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.