BOOK VI. (continued 5)

Rhases makes some interesting remarks on the sawing of bones. He directs us to stretch the flesh upwards and downwards, with a piece of cloth, so that it may not come in the way of the teeth of the saw. When it is necessary to saw a rib or a bone, near any important membrane or organ, he recommends us to use a plate (tabella), to protect the soft parts from the saw. When the bone connected with a joint is diseased, he directs us to extract it at the joint. When the os brachii, or tibia, is diseased, he recommends us to extract it entire, but forbids to meddle with the head of the femur or the vertebræ. In another place he declares it as his opinion that when a joint is swelled, and the bone diseased, (in cases of white swelling?) it will be impossible to effect a cure unless the whole diseased portion of the bone be cut out. (Cont. xxix.) From these passages it is quite obvious that the ancients practised excision of the bones of joints. See also what our author says on this subject in the seventy-seventh section of this book. A Cooper or a Liston could not recommend a bolder plan of treatment in such cases.

Theodoricus, Guy of Cauliac, and the other surgical writers of that age, follow closely in the footsteps of the ancients, especially of the Arabians. When the mortified part is near to a joint, they recommend amputation at it. In other cases they direct us to make an incision between the sound and the dead parts, to saw the bone with a fine saw, and to stop the bleeding with a heated iron. Theodoricus recommends stupifying medicines, such as opium, hyoscyamus, mandragora, or cicuta, before the operation. Ambrose Paré has undoubtedly the merit of introducing the use of the ligature into modern practice in amputations, and, in fact, Archigenes seems to be the only ancient authority who mentions it in such cases. We have shown, however, in another place, that the ligature was freely used by the ancients for stopping bleeding from wounds.

SECT. LXXXV.—ON PTERYGIA ABOUT THE NAILS.

The pterygium is a fleshy excrescence about the nails, covering part of the nail, and being commonly formed in the large fingers and toes. But those in the feet arise most commonly from an accident, whereas, those in the hands arise from whitlow, the inflammation being neglected and turning to pus. For, the pus being allowed to remain, corrodes and corrupts the root of the nail, and often destroys the whole of it, but generally the one half, while a portion of it uncorroded is left at the root of the nail, and sometimes the whole root is left uncorroded. Sometimes, too, it corrupts the bone, when a disagreeable smell arises from it, and the extremity of the finger becomes swelled and appears livid. They are to be treated, then, by cutting and removing all the remaining part of the nail with the point of a scalpel, and then burning both the ulcerated and cut part with cauteries. For, the pterygium is a spreading disease, and does not stop unless burnt, so that, if neglected, it affects the whole finger. If, while the nail and bone remain sound, the inner angle of the nail sink down and pierce the adjacent flesh, it occasions inflammation; and in this case the irritating portion is to be raised upon a thin probe, or some such thing put under it, and removed with the point of a scalpel, and the excrescence eaten down with an escharotic medicine. And most cases are cured by being treated in this way. But if larger, it is first to be cut out with a scalpel, and then the medicine is to be used.

Commentary. We have given an account of the ancient treatment of pterygia by medicines towards the end of the Third Book.

Celsus recommends excision with the knife and the application of cauteries or strong caustics afterwards. (vi, 19.)

Aëtius and Oribasius trust to septic and caustic applications without an operation. Antyllus (apud Rhasis Cont. xxxvi,) recommended excision and burning when the discharge from the ulcer is fetid.

Albucasis, like our author, recommends us to cut off the piece of nail that is attached, and then to apply a burning iron to the part. The burning, he adds, is of great consequence. When the bone is diseased he directs us to take it out, which generally may be done at the joint. (Chirurg. ii, 9.)

Haly Abbas likewise directs us to cut off the piece of nail and apply the cautery. He says, if this be neglected the bone is apt to become diseased. When pus is seated below the nail, he recommends us to introduce the head of a probe under it, and cut upon it with a knife; after which a caustic medicine is to be applied to the flesh. (Pract. ix, 66.)

SECT. LXXXVI.—ON A BRUISED NAIL.

Since, owing to nails having been bruised by accidents, pains supervene, which compel us to operate upon them, it will be sufficient to give you Galen’s account of the matter. He says, then: “When the nails are contused we have found the evacuation of the blood a palpable remedy for soothing the pain, when it and the throbbings are very violent. But we must make an oblique incision, not straight from above downwards, with a sharp scalpel, so that when the blood is evacuated the divided part of the nail may serve as a cover to the parts under it. But if you make a straight incision from above down to the fleshy excrescence, as it is called, another body is formed from the flesh below the nail shooting out through the division of the nail, whence pains again invade, as in the complaint we call paronychia, owing to the flesh under the nail being compressed by it. Wherefore, one may see the patients immediately relieved from pain by this section. On the following days we may gently raise the divided part of the nail, and press the sanies from under the nail, and then again, as I said, apply the nail as a cover to the flesh below. The rest of the treatment of the finger should be soothing and discutient.”

Commentary. Avicenna and Rhases approve of the plan of treatment here recommended, upon the authority of Galen. Rhases, in fact, gives the very words of Galen. (Cont. xxxvi.)

Albucasis directs us, in the case of a bruised nail, first to have recourse to venesection, and then to make a transverse (oblique?) incision through it. (Chirurg. ii, 91.)

See our remarks in the sixtieth section of this Book on the confusion of the terms transverse and oblique by the translators of the Arabians.

The same treatment is recommended by Haly Abbas. (Pract. ix, 67.)

SECT. LXXXVII.—ON CLAVI, MYRMECIA, AND ACROCHORDONES.

The clavus is a round callus, white, resembling the head of a nail, and occurring in all parts of the body, but more especially on the soles of the feet and the toes, occasioning pain and lameness in walking. Wherefore, having scarified around the clavus or corn, and taken hold of it with a forceps, we cut it out by the roots with a sharp-pointed scalpel or lancet for bleeding. Some, in order that they may not grow again, use heated cauteries. The myrmecia is a prominence of the skin, small, callous, round, thick, spreading deep at the base, and, if rubbed, occasioning a sensation like the bites of ants, and being formed in all parts of the body, but more especially in the hands. Wherefore, some, among whom is Galen, advise us to scarify around the myrmecia with the stalk of a hard feather, such as those of old fowls, of geese, and of eagles, and to push it down so as to remove the myrmecia from the root. Others do the same thing with a copper or iron tube. The moderns are satisfied to scarify around it, and, having seized it with a forceps, to cut it out like corns with a scalpel. The acrochordon is a small rising of the surface, free of pain, callous, for the most part round, and having a narrow base so as to appear to hang. It is so called from its resemblance to the end of a cord. Having stretched out the protuberance then we may cut it out; or, otherwise, we may tie a thread or a hair round it. I have known many who consumed this and all the afore-mentioned protuberances with what is called the cold cautery.

Commentary. We have already treated fully of these diseases towards the end of the Third Book and in the Fourth, to which we refer the reader for further information on this head.

Celsus recommends us merely to shave the clavus or corn. The others he directs us to remove by caustics, such as the lees of wine (potass?), or a mixture of alum and sandarach. The acrochordon, he says, when cut out leaves no roots behind. (v, 28.)

Albucasis particularly recommends burning for the cure of clavus and myrmecia. This may be accomplished either with fire or hot water. If the former method is preferred, an iron proportionate to the size of the corn is to be heated red-hot and applied to it, and the burning carried to such an extent as to occasion suppuration. In the other method a funnel of copper or iron, or else the quill of a vulture is to be applied to the corn, and then filled with boiling water. By these means, he says, the corn may be eradicated. (Chirurg. i, 55.)

See also Haly Abbas (Pract. ix, 12) and Rhases (Cont. xxxvi.) Rhases does not state very distinctly the difference between the myrmecia and acrochordon. He speaks of scraping them out with a hard pen, and of tying them at the base; but upon the whole he approves most of taking hold of them with a forceps and dissecting them out.

Avicenna recommends us to cut out the clavus and then apply a caustic medicine to the part. (iv, 7, 4, 14.)

SECT. LXXXVIII.—ON THE EXTRACTION OF WEAPONS.

That the extraction of weapons is a most important department of surgery is declared by the Poet Homer, when he says:

We must first describe the different kinds of weapons. Warlike instruments, then, differ from one another in material, figure, size, number, mode, and power. In material, then, as the shafts are made of wood or of reeds; and the heads themselves are either made of iron, copper, tin, lead, horn, glass, bones, and of reeds, too, or of wood: and such differences are found especially among the Egyptians. In figure, inasmuch as some are round, some angled (as triangular), some pointed and lance-shaped, as some have three points; some are barbed and some are without barbs; and of the barbed, some have the barbs turned backwards, so that in attempting to extract them they may fasten in the parts; and some forwards, so that when pushed they may do the same thing: some have them diverging in opposite directions like the forked lightning, in order that whether pulled or pushed they may fasten in the parts. Some missiles have their barbs united by a hinge, which being expanded in the extraction, prevent the weapon from being drawn out. They differ in size, inasmuch as some are three fingers’ breadth in size, and some are as small as one finger, which are called micca in Egypt, and some are intermediate between them. In number, inasmuch as some are simple and some compounded. For certain small pieces of iron are inserted in them, which, in the extraction of the weapon, remain concealed in deep-seated parts. In mode, as some have the sharp extremity fixed to a tail and some to a shaft; and some have it carefully inserted in the shaft, and some carelessly, so that in the extraction they may separate and leave the head behind. In power, as some are not poisoned and some are poisoned. Such are the differences of weapons. We now proceed to treat of the extraction, both in cases of those who have been wounded in war and those not in war, whether voluntarily and involuntarily, under whatever circumstances, and of whatever materials they may be composed. There are two modes of extracting weapons from fleshy parts; either by pulling them backwards, or pushing them forwards. When the weapon is fixed superficially the extraction is made by pulling it back, and in like manner when it is lodged deep, but the opposite parts, if wounded, would occasion danger from hemorrhage or sympathy. It is to be pushed forwards when lodged deep, and the intervening substances between it and the opposite side are of small size, and neither nerve, bone, nor any such thing is an obstacle to the division. When a bone is wounded, the mode of extraction is by pulling; if, therefore, the head of the weapon be in sight, we make the extraction immediately; but, if it is hid, we must, says Hippocrates, get the wounded person to put himself in the same posture as when he received the wound, and thus make the examination; or, if this cannot be done, he is to be placed in the nearest possible to it, and thus it is to be examined with a sound. If the head of the weapon has fixed in the flesh, it is to be drawn out with the hands, or by laying hold of the appendage, which is called the shaft, if it has not fallen off. This part is mostly made of wood. When it has fallen off, we make the extraction by means of a tooth-extractor, or a root-extractor, or an instrument for extracting weapons, or any other convenient instrument. And sometimes we make an incision in the flesh around it in the first place, if the wound do not admit the instrument. And if the head of the weapon has passed to the opposite side, and it is found impossible to extract it by the way in which it entered, having divided the parts opposite we extract it through them, either drawing it out in the manner mentioned, or we make a hole with the weapon itself, pushing it either by the shaft, or, if it has come away, by an impellent instrument, taking care not to divide a nerve, vein, artery, or any important part, for it would be disgraceful if, in extracting the weapon, we should do more mischief than the weapon itself had done. If the weapon has a tail, which is ascertained by examination with the probe, having introduced the female part of the impellent instrument and fixing it, we push the weapon forwards, but if it has a shaft, the male part. And if the head when extracted appear to have notches, so that other small pieces of iron might be inserted in them, we make an examination again with the probe, if we find them we extract them in the same manner. And if the weapon has barbs in opposite directions, which do not yield to our pulling, we must make an incision in the adjacent parts, if no important vessel or the like lie there, and when the weapon is laid bare, we extract it without trouble. Some apply a tube about the barbs, so that when they draw out the weapon the flesh may not be torn by the barbs. If the wound does not become inflamed, we may use sutures, and heal it up like a bloody wound; but if it inflame we may remove the inflammation by embrocations, cataplasms, and the like. If the weapon be poisoned we must, if possible, cut off all the flesh which has imbibed the poison, which is known by its being altered from the sound flesh, for it appears pale, livid, and as it were dead. They say that the Dacians and Dalmatians touch the points of their weapons with elecampane, called also ninum, and that when it thus becomes mixed with the blood of the wounded animal it proves fatal, although it is eaten by them with impunity. If, again, the weapon fix in a bone, we make trial with the instrument, and, if flesh prevent the extraction, we cut it off, or separate it; but if it be lodged deep in the bone (which we know by its being so firm that it cannot be shaken with a considerable force) we first remove the remaining part of the bone with a cutting instrument, or bore it with trephines if it has considerable thickness, and thus disengage the weapon. If a weapon be lodged in any important part, such as the brain, heart, throat, lungs, liver, stomach, intestines, kidneys, womb, or bladder, and fatal symptoms have already shown themselves, as the extraction would occasion much laceration we must decline the attempt, lest while we do no good we expose ourselves to the reprobation of ignorant people. But if the result be dubious, we must make the attempt, having first given warning of the danger. For in many cases, when an abscess has formed in some vital part, recovery has unexpectedly taken place; and the lobe of the liver, part of the omentum and peritoneum, and the whole uterus are said to have been taken away, and yet death was not the consequence. And we often open the windpipe intentionally, in cases of angina, as we mentioned under the head of Laryngotomy. To leave the weapon then as it is, occasions certain death, and exhibits the art in an inhumane light, whereas by extracting it we might possibly save a life. It is not difficult to ascertain when an important part is wounded, this being discovered by the peculiarity of the symptoms, the discharges, and situation of the parts. When, therefore, the membranes of the brain are wounded, there is intense pain of the head, the eyes are fiery, the tongue red, and there is aberration of intellect; but if it is attended with a wound of the brain, there is prostration of strength, with loss of speech, distortion of the countenance, vomiting of bile, a discharge of blood from the nostrils, an evacuation of a white and pultaceous fluid by the auditory foramen, and of ichor, if it can find a passage by the wound. If the weapon has penetrated to the cavity of the chest, and sufficient room is left for it, the breath passes out. When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats, and deliquium animi, and death follows in a short time. When the lungs are wounded, if the opening be sufficiently large, a frothy blood passes out at it; but if not, it is rather vomited up, the vessels of the neck are swelled, the tongue changes colour, and there is an urgent desire of cold things. When the diaphragm is wounded the weapon appears lodged about the false ribs, there are large inspirations with pain, sighs, and heavings of the parts about the shoulder-joints. If the viscera of the abdomen are wounded, the nature of the injury will be apparent from the discharge, if the wound be sufficiently large, or if the weapon be extracted, or if the shaft be broken internally; for chyle is evacuated from the stomach, and fæces from the intestines; sometimes the omentum or an intestine protrudes. When the bladder is wounded urine is discharged. When the membranes of the brain or the cerebrum itself is wounded, we extract the weapon by trepanning the skull, as will be described presently in fractures of the bones of the head. If the weapon is lodged in the chest, and does not come out readily, it is to be extracted by means of a moderate incision in the intercostal space, or by cutting out a rib with the assistance of the instrument called meningophylax. In like manner, when the stomach, bladder, and other deep-seated parts are wounded, if the weapon come out readily it is to be extracted without more ado; but if not, we must enlarge the wound, and afterwards use the dressings for fresh wounds. In wounds of the abdomen, gastroraphé as formerly described may be had recourse to, if necessary. But if the weapon has lodged in any of the larger vessels, such as the internal jugulars or carotids, and the large arteries in the armpits or groins, and if the extraction threaten a great hemorrhage, they are first to be secured with ligatures on both sides, and then the extraction is to be made. If parts have been fastened to one another, such as the arm to the chest, or the fore-arm to the other parts of the body, or the feet to one another, if the weapon (as a spear) do not penetrate through both parts, we are to take hold of the weapon externally and extract as if only one part were affected, but if it has passed through both, having sawed the wood through the middle, we extract each part singly, in the most convenient direction. But since often stones or the sharp points of rocks, or pieces of lead, or the like, are lodged in the body, either being impelled with force from a sling, or happening to be acuminated, they are to be known by the swelling being hard and irregular, and by the solution not being everywhere straight, but larger than common, and having the skin bruised and livid, and the pain being attended with a sense of weight. They are, therefore, to be dislodged by means of suitable instruments, or scraped out with the concave part of a specillum or of an ear-specillum adapted for wounds; or, if they can be applied, a tooth-extractor or a root-extractor may be used for pulling them out. In many instances weapons lodged in the body lie concealed, and a long time after, when the wounds are healed up, the part having suppurated bursts, and the weapon drops out.

Commentary. Hippocrates considered the extraction of weapons to be one of the most important departments of surgery. It is to be fully learned, he says, only by attaching oneself to a foreign army. (De Medico.) He makes some interesting remarks on the subject in his treatise ‘De Capitis Vulneribus.’

We must now attempt to give an abstract of Celsus’s very interesting chapter on the Extraction of Weapons. Every weapon is to be extracted either by the part at which it enters or by that to which it tends. If it is not deep-seated, or if it has not passed any great vessels or nerves, there is no better plan than to draw it out as it entered. But if there is a greater space through which it must return than there would be to push it out, and if it has already passed the vessels and nerves, it will be better to open what remains undivided, and extract it in this direction. If the weapon is to be drawn backwards, the opening is to be enlarged by a scalpel, which will occasion less inflammation and obstruction of the parts than if they are torn by the weapon itself. In whichever way it be extracted great care ought to be taken that no nerve, large vein, or artery be divided. If any of these parts be detected in the wound they are to be drawn aside with a blunt hook. These are his general directions. He then subjoins instructions for extracting particular kinds of weapons. An arrow being a slender body, and generally impelled with great force, is often lodged deep, and is to be extracted for the most part rather by the opposite side to which it entered, especially as it has barbs, which tear most if drawn backwards. The flesh about the weapon is to be separated by means of a suitable instrument, and then if the head (mucro) appear with the shaft (arundo) fixed to it, the weapon is to be propelled until it can be laid hold of at the opposite side and extracted; or if the shaft has fallen out and only the iron remain lodged within, the head is to be seized with the fingers or a forceps, and removed, and it is to be extracted by the opening at which it entered, upon the same principles; for the wound being enlarged, the weapon is to be drawn back by the shaft if it remain, or otherwise by the iron itself. If there appear to be barbs upon the arrow, and if short and small, they are to be broken off with a pair of pincers; or, if larger and stronger, they are to be covered with split writing-pens (fissis scriptoriis calamis) to prevent them from tearing the flesh during extraction. And here we may mention, that the common calamus scriptorius of the ancients was made from an Egyptian reed. See Montfauçon (Palæographia Græca, p. 3.) When the weapon which is lodged in the body is large it must not be extracted by the opposite side, as it would make the wound too large. He directs us to draw it back by means of an instrument invented by Diocles, of which he gives a description. Another class of weapons which must sometimes be extracted are leaden balls, stones, or any such thing which breaks the skin, and is buried within. In all such cases the wound, he says, must be enlarged and the body extracted with a forceps. A complication which increases the difficulty of extraction arises from the weapon being lodged in a bone, or between two bones at a joint. When lodged in a bone it is to be moved about until loosened, when it is to be grasped with a forceps and extracted in the same way that a tooth is pulled out. It rarely happens that the weapon cannot be removed in this way; but if it remain fixed in the bone, it is to be struck with some iron instrument until it be shaken from the place where it is lodged. When other means do not succeed, the bone is to be perforated with a trephine. When the body is lodged in a joint between two bones, the two members about the wound are to be wrapped round with strips of cloth, or leathern thongs, and thereby separated by pulling in opposite directions, by which means the space between them will be slackened, and then the weapon may be removed without difficulty. When the weapon had been poisoned, these things must be done with all possible despatch, and the remedies applied which are used when a poison has been swallowed, or a person has been stung by a serpent. The wound from which a weapon has been extracted requires no other treatment than what is applicable for ordinary injuries. (vii, 5.)

Albucasis borrows mostly from our author the account which he gives of the construction of weapons and the symptoms occasioned by the wounds which they inflict. He also relates some interesting cases of recovery from very severe wounds. An arrow entered at the root of a man’s nose and was extracted by Albucasis behind his ear; and the man recovered without having sustained any injury to the eye. He extracted another large arrow which had lodged deep below the eye of a Jew; and in this case also the sight was not impaired. He extracted a barbed arrow which had lodged in the throat of a Christian, by enlarging the wound, and the man recovered. An arrow had lodged in a man’s belly, so that, at first sight, Albucasis considered the case as hopeless; but, after thirty days, as no mortal symptoms had supervened, he enlarged the wound and extracted the weapon. He saw a man who had got an arrow lodged in his back; the wound healed, but after an interval of seven years the weapon came out below his buttocks. He knew a woman who had an arrow lodged in her belly, and the wound healed, and the weapon never afterwards occasioned her any inconvenience. He knew a man who had an arrow lodged in his face, and the wound healed up, and never gave him much trouble. He relates that he extracted an arrow which had been buried in the nose of a prince, after making various fruitless attempts for the space of four months. He then delivers general directions for the extraction of weapons, borrowing, as usual, very freely from our author. When a weapon cannot readily be got extracted at the time, he recommends us to let it alone until it become loosened by the putrefaction of the surrounding parts. When impacted in a bone, he directs us either to move it about until it is loosened, or to perforate the bone with a trephine. When lodged in the cranium, it is to be removed in like manner with a trephine, provided the dura mater is not injured, for if it is wounded the case must not be interfered with. When a weapon is lodged deep in any part of the body where there are no large nerves, veins, or bones, he directs us to enlarge the wound and extract the weapon; but if it has barbs, the fleshy parts about it must first be carefully separated to prevent them from being torn. When a weapon passes through a limb, or attaches one part of the body to another, he directs us to cut off the part which projects, and then extraction may easily be accomplished. If fastened in a bone, he advises us to turn it round so as to loosen it; and if that does not suffice, he recommends us to leave it for a few days, when it may be extracted without difficulty. If the shaft or wooden part of a weapon be broken off, he directs us to apply to the head an impellent instrument with a concave extremity, so as to adapt itself to the form of the body which is to be extracted. When the weapon is poisoned, he recommends us, if possible, to cut out the flesh around it. When a weapon lodges in the breast, belly, bladder, or side, and can be felt with a probe, he directs us to cut cautiously upon it, taking care not to wound a vein or nerve. He concludes with giving drawings of forcipes and impellents. (Chirurg. ii, 96.)

Rhases gives sensible directions for the management of these cases, but they are so similar to those of our author that we need not dwell upon them. If the size of the wound permit, he directs us to introduce a forceps to the iron head and draw it out. If the opening be too small, he recommends us to enlarge it. When the weapon has nearly passed through the limb, he advises us to push it out at the opposite side. Thorns and such like sharp things are to be removed by the application of extractive plasters. (Ad Mans. vii, 25.)

Avicenna gives a literal translation of the present chapter of Paulus, and supplies nothing additional of much interest. (iv, 4, 2, 10.)

The account given by Haly Abbas is full, but like that of Albucasis. He mentions that he had seen cases in which an arrow had been lodged in the intestines, and although fæces were discharged by the wound, the patient recovered. He adds that others relate cases in which recovery took place although the liver or omentum had been wounded. (Pract. ix, 15.)

The rules for the extraction of weapons laid down by Theodoricus and all the earlier authorities are mostly copied from the ancient authors. (i, 22.)

It would be naturally expected that we should give some account in this place of the surgery in the heroic ages, as far as it can be learned from the poems of Homer and the Commentary of Eustathius. The Commentator remarks that three methods of extracting weapons are mentioned by Homer: 1. By evulsion or pulling the weapon backwards, as in the case of Menelaus. (Iliad, iv, 214.) 2. By protrusion or pushing it forwards, as in the case of Diomedes. (Iliad, v, 112.) 3. By enlarging the wound and cutting out the weapon, as practised by Patroclus in the case of Eurypylus. (Iliad, xi, 218.) He further remarks that it appears to have been a common practice to suck a wound with the mouth; and, he adds, that this method was still in use among a barbarous people in his days. (Iliad, iv, 219.) The weapons used in the Trojan war were swords, spears or javelins, stones flung by the hand or by a sling, hatchets or axes, as used by the Trojans on certain occasions (Iliad, xii, 590), and arrows. Eustathius remarks, however, that there would appear to have been very few bowmen. In his Commentary on the Odyssey he states that poisoned arrows were never employed in war, but only for killing wild beasts. (Odyss. i, 260.) We believe that no weapons of iron were used in the war of Troy, and that they were all made of copper. (See Jameson’s Mineralogy, iii.) Little transpires from Homer with regard to the internal treatment. In one place (Iliad, xi, 638) mention is made of a mixture of wine and cheese having been given to a wounded warrior, which practice, Eustathius says, had given rise to a variety of conjectures. Some supposed that the wound in the case referred to was so slight as not to render the administration of stimulants improper; others rather believed that the loss of blood had been so great as to call for the use of wine to support the strength. But many, he adds, were of opinion that men in the heroic ages lived so temperately that their constitutions readily bore things on extraordinary occasions, which in after ages were reckoned to be of too inflammatory a nature. This explanation is advocated by Athenæus. (Deipnos, i.) In the Odyssey, mention is made of a hemorrhage being stopped by incantation, which shows, as Eustathius remarks, that amulets and incantations were as ancient as the heroic ages.

SECT. LXXXIX.—ON FRACTURES AND THEIR DIFFERENCES.

Having described the surgical operations on the fleshy parts, we have next to give an account of those which relate to the bones, I mean the treatment of fractures and dislocations; for these also fall under the department of surgery. And first, of fractures, beginning with fractures of the bones of the head, because they hold an intermediate place between the operations on the fleshy parts and the bones, and because the cranium overtops all the other parts. In general terms, then, a fracture is a division of a bone, or rupture, or excision of it, produced by external violence. The differences of fractures are many. A bone, then, is said to be fractured raphanatim, scandulatim, in unguem, polentatim, and per defractionem. A fracture raphanatim is a transverse one through the thickness of the bone, and is called also cucumeratim and caulatim, because cucumbers and cabbages break in this way. Scandulatim is a longitudinal fracture of a bone. In unguem is a fracture at one part straight, and at its extremity lunated, and it is also called arundatim. Polentatim is a fracture of a bone into small pieces; and it is also called nucatim by some: Defractio or præcisio is when part of a bone is taken away with tearing of the skin, so that part is removed and is wanting. These are the differences of fractures.

Commentary. The following is a list of the ancient authors who have treated of fractures and dislocations: Hippocrates (de Fracturis; de Articulis; de Vulner. Capit.; Officina Medici); Galen (Comment. in eosdem, Meth. Med. vi.); Celsus (viii); Oribasius (de Machinamentis, &c.); Nicetæ Collectio ex Chirurg. Græc.; Apollonius Citiensis (Scholia in Hippocrat. ed. Dietz); Avicenna (iv, 5, 23); Rhases (ad Mansor. vii, 26; Divis i, 140; Cont. xxix); Averrhoes (Collig. vii, 36); Avenzoar (ii, 6, 1); Haly Abbas (Pract. ix, ad finem.)

Hippocrates does not make use of the technical terms explained by our author in this section, and Galen hints that he thinks his Master did better in confining himself to words generally understood. Galen defines only a few of these terms. He calls that kind of fracture in which the end of a bone at an articulation is entirely taken away, âbruptio (ἄπαγμα.) A transverse fracture with a complete separation of the broken portions is called a fracture caulatim (καυληδὸν.) A longitudinal division not attended with an entire separation of the parts is called scandulatim (σχιδακηδὸν.) He thinks the later writers on the subject who had introduced the use of such terms as raphanatim (ῥαφανηδὸν) and polentatim (ἀλφιτηδὸν) had refined too much.

All the terms mentioned by our author occur in a fragment of Soranus, preserved in the collection of Nicetas. They are also treated of very elaborately in the fragments of Heliodorus, contained in the same collection.

Celsus, who was studious of perspicuity and elegance, avoids all technical terms as much as possible. He thus defines the varieties of fractures. A bone, he says, may be split longitudinally like a piece of wood, or it may be broken transversely or obliquely, and its ends may be blunt or sharp, which last variety is the worst of all, as they cannot be easily made to unite with the other parts, and are apt to wound the muscles and nerves. Sometimes the bone is broken into fragments, and in certain bones a fragment is occasionally separated entirely from the broken bone.

The Arabians, especially Avicenna, Haly Abbas, and Albucasis, adopt the terms used by our author. Albucasis remarks, that the fracture of a bone is recognised by the derangement of the broken pieces, by their projection, and the crepitus produced upon pressure. He says, however, that there may be a fissure without derangement or crepitus.

SECT. XC.—ON FRACTURES OF THE BONES OF THE HEAD.

In particular, then, a fracture in the head is a division of the cranium, sometimes simple and sometimes complex, occasioned by some external violence. The differences of fractures of the head are these: a fissure, an incision, an expression, a depression, an arched fracture, and, in infants, a dent. A fissure, then, is a division of the skull, either superficial or deep, when the inward bone is not removed out of its place. An incision, or slash, (ἐγκοπὴ) is a division of the skull with refraction of the fractured bone (if the injured bone be broken off some call the affection deasciatio, i. e. as if done by a hatchet). An expression is a division of a bone into many parts, with a sinking down of the fractured pieces upon the membrane of the brain. A depression (ἐγγίσωμα) is a division of a bone with a sinking downwards of the fractured bone from its natural position towards the meninx. An arched fracture (καμάρωσις), as Galen says, is a division of the skull attended with elevation of the fractured pieces in the middle, and depression around the edges of the sound parts, like as in expression. Such is his opinion. Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. There are two different kinds of indentation, for either the bone is depressed through its whole thickness, so that often a separation of the membrane of the brain takes place, or it is pressed upon by the skull throughout; or sometimes the indentation does not affect the skull through its whole thickness but only its outer plate down to the diploe. To these differences some also add that by repercussion, which happens, say they, when a fracture of the cranium takes place opposite to the part which received the blow. But they are in a mistake, for what happens to glass vessels does not, as they say, happen here; for, this happens to them from their being empty, but the skull is full and otherwise strong. But when many other parts of the head have been struck, as in a fall, and a fissure of the skull takes place without a solution of continuity of the skin, an abscess afterwards forms in it, and being opened, this fissure is discovered, which appears to them to have been occasioned by the blow on the opposite side; and this is to be cured like the fissure first mentioned. If a fracture, then, occur in the head, it is discovered by the sharpness, weight, hardness, or violent force of the body which struck it, and by the symptoms which supervene upon the person who has been struck, such as vertigo, loss of speech, and sudden prostration, more particularly if it be a fracture with depression, or contusion, or expression, or the internally-arched fracture, owing to the compression of the brain. It is also discovered by its appearances to the senses; for if there be a considerable division of the skin we ascertain the occurrence readily thereby; but if there be no division, or a very narrow one, and we suspect a fracture, we make an incision in the skin and ascertain it by the sight, or by probing it with an instrument. If then it be any of the other kinds of fracture it will readily be apparent, but if it is only a narrow capillary fissure which eludes the sense, having poured on the part some black liquid medicine, or the common writing ink, we scrape the bone, for the fissure appears black, and we must go on scraping until the symptoms of the fissure disappear; but if it extend to the membrane we must desist from the scraping, and endeavour to ascertain whether the membrane has separated from the bone or remains fixed. For if it remain, the inflammation of the wound continues moderate, the patient gets gradually freed from the fever, and the pus appears concocted. But if the membrane has separated, the pains increase and the fever in like manner, the bone changes colour, and then unconcocted pus is discharged; and if the person who has the charge of it neglect the case, and has not recourse to perforation, still more grievous symptoms will come on, vomiting of bile, convulsions, disorder of intellect, and acute fever, under which circumstances one must decline operating. But if these are not present, and the membrane has not separated, and if the fracture be a mere fissure, it may be cured by scraping alone, although it be of considerable depth. If it extend to the diploe only it is to be scraped down to it, or the broken bone removed, as will be described. If broken into small pieces, these also are to be extracted with a convenient instrument. And if the membrane separate, and you have treated the patient from the commencement, and if it be winter, endeavour by all means to effect the removal of the bone before the fourteenth day; but, if in summer, before the seventh, while the afore-mentioned symptoms have not come on you may operate in this way:

The Operation.—Having first shaved the head about the wound, we make two incisions intersecting one another at right angles like the Greek letter Χ, one of them being the wound already existing; then dissecting the four angles at the top, so that the bone about to be perforated may be wholly laid bare, if there be bleeding we apply pledgets moistened in oxycrate, but if not dry ones; and then applying a compress out of wine and oil, we use a proper bandage; and next day, if no new symptom supervene, we proceed to perforate the affected bone. Wherefore, having placed the patient on a seat, or in a reclining posture suitable to the wound, and stuffed his ears with wool in order to avoid the noise of the perforation, we loosen the bandage from the wound, and having removed all the dressings and sponged it, we direct two assistants with small twisted bands to retract the four angles of the parts lying over the fracture, and if the bone be weak, either naturally or from the fracture, we cut it out with counter-perforators, beginning first with the broader ones and changing to the narrower, and then using those which are of the form of a specillum, striking gently with the mallet to avoid shaking the head. But if the bone be strong it is to be first perforated with that kind of perforators called abaptistæ, which have certain eminences projecting a little above the point that prevent them from sinking down to the membrane, and then, by using the chisels, we remove the fractured bone not at once, but by pieces, if possible with the fingers, or otherwise with a tooth forceps, or bone forceps, or hair-nippers, or some such instrument. The space between the perforations should be as great as the breadth of the largest head of a specillum, and its depth should be until it is near the inner surface of the bone, taking care that the perforator (trepan?) do not touch the membrane. Therefore, in order to suit the thickness of the bone with the size of the perforator, several ought to be previously prepared for the purpose. But if the fracture extend only to the diploe the perforation should be carried no farther. After the removal of the bone, having cleared away any asperity that remained after the cutting of the bone with a carving instrument, or the extremity of a perforator, using the meningo-phylax as a protector, and bringing away carefully the small bones and spiculæ which remain, we proceed to the application of the dressings. This is the more common, and at the same time the easiest and least dangerous mode of operating; but the method of performing it with a sort of incisor called lenticular is greatly praised by Galen, being performed without perforation after the part has been scraped all round with hollow chisels (κυκλίσκοι). Wherefore he says thus: “If you have once laid bare the place, then applying the incisor, which has a projection at the extremity like a lenticular, blunt and smooth, but sharp longitudinally, when you apply the broad part of the lenticular to the meninx, divide the cranium by striking with the small hammer. For we have all that we require in such operations; for the membrane, even if the operator were half asleep, could not be wounded being in contact only with the broad part of the lenticular, and if anything adhere to the cranium, the round part of the lenticular removes its adhesion without trouble. And behind it follows the incisor, or knife itself, dividing the skull; so that is impossible to discover another mode of operating more free from danger or more expeditious.” But the mode of operating with saws and the instruments called chœnicides or modioli (trepans?) is condemned by the moderns as a bad one, and the operation may be done as we described for fissure. The same mode of removing bones will be applicable in the other fractures of the cranium. But regarding the amount of bones requiring extraction Galen informs us, writing thus plainly: “What parts of a fractured bone are to be removed I will now explain to you in order. When it is greatly bruised it is to be taken out entire, but if certain fissures extend from it farther, as sometimes they appear to do, we must not pursue them to their termination, well knowing that no harm will result from them if everything else be properly done.” After the operation, having dipped a simple linen rag of the size of the wound in oil of roses, we lay it over the membrane as a cover, and in like manner, having dipped a small ball of wool in oil of roses, we put it over the aforesaid rag, and then having moistened a doubled compress in wine and oil, or in the same oil of roses, we apply it to the whole wound, taking care that they be not too heavy for the meninx. We then have recourse to a broad bandage, which also must not be made tight, but so as merely to preserve the pledgets. And the regimen is to be what is called anti-inflammatory and such as is applicable for fevers, frequently bathing the membrane with oil of roses. After the third day loosing them and sponging the part we pursue the treatment applicable for recent wounds and the anti-inflammatory; sprinkling upon the meninx some of the powders called cephalics until it incarnate, and sometimes scraping the bone, if it require it, on account of certain projecting spiculæ, or for the sake of incarnation itself. And we may apply medicines of the ingredients recommended for wounds.

On inflammation of the membrane of the brain. Often after the operation the membrane is inflamed, so as not only to rise above the skull but likewise above the skin, and is attended with hardness, and obstructs the natural pulsatory motion of the brain, in which case convulsions and other severe symptoms, or death, for the most part supervene. It becomes inflamed either from the irritation of some sharp projecting piece of bone, or from the weight of the dressings, or from cold, or from eating too much, or from drinking wine, or some other cause not apparent. If then the cause be obvious it is to be speedily removed, or, if it is not, it will be proper to contend strenuously against it, either by having recourse to venesection, if nothing prohibit it, or to a diet suitable for inflammation. We must also use topical remedies, such as warm embrocations with hot rose-oil, and bathing the part with the decoction of marshmallows, or of fenugreek, of linseed, of camomile, and such like, and cataplasms of raw barley flour, or of linseed with the aforementioned decoction and the grease of a fowl; and irrigations with wool to be poured upon the head and occiput, and some anti-inflammatory oil is also to be poured into the meatus auditorius. The viscera also are not to be neglected, but suitable cataplasms are to be applied to them. And care is to be taken of the whole body, putting the patients into warm baths and anointing them. If the inflammation continues and nothing else prohibit, Hippocrates directs us to purge them with cholagogue medicines.

On blackness of the meninx. When the meninx turns black, if the blackness be superficial, and has been brought on by medicines which have that property, we may remove it by applying three parts of honey with rose-oil upon pledgets, along with the other suitable treatment. But if the blackness has come on spontaneously, more particularly if deep-seated, and be attended with other dangerous symptoms, then we must refrain from using them, for these appearances indicate a dissolution of the natural heat. I knew a person who had his skull trephined a year after the accident, and recovered. The fracture was from a weapon, and was situated on the bregma, and the discharge having an outlet, the meninx was thereby preserved free from injury.

Commentary. Hippocrates very properly lays it down as a rule that no injuries of the head are to be considered as trifling, since wounds affecting only the integuments will sometimes prove dangerous if neglected. He treats distinctly of fissures, contusions, and fractures of the cranium, which is an excellent arrangement of these accidents. Our limits, however, will not allow of our entering minutely into an explanation of his modes of treatment. In fractures of the head he forbids liquid applications, especially wine. He calls the trephine by the name of τρύπανον; and makes mention of a raspatory (ξυστὴρ). It would appear that his object in applying the trepan was altogether preventive; that is to say, that he had recourse to the operation in order to prevent inflammation and swelling of the brain, and not to remove the effects of them. He holds that severe contusions without fracture and fissures are more dangerous than injuries attended with depression and considerable separation of the fractured portions, and it is in the former class of cases that he recommends trepanning. When the bone is broken into several pieces, he says it stands in no need of the trephine. One of the varieties of fracture, which he describes with surprising accuracy, is the separation of the bones at a suture. It, he adds, seldom requires the use of the trephine. He remarks, that convulsions often occur in consequence of injuries of the head, and that the convulsions are in the opposite side to that in which the injury of the brain is seated. He gives an excellent account of erysipelas of the face supervening upon injury of the head, and recommends it to be treated with cholagogues. Altogether, his work ‘On Injuries of the Head’ bespeaks extensive acquaintance with the subject, and we need have little hesitation in pronouncing it to be one of the most valuable relics of antiquity. In one of his aphorisms, he states that concussion of the brain occasions loss of speech; that is to say, as Galen explains his meaning, superinduces apoplectic symptoms.

Galen mentions three sorts of instruments for operating upon the cranium, namely the cyclisci, the lenticulars, and the narrow raspatories. Fractures are classed by him into those which extend only to the diploe, and those which penetrate to the inner surface of the bone. He likewise divides them into simple fissures, contusions, and depressions inflicted by the body, which occasioned the injury. When the fissure extends down only to the diploe, he directs us to scrape down the bone with raspatories, and then to apply the medicines called cephalics, consisting of Illyrian iris, the farina of tares, manna, birthwort, and panacea. Of the fractures which extend to the meninx, if a simple fissure, it may be treated in the same manner by raspatories; but if attended with contusion, by perforating it all round with an auger (trepan?), and then using the scalpel, or by means of the cyclisci at once. Some, he says, instead of these instruments, use the abaptista, which had a circular border projecting a little above the sharp extremity of the perforator. Some, he says, from timidity, use only the instrument called chœnix (modiolus). Of all modes, however, he prefers that by the lenticular, as stated by our author. He then defines the engeisoma and camerosis, which we have translated the depressed and the arched fractures, the former being attended with depression, and the latter with elevation in the middle of the fracture. These are to be taken out entire by means of a lenticular or bone forceps. This, by the way, was the practice of the celebrated Heliodorus, of whose opinions on this subject we will give a short abstract below. (Nicetæ Collectio.) Such is Galen’s general treatment of fractures of the skull. In a word, he lays it down as a rule, that parts which are greatly comminuted, must be entirely removed; but that fragments, which extend far, must not be followed to their extremities. He forbids the use of bandages. He mentions having trepanned the head occasionally, but states that he generally left this task to the Roman surgeons. Sprengel remarks, that Galen was averse to the use of the trepan, and preferred the two instruments called by him φακωτὸς and κυκλίσκος. The latter, he remarks, was, properly speaking, a hollow chisel (un ciseau creux), which he drove in with a hammer. The former was a true lenticular-knife, resembling that described by Petit and Bell (Hist. de la Méd., 18.)

We will now attempt an abstract of Celsus’s lengthy account of these accidents. When the skull has been struck, he recommends us in the first place to inquire whether the person has vomited bile, has experienced dimness of vision, with loss of speech, or a discharge of blood from the nose and ears; whether he fell down at the time, and if he lay in a comatose and senseless state. These symptoms, he says, indicate a fracture of the bone, and the accident is to be looked upon as serious. But if torpor has come on, with mental aberration, paralysis, or contraction of the tendons, it is probable that the membrane of the brain has been injured, and little hopes of recovery need be entertained. In order to ascertain whether or not the bone be fractured, nothing answers better, he says, than making an examination with a specillum (sound), that is neither too sharp nor too blunt. If the bone is felt to be everywhere smooth, we are certain that it is sound; but if roughness is detected, we know that it is occasioned by a fracture. He warns us, however, not to mistake a suture for a fissure, as was once done by Hippocrates, upon whom he bestows a merited eulogium for this frank confession of his own blunder. When this method of inspection does not succeed, he advises us to pour writing ink on the part and to scrape the bone, which will appear black when there is a fissure. Sometimes, however, he adds, the blow has been sustained on one part of the skull, and the fissure occurs in another. This is the case of fracture by repercussion, of which we will make further mention afterwards. Celsus says, we ought to suspect the existence of it when symptoms of fracture have occurred without our being able to detect one in the part which received the blow. He also recommends us, if softness and swelling be detected in any part, to examine it, as it is likely that a fissure of the bone may be found there. (By the softness and swelling, of which he speaks, he probably meant the puffy tumour, described by Mr. Pott, in his work on ‘Injuries of the Head.’) Sometimes, he adds, but rarely, although the skull be safe, a vessel in the membrane of the brain bursts and pours forth much blood, which, becoming coagulated, occasions great pain and dimness of sight. In such a case, he says, the pain will point out the seat of the extravasation, and if an incision be made in the skin, the bone will be found to be pale—“eo loco cute incisâ, pallidum os reperitur.” (Heliodorus, in like manner, states that when extravasation has taken place within the cranium, the bone will be found to be pale—Nicetæ Collectio.) The fact that in cases of extravasation below the skull the bone is pale, that is to say, does not bleed, is pointed out by Mr. Abernethy as an unerring guide to practice in such cases. He says, “unless one of the large vessels of the dura mater be wounded, the quantity of blood poured out will probably be inconsiderable; I believe that a bone so circumstanced will not be found to bleed.” Celsus then proceeds to the description of the operation. If the injured portion of the bone is not sufficiently exposed, he directs us in the first place to enlarge the wound of the integuments. The periosteum is then to be scraped away with a raspatory. The form of the incision, if made solely by the operator, is to consist of two cross lines intersecting one another like the letter Χ, from the extremities of which the skin is to be dissected away. If there be a discharge of blood it is to be stopped by a sponge dipped in vinegar, or by compresses, while the head is elevated. In cases of fracture and fissure of the cranium, the ancient surgeons, he says, had immediate recourse to instruments for cutting out the part; but he recommends the surgeon, in the first place, to try the effect of applications for allaying the irritation, such as suitable plasters, with wool soaked in vinegar, proper bandages, and the like. This treatment is to be continued for five days, and on the sixth the part is to be fomented with a sponge soaked in warm water. If the skin begin to heal, and the fever to abate, and if the appetite return, with sound sleep, he recommends perseverance in the use of these applications. In this manner, he adds, fissures will often be filled with callus; thus, also, bones more extensively fractured may become united with callus, which forms a much better cover to the brain than the common integuments after a piece of bone has been cut out. But if, on the other hand, fever set in at the first with disturbed sleep, a copious discharge from the wound which shows no appearance of healing; if the glands of the neck swell, or if violent pain comes on, with loathing of food, the surgeon must proceed forthwith to the operation. Dangerous consequences, he adds, may arise either from a fissure or a depression. A fissure may allow fluids to descend to the membrane of the brain, and thereby give rise to pain and inflammation. A depression in like manner may occasion irritation, and spiculæ of bones by wounding the brain may prove particularly troublesome. As a general rule, he recommends as little of the bone as possible to be removed. If the one edge overtop the other, it will be sufficient to remove with a raspatory the prominent part; for when it is taken away there will be a sufficient opening for the cure. If the edges are firmly compressed together, a hole is to be bored with a wimble (terebra) on its side, at the distance of a finger’s breath, and from it two lines are to be cut to the fissure with a raspatory (scalpel), in the form of the letter V, so that its vertex may be at the hole, and its base at the fissure. If the fracture be long, more of these holes must be cut out. In cases of depression the whole depressed portion must be removed. In whatever way the pieces of bone are cut they are all to be removed by means of a suitable forceps. But we will not occupy more space in explaining his method of operating, as we have been already more than usually prolix. Enough has been said to show that the practice of Celsus was sensible, and in many respects not very different from that which is now followed in such cases. It will be seen that he was not forward to perforate the skull, and that many of the rules of treatment lately laid down as new discoveries are distinctly mentioned by him. For a description of the instruments used by him, namely, the modiolus, terebræ, and scalper excisorius, we must refer the reader to the original work. (viii, 3.)

The different kinds of fracture to which the skull is subject, and the treatment of them, are given very minutely in the Fragments of Heliodorus, published by Cocchi (Ch. Vet. 100, &c.); but as the views of the subject there laid down are nearly the same as our author’s, we shall only give a few specimens of the doctrines he inculcates. He describes very distinctly the species of fracture called diastasis, namely, the separation of two bones of the head at a suture. He directs that the head should be moulded into its former shape, and secured with compresses and tight bandaging. When matter forms he recommends it to be cut down upon. When depression of the bone without fracture occurs in children, it is not to be much interfered with, if no untoward symptoms come on. But if any collection take place, it is to be evacuated, even if trepanning should be required for this purpose. He says, in the treatment of simple injuries of the scalp, that the cure by the first intention is the quickest, but the suppurative the safest. In the same Collection there are a few fragments of Archigenes, containing some curious and important matter. He describes diastasis of the bones with more minuteness than any other ancient author, but does not touch upon the treatment. He appears to treat of hernia cerebri under the name of hypersarcosis, and recommends the excrescence to be removed, with septic medicines or the scalpel, down to the membrane (dura mater); after which a light dressing dipped in rose-oil is to be applied, and the part surrounded with a circular bandage. (Chirurg. Vet. p. 119.) Effusion of blood within the cranium is indicated by fevers coming on with chills, inordinate heat, disturbed sleep, eyes glossy, muddy, and red, loss of flesh, &c. In such cases, he remarks, if operated upon speedily, they exhibit promises of recovery, but generally soon die. (Ibid. 117.)

Albucasis enumerates the same varieties of fracture as our author, and his description of the operation is little different. The drawings which he gives of the surgical instruments used by the ancients in operations on the head are interesting, as they tend to illustrate the descriptions of Paulus and the other authorities. We may remark, by the way, that his abaptista, which he calls terebra non profundantia, are a sort of spear-shaped instruments, having a globular ball a short way above their extremity. They, therefore, had no resemblance to a modern trephine with a conical crown.

Avicenna gives a very full account of injuries of the head, but it is taken almost word for word from Galen and our author. Nearly the same may be said of Haly Abbas.

Avenzoar states that trepanning the skull will be proper when there is fracture with depression; but laments that in his time it would be difficult to find a surgeon capable of performing the operation. Averrhoes likewise intimates that he did not know a surgeon who could trepan the skull. This is an additional proof to what we have mentioned in the section on amputation that the Arabians in general were very timid operators.

Rhases strongly inculcates the propriety of having recourse promptly to the operation, when the bone is fractured and depressed, before dangerous symptoms have come on. Unless there be pressure on the brain, however, he does not approve of having immediate recourse to the operation.

It will be remarked that Celsus affirms, and our author denies, the occurrence of fracture by repercussion. It is the same as la fracture par contre-coup of the French medical authors, or the counter-fissure, namely, the fractura per resonitum of the earlier authorities. Soranus, who, like Celsus, believes in its occurrence, defines it to be a fissure which takes place in the part of the cranium opposite to that which received the blow. (Nicetæ Collectio.) Hippocrates himself makes mention of the counter-fissure, and pronounces it to be incurable, as the surgeon has no certain data to discover its existence. (Vul. Cap. viii.) Tulpius, Paré, and Van Sweiten have related cases of the counter-fissure. (See Comment. in Boerhaav. Aph. 254.) Heister also believed in its occurrence. (Chirurg. i, 1, 14.) For cases of it he refers to D. Wagnerus, (Dissert. de contra-fissura,) and Le Maire (De resonitu.) He is mistaken, however, when he quotes Ægineta as an authority for it. Sabatier relates a case of fracture par contre-coup in the sternum occasioned by a fall on the back. (Mémoires de l’Institut Natural, ii, 120.) See also Sprengel (Hist. de la Méd. 17.) Garengoit further relates various cases of the contre fissure. Bertaphalia defines it in much the same terms as Soranus. (v, 5.) Mr. Guthrie treats learnedly of this subject; but although he quotes many instances from the earlier authorities of fracture on one side of the head from a blow on the other, he states that in later years there is little proof of such an occurrence taking place. He admits, however, as indisputable the occurrence of fracture at the base of the skull from a blow on the vertex or back of the head. (Injuries of the Head, 65.) He also states that the term ἀπήχημα of our author, and that of ‘resonitus,’ as used by Latin authors, was applied to that species of fracture when the inner plate of the skull is knocked in or fractured, without the outer one being injured. (Ibid.) It does not appear, however, that the ancients applied the term in this sense. Thus Soranus, as stated above, defined it to be a fissure produced in the parts of the skull opposite to those which have received the blow. See the learned note of Cocchi. (Ap. Chirurg. Vet. 47.) Galen’s definition is to the same effect. (Ibid. 107.)

The treatment here recommended for inflammation of the membranes of the brain is so judicious, that even at the present day scarcely any improvement could be made on it. Our late authorities have shown the utility of cholagogue purgatives in such cases, and it will be remarked that they are recommended by our author and Hippocrates. (De Cap. Vuln. 27.)

Celsus directs us, when the dura mater gets inflamed and swelled, to pour tepid rose-oil upon it; and if it rise above the bone to apply lentil or vine leaves pounded with fresh butter or the grease of geese. He enjoins us to avoid all kinds of food requiring mastication, also smoke and sternutatories. When the brain projects beyond the bone (a case called hernia cerebri by modern surgeons), he advises us to sprinkle it with squama æris, and to use cicatrizing applications. A person who has sustained a fracture of the skull is advised to avoid the sun, wind, frequent baths, and the free use of wine until the wound is healed.

Aëtius recommends bleeding and laxative clysters. (vi, 47.)

Heliodorus recommends abstinence at first, and afterwards spare diet, water for drink, bleeding, when the inflammation is violent and the patient full, light dressings, cataplasms of melilot, linseed, and oil, and fomentations with decoctions of fenugreek or mallows. Archigenes directs us when there is a fungous tumour projecting above the bone, to remove it with septics or the scalpel, and then to apply pledgets. (Nicetæ Collect.)

Avicenna and Albucasis repeat our author’s directions. Haly Abbas follows in the same strain, recommending us to remove any cause of irritation, to pour refrigerant oils on the place, and to have recourse to venesection. (Pract. ix, 85.)

Our author having alluded to the pulsatory motion of the brain, we will state briefly the opinions of the principal ancient and modern authorities on this matter. Besides our author, Hippocrates, Galen, Oribasius, and Aëtius, among the ancients, mention a certain movement of the brain, namely, a swelling up during expiration, and a falling down during inspiration. Fallopius, Vesalius, Voltherus, Coiter, and Boerhaave maintained that this opinion is unfounded. But Columbo, Piccolomini, Dulaurens, Riolan, Littré, and more recently, Schliting, Lamure, Haller, Lorri, Vic d’Azyr, and Dumas, have reproduced this ancient truth. We once had an opportunity of observing the pulsatory motion of the brain in the case of a poor boy who had lost a considerable piece of the skull by exfoliation.

This would appear to be the most suitable occasion which we shall have to introduce an account of the osseous tumour, nearly all the information regarding which is derived from a fragment of Heliodorus. He describes it as a hard resistent tumour, immoveable, without pain, or change of colour. He says it occurs on all parts of the body, but more especially on the head, about the temples, when if one is formed on each side they are called horns. He directs that the tumour should be cut out from the very base, and the bone scraped with a raspatory. The wound is to be healed by glueing (the first intention?), if possible, but otherwise by suppurative applications. (Ch. Vet. 124.)

SECT. XCI.—ON FRACTURE AND CONTUSION OF THE NOSE.

The under part of the nose being cartilaginous does not admit of fracture, but it is liable to be crushed, flattened, and distorted; but the upper part being of a bony substance is sometimes fractured. In such cases Hippocrates prohibits bandaging, which only increases the flatness and distortion, unless when from a blow the parts about the middle of the nose protrude. For in these cases he applies a suitable bandage with medicines, in order to give the nose its proper shape. When, therefore, the nose is fractured in its under parts, having introduced the index or little finger into the nostril, push the parts outwards to their proper position. When the fracture is of the inner parts this is to be done with the head of a probe immediately, during the course of the first day, or not long afterwards, because the bones of the nose get consolidated about the tenth day. But they are to be put into the proper position with the index-finger and thumb externally. In order to prevent the bones from changing their position, two wedge-like tents, formed of a twisted linen rag, are to be applied, one to each nostril, even if but one part of the nose be deranged, and these are to be allowed to remain until the bone or cartilage gets consolidated. And some sew the quills of the feathers of a goose into the rags, and thus introduce them into the nose, in order that they may preserve the parts in position without obstructing the respiration; but this is unnecessary, as respiration is carried on by the mouth. If the nose become inflamed we may use some anti-inflammatory application to it, such as that from juices (diachylon), the one from vinegar and oil, and such like; or a cataplasm of fine wheaten flour boiled with manna or gum may be applied, both for the sake of the inflammation and in order to keep the nose in position. When the nose is distorted to either side, Hippocrates directs us, after it has been restored to its proper position, to take a piece of leather of a finger’s breadth, and having spread one of its ends with taurocolla or gum, to fasten one extremity of it on that side of the nose to which it inclines, and after it dries to bring the thong by the opposite ear to the occiput and forehead, and to fix the other end of the thong firmly there, so that the nose being drawn sideways may take the proper position in the middle. This practice, however, is not much approved of by the moderns. If the bones of the nose are broken into small pieces we must make an incision or enlarge the wound, and having removed the small bones with a hair forceps, unite the divided parts with sutures, and use the applications for recent wounds and those of an agglutinative nature. If there be a sore within the nose it is to be cured with the pledgets called lemnisci, spread with suitable ointments. Some also use leaden tubes until it cicatrize, lest a fleshy excrescence should arise from the ulcer.

Commentary. Some account of Hippocrates’s practice is given by our author. As here mentioned, he strongly disapproves of bandages which, he says, never fail to disappoint the expectations of both surgeon and patient. He directs us to replace the broken parts, either with the fore-finger or a specillum. He also describes the application of the piece of thong; a distinct account of which is given by our author. (De Articulis, 30.)

Galen, in his ‘Commentary,’ explains the obscurities in the text, but supplies no additional facts or views of practice. He greatly disapproved of agglutinative applications and bandages. (Fragmentum ap. Nicetæ Collect.)

Celsus gives a full account of fractures of the nose, but as he follows the plan of treatment recommended by Hippocrates, it will be unnecessary to dwell long upon it. When the cartilages are fractured, the pieces are to be replaced with a specillum, or with two fingers pressing on both sides; then oblong tents sewed round with a thin soft skin are to be introduced into the nostrils; or a large quill smeared with gum, or artificers’ glue may be applied in like manner. He speaks of the leathern thong, but uses it under somewhat different circumstances than those for which our author recommends it. He directs us to fasten the middle of it to the nose, and the extremities to the temples on either side. When any fragment of a bone does not coalesce properly with the rest, he recommends us to extract it with a forceps. The case, he properly states, is more dangerous when there is an external wound; but in this case he recommends us to apply one of the plasters adapted for recent wounds; like the others he disapproves of bandages.

Rhases, Avicenna, Haly Abbas, and Albucasis lay down exactly the same rules of practice as Hippocrates and our author.

The recent authorities consider the introduction of the tents into the nostrils unnecessary, and even prejudicial. (See Bell’s Operative Surgery; Cooper’s Surgical Dictionary.) But the earlier modern writers adopt exactly the practice of the ancients. Theodoricus recommends us to turn the nose to its proper shape when distorted, by means of a strip of linen fastened to its extremity with ichthyocolla, or the gluten of hides, as directed by the ancients. (ii, 29.)

SECT. XCII.—ON FRACTURE OF THE LOWER JAW, AND CONTUSION OF THE EAR.

We have treated of contusion of the ear in the Third Book, as this affection is not of the nature of a fracture. But the lower jaw is fractured from many causes. If, then, it be only fractured externally, and is not divided into two, as it occasions a curvature inwardly, the symptoms of it are obvious. Wherefore, having introduced the index and middle fingers of one hand—of the right, if the right jaw be fractured, and of the left, if it is the left—we push outwards the internal curvature of the fracture, which is to be secured with the other hand externally. The bones of the jaw are ascertained to be set straight by the equality of the teeth. When the jaw is fractured completely across, (that is to say, caulatim,) it is to be set by making extension and counter-extension, with the aid of an assistant; and the teeth, separated at the broken part, are to be fastened together, as Hippocrates says, and bound with gold, namely, with a ligature or thread of gold. But since this is not readily procured by everybody, a strong flaxen thread, a piece of fine linen, horse-hairs, or the like, may be substituted. If the fracture be attended with an external wound, we must examine with a probe and ascertain whether a piece of bone be broken off, and if this be found to be the case, and the wound is small, it is to be enlarged and the broken piece or pieces removed with some suitable instrument, and the lips of the wound united with sutures; then dressings suitable to recent wounds with bandages are to be applied. If there be no wound, a simple cerate is to be applied to the jaw along with suitable bandages. In applying the bandage, the middle of it is to be placed on the occiput, and the fold of it brought along by the ears on both sides to the chin, and then from the chin to the occiput again, and then again to the chin, and thence by the cheeks to the bregma, and then again to below the occiput, where the bandage must terminate. Upon these again a cover, that is to say, another bandage, is to be applied to the forehead and fastened behind the head, in order to secure the aforementioned bandages. Some, also, apply a light splint, or a piece of leather of proper size, to the jaw, and bandage it as we have described. Others use the bandage called a muzzle. If both sides of the jaws are separated at the symphysis, having removed them a little asunder with both the hands, adapt them again to one another, and having fastened the teeth together as aforesaid with a ligature, and applied the proper bandages, order the patient to be nourished with thin soups, because mastication is hurtful in this case. And, if you suspect that it has been deranged from its position, loose the bandages on the third day, and apply them again, and do in like manner until the callus be formed. The callus of the jaw-bone is generally formed within three weeks at most, because it is spongy and full of marrow. If any inflammation come on, we must not neglect the embrocations and cataplasms suitable to it; which practice is to be observed in all cases.

Commentary. Our author’s account of fractures of the lower jaw is taken almost word for word from Hippocrates. (De Articulis.) He divides them into external fractures, and fractures caulatim (or cauledon), which, agreeably to the explanation of this term, given in the 89th section, Galen interprets to be a complete separation of the fractured portions. He directs us to fasten the teeth with a gold thread; and in other respects also his practice is exactly the same as our author’s. His account of fracture at the symphysis is very correct.

Soranus gives a very sensible account of this subject. A transverse fracture, he says, often takes place, but a longitudinal one seldom, and in certain cases it is not attended with any distortion. It is to be recognized by examination with the fingers, when any displacement of the parts and crepitus will be recognized. Fracture in the ramus may be distinguished from dislocation, by there being mobility in the former case, whereas there is none in the latter. (Chirurg. Vet. p. 49.)

Celsus says, that in fractures of the jaw-bone the separated portions are never completely disjoined. When the bone is fairly broken transverse, the tooth at the fractured part protrudes, and is therefore to be secured to the adjoining one with a hair. He then recommends us to apply a double compress, moistened in wine and oil, with agglutinants; and afterwards a bandage or soft piece of leather is to be put on with its middle at the chin, and its extremities fastened above the head. In this, as in every other species of fracture, he recommends at first abstinence, and afterwards, liquid food; not allowing a full diet until the inflammation has subsided. He says, a fractured jaw-bone gets consolidated between the 14th and the 21st day.

Albucasis evidently copies from our author; and Avicenna and Rhases do so avowedly.

Haly Abbas gives a similar account, recommending us to secure the teeth with a thread; and then to apply bandages, and occasionally a compress, as directed by our author.

By the first variety, described by all the ancient authorities, was meant, we suppose, a fracture of the condyle.

SECT. XCIII.—ON FRACTURE OF THE CLAVICLE.

The clavicle in its natural position is united to the sternum at its inner extremity, and at its outer it is articulated with the acromion; and, therefore, as it supports the shoulder and the arm itself, if it undergo a fracture in any part whatever, the portion of it united to the shoulder sinks down, being dragged along with the arm. It is better, then, that the fracture be transverse, and not longitudinal, or partly straight with a lunated extremity, according to the opinion of most surgeons. For that which is fractured transversely, can, by extension and compression with the fingers, be readily restored to its proper position; but the other kinds of fracture have prominences not easily arranged. If, therefore, it be broken in any way through its whole thickness, let one assistant take hold of the arm connected with the fractured clavicle, pulling it at the same time outwards and upwards; and let another pull the opposite shoulder, or at least the neck, and let them make counter-extension. The surgeon then, with his fingers, is to set the fracture, pushing down what is prominent, and drawing outwards what is situated too deep. If more counter-extension be required, a ball of rags, wool, or something such, may be applied below the armpit, and the elbow brought to the rib adjoining to it; and the other things may be done as described already. But if it is found impossible to raise up the end of the clavicle connected with the shoulder that is lodged down below, having laid the man on his back, and placed a moderate cushion under his back, let an assistant push the shoulders downwards, so that the bone of the clavicle which is lodged below may be bent upwards, and then set the fracture with the fingers. But if part of the clavicle be broken off and unconnected, and if we find it irritating the parts, we must make a straight incision with a scalpel and remove the broken portion, and smooth the remainder with chisels, taking care that the instrument called meningophylax, or another chisel be put under the clavicle to make it steady; and if no inflammation is present, we may use sutures, but otherwise, pledgets. And having prepared various splenia (compresses), we must apply the larger and thicker to the projecting part of the bone; and these, when inflammation is present, are to be dipped in oil, but otherwise they are to be applied dry. And having put a moderate ball of wool under the nearer armpit, we apply a suitable bandage round by the armpits, the fractured clavicle and the scapula, bringing the folds in a proper direction; and if the part of the clavicle connected with the shoulder fall downwards, the middle of a broad thong is to be put under the elbow of the same side, and the whole arm suspended by the neck, and the hand is to be slung in another bandage as in cases of bleeding at the elbow. But if, which rarely happens, the outer part be uppermost, we must not have recourse to this arrangement of the arm. The patient must lie in a supine position, and live upon a spare diet, and if necessary, embrocations and other suitable applications are to be made until the callus is formed. The callus of the clavicle is formed in about twenty days at most.

Commentary. Hippocrates gives such an account of this accident as clearly bespeaks his intimate acquaintance with the subject. Transverse fractures, he says, are easily healed, whereas such as are oblique prove more difficult to manage. He justly remarks, that the deformity occasioned by this injury appears at first very great, and annoys both the patient and his physician, but that it gradually becomes less, and the patient, feeling little inconvenience from it, grows careless, and the physician, seeing no evil consequences result from this neglect, acquiesces in it, and presently it is found that proper callus is formed. Hippocrates further exposes the mistake of those who endeavour to push down the projecting bone, which, he justly remarks, cannot be effected. The part which projects, as he states, is almost universally the extremity attached to the sternum, the other portion being dragged down by the weight of the arm; and hence the mistake is obvious of those who attempt to push down the upper extremity. He recommends the patient to lie in bed until adhesion takes place, which generally occurs between the fourteenth and twentieth day. (De Articulis, 16.)

Galen directs us to apply four splenia or oblong compresses intersecting one another like the letter Χ. (Comment, et Fragment, apud Nicetæ Collect.) When the fracture is near the shoulder, Galen recommends the spica bandage (De Fasciis), for a drawing and description of which, see Heister’s ‘Surgery,’ (p. iii, c. 4, §1, c. 3.)

Celsus agrees entirely with the account of the matter given by Hippocrates. When the bone is broken transversely, he says, it will sometimes unite readily without the application of a bandage. In general, as he explains, the upper end of the fractured portions is the part attached to the sternum, the other being attached to the shoulder and dragged down along with the arm. He mentions that this is so generally the state of the parts, that some great masters of the art had declared that they had never seen a case in which the end attached to the shoulder projected, but that Hippocrates, who is rich in information upon these subjects, had affirmed upon his own authority that such an occurrence is to be met with. In setting the fracture he properly directs us to raise the shoulder; and his mode of bandaging would seem to have been little different from that now generally followed. He directs us to fill the armpit with wool, and to apply over the fractured portions of the bone a compress three times folded, and moistened in wine and oil; or, if the bone is broken into many fragments, a splint formed of cane (ferula). If the bones incline to the common position, the arm is to be fixed to the side, but if the outer end has a tendency upwards, the arm is to be tied to the neck. The man is to be laid on his back. All spiculæ of bones are to be cut out, if it is found that they are wounding the flesh.

Albucasis follows our author closely. He particularly enjoins the surgeon when there are any projecting spiculæ, to make an incision and cut them out; after which, a suture may be used to heal the integuments, provided the wound is large. A compress, soaked in rose-oil, vinegar, and wine, is to be applied to allay inflammation. He directs the patient to sleep on his back with a pillow under his armpit.

Rhases, Avicenna, and Haly Abbas give exactly the same account of the accident as Albucasis and our author.

SECT. XCXIV.—ON THE SCAPULA.

The scapula is not fractured in its broad and tabular part, but a fracture may sometimes take place at its spine. The fracture being sometimes what is called by expression, sometimes a simple fracture, and sometimes a piece is broken off. The expression, then, is ascertained by the touch, exhibiting a hollow, and occasioning torpidity of the adjacent arm and a throbbing pain. Simple fracture is known by its roughness and local pain. Both are to be managed according to the anti-inflammatory plan of treatment. When a piece is broken off, which also may be ascertained by the touch, if it gives no disturbance it may be fixed by a convenient bandage, but when it moves about and produces irritation, it is to be removed by an incision, and sutures used, as described above. Bandages like those for the clavicle are to be applied, and the patient is to be laid on the opposite side.

Commentary. Hippocrates has not treated particularly of this fracture.

Celsus treats in general terms of the cheek-bone, breast-bone, the broad bone of the scapula, the spine, os sacrum, &c. If there be an external wound, it is to be healed with suitable dressings; after which the fissure or hole in the bone will fill up with callus. If the skin be entire, he merely enjoins rest, a suitable cerate, and gentle bandages.

Albucasis and Avicenna, as usual, copy from our author. The former states that fractures of the scapula are healed in twenty or twenty-five days. Haly Abbas, like the others, directs us to remove any spiculæ which occasion irritation, to apply soothing cataplasms, and suitable bandages. Rhases remarks that the body of the bone is little subject to fractures, but that its extremities may be broken off. A fracture of the hollow portion of it is ascertained by a rising in the part; fissures are recognized only by the local pain.

SECT. XCV.—ON THE BREAST-BONE.

The middle of the sternum is fractured by simple division and by expression, and the extremity of it is broken off. When, therefore, the fracture is deranged, pain and inequality of the place follow, and there is crepitus upon pressure with the fingers. When by expression, there is violent pain, dyspnœa, and cough, owing to the pleura being irritated; and rarely there is vomiting of blood, a hollow in the fractured place, and yielding thereof. The same treatment is to be applied as that recommended for the scapula. When the fracture is by expression, we may practise Hippocrates’s mode of setting which he recommended for the clavicle when it inclines inwards, having recourse to the supine posture, the application of a cushion upon the back, pressing down the shoulders, and drawing the sides together with the hands. The sides being covered with wool, we apply a circular bandage, having first put on two thongs straight from the shoulders, so that afterwards the two ends may be united in a proper manner, and prevent the circular bandage from falling off.

Commentary. Hippocrates holds injuries of the sternum to be more dangerous than those of the ribs. He recommends in this case a light diet, rest, silence, bleeding at the arm, and so forth. (De Artic. 50.)

Celsus directs this fracture to be treated upon general principles, as explained in the preceding section.

The Arabians evidently follow our author. Albucasis speaks of applying thin splints.

The reader will find, upon reference to the ninetieth section, that a fracture by expression is a comminuted fracture with depression.

SECT. XCVI.—ON THE RIBS.

Of the ribs, called also spathæ, those which are long admit of a fracture in any part, but the false only at the spine, because there only they are of a bony nature; for at their anterior part they are cartilaginous, and are liable to be crushed, but not fractured. The diagnosis is not difficult, for an inequality presents itself to the fingers of the examiner, and there is crepitus with derangement at the fractured part. When the fractured parts incline inwards there is a violent pungent pain, more severe than that in pleurisy, from the pleura being wounded as with a sharp instrument; there is difficulty of breathing, cough, and often vomiting of blood. The other modes of displacement, then, may be rectified by the fingers, but in that inwards this cannot be done, owing to the difficulty of applying distension. Wherefore, some direct us to give much flatulent food, in order that by the inflation and distension occasioned by it the fracture may be propelled outwards. But this is not necessary, for there is no communication between the chest and the organs of nutrition, and besides, the inflammation will be augmented by repletion. Others apply a cupping instrument, which is not amiss, unless a collection of humours should be occasioned by the suction, and the fracture be thereby pushed more inwardly. Wherefore, Soranus says, “Let the parts be covered with wool dipped in hot oil, and let the intercostal space be filled with compresses, in order that the circular bandage applied, as in the case of the sternum, may lie smooth. And let everything be done, as in pleurisy, according to the degree of accident. But if any great necessity compel us, owing to the pleura being irritated, we must divide the skin and lay bare the broken part of the rib; and then putting the instrument for protecting membranes under, to prevent the pleura from being wounded, cut off properly, and remove the irritating pieces of bone. After this the parts which are not inflamed are to be united and cured as recent wounds; but such as are inflamed are to be covered with pledgets dipped in oil. The diet and treatment must be anti-inflammatory, and the patient is to be laid in the easiest posture.”