De Medicina

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

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, 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

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 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.