First draft. This English translation was generated by
Claude Sonnet 4.6, critiqued by Claude Haiku 4.5, and adjudicated/corrected
once by Claude Sonnet 4.6. It is published for reading and review, not as a
final scholarly edition. Hippocratic medical recipes and treatments are
historical text, not medical advice.
The practitioner ought to make the extensions in dislocations and fractures as straight as possible; for this is the most fitting way.
1
If it inclines — one way or the other — let it lean toward the prone position; for the error is smaller than if it leans toward the supine. Those who deliberate nothing beforehand make no error in most cases; for the person being bandaged stretches out the hand of his own accord, compelled by right nature to do so. But practitioners who are supposedly being clever — some of them go wrong. There is not much difficulty in handling a broken hand, and it is within the reach of virtually any practitioner, so to speak; yet I am compelled to write at greater length about it, because I know that practitioners who were thought to be clever gained that reputation from the positions of the hand in bandaging — positions from which they should rather have been judged ignorant. For many other things in this craft are judged in this way: people praise what is strange and showy, not yet understanding whether it is good, more than what is familiar, which they already know to be good; and they praise the bizarre more than what is plain. I must therefore speak of as many of the practitioners' errors as I wish — to unteach some and to teach about the nature of the hand; and indeed this account is a lesson about other bones of the body as well. Now someone handed over a broken hand to be bandaged, having placed it prone; and the bandager compelled him to hold it just as archers do when they fit an arrow to the shoulder, and in that position bound it up, believing this to be the natural position for it; and he brought forward as evidence all the bones in the forearm — that they were aligned in a straight line with one another — and the skin-surface, that it maintains its own straight alignment both on the outer side and on the inner side; and he said that the flesh and sinews grew in this way too, and he brought forward archery as evidence.
2
Saying and doing these things, he was thought to be clever; but he had forgotten other crafts — both those that work by strength and those that work by technique — not knowing that the natural position is different in different activities, and that in the same task the natural positions of the right hand differ from those of the left, as the case may be. For the natural position is different in javelin-throwing, different in slinging, different in stone-throwing, different in boxing, different in resting. And as many crafts as one might find, one would observe that the natural position of the hands is not the same in each craft; rather, the hands take their position according to the instrument each person holds and according to the work he wishes to accomplish. For one who practises archery, it is reasonable that this position of the other hand is most effective; for the hinge-like joint of the upper arm, pressing in the notch of the forearm in this position, creates a straight alignment between the bones of the forearm and the upper arm, as if the whole were a single piece; and the bending of the joint is fully bent in this position. It is reasonable, then, that the region is most unbending and most taut in this way, and does not give way or yield along with the bow-string when it is drawn by the right hand; and in this way the string is drawn to the greatest extent and released from the most firm and most collected position; for from such releases of arrows, both the force and the range are greatest. But bandaging and archery have nothing in common. For, if after bandaging he had ordered the hand to be kept in this position, he would have added many other pains greater than the wound; and if he had ordered it to be bent, the bones, sinews, and flesh would no longer be in the same arrangement but would be rearranged differently while the bandage held firm — and what use is the archery position then? And perhaps he would not have gone wrong in his clever reasoning, had he let the wounded man himself present his hand. But another of the practitioners, placing the hand supine, ordered it to be extended in that way, and so positioned bound it up, believing this to be the natural position, taking the skin-surface as his sign, and believing the bones to be in their natural arrangement because the projecting bone beside the wrist, on the side of the little finger, appears to be in a straight line with the bone from which people measure the cubit.
3
He brought forward these proofs that it was naturally so arranged, and seemed to speak well. But in fact, if the hand were extended supine, it would be severely painful; and anyone might understand this by extending his own hand — how painful the position is. Indeed, a weaker man who has a stronger man's arm in this way, in his own hands, so that the elbow bends supine, could lead him wherever he wished; for even if the stronger man had a sword in that hand, he would be unable to do anything with the sword, so violent is this position. Moreover, if someone were to bandage it in this position and leave it so, the pain would be greater if the patient were to walk about, and great even if he were lying down. And if he bent the hand, all the muscles and bones would necessarily take a different shape. He was also unaware of these further errors in the position apart from the other harm: the bone projecting beside the wrist, on the side of the little finger — this belongs to the forearm; while the one at the bend, from which people measure the cubit — that is the head of the upper arm bone. [The author here identifies what he considers two distinct bones, yet believes his opponent has confused them as one; the identification reflects pre-Galenic anatomical understanding in which the bone at the elbow-bend measured for the cubit is treated as the head of the humerus, while the ulnar styloid at the wrist is distinguished from it.] He supposed this and that were the same bone, and many others have too; but that bone is identical with what is called the olecranon, on which we rest when we lean. So when the hand is held supine, the bone appears twisted; and the sinews stretching from the wrist from the inner side and from the fingers — these become twisted when the hand is held supine; for these sinews extend toward the bone of the upper arm, from which the cubit is measured. These are the errors and ignorances, so numerous and so grave, concerning the nature of the hand. But if one extends a broken hand as I direct, the bone beside the little finger — the one extending toward the olecranon — will be set straight, and the sinews extending from the wrist toward the extremities of the upper arm bone will be in straight alignment; and when the arm is taken up, it will be in nearly the same position as when being bandaged — painless for the patient walking, painless and without fatigue for the patient lying down. The patient should be seated so that the projecting part of the bone faces toward the brightest of the available lights, so that it does not escape the notice of the practitioner during extension whether it has been adequately straightened. And indeed the projection felt by the hand would not escape the notice of the experienced man as his hand is applied; moreover, it is most painful when touched at the projection. Of the bones of the forearm, when both are not broken, the healing is easier if the upper bone is the one injured, even though it is the thicker one; partly because the sound bone underneath acts as a foundation, and partly because the break is more easily hidden, except near the wrist — for the growth of flesh is thick toward the upper part.
4
The lower bone is without flesh, not easy to conceal, and requires stronger extension. If this bone is not the one fractured, but the other, a more moderate extension suffices; if both are broken, the strongest extension is needed. I have already seen a child over-extended beyond what was necessary; but most patients are extended less than is needed. When they make the extension, they should correct the position by pressing with the palms; then, after anointing with wax-salve — not too abundant, so that the bandages do not slip around — bind it up in such a way that the tip of the hand will not be lower than the elbow but somewhat higher, so that the blood does not flow down to the extremity but is held back. Then bind with the linen bandage, starting at the fracture; pressing firmly, but not squeezing too hard. When you have gone around the same spot two or three times, proceed with the bandaging upward, so that the influx of blood is held back, and end there; the first bandages should not be long. Of the second bandages, the start should be placed at the fracture; and having gone around once in the same place, then proceed downward, pressing less firmly and carrying it over a greater span, so that the bandage itself is long enough to run back to where the other one ended. The bandages here should be wound toward the left or toward the right, whichever is advantageous for the shape of the fracture and whichever direction it is beneficial for the bandage to incline. After this, linen pads should be stretched out, anointed with a little wax-salve; for this is both gentler and more convenient; then bind again with the linen bandages in alternation, sometimes to the right, sometimes to the left; and mostly starting from below and going upward, but sometimes also from above going downward. The slightly drying parts should be treated with pads applied in circles; and by the number of turns, not all at once correcting everything, but gradually. The wrappings around the wrist of the hand should be made loose, at one time and another. A sufficient quantity of bandages at the start: two portions. The signs of good treatment and correct bandaging are these: if you ask the patient whether he feels pressed upon and he says he does feel pressed, but moderately, and especially if he says it is at the fracture — the one correctly bandaged should say that such is his condition throughout.
5
The signs of the right degree are these: on the day he is bandaged and through the night, let him feel himself no less pressed upon than before, but rather more; and on the following day let a slight soft swelling come to the tip of the hand — this is a sign of the right degree of your pressure. At the end of that day, let him feel himself pressed upon less; and on the third day, let the bandages seem loose to you. If any of the things mentioned is lacking, you should know that the bandaging is looser than the right degree; if any is in excess of the things mentioned, you should know that it was pressed more than the right degree; and guided by these signs, when you next bandage, either loosen more or press more. When you undo it on the third day, after extending and correcting, bind again; and if you have happened to bandage correctly the first time, this bandaging should press a little more than the other. The starting-points should be placed at the fracture, just as before; for if you first press here, the ichor is drawn out from this point toward the extremities on either side; but if you first press somewhere else, it is drawn there from the part pressed — and it is useful to understand this in many connections. So always the beginning of the bandaging and the pressing should be from this region, and the rest in proportion, so that as you carry it farther from the fracture, you press less. Never put on the bandage entirely loose — it should lie close. Then, at each subsequent bandaging, more bandages should be used. When asked, the patient should say it is pressed a little more than before, and especially at the fracture, and the rest in proportion; and regarding the swelling and the pain and the relief — let these occur in proportion to the first bandaging. When it is the third day, let the bandages seem looser. Then undo and bind again, pressing a little more, and with all the bandages with which it was to be bandaged; and then let all these same things happen to the patient as in the first periods of bandaging. When the third day comes — that is, the seventh from the first bandaging — if it has been correctly bandaged, the swelling will be at the tip of the hand, and even that not very great; and the bandaged region will be found, at each successive bandaging, to be thinner and leaner, and on the seventh day very much so, and the broken bones will be more movable and more easily directed toward correct alignment.
6
If these things are as described, you should correct the alignment and bind as toward splints, pressing a little more than before — unless there is considerable pain from the swelling at the tip of the hand. When you have bound with the linen bandages, you should place the splints around and enclose them in the fastenings as loosely as possible — just enough to keep still — so that the application of the splints adds nothing to the pressure on the hand. After this, the pain and the reliefs should be the same as in the first periods of bandaging. When on the third day the patient says it is loose, then one should press the splints, most of all at the fracture, and the other places in proportion, where the bandaging had been slacker rather than tighter. The splint should be thickest where the fracture protrudes, but not by much. One should take care above all that the splint does not lie along the straight line of the great digit, but to one side or the other, nor along the straight line of the little one where the bone projects at the wrist, but to one side or the other. If for the fracture it should happen to be beneficial to place some of the splints along these lines, they should be made shorter than the others, so that they do not reach the projecting bones beside the wrist; for there is danger of ulceration and of stripping of the sinews. The splints should be pressed every three days very gently, keeping to this principle: that the splints are applied for the protection of the bandaging, not bound on for the sake of pressing. If you know well that the bones have been sufficiently straightened in the earlier bandagings, and neither any itching is troublesome nor any ulceration is suspected, you should leave it bandaged in the splints until more than twenty days have passed.
7
In thirty days altogether, for the most part, the bones of the forearm consolidate on the whole; but nothing is exact — for nature differs greatly from nature, and age from age. When you undo it, you should pour warm water over it, and re-bandage, pressing a little less than before and using fewer bandages. Then, undoing it every three days, bandage again, pressing less and with fewer bandages. When you suspect, once it is bound in splints, that the bones do not lie correctly, or if something else is troubling the wounded man, undo it at the halfway point of the time, or a little before, and re-bandage. The diaita for those in whom no wounds occur from the start and no bones protrude, a fairly moderate one is sufficient; but they should eat more sparingly for up to ten days, since they are already resting; and they should use mild foods, such as will provide moderation in the passage through; and they should abstain from wine and meat-eating; and then gradually return to full strength. This account lies like a just ordinance for the treatment of fractures — how one must handle them and what results from right handling; and whatever does not result in this way, one must know that in the handling something was lacking or in excess. One must further understand these additional matters in this simple method — things that practitioners do not attend to carefully, though they are such as can ruin every treatment and every bandaging when done incorrectly. For if both bones are broken, or only the lower one, and the bandaged patient holds his hand supported in some sling, and the sling happens to be thickest at the fracture, while the hand hangs free on either side, this patient will necessarily be found holding the bone twisted toward the upper side; but if, with the bones broken in this way, he holds both the tip of the hand and the elbow region in the sling, while the rest of the forearm is not suspended, he will be found holding the bone twisted toward the lower side. Therefore the forearm should for the most part, and the wrist of the hand, be suspended evenly in a sling of good breadth, soft material. If the upper arm bone is broken, and someone stretches the arm out and extends it in that position, the muscle of the upper arm will be bandaged under tension; and when, once bandaged, the patient bends the elbow, the muscle of the upper arm will take on a different shape.
8
The most fitting extension of the upper arm is this: a piece of wood about a cubit long, or a little shorter — like the handles of small spades — should be hung, tied with a rope on each side; and the patient should be seated on something elevated, with the arm resting over it, so that the handle comes under the armpit fitting suitably, so that the patient can barely sit down and is nearly lifted off the seat; then something else should be placed underneath as a support, and a leather cushion placed under, one or more, so that the forearm lying horizontally is held at the right height to form a right angle. The best thing is to take a broad soft piece of leather, or to throw a broad band around, and hang from it one of the large weights, such as will provide adequate extension; if not, then one of the sturdy men, with the forearm in this position, should press down alongside the elbow. The practitioner, standing upright, should operate with one foot on something higher, correcting the bone with the palms; and he will correct it easily — for the positioning is good, if one has prepared well. Then he should bind, placing the starting-points at the fracture, and handle everything else as previously advised; and he should ask the same questions; and use the same signs to determine whether it is at the right degree or not; and bind every three days, pressing more; and on the seventh or ninth day bind in splints, until more than thirty days have passed. And if he suspects the bone does not lie correctly, at some point during this time he should undo it, and having set it well, re-bandage. The bone of the upper arm consolidates for the most part in forty days. When these days have passed, you should undo it and press less with the bandages, and bind with fewer. The diaita should be somewhat stricter than before, and for a longer time; and one should judge the strength by the swelling at the tip of the hand. One must further understand this: that the upper arm bone naturally curves outward; it tends therefore to be twisted in that direction when not properly treated. And indeed all other bones, toward whichever side they naturally incline when fractured, tend to be twisted in that direction during treatment. When therefore something of this kind is suspected, one must take hold of the upper arm additionally with a broad band, binding it around the chest; and when the patient is about to rest, one should place between the elbow and the ribs a pad folded in many layers, or something similar; for in this way the curve of the bone would be straightened; one must guard, however, that it is not bent too much inward. The foot of a human being is composed of many small bones, just as the tip of the hand.
9
These bones are not much given to fracturing unless the skin is also wounded by something sharp or heavy; those that are wounded will be discussed in the section on wounds, how they should be treated. If any joint is displaced from its place — whether a toe joint or any other of the bones of what is called the tarsus — each must be compelled back into its own place, just as has been described for the hand; and treated with wax-salve, pads, and linen bandages, just as fractures are, except for splints, pressing in the same way and binding every three days; and the patient being bandaged should give responses similar to those in fractures — regarding the feeling of pressure and regarding loosening. All these heal completely in twenty days, except for those that connect with the bones of the lower leg; and by the natural progression itself. It is beneficial for the patient to lie down during this time; but they do not dare to, treating the condition with contempt, and they walk about before they are healed. For this reason, most of them do not recover completely. But often the pain reminds them — understandably; for the feet bear the whole weight of the body. When therefore they walk about while not yet healed, the displaced joints knit together badly; this is why at one time and another, when they walk, they feel pain in the parts near the lower leg. Those that connect with the bones of the lower leg are larger than the others, and when these are displaced the healing takes longer.
10
The treatment is the same [as before]; but more linen strips and more pads are to be used, and the bandaging is to extend on all sides, both ways; and the pressure, as in all other cases, is to be applied most at the site where the bone was displaced, and the first turns of the bandages are to be made there. At each loosening, much warm water is to be used; and in all injuries at joints, warm water in abundance is to be poured over them. The signs of adequate and inadequate pressure and relaxation are to be shown at the same times as in the foregoing cases, and the re-bandagings likewise are to be carried out in the same way. These patients reach full recovery in about forty days, if they are willing to stay lying down; but if not, they suffer the same things as before, and more so.
As for those who, having leapt from something high, come down hard on their heel — in these cases the bones are separated, small vessels burst open as the flesh around the bone is bruised on both sides, and swelling and great pain follow.
11
For this bone is not small, and it projects directly beneath the straight line of the shin, and it is connected to veins and sinews of critical importance; and the rear tendon is attached to this bone. These patients are to be treated with wax ointment, pads, and linen strips; and very abundant warm water is to be used in addition to these. More linen strips are also needed for these cases, and otherwise the best and most gentle ones that can be had. If the patient happens to have naturally soft skin around the heel, leave it as it is; but if it is thick and hard, as some people have, it must be cut uniformly and thinned without piercing through. To bandage these cases properly is not within every man's ability; for if one bandages as the parts around the ankle are otherwise bandaged — sometimes passing around the foot, sometimes around the tendon — these constrictions isolate the heel where the bruising occurred, and in this way there is danger that the heel bone will become gangrenous; and indeed if it does gangrene, the disease is capable of lasting a whole lifetime. For even those other cases in which gangrene does not arise in this manner, but in which the heel has blackened while lying down through neglect of proper positioning, or in which a wound in the shin has become critical, prolonged, and shared with the heel, or in the thigh, or in which some other disease has given rise to prolonged lying on the back — these too are, in such cases, long-lasting, troublesome, and repeatedly breaking open, unless they are treated with good attentive care and much rest, as with frankly gangrenous cases; and those going gangrenous in such a manner present great dangers to the body in addition to the other harm. For there may arise very acute, continuous, trembling, hiccupping fevers that lay hold of the mind, and of short duration, proving fatal; and there could be livid discolorations of hemorrhagic vessels, nausea, and gangrenous states from the pressure — and these things could occur apart from the other gangrene. Now all this has been said concerning what the most violent bruisings lead to; but most cases are bruised on both sides mildly, and no great urgency of care is needed, though nonetheless one must manage them correctly. When, however, the impact seems to have been severe, one must do the things stated, and apply the greatest part of the bandaging passing around the heel, at one time counterbalancing toward the extremities of the foot, at another toward the middle, at another toward the parts around the shin; and one must additionally bandage all the neighboring parts on both sides, as has been said before; and the pressure is not to be made strong, but distributed among many linen strips. It is also better to give hellebore to drink on the same day, or the next day; and to loosen the bandage on the third day and re-bandage. The following are signs whether the case is turning worse or not: when the bursts of the veins, the blackened areas, and the parts near them become reddish and hardened, there is danger of a turn for the worse. If the patient is without fever, purge upward with a drug, as has been said, and likewise in any cases not continuously fevered; but if continuously fevered, do not give a drug, but withhold food and gruels, and let the drink be water, not wine, but the sweet-sour vinegar-honey mixture.
11 (50)
If the case is not going to turn worse, the bursts and blackened areas and the surrounding tissues become yellowish-green and not hard — this is a favorable sign in all bursting cases that are not going to take a turn for the worse; but when the livid discoloration is accompanied by hardening, there is danger of the parts going black. The foot should be arranged so that it is kept mostly a little higher than the rest of the body. The patient could recover fully in sixty days, if he stays still.
The shin consists of two bones; in one dimension one is considerably thinner than the other, in another dimension not much thinner; they are connected to each other at the foot end and share a common growth-end; along the straight length of the shin they are not connected; at the thigh end they are connected and have a growth-end, and the growth-end has a separating junction; the one bone is slightly longer — the one on the side of the little toe; such is the nature of the bones in the shin.
13
The parts at the foot end sometimes slip out of place — sometimes both bones together along with the growth-end, sometimes the growth-end alone is displaced, sometimes one of the two bones. These are less troublesome than the cases at the wrist of the hands, if people are willing to stay still. The treatment is similar to that for those cases; the reduction must be made by traction, as in those cases, but stronger traction is required, inasmuch as the body is stronger here. For most cases two men suffice, one pulling on each side. If they are not strong enough, it is easy to make the traction stronger: one should dig in an anchor post or something like it, wrap something soft around the foot, then bind the foot with broad ox-leather straps, and having fastened the ends of the straps either to a pestle or to another piece of wood, insert the tip of the wood into the anchor post and lever it back; while others pull in the opposite direction, grasping at the shoulders and behind the knee. It is also possible to engage the upper body with a fixed support: if you wish, bury a smooth round piece of wood deep in the ground, leaving part of it projecting above, and place this part between the legs near the perineum, so that it prevents the body from following those pulling at the foot end; and then, to prevent the body leaning toward the leg being pulled, have someone seated to the side push the buttock, so that the body is not dragged around. Alternatively, if you wish, fix pieces of wood on each side against the armpits, with the arms stretched alongside and held in that position; and let someone additionally take hold at the knee and so make a counter-pull. And if you wish instead of holding at the knee, tie further straps around the thigh, bury another anchor post above the head, suspend the straps from a piece of wood, and pressing the wood against the anchor post, pull in the direction opposite to those at the foot end. And if you prefer, instead of anchor posts, stretch a suitable support beam under the bed, and then, pressing and levering the pieces of wood against the head of the support beam on each side, pull the straps taut; or if you like, setting up pulleys on each side, use those for the traction. There are many other methods of traction. The best thing, for one who practices in a large city, is to own a prepared piece of timber in which all the necessary forceful means are available for all fractures and all joint reductions by traction and levering; and the piece of timber suffices if it is such as the square oak columns that are made — in length, width, and thickness.
When you have stretched sufficiently, it is then easy to reduce the joint; for it is suspended in the straight line above its original seat.
14
So it must be set straight with the palms of the hands, pressing some against the projecting displaced part and counter-pressing others on the other side below the ankle. When you have made the reduction, if possible, bandage while traction is still held; but if the straps prevent this, loosen them and maintain counter-traction until you have finished bandaging. Bandage in the same manner, applying the starting-point of the linen strips similarly over the projecting displaced part, making the first turns most numerous over that spot, and the greatest number of pads there, and the pressure especially there; and additionally bandage on both sides for some distance. This joint needs to be under somewhat more pressure in the first bandaging than the one in the hand. When you have bandaged, let the bandaged part be held higher than the rest of the body, and the positioning must be such that the foot will be as little as possible left hanging unsupported. The thinning of the body is to be carried out in proportion to the magnitude of the displacement; for some displace little, some much. In general, one must thin and for a longer time in injuries of the legs than in those of the arms; for these are larger and thicker than those, and moreover it is necessary that the body be at rest and lying down. As for re-bandaging the joint, nothing prevents doing it on the third day, nor is there any urgency. And all the other matters are to be treated in a similar manner to what has gone before. If the patient is willing to stay quietly lying down, forty days are sufficient, provided the bones settle back again properly into their own place; but if he is unwilling to stay still, he would not make easy use of the leg and would be compelled to be bandaged for a long time. In all cases where the bones do not settle completely into their own place but something falls short, the hip and thigh and shin waste away over time; and if the displacement is inward, the outer part wastes, and if outward, the inner part. Most displacements are inward.
When both bones of the shin are broken without wounding, stronger traction is required.
15
Traction is to be applied in some of the methods described above, if the displacements are great. Traction from men is also sufficient; in most cases two strong men, one on each side pulling against each other, would do. The traction must be straight, in accordance with the natural line and along the straight alignment of the shin and thigh — both when you are applying traction to a broken shin and when to a broken thigh. And the bandaging too is to be done in this way, with both ends extended, whichever of these you are bandaging; for the same thing is not beneficial for a leg and for an arm. For when the bones of the forearm and upper arm are broken and bandaged, the arm is supported in a sling; and if you bandage it extended, the disposition of the flesh changes when the elbow is bent; for the elbow cannot be kept extended for a long time, since it is not often accustomed to being in such a position, but to being bent; and moreover, since people can move about when wounded in the arm, they need the elbow to be bent. The leg, however, in walking and standing is accustomed sometimes to be extended, sometimes to be nearly extended; and it is accustomed to hang down naturally, and moreover to carry the rest of the body; for this reason it bears the extended position easily when necessity requires it; and moreover when lying in bed it is often in this position; and when it is injured, necessity enslaves the will in this respect — since they become unable to rise up — so that they do not even think of bending and standing up, but stay quiet lying in that position. For these reasons, then, regarding the arm and the leg, neither the traction nor the bandaging in a given position is the same. If the traction from the men is sufficient, there is no need to labor needlessly; for it is somewhat inelegant to use mechanical devices when there is no need; but if the traction from the men is not sufficient, one of the other forceful means is also to be applied, whichever is suitable. When the traction has been adequately applied, it is then easy to set the bones straight and bring them back to their natural alignment, straightening and refining them with the palms of the hands. When you have set them right, bandage with the linen strips while the limb is stretched, whether it is useful to carry the first linen strips to the right or to the left; and the start of the linen strip is to be placed at the fracture site, and the first turns are to be made there; and then it is to proceed upward toward the upper shin, bandaging as has been described for the other fractures.
16
The linen strips for the leg must be wider, longer, and much more numerous than those for the arm. When you have bandaged, lay the limb on something level and soft, so that it is not twisted this way or that, neither bent backward nor bent forward; and most useful is a cushion, of linen or wool, not hard, made with a soft hollow running lengthwise down the middle, placed underneath, or something similar to this. Concerning the gutters placed under fractured legs, I am in doubt what to advise — whether they should be placed or not. They do help, but not as much as those who place them think. For the gutters do not force the patient to stay still, as they suppose; for when the rest of the body turns this way or that, the gutter does not compel the leg not to follow, unless the patient himself takes care; nor does the gutter prevent the leg from moving this way or that independently of the body. And indeed it is more uncomfortable to have a piece of wood stretched under the limb, unless someone equally puts something soft into it. It is most useful in the changes of the under-bedding and in the going to the privy. So it is possible both with a gutter and without a gutter to manage the case well or badly; but it is more persuasive to the common people, and the physician appears less liable to error, if a gutter is placed underneath — and yet it is less skillful. For the limb must lie on something level and soft, completely straight in every respect; since the bandaging is necessarily overmastered by the distortion in the positioning, in whatever direction and to whatever extent it leans. The bandaged patient should report the same signs as have been described before; and indeed the bandaging should be of such a kind, and the swelling should likewise be driven toward the extremities, and the relaxations likewise, and the re-bandagings every other day, and the bandaged part should be found thinner, and the bandagings are to be applied more firmly and with more linen strips; and the foot too is to be included loosely, unless the injury is very close to the knee. The bones must be stretched moderately and corrected at each bandaging; for if the treatment is carried out correctly and the swelling subsides in proportion, the bandaged area will be yet thinner and leaner, and the bones yet more amenable to being guided, responding better to the traction. When the seventh, ninth, or eleventh day comes, the splints are to be applied, as has been described for the other fractures. The snares of the splints must be guarded against over the region of the ankles and over the tendon in the shin of the foot. The bones of the shin consolidate in forty days, if properly treated. If you suspect that any of the bones needs some correction, or you fear some wound developing, you must in the intervening time loosen and after arranging properly re-bandage. If only one bone of the shin is broken, weaker traction is required, though one must not fall short or be slack in the traction — above all the traction must be applied in the first bandaging, to the extent that it always reaches in every fracture; or if not, as quickly as possible; for whatever pressure one applies with the bandaging when the bones are not properly set, that area becomes more painful.
17
The rest of the treatment is the same. Of the two bones, the inner one of what is called the shin-front is more troublesome to treat, requires more traction, and if the bones are not set correctly it cannot be concealed — for it is entirely visible and without flesh cover; and the patient would be much slower to walk on the leg if this bone is broken.
18
If the outer bone is broken, patients bear it much more easily, and it is much easier to conceal even if it is not set well, for it has flesh over it; and they stand on their feet quickly, since the greater part of the weight is carried by the inner bone of the shin-front. For the inner bone bears the greater share of the stress both by reason of the leg itself and the straight-line alignment of the load along the leg; for the head of the thighbone supports the upper part of the body, and this is situated on the inner side of the leg, not the outer, but along the line of the shin-front; and at the same time the other half of the body is more adjacent to this alignment than to the outer one; and at the same time the inner is thicker than the outer, just as in the forearm the bone along the line of the little finger is thinner and longer. At the lower joint, however, the arrangement of the longer bone is not the same; for the elbow and the back of the knee bend differently. For these reasons, when the outer bone is broken, the patient treads quickly; when the inner bone is broken, slowly. If the bone of the thigh is broken, above all one must ensure that the traction is not applied deficiently; for if applied in excess it would do no harm.
19
For not even if one were to bandage the bones while they are held apart by the force of the traction would the bandaging be able to keep them apart; but the bones would come together as soon as those pulling let go; for the flesh, being thick and strong, will master the bandaging and not be mastered by it. Regarding the matter at hand, therefore, one must stretch well and without any twisting, falling short in nothing; for it is a great disgrace and injury to leave the thigh shorter. An arm, if it becomes shorter, can be hidden, and the error is not serious; but a leg become shorter would render the person lame; for the healthy one convicts it by comparison, being longer — so that it is more profitable for one who is going to be badly treated to have both legs broken rather than one; for he would at least be balanced with himself. When, however, you have stretched sufficiently, you must set the bones straight with the palms of the hands and bandage in the same manner as has been written before, and apply the starting-point of the linen strip as has been described, distributing the bandaging upward. And the patient is to report the same signs as before, and is to rest and recover in the same way, and re-bandaging is to be done likewise; and the application of splints is the same. The thigh consolidates in fifty days. One must also keep in mind that the thigh curves toward the outer part more than the inner, and toward the front more than the back; and it is into these directions that it becomes distorted when not properly treated; and indeed in these same directions it is itself less fleshy, so that distortion cannot be concealed.
20
If therefore you suspect anything of this sort, mechanical devices are to be employed as has been advised for the distorted upper arm. A few linen strips are to be wound additionally around the hip and flanks, so that the groin region and the joint at what is called the fold of the groin may be additionally bandaged; for this is also otherwise beneficial, and so that the tips of the splints may not injure by pressing against unbandaged parts. The splints must always be left well clear of the bare skin on both sides; and the placement of the splints must always be taken care of, so that they will not rest against a bone that naturally projects beside the joints, nor against a sinew. The swellings at the hollow of the knee, or at the foot, or at any other part raised up by the pressure — these are to be bound with much wool, dirty and well worked, moistened with wine and oil, with a smearing of wax ointment underneath; and if the splints press, they are to be slackened.
21
You could make the swellings subside faster if, setting aside the splints, you were to bandage the swellings with numerous linen strips, starting from the lowest point and working upward; for in this way the swelling would subside most quickly and would be drawn back up under the original bandages. But this method of bandaging is not to be used, unless there is danger of blistering or blackening in the swelling; and nothing of this kind occurs, unless one presses the fracture too hard, or keeps it hanging down, or scratches it with the hand, or something else irritating falls against the skin. If one places a gutter under the thigh itself without extending it past the hollow of the knee, it would harm more than help; for it would prevent neither the body nor the shin from moving independently of the thigh.
22
For it would be irritating when pressing against the hollow of the knee; and it would urge the patient to do precisely what must least be done — for the knee must least of all be bent, since this would throw the whole bandaging into disorder. And when both the thigh and the lower leg are bandaged, whoever bends at the knee must necessarily have the muscles taking different positions at different times; and necessarily the broken bones too must be subject to movement. One must therefore make it a matter of the greatest concern that the hollow of the knee be kept fully extended. It would seem to me, then, that the tube-splint extending from the hip to the foot would be beneficial when placed underneath; and further, to wrap a band loosely around the hollow of the knee together with the tube-splint, just as infants are swaddled in their beds. Then, if the thigh should twist upward or to the side, it would be easier to restrain in this way together with the tube-splint. Either, then, the tube-splint should be made to run continuously from end to end, or it should not be made at all. One must take very great care of the heel itself, that it be in good position — both in fractures of the lower leg and in fractures of the thigh.
23
For if the foot hangs unsupported while the rest of the lower leg is propped up, the bones of the shin must necessarily appear convex; but if the heel is propped up higher than is fitting, and the rest of the lower leg is left somewhat suspended, then this bone of the shin must necessarily appear more concave than is fitting — especially if the person's heel happens by nature to be large. Moreover, all bones consolidate more slowly if they do not lie in accordance with their natural position, and also if they do not remain at rest in the same position; and the bony calluses are weaker. So much then for those in whom the bones are broken but do not protrude, and in whom no wound has otherwise occurred.
24
In those cases where the bones are broken in a simple manner and not in many splinters, and have protruded but were reduced on the same day or the next day, and are settling back into their place, and separation of bone splinters is not expected — or also in cases where a wound has formed but the broken bones do not protrude, and the manner of the fracture is not such as to make separation of bone splinters to be expected — some practitioners treat such patients doing neither great good nor great harm: they treat the wounds with some cleansing agent, or apply a pitch-wax dressing, or a blood-stanching one, or some other thing they are accustomed to do; and on top they bind on wine-soaked compresses or unwashed wool, or something of that sort. Then, when the wounds become clean and are already closing together, at that point they try to bandage with many layers of bandage-cloth and to correct alignment with splints. This treatment does some good and no great harm. Yet the bones cannot settle back into their own place in the same way; rather, the bones become somewhat more bulging than the right degree in that spot; and they may also become shorter, in those cases where both bones of the forearm or the lower leg are broken. There are others again who treat such cases with bandage-cloth straightaway, binding the bandage-cloth on one side and the other but leaving a gap at the wound itself, and letting it get some air; then they apply to the wound one of the cleansing agents, and tend it with wine-soaked compresses or unwashed wool.
25
This treatment is bad, and those who treat in this way are likely to be showing the greatest lack of understanding, both in other fractures and in such cases as these. For it is of the greatest importance to know in what manner one must place the beginning of the bandage-cloth, and at what point the pressure must be greatest, and what benefits result if one places the beginning correctly and presses where one must, and what harm results if one does not place it correctly and does not press where one most ought to, but rather on one side and the other. Now it has been stated in what was written above what comes of each approach; and the practice of medicine itself bears witness: for the swelling must necessarily be driven out into the wound itself, in a patient bandaged in this way. For even if healthy skin were bandaged on one side and the other, but left uncovered in the middle, it would swell most at the gap, and become discolored; how then would a wound not suffer these same things? It follows necessarily that the wound is discolored and pulled apart, weeping and with pus unable to discharge properly, and that bones which were not going to separate will now tend toward separation; and the wound will be throbbing and feverish. And because of the swelling they are forced to apply a poultice — which is also unhelpful to those bandaged on one side and the other, since it adds a useless weight on top of the other throbbing. And in the end they release the bandages whenever things turn worse, and treat what remains without bandaging. And no less, if they receive some other wound of the same kind, they treat it in the same way; for they do not think that the bandaging on one side and the other, and the cooling of the wound, is the cause, but rather some other misfortune. But I would certainly not have written so much on this subject if I did not know clearly that this bandaging is harmful, and that many practice it in this way, and that the lesson is crucial, and that it is evidence that what was written above was written correctly — namely whether fractures must be pressed most, or least. Now, to speak in summary: for those in whom separation of the bones is not expected to occur, one must employ the same treatment as for those whose bones are broken but have no wound; for the extensions and corrections of the bones must be performed in the same manner, and the bandaging in a similar fashion.
26
For on the wound itself one should smear pitch-wax salve and apply a thin doubled compress, and around it smear white wax salve. The bandage-cloths and other materials should be split somewhat wider than if there were no wound; and whichever is applied first should be considerably wider than the wound. For narrower ones encircle the wound like a girdle — which must not happen; rather, the first wrapping should cover the whole wound and the bandage-cloth should overlap on both sides. One must therefore begin the bandage-cloth directly at the line of the wound, pressing a little less than one would if there were no wound, and extending the bandaging as was also described before. The bandage-cloths should always be of the soft kind, and somewhat more so in such cases than if there were no wound. The quantity of bandage-cloths should be no fewer than those specified before, but rather somewhat more. When the bandaging is applied, it should seem to the patient to be snugly fitted but not under pressure; and he should say that the fit is snuggest at the wound. The times should be the same — on the side of seeming more snugly fitted, and on the side of seeming to slacken — as has also been described previously. Re-bandage every third day, making all adjustments in similar fashion as described before, except that overall one should press these wounded cases somewhat less than the unwounded cases. And if things proceed according to what is to be expected, the area at the wound will always be found more reduced in swelling, and reduced too will be everything else held under the bandaging; and suppurations will occur more swiftly than in wounds treated otherwise; and whatever small pieces of flesh were blackened and deadened in the wound will more swiftly rupture and fall away with this treatment than with others; and the wound so treated will more swiftly tend toward scarring than if treated otherwise. The cause of all these things is that the area at the wound becomes lean, and the surrounding parts lean as well. Now everything else must be treated in the same way as bones broken without a wound. Splints must not be applied. For this reason also the bandage-cloths for these patients should be more numerous than for the others — both because the pressure is less, and because the splints are applied later. If, however, you do apply splints, do not apply them in line with the wound, and also apply them loosely, taking care that there will be no great constriction from the splints. This too has been stated in what was written above. The diaita (regimen / ordering of life) must be kept more precise and for a longer time in those who have wounds from the beginning, and in those whose bones protrude; and to speak in sum, in the most severe injuries the diaita must be more precise and of longer duration. The same treatment of wounds applies also in those whose bones are broken but who had no wound from the beginning, and in whom it arises during treatment — whether from greater pressure by the bandage-cloth, or from a splint pressing in by its setting, or from some other cause.
27
Such cases are recognized, if there is a wound, by the pain and by the throbbing; and the swelling in the extremities becomes harder in such patients, and if you draw a finger across it the redness rises up, and then quickly flows back again. If therefore you suspect something of the sort, you should undo the bandaging; and if there is itching at the sub-bandage pieces, or over the rest of the bandaged area, use pitch-wax salve instead of the other. But if there is none of this, and the wound itself is found to be irritated, blackened over a large area or unclean, with the flesh suppurating and the sinews about to fall away, you must not allow any cooling of these patients whatsoever, nor be afraid of this suppuration, but treat them in other respects in the same manner as those who had a wound from the beginning. With the bandage-cloths you must begin binding from the swelling in the extremities with very loose turns, and then work the bandaging upward always, so that there is no pressure anywhere, but the best fit is at the wound, and less so at the other parts. The first bandage-cloths should be clean and not narrow; and the quantity of bandage-cloths should be as many as there would be if they were being bandaged with splints, or a little fewer. On the wound itself, an adequate pledget smeared with white wax salve; for whether flesh or sinew blackens, it will fall away — for such things must not be treated with sharp remedies but with gentle ones, as are burns from fire. Re-bandage every third day; do not apply splints; and keep the patient more at rest than before, and on reduced food. One should know, whether it is flesh or sinew that is going to fall away, that in this way it will spread far less extensively, will fall away far more swiftly, and the surrounding parts will be far more reduced in swelling, than if one were to remove the bandages and apply one of the cleansing medicaments to the wound. And indeed even when what is to fall away has fallen away, the wound granulates more swiftly when treated in this way than otherwise, and forms a scar more swiftly. All this, however, depends on applying the bandaging correctly and with measure. The positions too contribute, and what kinds they must be, and the rest of the diaita, and the suitability of the bandage-cloths. If, however, you are mistaken in fresh injuries, not expecting a separation of bones to occur, but they are likely to come away, you need have no great fear of this manner of treatment; for no great harm would come about, provided only you are able to apply the bandagings well and without damage by hand.
28
The following is a sign that separation of bones is about to occur in this manner of treatment: plentiful pus flows from the wound, and the pus appears turgid. Re-bandage more frequently on account of the moisture; since otherwise indeed patients remain free of fever, provided they are not pressed too hard by the bandaging, and the wound and the surrounding parts are lean. Now in separations of very thin pieces of bone, no great change of treatment is needed — except to bandage more loosely so that the pus is not obstructed but flows freely, and to re-bandage more frequently, until the bone separates, and to apply no splints. But in those cases where separation of a larger piece of bone is expected to occur — whether you foresee it from the beginning or recognize it later — the same treatment is no longer needed. Rather the extensions and corrections must be performed as described; but doubled compresses should be made, not less than half a span in width (taking the character of the wound as the measure), and in length not much less than what goes twice around the wounded part, but considerably more than what goes once around — as many as would be of benefit — and steeping these in dark astringent wine, one should begin from the middle, rolling as a sub-bandage is applied from two starting ends, and then releasing the ends alternating in the manner of an adze-handle.
29
These things should be done at the wound itself and on both sides of the wound; and they should not press at all, but only be placed there for the sake of fitting snugly around the wound. On the wound itself one must place pitch-wax salve, or one of the blood-stanching agents, or one of the other medicaments that is compatible with moistening — for whether flesh or sinew blackens, it will fall away. And if the season is summer, moisten the compresses frequently with wine; if the season is winter, place over it plentiful unwashed wool dampened with wine and oil. One must have smooth material laid beneath, and ensure easy drainage, guarding against seepage, remembering that parts left in the same positions for a long time produce sores that are hard to heal. Those who cannot be treated by bandaging through any of the methods described or those that will be described — for these patients one must make it a greater concern that they will hold the broken part of the body in correct straight alignment, paying attention to the upper part even more than the lower.
30
If one intends to work well and with ease, it is worth also constructing a device whereby the broken part of the body will maintain a proper and non-violent extension; and in the lower leg especially it is possible to construct such a device. Now there are some who, for all fractures of the lower leg, both those that are bandaged and those that are not, tie the foot to the bed at the very tip, or to some other piece of wood planted in the ground alongside the bed. These men do every harm and no good: for having the foot tied is no remedy for extension, since the rest of the body will approach toward the foot no less, and so there would be no more stretching; nor again does it give any benefit for straight alignment, but rather harms it, since when the rest of the body turns one way or the other, the binding will not prevent the foot and the bones attached to the foot from following the rest of the body. And if it were not tied, it would be twisted less; for it would be carried along less tardily in the movement of the rest of the body. But if someone were to stitch two balls from Egyptian leather such as those worn by people long kept in heavy leg-irons, and the balls had layers on each side — deeper ones toward the wound side, shallower ones toward the joint side — and were bulky and soft and well fitted, one below the ankle and one below the knee; and the lower ball had attached to its outer lateral edge pairs of short loops — whether of single or double straps — some on each side of the ankle and some on each side of the knee; and the upper ball had similar attachments along the same straight line. Then, taking four cornel-wood rods of equal size with one another, about a finger's breadth in thickness, and in length so as to fit, when bent, into the loops — taking care that the ends of the rods would lodge not against the skin but against the ends of the balls — there should be three pairs of rods and more, with some pairs a little longer than others and some a little shorter and smaller, so as to allow more extension if desired, or less; and the rods should be on each side of the ankles. If this device is well constructed, it would provide an extension both correct and even along the straight line, and there would be no pain at the wound; for what is pressed out, if anything is pressed, would be driven partly toward the foot and partly toward the thigh; and the rods, some on one side and some on the other of the ankles, would be better positioned so as not to impede the placement of the lower leg; and the wound would be easily inspected and easily supported — for there is nothing in the way if one wishes to join the two upper rods together, and if one wishes to lay something lightly over so that what is laid on is suspended clear of the wound. If then the balls are stitched to be gentle and fine and soft and new, and the tension of the rods is fitted well, as has already been described, the device is useful; but if any of these things is not in good order, it would harm more than it would help.
30 (50)
All other devices must either be constructed well, or not constructed at all; for it is shameful and unskillful to be at a loss with devices while attempting to devise them. Now on this point: most practitioners treat fractures — both those with wounds and those without wounds — during the first days with unwashed wool; and this does not seem unskillful to them.
31
Those who are compelled by the immediacy of fresh injuries, having no bandage-cloths, to prepare with wool — for these there is the most excuse; for without bandage-cloths one could not apply anything else much better than wool to such cases. It must be very plentiful, and very well worked, and not rough; for the little and the poor has little power as well. But those who judge it right to apply wool for one or two days, and then on the third and fourth day bind with bandage-cloths and apply pressure and extension then especially — these show a very considerable and quite critical lack of understanding of medical practice; for all wounds must least of all undergo rough handling and manipulation on the third and fourth day, to speak in summary; and all probing too must be avoided on these days, and in whatever other wounds there is irritation. For in general the third and fourth day produces the turnings-for-the-worse in most wounds — both whatever is tending toward inflammation and impurity, and whatever is going to fever. And this lesson is of very great worth, if any is. For what of the most critical matters in medicine does it not touch, not only in wounds but in many other diseases as well — unless someone were to say that other diseases too are wounds. For there is some reasonableness in that account as well: in many respects the one class is akin to the other. Those, however, who judge it right to use wool until seven days have passed, and then to extend and correct and bind with bandage-cloths — these would not seem equally lacking in understanding; for the most critical point of the inflammation has passed, and the bones would be loose and tractable after these days. Yet this practice too falls far short of the bandaging with bandage-cloths from the beginning; for that method shows patients at seven days free of inflammation and prepares them for the secure application of splints; whereas this method falls far behind, and has certain other disadvantages — but it would be long to write them all out. In those cases where broken and protruding bones cannot be settled back into their own place, the following is the procedure: iron levers must be made after the manner of the pry-bars used by stone-cutters, some broader, some narrower; and there should be three and more, so that one may use those that fit best. Then with these one must lever simultaneously with the extension, slipping them under — pressing the lower end against the lower part of the bone, and the upper end of the iron against the upper part — in simple terms, just as one would forcefully lever a stone or a piece of wood; and the irons should be as sturdy as possible, so that they do not bend.
31bis [35]
This is a powerful remedy, provided the iron instruments are suitable and the levering is done as it should be. For of all the devices that human beings have contrived, these three are the most powerful: the rotation of the windlass, levering, and wedging. Without these, or some one of them, or all of them, people accomplish none of the most demanding tasks. So this levering is not to be scorned; for either the bones will be reduced in this way, or they cannot be reduced at all. But if the upper part of the displaced bone does not provide a suitable seat for the lever, but, being too sharp, slides away, one must carve out a secure seat in the bone for the lever. Levering and traction must be done on the same day, or the second day; not on the third; and on the fourth and fifth, as little as possible. For even without reducing the bone, mere disturbance during these days would produce inflammation — and no less so if one does reduce it; indeed, if one does reduce it, convulsion would far more likely result than if one failed to reduce it. This must be well understood: for if convulsion should come on after reduction, there is not much hope of survival; and it is advantageous to push the bone back out again, if this can be done without disturbance. For convulsions and tetanus arise not from looser states of the critical moment but more from states of tension. Concerning the case at hand, then, one must not cause disturbance on the days mentioned above, but attend carefully to keeping the wound as free from inflammation as possible and promoting suppuration as fully as possible. When seven days have passed, or a few more, if the patient is without fever and the wound is not inflamed, there is less obstacle to attempting reduction, if you expect to succeed; but if not, there is no need to cause and endure disturbance to no purpose. If you do reduce the bones to their proper place, the methods of treatment have already been set out — both when you expect bone to separate and when you do not.
32 [5]
When you expect bone to separate, the bandaging on all such cases must be done in the manner of bandages, beginning for the most part from the middle of the bandage — as a subligature is applied from two ends — and one must calibrate the bandaging according to the shape of the wound, so that it will be drawn as little as possible and forced out of position by the bandaging; for with some cases it is natural to bandage to the right, with others to the left, with others from two ends. Those bones which it proved impossible to reduce — these must be known to be destined to separate; likewise all that have been entirely stripped of flesh. In some cases the upper part is stripped, in others the flesh dies around the bone on all sides. In some cases the bones have been rotting since the original wound, in others not; some more, some less; some in small areas, some in large.
33 [25]
For these reasons just stated, it is not possible to give a single answer as to when the bones will separate. Some separate sooner because of their small size, some because they are held only at the tip; others, because they do not separate but rather scale off, having dried out and become decayed. Besides this, the treatment also makes some difference. In general, those bones separate most quickly where both the suppuration is quickest and the growth of flesh is quickest and most favorable; for the flesh growing up beneath the damaged area generally lifts the bones upward. If the whole circumference of a bone separates within forty days, that is a good separation; for some cases reach sixty days, or more. Bones of looser texture separate more quickly; those of denser texture, more slowly; other smaller ones, much further within, and so on variously. One must saw off a projecting bone in the following circumstances: if reduction cannot be achieved and it seems that only a small piece needs to be removed and this is feasible; or if it is irritating and somewhat lacerated among the small flesh-parts, causing discomfort, and happens to be bare — in that case too it must be removed. In other cases it makes no great difference whether one saws it off or not. For one must know clearly that all bones which are completely deprived of flesh and dried out will completely separate. Those that are about to scale off should not be sawn. One must judge those that will completely separate from the established signs. These cases should be treated with compresses and the wine-based treatment, just as has been set out before for bones that are going to separate.
34 [5]
One must take care not to apply cold moisture in the early period; for there is danger of feverish chills, and danger of convulsions — for cold provokes convulsion, and moreover also wounds. One must know that the bodies necessarily become shorter in cases where both bones have been broken, displaced, and treated, and in those where the whole circumference of the bone has separated. As for those in whom the bone of the thigh or the upper arm has protruded, these patients do not generally survive.
35 [15]
For the bones are large and full of marrow, and many critical sinews, muscles, and vessels are wounded at the same time; and if you reduce them, convulsions tend to follow; while if they are not reduced, there tend to be acute fevers, bilious, with hiccup, and the patient turns dark. Those in whom the bone is not reduced and no attempt at reduction has been made survive no less; and they survive even more when it is the lower part of the bone that has protruded rather than the upper. Yet some may survive when reduction has been made, though rarely. For care makes a great difference, care against care, and the bodily constitutions differ in their capacity to bear the condition. It also makes a great difference whether the bones protrude to the inner side of the upper arm or thigh; for there are many critical stretches of vessels on the inner side, some of which, when pierced, are fatal; there are some on the outer side also, but fewer. In such wounds, then, the dangers must not be kept hidden — what kind they are — and one must speak of them in advance, at the right moments. But if you are compelled to reduce and expect to succeed, and the displacement of the bone is not great, and the muscles have not contracted (for they tend to run together), levering along with traction would serve well in these cases too. When you do reduce the bone, one must give a gentle dose of hellebore on the same day, if the reduction is on the same day; otherwise, one should not attempt it at all.
36 [15]
The wound must be treated in the same way as in cases of fractured bones of the head, and nothing cold should be applied. The patient must be completely deprived of food; and if the patient is bitter-bile-natured by constitution, the diaita — regimen (ordering of life) — should be maintained with a small amount of fragrant oxymel dripped into water; if not bitter-bile-natured, plain water as drink. If fever is continuous, one must maintain this diaita for at least fourteen days; if without fever, for seven days; then by gradual stages bring the patient back to an ordinary diaita in reasonable measure. And for those in whom the bones have not been reduced, the medication should be the same, and the care of the wounds and the diaita likewise; similarly, the suspended part of the body should not be stretched but rather drawn in, so that the part at the wound is more relaxed. The separation of the bones takes a long time, as has been said before. One must especially avoid such cases, provided one has a fair way to avoid them; for the hopes are few and the dangers many; and if one does not reduce, one would seem to lack skill, and if one does reduce, one would bring the patient closer to death than to survival. The slippings at the knee, and the displacements of the bones there, are much simpler than the movements and slippings at the elbow.
37 [20]
For the joint of the thigh is more compact relative to its size than that of the upper arm, having only a single natural mode, and that a rounded one; while the joint of the upper arm is large and has more gradations. Moreover, the bones of the lower leg are of similar length, and the outer bone projects just a little — not worth mentioning — presenting no serious obstacle; and it is from here that the outer tendon alongside the hollow of the knee has its origin. But the bones of the forearm are unequal: the shorter one is considerably thicker, while the more slender one projects and extends well beyond the joint; it is, however, also attached by sinews at the common junction of the bones. The slender bone has a larger share of the attachment of sinews in the upper arm than the thick one. Such, then, is the nature of these joints and of the bones of the elbow. And because of the nature of the structure, the bones at the knee slip often but fall back in easily, and no great inflammation attaches, nor is the joint bound up. They slip most often to the inner side, sometimes also to the outer, and sometimes into the hollow of the knee. The reductions of all these are not difficult. For those slipping outward and inward, the patient should sit on something low to the ground and hold the leg somewhat higher, though not much. Traction of moderate extent is generally sufficient, one person pulling the lower leg while another provides counter-traction on the thigh. But the problems at the elbow are more troublesome than those at the knee, harder to reduce, both because of the inflammation and because of the structure, unless someone reduces it immediately.
38 [5]
For it slips less than those cases, but is harder to reduce and harder to set, and inflammation supervenes more readily and callus forms more readily. In these cases too, most are small inclinations — now toward the rib side, now outward — with the whole joint not displaced but, while remaining in the socket of the bone of the upper arm, the projecting bone of the forearm has gone out of position.
39–40 [5]
In cases of this kind, wherever the slip occurs, it is easy to reduce, and straight traction in line with the upper arm suffices — one person pulling at the wrist, another applying counter-traction around the armpit, while another places the palm of one hand against the displaced joint and pushes, and with the other hand pushes back from close to the joint. Slippings of this kind yield quickly to reduction if one reduces them before they become inflamed. They slip most often to the inner side, but also to the outer; both are evident from the shape. And such cases often fall back in without strong traction. For those slipping inward, one must push the joint back toward its natural position and turn the forearm so as to incline more toward pronation. These are the most common slippings of the elbow. But if the joint passes over the projecting bone of the forearm and enters the socket of the upper arm — either this way or that — this happens rarely; and if it does happen, the straight traction in line is no longer equally suitable for slippings of this kind, for in such traction the projecting bone of the forearm prevents the upper arm from passing back.
41 [5]
For those dislocated in this way, traction must be applied in the manner already described for bandaging fractured bones of the upper arm: pulling upward from the armpit, and forcing the elbow itself downward; for in this way the upper arm would best be suspended above its own step-joint. If it is thus suspended, the setting is easy: pressing with the palms, one pushes the protruding part of the upper arm into place, while another pushes from below against the elbow's point as counter-pressure, inclining in line with the forearm. The same method goes for both. This traction is perhaps the most appropriate for this kind of slipping; it could also be reduced from straight traction, but less readily than this way. If the upper arm slips forward — this happens very rarely, but what sudden violent jolt would not dislocate something? For many things fall out contrary to their natural structure, even when the obstacle is great — in this dislocation there is something large being overcome, namely the step over the thicker of the bones, and there is considerable tension in the sinews; yet it has indeed dislocated in some.
42 [20]
The sign in those who have dislocated in this way: they cannot bend the elbow at all, and the joint is evident to the touch. If it is not reduced immediately, strong, violent, feverish inflammations will occur; but if someone is present right away, reduction is easy. One must insert a hard bandage — a hardened rolled bandage, not large, suffices — sideways into the bend of the elbow, then suddenly flex the elbow and bring the hand as close as possible to the shoulder. This reduction is sufficient for those dislocated in this way. Yet also straight traction can set this type of dislocation, as follows: with the palms of the hand, one person places the palm against the protruding part of the upper arm near the bend and pushes it back, while another person places the palm below against the point of the elbow and pushes it in counter-pressure in line with the forearm. In this type of slipping, the traction described earlier — as used in bandaging fractured bones of the upper arm — can also be applied; and once traction has been applied, the pressures with the palms must be made in the manner already described. If the upper arm dislocates backward — this happens rarely, and it is the most painful of all and most feverish, with continuous fevers, pure-bile fevers, deadly and short-lived — these patients cannot extend the arm.
43 [5]
If you are present immediately, you must force it by extending the elbow, and it falls back in by itself. But if fever forestalls you, you must no longer attempt reduction; for the pain would increase if the patient were compelled to move. To speak in summary: one must not reduce any other joint either when the patient is feverish — and the elbow least of all. There are also other injuries at the elbow that cause trouble: the thicker bone is sometimes displaced from the other, and they can neither flex nor extend in the normal way.
44 [5]
This becomes evident on palpation along the bend of the elbow, beside the branching of the vessel running down from the muscle above. In cases of this kind, it is no longer easy to restore the bone to its natural position; for it is not easy to seat any other displaced common junction of two bones in its original natural position, and the separation necessarily retains a bulk. How one must bandage at a joint has been stated in the section on bandaging at the ankle. There are also cases in which the bone of the forearm that lies beneath the upper arm is fractured — sometimes the cartilaginous part from which the tendon behind the upper arm has its origin; [sometimes the anterior part at the origin of the anterior coronoid process;] and when this is disturbed, the case becomes feverish and malignant; yet the joint remains in its own place, for the whole base of it projects here.
45 [10]
When the head of the upper arm is pulled away to the side where it projects, the joint becomes more unstable if it has been broken off entirely. But to speak in summary, all fractured bones are less damaging than those in which the bones are not fractured but critical vessels and sinews are bruised on all sides in these regions; for the latter come closer to death than the former, if set on fire by continuous fever — though such fractures are few. Sometimes the head of the upper arm itself is fractured at the epiphysis; this, though it seems to be far more seriously damaging, is in fact far simpler than the injuries at the elbow.
47 [20]
How each dislocation is best treated has been set out, and why it is most advantageous to reduce a joint immediately, because of the rapid inflammation of the sinews. For even if the dislocated part is reduced immediately, the sinews tend nonetheless to undergo tension and to prevent for some time both the extension that normally occurs and the flexion. It is advantageous to treat all these cases similarly — both those in which breakage occurs, those in which separation occurs, and those in which slipping occurs — for all must be treated with many bandages, compresses, and wax-dressing, just as with other fractures. The position of the elbow in all these cases must be made the same as that used when a fractured upper arm or forearm was being bandaged. For this position is the most common to all slippings, movements, and fractures; the most common also in relation to subsequent extension — extending and flexing each part fully; for from this position the paths to both are approximately equal. This position is also the most convenient and easiest for the patient himself to maintain. Furthermore, beyond all this, if the arm were fixed by the callus formation: if the hand were fixed extended, it would be better for the person if it were not there at all, for it would be much more of an obstacle and of little use; if bent, it would be more useful; but far more useful if fixed in the intermediate position. Such are the considerations regarding position. One must bandage by placing the start of the first bandage at the site of the injury — whether there is a fracture, a dislocation, or a separation — and making the first turns at this point; and the pressure should be greatest there, with less on either side.
48 [25]
The bandaging should be common to both the forearm and the upper arm, and should extend considerably further on each side than most practitioners do, so that the swelling is drawn away from the injury as much as possible on both sides. The point of the forearm should also be included in the turns, whether the injury is at that point or not, so that the swelling does not collect around it. In the bandaging one must take care as far as possible that too much of the bandage does not accumulate at the bend. The injury site must be compressed as firmly as possible. And let the same rules hold for the tightening and loosening, and the timing of each, just as has been written before in the treatment of fractured bones. The re-bandagings should be every third day; and on the third day it should seem to be loosening, just as then. Splints should also be applied around at the appropriate time — for this is not out of place for those with and without fractured bones, if there is no fever — as loose as possible, those from the upper arm arranged downward, those from the forearm relaxed upward; and the splints should not be thick. They must necessarily also be unequal to one another, and alternate with one another as may be advantageous, judging in relation to the flexion. And the application of compresses should be made in the same manner as has been stated for the splints, placing them somewhat more bulky at the site of injury. The timing should be judged from the inflammation and from what has been written before.