                                     400 BC
                                  ON FRACTURES
                                 by Hippocrates
                          Translated by Francis Adams
                     ON FRACTURES

  IN TREATING fractures and dislocations, the physician must make
the extension as straight as possible, for this is the most natural
direction. But if it incline to either side, it should rather turn
to that of pronation, for there is thus less harm than if it be toward
supination. Those, then, who act in such cases without deliberation,
for the most part do not fall into any great mistake, for the person
who is to have his arm bound, presents it in the proper position
from necessity, but physicians who fancy themselves learned in these
matters, are they who commit blunders. There is no necessity for
much study, then, in order to set a broken arm, and in a word, any
ordinary physician can perform it; but I am under the necessity of
giving the longer directions on this subject, because I know
physicians who have the reputation of being skilled in giving the
proper positions to the arm in binding it up, while in reality they
are only showing their own ignorance. But many other things in our art
are judged of in this manner, for people rather admire what is new,
although they do not know whether it be proper or not, than what
they are accustomed to, and know already to be proper; and what is
strange, they prefer to what is obvious. I must now state what the
mistakes of medical men are, which I wish to unteach, and what
instructions I have to give as to the management of the arm; for
what I have to say regarding it, will apply to the other bones in
the body.
  2. The arm, then, for that is the subject we were treating of, was
presented in the prone position to be bound, but the physician
forced his patient to hold it as the archers do when they project
the shoulder, and in this position he bound it up, thinking within
himself that he was acting according to Nature, and in proof of this
he pointed out that all the bones in the fore-arm were thus in a
straight line, and that the integuments both inside and outside,
were also in a straight line, and that the flesh and nerves (tendons?)
were thus put in their natural position, and he appealed to what
happens in archery, as a proof of this. And so saying, and so doing,
he is looked up to as a sage; and yet he forgets that in all the other
arts and performances, whether executed whether executed by strength
or dexterity, what is reckoned the natural position is not the same,
and that in the same piece of work it may happen that the natural
position of the right arm is not the same as that of the left. For
there is one attitude in throwing the javelin, and another in
slinging, another in casting stones, another in boxing, and another in
a state of repose. And whatever arts one examines, it will be found
that the natural position of the arms is not the same in each, but
that in every case the arms are put into the attitude which suits best
with the instrument that is used, and the work to be performed. In
practicing archery, no doubt this is the best attitude of the left
arm, for gingly-moid extremity of the humerus being fixed in the
cavity of the ulna, in this position, throws the bones of the
forearm and arm into a line, as if they constituted a single bone, and
all flexion at the joint is prevented in this position. It is no doubt
certain that the member is thus put into the most unbending and
extended position possible, so as not to be overcome or yield when the
string is drawn by the right arm, and thus will the archer be
enabled to draw the string farthest, and discharge his arrow with
the greatest force and rapidity, for arrows thus discharged have the
greatest swiftness and force, and are carried to the greatest
distances. But there is nothing in common between the binding up of an
arm and archery. Moreover, if having thus bound up the arm, the
physician direct the patient to keep it thus, he will occasion him
greater pain than he had from the wound itself; and thus also, if
the physician order him to bend the arm, neither the bones, the
nerves, nor the flesh will any longer be in the same condition, but
will be arranged differently, having overcome the bandaging. What use,
then, is there of the archer's attitude? And these mistakes, the
physician, conceited in his knowledge, would probably not have
committed if he had allowed the patient himself to present his arm.
  3. But another physician putting the arm into the state of
supination, gives orders to extend the arm thus, and bandages it in
this position, reckoning it the one according to nature, judging
thus from the skin, and also fancying the bones to be thus in their
natural position, because the bone which protrudes at the wrist, where
the little finger is, appears to be in a line with the bone from which
people measure the bone of the fore-arm. These things he brings
forward as proofs that the parts are in their natural state, and he is
supposed to speak correctly. But, indeed, if the arm be kept stretched
in a supine position, it will become very painful, and this fact any
one may ascertain by extending his own arm in this attitude. And
also a weaker man grasping with his hands a stronger man whose arm
is turned in a supine position, could lead him wherever he chose,
and neither, if a man held a sword thus in his hand, could he make any
proper use of it, so constrained is this position. And, moreover,
if, when a physician has thus bound up the arm, he allow it to
remain in the same position, the patient will endure greater pain if
he walk about, but considerable, even if he remain at rest. And
thus, too, if he shall bend the arm, the muscles and the bones must
necessarily assume a different position. But, in addition to other
mischief, he is ignorant of these facts regarding the position, that
the bone which protrudes at the wrist, close to the little finger,
belongs to the fore-arm, whereas the one at the joint, from which
people measure the fore-arm, is the head of the humerus. He fancies
that both these belong to the same bone, and many others are of this
opinion. The latter, in fact, is the same part as that which is called
the elbow, upon which we sometimes rest, and when he holds the arm
thus in a supine position, in the first place the bone appears
distorted, and in the next place the tendons which extend from the
carpus along the inner side and from the fingers become distorted
while the arm has a supine position; for these tendons proceed to
the bone of the humerus, from which the fore-arm is measured. Such,
and so many mistakes and marks of ignorance are committed, regarding
the natural construction of the arm. But if one will extend a broken
arm as I direct, he will turn the bone, situated at the extremity of
the little finger, into the straight line, and also the one at the
elbow, and the tendons which stretch from the carpus to the
extremity of the humerus will be placed in the straight line; and when
the arm is suspended in a sling, it will be in the same attitude as
that in which it was bound up, and will give no pain to the patient
when he walks about, nor when he lies reclined, and will not become
fatigued. The man should be so seated that the prominent part of the
bone may be turned to the brightest light which is at hand, so that
the operator in making the extension, may be at no loss to discover if
it be sufficiently straight. The prominence of a broken bone could not
escape being detected by the hand of an experienced person, when
applied for this purpose, and, moreover, the projecting part is
particularly painful to the touch.
  4. In cases of fracture in either of the bones of the forearm, it is
easier to effect a cure if the upper bone be broken, although it be
the thicker one, both because the sound bone is situated below, and
forms a support to it, and because the deformity is more easily
concealed, there being a thick mass of flesh on the upper side, except
near to the wrist. But the lower bone is without a covering of
flesh, is not easily concealed, and requires stronger extension. If it
is not this bone, but the other which is broken, a more feeble
extension proves sufficient, but if both be broken, a more powerful
extension is required. In the case of a young person I have known
the extension made more strong than was necessary, but in general
the extension made is less than what is required. And when they are
extended, the physician should apply the palms of the hands, and
adjust the fractured parts and then having rubbed the parts with
cerate, but not in large quantity so that the bandages may not come
off, it is to be bound up in this state, care being taken that the
hand be not lower than the elbow, but a little higher, so that the
blood do not flow toward the extremity, but may be determined to the
upper part; and then it is to be secured with the bandage, the head of
which is to be placed at the fracture, and the bandage should impart
firmness to the parts without occasioning strong compression. When you
have carried the bandage twice or thrice round at the seat of the
fracture, it is to be carried upward, so that the afflux of blood into
it may be stopped, and the bandage should terminate there, and the
first bandages ought not to be long. The head of the second bandage is
also to be placed upon the seat of the fracture, and a single round of
it being made there, it is then to be carried downward, and is not
to be applied so tight as the other, and there should be greater
distances between the turns, so that the bandage may prove
sufficient to revert to the spot where the other terminated. The
bandages may be rolled to the left hand or to the right, or to
whatever side suits best with the position of the fractured arm, or
according to the inclination which it may have. Afterward we must
place along the arm, compresses, smeared with a little cerate, for
thus they occasion less uneasiness, and are more easily arranged.
And then we must apply the bandages crossways, sometimes to the
right hand, and sometimes to the left, for the most part beginning
below and terminating above, but sometimes commencing above and ending
below. The parts which are thinly covered with flesh should be wrapped
round with compresses, and inequalities should be made up, not by a
number of folds at once, but by degrees. Some slack turns are also
to be made around the wrist, to this side and to that. These two
bandages are sufficient at first.
  5. And these are the signs that the patient has been well treated
and properly bandaged: if you ask him if the arm feels tight, and he
says it does, but moderately so, and especially about the fracture;
and this reply he should make all along, if the bandage be properly
applied. And these are symptoms of the bandaging being moderately
tight; if for the first day and night he fancies that the tightness
does not diminish, but rather increases; and if on the next day
there be a soft swelling in the hand, for this is a sign of moderate
compression, but at the end of the second day the compression should
feel less, and on the third day the bandaging should appear loose. And
if any of these symptoms be wanting, you may conclude that the
bandaging is slacker than it should be; or if any of these symptoms be
in excess, you may infer that the compression is more than moderate;
and judging from these, you will apply the next bandages either
slacker or tighter. Having removed the bandages on the third day,
you must make extension and adjust the fracture, and bind it up again;
and if the first bandaging was moderately applied, the second
bandaging should be made somewhat tighter. The heads the bandages
should be placed on the fractures as in the former case; for, so
doing, the humors will be driven to the extremities, whereas if you
bandage any other part beforehand, the humors will he forced from it
to the seat of the fracture: it is of much importance that this should
be properly understood. Thus the bandaging and compression should
always commence at the seat of the fracture, and everything else
should be conducted on the same principle, so that the farther you
proceed from the fracture, the compression should always be the
less. The bandages should never be actually loose, but should be
smoothly put on. At each dressing the number of bandages should be
increased; and the patient, if asked, should answer, that he feels the
bandages somewhat tighter than on the former occasion, especially
about the fracture, and everything else in proportion; and with
respect to the swelling, the pain, and recovery, everything should
proceed as after the former dressing. But on the third day the outer
bandaging should appear looser. Then having removed the bandages,
you should bind it up again, somewhat tighter than before, and with
all the bandages which will be required on the occasion, and
afterwards one ought to experience the same train of symptoms as at
the former periods of bandaging.
  6. When the third day arrives, that is to say, the seventh from
the first dressing, if properly done, the swelling in the hand
should be not very great; and the part which has been bandaged
should be found more slender and less swelled at each time, and on the
seventh day the swelling should be quite gone, and the broken bones
should be more readily moved, and admit of being easily adjusted.
And if these things be so, you should, after setting the fracture,
apply the bandages so as to suit the splints, and a little more
tight than formerly, unless there be more pain from the swelling in
the hand. When you have applied the bandages, you must adjust the
splints all around the limb, and secure them secure them with
strings so loose as just to keep them in their place, without the
application of the splints contributing at all to the compression of
the arm. After this the pain and recovery should proceed as in the
preceding periods of the bandaging. But if, on the third day, the
patient say that the bandaging is loose, you must then fasten the
splints, especially at the fracture, but also elsewhere, wherever
the bandaging is rather loose than tight. The splint should be
thickest where the fracture protrudes, but it should not be much
more so than elsewhere. Particular attention should be paid to the
line of the arm corresponding to the thumb, so that no splint be
laid on it, but upon each side of it, nor in the line of the little
finger where the bone is prominent at the wrist, but on each side of
it. And if it be found necessary that splints should be applied in
these directions at the seat of the fracture, they should be made
shorter than the others, so as that they may not reach the bones which
are prominent at the wrist, for otherwise there is danger of
ulceration, and of the tendons being laid bare. The splints should
be adjusted anew every third day, in a very gentle manner, always
keeping in mind that the object of the splints is to maintain the
lower bandages in their place, and that they are not needed in order
to contribute to the compression.
  7. If, then, you see that the bones are properly adjusted by the
first dressings, and that there is no troublesome pruritus in the
part, nor any reason to suspect ulceration, you may allow the arm to
remain bandaged in the splints until after the lapse of more than
twenty days. The bones of the fore-arm generally get consolidated in
thirty days altogether; but there is nothing precise in this matter,
for one constitution differs from another, and one period of life from
another. When you remove the bandages, you must pour hot water on
the arm and bind it up again, but somewhat slacker, and with fewer
bandages than formerly: and again on the third day you undo the
bandages, and bind it still more loosely, and with still fewer
bandages. And if, while the arm is bound up in the splints, you should
at any time suspect that the bones do not lie properly, or if anything
about the bandages annoys the patient, you should loose them at the
middle of the time, or a little earlier, and apply them again. A
diet slightly restricted will be sufficient in those cases in which
there was no external wound at first, or when the bone does not
protrude; but one should live rather sparingly until the tenth day, as
being now deprived of exercise; and tender articles of food should
be used, such as moderately loosen the bowels; but one should
abstain altogether from flesh and wine, and then by degrees resume a
more nourishing diet. This diet. may be laid down as a just rule in
the treatment of fractures, both as to how they should be treated, and
what will be the results of a proper plan of treatment; so that one
may know, that if things do not turn out thus, there has been some
defect or excess in the treatment. And in this simple plan of
treatment it is necessary to attend also to the following
directions, which some physicians pay little attention to, although,
when improperly executed, they are capable of marring the whole
process of bandaging: for if both the bones be broken, or the lower
one only, and the patient who has got his arm bandaged keep it slung
in a shawl, and that the shawl is particularly loose at the
fracture, so that the arm is not properly suspended at this end or
that, in this case the bone must necessarily be found distorted
upwards; whereas, when both bones are thus broken, if the arm
recline in the shawl at the wrist and elbow, but the rest of it be not
kept up, the bone in this case will be distorted to the lower side.
The greater part of the arm and the wrist of the hand should therefore
be equally suspended in a broad soft shawl.
  8. When the arm is broken, if one stretch the fore-arm and adjust it
while in this position, the muscle of the arm will be bound while
extended; but when the dressing is over, and the patient bends his arm
at the elbow, the muscle of the arm will assume a different shape. The
following, then, is the most natural plan of setting the arm: having
got a piece of wood a cubit or somewhat less in length, like the
handles of spades, suspend it by means of a chain fastened to its
extremities at both ends; and having seated the man on some high
object, the arm is to be brought over, so that the armpit may rest
on the piece of wood, and the man can scarcely touch the seat, being
almost suspended; then having brought another seat, and placed one
or more leather pillows under the arm, so as to keep it a moderate
height while it is bent at a right angle, the best plan is to put
round the arm a broad and soft skin, or broad shawl, and to hang
some great weight to it, so as to produce moderate extension; or
otherwise, while the arm is in the position I have described, a strong
man is to take hold of it at the elbow and pull it downward. But the
physician standing erect, must perform the proper manipulation, having
the one foot on some pretty high object, and adjusting the bone with
the palms of his hands; and it will readily be adjusted, for the
extension is good if properly applied. Then let him bind the arm,
commencing at the fracture, and do otherwise as directed above; let
him put the same questions and avail himself of the same signs to
ascertain whether the arm be moderately tight or not; and every
third day let him bind it anew and make it tighter; and on the seventh
or ninth day let him bind it up with splints, and leave it so until
after the lapse of more than thirty days. And if he suspect that the
bone is not lying properly, let him remove the bandages in the
interval, and having adjusted the arm, let him bind it up again. The
bone of the arm is generally consolidated in forty days. When these
are past, the dressing is to be removed, and fewer and slacker
bandages applied instead of it. The patient is to be kept on a
stricter diet, and for a longer space of time than in the former case;
and we must form our judgment of it from the swelling in the hand,
looking also to the strength of the patient. This also should be
known, that the arm is naturally inclined outward; to this side,
therefore, the distortion usually takes place, if not properly
treated; but indeed, all the other bones are usually distorted
during treatment for fracture to that side to which they naturally
incline. When, therefore, anything of this kind is suspected, the
arm is to be encircled in a broad shawl, which is to be carried
round the breast, and when the patient goes to rest, a compress of
many folds, or some such thing, is to be folded and placed between the
elbow and the side, for thus the bending of the bone will be
rectified, but care must be taken lest it be inclined too much
inwards.
  9. The human foot is composed of several small bones like the
hand. These bones therefore are scarcely ever broken, unless the
skin at the same time be wounded by some sharp and heavy body. The
treatment of stich injuries, therefore, will be delivered under the
head of wounds. But if any bone be moved from its place, or a joint of
the toes be luxated, or any of the bones of the part called the tarsus
be displaced, it must be forced back again to its place as described
with regard to the hand; and is to be treated with cerate, compresses,
and bandages, like the fractures, with the exception of the splints;
and is to be secured tightly in the same way, and the bandages renewed
on the third day; and the patient thus bandaged should return the same
answers as in fractures, as to the bandages feeling tight or slack.
All these bones recover perfectly in twenty days, except those that
are connected with the bones of the leg, and are in a line with
them. It is advantageous to lie in bed during the whole of this
time; but the patients, thinking light of the complaint, have not
perseverance to do this, and they walk about before they get well;
wherefore many of these do not make a perfect recovery. And often
the pain puts them in mind of the injury; and deservedly, for the feet
sustain the weight of the whole body. When, therefore, they walk about
before they are whole, the joints which have been luxated are cured
incompletely; and, on that account, while walking about, they have
pains in the leg from time to time.
  10. But those bones which are connected with the bones of the leg
are larger than the others, and the cure of them when luxuated is more
protracted. The mode of treatment then is the same; but we must use
more bandages and more splints, and the bandage is to be carried round
to this side and to that, and pressure is to be made as in the other
cases, particularly at the seat of the luxation, and the first circles
of the bandages are to be made there. And at each time the bandages
are taken off, much hot water is to be used, for in all injuries at
joints the affusion of hot water in large quantity is to be had
recourse to. And the same symptoms of compression and relaxation
should manifest themselves in the same times, as in the cases formerly
treated of, and the subsequent bandagings should be conducted in
like manner. These cases get completely well for the most part in
forty days, if the patients have resolution to keep their bed; but
if not, they are subjected to the complaints formerly described, or
still worse.
  11. In persons who jumping from any high object pitch upon their
heel with great force, the bones are separated, and the veins pour
forth their contents, owing to the contusion of the flesh
surrounding the bone, and hence a swelling and much pain supervene.
For this bone (os calcis) is not a small one, protrudes beyond the
line of the leg, and is connected with important veins and tendons;
for the back tendon of the leg is inserted into this bone. Such
cases are to be treated with cerate, and with compresses and bandages;
and hot water is to be used in large quantity; and they require many
bandages, which ought to be particularly good and appropriate. And
if the patient happen to have a tender skin about the heel, nothing is
to be done to it; but if, as some have it, the skin be thick and
hardened, it is to be pared down smoothly and thinned, but without
wounding it. It is not everybody who can apply the bandage properly in
such cases; for if one shall bind the parts, as in other accidents
about the ankle, sometimes bringing a fold round the foot and
sometimes round the tendon, these turns leave out the heel, which is
the seat of the contusion, and thus there is danger that the os calcis
may sphacelate; and if this should take place, the impediment may
endure for life and also in all the other cases of sphacelus, not
proceeding from such a cause as this; as when, from being carelessly
allowed to lie in a certain position during confinement to bed, the
heel becomes black, or when a serious wound has occurred in the leg
and it is long of healing, and is connected with the heel, or when the
same thing happens in the thigh, or when in any disease a protracted
decubitus takes place on the back, in all such cases the sores are
inveterate, troublesome, and frequently break out again, unless
particular attention be paid to the cure, along with much rest, as
in all the cases attended with sphacelus. And cases of sphacelus
connected with this cause, in addition to other inconveniences, are
attended with great danger to the whole body. For they are apt to be
attended with very acute fevers, of the continual type, accompanied
with tremblings, hiccup, aberration of intellect, and which prove
fatal within a few days: and there may be lividities of bloody
veins, with nausea, and gangrene from pressure; these diseases may
occur, besides the sphacelus. Those which have been described are
the most violent contusion; but in general the contusions are mild,
and no great care is required with regard to the treatment, and yet it
must be conducted properly. But when the contusion appears to be
severe, we must do as described above, making many turns of the
bandage around the heel, sometimes carrying it to the extremity of the
foot, sometimes to the middle, and sometimes around the leg; and, in
addition, all the surrounding parts are to be bandaged in this
direction and that, as formerly described; and the compression
should not be made strong, but we should make use of many bandages,
and it is better also to administer hellebore the same day or on the
morrow; and the bandages should be removed on the third day and
reapplied. And these are the symptoms by which we discover whether the
case will get worse or not: when the extravasated blood, the
lividities, and the surrounding parts become red and hard, there is
danger of an exacerbation. But if there be no fever, we must give
emetics, as has been said, and administer the other remedies which are
applicable when the fever is not of a continual type; but if continual
fever be present, we must not give strong medicines, but enjoin
abstinence from solid food and soups, and give water for drink, and
not allow wine but oxyglyky (a composition from vinegar and honey?).
But if the case be not going to get worse, the ecchymosed and livid
parts, and those surrounding them become greenish and not hard; for
this is a satisfactory proof in all cases of ecchymosis, that they are
not to get worse; but when lividity is complicated with hardness,
there is danger that the part may become blackened. And we must so
manage the foot as that it may be generally raised a little higher
than the rest of the body. Such a patient will get well in sixty
days if he keep quiet.
  12. The leg consists of two bones, of which the one is much more
slender than the other at one part, but not much more slender at
another. These are connected together at the foot, and form a common
epiphysis, but they are not united together along the line of the leg;
and at the thigh they are united together and form an epiphysis, and
this epiphysis has a diaphysis; but the other bone in a line with
the little toe is a little longer. Such is the nature of the bones
of the leg.
  13. Sometimes the bones connected with the foot are displaced,
sometimes both bones with their epiphysis; sometimes the whole
epiphysis is slightly moved, and sometimes the other bone. These cases
are less troublesome than the same accidents at the wrist, if the
patients will have resolution to give them rest. The mode of treatment
is the same as that of the other, for the reduction is to be made,
as of the other, by means of extension, but greater force is required,
as the parts of the body concerned are stronger in this case. But, for
the most part, two men will be sufficient, by making extension in
opposite directions, but, not withstanding, if they are not
sufficiently strong, it is easy to make more powerful extension in the
following way: having fixed in the ground either the nave of a
wheel, or any such object, something soft is to be bound round the
foot, and then some broad thongs of ox-skin being brought round it,
the heads of the thongs are to be fastened to a pestle or any other
piece of wood, the end of which is to be inserted into the nave, and
it, the pestle, is to be pulled away, while other persons make
counter-extension by grasping the shoulders and the ham. It is also
sometimes necessary to secure the upper extremity otherwise; this if
you desire to effect, fasten deeply in the ground a round, smooth
piece of wood, and place the upper extremity of the piece of wood at
the perineum, so that it may prevent the body from yielding to the
pulling at the foot, and, moreover, to prevent the leg while
stretched, from inclining downward; some person seated at his side
should push back the hip, so that the body may not turn round with the
pulling, and for this purpose, if you think fit, pieces of wood may be
fastened about the armpits on each side, and they are to be
stretched by the hands, and thus secured, while another person takes
hold of the limb at the knee, and aids in thus making
counter-extension. Or thus, if you prefer it: having bound other
thongs of leather about the limb, either at the knee, or around the
thigh, and having fastened another nave of a wheel in the ground above
the head, and adjusted the thongs piece of wood adapted to the nave,
extension may thus be made in the opposite direction to the feet. Or
if you choose, it may be done thus: instead of the naves, lay a
moderate-sized beam under the couch, and then having fastened pieces
of wood in this beam, both before and behind the head, make
counter-extension by means of thongs, or place windlasses at this
extremity and that, and make extension by means of them. There are
many other methods of making extension. But the best thing is, for any
physician who practices in a large city, to have prepared a proper
wooden machine, with all the mechanical powers applicable in cases
of fractures and dislocation, either for making extension, or acting
as a lever. For this purpose it will be sufficient to possess a
board in length, breadth, and thickness, resembling the quadrangular
threshing-boards made of oak.
  14. When you have made proper extension, it is easy reduce the
joint, for the displaced bone is thus raised into a line with the
other. And the bones are to be adjusted with the palms of the hands,
pressing upon the projecting bone with the one, and making
counter-pressure below the ankle with the other. When you have
replaced the bones, you must apply the bandages while the parts are
upon the stretch, if you possibly can; but if prevented by the thongs,
you must loose them, and make counter-extension until you get the
bandages applied. The bandage is to be applied in the manner
formerly described, the heads of the bandages being placed on the
projecting part, and the first turns made in like manner, and so
also with regard to the number of compresses and the compression;
and turns of the bandages are to be brought frequently round on this
and on that side of the ankle. But this joint must be bound more tight
at the first dressing than in the case of the hand. But when you
have applied the bandage, you must place the bandaged part somewhat
higher than the rest of the body, and in such a position that the foot
may hang as little as possible. The attenuation of the body is to be
made proportionate to the magnitude of the luxation, for one
luxation is to be a small, and another to a great extent. But in
general we must reduce more, and for a longer time, in injuries
about the legs, than in those about the hands; for the former parts
are larger and thicker than the latter, and it is necessary that the
body should be kept in a state of rest, and in a recumbent position.
There is nothing to prevent or require the limb to be bandaged anew on
the third day. And all the treatment otherwise is to be conducted in
like manner, as in the preceding cases. And if the patient have
resolution to lie quiet, forty days will be sufficient for this
purpose, if only the bones be properly reduced, but if he will not lie
quiet, he will not be able to use the limb with ease, and he will find
it necessary to wear a bandage for a long time. When the bones are not
properly replaced, but there has been some defect in this respect, the
hip, the thigh, and the leg become wasted, and if the dislocation be
inward, the external part of the thigh is wasted, and vice versa.
But for the most part the dislocation is inward.
  15. And when both bones of the leg are broken without a wound of the
skin, stronger extension is required. We may make extension by some of
the methods formerly described, provided the bones ride over one
another to a considerable degree. But extension by men is also
sufficient, and for the most part two strong men will suffice, by
making extension and counterextension. Extension must naturally be
made straight in a line with the leg and thigh, whether on account
of a fracture of the bones of the leg or of the thigh. And in both
cases they are to be bandaged while in a state of extension, for the
same position does not suit with the leg and the arm. For when the
fractured bones of the arm or fore-arm are bandaged, the fore-arm is
suspended in a sling, and if you bind them up while extended, the
figures of the fleshy parts will be changed in bending the arm at
the elbow, for the elbow cannot be kept long extended, since persons
are not in the custom of keeping the joint long in this form, but in a
bent position, and persons who have been wounded in the arm, and are
still able to walk about, require to have the arm bent at the
elbow-joint. But the leg, both in walking and standing, is
habitually extended, either completely or nearly so, and is usually in
a depending position from its construction, and in order that it may
bear the weight of the rest of the body. Wherefore it readily bears to
be extended when necessary, and even when in bed the limb is often
in this position. And when wounded, necessity subdues the
understanding, since the patients become incapable of raising
themselves up, so that they neither think of bending the limb nor of
getting up erect, but remain lying in the same position. For these
reasons, neither the same position nor the same mode of bandaging
applies to the arm and to the leg. If, then, extension by means of men
be sufficient, we should not have recourse to any useless
contrivances, for it any useless contrivances, for it is absurd to
employ mechanical means when not required; but if extension by men
be not sufficient, you may use any of the mechanical powers which is
suitable. When sufficiently extended, it will be easy to adjust the
bones and bring them into their natural position, by straightening and
arranging them with the palms of the hand.
  16. When the parts are adjusted, you should apply the bandages while
the limb is in a stretched position, making the first turns to the
right or to the left, as may be most suitable; and the end of the
bandage should be placed over the fracture, and the first turns made
at that place; and then the bandage should be carried up the leg, as
described with regard to the other fractures. But the bandages
should be broader and longer, and more numerous, in the case of the
leg than in that of the arm. And when it is bandaged it should be laid
upon some smooth and soft object, so that it may not be distorted to
the one side or the other, and that there may be no protrusion of
the bones either forward or backward; for this purpose nothing is more
convenient than a cushion, or something similar, either of linen or
wool, and not hard; it is to be made hollow along its middle, and
placed below the limb. With regard to the canals (gutters?) usually
placed below fractured legs, I am at a loss whether to advise that
they should be used or not. For they certainly are beneficial, but not
to the extent which those who use them suppose. For the canals do
not preserve the leg at rest as they suppose; nor, when the rest of
the body is turned to the one side or the other, does the canal
prevent the leg from following, unless the patient himself pay
attention; neither does the canal prevent the limb from being moved
without the body to the one side or the other. And a board is an
uncomfortable thing to have the limb laid upon, unless something
soft be placed above it. But it is a very useful thing in making any
subsequent arrangements of the bed and in going to stool. A limb
then may be well or ill arranged with or without the canal. But the
common people have more confidence, and the surgeon is more likely
to escape blame, when the canal is placed under the limb, although
it is not secundum artem. For the limb should by all means lie
straight upon some level and soft object, since the bandaging must
necessarily be overcome by any distortion in the placing of the leg,
whenever or to whatever extent it may be inclined. The patient, when
bandaged, should return the same answers as formerly stated, for the
bandaging should be the same, and the same swellings should arise in
the extremities, and the slackening of the bandages in like manner,
and the new bandaging on the third day; and the bandaged part should
be found reduced in swelling; and the new bandagings should be more
tightly put on, and more pieces of cloth should be used; and the
bandages should be carried loosely about the foot, unless the wound be
near the knee. Extension should be made and the bones adjusted at
every new bandaging; for, if properly treated, and if the swelling
progress in a suitable manner, the bandaged limb will have become more
slender and attenuated, and the bones will be more mobile, and yield
more readily to extension. On the seventh, the ninth, or the
eleventh day, the splints should be applied as described in treating
of the other fractures. Attention should be paid to the position of
the splints about the ankles and along the tendon of the foot which
runs up the leg. The bones of the leg get consolidated in forty
days, if properly treated. But if you suspect that anything is wanting
to the proper arrangement of the limb, or dread any ulceration, you
should loose the bandages in the interval, and having put everything
right, apply them again.
  17. But if the other bone (fibula?) of the leg be broken, less
powerful extension is required, and yet it must not be neglected,
nor be performed slovenly, more especially at the first bandaging. For
in all cases of fracture this object should be attained then as
quickly as possible. For when the bandage is applied tight while the
bones are not properly arranged, the properly arranged, the part
becomes more painful. The treatment otherwise is the same.
  18. Of the bones of the leg, the inner one, called the tibia, is the
more troublesome to manage, and requires the greater extension; and if
the broken bones are not properly arranged, it is impossible to
conceal the distortion, for the bone is exposed and wholly uncovered
with flesh; and it is much longer before patients can walk on the
leg when this bone is broken. But if the outer bone be broken, it
causes much less trouble, and the deformity, when the bones are not
properly set, is much more easily concealed, the bone being well
covered with flesh; and the patients speedily get on foot, for it is
the inner bone of the leg which supports the most of the weight of the
body. For along with the thigh, as being in a line with weight
thrown upon the thigh, the inner bone has more work to sustain;
inasmuch as it is the head of the thigh-bone which sustains the
upper part of the body, and it is on the inner and not on the outer
side of the thigh, being in a line with the tibia; and the other
half of the body approximates more to this line than to the external
one; and at the same time the inner bone is larger than the outer,
as in the fore-arm the bone in the line of the little finger is the
slenderer and longer. But in the joint of the inferior extremity,
the disposition of the longer bone is not alike, for the elbow and the
ham are bent differently. For these reasons when the external bone
is broken, the patients can soon walk about; but in fractures of the
inner, it is a long time before they can walk.
  19. When the thigh-bone is broken, particular pains should be
taken with regard to the extension that it may not be insufficient,
for when excessive, no great harm results from it. For, if one
should bandage a limb while the extremities of the bone are
separated to a distance from one another by the force of the
extension, the bandaging will not keep them separate, and so the bones
will come together again as soon as the persons stretching it let go
their hold; for the fleshy parts (muscles?) being thick and strong,
are more powerful than the bandaging, instead of being less so. In the
case then which we are now treating of, nothing should be omitted in
order that the parts may be properly distended and put in a straight
line; for it is a great disgrace and an injury to exhibit a
shortened thigh. For the arm, when shortened, might be concealed,
and the mistake would not be great; but a shortened thigh-bone would
exhibit the man maimed. For when the sound limb is placed beside it,
being longer than the other, it exposes the mistake, and therefore
it would be to the advantage of a person who would be improperly
treated that both his legs should be broken, rather than either of
them; for in this case the one would be of the same length as the
other. When, then, proper extension has been made, you must adjust the
parts with the palms of the hands, and bandage the limb in the
manner formerly described, placing the hands of the bandages as was
directed, and making the turns upward. And the patient should return
the same answers to the same questions as formerly, should be pained
and recover in like manner, and should have the bandaging renewed in
the same way; and the application of the splints should be the same.
The thigh-bone is consolidated in forty days.
  20. But this also should be known, that the thigh-bone is curved
rather to the outside than to the inside, and rather forward than
backward; when not properly treated, then, the distortions are in
these directions; and the bone is least covered with flesh at the same
parts, so that the distortion cannot be concealed. If, therefore,
you suspect anything of this kind, you should have recourse to the
mechanical contrivances recommended in distortion of the arm. And a
few turns of the bandage should be brought round by the hip and the
loins, so that the groin and the articulation near the perineum may be
included in the bandage; and moreover, it is expedient that the
extremities of the splints should not do mischief by being placed on
parts not covered with the bandages. The splints, in fact, should be
carefully kept off the naked parts at both ends; and the arrangement
of them should be so managed, as that they may not be placed on the
natural protuberances of the bone at the knee-joint, nor on the tendon
which is situated there.
  21. The swellings which arise in the ham, at the foot, or in any
other part from the pressure, should be well wrapped in unscoured
and carded wool, washed with wine and oil, and anointed with cerate,
before bandaging; and if the splints give pain they should be
slackened. You may sooner reduce the swellings, by laying aside the
splints, and applying plenty of bandages to them, beginning from below
and rolling upward; for thus the swellings will be most speedily
reduced, and the humors be propelled to the parts above the former
bandages. But this form of bandaging must not be used unless there
be danger of vesications or blackening in the swelling, and nothing of
the kind occurs unless the fracture be bound too tight, or unless
the limb be allowed to hang, or it be rubbed with the hand, or some
other thing of an irritant nature be applied to the skin.
  22. More injury than good results from placing below the thigh a
canal which does not pass farther down than the ham, for it neither
prevents the body nor the leg from being moved without the thigh.
And it creates uneasiness by being brought down to the ham, and has
a tendency to produce what of all things should be avoided, namely,
flexion at the knee, for this completely disturbs the bandages; and
when the thigh and leg are bandaged, if one bend the limb at the knee,
the muscles necessarily assume another shape, and the broken bones are
also necessarily moved. Every endeavor then should be made to keep the
ham extended. But it appears to me, that a canal which embraces the
limb from the nates to the foot is of use. And moreover, a shawl
should be put loosely round at the ham, along with the canal, as
children are swathed in bed; and then, if the thigh-bone gets
displaced either upward or to the side, it can be more easily kept
in position by this means along with the canal. The canal then
should be made so as to extend all along the limb or not used at all.
  23. The extremity of the heel should be particularly attended to, so
that it may be properly laid, both in fractures of the leg and of
the thigh. For if the foot be placed in a dependent position, while
the rest of the body is supported, the limb must present a curved
appearance at the forepart of the leg; and if the heel be placed
higher than is proper, and if the rest of the leg be rather too low,
the bone at the forepart of the leg must present a hollow, more
especially if the heel of the patient be naturally large. But all
the bones get consolidated more slowly, if not laid properly, and if
not kept steady in the same position, and in this case the callus is
more feeble.
  24. These things relate to cases in which there is fracture of the
bones without protrusion of the same or wound of any other kind. In
those cases in which the bones are simply broken across, and are not
comminuted, but protrude, if reduced the same day or next, and secured
in their place, and if there be no reason to anticipate that any
splintered bones will come away; and in those in which the broken
bones do not protrude, nor is the mode of fracture such that there
is reason to expect the splinters will come out, some physicians
heal the sores in a way which neither does much good nor harm, by
means of a cleansing application, applying pitch ointment, or some
of the dressings for fresh wounds, or anything else which they are
accustomed to do, and binding above them compresses wetted with
wine, or greasy wool, or something else of the like nature. And when
the wounds become clean and are new healed, they endeavor to bind up
the limb with plenty of bandages, and keep it straight with
treatment does some good, and never much harm. The bones, however, can
never be equally well restored to their place, but the part is a
little more swelled than it should be; and the limb will be somewhat
shortened, provided both bones either of the leg or fore-arm have been
fractured.
  25. There are others who treat such cases at first with bandages,
applying them on both sides of the seat of the injury, but omit them
there, and leave the wound uncovered, and afterward they apply to
the wound some cleansing medicine, and complete the dressing with
compresses dipped in wine and greasy wool. This plan of treatment is
bad, and it is clear that those who adopt this mode of practice are
guilty of great mistakes in other cases of fracture as well as
these. For it is a most important consideration to know in what manner
the head of the bandage should be placed and at what part the greatest
pressure should be, and what benefits would result from applying the
end of the bandage and the pressure at the proper place, and what
mischiefs would result from applying the head of the bandage and the
pressure otherwise than at the proper place. Wherefore it has been
stated in the preceding part of the work what are the results of
either; and the practice of medicine bears witness to the truth of it,
for in a person thus bandaged, a swelling must necessarily arise on
the wound. For, if even a sound piece of skin were bandaged on
either side, and a part were left in the middle, the part thus left
unbandaged would become most swelled, and would assume a bad color;
how then could it be that a wound would not suffer in like manner? The
wound then must necessarily become discolored and its lips everted,
the discharge will be ichorous and without pus, and the bones, which
should not have got into a state of necrosis, exfoliate; and the wound
gets into a throbbing and inflamed condition. And they are obliged
to apply a cataplasm on account of the swelling, but this is an
unsuitable application to parts which are bandaged on both sides,
for a useless load is added to the throbbing which formerly existed in
it. At last they loose the bandages when matters get very serious, and
conduct the rest of the treatment without bandaging; and
notwithstanding, if they meet with another case of the same
description, they treat it in the same manner, for they do not think
that the application of the bandages on both sides, and the exposure
of the wound are the cause of what happened, but some other untoward
circumstance. Wherefore I would not have written so much on this
subject, if I had not well known that this mode of bandaging is
unsuitable, and yet that many conduct the treatment in this way, whose
mistake it is of vital importance to correct, while what is here
said is a proof, that what was formerly written as to the
circumstances under which bandages should be tightly applied to
fractures or otherwise has been correctly written.
  26. As a general rule it may be said, that in those cases in which a
separation of bone is not expected, the same treatment should be
applied as when the fractures are not complicated with an external
wound; for the extension, adjustment of the bones, and the
bandaging, are to be conducted in the same manner. To the wound itself
a cerate mixed with pitch is to be applied, a thin folded compress
is to be bound upon it, and the parts around are to be anointed with
white cerate. The cloths for bandages and the other things should be
torn broader than in cases in which there is no wound, and the first
turn of the bandage should be a good deal broader than the wound.
For a narrower bandage than the wound binds the wound like a girdle,
which is not proper, or the first turn should comprehend the whole
wound, and the bandaging should extend beyond it on both sides. The
bandage then should be put on in the direction of the wound, and
should be not quite so tight as when there is no wound, but the
bandage should be otherwise applied in the manner described above. The
bandages should be of a soft consistence, and more especially so in
such cases than in those not complicated with a wound. The number of
bandages should not be smaller, but rather greater than those formerly
described. When applied, the patient should have the feeling of the
parts being properly secured, but not too tight, and in particular
he should be able to say that they are firm about the wound. And the
intervals of time during which the parts seem to be properly adjusted,
and those in which they get loose, should be the same as those
formerly described. The bandages should be renewed on the third day,
and the after treatment conducted in the same manner as formerly
described, except that in the latter case the compression should be
somewhat less than in the former. And if matters go on properly, the
parts about the wound should be found at every dressing always more
and more free of swelling, and the swelling should have subsided on
the whole part comprehended by the bandages. And the suppurations will
take place more speedily than in the case of wounds treated otherwise;
and the pieces of flesh in the wound which have become black and dead,
will sooner separate and fall off under this plan of treatment than
any other, and the sore will come more quickly to cicatrization when
thus treated than otherwise. The reason of all this is, that the parts
in which the wound is situated, and the surrounding parts, are kept
free of swelling. In all other respects the treatment is to be
conducted as in cases of fracture without a wound of the
integuments. Splints should not be applied. On this account the
bandages should be more numerous than in the former case, both because
they must be put on less tight, and because the splints are later of
being applied. But if you do apply the splints, they should not be
applied along the wound, and they are to be put on in a loose
manner, especial care being taken that there may be no great
compression from the splints. This direction has been formerly
given. And the diet should be more restricted, and for a longer
period, in those cases in which there is a wound at the
commencement, and when the bones protrude through the skin; and, in
a word, the greater the wound, the more severe and protracted should
the regimen be.
  27. The treatment of the sores is the same in those cases of
fracture in which there was no wound of the skin at first, but one has
formed in the course of treatment, owing to the pressure of the
splints occasioned by the bandages, or from any other cause. In such
cases it is ascertained that there is an ulcer, by the pain and the
throbbing; and the swelling in the extremities becomes harder than
usual, and if you apply your finger the redness disappears, but
speedily returns. If you suspect anything of the kind you must loose
the dressing, if there be any itching below the under-bandages, or
in any other part that is bandaged, and used a pitched cerate
instead of the other. If there be nothing of that, but if the ulcer be
found in an irritable state, being very black and foul, and the fleshy
parts about to suppurate, and the tendons to slough away, in these
cases no part is to be exposed to the air, nor is anything to be
apprehended from these suppurations, but the treatment is to be
conducted in the same manner as in those cases in which there was an
external wound at first. You must begin to apply the bandages
loosely at the swelling in the extremities, and then gradually proceed
upward with the bandaging, so that it may be tight at no place, but
particularly firm at the sore, and less so elsewhere. The first
bandages should be clean and not narrow, and the number of bandages
should be as great as in those cases in which the splints were used,
or somewhat fewer. To the sore itself a compress, anointed with
white cerate, will be sufficient, for if a piece of flesh or nerve
(tendon?) become black, it will fall off; for such sores are not to be
treated with acrid, but with emollient applications, like burns. The
bandages are to be renewed every third day, and no splints are to be
applied, but rest is to be more rigidly maintained than in the
former cases, along with a restricted diet. It should be known, that
if any piece of flesh or tendon be to come away, the mischief will
spread much less, and the parts will much more speedily drop off,
and the swelling in the surrounding parts will much more completely
subside, under this treatment, than if any of the cleansing
applications be put upon the sore. And if any part that is to come
away shall fall off, the part will incarnate sooner when thus
treated than otherwise, and will more speedily cicatrize. Such are the
good effects of knowing how a bandage can be well and moderately
applied. But a proper position, the other parts of the regimen, and
suitable bandages cooperate.
  28. If you are deceived with regard to a recent wound, supposing
there will be no exfoliation of the bones, while they are on the eve
of coming out of the sore, you must not hesitate to adopt this mode of
treatment; for no great mischief will result, provided you have the
necessary dexterity to apply the bandages well and without doing any
harm. And this is a symptom of an exfoliation of bone being about to
take place under this mode of treatment; pus runs copiously from the
sore, and appears striving to make its escape. The bandage must be
renewed more frequently on account of the discharge, since otherwise
fevers come on; if the sore and surrounding parts be compressed by the
bandages they become wasted. Cases complicated with the exfoliation of
very small bones, do not require any change of treatment, only the
bandages should be put on more loosely, so that the discharge of pus
may not be intercepted, but left free, and the dressings are to be
frequently renewed until the bone exfoliate, and the splints should
not be applied until then.
  29. Those cases in which the exfoliation of a larger piece of bone
is expected, whether you discover this at the commencement, or
perceive subsequently that it is to happen, no longer require the same
mode of treatment, only that the extension and arrangement of the
parts are to be performed in a manner that has been described; but
having formed double compresses, not less than half a fathom in
breadth (being guided in this by the nature of the wound), and
considerably shorter than what would be required to go twice round the
part that is wounded, but considerably longer than to go once round,
and in number what will be sufficient, these are to be dipped in a
black austere wine; and beginning at the middle, as is done in
applying the double-headed bandage, you are to wrap the part around
and proceed crossing the heads in the form of the bandage called
"ascia." These things are to be done at the wound, and on both sides
of it; and there must be no compression, but they are to be laid on so
as to give support to the wound. And on the wound itself is to be
applied the pitched cerate, or one of the applications to recent
wounds, or any other medicine which will suit with the embrocation.
And if it be the summer season, the compresses are to be frequently
damped with wine; but if the winter season, plenty of greasy wool,
moistened with wine and oil, should be applied. And a goat's skin
should be spread below, so as to carry off the fluids which run from
the wound; these must be guarded against, and it should be kept in
mind, that parts which remain long in the same position are subject to
excoriations which are difficult to cure.
  30. In such cases as do not admit of bandaging according to any of
the methods which have been described, or which will be described,
great pains should be taken that the fractured part of the body be
laid in a right position, and attention should be paid that it may
incline upward rather than downward. But if one would wish to do the
thing well and dexterously, it is proper to have recourse to some
mechanical contrivance, in order that the fractured part of the body
may undergo proper and not violent extension; and this means is
particularly applicable in fractures of the leg. There are certain
physicians who, in all fractures of the leg, whether bandages be
applied or not, fasten the sole of the foot to the couch, or to some
other piece of wood which they have fixed in the ground near the
couch. These persons thus do all sorts of mischief but no good; for it
contributes nothing to the extension that the foot is thus bound, as
the rest of the body will no less sink down to the foot, and thus
the limb will no longer be stretched, neither will it do any good
toward keeping the limb in a proper position, but will do harm, for
when the rest of the body is turned to this side or that, the
bandaging will not prevent the foot and the bones belonging to it from
following the rest of the body. For if it had not been bound it
would have been less distorted, as it would have been the less
prevented from following the motion of the rest of the body. But one
should sew two balls of Egyptian leather, such as are worn by
persons confined for a length of time in large shackles, and the balls
the balls should have coats on each side, deeper toward the wound, but
shorter toward the joints; and the balls should be well stuffed and
soft, and fit well, the one above the ankles, and the other below
the knee. Sideways it should have below two appendages, either of a
single or double thong, and short, like loops, the one set being
placed on either side of the ankle, and the other on the knee. And the
other upper ball should have others of the same kind in the same line.
Then taking four rods, made of the cornel tree, of equal length, and
of the thickness of a finger, and of such length that when bent they
will admit of being adjusted to the appendages, care should be taken
that the extremities of the rods bear not upon the skin, but on the
extremities of the balls. There should be three sets of rods, or more,
one set a little longer than another, and another a little shorter and
smaller, so that they may produce greater or less distention, if
required. Either of these sets of rods should be placed on this side
and that of the ankles. If these things be properly contrived, they
should occasion a proper and equable extension in a straight line,
without giving any pain to the wound; for the pressure, if there is
any, should be thrown at the foot and the thigh. And the rods are
commodiously arranged on either side of the ankles, so as not to
interfere with the position of the limb; and the wound is easily
examined and easily arranged. And, if thought proper, there is nothing
to prevent the two upper rods from being fastened to one another;
and if any light covering be thrown over the limb, it will thus be
kept off from the wound. If, then, the balls be well made, handsome,
soft, and newly stitched, and if the extension by the rods be properly
managed, as has been already described, this is an excellent
contrivance; but if any of them do not fit properly, it does more harm
than good. And all other mechanical contrivances should either be
properly done, or not be had recourse to at all, for it is a
disgraceful and awkward thing to use mechanical means in an
unmechanical way.
  31. Moreover, the greater part of physicians treat fractures, both
with and without an external wound, during the first days, by means of
unwashed wool, and there does not appear to be anything improper in
this. It is very excusable for those who are called upon to treat
newly-received accidents of this kind, and who have no cloth for
bandages at hand, to do them up with wool; for, except cloth for
bandages, one could not have anything better than wool in such
cases; but a good deal should be used for this purpose, and it
should be well carded and not rough, for in small quantity and of a
bad quality it has little power. But those who approve of binding up
the limb with wool for a day or two, and on the third and fourth apply
bandages, and make the greatest compression and extension at that
period, such persons show themselves to be ignorant of the most
important principles of medicine; for, in a word, at no time is it
so little proper to disturb all kinds of wounds as on the third and
fourth day; and all sort of probing should be avoided on these days in
whatever other injuries are attended with irritation. For,
generally, the third and fourth day in most cases of wounds, are those
which give rise to exacerbations, whether the tendency be to
inflammation, to a foul condition of the sore, or to fevers. And if
any piece of information be particularly valuable this is; to which of
the most important cases in medicine does it not apply? and that not
only in wounds but in many other diseases, unless one should call
all other diseases wounds. And this doctrine is not devoid of a
certain degree of plausibility, for they are allied to one another
in many respects. But those who maintain that wool should be used
until after the first seven days, and then that the parts should be
extended and adjusted, and secured with bandages, would appear not
to be equally devoid of proper judgment, for the proper judgment,
for the most dangerous season for inflammation is then past, and the
bones being loose can be easily set after the lapse of these days. But
still this mode of treatment is far inferior to that with bandages
from the commencement; for, the latter method exhibits the patient
on the seventh day free from inflammation, and ready for complete
bandaging with splints; while the former method is far behind in
this respect, and is attended with many other bad effects which it
would be tedious to describe.
  31a. In those cases of fracture in which the bones protrude and
cannot be restored to their place, the following mode of reduction may
be practiced:- Some small pieces of iron are to be prepared like the
levers which the cutters of stone make use of, one being rather
broader and another narrower; and there should be three of them at
least, and still more, so that you may use those that suit best; and
then, along with extension, we must use these as levers, applying
the under surface of the piece of iron to the under fragment of the
bone, and the upper surface to the upper bone; and, in a word, we must
operate powerfully with the lever as we would do upon a stone or a
piece of wood. The pieces of iron should be as strong as possible,
so that they may not bend. This is a powerful assistance, provided the
pieces of iron be suitable, and one use them properly as levers. Of
all the mechanical instruments used by men, the most powerful are
these three, the axis in peritrochio, the lever, and the wedge.
Without these, one or all, men could not perform any of their works
which require great force. Wherefore, reduction with the lever is
not to be despised, for the bones will be reduced in this way, or
not at all. But if the upper fragment which rides over the other
does not furnish a suitable point of support a suitable point of
support for the lever, but the protruding part is sharp, you must
scoop out of the bone what will furnish a proper place for the lever
to rest on. The lever, along with extension, may be had recourse to on
the day of the accident, or the accident, or next day, but by no means
on the third, the fourth, and the fifth. For if the limb is
disturbed on these days, and yet the fractured bones not reduced,
inflammation will be excited, and this no less if they are reduced;
for convulsions are more apt to occur if reduction take place, than if
the attempt should fail. These facts should be well known, for if
convulsions should come on when reduction is effected, there effected,
there is little hope of recovery; but it is of use to displace the
bones again if this can be done with out trouble. For it is not at the
time when the parts are in a particularly relaxed condition that
convulsions and tetanus are apt to supervene, but when they are more
than usually tense. In the case we are now treating of, we should
not disturb the limb on the aforesaid days, but strive to keep the
wound as free from inflammation as possible, and especially
encourage suppuration in it. But when seven days have elapsed, or
rather more, if there be no fever, and if the wound be not inflamed,
then there will be less to prevent an attempt at reduction, if you
hope to succeed; but otherwise you need not take and give trouble in
vain.
  32. When you have reduced the bones to their place, the modes of
treatment, whether you expect the bones to exfoliate or not, have been
already described. All those cases in which an exfoliation of bone
is expected, should be treated by the method of bandaging with cloths,
beginning for the most part at the middle of the bandage, as is done
with the double-headed bandage; but particular attention should be
paid to the shape of the wound, so that its lips may gape or be
distorted as little as possible under the bandage. Sometimes the turns
of the bandage have to be made to the right, and sometimes to the
left, and sometimes a double-headed bandage is to be used.
  33. It should be known that bones, which it has been found
impossible to reduce, as well as those which are wholly denuded of
flesh, will become detached. In some cases the upper part of the
bone is laid bare, and in others the flesh dies all around; and,
from a sore of long standing, certain of the bones become carious, and
some not, some more, and some less; and in some the small, and in
others the large bones. From what has been said it will be seen,
that it is impossible to tell in one word when the bones will
separate. Some come away more quickly, owing to their smallness, and
some from being merely fixed at the point; and some, from pieces not
separating, but merely exfoliating, become dried up and putrid; and
besides, different modes of treatment have different effects. For
the most part, the bones separate most quickly in those cases in which
suppuration takes place most quickly, and when new flesh is most
quickly formed, and is particularly sound, for the flesh which grows
up below in the wound generally elevates the pieces of bone. It will
be well if the whole circle of the bone separate in forty days; for in
some cases it is protracted to sixty days, and in some to more; for
the more porous pieces of bone separate more quickly, but the more
solid come away more slowly; but the other smaller splinters in much
less time, and others otherwise. A portion of bone which protrudes
should be sawn off for the following reasons: if it cannot be reduced,
and if it appears sons: that only a small piece is required in order
that it may get back into its place; and if it be such that it can
be taken out, and if it occasions inconvenience and irritates any part
of the flesh, and prevents the limb from being properly laid, and
if, moreover, it be denuded of flesh, such a piece of bone should be
taken off. With regard to the others, it is not of much consequence
whether they be sawed off or not. For it should be known for
certain, that such bones as are completely deprived of flesh, and have
become dried, all separate completely. Those which are about to
exfollate should not be sawn off. Those that will separate
completely must be judged of from the symptoms that have been laid
down.
  34. Such cases are to be treated with compresses and vinous
applications, as formerly laid down regarding bones which will
separate. We must avoid wetting it at the beginning with anything
cold; for there is danger of febrile rigors, and also of
convulsions; for convulsions are induced by cold things, and also
sometimes by wounds. It is proper to know that the members are
necessarily shortened in those cases in which the bones have been
broken, and have healed the one across the other, and in those cases
in which the whole circle of the bone has become detached.
  35. Those cases in which the bone of the thigh, or of the arm,
protrudes, do not easily recover. For the bones are large, and contain
much marrow; and many important nerves, muscles, and veins are wounded
at the same time. And if you reduce them, convulsions usually
supervene; and, if not reduced, acute bilious fevers come on, with
singultus and mortification. The chances of recovery are not fewer
in those cases in which the parts have not been reduced, nor any
attempts made at reduction. Still more recover in those cases in which
the lower, than those in which the upper part of the bone protrudes;
and some will recover when reduction has been made, but very rarely
indeed. For modes of treatment and peculiarity of constitution make
a great difference as to the capability of enduring such an injury.
And it makes a great difference if the bones of the arm and of the
thigh protrude to the inside; for there are many and important vessels
situated there, some of which, if wounded, will prove fatal; there are
such also on the outside, but of less importance. In wounds of this
sort, then, one ought not to be ignorant of the dangers, and should
prognosticate them in due time. But if you are compelled to have
recourse to reduction, and hope to succeed, and if the bones do not
cross one another much, and if the muscles are not contracted (for
they usually are contracted), the lever in such cases may be
advantageously employed.
  36. Having effected the reduction, you must give an emollient
draught of hellebore the same day, provided it has been reduced on the
day of the accident, but otherwise it should not be attempted. The
wound should be treated with the same things as are used in
fractures of the bones of the head, and nothing cold should be
applied; the patient should be restricted from food altogether, and if
naturally of a bilious constitution, he should have for a diet a
little fragrant oxyglyky sprinkled on water; but if he is not bilious,
he should have water for drink; and if fever of the continual type
come on, he is to be confined to this regimen for fourteen days at
least, but if he be free of fever, for only seven days, and then you
must bring him back by degrees to a common diet. To those cases in
which the bones have not been reduced, a similar course of medicine
should be administered, along with the same treatment of the sores and
regimen; and in like manner the suspended part of the body should
not be stretched, but should rather be contracted, so as to relax
the parts about the wound. The separation of the bones is
protracted, as also was formerly stated. But one should try to
escape from such cases, provided one can do so honourably, for the
hopes of recovery are small, and the dangers many; and if the
physician do not reduce the fractured bones he will be looked upon
as upon as unskillful, while by reducing them he will bring the
patient nearer to death than to recovery.
  37. Luxations and subluxations at the knee are much milder accidents
than subluxations and luxations at the elbow. For the knee-joint, in
proportion to its size, is more compact than that of the arm, and
has a more even conformation, and is rounded, while the joint of the
arm is large, and has many cavities. And in addition, the bones of the
leg are nearly of the same length, for the external one overtops the
other to so small an extent as hardly to deserve being mentioned,
and therefore affords no great resistance, although the external nerve
(ligament?) at the ham arises from it; but the bones of the fore-arm
are unequal, and the shorter is considerably thicker than the other,
and the more slender (ulna?) protrudes, and passes up above the joint,
and to it (the olecranon?) are attached the nerves (ligaments?)
which go downward to the junction of the bones; and the slender bone
(ulna?) has more to do with the insertion of the ligaments in the
arm than the thick bone (radius?). The configuration then of the
articulations, and of the bones of the elbow, is such as I have
described. Owing to their configuration, the bones at the knee are
indeed frequently dislocated, but they are easily reduced, for no
great inflammation follows, nor any constriction of the joint. They
are displaced for the most part to the inside, sometimes to the
outside, and occasionally into the ham. The reduction in all these
cases is not difficult, but in the dislocations inward and outward,
the patient should be placed on a low seat, and the thigh should be
elevated, but not much. Moderate extension for the most part
sufficeth, extension being made at the leg, and counter-extension at
the thigh.
  38. Dislocations at the elbow are more troublesome than those at the
knee, and, owing to the inflammation which comes on, and the
configuration of the joint, are more difficult to reduce if the
bones are not immediately replaced. For the bones at the elbow are
less subject to dislocation than those of the knee, but are more
difficult to reduce and keep in their position, and are more apt to
become inflamed and ankylosed.
  39. For the most part the displacements of these bones are small,
sometimes toward the ribs, and sometimes to the outside; and the whole
articulation is not displaced, but that part of the humerus remains in
place which is articulated with the cavity of the bone of the
forearm that has a protuberance (ulna?). Such dislocations, to
whatever side, are easily reduced, and the extension is to be made
in the line of the arm, one person making extension at the wrist,
and another grasping the armpit, while a third, applying the palm of
his hand to the part of the joint which is displaced, pushes it inward
ward, and at the same time makes counterpressure on the opposite
side near the joint with the other hand.
  40. The end of the humerus at the ,elbow gets displaced
(subluxated?) by leaving the cavity of the ulna. Such luxations
readily yield to reduction, if applied before the parts get
inflamed. The displacement for the most part is to the inside, but
sometimes to the outside, and they are readily recognized by the shape
of the limb. And often such luxations are reduced without any powerful
extension. In dislocations inward, the joint is to be pushed into
its place, while the fore-arm is brought round to a state of
pronation. Such are most of the dislocations at the elbow.
  41. But if the articular extremity of the humerus be carried to
either side above the bone of the fore-arm, which is prominent, into
the hollow of the arm (?), this rarely happens; but if it does happen,
extension in the straight line is not so proper under such
circumstances; for in such a mode of extension, the process of the
ulna (olecranon?) prevents the bone of the arm (humerus?) from passing
over it. In dislocations of this kind, extension should be made in the
manner described when treating of the bandaging of fractured bones
of the arm, extension being made upward at the armpit, while the parts
at the elbow are pushed downward, for in this manner can the humerus
be most readily raised above its cavity; and when so raised, the
reduction is easy with the palms of the hand, the one being applied so
as to make pressure on the protuberant part of the arm, and the
other making counter-pressure, so as to push the bone of the
fore-arm into the joint. This method answers with both cases. And
perhaps this is the most suitable mode of reduction in such a case
of dislocation. The parts may be reduced by extension in a straight
line, but less readily than thus.
  42. If the arm be dislocated forward- this rarely happens, indeed,
but what would a sudden shock not displace? for many other things
are removed from their proper place, notwithstanding a great
obstacle,- in such a violent displacement the part (olecranon?)
which passes above the prominent part of the bones is large, and the
stretching of the nerves (ligaments?) is intense; and yet the parts
have been so dislocated in certain cases. The following is the symptom
of such a displacement: the arm cannot be bent in the least degree
at the elbow, and upon feeling the joint the nature of the accident
becomes obvious. If, then, it is not speedily reduced, strong and
violent inflammation, attended with fever, will come on, but if one
happen to be on the spot at the time it is easily reduced. A piece
of hard linen cloth (or a piece of hard linen, not very large,
rolled up in a ball, will be sufficient) is to be placed across the
bend of the elbow, and the arm is then to be suddenly bent at the
elbow, and the hand brought up to the shoulder. This mode of reduction
is sufficient in such displacements; and extension in the straight
line can rectify this manner of dislocation, but we must use at the
same time the palms of the hands, applying the one to the projecting
part of the humerus at the bend of the arm for the purpose of
pushing it back, and applying the other below to the sharp extremity
of the elbow, to make counter-pressure, and incline the parts into the
straight line. And one may use with advantage in this form of
dislocation the method of extension formerly described, for the
application of the bandages in the case of fracture of the arm; but
when extension is made, the parts are to be adjusted, as has been also
described above.
  43. But if the arm be dislocated backward (but this very rarely
happens, and it is the most painful of all, and the most subject to
bilious fevers of the continual type, which prove fatal in the
course of a few days), in such a case the patient cannot extend the
arm. If you are quickly present, by forcible extension the parts may
return to their place of their own accord; but if fever have
previously come on, you must no longer attempt reduction, for the pain
will be rendered more intense by any such violent attempt. In a
word, no joint whatever should be reduced during the prevalence of
fever, and least of all the elbow-joint.
  44. There are also other troublesome injuries connected with the
elbow-joint; for example, the thicker bone (radius?) is sometime
partially displaced from the other, and the patient can neither
perform extension nor flexion properly. This accident becomes
obvious upon examination with the hand at the bend of the arm near the
division of the vein that runs up the muscle. In such a case it is not
easy to reduce the parts to their natural state, nor is it easy, in
the separation of any two bones united by symphysis, to restore them
to their natural state, for there will necessarily be a swelling at
the seat of the diastasis. The method of bandaging a joint has been
already described in treating of the application of bandages to the
ankle.
  45. In certain cases the process of the ulna (olecranon?) behind the
humerus is broken; sometimes its cartilaginous part, which gives
origin to the posterior tendon of the arm, and sometimes its fore
part, at the base of the anterior coronoid process; and when this
displacement takes place, it is apt to be attended with malignant
fever. The joint, however, remains in place, for its whole base
protrudes at that point. But when the displacement takes place where
its head overtops the arm, the joint becomes looser if the bone be
fairly broken across. To speak in general terms, all cases of
fractured bones are less dangerous than those in which the bones are
not broken, but the veins and important nerves (tendons?) situated
in these places are contused; for the risk of death is more
immediate in the latter class of cases than in the former, if
continual fever come on. But fractures of this nature seldom occur.
  46. It sometimes happens that the head of the humerus is fractured
at its epiphysis; and this, although it may appear to be a much more
troublesome accident, is in fact a much milder one than the other
injuries at the joint.
  47. The treatment especially befitting each particular dislocation
has been described; and it has been laid down as a rule, that
immediate reduction is of the utmost advantage, owing to the rapid
manner in which inflammation of the tendons supervenes. For even
when the luxated parts are immediately reduced, the tendons usually
become stiffened, and for a considerable time prevent extension and
flexion from being performed to the ordinary extent. are to be treated
in a similar way, whether the extremity of the articulating bone be
snapped off, whether the bones be separated, or whether they be
dislocated; for they are all to be treated with plenty of bandages,
compresses, and cerate, like other fractures. The position of the
joint in all these cases should be the same, as when a fractured arm
or fore-arm has been bound up. For this is the most common position in
all dislocations, displacements, and fractures; and it is the most
convenient for the subsequent movements, whether of extension or
flexion, as being the intermediate stage between both. And this is the
position in which the patient can most conveniently carry or suspend
his arm in a sling. And besides, if the joint is to be stiffened by
callus, it were better that this should not take place when the arm is
extended, for this position will be a great impediment and little
advantage; if the arm be wholly bent, it will be more useful; but it
will be much more convenient to have the joint in the intermediate
position when it becomes ankylosed. So much with regard to position.
  48. In bandaging, the head of the first bandage should be placed
at the seat of the injury, whether it be a case of fracture, of
dislocation, or of diastasis (separation?), and the first turns should
be made there, and the bandages should be applied most firmly at
that place, and less so on either side. The bandaging should
comprehend both the arm and the fore-arm, and on both should be to a
much greater extent than most physicians apply it, so that the
swelling may be expelled from the seat of the injury to either side.
And point of the fore-arm should be comprehended in the bandaging,
whether the injury be in that place or not, in order that the swelling
may not collect there. In applying bandages, we must avoid as much
as possible accumulating many turns of the bandage at the bend of
the arm. For the principal compression should be at the seat of the
injury, and the same rules are to be observed, and at the same
periods, with regard to compression and relaxation, as formerly
described respecting the treatment of broken bones; and the bandages
should be renewed every third day; and they should appear loose on the
third day, as in the other case. And splints should be applied at
the proper time (for there is nothing unsuitable in them, whether
the bones be fractured or not, provided there is no fever); they
should be particularly loose, whether applied to the arm or the
forearm, but they must not be thick. It is necessary that they
should be of unequal size, and that the one should ride over the
other, whenever from the flexion it is judged proper. And the
application of the compresses should be regulated in the same manner
as has been stated with regard to the splints; and they should be
put on in a somewhat more bulky form at the seat of the injury. The
periods are to be estimated from the inflammation, and from what has
been written on them above.


                           -THE END-
