De Medicina

10 Similar again in great part are accidents to the upper arm and thigh and their treatment; there are also some points common to the arms, forearms, thighs, legs and digits, since there is least danger when the middle of the bone is fractured. The nearer the fracture is to either the upper or the lower end the worse it is; for they are at once more painful and more difficult to treat. The least troublesome is the simple transverse fracture; the multiple and the oblique are worse; the worst are those where the fragments are pointed. Now sometimes the fractured bones in these cases remain in their places; but much more often they slip out and overlap each other; this is the first question to be decided, and the signs are unmistakable. If the fragments are in contact, they make a sound when moved and produce a stabbing sensation; they are not level to the touch. But if they are in touch not directly but obliquely, which happens when the fragments are not in their place, that limb will be shorter than the other, and its muscles swell up. Therefore if this has been noted, the limb ought to be stretched at once; for the sinews and muscles which the bones keep on the stretch are contracted, and do not come into their proper place unless someone forces them into position. Moreover if this is not done at first, inflammation sets in; during which it is both difficult and dangerous to employ force to

the sinews; for either spasm or gangrene follows, or, even if the case goes very favourably, suppuration. Therefore if the fragments have not been replaced before the inflammation, this must be done after. Now a finger or any other limb that is still supple can be stretched by one man alone, when he takes one end with his right, the other with his left hand: a stronger limb requires two men to pull in op directions. If the sinews are more resistant, as in powerful men, especially in their thighs and legs, leather straps or linen bands are to be put round each end of the joints, and pulled in opposite directions by several persons. When by force the limb has been made a little longer than it should be, then at length the bones must be pushed back into their place by the hands. A sign of the replacement is that the pain disappears, and the limb becomes equal to the other. Then cloths folded over two or three times and dipped in both wine and oil are wrapped round the part, and it is best for these to be of linen. Generally six bandages are needed. The first, a very short one, is to make three turns over the fracture in the form of a spiral carried upwards; three such turns are sufficient. The second bandage, half as long again, should begin over any projection if there is one; if the bone is quite smooth, it may begin anywhere over the fracture, in an opposite direction to the first bandage, and go downwards, then back over the fracture to end above the first bandage. Over these two bandages is spread a cerate on a broader layer of lint in order to hold the bandages in place; and if at any point bone projects, a triple layer of wool, soaked in wine and oil, is put over it. The foregoing are surrounded by a third bandage, and then by a fourth, the turns always following a direction the reverse of the bandage underneath. The third bandage ends below, the other three above the fracture. It is better to make the turns of the bandage numerous rather than tight, for a part which is constricted is damaged and disposed to gangrene; now a joint should be bandaged as little as possible, but this is necessary if the bone is fractured close to it. The limb should be kept bandaged until the third day: and it ought to be so bandaged that on the first day, whilst it does not hurt, yet it should not seem to be slack; on the second day it should be slacker, and on the third almost loose. Then the limb must be bandaged again, and a fifth bandage added to the others; on the fifth day the bandaging should be undone, and the limb wrapped in six bandages, put on so that the third and fifth bandages finish below, the others ending above. And, whenever the limb is uncovered, it is to be fomented with hot water. But if the fracture is near a joint, from time to time wine with the addition of a little oil is to be dropped into it, and the same treatment is continued until the inflammation has subsided or the limb has become even a little smaller than ordinary. This occurs by the seventh, or certainly by the ninth day; then the bones are easily manipulated. Therefore if not yet in place, they should be put back; if any fragments project, they must be pushed back into position; then the limb is to be bandaged as before, and over the fracture splints are arranged above so as to hold the fragments firmly in position; and the broader and stronger split is put on the side to which the fractured ends tend to deviate. All these splints should all be bent opposite to a joint so as not to injure it, and they should not press more than is requisite to hold the fragments in place; and since after a while they become loose, every third day the straps keeping them in place are tightened; if there is no itching, or pain, they are kept on for two-thirds of the time which it takes for such a fractured bone to unite; after that the part is fomented lightly with hot water, for the diseased matter must be first dissolved, than extracted. For this reason there should also be gentle inunction with liquid cerate, and superficial rubbing; and the bandaging should be looser. Every third day this bandage is removed, and omitting the hot fomentations, the same treatment is carried out, such that at each change there is one bandage less.

The foregoing treatment is general, the following applies to particular fractures. If the upper arm is fractured, extension is not made as in other limbs, but the patient is seated on a high stool, whilst the surgeon faces him on a lower one. One bandage about the patient's neck is to serve as a sling to support the forearm; another is looped under the armpit and is knotted over the head; a third surrounding the lower end of the humerus is carried down and has its ends tied together below. Then an assistant behind the patient stretches out his right forearm through the second loop, if it is the patient's right humerus which is to be extended, his left if it is the left, and grasps a stick placed upright between the patient's thighs. At the same time the surgeon puts his right foot in the third loop I have described, if the left arm is being

treated, his left foot if the right. And at the same time the assistant lifts one loop up while the surgeon presses the other down, the result being that the humerus is gently extended. Now the bandages, if the middle or lower part of the bone is broken, are shorter, but longer for the upper part, so that they may stretch thence under the opposite armpit too, over the chest and blade-bones. And they . . . But from the first the forearm during the bandaging must be flexed thus, and, since it must be put so even before the bandaging, this ensures that it cannot later, when in the sling, bend the upper arm from the position in which it was while being bandaged. And when the forearm is in a sling, the upper arm too is to be loosely bandaged to the side; this causes is to be moved as little as possible, and so the bones keep in the position in which they have been set. When it is the time for applying the splints, the longest should be placed externally, shorter ones over the biceps in front, the shortest under the armpit. And when the fracture is near the elbow joint, the bandage must be taken off more frequently, or the sinews will become fixed, and the forearm rendered useless. Whenever the bandages are removed, the site of the fracture should be held by the hand, the elbow fomented with warm water, and rubbed with liquid cerate. The splints should not be applied at all over the bony points of the elbow, or should be somewhat shorter.

And if the forearm is fractured, the first thing to consider is whether one or both bones are broken; not that a different treatment is to be adopted, but

first in order that there should be more forcible extension if both bones are fractured, because the tendons necessarily contract less when one bone is unbroken and keeps them on the stretch, secondly that greater care may be taken in setting the bones when the fellow bone affords no aid; for when one bone is intact, it is of more assistance to the other which is fractured than are bandages and splints. Now when applying the bandage to the forearm the thumb should be turned somewhat towards the chest, for this is the most natural position for the forearm; and after applying the bandage to the forearm it is most comfortable placed in a sling, the broader part of which encloses the forearm, whilst its tapering ends are knotted around the neck. And thus the forearm is comfortably slung from the neck, and it should hang a little above the level of the opposite elbow.

. . . But if there is any fracture at the top of the ulna, fixation by a bandage is wrong, for it renders the forearm immobile. And if nothing is done except for the relief of pain, the limb will become as useful as before.

In the case of the leg it is equally important that one bone at least should be sound. One thing is common to fractures of leg and thigh, that after being bandaged the limb is laid in a gutter-splint. This splint should have two holes near the lower end, by which any fluid that has formed may run off; and there should be a stay for the sole of the foot both to support it and stop it from slipping backwards; and at the sides are slots so that when straps are passed through these, a kind of stay holds the leg and thigh as they have been set. If the leg is fractured, the splint should start from the sole; if the

thigh, from about the ham up to the hip; if the fracture is near the head of the thigh, the hip should be included as well. It must not be overlooked, however, that if the thigh-bone is fractured it becomes shorter, for it never returns to its former state, and that afterwards the patient treads on the tips of the toes of that leg; but the disablement is much uglier when neglect is added to misfortune.

For a finger, it is enough to bandage it to a single strip of wood when the inflammation is over.

While these instructions are for individual bones, the following are general for all. For the first days fasting; next a more liberal diet as soon as the callus should be forming; abstinence from wine for a long time; free fomentation with hot water while there is inflammation; more sparing when it has subsided, then long continued but gentle inunction with liquid cerate, for the extremities of the fractured limb. And the limb should not be exercised too soon but brought back to its former use gradually.

The case is rather more grave, when there is a flesh wound as well as a fracture, and especially when muscles of the thigh and upper arm are involved: for they are liable to more severe inflammations and also have a greater tendency to gangrene. And in the case of the thigh-bone, if the fragments have separated from one another, amputation is generally necessary. The upper arm also is liable to this danger, but is more easily preserved. And these dangers are greater if the fracture is co to joints. We must therefore act with greater caution, and the muscle crossing the wound should be cut through. If there has been little haemorrhage, blood should be let; the patient

must be made thin by a low diet. In all other limbs there must be gradual extension and a rather gentle replacement of the bones in position; but in these it is inexpedient to stretch the sinews; nor should the bones be handled; and the patient is to be allowed the posture he finds least painful. Now upon all wounds of this kind there is to be applied first lint soaked in wine to which a little rose oil has been added; the other remedies are as before. The bandages should be somewhat wider than the wound, slacker perhaps than if there is no wound; the more easily a wound can be harmed, and attacked by gangrene, the less tightly it should be bandaged. Rather by having a number of bandages we must arrange that, although loose, they afford equal support. This will be the treatment for the thigh-bone or upper arm if the fragments are in good line; but if they are not so, the bandaging is applied only so far as to keep the medicaments in place. The rest of the treatment is the same as described before except that no cane nor gutter-splints are put on, under which it is impossible for a wound to heal, but only plenty of wide bandages, which likewise are kept well soaked with warm oil and wine, especially in the first inflammation. And the diet at first must be low; wine is improper; the wound is to be fomented with hot water, and chill avoided in every way; and we should pass on to medicaments which induce suppuration, the treatment being directed rather to the wound than to the fracture; consequently the bandage must be removed every day and the wound dressed. In this treatment when a small fragment of bone projects, if it is blunt, it is pushed back into place; if it is pointed, the projection, if long, is cut off before replacing it; if short, it is filed off; and in either case it is smoothed down with a chisel, and then pushed back. And if this cannot be done with the hand, pinchers, such as smiths use, must be applied on the concave side to the end of the bone which is in a correct position in order that the convex side may force the projecting bone into place. If the projecting fragment is larger, and covered with small membranes, it is best to leave these to be loosened by medicaments, and then to cut off the bone as soon as it is laid bare; of course this is to be done soon. By this method the bones may join and the wound also may heal, the former in due time, the latter as circumstances permit.

It happens also occasionally in the case of a large wound that some fragments die, so to speak, and fail to unite with the rest of the bone; this as usual can be learnt from the character of the discharge. It is then particularly necessary to loosen the bandage and dress the wound more often. It generally happens that after some days such bone comes away by itself. Although the condition of the wound is bad before, nevertheless surgery can sometimes cure it. But if in wounds of this kind pain and inflammation occur, the limb must be bathed in cold water, and you will have to do this for some time. For often the sound skin is broken by a fragment of bone, and at once irritation and pain occur. When this happens the wound must be unbandaged at once, and fomented in summer with cold water, in winter with lukewarm water, then the myrtle cerate must be put on. But at times the fracture irritates

the flesh by projections like needle-points: as soon as this is known by the itching and pricking, the surgeon is obliged to expose and cut off these points. The rest of the treatment is in either case the same as when a blow cause the wound in the first instance.

When the wound is clean in these cases too food must be given that makes the flesh grow. If the limb is still too short, and the bones are not in place, a thin wedge, as smooth as possible, should be inserted between the fractured ends, so that the head of the wedge projects a little out of the wound; every day it is driven inwards a little until by this means the limb becomes like the other; then the wedge is taken out and the wound left to heal; to encourage it to heal the limb is fomented with a cold decoction of myrtle, ivy or similar vervains; a desiccating medicament is smeared on; and special care must be taken to keep the limb at rest until there is firm union.

But if at any time the bones have not united, because they have often been unbandaged and moved about, then the treatment is obvious; keep them still and they may unite. If the fracture is of long standing, the limb is stretched in order to reproduce et injury to some extent; the fractured ends must be separated by manipulation, so that when allowed to come into contact they rub one another; thus any fatty tissue is rubbed of, and the whole thing is like a fresh fracture; great care, however, must be taken that sinews and muscles are not injured. Then the limb is to be fomented with a decoction of pomegranate rind and wine; and this, mixed with white of egg, is used as a dressing; it is changed on the third day, and the

limb fomented with the decoction of vervains mentioned above; on the fifth day this is repeated and splints placed round it. The rest of the treatment before and after this is the same as described above.

But sometimes the bones unite with one another sideways, and the limb is then shorter and misshapen; and if the ends are at all pointed, sharp prickings are felt. On this account the bones should be re-fractured and put straight. It is done in this way; the limb is fomented freely with hot water, smeared with a liquid cerate, then stretched. And meanwhile the surgeon handles the bones, and as the callus is still soft, separates the ends, and forces the projecting piece into place; and if he is not strong enough to do this, he puts a ruler wrapped in wool over the projecting bone; and by bandaging it like this forces the bone back to its original place. But occasionally, though the fragments are in correct apposition, too much callus develops and there is a swelling over the fracture. When this happens the limb should be gently rubbed for a long while with oil containing salt and soda, and then fomented freely with hot water and salt; and a poultice should be applied as a dispersive, besides firmer bandages; use a diet of green vegetables, and an emetic besides, which reduces the callus together with the flesh. And it is of advantage in this condition to apply mustard mixed with a fig to the corresponding limb until it causes irritation and draws away the diseased matter. When by this means the swelling has been reduced, return is made to the ordinary course of life.

11 So much for the discussion of fractured bones. Turning to dislocations, these are of two kinds: for at times bones which are conjoined gape asunder, as when the shoulder-bone recedes from the clavicle, and, in the forearm, the radius from the ulna, or in the leg the tibia from the fibula; sometimes after a jump the heel-bone from the ankle, though this is rare; at times joints slip out of position. I will speak of the former first.

Now when anything of this sort happens, there is a depression at once on the spot, and when the finger is put into this a gap is felt; after this severe inflammation arises, particularly at the ankle; indeed this is often a cause of fevers also and gangrene and spasms of the sinews or rigors, which bend back the head to the shoulder-blade. To avoid these things the same is to be done as was laid down for bone injuries in general, so that pain and swelling may be thereby relieved. For bones so separated never again unite, and even if the appearance of the limb is somewhat impaired its usefulness is not.

Since all joints, including the jawbone and vertebrae, are held in place by strong sinews, they are displaced either by force or after some accident which has ruptured or weakened the sinews, and this occurs more readily in boys and youths, than in the more robust. And these joints slip out

forwards, backwards, inwards, outwards, some in all directions, some in certain only. And there are some signs which are common to all, some special to each; there is always a swelling in the part into which the bone has ruptured, and a hollow whence the bone has receded. These signs are found in all, but others only in some cases; these I will describe when speaking of each separately. But while it is possible for all joints to slip out, yet not all can be replaced. For the head is never forced back into position, nor is a spinal vertebra, nor a jawbone which has been dislocated forwards on both sides, and has become inflamed before it has been replaced. Again, any joints which have slipped owing to a lesion of their sinews, even when forced back into position slip out again. Also when joints have been dislocated in childhood, and have not been replaced, there is less growth than elsewhere. The flesh of all which are out of place wastes, and in the near more than in the distant part of the limb; for instance, if the upper arm-bone is not in its place, the wasting is more here than in the forearm, more in the forearm than in the hand. Again, according to the site and character of the accidents, more or less use of the limb is retained; and the more use is retained, the less does it waste. Now every dislocation ought to be replaced before there is inflammation; but if this has set in already, the limb is not to be disturbed until after it subsides; only when it has ended should replacement be attempted in the limbs which allow of it. But for this much depends upon the general constitution of the patient and his sinews. For if his body is slender, and humid, if sinews are weak, the bone is readily replaced; but just as the bones slips out more easily in the first instance, so the replacement is less secure. With an opposite type of constitution the replacement is more lasting but there is more difficulty in restoring that which has been put out of position. The inflammation should be relieved by applying greasy wool saturated with vinegar: there should be abstinence from food, in the case of the stronger joints, for three days, some he said for five; warm water is drunk, enough to relieve thirst; this regimen must be followed more strictly after dislocation of bones which are held in place by strong and large muscles; far more strictly indeed if fever supervenes; then after the fifth day there should be hot-water fomentation; when the wool is removed, a cerate must be applied made with cyprus oil with the addition of soda, until all inflammation has ended. Then the limb is to be rubbed, good food given and wine in moderation; and now also the natural use of the limb is to be encouraged; because though movement when it gives pain is harmful, it is otherwise most beneficial to the body. After these generalities, I will now speak of particular cases.

12 The lower jaw is displaced forwards, sometimes on one side, sometimes on both. If on one side, it inclines with the chin to the opposite side, the teeth do not correspond with their fellows, but the canine are under the incisors. But if on both sides, the whole chin is moved forwards, and the lower teeth stick out beyond the upper ones; and the muscles above appear tense. As soon as possible the patient is to be seated on a stool, with an assistant behind holding his head, or with his

back against a wall and a hard leather cushion between the wall and the back of his head, against which his head is firmly pushed by the assistant, to keep it from moving. Then the surgeon's thumbs, which have been wrapped round with strips of linen or bandages so that they may not slip, are inserted into the mouth whilst the fingers are applied outside. When the jaw has been grasped firmly, if it has slipped forwards to one side, the chin is to be pressed down towards the throat with a jerk. Then simultaneously the head is firmly held, and the chin being raised the jaw is forced back to its place, and the mouth is closed so that all this is done almost with one movement. If it has been dislocated on both sides all the same movements are to be done except that the jaw is forced straight backwards. When the bone is in its place, if the accident has been attended with pain in the eyes and neck, blood is to be let from the arm. For all patients with dislocated bones, a more liquid diet is proper at first, but especially in this case, since even talking, as it causes constant movement of the mouth by means of the sinews, is harmful.

13 As I stated in the first part, the head is held by two processes, inserted into two cups in the highest vertebra. These processes sometimes slip out backwards; with the result that the sinews under the occiput are stretched, and the chin fixed to the chest; the man cannot drink or speak, and sometimes has involuntary emission of semen; upon these symptoms death very quickly supervenes. Now I

 thought this condition should be described, not that there is any treatment for it, but that it may be recognized by these indications, and that those who have lost someone in this way may not deem the medical man to have been at fault.

14 The same fate awaits those whose spinal vertebrae have been dislocated; for this cannot happen without rupture of the marrow in the middle of them, and of the two little membranes which pass oust between the two processes at the side, and of the sinews which hold them together. But the vertebrae may slip pout both backwards and forwards, above the diaphragm or below it. The direction of the displacement is indicated either by a swelling or by a hollow at the back. If it happens above the diaphragm, there is paralysis of the arms, and vomiting or spasm follow, breathing is difficult, pain is severe, and hearing blunted. If below the diaphragm, the lower limbs are paralysed, the urine is suppressed, or sometimes is passed involuntarily. From such accidents the man dies more slowly than when the head is displaced, yet within three days. As for what Hippocrates said, that when a vertebra has been displaced backwards, the man is to be laid out on his face, and stretched out, while an assistant presses his heel upon the displaced bone and pushes it inwards, that procedure is only to be adopted when the bone has slipped out a little, not if there is a total displacement. For occasionally weakness of the sinews causes a vertebra, although not displaced, to project a little, either backwards or forwards. This is not a fatal accident, but we cannot press upon a vertebra from within; it cannot even be touched; and if it is pressed upon from outside,

it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.