De Medicina (Celsus)

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	De Medicina Author: Celsus	Translator: Walter George Spencer
193	Ab his ad maxillam uenturus indicanda quaedam puto communiter ad omnia ossa pertinentia , ne saepius eadem dicenda sint . Omne igitur os modo rectum ut li gnum in longitudine m finditur , modo frangitur transuorsum , interdum oblicum ; atque id ipsum nonnumquam retusa habet capita , nonnumquam acuta . Quod genus pessimum est , quia neque facile committuntur , quae nulli retuso innituntur , et carnem uulnerant , interdum neruum quoque aut musculum : quin etiam aliquando plura fragmenta fiunt . Sed in aliis quidem ossibus ex toto saepe fragmentum a fragmento recedit : maxillae uero semper aliqua parte etiam uexata ossa inter se cohaerent . Igitur inprimis digitis duobus utrimque prementibus et ab ore et ab cute omnia ossa in suam sedem compellenda sunt ; deinde , si transuersa maxilla fracta est ( sub qu o casu fere dens super proximum dentem excedit ) , ubi ea in suam sedem conlocata est , duo proximi dentes aut , si hi labant , ulteriores inter se seta deligandi sunt . Id in alio genere fracturae superuacuum est , cetera eadem facienda sunt : nam linteolum duplex madens uino et oleo superiniciendum cum eadem simil a et eadem turis fuligine est ; deinde aut fascea aut mollis habena media in longitudinem incisa , ut utrimque mentum conplectatur et inde capita eius supra caput adducta ibi deligentur . Illud quoque ad omnia ossa pertinens dictum erit , famem primum esse necessariam ; deinde a die tertio umidum cibum , sublata inflammatione paulo pleniorem , eumque qui carnem alat : uinum per omne tempus esse alienum ; deinde tertio die resolui debere , foueri per spongia m uapore aquae calidae , eademque quae primo fuerunt superdari : idem die quinto fieri et donec inflammatio finiatur , quae uel nono die uel septumo fere soluitur . Ea sublata , rursus ossa esse tractanda , ut , si quid fractum loco suo non est , reponatur : neque id esse soluendum , nisi duae partes eius temporis , intra quod quaeque ossa conferu ent, transi erint . Fere uero int er quartum decimum et unum et uicensimum diem sanescunt maxilla , malae , iugulum , pectus , latum os scapularum , costae , spina , coxarum os , ta li , calx , manus , planta : inter uicensimum et tricensimum diem crura , bracchiaque : inter septimum et uicensimum et quadragensimum umeri et femina . Sed in maxilla illud quoque adiciendum est , quod umidus cibus diu adsumendus est . Atque etiam cum tempus processit , in lagano similibusque aliis perseuerandum est neque quicquam edendum duri , donec ex toto maxillam callus firmarit ; itemque utique primis diebus habendum silentium .	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.
194	Iugulum uero si transuersum fractum est , nonnumquam per se rursus recte coit et , nisi mouetur , sanari sine uinctura potest : nonnumquam uero , maxime que ubi motum est , elabitur . Fereque id , quod a pectore est , * * * id , quod ab umero est , in posteriorem partem inclinatur . Cuius ea ratio est , quod per se non mouetur , sed cum umeri motu consentit * * * itaque eo subsistente sub i d umer o agitatur . Raro uero admodum in priorem partem iugulum inclinatur , adeo ut magni professores numquam se uidisse memoriae mandarint . Sed locuples tamen eius rei auctor Hippocrates est . Verum ut dissimilis uterque casus est , sic quaedam dissimilia requirit . Vbi ad scapulas iugulum tendit , simul dextra manu plana propellendus in posteriorem partem umerus est , et illud in priore m adtrahendum . Vbi ad pectus conuersum est , ipsum quidem retro dandum , umerus autem in priorem partem adducendus ac si is inferior est , non id , quod a pectore est , deprimendum est , quia immobile est , sed umerus ipse adtollendus erit : a t s i superior est , id , quod a pectore est , inplendum lana et umerus ad pectus deligandus est . Si acuta fragmenta sunt , incidi contra cutis debet : ex ossibus ea , quae carnem uulnerant , praecidenda , tum retussa ossa committenda sunt . Si quod ab aliqua parte eminet , opponendum ei triplex linteolum est in uino et oleo tinctum . Si plura fragmenta sunt , excipienda sunt e a ex ferula facto ca naliculo eodemque intus incerato , ne fascea diducatur ; quae iugulo composito circumdanda est saepius potius quam ualentius ; quod ipsum quoque in omnibus ossibus fractis perpetuum est . A dextro uero iugulo , si id fractum est , ad alam sinistram , a sinistro ad dextram † rursusque sub ala sua fasciari debet . Post haec si iugulum ad scapulas inclinatum est , brachium ad latus ; si in partem priorem , ad ceruicem deligandu m est supinusque homo conlocandus . Cetera eadem facienda , quae supra conprehensa sunt . Sunt uero plura ossa fere inmobilia uel dura uel cartilaginosa , quae uel franguntur uel forantur uel conliduntur uel finduntur , ut malae , pectus , latum os scapularum , costae , spina , co xarum os , tali , calx , manus , planta . Horum omnium eadem curatio est . Si supra uulnus est , id suis medicamentis nutriendum est ; quo sanescente , rimas quoque ossis , aut si quod f oramen est , callus implet . Si cutis integra est et os laesum esse ex dolore colligimus , nihil aliud quam quiescendum , inponendumque ceratum est et leniter deligandum , donec sanitate ossis dolor finiatur .	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.
195	Proprie quaedam tamen de costa dicenda sunt ; quia iuxta uiscera est , grauioribusque periculis is locus expositus est . Haec quoque igitur interdum sic finditur , ut ne summum quidem os sed interior pars eius , quae rara est , laedatur , interdum sic , ut eam tota m is casu s perruperit . Si tota fracta non est , nec sanguis expuitur nec febricula sequitur , nec quicquam suppurat , nisi admodum raro , nec dolor magnus est : tactu tamen is locus leniter indolescit . Sed abunde est eadem , quae supra scripta sunt , facere , et a media fascea incipere deligare , ne in alterutram partem haec cutem inclinet . Ab uno uero et uicensimo die , quo utique os esse debet glutinatum , id agendum cibis uberioribus est , ut corpus quam plenissimum fiat , quo melius os uestiat , quod illo loco tenerum adhuc iniuriae sub tenui cute expositum est . Per omne autem tempus curationis uitandus clamor , strictior quoque * , tumultus , ira , motus uehementior corporis , fumus , puluis , et quicquid uel tussim uel sternumentum mouet ; ne spiritum quidem magnopere continere expedit . At si tota costa perfracta est , casus asperior est : nam et graues inflammationes et febris et suppuratio et saepe uitae periculum sequitur : et sanguis spuitur . Ergo , si uires patiuntur , ab eo bracchio , quod super eam costam est , sanguis mittendus est : si non patiuntur , aluus tamen sine ullo acri ducenda est , diutiusque inedia pugnandum . Panis uero ante septimum diem non adsumendus , sed una sorbitione uiuendum ; inponendumque ei loco ceratum ex lino factum , cui cocta quoque resina adiecta sit ; aut Polyarchi malagma , aut panni ex uino et rosa et oleo ; superque inponenda lana sucida mollis et duae fasceae a mediis orsae minimeque adstrictae . Mult o uero magis omnia uitanda , quae supra posui , adeo ut ne spiritus quidem saepius mouendus sit . Quod si tussis infestabit , potio sumenda erit uel ex trixsagine uel ex ruta uel ex sto echade uel ex cumino et pipere . Grauioribus uero doloribus urguentibus cataplasma inponi quoque conueniet uel ex lolio uel ex hordeo , cui pinguis fici tertia pars sit adiecta ; et id quidem interdiu superiacebit : noctu uero idem aut ceratum aut malagma aut panni , quia potest cataplasma decidere . Ergo cottidie quoque resoluetur , donec iam cerato aut malagmate possumus esse contenti . Et decem quidem diebus extenuabitur fame corpus , ab undecimo uero ali incipiet ; ideoque etiam laxior quam primo fascea circumligabitur ; fereque ea curatio ad quadragesimum diem perueniet . Qu od si me tus erit suppurationis , plus malagma quam ceratum ad digerendum proficiet . Si suppuratio uicerit , neque per quae supra scripta sunt discuti potuerit , omnis mora uitanda erit , ne os infra uitietur : sed qua parte maxime tumebit , demittendum erit candens ferramentum , donec ad pus perueniat ; idque effundendum . Si nusquam caput se ostendet , ubi maxime pus sub sit , sic intellegimus : creta Cimolia totum locum inlinemus et siccari patiemur : quo loco maxime umor in ea perseuerabit , ibi pus proximum erit eaque uri debebit . Si latius aliquid abscedet , duobus aut tribus locis erit perforandum . Demittendum erit lin amentum aut aliquid ex penicillo , quod summum lino sit deuinctum , ut facile educatur . Reliqua eadem , quae in ceteris adustis , facienda sunt . Vbi purum erit ulcus , ali corpus debebit , ne tabes perniciosa futura id malum subsequatur . Nonnumquam etiam leuius ipso osse adfecto et inter initia neclecto , non pus sed umor quidam muccis similis intus coit , mollescitque contra cutis ; in qua simili ustione utendum est . In spina quoque est quod proprie notemus . Nam si id , quod ex uertebra excedit , aliquo modo fractum est , locus quidem concauus fit , punctiones autem in eo sentiuntur , quia necesse est ea fragmenta spinosa esse ; quo fit , ut homo in interiorem partem subinde nitatur . Haec noscendae rei sunt : medicamentis uero isdem opus est , quae prima parte huius capitis exposita sunt .	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 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- 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 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.
196	Similes rursus ex magna parte casus curationesque sunt umer i et femoris : communia etiam quaedam umeris , bracchiis , feminibus , cruribus , digitis : siquidem e a minime periculose media franguntur . Quo propior fractura capiti uel superiori uel inferiori est , eo peior est : nam et maiores dolores adfert et difficilius curatur . Ea maxime tolerabilis est simplex transuersa ; peior , ubi multa fragmenta atque ubi obliqua ; pessimum , ubi eadem acuta sunt . Nonnumquam autem fracta in his ossa in suis sedibus remanent ; multo saepius excidunt aliudque super aliud effertur ; idque ante omnia considerari debet et sunt notae certae . Si suis sedibus sunt , mota res onan t , punctionisque sensum repraesentant ; tactu inaequalia sunt . Si uero non aduersa sed obliqua iunguntur , quod fit ubi loco suo non sunt , membrum id altero iam erit breuius et musculi eius tument .— Ergo si hoc depre nsum est , protinus id membrum oportet extendere : nam nerui musculique intenti per ossa contrahuntur neque in suum locum ueniunt , nisi illos per uim aliquis intendit . Rursus , si primis diebus id omissum est , inflammatio oritur ; sub qua et difficile et periculose uis neruis adhibetur : nam distentio neruorum uel cancer sequitur , uel cert e , ut mitissime a gatur, pus . Itaque si antea reposita ossa non sunt , postea reponenda sunt . Intendere autem digitum uel aliud quo dque membrum , si adhuc tenerum est , etiam unus homo potest , cum alteram partem dextr a , alteram sinistr a prendit : ualentius membr um duobus eget , qui in diuersa contendant . Si firmiores nerui sunt , ut in uiris robustis maximeque eorum feminibus et cruribus euenit , habenis quoque uel linteis fasceis utrimque capita articulorum deliganda , et per plures in diuersa ducenda sunt . Vbi paulo longius quam naturaliter esse debet membrum uis fecit , tum demum ossa manibus in suam sedem compellenda sunt , indiciumque ossi s repositi est dolor sublatus et membrum alteri aequatum . * inuoluendum duplicibus triplici busue panni s et in uino et oleo tinctis , quos linteos esse commodius est . Fere uero fasceis sex opus est . Prima breuissima adhibenda , quae circa fractura m ter uoluta , sursum uersum feratur et quasi in coclea m serpat ; satisque est eam ter hoc quoque modo circuire . Altera dimidio longio r , eaque , si qua parte os eminet , ab ea ; si totum aequale est , undelibet super fracturam debet incipere priori aduersa deorsumque tendere , atque iterum de fractura reuer sa in superiore parte ultra priorem fasciam desinere . Super has iniciendum latiore linteo ceratum est , quod eas contineat ; ac si qua parte os eminet , triplex ea pannus obiciendus eodem uino et oleo madens . Haec tertia fascia comprehendenda sunt , quartaque sic , ut semper insequens priori aduersa sit , et tertia tantum inferiore parte , tres in superiore f iniant ur. Atqu e satius est saepius circuire quam adstringi : siquidem id , quod adstrictum est , alienatur et cancro oportunum est : articulum autem quam minime uincire opus est , sed si iuxta hunc os fractum est , necesse est . Deligatum uero membrum in diem tertium continendum est ; eaque uinctura talis esse debet , ut primo die nihil offenderit , non tamen laxa uisa sit , secundo laxior , tertio iam paene resoluta . Ergo tum rursum id membrum deligandum , adiciendaque prioribus quinta fascia est ; iterumque quinto die resoluendum est , et sex fasceis inuoluendum sic , ut tertia et quinta infra , ceterae supra finiantur . Quotienscumque autem soluitur membrum , calida aqua fouendum . Sed si iuxta articulum fractura est , † die instillandum uinum est , exigua parte olei adiecta , eademque omnia facienda , donec adeo inflammatio soluatur uel tenuius quoque quam ex consuetudine id membrum fiat . Quod si septimus dies non dedit , certe nonus exhibet ; tum facillime ossa tractantur . Rursus ergo si parum commissa sunt , committi debent : si qua fragmenta eminent , in suas sedes reponenda sunt ; deinde eodem modo membrum deligandum , ferulaeque super adcommodandae sunt , quae fi xae circumpositaeque ossa in sua sede contineant ; et in quam partem fractura inclinat , ab ea latior ualentiorque ferula inponenda est . Easque omnes c ontra articulum esse oportet resimas , ne hunc laedant , nec ultra astringi quam ut ossa contineant ; et cum spatio laxentur , tertio quoque die paulum habenis suis coartari ; ac si nulla prurigo , nullus dolor est , sic manere , donec duae partes eius temporis , qu o quo dque os conferuet , compleantur : postea leuius aqua calida fouere , quia primo digeri materiam opus est , tum euocari . Ergo cerato quoque liquido id leniter est unguendum , perfricandaque summa cutis est ; laxiusque id deligandum est . Tertio quoque die soluendum sic , ut remota calida aqua cetera eadem fiant : tantummodo singulae fasciae , quotiens resolutae fuerint , subtrahantur . Haec communia sunt , illa propria : siquidem umerus fractus non sic ut membrum aliud intenditur , sed homo conlocatur alto sedili , medicus autem humiliore aduersus . Vna fascia bracchium amplexa e x ceruice ipsius , qui laesus est , id sustineat ; altera ab † altera parte super caput data ibi accipit nodum ; tertia uincto imo umero deorsum demittitur , ibi quoque capitibus eius inter se uinctis . Deinde ab occipitio ipsius minister sub ea fascea , quam secundo loco posui , porrecto , si dexter umerus ducendus est dextro , si sinister sinistro brachio demissum inter femina eius , qui curatur , baculum tenet : medicus super eam fasceam , de qua tertio loco dixi , plantam inicit dextra m si sinister , sinistram si dexter umerus curatur ; simulque alteram fasciam minister attollit , alteram premit medicus ; quo fit ut leniter umerus extendatur . Fasceis uero , si medium aut imum os fractum est , breuioribus opus est ; si summum , longioribus , ut ab eo sub altera quoque ala per pectus et scapulas porrigantur . Quae * * * Protinus uero bracchium , cum deligatur , sic inclinandum est idque efficit , cu m ante fascias quoque sic figurandum sit , ne postea suspens um aliter atque cum deligabatur , umerum inclinet . Bracchioque suspenso ipse quoque umerus ad latus leniter deligandus est ; per quae fit , ut minime moueatur ideoque ossa sic se habe ant, ut aliquis composuit . Cum ad ferulas uentum est , extrinsecus esse earum longissimae debent , a lacerto breuiore s, sub ala breuissimae . Saepiusque eae resoluendae sunt , ubi in uicinia cubiti umerus fractus est , ne ibi nerui rigescant et inutile bracchium efficiant . Quotiens solutae sunt , fractura manu continenda , cubitus aqua calida fouendus est et molli cerato perfricandus ; ferulaeque uel omnino non inponendae contra eminentia cubiti , uel aliquanto breuiores sunt . Ac si bracchium fractum est , in primis considerandum est , alterum os an utrumque comminutum sit ; non quo alia in eiusmodi casu curatio admouenda sit , sed primum , ut ualentius extendatur , si utrumque os fractum est , quia necesse est minus neruos contrahi altero osse integro eosque intendente ; deinde , ut curiosius omnia in continendis ossibus fia nt, si neutrum alteri auxilio est : nam ubi alterum integrum est , plus opis in eo quam in fasciis ferulisque est . Deligari autem bracchium debet paulum pollice ad pectus inclinato , siquidem is maxime bracchii naturalis habitus : idque inuolutum mitella commodissime excipitur , quae latitudine ipsi bracchio , perangustis capitibus collo inicitur . Atque ita commode bracchium ex ceruice suspensum est , idque paulum supra cubiti alterius regionem pendere oportet . Quod si ex summo cubito quid f ractum sit , glutinare id uinciendo alienum est : fit enim bracchium inmobile . Ac si nihil aliud quam dolori occursum est , idem qui fuit eius usus est . In c rure aeque ad rem pertinet alterum saltem os integrum manere . Commune uero ei femorique est quod , ubi deligatum est , in canalem coniciendum est . Is canalis et inferiore parte f oramina II habere debet , per quae , si quis umor excesserit , descendat ; et a planta moram , quae simul et sustineat eam et delabi non patiatur ; et a lateribus caua , per quae loris datis morae quaedam crus femurque , ut collocatum est , detinea nt. Esse etiam is debet a planta , si crus fractum est ; circa poplitem , si femur , usque ad coxam ; si iuxta superius caput femoris , sic , ut ipsa quoque e i coxa insit . Neque tamen ignorari oportet , si femur fractum est , fieri breuius , quia numquam in anti cum statum reuertitur , summisque digitis postea cruris eius insisti : sed multo tamen f oedior debilitas est , ubi fortunae neglegentia quoque accessit . Digitum satis est ad unum surculum post inflammationem deligari . His proprie ad singula membra pertinentibus , rursus illa communia sunt : primis diebus fames ; deinde tum , cum iam increscere callum oportet , liberalius alimentum ; longa a uino abstinentia ; fomentum aquae calidae , dum inflammatio est , libera le; ubi ea desit , modicum ; tum etiam longior ulterioribus e x liquido cerato membris et mollis tamen unctio . Neque protinus exercendum id membrum , sed * ad antiquos usus reducendum est . Grauius aliquanto est , cum ossis fracturae carnis quoque uulnus accessit , maxumeque si id musculi femoris aut umeri senserunt : nam et inflammationes multo grauiores et promptiores cancr os habent . Ac femur quidem , si ossa inter se recesserunt , fere praecidi necesse est . Vmerus uero quoque in periculum uenit , s ed facilius conseruatur . Quibus periculis etiam magis id expositum , quod iuxta ipsos articulos ictum est . Curiosius igitur agendum est , et musculus quidem , per mediam plagam transuersus praecidendus ; sanguis uero , si parum fluxit , mittendus ; corpus inedia extenuandum . Ac reliqua quidem membra lentius intendenda , et lenius in is ossa in suam sedem reponenda sunt : in his uero neque intendi neruos neque ossa tractari satis expedit ; ipsique homini permittendum est , ut sic ea collocata habeat , quemadmodum minime laedunt . Omnibus autem his uulneribus inponendum primo linamentum est uino madens , cui rosae paulum admodum adiectum sit , cetera eadem . Deligandaque fas cis sunt aliquanto quam uulnus latioribus , laxius scilicet quam si ea plaga non esset : quanto facilius et alienari et occupari cancro uulnus potest * * * numero potius fasciarum id agendum est , ut laxae quoque aeque contineant . Quod in femore umeroque sic fiet , si ossa forte recte concurrerint : sin aliter se habebunt , eatenus circumdari fascia debebit , ut inpositum medicamentum contineat . Cetera eadem , quae supra scripsi , facienda sunt , praeterquam quod neque ferulis neque canalibus , inter quae uulnus sanescere non potest , sed pluribus tantummodo et latioribus fasceis opus est : ingerendumque subinde in eas est calidum oleum et uinum , magisque in * * * primo fame utendu m ; * e st alien um; uulnus calida aqua fouendum , frigusque omni ratione uitandum ; et transeundum ad medicamenta , quae puri mouend o sunt ; maiorque uulneri quam ossi cura agenda : ergo cottidie soluendum nutriendumque est . Inter quae si qu od paruulum fragmentum ossis eminet , id si retusum est , in suam sedem dandum ; si acutum , ante acumen eius , si longius est , praecidendum ; si breuius , limandum et utrumque scalpro l euandum ; tum ipsum recondendum est . Ac si id manus facere non potest , uulsella , quali fabri utuntur , inicienda est recte se haben ti capiti ab ea parte , qua sima est , ut ea parte , qua gib ba est , eminens os in suam sedem compellat . Si id maius est membranulisque cing itur , sinere oportet ea s sub medicamentis resolui , idque os , ubi iam nudatum est , abscidere ; quod maturius scilicet faciendum est . Potestque ea ratione et os coire et uulnus sanescere , illud suo tempore , hoc prout se habet . Nonnumquam etiam in magno uulnere euenit , ut fragmenta quaedam uelut emoriantur neque cum ceteris coeant ; quod hic quoque ex modo fluentis umor is colligitur . Quo magis necessarium est saepius ulcus resoluere atque nutrire . Sequitur uero , ut id os per se post aliquot dies excidat . Cum iam misera antea condicio uulneris sit , tamen id interdum manus * * * diutiusque facies . Saepe enim integra cutis osse abrumpitur , protinusque prurigo et dolor oritur . Quae soluere , si accidit , maturius oportet , et fouere aqua per aestatem frigida , per hiemem egelida ; deinde ceratum myrteum inpon endum . At interdum fractur a quibusdam uelut aculeis carnem uexat : qu o prurigin e et p unctionibus cognit o , aperire id medicus e osque aculeos praecidere necesse habet . Reliqua uero curatio in utroque hoc casu eade m est , quae ubi ictus protinus * intulit . Puro iam ulcere cibis hic quoque utendum est carnem producentibus . Si breui us adhuc membrum est et ossa loco suo non sunt , e o paxillus tenuis quam leuissimi generis inter ea demitti debet sic , ut capite paululum supra ulcus emineat ; isque cottidie plenior adigendus est , donec par id membrum alteri fiat ; tum paxillus remouendus ; uulnus sanandum est ; cicatrix inducta fouenda frigida aqua est , in qua myrtus , hedera , aliaeue similes uerbenae decoctae sint ; inlinendumque medicamentum est quod siccet ; et magis etiam hic qu iescundum , donec id membrum confirmetur . Si quando uero ossa non conferuuerunt , qu ia saepe solut um, saepe motu m , in apert o deinde curatio est : possunt enim coire * * Si uetustas occupauit , membrum extendendum est , ut aliquid laedatur : ossa inter se manu diuidenda , ut concurrendo exasperentur , ut , si quid pingue est , eradatur totumque id quasi recens fiat , magna tamen cura habita , ne nerui musculiue laed antur. Tum uino fouendum est , in quo malicorium de coctum sit ; i nponendumque id ipsum oui albo mixtum : tertio die resoluendum fouendumque aqua , in qua uerbenae , de quibus supra dixi , decoctae sint : quinto die idem faciendum , ferulaeque circumdandae . Cetera et ante et post eadem facienda , quae supra scripsi . Solent tamen interdum transuersa inter se ossa conferuere , eoque et breuius membrum et indecorum fit ; et si capita acutiora sunt , adsiduae punctiones sentiuntur . Ob quam causam frangi rursus ossa et derigi debent . Id hoc modo fit . Calida aqua multa membrum id fouetur , et ex cerato liquido perfricatur intenditurque . Et inter haec medicus pertractans ossa , ut adhuc tenero callo , manibus ea d iducit , compelli tque id , quod eminet , in suam sedem ; et , s i parum ualuit , ab ea parte , in qua m os se inclinat , e i inuolutam lana regulam obicit ; atque ita deligando adsuescere iterum uetustae sedi cogit . Nonnumquam autem recte quidem ossa co ierunt , superincreuit uero nimius callus , ide oque locus is intumuit . Quod ubi incidit , diu leuiterque id membrum perfricandum est ex oleo et sale et nitro , multumque aqua calida salsa fouendum ; et inponendum malagma quod digerat , adstrictiusque alligandum ; holeribusque et praeterea uomitu utendum , per quae cum carne callus quoque extenuatur . Confertque aliquid e o sinapi quod cum ficu in alterum par membrum inpositum * donec id paulum erodat eoque euocet materiam . Vbi his tumor extenuatus est , rursus ad ordinem uitae reuertendum est .	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.