4 Therefore after a blow on the head first we
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must enquire whether the patient has had bilious vomiting, whether there has been obscurity of vision, whether he has become speechless, whether he has had bleeding from the nose or ears, whether he fell to the ground, whether he has lain senseless as if asleep; for such signs do not occur unless with fractured bone; and when they are present, we must recognize that treatment is necessary but difficult. If in addition there is also stupor, if the mind wanders, if either paralysis or spasm has followed, it is probable that the cerebral membrane has also been lacerated; and then there is little hope. But if none of these signs follows the injury, it is not even certain whether the bone is broken: and the first thing then to consider is whether he was struck by a stone or club or sword or other such weapon, and whether such a weapon was blunt or pointed, medium or heavy, used with much or little force; for the lighter the blow, the more easily we may conclude that the bone has resisted it. But the best plan is to make certain by exploration. Accordingly a probe should be introduced into the wound; it should be neither very fine nor pointed, lest it enter one of the natural sutures and give rise to a false belief in a fracture of bone; neither should it be too thick lest small fissures be missed. When the probe comes into contact with the bone, if nothing but what is smooth and slippery is met with, it can be seen that the bone is intact; if any roughness is met with, at least where there are no sutures, it is a sign that the bone is fractured. Hippocrates, with great men's love of truth in great matters, has described how he had
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been deceived by sutures. For shallow minds, because they have nothing, never belittle themselves; such a sincere confession of the truth befits a great mind which will still have many titles to greatness, and especially in performing the task of handing down knowledge for the advantage of posterity, that no one else may be deceived again by what has deceived him. But my regard for the memory of a great teacher has somehow led me into this digression. Now a suture may possibly deceive just because it is rough too; so that although there is really a fissure, yet we may take it to be a suture, where it is likely that there is one. Therefore we must not be deceived just by this; the safest way is to lay bare the bone. For as I have stated above, sutures are not always in the same position, and a natural union of bone and a fissure from injury may coincide, or the fissure may be close by. Therefore sometimes when the blow was severe, although nothing is detected by the probe, it is still best to open the place up. And if even then no fissure is visible, ink is to be applied over the bone, then it is to be scraped with a chisel; for a fissure will retain the blackness. It may even happen that the blow may have been upon one part of the head, and fracture at another. Thus if anyone has been heavily struck and bad signs have followed, and no fissure has been found in the part where the scalp has been wounded, it is worth while to examine whether some other part is softer and swollen, and to lay it open; then perhaps fissured bone may be found there. Even if it be uselessly incised, the scalp heals without much trouble. A fractured bone unless it is treated causes severe inflammations,
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and is treated afterwards with greater difficulty. Rarely, but now and then, it happens, however, that whilst the bone remains whole and sound, yet within the skull a blood-vessel in the cerebral membrane has been ruptured by the blow and some blood has escaped, and this having formed a clot, causes great pains, or sometimes obscures vision. But generally the pain is directly over the clot, and when the scalp at that point is incised, the bone is found to be pallid; if so, that bone also is to be cut out.
But for whatever cause this treatment is necessary, if the scalp has not been laid open sufficiently, it must be incised more widely until the injury is well in view. In doing so we must see that none of the fine inner membrane covering the skull, under the scalp, remains over the bone; for whenever this is lacerated by the chisel or trepan it causes severe fevers with inflammations, and so it is better to raise it wholly off the bone. If there is a cut as part of the wound we must take it as it is; if we have to make it, the best incision is generally that which is formed by two lines in the shape of the letter X; next the scalp is raised by cutting under each of the little tongues. When doing this if bleeding takes place it must be checked by the application of a sponge saturated with vinegar from time to time, also it must be absorbed by swabs of dry lint and the head must be raised higher. There need be no anxiety unless it comes from among the muscles covering the temples; but there also this is the safest method of dealing with it.
In every case of a fissured or fractured bone, the older practitioners resorted at once to the instruments for cutting out the fragments. But it is much
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better first to try the plasters which are prepared for the cranium. One of these dissolved in vinegar is to be put upon the fissured or fractured bone by itself; next over this, a little overlapping the wound, lint steeped in the same, and over this unscoured wool sprinkled with vinegar; then the wound is bandaged and the dressing changed daily, and so treated up to the fifth day; on the sixth day also the wound is steamed by means of a sponge, then dressed as before. And if granulation begins, and the feverishness either subsides or lessens, and appetite returns, and there is sufficient sleep, we should persevere with the same applications. Next as time goes on, the plaster is to be softened by the addition of the cerate made with rose oil that it may cause the flesh to grow more readily; for by itself it has a repressant action. Under this treatment fissures are often filled up by some callus which forms a sort of scab in the bone; and if the fragments are more widely separated, any that are not in contact also become fastened together by the same callus, and this is a better covering for the brain than the flesh which grows up after the bone has been excised. But if under this first treatment fever becomes intensified and sleep short and disturbed by dreams, while the wound discharges and does not heal, and the glands in the neck on each side swell, and there is great pain, and in addition a growing aversion to food, then at length we must resort to surgery with the chisel.
A blow on the cranium involves two dangers; either a split bone or a depressed fracture. If the bone is split, the edges may remain in close contact, either because one margin overrides the other, or
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because they have become closely interlocked again. Hence it follows that humour collects on to the cerebral membrane but has no means of exit, and so irritates it, exciting severe inflammation. But when there is a depressed fracture, the bone presses on the cerebral membrane and sometimes also sharp points like needles from the fractured bone cause irritation. Cases like this require assistance, with as little loss of bone as possible. Therefore if one edge overlies the other, it is sufficient to cut away the overlying edge with a flat chisel; when this is removed a gap is left wide enough for treatment. But when the fractured edges have become interlocked, a hole should be made with a trepan at a finger's breadth to one side; and from this two cuts should be made with the chisel to the fissure, in the form of the letter V, with the apex at the hole and the base at the fissure; but if the fissure is a lone one, similar curs should be made from a second hole. And thus there is no concealed cavity in that bone, and a way out is given freely to all harmful material within. Even when the fractured bone is depressed, it need not all be excised. But whether completely broken off and separated from the rest, or still attached by a small portion to the skull around, the fragment should be separated by the chisel from the sound bone. Next, in the depressed fragment, close to the groove which we have just made, holes are to be bored as well; two when the damage is of small extent, three when larger, and the intervening partitions must be cut through. Next the chisel is to be so used on each side of the said groove, that a crescent-shaped gap is made with its convexity on the side of the fragment, and its horns directed
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towards the intact bone. Then if there are any detached fragments which can be easily removed, they are to be seized with forceps made for the purpose and particularly the pointed fragments which are irritating the membrane. If this cannot be done easily, the plate which I have suggested as a guard of this membrane is to be passed underneath in order that all pointed fragments which project inwards may be cut away over the plate, and any depressed bone is to be raised by means of the same plate. This method of treatment ensures that fragments still attached become consolidated; and detached fragments come away in course of time under the dressing without any pain; and by that treatment there is left a gap in the skull large enough for the extraction of matter; and the brain is better protected by leaving the bone than if it had been excised. After this, that membrane should be sprinkled with strong vinegar, in order that any bleeding from it may be checked, or any collection of clot which remains inside may be broken up. Then the same plaster, softened as described above, should be put on the membrane itself; and the rest of the dressing as before, ointment on the lint, and unscoured wool; the patient should be kept in a warm room; the wound dressed daily, even twice a day in summer.
But if the membrane swells up through inflammation, it is to be bathed with tepid rose oil; if it swells so as to project even above the level of the skull, well-ground lentils or crushed vine leaves, mixed either with fresh butter or goose-grease, will control it; and the neck should be anointed with liquid cerate containing iris oil. But if it shall ap-
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pear that the membrane is not clean, equal parts of its special medicament and of honey are to be mixed together and poured on, and to keep this in place one or two pads of lint must be put on, and over all linen upon which some of the medicament has been smeared. When the membrane is clean, a cerate to form flesh is to be added to the medicament and similarly applied.
As regards abstinence and the food and drink at first and later, the same course is to be adopted as I prescribed for wounds, and all the more because the danger is greater when this part is affected. And even when the time has come not only to sustain but also to build up the patient, still anything requiring mastication should be avoided; and also smoke and anything which provokes sneezing. But there is good hope when the membrane is movable and of normal colour, when the flesh growing up is a brit red, and when the jaw and neck move with ease. Bad signs are: the membrane immobile, black or livid or any other unwholesome colour; delirium, acrid vomiting, paralysis or spasm livid flesh, rigor of jaw and neck. As for other signs — sleep, appetite, fever, colour of the pus — the indications as to recovery or death are the same as in the case of other wounds. When things are going well, flesh grows up from the ma itself and from the bone as well if it is in two layers, so that the space between the bones becomes filled up; sometimes it even grows out above the skull. If this occurs copper scales are to be dusted on in order to repress and control it. Also applications to induce a scar must be laid on the flesh. And this is readily brought about everywhere except on the forehead a little above the eye-
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brows; for there it is almost impossible to avoid a lifelong wound which has to be kept covered by medicated lint. It should be the rule for all cases in which the skull has been fractured, that until the scar is firm, the patient should avoid sun, wind, frequent baths, and the free use of wine.
5 In the nostrils again either the bony or cartilaginous part may be broken, and that either in front, or to one side. If both are broken across, or one of them, the nose sinks in and the breath is drawn through with difficulty; if bone on one side is broken, there is a depression; if cartilage, the nose is bent to the opposite side.
Whatever occurs in the case of the cartilage, it must be gently raised either by passing a probe under it or by compressing with a finger on each side; then a roll of folded linen with thin leather sewn on over it is introduced; or some sort of dry pad similarly shaped; or a large quill smeared with gum or joiner's glue, and wrapped round with soft thin leather, which will prevent the cartilage from sinking in again. But if broken across, both nostrils are to be filled equally; if on one side, the nostril on the side to which the nose is bent should be filled with a thicker roll, the other nostril with a thinner one. Outside also a strap of soft leather, the middle smeared with a mixture of fine flour and incense soot, is applied, and it must be carried back behind the ears and fastened to the forehead by its two ends. The flour and incense when dried sticks to the skin like glue and keeps the nose in place. If what has been inserted causes
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irritation, as happens mostly when the septal cartilage inside is fractured, the nostrils are to be raised and kept in place by the strip of leather alone; then this too is removed at the end of a fortnight after loosening with warm water, and afterwards every day the nose should be fomented with the same.
But if the bone is broken, this also is put back into position by the finger; and when the injury is in front, both nostrils are plugged; when on one side, the nostril on the side towards which the bone has been displaced. Cerate is to be applied, and the part bound fairly tightly, because in this position callus grows not only sufficiently to cause union, but even into a tumour. From the third day the nose is to be fomented with hot water, more especially as it begins to unite. Even if there are several fragments, each is to be forced into place by the fingers applied outside, and the strip in the same way is to be put on outside, and a cerate over it, and no additional bandage. But if any fragment has become completely separated and will not unite with the rest, this will be recognized by the fluid which is discharged freely from the lesion; then the fragment should be extracted by means of a forceps; when the inflammatory reaction is at an end, some medicament from among the mild repressants is applied.
The case is worse when there is an external wound as well as a fracture, whether of bone or cartilage. This only occurs rarely. If it does happen, the fragments are to be replaced into position in the same way, while the skin is dressed with one of the plasters suitable for recent wounds; but no bandage must be put over it.
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6 In the ear also the cartilage is sometimes ruptured. If this happens, before suppuration has supervened, an agglutinating medicament should be put on; for this often prevents suppuration, and cures the ear. As in the case of the nose, it must not be overlooked that the cartilage itself does not agglutinate, but flesh grows round it and so the place becomes consolidated. Hence, if the skin is torn along with rupture of the cartilage, the skin on both sides is to be stitched. But I speak now of a case where the cartilage is broken, but the skin intact. Now in that case if suppuration supervenes, the skin on the other side is to be laid open and a crescent-shaped piece of cartilage cut out beneath; then a mild styptic such as lycium dissolved in water is put on until bleeding ceases; next lint smeared with a plaster without any grease is applied and soft wool to fill the space between the ear and the head; then the ear is lightly bandaged, and from the third day the ear is steamed as in the case of the nose (5.4). In these kinds of injuries also fasting is necessary at first until inflammation has ceased.
7 As I am going to pass on from the above to the lower jaw I think I ought to point out certain matters pertaining to fractures so as not to have to say the same things too often. Any bone, then, may be split, either in a straight line as a log of wood is cleft lengthwise, or across, sometimes obliquely; and in the latter case, the fractured ends are sometimes blunted, sometimes pointed. The last is the
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worst because two ends are not brought together easily when they have nothing blunt to rest against, and they lacerate the flesh, sometimes also sinews and muscles; indeed sometimes there are several fragments. Now in other bones one fragment often separates from another completely; but in the case of the jaw the pieces of bone even when injured are always in contact with one another at some point. Begin then by applying pressure with the two thumbs in the mouth and two fingers on the skin outside, and force all the fragments into position; next, if the lower jaw has been broken across, in which case generally one tooth stands higher than its neighbour, when it has been put back into position tie together with horsehair the two adjacent teeth, or if these are loose, teeth further away. In other varieties of this fracture, the binding is superfluous, but what follows is the same for all: a double fold of linen soaked in wine and oil is to be put on, smeared with fine flour and incense as before; then over this a bandage or strip of soft leather has a slit made in the middle to enclose the chin on each side and thence the ends are carried to the top of the head and tied there. What follows applies to fractures in general: fasting is a necessity at first; then from the third day a fluid diet, and when the inflammation has subsided a somewhat fuller diet to build up the strength; wine is wrong throughout; then on the third day the bandage is removed, and the part fomented with steam by means of a sponge, and the bandage reapplied as before; the same thing is to be done again on the fifth day and so on until the inflammation has ceased, which is generally by the ninth or the seventh day. The inflammation gone,
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the bones must be examined again, and if the fractured ends are not in place, they are reset; after which the bandaging should not be dispensed with until two-thirds of the time has elapsed which such bones take to unite. Bones generally reunite as follows: between the fourteenth and twenty-first days the lower jaw, cheek-bones, clavicle, sternum, blade-bones, ribs, spine, hip-bone, astragalus, heel-bone, and the bones of the hands and feet; between the twentieth and thirtieth days the bones of the leg and forearm; between the twenty-seventh and fortieth days the upper arm and thigh. But in the case of the lower jaw, there is this addition, that fluid food has to be taken for a longer period. And even after time has elapsed the patient must continue to eat pancakes and such-like, and must not eat anything hard until the formation of callus has rendered the lower jaw quite firm; also, at any rate for the first days, the patient should not speak.
8 Now if the clavicle has been broken across, it sometimes unites correctly by itself, and unless moved can be cured without being bandaged; but sometimes, and especially when it has been moved, it slips out of place. And generally the fragment on the side of the breast is bent forwards, that on the side of the shoulder backwards. The reason is that the bone has no independent movement, but moves with the shoulder, while the part attached to the breast is immovable; therefore while this remains stationary, the shoulder-fragment is displaced below it by the movement of the shoulder. But so seldom does the clavicle incline forwards that great teachers have recorded that they have
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never seen it. However, the authority of Hippocrates is ample on this matter. But as the two cases are different, so they require different treatment. When the clavicle points towards the blade-bones, the shoulder is to be forced backwards with the palm of the right hand, and simultaneously the clavicle must be brought forwards. When the clavicle has been turned towards the chest it must be directed backwards, and the shoulder is to be drawn forwards, and if the shoulder is lower, the breast-fragment is not to be pressed down, for it is immobile, but the shoulder must be raised. And if the shoulder is higher the breast-fragment is to be covered with wool, and the arm bandaged to the chest. If the fragments have pointed ends, the skin over them should be incised, and the splinter which are injuring the flesh cut off from the bones, after which the blunted ends are to be brought together. If any part of the clavicle projects it should be covered with three layers of linen soaked in wine and oil. If the fragments are numerous, they must be fixed with a gutter-splint made of cane smeared on its inner side with cerate so that it does not slip under the bandage. The turns of the bandage when the clavicle is fixed should be many, rather than tight, and this should be the rule in the case of other fractured bones. If the right clavicle is fractured, the bandage must be carried from it to the left armpit, if the left clavicle, to the right armpit, then back under the armpit of the fractured side. After this, if the clavicle is inclined towards the shoulder-blade, the forearm is bandaged to the side; if it points forwards, the forearm is bandaged to the neck and the patient kept on his back. All the rest of
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the treatment is the same that was described above.
But there are several bones almost immobile whether hard or cartilaginous, which cn be either fractured or bored into or crushed or split; such are the cheek-bones, breast-bone, shoulder-blade, ribs, spine, hip, ankle-bones, heel-bone, bones of the palm and sole. All these are treated in a similar way. If there is a wound over the fracture, it is to be dressed with the appropriate medicaments; as the wound heals callus also fills fissures in the bone or any perforation. If the skin is intact and we gather from the pain that the bone is injured, there is nothing else to do but to rest, apply a cerate and a light bandage until the pain is ended by the healing of the bone.
9 There is, however, something special to be said of the rib, because it is near the viscera, and that region is exposed to greater danger. A rib then is sometimes split so as not to injured the upper bone, but only the thin structure on its inner side; sometimes it is completely broken across. If the fracture is incomplete, blood is not expectorated, and fever does not follow, nor is there suppuration except very rarely, nor great pain; nevertheless there is some tenderness to touch, but it is quite enough to do what has been described above, and to begin the bandaging from the middle of the bandage that it may not displace the skin to either side. Then after twenty-one days, by which time the bone other formed a firm union, a fuller diet is to be administered in order to fatten the body as much as possible, so as to cover the bone better, for the bone there whilst still tender is
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liable to injury owing to the thinness of the skin. But during the whole course of recovery the patient muting or even straining the voice, noise, anger, violent bodily movements, smoke, dust, and anything that causes a cough or sneeze; it is not even advisable to hold the breath for long. But if a rib has been broken right across the case is more severe; for grave inflammations follow and fever and suppuration and often danger to life: and blood is expectorated. If therefore the strength allows, blood should be let from the arm on the side of the injury; if strength does not allow of this the trouble is, however, to be countered by a clyster that will not irritate, and by a low diet for a long while. Bread is not allowed before the seventh day, but only broth; and locally a cerate is to be applied made of linseed, to which boiled resin is added; or the poultice of Polyarchus, or cloths soaked in wine, rose oil and olive oil; and over that oft undressed wool then two bandages beginning from the middle and loosely bound on. But it is more important to avoid all the things mentioned above, so much so that even breathing should not be hurried. If cough is persistent, a draught of germander or rue or French lavender or of cumin and pepper should be taken. But if more severe pain comes on a plaster of darnel or of barley meal is also to be applied, to which is added a third of a ripe first and this will lie upon the place by day; but at night, as the plaster may become displaced, use the same cerate or poultice or cloths as above. Therefore too the dressing must be taken off every day until we find the cerate or poultice suffi-
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cient. And for ten days the patient may be thinned down by hunger, from the eleventh day he may begin nourishing food; and with that the bandages may be applied round even more loosely than at first; and generally this treatment will continue till the fortieth day. But if there is danger of suppuration, the poultice will be more likely to disperse it than the cerate. If the suppuration gains way, and the treatment above described fails to disperse it, there must be no delay lest the bone underneath become diseased; but where there is most swelling, the red-hot cautery is to be applied until it reaches pus; and that is to be let out. When no pointing of the swelling is evident, we may learn where the pus is chiefly deposited as follows. We smear the whole region with pipe-clay and allow it to dry; the spot where it remains moist the longest marks the neighbourhood of the pus, and there the cautery should be applied. If the suppuration is widely spread, two or three places must be perforated by the cautery. We should then introduce a strip of linen, or some kind of tent bound round with a thread so that it can be easily withdrawn. The rest of the treatment is as in other cauterizations. When the ulceration has cleaned, then the patient should be well fed, lest this disease be followed by what may become fatal wasting. Sometimes even when the bone has been only slightly affected but neglected at first, not pus but a humour somewhat like mucus collects within, and there is a softening under the skin; here also the cauter is to be used.
About the spine there is also something special to note. For if a spinal process has in any way been fractured, there is a depression at that spot, also
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pricking pains are felt in it, because such fragments are necessarily spiky; this consequently makes the patient lean forwards. These are the signs of the condition; but the same medicaments are required as have been mentioned in the early part of this chapter.
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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,
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it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.