SECT. XCVIII.—ON THE VERTEBRÆ, SPINE OF THE BACK, AND OS SACRUM.
The round bodies of the vertebræ may sometimes be crushed, but rarely undergo fracture, in which cases the membranes of the spinal marrow or the marrow itself being compressed, sympathetic nervous affections take place, and death speedily follows, more particularly if the vertebra of the neck be affected. Wherefore, having first given warning of the danger, we must, if possible, attempt to extract by an incision the compressing bone, or if not we must soothe the part by the anti-inflammatory treatment. But if any of the processes of the vertebræ, of which the spine, as it is called, consists, be broken off, it will readily be felt upon examination with the finger, the broken piece yielding and returning again to its position, and, therefore, we must make an incision of the skin externally and extract it, and having united the wound with sutures, pursue the treatment for recent wounds. When the os sacrum is fractured the index-finger of the left hand is to be introduced into the anus, while with the other we manage as we best can the fractured bone; or if we feel any piece broken off, we make an incision and lay hold of it, and apply bandages and suitable treatment.
Commentary. Celsus remarks that when a piece of one of the vertebræ is broken off a hollow is felt in the place, it is attended with pain, and the person is compelled to bend inwards. The treatment is to be conducted upon general principles, as explained under fractures of the scapula.
Albucasis lays it down as a rule that when a fracture of the cervical vertebræ produces paralysis and insensibility of the arms, the case may be abandoned as hopeless. When, after a fracture of the dorsal vertebræ, it is remarked that there is paralysis and insensibility of the lower extremities, and that the alvine and urinary discharges are passed unconsciously, he, in like manner, pronounces the case to be desperate. When a piece of bone is broken off and occasions great irritation, he recommends us, like our author, to make an incision and take it out.
Haly Abbas and Avicenna borrow everything from Paulus.
Rhases gives many curious remarks upon injuries of the spine, but several of them are borrowed from Galen. (De Locis Affectis.) Galen relates many cases to show that retention of the urine and fæces is a common effect of an injury of the spine. He also mentions that loss of speech is sometimes the consequence of the upper part of the spine being injured. Rhases relates the case of a man who lost the sensibility of his arms from an injury of the last vertebra of the neck, produced by a fall from a horse. He states, that when the injury is below the neck the respiration is never affected. He inculcates that whenever there is paralysis of the limbs, or of any part after a fall, it arises from some injury of the spine. (Cont. i.)
When the sacrum or os coccygis is fractured, he directs us to replace the parts by introducing the finger per anum. (Cont. xxix.)
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.)