SECT. XCIX.—ON THE ARM.
When the arm is broken Hippocrates makes the extension thus: he says, “We must take an oblong piece of wood, such as that which is put into the holes at the end of spades, and fastening ropes to its extremities, suspend it transversely from some beam, and placing the man upon some elevated object more erect than what is called the erect sleeping posture, we pass his hand over the above-mentioned piece of wood, so that the middle of the wood may be fitted to the armpit, and his arm being bent at a right angle, an assistant stooping down takes hold of the hand, and then some heavy object, such as a stone, a leaden ball, or the like, is to be fastened to the elbow, and being allowed to hang suspended, in this way you must set the fracture, or instead of a weight an assistant may pull down the arm, and instead of the above-mentioned piece of wood some use the step of a ladder.” Soranus, however, proceeds thus: Having placed the man in a chair, or, which is better, as it occasions less disturbance, in a supine posture, then having put a ligature round the wrist and suspended it from the neck so as to preserve its angular figure, we direct two assistants, the one to apply his fingers below the fracture and the other above, and thus to make the extension. Or if we require stronger pulling we apply two equal pieces of thong to the arm, the one above the fracture and the other below, and giving one of the pieces of thong to the assistant who stands above the patient’s head, and the other to the one at his feet, we order them to make counter-extension. If the fracture be near the top of the shoulder we apply the middle of the thong to the armpit and direct the assistant at the head to hold it, and, while the other pulls in the opposite direction, we make the counter-extension as above. And when the fracture is at the elbow, the ligature is to be applied there or at the wrist. The bones of the fracture being properly set, the extension is to be relaxed, and it is to be bound up according to the method of Hippocrates. When the fracture is free from inflammation and recent, we must use linen bandages of a proper length, and three or four fingers in breadth, which have been soaked in water or oxycrate, but when there is inflammation, thin soft pieces of wool steeped in oil are to be used. And if the fracture be at the middle of the arm the bandaging must commence at the fracture, and after two or three turns the bandaging is to be carried upwards, in order, as he says, that the overflow of blood to the part may be intercepted; and it is to terminate there. A second bandage is then to be applied with its head at the fracture, and, having done as in the former case, carry it from above downwards, and again reverting from thence upwards let it terminate there. There should be a moderate degree of tightness according to our own feeling and that of the patient. If the fracture be near the top of the shoulder, the first bandage should take in the acromion, scapula, and sternum, so as to form what is called the crane bandage. The second one is to extend to the elbow, and reverting from thence to the upper parts it is to take in, with the acromion, the scapula and sternum, like the first bandage. If the fracture be at the elbow, the fore-arm is to be taken in with the bandage, the figure of the elbow-joint being preserved. And so in like manner with the other members, such as the fore-arm, the thigh, and the leg; and when the fracture is in any part near a joint, and not in the middle of the limb, the joint is to be bound along with it. After the bandaging the moderns immediately apply splints, in order to preserve the bones which have been set in their proper shape, tightening them agreeably to the patient’s feeling and the swelling occasioned by the inflammation. But the ancients did not apply the splints until after the seventh day, within which period, as the inflammation had declined, the limb had become less swelled. Hippocrates orders the bandages to be loosed every three days, lest, owing to the part being constantly covered up, distension and pruritus should come on, and that the insensible perspiration might not be obstructed after the bone has become firm; for that by these means not only does a painful pruritus take place in certain cases, but ulceration of the skin is occasioned by the acrimony of the sanious humours. He directs us, therefore, to bathe with tepid water, so as to dispel the humours, but after the seventh day to loose the bandages at greater intervals, because the parts no longer require the expulsion of the humours; the formation of callus thus goes on properly. The splints are to be applied in this manner. Compresses, thrice folded and dipped in oil, are to be put upon the bandages, and if the limb be of equal thickness this is to be done even; but if it is of unequal thickness, the hollow parts are to be filled up with the compresses so as to make the arm of equal thickness for the application of the splints; then the splints being wrapped with a moderate quantity of wool or flax, we apply them around the fracture, being not more than a finger’s breadth distant from one another, binding them moderately tight, and taking care, as much as possible, that the splints do not come in contact with a joint, and being more particularly careful of the inner part of the joint, for there they sometimes occasion ulcers and inflammations of tendons. But there the bandaging must be made slacker; and stronger, on the other hand, where the fracture swells up. It is better that the chest should be moderately bound with the arm, lest by its motions it should derange the position. If inflammation should come on (which we know by the swelling and redness around, and from the limb being more tightly bound than formerly), or if the fracture become deranged, or if, without these occurring, the bandages become slacker, or, on the other hand, tighter than proper, the bandages are to be loosed and everything rectified. The patient is to be laid in a supine position, with his hand upon his stomach, and a soft pillow is to be placed under the arm having a skin upon it to receive the embrocations which run from it. The part is to be bathed with warm oil every day, more especially if inflammation be present, and during the time of inflammation he is to be fed sparingly, and afterwards moderately, to promote the growth of callus. He must lie quiet until the callus is formed, which, in the arm and leg, takes place about the fortieth day. After this the bandages are to be loosed, and after using the bath he is to be treated with plasters suitable to fractures. This mode of procedure is applicable in almost all cases of fracture of limbs.
Commentary. Hippocrates’s account of fracture of the os humeri, as quoted by Paulus, is from the eighth chapter of his work ‘De Fracturis,’ but our author has used considerable liberties in making the extract. The mode of using the piece of wood for suspending the arm is easily understood, from his own description without the commentary of Galen. (See p. 541, t. v, ed. Basil.) In the edition by Littré it is, moreover, well illustrated by a drawing. (T. iii, p. 445.) He directs the splints not to be applied until the seventh day, in order to give time for the inflammation and swelling to subside. He says, the bone gets consolidated in about forty days. He justly remarks, that when distortion of the arm takes place it is to the outside, that is to say, backwards. His method of bandaging for fractures of the arm and fore-arm was the same. He directs us in the first place to put a cerate to the part, and then to apply the first bandage, beginning at the fracture, and carrying it two or three turns upwards, so as to prevent the blood from falling down into the part. The second bandage is to commence above the fracture, and is to be carried downwards. Afterwards splenia or oblong compresses, spread with cerate, are to be laid over them, and these are to be secured by strips of linen cloth. These bandages are to be removed when they become slack, generally about the third day. On the seventh the ferulæ or splints are to be applied, the limb by that time having lost its swelling, and they are to be allowed to remain until the 24th day after the accident. When swellings arise on any part of a limb from pressure, they are to be anointed with cerate or wine and oil, and wrapped in soft wool; and if the splints be hurting the limb they are to be removed for a time. (De Fract. 21.) When the bandages are taken off, he directs that hot water should be poured upon the limb. He recommends a spare diet unless there be a wound of the integuments. (De Fract. and Galen. Comment.) It may be proper to give some more account of the splenia and ferulæ (νάρθηκες), used by Hippocrates in fractures of the extremities. In his work entitled ‘The Surgeon’s Shop’ (ἰήτρειον), he directs the length of the splenia to be made proportionate to the part which they are applied to, their breadth three fingers, their thickness three or four folds, and their number such as to encircle the limb without doing either more or less. It appears quite clear that they consisted of folded linen. The intention of them was to give some support to the part. He directs the splints to be smooth, even, concave, and somewhat shorter than the length of the bandages, in order not to hurt the sound skin. It appears, then, that the whole apparatus used by Hippocrates in the treatment of fractures, consisted, 1st, of two under-bandages, 2d, of splenia or folded compresses, 3d, of the ferulæ or splints, 4th, of an outer bandage to secure the splints. With regard to the cerate used in the Hippocratic system of bandaging, it is important to state that, from a passage in his treatise, ‘Officina Medici,’ it would appear that the cerate was not only applied to the skin, but that, for the sake of greater security, every fold of the bandages was rubbed with it. See Galen’s Commentary on the work, (T. v. p. 692, ed. Basil,) and Littré’s Hippocrates, (T. iii, p. 316.) It remains to be mentioned, that the bandages were secured by means of a thread or with a needle. (Off. Med. 8.) Nothing can surpass the judgment and precision with which Hippocrates lays down his rules for the application of the bandages. (Ibid.)
Galen describes the splenia as being pieces of linen folded three or four times, which are to be laid along the arm longitudinally. He directs us to spread them with cerate. He says that they support the limb. He says distinctly that all the folds of the bandages should be rubbed with cerate in order to give greater support. All his directions for the treatment of a broken limb are most judicious. When at first there is much pain and inflammation, he recommends bleeding and purging; but when the callus begins to form, he directs the patient to use a nourishing diet. Spiculæ and scales of bone are in general to be allowed to exfoliate of themselves, and not removed forcibly by the surgeon. (Comment. and Fragment. ap. Nicetæ Collect.)
Celsus lays down the principles of treatment in fractures of the arm, fore-arm, thigh, and leg so circumstantially, that we can afford room only for an outline of them. He recommends no time to be lost in getting the displaced parts properly reduced. For this purpose, if the limb be strong, two assistants may be required to pull in contrary directions; and if other means do not succeed, thongs of leather, or linen bandages, may be attached to each end of the broken limb to make extension and counter-extension with them. When the ends of the bone have been adjusted, (which is known by the pain and deformity being removed,) the limb is to be wrapped in linen cloths folded two or three times, and dipped in wine and oil. Six bandages or rollers (fasciæ) are then to be applied. The first is the shortest, which is to be three times rolled round the limb upwards in a spiral direction, and three times generally will be sufficient. The second must be one half longer, and is to commence wherever the bone projects; or if there be no projection, at any part of the fracture; and is to be carried first downwards and then upwards, so as to terminate a little above the former. These are to be secured by a broader linen cloth spread with cerate. The third and fourth bandages are then to be applied upon the principle, that the latter is to be put on in the contrary direction to the former; and further, it is to be observed that the third bandage terminates below, whereas all the others terminate above the fracture. Upon the whole, he adds, it is better to secure the limb with many than with tight bandages, these being apt to occasion mortification. When properly applied they ought not to be loose on the first day, yet such as not to give pain; slacker on the second, and loose on the third day. They are then to be removed and again applied, and a fifth bandage is now to be superadded to them; and again, these are to be taken off on the fifth day, and six bandages put on, in such a manner that the third and fifth may terminate below, and all the others above. Whenever the bandages are taken off, the limb is to be bathed with hot water, and proper fomentations applied to allay the inflammation, which will generally be found to have subsided about the seventh or ninth day. Then the bandages are again to be put on as directed above, and ferulæ or splints are also to be added, taking care to put on a stronger and broader splint at the side to which the fractured bone has a tendency to be protruded. These must all be rounded where they come in contact with a joint, to avoid injuring it; they are only to be secured with such tightness as to keep the bones in their place, and when they get loose their thongs are to be tightened. The bandages are to be removed gradually. These are his general directions for all fractures of the extremities, and it is to be remarked that his mode of treatment is essentially the same as that of Hippocrates. He afterwards describes at considerable length the method of setting the broken ends of the os humeri. After this is accomplished he directs us to bind the arm gently to the side. With regard to the splints, he properly recommends the longest to be applied externally; shorter ones on the brawn of the arm (over the biceps muscle?), and the shortest under the armpit. He advises us to remove them frequently when the fracture is situated near the fore-arm; and at these times the arm is to be bathed with hot water, and rubbed with a soft cerate.
It will be seen that the methods of Hippocrates and Celsus, although the same in principle, differ in the following respects. Hippocrates uses three bandages, Celsus six: Hippocrates uses small compresses, Celsus large pieces of linen: Hippocrates uses cerate, Celsus wine and oil.
The Arabians conducted the treatment in much the same way as the Greeks. In cases of fracture of the arm, Albucasis directs us to make the bandages of soft, thin linen cloth; but of broader and firmer linen if the thigh or leg is to be treated. Below them is to be applied a smooth cloth spread with a suitable liniment. After the under bandages have been put on in the manner already described, the splints are to be applied, provided no swelling nor inflammation be present, for in that case they are to be deferred for a few days. These splints are to be constructed from the middle part of the alcanna, or of pine, or of the palm-tree, or of a tree which he calls calingi.
Avicenna directs us to form the splints of the wood of alcanna, or of oleander, or of pomegranate tree, or the like. The length of the splints is to be made equal to that of the limb, and their greatest breadth about three fingers. They are to be secured with another bandage and pieces of tape made of linen cloth. There is to be an interval of a finger’s breadth between each splint. He says, it is best to apply four splints of such a length as to reach from joint to joint. They are to be smooth and even so as not to injure any part. In cases of fracture of the os humeri he directs us to surround the nearest joint with the bandages, and, if the fracture be in the middle, to make them take in both extremities. He recommends us to foment the limb with vinegar and water, or water alone. The arm is to be fastened to the side and the hand laid on the stomach.
Haly Abbas, in giving directions for the treatment of fractures in general, recommends the splints to be made of pieces of alcanna, or any hard wood. Afterwards he directs the limb to be laid upon a table having a pad (pannus) placed on it, which last is to be secured with fillets. He gives particular directions not to apply the splints over the processes of bones, and when inflammation comes on he forbids splints to be used at all; in that case the patient is to be kept upon restricted diet. The bandages are to be removed in the course of three days.
The directions given by the experienced Rhases about the bandages and splints are very similar to our author’s, and therefore need not be repeated.
See an account of the ancient splenia, or compresses, and of the ferulæ, or splints, in Scultet’s ‘Arsenal de Chirurgie.’ (29, 30.) See also Van Swieten’s ‘Commentary,’ (354.) Van Swieten remarks, that although the eighteen-tailed bandage be supposed a modern invention, a similar one is described by Hippocrates, (De Fract.) and by Galen in his commentaries on the same.
Le Clerc gives a pretty full description of the Celsian method of treating fractures. (Hist. de la Méd.) See also Fabricius ab Aquapendente (Œuv. Chir. ii, 3, and i, 4). We are certain it will be generally admitted that the waxed apparatus of the ancients in the case of fractures was probably quite as efficacious as the starched bandages which have been introduced of late years with so much advantage.