WINMX Assorted Textfiles/Ebooks.tar/Text - Philosophy - Hippocrates - Instruments of Reduction.txt

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                                     400 BC
                            INSTRUMENTS OF REDUCTION
                                 by Hippocrates
                          translated by Francis Adams

  With regard to the construction of bones, the bones and joints of
the fingers are simple, the bones of the hand and foot are numerous,
and articulated in various ways; the uppermost are the largest; the
heel consists of one bone which is seen to project outward, and the
back tendons are attached to it. The leg consists of two bones, united
together above and below, but slightly separated in the middle; the
external bone (fibula), where it comes into proximity with the
little toe, is but slightly smaller than the other, more so where they
are separated, and at the knee, the outer hamstring arises from it;
these bones have a common epiphysis below, with which the foot is
moved, and another epiphys is above,* in which is moved the
articular extremity of the femur, which is simple and light in
proportion to its length, in the form of a condyle, and having the
patella (connected with it?), the femur itself bends outward and
forward; its head is a round epiphysis which gives origin to
ligament inserted in the acetabulum of the hip-joint. This bone is
articulated somewhat obliquely, but less so than the humerus. The
ischium is united to the great vertebra contiguous to the os sacrum by
a cartilaginous ligament. The spine, from the os sacrum to the great
vertebra, is curved backward; in this quarter are situated the
bladder, the organs of generation, and the inclined portion of the
rectum; from this to the diaphragm it proceeds in a straight line
inclining forward, and the psoae are situated there; from this
point, to the great vertebra above the tops of the shoulders, it rises
in a line that is curved backward, and the curvature appears greater
than it is in reality, for the posterior processes of the spine are
there highest; the articulation of the neck inclines forward. The
vertebrae on the inside are regularly placed upon one another, but
behind they are connected by a cartilaginous ligament; they are
articulated in the form of synarthrosis at the back part of the spinal
marrow; behind they have a sharp process having a cartilaginous
epiphysis, whence proceeds the roots of nerves running downward, as
also muscles extending from the neck to the loins, and filling the
space between the ribs and the spine. The ribs are connected to all
the intervertebral spaces on the inside, from the neck to the lumbar
region, by a small ligament, and before to the sternum, their
extremities being spongy and soft; their form is the most arched in
man of all animals; for in this part, man is, of all animals, the
narrowest in proportion to his bulk. The ribs are united to each
vertebra by a small ligament at the place from which the short and
broad lateral processes (transverse processes?) arise. The sternum
is one continuous bone, having lateral pits for the insertion of the
ribs; it is of a spongy and cartilaginous structure. The clavicles are
rounded in front, having some slight movements at the sternum, but
more free at the acromion. The acromion, in man, arises from the
scapula differently from most other animals. The scapula is
cartilaginous toward the spine, and spongy elsewhere, having an
irregular figure externally; its neck and articular cavity
cartilaginous; it does not interfere with the movements of the ribs,
and is free of all connection with the other bones, except the
humerus. The head of the humerus is articulated with its (glenoid?)
cavity, by means of a small ligament, and it consists of a rounded
epiphysis composed of spongy cartilage, the humerus itself is bent
outward and forward, and it is articulated with its (glenoid?)
cavity by its side, and not in a straight line. At the elbow it is
broad, and has condyles and cavities, and is of a solid consistence;
behind it is a cavity in which the coronoid process (olecranon?) of
the ulna is lodged, when the arm is extended; here, too, is inserted
the benumbling nerve, which arises from between the two bones of the
forearm at their junction, and terminates there.

  * Epiphysis means a close union of the two bones by means of a
ligament.

  2. When the nose is fractured, the parts should be modeled
instantly, if possible. If the fracture be in its cartilaginous
part, introduce into the nostrils a tent formed of caddis, inclosed in
the outer skin of a Carthaginian hide, or anything else which does not
irritate; the skin is to be glued to the parts displaced, which are to
be thus rectified. Bandaging in this case does mischief. The treatment
is to consist of flour with manna, or of sulphur with cerate. You will
immediately adjust the fragments, and afterward retain them in place
with your fingers introduced into the nostrils, and turning the
parts into place; then the Carthaginian skin is to be used. Callius
forms even when there is a wound; and the same things are to be
done, even when there is to be exfoliation of the bones, for this is
not of a serious nature.

  3. In fractures of the ears, neither bandages nor cataplasms
should be used; or, if any bandage be used, it should be put on very
tight; the cerate and sulphur should be applied to agglutinate the
bandages. When matter forms in the ears, it is found to be more deeply
seated than might be supposed, for all parts that are pulpy, and
consist of juicy flesh, prove deceptious in such a case. But no harm
will result from making an opening, for the parts are lean, watery,
and full of mucus. No mention is here made of the places and
circumstances which render it fatal to make an opening. The cure is
soonest effected by transfixing the ear with a cautery; but the ear is
maimed and diminished in size, if burned across. If opened, one of the
gentle medicines for flesh wounds should be used as a dressing.

  4. The jaw-bone is often slightly displaced (subluxated?), and is
restored again; it is dislocated but rarely, especially in gaping;
in fact, the bone is never dislocated unless it slips while the
mouth is opened wide. It slips, however, the more readily from its
ligaments being oblique, supple, and of a yielding nature. The
symptoms are: the lower jaw protrudes, it is distorted to the side
opposite the dislocation, and the patient cannot shut his mouth;
when both sides are dislocated, the jaw projects more, the mouth can
be less shut, but there is no distortion; this is shown by the rows of
the teeth in the upper and lower jaw corresponding with one another.
If, then, both sides be dislocated, and not immediately reduced, the
patient for the most part dies on the tenth day, with symptoms of
continued fever, stupor, and coma, for the muscles there induce such
effects; there is disorder of the bowels attended with scanty and
unmixed dejection; and the vomitings, if any, are of the same
character. The other variety is less troublesome. The method of
reduction is the same in both:-The patient being laid down or
seated, the physician is to take hold of his head, and grasping both
sides of the jaw-bone with both hands, within and without, he must
perform three manoeuvres at once,-rectify the position of the jaw,
push it backward, and shut the mouth. The treatment should consist
of soothing applications, position, and applying a suitable bandage to
support the jaw-bone, so as to cooperate with the reduction.

  5. The bone of the shoulder is dislocated downward. I have never
heard of any other mode. The parts put on the appearance of
dislocation forward, when the flesh about the joint is wasted during
consumption, as also seems to be the case with cattle when in a
state of leanness after winter. Those persons are most liable to
dislocations who are thin, slender, and have humidities about their
joints without inflammation, for it knits the joints. Those who
attempt to reduce and rectify dislocations in oxen, commit a
blunder, as forgetting that the symptoms arise from the manner in
which the ox uses the limb, and that the appearance is the same in a
man who is in a similar condition, and forgetting also that Homer
has said, that oxen are most lean at that season. In this dislocation,
then, when not reduced, the patient cannot perform any of those acts
which others do, by raising the arm from the side. I have thus
stated who are the persons most subject to this dislocation, and how
they are affected. In congenital dislocations the nearest bones are
most shortened, as is the case with persons who are weasel-armed;
the fore-arm less so, and the hand still less; the bones above are not
affected. And the parts (near the seat of the injury) are most
wasted in flesh; and this happens more especially on the side of the
arm opposite the dislocation, and that during adolescence, yet in a
somewhat less degree than in congenital cases. The deep-seated
suppurations occur most frequently to new-born infants about the joint
of the shoulder, and these produce the same consequences as
dislocations. In adults, the bones are not so diminished in size,
and justly, seeing that the others will not increase as in the
former case; but wasting of the flesh takes place, for it is
increased, and is diminished every day, and at all ages. And attention
should be paid to the force of habit, and to the symptom produced by
the tearing away of the acromion, whereby a void is left, which
makes people suppose that the humerus is dislocated. The head of the
humerus is felt in the armpit, and the patient cannot raise his arm,
nor swing it to this side and that, as formerly. The other shoulder
shows the difference. Modes of reduction:-The patient himself having
placed his fist in the arm pit, pushes up the head of the humerus with
it, and brings the hand forward to the breast. Another:-Force it
backward, so that you may turn it round. Another:-Apply your head to
the acromion, and your hands to the armpit, separate the head of the
humerus (from the side?), and push the elbow in the opposite
direction; or, instead of your knees, another person may turn aside
the elbow, as formerly directed. Or, place the patient on your
shoulder, with the shoulder in his armpit. Or, with the heel,
something being introduced to fill up the hollow of the armpit, and
using the right foot to the right shoulder. Or, with a pestle. Or,
with the step of a ladder. Or, by rotation made with piece of wood
stretched below the arm. Treatment:-As to attitude, the arm placed
by the side, the hand and shoulder raised; the bandaging and
adjustment of the parts while in this attitude. If not reduced, the
top of the shoulder becomes attenuated.

  6. When the acromion is torn away, the appearance is the same as
in dislocation of the shoulder; but there is no impediment, except
that the bone does not return to its position. The figure should be
the same as in dislocation, both as regards bandaging and suspending
the limb. The bandaging according to rule.

  7. When partial displacement (sub-luxation?) takes place at the
elbow, either inside or outside, but the sharp point (olecranon?)
remains in the cavity of the humerus, make extension in a straight
line, and push the projecting parts backward and to the sides.

  8. In complete dislocations to either side, make extension while the
arm is in the position it is put in to be bandaged for a fracture, for
thus the rounded part of the elbow will not form an obstacle to it.
Dislocation most commonly takes place inward. The parts are to be
adjusted by separating the bones as much as possible, so that the
end of the humerus may not come in contact with the olecranon, but
it is to be carried up and turned round, and not forced in a
straight line; at the same time the opposite sides are to be pushed
together, and the bones reduced to their place. In these cases
rotation of the elbow cooperates; that is to say, turning the arm into
a state of supination and pronation; so much for the reduction. With
regard to the attitude in which it is to be put,-the hand is to be
placed somewhat higher than the elbow, and the arm by the side; this
position suits with it when slung from the neck, is easily borne, is
its natural position, and one adapted for ordinary purposes, unless
callus form improperly: the callus soon forms. Treatment:-By
bandages according to the common rule for articulations, and the point
of the elbow is to be included in the bandage.

  9. The elbow, when luxated, induces the most serious consequences,
fevers, pain, nausea, vomiting of pure bile; and this especially in
dislocations backward, from pressure on the nerve which occasions
numbness; next to it is dislocation forward. The treatment is the
same. The reduction of 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. In it
a hard ball is to be placed in the bend of the elbow, and the fore-arm
is to be bent over this while sudden extension is made.

  10. Diastasis of the bones may be recognized by examining the part
where the vein which runs along the arm divides.

  11. In these cases callus is speedily formed. In congenital
dislocations, the bones below the seat of the injury are shorter
than natural; in this case, the greatest shortening is in the nearest,
namely, those of the fore-arm; second, those of the hand; third, those
of the fingers. The arm and shoulders are stronger, owing to the
nourishment which they receive, and the other arm, from the additional
work it has to perform, is still more strong. The wasting of the
flesh, if the dislocation was outward, is on the inside; or if
otherwise, on the side opposite the dislocation.

  12. In dislocation at the elbow, whether outward or inward,
extension is to be made with the fore-arm at right angles to the
arm; the arm is to be suspended by a shawl passed through the
armpit, and a weight is to be attached to the extremity of the
elbow; or force is to be applied with the hands. The articular
extremity being properly raised, the parts are to be adjusted with the
palms of the hands, as in dislocations of the hands. It is to be
bandaged, suspended in a sling, and placed, while in this attitude.

  13. Dislocations backward are to be rectified with the palms of
the hands along with sudden extension. These two acts are to be
performed together, as in other cases of the kind. In dislocation
forward, the arm is to bend around a ball of cloth, of proper size,
and at the same time replaced.

  14. If the displacement be on the other side both these operations
are to be performed in effecting the adjustment of the arm. With
regard to the treatment,-the position and the bandaging are the same
as in the other cases. For all these cases may be reduced by
ordinary distention.

  15. With regard to the modes of reduction, some act upon the
principle of carrying the one piece of bone over the other, some by
extension, and some by rotation: these last consist in rapidly turning
the arm to this side and that.

  16. The joint of the hand is dislocated inward or outward, but
most frequently inward. The symptoms are easily recognized; if inward,
the patient cannot at all bend his fingers, but if outward, he
cannot extend them. Reduction:-By placing the fingers above a table,
extension and counter-extension are to be made by assistance, while,
with the palm of the hand or the heel on the projecting bone, one
presses forward, and from behind, upon the other bone, and lays some
soft substance on it; and, if the dislocation be above, the hand is to
be turned into a state of pronation; or, if backward, into a state
of supination. The treatment is to be conducted with bandages.

  17. The whole hand is dislocated either inward, or outward, but
especially inward, or to this side or that. Sometimes the epiphysis is
displaced, and sometimes there is displacement (diastasis) of the
one bone from the other. Powerful extension is to be made in this
case; and the projecting part is to be pressed upon, and
counter-pressure made on the opposite side: both modes being performed
at the same time, both backward and laterally, either with the hands
on a table, or with the heel. These accidents give rise to serious
consequences and deformities; but in time the parts get so strong as
to admit of being used. The treatment consists of bandages
comprehending the hand and forearm, and splints are to be applied as
far as the fingers; when put in splints, they are to be more
frequently loosed than in fractures, and more copious allusions of
water are to be used.

  18. In congenital dislocations the hand becomes shortened, and the
atrophy of the flesh is generally on the side opposite the
dislocation. In the adult the bones remain of their proper size.

   19. The symptoms of dislocation of the finger are obvious, and need
not be described. This is the mode of reduction:-By stretching in a
straight line, and making pressure on the projecting part, and
counter-pressure, at the opposite side, on the other. The proper
treatment consists in the application of bandages. When not reduced,
the parts unite by callus outside of the joints. In congenital
dislocations, and in those which occur during bones below the
dislocation are shortened, and the flesh is wasted principally on
the side opposite to the dislocation; in the adult the bones remain of
their proper size.

  20. Dislocation at the hip-joint occurs in four modes, inward most
frequently, outward next, the others of equal frequency. The
symptoms:-The common, a comparison with the sound leg. The peculiar
symptoms of dislocations inward; the head of the bone is felt at the
perineum; the patient cannot bend his leg as formerly; the limb
appears elongated, and to a great extent, unless you bring both
limbs into the middle space between them in making a comparison of
them; and the foot and the knee are inclined outward. If the
dislocation has taken place from birth, or during one's growth, the
thigh is shortened, the leg less so, and the others according to the
same rule; the fleshy parts are atrophied, especially on the
outside. Such persons are afraid to stand erect, and crawl along on
the sound limb; or, if compelled, they walk with one or two staves,
and bear up the affected limb; and the smaller the limb so much the
more do they walk. If the accident happens to adults the bones
remain of their proper size, but the flesh is wasted, as formerly
described; the patients walk in a wriggling manner, like oxen; they
are bent toward the flank, and the buttock on the uninjured side is
prominent; for the uninjured limb must necessarily come below that
it may support the body, whilst the other must be carried out of the
way, as it cannot support the body, like those who have an ulcer in
the foot. They poise the body by means of a staff on the sound side,
and grasp the affected limb with the hand above the knee so as to
carry the body in shifting from one place to another. If the parts
below the hip-joint be used, the bones below are less atrophied, but
the flesh more.

  21. The symptoms and attitudes in dislocation outward are the
opposite, and the knee and foot incline a little inward. When it is
congenital, or occurs during adolescence, the bones do not grow
properly; according to the same rule, the bone of the hip-joint is
somewhat higher than natural, and does not grow proportionally. In
those who have frequent dislocations outward, without inflammation,
the limb is of a more humid (flabby?) temperament than natural, like
the thumb, for it is the part most frequently dislocated, owing to its
configuration; in what persons the dislocation is to a greater or less
extent; and in what persons it is more difficultly or easily produced;
in what there is reason to hope that it can be speedily reduced, and
in what not; and the remedy for this; and in what cases the
dislocation frequently happens, and treatment of this. In
dislocation outward from birth, or during adolescence, or from
disease, (and it happens most frequently from disease, in which case
there is sometimes exfoliation of the bone, but even where there is no
exfoliation), the patients experience the same symptoms, but to an
inferior degree to those in dislocations inward, if properly managed
so that in walking they can put the whole foot to the ground and
lean to either side. The younger the patient is, the greater care
should be bestowed on him; when neglected, the case gets worse; when
attended to, it improves; and, although there be atrophy in all
parts of the limb, it is to a less extent.

  22. When there is a dislocation on both sides, the affections of the
bones are the same; the flesh is well developed, except within, the
nates protrude, the thighs are arched, unless there be sphacelus. If
there be curvature of the spine above the hip-joint, the patients
enjoy good health, but the body does not grow, with the exception of
the head.

  23. The symptoms of dislocation backward are:-The parts before
more empty, behind they protrude, the foot straight, flexion
impossible, except with pain, extension least of all: in these the
limb is shortened. They can neither extend the limb at the ham, nor at
the groin, unless it be much raised, nor can they bend it. The
uppermost joint, in most cases, takes the lead: this is common in
joints, nerves, muscles, intestines, uteri, and other parts. There the
bone of the hip-joint is carried backward to the nates, and on that
account it is shortened, and because the patient cannot extend it. The
flesh of the whole leg is wasted in all cases, in which most, and to
what extent, has been already stated. Every part of the body which
performs its functional work is strong, but, not withstanding, if
inactive, it gets into a bad condition, unless its inactivity arise
from fatigue, fever, or inflammation. And in dislocations outward, the
limb is shortened, because the bone is lodged in flesh which yields;
but, not withstanding, in dislocations inward, it is longer, because
the bone is lodged on a projecting bone. Adults, then, who have this
dislocation unreduced, are bent at the groins in walking, and the
other ham is flexed; they scarcely reach the ground with the ball of
the foot; they grasp the limb with the hand, and walk without a
staff if they choose; if the staff be too long, their foot cannot
reach the grounds-if they wish to reach the ground, they must use a
short staff. There is wasting of the flesh in cases attended with
pain; and the inclination of the leg is forward, and the sound leg
in proportion. In congenital cases, or when in adolescence, or from
disease, the bone is dislocated (under what circumstances will be
explained afterward), the limb is particularly impaired, owing to
the nerves and joints not being exercised, and the knee is impaired
for the reasons stated. These persons, keeping the limb bent, walk
with one staff or two. But the sound limb is in good flesh from usage.

  24. In dislocations forward the symptoms are the opposite: a vacuity
behind, a protuberance before; of all motions they can least perform
flexion, and extension best; the foot is straight, the limb is of
the proper length at the heel; at its extremity the foot a little
turned up; they are especially pained at first: of all these
dislocations retention of urine occurs most frequently in this
variety, because the bone is lodged among important nerves. The fore
parts are stretched, do not grow, are diseased, and are obnoxious to
premature decay; the back parts are wrinkled. In the case of adults,
they walk erect, resting merely on the heel, and this they do
decidedly if they can take great steps; but they drag it along; the
wasting is least of all in this variety of dislocation, owing to their
being able to use the limb, but the wasting is most behind. The
whole limb being straighter than natural they stand in need of a staff
on the affected side. When the dislocation is congenital, or has
occurred during adolescence, if properly managed, the patient has
the use of the limb as well as adults (otherwise?) have of it. But, if
neglected, it is shortened and extended, for in such cases the joint
is generally in a straight position. The diminution of the bones,
and wasting of the fleshy parts, are analogous.

  25. In reduction-the extension of the thigh is to be powerful, and
the adjustment what is common in all such cases, with the hands, or
a board, or a lever, which, in dislocations inward, should be round,
and in dislocations outward, flat; but it is mostly applicable in
dislocations outward. Dislocations inward are to be remedied by
means of bladders, extending to the bare part of the thigh, along with
extension and binding together of the limbs. The patient may be
suspended, with his feet a little separated from one another, and then
a person inserting his arm within the affected limb, is to suspend
himself from it, and perform extension and readjustment at the same
time; and this method is sufficient in dislocations forward and the
others, but least of all in dislocations backward. A board fastened
under the limb, like the board fastened below the arm in
dislocations at the shoulder, answers in dislocations inward, but less
so in the other varieties. Along with extension you will use
pressure either with the foot, the hand, or a board, especially in
dislocations forward and backward.

  26. Dislocations at the knee are of a milder character than those of
the elbow, owing to the compactness and regularity of the joint; and
hence it is more readily dislocated and reduced. Dislocation generally
takes place inward, but also outward and backward. The methods of
reduction are-by circumflexion, or by rapid excalcitration, or by
rolling a fillet into a ball, placing it in the ham, and then
letting the patient's body suddenly drop down on his knees: this
mode applies best in dislocations backward. Dislocations backward,
like those of the elbows, may also be reduced by moderate extension.
Lateral dislocations may be reduced by circumflexion or
excalcitration, or by extension (but this is most applicable in
dislocation backward), but also by moderate extension. The
adjustment is what is common in all. If not reduced, in dislocations
backward, they cannot bend the leg and thigh upon one another, but
neither can they do this in the others except to a small extent; and
the fore parts of the thigh and leg are wasted. In dislocations inward
they are bandy-legged, and the external parts are atrophied. But, in
dislocations outward, they incline more outward, but are less lame,
for the body is supported on the thicker bone, and the inner parts are
wasted. The consequences of a congenital dislocation, or one occurring
during adolescence, are analogous to the rule formerly laid down.

  27. Dislocations at the ankle-joint require strong extension, either
with the hands or some such means, and adjustment, which at the same
time effects both acts; this is common in all cases.

  28. Dislocations of the bones of the foot are to be treated like
those of the hand.

  29. Dislocations of the bones connected with the leg, if not
reduced, whether occurring at birth or during adolescence, are of
the same character as those in the hand.

  30. Persons who, in jumping from a height, have pitched on the heel,
so as to occasion diastasis (separation) of the bones, ecchymosis of
the veins, and contusion of the nerves,-when these symptoms are very
violent, there is danger that the parts may sphacelate, and give
trouble to the patient during the remainder of his life; for these
bones are so constructed as to slip past one another, and the nerves
communicate together. And, likewise in cases of fracture, either
from an injury in the leg or thigh, or in paralysis of the nerves
connected with these parts, or, when in any other case of
confinement to bed the heel, from neglect, becomes blackened, in all
these cases serious effects result therefrom. Sometimes, in addition
to the sphacelus, very acute fevers supervene, attended with hiccup,
tumors, aberration of intellect, and speedy death, along with lividity
of the large bloodvessels, and gangrene. The symptoms of the
exacerbations are these: if the ecchymosis, the blackened parts, and
those around them, be somewhat hard and red, and if lividity be
combined with the hardness, there is danger of mortification; but, not
withstanding, if the parts are sublivid, or even very livid and
diffused, or greenish and soft, these symptoms, in all such cases, are
favorable. The treatment consists in the administration of
hellebore, if they be free from fever, but otherwise, they are to have
oxyglyky for drink, if required. Bandaging,-agreeably to the rule in
other joints; but this is to be attended to also,-the bandages
should be numerous, and softer than usual; compression less; more
water than usual to be used in the allusions; to be applied especially
to the heel. The same object should be sought after in the position as
in the bandaging, namely, that the humors may not be determined to the
heel; the limb to be well laid should have the heel higher than the
knee. Splints not to be used.

  31. When the foot is dislocated, either alone, or with the
epiphysis, the displacement is more apt to be inward. If not
reduced, in the course of time the parts of the hips, thigh, and
leg, opposite the dislocation, become attenuated. Reduction:-As in
dislocation at the wrist; but the extension requires to be very
powerful. Treatment:-Agreeably to the rule laid down for the other
joints. Less apt to be followed by serious consequences than the
wrist, if kept quiet. Diet restricted, as being in an inactive
state. Those occurring at birth, or during adolescence, observe the
rule formerly stated.

  32. With regard to slight congenital dislocations, some of them
can be rectified, especially club-foot. There is more than one variety
of club-foot. The treatment consists in modeling the foot like a piece
of wax; applying resinous cerate, and numerous bandages; or a sole, or
a piece of lead is to be bound on, but not upon the bare skin; the
adjustment and attitudes to correspond.

  33. If the dislocated bones cause a wound in the skin, and protrude,
it is better to let them alone, provided only they are not allowed
to hang, nor are compressed. The treatment consists in applying
pitched cerate, or compresses dipped in hot wine (for cold is bad in
all such cases), and certain leaves; but in winter unwashed wool may
be applied as a cover to the part; neither cataplasms nor bandaging;
restricted diet. Cold, great weight, compression, violence, restricted
position, all such are to be accounted as fatal measures. When treated
moderately (they escape), maimed and deformed; for, if the dislocation
be at the ankle, the foot is drawn upward, and, if elsewhere,
according to the same rule. The bones do not readily exfoliate; for
only small portions of them are denuded, and they heal by narrow
cicatrices. The danger is greatest in the greatest joints, and those
highest up. The only chance of recovery is, if they are not reduced,
except at the fingers and hand, and in these cases the danger should
be announced beforehand. Attempts at reduction to be made on the first
or second day; or, if not accomplished then, on the tenth, by no means
on the fourth. Reduction by levers. Treatment:-As in injuries of the
bones of the head, and the part is to be kept hot; and it is better to
give hellebore immediately after the parts have been reduced. With
regard to the other bones, it should be well known, that, if replaced,
death will be the consequence; the more surely and expeditiously,
the greater the articulation, and the more high its situation.
Dislocation of the foot is attended with spasm (tetanus) and gangrene;
and if, upon its being replaced, any of these symptoms come on, the
chance of recovery, if there be any chance, is in displacing it
anew; for spasms do not arise from relaxation, but from tension of the
parts.

   34. Excision, either of articular bones or of pieces of bones, when
not high up in the body, but about the foot or the hand, is
generally followed by recovery, unless the patient die at once from
deliquium animi. Treatment:-As in injuries of the head; warmth.

  35. Sphacelus of the fleshy parts is produced by the tight
compression of bleeding wounds, and by pressure in the fractures of
bones, and by blackening, arising from bandages. And in those cases in
which a portion of the thigh or arm, both the bones and the flesh drop
off, many recover, the case being less dangerous than many others.
In cases, then, connected with fracture of the bones, the separation
of the flesh quickly takes place, but the separation of the bone, at
the boundary of its denuded part, is slower in taking place. But the
parts below the seat of the injury, and the sound portion of the body,
are to be previously taken away (for they die previously), taking care
to avoid producing pain, for deliquium animi may occasion death. The
bone of the thigh in such a case came away on the eightieth day, but
the leg was removed on the twentieth day. The bones of the leg, in a
certain case, came away at the middle of the sixtieth day. In these
cases the separation is quick or slow, according to the compression
applied by the physician. When the compression is gently applied the
bones do not drop off at all, neither are they denuded of flesh, but
the gangrene is confined in the more superficial parts. The
treatment of such cases must be undertaken; for most of them are
more formidable in appearance than in reality. The treatment should be
mild, but, not withstanding, with a restricted diet; hemorrhages and
cold are to be dreaded; the position, so as that the limb may be
inclined upward, and afterward, on account of the purulent abscess,
horizontally, or such as may suit with it. In such cases, and in
mortifications, there are usually, about the crisis, hemorrhages and
crisis, hemorrhages and violent diarrhoeas, which, however, only
last for a few days; the patients do not lose their appetite,
neither are they feverish, nor should they be put upon a reduced diet.

  36. Displacement of the spine, if inward, threatens immediate death,
attended with retention of urine and loss of sensibility. Outward, the
accident is free from most of these bad effects, much more so than
where there is merely concussion without displacement; the effects
in the former case being confined to the spot affected, whereas in the
latter they are further communicated to the whole body, and are of a
mortal character. In like manner, when the ribs are fractured, whether
one or more, provided there be no splinters, there is rarely fever,
spitting of blood, and sphacelus, and ordinary treatment without
evacuation will suffice, provided there be no fever;-bandaging,
according to rule; and the callus forms in twenty days, the bone being
of a porous nature. But in cases of contusion, tubercles form, along
with cough, suppurating sores, and sphacelus of the ribs, for nerves
from all the parts run along each rib. In many of these cases
haemoptysis and empyema also take place. The management of this case
consists in careful treatment, bandaging according to rule, diet at
first restricted, but afterward more liberal, quiet, silence,
position, bowels, and venereal matters regulated. Even when there is
no spitting of blood, these contusions are more painful than
fractures, and are more subject in time to relapses; and when any
mucous collection is left in the part, it makes itself be felt in
disorders of the body. Treatment:-burning, when the bone is
affected, down to the bone, but not touching the bone itself; if in
the intercostal space, the burning must not extend through it, nor
be too superficial. In sphacelus of the ribs, tents are to be tried,
all other particulars will be stated afterward: but they should be
learned by sight rather than by words, namely, food, drink, heat,
cold, attitude; medicines, dry, liquid, red, dark, white, sour, for
the ulcers, and so with regard to the diet.

  37. Displacements (of the vertebrae) from a fall rarely admit of
being rectified, and those above the diaphragm are most difficult to
rectify. When the accident happens to children, the body does not
grow, with the exception of the legs, the arms, and head. Excurvation,
in adults, speedily relieves the individual from the disease he is
laboring under, but in time it renews its attack, with the same
symptoms as in children, but of a less serious nature. Some
individuals have borne this affection well, and have turned out to
be brawny and fat. But few of them have lived to the age of sixty.
Lateral curvatures also occur, the proximate cause of which is the
attitudes in which these persons lie. These cases have their
prognostics accordingly.

  38. The rule for the reduction and adjustment:-The axle, the
lever, the wedge, pressure above; the axle to separate, the lever to
push aside. Reduction and adjustment are to be accomplished by
forcible extension, the parts being placed in such a position as
will facilitate the conveying of the displaced bone over the extremity
of the bone from which it was displaced: this is to be accomplished
either with the hands, or by suspension, or axles, or turned round
something. With the hands this is to be effected properly, according
to the structure of the parts. In the case of the wrist and elbow, the
parts are to be forced asunder, at the wrist in the line of the elbow,
and the elbow with the fore-arm at a right angle with the arm, as when
it is suspended in a sling. When we want to separate the protruding
bones, and force them into place, in the case of the fingers, the
toes, or the wrist, the proper separation may be made by hands,
while the projecting part is forced into its place by pressing down
with the heel or the palm of the hand upon some resisting object,
while something moderately soft is laid under the projecting part, but
nothing such under the other, and then pressure is to be made backward
and downward, whether the dislocation be inward or outward. In lateral
displacement, pressure and counter-pressure must be made on the
opposite sides. Displacements forward can be reduced neither by
sneezing, nor coughing, nor by the injection of air, nor by the
cupping-instrument; and if anything can do good in such a case, it
is extension. People are deceived in fractures of the spinal
processes, the pain of which causing the patient to stoop forward, the
case is taken for dislocation inward; these fractures heal speedily
and easily. Dislocation outward is to be remedied by succussion,
when high up, toward the feet; and when situated low down, in the
contrary direction; the part is to be pressed back into its place,
either with the foot or a board. Dislocations to either side, if
they admit of any remedy, are to be treated by extension, and suitable
attitudes, with regimen. The whole apparatus should be broad, soft,
and strong; or otherwise, they should be wrapped in rags; before being
used, they should all be prepared proportionately to the length,
height, and breadth. In applying extension to the thigh, for
example, the bands should be fastened at the ankle and above the knee,
these stretching in the same direction, another band to be passed by
the loins, and around the armpits, and by the perineum and thigh,
one end passing up the breast and the other along the back, these
all stretching in the same direction and being fastened either to a
piece of wood resembling a pestle or to an axle. When this is done
on a couch, either of its feet is to be fastened to the threshold, and
a strong block of wood is to be laid across the other, and the
pieces of wood resembling a pestle are to be raised on these, to
make extension and counter-extension; the naves of a wheel are to be
fastened in the floor, or a ladder is to be adjusted, so that
extension may be made in both directions. The thing commonly used is a
bench six cubits long, two cubits broad, one fathom in thickness,
having two low axles at this end and that, and having at its middle
two moderate sized pillars, to which is to be adjusted a transverse
piece of wood like the step of a ladder, which is to receive the piece
of wood tied below the limb, as is done in dislocation at the
shoulder; and the bench is to have excavations like trays, smooth,
four inches in breadth and depth, and at such an interval as to
leave room for the lever used to reduce the limb. In the middle of the
bench a square hole is to be scooped out to receive a small pillar,
which, being adjusted to the perineum, will obviate the tendency of
the body to slip downward, and being rather loose may act somewhat
as a lever. In certain occasions a piece of wood is required, which is
inserted into a hole scooped out of the wall; the other end of it is
then to be pressed down, something moderately soft being placed
under it.

  39. In those cases where the bone of the palate has exfoliated,
the nose sinks in its middle. In contusions of the head without a
wound, either from a fall, a fracture, or pressure, in certain of
these cases acrid humors descend from the head to the throat, and from
the wound in the head to the liver and thigh.

  40. The symptoms of subluxations and luxations, and where, and
how, and how much these differ from one another. And the cases in
which the articular cavity has been broke off, and in which the
ligament has been torn, and in which the epiphysis has broken in
which, and how, when the limb consists of two bones, one or both are
broken: in consequence of these the dangers, chances in which bad, and
when the injuries will result in death, and when in recovery. What
cases are to be reduced or attempted, and when, and which, and when
not; the hopes and dangers in these cases. Which and when congenital
dislocations are to be undertaken: the parts in a state of growth, the
parts fully grown, and why sooner, or slower: and why a part becomes
maimed, and how, and how not: and why a certain part is atrophied, and
where, and how, and in what cases to a less extent. And why
fractured parts unite sooner or slower, how distortions and
callosities form, and the remedy for them. In what cases there are
external wounds, either at first or afterwards: in what fractures
the bones are shortened, and in what not: in what cases the
fractured bones protrude, and when they protrude most: in what cases
dislocated bones protrude. That physicians are deceived, and by what
means, in what they see, and in what they devise, regarding
affections, and regarding cures. Established rules with regard to
bandaging: preparation, presentation of the part, extension,
adjustment, friction, bandaging, suspension and placing of the limb,
attitude, seasons, diet. The more porous parts heal fastest, and
vice versa. Distortions, where the bones are crooked. Flesh and
tendons wasted on the side of the dislocation. The force used in
reduction to be applied at as great a distance as possible from the
seat of the displacement. Of nerves (ligaments?), those which are in
motion and in humidity (flabby?) are of a yielding nature; those
that are not, less so. In every dislocation the most speedy
reduction is best. Reduction not to be made while the patient is in
a febrile state, nor on the fourth or fifth day; and least of all,
in those of the elbow, and all cases which induce torpor; the
soonest the best, provided the inflammatory stage be avoided. Parts
torn asunder, whether nerves, or cartilages, or epiphyses, or parts
separated at symphyses, cannot possibly be restored to their former
state; but callus is quickly formed in most cases, yet the use of
the limb is preserved. Of luxations, those nearest the extremities are
least dangerous. Those joints which are most easily dislocated are the
least subject to inflammation. Those which have been least inflamed,
and have not been subjected to after-treatment, are most liable to
be dislocated anew. Extension should be made in the position most
calculated to enable the one bone to clear the extremity of the other,
attention being paid to configuration and place. Adjustment to be made
in the direction of the displacement; to push the displaced limb
straight backward and sideways. Parts suddenly drawn aside are to be
suddenly drawn back by a rotatory motion. Articulations which have
been oftenest dislocated are the most easily reduced; the cause is the
conformation of the nerves (ligaments?) or of the bones; of the
ligaments that they are long and yielding; and of the bones, the
shallowness of the articular cavity, and roundness of the head [of the
bone that enters it]. Usage, by its friction, forms a new socket.
The cause-the disposition, and habit, and age. A part somewhat
mucous is not subject to inflammation.

  41. In those cases where there are wounds, either at first, or
from protrusion of the bones; or afterwards, from pruritus, or
irritation; in the latter case you are immediately to unloose the
bandages, and having applied pitched cerate to the wound, bandage
the limb, placing the head of the roller upon the wound, and
proceeding otherwise as if there were no wound in the case; for thus
will the swelling be reduced as much as possible, and the wound will
suppurate most quickly, and the diseased parts will separate, and when
it becomes clean the wound will most quickly heal. Splints are not
to be applied to the place, nor is it to be bound tight. Proceed
thus when no large bones exfoliate, but not in the latter case, for
then there is great suppuration, and the same treatment is not
applicable, but the parts require to be exposed to the air on
account of the abscesses. In such cases where the bones protrude,
and whether reduced or not, bandaging is not befitting, but distention
is to be practiced by means of rolls of cloth, made like those used
upon shackles; one of these is to be placed at the ankle, and the
other at the knee; they are to be flattened toward the leg, soft,
strong, and having rings; and rods made of cornel, and of a proper
length and thickness are to be adjusted to them, so as to keep the
parts distended; and straps, attached to both extremities, are to be
inserted into the rings, so that the extremities being fixed into
the rolls, may effect distention. Treatment:-Pitched cerate, in a
hot state; the attitudes, position of the foot and hip; regulated
diet. The bones which have protruded through the skin are to be
replaced the same day, or next; not on the fourth or fifth, but when
the swelling has subsided. Reduction is to be performed with levers;
when the bone does not present any place upon which the lever can
rest, a portion of the part which prevents this is to be sawed off.
But the denuded parts will drop off, and the limb become shortened.

  42. Dislocations at the joints are to a greater and less extent.
Those that are to a less extent are the most easily reduced; those
that are to a greater extent occasion lesions of the bones, of the
ligaments, of the joints, of the fleshy parts, and of the attitudes.
The thigh and arm resemble one another very much in their
dislocations.
                                    THE END