Galen informs us that the canals were made of different kinds of wood. He speaks of a surgeon in his time who made them from the wood of the phillyrea. He makes mention of a method of supplying their place by means of a bolster laid below the limb and tied round it with fillets. (Nicetæ Collect. and Comment. l. c.)
Avicenna and Albucasis take notice of these machines, but neither of them with approbation. They also speak of securing the limb in the way described by our author.
The canals would appear to be the machines which Rhases mentions by the name of barangi. (Cont. xxix.)
SECT. CVII.—ON FRACTURES COMPLICATED WITH A WOUND.
When a fracture is attended with a wound, if there be a hemorrhage it is to be first stopped; and if there be inflammation, we must use the applications suitable to it; and if there be contusion of the flesh, we must scarify the flesh to remove all apprehension of gangrene; or if gangrene or any other spreading mortification has come on, we must meet it with suitable remedies. The treatment of each of these cases you have had delivered in the [Fourth Book]. When none of these symptoms is present, nor much of the bone exposed, we may use hooks and sutures, and effect the cure by the treatment for recent wounds, having first cut out any broken pieces of bone which move about and produce irritation. But if a large bone project, which, for its size, cannot be brought into contact by the extension, it will require consideration. Hippocrates, then, in fractures of the thigh and arm, dissuades from replacing at once the protruding bones, predicting danger from it, owing to the inflammation or perhaps spasm of the muscles and nerves which are apt to be brought on by the extension. But time has shown that this attempt will sometimes succeed. Of whatever bones, therefore, we endeavour to replace the protruded ends, we must not meddle with them when in a state of inflammation, but on the first day, before inflammation has come on, or about the ninth day, when the inflammation has gone off. We may set them by an instrument called the lever. It is an iron instrument about seven or eight fingers’ breadth in length, and of moderate thickness that it may not bend during the operation; with its extremity sharp, broad, and moderately bent. Its sharp extremity, then, is to be put under the protruding prominence of the bone, and by pushing at the other end while moderate extension of the limb is made, we bring the extremities of the fracture together; or, if we cannot do so, we must cut off the projections by counter-perforators (chisels), or saw them off in the manner described when treating of fistulæ. Having removed the spiculæ of bones and set the limb aright, we cure the wound by dressing with pledgets. But in those members which are double or in pairs, we must take care when the bones of either of them are sawn off, that no contraction of the limb take place, but that it be kept of its proper length by extension. The bandaging is to be thus applied: the circular folds are to be arranged on both sides of the wound, and oblique ones according to the length of the sore, so that they may intersect one another in the form of the Greek letter Χ, and prevent the lips of it from gaping. And when the ulcer is foul, we must apply dressing with cleansing ointments; but if clean, with incarnating, and the other articles of known efficacy. Hippocrates used the pitch-plaster, which is said to have been the same as the ointment, tetrapharmacon, called also basilicon. After the sore has incarnated we apply splints. Some apply them from the first, taking care not to hurt the parts about the ulcer, and tightening them according to necessity, or again slackening them. When a scale of bone is going to exfoliate, which we ascertain from the discharge being more copious and thin, we must remove the loose fungous flesh about it, and the bandages must be applied loose; but having removed the scale with a hook or some such instrument, we must have recourse to tighter bandages. During the whole time of the healing of the sore, the dressing called motophylax with some of the anti-inflammatory medicines is to be laid over the wound, to be kept on with a simple bandage, which is to be removed at each dressing; everything else remaining the same as described in the treatment of the arm.
Commentary. Hippocrates treats of these cases at great length. His method of rectifying the protruded ends of bones by means of a lever, is described by our author. He says, it may be done on the first or second day, but not on the third or fourth, after the inflammation is begun, for fear of occasioning convulsions. Compresses dipped in wine and oil, or soft bandages are to be used, but splints are not to be applied until the sore puts on a healthy appearance. He mentions that some were in the practice of bandaging the limb above and below the wound, and leaving it bare, in order to allow the discharges to escape; but this practice he greatly disapproves of, as tending to produce swelling in the place; and he recommends the whole limb to be well secured with bandages, but then not too tight. He states that all bones which are completely denuded, must exfoliate and come out. When a bone projects and cannot be replaced, he directs the surgeon to cut it off if it irritate the soft parts. No splints are to be applied when there is a bone which it is seen will exfoliate. If it be the summer season, the compresses applied to the wound are to be frequently soaked with wine; but if it be winter, greasy wool is to be dipped in wine and oil and applied. Compound fractures of the thigh or arm, attended with protrusion of the broken bone, are said to be peculiarly dangerous; for if replaced, they are apt to occasion convulsions; and if let alone, they give rise to acute bilious fevers. Some, however, he adds, recover when the bone is replaced. (De Fract. cum Comment. Galeni.) Galen explains, that the danger in cases of fractured femur and humerus arises from their vicinity to important blood-vessels and muscles.
Celsus lays down the rules for conducting the treatment in these cases with great precision. He states, that fractures complicated with a wound of the skin are generally dangerous, especially when it is the humerus or femur. In the latter case he directs us to saw off the ends of the bone. The case of a fractured humerus is more easily managed. The danger is greatly increased when the fracture is near a joint. He recommends us to divide any muscle which may run across the wound, to let blood, and put the patient upon a restricted diet. In other fractures the bones are to be gently replaced. The wound is to be dressed with a pledget dipped in wine, to which roses have been added. This application is borrowed from Hippocrates. The bandages are to be put on somewhat slacker than when there is no external wound. Neither splints nor canals must be used, but broad bandages. The parts are to be fomented with hot oil and wine, and the dressings renewed every day. When a small fragment of a bone projects, if it be blunt, he recommends us to replace it; but if sharp, he directs us to saw it off, and then replace the bones with the hands or a suitable instrument. Sometimes fragments of bones die, and after a time drop out; and sometimes sharp spiculæ irritate the soft parts, in which case he recommends us to enlarge the wound and cut off the projecting points.
The treatment recommended by Albucasis is very judicious. If inflammation be present, he directs us to subdue it by bleeding; and, in that case, reduction is not to be attempted until the ninth day; but in all other cases it is to be done at first. When it cannot be reduced by the hands, an iron instrument seven or eight fingers’ breadth in length, and two fingers broad, is to be used as a lever for this purpose. When the ends of the fracture are sharp and cannot be replaced, they are to be cut off or sawed. His saw bears a considerable resemblance to that of the late Mr. Hey, of Leeds. He recommends an astringent wine as a suitable application, but condemns all cerates which contain oil. The bandages are to be put on very slack. Splints are not to be applied while the wound is irritable and ill-conditioned. When it does not heal, he says we ought to suspect that it is prevented by spiculæ of bones, which are to be sought out and extracted.
Avicenna and Rhases give very proper directions about removing spiculæ of bones, and applying slack bandages, but they evidently copy from Hippocrates and our author.