SECT. CXXI.—ON DISLOCATIONS WITH A WOUND.
In the case of dislocations with a wound the utmost discretion is required. For these, if reduced, occasion the most imminent danger, and sometimes death, the surrounding nerves and muscles being inflamed by the extension, so that strong pains, spasms, and acute fevers are produced, more particularly in the case of the elbows, knees, and joints above, for the nearer that they are to the vital parts the greater is the danger they induce. Wherefore, Hippocrates, by all means, forbids us to apply reduction and strong bandaging to them, and directs us to use only anti-inflammatory and soothing applications to them at the commencement, for that by this treatment life may sometimes be preserved. But what he recommends for the fingers alone, we would attempt to do for all the other joints: at first, and while the part remains free from inflammation, we would reduce the dislocated joint by moderate extension, and if we succeed in our object we may persist in using the anti-inflammatory treatment only. But if inflammation, spasm, or any of the afore-mentioned symptoms come on, we must dislocate it again if it can be done without violence. If, however, we are apprehensive of this danger (for perhaps if inflammation should come on it will not yield,) it will be better to defer the reduction of the greater joints at the commencement; and when the inflammation subsides, which happens about the seventh or ninth day, then, having foretold the danger from reduction, and explained how, if not reduced, they will be mutilated for life, we may try to make the attempt without violence, using also the lever to facilitate the process. We are to apply the same treatment to the ulcer as recommended for fractures with a wound.
Commentary. Hippocrates, as stated by our author, was decidedly averse to immediate reduction in cases of dislocation complicated with an external wound. Hence, in compound dislocations at the ankle, he forbids us to interfere at first, as attempts at reduction will certainly bring on convulsions or gangrene. Modern experience agrees with that of the father of medicine as to the danger attending these accidents. Compound luxations at the wrist, he says, prove fatal if reduced, but if let alone they generally get better. (De Artic. 64.) Compound dislocations at the knee are said to be particularly dangerous. (Ibid. 66.)
Celsus follows the line of practice recommended by Hippocrates. In cases of compound dislocations at the shoulder and hip-joint, he states that the danger is great if they are left unreduced, but pronounces death to be certain if they are reduced. Like Hippocrates, he approves of immediate reduction only in dislocations of the bones of the feet and hands. Even these, however, are not to be interfered with while the parts are in an inflamed state. He approves of bleeding, a spare diet, and rest. When a naked bone protrudes and cannot be got restored to its place, he advises it to be sawed off. (viii, 25.)
Galen gives his unqualified sanction to the practice of Hippocrates. See his commentary on the work ‘De Articulis’ and ‘Nicetæ Collectio.’
Albucasis, like our author, recommends gentle attempts at reduction before swelling and inflammation come on, and soothing treatment afterwards.
The practice of Haly Abbas differs nothing in principle from that of our author and Albucasis. If reduction has not been performed early, he forbids it until the inflammation has subsided.
Rhases appears to have copied his rules of treatment from our author. He recommends us, if possible, to replace the parts before inflammation comes on, but forbids it while they are in that state, for fear of occasioning convulsions and death.