On Joints — First Draft Translation

ON JOINTS. I know of the shoulder joint slipping out in one way only: into the armpit. I have never seen it go upward, nor outward. I will not, however, assert strongly — though I do have something to say on the matter — whether it could slip those ways or not. 1. Nor yet have I ever seen what seemed to me to be a true forward dislocation. Physicians, it is true, think it slips forward very readily, and they are most deceived in those cases where phthisis has seized the flesh around the joint and the arm; for in such persons the head of the humerus appears to protrude forward entirely. And I, for my part, once said that no such dislocation had occurred and was spoken of contemptuously both by physicians and by laymen on account of this matter; for in their judgment I alone had failed to see it, while the others had seen aright. I could not persuade them — or only barely — that the case was as follows: if one were to strip the flesh from the shoulder-ridge of the humerus, strip it where the muscle extends upward, and strip the tendon that extends along the armpit toward the collarbone and chest, the head of the humerus would appear to jut forward strongly, even though it had not in fact been dislocated; for the head of the humerus is by nature inclined forward, while the rest of the bone of the humerus curves outward. The humerus meets the hollow of the shoulder blade obliquely when the arm is extended alongside the ribs; but when the entire hand is stretched forward, then the head of the humerus comes to lie directly opposite the hollow of the shoulder blade, and it no longer appears to protrude forward. Concerning what we are discussing, then: I have never seen a forward dislocation either. Yet I will not assert strongly about this either, whether it could occur that way or not. Now, when the humerus does slip into the armpit — since this happens to many people — many know how to reduce it; and it is a good thing to learn all the methods by which physicians perform reduction, and how one might use these very methods to best advantage. One should use the strongest method when one sees the most forceful necessity; and the strongest is the one that will be described last. In those whose shoulder slips out frequently, most are capable of reducing it themselves: they place the knuckles of the other hand into the armpit and force the joint upward, while bringing the elbow toward the chest. 2. A physician could reduce it in this same manner — if he slips his fingers inward under the armpit, on the inner side of the dislocated joint, and forces it away from the ribs, while pressing his own head against the acromion for counter-bracing, and pushing the arm against the ribs with his knees placed at the elbow along the humerus. It is advantageous for the one performing the reduction to have strong hands. Or he could do this with his hands and head in the manner described, while someone else brings the elbow alongside the chest. There is also a method of shoulder reduction by swinging the forearm backward over the spine, then with one hand bending back upward at the elbow, while with the other pressing from behind at the joint. This method of reduction, and the one previously described, being not in accordance with nature, nonetheless by rocking the joint this way and that force it to fall back in. Those who attempt reduction with the heel bring a force closer to the natural one: the patient must lie on his back on the ground, and the one performing the reduction must sit on the ground on whichever side the joint has been dislocated; then, grasping with his own hands the injured hand, he draws it taut, and thrusting the heel into the armpit, pushes against it — the right heel into the right, the left into the left. 3. One must insert into the hollow of the armpit something round and fitting; most suitable are very small, hard balls such as are sewn together from many layers of leather. For if nothing of this sort is placed in, the heel cannot reach the head of the humerus; for when the arm is drawn taut, the armpit becomes hollow — the tendons on either side of the armpit, contracting in opposition, work against it. Someone seated on the other side of the person being stretched must hold down at the sound shoulder, so that the body is not dragged across, since the injured hand is being pulled to the other side. Then, a strap of adequate width — after the ball has been placed in the armpit, with the strap wrapped around the ball and holding it — someone should sit above the head of the patient, take hold of both ends of the strap, and draw against the pull, placing his foot against the bone of the acromion. The ball should be placed as far inward as possible and as close to the ribs as possible, and not upon the head of the humerus. There is also another method of reduction, that by which the patient is lifted by the shoulders into upright position: the one lifting must be larger than the patient; grasping the arm, he places his own pointed shoulder under the armpit; then turns around, as if to sit down, calculating so as to hang the patient over his own shoulder at the armpit; he should make himself higher on that shoulder than on the other; and he should press the hanging man's arm against his own chest as quickly as possible; in this posture, when he lifts the man up, he should shake upward, so that the rest of the body counterbalances that of the arm being held; and if the man is too light, a light boy should hang from him at the back. 4. All these methods of reduction are useful in wrestling schools, since they require no additional equipment to be brought in; one could also use them elsewhere. Those who operate by leverage over a pestle also bring a force near to the natural one: the pestle should be wrapped in some soft band (for it will be less likely to slip), and forced between the ribs and the head of the humerus; and if the pestle is short, the patient should sit on something so that he can barely throw his arm over the pestle; but it is best for the pestle to be rather long, so that the man standing is nearly suspended over the beam. 5. Then the arm and forearm should be extended alongside the pestle, while someone forces the other side of the body downward, throwing his arms around the neck alongside the collarbone. This method of reduction is fairly natural and can reduce the dislocation, if it is properly rigged. There is also another method using a ladder-rung, of a similar kind and even better, because the body can be more securely counterbalanced in either direction when lifted; for when the shoulder is lodged against the pestle-like lever, there is a danger of the body rolling one way or the other; though on the ladder-rung, something round and fitting must also be bound above, into the hollow of the armpit, which will additionally force the head of the humerus to return to its natural place. 7. The strongest of all methods of reduction is the following. One needs a piece of wood about five fingers' breadth wide, or four fingers' as a general rule, about two fingers' thick or even thinner, and about two cubits long or a little less. One end should be rounded and narrowest and thinnest at that end; it should have a small rim projecting a little at the end of the rounded part, on the side facing not the ribs but the head of the humerus, so that when inserted it fits into the armpit along the ribs under the head of the humerus; the tip of the wood should be wrapped with linen or a soft band so that it may be gentler. Then one must push the head of the wood under the armpit as far inward as possible between the ribs and the head of the humerus, stretch the entire arm alongside the wood, and bind it down along the humerus, along the forearm, and along the wrist, so that it remains as still as possible; above all one must ensure that the tip of the wood is as far inward in the armpit as possible, having passed beyond the head of the humerus. Then one must fasten a crossbar securely between two upright posts, then carry the arm with the wood over the crossbar, so that the arm is on one side, the body on the other, and the crossbar is at the armpit; then press the arm down with the wood on one side over the crossbar and the rest of the body down on the other side. The crossbar should be fastened at such a height that the rest of the body is barely lifted on the tips of the toes. This method is by far the strongest for shoulder reduction; for it levers most correctly, if only the wood is on the inner side of the head of the humerus; the counterbalancing forces are most true, and safe for the bone of the humerus. Recent dislocations fall back in more quickly than one might expect, even before it seems that traction has been properly applied; and this is the only method of reduction capable of reducing old dislocations — unless flesh has already grown over the socket with time and the head of the humerus has already worn a groove for itself in the place where it has lodged; though it seems to me that even such a long-standing dislocation of the humerus could be reduced by this method (for what would a true lever not move?), yet it would not in my judgment stay in place but would slip back again as is its habit. The same effect can also be achieved by forcing the patient down over a ladder-rung, having arranged it in this fashion. It is also quite adequate to force the reduction over a large Thessalian chair, if the dislocation is recent; though the wood must be prepared as described; the patient is seated sideways on the chair, then the arm together with the wood is thrown over the back of the chair, the body forced down on one side, and the arm with the wood on the other. The same can also be done by forcing over a double door. One should always use whatever happens to be at hand. One must know that natures differ greatly from one another in the ease with which displaced parts fall back in: the socket itself may differ — one being more easily surmounted, another less so; but the greatest difference lies in the binding of the sinews, which in some has give, in others is held taut. 8. The looseness that occurs in people at their joints comes about through the sinews' attachment, when they are naturally lax and bear stretching easily; for one can see many who are so loose that whenever they wish, their joints slip out painlessly and settle back painlessly. The condition of the body also makes some difference: in those who are well-limbed and well-fleshed, dislocation occurs less often and reduction is more difficult; but when they are thinner and less fleshed than their usual selves, then dislocation occurs more readily and reduction is easier. Evidence that things stand thus is also the following: in cattle the thighs slip out of the socket most when they are thinnest; cattle are thinnest at the end of winter; that is also when they dislocate most — if indeed such a thing ought to be written in medicine, as it ought; for Homer had well observed that of all livestock oxen toil most at this season, and among oxen the plowing oxen, because they work through the winter. It is these, then, that dislocate most; for it is these that grow thinnest. Other livestock can graze on short grass; but cattle cannot easily, before the grass grows tall. In other animals the projecting lip is thin and the upper jaw narrow; in cattle the projecting lip is thick and the upper jaw also thick and blunt; on account of this they cannot push their mouths under short grass. And again, the solid-hoofed animals, having teeth on both jaws, are able to crop and can push their teeth under short grass, and they take more pleasure in grass in this condition than in tall grass; for short grass is on the whole better and firmer than tall grass, especially before the tall grass has seeded. For this reason, then, he made these verses thus: ['As when welcome spring came to the spiral-horned oxen'] — because tall grass appears most welcome to them. And further, the ox naturally has this joint looser than other animals; on account of this the ox twists its feet in walking more than other animals, and most of all when it is thin and old. For all these reasons the ox dislocates most; and more has been written about it because all these things serve as testimony to what was stated earlier. Concerning the matter at hand, then: dislocation occurs more in the lean, and reduction happens more quickly than in the well-fleshed; and there is less inflammation in the moist and lean than in the dry and well-fleshed, and the condition is less fixed for the subsequent period. Moreover, if mucoid fluid is present in excess beyond the normal without inflammation, the joint would be slippery in this way as well; for joints are on the whole more mucoid in the lean than in the well-fleshed; and indeed the flesh of the thin, in those who have not been rightly slimmed by a craft, is more mucoid than that of the fat. In those in whom mucoid fluid arises together with inflammation, the inflammation holds the joint bound; for this reason, joints with mucoid fluid that is accompanied by inflammation do not tend to dislocate, though they would dislocate — either more or less — if some degree of inflammation had not been present. 9. Those in whom, once the joint has been reduced, the surrounding parts do not become inflamed and who can use the shoulder painlessly at once, do not think they need to take care of themselves; yet it is for the physician to foresee what will happen in such cases — for in those persons dislocation recurs more readily than in those whose sinews become inflamed. This holds true for all joints alike, and especially for the shoulder and the knee; for these are the most prone to slipping. Those in whom the sinews become inflamed cannot use the shoulder; for pain and the tension of the inflammation prevent it. Such persons must be treated by applying a wax-salve, compresses, and many linen bandages; soft, clean wool rolled together should be placed in the armpit as filling for the hollow, to serve both as support for the bandaging and to hold the joint at rest; the arm should be kept inclined upward for the most part — for in this position the head of the shoulder would be furthest from the place into which it slipped. After bandaging the shoulder, the arm should also be bound against the ribs with a band wrapped around the body in a circle. The shoulder must also be rubbed gently and with ample oil. The physician must be experienced in many things, and indeed in rubbing as well; for the same name does not produce the same result: rubbing can bind a joint that is looser than the right degree, and can loosen a joint that is harder than the right degree; but we shall define the matter of rubbing in another discourse. Such a shoulder, then, it is beneficial to rub with soft hands and otherwise gently; the joint should be moved — not forcibly, but only so far as it can be moved without pain. All things settle, some in more time, some in less. One must recognize by the following signs that the humerus has been dislocated: first, since men's bodies are symmetrical, with hands and legs matching, one must use the healthy part as a guide to the unhealthy, and the unhealthy to the healthy — not looking at other people's joints (for some are naturally more prone to displacement than others) but at those of the sick person himself, if the healthy side differs from the affected side. 10. This has been correctly stated, but it has very much scope for confusion; for such reasons it is not enough to know this craft by word alone, but one must also practice by doing; for many people, because of pain or for some other reason, even when their joints are not displaced, cannot nonetheless place themselves into the same positions as a healthy body assumes. One must therefore comprehend and take note of such circumstances as well. Moreover, the head of the humerus appears to lie far more clearly in the armpit in the dislocated case than in the healthy; and above at the shoulder-ridge the region appears hollow, and the bone of the acromion appears to protrude, since the joint has slipped into the space below; yet there is some scope for confusion even here, which will be written about later — for it is worth writing about. Furthermore, in the dislocated case the elbow appears to stand farther away from the ribs than the other; and if one tries to bring it up, it can be brought up, but with difficulty. And further, to raise the arm upright alongside the ear with the elbow extended, they are not as well able to do as with the healthy arm, nor to move it to either side in the same manner. These, then, are the signs of a dislocated shoulder; and the methods of reduction are those described, along with the following treatments. The learning of how to treat shoulders that dislocate frequently deserves attention; for many have already been prevented from athletic contest by this mishap, though otherwise in all respects worthy; and many in military service have become useless and have perished on account of this mishap. And at the same time it deserves attention for this reason also: that I know of no one who treats it correctly, some not even attempting it, others thinking and doing the opposite of what is beneficial. 11. Many physicians have already burned dislocating shoulders — at the shoulder-ridge, at the front where the head of the humerus protrudes, and a little at the back of the shoulder-ridge. These cauterizations would have been correct if the humerus were slipping upward, forward, or backward; but as things stand, since it slips downward, these cauterizations promote dislocation rather than prevent it — for they shut off the head of the humerus from the open space above. The correct way to cauterize in such cases is as follows: grasping the skin at the armpit with the fingers, pull it as directly as possible in the very line along which the head of the humerus slips out; then, having drawn the skin thus, burn through it to the other side. The irons to be used for burning should not be thick, nor should they be entirely blunt-ended, but elongated — for they pass through more quickly — and one should press with the hand; one should also burn through in a single pass, so that it gets through as quickly as possible in proportion to the force; for thick irons, passing through slowly, make the sloughs of the burnings wider, and there would be a risk that the scars would grow together; this would be no worse in outcome, but more unsightly and less skillful. When you have burned through to the other side, in most cases it will be sufficient to place only these sloughs in the lower part; but if there appears to be no risk of the scars growing together, but rather a wide gap between them, one should thread a thin probe through the burnings while the skin is still held up — for one could not thread it otherwise; and after threading it, release the skin, then place another slough in the middle between the sloughs using a thin iron, and burn through until it meets the probe. How much skin one should grasp from the armpit must be judged by the following signs: in all persons there are glands beneath the armpit, larger or smaller, and in many other places of the body as well. But concerning the glands in relation to the whole body, what they are and what they indicate and what power they have in various situations, this will be written about in another discourse. The glands must not be included in what is grasped, nor anything inward of the glands — for the danger is great; they are neighbors of the most critically placed cords. As much as lies outward of the glands should be grasped as fully as possible — for it is harmless. One must also know the following: if you draw the arm strongly upward, you will not be able to grasp any skin worth mentioning from under the armpit — for it is consumed in the extension; and moreover, the cords which must on no account be wounded become exposed and taut in this position. But if you raise the arm a little, you will grasp much skin, and the cords which must be guarded will fall inward and forward of the operative field. Does it not follow, then, that in every part of the craft one must above all make it one's concern to find the correct positions for each procedure? These, then, are the matters concerning the armpit; and those seizures of skin are sufficient, if the sloughs are correctly placed. Outside the armpit there are only two places where one may place sloughs to serve the condition: one at the front between the head of the humerus and the tendon running along the armpit; and here the skin should be burned entirely through, but one should not go deeper — for a large vein is nearby, as are sinews, neither of which should be heated. 11 (50) [10] On the outer side, it is possible to place another eschar considerably higher than the tendon along the armpit, and a little lower than the head of the upper arm bone; the skin must be burned through completely, but one must not make this eschar very deep, for fire is hostile to the sinews. Throughout the entire course of treatment, one must treat the wounds without ever extending the arm forcefully upward, but only moderately, as much as is needed for the care of the wounds; for thus the wounds would cool less (it is advantageous to keep all burn injuries covered so that they heal properly); they would be less pulled open; they would bleed less; and convulsive spasm would be less likely to supervene. When the wounds have become clean and are moving toward scarring over, at that point one must keep the arm bound against the ribs at all times, both night and day. And even when the wounds have healed, one must similarly keep the arm bound to the ribs for a long time; for in this way it would most readily form a scar, and the open space through which the arm chiefly slips would be closed off. In those cases where the shoulder proves impossible to reduce, if they are still in the growing period, the bone of the upper arm does not tend to grow equally with the healthy side, but grows to some extent, yet becomes shorter than the other. And those who are called galiankonoi (weasel-armed) from birth arise from two different misfortunes: either some such dislocation befalls them while they are still in the womb, or from another misfortune about which something will be written later. Moreover, all those in whom deep and submerged suppurations develop at the head of the upper arm bone while they are still infants — all of these also become galiankonoi; and whether they are cut, or cauterized, or whether it bursts of its own accord, one must understand clearly that this is how matters stand. 12 [20] Those who are galiankonoi from birth are, however, most capable of using the hand; yet even they cannot raise the arm up beside the ear by extending the elbow, but fall far short of this compared with the healthy arm. In those who are already grown men when the shoulder dislocates and is not reduced, the top of the shoulder becomes more fleshless, and the condition of that part is thin; yet when they cease being in pain, all the tasks that must be performed by lifting the elbow away from the ribs out to the side — these they cannot perform equally; but all the tasks that must be performed by carrying the arm alongside the ribs, whether backward or forward, these they can perform; for they could draw an adze, and a saw, and they could hew with an axe, and dig, raising the elbow not very high, and all the other things that are done from such positions. In those whose acromion has been wrenched away, the avulsed bone is seen to protrude; this is the point of junction between the clavicle and the shoulder blade, for the nature of the human being at this point differs from that of other animals. 13 [25] Physicians are most often deceived in this injury — for when the avulsed bone stands up, the region of the shoulder appears sunken and hollow on account of this — so as to fear it is a dislocated shoulder. I know many physicians who are otherwise not incompetent, who have already done great harm attempting to reduce such shoulders, believing them to be dislocated, and who do not stop until they despair or are at a loss, convinced that they themselves are performing the reduction. For these cases the treatment is the same as for all such conditions: wax ointment, pads, linen bandages, and bandaging of that kind. One must, however, press down the projecting part, place most of the pads over it, press especially there, and keep the arm attached to the ribs in the upward position; for in this way the avulsed part would most nearly be brought close together. These things one must know clearly, and may state with confidence, if you wish to put it otherwise: that no harm, whether small or great, comes to the shoulder from this injury, but the region is disfigured; for this bone would not be settled back into its original seat in the same way it was by nature, but of necessity it protrudes more or less upward. No other bone returns to the same position when it has been joined to another bone and, having grown fast, is wrenched away from its original natural attachment. The acromion becomes free from pain within a few days if it is properly bandaged. A clavicle that is broken cleanly through is easier to treat; if it is broken lengthwise, it is harder to treat. 14 [55] The opposite, however, is the case from what one might expect: the one broken cleanly through one might more readily compel back into its natural position; for even if one were very careful, one could bring the upper fragment downward by suitable positions and appropriate bandaging; and if it were not perfectly settled, the projecting part of the bone at least does not become very sharp. In those whose bone is broken lengthwise, the misfortune resembles that of bones that have been wrenched away, as described above; for it does not readily settle together with itself, and the projecting tip of the bone becomes very sharp. In sum, one must know that no harm comes to the shoulder or to the rest of the body from the fracture of the clavicle, unless gangrene supervenes; and this happens rarely. Disfigurement, however, does result from the fracture of the clavicle — at first most unsightly, but then it diminishes in appearance. The clavicle heals rapidly, as do all other spongy bones, for such bones produce callus formation quickly. When the fracture is fresh, the injured persons are anxious, thinking the harm greater than it is; and the physicians are eager, supposedly, to treat it rightly; but as time passes, the injured persons — inasmuch as they are neither in pain nor prevented from walking or eating — become neglectful; and the physicians in turn, since they cannot show the parts looking fine, slip away and are not troubled by the negligence of the injured. Meanwhile, callus formation proceeds rapidly. The manner of bandaging that has been established is similar to what most use: to treat with wax ointment, pads, and soft linen bandages; and these points must be understood especially in this treatment — that one must place most of the pads over the projecting part and press hardest there with most of the bandages. There are some who have devised the refinement of binding on a heavy lead weight, to force down the projection; but perhaps not even those who simply bandage understand anything; and yet this method is not suited for a fractured clavicle, for it is not possible to force down the projection at all in any meaningful way. Others again, having observed that these bandagings are unsound and do not force down the projections in accordance with nature, do bandage them using pads and linen bandages as the others do; but having girded the person with some kind of band at his most natural girth, when they have placed the pads over the projecting parts of the fracture, heaping them up against the projections, they attach the beginning of the bandage to the girdle-band at the front, and so bandage, stretching it along the line of the clavicle, drawing it to the back; and then passing it around the girdle-band, they bring it to the front, and again to the back. Some of these do not pass the bandage around the girdle-band, but pass it around the perineum and right beside the seat, and carrying the bandage around beside the spine, they press the fracture in this way. To one who is inexperienced in hearing this, it seems to be nearly in accord with nature, but to one who uses it, it is useless; for it holds firm for no length of time, not even if one were to lie down — though it would be closest to adequate in that position; and yet even if while lying down one were to bend the leg, or were oneself bent, all the bandages would be displaced; and besides, the bandaging is troublesome: for the seat is hemmed in, and all the bandages come together in that constricted space; and those applied around the belt are not fastened so tightly that they would not be forced to slide upward, and then of necessity all the bandages would be slack. 14 (50) [5] One would seem to be doing the nearest thing to right — though not accomplishing much — if one were to pass some of the bandages around the belt, but apply the main bandaging with most of the bandages in the established way; for in this way the bandages would hold best and assist one another. Most matters have now been stated that apply to those who fracture the clavicle. One must also understand this further: that the clavicle as a rule fractures so that the bone growing from the sternum protrudes upward, while the bone growing from the acromion lies at the lower part. The reasons for this are as follows: the sternum can move neither much downward nor upward, for the play of the joint at the sternum is small — the sternum is continuous with itself and with the spine; and the clavicle especially, near the shoulder joint, is prone to movement, for it is of necessity frequently in motion on account of its junction with the acromion. Moreover, when injured, the part attached to the sternum retreats upward and does not readily yield to being forced downward; for it is naturally light, and it has more open space above than below. The shoulder, the arm, and what is attached to them hang free from the ribs and chest, and for this reason they can be raised considerably upward and lowered considerably downward; so when the clavicle is broken, the bone near the shoulder inclines downward, for it is more disposed, together with the shoulder and arm, to tilt downward rather than upward. Since, therefore, matters stand thus, those who think they can force the projecting bone downward do not understand. Rather, it is plain that the lower part must be brought up to the upper; for this part has movement, and this is the part that has departed from its natural position. It is therefore clear that there is no other way to compel it (for bandagings no more force it toward nor away), but if one were to compel the arm, while it lies alongside the ribs, as far upward as possible, so that the shoulder appears as sharp-angled as possible, it is plain that in this way it would be fitted against the bone growing from the sternum, from which it was parted. If, then, one were to use the established bandaging for the sake of rapid union, but regard everything else as of no account compared with the position described, one would both understand correctly and treat most rapidly and most effectively. Having the person lie down matters greatly; fourteen days are sufficient if one keeps still, and twenty are at most the maximum. If, however, a clavicle were fractured in the opposite way in someone — which rarely happens — so that the bone from the sternum has slipped under while the bone from the acromion protrudes and rides over the other, these cases would require no major treatment; for the shoulder and arm themselves when released would settle the bones against one another, and a simple bandaging would suffice, and the days of callus formation would be few. 16 [20] If it is not fractured in this way but slips sideways in one direction or the other, one would need to bring it back to its natural position by bringing up the shoulder together with the arm, as has been said before; and when it is settled into its original position, the rest of the treatment would be rapid. In most cases the deviations are corrected by the arm itself being forced upward. For those cases where the bone from above has slipped sideways or downward, correction would be assisted if the person lay on his back with something a little higher placed under the space between the shoulder blades, so that the chest is as arched back as possible; and if someone brings the arm up alongside the ribs stretched out straight, while the physician places the palm of one hand against the head of the upper arm and pushes it away, and with the other hand sets right the broken bones, in this way one would most readily bring it to its natural position; though as has already been said, the upper bone does not readily tend to slip under. For most patients, once bandaged, the position assists them — keeping the elbow right alongside the ribs and so forcing the shoulder upward; but for some the shoulder must be forced upward as described, and the elbow brought toward the chest, while the hand itself is held beside the acromion of the healthy shoulder. If the person is willing to lie down, one must apply a support so that the shoulder is as high as possible; if they move about, one must make a sling from a band, fashioned about the point of the elbow, and suspend it around the neck. For a joint of the elbow that has shifted or partially dislocated to the inner or outer side, while the point remains in the hollow of the upper arm bone, one must extend it straight and push the projecting part backward and to the side. 18 [5] For those cases of complete dislocation in either direction, traction in the position in which the upper arm bone is bandaged when fractured; for in this way the curve of the elbow will not obstruct. It dislocates most toward the side of the ribs. For the corrections, drawing the part away as far as possible so that the head does not touch the coronoid process, one must swing it around in an arc and bend it around, and not force it straight; at the same time pushing in opposite directions on each side and guiding it into place. Rotation of the elbow would also assist in these cases — in one kind toward the supine, in the other toward the prone. Treatment as to position: keep the hand a little higher than the elbow, the arm alongside the ribs; the recovery, placing, and carrying of the arm are comfortable in this position; and the nature of the part and its use in common tasks are preserved, provided callus does not form badly; it calluses rapidly. Treatment: linen bandages according to the established rule for joints, and bandaging over the point. Most troublesome of all to the elbow are fevers, nauseating pain, undiluted bilious discharge; and of the elbow especially the posterior part on account of numbness, the anterior second; the treatment is the same. For reductions: of the posterior dislocation, extend and pull straight — the sign being that they cannot extend; of the anterior, they cannot bend; for this one, placing something rolled up and hard, bend it suddenly around this from extension. 20 [5] A sign of separation of the bones is detectable by probing along the vein that branches along the upper arm. These heal by callus formation rapidly. From birth, the bones below the injury are shorter — most the bones nearest to the forearm, second the hand, third the fingers; the upper arm and shoulder are stronger on account of nourishment; and the other hand is even stronger on account of its use in tasks. 21 [5] Wasting of flesh: if the dislocation was to the outside, the wasting is on the inside; if otherwise, opposite to the direction of dislocation. If the elbow goes out inward or outward, traction in the position where the forearm makes an angle with the upper arm; suspend the armpit by lifting it with a band, and by placing something as a weight under the very tip of the elbow beside the joint, hang it, or force it down with the hands; and when the joint is thus elevated, guide it with the palms, as in hand procedures; bandaging in this position, and recovery, and placement. 23 For those that have gone backward, correct them suddenly by extension, using the palms; at the same time one must attend to this in the correction as in the others. If forward, wrapping around a rolled linen cloth of good bulk, bend and correct simultaneously. If it is inclined to one side, in the correction both must be done simultaneously. 24 For the practice of treatment, the position and the bandaging are common. It is also possible for all cases to coincide in resolution from traction. Of the reductions, some are accomplished by suspension, some by traction, some by rolling; and these latter by extremes of position, one way or the other, combined with speed. 26 [5] The joint of the wrist slips either inward or outward, most often inward. The signs are clear: if inward, they cannot bend the fingers; if outward, they cannot extend them. Reduction: holding the fingers over a table, some pull traction, others make counter-traction, and push the protruding part with the palm or the heel simultaneously, forward and from below against the other bone, placing a soft pad underneath; if upward, turning the hand over; if downward, with the hand supine. Treatment: linen bandages. The hand as a whole slips, either inward or outward, or to one side or the other, most often inward; and sometimes the epiphysis has been displaced; sometimes one of the bones has separated. 27 [10] For these, strong traction must be applied; push the protruding part away and push the other part against it — two directions simultaneously, backward and to the side — either with the hands on a table or with the heel. These are stubborn and unsightly, but in time grow strong enough for use. Treatment: linen bandages, together with the hand and forearm; and apply splints extending to the fingers; when placed in splints, these must be unbound more frequently than fractures, and more abundant irrigation applied. From birth, the hand becomes shorter, and the wasting of flesh is mostly opposite to the direction of the dislocation; when grown, the bones remain as they are. 29 [5] For a joint of a finger that has slipped, the signs are clear. Reduction: pulling straight, push the protruding part away, push the other in opposition; treatment: linen bandages. If it has not been reduced, it becomes encrusted with callus on the outside. Dislocated from birth or during growth, the bones below the slip shorten and the flesh wastes mostly in the direction opposite to the dislocation; when grown, the bones remain as they are. The jaw fully dislocates in only a few people; for the bone growing from the upper jaw is yoked against the bone attached below the ear, which closes off the heads of the lower jaw, being above one and below the other of these heads. 30 [45] The extremities of the lower jaw — the one not easily accommodated inward because of its length, the other being coronal and projecting above the cheekbone — and from both of these extremities sinew-like tendons grow out, from which are suspended the muscles called the temporal and the masseter muscles. They are so named, and they move, because they are suspended from there; for in eating, and in speaking, and in the other uses of the mouth, the upper jaw stays still — for it is joined to the head and is not separately articulated — while the lower jaw moves, for it is articulated separately from the upper jaw and from the head. Why this joint is the first to show itself contracted in convulsions and tetanus, and why blows to the temporal region are critical and cause stupor, will be stated in another work. Concerning why this joint does not readily dislocate, the reasons are these: and this too is a reason — that occasions of food are not commonly such as to require a person to open the mouth more than is possible; and it would dislocate from no other position than from turning the jaw to one side while opening the mouth wide. This also contributes to its dislocating: all the sinews and all the muscles that lie beside the joints, or from joints from which they are bound, whichever of these are most frequently set in motion through use, these are best able to yield to extensions, just as the best-worked leathers have the greatest degree of yielding. The joint we are speaking of, then, dislocates rarely; yet it is often caught in yawning, just as many other displacements of muscles and sinews produce the same. The signs when it has dislocated are chiefly evident from this: the lower jaw protrudes forward, and is drawn aside opposite to the side of the slip, and the coronoid process of the bone appears more prominent alongside the upper jaw, and they have difficulty bringing the lower jaws together. For these, the reduction is obvious, and it would be performed fittingly as follows: one person must hold the head of the injured, and another, grasping the lower jaw both from within and from outside with the fingers along the chin, while the person opens as moderately wide as he can, must first move the lower jaw around for some time, guiding it this way and that with the hand, and instruct the person himself to keep the jaw relaxed and to give way and yield as much as possible; then have the patient suddenly open wide, directing attention to three actions at once: for the jaw must be guided from its distortion back to the natural position, the lower jaw must be pushed backward, and following upon these the jaws must be brought together and not remain open. This is the reduction, and it cannot be accomplished from any other positions. Only brief treatment suffices: applying a wax-ointment pad, bind it with a loose bandage. It is safer to manage the patient lying on his back, with his head resting on a leather cushion as full as possible, so that it yields as little as possible; and someone must hold the head of the injured person. If both jaws dislocate, the treatment is the same. 31 [10] These patients are somewhat less able to bring the jaws together to close the mouth; for their jaws protrude forward, yet without twisting — and you would recognize the absence of twisting most clearly from the alignment of the teeth, upper and lower, in their line. For these patients it is beneficial to reduce as quickly as possible; the method of reduction has been stated above. If reduction fails, there is danger to the psyche from continuous fevers and a sluggish lethargy — for those muscles are prone to torpor, and they become altered and tensed beyond their nature; and the belly tends in such patients to pass bilious, unmixed, scanty stools; and if they vomit, the vomit is also unmixed. These patients tend to die most often around the tenth day. If the lower jaw is fractured, and the bone is not completely severed but remains continuous yet displaced, the bone must be straightened — inserting the fingers obliquely along the tongue from inside and pressing against the outside as appropriate — and if the teeth in the region of the wound are displaced and loosened, once the bone is straightened the teeth must be bound to one another, not merely two of them but more, preferably with gold wire until the bone consolidates, or if not, with linen thread; then dress with wax-salve, a few pledgets, and a few linen bandages, pressing not too firmly but loosely. 32 [15] For one must know well that bandaging with linen cloths, in a fracture of the jaw, would give small benefit if applied well, but great harm if applied badly. It is necessary to probe frequently along the tongue and to hold the fingers for a long time correcting the displaced part of the bone; best of all, if it were always possible — but it is not. If the bone is completely severed (this happens rarely), the bone must be straightened in the manner already described. 33 [5] Once you have straightened it, the teeth must be bound as previously stated; for this would greatly contribute to stillness — especially if someone ties them correctly as one should, having fastened the fastenings. But the fact is, it is not easy to describe in writing every manual operation with precision; one must also form a judgment from what is written. Then, for the strap of Carthaginian leather: if the injured person is younger, the soft inner layer suffices; if more fully grown, the full hide itself should be used. Cut to a width of about three fingers, or as may fit; smear the jaw with gum (for it adheres better this way) and glue the end of the strap with adhesive to the broken-off part of the jaw, leaving about a finger's breadth from the wound, or a little more — this on the lower part; and the strap should have a cut along the line of the chin so that it straddles the point of the chin. A second strap of the same kind, or a little wider, must be glued to the upper part of the jaw, leaving the same distance from the wound as the first left; and this strap also should be split for the passage around the ear. The straps should taper toward the junction; in the gluing, the flesh side of the leather should be against the skin, for it adheres better that way. Then, pulling on this strap too — somewhat more on the one around the chin — so that the jaw is displaced as little as possible, join the straps at the top of the head, then bind around the forehead with a linen cloth, and there should be an outer covering, as is customary, so that the bindings stay still. The patient should lie on the sound jaw, not resting on the jaw itself but on the head. The body should be reduced for ten days, then nourished again without delay; for if there is no inflammation in the first days, the jaw consolidates within twenty days — it calluses quickly, as do the other spongy bones, if gangrene does not set in. But the gangrene of all bones together is a long separate account that remains. This traction from the glued applications is gentle, easily regulated, and useful for many corrections in many situations. Those physicians who are skilled with their hands but not with their minds are this way in other wounds and in jaw fractures as well: they bandage the broken jaw in varied, fine, and poor ways. For every bandaging of the jaw thus broken tends to displace the bone-fragments further rather than lead them back toward nature. If the lower jaw is wrenched apart at the symphysis at the chin — and this is the only symphysis in the lower jaw; the upper has many, but I do not wish to lead the account astray, for about these things one must speak in other kinds of diseases — if then the symphysis at the chin separates, straightening it is within any man's ability: the part that has moved outward must be pushed inward by pressing the fingers against it, and the part inclined inward must be raised outward by pressing the fingers under it. 34 [5] In a separation, however, one must do these things while applying traction; for in this way the parts will more readily come to their natural position than if one tries to force the bones against each other by grinding them together. This is a graceful thing to know for all such memoranda. Once you have straightened it, the teeth on each side must be bound to one another as previously stated. Treatment should be with wax-salve, a few pledgets, and a few linen bandages. A brief, varied bandaging most suits this region, for it is nearly balanced — though not quite balanced — and the circuit of the linen should be made, if the right jaw has shifted, toward the right (it is considered right-sided if the right hand leads the bandaging), and if the other jaw has shifted, the bandaging must be led the other way. If someone has reduced it correctly and kept it still as one should, healing is quick and the teeth suffer no damage; if not, healing takes longer, the teeth become displaced, and they are damaged and useless. If the nose is fractured, there is more than one mode of breaking; but many other harms are done by those who delight in fine bandagings without understanding — in nose cases above all; for the nose bandaging is the most varied of all, having the most many-shaped props and the most varied diamond-shaped gaps and intervals in the skin. 35 [5] As has been said, those who pursue mindless manual dexterity are glad to encounter a broken nose so that they may apply a bandage. For a day or two the physician is pleased and the bandaged patient is content; then the bandaged person quickly becomes disgusted, for the appliance is a nuisance; and the physician considers it enough, once he has shown that he knows how to bandage a nose in varied ways. Such a bandage does everything contrary to what is needed: first, those whose nose is flattened by the fracture would clearly be more flat-nosed if pressed still more from above; second, those in whom the nose is twisted to one side or the other, whether at the cartilage or higher up, would plainly get no benefit from a bandage applied from above, and would be harmed rather than helped — for it would not align well with pledgets the displaced side of the nose, though the bandagers do not even do that. The bandaging seems to me most nearly effective if the flesh is pressed flat against the bone along the middle of the nose at its edge, or if there is a small injury at the bone — not large; for in such cases the nose acquires a callus-growth and becomes somewhat rugged. But even for these, the bandaging really does not require much fuss, if one needs to bandage at all. It suffices to stretch a waxed pledget over the bruised part, then to pass a linen cloth around it once, as though from two starting points. 36 [5] The best treatment, however, is to apply a poultice of wheat flour — the fine-sifted, washed kind — kneaded sticky and in small amount to such injuries. If the flour comes from good wheat and is cohesive, use it for all such cases; if it is not very cohesive, dissolve a little gum resin as smooth as possible in water and knead the flour with this, or mix in a very little gum in the same way. For those in whom the nose is fractured with displacement downward and toward flatness, if it is seated from the front along the cartilage, it is possible to insert some corrective device into the nostrils; if not, one must straighten all such cases by inserting the fingers into the nostrils if this is feasible; if not, by using a thick smooth instrument — not pushing it forward toward the front of the nose with the fingers, but where the nose is settled — while from outside grasping the nose on each side with the fingers, pressing together and lifting upward at the same time. 37 [5] If the fracture is entirely at the front, it is possible to insert something inside the nostrils, as has already been said — either the chaff from a half-processed grain, or something similar wrapped in a linen cloth, or better yet stitched into Carthaginian leather, shaping it to fit the area where it will lie. If the fracture is further back, nothing can be inserted inside; for if the appliance is a nuisance even at the front, how much more so further inside? The first thing, then, is to model the nose both from within and from without, without holding back, and to restore it to its original shape and correct it. For a broken nose is very readily modeled, especially on the same day, or if not, a little later; but physicians are slack and handle it too gently at first, less firmly than needed. One must lay the fingers alongside the nose on each side, as far down along the natural line of the nose as possible, press together from below, and in this way the nose is most effectively straightened together with the correction from inside. And for such tasks no physician is like another's index fingers, if one is willing both to practice and to dare; for these are most suited to the natural shape. One must lay each finger alongside, pressing the whole length of the nose, holding gently in this way — best, if possible, always, until it consolidates; if not, for as long as possible — oneself, as stated; or if not, a child or some woman, for the hands must be soft. In this way one whose nose has settled not crookedly but straight downward — balanced — would be most finely treated. I, for my part, have not seen a nose broken in this way that could not be corrected — if properly compressed before the callus formed — if someone was willing to treat it rightly. But people set a high value on not being disfigured, yet they neither know how to undergo the care nor dare to, unless they are in pain or fear death; and yet the callusing of the nose takes little time — it consolidates in ten days, if gangrene does not intervene. For those in whom the bone is broken to the side, the treatment is the same; the correction, clearly, must be made not with equal pressure on both sides, but pushing the part that is displaced toward nature, forcing from outside, probing into the nostrils, and correcting without hesitation what has inclined inward, until you have straightened it — knowing well that if you do not straighten it at once, the nose cannot avoid remaining twisted. 38 [30] Once you have brought it to its natural position, one must apply the fingers — or one finger — to the spot where it protruded, and hold it there, either oneself or someone else, until the wound consolidates; and also pushing the small finger into the nostril, one must from time to time correct what has tilted. If any inflammation arises in these cases, one must use lard; but one must keep the fingers applied equally, even while the lard is in place. If at the cartilage the break goes to the side, the tip of the nose must inevitably be twisted. For such cases one must insert into the tip of the nostril one of the correctives mentioned, or something resembling them. One would find many suitable things that have no smell and are moreover mild; I myself once inserted a piece of a sheep's lung — for this happened to be at hand — since sponges when inserted absorb moisture. Then one must glue a strip of Carthaginian leather, cut to the width of a large finger or as may fit, to the outside against the displaced nostril; then draw the strap in whatever direction is fitting — though one should pull a little more than would make the nose perfectly upright and aligned. Then (let the strap be long), bringing it down from below the ear, carry it around the head; and it is possible to glue the end of the strap at the forehead, or to wrap it still longer around the head and tie it off. This at once provides a fair correction, is easily regulated, and allows one to make the counter-balance of the nose more or less as desired. Moreover, for those in whom the nose is broken to the side, the other treatments should be applied as already described; and most cases also require a strap glued to the tip of the nose for the sake of counter-balance. For those in whom along with the fracture wounds also occur, there is no need to be disturbed by this; apply to the wounds either a pitch dressing or one of the blood-stanching preparations; for most such wounds heal readily, even if bone is likely to come away. 39 [10] The first correction must be done without hesitation, leaving nothing undone, and the corrections with the fingers afterward, using them with less force — but using them; for the nose is the most easily shaped of any part of the body. As for using the adhesive straps and the counter-balance, there is absolutely nothing preventing their use, whether there is a wound or inflammation — for they are entirely painless. If an ear is fractured, all bandagings are harmful; for one cannot apply one loosely enough, and if one presses harder, the harm is greater; since even a healthy ear, when pressed by a bandage, becomes painful, throbbing, and feverish. 40 [35] As for poultices — the heaviest are on the whole the worst; and besides, most of them are bad and tend to cause suppression, and they produce more mucous secretion and thereafter troublesome suppurations. A fractured ear needs these least of all; the closest to acceptable, if anything must be used, is the sticky flour — but even this must have no weight. Touching as little as possible is beneficial; for sometimes applying nothing is a good remedy — for the ear and for many other things. One must also guard against lying on it. The body should be reduced, especially in those in whom there is danger of the ear becoming suppurant; and it is also better to loosen the bowel; and if the patient is prone to vomiting, to vomit after purging. If suppuration does come about, one must not open it quickly; for many of what seem about to suppurate are sometimes reabsorbed, even if one applies no poultice. If forced to open it, healing is quickest if one cauterizes through; one must know clearly, however, that the ear will be shrunken and smaller than the other if cauterized through. If one does not cauterize through, one must incise the raised part — not too small an incision; the pus, however, is found through a thicker layer than one might suppose; and to speak in summary, all such mucous and mucus-producing things, being sticky, when lightly touched slip away quickly under the fingers in all directions — for this reason physicians find such things through a thicker layer than they expect. Indeed, some ganglionic swellings, those that are soft and have mucous flesh, many physicians open, expecting to find a discharge into them; the physician's judgment is thus deceived, but the condition itself suffers no harm from being opened. As for which watery or mucus-filled regions, and in what regions of the body, being opened brings death or other injury — this will be written in another account. When one has incised the ear, one must keep away from all poultices and all pledget-packing; treat with a blood-stanching preparation or something else that will cause neither weight nor pain; for if the cartilage begins to be stripped bare and develops deposits beneath, it is troublesome — and this happens because of those treatments. For all cases that have turned worse, cauterization through is the most adequate remedy. As for the vertebrae of the spine — those that are drawn into a hump by disease — in most cases these cannot be resolved, particularly those that become hunched above the point of attachment of the diaphragm. 41 [45] Some of those below can be resolved when varicose veins develop in the legs — especially when they develop in the vein behind the knee; and in those whose humps do resolve, they also develop in the groin vein; and in some cases prolonged dysentery has already resolved them. For those in whom the spine becomes humped while they are still children, before the body has completed its growth, the body does not wish to grow along the spine, but the legs and arms reach full development — these parts fall short. Those in whom the hump is above the diaphragm: their ribs do not wish to grow broad but forward, the chest becomes pointed rather than wide, they become short of breath and wheezing — for the cavities that receive and propel pneuma have less space. Moreover, they are forced to hold the neck bent back at the large vertebra so that the head does not fall forward; this too creates much narrowing for the throat on its inner side — for even in naturally straight people this bone, if it inclines inward, causes difficulty of breathing until it is pressed back. Because of such a posture these people appear more prominent in the throat than healthy people; and they are for the most part subject to hard, unripened tumor-growths in the lung; for the cause of the hump and its tension in most cases arises from such inner gatheringsȇto which the nearby sinews become party. Those in whom the hump is below the diaphragm — in some of these kidney diseases and bladder diseases arise in addition; and there are also abscesses with suppuration along the flanks and groins, long-lasting and hard to heal, but neither of these resolves the humps. Their hips become even more lacking in flesh than in those with the hump above; but the entire spine is longer in these than in those humped above; pubescence and beard growth are slower and more incomplete, and they are less fertile than those humped above. Those in whom the hump comes on when the body is already fully grown — in these the hump produces a crisis corresponding to the disease present at the time; but in time it shows something of the same signs as in younger patients, more or less — though on the whole all such things are somewhat less malignant. Many, however, have already borne the hump easily and healthily into old age — especially those in whom the body turns toward being well-fleshed and fat; though a few of even these have lived past sixty years, while most are shorter-lived. In some cases the vertebrae are also curved to the side, this way or that; almost all or most such things arise from inner twistings in the spine; and in some cases the postures in which they have grown accustomed to lying contribute along with the disease. But about these things it will be said in the account of chronic diseases of the lung; for there the most graceful prognostic signs about what is to come are to be found. Of those in whom the spine becomes humped from a fall, few of these have been mastered so as to be straightened. 42 [5] For shaking on the ladder has straightened no one yet, so far as I know; and the physicians who practice it most are those who desire to impress a large crowd — for to such people these things are marvelous, if they see someone suspended or tossed about, and whatever is like this; they always crow about these things and no longer care what came of the procedure, whether bad or good. The physicians, however, who practice such things are bunglers, those I have known; for the idea is ancient, and I myself greatly praise the first man who devised this and every other device that was thought out in accordance with nature — for it would not be beyond my expectation that, if someone prepared the apparatus well and shook well, some cases might even be straightened. I myself, however, have been ashamed to treat all cases in this manner, for this reason: that such methods belong more to tricksters. For those in whom the hump comes close to the neck, these shakings with the head downward are less likely to help — for the head and the shoulders carry little weight as they fall downward; but for such patients it is likely they would be better straightened by being shaken with the feet downward — for in that direction the downward pull is greater. 43 [25] For those in whom the hump is lower down, it is more fitting that they be shaken head-downward. If then someone wishes to perform the shaking, he would prepare correctly in the following way. The ladder must be strewn well with leather pads placed crosswise, or with fig-wood pads, fastened on securely, extending a little beyond the length of the body and on either side, more than enough to contain the person's body. Then the person must be laid on his back upon the ladder. After that, the feet are to be bound at the ankles to the ladder — not straddling — with a binding that is secure yet soft. Each knee is to be bound both below and above. The hips are also to be bound. Around the flanks and around the chest, loose bandages are to be wrapped in such a way that they do not hinder the shaking. The arms, stretched alongside the flanks, are to be secured against the body itself, and not against the ladder. When you have prepared things in this way, raise the ladder suspended from some high tower, or from the gable of a house. The place where you perform the shaking must be firm and unyielding. Those who do the hoisting must be well trained, so that they release all together, evenly, with equal weight on both sides, and suddenly — so that neither does the ladder come down to the ground tilting to one side, nor do they themselves lurch forward. Releasing from a tower or from a fixed mast fitted with a pulley-block, one could make the preparation still better, so that the tackle being slackened runs on a pulley or a windlass. It is disagreeable to speak at length about these matters; yet from these arrangements someone could best be shaken. If, however, the hump were very high up, and one absolutely had to shake, shaking feet-downward is more beneficial, as has already been said, for in that way the downward pull in that direction becomes greater. 44 [15] For the upward shaking one must brace the body by binding firmly against the ladder at the chest, and at the neck with the loosest possible bandage — just enough to keep the head itself also bound against the ladder at the forehead for the sake of straightening. The arms, stretched alongside the body, are to be bound to it and not to the ladder. The rest of the body must be unbound, except that, for the sake of straightening, various loose bandages are wrapped here and there. One must take care that these bindings do not hinder the shaking. The legs are not to be bound to the ladder, but to one another, so that they are straight along the line of the spine. These things must be done in this fashion if one absolutely must be shaken on the ladder. It is disgraceful in every craft, and not least in medicine, to provide great commotion, great spectacle, and great talk, and then help not at all. First one must know the nature of the spine — what kind of thing it is — for it would be needed in many diseases. 45 [30] On the side facing the belly, the vertebrae are flush with one another on the inner surface and are bound to one another by a mucous and sinewy ligament that grows from the cartilages all the way to the spinal marrow. Other sinewy tensions run straight through, attached on either side of them. The communions of veins and arteries — how many and what kind, and from where they set out, and what they can do in their respective situations — will be made clear in another account; likewise, with what sheaths the spinal marrow itself is wrapped, and from where these set out, and where they reach their effects, and what they share their workings with, and what they are capable of. On the other side, the vertebrae are joined to one another in hinge joints. Common tensions run alongside all of them, both on the outer parts and on the inner parts. There is a bony projection outward from every vertebra, one from each, from the larger ones and from the smaller ones alike. On these projections there are growths of cartilage, and from those a branching of sinews that is kindred to the outermost tensions. The ribs grow attached, their heads inclining more toward the inner side than the outer, and they are joined at each individual vertebra. The human ribs are the most curved of all animals, in a bow-like fashion. The space between the ribs and the bones projecting from the vertebrae is filled on each side by the muscles, which begin from the neck and extend to their attachment. The spine itself along its length is straight-with-curves: from the sacred bone up to the great vertebra beside which the attachment of the legs is joined — up to that point it is kyphotic; for the bladder, the genitals, and the loose part of the rectum are located in this region. From that point to the attachment of the diaphragm it is straight-lordotic; and this region alone has muscle attachments from the inner parts, which they call the psoas. From there to the great vertebra above the shoulder blades it is straight-kyphotic; and it appears even more so than it is, for the spine has at its middle the highest projections of the bones, and lesser ones on either side. The joint of the neck itself is lordotic. Now for those in whom kyphosis develops at the vertebrae, a large displacement having broken away from the joining — whether of one vertebra or of several — this does not occur in very many people, but in few. 46 [45] For injuries of that kind are not easy to produce. It is not easy for displacement to occur outward unless one were struck forcibly from the front through the belly (and in that case the person would perish), or unless someone falling from a height should land on the hips or the shoulders (even so he might die, though not immediately). On the other hand, from behind it is not easy for such a leap inward to occur unless some very great weight fell upon it; for each of the bones that project outward is such that it would itself be broken before making a great displacement inward, having forced apart the ligaments and the interlocking joints. The spinal marrow too would be in distress if it had to make its bend through a small space when a vertebra leaps in such a fashion. The leaping vertebra would press upon the spinal marrow, if it did not actually rupture it; and being pressed and cut off, it would produce numbness of many important and critical parts — so that the physician would not be concerned with how he must set the vertebra right, given that many other violent and serious evils are present. So it is clear that it is not possible to reduce such a case — neither by shaking on the ladder, nor by any other method — unless someone cut the person open and then, thrusting the hand into the belly, pushed outward with the hand from within; and this one can do on a corpse but scarcely on a living person. Why then do I write these things? Because some physicians believe they have treated people in whom vertebrae have fallen inward, having passed entirely beyond the joints. And yet some consider this kind of distortion the easiest from which to recover, requiring no reduction at all, but holding that such cases heal spontaneously. Many people are ignorant of this, and they benefit from that ignorance — for they persuade the bystanders of false cures. They are deceived for this reason: they think the spinal projections visible along the backbone are the vertebrae themselves, because each one feels rounded when touched — not knowing that these are the bones that grow out from the vertebrae, as has been discussed a little earlier; whereas the vertebrae themselves are far deeper within. For of all animals the human being has the narrowest body cavity, relative to his size, from back to front — and likewise in the chest region. So when one or more of these projecting bones is forcibly broken, the region becomes lower at that point than on either side, and for that reason they are deceived into thinking the vertebrae have gone inward. What further deceives them is the postures of those who are injured: if they try to bend, they are in pain, as the skin at the injured spot becomes taut; and at the same time the broken bones chafe the skin more in that position. But if they arch backward into lordosis, they are more at ease, since the skin at the wound becomes more slack and the bones chafe less. Moreover, if someone touches them, they yield into lordosis at that spot, and the region appears empty and soft to the touch. All these things that have been described further deceive the physicians. Such patients recover quickly and without harm of their own accord, for all bones of this kind that are spongy callus over quickly. 47 [55] The spine also becomes scoliotic in healthy people — in many ways, for so it is both by nature and by use; besides, it is prone to collapse under old age and from pains. The kyphoses that occur in falls most commonly arise when one lands on the hips or falls onto the shoulders. For in the kyphosis one vertebra must appear higher on the outer surface and those on either side less so; there is not one that has leaped far from the others, but each gives a little, and together the total becomes considerable. For this reason too the spinal marrow bears such distortions tolerably — because the distortion is circular in form and not angular. The apparatus for forced reduction must be constructed as follows. One may sink a strong and wide plank of wood having a lengthwise groove into the ground; or instead of the wood one may cut a lengthwise groove in a wall, a cubit or so above the floor, or to whatever height seems appropriate. Then one places crosswise something like an oak pillar, square in section, leaving from the wall just enough space for someone to pass through if needed. Over the pillar one spreads either cloaks or something else that will be soft yet will not give way greatly. The patient is to be steamed if possible, or bathed in a great deal of warm water. Then he is laid prone, stretched out, and his arms, extended naturally, are bound to his body. A soft strap — adequately wide and long — made by joining two crossing straps at the middle, must be wrapped twice around the middle of the chest as close to the armpits as possible. Then the excess of each strap is brought through the armpit and wrapped over the shoulders. Then the ends are fastened to a pestle-like piece of wood, adjusted to fit the length of the underlying plank, against which the pestle-like piece is braced for counterpressure and traction. By a similar binding tied above the knees and above the heels, the ends of the straps are to be fastened to a similar piece of wood. Another strap — broad, soft, strong, band-like, having adequate width and length — is to be bound firmly around the loins in a circle as close to the hips as possible. Then the excess of this band, together with both ends of the straps, is fastened to the piece of wood at the feet. Then traction is applied in this arrangement in both directions simultaneously — evenly balanced and in a straight line. For such traction, if properly constructed and applied, would cause no great harm — unless someone deliberately intended injury. The physician, or another person who is strong and not unskilled, must place the palm of his hand on the hump and place the other hand on top of the first and press down forcibly — understanding at the same time whether it is its nature to be pressed straight downward, or toward the head, or toward the hips. This forcing is the most harmless. And it is also harmless for someone to sit upon the hump while the patient is himself being stretched, and to jolt him after raising himself up. Indeed, stepping on it with the foot and riding on the hump, and gently jolting up and down — nothing prevents this; and someone used to the wrestling-ground would be suitably fitted for such an action. The most powerful of the forcings, however, is this: if the wall where the groove is cut, or the plank that has been sunk where it is grooved, is lower than the person's spine by what seems a fitting amount, and a linden-wood board — not thin — is set in it, or one of some other wood; and then a piece of folded cloth in many layers, or a small leather pad, is placed on the hump — for it is better to have as little as possible interposed, taking care only that the board's hardness does not cause untimely pain — and the hump is positioned as directly as possible in line with the groove in the wall, so that the board, where the spine projects most, exerts its pressure directly at that point when placed. 47 (50) [5] When it is placed, one person must press down the end of the board — whether one person is needed or two — while others stretch the body lengthwise as described earlier, some in one direction, some in the other. One may also carry out the stretching with small windlasses — either by sinking them beside the plank, or by having the frames of the small windlasses built into the plank itself — whether one wishes them to stand upright projecting a little on either side, or at the head of the plank, one on each side. These forcings are well controlled both toward greater and toward lesser intensity, and they have such strength that even if someone wished to harm rather than to heal, and brought a person into such forcings, he could do so powerfully in this way as well. For even by stretching lengthwise alone in both directions, without adding any other forcing, one could achieve adequate traction; and if not by stretching, but by the board alone used in this way, one could force adequately. Good, then, are such powers as allow one to use them in weaker or stronger degree, controlling them oneself. And indeed they force in accordance with nature: for the pressing forces what is displaced to go back into its place, while the stretchings in accordance with nature stretch what has contracted in accordance with nature. So I know no forcings more admirable than these, nor more just. For the straight alignment of the traction along the very spine below and at what is called the sacred bone has no hold at all; and above, at the neck and at the head, there is a hold, but the traction in that direction is unbecoming to look upon and, if excessive, would cause additional harm. I once attempted, having stretched the patient on his back, to place an uninflated skin beneath the hump, and then to blow air into the underlying skin with a tube from a forge. But it did not work out for me. For when I stretched the patient well, the skin was overcome and the air could not be forced in; and besides, there was ready risk of slipping, since both the hump of the person and the bulge of the filling skin were being forced into the same space. When, on the other hand, I did not stretch the patient vigorously, the skin swelled out from the air, and the person arched backward into lordosis everywhere rather than where it was beneficial. I wrote this deliberately, for these too are fine lessons — things that, when tried, proved unworkable, and the reasons why they failed. For those in whom the vertebrae become scoliotic inward from a fall, or from the impact of some heavy weight, no single vertebra generally displaces greatly far from the others; but if one or more does displace greatly, they bring death. And as has been said before, this deviation too is circular and not angular. 48 [5] In these cases urine and stool are more suppressed than in those with outward kyphosis, the feet and the whole legs become colder, and these cases are more lethal than those. Even if they survive, the urine in these cases tends to be more mucous-flowing, and they have less control of the legs and more numbness. If the lordosis occurs in the upper part, they become without control of the whole body and entirely numbed. I myself have no contrivance by which one must restore such a person to his former state — unless the shaking on the ladder or some other such treatment or traction, as described a little earlier, were capable of helping. For forcing combined with traction I have no apparatus — as the board provides it in kyphosis. For how could anyone force from the front through the belly? It is not possible. And indeed neither coughs nor sneezes have any power to assist the traction. Nor would an injection of air blown into the belly accomplish anything. And in truth the application of large cupping vessels, supposedly to draw inward the inward-tilting vertebrae, is a great error of judgment: for they push rather than draw, and those who apply them do not even recognize this. For the more and the larger the cups one applies, the more the patients arch into lordosis, as the skin is pulled upward together. I could describe other methods of shaking than those previously described, which one might think better suited to the condition; but I have no great confidence in them, and for that reason I do not write them. One must grasp all at once about these matters, as has been said in summary: that deviations toward lordosis are destructive and maiming, while those toward kyphosis are, in general, free from fatal harm, from suppression of urine, and from numbness. For the outward kyphosis does not stretch the channels running through the belly nor prevent them from flowing freely; whereas lordosis does both of these and adds to many other evils besides. Indeed, far more people lose control of their legs and arms and become numbed throughout the body and have their urine suppressed — those in whom the hump does not displace either outward or inward, but are violently shaken in the straight line of the spine — than those in whom the hump does displace; the latter suffer such things less. And in medicine one can observe many other things of this kind, where the severe cases are free from harm and resolve the entire crisis of the disease by themselves, while the milder ones are maiming and give rise to long drawn-out chronic diseases and involve the rest of the body further. 49 [5] Rib fracture is also of such a character. In those whose rib — one or more — is broken in the way it most commonly breaks, without the bones separating into the inner side and without being stripped bare, few have already gone on to develop fever; nor have many already spat blood, nor do many develop empyema, nor need plugging of wounds, nor do necroses of the bones occur; and a simple diaita (regimen) suffices. For if continuous fever does not take hold of them, bloodletting is worse for such cases than refraining from it — more painful, more fever-producing, more cough-producing; for a moderate fullness of the belly acts as a brace for the ribs, whereas depletion produces a sagging in the ribs, and the sagging produces pain. Externally too a simple bandaging suffices for such cases — applying a plaster-cloth and pads and linen cloths, pressing gently, making the bandaging even, or adding something woolly on top. A rib consolidates in twenty days, for the callousing of such bones is rapid. When, however, the flesh around the ribs has been bruised — whether by a blow, by a fall, by impact, or by some other such cause — many have already spat a great deal of blood. For the channels that run along the soft underside of each rib, and the tensions, have their origins from the most critical parts of the body. Many, therefore, have already become cough-ridden, have developed phthisis, empyema, need for plugging, and the rib has undergone necrosis in their cases. 50 [45] But as for those to whom none of such things happened additionally — though their flesh around the ribs was bruised — they nonetheless cease from pain more slowly than those in whom a rib has been broken; and the site in such injuries is more prone to recurrences of pain than in the other cases. Most people neglect such injuries more readily than they would neglect a broken rib; yet such persons need more rigorous treatment. For it is beneficial to keep the diaita contracted, to keep the body as still as possible, to abstain from sexual intercourse, from fatty foods, from rough and harsh foods, and from all strong foods; to have a vein cut at the elbow; to keep silence as much as possible; to bind the bruised site with compresses that are not many-layered but numerous and much broader in every direction than the bruise; to anoint underneath with wax-salve; to bandage with broad linen cloths together with broad, soft bandage-strips, pressing with moderate firmness, so that the person bandaged cannot say he is being squeezed very hard, nor yet that it is slack. The person applying the bandage should begin at the bruise and press there most firmly; and the bandaging should be done as if one bandages from two starting-points, so that the skin around the ribs does not tilt to one side but is evenly balanced; and one should bandage either every day or every other day. It is better also to soften the belly gently with something mild, so far as evacuation of food is concerned; and for some ten days to make the body lean, then to build it up again and soften it. With the bandaging, while you are making lean, use it with more pressure; but when you are bringing the body to softness, use it more loosely. And if blood is spat up at the outset, the care and the bandaging must be maintained for forty days; if blood is not spat, twenty days of care is sufficient in most cases. The durations must be judged beforehand according to the severity of the injury. As for those who neglect such bruisings — even if nothing else worse happens to them — still the bruised site has flesh that is more mucoid than it had before. Wherever something of that sort is left behind and is not well resolved in the healing, it is worse if the mucoid matter is left behind next to the bone itself; for the flesh no longer adheres to the bone in the same way, the bone becomes more diseased, and in many persons prolonged gangrenous decay of the bone has already arisen from such causes. But even if it is not next to the bone but the flesh itself is mucoid, still recurrences occur and pains arise from time to time, if the body happens to be put under strain; and for this reason one should use the bandaging — good at once, and continued for a long time — until the extravasated fluid (ἐκχύμωμα) produced in the bruise has been dried up and reabsorbed, the site has been built up with healthy flesh, and the flesh has come into contact with the bone. For those who, having been neglected, reach a chronic state, and the site becomes painful and the flesh is somewhat mucoid, burning is the best treatment. 50 (50) [5] If the flesh itself is mucoid, one must burn down to the bone, but without thoroughly heating the bone through. If the mucoid matter is between the ribs, one should not burn on the surface alone even in that case, but take care not to burn through to the other side. If the bruise seems to be against the bone, and is still fresh, and the bone has not yet undergone gangrenous decay, and if it is quite small, one should burn in the manner described; if however the swelling along the bone is oblong, more eschars must be applied. Concerning gangrenous decay of a rib, it will be discussed along with the treatment of packed-wound cases. If the joint of the thigh is dislocated from the hip, it dislocates in four ways: most often inward, next most often outward; it does also dislocate backward and forward, but rarely. In those where the head has gone inward, the leg appears longer when compared alongside the other, for two plausible reasons: the head of the femur comes to rest upon the bone that grows from the ischium and runs upward toward the pubis, and the neck of the joint rides upon the rim of the socket. 51 [15] From the outside the buttock appears hollow, since the head of the femur has tilted inward; and the lower end of the femur at the knee is forced to tilt outward, and the shin and the foot likewise. Since the foot tilts outward, physicians from inexperience hold the sound foot toward this one, instead of this one toward the sound foot; for this reason the injured leg appears much longer than the sound one; and in many other respects such cases have subtleties that escape notice. Moreover, they cannot flex at the groin in the same way as the sound leg. And the head of the femur, when pressed on in the perineum region, is clearly prominent to palpation. These then are the signs in cases where the femur has been dislocated inward. In those where the dislocated joint has not been reduced but has been given up on and neglected, the gait involves swinging the leg around as cattle do, and most of their support is on the sound leg. 52 [45] They are forced to be hollow and curved at the flank and at the dislocated joint; on the sound side the buttock is forced to be rounded outward; for if one were to step outward with the foot of the sound leg, one would push the rest of the body toward the injured leg to carry the weight, but the injured leg would not be able to bear it — how could it? — and so one is forced to step inward rather than outward with the foot of the sound leg; for in this way the sound leg best bears its own portion of the body and the portion belonging to the injured leg. Being hollowed at the flank and at the joints, they appear small and are forced to lean sideways on a staff on the side of the sound leg; for they need counterpressure there, since that is the direction toward which the buttocks lean and where the body's weight is carried. They are also forced to stoop forward; for they are forced to brace the hand on the side of the injured leg against the thigh laterally, since the injured leg cannot bear the body's weight during the transfer of steps unless it is held pressed down to the ground. In these postures, then, they are forced to be arranged — not from the person's own deliberation about which posture is easiest, but the misfortune itself teaches them from the circumstances to choose what is easiest. For indeed all those who have a wound in the foot or shin and cannot step firmly on the leg — even infants — walk in this way: they step outward with the injured leg, and they gain two advantages, since two things are needful for them: the body's weight on the outward-stepping foot is not borne as heavily as on the inward-stepping foot, because the weight does not fall straight down upon it; but much more so when the foot is placed beneath, for then the weight falls straight — both in the walking itself and in the transfer of steps. In this posture one can most quickly bring the sound leg forward, if one steps outward with the injured leg and inward with the sound one. The point being made is that the body itself finds for itself the easiest of postures. For those who have not yet reached full growth when the joint dislocates and fails to be reduced, the thigh, shin, and foot are crippled; for the bones do not grow in length equally, but become shorter — the femur most of all — and the whole leg becomes fleshless, muscleless, womanish (ἐκτεθηλυσμένον: softened and wasted through disuse), and thinner, partly because of the loss of the joint's proper place, and partly because it is impossible to use it since it does not lie in its natural position. For some use (χρῆσις) protects against excessive womanishness, and it also protects somewhat against failure to grow in length. The worst harm occurs in those for whom this joint dislocates while they are still in the womb; second, in those who are the youngest infants; least of all in those fully grown. For those fully grown, the manner of walking has been described. For those in whom this misfortune occurs while they are infants, most give up on correcting the body's posture and crawl badly toward the sound leg, pressing the hand of the sound-leg side to the ground; and some give up on upright walking — even those in whom the misfortune occurs after they are fully grown. 52 (50) [5] But those infants who, having this misfortune, are correctly guided, use the sound leg upright and carry a staff under the armpit on the sound-leg side, and some carry it under both arms; they hold the injured leg suspended, and are the more comfortable in proportion as their injured leg is shorter; the sound leg is no less strong for them than if both were sound. In all such cases the flesh of the leg becomes womanish, though the flesh on the outer side becomes somewhat more womanish than that on the inner side, for the most part. Some tell the story that the Amazons immediately dislocate the joints of their own male offspring while still infants — some at the knees, some at the hips — ostensibly so that they become lame and the male sex may not conspire against the female; and they then make use of these males as craftsmen in all work of leather or bronze or any other sedentary craft. 53 [45] Whether this is true I do not know; but that such things could happen, I know, if one were to dislocate joints while they are still infants. The difference is greater, in the case of the hips, between dislocation inward and dislocation outward; in the case of the knees there is some difference, but less. The manner of lameness is different in each case: those in whom the dislocation is outward become more kyllo-configured (κυλλοί: a foot-deformity turning inward); those in whom it is inward are less able to stand upright. Similarly, if the dislocation is at the ankle: if outward, they become kyllo-configured but are able to stand; if inward, they become blaisos-configured (βλαισοί: a deformity with outward splaying) and are less able to stand. The co-growth of the bones proceeds as follows: those in whom the shin-bone at the ankle is displaced — in these, the bones of the foot grow along the least, since they are nearest to the injury; the shin bones do grow, but somewhat less than the sound side; the flesh, however, wastes. In those where the joint remains in its natural position at the ankle but is displaced at the knee, the shin-bone is not inclined to grow along equally, but becomes the shortest, since it is nearest to the injury; the bones of the foot waste somewhat, but not equally, as was said a little earlier, because the joint near the foot is intact; if they could use it as the kyllo-configured person does, the bones of the foot would waste even less in these persons. In those in whom the dislocation is at the hip, the femur bone is not inclined to grow along equally — since it is nearest to the injury — but becomes shorter than the sound one; the shin bones, however, do not fail to grow proportionally in these cases, nor do the foot bones, for this reason: that the joint of the femur near the shin remains in its own natural condition, and likewise that of the shin near the foot; the flesh, however, wastes in the whole leg in these persons; if they could use the leg, the bones would still grow more together, as has been said before, except for the femur, and they would be less fleshless — though much more fleshless than if it were sound. Evidence that this is so: those who, when the upper arm has dislocated, have become galiankonoi (γαλιάγκωνες: those with a withered arm, literally 'weasel-elbowed') from birth, or during growth before reaching full development — these have the bone of the upper arm short, but the forearm and the wrist somewhat less deficient than the sound side, for the reasons stated: that the upper arm is nearest of all to the joint of the injury, so that it has for that reason become shorter; while the forearm in its turn does not equally respond to the misfortune, because the joint of the upper arm near the forearm remains in its original natural state, and the wrist is still further removed from the misfortune than the forearm. For these stated reasons, those of the bones that do not grow together do not grow together, and those that do grow together do grow together. For the good fleshing of the hand and arm, the hard use of the hand greatly helps; for most manual tasks the galiankonoi eagerly perform with that hand, as much as they can with the other, no less than with the uninjured one; for the body does not need to be borne upon the hands as upon the legs, but the tasks done with them are light. 53 (50) [5] On account of the use, the flesh along the hand and forearm does not waste in the galiankonoi, but the upper arm too gains something in good flesh for these reasons. But when the hip has become dislocated outward from birth or while still an infant, the flesh wastes more in that case than with the hand, because they cannot use the leg. One piece of evidence will come also in what is said a little later, that these things are so. In those in whom the head of the femur goes outward, the leg appears shorter when stretched alongside the other — naturally; for the head of the femur does not rest upon a bone, as it does when it has gone inward, but has its natural shape tilted beside a bone and is supported in soft, yielding flesh; for this reason it appears shorter. 54 [5] On the inner side the thigh beside what is called the plichas appears more hollow and more fleshless; on the outer side the buttock appears somewhat more rounded, since the head of the femur has slipped outward; and the buttock also appears higher up, since the flesh there has yielded to the head of the femur; the lower end of the femur at the knee appears to tilt inward, and the shin and foot likewise; and they cannot flex as the sound leg can. These, then, are the signs of the femur dislocated outward. In those already fully grown when the joint has dislocated and not been reduced, the whole leg appears shorter; in walking they cannot reach the ground with the heel but step on the ball of the foot; they incline slightly inward with the tips of the toes. 55 [5] The injured leg can bear the body's weight in these persons much more than in those in whom the dislocation is inward, partly because the head of the femur and the neck of the joint — which by nature grows obliquely — have found support beneath a considerable part of the ischium; and partly because the foot is not forced to tilt outward but is close to the straight vertical line of the body and even tends inward. When therefore the joint has worn a track in the flesh into which it has slipped, and the flesh has become glutinous, it becomes painless in time; and when it is painless, they are able to walk without a staff if they so choose; and they are able to bear the body's weight on the injured leg. On account of this use, the flesh becomes less womanish in such persons than in those described a little before; the degree of womanishness varies, but the inner side tends to become somewhat more womanish than the outer, for the most part. However, some of these persons cannot put on a sandal because of the stiffness of the leg, while some can. In those in whom this joint dislocates while they are still in the womb, or during growth the joint has forcibly slipped out and not been reduced, or the joint is dislocated and thrown out by disease (for many such things happen, and in some of these, if the femur undergoes gangrenous decay, chronic suppurations and packed-wound cases arise, and in some persons exposure of bones occurs) — alike for those in whom gangrenous decay occurs and those in whom it does not, the femur bone becomes much shorter and is not inclined to grow together as the sound one; the shin bones do become shorter than the other side, but only slightly, for the same reasons stated before. Such persons are able to walk, some of them in the manner of those in whom the dislocation occurred after full growth and was not reduced, and others with the whole foot on the ground but swaying in their gait, forced to do so by the shortness of the leg. These outcomes come about if they have been carefully and correctly guided in the postures in which they should be before becoming firm in walking, and carefully and correctly guided once they have become firm. Those require the most careful attention in whom this misfortune occurs when they are youngest infants; for if they are neglected while still infants, the whole leg becomes completely useless and fails to grow. The flesh of the whole leg wastes more than that of the sound leg; yet it wastes much less in these persons than in those in whom the dislocation is inward, because of the use and the exertion — that is, being able straightway to use the leg, as was said a little before concerning the galiankonoi. There are some whose joints in both legs have gone outward — in some from birth straightway, in others through disease; in these the bones undergo the same conditions; the flesh however becomes least womanish in such persons, and the legs become well-fleshed except perhaps for a slight deficiency on the inner side; the reason they are well-fleshed is that both legs are used equally; for they sway equally from side to side in walking; and these persons appear very conspicuously prominent in the buttocks because of the displacement of the joints. 56 [5] But if the bones do not undergo gangrenous decay in them, and they do not become hump-backed above the hips (for some are overtaken by such things as well), if then none of that happens, they get along sufficiently healthy in other respects; they do however become less developed in body overall, except for the head. As for those in whom the head of the femur is dislocated backward — and this happens rarely — these cannot extend the leg either at the dislocated joint or very much at the hollow of the knee; but of all dislocations, these extend the least both the joint at the groin and the joint at the hollow of the knee. 57 [5] One must further understand this as well (for it is useful and of great worth, and most people fail to notice it): that even healthy persons cannot fully extend the joint at the back of the knee unless they also extend together the joint at the groin — except if they raise the foot quite high, in which case they could do it. Nor again can they bend the joint at the back of the knee equally well without also bending the joint at the groin; it is much harder. Many other parts of the body share such kindred connections — in the tensing of sinews, in the postures of muscles (and there are very many such things worth knowing, more than anyone would suppose), and in the nature of the intestine, and the whole belly, and in the wanderings and tensings of the womb. But about these matters there will be an account elsewhere, akin to what is being said now. Regarding the subject under discussion: they cannot extend the leg, as has already been said; and the leg appears shorter for two reasons — both because it is not extended, and because it has slipped toward the flesh of the buttock. For the structure of the hip-bone is such, on the side where the head and neck of the femur are situated, that when dislocation occurs, it naturally slopes downward over the outer part of the buttock. They can bend it, however, whenever pain does not prevent them; and the lower leg and foot appear fairly straight, not tilted much one way or the other. At the groin, the flesh seems somewhat hollow, even to the touch, since the joint has slipped to the other side; but at the buttock itself, when felt with the hand, the head of the femur seems to protrude more. These then are the signs in one whose femur has dislocated posteriorly. For one who is already fully grown when it dislocates and it is not reduced: he is able to walk, once time has passed and the pain has stopped and the joint has grown accustomed to pivoting within the flesh; but walking forces him to bend strongly at the groin, for two reasons — first, because the leg is much shorter for the reasons stated, and the heel falls far short of touching the ground; he barely reaches it with the ball of the foot, and even that only if he himself bends at the groin and simultaneously bends the other leg at the back of the knee. 58 [45] Beyond this he is forced to press with the hand on the side of the damaged leg against the upper part of the thigh at each step; and this very action itself also compels him to bend at the groin. For in the shifting of legs during walking, the body cannot be supported on the damaged leg unless the damaged limb is pushed down against the ground by the hand, since the joint does not stand beneath the body but has shifted outward and backward at the hip. For if he were to try to bear weight on the foot even briefly with no other support, he would fall backward — the tendency being strong, since the hips project far backward over the base of the foot and the spine inclines toward the hips. Such persons can walk without a staff if they have otherwise grown accustomed to it, because the base of the foot maintains its natural straight alignment and is not tilted outward, which is why they have no need for a counter-pole. Those who prefer to use a staff under the armpit on the side of the damaged leg, instead of gripping the thigh: if they use a longer staff they will walk more upright but will not press the foot to the ground; if on the other hand they wish to press the foot down, they must carry a shorter staff and must bend at the groin. The wasting of flesh in these cases proceeds according to the same principle as stated before: in those who keep the leg raised and put it to no exertion, the wasting is greatest; in those who make the most use of treading on it, the wasting is least. The healthy leg, however, is not helped — rather it grows more misshapen — if they use the damaged leg on the ground; for in assisting that leg it is forced to thrust the hip out and to bend at the back of the knee. But if one does not put the damaged leg to the ground but keeps it raised and uses a staff for support, then the healthy leg grows strong; for it is exercised in its natural state and the exertions strengthen it. Someone might say that such matters lie outside the art of healing — for what need is there to study further what has already become irremediable? But this view falls far short of the truth; for it belongs to the same understanding to comprehend these things too, since they cannot be separated from one another. For with what can be remedied, one must contrive that it does not become irremediable, understanding where it is most needful to prevent it from reaching that state; with what is irremediable, one must understand it so as not to cause harm by futile intervention; and prognoses that are brilliant and agonistic come from discerning how each case stands, and in what manner, and when it will reach its conclusion, whether it turns toward the remediable or the irremediable. 58 (50) [5] For those in whom the joint slips backward in this way from birth, or in the course of growing, whether by violence or by disease — and many such dislocations occur in the course of diseases; what sorts of diseases these are, in which such things dislocate, will be written later — if it slips out and is not reduced: the bone of the femur becomes short, and the whole leg is damaged, growing less developed and much more lacking in flesh, because the person makes no use of it. The joint at the back of the knee is also damaged in these cases, for the sinews become tense for the reasons stated before; which is why those whose hip has dislocated in this way cannot extend the joint at the back of the knee. To state the matter in summary: everything in the body that has come about for use, if used moderately and exercised in the exertions to which each part is accustomed, becomes healthy, growing, and aging well; but if not used and left idle, it becomes more diseased, undeveloped, and ages quickly. Among these parts, joints and sinews suffer this not least if one does not use them. In this mode of dislocation they are damaged somewhat more than in the others, for these reasons: the whole leg becomes undeveloped, both in terms of bone growth and flesh. Such persons, when they have grown to adulthood, keep the leg raised and bent, supported on the other leg, steadied by a staff — some by one, some by two. In those whose femoral head dislocates anteriorly — and this happens in few cases — they can fully extend the leg, but are least able to bend at the groin; and they suffer pain if forced to bend at the back of the knee as well. 59 [5] The length of the leg appears much the same, at the heel especially; but the tip of the foot tends somewhat less to project forward. The whole leg maintains its natural straight alignment and inclines neither one way nor the other. These persons suffer pain at once most acutely, and retention of urine occurs in their case at first more than in other dislocations, since the head of the femur is lodged in these cases closest to the critical sinews. At the groin the region appears swollen and under tension; at the buttock it appears more wrinkled and lacking in flesh. These then are the signs described, in one whose femur has dislocated in this way. For those who are already grown when this joint dislocates and it is not reduced: once their pain has ceased and the joint has grown accustomed to pivoting in the place where it dislocated, they can walk nearly upright without a staff, and quite erect indeed, but on the damaged side, since they are unable to bend either at the groin or at the back of the knee; and on account of the inflexibility at the groin they use the whole leg in a straighter manner when walking than when they were healthy. 60 [10] And sometimes they drag the foot along the ground, since they do not easily bend the joints above and since they plant the whole foot; for these persons tread no less on the heel than on the forepart. If they were able to take great strides, they would be very much heel-treaders, since even healthy persons, the longer the stride they take in walking, the more they tread on the heel when placing the foot and lifting the other. Those in whom the dislocation is of this kind scrape along even more with the heel than with the forepart; for the front of the foot, when the other leg is extended, cannot curve forward in the same way as when the leg is bent; nor can the foot arch upward when the leg is bent as it can when the leg is extended. Healthy nature is thus freely mobile in these respects, as described; but when the joint dislocates and is not reduced, they are constrained to walk as described — with the leg rigid and straight — for the reasons stated. The leg becomes more lacking in flesh than the other, at the buttock, at the calf, and at the back of the thigh. In those in whom the joint slips in this way while they are still infants and is not reduced, or in whom this condition is present from birth, in these too the bone of the femur wastes more than the bones of the lower leg and foot; yet in this mode of dislocation the femur is wasted least. The flesh wastes throughout, but most at the back of the thigh, as has already been said before. Those who are reared rightly are able to make use of the leg as they grow — the leg being somewhat shorter than the other, though they support themselves with a staff on the same side as the damaged leg; for they cannot readily use the ball of the foot without the heel, in the manner of putting weight forward as some are able to do in other cases of lameness; and the reason for this inability is the one stated a little earlier — which is why they need a staff. Those who are neglected and make no use of the leg on the ground but keep it raised: in these, the bones waste more in the course of growth than in those who use it; the flesh too wastes much more than in those who use it; and at the joints the leg becomes more rigidly fixed in its straight position in these cases than in those whose dislocation is otherwise. To state the matter in summary: joints that dislocate and slip do not all dislocate and slip to the same degree — sometimes much more, sometimes much less; and in those where the slip or dislocation is much greater, it is generally harder to reduce, and if not reduced, the resulting disablements and damages are greater and more conspicuous — to bones, flesh, and form; when the dislocation and slip is lesser, these are easier to reduce than the others, and if reduction is missed or neglected, the disablements are smaller and less harmful than in those just described. 61 [20] Other joints differ very greatly in whether the slip is lesser or greater; but the heads of the femur and the upper arm slip in a way that is most uniform with itself in each case. For since the heads are round and have a simple, smooth roundness, and the sockets that receive them are circular and fit the heads, for this reason it is not possible for them to slip out only halfway; they would slip, because of their roundness, either fully outward or fully inward. In the case under discussion, then, they fully dislocate — since there is no other way they can dislocate — and yet even these sometimes spring further from their natural position, sometimes less; and the femur suffers this somewhat more than the upper arm. For some dislocations that are congenital, if the slip is small, they can be brought back to the natural state — especially the joints near the foot. 62 [45] Those who are born club-footed: most of these cases are treatable, provided the deviation is not very great, or it happens that the children are already considerably grown. The best course is to treat such cases as quickly as possible, before there is very great deficiency in the bones of the foot, and before there is very great deficiency in the flesh of the lower leg. The form of club-foot is not one but several; in most cases the joints are not completely dislocated but the foot is twisted into a fixed abnormal position through habitual posture. In treatment one must attend to the following: push and straighten the outer bone of the lower leg at the ankle inward; push the back of the heel outward, so that the bones projecting in the middle and at the side of the foot meet one another; then turn the toes all together, with the great toe, inward and so force them around. Bind with a resin-wax dressing, with pads and soft bandages, not too few and not pressing too hard; make the turns of the bandaging in the same direction as the correction of the foot by the hands, so that the foot appears to lean somewhat more toward the outward-turned position. A sole-piece should be made, either of not-too-hard leather or of lead, and applied as a supplementary binding — not placed against the skin, but when you are about to apply the final layers of bandage. When the bandaging is complete, the beginning of one of the bandages with which it is bound must be stitched to the lower foot bandages at the level of the little toe; then, drawing it upward to what seems a moderate degree, wrap it around above the calf, so that it holds, arranged in this way. To put it simply: as in modeling wax, one must bring back toward its proper natural form both what has been deflected and what has been drawn up contrary to nature, correcting it with the hands in this way and likewise with the bandaging — approaching it not forcibly but gently; and stitch the bandages as is useful for achieving the corrections needed, for different types of lameness require different corrections. A little sandal should be made of lead, bound on the outside of the bandaging, shaped like what the Chian boots had; but there is no need of this if one has correctly corrected with the hands, correctly applied the bandages, and correctly performed the corrections. This then is the treatment, and there is no need of cutting, burning, or any other elaborate procedure; for such cases respond to treatment more quickly than one would think. One must persist over time, however, until the body grows in the right positions. When the matter has reached the stage of footwear, the most suitable boots are those called mud-treaders; for of all footwear these are least controlled by the foot — rather they control it. The Cretan style of footwear is also suitable. In those in whom the bones of the lower leg, having dislocated, have made a wound and protrude entirely beside the joints near the foot, whether tilted inward or outward: do not reduce these, but let any physician who wishes attempt the reduction. 63 [35] For one must clearly understand that a person will die if the bones are reduced and remain in place, and life will be of short days for these persons; few of them would survive seven days, for convulsion is what kills; and moreover gangrene tends to seize the lower leg and foot. These things must be known with certainty to be what will happen. Nor does it seem to me that hellebore would help, even given on the same day and taken again thereafter — and that is the nearest thing to anything of that sort, though I do not think even that would work. If, however, the bones are not reduced, and no one attempts reduction from the beginning, most of them survive. The lower leg and foot must be positioned as the patient himself wishes, only they must not be hanging free or moved about; treat with a pitch plaster and pads soaked in wine, few of them, not too cold — for cold in such cases invites convulsion. Suitable also are leaves of beet, or coltsfoot, or some other such plant, applied half-boiled in dark astringent wine as treatment over the wound and its surroundings; smear the wound itself with a warm wax dressing. If the season is wintry, also moisten over the top with raw wool sprinkled with warm wine and oil. Bind nothing tight, apply no plaster; for one must know well that compression and the burden of heavy applications is entirely harmful in such cases. Certain of the blood-stanching preparations are also suitable for such conditions — those among them that are beneficial; apply wool soaked in wine and leave it a long time. The shortest-lasting of the blood-stanching preparations, and those fixed with resin, are not equally suitable for these — for the cleansing of such wounds takes a long time, and they remain wet for a long time; some of these it is good to bind. One must certainly know clearly that the person must unavoidably become shamefully lame; for the foot is drawn upward in such cases, and the slipped-out bones are seen protruding externally. For the most part none of the bones in such cases are stripped bare — only to a slight extent — nor do they fall away; rather they are enclosed by thin, weak scar tissue, and this only if the patient remains still for a long time. If not, the danger is that an unhealable small wound will be left behind. Nevertheless, regarding the matter under discussion, those treated in this way survive; but if the joint is reduced and stays in, they die. The same account applies here if the bones of the forearm at the wrist, having made a wound, protrude — whether on the inner or outer side of the hand. 64 [10] For one must know clearly that the person will die within a few days, in the kind of death already described, if the bones are reduced and remain in place. In those where reduction is not attempted, many more survive; the treatment suitable for such cases is as described. The misshapen form of the lameness is bound to be ugly, and the fingers of the hand weak and useless; for if the bones have slipped inward, they cannot bend the fingers; if outward, they cannot extend them. In those in whom a bone of the lower leg, having made a wound beside the knee, protrudes — whether to the outside or the inside — if one reduces it, death is even readier than in the other cases, though even in those death was ready. 65 [5] If you treat without reducing, there is hope of survival only in this way. These cases are more dangerous than the others in proportion as they are higher up and the more powerful the part, and the more powerful the part from which the slip has occurred. If the bone of the femur near the knee, having made a wound, slips out: if reduced and remaining in place, it will bring death more violently and more quickly than the cases described before; if not reduced, it is much more dangerous than those; yet this is the only hope of survival. The same account holds for the joints at the elbow and for those of the forearm and upper arm; for of these, whatever dislocates and protrudes having made a wound, all bring death if reduced; if not reduced, there is hope of survival; and lameness readily follows for those who survive. 66 [5] For those in whom reduction is attempted, the higher the joint the more fatal; and even for those not reduced, these same higher ones are more dangerous. If in any person the uppermost joints dislocate, make a wound, and protrude: these, if reduced, would be most swiftly fatal, and if not reduced most dangerous; the treatment has already been described, such as seems to me most suitable for these cases. In those in whom joints of the fingers — of foot or hand — have dislocated, made a wound, and protruded, the bone not being broken but having been pulled apart at the junction itself: in these, if the bones are reduced and remain, there is some danger of convulsion unless they are treated well; yet it is worth attempting reduction, having first said that it requires great vigilance and care. 67 To reduce with the small lever is easiest, most powerful, and most skillful, just as was also said earlier regarding bones that are fractured and protruding. After reduction, the patient must keep as still as possible, lie down, and eat little. It is also better to purge upward with some mild purgative. The wound should be treated either with blood-stanching wet dressings, or with many-eyed sponges, or with those things used to treat fractured bones of the skull; and apply nothing whatsoever that is very cold. The joints of the digits are least dangerous; those still higher up are more dangerous. Reduction must be done on the same day or the next; on the third or fourth day, least of all — for when cases are on the fourth day, they most tend to show adverse turns. For those in whom it is not possible to reduce immediately, one must let those days already mentioned pass; for if you reduce within ten days, convulsion must be reckoned with. And if convulsion comes on after reduction, the joint must be quickly dislocated again, and the part bathed with warm water as often as possible, and the whole body kept warm, well-oiled, and soft, especially at the joints; and the whole body should be kept bent rather than extended. One must expect, moreover, that reduced joints in fingers will tend to suppurate; for most cases go this way, if any degree of inflammation arises beneath — so much so that, if the physician were not going to incur blame on account of the ignorance of ordinary folk, there would be absolutely no need whatsoever even to reduce at all. Such, then, is the danger of reducing bones that protrude at joints, as has been said. As for those cases where joints of the fingers are completely severed, these are for the most part without harm, unless one suffers fainting at the moment of the wound itself and is thereby injured; and a simple treatment will suffice for wounds of this kind. 68 Furthermore, those cases where bones are severed not at the joints but at some other part of the bone — these too are without harm, and heal more readily than the others. And where fractured bones of the fingers protrude but not at the joint, these too are without harm when reduced. Complete severances of bones, both at joints and elsewhere — in the foot, in the hand, in the lower leg at the ankles, in the forearm at the wrists — in most cases of severance these turn out without harm, provided fainting does not immediately overwhelm the patient, or a continuous fever come on when they are in the fourth day. Gangrene of flesh, however — occurring in bleeding wounds that have been bound tightly, and in fractures compressed more than is fitting, and in other violent bindings — causes tissues to fall away in many patients; and most of these survive. Those in whom some part of the thigh falls away, both flesh and bone, also survive; and those in whom part of the upper arm does likewise, though less so. With the forearm and lower leg fallen away, they survive still more easily. 69 In those whose ischemic constrictions and blackenings came on immediately after the bones were broken, the bodily separations happen quickly and what falls away falls away fast, since the bones have already given way beforehand. But in those whose blackenings come on while the bones are still sound, the flesh dies quickly in these cases too, while the bones separate slowly, at whatever point the boundary of the blackening and the denuding of the bone come to be. One must remove — at the joint — whatever lies below the body's level of the boundary of the blackening, when it has already died completely and is without sensation, taking care not to wound living tissue; for if the patient feels pain when being cut, and the body has not yet died at the part being cut, there is great danger of fainting from the pain; and such faintings have already destroyed many at once. I myself have seen a thighbone, denuded in this manner, separate on the eightieth day; but the lower leg of this man was removed at the knee on the twentieth day, and it seemed to me even closer — for I did not act all at once, but decided to do something on the side of greater caution. Bones of the lower leg from such blackening, situated quite at mid-shaft of the leg, separated from me on the sixtieth day, those that had been denuded of them. For treatment may differ from treatment in making the denuded bones fall away more quickly or more slowly; and one degree of compression may differ from another — both in greater or lesser strength and in making the sinews, flesh, arteries, and veins die of blackening more quickly or more slowly; since in those cases where death occurs without strong constriction, some of these do not reach as deep as bone-level but slough off more superficially; and some do not reach even sinew-level but slough off yet more superficially. For these reasons stated, it is not possible to set one fixed number of days for the time in which each of these things reaches its crisis. One should accept such treatments with confidence; for they look more frightening than they are to treat; and a gentle treatment suffices for all such cases — for they resolve themselves on their own. One must attend to the diaita — regimen and ordering of life — so that the patient remains, as far as possible, free of fever, and the body should be arranged in proper positions. Proper positions are these: neither to let the wound be elevated nor inclined downward, but rather tilted somewhat upward, at least until it has completely broken away; for during this time there is a danger of bleeding — it is for this reason that the wounds must not be placed in a downward-inclined position, but the opposite. But when a longer time has passed and the wounds have become clean, the same positions are no longer fitting; rather, a straight placement, and sometimes one inclined downward; for in time, in some of these cases, abscesses of pus form and they need bandaging-strips. One must expect that such patients will in time be distressed by dysentery; for dysentery comes on in most cases of blackening and also in hemorrhages from wounds; and it comes on for the most part after the blackenings and hemorrhage have already reached their crisis, and it sets in violently and forcefully — yet it does not last many days, nor is it fatal; for such patients do not become strongly averse to food, nor is it otherwise beneficial to keep the vessels empty. 70 A dislocation of the thigh at the hip must be reduced as follows, when it has slipped inward. This is a good, proper, and natural method of reduction, and one that has something of the athletic display in it — for whoever takes pleasure in showing off in such matters. One must suspend the person by the feet from a crossbeam with a binding that is strong yet soft and broad. The feet should be separated from each other by about four fingers' breadth, or even less. A broad and soft strap should also be bound above the kneecaps, extending up to the crossbeam. The injured leg must be stretched about two fingers' breadth more than the other. The head should be about two cubits from the ground, or a little more or less. The hands should be bound alongside the flanks with something soft, extended along the sides. All this must be arranged while the person is lying on his back, so that he hangs for as short a time as possible. When he has been suspended, a man who is well trained and not weak must pass his forearm between the thighs, then place his forearm between the perineum and the protruding head of the femur, then join his other hand to the raised one, stand upright beside the body of the suspended man, and suddenly drop into a hanging position, being suspended in the air, balancing as evenly as possible. This method of reduction provides everything that is naturally required: the body itself, being suspended, exerts traction by its own weight; and the man hanging off simultaneously forces the head of the femur to rise above the socket while levering it with the bone of his forearm and forcing it to slide back into its original natural position. The bindings must be excellently prepared, and the suspended man must be judged to be as secure as possible. As has been said before, there is a great difference among people's natural constitutions with respect to ease or difficulty of reduction — and why this difference is great has been stated earlier in the discussion on the shoulder. 71 For in some patients the thigh falls into place without any preparation — just a little traction sufficient to direct it with the hands, and a brief rocking movement; and in many patients it has fallen into place after they bent the leg at the joint, having performed a swinging movement. But the great majority do not respond to casual preparation; for this reason one must know the most powerful methods for each case in the entire art, and use whichever seems appropriate in each instance. Methods of traction have been stated in what was written earlier, so that one may use whichever is at hand. Strong counter-traction is needed — on one side of the leg, on the other side of the body; for if it is well stretched, the head of the femur will be raised above its original seat; and if it is raised in this way, it is no longer easy even to prevent it from settling into its own seat, so that any levering and corrective action already suffices. But they fall short in the traction — that is why the reduction gives more trouble. One must therefore attach the bindings not only at the foot but also above the knee, so that during traction the binding falls more on the knee joint rather than the hip joint. This is how the traction toward the foot must be arranged. And the traction in the other direction must not only be resisted by a binding around the chest and the armpits, but also by a long, double-folded, strong, smooth strap passed along the perineum, extended backward along the spine and forward along the collarbone, attached to the head of the opposite traction — so as to force in both directions with those extending here and those extending there. The strap along the perineum must not be stretched around the head of the femur but between the head and the perineum; and during traction, pressing the fist against the head of the femur, one should push it outward; and if, despite the pulling, it is still being raised upward, then by passing the hand through and joining it to the other hand, one should simultaneously pull it downward and simultaneously force it outward; and another person should gently correct the part of the femur near the knee toward the inner side. It has already been stated earlier that it is worthwhile for whoever practices in a populous city to have a square plank, about six cubits long or a little more, about two cubits in width, and of sufficient thickness — a span is enough; then it should have a groove along its length on each side, so that the device is not too high for the occasion; then short, strong uprights, strongly fitted, with a pin on each side; then it suffices to have five or six long channels cut in half of the plank (though nothing prevents having them throughout), at intervals of about four fingers from each other, themselves of three fingers' breadth in width and similarly in depth. 72 In the middle of the main plank there must also be a deeper rectangular notch of about three fingers, and into this notch, whenever it seems additionally required, a wooden peg shaped to fit the notch must be driven, rounded at the top; it is to be driven in, whenever it seems fitting, between the perineum and the head of the femur. This upright peg prevents the body from giving way toward those pulling at the feet; for sometimes the peg itself suffices in place of the counter-traction from above; and sometimes also, when the leg is stretched in both directions, this same peg, lying loose to one side or the other, can be useful for levering the head of the femur outward. It is for this reason that the channels have been cut — so that, in whichever of them fits, an inserted wooden lever may lever beside the heads of the joints, or bearing directly on the heads simultaneously with traction, whether it is useful to lever outward or inward, and whether the lever needs to be round or flat-bladed; for different joints call for different levers. This lever action combined with traction is useful for the reduction of all joints of the legs. For the case under discussion, a round lever is fitting; but for a joint that has fallen outward, a flat-bladed one will be fitting. From these mechanisms and forcings, no joint seems to me capable of being at a loss to fall into place. One might find also other methods of reducing this joint; for if the large plank has in the middle and at its sides two uprights of about a foot's height — whatever height seems fitting — one on one side, one on the other, and then a crossbar is set in the uprights like a rung of a ladder, and the sound leg is then passed through between the uprights while the injured leg rests above the rung, fitting precisely at the height and at the joint where it has been displaced — the fitting is easy; for the rung must be made somewhat higher than appropriate, and a garment folded many times, as needed, stretched beneath the body. 73 Then a separate plank of moderate width and length, extended beneath the leg up to the ankle, reaching as far as possible beyond the head of the femur, must be there; it must be bound to the leg so as to fit moderately. Then, while the leg is being stretched — whether by a pestle-shaped piece of wood or by one of these traction methods — the leg must simultaneously be forced down about the rung, together with the bound plank, toward the lower part; and someone must hold the person above the joint at the hip. For in this way, simultaneously the traction would raise the head of the femur above the socket, and the levering would push the head of the femur into its original natural position. All these forcings that have been described are strong, and all are stronger than the trouble, if one prepares them correctly and well. As has also already been said before, by far the greater number of cases in most patients are reduced with weaker tractions and simpler preparations. And if the head of the femur has slipped outward, the tractions must be made in both directions as described, or in some such manner; but the levering must be done with a flat-bladed lever simultaneously with traction, forcing from the outer side to the inner, placing the lever at the buttock itself and a little above; and someone should brace with the hands against the sound hip at the buttock, so that the body does not give way — or with some other lever of this kind, placing it underneath and pressing, taking it from the appropriate channel as a counter-hold; and the part of the displaced femur near the knee should be gently guided inward from the outside. 74 Suspension, however, will not be fitting for this mode of dislocation of the joint; for the forearm of the suspended man would push the head of the femur away from the socket. One might, however, contrive the levering with the plank stretched beneath so as to be fitting even for this mode of dislocation, attaching it from outside. But why say more? For if it is correctly and well stretched, and correctly levered, what joint so displaced could fail to fall into place? And if the femur has fallen backward, the tractions and counter-tractions must be applied in the manner described; and spreading a many-folded garment on the plank so that it is as soft as possible, the person is laid face-down and traction applied in this way; and simultaneously with the traction the plank must be pressed down in the same manner as for humped-backs, placing the plank along the line of the buttock region, and more toward the lower part rather than the upper part of the hips; and the groove cut in the wall for the plank must not be straight but inclined a little toward the feet. 75 This method of reduction is most natural for this mode of dislocation, and at the same time the most powerful. Perhaps instead of the plank a person sitting, or pressing with the hands, or stepping on, and suddenly swinging in the air simultaneously with the traction would also suffice. No other of the methods previously described is natural for this mode of dislocation. If the femur has slipped forward, the same mode of traction must be applied; but a man as strong as possible with his hands and as well trained as possible must press the palm of one hand beside the groin and, taking hold of his own hand with the other hand, simultaneously push the displaced bone downward and toward the front of the knee. 76 For this is the method of reduction most natural for this mode of dislocation. And suspension too is close to the natural method — but the person who hangs off must be experienced, so as not to lever the joint with his forearm but to perform the hanging-off around the middle of the perineum and at the sacred bone. Reduction of this joint by means of a wineskin has also gained repute; and I have already seen some who, through incompetence, were attempting to reduce even outward displacements and backward ones with a wineskin, not knowing that they were displacing it further rather than reducing it. The person who first devised the method, clearly, attempted to reduce with a wineskin in cases that had slipped inward. 77 One must know, then, how to use a wineskin if it should be needed; and one must recognize that many other things are better than a wineskin. The wineskin should be placed uninflated between the thighs, drawn as far up toward the perineum as possible; then, beginning from above the kneecaps, the thighs should be bound to one another with a bandage up to the mid-thigh; then, inserting a bronze tube into one of the openings left free, a bellows should be forced into the wineskin. The person should lie on his side, keeping the injured leg uppermost. This is the preparation. Most prepare it worse than I have described; for they do not bind the thighs for a sufficient length, but only at the knees, and they do not apply traction — which one must additionally apply. Nevertheless, some have already effected reduction this way, having hit upon an easy case. It is not very comfortable to be forced in this way; for the wineskin, as it is inflated, does not have its bulkiest part at the joint of the head that most needs to be levered, but at its own center — at roughly the middle of the thighs or even lower; and the thighs by nature are bow-shaped — fleshy and close together above, somewhat lean below — so that the natural shape of the thighs also forces the wineskin away from the most critical place. If, then, one inserts a small wineskin, its small force will be incapable of compelling the joint. If a wineskin must be used, the thighs must be bound to each other for a great length, and the wineskin must be inflated simultaneously with the traction of the body; and both legs together should also be bound in this manner of reduction at the end. One must make it one's highest concern in the whole art to make the diseased part healthy; but if it is possible to make them healthy in many ways, one must choose the least troublesome — for this is both more worthy of a good man and more skillful, for whoever does not covet the fraudulent posturing of the crowd-pleaser. 78 [40] Concerning the matter under discussion, then, the following kinds of makeshift traction of the body might be devised, so as to find what is workable from whatever is at hand. First: if soft and gentle leather straps are not available, but only iron things, weapons, or ropes, one must wrap them with bandage-strips or with torn scraps of wild-fig fiber, wrapping most thoroughly at the place where the straps will grip, and even a little beyond; then bind with the straps in this way. Second: the person must be stretched out well on a bed — whichever of those available is strongest and largest; and the feet of the bed, either those at the head-end or those at the foot-end, must be braced against the threshold, whether it is more convenient from outside or inside; alongside the other feet of the bed, a squared timber is to be inserted crosswise, running from one bedpost to the other; if the timber is thin, let it be tied to the feet of the bed; if it is thick, there is no need. Then the leading ends of the straps — both those at the head-end and those at the foot-end — must each be fastened to a lever (hyperon) or to some other similar piece of wood; and the strap must be straight in line with the body, or even a little above it, and be proportionately extended to the levers, so that, standing upright, one presses against the threshold and the other against the inserted timber; and then by bending the levers back in this way, the traction is to be made. A ladder with strong rungs, stretched under the bed, is also sufficient in place of both the threshold and the timber placed alongside, so that the levers, pressing against the fitting rungs on either side, when bent back, make the traction on the straps. The joint of the thigh is also reduced in the following way, when it has slipped inward and forward: dig the ladder into the ground, seat the person on it, then, stretching the healthy leg gently, bind it wherever it fits; and from the injured one, either pour water into a jar and hang it, or throw stones into a basket and hang that. Another method of reduction: if the joint has slipped inward, a cross-beam must be bound between two posts at a suitable height; let the cross-beam project on the one side by as much as the distance of the buttock; wrapping a garment around the person's chest, seat the person on the projecting part of the cross-beam; then draw the chest toward the post with something broad; next, have someone hold the healthy leg so that it does not slip around; and from the injured leg hang a weight of whatever amount fits, as has already been described above. First of all, then, one must know that the joints of all bones are, for the most part, a head and a socket; and in some cases the cavity is socket-shaped and elongated; some of the cavities are of a shallow-cup (glene) form. 79 [10] All dislocated joints must always be reduced, most of all immediately and straightaway while they are still warm; if not, as quickly as possible. For it is easier and quicker for the one reducing to do the reduction, and the reduction is far less painful for the patient if it is done before swelling sets in. One must always, before reducing any joint, first knead it and rock it back and forth; for it is more willing to be reduced. Alongside every reduction of joints, one must thin down the patient — most especially for the largest and most difficult joints to reduce, least for the smallest and easiest. If any joint of the fingers of the hand is dislocated — whether the first, the second, or the third — the method of reduction is the same and equal throughout; the larger joints are always more difficult to reduce, however. 80 [30] It dislocates in four ways: upward, downward, or to either side laterally; most often upward, least often to the sides, in the course of vigorous movement. On either side of the place where it has come out there is, as it were, a rim. If it has dislocated upward or downward — since this region is smoother — or to the sides, and at the same time the crossing is small, once the joint is shifted it is easy to reduce. The method of reduction is this: wrap the tip of the finger with a bandage or something similar, so that when you pull by grasping the tip it does not slip away; once you have wrapped it, have one person grip above the wrist of the hand and another grip the wrapped part; then both are to pull toward themselves as strongly as possible, and at the same time push the displaced joint back into its place. If it has dislocated to the side, the manner of traction is the same; but when it seems to you that it has crossed the line, simultaneously while pulling you must push it directly back into its place, and another person on the other side of the finger must guard and push up so that it does not slip away again from that direction. The lizard-traps woven from palm-leaves also manage reduction well enough, if you apply traction on the finger from both sides, grasping with one hand the lizard-trap and with the other the wrist. After reducing, one must bandage as quickly as possible with the finest linen strips, waxed with a cerate that is neither too soft nor too hard but moderately consistent; for the hard kind stands off from the finger, while the soft and fluid kind melts away and is lost as the finger warms. A finger joint should be unwrapped on the third or fourth day; in general, if it is inflamed, unwrap more frequently; if not, less frequently. I say this regarding all joints. A finger joint settles in fourteen days. The method of treatment is the same for fingers of the hand and of the foot. In connection with all reductions of joints, one must thin the patient down and starve him by strangulation of appetite until the seventh day; if there is inflammation, unwrap more frequently; if not, less frequently. The affected joint must always be kept at rest, positioned and lying in the finest possible posture. [Section 81 is absent from the source text; a lacuna or omission is indicated by the numbering gap.] 82 [10] The knee is more tractable than the elbow because of its compact arrangement and its natural suitability, which is why it both dislocates and falls back into place more easily; it dislocates most often inward, but also outward and backward. Methods of reduction: from a bent position — either by kicking out sharply, or by rolling up a mass of bandage, placing it in the hollow of the knee, and then suddenly releasing the body into a crouching position around this. It can also be reduced with moderate traction, like the elbow, for those that go backward; those that go to one side or the other — from a bent position or by kicking out, but also from moderate traction. The correction is common to all. If it does not go in: those with a backward dislocation cannot bend the knee, nor can the others at all; the front of the thigh and lower leg wastes; if inward, they become more knock-kneed, and the outer part wastes; if outward, they become more bow-legged, but are less lame — since they bear on the thicker bone — and the inner part wastes. Those from birth or during growth follow the reasoning stated earlier. The ankle region requires strong traction, either with the hands or with similar means, while at the same time effecting the correction; this is common to all cases. 84 Things in the foot, like those in the hand, recover fully. Those of the lower leg that share in the injury, and those that have dislocated from birth or that have been disjointed during growth, are the same as in the hand. 86 [20] Those who have leaped from a height and planted on the heel, so that the bones are separated, the veins are suffused with extravasated blood, and the sinews are swollen on both sides — when the serious consequences occur — there is a danger that, if sphacelism takes hold, it causes trouble for life; for the bones are porous, and the sinews share connections with one another. Indeed, even in those where fracture is most severe — whether from a wound in the lower leg or in the thigh — or where sinews shared with these have come loose, or where from careless bed-rest the heel has blackened, in these cases too the relapses arise from such causes. Sometimes, in addition to the sphacelism, there occur acute fevers with hiccupping, affecting the mind, and rapidly fatal; and also livid discolorations from blood-hemorrhaging veins. Signs of relapse: if the extravasations, the dark patches, and the tissue around them are somewhat hard and reddish — and if with hardness lividness appears, there is danger of blackening — these are unfavorable. Good signs in all such cases: if the discolorations are somewhat livid, or even deeply livid and well-suffused, or pale-green and soft. Treatment: if there is no fever, hellebore; if there is fever, not hellebore; but a drink of oxyglykys (sweet-and-sour), if needed. Bandaging: as for joints; and for all such cases, preferably for the bruised parts, with more and softer linen cloths; less compression; apply the most wrappings especially to the heel. The positioning — the same as dictated by the bandaging — so that pressure is not pushed onto the heel. Splints are not to be used. In cases where the foot slips out by itself, or together with the epiphysis, it dislocates more often inward. 87 [5] If it does not go back in, over time the hip, the thigh, and the part of the lower leg opposite the dislocation all become thin. Another method of reduction, as with the wrist — strong traction. Treatment: the rule for joints. It is prone to relapse, but less so than the wrist, provided the patient remains still. Diaita (regimen/way of living) reduced, for those resting. Those from birth or during growth: according to the reasoning stated earlier.