The seven books of Paulus Ægineta, volume 2 (of 3)

by Aegineta Paulus

SECT. CXX.—ON DISLOCATION AT THE ANKLE, AND ALSO OF THE TOES.

The articulation at the ankle, if but a little displaced, is remedied by moderate extension; but if completely dislocated, it requires greater force. We may endeavour therefore, in this case, to make strong extension by the hands; but if reduction does not take place, having stretched the man on the ground in a supine posture, we are to fasten into the floor a long and strong peg, between his two thighs, so as to prevent the body from yielding to the extension by the foot; or rather let the peg be fastened before the man is laid down; or if we have the large board at hand on the middle of which, as we said, a wooden peg a foot long is fastened, we may make the extension upon it. An assistant then grasping the thigh, and making counter-extension, another assistant is to pull the foot with his hands or by a thong, and the surgeon is to rectify the dislocation with his hands, while some other person keeps the other foot down below. After the reduction it is to be bound carefully, some folds of the bandage being carried along the front of the foot, and some towards the ankle; but we must take care not to include the posterior tendon which is inserted into the heel. And the man is to be kept from walking for forty days; for those who attempt to walk before the cure is completed impair the actions of the part. If from a leap, as commonly happens, the bone of the heel is moved from its place, or if any inflammatory state is brought on, it is to be remedied by gentle extension and reduction, anti-inflammatory embrocations and secure bandages, the man being kept also in a quiet state until the part is restored. And dislocation of the toes, as we said with regard to the fingers, may be remedied without difficulty by moderate extension. In all these luxations and sub-luxations, after the reduction, and rest for a suitable number of days, any inflammation or swelling which may remain in the joints, and occasion a protracted impairment of the function thereof, is to be cured by emollient applications, the materials of which must be known to every one who is conversant with the matters relative to our art.

Commentary. Hippocrates states that dislocation at the ankle is generally produced by leaping from a great height. He remarks that the accident gives rise to excessive swelling of the part. When the parts have been reduced, he directs us to apply a bandage to retain them properly in position, which, he says, it requires some address to perform in a suitable manner. He recommends us to reduce dislocations of the toes and of the bones of the foot like those of the hand. His account of dislocations of the astragalus and of the os calcis is curious, but there is some difficulty in clearly apprehending his views. We need scarcely say that it is a subject still requiring elucidation.

According to Celsus, dislocations at the ankle-joint may take place in all directions. He recommends us to reduce them with the hands, by making extension and counter-extension. He advises us to make the patient lie in bed longer than in ordinary cases.

Oribasius makes mention of only three modes of dislocation at the ankle; namely, inwards, outwards, and backwards.

According to Albucasis, dislocation at the ankle can only take place inwards or outwards. When the bones of the tarsus are displaced, he directs us to restore them by making the patient put his foot upon the ground; and the surgeon, by placing his foot upon it and standing erect, is to push them into their place. After reduction, a splint is to be put under the sole, and secured with bandages. Rhases, Avicenna, and Haly Abbas evidently copy from our author. They give the same account as Hippocrates of dislocation of the astragalus.

Luxations of the tarsal bones are described in Sir Astley Cooper’s ‘Surgical Lectures,’ and other modern works. Modern authors are agreed that dislocations may take place in all directions, and that they may be complete or incomplete. It will be remarked that Paulus makes mention of sub-luxations.

This is the place where we shall be expected to give some account of the knowledge possessed by the ancients of the nature and treatment of Club-foot. It is singular that Hippocrates is almost the only ancient author who has treated of the subject in an interesting manner, and of him one need have little hesitation in affirming, that he displays more practical acquaintance with it than any other writer until the time of Stromeyer. He states that there are more than one variety of this impediment; that it is not, properly speaking, a dislocation, but a declination of the foot from its natural position; and that most cases of congenital club-foot admit of cure, if it be attempted before the limb is much wasted. He gives minute directions for restoring the limb to its proper shape by the fingers, and for securing it with waxed bandages and compresses, above which a piece of stout leather or a plate of lead is to be bound. Over all a leaden boot, like the Chian shoes, may be applied if necessary. By these means, he does not hesitate to declare that the deformity may be generally overcome more readily than one would have believed, “without cutting or burning, or any other complex mode of treatment.” (De Articulis, 62.) Galen’s commentary on this chapter is of use in illustrating the text of Hippocrates, but supplies no additional information for any practical purpose. (v, 642, ed. Basil.)