On Levers (The Carrier) — First Draft Translation

ON LEVERS. The nature of bones: the fingers have simple both bones and joints; the hand and foot have many, joined to one another in different ways; the largest are the uppermost. The heel is one, as it appears from the outside; toward it the posterior tendons extend. 1. The lower leg has two bones, held together above and below, but separated by a small gap in the middle. The outer one, toward the small toe, is a little thinner; it is separated most here and carries less weight at the knee, and the tendon arising from it runs along the outside beside the ankle. Below, they share a common epiphysis, toward which the foot moves; they have another epiphysis above, in which the joint of the thigh-bone moves — simple and compact relative to its length; the form is condyloid, having a kneecap. The shaft itself curves outward and forward. The head is a rounded epiphysis, from which the sinew in the socket of the hip arises. This too is attached somewhat obliquely, though less so than the arm-bone. The hip attaches to the great vertebra beside the sacred bone by means of a cartilage-and-sinew bond. The spine from the sacred bone up to the great vertebra is kyphotic; the bladder, the seed, and the bent portion of the bowel are situated in this region. From there up to the diaphragm it goes in a straight lordotic curve, and the loins lie along this section. From there to the great vertebra above the shoulder-blades it is straight-kyphotic; it appears even more so than it is, for the posterior processes of the vertebrae are tallest at this point. The joint of the neck is lordotic. The vertebrae are flush with one another on the inner side, held together by the cartilages on the outer side through a sinew; their articulation lies at the posterior of the spinal cord. Posteriorly they have a sharp outgrowth bearing a cartilaginous epiphysis, from which a downward projection of sinews arises, just as the muscles also grow alongside from the neck to the loins, filling the space between the ribs and the spine. The ribs are attached by a small sinew at the processes of the vertebrae from the neck to the loins on the inner side; at the front toward the chest they have a soft and yielding tip; the form most bent of any living creature — for the human being is narrowest there in bulk; and where the ribs have a short and broad lateral outgrowth, they are attached to each vertebra by a small sinew. The chest is continuous with itself, having lateral processes where the ribs are attached, and is soft and cartilaginous. The collarbones curve forward, having small movements toward the chest and more frequent ones toward the acromion. The acromion grows from the shoulder-blades, unlike in most other creatures. The shoulder-blade is cartilaginous on the side toward the spine, otherwise spongy, having an uneven outer surface; it has a cartilaginous neck and socket, from which the ribs have their movement; it is easily freed from bones, except from the arm-bone. The head of this bone is suspended from the socket by a small sinew, having a rounded epiphysis of soft cartilage; the shaft itself curves outward and forward, oblique, not straight relative to the socket. The part toward the elbow is broad, condyloid, grooved, and solid, hollow at the back, in which the coronoid process from the ulna lodges when the arm is extended; into this also the numbing sinew terminates, the one that arises and ends from the middle of the process between the bones of the forearm. A broken nose is reshaped, if possible, at once. 2. If the cartilage is involved, insert a tuft of linen cloth secured by a Carthaginian strip [λοπῷ καρχηδονίῳ — the exact material is uncertain], or in some other material that will not irritate; with the strip, bring the displaced parts into alignment and support them. Bandaging does harm in these cases. Treatment: with meal and frankincense, or with sulfur in a wax-salve. Reshape it at once, then hold it in position with the fingers, working it back and turning it; and the Carthaginian strip. Callus will form, even if there is an ulcer, even if the bones are about to come away — for these are not the most troublesome cases — and one should proceed in this way. A broken ear: do not bandage, nor apply a poultice; if anything is needed, the wax-salve is the lightest; and seal with sulfur. 3. Those ears that are suppurating are found by probing through thickness. All those that are full of mucous material and watery flesh are deceptive [i.e., they conceal their true condition from the clinician]; no harm will come when such a thing is opened, for they are fleshless and watery, full of mucus — but wherever and whatever sort they are that are lethal, if neglected. Cauterization of the ears straight through heals most quickly; but the ear becomes bent and smaller if burned through. If it is opened, one must use a light, bloody dressing. The jaws are frequently dislocated and replaced; they fall out rarely, most often in those who gape — for the jaw does not fall out unless one opens wide and bends it to the side; it falls out more readily because the sinews being oblique and twisted give way together. 4. Signs: the lower jaw protrudes and is twisted to the opposite side of the dislocation; they cannot bring the teeth together. If both are dislocated, they protrude more, come together less, without lateral twisting; the alignment of the upper teeth with the lower marks the limits. If both are dislocated and do not go back immediately, these patients die on about the tenth day with continuous fever and dull stupor; for these muscles are of such a character; the belly is upset with small amounts of unmixed matter; and if they vomit, they vomit such things. The one-sided dislocation is less dangerous. The reduction is the same for both: with the patient lying or sitting, standing at the head, grasping both jaws with both hands from inside and outside, do three things simultaneously — push straight, push back, and close the mouth. Treatment: with poultices, positions, and support of the chin, doing the same things as in the reduction. The shoulder falls out downward. 5. In no other direction have I heard of it doing so. It seems to fall forward in those whose flesh around the joint has wasted away through phthisis, as is also apparent in cattle in winter because of their thinness. And it dislocates more readily in the lean or thin [or dry], and in those who have moisture about the joints without inflammation — for inflammation itself binds [the joint and so prevents dislocation]; those who have moisture without inflammation are therefore at risk. Those who reduce it in cattle by pinning err, both because through the manner of use — how a cow uses its leg — it passes unnoticed, and because the position is common to a human being in such a condition, and because of the Homeric example, and because cattle are thinnest at that time. And those who lift the forearm obliquely away from the ribs cannot manage it well in cases where the bone has not fallen. Which persons are most prone to dislocation, and what their condition is, has been stated. In those born with it, or in those in whom it occurs during growth, the nearest bones are more shortened — as in these cases those with weasel-arms; the forearm less, the hand still less, what is above not at all. And they are most fleshless near the lesion; wasting is greatest on the side opposite to the displacement, and in those growing, somewhat less than in those with it from birth. And deep suppurations alongside the joint occur mostly beside the shoulder in newborns, and in these it produces the same effects as dislocations. If it happens in those already grown, the bones are not diminished — for they cannot be, since others do not grow likewise alongside — but there is wasting of the flesh; for this increases and decreases day by day, and according to age. And the positions that are possible, and the sign of the area beside the acromion being drawn down and hollow — because when the acromion is pulled away and there is a hollow, they think the arm-bone has fallen. The head of the arm-bone appears in the armpit; for they cannot raise the arm nor draw it to either side in the same way; the other shoulder indicates it. Reductions: the patient himself, placing his fist under the armpit, pushes the head upward while drawing the hand across toward the chest. Another: force the arm back so that it wobbles to both sides. Another: with the head against the acromion, with the hands under the armpit, draw the head of the arm-bone away, and with the knees push the elbow away — or instead of the knees, draw the other elbow along, as before. Or sit on the shoulder with the shoulder placed under the armpit; or with the heel, placing padding in the armpit — right side with right; or around a pestle; or around a ladder-rung; or the circuit-method with the wood stretched under the arm. Treatment: the position — arm against the ribs, the hand held at the extreme upward, shoulder upward; bandaging in this way, and support. If it does not go back, the acromion gradually thins. An avulsed acromion presents the same appearance as a dislocated shoulder, but the patient loses nothing by it, and it does not return to the same position. 6. The same position as for the one dislocated, in bandaging and support; and bandaging as is customary. When the elbow joint is displaced either toward the side or outward, with the sharp process remaining in the hollow of the arm-bone — drawing straight, push the projecting parts backward and to the side. 8. For those completely displaced either way: traction in the position in which the arm-bone is bandaged — for in this way the bend of the elbow will not obstruct. It falls out most often toward the side of the ribs. For the reductions, drawing apart as much as possible so that the head does not touch the coronoid process, bring it around elevated and flex it, and do not force it straight; at the same time push the opposite parts in each direction, and push it into place. Rotation of the elbow in addition would help in these cases — in one direction into supination, in the other into pronation. Reduction: as regards position, hold the hand a little higher than the elbow, and the arm along the ribs; in this position also support and carrying, and naturally comfortable, and use in ordinary activity, if it has not callused badly — for it calluses quickly. Treatment: with bandages according to the rule for joint injuries, and bind the sharp process additionally. The elbow is most troublesome with fevers, nausea-accompanied pain, and unmixed bile; most of all with the elbow displaced posteriorly because of the numbing quality, and second with anterior displacement. 9. Treatment the same. Reductions: for the posterior, extend and apply traction — the sign is that they cannot extend; for the anterior, they cannot flex. For this one, placing something hard and rolled up, flex it around this suddenly from extension. The sign of separation of the bones: probing alongside the vein that branches along the arm-bone. 11. These callus quickly. From birth, the bones below the lesion are shorter — most those nearest the forearm, second the hand, third the fingers. The arm-bone and shoulder are stronger because of their nourishment. The other hand is even stronger still because of the greater work it performs. Wasting of the flesh: if the dislocation was outward, wasting is inward; if otherwise, toward the opposite side of the displacement. If the elbow has gone out or inward, traction in the angled position common to the forearm relative to the arm; for, having taken up the armpit in a sling, suspend it, and placing something as a weight at the very tip of the elbow near the joint, hang it, or force it down with the hands. 12. When the joint has been sufficiently suspended, the lateral movements with the palms of the hands, as for those in the hands. Bandaging in this position, and support, and placement. For those displaced posteriorly, correct suddenly by extending, using the palms; and at the same time in the correction one must also do the other things. 13. If displaced anteriorly, around a rolled and adequately padded linen cloth, correct by flexing simultaneously. If it is inclined to one side, in the correction both things must be done at the same time. 14. For the aftercare, the position and bandaging are common to all. For all can converge by traction in common. Of the reductions, some are achieved by suspension, some by traction, some by levering; these proceed from the extreme positions of the postures, this way or that, together with speed. 16. The wrist joint slips either inward or outward, most often inward. The signs are clear: if inward, they cannot flex their fingers at all; if outward, they cannot extend them. Reduction: with the fingers over a table, some pulling, others pulling the opposite way, push the projecting part with the palm of the hand or the heel simultaneously forward and downward against the other bone, placing soft padding underneath; and if displaced upward, turning the hand over; if downward, supine. Treatment: with bandages. The whole hand slips inward or outward, most often inward, or to one side or the other; sometimes the epiphysis has shifted; sometimes one of the two bones has separated. 17. In these cases strong traction must be applied, and the projecting part pushed in while the other is pushed the opposite way — two forms simultaneously, both backward and to the side — either with the hands on a table, or with the heel. These cases are troublesome and unsightly, but over time they strengthen for use. Treatment: with bandages together with the hand and forearm, and place splints as far as the fingers; things placed in splints should be loosened more frequently than fractures, and more irrigation should be used. From birth, the hand becomes shorter, and wasting of the flesh is greatest on the opposite side from the displacement; in those already grown the bones remain. 19. The joint of a finger that has slipped: its sign is obvious — there is no need to describe it. Its reduction is this: draw it straight, push the projecting part in, and push the opposite part the other way. The appropriate treatment: bandaging with linen. For if it does not go back, it calluses over on the outside. From birth or when dislocated during growth, the bones below the slip are shortened; and the flesh wastes most on the side opposite the displacement; in those already grown the bones remain. The hip joint falls out in four ways: inward most often, outward second, the others equally. 20. Signs: common to all — the other leg; particular to the inward: the head is palpable alongside the perineum, they flex unequally, the leg appears longer, and considerably so, unless you bring both legs into the midline and stretch them out together; for indeed the foot and knee incline outward. If the dislocation occurred from birth or during growth, the thigh is shorter, the lower leg less so, and the rest proportionally; the flesh wastes, most of all on the outer side. These patients are reluctant to stand upright and roll to the healthy side; if compelled, they walk with one or two supports, and they lift the leg — for the smaller it is, the lighter. If in those already grown, the bones remain, and the flesh wastes as described; they walk in a rotating manner like cattle, bent in the flank, leaning on the hip to the healthy side; for one leg must step under in order to carry the weight, while the other must step aside (for it cannot carry), as with those who have an ulcer on the foot. On the healthy side, they brace laterally against the body with a staff, and force the injured leg down with the hand above the knee so that it carries the body's weight during the step. When the hip is used below the level of the hip-joints, the bones waste less below and the flesh more. For the outward displacement, the signs and postures are opposite, and the knee and foot incline slightly inward. 21. In those affected during growth or from birth, growth is not proportional in the same way; the hip is somewhat higher, not equally so. Those in whom it frequently falls out to the outside without inflammation use the leg with more moisture, as with the great toe of the hand — for this falls out most by nature. Which persons have it fall out more or less, in which it is harder or easier to fall, in which there is hope of quicker reduction and in which not — the remedies for this; and in those in whom it falls out repeatedly, the treatment of this. From birth, or during growth, or from disease — most often from disease — in some the bone has been seized by gangrene, but also in those in whom it has not, all the effects occur, but less than with the inward dislocation, if they are well looked after, such that even walking on the whole foot, they can swing it; this requires the most care, and in the very youngest; if neglected, the outcome is bad; if cared for, benefit follows; in the whole limb, though somewhat less, there is wasting. When both are displaced in this way, the same affections of the bones occur; they are well-fleshed except on the inner side, with projecting buttocks, bowed thighs, unless gangrene has taken hold. 22. If they become kyphotic above the hip-joints, they are otherwise healthy but the body does not grow, except the head. For those with posterior displacement, the signs are: flatter in front, projecting behind, the foot straight, they cannot flex without pain, and can extend least; these have a shorter leg. 23. But they cannot fully extend at the hollow of the knee or at the groin unless they lift considerably, nor can they flex. In most cases the upper joint leads first; this is common to joints, sinews, muscles, intestines, the womb, and other things. On this account the bone of the hip slopes down toward the buttock — hence it is shortened, and because they cannot extend. Flesh wastes in the whole leg in all cases; in which cases most, and toward where, has been stated. Each part of the body, doing its own work, grows strong; when idle, it deteriorates — except from fatigue, fever, and inflammation. The outer displacement, because it yields into yielding flesh, is shorter; the inner, because it rests against projecting bone, is longer. If then in those already grown it does not go back, they walk bent at the groin, and the other leg bends at the hollow of the knee; the chest is barely reached; they grasp the leg with the hand, without a staff, if they wish; for if it is too long, they cannot step; if they do step, it is short. Wasting of flesh: in those who labor, the inclination is forward, and the healthy side proportionally. For those affected from birth, or during growth, or who fell ill from disease and dislocation occurred (in which cases it will be specified) — these are most harmed through the inactivity of the sinews and joints; and the knee is damaged along with them for the reasons stated. These walk with the leg bent, on one or two supports; the healthy limb is well-fleshed through use. For those with forward displacement, the signs are opposite: flat behind, projecting in front; these flex the leg least and extend it most; foot straight, leg equal, heel slightly retracted at the extreme. 24. These suffer most at once, and retention of urine occurs most in these dislocations — for it presses on the critical tensions. The anterior parts are overstretched, fail to grow, are prone to disease, and age quickly; the posterior parts are wrinkled. In those already grown, they walk upright, stepping more on the heel; and if they could take a large step, even more so; but they drag the foot; wasting is least in these, and the use is the cause — most of all posteriorly; throughout the whole leg they are straighter than normal, and they need a support on the injured side. For those from birth or during growth, if well cared for, the use is as in those already grown; if neglected, short and extended — for in these the joints callus most in the straight position. The diminutions of the bones and the wastings of the flesh are proportional. Strong traction is required for the thigh, and the correction is common, either by hands, or by plank, or by lever — a round one for the inward, a flat one for the outward, especially for the outward. 25. For the inward, after treating with wineskins to keep the thigh moderately dry — traction and binding of the legs: suspend the feet with a small gap, then, having braided them together, have someone hang suspended, doing both things at the same time during the correction. This is sufficient also for the forward displacement and for the others, but least for the outward. The placement of wood, as for the shoulder under the arm, for those with inward displacement; for the others, less so. Forced pressures with traction — most of all for the anterior or posterior — sitting with the foot or hand or a plank. The knee is simpler than the elbow, because of its compactness and good natural form; which is why it falls out and back in more readily. 26. It falls out most often inward, but also outward and backward. Reductions: either from the flexed position, or by a sharp kick, or by rolling up a mass of bandage, placing it behind the knee, and suddenly dropping the body around it into a squatting position — most of all for the posterior displacement; the posterior can also fall back by moderate traction, like the elbow. For the lateral displacements, either from the flexed position, or a sharp kick, [or] in the set position — mainly the posterior method itself; but also by moderate traction. The correction is common to all. If it does not go back: in those with posterior displacement, they cannot flex — nor can those with the others manage at all; the front of the thigh and lower leg wastes. If inward, they are more bandy-legged, and the outer side wastes. If outward, they are more knock-kneed, lame less so — for they bear the weight on the thicker bone — and the inner side wastes. From birth or during growth, proportional to what was said before. Those at the ankle require strong traction, either with the hands or other such means, with correction doing both things at once; this is common to all. 28. What concerns the foot is analogous to what concerns the hand, when healthy. What concerns the lower leg, when associated and unreduced, dislocated from birth or during growth — these are the same as for the hand. 30 [20] As for those who, having leaped from a height, planted themselves on the heel so that the bones were forced apart, the veins extravasated, and the sinews crushed on both sides — when the worst of these conditions develops, there is danger that, should gangrene set in, it will cause lifelong trouble. The bones become twisted, and the sinews share connection with one another. Indeed, even in those whose leg or thigh is broken by a wound, when the sinews that communicate with these parts are severed, or when from some other careless lying-down the heel has turned black, there too the condition proves obstinate from such causes. Sometimes, in addition to the gangrene, there come fevers of extreme sharpness — with hiccough, with trembling, affecting the mind, quickly fatal — and further: livid discolorations from hemorrhaging veins, and gangrenous spreading. Signs of the cases that have turned obstinate: if the extravasations, the dark patches, and the parts around these are somewhat hard and somewhat red — for if there is livid discoloration together with hardening, there is danger of blackening; but if they are somewhat livid or even fully livid and diffuse, or somewhat pallid-green and soft, these are in all such cases favorable signs. Treatment: if the patients are free of fever, give hellebore; if not, do not; but give a sweet-acid drink to be taken if needed. Bandaging: the binding of joints; and in addition to these: use more and softer linen cloths rather than compresses for the bruised parts; less pressure; more water; apply the wrappings most fully around the heel. The position: as the bandaging dictates, so that pressure is not forced back onto the heel; above the knee; let it be well arranged; do not use splints. When the foot is dislocated — whether alone or together with the epiphysis — it falls more often inward. 31 [5] If it does not go back in, over time the side of the hip, thigh, and shin opposite to the slippage wastes away. Reduction: as for the wrist, but traction stronger. Treatment: the standard rule for joints. It becomes obstinate less than the wrist, if the patient rests. Diaita (regimen) should be reduced, since they are inactive. As for cases arising from birth or during growth: according to the reasoning given before. Since small congenital displacements — those present from birth — are in some cases able to be corrected; most of all the clubfoot, for there is not just one form of clubfoot. 32 [5] The treatment for this: model with wax; a resinous wax-salve, many linens, or apply a sole or a small lead plate, not against bare skin; in the recovery, let the positions agree. If dislocated parts, having made a wound, protrude, it is better to leave them, so that they are not held suspended nor forcibly pushed back. 33 [20] Treatment: with a pitch-plaster, or with warm wine-soaked compresses (for in all such cases cold is harmful), and with leaves; in winter, with unwashed fleeces for the purpose of covering; do not apply poultices, nor bind; diaita should be spare. Cold, heavy weight, pressure, constraint, disordering of position — one must know that all these are destructive. Those treated moderately end up with a shameful lameness; for if the curvature occurs at the level of the foot, the foot is drawn upward, and if anywhere else, proportionately. Bones do not much fall away; they are stripped only slightly, and scar over thinly. Of these cases, the largest are the most dangerous, and those highest up. The only hope of preservation lies in not attempting reduction — except in what involves the toes and the extremity of the hand; and even for these, let the physician declare the dangers beforehand; attempt reduction either on the first day or the second; if not then, toward the tenth; least favorable on the fourth day; the reduction: use small levers; the treatment: as for the bones of the head, and heat; it is better to use hellebore immediately in those cases where reduction is being attempted. For the rest, one must know clearly that, when reduction is performed, deaths occur — most of all and most quickly in the largest and highest cases. A foot that has come out: spasm, gangrene; and if, after reduction has been accomplished, any of these things supervenes, there is hope in letting it back out — if there is any hope at all; for the spasms do not come from what is slackened but from what is under tension. Amputations, whether at a joint or through the bones, not high up but close to the foot or close to the hand — these mostly survive, unless they perish very quickly from fainting. 34 Treatment: as for the head, heat. Also: gangrene of the flesh — and in hemorrhaging wounds what is constricted, and in fractures of bones what is compressed, and in ligatures what has turned black. 35 [20] As for those in whom a part of the thigh and upper arm falls away — both bones and flesh — many survive, since in general the rest is more bearable. In those cases, then, when the bones are broken: the surrounding tissue-breaks are rapid, while the falling away of the bones occurs at the boundary of where the stripping is, and falls away there, but more slowly. It is necessary to remove the parts below the wound and away from the healthy tissue; for these die first — taking care against pain; for they die together with the fainting. A bone of the thigh was released from such a condition on the eightieth day, while the shin was removed on the twentieth; the bones of the shin at mid-length were released on the sixtieth day. In such cases, both quickly and slowly, the medical compressions play their role. But in all other cases where things progress quietly, the bones do not fall away, nor is there stripping of the flesh — rather it is more superficial. One must expect these things; for most are more frightening than they are harmful. The treatment should be gentle: with heat, and an exact diaita; danger of hemorrhage, of cold; positions should be inclined upward at first, then equal on each side for the sake of the settling of pus, or as much as is beneficial. In such cases and in cases of blackening: hemorrhages, dysenteries around the crisis — violent but brief in duration; not much loss of appetite, not much fever, and there should be no emptying of the vessels. Curvature inward is near-fatal, with retention of urine and numbness; curvatures outward are mostly harmless in these respects, much more so than those which, though shaken, have not been displaced — the latter reach their own crisis by themselves, while the former contribute further to the body's general condition, and they remain in critical positions. 36 [20] For example: ribs when broken — few cases with fever, or with spitting of blood, or with gangrene — whether one or several are broken but not shattered; and the treatment is straightforward, not emptying the vessels if there is no fever; binding as is the rule; the callusing-over in twenty days, since the part is loose-textured. If the rib is crushed on both sides, there are nodular swellings, coughing, pledget-wound complications, and the ribs undergo gangrene; for alongside each rib, sinews extend from all directions. Many also spat blood and developed suppuration within. The careful practice — treatment, bandaging as is the rule; at first strict diaita, then softening; rest, quiet; positions, the belly, sexual activity. But in those cases that are bloodless, the pain is sharper than in those with fractures, and more prone to recurrence over time; and in those where a mucous residue remains, it keeps giving reminder in times of exertion. Treatment: cauterization — in those arising from bone, down to the bone but not the bone itself; and if in the middle, not beyond and not at the surface. Gangrene — and also attempt the pledget-treatment; everything that is coming will be described. Things visible cannot be expressed in words: foods, drinks, warmth, cold, position — and also that remedies, some dry, some wet, some reddish, some black, some white, some astringent, applied to wounds — so too with regimens. Those arising from falls are less able to be straightened; and the parts above the diaphragm are harder to straighten. 37 [5] In children, the part does not grow along with the rest, but only the legs, arms, and head. In those already grown, curvature: at first it keeps the disease in check, but over time it gives signs through the same channels as in younger patients, though less malignantly. There are some who have borne it easily, in cases where the condition has turned toward good flesh and fatness. Few of these have lived to around sixty years. Moreover, lateral crookings also occur; and the positions in which they lie contribute to these; and these things have prognostic significance. The rule of reduction and correction: the frame-bench, the lever, the wedge, the press-screw — the frame-bench to draw away, the lever to draw to the side. 38 [45] Those things that must be reduced or corrected must be forcibly extended, in whatever position each will be most lifted clear; and the part that has come out must be dealt with above the point from which it came out; this is done either with the hands, or by suspension, or with frame-benches, or around some fixed object. With the hands, then, correctly part by part; for the wrist and elbow it is sufficient to force: the wrist straight in line with the elbow, the elbow held at an angle to the upper arm — as, for example, the fulcrum stretched under the arm alongside the upper arm. In those cases involving a toe, finger, wrist, or the outward curvature of a hump, it is necessary to force outward and to press down; in all other cases the forcing with hands is sufficient, but to press down the projecting parts onto a seat, using the heel or the palm of the hand on some support — so that under the projecting part there lies a suitably sized soft mass, while against the other side one must push back and down without spreading beneath; whether it has fallen inward or outward — and the lateral ones: push some one way, push the others back the other way, both together on one side. As for humps inward: neither sneezing, nor coughing, nor injection of air, nor cupping-vessel is of use; if anything, traction. The error here: people suppose that sometimes when vertebrae are broken the lordotic curvatures appear to have slipped inward because of the pain; but these heal quickly and are easy. For outward humps: shaking down — for those higher up, toward the feet; for those lower down, the opposite; forced pressing combined with traction, either with a seat, or foot, or board. For those to one side or the other: if anything, traction, and further the positions during the diaita. All the instruments must be broad, smooth, strong; if not, they must be pre-wrapped in rags; everything must be prepared before the moments of constraint — all the lengths, heights, and widths measured proportionally. For traction as of the thigh: the binding at the ankle and above the knee — these pulling in the same direction; and around the hip, around the armpits, around the perineum and thigh — the middle section, starting from the anchor point, one end pulling toward the chest, the other toward the back — all these pulling in the same direction, fastened either to a pestle-shaped post or to a frame-bench. For one operating on a bed: on one side the foot-end must be braced against a threshold, and against the other side a strong transverse beam must be placed, and the pestle-shaped structures above, bracing against these, must be used to produce traction, either by driving wheel-spokes into the ground or by setting up a ladder and pushing from both sides. The standard apparatus: a board of six cubits in length, two cubits wide, one span thick, having two low pegs on each side, and also at the center proportionate upright posts, from which a crossbar-frame is fitted as a support for the beam, just as in the shoulder apparatus; and having carved grooves — smooth, like troughs — four fingers wide and deep, and spaced at such intervals as the levering itself requires for correction; and at the center a square-cut groove, to accommodate an upright post which, placed alongside the perineum, will prevent lateral rolling, and when slightly loose will serve as a lever-support. One must, when the board has something carved into the wall at its end, push the tip of the beam in, and on the other side press down, placing something soft and suitably sized underneath. In those from whom the bone from the palate has separated, the nose settles in the middle. 39 [5] Those who have had their heads struck without a wound — whether something has fallen on them, or a fracture has occurred, or compression — in some of these sharp discharges travel from the head down through the throat, and from a wound in the head, also to the liver and to the thigh. Signs of shifts and displacements: how, in what way, and how much these differ from one another. 40 [10] And those in whom the socket has broken; those in whom a small sinew has torn away; those in whom an epiphysis has broken off — and in what manner, and whether one or two of the two there are — dangers in these cases, hopes, which cases bad outcomes, and when bad outcomes toward death, toward secure health. And what must be reduced or manipulated, and when, and what must not, or when not — hopes in these cases, dangers. What kind and when must be manipulated: dislocations from birth, those in the growing, those in the grown; and what heals more quickly, what more slowly; what leaves lameness and how, and what does not; and why, and what will waste away, and where, and how, and in which cases less. And that broken parts heal more quickly and more slowly — in what cases the distortions and over-callusing occur, and remedies for these. Those in whom wounds arise immediately or later; those with broken bones — which have less, which do not; those in whom the broken bone protrudes, and where it protrudes more; those in whom a displaced joint protrudes. The errors — and what causes them — in what people observe, and in what they think about the conditions and the treatments. According to the established rules concerning bandaging: preparation, provision, traction, correction, rubbing, bandaging, recovery, placing, position, timing, diaita. The most loosely-textured parts heal most quickly; the opposite, oppositely. Distortions occur on the convex side; wasting of flesh and sinew occurs on the side of the displacement. The part that has been reduced will be as far as possible from the region from which it was displaced. As for sinews: those that are in motion and in a fluid state are capable of yielding; those that are not, less so. Best of all: if reduction follows as quickly as possible at the point where displacement occurred. Do not reduce when the patient has a fever, nor on the fourth or fifth day; the elbow least of all, and all those that are numb; the sooner the better, passing by the inflammation. Parts that are torn away — sinews, cartilages, epiphyses — or that are parted at points of natural union cannot be made like what they were; in most cases callus forms quickly, but function is preserved. Of displacements, the extremities are easier to deal with. Those easiest to displace cause the least inflammation; those that produce the least heat, and have not been subsequently treated, most readily displace again. Stretch out in such a position in which the part will most be lifted clear, looking to the nature and the site. Correction follows the path of the exit: push back to straight and to the side; but those that have contracted quickly must be countered quickly by a rotational draw. Those that displace most often go back in most easily; the reason lies in the nature, either of the sinews or of the bones — for sinews, length or excess looseness; for bones, flatness of the socket or baldness of the head; habit makes a wearing groove; the cause is also the state, and the habitual condition, and the age. The somewhat mucous is non-inflammatory. Those in whom wounds arose — either immediately from protruding bones, or later, or from itching or roughening — if the physician perceives any of this, he should immediately undo the bandage, apply a pitch-plaster over the wound, and bind with the first turn falling on the wound, and the rest as though the injury were not there; for in this way the wound itself will be least distended, and will suppurate most quickly, and break open, and once cleansed will heal most quickly; but splints should neither be applied over that spot nor pressed; and for those in whom the bones separating are not large, proceed thus; but where they are large, do not — for there is much suppuration, and in those cases it is no longer the same procedure, but ventilation is needed for the sake of drainage. 41 [20] For all such cases where there is protrusion — whether reduction is accomplished or not — bandaging is not appropriate; but extension-apparatus: spherical pads made like leg-irons, one at the ankle and one at the knee, broad against the shin, smooth, strong, having rings; and rods of proportionate length and thickness from cornel-wood, so as to produce traction; and leather straps fastened from both extremities into the rings, so that the tips, pressing into the spheres, force extension. Treatment: warm pitch-plaster; positions, and placement of the foot and hip; exact diaita. Reduce protruding bones the same day or the second day; on the fourth or fifth day, do not — but when they are dry and lean. The reduction: with levering instruments; or if the bone being reduced has no purchase point, saw off the parts that obstruct it. Moreover: those parts that have been stripped will fall away, and the limbs will be shorter. Joints slip more in some cases and less in others; and those that slip less are easier to reduce; those that slip more produce greater injuries to bones, sinews, joints, flesh, and positions. 42 The thigh and the upper arm are most similar to each other in how they displace.