of the ulna (
If the arm be dislocated forward—this rarely happens, indeed, but what would a sudden shock not displace? for many other things are removed from their proper place, notwithstanding
But if the arm be dislocated backward (but this very rarely happens, and it is the most painful of all, and the most subject to bilious fevers of the continual type, which prove fatal in the course of a few days), in such a case the patient cannot extend the arm. If you are quickly present, by forcible extension the parts may return to their place of their own accord; but if fever have previously come on, you must no longer attempt reduction, for the pain will be rendered more intense by any such violent attempt. In a word, no joint whatever should be reduced during the prevalence of fever, and least of all the elbow-joint.
There are also other troublesome injuries connected with
In certain cases the process of the ulna (
It sometimes happens that the head of the humerus is fractured at its epiphysis; and this, although it may appear to be a much more troublesome accident, is in fact a much milder one than the other injuries at the joint.
The treatment especially befitting each particular dislocation has been described; and it has been laid down as a rule, that immediate reduction is of the utmost advantage, owing to the rapid manner in which inflammation of the tendons supervenes. For even when the luxated parts are immediately reduced, the tendons usually become stiffened, and for a considerable time prevent extension and flexion from being performed
In bandaging, the head of the first bandage should be placed at the seat of the injury, whether it be a case of fracture, of dislocation, or of diastasis (
Data Entry
- -This pointer pattern extracts section.
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;
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.
- 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
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 may also be - used elsewhere.
- 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
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.
- 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
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. Thesolidungula 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,"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.
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
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.
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
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.
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
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 beingsecundum 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.
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. -
- 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,
- whilesternal 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.
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.
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
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.
-Diastasis of the bones may be recognized by examining the part where the vein - that runs along the arm divides.
-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.
-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.
- 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
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.
-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.
-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.
-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.
- In congenital dislocations (at the wrist) the hand becomes
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.
- 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 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.
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
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.
- 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 beexfoliation?). 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.
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
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
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.
- 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
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
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,
-
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
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 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.
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
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
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.
- In the first place, the structure of the spine should be 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, theirbehind?) 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.
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 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 attitudes of the patient contribute also to deceive
- them; for if they attempt to put themselves into a bent position, they
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 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
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,
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.
- 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
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
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 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.
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 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 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.
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
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 galiancones).
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.
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 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.
-
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 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.
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
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,
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. -
- 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,
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 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.
- 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,
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.
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.
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.
- 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 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 mode of treatment; something, too, depends upon whether the
- compression be stronger or weaker, and whether the nerves, flesh, arteries, and
- veins are quicker or slower in becoming blackened and in dying; since, when the
- parts are not strongly compressed, the separation is more superficial, and does
- not go the length of laying the bones bare, and in some cases it is still more
- superficial, so as not even to expose the nerves. For the reasons now stated, it
- is impossible to define accurately the time at which each of these cases will
- terminate. The treatment of such cases, however, is to be readily undertaken,
- for they are more formidable to look at than to treat; and a mild treatment is
- sufficient in all such cases, for they come to a crisis of themselves; only the
- diet must be attended to, so that it may be as little
Dislocation inward at the hip-joint is to be reduced in the following manner:
- (it is a good, proper, and natural mode of reduction, and has something of
- display in it, if any one takes delight in such ostentatious modes of
- procedure). The patient is to be suspended by the feet from a cross-beam with a
- strong, soft, and broad cord; the feet are to be about four inches or less from
- one another; and a broad and soft leather collar connected with the cross-beam
- is to be put on above the knees; and the affected leg should be so extended as
- to moved be two inches longer than the other; the head should be about two
- cubits from the ground, or a little more or less; and the arms should be
- stretched along the sides, and bound with something soft; all these preparations
- should be made while he is lying on his back, so that he may be suspended for as
- short a time as possible. But when the patient is suspended, a person properly
- instructed and not weak, having introduced his arm between his thighs, is to
- place his fore-arm between the perineum and the dislocated head of the os
- femoris; and then, having joined the other hand to the one thus passed through
- the thighs, he is to stand by the side of the suspended patient, and suddenly
- suspend and swing himself in the air as
Wherefore, as formerly stated, men's constitutions differ much from one another
- as to the facility or difficulty with which dislocations are reduced; and the
- cause of this was also stated formerly in treating of the shoulder. In some the
- thigh is reduced with no preparation, with slight extension, directed by the
- hands, and with slight movement; and in some the reduction is effected by
- bending the limb at the joint, and making rotation. But much more frequently it
- does not yield to any ordinary apparatus, and therefore one should be acquainted
- with the most powerful means which can be applied in each case, and use whatever
- maybe judged most proper under all circumstances. The modes of extension have
- been described in the former parts of the work, so that one may make use of
- whatever may happen to be at hand. For, extension and counter-extension are to
- be made in the direction of the limb and the body; and if this be properly
- effected, the head of the thigh-bone will be raised above its ancient seat; and
- if thus raised, it will not be easy to prevent it from settling in its place, so
- that any ordinary impulse with the lever and adjustment will be quite
- sufficient; but some apply insufficient extension, and hence the reduction gives
- much trouble. The bands then should be fastened, not only at the foot, but also
- above the knee, so that the force of the extension may not be expended on the
- knee-joint more than upon the hip-joint. The extension in the direction of the
- foot is to be thus contrived. But the counter-extension is not only to be
- managed by means of something carried round the chest and armpits, but also by a
- long, double, strong, and supple thong applied to the perineum, and carried
- behind along the spine, and in front along the collar-bone between the
- legs?) and grasp it with the other hand, so as at the same time to make
- extension, and force the dislocated limb outward; while some other person
- sitting by the knee quietly directs it inward.
It has been formerly stated by us that it will be of importance for any person
- who practices medicine in a populous city to get prepared a quadrangular board,
- about six cubits or a little more in length, and about two cubits in breadth; a
- fathom will be sufficient thickness for it; and then along it from the one end
- to the other, an excavation must be made, so that the working of the levers may
- not be higher than is proper; then at both sides we are to raise short, strong,
- and strongly-fixed posts, having axles; and in the middle of the bench five or
- six long grooves are to be scooped out about four inches distant from one
- another, three inches will be a sufficient breadth for them, and the depth in
- like manner; and although the number of grooves I have mentioned will be
- sufficient, there is nothing to prevent their being made all over the bench. And
- the bench should have in its middle a pretty deep hole, of a square shape, and
- of about three inches in size; and into this hole, when judged necessary, is to
- be adjusted a corresponding piece of wood, rounded above, which, at the proper
- time, is to be adjusted between the perineum and the head of the thigh-bone.
- This upright piece of wood prevents the body from yielding to the force dragging
- downward by the feet; for sometimes this piece of wood serves the purpose of
- counter-extension upward; and sometimes, too, when extension and
- counter-extension are made, this piece of wood, if susceptible of some motion to
- this side or that, will serve the purpose of a lever for pushing the head of the
- thigh-bone outward. It is on this account that several grooves are scooped out
- on the bench,
And one might find out other modes of reduction for this joint. If the large
- bench were to have raised on it two posts about a foot (in
- diameter?), and of a suitable height, on each side near its middle, and
- if a transverse piece of wood like the step of a ladder, were inserted in the
- posts, then if the sound leg were carried through between the posts, and the
- injured limb were brought over the transverse piece of wood, which should be
- exactly adapted in height to the joint which is dislocated (and it is an easy
- matter so to adjust it, for the step of the ladder should be made a little
- higher than required, and a convenient robe, folded several times, is to be laid
- below the patient's body), then a piece of wood, of suitable breadth and length,
- is to be laid below the limb, and it should reach from the ankle to beyond the
- head of the thigh-bone, and should be bound moderately tight to the limb. Then
- the limb being extended, either by means of the pestle-like piece of wood
- (formerly described), or by any of the other methods of extension, the limb
- which is carried over the step with the piece of wood attached to it, is to be
- forced downward, while somebody grasps the patient above the hip-joint. In this
- manner the extension will carry the head of the thighbone above the acetabulum,
- while the lever power that is exercised will push the head of the thigh-bone
- into its natural seat. All the above-mentioned powers are strong, and more than
- sufficient to rectify the accident, if properly and skill-
If the head of the bone slip outward, extension and counter-extension must be - made as described, or in a similar manner. But along with the extension a broad - lever is to be used to force the bone from without inward, the lever being - placed at the nates or a little farther up, and some person is to steady the - patient's body, so that it may not yield, either by grasping him at the buttocks - with his hands, or this may be effected by means of another similar lever, - adjusted to one of the grooves, while the patient has something laid below him, - and he is secured, and the dislocated thigh is to be turned gently from within - outward at the knee. Suspension will not answer in this form of dislocation, - for, in this instance, the arm of the person suspended from him, would push the - head of the thigh-bone from the acetabulum. But one might use the piece of wood - placed below him as a lever, in such a manner as might suit with this mode of - dislocation; it must work from without. But what use is there for more words? - For if the extension be well and properly done, and if the lever be properly - used, what dislocation of the joint could occur, that might not be thus reduced? -
- In dislocation of the thigh, backward, extension and counter-extension should be
- made as has been described; and having laid on the bench a cloth which has been
- folded several times, so that the patient may lie soft, he is to be laid on his
- face, and extension thus made, and, along with the extension, pressure is to be
- made with a board, as in the case of humpback, the board being placed on the
- region of the nates, and rather below than above the hip-joint; and the hole
- made in the wall for the board should not be direct over, but should be inclined
- a little downward, toward the feet. This mode of reduction is particularly
- appropriate to this variety of dislocation, and at the same time is very strong.
- But perhaps, instead of the board, it might be sufficient to have a person
- sitting (on the seat of luxation?), or pressing with his
- hands, or with his foot, and suddenly raising himself up, along with the
- extension. None of the other afore-
In dislocation forward, the same mode of extension should be made; but a person - who has very strong hands, and is well trained, should place the palm of the one - hand on the groin, and taking hold of this hand with the other, is at the same - time to push the dislocated part downward, and at the same time to the fore part - of the knee. This method of reduction is most especially conformable to this - mode of dislocation. And the mode of suspension is also not far removed from - being natural, but the person suspended should be well trained, so that his arm - may not act as a lever upon the joint, but that the force of the suspension may - act about the middle of the perineum, and at the os sacrum.
- Reduction by the bladder is also celebrated in dislocations at this joint, and I
- have seen certain persons who, from ignorance, attempted to reduce both
- dislocations outward and backward therewith, not knowing that they were rather
- displacing than replacing the parts; it is clear, however, that he who first
- invented this method intended it for dislocation inward. It is proper, then, to
- know how the bladder should be used, if it is to be used, and it should be
- understood that many other methods are more powerful than it. The bladder should
- be placed between the thighs uninflated, so that it may be carried as far up the
- perineum as possible, and the thighs beginning at the patella are to be bound
- together with a swathe, as far up as the middle of the thigh, and then a brass
- pipe is to be introduced into one of the loose feet of the bladder, and air
- forced into it, the patient is to lie on his side with the injured limb
- uppermost. This, then, is the preparation; some, however, do the thing worse
- than as I have described, for they do not bind the thighs together to any
- extent, but only at the knees, neither do they make extension, whereas extension
- should be made, and yet some people by having the good fortune to meet with a
- favorable case, have succeeded in making reduction. But it is not a convenient
- method of applying force, for the bladder, when inflated, does not present its
- most prominent part to the articular extremity of the femur, which is the place
-
The prime object of the physician in the whole art of medicine should be to cure
- that which is diseased; and if this can be accomplished in various ways, the
- least troublesome should be selected; for this is more becoming a good man, and
- one well skilled in the art, who does not covet popular coin of base alloy. With
- regard to the subject now on hand, the following are domestic means of making
- extension of the body, so that it is easy to choose from among the things at
- hand:-In the first place, when soft and supple thongs are not at hand for
- ligatures, either iron chains, or cords, or cables of ships, are to be wrapped
- round with scarfs or pieces of woolen rags, especially at the parts of them
- which are to be applied, and in this state they are to be used as bands. In the
- second place, the patient is to be comfortably laid on the strongest and largest
- couch that is at hand, and the feet of the couch, either those at the (patient's?) head, or those at the feet, are to be fastened
- to the threshold, either within or without, as is most suitable; and a square
- piece of wood is to be laid across, and extending from the one foot to the
- other; and if this piece of wood be slender, it should be bound to the feet of
- the couch, but, not withstanding, if it be thick, there will be no necessity for
- this; then the heads of the ligatures, both of those at the head and those at
- the feet, are to be fastened to a pestle, or some such piece of wood, difficult
- to reduce at either end; the ligatures should run along the line of the body, or
- be a little elevated above it, and it should be stretched proportionally to the
- pestles, so that, standing erect, the one may be the foot of the couch?), as the pestles
- can be fastened to the steps at either end, and when drawn back they thus make
- extension of the ligatures. Dislocation, inward or forward, may be reduced in
- the following manner: a ladder is to be fastened in the ground, and the man is
- to be seated upon it, and then the sound leg is to be gently stretched along and
- bound to it, wherever it is found convenient; and water is to be poured into an
- earthen vessel, or stones put into a hamper and slung from the injured leg, so
- as to effect the reduction. Another mode of reduction: a cross-beam is to be
- fastened between two pillars of moderate height; and at one part of the
- cross-beam there should be a protuberance proportionate to the size of the
- nates; and having bound a coverlet round the patient's breast, he is to be
- seated on the protuberant part of the cross-beam, and afterward the breast is to
- be fastened to the pillar by some broad ligature; then some one is to hold the
- sound leg so that he may not fall off, and from the injured limb is to be
- suspended some convenient weight, as formerly described.
It should be particularly known that the union of all bones is, for the most
- part, by a head and socket (cotyle); in some of these the
- place (socket?) is cotyloid and oblong, and in some the
- socket is glenoid (shallow?). In all dislocations reduction
- is to be effected, if possible, immediately, while still warm, but otherwise, as
- quickly as it can be done; for reduction will be a much easier and quicker
- process to the operator, and a much less painful one to the patient, if effected
- before swelling comes on. But all the joints when about to be reduced should be
- first softened, and gently moved about; for, thus they are more easily reduced.
- And, in all cases of reduction at joints, the patient must be put on a spare
- diet, but more especially in the case of the greatest joints, and those most
- difficult to reduce, and less so in those which are very small and easily
- reduced.
If any joint of the fingers is dislocated, whether the first,
After all reductions of joints the patient should be confined to a restricted
- diet and abstinence until the seventh day;
Accidents at the knee are more mild than at the elbow, from its being compact, - regular, and elegant in its construction; and, therefore, it is more readily - dislocated and reduced. It is most frequently dislocated inward, but also - outward and backward. The modes of reduction are these: by flexion at the knee, - or by sudden calcitration, or having rolled a swathe into a ball, and fixed it - in the ham, the patient's body is to be suddenly dropped on its bended knees. - Dislocation backward, also, as in the case of the elbow, may be reduced by - moderate extension, and to either side, either by flexion or calcitration, but - also by moderate extension. The adjustment is the same in all cases. In - dislocations backward which are not reduced, the patient cannot bend the joint, - but neither can he, to any great extent, in the other varieties; the thigh and - leg are wasted in front; but if inward the patients become bow-legged, and the - external parts are wasted; but if outward they become more bandy-legged, but the - impediment is less, for the body is supported on the larger of the bones, and - the inner parts are wasted. When these accidents happen at birth or during - adolescence, they follow the rule formerly stated.
-Dislocations at the ankle-joints require strong extension, either with the hands - or some such means; and adjustment, which at the same time effects both - purposes, as is common in all cases.
-Injuries of the foot are to be remedied like those of the hand.
-The bones connected with the leg, and which are dislocated, either at birth or - during adolescence, follow the same course as those in the hand.
- When persons jumping from a height pitch on the heel, so as to occasion
- separation (diastasis) of the bones, ecchymosis of the
- veins, and contusion of the nerves; when these symptoms are very violent there
- is danger of sphacelus, and that the case may give trouble during life, for the
- bones are so constructed as tendons?) connected with these parts, or from neglect during
- confinement to bed, when the heel gets blackened the most serious consequences
- result therefrom. Sometimes, in addition to the sphacelus, there come on acute
- fevers accompanied with hiccup, aberration of intellect, and speedy death, with
- lividities of the large blood-vessels. With regard to the symptoms attending
- exacerbations, if the ecchymosed and blackened parts and those around be
- somewhat hard and red, and if along with the hardness there be lividity,
- mortification is to be apprehended; but if the parts be slightly livid, or even
- very livid, and the swelling diffused, or if greenish and soft, these
- appearances, in such cases, are all favorable. The treatment, if no fever be
- present, consists in the administration of hellebore, but otherwise (it is not
- to be given, but oxyglyky (decoction of
- honeycombs and vinegar) is to be given for drink, if required.
- Bandaging as in the other articulations: above all, more especially in
- contusions, the bandages should be numerous and softer than usual, but the
- compression should be less; most turns should be made around the heel. Position,
- like the bandaging, should be so regulated as not to determine to the heel.
- Splints are not to be used.
When the foot is dislocated, either alone or along with its epiphysis, the
- displacement is, for the most part, to the inside. If not reduced, in the course
- of time, the hip, the thigh, and the side of the leg opposite the dislocation,
- become atrophied. Reduction is the same as in the wrist, but the extension
- requires to be very powerful. Treatment, agreeably to the general rule for
- joints. Exacerbations do occur, but less frequently than in dislocations at the
- wrist, provided the parts get rest. While they remain at rest the diet should be
- restricted. Those which occur at birth, or during adolescence, follow the rule
- formerly stated.
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 (
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.
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
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 may also be used elsewhere.
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
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.
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 (
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 (As when to horned cattle dear the vernal season comes,
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
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.
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
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
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
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
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.
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
When the elbow-joint is displaced or dislocated to the side or outward, while its sharp point (
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 (
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.
Diastasis of the bones may be recognized by examining the part where the vein that runs along the arm divides.
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.
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.
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
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.
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.
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.
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.
In congenital dislocations (at the wrist) the hand becomes
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.
The jaw-bone, in few cases, is completely dislocated, for the zygomatic process formed from the upper jaw-bone (
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
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.
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
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
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
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.
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
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
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,
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
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
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
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
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.
In the first place, the structure of the spine should be known, for this knowledge is requisite in many diseases. Wherefore, on the side turned to the belly (
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
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 (
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? (
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.
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 (
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 (
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
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
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
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
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 (
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
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
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
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,
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.
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,
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 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.
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,
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 (
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 (
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.
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
Dislocation inward at the hip-joint is to be reduced in the following manner: (it is a good, proper, and natural mode of reduction, and has something of display in it, if any one takes delight in such ostentatious modes of procedure). The patient is to be suspended by the feet from a cross-beam with a strong, soft, and broad cord; the feet are to be about four inches or less from one another; and a broad and soft leather collar connected with the cross-beam is to be put on above the knees; and the affected leg should be so extended as to moved be two inches longer than the other; the head should be about two cubits from the ground, or a little more or less; and the arms should be stretched along the sides, and bound with something soft; all these preparations should be made while he is lying on his back, so that he may be suspended for as short a time as possible. But when the patient is suspended, a person properly instructed and not weak, having introduced his arm between his thighs, is to place his fore-arm between the perineum and the dislocated head of the os femoris; and then, having joined the other hand to the one thus passed through the thighs, he is to stand by the side of the suspended patient, and suddenly suspend and swing himself in the air as
Wherefore, as formerly stated, men’s constitutions differ much from one another as to the facility or difficulty with which dislocations are reduced; and the cause of this was also stated formerly in treating of the shoulder. In some the thigh is reduced with no preparation, with slight extension, directed by the hands, and with slight movement; and in some the reduction is effected by bending the limb at the joint, and making rotation. But much more frequently it does not yield to any ordinary apparatus, and therefore one should be acquainted with the most powerful means which can be applied in each case, and use whatever maybe judged most proper under all circumstances. The modes of extension have been described in the former parts of the work, so that one may make use of whatever may happen to be at hand. For, extension and counter-extension are to be made in the direction of the limb and the body; and if this be properly effected, the head of the thigh-bone will be raised above its ancient seat; and if thus raised, it will not be easy to prevent it from settling in its place, so that any ordinary impulse with the lever and adjustment will be quite sufficient; but some apply insufficient extension, and hence the reduction gives much trouble. The bands then should be fastened, not only at the foot, but also above the knee, so that the force of the extension may not be expended on the knee-joint more than upon the hip-joint. The extension in the direction of the foot is to be thus contrived. But the counter-extension is not only to be managed by means of something carried round the chest and armpits, but also by a long, double, strong, and supple thong applied to the perineum, and carried behind along the spine, and in front along the collar-bone
It has been formerly stated by us that it will be of importance for any person who practices medicine in a populous city to get prepared a quadrangular board, about six cubits or a little more in length, and about two cubits in breadth; a fathom will be sufficient thickness for it; and then along it from the one end to the other, an excavation must be made, so that the working of the levers may not be higher than is proper; then at both sides we are to raise short, strong, and strongly-fixed posts, having axles; and in the middle of the bench five or six long grooves are to be scooped out about four inches distant from one another, three inches will be a sufficient breadth for them, and the depth in like manner; and although the number of grooves I have mentioned will be sufficient, there is nothing to prevent their being made all over the bench. And the bench should have in its middle a pretty deep hole, of a square shape, and of about three inches in size; and into this hole, when judged necessary, is to be adjusted a corresponding piece of wood, rounded above, which, at the proper time, is to be adjusted between the perineum and the head of the thigh-bone. This upright piece of wood prevents the body from yielding to the force dragging downward by the feet; for sometimes this piece of wood serves the purpose of counter-extension upward; and sometimes, too, when extension and counter-extension are made, this piece of wood, if susceptible of some motion to this side or that, will serve the purpose of a lever for pushing the head of the thigh-bone outward. It is on this account that several grooves are scooped out on the bench,
And one might find out other modes of reduction for this joint. If the large bench were to have raised on it two posts about a foot (
If the head of the bone slip outward, extension and counter-extension must be made as described, or in a similar manner. But along with the extension a broad lever is to be used to force the bone from without inward, the lever being placed at the nates or a little farther up, and some person is to steady the patient’s body, so that it may not yield, either by grasping him at the buttocks with his hands, or this may be effected by means of another similar lever, adjusted to one of the grooves, while the patient has something laid below him, and he is secured, and the dislocated thigh is to be turned gently from within outward at the knee. Suspension will not answer in this form of dislocation, for, in this instance, the arm of the person suspended from him, would push the head of the thigh-bone from the acetabulum. But one might use the piece of wood placed below him as a lever, in such a manner as might suit with this mode of dislocation; it must work from without. But what use is there for more words? For if the extension be well and properly done, and if the lever be properly used, what dislocation of the joint could occur, that might not be thus reduced?
In dislocation of the thigh, backward, extension and counter-extension should be made as has been described; and having laid on the bench a cloth which has been folded several times, so that the patient may lie soft, he is to be laid on his face, and extension thus made, and, along with the extension, pressure is to be made with a board, as in the case of humpback, the board being placed on the region of the nates, and rather below than above the hip-joint; and the hole made in the wall for the board should not be direct over, but should be inclined a little downward, toward the feet. This mode of reduction is particularly appropriate to this variety of dislocation, and at the same time is very strong. But perhaps, instead of the board, it might be sufficient to have a person sitting (
In dislocation forward, the same mode of extension should be made; but a person who has very strong hands, and is well trained, should place the palm of the one hand on the groin, and taking hold of this hand with the other, is at the same time to push the dislocated part downward, and at the same time to the fore part of the knee. This method of reduction is most especially conformable to this mode of dislocation. And the mode of suspension is also not far removed from being natural, but the person suspended should be well trained, so that his arm may not act as a lever upon the joint, but that the force of the suspension may act about the middle of the perineum, and at the os sacrum.
Reduction by the bladder is also celebrated in dislocations at this joint, and I have seen certain persons who, from ignorance, attempted to reduce both dislocations outward and backward therewith, not knowing that they were rather displacing than replacing the parts; it is clear, however, that he who first invented this method intended it for dislocation inward. It is proper, then, to know how the bladder should be used, if it is to be used, and it should be understood that many other methods are more powerful than it. The bladder should be placed between the thighs uninflated, so that it may be carried as far up the perineum as possible, and the thighs beginning at the patella are to be bound together with a swathe, as far up as the middle of the thigh, and then a brass pipe is to be introduced into one of the loose feet of the bladder, and air forced into it, the patient is to lie on his side with the injured limb uppermost. This, then, is the preparation; some, however, do the thing worse than as I have described, for they do not bind the thighs together to any extent, but only at the knees, neither do they make extension, whereas extension should be made, and yet some people by having the good fortune to meet with a favorable case, have succeeded in making reduction. But it is not a convenient method of applying force, for the bladder, when inflated, does not present its most prominent part to the articular extremity of the femur, which is the place
The prime object of the physician in the whole art of medicine should be to cure that which is diseased; and if this can be accomplished in various ways, the least troublesome should be selected; for this is more becoming a good man, and one well skilled in the art, who does not covet popular coin of base alloy. With regard to the subject now on hand, the following are domestic means of making extension of the body, so that it is easy to choose from among the things at hand:-In the first place, when soft and supple thongs are not at hand for ligatures, either iron chains, or cords, or cables of ships, are to be wrapped round with scarfs or pieces of woolen rags, especially at the parts of them which are to be applied, and in this state they are to be used as bands. In the second place, the patient is to be comfortably laid on the strongest and largest couch that is at hand, and the feet of the couch, either those at the (
It should be particularly known that the union of all bones is, for the most part, by a head and socket (
If any joint of the fingers is dislocated, whether the first,
After all reductions of joints the patient should be confined to a restricted diet and abstinence until the seventh day;
Accidents at the knee are more mild than at the elbow, from its being compact, regular, and elegant in its construction; and, therefore, it is more readily dislocated and reduced. It is most frequently dislocated inward, but also outward and backward. The modes of reduction are these: by flexion at the knee, or by sudden calcitration, or having rolled a swathe into a ball, and fixed it in the ham, the patient’s body is to be suddenly dropped on its bended knees. Dislocation backward, also, as in the case of the elbow, may be reduced by moderate extension, and to either side, either by flexion or calcitration, but also by moderate extension. The adjustment is the same in all cases. In dislocations backward which are not reduced, the patient cannot bend the joint, but neither can he, to any great extent, in the other varieties; the thigh and leg are wasted in front; but if inward the patients become bow-legged, and the external parts are wasted; but if outward they become more bandy-legged, but the impediment is less, for the body is supported on the larger of the bones, and the inner parts are wasted. When these accidents happen at birth or during adolescence, they follow the rule formerly stated.
Dislocations at the ankle-joints require strong extension, either with the hands or some such means; and adjustment, which at the same time effects both purposes, as is common in all cases.
Injuries of the foot are to be remedied like those of the hand.
The bones connected with the leg, and which are dislocated, either at birth or during adolescence, follow the same course as those in the hand.
When persons jumping from a height pitch on the heel, so as to occasion separation (
When the foot is dislocated, either alone or along with its epiphysis, the displacement is, for the most part, to the inside. If not reduced, in the course of time, the hip, the thigh, and the side of the leg opposite the dislocation, become atrophied. Reduction is the same as in the wrist, but the extension requires to be very powerful. Treatment, agreeably to the general rule for joints. Exacerbations do occur, but less frequently than in dislocations at the wrist, provided the parts get rest. While they remain at rest the diet should be restricted. Those which occur at birth, or during adolescence, follow the rule formerly stated.
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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 (
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.
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
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 may also be used elsewhere.
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
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.
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 (
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 (As when to horned cattle dear the vernal season comes,
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
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.
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
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
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
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
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.
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
When the elbow-joint is displaced or dislocated to the side or outward, while its sharp point (
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 (
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.
Diastasis of the bones may be recognized by examining the part where the vein that runs along the arm divides.
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.
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.
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
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.
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.
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.
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.
In congenital dislocations (at the wrist) the hand becomes
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.
The jaw-bone, in few cases, is completely dislocated, for the zygomatic process formed from the upper jaw-bone (
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
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.
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
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
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
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.
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
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
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,
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
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
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
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
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.
In the first place, the structure of the spine should be known, for this knowledge is requisite in many diseases. Wherefore, on the side turned to the belly (
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
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 (
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? (
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.
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 (
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 (
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
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
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
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
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 (
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
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
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
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,
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.
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,
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 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.
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,
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 (
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 (
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.
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
Dislocation inward at the hip-joint is to be reduced in the following manner: (it is a good, proper, and natural mode of reduction, and has something of display in it, if any one takes delight in such ostentatious modes of procedure). The patient is to be suspended by the feet from a cross-beam with a strong, soft, and broad cord; the feet are to be about four inches or less from one another; and a broad and soft leather collar connected with the cross-beam is to be put on above the knees; and the affected leg should be so extended as to moved be two inches longer than the other; the head should be about two cubits from the ground, or a little more or less; and the arms should be stretched along the sides, and bound with something soft; all these preparations should be made while he is lying on his back, so that he may be suspended for as short a time as possible. But when the patient is suspended, a person properly instructed and not weak, having introduced his arm between his thighs, is to place his fore-arm between the perineum and the dislocated head of the os femoris; and then, having joined the other hand to the one thus passed through the thighs, he is to stand by the side of the suspended patient, and suddenly suspend and swing himself in the air as
Wherefore, as formerly stated, men’s constitutions differ much from one another as to the facility or difficulty with which dislocations are reduced; and the cause of this was also stated formerly in treating of the shoulder. In some the thigh is reduced with no preparation, with slight extension, directed by the hands, and with slight movement; and in some the reduction is effected by bending the limb at the joint, and making rotation. But much more frequently it does not yield to any ordinary apparatus, and therefore one should be acquainted with the most powerful means which can be applied in each case, and use whatever maybe judged most proper under all circumstances. The modes of extension have been described in the former parts of the work, so that one may make use of whatever may happen to be at hand. For, extension and counter-extension are to be made in the direction of the limb and the body; and if this be properly effected, the head of the thigh-bone will be raised above its ancient seat; and if thus raised, it will not be easy to prevent it from settling in its place, so that any ordinary impulse with the lever and adjustment will be quite sufficient; but some apply insufficient extension, and hence the reduction gives much trouble. The bands then should be fastened, not only at the foot, but also above the knee, so that the force of the extension may not be expended on the knee-joint more than upon the hip-joint. The extension in the direction of the foot is to be thus contrived. But the counter-extension is not only to be managed by means of something carried round the chest and armpits, but also by a long, double, strong, and supple thong applied to the perineum, and carried behind along the spine, and in front along the collar-bone
It has been formerly stated by us that it will be of importance for any person who practices medicine in a populous city to get prepared a quadrangular board, about six cubits or a little more in length, and about two cubits in breadth; a fathom will be sufficient thickness for it; and then along it from the one end to the other, an excavation must be made, so that the working of the levers may not be higher than is proper; then at both sides we are to raise short, strong, and strongly-fixed posts, having axles; and in the middle of the bench five or six long grooves are to be scooped out about four inches distant from one another, three inches will be a sufficient breadth for them, and the depth in like manner; and although the number of grooves I have mentioned will be sufficient, there is nothing to prevent their being made all over the bench. And the bench should have in its middle a pretty deep hole, of a square shape, and of about three inches in size; and into this hole, when judged necessary, is to be adjusted a corresponding piece of wood, rounded above, which, at the proper time, is to be adjusted between the perineum and the head of the thigh-bone. This upright piece of wood prevents the body from yielding to the force dragging downward by the feet; for sometimes this piece of wood serves the purpose of counter-extension upward; and sometimes, too, when extension and counter-extension are made, this piece of wood, if susceptible of some motion to this side or that, will serve the purpose of a lever for pushing the head of the thigh-bone outward. It is on this account that several grooves are scooped out on the bench,
And one might find out other modes of reduction for this joint. If the large bench were to have raised on it two posts about a foot (
If the head of the bone slip outward, extension and counter-extension must be made as described, or in a similar manner. But along with the extension a broad lever is to be used to force the bone from without inward, the lever being placed at the nates or a little farther up, and some person is to steady the patient’s body, so that it may not yield, either by grasping him at the buttocks with his hands, or this may be effected by means of another similar lever, adjusted to one of the grooves, while the patient has something laid below him, and he is secured, and the dislocated thigh is to be turned gently from within outward at the knee. Suspension will not answer in this form of dislocation, for, in this instance, the arm of the person suspended from him, would push the head of the thigh-bone from the acetabulum. But one might use the piece of wood placed below him as a lever, in such a manner as might suit with this mode of dislocation; it must work from without. But what use is there for more words? For if the extension be well and properly done, and if the lever be properly used, what dislocation of the joint could occur, that might not be thus reduced?
In dislocation of the thigh, backward, extension and counter-extension should be made as has been described; and having laid on the bench a cloth which has been folded several times, so that the patient may lie soft, he is to be laid on his face, and extension thus made, and, along with the extension, pressure is to be made with a board, as in the case of humpback, the board being placed on the region of the nates, and rather below than above the hip-joint; and the hole made in the wall for the board should not be direct over, but should be inclined a little downward, toward the feet. This mode of reduction is particularly appropriate to this variety of dislocation, and at the same time is very strong. But perhaps, instead of the board, it might be sufficient to have a person sitting (
In dislocation forward, the same mode of extension should be made; but a person who has very strong hands, and is well trained, should place the palm of the one hand on the groin, and taking hold of this hand with the other, is at the same time to push the dislocated part downward, and at the same time to the fore part of the knee. This method of reduction is most especially conformable to this mode of dislocation. And the mode of suspension is also not far removed from being natural, but the person suspended should be well trained, so that his arm may not act as a lever upon the joint, but that the force of the suspension may act about the middle of the perineum, and at the os sacrum.
Reduction by the bladder is also celebrated in dislocations at this joint, and I have seen certain persons who, from ignorance, attempted to reduce both dislocations outward and backward therewith, not knowing that they were rather displacing than replacing the parts; it is clear, however, that he who first invented this method intended it for dislocation inward. It is proper, then, to know how the bladder should be used, if it is to be used, and it should be understood that many other methods are more powerful than it. The bladder should be placed between the thighs uninflated, so that it may be carried as far up the perineum as possible, and the thighs beginning at the patella are to be bound together with a swathe, as far up as the middle of the thigh, and then a brass pipe is to be introduced into one of the loose feet of the bladder, and air forced into it, the patient is to lie on his side with the injured limb uppermost. This, then, is the preparation; some, however, do the thing worse than as I have described, for they do not bind the thighs together to any extent, but only at the knees, neither do they make extension, whereas extension should be made, and yet some people by having the good fortune to meet with a favorable case, have succeeded in making reduction. But it is not a convenient method of applying force, for the bladder, when inflated, does not present its most prominent part to the articular extremity of the femur, which is the place
The prime object of the physician in the whole art of medicine should be to cure that which is diseased; and if this can be accomplished in various ways, the least troublesome should be selected; for this is more becoming a good man, and one well skilled in the art, who does not covet popular coin of base alloy. With regard to the subject now on hand, the following are domestic means of making extension of the body, so that it is easy to choose from among the things at hand:-In the first place, when soft and supple thongs are not at hand for ligatures, either iron chains, or cords, or cables of ships, are to be wrapped round with scarfs or pieces of woolen rags, especially at the parts of them which are to be applied, and in this state they are to be used as bands. In the second place, the patient is to be comfortably laid on the strongest and largest couch that is at hand, and the feet of the couch, either those at the (
It should be particularly known that the union of all bones is, for the most part, by a head and socket (
If any joint of the fingers is dislocated, whether the first,
After all reductions of joints the patient should be confined to a restricted diet and abstinence until the seventh day;
Accidents at the knee are more mild than at the elbow, from its being compact, regular, and elegant in its construction; and, therefore, it is more readily dislocated and reduced. It is most frequently dislocated inward, but also outward and backward. The modes of reduction are these: by flexion at the knee, or by sudden calcitration, or having rolled a swathe into a ball, and fixed it in the ham, the patient’s body is to be suddenly dropped on its bended knees. Dislocation backward, also, as in the case of the elbow, may be reduced by moderate extension, and to either side, either by flexion or calcitration, but also by moderate extension. The adjustment is the same in all cases. In dislocations backward which are not reduced, the patient cannot bend the joint, but neither can he, to any great extent, in the other varieties; the thigh and leg are wasted in front; but if inward the patients become bow-legged, and the external parts are wasted; but if outward they become more bandy-legged, but the impediment is less, for the body is supported on the larger of the bones, and the inner parts are wasted. When these accidents happen at birth or during adolescence, they follow the rule formerly stated.
Dislocations at the ankle-joints require strong extension, either with the hands or some such means; and adjustment, which at the same time effects both purposes, as is common in all cases.
Injuries of the foot are to be remedied like those of the hand.
The bones connected with the leg, and which are dislocated, either at birth or during adolescence, follow the same course as those in the hand.
When persons jumping from a height pitch on the heel, so as to occasion separation (
When the foot is dislocated, either alone or along with its epiphysis, the displacement is, for the most part, to the inside. If not reduced, in the course of time, the hip, the thigh, and the side of the leg opposite the dislocation, become atrophied. Reduction is the same as in the wrist, but the extension requires to be very powerful. Treatment, agreeably to the general rule for joints. Exacerbations do occur, but less frequently than in dislocations at the wrist, provided the parts get rest. While they remain at rest the diet should be restricted. Those which occur at birth, or during adolescence, follow the rule formerly stated.