Chapter XXVII: Preface (5)

But if the bone be fractured, that must also be reduced into its place by the fingers; and when the fracture is in the fore part, both nostrils must be filled; when on the side, that to which the bone has been forced; cerate also must be applied, and it is to be bound down a little more tightly; because in that part, there not only grows callus enough to make it sound, but even to form an eminence. From the third day, it must be fomented with hot water, and the more so, the nearer it may be expected to approach a sound state. And if there be several small pieces in the fracture, nevertheless each of them _that are beat in_, must be forced into its place by the fingers: also the strap must be applied externally, as before directed; and over that a cerate, without any other bandage.

But if any fragment be separated all round, and will not be united with the rest, as may be known from the humour, which will be discharged in great quantity from the wound, it must be extracted by a vulsella; and when the inflammation is gone, some one of those medicines that are gently repellent, must be applied. The case is worse, when besides a fracture of the bone, or cartilage, there is also a wound in the skin. This very seldom occurs. When it does happen, they must nevertheless be raised to their place in the same manner; and upon the skin must be laid some one of these plaisters, that are adapted to recent wounds: but no bandage must be applied over it.

CHAP. VI.

OF FRACTURES OF THE EARS.

Sometimes the cartilage of the ear is broke. When this happens, an agglutinating medicine must be applied, before a suppuration begins; for that often prevents it, and heals the ear. Both here and in the nose, it should be understood, that the cartilage itself is not re-united, but that the flesh growing round it consolidates the part; and therefore, if, together with the skin the cartilage is broke, the skin is sewed on both sides; but I now speak of the cartilage fractured, when the skin is entire. If pus then is already formed, the skin must be opened on one side, and over against the incision, the cartilage itself must be cut in a lunated form; then a gentle styptic must be used; such as lycium diluted with water, till the bleeding be stopped; after that a plaister that is not greasy, spread upon linen, must be laid on, and soft wool put behind the ear, to fill up the space between that and the head; then it must be fastened by a gentle bandage; and from the third day fomented with warm water, as I directed for the nostrils; and in these kinds of accidents, at first abstinence is necessary, till the inflammation be gone.

CHAP. VII.

OF A FRACTURED MAXILLA, TOGETHER WITH SOME GENERAL OBSERVATIONS RELATING TO FRACTURES.

As I am to proceed from these parts to the lower jaw, I think it proper to insert some observations relating to all the bones in general, to prevent a frequent repetition of them. Every bone then is sometimes split longitudinally, like wood, sometimes is fractured transversely, sometimes obliquely; and in this last species the ends are sometimes blunt, sometimes acute, which last is of the worst kind; because they are not easily united, where they do not rest upon something obtuse, then they also wound the flesh, and sometimes a nerve or a muscle: moreover, one fragment sometimes happens to be divided into several. In fractures of the other bones, one end often recedes entirely from the other; but the broken ends of a jaw-bone remain always in contact in some one part.

Therefore, first the bones are to be forced into their place, by two fingers pressing on each side, both within the mouth and upon the chin; then if the fracture of the jaw-bone be transverse, (in which case one tooth generally stands out beyond that next to it) when it is reduced, the two contiguous teeth, or if they are loose, those next to them, must be tied together by a horse-hair. In a different kind of fracture this is needless. All the other steps are the same _as in the above-described fractures_; for a double linen cloth dipped in wine and oil must be laid upon it, and with that fine flour, and the soot of frankincense; then a roller or soft strap, with a longitudinal opening in the middle, that it may take in the chin both above and below; and lastly, the ends of it must be brought over the head and tied there.

With regard to the bones in general, it may further be remarked once for all, that fasting at first is necessary; then from the third day moist food; when the inflammation is removed a little fuller diet and such as promotes the growth of flesh; wine is hurtful through the whole time. On the third day, they ought to be opened, and fomented with the vapour of hot water by a spunge, and the same dressings, as at first, are to be put on; this to be repeated on the fifth day, and so on, till the inflammation is gone, which ceases, either on the ninth day, or generally on the seventh: when that is removed, the bones must be examined again, that if any fragment is not in its place, it may be reduced, and the bandage must not be taken away, till two thirds of the time have elapsed, in which the several bones unite.

Now, generally between the fourteenth and twenty-first day, the following bones heal: the lower jaw, cheek-bone, clavicle, breast-bone, scapula, ribs, the spine at the hips, the ancle-bone, heel, hand, and foot; between the twentieth and thirtieth, the bones of the leg and fore arm; between the twenty-seventh and fortieth, the arm and thigh bones.

But concerning the lower jaw-bone I must add, that the case requires the long use of a liquid diet. Also far a considerable time pancakes and such like must be continued, and nothing be chewed, till the callus has perfectly restored the strength of the bone: and for some days, at first, the patient must not speak at all.

CHAP. VIII.

OF A FRACTURED CLAVICLE.

The clavicle, if it be fractured transversely, sometimes unites very well of itself, and if it be not moved, may do well without a bandage; but sometimes, and especially when it is moved, it slides away; and generally the part next the breast lies over, and behind that next the humerus. The reason of which is, that it does not move by itself; but complies with the motion of the humerus: therefore, this standing still, the humerus is moved upon it. That part of the clavicle, next the breast, very seldom lies on the forepart; insomuch that men of great character in the profession have told us they never met with it; but the authority of Hippocrates is sufficient to put the fact beyond dispute.

However, as these cases are dissimilar, so each requires a treatment somewhat different from the other. When the clavicle flies back towards the scapulæ, the humerus must be pushed backward by the palm of the right hand, and at the same time the clavicle itself be brought forward. When turned to the breast, this must be forced backward, and the humerus brought forward; and if the humerus fall below the other, that part of the bone next the breast must not be depressed, because it is immoveable; but the humerus itself must be raised; but if it rise higher, the part next the breast must be filled with wool, and the arm bound down to the breast. If there be sharp pieces in the fracture, an incision must be made in the skin over it; and any parts of the bone, that wound the flesh, must be cut off; then the blunted bones must be brought together; and if there be a prominence any where, it must be kept down by a linen cloth, three times folded, dipped in wine and oil: if there be several fragments, they are to be covered with a splint, the inside of which is to be smeared with wax, lest the roller should slip on one side. The roller must be bound over the clavicle, when reduced, rather often than tight: and this rule holds in all fractures. In a fracture of the right clavicle, the bandage ought to pass from it to the left arm-pit; if, of the left _clavicle_, to the right; and again under the arm-pit of the affected bone: this done, if the clavicle be inclined toward the scapula, the fore-arm must be tied to the side; if forward, to the neck; and the patient laid on his back. All the other directions given before must be observed.

Now there are several bones that have very little motion, and are either hard, or cartilaginous, which are liable to be fractured, or pierced, or bruised, or fissured, as the malae, the breast-bone, scapula, ribs, spine of the hips, ancle-bone, heel, hand, and foot. The method of cure is the same in all these. If there is an external wound, that must be dressed with the medicines proper for it. While the wound is healing, a callus also fills up the fissures of the bone, or any vacuity that may be in it. If the skin is entire, and from the pain we infer that the bone is injured, there is nothing else to do but rest; and cerate must be applied, and tied on gently, till the pain is removed by the bone becoming sound.

CHAP. IX.

OF FRACTURES OF THE RIBS AND SPINE.

But there are some peculiarities to be observed relating to the ribs; because they are near the viscera, and that part is exposed to great dangers. A rib then is sometimes fissured in such a manner, that not the exterior surface of the bone, but the interior part of it, which is thin, is hurt; sometimes it is broke entirely through. If the whole is not fractured, there rarely follows either a spitting of blood, or a febricula, or any suppuration; and the pain is not great; however the place is slightly pained upon being touched. But this case requires no more than to do what is above directed; and in binding it up to begin at the middle of the roller (_a double-headed roller_) lest it draw the skin to either side. After the twenty-first day, when the bone ought to be united, we must endeavour, by a more plentiful diet, to render the body as plump as possible, that it may cover the bone the better; which being yet tender is in that part exposed to injuries under a thin skin. And through the whole time of the cure, vociferation must be avoided, and even speaking, hurrying, anger, all violence of motion, smoke, dust, and whatever excites either coughing or sneezing; and it is not even proper to hold in the breath much.

But if a rib be entirely broke through, the case is more troublesome: for both violent inflammations, and a fever and suppuration, and often a danger of death ensue; and a spitting of blood. Therefore, if the strength admits, blood must be taken from the arm of the same side with the rib; if it does not allow this, a clyster must be given, but without any thing acrid; and the patient must fast a considerable time. He must not eat bread before the seventh day, but live upon gruel alone; and upon the part must be applied cerate made of lycium, with an addition of boiled resin; or the malagma of Polyarchus; or cloths squeezed out of wine, rose oil, and common oil; and over these soft sordid wool, and two double-headed rollers, but not tight. What I mentioned before as hurtful, are in this case to be avoided with greater caution; so that even the breath must not be too often fetched. But if a cough be troublesome, a potion must be taken for it, either of germander, or rue, or the herb staechas, or of cummin and pepper. When there are severe pains, it is proper to lay on a cataplasm either of darnel or barley, with an addition of a third part of mellow figs. And this must lie on in the day time; but in the night, either cerate, or a malagma, or cloths; because the cataplasm may drop off. Therefore it must be opened every day, till such time as we may be content with the cerate or malagma. And for ten days the body must be reduced by fasting; from the eleventh we must begin to nourish it; and therefore the bandage about it must be more lax than at first; and generally this method is continued to the fortieth day.

In the course of which, if there be any fear of a suppuration, the malagma will be more effectual to discuss it than cerate. If, notwithstanding, the suppuration take place, and cannot be discussed by the medicines prescribed before, no time must be lost, lest the bone below be affected; but in the part where it shall swell most, a hot iron must be introduced, till it reach the pus, which must be evacuated. If a tumour does not appear any where, we may discover where the pus is principally lodged in this manner. We must rub all the part with Cimolian chalk, and suffer it to dry; and wherever the moisture shall penetrate deepest, there the pus is nearest to the skin; and here the actual cautery is to be used. If there shall be a pretty large abscess, it will require two or three perforations; and lint to be put into them, or some part of a penecillum; which may be tied by a thread at the top, that it may be easily drawn out. What remains to be done is the same as in other burns. When the ulcer shall be clean, the body must be nourished, lest a consumption follow, which would be fatal. Sometimes too, when the bone is more slightly affected, and neglected at first, not pus, but a certain humour like mucus is collected within, and the skin over it grows soft; in which case, we must use the cautery in the same manner.

[Sidenote: _Fracture of the spine._]

There is also something peculiar to be noted in the spine: for if any part has separated from a vertebra, or is any way broken(16), the part becomes hollow; prickings are felt there, because these fragments must necessarily be jagged: whence it happens, that the patient now and then leans forward. These are indications of the case; and the same medicines are necessary, which have been mentioned in the first part of this chapter.

CHAP. X.

OF FRACTURES OF THE HUMERUS, FORE-ARM, THIGH, LEG, FINGERS, AND TOES.

The cases which occur in the arms and thighs, and their methods of cure, are in a great measure similar. There are also some general things that belong equally to the arms, fore-arms, thighs, legs, fingers, and toes; for a fracture in the middle of these is least dangerous; but the nearer the fracture is, either to the superior or inferior head, so much the worse: for it both creates greater pain, and is more difficult to cure. Of fractures, the most innocent is a simple transverse one; worse, where it is oblique, and where there are fragments; worst of all, when these are sharp. Sometimes the bones in these parts being fractured, continue in their places: but they much more frequently give way, and one part lies over the other. This circumstance ought to be first of all considered; and there are certain marks for knowing it. If they are displaced, they are bent, and cause the sensation of pricking, and are unequal to the touch. But if they meet one another, not directly, but obliquely (which happens, when they are not in their place) that limb is shorter than the other, and the muscles of it swell.

Therefore, if this is found to be the case, it is proper to extend the limb immediately: for the tendons and muscles being _in a natural state kept_ stretched by the bones, are _in this case_ contracted; neither do they return to their place, unless they be extended by force. Again, if that is neglected for some days at first, an inflammation comes on, during which, it is both difficult and dangerous to use violence to the tendons; for there follows a convulsion or gangrene; or at least, which is the mildest of the bad consequences, a suppuration; therefore, if the bones have not been replaced before _the inflammation_, they must not be reduced till after it is gone. Now one person alone may extend a finger, also any other member, if it be of a child, by taking hold of one part with his right hand, and the other with his left. A stronger limb requires two to pull different ways. If the tendons are very firm, as is the case in robust men, and chiefly in their thighs and legs, the ends of the joints on both sides must be tied with straps, or linen rollers, and pulled contrary ways by several persons; and when this force has stretched the limb a little beyond its natural length, then the bones must be pressed by the hands into their place; and the sign of a bone’s being reduced, is the removal of the pain. The limb being made equal with the other, must be wrapt up in cloths two or three times doubled, dipped in wine and oil; for which purpose linen is best.

Six bandages are generally required. The first to be applied is the shortest; which should be rolled about the fracture(17), and ascend spirally like a screw; and it is sufficient for it to go round in this manner thrice. The second is one half longer than this; which, if the bone project in any part, must begin there; if it be every where equal, it may begin any where upon the fracture, and go in an opposite direction to the former, tending downwards, and returning again to the fracture, end in the upper part beyond the former bandage. Over these must be laid cerate, upon a broad piece of linen, to keep them on. And if the bone is prominent in any part, a cloth, three times doubled, moistened in the wine and oil before mentioned, must be laid upon it. These are to be secured by a third and a fourth bandage, in such a manner, that the following move always in a contrary direction to the former, the third alone must end in the lower part, and the other three in the superior; because it is better to make several convolutions, than to bind it tight; for a strict bandage disorders a part, and makes it liable to a gangrene. We ought to bind an articulation as little as possible; but if the fracture of the bone is near the joint, there is a necessity for it.

When the limb is bound up, it must be kept so to the third day, and the bandage should be such, as on the first day not to hurt _by its stricture_, and yet not to seem lax; on the second it should be a little laxer; the third almost loosened. Therefore, the limb must then be bound up again, and a fifth roller must be added to the former; after which it must be again opened on the fifth day, and then secured by six rollers, in such a manner, that the third and fifth may end below, and the rest above. As often as the limb is opened, it must be fomented with hot water. But if the fracture be near a joint, wine, with the addition of a small proportion of oil, must be dropped upon it for a long time, and all the other directions observed, till the inflammation leave it, or the limb become smaller than ordinary: which, if it does not happen on the seventh day, will certainly be effected by the ninth. Then the bones are handled with great ease.

Therefore, if they are not well joined to each other, they must be set again; and if any fragments rise above the rest, they must be reduced into their places, and then the limb must be rolled up in the same manner, and splints be fitted round it, to keep the bones in their places. And on that side, to which the fracture inclines, a broader and stronger splint must be applied. About a joint all these should turn outward, that they may not hurt it, and be bound no tighter than is necessary to secure the bone: as they grow laxer in time, they must be a little tightened every third day by their straps; and if there be no itching nor pain, continue so, till two-thirds of the time be compleated, in which each of these bones unites; afterwards, it is to be bathed more gently with hot water; for at first it is necessary to dissipate the humours, and afterwards to make them transpire. Therefore it must also be anointed lightly with liquid cerate, and the surface of the skin rubbed; and the fracture be bound up more loosely. It must be opened every third day, and all the applications be repeated, except the hot water; only one of the rollers, as often as it is loosed, must be withdrawn.

[Sidenote: _Of a fractured humerus._]

The foregoing rules are general; the following peculiar to each bone. If the humerus be fractured, the extension must not be made as in another limb; but the patient is placed in a high seat, and the physician in a lower one opposite to him. Then the patient’s fore-arm is to be supported by a bandage passed round it, and fastened behind the neck. _This done_, a second bandage, _with two heads_, is to be rolled round the upper part of the humerus, and have its two ends tied into a knot above the head. Lastly, a third bandage of the like kind is to be fastened to the lower part of the humerus, and carried downwards, its two ends being also tied together. Then, from behind the patient’s head, an assistant stretching his own arm _through the loop of_ the second mentioned roller, his right, if the right humerus is to be extended, his left, if the left _humerus_, takes hold of a stick placed between the patient’s thighs; the physician also sets his right foot, if he be to operate upon the left humerus, his left, if upon the right, on the third of these rollers; and at the same time the assistant raises the one roller, and the physician depresses the other; by which means, the humerus is gently extended. If the fracture be in the middle or lower part of the bone, shorter rollers are required; if in the superior, longer; so that they may be extended from thence over the breast, under the other arm-pit to the shoulders. In binding it up, the fore-arm must be so inclined, and the affected part put into such a position by the bandages, that the suspending of the forearm afterwards, do not turn the humerus any other way, than when it was bound up. And the fore-arm being hung, the humerus is to be also gently tied down to the side; by which means it will be prevented from moving, and therefore the bones continue as they have been set. When we come to the application of splints, these ought to be longest on the external side, shorter on the fore-part, but shortest of all under the arm-pit. And when the humerus is fractured near the cubitus, they must be pretty often removed, lest the tendons there grow rigid, and the fore-arm be rendered useless. Whenever they are removed, the fracture must be held in the hand; and the cubitus fomented with hot water, and rubbed over with soft cerate; and splints must either not be put upon the processes of the cubitus at all, or they must be somewhat shorter _than the others_.

[Sidenote: _Of a fracture of the fore-arm._]

But if there is a fracture in the fore-arm, it must be first of all considered, whether one bone or both be broken: not that there is any different method of cure to be used; but first that the extension may be the stronger, if both bones be fractured, because the tendons must necessarily be less contracted, when one of the bones is entire, and keeps them upon the stretch; in the next place, that every thing which relates to securing the bones, may be done with the greater accuracy, if one of them does not help the other: for where one is unhurt, it helps more than rollers and splints. The fore-arm ought to be tied up with the thumb turned a little toward the breast; for that is the most natural posture of the fore-arm: and after the bandages are put on, it is best held in a scarf, the full breadth of which is under the fore-arm, with its ends, which are very narrow, fixed over the neck; thus the arm is conveniently suspended from the neck, and ought to hang a little higher than the other elbow.

But if any part of the top of the cubitus be fractured, it is improper to secure it by bandages, because the fore-arm becomes immoveable. And if means only are found(18) to remove the pain, it remains as useful as before.

[Sidenote: _Fractures of the thighs and legs._]

It is of equal importance in the leg for one of the bones to continue entire. Both in this and the thigh it is fit after binding it up to put it in a box. This box ought to have holes below, through which any humour that is discharged, may descend; and at the foot a prop, which may both sustain, and not suffer it to slip; and holes in the sides, through which straps being past, some bars[IC] may keep the leg and thigh in their position. If it be a fracture of the leg, this ought to reach from the foot to the ham; if of the thigh, as far as the hip; if near the head of the thigh-bone, so as that the hip likewise may be within it. We ought not to be ignorant, however, that a fractured thigh becomes shorter, because it never entirely returns to its former state; and that the person ever after supports himself upon his toes in that foot, which occasions great weakness; however it is much worse, where the misfortune has been encreased by neglect.

[IC] morae.

[Sidenote: _Fractures of the fingers._]

It is sufficient to bind a finger to one small twig, after the inflammation is gone.

[Sidenote: _General rules._]

The foregoing directions are confined to the cases relating to particular limbs; the following are general: fasting for some days at first; then when the callus is growing, a pretty full diet; long abstinence from wine; plentiful fomentations of hot water, while the inflammation continues; when that has ceased, they must be more sparing; lastly, a pretty long but gentle rubbing of liquid cerate into the more remote parts. Nor must the limb be immediately put upon exercise, but by degrees returned to its former motions.

The case is a good deal worse, when, besides the fracture of the bone, there is also a wound in the flesh; and particularly if that happen in the muscles of the thigh or arm: for the inflammations there are much greater, and they are more liable to gangrenes. And generally, where the bones of the thigh have slipped past each other, it is necessary to cut it off. The arm is also endangered in the same circumstances, but is more easily preserved. And these dangers are still more to be apprehended, if the fracture be near the joints: therefore, such a case must be treated with more care, and the muscle must be cut through transversely over the middle of the wound; and if the hæmorrhage has been but small, the patient must be bled, and extenuated by fasting for ten days. And though the other limbs may be extended slowly, and the bones reduced gently to their place; yet in these it is not quite expedient either to extend the tendons, or handle the bones. And the patient must be allowed to keep them in the position that is easiest to him. To all such wounds must be applied, at first, lint dipped in wine, with an addition of a very little rose oil: the other management is the same as above recommended. They are to be bound up with rollers broader(19) than the wound; which must be applied looser, than if there was not a wound there; and as the wound is more liable to corruption and a gangrene, we are by a number of rollers to manage it so, that though they are slack, they may keep the bones firm.

This method may be followed in the thigh or arm, provided the bones have chanced to return to their proper place; but if they be in any different situation, they must only have such a bandage, as will keep on the medicine that is applied. The other directions I gave before must be observed: except that neither splints nor boxes be used, with which the wound cannot heal; but only more and broader rollers are necessary; and both hot oil and wine must be poured upon them now and then; more frequently the latter. At the beginning the patient must fast; the wound must be bathed with hot water; he must avoid the cold; and recourse must be had to medicines for promoting digestion of the wound, and more care must be taken of the wound than the bone: for that reason it must be opened every day and dressed.

In the mean time, should any small fragment of the bone project, if it be blunt, it must be reduced into its place; if sharp, its point, when long, must first be cut off, when short, filed, and in either case smoothed with a chisel; and then it must be returned in again. And if that cannot be done by the hand, a vulsella, such as workmen make use of, must be applied with that part(20) which turns inward to the sharp point of the bone, that by its convex part the prominent bone may be thrust into its place. If it be too large, and covered by small membranes, we should allow these to be dissolved by medicines, and when the bone is laid bare, cut it off; which is to be done pretty early, and afterwards, in this method we may let the bone unite and the wound heal; the first in its proper time, and the other as the circumstances admit.

Sometimes too it happens in a large wound, that some fragments as it were mortify, and do not unite with the rest. This may be discovered from the quantity of discharge; which makes it necessary to open the ulcer oftener than it is dressed; and the consequence generally is, that this bone, after some days, of itself falls off; otherwise, though the condition of the wound is miserable enough before, that often encreases it, and makes it more tedious of cure. The bone too is often broken away, when the skin is entire, and immediately an itching and pain come on. Wherefore, if that happens it is proper to open it the sooner, and bathe it in the summer time with cold water; and in the winter with water just warm; and then apply myrtle cerate.

Sometimes, the fracture, by some points like prickles, irritates the flesh: which being discovered by the itching and prickings, the physician must open it, and cut off these points. The other part of the cure is the same in both these cases as in a recent wound. When the ulcer is clean, nourishing food must be taken. If the limb is still too short, and the bones are not in their places, a wedge of the smallest and smoothest kind must be put in between them with its head standing out a little, and the thick part of it must be driven farther in every day, till that limb be equal to the other. Then the wedge must be taken out, and the wound healed up. When a cicatrix is brought on, it must be bathed with a decoction of myrtle, ivy, and other like vervains, cold, and a drying medicine applied upon it; and in this case, there is a greater necessity for rest, till the limb recover its strength.

When the bones happen not to unite, because they have been often opened, and often moved, the method of cure is obvious; for they may unite. If the fracture be of long standing, the limb must be extended, to create a fresh injury; the bones must be separated from one another by the hand, that their surfaces may be roughened by rubbing against each other, and if there be any fat substance, it may be abraded, and the whole of it become as it were recent: great care, however, must be taken not to wound tendons or muscles. Then it must be bathed with a decoction of pomegranate bark in wine; and the same mixed with the white of eggs, must be applied to it; on the third day it must be opened, and bathed with a decoction of the vervains abovementioned: which must be repeated on the fifth day, and splints put round it; the other steps, both before and after, which I directed already, must be taken in the same manner. However, sometimes the bones unite obliquely(21); and thus the limb becomes both shorter and deformed, and if the ends are pretty sharp, continual prickings are felt: for this reason the bones ought to be fractured again, and put in a proper direction. It is done in this manner. The limb is fomented with plenty of hot water, and rubbed over with liquid cerate and extended; in the mean time, the physician handling the bones, the callus being yet tended, separates them by his hands, and forces the part that projects, into its place: and if that is not effectual, on that side, to which the bone inclines, he puts a regula wrapped up in wool; and by thus binding it up brings it to a habit of lodging in its former place.

Sometimes also, though the bones have united as they should do, too large a callus grows upon them; and therefore the part is swelled. When this happens, the limb must be rubbed gently for a long time, with oil, salt and nitre, and bathed with plenty of salt water; a discutient malagma must be applied; and a tight bandage put on; and the patient must eat herbage, and take vomits; by which course, the callus is reduced together with the flesh. Some good is done by an application of mustard and a fig upon another limb, till it corrode a little, and derive the matter to that part. When the tumour is lessened by these means, the person may return to his ordinary course of life.

CHAP. XI.

OF LUXATIONS.

Thus far then we have treated of fractures. Now the bones are dislocated in two ways. For sometimes those that are joined together, separate from each other, as when the broad bone of the scapula recedes from the humerus(22), and in the fore-arm the radius from the cubitus, and in the leg, the tibia from the fibula, and sometimes in leaping the heel-bone from the ancle; which last, however, seldom happens. Sometimes the articulations are displaced. I shall speak first of the former.

When such an accident happens, the part is immediately hollow, and by pressing upon it with the finger one feels a cavity. After that, a violent inflammation comes on; and particularly in the ancle; for generally it occasions fevers and gangrenes, and either convulsions, or contractions, which draw the head down upon the shoulders. To avoid which, the same method must be followed here, as in injuries of the moveable bones. And whenever it happens, the medicines prescribed before must be laid on these parts to remove the pain and tumour: for bones once separated in this manner never come together again; and though some degree of comeliness be attainable in the part, yet it is of no use(23).

But the lower jaw and the vertebræ, and all the joints, though they be secured by strong ligaments, are luxated by the force of a blow, or when the ligaments are either ruptured, or some way weakened; and more easily in children or lads, than in those that are more robust. And they slip out forward and backward, and inward and outward; some of them in all these ways, others in particular ways. And there are some general signs belonging to all, others peculiar to each one: for there is always a tumour in that part, to which the bone is propelled, and a cavity in that from whence it recedes. Now these marks are common to them all; the others peculiar to the several bones will be mentioned, when I speak of each case distinctly.

But though all the articulations may be dislocated, they cannot be all replaced; for the head is never reduced, nor a vertebra in the spine, nor a jaw-bone, which being out on both sides, has raised an inflammation before it could be returned. Again, those that slip out from the fault of the ligaments, when they are forced into their places, give way again. And those that have been dislocated in childhood, and have not been reduced, grow less than the rest: and the flesh of all these that are not in their place, is decayed, and more so in the member nearest to it, than in one beyond it. For instance, if the humerus is not in its place, the arm wastes more than the fore-arm, and that more than the hand. Then according to the situations, and the nature of the accidents, there is left either more or less use of the limb; and the more use remains of it, the less it is wasted.

Now whatever is dislocated should be reduced before an inflammation begin. If that has already seized it, till it cease, it must not be meddled with; after its removal, trial must be made in such limbs as are reducible. A great deal depends upon the habit both of the body and the ligaments: for if the body be slender, or humid, or if the ligaments be weak, the bone is more quickly reduced; but it is both more liable to dislocation, and is less firmly held after it is reduced(24). Bodies of the contrary qualities hold it faster in its place; but when once forced out, admit of its return with difficulty. It is proper to alleviate the inflammation by applying sordid wool squeezed out of vinegar; and if the misfortune be in a strong articulation, to abstain from food for three, and sometimes even five days; to drink warm water till the thirst be gone; to observe these rules more strictly in luxations of those bones, that are held by strong large muscles; and much more so if a fever has ensued; on the fifth day to foment with hot water; and taking away the wool, to apply cerate made of Cyprine oil, with the addition of nitre, till the inflammation be entirely removed. Then it is proper to use friction to the limb; to take food of good juices, wine in moderate quantity; and by this time, to make some use of the limb: because motion, as it is extremely hurtful in pain, so it is very salutary when the pain is removed. These observations are general; I shall now treat of the particular cases.

CHAP. XII.

OF A LUXATED MAXILLA.

In a dislocation of the lower jaw it is pushed forward, but sometimes on one side, sometimes on both. If on one side, it inclines together with the chin to the contrary side, the teeth do not answer to each other, but the canine teeth below are opposite to the incisores: if on both sides, the chin leaves its place, and is protruded to the external part; and the lower teeth come farther out than the upper; and the muscles of the temples appear tense. The patient, as soon as possible, must be placed in a seat in such a manner, that an assistant may secure his head behind; or he may be seated near a wall, putting a hard leather cushion between the wall and his head, and let his head be pressed upon the cushion by an assistant, that it may be kept the steadier; then the thumbs of the physician being wrapped up with linen cloths, or rollers, that they may not slip, must be introduced into his mouth; and the fingers must be applied externally. When the maxilla is firmly grasped, if the luxation be on one side, the chin must be shaken, and brought towards the throat; then at the same time his head must be held, and the chin being raised, the maxilla forced into its place, and the mouth shut; and all this must be done almost in the same instant. But if the luxation be on both sides, the same method must be taken; but the jaw-bone must be forced back equally on both sides. When the bone is replaced, if the case was attended with a pain of the eyes and neck, blood must be taken from the arm. And as liquid food at first is proper for all persons, whose bones have been dislocated, so particularly in this circumstance; where even frequent speaking, by the motion of the mouth, hurts the nerves of the temples(25).

CHAP. XIII.

OF A LUXATION OF THE HEAD.

In the first part of this book, I have already observed, that the head is secured upon the neck by two processes received into two depressions of the upper vertebra. These processes are sometimes dislocated toward the posterior part; the consequence of which is, that the nerves below the occiput are extended, the chin is fixed upon the breast, and the patient can neither drink, nor speak, and sometimes discharges his semen involuntarily. Such patients die very quickly. I judged it necessary to mention this case, not because there is any cure for it; but that it might be known by its symptoms, and if any should lose a friend in this way, they might not think it was for want of a physician.

CHAP. XIV.

OF A LUXATION IN THE SPINE.

The same misfortune attends those, whose vertebræ of the spine are luxated. For this cannot happen, unless both the medulla, which passes through the middle, and the two membranes, that go through the two processes on the sides, as also the ligaments, that secure them, be ruptured. They are dislocated both backward, and forward; both above and below the transverse septum. As they slip the one way or the other, there will be either a swelling or a cavity behind. If this happens above the septum, the hands become paralytick, a vomiting or convulsions follow, the breath is oppressed, and a violent pain and deafness ensue. If below the septum, the thighs are paralytick, the urine is suppressed, and sometimes it even flows involuntarily. Though a person does not in such cases die so quickly as where the head is luxated, yet it commonly happens within three days; for what Hippocrates has directed in a vertebra luxated externally, that the patient must be laid prone, and extended, and then a person ought to stand upon him with his heel and force it in, must be understood of those, that are but partially displaced, not of these, that are entirely luxated; for sometimes a weakness of the ligaments causes a vertebra to protuberate forwards, though it be not dislocated: this is not mortal. But it is not possible to force it back from the internal part. If any vertebra be reduced from the external side, it generally returns again, unless, which is very rare, the tone of the nerves be restored(26).

CHAP. XV.

OF A LUXATION OF THE HUMERUS.

The humerus slips sometimes into the axilla, sometimes forward. If it has fallen into the arm-pit, the cubitus recedes from the body, and cannot be brought upward with the humerus to the ear of the same side; also that arm is longer than the other: if forward, the upper part of the fore-arm is extended, but not to its full length; and the cubitus is moved with more difficulty forward than backward.

Therefore if the humerus has fallen into the arm-pit, and the patient be young, or of a lax habit, so that the ligaments are weak, it is sufficient to place him in a seat; and to order one assistant to draw back gently the head of the broad bone of the scapula, and another to extend the fore-arm; while the physician himself sitting behind, with his knee under the patient’s arm-pit, forces the humerus upwards, and at the same time presses the scapula with one hand, while he pushes the cubit to the side with the other.

But if the patient be of a large stature, or the ligaments more robust, a wooden spatha is necessary of the thickness of two fingers, and so long as to reach from the arm-pit to the fingers. In the top of it, is a small round head a little hollowed; that it may receive some part of the head of the humerus; and in three places at due distances there are two holes made for the admission of soft straps. This spatha being wrapt up in a roller, that it may hurt the less, is applied from the fore-arm to the arm pit, in such a manner, that the head of it is put under the axilla; then it is tied to the arm by its straps, in one place a little below the head of the humerus, another a little above the elbow, and the third above the hand; to which purpose the distances of the holes are then also to be adapted. The arm being thus tied up is put over a step of a ladder, so high, that the patient cannot stand upon the ground; and at the same time his body is suffered to sink on one side, and his arm kept extended on the other; the effect is, that the head of the humerus, being impelled by the head of the spatha, is forced into its place, sometimes with a crack, sometimes without it. It appears from Hippocrates alone, that there are many other methods; but none of them has been more approved by experience than this.

But if the humerus is luxated forward, the patient must be laid on his back, and a roller, or strap put round the middle of the arm-pit, and the ends of it delivered to one assistant behind the patient’s head, and his fore-arm to another; then the first must be ordered to extend the strap, and the other the fore-arm; and the physician must thrust back the patient’s head with his left hand, and with his right raise the cubitus together with the humerus, and force the bone into its place; which in this case is more easily reduced than in the former.

When the humerus is replaced, wool must be put under the arm-pit; that if the bone was in the interior part, it may prevent its returning; if forward, that it may however be more conveniently rolled up. Then the roller being first carried under the arm-pit, ought to surround the head of the bone, and passing over the breast to the other arm-pit, and from that to the scapulæ, and back again to the head of the _luxated_ humerus, it must be carried round in this manner several times, till the head of the humerus be well secured. The humerus being thus bound up is better fixed, if it be drawn close to the side, and tied down to it with a roller.

CHAP. XVI.

OF A LUXATION OF THE CUBITUS.

From what has been said in the first part of this book, it may be understood, that three bones meet together at the elbow, the humerus, radius, and cubitus. If the cubitus, which is fixed to the humerus, separates from it, the radius, which is contiguous to it, is sometimes dislocated, and sometimes remains firm. Now the cubitus may be luxated in all the four different ways. If it be displaced forward, the fore-arm is extended, and cannot be bent; if backward, the fore-arm is bent, cannot be extended, and is shorter than the other; sometimes it brings on a fever and bilious vomiting; if externally, or internally, the fore-arm is stretched, but is a little bent to that part, from whence the bone has receded.

Whatever species it be, the method of reduction is the same (and not only in the cubitus, but in all the larger limbs, which are joined in the articulation by a long process) to extend both limbs different ways, till there be a void space between the bones; and then to thrust the luxated bone from that side, into which it has prolapsed, to the contrary. However the methods of extension are various according to the strength of the ligaments, and the position of the luxated bones. And sometimes the hands alone are used, sometimes other means.

Therefore if the cubitus is displaced forward, it is sufficient for it to be extended by two hands, sometimes assisted by two straps; then some round body must be put into the bend of the elbow, and upon that, the cubitus is to be suddenly forced towards the humerus. But in the other cases the best method is so extend the fore-arm in the same manner, as was directed in a fractured humerus, and then to reduce the bones.

The remaining part of the cure is the same as in the other luxations; only this must be sooner, and more frequently opened, also more plentifully fomented with hot water, and rubbed longer with oil, and nitre, and salt. For the cubitus, whether it remain displaced, or be reduced, is more quickly surrounded by a callus than another joint, and if this grows, while the arm is at rest, it afterwards prevents its flexure.

CHAP. XVII.

OF A LUXATED HAND.

The hand too may be displaced in all the four directions. If it slips backward, the fingers cannot be extended; if forward, they cannot be bent; if on either side, the hand is turned to the opposite, that is, either toward the thumb, or the little finger, and may be replaced without much difficulty. The hand and fore-arm should be extended on something, that is hard and will not give way, the hand being prone, if the luxation was to the posterior part; and supine, if forward; if internally, or externally, it should be laid on one side. When the ligaments are sufficiently stretched, if the luxation was lateral, it must be repelled to the contrary side by the hands: but where it was forward, or backward, some hard body is to be put upon it, and pressed upon the prominent bone by the hand, which additional force pushes it more easily into its place.

CHAP. XVIII.

OF LUXATIONS IN THE PALM.

The bones also in the palm are sometimes dislocated, and that either forward, or backward. For they cannot be luxated laterally by reason of the resistance from the parallel bones on each side. There is only one indication of it, which is common to them all: a tumour in that part, to which the bone comes, and a cavity in the other, from which it recedes. But the bone being well pressed by a finger, returns without extension to its place.

CHAP. XIX.

OF LUXATED FINGERS.

In the fingers there are as many different cases, and the same signs, as in the hands. But an equal degree of force is not necessary in their extension; because the _several_ bones are shorter, and the ligaments less strong. They ought only to be extended upon a table, when the luxation is forward or backward; and then compressed with the palm of the hand that thus the finger may be(27) restored to the place from whence it slipped.

CHAP. XX.

OF A LUXATION OF THE FEMUR.

Having treated of the humerus(28), what I said there may seem to suffice for the lower extremities; for there is some similitude in this case between the femur, and humerus, the tibia, and cubitus, the foot and hand. However something must be said in particular about these.