                                     400 BC
                              ON THE ARTICULATIONS
                                 by Hippocrates
                          translated by Francis Adams
                     ON THE ARTICULATIONS.

  I am acquainted with one form in which the shoulder-joint is
dislocated, namely, that into the armpit; I have never seen it take
place upward nor outward; and yet I do not positively affirm whether
it might be dislocated in these directions or not, although I have
something which I might say on this subject. But neither have I ever
seen what I considered to be a dislocation forward. Physicians,
indeed, fancy that dislocation is very apt to occur forward, and
they are more particularly deceived in those persons who have the
fleshy parts about the joint and arm much emaciated; for, in all
such cases, the head of the arm appears to protrude forward. And I
in one case of this kind having said that there was no dislocation,
exposed myself to censure from certain physicians and common people on
that account, for they fancied that I alone was ignorant of what
everybody else was acquainted with, and I could not convince them
but with difficulty, that the matter was so. But if one will strip the
point of the shoulder of the fleshy parts, and where the muscle
(deltoid?) extends, and also lay bare the tendon that goes from the
armpit and clavicle to the breast (pectoral muscle?), the head of
the humerus will appear to protrude strongly forward, although not
dislocated, for the head of the humerus naturally inclines forward,
but the rest of the bone is turned outward. The humerus is connected
obliquely with the cavity of the scapula, when the arm is stretched
along the sides; but when the whole arm is stretched forward, then the
head of the humerus is in a line with the cavity of the humerus, and
no longer appears to protrude forward. And with regard to the
variety we are now treating of, I have never seen a case of
dislocation forward; and yet I do not speak decidedly respecting it,
whether such a dislocation may take place or not. When, then, a
dislocation into the armpit takes place, seeing it is of frequent
occurrence, many persons know how to reduce it, for it is an easy
thing to teach all the methods by which physicians effect the
reductions, and the best manner of applying them. The strongest of
those methods should be used when the difficulty of reduction is
particularly great. The strongest is the method to be last described.

  2. Those who are subject to frequent dislocations at the
shoulder-joint, are for the most part competent to effect the
reduction themselves; for, having introduced the knuckles of the other
hand into the armpit, they force the joint upward, and bring the elbow
toward the breast. The physician might reduce it in the same manner,
if having introduced his fingers into the armpit on the inside of
the dislocated joint, he would force it from the ribs, pushing his own
head against the acromion, in order to make counter-pressure, and with
his knees applied to the patient's elbow pushing the arm to the sides.
It will be of advantage if the operator has strong hands, or the
physician may do as directed with his head and hands, while another
person brings the elbow toward the breast. Reduction of the shoulder
may also be effected by carrying the fore-arm backward to the spine,
and then with the one hand grasping it at the elbow, to bend the arm
upward, and with the other to support it behind at the articulation.
This mode of reduction, and the one formerly described, are not
natural, and yet by rotating the bone of the joint, they force it to
return.

  3. Those who attempt to perform reduction with the heel, operate
in a manner which is an approach to the natural. The patient must
lie on the ground upon his back, while the person who is to effect the
reduction is seated on the ground upon the side of the dislocation;
then the operator, seizing with his hand the affected arm, is to
pull it, while with his heel in the armpit he pushes in the contrary
direction, the right heel being placed in the right armpit, and the
left heel in the left armpit. But a round ball of a suitable size must
be placed in the hollow of the armpit; the most convenient are very
small and hard balls, formed from several pieces of leather sewed
together. For without something of the kind the heel cannot reach to
the head of the humerus, since, when the arm is stretched, the
armpit becomes hollow, the tendons on both sides of the armpit
making counter-contraction so as to oppose the reduction. But
another person should be seated on the other side of the patient to
hold the sound shoulder, so that the body may not be dragged along
when the arm of the affected side is pulled; and then, when the ball
is placed in the armpit, a supple piece of thong sufficiently broad is
to be placed round it, and some person taking hold of its two ends
is to seat himself above the patient's head to made counter-extension,
while at the same time he pushes with his foot against the bone at the
top of the shoulder. The ball should be placed as much on the inside
as possible, upon the ribs, and not upon the head of the humerus.

  4. There is another method of reduction performed by the shoulder of
a person standing. The person operating in this way, who should be
taller than the patient, is to take hold of his arm and place the
sharp point of his own shoulder in the patient's armpit, and push it
in so that it may lodge there, and having for his object that the
patient may be suspended at his back by the armpit, he must raise
himself higher on this shoulder than the other; and he must bring
the arm of the suspended patient as quickly as possible to his own
breast. In this position he should shake the patient when he raises
him up, in order that the rest of the body may be a counterpoise to
the arm which is thus held. But if the patient be very light, a
light child should be suspended behind along with him. These methods
of reduction are all of easy application in the palestra, as they
can all be performed without instruments, but they also be used
elsewhere.

  5. Those who accomplish the reduction by forcibly bending it round a
pestle, operate in a manner which is nearly natural. But the pestle
should be wrapped in a soft shawl (for thus it will be less slippery),
and it should be forced between the ribs and the head of the
humerus. And if the pestle be short, the patient should be seated upon
something, that his arm can with difficulty pass above the pestle. But
for the most part the pestle should be longer, so that the patient
when standing may be almost suspended upon the piece of wood. And then
the arm and forearm should be stretched along the pestle, whilst
some person secures the opposite side of the body by throwing his arms
round the neck, near the clavicle.

  6. But the method with a ladder is another of the same kind, and
still better, since by it the body can be more safely counterpoised on
this side; and that, while in the method which the piece of wood
resembling a pestle, there is danger of the body tumbling to either
side. But some round thing should be tied upon the step of the
ladder which may be fitted to the armpit, whereby the head of the bone
may be forced into its natural place.

  7. The following, however, is the strongest of all the methods of
reduction. We must get a piece of wood, five, or at least four
inches broad, two inches in thickness, or still thinner, and two
cubits in length, or a little less; and its extremity at one end
should be rounded, and made very narrow and very slender there, and it
should have a slightly projecting edge (ambe) on its round
extremity, not on the part that is to be applied to the side, but to
the head of the humerus, so that it may be adjusted in the armpit at
the sides under the head of the humerus; and a piece of soft shawl
or cloth should be glued to the end of the piece of wood, so as to
give the less pain upon pressure. Then having pushed the head of
this piece of wood as far inward 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 fore-arm,
and the wrist, so that it may be particularly well secured; but
great pains should be taken that the extremity of this piece of wood
should be introduced as far as possible into the armpit, and that it
is carried past the head of the humerus. Then a cross-beam is to be
securely fastened between two pillars, and afterward the arm with
the piece of wood attached to it is to be brought over this
cross-beam, so that the arm may be on the one side of it and the
body on the other, and the cross-beam in the armpit; and then the
arm with the piece of wood is to be forced down on the one side of the
cross-beam, and the rest of the body on the other. The cross-beam is
to be bound so high that the rest of the body may be raised upon
tip-toes. This is by far the most powerful method of effecting
reduction of the shoulder; for one thus operates with the lever upon
the most correct principles, provided only the piece of wood be placed
as much as possible within the head of the humerus, and thus also
the counter-balancing weights will be most properly adjusted, and
safely applied to the bone of the arm. Wherefore recent cases in
this way may be reduced more quickly than could be believed, before
even extension would appear to be applied; and this is the only mode
of reduction capable of replacing old dislocations, and this it will
effect, unless flesh has already filled up the (glenoid) cavity, and
the head of the humerus has formed a socket for itself in the place to
which it has been displaced; and even in such an old case of
dislocation, it appears to me that we could effect reduction (for what
object would a lever power properly applied not it move?), but it
would not remain in its place, but would be again displaced as
formerly. The same thing may be effected by means of the ladder, by
preparing it in the same manner. If the dislocation be recent, a large
Thessalian chair may be sufficient to accomplish this purpose; the
wood, however, should be dressed up as described before; but the
patient should be seated sideways on the chair, and then the arm, with
the piece of wood attached to it, is to be brought over the back of
the chair, and force is to be applied to the arm, with the wood on the
one side, and the body on the other side. The same means may be
applied with a double door. One should always use what happens to be
at hand.

  8. Wherefore it should be known that one constitution differs much
from another as to the facility with which dislocations in them may be
reduced, and one articular cavity differs much from another, the one
being so constructed that the bone readily leaps out and another
less so; but the greatest difference regards the binding together of
the parts by the nerves (ligaments?) which are slack in some and tight
in others. For the humidity in the joints of men is connected with the
state of the ligaments, when they are slack and yielding; for you
may see many people who are so humid (flabby?) that when they choose
they can disarticulate their joints without pain, and reduce them in
like manner. The habit of the body also occasions a certain
difference, for in those who are in a state of embonpoint and fleshy
the joint is rarely dislocated, but is more difficult to reduce; but
when they are more attenuated and leaner than usual, then they are
subject to dislocations which are more easily reduced. And the
following observation is a proof that matters are so; for in cattle
the thighs are most apt to be dislocated at the hip-joint, when they
are most particularly lean, which they are at the end of winter, at
which time then they are particularly subject to dislocations (if I
may be allowed to make such an observation while treating of a medical
subject); and therefore Homer has well remarked, that of all beasts
oxen suffer the most at that season, and especially those employed
at the plow as being worked in the winter season. In them,
therefore, dislocations happen most frequently, as being at that
time most particularly reduced in flesh. And other cattle can crop the
grass when it is short, but the ox cannot do so until it becomes long;
for, in the others, the projection of the lip is slender, and so is
the upper lip, but in the ox the projection of the lip is thick, and
the upper jaw is thick and obtuse, and therefore they are incapable of
seizing short herbs. But the solidungula as having prominent teeth
in both their front jaws, can crop the grass and grasp it with their
teeth while short, and delight more in short grass than in rank;
for, in general, short grass is better and more substantial than rank,
as having not yet given out its fructification. Wherefore the poet has
the following line:

  As when to horned cattle dear the vernal season comes,*

because rank grass appears to be most sought after by them. But
otherwise in the ox, this joint is slacker than in other animals, and,
therefore, this animal drags his foot in walking more than any
other, and especially when lank and old. For all these reasons the
ox is most particularly subject to dislocations; and I have made the
more observations respecting him, as they confirm all that was said
before on this subject. With regard, then, to the matter on hand, I
say that dislocations occur more readily, and are more speedily
reduced in those who are lean than in those who are fleshy; and in
those who are humid and lank there is less inflammation than in such
as are dry and fleshy, and they are less compactly knit hereafter, and
there is more mucosity than usual in cases not attended with
inflammation, and hence the joints are more liable to luxations;
for, in the main, the articulations are more subject to mucosities
in those who are lean than in those who are fleshy; and the flesh of
lean persons who have not been reduced by a proper course of
discipline abounds more with mucosity than that of fat persons. But in
those cases in which the mucosity is accompanied with inflammation,
the inflammation binds (braces?) the joint, and hence those who have
small collections of mucosities are not very subject to
dislocations, which they would be if the mucosity had not been
accompanied with more or less inflammation.

*There is no such line in the works of Homer as they have come down to
us.

  9. In cases of dislocation those persons who are not attacked with
inflammation of the surrounding parts, can use the shoulder
immediately without pain, and do not think it necessary to take any
precautions with themselves; it is therefore the business of the
physician to warn them beforehand that dislocation is more likely to
return in such cases than when the tendons have been inflamed. This
remark applies to all the articulations, but particularly to those
of the shoulder and knee, for these are the joints most subject to
luxations. But those who have inflammation of the ligaments cannot use
the shoulder, for the pain and the tension induced by the inflammation
prevent them. Such cases are to be treated with cerate, compresses,
and plenty of bandages; but a ball of soft clean wool is to be
introduced into the armpit, to fill up the hollow of it, that it may
be a support to the bandaging, and maintain the joint in situ. The
arm, in general, should be inclined upward as much as possible, for
thus it will be kept at the greatest possible distance from the
place at which the head of the humerus escaped. And when you bandage
the shoulder you must fasten the arms to the sides with a band,
which is to be carried round the body. The shoulder should be rubbed
gently and softly. The physician ought to be acquainted with many
things, and among others with friction; for from the same name the
same results are not always obtained; for friction could brace a joint
when unseasonably relaxed, and relax it when unseasonably hard; but we
will define what we know respecting friction in another place. The
shoulder, then, in such a state, should be rubbed with soft hands;
and, moreover, in a gentle manner, and the joint should be moved
about, but not roughly, so as to excite pain. Things get restored
sometimes in a greater space of time, and sometimes in a smaller.

  10. A dislocation may be recognized by the following symptoms:-Since
the parts of a man's body are proportionate to one another, as the
arms and the legs, the sound should always be compared with the
unsound, and the unsound with the sound, not paying regard to the
joints of other individuals (for one person's joints are more
prominent than another's), but looking to those of the patient, to
ascertain whether the sound joint be unlike the unsound. This is a
proper rule, and yet it may lead to much error; and on this account it
is not sufficient to know this art in theory, but also by actual
practice; for many persons from pain, or from any other cause, when
their joints are not dislocated, cannot put the parts into the same
positions as the sound body can be put into; one ought therefore to
know and be acquainted beforehand with such an attitude. But in a
dislocated joint the head of the humerus appears lying much more in
the armpit than it is in the sound joint; and also, above, at the
top of the shoulder, the part appears hollow, and the acromion is
prominent, owing to the bone of the joint having sunk into the part
below; there is a source of error in this case also, as will be
described afterward, for it deserves to be described; and also, the
elbow of the dislocated arm is farther removed from the ribs than that
of the other; but by using force it may be approximated, though with
considerable pain; and also they cannot, with the elbow extended,
raise the arm to the ear, as they can the sound arm, nor move it about
as formerly in this direction and that. These, then, are the
symptoms of dislocation at the shoulder. The methods of reduction
and the treatment are as described.

  11. It deserves to be known how a shoulder which is subject to
frequent dislocations should be treated. For many persons owing to
this accident have been obliged to abandon gymnastic exercises, though
otherwise well qualified for them; and from the same misfortune have
become inept in warlike practices, and have thus perished. And this
subject deserves to be noticed, because I have never known any
physician treat the case properly; some abandon the attempt
altogether, and others hold opinions and practice the very what is
proper. For physicians have burned the shoulders subject to
dislocation, at the top of the shoulder, at the anterior part where
the head of the humerus protrudes, and a little behind the top of
the shoulder; these burnings, if the dislocation of the arm were
upward, or forward, or backward, would have been properly performed;
but now, when the dislocation is downward, they rather promote than
prevent dislocations, for they shut out the head of the humerus from
the free space above. The cautery should be applied thus: taking
hold with the hands of the skin at the armpit, it is to be drawn
into the line, in which the head of the humerus is dislocated; and
then the skin thus drawn aside is to be burnt to the opposite side.
The burnings should be performed with irons, which are not thick nor
much rounded, but of an oblong form (for thus they pass the more
readily through), and they are to be pushed forward with the hand; the
cauteries should be red-hot, that they may pass through as quickly
as possible; for such as are thick pass through slowly, and occasion
eschars of a greater breadth than convenient, and there is danger that
the cicatrices may break into one another; which, although nothing
very bad, is most unseemly, or awkward. When you have burnt through,
it will be sufficient, in most cases, to make eschars only in the
lower part; but if there is no danger of the ulcers passing into one
another, and there is a considerable piece of skin between them, a
thin spatula is to be pushed through these holes which have been
burned, while, at the same time, the skin is stretched, for
otherwise the instrument could not pass through; but when you have
passed it through you must let go the skin, and then between the two
eschars you should form another eschar with a slender iron, and burn
through until you come in contact with the spatula. The following
directions enable you to determine how much of the skin of the
armpit should be grasped; all men have glands in the armpit greater or
smaller, and also in many other parts of the body. But I will treat in
another work of the whole constitution of the glands, and explain what
they are, what they signify, and what are their offices. The glands,
then, are not to be taken hold of, nor the parts internal to the
glands; for this would be attended with great danger, as they are
adjacent to the most important nerves. But the greater part of the
substances external to the glands are to be grasped, for there is no
danger from them. And this, also, it is proper to know, that if you
raise the arm much, you will not be able to grasp any quantity of skin
worth mentioning, for it is all taken up with the stretching; and also
the nerves. which by all means you must avoid wounding, become exposed
and stretched in this position; but if you only raise the arm a
little, you can grasp a large quantity of skin, and the nerves which
you ought to guard against are left within, and at a distance from the
operation. Should not, then, the utmost pains be taken in the whole
practice of the art to find out the proper attitude in every case?
So much regarding the armpit, and these contractions will be
sufficient, provided the eschars be properly placed. Without the
armpit there are only two places where one might place the eschars
to obviate this affection; the one before and between the head of
the humerus and the tendon at the armpit; and then the skin may be
fairly burned through, but not to any great depth, for there is a
large vein adjacent, and also nerves, neither of which must be touched
with the heat. But externally, one may form another eschar
considerably above the tendon at the armpit, but a little below the
head of the humerus; and the skin must be burned fairly through, but
it must not be made very deep, for fire is inimical to the nerves.
Through the whole treatment the sores are to be so treated, as to
avoid all strong extension of the arm, and this is to be done
moderately, and only as far as the dressing requires; for thus they
will be less cooled (for it is of importance to cover up all sorts
of burns if one would treat them mildly), and then the lips of them
will be less turned aside; there will be less hemorrhage and fear of
convulsions. But when the sores have become clean, and are going on to
cicatrization, then by all means the arm is to be bound to the side
night and day; and even when the ulcers are completely healed, the arm
must still be bound to the side for a long time; for thus more
especially will cicatrization take place, and the wide space into
which the humerus used to escape will become contracted.

  12. When attempts to reduce a dislocated shoulder have failed, if
the patient be still growing, the bone of the affected arm will not
increase like the sound one, for although it does increase in so far
it becomes shorter than the other; and those persons called
weasel-armed, become so from two accidents, either from having met
with this dislocation in utero, or from another accident, which will
be described afterward. But those who while they were children have
had deep-seated suppurations about the head of the bone, all become
weasel-armed; and this, it should be well known, will be the issue,
whether the abscess be opened by an incision or cautery, or whether it
break spontaneously. Those who are thus affected from birth are
quite able to use the arm yet neither can they raise the arm to the
ear, by extending the elbow, but they do this much less efficiently
than with the sound arm. But in those who have had the shoulder
dislocated after they were grown up, and when it has not been reduced,
the top of the shoulder becomes much less fleshy, and the habit of
body at that part is attenuated; but when they cease to have pain,
whatever they attempt to perform by raising the elbow from the sides
obliquely, they can no longer accomplish as formerly; but whatever
acts are performed by carrying the arm around by the sides, either
backward or forward, all those they can perform; for they can work
with an auger or a saw, or with a hatchet, and can dig, by not raising
the elbow too much, and do all other kinds of work which are done in
similar attitudes.

  13. In those cases where the acromion has been torn off, the bone
which is thus separated appears prominent. The bone is the bond of
connection between the clavicle and scapula, for in this respect the
constitution of man is different from that of other animals;
physicians are particularly liable to be deceived in this accident
(for as the separated bone protrudes, the top of the shoulder
appears low and hollow), so that they make preparations as if for
dislocation of the shoulder; for I have known many physicians,
otherwise not inexpert at the art, who have done much mischief by
attempting to reduce such shoulders, thus supposing it a case of
dislocation; and they did not desist until they gave over mistake of
supposing that they had reduced the shoulder. The treatment, in
these cases, is similar to that which is applicable in others of a
like kind, namely, cerate, compresses, and suitable bandaging with
linen cloths. The projecting part must be pushed down, and the greater
number of compresses are to be placed on it, and most compression is
to be applied at that part, and the arm being fastened to the side
is to be kept elevated; for thus the parts which had been torn asunder
are brought into closest proximity with one another. All this should
be well known, and if you choose you may prognosticate safely that
no impediment, small or great, will result from such an injury at
the shoulder, only there will be a deformity in the place, for the
bone cannot be properly restored to its natural situation, but there
must necessarily be more or less tumefaction in the upper part. For
neither can any other bone be made exactly as it was, which having
become incorporated with another bone, and having grown to it as an
apophysis, has been torn from its natural situation. If properly
bandaged, the acromion becomes free of pain in a few days.

  14. When a fractured clavicle is fairly broken across it is more
easily treated, but when broken obliquely it is more difficult to
manage. Matters are different in these cases from what one would
have supposed; for a bone fairly broken across can be more easily
restored to its natural state, and with proper care the upper part may
be brought down by means of suitable position and proper bandaging,
and even if not properly set, the projecting part of the bone is not
very sharp. But in oblique fractures the case is similar to that of
bones which have been torn away, as formerly described; for they do
not admit of being restored to their place, and the prominence of
the bone is very sharp. For the most part, then, it should be known,
no harm results to the shoulder or to the rest of the body from
fracture of the clavicle, unless it sphacelate, and this rarely
happens. A deformity, however, may arise from fracture of the
clavicle, and in these cases it is very great at first, but by and
by it becomes less. A fractured clavicle, like all other spongy bones,
gets speedily united; for all such bones form callus in a short
time. When, then, a fracture has recently taken place, the patients
attach much importance to it, as supposing the mischief greater than
it really is, and the physicians bestow great pains in order that it
may be properly bandaged; but in a little time the patients, having no
pain, nor finding any impediment to their walking or eating, become
negligent; and the physicians finding they cannot make the parts
look well, take themselves off, and are not sorry at the neglect of
the patients, and in the meantime the callus is quickly formed. The
method of dressing which is most appropriate, is similar to that
used in ordinary cases, consisting of cerate, compresses, and
bandages; and it should be most especially known in this operation,
that most compresses should be placed on the projecting bone, and that
the greatest pressure should be made there. There are certain
physicians who make a show of superior skill by binding a heavy
piece of lead on the part in order to depress the projecting bone; but
this mode of treatment does not apply to the clavicle, for it is
impossible to depress the projecting part to any extent worth
mentioning. There are others who, knowing the fact that the bandages
are apt to slip off, and that they do not keep the projecting parts in
their place, apply compresses and bandages like the others, and then
having girt the patient with a girdle, where it is usually applied
with most effect, they make a heap of the compresses upon of the
compresses upon the projecting bone when they apply them, and having
fastened the head of the bandage to the girdle in front, they apply it
so as to bring the turns of it into the line of the clavicle, carrying
them to the back, and then bringing them around the girdle they
carry them to the fore part and again backward. There are others who
do not apply the bandage round the girdle, but carry the rounds of
it by the perineum and anus, and along the spine, so as to compress
the fracture. To an inexperienced person these methods will appear not
far from natural, but when tied, they will be found of no service; for
they do not remain firm any length of time, even if the patient keep
his bed, although in this position they answer best; and yet even when
lying in bed, should he bend his leg, or should his trunk be bent, all
the will be displaced; and, moreover, the bandaging is inconvenient,
in as much as the anus is comprehended by it, and many turns of the
bandage are crowded there in a narrow space. And in the method with
the girdle, the girdle cannot be so firmly girt around, but that the
turns of the bandage force the girdle to ascend, and hence of
necessity all the other bandages must be slackened. He would seem to
me to come nearest his purpose, although after all he effects but
little, who would take a few turns round the girdle, few turns round
the girdle, but would use the bandage principally to secure the former
bandaging; for in this manner the bandages would be most secure, and
would mutually assist one another. Every thing now almost has been
said which applies to fracture of the clavicle. But this also should
be known, that in fractures of the clavicle, it is the part attached
to the breast which is uppermost, and that the piece attached to the
acromion is the lowermost. The cause of this is, that for the most
part the breast can neither be depressed nor raised, there being but a
slight movement of the joint at the breast, for the sternum is
connected together on both sides with the spine. The clavicle admits
of most motion at the joint of the shoulder, and this arises from
its connection with the acromion. And, moreover, when broken, the part
which is connected with the sternum flies upward, and is not easily
forced downward; for it is naturally light, and there is more room for
it above than below. But the shoulder, the arm, and the parts
connected with them, are easily moved from the sides and breast,
and, on that account, they admit of being considerably elevated and
depressed. When, therefore, the clavicle is broken, the fragment
attached to the shoulder inclines downward, for it inclines much
more readily with the shoulder and arm downward than upward. Matters
being as I have stated, they act imprudently who think to depress
the projecting end of the bone. But it is clear that the under part
ought to be brought to the upper, for the former is the movable
part, and that which has been displaced from its natural position.
It is obvious, therefore, that there is no other way of applying force
to it (for the bandages no more force it to than they force it
from); but if one will push the arm when at the sides as much as
possible upward, so that the shoulder may appear as sharp as possible,
it is clear that in this way it will be adjusted to the fragment of
the bone connected with the breast from which it was torn. If one then
will apply a bandage, secundum artem, for the purpose of promoting a
speedy cure, and will reckon everything else of no value, except the
position as described, he will form a correct opinion of the case, and
will effect a cure in the speediest and most appropriate manner. It is
of great importance, however, that the patient should lie in a
recumbent posture. Fourteen days will be sufficient if he keep
quiet, and twenty at most.

  15. But if the clavicle be fractured in the opposite manner (which
does not readily happen), so that the fragment of bone connected
with the breast is depressed, while the piece connected with the
acromion is raised up and rides over other, this case does not require
much management, for if the shoulder and arm be let go, the
fragments of the bone will be adjusted to one another, and an ordinary
bandage will suffice, and the callus will be formed in the course of a
few days.

  16. If the fracture be not thus, but if it incline either forward or
backward, it may be restored to its natural position, by raising the
shoulder with the arm as formerly described, and brought back to its
natural place, when the cure will be speedily accomplished. Most of
the varieties of displacement may be rectified by raising the arm
upward. When the upper bone is displaced laterally or downward, it
would favor the adaptation of the parts if the patient would lie on
his back, and if some elevated substance were placed between the
shoulder-blades, so that the breast may be depressed as much as
possible upon the two sides; and if, while another person raised the
arm extended along the sides, the physician, applying the palm of
the one hand to the head of the bone, would push it away, and with the
other would adjust the broken bones, he would thus reduce the parts
most readily to their natural position. But, as formerly stated, the
upper bone (sternal fragment?) is rarely depressed downward. In most
cases, after the bandages have been applied, that position is
beneficial in which the elbow is fixed to the same side, and the
shoulder is kept elevated; but in certain cases, the shoulder is to be
raised, as has been directed, and the elbow is to be brought forward
to the breast, and the hand laid on the acromion of the sound side. If
the patient has the resolution to lie in bed, something should be
placed so as to support the shoulder, and keep it as much elevated
as possible. But if he walk about, the arm should be slung in a shawl,
which embraces the point of the elbow, and is passed round the neck.

  17. When the elbow-joint is displaced or dislocated to the side or
outward, while its sharp point (olecranon?) remains in the cavity of
the humerus, extension is to be made in a straight line, and the
projecting part is to be pushed backward and to the side.

  18. In complete dislocations toward either side, extension is to
be made as in bandaging fracture of the arm; for thus the rounded part
of the elbow will not form an obstacle to it. Dislocation, for the
most part, takes place toward the sides (inwardly?). Reduction is to
be effected by separating (the bones) as much as possible, so that the
end (of the humerus) may not come in contact with the olecranon, and
it is to be carried up, and turned round, and not forced in a straight
line, and, at the same time, the opposite sides are to be pushed
together, and propelled into their proper place. It will further
assist if rotation of the fore-arm be made at the elbow, sometimes
turning it into a supine position, and sometimes into a prone. The
position for the treatment consists in keeping the hand a little
higher than the elbow, and the arm at the sides; then it may either be
suspended or laid at rest, for either position will answer; and nature
and the usage of common means will accomplish the cure, if the
callus does not form improperly: it is formed quickly. The treatment
is to be conducted with bandages according to the rule for bandaging
articulations, and the point of the elbow is to be included in the
bandage.

  19. Dislocations at the elbow give rise to the most serious
consequences, such as fevers, pain, nausea, vomitings of pure bile,
and more especially when the humerus is displaced backward from
pressure on the nerve, which occasions numbness; next to it is the
dislocation forward; the treatment is the same; reduction in
dislocation backward is by extension and adaptation; the symptom of
this variety-loss of the power of extension; of dislocation
forward-loss of the power of flexion, and in this case reduction is to
be accomplished by placing a hard ball (in the bend of the elbow), and
bending the fore-arm about it, along with sudden extension.

  20. Diastasis of the bones may be recognized by examining the part
where the vein that runs along the arm divides.

  21. In those cases callus is quickly formed. In congenital
dislocations the bones below the seat of the injury are shorter than
natural, and, mostly, those nearest to the place; namely, the bones of
the fore-arm, next those of the hand; and, third, those of the
fingers. The arm and shoulder are stronger, owing to the nourishment
which they receive, and the other arm, from the additional work
which it has to perform, is still more strong. Wasting of the flesh
takes place on the inside if the dislocation be on the outside; or
otherwise, on the side opposite the dislocation.

  22. When the elbow is dislocated either inward or outward, extension
is to be made with the fore-arm at a right angle to the arm; the
arm, suspended by means of a shawl passed through the armpit, and a
weight attached to the extremity of the elbow; or force may be applied
with the hands; when the articular extremity has been cleared, the
displaced parts are to be rectified with the palms of the hand, as
in dislocations of the hands. It is to be bandaged, suspended in a
sling, and placed while in this attitude.

  23. Dislocations backward are to be rectified by the palms of the
hands, along with sudden extension; the two acts are to be performed
together, as in other cases of the kind. But in dislocation forward
the arm is to be bent around a ball of cloth of proper size, and at
the same time replaced.

  24. But if the displacement be on the other side, both these
operations are to be performed in effecting the adjustment. For
conducting the treatment, the position and bandaging are the same as
in the other cases. But all these cases may be reduced by ordinary
distention.

  25. Of the methods of reduction, some operate by raising up the
part, some by extension, and some by rotation: the last consists in
rapidly turning the fore-arm to this side and that.

  26. The joint of the hand is dislocated either inward or outward,
most frequently inward. The symptoms are easily recognized: if inward,
the patient cannot at all bend his fingers; and if outward, he
cannot extend them. With regard to the reduction,-by placing the
fingers above a table, extension and counter-extension are to be
made by other persons, while with the palm or heel of the hand on
the projecting bone one pushes forward, and another from behind on the
other bone; some soft substance is to be applied to it, and the arm is
to be turned to the prone position if the dislocation was forward, but
to the supine, if backward. The treatment is to be conducted with
bandages.

  27. The whole hand is dislocated either inward or outward, or to
this side or that, but more especially inward; and sometimes the
epiphysis is displaced, and sometimes the other of these bones is
separated. In these cases strong extension is to be applied, and
pressure is to be made on the projecting bone, and counter-pressure on
the opposite side, both at the same time, behind and at the side, with
the hands upon a table, or with the heel. These accidents give rise to
serious consequences and deformities; but in the course of time the
part gets strong, and admits of being used. The cure is with bandages,
which ought to embrace both the hand and fore-arm; and splints are
to be applied as far as the fingers; and when they are used they
should be more frequently unloosed than infractures, and more
copious affusions of water should be used.

  28. In congenital dislocations (at the wrist) the hand becomes
shortened, and the atrophy of the flesh occurs, for the most part,
on the side opposite to the dislocation. In an adult the bones
remain of their natural size.

  29. Dislocation at the joint of a finger is easily recognized.
Reduction is to be effected by making extension in a straight line,
and applying pressure on the projecting bone, and counter-pressure
on the opposite side of the other. The treatment is with bandages.
When not reduced, callus is formed outside of the joint. When the
dislocation takes place at birth, during adolescence the bones below
the dislocation are shortened, and the flesh is wasted rather on the
opposite than on the same side with the dislocation. When it occurs in
an adult the bones remain of their proper size.

  30. The jaw-bone, in few cases, is completely dislocated, for the
zygomatic process formed from the upper jaw-bone (malar?) and the bone
behind the ear (temporal?) shuts up the heads of the under jaw,
being above the one (condyloid process?), and below the other
(coronoid process?). Of these extremities of the lower jaw, the one,
from its length, is not much exposed to accidents, while the other,
the coronoid, is more prominent than the zygoma, and from both these
heads nervous tendons arise, with which the muscles called temporal
and masseter are connected; they have got these names from their
actions and connections; for in eating, speaking, and the other
functional uses of the mouth, the upper jaw is at rest, as being
connected with the head by synarthrosis, and not by diarthrosis
(enarthrosis?): but the lower jaw has motion, for it is connected with
the upper jaw and the head by enarthrosis. Wherefore, in convulsions
and tetanus, the first symptom manifested is rigidity of the lower
jaw; and the reason why wounds in the temporal region are fatal and
induce coma, will be stated in another place. These are the reasons
why complete dislocation does not readily take place, and this is
another reason, because there is seldom a necessity for swallowing
so large pieces of food as would make a man gape more than he easily
can, and dislocation could not take place in any other position than
in great gaping, by which the jaw is displaced to either side. This
circumstance, however, contributes to dislocation there; of nerves
(ligaments?) and muscles around joints, or connected with joints, such
as are frequently moved in using the member are the most yielding to
extension, in the same manner as well-dressed hides yield the most.
With regard, then, to the matter on hand, the jaw-bone is rarely
dislocated, but is frequently slackened (partially displaced?) in
gaping, in the same manner as many other derangements of muscles and
tendons arise. Dislocation is particularly recognized by these
symptoms: the lower jaw protrudes forward, there is displacement to
the opposite side, the coronoid process appears more prominent than
natural on the upper jaw, and the patient cannot shut his lower jaw
but with difficulty. The mode of reduction which will apply in such
cases is obvious: one person must secure the patient's head, and
another, taking hold of the lower jaw with his fingers within and
without at the chin, while the patient gapes as much as he can,
first moves the lower jaw about for a time, pushing it to this side
and that with the hand, and directing the patient himself to relax the
jaw, to move it about, and yield as much as possible; then all of a
sudden the operator must open the mouth, while he attends at the
same time to three positions: for the lower jaw is to be moved from
the place to which it is dislocated to its natural position; it is
to be pushed backward, and along with these the jaws are to be brought
together and kept shut. This is the method of reduction, and it cannot
be performed in any other way. A short treatment suffices, a waxed
compress is to be laid on, and bound with a loose bandage. It is safer
to operate with the patient laid on his back, and his head supported
on a leather cushion well filled, so that it may yield as little as
possible, but some person must hold the patient's head.

  31. When the jaw is dislocated on both sides, the treatment is the
same. The patients are less able to shut the mouth than in the
former variety; and the jaw protrudes farther in this case, but is not
distorted; the absence of distortion may be recognized by comparing
the corresponding rows of the teeth in the upper and lower jaws. In
such cases reduction should be performed as quickly as possible; the
method of reduction has been described above. If not reduced, the
patient's life will be in danger from continual fevers, coma
attended with stupor (for these muscles, when disordered and stretched
preternaturally, induce coma); and there is usually diarrhea
attended with billous, unmixed, and scanty dejections; and the
vomitings, if any, consist of pure bile, and the patients commonly die
on the tenth day.

  32. In fracture of the lower jaw, when the bone is not fairly broken
across, and is still partially retained, but displaced, it should be
adjusted by introducing the fingers at the side of the tongue, and
making suitable counter-pressure on the outside; and if the teeth at
the wound be distorted and loosened, when the bone is adjusted, they
should be connected together, not only two, but more of them, with a
gold thread, if possible, but otherwise, with a linen thread, until
the bone be consolidated, and then the part is to be dressed with
cerate, a few compresses, and a few bandages, which should not be very
tight, but rather loose. For it should be well known that in
fracture of the jaw, dressing with bandages, if properly performed, is
of little advantage, but occasions great mischief if improperly
done. Frequent examinations should be made about the tongue, and
prolonged pressure should be applied with the fingers, in order to
rectify the displaced bone. It would be best if one could do so
constantly, but that is impossible.

  33. But if the bone be fairly broken across (this, however, rarely
happens), it is to be set in the manner now described. When
adjusted, the teeth are to be fastened together as formerly described,
for this will contribute much toward keeping the parts at rest,
especially if properly fastened, and the ends of the thread secured
with knots. But it is not easy to describe exactly in writing the
whole manipulation of the case; but the reader must figure the thing
to himself from the description given. Then one must take a piece of
Carthaginian leather; if the patient be a younger person, it will be
sufficient to use the outer skin, but if an adult the whole
thickness of the hide will be required; it is to be cut to the breadth
of about three inches, or as much as will be required, and having
smeared the jaw with a little gum (for thus it sticks more
pleasantly), the end of the skin is to be fastened with the glue
near the fractured part of the jaw, at the distance of an inch or a
little more, from the wound. This piece is to be applied below the
jaw; but the thong should have a cut in it, in the direction of the
chin, so that it may go over the sharp point of the chin. Another
piece of thong like this, or somewhat broader, is to be glued to the
upper part of the jaw, at about the same distance from the wound as
the other thong; this thong should be so cut as to encircle the ear.
The thongs should be sharp-pointed at the part where they unite, and
in gluing them, the flesh of the thong should be turned to the
patient's skin, for in this way it will be more tenacious; then we
must stretch this thong, but still more so the one at the chin, in
order to prevent the fragments of the jaw from riding over each other,
and the thongs are to be fastened at the vertex, and then a bandage is
to be bound round the forehead, and a proper apparatus is to be put
over all, to prevent the bandages from being displaced. The patient
should lie upon the sound side of the jaw, not resting upon the jaw,
but upon the head. He is to be kept on a spare diet for ten days,
and then nourished without delay. If there be no inflammation during
the first days, the jaw is consolidated in twenty days; for callus
quickly forms in this, as in all the other porous bones, provided
there be no sphacelus (exfoliation?). But much remains to be said on
the sphacelus of bones in another place. This method of distention
with glued substances is mild, of easy application, and is useful
for many dislocations in many parts of the body. Those physicians
who have not judgment combined with their dexterity, expose themselves
in fractures of the jaws, as in other cases, for they apply a
variety of bandages to a fractured jaw-bone, sometimes properly, and
sometimes improperly. For all such bandaging of a fractured jawbone
has a tendency rather to derange the bones connected with the
fracture, than to bring them into their natural position.

  34. But if the lower jaw be disjointed at its symphysis in the
chin (there is but one symphysis in the lower jaw, but there are
several in the upper; but I am unwilling to digress from the
subject, as these matters will have to be touched upon in other
kinds of disease)-if, then, the symphysis be separated at the chin, it
is the work which anybody can perform, to rectify it; for the part
which protrudes is to be pushed inward by pressure with the fingers,
and the part that inclines inward is to forced outward by pushing with
the fingers from within. It is after having applied extension to
separate the fragments that this is to be done, for they will thus
be more easily restored to their natural position, than if one
should bring them together by using force. This is proper to be
known as applying to all such cases. When you have set the parts,
you must fasten the teeth on both sides to one another, as formerly
directed. The treatment is to be accomplished with cerate, a few
compresses, and bandages. This part, in particular, requires a short
but complex (?) bandaging, for it is nearly cylindrical, though not
exactly so; but the turn of the bandage is to be made, if the right
jaw was dislocated, to the right hand (that is said to be to the right
hand when the right hand conducts the bandaging); but if the other jaw
be the seat of the dislocation, the bandaging is to be made in the
other direction. And if matters be properly adjusted, and the
patient keep quiet, there will be a speedy recovery, and the teeth
will be uninjured; but if not, the recovery will be more protracted,
the teeth will be distorted, will give trouble, and become useless.

  35. Of fractures of the nose there are more than one variety, but
those who, without judgment, delight in fine bandagings, do much
mischief, most especially in injuries about the nose. For this is
the most complex of all the forms of bandaging, having most of the
turns of the bandage called "ascia," and rhomboidal intervals and
uncovered spaces of the skin. As has been said, those who practice
manipulation without judgment are fond of meeting with a case of
fractured nose, that they may apply the bandage. For a day or two,
then, the physician glories in his performance, and the patient who
has been bandaged is well pleased, but speedily the patient
complains of the incumbrance of the bandage, and the physician is
satisfied, because he has had an opportunity of showing his skill in
applying a complex bandage to the nose. Such a bandaging does
everything the very reverse of what is proper; for, in the first
place, those who have their nose flattened by the fracture, will
clearly have the part rendered still more flat, if pressure above be
applied to it; and further, those cases in which the nose is distorted
to either side, whether at the cartilage or higher up, will
evidently derive no benefit from bandaging above it, but will rather
be injured; for it will not admit of having compresses properly
arranged on either side of the nose, and indeed, persons applying this
bandage do not seek to do this.

  36. This bandaging would appear to me to answer best when the skin
surrounding the bone is contused on its ridge near the middle, or if
the bone itself have sustained some injury, but not a great one, in
such cases, redundant callus forms in the nose, and the part becomes a
little too prominent; and yet, even in these cases, the bandaging need
not require much trouble, if, indeed, any bandage be applied at all;
for it is enough if one lay a waxed compress on the contusion, and
then apply the double-headed bandage, thus taking one turn with it.
The best application to such accidents is a small cataplasm of wheaten
flour, washed, and mixed up into a viscid mass. If the flour be made
from good wheat, and if it be glutinous, it should be used alone for
all such cases, but if it be not very glutinous, a little of the manna
of frankincense, well pulverized, is to be moistened with water, and
the flour is to be mixed up with it, or a very little gum may be mixed
in like manner.

  37. In those cases in which the fractured portions are depressed and
flattened, if it is depressed in front at the cartilage, something may
be introduced into the nostrils to rectify the parts. If not, all such
deformities may be restored by introducing the fingers into the
nostrils, if this can be managed, but if not, a thick spatula is to be
introduced with the fingers, not to the fore part of the nose, but
to the depressed portion, and the physician is to take hold of the
nose externally on both sides, and at the same time raise it up. And
if the fracture be much in the fore part one may introduce into the
nostrils as already stated, either caddis scraped from a linen
towel, or something such wrapped up in a piece of cloth, or rather
stitched in Carthaginian leather, and moulded into a shape suitable to
the place into which it is to be introduced. But if the fracture be at
a greater distance, it is not possible to introduce anything within,
for if it was irksome to bear anything of the kind in the fore part,
how is it not to be so when introduced farther in? At first, then,
by rectifying the parts from within, and sparing no pains upon them
from without, they are to be brought to their natural position, and
set. A fractured nose may be readily restored to shape, especially
on the day of the accident, or even a little later, but the physicians
act irresolutely, and touch it more delicately at first than they
should; for the fingers should be applied on both sides along the
natural line of the nose, and it is to be pushed downward, and thus,
with pressure from within, the displacement is to be rectified. But
for these purposes no physician is equal to the index-fingers of the
patient himself, if he will pay attention and has resolution, for they
are the most natural means. Either of the fingers is to be placed
firmly along the whole nose, and thus it is to be gently held, and
steadily, if possible until it become firm, but if not, he himself
is to hold it for as long a time as possible, or if he cannot, a child
or woman should do it, for the hands ought to be soft. Thus may a
fracture of the nose, attended with depression, and not with
displacement to the side, but in a straight line, be most properly
treated. I have never seen a case of fractured nose which could not be
rectified when attempted, before callus is formed, provided the
treatment be properly applied. But although men would give a great
price to escape being deformed, yet at the same time they do not
know how to take care, nor have resolution, if they do not
experience pain, nor fear death, although the formation of callus in
the nose speedily place, for the most part is consolidated in ten
days, provided sphacelus do not take place.

  38. When the fractured bone is displaced laterally, the treatment is
the same, but it is obvious that the reduction is to be made, not by
applying equal force on both sides, but by pushing the displaced
portion into its natural position, and pressing on it from without,
and introducing something into the nostrils, and boldly rectifying the
fragments which incline inward, until the whole be properly
adjusted, well knowing that if you do not restore the parts at once,
it is impossible but that the nose must be distorted. But when you
restore the parts to their natural position, either the patient
himself, or some other person, is to apply one finger or more to the
part which protrudes, and keep it in position until the fracture be
consolidated; but the little finger is, from time to time, to be
pushed into the nostril, to rectify the parts which incline inward.
When any inflammation supervenes, dough must be used, but attention
must still be equally paid to the application of the fingers, although
the dough be on the part. But if the fracture be in the cartilage,
with lateral displacement, the end of the nose must necessarily be
distorted. In such cases some of the aforementioned means of
reduction, or whatever suits, is to be introduced into the nostril;
but there are many convenient things to be found which have no
smell, and are appropriate in other respects; thus, on one occasion, I
introduced a slice of sheep's lung, as it happened to be at hand;
for sponges, if introduced, imbibe humidities. Then the outer skin
of Carthaginian leather it to be taken, and a piece of the size of the
thumb, or what will answer, is to be cut off and glued to the
outside of the nostril which is turned aside, and then this piece of
thong is to be stretched to the proper degree, or rather a little more
than what will be sufficient to make the nose straight and regular.
Then (for the thong must be long) it is to be brought below the ear
and round the head, and the end of the thong may either be glued to
the forehead, or a still longer one may be carried all round the head,
and secured. This is a natural mode of setting the nose, is of easy
application, and is calculated to enable the counter-extension on
the nose to be made greater or less, as you may incline. In a case
where the fractured nose is turned to the side, the treatment is to be
conducted otherwise, as already described; and in most of them the
thong ought to be glued to the end of the nose, in order to make
extension in the opposite direction.

  39. When the fracture is complicated with a wound, one need not be
troubled on that account, but pitch-cerate or any of the
applications for fresh wounds is to be applied to the sores; for, in
general, they admit of easy cure, even when there is reason to
apprehend that pieces of bone will come out. The parts, at first,
are to be adjusted fearlessly, taking care that nothing is omitted,
and, subsequently, they are also to be adjusted with the fingers; more
softly, indeed, but still it must be done; and of all parts of the
body the nose is modeled with the greatest ease. And there is
nothing to prevent us from having recourse to the practice of gluing
on the thongs, and drawing the nose to the opposite side, even if
there be a wound or the parts be inflamed, for these thongs give no
pain.

  40. In fractures of the ear all sorts of bandages do harm. For one
would not think of applying it quite loose, and if applied more
tightly, it only does the more harm, for even the sound ear, when
confined with a bandage, becomes painful, throbs, and gets into a
febrile state. With regard to cataplasms, the heaviest, on the
whole, are the worst; but almost all kinds are bad, form abscesses,
occasion an increase of humors, and afterward troublesome
suppurations; and a fractured ear stands in less need of such
applications than any other part; the most ready, if required, is
the paste of meal, but neither should it have weight. It should
touch as little as possible; for it is a good sometimes to apply
nothing at all, both to the ear and to many other cases. Attention
must be paid to the patient's position during sleep. And the body must
be reduced, more especially if there be danger lest the ear suppurate;
it will also be better to open the bowels, and if the patient can be
readily made to vomit, this may be accomplished by means of the
syrmaism. If the part come to suppuration, it should not be hastily
opened; for often when matter appears to be formed it is absorbed
again, even when no cataplasm is applied. But if forced to open it,
the part will get soonest well if transfixed with a cautery, and yet
it should be well understood that the ear gets maimed, and is less
than the other if burned through. If not burned through, an
incision, and not a very small one, should be made on the upper
side; for the pus is found to be surrounded with a thicker covering
than one would have supposed; and it may be said, in general, that all
parts of a mucous nature and which form mucus, as being all viscid,
when touched, slip from below the fingers to either side; and on
that account the physician, in such cases, finds that he has to pass
his instrument through a thicker substance than he supposed; and in
certain ganglionic cases, when the skin is flabby and mucous, many
physicians open them, expecting to find a collection in them; here the
physician forms a wrong judgment, but by such a procedure no great
harm results to the patient from having had the part opened. But
with regard to watery parts, and such as are filled with mucus, and
which are situated in regions where every one of the parts, if opened,
will occasion death or some other injury, these will be treated of
in another work. When, therefore, incision is made in the ear, all
sorts of cataplasms and pledges should be avoided, and it is to be
treated either with applications for recent wounds, or anything else
which is neither heavy nor will occasion pain, for if the cartilage be
laid bare and abscesses form, the case will be troublesome; this
happens from such modes of treatment. In all aggravated cases, the
most effectual remedy is the transfixing of the part with a hot iron.
  41. The vertebrae of the spine when contracted into a hump behind
from disease, for the most part cannot be remedied, more especially
when the gibbosity is above the attachment of the diaphragm to the
spine. Certain of those below the diaphragm are carried off by varices
in the legs, more especially by such as occur in the vein at the
ham; and in those cases where the gibbosities are removed, the varices
take place also in the groin; and some have been carried off by a
dysentery when it becomes chronic. And when the gibbosity occurs in
youth before the body has attained its full growth, in these cases the
body does not usually grow along the spine, but the legs and the
arms are fully developed, whilst the parts (about the back) are
arrested in their development. And in those cases where the
gibbosity is above the diaphragm, the ribs do not usually expand
properly in width, but forward, and the chest becomes sharp-pointed
and not broad, and they become affected with difficulty of breathing
and hoarseness; for the cavities which inspire and expire the breath
do not attain their proper capacity. And they are under the
necessity of keeping the neck bent forward at the great vertebra, in
order that their head may not hang downward; this, therefore,
occasions great contraction of the pharynx by its inclination
inward; for, even in those who are erect in stature, dyspnoea is
induced by this bone inclining inward, until it be restored to its
place. From this frame of body, such persons appear to have appear
to have more prominent necks than persons in good health, and they
generally have hard and unconcocted tubercles in the lungs, for the
gibbosity and the distension are produced mostly by such tubercles,
with which the neighboring nerves communicate. When the gibbosity is
below the diaphragm, in some of these cases nephritic diseases and
affections of the bladder supervene, but abscesses of a chronic
nature, and difficult to cure, occur in the loins and groins, and
neither of these carries off the gibbosity; and in these cases the
hips are more emaciated than when the gibbosity is seated higher up;
but the whole spine is more elongated in them than in those who have
the gibbosity seated higher up, the hair of the pubes and chin is of
slower growth and less developed, and they are less capable of
generation than those who have the gibbosity higher up. When the
gibbosity seizes persons who have already attained their full
growth, it usually occasions a crisis of the then existing disease,
but in the course of time some of them attack, as in the case of
younger persons, to a greater or less degree; but, not withstanding,
for the most part, all these diseases are less malignant. And yet many
have borne the affection well, and have enjoyed good health until
old age, more especially those persons whose body is inclined to be
plump and fat; and a few of them have lived to beyond sixty years of
age, but the most of them are more short-lived. In some cases the
curvature of the spine is lateral, that is to say, either to the one
side or the other; the most of such cases are connected with tubercles
(abscesses?) within the spine; and in some, the positions in which
they have been accustomed to lie cooperate with the disease. But these
will be treated of among the chronic affections of the lungs; for
these the most suitable prognostics of what will happen in these cases
are given.

  42. When the spine protrudes backward, in consequence of a fall,
it seldom happens that one succeeds in straightening it. Wherefore
succussion on a ladder has never straightened anybody, as far as I
know, but it is principally practiced by those physicians who seek
to astonish the mob-for to such persons these things appear wonderful,
for example, if they see a man suspended or thrown down, or the
like; and they always extol such practices, and never give
themselves any concern whatever may result from the experiment,
whether bad or good. But the physicians who follow such practices,
as far as I have known them, are all stupid. The device, however, is
an old one, and I give great praise to him who first invented this,
and any other mechanical contrivance which is according to nature. For
neither would I despair, but that if succussion were properly gone
about, the spine, in certain cases, might be thereby rectified. But,
indeed, for my own part, I have been ashamed to treat all such cases
in this way, because such modes of procedure are generally practiced
by charlatans.

  43 Those cases in which the gibbosity is near the neck, are less
likely to be benefited by these succussions with the head downward,
for the weight of the head, and tops of the shoulders, when allowed to
hang down, is but small; and such cases are more likely to be made
straight by succussion applied with the feet hanging down, since the
inclination downward is greater in this way. When the hump is lower
down, it is more likely in this case that succussion with the head
downward should do good. If one, then, should think of trying
succussion, it may be applied in the following manner:-The ladder is
to be padded with leather lined cushions, laid across, and well
secured to one another, to a somewhat greater extent, both in length
and breadth, than the space which the man's body will occupy; he is
then to be laid on the ladder upon his back, and the feet, at the
ankles, are to be fastened, at no great distance from one another,
to the ladder, with some firm but soft band; and he is further to be
secured, in like manner, both above and below the knee, and also at
the nates; and at the groins and chest loose shawls are to be put
round in such a fashion as not to interfere with the effect of the
succussion; and his arms are to be fastened along his sides to his own
body, and not to the ladder. When you have arranged these matters
thus, you must hoist up the ladder, either to a high tower or to the
gable-end of a house; but the place where you make the succussion
should be firm, and those who perform the extension should be well
instructed, so that they may let go their hold equally to the same
extent, and suddenly, and that the ladder may neither tumble to the
ground on either side, nor they themselves fall forward. But, if the
ladder be let go from a tower, or the mast of a ship, fastened into
the ground with its cordage, it will be better, so that the ropes
run upon a pulley or axle-tree. But it is disagreeable even to enlarge
upon these matters; and yet, by the contrivances now described, the
proper succussion may be made.

  44. But if the hump be situated very high up, and if succussion be
by all means to be used, it will be better to do it with the feet
downward, as has been said, for the force downward will be the greater
in this case. The patient is to be well fastened to the ladder by
cords at the breast, at the neck by means of a very loose shawl so
as merely to keep the part properly on the ladder, and the head is
to be fastened to the ladder at the forehead, the arms are to be
stretched along and attached to the patient's body, and not to the
ladder, and the rest of the body is not to be bound, except so as to
keep it in place by means of a loose shawl wrapped round it and the
ladder; attention, moreover, should be paid that these ligatures do
not interfere with the force of the succussion, and the legs are not
to be fastened to the ladder, but should be placed near one another,
so as to be in line with the spine. These matters should be thus
arranged, if recourse is to be had at all to succussion on a ladder;
for it is disgraceful in every art, and more especially in medicine,
after much trouble, much display, and much talk, to do no good after
all.

  45. In the first place, the structure of the spine known, for this
knowledge is requisite in many diseases. Wherefore, on the side turned
to the belly (the anterior?) the vertebrae are in a regular line,
and are united together by a pulpy and nervous band of connection,
originating from the cartilages, and extending to the spinal marrow.
There are certain other nervous cords which decussate, are attached
(to the vertebrae?), and are extended from both sides of them. But
we will describe in another work the connections of the veins and
arteries, their numbers, their qualities, their origin, their
functional offices in particular parts, in what sort of sheaths the
spinal marrow is inclosed, where they arise, where they terminate, how
they communicate, and what their uses. On the opposite side
(behind?) the vertebrae are connected together by a ginglymoid
articulation. Common cords (nerves?) are extended to all parts, both
those within and without. There is an osseous process from the
posterior part of all and each of the vertebra, whether greater or
smaller; and upon these processes there are cartilaginous epiphyses,
and from them arise nervous productions (ligaments?), akin to the
external nerves (tonoi). The ribs are united to them, having their
heads inclined rather to the inside than the out, and every one of
them is articulated with the vertebrae; and the ribs in man are very
curved, and, as it were, arched. The space between the ribs and the
processes of the vertebrae is filled on both sides by muscles, which
arise from the neck and extend to the loins (?). The spine,
longitudinally, is a straight line slightly curved; from the os sacrum
to the great vertebra which is connected with the articulation of
the femur, the spine inclines backward, for the bladder, the organs of
generation, and the loose portion of the rectum, are situated there.
From this, to the attachment of the diaphragm, the spine inclines
inward, and this portion alone, from the internal parts, gives
origin to muscles, which are called psoae. From this to the great
vertebra (seventh cervical?) which is above the tops of the shoulders,
it is convex behind lengthways; but it is more in appearance than it
really is, for the spinous processes are highest in the middle, and
less so above and below. The region of the neck is convex before.

  46. In cases of displacement backward along the vertebrae, it does
not often happen, in fact, it is very rare, that one or more vertebrae
are torn from one another and displaced. For such injuries do not
readily occur, as the spine could not easily be displaced backward but
by a severe injury on the fore part through the belly (which would
prove fatal), or if a person falling from a height should pitch on the
nates, or shoulders (and even in this case he would die, but not
immediately); and it also would not readily happen that such a
displacement could take place forward, unless some very heavy weight
should fall upon it behind; for each of the posterior spinal processes
is so constructed, that it would sooner be broken than undergo any
great inclination forward from a force which would have to overcome
the ligaments and the articulations mutually connecting them. And
the spinal marrow would suffer, if from the displacement of a vertebra
it were to be bent even to a small extent; for the displaced
vertebra would compress the spinal marrow, if it did not break it; and
if compressed and strangled, it would induce insensibility of many
great and important parts, so that the physician need not give himself
any concern about rectifying the displacement of the vertebra,
accompanied, as it is, by many other ill consequences of a serious
nature. It is evident, then, that such a case could not be reduced
either by succussion or by any other method, unless one were to cut
open the patient, and then, having introduced the hand into one of the
great cavities, were to push outward from within, which one might do
on the dead body, but not at all on the living. Wherefore, then, do
I write all this? Because certain persons fancy that they have cured
patients in whom the vertebra had undergone complete dislocation
forward. Some, indeed, suppose that this is the easiest of all these
dislocations to be recovered from, and that such cases do not stand in
need of reduction, but get well spontaneously. Many are ignorant,
and profit by their ignorance, for they obtain credit from those about
them. These are deceived in this way, for they suppose the spinous
processes to be the vertebrae themselves, because every one of them
appears round to the touch, not knowing that these bones are processes
from the vertebrae, as formerly stated; but the vertebrae are at a
considerable distance before them; for of all animals, man, in
proportion to his bulk, has the belly (internal cavity?) the narrowest
from behind to before, especially at the breast. When, therefore,
any of these processes are severely fractured, whether one or more,
the part there appears lower than on either side, and for that
reason they are deceived, supposing that the vertebrae are displaced
inward. And the patient contribute also to deceive them; for if they
attempt to put themselves into a bent position, they are pained,
from the skin being stretched at the seat of the injury, and at the
same time the fragments of the bones wound the skin still more; but if
they bend forward, they feel easier, for the skin at the wound is thus
relaxed, and the bones are less disposed to hurt them; and if touched,
they shrink and bend forward, and the part which is touched appears
empty and soft. All the circumstances now mentioned contribute to
deceive the physician. Such patients speedily get well without any bad
effects, for callus readily forms in all such bones as are porous.

  47. There are many varieties of curvature of the spine even in
persons who are in good health; for it takes place from natural
conformation and from habit, and the spine is liable to be bent from
old age, and from pains. Gibbosities (or projections backward) from
falls generally take place when one pitches on the nates, or falls
on the shoulders. In this case some one of the vertebrae must
necessarily appear higher than natural, and those on either side to
a less degree; but yet no one generally has started out of the line of
the others, but every one has yielded a little, so that a considerable
extent of them is curved. On this account the spinal marrow easily
bears such distortions, because they are of a circular shape, and
not angular. The apparatus for the reduction in this case must be
managed in the following manner: a strong and broad board, having an
oblong furrow in it, is to be fastened in the ground, or, in place
of the board, we may scoop out an oblong furrow in the wall, about a
cubit above the floor, or at any suitable height, and then something
like an oaken bench, of a quadrangular shape, is to be laid along (the
wall?) at a distance from the wall, which will admit of persons to
pass round if necessary, and the bench is to be covered with robes, or
anything else which is soft, but does not yield much; and the
patient is to be stoved with vapor, if necessary, or bathed with
much hot water, and then he is to be stretched along the board on
his face, with his arms laid along and bound to his body; the
middle, then, of a thong which is soft, sufficiently broad and long,
and composed of two cross straps of leather, is to be twice carried
along the middle of the patient's breast, as near the armpits as
possible, then what is over of the thongs at the armpits is to be
carried round the shoulders, and afterward the ends of the thong are
to be fastened to a piece of wood resembling a pestle; they are to
be adapted to the length of the bench laid below the patient, and so
that the pestle-like piece of wood resting against this bench may make
extension. Another such band is to be applied above the knees and
the ankles, and the ends of the thongs fastened to a similar piece
of wood; and another thong, broad, soft, and strong, in the form of
a swathe, having breadth and length sufficient, is to be bound tightly
round the loins, as near the hips as possible; and then what remains
of this swathelike thong, with the ends of the thongs, must be
fastened to the piece of wood placed at the patient's feet, and
extension in this fashion is to be made upward and downward, equally
and at the same time, in a straight line. For extension thus made
could do no harm, if properly performed, unless one sought to do
mischief purposely. But the physicians, or some person who is
strong, and not uninstructed, should apply the palm of one hand to the
hump, and then, having laid the other hand upon the former, he
should make pressure, attending whether this force should be applied
directly downward, or toward the head, or toward the hips. This method
of applying force is particularly safe; and it is also safe for a
person to sit upon the hump while extension is made, and raising
himself up, to let himself fall again upon the patient. And there is
nothing to prevent a person from placing a foot on the hump, and
supporting his weight on it, and making gentle pressure; one of the
men who is practiced in the palestra would be a proper person for
doing this in a suitable manner. But the most powerful of the
mechanical means is this: if the hole in the wall, or in the piece
of wood fastened into the ground, be made as much below the man's back
as may be judged proper, and if a board, made of limetree, or any
other wood, and not too narrow, be put into the hole, then a rag,
folded several times or a small leather cushion, should be laid on the
hump; nothing large, however, should be laid on the back, but just
as much as may prevent the board from giving unnecessary pain by its
hardness; but the hump should be as much as possible on a line with
the hole made in the wall, so that the board introduced into it may
make pressure more especially at that especially at that spot. When
matters are thus adjusted, one person, or two if necessary, must press
down the end of the board, whilst others at the same time make
extension and counter-extension as along the body, as formerly
described. Extension may also be made with axles, which may either
be fastened in the ground beside the bench, or the post of the axles
may be attached to the bench itself, if you will make them
perpendicular and overtopping (the bench?) a little at both ends, or
at either end of the bench. These powers are easily regulated, so as
to be made stronger or weaker, and they are of such force, that if one
were to have recourse to them for a mischievous purpose, and not as
a remedy, they would operate strongly in this way also; for by
making merely extension and counter-extension longitudinally,
without any additional force, one might make sufficient extension; and
if, without making extension at all, one were only to press down
properly with the board, sufficient force might be applied in this
way. Such powers, then, are excellent which admit of being so
regulated, that they can be made weaker and stronger as required.
And the forces are applied in the natural way; for the pressure
above forces the displaced parts into their place. Natural extension
restores parts which have come too near one another to their natural
position. I, then, am acquainted with no powers which are better or
more appropriate than these; for extension along the spine downward
has no proper hold at the bone called the os sacrum; and extension
upward, along the neck and head, has indeed a hold; but extension thus
made is unseemly to behold, and, besides, if increased, may occasion
much mischief otherwise. I once made trial of the following plan.
Having placed the patient on his back, I put below the hump a bladder,
not inflated, and afterward introduced air into the bladder by means
of a brass pipe connected with it. But the experiment 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 distended bladder when they were pressed
together. But when I did not extend the man strongly, the bladder
was swelled up by the air, and the man became more bent forward than
proper. I have 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.

  48. In curvatures forward of the vertebrae from a fall, or from some
heavy body falling upon them, in general no one of them is displaced
far beyond the others, but if one or more be so displaced, the case
proves fatal; but, not withstanding, as formerly stated, the
displacement is circular, and not angular. In such cases, then, the
urine and faeces are more apt to be retained than in displacement
outward, the feet and the whole inferior extremities are colder, and
the symptoms are more fatal than in the former case; and if they do
survive, they are more subject to retention of the urine, and to
loss of strength, and to torpor in their legs. But if the displacement
be in the upper part, they experience loss of strength and torpor of
the whole body. I know no mechanical contrivance by which such a
displacement could be reduced, unless that one might be benefited by
succussion on a bladder, or any other similar plan of treatment,
such as extension, as formerly described. I am not aware of any mode
of pressure which might be applied along with the extension, like that
of the board in displacement backward; for how could one apply
pressure from before through the belly? (internal cavity?) The thing
is impossible. But neither coughing nor sneezing has any power so as
to cooperate with the extension, nor would the injection of air into
the bowels have any effect. And to apply large cupping instruments
with the view of drawing back the vertebrae which have protruded
forward, shows a great error of judgment; for they rather propel
than attract, and those who apply them are not aware even of this
fact, for the greater will be the inclination forward the greater
the instrument applied, the skin being forcibly drawn into the
cupping-instrument. I could tell of other modes of succussion than
those formerly described, which one might fancy would be more
applicable in such an affection; but I have no great confidence in
them, and therefore I do not describe them. On the main, it should
be known, respecting the accidents which I have briefly described,
that displacements forward are of a fatal and injurious nature; but
that displacements backward, for the most part, do not prove fatal,
nor occasion retention of urine nor torpor of the limbs, for they do
not stretch the ducts leading toward the intestines, nor occasion
obstruction of the same; but displacements forward produce both
these bad effects, and many others in addition. And truly they are
more apt to lose the power of their legs and arms, to have torpor of
the body, and retention of urine, who experience no displacement
either forward or backward, but merely a violent concussion along
the spine, while those who have displacement backward are least
subject to these symptoms.

  49. And one might observe many other instances in medicine, of
considerable injuries not proving serious, but producing a crisis in
some affection, while less considerable injuries prove more serious,
give rise to chronic diseases, and extend their effects to the whole
system. Now something similar may happen in fracture of the ribs;
for in fracture of one or more ribs, in general, if the fractured
bones are not driven inward, nor are laid bare, fever rarely
supervenes, neither does it often happen that there is haemoptysis,
empyema, and suppurating sores, which require treatment with pledgets,
nor necrosis of the bones; and in these cases the ordinary regimen
is sufficient. For, unless they be seized with continual fever, a
strict diet does more harm than good, by inducing inanition, and
increasing the pain, fever, and cough; for moderate fullness of the
intestines has a tendency to replace the ribs, while evacuation
leads to suspension of the ribs, and suspension induces pain. Ordinary
bandaging, externally, is sufficient in such cases; the bandages
should be applied moderately tight, along with cerate and
compresses, or a pad of wool may be applied. The rib is consolidated
in twenty days, for callus soon forms in such bones.

  50. But when there is contusion of the flesh about the ribs,
either from a blow, or a fall, or a bruise, or any like cause, there
is often copious vomiting of blood, for there are canals stretched
along the vacuity of each rib (intercostal space?), and nerves
proceeding from the most important parts of the body have their origin
there. Many of these, therefore, are troubled with coughs,
tubercles, empyema, external suppurations, and sphacelus of the
ribs. And even when no such symptoms supervene from contusion of the
skin about the ribs, still in such cases there is, generally, more
combined pain than in fractures of the ribs, and relapses of pain in
the seat of the injury are more apt to occur. Wherefore some
physicians pay much less attention to such injuries, than where the
rib is fractured, whereas, if they were wise, they would treat such
cases with far greater care than the other; for it is proper that
the diet should be restricted, that the patients should remain at rest
as much as possible, and abstain from venery, from fat articles of
food, from such as excite cough, and from everything strong; they
should be bled in the arm, speak as little as possible, should have
the contused part bound round with folded compresses, plenty of
bandages, broader than the contusion, and which should be smeared with
cerate; in applying the bandages, broad and soft shawls should be
used, and they should be put on moderately firm, so that the patient
will say that they are neither too tight nor loose, and the
bandaging should commence at the seat of the injury, and be made
more particularly tight there, and the bandaging should be conducted
as is done with a double-headed roller, so that the skin about the
ribs may not be ruffled, but may lie smooth, and the bandaging
should be renewed every day, or every alternate day. It is better also
to open the bowels with some gentle medicine, so as just to produce an
evacuation of the food, and the diet is to be restricted for ten days,
and then the body is to be recruited and filled up; while you are upon
the reducing system, the bandaging should be tighter, but when you are
making him up again, it must be looser; and, if he spit blood from the
commencement, the treatment and bandaging should be continued for
forty days; but if there be no haemoptysis, treatment for twenty
days will generally be sufficient; but the length of time must be
regulated by the magnitude of the injury. When such contusions are
neglected, if no greater mischief result there from, at all events the
bruised part has its flesh more pulpy than it had formerly. When,
therefore, any such thing is left behind, and is not properly
dissipated by the treatment, it will be worse if the mucosity be
lodged near the bone, for the flesh no longer adheres to the bone as
formerly, the bone becomes diseased, and chronic sloughings of the
bone in many cases arise from such causes. But if the mischief be
not upon the bone, but it is the flesh itself which is pulpy, relapses
and pains will return from time to time, if there happen to be any
disorder in the body; wherefore proper bandaging, and for a
considerable time, must be had recourse to, until the extravasated
blood forming in the bruise be dried up and absorbed, and the part
be made up with sound flesh, and the flesh adhere to the bone. The
best cure is the cautery in those cases which, from neglect, have
become chronic, and the place turns painful, and the flesh is pulpy.
And when the flesh itself is pulpy, the burning should be carried as
far as the bone, but the bone itself should not be heated; but if it
be in the intercostal space, you need not make the burning so
superficial, only you must take care not to burn quite through. But if
the contusion appear to be at the bone, if it be still recent, and the
bone has not yet become necrosed, if it be very small, it is to be
burned as has been described; but if the rising along the bone be
oblong, several eschars are to be burned over it. Necrosis of the
rib will be described along with the treatment of suppurating sores.

  51. There are four modes of dislocation at the hip-joint: of which
modes, dislocation inward takes place most frequently, outward, the
most frequently of all the other modes; and it sometimes takes place
backward and forward, but seldom. When, therefore, dislocation takes
place inward, the leg appears longer than natural, when compared
with the other leg, for two reasons truly; for the bone which
articulates with the hip-joint is carried from above down to the
ischium where it rises up to the pubes, upon it, then, the head of the
femur rests, and the neck of the femur is lodged in the cotyloid
foramen (foramen thyroideum?). The buttock appears hollow
externally, from the head of the thighbone having shifted inward,
and the extremity of the femur at the knee is turned outward, and
the leg and foot in like manner. The foot then being turned outward,
physicians, from ignorance, bring the sound leg to it and not it to
the sound leg; on this account, the injured limb appears to be much
longer than the sound one, and in many other cases similar
circumstances lead to error in judgment. Neither does the limb at
the groin admit of flexion as in the sound limb, and the head of the
bone is felt at the perineum too prominent. These, then, are the
symptoms attending dislocation of the thigh inward.

  52. When, then, a dislocation has not been reduced, but has been
misunderstood or neglected, the leg, in walking, is rolled about as is
the case with oxen, and the weight of the body is mostly supported
on the sound leg, and the limb at the flank, and the joint where the
dislocation has occurred is necessarily hollow and bent, while on
the sound side the buttock is necessarily rounded. For if one should
walk with the foot of the sound leg turned outward, the weight of
the body would be thrown upon the injured limb, but the injured limb
could not carry it, for how could it? One, then, is forced in
walking to turn the leg inward, and not outward, for thus the sound
leg best supports its own half of the body, and also that of the
injured side. But being hollow at the flank and the hip-joint, they
appear small in stature, and are forced to rest on a staff at the side
of the sound leg. For they require the support of a staff there, since
the nates inclines to this side, and the weight of the body is carried
to it. They are forced also to stoop, for they are obliged to rest the
hand on the side of the thigh against the affected limb; for the
limb which is injured cannot support the body in changing the legs,
unless it be held when it is applied to the ground. They who have
got an unreduced dislocation inward are forced to put themselves
into these attitudes, and this from no premeditation on their part how
they should assume the easiest position, but the impediment itself
teaches them to choose that which is most conformable to their present
circumstances. For persons who have a sore on the foot, or leg, and
cannot rest upon the limb, all, even children, walk in this way; for
they turn the injured limb outward in walking, and they derive two
advantages therefrom, to supply two wants; the weight of the body is
not equally thrown upon the limb turned outward, as upon the one
turned inward, for neither is the weight in a line with it, but is
much more thrown upon the one under the body; for the weight is in a
straight line with it, both in walking and in the shifting of the
legs. In this position one can most quickly turn the sound limb
under the body, by walking with the unsound limb outward, and the
sound inward. In the case we are now treating of, it is well that
the body finds out the attitudes which are the easiest for itself.
Those persons, then, who have not attained their growth at the time
when they met with a dislocation which is not reduced, become maimed
in the thigh, the leg, and the foot, for neither do the bones grow
properly, but become shortened, and especially the bone of the
thigh; and the whole limb is emaciated, loses its muscularity, and
becomes enervated and thinner, both from the impediment at the
joint, and because the patient cannot use the limb, as it does not lie
in its natural position, for a certain amount of exercise will relieve
excessive enervation, and it will remedy in so far the deficiency of
growth in length. Those persons, then, are most maimed who have
experienced the dislocation in utero, next those who have met with
it in infancy, and least of all, those who are full grown. The mode of
walking adopted by adults has been already described; but those who
are children when this accident befalls them, generally lose the erect
position of the body, and crawl about miserably on the sound leg,
supporting themselves with the hand of the sound side resting on the
ground. Some, also, who had attained manhood before they met with this
accident, have also lost the faculty of walking erect. Those who
were children when they met with the accident, and have been
properly instructed, stand erect upon the sound leg, but carry about a
staff, which they apply under the armpit of the sound side, and some
use a staff in both arms; the unsound limb they bear up, and the
smaller the unsound limb, the greater facility have they in walking,
and their sound leg is no less strong than when both are sound. The
fleshy parts of the limb are enervated in all such cases, but those
who have dislocation inward are more subject to this loss of
strength than, for the most part, those who have it outward.

  53. Some tell a story how the Amazonian women dislocate the joints
of their male children while mere infants, some at the knee, and
others at the hip-joint, that they may be maimed, and that the male
sex may not conspire against the female, and that they use them as
artisans to perform any sedentary work, such as that of a shoemaker or
brazier. Whether these things be true or not I do not know, but this I
know, that matters would be such as is represented, provided their
children, while infants, were to have their joints dislocated. The
consequences of dislocation inward at the hip-joint are much greater
than of dislocation outward at the hip-joint, but at the knee,
although there be some difference, it is less; but the mode of
either impediment is peculiar, their legs are more bandied when the
dislocation is outward, but those who have dislocation inward stand
erect on their feet with less freedom. In like manner, when the
dislocation is at the anklejoint, if outward they become vari (their
toes are turned inward?), but they can stand; but if the dislocation
be inward they become valgi (their toes are turned outward?), but they
have less freedom of standing. The proportional growth of their
bones is as follows: in those cases in which the bone of the leg is
dislocated, the bones of the feet grow very little, as being very near
the injury, but the bones of the leg increase in size, and with very
little defect, but the fleshy parts (muscles?) are wasted. But when
the ankle-joint is in its natural state, but the knee is dislocated,
in these cases the bones of the leg do not grow in like manner, but
become shortened, as being nearest the seat of the injury, and the
bones of the feet also are atrophied, but not in the same
proportion; because, as was said a little while ago, the ankle-joint
is safe, and if they could use it, as in the case of club-foot, the
bones of the foot would be still less atrophied. When the
dislocation takes place at the hip-joint, the bone of the thigh, in
this case, does not generally grow in like manner, as being the one
nearest the seat of the injury, but becomes shorter than the sound
one; but the growth of the bones of the leg is not arrested in like
manner; nor of those of the feet, for this reason, that there is no
displacement between the bones of the thigh and leg, nor between those
of the leg and foot; in those cases, however, the fleshy parts of
the whole limb are atrophied; but if they could make use of the
limb, the growth of the bones would be still more developed, as
formerly stated, only the thigh, although its flesh would be much less
wasted, would still be by no means so fleshy as the sound limb. The
following observations are a proof of this: those persons who are
weasel-armed (galiancones) from birth, owing to dislocation of the
humerus, or when the accident has happened to them before they have
attained their full growth, such persons have the bone of the arm
shortened, but those of the fore-arm and hand are little inferior in
size to the sound, for the reasons which have been stated, because the
humerus is the bone nearest to the joint affected, and, on that
account, it is shorter than natural; but the fore-arm is not equally
affected by the accident, because the joint at which the bones of
the arm and forearm are articulated remains in its natural
condition, and the hand is still further distant than the fore-arm
from the seat of the injury. Such are the reasons why certain of the
bones in this case increase in growth, and certain do not. The
laborious office of the hand contributes much to the development of
the flesh in the fore-arm and hand, for whatever work is done by the
hand, these weasel-armed persons strive to do no less effectually with
the other hand than with the sound; for the arms do not support the
weight of the body like the legs, and the work performed by them is
light. From exercise, then, the fleshy parts on the hand and
fore-arm are not atrophied in weasel-armed persons, and by these means
the arm, too, gains flesh. But in dislocation inward at the hip-joint,
whether from birth or from childhood, the fleshy parts, on that
account, are much more atrophied than those of the hand, because the
patients cannot exercise the leg. Another proof will be given in the
observations which will be presently stated, that these things are
such as I things are such as I have represented.

  54. When the head of the femur is dislocated outward, the limb in
these cases, when compared with the other, appears shortened, and this
is natural, for the head of the femur no longer rests on a bone as
in dislocation inward, but along the side of a bone which naturally
inclines to the side, and it is lodged in flesh of a pulpy and
yielding nature, and on that account it appears more shortened.
Inwardly, the thigh about the perineum appears more hollow and flabby,
but externally the buttock is more rounded, from the head of the thigh
having slipped outward, but the nates appear to be raised up, owing to
the flesh there having yielded to the head of the thigh-bone; but
the extremity of the thigh-bone, at the knee, appears to be turned
inward, and the leg and foot in like manner, neither does it admit
of flexion like the sound limb. These, then, are the symptoms of
dislocation outward.

  55. When such a dislocation is not reduced in adults, the whole limb
appears to be shortened, and in walking they cannot reach the ground
with the heel, but they walk with the ball of the foot on the
ground, and the points of their toes incline a little inward. But
the injured limb, in this case, can support the body much better
than in dislocation inward, both because the head of the femur and the
neck of its articular extremity, being naturally oblique, have
formed a bed under a considerable portion of the hip, and because
the extremity of the foot is not forcibly turned outward, but is
nearly in a line with the body, and is even inclined more inwardly.
When, then, the articular extremity of the femur has worn out a socket
for itself in the flesh where it was lodged, and the flesh is
lubricated, it ceases to be painful in the course of time, and when it
becomes free from pain, they can walk without a staff, if so inclined,
and they can support the body on the injured limb. From usage then, in
such cases, the fleshy parts are less enervated than in those which
have been mentioned a little before, still, however, they lose their
strength more or less; but in general there is more enervation when
the dislocation is inward than when it is outward. Some of them, then,
cannot wear their shoes, owing to the unbending state of their leg,
and some of them can. But when this dislocation takes place in
utero, and when the dislocation having occurred at any time before
manhood, from violence, has not been replaced, or when from disease
the articular extremity has started from its socket, and is
displaced (for many such cases occur, and from some of them, if the
femur become necrosed, obstinate suppurations requiring the use of
tents are formed, and in certain of them the bone is laid bare),
whether the bone become necrosed or not, the bone of the thigh is much
shortened, and does not usually grow like the sound one, the bones,
too, of the leg, become shorter than those of the other, but in a
small degree, for the same reasons that were formerly stated; such
persons can walk, some of them in the same fashion as adults having an
unreduced dislocation, and some of them walk with the whole foot on
the ground, but limp in walking, being obliged to do so by the
shortness of the limb. Such is the result, even though they be
carefully and properly trained in the attitudes before they have
strength for walking, and in like manner also, after they have
acquired the necessary strength; but those persons require the most
care who were very young when they met with the accident, for, if
neglected while children, the limb becomes entirely useless and
atrophied. The fleshy parts of the entire limb are more wasted than
those of the sound limb, but this is much less apt to happen in
their case than in dislocation inward, owing to usage and exercise, as
they are speedily able to make use of the limb, as was stated a little
before with regard to the weasel-armed (galiancones).

  56. There are persons who, from birth or from disease, have
dislocations outward of both the thighs; in them, then, the bones
are affected in like manner, but the fleshy parts in their case lose
their strength less; the legs, too, are plump and fleshy, except
that there is some little deficiency at the inside, and they are plump
because they have the equal use of both their legs, for in walking
they totter equally to this side that. Their nates appear very
prominent, from the displacement of the bones of the joint. But if
in their case the bones do not sphacelate (become carious?) and if
they do not become bent above the hip-joint, if nothing of this kind
happen to them, they become otherwise sufficiently healthy, but the
growth of all the rest of the body, with the exception of the head, is
arrested.

  57. In dislocations of the head of the femur backward, which
rarely occur, the patient cannot extend the leg, either at the
dislocated joint, or at the ham, to any extent, and of all the
dislocations, this is the variety in which the patients have the least
power of making extension at the groin and the ham. But, moreover,
this also should be known (for it is a valuable piece of knowledge,
and of much importance, and yet most yet most people are ignorant of
it), that persons in health cannot extend the joint at the ham, if
they do not extend the joint at the groin at the same time, unless
they raise the foot very high, for in this way they could do it;
neither also could they bend the joint at the ham, but with much
greater difficulty, if they do not bend the joint at the groin at
the same time. There are many other things in the body which have
similar connections, both with regard to the contractions of nerves
(ligaments?), and the positions of muscles, and many of them more
worthy of being known than is generally supposed, and with regard to
the nature of the intestine and that of the whole internal cavity, and
with regard to the displacements and contractions of the uterus; but
all these things will be treated of elsewhere, in a work akin to the
present one. But with regard to the matter on hand, they cannot make
extension, as has been already stated; and the limb appears shortened,
for two reasons-first, because it cannot be extended, and also because
the bone has slipped into the flesh of the nates; for the head and
neck of the femur, in this dislocation, are carried downward from
their natural situation, to the outside of the nates. But yet they can
bend the limb, unless prevented by pain, and the leg and foot appear
pretty straight, and not much inclined toward either side, but at
the groin the flesh, when felt, appears looser, from the bone of the
joint having slipped to the other side, but at the nates the head of
the femur may be felt to be more prominent than natural. Such are
the symptoms accompanying dislocation of the thigh backward.

  58. When this dislocation occurs in an adult, and is not reduced, he
can walk, indeed, after a time, and when the pain has abated, and when
he has been accustomed to rotate the articular bone in the flesh; he
finds it necessary, however, to make strong flexion at the groin in
walking, for two reasons, both because the limb, for the causes
already stated, becomes much shorter, and he is far from touching
the ground with his heel, and he can barely reach it with the ball
of his foot, and not even thus, unless he bend himself at the
groins, and also bend with the other leg at the ham. And in this case,
he is under the necessity of supporting the upper part of the thigh
with his hand at each step: this also contributes, in a certain
degree, to make him bend the body at the groins; for, during the
shifting of the feet in walking, the body cannot be supported on the
unsound be supported on the unsound limb, unless it be pressed to
the ground by the hand,-the end of the femur not being placed properly
under the body, but having slipped backward to the nates; and if he
should try to rest the weight of his body for a little, upon the foot,
without any other support, he would fall backward, for there would
be a great inclination in this direction, from the hips having
protruded backward far beyond the line of the foot, and the spine
inclining toward the hips. Such persons can walk, indeed, without a
staff, if so accustomed, for because the sole of the foot is in its
old line, and is not inclined outward, they do not require anything to
balance them. Such, however, as, instead of grasping the thigh, prefer
resting their weight upon a staff introduced into the armpit of the
affected side, these, if they use a longer staff, will walk, indeed,
more erect, but will not be able to reach the ground with the foot, or
if they wish to rest upon the foot, they must take a shorter staff,
and will require to bend the body at the groins. The wasting of the
fleshy parts is analogous to what happens in the cases formerly
described, for the wasting is greatest in those cases in which the
patients keep the limb up, and do not exercise it, whilst those who
practice walking, have the least atrophy. The sound leg, however, is
not benefited, but is rather rendered more deformed, if the injured
limb be applied to the ground, for it is forced to cooperate with
the other, being protruded at the hip, and bent at the ham. But if the
patient does not use the injured limb by applying it to the ground,
but carries it up, and rests upon a staff, the sound leg thereby gains
strength, for it is employed in its natural position, and further, the
exercise gives it strength. But it may be said, these things are
foreign to medicine; for what is the use of enlarging upon cases which
are already past remedy? This is far from being the case, for it
belongs to the knowledge of medicine to be acquainted also with these,
and they cannot possibly be separated from one another; for to such as
are curable, means are to be used to prevent them from becoming
incurable, studying how they may best be prevented from getting into
an incurable state. And incurable cases should be known, that they may
not be aggravated by useless applications, and splendid and creditable
prognostics are made by knowing where, how, and when every case will
terminate, and whether it will be converted into a curable or an
incurable disease. When then, from birth, or during one's youth,
this dislocation backward occurs, and is not reduced, whether it be
connected with violence or disease (for many such dislocations occur
in diseases, but the nature of the diseases in which dislocations take
place, will be described afterward); if, then, the dislocated limb
be not reduced, the bone of the thigh becomes shortened, the whole
limb is impaired, is arrested in its growth, and loses its flesh
from want of use; the articulation at the ham is also impaired, for
the nerves (ligaments?) become stretched, from cases formerly
stated, wherefore those who have this dislocation, cannot make
extension at the knee-joint. In a word, all parts of the body which
were made for active use, if moderately used and exercised at the
labor to which they are habituated, become healthy, increase in
bulk, and bear their age well, but when not used, and when left
without exercise, they become diseased, their growth is arrested,
and they soon become old. Among these parts the joints and nerves
(ligaments?), if not used, are not the least liable to be so affected;
they are impaired, then, for the reasons we have stated, more in
this variety of dislocation than in the others, for the whole limb
is wasted, both in its bones and in its fleshy parts. Such persons,
then, when they attain their full growth, keep the limb raised and
flexed, rest the weight of the body on the other leg, and support
themselves with a staff, some with one, and others with two.

  59. In dislocations of the head of the thigh-bone forward (they
are of rare occurrence), the patients cannot extend the leg
completely, but least of all can they bend it at the groin; they are
pained, also, if forced to bend the limb at the ham. The length of the
leg, if compared at the heel, is the same as that of the other; but
the extremity of the foot inclines less to project forward. But the
whole limb has its natural direction, and inclines neither to this
side nor to that. These cases are particularly attended with severe
pain, and they are more apt to be accompanied with retention of
urine at first than any of the other dislocations; for the head of the
thigh-bone is lodged very near to important nerves. And the region
of the groin appears swelled out and stretched, while that of the
nates is more wrinkled and flabby. The symptoms now stated are those
which attend this dislocation of the thigh-bone.

  60. When persons have attained their full growth before meeting with
this dislocation, and when it has not been reduced, upon the
subsidence of the pain, and when the bone of the joint has been
accustomed to be rotated in the place where it is lodged, these
persons can walk almost erect without a staff, and with the injured
leg almost quite straight, as it does not admit of easy flexion at the
groin and the ham; owing, then, to this want of flexion at the
groin, they keep the limb more straight in walking than they do the
sound one. And sometimes they drag the foot along the ground, as not
being able to bend the upper part of the limb, and they walk with
the whole foot on the ground; for in walking they rest no less on
the heel than on the fore part of the foot; and if they could take
great steps, they would rest entirely on the heel in walking; for
persons whose limbs are sound, the greater the steps they take in
walking, rest so much the more on the heel, while they are putting
down the one foot and raising the opposite. In this form of
dislocation, persons rest their weight more on the heel than on the
anterior part of the foot, for the fore part of the foot cannot be
bent forward equally well when the rest of the limb is extended as
when it is in a state of flexion; neither, again, can the foot be
arched to the same degree the limb is bent as when it is extended. The
natural state of matters is such as has been now described; and in
an unreduced dislocation, persons walk in the manner described, for
the reasons which have been stated. The limb, moreover, is less fleshy
than the other, at the nates, the calf of the leg, and the whole of
its posterior part. When this dislocation occurs in infancy, and is
not reduced, or when it is congenital, in these cases the bone of
the thigh is more atrophied than those of the leg and foot; but the
atrophy of the thigh-bone is least of all in this form of dislocation.
The fleshy parts, however, are everywhere attenuated, more
especially behind, as has been stated above. If properly trained, such
persons, when they grow up, can use the limb, which is only a little
shorter than the other, and yet they support themselves on a staff
at the affected side. For, not being able to use properly the ball
of the foot without the heel, nor to put it down as some can in the
other varieties of dislocation (the cause of which has been just now
stated), on this account they require a staff. But those who are
neglected, and are not in the practice of putting their foot to the
ground, but keep the limb up, have the bones more atrophied than those
who use the limb; and, at the articulations, the limb is more maimed
in the direct line than in the other forms of dislocation.

  61. In a word, luxations and subluxations take place in different
degrees, being sometimes greater and sometimes less; and those cases
in which the bone has slipped or been displaced to a much greater
extent, are in general more difficult to rectify than otherwise; and
if not reduced, such cases have greater and more striking impairment
and lesion of the bones, fleshy parts, and attitudes; but when the
bone has slipped, or been displaced to a less extent, it is easier
to reduce such cases than the other; and if the attempts at
reduction have failed, or have been neglected, the impairment in
such cases is less, and proves less injurious than in the cases just
mentioned. The other joints present great differences as to the extent
of the displacements which they are subject to. But the heads of the
femur and humerus are very similar to one another as to their
dislocations. For the heads of the bones are rounded and smooth, and
the sockets which receive the heads are also circular, and adapted
to the heads; they do not admit then of being dislocated in any
intermediate degree, but, not withstanding, from their rounded
shape, the bones slip either outward or inward. In the case we are now
treating of, then, there is either a complete dislocation or none at
all, and yet these bones admit of being displaced to a greater or less
extent; and the thigh is more subject to these differences than the
arm.

  62. Wherefore, then, some of these congenital displacements, if to a
small extent, may be reduced to their natural condition, and
especially those at the ankle-joint. Most cases of congenital
club-foot are remediable, unless the declination be very great, or
when the affection occurs at an advanced period of youth. The best
plan, then, is to treat such cases at as early a period as possible,
before the deficiency of the bones of the foot is very great, and
before there is any great wasting of the flesh of the leg. There is
more than one variety of club-foot, the most of them being not
complete dislocations, but impairments connected with the habitual
maintenance of the limb in a certain position. In conducting the
treatment, attention must be paid to the following points: to push
back and rectify the bone of the leg at the ankle from without inward,
and to make counter-pressure on the bone of the heel in an outward
direction, so as to bring it bring it into line, in order that the
displaced bones may meet at the middle and side of the foot; and the
mass of the toes, with the great toe, are to be inclined inward, and
retained so; and the parts are to be secured, with cerate containing a
full proportion of resin, with compresses, and soft bandages
insufficient quantity, but not applied too tight; and the turns of the
bandages should be in the same direction as the rectifying of the foot
with the hand, so that the foot may appear to incline a little
outward. And a sole made of leather not very hard, or of lead, is to
be bound on, and it is not to be applied to the skin but when you
are about to make the last turns of the bandages. And when it is all
bandaged, you must attach the end of one of the bandages that are used
to the bandages applied to the inferior part of the foot on the line
of the little toe; and then this bandage is to be rolled upward in
what is considered to be a sufficient degree, to above the calf of the
leg, so that it may remain firm when thus arranged. In a word, as if
moulding a wax model, you must bring to their natural position the
parts which were abnormally displaced and contracted together, so
rectifying them with your hands, and with the bandaging in like
manner, as to bring them into their position, not by force, but
gently; and the bandages are to be stitched so as to suit the position
in which the limb is to be placed, for different modes of the
deformity require different positions. And a small shoe made of lead
is to be bound on externally to the bandaging, having the same shape
as the Chian slippers had. But there is no necessity for it if the
parts be properly adjusted with the hands, properly secured with the
bandages, and properly disposed of afterward. This, then, is the
mode of cure, and it neither requires cutting, 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; when
recourse is had to a shoe, the most suitable are the buskins, which
derive their name from being used in 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.

  63. In cases of complete dislocation at the ankle-joint, complicated
with an external wound, whether the displacement be inward or outward,
you are not to reduce the parts, but let any other physician reduce
them if he choose. For this you should know for certain, that the
patient will die if the parts are allowed to remain reduced, and
that he will not survive more than a few days, for few of them pass
the seventh day, being cut off by convulsions, and sometimes the leg
and foot are seized with gangrene. It should be well known that such
will be the results; and it does not appear to me that hellebore
will do any good, though administered the same day, and the draught
repeated, and yet it is the most likely means, if any such there be;
but I am of opinion that not even it will be of service. But if not
reduced, nor any attempts at first made to reduce them, most of such
cases recover. The leg and foot are to be arranged as the patient
wishes, only they must not be put in a dependent position, nor moved
about; and they are to be treated with pitched cerate, a few
compresses dipped in wine, and not very cold, for cold in such cases
induces convulsions; the leaves also of beet, or of colt's foot, of
any such, when boiled in dark-colored austere wine, form a suitable
application to the wound and the surrounding parts; and the wound
may further be anointed with cerate in a tepid state. But if it be the
winter season, the part is to be covered with unscoured wool, which is
to be sprinkled from above with tepid wine and oil, but on no
account is either bandage or compress to be applied; for this should
be known most especially, that whatever compresses, or is heavy,
does mischief in such cases. And certain of the dressings used to
recent wounds are suitable in such cases; and wool may be laid upon
the sore, and sprinkled with wine, and allowed to remain for a
considerable time; but those dressings for recent wounds which only
last for a few days, and into which resin enters as an ingredient,
do not agree with them; for the cleansing of the sores is a slow
process, and the sore has a copious discharge for a long time. Certain
of these cases it may be advantageous to bandage. It ought also to
be well understood, that the patient must necessarily be much maimed
and deformed, for the foot is retracted outward, and the bones which
have been displaced outward protrude: these bones, in fact, not
being generally laid bare, unless to a small extent; neither do they
exfoliate, but they heal by thin and feeble cicatrices, provided the
patient keeps quiet for a length of time; but otherwise there is
danger that a small ulcer may remain incurable. And yet in the case we
are treating of, those who are thus treated are saved; whereas, when
the parts are reduced and allowed to remain in place, the patients
die.

  64. The same rule applies to dislocations at the wrist, attended
with a wound and projection of the bone, whether the bones of the
arm be displaced inward or outward. For this should be well
understood, that the patient will die in the course of a few days,
by the same mode of death as formerly described, if the bone be
reduced, and allowed to remain so. But in those cases in which they
are not reduced, nor any attempt made to reduce them, the patients,
for the most part, recover; and the same mode of treatment as has been
described will be applicable; but the deformity and impediment of
the limb must necessarily be great, and the fingers of the hand will
be weak and useless; for if the bones have slipped inward, they cannot
bend the fingers, or if outward, they cannot extend them.

  65. When the os tibiae, having made a wound at the knee, has
protruded through the skin, whether the dislocation be outward or
inward, in such a case, if the bone be reduced, death will be even
more speedy than in the other cases, although speedy also in them. But
the only hope of recovery is if you treat them without reduction.
These cases are more dangerous than the others, as being so much
higher up, as being so much stronger joints, and displaced from
bones which are so much stronger. But if the os femoris form a wound
at the knee, and slip through it, provided it be reduced and left
so, it will occasion a still more violent and speedy death than in the
cases formerly described; but if not reduced, it will be much more
dangerous than those cases mentioned before, and yet this is the
only hope of recovery.

  66. The same rule applies to the elbow-joint, and with regard to the
bones of the fore-arm and arm. For when these bones protrude through a
wound which they have made in the skin, all cases in which they are
reduced prove fatal; but if not reduced, there is a chance of
recovery; but to those that survive there is certain impediment. And
if in any instance the bones of the upper articulations
(shoulder-joint?), should be dislocated, and project through a wound
which they have made in the skin, these, if reduced, are followed by
more speedy death; and if not reduced, they are more dangerous than
the others. But the mode of treatment which appears to me most
suitable has been already described.

  67. When the joints of the toes or hands are dislocated, and the
bones protrude through a wound which they have made, and when there is
no fracture of the bone, but merely displacement of the joint, in
these cases, if the reduction be made and allowed to remain, there
is some danger of spasms (tetanus?) if not properly treated, and yet
it may be worth while to reduce them, having warned the patient
beforehand that much caution and care will be required. The easiest,
the most efficient method, and the one most conformable to art, is
that by the lever, as formerly described when treating of bones
which have been fractured and protruded; then the patient must be as
quiet as possible, lie in a recumbent position, and observe a
restricted regimen. And it will be better also that he should get some
gentle emetics. The sore is to be treated with dressings for fresh
wounds, which permit of allusions, or with the leaves of camomile,
or with the applications for fractured bones of the head, but
nothing very cold must be applied. The first (most distant?) joints
are least dangerous, but those still higher, are more so. Reduction
should be made the same day, or the next, but by no means on the third
or fourth, for it is on the fourth day that exacerbations especially
attack. In those cases, then, where immediate reduction cannot be
accomplished, we must wait until after the aforesaid days; for
whatever you reduce within ten days, may be expected to induce
spasm. But if the spasm supervene on its being reduced, the joint
should be quickly displaced, and bathed frequently with warm water,
and the whole body should be kept in a warm, soft, and easy condition,
and more especially about the joints, for the whole body should rather
be in a bent than in an extended state. Moreover, it is to be
expected, that the articular extremities of the bones of the fingers
will for this generally happens, if even the least degree of
inflammation take place, so that if it were not that the physician
would be exposed to censure, owing to the ignorance of the common
people, no reduction should be made at all. The reduction of the bones
of joints which have protruded through the skin, is attended with
the dangers which have been described.

  68. When the articular bones of the fingers are fairly chopped
off, these cases are mostly unattended with danger, unless deliquium
come on in consequence of the injury, and ordinary treatment will be
sufficient to such sores. But when resection is made, not at the
articulations, but at some other point in the bones, these cases
also are free from danger, and are still more easily cured than the
others; and the fractured bones of the fingers which protrude
otherwise than at the joint admit of reduction without danger.
Complete resections of bones at the joints, whether the foot, the
hand, the leg, the ankle, the forearm, the wrist, for the most part,
are not unattended with danger, unless one be cut off at once by
deliquium animi, or if continual fever supervene on the fourth day.

  69. With regard to the sphacelus of fleshy parts, it takes place
in wounds where there are large blood-vessels, which have been
strongly compressed, and in fractures of bones which have been bound
too tight, and in other cases of immoderate constriction, when the
parts which have been strangulated generally drop off; and the most of
such patients recover, even when a portion of the thigh comes away, or
of the arm, both bones and flesh, but less so in this case; and when
the fore-arm and leg drop off, the patients readily recover. In
cases then, of fracture of the bones, when strangulation and
blackening of the parts take place at first, the separation of the
dead and living parts quickly occurs, and the parts speedily drop off,
as the bones have already given way; but when the blackening
(mortification) takes place while the bones are entire, the fleshy
parts, in this case, also quickly die, but the bones are slow in
separating at the boundary of the blackening, and where the bones
are laid bare. Those parts of the body which are below the
boundaries of the blackening are to be removed at the joint, as soon
as they are fairly dead and have lost their sensibility; care being
taken not to wound any living part; for if the part which is cut off
give pain, and if it prove not to be quite dead, there is great danger
lest the patient may swoon away from the pain, and such swoonings
often are immediately fatal. I have known the thigh-bones, when
denuded in this manner, drop off on the eightieth day; but in the case
of this patient, the parts below were separated at the knee on the
twentieth day, and, as I thought, too early, for it appeared to me
that this should be done more guardedly. In a case which I had of such
blackening in the leg, the bones of the leg, as far as they were
denuded, separated at its middle on the sixtieth day. But the
separation of denuded bones is quicker or slower, according to the
mode of treatment; something, too, depends upon whether the
compression be stronger or weaker, and whether the nerves, flesh,
arteries, and veins are quicker or slower in becoming blackened and in
dying; since, when the parts are not strongly compressed, the
separation is more superficial, and does not go the length of laying
the bones bare, and in some cases it is still more superficial, so
as not even to expose the nerves. For the reasons now stated, it is
impossible to define accurately the time at which each of these
cases will terminate. The treatment of such cases, however, is to be
readily undertaken, for they are more formidable to look at than to
treat; and a mild treatment is sufficient in all such cases, for
they come to a crisis of themselves; only the diet must be attended
to, so that it may be as little calculated to create fever as
possible, and the body is to be placed in the proper positions:
these are, neither raised very high up, nor inclined much downward,
but rather upward, until the separation be completed; for at that time
there is most danger of hemorrhage; on this account, wounds should not
be laid in a declining position, but the contrary. But after a
while, and when the sores have become clean, the same positions will
no longer be appropriate; but a straight position, and one inclining
downward, may be proper; and in the course of time, in some of these
cases, abscesses form, and require bandages. One may also expect
that such patients will be attacked with dysentery; for dysentery
usually supervenes in cases of mortification and of hemorrhage from
wounds; it comes on generally when the blackening and hemorrhage
have arrived at a crisis, and is profuse and intense, but does not
last many days; neither is it of a fatal nature, for such patients
do not usually lose their appetite, nor is it proper to put them on
a restricted diet.

  70. Dislocation inward at the hip-joint is to be reduced in the
following manner: (it is a good, proper, and natural mode of
reduction, and has something of display in it, if any one takes
delight in such ostentatious modes of procedure). The patient is to be
suspended by the feet from a cross-beam with a strong, soft, and broad
cord; the feet are to be about four inches or less from one another;
and a broad and soft leather collar connected with the cross-beam is
to be put on above the knees; and the affected leg should be so
extended as to moved be two inches longer than the other; the head
should be about two cubits from the ground, or a little more or
less; and the arms 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. But when the patient is suspended, a person properly
instructed and not weak, having introduced his arm between his thighs,
is to place his fore-arm between the perineum and the dislocated
head of the os femoris; 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. This method comprises all
the conditions which are natural; for the body being suspended by
its weight, produces extension, and the person suspended from him,
along with the extension, forces the head of the thigh-bone to rise up
above the acetabulum; and at the same time he uses the bone of the
fore-arm as a lever, and forces the os femoris to slip into its old
seat. The cords should be properly prepared, and care should be
taken that the person suspended along with the patient have a
sufficiently strong hold.

  71. Wherefore, as formerly stated, men's constitutions differ much
from one another as to the facility or difficulty with which
dislocations are reduced; and the cause of this was also stated
formerly in treating of the shoulder. In some the thigh is reduced
with no preparation, with slight extension, directed by the hands, and
with slight movement; and in some the reduction is effected by bending
the limb at the joint, and making rotation. But much more frequently
it does not yield to any ordinary apparatus, and therefore one
should be acquainted with the most powerful means which can be applied
in each case, and use whatever maybe judged most proper under all
circumstances. The modes of extension have been described in the
former parts of the work, so that one may make use of whatever may
happen to be at hand. For, extension and counter-extension are to be
made in the direction of the limb and the body; and if this be
properly effected, the head of the thigh-bone will be raised above its
ancient seat; and if thus raised, it will not be easy to prevent it
from settling in its place, so that any ordinary impulse with the
lever and adjustment will be quite sufficient; but some apply
insufficient extension, and hence the reduction gives much trouble.
The bands then should be fastened, not only at the foot, but also
above the knee, so that the force of the extension may not be expended
on the knee-joint more than upon the hip-joint. The extension in the
direction of the foot is to be thus contrived. But the
counter-extension is not only to be managed by means of something
carried round the chest and armpits, but also by a long, double,
strong, and supple thong applied to the perineum, and carried behind
along the spine, and in front along the collar-bone and fixed to the
point from which counter-extension is made; and then force is to be so
applied, by means of this extension and counter-extension, that the
thong at the perineum may not pass over the head of the thigh-bone,
but between it and the perineum; and during the extension one should
strike the head of the femur with the fist, so as to drive it outward.
And when the patient is raised up by the stretching, you should pass a
hand through (between the legs?) and grasp it with the other hand,
so as at the same time to make extension, and force the dislocated
limb outward; while some other person sitting by the knee quietly
directs it inward.

  72. It has been formerly stated by us that it will be of
importance for any person who practices medicine in a populous city to
get prepared a quadrangular board, about six cubits or a little more
in length, and about two cubits in breadth; a fathom will be
sufficient thickness for it; and then along it from the one end to the
other, an excavation must be made, so that the working of the levers
may not be higher than is proper; then at both sides we are to raise
short, strong, and strongly-fixed posts, having axles; and in the
middle of the bench five or six long grooves are to be scooped out
about four inches distant from one another, three inches will be a
sufficient breadth for them, and the depth in like manner; and
although the number of grooves I have mentioned will be sufficient,
there is nothing to prevent their being made all over the bench. And
the bench should have in its middle a pretty 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 above, which, at the proper time, is to be adjusted between
the perineum and the head of the thigh-bone. This upright piece of
wood prevents the body from yielding to the force dragging downward by
the feet; for sometimes this piece of wood serves the purpose of
counter-extension upward; and sometimes, too, when extension and
counter-extension 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 outward. It is on this account that
several grooves are scooped out on the bench, so that this piece of
wood, being erected at the one which answers, may act as a lever,
either on the sides of the articular heads of bones, or may make
pressure direct on the heads along with the extension, according as it
may suit to push inward or outward with the lever; and the lever may
be either of a round or broad form, as may be judged proper; for
sometimes the one form and sometimes the other suits with the
articulation. This mode of applying the lever along with extension
is applicable in the reduction of all dislocations of the thigh. In
the case now on hand, a round lever is proper; but in dislocations
outward a flat lever will be the suitable one. By means of such
machines and of such powers, it appears to me that we need never
fail in reducing any dislocation at a joint.

  73. And one might find out other modes of reduction for this
joint. If the large bench were to have raised on it two posts about
a foot (in diameter?), and of a suitable height, on each side near its
middle, and if a transverse piece of wood like the step of a ladder,
were inserted in the posts, then if the sound leg were carried through
between the posts, and the injured limb were brought over the
transverse piece of wood, which should be exactly adapted in height to
the joint which is dislocated (and it is an easy matter so to adjust
it, for the step of the ladder should be made a little higher than
required, and a convenient robe, folded several times, is to be laid
below the patient's body), then a piece of wood, of suitable breadth
and length, is to be laid below the limb, and it should reach from the
ankle to beyond the head of the thigh-bone, and should be bound
moderately tight to the limb. Then the limb being extended, either
by means of the pestle-like piece of wood (formerly described), or
by any of the other methods of extension, the limb which is carried
over the step with the piece of wood attached to it, is to be forced
downward, while somebody grasps the patient above the hip-joint. In
this manner the extension will carry the head of the thighbone above
the acetabulum, while the lever power that is exercised will push
the head of the thigh-bone into its natural seat. All the
above-mentioned powers are strong, and more than sufficient to rectify
the accident, if properly and skillfully applied. For, as formerly
stated, in most cases reduction may be effected by much weaker
extension, and an inferior apparatus.

  74. If the head of the bone slip outward, extension and
counter-extension must be made as described, or in a similar manner.
But along with the extension a broad lever is to be used to force
the bone from without inward, the lever being placed at the nates or a
little farther up, and some person is to steady the patient's body, so
that it may not yield, either by grasping him at the buttocks with his
hands, or this may be effected by means of another similar lever,
adjusted to one of the grooves, while the patient has something laid
below him, and he is secured, and the dislocated thigh is to be turned
gently from within outward at the knee. Suspension will not answer
in this form of dislocation, for, in this instance, the arm of the
person suspended from him, would push the head of the thigh-bone
from the acetabulum. But one might use the piece of wood placed
below him as a lever, in such a manner as might suit with this mode of
dislocation; it must work from without. But what use is there for more
words? For if the extension be well and properly done, and if the
lever be properly used, what dislocation of the joint could occur,
that might not be thus reduced?

  75. In dislocation of the thigh, backward, extension and
counter-extension should be made as has been described; and having
laid on the bench a cloth which has been folded several times, so that
the patient may lie soft, he is to be laid on his face, and
extension thus made, and, along with the extension, pressure is to
be made with a board, as in the case of humpback, the board being
placed on the region of the nates, and rather below than above the
hip-joint; and the hole made in the wall for the board should not be
direct over, but should be inclined a little downward, toward the
feet. This mode of reduction is particularly appropriate to this
variety of dislocation, and at the same time is very strong. But
perhaps, instead of the board, it might be sufficient to have a person
sitting (on the seat of luxation ?), or pressing with his hands, or
with his foot, and suddenly raising himself up, along with the
extension. None of the other aforementioned modes of reduction are
natural in this form of dislocation.

  76. In dislocation forward, the same mode of extension should be
made; but a person who has very strong hands, and is well trained,
should place the palm of the one hand on the groin, and taking hold of
this hand with the other, is at the same time to push the dislocated
part downward, and at the same time to the fore part of the knee. This
method of reduction is most especially conformable to this mode of
dislocation. And the mode of suspension is also not far removed from
being natural, but the person suspended should be well trained, so
that his arm may not act as a lever upon the joint, but that the force
of the suspension may act about the middle of the perineum, and at the
os sacrum.

  77. Reduction by the bladder is also celebrated in dislocations at
this joint, and I have seen certain persons who, from ignorance,
attempted to reduce both dislocations outward and backward
therewith, not knowing that they were rather displacing than replacing
the parts; it is clear, however, that he who first invented this
method intended it for dislocation inward. It is proper, then, to know
how the bladder should be used, if it is to be used, and it should
be understood that many other methods are more powerful than it. The
bladder should be placed between the thighs uninflated, so that it may
be carried as far up the perineum as possible, and the thighs
beginning at the patella are to be bound together with a swathe, as
far up as the middle of the thigh, and then a brass 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. This, then, is the preparation; some, however, do the thing
worse than as I have described, for they do not bind the thighs
together to any extent, but only at the knees, neither do they make
extension, whereas extension should be made, and yet some people by
having the good fortune to meet with a favorable case, have
succeeded in making reduction. But it is not a convenient method of
applying force, for the bladder, when inflated, does not present its
most prominent part to the articular extremity of the femur, which
is the place that ought to be more especially pressed outward, but its
middle, which probably corresponds with the middle of the thigh, or
still lower down, for the thighs are naturally curved, being fleshy,
and in contact above, and becoming smaller downward, so that the
natural configuration of the parts forces the bladder from the most
proper place. And if a small bladder be introduced, its power will
be small, and unable to overcome the resistance of the articular bone.
But if the bladder must be used, the thighs are to be bound together
to a considerable extent, and the bladder is to be inflated along with
the extension of the body, and in this method of reduction both legs
are to be bound together at their extremity.

  78. The prime object of the physician in the whole art of medicine
should be to cure that which is diseased; and if this can be
accomplished in various ways, the least troublesome should be
selected; for this is more becoming a good man, and one well skilled
in the art, who does not covet popular coin of base alloy. With regard
to the subject now on hand, the following are domestic means of making
extension of the body, so that it is easy to choose from among the
things at hand:-In the first place, when soft and supple thongs are
not at hand for ligatures, either iron chains, or cords, or cables
of ships, are to be wrapped round with scarfs or pieces of woolen
rags, especially at the parts of them which are to be applied, and
in this state they are to be used as bands. In the second place, the
patient is to be comfortably laid on the strongest and largest couch
that is at hand, and the feet of the couch, either those at the
(patient's?) head, or those at the feet, are to be fastened to the
threshold, either within or without, as is most suitable; and a square
piece of wood is to be laid across, and extending from the one foot to
the other; and if this piece of wood be slender, it should be bound to
the feet of the couch, but, not withstanding, if it be thick, there
will be no necessity for this; then the heads of the ligatures, both
of those at the head and those at the feet, are to be fastened to a
pestle, or some such piece of wood, difficult to reduce at either end;
the ligatures should run along the line of the body, or be a little
elevated above it, and it should be stretched proportionally to the
pestles, so that, standing erect, the one may be fastened to the
threshold, and the other to the transverse piece of wood. Extension is
then to be made by bending back the ends of the pestles. A ladder,
having strong steps, if laid below the bed, will serve the purpose
of the threshold and the piece of wood laid along (the foot of the
couch?), as the pestles can be fastened to the steps at either end,
and when drawn back they thus make extension of the ligatures.
Dislocation, inward or forward, may be reduced in the following
manner: a ladder is to be fastened in the ground, and the man is to be
seated upon it, and then the sound leg is to be gently stretched along
and bound to it, wherever it is found convenient; and water is to be
poured into an earthen vessel, or stones put into a hamper and slung
from the injured leg, so as to effect the reduction. Another mode of
reduction: a cross-beam is to be fastened between two pillars of
moderate height; and at one part of the cross-beam there should be a
protuberance proportionate to the size of the nates; and having
bound a coverlet round the patient's breast, he is to be seated on the
protuberant part of the cross-beam, and afterward the breast is to
be fastened to the pillar by some broad ligature; then some one is
to hold the sound leg so that he may not fall off, and from the
injured limb is to be suspended some convenient weight, as formerly
described.

  79. It should be particularly known that the union of all bones
is, for the most part, by a head and socket (cotyle); in some of these
the place (socket?) is cotyloid and oblong, and in some the socket
is glenoid (shallow?). In all dislocations reduction is to be
effected, if possible, immediately, while still warm, but otherwise,
as quickly as it can be done; for reduction will be a much easier
and quicker process to the operator, and a much less painful one to
the patient, if effected before swelling comes on. But all the
joints when about to be reduced should be first softened, and gently
moved about; for, thus they are more easily reduced. And, in all cases
of reduction at joints, the patient must be put on a spare diet, but
more especially in the case of the greatest joints, and those most
difficult to reduce, and less so in those which are very small and
easily reduced.

  80. If any joint of the fingers is dislocated, whether the first,
second, or the third, the same method of reduction is to be applied,
but the largest joints are the most difficult to reduce. There are
four modes of displacement-either upward, downward, or to either side;
most commonly upward, and most rarely laterally, and in consequence of
violent motion. On both sides of its articular cavity there is a
sort of raised border. When the dislocation is upward or downward,
owing to the articular cavity having smoother edges there than at
the sides, if the joint of it be dislocated, it is more easily
reduced. This is the mode of reduction:-The end of the finger is to be
wrapped round with a fillet, or something such, that, when you lay
hold of it and make extension, it will not slip; and when this is
done, some person is to grasp the arm at the wrist, and another is
to take hold of the finger which is wrapped in the fillet, and then
each is to make considerable extension toward himself, and at the same
time the projecting bone is to be pushed into its place. But, if the
dislocation be lateral, the same mode of reduction is to be used;
but when you think that the extremity of the bone has cleared the rim,
at the same time that extension is made, the bone is to be pushed
direct into its place, while another person on the other side of the
finger is to take care and make counter-pressure, so that it may not
again slip out there. The twisted nooses formed from palm-shoots are
convenient for effecting reduction, if you will make extension and
counter-extension by holding the twisted string in the one hand and
the wrist in the other. When reduced, you must bind the part as
quickly as possible with bandages; these are to be very slender and
waxed with cerate, neither very soft nor very hard, but of middle
consistence; for that which is hard drops off from the finger, while
that which is soft and liquid is melted and lost by the increased heat
of the finger. The bandage is to be loosed on the third or fourth day;
but on the whole, if inflamed, it is to be the more frequently loosed,
and if otherwise, more rarely; this I say respecting all the joints.
The articulation of a finger is restored in fourteen days. The
treatment of the fingers and of the toes is the same.

  81. After all reductions of joints the patient should be confined to
a restricted diet and abstinence until the seventh day; and if there
be inflammation, the bandages are to be the more frequently loosed,
but otherwise, less frequently, and the pained joint is to be kept
constantly in a state of rest, and is to be laid in the most
convenient position possible.

  82. Accidents at the knee are more mild than at the elbow, from
its being compact, regular, and elegant in its construction; and,
therefore, it is more readily dislocated and reduced. It is most
frequently dislocated inward, but also outward and backward. The modes
of reduction are these: by flexion at the knee, or by sudden
calcitration, or having rolled a swathe into a ball, and fixed it in
the ham, the patient's body is to be suddenly dropped on its bended
knees. Dislocation backward, also, as in the case of the elbow, may be
reduced by moderate extension, and to either side, either by flexion
or calcitration, but also by moderate extension. The adjustment is the
same in all cases. In dislocations backward which are not reduced, the
patient cannot bend the joint, but neither can he, to any great
extent, in the other varieties; the thigh and leg are wasted in front;
but if inward the patients become bow-legged, and the external parts
are wasted; but if outward they become more bandy-legged, but the
impediment is less, for the body is supported on the larger of the
bones, and the inner parts are wasted. When these accidents happen
at birth or during adolescence, they follow the rule formerly stated.

  83. Dislocations at the ankle-joints require strong extension,
either with the hands or some such means; and adjustment, which at the
same time effects both purposes, as is common in all cases.

  84. Injuries of the foot are to be remedied like those of the hand.

  85. The bones connected with the leg, and which are dislocated,
either at birth or during adolescence, follow the same course as those
in the hand.

  86. When persons jumping from a height pitch on the heel, so as to
occasion separation (diastasis) of the bones, ecchymosis of the veins,
and contusion of the nerves; when these symptoms are very violent
there is danger of sphacelus, and that the case may give trouble
during life, for the bones are so constructed as to slip from one
another, and the nerves communicate together. And, indeed, in cases of
fracture, either from an injury in the leg or thigh, or in paralysis
of the nerves (tendons?) connected with these parts, or from neglect
during confinement to bed, when the heel gets blackened the most
serious consequences result therefrom. Sometimes, in addition to the
sphacelus, there come on acute fevers accompanied with hiccup,
aberration of intellect, and speedy death, with lividities of the
large blood-vessels. With regard to the symptoms attending
exacerbations, if the ecchymosed and blackened parts and those
around be somewhat hard and red, and if along with the hardness
there be lividity, mortification is to be apprehended; but if the
parts be slightly livid, or even very livid, and the swelling
diffused, or if greenish and soft, these appearances, in such cases,
are all favorable. The treatment, if no fever be present, consists
in the administration of hellebore, but otherwise (it is not to be
given, but oxyglyky (decoction of honeycombs and vinegar) is to be
given for drink, if required. Bandaging as in the other articulations:
above all, more especially in contusions, the bandages should be
numerous and softer than usual, but the compression should be less;
most turns should be made around the heel. Position, like the
bandaging, should be so regulated as not to determine to the heel.
Splints are not to be used.

  87. When the foot is dislocated, either alone or along with its
epiphysis, the displacement is, for the most part, to the inside. If
not reduced, in the course of time, the hip, the thigh, and the side
of the leg opposite the dislocation, become atrophied. Reduction is
the same as in the wrist, but the extension requires to be very
powerful. Treatment, agreeably to the general rule for joints.
Exacerbations do occur, but less frequently than in dislocations at
the wrist, provided the parts get rest. While they remain at rest
the diet should be restricted. Those which occur at birth, or during
adolescence, follow the rule formerly stated.
                                    THE END
