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-