DISLOCATIONS ***

Transcriber’s Note: The figures appear to have been mis-numbered: there
is no Fig. 23, nor any reference to one in the text.




                        THE APPARATUS USED BY THE
                         GREEKS AND ROMANS IN THE
                         SETTING OF FRACTURES AND
                      THE REDUCTION OF DISLOCATIONS.

                                    BY
                              JOHN S. MILNE,
             General Practitioner in Hartlepool (a smoky town
                   on the Northeast Coast of England).

                             REPRINT FROM THE
                       INTERSTATE MEDICAL JOURNAL,
                         Vol. XVI., Nos. 2 and 3.

                                ST. LOUIS:
                      INTERSTATE MEDICAL JOURNAL CO.
                                  1909.




THE APPARATUS USED BY THE GREEKS AND ROMANS IN THE SETTING OF FRACTURES
AND THE REDUCTION OF DISLOCATIONS.

By JOHN S. MILNE, General Practitioner in Hartlepool (a smoky town on the
Northeast Coast of England).


Let me point out that the scope of the paper does not cover the whole
ground of the wide knowledge possessed by the ancients on the subject of
fractures and dislocations. It is merely an enumeration of the apparatus
used in the treatment of these, with short extracts indicating the method
of employing them. The authorities on the subject are Hippocrates,
in his works on Fractures and Articulations, 460 B. C.; Galen in his
commentaries on these (130-200 A. D.); Celsus (about 20 A. D.); a chapter
by Heliodorus preserved in the works of Oribasius (325 A. D.), and the
little encyclopedia of Paulus Ægineta (6th Century A. D.) I have also
taken a few illustrations from the Armamentarium of Scultetus.

In the treatment of fractures the ancients employed, as we do to-day,
splints, pads and bandages.

Hippocrates in his book on _Fractures_ gives a very complete account of
the method of applying these.

First of all, the limb was smeared with a waxy composition, called
cerate, in order to prevent the bandages from slipping. The bones having
been got into position by means of extension and other manipulations, a
roller bandage soaked in cerate (Fig. 1) was fixed by one or two turns
round the seat of the fracture, and then carried upward for several
turns. (Fig. 2.)

Next, a second waxed bandage was applied, beginning as before at the
fracture, passing downwards for several turns (Fig. 3), and then upwards
to end at the same spot as the first bandage.

Next, elongated pads, formed of folded linen and stiffened with
cerate, (Fig. 4) were laid along the limb in such a way as to cover it
completely, and fixed by the application of roller bandages which had as
before been dipped in cerate.

No splints were applied at this time, so that so far, the treatment
corresponds in principle to the immovable bandages of gum and chalk or
plaster of Paris which we employ to-day. On the third day, the swelling
of the part having subsided and the bandaging having become somewhat
loose, the whole was removed and the limb bathed with hot water, and the
bandages and pads were applied as before.

[Illustration: FIG. 1. Waxing a bandage. After Scultetus. Double spatulæ
of the form shown are found among ancient Roman instruments from Pompeii.]

[Illustration: FIG. 2. Waxed bandage fixed over site of fracture and
carried upwards for several turns. After Scultetus.]

[Illustration: FIG. 3. Second waxed bandage fixed over the site of
fracture and carried downwards for several turns, preparing to return
upwards and end at the top of the first bandage. After Scultetus.]

Three days afterwards, _i. e._, on the seventh day from the accident, the
swelling was expected to be quite gone, and the bandages again loosened,
and now these having been removed and the limb having been bathed, the
pads and bandages were put on as before, but this time splints were
applied in addition. (Fig. 5.) These were narrow and rod-like, and were
arranged all round the limb, the breadth of a finger intervening between
each, and were kept in place by three or four strings tied just tight
enough to keep the splints in position without their action contributing
at all to the compression of the part. The splints were examined every
third day till bony union had taken place, and the whole dressing was
reapplied whenever it became loose.

In addition to the fixation by the above methods the part was further put
at rest by a sling, in the case of the upper limb, and in that of the
lower, by elevating it in bed on a pillow or a box splint.

Compound fractures were not treated with splints until the wound had
healed, but were lightly put up in pads and bandages and laid in a box
splint and dressed frequently. If there was much discharge, a goat’s skin
was placed beneath, to catch the discharge and embrocations.

We shall now consider a little more fully each of the materials mentioned
above.

_Roller Bandages._ Hippocrates says that the bandages should be clean,
light, soft, thin, and without seams, yet strong enough to bear
stretching. Their breadth should be proportionate to the part under
treatment. They should be three, four, or five finger breadths broad, and
as many cubits in length.

Rolling should be practiced with both hands together, and with either
separately, and it should be done quickly, elegantly and without causing
discomfort to the patient.

Sometimes the turns were to be made to the right, and sometimes to the
left, and sometimes a double headed bandage was to be used and applied
crosswise. After the bandage was on, it was to be finished off by
stitching with a needle and thread, lest a knot should cause discomfort.

All the methods of applying the roller bandage which we now employ,
together with many other complicated methods, are described by the
ancients, and will be found described and figured in the works of
Oribasius in the edition of Stephanus (_Medicae Artis Principes_) and
also in Scultetus.

_Pads (or “Compresses”)._ These were made of linen folded three or four
times. They were three or four fingers in breadth, and their length was
proportionate to the part.

They were applied longitudinally in such number as to encircle the limb.

In applying splints extra pads were put on parts where the bone
projected, as at the ankle.

_Splints._ Hippocrates says these should be smooth, even, rounded at the
ends, and concave. They should be secured with strings. Those at parts
where bone was prominent should be short so as not to press on the part.

[Illustration: FIG. 4. Applying the waxed compresses over the bandages.
After Scultetus, but Hippocrates says the compresses ought to completely
surround the limb and not be separated from each other by a space as this
figure shows. It makes the pads look like splints.]

[Illustration: FIG. 5. Applying the splints on the seventh day. After
Scultetus. First the two bandages have been put on, then the waxed pads,
the bandaging to fix which can be seen under the splints.]

[Illustration: FIG. 6. Splint for leg-fracture described by Hippocrates.
Made of elastic rods fitting into loops on shackle-like pads above the
ankle and below the knee. After Littré.]

Palladius says that they should be made of the wood of the lime tree, or,
where this could not be procured, reeds were to be used. They were to
be round, and secured with three loose fillets or ribands, one at their
upper, and one at their lower end, and one at the middle.

Paulus Ægineta says that they should be arranged not more than one
finger’s breadth from each other.

_Special Splints._ A special form of splints for fractures where the
deformity could not be kept reduced by ordinary methods is described by
Hippocrates.

“One should sew two round pads of Egyptian leather, such as are worn by
persons confined for long in shackles, and the pads should be deeper on
their aspect facing the wound, and shallower on that facing the joint,
and they should be well stuffed and soft and easy fitting, the one to the
part above the ankle, and the other to the part below the knee.

“Each pad should have two loops on its inner aspect and two on its outer.
(Fig. 6.)

“Then taking four equal rods of the wood of the cornel tree, each of the
thickness of a finger, and of such a length that they can be fitted into
the loops by bending, adjust them, two on the inside of the leg and two
on the outside.

“They should be of such a length that suitable extension may be kept up.

“The two which are uppermost (as the patient lies on his back) may be
tied together. (Fig. 7.)

“If the apparatus does not fit properly it will do more harm than good,
as indeed any other contrivance will.”

Galen, commenting on this passage, says that the pads which Hippocrates
describes as round are really like snakes or like the sausages which
butchers make, by filling intestines with chopped meat or other such food.

_Minor Splints._ In fracture of the lower jaw Hippocrates bound the teeth
together with gold wire, and applied a light splint of moulded leather on
the outside of the jaw.

In fracture of the nose, Paulus Ægineta says that tents of cloth were
applied to each nostril. Some sewed into these the quills of goose
feathers, so that the patient could breathe through these.

_Box Splints._ Hippocrates says that he is rather at a loss whether to
recommend box splints or not. They are of some use, but not of so much
as many suppose, and a board, unless padded, is rather an uncomfortable
thing for a limb to lie on. (Fig. 8.) However, the common people have
more confidence in the treatment where they are used; and they are useful
in such times as the bed requires rearranging or the patient has the
bowels moved.

If used at all they should be of sufficient length. Those for fracture of
the thigh should reach from the hip to the heel, for, if flexion of the
knee be allowed, distortion of the part is caused.

[Illustration: FIG. 7. Top view of the same to show the tying together of
the two top rods.]

[Illustration: FIG. 8. Box splint or “canal” after Scultetus.]

[Illustration: FIG. 9. The Glossocomium of Galen, applied for fracture of
the thigh. After Vidius.]

[Illustration: FIG. 10. Scamnum of Hippocrates after Littré.]

[Illustration: FIG. 11. Scamnum of Hippocrates after Vidius. It differs
from the description of Hippocrates in having slots instead of grooves,
but it is the oldest figure of the instrument.]

Nothing, however, is more convenient than a cushion or something similar,
either of wool or linen and not hard. It is to be made hollowed along its
middle, and laid below the limb. In any case a shawl should encircle both
splint and limb, as children are swathed in bed.

Paulus Ægineta describes the box splints as of wood or earthenware.
Some applied them only in cases of compound fracture. A better means of
steadying the limb, he thinks, is to make a long pillow of a garment,
and to fold it up at the sides, round the limb, and to steady the whole
with pillows. The garment should be lined with a skin, to catch the
embrocations.

Galen says that they should be rounded externally and hollowed inside.
They were made of different kinds of wood.

Celsus says that they should have in their lower part a hole for the
escape of discharge, and they should have a foot plate.

_Glossocomium of Galen._ This ingenious and useful splint, says Galen,
had been invented by the practitioners of his time.

It took its name, he says, from the Attic name for a box used for storing
papers of value or which one wished to conceal or to carry on a journey,
and was variously spelled glossocomum or glossocomium or with two t’s
instead of two s’s. (Fig. 9.)

It might be applied to the femur or the tibia, and was to be used
continually till callus had formed.

Galen gives a full description of it, but its principle is best
understood from a drawing such as that given by Vidius or Scultetus.

On rotating the handle the upper and lower fragments are simultaneously
pulled apart.

_Dislocations._ The different varieties of dislocations of the joints
were known to Hippocrates nearly as completely as we know them to-day,
and the various manipulations necessary for their reduction are fully
described.

Cases which resisted reduction by means of ordinary measures, such as
extension over the back of a chair or the lower half of a door in the
case of the shoulder, were treated by more powerful apparatus, improvised
or kept for the purpose.

Bands for extension and counterextension were applied. These consisted
preferably of supple leather, but in the absence of these Hippocrates
says that iron chains, cords, or the ropes for ships may be used, being
wrapped round with woolen cloth at the parts where they are to come in
contact with the skin.

In reducing dislocations of the fingers, Hippocrates says that nooses
formed from the twisted bast of palm shoots are suitable. Aristotle
refers to these in his book on the _Parts of Animals_.

The power to be applied was obtained by means of winches or drums on
axles, levers, wedges, screws and pulleys.

[Illustration: FIG. 12. The scamnum in use for Dislocation at the
astragalus.]

[Illustration: FIG. 13. Reduction of a Gibbosity of the spine by the
scamnum.]

Hippocrates only mentions three of these: “Of all the mechanical
instruments used by men the most powerful are these three, the winch,
the lever and the wedge.” He does not mention the screw, though it is
most likely that the Greeks of his time knew of it, but we shall see
that later the Greeks applied it, as in the machine of Nymphodorus, to
generate power for reducing dislocations.

Hippocrates does not in this passage refer to the use of the pulley,
though in another place he mentions it in connection with the treatment
of fracture of the spine, and we shall see several instances of its use
for converting the direction of motion in machines for the reduction of
dislocations.

In one of these, the machine of Fabrus, a system of pulleys is arranged
to give a considerable increase of power, so that it is not unlikely
that block and tackle arranged to multiply power would be used as well,
although we have no direct description of such.

We may note that Scultetus (Tab. xxi) illustrates a block and tackle
which he says that he has taken from Vitruvius, Lib. 10, ch. x, and which
he says was in use in his day for the reduction of dislocations.

As many of the surgeons were “_periodeutae_,” traveling about from
place to place, it was not possible for them to carry about the heavy
contrivances that the practitioner settled in a large town could have at
his command, but Hippocrates shows how to improvise imitations of these,
and small winches which could be attached to such household implements as
ladders were carried as part of the portable outfit.

_The Scamnum, or Bench, of Hippocrates._ This contrivance, of which the
first account (Fig. 10) is given by the father of medicine, was used by
all succeeding ancient surgeons, and Scultetus shows many figures of it
in actual use in his time. Galen had a very high opinion of it. He says
that all varieties of dislocation could be reduced by it.

Hippocrates says that “the best thing for any physician who practices in
a populous city is to have prepared a proper wooden machine with all the
mechanical powers applicable in cases of fractures and dislocations, both
for making extension and for levering.

“For this purpose, it will be sufficient to possess a board resembling in
length, breadth, and thickness, the quadrangular threshing boards made of
oak.

“It should be six cubits, or a little more, in length, and about two
cubits in breadth. A foot will be sufficient thickness for it.

“Along it from one end to the other an excavation (in the ground) must be
made so that the working of the levers may not be higher than necessary.

“Then at both sides we are to raise short, strong, and firmly fixed posts
carrying axles; and in the middle of the bench five or six long grooves
are to be scooped out, about four inches distant from each other, three
inches will be sufficient breadth and also depth for them, and although
the number of grooves I have mentioned will be sufficient there is
nothing to prevent their being made all over the bench.

[Illustration: FIG. 14. The scamnum in dislocation of the elbow, after
Vidius.]

[Illustration: FIG. 15. Reduction of dislocation of the Humerus by the
scamnum. After Vidius.]

“And the bench should have in its centre a fairly deep hole of a square
shape, and of about three inches in size, and into this hole, when judged
necessary, is to be adjusted a corresponding piece of wood, rounded in
its upper part, which at the proper time is to be adjusted between the
perineum and the head of the thigh bone. This upright prevents the body
from yielding to the force dragging downwards by the feet. For sometimes
this piece of wood serves the same purpose as counterextension (i. e., by
thongs) in an upward direction, and sometimes, too, when both extension
and counterextension are made, this piece of wood, if susceptible of
some motion to this side or that, will serve the purpose of a lever for
pushing the head of the thigh bone outwards.”

It is on this account that several grooves are scooped out in the bench.

The lever may be round or flat to suit different cases. Another mode of
using the scamnum was to raise two posts at the middle of the sides, and
to insert into them a transverse bar like the step of a ladder, to act as
a horizontal perineal bar.

Figure 10 shows the machine constructed from this description by Littré.

A figure of the machine, by Vidius, is somewhat different, (Fig. 11)
square holes taking the place of the longitudinal grooves described by
Hippocrates.

I shall now proceed to give a few descriptions of actual applications of
the machine to reduction of different dislocations, which, it is hoped,
will be readily understood by the aid of the accompanying figures, which
are mainly taken from drawings by Vidius in illustration of a chapter by
Heliodorus. One cannot help thinking that this machine must originally
have given the idea for the instrument of torture known as the rack. This
was well known in the time of Cicero.

Celsus says that the scamnum was quite powerful enough to produce rupture
of the muscles.

Fig. 12 shows the machine in use for dislocation forwards of the
astragalus. Extension and counterextension are being made by thongs
fastened below the knee and above the ankle.

Fig. 13 shows an attempt at reduction of the spine. Extension is being
made below the seat of the lesion by a thong passed round the abdomen
above the crest of the pelvis, while counterextension is maintained by a
thong passed under the armpits.

The operator’s assistant is levering down the gibbosity with a flat board
used as a lever.

Fig. 14 shows the reduction of a dislocated elbow. The forearm is pulled
down by a thong passed over its middle, while counterextension is
maintained by thongs attached to the humerus and the forearm near the
wrist.

[Illustration: FIG. 16. The Scamnum in dislocation of the jaw. After
Vidius.]

[Illustration: FIG. 17. Counterextension by an axillary loop on the
injured side and a perineal band on the other. Extension by a clove hitch
above the knee. The surgeon’s hands are seen levering the head of the
bone inwards while the assistant props the left side of the body.]

Fig. 15 shows reduction of the humerus. While the extension and
counterextension are made, the assistant pulls outwards the head of the
humerus by a thong passed under the arm in the axilla.

Fig. 16 shows reduction of a dislocated jaw. Heliodorus is the only
author who describes the use of a machine for this purpose, and it seems
rather a superfluous display of force but it may occasionally have been
necessary, as from what Hippocrates says it would seem that owing to the
dearth of practitioners in some parts it was not uncommon to meet with
cases which had remained unreduced for some time.

Of dislocation outwards at the hip (Fig. 17) Paulus Ægineta says:

“If the dislocation is outwards, the extension is to be made as above,
but the thong at the perineum is to be passed by the opposite parts,
the groin at the one side, the clavicle at the other. The surgeon is to
propel the limb from without inwards, the lever being fixed in one of the
furrows formerly prepared, and an assistant fixing the sound nates, that
the body may not yield.”

Hippocrates says that instead of the perineal extension band the upright
perineal prop may be used.

Of dislocation inwards, Paulus Ægineta says that if it be not reduced
after trying with the patient on his back and using the upright perineal
prop:

“The erect piece of wood (Fig. 18) is to be removed, and two other
pieces, i. e. the perineal prop of wood fixed on either side, like posts,
not more than a foot in length, and let another piece of wood be adapted
to them like the step of a ladder, so that the figure of the three pieces
of wood may resemble the Greek letter H, the middle piece of wood being
fixed a little below the tops.

“Then, the man being laid on the sound side, we bring the sound leg
between the posts, underneath the piece of wood corresponding to the step
of a ladder, while the injured one is brought above it, so that the head
of the thigh is upon it; but a folded garment is to be first wrapped
about it to prevent the thigh from being bruised. Then another board of
moderate breadth and of such a length as to extend from the head of the
thigh to the ankle, is to be bound along the inner side of the thigh to
the ankle.

“Then extension being made, either by the pestles mentioned in treating
of the dislocation of the vertebra or some such instrument, the leg is
to be pulled downwards along the board which is fastened to it, so that
by the force exerted on it the head of the thigh-bone may return to its
proper place.”

[Illustration: FIG. 18. The scamnum in dislocation inwards of the thigh.
Counterextension maintained by the horizontal bar.]

[Illustration: FIG. 19. Shows the ambè, fitted into a specially prepared
upright supported on an ornamented base. After Scultetus.]

[Illustration: FIG. 19A. Anterior and posterior views of the machine of
Fabrus. (After Vidius.) Between them is an ambè which has at its axillary
end a bolt to fit into the top cross-bar of the machine.

The power varies only with the ratio of the diameter of the axle to
length of crank. The pulleys do not multiply power.]

_The Ambè._ We have seen that in using the scamnum (Fig. 19) for the
reduction of dislocation inwards of the thigh, Paulus Ægineta, (also
Hippocrates, from whom Paul is copying), recommends us to fix a piece
of board along the inside of the thigh and leg, to assist in levering
the head of the bone into position. A board applied in this way was also
used in reducing the dislocations of the shoulder, either by levering the
board over the back of a chair or the lower half of a door, or by using
it in conjunction with some specially constructed machine, such as that
of Fabrus, with which we shall meet presently.

A board especially prepared for this purpose had a rounded enlargement on
its extremity, to assist in pushing the head of the humerus outwards.

The name of this enlargement (ἄμβη) gradually became transferred to the
whole instrument. The “ambè” was well known in England till well into the
last century.

The time of its disappearance in England may be fixed by a passage in
Adams’ edition of Hippocrates (vol. ii, p. 575) where he says: “Of
late years the ambè has fallen completely into disuse, and none of the
various modifications of it are to be seen except in the cabinets of the
curious.” (This was in 1849.)

Scultetus shows us an ambè mounted in a specially prepared upright for
use in the surgery (Fig. 19).

The ambè is thus described by Hippocrates:

“We must get a piece of wood five, or at least four, inches broad, two
inches in thickness, or thinner, and two cubits in length, or a little
less, and its extremity should be rounded, and made very narrow and very
slender there, and it should have a slightly projecting edge (ἄμβη) on
its round extremity—not on the part that is to meet the chest, but the
head of the humerus.

“A piece of soft shawl should be glued to the end of the piece of wood so
as to give the least pain on pressure.

“Having pushed the end of this piece of wood as far in as possible,
between the ribs and the head of the humerus, the whole arm is to be
stretched along this piece of wood, and is to be bound round at the
arm, the forearm, and the wrist, so that it may be particularly well
secured, but great pains should be taken that this piece of wood should
be introduced as far into the armpit as possible, and that it is carried
past the head of the humerus.

“Then a crossbeam is to be securely fixed between two pillars, and
afterwards the arm, with the piece of wood attached to it, is to be
brought over this crossbeam so that the arm may be on one side of it and
the body on the other and then the arm with the piece of wood is to be
forced down. The crossbeam is to be fixed so high that the rest of the
body is raised on tiptoe.

“This is by far the most powerful method of effecting the reduction of
the shoulder for thus one operates with the lever on the most approved
principles.”

Celsus (Bk. VII, ch. xv) describes the ambè thus:

“A wooden spattle is necessary if the body is rather big and the tendons
are rather strong, and it should be of the thickness of two fingers and
in length reach from the axilla to the fingers. And at the top of it
there is a head rounded and gently hollowed out, so as to receive a part
of the head of the humerus. In it there are two holes at three places
separated from each other by an interval, and in these soft thongs are
inserted.

[Illustration: FIG. 20. Patient with arm arranged in the machine of
Fabrus for reduction of dislocation of shoulder. The thongs from a clove
hitch applied above the elbow are taken over two pulleys above and two
pulleys below so that the clove hitch cannot move up nor down, and the
elbow is thus maintained at the same level. (N. B. These thongs are not
connected to the axle in any way.) Patient strapped so that he cannot
resist the treatment.]

[Illustration: FIG. 20A. Setting a fractured humerus in the manner
described by Hippocrates. After Vidius.]

[Illustration: FIGS. 21 AND 22. Portable winch, known as the plinthium of
Nileus, for affixing to a ladder.]

“This spattle, wound round with a bandage in order that it may not injure
by contact, is so applied to the arm at the axilla that its upper end is
put under the top of the axilla; then by its thongs it is bound to the
arm, at one place a little below the head of the humerus, at another a
little above the elbow, at a third above the hand—indeed the spaces and
holes have been arranged for this purpose.

“The arm, tied in this manner, is passed over the step of a poultry
ladder at such a height that the man cannot stand and while the body is
let down on one side, the arm is made tense on the other, and thus it is
brought about that the head of the humerus—impelled into position by the
end of the board—is reduced, sometimes audibly, sometimes not so.

“Many other methods can be learnt by reading Hippocrates alone but not
one has stood the test of experience better.”

_The Machine of Fabrus._ Heliodorus describes the construction of this
machine, and its application for the reduction of dislocations of the
humerus. Probably it is a machine used by artisans for some such purpose
as the elevation of large blocks of stone, as it seems unlikely that such
a large and cumbrous machine should have been especially invented for the
single purpose of reducing the dislocation of one joint. Two views of the
machine are given, (Fig. 19A).

It consists, as will be seen, of two upright posts supported on a heavy
base, while inside the posts a frame carrying two upright bars is raised
and depressed by the rotation of an axle acting on a system of pulleys.
Through the heads of the upright bars there passes another axle carrying
a padded projection which is placed in the armpit.

The arm is strapped to an ambè in the manner described already and is
passed over the axle, the patient standing on tiptoe outside the machine.
(Fig. 20.)

The arm is maintained at one level by thongs affixed by a clove hitch
above the elbow and passing over pulleys above and below. On rotating the
lower axle the frame is pushed upwards, forcing the head of the bone into
position, while at the same time an assistant forces the head of the bone
outwards by a half turn of the upper axle, causing the padded projection
to push outwards.

_Extemporized Apparatus and Substitutes._ Having now described the
apparatus which was used by practitioners settled permanently in populous
places, we may consider the substitutes for these which were used by
surgeons on their travels, or under other circumstances where the major
apparatus was unavailable.

Hippocrates says we must always be ready to make use of whatever happens
to be at hand.

He says that dislocation inwards at the hip may be reduced in the
following manner.

[Illustration: FIG. 24. Ladder arranged as a machine for the reduction of
dislocations. A Plinthium of Nileus has been tied on the lower part of
it and below this are two pulleys for the converting of the direction of
extension. A similar pair of pulleys have been tied on the top step of
the ladder.]

[Illustration: FIG. 25. Reduction of shoulder by ladder with Plinthium of
Nileus. Extension having been made, the operator is pulling out the head
of the humerus by a thong. The assistant is bearing down on the patient’s
neck.]

It is a good, proper and natural mode of procedure, and has something of
display in it, if anyone take delight in such ostentatious methods.

The patient is to be suspended from a crossbeam by the feet tied together
by a strong, soft and broad cord.

The feet are to be about four inches or less from each other and a broad
and soft leather collar also connected with the crossbeam, is to be put
on above the knees, and the affected leg should be so extended as to be
two inches higher than the other.

The head should be about two cubits from the ground and the arm should be
stretched along the sides, and bound with something soft.

All these preparations should be made while he is lying on his back so
that he may be suspended for as short a time as possible.

When the patient is suspended a person properly instructed and not weak,
having introduced his arm between his thighs is to place his forearm
between the perineum and the dislocated head of the femur, and then,
having joined the other hand to the one thus passed through the thighs,
he is to stand by the side of the suspended patient and suddenly suspend
and swing himself in the air as perpendicularly as possible.

In fracture of the humerus, if the bone be set while the elbow is
extended, the muscles of the arm will assume a different position when
the elbow is flexed.

To set it in the flexed position, therefore, suspend a piece of wood like
the handle of a spade from the roof by two chains one at each end.

Place the patient’s arm over this, so that the bar lies in the axilla.

Over the flexed forearm pass a shawl to which attach a great weight, so
as to produce extension on the lower fragment of the humerus and thus
reduce the deformity.

Apply the waxed bandages and compresses in this position.

_The Pestle._ Of reduction of the shoulder by means of the pestle,—an
article for the preparation of food to be found in every Greek
home,—Hippocrates says:

“Those who accomplish the reduction by forcibly bending it over a pestle
operate in a manner which is nearly natural. The pestle should be wrapped
in a soft shawl for thus it will be less slippery.

“It should be forced between the ribs and the head of the humerus. And if
the pestle be short the patient should be seated on something, so that
his arm can with difficulty pass over the pestle.

“But, for the most part, the pestle should be longer, so that the
patient, when standing, may be almost suspended by it. And then the
arm and forearm should be stretched along the pestle while some person
secures the opposite side of the body by throwing the arms round the neck
near the clavicle.”

Hesiod (Works and Days, 1, 421) says that the length of the culinary
pestle was three cubits.

[Illustration: FIG. 26. Reduction of the ulna.]

[Illustration: FIG. 27. Reduction of both bones at the elbow.]

[Illustration: FIG. 28. Reduction of the shoulder with the ladder in the
horizontal position. Operator pulling head of humerus outwards with a
thong.]

From other passages in Hippocrates it would seem that any pestle-like rod
may be indicated. The word Celsus uses means a staff.

Hippocrates describes several methods of improvising a scamnum.

Any strong couch may be used as the bench, and extension and
counterextension may be produced by poles levered against boards fixed to
the feet of the couch, thongs being attached to the middle of the poles.

Or instead of boards attached to the feet of the couch a ladder may be
placed below the couch and the poles levered against the steps of the
ladder.

If along with either of these methods it were desired to extemporize a
lever to press down a hump back, this could be done by driving a post
into the ground alongside the couch and making a hole in the post for the
end of the lever to play in.

Or the couch could be drawn alongside a wall and a hole made in the wall
for the end of the lever.

In fracture-dislocation of the foot the extension might be made as
follows:

Having fixed in the ground the nave of a wheel or some such object,
something soft is to be bound round the foot.

Next, some soft thongs are to be attached to the foot and the ends of the
thongs are to be fixed to a pestle or similar pole. The end of the pole
is to be fixed in the nave.

On pulling back the pole, the foot is extended, while counterextension is
made by pulling on the shoulders and the ham of the patient.

Or, counterextension can be made by driving a pole into the ground to act
as a perineal support.

_Ladder._ A ladder was an object which was always at hand and of service
in the reduction of dislocations.

In treating of the ambè we showed one use of the ladder, namely to reduce
the shoulder by levering the arm over a step. For other dislocations
portable fittings could be applied to generate power for extension and to
convert the direction of motion.

Thus, two pulleys might be affixed to the top steps and two to the lower,
and a portable winch fitted to the lower part of the ladder.

One simple form of winch for this purpose was called the _plinthium of
Nileus_.

It consisted merely of a small frame carrying an axle, with or without a
ratchet. (Figs. 21, 22.)

Fig. 24 shows a ladder fitted up with pulleys at its top and bottom and a
plinthium of Nileus below.

Fig. 25 shows the reduction of the humerus by a ladder so fitted. The
ladder having been fixed in the ground, the arm has been passed over a
step of the ladder and the plinthium of Nileus has tightened the thongs
attached to the arm till the patient is almost suspended.

The operator is pulling the head of the humerus outwards by means of a
fillet, while an assistant is pressing down the shoulders of the patient.

[Illustration: FIG. 29. Reduction of the wrist. The ladder is probably
meant to be lying flat, but in the figure it is shown tilted up on its
side in order to bring the parts into view.]

[Illustration: FIG. 30. Reduction of the dislocated astragalus with the
ladder in the horizontal position.]

Fig. 26 shows the reduction of the ulna at the elbow, and Fig. 27 the
reduction of both bones dislocated together. Fig. 28 shows the reduction
of the shoulder. The ladder is placed horizontally in this case, the ends
being supported on a pile of wood or stone blocks.

The patient is bound on the ladder, and while extension is made on the
arm, the head of the humerus is pulled outwards by a thong passed inside
it.

Fig. 29 shows the reduction of the wrist, extension and counterextension
are made by thongs affixed below and above the wrist by clove-hitches;
while Fig. 30 shows the reduction of the ankle on similar principles.

(In the case of the wrist the ladder is shown tilted up on its side, in
order to bring the parts into view.)

A portable winch of more powerful principle was the Glossocomum of
Nymphodorus. It is shown in Fig. 31; first, as it appeared when closed
and ready for use, and next, with one of the shutters removed to show its
internal construction.

It will be seen to consist of a crank, the rotation of which causes a
worm on it to turn a cogged wheel.

Round the axle of the cog wheel are ropes passing to another axle, the
circumference of which is increased by drums so as to multiply the power,
after the manner shown in the figure. One whole turn of axle moves
cogged wheel forward one cog. Some of the inner details of the winch are
shown below. Another portable winch was the Trispastum of Apelles or of
Archimedes. Its construction is shown in Fig. 32, which shows the sides
removed to display the working. In actual use, however, it was closed in
like the last winch.

_Reduction by Means of Inflating a Bladder._ In describing the reduction
of the dislocation of the spine Hippocrates says that he has tried to
reduce the deformity by inflating a bladder affixed to a bronze tube and
placed under the spine. The experiment, however, did not succeed for when
the man was fairly extended the bladder yielded, and the air could not be
forced into it, and besides, the hump of the patient was apt to slip off
the bladder.

Hippocrates says he has written this expressly, for it is a valuable
piece of knowledge to learn what things have been tried and have proved
ineffectual, and wherefore they did not succeed.

Again he says that reduction by the bladder was celebrated in the case of
the hip joint.

It is not a powerful method. It should be placed between the thighs
uninflated so that it may be carried as far up in the perineum as
possible, and the thighs, beginning at the patella, are to be bound round
with a swathe, as far up as the middle of the thigh, and then a bronze
pipe is to be introduced into one of the loose feet of the bladder and
air forced into it. The patient is to lie on his side with the injured
limb uppermost.

From this description it would seem that the bladder had consisted of
some small skin such as that of a kid.

[Illustration: FIG. 31. Glossocomum of Nymphodorus. Two views, one
showing it closed and ready for use, the other with the lid removed, to
show the principle. A crank drives a shaft with a worm thread on it. The
threads of the worm engage in notches in a drum. Ropes pass from the
axle on which the cogged wheel drum is carried, to drums carried on a
second axle. Below are parts of the machine showing its structure and
also the method of fixing the rope ends. After Vidius. Power, ONE TURN OF
AXLE only moves the cogged wheel one notch—great power therefore varying
with length of crank. Power still further increased by lower axle being
smaller than drums of upper.]

[Illustration: FIG. 32. Trispastum of Apelles or Archimedes with the
sides removed to show the works. The power depends on ratio of diameter
of axle to length of crank in this figure. But if the lower drums were
made smaller than upper as in Fig. 31, power would be further augmented
accordingly.]

[Illustration: FIG. 33. Succussion on a ladder for dislocation of the
spine. The patient is bound to the ladder by the lower part of the body,
the upper hanging free. The ladder is raised by the pulleys and suddenly
allowed to drop.]

_Succussion, or Suspension on a Ladder._ This was done for dislocation of
the spine, and usually to astonish the mob, Hippocrates says, although so
far as he was aware, the method had never straightened anybody yet. To
the mob, however, things of this sort are wonderful, and they never give
a thought as to their utility.

A ladder was padded with leather, and on this the patient was laid on his
back. The ankles were tied to the ladder by soft strong bands.

The arms were bound to the sides of the patient but not to the ladder.

By means of a rope or ropes affixed to the lower end of the ladder (Fig.
33) it was raised along the gable of a high house or a high tower, or the
mast of a ship fixed in the ground. The ropes should run over a pulley or
a winch.

For the sake of completeness we may conclude with a short account of the
materials used for the treatment of congenital clubfoot by Hippocrates.

Most cases are remediable. After pulling and pushing the parts into
position they are to be retained with cerate, made with a full proportion
of rezin, with compresses or pads similar to those described in the
treatment of fractures, and soft bandages applied in sufficient quantity
but not too tight. The foot should appear to incline a little outwards.

A sole of leather not very hard, or of lead, is to be bound on as you
are about to finish the bandaging, not in contact with the skin. The
bandaging is to be carried up to the top of the calf, and the bandages
are to be finished by stitching. A small shoe of lead is to be bound on
externally to the bandaging, having the same shape as the Chian slippers
had. This, however, should not be necessary. Thus this method requires
neither cutting (tenotomy) nor burning nor any other complex means, for
such cases yield sooner to treatment than one would believe. However they
are to be fairly mastered only by time and not until the body has grown
up in the natural shape, and then recourse is to be had to a shoe.

The most suitable are the buskins, which derive their name from traveling
through mud, for this sort of shoe does not yield to the foot but the
foot yields to it. A shoe shaped like the Cretan is also suitable.

(As Galen, the great admirer and annotator of Hippocrates, confesses that
he is unable to give an exact account of either the Chian slippers, the
buskins, or the Cretan shoes, we may leave it to individual imagination
to conjecture their appearance.)