BOOK VIII.

CHAP. I. OF THE SITUATION AND FIGURE OF THE BONES OF THE HUMAN BODY.

It now remains, that I speak of what relates to the bones: for the easier understanding of which, I shall first describe their situations and forms. The first then is the skull, which is concave on the internal side, externally gibbous, and on each side smooth, both where it covers the membrane of the brain, and where itself is covered by the skin, from which the hair grows. In the occiput and temples it is simple; but double from the forehead to the vertex. And the bones of it in their external part are hard; on the inside, where they are connected with each other, softer. And veins are distributed between them, which probably supply them with nourishment.

Now the skull is rarely entire without sutures; but in hot countries it is more frequently found so. And such a head is strongest, and the most safe from pain; of others, the fewer sutures there are, so much the freer is the head from complaints; for their number is not certain, nor indeed their situation. However, for the most part two above the ears divide the temples from the upper part of the head; the third running to each side through the vertex, separates the occiput from the top of the head; the fourth goes from the vertex along the middle of the head to the forehead; and this ends in some at the point, to which the hair extends, in others between the eye-brows, dividing the forehead itself(1). The other sutures are exactly fitted to each other upon the same level. But the transverse ones above the ears, grow gradually thinner to their edges; and thus the inferior bones slightly overtop the superior ones. The bone behind the ear is the thickest in the head; for which reason, probably hair does not grow there. Over these muscles too(2), that cover the temples, a bone is situated in the middle, which is inclined to the external part. But the face has the largest suture; which beginning from the one temple runs transversely through the middle of the eyes, and the nose, to the other temple; from which two short ones point downward under the internal angles. The cheek-bones also have each of them a transverse suture in the upper part. And from the middle of the nose, or the sockets of the upper teeth, proceeds one through the middle of the palate; and another also divides the palate transversely. These then are the sutures found in most people.

The largest foramina of the head are those of the eyes; next the foramina of the nose; then those we have at the ears. The foramina of the eyes run straight and undivided to the brain. Two foramina are observed in the nose, divided by a bone in the middle: for these about the eye-brows and angles of the eyes begin osseous, and so proceed near the third part of the way; then turning cartilaginous, the nearer they approach to the mouth, so much the softer and more fleshy they become. But these foramina, which from the beginning of the nostrils to the internal part are simple, are there again divided each into two courses; the branches opening into the fauces both emit and receive the breath; the others go to the brain; in the end they are branched into many small openings, which afford the sense of smelling. In the ear too the passage at first is straight, and simple, but farther in, it becomes winding; the part next the brain is separated into many and small openings, from which we have the faculty of hearing. Near these there are as it were two small sinuses; and above them, that bone terminates, which going in a transverse direction from the cheeks is sustained by the inferior bones. It may be called jugale from the same resemblance, which gave it the Greek name of Zygodes[ HW ]. The maxilla is a soft bone(3), and only one in number: the middle and lowest part of which compose the chin; from whence it proceeds on both sides to the temples; and this only moves: for the malæ with the whole bone, that contains the upper teeth, are immoveable: but the extremities of the maxilla shoot as it were into two horns. One of these processes is broader below(4), and is narrowed at the vertex, and being extended forward enters below the os jugale, and over that is tied down by the muscles of the temples. The other is shorter and rounder, and is lodged like a hinge in that cavity, which is near the foramina of the ear; and there turning itself different ways, gives the maxilla a power of moving.

The teeth are harder than bone; part of them are fixed in the lower jaw-bone, and part in the upper. The four first from their cutting are by the Greeks called tomici[ HX ]. On each side of these above and below stand the four canine teeth; beyond which there are commonly five maxillary teeth, except in those, in whom the genuine (dentes sapientiae) which generally grow late, have not come out. The fore teeth adhere each by one root, the maxillary by two at least, some by three or four. And a longer root commonly emits a shorter tooth; and the root of a straight tooth is straight, that of a crooked one bent. From this root in children, a new tooth springs, which most frequently forces out the former; sometimes however it appears above or below it.

Next to the head is the spine, which consists of twenty-four Vertebræ. There are seven in the neck, twelve by the ribs, and the other five are below the ribs. These are round and short, and send out two processes on each side; in the middle they are perforated, where the spinal marrow, connected with the brain, descends. The sides also between the two processes are perforated by small holes, through which, from the membrane of the brain similar small membranes proceed. And all the Vertebræ(5) (except the three uppermost) at the superior part in the processes themselves have small depressions; at the lower, on the contrary, they send out processes pointing downwards. The first then immediately sustains the head, by receiving small processes of it into two depressions; which is the reason that the surface of the head below is rendered unequal by two prominences. The second is inserted into the under part of the first, and the superior part of the second is round and narrow (processus dentatus) in order to admit of a circular motion, so that the first surrounding the second allows the head to move towards each side. The third receives the second in the same manner; whence the neck has great facility of motion. And indeed it would not be able to sustain the head, if straight and strong nerves on each side did not secure the neck; these the Greeks call Carotæ. For one of them in every flexure, being always stretched, prevents the upper parts from slipping further. The third Vertebra has prominences, which are inserted into that below it. All the rest are inserted each into its inferior one by processes pointing downwards; and by depressions, which they have on each side, they receive the superior, and are secured by many ligaments, and a great quantity of cartilage. And thus one moderate flexure forward being allowed, a man both stands erect for some kinds of employment, and at other times bends himself as the actions he is engaged in require.

Below the neck, the first rib is situated opposite to the shoulders. After that the six inferior ones(6) reach the bottom of the breast: and these at their origin being round, and furnished with something like small heads, are fixed to the transverse processes of the vertebræ, which are in that part a little depressed; then they grow broader, and bending outward, degenerate gradually into cartilage; and in that part being again turned gently inward, are joined to the pectoral bone: which begins strong and hard at the fauces, being excavated on each side, and terminates at the præcordia, where it is softened into a cartilage. And under the superior ribs there are five, which the Greeks call Nothæ (spurious) shorter, and thinner, which also gradually turn to cartilage, and adhere to the external parts of the abdomen; the lowest of these in the greatest part of it is nothing else but a cartilage.

From the neck two broad bones, one on either side, go to the shoulders, by us called scutula operta, by the Greeks Omoplatæ. These have cavities at their vertices; from the vertices they become triangular, and growing gradually broader tend to the spine; and the broader they are in any part, so much the duller is their sensation. These too at their extremity are cartilaginous, and in their back part lie as it were loose, because, unless at the top, they are fixed to no bone, but are there tied down by strong muscles and nerves.

But at the first rib(7) a little within the middle of it, a bone grows out, in that part indeed slender; but going forward, the nearer it comes to the broad bone of the scapula, it becomes thicker, and broader, bending a little inwards, which being a little enlarged at its other vertex, sustains the clavicle. This bone is crooked, and is to be reckoned amongst the hardest bones; the one end of it is joined to the bone I just mentioned before, and by the other it is fixed in a small depression of the pectoral bone, and is moved a little in the motion of the arm; and its lower head is connected by ligaments and a cartilage with the broad bone of the shoulders.

Here the humerus begins, which at both its ends is enlarged, soft, without marrow, and cartilaginous; in the middle round and hard, and containing marrow; is a little concave(8) in its fore and internal part; and convex in its posterior and external part. Now the fore part is next the breast; the posterior is toward the scapulæ; the internal next the side; and the external at the greatest distance from the side: which distinctions will afterwards appear applicable to all joints in the extremities. The upper end of the humerus is rounder than the other bones, which I have yet mentioned, and a small part of it is inserted into the vertex of the broad bone of the shoulder; the greatest part, standing out of it, is secured by ligaments. But the inferior head has two processes; the intermediate space between which, is even more depressed than its extremities.

This affords a reception to the fore-arm; which consists of two bones. The Radius, which the Greeks call cercis[ HY ], is the superior one and shorter, and at first being more slender, with its ends round, and a little concave, receives the small tubercle of the humerus, which is secured there by ligaments and a cartilage. The cubitus is the inferior and longer; it is at first larger in its upper end, and by two vertices, as it were, standing out, fixes itself into the sinus of the humerus, which I mentioned, betwixt its two processes. The two bones of the fore arm at first(9) are close together, then separate by degrees, and meet again at the hand, their former proportions being reversed: for there the radius is pretty large, and the cubitus very small. After that the radius rising to a cartilaginous head is inserted into its neck. The cubitus is round at its extremity, and projects a little on one part. And to save frequent repetition, this ought to be known, that most bones end in a cartilage, and that every articulation is thus terminated: for it could neither be moved, unless it pressed upon something smooth, nor be joined with flesh and ligaments, unless these were connected by some matter of a middle nature.

In the hand, the first part of the palm consists of many and small bones, the number of which is uncertain. But all of them are oblong and triangular, and connected together by a peculiar kind of structure, the plain of each one being higher than another alternately; whence it happens, that the whole makes up the appearance of one bone a little concave on the internal part. But from the hand two small processes are lodged in the cavity of the radius. Then at the other end five straight bones going to the fingers, compleat the palm; from which the fingers themselves have their origin. These consist each of three bones. The conformation of them all is the same. The more internal bone has a depression in its vertex, and receives the small tubercle of the external, and these are secured by ligaments. From them arise the nails, which grow hard: and thus they adhere by their roots, not to bone, but rather to flesh. This then is the construction of the superior parts.

But the lower part of the spine ends in the hip-bone, which is transverse, and far the strongest, and defends the womb, bladder, and intestine Rectum. And this in the external part is convex; at the spine inclined backward; on the sides, that is, at the hips themselves, it has round cavities; from whence arises the bone, which is called pecten; and that being situated transversely over the intestines under the pubes, strengthens the belly; it is straighter in men, but in women more bent externally, that it may not prevent the birth.

From these proceed the thigh bones; the heads of which are still rounder than those of the humeri; though the latter have more rotundity, than is found in any of the rest. A little lower they have two processes on the fore and posterior part. From that they descend hard and full of marrow, externally convex, and are again enlarged at the inferior heads. The superior ones are inserted into the cavities of the hip-bone, as the humeri into the bones of the scapulæ; then, lower down, they slope gently inward, that they may more equally sustain the superior parts. And their inferior heads have also depressions between them, that they may be the more easily received by the bones of the leg: which articulation is covered by a small, soft, and cartilaginous bone, which is called Patella. This floating above, and not being fixed to any bone, but bound down by flesh and tendons, and a little more inclined to the thigh bone, defends the joint in all flexures of the legs.

The leg consists of two bones; for in every thing the thigh resembles the arm, and the leg the fore-arm; so that the shape and elegance of the one may be known from the other; which beginning with the bones, answers also in the flesh. One of these bones is situated on the external part of the calf of the leg, and from that properly enough takes the name of Sura(10). This is shorter and more slender above, but is enlarged at the ancles. The other, which is placed in the fore part, and has the name of Tibia, is longer and larger in the upper part, and is alone connected with the lower end of the thigh-bone, as the cubitus is with the humerus: and these bones too, being joined both below and above, separate in the middle, as those of the fore arm.

The leg bones are received below by a transverse bone in the ancle; and that is situated above the heel bone; which in one part has a depression and in another prominences, and it both receives the processes from the ancle-bone, and is inserted into its cavity. And this is hard, without marrow, and projecting more to the posterior part makes a round figure there. The other bones of the foot are constructed in a similar manner to those of the hand. The soles answer to the palms, the toes to the fingers, and the nails to the nails.

CHAP. II. GENERAL DIVISION OF DISORDERS IN THE BONES. OF A BLACKNESS AND CARIES, AND THEIR TREATMENT.

Whenever a bone is injured, it is either corrupted, or fissured, or fractured, or perforated, or contused, or dislocated. A corrupted bone generally turns first oily, and afterwards either black or carious. These cases happen from large ulcers, or fistulas over them, when they have either grown antient, or have been seized with a gangrene. First of all it is necessary to lay bare the bone, cutting out the ulcer, and if the disorder extends farther than the ulcer was, to pare away the flesh below, till the sound part of the bone be exposed all round; then it is sufficient to cauterize the part that is oily, once or twice, by the application of an iron instrument, that so a scale may cast off; or to scrape it, till some blood appear, which is the mark of a sound bone: for whatever is vitiated must necessarily be dry. The same method must also be pursued in a cartilage that is injured; for that too must be scraped by a knife, till what remains be sound. And then what is thus scraped, whether bone or cartilage, must be sprinkled with nitre well powdered. And nothing else is to be done, where a caries or blackness is in the surface of the bone: for in that case, the cautery or the scraping must only be continued a little longer. A person, that scrapes these, ought to press the instrument boldly, that he may both do it effectually, and have the sooner done. The operation is finished, when we come to the white or firm bone. It is evident, that when the defect is a blackness, it ends in the white, and that where there is a certain degree of solidity, there the caries terminates. We have already observed, that there is also some blood in a sound bone: But when either of these happen to go in pretty deep, it is uncertain where they end.

It is easy to form a judgment in a caries, if a small probe is introduced into the foramina, which by penetrating more or less, shews that the caries is either in the surface, or of greater depth. The same may be collected(11) even from the pain and fever; for when these are moderate, it cannot have penetrated deep. A greater certainty is obtained however by the application of the perforator: for the disease ends, where the dust of the bone ceases to be black. Therefore if the caries has gone deep, several holes must be made in it by the perforator, as deep as the disease goes; then into these holes must be put hot irons, till the bone become entirely dry. For the consequences of this operation will be, that whatever is spoilt will be separated from the bone below; and the cavity will be filled up with flesh; and afterwards either no humour at all, or a small quantity will be discharged.

But if the blackness goes through(12) to the other side of the bone, it ought to be cut out. The same may be done also in a caries, that penetrates to the other side of the bone. But where the whole is spoilt, the whole must be taken away. If the inferior part is sound, so far as is corrupted, ought to be cut out. Likewise if the skull or pectoral bone, or a rib be carious, the actual cautery is needless, but there is a necessity for excision. Neither does the opinion of these people deserve our attention, who defer the excision to the third day after the bone is laid bare, before they cut it out; for in all cases it is safer to perform an operation, before an inflammation come on. Therefore both the skin is to be cut, and the bone laid bare, and freed from every fault, as far as possible, in the same moment. Now a disease in the pectoral bone is far the most pernicious of any; because though the operation have succeeded well, it hardly ever restores a perfect soundness.

CHAP. III. OF THE USE OF THE MODIOLUS AND PERFORATOR, AND OTHER INSTRUMENTS, ESPECIALLY FOR THE BONES OF THE HEAD.

There are two ways of cutting out a bone; if the part injured be very small, by a modiolus, which the Greeks call chœnicion[ HZ ], if larger by terebræ. I shall explain the method of each. The modiolus is a concave and round iron instrument with serrated edges in its lowest extremity; through the middle of which is put a pin, surrounded also by an interior circle. Of perforators there are two kinds: one of them resembling that, which carpenters use; the other with a longer head, which begins from a sharp point, and then turns quickly broader; and again from another beginning goes upward with thickness pretty near equal.

If the disease be confined to a small space, so that the modiolus can cover it, that must be used preferably. But if a caries appear below, the pin in the middle is put into the opening. If there be a blackness, a small hole is made by the angle of a chisel(13) to receive the pin, that the modiolus resting upon that, by being turned round may not slip, and then it is turned like the perforator by a strap. And there is a certain degree of pressure required, that both a perforation may be made, and it may go round; because if it be lightly impressed, it does not produce the effect; if too much, it has no motion. And it is not improper to drop in a little rose oil or milk, the smoothness of which may make it turn with the greater ease; yet too much of the liquid blunts the edge of the instrument. But when the modiolus has marked out a way for itself, the middle pin is taken out, and it is worked about by itself. And then, when the soundness of the inferior part is discovered by the dust, the modiolus is taken away.

But if the disease is more extended than to be covered by that, we must make use of the perforator. By this a hole is made in the limit, that divides the injured from the sound part of the bone; and not far from that a second, and a third, till the part, that is to be cut out, be surrounded with these holes. And in this case too the dust indicates how deep the perforator is to go. Then a chisel being drove by a mallet from one hole to another, cuts out the intermediate space between them; and thus a circumference is formed like to that, which is imprinted in a smaller circle by the modiolus. In whichever way the circle has been made, let the same chisel, laid flat on the corrupted bone, smooth each superior lamina, till the bone be left entirely sound.

A blackness hardly ever goes quite through a bone, but a caries does, especially where the skull is faulty. There also the disorder is discovered by the probe, which being introduced into the hole, that terminates at the sound part of the bone, both finds some resistance, and comes out moist. If it prove pervious, the probe going in deeper between the bone and the membrane, meets with no resistance, and comes out dry: not because there is no corrupt sanies within, but because it is there diffused, as being in a larger cavity.

Now whether a blackness, which the perforator has discovered, or a caries, which the probe has shewn, pass through the bone, the use of the modiolus is generally fruitless: because, where the disease has penetrated so deep, it must also necessarily be largely extended in breadth. Here then we must use the second kind of perforator above described; and to prevent its growing too hot, it must be dipped now and then in cold water. But then we must proceed with greater caution, when we have perforated either half through in a simple bone, or the superior lamina in a double one. The space itself guides us in the first case; and in the other, the blood. Therefore at that time the strap must be drawn slower, the left hand should press more gently, and be taken off pretty frequently: also the depth of the perforation is to be considered, that we may be sensible whenever the bone is broke through, and run no risque of wounding the membrane of the brain by its point, from which proceed violent inflammations, with danger of death.

When the holes are made, the intermediate spaces must be cut out in the same manner, but with much more circumspection; lest the angle of the chisel chance to wound the same membrane; till a passage be made, through which the instrument to protect the membrane may be introduced. The Greeks call it meningo-phylax[ IA ]. It is a copper plate, firm, bent a little upward towards the end, and externally smooth: which being introduced in such a manner, that its external surface be next the brain, is put under that part, which is to be separated by the chisel; and if it receives its angles, it stops its progress; and upon this account the physician repeats his strokes upon the chisel both more boldly, and more safely, till the bone being cut out all round is raised by this plate, and may be taken away without any hurt to the brain. When the whole bone is taken out, the edges must be scraped round and smoothed, and if any dust has fallen upon the membrane, it must be gathered up. When the superior part is taken away, and the inferior left, not only the edges, but the whole bone must be smoothed, that the skin may afterwards generate upon it without being hurt, which growing upon a rough bone, does not immediately become sound, but produces new pains.

The steps to be taken after the brain is uncovered, I shall mention, when I come to fractured bones. If any base is preserved, medicines not greasy, that are calculated for recent wounds, must be applied, and over them must be laid sordid wool moistened with oil and vinegar. In process of time flesh grows from the bone itself, which fills up the cavity made by the operation. And when any bone is cauterized, it separates from the sound part, and granulations sprout up between the sound and mortified part, which expel what has separated. And this, because it is a thin and small lamina, by the Greeks is called lepis[ IB ], that is, a scale.

It may happen too, that from a blow, a bone may be neither fissured, nor broke through, but the surface of it only contused, and rendered rough. When this occurs, it is sufficient to scrape and smooth it. Though these methods are most commonly practised in the head, yet they are common to the other bones too; so that wherever the like case shall occur, the same remedy must be used. But as they are fractured, fissured, perforated, and contused, they require some particular methods of cure in each kind, and in most of them, some general ones also. Of these I shall proceed to treat, beginning with the head.

CHAP. IV. OF FRACTURES OF THE SKULL.

When a blow has been received upon the skull, we must immediately enquire, whether the person has vomited bile; whether he have lost his sight, or his speech; whether blood has issued by his nostrils, or ears; whether he has immediately fallen down; whether he has lain insensible, as if asleep: for these do not happen without a fracture of the bone. And when they occur, we may be assured, that an operation is necessary, but of uncertain success. If besides, a torpor has come on; if he is delirious, if either a palsy, or a convulsion has followed, it is probable that the membrane of the brane too is wounded; and of such patients there is still less hope. But if none of these have ensued, and it may be doubted, whether the bone be fractured, it is first to be considered, whether the blow was given by a stone or a stick, or iron, or any other weapon, and whether the instrument was smooth, or rough, small or large, whether struck with force, or more lightly; because the more gentle the stroke was, so much the more easily we may suppose the bone to have resisted it. But it is best to examine that by a more certain mark. Therefore a probe ought to be introduced where the wound is, neither too small nor sharp, lest if it should light upon any of the natural sinuses, it mislead us into an opinion of a fracture, where there is none; and not too thick, lest small fissures escape it. When the probe comes to the bone, if nothing but what is smooth and slippery occur, one may judge it to be sound; if there is an asperity, especially where there are no sutures, that is an evidence the bone is fractured.

Hippocrates has recorded, that he was himself deceived by the sutures. This is the custom of great men, who have a just consciousness of their own superior abilities: for little minds, because they are deficient in every thing, never allow themselves to be deficient in any. An ingenuous confession of an error is worthy of a great genius, who will have enough besides to entitle him to esteem; and it is especially laudable in a practical art, which is handed down to posterity for their benefit; that they may not be deceived in the same way another was deceived before them. A regard to the memory of a professor, in other respects so great a man, led us into this digression.

Now a suture may deceive for this reason, because it is equal in asperity to the other; so that though there be a fissure, one may readily take it for a suture, in a place, where it is likely one lies below. Therefore it is not fit to be thus deceived; but the safest method is to lay bare the bone: for, as I observed before, the place of the sutures is not certain; and the same part may both have this natural junction, and be fissured by a blow, or may have some fissure near it. Nay sometimes, when the blow has been violent, though nothing be found by the probe, yet it is better to open it. And if even then the fissure is not manifest, writing ink must be drawn over the bone, and then scraped off with a chisel, for if there be any fissure it retains the blackness.

Sometimes it even happens, that the blow has been given on one side, and the bone fissured on the other. For that reason, if upon receiving a violent blow, bad symptoms have followed, and no fissure be found in that part, where the skin is lacerated; it is not improper to consider, whether any part on the opposite side be softer, and swelled; and to open that; for there a fissure in the bone will be found. Nor is it very troublesome to heal the skin again, though nothing has been discovered by the incision. A fractured bone, unless help be seasonably administered, brings on violent inflammations, and is treated with more difficulty afterwards.

Rarely, but sometimes it happens, that the whole bone remains sound; but from the blow some internal vein in the membrane of the brain is broke, and discharges blood, which being coagulated there, raises violent pains, and deprives some people of their sight. But there is generally a pain in the part that covers it, and an incision being made in the skin there, the bone is found pale; and therefore this must also be cut out. Upon whatever account this operation is necessary, if the opening of the skin is too small, it must be enlarged, till all the injured part be in view. In this great care must be taken to leave upon the bone no part of that fine membrane that covers the skull below the skin; because when this is lacerated by the chisel, or perforators, it excites violent fevers with inflammations. Therefore it is better to separate it entirely from the bone. If the external wound be made by the blow, we cannot alter the form of it. If we are to make one, the best is that made by two transverse lines in the shape of the letter X, that afterwards the skin may be cut below, beginning at each of the prominent angles.

If blood is discharged in the time of doing this, it must be frequently restrained by a spunge dipped in vinegar, and taken up by lint applied upon it, and the head raised high. This accident is attended with no danger except among the muscles, which secure the temples; but even in that place there is no safer method.

In almost every fissure, or fracture of the bone, the ancient physicians had immediate recourse to instruments to cut it. But it is far the best method, first to try plaisters that are composed for the skull. Some one of these, it is proper to soften with vinegar, and apply alone upon the fissured or fractured bone; then over that, somewhat broader than the wound, a piece of linen spread with the same medicine, and besides that, sordid wool dipped in vinegar; then to bind up the wound, and open it again every day; and dress it in this manner for five days; from the sixth, to foment it also with the vapour of hot water by a spunge, continuing all the former treatment. And if granulations begin to grow, if the febricula is either gone, or abated, if the appetite has returned, and the patient gets sufficient sleep, we must continue the same dressings. Some time after, the plaister must be softened, with the addition of a cerate made of rose oil, to promote the growth of flesh: for, by itself, it has a repellent quality. By this method often the fissures are filled with a kind of callus, which is as it were a cicatrix in a bone. And in large fractures, if the bones do not cohere together in any part, they are united by the same callus; and this is a far better covering to the brain, than the flesh that grows, when the bone is cut out. If, under the first treatment, the fever increases, the sleeps are short and disturbed by dreams, the ulcer is moist and does not fill, small glandular swellings rise in the neck; the pains are violent; and with all these the loathing of food increases; then, and only in that case, recourse must be had to the hand and the chisel.

There are two dangers attending a blow upon the skull; that it be either split, or depressed in the middle. If it is fissured, the lips of it may be compressed; either because one of them rises above the other, or even because they have run together again with force: whence it happens, that a humour descends upon the membrane, and has no vent, and thus irritates it, and brings on violent inflammations.

When the bone is depressed in the middle, it presses upon that same membrane of the brain; and sometimes also some sharp points from the fracture, prick it. In the cure of these cases as little as possible must be taken off the bone. Therefore, if one edge rests upon the other, it is sufficient to cut off the prominence with a plain chisel. After that is removed, if the fissure gapes a little, it is enough for the cure. But if the edges are compressed together, an opening must be made with the perforator, at a finger’s breadth distance on one side, and from that the chisel must be carried in two lines, to the fissure, in the form of the letter Λ: so that the vertex of it may be at the opening, and the base at the fissure.

But if the fissure extends to a great length, it will be proper to repeat the operation from another foramen; and thus nothing that is broke off can be concealed under the bone, and a large opening is procured for whatever is hurtful within. Nor is it necessary to cut out the whole of a fractured bone, though it be depressed; but if it be either entirely broke through, and has separated wholly from the cranium, or if it adhere to the surrounding skull in a small part, it must be divided from the sound bone by the chisel. Then in the depressed bone, near the fissure we have made, holes must be bored; if the injured part be small, two; if larger, three; and the spaces betwixt these must be cut out; and then the chisel must be drove on both sides to the fissure, in such a manner as to make a semicircular cavity, and let the middle part be toward the fracture, and the horns point to the sound bone. Then if any pieces be loose, and can be easily taken away, they must be removed by the forceps, which is made for that purpose, especially those sharp pieces, which irritate the membrane. If this cannot be easily done, the plate, which I called meningo-phylax, must be put below it; and above that whatever is prickly, and stands inward, must be cut off; and whatever is depressed inward must be raised by the same plate. The effect of such treatment is, that the fractured bones, if they adhere together in any part, may be consolidated; and wherever they are broke away, in time they may be separated by medicines without any pain; and at the same time a space may be left sufficiently large between them, to evacuate the sanies; and the brain may have a better protection from the bone than it would have had, if that were cut out.

After these things are done, the membrane must be sprinkled with sharp vinegar; that, if there be a discharge of blood from it, it may be restrained, or if any blood remain coagulated within, it may be discussed; then the same medicine must be applied, softened in the manner above prescribed, to the membrane itself; the other directions, which relate to the linen spread, and the sordid wool, must be observed in the same manner, and the patient must be kept in a warm place, and the wound dressed every day; and in summer even twice.

But if, by reason of an inflammation, the membrane has swelled, warm rose oil must be infused upon it. If it shall swell to such a height as to rise above the bones, it will be restrained by lentils well powdered, or vine leaves powdered, and mixed with either fresh butter, or recent goose fat; and the neck will require to be mollified by liquid cerate made of iris ointment. But if the membrane shall appear not to be clean, equal quantities of the plaister and honey must be mixed; which must be infused upon it; and to keep that on, a piece of lint or two must be clapped on, and that again covered with a linen cloth spread with a plaister. When the membrane is sufficiently clean, cerate must be added in the same manner to the plaister to promote the growth of flesh.

As to abstinence, and the food, and drink, in the first and more advanced stages of the cure, the same rules must be observed which I prescribed in wounds, and with the greater exactness, by how much a hurt in this part is more dangerous. Nay even when it shall be fit to allow such a quantity of food as not barely to sustain the patient, but to nourish him, yet every thing that requires chewing must be avoided; also smoke, and whatever excites sneezing. The membrane being moveable, and of its natural colour, granulations of ruddy flesh, and an easy motion of the lower jaw and neck, afford certain hopes of recovery. The bad signs are, the membrane immoveable, black, livid, or of any other vitiated colour; a delirium, acrid vomiting, a palsy, or convulsion, livid flesh, or rigor of the jaws and neck. The other symptoms that relate to sleep, appetite, fever, and the colour of the pus, are either salutary or mortal, as in other wounds.

When the case succeeds well, the growth of flesh begins from the membrane itself; or if the bone in that part be double, it sprouts from thence too, and fills up the void space between the bones; sometimes it even rises higher than the surface of the skull. If that happens, copper scales must be sprinkled on to keep it down; and medicines applied to bring a cicatrix over it, which is easily obtained in every place, except the part of the forehead, which is a little above the space that lies between the eyebrows (sinus frontalis): for there, an ulceration for the whole life after, can hardly be prevented; this must be covered with a linen cloth spread with a medicine. And the following directions must be always observed in a fractured skull, that till the cicatrix be strong, the sun, wind, frequent bathing, and excess in wine be avoided.

CHAP. V. OF FRACTURES OF THE NOSE.

In the nose, both the bone and the cartilage are liable to be fractured; and that sometimes happens in the fore part, sometimes on one side. If either both, or one of them be fractured in the fore part, the nostrils fall in, and the breath is drawn with difficulty. If the bone is fractured on one side, that part is hollow; if the cartilage, the nostrils are turned to the opposite side.

Any part of the cartilage, that has given way, must be gently raised, either by a probe put under it, or two fingers compressing it on both sides; then lint platted of a due length, sewed up in soft leather, must be put within; or some part of a dry penecillum composed in the same manner; or a large quill dipped in gum or joiner’s glue, and covered with soft leather, which prevent the cartilage from sinking in. But if the fracture be in the fore part, both nostrils are to be equally filled. If on one side, what is put in ought to be thicker in that part where the nose falls in, and smaller on the other; and externally, a soft strap must be carried round, the middle of which is spread with fine flour and soot of frankincense mixed together; and this must be drawn beyond the ears, and the two ends being crossed there and returned, are to be glued to the forehead: for it sticks to the skin like glue, and when it has grown hard, it keeps the nostrils firm. But if what is put within gives pain, which happens chiefly where the interior part of the cartilage is broke through, the nostrils being raised in the same(14) manner, must be only held firm by the strap abovementioned; then, after fourteen days, that must be removed; it is to be separated by hot water, with which also the swelled part(15) must be fomented every day.

But if the bone be fractured, that must also be reduced into its place by the fingers; and when the fracture is in the fore part, both nostrils must be filled; when on the side, that to which the bone has been forced; cerate also must be applied, and it is to be bound down a little more tightly; because in that part, there not only grows callus enough to make it sound, but even to form an eminence. From the third day, it must be fomented with hot water, and the more so, the nearer it may be expected to approach a sound state. And if there be several small pieces in the fracture, nevertheless each of them that are beat in, must be forced into its place by the fingers: also the strap must be applied externally, as before directed; and over that a cerate, without any other bandage.

But if any fragment be separated all round, and will not be united with the rest, as may be known from the humour, which will be discharged in great quantity from the wound, it must be extracted by a vulsella; and when the inflammation is gone, some one of those medicines that are gently repellent, must be applied. The case is worse, when besides a fracture of the bone, or cartilage, there is also a wound in the skin. This very seldom occurs. When it does happen, they must nevertheless be raised to their place in the same manner; and upon the skin must be laid some one of these plaisters, that are adapted to recent wounds: but no bandage must be applied over it.

CHAP. VI. OF FRACTURES OF THE EARS.

Sometimes the cartilage of the ear is broke. When this happens, an agglutinating medicine must be applied, before a suppuration begins; for that often prevents it, and heals the ear. Both here and in the nose, it should be understood, that the cartilage itself is not re-united, but that the flesh growing round it consolidates the part; and therefore, if, together with the skin the cartilage is broke, the skin is sewed on both sides; but I now speak of the cartilage fractured, when the skin is entire. If pus then is already formed, the skin must be opened on one side, and over against the incision, the cartilage itself must be cut in a lunated form; then a gentle styptic must be used; such as lycium diluted with water, till the bleeding be stopped; after that a plaister that is not greasy, spread upon linen, must be laid on, and soft wool put behind the ear, to fill up the space between that and the head; then it must be fastened by a gentle bandage; and from the third day fomented with warm water, as I directed for the nostrils; and in these kinds of accidents, at first abstinence is necessary, till the inflammation be gone.

CHAP. VII. OF A FRACTURED MAXILLA, TOGETHER WITH SOME GENERAL OBSERVATIONS RELATING TO FRACTURES.

As I am to proceed from these parts to the lower jaw, I think it proper to insert some observations relating to all the bones in general, to prevent a frequent repetition of them. Every bone then is sometimes split longitudinally, like wood, sometimes is fractured transversely, sometimes obliquely; and in this last species the ends are sometimes blunt, sometimes acute, which last is of the worst kind; because they are not easily united, where they do not rest upon something obtuse, then they also wound the flesh, and sometimes a nerve or a muscle: moreover, one fragment sometimes happens to be divided into several. In fractures of the other bones, one end often recedes entirely from the other; but the broken ends of a jaw-bone remain always in contact in some one part.

Therefore, first the bones are to be forced into their place, by two fingers pressing on each side, both within the mouth and upon the chin; then if the fracture of the jaw-bone be transverse, (in which case one tooth generally stands out beyond that next to it) when it is reduced, the two contiguous teeth, or if they are loose, those next to them, must be tied together by a horse-hair. In a different kind of fracture this is needless. All the other steps are the same as in the above-described fractures; for a double linen cloth dipped in wine and oil must be laid upon it, and with that fine flour, and the soot of frankincense; then a roller or soft strap, with a longitudinal opening in the middle, that it may take in the chin both above and below; and lastly, the ends of it must be brought over the head and tied there.

With regard to the bones in general, it may further be remarked once for all, that fasting at first is necessary; then from the third day moist food; when the inflammation is removed a little fuller diet and such as promotes the growth of flesh; wine is hurtful through the whole time. On the third day, they ought to be opened, and fomented with the vapour of hot water by a spunge, and the same dressings, as at first, are to be put on; this to be repeated on the fifth day, and so on, till the inflammation is gone, which ceases, either on the ninth day, or generally on the seventh: when that is removed, the bones must be examined again, that if any fragment is not in its place, it may be reduced, and the bandage must not be taken away, till two thirds of the time have elapsed, in which the several bones unite.

Now, generally between the fourteenth and twenty-first day, the following bones heal: the lower jaw, cheek-bone, clavicle, breast-bone, scapula, ribs, the spine at the hips, the ancle-bone, heel, hand, and foot; between the twentieth and thirtieth, the bones of the leg and fore arm; between the twenty-seventh and fortieth, the arm and thigh bones.

But concerning the lower jaw-bone I must add, that the case requires the long use of a liquid diet. Also far a considerable time pancakes and such like must be continued, and nothing be chewed, till the callus has perfectly restored the strength of the bone: and for some days, at first, the patient must not speak at all.

CHAP. VIII. OF A FRACTURED CLAVICLE.

The clavicle, if it be fractured transversely, sometimes unites very well of itself, and if it be not moved, may do well without a bandage; but sometimes, and especially when it is moved, it slides away; and generally the part next the breast lies over, and behind that next the humerus. The reason of which is, that it does not move by itself; but complies with the motion of the humerus: therefore, this standing still, the humerus is moved upon it. That part of the clavicle, next the breast, very seldom lies on the forepart; insomuch that men of great character in the profession have told us they never met with it; but the authority of Hippocrates is sufficient to put the fact beyond dispute.

However, as these cases are dissimilar, so each requires a treatment somewhat different from the other. When the clavicle flies back towards the scapulæ, the humerus must be pushed backward by the palm of the right hand, and at the same time the clavicle itself be brought forward. When turned to the breast, this must be forced backward, and the humerus brought forward; and if the humerus fall below the other, that part of the bone next the breast must not be depressed, because it is immoveable; but the humerus itself must be raised; but if it rise higher, the part next the breast must be filled with wool, and the arm bound down to the breast. If there be sharp pieces in the fracture, an incision must be made in the skin over it; and any parts of the bone, that wound the flesh, must be cut off; then the blunted bones must be brought together; and if there be a prominence any where, it must be kept down by a linen cloth, three times folded, dipped in wine and oil: if there be several fragments, they are to be covered with a splint, the inside of which is to be smeared with wax, lest the roller should slip on one side. The roller must be bound over the clavicle, when reduced, rather often than tight: and this rule holds in all fractures. In a fracture of the right clavicle, the bandage ought to pass from it to the left arm-pit; if, of the left clavicle, to the right; and again under the arm-pit of the affected bone: this done, if the clavicle be inclined toward the scapula, the fore-arm must be tied to the side; if forward, to the neck; and the patient laid on his back. All the other directions given before must be observed.

Now there are several bones that have very little motion, and are either hard, or cartilaginous, which are liable to be fractured, or pierced, or bruised, or fissured, as the malae, the breast-bone, scapula, ribs, spine of the hips, ancle-bone, heel, hand, and foot. The method of cure is the same in all these. If there is an external wound, that must be dressed with the medicines proper for it. While the wound is healing, a callus also fills up the fissures of the bone, or any vacuity that may be in it. If the skin is entire, and from the pain we infer that the bone is injured, there is nothing else to do but rest; and cerate must be applied, and tied on gently, till the pain is removed by the bone becoming sound.

CHAP. IX. OF FRACTURES OF THE RIBS AND SPINE.

But there are some peculiarities to be observed relating to the ribs; because they are near the viscera, and that part is exposed to great dangers. A rib then is sometimes fissured in such a manner, that not the exterior surface of the bone, but the interior part of it, which is thin, is hurt; sometimes it is broke entirely through. If the whole is not fractured, there rarely follows either a spitting of blood, or a febricula, or any suppuration; and the pain is not great; however the place is slightly pained upon being touched. But this case requires no more than to do what is above directed; and in binding it up to begin at the middle of the roller (a double-headed roller) lest it draw the skin to either side. After the twenty-first day, when the bone ought to be united, we must endeavour, by a more plentiful diet, to render the body as plump as possible, that it may cover the bone the better; which being yet tender is in that part exposed to injuries under a thin skin. And through the whole time of the cure, vociferation must be avoided, and even speaking, hurrying, anger, all violence of motion, smoke, dust, and whatever excites either coughing or sneezing; and it is not even proper to hold in the breath much.

But if a rib be entirely broke through, the case is more troublesome: for both violent inflammations, and a fever and suppuration, and often a danger of death ensue; and a spitting of blood. Therefore, if the strength admits, blood must be taken from the arm of the same side with the rib; if it does not allow this, a clyster must be given, but without any thing acrid; and the patient must fast a considerable time. He must not eat bread before the seventh day, but live upon gruel alone; and upon the part must be applied cerate made of lycium, with an addition of boiled resin; or the malagma of Polyarchus; or cloths squeezed out of wine, rose oil, and common oil; and over these soft sordid wool, and two double-headed rollers, but not tight. What I mentioned before as hurtful, are in this case to be avoided with greater caution; so that even the breath must not be too often fetched. But if a cough be troublesome, a potion must be taken for it, either of germander, or rue, or the herb staechas, or of cummin and pepper. When there are severe pains, it is proper to lay on a cataplasm either of darnel or barley, with an addition of a third part of mellow figs. And this must lie on in the day time; but in the night, either cerate, or a malagma, or cloths; because the cataplasm may drop off. Therefore it must be opened every day, till such time as we may be content with the cerate or malagma. And for ten days the body must be reduced by fasting; from the eleventh we must begin to nourish it; and therefore the bandage about it must be more lax than at first; and generally this method is continued to the fortieth day.

In the course of which, if there be any fear of a suppuration, the malagma will be more effectual to discuss it than cerate. If, notwithstanding, the suppuration take place, and cannot be discussed by the medicines prescribed before, no time must be lost, lest the bone below be affected; but in the part where it shall swell most, a hot iron must be introduced, till it reach the pus, which must be evacuated. If a tumour does not appear any where, we may discover where the pus is principally lodged in this manner. We must rub all the part with Cimolian chalk, and suffer it to dry; and wherever the moisture shall penetrate deepest, there the pus is nearest to the skin; and here the actual cautery is to be used. If there shall be a pretty large abscess, it will require two or three perforations; and lint to be put into them, or some part of a penecillum; which may be tied by a thread at the top, that it may be easily drawn out. What remains to be done is the same as in other burns. When the ulcer shall be clean, the body must be nourished, lest a consumption follow, which would be fatal. Sometimes too, when the bone is more slightly affected, and neglected at first, not pus, but a certain humour like mucus is collected within, and the skin over it grows soft; in which case, we must use the cautery in the same manner.

Fracture of the spine.

There is also something peculiar to be noted in the spine: for if any part has separated from a vertebra, or is any way broken(16), the part becomes hollow; prickings are felt there, because these fragments must necessarily be jagged: whence it happens, that the patient now and then leans forward. These are indications of the case; and the same medicines are necessary, which have been mentioned in the first part of this chapter.

CHAP. X. OF FRACTURES OF THE HUMERUS, FORE-ARM, THIGH, LEG, FINGERS, AND TOES.

The cases which occur in the arms and thighs, and their methods of cure, are in a great measure similar. There are also some general things that belong equally to the arms, fore-arms, thighs, legs, fingers, and toes; for a fracture in the middle of these is least dangerous; but the nearer the fracture is, either to the superior or inferior head, so much the worse: for it both creates greater pain, and is more difficult to cure. Of fractures, the most innocent is a simple transverse one; worse, where it is oblique, and where there are fragments; worst of all, when these are sharp. Sometimes the bones in these parts being fractured, continue in their places: but they much more frequently give way, and one part lies over the other. This circumstance ought to be first of all considered; and there are certain marks for knowing it. If they are displaced, they are bent, and cause the sensation of pricking, and are unequal to the touch. But if they meet one another, not directly, but obliquely (which happens, when they are not in their place) that limb is shorter than the other, and the muscles of it swell.

Therefore, if this is found to be the case, it is proper to extend the limb immediately: for the tendons and muscles being in a natural state kept stretched by the bones, are in this case contracted; neither do they return to their place, unless they be extended by force. Again, if that is neglected for some days at first, an inflammation comes on, during which, it is both difficult and dangerous to use violence to the tendons; for there follows a convulsion or gangrene; or at least, which is the mildest of the bad consequences, a suppuration; therefore, if the bones have not been replaced before the inflammation, they must not be reduced till after it is gone. Now one person alone may extend a finger, also any other member, if it be of a child, by taking hold of one part with his right hand, and the other with his left. A stronger limb requires two to pull different ways. If the tendons are very firm, as is the case in robust men, and chiefly in their thighs and legs, the ends of the joints on both sides must be tied with straps, or linen rollers, and pulled contrary ways by several persons; and when this force has stretched the limb a little beyond its natural length, then the bones must be pressed by the hands into their place; and the sign of a bone’s being reduced, is the removal of the pain. The limb being made equal with the other, must be wrapt up in cloths two or three times doubled, dipped in wine and oil; for which purpose linen is best.

Six bandages are generally required. The first to be applied is the shortest; which should be rolled about the fracture(17), and ascend spirally like a screw; and it is sufficient for it to go round in this manner thrice. The second is one half longer than this; which, if the bone project in any part, must begin there; if it be every where equal, it may begin any where upon the fracture, and go in an opposite direction to the former, tending downwards, and returning again to the fracture, end in the upper part beyond the former bandage. Over these must be laid cerate, upon a broad piece of linen, to keep them on. And if the bone is prominent in any part, a cloth, three times doubled, moistened in the wine and oil before mentioned, must be laid upon it. These are to be secured by a third and a fourth bandage, in such a manner, that the following move always in a contrary direction to the former, the third alone must end in the lower part, and the other three in the superior; because it is better to make several convolutions, than to bind it tight; for a strict bandage disorders a part, and makes it liable to a gangrene. We ought to bind an articulation as little as possible; but if the fracture of the bone is near the joint, there is a necessity for it.

When the limb is bound up, it must be kept so to the third day, and the bandage should be such, as on the first day not to hurt by its stricture, and yet not to seem lax; on the second it should be a little laxer; the third almost loosened. Therefore, the limb must then be bound up again, and a fifth roller must be added to the former; after which it must be again opened on the fifth day, and then secured by six rollers, in such a manner, that the third and fifth may end below, and the rest above. As often as the limb is opened, it must be fomented with hot water. But if the fracture be near a joint, wine, with the addition of a small proportion of oil, must be dropped upon it for a long time, and all the other directions observed, till the inflammation leave it, or the limb become smaller than ordinary: which, if it does not happen on the seventh day, will certainly be effected by the ninth. Then the bones are handled with great ease.

Therefore, if they are not well joined to each other, they must be set again; and if any fragments rise above the rest, they must be reduced into their places, and then the limb must be rolled up in the same manner, and splints be fitted round it, to keep the bones in their places. And on that side, to which the fracture inclines, a broader and stronger splint must be applied. About a joint all these should turn outward, that they may not hurt it, and be bound no tighter than is necessary to secure the bone: as they grow laxer in time, they must be a little tightened every third day by their straps; and if there be no itching nor pain, continue so, till two-thirds of the time be compleated, in which each of these bones unites; afterwards, it is to be bathed more gently with hot water; for at first it is necessary to dissipate the humours, and afterwards to make them transpire. Therefore it must also be anointed lightly with liquid cerate, and the surface of the skin rubbed; and the fracture be bound up more loosely. It must be opened every third day, and all the applications be repeated, except the hot water; only one of the rollers, as often as it is loosed, must be withdrawn.

Of a fractured humerus.

The foregoing rules are general; the following peculiar to each bone. If the humerus be fractured, the extension must not be made as in another limb; but the patient is placed in a high seat, and the physician in a lower one opposite to him. Then the patient’s fore-arm is to be supported by a bandage passed round it, and fastened behind the neck. This done, a second bandage, with two heads, is to be rolled round the upper part of the humerus, and have its two ends tied into a knot above the head. Lastly, a third bandage of the like kind is to be fastened to the lower part of the humerus, and carried downwards, its two ends being also tied together. Then, from behind the patient’s head, an assistant stretching his own arm through the loop of the second mentioned roller, his right, if the right humerus is to be extended, his left, if the left humerus, takes hold of a stick placed between the patient’s thighs; the physician also sets his right foot, if he be to operate upon the left humerus, his left, if upon the right, on the third of these rollers; and at the same time the assistant raises the one roller, and the physician depresses the other; by which means, the humerus is gently extended. If the fracture be in the middle or lower part of the bone, shorter rollers are required; if in the superior, longer; so that they may be extended from thence over the breast, under the other arm-pit to the shoulders. In binding it up, the fore-arm must be so inclined, and the affected part put into such a position by the bandages, that the suspending of the forearm afterwards, do not turn the humerus any other way, than when it was bound up. And the fore-arm being hung, the humerus is to be also gently tied down to the side; by which means it will be prevented from moving, and therefore the bones continue as they have been set. When we come to the application of splints, these ought to be longest on the external side, shorter on the fore-part, but shortest of all under the arm-pit. And when the humerus is fractured near the cubitus, they must be pretty often removed, lest the tendons there grow rigid, and the fore-arm be rendered useless. Whenever they are removed, the fracture must be held in the hand; and the cubitus fomented with hot water, and rubbed over with soft cerate; and splints must either not be put upon the processes of the cubitus at all, or they must be somewhat shorter than the others.

Of a fracture of the fore-arm.

But if there is a fracture in the fore-arm, it must be first of all considered, whether one bone or both be broken: not that there is any different method of cure to be used; but first that the extension may be the stronger, if both bones be fractured, because the tendons must necessarily be less contracted, when one of the bones is entire, and keeps them upon the stretch; in the next place, that every thing which relates to securing the bones, may be done with the greater accuracy, if one of them does not help the other: for where one is unhurt, it helps more than rollers and splints. The fore-arm ought to be tied up with the thumb turned a little toward the breast; for that is the most natural posture of the fore-arm: and after the bandages are put on, it is best held in a scarf, the full breadth of which is under the fore-arm, with its ends, which are very narrow, fixed over the neck; thus the arm is conveniently suspended from the neck, and ought to hang a little higher than the other elbow.

But if any part of the top of the cubitus be fractured, it is improper to secure it by bandages, because the fore-arm becomes immoveable. And if means only are found(18) to remove the pain, it remains as useful as before.

Fractures of the thighs and legs.

It is of equal importance in the leg for one of the bones to continue entire. Both in this and the thigh it is fit after binding it up to put it in a box. This box ought to have holes below, through which any humour that is discharged, may descend; and at the foot a prop, which may both sustain, and not suffer it to slip; and holes in the sides, through which straps being past, some bars[ IC ] may keep the leg and thigh in their position. If it be a fracture of the leg, this ought to reach from the foot to the ham; if of the thigh, as far as the hip; if near the head of the thigh-bone, so as that the hip likewise may be within it. We ought not to be ignorant, however, that a fractured thigh becomes shorter, because it never entirely returns to its former state; and that the person ever after supports himself upon his toes in that foot, which occasions great weakness; however it is much worse, where the misfortune has been encreased by neglect.

Fractures of the fingers.

It is sufficient to bind a finger to one small twig, after the inflammation is gone.

General rules.

The foregoing directions are confined to the cases relating to particular limbs; the following are general: fasting for some days at first; then when the callus is growing, a pretty full diet; long abstinence from wine; plentiful fomentations of hot water, while the inflammation continues; when that has ceased, they must be more sparing; lastly, a pretty long but gentle rubbing of liquid cerate into the more remote parts. Nor must the limb be immediately put upon exercise, but by degrees returned to its former motions.

The case is a good deal worse, when, besides the fracture of the bone, there is also a wound in the flesh; and particularly if that happen in the muscles of the thigh or arm: for the inflammations there are much greater, and they are more liable to gangrenes. And generally, where the bones of the thigh have slipped past each other, it is necessary to cut it off. The arm is also endangered in the same circumstances, but is more easily preserved. And these dangers are still more to be apprehended, if the fracture be near the joints: therefore, such a case must be treated with more care, and the muscle must be cut through transversely over the middle of the wound; and if the hæmorrhage has been but small, the patient must be bled, and extenuated by fasting for ten days. And though the other limbs may be extended slowly, and the bones reduced gently to their place; yet in these it is not quite expedient either to extend the tendons, or handle the bones. And the patient must be allowed to keep them in the position that is easiest to him. To all such wounds must be applied, at first, lint dipped in wine, with an addition of a very little rose oil: the other management is the same as above recommended. They are to be bound up with rollers broader(19) than the wound; which must be applied looser, than if there was not a wound there; and as the wound is more liable to corruption and a gangrene, we are by a number of rollers to manage it so, that though they are slack, they may keep the bones firm.

This method may be followed in the thigh or arm, provided the bones have chanced to return to their proper place; but if they be in any different situation, they must only have such a bandage, as will keep on the medicine that is applied. The other directions I gave before must be observed: except that neither splints nor boxes be used, with which the wound cannot heal; but only more and broader rollers are necessary; and both hot oil and wine must be poured upon them now and then; more frequently the latter. At the beginning the patient must fast; the wound must be bathed with hot water; he must avoid the cold; and recourse must be had to medicines for promoting digestion of the wound, and more care must be taken of the wound than the bone: for that reason it must be opened every day and dressed.

In the mean time, should any small fragment of the bone project, if it be blunt, it must be reduced into its place; if sharp, its point, when long, must first be cut off, when short, filed, and in either case smoothed with a chisel; and then it must be returned in again. And if that cannot be done by the hand, a vulsella, such as workmen make use of, must be applied with that part(20) which turns inward to the sharp point of the bone, that by its convex part the prominent bone may be thrust into its place. If it be too large, and covered by small membranes, we should allow these to be dissolved by medicines, and when the bone is laid bare, cut it off; which is to be done pretty early, and afterwards, in this method we may let the bone unite and the wound heal; the first in its proper time, and the other as the circumstances admit.

Sometimes too it happens in a large wound, that some fragments as it were mortify, and do not unite with the rest. This may be discovered from the quantity of discharge; which makes it necessary to open the ulcer oftener than it is dressed; and the consequence generally is, that this bone, after some days, of itself falls off; otherwise, though the condition of the wound is miserable enough before, that often encreases it, and makes it more tedious of cure. The bone too is often broken away, when the skin is entire, and immediately an itching and pain come on. Wherefore, if that happens it is proper to open it the sooner, and bathe it in the summer time with cold water; and in the winter with water just warm; and then apply myrtle cerate.

Sometimes, the fracture, by some points like prickles, irritates the flesh: which being discovered by the itching and prickings, the physician must open it, and cut off these points. The other part of the cure is the same in both these cases as in a recent wound. When the ulcer is clean, nourishing food must be taken. If the limb is still too short, and the bones are not in their places, a wedge of the smallest and smoothest kind must be put in between them with its head standing out a little, and the thick part of it must be driven farther in every day, till that limb be equal to the other. Then the wedge must be taken out, and the wound healed up. When a cicatrix is brought on, it must be bathed with a decoction of myrtle, ivy, and other like vervains, cold, and a drying medicine applied upon it; and in this case, there is a greater necessity for rest, till the limb recover its strength.

When the bones happen not to unite, because they have been often opened, and often moved, the method of cure is obvious; for they may unite. If the fracture be of long standing, the limb must be extended, to create a fresh injury; the bones must be separated from one another by the hand, that their surfaces may be roughened by rubbing against each other, and if there be any fat substance, it may be abraded, and the whole of it become as it were recent: great care, however, must be taken not to wound tendons or muscles. Then it must be bathed with a decoction of pomegranate bark in wine; and the same mixed with the white of eggs, must be applied to it; on the third day it must be opened, and bathed with a decoction of the vervains abovementioned: which must be repeated on the fifth day, and splints put round it; the other steps, both before and after, which I directed already, must be taken in the same manner. However, sometimes the bones unite obliquely(21); and thus the limb becomes both shorter and deformed, and if the ends are pretty sharp, continual prickings are felt: for this reason the bones ought to be fractured again, and put in a proper direction. It is done in this manner. The limb is fomented with plenty of hot water, and rubbed over with liquid cerate and extended; in the mean time, the physician handling the bones, the callus being yet tended, separates them by his hands, and forces the part that projects, into its place: and if that is not effectual, on that side, to which the bone inclines, he puts a regula wrapped up in wool; and by thus binding it up brings it to a habit of lodging in its former place.

Sometimes also, though the bones have united as they should do, too large a callus grows upon them; and therefore the part is swelled. When this happens, the limb must be rubbed gently for a long time, with oil, salt and nitre, and bathed with plenty of salt water; a discutient malagma must be applied; and a tight bandage put on; and the patient must eat herbage, and take vomits; by which course, the callus is reduced together with the flesh. Some good is done by an application of mustard and a fig upon another limb, till it corrode a little, and derive the matter to that part. When the tumour is lessened by these means, the person may return to his ordinary course of life.

CHAP. XI. OF LUXATIONS.

Thus far then we have treated of fractures. Now the bones are dislocated in two ways. For sometimes those that are joined together, separate from each other, as when the broad bone of the scapula recedes from the humerus(22), and in the fore-arm the radius from the cubitus, and in the leg, the tibia from the fibula, and sometimes in leaping the heel-bone from the ancle; which last, however, seldom happens. Sometimes the articulations are displaced. I shall speak first of the former.

When such an accident happens, the part is immediately hollow, and by pressing upon it with the finger one feels a cavity. After that, a violent inflammation comes on; and particularly in the ancle; for generally it occasions fevers and gangrenes, and either convulsions, or contractions, which draw the head down upon the shoulders. To avoid which, the same method must be followed here, as in injuries of the moveable bones. And whenever it happens, the medicines prescribed before must be laid on these parts to remove the pain and tumour: for bones once separated in this manner never come together again; and though some degree of comeliness be attainable in the part, yet it is of no use(23).

But the lower jaw and the vertebræ, and all the joints, though they be secured by strong ligaments, are luxated by the force of a blow, or when the ligaments are either ruptured, or some way weakened; and more easily in children or lads, than in those that are more robust. And they slip out forward and backward, and inward and outward; some of them in all these ways, others in particular ways. And there are some general signs belonging to all, others peculiar to each one: for there is always a tumour in that part, to which the bone is propelled, and a cavity in that from whence it recedes. Now these marks are common to them all; the others peculiar to the several bones will be mentioned, when I speak of each case distinctly.

But though all the articulations may be dislocated, they cannot be all replaced; for the head is never reduced, nor a vertebra in the spine, nor a jaw-bone, which being out on both sides, has raised an inflammation before it could be returned. Again, those that slip out from the fault of the ligaments, when they are forced into their places, give way again. And those that have been dislocated in childhood, and have not been reduced, grow less than the rest: and the flesh of all these that are not in their place, is decayed, and more so in the member nearest to it, than in one beyond it. For instance, if the humerus is not in its place, the arm wastes more than the fore-arm, and that more than the hand. Then according to the situations, and the nature of the accidents, there is left either more or less use of the limb; and the more use remains of it, the less it is wasted.

Now whatever is dislocated should be reduced before an inflammation begin. If that has already seized it, till it cease, it must not be meddled with; after its removal, trial must be made in such limbs as are reducible. A great deal depends upon the habit both of the body and the ligaments: for if the body be slender, or humid, or if the ligaments be weak, the bone is more quickly reduced; but it is both more liable to dislocation, and is less firmly held after it is reduced(24). Bodies of the contrary qualities hold it faster in its place; but when once forced out, admit of its return with difficulty. It is proper to alleviate the inflammation by applying sordid wool squeezed out of vinegar; and if the misfortune be in a strong articulation, to abstain from food for three, and sometimes even five days; to drink warm water till the thirst be gone; to observe these rules more strictly in luxations of those bones, that are held by strong large muscles; and much more so if a fever has ensued; on the fifth day to foment with hot water; and taking away the wool, to apply cerate made of Cyprine oil, with the addition of nitre, till the inflammation be entirely removed. Then it is proper to use friction to the limb; to take food of good juices, wine in moderate quantity; and by this time, to make some use of the limb: because motion, as it is extremely hurtful in pain, so it is very salutary when the pain is removed. These observations are general; I shall now treat of the particular cases.

CHAP. XII. OF A LUXATED MAXILLA.

In a dislocation of the lower jaw it is pushed forward, but sometimes on one side, sometimes on both. If on one side, it inclines together with the chin to the contrary side, the teeth do not answer to each other, but the canine teeth below are opposite to the incisores: if on both sides, the chin leaves its place, and is protruded to the external part; and the lower teeth come farther out than the upper; and the muscles of the temples appear tense. The patient, as soon as possible, must be placed in a seat in such a manner, that an assistant may secure his head behind; or he may be seated near a wall, putting a hard leather cushion between the wall and his head, and let his head be pressed upon the cushion by an assistant, that it may be kept the steadier; then the thumbs of the physician being wrapped up with linen cloths, or rollers, that they may not slip, must be introduced into his mouth; and the fingers must be applied externally. When the maxilla is firmly grasped, if the luxation be on one side, the chin must be shaken, and brought towards the throat; then at the same time his head must be held, and the chin being raised, the maxilla forced into its place, and the mouth shut; and all this must be done almost in the same instant. But if the luxation be on both sides, the same method must be taken; but the jaw-bone must be forced back equally on both sides. When the bone is replaced, if the case was attended with a pain of the eyes and neck, blood must be taken from the arm. And as liquid food at first is proper for all persons, whose bones have been dislocated, so particularly in this circumstance; where even frequent speaking, by the motion of the mouth, hurts the nerves of the temples(25).

CHAP. XIII. OF A LUXATION OF THE HEAD.

In the first part of this book, I have already observed, that the head is secured upon the neck by two processes received into two depressions of the upper vertebra. These processes are sometimes dislocated toward the posterior part; the consequence of which is, that the nerves below the occiput are extended, the chin is fixed upon the breast, and the patient can neither drink, nor speak, and sometimes discharges his semen involuntarily. Such patients die very quickly. I judged it necessary to mention this case, not because there is any cure for it; but that it might be known by its symptoms, and if any should lose a friend in this way, they might not think it was for want of a physician.

CHAP. XIV. OF A LUXATION IN THE SPINE.

The same misfortune attends those, whose vertebræ of the spine are luxated. For this cannot happen, unless both the medulla, which passes through the middle, and the two membranes, that go through the two processes on the sides, as also the ligaments, that secure them, be ruptured. They are dislocated both backward, and forward; both above and below the transverse septum. As they slip the one way or the other, there will be either a swelling or a cavity behind. If this happens above the septum, the hands become paralytick, a vomiting or convulsions follow, the breath is oppressed, and a violent pain and deafness ensue. If below the septum, the thighs are paralytick, the urine is suppressed, and sometimes it even flows involuntarily. Though a person does not in such cases die so quickly as where the head is luxated, yet it commonly happens within three days; for what Hippocrates has directed in a vertebra luxated externally, that the patient must be laid prone, and extended, and then a person ought to stand upon him with his heel and force it in, must be understood of those, that are but partially displaced, not of these, that are entirely luxated; for sometimes a weakness of the ligaments causes a vertebra to protuberate forwards, though it be not dislocated: this is not mortal. But it is not possible to force it back from the internal part. If any vertebra be reduced from the external side, it generally returns again, unless, which is very rare, the tone of the nerves be restored(26).

CHAP. XV. OF A LUXATION OF THE HUMERUS.

The humerus slips sometimes into the axilla, sometimes forward. If it has fallen into the arm-pit, the cubitus recedes from the body, and cannot be brought upward with the humerus to the ear of the same side; also that arm is longer than the other: if forward, the upper part of the fore-arm is extended, but not to its full length; and the cubitus is moved with more difficulty forward than backward.

Therefore if the humerus has fallen into the arm-pit, and the patient be young, or of a lax habit, so that the ligaments are weak, it is sufficient to place him in a seat; and to order one assistant to draw back gently the head of the broad bone of the scapula, and another to extend the fore-arm; while the physician himself sitting behind, with his knee under the patient’s arm-pit, forces the humerus upwards, and at the same time presses the scapula with one hand, while he pushes the cubit to the side with the other.

But if the patient be of a large stature, or the ligaments more robust, a wooden spatha is necessary of the thickness of two fingers, and so long as to reach from the arm-pit to the fingers. In the top of it, is a small round head a little hollowed; that it may receive some part of the head of the humerus; and in three places at due distances there are two holes made for the admission of soft straps. This spatha being wrapt up in a roller, that it may hurt the less, is applied from the fore-arm to the arm pit, in such a manner, that the head of it is put under the axilla; then it is tied to the arm by its straps, in one place a little below the head of the humerus, another a little above the elbow, and the third above the hand; to which purpose the distances of the holes are then also to be adapted. The arm being thus tied up is put over a step of a ladder, so high, that the patient cannot stand upon the ground; and at the same time his body is suffered to sink on one side, and his arm kept extended on the other; the effect is, that the head of the humerus, being impelled by the head of the spatha, is forced into its place, sometimes with a crack, sometimes without it. It appears from Hippocrates alone, that there are many other methods; but none of them has been more approved by experience than this.

But if the humerus is luxated forward, the patient must be laid on his back, and a roller, or strap put round the middle of the arm-pit, and the ends of it delivered to one assistant behind the patient’s head, and his fore-arm to another; then the first must be ordered to extend the strap, and the other the fore-arm; and the physician must thrust back the patient’s head with his left hand, and with his right raise the cubitus together with the humerus, and force the bone into its place; which in this case is more easily reduced than in the former.

When the humerus is replaced, wool must be put under the arm-pit; that if the bone was in the interior part, it may prevent its returning; if forward, that it may however be more conveniently rolled up. Then the roller being first carried under the arm-pit, ought to surround the head of the bone, and passing over the breast to the other arm-pit, and from that to the scapulæ, and back again to the head of the luxated humerus, it must be carried round in this manner several times, till the head of the humerus be well secured. The humerus being thus bound up is better fixed, if it be drawn close to the side, and tied down to it with a roller.

CHAP. XVI. OF A LUXATION OF THE CUBITUS.

From what has been said in the first part of this book, it may be understood, that three bones meet together at the elbow, the humerus, radius, and cubitus. If the cubitus, which is fixed to the humerus, separates from it, the radius, which is contiguous to it, is sometimes dislocated, and sometimes remains firm. Now the cubitus may be luxated in all the four different ways. If it be displaced forward, the fore-arm is extended, and cannot be bent; if backward, the fore-arm is bent, cannot be extended, and is shorter than the other; sometimes it brings on a fever and bilious vomiting; if externally, or internally, the fore-arm is stretched, but is a little bent to that part, from whence the bone has receded.

Whatever species it be, the method of reduction is the same (and not only in the cubitus, but in all the larger limbs, which are joined in the articulation by a long process) to extend both limbs different ways, till there be a void space between the bones; and then to thrust the luxated bone from that side, into which it has prolapsed, to the contrary. However the methods of extension are various according to the strength of the ligaments, and the position of the luxated bones. And sometimes the hands alone are used, sometimes other means.

Therefore if the cubitus is displaced forward, it is sufficient for it to be extended by two hands, sometimes assisted by two straps; then some round body must be put into the bend of the elbow, and upon that, the cubitus is to be suddenly forced towards the humerus. But in the other cases the best method is so extend the fore-arm in the same manner, as was directed in a fractured humerus, and then to reduce the bones.

The remaining part of the cure is the same as in the other luxations; only this must be sooner, and more frequently opened, also more plentifully fomented with hot water, and rubbed longer with oil, and nitre, and salt. For the cubitus, whether it remain displaced, or be reduced, is more quickly surrounded by a callus than another joint, and if this grows, while the arm is at rest, it afterwards prevents its flexure.

CHAP. XVII. OF A LUXATED HAND.

The hand too may be displaced in all the four directions. If it slips backward, the fingers cannot be extended; if forward, they cannot be bent; if on either side, the hand is turned to the opposite, that is, either toward the thumb, or the little finger, and may be replaced without much difficulty. The hand and fore-arm should be extended on something, that is hard and will not give way, the hand being prone, if the luxation was to the posterior part; and supine, if forward; if internally, or externally, it should be laid on one side. When the ligaments are sufficiently stretched, if the luxation was lateral, it must be repelled to the contrary side by the hands: but where it was forward, or backward, some hard body is to be put upon it, and pressed upon the prominent bone by the hand, which additional force pushes it more easily into its place.