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.”
Commentary. Hippocrates gives a full and accurate account of this accident. He remarks that when the broken ends of the bone are not pushed inwards, it seldom happens that fever or any unpleasant symptoms supervene. When fever is not present he thinks that abstinence by occasioning an emptiness of the belly, proves rather prejudicial by removing what otherwise tends to support the part affected, which is thereby made to hang unsupported. In this case a slight bandage will be sufficient. The ribs, he says, become united in about twenty days. When the skin about the ribs is bruised by a blow or any other such cause, much blood, he says, is often vomited up. Galen, in his commentary on this passage, states that when the vessels of the pleura are wounded and blood effused into its cavity, a spitting of blood may take place although the lungs themselves have not been injured. The treatment recommended by Hippocrates consists of bleeding at the elbow, enjoining silence, applying folded compresses with broad bandages, neither too tight nor too loose. He directs us to use a double-headed bandage, and to commence at the seat of the fracture. He approves of gentle aperients and restricted diet for ten days, after which period nourishing food is to be given. He adds, that when the proper treatment is neglected, even if no other inconvenience should result from it, a viscid collection is sure to form in the part. When, in addition to this swelling, a chronic pain gets seated in the part, he advises the actual cautery to be applied. (De Articulis.)
Celsus, with his characteristic elegance and terseness, expounds the rules of practice delivered by Hippocrates. He directs us to apply a bandage, to bleed from the arm, to open the belly; to avoid noise, speaking, tumultuous passions, smoke, dust, and whatever is calculated to excite coughing and sneezing. Gruels only are to be taken before the seventh day, after which bread may be used. When the pain is violent he directs us to apply a cataplasm made from darnel, or barley with fat figs. Should a collection of matter take place it is to be opened with a red-hot iron. When mucus forms about the fracture, he recommends the application of the cautery. The above is but an imperfect outline of his admirable chapter on fractures of the ribs.
Avicenna professedly copies from our author. Haly Abbas, Rhases, and Albucasis give nearly the same account, without the slightest addition of any importance. They all approve of making an incision and extracting the pieces of bones which may happen to be irritating the pleura. Albucasis gives a drawing of the meningophylax, or instrument for protecting membranes during the sawing of bones.