11. 11 So much for the discussion of fractured bones. Turning to dislocations, these are of two kinds: for at times bones which are conjoined gape asunder, as when the shoulder-bone recedes from the clavicle, and, in the forearm, the radius from the ulna, or in the leg the tibia from the fibula; sometimes after a jump the heel-bone from the ankle, though this is rare; at times joints slip out of position. I will speak of the former first. Now when anything of this sort happens, there is a depression at once on the spot, and when the finger is put into this a gap is felt; after this severe inflammation arises, particularly at the ankle; indeed this is often a cause of fevers also and gangrene and spasms of the sinews or rigors, which bend back the head to the shoulder-blade. To avoid these things the same is to be done as was laid down for bone injuries in general, so that pain and swelling may be thereby relieved. For bones so separated never again unite, and even if the appearance of the limb is somewhat impaired its usefulness is not. Since all joints, including the jawbone and vertebrae, are held in place by strong sinews, they are displaced either by force or after some accident which has ruptured or weakened the sinews, and this occurs more readily in boys and youths, than in the more robust. And these joints slip out forwards, backwards, inwards, outwards, some in all directions, some in certain only. And there are some signs which are common to all, some special to each; there is always a swelling in the part into which the bone has ruptured, and a hollow whence the bone has receded. These signs are found in all, but others only in some cases; these I will describe when speaking of each separately. But while it is possible for all joints to slip out, yet not all can be replaced. For the head is never forced back into position, nor is a spinal vertebra, nor a jawbone which has been dislocated forwards on both sides, and has become inflamed before it has been replaced. Again, any joints which have slipped owing to a lesion of their sinews, even when forced back into position slip out again. Also when joints have been dislocated in childhood, and have not been replaced, there is less growth than elsewhere. The flesh of all which are out of place wastes, and in the near more than in the distant part of the limb; for instance, if the upper arm-bone is not in its place, the wasting is more here than in the forearm, more in the forearm than in the hand. Again, according to the site and character of the accidents, more or less use of the limb is retained; and the more use is retained, the less does it waste. Now every dislocation ought to be replaced before there is inflammation; but if this has set in already, the limb is not to be disturbed until after it subsides; only when it has ended should replacement be attempted in the limbs which allow of it. But for this much depends upon the general constitution of the patient and his sinews. For if his body is slender, and humid, if sinews are weak, the bone is readily replaced; but just as the bones slips out more easily in the first instance, so the replacement is less secure. With an opposite type of constitution the replacement is more lasting but there is more difficulty in restoring that which has been put out of position. The inflammation should be relieved by applying greasy wool saturated with vinegar: there should be abstinence from food, in the case of the stronger joints, for three days, some he said for five; warm water is drunk, enough to relieve thirst; this regimen must be followed more strictly after dislocation of bones which are held in place by strong and large muscles; far more strictly indeed if fever supervenes; then after the fifth day there should be hot-water fomentation; when the wool is removed, a cerate must be applied made with cyprus oil with the addition of soda, until all inflammation has ended. Then the limb is to be rubbed, good food given and wine in moderation; and now also the natural use of the limb is to be encouraged; because though movement when it gives pain is harmful, it is otherwise most beneficial to the body. After these generalities, I will now speak of particular cases.
11. Ac de fractis quidem ossibus hactenus dictum sit. MOVENTVR autem ea sedibus suis duobus modis: nam modo quae iuncta sunt inter se ⟨de⟩hiscunt, ut cum latum scapularum os ab umero recedit, et in brachio radius a cubito, et in crure tibia a sura; interdum [a saltu] calcis os a talo, quod raro tamen fit: modo articuli suis sedibus excidunt. Ante de prioribus dicam. Quorum ⟨ubi aliquid incidit, protinus is locus⟩ cau⟨us⟩ est, depressusque digitus sinum inuenit; deinde grauis inflammatio oritur, atque in talis praecipu⟨e⟩: siquidem febres quoque et cancros et neruorum uel distentiones uel rigores, qui caput scapulis adnectunt, mouere consueuit. Quorum uitandorum causa facienda ea⟨dem⟩ sunt, quae in ossibus ⟨omn⟩ibus laesis [aliquid ubi incidit, protinus is locus] proposita sunt, ut dolor tumorque per ea tollantur. Nam diducta ossa numquam ⟨rursus⟩ inter se iunguntur, et ut aliquid decoris eo loco, sic nihil usus amittitur. Maxilla uero et uertebra omnesque articuli, cum ualidis neruis conprendantur, excidunt ⟨aut⟩ ui expulsi, aut aliquo casu neruis uel ruptis ⟨uel⟩ infirm⟨a⟩tis, faciliusque in pueris et adulescentulis quam in robustioribus. Hique elabuntur in priorem * * * in exteriorem partem, quidam omnibus modis, quidam certi⟨s⟩. Sunt⟨que⟩ quaedam communia omnium signa, quaedam propria sunt ⟨cuiusque⟩: siquidem semper ea parte est tumor, in qua⟨m⟩ os prorumpit; ea sinus, ⟨a⟩ qua recessit. Et haec quidem in omnibus deprenduntur, alia uero in singulis; quae, simul atque de quoque dicam, proponenda erunt. Sed ut excidere omnes articuli [non] possunt, sic non omnes reponuntur. Caput enim numquam * * compellitur, neque in spina uertebra, neque ea maxilla, quae, utraque parte prolapsa, antequam reponer⟨e⟩tur, inflammationem mouit. Rursus ⟨si⟩ qui neruorum uitio prolapsi sunt, conpulsi quoque in suas sedes iterum excidunt. A⟨c⟩ quibus in pueritia exciderunt neque repositi sunt, minus quam ceteri crescunt. Omniumque, quae loco suo non sunt, caro e⟨ma⟩cres⟨cit,⟩ magi⟨s⟩que in proximo membro quam ulteriore, ut puta, si umerus loco suo non est, maior in eo ipso fit quam in brachio, maior in hoc quam in manu ⟨m⟩acies. Tum pro sedibus et pro casibus, qui inciderunt, aut maior aut minor usus ⟨eius⟩ membri relinquitur; quoque in e⟨o⟩ plus usus superest, eo minus id extenuatur. Quicquid autem loco suo motum est, ante inflammationem reponendum est: ⟨si⟩ illa occupauit, dum conquiescat, n⟨on⟩ lacessendum: ubi finitast, temptandum in is membris, quae id patiuntur. Multum autem eo confert et corporis et neruorum habitus. Nam si corpus tenue, si umidum est, si nerui infirmi, expeditius os reponitur: sed ut primo facilius excidit, ⟨i⟩t⟨a⟩ postea minus fideliter continetur. Quae contraria his sunt, melius continent: sed id, quod expulsum est, difficulter admittunt.—Oportet autem ipsam inflammationem leuare super sucida lana ex aceto inposita: a cibo, si ualentioris articuli casus est, triduo, interdum etiam quinque diebus abstinere; bibere aquam calidam, dum sitim finiat; curiossiusque haec facere is ossibus motis, quae ualidis plenisque musculis continentur: si uero etiam febris accessit, multo magis; deinde ex die quinto ⟨fouere⟩ aqua calida; remotaque ⟨l⟩ana ceratum inponere ex cyprino factum, nitro quoque adiecto, donec omnis inflammatio finiatur. Tunc [in]frictionem ei membro adhibere; cibis uti bonis; uti uino modice; iamque ad usus quoque suos id membrum promouere, quia motus ut in dolore pestifer, sic alias saluberrimus corpor⟨i⟩ est. Haec communia sunt, nunc de singulis dicam.
12. 12 The lower jaw is displaced forwards, sometimes on one side, sometimes on both. If on one side, it inclines with the chin to the opposite side, the teeth do not correspond with their fellows, but the canine are under the incisors. But if on both sides, the whole chin is moved forwards, and the lower teeth stick out beyond the upper ones; and the muscles above appear tense. As soon as possible the patient is to be seated on a stool, with an assistant behind holding his head, or with his back against a wall and a hard leather cushion between the wall and the back of his head, against which his head is firmly pushed by the assistant, to keep it from moving. Then the surgeon's thumbs, which have been wrapped round with strips of linen or bandages so that they may not slip, are inserted into the mouth whilst the fingers are applied outside. When the jaw has been grasped firmly, if it has slipped forwards to one side, the chin is to be pressed down towards the throat with a jerk. Then simultaneously the head is firmly held, and the chin being raised the jaw is forced back to its place, and the mouth is closed so that all this is done almost with one movement. If it has been dislocated on both sides all the same movements are to be done except that the jaw is forced straight backwards. When the bone is in its place, if the accident has been attended with pain in the eyes and neck, blood is to be let from the arm. For all patients with dislocated bones, a more liquid diet is proper at first, but especially in this case, since even talking, as it causes constant movement of the mouth by means of the sinews, is harmful.
12. Maxilla in priorem partem propellitur, sed modo altera parte, modo utraque. Si alter⟨a⟩, in contrariam partem ipsa mentum⟨que⟩ inclinatur; dentes paribus non respondent, sed sub is, qui secant, canini sunt. A⟨t⟩ si utraque, totum mentum in exteriorem partem promouetur; inferioresque dentes longius quam superiores excedunt; intentique super musculi apparent. —Primo quoque tempore autem homo in sedili conlocandus est sic, ut minister a posteriore parte caput eius contineat, uel sic, ut iuxta parietem is sedeat, subiecto inter parietem et caput eius scorteo puluino ⟨duro,⟩ eoque caput e⟨ius⟩ per ministrum urgeatur, quo sit immobili⟨u⟩s. Tum medici digiti pollices linteolis uel fasceis, ne delabantur, inuoluti in os eius coiciendi, ceteri extrinsecus admouendi sunt. Vbi uehementer maxilla adprehensa est, ⟨si un⟩a parte procidit, concutiendum mentum ⟨et⟩ ad guttur adducendum est. Tum simul et caput adprehendendum, et excitato mento maxilla in suam sedem conpellenda, et os eius conprimendum est sic, ut omnia paene uno ⟨mo⟩mento fiant. Si⟨n⟩ utraque parte prolapsa est, eadem omnia eadem facienda, sed aequaliter retro maxilla agenda est. Reposito osse, si cum dolore oculorum et ceruic⟨i⟩s ist⟨e⟩ casus incidit, ex brachio sanguis mittendus est. Cum omnibus uero, quo⟨rum⟩ ossa mota sunt, primo liquidior cibus conueniat, tum his praecipue, adeo ut sermo quoque frequenti motu oris per neruos laedat.
13. 13 As I stated in the first part, the head is held by two processes, inserted into two cups in the highest vertebra. These processes sometimes slip out backwards; with the result that the sinews under the occiput are stretched, and the chin fixed to the chest; the man cannot drink or speak, and sometimes has involuntary emission of semen; upon these symptoms death very quickly supervenes. Now I thought this condition should be described, not that there is any treatment for it, but that it may be recognized by these indications, and that those who have lost someone in this way may not deem the medical man to have been at fault.
13. Caput duobus processibus in duos sinus summae uertebrae demissis super ceruicem contineri in prima parte proposui. Hi processus interdum in posteriorem partem excidunt; quo fit, ut, ⟨qui⟩ nerui s⟨unt⟩ sub occipitio, extendantur, mentum pectori adglutinetur, neque bibere is, neque lo⟨qui⟩ possit, interdum sine uoluntate semen emittat; quibus celerrime mors superuenit. Ponendum autem hoc esse credi⟨di,⟩ non ⟨quo⟩ curatio eius rei ulla sit, sed ut res indiciis cognosc⟨er⟩etur et non putarent sibi medicum defuisse, ⟨si qui⟩ sic aliquem perdidisse⟨n⟩t.
14. 14 The same fate awaits those whose spinal vertebrae have been dislocated; for this cannot happen without rupture of the marrow in the middle of them, and of the two little membranes which pass oust between the two processes at the side, and of the sinews which hold them together. But the vertebrae may slip pout both backwards and forwards, above the diaphragm or below it. The direction of the displacement is indicated either by a swelling or by a hollow at the back. If it happens above the diaphragm, there is paralysis of the arms, and vomiting or spasm follow, breathing is difficult, pain is severe, and hearing blunted. If below the diaphragm, the lower limbs are paralysed, the urine is suppressed, or sometimes is passed involuntarily. From such accidents the man dies more slowly than when the head is displaced, yet within three days. As for what Hippocrates said, that when a vertebra has been displaced backwards, the man is to be laid out on his face, and stretched out, while an assistant presses his heel upon the displaced bone and pushes it inwards, that procedure is only to be adopted when the bone has slipped out a little, not if there is a total displacement. For occasionally weakness of the sinews causes a vertebra, although not displaced, to project a little, either backwards or forwards. This is not a fatal accident, but we cannot press upon a vertebra from within; it cannot even be touched; and if it is pressed upon from outside, it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.
14. Idem casus manet ⟨e⟩os, quorum in spina uertebrae excide⟨ru⟩nt: id enim non potest fieri, nisi et medulla, quae per medium, et duabus membranulis, quae per duos a lateribus processus feruntur, et neruis, qui contine⟨n⟩t, ruptis. Excidunt autem et in posteriorem partem et in priorem et supra saeptum transuersum et infra. In utram[que] partem excideri⟨n⟩t, a posteriore parte uel tumor uel sinus †donec. Si super saeptum id incidit, manus resoluuntur, uomitus aut neruorum distentio insequitur, spiritus difficulter mouetur, dolor urguet et aures obtusae sunt. Si sub sae⟨pt⟩o, femina resoluuntur, urina subprimitur, interdum etiam sine uoluntate prorumpit. Ex eiusmodi casibus, ut tardius qua⟨m⟩ ex capitis, sic tamen intra triduum homo moritur. Nam quod Hippocrates dixit, uertebra in exteriorem partem prolapsa pronum hominem collocandum esse et extendendum, tum calce aliquem super ipsum ⟨os⟩ debere consistere, ⟨et⟩ ⟨id⟩ intus inpellere, in is accipiendum, quae paulum excesserunt, non is, quae toto loco mota sunt. Nonnumquam enim neruorum inbecillitas efficit, ut, quamuis non exciderit uertebra, tantum paruum tamen aut * * * in priorem partem promineat. Id non iugulat: sed ab interiore parte ne contingit quidem †posse: ab exteriore si propulsum est, plerumque iterum redit, nisi, quod admodum rarum est, uis neruis restituta est.
15. 15 Passing to the humerus, it is sometimes put out into the armpit, sometimes forwards. If it is dislocated into the armpit, the elbow stands out from the side; again, this elbow, together with the upper arm, cannot be raised to the level of the ear on the same side, and that forearm is longer than the other. But if forwards, the upper forearm can be stretched out, but not to its full extent; and it is more difficult to stretch out the elbow forwards than backwards. So if the upper bone has slipped out into the armpit and the patient is still young or supple, at any rate if the sinews are not very powerful, it is sufficient to have him held on a stool; one of the two assistants is directed to press gently upon the head of the blade-bone, while the other stretches the forearm; then the surgeon seated behind thrusts one hand into the point's armpit, presses the bone up with this hand, and with the other presses the elbow to the side. But for a more powerful patient, with stronger sinews, a wooden board is required, two fingers thick, and lon enough to reach from the armpit to the fingers; the upper end is rounded and slightly hollowed to admit a small part of the head of the humerus. In three places in this, with a space between, are two slots through which soft straps are passed. And this board, covered with bandage to avoid injury by contact, is so applied from the forearm to the armpit, that its upper end is put under the armpit: it is then tied to the limb by its straps, one just below the head of the humerus, the second a little above the elbow, the third short of the wrist, to which purpose the two spaces between the six holes are adapted. The limb so fixed is passed over a rung of a poultry ladder at such a height that the patient himself cannot stand firmly; and whilst his body is allowed to sink down to one side, the limb is stretched on the other side; and thus it comes about that the top of the humerus is forced upwards into place by the top of the board, sometimes with, sometimes without a sound. It is easy to learn that there are many other methods by reading Hippocrates alone, but no other has met with more approval in practice. But if the humerus is put out forwards, the man is laid on his back and a bandage or a leather strap passed under his armpit, the ends of which are handed to one assistant behind the man's head and his forearm to another assistant; and it must be arranged that the former pulls the strap, the latter the forearm. Then the surgeon should thrust back the man's head with his left hand, whilst with his right he raises the elbow together with the upper arm and forces the bone back into place; and reduction is easier in this case than in the previous one. When the bone has been replaced, the armpit is filled with wool; if the bone had moved backwards, to prevent it from slipping back; if forwards, to make the bandaging more effective. Then the bandage must first pass under the armpit and control the head of the bone, then stretch across the chest under the opposite armpit, next over the shoulder-blades and again back to the head of the same arm-bone, and it is to be carried round several times in the same way until bone is well held. The bone when bandaged in this way is held in place more comfortably if it is also bandaged close to the side.
15. Vmerus autem modo in alam excidit, modo in partem priorem. Si in alam delapsus e⟨s⟩t, cubitus recedit ⟨a⟩ latere; rursum iuxta eiusdem partis aurem cum umero porrigi non potest, longius⟨que⟩ altero id brachium est. ⟨At si⟩ in priorem partem, summ⟨u⟩m quidem brachium extenditur, minus tamen quam naturaliter; difficiliusque in priorem partem quam in posteriorem cubitus porrigitur. Igitur si in alam umerus excidit, et uel puerile adhuc est corpus uel molle, certe inbecillius neruis intentum est, satis est conlocare id in sedili; et ex duobus ministris alteri imperare, ut caput lati scapularum oss⟨is⟩ leniter redducat, alteri ut brachium extendat: ipsum posteriore parte residentem †renum sub ala eius †coire; simulque et ill⟨a⟩ os * et altera manu brachium eius ad latus impellere. At si uastius corpus neruiue robustiores sunt, necessaria est spatula lignea, et quae crassitudinem duorum digitorum habet, longitudin⟨e⟩ ab ala usque ad digitos peruenit; in qua summa capitulum est rotundum, leniter cauum, ut recipere particulam aliquam ex capite umeri possit. In ea bina foramina tribus locis sunt inter se spatio distantibus, in quae lora mollia coiciuntur. Eaque spata fascia inuoluta, quo minus tactu laedat, ad alam brachio derigitur sic, ut caput eius summae alae subiciatur; deinde loris suis ad brachium deligatur, uno loco paulum ⟨infra umeri caput, altero paulum⟩ supra cubitum, tertio citra manu⟨m;⟩ cu⟨i⟩ rei protinus interualla ⟨II VI⟩ quoque foraminum aptata sunt. Sic brachium deligatum super scalae gallinariae gradum traicitur, ita altae, ut consistere homo ipse non possit; simulque in alteram partem corpus demittitur, in alteram brachium intenditur; eoque fit, ut capite ligni caput umeri inpulsum in suam sedem modo cum sono, modo sine hoc compellatur. Multas alias esse rationes scire facile est uno Hippocrate lecto, sed non alia magis usu conprobata est. At si in partem priorem umerus excidit, supinus homo collocandus est; fasciaque aut habena media ala circumdanda est, capitaque eius post caput hominis ministro tradenda, brachium alteri; praecipiendumque, ut il⟨l⟩e habenam, hic brachium extendat. Deinde medicus caput quidem hominis sinistr⟨a⟩ debet repellere; dextra uero cubitum cum umero attollere et os in suam sedem compellere; faciliusque id in hoc casu quam in priore reuertitur. Reposito umero lana alae subicienda est; si interiore parte os fuit, ut ei opponatur; si in priore, ut tamen commodius deligetur. Tum fascia primum sub ala obuoluta caput eius debet conprehendere; deinde per ⟨p⟩ectus ad alteram alam, ab eaque ad scapulas, russusque ad eiusdem umeri caput tendere; saepiusque eadem ratione circumagi, donec bene id teneat. Vinctus hac ratione umerus ⟨commodius⟩ continetur, si adductus ad latus si⟨c⟩ quoque fascia deligatur.
16. 16 From what was said at the beginning of this book, it can be understood how the three bones, humerus, radius and ulna, meet together at the elbow. If the ulna which is connected to the upper arm slips away from it, the radius which is joined to the ulna is sometimes dragged with it, sometimes remains in position. The ulna can slip out in all four directions: but if it is dislocated forwards, the forearm is extended and cannot be flexed; if backwards, the forearm is flexed and cannot be extended, and it is shorter than on the opposite side; sometimes this causes fever and bilious vomiting. If the ulna has been dislocated outwards or inwards, the forearm is stretched but a little bent towards the part from which the bone has receded. Whatever has happened, there is one method of treatment which holds good not only for the ulna but also for all long bones which are connected at their articulation by a long head. Each limb is to be pulled in opposite directions until there is a gap between the bones. Then the bone which has fallen out of place is forced into the opposite direction from the position into which it has slipped. The methods of extension, however, are various according to the strength of the sinews, and the direction in which the bones have given way. And sometimes only the hands are used, sometimes other means have to be applied. Thus if the ulna has slipped for-wards, extension by two hands, at times aided by straps, is sufficient; then some round object is to be put in front of the biceps and the ulna suddenly flexed over it towards the upper arm. But in other forms of displacement, it is best to stretch the forearm as described above for fracture of the elbow and then to replace the bones. The rest of the treatment is the same as in all other cases; only the dressing must be taken off more quickly and more often and there must be more plentiful fomentations with hot water, and more prolonged rubbing with oil, nitre and salt. For whether the elbow remains out of place or is put back again, callus forms more quickly round it than round any other joint, and if this callus has grown through resting the joint it prevents flexion afterwards.
16. In cubito autem tria co⟨i⟩re ossa umeri ⟨et⟩ radii et cubiti ipsius, ex is, quae prima parte huius uoluminis posita sunt, intellegi potuit. S⟨i⟩ cubitus, qui adnexus umero est, ab hoc excidit, radius, qui adiunctus est, interdum trahitur, interdum subsistit. In omnes uero quattuor partes excidere cubitus potest: sed si in priorem prolapsus est, extentum brachium est neque recur⟨u⟩atur; si in posteriorem, brachium curuum est neque extenditur, breuiusque altero est; interdum febrem uomitum⟨que⟩ bilis mouet; si in exteriorem ⟨interiorem⟩ue, brachium porrectum est, ⟨sed⟩ paulum in ea⟨m⟩ parte⟨m,⟩ a qua os recessit, recuruatum.—Quicquid incidit, reponendi ratio una est; neque in cubito tantum sed in omnibus quoque membris longis, ⟨quae⟩ per articulum * longa testa ⟨iungun⟩tur: utrumque membrum in diuersas partes extendere, donec spatium inter ossa liberum sit; tum id os, ⟨quod⟩ excidit, ab ea parte, in quam prolapsum est, in contrariam impellere. Extendendi tamen alia atque alia genera sunt, prout aut nerui ualent, aut ossa ⟨huc illucue se dederunt.⟩ Ac modo manibus solis utendum est, modo quaedam alia adhibenda. Ergo si in priorem partem cubitus prolapsus est, extendi per duos manibus, interdum etiam habenis adiectis, satis est; deinde rotundum aliquid a lacerti parte ponendum est, et super ⟨id repente⟩ cubitus ad umerum inpellendus est. At in aliis casibus commodissimum est eadem ratione brachium extendere, quae fracto cubito supra posita ⟨est⟩, et tum ossa reponere. Reliqua eadem curatio est, quae in omnibus: celerius tantum ⟨et⟩ saepius id resoluendum est, multa magis aqua calida fouendum, diutius ex oleo et nitro ac sale perfricandum. In cubito enim celerius quam in ullo alio articulo, siue ⟨extra remansit siue⟩ intus reuertit, callus circumdatur; isque si per quietem increuit, flexus illius postea prohibet.
17. 17 The hand also may be dislocated in all four directions. If it has slipped out backwards, the fingers cannot be stretched out; if forwards, they do not bend; if to either side, the hand is turned in the opposite direction either towards the thumb or towards the little finger. It can be replaced without difficulty. The hand, supported on a hard and resistant object, must be stretched one way, the forearm the other, in such a way that the hand is palm downwards if the bone has slipped out backwards, palm upwards if forwards; if the displacement is inwards or outwards, upon the side. When the sinews are sufficiently stretched, the surgeon's hands push back the bone, in the opposite direction to the side to which it has slipped. Where the dislocation is forwards or backwards, some hard object is placed upon the hand, and pressed on the projecting bone, and by this additional force the bone is more readily pushed back into place.
17. Manus quoque in omnes quattuor partes prolabitur. Si in posteriorem partem excidit, porrigi digiti non possunt; si in priorem, non inclinantur; si in alterutrum latus, manus in contrarium [id est aut ad pollicem aut ad minimum digitum] conuertitur. Reponi non difficillime potest. Super durum locum et renitentem ex altera parte intendi manus, altera brachium debet sic, ut prona sit, si in posteriorem partem os excidit; supina, si in priorem; ⟨si in interiorem⟩ exterioremue, in latus. Vbi ⟨satis⟩ nerui diducti sunt, ⟨o⟩s, qu⟨od⟩ in alterutrum latus procidit, manibus in contrarium repellendum est. At is, quae in priorem ⟨posteriorem⟩ue partem lapsa sunt, super inponendum durum aliquid, idque supra prominens os manu urguendum est, per quod uis adiecta facilius ⟨id⟩ in suam sedem compellit.
18. 18 In the palm also bones are sometimes moved from their places, either forwards or backwards; for they cannot move sideways because of the bones on either side. There is but one sign, and that common to all, a swelling over the displacement, a hollow at the spot from which the bone has receded. But without extension the bone is returned into its place imply by firm pressure with a finger.
18. In palma qu⟨o⟩que ossa interdum suis sedibus pro⟨mo⟩uentur, modo in priorem partem, modo in posteriorem: in latus enim moueri paribus ossibus oppositis non possunt. Signum id solum est omniumque commune: tumo⟨r⟩ ea parte, in quam os uenit; ab ea sinu⟨s⟩, a qua recessit. Sed sine intentione digito tantummodo bene pressum os in suam sedem reuertitur.
19. 19 Now the fingers can be dislocated in almost as many ways as the hand and the signs are the same. But in stretching these less force is required, for the joints are shorter and the sinews less strong. They only need to be stretched out on a table, when the dislocation is forwards or backwards; then reduction is made with the palm of the hand; but when the displacement is to one side, by means of the surgeon's fingers.
19. At in digitis totidem fere casus eademque signa sunt, quae in manibus. Sed in his extendendis no⟨n⟩ aeque ui opus est, quo⟨m⟩ et articuli breuiores et nerui minus ualidi sint. Super mensam ⟨tan⟩tummodo intendi debent, qui uel in priorem ⟨uel in posteriorem⟩ partem exciderunt; tum i⟨ma⟩ palma conpelli: at id, quod in latus elapsum est, digitis restitui.
20. 20 Since I have described the above, I can be held also to have described displacements in the legs: for in this kind of accident also there is some similarity between the thigh and upper arm, between the tibia and ulna, between the foot and the hand. But there are also some special points to note about the legs. The thigh-bone may be moved out of place in all four directions, oftenest inwards, next outwards, very rarely forwards or backwards. If it has been dislocated inwards, the leg is longer than the other, and is bowed; for the point of the foot looks outwards; if outwards, the leg becomes shorter and knock-need, and the foot is inclined inwards; the heel in walking does not touch the ground, but only the extreme end of the sole; the leg in this case supports the rest of the body better and more uprightly than in the other and there is less need for a stick. If forwards, the leg is extended and cannot be bent; as far as the heel the injured leg is the length of the other one, but the extremity of the sole is less bent forward; and in this case there is marked pain, and very often the urine is suppressed. When the inflammation and pain have subsided, the patients walk fairly and the whole of their foot touches the ground. If backwards, the leg cannot be stretched out, and is shorter; when the patient is standing the heel in these cases too cannot touch the ground. But the great danger with regard to the thigh is that it is difficult to replace, or, after replacement, slips again out of position. Some hold that it always does so; but such renowned authorities as Hippocrates and Diocles and Phylotimus and Nileus and Heracles of Tarentum have related that they had completely restored such cases; nor would Hippocrates, Andreas, Nileus, Nymphodorus, Protarchus, Heraclides, and a certain smith as well, have invented so many sorts of instruments for making extension on the thigh after this accident, if it had been all of no use. But although that opinion is a false one, there is this truth in it: since the ligaments and muscles there are very strong, if they retain their strength they scarcely allow of replacement; if not, they do not keep in place afterwards. Replacement, then, is to be attempted; and if the limb is weak it is sufficient to stretch it by straps, one from the groin, another from the knee; if stronger, the assistants will have more purchase if they have knotted the straps around long poles; and if after pressing the lower ends of the poles against firm supports, they have drawn the upper ends towards themselves with both hands. Even more forcible pressure can be exerted by stretching the limb over a bench, at either end of which is a windlass to which the straps are attached; when these are rotated as in a winepress, it is possible, by continuing to do this, even to rupture the ligaments and muscles, and not merely to stretch them. Now the patient is to be laid upon this bench, on his face or back or side, so that that part is always the higher into which the bone has slipped, and that from which it has receded the lower. When the sinews have been stretched, if the bone comes forwards, some round object is placed over the groin and the patient's knee must be pulled back over it with a jerk, in the same way and for the same reason for which this was done in the case of the forearm; as soon as the thigh can be bent up, the bone is in place. In the other cases, when the bones under extension have receded a little from each other, the surgeon should force the projecting part back, whilst an assistant presses the hip in the opposite direction. When the bone is replaced nothing further need be done, but the patient must be kept in bed for a rather long time or the thigh may become displaced again on moving while the sinews are still relaxed.
20. Cum de his dixerim, de is quoque, quae in cruribus sunt, uideri possum dixisse: siquidem etiam in hoc casu quaedam similitudo est femori et umero, tibiae et cubito, pedi et manui. Quaedam tamen separatim quoque de his dicenda sunt. Femur in omnes quattuor partes promouetur, saepissime in interiorem, deinde in exteriorem, raro admodum in priorem aut posteriorem. Si ⟨in⟩ interiorem partem prolapsum est, crus longius altero et ua⟨ti⟩um est: extra enim pes ultimus spectat; si in ⟨ex⟩teriorem, breuius uarumque fit, et ⟨pes⟩ intus inclinatur; calx ingressu terram non contingi⟨t,⟩ sed planta i⟨ma⟩; melius⟨que⟩ id crus superiusque corpus quam in priore casu fert, minusque baculo eget. Si in priorem, crus extensum est, in⟨c⟩li⟨n⟩arique non potest; alteri cruri ad calcem par est: sed ima planta minus in priorem partem inclinatur; dolorque in hoc casu praecipuus est, et maxime urina supprimitur. Vbi cum dolore inflammatio quieuit, commode ingrediuntur, totusque eorum pes ⟨inc⟩ed⟨i⟩t. Si in posteriorem, extendi non potest crus, breuiusque ⟨est⟩; ubi constitit, calx ⟨his⟩ quoque terram non contingit. Magnum autem femori periculum est, ne ⟨uel⟩ difficulter reponatur, uel repositum rursu⟨s⟩ excidat. Quidam iterum semper excidere contendunt: sed Hippocrates et Diocles et Ph⟨y⟩lotimus et Nileus et Heraclides Tarentinus, clari admodum auctores, ex toto se restituisse memoriae prodiderunt: neque tot genera machinamentorum quoque ad extendendum in hoc casu femur Hippocrates, Andreas, Nileus, Nymphodorus, Protarchus, Heraclides, quidam quoque faber repperissent, si id frustra esset. Sed ut haec falsa opinio est, sic illud uerum est: cum ibi ualentissimi nerui musculique sint, si suum robur habent, uix admittere; si non habent, postea non continer⟨e⟩. Temptandum igitur est: et si tenerum membrum est, satis est haben⟨a⟩ alter⟨a⟩ ab inguine, alter⟨a⟩ a genu intendi; ⟨si⟩ ualidius, melius adducent, qui easdem ⟨habenas⟩ ad ⟨b⟩acula ualida deligarint; cumque eorum fustium imas partes oppositae morae obiecerint, superiores ad se utraque manu traxerint. Etiamnum ualentius intenditur membrum super scamnum, cui ab utraque parte axes sunt, ad quos habenae illae deligantur; qui, ut in torcularibus conuersi, rumpere quoque, si quis perseuerauerit, non solum extendere neruos et musculos possunt. Collocandus autem homo super id scamnum est aut pronus aut supinus aut in latus sic, ut semper ea pars superior sit, in quam os prolapsum est, et ⟨ea⟩ inferior, a qua recessit. Neruis extensis, si in priorem partem os uenit, rotundum aliquid super inguen ponendum, subitoque super id genu adducendum est eodem modo eademque de causa, qua idem in brachio fit: protinusque, si conplicari femur potest, intus est. In ceteris uero casibus, ubi ossa ⟨per uim⟩ paulum inter se recesserunt, medicus debet id, quod eminet, retro cogere; minister contra inde coxam propellere. ⟨Re⟩posito osse, nihil aliud [noui] curatio requirit, quam ut diutius is in lecto detineatur, ne, si motum adhuc neruis laxioribus femur fu⟨er⟩it, rursus erumpat.
21. 21 It is very well known that the knee is put out externally and internally and backwards. Many have written that it does not slip out forwards; and this may be very near the truth, for the knee-cap is there right in front and holds the head of the tibia in place. Meges, however, has recorded a case in which he replaced a knee which had slipped forwards. In cases affecting the knee-joint the sinews can be extended by the same means as I have described for the thigh. And when it has slipped out backwards, as described above, a round ball of some kind is placed on the ham, and when the leg is bent up over it, the knee slips back again. In the other cases it is to be replaced by the surgeon's hands while the bones are being drawn apart in opposite directions.
21. Genu uero et in exteriorem ⟨et interiorem⟩ et in posteriorem partem excidere notissimum est. In priorem non prolabi plerique scripserunt; potestque ⟨id⟩ uero proximum esse, cum inde opposita patella ipsa quoque caput tibiae contineat. M⟨e⟩g⟨e⟩s tamen eum, cui in priorem partem excidi⟨sset⟩, a se curatum esse memoriae prodidit. —In his casibus intendi nerui rationibus isdem, quas in femore rettuli, possunt. Et id quidem, quod in posteriorem partem excidit, eodem modo, rotundo aliquo super poplitem inposito adductoque eo crure, reconditur. Cetera uero manibus simul, dum ossa in diuersas partes * * * conpellentur.
22. 22 The ankle can be dislocated in all fought directions. When it slips inwards, the sole of the foot is turned outwards; when outwards, the contrary sign is exhibited. If the ankle is dislocated forwards, the broad sinew behind is hard and tense, and in those cases manipulation is required; if backwards, the heel is almost hidden and the sole is elongated. But this is also replaced by manipulation, the foot and leg first being stretched in opposite directions. And after this kind of accident also, the patient should stay for a long while in because, lest the ankle, which sustains the whole weight of the body, should give way and again be displaced if the sinews have not gained strength enough for bearing the weight. At first low shoes should be worn, so that the ankle may not be injured by tight lacing.
22. Talus in omnes partes prolabitur. Vbi in interiorem partem excidit, ⟨i⟩ma pars pedis in exteriorem partem conuertitur; ubi huic contrarius casus, contrarium etiam signum extat. Si in priorem partem erumpit, a posteriore latus neruos durus et insanus est: m⟨a⟩n⟨u⟩que his opus est: si in posteriorem, ⟨cal⟩x paene conditur, pla⟨nt⟩a maior fit. Reponitur autem is quoque per manus, prius in diuersa pede et crure d⟨i⟩ductis. Et in hoc quoque casu diutius in lectulo perseuerandum est, ne is talus, qui totum corpus sustinet, parum confirmatis neruis ferendo oneri, cedat rursusque prorumpat. Calciamentis quoque humilioribus primo tempore utendum, ne uinctura talum ipsum laedat.
23. 23 The bones of the sole of the foot may come out like those of the hand, and are set after the same fashion. Only the bandage should also include the heel, in case, when the middle and front part of the sole have to be bandaged, if the ankle is left unbandaged, too much matter should accumulate there, and lead to suppuration.
23. Plantae ossa isdem modis quibus in manu prodeunt, isdemque conduntur. Fascia tantummodo calcem quoque debet comprehendere, ne, cum mediam plantam imumque eius uinciri necesse est, liber ⟨t⟩al⟨us⟩ in medio relictus materiam pleniorem recipiat ideoque suppuret.
24. 24 For the toes the same treatment is required as was laid down for the fingers. But the middle or end joint when replaced may be fixed in some kind of gutter splint.
24. In digitis nihil ultra fieri debet quam quod in is, ⟨qui⟩ sunt in manu, positum est. Potest tamen conditus articulus medius aut summus canaliculo aliquo contineri.
25. 25 This is the treatment for those cases in which no wound accompanies the dislocation.... In these cases too there is not only great danger but it is more serious, the larger the limb, and the more powerful the sinews and muscles controlling it. Hence in the case of the shoulder and hip joints there is risk of death: and if the bones are set, there is no hope at all; if not, there is still some danger, and in either case the nearer the wound is to the joint the greater the cause for anxiety. Hippocrates said that no such dislocation could be replaced safely except those of fingers and toes, and feet and hands, and even in these cases it was best not to be in a hurry. Some have also replaced elbows and knees; and have then let blood at the elbow, lest gangrene and spasm should arise, after which generally in such cases an early death follows. Even a finger, in which the damage and therefore the damage is least, ought not to be reset whilst there is inflammation, or indeed at a later stage when the condition is of long standing. Moreover, when after replacement the sinews become tense, the bone should at once be put out again. Where there is a dislocation and a wound as well, the limb which has not been seet should lie in the position easiest to the patient; only it must not be moved or hang downwards. In every disorder of this kind there is great advantage in prolonged abstinence, and then in the treatment described above for fractured bones when there is also a wound. If bare bone projects, it will always be troublesome; hence the projection is to be sawn away and dry lint and medicaments without lard put on, until what is possible in the way of healing for such a case is arrived at; for weakness of the limb follows and the scar that forms is thin, and this of necessity is afterwards readily subject to injury.
25. Haec facienda sunt in is casibus, ubi sine uulnere ossa exciderunt. * * * Hic quoque et ingens periculum est, et eo grauius, quo maius membrum est, quoue ualidioribus neruis aut musculis continetur. Ideoque ⟨in⟩ umeris femoribusque metus mortis est: ac, si reposita e⟨i⟩s ossa sunt, spes nulla est; ⟨si⟩ non reposita, tamen nonnullum periculum est; eoque maior in utroque timor est, quo propius uulnus articulo est. Hippocrates nihil t⟨u⟩to reponi posse praeter digitos et plantas et manuus dixit, atque in his quoque diligenter esse agendum, ne praecipitarent. Quidam brachia quoque et crura reposuerunt; et ne cancri distentionesque neruorum orirentur, sub quibus ⟨in⟩ eiusmodi casu f⟨e⟩re mors matura e⟨s⟩t, sanguinem ex brachio miserunt. Verum ne digitus quidem, in quo minimum ut malum, sic etiam periculum est, reponi debet, aut in inflammatione aut postea, cum iam uetus res est. Sic quoque reposito osse nerui ⟨ubi⟩ distenduntur, rursus id protinus expellendum est. Omne autem membrum, quod cum uulnere loco motum neque repositum est, sic iacere conuenit, ut maxime cubantem iuuat; tantum ne moueatur neue dependeat. In omnique tali mo⟨rb⟩o magnum ex longa fame praesidium est, deinde ex curatione eadem, quae proposita est, ubi ossibus fractis uulnus accessit. Si nudum os eminet, impedimento semper futurum est: id⟨eo⟩ quod excedit abscidendum est, inponendaque super arida linamenta sunt et medicamenta non pinguia, donec quae sola esse in eiusmodi re sanitas potest, ueniat: nam et debilitas sequitur et tenuis cicatrix inducitur, quae necesse est facile noxae postea pateat.